ISSN 1016-5169 | E-ISSN 1308-4488
Archives of the Turkish Society of Cardiology - Turk Kardiyol Dern Ars: 39 (7)
Volume: 39  Issue: 7 - October 2011
ORIGINAL ARTICLE
1. Incremental effects of serum uric acid levels, autonomic dysfunction, and low-grade inflammation on nocturnal blood pressure in untreated hypertensive patients and normotensive individuals
Murat Erden, Sinan Altan Kocaman, Fatih Poyraz, Salih Topal, Asife Sahinarslan, Bulent Boyaci, Atiye Cengel, Mehmet Ridvan Yalcin
PMID: 21983762  doi: 10.5543/tkda.2011.01545  Pages 531 - 539
Objectives: We aimed to evaluate the associations between nocturnal blood pressure (BP) and serum uric acid (SUA) level, low-grade inflammation, and cardiac autonomic function in untreated dipper and nondipper hypertensive patients and normotensive individuals.
Study design: The study included 92 consecutive patients (44 men, 48 women; mean age 51.6±9.7 years) who presented for initial evaluation of hypertension. All patients underwent 24-hour Holter monitoring to assess heart rate variability (HRV) and ambulatory BP. Serum high-sensitivity C-reactive protein (hs-CRP) and SUA levels were measured. Due to the non-normal distribution of hs-CRP and microalbuminuria (MAU), they were normalized by logarithmic transformation.
Results: Of the study group, 60 patients (65.2%) were diagnosed as hypertensive (50% nondippers). In univariate correlation analysis, log(MAU) showed a significant correlation with nocturnal BP (r=0.560, p<0.001). Among HRV parameters, SDNN, SDANN, and triangular index were inversely correlated with log(hs-CRP) (r=-0.356, p=0.001; r=-0.350, p=0.001; r=-0.314, p=0.002, respectively) and nighttime BP (r=-0.286, p=0.006; r=-0.251, p=0.02; r=-0.294, p=0.004, respectively). Log(hs-CRP) was positively correlated with nighttime BP (r=0.302, p=0.003). Serum UA levels were correlated with only nocturnal BP; i.e., nocturnal mean (r=0.260, p=0.01), systolic (r=0.249, p=0.016), and diastolic BP (r=0.249, p=0.017). In multiple linear regression analysis, log(hs-CRP) and age were independent predictors of cardiac autonomic dysfunction, and log(hs-CRP), SUA, and HRV parameters were independent predictors of nocturnal BP measurements.
Conclusion: Our findings suggest the role of low-grade inflammation, uric acid levels, and autonomic dysfunction even in the early stages of hypertension.

2. In-hospital prognostic value of admission plasma B-type natriuretic peptide levels in patients undergoing primary angioplasty for acute ST-elevation myocardial infarction
Vecih Oduncu, Ayhan Erkol, Ali Cevat Tanalp, Cihan Dündar, İbrahim Halil Tanboga, Dicle Sırma, Ali Karagöz, Can Yücel Karabay, Akın İzgi, Selçuk Pala, Kürşat Tigen, Cevat Kırma
PMID: 21983763  doi: 10.5543/tkda.2011.01610  Pages 540 - 548
Objectives: We assessed in-hospital prognostic value of admission plasma B-type natriuretic peptide (BNP) levels in patients undergoing primary percutaneous coronary intervention (p-PCI) for acute ST-elevation myocardial infarction (STEMI).
Study design: In a retrospective design, we evaluated 992 patients (801 males, 191 females; mean age 56±12 years) treated with p-PCI for STEMI. The patients were divided into two groups according to the admission BNP levels, taking the cut-off value of BNP as 100 pg/ml; i.e, ≥100 pg/ml (n=334, 33.7%) and <100 pg/ml (n=658, 66.3%). Postprocedural angiographic and clinical in-hospital results were recorded.
Results: No-reflow (24% vs. 9%), heart failure (32.3% vs. 5.5%) and death (15.6% vs. 1.7%) were significantly more common in patients with BNP ≥100 pg/ml (p<0.001). In multivariate analysis, elevated baseline BNP level was identified as an independent predictor of no-reflow (OR=1.83; 95% CI 1.22-2.74, p=0.003), acute heart failure (OR=2.67; 95% CI 1.55-4.58, p<0.001), and in-hospital mortality (OR=3.28; 95% CI 1.51-7.14, p=0.003). In receiver operating characteristic curve analysis, the area under the curve and sensitivity/specificity of the cut-off value of BNP (100 pg/ml) for prediction of clinical endpoints were 0.741 and 58.6%/70.3% for no-reflow, 0.822 and 75%/73.3% for heart failure, and 0.833 and 82.5%/69.4% for death, respectively (p<0.001 for all).
Conclusion: Elevated admission BNP level is an independent predictor of angiographic no-reflow, acute heart failure, and mortality in STEMI patients during in-hospital period, suggesting that it might be incorporated into traditional risk scoring systems to improve early risk stratification.

