Sibel Turhan

Torsade de pointes associated with moxifloxacin: A rare but potentially fatal adverse event

Torsade de pointes occuring due to a long QT interval is a rare but potentially fatal arrhythmia. Acquired long QT develops most commonly because of drugs that prolong ventricular repolarization. It has been reported that fluoroquinolone antimicrobials prolong the corrected QT interval but rarely cause torsade de pointes. A patient with torsade de pointes risk factors (female sex, advanced age, extreme bradycardia and renal failure) who developed the condition on the fourth day of 400 mg/day of oral moxifloxacin treatment is presented. After the moxifloxacin was stopped, the corrected QT interval normalized and a permanent cardiac pacemaker was implanted. During 11 months of follow-up, arrhythmia did not recur.

Second recurrence of familial cardiac myxomas in atypical locations

Recurrence rates reported for cardiac myxomas are 4% to 7% for sporadic cases and 10% to 21% for familial cases. Although recurrence rates are high, second recurrences are rare. Familial cardiac myxomas in a mother and daughter are reported, both of whom had their second recurrences within six years. Both had recurrences in uncommon places, such as the left atrial posterior wall, between the left atrial appendage and the pulmonary vein, and the anterior mitral leaflet.

Association between the dosage and duration of statin treatment with coronary collateral development.

BackgroundThe coronary collateral circulation is an alternative source of blood supply to myocardium in the presence of advanced coronary artery disease and the therapeutic promotion of collateral growth appears to be a valuable treatment strategy in these patients. Although it has been shown in in-vivo studies that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) promote vasculogenesis and accelerate coronary collateral development in ischemic tissues, there are discordant results in clinical studies. Our aim was to investigate the effect of statin therapy, including dosage and duration of treatment, on coronary collateral growth in patients with advanced coronary artery disease. MethodsStudy population consisted of 400 (306 men, with the mean age of 62±10 years) consecutive patients who have undergone clinically indicated coronary angiography and had at least one major coronary artery stenosis of ≥95%. Coronary collaterals were graded from 0 to 3 according to the Cohen–Rentrop method and patients with grade 0–1 collateral development were regarded as having poor collateral and patients with grade 2–3 collateral development were regarded as having good collateral. ResultsAmong 400 patients, 196 (48%) were on statin therapy. Patients with good collateral score were more likely to have stable angina pectoris as clinical presentation (P<0.001), and were on statin therapy (P=0.001), and have multivessel disease (P=0.003). Statin therapy for less than 3 months had no effect on collateral development (P=0.19); however, patients who were on statin therapy for more than 3 months had significantly better collateral development (P=0.002). Statin therapy had no effect on coronary collateral development in patients having <10 mg atorvastatin-equivalent dose (P=0.13); however, patients having ≥10 mg atorvastatin-equivalent dose had better collateral development (P<0.001). Diabetes mellitus was the only negative predictor for coronary collateral formation (P=0.03). On multivariate analysis, stable angina pectoris [odds ratio 2.88, 95% confidence interval (1.8–4.7), P<0.001], statin therapy with ≥10 mg atorvastatin-equivalent dose [odds ratio 2.06, 95% confidence interval (1.3–2.6), P<0.001] and having multivessel disease [odds ratio 1.86, 95% confidence interval (1.16–3), P=0.01] were found to be associated with rich collateralization. ConclusionStatin therapy (≥10 mg atorvastatin-equivalent dose), stable angina pectoris and having multivessel disease are associated with enhanced coronary collateral development in patients with advanced coronary artery disease.

Two-Dimensional Longitudinal Strain and Strain Rate Imaging for Assessing the Right Ventricular Function in Patients with Mitral Stenosis

Background: Longitudinal two‐dimensional strain (L2DS) deformation is a novel technique that evaluates global and regional right ventricular (RV) function. The aim of the study was to investigate the systolic function of RV by using this method in patients with pure mitral stenosis (MS). Methods: Conventional echocardiography and L2DS analysis were performed in 45 MS patients and 21 healthy controls. For strain analysis apical four‐chamber views were obtained and by using a software system, peak systolic strain and strain rates were calculated off‐line in each segment. Results: The mean global longitudinal strain (GLS) of the whole RV (−20 ± 7 vs. −24 ± 6%, P= 0.02) and mean GLS of the septum (−19 ± 7 vs. −23 ± 5%, P = 0.03) were significantly reduced in the MS patients. Compared with the control group no significant change was determined in the mean GLS of the RV free wall (RVFW). While the mean global longitudinal strain rates (GLSR) of the entire RV and RVFW were similar between the groups, a significant difference in the mean GLSR of the septum (−1.2 ± 0.4 vs. −1.5 ± 0.3 s−1, P= 0.005) was determined in the patients with MS. A regional analysis demonstrated that MS patients had significantly reduced strain and strain rates in the basal and mid‐segments of the septum, whereas only lower strain values in the basal RVFW. Conclusions: RV systolic function evaluated by L2DS analysis in patients with MS has shown decreased global and segmental systolic functions. (ECHOCARDIOGRAPHY 2010;27:525‐533)

The association of elevated white blood cell count and C-reactive protein with endothelial dysfunction in cardiac syndrome X.

