Uğur Arslan

Association between nonalcoholic fatty liver disease and coronary artery disease

AimsTo demonstrate whether there is a relationship between the presence of nonalcoholic fatty liver disease (NAFLD) and the presence and extent of coronary artery disease (CAD). Patients and methodsNinety-two consecutive patients who planned to undergo coronary angiographies (CAG) without known CAD, other than findings of acute coronary syndrome, were enrolled in this study. Abdominal ultrasonography was performed before the CAG to detect NAFLD. CAD was defined as a stenosis of at least 50% in at least one major coronary artery. The extent of CAD was measured according to the number of major coronary artery/arteries affected by CAD. All the risk factors for CAD were included in a binary logistic regression model. Forward, backward, or step-wise selections were not used. P<0.05 was accepted as being significant. ResultsSixty-five of the 92 patients (70.7%) were detected, by abdominal ultrasonography, to have fatty liver and 43 patients out of 92 (46.7%) were detected, by CAG, to have significant CAD. According to the results of logistic regression analysis, the presence of NAFLD independently increased the risk for CAD, as seen in CAG [odds ratio (OR), 95% confidence interval (CI): 6.73 (1.14–39.61); P=0.035]; this was despite factoring in the other risk factors for CAD and the components of metabolic syndrome. NAFLD was more commonly found in patients as the extent of CAD increased (P=0.001). ConclusionThe presence of NAFLD is independently associated with the presence and extent of CAD. Future studies are needed to explain the mechanisms of this relationship.

Dual coronary artery–pulmonary artery fistulas

A 62-year-old man presented with exertional angina. His physical examination and electrocardiogram were normal. Myocardial perfusion scintigraphy showed ischemia of the anterior wall of the left ventricle. The patient’s echocardiographic examination was normal. Coronary angiography revealed dual coronary artery fistulas originating from the first diagonal and conus branches of the right coronary artery and opening into the main pulmonary artery (Figures 1 and ​and2).2). Coil occlusion of the fistulas was recommended to the patient. Figure 1) Coronary angiography (90° left anterior oblique, 0° caudal projection) Figure 2) Coronary angiography (46° left anterior oblique, 0° caudal projection)

Relationship between N-terminal pro-B type natriuretic peptide and extensive echocardiographic parameters in mild to moderate aortic stenosis

CONTEXT The N-terminal pro-B type natriuretic peptide levels (NT pro-BNP) are increased in cases of volume or pressure overload. AIMS To examine NT pro-BNP levels and enclose whether any relationship is present between the levels of NT pro-BNP and extensive echocardiographic parameters in asymptomatic patients with mild to moderate aortic stenosis (AS). SETTINGS AND DESIGN A cross-sectional study about the NT pro-BNP levels was conducted in 37 asymptomatic AS patients and compared with 40 controls. METHODS Patients < 70 years old with mild to moderate AS with a peak transaortic gradient > 20 mm Hg in transthoracic echocardiogram were included in our study. Extensive echocardiographic parameters and NT pro-BNP levels were obtained from these patients and these indices were compared with the control population selected from the patients who had similar clinical characteristics with the AS patients. STATISTICAL ANALYSIS NT-proBNP values were found to be distribution free. Spearman correlation coefficient was used for correlation analysis. Mean values were compared by the Kruskal-Wallis test. RESULTS The NT pro-BNP levels were increased in patients with AS (median; interquartiles range: 686 [449-855] pg/mL vs. 140 [116-150] pg/mL, P < 0.001). Among patients with AS, when correlation analysis was performed mean transaortic gradient, aortic valve area index, myocardial performance index, E(m)/A(m) ratio, left-ventricular mass index (LVMI) and E/E(m) ratio had correlations (r=0.38, P = 0.026; r=-0.46, P =0.008; r=0.19, P =0,049; r=-0.22, P =0.04, r=0.49, P =0.003 and r=0.53, P <0.001 respectively) with plasma NT pro-BNP levels. The LVMI (r = 0.49, P = 0.003) and E/E(m) ratio (r = 0.53 P < 0.001) have the strongest correlations when compared to other parameters. CONCLUSION Plasma NT pro-BNP levels are increased in even asymptomatic patients with AS and correlated with several echocardiographic parameters related to severity of AS and degree of diastolic dysfunction. As a result, NT pro-BNP levels may be used in the follow-up of asymptomatic patients having mild to moderate AS.

