Predictive value of transmitral A-wave acceleration time for paroxysmal atrial fibrillation.

BACKGROUND: It has been shown that transmitral A-wave (TMAW) is affected in paroxysmal atrial fibrillation (PAF), and decreased left atrial contractions cause a decrease in the TMAW velocity. The relationship between TMAW acceleration time (TMAW-AccT) and PAF is unknown. In this study, the predictive value of TMAW-AccT for PAF was investigated. METHODS: Seventy PAF patients (mean age: 57.8 ± 11.0 years) and 70 control patients (mean age: 58.1 ± 10.5 years) were included in the study. Transthoracic echocardiography was performed in sinus rhythm in all patients. For TMAW-AccT, the time between the basal point of the A-wave and the highest point reached was measured. RESULTS: Transmitral A-wave -AccT was significantly longer in the PAF group than the control group (TMAW-AccT; 88.5 ± 18.1 vs 77.2 ± 16.4 ms, P = .000, respectively). The left atrial diameter and the left atrial volume index were similar between the groups (P = .07, P = .18, respectively). According to a multivariate logistic regression analysis, the TMAW-AccT (OR: 1.02, 95% confidence interval 1.02-1.07, P < .001) was a predictor of PAF. A receiver operating characteristic curve analysis showed a cutoff value of TMAW-AccT of >82 ms (sensitivity: 65.7%, specificity: 64.3%, positive predictive value: 64.8%, negative predictive value: 65.2%). CONCLUSION: Transmitral A-wave-AccT can be used as an early marker in detecting PAF without dilated left atrium.

Renal Drug Dosage Adjustment According to Estimated Creatinine Clearance in Hospitalized Patients With Heart Failure.

It is of clinical importance to determine creatinine clearance and adjust doses of prescribed drugs accordingly in patients with heart failure to prevent untoward effects. There is a scarcity of studies in the literature investigating this issue particularly in patients with heart failure, in whom many have impaired kidney function. The purpose of this study was to determine the degree of awareness of medication prescription as to creatinine clearance in patients hospitalized with heart failure. Patients hospitalized with a diagnosis of heart failure were retrospectively evaluated. Among screened charts, patients with left ventricular ejection fraction <40% and an estimated glomerular filtration rate (eGFR) of ≤50 mL/min were included in the analysis. The medications and respective doses prescribed at discharge were recorded. Medications requiring renal dose adjustment were determined and evaluated for appropriate dosing according to eGFR. A total of 388 patients with concomitant heart failure and renal dysfunction were included in the study. The total number of prescribed medications was 2808 and 48.3% (1357 medications) required renal dose adjustment. Of the 1357 medications, 12.6% (171 medications) were found to be inappropriately prescribed according to eGFR. The most common inappropriately prescribed medications were famotidine, metformin, perindopril, and ramipril. A significant portion of medications used in heart failure requires dose adjustment. Our results showed that in a typical cohort of patients with heart failure, many drugs are prescribed at inappropriately high doses according to creatinine clearance. Awareness should be increased among physicians caring for patients with heart failure to prevent adverse events related to medications.

Effect of serum uric acid on the positive predictive value of dobutamine stress echocardiography.

There is controversial data regarding the relationship between uric acid (UA) and coronary artery disease and cardiovascular events. Despite the deleterious effects of hyperuricemia on endothelial function, the effect of UA on myocardial ischemia has not been previously studied. We aimed to investigate the relationship between UA and myocardial ischemia that was identified using dobutamine stress echocardiography (DSE). In this retrospective study, the laboratory and DSE reports of 548 patients were reviewed. The patients were divided into two groups based on the presence of ischemia and further subdivided into three groups according to the extent of ischemia (none, ischemia in 1-3 segments, ischemia in >3 segments). Serum UA levels were compared. Determinants of ischemia were assessed using a regression model. UA was increased in patients with ischemia and was correlated with the number of ischemic segments (p < 0.001). A cutoff value of UA > 5 mg/dl had 63.9 % sensitivity, 62.0 % specificity, 42.5 % positive predictive value (PPV), and 79.6 % negative predictive value for ischemia. When the positive DSE exams were further sorted according to the UA cutoff, the PPV of DSE increased from 80.2 to 94.0 %. Uric acid (odds ratio 1.51; 95 % CI 1.14-1.99), diabetes mellitus, HDL and glomerular filtration rate were found to be independent determinants of myocardial ischemia in DSE. Increased UA is associated with both the presence and extent of DSE-identified myocardial ischemia. A UA cutoff may be a good method to improve the PPV of DSE.

