Sedat Turkoglu

Association between nonalcoholic fatty liver disease and coronary artery disease

AimsTo demonstrate whether there is a relationship between the presence of nonalcoholic fatty liver disease (NAFLD) and the presence and extent of coronary artery disease (CAD). Patients and methodsNinety-two consecutive patients who planned to undergo coronary angiographies (CAG) without known CAD, other than findings of acute coronary syndrome, were enrolled in this study. Abdominal ultrasonography was performed before the CAG to detect NAFLD. CAD was defined as a stenosis of at least 50% in at least one major coronary artery. The extent of CAD was measured according to the number of major coronary artery/arteries affected by CAD. All the risk factors for CAD were included in a binary logistic regression model. Forward, backward, or step-wise selections were not used. P<0.05 was accepted as being significant. ResultsSixty-five of the 92 patients (70.7%) were detected, by abdominal ultrasonography, to have fatty liver and 43 patients out of 92 (46.7%) were detected, by CAG, to have significant CAD. According to the results of logistic regression analysis, the presence of NAFLD independently increased the risk for CAD, as seen in CAG [odds ratio (OR), 95% confidence interval (CI): 6.73 (1.14–39.61); P=0.035]; this was despite factoring in the other risk factors for CAD and the components of metabolic syndrome. NAFLD was more commonly found in patients as the extent of CAD increased (P=0.001). ConclusionThe presence of NAFLD is independently associated with the presence and extent of CAD. Future studies are needed to explain the mechanisms of this relationship.

Serum uric acid levels as a predictor of in-hospital death in patients hospitalized for decompensated heart failure

Objectives — The aim of this study was to determine the value of serum uric acid levels in predicting in-hospital mortality of chronic heart failure patients hospitalized for decompensation in spite of appropriate medical therapy. Methods and results — This study was conducted in patients who were admitted to our clinic between January 2003 and April 2004 due to decompensated heart failure. Only patients who had a functional capacity of class IV and who already received loop diuretic and ACE inhibitor therapy before their admission were included. Patients with recurrent admissions during this period were excluded. Eighty-five patients fulfilled these criteria: group I consisted of 25 patients who died during hospitalization whereas group II consisted of 60 patients who were discharged alive after treatment. Age, sex, left ventricular ejection fraction derived from 2-D echocardiography, serum sodium (Na), gamma-glutamyl transpeptidase (GGT), creatinine, uric acid levels, white blood cell counts and drugs used on admission were the selected parameters as predictors of in-hospital mortality in these patients.When stepwise logistic regression analysis was used, female sex and serum uric acid levels at admission appear to be the only predictors of death during that hospitalization independent of other variables. Conclusions — Serum uric acid levels may be used as a predictor of death in hospitalized heart failure patients with class IV symptoms.

Plasma asymmetric dimethylarginine and L-arginine levels in patients with cardiac syndrome X.

BackgroundEndothelial dysfunction and subsequently impaired microvascular circulation are the leading mechanisms in the development of cardiac syndrome X (CSX). The study evaluated the plasma asymmetric dimethylarginine (ADMA) and L-arginine levels of the patients with CSX and the control group and aimed to determine any relationship between these parameters and epicardial coronary blood flow and myocardial tissue perfusion. MethodsThe study group consisted of 32 patients (mean age: 52.6±9.4 years, 14 men) with typical exertional angina, positive exercise test, and normal coronary arteries diagnosed as CSX. Plasma ADMA, L-arginine levels, and L-arginine/ADMA ratio were compared with the values of the control group, which consisted of 17 age-matched and sex-matched individuals. Concentrations of L-arginine and ADMA were measured by high-performance liquid chromatography. In all the coronary territories, epicardial coronary flow was assessed by thrombolysis in myocardial infarction (TIMI) frame count (TFC) method, and tissue level perfusion, by myocardial blush grade (MBG) method. A MBG score less than 3 was considered an impaired myocardial perfusion, and a MBG score of ‘3’ in all the coronary territories, a normal myocardial perfusion. ResultsThe plasma ADMA levels of the study group were higher than those of the control group (0.83±0.38 vs. 0.55±0.44 μmol/l, P=0.03), whereas plasma L-arginine levels were similar in both groups (70.25±21.89 vs. 76.09±18.22 μmol/l, P=0.36), resulting in a diminished L-arginine/ADMA ratio in the patients with CSX [82.3 (60.2–128.8) vs. 242.2 (76.7–386.4), P=0.003]. In CSX group, the patients with abnormal myocardial tissue perfusion had increased plasma ADMA levels compared with those with normal tissue perfusion (0.99±0.37 vs. 0.69±0.34 μmol/l, P=0.02), whereas plasma L-arginine levels were similar in both groups. No correlations were observed between TFC values and plasma ADMA, L-arginine levels, and L-arginine/ADMA ratio. Plasma ADMA levels, however, were negatively correlated with MBG scores (r=−0.349, P=0.014). ConclusionWe have shown for the first time that in the patients with CSX, increased plasma ADMA levels might be associated with impaired myocardial tissue perfusion when assessed by MBG.