3. Impaired right ventricular functions in metabolic syndrome patients with preserved left ventricular ejection fraction
Özlem Karakurt, Sanem Öztekin, Nuray Yazıhan, Ramazan Akdemir
PMID: 21983764  doi: 10.5543/tkda.2011.01512  Pages 549 - 556
Objectives: Metabolic syndrome (MetS) has been shown to be independently associated with increased risk for incident heart failure and coronary artery disease. We investigated whether there is deterioration in right ventricular functions in MetS patients with preserved left ventricular functions and its association with the number of MetS components.
Study design: The study included 192 consecutive patients (148 women, 44 men; mean age 54.3±8.5 years) with the diagnosis of MetS based on the NCEP-ATP III criteria and 20 healthy controls (12 women, 8 men; mean age 51.6±8.4 years). All subjects underwent conventional and tissue Doppler (TDI) echocardiography to assess left and right ventricular functions, including right ventricular myocardial performance index (MPI) and tricuspid annular plane systolic excursion (TAPSE).
Results: The number of MetS components were three in 43.8%, four in 31.3%, and five in 25% of the patients. Right ventricular TDI-derived MPI was higher in patients with MetS compared to controls [median 0.5 (range 0.2-3.3) vs. 0.3 (0.1-0.7), p=0.000]. This was possibly due to significantly shortened right ventricular ejection time in MetS patients (p<0.05). Although TAPSE was within the normal range in MetS patients, it was significantly decreased compared to controls (p=0.000), accompanied by significantly lower TDI-derived S wave, E wave, and E/A ratio (p=0.000). None of the MetS components were significantly correlated with right ventricular TDI-derived MPI. There was no association between the number of MetS components and echocardiographic parameters.
Conclusion: Our findings show that, despite preserved left ventricular systolic functions, both systolic and diastolic functions of the right ventricle deteriorate in MetS patients.

