Relationships between P wave dispersion, atrial electromechanical delay, left atrial remodeling, and NT-proBNP levels, in patients with hypertrophic cardiomyopathy.

BACKGROUND: We evaluated the associations among the well-known atrial fibrillation (AF) predictors including P-wave dispersion (PWD), intra- and inter-atrial electromechanical dyssynchrony (EMD), left atrial (LA) phasic functions, and plasma N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) levels, in patients with hypertrophic cardiomyopathy (HCM). METHODS: Seventy patients with HCM and age and sex matched 70 subjects were enrolled. PWD, LA total emptying fraction (LATEFr), active emptying fraction (LAAEFr), passive emptying fraction (LAPEFr), expansion index (LAEI) intra- and inter-atrial EMD were calculated. Levels of NT-proBNP of all subjects were determined. RESULTS: Higher PWD (p = 0.006), significantly decreased LAEI (p < 0.001), LATEFr, and LAPEFr (both p values < 0.001) values and significantly increased inter-atrial (p < 0.001), LA (p = 0.001), and right atrial dyssynchrony (p < 0.001) were observed in the HCM group compared to controls. PWD was negatively correlated with LAEI (r = -0.236, p = 0.005) and LATEFr (r = -0.242, p = 0.04), however not with LAPEFr (p = 0.7), or LAAEFr (p = 0.3). Except for the LA lateral wall PA' (r = 0.283, p = 0.02), PWD was not correlated with any atrial EMD parameter. Inter-atrial dyssynchrony was related to LAEI (r = -0.272, p = 0.001), LATEFr (r = -0.256, p = 0.03), and LAPEFr (r = -0.332, p = 0.006), but not, however, to LAAEFr (p = 0.4). The plasma NT-proBNP levels of patients were not correlated with either PWD (p = 0.927) or inter-atrial dyssynchrony (p = 0.102). CONCLUSIONS: PWD and inter-atrial dysynchrony seem to independently promote AF, although both are associated with LA reservoir function in HCM populations. The NT-proBNP level is not associated with these two AF predictors in patients with HCM. NT-proBNP seems to be a poor marker of atrial electrical remodeling in HCM patients.

The left atrial phasic functions and the relationship with plasma N-terminal pro-B-type natriuretic peptide levels and symptomatic states in patients with hypertrophic cardiomyopathy.

OBJECTIVE: We aimed to evaluate left atrium (LA) phasic functions and relation with N-terminal pro-B- type natriuretic peptide (NT-proBNP) levels and symptomatic states of the patients with hypertrophic cardiomyopathy (HCM). METHODS: Left atrial volume was calculated at end-systole (Vmax), end-diastole and pre-atrial contraction by echocardiography in 75 patients with HCM and 75 control subjects. Left atrial ejection fraction (LAEF), expansion index (LAEI), active emptying volume index (LAAEVI) and fraction (LAAEFr), passive emptying volume index (LAPEVI) and fraction (LAPEFr) were calculated. NT-proBNP levels were measured. RESULTS: Left atrial active emptying volume (LAAEV) positively correlated with Vmax (r=0.343, p=0.003) up to a point, but then reached a plateau with larger LA volumes in HCM group. The LAAEFr was the only variable which was similiar between asymptomatic patients and controls, but was significantly decreased in symptomatic patients (p<0.05). NT-proBNP was correlated with LAEF (r=-0.32, p=0.005), LAEI (r=-0387, p=0.001), and LAAEFr (r=-0.25, p=0.035) but not related with LAPEFr (p=0.4). In receiver operating characteristic curve analysis an NT-proBNP cut-off value of 1415 pg/mL identified reduced LAEF with 87% specificity and 59% sensitivity [AUC=0.77 (95% CI: 0.65-0.89), p=0.004], a cut-off value of 820 pg/mL predicted impaired LAEI with 81% specificity ve 67% sensitivity [AUC=0.78 (95% CI: 0.66-0.9), p<0.001]; while a cut-off value of 1320 pg/mL predicted impaired LAAEFr with 76% specificity and 67% sensitivity [AUC=0.79 (95% CI: 0.68-0.91), p=0.02]. CONCLUSION: In HCM, LA phasic functions alter according to the Frank-Starling mechanism indicating occurrence of a secondary atrial myopathy. Impairment of LA booster pump function seems to be associated with appearance of symptoms and NT-proBNP levels predict the deterioration of LA reservoir and pump functions in HCM population.

