Cardiac autonomic functions in obese children.

OBJECTIVE: The autonomic nervous system is assumed to have a role in the pathophysiology of obesity. In this study, we evaluated the autonomic system by measuring heart rate variability (HRV) in obese children. METHODS: Thirty-two obese and 30 healthy children (mean ages: 11.6±2.0 years and 11.0±2.9 years, respectively) were enrolled in the study. Obesity was defined as a body mass index higher than 97th percentile for age- and gender-specific reference values. All participants were free of any disease and none of them was receiving any medication. Twenty-four-hour ambulatory electrocardiographic recordings were obtained and the time-domain and frequency-domain indices of HRV were analyzed. The study group was evaluated with respect to insulin resistance by HOMA-IR values. RESULTS: A significant decrease in calculated HRV variables was observed in obese children as compared to controls. The HRV alteration was found in both time-domain and frequency-domain parameters. The subgroup analysis of the study group revealed a significant decrease in all investigated HRV parameters in the insulin-resistant obese children compared to the non-insulin-resistant obese ones. CONCLUSIONS: Our results indicate that HRV is decreased in obese children, which implies parasympathetic withdrawal and sympathetic predominance. A marked decrease in HRV was observed in insulin-resistant obese children compared to their non-insulin-resistant counterparts. We propose that autonomic imbalance pertaining especially to insulin resistance may be involved in the pathogenesis of obesity in pediatric patients.

Mediterranean fever (MEFV) gene mutation frequency is not increased in adults with rheumatic heart disease.

It is well established that there are people with higher risk of developing acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Mediterranean fever (MEFV) gene mutations might be one of the genetic predisposition factors in the development of ARF/RHD since defect in familial Mediterranean fever (FMF) patients is proposed to be heightened inflammatory response to certain stimuli. Previous clinical observations suggested a relationship between FMF and ARF/RHD. The aim of this study was to investigate the role of the MEFV gene mutations in the susceptibility to RHD in Turkish patients. A total of 100 patients with RHD and 100 healthy controls were included in the study. Diagnosis of RHD was based on echocardiographic findings in which a predominant mitral stenosis was used as an inclusion criterion. Genetic analysis was carried out by sequence analysis investigating two hot spots (exons 2 and 10) for MEFV mutations. Mutation analysis showed that 22 RHD patients (22%) and 24 healthy controls (24%) carried at least one mutated allele. MEFV mutations were identified in 22 of 200 (11%) chromosomes in RHD patients while 26 of the 200 (13%) chromosomes of healthy controls were found to carry a mutated allele. No difference was found in allele frequencies and their distribution between the patients and healthy controls (p = 0.54). MEFV mutations are not associated with a predisposition to develop RHD in adult Turkish patients.

Normotensive glaucoma and risk factors in normotensive eyes with pseudoexfoliation syndrome.

PURPOSE: To evaluate the prevalence of normotensive glaucoma (NTG) in patients with pseudoexfoliation (PEX) syndrome. METHODS: In this prospective study, 178 eyes of 178 patients with PEX syndrome who had no previous history of antiglaucomatous treatment were evaluated in terms of NTG prevalence. NTG diagnosis was based on the presence of glaucomatous optic nerve head damage with glaucomatous visual field defects, open angles, and intraocular pressure (IOP) levels less than 22 mm Hg. Two groups of normotensive pseudoexfoliative eyes with or without glaucomatous findings were compared in terms of age, sex, the presence of systemic diseases and mean IOP, maximum IOP, and IOP fluctuation levels. RESULTS: The IOP levels were below 22 mm Hg in 109 of the 178 eyes, and 24% (n=27) of those eyes were diagnosed as NTG. There were no significant differences between the eyes with or without glaucoma in terms of age, sex, and the presence of systemic diseases (P>0.05). The mean IOP, maximum IOP, and IOP fluctuation levels were significantly higher in eyes with NTG when compared with eyes without glaucoma (P<0.05). Univariate analysis revealed that significant risk factors associated with NTG in patients with PEX syndrome were higher mean IOP (> or =14 mm Hg), higher maximum IOP (> or =18 mm Hg), and greater IOP fluctuation (> or =4 mm Hg). In multivariate analysis, these factors were higher maximum IOP and greater IOP fluctuation range (P=0.003, P<0.001, respectively). CONCLUSIONS: There are glaucomatous findings in a significant proportion of normotensive patients with PEX syndrome. The high maximum IOP levels and greater IOP fluctuation range may be contributory factors in the pathogenesis of NTG in patients with PEX syndrome.

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.

The effect of the content of the knowledge on adherence to medication in hypertensive patients.

