ISSN 1016-5169 | E-ISSN 1308-4488
Archives of the Turkish Society of Cardiology - Turk Kardiyol Dern Ars: 36 (2)
Volume: 36  Issue: 2 - March 2008
1. Turkish Adult Risk Factor Survey 2007: decline in all-cause and coronary mortality
Altan Onat, Dursun Dursunoğlu, Serkan Bulur, Zekeriya Küçükdurmaz, Zekeriya Kaya, Serkan Ordu, Murat Uğur
PMID: 18497551  Pages 77 - 81
Objectives: We analyzed all-cause and coronary mortality as well as incident coronary heart disease (CHD) among the participants of the Turkish Adult Risk Factor Study, who resided essentially in the Marmara and Central Anatolia regions and were surveyed in the summer of 2007.
Study design: Information on the mode of death was obtained from first-degree relatives and/or health personnel of the local heath office. Most of the participants who were alive underwent physical examination and 12-lead electrocardiography. Incident CHD was defined as fatal or nonfatal myocardial infarction that occurred after the previous survey or incident stable angina and/or myocardial ischemia.
Results: Of 1,618 participants to be surveyed, 961 were examined, 501 subjects were assessed based on information obtained, 18 men and 12 women were dead, and 52 subjects were lost to follow-up. The number of newly recruited subjects was 138. Addition of 3,010 person-years of follow-up raised the total follow-up of the survey to 48,500 person-years. Eight deaths were attributed to CHD; new coronary events were identified in 16 subjects. Annual mortality was estimated as 10.0 and coronary mortality as 2.7 per 1,000 adults. Overall mortality which was 11.2 per 1,000 person-years in the original cohort declined to 9.1 and 5.9 in more recently recruited 1997/98 and 2002/03 cohorts, respectively. In the age bracket of 45 to 74 years, all-cause mortality which was 15.2 in 2004 decreased to 10.2 per 1,000 person-years in the past three years (p=0.003), with a corresponding decrease in coronary mortality from 6.0 to 5.1 (p<0.18), indicating that the decreasing trend in overall mortality and coronary deaths observed in this age group in the previous years did not level off.
Conclusion: Our data show that the incidences of overall and coronary mortality continue to decline.

2. Increased pulmonary artery stiffness and its relation to right ventricular function in patients with systemic lupus erythematosus
Dursun Duman, Seval Masatlıoğlu, Refik Demirtunç, Bilgehan Karadağ
PMID: 18497552  Pages 82 - 89
Objectives: Pulmonary hypertension and right ventricular (RV) dysfunction are severe complications of systemic lupus erythematosus (SLE). The role of increased pulmonary artery stiffness (PAS) has not been studied in RV dysfunction. We investigated the relationship between PAS and RV function in SLE patients without cardiovascular symptoms.
Study design: The study included 32 patients with SLE (30 males, 2 females; mean age 34±9 years) and 30 age- and sex-matched healthy controls (28 males, 2 females; mean age 36±5 years). All the subjects underwent echocardiographic examination. Using Doppler echocardiography, PAS was calculated by dividing maximal frequency shift of the pulmonary flow by the acceleration time. To assess RV function, RV myocardial performance index (MPI) was determined by the sum of isovolumetric contraction and relaxation times divided by the ejection time. In addition, tricuspid annular plane systolic excursion (TAPSE) was measured on two-dimensional M-mode recordings.
Results: Compared to the control group, patients with SLE exhibited significantly higher PAS (p=0.004) and RV MPI (p=0.001), and lower TAPSE (p=0.001). In univariate correlation analysis, SV MPI was significantly correlated with PAS (r=0.60, p=0.001), age (r=0.48, p=0.003), SLE duration (r=0.51, p=0.002), and pulmonary artery systolic pressure (r=0.36, p=0.03). Multivariate linear regression analysis showed that PAS (95% CI 0.002-0.005; p=0.001) and SLE duration (95% CI 0.001-0.004; p=0.004) were independently associated with RV MPI. In addition, a significant inverse relationship was found between TAPSE and RV MPI (r=-0.48, p=0.005). Twenty-four SLE patients had normal RV function (TAPSE ≥17 mm). Eight patients with RV dysfunction (TAPSE <17 mm) had significantly different RV MPI (p=0.001), PAS (p=0.002), age (p=0.04), and SLE duration (p=0.004).
Conclusion: Our data suggest that increased PAS is strongly associated with the development of RV dysfunction in patients with SLE.

