Left ventricular hypertrophy and arterial stiffness in essential hypertension.

AIM: The aim of this study was to evaluate the association between an increase in arterial stiffness and the development of left ventricular hypertrophy in essential hypertension patients. MATERIALS AND METHODS: One hundred forty essential hypertension patients were included in the study. Patients were divided into two groups based on echocardiographic measurements; with left ventricular hypertrophy (n=70) and without left ventricular hypertrophy (n=70). The criterion for hypertrophy was accepted as an intraventricular septum and posterior wall thickness in diastole of 11 mm or above. Aortic stiffness values of the patients groups were measured noninvasively by arteriography through the brachial artery. Pulse wave velocity (PWV) measurements were used as indicators of arterial stiffness. RESULTS: When compared to the group without left ventricular hypertrophy, elevated systolic blood pressure, mean blood pressure, and pulse pressure were located in the left ventricular hypertrophy group at a significant level (p > 0.01). A statistically significant difference was not observed in the diastolic blood pressure and pulse measurements of the groups. Pulse wave velocity, the indicator of arterial stiffness, was elevated to a significant degree in the left ventricular hypertrophy group (p > 0.01). While a positive correlation was found between pulse wave velocity and left ventricle mass index, microalbuminuria, high sensitive C-reactive protein (Hs-CRP), and left ventricle end-diastolic volume, a negative correlation was found between pulse wave propagation velocity and left ventricle E/A. CONCLUSIONS: In conclusion, pulse wave analysis is a valuable method for predicting cardiac hypertrophy in essential hypertension (Tab. 6, Ref. 25).

Effects of apolipoprotein E genotypes and other risk factors on the development of coronary artery disease in Southern Turkey.

BACKGROUND: Apolipoprotein E (apoE) plays a major role in lipoprotein metabolism and lipid transport. Associations between apoE genotypes, coronary artery disease (CAD) and other risk factors have been described by many investigators. The aim of this study was to investigate the role of apoE gene polymorphism and other risk factors in the development of CAD in subjects whose coronary arteries were evaluated by means of coronary angiography. METHODS: The study population consisted of 199 subjects (114 male and 55 female). Of the total, 107 had CAD. The apoE gene was amplified by polymerase chain reaction (PCR) and then digested by CfoI restriction enzyme. The plasma lipid levels and other risk factors were also determined in all subjects. RESULTS: The epsilon2 and epsilon4 allele frequencies and genotypes carrying epsilon4 allele were significantly higher in CAD (+) patients. Plasma lipids except triglycerides were increased in CAD (+) cases. We found that apoE genotypes, HT, DM, male gender, age and smoking were the independent predictors of CAD. There was no association between apoE alleles and lipids. CONCLUSION: We conclude that apoE polymorphism (presence of epsilon4 allele) is associated with the development of CAD in Southern Turkey. In our study, we did not observe any effect of apoE alleles on lipid levels.

Clinical characteristics influence left and right ventricular diastolic function in healthy individuals.

The aim of this study was to determine whether clinical characteristics have an influence on left (LV) and right ventricular (RV) diastolic function indices measured by echocardiography in healthy individuals. Five hundred and three volunteers (253 women and 250 men) aged 18-66 years (mean 36.9 +/- 11.9) who were normotensive and free of clinically apparent heart disease were included in the study. Mitral and tricuspid peak E wave and A wave velocities, E/A ratio, deceleration time (DT) of the E wave, and left ventricular isovolumetric relaxation time (IVRT) were evaluated as left and right ventricular diastolic function indices. In order to determine the effects of age, gender, body surface area (BSA), waist/hip ratio (WHR), and heart rate (HR) on left and right ventricular diastolic function indices Student's t test and correlation and linear regression analysis were used. IVRT and deceleration time of the mitral E wave (DTm) were significantly longer in men. Mitral and tricuspid A wave velocities, tricuspid E/A ratio, and deceleration time of the tricuspid E wave (DTt) were similar in both genders. Mitral and tricuspid E wave velocities and mitral E/A ratio were greater in women. Mitral E wave velocity and IVRT mostly correlated with WHR. Age was found to be the most important factor affecting mitral A wave velocity, DTm, E/A ratio, and right ventricular diastolic function indices. This study shows that age, heart rate, body surface area, and waist/hip ratio have important correlations with Doppler echocardiographic diastolic indices in normal individuals and should be considered in the evaluation of LV and RV diastolic function.

Clinical characteristics influence aortic root dimension and blood flow velocity in healthy subjects.

