Association of heart rate profile during exercise with the severity of coronary artery disease.

BACKGROUND: Coronary artery disease is the leading cause of morbidity and mortality around the world. Autonomic nervous system abnormalities are associated with coronary artery disease and its complications. Exercise stress tests are routinely used for the detection of the presence of coronary artery disease. In this study, we observed the association between heart rate profile during exercise and the severity of coronary artery disease. METHOD AND RESULTS: One hundred and sixty patients with abnormal exercise treadmill test (> or =1 mm horizontal or downsloping ST-segment depression; 119 men, 41 women; mean age = 57 +/- 9 years) were included in the study. Use of any drug affecting heart rate was not permitted. Resting heart rate before exercise, maximum heart rate during exercise, and resting heart rate after exercise (5 min later) were measured and two parameters were calculated: heart rate increment (maximum heart rate - resting heart rate before exercise) and heart rate decrement (maximum heart rate - resting heart rate after exercise). All patients underwent selective coronary angiography and subclassified into two groups according to stenotic lesion severity. Group 1 had at least 50% of stenotic lesion and group 2 had less than 50%. Patients in the first group had increased resting heart rate, decreased maximum heart rate, decreased heart rate increment, and decreased heart rate decrement compared with second group. All patients were classified into tertiles of resting heart rate, heart rate increment, and heart rate decrement level to evaluate whether these parameters were associated with severity of coronary artery stenosis in the study. The multiple-adjusted odds ratio of the risk of severe coronary atherosclerosis was 21.888 (95% confidence interval 6.983-68.606) for the highest tertile of resting heart rate level compared with the lowest tertile. In addition, the multiple-adjusted odds ratio of the risk of severe coronary atherosclerosis was 20.987 (95% confidence interval 6.635-66.387) for the lowest tertile of heart rate increment level compared with the highest tertile and 2.360 (95% confidence interval 1.004-5.544) for the lowest tertile of heart rate decrement level compared with the highest tertile. CONCLUSION: Altered autonomic nervous system regulation affects heart rate profile, increased resting heart rate, decreased heart rate increment, and decreased heart rate decrement, during exercise and this effect is strongly and independently associated with the severity of coronary artery disease.

The prevalence of aspirin resistance in patients with metabolic syndrome.

OBJECTIVES: Aspirin is recommended for primary prevention in patients with metabolic syndrome (MetS). In this study, we evaluated aspirin resistance in MetS patients. STUDY DESIGN: The study included 32 patients (23 males, 9 females; mean age 60.7+/-11.4 years) with the diagnosis of MetS, according to the criteria of the International Diabetes Federation. Aspirin resistance was determined by the PFA-100 analysis (Platelet Function Analyzer). The results were compared with a control group of 30 patients (16 males, 14 females; mean age 61.6+/-7.3 years) without MetS. All the patients were taking aspirin at the time of the PFA-100 analysis. RESULTS: Overall, 21 patients (33.9%) were aspirin nonresponders. The prevalence of aspirin resistance was 46.9% in the MetS group, and 20% in the control group. The difference between the two groups was statistically significant (p=0.033). Compared to aspirin responders, fasting blood glucose level was higher (102.0+/-14.6 mg/dl vs. 95.3+/-9.9 mg/dl; p=0.036) and waist circumference tended to be greater in nonresponders (97.4+/-14.1 cm vs. 89.7+/-15.0 cm; p=0.053). Multivariate logistic regression analysis showed that MetS (OR 0.28, 95% CI 0.09-0.88; p=0.029), fasting blood glucose (OR 0.95, 95% CI 0.91-0.99; p=0.045), uric acid (OR 0.46, 95% CI 0.28-0.76; p=0.002), gamma-glutamyl transferase (OR 1.04, 95% CI 1.00-1.08; p=0.043), high-sensitivity C-reactive protein (OR 1.07, 95% CI 1.01-1.12; p=0.015) levels and platelet count (OR 0.99, 95% CI 0.98-0.99; p=0.034) significantly affected aspirin resistance. CONCLUSION: Our results show that a significant proportion of MetS patients will not benefit from aspirin use due to high aspirin resistance.

