Right ventricular free-wall longitudinal speckle tracking strain in patients with pulmonary arterial hypertension under specific treatment.

BACKGROUND: Right ventricular (RV) dysfunction is a major determinant of outcomes in patients with pulmonary arterial hypertension (PAH), although the optimal measure of RV function is poorly defined. We evaluated the utility of RV free-wall speckle tracking strain as an assessment tool for RV function in patients with PAH who are already under specific treatment compared with conventional echocardiographic parameters and investigated the relationship of RV free-wall strain with clinical hemodynamic parameters of RV performance. METHODS: Right ventricular free-wall strain was evaluated in 92 patients (Group-1 and Group-4 pulmonary hypertension) who were on PAH-specific treatment for at least 3 months. Right atrial (RA) area, RV FAC, TAPSE, tricuspid S, functional class, 6-minute walking distance, and NT-proBNP were studied. The mean duration of follow-up was 222±133 days. RESULTS: All patients were under PAH-specific treatment, and mean RV free-wall strain was -13.16±6.3%. RV free-wall strain correlated well with functional class (r=.312, P=.01), NT-proBNP (r=.423, P=.0001), RA area (r=.427, P=.0001), FAC (r=-.637, P=.0001), TAPSE (r=-.524, P=.0001), tricuspid S (r=-.450, P=.0001), 6-minute walking distance (r=-.333, P=.002). RV free-wall strain significantly correlated with all follow-up adverse events, death, and clinical right heart failure (RHF) (P=.04, P=.03, P=.02, respectively). According to the receiver operator characteristic analysis, the cutoff value for RV free-wall strain for the development of clinical RHF was -12.5% (sensitivity: 71%, specificity: 67%) and for all cardiovascular adverse events (death included) was -12.5% (sensitivity: 54%, specificity: 64%). CONCLUSION: Assessment of RV free-wall strain is a feasible, easy-to-perform method and may be used as a predictor of RHF, clinical deterioration, and mortality in patients already under PAH-specific treatment.

Diagnosis and Treatment Patterns of Chronic Thromboembolic Pulmonary Hypertension in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia: A Registry Study.

BACKGROUND: Patients with chronic thromboembolic pulmonary hypertension (CTEPH) in countries with limited resources have, to date, been poorly represented in registries. OBJECTIVE: This work assesses the epidemiology, diagnosis, hemodynamic and functional parameters, and treatment of CTEPH in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia. METHODS: A prospective, cohort, phase IV, observational registry with 3-year follow-up (n = 212) in patients aged ≥ 18 years diagnosed with CTEPH was created. Clinical, hemodynamic, and functional parameters were obtained at an initial visit, follow-up visits, and a final visit at the end of 3 years' observation or end of follow-up. Data were recorded on electronic case report forms. Parameters evaluated included 6-minute walking distance (6MWD), use of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), pulmonary hypertension (PH)-targeted therapy, and survival. All statistical analyses were exploratory and descriptive, and were performed in the overall population. RESULTS: The most common symptoms were typical of those expected for CTEPH. Almost 90% of patients underwent right heart catheterization at diagnosis or initial study visit. In total, 66 patients (31%) underwent PEA before the initial visit; 95 patients (45%) were considered operable, 115 (54%) were inoperable, and two (1%) had no operability data. Only 26 patients (12%) had been assessed for BPA at their initial visit. PH-targeted therapy was documented at diagnosis for 77 patients (36%), most commonly a phosphodiesterase type 5 inhibitor (23%). Use of PH-targeted therapy increased to 142 patients (67%) at the initial visit, remaining similar after 3 years. Use of riociguat increased from 6% of patients at diagnosis to 38% at 3 years. Between baseline and end of observation, results for patients with paired data showed an increase in 6MWD. Survival at the end of observation was 88%. CONCLUSIONS: These data highlight the current diagnosis and management of CTEPH in the participating countries. They show that early CTEPH diagnosis remains challenging, and use of off-label PH-targeted therapy is common. CLINICALTRIALS: gov: NCT02637050; registered December 2015.

