Sirri Kes

Effects of Stroke Localization on Cardiac Autonomic Balance and Sudden Death

BACKGROUND AND PURPOSE Stroke has been shown to alter autonomic function. The purpose of this study was to show the differential effects of stroke localization on autonomic function parameters assessed by heart rate variability (HRV). METHODS To determine the differential effect of ischemic stroke localization on autonomic cardiac innervation, we evaluated 62 patients with ischemic stroke and 62 age- and sex-matched controls. The localization of the infarct was determined by CT and MRI. Power spectrum analysis of HRV was performed. Myocardial necrosis was ruled out by echocardiography and creatine kinase myocardial isoenzymes measurements. RESULTS All stroke patients had significantly decreased low frequency, high frequency, and standard deviation of all relative risk intervals values (P<0.001). However, patients with right-middle cerebral artery (R-MCA) and insula lesions had significantly lower power spectrum analysis values compared with all other localizations (P<0.001). In addition, 5 patients with R-MCA insular lesions died suddenly compared with 2 patients with left-middle cerebral artery insular lesions during hospitalization. Both sympathetic- and parasympathetic-controlled HRV were decreased in patients with ischemic stroke. The most pronounced decrease was found in the territory of R-MCA insular cortex, which suggests that cardiac autonomic tone may be regulated by insula and that these patients are more prone to cardiac complications such as arrhythmias and sudden death due to autonomic imbalance. CONCLUSION We conclude that stroke in the region of insula (especially the right) leads to decreased HRV and to increased incidence of sudden death.

P Wave Dispersion on 12-Lead Electrocardiography in Patients with Paroxysmal Atrial Fibrillation

The prolongation of intraatrial and interatrial conduction time and the inhomogeneous propagation of sinus impulses have been shown in patients with atrial fibrillation. Recently P wave dispersion (PWD), which is believed to reflect inhomogeneous atrial conduction, has been proposed as being useful for the prediction of paroxysmal atrial fibrillation (PAF). Ninety consecutive patients (46 men, 44 women; aged 55 ± 13 years) with a history of idiopathic PAF and 70 healthy subjects (42 men, 28 women; mean age, 53 ± 14 years) were studied. The P wave duration was calculated in all 12 leads of the surface ECC. The difference between the maximum and minimum P wave duration was calculated and this difference was defined as P wave dispersion (PWD = Pmax ‐ Pmin). All patients and controls were also evaluated by echocardiography to measure the left atrial diameter and left ventricular ejection fraction (LVEF). There was no difference between patients and controls in gender (P = 0.26), age (P = 0.12), LVEF (66 ± 4% vs 67 ± 5%, P = 0.8) and left atrial diameter (36 ± 4 mm vs 34 ± 6 mm, P = 0.13). P maximum duration was found to be significantly higher in patients with a history of PAF (116 ± 17 ms) than controls (101 ±11 ms. P < 0.001). P wave dispersion was also significantly higher in patients than in controls (44 ± 15 ms vs 27 ± 10 ms, P < 0.001). There was a weak correlation between age and P wave dispersion (r = 0.27, P < 0.001). A P maximum value of 106 ms separated patients with PAF from control subjects with a sensitivity of 83%, a specificity of 72%, and a positive predictive accuracy of 79%. A P wave dispersion value of 36 ms separated patients from control subjects with a sensitivity of 77%, a specificity of 82%, and a positive predictive accuracy of 85%. In conclusion, P maximum duration and P wave dispersion calculated on a standard surface ECG are simple ECG markers that could be used to identify the patients with idiopathic paroxysmal atrial fibrillation.

Design and evaluation of sustained-release and buccal adhesive propranolol hydrochloride tablets

Abstract The release of propranolol hydrochloride incorporated into sustained-release and buccal adhesive tablets was studied in vitro. The formulation containing 20% hydroxypropyl methylcellulose (HPMC) yielded good sustained-release matrix tablets. Buccal adhesive controlled-release tablets were prepared by compression of HPMC with polycarbophil (PAA), which served as the bioactive adhesive compound. The release behaviour of buccal adhesive tablets was found to be non-Fickian. The adhesion force was significantly affected by the mixing ratio of HPMC and PAA in the tablet and the weakest adhesion force was observed at the ratio of 1:1 (HPMC:PAA). Interpolymer complex formation was confirmed between HPMC and PAA in acidic medium by turbidity, viscosity and FT-IR measurements. The kinetics of sustained-release and buccal adhesive tablets of propranolol were examined in nine healthy volunteers. Conventional propranolol (Dideral®) was also studied for comparison purposes. As compared to conventional propranolol (40 mg), a single dose of 20% HPMC (160 mg) produced a smoother plasma level profile, with lower and delayed peak times. Dose corrected AUC0–8 values were greater after Dideral® than after 20% HPMC (168.7 ± 80.3 vs 97.3 ± 36.1 ng h ml−1 p 0.05) in the AUC0–4 values between 20% HPMC and buccal adhesive tablets.