[A rare complication of brucellosis: mitral valve endocarditis]. / Brusella infeksiyonunun nadir bir komplikasyonu: mitral kapak endokarditi.

Early diagnosis of brucella endocarditis is of paramount importance because of its fatal consequences. The most commonly affected localization is the aortic valve, while mitral valve involvement is rare. A 44-year-old male patient with a history of rheumatic heart disease presented with fever, fatigue, and back pain. Three consecutive blood cultures revealed growth of Brucella melitensis. On transthoracic echocardiography, mitral valve area was 1.5 cm2 and there was mild mitral regurgitation. Transesophageal echocardiography showed multiple vegetations on the anterior and posterior mitral valve leaflets. Combination of medical and surgical treatment was planned for the patient with the diagnosis of brucella endocarditis.

Association of aortic pressures with fasting plasma glucose in patients with and without impaired fasting glucose.

BACKGROUND: Diabetes mellitus and impaired fasting glucose (IFG) are associated with future cardiovascular disorders. Aortic pulse pressure (PP) and fractional pulse pressures (FPPs) are strong and independent indicators of the risk of coronary heart disease. These conditions have been reported to be associated with endothelial dysfunction. In the present study, aortic PP and FPPs of patients with and without impaired fasting glucose were evaluated. METHODS: Fifty patients with IFG with a mean age of 56.8+/-12.2 years and 47 patients with normal fasting glucose (NFG) with a mean age of 53.1+/-11.2 years were included in the study. All subjects had angiographically proven normal coronary arteries without coronary slow flow. Aortic systolic and diastolic blood pressures were measured invasively. Mean pressure, PP and FPPs (aortic PP/mean pressure) were calculated. RESULTS: All parameters measured were significantly higher in the IFG group than in the control (NFG) group (133+/-21 mmHg and 117+/-12 mmHg, p<0.001 for aortic systolic pressure; 79+/-12 mmHg and 74+/-8 mmHg, p = 0.035 for aortic diastolic pressure; 97+/-14 mmHg and 88+/-9 mmHg, p = 0.001 for aortic mean pressure; 54+/-13 mmHg and 43+/-8 mmHg, p<0.001 for aortic PP; 0.56+/-0.10 and 0.48+/-0.08, p<0.001 for aortic FPP). In addition, in linear regression analysis, a positive correlation was found between fasting plasma glucose and the aortic FPP (p = 0.001, R2 = 0.12). CONCLUSION: Ascending aorta PP and FPPs are significantly associated with the presence of IFG. These findings suggest that IFG is associated with endothelial dysfunction and so aortic stiffness.

[The prevalence of angiographically significant coronary artery disease in patients with isolated secundum atrial septal defect]. / Izole sekundum tip atriyal septal defekt bulunan hastalarda anjiyografik olarak ciddi koroner arter hastaligi sikligi.

OBJECTIVES: Atrial septal defect (ASD) and coronary artery disease (CAD) may coexist in adults, especially in the elderly. The aim of this study was to determine the prevalence of CAD in patients undergoing both catheterization for ASD and selective coronary angiography and to evaluate the relationship of CAD with symptoms and risk factors. STUDY DESIGN: The study included 138 consecutive patients (40 males, 98 females; mean age 54+/-10 years; range 31 to 74 years) who underwent catheterization for isolated secundum ASD and selective coronary angiography at the same session. The mean shunt was 2.6+/-0.8 in the patient group. Significant CAD was defined as the presence of = or >50% stenotic lesions during angiography. RESULTS: Significant CAD was detected in 12 patients (8.7%). Patients with CAD exhibited a higher mean age (61+/-10 vs 54+/-10 years, p=0.016) and male preponderance (83.3% vs 23.8%, p<0.001). Risk factors and hemodynamic parameters did not differ between the two groups. Laboratory parameters were also similar except for a higher triglyceride level in patients without CAD (123+/-64 mg/dl vs 71+/-40 mg/dl, p=0.006). Angina pectoris was present in four patients (33.3%) in the CAD group, compared to 28 patients (22.2%) without CAD. For angina pectoris to predict CAD, the sensitivity, specificity, positive and negative predictive rates were 33.3%, 77.8%, 12.5%, and 92.5%, respectively. The corresponding figures were 50.0%, 33.3%, 6.7%, and 87.5% for at least one risk factor, and 16.7%, 82.5%, 8.3%, and 91.2% for combination of angina pectoris with at least one risk factor. CONCLUSION: Despite increased prevalence of CAD in adults, its prevalence is relatively low in patients with ASD. Thus, routine coronary angiography performed to detect CAD in patients with ASD increases complications and decreases cost-effectiveness.

