Evaluation of beta-blockers on left ventricular dyssynchrony and reverse remodeling in idiopathic dilated cardiomyopathy: A randomized trial of carvedilol and metoprolol

BACKGROUND

The effect of b-blockage on cardiac dyssynchrony in idiopathic dilated cardio-myopathy (IDC) is unknown. This study evaluated the impact of carvedilol and metoprolol succinate on left ventricular (LV) dyssynchrony and reverse remodeling in IDC.

METHODS

In this small, prospective, double-blind study, we randomly assigned 81 IDC patients to receive carvedilol or metoprolol succinate. Echocardiographic measurements (dyssynchrony, LV volumes and ejection fraction [EF]) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were obtained at baseline and at first and sixth month of therapy.

RESULTS

A total of 74 (91%) patients completed all investigations at sixth month (38 and 36 taking carvedilol and metoprolol succinate, respectively). In the carvedilol group, reduction in LV end diastolic volume (D LVEDV at 6 months, 50 ± 15 mL to 40 ± 17 mL, p = 0.03) and increase in LVEF (D LVEF, 7 ± 2% to 5 ± 3%, p = 0.02) was higher compared to the metoprolol group. Also improvement in inter-ventricular dyssynchrony achieved with carvedilol was higher than metoprolol (D interventricular delay at 6 months, 11 ± 8 ms to 6 ± 7 ms, p = 0.03). However, improvement in intraventricular dyssynchrony was similar in the two groups (D intraventricular delay, 9 ± 7 ms to 9 ± 6 ms, p = 0.91). Improvements in LV mechanical dyssynchrony and reverse remodeling achieved with both drugs were accompanied by reduction in NT-proBNP levels in both carvedilol and metoprolol groups (1614 ± 685 pg/mL to 654 ± ± 488 pg/mL and 1686 ± 730 pg/mL to 583 ± 396 pg/mL, respectively, p < 0.001 for both).

CONCLUSIONS

Although reduction in LVEDV and increase in LVEF was higher with carvedilol, improvement in intraventricular dyssynchrony was similar in carvedilol and metoprolol groups.

Relation between serum total bilirubin levels and severity of coronary artery disease in patients with non-ST-segment elevation myocardial infarction

We studied 403 consecutive patients with non-ST-segment elevation myocardial infarction (NSTEMI). This population was divided into tertiles according to the SYNTAX score (SXscore). The high SXscore group was defined as an SXscore ≥13, and the low SXscore group as an SXscore <13. The total bilirubin (sTB) and direct bilirubin levels of patients were significantly higher in the high SXscore group (P = .001 and P = .007, respectively). There was a correlation between sTB and SXscore (r = .495; P = .005). On multivariate linear regression analyses, age (β = .100; P = .041), sTB levels (β = .171; P = .005), low-density lipoprotein cholesterol (β = .121; P = .014), and troponin-I (β = .124; P = .011) remained independent correlates of high SXscore. The mean follow-up period was 18.2 months. All-cause mortality rate was higher in the high SXscore group but did not reach significance (P = .058). In conclusion, high sTB level is independently associated with severity of coronary artery disease in patients with NSTEMI. However, no association was found with long-term mortality.

The Relationship Between Neutrophil-to-Lymphocyte Ratio and Coronary Collateral Circulation

Neutrophil/lymphocyte ratio (NLR) has been proposed as a prognostic marker to determine systemic inflammatory response and atherosclerosis. Our aim was to determine the relationship between NLR and development of coronary collateral circulation (CCC) in patients with stable coronary artery disease (CAD). A total of 521 consecutive patients with stable CAD who underwent coronary angiography and documented total occlusion in one of those major coronary arteries were included in this study. Levels of fasting blood glucose, white blood cell, and NLR were significantly higher in patients with poor collateral than in those with good collateral. After multivariate analysis, high level of NLR was an independent predictor of CCC together with levels of fasting blood glucose. The receiver–operating characteristic analysis provided a cutoff value of 2.75 for NLR to predict poor CCC with 65% sensitivity and 68% specificity. We demonstrated an independent association between levels of NLR and development of CCC in patients with stable CAD.

Association between uric acid and coronary collateral circulation in patients with stable coronary artery disease

Serum uric acid (SUA) levels have been proposed as a biomarker of coronary artery disease (CAD) and coronary collateral circulation (CCC). We investigated the association between SUA levels and development of CCC in patients with stable CAD. Consecutive patients (n = 480) with stable CAD who underwent coronary angiography and documented total occlusion in 1 of the major coronary arteries were included in this study. Levels of fasting blood glucose, white blood cell (WBC), creatinine, platelet count, and SUA were significantly higher in patients with poor CCC than in those with good CCC. After multivariate analysis, high levels of SUA were an independent predictor of CCC together with levels of fasting blood glucose and WBC. The receiver-operating characteristic analysis provided a cutoff value of 5.65 mg/dL for SUA to predict poor CCC with 60% sensitivity and 66% specificity. High levels of SUA may be associated with poor CCC in patients with stable CAD.