4. Increased aortic pulse wave velocity in obese children
Ataç Çelik, Mustafa Özçetin, Yasemin Yerli, İbrahim Halil Damar, Hasan Kadı, Fatih Koç, Köksal Ceyhan
PMID: 21983765  doi: 10.5543/tkda.2011.01694  Pages 557 - 562
Objectives: Obesity may start in childhood and obese children are more likely to grow up to be obese adults. Atherosclerosis is one of the most important complications of obesity. Pulse wave velocity (PWV), a noninvasive measure of arterial stiffness, is accepted to be an indicator of subclinical atherosclerosis. The aim of the study was to determine PWV in obese children.
Study design: The study included 30 obese (12 boys, 18 girls; mean age 13±2 years) and 30 lean children (13 boys, 17 girls; mean age 12.5±1.7 years). Weight and height were measured and obesity was defined as body mass index (BMI) of greater than the 95th percentile for age. All the subjects underwent echocardiographic evaluation and blood samples were obtained. Pulse-wave velocity was calculated using the following equation: PWV (m/sec) = height-based aortic length (cm)/(100xtransit time [sec]). The latter was measured as the difference in the time of onset of two flows at the diaphragm and the aortic valve.
Results: Obese subjects had significantly higher blood pressure levels compared to the control group (p<0.001). The two groups were similar with respect to fasting glucose, hemoglobin, serum creatinine, and lipid levels. Among echocardiographic parameters, left ventricular end-diastolic dimension, interventricular septum thickness, posterior wall thickness, left ventricular mass index, left atrium dimension, and aortic root dimension were significantly increased in obese subjects compared to controls (p<0.01). Obese children had significantly higher PWV values than the controls (4.0±0.8 vs. 3.3±0.7 m/sec, p<0.001). A positive significant correlation was found between PWV and BMI (r=0.391, p=0.002).
Conclusion: Our findings show that aortic PWV is increased in obese children, suggesting that obesity may cause subclinical atherosclerosis even at early ages.

5. Comparative effects of nebivolol and valsartan on atrial electromechanical coupling in newly diagnosed stage 1 hypertensive patients
Burak Altun, Gürkan Acar, Ahmet Akçay, Abdullah Sökmen, Hakan Kaya, Sedat Köroğlu
PMID: 21983766  doi: 10.5543/tkda.2011.01585  Pages 563 - 567
Objectives: Hypertension is an important cardiovascular risk factor for the development of atrial fibrillation (AF). Increased atrial electromechanical coupling time interval measured by tissue Doppler is accepted as an important factor for prediction of AF development in hypertensive patients. The aim of this study was to compare the effects of valsartan, an angiotensin receptor blocker, and nebivolol, a beta-blocker, on atrial electromechanical coupling in newly diagnosed stage 1 hypertensive patients.
Study design: The study included 60 newly diagnosed stage 1 hypertensive patients with no other systemic disease. The patients were randomized to receive nebivolol 5 mg (30 patients; 21 women, 9 men; mean age 48.4±11.4 years) and valsartan 160 mg (30 patients; 21 women, 9 men; mean age 49.8±11.3 years). All the patients underwent tissue Doppler echocardiographic examination before and three months after treatment to compare the effects of the two drugs on atrial electromechanical coupling.
Results: Baseline blood pressures, electrocardiographic and echocardiographic findings, and atrial electromechanical coupling were similar in both groups (p>0.05). Both drugs significantly reduced blood pressure after treatment, with similar efficacy (p>0.05). Atrial electromechanical coupling time intervals showed significant decreases in both groups.
Conclusion: Prolonged interatrial electromechanical time intervals in hypertensives are improved with antihypertensive treatment.

6. Usefulness of high-sensitivity CRP increases during circadian rhythm for prediction of long-term cardiovascular events in patients with stable coronary artery disease
Mevlüt Koç, Durmuş Yıldıray Şahin, Onur Kadir Uysal, Osman Karaarslan, Esra İşler, Gülcan Abalı, Mustafa Kemal Batur
PMID: 21983767  doi: 10.5543/tkda.2011.01649  Pages 568 - 575
Objectives: We investigated the value of circadian variations in high sensitivity C-reactive protein (hs-CRP) levels in prediction of long-term cardiovascular events (CVE) in patients with stable coronary artery disease (CAD).
Study design: The study included 94 patients (70 men, 24 women; mean age 58±9 years) with stable CAD. High sensitivity CRP levels were measured at six-hour intervals, namely, morning (06: 00), midday (12: 00), evening (18: 00), and midnight (24: 00). Absolute change in hs-CRP (absolute ΔCRP) was calculated by subtracting the midday hs-CRP level from that of the morning. Relative change in hs-CRP (relative ΔCRP) was calculated by dividing absolute ΔCRP by the midday hs-CRP level. The patients were followed-up for a mean of 40.2±8.0 months for monitoring of CVE.
Results: During the follow-up period, CVE occurred in 24 patients (25.5%). Patients who developed CVE exhibited significantly higher serum creatinine, B-type natriuretic peptide, morning, evening, and midnight hs-CRP levels, absolute and relative ΔCRP, and left atrial end-diastolic diameter compared to patients without CVE (p<0.05). In logistic regression analysis, only left atrial end-diastolic diameter and absolute ΔCRP were independent predictors of CVE (OR=1.11, 95% CI 1.003-1.236, p=0.044 and OR=1.58, 95% CI 1.195-2.090, p=0.001, respectively). Every 1 mg/l increase in absolute ΔCRP represented a 58.1% increase in CVE risk. In receiver operating characteristics curve analysis, the cut-off value of 2 mg/l for absolute ΔCRP predicted CVE with 89.5% sensitivity and 84.2% specificity.
Conclusion: Our findings suggest that absolute circadian increases in hs-CRP levels may be helpful in predicting long-term CVEs in patients with stable CAD.

