The effects of perindopril on aortic elasticity and inflammatory markers in hypertensive patients.

BACKGROUND: Inflammation plays an important role in hypertension and in atherosclerosis. Inflammatory changes induced even in prehypertensive subjects can lead to increased arterial stiffness. The effects of perindopril on both inflammatory and aortic elasticity markers were tested in hypertensive patients. MATERIAL/METHODS: One hundred nine hypertensive patients not taking any antihypertensive therapy were included in the study. Aortic strain, aortic distensibility, aortic stiffness index, and inflammatory markers, including CRP, IL-1alpha IL-1beta, and TNF-alpha, were measured in all patients before and after twenty weeks of perindopril therapy. RESULTS: While aortic strain and distensibility showed statistically significant increases with perindopril therapy, the aortic stiffness index and inflammatory markers were found to decrease. CONCLUSIONS: Perindopril therapy resulted in an improvement in aortic elastic properties. There was also an attenuation of inflammatory status of the patients as reflected by lower inflammatory marker levels compared with pretreatment values.

Levosimendan has an inhibitory effect on platelet function.

Levosimendan enhances cardiac contractility by increasing myocyte sensitivity to calcium, and induces vasodilatation. Although studies have evaluated the efficacy of levosimendan in heart failure, it is not clear whether it might produce functional influence on platelet response. In this study, the effect of levosimendan on platelet aggregation was investigated. Platelet function tests were performed in 12 healthy male volunteers. Three concentrations of levosimendan solution were prepared that would result in 10, 25, and 45 ng/ml levosimendan concentrations in the blood similar to that observed after clinical therapeutic intravenous application of 0.05-0.1 microg/kg/min. Each concentration of levosimendan solution and a control diluent without levosimendan were incubated with whole blood at 37 degrees C. After incubation for 15 min, aggregation responses were evaluated with adenosine diphosphate (ADP) (5 and 10 microM) and collagen (2 and 5 microg/ml) in platelet-rich plasma. Preincubation with all dilutions of levosimendan inhibited aggregation of platelets induced by ADP and collagen significantly. Levosimendan also inhibited significantly the secondary wave of platelet aggregation induced by ADP. The results showed that there was a relationship between levosimendan concentration and inhibition of platelet aggregation. In conclusion, this study with an in vitro model showed that levosimendan had a significant inhibitory effect on platelets in clinically relevant doses.

Evaluation of plasma adiponectin levels in young men with coronary artery disease.

OBJECTIVE: In this study, we investigated the relation between plasma adiponectin levels and other risk factors in a young patient population. MATERIAL AND RESULTS: We enrolled consecutively 69 young patients (< 45 years) with coronary artery disease in the study group. he patient enrollment period was between February 2003 and November 2004. The control group consisted of 42 age- and sex-matched healthy subjects. Anthropometric, lipid and other variables including adiponectin, fasting glucose and plasma insulin levels were measured in all subjects. Appropriate statistical analyses were performed to determine the differences between the groups, the relation between adiponectin and other parameters and independent factors that predict CAD. There was a statistically significant difference between the groups in terms of lipid parameters (triglycerides, total cholesterol, HDL and LDL cholesterol). Mean plasma adiponectin levels were significantly lower in the patients (P < 0.05). Among the risk factors adiponectin had a significant negative association with the plasma triglyceride level (P < 0.01). Logistic regression analysis revealed triglycerides and adiponectin as independent predictors of CAD. The areas under the ROC curves of adiponectin and triglycerides were not different (P > 0.05). CONCLUSION: We found a decreased plasma adiponectin level in young male patients with coronary artery disease. It may be a novel marker of atherosclerosis in young men.

Coronary angiography for follow-up of heart transplant recipients: insights from TIMI frame count and TIMI myocardial perfusion grade.

