Diagnosis and Treatment Patterns of Chronic Thromboembolic Pulmonary Hypertension in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia: A Registry Study

BACKGROUND

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) in countries with limited resources have, to date, been poorly represented in registries.

OBJECTIVE

This work assesses the epidemiology, diagnosis, hemodynamic and functional parameters, and treatment of CTEPH in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia.

METHODS

A prospective, cohort, phase IV, observational registry with 3-year follow-up (n = 212) in patients aged ≥ 18 years diagnosed with CTEPH was created. Clinical, hemodynamic, and functional parameters were obtained at an initial visit, follow-up visits, and a final visit at the end of 3 years' observation or end of follow-up. Data were recorded on electronic case report forms. Parameters evaluated included 6-minute walking distance (6MWD), use of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), pulmonary hypertension (PH)-targeted therapy, and survival. All statistical analyses were exploratory and descriptive, and were performed in the overall population.

RESULTS

The most common symptoms were typical of those expected for CTEPH. Almost 90% of patients underwent right heart catheterization at diagnosis or initial study visit. In total, 66 patients (31%) underwent PEA before the initial visit; 95 patients (45%) were considered operable, 115 (54%) were inoperable, and two (1%) had no operability data. Only 26 patients (12%) had been assessed for BPA at their initial visit. PH-targeted therapy was documented at diagnosis for 77 patients (36%), most commonly a phosphodiesterase type 5 inhibitor (23%). Use of PH-targeted therapy increased to 142 patients (67%) at the initial visit, remaining similar after 3 years. Use of riociguat increased from 6% of patients at diagnosis to 38% at 3 years. Between baseline and end of observation, results for patients with paired data showed an increase in 6MWD. Survival at the end of observation was 88%.

CONCLUSIONS

These data highlight the current diagnosis and management of CTEPH in the participating countries. They show that early CTEPH diagnosis remains challenging, and use of off-label PH-targeted therapy is common.

CLINICALTRIALS

gov: NCT02637050; registered December 2015.

Could Impedance Cardiography be a Non-Invasive Alternative Method of Measuring Cardiac Output in Patients with Pulmonary Hypertension?

BACKGROUND

Pulmonary hypertension guidelines recommend invasive right heart catheterization for diagnosis and clinical follow-up. Our aim was to compare non-invasive impedance cardiography with invasive techniques for cardiac index measurements and mortality prediction in patients with pulmonary hypertension.

METHODS

Between 2008 and 2018, 284 right heart catheterizations were performed for the diagnosis of pulmonary hypertension in 215 patients with mean pulmonary artery pressure >25 mm Hg, and at least 2 methods used for cardiac output measurement were included in the study retrospectively. Patients were evaluated with Pearson's correlation in 3 groups: estimated Fick (eFick) method and thermodilution (group 1), eFick method and impedance cardiography (group 2), and thermodilution and impedance cardiography (group 3). We also compared the predictive power of cardiac index measured by different methods for 1-year overall mortality and hospitalizations.

RESULTS

There were strong and moderate positive correlations in groups 1 and 3, respectively (r = 0.634, P <.001, r = 0.534, P =.001), and the weakest correlation was in group 2 (r = 0.390, P =.001). The mean difference (bias) between eFick method versus impedance cardiography, impedance cardiography vs. thermodilution, and eFick method vs. thermodilution was 0.6 mL/min, 0.47 mL/min, and -0.2 mL/min respectively, but limits of agreement were wide. In both groups, cardiac index <2.5 L/min/m2 as measured by thermodilution significantly predicted 1-year mortality. Also, impedance cardiography was better than eFick method in predicting mortality (P =.02).

CONCLUSIONS

Our single-center real-life data showed that for cardiac output and cardiac index measurements, impedance cardiography provides a moderate correlation with thermodilution and is fair with eFick method methods. Moreover, thermodilution appeared superior to both eFick method and impedance cardiography, while impedance cardiography was even better than eFick method in predicting 1-year adverse events, including total mortality and hospitalization, in patients with pulmonary hypertension.

Could Heart Rate Variability Serve as a Prognostic Factor in Patients with Pulmonary Hypertension? A Single-center Pilot Study

OBJECTIVE

Heart rate variability (HRV), which is defined as cyclic changes in sinus rate with time, is used as a measure of cardiac autonomic tone. Our aim was to determine the impact of HRV on short-term prognosis in pulmonary hypertension (PH).

METHODS

We enrolled 64 PH patients and 69 healthy subjects (control group). Patients were evaluated by Holter-ECG, echocardiography, and laboratory tests. 24-h Holter-ECG monitoring was used for HRV. The development of adverse events (right heart failure, hospitalization, syncope, and death) during the 6-month follow-up was evaluated in PH group.

RESULTS

PH group (39 ± 16 years, 37.5% males) comprised of 16 patients with idiopathic pulmonary arterial hypertension (PAH) (25%), 36 patients with PAH associated with congenital heart disease (56.3%), 3 PAH associated with connective tissue disease (4.7%), 1 with portopulmonary (1.6%), and 8 chronic thromboembolic PH (12.5%). The time-dependent (standard deviation of all NN intervals for a selected time period [SDNN], standard deviation of the 5-min mean R-R intervals tabulated over an entire day [SDANN], SDNN Index, and Triangular Index) and frequency-dependent HRV indices (low frequency, high-frequency power, and total power,) were significantly reduced in those with PH. Functional class was negatively associated with SDNN, SDANN, SDNN Index, and Triangular Index. Adverse events developed in 25% of the patients during the 6-month follow-up period (200 ± 92 days) (7 patients had right-heart failure, 5 syncope, 12 patients were hospitalized, and 9 had died). All the time and frequency-dependent indices significantly associated with adverse events. Mortality correlated with SDNN (rS = -0.354, P = 0.005), SDANN (rS = -0.368, P = 0.004), SDNN Index (rS = -0.257, P = 0.045), Triangular Index (rS = -0.310, P = 0.014), and VLF (rS = -0.265, P = 0.039).

CONCLUSION

HRV is significantly depressed in patients with PH and is associated with the clinical status. HRV indices might predict clinical deterioration, adverse events, and mortality for 6 months. Non-invasive assessment of HRV through Holter-ECG may be a valuable and practical tool in risk stratification of patients with PH for short-term outcomes.

Long-Term Natural Course of Patients with Pulmonary Artery Pressures in the Range of 21-24 mmHg: Insights from a Single-Center Study

OBJECTIVE

Slightly elevated mean pulmonary artery pressure (mPAP) was previously termed as ''borderline pulmonary hypertension (PH)''. We examined the long-term prognosis of patients with mPAP values between 21 and 24 mmHg, who were referred with the suspicion of pulmonary hypertension.

METHODS

Our retrospective study included patients with moderate-to-high echocardiographic risk who underwent right heart catheterization (RHC) between 2008 and 2021 and were followed for at least 1 year. Patients with mPAP <21 mmHg and mPAP 21-24 mmHg were compared. Demographic and clinical characteristics and prognoses of the groups were compared. All-cause mortality over a mean follow-up of 5 years (min 1-max 13 years) was evaluated.