Prognostic value of Tpeak-Tend interval in patients with acute pulmonary embolism.

BACKGROUND: The aim of this study was to examine the Tpeak-Tend (Tpe/corrected Tpe) interval, which is an indicator of transmural myocardial repolarization, measured non-invasively via electrocardiogram in patients with acute pulmonary embolism (PE), and to investigate the relationship with 30-day mortality and morbidity. METHODS: The study included 272 patients diagnosed with acute PE, comprising 154 females and 118 males, with a mean age of 63.1 ± 16.8 years. Tpe/cTpe intervals were calculated from the electrocardiograms with a computer program after using a ruler or vernier caliper manual measuring tool to obtain highly sensitive measurements. The relationship between the electrocardiogram values and 30-days mortality and morbidity were measured. RESULTS: The study group was divided into three groups according to cTpe intervals: Group 1, < 113 ms; Group 2, 113-133 ms; and Group 3, > 133 ms. White blood cell count and troponin T levels, corrected QT intervals with QRS complex durations, percentage of right ventricle dilatation with right/left-ventricular ratio, 30-day death, and combinations of these values were seen at a higher rate in Group 3 patients compared to the other groups. Kaplan-Meier analysis showed that the cTpe interval measured at > 126 ms could be used as a cut-off value in the prediction of mortality and morbidity. The cTpe cut-off values of 126 ms had sensivity, specificity, negative predictive value, and positive predictive value of 80.56 %, 59.32 %, 95.2 %, and 23.2 %, respectively. CONCLUSIONS: cTpe interval could be a useful method in early risk stratification in patients with acute PE.

Uric acid level and erectile dysfunction in patients with coronary artery disease.

INTRODUCTION: Erectile dysfunction (ED) is a frequent complaint of elderly subjects and is closely associated with endothelial dysfunction and cardiovascular disease (CVD). Uric acid is also associated with endothelial dysfunction, oxidative stress, and CVD, raising the hypothesis that an increased serum uric acid might predict ED in patients who are at risk for coronary artery disease (CAD). AIM: This study aims to evaluate the association of serum uric acid levels with presence and severity of ED in patients presenting with chest pain of presumed cardiac origin. METHODS: This is a cross-sectional study of 312 adult male patients with suspected CAD who underwent exercise stress test (EST) for workup of chest pain and completed a sexual health inventory for men survey form to determine the presence and severity of ED. Routine serum biochemistry (and uric acid levels) were measured. Logistic regression analysis was used to assess risk factors for ED. MAIN OUTCOME MEASURES: The short version of the International Index of Erectile Function questionnaire diagnosed ED (cutoff score ≤ 21). Serum uric acid levels were determined. Patients with chest pain of suspected cardiac origin underwent an EST. RESULTS: One hundred forty-nine of 312 (47.7%) male subjects had ED by survey criteria. Patients with ED were older and had more frequent CAD, hypertension, diabetes and impaired renal function, and also had significantly higher levels of uric acid, fibrinogen, glucose, C-reactive protein, triglycerides compared with patients without ED. Uric acid levels were associated with ED by univariate analysis (odds ratio = 1.36, P = 0.002); however, this association was not observed in multivariate analysis adjusted for estimated glomerular filtration rate. CONCLUSION: Subjects presenting with chest pain of presumed cardiac origin are more likely to have ED if they have elevated uric acid levels.

The relationship between uric acid and erectile dysfunction in hypertensive subjects.

