Thrombolysis in patients with pulmonary embolism and elevated heart-type fatty acid-binding protein levels.

Recent studies have reported that a novel cardiac biomarker, heart-type fatty acid-binding protein (h-FABP), significantly predicts mortality inpatients with pulmonary embolism (PE) at intermediate risk. The aim of this study was to evaluate the effect of thrombolytic therapy on prognosis of the intermediate risk acute PE patients with elevated levels of h-FABP. This is non-interventional, prospective, and single-center cohort study where 80 patients (mean age 62 ± 17 years, 32 men) with confirmed acute PE were included. Only patients with PE at intermediate risk (echocardiographic signs of right ventricular overload but without evidence for hypotension or shock) were included in the study. h-FABP and other biomarkers were measured upon admission to the emergency department. Thrombolytic (Thrl) therapy was administered at the physician's discretion. Of the included 80 patients, 24 were h-FABP positive (30%). 14 patients (58%) with positive h-FABP had clinical deterioration during the hospital course and required inotropic support and 12 of these patients died. However, of 56 patients with negative test, only 7 patients worsened or needed inotropic support and five patients died during the hospital stay. Mortality of patients with PE at intermediate risk was 21%. The 30-day mortality rate was significantly higher in h-FABP(+) patients compared to h-FABP(-) patients (9 vs. 50%, p < 0.001). Multivariate analysis revealed h-FABP as the only 30 day mortality predictor (HR 7.81, CI 1.59-38.34, p = 0.01). However, thrl therapy did dot affect the survival of these high-risk patients. Despite, h-FABP was successful to predict 30-days mortality in patients with PE at intermediate risk; it is suggested to be failed in determining the patients who will benefit from thrl therapy.

Investigation of oxidative stress markers in essential hypertension.

BACKGROUND: The main goal of this study was to evaluate ischemia modified albumin (IMA), total antioxidant status (TAS), and total oxidant status (TOS) levels in treated essential hypertensive patients and to compare them with levels of normotensive subjects. METHODS: In 45 hypertensive and 30 control subjects, serum levels of IMA were determined manually using a spectrophotometric Co(II)-albumin binding assay. TAS and TOS levels were evaluated spectrophotometrically. Lipid profile was estimated by routine methods. RESULTS: Hypertensive patients had significantly higher levels of TOS and IMA (p = 0.020 and p = 0.034, respectively) and lower levels of TAS (p = 0.016) in comparison with control subjects. Serum levels of TAS were negatively correlated with TOS and IMA levels in the patient group. Serum levels of TOS were also positively correlated with IMA levels. There was no significant correlation between blood pressure and TAS, TOS, and IMA levels. CONCLUSIONS: Our results showed higher levels of IMA in hypertensive patients. We suggest that higher levels of IMA may result from increased oxidative stress and decreased antioxidant status in hypertensive patients.

Blunted heart rate recovery is associated with exaggerated blood pressure response during exercise testing.

Increased sympathetic activity and endothelial dysfunction are the proposed mechanisms underlying exaggerated blood pressure response to exercise (EBPR). However, data regarding heart rate behavior in patients with EBPR are lacking. We hypothesized that heart rate recovery (HRR) could be impaired in patients with EBPR. A total of 75 normotensive subjects who were referred for exercise treadmill test examination and experienced EBPR were included to this cross-sectional case-control study. The control group consisted of 75 age- and gender-matched normotensive subjects without EBPR. EBPR was defined as a peak exercise systolic blood pressure (BP) ≥210 mmHg in men and ≥190 mmHg in women. HRR was defined as the difference in HR from peak exercise to 1 min in recovery; abnormal HRR was defined as ≤12 beats/min. These parameters were compared with respect to occurrence of EBPR. Mean values of systolic and diastolic BP at baseline, peak exercise, and the first minute of the recovery were significantly higher in the subjects with EBPR. Mean HRR values were significantly lower (P < 0.001) in subjects with EBPR when compared with those without. Pearson's correlation analysis revealed a significant positive correlation between the decrease in systolic BP during the recovery and degree of HRR in individuals without EBPR (r = 0.42, P < 0.001). Such a correlation was not observed in subjects with EBPR (r = 0.11, P = 0.34). The percentage of abnormal HRR indicating impaired parasympathetic reactivation was higher in subjects with EBPR (29 % vs 13 %, P = 0.02). In logistic regression analyses, HRR and resting systolic BP were the only determinants associated with the occurrence of EBPR (P = 0.001 and P < 0.001, respectively). Decreased HRR was observed in normotensive individuals with EBPR. In subjects with normal BP response to exercise, a linear correlation existed between the degree of HRR and decrease in systolic BP during the recovery period. However, such a correlation was not found in subjects with EBPR. Our data suggest that mechanisms underlying the blunting of the HRR might be associated with the genesis of EBPR. The association between the extent of HRR and adverse cardiovascular outcomes in patients with EBPR needs to be investigated in detail in future research.

