Usability of myocardial work parameters in demonstrating myocardial involvement in INOCA patients.

BACKGROUND: Myocardial work (MW) is a novel echocardiographic modality, which has been shown to have diagnostic and prognostic values in patients with cardiovascular diseases, patients with obstructive coronary artery disease, in particular. However, only a handful of studies have examined the MW analysis in ischemia with nonobstructive coronary artery (INOCA) disease. This study, therefore, aimed to detect the early left ventricular involvement in INOCA patients diagnosed by an invasive coronary angiography performing the MW analysis. METHODS: This study included a total of 119 patients with nonobstructive coronary artery disease diagnosed by invasive coronary angiography, who were checked for prior ischemia tests performing myocardial perfusion scintigraphy. Out of these 119 patients, 49 patients developed ischemia (i.e., ischemic group) diagnosed using cardiac single-photon emission computed tomography, whereas 70 patients did not (i.e., nonischemic group). The subjects were divided into three groups based on the global MW tertiles. The groups were compared in terms of the conventional, longitudinal strain, and MW findings by conducting echocardiographic examinations. RESULTS: The study subjects were divided into three groups based on the global constrictive work (GCW) value. The three groups were not statistically different in terms of the mean age of the patients (53.0 ± 12 vs. 52.4 ± 13.3 vs. 52.1 ± 12.3; p = 0.96). Furthermore, the three groups were not statistically different regarding the gender, height, weight, and laboratory parameters of the patients except albumin. There was no statistically difference among the tertiles of GCW groups in the measurements of cardiac chambers, LA diameter, interventricular septum, E wave, and A wave. Also, there was no statistical difference in tissue Doppler recordings. The parameters associated with MW were examined, three groups were not statistically different in terms of the global waste work (GWW) (116 ± 92, 122 ± 73, 135 ± 62, p = 0.52, respectively). In contrast, the three groups were different regarding the Global work index (GWI) (1716 ± 300, 1999 ± 130, 2253 ± 195, p < 0.001, respectively), GCW (1888 ± 206, 2298 ± 75, 2614 ± 155, p < 0.001, respectively), and Global work efficiency parameters (92.8 ± 3.6, 94.4 ± 3.2, 95.1 ± 1.8 p = 0.004, respectively). CONCLUSION: It was concluded that the MW parameters GCW and GWI may have been used for predicting INOCA in patients.

Transcatheter Closure or Surgery for Symptomatic Paravalvular Leaks: The Multicenter KISS Registry.

BACKGROUND: The optimal treatment of symptomatic paravalvular leak (PVL) remains controversial between transcatheter closure (TC) and surgery. This large-scale study aimed to retrospectively evaluate the long-term outcomes of the patients who underwent reoperation or TC of PVLs. METHODS AND RESULTS: A total of 335 (men, 209 [62.4%]; mean age, 58.15±12.77 years) patients who underwent treatment of PVL at 3 tertiary centers between January 2002 and December 2021 were included. Echocardiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary end point was defined as the all-cause death during follow-up. The regression models were adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The initial management strategy was TC in 171 (51%) patients and surgery in 164 (49%) cases. Three hundred cases (89.6%) had mitral PVL, and 35 (10.4%) had aortic PVL. The mean left ventricular ejection fraction was 52.03±10.79%. Technical (78.9 versus 76.2%; P=0.549) and procedural success (73.7 versus 65.2%; P=0.093) were similar between both groups. In both univariate and multivariable logistic regression analysis, the in-hospital mortality rate in the overall population was significantly higher (15.9 versus 4.7%) in the surgery group compared with the TC group (unadjusted odds ratio, 3.13 [95% CI, 1.75-5.88]; P=0.001; and adjusted odds ratio (inverse probability-weighted), 4.55 [95% CI, 2.27-10.0]; P<0.001). However, the long-term mortality rate in the overall population did not differ between the surgery group and the TC group (unadjusted hazard ratio [HR], 0.86 [95% CI, 0.59-1.25]; P=0.435; and adjusted HR (inverse probability-weighted), 1.11 [95% CI, 0.67-1.81]; P=0.679). CONCLUSIONS: The current data suggest that percutaneous closure of PVL was associated with lower early and comparable long-term mortality rates compared with surgery.

