Relationship Between Epicardial Adipose Tissue and Body Composition as Determined by Multi-Frequency Bioelectrical Impedance Analysis in Patients with Stage 5 Chronic Kidney Disease.

BACKGROUND The main cause of mortality among chronic kidney disease (CKD) patients is cardiovascular disease (CVD). Epicardial adipose tissue (EAT) is considered to be novel cardiovascular risk factor. We assessed EAT in non-dialyzed stage 5 CKD patients and explored the association of EAT with body composition as determined by multi-frequency BIA. MATERIAL AND METHODS The present included 70 stage 5 CKD patients who had not undergone dialysis and 40 healthy control subjects. EAT thickness was assessed by echocardiography. Hydration status and body composition were evaluated by multi-frequency bioelectrical impedance analysis. RESULTS Stage 5 CKD patients had significantly higher EAT thickness than healthy subjects (6.56±1.18 vs. 4.05±1.45, p<0.001). Fat tissue mass, systolic blood pressure (SBP), age, fat tissue index, and body mass index were positively correlated with EAT thickness in the CKD patient group (p<0.05). Lean tissue mass, lean tissue index (LTI), and high-density lipoprotein (HDL) were negatively correlated with EAT thickness in the CKD patient group (p<0.05). Stepwise multiple regression analysis showed that age, SBP, and LTI were independently associated with EAT thickness in CKD patients. CONCLUSIONS We found significantly higher EAT thickness in stage 5 CKD patients who were not on dialysis compared to healthy controls. EAT was significantly associated with age, SBP, and LTI in CKD patients. Interventions to reduce the risk factors associated with EAT thickness might protect against CVD disease in CKD patients.

Myocardial Performance Index for Patients with Overt and Subclinical Hypothyroidism.

BACKGROUND Hypothyroid has several effects on the cardiovascular system. Global myocardial performance index (MPI) is used in assessment of both left ventricular (LV) systolic and diastolic function. We compared MPI in hypothyroidism patients vs. normal control subjects. MATERIAL AND METHODS Eighty-two hypothyroid patients were divided into 2 groups: a subclinical hypothyroid (SH) group (n=50), and an overt hypothyroid (OH) group (n=32). The healthy control group (CG) constituted of 37 patients. TSH, FT3, and FT4, anti-TPO, anti-TG, insulin, lipid values, and fasting glucose levels were studied. All patients underwent an echocardiographic examination. Myocardial performance indexes were assessed and standard echocardiographic examinations were investigated. RESULTS MPI averages in OH, SH, and control groups were 0.53±0.06, 0.51±0.05, and 0.44±0.75 mm, respectively. MPI was increased in the OH and SH groups in comparison to CG (p<0.001, p<0.001, respectively). CONCLUSIONS MPI value was significantly higher in hypothyroid patients in comparison to the control group, showing that regression in global left ventricular functions is an important echocardiographic finding. Future studies are required to determine the effects of this finding on long-term cardiovascular outcomes.

The Relationship of Fluid Overload as Assessed by Bioelectrical Impedance Analysis with Pulmonary Arterial Hypertension in Hemodialysis Patients.

BACKGROUND Pulmonary arterial hypertension (PAH) is common disease among hemodialysis (HD) patients and is associated with increased morbidity and mortality. However, its pathogenesis has not been completely elucidated. We aimed to evaluate the frequency of PAH in HD patients, as well as the relationship between fluid status and PAH. MATERIAL AND METHODS We enrolled 77 HD patients in this study. Multifrequency bioimpedance analysis (BIA) was used to assess fluid status. BIA was performed before and 30 min after the midweek of HD. Overhydration (OH)/extracellular water (ECW)% ratio was used as an indicator of fluid status. Fluid overload was defined as OH/ECW ≥7%. Echocardiographic examinations were performed before and after the HD. Pulmonary arterial hypertension was defined as systolic pulmonary artery pressure at rest (sPAP) higher than 35 mmHg. RESULTS PAH was found in 33.7% of the HD patients. OH/ECW and the frequency of fluid overload were significantly higher in HD patients with PAH than those without PAH, whereas serum albumin and hemoglobin levels were significantly lower. sPAP level was significantly higher in HD patients with fluid overload than in those without fluid overload after hemodialysis session. Furthermore, sPAP, OH/ECW levels, and the frequency of PAH were significantly reduced after HD. We also found a significant positive correlation between sPAP and OH/ECW. Multivariate logistic regression analysis demonstrated fluid overload to be an independent predictor of PAH after HD. CONCLUSIONS PAH is prevalent among HD patients. This study demonstrated a strong relationship between fluid overload and PAH in HD patients.

