Muharrem Akhan

Higher Neutrophil to Lymhocyte Ratio in Patients With Metabolic Syndrome

We read with great interest the article ‘‘Correlation of Neutrophil to Lymphocyte Ratio With the Presence and Severity of Metabolic Syndrome’’ by Buyukkaya et al. They aimed to investigate the relationship between the criteria comprising metabolic syndrome (MS) and neutrophil–lymphocyte ratio (N/L ratio) as a novel, simple, and reliable indicator of inflammation. They showed that patients with MS had significantly higher N/L ratio compared to those without MS. Furthermore, N/L ratio increased as the severity of MS increased. A strong positive correlation was revealed between the severity of MS and N/L ratio and between the severity of MS and the highsensitivity C-reactive protein (hsCRP). In addition, the correlation analysis revealed a positive correlation between hsCRP and NLR in the patient population. The measurements of white blood cells (WBCs), neutrophils, and lymphocytes in the patients with MS were higher than those without MS. The study is successful in planning and presenting the results. We believe that these findings will enlighten further studies about the association between the severity of MS and the N/L ratio. Thanks to the authors for their contribution. The WBC count is one of the useful inflammatory biomarkers in clinical practice. Leukocyte subtype and N/L ratio are also indicators of systemic inflammation. Although WBCs are in normal range, subtypes of WBCs may predict cardiovascular mortality. The N/L ratio is also an inflammatory marker of major adverse cardiac events. Some comments may be of interest. Although the authors have showed patients with MS had significantly higher N/L ratio compared to those without MS, some of the factors affecting these markers such as smoking, alcohol, and malignancy were not mentioned in this study. In addition, the authors could add a MS subgroup analysis. A subgroup analysis of MS according to age, sex, CRP, WBCs, neutrophils, and lymphocytes might affect the results of the study.

Asymmetric Dimethylarginine and Augmentation Index in Newly Diagnosed Patients With Hypertension

Pulse wave velocity (PWV), augmentation index (Aix), and central aortic pressure (CAP) are arterial stiffness markers of endothelial dysfunction (ED). We investigated the relationship between arterial stiffness parameters and asymmetric dimethylarginine (ADMA; a marker of ED), in newly diagnosed patients with hypertension (n = 101; 61 females). These patients were investigated in accordance with the recommendations of hypertension guidelines. Arterial stiffness was measured, and serum ADMA and C-reactive protein (CRP; a marker of inflammation) levels were determined. In both women and men, there was no difference in terms of age, body mass index, systolic and diastolic blood pressures, PWV, CAP and the levels of ADMA, while Aix and CRP levels were significantly higher in women (P = .004, P = .046, respectively). In the whole group, ADMA levels correlated with Aix (Pearson r = .237, P = .024). Our findings provide further evidence of a link between arterial stiffness and ED in newly diagnosed patients with hypertension.

Red Cell Distribution Width Should Be Assessed together with Other Inflammatory Markers in Daily Clinical Practice

