Acute coronary stenosis in a young man with Behçet's syndrome.

OBJECTIVE: To present a case of myocardial infarction due to Behçet's syndrome. CLINICAL PRESENTATION AND INTERVENTION: A 27-year-old man who was known to have Behçet's syndrome for 1 year presented with retrosternal fluctuating chest pain, which radiated to the epigastrium 5 h prior to admission. Coronary angiography showed total occlusion of the left anterior descending coronary artery, which was successfully treated with coronary stent implantation. CONCLUSION: This case shows that patients with Behçet's syndrome who had acute chest pain should be thoroughly examined for any signs of acute myocardial infarction.

The predictive value of CRP levels on future severe renal disease in overweight and obese subjects without diabetes mellitus and hypertension.

BACKGROUND: Obesity and related disorders have a high prevalence all over the world. Increased C-reactive protein (CRP) value in obese individuals and its potential adverse effects have been reported. Here we have investigated the relationship between CRP levels and renal functions in nondiabetic, nonhypertensive, overweight, and obese individuals. The aim of this study was to evaluate the predictive value of CRP levels on future severe renal disease. METHODS: One hundred sixty individuals were included in the study. They were grouped as normal weight, overweight, and obese. Anthropometric measurements, renal function tests, and serum hsCRP values were obtained. Mean values were compared and correlation analysis was performed. RESULTS: Significant differences were detected between the groups according to body mass index, waist circumference (WC), and body fat percentage. There was a significant difference with respect to creatinine clearance (CC). Difference in the mean urinary albumin excretion (UAE) was significant between normal-weight and overweight subjects. There was a linear increase in serum CRP values in parallel to the increase in body weight; mean values were significant between groups. A positive correlation was detected between CC and body mass index and WC, and there were significant correlations between CRP and anthropometric measurements, CC and UAE. CONCLUSIONS: This study showed that increased CRP levels in nondiabetic, nonhypertensive, overweight, and obese individuals could possibly associated with impaired renal functions that might be originating from endothelial dysfunction. Determination of cutoff levels of CRP, as in cardiovascular diseases, may be useful for early estimation and prevention of renal diseases.

Statins may be useful in diabetic foot ulceration treatment and prevention.

Diabetic foot ulcers (DFUs) consist of an interaction of neuropathy, ischemia and infection. Neuropathy affects sensory, motor and autonomic pathways. Pathogenic factors for neuropathy include hyperglycemia, nonenzymatic glycosylation, oxidative stress, ischemic and hypoxic factors, nerve growth factor anomalies, activation of polyol pathway and immunologic abnormalities. All these factors are stated to contribute to microvascular disease and neural dysfunction. Peripheral neuropathy and ischemia combined with repetitive traumas can lead to diabetic foot ulceration. Fifteen percent of diabetic patients develop foot ulcers during their lifetime and nonhealing ulcers are responsible for 85% of nontraumatic lower extremity amputation. On the other hand, the treatment cost of foot disease in diabetic patients is estimated at $1 billion annually. When these conditions are considered, it is very important to design improved and novel strategies for treatment and prevention of diabetic foot disease. Lipid-lowering agents, such as statins, have been shown to prevent cardiovascular events in patients with diabetes. However, in addition, to preventing macrovascular diseases, statins may also be able to retard the progression of microvascular complications of diabetes. Statins alter the balance between vasodilatation and vasoconstriction in favor of vasodilatation by increasing nitric oxide (NO) synthesis, by downregulating endothelin 1 (ET-1) synthesis and reducing vascular response to angiotensin-2 (AT-2). These agents have been shown to augment cerebral blood flow by upregulating endothelial nitric oxide synthase (eNOs) and to reduce cerebral infarct size in a murine model of cerebral ischemia. In addition, recent in vivo and in vitro investigations have evidenced that statins have a favorable effect on diabetic peripheral neuropathy independent of its lipid-lowering effect by demonstrating restoration or preservation of microcirculation of the sciatic nerve. We hypothesized that statins can be useful for the prevention and treatment of diabetic foot. Possible mechanisms include the reduction of neuropathy and ischemia or through growth factors, the effectiveness of which has been shown for fracture healing in animal models.