Secondary chordae rupture due to low-tension electricity trauma.

The most frequent cardiac pathologies caused by electric shock are arrhythmias with a wide clinical picture ranging from sinus tachycardia to asystole. Cardiac mechanical complications secondary to electric shock have rarely been reported. Despite the use of electrocardiography and cardiac monitorization in evaluating dysrhythmias and in the patients' follow-up, there is still no consensus on how to assess patients against probable mechanical complications and how to follow up these patients. In this study, we have presented the rupture in the secondary chordae of the mitral anterior leaflet caused by low-voltage electrical trauma. To our knowledge, this is the first cardiac mechanical complication reported as a consequence of low-tension electrical trauma.

P-wave dispersion for predicting paroxysmal atrial fibrillation in acute ischemic stroke.

BACKGROUND: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (P(d)) might be a useful marker in predicting PAF in patients with acute ischemic stroke. METHODS: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared. RESULTS: Maximum P-wave duration (p=0.002), P(d) (p<0.001) and left atrium diameter (p=0.04) were significantly higher in patients with PAF when compared to patients without PAF. However, in binary logistic regression analysis P(d) was the only independent predictor of PAF. The cut-off value of P(d) for the detection of PAF was 57.5 milliseconds (msc). Area under the curve was 0.80 (p<0.001). On a single 12-lead ECG, a value higher than 57.5 msc predicted the presence of PAF with a sensitivity of 80% and a specificity of 73%. CONCLUSION: P(d) on a single 12-lead ECG obtained within 24 hours of an acute ischemic stroke might help to predict PAF and reduce the risk of recurrent strokes.

Therapy-resistant ventricular tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of electrical storm.

Electrical storm is a challenging diagnosis for the clinician and requires detailed evaluation of the patient. Amiodarone is frequently used for the cessation of ventricular tachycardia attacks. Within antiarrhythmic effects of amiodarone, there are some harmful effects of the recent drug. Thyroid gland toxicity is one of the most important adverse effects of amiodarone and is called amiodarone-induced thyrotoxicosis. Thyrotoxicosis may alter arrhythmia and lead to frequent ventricular tachycardia attacks. Herein, we report a case of electrical storm caused by amiodarone-induced thyrotoxicosis.

Exaggerated blood pressure response to exercise--a new portent of masked hypertension.

Masked hypertension (MHT) is a popular entity with increased risk of developing sustained hypertension, heart attack, stroke, and death. Subjects have normal blood pressure (BP) at office but elevated values at night so it is difficult to diagnose. Exaggerated blood pressure response to exercise (EBPR) is also a predictor of future hypertension. To investigate the relationship between these two entities, we evaluated 61 normotensive subjects with EBPR. The subjects underwent 24-h ambulatory blood pressure monitoring (ABPM). The prevalence of masked hypertension among subjects with EBPR was 41%. Body mass index (BMI), non-high density lipoprotein (HDL) cholesterol, diastolic blood pressure (DBP) at peak exercise and recovery, nondipping DBP pattern, and elevated early morning average BPs were associated with masked hypertension. In multivariate logistic regression analysis, the DBP measured at peak exercise was detected as an independent predictor of MHT in subjects with EBPR. Subjects with abnormally elevated BP during exercise are prone to MHT, necessitate medical assessment and close follow-up for hypertension.

