Heart Rate Acceleration and Recovery Indices are Not Related to the Development of Ventricular Premature Beats During Exercise Test.

BACKGROUND: Changes in heart rate (HR) during exercise and recovery from exercise are mediated by the balance between sympathetic and vagal activity. HR acceleration (HRA) and recovery (HRR) are important measures of cardiac autonomic dysfunction and directly correlated with sympathetic and parasympathetic activity. It is not known if the autonomic nervous system related to ventricular arrhythmias during exercise. The purpose was to evaluate the HRA and HRR in patients with and without premature ventricular complex (PVC) during exercise, and to examine the factors that might affect HRA and HRR. METHODS: The records of consecutive patients undergoing routine exercise test were reviewed. The characteristics and the HRA and HRR were compared between patients with and without PVC during exercise. RESULTS: A total of 232 patients (145 men) were recruited; 156 (103 men) developed PVCs during the exercise. Max HR was significantly lower in men with PVCs than in those without, which were not mirrored in women. There was no difference in HRA and HRR between the patients with and without exercise-induced PVCs in both genders. Compared to the men with PVCs, women had higher body mass index, shorter total exercise time, and higher HRA indices after the 3 and 6 minutes exercise. In patients with PVCs, the HRA and HRR indices were similar regardless of the presence of coronary artery disease and the phase of exercise test where PVC developed. CONCLUSIONS: Although exercise performance may be different between the genders, the HRA or HRR indices were not related to the development of PVC during exercise in both genders. KEY WORDS: Exercise-induced arrhythmias; Heart rate acceleration; Heart rate recovery.

Increased pulse wave velocity and carotid intima-media thickness in patients with carpal tunnel syndrome.

INTRODUCTION: Carpal tunnel syndrome (CTS) is associated with cardiovascular risk factors. The aim of our study was to determine whether carotid intima-media thickness (CIMT) and carotid-femoral pulse wave velocity (cf-PWV), as surrogates of cardiovascular disease and arterial stiffness, are increased in patients with carpal tunnel syndrome. METHODS: Forty patients with CTS and 40 gender- and age-matched controls underwent cf-PWV assessment, CIMT measurement, and nerve conduction study. RESULTS: CIMT and cf-PWV were increased significantly in patients with CTS. They correlated positively with median sensory and motor nerve distal latency. Whereas both CIMT and PWV related to CTS, only CIMT independently predicted CTS. CONCLUSIONS: There is both increased pulse wave velocity and CIMT and a positive correlation between these parameters and median nerve sensory distal latency in patients with CTS. CTS appears to be associated with arterial stiffness and atherosclerotic burden, but the underlying mechanisms require further study.

Non-dipping pattern in untreated hypertensive patients is related to increased pulse wave velocity independent of raised nocturnal blood pressure.

BACKGROUND: Non-dipper pattern, characterized by diminished nocturnal decline in blood pressure (BP), is associated with an increase in cardiovascular events. Carotid-femoral pulse wave velocity (CF-PWV) has been accepted as the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. In this study, we investigated the association between PWV as the surrogate of arterial stiffness and non-dipper pattern in untreated hypertensive patients. METHODS: The present study was cross-sectional and observational. Hypertensive patients were diagnosed according to ambulatory BP measurements (mean BP ≥ 130/80 mmHg). Eighty-four hypertensive patients, consulted for initial evaluation of hypertension, were enrolled. CF-PWV as the indicator of arterial stiffness was measured by a validated tonometry system (SphygmoCor). Patients with the history of any cardiovascular disease were excluded from the study. RESULTS: Fifty-six patients had non-dipper pattern and 28 patients had dipper pattern in the study. Baseline characteristics were not significantly different between the two groups, except the CF-PWV (non-dipper vs dipper; 8.91 ± 2.53 vs 7.66 ± 1.08 m/s, p = 0.002), female gender (55% vs 32%, p = 0.045) and nocturnal BP measurements (for mean BP; 106 ± 11 vs 92 ± 8 mmHg, p < 0.001). Multiple logistic regression analysis including age, gender, BP and PWV measurements, revealed female gender (odds ratio, OR = 5.112, 95% confidence interval, CI 1.282-20.4, p = 0.021), nocturnal mean BP (OR = 1.243, 95% CI 1.107-1.396, p < 0.001) and CF-PWV (OR = 1.992, 95% CI 1.240-3.198, p = 0.004) as the independent predictors of non-dipper hypertensive pattern. CONCLUSION: Our results suggest that diminished nocturnal decline in BP is independently associated with PWV and nocturnal BP rather than daytime BP. Non-dipper pattern, mainly related to increased PWV and impaired modulation of vascular smooth muscle tone during the night, may justify an increased cardiovascular risk in these patients.

