Murat Uğur

The relationship between red blood cell distribution width and the clinical outcomes in non-ST elevation myocardial infarction and unstable angina pectoris: a 3-year follow-up.

ObjectivesRed blood cell distribution width (RDW), a marker of variation in the size of the circulating red blood cells, was evaluated in patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP). BackgroundHigher RDW is associated with mortality in the general population, particularly in those with symptomatic cardiovascular disease, and heart failure. We hypothesized that admission RDW might be predictive of adverse clinical outcomes for patients with NSTEMI and UAP. MethodsWe prospectively enrolled 310 patients with NSTEMI and UAP (mean age 59.3±11.9 years; 236 men, 74 women) in this study. Admission RDW was measured and the study population was classified on the basis of RDW tertiles. A high RDW (n=95) was defined as a value in the upper third tertile (>14%) and a low RDW (n=215) was defined as any value in the lower two tertiles (⩽14%). The patients were followed up for clinical outcomes for up to 3 years after discharge. ResultsIn the Kaplan–Meier survival analysis, the 3-year mortality rate was 19% in the high RDW group versus 5.6% in the low RDW group (P<0.001). In the receiver operating characteristic curve analysis, an RDW value of more than 14% yielded a sensitivity of 60% and a specificity of 72.5%. A significant association was found between a high admission RDW level and the adjusted risk of cardiovascular mortality (hazard ratio: 3.2, 95% confidence interval: 1.3–7.78, P=0.01). ConclusionRDW is a readily available clinical laboratory value associated with long-term cardiovascular mortality in NSTEMI and UAP.

Lifestyle and Metabolic Determinants of Incident Hypertension, With Special Reference to Cigarette Smoking : A Longitudinal Population-Based Study

BACKGROUND Lifestyle and metabolic determinants of incident hypertension in a population with a high prevalence of metabolic syndrome (MetS) need to be further assessed. METHODS A representative sample of middle-aged and elderly Turkish adults was prospectively evaluated over a mean 7.4 years, after exclusion of prevalent hypertension and major renal dysfunction. RESULTS In 2,427 men and women, aged 45.8 +/- 11.7 years, Kaplan-Meier analysis showed in combined genders mean time to incident hypertension to be 7.23 years in never, 7.78 years in current smokers (P < 0.001). Age and female sex were major determinants of subsequent hypertension after adjustment for physical activity grade, family income bracket, smoking status, usage of alcohol and of hormone replacement or birth control pill. Relative risk (RR) for incident hypertension of current vs. never smoking was reduced in women (P = 0.058) and both genders combined (P = 0.054). Former smokers uniformly exhibited significantly higher risk for the development of hypertension than both never (P = 0.054) and current (P < 0.001) smokers, whereby abdominally obese individuals were at increased risk. In further multivariable models, circulating C-reactive protein (CRP) and fasting insulin emerged as modest independent determinants and waist girth, modulated by current smoking, as a major determinant of subsequent hypertension. CONCLUSIONS Age, female sex, and waist circumference are major and serum insulin and CRP modest determinants of incident hypertension in middle-aged Turkish adults in whom current cigarette smoking plays a protective role at borderline significance, largely by modulating waist girth. Former smokers with abdominal obesity are under higher risk of subsequent hypertension than current smokers.

Visceral adipose tissue and body fat mass: Predictive values for and role of gender in cardiometabolic risk among Turks