RESULTS

A total of 140 patients (mean age 53.1 ± 14.8 years, female 74.5%) with mPAP values <25 mmHg measured of the 395 diagnostic RHCs. Mean follow-up was 4.92 ± 3.13 years. NT-pro-BNP and 6-min walking distance were better in patients with mPAP <21 mmHg. Echocardiographic findings suggestive of PH were more common in mPAP 21-24 mmHg group (P < 0.05). Both the pulmonary artery wedge pressure and cardiac index values were significantly deteriorated in individuals with mPAP 21-24 mmHg (P = 0.001). All-cause mortality tended to be higher in the borderline PH group but did not reach to statistical significance.

CONCLUSION

Our single-center observational study revealed that the individuals with an mPAP of 21-24 mmHg tended to have a worser prognosis than those with mPAP of <21 mmHg for up to 13-year follow-up.

Takotsubo syndrome early after treatment due to non cardiotoxic chemotherapy agents

Takotsubo syndrome (TTS), acute stress-induced cardiomyopathy, is known to have a dramatic clinical presentation mimicking acute myocardial infarction. Recently developed chemotherapeutic drugs have resulted in improvements in morbidity and mortality in many forms of cancer. However, some chemotherapeutic drugs are cardiotoxic and may cause heart failure. Gemcitabine and vinorelbine are commonly used drugs for various solid organ neoplasms. While neither of these chemotherapeutic drugs has been directly associated with cardiotoxicity, there are a few case reports in the literature related to gemcitabine treatment- induced cardiomyopathy. This case report describes a case of TTS developing within hours of gemcitabine and vinorelbine chemotherapy.

Hepatic and splenic sonographic and sonoelastographic findings in pulmonary arterial hypertension

Purpose

The aim of this study was to evaluate the associations of sonographic and sonoelastographic parameters with clinical cardiac parameters, as well as to assess their value in predicting survival in patients with pulmonary arterial hypertension (PAH).

Methods

Thirty-six patients with PAH and normal liver function were prospectively enrolled in this prospective study along with 26 healthy controls, all of whom underwent ultrasound and point shear wave elastography examinations. Additionally, the portal vein pulsatility index (PVPI), inferior vena cava collapsibility index, and clinical cardiac variables were obtained in PAH patients. The values of hepatic (LV_s) and splenic shear wave velocity (SV_s) were compared between PAH patients and controls. The relationships between all sonographic and clinical parameters in the PAH patients were analyzed. Furthermore, their prognostic value in predicting survival was investigated.

Results

LV_s values in PAH patients (median, 1.62 m/s) were significantly higher than in controls (median, 0.99 m/s), while no significant difference was observed in SV_s values. Patients with higher grades of tricuspid regurgitation (TR) had significantly different values of PVPI (P=0.010) and sonoelastographic parameters (P<0.001 for LV_s and P=0.004 for SV_s) compared to those with less severe TR. Tricuspid annular plane systolic excursion values were the only investigated parameter found to be associated with survival (hazard ratio, 0.814; 95% confidence interval, 0.694 to 0.954; P=0.011).

Conclusion

Our results demonstrated a direct association between cardiac congestion (i.e., the severity of TR) and liver stiffness, which should be kept in mind during the assessment of fibrosis in patients with PAH.

Is there a gender gap in secondary prevention of coronary artery disease in Turkey?

OBJECTIVE

It has been reported that women receive fewer preventive recommendations regarding pharmacological treatment, lifestyle modifications, and cardiac rehabilitation compared with men who have a similar risk profile. This study was an investigation of the impact of gender on cardiovascular risk profile and secondary prevention measures for coronary artery disease (CAD) in the Turkish population.

METHODS

Statistical analyses were based on the European Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE)-IV cross-sectional survey data obtained from 17 centers in Turkey. Male and female patients, aged 18 to 80 years, who were hospitalized for a first or recurrent coronary event (coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or acute myocardial ischemia) were eligible.

RESULTS

A total of 88 (19.7%) females and 358 males (80.3%) were included. At the time of the index event, the females were significantly older (p=0.003) and had received less formal education (p<0.001). Non-smoking status (p<0.001) and higher levels of depression and anxiety (both p<0.001) were more common in the female patients. At the time of the interview, conducted between 6 and 36 months after the index event, central obesity (p<0.001) and obesity (p=0.004) were significantly more common in females. LDL-C, HDL-C or HbA1c levels did not differ significantly between genders. The fasting blood glucose level was significantly higher (p=0.003) and hypertension was more common in females (p=0.001). There was no significant difference in an increase in physical activity or weight loss after the index event between genders, and there was no significant difference between genders regarding continuity of antiplatelet, statin, beta blocker or ACEi/ARB II receptor blocker usage (p>0.05).

CONCLUSION

Achievement of ideal body weight, fasting blood glucose and blood pressure targets was lower in women despite similar reported medication use. This highlights the importance of the implementation of lifestyle measures and adherence to medications in women.

Preliminary results from a nationwide adult cardiology perspective for pulmonary hypertension: RegiStry on clInical outcoMe and sUrvival in pulmonaRy hypertension Groups (SIMURG)

OBJECTIVE

The present study was designed to evaluate the characteristics of pulmonary hypertension (PH) and adult cardiology practice patterns for PH in our country.

METHODS

We evaluated preliminary survey data of 1501 patients with PH (females, 69%; age, 44.8±5.45) from 20 adult cardiology centers (AdCCs).

RESULTS

The average experience of AdCCs in diagnosing and treating patients with PH was 8.5±3.7 years. Pulmonary arterial hypertension (PAH) was the most frequent group (69%) followed by group 4 PH (19%), group 3 PH (8%), and combined pre- and post-capillary PH (4%). PAH associated with congenital heart disease (APAH-CHD) was the most frequent subgroup (47%) of PAH. Most of the patients' functional class (FC) at the time of diagnosis was III. The right heart catheterization (RHC) rate was 11.9±11.6 per month. Most frequently used vasoreactivity agent was intravenous adenosine (60%). All patients under targeted treatments were periodically for FC, six-minute walking test, and echo measures at 3-month intervals. AdCCs repeated RHC in case of clinical worsening (CW). The annual rate of hospitalization was 14.9±19.5. In-hospital use of intravenous iloprost reported from 16 AdCCs in CWs. Bosentan and ambrisentan, as monotreatment or combination treatment (CT), were noted in 845 and 28 patients, respectively, and inhaled iloprost, subcutaneous treprostinil, and intravenous epoprostenol were noted in 283, 30, and four patients, respectively. Bosentan was the first agent used for CT in all AdCCs and iloprost was the second. Routine use of antiaggregant, anticoagulant, and pneumococcal and influenza prophylaxis were restricted in only two AdCCs.

CONCLUSION

Our nationwide data illustrate the current status of PH regarding clinical characteristics and practice patterns.

