ISSN 1016-5169 | E-ISSN 1308-4488
Archives of the Turkish Society of Cardiology - Turk Kardiyol Dern Ars: 26 (4)
Volume: 26  Issue: 4 - May 1998
1. Summaries of Articles

Pages 196 - 200
Abstract | English Full Text

2. Clinical Significance of Relation Between Coronary Collateral Circulation and STscgmentff-wave Changes in Acute Myocardial Infarction
Hasan KADI, Turhan KÜRÜM, Cengiz KORUCU, Gültaç ÖZBAY
Pages 201 - 206
Following acute myocardial infaretion (AMI), some patients retain ST segment elevation and upright T waves, a pattern usually seen within minutes to hours of AMI, even, after 72 hours. It often identifies a transmural AMI which results from a persistent total obstruction of the infarct-related coronary artery and inadequate collateral flow. Twenty-two patients were studied to te st the hypothesis that absence of adequate callateral flow was responsible for pe rsistent ST elevation and that adequate collateral flow was associated with the more typical resolution of ST elevation. The study group consisted of 22 patients with AMI admitted to the coronary care u nit between 1995 and 1997 in whom a totally obstructed infarct-related artery by coronary angiography were observed. Group A consisted of 10 patients with an ECG demonstrating ST-segment elevation and upright T waves C.72 hours after AMI. Group B consisted of 12 patients with an ECG demansırating resolution of STsegment elevation accompanied by inversion of T waves within 72 hours of the AMI. There were no significant differences between the two groups regarding age, sex, risk factors, preinfarction angina, maximum and total reciprocal changes. Total ST segment elevation, maximum ST segment elevation were higher in group A vs group B (p

3. Usefulness of Precordial T -wave Increase During Exercise Stress Test in Detecting Coronary Artery Disease
Hakan TIKIZ, Uğur Kemal TEZCAN, Savaş AÇIKGÖZ, Ercan VAROL, Ahmet Duran DEMİR, Emine KÜTÜK, Siber GÖKSEL
Pages 207 - 212
The usefulness of T -wave changes observed in precordial derivations (Vı.6) during exercise stress testing (EST), in detecting coronary artery disease (CAD) was evaluated in this study. For this purpose, 163 patients w ere enrolled. Precordial T -wave amplitudes were recorded before exercise, immediately after peak exercise and at Iate recovery period. Coronary angiographic exaınination was performed later on. Normal coronary arteries in 55 patients (Group-1) , single-vessel disease in 73 patients (Group-2) and ınulti-vesse l d isease in 35 patients (Group-3) were found. In evaluation of precordial T-wave amplitudes at base and in maximal heart rate during EST, significant T-wave amplitude increase was found in leads V3.6 in patients with normal coronary arteries (Group- i ), and in Ieads Vı.6 in patients with CAD (group 2-3). In all precordial leads. Vı had the highest sensitivity and specificity (21% and 87%, respectively) in detecting coronary artery disease when 3 ının or more increase in T-wave amplitude was accepted as a positive c riterion for CAD (cut-off value=3). An increase of C.3 mm in T-wave aınplitude was observed ıno stly in proximal LAD disease among all patients (13/33, 39%) and when only T -wave criterion was evaluated, overall specificity was increased slightly (from 78% to 87%, p>0.05). When T-wave aınplitude increase and ST segment depression were evaluated individually, significant increase in sensitivity was detected only in the single-vessel group (from 56% to 7 1%, p<0.002) and a slight increase in diagnostic accuracy was observed in all patients and in single-vessel disease (from 70% to 74% and from 66% to 70%, respectively, p>0.05). Combining these two criteria, the overall sensitivity decreased to ıo%, however specificity increased from 78% to 96% (p<0.005). In conclusion, an increase of 3 mm or more in Twave amplitude in lead Yı during EST is evident especially in severe proximal LAD stenosis among all patients, and evaluation of this criterion on ST segment depression individually, may be useful especially in increasing sensitivity in one-vessel disease, combining these criteria with ST segment depression may be useful in diminishing falsepositive results in EST.

