[Pulmonary hypertension spectrum: 16 years of experience from a single center]. / Pulmoner hipertansiyon etiyolojisinin arastirilmasi: Tek merkezden 16 yillik deneyim.

OBJECTIVE: Pulmonary hypertension (PH) is multidisciplinary disorder that should be diagnosed and treated by specialized centers. Progress in the field of PH diagnosis has led to new classifications of the disease. The aim of this study was to determine the etiological properties of PH diagnosed at one center. METHODS: A retrospective search of the database of the right heart catheterization laboratory was conducted. All of the patients who underwent right heart catheterization (RHC) and were diagnosed with PH were included in the study and grouped according to etiology. RESULTS: A total of 379 patients with PH (23 female; 53.2±14.7 years) were included in the current research. There were 82 patients classified as having pulmonary arterial hypertension (PAH). The leading cause among the PAH subgroups was congenital heart disease, and valve disease were found to be most the common reason for postcapillary PH. There was a statistically significant difference in the mean and systolic pulmonary artery pressure and left ventricular ejection fraction between the PH groups (p<0.001, p=0.003, p<0.001, respectively). CONCLUSION: The results of this study indicated that the leading causes of PAH and postcapillary PH were congenital heart disease and valve disease, respectively. Additional research of the etiological properties of PH should be performed by specialized centers in Turkey.

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.

Efficacy and safety of valsartan and amlodipine single-pill combination in hypertensive patients (PEAK study).

OBJECTIVES: This study was designed to assess the safety, compliance and efficacy of amlodipine (Aml) and valsartan (Val) single-pill combination (SPC) in a large hypertensive patient population. STUDY DESIGN: This is a non-interventional, observational, open label study conducted in 166 centers in Turkey with a 24-week follow-up period. RESULTS: Of the 1184 enrolled patients, two-thirds were female (62.2%). The mean age was 57.7±11.3 years, and 26.1% of the patients were older than 65 years. The majority of patients (82.3%) were overweight or obese. During the course of the study, 150 (12.7%) patients experienced a total of 174 adverse events (AEs). The overall mean (SD) compliance rate was determined to be 96.9 (0.2)%. The most commonly reported AE was edema, with a new-onset edema incidence of 6.7%. In the entire group, Aml/Val SPC significantly reduced both systolic and diastolic blood pressure (BP), with a reduction of 29.6±0.9 / 14.7±0.6 mmHg (for each, p<0.001). CONCLUSION: As a result of the low incidences of AEs and new-onset edema, the safety profile of Aml/Val SPC proved to be optimal. Aml/Val SPC reduced BP efficiently and met the needs of most patients to achieve the targets. Aml/Val SPC seems to be a beneficial option for effective BP control, which is a key factor influencing cardiovascular outcome.

Incremental effects of serum uric acid levels, autonomic dysfunction, and low-grade inflammation on nocturnal blood pressure in untreated hypertensive patients and normotensive individuals.

OBJECTIVES: We aimed to evaluate the associations between nocturnal blood pressure (BP) and serum uric acid (SUA) level, low-grade inflammation, and cardiac autonomic function in untreated dipper and nondipper hypertensive patients and normotensive individuals. STUDY DESIGN: The study included 92 consecutive patients (44 men, 48 women; mean age 51.6 ± 9.7 years) who presented for initial evaluation of hypertension. All patients underwent 24-hour Holter monitoring to assess heart rate variability (HRV) and ambulatory BP. Serum high-sensitivity C-reactive protein (hs-CRP) and SUA levels were measured. Due to the non-normal distribution of hs-CRP and microalbuminuria (MAU), they were normalized by logarithmic transformation. RESULTS: Of the study group, 60 patients (65.2%) were diagnosed as hypertensive (50% nondippers). In univariate correlation analysis, log(MAU) showed a significant correlation with nocturnal BP (r=0.560, p<0.001). Among HRV parameters, SDNN, SDANN, and triangular index were inversely correlated with log(hs-CRP) (r=-0.356, p=0.001; r=-0.350, p=0.001; r=-0.314, p=0.002, respectively) and nighttime BP (r=-0.286, p=0.006; r=-0.251, p=0.02; r=-0.294, p=0.004, respectively). Log(hs-CRP) was positively correlated with nighttime BP (r=0.302, p=0.003). Serum UA levels were correlated with only nocturnal BP; i.e., nocturnal mean (r=0.260, p=0.01), systolic (r=0.249, p=0.016), and diastolic BP (r=0.249, p=0.017). In multiple linear regression analysis, log(hs-CRP) and age were independent predictors of cardiac autonomic dysfunction, and log(hs-CRP), SUA, and HRV parameters were independent predictors of nocturnal BP measurements. CONCLUSION: Our findings suggest the role of low-grade inflammation, uric acid levels, and autonomic dysfunction even in the early stages of hypertension.

Endothelial progenitor cells (CD34+KDR+) and monocytes may provide the development of good coronary collaterals despite the vascular risk factors and extensive atherosclerosis.