May primary empty sella turcica be a cause of isolated ACTH deficiency? A case report and the review of related literature.

Isolated ACTH deficiency is an uncommon cause of secondary adrenocortical insufficiency and accompaniment with primary empty sella has been reported in several cases. We present a case of isolated ACTH deficiency associated with empty sella. A sixty-two year old woman was admitted to our endocrine clinic with complaints of weakness, fatigue, weight loss, nausea, vomiting, and lack of appetite for about one month. Physical examination indicated orthostatic hypotension and epigastric tenderness. Laboratory investigations revealed hypoglycemia, hyponatremia and anemia, in addition low plasma cortisole and ACTH levels. Serum cortisole responses to short and prolonged ACTH stimulation were tested and partial and accurate responses were obtained, respectively. Plasma ACTH and serum cortisole levels failed to respond after intravenous injection of human corticotropin releasing hormone. Other hypophysial hormone levels were within the normal reference ranges. Although cranial and abdominal computerized tomography images were evaluated as normal, cranial magnetic resonance imaging of the pituitary gland revealed 'primary empty sella turcica'. Replacement therapy with methylprednisolon resulted in the improvement of hypoglycemia, hyponatremia and clinical symptoms. Based on these results, the patient was diagnosed as isolated ACTH deficiency and was scheduled for follow up by our outpatient clinic. Our report is consistent with other reports pointing out that primary empty sella may be responsible for pathogenesis of isolated ACTH deficiency.

Myocardial bridging of obtuse marginal branch of the left circumflex artery associated with congenital corrected transposition of the great arteries.

A 54-year-old male was admitted to the emergency department with progressive dyspnea and chest pain during exercise. Congenital corrected transposition of the great arteries was detected on echocardiography. Coronary angiography revealed myocardial bridging on the obtuse marginal branch of the left circumflex coronary artery. Being a rare complex cardiac anomaly we discussed the congenitally corrected transposition of the great arteries (CCTGA) in association with myocardial bridging.

Effects of thyroxin therapy on cardiac function in patients with subclinical hypothyroidism: index of myocardial performance in the evaluation of left ventricular function.

OBJECTIVE: We investigated the effects of thyroxine (T4) therapy on the cardiac function in subclinical hypothyroidism (SHT) by using the index of myocardial performance (IMP) and the conventional echocardiographic parameters. METHODS: Forty-five SHT patients (F/M:38/7, age 39.9+/-7.9) and 29 healthy subjects (F/M:25/4, age 38.3+/-8.6) were studied. Patients were randomly assigned, in a double-blind manner to receive T4 therapy (group I) or a placebo (group II) and for a period of up to 12 months, were followed up using thyroid function tests and both conventional and Doppler echocardiographic measurements. RESULTS: At the baseline, the SHT patients has a significantly higher isovolumic relaxation time (IRT) (98.3+/-23.7 vs. 81.7+/-14.7<0.01), IMP (0.52+/-0.06 vs. 0.42+/-0.05; P<0.001), A max (late mitral peak velocity) (83.4+/-12.6 vs. 74.3+/-13.5; P<0.01) and significantly lower (early mitral peak velocity) Emax/Amax ratio (1.19+/-0.18 vs. 1.34+/-0.17; P<0.01) than the individuals in the control group. In group I, the thyroid hormone profile became normalized after 1 year of L-T4 therapy, but there was no significant change in the left ventricular (LV) morphology or systolic function. After 1 year of follow-up, group I showed a significant reduction of MPI (0.53+/-0.05 vs. 0.42+/-0.07; P<0.001), Amax (84.2+/-13.7 vs. 74.5+/-11; P<0.001) and IRT (98.6+/-23.7 vs. 82.9+/- 23.3; P<0.001) along with a normalization of the E/A ratio (1.17+/-0.16 vs. 1.33+/-0.19; P<0.001). Conversely, no change was observed in group II. CONCLUSIONS: An impairment of left ventricular diastolic function, which may be reversible with T4 therapy, was observed in the SHT patients, and IMP may be useful in the evaluation of LV myocardial dysfunction in these patients.