4. Anti-ischaemic and Anti-anginal Effects of Nisoldipine and Ramipril in Patients with Cardiological S)'ndrome X
Fatih ÖZÇELİK, Armağan ALTUN, Gültaç ÖZBAY
Pages 213 - 217
We investigated anti-ischaemic and anti-anginal effects of nisoldipine and ramipril in patients with the cardiological syndrome X. After a two-week wash-out period, 1 8 patients (7 men, 1 ı women; m ean age: 46± ı O years) w ith cardiological syndrome X (stable angina pectoris, positive exercise test, negative ergonovine test, and normal coronary angiography) were given nisoldipine 5 mg twice daily for four weeks. And after a second twoweek wash-out period, the same patients were given ramipril 2.5 mg daily for four weeks. Treadınili exercise test with modified Bruce protocol was performed at the en d of each period. The time until anginal attack occurred (p=0.006 vs p=0.02), total exercise time (p=0.0008 vs p=0.02), and mean metabolic equivalent (p=O.OOı6 vs p=O.O 1) were increased significantly after nisoldipine and ramipril therapy periods. The time until ST segment depression by Imm occurred (p=0.002) was increased significantly after nisoldipine therapy. The time until ST segment de press i on recovery (p=O.O 16 vs p=O.O 1 2), the weekly number of angina pectoris (p=O.OO vs p=0.028), and the weekly number of sublingual nitroglycerin consumption (p=O.OO vs p=0.012) were decreased significantly after nisoldipine and ramipril therapy periods. We conclude that ıo mg/daily nisoldipine or 2.5 mg/daily has anti-ischaemic and anti-anginal effects in patients with cardiological syndrome X.

5. Cardiac Death in Patients with Peripheral Vascular Disease and QT Dispersion
Dilek URAL, Baki KOMSUOĞLU, Özhan GÖLDELİ, Ali ÖVET, Fahri ÖZCAN, Zerrin UZUN
Pages 218 - 222
In patients with peripheral artery disease, additional cardiac diseases such as coronary artery disease and hypertension are frequent findings. The existence of coronary atherosclerosis is the Icading factor predicting prognosis. The aim of study was to investigate cardiac death in paticnts with peripheral artery disease without cardiac symptoms and its relation with QT dispersion. The study group consisted of 35 patients (aged 61 ±7 years, 32 males, 3 females) who underwent surgical treatmont because of peripheral arteriopathy and 72 age-matched controls (aged 61±1 years, 54 males, ı8 females). In all subjects, risk factors wcre evaluated with physical examination and laboratory findings. Echocardiographic and 12- lead electrocardiographic examinations were made and QTc interval and QT dispersion were calculated. The study group was followed for two years and cardiac deaths were recorded. Echocardiographic findings were normal in 13 patients (37%), left ventricular hypertrophy and left ventricular dilatation (isolated or accompanying an increase in left ventricular wall thickness) were detected in the remaining patients (63% ). In the control group, echocardiographic findings were normal except in 2 subjects (%3). QT, QTc interval and QT dispersion were significantly prolonged in the patients group compared with the controls. Subjects with a QT dispersion longer than 50 ms (mean of the control ± 2 SD) were 18 cases in the patients group and one in the control group. During the follow-up period, patients died due to cardiac events in the patients group, whereas nobody in the control group. In patients with peripheral artery disease, a QT dispersion of 50 ms had 86% sensitivity, 57% specificity, 33% positive predictivity and 94% negative predictivity in predicting cardiac death. In 5 of the 7 patients who died during the study period, left ventricular dilatation and a QT dispersion langer than 50 ms had been detected. It is concluded that in patients with peripheral artery disease who are asymptomatic for cardiac diseases, echocardiographic findings and QT dispersion are useful methods to predict the risk of cardiac death.

