Ozlem Esen

Prognostic Value of Fractional Flow Reserve: Linking Physiologic Severity to Clinical Outcomes

BACKGROUND Fractional flow reserve (FFR) has become an established tool for guiding treatment, but its graded relationship to clinical outcomes as modulated by medical therapy versus revascularization remains unclear. OBJECTIVES The study hypothesized that FFR displays a continuous relationship between its numeric value and prognosis, such that lower FFR values confer a higher risk and therefore receive larger absolute benefits from revascularization. METHODS Meta-analysis of study- and patient-level data investigated prognosis after FFR measurement. An interaction term between FFR and revascularization status allowed for an outcomes-based threshold. RESULTS A total of 9,173 (study-level) and 6,961 (patient-level) lesions were included with a median follow-up of 16 and 14 months, respectively. Clinical events increased as FFR decreased, and revascularization showed larger net benefit for lower baseline FFR values. Outcomes-derived FFR thresholds generally occurred around the range 0.75 to 0.80, although limited due to confounding by indication. FFR measured immediately after stenting also showed an inverse relationship with prognosis (hazard ratio: 0.86, 95% confidence interval: 0.80 to 0.93; p < 0.001). An FFR-assisted strategy led to revascularization roughly half as often as an anatomy-based strategy, but with 20% fewer adverse events and 10% better angina relief. CONCLUSIONS FFR demonstrates a continuous and independent relationship with subsequent outcomes, modulated by medical therapy versus revascularization. Lesions with lower FFR values receive larger absolute benefits from revascularization. Measurement of FFR immediately after stenting also shows an inverse gradient of risk, likely from residual diffuse disease. An FFR-guided revascularization strategy significantly reduces events and increases freedom from angina with fewer procedures than an anatomy-based strategy.

Cigarette smoking and heart rate variability: dynamic influence of parasympathetic and sympathetic maneuvers.

Background: Cigarette smoking has been associated with increased activity of the sympathetic nervous system. In this study, we investigated cardiac autonomic function in heavy smokers and nonsmoker controls by analysis of heart rate variability (HRV).

Acute effect of cigarette smoking on heart rate variability

Acute cigarette smoking enhances adrenergic activity and thus may be associated with hemodynamic changes in the cardiovascular system. In this study, the acute effect of cigarette smoking on heart rate variability (HRV) was studied. Fifteen subjects were included in the study. Time domain (the mean R-R interval, the standard deviation of R-R interval, and the root mean square of successive R-R interval differences) and frequency domain (high-frequency, low-frequency ratio, and low-frequency/high-frequency ratio) parameters of HRV were obtained from all participants for each 5-minute segment: 5 minutes before and 5, 10, 15, 20, 25, and 30 minutes after smoking a cigarette. The mean R-R interval, the standard deviation of R-R interval, and the root mean square of successive R-R interval differences significantly decreased within the first 5-minute period compared with baseline, and then the standard deviation of R-R interval increased within the 20- to 30-minute period. The low-frequency high-frequency ratio significantly decreased within the first 5 minutes after smoking and then remained unchanged throughout the study period. Similarly, low-frequency and high-frequency power increased within the first 5 minutes compared with baseline. Acute cigarette smoking alters HRV parameters, particularly within the first 5 to 10 minutes after smoking.

Tenting area reflects disease severity and prognosis in patients with non-ischaemic dilated cardiomyopathy and functional mitral regurgitation.

To define which echocardiographic parameters are related to the degree of functional mitral regurgitation (FMR) and to establish their relationship with clinical status, plasma B‐type natriuretic peptide (BNP) levels, and prognosis in patients with non‐ischaemic dilated cardiomyopathy (NICMP).

Tissue Doppler Evaluation of Tricuspid Annulus for Estimation of Pulmonary Artery Pressure in Patients with COPD

Because transthoracic echocardiography is an inexpensive, easy, and reproducible method, it is the most commonly used noninvasive diagnostic tool to determine pulmonary artery pressure (PAP). Tissue Doppler imaging (TDI) emerged as a new echocardiographic method that can be applied in various clinical conditions. In our study we aimed to evaluate the relationship between tricuspid lateral annulus TDI parameters and pulmonary artery systolic pressure (PASP) as estimated by continuous wave Doppler in patients with chronic obstructive pulmonary disease (COPD). A total of 51 (42 men, mean age: 62.3 ± 8.2 years) patients with clinically stable COPD were included in the study. The tricuspid annular systolic myocardial velocity (Sm), velocity time integral of Sm (SmVTI), early (Em) and late (Am) peak diastolic myocardial velocities, and myocardial isovolumic relaxation time (IVRTm) were acquired as well as two-dimensional (2-D) and conventional Doppler data. When compared with values of patients without pulmonary hypertension (PHT), Sm, SmVTI, Em, and Em/Am values were found to be lower and IVRTm values higher in patients with PHT. When all the patients were analyzed, there was a significant negative correlation between PASP and Sm and SmVTI (r = −0.82, p < 0.001 and r = −0.84, p < 0.001, respectively). Sm velocity ≤ 12 cm/s had a sensitivity of 85% and a specificity of 93.3% for predicting PASP > 40 mmHg. SmVTI ≤ 2.5 cm had a sensitivity of 85.7% and a specificity of 90% for detecting PHT. In our study, there was significant negative correlation between tricuspid lateral annular Sm and SmVTI values and PASP in patients with stable COPD irrespective of the presence of PHT. Tricuspid annular Sm and SmVTI had very good level sensitivity and specificity for predicting PHT. In conclusion, it might be suggested that in cases where noninvasive PASP measurement is not possible, TDI can be used as an alternative and reliable method to assess PAP.