CASE REPORT
7. Intercoronary continuity between the right and circumflex coronary arteries causing myocardial ischemia
Taner Ulus, Bulent Gorenek, Huseyin Ugur Yazici, Hande Ozduman
PMID: 21983768  doi: 10.5543/tkda.2011.01575  Pages 576 - 578
Intercoronary continuity refers to a bidirectional flow in patients with normal coronary arteries. Although such connections have been proposed to have a protective role against potential obstructive coronary artery disease, their functional significance is unclear. We report on a 53-year-old woman who presented with typical chest pain. Exercise myocardial perfusion imaging revealed perfusion defects involving the basal regions of the inferior and inferoseptal walls. Coronary angiography showed an intercoronary continuity between the right coronary artery and circumflex artery. Following institution of medical therapy, the patient’s complaint improved and she had no complaint during one-year follow-up. This is the first reported case in which an intercoronary continuity was associated with myocardial ischemia.

8. Successful percutaneous epicardial ablation of an accessory pathway located at the right atrial appendage
Sedat Köse, İbrahim Başarıcı, Kutsi Hasan Kabul, Cem Barçın
PMID: 21983769  doi: 10.5543/tkda.2011.01551  Pages 579 - 583
In patients with Wolff-Parkinson-White syndrome, difficulty in ablation of accessory pathways is associated with failures and recurrences. Epicardially located accessory pathways may require different management strategies when conventional ablation attempts fail. In particular, an epicardial accessory pathway communicating the right atrial appendage to the right ventricle is an extraordinary situation resulting in difficulties in ablation. Hereby, we report on a challenging case of percutaneous epicardial ablation of an epicardial accessory pathway located at right atrial appendage in a 28-year-old man with Wolff-Parkinson-White syndrome, who had a prior history of unsuccessful endocardial ablation. Percutaneous epicardial ablation may be a viable option obviating the necessity of surgical ablation procedures for difficult ablation cases with epicardial accessory pathways.

9. Agitated saline contrast use in a case with peripheral pulmonary artery stenosis
Zafer Işılak, Mehmet Uzun, Fethi Kılıçaslan, Ömer Uz
PMID: 21983770  doi: 10.5543/tkda.2011.01591  Pages 584 - 586
We present a case of peripheral pulmonary artery stenosis that was incidentally detected by agitated saline contrast study. A 19-year-old male patient underwent cardiologic examination to determine suitability for military service. He had exertional intolerance since early childhood. Physical examination showed a murmur over the entire right hemithorax. Echocardiography showed moderately enlarged right ventricle, right atrium, and main pulmonary artery, and color Doppler showed mild tricuspid regurgitation. Right ventricular systolic pressure was estimated as 55-60 mmHg from the tricuspid regurgitation jet. For further evaluation of the systolic murmur, agitated saline contrast echocardiography was performed. During continuous wave Doppler examination while there were remnants of bubbles in the right heart and pulmonary vascular bed, a systolodiastolic flow with a peak gradient of 30 mmHg was noted. After disappearance of the bubbles, the signal was not detectable. Repeat agitated saline contrast examination again showed a gradient of 35 mmHg. A stenosis in the distal branches of the right pulmonary artery was suspected. Finally, computed tomography revealed multiple stenoses in the pulmonary vascular bed. To our best knowledge, this is the first case in which agitated saline contrast examination enabled the diagnosis of peripheral pulmonary artery stenosis.

