Doppler Tissue Evaluation of Atrial Conduction Properties in Patients With Non-alcoholic Fatty-liver Disease.

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in clinical practice, and there is an increasing trend in its prevalence in the general population. Recent studies have demonstrated increased risk of atrial fibrillation (AF) in NAFLD. However, information on the mechanism of increased risk of AF in NAFLD is lacking. Impaired atrial conduction is an important factor in the pathophysiology of AF. We aimed to investigate atrial conduction properties in patients with NAFLD by tissue Doppler echocardiography. Fifty-nine ultrasound diagnosed NAFLD patients without clinical diagnosis of hypertension, diabetes mellitus, or cardiac disease and 22 normal subjects as controls were included in this study. Atrial conduction properties were assessed by electromechanical delay (EMD) derived from Doppler tissue echocardiography examination and P-wave dispersion (PWD) calculated from the 12-lead electrocardiogram. Inter-atrial and intra-atrial EMD intervals were significantly longer in NAFLD patients than in controls (inter-atrial EMD, 31.9 ± 8.5 ms vs. 23.4 ± 4.6 ms,p= 0.0001, and intra-atrial EMD, 14.3 ± 5.2 vs. 10.2 ± 4.0 ms,p= 0.001). Similarly, PWD was significantly higher in NAFLD patients compared with controls (49.2 ± 6.3 ms vs. 43.3 ± 4.2 ms,p= 0.0001). Maximum left atrial volume was also significantly higher in the NAFLD group than in controls (51 ± 11 mL vs. 34 ± 9 mL,p< 0.0001). This study demonstrated that atrial conduction is impaired in patients with NAFLD. Also, in a patient population of NAFLD without any clinical diagnosis of cardiac disease, diabetes, or hypertension, left atrial volume was increased compared with controls. These findings suggest impaired atrial conduction as a factor in increased risk of AF in NAFLD.

Evaluation of endothelium functions by flow-mediated dilatation in pediatric patients with Crimean-Congo hemorrhagic fever.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a systemic viral disease that also affects the endothelium. Thrombocytopenia and hemorrhage are seen in this disease. But, the cause of thrombocytopenia is not clear. We hypothesized that endothelium dysfunction may be the cause of thrombocytopenia. We evaluated the endothelium functions by flow-mediated dilatation (FMD) in CCHF. METHODS: Consecutive children with suspected CCHF who applied to our hospital were evaluated for recruitment into the study. FMD analysis was done in the active and healing period of the disease. Diagnosis was confirmed or ruled out by polymerase chain reaction and/or ELISA test. Basal brachial artery diameter (BBAD) and dilated brachial artery diameter (DBAD) after ischemic period were measured and percent dilatations [(DBAD-BBAD)/BBAD, FMD%] were computed from all subjects. RESULTS: Fifty-four children (40 male, mean age 12.4 ± 4.4 years) were recruited into the study. CCHF diagnosis was confirmed in 28 children and ruled out in 26 children. Groups were similar for age and gender. FMD% was significantly decreased in CCHF patients when comparing this with the control patients in the active period (2.65 ± 2.76 vs. 13.76 ± 7.95, P < 0.001). FMD% was correlated with platelet count in the active period of the disease (r = 0.599, P = 0.004). FMD% was recovered in the healing period (2.65 ± 2.76 vs. 14.72 ± 2.66, P < 0.001) and was not significantly different from basal values of control patients (P > 0.05). CONCLUSIONS: FMD is significantly decreased in CCHF and recovers in the healing period. So, endothelium functions are disturbed, and disturbance is correlated with thrombocytopenia in CCHF.

Infective endocarditis and complications; a single center experience.