Subacute lower extremity arterial thrombosis; early outcomes of catheter directed thrombolysis with alteplase and importance of malnutrition assessed by CONUT score.

OBJECTIVE: In this study, we aimed to report early outcomes of catheter-directed thrombolysis (CDT) with alteplase in patients with subacute limb ischemia and to assess whether there is a link between malnutrition (determined by Controlling Nutritional Status [CONUT] score) and response to thrombolysis and bleeding. METHODS: This was a retrospective study conducted between 2007 and 2020 with 118 patients with Rutherford class 3 (34.7%), class 4 (40.7%), and class 5 (24.6%) symptoms owing to infraaortic subacute thrombotic occlusion who were treated with catheter-directed thrombolysis. RESULTS: Immediate technical success (Thrombolysis in Myocardial Infarction [TIMI] grade 2/3) was achieved in 56%, overall technical success after all adjunctive procedures was seen in 83.9%. Clinical success was obtained in 74.5% within 30 days. Major bleeding occurred in 11.8%. When we excluded access site hematomas, the rate of major bleeding was 5.1%. In-hospital mortality rate was 5.1%, and the amputation rate within 30 days was 12.7%. Any-degree malnutrition was detected in 48.3% according to CONUT score (≥2). Any-degree malnutrition was associated with failed thrombolysis and bleeding. The CONUT score predicted insufficient lytic response even after adjustment for confounding factors; however, serum C-reactive protein or neutrophil/lenfosit ratio did not. Other predictors of immediate technical failure after thrombolysis were symptom duration, Rutherford class 4/5 symptoms, and worsened distal runoff. CONCLUSION: In patients with subacute limb ischemia, CDT combined with adjunctive interventions was effective in many patients at the expense of a substantial risk of bleeding and death. Malnutrition was associated with insufficient lytic response and bleeding. Physicians should be aware of malnutrition and consider the nutritional status of patients with limb ischemia when selecting appropriate treatment.

Alteration of serum biomarkers in patients with hypertrophic cardiomyopathy with and without atrial fibrillation.

Aim: We sought to determine the relationship between presence of atrial fibrillation (AF) and serum biomarkers, including native thiol (antioxidant), disulphide/native thiol ratio, Hs-CRP and high-sensitivity Troponin-I (Hs-TnI) in hypertrophic cardiomyopathy (HCM). Materials & methods: We enrolled consecutive 121 HCM outpatients without AF and 40 HCM outpatients with AF. A 12-lead electrocardiogram, transthoracic echocardiography and 24/48-h ambulatory rhythm monitoring were performed for all patients. Fasting venous blood samples were taken from all study patients to measure serum thiol-disulphide homeostasis, Hs-CRP and Hs-TnI. Results: Serum-native thiol was lower and disulphide/native thiol ratio was more oxidized in HCM patients with AF (p < 0.001). Also, HCM patients with AF had higher Hs-TnI and Hs-CRP than no-AF HCM patients. Disulphide/native thiol ratio, serum-native thiol, age, NYHA functional class≥III, and advanced diastolic dysfunction were independently associated with the presence of AF in HCM. Conclusion: In addition to clinical and echocardiographic findings, oxidative stress is also associated with AF in HCM patients.

The Relationship Between Contrast Associated Nephropathy and Coronary Collateral Circulation in very Old Patients.

