Early changes in atrial conduction times in hypertensive patients with elevated pulse pressure.

OBJECTIVE: Pulse pressure (PP) is the difference between systolic and diastolic blood pressure, and is an independent predictor of atrial fibrillation (AF). In this study we investigated the relationship between PP and atrial conduction times. METHODS: The study included 157 patients with essential hypertension. PP of 60 mmHg or more was regarded as elevated (n=56). Atrial electromechanical delay (EMD) was assessed with tissue Doppler echocardiography and P-wave dispersion (Pd) was calculated from the electrocardiogram. RESULTS: Left atrial volume index (23.6±4.9 ml/m2 vs. 25.2±6.5 ml/m2, p=0.141), left ventricular mass index (77.3±13.5 g/m2 vs. 80.9±19.6 g/m2, p=0.180) and grade I diastolic dysfunction (42% vs. 53%, p=0.242) were similar between groups. Inter-atrial (33.6±9.2 ms vs. 41.5±11.3 ms, p<0.001), intra-left atrial (23.0±8.8 ms vs. 28.2±10.6 ms, p=0.001) and intra-right atrial (10.5±5.8 ms vs. 13.2±4.9 ms, p=0.004) EMD were found to be higher in patients with elevated PP. P-maximum (108±8 ms vs. 114±9 ms, p<0.001) and Pd (30±13 ms vs. 38±13 ms, p<0.001) were also prolonged in patients with elevated PP. Multivariate linear regression analysis revealed that PP was independently associated with inter-atrial EMD (ß=0.379, t=4.088, p<0.001). CONCLUSION: This study showed that elevated PP is associated with prolonged atrial EMD and Pd. Atrial conduction is disturbed in hypertensive patients with elevated PP before the development of significant structural remodeling.

The relationship between 24-hour ambulatory blood pressure load and neutrophil-to-lymphocyte ratio.

INTRODUCTION AND OBJECTIVE: The neutrophil-to-lymphocyte ratio (NLR) is established as a reliable marker of systemic inflammation. Low-grade inflammation has a key role in the pathogenesis and progression of hypertension (HTN). Blood pressure (BP) load, defined as the percentage of abnormally elevated BP readings, is a good marker of HTN severity. We aimed to evaluate the relationship between HTN severity and NLR using averaged ambulatory BP readings and BP load. METHODS: A total of 300 patients with untreated essential HTN were included in this cross-sectional study. Patients were divided into quartiles according to NLR values (first: <1.55; second: 1.55-1.92; third: 1.92-2.48; and fourth: >2.48). Averaged ambulatory BP values and BP load were assessed for each quartile. RESULTS: In the interquartile evaluation there were no differences between quartiles in terms of baseline demographic, clinical and echocardiographic characteristics (p>0.05). Daytime systolic BP (SBP), 24-hour diastolic BP (DBP), daytime DBP, daytime SBP load, 24-hour DBP load and daytime DBP load were found to be significantly higher in the upper two quartiles (p<0.05 for all). In correlation analysis, log NLR values were found to be positively correlated with 24-hour SBP, DBP, SBP load and DBP load (Pearson coefficients of 0.194, 0.197, 0.157 and 0.181, respectively; p<0.01 for all). In multivariate analysis, log NLR had an independent association with 24-hour SBP and DBP and 24-hour SBP and DBP load. CONCLUSION: This study showed for the first time that increased NLR is independently associated with HTN severity in untreated essential HTN patients.

A Novel Marker of Impaired Aortic Elasticity in Never Treated Hypertensive Patients: Monocyte/High-Density Lipoprotein Cholesterol Ratio.

