Comparison of the Effects of Nitroglycerin and Nitroprusside on Transmitral Doppler Flow Parameters in Patients with Hypertensive Urgency

BACKGROUND:

Sodium nitroprusside (NIP) and nitroglycerin (NIT) are frequently selected agents for acutely reducing blood pressure. However, it is not clear which agent is more efficacious in improving left ventricular filling pressure in hypertensive crises.

OBJECTIVE:

To compare the acute effects of nitroglycerin (NIT) and nitroprusside (NIP) on transmitral Doppler filling parameters in patients with hypertensive urgency.

METHODS:

We identified 37 patients from our emergency department with hypertensive urgency and left ventricular filling abnormalities. Hypertensive urgency was defined as a severe blood pressure elevation without evidence of progressive end-organ injury. Patients were randomized to receive an infusion of NIT or NIP. NIT was infused at a starting dose of 10 μg/min; NIP was infused at a starting dose of 0.25 μg/kg/min. The infusion rates were adjusted to decrease mean arterial pressure by 25%, and this reduction was obtained within 2 hours in all patients. Diastolic filling parameters were measured by using echocardiography before and after treatment. Pulsed-wave Doppler transmitral flow velocities were used. Early diastolic flow, atrial contraction signal, early diastolic flow/atrial contraction signal, deceleration time, and isovolumetric relaxation time (IVRT) were measured.

RESULTS:

There were no differences between groups in baseline demographic and echocardiographic parameters. Blood pressure decreased significantly in both treatment groups. In posttreatment echocardiographic examinations, atrial contraction signal, deceleration time, and IVRT were significantly decreased in both treatment groups. Early diastolic flow was significantly decreased in the NIT group. There were no significant differences between the groups in terms of posttreatment early diastolic flow, atrial contraction signal, deceleration time, and IVRT values.

CONCLUSIONS:

In hypertensive urgency with left ventricular filling abnormalities, reduction of blood pressure associated with NIT or NIP treatment may improve transmitral Doppler filling parameters. There were no differences demonstrated between the 2 agents.

Galectin-3: A biochemical marker to detect paroxysmal atrial fibrillation?

PURPOSE

Atrial fibrillation (AF) is the most common form of arrhythmia. AF leads to electrical remodelling and fibrosis of the atria; however, the mechanism(s) remain poorly understood. Galectin-3 is a potential mediator of cardiac fibrosis. The present study aimed to examine the relationship between serum galectin-3 levels and paroxysmal AF.

METHODS

Forty-six patients with paroxysmal AF and preserved left ventricular systolic function, and 38 age- and gender-matched control subjects, were involved in the study. Serum galectin-3 levels were analyzed with an enzyme-linked immunosorbent assay (ELISA).

RESULTS

Serum galectin-3 levels (median 1.38 ng/mL; 1.21 ng/mL-1.87 ng/mL; p< 0.001) were significantly elevated in patients with paroxysmal AF compared with the control. Left atrial diameter was significantly higher in patients with paroxysmal AF (41.2±3.0 mm vs. 39.6±3.3 mm). Left atrial diameter was found to be significantly correlated with serum galectin-3 levels in patients with paroxysmal AF (r= 0.378, p= 0.001).

CONCLUSION

Serum galectin-3 levels are significantly elevated and significantly correlated with left atrial diameter in patients with paroxysmal AF.

Galectin-3: A biochemical marker to detect paroxysmal atrial fibrillation?

Purpose: Atrial fibrillation (AF) is the most common form of arrhythmia. AF leads to electrical remodelling and fibrosis of the atria; however, the mechanism(s) remain poorly understood. Galectin-3 is a potential mediator of cardiac fibrosis. The present study aimed to examine the relationship between serum galectin-3 levels and paroxysmal AF. Methods: Forty-six patients with paroxysmal AF and preserved left ventricular systolic function, and 38 age- and gender-matched control subjects, were involved in the study. Serum galectin-3 levels were analyzed with an enzyme-linked immunosorbent assay (ELISA). Results: Serum galectin-3 levels (median 1.38 ng/mL; 1.21 ng/mL-1.87 ng/mL; p< 0.001) were significantly elevated in patients with paroxysmal AF compared with the control. Left atrial diameter was significantly higher in patients with paroxysmal AF (41.2±3.0 mm vs. 39.6±3.3 mm). Left atrial diameter was found to be significantly correlated with serum galectin-3 levels in patients with paroxysmal AF (r= 0.378, p= 0.001). Conclusion: Serum galectin-3 levels are significantly elevated and significantly correlated with left atrial diameter in patients with paroxysmal AF.