Background: The aim of this study was to investigate whether there is a relationship between coronary collateral circulation (CCC) and contrast associated nephropathy (CAN) in very elderly patients. Methods: Patients aged 90 years or older with at least one major occlusion of the coronary artery proximal or mid-section were included in the study. CCC was graded according to the Rentrop classification. CAN was defined as an increase in blood creatinine value of 25% or more on the second day after coronary angiography. Results: Thirty-six patients who met the study criteria were included in the study. In the study group, CAN developed in 12 patients (CAN (+) group), 24 patients did not develop CAN (CAN (-) group). The creatinine levels before coronary angiography were 1.05 ± 0.12 in the CAN (-) group and 1.22 ± 0.14 in the CAN (+) group. Baseline creatinine values were significantly higher in the CAN (+) group (p = 0.001). The contrast agent used in the CAN (+) group was significantly higher (p = 0.001). In the CAN (+) group, nine patients (43%) had poor collateral circulation, whereas only three patients (20%) had well-developed collateral circulation. In a logistic regression analysis, the collateral class was not a risk factor for CAN, whereas contrast agent volume and basal creatinine were independent predictors of CAN. Conclusion: We found that CCC grade was not associated with the development of CAN in very old patients, but the amount of contrast agent and pre-procedure creatinine values were independent variables in the development of CAN.

Postoperative atrial fibrillation in patients with left atrial myxoma.

INTRODUCTION: The aim of this study was to determine the factors associated with postoperative atrial fibrillation (AF) in patients with left atrial (LA) myxoma. METHODS: Thirty-six consecutive patients with LA myxoma (10 men, mean age: 49.3 ± 15.7 years), who were operated on between March 2010 and July 2012, were included in this retrospective study. Pre-operative electrocardiograms and echocardiographic examinations of each patient were reviewed. RESULTS: Postoperative AF developed in 10 patients, whereas there was no evidence of paroxysmal AF after resection of the LA myxoma in the remaining 26 patients. The patients who developed AF postoperatively were significantly older than those who did not develop AF (median: 61.5 vs 46 years; p = 0.009). Among the electrocardiographic parameters, only P-wave dispersion differed significantly between postoperative AF and non-AF patients (median: 57.6 vs 39.8 ms, p = 0.004). Logistic regression analysis revealed P- wave dispersion (OR: 1.11, 95% CI: 1.003-1.224, p = 0.043) and age (OR: 1.13, 95% CI: 1.001-1.278, p = 0.048) as independent predictors of postoperative AF in our cohort of patients. CONCLUSIONS: P-wave dispersion is a simple and useful parameter for the prediction of postoperative AF in patients with LA myxoma.

Two-dimensional strain and strain rate imaging of the left atrium and left ventricle in adult patients with atrial septal defects before and after the later stage of percutaneous device closure.

AIM: Atrial septal defect (ASD) causes chronic volume overload of the right heart. The potential adverse effects of this long-standing volume overload to left atrium (LA) and left ventricle (LV) and their response to ASD closure has been poorly studied. METHODS: We studied 20 ASD patients before the procedure, at the 24-hour and 1 month following the percutaneous closure. Twenty age-matched controls served as the control group. The analysis for atrial deformation was performed on the lateral wall, mid segment of the LA from apical four-chamber view. Peak longitudinal strain (S) and strain rate (SR) during LA reservoir, passive emptying, atrial contraction phases and LV global longitudinal systolic S and SR were measured. RESULTS: Peak S and SR at LA reservoir, conduit and late contraction phases in ASD patients were similar to controls. All of these parameters increased immediately after the closure of the defect. Similarly, SLV and SRLV in ASD patients were not significantly different from the controls and significantly increased after the closure. But LA S, SR and LV S, SR results decreased in 1 month after the closure. SLV in ASD patients was significantly correlated with echocardiographic findings and the invasively measured defect size. CONCLUSION: LA and LV S and SR are not significantly affected in ASD patients. However, correction of the long-standing volume overload by percutaneous closure causes an early increase in LA and LV longitudinal deformation that correlates with the magnitude of the atrial septal defect. But this increase decreased in 1 month after closure.

The relation of platelet-lymphocyte ratio and coronary collateral circulation in patients with stable angina pectoris and chronic total occlusion.

