Okan Er

Association between gamma-glutamyltransferase and coronary artery calcification

BACKGROUND The exact mechanisms behind the association between atherosclerosis and gamma-glutamyltransferase (GGT) are unclear. Coronary artery calcification (CAC) detected by computerized tomography is an important marker of atherosclerosis and its severity correlates with coronary plaque burden. The aim of this study was to investigate if serum GGT levels are associated with CAC in patients without known coronary heart disease (CHD) who had low-intermediate risk for CHD. METHODS Two hundred and seventy two patients who had low-intermediate risk for coronary artery disease were included in the study. Serum GGT levels were measured spectrophotometrically. CACS (Agatston method) were performed using a 64-slice computerized tomography scanner. The patients were grouped according to their GGT values in four quartiles. RESULTS Patients in higher GGT quartiles had elevated CAC score (P<0.001). Patients in higher GGT quartiles were predominantly males (P<0.001) and were more likely to be smoking (P=0.004), and have elevated uric acid (P<0.001), fasting blood glucose (P<0.001), CRP levels (P=0.003) and 10-year total cardiovascular risk (P=0.007) and low HDL levels (P<0.001). Positive correlations were found between log GGT and CAC (r=0.233, P<0.001). In the multivariate analysis GGT, age, smoking and serum uric acid levels appeared as independent factors predictive of presence of CAC. CONCLUSIONS We demonstrated a significant correlation between serum GGT levels and CAC and CHD risk factors. Serum GGT level was an independent marker of CAC.

Serum uric acid level is an independent risk factor for presence of calcium in coronary arteries: an observational case-controlled study.

OBJECTIVE A link between uric acid levels and cardiovascular diseases has been previously reported. Coronary artery calcium score (CACS) is a marker of atherosclerotic disease and a predictor of cardiovascular events. We sought to determine if serum uric acid level is an independent risk factor for the presence of calcium in coronary arteries. METHODS Four hundred and forty-two patients who were evaluated in the cardiology outpatient clinic for suspected coronary heart disease with a low-moderate risk for coronary artery disease were included in this observational case-controlled study. Serum uric acid levels were measured with colorimetric methods. CACS were performed using a 64-slice CT scanner. Patients were divided to 3 groups according to their CACS value (Group 1: CACS=0, Group 2: CACS 1-100, Group 3: CACS>100). RESULTS The demographical characteristics and laboratory findings of 3 groups were similar, except age, fasting glucose levels and serum uric acid levels. Serum uric acid levels were found to increase significantly with increasing CACS (p=0.001). Patients were grouped according to presence CAC (CACS=0 and CACS≥1) and in the multiple regression analysis, age (OR, 1.11, 95% CI, 1.07-1.16), smoking (OR, 3.83, 95% CI, 2.06-7.09), serum uric acid levels (OR, 1.26, 95% CI, 1.04-1.54) and average 10-year total risk of Framingham risk score (OR, 1.13, 95% CI, 1.04-1.09) appeared as independent factors predictive of presence of CAC (p<0.05). CONCLUSION Serum uric acid level is an independent risk factor for presence of coronary calcium. Moreover, increasing levels of serum uric acid are associated with increasing CACS.

