Usefulness of parathyroid hormone as a predictor of heart failure with preserved ejection fraction.

OBJECTIVE: To investigate the relation between parathyroid hormone (PTH) and heart failure with preserved ejection fraction (HF-PEF) in outpatients. METHODS: One hundred consecutive patients who had preserved left ventricular (LV) ejection fraction and heart failure (HF) symptoms, were enrolled. Echocardiography, assessing the diastolic functions was performed. Blood samples were collected for intact PTH and brain natriuretic peptide (BNP). RESULTS: Significant correlations between PTH level and predictors of advanced HF-PEF were found (p < 0.05). PTH level and left atrium diameter were found to be independent predictors of DHF. CONCLUSION: Measurement of serum PTH provides complementary information for the diagnosis and prognosis of HF-PEF.

Heart rate recovery in epilepsy.

Autonomic manifestations regarding cardiac function in epilepsy are not rare and are being recognized with increasing frequency. The aim of this study was to assess autonomic function by measuring heart rate recovery (HRR), an index of vagal activity, in patients with epilepsy who were not taking any medication. Fourteen patients (eight with primary generalized epilepsy, four with secondary generalized epilepsy, and two with complex partial epilepsy) and 14 control subjects underwent exercise tolerance tests according to the modified Bruce protocol. HRR at 1 and 3 min (HRR1 and HRR3) were calculated. HRR1 and HRR3 were increased in patients with epilepsy. These results suggest increased parasympathetic function in epilepsy and support results of previous studies indicating autonomic dysfunction in epilepsy.

Interpretation of electrocardiogram images sent through the mobile phone multimedia messaging service.

OBJECTIVE: In this study, the diagnostic accuracy of interpretations of electrocardiogram (ECG) images taken by a mobile phone and sent as multimedia message was investigated. MATERIALS AND METHODS: The ECGs of 305 patients who were admitted to the emergency department with cardiac complaints were photographed with the camera of a Nokia (Espoo, Finland) N93 mobile phone. The images were sent via a multimedia messaging system to an identical mobile phone carried by a cardiologist and were interpreted on the screen of that mobile phone. Another cardiologist and an emergency physician interpreted ECG paper printouts separately. The findings of the core laboratory were used as the gold standard. The interpretation errors were scaled from 1 to 4 with respect to the significance of findings. RESULTS: The total ratio of Grade 4 errors, which consisted of significant errors, did not show any significant difference (p=0.76) between the interpretations by the emergency medicine specialist and the cardiologist who interpreted the ECGs on the mobile phone; the cardiologist who interpreted the ECG paper printouts made significantly fewer mistakes than the other two specialists (p=0.025 and p=0.023, respectively). The separate assessment of the findings showed that in the diagnostic process of ST-segment elevation, depression, and supraventricular tachycardia, the consistency of the interpretations (κ=0.81, κ=0.81, and κ=1.0, respectively) made on the mobile phone screen was slightly better than that of the emergency medicine specialist (κ=0.73, κ=0.77, and κ=0.80, respectively) and was similar to that of the cardiologist (κ=0.91, κ=0.91, and κ=1.0, respectively) who interpreted ECG paper printouts. CONCLUSIONS: Our findings suggest that sending the ECG images via a multimedia message service may be a practical and inexpensive telecardiology procedure.

A pericardial hydatid cyst and pregnancy.

A cardiac hydatid cyst in pregnancy is a very rare condition. Surgical intervention followed by medical therapy is the treatment of choice. A hydatid disease in pregnancy is challenging with a varied presentation and manifestation. A pregnant woman presented with a ruptured pericardial cyst diagnosed by echocardiography, magnetic resonance and serology. Finally, she received medical treatment and no surgical intervention.

A case of mediastinal mesenchymal tumor resembling hemopericardium.

