A novel prediction of simulated fluid responsiveness by echocardiography assessment of tricuspid annulus tissue velocity with passive leg raising

Background:

Fluid responsiveness can be predicted by the effect of passive leg raising on cardiac output.

Objectives:

This research aimed to compare the changes in cardiac output and the peak systolic velocity values of Tricuspid annulus velocity at the free wall (S’) before and after passive leg raising in healthy volunteers.

Methods:

The study was approved by ethical commission. The desired sample size was 28, and 57 volunteers were included after they signed informed consent. The first measurements, including vital signs, S’, and cardiac output, were taken with the participants lying supine and were performed in the morning after 12 h fast. The participants were then asked to lie in a semirecumbent position for 3 min. After 3 min, the head of the bed was lowered to the supine position and the participants’ legs were elevated at 45°. Secondary measurements were repeated in this position. The differences between vital signs, cardiac output, and S’ measurements before and after passive leg raising were statistically compared. The level of significance was set as p < 0.05.

Results:

The mean values of cardiac output and S’ before passive leg raising was 9.59 L/min and 11.57 cm/s, respectively; however, those increased to 11.44 L/min and 13.72 cm/s after passive leg raising. The average increases were 16.17% for cardiac output and 15.67% for S’. The changes of cardiac output and S’ were statistically significant. The changes of vital signs before and after passive leg raising were statistically insignificant.

Conclusion:

This study has demonstrated the concordance of rise in cardiac output with S’ change by passive leg raising in healthy subjects. Further studies are needed to validate the use of S’ values in critically ill subjects.

Combining clinical predictors to better predict for the no-reflow phenomenon

OBJECTIVE

We aimed to determine whether the combination of a CHA2DS2-VASc score (C: Congestive Heart Failure, H: Hypertension, A2: Age ≥ 75 years, D: Diabetes mellitus, S: Stroke history, V: Vascular disease, A: Age ≥ 65 years, Sc: Sex category) and pre-percutaneous coronary intervention (PCI) thrombus load score was more sensitive at detecting the no-reflow phenomenon compared to the CHA2DS2-VASc score alone or to the thrombus load score alone in patients with acute ST-elevation myocardial infarction (STEMI) who had underwent primary PCI (PPCI).

PATIENTS AND METHODS

497 patients with acute STEMIs were divided into two groups: no-reflow group (n: 194) and control group (n: 303). The Thrombolysis In Myocardial Infarction (TIMI) flow grading and Myocardial Blush Grade (MBG) were used together to define angiographic no-reflow as TIMI flow < 3 (with any MBG grade) or TIMI flow 3 with MBG 0 or 1. Successful reperfusion was defined as TIMI flow 3 with MBG 2 or 3.

RESULTS

CHA2DS2-VASc score was significantly higher in the no-reflow group than in the control group (2 [1-4] vs. 1 [0-3], p < 0.001]. Compared with the control group, the no-reflow group had a higher pre-PCI thrombus score (5 [4-5] vs. 4 [3-5], p = 0.001). Compared with the CHA2DS2-VASc score alone, the combined use of the pre-PCI thrombus score and the CHA2DS2-VASc score was associated with significant improvements in the ability to predict no-reflow (AUC) (0.65 vs. 0.60, p < 0.05). The addition of the pre-PCI thrombus score to the CHA2DS2-VASc score was related to a significant net reclassification improvement of 6.7% (p = 0.047) and an integrated discrimination improvement of 0.036 (p < 0.05).

CONCLUSIONS

We have found that the combination of a CHA2DS2-VASc score and a pre-PCI thrombus load score was more sensitive in detecting the no-reflow phenomenon than only a CHA2DS2-VASc score in patients who underwent PPCIs for STEMIs.

Assessment of bicuspid aortic valve phenotypes and associated pathologies: A transesophageal echocardiographic study

OBJECTIVE

We investigated the frequency of different bicuspid aortic valve disease (BAV) phenotypes,the associated valvular pathologies, and the aortopathy phenotypes, using 2-dimensional (2D) transthoracic, 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE.

METHODS

A total of 154 patients with BAV were included. Five BAV phenotypes were detected. To better define valvular pathologies, binary classifications of BAV were used: BAV with antero-posterior commisural line (BAV-AP) and right-left commissural line (BAV-RL). Aortopathy phenotype was classified according to the involved tract(s).

