Olcay Ozveren

Predictive value of noninvasively determined endothelial dysfunction for long-term cardiovascular events and restenosis in patients undergoing coronary stent implantation: a prospective study.

BackgroundEndothelial dysfunction plays a key role in atherosclerosis and predicts future cardiovascular events in individuals with or without coronary artery disease and improves with risk reduction therapy. We sought to determine the predictive value of endothelial dysfunction for long-term cardiovascular events and in-stent restenosis in patients undergoing percutaneous coronary intervention (PCI). MethodsUsing high-resolution ultrasound, we assessed endothelial function by using the brachial artery flow-mediated dilation (FMD) method in 135 patients with coronary artery disease before elective coronary stenting. Patients were prospectively followed up for an average of 12 months after PCI. ResultsThirty patients had an event during follow-up including cardiac death (four patients), myocardial infarction (nine patients), unstable angina/non-ST elevation myocardial infarction (15 patients), and stroke (two patients) and in-stent restenosis was determined in 16 of these patients. Endothelium-dependent FMD was significantly lower in patients who had an event compared with those without an event (4.7±1.9 vs. 6.0±2.0%, P=0.007), whereas endothelium-independent vasodilation to nitroglycerin was similar in both groups. FMD was the only predictor of cardiovascular events (P=0.03). Impaired endothelial function was associated with a significantly higher incidence of cardiovascular events and in-stent restenosis by Kaplan–Meier analysis. When a cutoff point of 7.5% was used, flow-mediated dilation had a sensitivity of 93%, specificity of 37%, and negative predictive value of 95% for cardiovascular events. ConclusionImpaired brachial artery FMD is associated with long-term cardiovascular events and in-stent restenosis in patients undergoing PCI. Noninvasive assessment of endothelial function may serve as a surrogate marker for the estimation of future cardiovascular event risk and long-term follow-up in these patients.

Takotsubo syndrome: an underdiagnosed complication of 5-fluorouracil mimicking acute myocardial infarction.

Takotsubo syndrome (TTS)/cardiomyopathy is a syndrome that mimics acute myocardial infarction in the absence of coronary artery disease and is characterized by acute onset of chest pain, electrocardiographic abnormalities, and reversible left ventricular dysfunction. It is usually induced by emotional and physical stress. Fluorouracil is one of the most frequently used chemotherapy agents and a relatively common adverse reaction of fluorouracil is cardiotoxicity. Herein we describe a patient without a history of cardiovascular disorder who developed severe heart failure during infusion of fluorouracil for metastatic gastric cancer. Remarkably, the patient did not develop TTS during prior chemotherapy regimen, which also included fluorouracil. The patients findings were consistent with the proposed TTS diagnostic criteria and coronary angiography was normal, without obstructive coronary artery disease. With supportive care, the patients cardiac functions returned to normal. TTS is not a well known syndrome to clinicians and this condition appears to occur more frequently than previously thought. In addition to the presented case, a review of the clinical features and outcome of 10 reported cases of fluorouracil-induced TTS is presented.

The risk of false results in the assessment of platelet function in the absence of antiplatelet medication: Comparision of the PFA-100, multiplate electrical impedance aggregometry and verify now assays

