Semra Topcu

High Serum Bilirubin Concentrations Preserve Coronary Flow Reserve and Coronary Microvascular Functions

Background—Elevated serum bilirubin concentrations protect against atherosclerotic diseases; however, it is not clear whether higher serum bilirubin concentrations in physiological ranges work in favor of the cardiovascular system in younger persons with no cardiovascular risk factors. Accordingly, we investigated the effects of high, intermediate, and low serum bilirubin concentrations on coronary flow reserve (CFR). Methods and Results—Fifty-two healthy subjects with hyperbilirubinemia (total bilirubin 1.43±0.33 mg/dL; mean age 35.9±7.3), 55 subjects with intermediate bilirubin level (total bilirubin: 0.69±0.11 mg/dL; mean age: 36.4±6.8), and 53 healthy subjects with hypobilirubinemia (total bilirubin 0.37±0.08 mg/dL; mean age, 37.6±6.6) were studied. Transthoracic second harmonic Doppler echocardiography examination was performed using an Acuson Sequoia C256 Echocardiography System. Coronary diastolic peak flow velocities were measured at baseline and after dipyridamole infusion (0.84 mg/kg over 6 minutes). CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities. Demographic features, coronary risk factors, echocardiographic measurements, and biochemical measurements were similar among the 3 groups, except high-sensitivity C-reactive protein (hsCRP). CFR values were significantly higher in subjects with high bilirubin concentrations than those were in the intermediate and the low bilirubin groups (3.19±0.73; 2.75±0.42; 2.56±0.52, respectively; P<0.0001), and hsCRP levels were significantly lower in subjects with high bilirubin concentrations than those in both intermediate and low bilirubin groups (1.4±1.0, 2.0±1.7, 3.0±1.9 mg/L, respectively; P<0.001). hsCRP levels correlated with total bilirubin concentration and with CFR. Conclusion—Elevated serum bilirubin concentrations protect from CFR impairment, coronary microvascular dysfunction, and possibly coronary atherosclerosis.

Impaired Coronary Flow Reserve in Hemodialysis Patients: A Transthoracic Doppler Echocardiographic Study

Background: Coronary flow reserve (CFR) reflects the functional capacity of microcirculation to adapt to blood demand during increased cardiac work. In this study, CFR of hemodialysis patients with angiographically normal coronary arteries was evaluated using transthoracic second harmonic Doppler echocardiography. Methods and Results: Ten hemodialysis patients, and 14 sex-, age- and left ventricular mass index-matched hypertensive controls with angiographically normal coronary arteries underwent transthoracic second harmonic Doppler echocardiographic examination. Coronary basal diastolic peak flow velocities and hyperemic peak flow velocities after dipyridamole infusion (0.56 mg/kg over 4 min) were measured. CFR was defined as the ratio of hyperemic to basal diastolic peak velocities. CFR ≧2.0 was regarded as normal. Additionally, Doppler tissue imaging pulse wave measurements were taken from the lateral and septal corners of the mitral annulus. CFR values were significantly lower in the study group than in the control group (2.03 ± 0.3 vs. 2.61 ± 0.5, p = 0.005). In 5 of 10 hemodialysis patients, CFR was <2.0 (50%), however in only 1 of 14 control patients it was <2.0 (5%). Conclusions: Impairment of coronary microvasculature occurs earlier in patients with chronic renal failure and may be the harbinger of subsequent primary uremic myocardial disease. In patients with chronic renal failure and normal coronary arteries, decreased CFR by transthoracic echocardiography might be regarded as an early finding of an affected coronary vasculature.