The effects of different hormone treatment on endothelial function in healthy postmenopausal women.

We aimed to compare the effects of different types of hormone treatment (HT) on endothelial function by means of brachial artery ultrasonographic examination in postmenopausal women. Sixty-two healthy postmenopausal women were included in this study. Subjects were assigned to one of the five groups receiving 6 months of treatment [estrogen (conjugated estrogen), estrogen (conjugated estrogen) plus progesterone (medroxyprogesterone acetate; MPA), raloxifene, tibolone or control]. Endothelial function was assessed by measurement of flow-mediated dilatation (FMD) and nitrate-dependent dilatation in the brachial artery. At the end of 6 months, FMD values were found to be significantly increased in women with HT use than the control group (p = 0.001). In subgroups, FMD increased significantly in the estrogen [12 ± 7 versus 25 ± 8, p = 0.001] and raloxifene groups [7 ± 5 versus 11 ± 3, p < 0.01] compared to tibolone and estrogen plus progesterone groups. In conclusion, endothelial function is impaired in postmenopausal women. Both estrogen and raloxifene regimens may improve endothelial functions in healthy postmenopausal women. The direct protective effects of these HT on the healthy endothelium may be more remarkable than the favorable effects on lipid profile.

An observational study to evaluate factors responsible and actions taken for hypertensive patients who are not at blood pressure goal: i-target Goal Study.

To evaluate the percentage of hypertensive patients who could achieve target blood pressure (TBP) according to the guidelines in the context of recommended measures and the factors responsible for failure. A total of 589 hypertensive patients (59.0% female; mean age: 57.7 ± 10.4 years) were assessed twice for TBP achievement based on 2007 ESH/ESC guidelines and the investigators' view, in addition to the recommended measures and possible causes of failure in hypertension management in this national multi-center (n = 99), non-interventional observational study. Only 29.5% of the patients at the first visit and 46.8% at the second visit achieved the TBP levels specified by the guidelines. However, the investigators' evaluation indicated a higher achievement rate at the first (43.5%) as well as the second (69.1%) visit when compared with the guideline-based assessments (P < 0.001). The primary reasons identified by the investigators for the failure to reach TBP were non-compliance with dietary recommendations (61.6%) at the first visit and non-compliance with treatment (63.92%) at the second visit. Recommendations for lifestyle were the most commonly identified treatment plan by the investigators at both visits (62.9% and 66.1%, respectively). Although more patients achieved the TBP levels specified by the guidelines for the second visit compared with the first, effective blood pressure control was achieved only in 29.5% of our patients. Interestingly, the investigators had a more optimistic view about their patients' control of hypertension, which may have contributed to a poor achievement of TBP.

[Pneumopericardium after pericardiocentesis: a case report]. / Perikardiyosentez sonrasi pnömoperikardiyum: Olgu sunumu.

Pneumopericardium is defined by the presence of air in the pericardial sac. We present a 61-year-old cachectic woman who developed pneumopericardium after pericardiocentesis. She presented with complaints of fatigue and shortness of breath. The chest X-ray showed an increased cardiothoracic ratio, and echocardiographic examination showed a marked pericardial effusion. Pericardiocentesis was performed and a total of 860 ml hemorrhagic pericardial fluid was aspirated. At the end of the first week after removal of the catheter, control chest radiography showed air-fluid levels in the pericardial cavity, and echocardiography revealed dense air bubbles in the decreased pericardial effusion. As the patient was hemodynamically stable, she was monitored on medical treatment. However, five days later, pericardiocentesis was repeated due to a significant increase in the pericardial effusion despite decreased amount of air. As no etiologic factor could be elicited, a connective tissue disease was considered and a corticosteroid was added to her treatment, which resulted in a rapid decline in the pericardial effusion on follow-up chest radiography and echocardiography. She was discharged on steroid therapy.