RESULTS

Of the patients, 53.2% had type 1, 16.2% type 2, 15.6% type 3, 1.3% type 4, and 13.6% had type 5 BAV. The prevalence of BAV-AP and BAV-RL was 68.2% and 31.8%, respectively. No difference was detected with respect to aortic regurgitation between BAV-AP and BAV-RL (p=0.9), but the BAVRL group had an increased propensity to have a stenotic aortic valve (p=0.003). The indexed aortic diameter was larger in BAV-AP cases than BAV-RL at the sinus of Valsalva (p=0.008). In patients with dilatation of the root and tubular portion, a predominance of BAV-AP versus BAV-RL was observed (85% vs 15%). A markedly low prevalence of the root phenotype (3.2%) was observed. In 90.1% of the patients, 2D TEE was sufficient to classify BAV phenotypes; further 3D imaging was needed in 9.9% of the cases.

CONCLUSION

There may be racial differences in the frequency of valvular and aortopathy phenotypes in patients with BAV. BAV phenotypes differ with respect to aortic stenosis and aortopathy phenotypes. TEE may have good diagnostic utility in differentiating BAV phenotypes.

A bedside ultrasound technique for fluid therapy monitoring in severe hypovolemia: Tissue Doppler imaging of the right ventricle

Fluid therapy is one of the main issues for hemodynamic resuscitation. Tissue Doppler imaging (TDI) of the right ventricle (RV) with bedside ultrasound (BUS) technique is a new dynamic method to identify fluid responsiveness in patients with hypotension. Here, we present the case of a hypotensive patient monitored with TDI measurements of RV. A 75-year-old male patient was admitted to the emergency department (ED) with the complaint of diarrhea. He was in severe hypovolemia, with hypotension, tachycardia, and tachypnea. His laboratory results were normal. BUS was performed on the patient by the ED physician. The velocity of the excursion of the tricuspid valve measured at presentation was 14.47 cm/s and, together with collapsed inferior vena cava (IVC), this finding led to the decision to begin fluid therapy immediately. The patient underwent 2 L of fluid therapy with 0.9% NaCl in a 2-h period. Control BUS after fluid therapy revealed decreased TDI velocity of tricuspid annulus to 11.81 cm/s and dilated IVC not collapsing sufficiently with respiration. The patient received his maintenance therapy after admission to the internal medicine department and was discharged from the service after 3 days. TDI in fluid responsiveness may find a clinical role in the future by the clinical studies.

Bedside lung ultrasonography for diagnosis of pneumonia

Objective

The aim of this study was to investigate the accuracy of bedside lung ultrasound (BUS) in the diagnosis of community-acquired pneumonia (CAP) in patients with dyspnoea presenting to the emergency department (ED) and to analyse the characteristic sonographic findings of CAP.

Methods

After a six-hour training program, BUS procedures were performed between October 2011 and February 2012 to prospectively evaluate patients presenting to the ED with dyspnoea. Chest X-ray (CXR) or computerised tomography (CT) were ordered, depending on the presence of consolidation signs on CXR. The outcome was determined by consolidation findings on CXR or CT. BUS results were compared using Chi-squared testing.

Results

Of the 112 enrolled patients with dyspnoea, 40 patients were excluded and 72 were included in the study. Thirty-four patients were BUS positive. Of these, CXR or CT findings agreed with the BUS findings in 27 patients. In 38 cases, BUS was negative, and one patient was diagnosed with pneumonia based on the CT report. The sensitivity, specificity, PPV, NPV, and the positive and negative likelihood ratios for BUS were 96.4%, 84.1%, 79.4%, 97.4%, 6.1 and 0.042, respectively. The diagnostic accuracy of BUS was 89%. The presence of consolidation signs, either shred or hepatisation, were the most frequent sonographic findings in our study.

Conclusions

Acute alveolar consolidation can be diagnosed easily by performing BUS with high degree of accuracy in EDs.

