Serum Krebs von den Lungen-6: promising biomarker to differentiate CPFE from IPF.

Background   Combined pulmonary fibrosis and emphysema (CPFE) has been recognised as a phenotype of pulmonary fibrosis. We aimed to compare serum surfactant protein-A (SP-A), surfactant protein-D (SP-D) and Krebs von den Lungen-6 (KL-6) levels, functional parameters, in CPFE and  IPF (idiopathic pulmonary fibrosis) patients. Methods Patients diagnosed with 'CPFE' and 'IPF' were consecutively included in 6 months as two groups. The patients with connective tissue diseases are excluded. Results           In this study, 47 patients (41 males, 6 females) with CPFE (n = 21) and IPF (n = 26) with a mean age of 70.12 ± 8.75 were evaluated. CPFE patients were older, had more intense smoking history, had lower DLCO/VA, lower FVC, and worse six-minute walking distance than the IPF group (p=0.005, p=0.027, p=0.02, p<0.001, p=0.001, respectively). Serum KL-6 levels were higher in CPFE group compared to IPF group [264.70 U/ml (228.90-786) vs 233.60 (101.8-425.4), p<0.001]. Serum KL-6 levels of 245.4 U/ml and higher have 81% sensitivity and 73% specificity for the discrimination of CPFE from IPF. Conclusions   Our study has shown that serum KL-6 level is a promising biomarker to differentiate CPFE from IPF. In CPFE cases respiratory and functional parameters are worse than those of pure fibrosis cases.

Management of Hyperkalemia in Heart Failure.

Hyperkalemia is a common electrolyte abnormality in heart failure (HF) that can cause potentially life-threatening cardiac arrhythmias and sudden cardiac death. HF patients with diabetes, chronic kidney disease and older age are at higher risk of hyperkalemia. Moreover, hyperkalemia is also often associated with the use of renin-angiotensin-aldosterone system inhibitors (RAASi) including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists and sacubitril-valsartan. In clinical practice, the occurrence of hyperkalemia is a major concern among the clinicians and often limits RAASi use and/or lead to dose reduction or discontinuation, thereby reducing their potential benefits for HF. Furthermore, recurrent hyperkalemia is frequent in the long-term and is associated with an increase in hyperkalemia-related hospitalizations. Therefore, management of hyperkalemia has a special importance in HF patients. However, treatment options in chronic management are currently limited. Dietary restriction of potassium is usually ineffective with variable adherence. Sodium polystyrene sulfonate is commonly used, but its effectiveness is uncertain and reported to be associated with intestinal toxicity. New therapeutic options such as potassium binders have been suggested as potentially beneficial agents in the management of hyperkalemia. This document discusses prevalence, predictors and management of hyperkalemia in HF, emphasizing the importance of careful patient selection for medical treatment, uptitration of the doses of RAASi, regular surveillance of potassium and treatment options of hyperkalemia.

What have we learned from Turkish familial hypercholesterolemia registries (A-HIT1 and A-HIT2)?

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is a common genetic disease of high-level cholesterol leading to premature atherosclerosis. One of the key aspects to overcome FH burden is the generation of large-scale reliable data in terms of registries. This manuscript underlines the important results of nation-wide Turkish FH registries (A-HIT1 and A-HIT2). METHODS: A-HIT1 is a survey of homozygous FH patients undergoing low density lipoprotein (LDL) apheresis (LA). A-HIT2 is a registry of adult FH patients (homozygous and heterozygous) admitted to outpatient clinics. Both registries used clinical diagnosis of FH. RESULTS: A-HIT1 evaluated 88 patients (27 ±â€¯11 years, 41 women) in 19 centers. All patients were receiving regular LA. There was a 7.37 ±â€¯7.1-year delay between diagnosis and initiation of LA. LDL-cholesterol levels reached the target only in 5 cases. Mean frequency of apheresis sessions was 19 ±â€¯13 days. None of the centers had a standardized approach for LA. Mean frequency of apheresis sessions was every 19 ±â€¯13 (7-90) days. Only 2 centers were aware of the target LDL levels. A-HIT2 enrolled 1071 FH patients (53 ±â€¯8 years, 606 women) from 31 outpatients clinics specialized in cardiology (27), internal medicine (1), and endocrinology (3); 96.4% were heterozygous. 459 patients were on statin treatment. LDL targets were attained in 23 patients (2.1% of the whole population, 5% receiving statin) on treatment. However, 66% of statin-receiving patients were on intense doses of statins. Awareness of FH was 9.5% in the whole patient population. CONCLUSIONS: The first nationwide FH registries revealed that FH is still undertreated even in specialized centers in Turkey. Additional effective treatment regiments are urgently needed.