Comparison of tissue Doppler dynamics with Doppler flow in evaluating left atrial appendage function by transesophageal echocardiography in prehypertensive and hypertensive patients.

Increased blood pressure (BP) is associated with an increase in cardiovascular mortality and morbidity. We aimed to analyze the effect of increased BP onto the function of left atrial appendage (LAA) in early stages of hypertension. Transesophageal echocardiography (TEE) was prospectively performed to assess LAA functions in 120 patients with increased BP, and in 58 normotensive subjects without cardiovascular disease. Patients with increased BP were divided according to Joint National Committee VII (JNC VII) report: prehypertensive, stage-1 hypertensive and stage-2 hypertensive patients. During TEE, LAA late-emptying velocities (LAAEV) were significantly reduced only in stage-2 hypertensives as compared with control group (P < 0.001). In contrast, LAA late-contracting velocity (LAA TDI-D2) was significantly reduced in prehypertensive,stage-1 hypertensive and stage-2 hypertensive patients, when compared with control group (P < 0.05, P < 0.001, and P < 0.001, respectively). The LAA maximal areas were increased significantly only in stage-2 hypertensive patients when compared with control group (P < 0.05). During TEE, left atrial spontaneous echocardiographic contrast was found in 2 of 36 patients in prehypertension group, in 7 of 40 patients in stage-1 hypertension group, and in 10 of 44 patients in stage-2 hypertension group. Left atrial thrombi were observed in 3 (6.8%) patients of stage-2 hypertension group. In conclusion, in patients with untreated prehypertension and hypertension, elevation of afterload imposed on left atrium involved both left atrium and LAA, resulting in impairment of the LAA function. Tissue Doppler imaging (TDI) enables the detection of this functional impairment in early stages of hypertension, even in prehypertensive phase, when compared with conventional Doppler flow measurement of the LAA. Even in prehypertensive phase, BP should be decreased to normal levels to prevent the LAA dysfunction.

Thrombophilia in young patients with acute myocardial infarction.

OBJECTIVE: To investigate the association of thrombophilia and coronary artery disease (CAD) in patients with myocardial infarction (MI). METHODS: Under the age of 45 years, 129 patients with MI and 107 control subjects were included into the study. Traditional risk factors of CAD and protein C, S, antithrombin III deficiencies, factor V Leiden (FV Leiden), prothrombin G20210A and methylenetetrahydrofolate reductase (MTHFR) C677T mutations were investigated. RESULTS: There were statistically significant differences in terms of obesity, smoking, triglyceride, total cholesterol, high-density lipoprotein, high-density lipoprotein, and very-low-density lipoprotein cholesterol, family history, hypertension, diabetes, and left ventricular hypertrophy between patients and controls. None of the patients and controls had protein C, protein S, and antithrombin III deficiencies. Ten patients (7.8%) and 4 controls (3.7%) had heterozygote FV Leiden mutation. Homozygous prothrombine G20210A gene mutation was detected in one patient (1.1%). Homozygous MTHFR C677T mutation was observed in 7.8% (patients) and in 6.5% (controls). Heterozygous MTHFR C677T mutation was detected 36.4% in patients and 31.7% in controls. The difference was not statistically significant in terms of carriage of thrombophilic mutations. CONCLUSION: We found that traditional risk factors increased the risk of CAD. Prothrombin G20210A, FV Leiden and MTHFR C677T mutations, protein C, S and AT-III deficiencies did not increase the risk of CAD in our young population.

Elevated plasma N-terminal pro-brain natriuretic peptide levels in acute ischemic stroke.

