Turan Erdoğan

Increased pulse wave velocity in patients with panic disorder: Independent vascular influence of panic disorder on arterial stiffness

OBJECTIVE Acute and chronic mental stress and many psychiatric disorders have been accepted as a cause of cardiovascular disease. Panic disorder, a subtype of anxiety disorder, has been associated with increased risk of fatal myocardial infarction and sudden cardiac death in epidemiological studies. Carotid-femoral pulse wave velocity (CF-PWV) is currently the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. The aim of our study is to measure PWV as the surrogate of arterial stiffness and vascular involvement in patients with panic disorder. METHODS Forty-two patients with PD, and 30 control participants were included in the study. Patients with hypertension, diabetes mellitus, or the history of any cardiovascular disease were excluded from study. RESULTS Baseline characteristics were not significantly different between the two groups, except carotid-femoral pulse wave velocity (PD vs. control; 7.51±2.02 vs. 6.24±1.09 m/s, p=0.001), heart rate, and smoking status. Additionally, CF-PWV positively correlated with age (r=0.250, p=0.034), heart rate (r=0.284, p=0.017), systolic and diastolic blood pressure (r=0.393, p=0.001 and r=0.286, p=0.015, respectively) significantly. However, only the presence of panic disorder was independently related to PWV (βeta: 0.317, p=0.011) in the multivariate analysis including age, heart rate, smoking status and blood pressure measurements. CONCLUSION Increased pulse wave velocity in patients with panic disorder may justify the associated risk as documented in previous studies, and may be useful in identifying the patients with higher risk of future cardiovascular complications.

The importance of fragmented QRS complexes in prediction of myocardial infarction and reperfusion parameters in patients undergoing primary percutaneous coronary intervention.

OBJECTIVES The QRS complex fragmentations (fQRS) frequently seen on admission electrocardiograms (ECGs) with narrow or wide QRS complex are associated with increased morbidity and mortality. The causative relationship between fQRS and cardiac fibrosis is known, but the relation of fragmented QRS before and after primary percutaneous coronary intervention (p-PCI) with myocardial infarction and reperfusion parameters has not been studied until now. STUDY DESIGN The study included 184 consecutive patients with ST elevation myocardial infarction (STEMI) who underwent p-PCI. Presence or absence of fQRS on pre- and post-PCI ECGs and its change following PCI were investigated. In addition, independent predictors of fQRS were also investigated. Patients with significant organic valve disease and patients having any QRS morphology with QRS duration ?120 ms as well as patients with permanent pacemakers were excluded from the study. RESULTS Patients with fQRS on admission ECG had higher leukocyte counts (p=0.001), higher CK-MB (p=0.001) and troponin levels (p=0.005), increased pain to balloon time (p=0.004), higher Killip score (p<0.001), prolonged QRS time (p<0.001), higher Gensini score (p<0.001) and more frequent Q waves on ECG (p<0.001) in comparison to patients with non-fragmented QRS. In addition, these patients usually had an infarction of anterior territory related to a lesion in proximal LAD and wider jeopardized myocardium (p<0.001). fQRS was significantly related to infarction and myocardial reperfusion parameters before and after p-PCI. In the setting of STEMI, absence of fQRS on admission ECG predicted increased ST resolution, higher reduction in QRS duration, and better myocardial reperfusion. CONCLUSION FQRS may be useful in identifying patients at higher cardiac risk with larger areas of ischemic jeopardized or necrotic myocardium.

Effect of epicardial adipose tissue on diastolic functions and left atrial dimension in untreated hypertensive patients with normal systolic function

BACKGROUND Adipose tissue is the source of many adipokines affecting the cardiovascular system either locally or systemically. Although hypertension is one of the most important factors in diastolic dysfunction (DD), the exact cause of this relationship is unknown. There is no specific study in the current literature regarding the association of epicardial adipose tissue (EAT) with left ventricular DD in patients with essential hypertension. METHODS The present study was cross-sectional and observational, including 127 patients with untreated hypertension who underwent a complete transthoracic echocardiographic examination as well as measurements of EAT and diastolic parameters. RESULTS EAT was significantly correlated with left atrial dimension, DD parameters, and left ventricular (LV) mass as well as age and blood pressure measurements. EAT was also correlated with Framingham risk score (p<0.001). Age and EAT were significantly increased in patients with high grades of DD compared to those with low values (p<0.001 and p=0.001, respectively). Linear regression analyses revealed EAT as an independent predictor of all DD parameters. The area under the curve values of EAT were similar to age and higher than those of LV mass and mean BP for both the presence of DD and grade two DD. CONCLUSION Based on our findings, increased EAT may be associated with diastolic dysfunction and left atrial dilatation due to local or systemic effects in untreated hypertensive patients. This relationship is independent of and stronger than abdominal obesity, implicating the clinical importance of measuring EAT thickness.