The aim of this study was to determine if aortic root dimension and blood flow velocity correlate with clinical and echocardiographic characteristics of healthy individuals. To assess the aortic root dimension and blood flow velocity in a healthy population, 503 subjects (253 women and 250 men) aged 18 to 66 years (mean, 36.9+/-11.9 years) who were normotensive, free of clinically apparent heart disease and any drug at the baseline examination were included in the study. M-mode echocardiographic measurements were performed according to the criteria recommended by the American Society of Echocardiography. Aortic blood velocity was obtained by pulsed wave Doppler echocardiography. Correlations between aortic root dimension and blood flow velocity and age, gender, body surface area, waist/hip ratio, and echocardiographic parameters such as left ventricular mass, ejection fraction, and left ventricular systolic and diastolic dimensions were evaluated by using regression analysis and Student's t test. Men had greater aortic root dimension (p<0.001). There were correlations between aortic root dimensions and age, body surface area, waist/hip ratio, and left ventricular mass in both genders (p<0.05). No correlation was found with left ventricular dimensions and ejection fraction. Aortic blood flow velocity correlated only with age (r=0.32, p<0.001). There was no gender difference in aortic blood flow velocity. This study shows that age, gender, body surface area, and waist/hip ratio should be considered in the evaluation of aortic root dimension. However, only age has an important impact on aortic blood flow velocity in both genders.

Bronchoscopy as an indicator of tracheobronchial fungal infection in non-neutropenic intensive-care unit patients.

We aimed to establish that a bronchoscopic view can be as reliable as microbiology, and support an empirical tracheobronchial fungal infection (TBFI) treatment decision. We retrospectively studied 95 respiratory failure patients with suspected TBFI admitted to the intensive-care unit (ICU) in 2008 with sticky secretions, hyperaemic mucosa, and whitish plaques on bronchoscopic view. Patients not suspected of having TBFI were chosen as a control group (n = 151). Broncheoalveolar lavage (BAL) fluid was cultured, and biopsy samples were taken from the lesions. Biopsy samples positive for fungi were defined as 'proven', only BAL-positive (+ fungi) cases were 'probable TBFI', and BAL-negative (- fungi) cases were 'possible TBFI'. BAL (+ fungi) and BAL (- fungi) in the control group were defined as 'colonization' and 'no TBFI', respectively. The sensitivity, specificity and positive and negative predictive values of BAL (+ fungi) were 85.1% (63/74), 81.4% (140/172), 66.3% (63/95), and 92.7% (140/151), respectively. Biopsies were performed in 78 of 95 patients, and 28 were proven TBFI with fungal elements, and 100% were BAL (+ fungi). Probable TBFI was seen in 30 of 95 patients with BAL (+ fungi), and possible TBFI (BAL(- fungi)) in 25 of 95. Among the 95 patients, microbiology revealed fungi (90.5% Candida species; 9.5% Aspergillus) in 63 (66.3%). In the controls, the colonization and no TBFI rates were 11 of 151 and 140 of 151, respectively. Observing sticky secretions, hyperaemic mucosa and whitish plaques by bronchoscopy is faster than and may be as reliable as microbiology for diagnosing TBFI. These findings are relevant for empirical antifungal therapy in suspected TBFI patients in the ICU.

Echocardiographic findings in mild and severe forms of sickle cell anemia.

M-mode echocardiographic findings were compared between sickle cell anemic and healthy children. Patients were composed of two groups; Group 1: mild group with no crises, no blood transfusions at the ages of 5.0 to 13.0, total of 12 children; Group 2: severe group, with frequent crises with requirement of blood transfusions at the ages of 3.0 to 13.0 years, total of 18 children. Control group was composed of 12 healthy children aged 5.0 to 13.0. When M-mode echocardiographic findings were compared, important findings were as follows: Mean left atrium dimension was increased both in the mild and severe groups (P < 0.001) compared with controls. This finding also supports the increase in the left ventricle end-diastolic dimension in both the severe and mild groups as compared with controls (P < 0.001). The increase in end-diastolic left ventricle dimension could be due to anemia present in the patients, but there was no difference between the two patient groups. Posterior left ventricle thickness and left ventricle mass was increased in both the mild and severe groups compared with controls (P < 0.001, P < 0.05), respectively. Left ventricular fractional shortening was more or less the same with controls. In spite of left ventricular volume load and dilatation, left ventricular contraction was good and systolic function was normal, and there was no correlation between the ECHO findings and hematological indices.