Serum paraoxonase activity in patients with ischaemic and nonischaemic dilated cardiomyopathy.

BACKGROUND: This study examined whether the serum PON1 activity is different in patients with ischaemic dilated cardiomyopathy (IDCM) and nonischaemic dilated cardiomyopathy (NDCM) and the relation between the serum PON1 activity and serum pro-BNP levels. METHODS AND RESULTS: In this study, we enrolled 60 patients with left ventricular systolic failure (New York Heart Association [NYHA] class III-IV) and a left ventricular ejection fraction (EF) < 40% as determined by echocardiography and 30 healthy subjects. The patients with systolic heart failure were divided into two groups: patients with IDCM and patients with NDCM. Blood samples were obtained to measure the serum PON1 activity and the serum pro-BNP levels. The median serum PON1 activities were lower among the patients with IDCM or with NDCM compared with the control subjects (p < .001, p = .043, respectively). Compared with the control subjects, the patients with IDCM or with NDCM had higher serum pro-BNP levels (p < .001, p < .001, respectively). The serum PON1 activity was negatively correlated with the serum pro-BNP levels in patients with IDCM (r = -0.548, p < .001). The area under the ROC curve of the serum PON1 activity was 0.798. Using a serum PON1 activity of 201.3 U/L as a cut-off value, the sensitivity was 86.84% and specificity was 66.67% for the diagnosis of IDCM. CONCLUSIONS: In this study, the serum PON1 activity was significantly reduced in the patients with IDCM or with NDCM compared with the control subjects. The serum PON1 activity of the patients with IDCM was negatively correlated with the serum pro-BNP levels.

[Approach to heart failure in the elderly]. / Yaslilarda kalp yetersizligine yaklasim.

The prevalence of heart failure increases with age. Several specific changes in cardiac structure and function are associated with cardiac ageing. Because of age-associated changes leading to diastolic dysfunction, heart failure with preserved ejection fraction is the most common form of heart failure in the elderly. The diagnosis of heart failure may be difficult to diagnose in elderly patients because of a lack of typical symptoms and physical findings. The elderly patients may respond differently to heart failure medications. Age-associated changes in physiology, comorbidities, drug interaction, medication side-effects, and compliance should be considered when choosing a drug to manage heart failure in the elderly.

[Approach to mitral valve diseases in the elderly]. / Yaslilarda mitral kapak hastaliklarina yaklasim.

Valvular disease continues to be an important cause of morbidity and mortality across the globe with an increasing number of elderly patients affected by degenerative valvular diseases. Mitral valve disease is the most common of the valvular heart disorders, particularly in ageing populations, with a prevalence of more than 10% in people aged older than 75 years. Mitral regurgitation (MR) is divided into either primary (or organic) or secondary (or functional) MR. It is necessary to distinguish primary from secondary MR because these diseases differ not only by their cause, but also by their prognosis and management. Mitral stenosis is usually due to rheumatic disease, but annular calcification might cause obstruction in mitral valve , particularly in the elderly population. Because of the accompanying risk factors and comorbidities with the increasing age, surgical interventions have been replaced by catheter based alternative treatment options.

Iron deficiency and anemia in heart failure.