BACKGROUND: Endothelial dysfunction plays a major role in erectile dysfunction (ED). Uric acid (UA) is a marker of endothelial dysfunction. We hypothesized that increased UA levels may be associated with ED and aimed to investigate whether there is a relationship between, UA and ED in hypertensive patients. METHODS: A total of 200 hypertensive patients who have a normal treadmill exercise test were divided into two groups based on the Sexual Health Inventory for Men (SHIM) test (< 21 defined as ED n = 110, and ≥ 21 defined as normal erectile function n = 90). The differences between the ED and normal erectile function groups were compared and determinants of ED were analyzed. MAIN RESULTS: The prevalence of ED was found to be 55.0%. Office blood pressure level was comparable between groups. UA levels were significantly increased in the ED group (6.20 ± 1.56 vs 5.44 ± 1.32, p = 0.01). In a regression model, age [odds ratio (95% confidence interval): 1.08 (1.04-1.14), p = 0.001], smoking [odds ratio: 2.33 (1.04-5.20), p = 0.04] and UA [odds ratio: 1.76 (1.28-2.41), p = 0.04] were independent determinants of ED. An UA level of > 5.2 mg/dl had 76.2% sensitivity, 43.7% specificity, 62.9% positive and 59.4% negative predictive value for determining ED. CONCLUSION: UA is an independent determinant of ED irrespective of blood pressure control and questioning erectile function for hypertensive patients with increased UA levels may be recommended.

Gender-related changes of the epicardial fat thickness and leptin in obstructive sleep apnea.

BACKGROUND: Epicardial fat thickness (EFT), an indicator of visceral obesity, and leptin are 2 novel markers for studying the obstructive sleep apnea (OSA) population. This study aimed to investigate the effects of gender on leptin levels and EFT, and the relation with OSA severity. METHODS: A total of 149 patients with OSA (female/male 55/94 and mean age 50.8 ± 9.2 years) and 50 control patients (female/male 24/26 and mean age 48.9 ± 8.8 years) were included in the study. The study population was divided into 4 groups according to apnea/hypopnea index (AHI) as control (AHI <5), the mild OSA (AHI 5-14), the moderate OSA (AHI 15-29), and the severe OSA (AHI ≥30). EFT was obtained from parasternal long-axis and parasternal short-axis echocardiographic images. RESULTS: Leptin levels among females were significantly higher than among males (10.5 [7.8] vs. 5.4 [4.5] ng/mL, P = 0.001, respectively). Among women, leptin levels were significantly higher in the severe OSA group compared to the control group (9.8 [9.0] vs. 15.5 [10.1] ng/mL, P = 0.05, respectively). Conversely, no relation was observed between OSA severity and the leptin levels among men. EFT was not significantly different between the 2 genders (P > 0.05). EFT was thicker in the severe OSA group than in the control and mild OSA groups among women, whereas EFT was not changed according to OSA severity among males (P > 0.05). CONCLUSION: Leptin and EFT may be a valuable parameter in the evaluation of OSA severity in women than in men.

The relationship between exercise capacity and masked hypertension in sedentary patients with diabetes mellitus.

AIM: Although exaggerated blood pressure responses (EBPR) to exercise have been related to future hypertension and masked hypertension (MHT), the relationship between exercise capacity and MHT remains unclear. A sedentary life style has been related to increased cardiovascular mortality, diabetes mellitus (DM), and hypertension. In this study, we aimed to examine the relationship between exercise capacity and MHT in sedentary patients with DM. METHODS: This study included 85 sedentary and normotensive patients with DM. Each patient's daily physical activity level was assessed according to the INTERHEART study. All patients underwent an exercise treadmill test, and exercise duration and capacity were recorded. Blood pressure (BP) was recorded during all exercise stages and BP values ≥ 200/110 mmHg were accepted as EBPR. MHT was diagnosed in patients having an office BP <140/90 mmHg and a daytime ambulatory BP >135/85 mmHg. Patients were divided into two groups according to their ambulatory BP monitoring (MHT and normotensive group). RESULTS: The prevalence of MHT was 28.2%. Exercise duration and capacity were lower in the MHT group than in the normotensive group (p<0.05) and were negatively correlated with age, HbA1c, mean daytime BP, and mean 24 hour BP. Peak exercise systolic BP and the frequency of EBPR were both increased in the MHT group (25.0% and 8.1%, respectively, p=0.03). According to a multivariate regression, exercise capacity (OR: 0.61, CI95%: 0.39-0.95, p=0.03), EBPR (OR: 9.45, CI95%: 1.72-16.90, p=0.01), and the duration of DM (OR: 0.84, CI95%: 0.71-0.96, p=0.03) were predictors of MHT. CONCLUSION: Exercise capacity, EBPR, and the duration of DM were predictors of MHT in sedentary subjects with DM.