Double right coronary artery: a report of two cases

Coronary artery anomalies are usually incidentally diagnosed at the time of coronary angiography or autopsy. In a large series of 70,850 patients undergoing coronary angiography, the incidence of coronary anomalies was found to be 0.24–1.3%. The majority of these were reported to be anomalies of origin or distribution, with separate ostia of the left anterior descending artery and left circumflex artery being the most common.1 Although many of the primary congenital coronary anomalies are hemodynamically insignificant, it is important to know the anatomic variants in patients with coronary artery disease who are undergoing either surgical myocardial revascularization or coronary angioplasty.2 Double right coronary artery is a very rare coronary abnormality that is generally considered benign. In this report, we present two cases of double right coronary artery (RCA). Case Report 1 A 40-year-old woman was admitted to our center with dyspnea. She had been experiencing shortness of breath and dyspnea on exertion for two months. Her risk factors for coronary artery disease included a history of diabetes mellitus and a family history of premature atherosclerotic heart disease. Her physical examination was unremarkable; cardiac and lung auscultations were normal. Her blood pressure was 125/80 mmHg and pulse was 64 beats/min. The chest X-ray was normal. Routine blood and biochemical laboratory tests were nonspecific and nondiagnostic. The electrocardiogram showed a sinus rhythm with clearly negative T waves in D2–D3 and aVF. An exercise stress test showed ST-segment depression in the inferior leads at peak exercise, which was asymptomatic. The patient underwent selective left and right coronary artery angiography. The left coronary angiography revealed a normal origin and course of the left main artery (LM), the left circumflex artery (LCx) and the left anterior descending (LAD) arteries. The LCx and LAD arteries were normal. The right coronary angiography revealed two different right coronary arteries arising from a common ostium in the right coronary sinus. Both coursed along the atrioventricular groove and terminated via individual posterior descending arteries (PDA) (Figure 1). Both arteries were free of any angiographically identifiable atherosclerotic lesion. Figure 1 Left anterior oblique view showing a double right coronary artery. Case Report 2 A 66-year-old woman was admitted to our center with chest pain. She was complaining of angina and dyspnea on exertion lasting one week. Her risk factors for coronary artery disease included a history of diabetes mellitus and hypertension. The physical examination was completely normal. Cardiac enzymes and troponin–T were also found to be normal. The patient underwent selective left and right coronary artery angiography. The left coronary arteries were of normal origin and distribution. The right coronary angiography revealed two separate RCAs originating from a single ostium in the right sinus of Valsalva. Both RCAs gave off branches with typical courses and in parallel distribution (Figure 2). Both arteries were free of any angiographically identifiable atherosclerotic lesion. Figure 2 Selective right coronary angiography (left anterior oblique projection). DISCUSSION Coronary anomalies are incidentally detected during routine coronary angiography. Congenital coronary anomalies are seen in approximately 1% of adult patients.3 Double RCA is a very rare type of coronary abnormality. There was no mention of this anomaly in a series of 126,595 patients who underwent coronary angiography.3 The first report about double RCA anomaly in the literature was by Barthe et al.4 They observed double RCA originated from one ostium. The vessels were within the right atrioventricular groove. After the origin of a conus artery and a ventricular branch, the most anterior RCA descended toward the acute margin of the heart and terminated in a small posterior descending artery. The second RCA terminated in a small posterior descending and posterolateral branches. In our cases, both right coronary arteries were almost identical in size and both gave rise to a PDA. The correct diagnosis of double RCA is not easily made based on conventional coronary angiography because it is difficult to distinguish this variation from that of a high takeoff of a large right ventricular branch. This alternative diagnostic possibility creates uncertainty in making the correct diagnosis of double RCA.5 Though double RCA is a relatively rare entity, it is not necessarily benign, as it has been associated with atherosclerosis, life-threatening arrhythmia and myocardial infarction.6,7,8 However, our patients’ coronary arteries were free of atherosclerotic lesions. In the absence of atherosclerotic stenosis, ischemia can be a result of anatomical malformations, including an acute takeoff angle of the anomalous vessel, myocardial squeezing, vasospasm and a small artery.1 In these cases, double RCAs were identified as isolated coronary anomalies. Two previous studies have reported double RCA in combination with other anomalies.9,10 Double RCA has been reported 18 studies and in 20 cases.11 Interestingly, 12 of these cases were identified in the Turkish population. This suggests that certain coronary artery anomalies may be associated with a particular genetic background. The double RCA anomaly is seen mostly in males, as are other congenital coronary anomalies, though our patients were both female.12 In conclusion, although double right coronary artery is a rare anomaly, every operator should be familiar with it in order to perform an adequate examination.

