New insights into the mechanisms of diastolic dysfunction in patients with type 2 diabetes.

BACKGROUND: Little is known about the role of advanced glycation end products (AGEs) and their receptor (RAGE) in diabetic cardiovascular complications. Therefore, we aimed to evaluate the association of serum soluble RAGE (sRAGE) levels and left ventricular (LV) diastolic dysfunction in patients with type 2 diabetes. METHODS: Our study consisted of 40 patients with type 2 diabetes and 40 age- and sex-matched healthy control group. Subjects with age ≥ 50 years old and any cardiovascular risk factors or conditions were excluded from the study. Serum sRAGE levels determined by enzyme-linked immunosorbent assay and LV diastolic dysfunction were evaluated according to current American Society of Echocardiography guidelines. RESULTS: Baseline characteristics were similar between groups except body mass index, waist-hip ratio, and fasting glucose levels. Serum sRAGE level was significantly lower in diabetic group compared with control group (676 ± 128 vs. 1044 ± 344, p < 0.05). Diastolic dysfunction was observed in 50% of diabetic patients (40% grade I and 10% grade II). Correlation analysis showed that serum sRAGE was negatively correlated with duration of diabetes, septal E'/A', lateral E'/A', and average E/E'. In multivariate regression analysis, serum sRAGE level was strongly associated with diastolic dysfunction in patients with type 2 diabetes. CONCLUSION: Our study showed that serum sRAGE level was significantly lower in type 2 diabetic patients aged < 50 years old. Also, sRAGE has negative correlation with the duration of diabetes and it was significantly associated with the presence of diastolic dysfunction in type 2 diabetes.

Prevalence of coronary artery disease before valvular surgery in patients with rheumatic valvular disease.

BACKGROUND: Although many patients with valvular heart disease have concomitant coronary artery disease (CAD), there are limited data on the association between rheumatic valvular disease (RVD) and CAD. In this study, we aimed to investigate the prevalence of CAD in a group of patients with RVD and undergoing coronary angiography before valvular surgery. METHODS: In this retrospective analysis, we enrolled a total of 1075 patients (658 women, 61.2%; mean age: 53.2 ± 9.9 years) who underwent coronary angiography for the evaluation of CAD before valvular surgery between January 2003 and May 2010. RESULTS: The overall prevalence of significant CAD was 11.1%. Patients with significant CAD were older than patients without significant CAD (55.16 ± 10.4 vs. 51.45 ± 9.1; P<0.001). In addition, hypertension, smoking, diabetes mellitus, and dyslipidemia were more prevalent among patients with significant CAD (P<0.05). After adjustment for several risk factors, only aortic stenosis remained the predictor of significant CAD (odds ratio: 1.66; 95% confidence interval: 1.26-2.19; P<0.001). However, aortic regurgitation was inversely associated with the presence of CAD (odds ratio: 0.56; 95% confidence interval: 0.21-1.01; P<0.001). CONCLUSION: The overall prevalence of CAD in our population with RVD was low. Rheumatic aortic stenosis is associated with an increased prevalence of CAD, whereas the prevalence of CAD is lower in those patients with aortic regurgitation.

Diagnostic accuracy and clinical utility of echocardiographic indices for detecting left ventricular diastolic dysfunction in patients with coronary artery disease and normal ejection fraction.