Prognostic value of neutrophil to lymphocyte ratio in patients with acute pulmonary embolism: a restrospective study.

BACKGROUND: Acute pulmonary embolism (PE) is a serious clinical condition characterised by a high mortality rate. Previous studies showed that leukocytosis was associated with recurrences of venous thromboemboli, major bleeding and increased mortality. The aim of the present study was to investigate the prognostic value of neutrophil to lymphocyte ratio (NLR) in patients with acute PE during short term follow-up. METHOD: A total of 640 patients were screened by I26 code of ICD-9 and 359 patients were included as cases of confirmed acute PE. Admission blood counts and clinical data were obtained from medical charts. The predictors of 30-day mortality were examined. RESULTS: Fifty-one out of 359 patients (14.2%) included in the study died during 30 days follow-up. In multivariate Cox regression analysis systolic blood pressure (HR:0.97 (0.94-0.99 CI95%), p=0.019), diabetes mellitus (HR:3.3 (1.30-8.39 CI95%), p=0.012), CK-MB(HR:1.03 (1.01-1.06 CI95%), p=0.024) and NLR (HR:1.03 (1.01-1.06 CI95%), p=0.008) were predictors of 30-day mortality. An optimal cut-off value of NLR was determined as 9.2 by using ROC curve. Hazards ratio of NLR>9.2 was found to be 3.60 (1.44-9.18 CI95%, p=0.006). NLR>9.2 had a sensitivity, specificity, negative predictive value, and positive predictive value of 68.6%, 80.5%, 93.9% and 36.5%, respectively. CONCLUSION: NLR on hospital admission may be a predictor of 30-day mortality in acute PE. Since complete blood count is a part of the routine laboratory investigation in the most hospitalised patients use and preliminary promising results of this study, NLR should be investigated in future prospective randomised trials regarding prognostic value in acute PE.

Diastolic Strain Parameters are Associated with Short Term Mortality and Rehospitalization in Patients with Advanced Heart Failure. / Parâmetros de Strain Diastólico Estão Associados à Mortalidade em Curto Prazo e à Reinternação em Pacientes com Insuficiência Cardíaca Avançada.

BACKGROUND: Heart failure (HF) is a leading cause of hospitalization and mortality worldwide and places a great economic burden on healthcare systems. Identification of prognostic factors in HF patients is of great importance to establish optimal management strategies and to avoid unnecessary invasive and costly procedures in end-stage patients. OBJECTIVES: In the current study, we aimed to investigate the association between diastolic strain parameters including E/e' SR, and short-term outcomes in advanced HF patients. METHODS: The population study included 116 advanced HF with reduced ejection fraction (HFrEF) patients. Clinical, laboratory, and echocardiographic evaluations of the patients were performed within the first 24 hours of hospital admission. Patients were followed for one month and any re-hospitalization due to worsening of HF symptoms and any mortality was recorded. The level of significance adopted in the statistical analysis was 5%. RESULTS: E/e' SR was significantly higher in the patient group compared to the control group (p=0.001). During one-month follow-up, 13.8% of patients died and 37.1% of patients were rehospitalized. Serum NT-ProBNP (p=0.034) and E/e' SR (p=0.033) were found to be independent predictors of mortality and ACEI use (p=0.027) and apical 3C strain (p=0.011) were found to be independent predictors of rehospitalization in the patient group. CONCLUSION: Findings of the current prospective study demonstrate that E/e' SR measured by speckle tracking echocardiography is an independent and sensitive predictor of short-term mortality in advanced HFrEF patients and may have a role in the identification of end-stage HFrEF patients.