Current Role of Laser Angioplasty of Restenotic Coronary Stents

Treatment of in-stent restenosis (ISR) with conventional percutaneous transluminal coronary angioplasty (PTCA) causes significant recurrent neointimal tissue growth in 30-85%. Therefore, laser ablation of intrastent neointimal hyperplasia before balloon dilation can be an attractive alternative. However, the long-term outcomes of such treatment have not been studied thoroughly enough. This prospective case-control study evaluated angiographic and clinical outcomes of PTCA alone and a combination of excimer laser coronary angioplasty (ELCA) and adjunct PTCA in 125 patients with ISR. ELCA was performed before balloon dilation in 67 patients, PTCA alone was performed in 58 patients. Basic demographic and clinical data were comparable in both groups. Lesions included in ELCA group were longer (17.1 ±9.9 vs 13.6 ±9.1 mm; p=0.034), more complex (36.5% type C stenoses vs 14.3%; p=0.006), and more frequently had reduced distal blood flow (TIMI <3: 18.9% vs 4.8%; p=0.025) compared to lesions in the PTCA group. Immediate angiographic results of PTCA and ELCA + PTCA appeared to be comparable. PTCA alone was successful in 57 patients (98.3%), ELCA + PTCA, in 66 patients (98.5%). The rates of hospital complications were comparable (3.0% in ELCA group vs 8.6% in PTCA group). The 1-year follow-up showed that the rates of major adverse cardiac events (MACE) were comparable in the 2 groups (37.3% in ELCA group vs 46.6% in PTCA group). The rates of target vessel revascularization (TVR) within 1 year after the intervention were also similar in the 2 groups (32.8% vs 34.5%). The data mean that ELCA in patients with complex ISR is efficient and safe. Despite a higher complexity of lesions in the ELCA group, no increase in the rate of complications was registered.

Antiplatelet Effect of Sequential Administration of Cilostazol in Patients with Acetylsalycilic Acid Resistance

BACKGROUND

Acetylsalicylic acid (ASA) resistance in patients with coronary artery disease is an important medical problem that can affect treatment decision-making and outcomes. Cilostazol has been investigated to determine its effectiveness in patients with acetylsalicylic acid resistance. The aim of this study was to evaluate the antiplatelet efficacy of sequential administration of CLZ in patients with ASA resistance.

METHODS

A total of 180 patients were enrolled in our study. Patients with stable coronary artery disease were first given orally ASA 100 for 10 days, followed by collagen/epinephrine induced closure time (CTCEPI) measurements. Those who were found to be resistant to orally 100 mg of ASA were given orally 300 mg of ASA for an additional 10 days after which we repeated CTCEPI measurements. Those patients with resistance to orally 300 mg ASA were then given CLZ at a daily dose of orally 200 mg for 10 days followed by a final CTCEPI measurement.

RESULTS

The rate of resistance to 100 mg ASA was 81/180 (45%) compared to a rate of 35/81 (43.2%) with 300 mg ASA. Of the 35 patients found to be resistant to 300 mg ASA, 22 (62.9%) also failed to respond to CLZ treatment. Overall, sequential administration of 300 mg ASA and 200 mg CLZ resulted in a reduction in the number of non-responders from 45% to 12.2%.

CONCLUSIONS

Initiation of CLZ could be of benefit in some patients with ASA-resistance for whom an effective anti-aggregant effect is of clinical importance.

The Investigation of a Disintegrin and Metalloproteinase with ThromboSpondin Motifs (ADAMTS) 1, 5 and 16 in Thoracic Aortic Aneurysms and Dissections

BACKGROUND

Disintegrin-like and Metalloproteinase with Thrombospondin Motifs (ADAMTS) proteins that are fundamentally located in the extracellular matrix (ECM) have critical roles on different cellular processes by altering the ECM architecture. It has been known that expression of some members of these proteinases increases in aneurismal and dissectional aortic tissue. The purpose of this study is to investigate ADAMTS1, 5, 16 and tissue inhibitors of metalloproteinases-1, -2 (TIMP-1, -2) levels in aortic tissue obtained from patients with thoracic aortic aneurysms and dissections and to achieve new insights about the function of ADAMTS family members.

METHODS

We investigated ADAMTS1, 5, and 16 expression in human thoracic aortic aneurysms (TAA) (n = 22), thoracic aortic dissections (TAD) (n = 12), and thoracic aortas from age-matched control organ donors (n = 6) (a total number of 34 cases and 6 controls). The expression levels of ADAMTS proteins were determined by Western blot technique using anti-ADAMTS1, ADAMTS5, ADAMTS16, TIMP-1 and TIMP-2 antibodies.

RESULTS

ADAMTS1, 5, and 16 protein expressions were significantly higher in thoracic aortic aneurysm and dissection tissues compared to control aortic tissues. Furthermore, TIMP-1 protein levels decreased in TAA and TAD tissues, TIMP-2 did not change.

CONCLUSIONS

Under the light of our findings, increased expression of ADAMTS1, 5, and 16 proteins may promote deceleration in thoracic aortic aneurysm progression. This is the first study that demonstrates ADAMTS5 and ADAMTS16 proteolytic activity in aneurysm and dissection.