OBJECTIVE: The aim of present study was to assess the clinical utility and diagnostic accuracy of diastolic dysfunction criteria that were recommended in current American Society of Echocardiography and European Association of Echocardiography recommendations for prediction of increased LVEDP (>16 mmHg) in patients with coronary artery disease and normal EF. METHODS: Forty-five consecutive patients (mean age=61.5±10.3 years) referred for cardiac catheterization were enrolled in this prospective study. All patients underwent transthoracic echocardiography and tissue Doppler imaging within 24 hours before cardiac catheterization. Patients were divided into 2 groups according to left ventricular end diastolic pressure (LVEDP) (LVEDP>16 mmHg, n=23; LVEDP≤16 mmHg, n=22). Receiver operating characteristics curve analyses were performed and sensitivity, specificity, positive predictive value and negative predictive value were calculated for indices to detect high LVEDP. RESULTS: Among the indices, left atrial volume index (LAVI) ≥34 ml/m2 (sensitivity=60.0% and specificity=90.0%) and ratio of transmitral to septal annular velocities during early filling (septal E/e' ratio) ≥15 (sensitivity=30.4% and specificity=95.5%) had more reasonable sensitivity and specificity. Receiver operating characteristics curve analysis revealed that best predictors of high LVEDP were septal E/e' [area under curve (AUC)=0.694, standard error (SE)=0.66, p=0.01] and LAVI (AUC=0.669, SE=0.63, p=0.045]. There were statistically significant correlations between LVEDP and septal E/e' (r=0.541, p=0.001) and LAVI (r=0.461, p=0.002). A proposed algorithm consisting LAVI ≥34 ml/m2 and septal E/e' >8 could determine diastolic dysfunction with a 95.6% sensitivity and 54.5% specificity. CONCLUSION: Septal E/e' (≥15) and LAVI (≥ 34 ml/m2) were the better predictors of the increased LVEDP than the other echocardiographic parameters. There were statistically significant moderate positive correlations of LVEDP with septal E/ e' and LAVI. Combination of LAVI and septal E/e' is useful to detect diastolic dysfunction.

Pulmonary embolism presenting with evolving electrocardiographic abnormalities mimicking anteroseptal myocardial infarction: a case report.

OBJECTIVES: To report a case with dynamic ST segment elevation suggestive of anteroseptal acute myocardial infarction (AMI) that proved to be bilateral pulmonary thromboembolism (PTE). CLINICAL PRESENTATION AND INTERVENTION: A 50-year-old woman with syncope was transferred to the emergency department. Findings from the admission electrocardiogram were suggestive of anteroseptal AMI; however, coronary angiography revealed that the patient had normal coronary arteries. On further evaluation, the patient was found to have massive bilateral PTE. CONCLUSION: This report emphasizes the role of evolving electrocardiographic changes in the diagnosis of PTE, particularly in patients with chest pain and ST segment elevation suggestive of acute coronary syndrome.

Are the conventional cutoff values adequate to define hypertension in young women?

BACKGROUND: Women have lower systolic blood pressure (SBP) levels than men during early adulthood. Diastolic blood pressure (DBP) tends to be just marginally lower in women than men regardless of age. OBJECTIVE: Aims of this study were (i) to determine 95th percentile value of SBP, DBP, and mean arterial blood pressure in healthy women, and (ii) to evaluate the effects of basal demographic and anthropometric features on blood pressure. METHODS: Six hundred and fifty-four consecutive participants (18-35 years old) were initially enrolled in the study but among them 54 (8.2%) cases were excluded. Demographic features, relevant personal and family history data about hypertension, smoking habits, and use of medications were interviewed using a questionnaire. Blood pressure, height, weight, and waist circumference of every case were measured. RESULTS: Of the 600 patients (mean age, 24.6±4.0 years), 124 (20.7%) were currently smokers, 20 (3.3%) had history of hypertension during pregnancy, and 291 (48.5%) had family history of hypertension in women (mean age, 61.0±9.51 years). Reference ranges of 5th and 95th percentile values for SBP were determined as 74 and 115 mmHg, for mean arterial blood pressure as 57 and 85 mmHg, for DBP as 45 and 72 mmHg, respectively. CONCLUSION: In conclusion, cutoff values of hypertension in healthy women, which were determined by our study, are lower than the standard cutoff values for definition of hypertension in adults. However, clinical importance of these findings should be investigated in further studies involving larger population with prospective follow-up.

