Anti-inflammatory treatment improves systolic and diastolic tissue doppler parameters in patients with newly diagnosed rheumatoid arthritis.

BACKGROUND: The frequency of cardiovascular system involvement is increased in rheumatoid arthritis (RA) and may result in serious morbidity and mortality. Early intervention and control of the disease activity may reduce the risk of cardiovascular events. The purpose of this study is to examine the effects of steroids and methotrexate (Mtx) on the heart functions of newly diagnosed RA patients. METHODS: Our study is a prospective cohort study involving thirty-six newly diagnosed RA patients according to the American Society of Rheumatology classification criteria. Right and left ventricular echocardiography, and Doppler parameters were evaluated in these patients thrice; before treatment, after one month of steroid treatment, and after three months of Mtx treatment, and laboratory/clinical parameters were noted. RESULTS: The mean age of the patients was 52.66 ± 13.66 years. After the treatment, a significant decrease was observed in the values of inflammatory markers (ESR and CRP) and disease activity score (DAS28) [p < .05]. Left ventricular tissue Doppler showed an increase in lateral S, septal S, and mitral S waves compared to baseline (8.37 ± 1.89 vs 10.0 ± 1.8 cm/s p = .001). While there was a decrease in tissue Doppler tricuspid a wave (18.33 ± 4.76 vs 15.63 ± 4.36 p = .016), an increase in Tricuspid E/e' value and Tricuspid tissue Doppler e/a value was detected after treatment (0.76 ± 0.30) vs 0.94 ± 0.53) p < .010). Significant changes were found to be more prominent after the Mtx treatment. CONCLUSION: In RA patients, steroid and Mtx treatment significantly positively affects left ventricular systolic and right ventricular diastolic functions.

Intimal intussusception in aortic dissection and coexisting coronary artery disease.

Intimal tear is rarely circumferential in aortic dissection. In such an instance, intimal intussusception may occur. This exposes the patient to the additional risk of severe aortic regurgitation, blockage of the left main coronary artery ostium, or both in proximal intimal intussusception in ascending aortic dissection. Here we present a 61-year-old patient with ascending aortic dissection, aortic regurgitation caused by an intussuscepted proximal intimal flap, and coexisting coronary artery disease. The presenting symptoms and electrocardiographic findings simulated an acute coronary syndrome. Among other diagnostic measures, only transesophageal echocardiography clearly defined the pathologic condition. The patient underwent a successful aortic root replacement and coronary artery bypass grafting.

Comparison of single-dose and repeated levosimendan infusion in patients with acute exacerbation of advanced heart failure.

BACKGROUND: Levosimendan (LS) is a novel inodilator that improves cardiac performance, central hemodynamics, and symptoms of patients with decompensated chronic heart failure. The aim of this study was to compare the effects of single and repeated LS infusion on left ventricular performance, biomarkers, and neurohormonal activation in patients with acute heart failure. MATERIAL AND METHODS: Twenty-nine consecutive patients with acute exacerbation of advanced heart failure were included in this study. LS was initiated as a bolus of 6 µg/kg followed by a continuous infusion of 0.1 µg/kg/min for 24 hours in both groups who received intravenous single and repeated (baseline and at 1 and 3 months) treatment. Physical examination, echocardiography, and biochemical tests (brain natriuretic peptide, tumour necrosis factor-alpha, interleukin-1beta, 2, and 6) were performed before treatment and on 3 day of the treatment. The last evaluation was performed at 6 month after the baseline treatment. RESULTS: Twenty male and 9 female patients with mean age of 60.2 ± 7.4 years were included in this study. A significant improvement in New York Heart Association functional status and myocardial performance index was detected only in the repeated LS treated patients at 6 month compared to the pretreatment status (p=0.03 and p<0.001; respectively). In addition, a significant decrease in brain natriuretic peptide (p<0.01) and plasma interleukin-6 (p=0.05) levels were also achieved only in patients who were given repeated LS. CONCLUSIONS: Our study showed that repeated LS treatment is more effective compared to the single dose LS treatment in improving clinical status, hemodynamic and laboratory parameters in patients with acute exacerbation of advanced heart failure.