Galectin-3 as a new biomarker of diastolic dysfunction in hemodialysis patients

BACKGROUND

Galectin-3 (gal-3) is an emerging prognostic biomarker in heart failure (HF). Clinical and experimental studies suggest that gal-3 is an important mediator of HF. Here we aimed to examine the relationship between gal-3 and diastolic dysfunction in patients undergoing maintenance hemodialysis (HD).

METHODS

We examined the relationship between plasma gal-3 levels and left ventricular diastolic function. Plasma gal-3 was measured in 87 subjects with chronic HD and in 45 healthy controls using biochemical evaluations. Conventional echocardiography and pulsed tissue Doppler assessment were performed in all patients. Left ventricular diastolic dysfunction (LVDD) was defined as E' < 8 cm/s. The E/E' ratio was used as the main determinant of LVDD grade.

RESULTS

The mean gal-3 concentrations were: 16.05 ng/ml (13.89-19.75) in healthy controls; 14.54 ng/ml (10.85-17.65) in HD patients with normal diastolic function; and 23.30 ng/ml (20.12-26.87) in HD patients with LVDD (p  < 0.01). Plasma gal-3 levels correlated with E/E' (r = 0.933, p  < 0.01), left atrial volume index (r = 0.713, p  < 0.01), and E' (r = -0.685, p  < 0.01). ROC analysis showed that the best gal-3 cut-off point for the diagnosis of LVDD was 20.12 ng/ml with a sensitivity of 67.6 % and specificity of 84.6 % (AUC = 0.803).

CONCLUSION

We suggest that gal-3 may be a promising biomarker for the detection of LVDD in HD patients.

Association between Red Blood Cell Distribution Width and Coronary Artery Calcification in Patients Undergoing 64-Multidetector Computed Tomography

Background and Objectives

The red blood cell distribution width (RDW) has been found to be associated with cardiovascular morbidity and mortality. The objective of this study was to determine whether the RDW measures are associated with the coronary artery calcification score (CACS) in patients who did not present with obvious coronary heart disease (CHD).

Subjects and Methods

A total of 527 consecutive patients with a low to intermediate risk for CHD but without obvious disease were enrolled in this study. The study subjects underwent coronary computerized tomography angiography and CACS was calculated. The patients were divided into two groups based on CACS: Group I (CACS≤100) and Group II (CACS>100). The two groups were compared in terms of classic CHD risk factors and haematological parameters, particularly the RDW.

Results

Group I patients were younger than Group II patients. The Framingham risk score (FRS) in patients of Group II was significantly higher than that in patients of Group I. Group II patients had significantly elevated levels of haemoglobin, RDW, neutrophil count, and neutrophil/lymphocyte ratio compared with Group I patients. CACS was correlated with age, RDW, and ejection fraction. In the multivariate analysis, age, RDW, and FRS were independent predictors of CACS. Using the receiver-operating characteristic curve analysis, a RDW value of 13.05% was identified as the best cut-off for predicting the severity of CACS (>100) (area under the curve=0.706).

Conclusion

We found that the RDW is an independent predictor of the CACS, suggesting that it might be a useful marker for predicting CAD.

Association between Platelet-to-Lymphocyte Ratio and Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

OBJECTIVE

Contrast-induced nephropathy (CIN) is associated with significantly increased morbidity and mortality after percutaneous coronary intervention (PCI). Patients with acute coronary syndrome (ACS) are at higher risk of CIN. The platelet-to-lymphocyte ratio (PLR) is closely linked to inflammatory conditions. We hypothesized that PLR levels on admission can predict the development of CIN after PCI for ACS.

SUBJECTS AND METHODS

A total of 426 patients (mean age 63.17 ± 13.01 years, 61.2% males) with ACS undergoing PCI were enrolled in this study. Admission PLR levels were measured before PCI. Serum creatinine values were measured before and within 72 h after the administration of contrast agents. Patients were divided into 2 groups: the CIN group and the no-CIN group. CIN was defined as an increase in serum creatinine level of ≥0.5 mg/dl or 25% above baseline within 72 h after contrast administration.

RESULTS

CIN developed in 53 patients (15.9%). Baseline PLR was significantly higher in patients who developed CIN compared to those who did not (160.8 ± 29.7 and 135.1 ± 26.1, respectively; p < 0.001). Multivariate analyses found that PLR [odds ratio (OR) 3.453, 95% confidence interval (CI) 1.453-8.543; p = 0.004] and admission creatinine (OR 6.511, 95% CI 1.759-11.095; p = 0.002) were independent predictors of CIN.

CONCLUSIONS

The admission PLR level is an independent predictor of the development of CIN after PCI in ACS.