OBJECTIVE We investigated the predictive values of visceral adipose tissue area (VAT) and body fat mass for a composite endpoint consisting of type 2 diabetes and coronary heart disease and for incident metabolic syndrome. METHODS We analyzed at 4-y follow-up 157 middle-aged men and women in whom body composition analyzer and single-scan computerized tomography had been used. RESULTS Sex- and age-adjusted mean areas of visceral fat were 1.5-fold greater in individuals with than without the composite endpoint (P<0.001), whereas abdominal subcutaneous fat was similar. Analysis of receiver operating characteristics for the optimal criterion regarding the composite endpoint (in 37 participants) indicated a VAT of 130 cm(2) and accuracies of 60% in men and 85% in women. Whereas age-adjusted VAT alone significantly predicted the composite endpoint in men, body fat mass or VAT predicted it in women (with 2.2- to 2.6-fold relative risks for 1-SD increment). Age-adjusted incident metabolic syndrome was significantly predicted by each parameter in men but only by fat mass in women. CONCLUSION Visceral adiposity in men and body fat mass in women seem to be of greater relevance in cardiometabolic risk for the prediction of which 130 cm(2) of VAT in both sexes and/or 27 kg of fat mass in women are useful cutoffs. Sex differences may reflect the predominating role of visceral adiposity in men and of insulin resistance in women in this risk.

Impact of day versus night as intervention time on the outcomes of primary angioplasty for acute myocardial infarction

Background: Conflicting datas exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST‐segment elevation myocardial infarction (STEMI) when the intervention is performed during night hours. Methods and Results: 2,644 consecutive patients with STEMI (mean age 56.7 ± 11.9, years, 2,188 male) undergoing primary PCI between October 2003 and March 2008 were retrospectively enrolled into this study (single high‐volume center: >3,000 PCIs/year). Day time was defined according to intervention between 08:00 am and 06:00 pm and night as intervention time between 06:00 pm and 08:00 am. 1,141 patients (43.2%) were treated during the day and 1,503 (56.8%) at night. The baseline characteristics of both groups were similar except for more frequent hypertension (42.6 vs. 36.5%; P = 0.002), women (19.7 vs. 15.4%; P = 0.003), and old (≥75y) patients (9.6 vs. 7.4; P = 0.046) in the day time group. Compared with those treated during night time, day time patients had longer angina‐reperfusion times (mean, 205 vs. 188 minutes, P = 0.016). Door‐to‐balloon times were similar (P = 0.87), and less than 90 minutes in both groups. There were no differences concerning clinical events and PCI success between the two groups. Hospital mortality was 6.1% during the day and 5.2% during the night (OR 0.98, 95% CI 0.7–1.36; P = 0.89). The median follow‐up time was 21 months. The Kaplan‐Meier survival plot for long‐term cardiovascular death was not different for both groups (P = 0.78). In‐hospital and long‐term cardiovascular mortality was also similar in shock and nonshock subgroups. Conclusions: Primary PCI can be performed safely during the night at a high‐volume PCI center with suitable and effective organization of cardiology department and catheterisation laboratory with 24 hours per day, 7 days per week onsite staffing.

Comparison of outcomes in young versus nonyoung patients with ST elevation myocardial infarction treated by primary angioplasty.

ObjectivesWe sought to determine in-hospital and intermediate-term outcomes of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) in young adults. MethodsWe reviewed 2424 consecutive patients treated with primary angioplasty for acute MI; 465 were aged 45 or less (young group) and 1959 were 46–74 years of age (nonyoung group). Clinical characteristics, in-hospital and intermediate-term outcomes of primary PCI were analyzed. ResultsCompared with nonyoung patients, the young patients had significantly lower in-hospital and intermediate-term mortality (for in-hospital mortaliy: 5.4 vs. 1.2%, P<0.001; for intermediate-term mortality: 5 vs. 1.3%, P<0.001). By multivariate Cox regression analysis in all 2424 patients; cardiogenic shock, diabetes mellitus, anterior MI and unsuccessful procedure were independent predictors of both in-hospital and intermediate-term mortality whereas age [odds ratio (OR): 1.07, P<0.001], female sex (OR: 1.88, P = 0.04), MI history (OR: 3.05, P = 0.001) and multivessel disease (OR: 2.15, P = 0.01) were independent predictors of only intermediate-term mortality. The young group had lower unsuccessful procedure rates of primary PCI for STEMI (4.9 vs. 10.1%, P = 0.001). ConclusionThese results suggest that young adults who underwent primary PCI have favorable in-hospital and intermediate-term outcomes. Moreover, primary PCI for young adults with STEMI is safer, more feasible and effective than for a relatively older population.