Evaluation of arterial stiffness for predicting future cardiovascular events in patients with ST segment elevation and non-ST segment elevation myocardial infarction.

BACKGROUND: Arterial stiffness parameters in patients who experienced MACE after acute MI have not been studied sufficiently. We investigated arterial stiffness parameters in patients with ST segment elevation (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). METHODS: Ninety-four patients with acute MI (45 STEMI and 49 NSTEMI) were included in the study. Arterial stiffness was assessed noninvasively by using TensioMed Arteriograph. RESULTS: Arterial stiffness parameters were found to be higher in NSTEMI group but did not achieve statistical significance apart from pulse pressure (P = 0.007). There was no significant difference at MACE rates between two groups. Pulse pressure and heart rate were also significantly higher in MACE observed group. Aortic pulse wave velocity (PWV), aortic augmentation index (AI), systolic area index (SAI), heart rate, and pulse pressure were higher; ejection fraction, the return time (RT), diastolic reflex area (DRA), and diastolic area index (DAI) were significantly lower in patients with major cardiovascular events. However, PWV, heart rate, and ejection fraction were independent indicators at development of MACE. CONCLUSIONS: Parameters of arterial stiffness and MACE rates were similar in patients with STEMI and NSTEMI in one year followup. The independent prognostic indicator aortic PWV may be an easy and reliable method for determining the risk of future events in patients hospitalized with acute MI.

Coronary artery fistula presenting as unstable angina pectoris in patients with antiphospholipid syndrome.

The cardiovascular system is one of the primary targets in patients with antiphospholipid syndrome. The valves are the most frequently affected. Atherosclerosis and coronary thrombosis are also seen. The risk of acute coronary syndrome is 10 times higher in patients with APS. We present an APS patient case who was hospitalized with acute coronary syndrome and who was later found to have coronary artery fistula.

A new index (CHOLINDEX) in detecting coronary artery disease risk.

OBJECTIVE: Coronary artery disease (CAD) risk increases with the elevation of low-density lipoprotein cholesterol (LDL-C), triglyceride (TG) and low level high-density lipoprotein cholesterol (HDL-C) levels. However, the magnitude at which CAD risk increases with every lipid parameter is controversial. We developed a new index called CHOLINDEX, in order to evaluate CAD risk, and investigated its reliability. METHODS: Three hundred and seven patients (190 males and 117 females, aged between 26-80 years, mean 53.6 ± 10.2 years) who underwent diagnostic coronary angiography were included in the study. Risk factors and lipid profiles of all patients were noted. CHOLINDEX was calculated by using a formula as follows: CHOLINDEX=LDL-C-HDL-C (TG<400 mg/dL), LDL-C-HDL-C + 1/5 of TG (TG ≥ 400 mg/dL). RESULTS: Of the 307 patients, 180 had CAD. We found that age, male gender, hypertension, diabetes mellitus, smoking and CHOLINDEX were independent predictors of CAD. The logistic regression analysis showed that the CHOLINDEX had a much more significant relation with CAD (odds ratio=1.011, 95% CI=1.003-1.019) compared with other lipid parameters. CONCLUSION: CHOLINDEX is a simple index which can be used reliably in prediction of CAD like other lipid parameters in daily clinical practice.

The Turkish registry of heart valve disease.

OBJECTIVES: Valvular heart diseases (VHD) occur frequently in Turkey. However, epidemiological studies of VHD have not been completed until now. The aim of this study is to identify the VHD type, clinical, laboratory characteristics, and treatment methods among VHD patients in Turkey. STUDY DESIGN: The study was conducted prospectively between June 2009 and June 2011 at 42 centers, and included patients with native VHDs, infective endocarditis, and/or previous valve interventions. RESULTS: All medical data from 1300 patients were recorded. Mean age was 57±18 years and the female/male ratio was 1.5. VHD was native in 84% of patients, 15% had previous interventions, and 1% had infective endocarditis. Among the native VHDs, mitral regurgitation was the most frequent lesion (43%), followed by multiple VHDs (32%). Degenerative etiology (86%) was more frequent in aortic VHD, and rheumatic origin was the main cause in all VHDs. While the prevalence of aortic stenosis increased with age, mitral stenosis decreased with patient age. The most frequent symptom was shortness of breath (73%). Clinical and echocardiographic examinations (54%) were mostly used as diagnostic techniques for determining treatment course. Percutaneous mitral balloon valvuloplasty (PMBV) was performed in 76% of the patients with mitral stenosis and mechanical prosthetic valve replacement was performed in 74% of the patients with other lesions. CONCLUSION: This study showed that the main cause of VHD is rheumatic fever. Mitral regurgitation and multiple valvular lesions are the most frequent VHDs in Turkey. PMBV and mechanical prosthetic valve replacement are the preferred treatment methods for VHD.