Background — The aim of the study is to evaluate the association of inflammatory markers with endothelial function in syndrome X. Methods — The study population consisted of 59 prospectively enrolled patients (28 women and 31 men; mean age, 50.29 ± 6.48 years) and 51 healty control subjects (18 women and 33 men; mean age, 51.04 ± 7.25 years). High-sensitive CRP (hs-CRP), white blood cell (WBC) count and its subtypes [neutrophil (N), lymphocyte (L) and monocyte (M)] were measured in each subject. Endothelial function was assessed with the brachial artery flow-mediated dilatation (FMD) technique. Results — WBC counts and hs-CRP levels were significantly higher in patients who had syndrome X than in control subjects (7.53 ± 1.52 ≈ 109 cells/L versus 6.21 ± 1.17 ≈ 109 cells/L, P = 0.0001, and 3.11 ± 0.63 mg/L versus 2.68 ± 0.76 mg/L, P= 0.002, respectively). Neutrophil count and N/L ratio was significantly increased in syndrome X when compared with the control subjects (5.14 ± 1.10 ≈ 109 cells/L versus 4.11 ± 0.76 ≈ 109 cells/L, P = 0.0001 and 2.75 ± 1.06 versus 2.37 ± 0.65, P= 0.02, repectively). Other subtype counts were similar between the groups. FMD was impaired significantly in patients who had syndrome X in comparison with the control subjects (5.71 ± 4.08% versus 16.02 ± 4.13%, P= 0.0001). There was a significant correlation between hs-CRP levels and FMD measurements (r = –0.44; P= 0.0001). Furthermore, the correlation between WBC count and FMD measurements were also significant (r = –0.48; P= 0.0001). Conclusions — The present study showed that hs-CRP and WBC count were higher in patients with syndrome X than in control subjects. Furthermore, endothelial function was impaired significantly in patients with syndrome X. The increased levels of hs-CRP and WBC count may suggest that these markers may be used in clinical practice for the assessment of the inflammatory status of the endothelium in syndrome X.

Facilitation of radial artery cannulation by periradial subcutaneous administration of nitroglycerin.

PURPOSE To determine whether subcutaneous administration of nitroglycerin mixed with local anesthetic agent results in effective vasodilation of the radial artery, and whether this technique improves access time and decreases complications. MATERIALS AND METHODS This prospective study consisted of two consecutive investigations. In the first (n = 30), only local anesthetic agent (prilocaine 2%) was injected into one arm, and local anesthetic agent plus 500 microg nitroglycerin was injected into the other arm. Radial artery diameters before and after injections were measured by ultrasonography. In the second, 33 patients received local anesthetic agent (prilocaine 2%) plus 500 microg nitroglycerin (group A) and 30 received only local anesthetic agent (group B) to determine whether the addition of nitroglycerin would improve radial artery access time, duration of angiography, perception of arterial pulse (ie, pulse score), number of punctures before successful cannulation, and complication rates. RESULTS In the first investigation, radial artery diameter increased significantly in the nitroglycerin-treated arm (2.3 mm +/- 0.4 vs 2.9 mm +/- 0.5; P = .05). In the second, there were no significant differences between groups with respect to age, sex, duration of angiography, and number of punctures before cannulation. However, the pulse score increased and radial artery access time improved significantly after addition of nitroglycerin (79% vs 10% [P < .001] and 75 sec +/- 47 vs 132 sec +/- 100 [P = .005], respectively). Radial artery spasm and thrombosis were less frequently observed in group A, albeit to an insignificant extent (P = .39 and P = .49, respectively). CONCLUSIONS Subcutaneous administration of nitroglycerin significantly increased radial artery diameter, which can lead to facilitation of catheterization of the radial artery for arteriography and interventions.

The relationship between angiotensin converting enzyme gene I/D polymorphism and qt dispersion in patients with hypertrophic cardiomyopathy

Introduction: Hypertrophic cardiomyopathy (HCM) is characterized by disorganized myocardial architecture, and may cause ventricular arrhythmias and sudden death. The angiotensin-converting enzyme (ACE) with two deletion alleles (DD genotype) has been proposed to be associated with increased myocardial collagen content. We evaluated QT dispersion (QTd), which reflects regional differences in ventricular repolarization, in HCM patient and controls among the three different ACE genotypes. Materials and methods: Sixty-three patients with HCM and 20 healthy subjects were included in the study. QT parameters were measured from 12 lead electrocardiograms. ACE genotypes were determined from the DNA extracted from peripheral blood by a polymerase chain reaction (PCR) method. QT parameters were compared among the three ACE genotypes both in HCM patients and controls. Results: Median ages were similar in HCM and control groups. QTd and corrected QTd (QTcd) were significantly greater in the HCM group compared with the controls. The frequencies of each genotype were similar in both groups. Although QTd and QTcd did not differ among the three genotypes in the control subjects, they were significantly greater in patients with DD genotype compared with other genotypes in the HCM group. Conclusion: QTd and QTcd are increased in patients with HCM, especially in those with the DD genotype.

