Bleeding complications during cardiac electronic device implantation in patients receiving antithrombotic therapy: is there any value of local tranexamic acid?

BACKGROUND: The perioperative use of antithrombotic therapy is associated with increased bleeding risk after cardiac implantable electronic device (CIED) implantation. Topical application of tranexamic acid (TXA) is effective in reducing bleeding complications after various surgical operations. However, there is no information regarding local TXA application during CIED procedures. The purpose of our study was to evaluate bleeding complications rates during CIED implantation with and without topical TXA use in patients receiving antithrombotic treatment. METHODS: We conducted a retrospective analysis of consecutive patients undergoing CIED implantation while receiving warfarin or dual antiplatelet (DAPT) or warfarin plus DAPT treatment. Study population was classified in two groups according to presence or absence of topical TXA use during CIED implantation. Pocket hematoma (PH), major bleeding complications (MBC) and thromboembolic events occuring within 90 days were compared. RESULTS: A total of 135 consecutive patients were identified and included in the analysis. The mean age was 60 ± 11 years old. Topical TXA application during implantation was reported in 52 patients (TXA group). The remaining 83 patients were assigned to the control group. PH occurred in 7.7 % patients in the TXA group and 26.5 % patients in the control group (P = 0.013). The MBC was reported in 5.8 % patients in the TXA and 20.5 % patients in control group (P = 0.024). Univariate logistic regression analysis identified age, history of recent stent implantation, periprocedural spironolactone use, periprocedural warfarin use, perioperative warfarin plus DAPT use, cardiac resynchronization therapy, and topical TXA application during CIED implantation as predicting factors of PH. Multivariate analysis showed that perioperative warfarin plus DAPT use (OR = 10.874, 95 % CI: 2.496-47.365, P = 0.001) and topical TXA application during CIED procedure (OR = 0.059, 95 % CI: 0.012-0.300, P = 0.001) were independent predictors of PH. Perioperative warfarin plus DAPT use and topical TXA application were also found to be independent predictors of MBC in multivariate analyses. No thromboembolic complications was recorded in the study group. CONCLUSION: The present study demonstrated that the topical TXA application during CIED implantation is associated with reduced PH and MBC in patients with high bleeding risk.

The value of exercise SPET for the detection of coronary artery steal syndrome secondary to unligated major side branch of left internal mammary artery.

OBJECTIVE: The clinical significance of unligated major left internal mammary artery (LIMA)-side branches (SB) remains controversial in patients with previous coronary artery bypass graft (CABG) surgery. The aim of this study was to investigate the clinical significance of unligated major LIMA-SB by using exercise myocardial perfusion imaging (MPI) with single-photon emission tomography. SUBJECTS AND METHODS: We conducted a retrospective analysis of 2819 consecutive patients who underwent diagnostic angiography. There were 407 CABG patients with LIMA graft. The demographic, laboratory, pre-angiographic stress test and angiographic data of these patients were collected. A subgroup of patients with unligated major LIMA-SB who were referred to angiography with the diagnosis of stable angina pectoris and positive exercise MPI was identified and divided into two groups for comparison: anterior wall vs non-anterior wall ischemia groups. RESULTS: Among 407 patients with LIMA graft, 112 (27.5%) patients were found to have unligated major LIMA-SB. In a subgroup of patients (n=45) with positive exercise MPI and patent LAD-LIMA system with unligated major LIMA-SB, the median values of diameter and length of unligated major LIMA-SB were statistically higher in anterior wall ischemia group (n=24) compared to non-anterior wall ischemia group (1.8mm vs 0.6mm, P<0.001 and 17.0cm vs 8.0cm, P<0.001, respectively). The cut-off values of unligated major LIMA-SB length and diameter were 11cm and 1.3mm respectively. Unligated major LIMA-SB with a length of ≥11.0cm and a diameter of >1.3cm had 95.8% of sensitivity and 100% of specificity for predicting anterior wall ischemia on exercise MPI. In patients with anterior wall ischemia, summed stress score and summed difference score were improved after percutaneous coil embolization of large unligated major LIMA-SB with ≥11.0cm length and >1.3mm diameter. CONCLUSION: Large unligated major LIMA-SB with ≥11.0cm length and >1.3mm diameter seems to be a potential source of ischemia in CABG patients. We suggest that exercise MPI might be a first option noninvasive test in evaluating the clinical significance of unligated major LIMA-SB and the effectiveness of embolization therapy.

