Objectives: We evaluated the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) for further risk stratification of intermediate-risk patients with non-ST elevation acute coronary syndromes (NSTE-ACS).
Study design: The study included 137 intermediate-risk patients (85 men, 52 women; mean age 62±11 years) with ACS, based on the TIMI risk score (scores 3 to 5). Serum NT-proBNP levels were measured 12 hours after the last anginal episode. The patients were divided into four groups according to the following NT-proBNP quartiles: 17-310 pg/ml (n=34), 313-688 pg/ml (n=35), 724-2,407 pg/ml (n=34), and 2,575-24,737 pg/ml (n=34). Primary endpoint of the study was mortality. The mean follow-up was 21.8±7.1 months.
Results: There were 27 deaths (19.7%), 14 of which were in the 4th quartile (4th vs 1st, 2nd, and 3rd quartiles: p=0.02, p=0.01, and p<0.01, respectively). The first three quartiles did not differ significantly in this respect. In Kaplan-Meier analysis, patients in the 4th quartile had the lowest cumulative survival (log rank test, 4th vs 1st, 2nd, and 3rd quartiles: p=0.041, p=0.026, and p=0.009, respectively). NT-proBNP level was significantly higher in nonsurvivors than in survivors (p=0.01). In univariate analysis, mortality was also associated with the TIMI risk score, ejection fraction, and age. Patients who died were older (65.6±11.9 years vs 60.7±11.0 years; p=0.048) and had a lower ejection fraction (46.3±11% vs 54.1±9.8%; p<0.001) than patients who survived. Mortality rates corresponding to TIMI risk scores of 3, 4, and 5 were 25.9%, 29.6%, and 44.4%, respectively (p=0.58 for TIMI 3 vs 4; p=0.001 for TIMI 3 vs 5; p=0.013 for TIMI 4 vs 5). Cox proportional hazards regression analysis showed that only TIMI risk score was an independent predictor of mortality (hazard ratio 2.3, 95% confidence interval 1.4-3.8, p=0.001).
Conclusion: NT-proBNP has an additive predictive value over TIMI risk score in predicting long-term mortality in intermediate-risk patients with ACS.

Objectives: This study was designed to evaluate clinical, laboratory, microbiological, and echocardiographic characteristics of infective endocarditis (IE) at a tertiary care center in Turkey and to identify predictors of in-hospital mortality.
Study design: Based on a systematic retrospective review of clinical records covering 1997 to 2007, we analyzed data and outcomes of 68 patients (40 males, 28 females; mean age 51±20 years) with definite or possible IE according to the modified Duke criteria.
Results: Native valve endocarditis (NVE) was seen in 28 patients (41.2%), and prosthetic valve endocarditis (PVE) was seen in 38 patients (55.9%). Pacemaker endocarditis (PE) was observed in only two patients (2.9%). Nineteen patients (27.9%) had nosocomial IE. The most frequent predisposing factor for NVE was rheumatic heart disease (n=11; 39.3%). Echocardiography failed to show any signs of involvement in five patients (13.2%) with PVE. The most common causative microorganisms of NVE, PVE, and PE were staphylococci (n=28; 41.2%). At least one complication developed in 46 patients (67.7%), congestive heart failure being the most common (n=38; 55.9%). Forty-one patients (60.3%) underwent combined medical and surgical treatment. In-hospital mortality occurred in 17 patients (25%). Mortality rates were 37.5%, 30%, and 14.3% for early and late PVE and NVE, respectively. Mortality was significantly higher with nosocomial IE (57.9%) compared to 12.2% in the remaining patients. In multivariate analysis, septic shock (p=0.011) and nosocomial infection (p=0.032) were independently associated with in-hospital mortality.
Conclusion: Compared to the European series, IE in our cohort occurred in a relatively younger population, with rheumatic heart disease as the most common underlying heart disease. The rates of PVE, nosocomial IE, and surgical treatment were about the same.