Isolated right ventricular infarction due to occlusion of the right ventricular branch in the absence of percutaneous coronary intervention

Isolated right ventricular myocardial infarction accounts for only 3% of all infarctions. It has previously been reported as a complication of percutaneous coronary intervention involving the right coronary artery secondary to occlusion of the right ventricular branch. In the present report, a patient is described in whom isolated right ventricular myocardial infarction developed due to occlusion of the right ventricular branch of the right coronary artery in the absence of percutaneous intervention.

Endothelial progenitor cells (CD34+KDR+) and monocytes may provide the development of good coronary collaterals despite the vascular risk factors and extensive atherosclerosis.

OBJECTIVE Endothelial progenitor cells (EPC) have a regenerative role in the vascular system. In this study, we aimed to evaluate simultaneously the effects of EPC and inflammatory cells on the presence and the extent of coronary artery disease (CAD) and the grade of coronary collateral growth in patients with clinical suspicion of CAD. METHODS This study has a cross-sectional and observational design. We enrolled 112 eligible patients who underwent coronary angiography consecutively (mean age: 59±9 years). The association of circulating inflammatory cells and EPC (defined by CD34+KDR+ in the lymphocyte and monocyte gate) with the presence, severity and extent of CAD and the degree of collateral growth were investigated. Logistic regression analysis was used to define the predictors of collateral flow. RESULTS Of 112 patients 30 had normal coronary arteries (NCA, 27%, 55±9 years) and 82 had CAD (73%, 61±8 years). Among the patients with CAD, the percent degree of luminal stenosis was <50% in 12 patients; 50-90% in 35 patients; and ≥90% in the other 35 patients. Circulating inflammatory cells were higher (leukocytes, 7150±1599 vs 8163±1588 mm(-3), p=0.001; neutrophils, 4239±1280 vs 4827±1273 mm(-3), p=0.021; monocytes, 512±111 vs 636±192 mm(-3), p=0.001) and EPCs were lower (0.27±0.15% vs 0.17±0.14%, p<0.001; 21±15 vs 13±12 mm(-3), p=0.004) in CAD group than NCA group. When we investigated the collateral growth in patients having ≥90% stenosis in at least one major coronary artery, we found that the patients with good collateral growth had significantly higher EPC (0.22±0.17% vs 0.10±0.05%, p=0.009; 18±15 vs 7±3 mm(-3), p=0.003) in comparison to patients with poor collateral growth. Presence of EPC was associated with reduced risk for coronary artery disease (OR: 0.934, 95%CI: 0.883-0.998, p=0.018) and was an independent predictor for good collateral growth (OR: 1.295, 95%CI: 1.039-1.615, p=0.022). A sum of CD34+KDR-, CD34+KDR+ and CD34-KDR+ cells (192±98 mm(-3)), and a CD34-KDR- cell subpopulation within monocyte gate (514±173 mm(-3)) reached to highest counts in good collateral group among all study population. CONCLUSION Endothelial progenitor cells can be mobilized from bone marrow to induce the coronary collateral growth in case of myocardial ischemia even in presence of the vascular risk factors and extensive atherosclerosis. This finding may be supportive to investigate the molecules, which can specifically mobilize EPC without inflammatory cells.

Heart fatty acid binding protein and myoglobin after reperfusion of acute myocardial infarction

Objective — The aim of this study was to disclose the release kinetics of heart fatty acid binding protein (HFABP) and myoglobin in acute myocardial infarction (AMI) reperfused by primary percutaneous coronary intervention (PPCI) and to determine the influence of the quality of coronary flow post PPCI on the release properties of these markers. Methods and results — Twenty-four patients with AMI who underwent successful PPCI and had no evidence of reocclusion within the first 120 minutes were studied. Serum myoglobin and HFABP levels at baseline and at 15, 30, 45, 60, 90 and 120 minutes after reperfusion were measured. Corrected TIMI frame count (CTFC) in the relevant vessel post PPCI was used to categorize patients in group 1 (CTFC > 21) and group 2 (CTFC < 21). Biomarker ratios at each sampling point were calculated by dividing the serum level of the biomarker at the specific sampling time by its baseline level. Baseline myoglobin and HFABP levels rose significantly at 15 minutes (153 ± 251.5 pg/L vs. 904.3 ± 542.6 pg/L, 10.9 ± 8 pg/L vs. 17.8 ± 9.1 pg/L, both P < 0.0001) after successful PPCI. Group 2 patients tended to have higher biomarker ratios at each time point as compared to group 1. Conclusions — Successful PPCI for AMI results in a significant increase of both HFABP and myoglobin levels within 15 minutes of vessel opening and the quality of flow in the infarction-related artery post PCI as evaluated by CTFC does not influence the release kinetics of these biomarkers.