Blood pressure changes in migraine patients before, during and after migraine attacks.

Migraine attacks are characterized by headaches associated with neurological, gastrointestinal, and autonomic symptoms. A relationship between migraine and hypertension or hypotension is controversial. In this study, we aimed to determine if blood pressure changes were related to migraine attacks. From the outpatient clinic of our neurology department, 62 normotensive migraine patients with and without aura were chosen for study in accordance with the International Headache Society 2004 criteria. A questionnaire including general and specific questions was given to the patients to be filled out during 6 consequent migraine attacks. The patients received a fully automatic digital brachial upper arm sphygmomanometer (Omron M 4-1) to measure the changes in their blood pressure during attacks. The patients were asked to record their blood pressure changes 3 times: (1) just before or very early, (2) during (when headache peaks), and (3) 1 hour after the attack. Twenty-three of the 62 patients (57 women, 5 men) had migraine with aura (22 women and 1 man), and 39 of them did not have aura (35 women and 4 men). There was no statistically significant difference between systolic and diastolic values obtained before or very early, during the peak level, and 1 hour after the end of the attacks (P > 0.05). Although diastolic hypotensive values were not different statistically between groups, when all the patients were considered, diastolic hypotensive values were detected in a considerable number of patients (a total of 115 measurements). In this normotensive migrainous population, we observed that diastolic hypotension before or very early, during, and after migraine attack was the most significant result (5.1%). Although it was not statistically significant, the total number of hypotensive values was remarkable.

High inflammatory activity related to the number of metabolic syndrome components.

It has been known that each component of the metabolic syndrome (MS) has an atherogenic potential and increases the risk of cardiovascular events. Therefore, patients who have MS are candidates for the development of atherosclerosis and accompanying complications. In this study, the authors assessed the levels of acute phase reactants as an indicator of inflammation in patients with MS. Twenty-five patients with recently diagnosed MS and not treated before who had at least 3 of 5 diagnostic criteria of MS listed in the Third Report of the Adult Treatment Panel National Cholesterol Education Program (NCEP-ATP III) guidelines were included in the study. Twenty healthy patients constituted the control group. Inflammatory parameters were compared between the groups. There was no significant difference between the MS and control group with regard to age and sex. White blood cell count (/mm(3)), high-sensitivity C-reactive protein (hs-CRP), uric acid, interleukin (IL) 6, and fibrinogen levels were found to be significantly higher in the MS group. Number of MS components was strongly correlated with serum levels of hs-CRP (r=0.688, P=.0001), IL-6 (r=0.546, P=.0001), fibrinogen (r=0.551, P=.0001), uric acid (r=0.517, P=.0001), and leucocyte count (/mm(3)) (r=0.456, P=.002). Inflammation plays an important role in atherosclerotic complications, which is activated in MS. Increased number of MS components are strongly associated with elevated inflammatory and metabolic markers. Measurement of serum inflammatory parameters in patients with MS may be beneficial in detection and management of cardiovascular events and in the assessment of efficacy of treatment.

Global cardiometabolic risk profile in patients with hypertension: results from the Turkish arm of the pan-European GOOD survey.