[Mean systolic annular velocity and strain score index: new and non-invasive parameters for the evaluation of acute myocardial infarction patients]. / Ortalama sistolik anüler velosite ve strain skor indeksi: akut miyokart enfarktüsü hastalarinin degerlendirilmesinde yeni ve invazif olmayan parametreler.

OBJECTIVE: To evaluate the diagnostic value of mean annular velocity (MAV) and strain score index (SSI) for determination of the left ventricular systolic dysfunction in patients with first acute myocardial infarction (AMI). METHODS: Seventy-one patients (55 male, mean age: 59+/-12 years) with first acute ST-elevation myocardial infarction and 30 healthy subjects were included in this cross-sectional and observational study. Echocardiography with tissue Doppler and strain analysis was performed during initial hospital admission. Peak systolic myocardial velocities were recorded from 4 different sites on the mitral annulus. A MAV value was calculated and the peak systolic strain values of 12 segments were measured and a mean SSI was calculated. ROC curve analysis was used in order to determine cut-off values for MAV and SSI. RESULTS: The patients with AMI had a significantly reduced MAV compared with healthy subjects (5.52+/-1.78 cm/s vs 9.80+/-1.13 cm/s, p<0.001). In ROC analysis, a cut-off value of 8.41 cm/s (AUC 0.915, 95%CI 0.887-0.952, p<0.001) for MAV differentiated AMI patients from controls with 97.2% sensitivity and 93.3% specificity. The patients with AMI have also decreased SSI (11.23+/-2.83 vs 19.11+/-2.05, p<0.001). A cut-off value of 15.35% differentiated AMI patients from controls with 94.4% sensitivity and 100% specificity (ROC AUC 0.945, 95%CI 0.901-0.972, p<0.001). There was a good correlation between left ventricular EF and MAV (r=0.73, p<0.001) and SSI (r=0.66, p<0.001). CONCLUSION: The patients with first myocardial infarction have decreased mean systolic annular velocity and mean systolic strain score index.

Intron 4 VNTR polymorphism of eNOS gene is protective for cardiac syndrome X.

Microvascular abnormalities caused by endothelial dysfunction seem to be responsible for the myocardial ischemia in patients with cardiac syndrome X (CSX). Nitric oxide is a key mediator of endothelial function and is synthesized by endothelial nitric oxide synthase (eNOS). We investigated if the 3 potential polymorphisms of the eNOS gene (VNTR in intron 4, T786C polymorphism in the promoter region, and G894T polymorphism in exon 7) are independent risk factors for CSX. Sixty-nine patients with CSX and 73 healthy controls were studied. Genotypes were determined through polymerase chain reaction with or without restriction endonuclease digestions. Genotype distribution was significantly different between patients with CSX and controls for intron 4aa (allele for 4 repeats of 27 bp), intron 4aa genotype frequency being 3.2% and 6.8%, respectively. The presence of intron 4a is 3.2 (odds ratio) times protective (95% confidence interval, 1.5-6.8) for the risk of CSX disease. The protective effect of intron 4a polymorphism also holds after adjustment for age and sex and when the study group is limited to those without hypertension and hyperlipidemia. No significant difference was observed in genotype distribution of G894T and T786C polymorphism between patients with CSX and controls. In conclusion, intron 4aa genotype of eNOS gene is protective for CSX. No association was found between promoter and exon 7 polymorphisms of eNOS gene and CSX.

Association of plasma osteopontin levels with coronary calcification evaluated by tomographic coronary calcium scoring.