OBJECTIVES: We aimed to investigate the relationship between the platelet-lymphocyte ratio (PLR) and coronary collateral circulation (CCC) in patients with stable angina pectoris (SAP) and chronic total occlusion (CTO). METHODS: A total of 294 patients with both SAP and CTO were classified according to their Rentrop collateral grades as either poor (Rentrop grades/0-1) or good (Rentrop grades/2-3). RESULTS: The PLR values were significantly higher in patients with poor CCC than in those with good CCC (156.8 + 30.7 vs 132.1 + 24.4, P < 0.001). In regression analysis, PLR (unit = 10) [odds ratio 1.48, 95% confidence interval (CI) 1.33 -1.65; P < 0.001] and high-sensitivity C-reactive protein were found to be the independent predictors of poor CCC. In receiver operator characteristic curve analysis, optimal cut-off value of PLR to predict poor CCC was found as 138.1, with 76% sensitivity and 65% specificity. CONCLUSION: PLR may be an important, simple, and cost effective tool predicting the degree of collateralization in patients with SAP and CTO.

Decreased plasma adiponectin is associated with impaired left ventricular longitudinal systolic function in hypertensive patients: a two-dimensional speckle tracking study.

The influence of plasma adiponectin levels on myocardial contractile function has not been fully examined. We aimed to investigate the relationship between three-directional systolic function and plasma adiponectin levels in asymptomatic hypertensive patients using two- dimensional speckle-tracking echocardiography. The study population consisted of 78 patients with hypertension and 40 healthy controls. Longitudinal strain was significantly reduced in all patients, including those without LV hypertrophy (p=0.009). In multiple-regression analysis, plasma adiponectin levels (ß=-0.273, p=0.008) and LV mass index (ß=0.458, p<0.001) independently correlated with LV longitudinal strain. Decreased plasma adiponectin concentrations were associated with the progression of LV hypertrophy with impaired LV longitudinal systolic function.

The relationship between gamma-glutamyltransferase and coronary collateral circulation in patients with chronic total occlusion.

OBJECTIVE: The aim of this study was to evaluate the relation between blood gamma-glutamyltransferase (GGT) levels and coronary collateral circulation in patients with chronic total occlusion (CTO). METHODS: Two hundred twenty-two patients with chronic stable coronary artery disease (CAD) and CTO were included in this cross-sectional, observational study. Coronary collaterals were graded from 0 to 3 according to the Rentrop method. Patients with grade 0-1 collateral development were regarded as poor collateral group (n=66) while patients with grade 2-3 collateral development were regarded as good collateral group (n=156). Statistical analysis was performed using independent samples t, Mann-Whitney U and Chi-square tests, logistic regression and receiver operator curve analysis. RESULTS: The poor coronary collateral group had significantly higher levels of serum GGT compared to the good collateral group (p<0.001). Multiple logistic regression analysis showed that GGT levels were independent predictors of poor collateral circulation (OR-0.946, 95% CI=0.918-0.9719, p<0.001). The result of ROC curve analysis for GGT was as following: area under the ROC curve (AUC)=0.732, 95% CI: 0.622-0.841, p<0.001. CONCLUSION: Higher GGT levels are associated with poor coronary collateral circulation in patients with CTO. GGT may be used to predict the grade of coronary collateral circulation in CTO patients with chronic stable CAD.

The effect of cilostazol on right heart function and pulmonary pressure.

INTRODUCTION: Cilostazol is a PDE3 inhibitor and used to treat peripheral arterial disease. There are few reports on the influence of cilostazol on heart. AIMS: The aim of this study was to assess this effect on right ventricular function and pulmonary artery pressure. METHODS: Forty patients with normal left and right ventricular ejection fraction and mild or moderate pulmonary artery hypertension were enrolled in the study. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), tissue Doppler imaging (TDI), and two-dimensional speckle-tracking echocardiography (2D-STE) before and after oral administration of cilostazol. Also pulmonary artery pressure assessed before and after administration of cilostazol. RESULTS: After cilostazol administration, there were significant increases in the TAPSE (1.9 ± 0.3 cm vs. 2.2 ± 0.3 cm, P < 0.001). Peak longitudinal strain (-18.7 ± 4.5% vs. -21.3  ± 3.7%, P = 0.001), isovolumetric acceleration (IVA) (176.6 ± 62.7 cm/sec(2) vs. 200.6 ± 61.9 cm/sec(2) , P = 0.025), right ventricular FAC increased significantly (37.6 ± 8.0% vs. 41.5 ± 8.9%, P < 0.001). Pulmonary artery pressure decreased significantly (39.9 ± 7.9 vs. 36.6 ± 5.5 mmHg, P = 0.001) after cilostazol administration. CONCLUSION: Our study demonstrated that cilostazol improved right ventricular systolic function and reduced pulmonary artery pressure.

