Association between ACE and AGT polymorphism and cardiovascular risk in acromegalic patients.

PURPOSE: Whether the renin-angiotensin-aldosterone system plays a role or not in the development of cardiovascular morbidity in acromegaly patients is unknown. The aim of the study was to investigate the association between ACE (I/D) and AGT (M235T) gene polymorphisms and cardiovascular and metabolic disorders in the acromegaly. METHODS: The study included one hundred and seventeen acromegalic patients (62 F/55 M, age: 50.2 ± 12.3 years) and 106 healthy controls (92 F/14 M, age: 41.4 ± 11.3 years). PCR method was used to evaluate the prevalence of ACE and AGT genotype. RESULTS: The genotypes of ACE polymorphism in acromegalic patients were distributed as follows; 41.0% (n: 48) for DD, 44.4% (n: 52) for ID and 14.5% (n: 17) for II genotype. The control group had significantly different distribution of the ACE polymorphism [48.1% (n: 51) for DD, 25.5% (n: 27) for ID and 26.4% (n: 28) for II genotype]compared to acromegalic group. Regarding AGT polymorphism, AGT-MT genotype was seen in 88.9% of the acromegalic patients while MM and TT genotype (9.4% and 1.7%, respectively) were present in the rest. The controls had similar distribution of the AGT genotype with the acromegaly group (80.2% MT genotype, 15.1% MM genotype and 4.7% TT genotype). Due to the small number of patients with TT allele (n: 2), T carriers for AGT genotype (AGT-MT+TT) were subgrouped and compared to those with AGT-MM group. ACE-DD, ID and II groups had similar anthropometric measures, blood pressure values and baseline GH and IGF-1 levels. Significantly higher baseline GH levels were found in AGT-MM group compared to T allele carriers [40 (16-60) vs. 12 (5-36) µg/L, p < 0.05]. The compared groups in both polymorphisms had similar fasting plasma glucose levels. Patients with ACE-II genotype had significantly higher HDL-C levels compared to those with ACE-DD and ACE-ID polymorphisms (p < 0.05) whereas there was no significant difference in lipid profile between AGT-MM group and AGT-T allele carriers. Moreover, the compared groups in both polymorphisms had similar distribution of hyperlipidemia, hypertension, impaired glucose metabolism (prediabetes or type 2 diabetes mellitus) and coronary artery disease. In terms of echocardiographic parameters, systolic and diastolic function was similar among the groups in ACE and AGT genotypes. Interestingly, AGT-MM group had higher mitral inflow Apeak values than T allele carriers (0.94 ± 0.46 vs. 0.73 ± 0.20; p = 0.051). No significant difference was observed in LV mass index values in acromegalic patients among the groups in both polymorphisms. CONCLUSIONS: Both ACE (I/D) and AGT (M235T) gene polymorphisms do not seem to have a significant effect on the development of clinical properties or cardiovascular comordities of acromegalic patients.

The clinical and cardiometabolic effects of d3-growth hormone receptor polymorphism in acromegaly.

PURPOSE: Exon 3-deleted GH receptor variant (d3-GHR) is associated with increased responsiveness to exogenous GH. The aim of this study was to determine the effect of d3-GHR polymorphism on the GH/IGF-1 relationship, clinical parameters, and comorbidity in acromegalic patients. METHODS: The study included 118 acromegalic patients (61 female and 57 male; mean age: 50.3 ± 12.2 years) and 108 healthy controls (94 female and 14 male: mean age: 41.1 ± 11.1 years). The prevalence of GHR genotypes was evaluated via PCR. RESULTS: In all, 71 (60.2%) patients had the fl/fl-GHR genotype, 40 (33.9%) were heterozygous for the fl/d3-GHR genotype, and 7 (5.9%) were homozygous for the d3/d3-GHR genotype. The prevalence of fl/fl-GHR, fl/d3-GHR, and d3/d3-GHR genotypes in the control group was 57.4, 29.6, and 13.0%, respectively-similar prevalences as in the patient group. Patients that were heterozygous and homozygous for the d3 allele were subgrouped (d3-GHR subgroup), and were compared to those with the fl/fl-GHR genotype (fl/fl-GHR subgroup). Anthropometric measures, features of pituitary adenoma, and baseline GH and IGF-1 levels were similar in both subgroups. The prevalence of coronary artery disease, hypertension, hyperlipidemia, type 2 diabetes mellitus, and multinodular goiter did not differ between patient subgroups. In total, 24 (20.3%) of the patients had cancer and the prevalence of cancer was similar in the d3-GHR (14.9%) and fl/fl-GHR (23.9%) subgroups (P = 0.23). More of the acromegalic patients that were d3 carriers had discordant GH and IGF-1 levels at baseline and post surgery, but the difference was not significant. A significant correlation between basal GH and IGF-1 levels was observed only in the patients with the fl/fl-GHR genotype (R(2) = 0.227, P < 0.001). CONCLUSION: The d3-GHR variant genotype did not have an effect on clinical features or comorbidity in acromegalic patients, but it might play a role in GH/IGF-1 level discordance in acromegaly.

