Zafer Isilak

Neutrophil–Lymphocyte Ratio May Predict Left Atrial Thrombus in Patients With Nonvalvular Atrial Fibrillation

Objective: Neutrophil–lymphocyte ratio (NLR) has been associated with poor outcomes in patients with cardiovascular diseases. We aimed to compare NLRs among patients with nonvalvular atrial fibrillation (AF) with or without left atrial (LA) thrombus. Methods: A total of 309 (70.1 ± 9.8 years, 49% male) patients with nonvalvular AF have undergone transoesophageal echocardiography (TEE) to assess the presence of LA thrombus. Baseline NLR was measured by dividing neutrophil count to lymphocyte count. Results: Left atrial thrombus was detected in 32 (10.3%) of 309 patients. Mean NLR (2.2 ± 1.0 vs 2.7 ± 1.1, P = .026) was significantly higher among patients with LA thrombus compared to patients without LA thrombus. On multivariate analysis, NLR (odds ratio 1.59, 95% confidence interval 0.87-4.18; P < .02) was an independent risk factor for the presence of LA thrombus in patients with nonvalvular AF. Conclusion: Neutrophil–lymphocyte ratio, an emerging marker of inflammation, was independently associated with the presence of LA thrombus in patients with nonvalvular AF.

The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation.

Objective: To investigate whether or not the CHA2DS2-VASc score predicts left atrial (LA) thrombus detected on pre-cardioversion transoesophageal echocardiography (TEE). Materials and Methods: The medical records of patients who had undergone TEE were reviewed to assess the presence of LA thrombus prior to direct-current cardioversion for atrial fibrillation (AF). The CHA2DS2-VASc score was calculated for each patient. Clinical TEE reports were reviewed for the presence of LA thrombus. Patients with a valve prosthesis or rheumatic mitral valve disease were excluded from this study. Results: A total of 309 patients were identified. The mean age was 70.1 ± 9.8 years and 151 (49%) patients were males and 158 (51%) were females. LA thrombus was seen in 32 (10.3%) of the 309 patients. Fifty (16.2%) patients had a low CHA2DS2-VASc score (0-1), 230 (74.4%) had an intermediate score (2-4) and 29 (9.4%) had a high score (5-9). The incidence of LA thrombus in the low, intermediate and high CHA2DS2-VASc score groups was 0, 4.4 and 68.7%, respectively. The LA thrombus risk increased with increasing CHA2DS2-VASc scores. On multivariate logistic analysis, the CHA2DS2-VASc score (OR 3.26, 95% CI 2.3-4.65; p = 0.001) and age (OR 0.93, 95% CI 0.88-0.98; p = 0.004) were independent risk factors for LA thrombus in patients with non-valvular AF. Conclusion: A high CHA2DS2-VASc score was independently associated with the presence of LA thrombus in patients with non-valvular AF.

CA-125 level is associated with right ventricular echocardiographic parameters in patients with COPD.

Objective: A few studies have shown that elevated CA-125 levels are associated with chronic obstructive pulmonary disease (COPD). However, there are no data concerning the associaton between serum CA-125 levels and right ventricular (RV) function in COPD patients. This study aimed to evaluate the relationship between CA-125 level and RV echocardiographic parameters in COPD patients. Methods: Fifty-two patients with COPD (39 male/13 female, mean age 68.9 ± 5.7 years) were studied. The control group consisted of 30 age-sex matched healthy volunteers (23 male/7 female, mean age 64.2 ± 6.3 years). Patients were divided into two subgroups: patients without pulmonary hypertension (group I, n = 25) and with pulmonary hypertension (group II, n = 27). Conventional echocardiographic parameters, tissue Doppler imaging (TDI) and CA-125 level measurements were performed in all subjects. Results: Patients in group II had significantly higher CA-125 levels than those in group I and controls (P < 0.01). CA-125 levels in group I were also higher than control group (P < 0.05). CA-125 levels were correlated with left ventricle E/A ratio, systolic pulmonary artery pressure (sPAP), RV myocardial performance index, and RV fractional area change (r = 0.37, 0.56, 0.34, and - 0.42, respectively, all with P < 0.05). There was an independent correlation between CA-125 levels and sPAP values (&bgr; = 0.76, P < 0.001) Conclusions: Our results show an independent correlation between CA-125 levels and systolic pulmonary artery pressure in COPD patients. The clinical utility of these results at this point in time is unknown and deserves future research.

