Tugrul Inanc

Platelet activation and inflammatory response in patients with non-dipper hypertension

OBJECTIVE Non-dipper hypertensives had about three times the risk of atherosclerotic events than hypertensives whose blood pressure was >10% lower at night compared to daytime (dippers). Platelet activation and inflammatory response may derive from most atherosclerotic events. Mean platelet volume (MPV) is a determinant of platelet activation and high sensitive C-reactive protein (hs-CRP) is the best candidate assay to identify and monitor the inflammatory response. We aimed to determine whether MPV and hs-CRP levels are elevated in non-dipper patients compared to dippers and healthy controls. In addition, we tried to find out if MPV and CRP are related to each other or not in non-dipper hypertensives. METHOD The total 126 patients study group included 86 patients with hypertension and 40 healthy subjects (16 male, mean age; 51+/-4) as control. Ambulatory blood pressure monitoring was performed for all patients. Hypertensive patients were divided into two groups; 46 dipper patients (18 male, mean age; 50+/-9) and 40 non-dipper patients (17 male, mean age; 53+/-11). Clinical baseline characteristics were similar between groups. We measured mean platelet volume in a blood sample collected in EDTA tubes and high-sensitive CRP was measured by using BN2 model nephlometer. RESULTS Non-dipper patients demonstrated higher levels of MPV compared to dippers and normotensives (9.72+/-0.52 fl vs 9.38+/-0.33 fl and 8.92+/-0.42 fl, p<0.05, respectively). High-sensitive CRP levels were also significantly higher in non-dippers compared to dippers and normotensives (4.9+/-1.7mg/l vs 3.8+/-1.5mg/l and 2.7+/-0.8mg/l, p<0.05, respectively). There was significant positive correlation between MPV and CRP levels (p=0.002, r=0.482) in non-dipper hypertensives. CONCLUSION Our results suggest that patients with non-dipping tend to have increased platelet activation and inflammatory response. Increased platelet activation and inflammatory response could contribute to increase the atherosclerotic risk in non-dipper patients compared to dippers.

The mean platelet volume in patients with non-dipper hypertension compared to dippers and normotensives

Abstract Objectives. Increased platelet activation plays an important role in the development of atherosclerosis. Mean platelet volume (MPV) is a determinant of platelet activation. In our study, we aimed to determine whether MPV levels are elevated in non-dipper patients compared with dippers and healthy controls. In addition, we tried to find out if MPV levels are correlated with blood pressure measurements in hypertensive patients. Methods. This cross-sectional study included 56 hypertensive patients; 27 age- and sex-matched healthy volunteers were enrolled to study as a control subjects. Ambulatory blood pressure monitoring was performed for all patients. Hypertensive patients were divided into two groups: 28 dipper patients (10 male, mean age 51 ±8 years) and 28 non-dipper patients (11 male, mean age 53±10 years). MPV was measured in a blood sample collected in EDTA tubes and was also used for whole blood counts in all patients. Results. In non-dipper patients, 24-h systolic blood pressure (141.5±10.21 vs 132.3±7.7 mmHg, p<0.001), 24-h diastolic blood pressure (88.2±8.5 vs 81.0±8.2 mmHg, p<0.01) and 24-h average blood pressure (105.7±8.5 vs 97.7±7.4 mmHg, p<0.001) are significantly higher than dippers. Whereas daytime measurements were similar between dippers and non-dippers, there was a significant difference between each group during night-time measurements (night-time systolic 137.1 ±11.0 vs 120.2±8.0 mmHg, p<0.001; night-time diastolic 85.3±8.0 vs 72.8±7.9 mmHg, p<0.001). Non-dipper patients (9.61 ±0.42 fl) demonstrated higher levels of MPV compared with dippers (9.24±0.35 fl) and normotensives (8.87±0.33 fl) (p<0.001 and p<0.001, respectively). There was significant correlation between MPV and ambulatory diastolic and systolic blood pressure in non-dipper hypertensives. Conclusion. Our results suggest that MPV, a determinant of platelet activation, has a positively correlation with blood pressure and elevated in non-dipper compared with dippers and controls. Increased platelet activation could contribute to increase the atherosclerotic risk in non-dipper patients compared with dippers.

Plasma B-type natriuretic peptide in diagnosing inferior myocardial infarction with right ventricular involvement.

