Ozan Kinay

Plasma interleukin-6 levels are increased in coronary artery ectasia

Objective — Recent studies have suggested a cytokine-induced tissue inflammation in the pathogenesis of abdominal aortic aneurysms and it has been documented that circulating interleukin-6 (IL-6) levels in these patients are increased.The aim of this study was to investigate whether a similar association also exists for patients with coronary ectasia, which may also be regarded as an abnormal dilatation of the arterial system. Methods and results — The study group was composed of 43 patients with coronary ectasia and 48 patients with normal coronary arteries constituted the control group. Coronary diameters were measured by quantitative angiography. A coronary diameter index was defined for each segment as the coronary diameter divided by the body surface area (BSA). A coronary segment with a diameter index of more than 1.5 fold of the control group was defined as ectatic. Baseline characteristics of the two groups were similar. Serum IL-6 levels were significantly higher in patients with coronary ectasia (5.18 ± 2.04 pg/ml vs. 4.13 ± 0.5 pg/ml, p = 0.002). There was no significant correlation with the maximal diameter of the most dilated coronary segment and IL-6 levels in patients with coronary ectasia (r = 0.10, p = 0.50). Conclusions — Results of this study have demonstrated increased levels of circulating IL-6 in patients with coronary ectasia which might indicate a possible role of inflammatory processes. Absence of a significant correlation between the dimensions of the ectatic segments and IL-6 levels might be due to the narrower range of the diameters of the coronary arteries compared with the abdominal aorta.

Factors influencing emergency department arrival time and in-hospital management of patients with acute myocardial infarction.

Reperfusion of the infarct-related artery in the very first hour (“golden hour”) of acute myocardial infarction (AMI) significantly reduces mortality rates. Several factors may delay the initiation of reperfusion therapy (ie, thrombolytic therapy or primary percutaneous transluminal coronary angioplasty [PCTA]), most of which are related to patients. A total of 520 patients with suspected AMI were evaluated in the emergency department of Dokuz Eylül University Hospital between March 1996 and October 1999. After inclusion criteria were applied, the study consisted of 178 patients with a history of AMI. Analyzed data that affected patients’ arrival to the hospital were obtained from responses to a questionnaire. The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, Ill), version 11.0, was used for all statistical analyses. The mean “symptom onset-hospital arrival time” was 188±325 min for the entire study group. The median delay was 110 min (∼2 h). Only 39 (22%) patients arrived to the hospital within the first hour. The mean time needed for late responders (n=109, 74%) (hospital arrival later than 1 h after symptom onset) to arrive was 245±363 min. According to the results of this study, many patients with AMI who may be eligible for reperfusion therapy miss the “golden hour” because of late hospital arrival. Some groups of patients (ie, elderly, women, those with diabetes) were especially late in arriving. To reduce such delays, training programs may be advised to focus on these groups of patients. Arrival times to the hospital during AMI can be greatly improved by efficient public education programs targeted to these groups.

Efficacy of propafenone for maintaining sinus rhythm in patients with recent onset or persistent atrial fibrillation after conversion: a randomized, placebo-controlled study.

Objective — The aim of this study was to investigate the efficacy and safety of propafenone in the prevention of atrial fibrillation (AF) relapse after restoration of sinus rhythm. Methods — This study consisted of 110 consecutive patients with recent onset and persistent AF. After restoration of sinus rhythm, patients were randomized to propafenone (n: 58, age: 60 ± 12 years) or placebo (n: 52, age: 62 ± 10 years).There were 11 withdrawals (7 in the propafenone and 4 in the placebo group) during follow-up. Follow-up evalutations were conducted at the first, 3rd and then at an interval of three months during 15 months. The clinical characteristics in both groups were comparable.The AF relapse was analysed by the Kaplan-Meier method. Results — At 15-month follow-up, AF relapsed in 20 (39%) and 31 (65%) patients in the propafenone and placebo groups, respectively (p = 0.015). In subgroup analysis, AF recurrence was significantly lower in the propafenone group than in the placebo group only in the recent onset AF patients with spontaneous conversion (21% vs. 61%, p = 0.01). However, the AF relapse rates were similar in patients with persistent AF and with recent AF who converted to sinus rhythm pharmacologically or electrically in the propafenone and placebo groups. Four patients on propafenone and one on placebo had adverse effects necessitating discontinuation of the drug (p = 0.36). Conclusion — At 15 months, propafenone seems to be superior to placebo for maintaining sinus rhythm in patients with recent onset or peristent AF. This superiority originates mainly from patients with recent onset AF in whom sinus rhythm occurred spontaneously. Its adverse effects are similar to placebo. (Acta Cardiol 2004; 59(3): 255-261)

Chylous ascites due to constrictive pericarditis.

Chylous ascites due to constrictive pericarditis is an extremely rare clinical entity, possibly caused by the augmented lymph production and high impedance to lymph drainage due to central venous hypertension. The authors describe a patient with chylous ascites caused by constrictive pericarditis in the absence of lymphatic obstruction. Cardiac catheterization is essential for the confirmation of accurate diagnosis of constrictive pericarditis. Magnetic resonance imaging of the heart is also very helpful in the diagnosis. The patient was symptom free and his ascites and edema completely resolved after pericardiectomy.

