Relationship of serum HLA-B alleles and TNF-α with rheumatic heart disease

Background/aim: Acute rheumatic fever and rheumatic heart disease are major causes of morbidity and mortality in developing countries. Genetic studies have determined that the immune response in rheumatic heart disease is genetically controlled and that there is a close relationship between the gene of concern and the class II human leukocyte antigen (HLA) gene. The aim of this study was to evaluate the relationship of serum HLA-B alleles and tumor necrosis factor alpha (TNF-α) with rheumatic heart disease. Materials and methods: A total of 50 consecutive patients with rheumatic heart disease and 50 controls were enrolled in the study. HLA alleles were analyzed using sequence-specific primer-polymerase chain reaction and nucleotide sequencing. Results: The HLA-B35 allele was significantly more common in patients with rheumatic heart disease than the control group (P = 0.043). The HLA-B44 allele was significantly more common in control patients than in patients with rheumatic heart disease (P = 0.014). There was a significant inverse correlation between high-sensitivity C-reactive protein and mitral valve area (P = 0.001). There was no correlation between TNF-α levels and mitral valve area (P = 0.066). Conclusion: Our findings confirmed the association between HLA-B alleles and rheumatic heart disease.

The Relationship between Pre-Infarction Angina and Serum Sphingosine-1-Phosphate Levels.

BACKGROUND: Pre-infarction angina reduces myocardial infarct size by preventing the myocardium from being subjected to ischemia reperfusion (I/R) injury. Ischemic preconditioning is the proposed mechanism for this effect. Sphingosine 1 phosphate (S1P) activates ischemic preconditioning pathways and may play a role in the presence of cardioprotective effects of pre-infarction angina. Therefore, we evaluated the relationship between pre-infarction angina and serum S1P levels. METHODS: Between May 2011 and January 2012, 79 patients with acute myocardial infarction were included in the study. In addition to taking routine medical histories, all of the patients were questioned as to whether or not they had pre-infarction angina. We determined patients serum levels of S1P at admission and discharge, and peak creatine kinase MB and troponin levels were also measured in the pre-infarction angina positive and negative groups. RESULTS: Of the 79 patients included in the study, 36 had pre-infarction angina and 43 had not. Baseline characteristics were similar between the groups. The median level of serum S1P in patients with pre-infarction angina was significantly higher than in those without pre-infarction angina both at admission and discharge [0.54 (0.14-1.35) vs. 0.26 (0.12-0.62) p = 0.014/0.51 (0.20-1.81) vs. 0.30 (0.13-0.68) p = 0.010]. Serum high sensitive troponin levels were significantly lower in patients with pre-infarction angina [0.97 (0.39-3.07) vs. 2.56 (0.9-6.51) p = 0.034]. Serum S1P levels both at admission and discharge tended to be higher in patients with more angina episodes, but the differences between these subgroups were not statistically significant. CONCLUSIONS: Patients who experienced pre-infarction angina had higher serum S1P levels than patients without pre-infarction angina. This study supported our hypothesis that the cardioprotective effects of pre-infarction angina may in part be mediated by S1P. KEY WORDS: Ischemic preconditioning; Pre-infarction angina; Sphingosine 1 phosphate.

Relationship between Retinal Nerve Fiber Layer Thickness and Aortic Distensibility in Peripheral Arterial Disease Patients.