Bedside Echocardiography in Acute Myocardial Infarction Patients with Hemodynamic Deterioration

Ventricular septal (VS) rupture after acute myocardial infarction (AMI) is an uncommon complication in the reperfusion era. Bedside echocardiography (BECH) continues to be a strong diagnostic tool for emergency physicians treating dyspneic patients, especially for decision-making on the management strategies to use with these unstable patients. In the case we present here, a patient is diagnosed with a delayed mechanical complication after AMI, and a swift management plan is made with the aid of point-of-care BECH. The patient is a 72-year-old man with dyspnea who was admitted to the ED 5 days after receiving a primary percutaneous coronary intervention with stent implantation for AMI; in the ED, the patient was diagnosed, via BECH, with a VS rupture. On arrival, his vital signs and the results of his physical examination depicted shock and low perfusion with wet lung. A cardiac examination revealed a new 2/6 harsh holosystolic murmur along the left sternal border without pretibial oedema. Emergency physicians performed BECH, and subcostal views of the heart revealed a wide interventricular septal rupture and left-to-right shunting with minimal pericardial effusion. The patient underwent surgery immediately to repair the defect. The post-operative course was uneventful, and he was discharged in stable condition on the seventh day after the surgery. The use of BECH to recognize a VS rupture is critical because such a defect may be the most important determinant of mortality in AMI patients who are in shock. BECH thus can influence clinicians' acute management and disposition decisions.

Assessment of Contributors of Aortopathy and Subclinical Left Ventricular Dysfunction in Normally Functioning Bicuspid Aortic Valves

BACKGROUND

Left ventricular (LV) function and the dimensions of aortic valves from normally functioning bicuspid aortic valve (BAV) patients were compared with those of healthy control patients. A comparison between patients with antero-posterior BAV (BAV-AP) or right-left BAV (BAV-RL) was also performed, and the determinants of aortopathy and LV function were investigated.

METHODS

Sixty-eight patients with aortic velocities <2 m/s and trivial or mild aortic regurgitation were included in the study. All patients underwent transesophageal echocardiography to diagnose BAV and identify associated phenotypes. Twodimensional (2D), Doppler echocardiographic evaluation, and strain imaging were also performed, and the results compared with those obtained from 55 age- and gender-matched healthy controls.

RESULTS

The LV ejection fractions were similar between BAV patients and healthy controls, while LV global longitudinal strain (LVGLS) (p = 0.03) and LV global circumferential strain (LVGCS) (p = 0.02) were significantly lower among BAV patients. Aortic velocities and aortic dimensions at theannulus, sinus of Valsalva and sinotubular junction were significantly greater in BAV patients (all p <0.001). The diameter of the tubular ascending aorta (AA) was correlated with age (r = 0.55, p <0.001), septal E/e' (r = 0.4, p = 0.003), and LV mass index (r = 0.29, p = 0.024). Multivariate analyses revealed that the primary determinant of the AA diameter in BAV patients was age (β = 0.38, p = 0.04), and enlargement of the AA was independent of the diastolic properties of the left ventricle and LVGLS. No significant differences were observed among the 2D or Doppler echocardiography parameters, nor among strain measurements, between BAV-AP (n = 47) and BAV-RL (n = 21) phenotypes.

CONCLUSIONS

Subclinical myocardial dysfunction was observed in BAV patients with normal aortic valve function. LV dysfunction was independent of age, aortic velocity and AA diameter, which suggested the presence of intrinsic myocardial disease. Aging contributes to aortic dilatation in normally functioning BAV.

Visual estimation of bedside echocardiographic ejection fraction by emergency physicians

Introduction

The objective of this study was to determine whether bedside visual estimates of left ventricular systolic function (LVSF) by emergency physicians (EP) would agree with quantitative measurement of LVSF by the modified Simpson’s method (MSM), as recommended by the American Society of Echocardiography.

Methods

After limited focused training, 2 trained EPs performed bedside echocardiography (BECH) procedures s between January and June 2012 to prospectively evaluate patients presenting to the emergency department (ED) with dyspnea. EPs categorized their visually estimated ejection fractions (VEF) as either low or normal. Formal echocardiography were ordered and performed by an experienced cardiologist using the MSM and accepted as the criterion standard. We compared BECH results for each EP using chi-squared testing and performed correlation analysis by Pearson correlation coefficient.

Results

Of the 146 enrolled patients with dyspnea, 13 were excluded and 133 were included in the study. Comparison of EPs vs. cardiologist’s estimate of ejection fraction yielded a Pearson’s correlation coefficient of 0.77 (R, p<0.0001) and 0.78 (R, p<0.0001). Calculated biserial correlations using point-biserial correlation and z-scores were 1 (rb, p<0.0001) for both EPs. The agreement between EPs and the cardiologist was 0.861 and 0.876, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and the positive and negative likelihood ratios for each physician were 98.7–98.7%, 86.2–87.9%, 0.902–0.914, 0.980–0.981, 7.153–8.175, 0.015–0.015, respectively.