6. A Method for Evaluating the Success of Slow Pathway Ablation: PR>RR Finding During Rapid Atrial Pacing
Uğur Kemal TEZCAN, Hakan TIKIZ, Ahmet Duran DEMİR, Yücel BALBAY, Mustafa SOYLU, Şule KORKMAZ, Siber GÖKSEL
Pages 223 - 227
Atrioventricular nodal reentrant tachycardia (A VNRT) occurs ın patients with dua! atrioventricular (AV) nodal physiology. However, dua! AV nodal physiology cannot be demonstrated in a signifıcant proportion of patients w ith A VNRT. During rapid atrial pacing at the maximum rate with consistenı 1:1 AV conduction, PR interval often exeecds the pacing cycle Jength in patients with A VNRT. This finding, deseribed as PR>RR, was proposed to be consistent with antegrade slow pathway conduction and useful method for evaluating the success of slow pathway ablation in patients with A VNRT and without demosırable dua! AV nodal physiology. The purpose of this prospective study was to determine the diagnostic value of the PR>RR find ing as an indicator of antegrade slow pathway conduction and A VNRT. The PR and RR intervals were measured during rapid atrial pacing at the maximum rate with consistent 1:1 AV conduction in 2 groups of patients. Group 1: patients w ith A VNRT (n=20) and Group 2: control subjects (n=2 1 ). Radiofrequency catheter ablation of the slow pathway was performed in all Group 1 patients. After slow pathway ablation, the study protocol was repeated in Group 1 patients. PR>RR finding was present in ıo of 20 Group 1 patients (50%) and 2 of 2ı Group 2 patients (9.5%, p=0.006). After slow pathway ablation, PR>RR finding was no longer preseni in any Group ı patients. The finding of PR>RR had a sensitiviıiy of 50 % for A VNRT, a specificity of 90%, a negative predictive value of 66% and a positive predictive value of 84%. In conclusion, although the sensiıivity of PR>RR finding for AVNRT is low, because of its high specificity and positive predictive value, this finding may be usefuı for evaluating the success of slow pathway ablation in patients with A VNRT in whom tachycardia inducıion is not reproducibe and dua! AV nodal physiology cannot be demonstrated.

7. Assessment of Insulin Resistance by the Hyperinsulinemic Euglycemic Glucose Clamp Technique in Young Men With Coronary Artery Disease
Cemal SAĞ, Hakan ERDEM, Hürkan KURŞAKLIOĞLU, Adnan HAŞİMİ, Sedat KÖSE, Mustafa KUTLU, Fikri KOCABALKAN, Ertan DEMİRTAŞ
Pages 228 - 233
Insulin resistance has an important role in the pathogenesis of metabolic disorders such as hyperinsulinemia, glucose intolcrance, obcsity, and dyslipidemia, all established risk factors for coronary artery disease (CAD). In a number of prospective studies, an independent relationship was noted between CAD and hyperinsulinemia and insulin resistance; and has been suggcsted that insulin resistance isa risk factor for CAD. In this study, insulin res istance was studied by the hyperinsulinemic euglysemic glucose c lamp technique in ı6 male patients w ith CAD (Group ı), diagnosed all by coronary angiography and in 16 male healthy controls (Group 2), younger than 35 years. In our study, "M" value was found as a 4.37± 1.1 mg/kg/min in Group 1, and 7 .9± 1.1 mg/kg/min in Group 2. Insulin resistance was found in 7 of 16 in Group 1. w hile Group 2 no insulin resistance w as found, (p<0.05). In the patient group triglyceride, total and LDLcholesterol, insulin and C-peptide levels were statistically higher than controls (p<0.05). W e found that young patients with newly diagnosed CAD, did show insulin resistance, in variance from other studies. As a result, insulin resistance is an important risk factor in premature CAD.