Use of tissue Doppler echocardiography in early detection of left ventricular systolic dysfunction in patients with mitral regurgitation

Objective: Left ventricular ejection fraction (EF) and left ventricular (LV) end-systolic diameter measurements are the most widely accepted and utilized methods to demonstrate LV dysfunction in patients with mitral regurgitation (MR). However, these parameters still have many drawbacks in predicting early LV dysfunction. This study investigates the clinical usefulness of tissue Doppler echocardiography technique in detecting early disturbance of myocardial contractility in asymptomatic patients with chronic, severe MR and normal LV ejection fraction values. Methods and Results: Regional systolic peak velocities of mitral annular motion during the ejection phase of systole (SW2) were obtained at the mitral annuli of the ventricular septal, lateral, anteroseptal, posterior, anterior and inferior wall sites in the long axis in 31 asymptomatic patients with severe MR (with a regurgitant volume of more than 50 ml) and with EFs more than 60%. The patients were grouped according to their dP/dt values (more or less than 1300 mm Hg/s) estimated non-invasively by using continuous Doppler wave of MR SW2 measurements of Group I were higher than Group II in all of the analyzed segments. The difference was statistically significant for all of the segments. SW2 values of the whole study group was moderately correlated with dP/dt measurements in all of the analyzed segments other than the interventricular septum. Conclusion: SW2 measurements in the long axis, which are considered to be relatively independent from afterload conditions may be helpful in early detection (while EF is still in normal range) of LV systolic dysfunction during the follow-up of patients with chronic MR.

Infection with Chlamydia pneumoniae but not Helicobacter pylori is related to elevated apolipoprotein B levels.

Objective — Results of many studies show that apolipoprotein B (apo B) is a better marker of risk of vascular disease than other lipid markers including LDL and HDL-cholesterol and triglycerides. We investigated the association between two infectious agents: C. pneumoniae and H. pylori, known to have an atherogenic effect, and apo B, to evaluate the effects of chronic infections on apo B levels. Methods and results — The study group consisted of 257 patients in whom diagnostic coronary angiography was performed. C. pneumoniae IgG and IgM and H. pylori IgG and IgA antibodies were measured by enzyme-linked immunosorbent assay and apo B levels were measured by the nephelometry method. Established risk factors of atherosclerosis were recorded.Of 257 patients recruited, 104 had normal vessels, 88 had 3 or more vessels obstructed and 65 had ectatic vessels without atherosclerosis. Mean apo B concentration was significantly higher in C. pneumoniae IgG and IgM positive healthy subjects compared with C. pneumoniae negatives (0.954 vs. 0.722 and 0.973 vs. 0.851, p < 0.001 and p = 0.007, respectively). Apo B levels were significantly higher in severe atherosclerotic patients (0.985 ± 0.234 g/l) compared with control subjects (0.892 ± 0.244 g/l) (p = 0.008), but the difference was not significant in ectatic subjects (0.946 ± 0.272 g/l) when compared with controls (p = 0.18). Apo B levels were higher but not statistically significant in H. pylori antibody positive cases when compared with negatives. Conclusions — Apo B levels increased with C. pneumoniae infection. This finding supports the hypothesis that lipid profiles change to atherogenic lipid profile in chronic infections.

Predictors of exercise induced myocardial ischemia in patients with isolated coronary artery ectasia.

The aim of this study was to investigate the angiographic predictors of exercise induced ischemia in patients with isolated coronary ectasia. We have prospectively analysed coronary angiograms of 1521 consecutive patients undergoing cardiac catheterisation. The overall incidence of coronary ectasia was 6.7% (102 patients). Forty-six patients (3%) with non-obstructive, diffuse or segmental coronary ectasia (i.e. isolated coronary ectasia) constituted the main study group. Coronary angiograms were reviewed for stigmata of an impaired coronary blood flow such as ‘slow flow’, ‘segmental backflow phenomenon’ and stasis. ‘Slow flow’ was quantified with frame counting. An ectasia-jeopardy score was also described in order to assess the effect of the extent of coronary ectasia on exercise induced ischemia. Exercise induced ischemia was observed in 24 patients (52%). Exercise test was abnormal in 70% of the patients with diffuse ectasia and 26% of patients with segmental ectasia (p = 0.003). The frame count of the arteries of the study group was higher than the control group but the correlation between the frame count of the ectatic vessels and exercise induced ischemia was not significant. Stasis of the dye also did not correlate with ischemia. There was a significant correlation between exercise induced ischemia and backflow phenomenon in left anterior descending artery (LAD) (r = 0.56, p = 0.0001). Exercise induced ischemia was best correlated with the ectasia-jeopardy score (r = 0.77, p = 0.0001) and a score of ≥4 identified the patients at risk with 90% sensitivity and 80% specificity. In conclusion, the extent of the ectasia within the coronary tree, diffuse ectasia and backflow-phenomenon in LAD were identified as the most important predictors of exercise induced ischemia.