New prognostic markers in pulmonary arterial hypertension: CRP to albumin ratio and uric acid.

INTRODUCTION: Idiopathic pulmonary hypertension(IPAH) is a rare disease that causes severe morbidity and mortality despite advances in treatment management. Evaluating the prognosis of the disease is critical in determining therapeutic approaches. We aimed to evaluate the prognostic significance of C-reactive protein/albumin ratio (CAR) and uric acid, which is an easily applicable and inexpensive parameter in patients with IPAH. METHODS: Seventy-two IPAH patients and 99 consecutive non-IPAH patients as a control group were enrolled in the study retrospectively. Right heart catheterization(RHC), echocardiography, and laboratory parameters of the two groups and those who died and survived among the IPAH patients were compared. RESULTS: IPAH and control group were compared at the first stage and CAR (1.98(0.28-10.74), 0.75(0.22-4.7),respectively;p < 0.01) and uric acid (0.33(0.19-0.87), 0.3(0.11-0.48) mmol/L, respectively; p = 0.03) values were significantly higher in the pulmonary hypertension group compared to the control group. Compared with the surviving IPAH patients, CAR (4.60(1.39-10.74),1.54(0.28-6.74),respectively;p < 0.001) and uric acid levels (0.458(0.26-0.87), 0.315(0.19-0.56) mmol/L, respectively; p < 0.001) were significantly higher in the group of patients who died. In the multivariate Cox regression models uric acid(p < 0.001) and CAR(p < 0.001) were found to be associated with survival time. Receiver operating characteristic curves (ROC) analyses showed that > 1.54 CAR value (AUC = 0.81,Sens:85.7%,Spec:56.9%,p < 0.001) and > 5.85 mg/dL (>0.348 mmol/L) uric acid value (AUC = 0.864, Sens:85.7%, Spec:78.4%, p < 0.001) are strong predictors for mortality. CONCLUSION: In this study, we showed that simple markers such as CAR, which augment the inflammation marker feature of CRP, and uric acid can give prognostic information in PAH patients.

Dronedarone: a promising alternative for the management of atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is the most frequently encountered chronic arrhythmia associated with significant morbidity. It is generally encountered in the elderly, and will presumably become more prevalent in the future due to the increasing proportion of the elderly in the population. Major studies on AF have demonstrated no significant difference between rhythm and rate control in terms of mortality. However, young population with new-onset or lone AF, or patients in whom the maintenance of sinus rhythm is a must (due to recurrent thromboembolic events etc.) still gives rise to significant concerns related to the obligatory long-term prophylaxis. The long-term administration of the currently available conventional agents (amiodarone, dofetilide, sotalol, propafenone,flecainide etc.) is considered as a 'double edged sword' due to the presence of life-threatening adverse effects including pro-arrhythmia and organ toxicity associated with these agents. Several molecules are being developed for the management of AF. However, only a few novel agents confer promising results with respect to safety and efficacy issues in the major studies. DISCUSSION: Dronedarone is an amiodarone analogue without iodine moiety in its structure, and is similar to amiodarone with regard to its structural and electrophysiological properties. Dronedarone is largely denuded of the potentially life-threatening adverse effects of anti-arrhythmics. Major clinical studies have demonstrated both rhythm and rate-controlling efficacy of dronedarone compared to placebo without any serious adverse effects in patients with AF. However, the ANDROMEDA trial, a large scale study including patients hospitalized for symptomatic congestive heart failure (with severely depressed left ventricular systolic functions) was prematurely terminated due to the increased mortality in the dronedarone arm compared to placebo indicating a lack of safety in this group of patients. Conversely, the recently published ATHENA study (including more than 4,600 high risk patients, but excluding those with severe heart failure) demonstrated a significant reduction in cardiovascular hospitalizations and cardiovascular mortality with dronedarone compared to placebo. In contrast, the DIONYSOS study, comparing dronedarone with amiodarone, demonstrated better safety, but lower efficacy of dronedarone for the maintenance of sinus rhythm in patients with AF. CONCLUSION: Further clinical trials (including head to head comparison with other conventional anti-arrhythmics) are still required to determine the place of dronedarone in the management of AF. The present review focuses on basic and clinical aspects of dronedarone, a novel agent for the management of AF.