BACKGROUND: Monocyte to high density lipoprotein cholesterol ratio (MHR) is generally understood to be a candidate marker of inflammation and oxidative stress. Therefore, we aimed to assess the association between MHR and aortic elastic properties in hypertensive patients. METHODS: A total of 114 newly-diagnosed untreated patients with hypertension and 71 healthy subjects were enrolled. Aortic stiffness index, aortic strain and aortic distensibility were measured by using echocardiography. RESULTS: Patients with hypertension had a significantly higher MHR compared to the control group (p < 0.001). Also, aortic stiffness index (p < 0.001) was significantly higher and aortic distensibility (p < 0.001) was lower in the hypertensive group. There was a positive correlation of MHR with aortic stiffness index (r = 0.294, p < 0.001) and negative correlation with aortic distensibility (r = -0.281, p < 0.001). In addition, MHR and high sensitivity C-reactive protein have a positive correlation (r = 0.30, p < 0.001). Furthermore, MHR was found to be an independent predictor of aortic distensibility and aortic stiffness index. CONCLUSIONS: In patients with newly-diagnosed untreated essential hypertension, higher MHR was significantly associated with impaired aortic elastic properties.

Sleep related bradyarrhythmic events and heart rate variability in apparently healthy individuals.

OBJECTIVE: It is thought that abnormal cardiac impulses of the autonomic nervous system during sleep are responsible for sleep-related bradyarrhythmias. Despite a proposed common etiopathogenesis and having common name of "sleep-related bradyarrhythmias," precise importance of sinoatrial or atrioventricular (AV) node involvement remains elusive. This study aimed to determine whether there is a difference in sleeprelated bradyarrhythmias from the point of view of heart rate variability (HRV). METHODS: Patients were evaluated using 24-hour Holter electrocardiogram monitor. After careful medical evaluation, apparently healthy individuals with sleep-related sinus pauses ≥2 seconds on at least 1 occasion or those in whom Mobitz type I AV block occurred were included. Frequency and time domain analyses were conducted for daytime, nighttime, and 24-hour period. RESULTS: Total of 37 patients with sinus pause(s), 40 patients with Mobitz type I AV block(s), and 40 healthy controls were included. On HRV analyses, all time and frequency domain parameters were better in sinus pause group for daytime, nighttime, and 24-hour average (p<0.05 for all). Results of heart rate-corrected HRV analyses still showed significantly better total power (TP) and very low frequency (VLF) in the sinus pause group compared with AV block group (TP: 7.1x10-3 vs. 5.4x10-3, p=0.011; VLF: 4.9x10-3 vs. 3.7x10-3, p=0.007). CONCLUSION: Despite proposed common autonomic mechanisms, sleep-related sinus pause cases demonstrated better HRV profile in comparison with Mobitz type I AV block.

Endocan and Non-Dipping Circadian Pattern in Newly Diagnosed Essential Hypertension.

BACKGROUND AND OBJECTIVES: Non-dipper hypertension is frequently accompanied by endothelial dysfunction and activation. Previous studies suggested that endocan may be a novel endothelial dysfunction marker. This study aims to investigate the association between circadian blood pressure (BP) pattern and plasma endocan levels together with high-sensitivity C-reactive protein (hsCRP) in patients with newly diagnosed untreated hypertension. SUBJECTS AND METHODS: Twenty-four hour ambulatory blood pressure monitoring was recorded in 35 dipper, 35 non-dipper hypertensives and 35 healthy controls. Endocan levels were measured by enzyme-linked immunosorbent assay. Serum levels of hsCRP were also recorded. RESULTS: Despite similar daytime and 24-hour average BP values between dippers and non-dippers, statistically significant high nocturnal BP was accompanied by a non-dipping pattern (Systolic BP: 132±9 vs. 147±11 mmHg; Distolic BP: 80±7 vs. 91±9 mmHg, respectively, p<0.001 for both). Non-dipper patients demonstrated higher endocan levels compared to dippers and normotensives (367 (193-844) pg/mL, 254 (182-512) pg/mL and 237 (141-314) pg/ml, respectively, p<0.001). HsCRP levels were significantly higher in non-dippers than the other groups (p=0.013). In a multivariate logistic regression analysis, endocan (p=0.021) and hsCRP (p=0.044) were independently associated with a non-dipping pattern. CONCLUSION: Elevated endocan levels were found in non-dipper groups. Endocan and hsCRP were found to be independently associated with a non-dipping pattern. We suggest that elevated levels of endocan in non-dipper hypertensive patients might be associated with a longer duration of exposure to high BP. These results point to the possible future role of endocan in selection of hypertensive patients at higher risk or target organ damage.