ORIGINAL ARTICLE
3. Genetic analysis of the Irx4 gene in hypertrophic cardiomyopathy
Fatih Bayrak, Evrim Kömürcü-bayrak, Bülent Mutlu, Gökhan Kahveci, Nihan Erginel-ünaltuna
PMID: 18497553  Pages 90 - 95
Objectives: The Irx4 gene is predominantly expressed in cardiac ventricles. It has been demonstrated in animal studies that disruption of the Irx4 gene caused inhibition of chamber-specific expression of myosin heavy chain genes, resulting in abnormal ventricular gene expression and cardiac hypertrophy. In this study, we aimed to investigate a possible association between mutations in the Irx4 gene and hypertrophic cardiomyopathy (HC).
Study design: The study included 68 patients (32 females, 36 males; mean age 49 years; range 17 to 74 years) with HC and 67 healthy controls (33 females, 34 males; mean age 45 years; range 20 to 88 years). All the patients were evaluated with a detailed history, physical examination, 12-lead electrocardiography, and transthoracic echocardiography. DNA samples of all the subjects were extracted. Genomic DNA fragments were amplified by polymerase chain reaction and screened by single-strand conformation polymorphism analysis. DNA sequences were determined through an automated sequencing system.
Results: All exons in the Irx4 gene were examined. No mutations were detected associated with HC. Four polymorphisms were identified including G355>A, A381>G, G1203>A, and C1431>T. Compared with patients having the GA and GG genotyes, patients with the AA genotype of A381>G polymorphism were found to have a higher maximal left ventricle outflow tract gradient (p=0.03), prolonged corrected QT dispersion (p=0.05), and albeit not statistically significant, increased septal thickness (p=0.07).
Conclusion: This is the first human study investigating the association between the Irx4 gene and HC. Polymorphism A381>G of the Irx4 gene may have a modifier effect on septal thickness, resulting in increased corrected QT dispersion and higher outflow gradients.

4. The effect of postural changes (leg lifting) on tissue Doppler parameters in coronary artery disease
Bahar Pirat, Aylin Yıldırır, Vahide Şimşek, Bülent Özin, Haldun Müderrisoğlu
PMID: 18497554  Pages 96 - 102
Objectives: We investigated the effect of increased preload through postural changes (leg lifting) on tissue Doppler parameters in patients with and without coronary artery disease (CAD).
Study design: The study included 42 patients who were scheduled for coronary angiography. All the patients underwent standard two-dimensional, color Doppler and tissue Doppler echocardiography before coronary angiography. Tissue Doppler imaging was performed from septal and lateral mitral annuluses at baseline and during 45º leg lifting followed by two-minute stabilization. Patients were grouped based on coronary angiography findings: those having stenosis greater than 70% were considered to have CAD and those with normal coronary arteries comprised the control group. Echocardiography measurements were compared between the two groups.
Results: Angiography showed normal coronary arteries or border irregularities in 22 patients and CAD in 20 patients. The two groups were similar with regard to demographic data and ejection fractions, except for male preponderance in the CAD group. Compared with the control group, patients with CAD exhibited a significantly lower isovolumic acceleration rate (IVA) at the lateral (p=0.007) and septal (p=0.03) mitral annuluses. In the control group, leg lifting resulted in increased systolic velocity (S) compared with baseline at the lateral (p=0.009) and septal (p=0.01) annuluses, whereas S wave augmentation was only significant at the septal annulus (p=0.009) in patients with CAD. No significant change was observed in IVA following leg lifting in both groups.
Conclusion: Preload alteration induced by leg lifting resulted in similar changes in tissue Doppler parameters in patients with and without CAD, except for blunted augmentation of S wave at the lateral annulus in CAD. Detection of decreased IVA at baseline may be a useful finding for CAD.