OBJECTIVES: We evaluated the results of the Turkish arm of the GOOD survey which investigated the cardiometabolic risk profile and the control of blood pressure (BP) of adult hypertensive outpatients in 12 countries across Europe. STUDY DESIGN: A total of 218 hypertensive patients (139 females, 79 males; mean age 57.2±10.9 years) from Turkey were included in this pan-European survey. Blood pressure control (defined as BP <140/90 mmHg for nondiabetics and <130/80 mmHg for diabetics) and cardiometabolic risk factors such as diabetes mellitus, metabolic syndrome, obesity, sedentary lifestyle, and atherogenic dyslipidemia were evaluated in accordance with the 2003 ESH/ESC guidelines on management of hypertension. RESULTS: Control of BP was achieved in only 21.6% of the patients diagnosed with hypertension for a mean duration of 7.7±5.4 years. The mean systolic and diastolic BPs were 144±21 mmHg and 88±14 mmHg, respectively. The most frequent concomitant disease was type 2 diabetes mellitus (66 patients, 30.3%). Patients with diabetes had a higher prevalence of metabolic syndrome compared to nondiabetics (78.8% vs. 48%, p<0.01). The absence of BP control was more pronounced among diabetics than in nondiabetics for systolic (77.3% vs. 63.8%) and diastolic (84.9% vs. 57.2%) pressures. Nearly half of the hypertensive patients had atherogenic dyslipidemia, but only 35.8% of them were treated with lipid lowering drugs. CONCLUSION: Despite appropriate treatment, poor BP control in Turkish hypertensive patients was associated with metabolic syndrome, diabetes, and undertreatment of atherogenic dyslipidemia. Therefore, more effective measures must be taken in the management of cardiovascular risk factors to improve BP control.

A remnant sewing needle in the right ventricle as a cause of chest pain.

Sewing needles, albeit a rare case of penetrating cardiac injury, are potentially life-threatening. We report a case of a self-inflicted remnant intracardiac sewing needle which is diagnosed with nonspecific chest pain and successfully extracted 23 months after its insertion.

Comparison of ischemic side effects of levosimendan and dobutamine with integrated backscatter analysis.

BACKGROUND: Levosimendan improves cardiac contractility without increasing oxygen consumption. However, its effects on ischemia were not supported with the utilization of a noninvasive parameter of myocardial characterization. HYPOTHESIS: The changes observed in integrated backscatter (IBS) may be reflective of change in myocardial ischemia. In this study, the effect of levosimendan on ischemia detected by IBS was evaluated in patients with ischemic heart failure (HF). METHODS: Patients who had LVEF < 40% and NYHA III-IV symptoms of HF were included in this study. Patients were randomized to levosimendan (n = 21), or to dobutamine (n = 25) groups. The cyclic variation of integrated backscatter (CVIBS) was determined as the difference between the maximal and minimal values in a cardiac cycle, average of three consecutive beats. CVIBS was taken from the mid-anteroseptal, mid-inferior, and mid-posterolateral areas of the parasternal short axis images before the drug administration and at the end of the 24-hour infusion period. RESULTS: Baseline characteristics and concomitant medications were similar in both groups. A significant reduction in CVIBS was detected in anteroseptal (7.6 +/- 1.4 dB versus 5.9 +/- 0.8 dB, p = 0.01), inferior wall (7.4 +/- 0.8 dB versus 6.7 +/- 1.5 dB, p = 0.03), and posterolateral wall (9.0 +/- 1.2 dB versus 8.2 +/- 0.6 dB, p = 0.04) after dobutamine administration, while no significant changes were observed in the levosimendan group in all walls. CONCLUSIONS: Unlike dobutamine, levosimendan may not induce myocardial ischemia as shown by CVIBS at commonly used dosages in the setting of decompensated HF without active ischemia.

Comparison of the effects of new and conventional hormone replacement therapies on left ventricular diastolic function in healthy postmenopausal women: a Doppler and ultrasonic backscatter study.

We aimed to compare the effects of new treatment modalities to conventional hormone replacement therapy (HRT) on left ventricular (LV) diastolic function, by means of conventional and tissue Doppler echocardiography and the myocardial integrated backscatter (IBS) in postmenopausal women. One hundred and fifty healthy postmenopausal women were included in this study. Subjects were assigned to one of the five groups receiving 1 year of treatment (estrogen, estrogen plus progesterone, raloxifene, tibolone or placebo). E and A wave velocity, E/A ratio, isovolumic relaxation time (IVRT), deceleration time (DT), peak early (Em) diastolic mitral annular velocity, E/Em ratio, the cyclic variation of integrated backscatter (CVIBS) and the mean value of the IBS signal (MIBS) were determined before and 12 months after therapy. E (76 +/- 10 vs. 98 +/- 8 cm/s, P = 0.0001 and 78 +/- 10 vs. 90 +/- 12 cm/s, P = 0.02, respectively), Em (14.3 +/- 2.4 vs. 16.4 +/- 2.5 cm/s, P = 0.001 and 15.1 +/- 3.4 vs. 16.2 +/- 3.5 cm/s, P = 0.01, respectively), and E/A ratio (1.15 +/- 0.3 vs. 1.42 +/- 0.4, P = 0.0001 and 1.0 +/- 0.2 vs. 1.22 +/- 0.2, P = 0.01, respectively) were increased significantly compared to pretreatment in both estrogen and raloxifene groups while DT, A, E/Em, and IVRT were significantly decreased. A significant increase in CVIBS and decrease in MIBS were detected 12 months after estrogen and raloxifene administration while no significant changes were observed in other groups. Changes in the MIBS and CVIBS were found to be independently associated with the observed changes in the diastolic function indexes during therapy. Both estrogen and raloxifene regimens may improve LV diastolic functions in healthy postmenopausal women. This improvement may be a result of direct cardiac effects on LV myocardium.

