Comparison of three diuretic treatment strategies for patients with acute decompensated heart failure.

BACKGROUND: There are few prospective data available for establishing a standard diuretic administration regimen for patients with acute decompensated heart failure (ADHF). We aimed to assess the safety and efficacy of three regimens of furosemide administration in patients with ADHF with regard to diuresis, renal functions, and in-hospital outcomes. METHODS: A total of 43 patients who presented with ADHF were randomized into three groups: (a) continuous infusion (cIV) of 160 mg furosemide for 16 h/day (n = 15); (b) bolus injections (bI) of 80 mg furosemide twice a day (n = 14); (c) and administration of 160 mg furosemide plus hypertonic saline solution (HSS) as an infusion for 30 min once a day (n = 14). All regimens were continued for 48 h. Study endpoints were negative fluid balance assessed by loss of body weight, change in the serum creatinine (baseline to 48 h and baseline to compensated state), and length of hospitalization. RESULTS: There was no significant difference in the mean change in serum creatinine level at the end of 48 h between groups (p = 0.08). There was also no significant difference among groups regarding loss of body weight (p = 0.66). A significantly shorter hospitalization was observed in patients treated with HSS compared with the other groups (cIV group 6.6 ± 3.4 days vs. bI group 7.9 ± 4.1 days vs. HSS group 3.7 ± 1.3 days; p < 0.01). CONCLUSION: All three furosemide regimens have similar renal safety and efficacy measures. However, administration of furosemide plus HSS may be the preferred diuretic strategy because of its shorter hospital stay.

Dasatinib-induced pulmonary hypertension in acute lymphoblastic leukemia: case report.

Pulmonary hypertension (PHT) is a pathological condition determined as an increase in mean pulmonary arterial pressure ≥25 mmHg. Pulmonary arterial hypertension (PAH) is precapillary PHT and a life-threatening disease group which consists of different etiologies with the same pathological and clinical findings, and which is characterized by elevated pulmonary vascular resistance. Dasatinib is a dual Src/Abl kinase inhibitor associated with higher affinity for BCR/ABL kinase than imatinib, and is used in the treatment of chronic myelocytic leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia (ALL). We describe a case with ALL, in whom dasatinib treatment induced PAH, and who recovered with bosentan treatment.

[The management of adult female patients with Eisenmenger syndrome and advanced pulmonary arterial hypertension treatment: single center experience and follow-up for 5 years]. / Eriskin kadin hastalarda Eisenmenger sendromuna yaklasim ve pulmoner arteriyel hipertansiyonda spesifik tedavi: tek merkeze ait klinik sonuçlar ve bes yillik izlem.

OBJECTIVES: Eisenmenger syndrome (ES) occurs as the most advanced form of pulmonary arterial hypertension (PAH) in patients with congenital heart disease. In this study, we aimed to evaluate the management of ES patients, follow-up and specific PAH treatment applying and clinical outcomes during 5 years. STUDY DESIGN: During the period of the month between May 2008 and 2013 ES female patients were included in the study and followed an average for 5 years. Clinical findings, brain natriuretic peptide levels, transthoracic and right heart catheterization findings, 6-min walking test distance were recorded. PAH specific treatment as bosentan, iloprost and sildenafil was given to patients according to guidelines. The patients were evaluated with 3 months intervals as requirement for hospitalization, combination treatment, and mortality. RESULTS: A total of 12 patients were included in the study. All of the patients were women, the mean age was 36.5. As prognostic echocardiographic data, the patients had high pulmonary artery pressure (109.81 ± 24.94 mmHg) related with increased right ventricular wall thickness, elevated right atrial pressure, severe pulmonary regurgitation in 40%, shortened pulmonary acceleration time, diminished myocardial tissue Doppler velocities of the left and right ventricles, increased right atrium area/left atrial area ratio (1.35 ± 0.40), lower right ventricular fractional area change. During the follow-up period of 5 years, a total of 16 events occurred. Combination treatment was required in 8 patients. CONCLUSION: Eisenmenger syndrome is a multi-system affecting disease and due to high morbidity and mortality risk patients with ES should be followed by specialized centers. PAH specific treatment improves the disease course and survival of patients.

The effect of body weight on left atrial function determined by longitudinal strain analysis in young adults.