Increased plasminogen activator inhibitor-1 levels in patients with isolated coronary artery ectasia.

Isolated coronary artery ectasia (ICAE) is defined as the ectasia of the coronary arteries without concomitant coronary artery stenosis. The etiology and the clinical course of ICAE are still not clear. Increased levels of plasminogen activator inhibitor-1 (PAI-1) inhibit vasa vasorum, leading to diminished vessel wall supply and thus contributes to aortic aneurysm expansion. Whether the same process has role in coronary artery ectasia is not known. The aim of this study is to investigate the association between PAI-1 and coronary artery ectasia in patients without concomitant obstructive coronary artery disease. Among 2830 patients who underwent coronary angiography between March 2010 and 2011, 55 patients (40 male, 15 female, mean age 60 ± 8 years) with ICAE, formed our study group. 27 patients with similar patient characteristics, with angiographically proven normal coronary arteries, were enrolled as the control group. The basal characteristics were similar between two groups. PAI-1 levels were statistically higher in the ICAE group compared to the control group (104.13 ± 56.65 and 63.39 ± 35.01 ng/dl, respectively) (P = 0.008). A significant positive correlation between CAE and PAI-1 (r = 0.358, P = 0.007) was also demonstrated. Serum high sensitive C reactive protein (hsCRP) levels did not differ between two groups (P > 0.05). The plasma PAI-1 levels were significantly higher in ICAE patients compared to normal coronary artery group. Increased PAI-1 levels may diminish vasa vasorum by antiangiogenic activity leading to coronary ectasia.

Relationship of fragmented QRS with prognostic markers and in-hospital MACE in patients undergoing CABG.

BACKGROUND: Fragmented QRS complex (fQRS) is associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. However, its prognostic role has not been studied comprehensively in patients undergoing coronary artery bypass graft (CABG) surgery. In this study, we investigated the relationship between the presence of fQRS, and the prognostic markers and in-hospital major adverse cardiovascular events (MACE). METHODS: Two hundred and forty two eligible patients who underwent CABG surgery at our institution were enrolled consecutively. In analysis of fragmentations on electrocardiograms, presence of fQRS was defined as various RSR' patterns (≥ 1 R' or notching of S wave or R wave) with or without Q waves without a typical bundle-branch block in two contiguous leads corresponding to a major coronary artery territory. MACE was defined as cardiac death, recurrent myocardial infarction, heart failure, cerebrovascular event, sustained ventricular tachycardia or fibrillation. RESULTS: Patients with fragmented QRS had older age (64 ± 10 vs. 61 ± 9 years, p = 0.03), prolonged QRS time (99 ± 11 vs. 87 ± 11 ms, p < 0.001), higher rate of Q wave on ECG (29% vs. 12%, p = 0.001), higher European system for cardiac operative risk evaluation (EUROSCORE) (4.0 ± 1.9 vs. 2.6 ± 1.6, p < 0.001) and lower left ventricular ejection fraction (LVEF)% (43 ± 12 vs. 60 ± 12, p < 0.001) in comparison to patients with non-fragmented QRS. In addition, the patients with fQRS had longer cross-clamp time (67 ± 23 vs. 55 ± 20 minutes, p = 0.001) and extracorporeal circulation (105 ± 31 vs. 91 ± 30 minutes, p = 0.003), increased inotropic usage (p < 0.001) and prolonged cardiac surgery intensive care unit (53 ± 25 vs. 35 ± 12 hours, p < 0.001) and in-hospital stay after CABG. CONCLUSION: FQRS may have additional value in the assessment of cardiac function and in prediction of intra- and post-operative hemodynamic instability and adverse cardiovascular events. Fragmentations on admission ECG may be useful for identifying patients with higher risk who will need additional support after CABG surgery.

Increased epicardial adipose tissue thickness is correlated with ascending aortic diameter.