Prevention of recurrent cryptogenic stroke with percutaneous closure of patent foramen ovale; one year follow-up study with magnetic resonance imaging and Holter monitoring.

OBJECTIVES: In this study, we aimed to evaluate the effect of percutaneous closure of patent foramen ovale (PFO) on the recurrence of stroke and new cardiac arrhythmia using magnetic resonance imaging (MRI) and Holter monitoring. STUDY DESIGN: Patients with PFO had >1 previous stroke or transient ischemic attack documented with MRI in the first event. PFO with right to left shunt was detected by transesophageal echocardiography (TEE) and transcranial Doppler ultrasound. MRI examinations were performed on patients before and one year after PFO closure was applied. A twenty-four hour Holter monitoring was performed in all patients within 1 month before and 6 months after the procedure. RESULTS: Percutaneous PFO closure was performed on 47 patients (25 female, mean age: 38.7 years) who had cerebral ischemic events detected by MRI. A year after the procedure, TEE showed that there was no residual interatrial right-to-left shunting. After a 14 month follow-up, no new cerebrovascular event and no new lesion on MRI were recorded. The incidence of arrhythmia did not increase significantly after the procedure on Holter monitoring (p=0.917). CONCLUSION: One-year clinical and MRI follow-up study of patients with cerebral ischemic events and percutaneous closure of PFO showed no recurrent event and no significant complication associated with the procedure. In addition, Holter monitorization demonstrated that the procedure did not increase the incidence of arrhythmias compared with pre-procedural monitoring.

Assessment of cardiac autonomic functions by heart rate recovery, heart rate variability and QT dynamicity parameters in patients with acromegaly.

Cardiovascular complications are the most common causes of morbidity and mortality in acromegaly. However, there is little data regarding cardiac autonomic functions in these patients. Herein, we aimed to investigate several parameters of cardiac autonomic functions in patients with acromegaly compared to healthy subjects. We enrolled 20 newly diagnosed acromegalic patients (55% female, age:45.7 ± 12.6 years) and 32 age- and gender-matched healthy subjects. All participants underwent 24 h Holter recording. Heart rate recovery (HRR) indices were calculated by subtracting 1st, 2nd and 3rd minute heart rates from maximal heart rate. All patients underwent heart rate variability (HRV) and QT dynamicity analysis. Baseline characteristics were similar except diabetes mellitus and hypertension among groups. Mean HRR1 (29.2 ± 12.3 vs 42.6 ± 6.5, p = 0.001), HRR2 (43.5 ± 15.6 vs 61.1 ± 10.8, p = 0.001) and HRR3 (46.4 ± 16.2 vs 65.8 ± 9.8, p = 0.001) values were significantly higher in control group. HRV parameters as, SDNN [standard deviation of all NN intervals] (p = 0.001), SDANN [SD of the 5 min mean RR intervals] (p = 0.001), RMSSD [root square of successive differences in RR interval] (p = 0.001), PNN50 [proportion of differences in successive NN intervals >50 ms] (p = 0.001) and high-frequency [HF] (p = 0.001) were significantly decreased in patients with acromegaly; but low frequency [LF] (p = 0.046) and LF/HF (p = 0.001) were significantly higher in acromegaly patients. QTec (p = 0.009), QTac/RR slope (p = 0.017) and QTec/RR slope (p = 0.01) were significantly higher in patients with acromegaly. Additionally, there were significant negative correlation of disease duration with HRR2, HRR3, SDNN, PNN50, RMSSD, variability index. Our study results suggest that cardiac autonomic functions are impaired in patients with acromegaly. Further large scale studies are needed to exhibit the prognostic significance of impaired autonomic functions in patients with acromegaly.

Evaluation of the relation between subclinical systolic dysfunction defined by four-dimensional speckle-tracking echocardiography and growth differentiation factor-15 levels in patients with acromegaly.