[EUROASPIRE-IV: European Society of Cardiology study of lifestyle, risk factors, and treatment approaches in patients with coronary artery disease: Data from Turkey]

OBJECTIVE

Data from EUROASPIRE-IV Turkey report investigating risk factors and adherence to guidelines in patients hospitalized for coronary artery disease are presented and results are compared with those of EUROASPIRE-III Turkey and EUROASPIRE-IV Europe.

METHODS

Study was performed in 24 European countries, including Turkey (17 centers). Patients (18-80 years old) hospitalized for coronary (index) event during preceding 3 years were identified from hospital records and interviewed ≥6 months later. Patient information regarding index event was acquired from hospital records. Anamnesis was obtained during the interview, and physical examination and laboratory analyses were performed.

RESULTS

Median age at the index coronary event was 58.8 years, and it was significantly decreased compared with last EUROASPIRE-III study (60.5 years), which was conducted at the same centers 6 years earlier (p=0.017). Of all patients, 19.3% were under 50 years of age and mean age was lower than that of EUROASPIRE-IV Europe (62.5 years). Comparing EUROASPIRE-IV Turkey with EUROASPIRE-III Turkey, rate of smokers increased to 25.5% from 23.1% (p=0.499), obesity increased to 40.7% from 35.5% (p=0.211), total cholesterol level increased to 49.6% from 48.3% (p=0.767), and diabetes rate increased to 39.7% from 33.6% (p=0.139), however none of the differences reached a level of statistical significance. Only 11.7% of the smokers quit after coronary event. Rates for these factors were lower in EUROASPIRE-IV Europe (16% for smoking, 37.6% for obesity, and 26.8% for diabetes).

CONCLUSION

EUROASPIRE-IV Turkey data revealed that secondary prevention was unsatisfactory and had progressed unfavorably compared with last EUROASPIRE study, some risk factors were more uncontrolled than overall European average, and coronary artery events at young age remain an important problem.

Sequencing of mutations in the serine/threonine kinase domain of the bone morphogenetic protein receptor type 2 gene causing pulmonary arterial hypertension

OBJECTIVE

Germline mutations in the bone morphogenetic protein receptor type-2 (BMPR2) gene are considered to be a major risk factor for pulmonary arterial hypertension (PAH). BMPR2 mutations have been reported in 10%-20% of idiopathic PAH and in 80% of familial PAH cases. The aim of this study was to evaluate the frequency of mutations in the serine/threonine kinase domain of the BMPR2 gene in a group of patients from a single PAH referral center in Turkey.

METHODS

This cross-sectional study used a DNA-sequencing method to investigate BMPR2 mutations in the serine-threonine-kinase domain in 43 patients diagnosed with PAH [8 with idiopathic PAH and 35 with congenital heart disease (CHD)] from a single PAH referral center. Patients were included if they had a hemodynamically measured mean pulmonary arterial pressure of >25 mm Hg with a mean pulmonary capillary wedge pressure of ≤15 mm Hg. Patients with severe left heart disease and/or pulmonary disease that could cause pulmonary hypertension were excluded. Associations between categoric variables were determined using the chi-square test. Differences between idiopathic and CHD-associated PAH groups were compared with the unpaired Student's t-test for continuous variables.

RESULTS

We detected a missense mutation, [p.C347Y (c.1040G>A)], in one patient with idiopathic PAH in exon 8 of the BMPR2 gene. The mutation was detected in a 27-year-old female with a remarkable family history for PAH. She had a favorable response to endothelin receptor antagonists. No mutations were detected in the exons 5-11 of the BMPR2 gene in the PAH-CHD group.

CONCLUSION

A missense mutation was detected in only one of the eight patients with idiopathic PAH. The BMPR2 missense mutation rate of 12.5% in this cohort of Turkish patients with idiopathic PAH was similar to that seen in European registries. The index patient was a young female with a family history remarkable for PAH; she had a good long-term response to PAH-specific treatment, probably due to the early initiation of the treatment. Genetic screening of families affected by PAH might have great value in identifying the disease at an early stage.

[The psychometric properties of the Turkish version of Myocardial Infarction Dimensional Assessment Scale (MIDAS)]

OBJECTIVE

The purpose of this study was to describe the psychometric properties of the Myocardial Infarction Dimensional Assessment Scale (MIDAS).

METHODS

This is a methodological cultural adaptation study. The MIDAS consists of 35-items covering seven domains: physical activity, insecurity, emotional reaction, dependency, diet, concerns over medication, and side effects which are rated on a five-point Likert scale from 1: never to 5:always. The highest score of MIDAS is 100.Quality of life (QOL) decreases as the score of scale increases. Overall 185 myocardial infarction (MI) patients were enrolled in this study. Cronbach alpha was used for the reliability analysis. The criterion validity, structural validity, and sensitivity analysis approach was used for validity analysis. New York Heart Association (NYHA) and the Canadian Cardiovascular Society Functional Classifications (CCSFC) for testing the criterion validity; SF-36 for construct validity testing of the Turkish version of the MIDAS were used.

RESULTS

The range of Cronbach alpha values is 0.79-0.90 for seven domains of the scale. No problematic items were observed for the entire scale. Medication related domains of the MIDAS showed considerable floor effects (35.7%-22.7%). Confirmatory Factor analysis indicators [Comparative Fit Index (CFI) =0.95 and Root Mean Square Error of Approximation (RMSEA) =0.075] supported the construct validity of MIDAS. Convergent validity of the MIDAS was confirmed with correlation of SF-36 scale where appropriate. Criterion validity results was also satisfactory by comparing different stages of the NYHA and the CCSFC (p<0.05).

CONCLUSION

Overall results revealed that Turkish version of the MIDAS is a reliable and valid instrument.

[Reliability and validity of the Turkish version of the Chronic Heart Failure Questionnaire]

OBJECTIVE

Any disease specific Health Related Quality of Life Instrument for Chronic Heart Failure (CHF) is lacking in Turkey. The aim of this study is to adapt the Chronic Heart Failure Questionnaire (CHQ) into Turkish and probe the reliability and validity of this questionnaire.

METHODS

There are four dimensions of this 20 items scale. These dimensions are: dyspnea (5 items), fatigue (4 items), emotional status (7 items) and mastery (4 items). Response options were evaluated using a 7 -point Likert type scale. Quality of life (QOL) improves as the score increases. A total of 205 CHF patients hospitalized in the Department of Cardiology of Ege University hospital were enrolled in this study. The CHQ was applied to the patients twice with a wash-out period of 15 days. Confirmatory approach was used during the reliability and validity analysis. Cronbach alpha test was used for the reliability analysis. Confirmatory factor analysis (CFA) was used for the construct validity testing. NYHA classification for testing the criterion validity; SF-36 and WHOQOL-100 General Health and QOL facet for convergent validity testing of the Turkish version of the CHQ were used. Responsiveness to change was evaluated by Effect Size analysis by using test-retest data.