The delta fractional flow reserve can predict lesion severity and long-term prognosis

BACKGROUND Fractional flow reserve (FFR) is a method which is used to identify the angiographically intermediate lesions requiring revascularization. However, physiological importance and clinical usability of delta (Delta) FFR, the difference between FFR in baseline conditions (FFRbase, resting) and after adenosine administration (FFRmin, hyperemic), is currently unknown. We aimed to investigate whether DeltaFFR may be helpful in the identification of the lesion severity and predictability of long-term prognosis. METHOD AND RESULTS We enrolled 123 consecutive patients with an intermediate lesion (40-70% stenosis) at LAD in this study. The patients were divided into three groups according to FFRmin results (group I: FFR>0.80, n=71; group II: FFR between 0.75 and 0.80, n=28; group III: FFR<0.75, n=24). We followed the patients for a mean duration of 36+/-17 months for major adverse cardiac events (MACE). For the sensitivity and the specificity of DeltaFFR to detect the lesion severity, the area under ROC curve was found as 0.873 (95% CI: 0.788-0.958, P<0.001). When >or=15 is accepted as the cut-off value for DeltaFFR, the specificity was 95%, the sensitivity was 59% for lesion severity. When we compared the predictability of MACE by FFRmin and DeltaFFR, there is no difference in FFRmin groups (FFR<0.75, 0.75-0.80 and FFR>0.80) (29%, 46% and 30%, respectively, P=0.247). However, between the groups which were determined according to cut-off values for DeltaFFR (DeltaFFR<10; DeltaFFR, 10-15; DeltaFFR>or=15) among the patients with FFR<or=0.80, MACE was significantly different (73%, 44%, 11%; respectively, P=0.003). CONCLUSION DeltaFFR may represent the vascular ischemic compensatory capacity to a significant lesion and this response capacity shows the severity of the lesion with high specificity. Decreased and insufficient vascular response capacity to a significantly lesion relates to the poor long-term clinical prognosis. DeltaFFR may be helpful in the identification of the lesion severity in the assessment of intermediate coronary lesions; it can be used as a guide for revascularization decision and in predictability of long-term clinical prognosis.

Atrial Fibrillation Induced by Gemcitabine Treatment in a 65-Year-Old Man

Gemcitabine, a pyrimidine analogue, is a cell cycle-specific antineoplastic agent that is structurally related to cytarabine. Major side effects of the treatment with gemcitabine are hepatic dysfunction, myelosuppression, renal impairment and pulmonary toxicity. Development of atrial fibrillation (AF) during gemcitabine treatment is very rare and was reported in only 2 case reports in the literature. Case Report: We report the case of a 65-year-old man who developed AF under gemcitabine therapy for non-small cell lung cancer (stage IIIB). In this patient, AF was intrinsically associated with chemotherapy administration which triggered arrhythmia. Conclusion: Although AF caused by gemcitabine appears to be rare, patients at risk of developing atrial fibrillation should be closely monitored for this complication.

Endothelial progenitor cells (CD34+KDR+) and monocytes may provide the development of good coronary collaterals despite the vascular risk factors and extensive atherosclerosis.