PURPOSE: Obesity is a risk factor for various cardiovascular disorders. Left atrial (LA) function is vital for predicting adverse outcomes in many diseases. LA strain was recently proposed as a noninvasive and valuable parameter for LA functional evaluation. We investigated the effect of body mass index (BMI) values on left atrial functions determined by longitudinal strain analysis in young adults without concomitant disease. METHODS: We prospectively included 134 subjects in our study. Participants were categorized into three subgroups, obese, overweight, and control, according to their BMI. Conventional echocardiographic measurements and strain analysis were performed on all patients. RESULTS: There were 41 patients (30.5%) in the obesity group, 46 patients (34.3%) in the overweight group, and 47 patients (35.0%) in the control group. Obese patients had significantly larger LA volume (46.9 ± 12.1 ml; p < 0.001) compared to overweight and control subjects; however, LA volume index (21.4 ± 6.1 ml/m2 vs. 22.4 ± 6.1 ml/m2 vs. 22.4 ± 5.0 ml/m2; p = 0.652) were similar between groups. In the LA strain analysis, obese patients were found to have lower left atrial reservoir longitudinal strain (LASr) compared to both the overweight and control group (44.2 ± 5.8% vs. 39.1 ± 3.7% vs. 36.5 ± 4.9%; p < 0.001); moreover obese patients had significantly worse left atrial contraction phase longitudinal strain (LASct) (-15.1 ± 3.1% vs. -13.1 ± 2.5%; p = 0.007) and left atrial conduit phase longitudinal strain (LAScd) (-29.0 ± 7.1% vs. -23.3 ± 5.4%; p < 0.001) values compared to the control group. However, LASct and LAScd values did not differ between overweight and obese patients. CONCLUSION: LA function determined by LA strain analysis was impaired in obese and overweight individuals compared to the control group, even in the early stages of life. The prognostic significance of this finding should be investigated in prospective studies.

Long term tirofiban infusion before percutaneous coronary intervention in patients with angiographically massive intracoronary thrombus.

OBJECTIVE: To evaluate the impact of long term tirofiban infusion before percutaneous coronary intervention (PCI) on the angiographic results in the setting of visible intracoronary thrombus and compare this with conventional PCI performed without tirofiban. METHODS: Out of 2,835 PCI procedures performed in Gazi University Hospital, Ankara, Turkey between 1999 and 2006, 156 (5.5%) patients with massive thrombus in whom PCI were applied, were included in this retrospective study. Out of these 156 patients, 82 (53%) had PCI in the presence of angiographically apparent thrombus without tirofiban and named as group A. The remaining 74 (47%) received long term tirofiban infusion before PCI and were named as group B. RESULTS: Although the baseline thrombolysis in myocardial infarction (TIMI) 0-2 flow was no different between the groups, it is significantly lower in group B compared to group A after the PCI (8.1% versus 23.2%, p=0.015). The decrease in thrombus burden in group B after tirofiban infusion was also statistically significant compared to pre-tirofiban levels (1.77 -/+ 1.05 versus 3.42 -/+ 0.76, p<0.001). Group B had better flow characteristics with a 91.9% TIMI 3 flow after PCI. Intervention was successful in the majority technically, however, no reflow was observed in 17 patients (20.7%) in group A and in 2 patients (2.7%) in group B (p<0.001). Major bleeding requiring transfusion was observed in both groups A (3 patients) and B (4 patients) due to gastrointestinal bleeding or access site hematomas (3.7% versus 5.4%, non significant). CONCLUSION: Pre-PCI longterm tirofiban infusion strategy in thrombus containing lesions seems to be a safe and feasible approach in avoiding no re-flow and dissolving the massive thrombus.

Corrected thrombolysis in myocardial infarction frame counts in diabetic patients with angiographically normal coronary arteries.

OBJECTIVE: To evaluate corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) in patients with angiographically normal coronary arteries and diabetes mellitus, a condition known to be associated with microvascular dysfunction. METHODS: Patients who underwent coronary angiography in Gazi University Hospital, Ankara, Turkey between January 2000 and January 2005 were studied. Corrected TIMI frame count was calculated over the left anterior descending (LAD), left circumflex (Cx) and right coronary arteries (RCA) in 118 diabetic and 122 non-diabetic patients with normal coronary angiogram. RESULTS: The mean CTFC values of the LAD, Cx, and the RCA were similar in diabetics and nondiabetics 21.0 +/= 7.5 versus 21.3 +/= 9.6, 23.3 +/= 9.7 versus 23.5 +/= 10.8, 17.9 +/= 6.7 versus 18.7 +/=7.4 respectively, p>0.05 for all comparisons. In stepwise multivariate linear regression analysis, body surface area had a significant correlation with CTFC of all the 3 coronary arteries. CONCLUSION: We conclude that CTFC in diabetics and non-diabetics with angiographically normal coronary arteries is similar. Since microvascular disease is an inherent component of diabetes, our finding may reflect the inadequacy of CTFC in predicting microvascular disease in diabetic patients with normal coronary angiograms.