Dasatinib-induced pulmonary hypertension in acute lymphoblastic leukemia: case report

Pulmonary hypertension (PHT) is a pathological condition determined as an increase in mean pulmonary arterial pressure ≥25 mmHg. Pulmonary arterial hypertension (PAH) is precapillary PHT and a life-threatening disease group which consists of different etiologies with the same pathological and clinical findings, and which is characterized by elevated pulmonary vascular resistance. Dasatinib is a dual Src/Abl kinase inhibitor associated with higher affinity for BCR/ABL kinase than imatinib, and is used in the treatment of chronic myelocytic leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia (ALL). We describe a case with ALL, in whom dasatinib treatment induced PAH, and who recovered with bosentan treatment.

Heart rate variability in neurally mediated reflex syncope

Objective — The aim of this study was to investigate the heart rate variability (HRV) parameters in patients with neurally mediated reflex syncope. Methods — Thirty-three patients (10men, age range 16-50years) who were scheduled to undergo head-upright tilt test (HUTT) with a typical history of vasovagal syncope (VVS) underwent 24-hour Holter monitoring in an attempt to study HRV parameters. Sixteen individuals without syncope and similar baseline characteristics made up the control group. Results — Seventeen of the 33syncopal patients showed HUTT positivity. All the time domain HRV parameters except the mean RR interval were higher in the HUTT (+) syncopal patients than in the negative responders. Although not statistically significant, the positive responders had higher NN50, pNN50, RMSSD and SDNNi values than the control group. HUTT (-) VVS patients had lower SDNN and SDANN values when compared with the control group.The other HRV parameters did not differ significantly between the HUTT (-) patients and the control group. Conclusion — Increased parasympathetic tonus as reflected by significantly higher HRV parameters is associated with a greater frequency of HUTT positivity in patients with syncope and no organic heart disease.

Possible anaphylactic reaction to taxus stent: A case report

We report a patient who experienced an anaphylactic reaction during coronary artery stenting. Immediately after a polymer‐based paclitaxel‐eluting stent (Taxus, Boston‐Scientific) is deployed, the patient developed profound hypotension and an erythematous rash. The case complicated with coronary spasm and a new thrombus formation making a second stent implantation necessary. The reaction was successfully reversed with epinephrine, steroid, antihistaminic, a 9‐hr infusion of dopamine, and intraaortic balloon counterpulsation.

Long-term clinical effects of magnetic resonance imaging in patients with coronary artery stent implantation.

ObjectivesWe sought to investigate the early and late effects of magnetic resonance imaging (MRI) on stent thrombosis and major adverse coronary events after coronary artery stent (CAS) implantation at a long-term follow-up period. MethodsForty-three patients (28 men, mean age 63±10 years) who underwent CAS implantation before MRI examination were included. MRI was performed on a 1.5-T MR-system with a phased array multicoil. An average of 1.3 stents per patient were implanted (1–4 stents). More than one MRI was performed for two patients. Patients who underwent MRI within 8 weeks after the procedure were included in the early-term group (17 patients), and those who underwent MRI after 8 weeks were included in the late-term group (26 patients). ResultsMean follow-up period was 36±15 months. There was no acute or subacute stent thrombosis. Late stent thrombosis that resulted in acute myocardial infarction was observed in a patient from the early group after an operation for prostate hyperplasia 5 months after MRI, and the patient underwent percutaneous coronary artery angioplasty. De-nova lesion was observed in four patients in the early group and two patients in the late group (P=0.14). In-stent restenosis was recorded in two patients in the early group and three patients in the late group (P=0.98). Composite major adverse cardiac events (acute coronary syndrome, myocardial infarction, death, and cerebrovascular event) were observed in seven of the early-group patients (41%), and in six of the late-group patients (23%) (P=0.20). ConclusionMRI can be safely performed in patients with CAS implantation both in the early and late course, and is not associated with an increased risk of major adverse clinical cardiac events at long-term follow-up.