Heart failure is an important community health problem. Prevalence and incidence of heart failure have continued to rise over the years. Despite recent advances in heart failure therapy, prognosis is still poor, rehospitalization rate is very high, and quality of life is worse. Co-morbidities in heart failure have negative impact on clinical course of the disease, further impair prognosis, and add difficulties to treatment of clinical picture. Therefore, successful management of co-morbidities is strongly recommended in addition to conventional therapy for heart failure. One of the most common co-morbidities in heart failure is presence of iron deficiency and anemia. Current evidence suggests that iron deficiency and anemia are more prevalent in patients with heart failure and reduced ejection fraction, as well as those with heart failure and preserved ejection fraction. Moreover, iron deficiency and anemia are referred to as independent predictors for poor prognosis in heart failure. There is strong relationship between iron deficiency or anemia and severity of clinical status of heart failure. Over the last two decades, many clinical investigations have been conducted on clinical effectiveness of treatment of iron deficiency or anemia with oral iron, intravenous iron, and erythropoietin therapies. Studies with oral iron and erythropoietin therapies did not provide any clinical benefit and, in fact, these therapies have been shown to be associated with increase in adverse clinical outcomes. However, clinical trials in patients with iron deficiency in the presence or absence of anemia have demonstrated considerable clinical benefits of intravenous iron therapy, and based on these positive outcomes, iron deficiency has become target of therapy in management of heart failure. The present report assesses current approaches to iron deficiency and anemia in heart failure in light of recent evidence.

Practical approaches for the treatment of chronic heart failure: Frequently asked questions, overlooked points and controversial issues in current clinical practice.

Heart failure (HF) is a progressive disorder associated with impaired quality of life, high morbidity, mortality and frequent hospitalization and affects millions of people from all around the world. Despite further improvements in HF therapy, mortality and morbidity remains to be very high. The life-long treatment, frequent hospitalization, and sophisticated and very expensive device therapies for HF also leads a substantial economic burden on the health care system. Therefore, implementation of evidence-based guideline-recommended therapy is very important to overcome its worse clinical outcomes. However, HF therapy is a long process that has many drawbacks and sometimes HF guidelines cannot answers to every question which rises in everyday clinical practice. In this paper, commonly encountered questions, overlooked points, controversial issues, management strategies in grey zone and problems arising during follow up of a HF patient in real life clinical practice have been addressed in the form of expert opinions based on the available data in the literature.

Acute effect of hemodialysis on arterial elasticity.

BACKGROUND/AIM: Reduced arterial elasticity is an independent predictor of cardiovascular mortality in patients with end-stage renal disease (ESRD). Hemodialysis (HD) treatment per se can bring additional risk factors for vascular disease. Our study was designed to determine whether a single hemodialysis session leads to an acute alteration in parameters of arterial elasticity in ESRD. MATERIALS AND METHODS: In this study, 58 patients undergoing chronic hemodialysis and 29 healthy controls were enrolled. Large artery elasticity index (LAEI) and the small artery elasticity index (SAEI) were measured by applanation tonometry. The acute effect of a hemodialysis session on arterial elasticity indices was assessed by comparison of prehemodialysis and posthemodialysis determinations. RESULTS: At baseline, LAEI did not differ significantly in patients compared with controls. In contrast, the SAEI was significantly lower in patients (4.1 ± 2.6 mL/mmHg x 100) than in healthy individuals (8.9 ± 3.4 mL/mmHg x 100, P < 0.05). In patients with ESRD, no significant changes in LAEI was observed after HD, but SAEI deteriorated significantly (from 4.1 ± 2.6 mL/mmHg x 100 to 3.4 ± 2.3, P < 0.05). CONCLUSION: We conclude that ESRD patients face a significant reduction in SAEI, which is exacerbated by a dialysis procedure.

Acute Haemodialysis-induced Changes in Tissue Doppler Echocardiography Parameters.