Epicardial adipose tissue (EAT), localized beneath the visceral pericardium, is a metabolically active endocrine and paracrine organ with possible interactions within the heart. Recent studies identified possible roles of uric acid (UA)-induced oxidative stress and increased inflammatory status in the pathogenesis of ascending aortic dilatation. The aim of this study was to investigate whether EAT is an independent factor for ascending aortic dilatation. The patients were evaluated by a complete transthoracic echocardiographic examination including measurements of EAT and aortic dimensions. Serum levels of UA and C-reactive protein and EAT thicknesses were compared in 38 patients with dilated ascending aorta (DAA) (the diameter ≥ 37 mm) vs. 107 subjects with normal aortic diameter (AD) of < 37 mm. EAT thickness was significantly higher in DAA group compared to normal AD group (8.3 ± 2.7 vs. 5.4 ± 2.2 mm, p < 0.001) as well as age (53 ± 10 vs. 48 ± 9 years, p = 0.004), the presence of hypertension (54% vs. 30%, p = 0.009) and UA levels (6.0 ± 1.4 vs. 5.2 ± 1.1 mg/dL, p < 0.001). There was a strong correlation between EAT thickness and ascending aortic diameter (r = 0.521, p < 0.001). In multiple logistic regression analysis, EAT thickness (OR: 1.429, p = 0.006), body mass index (OR: 1.169, p = 0.014) and UA levels (OR: 1.727, p = 0.023) were independently correlated to ascending aortic dilatation. We therefore propose that increased EAT thickness is an independent predictor of ascending aortic dilation.

Relationship of the angiographic extent of peripheral arterial disease with coronary artery involvement.

OBJECTIVE: To determine the co-incidence of coronary artery disease (CAD) in patients investigated for peripheral arterial disease (PAD), and to establish the relationship between the risk factors in the two groups of patients. METHODS: The prospective study, done from January 2005 and April 2009, at the Cardiology Clinic of Rize Education and Research Hospital, Rize and John F. Kennedy Hospital, Istanbul, Turkey, had a cohort of 307 patients who had been diagnosed with peripheral artery disease either clinically or by ultrasonography for the arteries of the lower extremities and had undergone coronary angiography and peripheral angiography in the same or different sessions. The patients were evaluated in terms of age, gender and atherosclerotic risk factors. Relationship of the extent of peripheral arterial disease with coronary artery involvement was investigated. RESULTS: Of the 307 patients, 251 (81.8%) were male, and the mean age was 62.1 +/- 9.5 years. In the study population, 178 (58.0%) patients were diagnosed as hypertensive, 84 (27.4%) patients were diabetic, 18 (5.9%) patients had a family history of coronary artery disease, 111 (36.2%) were smokers, 149 (48.5%) were hypercholesterolemic, and 20 (6.5%) had cerebrovascular/carotid disease. In 92.3% of patients with peripheral arterial disease, various levels of coronary stenosis (P = 0.007) was noticed. Hypertension was a risk factor for both coronary and peripheral artery diseases (p = 0.012 and 0.027, respectively). Univariate logistic regression analysis demonstrated that the presence of peripheral artery disease was related to the coronary variety (Odds ratio [OR]: 6, 95% CI: 1.4-25.5, P = 0.016) and severe cases (diffused atherosclerotic stenosis and complete occlusion in all segments) significantly indicated the presence of some coronary pathology (OR: 8, 95% CI: 1.7-37.4, P = 0.008). This relationship maintained its significance after adjustment for age, gender, hypercholesterolaemia, smoking, hypertension, diabetes, family history, and the presence of cerebrovascular/carotid disease (p = 0.010). CONCLUSIONS: Peripheral coronary artery diseases had similar risk factors. The extent of peripheral arterial disease observed during peripheral lower extremity angiography was significantly associated with the presence and severity of coronary artery disease. Particular attention should be focused on the possibility of coronary artery disease in patients with established and extensive peripheral arterial disease. Non-invasive, as well as invasive tests, should be performed to decrease morbidity and mortality risk of such patients.

The importance of fragmented QRS complexes in prediction of myocardial infarction and reperfusion parameters in patients undergoing primary percutaneous coronary intervention.

