Muslihittin Emre Erkus

Evaluation of thiol levels, thiol/disulfide homeostasis and their relation with inflammation in cardiac syndrome X.

ObjectivesCardiac syndrome X (CSX) is characterized by the presence of myocardial ischemia in the absence of coronary artery stenosis on angiograms. Its relation to oxidative stress and inflammation is well known. There are no data on thiols and their relation with inflammation in CSX. The aim of this study was to investigate thiol levels and thiol/disulfide homeostasis in CSX patients. Materials and methodsFifty consecutive patients who had documented myocardial ischemia and normal coronary angiogram (CSX group), and 45 age-matched and sex-matched consecutive patients who had normal coronary angiogram without myocardial ischemia (control group) were enrolled in this study. C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), native thiol, total thiol, and disulfide levels were measured and disulfide/thiol ratios were calculated in all patients. ResultsDemographic, clinical, basic laboratory, and echocardiographic characteristics were similar in the two groups (P>0.05). Serum total thiol, native thiol, and disulfide levels decreased significantly in the CSX group compared with the control group (P<0.001). CRP and NLR increased significantly in the CSX group compared with the control group (P<0.001). Although disulfide/native thiol levels increased in the CSX group, this reduction did not reach statistical significance (5.8 vs. 5.5, P>0.05). The reduction of thiols was correlated negatively with CRP and NLR (P<0.001). Although univariate logistic regression analyses showed that serum total and native thiol levels, CRP and NLR were independent predictors for CSX estimation, stepwise multivariate logistic regression analysis showed only total thiol levels as an independent predictor for CSX (odds ratio=0.966, 95% confidence interval: 0.950–0.982, P<0.001). Also, receiver operating characteristic curve analysis showed that serum total thiol values of 338.4 or below could predict the CSX with 86% sensitivity and 84% specificity (area under curve=0.903; 95% confidence interval: 0.842–0.965). ConclusionSerum total thiol levels decreased significantly in CSX and this reduction independently predicted CSX with strong sensitivity and specificity. This suggests that the reduction in thiols along with increased inflammation may play a pathophysiological role in the development of CSX.

Evaluation of Pulmonary Artery Stiffness in Patients with Obstructive Sleep Apnea Syndrome

To investigate whether obstructive sleep apnea syndrome (OSAS) has any effect on pulmonary artery stiffness (PAS) derived from echocardiographic calculation.

Smoking, Diabetes Mellitus, Thyroid Dysfunction, and a Variety of Drugs Have Potential Effects on Serum HDL-C Level

We read the article by Al Riyami et al with interest. They report the effect of residing altitude on levels of high-density lipoprotein cholesterol (HDL-C) in an Omani Arab population. As emphasized by the authors, HDL-C levels can be affected by several factors. The effect of genetic variations and possible differences in physical activity and dietary habits were listed in the limitation section of the study. However, other clinical and biochemical data should have been considered before concluding that the main reason for the HDL-C difference between 2 groups was residing altitude. For example, cigarette smoking has a potential lowering effect on HDL-C levels. Details regarding smoking status were lacking. Actually, we do not expect an important difference with regard to smoking status between these patient groups. But, these data could have been obtained by a detailed medical history. Also, the proportion of diabetic patients in both groups was not reported although one determinant of diabetic dyslipidemia is low HDL-C. The authors compared 2 groups with regard to the fasting plasma glucose and 2-hour postprandial plasma glucose, yielding statistically higher values in patients living at low altitude than those in patients living at high altitude. Giving the reported glucose levels, we did not consider higher proportion of diabetic patients in any group unless some of patients were under antidiabetic regimes (oral antidiabetic or insulin). This issue should be cleared. Another limitation was the absence of data about thyroid function. Thyroid dysfunction can alter serum HDL-C levels. Hashimoto thyroiditis is a common thyroid disorder that is seen mostly in middle-aged female patients—like most of the patients in the study—in endemic areas. Therefore, thyroid function tests should have been performed in all patients, especially if the study was conducted in an endemic zone for goiter. Finally, several drugs such as metformin, sulfonylureas, and glucocorticoids as well as antihyperlipidemic drugs have an effect on HDL-C levels. In brief, the concept that HDL-C levels are higher in patients living at high altitude has been challenged, given the abovementioned limitations. To better understand the relation between HDL-C and living at high altitude, we suggest that future studies should evaluate the role of confounding factors. If these results are available, it may be helpful to present them in a response letter.

A curable cause of hypertension: renal artery pseudoaneurysm

SummaryRenal artery aneurysms and pseudoaneurysms are rare vascular abnormalities. These anomalies, which are usually asymptomatic, may be associated with hypertension. Here, we present the successful treatment of a renal artery pseudoaneurysm in a patient with hypertension, with an overview of the literature.

A very rare coronary artery anomaly, intercoronary communication, that may be lucky for some patients

We read the paper by Abreu et al. entitled ‘Coronary arcade: A rare anomaly of the coronary circulation’ with great interest, and we thank them for their interesting report. They asserted that the cause of the chest pain and ECG alterations observed during exercise testing in the case presented may be the result of transient disturbances in coronary blood flow during the test. Furthermore, they state that intercoronary communication (ICC) may be unrelated to ischemia, and that it may even function as a natural bypass, protecting against ischemia. Herein, we present our case supporting their idea.

Successful treatment of an aneurysmatic aorta-right atrial tunnel by vascular plug: a very rare case

A 57-year-old female patient was admitted to the clinic with dyspnea. She was found to have a grade 3/6 continuous murmur over the right parasternal area. Transthoracic echocardiography revealed a tunnel stemming from the right sinus of Valsalva (RSV) and draining into the right atrium (Figures 1A-D). Pulmonary artery pressure and left-to-right shunt ratio were 65 mmHg and 2.2 respectively. Coronary and computed tomography angiography showed a giant aneurysmatic tunnel stemming from the aorta (Figures E, F and Video 1*), and also revealed the right coronary artery (RCA) originating from the proximal segment of the tunnel and the normal nature of the other coronary arteries (Figure G-J and Video 1*). The anomaly was successfully treated by closing the middle of the tunnel using an Amplatzer vascular plug II (12x9 mm) (Figures J-L and Video 2*). Aorta-right atrial tunnel (ARAT) is an abnormal tubular connection between the ascending aorta and right atrium, and is a very rare congenital cardiac anomaly leading to the left-to-right shunt. ARAT generally originates from the left sinus of Valsalva, and only very rarely from the right. It should be treated due to the risk of cardiac failure, coronary steal, aneurysm formation or rupture, and endocarditis. Surgical closure of the tunnel is usually suggested. However, if there are no other cardiac anomalies and the RCA does not arise from the tunnel, trans-catheter techniques offer an alternative procedure. A few cases with ARAT arising from the right sinus of Valsalva have been reported in the literature. They were treated surgically, except for a 10-year-old patient treated with coil occlusion and a 4-year-old treated using an Amplatzer Duct Occluder II. However, in these two cases the RCA stemmed from the aorta, not from the tunnel. In the case we report, the ARAT arose from the right sinus of Valsalva, and the RCA originated from the proximal segment of the tunnel. The patient was successfully treated by placing a vascular plug in the middle of the ARAT. The case suggests that in the diagnosis of continuous murmur and left-to-right shunts, ARAT should be considered, and therefore it should be carefully screened. In addition, the catheter-based treatment of ARAT should be given priority over surgery in appropriate cases. 316