OBJECTIVE: It was suggested that knowledge might influence the adherence to treatment in hypertension. Accordingly, in this study, we investigated the effects of content of knowledge on medication adherence and knowledge-based predictors of adherence to treatment in hypertensive patients. METHODS: This cross-sectional study included 227 hypertensive patients (70% female;mean age: 57+/-12 years), who were followed by cardiology and internal medicine clinics. The patients were asked to fulfill a questionnaire including 40 items. Besides the demographic and disease-related questions, the patients were also asked (1) the name of the drug, (2) the duration of the drug use;(3) the reason of using the drug;(4) the cause of hypertension;(5) the target level of hypertension;(6) the result of hypertension;(7) the side effects of antihypertensive medicines. Statistical analyses were performed using Chi-square, Fischer exact, Mann Whitney U tests and logistic regression analysis. RESULTS: It was found that 163 (72%) were adherent and 64 (28%) were nonadherent to the treatment. Angiotensin-II receptor antagonist use (OR=4.405;95%CI: 1.561-12.365, p=0.022) and hypertension duration > or =5 years (OR=0.446;95%CI: 0.246-0.811, p=0.006) was found to be independently related to adherence. Among the knowledge-based variables, knowing the duration of use of the medicine (OR=6.822;95% CI: 1.478-31.241, p=0.075), the reason of use of medicine (OR=2.828;95% CI: 1.445-5.543, p=0.018), the cause of the hypertension (OR=3.447;95% CI: 1.889-6.290, p=0.037) and the target level of blood pressure (OR=12.859;95% CI: 5.045-32.640, p<0.001) significantly increased the adherence rates. On the other hand, knowing the name of the medicine (p=0.112) or the results of hypertension (p=0.719) had no effect on adherence, while knowing the side effects of the medicine (OR=0.607;95% CI: 0.340-1.084, p=0.005) had negative effect. The total number of correct answers was also higher in patients with adherence to treatment (p=0.002). CONCLUSION: Patient knowledge about hypertension and medications is associated with higher adherence rates. However, it should be taken into consideration that the possible effects of knowledge may differ according to its content.

The relation between coronary lesion distribution and risk factors in young adults.

OBJECTIVE: In this cross-sectional, case-controlled study, we aimed to evaluate classical and novel risk factors in young patients with coronary artery disease (CAD), and the relation between coronary risk factors and coronary lesion distribution. METHODS: Fifty-three patients under age of 45 years with severe coronary artery stenosis on angiography (group A) and age matched sixty patients having normal or non-critical stenosis on coronary angiography (group B) comprised the study groups. Conventional (smoking, family history, diabetes, hypertension) and novel risk factors (lipoprotein (a), homocysteine) were compared between the groups. Moreover, the relation between risk factors, and coronary lesions distribution, including left main artery (LMA) or proximal or mid left anterior descending (LAD) artery and remaining coronary lesions was investigated. Logistic regression analysis was used to define confounding factors predicting severe CAD and coronary lesion distribution and ROC curve analysis was performed to determine the cut-off value of independent factors, which were assessed by logistic regression analysis. RESULTS: Smoking was more prevalent in group A compared to group B. Lipoprotein (a) and homocysteine levels were also higher in group A than group B. For group A and B median (max-min) values of lipoprotein (a) were 34 (2-174) mg/dl and 38 (2-203) mg/dl (p=0.038), respectively and homocysteine levels were 12.3 (5-56.6) micromol/L and 9 (1.4-19) micromol/L (p=0.012), respectively. Smoking and homocysteine were independent predictors of severe CAD in young patients according to logistic regression analysis with an Odds ratio of 3.7 (95% CI=1.572-8.763; p=0.002) and 1.2 (95% CI=1.045-1.341; p=0.008), respectively. For predicting significant CAD the cut-off value of homocysteine was 11.6 micromol/L with a sensitivity and specificity of 53% and 77%, respectively (AUC=0.637; 95% CI=0.542-0.725; p=0.008). Within group analysis in group A patients revealed that only homocysteine was an independent predictor of LMA or proximal or mid-LAD lesion presence with an odds ratio of 1.2 (95% CI=1.011-1.465; p=0.016). ROC curve analysis revealed a cut-off value of 12 micromol/L in predicting LMA or proximal or mid-LAD lesions with a sensitivity and specificity of 65% and 91%, respectively (AUC=0.735; 95% CI=0.594-0.850; p=0.002). CONCLUSION: In our study, we found that young patients with severe CAD had different risk profile with higher frequency of smoking and increased levels of lipoprotein (a) and homocysteine. While smoking status and homocysteine may be used for prediction of severe CAD in young individuals, only homocysteine predicted coronary lesion distribution in LMA and proximal or mid-LAD.

Successful percutaneous intervention to acute myocardial infarction presenting with typical chest pain in transplanted heart.

