Based on the data of the Turkish Adult Risk Factor study accumulated over ll years, this paper attempts to clıa rac teri ze the disparity between the risk profiles of Turks and Western populations and to ascribe these to plausible pathogenetic mechanisms. Findings of the majority of patients w ith coronary heart disease (CHD) anel differences of data from the adult populations of Turks and Danes (of the Copenhagen City study) clearly show that - rather than LDL-cholesterol elevation - Turks exhibit str.iking features involving HDL-cholesterol , triglycerides, apolipoprotein (apo) B, (central) obesity , hyperinsulinemia and bloaci pressure. Turkish women, in particular, elisplay a profile of ri sk higher than men in regard to obesity, blood pressure and apo B. Triglyceride and apo B features indicare that excess number of smail dense LDL partides is widespread among Turkish adults. Underly ing th is ri sk profile - to be designated as atherogenic dyslipidemia - are visceral obesity and insulin resistance. lmpaired "fatty acid trapping" by ad ipose tissue, increased seeretian of VLDL by the liver, excess depositian of triglycerides in skeletal muscle and d iminished insulin sens itiv ity presumably account for these features of coronary risk. Our data d ispute the hypothesis that genetic factors are the main determinant of low HDL-C levels and support that the frequ ently encountered fas ring hypertriglyceridemia - asi de central obesity, cigare tte smoking and sedentary lifesry le - is the primary factor. l mplications of the proposecl hypothesis include a more accurate risk assessment in individuals having total cholesterol levels 180-200 mg/di and the potential improvement of cardiovascular health in millions of Turks by adapting appropriate li fesryle in primary and secondary prevention.

The ACS Multi-link (ML) intracoronary s ıe nt is a second generation, balloon expandable stainl ess steel stent des igneel to avoid the negative features of c urrently available stents. The largest amount of information available on the long te rm o uıcome of coronary stenting is based on the use of Palmaz-Schatz stent. Less data exist on long-term fo llow-up results of Multi-link coronary stent implantations. We present the long-term (>3 years) elinical anel angiographic fo llow-up results of the ACS Multilink coronary stents implanted in our institution. From May 1996 to December J 997 a total number of 125 patients underwent 133 coronary ML stent implantations. Stented vessels were: 49% LAD, 3 1% RCA, 20% Cx coronary a ıte ı-y. lndications fot stent inıp l a ntati on were elective in 64%, s ub opt inıa l resul ı in 26%, bailout in 10% of patients. The mean reference diameter of stented vessels was 3.2 ± 0.2 mm. The m ean percentage stenosis w as 80± 1 1% and 3±5 % before anel after stenı iınplanı aı i on , respecti vely. Lo ng-terın elinical fo llow-up was completed in 75% (80 nıale, nıean age 53±10) of the patients (eitlıer by interview or phone), and ang iographic fol low-up (37± 12 ın on th s) was coınpl eted in 58% of the patients. The re was no baseline elinical and ang iographic differences between angiographicall y checkeel and the reınainin g paıi ents . Angiographic restenesis (>50% d i ameıer stenos is) was d etected in 22% of stents. Target les ion revascul arisation was 12%, non-targer lesion revascularisation was 14% in ang iographi cally followed pts. During follow-up period d eaılı and new MI occurred in 12% and 6% of paı ienıs, respectively, and survival rate was 88%. Our study provides long-terın fo llow-up results of intracoronary Multi-link stent iınp l a ntations for native coronary arterylesions. Our data show that elinical and angiographic benefit of ML stents is comparable to the first generatian stents especially to the Palmaz-Schatz stents of which res ults have been reported prev iously. An important rate of non target lesion revascularisation occurs during followup period.

Although atrial fibril lation co ınpromi ses left ventricular funct ion in patie nts with Ieft ventricular dysfunction (L VD), it is not known whether or not L VD has any direct effect on atrial fibrillation occurrence. Beta blackers are the most comınan drugs used in atrial fibrill ation prophylaxis. The ai m of this study was to investigate the atrial fibrillation occ urrence in patients unde rgoing coronary artery bypass grafting (CABG) surgery and the prophylactic effect of metoprolol in these cases. In this pros pective study, 526 patients who underwent CABG surgery were included, 253 of them with high left ventricular performance score (Group I) and 273 with normal left ventricular performance score (Group ll). Metoprolol was given 80 patients in group I and I 15 patients in group II in the postoperative period. The remaining patients (173 in group I, 158 in group Il) were not given any antiarrhythmic drugs. In pat ients wi th impaired le ft ventricular performance, atrial fibri llation occured 5 patients in g roup la (6.3%), and 28 patients in group Ib (16.2%). In patients with normal ventric ular performance, 6 patients in group Ila (5.2%) and 24 patients in group Ilb (15.2 %) atrial fibrillation was encountered (p<0.05). In both groups, mean occurrence time of atr ial fibrillat ion was the second postoperative day (p>0.05). Although duration of intensive care unit was s iınil ar in all groups (p>0.05), hos pitalization time was significantly longer in patients with atrial fib rillation than those of patients with normal sinus rhythm (p<0.05). In conclusion, the use of metoprolol was effective for preventing atrial fibrillation after CABG surgery e ither in. patients with normal or in paticnts wi th impaired left ventricular function. On the other hand, development of atrial fibril lation prolongs the hospitali zation durat ion, but not the stay in the intensive care unit after CABG surgery.