PURPOSE: In patients with acromegaly, the long-term presence of elevated GH and IGF-1 levels is associated with an unfavorable cardiovascular risk profile. We aimed to assess the relationship of four-dimensional speckle tracking echocardiographic (4DSTE) measurements with growth differentiation factor-15 (GDF-15) levels and the Framingham Cardiovascular Risk Score (FRS) in patients with acromegaly. METHODS: A single-center, cross-sectional study was conducted. The study included 40 acromegaly and 32 age- and gender-matched controls. Anthropometric, biochemical, and echocardiographic assessments were performed. GDF-15 levels were measured using ELISA. RESULTS: In the controlled acromegaly group, global longitudinal (GLS), circumferential (GCS), area (GAS), and radial (GRS) strain measurements identified by 4DSTE were lower than those of the controls (p < 0.05). Moreover, strain parameters were lower in active acromegaly patients than in controls, but the difference was not statistically significant. The GLS was negatively correlated with age, the estimated disease duration, and FRS. Serum GDF-15 levels showed no significant difference between the acromegaly and control groups. In patients with acromegaly, serum GDF-15 levels were positively correlated with age, waist-to-hip ratio, systolic and diastolic blood pressure, FRS, fasting plasma glucose, and HbA1c, but not with strain parameters. The multiple regression analysis revealed that FRS was an independent factor associated with serum GDF-15 levels in patients with acromegaly and the overall cohort (p < 0.001). CONCLUSION: Our study demonstrates that while LVEF was within normal limits, global strain parameters (GLS, GCS, GAS, and GRS) measured by using a novel imaging technique, 4DSTE, were lower in patients with acromegaly, suggesting the presence of subclinical systolic dysfunction in patients with acromegaly. GDF-15 can be a potential predictor of cardiovascular risk in patients with acromegaly.

Fragmented QRS complex predicts the arrhythmic events in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia.

BACKGROUND: Fragmented QRS (frQRS) complex, with various morphology, has been recently described as a diagnostic criterion of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). However, there are little data regarding the prognostic role of frQRS in these patients. Therefore, we aimed to investigate the association of frQRS with arrhythmic events in patients with ARVC/D. METHODS: Seventy-eight patients (51 men, 65.4%; mean age: 31.25 ± 11.5 years) with the diagnosis of ARVC/D according to 2010 modified Task Force Criteria were analyzed retrospectively. Baseline ECG evaluation revealed frQRS complex in 46 patients (59%). Eleven patients with complete/incomplete right bundle branch block were excluded from the study. The phenomenon of frQRS was defined as deflections at the beginning of the QRS complex, on top of the R-wave, or in the nadir of the S-wave similar to the definition in CAD in either one right precordial lead or in more than one lead including all standard ECG leads. RESULTS: During 38 ± 14 months follow-up period, 3 patients (3.8%) died suddenly, 36 patients (46.1%) experienced arrhythmic events (32 ventricular tachycardias [VTs] and 4 ventricular fibrillation [VF], 30 in the ICD group). The frQRS was significantly associated with arrhythmic events (P < 0.001). Also, the number of ECG leads with frQRS complex was higher in patients with arrhythmic events (5.08 ± 2.5 vs 1.14 ± 1.7, P < 0.001, respectively). CONCLUSION: The frQRS complex on standard 12-lead ECG predicts fatal and nonfatal arrhythmic events in patients with ARVC/D. Therefore, large scale and prospective studies are needed to confirm those findings.

The association of premature ovarian failure with ventricular repolarization dynamics evaluated by QT dynamicity.

AIMS: The association between premature ovarian failure (POF) and cardiovascular diseases has been investigated in a few studies, but none have looked at ventricular repolarization abnormalities in these patients. In this study, we aimed to evaluate the ventricular repolarization by QT dynamicity in patients with POF. METHODS AND RESULTS: We enrolled 26 female patients (mean age 37.5 ± 10.1 years) with primary POF and 31 healthy female subjects (mean age 37.5 ± 9.0 years). The linear regression slopes of the QT interval measured to the apex and to the end of the T-wave plotted against RR intervals (QTapex/RR and QTend/RR slopes, respectively) were calculated from 24 h Holter recordings using a standard algorithm. QTapex/RR and QTend/RR slopes were more steeper in the POF patients in contrary to healthy control subjects (QTapex/RR = 0.184 ± 0.022 vs. 0.131 ± 0.019, P < 0.001; QTend/RR = 0.164 ± 0.021 vs. 0.128 ± 0.018, P < 0.001). Pearson's correlation analyses revealed a stronger negative correlation between oestradiol (E2) and QTapex/RR (r = -0.715, P < 0.001). There was also a moderate negative correlation between E2 and QTend/RR (r = -0.537, P < 0.001). Serum follicle-stimulating hormone level was positively correlated with QTapex/RR (r = 0.681, P < 0.001) and QTend/RR (r = 0.531, P < 0.001). CONCLUSIONS: Our study results suggest that QT dynamicity is impaired in patients with POF despite the absence of overt cardiovascular involvement. Further studies are needed to elucidate the prognostic significance and clinical implications of impaired ventricular repolarization in patients with POF.