RESULTS

The range of Cronbach alpha values is 0.72-0.94. A considerable ceiling and floor effects were observed for the dyspnea dimension of the scale but no problematic items were observed for the entire scale. The CFA results supported the original four factors scale structure. Criterion and construct validity rebuts were satisfactory. Effect sizes obtained among dimensions of the CHQ were between 0.13 and 0.56.

CONCLUSION

Overall results revealed that Turkish version of the CHQ is a reliable and valid instrument to be used for the evaluation of CHF patients.

[Evaluation of hospitalization period and five-year follow-up of patients admitted with acute coronary syndrome following coronary artery bypass graft surgery]

OBJECTIVES

We evaluated patients admitted with the diagnosis of acute coronary syndrome (ACS) after coronary artery bypass graft (CABG) surgery.

STUDY DESIGN

This retrospective study included 72 consecutive CABG patients (10 women, 62 men; mean age 63±9 years; range 45 to 83 years). Acute coronary syndrome was defined as the presence of unstable angina or myocardial infarction (MI) with or without ST elevation. Time from CABG surgery to admission with ACS was defined as bypass age. Following discharge, information was derived by phone calls from the patients or relatives on cardiovascular events within a five-year period.

RESULTS

On admission, 14 patients (19.4%) had non-ST elevation MI, nine patients (12.5%) had ST elevation MI, and 49 patients (68.1%) had unstable angina. The mean bypass age was 5.6±3.5 years. Of the study group, 38.9% were obese, 25% were diabetic, 54.2% were hypertensive, 44.4% were hyperlipidemic, and 26.4% were current smokers. Medications before admission included aspirin (81.9%), statin (25%), beta-blocker (27.8%), ACE inhibitor or angiotensin receptor blocker (27.8%), and calcium channel antagonist (36.1%). Increased LDL cholesterol (≥100 mg/dl) and decreased HDL cholesterol (≤50 mg/dl) levels were present in 55.6% and 80.6%, respectively. Mortality occurred in 15 patients, four during hospitalization, and 11 after discharge. The overall mortality rate was 21.4%. In correlation analysis, mortality was positively correlated with age (r=0.34, p=0.005), bypass age (r=0.37, p=0.001), CRP level (r=0.31, p=0.033) and negatively correlated with beta-blocker use (r=-0.25, p=0.041) and ejection fraction (r=-0.37, p=0.016).

CONCLUSION

Our results show that, following CABG surgery, special consideration should be given to risk factor management and use of agents with proven effects against cardiovascular mortality such as statins, beta-blockers, and ACE inhibitors.

[Current approach to the treatment of pulmonary arterial hypertension and our experience in the Cardiology Department of Medicine Faculty of Ege University]

Pulmonary arterial hypertension is a progressive disease marked by increased pulmonary artery resistance leading to right heart failure and has very high mortality. Survival rates have somewhat improved in recent years due to the development of new drugs and early diagnosis. This review aims to summarize the current therapeutic approach to pulmonary arterial hypertension and share our experience at our center.

The impact of diabetes and coronary artery disease on mortality and morbidity in patients with hypertension

OBJECTIVES

We evaluated the impact of diabetes mellitus (DM) and/or coronary artery disease (CAD) on cardiovascular endpoints in a cohort of hypertensive patients.

STUDY DESIGN

The Vascular Risk Study is a cross-sectional, multicenter, observational study conducted among 5,600 patients from various regions of Turkey. This analysis included 2,664 patients (1,643 women, 1,021 men; mean age 65.3 years; range 55-99 years) whose follow-up data were adequate among a population of 4,506 hypertensive subjects. Cardiovascular primary and secondary endpoints at the end of a five-year follow-up were assessed in patients who had hypertension alone, and in those having DM and/or CAD. Information on the cause of death was obtained from the relatives of the patients by follow-up phone calls.

RESULTS

There were 1,171 patients (44%) with isolated hypertension, 631 (23.7%) with DM, 530 (19.9%) with CAD, and 332 (12.5%) with both DM and CAD. The presence of either DM or CAD was associated with significant increases in the incidences of all endpoints. The occurrences of primary and secondary endpoints, cardiovascular death, and all death were similar in hypertensive patients who had DM without CAD and in patients who had CAD without DM. In survival analysis, the incidence of cardiovascular death was lowest (5.7%) in hypertensive patients without DM and CAD, and highest (18.4%) in hypertensive patients with DM and CAD. The cumulative survival rates were similar in hypertensive patients with either DM or CAD alone (p>0.05).

CONCLUSION

This study demonstrated that the level of cardiovascular risk associated with DM was equal to the risk associated with CAD in hypertensive patients and that the coexistence of DM and CAD in these patients increases the risk geometrically.

[Atorvastatin in primary prevention]

Statins are one of the most widely used drugs in medical treatment and have been shown to prevent cardiovascular disease or reduce risk in a large number of studies. Although there is a general class effect, there are differences with regard to structure and efficacy between these agents. Among these agents, atorvastatin is a potent statin whose efficacy has been demonstrated in many clinical trials. Despite the presence of numerous clinical studies, data on atorvastatin related to primary prevention are limited compared to secondary prevention. In this article, clinical results of primary prevention trials with atorvastatin and data on its cost-effectiveness are reviewed. It is concluded that atorvastatin has a role in primary prevention and the cost of its use seems to be lower than commonly accepted cost-effectiveness thresholds.

[Seven years of experience in patients with pulmonary arterial hypertension in Ege University Hospital: diagnostic approach of a single center]

OBJECTIVE

Pulmonary arterial hypertension (PAH) is a term used to define a variety of progressive conditions that have in common, increased pulmonary vascular resistance leading to right heart failure and death. There has been considerable decrease in mortality and morbidity with the advances in PAH treatment over the past decade. However, since there is no epidemiologic study in Turkey, the prevalence of PAH and its importance is not known yet. This study aimed to evaluate the diagnostic clinical experience of Ege University Medical School Cardiology Department with PAH patients.

METHODS

We evaluated the diagnostic approach to patients referred to our department with the diagnosis of PAH since 2000 by retrospective analysis method.

RESULTS

The diagnosis of pulmonary hypertension was definite in 70 patients (mean age 47+/-16 years, 61% women). Etiology from most prevalent to least was as following: congenital heart diseases (27%), chronic thromboembolic pulmonary hypertension (24%), connective tissue diseases-scleroderma (14%), idiopathic PAH (8%), diastolic dysfunction (3%), pulmonary disease (3%), pulmonary veno-occlusive disease (2%), hepatopulmonary hypertension (1%), and HIV-infection associated PAH (1%). At diagnosis, 68% of patients were in NYHA functional class-III or IV. Six-minute walk test was 263+/-127 m. Mean pulmonary artery pressure was 65+/-20 mmHg. The prognostic marker pro-BNP (brain natriuretic peptide) level was 3208+/-4145 pg/ml.

CONCLUSION

Our practice shows that PAH is diagnosed late in the course of the disease in Turkey. This can be overcome with structured management in designated centers with multidisciplinary team-working in a shared care approach. There is also an urgent need for an epidemiological registry in order to determine the burden of PAH in Turkey and increase the awareness of doctors.