Detection of aortic plaques by transesophageal echocardiography in patients with ischemic stroke.

Twenty-eight consecutive patients, aged 34-78 years with non-cardiogenic ischemic stroke were evaluated by transesophageal echocardiography (TEE). All patients were in sinus rhythm. Six of 28 patients (21.4%) displayed protruding masses in the aortic lumen. Five of these masses were located in the ascending aorta and one in the thoracic aorta. Our study suggests that cerebral infarction may also be due to aortic atherosclerotic plaques. Although our findings do not necessarily provide a causative link between atherosclerotic lesions in the aortic lumen and cerebral infarction, they may be an alternative potential source of stroke. TEE is the method of choice in detecting such lesions at the present time.

Aortic atherosclerosis is a marker for significant coronary artery disease.

Atherosclerosis is a generalized process that may involve the entire vasculature as well as the coronary arteries. Aortic atherosclerosis (AA) is associated with an increased risk for recurrent ischemic stroke and cardiovascular death and can be diagnosed by transesophageal echocardiography (TEE). We performed TEE in 60 patients (47 men and 13 women; age range 37-78, mean 53.5 +/- 9.9) who underwent coronary angiography, to assess whether atherosclerosis in the thoracic aorta correlates with coronary artery disease (CAD) or may be a marker for it. Significant CAD was defined as either > 50% reduction of internal diameter of the left main coronary artery or > 70% reduction of the internal diameter in the anterior descending, right coronary or circumflex artery. The number of diseased vessels was based on the Coronary Artery Surgery Study criteria. A grading system was used to detect AA. The thoracic aorta was considered to be normal and classified as grade I when the internal surface was smooth and without lumen irregularities or increased echo-intensity. Grade II changes consisted of increased echodensity of the intima without lumen irregularity or thickening. Grade III changes consisted of increased echodensity of intima with well defined atheroma extending < 3 mm in the aorta. Grade IV and V changes consisted of atheroma > 3 mm and protruding mobile plaques, respectively. Grades III-V were considered as AA. Twenty two of the 29 patients (75.9%) with CAD and 10 of the 31 patients (32.3%) without CAD had AA detected by TEE. There was a significant relationship between CAD and AA (r = 0.44, p < 0.001). The sensitivity and specificity of AA in detecting CAD were 75.9% and 67.7%, respectively. Our data suggest that AA is common in patients with significant CAD. Detection of AA by TEE may be a marker for CAD and early detection of aortic atherosclerosis may contribute to diagnostic and therapeutic interventions and thereby improve the prognosis.

Transesophageal echocardiography in various ischemic stroke subtypes.

Transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) in detecting the potential source of emboli in cardioembolic strokes (CES). To establish the prevalence of a potential cardiac source of embolism detectable on TEE and its relationship to vascular risk factors, an unselected ischemic stroke population was evaluated. Twenty-six age and sex-matched cases with normal cardiological and neurological examinations as well as normal CT-scans, TTE and ECGs were included in the study as the control group. One hundred and eight patients with cardioembolic stroke (53 patients), atherothrombotic stroke (36 patients), and lacunar stroke (19 patients) were investigated by TTE and TEE. Seven of the 26 (26.9%) controls had thoracic atherosclerotic plaques on TEE examinations. The prevalence of abnormal TEE findings in patients was higher compared to the controls (p < 0.001). TEE revealed more specific findings in every etiological group when compared to TTE (74.0% vs 10.2%, p < 0.001). Atrial fibrillation correlated with the abnormalities of TEE (p < 0.05) while other risk factors did not. Left atrial spontaneous echo contrast was the most common finding on TEE of cases with cardioembolic stroke while atherosclerotic aortic plaques were mostly encountered in patients with atherothrombotic stroke. No specific findings by TEE were seen in patients with lacunar stroke. TEE is capable of detecting definite etiologies in cardioembolic stroke and associated cardiac pathologies in atherothrombotic stroke and lacunar stroke. These observations suggest that TEE is a useful tool to guide the physician for the treatment of ischemic stroke patients.

Thromboembolism risk in patients with mitral stenosis.