Adropin: A New Marker for Predicting Late Saphenous Vein Graft Disease after Coronary Artery Bypass Grafting

Purpose: Saphenous vein graft disease (SVGD), defined as an occlusion of 50% or more of the SVG excluding distal anastomotic occlusion, is an important predictor of morbidity after coronary artery bypass grafting (CABG). Late graft occlusion is a serious complication that often limits the use of the saphenous vein as a coronary bypass graft. Late graft occlusion is particularly common in old, degenerated venous grafts with advanced atherosclerotic plaques. Adropin has been implicated in the homeostatic control of metabolism. The purpose of this study was to investigate whether serum adropin levels are associated with late SVGD following CABG. Methods: Thirty-eight patients with SVGD involving at least one graft (occluded group; 14 females, 24 males) and 42 patients with a patent saphenous vein graft (patent group; 15 females, 27 males) were enrolled in this study. Venous blood samples were taken from all of the participants to measure plasma adropin levels using an enzyme-linked immunsorbent assay kit. Results: The mean adropin level was significantly lower in the occluded group than in the patent group (3.2 ± 0.71 vs. 4.9 ± 1.51 ng/mL, p < 0.001). Multivariate regression analysis showed that the adropin level was the independent predictor of late saphenous vein graft occlusion. Conclusions: Adropin levels are lower in patients with late saphenous vein graft occlusion and these reduced adropin levels, together with other factors, may lead to saphenous vein graft occlusion. Larger and prospective studies are needed to determine if adropin plays a role in the pathogenesis of SVGD.

Angiographic characteristics of coronary artery fistulas

OBJECTIVES

Coronary artery fistula (CAF) in adults is a rare form of coronary artery anomaly. It is often diagnosed incidentally during coronary angiography. The aim of this study was to evaluate the clinical and angiographic characteristics of adult patients with CAF.

STUDY DESIGN

We retrospectively reviewed the database of 70,850 patients who had undergone coronary angiography in five different invasive cardiology centers in the southeastern region of Turkey. Among them, 56 patients had CAF (39 males, 17 females, mean age: 63.7±10.4 years). Demographic data, clinical evaluation and cardiac catheterization reports were reviewed from the medical records.

RESULTS

A total of 58 fistulas were detected in 56 patients; two patients (3.6%) had bilateral fistulas originating from both the left and right coronary artery. In our angiographic series, CAF prevalence was 0.08%. Dyspnea on exertion and/or angina pectoris was the most common symptom (69%). Fifteen patients (26.8%) had concomitant obstructive coronary artery disease. Coronary artery fistulas originated mainly from the left anterior descending artery (n=30, 51.7%). Others originated from the right coronary artery (n=15, 25.9%), circumflex artery (n=6, 10.3%), and right sinus of Valsalva (n=3, 5.2%). In four patients (n=4, 7.1%), multiple micro fistula were draining into the left ventricle.

CONCLUSION

In our angiographic series, the prevalence of CAF was 0.08%, and the most common site of origin was the left anterior descending artery.

Coronary intervention for acute coronary syndrome in a 51-year-old man with immune thrombocytopenic purpura: a case report

Introduction

Treatment of the rare cases of patients with chronic idiopathic thrombocytopenic purpura with acute coronary syndrome can be a significant problem. The patient in our case report was treated successfully with percutaneous coronary intervention.

Case presentation

A 51-year-old man of Turkish origin who had idiopathic thrombocytopenic purpura was admitted to our hospital with severe chest pain. His electrocardiography was normal on admission but dynamic ischemic changes were observed during follow-up. He underwent immediate coronary angiography. In his angiography, left anterior descending artery stenosis was 90% together with the diagonal ostium. Percutaneous coronary intervention was performed successfully. Bleeding complications were not observed after the procedure.

Conclusions

We report the presence of a rare case of chronic idiopathic thrombocytopenic purpura in a patient with acute coronary syndrome. In this situation a serious multidisciplinary approach is required before coronary intervention.

Epicardial adipose tissue and pericoronary fat thickness measured with 64-multidetector computed tomography: potential predictors of the severity of coronary artery disease

OBJECTIVE

The aim of the present study was to investigate the relationship between pericoronary fat and the severity and extent of atherosclerosis, quantified using 64-multidetector computed tomography, in patients with suspected coronary artery disease.

METHODS

The study population consisted of 131 patients who were clinically referred for noninvasive multislice computed tomography coronary angiography for the evaluation of coronary artery disease. Patients were classified as follows: no atherosclerosis, Group 1; nonobstructive atherosclerosis (luminal narrowing <50% in diameter), Group 2; and obstructive atherosclerosis (luminal narrowing ≥ 50%) in a single vessel or obstructive atherosclerosis in the left main coronary artery and/or multiple vessels, Group 3. Epicardial adipose tissue was defined as the adipose tissue between the surface of the heart and the visceral layer of the pericardium (visceral epicardium). Epicardial adipose tissue thickness (mm) was determined in the right ventricular anterior free wall. The mean thickness of the pericoronary fat surrounding the three coronary arteries was used for the analyses.

RESULTS

The average thickness over all three regions was 13.2 ± 2.1 mm. The pericoronary fat thickness was significantly increased in Group 3 compared with Groups 2 and 1. The epicardial adipose tissue thickness was significantly increased in Group 3 compared with Groups 2 and 1. A receiver operating characteristic curve for obstructive coronary artery disease was assessed to verify the optimum cut-off point for pericoronary fat thickness, which was 13.8 mm. A receiver operating characteristic curve for obstructive coronary artery disease was also assessed to verify the optimum cut-off point for epicardial adipose tissue, which was 6.8 cm.