Dose-dependent acute effects of passive smoking on left ventricular cardiac functions in healthy volunteers

OBJECTIVE

We have previously shown that acute passive smoking impaired left ventricular diastolic function in healthy volunteers. The aim of this study was to determine whether length of exposure and/or ambient smoke concentration is the key determinant of this outcome.

METHODS

We measured blood carboxyhemoglobin (COHb)and lactate level to investigate the acute effects of passive smoking on tissue oxygenation. A total of 90 healthy nonsmoker volunteers were prospectively enrolled into the study. Each of 30 subjects were exposed to carbon monoxide (CO) less than 5.0 ppm smoke in group A for 30 minutes, to CO 5 to 10 ppm smoke in group B for 30 minutes, and to CO less than 5.0 ppm smoke in group C for 60 minutes. Hemodynamic parameters were obtained, blood samples for measuring COHb and lactate levels were taken and echocardiographic examinations were performed at baseline and after exposure to passive smoking.

RESULTS

Mean ± SD CO levels in groups A, B, and C were 4.2 ± 0.5 ppm, 9.2 ± 0.3 ppm, and 4.1 ± 0.8 ppm, respectively. There was no change in left ventricular systolic functions in all groups. Left ventricular diastolic functions were impaired in groups B and C, whereas no change was observed in group A. Carboxyhemoglobin and lactate levels increased after passive smoking in groups B and C. However, group B had significantly higher COHb and lactate levels compared to group C (P < 0.001).

CONCLUSIONS

Our results suggested that passive smoking at a certain dose in relation with length of exposure and ambient smoke concentration seems to cause relative left ventricular diastolic dysfunction.

Renal impairment and coronary collaterals in patients with acute coronary syndrome

OBJECTIVE

We aimed to elucidate the relationship between mild-to-moderate renal impairment and the development of coronary collateral vessels (CCV) in patients with acute coronary syndrome (ACS).

METHODS

We enrolled 461 patients with ACS who underwent coronary angiography for the first time. The development of CCV was assessed with the Rentrop score. Kidney function was classified according to the estimated glomerular filtration rate (eGFR). The Gensini score was used to show the extent of atherosclerosis.

RESULTS

The mean eGFR value was 89.9 ± 24.3 U/l for patients with no development of collaterals and 82.7 ± 20.5 for patients who had CCV. The mean age was 59 ± 11 years and 349 patients (75.7 %) were male. Rentrop classifications 1-2-3 (presence of CCV) were determined in 222 (48.1 %) patients. The presence of CCV was significantly associated with low levels of eGFR (p = 0.001), increased serum creatinine levels (p = 0.034), high levels of serum albumin (0.036), and the Gensini score (p < 0.001). Multivariate analysis showed that the Gensini score was an independent predictor of the presence of CCV (OR = 1.090, 95 % CI: 1.032-1.151, p = 0.002).

CONCLUSION

We suggest that the association between mild-to-moderate renal impairment and the presence of CCV may be explained by increased myocardial ischemia and severe CAD.

Glomerular filtration rate is associated with burden of coronary atherosclerosis in patients with acute coronary syndrome

We aimed to elucidate the relationship between mild to moderate renal impairements and burden of atherosclerosis in patients with acute coronary syndrome (ACS). A total of 380 patients with ACS were included in the study. Gensini and SYNTAX scores were also calculated. Kidney function was classified based on estimated glomerular filtration rate (eGFR) into stage 1: eGFR >90, stage 2: 60 to 89, and stage 3: 30 to 60 mL/min per 1.73 m(2). Gensini and SYNTAX scores were higher in stages 2 and 3 than in stage 1. Also, the number of diseased vessels, number of critical lesions (>50 and 70%), left main disease, and number of total occlusion vessels were higher in stages 2 and 3 than in stage 1. Multivariate linear regression analysis demonstrated that a decreased eGFR was an independent risk factor for SYNTAX and Gensini scores together with age and male gender.

Relation between mean platelet volume and coronary collateral vessels in patients with acute coronary syndromes

OBJECTIVE

Elevated mean platelet volume (MPV) has been proposed as a risk factor for coronary artery disease (CAD) and is associated with poor clinical outcome in acute coronary syndrome (ACS). We aimed to evaluate the association of MPV with presence of coronary collateral vessel (CCV) in patients with ACS.