[Cardiac failure secondary to idiopathic hypoparathyroidism: a case report]. / Idiyopatik hipoparatiroidiye bagli gelisen kalp yetersizligi: olgu sunumu.

Hypocalcemic cardiomyopathy due to hypoparathyroidism is a very rare condition. Ensuing heart failure due to hypocalcemia is refractory to conventional treatment. We reported a 41-year-old man who developed cardiac failure due to hypocalcemia secondary to idiopathic hypoparathyroidism. Echocardiography showed biventricular low ejection fraction, dilated heart chambers, pulmonary hypertension, and valvular regurgitations. Serum calcium and parathyroid hormone levels were low. After treatment of heart failure and calcium-vitamin D supplementation, signs and symptoms of heart failure improved rapidly. At 6 months, biventricular systolic and diastolic functions returned to normal. Serum calcium level should be monitored in every patient with cardiac failure and hypocalcemia should be considered in patients with refractory heart failure.

Effects of levosimendan on left atrial functions in patients with ischemic heart failure.

BACKGROUND: With further progression of left ventricular (LV) dysfunction, the left atrial (LA) contribution to LV filling gradually decreases, and LA dysfunction deteriorates the decreased LV filling in patients with heart failure (HF). HYPOTHESIS: This study sought to investigate the effects of levosimendan on LA function in patients with HF. METHODS: A total of 60 patients having acute decompensated HF with ischemic cardiomyopathy and LV ejection fraction (LVEF) < 40% were included in the study. Patients were randomized to levosimendan (n = 30) or to dobutamine (n = 30). Before and 24 h after treatment, LVEF, mitral inflow peak E and A wave velocity, E/A ratio, mitral lateral annulus peak Em wave velocity, E/Em ratio, LA volumes, and from the LA volumes the active emptying fraction (AEF), passive emptying fraction (PEF), and reservoir fraction (RF) were measured. RESULTS: All LA volumes were significantly reduced after levosimendan administration, but in the dobutamine group only minimal volume (Vmin) was reduced. Although AEF increased in both groups, the improvement of AEF was greater in the levosimendan group than in the dobutamine group (14% +/- 9% versus 2% +/- 1%, p = 0.001). The PEF (12% +/- 8% versus 21% +/- 6%, p = 0.04) and RF (23% +/- 4% versus 38% +/- 3%, p = 0.001) significantly increased after levosimendan administration, whereas these parameters did not change after dobutamine. In patients receiving levosimendan, there was a significant, positive correlation between PEF and Em (r = 0.475, p = 0.008), and there were significant negative correlations between PEF and E/Em (r = - 0.491, p = 0.006), and AEF and E/Em (r = - 0.654, p = 0.001). CONCLUSIONS: Left atrial functions respond better to levosimendan than to dobutamine in decompensated HF.

Circadian and infradian rhythms of vasovagal syncope in young and middle-aged subjects.