Impaired aortic elastic properties in patients with adult-onset hypogonadism.

BACKGROUND: Recent studies have shown a strong relationship between testosterone levels and vasomotor actions. The aim of this study is to compare the elastic properties of the aorta in male patients with hypogonadism and eugonadal healthy control subjects. METHOD: A total of 22 male with hypogonadism (mean age: 35.2 ± 9.5 years, mean disease duration: 5.3 ± 1.8 years) and 25 age-, sex- and weight-matched eugonadal healthy subjects (mean age: 34.5 ± 8.2 years) were enrolled in the study. Aortic stiffness (ß) index, aortic strain (AoS) and aortic distensibility (AoD) were calculated from the aortic diameters measured by transthoracic echocardiography and blood pressure obtained by sphygmomanometer. RESULTS: The routinely performed echocardiographic parameters were similar between patient and control groups. There were significant differences between the control and patient groups in ß index (1.75 ± 0.44 vs 2.68 ± 1.72, p < 0.001), AoS (18.52 ± 6.44 vs 12.35 ± 3.88%, p < 0.001) and AoD (7.56 ± 2.86 vs 3.96 ± 1.24, 10(-6) cm(2)/dyn, p < 0.001). There were statistically significant positive correlations between the serum total testosterone level and AoD (r = 0.539, p < 0.001) and AoS (r = 0.372, p = 0.036); moreover, there was a negative correlation between the serum total testosterone level and ß index (r = - 0.462, p = 0.001). In multivariate analysis, serum total testosterone level was significantly related with AoD, AoS and ß index (respectively, RR = 2.88, p = 0.004; RR = 3.45, p = 0.001; RR = 2.64, p = 0.01). CONCLUSION: The study results showed that aortic elasticity was impaired in patients with hypogonadism. We also have demonstrated a statistically significant correlation between aortic elastic properties and the serum total testosterone level.

[Hypertension treatment and evolving role of angiotension receptor blockers in recent guidelines]. / Güncel kilavuzlar esliginde hipertansiyon tedavisi ve anjiyotensin reseptör blokerlerinin gelisen rolü.

It was estimated that, total number of adults with hypertension was approximately 1 billion worldwide. This number was predicted to increase to a total of 1.5 billion in 2025. Hypertension is the most important risk factor for cardiovascular morbidity and mortality. The relationship between blood pressure and risk of cardiovascular events is continuous, consistent, and independent of other risk factors. The higher the blood pressure, the greater the possibility of heart attack, heart failure, stroke, and kidney diseases. The main purpose of hypertension treatment is to reduce the cardiovascular and renal morbidity and mortality. In this review, the principles of pharmalogical therapy and evolving role of angiotension receptor blockers in hypertension will be summarised according to recent guidelines.

[Pulmonary vein isolation with the cryoballoon technique in atrial fibrillation treatment: single centre experience]. / Atriyum fibrilasyonu tedavisinde kriyobalon teknigi ile pulmoner ven izolasyonu: Tek merkez deneyimi.

OBJECTIVES: Pulmonary vein (PV) isolation with cryothermal energy is a recently introduced technique in patients with atrial fibrillation (AF). It may reduce procedural times and serious complications associated with radiofrequency (RF) ablation. We aimed to present the baseline characteristics and follow-up data of our study population undergoing cryoballoon AF ablation. STUDY DESIGN: A total of 236 patients (126 male, 110 female; mean age 54.6±10.45; range 16 to 78 years) underwent PV isolation with 28 mm cryoballoon due to symptomatic AF. These patients failed with at least one previous antiarrhythmic drug. The postprocedure in the first 3 months was defined as blanking period. Median follow-up time was 14 (3-24) months. Procedural success, complicaitons, and follow-up results were defined according to Heart Rhythm Society guidelines. RESULTS: Acute procedural success rate (>=3 PV isolation) was 99.5%. Mean procedural and fluoroscopy times were 72.5±5.3 (50-90) min and 14±3.5 (12-24) min. Major complications were observed in 3 patients (1.2%). At the median 14 month follow-up, 80.6% of paroxysmal AF patients and 49.2% of persistant AF patients were free from AF recurrence. RF ablation was performed in 10 patients with recurrence. Smoking, body mass index, non-paroxysmal AF type, AF duration (years), left atrial size, and early recurrence were the predictors of recurrence in multivariate regression analysis. CONCLUSION: This study represents the first experience with cryoballoon ablation for AF in Turkey. The efficacy and safety of cryoballoon AF ablation technique was shown due to the acceptable success and low complication rates in paroxysmal AF patients. Particularly, patients with early recurrence should be closely followed-up.