CONCLUSION

We showed that the epicardial adipose tissue and pericoronary fat thickness scores were higher in patients with obstructive coronary artery diseases.

Sudden unilateral vision loss arising from calcified amorphous tumor of the left ventricle

Calcified amorphous tumor of the heart is a very rare non-neoplastic intracavitary mass. The clinical presentation is similar to that of other cardiac masses. The precise cause and best approach to treatment remain unclear. We describe a case of cardiac calcified amorphous tumor presenting with refractory unilateral vision loss that was successfully treated by surgical excision. To our knowledge, this is only the 2nd reported case of retinal arterial embolism due to cardiac calcified amorphous tumor in the English-language literature.

Serum uric acid level is an independent risk factor for presence of calcium in coronary arteries: an observational case-controlled study

OBJECTIVE

A link between uric acid levels and cardiovascular diseases has been previously reported. Coronary artery calcium score (CACS) is a marker of atherosclerotic disease and a predictor of cardiovascular events. We sought to determine if serum uric acid level is an independent risk factor for the presence of calcium in coronary arteries.

METHODS

Four hundred and forty-two patients who were evaluated in the cardiology outpatient clinic for suspected coronary heart disease with a low-moderate risk for coronary artery disease were included in this observational case-controlled study. Serum uric acid levels were measured with colorimetric methods. CACS were performed using a 64-slice CT scanner. Patients were divided to 3 groups according to their CACS value (Group 1: CACS=0, Group 2: CACS 1-100, Group 3: CACS>100).

RESULTS

The demographical characteristics and laboratory findings of 3 groups were similar, except age, fasting glucose levels and serum uric acid levels. Serum uric acid levels were found to increase significantly with increasing CACS (p=0.001). Patients were grouped according to presence CAC (CACS=0 and CACS≥1) and in the multiple regression analysis, age (OR, 1.11, 95% CI, 1.07-1.16), smoking (OR, 3.83, 95% CI, 2.06-7.09), serum uric acid levels (OR, 1.26, 95% CI, 1.04-1.54) and average 10-year total risk of Framingham risk score (OR, 1.13, 95% CI, 1.04-1.09) appeared as independent factors predictive of presence of CAC (p<0.05).

CONCLUSION

Serum uric acid level is an independent risk factor for presence of coronary calcium. Moreover, increasing levels of serum uric acid are associated with increasing CACS.

[Two cases of acute coronary syndrome after intake of Clavis Panax]

Atherosclerotic cardiovascular disease is an epidemic in today's world. It is one of the most common causes of hospitalization and death. Therefore, remedies to control or heal the disease are continuously sought. In addition to scientifically researched therapies, patients frequently utilize alternative medicine. However, effective and toxic doses, metabolisms, and drug interactions of the herbs and herbal nutrition supplements are largely unknown. Herein, we present two cases with acute coronary syndrome. The first case was admitted with a diagnosis of acute inferior myocardial infaction (MI) and a stent was implanted to the occluded right coronary artery (RCA). There was a 50% stenosis in his left anterior descending artery (LAD). He was admitted with a diagnosis of non-ST elevation MI (NSTEMI) 6 months later. In the coronary angiogram, there was stent restenosis in RCA, the lesion in LAD had become thrombotic and progressed to a stenosis of 90%. He was referred to surgical revascularization. The second case was admitted for acute inferior MI and a stent was implanted to the occluded circumflex artery. Two months later, he was hospitalized for NSTEMI. Progression of coronary plaques to stenosis and stent restenosis was detected and he was referred to surgical revascularization. Both patients used the product sold as Clavis Panax, which contains panax ginseng, tribulus terrestris, and oat, after their first coronary intervention. Intake of a mixture of plant extracts may have serious consequences in humans as drug interactions and side effects are unknown.

Association between gamma-glutamyltransferase and coronary artery calcification

BACKGROUND

The exact mechanisms behind the association between atherosclerosis and gamma-glutamyltransferase (GGT) are unclear. Coronary artery calcification (CAC) detected by computerized tomography is an important marker of atherosclerosis and its severity correlates with coronary plaque burden. The aim of this study was to investigate if serum GGT levels are associated with CAC in patients without known coronary heart disease (CHD) who had low-intermediate risk for CHD.

METHODS

Two hundred and seventy two patients who had low-intermediate risk for coronary artery disease were included in the study. Serum GGT levels were measured spectrophotometrically. CACS (Agatston method) were performed using a 64-slice computerized tomography scanner. The patients were grouped according to their GGT values in four quartiles.