Mediastinal neoplasms are rare in the elderly, and clinical suspicion is the first and most important step of differential diagnosis. Mediastinal tumors can be misdiagnosed because their symptoms or signs can overlap with cardiovascular diseases, which have a higher prevalence among the older population. The diagnostic process should be managed with multimodality imaging and clinical judgement. Here, the case of a 74-year-old male patient, who presented with shortness of breath, is examined. A chest X-ray revealed an increased cardiothoracic ratio, and he was diagnosed with hemopericardium following an emergent chest computed tomography. In the echocardiography, it was suspected that a hyperechogenic area adjacent to the heart might be due to a mass, and further examinations confirmed a mediastinal neoplasm. A surgical biopsy was performed, and it was determined to be a mesenchymal tumor. To conclude, clinicians should keep in mind the possibility of paracardiac neoplasm in the elderly, as well as in other age groups, when encountering mediastinal widening so that the patient can be protected from unnecessary interventions such as pericardiocentesis.

Selective autonomic screening in Guillain-Barré syndrome.

BACKGROUND: Autonomic dysfunction is a common and important complication in Guillain-Barre syndrome (GBS) and may be the cause of significant morbidity or death. Objectives : To show the possible autonomic involvement in patients with GBS. MATERIALS AND METHODS: The sympathetic skin response (SSR) and the parameters of heart rate variability gathered from a 24-h electrocardiogram recording were studied in 14 patients with GBS [13 with acute inflammatory demyelinating polyneuropathy (AIDP) and one with acute motor axonal neuropathy (AMAN)]. RESULTS: In two of the patients, SSR couldn't be elicited. In the rest of the patients, amplitude of SSR was found to be decreased when compared with the control subjects. In the time domain analysis of the 24-h electrocardiogram, SDNN (the standard deviation of all R-R intervals), SDANN (the standard deviation of the averages of R-R intervals during all 5-min periods that constitute the 24-h day), SDNN index (mean of the standard deviations of all R-R intervals for all 5-min segments of the 24-h recording); in the frequency domain analysis HF(high frequency), LF(low frequency), VLF (very low frequency) and total power were found decreased in patients when compared with the control subjects. When the mean values with standard deviations of controls were compared with the patients' values one by one, the pregnant patient with AMAN had increased heart rate variability parameters. The remaining 13 patients had decreased values. CONCLUSIONS: These findings reflect an involvement of both the parasympathetic and sympathetic systems in GBS. Our results suggest that SSR and heart rate variability parameters may be used for early detection of any autonomic dysfunction in patients with GBS.

Evaluation of Subclinical Atherosclerosis with Carotid Intima-Media and Epicardial Fat Thickness in Patients with Sarcoidosis.

OBJECTIVES: Since many similar mechanisms may play a role in the pathophysiology of sarcoidosis and atherosclerosis, the risk of subclinical atherosclerosis may be increased in patients with sarcoidosis. The aim of this study was to evaluate known markers of subclinical atherosclerosis, namely epicardial fat thickness (EFT) and carotid intima-media thickness (CIMT) in patients with sarcoidosis. MATERIALS AND METHODS: This cross-sectional study included a total of 183 subjects, including 94 patients with sarcoidosis (patient group) and a control group of 89 healthy individuals. Measurements of EFT and CIMT were taken from all subjects and recorded. The groups were compared, and differences were analyzed statistically. RESULTS: EFT was higher in patients than in control subjects (6.42±1.12 mm vs 7.13±1.41 mm, p<0.001). CIMT was higher in patients than in control subjects (0.51±0.02 mm vs 0.52±0.02 mm, p=0.003). CONCLUSION: EFT and CIMT were found to be higher in patients with sarcoidosis than in healthy people. These results indicate that the risk of subclinical atherosclerosis might be increased in these patients.

Assessment of Atrial Fibrillation and Ventricular Arrhythmia Risk after Bariatric Surgery by P Wave/QT Interval Dispersion.