Early-mid term follow-up results of percutaneous closure of the interatrial septal defects with occlutech figulla devices: a single center experience.

BACKGROUND: Percutaneous closure of secundum type atrial septal defect (ASD) and patent foramen ovale (PFO) has gained widespread use in recent years. Herein, we evaluated the safety and efficacy of the Occlutech® Figulla devices for PFO and ASD closure in a reference tertiary center. METHODS: All 143 patients (46.9% male, mean age 39.3 ± 12.2 years) who underwent transcatheter PFO (n = 85) and ASD (n = 58) closure with Occlutech® Figulla devices between February 2009 and October 2011 were included in this study. An echocardiographic follow-up examination was performed at the 1st, 6th, and 12th month visits. RESULTS: The devices were successfully implanted in all 143 patients (100%). In-hospital periprocedural complications were device embolization (0.7%; 1 ASD patient), atrial fibrillation (1.4%; 1 ASD and 1 PFO patients), supraventricular tachycardia (0.7%; 1 PFO patient), and vascular access hematoma (0.7%; 1 ASD patient). Among ASD patients, 2 patients had trivial (jet width <1 mm in diameter) and 1 patient had small (1-2 mm) residual shunts before hospital discharge, which disappeared after the 6-month visit. During the mean 15.4 ± 9.6 months follow-up, all patients were asymptomatic and no ischemic stroke, cardiac perforation, device erosion, embolization, thrombus formation, or malposition of the device was observed. CONCLUSIONS: Percutaneous PFO and secundum type ASD closure with the novel Occlutech® Figulla Occluder devices without left atrial central pin and with significantly reduced meshwork was safe, feasible, and effective.

Evolution in transvenous extraction of pacemaker and implantable cardioverter defibrillator leads using a mechanical dilator sheath.

BACKGROUND: With developing technology, transvenous lead extraction (TLE) has undergone an explosive evolution due to incremental problems related to lead infection and malfunction. OBJECTIVE: We aimed to present our experience in TLE with the Evolution®Mechanical Dilator Sheath (Cook Medical, Grandegrift, PA, USA). METHODS: Between June 2009 and July 2011, the Evolution®mechanical dilator sheath was used for the extraction of 140 pacemaker (PM) and implantable cardioverter-defibrillator (ICD) leads in 66 patients. Indications for extraction, procedural success, and complications were defined according to Heart Rhythm Society Guidelines. RESULTS: Indications for TLE were infection in 39 patients (59.1%), lead malfunction in 26 patients (39.4%), and lead displacement in one patient (1.5%). Extracted devices were PM in 28 cases (42.3%), ICD in 26 cases (39.4%), and biventricular cardioverter defibrillator in 12 cases (18.2%). Among 140 leads, 31 (22.1%) were right ventricular, 49 (35.0%) were defibrillator coil, 47 (33.6%) were atrial, and 13 (9.3%) were coronary sinus electrodes. The median time interval from the lead implantation to lead extraction was 85 months (range 22-240 months). Complete procedural success with the Evolution®system alone was achieved in 58 (87.9%) patients and overall clinical success was 98.5%. Four leads were completely removed with the help of a femoral snare and partial success was achieved in three leads with a remaining small ventricular tip. Major complication was observed in only one (1.5%) patient without any mortality. CONCLUSIONS: Our experience confirms that the hand-powered Evolution system is an effective extraction tool for chronically implanted PM/ICD leads. Randomized controlled studies are required to evaluate success and complication rates in comparison to other techniques.

Association of type 2 diabetes mellitus with coronary atherosclerotic plaque burden and morphology measured by multidetector computed tomography coronary angiography.