Prediction of pharmacologically induced baroreflex sensitivity from local time and frequency domain indices of R-R interval and systolic blood pressure signals obtained during deep breathing.

Pharmacological measurement of baroreflex sensitivity (BRS) is widely accepted and used in clinical practice. Following the introduction of pharmacologically induced BRS (p-BRS), alternative assessment methods eliminating the use of drugs were in the center of interest of the cardiovascular research community. In this study we investigated whether p-BRS using phenylephrine injection can be predicted from non-pharmacological time and frequency domain indices computed from electrocardiogram (ECG) and blood pressure (BP) data acquired during deep breathing. In this scheme, ECG and BP data were recorded from 16 subjects in a two-phase experiment. In the first phase the subjects performed irregular deep breaths and in the second phase the subjects received phenylephrine injection. From the first phase of the experiment, a large pool of predictors describing the local characteristic of beat-to-beat interval tachogram (RR) and systolic blood pressure (SBP) were extracted in time and frequency domains. A subset of these indices was selected using twelve subjects with an exhaustive search fused with a leave one subject out cross validation procedure. The selected indices were used to predict the p-BRS on the remaining four test subjects. A multivariate regression was used in all prediction steps. The algorithm achieved best prediction accuracy with only two features extracted from the deep breathing data, one from the frequency and the other from the time domain. The normalized L2-norm error was computed as 22.9% and the correlation coefficient was 0.97 (p=0.03). These results suggest that the p-BRS can be estimated from non-pharmacological indices computed from ECG and invasive BP data related to deep breathing.

Low pulse pressure as a predictor of death in patients with mild to advanced heart failure.

The prognostic value of pulse pressure has been investigated in heart-failure patients. Low pulse pressure in advanced heart failure and high pulse pressure in mild heart failure have been separately linked to increased mortality rates. We prospectively investigated an association between pulse pressure and 2-year cardiovascular death in an entire heart-failure population. We prospectively enrolled 225 heart-failure patients (New York Heart Association [NYHA] functional class, I-IV; mean age, 56.5 +/- 12.3 yr; 188 men). The patients' blood pressures were measured in accordance with recommended guidelines. Pulse pressures were calculated as the difference between systolic and diastolic blood pressure values. The patients were monitored for a mean period of 670 +/- 42 days for the occurrence of cardiovascular death. All patients were divided into quartiles according to their pulse pressures (<35, 35-45, 46-55, and >55 mmHg). Pulse pressure decreased as NYHA class worsened (P <0.001). Patients in the <35-mmHg quartile had the lowest plasma sodium concentrations, left ventricular ejection fractions, and systolic myocardial velocities upon echocardiography; and the highest left ventricular dimensions, early diastolic/late diastolic filling velocity ratios, and peak early/peak late diastolic myocardial velocity ratios. Pulse pressure independently predicted death in the patients with advanced heart failure and in the entire population. Upon receiver operating characteristic analysis, a 30-mmHg cutoff value for pulse pressure predicted death with 83.7% sensitivity and 79.7% specificity. Pulse pressure is easily calculated and enables the prediction of cardiovascular death in patients with mild to advanced heart failure. Pulse pressure can be used reliably as a prognostic marker in clinical practice.

[Anomalous single coronary artery presenting as typical angina pectoris: a case report]. / Tipik angina pektorise neden olan tek koroner arter anomalisi: Olgu sunumu.