OBJECTIVES Evaluation of aspirin (ASA) responsiveness with platelet function tests varies by the choice of blood mixture and functional test and cut off values for defining the the treatment used. Addition to that we also aimed to determine agreement between three tests and to research whether there is any necessity to measure baseline platelet activity. METHODS The study group comprised of 52 patients with multiple risk factors receiving primary prophylaxis of ASA (100 mg/day). For each patient inhibition of platelet aggregation with aspirin was determined using three different whole blood tests: Multiplate electrical impedance aggregometry, Verify Now Aspirin, and collagen-epinephrine closure time PFA-100. Platelet aggregation was assessed with multiplate electrical impedance aggregometry,and was defined as the area under curve (AUC,AUxmin). Maximal 6,4 microM collagen-induced AUC were used to quantify platelet aggregation due to ASA. The ASA response was defined as >30 % reduction in basal platelet aggregation with multiplate electrical impedance aggregometry. Collagen induced platelet aggregation at the Verify Now Aspirin assay quantitated the ASA-induced platelet inhibition as aspirin reaction units (ARU). According to manufacturer insert ARU>550 indicates aspirin resistance. ASA platelet function studies were assessed twice at baseline (pre-aspirin), and after 7 day(post-aspirin) were performed. RESULTS After ASA intake none of the patients was found aspirin resistant with PFA-100. (CEPI-CT (129+/-36 vs 289+/-18 ). None of the patients was found aspirin resistant with PFA-100. As>30 % reduction in basal platelet aggregation with multiplate electrical impedance aggregometry is selected all of the patients have been stratified as responders.(COL TEST 688+/-230 vs 169+/-131 AU) None of the patients with Verify Now Aspirin found resistance to ASA(594+/-62 vs 446+/-43).Prior to ASA intake 15 of all patients with VN(501+/-16) and 2 of all patients with multiplate electrical impedance aggregometry (223+/-40 AUC )aggregation levels below the cut off label before ingestion of ASA.None of the patients was above the cut off label with PFA -100 (129+/-36). CONCLUSIONS Verify Now ASA assay, multiplate electrical impedance aggregometry and PFA-100 seem to be reliable tests in reflecting ASA effect on platelets. Cut off labels for the defining the responsiveness given by manufacturer may show significant interindividual variability with Verify Now ASA assay and multiplate electrical impedance aggregometry, and these test may show platelet inhibition despite the absence of ASA intake. Consideration of the pretreatment values may eliminate the risk of overestimation in the assessment of platelet inhibition by ASA.

Epicardial fat thickness is associated with non-dipper blood pressure pattern in patients with essential hypertension.

Objective. Epicardial fat tissue reflects visceral adiposity and is a suggested cardiometabolic risk factor. Patients with abdominal obesity have an increased prevalence of the non-dipper blood pressure (BP) pattern, but it is unclear whether the same is true of patients with increased epicardial fat thickness (EFT). The association between EFT and circadian BP changes in patients with recently diagnosed essential hypertension was examined. Methods. Sixty hypertensive patients underwent echocardiography, treadmill stress testing, and 24 hours of ambulatory BP monitoring. Epicardial fat thickness and left ventricular mass (LVM) index were measured by using transthoracic echocardiography. The patients were categorized into two groups according to their BP pattern (group 1, non-dippers; group 2, dippers). Results. The mean EFT and LVM of patients in group 1 (n = 24) (EFT, 7.6 ± 2.1 mm; LVM, 130 ± 31.2 g/m2) were significantly greater than those of group 2 (n = 36) (EFT, 5.5 ± 1.2 mm, P = .0001; LVM, 107 ± 23.7 g/m2, P = .002). The average systolic BP over 24 hours (BPs 24) and average diastolic BP over 24 hours (BPd 24) of group 1 (BPs 24, 151.1 ± 17.6 mm Hg; BPd 24, 94.1 ± 16.5 mm Hg) were significantly higher than those of group 2 (BPs 24, 136.7 ± 11.9 mm Hg, P = .0001; BPd 24, 84.6 ± 10.6 mm Hg; P = .008). Multivariate backward logistic regression analysis demonstrated that the non-dipper BP pattern was associated with EFT (standardized β coefficient = 0.87, P = .005) and LVM (standardized β coefficient = 0.43, P = .016). An EFT ≥ 7 mm was associated with the non-dipper BP pattern with 44% sensitivity and 94% specificity (receiver operating characteristic area under curve of 0.72, 95% CI [0.59–0.83], P = .0007). Conclusions. Epicardial fat thickness was above average in newly diagnosed, untreated hypertensive patients with non-dipper BP pattern. The echocardiographic measurement of EFT may be used to indicate increased risk of hypertension-related adverse cardiovascular events.