Objectives: We evaluated the role of admission high-sensitivity C-reactive protein (hs-CRP) level in estimating myocardial perfusion and in-hospital adverse events in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
Study design: The study included 43 consecutive patients (34 males, 9 females; mean age 59±11 years) who underwent PCI for STEMI within six hours after the onset of symptoms. Coronary angiograms were evaluated with respect to TIMI flow grade, corrected TIMI frame count, and myocardial blush grade (MBG). Electrocardiograms obtained 90 min after PCI were analyzed for ST-segment resolution. In-hospital adverse events were recorded. hs-CRP level was measured by immunonephelometry in blood obtained immediately before PCI.
Results: The mean hs-CRP level was 1.35±1.17 mg/dl. Based on the median hs-CRP value (0.98 mg/dl), 22 patients with a low hs-CRP level had a lower frequency of hypertension (p=0.047), decreased TIMI frame counts of the left anterior descending (p=0.010) and circumflex (p=0.033) arteries, a higher rate of ST resolution (p=0.000), improved MBG (p=0.015), and shorter hospitalization (p=0.028). Adverse events occurred in six patients (14%), in five of whom (5/21) the hs-CRP level was above 0.98 mg/dl. hs-CRP was significantly correlated with corrected TIMI frame counts of the left anterior descending (r=0.388, p=0.01) and circumflex arteries (r=0.336, p=0.027), length of hospitalization (r=0.357, p=0.019), and inversely correlated with MBG (r=-0.415, p=0.006). In multivariate regression analysis, hs-CRP was found to be an independent predictor of ST resolution (p=0.008). ROC analysis showed that a higher level of hs-CRP than 0.88 mg/dl predicted poor MBG with 73% sensitivity and 31% specificity (95% CI 0.577-0.899, p=0.01).
Conclusion: In STEMI patients undergoing primary PCI, high levels of admission hs-CRP are associated with poor myocardial perfusion and longer hospitalization.

Objectives: Inflammation plays an important role in the pathogenesis of metabolic syndrome (MS). We investigated the effect of fluvastatin treatment on inflammatory markers in patients with MS.
Study design: The study included 47 patients (36 females; 11 males; mean age 55±8 years) with MS. The diagnosis of MS was based on the presence of at least three criteria of the NCEP ATP III guidelines. All the patients received 80 mg fluvastatin treatment for six weeks. Laboratory parameters were measured before and after treatment, and flow cytometric analysis of peripheral blood leukocytes was performed. The results were compared with those of 47 age- and sex-matched healthy controls (33 females, 14 males; mean age 52±8 years).
Results: Fluvastatin treatment resulted in significant decreases in levels of total cholesterol, LDL cholesterol, triglyceride (p<0.005), and C-reactive protein (p<0.05). Thirty-three patients (70.2%) had insulin resistance, which remained unchanged following treatment. Flow cytometric analysis after treatment showed significant decreases in total lymphocytes, and in surface antigens of CD16+56 and CD8+(CD28+) on leukocytes, CD11c on granulocytes, and a significant increase in the CD4/CD8 ratio (p<0.05).Compared to the control group, the mean baseline values of fluorescence density (FD) of CD14, CD11b, CD11c, and CD63 on monocytes, and CD11b and CD11c on granulocytes were significantly higher in patients with MS (p<0.05). Following fluvastatin treatment, there were significant decreases in the mean FD of CD3 on lymphocytes, and of CD11b and CD11c on both monocytes and granulocytes (p<0.05); of these, all FD values were similar to those in the control group (p>0.05).
Conclusion: Our data demonstrate that inflammation may have a significant role in the pathogenesis of MS and that this effect can be controlled with statin treatment.

Objectives: We developed a questionnaire to measure the knowledge level of adults about risk factors for cardiovascular diseases (CVD) and assessed its validity and reliability.
Study design: We developed the Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) Scale in the light of the literature data. It consisted of 28 items, questioning the features of CVD in the first four items, risk factors in 15 items, and the results of adopting a risk-free attitude in nine items. All the items were based on true/false statements, requiring a response in the form of “Yes”, “No” or “Don’t know”. To determine its validity and reliability, the scale was administered to 200 participants older than 20 years, of whom 144 individuals were involved in test-retest evaluations. Internal consistency was estimated using the Cronbach’s alpha. To determine the validity of the scale, individuals with CVD and/or familial history were compared with those without CVD and/or familial history.
Results: The rates of true responses varied between 44.5% and 96.5%. The mean score was 19.3±3.2 (range 5 to 27), and the median item-total correlation was 0.26 (range 0.13 to 0.51). Internal consistency coefficient (Cronbach’s alpha) was 0.768. There was a strong positive correlation between the test and retest total scores (r=0.850; p=0.000). Individuals with CVD and/or familial history had a significantly higher mean score than those without CVD and/or familial history (20.2±3.1 vs 19.3±3.2; p=0.032).
Conclusion: In Turkey, CARRF-KL is the first scale developed to measure the knowledge level of individuals about risk factors for CVD, with good indices of validity and reliability.

Free-floating right heart thrombus can be seen in 4% to 18% of patients presenting with acute pulmonary embolism. A 76-year-old man was admitted to the intensive coronary care unit due to resting dyspnea and pleuritic pain of sudden onset, raising a high suspicion of acute pulmonary embolism. A recent coronary angiogram showed a 50% stenosis in the proximal left anterior descending coronary artery. He had diabetes and hypertension for more than 10 years, but no history of venous thromboembolism. Bed-side transthoracic echocardiography revealed dilated right heart chambers, and a huge (78x12 mm) mobile mass in the inferior vena cava. We witnessed the migration of the thrombus from the inferior vena cava to the right atrium. The thrombus then totally lodged in the right atrial cavity and protruded into the right ventricle. Surgical removal of the thrombus was decided. However, during induction of anesthesia, cardiac arrest developed. All resuscitation efforts including open heart massage were unsuccessful. The thrombotic material removed from the right atrium was 150 mm in length. Pathological examination showed the mass to be a thrombus.