AIM AND OBJECTIVE: To evaluate the relationship between aortic distensibility (AD) and aortic stiffness B index (ASBI) with retinal nerve fiber layer (RNFL) thickness measured with HD-OCT in peripheral arterial disease (PAD) patients. MATERIALS AND METHODS: Twenty-six PAD patients and 22 age-matched healthy control were enrolled. Subjects with PAD were classified into two groups. Patients with diabetes (DM) or hypertension (HT) comprised group I (n = 18) and without DM or HT comprised group II (n = 8). Color Doppler imaging was performed on all patients and PAD was diagnosed by using the ankle-brachial index (ABI). Retinal nerve fiber layer thickness values between control and PAD patients and correlations between RNFL thickness and aortic stiffness parameters (AD and ASBI) were evaluated. RESULTS: The inferior-nasal and inferior-temporal quadrant were the thickest in healthy subjects and the PAD group. Retinal nerve fiber layer thickness significantly decreased in superior-nasal, temporal, inferior-nasal quadrants in group I than healthy subjects (p < 0.001, p = 0.005, p < 0.001). Temporal and inferior-nasal quadrant thicknesses were statistically significantly thinner in group II than controls (p = 0.02, p < 0.001). The nasal RNFL quadrant was significantly thinner in group I than group II (p = 0.014). The correlation between RNFL thickness and aortic elasticity parameters in each group was not found to be significant. CONCLUSION AND CLINICAL SIGNIFICANCE: Isolated PAD without DM or HT may lead to localized RNFL loss in temporal and inferior-nasal quadrants. Aortic elasticity parameters did not seem to be correlated with RNFL thickness in PAD. HOW TO CITE THIS ARTICLE: Kumova D, Aktas Z, Eyiol A, et al. Relationship between Retinal Nerve Fiber Layer Thickness and Aortic Distensibility in Peripheral Arterial Disease Patients. J Curr Glaucoma Pract 2021;15(2):86-90.

High incidence of co-existing factors significantly modifying the phenotype in patients with Fabry disease.

Fabry disease results from deficiency of the lysosomal enzyme alpha-galactosidase A. The families of 11 index cases were screened by enzyme and molecular assays. Further clinical and laboratory investigations were carried out in all cases. Including 33 new patients, a total of 28 females (Age 25,82 ±â€¯12,1 Range 8-46) and 16 males (Age 24,56 ±â€¯15,04 Range 2-48) were investigated. Ten different disease-causing variants were found two of them being novel. One patient had co-existing familial mediteranian fever, one had celiac disease and three had rheumatological disorders. Lipoprotein (a) levels were elevated in 17,6%, homocysteine in 22,2%, total and low density cholesterol in 12% and antithrombin 3 levels were elevated in 13,3%. One patient was found to be heterozygous for prothrombin p.G20210A disease-causing variant (5,8%) and two for factor V Leiden disease-causing variant (11,7%). Anticardiolipin IgM antibody was found to be positive in 11,7%. The patients with abnormal cranial imaging were also noticed to have additional risk factors for thrombosis. This study provides the largest data about Fabry patients from Turkey and implies that co-existing risk factors unrelated to Fabry Disease have significant association with the presence of clinical symptoms in females and might cause an early and severe clinical course in males.

Heart rate variability and heart rate turbulence in mild-to-moderate aortic stenosis.

AIMS: To study heart rate (HR) variability and HR turbulence parameters in mild-to-moderate aortic stenosis (AS) and to disclose whether any relationship exists between these parameters and echocardiographic findings. METHODS AND RESULTS: Forty-three asymptomatic patients with mild-to-moderate AS (AS group) were studied. Echocardiographic parameters and HR variability and HR turbulence indices obtained over 24 Holter ECG recordings were compared with those of an age and sex matched control population free of cardiovascular disease. Correlation between echocardiographic findings and HR variability and HR turbulence indices was also studied in the AS group. All HR variability parameters except mean RR interval, RMSSD, and pNN50 and one HR turbulence parameter, turbulence onset, were significantly disturbed in the AS group. Echocardiographic findings of diastolic dysfunction had significant correlations with HR variability and HR turbulence parameters in AS patients. CONCLUSION: Symphatovagal imbalance as shown by disturbed HR variability and HR turbulence parameters was demonstrated for the first time in patients with mild-to-moderate AS. This imbalance, which was shown to be correlated with echocardiographic findings of diastolic dysfunction, may lead to arrhythmic complications in this seemingly low-risk patient population.

The detailed assessment of left and right ventricular functions by tissue Doppler imaging in patients with familial Mediterranean fever.