BACKGROUND: B-type natriuretic peptide (BNP) is a neurohormone secreted mainly in the cardiac ventricles in response to volume expansion and pressure overload. The aim of this study was to assess plasma N-terminal proBNP (NT-proBNP) changes in acute ischemic stroke (AIS). METHODS: The study group consisted of 57 (37 women aged 64 +/- 12 years) patients who had their first AIS and no history or signs of cardiovascular disease. An age-matched control group was also included (n = 57, 36 women aged 61 +/- 6 years). NT-proBNP, troponin I (TnI), and creatine kinase-MB were evaluated. A thorough cardiovascular and neurological investigation, including imaging techniques and lesion size determination, was also performed. RESULTS: The log NT-proBNP peak levels, TnI, and creatine kinase-MB levels were significantly higher in AIS compared with controls (7.25 +/- 1.77 vs 3.48 +/- 0.76 pg/mL, P < .0001; 0.76 +/- 0.54 vs 0.5 +/- 0.0 ng/mL, P < .001; 57 +/- 37 vs 13 +/- 4 U/L, P < .001, respectively). The log NT-proBNP correlated positively with TnI (r = 0.29, P = .03) and heart rate (r = 0.41, P = .002), and negatively with left ventricular ejection fraction (r = -0.67, P < .0001). Patients with signs of marked myocardial ischemia and patients with insular cortex involvement had even higher NT-proBNP levels. After adjustment for relevant factors, the relation between the log NT-proBNP and AIS as well as insular cortex involvement was observed to be insignificant (P > .05 for both). CONCLUSIONS: Our results show that NT-proBNP plasma levels are significantly elevated in AIS and might be of clinical importance as a supplementary tool for the assessment of cardiovascular function in patients with AIS.

Complement activation in acute coronary syndromes.

The complement system is part of the host defence response. However, considerable evidence suggests that complement plays an important role in the pathophysiology of ischemic heart disease. The aim of this study was to evaluate complement activation in patients with all forms of acute coronary syndromes (ACS) and to examine the relationship between the degree of complement activation and myocardial injury. The study population included 152 subjects (26 females): 82 with ACS (35 acute myocardial infarction (AMI), 22 non-Q wave MI (NQMI), 25 unstable angina (UAP)) (Group A), 35 stable angina (SA) (Group B), and 35 healty control subjects (Group C). Complement 3 (C3), Complement 4 (C4), C-reactive protein (CRP), troponin I (TnI) as well as creatine kinase MB (CK-MB) were evaluated. Patients' blood samples were taken on admission (day 1) and after 2, 3 and 7 days in group A. However, only one measurement was performed in the groups B and C. Plasma C3 and C4 peak levels were significantly higher in patients with AMI (141+/-29 and 35+/-11 mg/dl) and NQMI (136+/-13 and 35+/-7 mg/dl) than in patients with SA (128+/-14 and 27+/-10 mg/dl) and the control subjects (114+/-22 and 22+/-7 mg/dl) (p<0.03). Also, C3 and C4 serum levels in patients with SA and UAP (126+/-16 and 31+/-7 mg/dl) were significantly higher than those in control subjects (p<0.01, p<0.03, respectively). At 1-week follow-up, there were no significant differences between the plasma levels of C3 and C4 in patients with UAP (p>0.05). However, plasma levels of C3 and C4 were significantly different between days in patients with AMI and NQMI (p<0.0001). Plasma C3 and C4 levels in ACS showed a relationship with peak CK-MB and Tn I levels (p<0.01). Plasma CRP level in ACS showed positive correlation with C3 (p<0.01) and C4 (p<0.001). In this study, we determined that plasma C3 and C4 levels were elevated in ACS and SA. Although C3 and C4 were higher in ACS and SA, the systemic levels of inflammatory markers in patients with SA and UAP were lower than those found in the AMI and NQMI groups. The relationship between C3, C4 levels and ACS further suggests that the complement activation is related to necrosis within the myocardium.

Iatrogenic left atrioventricular fistula after aortic valve re-replacement.