BACKGROUND: The aim of this study was to evaluate the course of Thrombolysis in Myocardial Infarction (TIMI) frame count (TIMI FC) and myocardial perfusion grade (TIMI MPG) in heart transplant recipients and whether these parameters could predict mortality. METHODS: Sixty-two heart transplant recipients were enrolled in this study. All patients had coronary angiography at baseline and at 1 year, which were evaluated for TIMI FC and TIMI MPG. Also, 50 vessels in 35 patients were analyzed with volumetric intravascular ultrasound (IVUS) at baseline and at 1 year. Rejection episodes and mortality were recorded during the follow-up period. RESULTS: The mean follow-up interval was 51.5 +/- 17.2 months (range 12.2 to 78.4 months). TIMI FCs of all three coronary arteries and global TIMI FC (gTIMI FC) significantly increased from baseline during the first year (p < 0.0001). TIMI MPG deteriorated significantly (p < 0.0001 for left anterior descending and circumflex coronary arteries, p = 0.002 for right coronary artery). There was no correlation between changes in TIMI FC and progression of transplant vasculopathy as assessed by IVUS. Episodes of Grade > or = 3A rejection were significantly more frequent in the stable gTIMI FC group (p = 0.03). Mortality rate was significantly higher in the group with increasing gTFC (p = 0.02). CONCLUSIONS: gTIMI FCs and TIMI FCs of coronary arteries increase, and TIMI MPG gradually deteriorates during the first year after transplantation. Mortality rate is significantly higher in patients whose gTIMI FC increases from baseline. Change in gTIMI FC is a simple quantitative predictor of long-term mortality in heart transplant recipients.

Left ventricular function in male patients with secondary hypogonadism.

BACKGROUND: In addition to the effects on ventricular repolarization, testosterone could also affect left ventricular performance. The enhancement of left ventricular contractility in testosterone-deficient rats following testosterone replacement implies to the possible testosterone effect. OBJECTIVES: The aim of the current study is to reveal the alterations of left ventricular functions, if any, in secondary hypogonadal male patients. METHODS: Thirty-four males with secondary hypogonadism comprised the study group. The control group consisted of 30 healthy subjects. Echocardiographic measurements including left ventricular dimensions, ejection fraction, mitral inflow, and left ventricular outflow parameters were obtained from all subjects. Tissue Doppler parameters were also measured from left ventricular lateral wall and interventricular septum. RESULTS: Left ventricular diameters, wall thicknesses, and performance parameters were similar in both groups. Mitral inflow parameters showed a statistically insignificant difference. Pulse-wave tissue Doppler interpretation of hypogonadal and healthy subjects were similar in terms of lateral and septal basal segment Sm, Em, and Am wave velocities. CONCLUSIONS: Regarding the findings of previous studies that showed impaired myocardial contractility and lusitropy in testosterone deficient rats and our study results, further studies are needed for better understanding of testosterone's effects on human myocardium.

[Relationship between coronary risk calculation and distribution of the coronary artery lesions and risk factors]. / Koroner risk katsayisi ile koroner anjiyografik olarak damar tutulumu ve risk faktörleri arasindaki iliski.

OBJECTIVES: Early diagnosis and treatment of coronary artery disease is gaining more importance because of its increasing incidence. The calculation of coronary risk score is one of the most important approaches. The aim of the study is to find out the relation between coronary risk score and vessel distribution of the coronary heart disease. METHODS: The study included 49 patients (mean age = 63+/-8 years; 36 males) whose coronary disease was proven by coronary angiography. The severity of the disease is established according to the number of the vessels with >50% stenosis. RESULTS: According to the results; age (p=0.548), gender (p=0.116), uric acid (p=0.091), and smoking (p=0.718) are not effective on diseased vessel distribution. Similarly, total coronary risk score and vessel involvement was not correlated (p=0.115). The ten year coronary risk and vessel involvement was not in good correlation, too (p=0.523). Low-density lipoprotein (LDL)-cholesterol levels were lower in patients with multiple vessel disease but the statistical significance was borderline (p=0.051). High-density lipoprotein (HDL)-cholesterol levels were lower in multiple vessel disease (p=0.004). Both LDL-cholesterol and HDL-cholesterol scores were decreasing with increased number of involved vessels (p=0.035, p=0.001). Multivariate analysis revealed that blood pressure score, and HDL cholesterol score were directly related and LDL-score were inversely related to the number of the involved vessels. The height and vessel involvement was also in good correlation (p=0.024). CONCLUSION: The LDL-cholesterol, HDL-cholesterol, diastolic blood pressure and height are affective on the number of the involved vessels. The total coronary risk scores are not correlated with the severity and distribution of the disease.