The incidence of left atrial diverticula in coronary CT angiography

PURPOSE The aim of this study was to characterize the frequency and location of left atrial diverticula by using multidetector computed tomography (MDCT). MATERIALS AND METHODS Cardiac imaging was performed for 454 patients using 64MDCT. Most patients were being examined for coronary artery disease. All images were interpreted by two radiologists on a three-dimensional workstation using multiplanar reformatting, maximum intensity projection, and volumerendering. Diverticula were characterized by localization and diameter. RESULTS A total of 207 atrial diverticula were diagnosed in 186 (41%) of the 454 patients in this study. The diameters of left atrial diverticula ranged from 2 mm to 16 mm, with an average diameter of 5.2 mm. Left atrial diverticula were located anterosuperiorly in 166 patients (36.6%), anteriorly in four patients (0.9%), anteroinferiorly in three patients (0.7%), inferolaterally in one patient (0.2%), inferomedially in two patients (0.4%), laterally in two patients (0.4%), posterosuperiorly in one patient (0.2%), and superiorly in seven patients (1.5%). CONCLUSION Left atrial diverticula are frequently detected during routine cardiac computed tomography angiography examinations. From the Departments of Radiology, and Cardiology, GATA Haydarpasa Teaching Hospital, İstanbul, Turkey.

Abnormal aortic elasticity in patients with liver steatosis

AIM Non-alcoholic fatty liver disease (NAFLD) may be associated with insulin resistance. We aimed to evaluate elastic properties of aorta in patients with NAFLD. MATERIAL AND METHOD Ninety-two patients with NAFLD and 47 healthy subjects were performed ultrasonographic and echocardiographic examination. Aortic stiffness index (ASI), aortic distensibility (AD) and aortic strain (AS) were compared between healthy subjects and patients and also among grade I and II liver steatosis. Statistical analysis was performed by Independent-Samples t-test, Pearsons correlation test using SPSS 11.0. RESULTS ASI was significantly increased whereas AS and AD were reduced (p>0.05) in patients compared to normal ones. ASI was significantly increased while AD and AS slightly increased in patients with grade II liver steatosis compare to grade I. SBP and DBP, cholesterol levels, fasting blood glucose (FBG) were also increased and doppler flow parameters of mitral inflow were abnormally changed in those patients. ASI was positively correlated with FBG, ALT and ALP levels, LDL cholesterol, heart rate and deceleration time of mitral E wave. CONCLUSION Elastic properties of aorta were abnormally changed in patients with NAFLD. Multiple hemodynamic abnormalities probably associated with insulin resistance may be accountable for abnormal elastic properties of aorta.

Novel vagal maneuver technique for termination of supraventricular tachycardias

Hemodynamically unstable patients with supraventricular tachycardias (SVTs) should be treated with electrical cardioversion. If the patient is stable, acute termination of tachycardia can be achieved by vagal maneuvers or medical therapy. The Valsalva maneuver, carotid massage, and ice to the face are the most common vagal maneuvers. In our experience with patients, we observed that vagal stimulation increases with lying backward. Our suggested maneuver is based on quickly lying backward, from a seated position. Then, a short and powerful vagal stimulation occurs. Thus, SVT episodes can be terminated. Here we present our experience of a new maneuver for terminating SVT, with cases.

Endocan and endothelial dysfunction.

We read the article ‘‘Endocan—A Novel Inflammatory Indicator in Newly Diagnosed Patients With Hypertension: A Pilot Study’’ by Balta et al. They evaluated serum levels of endocan in newly diagnosed patients with untreated essential hypertension (HT). They concluded that endocan may be a surrogate endothelial dysfunction marker and may have a functional role in endothelium-dependent pathological disorders. Atherosclerosis is the most frequent cause of death worldwide. Inflammation plays an important role in the pathogenesis of atherosclerosis. Endothelial dysfunction is regarded as the initial lesion in the development of atherosclerosis. Elevated levels of systemic inflammatory markers are associated with cardiovascular (CV) disease. Endocan is a new candidate immunoinflammatory marker that may be associated with CV diseases and their clinical consequences. Hypertension and endothelial dysfunction are associated although the underlying mechanisms are not completely defined. It is possible that endothelial injury and dysfunction are caused by oxidative stress in the relationship between HT and endothelial dysfunction. Epidemiologic data support an association between different inflammatory markers and HT. Furthermore, inhibiting endocan release by neutralizing endocan antibody enhanced survival rate. Yilmaz et al also demonstrated that plasma endocan concentrations correlated positively with both markers of inflammation, and endocan levels were associated with allcause mortality and CV events in patients with chronic kidney disease. Endocan was a strong predictor of overall and CV mortality in these patients. Endocan may have potential as a useful long-term indicator of chronic renal allograft injury in renal transplant recipients, but further study is needed to verify these findings. Tok and coworkers reported that serum endocan concentrations decreased in patients with liver disease. In contrast to previous studies, they showed a negative correlation between endocan levels and inflammation stage of chronic hepatitis. Balta et al have previously shown that patients with Behçet disease (BD) had significantly higher serum levels of endocan. Also, they have shown in patients with BD that serum endocan levels correlated positively with C-reactive protein and erythrocyte sedimentation rate and activity of the disease. Serum levels of endocan were also higher in patients having BD with systemic involvement. These authors have also shown that patients with psoriasis vulgaris had significantly higher serum levels of endocan. Additionally, in patients with psoriasis, serum endocan levels correlated positively with CV risk and activity of disease. In addition, some medications may affect endocan levels. Antihypertensive therapy (eg, valsartan and amlodipine) significantly lowered endocan levels in patients with newly diagnosed HT. In this context, medication should be considered, when endocan is assessed. Although the authors said that the main limitation of their study was the relatively small sample size and composed of newly diagnosed individuals with HT, small sample size may additionally not allow defining the inflammatory state in those patients with newly diagnosed HT. Moreover, duration from the onset to the actual diagnosis of HT could not be determined from current clinical and laboratory data. In conclusion, endocan is a novel marker to assess endothelial dysfunction but without other inflammatory markers, endocan alone may not provide information to clinicians about the characteristics of inflammation in patients with HT. It would have been better if those factors were included in the article.