Impaired coronary microvascular function and increased intima-media thickness in rheumatoid arthritis

BACKGROUND Rheumatoid arthritis (RA) is associated with excessive cardiovascular mortality. Recently, some studies have shown endothelial dysfunction in RA patients with high inflammatory activity. In addition, it has been suggested that the chronic inflammatory state of RA contributes to accelerated atherosclerosis. Therefore, we aimed to evaluate whether coronary microvascular dysfunction and increased carotid artery intima-media thickness exist in patients with a long history and well controlled disease activity of RA lacking traditional cardiovascular risk factors. METHODS Thirty RA patients (22 women; mean age 43.7+/-9.0) and 52 healthy volunteers (38 women; mean age 45.3+/-5.4) were included into the study. Using transthoracic echocardiography, each subject underwent echocardiographic examination including coronary flow reserve (CFR) and carotid intima-media thickness (IMT) measurement. RESULTS CFR values were statistically reduced for RA patients as compared to controls (2.4+/-0.5 vs. 2.7+/-0.4, P=0.002) whereas IMT values were significantly increased (0.6+/-0.1 vs. 0.5+/-0.1, P=0.001). In RA patients, CFR positively correlated with lateral Em/Am ratio (r=0.399, P=0.029), and negatively correlated with lateral isovolumic relaxation time (IVRT) (r=-0.744, P=0.005), IMT (r=-0.542, P=0.002) and RA disease duration (r=-0.495, P=0.005). Reflecting LV diastolic function, mitral E-wave deceleration time and isovolumic relaxation time were borderline significant between the groups, however lateral Em/Am ratio and lateral IVRT were statistically different. CONCLUSIONS Patients with RA had impaired CFR and increased carotid IMT, and these injurious effects correlated significantly with disease duration.

Light cigarette smoking impairs coronary microvascular functions as severely as smoking regular cigarettes

Background: Smoking is the most prevalent and most preventable risk factor for cardiovascular diseases. Smoking low-tar, low-nicotine cigarettes (light cigarettes) would be expected to be less hazardous than smoking regular cigarettes owing to the lower nicotine and tar yield. Objective: To compare the chronic and acute effects of light cigarette and regular cigarette smoking on coronary flow velocity reserve (CFVR). Methods: 20 regular cigarette smokers (mean (SD) age 24.8 (5.0)), 20 light cigarette smokers (mean age 25.6 (6.4)), and 22 non-smoker healthy volunteers (mean age 25.1 (4.2)) were included. First, each subject underwent echocardiographic examination, including CFVR measurement, after a 12 hour fasting and smokeless period. Two days later, each subject smoked two of their normal cigarettes in a closed room within 15 minutes. Finally, within 20–30 minutes, each subject underwent an echocardiographic examination, including CFVR measurement. Results: Mean (SD) CFVR values were similar in light cigarette and regular cigarette smokers and significantly lower than in the controls (2.68 (0.50), 2.65 (0.61), 3.11 (0.53), p = 0.013). Before and after smoking a paired t test showed that smoking two light cigarettes acutely decreased the CFVR from 2.68 (0.50) to 2.05 (0.43) (p = 0.001), and smoking of two regular cigarettes acutely decreased CFVR from 2.65 (0.61) to 2.18 (0.48) (p = 0.001). Conclusion: Smoking low-tar, low-nicotine cigarettes impairs the CFVR as severely as smoking regular cigarettes. CFVR values are similar in light cigarette and regular cigarette smokers and significantly lower than in controls.

Metformin therapy improves coronary microvascular function in patients with polycystic ovary syndrome and insulin resistance

Background  Women with polycystic ovary syndrome (PCOS) are thought to have increased cardiovascular risk. Metformin therapy reduces whole‐body insulin resistance (IR) in patients with type‐2 diabetes mellitus (DM).

Patients with Behcet's disease carry a higher risk for microvascular involvement in active disease period