Absence and Resolution of Fragmented QRS Predict Reversible Myocardial Ischemia With Higher Probability of ST Segment Resolution in Patients With ST Segment Elevation Myocardial Infarction

Background and Objectives Fragmented QRS complexes (fQRS) are associated with increased morbidity and mortality. The causative relationship between fQRS and cardiac fibrosis has been shown, but whether the presence and the number of fQRS on admission of electrocardiogram (ECG) predicts ST segment resolution in patients undergoing primary percutaneous coronary intervention (p-PCI) has not been investigated until now. Subjects and Methods This study included one hundred and eighty-four consecutive patients with ST elevation myocardial infarction (STEMI) who underwent p-PCI. The presence or absence of fQRS on pre and post-PCI ECG and their relation with myocardial infarction and reperfusion parameters were investigated. Results Patients with fQRS on admission of ECG or newly developed fQRS after p-PCI had increased inflammatory markers, higher cardiac enzyme levels, increased pain to balloon time, prolonged QRS time, more extended coronary involvement and more frequent Q waves on ECG in comparison to patients with absence or resolved fQRS. The presence and higher number of fQRS on admission or post-PCI ECGs were significantly related with low percent of ST resolution and myocardial reperfusion parameters. The area under the receiver operating characteristics curve values for the presence and number of fQRS to detect Thrombolysis in Myocardial Infarction Blush Grade 0 and 1, were 0.682 and 0.703. Conclusion In our study, fQRS was significantly related to infarction and myocardial reperfusion parameters before and after p-PCI. Successful myocardial reperfusion by p-PCI caused the reduction in number of fQRS and QRS time with higher ST resolution. fQRS may be useful in identifying the patients at higher cardiac risk with increased ischemic jeopardized or infarcted myocardium, and persistent or newly developed fQRS may predict low percent of ST segment resolution in patients undergoing p-PCI.

The Independent Relationship of Systemic Inflammation With Fragmented QRS Complexes in Patients With Acute Coronary Syndromes

Background and Objectives QRS complex fragmentations are frequently seen on routine electrocardiograms with narrow or wide QRS complex. Fragmented QRS complex (fQRS) is associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. In this study, we aimed to interrogate the relationship of systemic inflammation with the presence of fQRS in patients with acute coronary syndromes (ACS). Subjects and Methods Two-hundred and twenty eligible patients with ACS that underwent coronary angiography were enrolled consecutively in this study. Patients with significant organic valve disease and those with any QRS morphology that had a QRS duration ≥120 ms as well as patients with permanent pacemakers were excluded from this study. Results Patients with fQRS were of a higher age (p=0.02), had increased C-reactive protein (CRP) levels (p<0.001), prolonged QRS time (p<0.001), extent of coronary artery disease (CAD) (p<0.001), creatine kinase-MB (CK-MB) levels (p=0.006) and Q wave on admission electrocardiography (p<0.001) in comparison to patients with non-fragmented QRS. When we performed multiple logistic regression analysis, fQRS was found to be related to increased CRP levels {odds ratio (OR): 1.2, 95% confidence interval (CI): 1.045-1.316, p=0.007}, QRS duration (OR: 1.1, 95% CI: 1.033-1.098, p<0.001), extent of CAD (OR: 1.5, 95% CI: 1.023-2.144, p=0.037), Q wave (OR: 2.2, 95% CI: 1.084-4.598, p=0.03) and CK-MB levels (OR: 1.0, 95% CI: 1.001-1.037, p=0.04) independently. Conclusion In our study, we found that fQRS was independently related to increased CRP. Fragmented QRS that may result as an end effect of inflammation at cellular level can represent increased cardiac risk by different causative mechanisms in patients with ACS.

The degree of premature hair graying as an independent risk marker for coronary artery disease: a predictor of biological age rather than chronological age.