Primary angioplasty without on-site surgical back-up: the first experience with mobile catheterization facility.

BACKGROUND AND OBJECTIVES: The aim of the present study is to assess the safety and efficacy of performing primary angioplasty in a center without on-site surgical back-up, and compare the data with the literature. METHODS: Seventy-eight consecutive primary angioplasty procedures, performed in our center from January 2001 to February 2003, were followed prospectively. Clinical and demographic characteristics of the patients, procedural success, early and late outcomes of the patients were taken into account. The safety of angioplasty was assessed by the analysis of in-hospital complications (death, urgent need for repeat revascularization, AMI with or without ST-elevation and stroke). The angioplasty procedures were considered effective when the post-procedural residual stenosis did not exceed 50% with the distal Thrombolysis in Myocardial Infarction (TIMI) grade III flow. RESULTS: The device success rate was 92.3%. Angiographic success rate was 88.8%. In hospital mortality rate was 4.1%. These patients were admitted with cardiogenic shock; 1 died during the procedure and the other 2 died during hospital follow-up. One patient died suddenly and another developed acute MI during the 6-month follow-up period. No patients developed stroke or were referred for urgent surgery. Four patients (5.5%) underwent repeat angioplasty during follow-up. CONCLUSIONS: Primary angioplasty can be safely performed in centers without on-site surgery. The efficacy and safety requirements of angioplasty, performed in a center without on-site surgical back-up using a mobile catheterization facility were similar to the data obtained from the literature.

HLA-DR B1 and DQ B1 polymorphisms in patients with coronary artery ectasia.

OBJECTIVES: The purpose of our study was to evaluate the significance of polymorphisms in HLA class II genes in coronary artery ectasia (CAE) patients. METHODS AND RESULTS: Twenty-six patients with CAE without associated cardiac defects were enrolled in the study. CAE was defined as luminal dilation of 1.5- to 2.0-fold of normal limits. Ninety-five healthy subjects who were donors for different organ transplantations, were chosen as control group. Physical examination, electrocardiography and chest X-ray were completely normal in these cases. Both the patients and the control group were screened and compared for their HLA class II genotypes. HLA-DR B1*13, DR16, DQ2 and DQ5 genotypes were significantly more frequent in the patient group. When the known risk factors of coronary heart disease were compared in the patients carrying these genotypes with the non-carrying group, no significant differences were encountered. CONCLUSIONS: HLA-DR B1*13, DR16, DQ2 and DQ5 may be associated with the pathogenesis and increase the risk of CAE.

Three years of experience with a mobile angiograph in a center without on-site surgical back-up.

BACKGROUND: The safety of percutaneous coronary interventions (PCI) performed in centers without surgical back-up is controversial, but data from several western countries indicates that this approach can be extended to a larger number of hospitals. We assessed the safety and efficacy of performing angiography and PCI with a mobile C-arm angiograph in a center without on-site surgical back-up, and compared our data with that reported in the literature. METHODS: We retrospectively analyzed 1485 coronary angiograms and 172 PCI procedures performed in our center from January 2001 to May 2003 using a mobile angiograph. Half of the patients that have undergone PCI had refractory unstable angina and one-third had acute myocardial infarction (AMI). The safety of PCI was assessed by the analysis of in-hospital complications (death, urgent need for repeated revascularization, AMI with or without ST elevation and stroke). The PCI procedures were considered effective when the post-PCI residual stenosis did not exceed 50% with distal Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. RESULTS: In patients who underwent diagnostic coronary angiography there were no deaths, anaphylatic shock, acute renal failure or major ischemic complications. In patients who underwent PCI, the mortality rate was 1.1% (2 deaths), two patients (1.1%) developed acute MI with ST segment elevation, one patient (0.5%) underwent repeated PCI and three patients (1.7%) were referred for urgent by-pass surgery. CONCLUSIONS: Diagnostic and PCI procedures can be safely performed using a mobile angiograph. The efficacy and safety requirements of PCI, performed in a center without an on-site surgical back-up facility using a mobile angiograph were similar to other data reported in the literature.

Aberrant origin of the right ventricular coronary artery: A case report.