Comparison of myocardial performance index obtained either by conventional echocardiography or tissue Doppler echocardiography in healthy subjects and patients with heart failure.

This study was planned to investigate the normal reference values of myocardial performance index (MPI) obtained by tissue Doppler echocardiography (TDE) and the agreement between MPI measured by TDE and conventional MPI measured by pulsed-wave Doppler (PWD) in healthy subjects and patients with heart failure (HF). Two hundred and three patients with HF and 190 healthy subjects were enrolled in this study. Isovolumic contraction and relaxation time (ICT and IRT) and ejection time (ET) were measured from mitral inflow and left ventricular (LV) outflow. Tissue Doppler echocardiography recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus and same time intervals were measured. Myocardial performance index was calculated. The functional capacity of the patients with HF was determined according to New York Heart Association classification. TDE-MPI values were higher than conventional PWD-MPI values in both groups (53%+/-8% vs 48%+/-11%, P<0.0001 in the healthy subjects; 84%+/-21% vs 72%+/-19%, P<0.0001 in the patients with HF). Moderate agreement was found between PWD-MPI and LV mean TDE-MPI in both groups. In identifying patients with moderately or severely decreased LV ejection fraction, TDE-MPI had higher cutoff values than conventional PWD-MPI, and TDE-MPI had higher specificity, sensitivity, negative predictive value, and diagnostic accuracy. In patients with HF, TDE-MPI had a stronger correlation with LV ejection fraction and functional capacity than did PWD-MPI. TDE-MPI is an alternative to conventional PWD-MPI in assessment of cardiac function. However, the higher MPI cutoff points should be considered when this method is used for the evaluation of cardiac function.

Pericardial hemorrhage due to acetylsalicylic acid in a patient with essential thrombocythemia.

Essential thrombocythemia is a clonal myeloproliferative disorder that causes thrombocytosis. Essential thrombocythemia is characterized by increased incidence of thrombosis with arterial event more than venous events and hemorrhagic complications. Acetylsalicylic acid enhances both minor and major bleedings. The authors describe pericardial hemorrhage, which is related to the use of low-dose acetylsalicylic acid in a patient with essential thrombocythemia. The patient was successfully managed with clopidogrel therapy during the 16 months follow-up without recurrent thrombotic or hemorrhagic events.

The effect of nondipping blood pressure patterns on cardiac structural changes and left ventricular diastolic functions in normotensives.

BACKGROUND: Cardiac structural changes have been reported to be more prominent in nondipper normotensives than the dipper ones. But the influence of nondipping status on cardiac diastolic functions of normotensives has not been studied yet. In this study, we investigated the effect of nondipping status on both cardiac structural changes and left ventricular (LV) diastolic functions in normotensives. METHODS: We performed ambulatory blood pressure (BP) monitoring (ABPM) and echocardiography in 62 normotensive subjects with the following criteria: (1) office BP < 140/90 mmHg; (2) average 24-hour ambulatory BP < 130/80 mmHg. RESULTS: In the evaluation by tissue Doppler imaging (TDI), the early diastolic myocardial peak velocity (Em) and Em/late diastolic myocardial peak velocity (Am) ratio (Em/Am ratio) were lower in nondippers than those in dippers (P = 0.009 and P < 0.001, respectively). Isovolumic relaxation time (IRT) and myocardial performance index (MPI) were higher in nondippers than those in dippers (P = 0.036 and P = 0.026, respectively). Nondipping status, independent of other factors, was observed to cause both a decrease in the Em and Em/Am ratio and an increase in IRT. However, its effect on IRT was not statistically significant (coefficient =-0.27, P = 0.027; coefficient =-0.37, P = 0.002; coefficient = 0.20, P = 0.082, respectively). CONCLUSIONS: Nondipping of nocturnal BP seems to be a determinant of cardiac remodeling and LV diastolic dysfunction (LVDD) and may result in a cardiovascular (CV) risk independent of the increase in LV mass (LVM) in normotensives.