BACKGROUND: The association of obesity with atrial fibrillation (AF) and with ventricular arrhythmias is well documented. OBJECTIVE: The aim of this study was to investigate whether weight reduction by a laparoscopic sleeve gastrectomy has any effect on P wave dispersion (PWD), a predictor of AF, and corrected QT interval dispersion (CQTD), a marker of ventricular arrhythmias, in obese individuals. METHODS: In a prospective study, a total of 114 patients (79 females, 35 males) who underwent laparoscopic sleeve gastrectomy were examined. The patients were followed 1 year. PWD and CQTD values before and 3rd, 6th, and 12th months after the surgery were calculated and compared. RESULTS: There was a statistically significant decline in body mass index (BMI), PWD, and CQTD values among baseline, 3rd, 6th, and 12th months (p < 0.001 for all comparisons). Correlation analysis showed a statistically significant correlation between ΔPWD and ΔBMI (r = 0.719, p < 0.001), ΔPWD and Δleft ventricular end-diastolic diameter (LVEDD) (r = 0.291, p = 0.002), ΔPWD and Δleft atrial diameter (LAD) (r = 0.65, p < 0.001), ΔCQTD and ΔBMI (r = 0.266, p = 0.004), ΔCQTD and ΔLVEDD (r = 0.35, p < 0.001), ΔCQTD and ΔLAD (r = 0.289, p = 0.002). In multiple linear regression analysis, there was a statistically significant relationship between ΔPWD and ΔBMI (ß = 0.713, p < 0.001), ΔPWD and ΔLVEDD (ß = 0.174, p = 0.016), ΔPWD and ΔLAD (ß = 0.619, p < 0.001), ΔCQTD and ΔBMI (ß = 0.247, p = 0.011), ΔCQTD and ΔLVEDD (ß = 0.304, p < 0.001), ΔCQTD and ΔLAD (ß = 0.235, p = 0.009). CONCLUSION: PWD and CQTD values of patients were shown to be attenuated after bariatric surgery. These results indirectly offer that there may be a reduction in risk of AF, ventricular arrhythmia, and sudden cardiac death after obesity surgery.

Intima-media thickness in patients with rheumatic mitral stenosis.

The aim of the study was to determine carotid artery intima-media thickness (IMT) in patients with rheumatic mitral stenosis (RMS). Between January 2001 and December 2003, 112 consecutive patients who had been diagnosed with RMS were screened. Patients with known cerebrovascular disease, coronary artery disease, diabetes, hypertension, left ventricular hypertrophy, hyperlipidemia, abnormal laboratory results, smoking, or age over 50 years were excluded. Forty-eight patients (43 women, 5 men, mean age 39.7 +/-8.3 years) with RMS without risk factors were enrolled in the study. Age- and sex-matched healthy individuals (n = 48; 43 women, 5 men, mean age 39.6 +/-8.6 years) with normal echocardiographic findings constituted the control group. Carotid IMT was determined by using a high-resolution ultrasound system equipped with a 7-MHz imaging probe (Acuson 128 XP CI) with a computer measurement software. The mean common carotid artery IMT thicknesses both in the right (0.604 +/-0.112 mm vs 0.521 +/-0.072 mm) and in the left side (0.581 +/-0.097 mm vs 0.516 +/-0.065 mm) were significantly higher in patients with RMS than in the control group (p < 0.001). Backward stepwise logistic regression analysis identified RMS as independent predictors of increased IMT (OR, 17.25 (CI, 3.99 to 76.28), p <0.001). The present study demonstrated that RMS is associated with increased IMT. The findings indicate that in patients with RMS not only valvular but also systemic endothelium is damaged.

Effect of female gender on the outcome of coronary artery bypass surgery for left main coronary artery disease.

OBJECTIVE: Early mortality after coronary artery bypass grafting is generally higher in women than in men. This study analyzes the effect of female gender on early mortality of coronary artery bypass grafting particularly for left main coronary artery disease. METHODS: Study population consisted of 144 consecutive patients (33 women, 111 men) undergoing coronary artery bypass grafting for left main coronary artery disease. Mean follow-up was 25.1 +/- 14.0 months. Data were collected retrospectively and presented as mean +/- standard deviation. Survival analysis was done using Kaplan-Meier actuarial curve method with the log rank univariate test, followed by Cox's proportional rate multivariate model. RESULTS: Overall mortality was 7% in the patient population. Cox regression analysis revealed that the independent predictors of increased total mortality were female gender (HR 8.34, 95% CI 1.79 - 38.76, p=0.007), advanced age (HR 1.12, 95% CI 1.02-1.23, p=0.014), degree of left main coronary artery stenosis (HR 1.068, 95%CI 1.005-1.135, p=0.03), and left ventricular ejection fraction (HR 0.93, 95% CI 0.87-0.99, p=0.03). Female gender was found to be the only independent predictor of increased early mortality (HR 13.18, 95%CI 1.444-120.343, p=0.02). After discharge from the hospital, female gender was no more a predictor of increased mortality. CONCLUSION: According to these data, we may assume that female gender is related with increased mortality in coronary artery surgery for left main disease in the pre-discharge period however after discharge from hospital, long-term benefit of female survivors of coronary artery bypass grafting operated on for left main coronary artery disease might be as good as in men.