Repolarization characteristics and incidence of Torsades de Pointes in patients with acquired complete atrioventricular block

OBJECTIVE

Torsades de pointes (TdP) during bradyarrhythmias have been reported to be associated with gender, degree of QT prolongation and duration of bradyarrhythmia. We sought to investigate the repolarization characteristics on 12-lead electrocardiogram (ECG) and the incidence of TdP in patients with acquired complete atrioventricular block (CAVB).

METHODS

Fifty consecutive patients with acquired CAVB were included in the study. Patients with coronary artery disease, systolic dysfunction and previous cardiac surgery were excluded. Patients were monitored during hospitalization for ventricular arrhythmias (VA). Serum potassium, magnesium, calcium levels and thyroid-stimulating hormone were measured. Heart rate, QRS duration, QT/QTc, JT/JTc and Tpeak-Tend intervals were measured. Pathologic U waves, T-U complex, and QT morphologies were remarked.

RESULTS

Patients presented with presyncope (n=39, 78%), syncope (n=12, 24%), and palpitations (n=8, 16%). All patients were in sinus rhythm. Duration of CAVB was 8.5 days (median). Patients were divided into two groups based on JT interval. Group 1 (JT=or>500 ms, n=13) tended to have more female patients and more VAs in comparison to Group 2 (JT<500 ms, n=37). Group 1 patients had more pathologic U waves and T-U complexes, longer Tpeak-Tend intervals, and more long QT2 syndrome (LQT2)-like QT morphology in comparison to Group 2 patients. Group 2 patients had more often syncope. One patient in Group 2 developed ventricular fibrillation in the presence of hypokalemia and hypomagnesemia.

CONCLUSION

Torsades de Pointes during CAVB was rare among our patient population. The predictors of VA during CAVB were presence of prolonged QTc/JTc intervals, pathologic U wave and T-U complex, prolonged Tpeak-Tend interval, and LQT2-like QT morphology.

Pseudonormalization: clinical, electrocardiographic, echocardiographic, and angiographic characteristics

OBJECTIVE

Spontaneous pseudonormalization (PN) is a unique 12-lead electrocardiography (ECG) finding which has been reported to be associated with severe, transmural myocardial ischemia. To date, a paucity of data exists about the incidence and clinical characteristics of patients with PN. Therefore the aim of this study was to investigate the incidence and the electrocardiographic, echocardiographic, and angiographic characteristics of patients with PN.

METHODS

Clinical, laboratory, electrocardiographic, echocardiographic, and angiographic characteristics of 12 consecutive patients with PN on 12-lead ECG (Group 1) were compared with patients (Group 2, n=28) presenting with acute coronary syndrome (ACS) associated with ST-T wave changes without PN.

RESULTS

All patients presented with chest pain. The incidence of PN among patients presenting with ACS was 1%. Pseudonormalization was present in precordial leads in 11 and in inferior leads in 1 patient. Nine out of 12 (75%) patients in Group 1, 16 out of 28 (57%) patients in Group 2 had elevation of cardiac enzymes compatible with acute myocardial infarction. Severely narrowed or totally occluded ischemia and/or infarction-related coronary arteries were present in all patients in Group 1, in 20 (71%) patients in Group 2. Three patients in Group I and one patient in Group 2 had coronary artery thrombus formation. Group 1 patients had worse coronary collateral grading in comparison to Group 2 patients.

CONCLUSION

Pseudonormalization is a rare entity and it is typically associated with severely narrowed or totally occluded coronary arteries along with thrombus formation, and poor coronary collateral development.

Efficacy and safety of extended-release fluvastatin in Turkish patients with hypercholesterolaemia: TULIPS (Turkish Lipid Study)

OBJECTIVE

The efficacy and safety of extended-release fluvastatin (fluvastatin XL), 80 mg once daily, was assessed in Turkish patients with primary hypercholesterolaemia (low-density lipoprotein cholesterol (LDL-C) 3.37-5.70 mmol/l and triglyceride (TG) < 4.52 mmol/l).

RESEARCH DESIGN

In this open-label, prospective, multi-centre study, 154 patients were given fluvastatin XL 80 mg once daily and lipid levels were assessed after 2 and 12 weeks.

RESULTS

Fluvastatin XL 80 mg once daily significantly reduced LDL-C levels by 38.8 and 38.1% at weeks 2 (n = 140) and 12 (n = 116), respectively (p < 0.001 vs. baseline). Treatment with fluvastatin XL for 2 and 12 weeks significantly reduced total cholesterol levels by 30.2 and 27.4%, respectively (p < 0.001 vs. baseline) and reduced TG levels by 14.9 and 7.5%, respectively (p < 0.001 vs. baseline). Following stratification by risk factors for coronary heart disease (CHD) according to the National Cholesterol Education Program Adult Treatment Panel III guidelines, 87.3% of patients with > or = 2 risk factors, and 67.4% of patients with existing CHD or CHD risk equivalents achieved target LDL-C levels (< 3.37 mmol/l and < 2.59 mmol/l, respectively) with fluvastatin XL. Fluvastatin XL reduced high-density lipoprotein cholesterol by 8.9 and 4.7% at weeks 2 and 12 weeks, respectively. fluvastatin XL 80 mg once daily was generally well-tolerated.

CONCLUSIONS

This open-label study indicates fluvastatin XL 80 mg once daily is an effective and well-tolerated lipid-lowering therapy for the reduction of CHD risk in Turkish patients.

The effects of short term statin treatment on left ventricular function and inflammatory markers in patients with chronic heart failure

BACKGROUND

Statins may provide additional benefits in patients with cardiac failure due to their pleiotropic effects besides their cholesterol-lowering actions. In this study, we aimed to evaluate the impact of 12-week fluvastatin therapy on the inflammatory cytokines and the ventricular performance markers in patients with heart failure.

METHODS AND RESULTS

Fourty chronic heart failure patients, twenty with idiopathic dilated cardiomyopathy (DCM group) and 20 with ischemic cardiomyopathy (ICM group), for whom statin treatment was indicated according to Adult Treatment Panel III were included to this open label and prospective study. After a 12-week treatment with fluvastatin 80 mg/day; clinical functional capacity, echocardiographic indices of cardiac performance and inflammatory markers were evaluated. After the treatment, functional capacity (in DCM group: 2.05+/-0.4 versus 1.65+/-0.6, p=0.005; in ICM group: 2.25+/-0.5 versus 1.8+/-0.6, p=0.003), left ventricular ejection fraction, LVEF (from 30+/-5% to 33+/-5%, p=0.001 in DCM and 29+/-4% to 31+/-5%, p=0.001 in ICM group) and tissue Doppler mitral annular systolic velocity, Sm (5.8+/-1 cm/s to 7+/-1 cm/s, p=0.001 in DCM and 5.4+/-0.8 cm/s to 7+/-1 cm/s, p=0.001 in ICM group) improved. Tumor necrosis factor-alpha and interleukin-6 levels decreased, but no significant changes in high sensitive C-reactive protein and brain natriuretic peptide levels were detected with the fluvastatin treatment in both groups.