Effect of herbal medicine use on medication adherence of cardiology patients

PURPOSE Herbal drug use for cardiovascular disease is frequent and growing rapidly. The aim of this study is to investigate the effect of herbal medicine use on medication adherence of cardiology patients. METHODS All patients admitted to the outpatient cardiology clinics, who had been prescribed at least one cardiovascular drug before, were asked to complete a questionnaire. Participants were asked if they have used any herbals during the past 12 months with an expectation of beneficial effect on health. Medication adherence was measured by using the Morisky Scale. High adherence was defined as a Morisky score <2 and a score ≥ 2 was accepted as low adherence in our study. RESULTS Totally 390 patients (54.9% male and 45.1% female patients, mean age 58.9) participated in our study. 29.7% of them had consumed herbals in the past 12 months. The median Morisky score was significantly higher in herbal users than nonusers (p<0.001). Rate of low adherence, according to the Morisky Scale, was also higher in herbal users (61.2% vs. 29.9%, p<0.001). Number of herbals used was moderately correlated with the Morisky score (ρ=0.313, p<0.001). In stepwise, multivariate logistic regression analysis, herbal use was significantly associated with low medication adherence (OR: 3.76, 95% CI 2.36-6.09, p<0.001). CONCLUSION Herbal use was found to be independently associated with low medication adherence in our study population. Further studies are needed to elucidate the effect of herbal medicine use on medication adherence of cardiology patients.

Coexistence of Myocardial Infarction with Normal Coronary Arteries and a Left Circumflex Artery Anomaly Originating from the Right Coronary Artery with a Bridge in the Left Anterior Descending Artery

Congenital anomalies in the origin, course or distribution of the epicardial coronary arteries are found in 1 to 2 percent of the population. Asymptomatic coronary artery anomalies are generally diagnosed incidentally by routine coronary angiography or during autopsy.1 Approximately 80% of congenital anomalies of the coronary arteries are benign, while 20% of coronary artery anomalies produce life threatening symptoms, including arrhythmias, syncope, myocardial infarction or sudden death. These anomalies are especially dangerous when they courses between the aorta and the main pulmonary artery. It is not yet possible to determine the causes of a particular patient’s infarction. The valvular mechanism has been suggested to result from angulations at the arterial origin or from the compression of the artery between the aorta and the pulmonary artery during exercise.2 In some cases, spasms of the abnormal coronary artery (possibly due to endothelial damage) or arteriosclerosis have been considered to be the reasons for coronary arterial occlusion.3–4 We report a patient with two coronary anomalies, a left circumflex coronary artery (LCX) originating from the proximal right coronary artery (RCA) and a muscular bridge in the left anterior descending (LAD) midportion, who underwent successful fibrinolytic therapy for an inferolateral myocardial infarction.

A coronary proatherosclerotic marker: Pregnancy-associated plasma protein A and its association with coronary calcium score and carotid intima-media thickness

BACKGROUND Atherosclerosis, a chronic inflammatory disorder of the arteries, is responsible for the greatest number of deaths in westernized societies, with numbers increasing at a marked rate in developing countries. Coronary calcium score (CCS), carotid intima-media thickness (CIMT) and pregnancy-associated plasma protein A (PAPP-A) are predictors for the development of atherosclerosis. OBJECTIVES This study was aimed to investigate the relationship between CCS, CIMT and PAPP-A for earlier diagnosis of atherosclerosis. MATERIAL AND METHODS A total of 99 patients were included in the study. Coronary computerized tomography (CT) angiography was performed on all patients. The calcium scoring technique was performed using a sequential scanning mode. CIMT measurement was done through the area 1 cm distal of the bulbus arteriosus with carotid Doppler ultrasound. PAPP-A values were analyzed by double immunoenzymatic technique. RESULTS Out of 99 patients, 63 were found with coronary atherosclerosis using multislice computed tomography (MSCT) coronary angiography. When the cut-off point for CCS was taken to be 0.40, the sensitivity of this parameter was 97% and its specificity was 68.3%. When the cut-off point for CIMT was taken to be 0.60, the sensitivity and the specificity of these parameters were 75.0% and 87.3%, respectively, for the right measurements and 75.0% and 79.4%, respectively, for the left measurements. CONCLUSIONS This data support the conclusion that PAPP-A, like CCS and CIMT, is a parameter that can be used to detect subclinical atherosclerosis.