In the contrary to other rheumatologic disorders, there have been limited numbers of studies investigating the cardiac involvement in patients with familial Mediterranean fever (FMF), although the disease may carry a potential for cardiovascular disorders because of sustained inflammation during its course. In the present study, we used high usefulness tissue Doppler echocardiography for detailed analysis of cardiac changes in FMF patients. The study population included 30 patients with FMF (11 men, 19 women; mean age, 35 +/- 7 years, mean disease duration, 15.4 +/- 7.6 years) and 30 healthy subjects as controls (12 men, 18 women; mean age, 33 +/- 7 years). The diagnosis of FMF was established according to the Tell-Hashomer criteria. Left and right ventricular functions were measured using echocardiography comprising standard two-dimensional, M-mode, and conventional Doppler as well as tissue Doppler imaging. The conventional echocardiographic paratemeters were similar apart from left ventricular relaxation time was longer (107 +/- 25 vs 85 +/- 10 ms, p < 0.001, respectively) in patients with FMF. According to the tissue Doppler measurements, while systolic velocities of both ventricles were not different, diastolic filling velocities of left ventricle including E'(m) (12.6 +/- 3.4 vs 14.7 +/- 3.3 cm/s, p = 0.04), A'(m) (10.1 +/- 2.6 vs 8.6 +/- 2.0 cm/s, p = 0.015), and E'(m)/ A'(m) (1.24 +/- 0.4 vs 1.71 +/- 0.5 cm/s, p = 0.012) values were statistically different between the groups. Left ventricular myocardial performance indices and right ventricular diastolic functions were found similar between two groups. In addition, there were no significant correlations between the disease duration, clinical features, and echocardiographic parameters. In conclusion, we have demonstrated that although systolic functions were comparable in the patients and controls, left ventricular diastolic function indices were impaired in FMF patients by using tissue Doppler analysis.

Huge biatrial cardiac rhabdomyosarcoma resulting in bilateral atrioventricular valve obstruction.

We present a case report of a 28-year-old man with a huge tumor that occupies both dilated atria almost completely but not extending into the ventricles. Cardiac rhabdomyosarcoma (CR) is extremely rare in adult patients. Its rarity and heterogenous clinical presentation make diagnosis difficult. In our case, after we have made an initial diagnosis via echocardiography, we took biopsies under computed tomography (CT) guiding. Histologic examination showed a CR. We want to emphasize that CT-guided biopsy is a useful and applicable technique in establishing preoperative diagnosis of intracardiac masses.

LOAD limits for ambulatory pulse pressure and double product in normotensive and hypertensive subjects.

OBJECTIVE: The aim of this study was to to determine possible daytime (awake hours) and nighttime (sleeping hours) LOAD limits for ambulatory pulse pressure (PP) and double product (DP) in hypertensive (HT) subjects and secondly to assess whether there were significant differences in the LOAD values between hypertensive (HT) and normotensive (NT) subjects. METHODS: Seventy-eight untreated essential HT (46 female, 32 male; mean age 51.9+/-1.4 years) and 115 NT (89 female, 26 male; mean age 40.8+/-1.1 years) subjects participated in this study. Ambulatory blood pressure monitoring (ABPM) devices were applied to these subjects for 48 hours. Different possible ambulatory PP LOAD limits between 40 and 55 mmHg with 5 mmHg increments and ambulatory DP LOAD limits between 6000 and 12,000 mmHg x beats/min with 1000 mmHg x beats/min increments were used. Then according to these limits, LOAD values of NT and HT subjects have been assessed for daytime, nighttime and 48 hours. RESULTS: There were significant differences between NT and HT subjects in all the values for both ambulatory PP and DP. Although mean (total, day and night mean) values of HT subjects were higher approximately by 20% than of NT subjects, LOAD values for ambulatory PP in HTs were 33%-415% higher than in NTs (p<0.001). Hypertensive subjects' mean (total, day and night mean) values of DP were by 23%-33% higher than NTs values, but LOAD values for ambulatory DP in hypertensives were approximately 43%-673% higher than in NT subjects (p<0.001). CONCLUSIONS: We showed that although there were significant differences in the 48-hour, daytime and nighttime PP and DP means between NT and HT subjects, these differences became more prominent when possible LOAD limits were used for ambulatory PP and DP, One of these possible ambulatory PP and DP LOAD limits can be used in the clinical settings if a relationship with the end-organ damage will be showed by further studies.

B-type natriuretic peptide and extent of lesion on coronary angiography in stable coronary artery disease.