[The effect of nondipper blood pressure pattern on target organ damage in patients with metabolic syndrome]. / Metabolik sendromlu hastalarda nondipper kan basinci seyrinin hedef organ hasari üzerine etkisi.

OBJECTIVES: Both metabolic syndrome (MetS) and nondipping status (insufficient reduction in nocturnal blood pressure) have been linked with target organ damage. We evaluated the effect of nondipping status on target organ damage in subjects with MetS. STUDY DESIGN: Eighty-two patients diagnosed as having MetS were divided into two groups according to the findings of 24-hour ambulatory blood pressure monitoring as dipper (n=35, 19 women, 16 men; mean age 48.4+/-6.4 years) and nondipper (n=47, 35 women, 12 men; mean age 50.4+/-4.7 years). Cardiac damage was assessed by conventional and tissue Doppler echocardiography, and renal damage by 24-hour urinary albumin excretion. RESULTS: The two groups were similar with regard to age, body mass index, presence of diabetes, smoking, clinical and 24-hour, daytime and nighttime blood pressures, plasma lipid profile, distribution of and the mean total number of MetS criteria. The ratio of early (Em) to late (Am) left ventricular peak diastolic myocardial velocities (Em/Am) was significantly lower in nondippers (p=0.016). Nondippers also had higher values of left ventricular mass index, myocardial performance index, and 24-hour urinary albumin excretion, but these differences did not reach a significant level (p=0.110, p=0.099, p=0.093, respectively). Multivariate regression analysis showed increasing age and nondipping status as independent factors associated with decreased Em/Am ratio (beta=-0.25, p=0.020 and beta=-0.22, p=0.042, respectively). CONCLUSION: In subjects with MetS, nondipping status may be associated with both cardiac and renal damage independent of other components of MetS. Since the degree of diastolic dysfunction is more marked than that of albuminuria in nondippers, it may be extrapolated that the extent of cardiac damage surpasses renal damage in these subjects.

Is there any relationship between metabolic parameters and left ventricular functions in type 2 diabetic patients without evident heart disease?

BACKGROUND: The aim of the present study was to evaluate left ventricle (LV) systolic and diastolic function, using tissue Doppler echocardiography (TDE) and color M-mode flow propagation velocity, in relation to blood glucose status in normotensive patients with type 2 diabetes mellitus (T2DM) who had no clinical evidence of heart disease. METHODS: Seventy-two patients with T2DM (mean age 49.1 +/- 9.8 years) without symptoms, signs or history of heart disease and hypertension, and 50 ages matched healthy controls (mean age 46.1 +/- 9.8 years) had echocardiography. Systolic and diastolic LV functions were detected by using conventional echocardiography, TDE and mitral color M-mode flow propagation velocity (V(E)). Fasting blood glucose level (FBG) after 8 hours since eating a meal, postprandial blood glucose level (PPG), and HbA(1C) level were determined. The association of FBG, PPG and HbA(1C) with the echocardiographic parameters was investigated. RESULTS: It was detected that although systolic functions of two groups were similar, diastolic functions were significantly impaired in diabetics. No relation of FBG and PPG with systolic and diastolic functions was determined. However, HbA(1C) was found to be related to diastolic parameters such as E/A, Em/Am, V(E) and E/V(E) (beta=-0.314, P = < 0.05; beta=-0.230, P < 0.05; beta=-0.602, P < 0.001, beta= 0.387, P < 0.005, respectively). In addition to HbA(1C), LV, diastolic functions were also correlated with age and diabetes duration. CONCLUSION: Diastolic LV dysfunction may develop even in absence of ischemia, hypertension, and LVH in T2DM. FBG and PPG have no effect on LV functions, but HbA(1C) levels may affect diastolic parameters.