8. The Safety and Efficacy of Intravenous Enalaprilat In Acute Cardiogenic Pulmonary Edema
Kani GEMİCİ, İbrahim BARAN, Dilek YEŞİLBURSA, Sümeyye GÜLLÜLÜ, Bülent İLÇÖL, Ali AYDINLAR, Ali Rıza KAZAZOĞLU, Akın SERDAR, Ethem KUMBAY, Jale CORDAN
Pages 234 - 238
Angiotensin-converting enzyme (ACE) inhibitors which have been used for the treatment of chronic congestive heart failure, can also be used for the treatment of acute cardiogenic pulmonary edema. In this condition, patients are hemodynamically unstable and have high renin levels. The studies in this area are limited. The purpose of this study was to evaluate the efficacy and safety of intravenous enalaprilat in patients with acute cardiogenic pulmonary edema. The study was performed in 12 patients (7 men, 5 women; mean age 57.2±7.4 years) with acute cardiogenic pulmonary edema due to dilated cardiomyopathy, coronary artery disease, hypertensive heart disease or coronary and/or hypertensive heart disease. Hemodynamic and elinical parameters were measured and evaluated before and 1 O minutes after infusion of enalaprilat. Enalaprilat increased cardiac output, cardiac index and stroke volume (p

9. Continued Boom in 1997 in International Medical Publications from Turkey
Altan ONAT
Pages 239 - 245
A search was made of medical publications arising from institutions in Turkey appearing in medical periodicals covered by the Science Citation Index and comprised in the ISf CD-ROM 1997 Annual. This revealed a total of 1640 medical items making up almost half of all scientific publications originating from Turkey. When adjusted for publications jointly materialized with foreign medical centers and with nonmedical Turkish faculties (which constituted roughly 8% of the total), and when letters to the editar and meeting abstracts w ere exeluded, ı O ı O artieles in full text remained (ineluding editarials and reviews). This represented 0.5% of share in the respective world medical publications and a rise of 25% over the previous year. Thus Turkey doubled her output of international medical publications each 3 years over the past decade - a remarkable feat. The rise pertained to publications in basic (preclinical) fields as well as in elinical disciplines. The seven medical faculties (located in the three big cities) which produced 5 ı % of all medical publications were as follows: Hacettepe. Ankara, İstanbul, Aegean, Cerrahpaşa, Gazi and September 9th. The most significant trend over the previous years was a diversification of the publishing centers, in particular the rise to 17% of the share of nonacademic institutions. In cardiovascular medicine, 52 artieles in full text appeared in 1997 which represents a share of more than 0.4% in the world. References of each of these art ieles are provided as an appendix.

DERLEME
10. Beta-blocking Drugs in the Treatment of Congestive Heart Failure
Deniz GÜZELSOY, Zerrin YİĞİT
Pages 246 - 253
Despite basic and elinical research in congestive heart failure, this disorder continues to remain a major challenge therapeutically and there is a need for innovative drugs that alter the prognosis of heart failure. In recent years, research directed toward understanding of the pathophysiology of congestive heart failure showed that the level of neurohumoral activation is the predictor of survival. Clinical studies documented that the inhibition of overactivated renin-angiotensin-aldosteron system by angiotensin-converting enzyme inhibitors may improve symptoms and mortality. There is also inercasing evidence of beneficial effects of beta blacking drugs which counteract the long-term deleterious effects of overstimulated sympathetic nervous system. Several trials strongly suggest that beta-blockers should be used for the manageınent of heart failure, especially in patients with dilated cardiomyopathy. Mortality data from the carvedilol studies are also encouraging. However, there is stili a need to await the result of planned large-scale trials in larger numbers of patients with different etiologies for routine usage of beta blackers in all patients with congestive heart failure.

11. History of Cardiology
Teoman ONAT
Page 254
A graduate of Bologna Medical Faculty in 1653, and later prof. of medicine (1662), Malpighi pionecrcd the experimental study of living organisms and founded the science of microscopy. He discovered the capillary circulation (166 1 ), red blood corpuscles (1666), deseribed the structure of the ski n (M. la yer), papillae of the tongue, bodies in the spleen and kidneys (M. bodies and corpuscles) and the pulmonary alveoli. Microscopic exaınination in frogs while the heart was beeting, revealed opposite direction of blood in adjacent vessels and he observed further that blood broke into the eınpty space and was collected again by a gaping vessel. Two stamps and a posta! cancellatian depicting his portrait are presented.



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