Dual activity of serum lipoprotein-associated phospholipase A(2) yielding positive and inverse associations with cardiometabolic risk.

Abstract Background: The clinical relevance of serum lipoprotein-associated phospholipase A2 (Lp-PLA2) in populations prone to cardiometabolic risk needs exploration. We determined major covariates of Lp-PLA2 mass, and its associations with cardiometabolic disorders. Methods: In 736 Turkish adults, serum total Lp-PLA2 mass was determined by immunoassay. Its association with cardiometabolic risk was assessed in three categories. In a second sample of 98 subjects, enzyme protein in high-density lipoprotein (HDL) was also assayed after precipitation. Results: Significant inverse correlation existed with high triglyceride/low HDL cholesterol dyslipidemia, waist girth, apolipoprotein C-III, homeostatic model assessment, and linear inverse associations in women with lipoprotein (a) and fibrinogen, suggesting that Lp-PLA2 mass reflected insulin sensitivity and that HDL bound enzyme mass dominated the associations. Among men, positive linear association with total cholesterol suggested additional association with low-density lipoprotein (LDL)-bound enzyme. High (>450 ng/mL) opposed to low (<210 ng/mL) circulating Lp-PLA2 mass was associated with prevalent and incident coronary heart disease (CHD) in men. One SD increment in Lp-PLA2 was associated with a 1.64-fold (95% CI 1.00; 2.70) likelihood of CHD, after adjustment for potential confounders. Furthermore, Lp-PLA2 categories were significantly, independently and inversely associated in men with diabetes only (OR 0.61) and in women with metabolic syndrome only (OR 0.68), for a 1-SD increment. Conclusions: Serum total Lp-PLA2 mass may indicate either elevated or diminished cardiometabolic risk, specific for gender, depending on its partitioning in lipoprotein groups.

Patients with anemia on admission who have undergone primary angioplasty for ST elevation myocardial infarction: in-hospital and long-term clinical outcomes.

ObjectiveWe investigated the in-hospital and long-term follow-up (mean 21 months) results of patients with and without anemia on admission and who have undergone primary angioplasty for ST elevation myocardial infarction (STEMI). Study designA total of 2509 patients (616 patients with anemia on admission, 1893 patients without anemia on admission), who were treated with primary angioplasty due to STEMI, were included in this study. Demographics and basic clinical features of the patients, outcomes of the primary angioplasty procedures, and clinical course of the patients during and a mean period of 21-month follow-up after hospitalization were retrospectively evaluated. All the parameters were compared between anemic and nonanemic groups. ResultsThe mean age of the patients in anemic group was found to be higher than nonanemic group (61.5±11.4 vs. 54.8±11.4, P<0.001). The rates of death, major cardiac events, and severe cardiac insufficiency were significantly higher in anemic patients during hospitalization period. Moreover, frequency of death was also higher in anemic patients when compared with the nonanemic ones after a mean follow-up period of 21 months (P<0.001). Anemia on admission is an independent predictive factor for mortality in patients with STEMI who were treated with primary angioplasty (odds ratio: 2.2; 95% confidence interval: 1.2–4.0; P<0.009). ConclusionPatients with anemia on admission initially have high-risk profiles regarding their worse clinical outcomes during and 21 months after hospitalization. In accordance with the suggestion of the evidence-based medicine we conclude that etiology of anemia should be meticulously investigated and the oxygenization of the tissue should be provided with the appropriate treatment.

High absolute coronary disease risk among Turks: involvement of risk factors additional to conventional ones.