Comparative effects of levosimendan and dobutamine on right ventricular function in patients with biventricular heart failure.

Severe heart failure represents a major source of morbidity and mortality. Poor right ventricular function is an independent prognostic marker for mortality in patients with chronic heart failure. In this study, levosimendan (L) and dobutamine (D) in patients with severe chronic biventricular failure were compared. Forty consecutive patients, who were judged for inotropic therapy by their primary physicians, with acutely decompensated systolic heart failure and having moderate-to-severe right ventricular dysfunction with right ventricular fractional area change of

Acute heart failure and near-syncope associated with giant left atrial ball thrombus occluding left ventricular inflow tract.

A 70-year-old female patient was admitted to our department with symptoms and signs of acute heart failure and near syncope. After hospitalization, both transthoracic echocardiography (TTE) and subsequent transesophageal echocardiography (TEE) demonstrated a giant (4.9 x 3.9 cm) mobile, irregular, bright left atrial mass consistent with left atrial ball thrombus (LABT). The mass was found to occlude the left ventricular inflow tract (LVIT) above the mitral orifice (supravalvular) in the presence of normal mitral leaflets. After emergent surgical excision, the pathology of the left atrial mass was found to be consistent with thrombus. The case presented here suffered acute diastolic heart failure and near-syncope due to obstruction of the LVIT above the mitral orifice by a giant LABT.

Short QT syndrome: a very rare arrhythmogenic entity.

Short QT syndrome (SQTS) is a gene-related arrhythmogenic syndrome harbouring a large spectrum of symptoms ranging from mild palpitations to sudden cardiac death.The mutation of genes (KCNH2, KCNQ1, and KCNJ2) encoding for cardiac potassium channels plays a central role in SQTS. Electrocardiography is the primary important step in the diagnosis (short QT interval along with T wave changes), but ECG findings may be easily ignored. Treatment of the syndrome is still controversial. Some specific antiarrhythmic drugs and an implantable converter/defibrillator (ICD) have been considered as main therapeutic strategies. ICD implantation may be a life-saving procedure due to the presence of sudden cardiac death risk in patients with SQTS, but ICD-related problems such as inappropriate shock deliveries due to oversensing of prominent T waves have made medical therapy an alternative option. Notwithstanding the scarcity of cases, clinicians should keep this syndrome in mind, and be familiar with its clinical findings particularly when evaluating patients with palpitation, syncope or a history of sudden cardiac death.We present a brief review of the literature concerning the aetiology, clinical findings and therapeutic approach to this rare entity.

Impact of beta-blockers on sleep in patients with mild hypertension: a randomized trial between nebivolol and metoprolol.

INTRODUCTION: Sleep is an innate and essential part of human life. Various aspects of sleep are negatively affected by beta-blockers. We compared the impact of two beta-blockers, metoprolol succinate (extended release) and nebivolol, on sleep quality in patients with stage 1 hypertension. METHODS: This was a prospective, randomized, open-label, parallel-group study. Eligible patients were administered the Pittsburgh Sleep Quality Index (PSQI) questionnaire by a blinded interviewer and were randomized to receive metoprolol (starting dose 25 mg) or nebivolol (starting dose 2.5 mg) once daily for 6 weeks. The first dose was administered before patients left the clinic. Visits were scheduled for 1, 2, 4, and 6 weeks after the initiation of therapy. At the end of the study, patients were readministered the PSQI questionnaire by the same interviewer, as before blinded to treatment allocation. RESULTS: A total of 22 patients in the nebivolol group and 17 patients in the metoprolol group completed the study and were included in the data analysis (mean age of patients, 40.7 years). At study entry, systolic blood pressure (BP), diastolic BP, and PSQI scores were similar in the two groups. Over 6 weeks of treatment, systolic and diastolic BP normalized in both groups. Global PSQI score improved significantly in patients in the nebivolol group, whereas it worsened in the metoprolol group. The difference in effect of two beta-blockers was statistically significant (P<0.001). CONCLUSION: Nebivolol was associated with improved sleep (as assessed by the PSQI), whereas metoprolol was associated with a worsening of sleep characteristics.

