Nurgül Keser

Modified TEI Index: A Promising Parameter in Essential Hypertension?

Purpose: Modified TEI index is pointed to be more effective in the evaluation of global cardiac functions compared to systolic and diastolic measurements alone. We planned to determine its applicability in hypertension and relation with left ventricular mass index (LVMI). Methods: We studied 48 patients with mild/moderate hypertension and normal coronary angiograms. In total 22 patients (12 men, 10 women, mean age: 55 ± 6) with normal LVMI were studied in group I, 26 patients (12 men, 14 women, mean age: 57 ± 7) with increased LVMI in group II, and 20 patients (10 men, 10 women, mean age: 53 ± 7) with normal blood pressure as a control group. Standard 2D, Doppler, and mitral annulus pulse wave tissue Doppler were used for all measurements. Modified TEI index was calculated as diastolic time interval measured from end of Am wave to origin of Em (a′) minus systolic Sm duration (b′) divided by b(a′−b′/b′). Results: Modified TEI index was significantly higher in both groups than normal group and in group II than in group I. (Control group: 0.33 ± 0.05, group I: 0.51 ± 0.17, group II: 0.68 ± 0.16, P< 0.0001). Conclusion: Modified TEI index, a marker of left ventricular systolic and diastolic functions, is impaired in hypertensives before hypertrophy develops and impairment is more prominent in hypertrophy. Therefore, (1) modified TEI index in hypertensives is a safe, feasible, and sensitive index for evaluation of global ventricular functions. (2) Evaluation of hypertensives with this index periodically may guide interventions directed toward saving systolic and diastolic functions. (3) Modified TEI index is gaining importance as a complementary parameter to standard Doppler or in cases where standard Doppler has its limitations.

Can serum lipid and CRP levels predict the "severity" of aortic valve stenosis?

Background — Results of the studies performed have suggested that hypercholesterolaemia and inflammation are important aetiologic factors in aortic valve stenosis (AVS). However up to now no such data has been obtained to evaluate whether these predictors may still serve as valuable tools to estimate the progression and severity of AVS. If factors contributing to the “progression” of degenerative process can be understood and preventive measures can be taken, both clinical and economical beneficial effects can be achieved. The objective of this study is to investigate the correlation of serum cholesterol, triglyceride and CRP levels with the severity of aortic stenosis echocardiographically evaluated in patients with aortic valve stenosis. Material and methods — Aortic valvular areas of 60 patients (pts) hospitalized in our clinic with suspected AVS were calculated with Doppler echocardiography. Patients were grouped into mild, moderate and advanced AVS, each category containing 20 pts, and then were subclassified regarding those with and without coronary artery disease(CAD). Results — Total cholesterol and CRP levels were found to be 215±42 mg/dl and 2.0±1.4 mg/dl; 224±43 mg/dl and 2.4±2.1 mg/dl; 225±55 mg/dl and 2.7±2.1 mg/dl in pts with mild, moderate and advanced AVS, respectively. A statistically significant difference was not detected among the three groups (p>0.05).When subclasses were classified the levels were found to be much more increased in those patients having additional CAD. Conclusion — We have demonstrated that severity of AVS does not correlate significantly with hypercholesterolaemia and CRP and their levels do not rise in accordance with increasing severity of AVS. Elevations of lipid levels in AVS were found to correlate with the presence of CAD rather than the severity of AVS. So, not in patients with simply AVS but in patients under higher cardiovascular risks, investigation of CRP plus lipid levels might provide benefit with respect to preventive treatment and benefit from cholesterol-lowering drugs can be expected in such kind of patients.

Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome

BACKGROUND Patients with non-ST-elevation acute coronary syndrome are heterogeneous in terms of clinical presentation and immediate- and long-term risk of death or non-fatal ischemic events. The aim of the present study was to evaluate the relationship between the Global Registry of Acute Coronary Events (GRACE) score and severity of coronary artery disease angiographically evaluated by Gensini score in patients with non-ST-elevation acute coronary syndrome. METHODS A total of 245 patients with non-ST-elevation acute coronary syndrome were enrolled to the study. Based on the GRACE risk score classification system, the patients were divided into low- (n=97, 39.6%), intermediate- (n=84, 34.3%), and high- (n=64, 26.1%) risk groups. All patients underwent coronary angiography within five days after admission. RESULTS The Gensini scores were 26±29 in the low-risk group, 29±19 in the intermediate-risk group, and 38±23 in the high-risk group (p=0.016). The low-risk group was significantly different from the high-risk group (p=0.013), and the difference from the intermediate-risk group almost reached significance. Normal, noncritical, one and two, or multivessel disease were identified in 15 (6.1%), 31 (12.7%), 75 (30.6%), and 124 (50.6%) patients, respectively. The prevalence of multivessel disease was 28% in the low-risk group, 30% in the intermediate-risk group, and 42% in the high-risk group. The high-risk group was significantly different from the low-risk group (p<0.01). CONCLUSION Our study demonstrates that the GRACE score has significant value for assessing the severity and extent of coronary artery stenosis in patients with non-ST-elevation acute coronary syndrome.