Evaluation of heart rate recovery index in heavy smokers.

OBJECTIVE: Cigarette smoking increases the risk of cardiovascular events. The heart rate recovery index (HRRI) is an indicator of autonomous nervous system function and is an independent prognostic risk factor for cardiovascular diseases. In this study, we aimed to evaluate HRRI in heavy smokers. METHODS: A total of 179 apparently healthy subjects (67 non-smokers as the control group and 112 heavy smokers) were enrolled into this prospective cross-sectional study. The presence of hypertension, diabetes mellitus, and known cardiac or non-cardiac diseases was specified as the exclusion criteria. Heavy cigarette smoking was defined as the consumption of more than one packet of cigarette per day. All subjects underwent the maximal Bruce treadmill test. HRRIs of the heavy cigarette smoker group at 1, 2, 3, and 5 min after maximal exercise were calculated and compared to those of the control group. Student t-test, chi-square test, and analysis of covariance were used for statistical analysis. RESULTS: The baseline characteristics of the two groups were similar, except for body mass index and high-density lipoprotein level. HRRIs at 1, 2, 3, and 5 min after maximal exercise were found to be significantly lower in the heavy smoker group (HRRI1: 26.78±8.81 vs. 32.82±10.34, p<0.001; HRRI2: 44.37±12.11 vs. 51.72±12.87, p<0.001; HRRI3: 52.73±11.54 vs. 57.22±13.51, p=0.018; and HRRI5: 58.31±10.90 vs. 62.33±13.02, p=0.029). CONCLUSIONS: In the present study, we found that HRRI was impaired in heavy smokers. Our results suggest that beside previously known untoward effects on vascular biology, heavy smoking also has deleterious effects on the neuro-cardiovascular system.

Human Endothelial Cell-Specific Molecule-1 (Endocan) and Coronary Artery Disease and Microvascular Angina.

Endothelial cell-specific molecule-1 (endocan) is an immunoinflammatory marker linked to endothelial activation and dysfunction. We investigated the relationship between obstructive coronary artery disease (CAD), microvascular angina (MVA), and plasma levels of endocan. We included 53 healthy individuals as controls, 40 MVA patients, and 120 patients with obstructive CAD. The severity of CAD was assessed by the Gensini and SYNergy between percutaneous coronary intervention with TAXUS and Cardiac Surgery (SYNTAX) scores. Endocan levels were 382.7 (313.8-470.2) pg/mL in patients with obstructive CAD; 324.3 (277.1-460.7) pg/mL in MVA group, and 268.0 (226.4-336.5) pg/mL (P < .001) in controls. Endocan levels in obstructive CAD and MVA groups were similar but both were significantly higher than for the control group (P < .001 and P = .002, respectively). In subgroup analysis, similar to the hypertensive subgroup results, endocan was still an independent predictor of presence of obstructive CAD in normotensives (odds ratio = 1.005, 95% confidence interval = 1.001-1.010, P = .024). There was also an independent positive correlation between endocan levels and SYNTAX score both in the hypertensives (ß = 0.414, t = 3.21, P = .002) and in the normotensives (ß = .301, t = 2.23, P = .031). In conclusion, endocan could be a common predictor of the endothelium-dependent inflammatory processes, rather than related with specific risk factors.

Comparison of coronary artery dimensions in patients with chronic aortic regurgitation or stenosis.