BackgroundB-type natriuretic peptide (BNP) is secreted from the ventricles in response to volume expansion and pressure overload. We aimed to investigate plasma BNP levels in inferior myocardial infarction (MI) with and without right ventricular MI (RVMI). MethodsWe enrolled 49 patients (mean age: 60±10 years, 45 males) who were admitted with first acute inferior MI. Sixteen patients (mean age: 58±10 years, 15 males) had also RVMI. The BNP levels were measured at admission. All patients underwent echocardiographic examination in the first day of hospitalization. Receiver-operating characteristic curve was obtained for prediction of inferior MI with RVMI. ResultsInferior MI with RVMI had lower RV fractional area change (36±14% vs. 48±15%, P=0.03) and right ventricle lateral annulus S velocity (10.6±1.9 m/s, 12.2±2.6 m/s, P=0.02). The BNP levels were higher in inferior MI with RVMI than isolated inferior MI (75±44 pg/ml vs. 32±24 pg/ml, P=0.001). On the basis of the receiver-operating characteristic analysis, the cutoff value of BNP concentration >46 pg/ml provided the best discrimination of patients with and without RVMI (sensitivity 76%, specificity 88%) with positive and negative predictive values of 92 and 63%, respectively. ConclusionPlasma BNP levels are higher in inferior MI with RVMI than isolated inferior MI. RV involvement may be suspected when BNP levels are higher than 46 pg/ml in inferior MI.

Thrombus crossing through a patent foramen ovale

Paradoxical embolism across a patent foramen ovale (PFO) is a rare clinical entity and the thrombus is rarely caught passing through a PFO. A 65-year-old woman presented with dyspnea and pleuritic chest pain. Lower extremity venous Doppler ultrasound showed bilaterally extensive thrombosis at deep veins. Transthoracic echocardiographic examination showed two masses in both left and right atriums. In transesophageal echocardiography (TEE) interatrial septum was thin and aneurysmatic and a thrombus wedged through a patent foramen ovale and lodged in both atriums was demonstrated. We considered this mass as a thrombus crossing through a patent foramen ovale. He refused surgery and during anticoagulation therapy the patient had brachial artery embolism. Embolectomy material was reported as a thrombus.

Left Ventricular Strain and Strain Rate Echocardiography Analysis in Patients with Total and Subtotal Occlusion in the Infarct‐Related Left Anterior Descending Artery

Background: Numerous studies show that percutaneous coronary intervention has no clinical benefit in patients with total occlusion. Both regional and global left ventricle (LV) functions may be evaluated in detail by strain (S) and strain rate (SR) echocardiography. The purpose of this study is to evaluate whether S and SR echocardiography may be used to determine the total occlusion. Method: Sixty stable patients who have total or subtotal occlusion in the infarct‐related left anterior descending artery were enrolled (Total occlusion group: 35 and subtotal occlusion group: 25 patients). In all patients, LV longitudinal S and SR data were obtained from total 14 segments. Results: S values of middle and apical segments of LV were significantly lower in the total occlusion groups. In SR analysis, middle and apical values of all walls were significantly different between the groups. The total SR of the middle and apical segments was significantly lower in the total occlusion group (respectively, total SR in middle segments: −3.4 ± 0.8% vs. −4.6 ± 1.0%, P < 0.00001 and total SR in apical segments: −1.7 ± 0.5% vs. −2.8 ± 0.6%, P = 0.001). The total SR values of four walls were also significantly lower in the total occlusion group (−10.3 ± 2.0% vs. −13 ± 3.1%, P < 0.0001). For predicting total occlusion, the highest sensitivity levels (84%) were obtained in SR of middle‐anterior segment. SR of middle‐septum and middle‐lateral segments has the highest specificity levels (86%). Conclusion: Total occlusion in stable patients with acute coronary syndrome has an unfavorable effect on the LV regional and global functions. Patients with total occlusion may be identified by S and SR echocardiography. (Echocardiography 2011;28:203‐209)

Fatal Pulmonary Oedema Following Oxytocin Administration in a Pregnant Woman with Acute Myocardial Infarction

Acute myocardial infarction is a rare event in pregnant patients. Mechanical valves are naturally thrombogenic and require careful anticoagulation. Pregnancy produces a hypercoagulable situation and necessitates close follow-up in pregnant patients with mechanical heart valves. We present a 34-year-old pregnant woman who had mitral and aortic valve prosthesis. She developed resistant pulmonary oedema in the post-partum period after myocardial infarction. Oxytocin was used in this patient to induce midterm labour and prevent post-partum bleeding. Issues surrounding management of pulmonary oedema and use of oxytocin therapy during pregnancy are discussed. We emphasize the need for awareness of this condition and call attention to the risk of pulmonary oedema during labour.

The relation between microalbuminuria and coronary collateral vessel development in patients with unstable coronary artery disease.