Effect of Slow Coronary Flow on P-Wave Duration and Dispersion

The slow coronary flow (SCF) phenomenon is often considered to be an incidental angiographic finding; however, several reports have shown it to be associated with cardiac events. In this study we aimed to assess P-wave duration and dispersion (PWD) in patients with SCF and to compare it with that of healthy subjects. Thus, 40 patients with angiographically proven SCF and otherwise normal coronary arteries (group 1) and 36 sex-age-matched healthy subjects (group 2) were included in this study. A 12-lead surface ECG, recorded at a paper speed of 50-mm/s and 2 mV/cm standardization, was obtained from each subject. P-wave duration was measured manually by use of a caliper. The difference between the maximum (Pmax) and minimum P (Pmin)-wave duration was calculated and defined as PWD. All subjects had undergone echocardiographic examination to exclude valvular disorders and wall motion abnormalities. There was no significant difference between the 2 groups in demographies of age, sex, heart rate, or blood pressure. Maximum P-wave duration and PWD were significantly higher in group 1 than in group 2 (120 ±7 vs 115 ±5, p = 0.003; 44 ±12 vs 38 ±9, p = 0.01, respectively). However, there was no significant difference in Pmin duration (75 ±9 vs 78 ±7, p = 0.4). In conclusion; SCF and otherwise normal epicardial coronary artery was found to be associated with prolonged P-wave duration and increased PWD. This may result from microvascular ischemia and/or altered autonomic control of cardiovascular system observed in this group of patients.

Left ventricular noncompaction in a patient with multiminicore disease.

To the Editor Multiminicore disease (MmD) is an early-onset, heterogeneous condition in which at least four different subgroups have been distinguished. The most instantly recognizable ‘classical’ phenotype is characterized by the axial predominance of muscle weakness, spinal rigidity, early scoliosis, and respiratory insufficiency. The moderate form consists of distal weakness and wasting or predominant hip girdle involvement resembling central core disease (CCD). However, scoliosis and respiratory involvement are mild or absent in this group of patients. The two other forms of the disease are characterized by a clinical picture resembling the classical MmD form, but including ophthalmoplegia and by antenatal onset with arthrogryposis. The classical phenotype is attributable to recessive mutations in the selenoprotein N (SEPN1) gene, whereas recessive mutations in the skeletal muscle ryanodine receptor (RYR1) are responsible for MmD with ophthalmoplegia and for the moderate, ‘CCD-like’ form of MmD. Although cardiac impairment secondary to respiratory involvement is not uncommonly observed in the classic phenotype of MmD, primary cardiomyopathies have not been reported in the case of MmD because of mutations in the SEPN1 or RYR1 genes. Left ventricular noncompaction (LVNC) is a cardiomyopathy often associated with neuromuscular disorders, but it has not yet been reported in MmD patients.

Effect of acute cigarette smoking on left and right ventricle filling parameters: a conventional and tissue Doppler echocardiographic study in healthy participants.

Acute effects of smoking on left and right ventricular function is determined by conventional and tissue Doppler imaging methods in this study. Pulsed-wave Doppler indices of the left and right ventricle diastolic function, including mitral and tricuspid inflow peak early and late velocity and their ratio were obtained from 20 healthy subjects by conventional Doppler and tissue Doppler imaging. Echocardiographic indices of left and right ventricles, including isovolumetric relaxation time, deceleration time, isovolumetric contraction time, ejection time, and myocardial performance index of right ventricle were measured before and 30 minutes after smoking a cigarette. Mitral and tricuspid inflow parameters and right ventricular myocardial performance index significantly altered after smoking a cigarette. Among the tissue Doppler imaging parameters, mitral and tricuspid lateral annulus diastolic, but not systolic, velocities altered after smoking a cigarette. Acute cigarette smoking alters left and right ventricular diastolic functions in healthy nonsmokers.

Identifying Cardiovascular Risk Factors in a Patient Population With Coronary Artery Ectasia

Coronary artery ectasia (CAE) is frequently considered as a form of coronary artery disease. Cardiovascular risk factors were determined in a patient population with CAE. The 51 patients with isolated CAE (group 1), 61 patients with CAE coexisting with significant coronary stenosis (group 2), and 62 subjects with significant coronary stenosis (group 3) were included in the study, and the distribution of cardiovascular risk factors was compared. Thirty of 51 patients with isolated CAE had presented with typical angina pectoris, 8 patients with unstable angina pectoris, and 13 patients had atypical chest pain or palpitation. The 21 of 51 patients with isolated CAE had definitive positive treadmill exercise test results. Positive family history was similar in each group. The history of smoking was similar in group 1 and group 2 but higher than group 3. Frequency of hypertension was similar in group 1 and group 2 but higher than that in group 3. Frequency of diabetes mellitus was similar in group 1 and group 2 but lower than group 3. Plasma lipid levels and the number of patients with lipid disturbances were also similar in each group. In addition, C-reactive protein (CRP) levels were above the normal limits and there was no difference among groups with respect to plasma CRP levels. CAE appears to be associated with traditional cardiovascular risk factors such as hypertension, smoking, and hyperlipidemia. In addition, elevated CRP level in patients with CAE may suggest the role of inflammatory process in development of CAE.

Comparison of QT interval duration and dispersion in elderly population versus healthy young subjects

We compared QT dispersion (QTd) in 75 elderly and 36 young subjects and found that those over the age of 75 years had higher QTd than those younger than 75. In addition those older than 75 years had higher QTd values compared to the younger subjects. We concluded that QTd increased especially over the age of 75.