5. The relationship between aspirin resistance and endothelial dysfunction in patients with stable coronary artery disease
Burak Pamukçu, İmran Önür, Hüseyin Oflaz, Ali Elitok, Zehra Buğra, Yılmaz Nişancı
PMID: 18497555  Pages 103 - 107
Objectives: Endothelial dysfunction may enhance platelet aggregation despite regular aspirin therapy. We investigated the relationship between aspirin-resistant platelet aggregation and endothelial dysfunction in patients with stable coronary artery disease.
Study design: The study included 98 patients (60 males, 38 females; mean age 62±8 years) receiving medical treatment for stable coronary artery disease. Platelet function assays were performed with the Platelet Function Analyzer (PFA)-100 with collagen and epinephrine (Col/Epi) and collagen and adenosine diphosphate cartridges. Aspirin resistance was defined as a closure time of less than 186 seconds with Col/Epi cartridges despite regular aspirin therapy. Endothelial function was assessed via measurement of flow-mediated dilatation by brachial artery ultrasonography.
Results: Twenty patients (20.4%) were found to be aspirin-resistant by the PFA-100. There were no significant differences between patients with and without aspirin resistance with respect to the mean aspirin dose administered and other medications. The mean basal diameter of the brachial artery was 4.11 mm and the mean flow-mediated dilatation (percentage change from basal diameter) was 4.7% in patients with aspirin resistance. The corresponding figures were 4.14 mm and 5.3% in the absence of aspirin resistance (p>0.05).
Conclusion: In our study, endothelial dysfunction was found in all the patients with stable coronary artery disease, without any association of its presence and severity with aspirin resistance.

CASE REPORT
6. Bilateral coronary artery-pulmonary artery fistulas in a case with unstable angina pectoris
Alper Kepez, Ergün Barış Kaya, Ali Oto
PMID: 18497556  Pages 108 - 110
Bilateral coronary artery fistulas originating from both right and left coronary arteries are rare congenital abnormalities. A 58-year-old man presented with chest pain unrelated to exertion. Coronary angiography showed a fistula originating from the level of the first diagonal branch of the left anterior descending (LAD) coronary artery and a 95% stenosis just distal to the fistula. Right coronary angiography showed another fistula originating from the ostium of the right coronary artery. Both fistulas drained into the pulmonary artery. Coronary bypass surgery was performed for the LAD lesion using the left internal mammary artery graft, during which both fistulas were ligated. No complications were encountered postoperatively.

7. Acute myocardial infarction triggered by acute intense stress in a patient with panic disorder
İsmail Bıyık, Vedat Yagtu, Oktay Ergene
PMID: 18497557  Pages 111 - 115
Psychosocial stresses are associated with an increased risk for acute myocardial infarction (AMI). We report a 35-year-old male patient who developed AMI after acute psychological trauma. He presented with chest pain that began after being involved in a fight. He was extremely agitated. He did not have any risk factors for coronary disease except for panic disorder which was diagnosed six years before. Cardiac enzymes were found elevated. His electrocardiogram (ECG) showed ST-segment elevation in leads V2-6. After thrombolytic therapy with tissue plasminogen activator, his chest pain relieved and ST elevations on ECG regressed. Coronary angiography showed normal coronary arteries. Acute extraordinary stress may be responsible for AMI in this young patient as a result of sympathetic hyperactivity and coronary vasospasm.

8. Dual left anterior descending coronary artery: a case report
Bilal Boztosun, Mehmet Mustafa Can, Ayhan Olcay, Cevat Kırma
PMID: 18497558  Pages 116 - 119
Dual left anterior descending (LAD) artery originating from the right and left coronary arteries is a rare coronary anomaly. A 61-year-old male patient presented with anginal chest pain. He underwent coronary angiography upon detection of hypokinesia in the anterolateral wall of the left ventricle in transthoracic echocardiography. Left coronary angiography showed narrowing of the left anterior descending (LAD) artery after giving the first diagonal and first septal branches, without reaching the apex. There was a 95% stenosis in the proximal first diagonal artery and a 50% stenosis in the midsegment of the first septal artery. In right coronary angiography, another LAD was noted originating from the proximal right coronary artery and having an anterior course similar to the original LAD. It was longer than that originating from the left main coronary artery, giving many septal and diagonal branches. Stent implantation following elective predilatation was performed for stenosis in the proximal first diagonal artery. The patient was symptomless in the third month of treatment.