FUNDAMENTO: A insuficiência cardíaca é uma das principais causas de hospitalização e mortalidade em todo o mundo e representa um grande fardo económico para os sistemas de saúde. A identificação de fatores prognósticos em pacientes com IC é de grande importância para estabelecer estratégias de manejo ideais e evitar procedimentos invasivos e dispendiosos desnecessários em pacientes em estágio terminal. OBJETIVOS: No presente estudo, nosso objetivo foi investigar a associação entre parâmetros de strain diastólico, incluindo E/e' SR, e resultados de curto prazo em pacientes com IC avançada. MÉTODOS: O estudo populacional incluiu 116 pacientes com insuficiência cardíaca avançada com fração de ejeção reduzida (ICFEr) avançada. Avaliações clínicas, laboratoriais e ecocardiográficas dos pacientes foram realizadas nas primeiras 24 horas de internação. Os pacientes foram acompanhados por um mês e qualquer reinternação por piora dos sintomas de IC e qualquer mortalidade foi registrada. O nível de significância adotado na análise estatística foi de 5%. RESULTADOS: A E/e' SR foi significativamente maior no grupo de pacientes em comparação ao grupo controle (p=0,001). Durante o acompanhamento de um mês, 13,8% dos pacientes morreram e 37,1% dos pacientes foram reinternados. NT-ProBNP sérico (p=0,034) e E/e' SR (p=0,033) foram considerados preditores independentes de mortalidade e o uso de IECA (p=0,027) e strain 3C apical (p=0,011) foram considerados independentes preditores de reinternação no grupo de pacientes. CONCLUSÃO: Os resultados do presente estudo prospectivo demonstram que a E/e' SR medida pela ecocardiografia com speckle tracking é um preditor independente e sensível de mortalidade em curto prazo em pacientes com ICFEr avançada e pode ter um papel na identificação de pacientes com ICFEr em estágio terminal.

Self-reported sleep quality of patients with atrial fibrillation and the effects of cardioversion on sleep quality.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance encountered in clinical practice and is associated with impaired quality of life. Data from the previous studies have shown that sleep quality (SQ), as a component of life quality, may also deteriorate in patients with AF. However, it remains unclear; we do not know whether SQ improves after sinus rhythm is maintained. Therefore, we aimed to examine the relationship between SQ and AF, as well as the effects of sinus rhythm restoration with direct current cardioversion (DCC) on SQ among patients with persistent AF. METHODS: One hundred fifty-three patients with a diagnosis of nonvalvular AF and 150 age-matched control subjects with sinus rhythm were recruited. SQ was assessed using the Pittsburgh Sleep Quality Index (PSQI). The study was designed with two stages. First, the difference in SQ between AF patients and age-matched controls was examined. Patients with global PSQI scores greater than 5 were defined as "poor sleepers." Thus, a higher global PSQI score indicated worsened SQ. Predictors of poor SQ were also analyzed using a regression model. Second, the effect of rhythm control on SQ was studied in patients with AF who were eligible for DCC. Of the 65 patients with persistent AF, 54 patients with successful cardioversion were followed for 6 months. The remaining 11 patients, whose cardioversion was unsuccessful, were not followed. After 6 months of follow-up, the PSQI scores of patients with sinus rhythm maintenance (n = 39) and patients with AF recurrence (n = 15) were reassessed. Changes in global PSQI scores (baseline vs after 6 months) were analyzed. RESULTS: The PSQI scores were significantly higher in the AF group compared to the control group (9.4 ± 4.6 vs 5.8 ± 4.1, P = 0.001, respectively). The prevalence of poor sleepers was significantly higher in the AF group (76%) than in the control group (45%) (P < 0.001 by the χ(2) test). Multivariate logistic regression analysis showed that AF (odds ratio [OR]: 3.36, 95% confidence interval [CI]: 2.00-5.55), age (OR: 1.02, 95% CI: 1.00-1.04), and diabetes mellitus (OR:1.79, 95% CI: 1.03-3.14) were independent predictors of poor SQ. In the second stage, the effect of rhythm control on the SQ of the 54 patients with successful DCC was analyzed. PSQI scores improved significantly between baseline and the 6 months in sinus rhythm maintenance group (8.7 ± 4.1 vs 7.2 ± 3.8, P < 0.001, respectively). However, in the AF recurrence group, the change in global PSQI scores between baseline and the sixth month was not statistically significant (9.8 ± 4.5 vs 9.2 ± 4.2, P = 0.56, respectively). CONCLUSION: Patients with AF have shorter sleep duration and poor SQ. Maintenance of sinus rhythm after DCC may have a favorable effect on the SQ of patients with AF. Nevertheless, AF is an independent predictor of poor SQ.