Objectives:To confirm previous findings on excess absolute coronary heart disease (CHD) risk among Turks. Methods: The observed incident CHD risk of a representative population sample was compared with that anticipated by Fra- mingham risk scores (FRS). At 7.4 years of follow-up of 3,027 participants free of CHD at baseline, risk estimation was contrasted in the 398 cases of newly developed fatal and nonfatal CHD. Results:CHD developed at a rate 2.2 times higher than the anticipated risk. In sex-specific quintiles of FRS, the 10-year incidence of CHD events in males in the 2 highest quintiles was 2 times the anticipated levels. In women, the 3 highest quintiles displayed an incidence 2.7 times the anticipated risk. Such individuals typically had abdominal obesity and evidence of dysfunctional apolipoprotein (apo) A-I. Men had high levels of non-high-density lipoprotein (HDL) cholesterol, total apoC-III, apoB and triglycerides. In Cox proportional hazard regression analyses, the 10-year probability of remaining free of CHD was low (81.1% in men, 84.2% in women). Women exhibited C-reactive protein as an independent predictor of CHD, lack of protection by HDL cholesterol and no conferred risk from current smoking. The observed excess CHD risk was primarily attributed to central obesity and related dysfunction of HDL, apoC-III and apoA-I. Conclusion: Dysfunction of protective serum proteins associated with metabolic syndrome impacts on CHD events, in addition to conventional risk factors.

Impaired anti-inflammatory function of apolipoprotein A-II concentrations predicts metabolic syndrome and diabetes at 4 years follow-up in elderly Turks.

Abstract Background: We evaluated prospectively the predictive value of serum apolipoprotein (apo) A-II, the second major apolipoprotein of high-density lipoprotein (HDL), for cardiometabolic risk in Turkish adults showing abnormalities in other proteins that normally confer protection. Methods: Determinants of apoA-II and its associations with coronary heart disease (CHD), metabolic syndrome (MetS) and diabetes were investigated at 4 years follow-up in 193 elderly men and women. Results: ApoA-II concentrations at baseline, in addition to being significantly related to HDL-cholesterol, were directly associated with complement C3 in multivariate linear regression analyses comprising nine variables. Following adjustment for gender, age and HDL-cholesterol (>30/>33 g/L, in men and women, respectively), low serum apoA-II concentrations predicted incident MetS [relative risk (RR) 3.5 (95% CI 1.4; 8.6)] and type 2 diabetes [RR 4.5 (95% CI 1.3; 15.6)] in both genders at an increment of 1 SD. Increased apoA-II values were not associated with prevalent or incident CHD, and tended to be marginally atheroprotective only in males. Conclusions: Serum apoA-II concentrations confer risk for MetS and diabetes and exhibit evidence of anti-inflammatory properties among Turks. These findings support the effects seen for several other HDL protein constituents. This finding may explain the increased cardiometabolic risk among Turks. Clin Chem Lab Med 2009;47:1389–94.

Prediction of cardiovascular mortality in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention.

ObjectivesWe analyzed a large patient group to develop a clinical risk score that could be applied to patients after primary percutaneous coronary intervention (PCI). MethodsWe reviewed 2529 consecutive patients treated with primary PCI for ST-elevation myocardial infarction between 2003 and 2008. All clinical, angiographic and follow-up data were retrospectively collected. Independent predictors of in-hospital cardiovascular mortality were determined by multivariate Cox regression analysis in all study patients. ResultsFive variables (Killip class 2/3, unsuccessful procedure, contrast-induced nephropathy, diabetes mellitus, and age >70 years) were selected from the initial multivariate model. Each of them was weighted with 1 point according to their respective odds ratio for in-hospital mortality and then total risk score was calculated for each patient with a range of 0–5 points. For simplicity, four strata of risk were defined (low risk, score 0; intermediate risk, score 1; high risk, score 2 and very high risk, score ≥3). Each risk strata had a strong association with in-hospital cardiovascular mortality (P<0.001 for trend). Moreover, among survivors after an in-hospital period, our risk score continued to be a powerful predictor of long-term mortality (P<0.001 for trend). ConclusionIn patients treated with primary PCI, a risk score, which was developed from five risk factors readily available after intervention, may be useful to predict in-hospital and long-term cardiovascular mortality.