Right Coronary Artery Originating from the Left: Do Not Miss the Diagnosis!

OBJECTIVE: Left circumflex (LCx) artery originating from the right coronary arterial (RCA) system has been reported as the most common form of anomalous origination of a coronary artery from the opposite sinus (ACAOS). However, some studies claim that RCA originating from the left coronary sinus (LCS) is the most frequent form. The aim of this study was to determine the most common type of ACAOS in a single center. MATERIALS AND METHODS: The database of the catheterization laboratory was retrospectively searched. All patients who were performed coronary angiography between 1999 and 2006 were included to registry. All examinations were carefully analyzed to determine the most frequent type of ACAOS. RESULTS: We detected ACAOS in 35 cases (16 RCA originating from the LCS, 13 LCx from the RCS or the RCA, and 6 others) out of 5165 coronary angiograms. The most common form was RCA originating from LCS. Moreover, we revealed that 5 cases with RCA originating from the LCS were previously misdiagnosed and not reported as a coronary anomaly. CONCLUSIONS: RCA originating from the LCS was the most common form of ACAOS in our registry. The high change of misdiagnosis or underreporting of this anomaly could have biased the true prevalence.

Heart rate variability and heart rate turbulence in patients with type 2 diabetes mellitus with versus without cardiac autonomic neuropathy.

Cardiac autonomic neuropathy (CAN) is an important complication of diabetes mellitus (DM) and confers an increased cardiovascular risk. The aim of this study was to disclose the place of heart rate (HR) variability and HR turbulence for the detection of CAN in patients with type 2 DM and no obvious heart disease. Ninety patients who were <75 years old and had type 2 DM for >/=2 years were studied. CAN was diagnosed with a battery of cardiovascular reflex tests and the degree of neuropathic involvement was graded by the Ewing score. Time-domain HR variability and HR turbulence parameters were assessed on 24-hour digital Holter recordings. Thirty-five patients were found to have CAN. The clinical characteristics of patients with and without CAN were similar, except that the mean duration of DM and the number of patients using insulin were significantly increased in the group with CAN. All time-domain HR variability parameters were significantly lower in the group with CAN. Of the 2 HR turbulence parameters studied, turbulence onset was similar but turbulence slope was significantly lower in the group with CAN. The Ewing score significantly correlated negatively with all HR variability parameters and turbulence slope, and among all, turbulence slope was the most strongly correlated (r = -0.617, p <0.01). Receiver-operating characteristics analysis revealed a sensitivity of 97% and a specificity of 71% at a turbulence slope cut-off value of 3.32 for the detection of CAN. In conclusion, time-domain HR variability and HR turbulence parameters, except turbulence, onset were found to be significantly depressed in patients with type 2 DM and CAN. Decreases in all these parameters were found to correlate significantly with degree of neuropathic involvement. The most strongly correlated parameter, turbulence slope, was found to be highly sensitive and specific for the detection of CAN at a cut-off value of 3.32.

Losartan improves heart rate variability and heart rate turbulence in heart failure due to ischemic cardiomyopathy.