The effect of collateral circulation on left ventricular systolic function.

BACKGROUND: Conflicting reports exist on the influence of coronary collateral circulation on preservation of left ventricular systolic function. The aim of this study was to assess the effect of coronary collateral circulation on left ventricular systolic function in coronary artery disease. METHODS: Seventy-one consecutive patients having left anterior descending arteries with proximal or near-proximal stenosis of at least 95% (excluding 100%) were included in the study. The coronary collateral circulation to left anterior descending artery was evaluated with regard to its effects on left ventricular systolic function. RESULTS: Among the 71 patients, 46 patients were found to have a coronary collateral circulation grade of >or=1 (group 1), whereas the remaining 25 patients had coronary collateral circulation grade of 0 (group 2). The mean value of left ventricular function score in group 1 was higher than that of group 2 (3.69+/-2.34 vs. 2.00+/-1.55, P=0.002), whereas the mean value of left ventricular ejection fraction in group 1 was lower than that of group 2 (44.67+/-12.05 vs. 54.32+/-10.22, P=0.001). The value of coronary collateral circulation grade was found to be positively correlated with the value of left ventricular function score (P=0.01, r=0.3), and negatively correlated with the value of left ventricular ejection fraction (P=0.01, r=-0.3). CONCLUSION: Coronary collateral circulation to the severely stenotic left anterior descending artery was not found to have an improving effect on left ventricular systolic function. In contrast with the previous studies demonstrating the coronary collateral circulation-associated preservation of left ventricular systolic function, presence of coronary collateral circulation was found to accompany or be associated with impairment of left ventricular systolic function. The grade of coronary collateral circulation was also found to be positively correlated with the severity of left ventricular systolic dysfunction. Further research on larger patient populations based on a long-term follow-up is warranted to investigate this issue.

Heart rate turbulence: an additional parameter in determining the need for mechanical relief of mitral stenosis?

BACKGROUND AND AIM OF THE STUDY: Heart rate turbulence (HRT) is a relatively newer parameter which has predictive value for mortality and severity in a variety of cardiovascular diseases. The study aim was to investigate the relationship between HRT and isolated acquired mitral stenosis (MS) on the basis of symptoms considered important in prognosis and for determining mechanical relief of the stenotic valve. METHODS: Among 46 patients with MS undergoing transthoracic echocardiography (TTE), 22 with moderately severe or severe symptoms of MS (NYHA class 3-4) (group 1) were compared with 24 with mild to moderate or no symptoms of MS (NYHA class 1- 2) (group 2). Particular comparison was made with regards to HRT parameters of turbulence onset (TO) and turbulence slope (TS), along with basic clinical and conventional echocardiographic parameters. RESULTS: Group 1 differed significantly from group 2 in terms of mean mitral valve orifice area (p <0.001), mean transmitral gradient (p <0.001), and left atrial diameter (p <0.05). Among the Holter parameters, TO in group 1 was significantly higher than in group 2. Overall, in MS, an abnormal TO value (> or =0) was found to have sensitivity and specificity of 81.9% and 83.3%, respectively (p <0.05) in distinguishing cases with moderately severe or severe symptoms. CONCLUSION: TO, a parameter of HRT, may be useful in the distinction and confirmation of severe symptoms in MS, and may aid in determining the need for mechanical relief of MS, which is especially difficult when discrepancies occur between echocardiographic findings and symptoms.

Asymptomatic total anomalous pulmonary venous connection with double drainage in a young adult: a case report.