Pulmonary arterial hypertension and pregnancy.

This is the case report of a pregnant woman who refused pregnancy termination when diagnosed with pulmonary arterial hypertension (PAH) functional class 2-3 at the 24th week of gestation and of her newborn. A pregnant woman with PAH functional class 2-3 was treated with inhaled prostacyclin analog (iloprost), oral sildenafil, oxygen, and low molecular weight heparin. She delivered at 32nd week by Cesarean section. The infant required oxygen up to 36th week postconceptional age and had a short steroid treatment. The mother needed close cardiovascular monitorization, intensive oxygen and pulmonary vasodilator therapy for 2 months and was discharged with oxygen and oral iloprost treatment. A multidisciplinary approach together with pulmonary vasodilator therapy may be succesful in such a high-risk pregnant woman.

Long-Term Natural Course of Patients with Pulmonary Artery Pressures in the Range of 21-24 mmHg: Insights from a Single-Center Study.

OBJECTIVE: Slightly elevated mean pulmonary artery pressure (mPAP) was previously termed as ''borderline pulmonary hypertension (PH)''. We examined the long-term prognosis of patients with mPAP values between 21 and 24 mmHg, who were referred with the suspicion of pulmonary hypertension. METHODS: Our retrospective study included patients with moderate-to-high echocardiographic risk who underwent right heart catheterization (RHC) between 2008 and 2021 and were followed for at least 1 year. Patients with mPAP <21 mmHg and mPAP 21-24 mmHg were compared. Demographic and clinical characteristics and prognoses of the groups were compared. All-cause mortality over a mean follow-up of 5 years (min 1-max 13 years) was evaluated. RESULTS: A total of 140 patients (mean age 53.1 ± 14.8 years, female 74.5%) with mPAP values <25 mmHg measured of the 395 diagnostic RHCs. Mean follow-up was 4.92 ± 3.13 years. NT-pro-BNP and 6-min walking distance were better in patients with mPAP <21 mmHg. Echocardiographic findings suggestive of PH were more common in mPAP 21-24 mmHg group (P < 0.05). Both the pulmonary artery wedge pressure and cardiac index values were significantly deteriorated in individuals with mPAP 21-24 mmHg (P = 0.001). All-cause mortality tended to be higher in the borderline PH group but did not reach to statistical significance. CONCLUSION: Our single-center observational study revealed that the individuals with an mPAP of 21-24 mmHg tended to have a worser prognosis than those with mPAP of <21 mmHg for up to 13-year follow-up.

Could Heart Rate Variability Serve as a Prognostic Factor in Patients with Pulmonary Hypertension? A Single-center Pilot Study.

OBJECTIVE: Heart rate variability (HRV), which is defined as cyclic changes in sinus rate with time, is used as a measure of cardiac autonomic tone. Our aim was to determine the impact of HRV on short-term prognosis in pulmonary hypertension (PH). METHODS: We enrolled 64 PH patients and 69 healthy subjects (control group). Patients were evaluated by Holter-ECG, echocardiography, and laboratory tests. 24-h Holter-ECG monitoring was used for HRV. The development of adverse events (right heart failure, hospitalization, syncope, and death) during the 6-month follow-up was evaluated in PH group. RESULTS: PH group (39 ± 16 years, 37.5% males) comprised of 16 patients with idiopathic pulmonary arterial hypertension (PAH) (25%), 36 patients with PAH associated with congenital heart disease (56.3%), 3 PAH associated with connective tissue disease (4.7%), 1 with portopulmonary (1.6%), and 8 chronic thromboembolic PH (12.5%). The time-dependent (standard deviation of all NN intervals for a selected time period [SDNN], standard deviation of the 5-min mean R-R intervals tabulated over an entire day [SDANN], SDNN Index, and Triangular Index) and frequency-dependent HRV indices (low frequency, high-frequency power, and total power,) were significantly reduced in those with PH. Functional class was negatively associated with SDNN, SDANN, SDNN Index, and Triangular Index. Adverse events developed in 25% of the patients during the 6-month follow-up period (200 ± 92 days) (7 patients had right-heart failure, 5 syncope, 12 patients were hospitalized, and 9 had died). All the time and frequency-dependent indices significantly associated with adverse events. Mortality correlated with SDNN (rS = -0.354, P = 0.005), SDANN (rS = -0.368, P = 0.004), SDNN Index (rS = -0.257, P = 0.045), Triangular Index (rS = -0.310, P = 0.014), and VLF (rS = -0.265, P = 0.039). CONCLUSION: HRV is significantly depressed in patients with PH and is associated with the clinical status. HRV indices might predict clinical deterioration, adverse events, and mortality for 6 months. Non-invasive assessment of HRV through Holter-ECG may be a valuable and practical tool in risk stratification of patients with PH for short-term outcomes.