BACKGROUND: Heart rate variability (HRV) and heart rate turbulence are known to be disturbed and associated with excess mortality in heart failure. The aim of this study was to investigate whether losartan, when added on top of beta-blocker and angiotensin-converting enzyme inhibitor (ACEI) therapy, could improve these indices in patients with systolic heart failure. METHODS AND RESULTS: Seventy-seven patients (mean age 60.4 +/- 8.0, 80.5% male) with ischemic cardiomyopathy (mean ejection fraction 34.5 +/- 4.4%) and New York Heart Association Class II-III heart failure symptoms, already receiving a beta-blocker and an ACEI, were randomly assigned to either open-label losartan (losartan group) or no additional drug (control group) in a 2:1 ratio and the patients were followed for 12 weeks. The HRV and heart rate turbulence indices were calculated from 24-hour Holter recordings both at the beginning and at the end of follow-up. The baseline clinical characteristics, HRV, and heart rate turbulence indices were similar in the 2 groups. At 12 weeks of follow-up, all HRV parameters except pNN50 increased (SDNN: 113.2 +/- 34.2 versus 127.8 +/- 24.1, P = .001; SDANN: 101.5 +/- 31.7 versus 115.2 +/- 22.0, P = .001; triangular index: 29.9 +/- 11.1 versus 34.2 +/- 7.9, P = .008; RMSSD: 29.1 +/- 20.2 versus 34.3 +/- 23.0, P = .009; NN50: 5015.3 +/- 5554.9 versus 6446.7 +/- 6101.1, P = .024; NN50: 5.65 +/- 6.41 versus 7.24 +/- 6.99, P = .089; SDNNi: 45.1 +/- 13.3 versus 50.3 +/- 14.5, P = .004), turbulence onset decreased (-0. 61 +/- 1.70 versus -1.24 +/- 1.31, P = .003) and turbulence slope increased (4.107 +/- 3.881 versus 5.940 +/- 4.281, P = .004) significantly in the losartan group as compared with controls. CONCLUSIONS: A 12-week-long losartan therapy significantly improved HRV and heart rate turbulence in patients with Class II-III heart failure and ischemic cardiomyopathy already on beta-blockers and ACEI.

Association between nonalcoholic fatty liver disease and coronary artery disease.

AIMS: To demonstrate whether there is a relationship between the presence of nonalcoholic fatty liver disease (NAFLD) and the presence and extent of coronary artery disease (CAD). PATIENTS AND METHODS: Ninety-two consecutive patients who planned to undergo coronary angiographies (CAG) without known CAD, other than findings of acute coronary syndrome, were enrolled in this study. Abdominal ultrasonography was performed before the CAG to detect NAFLD. CAD was defined as a stenosis of at least 50% in at least one major coronary artery. The extent of CAD was measured according to the number of major coronary artery/arteries affected by CAD. All the risk factors for CAD were included in a binary logistic regression model. Forward, backward, or step-wise selections were not used. P<0.05 was accepted as being significant. RESULTS: Sixty-five of the 92 patients (70.7%) were detected, by abdominal ultrasonography, to have fatty liver and 43 patients out of 92 (46.7%) were detected, by CAG, to have significant CAD. According to the results of logistic regression analysis, the presence of NAFLD independently increased the risk for CAD, as seen in CAG [odds ratio (OR), 95% confidence interval (CI): 6.73 (1.14-39.61); P=0.035]; this was despite factoring in the other risk factors for CAD and the components of metabolic syndrome. NAFLD was more commonly found in patients as the extent of CAD increased (P=0.001). CONCLUSION: The presence of NAFLD is independently associated with the presence and extent of CAD. Future studies are needed to explain the mechanisms of this relationship.

Renal dysfunction is the most important predictor of the extent and severity of coronary artery disease in patients with diabetes mellitus.

OBJECTIVES: Diabetic patients tend to have more extensive and diffuse coronary artery disease (CAD) that may contribute to the less favorable outcomes in them. The aim of this study was to elucidate the predictors of the angiographic severity and extent of CAD in patients with diabetes. METHODS: A total of 203 diabetic patients (116 men; mean age, 61.9+/-10.8) who were referred for a first coronary angiogram were included. The extent and severity of CAD was assessed in several ways. The first was a simple classification in one-vessel, two-vessel, and three-vessel disease scoring system. The total numbers of segments with > or = 20 and > or = 50% stenosis were calculated as CASS 20 and CASS 50 scores, respectively. Hamsten and Gensini scores were also calculated. RESULTS: Of the 203 patients included in the study, 175 (86.2%) had CAD. Multivariate ordinal logistic regression analysis showed that age (Wald 5.741, P=0.017), glomerular filtration rate (Wald 5.032, P=0.025), previous myocardial infarction (Wald 10.955, P=0.001), and family history of CAD (Wald 7.236, P=0.007) were independent predictors of the severity of CAD, as assessed by the clinical zero-vessel to three-vessel disease scoring system. On stepwise multiple linear regression analysis, glomerular filtration rate was an independent predictor of the CASS 20 (r=-0.221, P=0.004), CASS 50 (r=-0.239, P=0.005), Gensini (r=-0.328, P<0.001), and Hamsten (r=-0.320, P<0.001) scores. Previous myocardial infarction was an independent predictor of the CASS 50 (r=0.355, P<0.001), Gensini (r=0.350, P<0.001), and Hamsten (0.256, P<0.001) scores. Age and sex were independent predictors for the CASS 50 (r=0.174, P=0.039; r=0.172, P=0.016, respectively) and Hamsten (r=0.212, P=0.011; r=0.244, P=0.001, respectively) scores. CONCLUSION: Renal function is one of the most important factors associated with the extent and severity of coronary atherosclerosis, whereas classical coronary risk factors and the degree of metabolic control were not associated with the severity of coronary atherosclerosis in diabetic patients.