OBJECTIVES: The QRS complex fragmentations (fQRS) frequently seen on admission electrocardiograms (ECGs) with narrow or wide QRS complex are associated with increased morbidity and mortality. The causative relationship between fQRS and cardiac fibrosis is known, but the relation of fragmented QRS before and after primary percutaneous coronary intervention (p-PCI) with myocardial infarction and reperfusion parameters has not been studied until now. STUDY DESIGN: The study included 184 consecutive patients with ST elevation myocardial infarction (STEMI) who underwent p-PCI. Presence or absence of fQRS on pre- and post-PCI ECGs and its change following PCI were investigated. In addition, independent predictors of fQRS were also investigated. Patients with significant organic valve disease and patients having any QRS morphology with QRS duration ?120 ms as well as patients with permanent pacemakers were excluded from the study. RESULTS: Patients with fQRS on admission ECG had higher leukocyte counts (p=0.001), higher CK-MB (p=0.001) and troponin levels (p=0.005), increased pain to balloon time (p=0.004), higher Killip score (p<0.001), prolonged QRS time (p<0.001), higher Gensini score (p<0.001) and more frequent Q waves on ECG (p<0.001) in comparison to patients with non-fragmented QRS. In addition, these patients usually had an infarction of anterior territory related to a lesion in proximal LAD and wider jeopardized myocardium (p<0.001). fQRS was significantly related to infarction and myocardial reperfusion parameters before and after p-PCI. In the setting of STEMI, absence of fQRS on admission ECG predicted increased ST resolution, higher reduction in QRS duration, and better myocardial reperfusion. CONCLUSION: FQRS may be useful in identifying patients at higher cardiac risk with larger areas of ischemic jeopardized or necrotic myocardium.

Risk factors for in-hospital mortality in infective endocarditis: five years' experience at a tertiary care hospital in Turkey.

BACKGROUND AND AIM OF THE STUDY: Despite recent improvements in diagnostic and therapeutic interventions, infective endocarditis (IE) is still associated with high in-hospital mortality rates. The study aim was to determine the clinical, laboratory and echocardiographic features of IE, and to evaluate the risk factors for in-hospital mortality. METHODS: A retrospective cohort study design was employed, with a main outcome measure of in-hospital mortality. A total of 107 patients (79 males, 28 females; mean age 45 +/- 16 years) admitted with the modified Duke criteria for definitive IE were included in the study during a five-year period between January 2004 and December 2008. RESULTS: Among the patients, the mitral valve alone was involved in 45% of cases, the aortic valve in 36%, tricuspid valve in 11%, and multiple valves in 8%. Forty-seven patients (44%) had prosthetic valves. Blood cultures were positive in 71 patients (66%). The most common isolated microorganisms were staphylococci, streptococci and Brucella melitensis. The in-hospital mortality rate was 27%. Leading causes of death were multi-organ failure and heart failure. In univariate analysis, factors associated with death were a longer duration of symptoms before hospitalization, previous history of IE, white blood cell count > or = 10,000/mm3, serum creatinine level > or = 2 mg/dl, vegetation size >15 mm, involvement of multiple valves, existence of severe regurgitation, cardiac abscess, and neurologic complications. Multivariate analysis showed that risk factors for mortality were multivalvular involvement (hazard ratio (HR) 4.7; 95% confidence interval (CI) 1.3-17.6; p = 0.021), vegetation size >15 mm (HR 5.5; 95% CI 2.1-14.6; p = 0.001), serum creatinine > or = 2 mg/dl (HR 4.1; 95% CI 1.8-9.4; p = 0.001), and previous history of IE (HR 3.5; 95% CI 1.2-11; p = 0.026). CONCLUSION: Multivalvular involvement, vegetation length >15 mm, serum creatinine level > or = 2 mg/dl on admission, and a previous history of IE, were independent predictors for in-hospital mortality in IE.

Paraoxonase activity might be predictive of the severity of aortic valve stenosis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve stenosis (AS) is the most common valvular heart disease in the western world, and in adults is invariably caused by the calcification of a normal tricuspid or congenital bicuspid valve. Calcific AS, as an active disease process, is characterized by lipid accumulation, inflammation and calcification that mimic atherosclerosis. Paraoxonase-1 (PON-1) is a high-density lipoprotein (HDL)-bound enzyme that exerts antiatherogenic properties by protecting low-density lipoprotein (LDL)-cholesterol from oxidative modification. The study aim was to examine the association between PON-1 activity and AS. METHODS: A total of 93 patients with angiographically normal coronary arteries was enrolled into the study. Transthoracic echocardiography was used to diagnose and grade the AS before the patients underwent selective coronary angiography. The patients were allocated to three groups of mild AS (n = 34), moderate AS (n = 31) and severe AS (n = 28). Paraoxonase activity was measured using a spectrophotometric technique. RESULTS: The mean PON-1 activity in patients with severe AS (64.4 +/- 29.8 U/l) was significantly lower than that in patients with mild and moderate AS (97.1 +/- 72.6 and 146.8 +/- 133.9 U/l; p = 0.03 and p = 0.002, respectively). Typically, PON-1 activity tended to be lower in moderate AS than in mild AS (p = 0.07). The serum PON-1 activity correlated positively with the aortic valve area, but negatively with the aortic mean and maximum gradients. CONCLUSION: The study results showed that PON-1 activity is lower in patients with calcific AS. In addition, PON-1 activity was inversely correlated with the severity of AS.