Conclusion

EPs with a focused training in limited BECH can assess LVSF accurately in the ED by visual estimation.

Parameters of heart rate variability can predict prolonged asystole before head-up tilt table test

BACKGROUND

We aimed to evaluate whether heart rate variability (HRV) could predict prolonged asystole before head-up tilt table test (HUTT) by comparing time domain HRV parameters of patients with type 2B vasovagal syncope (VVS) and patients with other types of VVS.

METHODS

Ninety-eight patients who examined with 24-hour Holter electrocardiogram monitoring before HUTT and diagnosed with VVS were enrolled. Patients were divided into two groups in accordance with their VVS type as group 1 (n = 43) consisting of patients with type 2B VVS and group 2 (n = 57) consisting of patients with other types of VVS. Time domain HRV parameters (SDNN, SDANN, SDNN index, RMSSD, pNN50) of two groups were compared. ROC curve analysis was performed to predict best cutoff values that could prognosticate occurrence of prolonged asystole during HUTT.

RESULTS

SDNN, SDANN, SDNN index values were significantly longer for group 1 compared to group 2 (P = 0.009, P = 0.006, P = 0.004; respectively). While a SDNN cutoff value of ≥151 ms predicted occurrence of type 2B VVS before HUTT with 69% sensitivity and 56% specificity, a SDANN value of ≥164 ms had 47% sensitivity and 87% specificity and a SDNN index value of ≥102 ms showed 40% sensitivity and 85% specificity.

CONCLUSIONS

In our study, we tried to demonstrate prediction of prolonged asystole by analyzing HRV parameters before HUTT. We found out that time domain HRV parameters were longer in patients with type 2B VVS than patients with other types of VVS. Our results need to be supported by extensive studies.

The effects of iodixanol and iopamidol on adhesion molecule serum levels in patients with angina pectoris undergoing coronary angiography: a randomized study

OBJECTIVE

To compare intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) serum levels between patients with stable (SAP) and unstable angina pectoris (USAP) undergoing coronary angiography (CAG), investigate effects of CAG on ICAM-1, VCAM-1 levels in SAP, USAP patients; probable different effects of non-ionic radiocontrast media (RCM), iso-osmotic iodixanol and low osmolar iopamidol, on these adhesion molecules (AM).

METHODS

In this randomized, prospective study, 2 groups consisting of patients with SAP (n=22) and USAP (n=22) undergoing CAG were included. For halves of each group iopamidol, for the other halves iodixanol were used as RCM, in turn for randomization. The patients were divided into 4 subgroups according to clinical presentations and used RCM(SAP-iodixanol, SAP-iopamidol USAP-iodixanol, USAP-iopamidol). ICAM-1, VCAM-1 levels were measured just before and 12 hours after CAG. Repeated measurements were compared with two-way ANOVA test.

RESULTS

Baseline VCAM-1 concentration was higher in USAP group than SAP group (p=0.001). ICAM-1, VCAM-1 concentrations increased significantly following CAG in SAP, USAP groups. ICAM-1, VCAM-1 concentration increments; didn't reach statistical significance in SAP-iodixanol subgroup, reached a borderline significance in SAP-iopamidol subgroup (p=0.06). In USAP-iodixanol subgroup; only VCAM-1 (p<0.001), in USAP-iopamidol subgroup; ICAM-1 (p=0.009), VCAM-1 (p=0.006) levels increased significantly following CAG. No complication was observed.

CONCLUSION

To our knowledge, this is the first study indicating ICAM-1, VCAM-1 inducing effect of CAG in patients with SAP, USAP and differential effects of iodixanol and iopamidol on ICAM-1, VCAM-1 serum levels. Further studies are needed to clarify the effects of CAG and different RCM on vascular inflammation, vessel injury, serum AM levels and their clinical significance. This study should be taken as a pilot, hypothesis-generating study.

An alternative approach to the bedside assessment of left ventricular systolic function in the emergency department: displacement of the aortic root

OBJECTIVES

Left ventricular ejection fraction (LVEF) is a crucial parameter in the management of patients with dyspnea in the emergency department (ED). The use of techniques other than echocardiography such as nuclear or magnetic resonance imaging to measure LVEF is unsuitable in the ED because of time constraints. This study aimed to compare echocardiographic aortic root (AR) excursion and LVEF measurement using the modified Simpson's method (biplane method of disks) as recommended by the American Society of Echocardiography.