OBJECTIVE: Effects of various conditions on coronary artery dimensions is an important research topic, and data regarding effect of aortic valvular diseases are limited. Aim of the present study was to investigate effects of aortic regurgitation (AR) and aortic stenosis (AS) on coronary artery dimensions. METHODS: Coronary dimensions of 95 patients (35 with isolated AR, 30 with isolated AS, and 30 without any valvular disease) were calculated. Patients with severe coronary artery disease and concurrent moderate to severe additional valvular disease were excluded. Mean diameter of major coronary arteries was determined using quantitative coronary angiography. RESULTS: The 3 study groups were similar in terms of baseline characteristics. Diameter of left main coronary artery was found to be greater in AR group than AS group (2.66±0.57 mm/m2 vs 2.36±0.49 mm/m2; p=0.015). Mean diameter of left anterior descending and left circumflex arteries were found to be similar in AR and AS groups, and greater than control group. Mean diameter of right coronary artery was found to be greater in AR group compared with controls; however, no significant difference was found in same measurement between AS group and controls. CONCLUSION: Present study findings indicate that coronary dimensions in AR group tend to be greater than AS group. Further studies investigating factors that affect coronary dimensions would be beneficial in order to demonstrate mechanisms and differences in AR and AS groups.

Evaluation of Tp-E Interval and Tp-E/QT Ratio in Patients with Aortic Stenosis.

BACKGROUND: The risk of syncope and sudden cardiac death due to ventricular arrhythmias increased in patients with aortic stenosis (AS). Recently, it was shown that Tp-e interval, Tp-e/QT, and Tp-e/QTc ratio can be novel indicators for prediction of ventricular arrhythmias and mortality. We aimed to investigate the association between AS and ventricular repolarization using Tp-e interval and Tp-e/QT ratio. METHODS: Totally, 105 patients with AS and 60 control subjects were enrolled to this study. The severity of AS was defined by transthoracic echocardiographic examination. Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were measured from the 12-lead electrocardiogram. RESULTS: Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were significantly increased in parallel to the severity of AS (P < 0.001, P = 0.001, and P = 0.001, respectively). Also, it was shown that Tp-e/QTc ratio had significant positive correlation with mean aortic gradient (r = 0.192, P = 0.049). In multivariate logistic regression analysis, Tp-e/QTc ratio and left ventricular mass were found to be independent predictors of severe AS (P = 0.03 and P = 0.04, respectively). CONCLUSIONS: Our study showed that Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were increased in patients with severe AS. Tp-e/QTc ratio and left ventricular mass were found as independent predictors of severe AS.

Increased Platelet to Lymphocyte Ratio is Related to Slow Coronary Flow.

Previous studies showed that both inflammation and platelets have a role in development of slow coronary flow (SCF). Platelet to lymphocyte ratio (PLR) as an emerging inflammatory indicator was significantly associated with adverse cardiovascular events. Therefore, we aimed to assess the relationship between PLR and SCF. Patients who had angiographically normal coronary arteries were enrolled in this retrospective study (n = 221 as SCF group and n = 293 as control group). Patients who had thrombolysis in myocardial infarction frame counts (TFC) above the normal cutoffs were considered to have SCF. Both PLR and C-reactive protein (CRP) were significantly higher in the SCF group. In correlation analysis, PLR has a significantly positive correlation with the left anterior descending artery TFC (P = .001), circumflex artery TFC (P < .001), right coronary artery TFC (P < .001), and serum CRP level (P < .001). In multiple logistic regression analysis, PLR was independently associated with presence of SCF (odds ratio: 1.014, P < .001). In conclusion, higher PLR levels were significantly and independently related to the presence of SCF. Besides, PLR was positively correlated with serum CRP level as a conventional marker for systemic inflammation.

Association Between Platelet to Lymphocyte Ratio and Saphenous Vein Graft Disease.

Atherosclerosis plays an important role in saphenous vein graft disease (SVGD). Previous trials showed that inflammatory blood cells play a role in this process. The platelet to lymphocyte ratio (PLR) has been proposed as a novel predictor for cardiovascular risk and indicator of atherosclerosis. The aim of this study was to assess the relationship between SVGD and PLR. A total of 220 patients with SVG were enrolled (n = 87 with SVGD and n = 133 with patent SVG). A ≥ 50% stenosis within the SVG was defined as clinically significant. Median PLR (P < .001) and mean platelet volume (MPV; P = .043) were significantly higher in patients with SVGD. Also, PLR showed significantly positive correlation with age of SVG (P < .05). Median age of SVGs was also higher in the SVGD group (P = .025). In multivariate logistic regression analyses, the PLR and MPV were independent predictors of SVGD. Using a cutoff level of 106.3, the PLR predicted SVGD with a sensitivity of 87.4% and a specificity of 80.3%. To the best of our knowledge, this study showed, for the first time, that PLR was independently associated with SVGD. Both PLR and MPV might predict SVGD.