OBJECTIVE: Although it is well established that plasma B-type natriuretic peptide (BNP) levels are higher in patients with acute coronary syndromes, the relationship between plasma BNP level and stable coronary artery disease is not clear. The aim of this study was to examine the relationship between plasma BNP levels and the extent of obstructive lesions on coronary angiography in stable coronary artery patients. METHODS: Plasma BNP concentrations were measured in 62 patients with a diagnosis of stable angina pectoris who had a left ventricular ejection fraction (LVEF) >or=45% on echocardiographic evaluation. Coronary angiography was performed for all patients, who were than divided into two groups according to the results of the angiography. Group I consisted of the patients who had a lesion leading to an obstruction of the lumen in any coronary artery by less than 50% or those who had normal coronary arteries. All other patients constituted group II. RESULTS: In group I (n=26), the mean plasma BNP level was 64.8+/-29.5 pg/ml. In group II (n=36), it was 99.7+/-55.4 pg/ml. BNP was significantly higher in group II (P=0.007) than group I. The BNP concentration of the patients with one-vessel disease (n=12), two-vessel disease (n=16), and three-vessel disease (n=8) were 77.9+/-34.9 pg/ml, 109.3+/-67.9 pg/ml, 113.3+/-48.1 pg/ml consecutively. In this respect, the plasma BNP was significantly higher in the groups with more extended vessel disease (P=0.02). When we compared the patients according to involvement of left anterior descending artery (LAD), BNP levels were significantly higher in this group, (116.1+/-55.8 pg/ml versus 64.1+/-30.2 pg/ml; P=0.001). CONCLUSION: Plasma levels of BNP were higher in patients who have stable coronary artery disease with preserved left ventricular systolic function. The level of increase in plasma BNP concentration was positively correlated with the extent of lesion and LAD involvement on coronary angiography.

Use of long-term combined therapy with inhaled iloprost and oral sildenafil in an adult patient with eisenmenger syndrome.

Eisenmenger syndrome is characterized by elevated pulmonary vascular resistance and right-to-left shunting of blood through a systemic to pulmonary circulation connection. Treatment requires either lung transplantation with intracardiac repair or heart-lung transplantation. There are inadequate data regarding treatment alternatives when the patient is not a candidate for surgery. In this article, we report on the case of a 68-year-old woman with Eisenmenger syndrome related to congenital heart disease who was treated with inhaled iloprost and oral sildenafil for 2 years.

Sidebranch occlusion after coronary stenting with or without balloon predilation: direct versus conventional stenting.

Direct stenting (DS) is a novel approach in percutaneous treatment of coronary artery lesions. Several studies confirmed the safety and feasibility of the procedure with success rates greater than 90%. However, the data regarding the incidence of sidebranch occlusion (SBO) after DS are scarce. The purpose of this study was to evaluate SBO (> 1 mm) after DS and compare it to conventional stenting (CS) with balloon predilation. The study population consisted of 151 patients (88 underwent DS, 63 underwent CS) with 185 sidebranches jailed by the stent (110 in DS group, 75 in CS group). SBO was observed in 20 out of 110 patients in the DS group (18.2%) and 18 out of 75 patients in the CS group (24%). Although the incidence of SBO was higher in the CS group compared to the DS group (24% vs. 18.2%, respectively), these values did not reach statistical significance (p > 0.05). Most of the SBOs were observed in cases with type D sidebranch morphology (p < 0.001) and in cases with sidebranch ostial diameter stenosis 50% (p = 0.019). None of the other clinical and angiographic variables predicted the SBO. To the best of our knowledge, this is the first report comparing incidence of SBO between two different PCI methods (CS vs DS). Randomized studies with larger patient populations should be conducted to compare this approach with conventional stenting.

Myocardial injury after apparently successful coronary stenting with or without balloon dilation: direct versus conventional stenting.

Direct stenting (i.e., stenting without balloon predilation) is a novel approach to the percutaneous treatment of coronary artery lesions. This approach, by reducing aggression to the vessel wall and immediately sealing the dissections created by balloon inflation by the endoprosthesis, may also significantly lower the rate of procedural ischemic complications. Our purpose was to measure cardiac troponin T (cTnT), creatine kinase and its isoform CKMB after apparently successful elective stent implantation with conventional stenting (CS) or direct stenting (DS) and to compare the procedural myocardial injury between these 2 approaches. Enzyme levels were measured before and 16 hours post-procedure. A second-generation commercial ELISA cTnT assay (Boehringer Mannheim Corporation) was used to measure cTnT with a cut-off of 0.1 ng/dl. There was no abnormality in any of the 3 enzymes in either group before the procedure. Although the incidence of cTnT was elevated in 4 of 37 patients (10.8%) in the DS group and in 5 out of 23 patients (21.7%) in the CS group at 16 hours post-procedure, these values did not reach statistical significance (p > 0.05). Creatine kinase and CKMB levels were not elevated in any of the patients. CTnT and CKMB measurements are needed to detect this minor myocardial damage. Randomized studies with larger patient populations should be conducted to compare the two different approaches.