This case describes a 45-year-old man with an abnormal origin of the right ventricular branch of the right coronary artery originating from a separate ostium in the right coronary sinus. Coronary arteries with abnormal origin constitute roughly 0.64% to 1.2% of all the representations encountered during coronary angiography. We suggest that the presence of such a vessel must be shown in patients undergoing coronary angiography and/or cardiac surgery.

Independent prediction of metabolic syndrome by plasma fibrinogen in men, and predictors of elevated levels.

UNLABELLED: The role of plasma fibrinogen levels in predicting metabolic syndrome (MetS) and assessment of determinants of these levels were investigated. A total of 2234 men and women, aged 49+/-12 years, representative of Turkish adults who had plasma fibrinogen determinations, were prospectively evaluated and followed for a mean of 6.6 years. The modified Clauss method was used for assays. MetS was defined by ATPIII criteria modified for male abdominal obesity. MetS cases at baseline were excluded in prospective analyses. Median (interquartile range) fibrinogen values were 2.87 (2.29; 3.56) g/L. Fibrinogen levels predicted significantly newly developing MetS in men (RR 1.40 [95%CI 1.07; 1.83] for a 2-fold increment), after adjustment for age and smoking status, and (RR 1.32 [95%CI 0.95; 1.83] again for doubling), after additional adjustment for all 5 components of MetS. MetS was not significantly predicted by fibrinogen levels in women in either multivariable model. By regression analysis of eight covariates, not waist circumference, but systolic blood pressure, current smoking and C-reactive protein (CRP) in men, and age in women were predictors of elevated (>3.0 g/L) fibrinogen at follow-up (p<0.05 in all). CONCLUSIONS: Plasma fibrinogen predicts MetS independently of its components in men, in contradistinction to women, and, hence, is likely one of its components. Hyperfibrinogenemia representing an inflammatory state is postulated as the underlying mechanism. Central obesity is linked to elevation in fibrinogen mainly through the mediation of blood pressure, CRP, and via being affected by cigarette smoking.

Topical atorvastatin in the treatment of diabetic wounds.

BACKGROUND: Currently, it is reported that statins may be useful in the treatment of diabetes mellitus foot ulceration. The aim of this study was to evaluate treatment of the wounds in streptozotocin-induced diabetic rats with local atorvastatin. METHODS: Two 15 x 15 mm-sized wounds were created in 28 streptozotocin-induced rats. A total of 56 diabetic wounds were studied in 8 groups (n = 7). No treatment was administered in the first and second groups, which lasted for 7 and 14 days, respectively. Third and fourth groups consisted of diabetic rats that were administered 1:1 mixture of lanolin and vaseline therapy for 7 and 14 days, respectively. One percent statin plus 1:1 mixture of lanolin and vaseline was used in the fifth and sixth groups for 7 and 14 days, respectively; and in seventh and eighth groups, 5% statin plus 1:1 mixture of lanolin and vaseline therapy was used for 7 and 14 days, respectively. On the 7th and 14th days, state of the wound healing was observed, and the percent of wound healing was determined by measuring its size and by performing a histopathologic study. The statistical analyses were performed by Mann-Whitney U test, using SPSS 14.0 software. RESULTS: On the 14th day, the rates of wound healing in the first, second, third, and fourth groups were 14%, 40%, 96.59%, and 96.51%, respectively. This ratio was calculated by the formula healing ratio (%) = 100 x (1-wound area/initial wound area). Accordingly, in the multiple comparisons, the rates of wound healing were found to be significantly higher in the diabetic rat groups administered 1% and 5% atorvastatin compared with those administered a mixture of lanolin-vaseline and the untreated group (for comparison each one P < 0.001). CONCLUSIONS: Local atorvastatin therapy may be useful for healing the wounds in diabetic rats. Further clinical and experimental studies are needed to confirm these results.

Relationship between angiographically documented coronary artery disease and low bone mass in men.