CONCLUSION

Fluvastatin improved cardiac functions and the clinical symptoms in HF patients with either idiopathic dilated or ischemic etiology. This positive effect of fluvastatin which might be secondary to inflammatory modulation was more marked in patients with ischemic etiology. Statins in HF deserves special attention by means of further large-scale trials.

The effect of myocardial surgical revascularization on left ventricular late potentials

BACKGROUND

The presence of ventricular late potentials (LP) is an important indicator for the development of ventricular tachyarrhythmias due to ischemic heart disease. The effect of myocardial revascularization on LP has remained controversial. The purpose of this study was to determine whether complete myocardial surgical revascularization (CABG) documented by myocardial perfusion scintigraphy might alter the substrate responsible for LP.

METHODS

Prospectively, enrolled patients undergoing elective CABG were evaluated with thallium-201 myocardial perfusion scintigraphy and signal- averaged ECG pre- and postoperatively. SAECG recordings were obtained serially: before, 48-72 hours and 3 months after CABG. LPS were defined as positive if SAECG met at least two of Gomes criteria. Scintigraphies were performed pre- and 3 months postoperatively for determination of the success of revascularization. Changes observed in SAECG recordings after CABG were compared between those with and without successful revascularization.

RESULTS

CABG resulted in successful revascularization in 23 patients and was unsuccessful in 17 (no change or deterioration of the perfusion defects). Preoperative SAECG values were not different between groups except for RMS values. The incidence of LP decreased significantly postoperatively in patients with improved myocardial perfusion, whereas there were no changes in patients who did not have postoperative perfusion improvement (McNemar test, P < 0.05).

CONCLUSIONS

LPs disappear following the elimination of myocardial ischemia by complete surgical revascularization. Persistence of ischemia following CABG usually results in the persistence of late potentials. The incidence of ventricular arrhythmias is expected to be unchanged in these patients and they should be reevaluated for reinterventions.

Endothelial function in patients with vasculogenic erectile dysfunction

OBJECTIVES

Erectile dysfunction (ED) commonly coexists with coronary artery disease (CAD) and/or risk factors for atherosclerosis. Because the silent or documented atherosclerosis or vascular risk factors are very frequent, the possibility of endothelial dysfunction in ED patients is expected to be increased. Our aim was to evaluate the endothelial functions in patients with vasculogenic ED with vascular risk factors and compare them with age-matched non-ED patients or healthy controls.

DESIGN

We studied 36 patients with presumed vasculogenic ED, 39 age-matched patients with similar risk factors without ED and 25 age-matched healthy controls without ED, known cardiovascular disease or risk factors. Erectile function was evaluated by the International Index of Erectile Dysfunction (IIEF) scores. Brachial artery flow-mediated dilatation (FMD) and nitroglycerine-mediated dilatation (NMD) were measured.

RESULTS

Baseline demographics were similar except the IIEF score and duration of diabetes in patients with ED. Brachial artery FMD and NMD were significantly reduced in patients with ED (3.2+/-3. vs. 6+/-4, p<0.0001 for FMD, 12.2+/-6 vs. 15.4+/-6 p=0.032 for NMD). In patients with similar risk factors but without ED, FMD was significantly lower but NMD were not different compared with healthy controls (6+/-4 vs. 10.2+/-3, p<0.0001 for FMD and 15.4+/-8 vs. 16.4+/-6, p=0.81). IIEF scores were weakly correlated with FMD (r=0.25, p=0.028) in patients with ED. There were significant correlations between FMD and NMD in patients with ED (r=0.46, p=0.05) and with risk factors (r=0.72, p<0.0001) but not in healthy controls (r=0.54, p=0.792). Vasculogenic ED patients have more markedly impaired endothelial and smooth muscle functions compared with patients with similar risk factors but no ED.

A giant inferoposterior true aneurysm of the left ventricle mimicking a pseudoaneurysm

A left ventricular aneurysm (LVA) is most commonly the result of myocardial infarction, usually involving the anterior wall. A left ventricular pseudoaneurysm (LVPSA) or false aneurysm forms when cardiac rupture is contained by adherent pericardium or scar tissue. The accurate diagnosis, although difficult to establish, is an important one to make because these aneurysms are prone to rupture. In this article, we report a challenging case of a cardiac aneurysm a year after a coronary bypass operation which could not be definitively diagnosed despite of imaging with different techniques including echocardiography, coronary angiography, left ventriculography and magnetic resonance imaging (MRI). The patient underwent a second cardiac surgery, the aneurysm was resected, the mitral valve was replaced and the defect in the ventricular wall was repaired. Because of the combined diagnostic capabilities like detailed and functional pathoanatomy and aneurysmal wall characterization, MRI seems to have multiple advantages in differential diagnosis.

Which patients have the highest cardiovascular risk? A follow-up study from Turkey

BACKGROUND

Recent guidelines target individuals at highest risk as a priority. However, implementation of guidelines even in this group is sub-optimal.

DESIGN

A multicenter, observational follow-up study.

METHODS

A total of 5600 consecutive patients > or =55 year with high risk of vascular events were evaluated for risk factors and medication usage and followed for 1 year for primary end-points (death, myocardial infarction, stroke), and secondary end-points (revascularization, hospitalization).

RESULTS

The patients were divided into two groups: those without and with vascular disease. In the first group, mortality at 1 year was significantly higher in those with end organ damage (5.8 versus 2.7%, P=0.005). Similarly, the mortality in patients with known vascular disease (CAD, peripheral vascular disease, ischaemic stroke) was higher in the presence of a previous vascular event (7.8 versus 5.3%, P=0.055, vascular event: non-fatal MI/stroke). The use of antiplatelets, statins, beta-blockers and angiotensin-converting enzyme inhibitors was low and did not improve in the follow-up period. The most important predictors of cardiovascular mortality were the presence of end organ damage [odds ratio (OR) 1.65, P=0.001], pre-existing vascular disease (OR 1.49, P=0.023) and protectively, the consistent use of angiotensin-converting enzyme inhibitors (OR 0.49, P=0.001).

CONCLUSION

In a high-risk Turkish population, the early mortality and morbidity due to cardiovascular events was unacceptably high and medical treatment inadequate. The presence of end organ damage and a previous vascular event increased the risk even further and should be vigorously questioned. Aggressive lifestyle modification and medical therapy should be instituted in these patients.