[The value of augmentation index and myocardial performance index obtained from cardiac catheterization pressure recordings in predicting coronary artery disease]. / Kardiyak kateterizasyona ait basinç kayitlarindan elde edilen artirma indeksi ve miyokardiyal performans indeksinin koroner arter hastaligini öngörme degerleri.

OBJECTIVE: The aim of the study was to determine the relation between some parameters, which can be obtained from cardiac catheterization pressure records, and coronary artery disease. METHODS: The study included 65 patients, in whom coronary angiography was performed by the cardiologists of the study. The parameters could be obtained in 40 patients (59+/-6 years; 28 male), and statistical analysis included the data of these patients. From the pressure recordings, myocardial performance index (MPI), isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), ejection time (ET), augmentation wave amplitude (AW), augmentation wave time (AWT) and augmentation index (AI) were measured manually. Coronary artery disease was defined as the presence of any lesion, without regarding the degree of narrowing. The parameters were evaluated with respect to relation with presence of coronary artery disease (Mann-Whitney U test), relation with risk factors for atherosclerosis (Mann-Whitney U test and Chi square test) and capability of predicting coronary artery disease (area under ROC curve, AUC). Statistical significance was set at 0.05. RESULTS: The presence of coronary artery was significantly related to AI, AWT, AW, IVCT and MPI (p<0.001 for all). The most sensitive parameters for coronary artery disease were AI (sensitivity 94%, AUC -0.846, p<0.001) and AW (sensitivity 94%, AUC -0.848, p<0.001), while the most specific one was AWT (specificity 82%, AUC -0.833, p<0.001). The MPI and IVCT were weakly related with risk factors, while IVRT had stronger relation. The parameters of augmentation wave were significantly related with high density lipoprotein cholesterol, whereas the relation with low density lipoprotein cholesterol was weak. CONCLUSION: The parameters, which are obtained from cardiac catheterization pressure recordings, are related with coronary artery disease. They may be useful for predicting future coronary artery disease especially in patients with normal coronary angiogram. It is useful to add these parameters into the reports of coronary angiograms.

A simple different method to use proximal isovelocity surface area (PISA) for measuring mitral valve area.

BACKGROUND: Angle-correction is an important limiting factor for using proximal isovelocity surface area (PISA) method in measuring mitral valve area (MVA). In this study, we derived a novel formula, which simplifies the angle-correction, and tested its use in patients with mitral stenosis (MS). METHODS: The study included 30 MS patients without concomitant aortic or mitral regurgitation. We used mathematical equations and established a relation between the angle and its corresponding border, 'a', by using linear regression analysis. It was found that MVA is equal to [(1.11*a2 + 0.95)* r2 (Val/Vmax)]. We compared this formula with plain angle-corrected and solid angle-corrected PISA methods, planimetry (reference method) and pressure-half time method by linear regression analysis. RESULTS: All methods were in significant relation with the reference method, two-dimensional planimetry. We found that there is a good relation between our method and planimetry (r = 0.79, p < 0.001), pressure half-time method (r = 0.85, p < 0.001), angle-corrected PISA method (r = 0.99, p < 0.001), and solid angle-corrected PISA method (r = 0.88, p < 0.001). The time duration of the new method was shorter (p < 0.001). CONCLUSION: Our method is an easy way for applying angle-corrected PISA method to mitral valve area measurement in patients with mitral stenosis. Absence of the need for estimating the angle is the major advantage.

Univentricular heart and supramitral ring: an unusual association.

Univentricular heart, which is rarely seen cardiac anomaly, is associated with various cardiac anomalies. The presence of supramitral ring and univentricular heart in the same patient is very interesting association which, to the best of our knowledge, was not reported previously.

Utility of myocardial performance index measured by left ventricular catheterization.