Plasma asymmetric dimethylarginine and L-arginine levels in patients with cardiac syndrome X.

BACKGROUND: Endothelial dysfunction and subsequently impaired microvascular circulation are the leading mechanisms in the development of cardiac syndrome X (CSX). The study evaluated the plasma asymmetric dimethylarginine (ADMA) and L-arginine levels of the patients with CSX and the control group and aimed to determine any relationship between these parameters and epicardial coronary blood flow and myocardial tissue perfusion. METHODS: The study group consisted of 32 patients (mean age: 52.6+/-9.4 years, 14 men) with typical exertional angina, positive exercise test, and normal coronary arteries diagnosed as CSX. Plasma ADMA, L-arginine levels, and L-arginine/ADMA ratio were compared with the values of the control group, which consisted of 17 age-matched and sex-matched individuals. Concentrations of L-arginine and ADMA were measured by high-performance liquid chromatography. In all the coronary territories, epicardial coronary flow was assessed by thrombolysis in myocardial infarction (TIMI) frame count (TFC) method, and tissue level perfusion, by myocardial blush grade (MBG) method. A MBG score less than 3 was considered an impaired myocardial perfusion, and a MBG score of '3' in all the coronary territories, a normal myocardial perfusion. RESULTS: The plasma ADMA levels of the study group were higher than those of the control group (0.83+/-0.38 vs. 0.55+/-0.44 micromol/l, P=0.03), whereas plasma L-arginine levels were similar in both groups (70.25+/-21.89 vs. 76.09+/-18.22 micromol/l, P=0.36), resulting in a diminished L-arginine/ADMA ratio in the patients with CSX [82.3 (60.2-128.8) vs. 242.2 (76.7-386.4), P=0.003]. In CSX group, the patients with abnormal myocardial tissue perfusion had increased plasma ADMA levels compared with those with normal tissue perfusion (0.99+/-0.37 vs. 0.69+/-0.34 micromol/l, P=0.02), whereas plasma L-arginine levels were similar in both groups. No correlations were observed between TFC values and plasma ADMA, L-arginine levels, and L-arginine/ADMA ratio. Plasma ADMA levels, however, were negatively correlated with MBG scores (r=-0.349, P=0.014). CONCLUSION: We have shown for the first time that in the patients with CSX, increased plasma ADMA levels might be associated with impaired myocardial tissue perfusion when assessed by MBG.

Effects of ritodrine hydrochloride tocolysis on echocardiographic parameters.

OBJECTIVE: Preterm delivery is a leading cause of perinatal mortality and morbidity. The aim of this study was to determine the effect of ritodrine hydrochloride, used for tocolysis and having serious cardiovascular side effects, on echocardiographic parameters. METHODS: Sixty-two pregnant women were included in our study. The study and control groups were composed of patients with preterm labor (group A, N = 30) and patients with uneventful pregnancies (group B, N = 32), respectively. While the patients in group A were evaluated before and during treatment, those in group B were evaluated only once for ejection fraction and fractional shortening of the left side of the heart with echocardiography and for the regional systolic and diastolic functions with the tissue Doppler technique. One-way ANOVA and a t-test (paired comparison) were used for statistical purposes. RESULTS: For the left side of the heart, it was shown that while fractional shortening increased with tocolysis (p < 0.05), neither the ejection fraction nor E/A ratio, showing diastolic function, changed significantly (p < 0.01). While systolic function parameters (S(asep) and S(alat)) increased due to the inotropic and chronotropic actions of the beta-mimetic agents (p < 0.05), regional diastolic function parameters (E(asep)/A(asep) and E(alat)/A(alat)) did not change (p > 0.05). CONCLUSIONS: Due to its potent inotropic and chronotropic effects, ritodrine hydrochloride increases myocardial oxygen demand significantly. Therefore, it should be used sparingly or avoided altogether in patients with ischemic or structural heart disease.