OBJECTIVES: The aim was to investigate the microbiological characteristics and complications of infective endocarditis (IE) in 119 patients treated in our center for IE, diagnosed by modified Duke criteria. STUDY DESIGN: The archive records of 119 patients (82 [69%] males; 37 [31%] females; mean age 39 ± 16 years) with a definite diagnosis of IE between January 1997 and November 2004 were systematically reviewed for clinical and microbiological properties and complications. RESULTS: The most common complaint of the patients was fever and malaise (102 patients, 85.7%, each). Culture was negative in 68 patients (57.1%), while Staphylococcus aureus was the most common etiological agent in culture positive cases. The aortic valve was the most common region of vegetation (43 patients, 36.1%). The frequency of surgical operation for valvular insufficiency due to IE was 75.6%, and the frequency of congestive heart failure was 53.8% (64 patients). CONCLUSION: IE is still an important disease considering its high morbidity and mortality rates, increased life expectancy of the patients, and increased number of valve replacement procedures.

Deterioration of heart rate recovery index in patients with non-alcoholic fatty liver disease (NAFLD).

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) has been considered as a benign disease often associated with central obesity and insulin resistance and, in general, with factors of the metabolic syndrome. Heart rate recovery after exercise is a function of vagal reactivation, and its impairment is an independent prognostic indicator for cardiovascular and all-cause mortality. The aim of our study was to evaluate the heart rate recovery index in patients with NAFLD. MATERIAL AND METHODS: The study population included 59 patients with NAFLD (mean age=42.3±9.3 years) and 22 healthy subjects as controls (mean age=40.7±6.5 years). Basal electrocardiography, echocardiography, and treadmill exercise testing were performed on all patients and controls. The heart rate recovery index was defined as the reduction in the heart rate from the rate at peak exercise to the rate at the 1st minute (HRR1), 2nd minute (HRR2), 3rd minute (HRR3), and 5th minute (HRR5) after stopping exercise stress testing. RESULTS: There were significant differences in HRR1 and HRR2 indices between patients with ED and the control group (19.9±8.2 vs. 34.1±9.6; p<0.001 and 24.3±5.4 vs. 40.5±9.1; p=0.006, respectively). Similarly, HRR indices after the 3rd and 5th minutes of the recovery period were significantly lower in patients with NAFLD compared with those indices in the control group (32.3±8.5 vs. 58.4±6.5; p=0.001 and 58±18.2 vs. 75.1±15.8; p<0.001). Effort capacity was markedly lower (11±1.9 vs. 12.5±1.5 METs; p=0.001) among the patients with NAFLD. CONCLUSIONS: The heart rate recovery index is deteriorated in patients with NAFLD. When the prognostic significance of the heart rate recovery index is considered, these results may help explain the increased occurrence of cardiac death. It points to the importance of the heart rate recovery index in the identification of high-risk patients.

Hypertensive response to exercise in dipper and non-dipper normotensive diabetics.

Non-dipper blood pressure (NDP) as an indicator of autonomic dysfunction could be associated with hypertensive response to exercise (HRE) in diabetic patients. HRE was determined as a predictor of development of unborn hypertension. We aimed to investigate if any correlation among NDP and HRE in normotensive type 2 diabetic patients. A total of 59 consecutive type 2 diabetic patients without history of hypertension and with normal blood pressure (BP) on ambulatory blood pressure monitoring (ABPM) were enrolled to the study. We divided the study population in to two groups depending on their BP on ABPM as dipper (group 1) or non-dipper (group 2). There were 22 patients (mean age 49.5 ± 7 and 10 male) in group 1 and 37 patients (mean age 53.1 ± 10 and 14 male) in group 2. Daytime diastolic and mean BP of dippers and night time systolic and mean BP of non-dippers were significantly higher. HRE was not significantly different between groups (59% vs. 62%, p = 0.820). Hemodynamic parameters during the exercise test were similar. At multivariate linear regression analysis, resting office systolic blood pressure (SBP) (r = 0.611, p < 0.001), male sex (r = 0.266, p = 0.002) and age (r = 0.321, p = 0.010) were independently correlated with peak exercises SBP. Logistic regression analyses identified the resting office SBP (OR 1.191, 95% CI 1.080-1.313; p < 0.001) and age (OR 1.161, 95% CI 1.038-1.298; p = 0.012) were independent predictors of HRE. This study revealed that HRE is not related with non-dipper BP in diabetic patients. This study could inspire to further studies to explore the main reasons of HRE in diabetes mellitus.