Evidence indicates that proteins controlling bone mineralization are also involved in the regulation of coronary calcification. The aim of the present study is to evaluate the association between plasma osteopontin (OPN) levels and coronary calcification quantified by using tomographic coronary calcium scoring. Plasma OPN levels were measured from samples of 80 intermediate-risk asymptomatic patients (56 +/- 10 years) who underwent tomographic coronary calcium scoring via multislice computed tomography for incremental risk stratification. There was no significant difference regarding OPN levels between patients with and without coronary calcification in the whole study population. Of 49 patients not receiving renin-angiotensin system inhibitors and/or statins, plasma OPN levels of patients with coronary calcification (38.7%) were significantly higher than those without coronary calcification (61.3%) (8.88 +/- 2.85 vs. 6.79 +/- 2.41, P = 0.008, respectively). On a binary logistic regression model, only age and plasma OPN level were found to be significant independent associated variables for the presence of coronary calcification in patients not receiving these medications (odds ratio for age, 1.15, P = 0.017; for plasma OPN levels, 1.63, P = 0.014). Our results indicate that plasma OPN levels may be predictive of coronary calcification, suggesting an important role of OPN in the atherosclerotic calcification pathogenesis.

[The early predictors of ventricular remodeling after myocardial infarction: the role of tumor necrosis factor-alpha]. / Akut miyokard infarktüsü sonrasi ventriküler yeniden biçimlenme erken belirleyicileri: Tümör nekrozis faktör-alfa'nin rolü.

OBJECTIVE: Ventricular remodeling (VR) is a pathologic process characterized by progressive ventricular dilatation occurring after acute myocardial infarction (MI) leading to left ventricular systolic dysfunction. The purpose of the study was to evaluate the efficacy of plasma tumor necrosis factor alpha (TNF-alpha) levels to predict the left VR. METHODS: This prospective observational cohort study included 72 consecutive patients with newly diagnosed MI with age ranging between 38-87 years (mean 59 +/- 12 years). Control group was consisted of 30 patients with no additional systemic disease and normal coronary arteriograms. Transthoracic echocardiography was performed to all patients and controls both in the beginning of the study and in the 6th follow-up. A coronary arteriography was also performed to all patients. Patients with an increment in the diastolic volume index more than 20% in the follow-up compared with basal values included in the VR subgroup. The patient subgroup with VR consisted of 19 patients. Statistical analyses were performed using ANOVA and Kruskal Wallis tests for comparison of variables between groups. Logistic regression and ROC analyses were used for evaluation of accuracy of TNF-alpha in prediction of VR. RESULTS: There were no significant differences between groups according to demographic characters. The basal plasma levels of TNF-alpha were higher in the patient subgroup with VR as compared with patients without VR and controls (14.59 +/- 4.28 pg/ml vs 7.30 +/- 4.48 pg/ml, and 1.64 +/- 1.49 pg/ml, p< 0.001). In logistic regression analysis only TNF-alpha predicted the VR (OR-1.356, 95% CI 1.117-1.647). Plasma TNF-alpha levels with a cut-off > or = 10.33 pg/ml were found to have 89.5% sensitivity and 79.3% specificity to predict the development of VR. CONCLUSION: These results demonstrate the increment of plasma TNF-alpha levels in the acute phase of MI and the close relationship between the TNF-alpha levels and VR in the patients with first MI.

Early electrocardiographic diagnosis of acute coronary ischemia on the paced electrocardiogram.

BACKGROUND: Twelve-lead electrocardiography (ECG) is the most important source for the early diagnosis of an acute myocardial ischemia. However, its diagnostic value when the sequence of ventricular activation is altered by ventricular pacing is unknown. The aim of the study was to evaluate the ECG changes on the paced ECG during percutaneous coronary intervention (PCI) by doing temporary pacing. METHODS AND RESULTS: Standard 12 lead baseline and temporary pacing ECG records were taken before the intervention in elective PCI patients. Standard 12 lead and temporary pacing ECG records were repeated during the balloon inflation. Fifteen (12 men and 3 women; age 57.2+/-9.7 years) subjects who were undergoing routine PCI were studied. Mean Delta ST deviation on the normal conduction ECG during inflation was 1.03+/-1.02 mV and mean Delta ST deviation on the paced ECG during inflation was 1.7+/-1.6 mV. The pre-inflation mean QRS duration on the paced ECG was 143.2+/-2.8 ms and during inflation mean QRS duration was 157.8+/-12.5 ms. The mean QRS prolongation was 14.6+/-13.6 ms on the paced ECG. Despite the presence of paced ECG abnormalities, significant ischemic ST segment deviations were seen after referencing the ST segment deviations to the pre-PCI. Also, there is significant QRS prolongation on the paced ECG during ischemia. CONCLUSIONS: The present study extends the correlation between normal and paced ECG during ischemia and the QRS prolongation could be a marker of myocardial ischemia on the paced electrocardiogram.