tion myocardial infarction patients [2] and, in another study, RDW significantly predicted hemoglobin A 1C independent of fasting blood glucose in healthy nondiabetic adults, suggesting the possibility of chronic hyperglycemia leading to an association between RDW and cardiovascular diseases [3] . In another recent study, a close relationship between high RDW and carotis intima media thickness and the incidence of carotid plaque was identified in 156 hypertensive patients [4] . Sometimes, conditions like the differential diagnosis of anemias might affect the RDW parameter, and this parameter might be changed in such an underlying condition. The anemic disease situation may mask the chronic ongoing inflammation. Therefore, RDW itself, alone, without other overt inflammatory markers, may not provide information about the chronic endothelial inflammatory condition of the patient at first glance. Thus, we think that it should be evaluated together with other inflammatory markers. In addition, RDW may be considered alongside with other conventional cardiac markers for the risk stratification of coronay syndrome patients admitted to emergency departments. Another point of view is that anemia is frequent among patients with cardiovascular disease and adversely affects prognosis. In this study, because there was a significant difference in hemoglobin levels We have read the article ‘Elevated red blood cell distribution width is associated with higher recourse to coronary artery bypass graft’ written by Ephrem and Kanei [1] with great interest. The authors have demonstrated an independent association of elevated red cell distribution width (RDW) with recourse to coronary artery bypass grafting. The study is successful in design and documentation. We believe that these findings will guide further studies about RDW as a surrogate marker of endothelial dysfunction and inflammation in patients with coronary artery disease. We want to thank the authors for their contribution. A complete blood count is an easy and cheap examination technique that provides information about the patient’s formed blood contents, including the red and white cells, platelets, the counts and dimensions of subgroups of cells, and parameters like the distribution widths. We already know that many factors can affect these counts and parameters. Bacterial infections and steroid usage may increase neutrophil counts, and viral infections especially may cause an increase in lymphocytes. RDW is basically used to distinguish iron deficiency anemias from thalassemias. RDW has recently been proposed as an independent predictor of all-cause longterm mortality in non-ST-segment elevaReceived: November 6, 2012 Accepted: November 19, 2012 Published online: January 15, 2013

Arterial stiffness and endothelial inflammation in prediabetes and newly diagnosed diabetes patients

OBJECTIVE There is a growing body of data supporting the association between diabetes and microcirculatory disfunction. We aimed to study e-selectin levels, and their associations with serum markers of inflammation and arterial stiffness in prediabetes and newly diagnosed diabetes patients in this study. SUBJECTS AND METHODS Sixty patients (25 females) with a newly established elevated fasting serum glucose [20 impaired fasting glucose (IFG), 20 impaired glucose tolerance (IGT), 20 newly diagnosed diabetes (T2DM)] and 17 healthy controls (13 females) were included in the study. Serum e-selectin and hs-CRP levels, and arterial stiffness parameters of the patients were studied. RESULTS Fasting serum glucose was the most important predictor of serum e-selectin levels. Pulse wave velocity and central aortic pressures were significantly higher in IFG, IGT and T2DM groups, compared to controls (p = 0.001, < 0.001, 0.013 and 0.015, 0.002, 0.009, respectively). The mean arterial pressure did not show any significant association with serum e-selectin and hs-CRP levels (β coefficient: 0.092, p = 0.358; and β coefficient: 0.189, p = 0.362, respectively). CONCLUSION Prediabetes patients have increasing e-selectin levels through the diagnosis of T2DM. E-selectin is associated with serum glucose levels. Prediabetic and newly diagnosed diabetics have higher arterial stiffness measurements. Serum e-selectin may be a good marker of endothelial inflammation and dysfunction increasing in parallel with serum glucose levels, predicting future cardiovascular events.

Peripheral Arterial Disease Assessment With Photoplethysmography and Continuous-Wave Doppler Ultrasound in Addition to Ankle-Brachial Index May Loss Time and Funds

We read the article ‘‘Photoplethysmography and ContinuousWave Doppler Ultrasound as a Complementary Test to Ankle Brachial Index in Detection of Stenotic Peripheral Arterial Disease’’ by Du Hyun Ro with interest. They concluded that ankle-brachial index (ABI) showed a significantly decreased sensitivity in detection of anatomically stenotic peripheral arterial disease (PAD), especially in stenosis below trifurcation level and both photoplethysmography (PPG) and continuouswave Doppler ultrasound (CWD) were complementary to ABI in these patients. Measurement of ABI manually by Doppler is a well-established method to screen for PAD and to predict the cardiovascular risk of patients. In this study, measuring PPG and CWD in addition to ABI measurement in patients with probable PAD was suggested as the ABI has a sensitivity of 69.3% and a specificity of 99.6% and it may miss a diagnosis of PAD. But in real life, a measurement of ABI as well as these additional methods may consume more time and lead to higher costs. Further studies are needed to answer these questions. A second challenge in the study is that the authors discussed ABI measurements but we do not know the real-time aortic or brachial blood pressure of these patients. It would be better if they provided enough data and the blood pressure measurements were standardized.