Microalbuminuria, considered a marker for systemic vascular disease, is a significant predictor of increased risk for cardiovascular morbidity and mortality in the general population. The relationship between microalbuminuria and cardiovascular disease is unknown. The aim of this study is to examine the association between microalbuminuria and coronary collateral vessel (CCV) development in nondiabetic and nonhypertensive patients with unstable coronary artery disease (USCAD). One hundred and six patients that had USCAD without hypertension and diabetes participated in the study. Microalbuminuria was assessed by radioimmunoassay in 24-h urine collections performed on the first day, and coronary angiography was performed 2–4 days after admissions. In total, 26 patients (mean age 56±14 years) had the criteria of the microalbuminuria group and 80 patients with normoalbuminuria (mean age 59±11 years), who had one or more diseased vessels with 80% or more stenosis, were included in the control group. The CCVs are graded according to the Rentrop scoring system and a Rentrop grade ≥1 was accepted as CCV development. CCV development was detected in eight (23%) of 26 patients in the microalbuminuria group and in 53 (74%) of 80 patients in the normoalbuminuria group. CCV development in the patients in the normoalbuminuria group was significantly different from that of the patients in the microalbuminuria group (r = −0.15, P = 0.006). In conclusion, these findings suggest that CCV development is poorer in the microalbuminuria group than the normoalbuminuria group. This study shows that in patients with USCAD, microalbuminuria, which is related to systemic vascular disease, affects CCV development negatively.

Prognostic factors in patients with implantable cardioverter-defibrillators.

We have read with great interest the report by Borleffs et al. ([1][1]) about atrial fibrillation (AF) and mortality in patients with implantable cardioverter-defibrillators (ICDs). The investigators found that AF is a prognostic factor in ICD patients, but some issues need to be considered. The

The role of heart-type fatty acid-binding protein in predicting properties of coronary atherosclerosis in patients with acute coronary syndrome.

IntroductionFatty acid-binding protein (FABP) is an independent predictor of cardiac events. However, the relation between increasing FABP and coronary atherosclerosis is unknown. We have investigated the relation between FABP and angiographic properties of coronary atherosclerosis in patients with acute coronary syndrome (ACS). MethodsThe study population consisted of 93 patients with ACS (mean age: 56±10 years). Patients presenting to the emergency department within 2 h after onset of anginal symptoms were enrolled in the study. FABP was measured at second, fourth and sixth hours of chest pain. Cut-off FABP was accepted as 1.9 ng/ml. Coronary atherosclerosis was assessed with diseased vessel number (≥50 and ≥70% luminal narrowing), Gensini and extent scores. ResultsMedian FABP-2 was 2.9 ng/ml (interquartile range: 1.6–10.4). Peak FABP was measured at fourth hour [median: 35.0 ng/ml (interquartile range: 2–77)]. There was a nonsignificant relation between angiographic findings and FABP-2. At fourth hour, Gensini, extent score and diseased vessel number were significantly higher above the cut-off level of FABP-4 (Gensini score: 3.7±3.4 vs. 6.2±3.4, P=0.005; extent score: 11.1±10 vs. 22.3±19.2, P=0.007; diseased vessel: 0.7±0.6 vs. 1.6±1.0, P=0.003, respectively). The sensitivity of FABP-2 for at least 50% lesion was 70%. The highest sensitivity was obtained at fourth hour (85% for ≥50% and 88% for ≥70% lesions). The sensitivity and positive predictive values for revascularization were 70 and 77% for FABP-2, 89 and 80% for FABP-4 and 89 and 81% for FABP-6. ConclusionFABP levels are closely related with angiographic properties of patients with ACS. FABP may be an early and important marker for predicting the coronary anatomy and decision of treatment.

The success of warfarin treatment for coronary thrombosis in a young patient with acute coronary syndrome.

and AVF. Troponin T, CK, and CK-MB values were elevated. Medical therapy, including clopidogrel, aspirin, intravenous nitroglycerine, and subcutaneous enoxaparine was started. He underwent cardiac catheterization immediately. Severe thrombus rich lesions were detected both in the proximal left anterior descending artery (LAD) and the circumflex artery (Cx), and the glycoprotein IIb/IIIa inhibitor, tirofiban infusion was started (Figure 1). Direct stent implantation was performed for the critical LAD culprit lesion. The patient became asymptomatic. We had considered angioplasty for the Cx lesion with a distal protection device. One week later, angiography showed decreased thrombus formation in the Cx (Figure 2). He was asymptomatic and the To the Editor: Thrombogenesis plays a major role in acute coronary syndromes. Smoking leads to endothelial dysfunction and predisposes to thrombus formation in coronary arteries. A 28-year-old man was admitted to our clinic with a complaint of typical chest pain. He had no prior history of cardiac disease and no coronary risk factor other than smoking. On physical examination, his arterial blood pressure was found to be 120/60 mm Hg, and his heart rate was 88 bpm. A mild systolic ejection murmur was noticed at the left sternal border. The presenting electrocardiography revealed sinus rhythm, ST segment elevation in leads V1-6, and reciprocal ST segment depression in leads DII, III,