BACKGROUND: Myocardial performance index (MPI) is a valuable index of global ventricular performance. It is almost always measured by Doppler echocardiography. The purposes of this study were (I) to compare MPI measured by catheterization (MPIc) and that measured by Doppler echocardiography (MPId), and (2) to compare it with the functional status. MATERIALS AND METHODS: The study included 80 patients who had undergone left heart catheterization. The MPIc was measured from the pressure recordings obtained at left ventricle and aorta. RESULTS: Mean MPId and MPIc were 0.40 +/- 0.12 and 0.42 +/- 0.12, respectively. Mean left ventricular end diastolic pressure (LVEDP) was 13 +/- 5 mm Hg. Mean heart rate was 77 +/- 11 beats/min. Mann-Whitney U test revealed that MPIc could discriminate between the functional statuses of the patients. The regression analysis revealed that there is a good correlation between MPIc and MPId, LVEDP or heart rate. There was no significant difference between MPIc and MPId (p > 0.05). CONCLUSION: The present data show that (I) the MPIc has a strong correlation with MPId; (2) it is a good discriminator of functional status. It may provide an additional information regarding the left ventricular performance in patients who underwent the cardiac catheterization.

The effect of combined Angiotensin-converting enzyme inhibition and calcium antagonism on allograft coronary vasculopathy validated by intravascular ultrasound.

BACKGROUND: Hypertension is a potential risk factor for allograft coronary vasculopathy. We evaluated the efficacy of angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists, and their combined use, on the development of coronary vasculopathy in hypertensive heart transplant recipients. METHODS: Eighty-two heart transplant recipients underwent serial intravascular ultrasound (IVUS) analysis at baseline (within 1 month) and at 1 year after transplantation and were evaluated for the development of coronary vasculopathy. Patients were divided into 4 groups. Nineteen normotensive recipients received no treatment, control (Group A). Hypertensive patients were treated with either ACE inhibitors (Group B, n = 37), calcium antagonists (Group C, n = 16), or both (Group D, n = 10). RESULTS: We found a significant reduction in IVUS indices of coronary vasculopathy in heart transplant recipients who used a combination of an ACE inhibitor and a calcium antagonist compared with recipients who used either drug alone (p < 0.05). This synergistic efficacy was independent of the baseline indices evaluated in a multivariate regression analysis model and was noted despite comparable mean arterial pressure among the 3 hypertensive groups at 1 year, thus suggesting the presence of a synergistic anti-proliferative effect beyond the anti-hypertensive efficacy. CONCLUSIONS: The combined use of an ACE inhibitor and a calcium antagonist is more effective than the individual use of either drug alone on the development of coronary vasculopathy in cardiac transplant recipients. Large randomized clinical trials are warranted to evaluate such a synergistic efficacy.

Elongation index as a new index determining the severity of left ventricular systolic dysfunction and mitral regurgitation in patients with congestive heart failure.

The shape of the left ventricle is an important echocardiographic feature of left ventricular dysfunction. Progression of the mitral regurgitation and consequent left ventricular remodeling is unpredictable in heart failure. Elongation index is an index of left ventricular sphericity. The surface area of the elongated ventricle is larger than that of a spherical one. The objective of this study was to assess the relation between elongation index and the degree of mitral regurgitation along with noninvasive indices of left ventricular function. Thirty-two patients (21 male, 11 female, mean age: 57 +/- 6 yrs) with congestive heart failure and mitral regurgitation were included. Patients were stratified into three groups according to vena contracta width as having mild (n = 11), moderate (n = 11) and severe mitral regurgitation (n = 10). The elongation index (EI) was considered as equal to {[(left ventricular internal area-measured) - (theoretical area of the sphere with measured left ventricular volume)]/(theoretical area of the sphere with measured left ventricular volume)}. Ejection fractions by the modified Simpson rule, dP/dt and sphericity index (SI) were also recorded. The relationship between (EI), ejection fraction, dP/dt and SI reached modest statistical significance (p < 0.05). When the EI and SI were compared, the correlation was also significant (p < 0.01). The areas under the receiver operator curve of EI and SI for discriminating dP/dt < 1000 mm Hg/s were 0.833 and 0.733, respectively. In conclusion, the elongation, which defines the shape of the left ventricle, might be related to the systolic function of the left ventricle and the degree of the mitral regurgitation. Further studies are needed to demonstrate its use in other clinical entities.