Conventional versus direct stenting in AMI: effect on immediate coronary blood flow.

There are no data regarding the potential benefits of direct stenting in the setting of AMI. The aim of this study was to evaluate the impact of direct stenting on the angiographic results and compare it to conventional stenting performed in the setting of AMI. We reviewed our institutional interventional database and identified 44 patients who had undergone stenting in the setting of AMI (29 primary and 15 rescue angioplasty). Patients were then divided into two groups; group A consisted of patients who had undergone conventional stenting (23 patients) and group B those who had undergone direct stenting (21 patients). Angiographic success was defined as TIMI flow grade 2. The baseline TIMI 0-1 flow was higher in group A compared to group B (74% vs. 24%; p < 0.05). TIMI flow rates before stenting (after balloon predilation in group A and after guidewire crossing in group B) and angiographic success (TIMI flow 2) after stenting were similar in both groups (p > 0.05). However, the final TIMI 3 flow were significantly better in group B after stenting (65% vs. 95%; p < 0.05). Although there was no no re-flow in group B, three patients in group A had no re-flow after balloon predilatation of lesions with baseline TIMI 2 flow. There was a statistical tendency to a higher TIMI 3 flow in patients treated with direct stenting in the setting of AMI. Direct stenting strategy in thrombus containing lesions seems to be a safe and feasible approach in avoiding no re-flow.

Accessory mitral valve tissue as a cause of left ventricular outflow tract obstruction and probable cause of cerebrovascular accident.

Accessory mitral valve tissue is a rare finding in echocardiographic examinations. We report a case with an echocardiographically detected accessory mitral valve tissue which caused left ventricular outflow tract obstruction and was presumably responsible for a cerebrovascular accident.

Medium-term follow-up of intermediate coronary stenoses left unrevascularized based on myocardial fractional flow reserve findings.

OBJECTIVE: Coronary stenoses of intermediate severity create difficulties in decision making when revascularization is concerned. Myocardial fractional flow reserve (mFFR), an accurate tool to identify physiological significance of individual coronary stenoses, may help solve this problem. METHODS AND RESULTS: Fifty-eight intermediate (30-70%) coronary stenoses in 51 patients (mean age 54.4 +/- 8.9 years, 9 women) were left unrevascularized because of normal (> or = 0.75) mFFR findings and the patients were prospectively followed with regard to the occurrence of death, myocardial infarction and target vessel revascularization. The mean reference vessel diameter, percent stenosis and mFFR of the intermediate lesions were 3.3 +/- 0.3 mm, 46.8 +/- 9.2% and 0.86 +/- 0.05, respectively. Of the 58 intermediate lesions, 20 (34%) were associated with perfusion defects on thallium scan. Significant (> 70%) disease in addition to the one with the intermediate stenosis was present in I coronary artery in 24 (47%), and 2 coronary arteries in 6 (12%) patients and angioplasty of at least one significant stenosis was performed at the initial evaluation in 18 (35%) patients. Follow-up for a mean of 16.6 +/- 6.6 months disclosed no death or myocardial infarction. Target vessel revascularization was performed in 3 (6%) patients at a mean of 4 +/- 2.6 months. A control angiogram, which was performed in 12 of 18 patients who had undergone angioplasty at the initial evaluation revealed restenosis in 3 (25%) patients with no significant angiographic changes in the target intermediate stenoses. Anginal status was found to be significantly improved at follow-up. CONCLUSIONS: In this study, we found that intermediate coronary stenoses with an mFFR > or = 0.75 have a favourable medium-term clinical outcome with respect to major cardiac adverse events when left unrevascularized based on mFFR findings.

Prospective randomized trial of transthoracic versus low-energy transvenous internal cardioversion in persistent atrial fibrillation.