The comparison in reduction of QT dispersion after primary percutaneous coronary intervention according to existence of thrombectomy in ST-segment elevation myocardial infarction.

BACKGROUND: Primary percutaneous coronary intervention (PPCI) is the standard treatment in patients with ST-segment elevation myocardial infarction (STEMI). Thrombectomy devices are used to remove thrombus or to prevent embolization of thrombus and plaque during PPCI. QT dispersion (the difference between maximal and minimal QT interval calculated on a standard 12-lead electrocardiogram) represents the regional nonuniformity of ventricular repolarization. It may reflect early coronary reperfusion in reducing electrophysiological instability by decreasing QT dispersion in the recovery phase after acute STEMI. HYPOTHESIS: Our aim was to show whether an additional effect of thrombectomy on reducing QT dispersion will be seen in patients undergoing PPCI for STEMI. METHODS: The study population included 80 consecutive patients who were admitted to the hospital within 12 hours after the onset of acute STEMI and angiographic evidence of intraluminal thrombus in the infarct-related artery. Patients with atrial fibrillation or flutter, intraventricular conduction abnormalities, pre-excitation, cardiogenic shock, cardiomyopathy, ventricular hypertrophy, and severe valvular heart disease were excluded from the study. RESULTS: There were no significant differences between groups regarding gender, age, cardiovascular risk factors, and time from symptom onset to treatment, except for smoking, which was much higher in the PPCI plus thrombectomy group. Infarct-related artery distribution (left anterior descending artery [LAD] to non-LAD), and neither the rate of balloon predilatation nor stent implantation were different between groups. Successful coronary patency was achieved in each case. QT interval measurements were similar between groups at admission. However, at 24 hours, QT and QTc dispersions were less in the PPCI plus thrombectomy group (41 ± 9 vs 33 ± 7 ms, P < 0.05 and 45 ± 8 vs 35 ± 7 ms, P = 0.03, respectively), but not in the other QT interval measurements. When patients were divided into 2 groups according to infarct-related artery (LAD and non-LAD groups), QT interval measurement parameters did not show any significant differences. CONCLUSIONS: Thrombectomy additional to PPCI helps more effective reperfusion at the microvascular level and provides additional prognostic information.

Evaluation of autonomic functions by heart rate variability after stenting in patients with carotid artery stenosis.

OBJECTIVE: Although carotid stenting is an effective treatment for severe carotid stenosis, it has been associated with alterations in autonomic functions during or shortly after the procedure. Heart rate variability (HRV) is an established tool for the asessment of autonumic functions. In this study, our aim was to investigate the relation between the alterations in autonomic functions and HRV by Holter monitoring parameters. METHODS: Patients (19 male, 8 female) that are suitable for carotid artery stenting, without a history of hypertension, diabetes mellitus, severe coronary artery or valvular heart disease, were enrolled to our study. Short-term HRV analysis recordings were obtained at the beginning, and after the procedure. The square root of the mean squared differences of successive NN intervals (RMSSD), total frequency, low frequency (LF), high frequency (HF), normalized units LF (LFnu), normalized units HF (HFnu), LF/HF ratios were analyzed. Results were statistically analysed by using Wilcoxon test. RESULTS: Total frequency did not show any significant changes after the procedure (1101 ± 829, 981 ± 855). While RMSSD and HFnu values significantly increased respectively (23 ± 12/33 ± 22, and 22 ± 10/35 ± 10, p < 0.05) after the procedure, HF values increased nonsignificantly after the procedure (82 ± 92/92 ± 108). LF, LFnu, and LF/HF values were significantly decreased after the procedure. (228 ± 166/112 ± 100, 70 ± 15/55 ± 18, 4 ± 2.5/2.1 ± 2, respectively, p < 0.05) CONCLUSIONS: While RMSSD and HF are used as markers of vagal activity, LF is a marker of sympathetic modulation and LF/HF ratio shows sympathovagal balance. In our study, we showed that carotid artery stenting is associated with increase in parasympathetic activation, and this finding is demonstrated by HRV parameters.