Heart fatty acid binding protein and myoglobin after reperfusion of acute myocardial infarction.

OBJECTIVE: The aim of this study was to disclose the release kinetics of heart fatty acid binding protein (HFABP) and myoglobin in acute myocardial infarction (AMI) reperfused by primary percutaneous coronary intervention (PPCI) and to determine the influence of the quality of coronary flow post PPCI on the release properties of these markers. METHODS AND RESULTS: Twenty-four patients with AMI who underwent successful PPCI and had no evidence of reocclusion within the first 120 minutes were studied. Serum myoglobin and HFABP levels at baseline and at 15, 30, 45, 60, 90 and 120 minutes after reperfusion were measured. Corrected TIMI frame count (CTFC) in the relevant vessel post PPCI was used to categorize patients in group I (CTFC > 21) and group 2 (CTFC < or = 21). Biomarker ratios at each sampling point were calculated by dividing the serum level of the biomarker at the specific sampling time by its baseline level. Baseline myoglobin and HFABP levels rose significantly at 15 minutes (153 +/- 251.5 microg/L vs. 904.3 +/- 542.6 microg/L, 10.9 +/- 8 microg/L vs. 17.8 +/- 9.1 microg/L, both P < 0.0001) after successful PPCI. Group 2 patients tended to have higher biomarker ratios at each time point as compared to group I. CONCLUSIONS: Successful PPCI for AMI results in a significant increase of both HFABP and myoglobin levels within 15 minutes of vessel opening and the quality of flow in the infarction-related artery post PCI as evaluated by CTFC does not influence the release kinetics of these biomarkers.

[As cardioprotective and angiogenic biomarker, can ghrelin predict coronary collateral development and severity of coronary atherosclerosis?] / Kardiyoprotektif ve anjiyojenik bir biyobelirteç olan ghrelin düzeyi koroner kolateral gelisimini ve koroner aterosklerozun ciddiyetini öngördürebilir mi?

OBJECTIVE: Ghrelin exerts protective effects on cardiovascular system by inhibiting progression of atherosclerosis, supression of vascular inflammation, and stimulating angiogenesis. Thus, the aim of this study was to investigate the effect of serum ghrelin on coronary collateral development and SYNTAX score in patients with severe coronary artery disease. METHODS: Total of 91 patients who had ≥90% stenosis in at least one major coronary artery were prospectively included in this cross-sectional, observational study. Collateral degree was graded according to Rentrop-Cohen classification. Patients with grade 2 or 3 collateral degree were allocated to Good Collateral Group and patients with grade 0 or 1 collateral degree were included in Poor Collateral Group. Ghrelin and vascular endothelial growth factor A (VEGF-A) levels were measured using radioimmunoassay and ELISA kits. RESULTS: Serum ghrelin and VEGF-A levels were significantly higher in Good Collateral Group. Furthermore, ghrelin level showed significant inverse correlation with SYNTAX score (r=0.348; p=0.001). In multivariable regression analysis, ghrelin (Odds ratio, 1.013; 95% confidence interval, 1.011-1.017; p=0.013), VEGF-A, fasting plasma glucose and presence of chronic total occlusion were independent predictors of good collateral development. In receiver operating characteristic curve analysis, ghrelin value cut-off point of ≥781 pg/mL predicted good collateral development with sensitivity of 73.1% and specificity of 67.7%. CONCLUSION: Findings suggested that ghrelin has antioxidant and antiinflammatory properties that protect endothelial functions and also stimulate angiogenesis, which results in development of good coronary collateral and inhibition of progression of coronary atherosclerosis.

Huge biatrial cardiac rhabdomyosarcoma resulting in bilateral atrioventricular valve obstruction.

We present a case report of a 28-year-old man with a huge tumor that occupies both dilated atria almost completely but not extending into the ventricles. Cardiac rhabdomyosarcoma (CR) is extremely rare in adult patients. Its rarity and heterogenous clinical presentation make diagnosis difficult. In our case, after we have made an initial diagnosis via echocardiography, we took biopsies under computed tomography (CT) guiding. Histologic examination showed a CR. We want to emphasize that CT-guided biopsy is a useful and applicable technique in establishing preoperative diagnosis of intracardiac masses.