METHODS

After 2 hours of theoretical video and hands-on training with 20 patients by an experienced echocardiographer, two emergency physicians prospectively evaluated patients with dyspnea. Two-dimensional echocardiograms of the parasternal long-axis view were obtained, and the displacement of the aortic root (DAR) was studied. M-mode DAR recordings were obtained, and distances were measured as the maximized anterior displacement of the AR from the horizontal axis at end-systole by using the leading-edge methodology. LVEF was measured by an experienced cardiologist using the modified Simpson's rule. The sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-), and positive and negative predictive values (PPV, NPV) were analyzed. A new formula for the prediction of the ejection fraction (EF) with the aid of DAR was then created.

RESULTS

The mean (±SD) age with of the 70 study patients was 69.7 (±11.91) years. In these patients, DAR was highly correlated with EF (point biserial correlation coefficient = 0.79, p < 0.001) and one-way analysis of variance (ANOVA) results were significant (F = 115.9; p < 0.001). The sensitivity was 94.4; specificity, 94.1; LR+, 16.6; LR-, 0.059; PPV, 94.4; and NPV, 94.1.

CONCLUSIONS

The results indicate that DAR is a sensitive index of left ventricular systolic function (SF) and can be used to reliably predict EF values using the rough formula of EF = 20 + 44 (DAR).

Comparing the Renal Safety of Isoosmolar Versus Low-Osmolar Contrast Medium by Renal Biomarkers N-Acetyl-β-d-Glucosaminidase and Endothelin

Iodixanol and iopamidol are commonly used contrast agents in coronary angiography. We evaluated the nephrotoxic effects of both contrast media in relation to renal biomarkers. A total of 38 low-risk patients who underwent coronary angiography were enrolled. Patients were randomized to receive either low-osmolar nonionic monomer or isoosmolar nonionic dimer contrast medium. N-Acetyl-β-d-glucosaminidase (NAG), endothelin, blood urea nitrogen, and urine and serum creatinine (SCr) levels were measured before  the procedure (T0), at 6 hours (T6), and at 1 year after the procedure. Plasma endothelin, urine NAG/creatinine, and SCr were higher; accordingly, the urine creatinine values were lower in both the groups when comparing T0 versus T6. The groups were similar with each other when comparing T0 and T6 values. Both the contrast agents may be safely used at a low volume for coronary angiography in low-risk patients. Endothelin and NAG are sensitive to acute renal changes in function. There is a need for further prospective investigations with more patients.

Prevalence and clinical features of atrial fibrillation in diabetic neuropathy: a cross-sectional, observational study

OBJECTIVE

This cross-sectional, observational study investigated prevalence and clinical features of atrial fibrillation (AF) in diabetic patient groups with or without autonomic neuropathy.

METHODS

One hundred and fourteen consecutive patients with pharmacologically treated type-II diabetes mellitus were enrolled for this study in our institution between January 2010 and December 2010. All patients underwent 12-lead electrocardiography on the day of enrollment for AF detection. All diabetic patients underwent neurologic examination for the presence of diabetic autonomic neuropathy (DAN). Following clinical evaluation, sympathetic skin responses (SSR) and RR interval variability (RRIV) analysis were used for the detection of autonomic neurologic involvement. Patients were divided into two groups according to presence (Group 1) or absence (Group 2) of DAN. Patient groups with or without DAN were compared for AF occurrence. Continuous and categorical data were compared with independent samples t- test and Chi-square statistical tests respectively.

RESULTS

Atrial fibrillation prevalence was 24% (n=29) in study population. Diabetic autonomic neuropathy was diagnosed in 47 (39%) patients. Basal characteristics of patients with or without DAN were comparable except glycosylated hemoglobin A (HbA1c) levels. HbA1c levels were found significantly higher in patients with DAN. Atrial fibrillation was diagnosed in 14 patients in Group 1 and in 15 patients in Group 2. Significantly increased AF prevalence (31.9% vs. 20.8%, p=0.014, in groups with and without DAN respectively) was observed in patient group with diabetic autonomic neuropathy.

CONCLUSION

The results of this study demonstrated an increased prevalence of AF in patients with diabetic autonomic neuropathy compared with non-neuropathic, diabetic patients. Further investigation of this relation with prospective studies is needed to demonstrate a causal relationship between diabetic autonomic neuropathy and AF.