AIMS: Diabetes mellitus (DM) is strongly associated with increased risk of coronary artery disease (CAD). The aim of this study was to determine differences in presence, extent and morphology of coronary atherosclerotic plaques (CAP) detected by multidetector computed tomography (MDCT) between symptomatic patients with and without diabetes. METHODS: The CAPs (calcified, non-calcified, mixed) were compared between patients with/without diabetes (104/257 DM; mean age 58.6 +/- 11 y; 46.3% male) who underwent dual-source 64-slice MDCT for evaluation of CAD. Severity, extent and morphology of CAPs were determined per each segment. RESULTS: Critical coronary stenosis was higher in patients with diabetes (33.7% vs. 19.6%) after adjustment for all risk factors (P = 0.022). Patients with DM had a higher prevalence and extent of CAP compared to non-diabetic subjects (87.5% vs. 43.8%, 4.8 +/- 3.5 vs. 1.9 +/- 2.7, respectively; P < 0.001). Noncalcified and mixed CAP were more prevalent in patients with diabetes as compared to those without diabetes (2.61 +/- 2.63 vs. 0.86 +/- 1.69, 0.81 +/- 1.6 vs. 0.35 +/- 0.96, respectively, P < 0.001). Patients with DM tended to have higher prevalence of significant 1-, 2- and 3-vessel disease (P = 0.006). CONCLUSIONS: Among individuals referred for the evaluation of CAD, those with DM had a higher risk of coronary stenosis and overall increased CAP burden independent from other cardiovascular risk factors shown by MDCT. Further studies are needed to evaluate the prognostic value of different plaque compositions observed in patients with diabetes.

Energy expenditure and glucose-lowering effect of different exercise modalities in diabetes mellitus.

OBJECTIVES: Hypoglycaemia is a serious complication of exercise in patients with type 2 diabetes mellitus (T2DM). The aim of this study was to test energy expenditure and the degree of the glucose-lowering effect of different exercise modalities. DESIGN: Cross-sectional study PARTICIPANTS: This study included 44 patients {35 women and nine men, mean age 51 [standard deviation (SD) 5] years} with T2DM [mean HbA1c 7% (SD 1%)]. MAIN OUTCOME MEASURES: Standardised exercise tests for walking, running and cycling were performed using the 6-minute walk test (6MWT), incremental shuttle walk test (ISWT), and symptom-limited maximal cycle exercise test, respectively. Energy expenditure was assessed with a multisensory accelerometer. Change in capillary glucose levels (∆glucose) was measured before and after each exercise modality. RESULTS: ∆Glucose was lower in the 6MWT {median 14 [interquartile range (IQR) 22] mg/dl} than in the ISWT [median 18 (IQR 23) mg/dl; median difference 7 mg/dl, 95% confidence interval (CI) of the difference 3-11] and the cycle test [median 18 (IQR 24) mg/dl; median difference 7 mg/dl, 95% CI 0-16]. Energy expenditure was lower during the 6MWT [median 41 (IQR 18) Kcal] compared with the ISWT [median 51 (IQR 23) Kcal; median difference 11 Kcal, 95% CI 6-16] and the cycle test [median 44 (IQR 25) Kcal; median difference 6 Kcal, 95% CI 0-13]. CONCLUSIONS: Energy expenditure and corresponding glucose-lowering effect during exercise in patients with T2DM can be predicted from the results of an exercise test. The type of exercise is related to the risk of hypoglycaemia. Walking is associated with the lowest energy expenditure and risk of hypoglycaemia, while cycling and running/jogging cause higher energy expenditure and greater reductions in glucose in patients with T2DM. CONTRIBUTION OF THE PAPER.

Cyanoacrylate for septal ablation in hypertrophic cardiomyopathy.

OBJECTIVE: Alcohol septal ablation (ASA) has been shown to be an effective treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are refractory to medical treatment. We describe an alternative approach for septal ablation with glue (cyanoacrylate), which is particularly useful in patients with the collateral formation to the right coronary artery in whom ASA is contraindicated. METHODS: In our method left coronary ostium was cannulated with 6-8F guiding catheter. Septal branch was cannulated with a 4F catheter and a microcatheter then cyanoacrylate mixture was instilled into the septal artery. Immediate polymerization prevents the leak into the left anterior descending coronary artery, and also into the right coronary artery (RCA) via septal collaterals. RESULTS: Glue septal ablation (GSA) was performed in 18 patients (6 patients had collateral branches to RCA). Immediately after the procedure peak left ventricular outflow (LVOT) gradient reduced significantly both in cardiac catheterization (65.0 ± 13.8 vs. 14.2 ± 5.7 mmHg, P < 0.001) and Doppler echocardiographic measurements (75.8 ± 19.9 vs. 18.0 ± 9.1 mmHg, P < 0.001). LVOT tract gradient reduction persisted after 6 months follow-up. Septal wall thickness (20.2 ± 3.7 mm vs. 16.5 ± 3.2 mm, P = 0.003) reduced and NYHA functional class (3.1 ± 0.4 vs. 2.2 ± 0.3, P < 0.001) improved. There was no significant complication during the procedure and within 6 months follow-up period. CONCLUSIONS: GSA seems to be an efficient and safe approach to HOCM, especially in patients with the collateral formation. Further experience is needed in order to assess the long-term efficacy and safety of this technique.