Red cell distribution width and hypertensive response to exercise in patients with type 2 diabetes mellitus.

OBJECTIVE: There is no study about hypertensive response to exercise (HRE), which is a marker of unborn hypertension (HT), and red cell distribution width (RDW) association, in diabetic normotensive patients. So, we aimed to investigate any correlation among RDW and HRE in normotensive type 2 diabetic patients. METHODS: Consecutive type 2 diabetic patients without history of HT and with normal blood pressure (BP) on ambulatory BP monitoring were included to the study. We divided the patients into two groups depending on their peak systolic BP on exercise; HRE (Group 1) or normal response to exercise (Group 2). RESULTS: Data of 75 diabetic patients (51.9 ± 9.7) were analyzed (31 male (48%)). Their mean RDW was 13.11 ± 0.46. Patients with HRE were significantly older than patients without HRE. Smoking was more frequent in Group 2. Gender distribution and body mass index were similar between the groups. Else hemoglobin, hematocrit, red blood cell count and RDW values were not significantly different. Office systolic BP and diastolic BP, daytime and 24-h systolic BP were significantly higher in Group 1 but heart rate was similar between the groups. CONCLUSIONS: This study revealed that RDW do not differ between diabetic normotensive patients with HRE or not.

Evaluation of atrial electromechanical coupling times in hemodialysis patients.

BACKGROUND: There are no definite data about the atrial electromechanical coupling times (AEMCT) in patients with end stage renal failure (ESRF). The aim of this study was to investigate the AEMCT in ESRF patients without hypertension (HT) and diabetes mellitus. METHODS: The study population consisted of 47 normotensive, nondiabetic ESRF patients and 41 healthy age/gender-matched control subjects. The time intervals from the onset of P-wave on the surface electrocardiogram to the beginning of late diastolic A-wave (PA) were obtained from the lateral mitral annulus (PA-lateral, maximum AEMCT), septal annulus (PA-septal), and tricuspid lateral annulus (PA-tricuspid). Time intervals were corrected according to the heart rate. The difference between PA-septal and PA-tricuspid (right AEMCT), PA-lateral and PA-septal (left AEMCT), and PA-lateral and PA-tricuspid (inter AEMCT) were calculated. Corrected time intervals were used for calculations. RESULTS: Groups were similar for age (52 ± 12.3 vs. 49.9 ± 6 years, P > 0.05) and gender. Maximum (61 ± 20 vs. 47 ± 13 ms; P < 0.001) AEMCT was significantly higher in the patients compared with the control group, but septal and tricuspid EMCT were not different (P > 0.05). Both inter-atrial (37 ± 21 vs. 24 ± 16 ms, P = 0.002) and left atrial (25 ± 18 vs. 12 ± 9 ms; P < 0.001) EMCT were significantly higher in patients when compared with the controls but intra-right atrial EMCT was not different. CONCLUSIONS: Atrial conduction parameters such as maximal EMCT, left atrial, and inter-atrial EMCTs were prolonged in ESRF patients. This prolongation is seen in ESRF patients even in the absence of factors that affect atrial coupling, such as HT.

Paliperidone: As a Possible Cause of Pericardial Effusion.

Paliperidone which is the active metabolite of risperidon is one of the novel antipsychotics. Controlled clinical studies proved its effectiveness on decreasing the positive and negative symptoms of schizophrenia. Some studies and case reports, reported its cardiovascular and cardiometabolic side effects. Cardiac tamponade, that may be mortal, wasn't reported as a side effect with paliperidone usage before. We present a 40 years old female with catatonic schizophrenia for eighteen years, whom was on 6 mg/day paliperidon for 3 years and presented with pericardial tamponade. We suggest that paliperdione may have cardiovascular and cardiometabolic side effects also in therapeutic doses.

Resting heart rate in children with Crimean-Congo hemorrhagic fever: a tool to identify patients at risk?