Epicardial adipose tissue measurement: inexpensive, easy accessible and rapid practical method.

We have read the article “Epicardial adipose tissue (EAT) is independently associated with increased left ventricular mass in untreated hypertensive (UHT) patients: an observational study” written by Erdoğan et al. (1) with a great interest. The authors aimed to evaluate the relationship between EAT and left ventricular hypertrophy (LVH) in patients with UHT. They concluded that EAT was related to increased LVM independent of body mass index (BMI), waist circumference, weight, systolic and diastolic blood pressure and other risk parameters, in patients with UHT. Determination of increased EAT by echocardiography may have an additional value as an indicator of cardiovascular risk and total visceral adipose tissue. Thanks to the authors for their contribution of the present study, which is successfully designed and documented. Cardiovascular diseases are the most important causes of mortality and morbidity in developed countries worldwide. It is widely recognized that accumulation of EAT is strongly related to the development of coronary artery disease (CAD). EAT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition. EAT measured by echocardiography has been known to be associated with metabolic syndrome (2). Additionally, echocardiography-based EAT measurement was related to several metabolic abnormalities and independently associated fatty liver disease (3). On the other hand, in kidney disease patients, EAT was positively correlated with atherosclerosis and the presence of coronary artery calcification (4). In addition, the duration of hypertension (HT) may be different in these patients. We think that the results of the study would be stronger, if the authors had mentioned these factors including the duration of HT, liver and kidney function tests. EAT can also be affected by the atherosclerotic risk factors such as alcohol consumption, hypothyroidism, impaired glucose tolerance and higher inflammatory status (5) such as an inflammatory disease, cardiac syndrome X and infection (6). In this point of view, in the present study, the authors did not mention some of these possible contributing factors. It would be better, if the authors gave information about these factors. EAT measurement with echocardiography has several advantages, including its inexpensive, easy accessibility, rapid applicability and good reproducibility. EAT has a 3-dimensional distribution and two-dimensional echocardiography cannot give adequate window of all cardiac segments especially in obese subjects and is highly dependent on acoustic windows. In this point of view, it would be better to give interobserver and intra-observer variability for EAT measurement in the current study (7). Finally, EAT itself without other inflammatory markers may not provide information to clinicians about the systemic inflammation. Therefore, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will evaluate further studies about EAT on cardiovascular risk factors.

Findings of Biopsy-Proven Chronicity and End-Stage Renal Failure Associated with Oral Sodium Phosphate Solution

Bowel purgatives containing oral sodium phosphate (OSP) solution are used frequently in general practice and they have the potential of causing acute kidney injury especially in patients with some identified risk factors. Kidney injury may lead to chronicity and end-stage renal disease. Here we present, with renal biopsy findings, an elderly patient suffering from end-stage renal failure due to OSP solution.

Investigation of the arterial stiffness and associated factors in patients with familial Mediterranean fever.

Objective: Because of the ongoing and recurring inflammatory state in familial Mediterranean fever (FMF), patients may experience a high risk of cardiovascular events. Our aim was to investigate the arterial stiffness and associated factors in patients with FMF. Methods: Sixty-nine consecutive FMF patients (including 11 females) and 35 controls (including 5 females) were enrolled in the study. The demographical, clinical, and laboratory data and genetic mutations of the patients were recorded. In the study, FMF patients according to the Tel-Hashomer criteria were included, whereas patients with other known inflammatory rheumatologic disease, atherosclerotic cardiovascular disease, hypertension, diabetes, those under the age of 18 years, or those refusing to participate in the study were excluded. Arterial stiffness measurements were performed using the TensioMed device (TensoMed Ltd, Budapest, Hungary). Results: The patient and control groups were similar in terms of the mean ages, BMIs, gender, systolic blood pressures, and smoking. FMF patients had a higher pulse wave velocity (PWV) (7.73±1.3 and 7.18±1.1 m/s; p=0.03) and lower brachial and aortic augmentation indexes (–64.6±14.6% and –54.6±25.9%, p=0.041 and 4.9±7.4% and 14.0±11.5%, p=0.025, respectively) compared with the controls. Thirty-one (45%) patients were in the “during-attack” state and had higher PWV (8.17±1.6 and 7.38±0.9 m/s; p=0.027) compared with the asymptomatic patients. PWV was correlated to serum CRP, WBC, ESR, fibrinogen, and neutrophil/lymphocyte ratios (r=0.666, 0.429, 0.441, 0.388, and 0.460, respectively). The genetic mutation and predominant attack type had no effect on arterial stiffness. Conclusion: FMF patients have increased arterial stiffness during attacks compared with asymptomatic patients and controls. The impaired arterial stiffness is correlated to the severity of the inflammatory state rather than to the attack type or genetic mutations.