Secondary chordae rupture due to low-tension electricity trauma.

The most frequent cardiac pathologies caused by electric shock are arrhythmias with a wide clinical picture ranging from sinus tachycardia to asystole. Cardiac mechanical complications secondary to electric shock have rarely been reported. Despite the use of electrocardiography and cardiac monitorization in evaluating dysrhythmias and in the patients' follow-up, there is still no consensus on how to assess patients against probable mechanical complications and how to follow up these patients. In this study, we have presented the rupture in the secondary chordae of the mitral anterior leaflet caused by low-voltage electrical trauma. To our knowledge, this is the first cardiac mechanical complication reported as a consequence of low-tension electrical trauma.

A new marker for myocardial injury in carbon monoxide poisoning: T peak-T end.

OBJECTIVES: Carbon monoxide (CO) poisoning frequently affects repolarization, resulting in abnormal electrocardiography findings. The goal of this study was to examine the effect of CO poisoning on the novel transmyocardial repolarization parameters T peak-T end (Tp-e), Tp-e dispersion, and Tp-e/QT and the relationship of these parameters to myocardial injury (MI). METHODS: This prospective study included 94 patients with CO poisoning and 40 healthy controls. Participants received an electrocardiography and had their blood drawn at admission and 6 and 24 hours after admission. The QT, Tp-e, Tp-e dispersion, and the Tp-e/QT ratio were calculated. Myocardial injury was determined based on an elevation in troponin any time during the first 24 hours. The patients were divided into 2 subgroups: those with and without MI. RESULTS: T peak-T end, Tp-e dispersion, and the Tp-e/QT ratio were higher at admission than after 6 and 24 hours of hospitalization and were higher than the control group (P < .001). There was a correlation between the carboxyhemoglobin level at admission and Tp-e and Tp-e dispersion (P < .001). The MI subgroup (n = 14) had a higher Tp-e at admission than did the non-MI subgroup (n = 80) (96 [11] milliseconds vs 87 [12] milliseconds, P = .03). There were no any significant differences in the Tp-e dispersion or the Tp-e/QT ratio between the 2 MI subgroups. Receiver operating characteristic analysis showed that a Tp-e cutoff value for MI of 91.5 milliseconds had a sensitivity of 72.7% and a specificity of 67.2%. CONCLUSION: Transmyocardial repolarization parameters indicative of arrhythmia were prolonged in patients with CO poisoning. T peak-T end was associated with MI.

The effect of smoking on myocardial performance index in middle-aged males after first acute myocardial infarction.

BACKGROUND: Cigarette smoking is associated with increased rates of coronary artery disease and acute myocardial infarction (MI). Paradoxically, smokers had lower mortality after MI. The purpose of this study was to evaluate the effect of chronic smoking on myocardial performance index (MPI) in middle-aged men after an acute MI. MATERIAL AND METHODS: A total of 429 patients (325 smokers vs. 104 nonsmokers) presenting with acute ST elevation MI were enrolled in this study. Thrombolysis in myocardial infarction (TIMI) flow of the infarct related artery was measured before and after the primary percutaneous coronary intervention (PCI), and Gensini score was also calculated. Conventional echocardiography and tissue Doppler echocardiography (TDI) were performed within 48-72 hours after onset of chest pain. Peak early (Em) and late (Am) diastolic velocities, peak systolic (Sm) mitral annular velocities and time intervals were recorded with TDI. The MPI, ratio of Em/Am, and E/Em were calculated. RESULTS: Baseline demographic and angiographic characteristics such as Gensini score, pre and, post PCI TIMI flow were similar in 2 groups. In contrast, LV MPI was preserved among smokers (0.59 ± 0.15 vs. 0.66 ± 0.14, P = 0.01), and Em/Am values were also higher in smokers (0.84 ± 0.28 vs. 0.75 ± 0.31, P = 0.01). Independent predictors of impaired MPI (≥0.60) were determined as nonsmoking status (odds ratio 2.940, 95% CI 0.98-5.83, P = 0.05), left anterior descending artery stenosis (odds ratio 3.196, 95% CI 1.73-5.91 P = 0.001), and, age (odds ratio 1.12, 95% CI 1.03-1.22, P = 0.01). CONCLUSIONS: Despite similar demographic and angiographic characteristics, smoker males had a paradoxically better MPI after acute MI.