OBJECTIVE: Electrical cardioversion (CV) is used to restore sinus rhythm (SR) in patients with atrial fibrillation (AF). In this prospective randomized study, we compared two different methods of electrical CV, namely transthoracic (TT) and low-energy transvenous internal CV (ICV), in patients with persistent AF with respect to efficacy, safety and the magnitude of myocardial damage provoked by either method. METHODS AND RESULTS: Fifty-two patients with persistent AF were randomly assigned to either TT (n = 26) or ICV (n = 26). The baseline characteristics of the two treatment groups were similar. TT CV was performed under sedation with hand-held electrodes in the apex-anterior position and high-energy (100-360J) monophasic shocks. ICV was performed by a single catheter approach utilizing a special balloon-directed catheter with proximal and distal arrays of shock electrodes that were positioned in the right atrium and left pulmonary artery under fluoroscopy. Truncated, biphasic shocks of low energy (1-15 joules) were used. Cardiac troponin T (cTpnT), creatine kinase (CK) and CK-MB levels were assessed before and 24 hours after each procedure. SR was restored in 24/26 (92%) patients in the ICV and 22/26 (85%) patients in the TT CV groups (p > 0.05). The mean energy to achieve SR was significantly higher with the TT method (9.8 +/- 4.3 J vs. 246.4 +/- 73.6 J, p < 0.05). CV with either method caused no elevation in cTpnT levels. Total CK and CK-MB levels remained unchanged with ICV. On the other hand, TT CV resulted in a significant increase in total CK (51.8 +/- 30 vs. 156.5 +/- 255.3, p < 0.05) and a nonsignificant rise in CK-MB levels (14.7 +/- 7 vs. 17.3 +/- 1.1, p > 0.05). CONCLUSIONS: In this prospective randomized comparison, TT and ICV were found to be equally effective to restore SR in patients with persistent AF No evidence of myocardial damage was detected with either method.

Effects of left ventricular systolic dysfunction on left atrial appendage and left atrial functions in patients with chronic nonvalvular atrial fibrillation.

OBJECTIVE: It has been claimed that left ventricular (LV) systolic dysfunction impairs left atrial (LA) and left atrial appendage (LAA) functions. In this study, we compared the LA and LAA function parameters in patients with chronic nonvalvular atrial fibrillation (AF) with and without LV systolic dysfunction. METHODS AND RESULTS: The study population consisted of 28 patients with chronic nonvalvularAF. Group I consisted of 12 patients with LV systolic dysfunction (mean age: 61 +/- 14 years; LV ejection fraction: 44 +/- 6%), group II of 16 patients with normal LV systolic function (mean age: 52 +/- 15 years; LV ejection fraction: 65 +/- 3%). LV ejection fraction (EF) was measured by echocardiography utilizing bi-plane area length method. The following LA and LAA transoesophageal echocardiography parameters were obtained: I) LA diameter, 2) LAA ejection velocity, 3) LAA filling velocity, 4) LAA ejection fraction, 5) pulmonary venous (PV) systolic velocity, 6) PV diastolic velocity, 7) PV systolic velocity/diastolic velocity ratio. The left atrium diameter was significantly larger in group I than in group 11 (4.7 +/- 0.7 cm vs. 3.8 +/- 0.6 cm, p < 0.05). The LAA ejection velocity and LAA ejection fraction were significantly lower in group I than in group 11 (22.6 +/- 15.5 cm/s vs 37.5 +/- 11.3 cm/s and 26.9 +/- 20.8% vs. 41.3 +/- 10.9%, p < 0.05 for both comparisons). The PV systolic velocity and PV systolic velocity/diastolic velocity ratio were significantly smaller in group I than in group II (26.2 +/- 14.8 cm/s vs. 51.5 +/- 22 cm/s and 0.7 +/- 0.6 vs. 1.2 +/- 0.5, p < 0.05 for both comparisons). Although decreased LAA filling and PV diastolic velocities were determined in group I, no significant difference existed between groups I and II. Thrombus and/or spontaneous echo contrast (SEC) in the LA and/or LAA were more frequent in group I (75% vs. 18%, p < 0.05). CONCLUSION: These results indicate that LV systolic dysfunction impairs various LA and LA function parameters and is associated with an increased frequency of SEC and/or LA thrombus in patients with chronic nonvalvularAF.

Frequency of cardiac troponin-t elevation after successful direct stenting.