Percutaneous extraction of cardiac pacemaker and implantable cardioverter defibrillator leads with evolution mechanical dilator sheath: a single-centre experience.

AIMS: The growing problem with endocardial lead infections and lead malfunctions has increased the interest in percutaneous lead removal technology. In this report, we present our initial experience in percutaneous lead extraction with a novel hand-powered sheath, the Evolution mechanical dilator sheath. METHODS AND RESULTS: During 13 months between June 2009 and July 2010, 41 leads in 23 patients were removed. All of the extracted leads were >12 months old, and indications for extraction were based on the recommendations of the Heart Rhythm Society. The leads were removed by using the Evolution mechanical dilator sheath (Cook Medical) with the rotational cutting force only, without laser or radiofrequency energy. Indications for lead removal included cardiac device infection in 7 (30.4%) cases, lead malfunction in the 15 (65.2%) cases, and lead displacement in the remaining 1 case (4.4%). In 14 (60.9%) cases, the extracted device was a pacemaker, and implantable cardioverter defibrillators (ICD) in 9 (39.1%) of them. Among 41 leads, 25 (60.9%) were right ventricular, 14 (34%) were atrial, and 2 (4.8%) were coronary sinus electrode. The median time from the preceding procedure was 74 months (25-180 months). Complete procedural success with Evolution system alone was achieved in 19 (82%) patients (35 leads). Four leads were completely removed with snaring and in two leads, partial success was achieved with a remaining ventricular tip smaller than 1.5 cm. Clinical success was 100%, and all of the patients discharged uneventfully without a major complication. CONCLUSIONS: Our experience confirms that the mechanical technique with Evolution system is an effective first-line method for chronically implanted pacemaker/ICD leads. Continued investigation is required to evaluate success and complication rates in comparison with other techniques.

Cardiac resynchronization therapy improves exercise heart rate recovery in patients with heart failure.

AIMS: Heart rate (HR) recovery (HRR), defined as the rate of decline in the HR immediately following the cessation of exercise, is influenced by autonomic function. Heart rate recovery in heart failure (HF) has been shown to correlate with severity of HF. Cardiac resynchronization therapy (CRT) improves cardiac autonomic functions in HF. We aimed to evaluate the effects of CRT on cardiac autonomic function assessed by HRR. METHODS AND RESULTS: Forty-eight patients [62.3 ± 10.7 years; 37 men; left ventricular (LV) ejection fraction 24.8 ± 4.1%] with HF were enrolled. A treadmill exercise testing was conducted in all patients by using a modified Naughton protocol before and 6 months after CRT. Heart rate recovery indices were calculated by subtracting first, second, and third minute HR from the maximal HR and designated as HRR1, HRR2, and HRR3, respectively. Standard echocardiography was performed before and 6 months after CRT. Left ventricular reverse remodelling (LVRM) was quantified as the percentage of decline in the LV end-systolic volume after CRT. Mean HRR1 (13.0 ± 5.9 vs. 17.9 ± 8.9 b.p.m., P = 0.001), HRR2 (20.5 ± 9.3 vs. 23.8 ± 11.3 b.p.m., P = 0.001), and HRR3 (25.7 ± 11.1 vs. 29.2 ± 12.0 b.p.m., P = 0.001) values improved 6 months after CRT. Pearson's analyses revealed a good positive correlation between LVRM and ΔHRR1 (r = 0.642, P = 0.001) and a moderate correlation between reduction LVRM and ΔHRR2 (r = 0.591, P = 0.033) and ΔHRR3 (r = 0.436, P = 0.001). CONCLUSION: Cardiac resynchronization therapy favourably alters the cardiac autonomic functions. Heart rate recovery indices improved after CRT and the degree of improvement in HRR indices correlated with LVRM.