Could Impedance Cardiography be a Non-Invasive Alternative Method of Measuring Cardiac Output in Patients with Pulmonary Hypertension?

BACKGROUND: Pulmonary hypertension guidelines recommend invasive right heart catheterization for diagnosis and clinical follow-up. Our aim was to compare non-invasive impedance cardiography with invasive techniques for cardiac index measurements and mortality prediction in patients with pulmonary hypertension. METHODS: Between 2008 and 2018, 284 right heart catheterizations were performed for the diagnosis of pulmonary hypertension in 215 patients with mean pulmonary artery pressure >25 mm Hg, and at least 2 methods used for cardiac output measurement were included in the study retrospectively. Patients were evaluated with Pearson's correlation in 3 groups: estimated Fick (eFick) method and thermodilution (group 1), eFick method and impedance cardiography (group 2), and thermodilution and impedance cardiography (group 3). We also compared the predictive power of cardiac index measured by different methods for 1-year overall mortality and hospitalizations. RESULTS: There were strong and moderate positive correlations in groups 1 and 3, respectively (r = 0.634, P <.001, r = 0.534, P =.001), and the weakest correlation was in group 2 (r = 0.390, P =.001). The mean difference (bias) between eFick method versus impedance cardiography, impedance cardiography vs. thermodilution, and eFick method vs. thermodilution was 0.6 mL/min, 0.47 mL/min, and -0.2 mL/min respectively, but limits of agreement were wide. In both groups, cardiac index <2.5 L/min/m2 as measured by thermodilution significantly predicted 1-year mortality. Also, impedance cardiography was better than eFick method in predicting mortality (P =.02). CONCLUSIONS: Our single-center real-life data showed that for cardiac output and cardiac index measurements, impedance cardiography provides a moderate correlation with thermodilution and is fair with eFick method methods. Moreover, thermodilution appeared superior to both eFick method and impedance cardiography, while impedance cardiography was even better than eFick method in predicting 1-year adverse events, including total mortality and hospitalization, in patients with pulmonary hypertension.

Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: the incidence, clinical and electrophysiologic characteristics, and the predictors.

INTRODUCTION: Idiopathic ventricular arrhythmias in the form of monomorphic premature ventricular contractions (PVC) and/or ventricular tachycardia (VT) can cause tachycardia-induced cardiomyopathy (TICMP). The aim of this study was to determine the incidence, clinical and electrophysiologic characteristics, and the predictors of TICMP in patients with idiopathic ventricular arrhythmias. METHODS: Study population consisted of 249 consecutive patients (148 F/101 M, 45 ± 20 y/o) with frequent PVCs and/or VT. All patients underwent transthoracic echocardiography and 24-hour Holter monitoring. TICMP was defined as left ventricular ejection fraction (LVEF) of ≤50% in the absence of any detectable underlying heart disease and improvement of LVEF ≥15% following effective treatment of index ventricular arrhythmia. RESULTS: Seventeen (6.8%) patients had TICMP. Patients with TICMP compared to patients with preserved LVEF were more likely to be male (65% vs 39%, P = 0.043) and asymptomatic (29% vs 9%, P = 0.018), and were more likely to have higher PVC burden (29.4 ± 9.2 vs 8.1 ± 7.4, P < 0.001), persistence of PVCs throughout the day (65% vs 22%, P = 0.001), and repetitive monomorphic VT (24% vs 0.9%, P < 0.001). PVC burden of 16% by ROC curve analysis best separated the patients with TICMP compared to patients with preserved LVEF (sensitivity 100%, specificity 87%, area under curve 0.96). CONCLUSIONS: TICMP was relatively common (∼1 in every 15 patients) in our study population. The predictors of TICMP were male gender, absence of symptoms, PVC burden of ≥16%, persistence of PVCs throughout the day, and the presence of repetitive monomorphic VT.