Direct stenting (stenting without balloon predilation) is a novel approach in percutaneous treatment of coronary artery lesions. This approach may also significantly lower the rate of procedural ischaemic complications by reducing aggression to the vessel wall and immediately sealing the dissections created due to balloon inflation by the endoprosthesis. However, the incidence of minor myocardial infarction after direct stenting is unknown. The purpose of this study was to measure cTnT, creatine kinase and its isoform, CK-MB after apparently successful elective stent implantation without balloon predilation. Enzyme levels were measured just before and 16 hours after the procedures. A second-generation commercial ELISA cTnT assay (Boehringer Mannheim Corporation) was used to measure cTnT with a cutoff of 0.1 ng/dl. There was no abnormality in all three enzymes before the procedure. CTnT was elevated in 6 patients (13.6%), CK and CK-MB were elevated in 1 (2.3%) patient at 16 hours after the procedure. Both CK and CK-MB elevation were observed in the patient with side branch occlusion. In all others cTnT measurements in addition to CK-MB measurements are needed to detect this minor myocardial damage. To the best of our knowledge this is the first report evaluating the incidence of myocardial injury after direct stenting. Direct stenting by avoiding balloon-induced complications may decrease procedural myocardial necrosis. Randomized studies with larger patient populations should be conducted to compare this approach with conventional stenting. CTnT measurements in addition to CKMB measurements are essential in detecting this minor myocardial damage.

Effects of verapamil slow release plus trandolapril combination therapy on essential hypertension.

BACKGROUND: Fixed-dose combination antihypertensive therapy has been recommended for patients with essential hypertension who are unresponsive to monotherapy or as a first-line treatment. OBJECTIVE: We investigated the effects of a fixed-dose combination of the phenylalkylamine-type calcium channel blocker verapamil slow release (SR)plus the angiotensin-converting enzyme inhibitor trandolapril on blood pressure (BP), serum lipid profile, urinary albumin excretion (UAE), left ventricular mass (LVM), and LVM index (LVMI), as well as the adverse events associated with this treatment. METHODS: Patients aged 30 to 65 years with mild to moderate essential hypertension were included in the study. All of the patients received capsules containing combination treatment with verapamil SR 180 mg plus trandolapril 2 mg orally, daily for 12 weeks. Mean arterial pressure (MAP), systolic BP (SBP), diastolic BP (DBP), and heart rate (HR) were measured at baseline and at 4, 8, and 12 weeks of treatment. Serum lipid profile, UAE, LVM, LVMI, and body mass index (BMI) were determined at baseline and at the end of the study period. All patients underwent electrocardiography and echocardiography at baseline and week 12. The primary end point of the study was to achieve an SBP/DBP ≤140/≤90 mm Hg (ie, normotensive) during week 12. All adverse events were assessed as mild, moderate, or severe at each visit. According to the response rate at week 12, patients were divided into 2 groups: those who became normotensive (responders) or those who remained hypertensive (SBP/DBP >140/>90 mm Hg; nonresponders). RESULTS: Forty-one patients (29 women, 12 men; mean [SD] age, 47.7 [7.8] years; mean [SD] BMI, 29.4 [3.5] kg/m(2)) were enrolled. The median durationof hypertension prior to enrollment was 5 months. Mean MAP, SBP, DBP, UAE, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), LDL-C/highdensity lipoprotein cholesterol (HDL-C) ratio, LVM, LVMI, and BMI decreased significantly after 12 weeks of combination treatment; HR and triglyceride level did not change significantly. Treatment-related adverse events occurred in 31.7% of patients, and none were severe or caused any patient to withdraw from the study. The most common adverse events were cough, constipation, headache, and dryness in the throat. Microalbuminuria, which may be a marker of endothelial dysfunction, was found in 7 (17.1%) patients at baseline and regressed significantly after 12 weeks. CONCLUSIONS: In this study population, the fixed-dose combination of verapamil-trandolapril was an effective and well-tolerated antihypertensive therapy. This combination significantly reduced MAP, BP, TC, LDL-C, LDL-C/HDL-C ratio, UAE, LVM, and LVMI. Also, microalbuminuria decreased after this treatment. Verapamil-trandolapril may be useful in preventing microalbuminuria and left ventricular hypertrophy in patients with essential hypertension.