A case of double coronary perforations and tamponade during left main percutaneous coronary intervention and treatment with stenting and autotransfusion.

Coronary perforation is a rare complication of percutaneous coronary intervention. A 60-year-old male patient with a diagnosis of hepatocellular carcinoma was admitted to our hospital with crescendo anginal attacks. Coronary angiogram revealed significant stenosis in distal left main coronary artery (LMCA). After implanting a 4.0×18 mm coronary stent from LMCA to left anterior descending artery (LAD), coronary angiography showed a perforation in the proximal part of the LAD and a plaque shift to the osteum of circumflex artery (Cx), causing 60% stenosis. Rupture was sealed by implantation of a polytetrafluoroethylene (PTFE) coated stent in proximal LAD. Due to ongoing chest pain and electrocardiographic ischemic changes, a 3.5×18 mm coronary stent was implanted in Cx. Unfortunately, another perforation occurred in Cx. The PTFE coated stent was not flexible enough to advance from the former LMCA to LAD stent to the Cx artery, and another 3.5×18 mm coronary stent was deployed in Cx artery successfully. Although control angiography showed complete sealing of the rupture, echocardiography showed a large pericardial effusion compressing the right side of the heart. Autotransfusion was done to stabilize the hemodynamic status. One-week later, coronary angiography did not show any contrast agent extravasation. In this case, we present double coronary perforations of the LAD and Cx arteries, and successful treatment with both covered and conventional stents and autotransfusion.

P-wave dispersion by 12-lead electrocardiography in carotid artery stenting.

OBJECTIVE: Although carotid artery stenting (CAS) is an effective treatment for severe carotid stenosis, it has been associated with alterations in autonomic functions during or shortly after the procedure. And, autonomic functions influence P-wave durations. In this study, our aim was to investigate P-wave durations on 12-lead surface electrocardiography after CAS. METHODS: Patients (19 male, 8 female) who are suitable for CAS, without a history of hypertension, diabetes mellitus, severe coronary artery or valvular heart disease, were enrolled in our study. 12-lead surface electrocardiography recordings were obtained at the beginning, immediately after and at the 24 h of the procedure. P-wave maximum, minimum and dispersion durations were analyzed by double-blinded observers. Results were statistically analysed using Friedman and Wilcoxon tests. RESULTS: The P maximum and P dispersion values were significantly increased immediately after the procedure and continued with high levels at 24-h recordings, respectively (128 ± 10/19 ± 7, 143 ± 14/37 ± 11, and 137 ± 11/30 ± 7 ms, p value <0.05). The P minimum value was significantly decreased immediately after the procedure (109 ± 11/105 ± 10 ms, p value <0.05). At 24-h recordings, a nonsignificant increase occured in P minimum values (106 ± 8 ms). CONCLUSIONS: P maximum and dispersion durations were significantly increased after the CAS and continued with high levels at 24-h recordings, which may be associated with the alterations in autonomic functions via augmented parasympathetic activity by vagally mediated stimulus. Overall, these findings suggest that decline in cardiovascular activity is prolonged at least 24 h after CAS.

Comparison of short-term outcomes after carotid artery stenting according to different stent designs.