Carbon monoxide poisoning increases Tpeak-Tend dispersion and QTc dispersion.

Summary Objective Carbon monoxide (CO) poisoning leads to cardiac dysrhythmia. Increased heterogeneity in ventricular repolarisation on electrocardiogram (ECG) shows an increased risk of arrhythmia. A number of parameters are used to evaluate ventricular repolarisation heterogeneity on ECG. The aim of our study is to investigate the effect of acute CO poisoning on indirect parameters of ventricular repolarisation on ECG. Methods Sixty-seven patients were included in this case–control study. Thirty patients with acute CO poisoning were assigned to group 1 (19 females, mean age: 30.8 ± 11.3 years). A control group was formed with patients without known cardiac disease (group 2, n = 37; 25 females, mean age: 26.0 ± 5.2 years). Twelve-lead ECG and serum electrolyte levels were recorded in all patients. Also, carboxyhaemoglobin (COHb) levels were recorded in group 1. Tpeak–Tend (TpTe) interval, TpTe dispersion, TpTe/QT ratio, QT interval and QTd durations were measured as parameters of ventricular repolarisation. Corrected QT (QTc) and QTc dispersion (QTcd) intervals were determined with the Bazett’s formula. Results The mean COHb level in group 1 was 27.6 ± 7.4% and mean duration of CO exposure was 163.5 ± 110.9 min. No statistically significant difference was found in age, gender, serum electrolytes or blood pressure levels between the groups. QRS, QT, QTc, TpTe interval and TpTe/QT ratio were similar between the groups (p > 0.05). QTcd (65.7 ± 64.4 vs 42.1 ± 14.2 ms, p = 0.003) and TpTe dispersion (40.5 ± 14.8 vs 33.2 ± 4.9 ms, p = 0.006) were significantly longer in group 1 than group 2. COHb level was moderately correlated with TpTe dispersion (r = 0.29; p = 0.01). Conclusion To our knowledge, this is the first study to investigate TpTe interval and dispersion in CO poisoning. Our results showed that TpTe dispersion and QTc dispersion increased after CO poisoning.

Assessment of cardiac autonomic functions by heart rate recovery indices in patients with myocardial bridge

BACKGROUND Heart rate (HR) recovery (HRR) reflects autonomic activity and predicts cardiovascular events. The aim of this study was to assess HRR in patients with myocardial bridge (MB). METHODS Medical recordings of 93 patients with MB and appropriate age, compared to 78 sex-matched healthy subjects were analyzed. MB was diagnosed via coronary computed tomography angiography after a positive exercise stress test (EST). HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during EST. RESULTS HRR1 (30.2 ± 13.3 bpm vs. 35.8 ± 10.4 bpm, p = 0.001) and HRR2 (52.3 ± 13.3 bpm vs. 57.1 ± 11.6 bpm, p = 0.013) were lower in patients with MB. In addition, HRR1 was lower in patients with left anterior descending (LAD) MB than non-LAD MB (28.5 ± 13.2 vs. 37.1 ± 11.4, p = 0.013). Presence of MB, deep MB, LAD MB and multi-vessel MB were predictors of HRR1 (p < 0.01 for all). In a multivariate analysis, LAD MB was the only significant independent predictor of HRR1 (b = -8.524, p = 0.009). CONCLUSIONS Patients with MB have impairment in HRR indices which is more pronounced among patients with LAD MB. Cardiac autonomic dysfunction in MB might be due to recurrent myocardial ischemia.

Nifedipine-Induced Gingival Hyperplasia: An Overlooked Adverse Effect

Gingival hyperplasia is a common finding in a routine dental practice. Though it has many etiological factors, hyperplasia due to drugs which are administered to treat the systemic problems is of major problem which needs attention. Here, we present a case of nifedipine-induced gingival hyperplasia and draw the attention of clinicians.