[The role of tissue Doppler echocardiography in the evaluation of functional capacity of patients with heart failure]. / Kalp yetersizligi olan hastalarda fonksiyonel kapasitenin degerlendirilmesinde doku Doppler ekokardiyografinin rolü

OBJECTIVES: We investigated correlations between the New York Heart Association (NYHA) functional classification system, which is commonly used to assess functional capacity, and conventional echocardiographic and tissue Doppler echocardiographic (TDE) parameters in patients with heart failure (HF). STUDY DESIGN: The study included 122 patients (31 females, 91 males; mean age 59+/-11 years) with HF, whose left ventricular (LV) ejection fraction (EF) was less than 50%. The patients were evaluated in two groups based on the NYHA class I-II (n=79; mean age 58 years) and class III-IV (n=43; mean age 61 years). Correlations were sought between the functional status and standard two-dimensional echocardiographic and TDE parameters. RESULTS: The NYHA class showed significant inverse correlations with LV EF, LV stroke volume, mitral deceleration time of early filling, and flow propagation velocity (Vp), and significant positive correlations with end-systolic and end-diastolic diameters and volumes, pulmonary artery pressure (PAP), and the E/Vp ratio. Mitral early (E) and late (A) diastolic peak velocities and the E/A ratio were not correlated. Concerning TDE parameters, the NYHA class was in significant inverse correlation with systolic (Sm), early (Em) and late (Am) diastolic myocardial velocities, and in positive correlation with the E/Em ratio, whereas no correlation was found with the Em/Am ratio. Linear regression analysis showed that Sm, EF, and PAP were independent variables of functional capacity (beta =-0.33, p<0.005; beta =-0.26, p<0.05; beta =0.23, p<0.05, respectively). CONCLUSION: There is significant relationship between myocardial velocities and functional capacity, and Sm, in particular, has the strongest association compared to conventional echocardiographic and other TDE parameters.

New parameters in identification of right ventricular myocardial infarction and proximal right coronary artery lesion.

OBJECTIVE: The diagnosis of right ventricular myocardial infarction (RVMI) accompanied by acute inferior myocardial infarction (MI) is still a problem that we encounter. This study was designed to find out the usefulness both of peak myocardial systolic velocity (Sm) and of the myocardial performance index (MPI) of the right ventricle measured by pulsed-wave tissue Doppler imaging (TDI) in assessing right ventricular function. METHODS: Sixty patients who experienced a first acute inferior MI (mean [+/- SD] age, 57 +/- 9 years) were prospectively assessed. An ST-segment elevation of >or= 0.1 mV in V(4)-V(6)R lead derivations was defined as an RVMI. From the echocardiographic apical four-chamber view, the Sm, the peak early diastolic velocity, peak late diastolic velocity, the ejection time, the isovolumetric relaxation time, and the contraction time of the right ventricle were recorded at the level of the tricuspid annulus by using TDI. Then, the MPI was calculated. The patients were classified into the following three groups, according to the localization of the infarct-related artery (IRA) detected using coronary angiography: group I, proximal right coronary artery; group II, distal right coronary artery; and group III, circumflex coronary artery. RESULTS: RVMIs were detected in sixteen patients, and the IRA in 27 patients was the proximal right coronary artery. The right ventricular Sm was observed to be significantly low in patients with RVMIs and those in group I compared to those without RVMIs and those in groups II and III (10.9 +/- 1.3 vs 14.3 +/- 3.2 cm/s, respectively [p < 0.001]; 11.5 +/- 2.5 vs 15.1 +/- 3 cm/s, respectively; and 14.9 +/- 2.6 cm/s, respectively [p < 0.001]). In the diagnosis of RVMI, the values for sensitivity, specificity, negative predictive value, and positive predictive value of Sm < 12 cm/s were 81%, 82%, 92%, and 62% respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 63%, 88%, 74%, and 81%, respectively. The MPI was high in the same patient groups (0.83 +/- 0.12 vs 0.57 +/- 0.11 in those patients without RVMI, respectively, [p < 0.001]; 0.74 +/- 0.13 vs 0.56 +/- 0.15 in group II and 0.54 +/- 0.07 in group III, respectively [p < 0.001]). The sensitivity, specificity, negative predictive value, and positive predictive value of an MPI of > 0.70 in the diagnosis of RVMI were calculated as 94%, 80%, 97%, and 63%, respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 78%, 91%, 83%, and 88% respectively. CONCLUSIONS: An Sm <12 cm/s and an MPI > 0.70 obtained by TDI may define RVMI concomitant with acute inferior MI, and the IRA.