Ruptured sinus of Valsalva aneurysm associated with aortic regurgitation and severe myocardial ischemia.

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly either presenting as a congenital heart disease or occurring secondary to cardiac surgical interventions. A 19-year-old male patient presented with chest pain and shortness of breath. On auscultation, a grade 4/6 early diastolic murmur was heard over the left lower sternal border and Erb's area with a thrill. Crepitating rales were heard over bilateral basal lung fields. The electrocardiogram showed right bundle branch block and ST depression. Troponin and CK-MB levels were increased. Shortly after admission, he developed ventricular fibrillation and was defibrillated three times. After restoration of hemodynamic stabilization, transthoracic echocardiography was performed, which showed grade 4 aortic regurgitation, patent foramen ovale, and an aneurysm of the sinus of Valsalva arising from the right coronary sinus, with rupture into the right ventricle. The patient underwent surgery under cardiopulmonary bypass, for repair of the ruptured SVA and patent foramen ovale and aortic valve replacement. He was discharged on the fifth postoperative day following an uneventful operation and postoperative course.

Influence of heavy cigarette smoking on heart rate variability and heart rate turbulence parameters.

BACKGROUND: Cigarette smoking increases the risk of cardiovascular events related with several mechanisms. The most suggested mechanism is increased activity of sympathetic nervous system. Heart rate variability (HRV) and heart rate turbulence (HRT) has been shown to be independent and powerful predictors of mortality in a specific group of cardiac patients. The goal of this study was to assess the effect of heavy cigarette smoking on cardiac autonomic function using HRV and HRT analyses. METHODS: Heavy cigarette smoking was defined as more than 20 cigarettes smoked per day. Heavy cigarette smokers, 69 subjects and nonsmokers 74 subjects (control group) were enrolled in this study. HRV and HRT analyses [turbulence onset (TO) and turbulence slope (TS)] were assessed from 24-hour Holter recordings. RESULTS: The values of TO were significantly higher in heavy cigarette smokers than control group (-1.150 +/- 4.007 vs -2.454 +/- 2.796, P = 0.025, respectively), but values of TS were not statistically different between two groups (10.352 +/- 7.670 vs 9.613 +/- 7.245, P = 0.555, respectively). Also, the number of patients who had abnormal TO was significantly higher in heavy cigarette smokers than control group (23 vs 10, P = 0.006). TO was correlated with the number of cigarettes smoked per day (r = 0.235, P = 0.004). While LF and LF/HF ratio were significantly higher, standard deviation of all NN intervals (SDNN), standard deviation of the 5-minute mean RR intervals (SDANN), root mean square of successive differences (RMSSD), and high-frequency (HF) values were significantly lower in heavy smokers. While, there was significant correlation between TO and SDNN, SDANN, RMSSD, LF, and high frequency (HF), only HF was correlated with TS. CONCLUSION: Heavy cigarette smoking has negative effect on autonomic function. HRT is an appropriate noninvasive method to evaluate the effect of cigarette on autonomic function. Simultaneous abnormal HRT and HRV values may explain increased cardiovascular event risk in heavy cigarette smokers.

Asymmetric dimethylarginine levels in patients with coronary artery ectasia.

BACKGROUND: Endothelial dysfunction might be one of the pathophysiological mechanisms in the development of coronary artery ectasia (CAE) although the exact mechanisms have not yet been demonstrated. Asymmetric dimethylarginine (ADMA), an endogenous competitive inhibitor of nitric oxide synthase, is also related to endothelial and structural dysfunction. AIM: To asses the relationship between CAE and ADMA plasma concentrations. METHODS: Thirty patients with CAE in a mean age of 55.5 +/- 3.6 years and 40 patients with normal coronary arteries in a mean age of 53.3 +/- 11.6 years were studied. The ADMA levels of all patients were analysed by ELISA method. RESULTS: The mean ADMA level in the CAE group was found to be significantly higher than the mean ADMA level in the normal coronary artery group (2.26 +/- 0.47 vs. 1.43 +/- 0.40 micromol/l, p < 0.001). The elevated ADMA level (> 1.80 micromol/l) was present in 83.0% of patients from the CAE group and 25.0% of patients from the normal coronary artery group (p < 0.001). Having an increased ADMA level enhanced the risk of CAE 15-fold. The multiple-adjusted OR of the risk of CAE was 18.71 (95% CI 4.95-70.68) for the higher ADMA level compared to the lower level. CONCLUSION: Asymmetric dimethylarginine level is significantly associated with the presence of coronary artery ectasia. These findings suggest that increased ADMA level may be associated with endothelial dysfunction leading to the development of coronary artery ectasia.