INTRODUCTION: In the developed countries, stroke is the third most common cause of death. There are many data indicating that stents reduce the risk of embolism but there are few publications assessing whether different stent designs can influence the periprocedural complications. AIM: To determine the effects of open- and closed-cell stent designs on 1-month results of carotid artery stenting (CAS). MATERIAL AND METHODS: The study group consisted of 290 consecutive patients (216 men and 74 women, mean age 66.6 ±8.7 years). Neuroprotection with a distal protection device was used in all cases. The patients were divided into two groups: the open-cell stent group (n = 144) and the closed-cell stent group (n = 138). Major adverse cardiac and cerebrovascular events (MACCE) described as myocardial infarction, stroke and death within 1 month were recorded and analysed subsequently. Periprocedural hypotension and transient cerebral ischaemia at 1 month after the CAS procedure were also assessed. RESULTS: We treated 290 carotid stenoses and stents were implanted in all patients. Fifteen patients (5.5%) were treated by staged CAS due to bilateral carotid artery disease. The technical success rate was 97.2%. There was no difference in the MACCE and transient cerebral ischaemia rate at 1 month between the two groups (p = 0.44 and p = 0.94, respectively). The incidence of ischaemic stroke was lower in the closed-cell stent group (2.77% vs. 0%; p = 0.04). The periprocedural rate of hypotension was higher in the closed-cell stent group (2.1% vs. 7.2%; p = 0.04). CONCLUSIONS: Closed-cell stents are associated with a low rate of ischaemic stroke. We think that closed-cell stents may be preferred in patients at high risk of embolism.

Comparison of left atrial mechanical function in nondipper versus dipper hypertensive patients: a speckle tracking study.

AIM: Nondippers are known to carry a high risk of cardiovascular morbidity and mortality. The aim of this study was to investigate the effects of dipper and nondipper status of hypertension on longitudinal systolic and diastolic functions of left atrial (LA) myocardial tissue by means of two-dimensional speckle-tracking echocardiography in treated hypertensive patients. METHODS: A total of 78 outpatients treated with antihypertensive drugs for at least 1 year were included in the study. The patients were classified as nondippers if their daytime ambulatory systolic and diastolic blood pressure did not decrease by at least 10% during the night. Global longitudinal LA strain/strain rate data were obtained by two-dimensional speckle imaging with automated software and compared between the groups. RESULTS: LA volume index, left ventricular (LV) wall thickness and mass index as well as filling pressure (E/E') were significantly higher in nondippers (all P < 0.001), whereas systolic tissue velocity (S') was significantly lower in nondippers. They also had decreased values of mean peak LA strain (dippers = 27.6 ± 5.5% vs. nondippers = 21.5 ± 4.5%, P < 0.001), strain rate during reservoir (dippers = 1.27 ± 0.4/sec vs. nondippers = 0.98 ± 0.3/sec, P = 0.001), and conduit period (dippers = 1.41 ± 0.4/sec vs. nondippers = 1.06 ± 0.3/sec, P < 0.001). Moreover, we found that LA mechanical dysfunction was closely associated with LV mass, filling pressure, and regional LV contractility. CONCLUSION: Nondipping in treated hypertensive patients was associated with an adverse cardiac remodeling and impaired LA mechanical function. Further studies are warranted to demonstrate the long-term prognostic significance of these findings.

Kounis syndrome secondary to simultaneous oral amoxicillin and parenteral ampicillin use in a young man.

The concurrence of acute coronary syndrome with allergy or hypersensitivity as well as with anaphylactic or anaphylactoid reactions is increasingly encountered in daily clinical practice. There are several reports associating mast cell activation with acute cardiovascular events in adults. This was first described by Kounis as 'allergic angina syndrome',progressing to 'allergic myocardial infarction'. The main mechanism proposed is the vasospasm of coronary arteries. We present a case of a 28-year-old man who was admitted to our hospital with thoracic pain and dyspnoea. The symptoms recurred after simultaneous use of 1 g amoxicillin/clavulanic acid orally and 1 g ampicillin/sulbactam parenterally for tonsillitis the night before presentation and on the morning of admission.