OBJECTIVE Age is the most important and uncorrectable coronary risk factor at the moment. The concept of measuring aging biologically rather than only chronologically may be of importance in clinical practice. Hair graying is the most apparent sign of biological aging in humans, yet its mechanism is largely unknown. Today, it is known that cardiovascular risk factors (CVRFs), especially in combination, cause premature atherosclerosis. In our opinion, premature hair graying or whitening may represent early atherosclerotic changes as a surrogate of host response to the CVRFs. In this study, we planned to investigate the relationship of hair graying with CVRFs and coronary atherosclerotic burden in order to determine whether it is an independent marker for coronary artery disease (CAD). METHODS The current study has a cross-sectional observational design. Two hundred and thirteen men who underwent coronary angiography with a suspicion of CAD were enrolled in the study. The patients were evaluated in terms of age, demographical properties and the CVRFs. Hair whitening score (HWS) was defined according to extent of gray/white hairs (1: pure black; 2: black>white; 3: black=white; 4: white>black; 5: pure white). Coronary atherosclerotic burden was assessed by the Gensini score. Analyses were performed in age-matched normal coronary arteries (NCA) and CAD groups. Linear and logistic regression analyses were used for the multivariate analyses of independent variables associated with hair greying. RESULTS The CVRFs were higher in CAD group. Hair whitening score (2.7 ± 1.3 vs. 3.3 ± 1.2, p=0.002), hair losing score (1.2 ± 0.9 vs. 1.5 ± 1.0, p=0.038) and xanthelasma rate (24% vs. 45%, p=0.013) were also significantly different between NCA and CAD groups. Age (p<0001), Gensini score (p<0.001) and coronary severity score (p=0.001) were higher in the categories of increased HWS. In multiple logistic regression analysis, only diabetes mellitus (OR: 3.240, 95% CI: [1.017-10.319], p=0.047), low-density lipoprotein cholesterol, (OR: 1.014, 95%CI: [1.001-1.027], p=0.029) and HWS (OR: 1.513, 95% CI: [1.054-2.173], p=0.025) were independently related to presence of CAD. Age (p<0.001), family history of CAD (p=0.004), hyperlipidemia (p=0.02) and serum creatinine levels (p=0.019) were found as independent predictors of hair graying. CONCLUSION In our study, we found that the degree of gray/white hairs is related to extent of CAD. Our findings also suggested that hair graying is a risk marker for CAD independent of age and other traditional risk factors. Biological age may be important in determining total risk of patients. During assessment of cumulative CVRF effects on human body, presence of biological aging signs may be useful in identifying individuals with increased risk of cardiovascular disease.

Elevated serum osteoprotegerin levels predict in-hospital major adverse cardiac events in patients with ST elevation myocardial infarction

The aim of our study was to investigate whether osteoprotegerin (OPG) is related to in-hospital major adverse cardiac events (MACE) and reperfusion parameters in patients with ST elevation myocardial infarction (STEMI). The OPG/receptor activator of nuclear factor-κB (RANK)/RANK ligand pathway has recently been associated with atherosclerosis. OPG is a predictor of cardiovascular events in patients with acute coronary syndrome. This study included 96 consecutive patients with STEMI undergoing primary percutaneous coronary intervention (PCI). Two groups with equal number of patients were formed according to median OPG level. The association of OPG levels on admission with post-procedural reperfusion parameters, and in-hospital MACE were investigated. Patients with higher OPG levels displayed higher neutrophil/lymphocyte ratio, admission troponin, admission glucose, and high-sensitive C-reactive protein. Higher OPG levels were associated with increased thrombolysis in myocardial infarction (TIMI) risk score, TIMI risk index, pain to balloon time, need for inotropic support, shock, and MACE, mainly driven by death. Reperfusion parameters were not different between the two groups. TIMI risk score, TIMI risk index, myocardial blush grade, estimated glomerular filtration rate (eGFR), number of obstructed vessels, and OPG significantly predicted adverse cardiac events. Multiple logistic regression analysis revealed OPG as an independent predictor of MACE as well as eGFR, number of obstructed vessels, and corrected TIMI frame count. OPG, a bidirectional molecule displaying both atheroprotective and pro-atherosclerotic properties, is currently known as a marker of inflammation and a predictor of cardiovascular mortality. The present study, for the first time, demonstrated that an increased OPG level is related to in-hospital adverse cardiovascular events after primary PCI in patients with STEMI.

Relationship of fragmented QRS with prognostic markers and in-hospital MACE in patients undergoing CABG