The Impact of Peripheral Arterial Disease on Outcome After Percutaneous Transluminal Angioplasty for Arteriovenous Fistula: A 1-Year Retrospective Analysis

PP-370 A significant proportion of end stage renal disease patients undergoing percutaneous transluminal angioplasty (PTA) for arteriovenous fistula (AVF) have concomitant peripheral arterial disease (PAD), which plays a crucial role in the selection process of determining an optimal vascular

Serum Sclerostin Levels are Associated with Aortic Valve Calcification in Maintenance Hemodialysis Patients

Aim: Data about cardiac response to recurrent electroconvulsive therapy (ECT) in healthy heart are lacking. We investigated the effects of recurrent (seven times) ECT on cardiac function to reveal the presence or absence of adaptive changes in patients free of cardiovascular disease. Method: We enrolled twenty-three patients who underwent to ECT with different psychiatric disorders. Echocardiographic examination including diastolic mitral inflow and tissue Doppler features was recorded before and after total seven times ECT in all patient. Result: Male/Female ratio was 11/12. Mean age was 37 (19-71). There was not a significant difference in mitral E wave velocities and tissue Doppler E’ velocities after the first ECT compared to baseline values. (p1⁄40.161, p1⁄40.083). The results were similar after the latest ECT session. (p1⁄40.463, p1⁄40.310). However there was a significant increase in transmitral A wave velocity after the first and the seventh ECT session compared to baseline values (p1⁄40.008, p1⁄40.017). Conclusion: Our study revealed that mitral diastolic inflow A wave velocity was increased 20 minutes after the ECT and this increase persisted after recurrent ECT sessions in apparently healthy hearts. This finding is considered possibly as the indicator of acutely increased sympathetic tone.

Response letter to 'Uric acid: A crucial marker of coronary artery calcium score?'

The letter by Yildiz [1] addresses an important issue regarding the relation between serum uric acid levels and coronary artery calcification (CAC). We are grateful for the enlightening and inspiring comments on our manuscript [2]. In our study [2] we showed that, GGT, age, smoking and serum uric acid levels appeared as independent factors predictive of the presence of coronary artery calcium score (CACS) in patients without known coronary heart disease (CHD) who had low-intermediate risk for CHD. The relation between CHD and uric acid is well known and recently a meta-analysis showed that hyperuricemia may increase the risk of CHD events, independently of traditional CHD risk factors [3] as pointed by Yildiz et al. [1]. There are contradicting data about the relation between CACS and serum uric acid levels. Previously some studies demonstrated a relation between CACS and serum uric acid levels [4–6] but one large scale study did not support these findings [7] as pointed by Yildiz et al. [1]. In another study, we demonstrated that serum uric acid level, age, smoking and Framingham risk score are independent risk factors for the presence of CAC in patients with a low-intermediate risk for coronary artery disease (unpublished data). We found a linear relationship between serum uric acid levels and CACS. The mechanisms behind the association between uric acid and CAC are still not fully explained. However, we think that, uric acid should be considered as an additional risk factor beyond traditional risk factors for coronary artery disease.

Two cases of acute coronary syndrome after intake of Clavis PANAX, coincidence or consequence?

Atherosclerotic cardiovascular disease is an epidemic in todays world. It is one of the most common causes of hospitalization and death. Therefore, remedies to control or heal the disease are continuously sought. In addition to scientifically researched therapies, patients frequently utilize alternative medicine. However, effective and toxic doses, metabolisms, and drug interactions of the herbs and herbal nutrition supplements are largely unknown. Herein, we present two cases with acute coronary syndrome. The first case was admitted with a diagnosis of acute inferior myocardial infaction (MI) and a stent was implanted to the occluded right coronary artery (RCA). There was a 50% stenosis in his left anterior descending artery (LAD). He was admitted with a diagnosis of non-ST elevation MI (NSTEMI) 6 months later. In the coronary angiogram, there was stent restenosis in RCA, the lesion in LAD had become thrombotic and progressed to a stenosis of 90%. He was referred to surgical revascularization. The second case was admitted for acute inferior MI and a stent was implanted to the occluded circumflex artery. Two months later, he was hospitalized for NSTEMI. Progression of coronary plaques to stenosis and stent restenosis was detected and he was referred to surgical revascularization. Both patients used the product sold as Clavis Panax, which contains panax ginseng, tribulus terrestris, and oat, after their first coronary intervention. Intake of a mixture of plant extracts may have serious consequences in humans as drug interactions and side effects are unknown.