RESULTS

Patients in higher GGT quartiles had elevated CAC score (P<0.001). Patients in higher GGT quartiles were predominantly males (P<0.001) and were more likely to be smoking (P=0.004), and have elevated uric acid (P<0.001), fasting blood glucose (P<0.001), CRP levels (P=0.003) and 10-year total cardiovascular risk (P=0.007) and low HDL levels (P<0.001). Positive correlations were found between log GGT and CAC (r=0.233, P<0.001). In the multivariate analysis GGT, age, smoking and serum uric acid levels appeared as independent factors predictive of presence of CAC.

CONCLUSIONS

We demonstrated a significant correlation between serum GGT levels and CAC and CHD risk factors. Serum GGT level was an independent marker of CAC.

Association of serum calcitonin with coronary artery disease in individuals with and without chronic kidney disease

BACKGROUND

Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). Recent data implicate disordered bone and mineral metabolism, including changes in serum levels of calcium, phosphate, parathyroid hormone (PTH), vitamin D, fibroblast growth factor-23 (FGF-23), and fetuin A, as novel risk factors for arterial calcification. The potential role of calcitonin, another hormonal regulator of mineral and bone metabolism, has not been studied in detail.

MATERIALS AND METHODS

We investigated the link between serum calcitonin and the total burden of coronary artery disease (CAD) using the validated Gensini score, in a cross-sectional study of 88 patients with estimated GFR (eGFR) between 46 and 87 ml/min/1.73 m² who underwent coronary angiography. We evaluated the associations between serum calcitonin, minerals (calcium, phosphate), calcium × phosphate product, and other factors that regulate mineral metabolism (intact PTH, 25-OH-vitamin D, FGF-23, and fetuin A) and the severity of CAD.

RESULTS

The mean serum calcitonin was 11.5 ± 7.8 pg/ml. In univariate analysis, the Gensini CAD severity score correlated significantly with male gender, eGFR, and serum levels of 25-OH-vitamin D, iPTH, FGF-23, fetuin A, and calcitonin (R = 0.474, P = 0.001 for the latter). In multivariate analysis adjusted for calcium, phosphate, 25-OH-vitamin D, iPTH, FGF 23, fetuin A, and calcitonin, only calcitonin (β = 0.20; P = 0.03), FGF-23, fetuin A, and 25-OH-vitamin D emerged as independent predictors of Gensini score. In the second step, we adjusted for the presence of traditional risk factors, proteinuria, and GFR. After these adjustments, the FGF-23 and fetuin A remained statistically significant predictors of the Gensini score, while calcitonin did not.

CONCLUSIONS

Our study suggests that, in addition to other well-known components of mineral metabolism, increased calcitonin levels are associated with greater severity of CAD. However, this relation was not independent of traditional and nontraditional cardiovascular risk factors. Longitudinal studies in larger populations including patients with more advanced CKD are needed.

[Frequency of sublingual nitroglycerin prescription in patients with coronary artery disease and angina and awareness of patients about the shelf life of the drug]

OBJECTIVES

ACC/AHA/ESC guidelines recommend sublingual nitroglycerin (SNG) in patients with stable angina pectoris and coronary artery disease (CAD). However, the shelf life of SNG following first use is six months for SNG tablets and two years for SNG sprays. We investigated the frequency of prescription of SNG tablets/sprays in patients having anginal symptoms and documented CAD and the awareness levels of patients about appropriate use of SNG.

STUDY DESIGN

Three hundred patients (201 men, 99 women; mean age 61.7±10.8 years) with documented CAD and angina were enrolled into this study. Angina pectoris was categorized according to the functional classification system of the Canadian Cardiovascular Society. Data on cardiovascular past histories, risk factors, medications, and the use of SNG were recorded.

RESULTS

At least one risk factor was present in 96% of the patients. Only 46% of the patients had a prescription for SNG. Of those with a prescription of SNG tablet and spray, 91.8% and 84.4% did not know the shelf life of the product, respectively. Of those who were routinely carrying SNG, 35.6% had an expired product. Of those with a prescription of SNG, only 65.9% were informed by the physician on the proper use of SNG.

CONCLUSION

Our results show that, despite recommendations of the guidelines, SNG is not prescribed to a substantial percentage of patients with CAD and angina, a considerable fraction of patients carry an expired product, and that patients are not adequately informed by the physicians on the use of SNG. These problems will certainly affect the optimal medical management of CAD and its efficacy.

Impaired heart rate variability as a marker of cardiovascular autonomic dysfunction in multiple sclerosis

Multiple sclerosis (MS) can cause alterations in autonomic cardiovascular functions. We aimed to investigate the correlation of disease activity and disability with heart rate variability (HRV) of cardiovascular autonomic dysfunction (CAD) demonstrated by 24-h Holter monitorization. Thirty-four patients with clinically active relapsing-remitting MS, age 33.8 +/- 7.6 years, were studied. Twenty healthy volunteers served as controls. The time domain long-term HRV parameters were recorded by a digicorder recorder calculated by ambulatory electrocardiograms. Variabilities in time domain were lower in the MS patients: SDNN (standard deviation of all R-R intervals, p = 0,019), SDANN (standard deviation of the averages of R-R intervals in all 5-minute segments of the entire recordings, p = 0,040), RMSSD (the square root of the mean of the sum of the squares of differences between adjacent R-R intervals, p = 0,026), HRVM (mean of the SDNN in all the 5-minute intervals, p = 0,029), HRVSD (standard deviation of the SDNN in all the 5-minute, p = 0,043). These results suggest that MS causes CAD manifesting as long-term HRV abnormalities. This illness seems to cause a dysfunction in parasympathetic cardiovascular tone. Depressed HRV parameters are independent from the clinicalfindings, but the illness progression partially seems to provoke a decrease in such parameters.