BACKGROUND: The most cardiovascular physiological and pathophysiological events show a circadian rhythm. It is thought that the autonomic nervous system and biologic factors play a key role in the pathogenesis of vasovagal syncope (VVS). In this study, we investigated the circadian and infradian variation of VVS. METHODS: A prospective consecutive series of 246 patients (142 women; mean age 36+/-7 years) with recurrent syncope and with a positive head-up tilt testing (HUT) were included in this study. The daily and weekly distributions of the syncopal episodes were investigated. The assessments of episodes were done according to the days of the week and three time periods of the day (6 a.m.-12 noon, 12 noon-6 p.m., 6 pm-12 midnight). RESULTS: According to the results of HUT, 76 patients (31%) had cardioinhibitory, 62 patients (25%) had vasodepressor, and 108 patients (44%) had mixed type of VVS. During the initial passive phase, 40% of patients (99/246) showed positive response. Time to syncope was 20+/-2 minutes during HUT. The mean number of syncopal episodes was 4+/-2/years. In all, 1,070 episodes were evaluated. The distribution of the episodes in 6-hour intervals was significantly different from uniform occurrence (38%, 33%, and 29%, respectively) (P=0.02). The frequency of episodes was higher in the morning (P=0.045) and in the middle of the week (P=0.046). A significant difference was found between week and weekend days in terms of the frequency of episodes (75.5% vs 24.5%, P=0.01). CONCLUSION: VVS may show a circadian and infradian rhythm.

[The determination of the factors impacting on in-hospital mortality in patients with acute heart failure in a tertiary referral center]. / Tersiyer bir merkezde akut kalp yetersizlikli hastalarda hastane içi mortaliteye etkili faktörlerin belirlenmesi.

OBJECTIVE: Despite impressive advances in therapeutics in the last years, acute heart failure (AHF) remains a major cause of cardiovascular morbidity and mortality. Patients hospitalized because of heart failure (HF), irrespective of left ventricular systolic function, represent a high-risk population with limited short-term prognosis. A substantial component of HF-related mortality occurs during a hospital stay. In this study, we aimed to determine the factors impacting on in-hospital mortality in patients with AHF. METHODS: During a 15-month period (December 2005-March 2007), 85 consecutive patients with (mean age: 64+/-8 years, male: 54%) an episode of AHF were included in this study. The effect of demographic, clinical, electrocardiographic, and echocardiographic characteristics, laboratory findings on in-hospital mortality were evaluated retrospectively. RESULTS: Of 85 patients 24.7% of patients had new-onset HF. Coronary artery disease (61%) was the most common underlying disease. The 44.7% of patients had hypertension, 37.6% had diabetes mellitus, 21% had chronic renal failure and 16.4% had chronic obstructive pulmonary disease. Left ventricular ejection fraction was 35+/-7%. In-hospital mortality rate was found as 11.7% (10 patients). The major cause of mortality was the progression of HF to cardiogenic shock in 60% of deaths. In comparison with surviving patients in terms of the clinical, demographic, electrocardiographic, and laboratory characteristics and left and right ventricular functions, patients died during hospitalization had higher blood urea nitrogen (45+/-20 mg/dl vs. 36+/-12 mg/dl, p=0.04), higher creatinine level (2.2+/-0.8 mg/dl vs. 1.1+/-0.5 mg/dl, p=0.001), and wider QRS duration (130+/-13 ms vs. 116+/-18 ms, p=0.04) whereas they had lower plasma sodium level (128+/-5 mmol/l vs. 135+/-9 mmol/l, p=0.02) and systolic blood pressure (p=0.01). Logistic regression analysis revealed that plasma creatinine level (OR 1.5, 95% CI 1.2 to 2.1, p=0.01), blood urea nitrogen (OR 2.1, 95% CI 1.8 to 3.1, p=0.001), plasma sodium level (OR 1.3, 95% CI 1.1 to 1.7, p=0.02), and systolic blood pressure (OR 2.2, 95% CI 1.9 to 2.8, p=0.01) were the independent predictors of in-hospital mortality. CONCLUSION: In-hospital mortality increases in patients who had lower systolic blood pressure, lower plasma sodium level, and renal dysfunction on admission.

Apical hypertrophic cardiomyopathy might lead to misdiagnosis of ischaemic heart disease.