BACKGROUND: The present study aimed to investigate the association between low bone mass (LBM) and coronary artery disease (CAD) in male patients. METHOD AND RESULTS: The data for 47 men who were screened for osteopenia and osteoporosis with dual energy X-ray absorptiometry and then underwent coronary angiography between February 2005 and May 2006 were retrospectively analyzed. Bone mineral density of the femur neck was stratified as normal (T score >-1.0 SD) or low (T score <-1.0 SD) and CAD was defined as > or = 50% occlusion in at least 1 major coronary artery. Thirty-two patients were found to have angiographically significant CAD. Patients in the LBM group had a significantly higher incidence of CAD. Low bone mass was significantly and positively correlated with the Gensini scores of the patients (r=0.6037, p<0.0001) and was found to be an independent predictor of CAD in multivariate logistic regression analysis (odds ratio: 5.4 [95% confidence interval 1.66 and 17.49]; p=0.0049). Repeated statistical analyses with the acceptance of CAD as coronary artery stenosis >75% confirmed the same results. CONCLUSION: Low bone mass was significantly associated with angiographically documented CAD in males.

Do cardiac neuropeptides play a role in the occurrence of atrial fibrillation after coronary bypass surgery?

BACKGROUND: One of the potential mechanisms to explain the occurrence of postoperative atrial fibrillation (AF) is imbalance of autonomic nervous system tone. The myocardium is innervated not only by cholinergic and adrenergic nerves but also by peptidergic nerves that synthesize and secrete neuropeptides. To investigate the possible role of cardiac neuropeptides in the development of AF after coronary artery bypass grafting (CABG), we analyzed the plasma levels of substance P (SubP), neuropeptide Y (NPY), and angiotensin II (Ang II) in patients who underwent elective on-pump CABG. METHODS: This prospective study group included 83 consecutive patients scheduled for elective, on-pump CABG. Depressed left ventricular (LV) function (ejection fraction [EF] less than 0.30), concomitant cardiac procedures, history of atrial fibrillation, second or third degree atrioventricular block, implanted pacemaker, postoperative myocardial infarction, use of class I or III antiarrhythmic drug, and hemodynamic deterioration were exclusion criteria. Preoperative and postoperative serum levels of SubP, NPY, and AngII were measured by radioimmunoassay technique. RESULTS: Postoperative AF occurred in 27 patients (32.5%). Using multivariate logistic regression analyses, only a decrease in SubP level (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 0.767 to 0.99, p = 0.031) and an increase in AngII level (OR = 2.61, 95% CI = 1.002 to 1.021, p = 0.023) after CABG were found to be independently associated with AF. Increased age (p = 0.02), diabetes mellitus (p = 0.023), preoperative use of beta blocker (p = 0.024), proximal right coronary artery involvement (p = 0.024), low preoperative sodium levels (p = 0.023), low LVEF (p = 0.013), and increased mitral E wave deceleration time (p = 0.044) were also associated with AF. CONCLUSIONS: These results indicate that the increase in AngII and the decrease in SubP after CABG may play a role in the occurrence of postoperative AF. Further studies are needed to define the physiologic and pathologic relevance of these substances at the occurrence of AF in patients who undergo CABG.

Multiple basilic vein aneurysms concomitant with multiple hemangiomas of the upper extremity: A case report.

Basilic vein aneurysms are rare clinical entities. A 21-year-old woman with basilic vein aneurysms and multiple hemangiomas in the right upper extremity is presented. The case is discussed in light of the relevant literature with emphasis on the use of Doppler ultrasonography and magnetic resonance venography.

Elastic properties of the ascending aorta and left ventricular function in patients with hypothyroidism.