Chronic heavy ethanol consumption is associated with decreased platelet aggregation in rats.

Although moderate alcohol consumption seems to be protective against atherosclerosis, coronary artery disease rate increases with its higher doses. Platelet aggregation is an important process which contributes to the atherosclerosis. The aim of this study was to determine whether heavy ethanol consumption stimulates or inhibits platelet aggregation. Fourteen adult male Wistar rats were used. Ethanol (7.2%, v/v) in a modified liquid diet was given to eight rats for 21 days, which mimicked characteristics similar to human chronic alcoholism. Six rats constituted the control group. Adenosine diphophate (ADP) and collagen-induced platelet aggregation was measured in whole blood. We found reduced ADP-induced mean maximal aggregation in the alcoholic rat group compared to the control group at dose of 5 microM (p < 0.005). We also found decreased platelet aggregation responses to collagen in the alcoholic group (p < 0.006 for 2 microg/ml collagen, and p < 0.05 for 5 microg/ml collagen). In conclusion, chronic heavy ethanol consumption results in the decreased platelet aggregation in a rat model of alcoholism. Therefore, increased mortality from coronary artery disease in chronic alcoholism may be explained by other factors such as dietary imbalances and coexisting conditions, which include hypertension and depression.

The effect of tirofiban and clopidogrel pretreatment on outcome of old saphenous vein graft stenting in patients with acute coronary syndromes.

In spite of developments in interventional cardiology, the success rate of saphenous vein graft stenting is still low in patients with acute coronary syndromes. In this study, we aimed at finding out the effect of pretreatment with Tirofiban, a glycoprotein IIb/IIIa inhibitor, and clopidogrel, an adenosine diphosphate antagonist, on the outcome of saphenous vein graft stenting in patients with acute coronary syndrome. A total of 47 patients, who had lesions in saphenous vein grafts and acute coronary syndrome, could be randomized to treated group (n = 24), who received Tirofiban and clopidogrel for 48 hours before the intervention, and untreated group (n = 23), who did not receive Tirofiban and clopidogrel. In the untreated group, the intervention was performed just after the coronary angiography. All patients underwent stenting as the standard intervention. The groups were compared by Mann-Whitney's U-test or Chi-Square test. The level of statistical significance was set at 0.05. There were no significant differences regarding age, gender, and atherosclerotic risk factors between the two groups. In treated group, precutaneous coronary intervention was successful in all patients and no-reflow phenomenon occurred in only one patient. The rate of no-reflow or slow-flow phenomenon was significantly lower in treated group (one patient vs 9 patients, p = 0.004). One patient in untreated group experienced ventricular fibrillation, which was converted to sinus rhythm after defibrillation. During short-term follow-up, there were no acute myocardial infarction, coronary bypass surgery or death in both groups. There was no major bleeding. Minor bleeding was more frequent in treated group, but it did not achieve statistical significance (3 vs 1; p = 0.322). In conclusion, pretreatment with tirofiban and clopidogrel before percutaneous coronary intervention might result in better immediate outcomes in old saphenous vein grafts without any significant increase in bleeding complications.

Left atrial functions after myocardial infarction.

Acute myocardial infarction results in not only left ventricular but also left atrial dysfunction. Left atrial function is important for optimal filling of the left ventricle. In this study, we aimed at evaluating left atrial functions 6 months after acute myocardial infarction in three different patient groups (thrombolytic therapy, primary percutaneous intervention, or no reperfusion strategies). Between October 2002 and May 2003, 48 patients with ST elevation myocardial infarction who were either administered thrombolytic therapy (group T, n=16), underwent primary angioplasty (group A, n=20), or underwent no reperfusion therapy (group C, n=12) at our unit were enrolled into the study. Echocardiography was performed in these patients 6 months after acute myocardial infarction. Left atrial contractility was assessed by atrial ejection force. Left atrial contribution was assessed by atrial fractional shortening and left atrial volume was calculated. The left atrial volume was significantly higher in group C (P<0.05), but there was no significant difference between groups A and T (P>0.05). Patients in group C had significantly lower atrial ejection force values compared with the other groups (P<0.05). Atrial fractional shortening was not significantly different among the three groups (P>0.05). Atrial ejection force, which is an indicator of left atrial contractility, is better with either angioplasty or thrombolysis. Left atrial volume is higher in patients who were not treated with reperfusion strategies. Further studies are needed to explain the mechanism involved.