Endothelial functions in Behçet’s disease

Behçet's disease (BD) is a systemic vasculitis, capable of involving all types of vessels. Endothelial dysfunction (ED) has been previously documented in BD. The aim of the study was to see whether ED was more prominent in Behçet's patients with vascular involvement (VI) than in those without. The study population consisted of 65 patients with BD, 27 of whom had VI, and 30 healthy controls. High-resolution ultrasound was used to measure endothelium-dependent vasodilatation (EDVD) of brachial artery. Overall, regardless of VI, EDVD was significantly impaired in patients with BD compared with controls (11.4 +/- 6.3 vs 20.4 +/- 9.1%,P = 0.001); however, EDVD was similar in BD patients with and without VI (9.7 +/- 6.3% vs 12.6 +/- 6.1%, P = 0.07). Patients with BD had significantly-higher plasma homocysteine levels than controls (13 +/- 6 micromol/L vs 9 +/- 3 micromol/L, P = 0.001). Plasma homocysteine levels were significantly higher in the subgroup with VI than in those without (15 +/- 7 micromol/L vs 12 +/- 4 micromol/L, P = 0.03); however, we found no positive/significant correlation between plasma homocysteine levels and EDVD. ED is a constant feature of BD, regardless of VI. Etiology of ED in BD is probably multifactorial, including high homocysteine levels. As both ED and elevated homocysteine levels may represent an early atherosclerotic process, a more structured approach to risk factor assessment is needed in BD.

Comparative Assessment of the Diagnostic Value of Neopterin and Acute Phase Proteins in Angiographically Assessed Stahle Coronary Artery Disease

Assessment of markers of systemic inflammation, such as acute-phase reactants C-reactive protein (CRP), fibrinogen and ceruloplasmin, sialic acid, a major component of these proteins and neopterin, a specific marker of cellular immune activation, in clinically stable coronary artery disease, may contribute to Staging and risk stratification. These markers were measured in 225 consecutive stable coronary artery disease patients before undergoing coronary angiography. According to their angiographic scores 32 patients were designated as having minor, 34 moderate and 96 severe coronary artery disease. 63 patients with negative angiograms were taken as the angiographic controls. High sensitive-CRP (hs-CRP) and fibrinogen were found to be higher in patients with angiographically established coronary artery disease, than in angiographic controls (p<0.05) and correlated with the severity and extent of disease. Ceruloplasmin and sialic acid concentrations did not differ between patients with and without angiographically cstablished coronary artery disease. Serum neopterin levels were sigificantly higher in patients undergoing coronary angiography than in healthy controls. Neopterin levels were similar between the different subgroups of coronary artery disease, suggesting that neopterin determinations do not contribute to the assessment of the presence and severity of disease in clinically stable patients. In stable angina, serum hs-CRP and plasma fibrinogen levels proved to be more effective than ceruloplasmin, sialic acid and neopterin in discriminating between patients with positive and negative angiograms and various degrees of coronary artery disease, thus in pointing out to increased risk. Our results, do not support the inclusion of neopterin in risk assessment of stable coronary artery disease.

Effect of statin therapy added to ACE-inhibitors on blood pressure control and endothelial functions in normolipidemic hypertensive patients

OBJECTIVE

Endothelium-dependent vasodilatation is impaired in hypertension. Statins have been shown to improve endothelial functions in hyperlipidemic subjects. We aimed to investigate the effect of statins on endothelium-dependent flow mediated dilatation (FMD) and blood pressure (BP) in normocholesterolemic hypertensive patients.

METHODS

This randomized prospective study consisted of 56 patients with newly diagnosed essential hypertension. All patients received angiotensin converting enzyme (ACE) inhibitor lisinopril (5 mg/day) as antihypertensive therapy, and half of them were randomized to simvastatin(20mg/day) irrespective of serum lipid levels. All subjects underwent brachial artery ultrasonographic examination for the measurement of FMD before randomization and at the end of 12 weeks treatment.

RESULTS

A total of 39 patients completed the study (21 patients in the statin + ACE inhibitor group, and 18 patients in the ACE-inhibitor alone group). Blood pressure levels were substantially reduced in both groups after treatment. In statin+ ACE-inhibitor group systolic pressure reduced by 23% (p=0.0001) and diastolic BP reduced by 23% (p=0.0001). In ACE-inhibitor alone group these ratios were 20% (p=0.001) and 21% (p=0.001), respectively. Meanwhile, pulse pressure (PP) decreased by 25% in statin+ ACE-inhibitor group (P=0.0001) and by 16% in ACE inhibitor-alone group (p=0.0051). Baseline FMD was significantly impaired in overall patients with hypertension as compared with healthy controls (13+/-8 vs. 24+/-8 %, P = 0.001). After treatment FMD decreased by 23% in lisinopril alone group (p=0.054). There were no correlations between FMD improvement, LDL reduction, BP or PP changes in both groups.

CONCLUSION

Addition of simvastatin to ACE-inhibitor treatment in newly diagnosed hypertensive patients with normal cholesterol levels, significantly reduced PP and facilitated BP control, but did not affect endothelium-dependent dilatation. Further long-term large scale studies are needed to clarify the effect of various statins on endothelial functions of either hypercholesterolemic or normocholesterolemic hypertensive patients.

The angiographic correlation between ST segment depression in noninfarcted leads and the extent of coronary artery disease in patients with acute inferior myocardial infarction: a clue for multivessel disease

BACKGROUND

Although reciprocal ST segment depression (RSTD) in patients with acute inferior myocardial infarction is a common electrocardiogram finding, its significance is not yet established. In this prospective study, the relationship between RSTD and the extent of coronary artery disease (CAD) was investigated.

PATIENTS AND METHODS

One hundred eighty-eight patients with acute inferior myocardial infarction who received thrombolytic therapy were enrolled in this study. The magnitude and location of ST segment depression in noninfarcted leads and the maximum ST segment elevation (STEmax) in inferior leads were measured. All patients were divided into two main groups according to the presence of RSTD and five subgroups according to the location of RSTD, the maximum RSTD and the STEmax. The coronary angiography was performed in all patients 28 +/- 4 days after acute myocardial infarction.

RESULTS

There were no significant differences in the proportion of coronary disease risk factors in patients with, versus those without, RSTD (P=0.6). Multivessel CAD was present in 63 of the 108 (58%) patients with RSTD and in 32 of the 80 (40%) patients with no RSTD (P=0.02). According to the location of reciprocal changes, multivessel disease was present in significantly more patients with anterior RSTD concomitant with or without lateral ST segment depression (P=0.01 and P=0.03, respectively); the proportion of single vessel disease was greater in patients with only lateral RSTD (P=0.02). In addition, the presence of anterior RSTD to a greater magnitude than the STEmax in inferior myocardial infarction increases the likelihood of multivessel disease (P=0.006).

CONCLUSIONS

The presence of RSTD during an acute inferior myocardial infarction correlates with the presence of multivessel CAD and may not be only an electrical phenomenon.

[Apoptosis and cardiovascular disease]

Apoptosis is defined as a genetically programmed cell death. Apoptotic cell death plays an important role both in heart development and cardiac disease. This review deals with the key features of this process. The modification of possible interactions between extrinsic and intrinsic factors affecting the cell during apoptotic process may be of major interest in preventing the progression of cardiovascular disease. Current issues on the pathogenetic role of apoptosis in heart disease and how these knowledge can be applied in clinical usage is also evaluated in this review.