PURPOSE: In this study, demographic, clinic, electrocardiographic and angiographic properties of patients, on whom coronary angiography was performed with the pre-diagnosis of coronary artery disease (CAD) and whose ventriculography demonstrated typical apical hypertrophic cardiomyopathy (AHCM), were investigated. METHODS: Seventeen patients (mean age 58 +/- 10 years, 10 male) with CAD pre-diagnosis, on whom coronary angiography was performed and had typical spade-like appearance on left ventriculography, were included in the study between January 2000 and May 2005. RESULTS: As risk factor for CAD, 8 (47%) patients had hypertension, 8 (47%) patients had dyslipidaemia, 2 (11%) patients had type 2 diabetes mellitus, 13 (77%) patients had a history of smoking, and 2 (11%) patients had family history. Seven (42%) patients presented unstable angina pectoris, 8 (47%) patients presented stable angina pectoris and 2 (11%) patients were asymptomatic. On coronary angiography, it was determined that 10 (58%) patients had normal coronary arteries, 3 (17%) patients had non-significant stenosis and 4 (25%) patients had myocardial bridging. Five (30%) patients revealed mid-ventricular obstruction and intraventricular gradient was 25 +/- 5 mmHg by the catheterization. All patients showed ''giant'' negative (> or = 10 mm) T waves in the precordial leads, whereas 2 patients had atrial fibrillation. Maximum wall thickness was measured as 18 +/- 4 mm in the apical region by transthoracic echocardiography. One patient (5%) who had mid-ventricular obstruction developed atrial fibrillation during 2 years follow-up, though any other events did not occur during hospitalization or follow-up period. CONCLUSIONS: Physicians caring for patients with chest pain should consider AHCM in their differential diagnosis in case of a patient with chest pain and electrocardiographic changes suggestive of CAD.

The role of tilt training in preventing recurrent syncope in patients with vasovagal syncope: a prospective and randomized study.

BACKGROUND: Recurrent vasovagal syncope (VVS) can be a severely disabling disorder that may lead to an important deterioration of quality of life because of the severity and recurrence of episodes. This study sought to investigate the effectiveness of repeated orthostatic self-training in preventing syncope in patients with recurrent VVS. METHODS: Eighty-two consecutive patients (mean age 41 +/- 4 years, 37 males) with recurrent VVS episodes and positive head-up tilt testing (HUT) were enrolled in this study. The patients were then randomized (1:1) to conventional therapy or conventional therapy plus additional tilt training sessions. The patients were followed for spontaneous syncope for one year. Primary end-points were the recurrence of syncope, the number of episodes, and the interval of time to the first recurrence. RESULTS: There were no significant differences of baseline clinical characteristics and parameters of HUT between the tilt training and control groups. The patients had 4 +/- 2/year syncopal episodes prior to the HUT. The mean follow-up after randomization was 12 +/- 2 months. Spontaneous syncope recurrence during follow-up was 56% (23 patients) versus 37% (15 patients) in the control and tilt training groups, respectively (P = 0.1). Time to first recurrence was also similar in both groups (70 +/- 20 days vs 50 +/- 15 days, P = 0.09). The frequency of recurrent syncopes was similar in all types of VVSs while the rate of episodes was significantly higher in control group in patients with vasodepressor type during follow-up period (32% vs 10%, P = 0.04). The mean number of recurrent syncope episodes was also similar in both groups (3 +/- 1 vs 2 +/- 1, P = 0.4). CONCLUSIONS: Tilt training was unable to influence the spontaneous syncope recurrence for recurrent VVS except for vasodepressor type.

ST-segment elevation in lead augmented vector right may also be caused by diffuse left main coronary artery vasospasm without fixed stenosis.

ST-segment deviation in lead augmented vector right (aVR) is useful for evaluating patients with acute coronary syndrome (ACS). The ST-segment elevation in this aVR in the patient with clinically suspected acute coronary syndrome suggests a strong possibility of left main coronary artery (LMCA) obstruction due to fixed stenosis. In this article, we report the first case, to our knowledge, of ST-segment elevation in lead aVR due to diffuse LMCA spasm.