The relationship between epicardial fat tissue thickness and visceral adipose tissue in lean patients with polycystic ovary syndrome

BackgroundPolycystic ovary syndrome (PCOS) is related to metabolic syndrome, insulin resistance, and cardiovascular metabolic syndromes. This is particularly true for individuals with central and abdominal obesity because visceral abdominal adipose tissue (VAAT) and epicardial adipose tissue (EAT) produce a large number of proinflammatory and proatherogenic cytokines. The present study aimed to determine whether there are changes in VAAT and EAT levels which were considered as indirect predictors for subclinical atherosclerosis in lean patients with PCOS.MethodsThe clinical and demographic characteristics of 35 patients with PCOS and 38 healthy control subjects were recorded for the present study. Additionally, the serum levels of various biochemical parameters were measured and EAT levels were assessed using 2D-transthoracic echocardiography.ResultsThere were no significant differences in mean age (p = 0.056) or mean body mass index (BMI) (p = 0.446) between the patient and control groups. However, the body fat percentage, waist-to-hip ratio, amount of abdominal subcutaneous adipose tissue, and VAAT thickness were higher in the PCOS patient group than in the control group. The amounts of EAT in the patient and control groups were similar (p = 0.384). EAT was correlated with BMI, fat mass, waist circumference, and hip circumference but not with any biochemical metabolic parameters including the homeostasis model assessment of insulin resistance index or the levels of triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein (HDL) cholesterol. However, there was a small positive correlation between the amounts of VAAT and EAT. VAAT was directly correlated with body fat parameters such as BMI, fat mass, and abdominal subcutaneous adipose thickness and inversely correlated with the HDL cholesterol level.ConclusionsThe present study found that increased abdominal adipose tissue in patients with PCOS was associated with atherosclerosis. Additionally, EAT may aid in the determination of the risk of atherosclerosis in patients with PCOS because it is easily measured.

Incremental Value of Live/Real Time Three-Dimensional over Two-Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Pouch.

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left‐sided (LASP) or right‐sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three‐dimensional transesophageal echocardiography (3DTEE) and who had a two‐dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.

ECG Changes Due to Hypothermia Developed After Drowning: Case Report

SUMMARY Drowning is one of the fatal accidents frequently encountered during the summer and is the most common cause of accidental death in the world. Anoxia, hypothermia, and metabolic acidosis are mainly responsible for morbidty. Cardiovascular effects may occur secondary to hypoxia and hypothermia. Atrial fibrillation, sinus dysrhythmias (rarely requiring treatment), and, in serious cases, ventricular fibrillation or asystole may develop, showing as rhythm problems on electrocardiogram and Osborn wave can be seen, especially during hypothermia. A 16-year-old male patient who was admitted to our hospitals emergency service with drowning is presented in this article. In our case, ventricular fibrillation and giant J wave (Osborn wave) associated with hypothermia developed after drowning was seen. We present this case as a reminder of ECG changes due to hypothermia that develop after drowning. Response to cardiopulmonary resuscitation after drowning and hypothermia is not very good. Mortality is very high, so early resuscitation and aggressive treatment of cardiovascular and respiratory problems are important for life.

Assessment of resting electrocardiogram, P wave dispersion and duration in different genders applying for registration to the School of Physical Education and Sports – results of a single centre Turkish Trial with 2093 healthy subjects

BACKGROUND The 12-lead electrocardiogram shows a broad range of abnormal patterns in trained athletes. The primary end point of this study was to investigate P wave dispersion, and P wave durations and related factors in different genders applying for registration to the School of Physical Education and Sports. METHODS AND RESULTS From 2006 to 2009, a total of 2093 students - 1674 boys with a mean age of 19.8 plus or minus 1.9 years and 419 girls with a mean age of 19.1 plus or minus 1.8 years - were included in the study. All 12 leads of the resting electrocardiogram were evaluated for P wave dispersion and electrocardiogram abnormalities. Baseline parameters such as age, body weight, body height, and body mass index, as well as electrocardiogram findings such as P wave maximal duration and P wave dispersion, were significantly higher in boys than in girls. Of all the parameters tested with correlation analysis, only gender (p = 0.03) (r = 0.04), body weight (p < 0.001) (r = 0.07), body height (p = 0.004) (r = 0.06), and body mass index (p = 0.01) (p = 0.05) were correlated with P wave dispersion. CONCLUSION The frequencies of all electrocardiogram abnormalities, P wave dispersion, and P wave maximal duration were higher in boys as compared with girls in an unselected student population applying for registration to the School of Physical Education and Sports; in addition, P wave dispersion was correlated with gender, body weight, body height, and body mass index.