Takotsubo syndrome early after treatment due to non cardiotoxic chemotherapy agents.

Takotsubo syndrome (TTS), acute stress-induced cardiomyopathy, is known to have a dramatic clinical presentation mimicking acute myocardial infarction. Recently developed chemotherapeutic drugs have resulted in improvements in morbidity and mortality in many forms of cancer. However, some chemotherapeutic drugs are cardiotoxic and may cause heart failure. Gemcitabine and vinorelbine are commonly used drugs for various solid organ neoplasms. While neither of these chemotherapeutic drugs has been directly associated with cardiotoxicity, there are a few case reports in the literature related to gemcitabine treatment- induced cardiomyopathy. This case report describes a case of TTS developing within hours of gemcitabine and vinorelbine chemotherapy.

Serum Endocan Levels Predict Angiographic No-Reflow Phenomenon in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Coronary Intervention.

No-reflow phenomenon (NRP) is an important problem in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). Endocan is synthesized and secreted by activated vascular endothelium, and it has been shown to be related to endothelial dysfunction and inflammation. We aimed to evaluate the relationship between endocan levels and NRP. Consecutive patients (n = 137) with STEMI who had undergone coronary angiography and pPCI were enrolled into the study. The clinical characteristics of the patients were obtained and endocan levels were measured. Endocan levels were significantly higher in the NRP (+) group compared with the NRP (-) group (P < .001). In multivariate analysis, endocan (P < .001, OR = 2.39, 95% CI = 1.37-4.15) was found to be an independent predictor of NRP. An endocan value of >2.7 ng/mL has 89.6% sensitivity and 74.2% specificity for the prediction of the NRP (area under the curve: 0.832, P < .001). The present study demonstrated that the endocan level is an independent predictor of the NRP in patients with STEMI who underwent pPCI. Endocan levels may be helpful in detecting patients with a higher risk of insufficient myocardial perfusion and worse clinical outcome.

Hepatic and splenic sonographic and sonoelastographic findings in pulmonary arterial hypertension.

PURPOSE: The aim of this study was to evaluate the associations of sonographic and sonoelastographic parameters with clinical cardiac parameters, as well as to assess their value in predicting survival in patients with pulmonary arterial hypertension (PAH). METHODS: Thirty-six patients with PAH and normal liver function were prospectively enrolled in this prospective study along with 26 healthy controls, all of whom underwent ultrasound and point shear wave elastography examinations. Additionally, the portal vein pulsatility index (PVPI), inferior vena cava collapsibility index, and clinical cardiac variables were obtained in PAH patients. The values of hepatic (LVs) and splenic shear wave velocity (SVs) were compared between PAH patients and controls. The relationships between all sonographic and clinical parameters in the PAH patients were analyzed. Furthermore, their prognostic value in predicting survival was investigated. RESULTS: LVs values in PAH patients (median, 1.62 m/s) were significantly higher than in controls (median, 0.99 m/s), while no significant difference was observed in SVs values. Patients with higher grades of tricuspid regurgitation (TR) had significantly different values of PVPI (P=0.010) and sonoelastographic parameters (P<0.001 for LVs and P=0.004 for SVs) compared to those with less severe TR. Tricuspid annular plane systolic excursion values were the only investigated parameter found to be associated with survival (hazard ratio, 0.814; 95% confidence interval, 0.694 to 0.954; P=0.011). CONCLUSION: Our results demonstrated a direct association between cardiac congestion (i.e., the severity of TR) and liver stiffness, which should be kept in mind during the assessment of fibrosis in patients with PAH.