Total anomalous pulmonary venous connection is an uncommon congenital anomaly in which all pulmonary venous return drains to the right atrium or one of its tributaries. Survival beyond infancy without surgical palliation is unlikely, so this anomaly is not encountered in the adult population with congenital heart disease. The patient presented here was 22 years old on admission and had no total anomalous pulmonary venous connection-associated symptoms. He underwent transthoracic echocardiographic examination for atypical chest pain. Transthoracic echocardiography along with cardiac catheterization favored the presence of a total anomalous pulmonary venous connection. Surgical correction of pulmonary venous confluence (draining to both the coronary sinus and right atrium) was performed successfully. This is a rare case of total anomalous pulmonary venous connection with no reported symptoms in contrast to the majority of patients who are symptomatic during the first year of life.

Comparison of myocardial performance index versus ratio of isovolumic contraction time/ejection time in left ventricular systolic dysfunction.

Myocardial performance index (MPI) has been regarded as an important parameter in the evaluation of ventricular systolic function in congestive heart failure. This study was designed to investigate the relationship between the ratio of isovolumic contraction time/left ventricular ejection time (IVCT/LVET), MPI, and LV systolic function. A total of 43 patients (patient group) with LV ejection fractions (LVEFs) <55% were compared with 43 patients (control group) with LVEF values >or=55%. LVEF was measured in all cases by 2-dimensional echocardiography via the modified Simpson method. Isovolumic relaxation time (IVRT), IVCT, LVET, ratio of IVCT/LVET, and MPI ([IVRT+IVCT]/LVET) were measured via Doppler echocardiography. The mean value for IVCT was found to be significantly higher (P<.001) and concomitant mean LVET value significantly lower (P=.027) in the patient group. Similarly, the mean value of MPI and the ratio of IVCT/LVET were found to be significantly higher (P<.001 for both) in the patient group. The value of the ratio of IVCT/LVET was found to have a significant negative correlation with the value of LVEF (r=-.947; P<.001) and a significant positive correlation with the value of MPI (r=.796; P<.001). The study reported here clearly demonstrates the noninferiority of the ratio of IVCT/LVET to MPI and the possibility of its substitution for MPI in the evaluation of LV systolic function.

The left anterior descending artery arising from the right sinus of Valsalva: a case report.

Coronary artery anomalies occur in less than 1% of patients who undergo coronary angiography and they account for 1% to 2% of all cases of congenital heart disease. The most commonly encountered anomaly, the circumflex artery originating from the right coronary artery or the right sinus of Valsalva, is usually well tolerated. The patient in the case presented here was found to have a left anterior descending artery arising from the right sinus of Valsalva - a situation that is very rarely encountered.

The severity of ST segment elevation in acute inferior myocardial infarction: does it predict the presence of a proximal culprit lesion along the right coronary artery course?

OBJECTIVE: Acute inferior myocardial infarction (AIMI) is generally characterized by ST segment elevation in the limb leads (D2, D3, aVF). Many trials have reported the close relation between the severity of this ST segment elevation and the extent of infarction, and also the prognosis. Based on the clinical studies, several electrocardiographic (ECG) criteria have also been propounded to identify the infarct-related artery. This study was conducted to investigate the possible relation between the severity of ST segment elevation and the proximity of the culprit lesion along the right coronary artery (RCA) course in AIMI. METHODS: Sixty patients (31 female, 29 male) admitted to our centre with diagnosis of first AIMI were included in the study. All cases underwent coronary angiography (CAG) on the 6th day of hospitalization. Patients with non-dominant RCAs were excluded from the study. The lesion with the highest degree of stenosis along the RCA course was accepted as the culprit lesion. The RCA was divided into 3 segments: proximal portion (from ostium to the first acute marginal (AM) artery), midportion (from the first AM to the last AM), distal portion (from the last AM on). In each case, a single value (STSE) was obtained by the addition of the amplitudes (mm) of ST segment elevation in the limb leads (D2, D3, aVF) during the hyperacute stage of AIMI. RESULTS: The patients with the culprit lesions in the proximal portion of the RCA were found to have a mean STSE value of 12.61+/-3.79 mm, while the patients having the culprit lesions in the mid and distal portions were found to have mean STSE values of 6.88+/-1.20 mm and 5.05+/-0.97 mm, respectively. There was a significant positive correlation between the severity of ST segment elevation and the culprit lesion proximity (r=0.82, p<0.01 for the proximal and r=0.7, p<0.05 for the mid portions of RCA). CONCLUSION: In AIMI, the severity of ST segment elevation and the proximity of the culprit lesion along the infarct-related RCA was found to be closely related, indicating the informative feature of ST segment elevation in the prediction of culprit lesion location.