Left ventriculoatrial fistula is a very rare cardiac disorder. The case is reported of a male patient who was admitted to the authors' clinic with dyspnea and fatigue. The patient had an atrioventricular fistula between the left atrium and left ventricle, and had undergone aortic valve re-replacement for prosthesis malfunction about one year previously. The fistula was considered to be the result of iatrogenic injury related to valve re-replacement surgery.

N-terminal proBNP plasma levels correlate with severity of mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Brain natriuretic peptide (BNP), a neurohormone, is secreted predominantly from the ventricular myocardium. Studies investigating BNP secretion in diseases affecting the right side of the heart are scarce. The relationship between N-terminal proBNP (NT-proBNP) and echocardiographic and clinical findings was studied in cases with isolated moderate to severe rheumatic mitral stenosis (MS), and in patients with previous mitral valve replacement (MVR). METHODS: Thirty-two patients with MS (mean age 41.2 +/- 5.7 years), 20 with MVR (mean age 46.0 +/- 4.6 years) and 30 healthy individuals (mean age 40.3 +/- 4.9 years) were included in the study. In addition to NT-proBNP measurements, detailed transthoracic echocardiography was performed in all patients and healthy subjects. RESULTS: Plasma levels of NT-proBNP were significantly higher in patients with MS than in those with MVR or in controls (99.8 +/- 12.7 versus 74.7 +/- 6.9 and 48.5 +/- 10.5 pg/ml, respectively; p <0.0001 all groups). NT-proBNP levels showed a significantly greater increase in severe MS than in moderate MS (109.8 +/- 5.6 versus 88.3 +/- 7.6 pg/ml, p <0.0001). NT-proBNP levels also were higher in MVR patients than in controls (74.7 +/- 6.9 versus 48.5 +/- 10.5 pg/ml; p <0.0001). Although NT-proBNP levels did not correlate with left ventricular ejection fraction (LVEF) in patients with MS (r = -0.33; p >0.05), there was a positive correlation with pulmonary artery pressure (r = 0.87; p <0.001) and a negative correlation with mitral valve area (MVA) (r = -0.89; p <0.0001). However, multivariate analysis identified only MVA as an independent correlate of NT-proBNP (beta = -0.47; p = 0.02). CONCLUSION: In patients with rheumatic MS, NT-proBNP levels correlated positively with MS severity. Moreover, NT-proBNP levels increased significantly in patients with MS, but were significantly lower in those who underwent MVR.

The association between NT-proBNP levels, functional capacity and stage in patients with heart failure.

OBJECTIVE: Amino-terminal probrain natriuretic peptide (NT-proBNP), a biologically inactive derivative of BNP, is clinically more useful owing to its longer half-life, higher plasma concentrations, lesser variation among individuals, and higher in vitro stability. In this regard, NT-proBNP may be a better indicator of the severity of ventricular dysfunction. In this study, the association of NT-proBNP levels with functional capacity and stage of heart failure was explored in patients with CHF. Also, we particularly focused on the presence and significance of neurohormonal activation in the group of patients classified as stage-A according to ACC/AHA guidelines. METHODS AND RESULTS: 64 patients with CHF (31 men, 33 women; mean age 58.26 +/- 10.59 y) and 36 healthy controls (24 men, 12 women; mean age 57.47 +/- 10.83) were included in this study. The New York Heart Association (NYHA) classification system (I, II, III, IV) was used to define the functional capacity; and the stage of the heart failure was based on the ACC/AHA guidelines (A, B, C, D). Healthy female participants had higher NT-proBNP levels compared to their male counterparts (p < 0.001). Left ventricular ejection fraction (LVEF) did not correlate significantly with functional capacity and stage of the disease. CHF patients had higher NT-proBNP compared to controls (p < 0.001). There was a positive correlation between NT-proBNP and functional capacity in patients, and NT-proBNP increased significantly with each increasing class of the disease. Similarly, a positive correlation existed between the stage of heart failure and NT-proBNP levels, which increased significantly with increasing stages of the disease. Patients with NYHA I and stage A disease had higher NT-proBNP levels compared to controls (p = 0.04). CONCLUSIONS: The severity of CHF can be objectively assessed by measuring the circulating levels of NT-proBNP. Even in NYHA I and stage A disease, NT-proBNP levels are higher compared to controls (p = 0.04). NT-proBNP can provide objective information regarding the severity of the disease and also aid in treatment decisions in patients with CHF.