An experience on radial versus femoral approach for diagnostic coronary angiography in Turkey.

OBJECTIVE: The radial approach has been increasingly used as an alternative to femoral access. The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach (TRA) for diagnostic coronary angiography, and to describe the difficulties associated with the technique as compared with transfemoral approach (TRF). METHODS: A series of 180 consecutive patients were divided to TRA or TFA groups by two operators. We compared the groups regarding procedural time, access time, fluoroscopy time, procedural failure, complications, contrast volume, length of hospital stay, and number of used coronary catheters. RESULTS: The number of used coronary catheters was not different between the two groups (p = 0.6). Total hospital length of stay was significantly shorter in the radial group (p <0.0001) than in femoral one. We found differences between the radial and femoral groups in the success rate (p<0.0001), contrast volume (p = 0.012), procedural time (p<0.0001), access time (p<0.0001), and fluoroscopy time (p<0.0001). We did not find any major complication in the radial group. There was a major bleeding in the femoral group. CONCLUSION: The TRA is a safe alternative to femoral catheterization although with lesser procedural success, longer procedural access, and radiation time, and more contrast volume.

Comparison of carotid intima-media thickness in patients with stable angina pectoris versus patients with acute coronary syndrome.

In this study, we found that carotid intima-media thickness (IMT) was significantly increased and carotid artery atherosclerotic plaques were detected more frequently in patients who had early-onset coronary artery disease compared with control subjects (0.73 +/- 0.10 vs 0.60 +/- 0.10 mm, p <0.001, and 40% vs 11%, p <0.001, respectively). Further, patients who had coronary artery disease and presented with an acute coronary syndrome were found to have significantly increased carotid IMT compared with patients who had stable angina pectoris (0.76 +/- 0.10 vs 0.70 +/- 0.10 mm, p <0.05). The IMT was greater in the patients who had acute coronary syndrome than in those who had stable angina pectoris.

Teleconsultation of coronary angiograms using smartphones and an audio/video conferencing application.

OBJECTIVE: To examine the feasibility and accuracy of teleconsultation of coronary angiograms using iPhone 4 and FaceTime. METHODS: The study was conducted in two stages. Coronary angiograms of 100 patients with single-vessel disease were retrospectively selected by a core laboratory unit and then re-evaluated by a consultant cardiologist on both an iPhone 4 screen via the FaceTime application and on the workstation monitor of the angiography laboratory. The interpretations of the consultant cardiologist on localization and severity of angiographic lesions were recorded and compared with those of the core laboratory. Using the same teleconsultation system, the consultant cardiologist outside the hospital was presented live angiographic images of 10 patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction. RESULTS: Interpretations of the consultant cardiologist on the localization and severity of 100 lesions on both the smartphone screen and workstation monitor showed high levels of agreement with the results of the core laboratory (for all, κ > 0.80). Of 10 patients whose PCI was performed under live video teleconsultation, eight patients underwent successful PCI while two patients had normal coronary arteries. There was an excellent agreement between the consultant cardiologist and the operator regarding lesion localization. CONCLUSIONS: Smartphones allow highly accurate interpretations on angiographic lesions and thus may serve as a supplementary teleconsultation tool in both elective and emergency situations.

Evaluation of blood rheology in patients with coronary slow flow or non-obstructive coronary artery disease.