Transcriptional profiling of septal wall of the right ventricular outflow tract in patients with idiopathic ventricular arrhythmias.

BACKGROUND: Frequent, monomorphic premature ventricular contractions (PVC) and/or ventricular tachycardia (VT) in patients with structurally normal heart usually arise from the right ventricular outflow tract (RVOT). The underlying arrhythmogenic substrate for the genesis of RVOT tachycardias is largely unknown. The aim of this study was to investigate the genome-wide transcriptional profiling of the septal wall of the RVOT in patients with RVOT tachycardia and control subjects. METHODS: Transcriptional profiling with Affymetrix 3' IVT microarray analysis (Affymetrix, Santa Clara, CA, USA) was performed on the endomyocardial biopsy samples obtained from the septal wall of the RVOT from three unrelated patients with RVOT tachycardia and three control subjects. All study subjects had normal right and left ventricular size and function. Microarray results were validated by real time polymerase chain reaction (PCR). RESULTS: There were 32 statistically significant up-regulated and 60 down-regulated genes in five biological networks in patient population compared with control subjects. Among those genes, there were eight down-regulated [ATP1A2, CACNA1C, Protein Phosphatase 2, Regulatory Subunit B, Gamma Isoform[PPP2R2C], PLCD3, GNAO1, Solute Carrier Family 6 (Transporter, Norepinephrine), Member 2(SLC6A2), CAMK2B, PIK3R2] and two up-regulated (CAMKK2 and ITPR3) genes related to myocardial intracellular calcium regulation. In addition, there were five down-regulated [T-box 3(TBX3), Bone Morphogenetic Protein 2(BMP2), Bone Morphogenetic Protein Receptor, Type IB(BMPR1B), MYH6, Ankyrin Repeat Domain 23 and 39(ANKRD23-39)] and one up-regulated gene (RGS1) related to cardiovascular functions. CONCLUSION: The expression of genes responsible for the regulation of myocardial intracellular calcium and the development of RVOT are significantly down-regulated in the septal wall of the RVOT in patients with RVOT tachycardia compared with control subjects.

[Evaluation of hospitalization period and five-year follow-up of patients admitted with acute coronary syndrome following coronary artery bypass graft surgery]. / Koroner arter baypas ameliyatindan sonra akut koroner sendromla basvuran hastalarda hastaneiçi dönem ve bes yillik izlem.

OBJECTIVES: We evaluated patients admitted with the diagnosis of acute coronary syndrome (ACS) after coronary artery bypass graft (CABG) surgery. STUDY DESIGN: This retrospective study included 72 consecutive CABG patients (10 women, 62 men; mean age 63±9 years; range 45 to 83 years). Acute coronary syndrome was defined as the presence of unstable angina or myocardial infarction (MI) with or without ST elevation. Time from CABG surgery to admission with ACS was defined as bypass age. Following discharge, information was derived by phone calls from the patients or relatives on cardiovascular events within a five-year period. RESULTS: On admission, 14 patients (19.4%) had non-ST elevation MI, nine patients (12.5%) had ST elevation MI, and 49 patients (68.1%) had unstable angina. The mean bypass age was 5.6±3.5 years. Of the study group, 38.9% were obese, 25% were diabetic, 54.2% were hypertensive, 44.4% were hyperlipidemic, and 26.4% were current smokers. Medications before admission included aspirin (81.9%), statin (25%), beta-blocker (27.8%), ACE inhibitor or angiotensin receptor blocker (27.8%), and calcium channel antagonist (36.1%). Increased LDL cholesterol (≥100 mg/dl) and decreased HDL cholesterol (≤50 mg/dl) levels were present in 55.6% and 80.6%, respectively. Mortality occurred in 15 patients, four during hospitalization, and 11 after discharge. The overall mortality rate was 21.4%. In correlation analysis, mortality was positively correlated with age (r=0.34, p=0.005), bypass age (r=0.37, p=0.001), CRP level (r=0.31, p=0.033) and negatively correlated with beta-blocker use (r=-0.25, p=0.041) and ejection fraction (r=-0.37, p=0.016). CONCLUSION: Our results show that, following CABG surgery, special consideration should be given to risk factor management and use of agents with proven effects against cardiovascular mortality such as statins, beta-blockers, and ACE inhibitors.