Analysis of the myocardial velocities in patients with mitral stenosis.

BACKGROUND: Pure mitral stenosis (MS) affects left-ventricular performance as a result of myocardial and functional factors. We planned this study to evaluate the effect of MS on right- and left-ventricular functions using Doppler tissue imaging (DTI). METHODS: A total of 46 patients with an established diagnosis of MS (mean age: 41 +/- 11 years), and 40 age-matched healthy individuals (mean age: 40 +/- 9 years) were included in this study. Echocardiography equipped with DTI function was performed on each participant. The mitral valve area was measured. Myocardial velocities were recorded at 4 different sites (septum, lateral, anterior, and inferior) of the left ventricle, and the right-ventricular free wall annulus by DTI. The positive systolic velocity when the mitral and tricuspid ring moved toward the cardiac apex, and 2 negative diastolic velocities when the mitral annulus moved toward the base away from the apex (1 during the early phase of diastole and another in the late phase of diastole [A(m)]) were measured. The early diastolic velocity/A(m) ratio was calculated for each wall. The mean of systolic and diastolic myocardial velocities of the left ventricle was calculated. Patients with pure MS were compared with healthy participants, and the relationship of DTI variables with mitral valve area was evaluated. RESULTS: The myocardial velocities of the left ventricle indicating left-ventricular function were found to be significantly lower in patients with pure MS. Right-ventricular annulus velocities, on the other hand, were similar in both groups. A significant positive correlation could be established between mitral valve area and mean positive systolic velocity, A(m) of the left ventricle, and right-ventricular A(m) (r = 0.50, P <.001; r = 0.48, P =.001; r = 0.45, P =.002, respectively), whereas a significant negative correlation (r = -0.42, P =.004) was established for right-ventricular early diastolic velocity/A(m) ratio. CONCLUSION: This first study where pure MS was evaluated by DTI shows that MS affects left-ventricular performance on long axis. The results indicate that the decrease in left-ventricular performance is caused by both functional and myocardial factors.

Effect of postmenopausal hormone replacement therapy on cardiovascular performance.

UNLABELLED: Postmenopausal hormone replacement therapy (HRT) has usually been evaluated the relationship with atherosclerotic disease, whereas its effect on direct cardiac functions hasn't been investigated in detail. This study was planned to investigate the long-term effects of HRT on cardiac functions and exercise performance. METHODS: Thirty-six postmenopausal women (mean age: 51 +/- 4 years, 39-60 years) were prospectively analyzed with pulsed wave Doppler echocardiography and symptom-limited exercise stress test before HRT (oral 0.625 mg conjugated estrogen and 2.5 mg medroxyprogesteron acetate/day), and at the third and the sixth months. The effect of HRT on left ventricular ejection fraction (EF), early filling velocity (E wave) and late filling velocity (A wave), E wave deceleration time (EDT), E/A ratio, myocardial performance index (MPI), exercise duration and METS changes were examined. RESULTS: HRT did not significantly alter the left ventricular EF. At the third month of HRT, there was an insignificant increase in E wave, EDT, and E/A ratio, whereas an insignificant decrease was noted in MPI (P > 0.05). However, at the sixth month of HRT, these changes became significant (68 +/- 12 vs. 75 +/- 13 cm/s, P < 0.01; 171 +/- 24 vs. 184 +/- 14 ms, P < 0.01; 1.01 +/- 0.23 vs. 1.11 +/- 0.27, P < 0.01, and 44 +/- 9 vs. 39 +/- 8%, P < 0.001, respectively). On the other hand, exercise duration and exercise METS values showed significant improvements at the third month of HRT (423 +/- 104 vs. 482 +/- 104 s, P < 0.001; 8.2 +/- 1.7 vs. 9.1 +/- 2 METS, P < 0.001). These improvements also continued at the sixth month of HRT. In conclusion, postmenopausal HRT leads to a progressive improvement on left ventricular function parameters, and in parallel, in exercise performance.