Intravascular volume dependency of left ventricular mass calculation by two-dimensional guided M-mode echocardiography

BACKGROUND Increased left ventricular mass (LVM) is an independent risk factor for cardiovascular morbidity and mortality, and may be used for risk stratification. Two-dimensional echocardiography, the most commonly used technique for estimation of LVM, uses the third power of the left ventricular internal diameter (LVID) for the calculation. OBJECTIVES To determine whether a decrease in intravascular volume after dialysis may cause inaccurate estimation of LVM by echocardiography. METHODS Thirty-eight patients undergoing hemodialysis due to chronic renal failure constituted the study group (14 women [37%] and 24 men [63%], mean age +/- SD 38.7+/-10.9 years). LVID, and interventricular and posterior wall thicknesses were measured by two-dimensionally guided M-mode echocardiography. Stroke volume and cardiac output were calculated using left ventricular outflow tract diameter and the pulsed-wave Doppler time-velocity integral obtained from left ventricular outflow tract. LVM was calculated by using Devereuxs formula, and was indexed for body surface area and height. All echocardiographic parameters were measured or calculated before and after dialysis (on the same day), and then compared. RESULTS There were no significant changes in wall thickness; however, LVID, LVM, the LVM/body surface index and the LVM/height index significantly decreased after dialysis (P<0.001 for each parameter). There was a significant correlation between the change in LVID and the change in LVM (P<0.001, r=0.59). Stroke volume and cardiac output also decreased significantly after hemodialysis (P<0.001 for each parameter). CONCLUSIONS Intravascular volume-dependent change in LVID causes inaccurate estimation of LVM, so volume status should be kept in mind, especially in serial assessment of LVM.

Effects of weight loss on ventricular systolic and diastolic functions and left ventricular mass assessed by tissue doppler imaging in obese geriatric women: preliminary report

Background and aims: Obesity is one of the most common diseases in the world. Particularly in elderly subjects, the effects of weight loss on cardiac functions have not been previously investigated by means of pulsed wave tissue doppler imaging (PWTDI). Using PWTDI, we examined the effects of weight loss on cardiac functions and left ventricular (LV) mass in obese geriatric women. Methods: Thirteen obese women aged 66–83 years (mean age 71.2±4.9 yrs) with a body mass index 35.&49 kg/m2 (mean body mass index 39.9±4.3 kg/m2) were evaluated by echocardiography and PWTDI. Only subjects with uncomplicated obesity were included. All measurements, including anthropometric variables, systolic and diastolic indices, and LV mass, were made before and after a 6-month Orlistat plus hypocaloric diet. Myocardial systolic wave (Sm) velocity, isovolumic acceleration (IVA), myocardial precontraction time (PCTm) and the PCTm to contraction time (CTm) ratio were calculated as systolic indices. Early diastolic wave (Em), late diastolic wave (Am), Em to Am ratio, myocardial relaxation time (RTm), deceleration time (DT) and isovolumic relaxation time (IVRT) were determined as diastolic measurements. Results: Subjects lost an average of 8.4±1.2 kg. LV mass decreased significantly after weight loss (p<0.001). In addition, IVRT decreased significantly (p=0.038). Only RTm decreased significantly (p=0.016), whereas other PWTDI parameters of LV remained the same. In the right ventricle, Sm velocity, IVA, Em, and Am velocities were similar. However, the PCTm to Am ratio decreased significantly (p=0.006), and the Em to Am ratio increased (p=0.04) and RTm decreased significantly (p=0.016) after weight loss. Conclusions: In obese geriatric women, weight loss improves ventricular diastolic functions and decreases LV mass. It also contributes to partial improvement in right ventricular systolic function.

Gadolinium:Nonionic contrast media (1: 1) coronary angiography in patients with impaired renal function

This study was to test safety and efficacy of 1:1 mixture of gadolinium:nonionic contrast media in avoiding contrast nephropathy during coronary angiography in patients with renal dysfunction. Although “off label” for x-ray angiography, gadolinium has drawn attention for its potential to avoid contrast nephropathy during coronary angiography. Initial data seem promising. Patients with a baseline creatinine of 1.5 mg/dl or more were included. In order to minimize contrast nephropathy risk, all patients were thoroughly hydrated and treated by N-acetylcysteine. After coronary angiography and/or percutaneous coronary intervention, renal function tests were remeasured on days 1, 2, and 3. A rise of 0.5 mg/dl or more in creatinine value in the following 3 days or the need for dialysis were considered as a contrast nephropathy event. Twenty-six patients were enrolled in this study. Ten were women and 16 were men. The mean age was 65.7 ± 11. Baseline creatinine value was 2.47 ± 0.74 mg/dl. The total amount of contrast medium used on 1:1 fashion was 57.1 ± 27.2 ml. No procedure-related cardiac complication or contrast nephropathy event occurred in this study. Although there was a slight loss in image quality, we felt that the results were adequate for interpretation. Although “off label,” using gadolinium contrast media in a 1:1 mixture with standard nonionic low osmolar contrast media seems to be a viable option in decreasing the likelihood of contrast nephropathy. Further evaluation appears to be warranted.