Coronary slow flow (CSF) has been documented in 25% of patients evaluated for angina or angina-like chest pain, despite the presence of normal epicardial coronary arteries on angiography. The risk for the development of clinical events in patients with non-obstructive coronary artery disease (NOCAD) is higher than in patients with completely normal coronary arteries. The object of this study was to evaluate changes in blood and plasma viscosity in patients with CSF or NOCAD. The study included 147 subjects (CSF, n = 42, NOCAD, n = 42 and controls, n = 63). Blood and plasma viscosity, complete blood counts, fibrinogen, and high sensitivity C-reactive protein (hs CRP) levels were measured. There was no significant difference between the groups with respect to blood and plasma viscosity (p > 0.05). Hemoglobin, hematocrit, and erythrocyte counts were significantly higher in the CSF group compared to the NOCAD group (p = 0.017, p = 0.023 and p = 0.023 respectively) and the control group (p = 0.026, p = 0.02 and p = 0.02, respectively). High sensitivity CRP levels in the NOCAD group were higher than the CSF group and the control group (p = 0.001 and p = 0.018, respectively). In conclusion, no significant difference was observed in the blood and plasma viscosity in patients with CSF or NOCAD. Increases in hemoglobin and hematocrit values without an increase in viscosity may play a role in the pathophysiology of CSF.

A rare cardiac malformation in a patient presenting with transient ischemic attack: isolated left ventricular diverticulum.

Left ventricular diverticulum is a rare congenital malformation consisting of a localized protrusion of the endocardium and myocardium from the free wall of the left ventricle (LV). The prevalence of the disease is 0.26% in nonselected patients who underwent cardiac catheterization. It is believed that the etiology is an intrinsic abnormality developing during embryogenesis. It often does not cause any symptoms. We report a case of isolated left ventricular diverticulum with complaints of transient ischemic attack.

Autonomic neural control of the cardiovascular system in patients with Behçet's disease in the absence of neurological involvement.

Behçet's disease (BD) is a chronic multi-system disease presenting with recurrent oral and genital ulceration, and relapsing uveitis. Heart rate recovery (HRR) after exercise is a marker of parasympathetic activity. A delayed recovery of systolic blood pressure (SBP) after exercise might reflect sympathetic hyperactivity. The analysis of variations in heart rate has also been used to determine the balance between sympathetic and vagal nerve activities in the heart. Our objective was to determine HRR, the SBP response to exercise and heart rate variability (HRV) in patients with BD in the absence of neurological involvement. The study population consisted of 32 patients with BD and 30 healthy controls who were matched with respect to age, sex, and physical activity. Heart rate recovery was calculated as the difference between heart rate at peak exercise and heart rate at 1, 2, and 3 min of recovery. Blood pressure recovery indexes were determined by dividing the systolic blood pressure at 2 and 3 min in recovery to the systolic blood pressure at peak exercise. In patients with BD, mean HRR at 1 min (HRR1) were not significantly different than that of controls (21 ± 7 vs 20 ± 7 bpm, p = 0.50). Although, resting mean SBP of patients with BD was higher than controls (121 ± 13 vs 115 ± 12 mmHg, p = 0.039), the SBP recovery indices of the patients with BD at 2 and 3 min were similar to those of controls (0.84 ± 0.07 vs 0.84 ± 0.09, p = 0.89 and 0.78 ± 0.09 vs 0.78 ± 0.08, p = 0.93, respectively). Both time domain and frequency domain parameters of patients with BD were similar to that of controls. This study shows that the patients with BD have normal HRR1 and normal SBP response to exercise and normal HRV. These findings might suggest unaltered autonomic neural control of the cardiovascular system in this disorder in the absence of neurological involvement.

Relation of serum parathyroid hormone level to severity of heart failure.

Increased parathyroid hormone (PTH) level is associated with all-cause mortality in patients with heart failure (HF). However its role for identifying advanced HF has not been previously studied. We aimed to investigate whether the assessment of serum PTH could enable clinicians to identify patients with advanced HF. One hundred fifty consecutive patients who visited our outpatient clinic with systolic HF were enrolled in the present study. Serum levels of PTH and brain natriuretic peptide (BNP) were measured across all New York Heart Association functional classes. Mean levels of PTH were 43 ± 19, 84 ± 56, 121 ± 47, and 161 ± 60 pg/ml in New York Heart Association functional classes I, II, III, and IV, respectively (p <0.001). In univariate analysis, body mass index, disease duration, PTH, BNP and hemoglobin levels, creatinine clearance, heart rate, systolic blood pressure, left ventricular ejection fraction, left ventricular diastolic diameter, left atrial size, presence of atrial fibrillation, and diuretic usage were found to be predictors of advanced HF. In multivariate logistic regression analysis, PTH level (hazard ratio 1.032, 95% confidence interval 1.003 to 1.062, p = 0.003) and body mass index (hazard ratio 0.542, 95% confidence interval 0.273 to 1.075, p = 0.079) were associated with advanced HF. Furthermore, serum PTH levels were correlated with BNP level and left ventricular ejection fraction (p <0.001 for the 2 comparisons). In receiver operator characteristics curve analysis, the optimal cut-off value of PTH to predict advanced HF was >96.4 pg/ml, with 93.3% sensitivity and 64.2% specificity. In conclusion, measurement of serum PTH could provide complementary information and a simple biomarker strategy to categorize patients with advanced HF based on increased PTH levels, allowing rapid risk stratification in these patients.