OBJECTIVE Endothelial progenitor cells (EPC) have a regenerative role in the vascular system. In this study, we aimed to evaluate simultaneously the effects of EPC and inflammatory cells on the presence and the extent of coronary artery disease (CAD) and the grade of coronary collateral growth in patients with clinical suspicion of CAD. METHODS This study has a cross-sectional and observational design. We enrolled 112 eligible patients who underwent coronary angiography consecutively (mean age: 59±9 years). The association of circulating inflammatory cells and EPC (defined by CD34+KDR+ in the lymphocyte and monocyte gate) with the presence, severity and extent of CAD and the degree of collateral growth were investigated. Logistic regression analysis was used to define the predictors of collateral flow. RESULTS Of 112 patients 30 had normal coronary arteries (NCA, 27%, 55±9 years) and 82 had CAD (73%, 61±8 years). Among the patients with CAD, the percent degree of luminal stenosis was <50% in 12 patients; 50-90% in 35 patients; and ≥90% in the other 35 patients. Circulating inflammatory cells were higher (leukocytes, 7150±1599 vs 8163±1588 mm(-3), p=0.001; neutrophils, 4239±1280 vs 4827±1273 mm(-3), p=0.021; monocytes, 512±111 vs 636±192 mm(-3), p=0.001) and EPCs were lower (0.27±0.15% vs 0.17±0.14%, p<0.001; 21±15 vs 13±12 mm(-3), p=0.004) in CAD group than NCA group. When we investigated the collateral growth in patients having ≥90% stenosis in at least one major coronary artery, we found that the patients with good collateral growth had significantly higher EPC (0.22±0.17% vs 0.10±0.05%, p=0.009; 18±15 vs 7±3 mm(-3), p=0.003) in comparison to patients with poor collateral growth. Presence of EPC was associated with reduced risk for coronary artery disease (OR: 0.934, 95%CI: 0.883-0.998, p=0.018) and was an independent predictor for good collateral growth (OR: 1.295, 95%CI: 1.039-1.615, p=0.022). A sum of CD34+KDR-, CD34+KDR+ and CD34-KDR+ cells (192±98 mm(-3)), and a CD34-KDR- cell subpopulation within monocyte gate (514±173 mm(-3)) reached to highest counts in good collateral group among all study population. CONCLUSION Endothelial progenitor cells can be mobilized from bone marrow to induce the coronary collateral growth in case of myocardial ischemia even in presence of the vascular risk factors and extensive atherosclerosis. This finding may be supportive to investigate the molecules, which can specifically mobilize EPC without inflammatory cells.

Levosimendan accelerates recovery in patients with takotsubo cardiomyopathy

BACKGROUND The aim of this study was to determine the efficacy and safety of levosimendan in takotsubo cardiomyopathy (TC). METHODS The study was conducted in a retrospective design and 42 consecutive patients were enrolled in 6 cardiovascular centers in Turkey. The records of TC patients having left ventricular ejection fraction (LVEF) £ 35% were examined at admission, discharge and recovery period including their clinical and echocardiographic data. RESULTS Of these 42 TC patients, 17 were treated with loading dose and i.v. infusion of levosimendan (group 1) and 25 were treated without levosimendan (group 2). Echocardiographic findings at admission and at discharge were similar and no serious complications were observed in either group. However recovery period including the interval of 50% increase in LVEF, time to achieve the baseline troponin values and hospitalization were significantly lower in patients taking levosimendan. CONCLUSIONS This is the first study using loading dose and subsequent continuous intravenous administration of levosimendan demonstrating accelerated recovery in patients with TC.

Monocyte heterogeneity in myocardial infarction with and without ST elevation and its association with angiographic findings