Comparison of the electrocardiographic features of complete left bundle branch block in patients with ischemic and nonischemic left ventricular dysfunction.

BACKGROUND: Differentiating ischemic (ILVD) from nonischemic left ventricular dysfunction (NILVD) is important prognostically and therapeutically but might be difficult clinically. The differentiating role of electrocardiographic (ECG) features in the presence of left bundle-branch block (LBBB) is debatable on differentiating ILVD from NILVD. OBJECTIVE: The present study assessed whether there is the role of certain ECG features in differentiating ILVD from NILVD in the presence of the complete LBBB. METHODS AND RESULTS: Patients who had LBBB were divided into two groups based on the presence and type of left ventricular dysfunction; (1) ILVD group (49 patients; 20 female; age: 65 +/- 11 years) and (2) NILVD group (49 patients; 22 female; age: 59 +/- 12 years), and numerous ECG features were compared. Most of these ECG features did not show any difference between the groups except for following ECG findings; the voltage of R wave in V6 were statistically higher in NILVD group compared ILVD group (p: 0.03); the depression of the ST-J point by more than 0.2 mV in V6 were also frequently observed in NILVD group compared ILVD group (5/ 10% vs 19/ 39% , p: 0.001); and the notching in the ascending or descending limb of the S wave in V1-4 leads were more in ILVD group (18/ 36% vs 8/ 16% p: 0.03; 9/ 16% vs 2/ 4%, p: 0.03, respectively). CONCLUSION: In the current study, although some ECG findings were found to be useful, ECG features in the presence of complete LBBB had poor value in differentiating ILVD from NILVD.

Comparison of presence and extent of coronary narrowing in patients with left bundle branch block without diabetes mellitus to patients with and without left bundle branch block but with diabetes mellitus.

We prospectively analyzed the clinical, echocardiographic, and coronary arteriographic data of 51 patients with type 2 diabetes mellitus with left bundle branch block (LBBB), 51 patients with type 2 diabetes mellitus without LBBB, and 51 patients with isolated LBBB matched for age and gender. Extent of coronary artery disease (CAD) was classified according to the standard method into 1-, 2-, or 3-vessel disease and was estimated by calculation of the Gensini score. The left ventricular ejection fraction was analyzed by echocardiography. Age, gender, and percentage of patients with a smoking habit or family history of CAD did not differ among the groups. The rates of hypertension and levels of serum creatinine, cholesterol, and triglycerides were statistically higher in group I compared with the other 2 groups. Patients with diabetes and LBBB (group I) had significantly higher scores for the severity (Gensini score) of CAD (p <0.001) and more 3-vessel disease (p <0.001). After adjustment for hypertension, hypertriglyceridemia, and hypercholesterolemia with covariance analysis, the presence of LBBB was also associated with a higher Gensini score in patients with diabetes compared with those with diabetes but without LBBB and those with isolated LBBB (p <0.001). The present study, for the first time, has shown that patients with type 2 diabetes mellitus and concomitant LBBB have more severe and extensive CAD and advanced left ventricular dysfunction compared with those with diabetes but without LBBB and those with isolated LBBB.

