Objectives: We analyzed the distribution of cumulative all-cause and cardiovascular mortality and incident coronary heart disease (CHD) across the seven geographic regions of Turkey and presented overall and coronary mortality findings of the 2010 survey of the Turkish Adult Risk Factor Study.
Study design: A total of 1406 participants were surveyed. Information on the mode of death was obtained from first-degree relatives and/or health personnel of local heath offices. Information on survivors was obtained from history, physical examination, and 12-lead electrocardiography.
Results: Of the surveyed participants, 686 were examined; information on health status was obtained in 577 subjects, and 32 participants (14 women, 18 men; mean age 72.3±15.6 years) were ascertained to have died. The total duration of follow-up was 2,520 person-years. Nineteen deaths were of coronary (n=16) or cerebrovascular (n=3) origin. Cumulative 20-year assessment of the entire cohort for the age bracket of 45-74 years disclosed a high coronary mortality rate, being 7.4 and 4.1 per 1000 person-years in men and women, respectively, and representing a limited decline after year 2000. Age-adjusted Cox regression analysis comprising 433 deaths and 506 incident CHD cases over a 7.3-year follow-up showed similar mortality rates across the regions, and a significantly high CHD incidence in males of the Black Sea and Marmara regions and in females of the Southeast Anatolia. Currently, 480,000 incident CHD cases are estimated yearly in Turkey.
Conclusion: The high age-adjusted overall mortality in Turkey shows nonsignificant differences across geographic regions, whereas the age-adjusted CHD incidence is high in the Black Sea and Marmara regions.

Objectives: We investigated whether serum monocyte chemoattractant protein-1 (MCP-1) level predicted coronary atherosclerotic burden in patients with stable coronary artery disease and its relationship with coronary collateral grade.
Study design: We prospectively included 196 patients (103 males, 93 females; mean age 59±11 years) who underwent coronary angiography for stable angina pectoris. Serum MCP-1 levels were determined before coronary angiography. Coronary atherosclerotic burden was measured by the Gensini score, and coronary collateral development was assessed by the Rentrop classification. The patients were divided into four groups: those with normal coronary arteries (NCA); those with coronary lesions of <70% luminal obstruction; and those with coronary lesions of ≥70% luminal obstruction accompanied by a good or poor collateral grade.
Results: The mean serum MCP-1 level was higher in patients with coronary lesions compared to patients with NCA (129±130 vs. 102±55 pg/ml, p=0.048). Although there were no significant differences in the MCP-1 levels of patients with NCA, with <70% luminal obstruction, and those with a significant luminal obstruction and a poor collateral grade, patients with significant luminal obstruction and a good collateral grade had significantly higher MCP-1 levels compared to the remaining groups (p=0.016). However, in multivariate regression analysis, MCP-1 level was not independently associated with the Gensini score.
Conclusion: Our findings suggest that serum MCP-1 level is higher in patients with coronary atherosclerosis, without a significant and independent association with coronary atherosclerotic burden. Significantly increased serum MCP-1 levels in patients with a good collateral grade may be an interesting issue of investigation.

Objectives: We investigated the effect of chronic kidney disease (CKD) on in-hospital results in patients undergoing primary percutaneous angioplasty for ST-segment elevation myocardial infarction (STEMI).
Study design: The study included 2,486 patients (2,070 men, 416 women) who were treated with primary angioplasty for STEMI. Of these, 273 patients (11%) were found to have CKD (glomerular filtration rate <60 ml/min/1.73 m2) before the procedure. Patients with and without CKD were evaluated with respect to demographic and clinical features, primary angioplasty findings, and in-hospital clinical results.
Results: Patients with CKD exhibited a higher mean age, Killip class, and higher frequencies of female gender, diabetes, hypertension, anemia, and previous myocardial infarction (p<0.05). Angioplasty showed higher rates of right coronary artery lesion, multivessel disease, contrast nephropathy, unsuccessful procedure, and increased stenosis rate and stent length in CKD patients (p<0.05). Cardiovascular mortality occurred in 11.7% and 1.4% of patients with and without CKD, respectively (p<0.001). Patients with CKD had significantly higher incidences of target vessel revascularization, major cardiac events, stroke, cardiopulmonary resuscitation, hemodialysis, ventricular tachycardia/fibrillation, severe heart failure, cardiogenic shock, and significant hemorrhage (p<0.05). Multivariate analysis showed that CKD was an independent predictor of mortality (OR=4.1, 95% CI 1.83-9.17; p=0.001).
Conclusion: Our findings show that CKD patients undergoing primary angioplasty for STEMI have an increased risk profile and poorer in-hospital results, and that CKD represents an independent risk factor for mortality.