10. Acute thrombus formation on an Amplatzer device during transcatheter closure of an atrial septal defect in a patient with homozygous factor V Leiden mutation
Vefik Yazıcıoğlu, Müslüm Şahin, Oğuz Karaca, Muhsin Turkmen
PMID: 21983771  doi: 10.5543/tkda.2011.01527  Pages 587 - 590
A 32-year-old woman underwent transcatheter closure of a secundum type atrial septal defect with the Amplatzer device. The procedure was started under premedication with aspirin, clopidogrel, and heparin. During the procedure, a highly mobile thrombus attached to the left atrial disc of the device was detected by transesophageal echocardiography (TEE). The device and the associated thrombus were successfully withdrawn and the patient was started on a combination of heparin and tirofiban infusion. The procedure was successfully completed without any recurrent thrombus formation or residual shunt. Further investigation for thrombophilia revealed homozygous factor V Leiden mutation and the patient was started on a life-long warfarin therapy. Follow-up TEE showed proper device position with no recurrent thrombus and the follow-up was uneventful.

11. Development of biventricular large apical thrombi and cerebral embolism in a young woman with peripartum cardiomyopathy
Mevlüt Koç, Durmuş Yıldıray Şahin, Kamuran Tekin, Murat Çaylı
PMID: 21983772  doi: 10.5543/tkda.2011.01534  Pages 591 - 594
Peripartum cardiomyopathy is a rare cardiac disorder. Although left ventricular apical thrombus formation is common in peripartum cardiomyopathy, biventricular apical thrombi formation is a very rare condition in these patients. A 21-year-old woman presented with complaints of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and palpitations that appeared three months after labor. Transthoracic echocardiography showed severe global hypokinesis, decreased left and right ventricular ejection fraction (left 30%, right 35%), increased left ventricular end-diastolic dimension (60 mm), grade 2 mitral regurgitation, and biventricular apical thrombi. On the second day of admission, she developed global aphasia and right hemiplegia. The patient was successfully treated with recombinant tissue plasminogen activator. Transthoracic echocardiography following treatment showed disappearance of biventricular apical thrombi. She had no neurologic deficit. Treatment for heart failure was continued due to persistence of global hypokinesis and left ventricular dilatation.

12. A rare cause of recurrent wheezing and respiratory distress: Scimitar syndrome
Yakup Ergül, Kemal Nişli, Nermin Güler, Ümrah Aydoğan
PMID: 21983773  doi: 10.5543/tkda.2011.01581  Pages 595 - 598
Scimitar syndrome is characterized by partial or total anomalous pulmonary venous return from the right lung. We present a 15-month-old boy who was diagnosed with Scimitar syndrome after examinations for recurrent wheezing and respiratory distress. The chest radiograph showed a scimitar sign in the right hemithorax, obscuring the contours of the right atrium. Echocardiography showed dilatation of the right heart cavities and increased flow in the inferior vena cava, without a cardiac abnormality. The patient underwent cardiac catheterization for radiographic and hemodynamic evaluations, during which a scimitar vein was detected, draining the right pulmonary veins to the inferior vena cava. Coil occlusion was performed on the abnormal artery arising from the infradiaphragmatic aorta. The patient was referred to surgery for repair of the anomalous pulmonary venous return and resection of the sequestered pulmonary segment.