BACKGROUND: Tissue Doppler imaging (TDI) is a method that determines the tissue motion and velocity within the myocardium. AIMS: To characterize acute haemodialysis (HD)-induced changes in TDI-derived indices for patients that have end-stage renal disease (ESRD). STUDY DESIGN: Cross sectional study. METHODS: Conventional echocardiography and TDI methods were applied to study ESRD patients (n=58) before and after HD. Pulmonary venous flow, mitral inflow, and TDI signals of the lateral and septal mitral annulus were examined for the determination of altered left-ventricular diastolic filling parameters. Flow velocities from early- (E) and late-atrial (A) peak transmitral; peak pulmonary vein systolic (S) and diastolic (D); and myocardial peak systolic (Sm) and peak early (Em) and late (Am) diastolic mitral annular velocities were also assessed for changes. RESULTS: Transmitral E and A velocities and the E/A ratio decreased significantly after HD (p<0.001). Pulmonary vein S (p<0.001) and D (p<0.001) velocities decreased, and S/D ratios increased significantly (p=0.027). HD led to a reduction in septal Em (p<0.001), lateral Em (p=0.006), and Am (p<0.001) velocities. Contrary to the decreases in Em and Am, the Em/Am ratio remained unchanged. CONCLUSION: A single HD session was associated with an acute deterioration in the diastolic parameters. Since the Em/Am ratio remained unchanged, we conclude that this index is a relatively load-independent measure of diastolic function in HD patients.

Treatment with a combination of bosentan and sildenafil allows for successful liver transplantation in a patient with portopulmonary hypertension.

Pulmonary arterial hypertension (PAH) that occurs in the setting of cirrhosis and portal hypertension is referred to as portopulmonary hypertension (PPHTN). Liver transplantation (LTx) is curative, but the presence of moderate-to-severe PPHTN may be a contraindication for transplantation because of the elevated risk of peri- and post-transplantation morbidity and mortality. We report a successful liver transplantation in a patient with liver cirrhosis after treatment of moderate-to-severe PPHTN with a combination of the dual endothelin receptor antagonist bosentan and the specific phosphodiesterase-5 inhibitor sildenafil.

Dislodgement of a sirolimus-eluting stent in the circumflex artery and its successful deployment with a small-balloon technique.

Coronary stent dislodgement or embolization before deployment is a rare but serious complication in interventional cardiology. A 60-year-old male presented with unstable angina five years after coronary artery bypass surgery. There was a stenosis (70%) in the obtuse marginal branch of the circumflex artery. During percutaneous coronary intervention, a sirolimus-eluting stent was stripped from its balloon mainly because of significant proximal angulation and incarcerated within the proximal circumflex artery. A smaller balloon dilatation catheter was advanced and pushed through the inside of the slipped stent. Using this technique, the stent could be advanced into the lesion and was successfully deployed. To our knowledge, this is the first case report on sirolimus-eluting stent dislodgement.

Successful treatment of saphenous venous graft thrombus by tirofiban infusion.

A 60-year old man with a history of coronary-artery bypass grafting presented with symptoms of acute coronary syndrome. Coronary angiography revealed a huge intraluminal thrombus in the saphenous vein graft to the second obtuse marginal branch of the left circumflex artery. A glycoprotein IIb/IIIa inhibitor (tirofiban) was administered intravenously. Two days later, thrombus dissolution and Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow were evident on repeat coronary angiography. Glycoprotein IIb/IIIa inhibitors may be useful in a thrombus-laden saphenous-vein graft.

Diffuse involvement of the heart and great vessels in primary cardiac lymphoma.

Primary cardiac lymphoma (PCL) is an extremely rare disorder. In this report, a 57-year-old male with diffuse large B-cell lymphoma involving the heart and great vessels is presented. Trans-thoracic echocardiography was the first modality used to establish the diagnosis. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) showed diffuse increased metabolic activity of the heart walls and hypermetabolic lesions occupying cardiac chambers in some areas. The patient underwent systemic chemotherapy, and after 13 days, a marked regression of the tumour mass was evident based on echocardiographic examination. After completing six R-CHOP chemotherapy treatments, PET imaging was planned to control the residual mass, but the patient was intubated due to pneumonia that developed after the sixth chemotherapy session and subsequently died due to sepsis.

A rare combination of left main coronary artery fistula to main pulmonary artery with severe left main coronary artery disease in a 69-year-old man.

A 69-year-old man was referred to our hospital with a diagnosis of non-ST elevation myocardial infarction. A selective left coronary angiography revealed a fistula connecting the left main coronary artery with the pulmonary artery in addition to severe left main coronary artery disease. The patient subsequently underwent ligation of fistulae and coronary bypass grafting. The combination of a fistula and severe artery disease seen in this patient is unusual because fistulas originating from the left main coronary artery drain into the pulmonary artery in patients with severe left main coronary artery disease.