Objectives: We investigated the incidence of thrombocytopenia in pediatric patients with Down syndrome following cardiac surgery for congenital heart disease.
Study design: We retrospectively evaluated 162 patients (81 girls, 81 boys; mean age 26.1±39.5 months) who underwent total surgical correction for congenital heart disease. The patients were divided into two groups with respect to the presence (n=118) or absence (n=44, controls) of Down syndrome. Platelet counts were performed preoperatively and on days 1 to 7 after surgery and thrombocytopenia was defined as a platelet count of less than 100,000/mm3.
Results: The incidence of thrombocytopenia was significantly higher in patients with Down syndrome compared to controls (61.9% vs. 34.1%, p=0.002). Severe thrombocytopenia was observed in 22% and 4.6% of cases with and without Down syndrome, respectively. Postoperative platelet counts showed sharp decreases in both groups, bottoming out on day 3 and with more significant decreases in patients with Down syndrome; they started to rise on day 4, but remained lower than baseline levels on day 7. The only significant differences between the two groups in preoperative and postoperative variables were higher incidences of reintubation (26.3% vs. 9.1%, p=0.003) and complications during intensive care (50.9% vs. 27.3%, p=0.007) in cases with Down syndrome. Comparison of patients with and without thrombocytopenia independent of Down syndrome yielded significant differences for thrombocytopenic patients with respect to age, operation age, the presence of cyanosis, type of surgery and operation time, aortic clamp and bypass times, lengths of intensive care and hospital stay, intubation and chest tube drainage times, and the incidence of postoperative complications (p<0.05).
Conclusion: Despite higher incidence of thrombocytopenia, the presence of Down syndrome was not associated with significant differences other than increased reintubation requirement and higher complication rate during intensive care.

Objectives: We assessed the effect of obstructive sleep apnea syndrome (OSAS) on cardiac autonomic function with the parameters of heart rate variability (HRV) and heart rate turbulence (HRT) and investigated the frequency of cardiac arrhythmias in patients with OSAS.
Study design: Seventy-six patients (27 women, 49 men; mean age 50.6±10.7 years; range 33 to 75 years) with an initial diagnosis of OSAS underwent polysomnography and simultaneous Holter monitoring. The diagnosis of OSAS was based on an apnea-hypopnea index (AHI) of ≥5. The patients were evaluated with time-and frequency-based parameters of HRV, and turbulence onset (TO) and turbulence slope (TS) parameters of HRT. Cardiac arrhythmias were also assessed on Holter monitoring.
Results: Fifty-three patients (69.7%) were diagnosed with OSAS, being mild in 25 (47.2%), moderate in 23 (43.4%), and severe in five (9.4%) patients based on the AHI. The patients were divided into two groups as those having an AHI of <5 (n=23) and ≥5 (n=53). There were no significant differences in HRV parameters between the two groups, but patients with OSAS exhibited a significantly higher TO (p=0.02) and a significantly lower TS (p<0.001). In bivariate correlation analysis, AHI showed a significant negative correlation with TS (r=-0.37, p=0.009) and a significant positive correlation with TO (r=0.36, p=0.01). The frequencies of short-sequence premature atrial and ventricular contractions were significantly higher in patients with OSAS (p<0.001).
Conclusion: Our findings suggest that blunting of HRT is more prominent than changes in HRV parameters in patients with OSAS, accompanied by increased frequency of cardiac arrhythmias.