OBJECTIVE: Endothelial progenitor cells (EPC) have a regenerative role in the vascular system. In this study, we aimed to evaluate simultaneously the effects of EPC and inflammatory cells on the presence and the extent of coronary artery disease (CAD) and the grade of coronary collateral growth in patients with clinical suspicion of CAD. METHODS: This study has a cross-sectional and observational design. We enrolled 112 eligible patients who underwent coronary angiography consecutively (mean age: 59±9 years). The association of circulating inflammatory cells and EPC (defined by CD34+KDR+ in the lymphocyte and monocyte gate) with the presence, severity and extent of CAD and the degree of collateral growth were investigated. Logistic regression analysis was used to define the predictors of collateral flow. RESULTS: Of 112 patients 30 had normal coronary arteries (NCA, 27%, 55±9 years) and 82 had CAD (73%, 61±8 years). Among the patients with CAD, the percent degree of luminal stenosis was <50% in 12 patients; 50-90% in 35 patients; and ≥90% in the other 35 patients. Circulating inflammatory cells were higher (leukocytes, 7150±1599 vs 8163±1588 mm(-3), p=0.001; neutrophils, 4239±1280 vs 4827±1273 mm(-3), p=0.021; monocytes, 512±111 vs 636±192 mm(-3), p=0.001) and EPCs were lower (0.27±0.15% vs 0.17±0.14%, p<0.001; 21±15 vs 13±12 mm(-3), p=0.004) in CAD group than NCA group. When we investigated the collateral growth in patients having ≥90% stenosis in at least one major coronary artery, we found that the patients with good collateral growth had significantly higher EPC (0.22±0.17% vs 0.10±0.05%, p=0.009; 18±15 vs 7±3 mm(-3), p=0.003) in comparison to patients with poor collateral growth. Presence of EPC was associated with reduced risk for coronary artery disease (OR: 0.934, 95%CI: 0.883-0.998, p=0.018) and was an independent predictor for good collateral growth (OR: 1.295, 95%CI: 1.039-1.615, p=0.022). A sum of CD34+KDR-, CD34+KDR+ and CD34-KDR+ cells (192±98 mm(-3)), and a CD34-KDR- cell subpopulation within monocyte gate (514±173 mm(-3)) reached to highest counts in good collateral group among all study population. CONCLUSION: Endothelial progenitor cells can be mobilized from bone marrow to induce the coronary collateral growth in case of myocardial ischemia even in presence of the vascular risk factors and extensive atherosclerosis. This finding may be supportive to investigate the molecules, which can specifically mobilize EPC without inflammatory cells.

Relationship between elevated levels of serum uric acid and saphenous vein graft disease.

OBJECTIVES: Several studies have shown an association between elevated serum uric acid (SUA) levels and coronary heart disease and cardiovascular mortality. We investigated the relationship between SUA levels and the patency of saphenous vein grafts (SVG) after coronary artery bypass graft (CABG) surgery. STUDY DESIGN: The study included 192 patients (152 men, 40 women) who underwent elective coronary angiography after a mean of 5.6 years following CABG surgery, which involved the use of at least one SVG. The patients were divided into two groups depending on the extent of SVG patency. Stenosis of 50% or greater within the SVG was accepted as hemodynamically significant. Serum uric acid levels were determined with the enzymatic colorimetric method. RESULTS: Ninety patients (71 men, 19 women; mean age 62+/-8 years) were found to have patent SVG. Stenotic SVGs were detected in 102 patients (81 men, 21 women; mean age 62+/-10 years). The time interval between surgery and angiography was significantly longer in the stenotic group (p<0.001). Compared to patients without SVG disease, the mean SUA level was significantly higher in patients with SVG disease (4.9+/-1.2 mg/dl vs 5.8+/-1.4 mg/dl; p=0.02). Serum uric acid levels were similar in patients having stenosis in a single vein graft or multiple vein grafts (p=0.224). In multiple regression analysis, SVG disease was independently associated with SUA (p<0.001), diabetes mellitus (p=0.028), and smoking (p=0.039). CONCLUSION: Our results show that there is a significant association between increased SUA levels and SVG disease in patients undergoing CABG, which may justify the need for early screening for hyperuricemia and antiuricemic treatment.

Assessment of left ventricular systolic and diastolic function by tissue Doppler analysis in patients with hypertension with or without hyperuricemia.

OBJECTIVE: Hyperuricemia (HU) is a well-recognized risk factor for cardiovascular diseases. The independence of this association from other confounding factors has remained controversial. The possible contributory effect of HU to myocardial impairment produced by hypertension (HT), however, has not been clarified yet. The study was designed to assess the left ventricular (LV) systolic and diastolic function in patients with HT with or without HU. Tissue Doppler imaging (TDI) was used for detailed analysis as this method was superior to other conventional echocardiographic techniques. METHODS: The study participants consisted of 27 patients (men 56%, mean age+/-SD; 55+/-10 years) with HT without HU, and 27 patients with HT with HU (men 62%, mean age+/-SD; 56+/-9 years), and 27 age-matched healthy control participants (men 57%, mean age+/-SD; 53+/-11 years). Cardiac functions were determined using echocardiography, comprising standard two-dimensional and conventional Doppler and TDI. Peak systolic myocardial velocity at mitral annulus (Sm), mitral inflow velocities and early diastolic mitral annular velocity (Em), late diastolic mitral annular velocity (Am), peak systolic mitral annular velocity, Em/Am, and myocardial performance index were calculated by TDI. RESULTS: Mitral inflow velocities and tissue Doppler-derived mitral annular diastolic velocities were significantly different in the patient groups (HT without HU and HT with HU) compared with the control cases. Tissue Doppler-derived myocardial performance index (LV-MPI) was significantly impaired in the patient groups compared with those of the control's (0.48+/-0.09, 0.53+/-0.07, and 0.39+/-0.07, respectively, P<0.001). Significant differences were also observed between the patients who had HT without HU and the patients who had HT with HU regarding LV-MPI. Significant correlations were observed between the serum uric acid levels and LV function parameters.

Severe coronary artery disease in a 21-year-old girl with pseudoxanthoma elasticum and anomalous origin of the right coronary artery.

Pseudoxanthoma elasticum (PXE) is a genetic disorder characterized by progressive calcific degeneration and fragmentation of the elastic fibres. We present a patient with PXE who had premature atherosclerosis that had involved severely all major coronary vessels as well as an anomalous origin of right coronary artery.