METHODS

A total of 417 patients with ACS were included in the study. All patients underwent coronary angiography on the first day after admission and patients with a greater than or equal to 80% obstruction in at least one epicardial coronary artery were included in the study. The CCVs are graded according to the Rentrop scoring system and a Rentrop grade 0 was accepted as no CCV development (group 1), Rentrop grade 1-2-3 were accepted as presence of CCV development (group 2).

RESULTS

The median of MPV was 9.1±1.4fl. Mean age was 60±12 year. Group 1 consisted of 233 (55.9%) patients and Group 2 consisted of 184 (44.1%) patients. Presence of CCV was significantly associated with high levels of MPV (p=0.005). Presence of CCV was also associated with presence of diabetes and systolic blood pressure.

CONCLUSION

High MPV on admission was associated with presence of CCV in patients with ACS.

Cardiac effects of chronic graft-versus-host disease after stem cell transplantation

Chronic graft-versus-host disease (GVHD) develops as a result of the immunologic response that donor T-lymphocytes generate against host tissue after allogeneic stem cell transplantation. We tried to elucidate the contribution of cardiac dysfunction to the high morbidity and mortality rates observed after GVHD. Forty patients who had undergone bone marrow transplantation were enrolled in this prospective study: 14 patients who had been diagnosed with chronic GVHD (manifestations beyond day 100 after hemopoietic cell transplantation) and 26 patients who had not. All patients had undergone baseline echocardiography before bone marrow transplantation and were monitored. After the expected period of time had elapsed for GVHD after transplantation, these patients were divided into 2 groups in accordance with whether or not they developed chronic GVHD. No significant differences were observed before bone marrow transplantation in the 2 groups' broad attributes or in their laboratory and echocardiographic findings (P >0.05). After transplantation, high-sensitivity C-reactive protein levels and erythrocyte sedimentation rates were significantly higher in the chronic GVHD group (P < 0.001 and P=0.01, respectively). Mean left ventricular mass was 227 ± 32.3 g in the GVHD group and 149.3 ± 27.4 g in the non-GVHD group (P < 0.001). The E/A flow rate was significantly higher in the non-GVHD group. This study shows that chronic GVHD increases left ventricular mass and impairs left ventricular diastolic function in patients who have developed chronic GVHD. In addition, it shows that inflammatory markers increase to higher levels in these patients. Comprehensive studies with larger samples are needed to more fully elucidate the cardiac effects of this disease.

Relation of neutrophil/lymphocyte ratio to coronary flow to in-hospital major adverse cardiac events in patients with ST-elevated myocardial infarction undergoing primary coronary intervention

With the growing understanding of the role of inflammation in patients with atherosclerotic disease, studies have focused on high-sensitivity C-reactive protein (hs-CRP) and other inflammatory markers in their association with outcomes in ST-segment elevation myocardial infarction. The goal of this study was to investigate the association of the neutrophil/lymphocyte (N/L) ratio and in-hospital major adverse cardiac events (MACEs) in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). The association of hs-CRP and N/L ratio on admission with Thrombolysis In Myocardial Infarction (TIMI) flow grade after PCI was assessed in 418 consecutive primary patients with PCI. The N/L ratio was significantly higher in the no-reflow group (TIMI grade 0/1/2 flow, n = 158) compared to that of the normal-flow group (TIMI grade 3 flow, n = 260, 4.6 ± 1.7 vs 3.1 ± 1.9, p <0.001). In-hospital MACEs were significantly higher in patients with no reflow (23% vs 7%, p <0.001). There was a significant and positive correlation between hs-CRP and N/L ratio (r = 0.657, p <0.001). In receiver operating characteristic analysis, N/L ratio >3.3 predicted no reflow with 74% sensitivity and 83% specificity. In a multivariate regression model, N/L ratio remained an independent correlate of no reflow (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.34 to 1.76, p <0.001) and in-hospital MACEs (OR 1.14, 95% CI 0.98 to 1.32, p = 0.043). The N/L ratio, an inexpensive and easily measurable laboratory variable, is independently associated with the development of no reflow and in-hospital MACEs in patients with ST-segment elevation myocardial infarction undergoing primary PCI.

Blood pressure response to exercise is exaggerated in normotensive diabetic patients

INTRODUCTION

The aim of this study was to investigate the blood pressure (BP) response to exercise in normotensive patients with type II diabetes mellitus (DM).

MATERIALS AND METHODS

A cross-sectional study was carried out on 75 normotensive subjects with type 2 DM (group 1), and 70 age-gender matched normotensive healthy volunteers (group 2). Treadmill exercise test, 24-h ambulatory BP monitoring (ABPM) were performed for each patients and healthy volunteers.