Objectives: We evaluated in-hospital results of primary percutaneous coronary intervention (PCI) in a high-volume tertiary center.
Study design: We retrospectively evaluated 1625 patients (1323 males, 302 females; mean age 56.0±11.6 years) who underwent primary PCI for acute ST-elevation myocardial infarction between January 2006 and April 2008. All coronary angiography procedures were performed using the femoral artery route. In-hospital clinical and angiographic results were recorded.
Results: On admission, 23% of the patients had diabetes mellitus, 49.6% had anterior myocardial infarction, and 4.9% had cardiogenic shock. The mean duration of pain was 171.2±121.2 minutes, and the mean door-to-balloon time was 31.6±7.2 minutes. Infarct-related artery was the left anterior descending artery in 49.7%, multivessel disease was present in 40.9%, TIMI 2/3 flow was present in 23.6%, and high-grade thrombus was observed in 66.8%. Primary PCI involved balloon dilatation (5.7%) and stent implantation (94.3%). The incidence of angiographic no-reflow was 11.9%. The mean hospital stay was 5.2±3.3 days. All-cause mortality occurred in 71 patients (4.4%). Other in-hospital events were reinfarction (1.4%), target vessel revascularization (1.9%), hemorrhagic/ischemic stroke (0.6%), stent thrombosis (1.2%), major bleeding (3.8%), blood transfusion (4.8%), heart failure (10.5%), atrial fibrillation (4%), and ventricular tachycardia (3.9%).
Conclusion: Primary PCI is an effective method in achieving complete revascularization of the infarct-related artery. Successful in-hospital results not only depend on the experience and equipment of the center, but also on how rapidly reperfusion is achieved.

With increasing life expectancy due to highly active antiretroviral therapy (HAART), the spectrum of human immunodeficiency virus (HIV)-associated morbidity and mortality has shifted from opportunistic infections toward associated chronic medical conditions. We report on a 26-year-old female patient receiving HAART for HIV infection, who developed spontaneous thrombosis of the proximal left anterior descending (LAD) artery, resulting in acute ST-elevation myocardial infarction. She had none of the conventional risk factors for the development of coronary artery disease. Following diagnostic coronary angiography that showed a large (16x3.4 mm) spontaneous thrombus in the proximal LAD artery, percutaneous coronary intervention was performed with prior aspiration of the occluding thrombus and implantation of a bare-metal stent. The patient was discharged with instruction of appropriate medical therapy. This case highlights the association between immunosuppression with HAART, particularly protease inhibitors, and the development of accelerated atherosclerosis in patients with HIV infection.

We present a combination of four rarely seen coronary anomalies: double right coronary artery originating from the right coronary sinus (RCS) and left main coronary artery, respectively, and separate origination of the left anterior descending (LAD) artery, circumflex artery (Cx), and septal perforator artery from the RCS. These anomalies were encountered in a 46-year-old male patient who had a previous diagnosis of spina bifida occulta and renal pelvis and presented with the complaint of chest pain of two-hour onset. He had no conventional coronary risk factors and no history of chest pain or syncope. Electrocardiography showed ST-segment elevation and cardiac enzyme levels were elevated. Coronary angiography was performed with the diagnosis of acute inferior myocardial infarction, which showed a severe stenosis in the mid portion of the LAD and total occlusion in the proximal part of the Cx. Balloon dilatation and stent implantation were performed for the Cx lesion and TIMI 3 flow was achieved. One month after the procedure, percutaneous coronary intervention was repeated for the LAD lesion and patency was achieved with balloon dilatation and stenting. Since visualization of all the coronary anomalies mentioned above posed some difficulties during coronary angiography, cardiac computed tomography angiography was also used to reveal the ostia and the courses of coronary arteries. This combination of four rare coronary anomalies has not been reported before.

Aerococcus viridans is not a common pathogen, and endocarditis due to A. viridans is very rare. A 44-year-old woman with persistent atrial fibrillation and rheumatic valvular heart disease was admitted with fever, sweating, weakness, and progressive shortness of breath. Transthoracic echocardiography (TTE) demonstrated a 8x9-mm vegetation attached to the right coronary cusp of the aortic valve, causing aortic obstruction. Blood cultures yielded A. viridans susceptible to penicillin. Despite optimal antibiotherapy, subsequent TTE controls revealed enlargement of the vegetation, reaching a size of 21x10 mm, and an increasing gradient across the aortic valve. The patient underwent successful aortic and mitral valve replacement and was stable in the postoperative period without any problem. This represents the first reported case of A. viridans endocarditis in which the size and location of vegetation caused obstruction to blood flow, indicating surgery.