Improvement in right ventricular systolic function after cardiac resynchronization therapy correlates with left ventricular reverse remodeling.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves left ventricular (LV) systolic function in heart failure (HF). However, the effects of CRT on right ventricular (RV) systolic function are not fully understood. OBJECTIVE: We aimed to determine echocardiographic correlates of improvement in RV systolic function after CRT. METHODS: Fifty-four patients (61.9 ± 10.5 years; 43 men; LV ejection fraction 24.6 ± 4.0%; QRS duration > 120 ms) with HF were enrolled. Standard echocardiography, strain rate (SR), and tissue Doppler imaging were performed in all patients before and 6 months after CRT. Pulsed-wave TDI-derived systolic indices of RV included systolic (RV(S) ) and isovolumic velocity (RV(IVV)) and isovolumic acceleration (RV(IVA)). Response to CRT was defined as decline in LV end-systolic volume (LVESV) ≥ 10%. RESULTS: When indices of RV systolic function were assessed between responders and nonresponders, in responders (38 patients, 70.4%) RV end-diastolic diameters (RVD1-3), mid-RV strain, and mid-RV SR improved significantly (P < 0.01, for all). RV(S) (10.77 ± 4.29 vs 12.62 ± 4.10 cm/sec, P = 0.005), RV(IVV) (14.71 ± 5.88 vs 18.52 ± 6.62 cm/sec, P < 0.001), and RV(IVA) (1.69 ± 0.70 vs 2.39 ± 0.77 m/sec(2) , P < 0.001) significantly increased among responders. There was no significant change in these parameters among nonresponders. Pearson's analyses revealed moderate positive correlations between reduction of LVESV and ΔRV(IVV) (r = 0.467, P = 0.001) and ΔRV(IVA) (r = 0.473, P = 0.001), respectively. CONCLUSIONS: RV diameters and systolic indices after CRT improved only in the responder group. Improvement in RV systolic performance after CRT is correlated with the reduction of LVESV.

The reproducibility of heart rate recovery after treadmill exercise test.

BACKGROUND: Although predictive value of heart rate recovery (HRR) has been tested in large populations, the reproducibility of HRR in treadmill exercise test has not been assessed prospectively. This prospective study examined whether HRR index has test-retest stability in the short term. METHODS: A total of 52 healthy volunteers without cardiovascular risk factors (mean age, 30 ± 10 years, 30 females) underwent standardized graded treadmill exercise test, and the test was repeated on the 7th and the 30th days. The subjects' maximal heart rates and the decrease of heart rate from the peak exercise level to the level of 1, 2, 3, 4, and 5 minutes after the termination of the exercise were examined on each test, and heart rates for each minute from the first, second, and third tests were compared for each individual. RESULTS: The maximal heart rates on the 1st, 7th, and the 30th days were 179 ± 11, 177 ± 10, 178 ± 10 beats/min, respectively [P = 0.07, intraclass correlation coefficient (ICC) = 0.92], and the 1st minute HRR indices after peak exercise were 33 ± 10, 33 ± 10, 33 ± 11, respectively (P = 0.66, ICC = 0.88). There was no statistical difference in the 2nd, 3rd, 4th, and 5th minute heart rates of the recovery phase among the 1st, 7th, and 30th day treadmill exercise tests, either. CONCLUSION: Maximal heart rates and the decline of heart rate to the 5th minute on recovery phase after treadmill exercise test have short-term reproducibility.

The prevalence of microalbuminuria and relevant cardiovascular risk factors in Turkish hypertensive patients.

OBJECTIVES: A growing body of data illustrates the importance of microalbuminuria (MAU) as a strong predictor of cardiovascular risk in the hypertensive population. The present study was designed to define the prevalence of MAU and associated cardiovascular risk factors among Turkish hypertensive outpatients. STUDY DESIGN: Representing the Turkish arm of the multinational i-SEARCH study involving 1,750 sites in 26 countries around the world, a total of 1,926 hypertensive patients from different centers were included in this observational and cross-sectional survey study. Patients with reasons for a false-positive MAU test were excluded. The prevalence of MAU was assessed using a dipstick test, and patients were inquired about comorbidities, comedication, and known cardiovascular risk factors. RESULTS: The overall prevalence of MAU was 64.7% and there was no difference between genders. Most of the patients (82.5%) had uncontrolled hypertension, 35.6% had dyslipidemia, and 35.5% had diabetes, predominantly type 2. Almost one-third of the patients (26.4%) had at least one cardiovascular-related comorbidity, with 20.3% having documented coronary artery disease (CAD). Almost all patients (96.8%) had one or more risk factors for cardiovascular disease in addition to hypertension, including family history of myocardial infarction or CAD, diabetes, dyslipidemia, lack of physical exercise, and smoking. A trend towards higher MAU values in the presence of CAD was determined. CONCLUSION: Microalbuminuria tests should be routinely used as a screening and monitoring tool for the assessment of subsequent cardiovascular morbidity and mortality among hypertensive patients.