Acute alcohol consumption is associated with increased interatrial electromechanical delay in healthy men

BACKGROUND Acute alcohol consumption can cause atrial fibrillation in patients with, and without, heart disease. Increased atrial electromechanical delay (EMD) has been associated with atrial fibrillation. We evaluated the atrial conduction properties by tissue Doppler imaging (TDI) echocardiography in healthy men following acute alcohol intake. METHODS Thirty healthy male volunteers were included in this study. Baseline ECG, heart rate, blood pressure, and TDI echocardiographic findings were compared to readings taken one hour after drinking six 12-oz cans of beer (76.8 g of ethanol). RESULTS Although the blood pressure and heart rate remained similar before and one hour after alcohol intake, Pmax and Pd values were significantly prolonged (114.2 ± 10.4 vs 100.8 ± 10.6, p = 0.002; 50.6 ± 9.6 vs 34.5 ± 8.8, p < 0.0001). Interatrial EMD was significantly increased after drinking alcohol compared to the baseline (19.8 ± 9.2 vs 14.0 ± 5.5 ms, p < 0.0002). CONCLUSIONS Acute moderate alcohol intake was associated with an increased interatrial EMD obtained by TDI echocardiography. This finding may help explain how these patients express increased susceptibility to atrial fibrillation.

Epicardial adipose tissue: a review of physiology, pathophysiology, and clinical applications.

Visceral fat tissue is an important predictor of cardio-metabolic diseases, carrying more risk than general fat accumulation. Epicardial fat, a particular form of visceral fat deposited around the heart, is considered an important cardiovascular risk predictor, in view of producing and releasing several adipo-cytokines. There is growing evidence about the physiological and metabolic importance of epicardial fat. Epicardial fat thickness and volume have both strong correlation between obesity, impaired fasting glucose, insulin resistance, metabolic syndrome, hypertension, diabetes mellitus, and atherosclerosis. Epicardial fat can be assessed by transthoracic echocardiography, cardiac magnetic resonance imaging, and computed tomography. In this article, we reviewed the anatomy, physiology, function, and the methods of assessment of epicardial fat tissue. We also have tried to discuss its relationship to metabolic syndrome and coronary atherosclerosis in the lights of recent findings.

Relation of the severity of contrast induced nephropathy to SYNTAX score and long term prognosis in patients treated with primary percutaneous coronary intervention

BACKGROUND SYNTAX score (SXscore) has been developed to assess the severity and complexity of coronary artery disease. The aim of this study was to evaluate whether baseline SXscore was associated with contrast induced nephropathy (CIN) after primary percutaneous coronary intervention (p-PCI) in patients with ST-elevation myocardial infarction (STEMI). Secondarily we aimed to investigate the relation of the severity of CIN to long term prognosis. METHODS We retrospectively enrolled 1893 patients with STEMI treated by p-PCI. We prospectively followed up the patients for a mean duration of 45 months. The patients were grouped according to the development of no nephropathy (grade 0, n: 1634), mild nephropathy (grade 1, n: 153) or severe nephropathy (grade 2, n: 106). RESULTS SXscore was significantly higher (19.4±5.9 vs 15.6±4.8, p<0.001) in patients with CIN (grades 1 and 2) compared to those without CIN. SXscore was higher in patients with grade 2 CIN compared to those with grade 1 CIN (18.5±5.7 vs 20.7±5.9, p<0.001). In the multivariate analysis, SXscore was identified as an independent predictor of CIN (for one unit increment, OR: 1.06, 95% CI: 1.01-1.14, p=0.006). At long-term follow-up, death (p<0.001), stroke (p=0.006), reinfarction (p=0.024) and permanent HD requirement (p<0.001) were most frequent in grade 2 nephropathy group. HD was associated with very high in-hospital (60%) and long-term (83.3%) mortality rates. CONCLUSIONS SXscore is an independent predictor of development and severity of CIN after p-PCI. CIN is associated with poor prognosis during both early and late postinfarction period.