BACKGROUND: We sought to clarify the possible role of elastic properties of the ascending aorta in the development of cardiac disease associated with hypothyroidism (HT). METHODS: A total of 37 patients with HT (age: 39.3 +/- 8.9 years) and 29 control subjects were studied. Ascending Aortic (Ao) diameter, Ao elastic indexes, strain (AoST), distensibility (AoD), stiffness index (AoSI), and pressure strain modulus were calculated from the echocardiographically derived Ao diameters. Myocardial performance index (MPI), E/A ratio, isovolumetric relaxation time (IVRT), deceleration time (DT) were measured by Doppler echocardiography to assess diastolic LV function. Patients were treated with levothyroxine and followed-up for 6 months. Thyroid function tests and echocardiographic measurements were repeated at the end of the study. RESULTS: AoD (cm2 dyn(-1) 10(-3)) and AoST (%) were significantly lower (3.8 vs. 6.1; P < 0.001, 7.4 vs. 12.6, P < 0.001; respectively), whereas AoSI was higher in HT patients (6.2 vs. 3.3; P < 0.001). After treatment, AoD and AoST were increased (5.7; P < 0.001 and 11.8; P < 0.001; respectively), whereas AoSI was decreased significantly (3.7; P < 0.001). Also, early/late mitral peak velocity ratio (Emax/Amax) was significantly lower in HT patients (1.19 vs 1.34; P < 0.01), whereas MPI was higher (0.52 vs. 0.42; P < 0.001). MPI showed a strong correlation with aortic root indexes [AoST (r =-0.61/P < 0.001); AoD, (r =-0.57/P < 0.002); AoSI, (r = 0.53/P < 0.005)] in the HT group. After 6 months of therapy, MPI significantly decreased P < 0.001) and E/A ratios were normalized (P < 0.001). CONCLUSIONS: Ao root functions have an important role on diastolic LV function. Levothyroxine replacement therapy can reverse all of these adverse effects of HT.

Effect of reperfusion on P-wave duration and P-wave dispersion in acute myocardial infarction: primary angioplasty versus thrombolytic therapy.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia occurring in about 10-20% of patients with acute myocardial infarction (AMI). P-wave dispersion (PWd) and P-wave duration (PWD) have been used to evaluate the discontinuous propagation of sinus impulse and the prolongation of atrial conduction time, respectively. This study was conducted to compare the effects of reperfusion either by thrombolytic therapy or primary angioplasty on P-wave duration and dispersion in patients with acute anterior wall myocardial infarction. METHODS: We have evaluated 72 consecutive patients retrospectively (24 women, 48 men; aged 58 +/- 12 years) experiencing acute anterior wall myocardial infarction (AMI) for the first time. Patients were grouped according to the reperfusion therapy received (primary angioplasty (PTCA) versus thrombolytic therapy). Left atrial diameter and left ventricular ejection fraction (LVEF) were determined by echocardiography in all patients. Electrocardiography was recorded from all patients on admission and every day during hospitalization. Maximum (P max) and minimum (P min) P-wave durations and P-wave dispersions were calculated before and after the treatment. RESULTS: There were not any significant differences between the groups regarding age, gender, left ventricular ejection fraction, left atrial diameter and volume, cardiovascular risk factors, and duration from symptom onset to treatment. P-wave dispersions and P-wave durations were significantly decreased after PTCA [Mean P max was 113 +/- 11 ms before and 95 +/- 17 ms after the treatment (P = 0.007)]. Mean PWd was 46 +/- 12 ms before and 29 +/- 10 ms after the treatment (P = 0.001). Also, P max and PWd were significantly lower in PTCA group (for P max 97 +/- 22 ms vs 114 +/- 16 ms and for PWd 31 +/- 13 ms vs 55 +/- 5 ms, respectively). CONCLUSIONS: Primary angioplasty reduces the incidence of AF by decreasing P max and P-wave dispersion.

Recurrent pericardial effusion due to retained cardiac pellets: a case report and review of the literature.

A 52-year-old man presented with severe dyspnea 6 months after a thoracic firearm injury. Many pellets distributed in the thoracic wall and an enlarged cardiac silhouette were detected on chest X-ray. There was low voltage in all 12 leads and electrical alternans on electrocardiography. Echocardiography showed a massive pericardial effusion causing cardiac tamponade. Pericardial drainage was performed and 2 400 cc of hemorrhagic fluid was drained using a sheath and pigtail catheter. Coronary arteries were evaluated as normal by angiography, but four pellets which were moving simultaneously within the heart were detected on cardiac fluoroscopy. We thought that the recurrent pericardial effusion in our patient was secondary to pericardial damage due to the gunshot wound, as is seen in postpericardiotomy syndrome. An excellent result was achieved by drainage of the pericardial fluid and oral administration of indomethacin plus prednisolone treatment.