ObjectivesMonocytes and mature macrophages play significant roles after myocardial infarction. Here, our aim is to investigate the monocyte heterogeneity in acute ST elevation myocardial infarction (STEMI) and non-STEMI separately and determine any possible relationships between monocyte heterogeneity and coronary angiographic characteristics. MethodsThirty STEMI, 30 non-STEMI, and 25 stable angina pectoris patients were enrolled. Blood samples were taken immediately at admission, and on days 2, 3, 4, 5, and 7 after STEMI or non-STEMI for cytometric analysis to determine monocyte heterogeneity. Peak creatine kinase (CK) and CK-myocardial band (CK-MB) levels were used to determine the severity of myocardial infarction. Coronary angiographic findings, such as the Gensini score, the presence of acute total occlusion, and development of no reflow after stenting, were noted. ResultsThe peak levels of CD14++CD16− monocytes were higher and were reached later in the STEMI group (631.6±116.7 vs. 539.6±103.0/mm3, P=0.003; day 2.73±0.64 vs. 2.27±0.74, P=0.011). Peak CK and CK-MB levels were correlated positively with CD14++CD16− monocytes in the non-STEMI group. The Gensini score was found to be correlated with the peak CD14+CD16+ monocyte levels in the non-STEMI and stable angina pectoris groups. Patients with total occlusion of the culprit artery had significantly higher levels of CD14++CD16− monocytes (642.3±113.2 vs. 532.5±98.2/mm3, P<0.001). The peak levels of CD14++CD16− monocytes were higher in patients with no reflow compared with the patients with thrombolysis in myocardial infarction grade 3 flow after percutaneous coronary intervention of the culprit lesion (688.1±104.6 vs. 565.1±111.0, P=0.002). In patients with no reflow, we also found higher peak CD14+CD16+ monocyte levels (82.3±12.1 vs. 71.2±10.6, P=0.02). ConclusionMonocyte heterogeneity differs in STEMI and non-STEMI. Peak levels of CD14++CD16− monocytes were higher and were reached later in the STEMI group compared with the non-STEMI group. More importantly, worse angiographic characteristics related to prognosis are associated with monocyte heterogeneity in both STEMI and non-STEMI patients.

Heart rate variability and heart rate turbulence in mild-to-moderate aortic stenosis

AIMS To study heart rate (HR) variability and HR turbulence parameters in mild-to-moderate aortic stenosis (AS) and to disclose whether any relationship exists between these parameters and echocardiographic findings. METHODS AND RESULTS Forty-three asymptomatic patients with mild-to-moderate AS (AS group) were studied. Echocardiographic parameters and HR variability and HR turbulence indices obtained over 24 Holter ECG recordings were compared with those of an age and sex matched control population free of cardiovascular disease. Correlation between echocardiographic findings and HR variability and HR turbulence indices was also studied in the AS group. All HR variability parameters except mean RR interval, RMSSD, and pNN50 and one HR turbulence parameter, turbulence onset, were significantly disturbed in the AS group. Echocardiographic findings of diastolic dysfunction had significant correlations with HR variability and HR turbulence parameters in AS patients. CONCLUSION Symphatovagal imbalance as shown by disturbed HR variability and HR turbulence parameters was demonstrated for the first time in patients with mild-to-moderate AS. This imbalance, which was shown to be correlated with echocardiographic findings of diastolic dysfunction, may lead to arrhythmic complications in this seemingly low-risk patient population.

Heart rate variability in neurally mediated reflex syncope

Objective — The aim of this study was to investigate the heart rate variability (HRV) parameters in patients with neurally mediated reflex syncope. Methods — Thirty-three patients (10men, age range 16-50years) who were scheduled to undergo head-upright tilt test (HUTT) with a typical history of vasovagal syncope (VVS) underwent 24-hour Holter monitoring in an attempt to study HRV parameters. Sixteen individuals without syncope and similar baseline characteristics made up the control group. Results — Seventeen of the 33syncopal patients showed HUTT positivity. All the time domain HRV parameters except the mean RR interval were higher in the HUTT (+) syncopal patients than in the negative responders. Although not statistically significant, the positive responders had higher NN50, pNN50, RMSSD and SDNNi values than the control group. HUTT (-) VVS patients had lower SDNN and SDANN values when compared with the control group.The other HRV parameters did not differ significantly between the HUTT (-) patients and the control group. Conclusion — Increased parasympathetic tonus as reflected by significantly higher HRV parameters is associated with a greater frequency of HUTT positivity in patients with syncope and no organic heart disease.