New parameters in the interpretation of exercise testing in women: QTc dispersion and QT dispersion ratio difference.

BACKGROUND: It has been reported that the increase of QT dispersion (QTD) that occurs due to increased inhomogeneity of the ventricular repolarization because of transient ischemia obtained by standard 12-lead electrocardiogram (ECG), the changes during exercise, and the differences between exercise and rest increase the accuracy of exercise test in the diagnosis of coronary artery disease (CAD). HYPOTHESIS: This study was designed to investigate the value of QTD parameters, which are reported to increase the diagnostic accuracy of exercise test in women. METHODS: Ninety-seven women who had undergone coronary angiography and exercise test were evaluated for diagnosis of chest pain. QT dispersion was calculated using the measurements of the highest and lowest values of QT interval obtained by ECG during peak exercise. The QTc using Bazett's equation, and the QTD ratio (QTDR) using QT/RR were calculated, and QTcD and QTD ratios were obtained. The difference between QTcD and QTDR was determined by extracting the rest values from the exercise values. RESULTS: The groups with normal coronaries (n = 48), single-vessel CAD (n = 24), and multivessel CAD (n = 25) were compared. The obtained QTD parameters at peak exercise and their differences between exercise and rest were found to be significantly increased in patients with CAD (p <0.001). Furthermore, these parameters were found to be higher in the patients with multivessel CAD than in those with single-vessel disease (p < 0.05). With the parameters QTcD > 60 ms and QTDR > 10%, greater sensitivity and specificity were obtained compared with ST-segment depression. The highest diagnostic accuracy was obtained with the QTD parameters calculated from the differences between rest and exercise values. The diagnostic accuracy of the difference of QTcD > 15 ms and the difference of QTDR > 5% was relatively higher than the other parameters (sensitivity, specificity, and negative and positive predictor values are 84, 88, 84, 87% and 84, 96, 85, 95%, respectively). CONCLUSION: The use of QTD parameters as variables of ECG, which is easily obtainable in the evaluation of exercise ECG in women, increases the diagnostic accuracy of the exercise test. In addition, the evaluation of QTD variables may provide information about the incidence of CAD.

Effect of left bundle branch block on systolic and diastolic function of left ventricle in heart failure.

This study was designed to examine the effect of left bundle branch block (LBBB) on systolic and diastolic function of the left ventricle (LV) in patients with heart failure and in normal subjects. Thirty-six patients with heart failure and LBBB (group I), 36 patients with heart failure with normal conduction (group II), and 41 subjects with isolated LBBB (group III) were compared. Coronary angiography was performed and LV end diastolic pressure was calculated. Echocardiography was performed on all patients. LV ejection fraction and mean rate of circumferential shortening were calculated. The following Doppler parameters were evaluated: peak rapid filling velocity (E wave), peak atrial filling velocity (A wave), E- and A-wave integrals, E-wave acceleration time and deceleration time (EDT) and rates (EAR and EDR), the E/A ratio and its integral, and diastolic flow time (DT). The ejection time, isovolumetric relaxation time (IRT), and preejection period were measured using the aortic and mitral flow. LV end diastolic pressure was calculated as 28 +/- 4 mm Hg, 22 +/- 5 mm Hg, and 15 +/- 3 mm Hg in groups I, II, and III, respectively. Although the systolic function parameters in group III patients were different, the diastolic function parameters of group II were found to be quite similar to those of group III patients. Comparison of group I patients with group II patients showed that there was a similarity between LV systolic function parameters while the diastolic function parameters were different (E/A, p = 0.004; EAR, p < 0.001; EDR, p < 0.001; EDT, p < 0.001; IRT, p = 0.024; DT, p = 0.03). In conclusion, this study evaluating the effects of LBBB in normal subjects (isolated LBBB) and patients with heart failure showed that LBBB causes diastolic function impairment in normal subjects similar to those of patients with heart failure, and also increases impairment of diastolic function in patients with heart failure.