QT dispersion in patients with different etiologies of left ventricular hypertrophy: the significance of QT dispersion in endurance athletes

Left ventricular hypertrophy (LVH) increases the risk of ventricular arrhythmias and sudden death and has a significant effect on total cardiovascular mortality. QT dispersion (QTd) is a measure of inhomogeneous repolarization and is used as an indicator of arrhythmogenicity. In this study we detected QTd in patients with different etiologies of left ventricular hypertrophy and the effect of LVH in QTd on endurance athletes. The study group consisted of 147 white male subjects with 3 different etiologies of LVH and 30 healthy male individuals. The underlying etiologies of LVH were essential hypertension, valvular aortic stenosis and long-term training (athletic heart). QTd was measured by surface electrocardiogram and Bazett's formula was used to correct QTd for heart rate (QTcd). Left ventricular mass was determined by transthoracic echocardiography and left ventricular mass index was calculated in relation to body surface area. The QTcd was significantly higher in patients with pathological LVH (due to hypertension and aortic stenosis) than in the athletes' group (physiological LVH) and healthy subjects (P<0.05). The magnitude of QTcd was similar between athletes and the control group (P=0.6). The difference of QTcd between the groups with pathological LVH was not statistically significant (P=0.1). In conclusion; the increasing of QT dispersion is associated with only pathological conditions of LVH. The left ventricular hypertrophy has not a negative effect in QT dispersion on endurance athletes. The measurement of QT dispersion may be a non-invasive useful method for screening additional pathological conditions in endurance athletes.

Early use of pravastatin in patients with acute myocardial infarction undergoing coronary angioplasty

AIM

To determine whether statin therapy initiated early in acute myocardial infarction together with thrombolytic therapy in patients with acute myocardial infarction results in clinical benefit through early plaque stabilization.

METHODS AND RESULTS

The study population consisted of 77 patients who underwent coronary balloon angioplasty of the infarct-related artery during the first month of acute myocardial infarction. These patients belonged to the cohort of the Pravastatin Turkish Trial (PTT). Forty of them were assigned randomly to have immediate pravastatin (40 mg/day) therapy adjunctive to thrombolytic therapy regardless of serum lipid levels and received statin treatment throughout the study. Lipid levels were determined immediately after admission and before angioplasty and at the end of 6 months. Patients were re-evaluated clinically and angiographically for cardiovascular adverse events and restenosis after a 6-month follow-up period. The baseline angiographic and clinical characteristics of the two groups were similar. The incidence of angina was significantly lower in the pravastatin group (30.0%, 12 patients) compared to the control group (59.5%, 22 patients) (p = 0.018). The cumulative major adverse cardiac events in the pravastatin group were significantly lower when compared to the control group (32.5% vs. 75.6%, p = 0.0001).

CONCLUSIONS

Early initiation of pravastatin therapy immediately after an acute myocardial infarction significantly decreased the frequency of major cardiac adverse events. Such early potential clinical benefits further strengthen the rationale for starting statin treatment as soon as possible after acute coronary events particularly in patients in whom invasive intervention is planned.

Soluble P-selectin and the success of thrombolysis in acute myocardial infarction

BACKGROUND

P-Selectin mediates adhesive interactions between platelets, leukocytes and endothelium to form thrombi. Our purpose was to investigate plasma soluble(s) P-selectin levels in patients with acute myocardial infarction (aMI) and the effect of thrombolysis on P-selectin levels.

METHODS

Patients with aMI within the first 6 h of chest pain were enrolled prospectively. sP-selectin levels were determined by ELISA in the plasma of patients with aMI (n=32), stable angina (n=18), and healthy controls (n=15). Samples were obtained before, 3 and 24 h after reperfusion therapy with tissue plasminogen activator. Seven patients showed recurrent angina or failure to reperfuse.

RESULTS

sP-selectin levels were significantly higher in aMI group than other groups (86.7+/-8.7 ng/ml, P<0.05). sP-selectin levels were similar in stable angina and control groups (28.8+/-4.4 vs. 25.4+/-7.3 ng/ml, P=NS). A significant increase in sP-selectin levels was observed 3 h after successful thrombolysis and this was followed by a decrease to near the baseline level late after reperfusion. But patients with failed reperfusion showed sustained high sP-selectin levels after 24 h of thrombolysis (P<0.05).

CONCLUSION

The plasma sP-selectin level is elevated in aMI and it increases further following thrombolytic therapy. This increase is probably induced by activation of endothelial cells or platelets after myocardial ischemia and reperfusion during aMI. As the elevated levels are sustained in patients with failed reperfusion, serial P-selectin levels may be used as a non-invasive indicator of successful thrombolysis in aMI.

A rare indication for stenting: persistent coronary artery spasm

A 34-year-old man presenting with angina both at rest and on exertion was investigated. He developed severe ST segment elevation and a brief period of ventricular tachycardia during an exercise tolerance test. On coronary angiography, 60% fixed luminal narrowing was observed in the proximal left anterior descending coronary artery and a severe spasm developed at this site, leading to temporary total occlusion of the vessel. Successful coronary angioplasty (PTCA) was performed on this lesion, with a residual 15% narrowing. However, the patient had a recurrence of angina 3 weeks later, despite being administered high doses of nitrate and calcium antagonist. During control angiography, the lesion severity was unchanged, but spasm developed again following contrast injection. At this time, a Palmaz-Schatz stent was implanted. Calcium antagonist, nitrate, Ticlopidine and low molecular weight heparin therapy was started. There was no recurrence of symptoms during a 3-month follow-up. The exercise tolerance test, and myocardial perfusion scintigraphy findings were normal and the stent was patent without restenosis at the end of the 3-month follow-up. Intracoronary stent implantation for persistent coronary spasm refractory to conventional medical therapy can be considered a feasible and attractive treatment modality for the control of symptoms.

Mitral balloon valvuloplasty with transesophageal echocardiography without using fluoroscopy

Balloon mitral valvuloplasty with Inoue technique was performed in two group of patients. In group I (n = 40) valvuloplasty was performed under fluoroscopy without using echocardiography, whereas in group II (n = 13) valvuloplasty was performed under the guidance of transesophageal echocardiography alone, without using fluoroscopy. Patients in two groups were comparable with regard to clinical variables and hemodynamic parameters. Two female patients in group II were pregnant. Transmitral pressure gradient decrease did not differ significantly between two groups (pressure gradient: 17 +/- 5 to 4 +/- 1 in group I and 15 +/- 4 to 3 +/- 1 mm Hg in group II). Mitral valvular area increase was also not different in two groups (1.09 +/- 0.2 cm2 to 2.3 +/- 0.5 cm2 in group I and 0.9 +/- 0.2 to 2 +/- 0.3 cm2 in group II). In 14 cases from group 1 and 2 cases from group II mitral regurgitation increased after valvuloplasty (p < .05). Left atrial perforation occurred in one patient from group 1 and 2 patients from group II. In conclusion, mitral balloon valvuloplasty under transesophageal echocardiographic guidance alone is a safe and effective procedure in the treatment of mitral stenosis.