Uric acid and pentraxin-3 levels are independently associated with coronary artery disease risk in patients with stage 2 and 3 kidney disease

BACKGROUND AND OBJECTIVES

Cardiovascular disease is prevalent in chronic kidney disease (CKD). Uric acid is increased in subjects with CKD and has been linked with cardiovascular mortality in this population. However, no study has evaluated the relationship of uric acid with angiographically proven coronary artery disease (CAD) in this population. We therefore investigated the link between serum uric acid (SUA) levels and (i) extent of CAD assessed by the Gensini score and (ii) inflammatory parameters, including C-reactive protein (CRP) and pentraxin-3, in patients with mild-to-moderate CKD.

MATERIAL AND METHODS

In an unselected population of 130 patients with estimated glomerular filtration rate (eGFR) between 90 and 30 ml/min/1.73 m(2), we measured SUA, serum pentraxin-3, CRP, urinary protein-to-creatinine ratio, lipid parameters and the severity of CAD as assessed by coronary angiography and quantified by the Gensini lesion severity score.

RESULTS

The mean serum values for SUA, pentraxin-3 and CRP in the entire study population were 5.5 ± 1.5 mg/dl, 6.4 ± 3.4 ng/ml and 3.5 ± 2.6 mg/dl, respectively. The Gensini scores significantly correlated in univariate analysis with gender (R = -0.379, p = 0.02), uric acid (R = 0.42, p = 0.001), pentraxin-3 (R = 0.54, p = 0.001), CRP (R = 0.29, p = 0.006) levels, eGFR (R = -0.33, p = 0.02), proteinuria (R = 0.21, p = 0.01), and presence of hypertension (R = 0.37, p = 0.001), but not with smoking status, diabetes mellitus, and lipid parameters. After adjustments for traditional cardiovascular risk factors, only uric acid (R = 0.21, p = 0.02) and pentraxin-3 (R = 0.28, p = 0.01) remained significant predictors of the Gensini score.

CONCLUSIONS

SUA and pentraxin-3 levels are independent determinants of severity of CAD in patients with mild-to-moderate CKD. We recommend a clinical trial to determine whether lowering uric acid could prevent progression of CAD in patients with CKD.

Cardiac flow parameters with conventional and pulsed tissue Doppler echocardiography imaging in patients with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is independently associated with the major cardiovascular risk factors. The aim of this study was to examine the echocardiographic profiles of patients with PCOS using conventional echocardiographic methods and tissue Doppler imaging.

METHODS

For this study, we have registered 48 women with PCOS and 21 healthy control subjects who were matched with respect to age and body mass index. Standard two-dimensional and M-mode measurement, transmitral valve flows and tissue Doppler imaging of mitral and tricuspid anulus were recorded.

RESULTS

In PCOS and control groups, left ventricular and atrium diameters, ejection fraction, mitral E/A ratio, deceleration time and isovolumic relaxation time were similar. There were no significant differences between patients with PCOS and control subjects with respect to tissue Doppler profiles.

CONCLUSION

Patients with PCOS execute echocardiographic measures of cardiac function that are similar to those of healthy women.

Fibroblast growth factor 23 and fetuin A are independent predictors for the coronary artery disease extent in mild chronic kidney disease

BACKGROUND AND OBJECTIVES

Cardiovascular disease in chronic kidney disease (CKD) is explained in part by traditional cardiovascular risk factors; by uremia-specific factors; and by abnormalities of mineral metabolism, factors involved in its regulation, and in the vascular calcification process.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In an unselected population of 177 patients with calculated GFR (eGFR) between 90 and 30 ml/min per 1.73 m(2), the link between the mineral metabolism abnormalities (calcium, phosphorus, calcium-phosphorus product), regulatory factors (parathyroid hormone [PTH], intact PTH [iPTH], vitamin D, fibroblast growth factor 23 [FGF 23], and fetuin A), and the severity of coronary artery disease (CAD) assessed by coronary angiography were evaluated in three subgroups defined by tertiles of Gensini lesion severity score.

RESULTS

The mean serum values for FGF 23 in the entire study population was 28.1 ± 17.3 RU/ml and for fetuin A was 473.1 ± 156.2 μg/ml. Patients with eGFR < 60 ml/min per 1.73 m(2) had significantly higher values of FGF 23 compared with patients with eGFR > 60 ml/min per 1.73 m(2). The Gensini score values significantly correlated with gender; arterial hypertension; and HDL cholesterol, eGFR, iPTH, FGF 23, and fetuin A levels. After the adjustments for traditional and uremia-related cardiovascular risk factors, the FGF 23 and fetuin A remained significant predictors of the Gensini score.

