Use of tolvaptan in patients hospitalized for worsening chronic heart failure with severe hyponatremia: The initial experience at a single-center in Turkey.

OBJECTIVE: The aim of the present study was to assess the efficacy and safety of tolvaptan for severe hyponatremia (SH) in hypervolemic heart failure (HF) patients within daily clinical practice. METHODS: We restrospectively reviewed our database on tolvaptan as an add-on treatment in hypervolemic patients admitted to our clinic due to deterioration of HF and having hyponatremia resistant to standard therapy. Severe hyponatremia was defined as serum sodium concentration ≤125 mEq/L. The database included demographic, clinical, laboratory, and echocardiographic findings on admission, and numerous outcome measures for oral tolvaptan treatment were used to assess its efficacy and safety. RESULTS: The study group consisted of 56 hypervolemic HF patients with severe hyponatremia (25 female and 31 male) with mean age of 66 years. All patients received a single dose of tolvaptan 15 mg daily for an average of 3.2 days due to severe hyponatremia. Sodium and potassium concentrations, fluid intake, and urine volume increased (p<0.0001, p=0.037, p<0.0001, and p<0.0001, respectively), whereas furosemide dosage, body weight, heart rate, systolic and diastolic blood pressure, and New York Heart Association class decreased significantly in response to tolvaptan treatment, without a rise in serum creatinine or urea concentrations (p<0.0001, p<0.0001, p=0.001, p<0.049, p<0.009 ve p=0.001, respectively). CONCLUSION: In this retrospective, single-centered study conducted in a small group of Turkish patients, short-term treatment with low-dose tolvaptan added to standard therapy of hypervolemic HF patients with severe hyponatremia was well tolerated with a low rate of major side effects and was effective in correcting severe hyponatremia.

Post-discharge heart failure monitoring program in Turkey: Hit-PoinT.

OBJECTIVE: The aim of this study was to assess the efficacy and feasibility of an enhanced heart failure (HF) education with a 6-month telephone follow- up program in post-discharge ambulatory HF patients. METHODS: The Hit-Point trial was a multicenter, randomized, controlled trial of enhanced HF education with a 6-month telephone follow-up program (EHFP) vs routine care (RC) in patients with HF and reduced ejection fraction. A total of 248 patients from 10 centers in various geographical areas were randomized: 125 to EHFP and 123 to RC. Education included information on adherence to treatment, symptom recognition, diet and fluid intake, weight monitoring, activity and exercise training. Patients were contacted by telephone after 1, 3, and 6 months. The primary study endpoint was cardiovascular death. RESULTS: Although all-cause mortality didn't differ between the EHFP and RC groups (p=NS), the percentage of cardiovascular deaths in the EHFP group was significantly lower than in the RC group at the 6-month follow up (5.6% vs. 8.9%, p=0.04). The median number of emergency room visits was one and the median number of all cause hospitalizations and heart failure hospitalizations were zero. Twenty-tree percent of the EHFP group and 35% of the RC group had more than a median number of emergency room visits (p=0.05). There was no significant difference regarding the median number of all-cause or heart failure hospitalizations. At baseline, 60% of patients in EHFP and 61% in RC were in NYHA Class III or IV, while at the 6-month follow up only 12% in EHFP and 32% in RC were in NYHA Class III or IV (p=0.001). CONCLUSION: These results demonstrate the potential clinical benefits of an enhanced HF education and follow up program led by a cardiologist in reducing cardiovascular deaths and number of emergency room visits with an improvement in functional capacity at 6 months in post-discharge ambulatory HF patients.

Association of monocyte to HDL cholesterol level with contrast induced nephropathy in STEMI patients treated with primary PCI.

BACKGROUND: Contrast induced nephropathy (CIN) has been proven to be a clinical condition related to adverse cardiovascular outcomes. In recent studies, the monocyte to high density lipoprotein ratio (MHR) has been postulated as a novel parameter associated with adverse renal and cardiovascular outcomes. In this study we investigated the association of MHR with CIN in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI). METHODS: Consecutive STEMI patients treated with primary PCI were prospectively recruited. Subjects were categorized into two groups; as patients who developed CIN (CIN+) and patients who did not develop CIN (CIN-) during hospitalization. CIN was defined as either a 25% increase in serum creatinine from baseline or 44.20 µmol/L increase in absolute value, within 72 h of intravenous contrast administration. RESULTS: A total number of 209 patients were included in the study. Thirty-two patients developed CIN (15.3%). In the CIN (+) patients, monocytes were higher [1.02 (0.83-1.39) vs. 0.69 (0.53-0.90) 109/L, p<0.01] and HDL cholesterol levels were lower [0.88 (0.78-1.01) vs. 0.98 (0.88-1.14) mmol/L, p<0.01]. In addition, MHR was significantly higher in the CIN (+) group [1.16 (0.89-2.16) vs. 0.72 (0.53-0.95) 109/mmol, p<0.01]. In multivariate logistic regression analysis, MHR, Mehran score, AGEF score and CV/eGFR were independently correlated with CIN. CONCLUSIONS: Higher MHR levels may predict CIN development after primary PCI in STEMI patients.

Impaired left ventricular systolic and diastolic functions in patients with early grade pulmonary sarcoidosis.