P-wave dispersion for predicting paroxysmal atrial fibrillation in acute ischemic stroke.

BACKGROUND: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (P(d)) might be a useful marker in predicting PAF in patients with acute ischemic stroke. METHODS: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared. RESULTS: Maximum P-wave duration (p=0.002), P(d) (p<0.001) and left atrium diameter (p=0.04) were significantly higher in patients with PAF when compared to patients without PAF. However, in binary logistic regression analysis P(d) was the only independent predictor of PAF. The cut-off value of P(d) for the detection of PAF was 57.5 milliseconds (msc). Area under the curve was 0.80 (p<0.001). On a single 12-lead ECG, a value higher than 57.5 msc predicted the presence of PAF with a sensitivity of 80% and a specificity of 73%. CONCLUSION: P(d) on a single 12-lead ECG obtained within 24 hours of an acute ischemic stroke might help to predict PAF and reduce the risk of recurrent strokes.

The relation between Lp-PLA2 levels with periodic limb movements.

OBJECTIVE: Lipoprotein-associated phospholipase A2 (Lp-PLA2), a novel marker of vulnerable plaque to prone rupture, is a predictor of both cardiovascular event and cerebrovascular event, and highly sensitive-C-reactive protein (hs-CRP) is an acute-phase response protein implicated in a broad range of cardiovascular diseases. We aimed to examine the association between periodic limb movements in sleep (PLMs) with circulating Lp-PLA2 and hs-CRP levels in patients with PLMs. METHODS: Seventy patients with newly diagnosed PLM with polysomnography were enrolled this study. Patients were divided into two groups according to PLM index (normal PLM index, <15; elevated PLM index, ≥15). Lp-PLA2 and hs-CRP concentrations were measured in serum samples by turbidimetric and nephelometric methods, respectively. The concentrations of these parameters were compared between two groups and correlation analysis was performed between PLMs and Lp-PLA2 and hs-CRP levels. RESULTS: Lp-PLA2 levels and hs-CRP were significantly increased in elevated PLM index group compared with the control group (206.8 ± 78.1 vs 157.8 ± 56.7, p = 0.003, and 4.2 ± 3.5 vs 2.4 ± 2.1, p = 0.02, respectively). PLM index was positively correlated with Lp-PLA2 levels (r = 0.40, p = 0.001) and hs-CRP (r = 0.24, p = 0.05). In the linear regression model, Lp-PLA2 was an independent predictor of PLM index (R(2) = 0.36, p = 0.005). CONCLUSION: This study demonstrated an independent linear relation between PLM index and Lp-PLA2. In addition, it was seen increased Lp-PLA2 and hs-CRP levels in patients with elevated PLM index. Based on these results, we can suggest that risk of vascular events may be increased in patients with PLMs and with increased PLM index.

The association among lipoprotein-associated phospholipase A2 levels, total antioxidant capacity and arousal in male patients with OSA.

BACKGROUND: The mechanisms of the increased cardiac and vascular events in patients with OSA are not well understood. Arousal which is an important component of OSA was associated with increased sympathetic activation and electrocardiographic changes which prone to arrhythmias. We planned to examine the association among arousal, circulating Lp-PLA2 and total antioxidant capacity in male patients with OSA. METHODS: Fifty male patients with newly diagnosed OSA were enrolled the study. A full-night polysomnography was performed and arousal index was obtained. Lp-PLA2 concentrations were measured in serum samples with the PLAC Test. Total antioxidant capacity in patients was determined with Antioxidant Assay Kit. RESULTS: Arousal was positively correlated with LP-PLA2 levels (r=0.43, p=0.002) and was negatively correlated with total antioxidant capacity (r= -0.29, p=0.04). Elevated LP-PLA2 levels and decreased total antioxidant activities were found in the highest arousal quartile compared with the lowest and 2nd quartiles (p=0.02, p=0.05, respectively). LP-PLA2 was an independently predictor of arousal index in regression model (ß=0.357, p=0.002) CONCLUSIONS: This study demonstrated a moderate linear relationship between arousal and LP-PLA2 levels. Also, total antioxidant capacities were decreased in the higher arousal index. Based on the study result, the patients with higher arousal index may be prone to vascular events.