Epicardial Adipose Tissue Thickness in Patients With Subclinical Hypothyroidism and the Relationship Thereof With Visceral Adipose Tissue Thickness

Background Subclinical hypothyroidism (SH) is associated with cardiovascular metabolic syndromes, especially dislipidemia and abdominal obesity. Visceral abdominal adipose tissue (VAAT) and epicardial adipose tissue (EAT) have the same ontogenic origin and produce many proinflammatory and proatherogenic cytokines. We evaluated EAT and VAAT thickness in patients with SH. Methods Forty-one patients with SH and 35 controls were included in the study. Demographical and anthropometric features of both patients and controls were recorded. Thyroid and metabolic parameters were measured. EAT was measured using 2D-transthoracic echocardiography. Results The age and gender distributions were similar in the two groups (P = 0.998 and P = 0.121, respectively). Body mass index (BMI), fat mass, waist circumference (WC), hip circumference (HC), the WC/HC ratio, and the thicknesses of VAAT and abdominal subcutaneous adipose tissue were higher in the case group than the control group (all P values < 0.01). However, both groups had similar EAT thickness (P = 0.532), which was positively correlated with BMI, fat mass, WC, HC, VAAT thickness, abdominal subcutaneous adipose tissue thickness, and serum triglyceride (TG) level (all P values < 0.01). We found no correlation between EAT thickness and thyroid-stimulating hormone (TSH) level, free thyroxine (FT4) level, or low-density lipoprotein-cholesterol (LDL-C) level, and anti-TPO level (all P values > 0.05). We found no difference between the two groups in fasting plasma glucose (FPG) level (P = 0.780), but the levels of LDL-C and TG differed significantly (P = 0.002 and P = 0.026, respectively). The serum TSH level was higher and the FT4 level was lower in the case than the control group (both P values <0.01). Conclusion Increased abdominal adipose tissue thickness in patients with SH is associated with atherosclerosis. To detemine the risk of atherosclerosis in such patients, EAT measurements are valuable; such assessment is simple to perform.

Left ventricular twist was decreased in isolated left bundle branch block with preserved ejection fraction

Objective: Left ventricular (LV) rotation and twist play an important role in LV contraction and relaxation. Left bundle branch block (LBBB) deteriorates both diastolic and systolic functions. We evaluated the LV twist in patients with LBBB and preserved ejection fraction (EF) (>50%) to determine twist as a potential marker for subtle myocardial dysfunction. Methods: This observational cross-sectional study included 34 LBBB patients with preserved EF who were free from ischemic and valvular disease (Group 1) and 36 healthy controls (Group 2). All patients underwent 2-D Doppler and 2-D speckle tracking echocardiography. LV apical, basal rotation, and twist were evaluated in both groups and compared accordingly. In addition, subjects were dichotomized considering the median twist value of the study population. Binary logistic regression analysis was performed to determine the independent variables associated with inframedian twist. Results: Baseline clinical characteristics were similar in LBBB patients and controls. Mean apical rotation (2.5°±1.9° vs. 4.4°±2.9°; p=0.002), basal rotation (-2.9°±2.3° vs. -4.1°±2.7°; p=0.05), and twist (5.4°±3° vs. 8.6°±3.3°; p<0.001) were decreased in group 1. Parameters related to intra- and interventricular mechanical dyssynchrony, such as longitudinal left ventricular dyssynchrony index (LVdys) and preejection interval of LV, interventricular mechanical delay (IVMD), and left posterior wall contractions (SPMWD) were significantly higher in the LBBB group. The median twist value of the studied population was 6.65°. Binary logistic regression analysis showed that only presence of LBBB was independently associated with inframedian twist (OR=6.250; 95% CI: 2.215–17.632; p<0.001). Conclusion The LBBB might have induced the reduction of LV twist by diminishing the LV rotation before inducing a prominent effect on the left ventricular ejection fraction (LVEF). Therefore, twist may be considered as a marker for subtle LV dysfunction in LBBB with substantially normal EF.

Left ventricular torsion in patients with obstructive sleep apnoea before and after continuous positive airway pressure therapy: assessment by two-dimensional speckle tracking echocardiography

Abstract Background: The purpose of the present study was to evaluate how obstructive sleep apnoea (OSA) influences left ventricular (LV) torsion and whether nasal continuous positive airway pressure (CPAP) therapy has any impact on LV torsion in OSA patients with established cardiovascular risk factors. Methods: LV torsion was assessed by two-dimensional speckle tracking echocardiography (STE) in 162 participants without overt cardiovascular disease. The participants were categorized according to the apnoea–hypopnea index (AHI) as controls and mild, moderate and severe OSA patients. Forty-three patients with AHI greater than 30 were enrolled to receive CPAP therapy for 24 weeks. Twenty-eight patients received CPAP therapy effectively (compliance: 65%). After completion of CPAP therapy, STE was repeated to evaluate LV torsion. Results: LV torsion was decreased in the severe OSA group compared to mild and moderate OSA but was similar to controls as a result of predominant decrease in apical rotation. AHI had no correlation with LV torsion in moderate OSA but a significant and mild negative correlation with LV torsion in severe OSA. When adjusted for potential confounding variables such as left ventricular mass index, diastolic dysfunction and the presence of hypertension, AHI and E/E′ remained significant predictors of LV torsion in OSA patients. LV apical rotation tended to increase after effective CPAP therapy. On the other hand, LV basal rotation decreased significantly. Conclusions: LV torsion was altered in OSA patients with varying degrees according to the disease severity. Furthermore, there was no significant change of torsion after 24 weeks of CPAP therapy.