Admission Hyperglycemia May Be the Result of Counterregulatory Hormones During Acute Coronary Syndrome Events

We intentionally read the article ‘‘Admission hyperglycemia predicts inhospital mortality and major adverse cardiac events after primary percutaneous coronary intervention in patients without diabetes mellitus’’ written by Ahmet Ekmekci et al with interest. They concluded that measurement of the admission blood glucose in ST-segment elevation myocardial infarction predicted inhospital mortality and major adverse cardiac event (MACE), and admission blood glucose >118 mg/dL required more attention. Admission blood glucose and even fasting blood glucose levels have been shown to have U-shaped curve of risk in patients with acute coronary syndrome. Patients with impaired glucose tolerance have increased severity of coronary artery disease. Impaired glucose metabolism during acute coronary events in nondiabetic patients could be due to stress-induced activation of cortisol and noradrenalin, growth hormone, and glucagon release. Elevations in counterregulatory hormones accelerate catabolism, hepatic gluconeogenesis, and lipolysis. These events elevate blood glucose, free fatty acids, ketones, and lactate. The rise in glucose blunts insulin secretion via the mechanism of glucose toxicity, resulting in further hyperglycemia. The vicious cycle of stressinduced hyperglycemia and hypoinsulinemia subsequently causes maladaptive responses in immune function, fuel production, and synthesis of mediators that cause further tissue and organ dysfunction as depressing myocardial contractility and contributing to pump failure. We think these studies show us that admission hyperglycemia is not the reason of mortality and MACE but the result of counterregulatory hormones due to stress-induced activation during acute coronary syndrome events.

The proper blood pressure may impair cardiovascular risk factors

We appreciate the article “Uncontrolled arterial hypertension in primary care – patient characteristics and associated factors” written by Corinne Chmiel et al. and read with great interest [1]. The study concluded that age, smoking and high body mass index (BMI) measurements are strong independent factors associated with higher blood pressure levels in patients with uncontrolled arterial hypertension and pointed to the importance of adequate pharmacological treatment as well as risk factor control [1]. The subject is important in terms of our daily practice and the study deserves emphasising with its successful design and results. Hypertension is a growing healthcare problem and constitutes a major risk factor for the development of atherosclerotic cardiovascular disease [2]. The proper blood pressure control and suitable follow up of the patients will prevent many probable comorbidities that may appear in an individual patient [3]. As we know, coronary artery disease may be related to blood pressure dysregulation. If the authors defined independent factors associated with higher blood pressure levels in patients with coronary artery disease, the results could be different. In addition, the proper blood pressure control may also be impaired by the cardiovascular risk factors such as diabetes mellitus or hypercholesterolaemia. Lifestyle change programmes may additionally improve the regulation of blood pressure. The authors may indicate whether there are differences in these factors between the two groups. In addition, the study has a cross-sectional design and did not follow the patients. We think that in order to make better comments about the effects of age, body mass index and smoking on hypertension and the number of drugs on blood pressure control, it would be better if these patients were followed for a particular time.