Electrocardiologic and echocardiographic features of patients exposed to scorpion bite.

The purpose of this study is to examine clinical progress and hemodynamic and electrocardiologic features (QT depression and heart rate variability [HRV]) of patients exposed to a scorpion bite. Seventeen patients bitten by scorpions, and, as a control group, 15 healthy subjects were included in the study. Standard electrocardiograph (ECG) records, 24-hour Holter-ECG, and Doppler echocardiographic examinations were performed. Holter ECG indicated sinus tachycardia, sinus bradycardia, paroxysmal supraventricular tachycardia, atrial fibrillation, first-degree and second-degree atrioventricular block not requiring treatment, early atrial beats, and early ventricular beats in the patients at frequencies of 82%, 12%, 35%, 12%, 8%, 70%, and 47%, respectively. HRV parameters that reflected parasympathetic activity (SD 35+/-13-43+/-16, RMS-SD: 20+/-9-30+/-12, high frequency: 7.8+/-2-4.3+/-3, p<0.05) were significantly lower (p<0.05). Low frequency, which especially showed sympathetic activity (LF: 11+/-13-11+/-23, p>0.05), was similar in both groups. In addition, the LF/HF ratio, which reflected sympathovagal balance, was significantly increased in the patient group (1.5+/-1-3.0+/-2, p=0.005). Corrected QT and QT dispersion values were not significantly different with respect to the control (p>0.05). In the patient group compared to the control, a significant decrease was determined in the proportion of mitral E velocity to mitral A velocity (mEv/mAv), diastolic filling period (DFP), and left ventricular ejection fraction (LVEF), while a significant increase was noticed in pulmonary artery pressure (PAP) (mEv/mAv: 0.9+/-0.4-1.7+/-0.6, DFP: 362+/-8.5-425+/-89, LVEF: 53.1+/-6.7-68.6+/-5.8, PAP: 38.1+/-13-27.2+/-6, p<0.05). Scorpion bite leads to serious cardiovascular disorders, associated with decreased HRV, decreased systolic and diastolic functions, increased arrhythmic events, and hemodynamic disturbance with sympathetic and parasympathetic balance disturbance.

Hepatopulmonary syndrome and right ventricular diastolic functions: an echocardiographic examination.

AIM: Liver functions are affected in the course of cardiac diseases, and similarly, liver diseases affect cardiac functions. Many studies in the literature have shown that left ventricular systolic and/or diastolic dysfunction may develop during chronic liver disease. However, there are limited studies investigating right ventricular functions during chronic liver diseases. METHODS: A total of 84 patients who had no systolic and/or diastolic dysfunction in the left ventricle (LV) were evaluated; 46 patients with liver cirrhosis; 10 (21.74%) cirrhotic patients with hepatopulmonary syndrome (HPS) (group 1), 36 (78.26) cirrhotic patients without HPS (group 2), and 38 healthy individuals were treated as control. RESULTS: Right ventricular diastolic dysfunction was determined in all patients of group 1 (100%), 26 of group 2 (72.22 %), and 4 of the controls (10.52%) (P<0.05). Tricuspid deceleration time (dt) was significantly different between the groups (P<0.05). In addition, right atrium (RA) diameters, right ventricle (RV) diameters, and RV wall thickness were significantly different between the groups (P<0.05). Pulmonary artery pressure (P<0.05) and pulmonary vascular resistance (P<0.05) were also seen to be higher in group 1 than those in group 2 and control group. CONCLUSIONS: Right ventricular diastolic dysfunction rate is high in chronic liver diseases. In the presence of HPS, right ventricular diastolic dysfunction is more remarkable in patients than those without HPS. Right ventricular diastolic dysfunction may result in dilatation and hypertrophy in the right heart.

Recurrent multiple cardiac hydatidosis.