Assessment of right ventricular function in patients with pulmonary arterial hypertension-congenital heart disease and repaired and unrepaired defects: Correlation among speckle tracking, conventional echocardiography, and clinical parameters.

OBJECTIVE: The purpose of this study is to compare the analysis of right ventricular (RV) free wall strain via 2D speckle tracking echocardiography with conventional echocardiography and clinical parameters in patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) receiving specific treatment. This study also aims to describe the differences between patients with repaired and unrepaired defects. METHODS: This prospective study included 44 adult patients with PAH-CHD who were receiving PAH-specific treatment in a single center. This study excluded patients with complex congenital heart disease. The authors studied the conventional echocardiographic parameters, such as RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), right atrial (RA) area, Tricuspid S', and hemodynamic parameters, such as functional class, 6-minute walking distance (6MWD), and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. RESULTS: The mean age of participants was 33.8±11.6 years, and 65.9% of participants were female. The mean RV free wall strain was -14.8±4.7%. Majority of the patients belonged to WHO functional class 2 (61.4%) with a mean NT-proBNP level of 619.2±778.4 and mean 6MWD of 400.2±86.9 meters. During the follow-up of 30.8±9.0 months, 6 patients (13.6%) developed clinical right heart failure, whereas 9 (20.5%) of them died. There was a positive and significant correlation between RV free wall strain and WHO functional class (r=0.320, p=0.03), whereas there was a negative correlation between RV free wall strain and FAC (r=-0.392, p=0.01), TAPSE (r=-0.577, p=0.0001), and Tricuspid S' (r=-0.489, p=0.001). There was no significant correlation of RV free wall strain with either RA area or 6MWD. Patients with repaired congenital heart defects had worse RV functional parameters and RV free wall strain than patients with unrepaired defects. CONCLUSION: The assessment of RV free wall strain via 2D speckle tracking echocardiography is a feasible method and correlates well with conventional echocardiography and clinical parameters in patients with PAH-CHD receiving specific treatment. (Anatol J Cardiol 2020; 23: 277-87).

Termination of idiopathic sustained monomorphic ventricular tachycardia by intravenous adenosine in a pregnant woman.

A 34-year-old pregnant woman presented to the emergency department with the complaints of palpitations at 32 weeks gestation. The diagnosis of right ventricular outflow tract ventricular tachycardia (VT) was made. Intravenous 5 mg of metoprolol and 25 mg of diltiazem did not terminate the VT. Ten milligrams of adenosine were administered. Within 10 s of adenosine administration, sustained VT converted to repetitive monomorphic VT and within 30 s to normal sinus rhythm. The mother and the foetus tolerated the medications well. Non-stress test for the assessment of the foetal well-being was normal.

[Atorvastatin in primary prevention]. / Birincil korunmada atorvastatin.

Statins are one of the most widely used drugs in medical treatment and have been shown to prevent cardiovascular disease or reduce risk in a large number of studies. Although there is a general class effect, there are differences with regard to structure and efficacy between these agents. Among these agents, atorvastatin is a potent statin whose efficacy has been demonstrated in many clinical trials. Despite the presence of numerous clinical studies, data on atorvastatin related to primary prevention are limited compared to secondary prevention. In this article, clinical results of primary prevention trials with atorvastatin and data on its cost-effectiveness are reviewed. It is concluded that atorvastatin has a role in primary prevention and the cost of its use seems to be lower than commonly accepted cost-effectiveness thresholds.