OBJECTIVE: We aimed to assess the association between resting heart rate (RHR) and severe infection in children with Crimean-Congo hemorrhagic fever (CCHF). METHODS: In all, 121 patients under 18 years of age with a laboratory-confirmed diagnosis of CCHF were enrolled in the study. Patients were classified into two groups based on disease severity (severe group and nonsevere group). RHR was measured by electrocardiography (ECG) on admission. Maximum P-wave duration (Pmax), P-wave dispersion (Pd), QRS duration, corrected QT interval, and QT dispersion were also measured. RESULTS: Mean age was 11.4±3.9 years and 84 patients were male. Twenty-six patients were classified as severe. Patients in this group had a higher RHR (103.6±10.4 vs. 80.5±8.1, p=0.001) than those with nonsevere disease. There was no difference in Pmax, Pd, QRS duration, QTcmax, or QTc dispersion. The optimal cutoff value of RHR to predict disease severity was>96 beats per minute (bpm), with 70.6% sensitivity and 50.1% specificity. Bleeding, thrombocytopenia (≤80×10(9)/L), elevated aspartate transaminase (AST) (>208 IU/L), elevated alanine transaminase (ALT) (>87 IU/L), elevated lactate dehydrogenase (LDH) (>566 IU/L), long activated partial thromboplastin time (aPTT) (>42 s), and increased hospitalization days were more frequent in patients with RHR >96 bpm. Multivariate logistic regression analysis revealed low platelet count (<80×10(9)/L), long aPTT (>42 s), high LDH (>566 IU/L), and elevated RHR (>96 bpm) as independent risk factors for severe disease. CONCLUSIONS: We conclude that elevated RHR was significantly associated with severe disease in children with CCHF, thus offering the potential to identify patients with increased risk.

Bradycardia seen in children with Crimean-Congo hemorrhagic fever.

INTRODUCTION: Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic viral disease with a high mortality rate. In clinical practice, we observed bradycardia in some pediatric patients with CCHF during the clinical course. So we aimed to report CCHF cases that presented bradycardia during the clinical course and the relation of bradycardia with the clinical findings and ribavirin therapy. METHODS: Charts of all hospitalized pediatric CCHF patients were reviewed with respect to age, sex, history of tick bite or history of removing a tick, other risk factors for CCHF transmission, and interval between the tick bite and the onset of symptoms. Outcomes and clinical and laboratory findings and medications were recorded for each patient. We searched the patient records for information regarding the existence of bradycardia. Bradycardia was accepted as the heart rate 2 standard deviations (SD) lower than the suspected heart rate based on age. RESULTS: Fifty-two patients (mean age 11.2 ± 4.4 years, 31 female) were enrolled into the study. Bradycardia was seen in seven patients. Six patients with bradycardia were male and only one was female, and the mean age was 13.1 ± 1.6 years. It was observed that male gender is frequent among patients with bradycardia, as compared with those without bradycardia (p=0.01). Bleeding was found to be more frequent in patients with bradycardia (p=0.02). There were significant differences between the bradycardia and nonbradycardia groups with regard to the requirements for fresh frozen plasma transfusion, the number of platelet suspension given, requirement for intravenous immune globulin (IVIG) and in the days of stay in hospital (p=0.01, p=0.03, p=0.03, p=0.04, respectively). CONCLUSION: Reversible bradycardia might be seen in the clinical course of pediatric CCHF patients, and the clinicians must be aware of this finding. The possibility that ribavirin may potentiate bradycardia cannot be assessed without a placebo-control study. So further studies may help to reveal the cause of the bradycardia, the disease itself, or the ribavirin therapy. Hence this study supports the need for a randomized, placebo-controlled study to assess intravenous ribavirin in treating CCHF and to support approval of the drug.

Evaluation of left ventricular diastolic function in nonhypertensive nondiabetic hemodialysis patients.