A total of 168 consecutive patients with predominant rheumatic mitral stenosis were evaluated by transthoracic (TTE) and transesophageal echocardiography (TEE). Of the 168 patients, 35 had previous embolic events (group I) and 133 had no emboli (group II). A total of 77 (45.8%) patients had atrial fibrillation. The frequency of atrial fibrillation was higher in group I than group II (68.6% vs 39.8%, p < 0.001). The incidence of left atrial enlargement was greater in group I (p < 0.001). Mitral valve area was found to be smaller in group I compared to group II (p < 0.001). In group I 83.3% and 29.2% of the patients with atrial fibrillation had left atrial spontaneous echo contrast (SEC) and left atrial thrombus, respectively, and 72.7% of the patients with sinus rhythm had left atrial SEC. In group II 79.2% and 20.8% of the patients with atrial fibrillation had left atrial SEC and left atrial thrombus whereas 28.6% and 2.6% of the patients with sinus rhythm had left atrial SEC and left atrial thrombus, respectively. The incidence of left atrial thrombus was significantly different in those patients with compared to those without embolic events (20% vs 9.7%, p < 0.01). In groups I and II, 28 of 35 (80%) and 64 of 133 (48.1%) patients had left atrial SEC (p < 0.01). Patients with left atrial SEC had a greater left atrial size (p < 0.01) and smaller mitral valve area (p < 0.01). Left atrial size was normal in 2 patients with left atrial SEC and SEC was not found in 55 patients with enlarged left atrium. Multiple logistic regression analysis showed that atrial fibrillation, mitral valve area and left atrial enlargement were independent predictors of the SEC (p < 0.001) and left atrial SEC was the principal determinant of thromboembolism. These data suggest that regardless of rhythm and atrial size, left atrial SEC is a principal determinant of thromboembolic risk in mitral stenosis. TEE may be able to detect those patients with mitral stenosis at risk for emboli and guide appropriate therapy.

Silent cerebral lesions on magnetic resonance imaging in subjects with coronary artery disease.

MRI of subjects with silent intracranial damages may provide more evidence than CT. Our objectives were to determine the prevalence of silent MRI lesions in patients with coronary artery disease. The study included 72 consecutive patients with angiographically proven coronary artery disease and 26 age and sex matched controls with normal coronary angiography. All subjects were evaluated for coronary atherosclerosis (Gensini and coronary angiography scores), the number of silent cerebral lesions detected by MRI, carotid stenosis and the risk factors for stroke. Thirty one of 72 (43.0%) patients had silent brain lesions on MRI while 8 of 26 (30.7%) control subjects showed silent brain infarction. The main finding on T2-weighted MRI was white matter hyperintensities (WMH) which were seen in all patients with silent brain lesions. The mean age of the patients with coronary artery disease and with silent cerebral lesions was significantly higher than that of patients without silent brain lesions. The Gensini score, coronary angiography score and prevalence of carotid stenosis are significantly higher in patients with silent cerebral lesions than that of patients without silent cerebral lesions. There was no significant difference between silent cerebral lesions and the other risk factors for stroke. Silent brain lesions are a common complication in patients with coronary artery disease. In patients with coronary artery disease, carotid artery stenosis and age were important risk factors for the development of silent brain infarction.

Decreased glutathione levels in acute myocardial infarction.

Although experimental studies have demonstrated that reduced glutathione (GSH) is involved in cellular protection from deleterious effects of oxygen free radicals (OFRs) in ischemia and reperfusion, there are controversial data on the correlation between the levels of erythrocyte GSH and the ischemic process. To clarify, we determined the erythrocyte GSH levels in 21 patients with acute myocardial infarction (AMI), aged 39-70, who were not given thrombolytic therapy and 21 age- and sex- matched healthy controls. Samples of blood were taken on days 1, 3, 5 and 7 from AMI patients and on the same days from the controls. The GSH levels of patients with AMI were significantly depressed by 11.5% as compared to the controls on the second day after infarction (7.44 +/- 1.71 vs 8.41 +/- 1.54 U/gHb p < 0.05). Although the total mean of GSH levels for all days was lower (3.8%) in patients than in the controls, this finding did not reach statistical significance (7.41 +/- 1.71 vs 7.71 +/- 1.27 U/gHb, ns). There was no correlation between the erythrocyte GSH levels and cardiac enzyme concentrations, infarct localization, hemodynamic status according to Killip classification and the frequency of ventricular arrhythmias. This preliminary work suggests that depressed GSH levels may be associated with an enhanced protective mechanism to oxidative stress in AMI. Measurements of erythrocyte GSH can be helpful in the estimation of oxidative stress in the course of AMI. However, further research must be done to determine the primary scavenger in AMI by analyzing all the enzymes and substrates involved in the endogeneous system that controls the effects of OFRs.