A giant dissecting aneurysm of ascending aorta.

Aortic aneurysm is a serious clinical challenge for the cardiologist. Aneurysm expansion frequently associated with significant dissection and rupture risk. Currently available diagnostic modalities make earlier diagnosis and therapy possible hence giant aneurysm with dissection is relatively rare. In this case report, we present a patient with giant aortic aneurysm with dissection.

Being well-informed about statin is associated with continuous adherence and reaching targets.

BACKGROUND: Statins are life saving drugs in cardiovascular practice. However, they still are underprescribed in many situations despite their well-established benefits. Adherence may be improved by increased comprehension of the patients. METHODS: Patients enrolled into a previous survey were randomized into two groups as those, who were informed comprehensively (Group 1) and those not (Group 2). 202 patients, all of whom were on secondary prevention, were contacted after median 15 months of follow up and evaluated whether they continued the statins, and reached targets. RESULTS: 102 out of 202 patients were those enrolled into Group 1, and 100 of them were those enrolled into Group 2. In Group 1, 62.7% of patients were on continuous statin therapy during period between initial and secondary contact, whereas, only 46% of patients in Group 2 were on continuous statin therapy (p = 0.017). Being well-informed about statin increased the likelihood of being on continuous statin therapy after median of 15 months by 1.977 folds. Concerning targets, 64.7% of those in Group 1 reached the targets, whereas, 43% of those in Group 2 reached the targets (p = 0.002). Being well-informed about statin increased the likelihood of having suggested targets by ATP III after median of 15 months by 2.430 folds. CONCLUSION: Providing patients with comprehensive knowledge about statins, even in patients, who were already on statin therapy, seems not only to improve adherence but also increase the percentage of those reaching targets.

A novel method to estimate pulmonary artery wedge pressure using the downslope of the Doppler mitral regurgitant velocity profile.

Continuous-wave (CW) Doppler recording of mitral regurgitation (MR) is a reflection of the left ventriculoatrial pressure gradient. Accordingly, this jet may yield information about pulmonary artery wedge pressure (PAWP). In this study, we derived and then evaluated a novel method for prediction of PAWP. Patients (n=80) with moderate to severe MR and left ventricular dysfunction were included in the study. Transthoracic echocardiography was performed in patients during pulmonary artery pressure monitoring. A satisfactory CW Doppler recording of MR was obtained in 63/80 (78%). On the late descending portion of the CW recording, the time from a velocity of 4 m/sec to the end of the jet was defined as t1, and from 3 m/sec to the end of the jet as t2. Mathematical derivation of t1/t2 as a predictor of PAWP, was performed based on Weiss' derivation. If t1/t2 was <1.30, the PAWP was normal. If t1/t2 > 1.44, the PAWP was > 16 mmHg. With this new mathematical derivation, it appears that the downslope of the CW Doppler MR waveform may be able to distinguish a normal from elevated PAWP.

A different method for measuring mitral valve area with special emphasis on concomitant aortic regurgitation: A new application of proximal isovelocity surface area method.

Measurement of mitral valve area is still a challenge for the echocardiographers. Each method has its own limitations. In this study we assessed a different method and compared it with the other methods. The study included 50 consecutive patients with mitral stenosis. The reference method was planimetry. The suggested method was compared with the pressure half-time method, proximal isovelocity surface area method with and without angular correction, and the continuity method. There was a good correlation between each method and planimetry. The suggested method had the best correlation both for patients with and without aortic regurgitation. The pressure half-time method and continuity method overestimated the mitral valve area for patients with aortic regurgitation, whereas proximal isovelocity surface area method without angular correction overestimated the area in all patients. In conclusion, this method has very good correlation with planimetry. It can be used both in patients with and without aortic regurgitation.