Gastroduodenal Helicobacter pylori infection diagnosed by Helicobacter pylori stool antigen is related to atherosclerosis.

Objective — The causative relation between Helicobacter pylori(H. pylori) and atherosclerosis has been determined as seropositivity or determination of H. pylori from atherome plaques by molecular methods.The site of entrance and the reservoir of the bacteria in the body is still a subject of discussion. In this study Helicobacter pylori stool antigen (HpSA) which shows gastrointestinal system colonization and infection with high specificity and sensitivity was determined in atherosclerotic, ectatic and angiographically normal groups. Methods and results — A total of 62 patients was categorized according to diagnostic coronary angiography as 12 had normal coronary arteries, eight had one, 18 had two, and 12 had three atherosclerotic coronary arteries. Twelve patients had ectatic vessels. There were 27 (44%) HpSA positive and 35 (56%) HpSA negative patients.There was a statistically significant relation between HpSA positivity and the degree of vessel involvement in coronary artery disease (CAD) patients, essentially between the group with three vessels (83%) obstructed and the normal group (25%). Ectatic vessel group had a higher incidence (50%) of HpSA positivity compared to the control group but not enough for statistical significance. Conclusions — The results indicate that gastrointestinal system H. pylori colonization increases the risk of atherosclerosis.We may speculate that the reservoir and spread of H. pylori is via gastrointestinal tract. Studies may be performed to detect whether gastrointestinal tract H. pylori infection treatment will decrease the risk of coronary artery damage caused by H. pylori.

Use of Intraventricular Dispersion of the Peak Diastolic Flow Velocity as a Marker of Left Ventricular Diastolic Dysfunction in Patients with Atrial Fibrillation

The aim of this study was to evaluate the use of intraventricular dispersion of the peak diastolic flow velocity as a marker of left ventricular diastolic dysfunction in patients with atrial fibrillation. Regional diastolic flow velocity patterns at 1, 2, and 3 cm away from the mitral tip toward the apex were simultaneously recorded with the mitral flow velocity pattern by using pulsed Doppler echocardiography in 24 patients with atrial fibrillation before electrical or medical cardioversion. Echocardiographic examination was repeated after 10 to 30 days (ie, at the time of recovery of left atrial mechanical functions) after cardioversion of atrial fibrillation in all patients. Thirteen patients were found to have diastolic dysfunction; the remaining 11 patients with a normal E/A ratio constituted the control group. Afterward, the data recorded before the cardioversion were analyzed for each patient. In subjects with normal diastolic function, the peak diastolic flow velocity (PDFV) at the mitral tips also was maintained at the positions 1 to 3 cm away from the tip in the left ventricular cavity (PDFV at the mitral tips: 0.84 m/s, PDFV at 3 cm: 0.85 m/s; P =.34). In contrast, the regional PDFV progressively decreased toward the apex in patients with diastolic dysfunction (PDFV at the mitral tips: 0.82 m/s, PDFV at 3 cm: 0.63 m/s; P =.0004). Only 77% of the initial velocity was maintained at 3 cm away from the mitral tips in patients with diastolic dysfunction, whereas almost 100% of the initial velocity was preserved in patients with normal diastolic function (P <.001). These findings suggest that the assessment of the intraventricular decrease in mitral PDFV may be used as a reliable marker of diastolic dysfunction in patients with atrial fibrillation.

Comparison of DDD versus VVIR pacing modes in elderly patients with AV block

OBJECTIVES Dual-chamber pacing is believed to have an advantage over single-chamber ventricular pacing. The aim of this study was to determine whether elderly patients who have implanted pacemakers for complete atrioventricular block gain significant benefits from dual-chamber (DDD) pacemakers compared with single chamber ventricular (VVIR) pacemakers. STUDY DESIGN This study was designed as a randomized, two-period crossover study-each pacing mode was maintained for 1 month. Thirty patients (16 men, mean age 68.87 ± 6.89 years) with implanted DDD pacemakers were submitted to a standard protocol, which included an interview, pacemaker syndrome assessment, health related quality of life (HRQoL) questionnaires assessed by an SF-36 test, 6-minute walk test (6MWT), and transthoracic echocardiographic examinations. All of these parameters were obtained on both DDD and VVIR mode pacing. Paired data were compared. RESULTS HRQoL scores were similar, and 6MWT results did not differ between the two groups. VVIR pacing elicited significant enlargement of the left atrium and impaired left ventricular diastolic functions as compared with DDD pacing. Two patients reported subclinical pacemaker syndrome, but this was not statistically significant. CONCLUSION Our study revealed that in active elderly patients with complete heart block, DDD pacing and VVIR pacing yielded similar improvements in QoL and exercise performance. However, after a short follow-up period, we noted that VVIR pacing caused significant left atrial enlargement and impaired left ventricular diastolic functions.