Determination of left ventricular filling pressure by new echocardiographic methods in patients with coronary artery disease.

AIM: The present study was designed to determine the reliability of the analysis of the time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity and mean systolic strain index, and comparing them with E/E' in the detection of increased left ventricular end-diastolic pressure (LVEDP) in patients with coronary artery disease. METHODS: Eighty patients (mean age: 57.2 +/- 11.5 years) referred for cardiac catheterization were studied. Patients were divided into 2 groups according to LVEDP (group 1: LVEDP > 20 mmHg, n = 39 patients; group 2: LVEDP < or = 20 mmHg, n = 41 patients). From the mitral inflow, peak E velocity was calculated. With tissue Doppler echocardiography, early diastolic velocity (E') measured from the septal, lateral, inferior and lateral mitral annulus and mean value of E' and E/E' ratio were calculated. The time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity (T(E'-E)) was calculated. From the apical chambers, the peak systolic strain value of 16 left ventricular (LV) segments was measured and the mean of these 16 segments was calculated and referred to as mean systolic strain index. RESULTS: The patients with increased LVEDP (group 1) had a higher E/E' ratio (13.8 +/- 3.4 vs. 9.9 +/- 2.8, P < 0.001) and lower mean systolic strain index (11.8 +/- 3.4 % vs. 13.5 +/- 3.6 %, P = 0.038) than patients in group 2. The sensitivity of E/E' > 13.42 for identifying LVEDP > 20 mmHg was 71%, with a specificity of 89%. The sensitivity of a mean systolic strain index < 10.57% for identifying LVEDP > 20 mmHg was 44%, with a specificity of 83%. T(E'-E )was not significantly different between the two groups. CONCLUSION: The decreased longitudinal function of the left ventricle is related to increased LVEDP. The E/E' ratio, which in recent years has been used for the prediction of LV filling pressures, was a better predictor for increased LVEDP than the mean systolic strain score index and the time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity in patients with coronary artery disease.

Comparison of strain doppler echocardiography and radiologic left ventriculography for quantitative assessment of regional myocardial function.

OBJECTIVE: We aimed to study the comparison of strain and strain rate parameters with conventional left ventriculography derived regional function. METHOD: Forty patients were included in the study. The study group was selected from patients who had undergone left ventriculography and coronary angiography for clinical indications. Regional myocardial function was assessed using the centerline method via ACOM PC Quantcor LVA measurement system. Patients were also evaluated with echocardiography. Strain and strain rate Doppler echocardiographic measurements were compared with conventional left ventriculography at anterobasal, anterolateral, inferior and posterobasal segments. RESULTS: Radiological left ventricular radial shortening was found to correlate with longitudinal strain shortening in all ventriculographic segments examined (anterobasal, r = 0.771, P < 0.0001; anterolateral, r = 0.790, P < 0.0001; posterobasal, r = 0.861, P < 0.0001; inferior, r = 0.815, P < 0.0001). Correlation was persistent both in patients with or without coronary artery disease. The sensitivity of a peak systolic longitudinal strain >12.5% for prediction of patients with radial shortening >or=20% was 75%, with a specificity of 100%. However, no relationship could be demonstrated between radiological left ventricular radial shortening and strain rate measurements. CONCLUSIONS: In our study it was shown that regional wall motion can be measured quantitatively via strain Doppler echocardiography with the left ventriculography as reference.