[Current approach to the treatment of pulmonary arterial hypertension and our experience in the Cardiology Department of Medicine Faculty of Ege University]. / Pulmoner arteryel hipertansiyon tedavisine güncel yaklasim ve Ege Universitesi Tip Fakültesi Kardiyoloji Klinigi'nin deneyimi.

Pulmonary arterial hypertension is a progressive disease marked by increased pulmonary artery resistance leading to right heart failure and has very high mortality. Survival rates have somewhat improved in recent years due to the development of new drugs and early diagnosis. This review aims to summarize the current therapeutic approach to pulmonary arterial hypertension and share our experience at our center.

The impact of diabetes and coronary artery disease on mortality and morbidity in patients with hypertension.

OBJECTIVES: We evaluated the impact of diabetes mellitus (DM) and/or coronary artery disease (CAD) on cardiovascular endpoints in a cohort of hypertensive patients. STUDY DESIGN: The Vascular Risk Study is a cross-sectional, multicenter, observational study conducted among 5,600 patients from various regions of Turkey. This analysis included 2,664 patients (1,643 women, 1,021 men; mean age 65.3 years; range 55-99 years) whose follow-up data were adequate among a population of 4,506 hypertensive subjects. Cardiovascular primary and secondary endpoints at the end of a five-year follow-up were assessed in patients who had hypertension alone, and in those having DM and/or CAD. Information on the cause of death was obtained from the relatives of the patients by follow-up phone calls. RESULTS: There were 1,171 patients (44%) with isolated hypertension, 631 (23.7%) with DM, 530 (19.9%) with CAD, and 332 (12.5%) with both DM and CAD. The presence of either DM or CAD was associated with significant increases in the incidences of all endpoints. The occurrences of primary and secondary endpoints, cardiovascular death, and all death were similar in hypertensive patients who had DM without CAD and in patients who had CAD without DM. In survival analysis, the incidence of cardiovascular death was lowest (5.7%) in hypertensive patients without DM and CAD, and highest (18.4%) in hypertensive patients with DM and CAD. The cumulative survival rates were similar in hypertensive patients with either DM or CAD alone (p>0.05). CONCLUSION: This study demonstrated that the level of cardiovascular risk associated with DM was equal to the risk associated with CAD in hypertensive patients and that the coexistence of DM and CAD in these patients increases the risk geometrically.

Effects of cardiopulmonary rehabilitation on pulmonary arterial hypertension: A prospective, randomized study.

OBJECTIVES: This study aims to investigate the effects of cardiopulmonary rehabilitation (CPR) on cardiopulmonary function, quality of life, depression, and hemodynamic parameters in patients with pulmonary arterial hypertension (PAH) and to compare the efficacy of hospital- and home-based exercise programs. PATIENTS AND METHODS: Between December 2014 to May 2016, a total of 30 patients with PAH were included in the study. The patients were randomly assigned to either a hospital-based (n=15) or home-based exercise program (n=15). The hospital group was assigned to a cardiac rehabilitation (three days/week, 1 hour/week 50 to 70% maximal oxygen uptake [PvO2]) program for eight weeks. The home-based exercise group received home exercises alone. Before and after eight weeks of rehabilitation, all patients were evaluated for their functional status (PvO2), pulmonary function including forced expiratory volume in one sec (FEV1), mL, forced vital capacity (FVC), mL and FEV1/FVC%, quality of life using Short Form-36 (SF-36), depression severity using Beck Depression Inventory, and hemodynamic parameters including left ventricular ejection fraction, right ventricular ejection fraction, left ventricular end-systolic diameter, left ventricular end-diastolic diameter, and systolic pulmonary arterial pressure. RESULTS: Of the patients, 12 completed the study in each group. There was no statistically significant difference in the functional status, quality of life, depression severity, and hemodynamic parameters after the rehabilitation compared baseline between the groups. CONCLUSION: Based on our study results, short-term CPR seems not to be beneficial in patients with PAH. We recommend long-term rehabilitation programs to achieve more benefits from aerobic exercise training in this patient population.