A rare cause of 2:1 atrioventricular block: carbamazepine.

We report a case of carbamazepine-induced 2:1 atrioventricular (AV) block. A 56-year-old man was admitted to our emergency department for recurrent attacks of dizziness and syncope. His serum carbamazepine level was within therapeutic range, and his electrocardiogram revealed 2:1 AV block. After withdrawal of carbamazepine therapy, the arrhythmia completely resolved. This report suggests that carbamazepine-induced AV block can occur even in therapeutic serum concentrations and that it can be reversible.

Relationship between serum vitamin D levels and angiographic severity and extent of coronary artery disease.

BACKGROUND: Vitamin D is known for its effect in calcium and bone homeostasis. There is an increasing evidence for health benefits accomplished by activated vitamin D that go beyond these classical functions. Previous studies have suggested that lower vitamin D levels are associated with increased cardiovascular disease risk. Therefore, we aimed to evaluate relationship between vitamin D levels and extent and severity of coronary artery disease. MATERIALS AND METHODS: A total of 746 patients in whom coronary angiography was performed between August 2012 and July 2013 were enrolled in this study. Serum vitamin D levels were measured, and patients were grouped according to their serum vitamin D levels (vitamin D <20 ng/mL (n = 602) Group 1 versus >20 ng/dL (n = 144) Group 2). Gensini score system was used to evaluate the association between serum vitamin D levels and severity and extent of coronary artery disease. RESULTS: There was no significant difference between the groups in terms of baseline characteristics and demographic characteristics. Mean serum vitamin D levels of all patient cohort was 15.54 ± 7.46 ng/mL. Group 1 and Group 2 had an average serum vitamin D levels of 12.6 ± 3.3 ng/mL and 27.5 ± 7.8 ng/mL, respectively. Gensini score for all cohort was 26.25 ± 34.32. Group 1 had an average Gensini score of 26.4 ± 35.7; on the other hand, Gensini score was 25.5 ± 27.5 in Group 2 (P = 0.097). CONCLUSIONS: This study failed to demonstrate significant relationship between serum vitamin D levels and the severity and extent of coronary artery disease. Further studies with more participation and homogenous groups with comparable individual and environmental features are needed to evaluate the association of serum vitamin D levels and cardiovascular diseases.

Comparison of three diuretic treatment strategies for patients with acute decompensated heart failure.

BACKGROUND: There are few prospective data available for establishing a standard diuretic administration regimen for patients with acute decompensated heart failure (ADHF). We aimed to assess the safety and efficacy of three regimens of furosemide administration in patients with ADHF with regard to diuresis, renal functions, and in-hospital outcomes. METHODS: A total of 43 patients who presented with ADHF were randomized into three groups: (a) continuous infusion (cIV) of 160 mg furosemide for 16 h/day (n = 15); (b) bolus injections (bI) of 80 mg furosemide twice a day (n = 14); (c) and administration of 160 mg furosemide plus hypertonic saline solution (HSS) as an infusion for 30 min once a day (n = 14). All regimens were continued for 48 h. Study endpoints were negative fluid balance assessed by loss of body weight, change in the serum creatinine (baseline to 48 h and baseline to compensated state), and length of hospitalization. RESULTS: There was no significant difference in the mean change in serum creatinine level at the end of 48 h between groups (p = 0.08). There was also no significant difference among groups regarding loss of body weight (p = 0.66). A significantly shorter hospitalization was observed in patients treated with HSS compared with the other groups (cIV group 6.6 ± 3.4 days vs. bI group 7.9 ± 4.1 days vs. HSS group 3.7 ± 1.3 days; p < 0.01). CONCLUSION: All three furosemide regimens have similar renal safety and efficacy measures. However, administration of furosemide plus HSS may be the preferred diuretic strategy because of its shorter hospital stay.