Cardiac hydatid cyst is an uncommon disease. We report on a woman admitted to our clinic with chest pain and palpitations. The ECG showed anterior ischemia, and coronary anatomy was normal. The diagnosis was: multiple cardiac hydatid cysts, for which she had undergone surgery 4 years earlier for a 5 x 5 hydatid cyst and treated with albendazole. Despite this, there was a recurrence of multiple cysts. Recurrence of intracavitary hydatid cyst is rare, and surgical treatment of multiple, small cysts remains controversial.

Insulin response to oral glucose loading and coronary artery disease in nondiabetics.

Hyperinsulinemia is related to coronary artery disease (CAD), as an indication of decreased insulin sensitivity. Although there are many studies showing the relation between fasting insulin levels and insulin resistance, there are fewer studies on postprandial insulin levels. The aim of the present study was to investigate the relationship between postprandial insulin levels and CAD and its extent in our patients. For this purpose, oral glucose tolerance testing was performed in 222 patients with no known diabetes and who were scheduled to undergo diagnostic coronary angiography. The patients were first separated into two groups, one group (group I) having an insulin response within reference values to oral glucose loading, and the other group (group II) with a higher than normal insulin response. The presence and extent of CAD in the two groups were compared. While 65% of the patients in group 1 had CAD, this rate increased to 79% in group 2 patients (P = 0.02). The mean vessel scores were 0.92 +/- 0.78 in group 1 and 1.67 +/- 0.99 (P < 0.0001) in group 2 patients. The stenosis scores were 2.192 +/- 2.077 in group 1 and 5.588 +/- 3.519 (P < 0.001) in group 2, while the extent scores were 1.230 +/- 1.292 in group 1 and 2.729 +/- 1.847 in group 2 (P < 0.0001). The differences between the two groups were significant. Postprandial insulin values were positively correlated with CAD (P = 0.001, r = 0.214), vessel scores (P < 0.0001, r = 0.326), stenosis scores (P < 0.0001, r = 0.261), and extent scores (P < 0.0001, r = 0.419). Logistic regression analysis revealed hyperinsulinemia increased CAD independent from the other risk factors (OR = 5.742, CI 95%: 1.809-18.227, P = 0.003).

Sociodemographic, clinical, and laboratory features of cases of organic phosphorus intoxication who attended the Emergency Department in the Southeast Anatolian Region of Turkey.

In this study, sociodemographic, laboratory, and clinical features of cases of organic phosphorus (OP) intoxication in the Southeast Anatolian region of Turkey were investigated. Patients with OP intoxication admitted to the Emergency Service of Dicle University Hospital in Diyarbakyir City between May and August 1998 were evaluated. This prospective cohort study included five male (M) and 19 female (F) consecutive patients. Five cases were accidental intoxication; however, 19 cases were suicide attempts. Mean age of cases was 24+/-11 years; 54.2% of them were under the age of 20 years and 83.3% of them were under the age of 30 years. The M/F ratio was 1.0/3.8. The cases of suicidal purposeful intoxications were mostly determined in singles (58.3%, P<0.05). Most of the cases had a primary education level (16, 66.7%) and a lower socioeconomic status (14, 58.3%); 79.2% of cases admitted to our emergency service received atropine in primary health care centers. In emergency service, pralidoxime (PAM) was administered to only 29.2% of cases. According to ECG examination, tachycardia (14, 58.3%), ST changes (13, 54.2%), and T changes (3, 12.5%) were mostly seen; bradycardia and serious ventricular arrhythmias were not seen in any case. Patients who received atropine plus PAM had higher rates of arrhythmias, but this was not statistically significant (P>0.05). The most observed biochemical features of cases were leukocytosis (21 cases), hypokalemia (18 cases), and hyponatremia (4 cases). Other biochemical features were not evidently altered. In present cases, the most frequently seen symptoms and findings were vomiting (18, 75%), feeling faint (17, 70.8%), and tachycardia and dozing off (14, 58.3%). Serious ventricular arrhythmias were not observed, and in our region, OP intoxication especially affected young unmarried females, and most of them resulted from a suicidal purpose.