Budd-Chiari syndrome (BCS) is a rare disorder characterized by hepatic venous obstruction. A 41-year-old male patient presented with right upper quadrant pain, abdominal distension, and dyspnea. He had a history of BCS that was associated with polycythemia vera. Abdominal computed tomography showed hepatomegaly and a hypodense filling defect suggestive of thrombus formation in the hepatic, splenic, and portal veins, and suprahepatic part of the inferior vena cava. Transthoracic echocardiography performed to assess the extension of this pathological process and its relation with intracardiac structures showed a mass lesion in the right atrium, about 4x3 cm in diameter. The lesion manifested as an intracardiac thrombus extending from the inferior vena cava. The patient underwent surgical treatment to remove the atrial mass. At surgery, the lesion turned out to be an atrial tumor, which was diagnosed as atrial myxoma in histopathologic examination. The symptoms of the patient resolved after surgery.

Origination of the right coronary artery from the distal left circumflex artery is a rare anomaly. A 63-year-old woman was admitted with subacute anteroseptal myocardial infarction. Electrocardiography showed a QS pattern in V1-V3 precordial leads without ST elevation. Cardiac enzyme levels were elevated (CK-MB 186 ng/ml, troponin I 27.1 ng/ml). Echocardiography showed hypokinesia of the anterior and lateral walls without valvular pathology. Coronary angiography revealed origination of the right coronary artery from the circumflex artery. The right coronary artery had a normal flow pattern and there were atherosclerotic plaques in the circumflex artery without a significant stenosis. Distal to the first diagonal branch of the left anterior descending artery, a 95% stenotic lesion was detected, which was treated with balloon dilatation followed by implantation of a bare metal stent. The patient was discharged with near-complete patency and without any complication.

Autosomal recessive dystrophic epidermolysis bullosa (DEB) is a chronic skin disorder characterized by widespread bullous formation, erosions, and scar formation. There have been reports of dilated cardiomyopathy and death in patients with DEB. The pathogenesis of cardiomyopathy in DEB remains uncertain, but some drugs, viral infections, iron loading, micronutrient deficiencies such as selenium and carnitine have been implicated. A 16-year-old boy who was followed-up from birth with the diagnosis of DEB presented with respiratory distress and heart failure symptoms of two-week history and early fatigue within the past year. Etiological evaluation showed a low plasma selenium level. Echocardiographic examination yielded the diagnosis of dilated cardiomyopathy. Findings of viral serology tests and metabolic screening were normal. Selenium replacement and anticongestive treatment were initiated, which led to partial improvement in cardiac functions. The authors draw attention to the possible role of micronutrient deficiency in the development of cardiomyopathy in patients with DEB.

Periprocedural bleeding and vascular complications after percutaneous coronary intervention (PCI) are associated with worse clinical outcomes and increased short- and long-term mortality. Vascular access-related bleeding accounts for more than 80% of all major bleeding events in PCI performed by the transfemoral approach. Transradial approach (TRA), on the other hand, virtually eliminates access site bleeding and vascular complications. Although clinical trials have mostly evaluated different pharmacological strategies for reducing bleeding risk, adoption of a radial rather than a femoral access may allow greater reductions in bleeding complications than pharmacological strategies alone. High-risk patients such as those with acute coronary syndrome and ST-segment elevation myocardial infarction, women, obese patients, and elderly subjects who are at increased risk for vascular complications and bleeding might particularly benefit from the radial approach. Besides increased patient safety, the TRA is associated with improved patient satisfaction, reduced cost, and length of hospital stay, thus allowing outpatient performance of uncomplicated PCI.

After reading the case reported by Sahin and Cols., screening for Influenza A infection in an patient with respiratory syndrome and acute chest pain, showed us a Parainfluenza 4 infection associated to myopericarditis. This patient presented a sudden-onset of chest pain mimicking acute coronary syndrome following a history of flu-like symptoms. By date, it has not been related Parainfluenza 4 infection to myopericarditis but, it should be suspected when respiratory syndrome is present. Even antiviral treatment is not approved, good medical condition at discharge was achieved with antiinflamatory therapy.

First of all, we want to thank to authors for their interest to our case report “Myocarditis Mimicking Acute Coronary Syndrome as a Complication of H1N1 Influenza A Virus Infection: A Case Report”.

editore mektup oldugu icin hazirlanmamistir.

Dual circumflex artery with an interarterial course discussed.