9. New discoveries in the mechanisms of apoptosis and cell survival and novel potential therapeutic strategies
Nazmi Gültekin, Kamil Karaoğlu, Emine Küçükateş
PMID: 18497559  Pages 120 - 130
New discoveries in the mechanisms of apoptosis and cell survival have been a major breakthrough in biological sciences in recent years of the new millennium. Apoptosis is genetically programmed cell death in any nucleated cells of the organism. This type of cell death occurs through different mechanisms from those seen in necrosis and complement lysis of any cell, without affecting the neighboring cells. In the nature, apoptosis and cell survival are very important not only for the elimination of cells that acquire unstable features, became useless, and detrimental for the organism, but also for the mechanisms of numerous biological events and disorders seen during the lifespan of many organisms –from the embryological period to death. The discovery of mechanisms of apoptosis and cell survival has enabled the development of new therapeutic strategies in heart diseases, cancers, neurodegenerative diseases, AIDS, and many disorders. Combination of opportunities afforded by degenerative medicine with those of new therapeutic approaches of regenerative medicine such as stem-cell therapy and somatic cell nuclear transfer will possibly introduce new horizons and rational therapeutic approaches in the foreseeable future.

CASE IMAGE
10. Pulmonary thromboembolism caused by a giant free-floating right atrial thrombus
Gürkan Acar, Sedat Köroğlu, Abdullah Sökmen, Cemal Tuncer
PMID: 18497560  Page 131
A 71-years-old man patient was admitted to our cardiology department with progressive dyspnea and bilaterally legs pain. His medical history unremarkable except bilateral deep venous thrombosis was diagnosed two days ago. Physical examination showed a respiratory rate of 32, pulse of 123 (irregular) and blood pressure of 100/70 mmHg. In addition, there were swelling and redness of the bilaterally legs. Electrocardiography revealed atrial fibrillation with ventricular rate of 130/minute, incomplete right bundle branch block and nonspesific ST segment and T-wave abnormalities. Transthoracic echocardiography was immediately performed and detected a giant, mobile, free-floating thrombus in the right atrium sometimes crossing through the tricuspid valve to the right ventricle (Fig. 1 and 2). There were severe tricuspid regurgitation and dilated right cardiac chambers, systolic pulmonary arterial pressure of 65 mmHg and normal left ventricular systolic functions. Clinical and echocardiographic findings of the patient were correlated with acute pulmonary embolism. Therefore, we immediately decided to administer thrombolytic therapy but hemodynamic status of the patient deteriorated in a few minutes and the patient was lost due to cardiopulmonary arrest.

11. Multiple fistulae between the left coronary arteries and left ventricle in a patient with angina pectoris
İbrahim Halil Kurt
PMID: 18497561  Page 132
Multiple micro-fistulaes of coronary arteries is a rare anomaly of heart which consists of a communication between left coronary arteries system and left ventricule. We describe that the clinical Picture of a patient with left anterior desending and circumflex coronary artery draining into the left ventricle. They have been associated with various clinical features. The purpose of this case was to define the clinical and coronary angiographic characteristics of patient who stable angina pectoris

12. 
2007 yılı üst düzey kardiyoloji makalelerimizle ilgili yayınlanmış dökümdeki eksikliklerin duyurulması
Altan Onat
Page 133
Abstract |Full Text PDF

LETTER TO EDITOR
13. Being a good doctor
MUTLU VURAL
Pages 134 - 135
letter to editor

CASE IMAGE
14. Answers of specialist
Serdar Küçükoğlu, Nevrez Koylan, Sema Akalın
Pages 136 - 138
Abstract |Full Text PDF

15. Comment on cardiology publications
Ertan Ural
Page 139
Abstract |Full Text PDF



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