CONCLUSIONS

This study suggests that in a relatively young population with mild-to-moderate alteration of kidney function and with less traditional cardiovascular risk factors, anomalies of the serum FGF 23 and fetuin A levels appear early in the course of disease and are independent major predictors for extent of CAD.

Heart rate variability in patients with iron deficiency anemia

BACKGROUND

Heart rate variability (HRV) is associated with increased cardiac risk factor in several conditions. The iron status of an individual may play an important role in cardiovascular health.

OBJECTIVE

To evaluate heart rate variability in patients with iron deficiency anemia.

METHODS

Twenty-three patients with iron deficiency anemia (mean hemoglobin (Hb) 8.6+/-2.2 g/dl) and 10 healthy people (mean Hb 13.9+/-1.2 g/dl) were assessed with 24-hour ambulatory Holter recordings during in hospital course having limited physical activity.

RESULTS

Although mean heart rate was significantly higher in patients with anemia, there was no significant difference regarding HRV parameters compared to the healthy group.

CONCLUSION

There was no significant difference in HRV parameters between patients with iron deficiency anemia with limited physical activity and healthy ambulatory people.

Diagnostic accuracy of 64-slice computed tomography in patients with suspected or proven coronary artery disease

OBJECTIVES

Multislice computed tomography (MSCT) is a promising noninvasive method of detecting coronary artery disease. However, most data have been obtained in selected series of patients. The purpose of this study was to investigate the accuracy of 64-slice CT in consecutive patients with suspected or proven coronary artery disease.

STUDY DESIGN

Seventy-three consecutive patients (57 males, 16 females; mean age 59+/-9 years; range 33 to 83 years) were examined by 64-slice CT before coronary angiography (CA). Eight patients had a history of percutaneous coronary intervention and stenting and five patients had a history of coronary artery bypass grafting. Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of MSCT for the detection of significant stenosis were calculated on a segmental, vessel, and patient basis.

RESULTS

Sixty-one patients were diagnosed as having at least one significant stenosis with CA. Of these, MSCT identified 58 patients correctly. Two patients were incorrectly diagnosed as having one-vessel disease by MSCT. Patient-based sensitivity, specificity, NPV, and PPV of MSCT were 95.1%, 83.3%, 76.9%, and 96.7%, respectively. Of 1065 segments evaluated, CA detected 141 significant stenoses. On MSCT, significant stenoses were correctly diagnosed in 116 segments. Twenty-four nonsignificant lesions were overestimated by MSCT. In segment-based analysis, the overall sensitivity was 82.3%, specificity was 97.4%, NPV was 97.3%, and PPV was 82.9%. The accuracy of MSCT was in full agreement with CA in the evaluation of stent and graft patency.

CONCLUSION

Our findings show that 64-slice CT is highly accurate for the detection of significant coronary artery disease in an unselected patient population and can be used as a noninvasive technique.

Acute rupture of a congenital sinus of Valsalva aneurysm after severe exercise

Ruptured aneurysms of the sinus of Valsalva may cause manifestations of prompt onset. A 22-year-old man with no previous cardiac complaints presented with dyspnea, palpitation, fatigue, and shortness of breath, all of which occurred after a football match. Transthoracic echocardiography showed an aneurysmal dilatation of the right sinus of Valsalva to the direction of the right ventricle. Color Doppler imaging showed a marked left-to-right turbulent flow from the aortic root to the right ventricle. Continuous Doppler imaging also revealed a continuous left-to-right systolodiastolic shunting. The patient was submitted to cardiovascular surgery for surgical repair.

Isolated single coronary artery: a series of 10 cases

BACKGROUND

Isolated single coronary artery (SCA) is an extremely rare congenital coronary anomaly. Some subgroups of SCA can lead to angina pectoris, acute myocardial infarction or even sudden death in the absence of atherosclerosis. Young patients, especially, have the risk of serious clinical events, but middle-aged-to elderly patients have a variable clinical course.

METHODS AND RESULTS

The aim of this study was to present the clinical and angiographic properties, relatively long-term follow-up (54+/-14 months) and management of adult patients (mean age 57+/-12 years) with SCA. The records of 70,850 patients undergoing coronary angiography between 1999 and 2005 were reviewed. Ten patients (0.024%) were found to have SCA, originating from the left sinus of Valsalva in 3 (30%) patients and from the right sinus of Valsalva in 7 patients (70%). No atherosclerotic involvement was seen in 7 (70%) patients. One patient was also treated by stent implantation to the SCA. Other patients were followed medically. All patients have been followed uneventfully.

CONCLUSION

Medical treatment is usually adequate for middle-aged to elderly patients with SCA in the absence of ischemia and/or acute coronary syndrome.