Allograft coronary artery disease (CAD) is the main limiting factor of the long-term survival in cardiac transplant recipients. It is present in approximately 50% of patients at 5 years post-transplant. Allograft CAD might result in congestive heart failure, ventricular arrhythmias and sudden cardiac death. Acute coronary syndrome is a rare presentation of allograft CAD, because symptoms are usually atypical or absent as a result of cardiac denervation. However, it should be reminded that reinnervation of the transplanted heart might occur, and angina pectoris could be felt as a sign of an acute coronary syndrome. We present a 27-year-old female cardiac transplant patient with an acute myocardial infarction, who was successfully treated with percutaneous transluminal coronary angioplasty.

Conventional and non-conventional coronary risk factors in male premature coronary artery disease patients already having a low Framingham risk score.

BACKGROUND: Individual risk factors and, more importantly, global risk assessment tools such as the Framingham risk score have been used successfully for risk prediction especially in older patients. However, there is paucity of data about the coronary heart disease prediction in premature coronary artery disease patients with a low Framingham risk score. METHODS AND RESULTS: We recruited 102 consecutive young patients without hypertension and diabetes mellitus in the study. All subjects had had chest pain and underwent coronary angiography since non-invasive diagnostic test results suggested ischaemia. Forty-five patients having at least one coronary lesion independent of severity were included in the study group.The remaining fifty-seven subjects without any coronary lesion were used as control group. Conventional and non-conventional risk factors were evaluated both in patients and control subjects. Framingham risk score and absolute 10-year hard CHD events risk were also calculated for each individual. The coronary heart disease group had a significantly higher smoking frequency as compared to the control group.They also had higher plasma levels of triglycerides, apolipoprotein B and apo B/AI ratio but a smaller LDL particle size.We failed to find any independent CHD predictor after logistic regression analysis. However, individual ROC curve analysis of risk factors revealed that apolipoprotein B, triglycerides and apo B/AI ratio have the highest area under the curve for coronary artery disease prediction. CONCLUSIONS: The Framingham risk score may underestimate the true risk of an individual. Incorporating non-conventional risk factors such as apolipoprotein B and apo B/apo AI ratio may provide valuable information in these patients.

Unoperated tetralogy of Fallot in a 68-year-old patient.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, generally treated with total correction within the first two years of life. Occasionally, some unoperated cases can reach older ages. A 68-year-old woman with diabetes mellitus presented with swelling in legs and abdomen, weakness, exertional dyspnea, and orthopnea. On physical examination, she had mild cyanosis with clubbing. Her blood pressure was 110/60 mmHg and pulse rate was 79 beat/min. She had a systolic ejection murmur and bilateral rales on basal lung areas. Massive edema was noted in both lower limbs. Electrocardiography showed atrial fibrillation with normal ventricular response. Chest radiography showed an increased cardiothoracic ratio and bilateral minimal pleural effusion. Echocardiography showed biatrial dilatation (right atrium 62 mm, left atrium 49 mm) and thickening of left ventricular walls. There was right ventricular hypertrophy with decreased systolic function. A very large ventricular septal defect and severe pulmonary stenosis were noted. The patient did not accept any interventional procedure. To our knowledge, this is the oldest unoperated TOF case reported from our country.

Perindopril, atenolol, and amlodipine prevent aortic ultrastructural changes in rats exposed to ethanol.

BACKGROUND: The effects of perindopril, an angiotensin-converting enzyme inhibitor, atenolol, a beta adrenergic receptor blocker, and amlodipine, a calcium channel blocker, were investigated in chronic alcohol administered rats. MATERIAL/METHODS: Adult male Wistar rats (240-320 g) were used in the present study. Alcohol was given to rats on a modified liquid diet for 21 days. Perindopril (2.5 and 5 mg/kg), atenolol (5 and 10 mg/kg), and amlodipine (5 and 10 mg/kg) were injected into rats in different groups intraperitoneally for 21 days. Control rats were pair fed an isocaloric liquid diet containing sucrose as a caloric substitute for alcohol. Saline was injected into the control rats for 21 days. The hearts were removed after the rats were anesthetized by ether, and 1-mm3 samples from the ascending aortas were fixed. Five fields per aorta were examined and photographed with a transmission electron microscope. Blood alcohol levels were also measured spectrophotometrically. RESULTS: Daily alcohol consumption of the rats was in the range of 12.09-15.50 g/kg. Blood alcohol concentrations were 145.63 mg/dl on the 21st day of alcohol consumption. Chronic alcohol consumption caused some marked aortic wall injuries. Perindopril, atenolol, and amlodipine at high doses, but not low doses, produced some significant beneficial effects on alcohol-induced aortic wall damage. CONCLUSIONS: These results imply that perindopril, atenolol, and amlodipine may have protective effects on heavy chronic alcohol consumption-induced aortic wall injury in rats only in high doses.