Plasma asymmetric dimethylarginine level and extent of lesion at coronary angiography.

BACKGROUND: Given that the endogenous nitric oxide synthase inhibitor, asymmetric dimethylarginine, can decrease nitric oxide bioavailability and lead to atherosclerosis, its concentration can be a good predictor for coronary artery disease. In this study, we investigated the relationship of plasma asymmetric dimethylarginine concentration with lesion distribution and severity at coronary artery angiography. METHOD: Ninety-eight patients with stable angina were enrolled prospectively. We divided the patients into two groups. Group I (n=37) included the patients with normal coronary arteries. All the other patients were included in group II (n=61). We calculated coronary atherosclerotic score and coronary vessel score. Plasma asymmetric dimethylarginine, L-arginine and symmetric dimethylarginine concentrations were measured and L-arginine/asymmetric dimethylarginine ratio was calculated. RESULTS: Plasma L-arginine and symmetric dimethylarginine concentrations did not differ in the two groups. The plasma asymmetric dimethylarginine level, however, was higher in group II patients than in group I patients (0.43+/-0.26 vs. 0.59+/-0.28 micromol/l, P=0.004) and L-arginine/asymmetric dimethylarginine ratio was lower in group II patients than in group I patients (262.0+/-186.4 vs. 176.6+/-139.8, P=0.019). Asymmetric dimethylarginine was positively correlated with the coronary atherosclerotic score (rs=0.273, P=0.006). Moreover, asymmetric dimethylarginine was an important predictor of angiographically defined coronary artery disease (odds ratio=14.42, P=0.004). CONCLUSION: Our findings support the hypothesis that the plasma asymmetric dimethylarginine concentration may be a good indicator of predicting coronary artery disease.

Heart rate variability in neurally mediated reflex syncope.

OBJECTIVE: The aim of this study was to investigate the heart rate variability (HRV) parameters in patients with neurally mediated reflex syncope. METHODS: Thirty-three patients (10 men, age range 16-50 years) who were scheduled to undergo head-upright tilt test (HUTT) with a typical history of vasovagal syncope (VVS) underwent 24-hour Holter monitoring in an attempt to study HRV parameters. Sixteen individuals without syncope and similar baseline characteristics made up the control group. RESULTS: Seventeen of the 33 syncopal patients showed HUTT positivity. All the time domain HRV parameters except the mean RR interval were higher in the HUTT (+) syncopal patients than in the negative responders. Although not statistically significant, the positive responders had higher NN50, pNN50, RMSSD and SDNNi values than the control group. HUTT (-) VVS patients had lower SDNN and SDANN values when compared with the control group. The other HRV parameters did not differ significantly between the HUTT (-) patients and the control group. CONCLUSION: Increased parasympathetic tonus as reflected by significantly higher HRV parameters is associated with a greater frequency of HUTT positivity in patients with syncope and no organic heart disease.

Serum uric acid levels as a predictor of in-hospital death in patients hospitalized for decompensated heart failure.

OBJECTIVES: The aim of this study was to determine the value of serum uric acid levels in predicting in-hospital mortality of chronic heart failure patients hospitalized for decompensation in spite of appropriate medical therapy. METHODS AND RESULTS: This study was conducted in patients who were admitted to our clinic between January 2003 and April 2004 due to decompensated heart failure. Only patients who had a functional capacity of class IV and who already received loop diuretic and ACE inhibitor therapy before their admission were included. Patients with recurrent admissions during this period were excluded. Eighty-five patients fulfilled these criteria: group I consisted of 25 patients who died during hospitalization whereas group II consisted of 60 patients who were discharged alive after treatment. Age, sex, left ventricular ejection fraction derived from 2-D echocardiography, serum sodium (Na), gamma-glutamyl transpeptidase (GGT), creatinine, uric acid levels, white blood cell counts and drugs used on admission were the selected parameters as predictors of in-hospital mortality in these patients. When stepwise logistic regression analysis was used, female sex and serum uric acid levels at admission appear to be the only predictors of death during that hospitalization independent of other variables. CONCLUSIONS: Serum uric acid levels may be used as a predictor of death in hospitalized heart failure patients with class IV symptoms.