The role of tissue Doppler study in the assessment of left ventricular dysfunction in obesity.

Purpose — The purpose of this study was to investigate the potential utility of tissue Doppler echocardiography in the assessment of left ventricular systolic and diastolic function in the obese population. Method — 96 obese (48 male, 48 female) patients and 50 normoweight (25 male, 25 female) control subjects were enrolled. Obese patients were subgrouped into mild (25-29.9 kg/m2), moderate (30-34.9 kg/m2) and significant (≥ 35 kg/m2) according to their body mass index (BMI). Left ventricular systolic and diastolic functions were evaluated by tissue Doppler imaging with conventional transthoracic echocardiography. Peak systolic velocity (Sm) of the lateral mitral annulus, the duration from electrocardiographic Q wave to Sm and early and late diastolic velocities (Em, Am) were recorded with tissue Doppler imaging. Results — The ejection fraction and fractional shortening values were found to be increased in the mildly and moderately obese subjects. Left ventricular diameters were increased in all of the patients in the obesity group; however, relative wall thicknesses were similar to control subjects. The peak systolic velocities of the mitral lateral annular area (Sm) were lower in moderately and significantly obese subjects compared to the control subjects. None of the study patients had systolic dysfunction by conventional echocardiographic assessment while prevalence of diastolic dysfunction was significantly higher in the obese group of which the prevalence proportionally increased with BMI. Diastolic dysfunction was also more prevalent in the subjects with abdominal obesity which was determined by waist circumference (WC). Conclusion — The ejection phase indices were increased in mildly and moderately obese subjects. However, in significantly obese subjects they were similar to control subjects by conventional echocardiographic methods. Sm values of the moderately and significantly obese patients were significantly lower when measured by tissue Doppler imaging. Diastolic function was also shown to be impaired in the moderately and significantly obese subjects when measured by tissue Doppler imaging.

A Single-Centre Study of Acute Cardiorenal Syndrome: Incidence, Risk Factors and Consequences

Objective: Cardiac and kidney diseases are common, and the impact of acute kidney injury (AKI) on patient outcome is well known. We aimed to investigate the incidence of acute cardiorenal syndrome (CRS) and the risk factors and outcomes associated with the disease. Methods: We conducted a retrospective cohort study comprising 289 patients with acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF), examining the incidence of AKI defined according to the Acute Kidney Injury Network (AKIN) classification, the factors contributing to AKI, and the impact of AKI on in-hospital mortality and hospital re-admission. Results: Of 71 patients with AKI, 36 (50.7%) had ACS and 35 (49%) had ADHF. Overall in-hospital mortality was 5.5% (n = 16). Multivariate logistic regression identified the following independent predictors of AKI in male patients with ACS: previous myocardial infarction at age >65 years (OR 5.967, 95% CI 1.16–30.47, p = 0.03), chronic kidney disease (OR 3.72, 95% CI 1.31–16.61, p = 0.01), and decreased hemoglobin levels (OR 0.684, 95% CI 0.53–0.88, p = 0.03). No variable was identified as an independent risk factor in ADHF patients. Kaplan-Meier survival curves indicated that patients with ACS plus AKI had significantly higher in-hospital mortality (log rank = 0.007). Conclusion: Acute CRS (type 1 CRS) is more frequent in patients with ADHF and can be considered multifactorial. Although CRS is less frequent in ACS patients, it is associated with longer hospital stay and with higher in-hospital mortality. The heart-kidney interaction should be managed collaboratively between cardiologists and nephrologists to increase our knowledge and enhance clinical approaches.

Kounis syndrome presenting with cardiogenic shock

Kounis syndrome has been found to be associated with coronary artery spasm and acute coronary syndrome developing due to mast cell degranulation. It is relatively newly described and is being reported more and more frequently. The drugs, endovascular devices, environmental agents and several allergic diseases likely to cause Kounis syndrome have been described. All patients presented with acute coronary syndrome and anaphylactic shock in the absence of hemodynamic failure. No patient was reported with cardiogenic shock.