The prevalence and the excess cardiovascular disease (CVD) risk imparted by coexistent hypercholesterolemia and hypertension in Turkish adults was investigated in the database of the Turkish Adult Risk Factor Study. Prevalence and associations were analyzed in the cross-sectional data of the survey 2002/03 as a whole, while the relative risk was evaluated based on the prospective analysis of the 5-year follow-up of the 1997/98 survey. Mean age of 2750 comprised in the cross-sectional survey was 51 (±12) years, whereas it was 48.8 ± 12.8 among 2225 subjects free of CVD at baseline in the prospective study. Participants receiving antihypertensive medication, or having a systolic blood pressure (BP) ?140 mmHg or a diastolic BP ?90 mmHg, were considered as hypertensive. Hypercholesterolemia >200 mg/dl, or LDL-cholesterol levels >130 mg/dl were regarded as hyperlipidemia. CHD was diagnosed by clinical findings and Minnesota coding of resting electrocardio-grams. Hypercholesterolemia coexistent with hypertension was found in 7.7% of men, and 13.4% of women; corresponding to 3.3 million Turkish adults. On the other hand, individuals displaying LDL-C levels >130 mg/dl combined with hypertension was noted to be 9.2%, corresponding to 2.9 million adults. In these persons, age, waist circumference, body mass index and triglyceride concentrations were significantly higher compared to the remaining cohort. In the prospective study, high LDL-C levels coexistent with high BP (receiving antihypertensive drugs, or having a systolic BP ?130 mmHg or a diastolic BP ?85 mmHg) were analyzed for CVD risk by logistic regression. Compared to the remaining persons, the relative risk was 2.4-fold (95%CI 1.7; 3.44), after adjustment for sex and age. The sex- and age-adjusted relative risk was 4.4-fold (95%CI 2.5; 7.7) in comparison to those who had neither elevated LDL-C nor elevated BP levels. The contribution to the risk of elevated BP appeared to be substantially greater than that of elevated LDL-C. It was concluded that one of every 10 Turkish adults 30 years of age or over is estimated to harbor coexistent hypercholesterolemia and hypertension, which imposes a high absolute and a higher than twice the CVD risk compared to the rest of adults. Measures to reduce the individual's global risk should be implemented. (Türk Kardiyol Dern Arş 2004; 32: 533-541)

In this study, we aimed to investigate the level and efficacy of treatment approaches to coronary artery disease(CAD) in a tertiary center. The study population consisted of 100 consecutive patients who were hospitalised in the previous month due to angina pectoris and CAD was verified by elective coronary angiography. The patients' demographic and clinical data, coronary risk factors, medicines prescribed before hospitalisation and on discharge, lipid levels, biochemical tests, blood pressures, coronary angiographic data, suggested treatment plan and information about the attending assistant doctor were obtained from the hospital's archive. The patients' mean age was 58±10 year, and 21% of them were female. Sixty-six percent of all patients were hyperlipidemic, 59% were hypertensive, and 18% diabetic. Five percent and twenty percent of all cases were not aware that they were hypertensive and hyperlipidemic, respectively. On admission, 46% and on discharge 66% of the patients were on beta blockers. Of the 34 patients, who were not prescribed beta blockers on disharge, 13 patients had absolute or relative beta-blocker contraindications and 7 were taking cardioselective calcium antagonists. No contraindications for beta blocker therapy were noted in the remaining 14 cases. On admission 31%, and on discharge 65% of patients were receiving statins. Of the 35 patients who were not on statins, 11 patients had indications for statin use. None of the patients had contraindications for statins. Thirty-two percent of patients were receiving angiotensin converting enzyme (ACE) inhibitors before admission and 66% were prescribed ACE inhibitors before discharge. Of the 34 patients who were not prescribed ACE inhibitors, only one patient had contraindication for ACE inhibitors. According to the guidelines, ACE inhibitors were indicated for 11 of these patients. Hence, use of beta blockers, ACE inhibitors and statins that have proved to be favourable on morbidity and mortality in CAD, has approached the levels reported in series abroad but it is still not satisfactory. In-hospital prescription of medicines, very important in increasing the patient's compliance, should be enhanced, and patients and physicians should be knowledged and encouraged about these agents. (Türk Kardiyol Dern Arş 2004; 32: 542-549)

Determining the Optimal Energy for External Cardioversion of Patients with Persistent Atrial Fibrillation We aimed to determine optimal energy levels for external cardioversion (ECV) in patients with persistent atrial fibrillation (AF) to patentiolly decrease myocardial damage due to shock and to shorten the procedure time with the object of reducing failed attempts. The study group involved 72 patients with persistent AF (mean time 143±112 days) who had not developed any intracardiac thrombus. All patients had already undergone anticoagulant therapy before ECV for either a long or a short term. They underwent ECV with 100 J, 200 J, 300 J, 360 J and 360 J step-up protocols until they achieved sinus rhythm (SR). Only 2 of 16 cases achieved SR with 100 J (12%). The remaining 70 patients received 200 J of whom only 14 could attain SR (20%). 39 of 59 cases who underwent 360 J achieved SR. 17 failed cases were exposed to 360 J for the second time by changing the electrode position and applying mild pressure to thorax. Five of the patients achieved SR (29%). The overall achievement rate for persistent AF sufferers was determined to be 83%. Application of ECV with 100 J and 200 J failed to provide sufficient SR in chronic AF sufferers (22%). We suggest that starting ECV with 100 J or 200 J will not only increase the number of shocks but also lead to extension of the procedure and, hence, to the likelihood of high myocardial damage. We therefore suggest that starting ECV with 360 J in persistent AF sufferers might be the optimal initial energy.