Relationship of fragmented QRS with prognostic markers and long-term major adverse cardiac events in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: Fragmented QRS (fQRS) complex is associated with increased sudden cardiac death, recurrent cardiovascular events, morbidity and mortality. However, the prognostic role of fQRS has not been comprehensively studied in patients undergoing coronary artery bypass graft (CABG) surgery. In this study, we planned to investigate the relationship of fQRS with prognostic markers and long-term major adverse cardiovascular events (MACEs) following isolated CABG surgery. METHODS: Two hundred and thirteen patients who underwent CABG surgery at our institution were enrolled consecutively. MACE was defined as cardiac death, recurrent myocardial infarction, decompensated heart failure and re-hospitalization. The patients were followed up for a mean duration of 26 ±â€Š10 months for MACE. RESULTS: Patients with fQRS had a higher rate of Q wave on ECG (30 vs. 10%, P < 0.001), more prolonged QRS time (99 ±â€Š11 vs. 88 ±â€Š13 ms, P < 0.001), higher EUROSCORE (4.0 ±â€Š1.9 vs. 2.7 ±â€Š1.5, P < 0.001) and lower left ventricular ejection fraction (44 ±â€Š12 vs. 56 ±â€Š12, P < 0.001) in comparison with patients with non-fQRS. In addition, patients with fQRS had increased short-term and long-term MACE (17 vs. 4%, P = 0.002; 23 vs. 6%, P < 0.001, respectively) after discharge. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of fQRS for predicting MACE were 67, 71, 23, 94 and 70%, respectively. fQRS [odds ratio (OR) 3.110, 95% confidence interval (CI) 1.157-8.362, P = 0.025] and prolonged QRS duration (>100 ms) (OR 3.898, 95% CI 1.463-10.39, P = 0.007) were the only independent predictors of long-term MACE in multivariate logistic regression analysis. However, QRS duration had a better association with MACE than the presence of fQRS. CONCLUSION: fQRS and prolonged QRS duration may have an additional value in predicting cardiac status and long-term prognosis. Fragmentations on admission ECG and prolonged QRS duration may be useful for identifying patients with higher long-term risk who will need more intense treatment and close follow-up after CABG surgery.

The effect of irritable bowel syndrome on carotid intima-media thickness, pulse wave velocity, and heart rate variability.

OBJECTIVE: Irritable bowel syndrome (IBS), a subgroup of functional somatic disorders, may be associated with autonomic dysfunction (AD). Heart rate variability (HRV), a measure of autonomic dysfunction, may predict survival. The aim of this study was to investigate the effect of IBS on HRV parameters, carotid intima-media thickness (CIMT) and carotid-femoral pulse wave velocity (cf-PWV) as surrogates of AD, subclinical atherosclerosis and arterial stiffness, respectively. METHODS: Our study was cross-sectional and observational. Thirty consecutive patients with IBS and 30 control participants underwent 24-hour Holter monitoring, cf-PWV assessment and CIMT measurement. The diagnosis of IBS was based on Rome III criteria. There were 24 patients with IBS-Constipation (80%), 4 patients with IBS-Diarrhea (13.3%), and 2 patients with IBS-Mixed (6.7%) in IBS group. Student t-test and χ2 test were utilized in order to compare continuous and categorical variables between two groups, respectively. RESULTS: Biochemical parameters did not differ between groups except for slightly increased creatinine in patients with IBS. cf-PWV and CIMT values were similar between groups. SDNN index and RMSSD were significantly impaired in patients with IBS compared to controls. Frequency analyses revealed lower LF, HF, and VLF in subjects with IBS. CONCLUSION: We demonstrated decreased parasympathetic modulation in patients with constipation predominant IBS. However, we could not demonstrate any changes in vascular structure and functions measured by carotid intima-media thickness and pulse wave velocity. Our results do not support accelerated atherosclerosis in IBS population.

The independent relationship of epicardial adipose tissue with carotid intima-media thickness and endothelial functions: the association of pulse wave velocity with the active facilitated arterial conduction concept.

BACKGROUND: Hypertension, identifiable by elevated blood pressure (BP), is a heterogeneous multifactorial disorder. Epicardial adipose tissue (EAT), a special fat depot that is related to visceral fat rather than total adiposity, shares the same microcirculation with myocardial tissue and coronary vessels. Recent studies have identified EAT as an active organ, which secretes several mediators, called adipokines, affecting the vascular system. The aim of this study was to evaluate the potential association between EAT and BP, endothelial function, carotid intima-media thickness (CIMT), and pulse wave velocity (PWV) independent of conventional and novel metabolic risk factors in patients with previously untreated hypertension. PATIENTS AND METHODS: Our study, which has a cross-sectional design, included 107 consecutive untreated hypertensive patients. Vascular status and functions were evaluated using CIMT, PWV, and flow-mediated dilation (FMD) of the brachial artery. The values of BP were obtained both by the traditional auscultatory method using a sphygmomanometer in an office and by ambulatory BP measurement. RESULTS: When we stratified the patients into three groups according to increased EAT values, CIMT (P<0.001), presence of carotid plaque (P=0.026), and BP values (P=0.001) were increased in the higher tertile compared with the lower tertile. FMD of the brachial artery decreased significantly with increasing EAT thickness (P<0.001). There was a significant, strong, and negative association between CIMT and FMD (r=-0.604, P<0.001). CIMT correlated positively to age (r=0.404, P<0.001), EAT (r=0.517, P<0.001), office systolic BP (r=0.241, P=0.016), ambulatory systolic BP (r=0.419, P<0.001), and diastolic BP (r=0.360, P=0.002). FMD correlated negatively to age (r=-0.390, P<0.001), EAT (r=-0.495, P<0.001), ambulatory systolic (r=-0.338, P=0.006), and diastolic BP (r=-0.281, P=0.024). Multivariate linear regression analyses, carried out to identify predictors of CIMT and FMD, showed only age, EAT, and mean ambulatory BP as independent predictors of both CIMT and FMD. CONCLUSION: Our study showed that EAT is an independent factor of adverse changes in CIMT, FMD, and PWV. Future studies, investigating the vascular influence of EAT at the molecular level, may provide therapeutic options to prevent its adverse vascular interactions.