High Sensitive CRP Level Is Associated With Intermediate and High Syntax Score in Patients With Acute Coronary Syndrome.

High sensitive C-reactive protein (hs-CRP) levels are associated with short- and long-term mortality in patients with acute coronary syndrome (ACS). We investigated whether baseline hs-CRP levels are associated with burden of coronary atherosclerosis assessed by SYNTAX score (SXScore).We enrolled 321 patients with ACS who underwent coronary angiography. The patients were divided into tertiles according to the SXScore: low SXScore (≤ 22), and intermediate-high SXScore (≥ 23).Subjects in the intermediate-high SXScore tertile had higher serum hs-CRP levels compare to low SXScore tertile patients (7.7 ± 3.4 mg/L versus 4.9 ± 2.5 mg/L, P < 0.001). The mean age of patients and prevalance of diabetes in the intermediate-high SXScore tertile were significantly higher than in the low SXScore tertile (63 ± 13 versus 58 ± 12 years P = 0.001 for age, P = 0.007 for diabetes). Multivariate logistic regression analysis showed that the strongest predictors of high SXScore were increased serum hs-CRP levels (OR: 1.14) together with multivessel disease (OR: 0.23), left ventricular ejection fraction (LVEF) (OR: 0.90), and troponin levels (OR: 1.12).Serum hs-CRP levels on admission in patients with ACS could predict the severity and complexity of coronary atherosclerosis together with multivessel disease, LVEF, and troponin levels. Thus, increased serum levels of hs-CRP were one of the strong predictors of high SXScore in ACS patients.

The effect of statin treatment on P-wave characteristics and atrial conduction time.

BACKGROUND AND AIM: The aim of this study was to evaluate the effect of statin treatment on P-wave morphology, dispersion, and tissue Doppler imaging-derived atrial conduction time (PA-TDI), which are known to be predictors of atrial fibrillation (AF). METHODS: A total of 132 patients with guideline-directed statin indications but no clinical atrial tachyarrhythmias were studied. P-wave duration, P-wave dispersion, and P-wave amplitude on surface 12-lead electrocardiogram and PA-TDI were evaluated before and after three months of statin (either atrovastatin 10-40 mg/d or rosuvastatin 10-20 mg/d) treatment. RESULTS: Total and low-density lipoprotein cholesterol were significantly reduced after statin therapy. P-wave dispersion significantly decreased from 39.6 ± 9.4 to 36.9 ± 9.6 ms. Statin treatment significantly decreased both the maximum (from 1.5 ± 0.36 to 1.45 ± 0.33 mV, p = 0.001) and the minimum (from 1.07 ± 0.28 to 1.04 ± 0.27 mV, p = 0.01) P-wave amplitude. The PA-TDI value was found to be significantly shorter after statin treatment (121.7 ± 18.7 vs. 118.7 ± 15.8 ms, p = 0.016) CONCLUSIONS: Short-term statin therapy was shown to significantly affect P-wave amplitude, P-wave dispersion, and atrial conduction time in a broad range of patients without any clinical atrial tachyarrhythmia.

Catheter inside the right heart for 22 years: to intervene or not to intervene?

Treatment of a central venous catheter emboli that has been asymptomatic for a number of years is controversial. A 56-year-old male patient who had an operation for sinus Valsalva aneurism rupture 22 years ago was referred to cardiology department for routine control. He had a mass inside the right heart on echocardiographic examination, and computed tomography revealed that this mass was an embolic piece of catheter. Catheters that have stayed inside the heart for a long time are removed due to the risk of distal embolisation and endocarditis, but the risk of removal is not known. Non-invasive follow-up of asymptomatic patients is often preferred because of the stabilisation of the embolised catheter due to endothelisation and the risk of complications during removal. Treatment of patients with catheter-piece emboli who are asymptomatic should be individualised, taking into account the risk of thrombosis, arrhythmia, and infection.