QT interval dispersion changes according to the vessel involved during percutaneous coronary angioplasty.

Increased QT dispersion (QTd) is a noninvasive marker of an electrophysiologic abnormality associated with high mortality in coronary artery disease. The purposes of this study were to measure changes in QTd and ST-segment changes immediately before, during and after intracoronary balloon inflation and to determine whether the coronary artery vessel involved and/or the duration of inflation affect(s) QTd. A total of 45 patients (32 men, 13 women, mean age 58 +/- 11 years) who were referred for elective percutaneous transluminal coronary angioplasty were included. The mean QT interval dispersions for all patients before the inflation, during the balloon inflation at 60 sec and after the balloon deflation at 5 min were 68 +/- 13 ms, 82 +/- 16 ms and 71 +/- 13 ms, respectively. There was no significant difference between baseline and 5 min after deflation. The increase in QTd during the balloon inflation was significant (p<0.01). There was no significant QTd change in patients with left circumflex artery (Cx) lesions during inflation and after deflation compared with baseline. The differences were statistically significant only in patients with left anterior descending (LAD) lesions and right coronary artery (RCA) lesions at 60 sec during balloon inflation (p=0.001 vs. p=0.04). Acute reversible myocardial ischemia induced by balloon inflation causes an increase in QTd limited to the LAD and RCA vessels. Therefore, when using QTd as a marker of myocardial repolarization abnormality due to acute reversible ischemia, the involved coronary artery vessel must be taken into account.

Effects of acute exercise on fibrinolysis and coagulation in patients with coronary artery disease.

Acute physical exertion may trigger an acute coronary syndrome. Furthermore, acute physical exercise may influence hemostatic markers in healthy individuals. However, the effect of acute exercise on blood fibrinolysis and coagulation in patients with coronary artery disease (CAD) is still not well understood. Nineteen untrained patients with angiographically proven CAD (age, 58 +/- 9 years, 12 males), and 25 age- and sex-matched controls without CAD (age, 56 +/- 6 years, 16 males) underwent a treadmill exercise test. Global fibrinolytic capacity (GFC) and prothrombin fragment 1 + 2 (F 1 + 2) levels were measured before exercise, at peak exercise, and 2 hours after recovery. There were no differences between the groups with respect to left ventricular ejection fraction, history of hypertension, body mass index, and serum lipids. Before exercise, GFC was significantly lower in patients with CAD when compared with controls (1.40 +/- 0.43 versus 3.28 +/- 1.19 microg/mL, respectively; P < 0.001). In patients with CAD, F 1 + 2 levels were significantly higher than those of controls (1.15 +/- 0.43 versus 0.79 +/- 0.10 nmol/L, respectively; P = 0.002). In both study groups, GFC levels increased significantly at peak exercise and decreased to baseline values 2 hours after recovery. At peak exercise, F 1 + 2 levels significantly increased in both study groups. However, while F 1 + 2 levels of controls decreased to baseline values 2 hours after recovery (0.79 +/- 0.10 versus 0.80 +/- 0.10 nmol/L; P > 0.05), F 1 + 2 levels of patients with CAD were still significantly elevated (1.15 +/- 0.43 versus 1.84 +/- 0.06 nmol/L; P = 0.002). Acute exercise increases coagulation and fibrinolysis both in untrained subjects with and without CAD. However, in patients with CAD, the equilibrium between fibrinolysis and coagulation during peak exercise is disturbed in favor of coagulation after recovery.

Aorta-right atrial fistula: a rare complication of prosthetic aortic valvular endocarditis.

Aortic root abscess is a well-known complication of aortic valve endocarditis but intracardiac fistulas are rarely seen. This report describes a patient with prosthetic valve endocarditis who had an aortic root abscess that ruptured into the right atrium creating an aortic-right atrial fistula and causing a highly mobile vegetative mass in the right atrium.