Atrial fibrillation is frequently encountered in patients with hyperthyroidism. Previously, it was shown that prolonged maximum P wave duration and increased P wave dispersion on 12-lead surface electrocardiograms (ECG) are closely related to the development of paroxysmal atrial fibrillation (PAF). In this study, these P wave parameters were measured from 12-lead surface ECG in hyperthyroid patients with or without PAF during sinus rhythm and compared to euthyroid controls. In addition, influence of pharmacologic antithyroid therapy on these P wave parameters was investigated. Fifty-two hyperthyroid patients were included in the study. All patients underwent 24-hour Holter recordings and then, patients were divided into two groups according to the presence (PAF+; n=29) or absence (PAF-; n=23) of PAF. Maximum P wave duration (P max), minimum P wave duration (P min) were measured from the 12-lead surface ECG and P dispersion (PWD=P max-P min) values were then calculated. P max values were found to be significantly longer in both PAF+ (114.8±11.6 ms) and PAF- (105.6±11ms) patient groups as compared to controls (91±7.6 ms; p<0.001 for both comparisons). PWD values of both PAF+ and PAF- groups were also significantly higher than the controls (53.3±12 ms, 43.6±10 ms and 31.2±5 ms, respectively; p<0.001 for both comparisons). Age-adjusted PWD were significatly associated with the prevalans of PAF. Moreover P max and PWD values were significantly higher in PAF+ group as compared to PAF- group (p=0.006 for P max, p=0.003 for PWD). There were no significant differences in P min among groups. After restoration of euthyroidism by antithyroid therapy, P max (106±10ms, p<0.001) and PWD (42.2±6.4 ms, p<0.001) were found to be significantly decreased in PAF+ group as compared to baseline. In PAF- patients, P max (97.7±14 ms, p=0.001) and PWD (34.5±6.4 ms, p<0.001) were also decreased. In both groups, no significant changes were detected in P min values between baseline and after treatment. It is concluded that prolongation of P max and PWD in hyperthyroid patients could reflect a propensity to develop atrial fibrillation. However, significant decline in both of these P wave parameters after management of hyperthyroidism is thought to be the result of decreased unfavorable effects of circulating thyroid hormones on atrial electrophysiology. (Türk Kardiyol Dern Arş 2004; 32: 556-563)

Third Generation Thrombolytic Agents in the Guidance of Trials Third generation thrombolytic agents were developed to have prolonged half-lives, improved enzymatic efficiency, resistance to plasma protease inhibitors and fibrin binding selectivity. Reteplase, tenecteplase, lanoteplase, monteplase, pamiteplase and staphylokinase are third generation thrombolytic agents. A common feature of these agents is their prolonged half-life in plasma, this makes them suitable for single or repeated bolus injections. Compared with the second generation agents, third generation thrombolytic agents result in a greater angiographic patency rate in patients with acute myocardial infarction. However, mortality rates have been similar. (Türk Kardiyol Dern Arş 2004; 32: 564-570)

Cardiac troponins are the regulatory proteins of thin actin filaments in myocardium. Troponin T and I are markers with high specificity and sensitivity for myocardial injury. Recently, they have been accepted as the standard markers for the diagnosis and risk statification in patients with acute coronary syndromes. However, serum cardiac troponin levels also rise in events other than acute coronary syndromes. This may lead to misdiagnosis and unnecessary invasive procedures. High levels of cardiac troponins in acute coronary syndromes are predictors of increased incidence mortality and morbidity. Raised cardiac troponin levels have also prognostic significance in patients with heart failure, sepsis, renal failure and pulmonary embolism. Troponin release from myocardium shows permanent or transient injury. This injury can be caused by many events like ischemia, inflammation, infection, toxins or increased wall strain. This review briefs the structure, mechanism of release, and biochemical analysis of cardiac troponins. The clinical events other than acute coronary syndromes that raise blood troponin T and I levels are described in addition to the probable mechanisms, clinical impact of that elevation and diagnostic decision. (Türk Kardiyol Dern Arş 2004; 32: 571-580)

Chronic Pericardial Effusion: Diagnostic and Therapeutic Methods Chronic pericardial effusion is a very important clinical situation that can cause morbidity and mortality. In parallel with having many different etiological factors, there are important differences in diagnostic and treatment methods of this problem. A good knowledge of clinical presentation of pericardial effusions, diagnostic methods, and different therapeutic approaches is very important. In this study, our aim is to look over the diagnostic and therapeutic approaches by searching the latest literature. According to these, in acute symptomatic effusions the method of therapeutic choice should be pericardiosynthesis with the guidance of echocardiography. The etiology plays a crucial role in the treatment of chronic effusions. In malignant effusions, pericardiocentesis, sclerosing therapy, and radiotherapy are the choice of treatments. In chronic recurrent effusions balloon pericardiotomy and in purulent and tuberculosis pericardial effusions surgery are the appropriate approaches. The latest studies are mostly based on the application of new therapeutic methods on pericardial pathologies. Especially, in patients who do not have the chance of percutaneous and surgical revascularization, the use of intrapericardial basic fibroblast growth factor to stimulate collateral revascularization is promising. (Türk Kardiyol Dern Arş 2004; 32: 581-590)