AIM: Diastolic dysfunction (DD) is common in hemodialysis (HD) patients. Because diabetes mellitus (DM) and hypertension (HT) are also common in this patient group, the exact reason for DD in HD patients is not clear. The present study evaluated left ventricular (LV) diastolic function in HD patients without DM and HT. METHODS: Fifty patients on HD and 34 age-matched and sex-matched healthy control individuals were enrolled. Echocardiography was performed in all participants. LV systolic and diastolic functions were evaluated by B-mode echocardiography, pulsed wave, and tissue Doppler imaging. The HD patients were divided into two groups according to the presence or absence of left ventricular hypertrophy (LVH) in echocardiography. RESULTS: LV dimensions and systolic function were within normal limits and similar between groups. However, the HD patients had significantly worse diastolic function (E/A: 0.78 ± 0.26 vs. 1.19 ± 0.28, P < 0.001, e'/a' septal: 0.77 ± 0.36 vs. 1.04 ± 0.21, P < 0.001) and increased filling pressure (E/e': 8.55 ± 3.2 vs. 5.79 ± 1.93, P < 0.001). Thirty-one (62%) patients had LVH, whereas 19 (38%) patients did not have LVH. LV systolic and diastolic functions were similar in HD patients with and without LVH. Seventeen (55%) hypertrophies were concentric and 14 (45%) were eccentric. Diastolic functions were similar in patients with either concentric or eccentric hypertrophy. CONCLUSION: Diastolic function is impaired in HD patients even in the absence of diseases that can cause DD such as HT and DM.

Reversible cardiomyopathy associated with autoimmune polyendocrine syndrome type II.

Recovery of the ventricular function in a patient with cardiomyopathy is very rare. Autoimmune polyendocrine syndrome is also very rare. We herein report a case of reversed cardiomyopathy associated with autoimmune polyendocrine syndrome type II (Schmidt's syndrome) composed of Addison's disease, vitiligo and Hashimoto's thyroiditis. The ventricular function and size were reversed following the administration of suitable hormone replacement therapy for polyendocrine syndrome.

[Our clinical experience of Takotsubo cardiomyopathy and the first case series from Turkey]. / Takotsubo kardiyomiyopatisi hakkinda klinik deneyimimiz ve ülkemizden bildirilen ilk olgu serisi.

OBJECTIVES: There is no data about the incidence, progress and prognosis of Takotsubo Cardiomyopathy (TC) from Turkey. This study aimed to search for the progress and short-term prognosis of TC patients and to increase the familiarity and awareness for TC in Turkey. STUDY DESIGN: We included 6 patients who were referred to our center with ST elevation myocardial infarction and diagnosed as TC according to the Mayo Clinic diagnostic criteria. RESULTS: Our patients' median age was 46 years (range 17 to 64 years) and 3 of them were males. Triggering factors included emotional stress (3 patients) and physical stress (3 patients). Median troponin I level was 1.65 ng/ml (0.48-2.20), excluding the patients who underwent cardiopulmonary resuscitation. ST elevation in precordial leads was observed on the ECG of 4 patients and in inferior leads on ECG of 2 patients. Five patients' coronary arteries were normal and were diagnosed as typical, but 1 patient had non-critical stenosis on the coronary arteries and was diagnosed with reverse TC. Four patients were discharged without any complications but 2 presented with sudden cardiac death. CONCLUSION: This study presented the first data about TC in Turkey while attempting to increase awareness about the disease. Emergent ventricle evaluation by ventriculography or echocardiography is recommended for acute coronary syndrome patients with non-critical stenosis for the differential diagnosis.

Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction.

PURPOSE: It is still unknown whether left ventricular ejection fraction (LVEF) might affect the magnitude of improvement after atrial fibrillation (AF) ablation on cardiac function in persistent or longstanding persistent AF (CAF) patients. METHOD: We performed echocardiography in 35 patients with CAF before and after catheter ablation (CA). Patients were stratified by LVEF into two groups prior to CA-normal LVEF (≥50 % LVEF, N group, n = 24) and a low LVEF group (<50 % LVEF, L group, n = 11). Patients were followed at 1 month, 3 months, 6 months, 1 year, and 2 years after ablation. RESULTS: After 15.8 ± 7.4 months follow-up, the L group showed greater improvement in LVEF and left atrial ejection fraction (LAEF; N group vs L group: LVEF difference (%), 5 ±8 vs 20± 13, p < 0.01; LAEF difference (%), 11 ± 12 vs 21 ± 10, p < 0.05). LA maximal volume and E/e' showed the same tendency after ablation, although the extent of improvement was not statistically significant. Both groups showed almost the same time course of improvement up to 2 years, although the L group showed earlier recovery in LVEF. CONCLUSION: The greater improvement in several cardiac functions was seen in patients with greater LV dysfunction, after the CA for CAF.