Increased myocardial collagen turnover in patients with progressive cardiac conduction disease.

BACKGROUND: Histopathologically, progressive cardiac conduction disease (PCCD) is characterized by progressive fibrosis and sclerodegenerative changes in the proximal and distal conduction system of the heart. Therefore, we sought to determine the serum levels of myocardial collagen turnover markers, extracellular matrix components, transforming growth factor beta(1) (TGFbeta(1)), and bone morphogenic protein-7 (BMP-7) in this population. METHODS: Study population included 20 patients (6 M/14 F, mean age 76 +/- 8 years) with acquired, permanent 2:1, or complete atrioventricular block and compared with age- and sex-matched, asymptomatic, healthy control subjects (n = 18, 6 M/12 F, mean age 75 +/- 7 years). Serum myocardial collagen turnover markers:matrix metalloproteinases (MMP-1, 2, 9), tissue inhibitor of matrix metalloproteinase (TIMP-1), amino-terminal propeptide of procollagen type I (PINP) and type III (PIIINP), carboxy-terminal telopeptide of collagen type I (CITP), and carboxy-terminal propeptide of procollagen type I (PICP), serum extracellular matrix components (laminin and fibronectin), TGFbeta(1), and BMP-7 levels were measured in both groups. RESULTS: Serum PICP (849 +/- 396 vs 631 +/- 294 ng/mL, P = 0.04), PIIINP (3.7 +/- 1.3 vs 3 +/- 1 mug/L, P = 0.03), CITP (0.68 +/- 0.35 vs 0.48 +/- 0.25 ng/mL, P = 0.037), and plasma MMP-9 (58.8 +/- 56 vs 25.9 +/- 17.3 ng/mL, P = 0.006) levels were higher in patient population compared to control subjects. Serum MMP-1 (24.1 +/- 20.5 vs 13.6 +/- 7.5 ng/mL, P = 0.045) and MMP-2 (1310 +/- 139 vs 1186 +/- 163 ng/mL, P = 0.01) levels were higher in control subjects compared to patient population. There was no difference in serum TIMP-1, PINP, laminin, fibronectin, TGFbeta(1), and BMP-7 levels between two groups. CONCLUSION: Our findings demonstrate the presence of increased myocardial collagen turnover and active fibrotic process in patients with PCCD compared to control subjects.

Is there a gender gap in secondary prevention of coronary artery disease in Turkey?

OBJECTIVE: It has been reported that women receive fewer preventive recommendations regarding pharmacological treatment, lifestyle modifications, and cardiac rehabilitation compared with men who have a similar risk profile. This study was an investigation of the impact of gender on cardiovascular risk profile and secondary prevention measures for coronary artery disease (CAD) in the Turkish population. METHODS: Statistical analyses were based on the European Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE)-IV cross-sectional survey data obtained from 17 centers in Turkey. Male and female patients, aged 18 to 80 years, who were hospitalized for a first or recurrent coronary event (coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or acute myocardial ischemia) were eligible. RESULTS: A total of 88 (19.7%) females and 358 males (80.3%) were included. At the time of the index event, the females were significantly older (p=0.003) and had received less formal education (p<0.001). Non-smoking status (p<0.001) and higher levels of depression and anxiety (both p<0.001) were more common in the female patients. At the time of the interview, conducted between 6 and 36 months after the index event, central obesity (p<0.001) and obesity (p=0.004) were significantly more common in females. LDL-C, HDL-C or HbA1c levels did not differ significantly between genders. The fasting blood glucose level was significantly higher (p=0.003) and hypertension was more common in females (p=0.001). There was no significant difference in an increase in physical activity or weight loss after the index event between genders, and there was no significant difference between genders regarding continuity of antiplatelet, statin, beta blocker or ACEi/ARB II receptor blocker usage (p>0.05). CONCLUSION: Achievement of ideal body weight, fasting blood glucose and blood pressure targets was lower in women despite similar reported medication use. This highlights the importance of the implementation of lifestyle measures and adherence to medications in women.