Echocardiographic Evidence of Cardiac Involvement in Ankylosing Spondylitis

Abstract: Aortic insufficiency, myocardial fibrosis and conduction disturbances are known complications of ankylosing spondylitis (AS). However, few studies have assessed left ventricular diastolic function and no data are available about P-wave analysis. In this study 88 AS patients and 31 healthy volunteers underwent clinical examination, electrocardiography, echocardiography and signal-averaged P-wave analysis for the evaluation of asymptomatic cardiac involvement. The aortic root in AS patients was larger and this was correlated with the duration of the disease. Five of 88 AS patients (5.7%) had evidence of mitral valve prolapse, six (6.8%) had thick and redundant mitral valves without prolapse, five (5.7%) had mild mitral regurgitation, two had moderate (2.3%) and two had mild (2.3%) aortic regurgitation. Examination of diastolic function revealed a lower peak of E-wave velocity (E) and E/A ratio, a higher peak of A-wave velocity (A) and acceleration rate of the A wave, a longer deceleration time of E-wave velocity and isovolumic relaxation time in the AS group compared to controls. Mean filtered P-wave duration (PWD) in AS was similar to that of controls. However, PWD in AS patients was positively correlated with left atrial dimension and acceleration rate of the A wave and negatively correlated with E and E/A ratio. In conclusion, cardiac involvement may be seen in AS patients in the absence of clinical manifestations. Echocardiographic examination of diastolic function can be used in this asymptomatic period. Further studies are needed to clarify the prognostic significance of diastolic abnormalities and the value of P-wave analysis in cardiac evaluation of these patients.

Increased plasma levels of soluble selectins in patients with unstable angina

BACKGROUND Inflammation plays an important role in the pathogenesis of unstable angina. Adhesion molecules, such as selectins, mediate the interactions between leukocytes, platelets and endothelial cells during inflammation and thrombogenesis. HYPOTHESIS The purpose of this study was to determine whether soluble E-selectin, P-selectin and L-selectin levels are increased in patients with unstable angina (UA). METHODS Soluble E-, P- and L-selectin levels were measured by enzyme-linked immunoassay in the peripheral blood of 23 patients with UA, 26 patients with stable angina (SA) and 15 control patients with angiographically normal coronary arteries. RESULTS Soluble E-selectin levels were significantly higher in patients with UA (45+/-11 ng/ml) than in controls (30+/-8 ng/ml, P<0.001), or patients with SA (34+/-8 ng/ml, P=0.001). Similarly, plasma levels of P- and L-selectin were significantly higher in patients with UA (427+/-144 and 772+/-160 ng/ml, respectively) than in patients with SA (278+/-79 and 643+/-94 ng/ml, respectively, P<0.005 vs. UA for both), or control patients (189+/-43 and 601+/-126 ng/ml, respectively, P=0.001 vs. UA for both). CONCLUSIONS Plasma levels of soluble selectins were increased in patients with UA compared with patients with SA or patients without angiographically visible coronary artery disease. Measurements of these adhesion molecules may be helpful as non-invasive markers of coronary plaque destabilization in UA.

Acute Anterior Myocardial Infarction Following a Mild Nonpenetrating Chest Trauma A Case Report

Myocardial infarction in patients under age 45 years is a relatively unusual phenomenon; blunt chest trauma is one of the nonatherosclerotic mechanisms leading to acute myocardial infarc tion in young adults. The authors report a rare case of anterior myocardial infarction in a 22-year- old man following a mild nonpenetrating chest trauma whose left chest was elbowed during a soccer game.

Left Ventricular Long-Axis Function Is Reduced in Patients with Rheumatic Mitral Stenosis