The effect of Valsalva maneuver on P wave in 12-lead surface electrocardiography in patients with paroxysmal atrial fibrillation.

The previous studies relating to the effect of the Valsalva maneuver on P wave do not provide detailed information. In those studies, the parameters related to P wave duration during the release phase of the Valsalva maneuver were evaluated. The authors evaluated P wave amplitude as well as P wave duration during the strain phase of the Valsalva maneuver. Thirty-seven normal subjects and 36 patients with paroxysmal atrial fibrillation (PAF) were included in the study. Twelve-lead surface electrocardiography (ECG) was obtained from all the patients before and during the strain phase of the Valsalva maneuver. The authors evaluated the parameters related to both P wave duration and P wave amplitude. The highest P wave voltage was expressed as the P wave amplitude maximum (P amp max), the lowest P wave voltage as the P wave amplitude minimum (P amp min), and the P wave amplitude dispersion (P amp dispersion) as "the P amp max - the P amp min." Also, the maximum P wave duration was expressed as the P maximum (P max), the minimum P wave duration as the P minimum (P min), and the P wave dispersion as "the maximum P wave duration (P max) - the minimum P wave duration (P min)." All these parameters were measured before and during the strain phase of the Valsalva maneuver. P max, P dispersion, P amp max, and P amp dispersion were higher in patients with PAF compared to those of normal subjects before the Valsalva maneuver. In normal subjects, P max, P wave dispersion, P amp max, and P amp dispersion values were significantly higher in the strain phase of the Valsalva maneuver than before (p<0.01, p<0.01, p<0.05, and p<0.05, respectively). In the patients with PAF, P max, P wave dispersion, P amp max, and P amp dispersion values were significantly lower during the strain phase of the Valsalva maneuver than before. In conclusion, in the patients with PAF, P wave parameters were decreased during the strain phase of the Valsalva maneuver, approaching to the normal levels.

Can P wave parameters obtained from 12-lead surface electrocardiogram be a predictor for atrial fibrillation in patients who have structural heart disease?

This study was planned to investigate the parameters detecting risk of developing atrial fibrillation (AF) in patients with sinus rhythm with structural heart disease. Forty-five patients with AF and 37 patients without AF but with structural heart disease (Group I) were included in this study. Thirty-eight patients (Group II) had successfully undergone medically or electrically cardioversion after transesophageal echocardiography. The restoration of sinus rhythm could not be achieved in 7 patients who were excluded from this study. After providing sinus rhythm, amiodarone was given orally to the patients to prevent recurrences. Left ventricular ejection fraction (LVEF) was calculated and left atrial diameter (LAD) was measured by echocardiography in group I and in group II after cardioversion. A 12-lead electrocardiography (ECG) was simultaneously obtained from all the patients. In these ECG recordings, maximum P wave duration (P max), minimum P wave duration (P min), and P wave dispersion (P dispersion) were calculated. P dispersion was expressed as "P max-P min." Also, the highest P wave voltage is expressed as P amplitude maximum (P amp max), the lowest P wave as P amplitude minimum (P amp min), and P amplitude dispersion (P amp dispersion) was calculated as the difference of both. In univariate analysis, P max, P dispersion, P amp max, P amp dispersion, LAD, LVEF, and old age were significant predictors of chronic AF (p < 0.001, p < 0.01, p < 0.01, p < 0.01, p = 0.003, p = 0.02, and p = 0.01, respectively). However, in multivariate analysis, P max and LAD were independent predictors of chronic AF in patients with structural heart disease (r = 0.39, p < 0.05; r = 0.34; p < 0.05, respectively). In conclusion, in estimating the risk of developing chronic AF, P max and LAD are predictive parameters in patients with sinus rhythm with structural heart disease.