Prediction of fractional flow reserve with angiographic DILEMMA score.

OBJECTIVE: Angiographic assessment of stenosis has limited predictive value for functionally significant lesions compared with fractional flow reserve (FFR). The recently developed angiographic DILEMMA score, which consists of minimal lumen diameter (MLD), lesion length (LL) and Bypass Angioplasty Revascularization Investigation (BARI) Myocardial Jeopardy Index (MJI) was found to have diagnostic value in predicting FFR ≤0.80. The present study was an investigation of prediction of FFR ≤0.80 using DILEMMA score and its relationship to resting distal coronary artery pressure/aortic pressure (Pd/Pa). METHODS: Records of consecutive patients who underwent coronary angiography and FFR were retrospectively analyzed. Assessment of MLD and LL was performed using quantitative coronary angiography. BARI MJI was calculated using angiographic calculation index. RESULTS: A total of 185 pressure wire analysis data sets from 150 patients were analyzed retrospectively. There were 82 lesions in FFR >0.80 group and 103 lesions in FFR ≤0.80 group. Negative correlation was found between FFR and DILEMMA score (r=-0.494; p<0.001), FFR and BARI-MJI (r=-0.378; p<0.001), and between FFR and LL (r=-0.314; p<0.001). Positive correlation was found between FFR and baseline Pd/Pa (r=0.713; p<0.001), and between FFR and MLD (r=0.415; p<0.001). DILEMMA score had negative correlation with resting Pd/Pa (r=-0.389; p<0.001). In receiver operating characteristic analysis for diagnosing FFR≤0.80, area under curve values of resting Pd/Pa, DILEMMA score, MLD, BARI-MJI, and LL were 0.862, 0.793, 0.780, 0.728, and 0.686, respectively. CONCLUSION: DILEMMA score had moderately strong correlation with FFR and good accuracy in diagnosing significant FFR, but it had weak correlation with resting Pd/Pa.

Evaluation of tumor markers CA-125 and CEA in acute myocardial infarction.

Serum carbohydrate antigen (CA-125) and carcinoembryonic antigen (CEA) have always been of clinical importance in the diagnosis and follow-up of various tumors. This study was devised to investigate the relationship between these tumor markers and acute myocardial infarction (MI). Seventy consecutive cases (59 male patients with a diagnosis of acute ST segment elevation MI and 11 male patients with a diagnosis of non-ST segment elevation MI; mean age, 57+/-8.2 y) were admitted to the University Medical Center and were included in this study as "the patient group." All patients in the patient group underwent transthoracic echocardiographic examination on the third day of hospitalization. On the basis of echocardiographic findings, these 70 patients were grouped according to left ventricular ejection fraction (EF) values; EF <55% (group 1) (n=40) and EF >or=55% (group 2) (n=30). Other parameters, including systolic pulmonary artery pressure (sPAP) and mean pulmonary artery pressure (mPAP), were also measured on transthoracic echocardiography. Serial blood samples (for follow-up of myocardial enzymes (eg, creatine kinase MB [CKMB], troponin I [TnI], troponin T, and other routine parameters) were drawn from each patient. Serum concentrations of CEA and CA-125 measured at the 72nd hour of hospitalization and peak serum concentrations of CKMB and TnI in the patient group were collected for comparison between subgroups (groups 1 and 2) and with "the control group," which included 30 subjects (mean age, 54+/-7.6 y) with no history or evidence of overt cardiac disease and with normal echocardiographic findings. The presence of any condition characterized by potential elevations in CA-125, CEA, and myocardial enzymes (CKMB, TnI) was considered an exclusion criterion. Patients included in patient groups 1 and 2 differed significantly in terms of mean EF, mean sPAP, mean mPAP, and mean CA-125 values (P<.001 for CA-125; P<.05 for the other values). EF was found to be negatively correlated with sPAP (r=-0.692, P=.000) and mPAP (r=-0.393, P=.001). EF was also negatively correlated with CA-125 (r=-0.557, P=.000). A positive correlation was noted between CA-125 and sPAP (r=0.396, P=.001) and between CA-125 and mPAP (r=0.754, P=.000). A statistically significant difference was identified between the patient and control groups with regard to values for EF, PAP, CA-125, and myocardial enzymes (CKMB and TnI) (P<.05 for mPAP; P<.001 for the other values). The serum concentration of CA-125, but not of CEA, may be elevated in those with acute MI compared with normal subjects. Regardless of the presence of pulmonary hypertension, elevations in CA-125 during myocardial infarction were significantly correlated with the severity of left ventricular systolic dysfunction on transthoracic echocardiography.