Left ventricular long‐axis function evaluated by M‐mode or tissue Doppler echocardiography has been shown to be useful indexes of left ventricular systolic function; however it has not been evaluated in patients with mitral stenosis. We examined the left ventricular long‐axis function of the patients with pure mitral stenosis and normal global systolic function as assessed by fractional shortening of the left ventricle (LV). Fifty‐two patients with pure mitral stenosis and twenty‐two healthy controls were evaluated by echocardiography. Although there was no statistically significant difference in global systolic function, M‐mode derived systolic motion of the septal side and (12 ± 3 vs 14.4 ± 1.5 mm, P = 0.016) the lateral side of mitral annulus (13.2 ± 3 vs 16.8 ± 2 mm, P = 0.001) were both significantly lower in the patients with mitral stenosis than control subjects. Similarly tissue Doppler systolic velocity of the septal annulus (7.6 ± 1.1 vs 10.4 ± 3.2 cm/s, P = 0.03) and lateral mitral annulus (7.6 ± 1.1 vs 10.4 ± 3.2 cm/s, P = 0.003) were also significantly lower in patients with mitral stenosis than in controls. There was a statistically significant correlation between septal annular motion and annular velocity (r = 0.643, P = 0.002). Septal annular motion and annular velocity were also correlated with left atrial ejection fraction (r = 0.338, P = 0.005 and r = 0.676, P = 0.001, respectively). Thus, patients with mitral stenosis had significantly impaired long‐axis function evaluated by M‐mode or tissue Doppler echocardiography despite normal global systolic function. (ECHOCARDIOGRAPHY, Volume 21, February 2004)

Assessment of Heart Rate Turbulence in the Acute Phase of Myocardial Infarction for Long-Term Prognosis

SADE, E., et al.: Assessment of Heart Rate Turbulence in the Acute Phase of Myocardial Infarction for Long‐Term Prognosis. This study is designed to assess the value of heart rate turbulence (HRT) in the acute phase of MI for prediction of long‐term mortality risk. The study included 128 consecutive acute MI patients with 24‐hour Holter recordings to evaluate HRT (turbulence onset and slope), SDNN, mean RR interval, and ventricular premature beat frequency. LVEF was evaluated by two‐dimensional echocardiography. Data from 117 patients (mean age 58 ± 11 years) were available for further analysis. Twelve patients died during follow‐up (mean 312 ± 78 days). Although SDNN < 70 ms was the most powerful predictor of mortality among all presumed risk factors (hazard ratio 20 [95% CI 2.6–158]; P = 0.004) in univariate Cox regression analysis, in multivariate analysis LVEF ≤ 0.40 and turbulence slope ≤2.5 ms/RR interval were the only independent predictors of mortality (hazard ratio 6.9 [95% CI 1.8–26]; P = 0.006, hazard ratio 7.3 [95% CI 1.4–37]; P = 0.016, respectively). Addition of HRT parameters for LVEF increased remarkably the positive predictive value (60%) without any decrease in the negative predictive value (92%). Blunted HRT reaction within the first 24 hours of acute MI is an independent predictor of long‐term mortality. Furthermore, its predictive power is comparable and also additive to that of LVEF. (PACE 2003; 26[Pt. I]:544–550)

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Effects of short-term atorvastatin treatment on global fibrinolytic capacity, and sL-selectin and sFas levels in hyperlipidemic patients with coronary artery disease

BACKGROUND The beneficial effects of HMG-CoA reductase inhibitors (statins) in patients with coronary artery disease (CAD) appear to be attributable not only to their lipid-lowering properties, but also to their therapeutic effects on the coagulation system, and anti-inflammatory effect. Furthermore, statins mitigate the apoptosis of vascular smooth muscle cells (VSMC) and macrophages in atherosclerotic plaques. HYPOTHESIS The purpose of this study was to evaluate the effects of short-term atorvastatin treatment on the fibrinolytic system and systemic inflammatory status, and on apoptosis in hyperlipidemic patients with CAD. METHODS The study population consisted of 36 hyperlipidemic patients (14 women and 22 men, mean age 53+/-9 years) with stable CAD, untreated with lipid-lowering medications. Serum lipoproteins, fibrinogen levels, sFas and sL-selectin, and global fibrinolytic capacity (GFC) were measured at baseline and after 12 weeks of treatment with atorvastatin, 10 mg/day. RESULTS Atorvastatin treatment decreased serum low-density lipoprotein (-39%, P=0.0001), total cholesterol (-32%, P=0.0001), and triglycerides (-22%, P=0.0001), and increased high-density lipoprotein (+13%, P=0.0001) at 12 weeks compared to baseline. These effects were associated with a decrease in plasma fibrinogen from 331+/-73 to 298+/-58 mg/dl (P=0.0001), and sL-selectin levels from 666+/-201 to 584+/-162 ng/ml (P=0.0001). sFas levels and GFC increased from 3754+/-1264 to 4873+/-1835 pg/ml and from 3.5+/-2.4 to 5.6+/-2.9 microg/ml, respectively (both P=0.0001). CONCLUSIONS These results suggest that lipid lowering with atorvastatin therapy significantly increases GFC, decreases fibrinogen levels, and causes leukocyte deactivation. Our findings also suggest that atorvastatin treatment mitigates apoptosis of VSMC in the atherosclerotic plaque. These effects of atorvastatin may, in part, explain the early decrease in cardiovascular events observed in clinical trials of statins.