An asymtomatic unicuspid aortic valve with aortic aneurysm and secundum type atrial septal defect.

Unicuspid aortic valve is a rare pathology among congenital heart diseases that requires cardiac surgery and is often confused with bicuspid valve. Herein, we report a case of a unicommisural form of unicuspid aortic valve concomitant with aortic aneurysm and secundum type atrial septal defect.

Myocardial perfusion SPECT and dobutamine stress tissue Doppler imaging in evaluation of patients with stable angina pectoris.

OBJECTIVE: To evaluate longitudinal function of ischemic and nonischemic myocardial tissue detected by Tc-99m MIBI single photon emission computed tomography (SPECT) prior to coronary revascularization in patients with stable angina pectoris. METHODS: We studied 24 consecutive patients (mean age 62+/-9 years; 5 women) with stable angina pectoris. All patients underwent myocardial perfusion SPECT. Tissue Doppler imaging (TDI) was performed to detect myocardial systolic velocities of anterior, inferior, septum and lateral walls at rest and peak dobutamine stress. RESULTS: A total of 96 segments were visualized with SPECT study. Maximum mean septal, lateral, anterior and inferior TDI systolic velocities were similar in ischemic and nonischemic segments (6.73+/-1.04 cm/sec, 6.93+/-1.34 cm/sec, respectively) at rest. At peak stress, maximum mean TDI systolic velocities were lower in the 37 ischemic segments (11.00+/-2.03 cm/sec) than 59 nonischemic segments (13.76+/-1.97 cm/sec, p = 0.001). Because we detected ischemia in whole group using both diagnostic tests, coronary angiography was decided. Critical coronary artery stenosis related to ischemic segments was detected and coronary revascularization decided. CONCLUSION: TDI with dobutamine stress can be used in patients with stable angina pectoris. In this study, we observed that quantitative data by TDI associated with SPECT showed an agreement for coronary revascularization.

Does atorvastatin affect androgen levels in men in the era of very-low LDL targeting therapy?

BACKGROUND: An adequate pool of free intracellular cholesterol is essential for steroidogenesis in gonads and LDL is the major source of cholesterol used in this pathway. Effect of peripheral LDL on the synthesis of steroids is dose dependent and although LDL levels around 100 mg/dl is demonstrated to be safe in terms of steroidogenesis, effect of LDL levels <70 mg/dl with higher doses of statins on steroidogenesis remains controversial. MATERIAL AND METHODS: Androgen and gonadotropin levels are prospectively evaluated at baseline and after 12 weeks of treatment in 77 male coronary heart disease patients receiving high doses of atorvastatin (40-80 mg daily) targeting serum LDL levels <70 mg/dl and in 83 male coronary heart disease patients receiving regular doses of atorvastatin (10-20 mg daily) targeting serum LDL levels <100 mg/dl. RESULTS: At the end of the study, mean LDL levels of the high and regular dose atorvastatin groups were 77+/-9 mg/dl and 98+/-10 mg/dl respectively. After twelve weeks of treatment, there were no significant alterations in serum total testosterone, free testosterone, sex hormone binding globulin, luteinizing hormone and follicle stimulating hormone levels between two groups. CONCLUSION: High dose atorvastatin in order to reach serum LDL levels around 70 mg/dl seems to be as safe as regular doses in order to reach serum LDL levels around 100 mg/dl, in terms of gonadal steroidogenesis in men with coronary heart disease.