Atorvastatin given prior to electrical cardioversion does not affect the recurrence of atrial fibrillation in patients with persistent atrial fibrillation who are on antiarrhythmic therapy.

OBJECTIVE: In this study, our aim was to evaluate the effect of a higher dose of atorvastatin on the recurrence rate of atrial fibrillation (AF) after electrical cardioversion (EC) in addition to antiarrhythmic therapy. SUBJECTS AND METHODS: 48 patients with persistent AF were included in this study. The patients were randomized to an atorvastatin 40-mg treatment group and a control group. Atorvastatin was started 3 weeks before EC and was continued for 2 months after EC. EC was performed using biphasic shocks after 3 weeks of treatment with the orally administered anticoagulant warfarin. Lipid and inflammatory parameters (high-sensitivity C-reactive protein, white blood cell count and fibrinogen level) were evaluated at the baseline and before EC. The endpoint of this study was electrocardiographically confirmed recurrence of AF of >10 min. RESULTS: There were no significant differences in baseline characteristics and lipid and inflammatory marker levels between the treatment and control groups. Total cholesterol and low-density lipoprotein levels were significantly decreased in patients taking atorvastatin for 2 months compared with baseline values (174 ± 31 vs. 129 ± 25 mg/dl, p = 0.001, and 112 ± 23 vs. 62 ± 20 mg/dl, p = 0.001, respectively), while no significant change occurred in control patients (168 ± 26 vs. 182 ± 29 mg/dl, p = 0.07, and 99 ± 18 vs. 108 ± 26 mg/dl, p = 0.1, respectively). At the end of the 2-month follow-up period, 9 patients (20.5%) experienced AF recurrence, and there was no significant difference in AF recurrence rate between the treatment and control groups (26 vs. 13%; p = 0.2). CONCLUSION: Atorvastatin therapy prior to EC does not prevent the recurrence of arrhythmia in patients with persistent AF who are receiving antiarrhythmic therapy.

Prognostic nutritional index and the risk of acute kidney injury in patients with acute coronary syndrome.

OBJECTIVE: Recent studies have linked malnutrition with undesirable outcomes in cardiovascular diseases. However, the underlying mechanism is unknown. Contrast-induced acute kidney injury (CI-AKI) increased cardiovascular mortality after percutaneous coronary intervention (PCI). This study hypothesizes that prognostic nutritional index (PNI) plays a role in the development of CI-AKI in patients with acute coronary syndrome undergoing emergency PCI. METHODS: This study enrolled 551 patients. PNI was determined as 10× serum albumin (g/dL)+0.005×total lymphocyte count (mm3). CI-AKI was characterized as the increase in serum creatinine ≥0.3 mg/dL level within 48 h after PCI. Patients were classified as either CI-AKI (+) or CI-AKI (-). RESULTS: CI-AKI has occurred in 72 of 551 patients (13.1%). PNI was significantly lower in the CI-AKI (+) group than in the CI-AKI (-) group (44.4±6.6 versus 47.2±5.8, p<0.001, respectively). Multivariate logistic regression analysis showed that PNI [odds ratio, OR: 1.631, 95% confidence interval (CI): 1.168-2.308, p=0.02] and estimated glomerular filtration rate (OR: 3.26, 95%CI 1.733-6.143, p<0.001) were independent risk factors for CI-AKI. CONCLUSIONS: PNI is an independent risk factor for CI-AKI. The development of CI-AKI may be the mechanism responsible for the relationship between poor nutritional status and adverse cardiac events.