A 41-year-old man presented with worsening angina. Coronary angiography showed 70% narrowing in the middle segment of the left anterior descending (LAD) coronary artery. Selective cannulation of the right coronary artery (RCA) could not be achieved with Judkins right 3.5- and 4.0-cm curve diagnostic catheters. Nonselective injection into the aortic root revealed an anomalous RCA originating from the left sinus of Valsalva and 80% narrowing just proximal to the right ventricle branch. Initial percutaneous coronary intervention (PCI) was directed to the LAD and an adequate angiographic result was achieved. One week later, PCI was performed for the RCA. Cannulation of the RCA was not possible with Judkins curve guiding catheters (right 4 and 5 cm; left 4, 5, and 6 cm). Eventually, selective cannulation was achieved with a 7-F multipurpose Hockey Stick guiding catheter and stent placement was accomplished. The patient had an uneventful recovery. The use of a multipurpose Hockey Stick catheter may be considered when the usual techniques fail to cannulate an anomalous RCA.

Acute myocardial infarction due to acetaldehyde syndrome has been rarely reported. A 22-year-old, chronic alcoholic man was admitted to our hospital with typical angina pectoris that developed after oral intake of disulfiram and alcohol together. The electrocardiogram showed hyperacute inferior myocardial infarction and he was successfully treated by thrombolytic therapy. Coronary angiogram revealed normal coronary arteries; thus, the event was probably secondary to coronary artery thrombosis and/or coronary vasospasm. Disulfiram is not a safe drug in patients unable to adhere to the strict restriction of alcohol intake, requiring a close supervision of individuals on disulfiram therapy.

Spontaneous pneumomediastinum is a rare disorder in children occurring mostly due to some triggering events. In general, no underlying cause is found. A 10-year-old boy was admitted with chest pain of acute onset, suggestive of pericardial effusion. His body temperature, blood pressure, pulse rate and respiratory rate were normal. Femoral pulses were palpable and he did not have cyanosis. Cardiac auscultation was normal except for a crunching sound. Electrocardiography showed no abnormality. There was no subcutaneous emphysema over the chest, neck or face. On the chest radiogram, suspected mediastinal air was noted. A left lateral chest X-ray revealed apparent presence of air in the anterior mediastinum. No etiologic cause could be documented. Pneumomediastinum resolved spontaneously within a week.

Hypocalcemic cardiomyopathy due to hypoparathyroidism is a very rare condition. Ensuing heart failure due to hypocalcemia is refractory to conventional treatment. We reported a 41-year-old man who developed cardiac failure due to hypocalcemia secondary to idiopathic hypoparathyroidism. Echocardiography showed biventricular low ejection fraction, dilated heart chambers, pulmonary hypertension, and valvular regurgitations. Serum calcium and parathyroid hormone levels were low. After treatment of heart failure and calcium-vitamin D supplementation, signs and symptoms of heart failure improved rapidly. At 6 months, biventricular systolic and diastolic functions returned to normal. Serum calcium level should be monitored in every patient with cardiac failure and hypocalcemia should be considered in patients with refractory heart failure.

Patients with prosthetic mechanical heart valves should always be on prophylactic anticoagulation therapy for thromboembolic events. As pregnancy represents a high-risk period for thrombosis, those with mechanical heart valves should be accorded greater importance. We presented two pregnant patients with prosthetic mechanical mitral valves, who developed mechanical valve thrombosis while on fractionated and unfractionated heparin treatment, respectively. One patient received intensive anticoagulation treatment, and the other underwent redo valve replacement. Both patients were free of symptoms

The output of publications in cardiovascular medicine during 2008 originating from Turkey’s institutions were evaluated based on data of the Web of Knowledge. Only original articles and reviews appearing full-text in source publications of Science Citation Index CD Edition alone were included. A weighted credit system was used for items published jointly by multiple institutions or with a noncardiological department. Turkey’s publications rose substantially to 220 articles and reviews, as her share of world publication rose from 10.0 to 10.8 per mille. Seven-eighths of the output originated from adult cardiology, pointing to a negative trend with respect to the fields of cardiovascular surgery and pediatric cardiology. Though the median impact factor was similar with 1.56 to that of the previous year, the finding that half of the publications appeared in periodicals with an impact factor of 1.19 to 2.88 showed a trend to target relatively better journals. Our established medical faculties, with the exception of the Aegean faculty, continued to lag behind in productivity, while the Başkent University led by far, and the Gülhane Military Medical Academy, Gazi University, and Siyami Ersek Cardiovascular Surgery Center were runners-up.