Fast track recovery protocol (FTRP) aims the extubation of the patie nt within 6-8 hours postoperatively, di scharge the patient from the intensive care unit (ICU) within 24 hours and from the hospital within 5 days after the operation. Currently available data is not sufficient for the applicability of this protocol in high risk patients. In th is study 203 consec uti ve high ri sk patients (EuroSCORE c 6) who underwent different card iac surgical procedures were evaluated for the applicability of FTRP. Factors increasing the time to extubation, ICU stay and length of hospital stay were s ıudied. Independent factors by logistic regression, were found to be determining increased time to extubation, EuroSCORE > 8 (p=O.OO 1 ), and additional cardiac procedures (p=0.02); for increased ICU s tay , blood usage (p=O.OOO I) and for increased length of hospital stay, time to exıubation > 360 minutes (p=0.02) and cardiopulmonary bypass period> 100 minules In 75 %of the patients FTRP was successfu lly applied. This study sugges ts that FTRP can be applied to high risk patients, however, perioperative and postoperative factors as well as preoperative ri sk factors play an important ro le for the success. Key words:

The last survey of the Turkish Adult Risk Factor Study, conducted in May, 2001, aimed, among other specific goals, to assess coronary morbidity and mortality in the last period. Similar epidemiological methods were applied as described previously. In a total of 1443 individuals of the cohort residing in the Marmara and Central Anatolian regions of Turkey, 1122 men and women were examined. Moreover information was obtained in 233 persons, and death was ascertained in 12 men and 5 women. Total follow-up exceeded 1500 person-years. Eleven new deaths of coronary origin were diagnosed. Annual all-cause mortality was estimated as 10.7 per mille, coronary mortality as 6.3 per mille. In the age-bracket 45-74 years, total mortality was 13.4 and coronary mortality 7.3 per mille. Total cases of annual new coronary heart disease (CHD) corresponded to 8.9 per mille. When compared to findings anticipated, this survey exhibited consistent ones with respect to total mortality. coronary mortality and new coronary events, but - though not reaching significance - excess findings in regard to CHD prevalence. This observation underlines once again the need for the urgent task of preventive cardiology in Turkey.

Objective and design: Endothelial dysfunction may play an important role in the pathogenesis of risk factors for coronary artery disease (CAD), and of chronic heart failure (CHF). The association between a variable number of tandem repeats (VNTRs) polymorphism in intron 4 of the endothelial constitutive nitric oxide synthase (ecNOS) gene and essential hypertension (EH), CHF, and the distribution of risk factors for CAD were investigated. Method: The study group consisted of 65 controls, 57 EH, and 50 CHF patients. The VNTRs of the ecNOS gene was amplified by the polymerase chain reaction to determine the number of repeats, and the allele frequencies were compared between the patients and control group. Results: Two alleles (a, b) containing four and five repeats were identified. The ab genotype was associated with EH (p=0.048, odds ratio= 2.54 (95% confidence interval (CI) 0.99-6.55), was more frequent in dilated CHF without reaching statistical significance, was similar in ischemic CHF compared to controls. Ab genotype patients with ischemic CHF were significantly younger (55±10 vs 65±80 years of age; p=0.047), had significantly lower high density lipoprotein cholesterol levels (0.7±0.16 vs 1.09±0.21 mmol/L (27±6 vs 42±8 mg/dl); p=0.005) compared to bb genotype. Conclusion: In this Turkish population the ecNOS gene is not associated with ischemic CHF, but with EH, and may be associated with non ischemic CHF. Young ab genotype patients with low HDL levels are at increased risk for CAD and CHF.

Biventricular pacing has recently been suggested as a therapeutic approach that has beneficial effects demonstrated in patients with advanced congestive heart failure and intraventricular conduction delay. It has been notified that the patients with significant QRS duration lengthening have more probability to benefit from this therapy. Although it has been demonstrated that symptomatic and left ventricular functional improvement can occur with biventricular pacing therapy, the effect on mortality has not been clarified yet. In this review, the results of biventricular pacing studies and the mechanisms of action of atrio-biventricular pacing have been discussed.

An unusual case of right ventricular outflow tract obstruction caused by a ıneınbranou s septuın aneurysın in a patient with ventricular septal defect is presented. An associated inlet type ventricular septa l defect was c losed wi th a polytetrafluoroethylene patch. The aneurysmal sac was plicated by taking obliteration sutures at its base and excised. Secondary infundibular hypertrophy was resected and infundibulotomy was closed with a pericardial patch. Patient displayed an uneventful course in the postoperative pe riod and d ischarged on the fifth postoperative day. A fo ll ow-up echocardiography at the second postope rat ive month revealed no abnormalities.

Incessant left a trial tachycard ia originating from mitral annulus is a rare tachyarrhythmia which may cause cardiomyopathy. A 20-year-old patient with recluced left ventricular systolic function and a left atrial tachycardia which was successfully ablated on the lateral mitral annulus was reported.