Background. Behcets disease (BD) is characterized with remissions and exacerbations. However, to date, there is no study to investigate a possible association of disease activity (active versus inactive disease period) with cardiovascular complications. Methods. Forty patients with BD were evaluated in both active and in inactive disease period. For the control group 45 healthy volunteers, age and sex matched, were registered. Subjects with at least a 15‐day lesion‐free period were regarded in inactive disease period, and subjects with any oral, skin, and/or genital lesion was regarded as in active disease period. In each subject coronary diastolic peak flow velocities (DPFV) were measured at baseline and after dipyridamole infusion (0.84 mg/kg over 6 minutes) using an Acuson Sequoia C256® echocardiography system. Coronary flow reserve (CFR) was defined as the ratio of hyperemic to baseline DPFV. Results. CFR values were significantly lower in BD patients compared to the controls (2.57±0.50 versus 2.87±0.53, P = 0.006). In active disease period, basal DPFV (24.6±7.5 versus 27.3±6.6, P = 0.019) was significantly higher than in the inactive disease period. In the active disease period hyperemic DPFV (61.7±14.9 versus 56.8±16.7, P = 0.015) values decreased significantly. Therefore, in the active disease period CFR significantly decreased from 2.57±0.50 to 2.09±0.46, P<0.001. The only independent predictor of CFR within the active disease period was the disease duration (β = −0.384, P = 0.012). Conclusion. Within the active disease period, coronary microvascular function is more prominently impaired in BD patients. Therefore, BD patients are possibly more vulnerable to cardiovascular manifestations when they are in an active disease period.

Acute Effects of Smoking Light Cigarettes on Coronary Microvascular Functions

To date, there has been no study comparing the possible acute effects on coronary microvascular functions of smoking light cigarettes (those with low tar and nicotine yield) and regular cigarettes.

Smoking mentholated cigarettes impairs coronary microvascular function as severely as does smoking regular cigarettes.

Objective — Smoking mentholated cigarettes inhibits the metabolism of nicotine and increases systemic exposure to cigarette smoke toxins. However, the possible effects of smoking mentholated cigarettes on coronary microvascular functions are unknown. We sought to investigate whether smoking mentholated cigarettes impairs coronary flow reserve (CFR) more so than smoking regular cigarettes. Methods — Twenty otherwise healthy smokers of regular cigarettes (6 women, 14 men; mean age, 25.6 ± 6.4 years) and 22 non-smoking control subjects were included in the study.To compare the acute effects of mentholated (0.9 mg nicotine, 11 mg tar, 12 mg carbon monoxide) and regular (0.9 mg nicotine, 12 mg tar, 12 mg carbon monoxide) cigarettes on CFR, all subjects underwent an echocardiographic examination that included CFR measurements at baseline. Twenty to 30 minutes after subjects had smoked 2 regular cigarettes and 2 mentholated cigarettes, CFR was again measured in subjects in the smoking group. Results — In response to smoking 2 regular and 2 mentholated cigarettes, CFR values declined from 2.56 ± 0.60 to 2.06 ± 0.38 (P < 0.004) and from 2.56 ± 0.60 to 2.14 ± 0.30 (P < 0.005), respectively. Smoking mentholated and regular cigarettes impaired CFR to the same degree (P =0.547). Conclusions — When compared with smoking regular cigarettes, smoking mentholated cigarettes has similar acute detrimental effects on coronary microvascular functions.

Combined primary repair of tetralogy of Fallot and aortic root replacement

Tetralogy of Fallot associated with ascending aortic aneurysm and aortic valve regurgitation is unusual. This combination necessitates a change in operative strategy during complete tetralogy repair. We present a 43-year-old woman who successfully underwent composite graft replacement of the ascending aorta and aortic valve during primary complete tetralogy repair. Histologic examination of the aorta revealed medial degeneration.

Silent cerebral infarct in patients with mitral valve prolapse.

It is still not clear whether mitral valve prolapse (MVP) is a risk factor for ischemic stroke. The aim of this study was to evaluate whether uncomplicated MVP is a risk factor for silent cerebral ischemic events. Fifty-two patients with uncomplicated MVP and 46 control subjects without MVP were included in the study. All subjects were evaluated for silent cerebral infarct (SCI) with a magnetic resonance imaging. Five (9.6%) of the patients who had MVP but no other risk factors for ischemic cerebral events had SCI. The results suggest that uncomplicated MVP is a risk factor for SCI, and that patients with MVP should receive anti-platelet-aggregating drugs.