Single coronary artery is described as an isolated coronary artery originating from the aortic root through a single ostium in the absence of another ostium, where isolated coronary artery is the only source for blood supply to the whole heart. We present a 53-year-old woman whose coronary angiography for typical chest pain revealed an isolated single coronary artery. On coronary angiography, the whole coronary system originated by a single trunk from the right sinus of Valsalva. Multislice computed tomography showed that the left anterior descending, circumflex, and right coronary arteries arose from a single ostium in the right sinus of Valsalva without a left main trunk. Despite maximal medical therapy, her chest pain persisted. The patient did not accept surgical treatment proposed for correction of the anomaly.

Cutoff values of NT-proBNP for the prediction of low functional capacity, decreased ejection fraction and cardiovascular events in patients with heart failure.

BACKGROUND: It has been demonstrated in numerous studies that N-terminal pro-B-type natriuretic peptide (NT-proBNP) is strongly associated with left ventricular ejection fraction (LVEF), functional capacity (FC), and cardiovascular (CV) mortality in heart failure (HF) patients. The aim of the present study was to determine the predictive cutoff values of NT-proBNP for predicting these parameters. METHODS: One hundred HF patients (88 male, 12 female, mean age 53.6 +/- 8.9 years) with left ventricular (LV) systolic dysfunction and impaired exercise capacity were enrolled into the study. Echocardiographic examination was performed. The NT-proBNP concentration was measured after resting for 20 min in the supine position. The modified Bruce protocol was utilized for exercise testing. The patients were followed for between 690 and 840 days (mean 750 +/- 30 days) for the occurrence of CV events. RESULTS: There was a strong negative correlation between NT-proBNP concentration and LVEF (p < 0.004). It was found that NT-proBNP is a strong predictor of LVEF < 30% (p < 0.001). When 940 pg/mL was accepted as a cutoff value for NT-proBNP for the prediction of an LVEF < 30%, the sensitivity and the specificity were 89.8% and 71.4%, respectively. NT-proBNP and left atrial diastolic dimension were the most significant parameters for predicting FC (p < 0.001, each one). An NT-proBNP cutoff value of 940 pg/mL responded to 78.8% sensitivity and 81% specificity for the prediction of FC < 5 METs. The observed independent predictors for the CV events were NT-proBNP, LV mass index, and resting heart rate (p < 0.001, p = 0.02 and p = 0.006, respectively). Every 1000 pg/mL elevation in NT-proBNP level resulted in a 27% increase in the occurrence of CV events (p < 0.006). Moreover, 940 pg/mL NT-proBNP cutoff value revealed a sensitivity and specificity of 86.7% and 64.7% respectively for the prediction of incident CV events. CONCLUSIONS: Use of NT-proBNP cutoff values is easy and reliable method for the prediction of low FC and decreased LVEF, and may aid identification of patients at the highest risk for future CV events. We suggest to use NT-proBNP cutoff value of 940 pg/mL for predicting these parameters.

Left atrial size may predict exercise capacity and cardiovascular events in patients with heart failure.

Our aim was to investigate, in patients with heart failure, the relationship between left atrial size and exercise capacity and cardiovascular events. Seventy-five patients (67 men and 8 women; mean age, 53.4 +/- 8.8 yr) with left ventricular ejection fractions of < or =0.45 (New York Heart Association functional classes I-III) were matched by age and sex with 20 healthy control subjects. Echocardiographic examinations were performed, as was exercise testing by the modified Bruce protocol. Patients were monitored for a period of 330 to 480 days for cardiac death or for heart failure that required hospitalization. The indexed left atrial diastolic size (beta level = -0.534, P <0.001) and left ventricular late diastolic filling velocity (beta level = 0.247, P <0.017) were the most important values in predicting low exercise capacity. The only independent predictor of low exercise capacity (<5 METS) was the indexed left atrial diastolic size (odds ratio, 1.428; 95% confidence interval, 1.09-1.702; P <0.001). Every 1 mm/m2 increase in indexed left atrial diastolic dimension caused a 42.8% increase in the risk of severe heart failure (exercise capacity, <5 METS). Independent predictors for cardiovascular events were indexed as left atrial systolic size (odds ratio, 1.383; 95% confidence interval, 1.145-1.671; P <0.001) and left ventricular early diastolic/late diastolic filling velocity (odds ratio, 1.096; 95% confidence interval, 1.010-1.189; P <0.027). Indexed left atrial diastolic and left atrial systolic size predict exercise capacity and cardiovascular events, respectively, in New York Heart Association functional class I through III heart failure patients.