Left ventricular diverticulum with contractile function in an unusual site.

The diverticulum of the left ventricular cavity is a rare congenital malformation. Various imaging modalities such as echocardiography, computed tomography, magnetic resonance imaging, and left ventriculography might be used for anatomic and functional properties of this abnormality. This report presents the case of a 48-year-old man with a contractile left ventricular diverticulum in the left ventricular outflow tract area and the evaluation with real-time multiplane and 3-dimensional transthoracic echocardiography.

Angiographic prevalence of myocardial bridging.

OBJECTIVE: Muscle fibers overlying the intramyocardial segment of an epicardial coronary artery are termed myocardial bridging. Variable prevalence has been described at autopsy and angiographic series with small and large sample sizes. The aim of the study was to investigate the angiographic prevalence of myocardial bridging in 25982 patients from Turkey. METHODS: We performed a retrospective study, evaluated the cases with myocardial bridging among patients undergone selective coronary angiography, and searched the angiographic prevalence of myocardial bridging in a very large sample size. We studied also the correlation between the severity of the bridging and risk factors for coronary artery disease. RESULTS: Among 25982 patients we found 316 cases of myocardial bridging in a retrospective manner. The total prevalence was 1.22%. Although, 96.52% of patients with myocardial bridging had the lesion in the left anterior descending coronary artery (LAD) as expected, distribution of bridges between mid- and distal segments were almost equal (52.79% and 47.21%, respectively). We subclassified patients in two groups, Group A (<50% of systolic compression) and Group B (>or=50% of systolic compression), according to the amount of systolic compression of LAD and studied relationship of risk factors for coronary artery disease between groups. Another subclassification was also made for patients having myocardial bridging without coronary or valvular heart disease and hypertrophic obstructive cardiomyopathy; Group 1 (<50% of systolic compression) and Group 2 (>or=50% of systolic compression). In these patients we studied correlation between the severity of the myocardial bridging and risk factors for coronary artery disease. The prevalence of bridges in circumflex and right coronary arteries individually and in all arteries as combination was also studied. CONCLUSION: In a very large group of patients from Turkey undergone selective coronary artery angiography, the angiographic prevalence of myocardial bridging was slightly higher than expected. Only diabetes mellitus as a risk factor for coronary artery disease was higher in groups representing <50% of systolic compression (Group A and 1) than in groups representing >or=50% of systolic compression (Group B and 2) but the importance of this result is not known.

Asymptomatic patent ductus arteriosus in a 41-year-old woman.

Patent ductus arteriosus is a rare adult congenital heart disease, especially asymptomatic cases are uncommon in older ages. We report here the case of a 41-year-old woman, who was incidentally found to have a patent ductus arteriosus. The patient also was asymptomatic. For anatomical demonstration, computerized tomography angiography was performed and then surgical intervention was applied.

Spontaneous twisting of a pacemaker lead in an unusual site.

Spontaneous twisting of a pacemaker electrode is a rare complication following implantation. If present, the electrode usually is twisted close to the pacemaker. This report presents the case of a 71-year-old female patient without any complaint associated with the twisting of the electrode. Telemetric study showed no abnormality thus, any intervention was not performed.