RESULTS

There were 67 patients (mean age 52 ± 9 years and 42% male) in group 1 and 68 healthy volunteers (mean age 51 ± 7 years and 43% male) in group 2. Eight patients from group 1 and 2 subjects from group 2 were excluded because of high BP on ABPM. Groups were similar for systolic BP (SBP) and diastolic BP (DBP) on office measurements and on ABPM. Groups were similar for rest SBP, DBP, heart rate, exercise duration on exercise test. Peak SBP was significantly higher in group 1 than in group 2, but peak DBP was not (196.9 ± 18 vs 165.9 ± 18.6 mmHg, p<0.001; 88.1 ± 11.6 vs 86.2 ± 8.7 mmHg, p = 0.283, respectively). Hypertensive response to exercise (HRE) was more frequent in group 1 than in group 2 [39 (58%) vs 6 (9%), p<0.001]. Independent predictors of peak SBP were DM, office SBP and male gender, while independent predictors of HRE were DM, office SBP and age in multivariate analysis.

CONCLUSIONS

SBP response to exercise is exaggerated in normotensive diabetic patients compared with non-diabetic subjects. DM, office SBP and male gender are independent predictors of peak SBP. DM, office SBP and age are independent predictors of HRE.

Changes in carotid intima-media thickness over two years in patients on haemodialysis

OBJECTIVE

To evaluate the progression of carotid intima-media thickness (CIMT) and to search for possible associations between these changes and other risk factors of atherosclerosis for 2 years in stable patients with chronic renal failure (CRF) on haemodialysis (HD).

METHODS

Study population consisted of 22 patients with newly diagnosed CRF. All patients underwent B-mode ultrasonography of common carotid artery for estimating CIMT and the presence of plaques before and after the first HD session (mean 24.22 +/- 2.14 months). The differences in CIMT before and after long-term HD treatment were compared. Acute phase proteins, calcium-phosphate balance and lipid profile were assessed and anthropometric parameters were measured.

RESULTS

Mean age was 55 +/- 13 years and 10 (45%) of the patients were female. After long-term HD treatment, (mean 24.22 +/- 2.14 months) the mean value for CIMT (0.57 +/- 0.08 mm) was significantly lower than that at baseline (0.68 +/- 0.12 mm) (p = 0.02). Only male gender and smoking were correlated with baseline CIMT. After long-term HD treatment, age, total cholesterol, LDL cholesterol, and triglyceride were related with CIMT. Diabetes and smoking were correlated with CIMT. Presence of plaque before HD only correlated with creatinine level and after long-term HD treatment only correlated with total cholesterol level.

CONCLUSION

We found that CIMT was significantly decreased 2 years after starting HD. An association between CIMT and other atherosclerotic risk factors (such as age, cholesterol, triglyceride etc.) could not be determined due to a small sample size.

Effect of infliximab treatment on QT intervals in patients with ankylosing spondylitis

BACKGROUND

Cardiovascular complications are one of the most common and the most serious extraskeletal manifestations of ankylosing spondylitis (AS). Infliximab, a monoclonal antibody against tumor necrosis factor, is widely used in the treatment of AS. QT dispersion (QTd), which relates to left ventricular function and is used as an index of cardiac dysrhythmia, may be useful as a prognostic guide. Early detection of possible cardiac involvement may not be clinically evident, whereas it may be detected by electrocardiography.

OBJECTIVES

The aim of this prospective study was to assess the effect of infliximab treatment on QT intervals in patients with AS.

METHODS

Twenty-one patients (17 females and 4 males) with AS who were in the active phase of disease (Bath Ankylosing Spondylitis Disease Activity Index score >4) were enrolled in the study. Infliximab was administered intravenously at a dosage of 5 mg/kg at weeks 0, 2, and 6 and every 6 weeks thereafter. QT intervals were recorded before and after 6 months of treatment.

RESULTS

QT corrected (QTc) for heart rate was significantly reduced in the patients with AS after 6 months of infliximab therapy (406 ± 5.5 vs 388 ± 6.6 milliseconds; P = 0.029). There was no difference in the QTc dispersion (34.3 ± 11.1 vs 34.1 ± 8.6; P = 0.171). Body mass index and lipid profile were slightly increased after the treatment, but the difference was statistically insignificant.

CONCLUSION

Inflammation can affect the ventricles with an unknown mechanism, and QTc may be slightly prolonged as a result in the active phase of AS. In our study, QTc was shortened under infliximab therapy by suppressing inflammation. Therefore, this effect may protect patients with AS from fatal arrhythmias and sudden cardiac death.