The relation between serum erythropoietin level and severity of disease and mortality in patients with chronic heart failure.

OBJECTIVE: We evaluated the relation between serum erithropoietin level and the severity of disease and mortality in patients with chronic heart failure (CHF). METHODS: We enrolled 96 CHF patients and 50 age- and sex-matched control subjects. Haemoglobin, haemotocrit, N terminal pro-B type natriuretic peptide (NT-proBNP) and erythropoietin levels and echocardiographic parameters were measured. The patients were contacted 1 year after the evaluations to determine survival. RESULTS: The patients had lower haemoglobin and haematocrit but higher serum erythropoietin and NT-proBNP levels than the control subjects. Serum erythropoietin and NT-proBNP levels increased with worsening functional class. The serum erythropoietin level correlated negatively with left ventricular ejection fraction (r = -0.404, P < 0.001), haemoglobin (r = -0.530, P < 0.001) and haematocrit (r = -0.496, P < 0.001) levels. The patients who died (n = 17) had lower haemoglobin and haematocrit levels and significantly higher erythropoietin and NT-proBNP levels. However, multivariate logistic regression analysis showed that only NT-proBNP level was an independent predictor of mortality (P = 0.002). CONCLUSION: Anaemia and resistance to erythropoietin develop proportionately to disease severity and left ventricular systolic dysfunction in patients with CHF. Although serum erythropoietin level seems related with mortality, this observation needs to be confirmed by studies with more patients and longer follow-up.

[A case of type IV dual left anterior descending coronary artery anomaly]. / Tip IV çift sol ön inen koroner arter anomalisi: Olgu sunumu.

Dual left anterior descending (LAD) artery is a very rare congenital coronary artery anomaly. A 51-year-old woman presented with atypical chest pain and palpitation. Electrocardiography showed nonspecific ST-segment depression in inferior and lateral leads. Coronary angiography showed a rudimentary LAD artery terminating in the midportion of the anterior interventricular sulcus, after giving the first septal branch. In right coronary angiography, there was another LAD artery originating from the proximal right coronary artery and coursing to the anterior interventricular sulcus. This anomaly was consistent with type IV dual LAD.

Usefulness of N-terminal pro-B-type natriuretic peptide increase with exercise for predicting cardiovascular mortality in patients with heart failure.

N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) level at rest is related to left ventricular (LV) function and cardiovascular mortality in patients with heart failure (HF). There are limited and controversial data regarding changes in NT-pro-BNP level during exercise in patients with HF. The aim of this study was to investigate the effects of exercise on NT-pro-BNP levels and the relation between increases in NT-pro-BNP and the LV ejection fraction and cardiovascular mortality in patients with HF. Seventy-five patients with HF (New York Heart Association classes I to III) and 20 healthy subjects were enrolled in the study. Echocardiographic examination was performed. The modified Bruce protocol was used for symptom-limited exercise testing. Levels of NT-pro-BNP were measured at rest and after peak exercise. The patients were followed up for 690 to 840 days for cardiovascular mortality. Exercise induced significant increases in NT-pro-BNP in patients and controls. Except for a relative increase in NT-pro-BNP during exercise (relative DeltaNT-pro-BNP), NT-pro-BNP concentrations at rest and during peak exercise and absolute increases in NT-pro-BNP during exercise (absolute DeltaNT-pro-BNP) were significantly higher in patients with HF (p <0.001). Absolute DeltaNT-pro-BNP was positively correlated with NT-pro-BNP at rest (p <0.001). The level of absolute DeltaNT-pro-BNP was the most important parameter in predicting a LV ejection fraction <30% (p <0.001). Absolute DeltaNT-pro-BNP and LV end-systolic volume were found to be independent predictors of mortality (p = 0.012 and p = 0.015, respectively). In conclusion, exercise induced increases in NT-pro-BNP in patients and healthy subjects. Absolute increase in NT-pro-BNP is a reliable parameter in predicting a low LV ejection fraction and may help in the identification of patients at high risk for mortality.