Abstract Background. Fragmented QRS complex (fQRS) is associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. However, its prognostic role has not been studied comprehensively in patients undergoing coronary artery bypass graft (CABG) surgery. In this study, we investigated the relationship between the presence of fQRS, and the prognostic markers and in-hospital major adverse cardiovascular events (MACE). Methods. Two hundred and forty two eligible patients who underwent CABG surgery at our institution were enrolled consecutively. In analysis of fragmentations on electrocardiograms, presence of fQRS was defined as various RSR′ patterns (≥ 1 R′ or notching of S wave or R wave) with or without Q waves without a typical bundle-branch block in two contiguous leads corresponding to a major coronary artery territory. MACE was defined as cardiac death, recurrent myocardial infarction, heart failure, cerebrovascular event, sustained ventricular tachycardia or fibrillation. Results. Patients with fragmented QRS had older age (64 ± 10 vs. 61 ± 9 years, p = 0.03), prolonged QRS time (99 ± 11 vs. 87 ± 11 ms, p < 0.001), higher rate of Q wave on ECG (29% vs. 12%, p = 0.001), higher European system for cardiac operative risk evaluation (EUROSCORE) (4.0 ± 1.9 vs. 2.6 ± 1.6, p < 0.001) and lower left ventricular ejection fraction (LVEF)% (43 ± 12 vs. 60 ± 12, p < 0.001) in comparison to patients with non-fragmented QRS. In addition, the patients with fQRS had longer cross-clamp time (67 ± 23 vs. 55 ± 20 minutes, p = 0.001) and extracorporeal circulation (105 ± 31 vs. 91 ± 30 minutes, p = 0.003), increased inotropic usage (p < 0.001) and prolonged cardiac surgery intensive care unit (53 ± 25 vs. 35 ± 12 hours, p < 0.001) and in-hospital stay after CABG. Conclusion. FQRS may have additional value in the assessment of cardiac function and in prediction of intra- and post-operative hemodynamic instability and adverse cardiovascular events. Fragmentations on admission ECG may be useful for identifying patients with higher risk who will need additional support after CABG surgery.

Relationship of fragmented QRS complexes with inadequate coronary collaterals in patients with chronic total occlusion.

Background Fragmented QRS (fQRS) complexes are defined as various RSR′ patterns (≥1 R′ or notching of S wave or R wave) in two contiguous leads corresponding to a major coronary artery territory. In previous studies, fQRS has been associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events (CVEs). The causative relationship between fQRS and cardiac fibrosis has been shown in prior studies. The association between inadequate (poor) coronary collaterals and presence of fQRS has not comprehensively been studied in patients with chronic total occlusion (CTO) until now. We tested the hypothesis that the presence of fQRS is associated with inadequate coronary collateral growth. Methods This study had a cross-sectional observational design. The study population consisted of patients who underwent coronary angiography with the suspicion of coronary artery disease at our institution in an outpatient manner. Patients who had CTO in at least one major epicardial coronary artery were included. Coronary angiograms of 148 eligible patients from our database were analyzed again. Ninety-three patients had good and 55 had poor collateral development according to the Cohen–Rentrop method. Results Patients with poor collateral development had higher plasma glucose (130 ± 54 vs. 116 ± 33 mg/dl, P = 0.047) and an older age (65 ± 10 vs. 61 ± 10 years, P = 0.042) in comparison to patients with good collateral growth. The presence and number of fQRS were higher in the poor collateral group than the good collateral group (64 vs. 32%, P < 0.001 and 2.3 ± 2.4 vs. 1.2 ± 2.0, P = 0.002, respectively). Left ventricular ejection fraction was significantly lower in the poor collateral group than the good collateral group (45 ± 11 vs. 51 ± 13, P = 0.014). There was a significant correlation between number of fQRSs and the echocardiographic wall-motion abnormality score (r = 0.662, P < 0.001). In multivariate analysis, only the presence of fQRS was independently related to poor collateral development (odds ratio, 3.559; 95% confidence interval, 1.708–7.415, P = 0.001). Conclusion We found that fQRS was independently related to inadequate coronary collaterals in patients with CTO. fQRS, which may be derived from the effects of myocardial ischemia or scar on myocardial electricity at the cellular level, can represent inadequate coronary collateral development in patients with CTO.

Bilirubin Level is Associated with Left Ventricular Hypertrophy Independent of Blood Pressure in Previously Untreated Hypertensive Patients.

Background and Objectives Left ventricular hypertrophy (LVH), a sign of subclinical cardiovascular disease, is an important predictor of cardiovascular morbidity and mortality. The aim of our study was to determine the association of left ventricular mass (LVM) with possible causative anthropometric and biochemical parameters as well as carotid intima-media thickness (CIMT) and brachial flow-mediated dilation (FMD) as surrogates of atherosclerosis and endothelial dysfunction, respectively, in previously untreated hypertensive patients. Subjects and Methods Our study included 114 consecutive previously untreated hypertensive patients who underwent echocardiography and ultrasonography to evaluate their vascular status and function via brachial artery CIMT and FMD. Results Among all study parameters, age, systolic blood pressure (BP), diastolic BP, pulse pressure, plasma glucose, uric acid, total bilirubin, direct bilirubin, hemoglobin, and CIMT were positively correlated with the LVM index. Multiple logistic regression analysis revealed that office systolic BP, age, male gender, and total bilirubin were independent predictors of LVH. Conclusion Bilirubin seems to be related to LVM and LVH. The positive association of bilirubin with these parameters is novel and requires further research.