Effect of epicardial adipose tissue on diastolic functions and left atrial dimension in untreated hypertensive patients with normal systolic function.

BACKGROUND: Adipose tissue is the source of many adipokines affecting the cardiovascular system either locally or systemically. Although hypertension is one of the most important factors in diastolic dysfunction (DD), the exact cause of this relationship is unknown. There is no specific study in the current literature regarding the association of epicardial adipose tissue (EAT) with left ventricular DD in patients with essential hypertension. METHODS: The present study was cross-sectional and observational, including 127 patients with untreated hypertension who underwent a complete transthoracic echocardiographic examination as well as measurements of EAT and diastolic parameters. RESULTS: EAT was significantly correlated with left atrial dimension, DD parameters, and left ventricular (LV) mass as well as age and blood pressure measurements. EAT was also correlated with Framingham risk score (p<0.001). Age and EAT were significantly increased in patients with high grades of DD compared to those with low values (p<0.001 and p=0.001, respectively). Linear regression analyses revealed EAT as an independent predictor of all DD parameters. The area under the curve values of EAT were similar to age and higher than those of LV mass and mean BP for both the presence of DD and grade two DD. CONCLUSION: Based on our findings, increased EAT may be associated with diastolic dysfunction and left atrial dilatation due to local or systemic effects in untreated hypertensive patients. This relationship is independent of and stronger than abdominal obesity, implicating the clinical importance of measuring EAT thickness.

Increased YKL-40 levels in patients with isolated coronary artery ectasia: an observational study.

OBJECTIVE: YKL-40, a new biomarker of localized inflammation, is secreted by macrophages within the atherosclerotic plaques. Coronary artery ectasia (CAE) is a clinical entity with unclear etiopathogenesis. Some studies have revealed that CAE may be a form of atherosclerosis that has more localized and intense inflammatory properties than atherosclerosis. The goal of this study was to investigate YKL-40 and C-reactive protein (CRP) levels in patients with isolated CAE compared to patients with normal coronary arteries (NCA) and coronary artery disease (CAD). METHODS: Our study has an observational and cross-sectional design. Forty-nine patients with isolated CAE (mean age: 60±10 years), 30 age-and gender-matched control participants with NCA (30 patients, mean age: 58±12 years) and 30 patients with CAD (mean age: 61±10 years), were included in the study. The relationship between YKL-40, CRP levels and the presence of CAE was investigated. Univariate and multiple logistic regression analysis were used for analysis of independent variables to predict CAE. RESULTS: Serum YKL-40 levels were significantly different among study groups (NCA: 110±53 µg/L, CAE: 144±68 and CAD: 180±117, p=0.005). CAD group and CAE group had significantly higher YKL-40 levels than NCA group (p=0.004 and p=0.015, respectively). CRP was not significantly different between three groups. In addition, there were no any statistically significant differences, with respect to age, gender, the presence of hypertension or diabetes mellitus, and the smoking status (p>0.05). Logistic regression analysis revealed only YKL-40 level as the determinant of CAE (OR: 1.010, 95% CI: 1.001-1.019, p=0.027). CONCLUSION: YKL-40 levels in patients with isolated CAE compared to patients with NCA were found significantly high and only YKL-40 level was established as the determinant of CAE. We believe that further studies are needed to clarify the possible causative roles of YKL-40 in patients with isolated CAE.