Is atrial electromechanical coupling delayed in patients with secundum atrial septal defect?

BACKGROUND: There is no available published information about the atrial electromechanical coupling time (AEMCT) in patients with atrial septal defect (ASD). The aim of this study was to investigate the relationship between ASD and AEMCT obtained by tissue Doppler imaging (TDI). METHODS: A total of 35 patients with ASD and 22 healthy controls were included in the study. The time intervals from the onset of the P-wave on the surface electrocardiogram to the beginning of the late diastolic A-wave (PA) representing AEMCT were obtained from the lateral mitral annulus, septal mitral annulus, and right ventricular (RV) tricuspid annulus, and named PA-lateral, PA-septal, and PA-tricuspid, respectively. The difference between PA-septal and PA-tricuspid, PA-lateral and PA-septal, and PA-lateral and PA-tricuspid were defined as intra-right AEMCT, intra-left AEMCT, and inter- AEMCT, respectively. RESULTS: PA-tricuspid, PA-septal, and PA-lateral values were longer in patients with ASD when compared with the controls, but did not reach statistical significance (39.9 ± 19.1 vs. 37.2 ± 15.5, P = 0.952; 49.6 ± 14.0 vs. 45.4 ± 11.1, P = 0.826 and 60.3 ± 16.3 vs. 59.7 ± 12.5, P = 0.437, respectively). There were no significant differences between the ASD and control groups in terms of inter-atrial, intra-right atrial, and intra-left AEMCT (21.3 ± 2.3 vs. 20.8 ± 4.6, P = 0.957; 9.7 ± 3.3 vs. 6.9 ± 1.3, P = 0.723 and 13.6 ± 4.7 vs. 10.9 ± 4.5, P = 0.518, respectively). Furthermore, ASD diameter and total septum length did not correlate with AEMCT. CONCLUSION: Both intra- and inter-AEMCT were not increased in patients with ASD than control subjects. In addition, we found no association between the ASD diameter and indices of AEMCT in patients with ASD.

Abnormal heart rate recovery in stable heart failure patients.

BACKGROUND: Heart rate decrease after exercise, that is associated with reactivation of parasympathetic system, is important, as it is also associated with mortality. Previous studies have shown that this is an independent mortality predictor in patients having no coronary artery disease and having normal left ventricular function. In our study, we aimed to study heart rate recovery (HRR) after exercise in patients having impaired left ventricular function. METHODS: One hundred and two consecutive patients (68 males, 34 females) requested to perform an exercise stress test were included in our study. Patients were divided into two groups as those having a normal heart rate reserve (Group1, n = 72) and those having an abnormal heart rate reserve (Group2, n = 30). RESULTS: In Group1 and Group2, resting heart rate averages were found to be 83.61 ± 18.01/min and 85.10 ± 13.40/min, respectively (P > 0.05), and maximum heart rates during exercise were 141.42 ± 19.70/min and 121.17 ± 19.01/min while those in Group1 had statistically significantly higher heart rates (P < 0.001). A statistically significant positive association was found in the correlation test carried out between the maximum heart rate during the treadmill exercise test and ejection fraction (EF) value (r = 0.201; P < 0.05). Metabolic equivalents of task values obtained during the treadmill exercise test in Group1 and Group2 were 9.48 ± 2.28 and 8.36 ± 2.50, respectively, and the difference between the said values was statistically significant (P < 0.05). CONCLUSIONS: We believe that the association between low EF and abnormal HRR is worth studying and randomized large-scale studies are needed to determine mortality risk.