Clinical importance of elevated CK-MB and troponin I levels in congestive heart failure.

Myocyte necrosis has been considered to play a fundamental role in the pathophysiology of congestive heart failure (CHF), which has usually evolved as a consequence of depletion of compensatory mechanisms and contractile reserve of myocardium. Elevated levels of creatine kinase MB (CK-MB) and troponin I (Tn-I) have been regarded as biochemical markers of myocyte necrosis. This study was planned to investigate the specificity and sensitivity of Tn-I and CK-MB in CHF and to examine the correlation of these markers with disease severity. A total of 104 patients (38 female, 66 male; mean age, 66 y [range, 36-89]) with symptoms and signs of heart failure on admission and with a reduced left ventricular ejection fraction (EF; by transthoracic echocardiography) were labeled "the patient group," and 58 patients (40 female,18 male; mean age, 61 y [range, 34-77]) with no signs or symptoms of CHF and with a normal EF detected by transthoracic echocardiography were included in the study as "the control group." Left ventricular EFs, end-diastolic diameters, and end-systolic diameters of patients in both groups were measured. Blood samples were drawn from all patients in both groups on admission, so that levels of CK-MB and Tn-I could be measured. All patients in both groups also underwent coronary angiography. Conditions leading to elevation of CK-MB or Tn-I were considered exclusion criteria. The 2 groups failed to show any significant differences in terms of mean age and the presence of coronary artery disease, hypertension, or diabetes mellitus (P>.05). Mean EF in the patient group was lower than that in the control group (P<.05). Mean CK-MB and Tn-I in the patient group were significantly higher than in the control group (P<.05). In the patient group, hypertensive patients were found to have significantly higher mean values of CK-MB than were seen in normotensive patients in the same group (P<.05). In the patient group, 52 cases were considered to be class I-II (New York Heart Association [NYHA]) (group 1), and 52 were considered to be class III-IV (group 2). Group 1, group 2, and the control group did not differ significantly from one another with regard to the presence of coronary artery disease, hypertension, and diabetes mellitus (P>.05). The mean EF in group 2 was significantly lower than that in group 1 and in the control group (P<.05); the mean EF in group 1 was significantly lower than that in the control group (P<.05). Group 1 values did not differ significantly from those of group 2 or the control group in terms of enzymatic markers (P>.05), but group 2 had significantly higher mean values of CK-MB and Tn-I than were noted in the control group (P<.05). The uphill course of CK-MB and Tn-I values from the control group to group 2 (NYHA class III-IV) was statistically significant (P<.05). Serum concentrations of CK-MB and Tn-I may become elevated in severely symptomatic patients with CHF (particularly NYHA class III-IV), demonstrating a relationship between clinical severity of the disease and elevation of myocardial enzymes (CK-MB and Tn-I).

Elevated mean pulmonary artery pressure in patients with mild-to-moderate mitral stenosis: a useful predictor of worsening renal functions?