REVIEW
13. Almanac 2011: stable coronary artery disease. The national society journals present selected research that has driven recent advances in clinical cardiology
Robert A. Henderson, Adam D. Timmis
PMID: 21983774  Pages 599 - 610
Abstract |Full Text PDF

14. Almanac 2011: heart failure. The national society journals present selected research that has driven recent advances in clinical cardiology
Andrew L. Clark
PMID: 21983775  Pages 611 - 620
Abstract |Full Text PDF

HOW TO?
15. (Pacemaker) Follow-up of a patient with permanent pacemaker
Murat Özdemir
PMID: 21983776  doi: 10.5543/tkda.2011.01764  Pages 621 - 624
Abstract |Full Text PDF

CASE IMAGE
16. Double-orifice mitral valve
Harun Evrengül, Emin Evren Özcan
PMID: 21983777  doi: 10.5543/tkda.2011.01604  Page 625
Abstract |Full Text PDF

17. Subvalvular pulmonary stenosis, right ventricular hypertrophy and patent foramen ovale
Orhan Doğdu, Oğuzhan Baran, Ömer Karaduman, Mikail Yarlıoğlueş
PMID: 21983778  doi: 10.5543/tkda.2011.01583  Page 626
Abstract |Full Text PDF

18. Surgical repair of interrupted aorta and ascending aortic aneurysm
Ömer Naci Emiroğulları, Mehmet Güngör Kaya, Ertuğrul Mavili, Aydın Tunçay
PMID: 21983779  doi: 10.5543/tkda.2011.01579  Page 627
Abstract |Full Text PDF

19. Incidental detection of pulmonary hamartoma by echocardiography
İsa Döngel, Burak Turan, Mehmet Mustafa Can, Mehmet Bayram
PMID: 21983780  doi: 10.5543/tkda.2011.01643  Page 628
Abstract |Full Text PDF

20. Noonan’s syndrome and aortic coarctation patients presenting with a giant aneurysm of the descending aorta: Image report of two cases
Mustafa Paç, Ayşe Esin Kibar, Mehmet Burhan Oflaz, Feyza Ayşenur Paç
PMID: 21983781  doi: 10.5543/tkda.2011.01603  Page 629
Abstract |Full Text PDF

LETTER TO EDITOR
21. Letter to the Editor: An unusual microorganism, Aerococcus viridans, causing endocarditis and aortic valvular obstruction due to a huge vegetation
Magnus Rasmussen, Ali Nazmi Çalık
PMID: 21983782  Pages 630 - 631
Dear Editor,

I read with interest the case report by Çalık and co-workers concerning a patient with endocarditis that did not respond to seemingly adequate antibiotic treatment. The authors typed the causative organism with an API test strip as Aerococcus viridans and discuss this organism.[1]

A. viridans was described in 1953[2] and additional aerococcal species including Aerococcus urinae[3] and Aerococcus sanguinicola[4] have been defined since then. A. viridans and A. sanguinicola have similar biochemical properties5 but A. sanguinicola seem to be more commonly isolated from infected patients than A. viridans.[6, Senneby et al. in preparation]. Importantly, the API system used by Çalık et al. fails to recognize A. sanguinicola and misclassifies this species as A. viridans.[6] Thus, it is possible that the organism causing the infection described by Çalık et al. is not A. viridans but instead A. sanguinicola. This potential misidentification may have occurred in many cases where A. viridans was identified only on the basis of the API or Vitek2 systems. Since biochemical typing of aerococci is difficult, 16S rRNA gene PCR and sequencing would be helpful to clarify the bacterial aetiology in this interesting case.

OTHER ARTICLES
22. Answers of specialist
Okan Erdoğan, İlyas Atar
Pages 632 - 633
Abstract |Full Text PDF

23. Comment on cardiology publications
Ertan Ural
Page 634
Abstract |Full Text PDF



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