AIMS: Cardiac sarcoidosis is symptomatic in only 5% of patients, and it is an independent predictor of mortality and carries a very poor prognosis. In our study, we aimed to assess left ventricle (LV) systolic and diastolic functions with tissue Doppler imaging (TDI) in patients with early grade pulmonary sarcoidosis. METHODS AND RESULTS: The study population included 55 patients with Grade I-II sarcoidosis (41 females, 14 males, mean age: 47.9 ± 10.1) and 22 healthy subjects. LV lateral and septal wall early myocardial peak velocity (E(m)), late myocardial peak velocity (A(m)), E(m) to A(m) ratio, myocardial relaxation time (RT(m)), myocardial systolic wave (S(m)) velocity, isovolumic acceleration (IVA), myocardial pre-contraction time (PCT(m)), contraction time (CT(m)), and the PCT(m) to CT(m) ratio were measured. No statistically significant difference was detected between the groups according to age, gender, body mass index, systolic and diastolic blood pressure, or heart rate. LV systolic parameters, LV septal, and lateral wall IVA, were significantly lower, and the PCT(m) to CT(m) ratio (P = 0.026) was higher at the septal annulus as compared with control group. E(m), a LV diastolic parameter, was significantly lower at the septal annulus. CONCLUSION: Cardiac sarcoid involvement is not rare and is treatable. It should be identified at an early stage. TDI, especially IVA, may be a suitable tool for the early detection of subclinical LV sarcoid involvement.

Continuous positive airway pressure therapy improves arterial elasticity in patients with obstructive sleep apnea.

BACKGROUND: Reduced arterial elasticity is an important mediator of accelerated atherogenesis and consequent increased cardiovascular morbidity in obstructive sleep apnea (OSA). The aim of our study was to investigate whether continuous positive airway pressure (CPAP) therapy may improve arterial elasticity in subjects with OSA. METHODS: In 44 subjects with OSA, we measured arterial elasticity by applanation tonometry before and after 6 months of treatment with CPAP. Nine OSA+ subjects withdrew from the study. RESULTS: The 35 patients with OSA who completed the 6-month CPAP treatment showed a marked reduction in both the large artery (LAEI, P=0.001) and small artery (SAEI, P=0.009) elasticity indices, independent of potential confounders. In OSA+ subjects who withdrew from the study, SAEI and LAEI did not change significantly over time. CONCLUSIONS: Six months of CPAP therapy improves arterial elasticity in subjects with OSA.

Successful treatment of saphenous venous graft thrombus by tirofiban infusion.

A 60-year old man with a history of coronary-artery bypass grafting presented with symptoms of acute coronary syndrome. Coronary angiography revealed a huge intraluminal thrombus in the saphenous vein graft to the second obtuse marginal branch of the left circumflex artery. A glycoprotein IIb/IIIa inhibitor (tirofiban) was administered intravenously. Two days later, thrombus dissolution and Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow were evident on repeat coronary angiography. Glycoprotein IIb/IIIa inhibitors may be useful in a thrombus-laden saphenous-vein graft.

[Impaired myocardial performance in sarcoidosis]. / Sarkoidozda bozulmus miyokard performansi.

Despite myocardial sarcoid involvement has been reported in 20-27% in autopsy series, only 5% of the patients are clinically symptomatic. This study was planned to evaluate right and left ventricular functions in patients with early stage sarcoidosis (stage I and II) without any findings of cardiac involvement with Tei index which globally shows systolic and diastolic functions of the ventricles was used. Seventy-two patients under follow-up for sarcoidosis without cardiac involvement (53 women, 19 men; mean age 49.1 ± 10.3 years) and nineteen age-matched healthy control subjects (14 women, 5 men; mean age 48.7 ± 6.5 years) were enrolled in the study. All subjects were evaluated with two-dimensional and Doppler echocardiography. Right and left ventricle Tei indices (myocardial performance index) were calculated from measured Doppler parameters. Peak velocity of the mitral A wave (A) was higher, peak velocity of the mitral E wave, E/A ratio were lower; and ejection time was shorter in patients with sarcoidosis (p< 0.05) compare to controls. Peak velocity of the tricuspid A wave was higher, E wave deceleration time was longer and E/A ratio was lower (p< 0.05) in sarcoidosis group. While left ventricular Tei index was higher in patients with sarcoidosis (p= 0.021), right ventricular Tei index was similar to healthy controls' (p>0.05). Left ventricular myocardial performance is disturbed in patients with early stage sarcoidosis. This can be related to a subclinical involvement of sarcoidosis.

The relationship between cardiac autonomic neuropathy and Tei index in patients with type II diabetes mellitus.

OBJECTIVE: We have investigated the relationship between silent cardiac autonomic neuropathy (CAN), one of the most important causes of mortality in diabetic patients, and the Tei index, which is an indicator of global ventricular function. METHODS: Among the patients with type 2 diabetes mellitus, 15 without autonomic neuropathy (Ewing score < 1) were accepted as CAN (-) and 18 with autonomic neuropathy (Ewing score > or =1) were accepted as CAN (+).Twelve healthy individuals were included in the control group. Diastolic dysfunction and Tei index were evaluated by means of 2-D and Doppler echocardiographic examination. RESULTS: Not only Doppler mitral, but also tricuspid inflow parameters showed a significant decrease in E/A ratio, an increase in A wave amplitude and deceleration time with CAN (+) patients. Left ventricular Tei index and Ewing score were found to be positively correlated (P < 0.001, r = 0.55). Likewise to the correlation in the left ventricle, a positive correlation was also detected between right ventricular Tei index and Ewing score (P = 0.004, r = 0.43). CONCLUSIONS: We have shown that in patients with type II diabetes, CAN is related with left and right ventricular diastolic dysfunction.We also have determined that the Tei index is in correlation with CAN (Ewing score), which is a complication of diabetes.