OBJECTIVE: Renal dysfunction commonly accompanies the course of cardiac disorders and strongly associates with increased morbidity and mortality. Elevated central venous pressure is related to worsening renal function in patients with heart failure. However, predictors of worsening renal function in mitral stenosis-whose pathophysiologic process is similar to heart failure with regard to right heart dysfunction-are unknown. This study aimed to evaluate whether clinical and echocardiographic parameters might predict worsening renal function in patients with mild-to-moderate mitral stenosis. METHODS: The current study has a prospective cohort design. Sixty consecutive patients (9 male, 51 female, mean age 50±13 years) with mild-to-moderate mitral stenosis were followed up for 34±13 months (range 1-60) and their renal functions were monitored. Worsening renal function was defined as a decline in glomerular filtration rate of ≥ 20% on follow-up. In order to presence or absence of worsening renal functions, study patients divided into two groups. Statistical analysis was performed using the Chi-square, Independent samples t / Mann-Whitney U tests, univariate and multivariate Cox proportional hazards analyses, receiver operating characteristic (ROC) and Kaplan-Meier curve analyses. RESULTS: Worsening renal function was observed in 14 patients (23%). In univariate analysis, male gender, mean pulmonary artery pressure (mPAP), peak tricuspid regurgitation velocity, systolic pulmonary artery pressure, digitalis and antiplatelet usage, right atrial size, and TEI index were determined to be predictors of worsening renal function. In a multivariate Cox proportional hazards model, mPAP (HR=1.136, 95% CI: 1.058-1.220, p<0.001) and male gender (HR=4.110, 95% CI: 1.812-9.322, p=0.001) were associated with increased risk of worsening renal function during the follow-up period. In ROC curve analysis, the optimal cut-off value of mPAP to predict worsening renal function was measured as more than 21 mmHg, with 78.6% sensitivity and 58.7% specificity (AUC 0.725, 95% CI 0.595-0.838). According to the Kaplan-Meier curve, a significant difference was found between those who had mPAP of >21 mmHg, and those who did not have, in terms of worsening renal function (p=0.006), and the difference between the groups increased after 30 months of follow-up. CONCLUSION: Elevated mean pulmonary artery pressure at the time of initial evaluation, in patients with mild-to-moderate mitral stenosis, might help to predict worsening renal function.

C-type natriuretic peptide is associated with the severity of Crimean-Congo hemorrhagic fever.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is characterized by vascular dysfunction, indicating the involvement of endothelial cells. C-type natriuretic peptide (CNP) plays a critical role in the coordination of vascular tone and is associated with the prognosis in critically ill patients such as those with sepsis and septic shock. We investigated whether CNP is related to the severity of CCHF. METHODS: Forty-eight consecutive patients with a laboratory confirmed diagnosis of CCHF and 40 age-sex-matched healthy volunteers as the control group were prospectively enrolled into the study. CCHF patients were classified according to the disease severity into a non-severe group (n=28) and a severe group (n=20). RESULTS: The CNP levels were detected to be 0.43 (0.4-0.7) ng/ml in the control group, 0.87 (0.7-1.0) ng/ml in the non-severe CCFH group, and 1.27 (0.8-1.7) ng/ml in the severe CCHF group. According to the receiver operating characteristics curve analysis, the optimal cut-off value of CNP to predict disease severity was >1.22 ng/ml, with 89.3% specificity and 55% sensitivity. CNP >1.22 ng/ml, lactate dehydrogenase >480 IU/l, and aspartate aminotransferase >202 IU/l were found to have prognostic significance in the univariate analysis. In the multivariate logistic regression analysis by forward stepwise method, CNP >1.22 ng/ml (odds ratio 8.336, p = 0.016) and lactate dehydrogenase >480 IU/l (odds ratio 16.206, p = 0.002) remained associated with disease severity after adjustment for confounding variables. CONCLUSIONS: CNP measurement could help in the risk stratification of patients with CCHF.

Cytokines: potential contributors to arrhythmogenesis in demyelinating syndromes?

Neurological disorders including chronic demyelinating syndromes (CDSs) have been known to elicit propensity to cardiac arrhythmias possibly due to autonomic imbalance, myocardial myocytolysis and some psychological conditions (major depression etc.) associated with these syndromes. CDSs are generally characterized by variable degrees of inflammatory response that may corrrelate with clinical disease activity (relapse, progression etc.). In the clinical setting, enhanced inflammatory response as measured with increased levels of inflammatory markers may predispose to cardiac arrhythmias via direct or indirect mechanisms. Therefore, substantial levels of inflammatory markers including pro-inflammatory cytokines associated with CDSs may serve as potential contributors to arrhythmogenesis indicating the possible link between disease activity and arrhythmia risk in patients with CDSs.