Resolution of a giant atrial thrombus following anticoagulation therapy.

We report on a patient in whom a giant thrombus in the left atrium was detected by transthoracic echocardiography. Anticoagulant theraphy was started. After two months of therapy, repeat echocardiography showed complete resolution of the thrombus. This case indicates that large and presumably organised thrombi may be treated with anticoagulant therapy.

Patent foramen ovale in a large population of ischemic stroke patients: diagnosis, age distribution, gender, and race.

BACKGROUND: Patent foramen ovale (PFO) is a well-recognized risk factor for ischemic strokes. The true prevalence of PFO among stroke patients is still under debate. Transesophageal echocardiography (TEE) is the "gold standard" in diagnosing PFO but the physiology requires right-to-left atrial shunting. In this report, we evaluate the prevalence of PFO in a diverse group of ischemic stroke patients studied by TEE. METHODS: TEE of 1,663 ischemic stroke patients were reviewed for cardiac source of embolism, including PFO and atrial septal aneurysm (ASA). Agitated saline bubble injection was performed to look for right to left atrial shunting. Success of maneuvers to elevate right atrial pressure (RAP) was noted by looking at the atrial septal bulge. RESULTS: Among 1,435 ischemic stroke patients analyzed, the presence or absence of PFO could not be determined in 32.1% because bulging of the septum could not be demonstrated in patients with negative contrast study despite aggressive maneuvers to elevate RAP. Of the remaining 974 patients, 294 patients (30.2%) had a PFO. The mean age was 61.5 years in both groups, with a bimodal distribution of PFO and the highest prevalence occurring in < or =30-year-old group. Prevalence of PFO was similar in men (32.4%) and women (28.15%, P = 0.15); and in Caucasian (32.1%) and African American (27.7%; P = 0.15). ASA was present in 2.02% and hypermobile septum in 2.49% of the 1,435 patients. PFO was seen in 79.3% of the patients with ASA. CONCLUSION: Successful elevation of RAP cannot be achieved in a significant number of patients undergoing TEE and determination of PFO may be difficult. In our series, the true prevalence of PFO among ischemic stroke patients was 30.2% taking into account only those patients who showed no shunting despite bulging of the atrium septum into the left atrium (PFO absent group) during the contrast study. There was no gender or racial difference in the prevalence of PFO, but there was a bimodal distribution in prevalence with age.

Relationship between the arterial calcification detected in mammography and coronary artery disease.

OBJECTIVE: Arterial calcification is frequently encountered in mammography. The frequency of breast arterial calcification (BAC) increases with increasing age. Studies have shown that BAC is seen more frequently among the people who are under the risk of coronary artery diseases (CAD) such as diabetes and hypertension. The objective of this study is to investigate the relationship between the arterial calcification detected in mammography and the CAD. MATERIAL AND METHODS: Screening mammography was performed in 123 women above the age of 40 years who had been examined with coronary angiography for the evaluation of CAD. The presence of BAC, number of affected vessels, and the distribution of calcification in the vessel wall were evaluated in the mammography. Subjects were questioned in terms of the cardiovasculary risk factors. The severity of CAD was evaluated according to the Gensini scoring. In addition, the number of blood vessels with stenosis of more than 50% was used as the vascular score. The correlation between Gensini and the vascular scores, and BAC was statistically evaluated using Mann-Whitney U and Kruskal-Wallis tests. RESULTS: Eighty (65%) of 123 patients had CAD. BAC was detected in the mammography of 49 (39.8%) subjects. The ages and duration of menopause of the cases with BAC were significantly higher than those without BAC (p<0.001). There was an almost significant correlation between the BAC and Gensini scores (p=0.059). There was a significant increase in the frequency of BAC among subjects with more than two vessels with stenosis (p=0.033). CONCLUSION: Frequency of BAC increases with increasing age. BAC is also frequently seen in subjects having severe coronary artery disease. Although increasing age may be a factor increasing the frequency of BAC, BAC may also be an indicator of CAD. Therefore, the mentioning of arterial calcification in mammography reports may be important in warning the clinician in terms of CAD.