Central venous obstruction and clinical predictors in patients with permanent pacemaker

OBJECTIVE

This study investigated the proportion of silent venous obstruction in patients who underwent pacemaker or lead reimplantation for various reasons. We also investigated independent predictors or risk factor of venous obstruction in this patient population.

METHODS

Seventy-three patients who underwent pacemaker pulse generator and/or lead reimplantation in our institution between 2007 and 2010 were enrolled for this retrospective case-control study. Prior to procedure, patients underwent ipsilateral venography. Patients' venographies were classified as non-significant obstruction (stenosis ≤70%, including normal venogram), significant obstruction (stenosis >70%) and complete obstruction. Continuous and categorical data were compared with Mann-Whitney U test and Chi-square statistics respectively. Logistic regression analysis was used to identify independent predictors of venous obstruction.

RESULTS

Complete or significant silent central venous obstruction (CVO) proportion was detected as 9.5% (n=7). Basal characteristics of patients with or without CVO were comparable. Significantly increased pacemaker pocket erosion incidence (57% vs 0%, p=0.001, in groups with and without CVO respectively) and significantly higher mean pacemaker age (15.3 ± 10.2 years vs 10.4 ± 5.1 years, p=0.047, in groups with and without CVO respectively) were found in group with CVO. Pacemaker pocket erosion (OR 3.00; 95% CI 1.024-9.302; p=0.001), higher pacemaker age (OR 1.33; 95% CI 1.026-1.733; p=0.02) were found as independent CVO predictors in multiple logistic regression analysis. Correlation analysis also revealed a significant correlation between previous or current pacemaker pocket erosion and CVO (r=0.80, p=0.001).

CONCLUSION

Ipsilateral venography is a useful procedure prior to pacemaker or lead reimplantation to detect CVO. In addition to the increased pacemaker age, current or past history of erosion and infection at pacemaker pocket are probable clinical conditions related to CVO. These clinical conditions create a predisposition to CVO with unknown mechanisms, according to the results of this preliminary study.

Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and Upright T wave in V1

We present a case of Wellens' syndrome together with upright T wave in lead V₁ in a man presenting with atypical chest pain, and we discuss the significance of its prompt recognition by the emergency physicians who are involved in the evaluation of patients with coronary artery disease in emergency departments.

Comparison of existing syncope rules and newly proposed anatolian syncope rule to predict short-term serious outcomes after syncope in the Turkish population

Background

We wished to compare the San Francisco Syncope Rule (SFSR), Evaluation of Guidelines in Syncope Study (EGSYS) and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk scores and to assess their efficacy in recognising patients with syncope at high risk for short-term adverse events (death, the need for major therapeutic procedures, and early readmission to the hospital). We also wanted to test those variables to designate a local risk score, the Anatolian Syncope Rule (ASR).

Methods

This prospective, cohort study was conducted at the emergency department of a tertiary care centre. Between December 1 2009 and December 31 2010, we prospectively collected data on patients of ages 18 and over who presented to the emergency department with syncope.

Results

We enrolled 231 patients to the study. A univariate analysis found 23 variables that predicted syncope with adverse events. Dyspnoea, orthostatic hypotension, precipitating cause of syncope, age over 58 years, congestive heart failure, and electrocardiogram abnormality (termed DO-PACE) were found to predict short-term serious outcomes by logistic regression analysis and these were used to compose the ASR. The sensitivity of ASR, OESIL, EGSYS and SFSR for mortality were 100% (0.66 to 1.00); 90% (0.54 to 0.99), 80% (0.44 to 0.97) and 100% (0.66 to 1.00), respectively. The specificity of ASR, OESIL, EGSYS and SFSR for mortality were 78% (0.72 to 0.83); 76% (0.70 to 0.82); 80% (0.74 to 0.85) and 70% (0.63 to 0.76). The sensitivity of ASR, OESIL, EGSYS and SFSR for any adverse event were 97% (0.85 to 1.00); 70% (0.52 to 0.82); 56% (0.40 to 0.72) and 87% (0.72 to 0.95). The specificity of ASR, OESIL, EGSYS and SFSR for any adverse event were 72% (0.64 to 0.78); 82% (0.76 to 0.87); 84% (0.78 to 0.89); 78% (0.71 to 0.83), respectively.

Conclusion

The newly proposed ASR appears to be highly sensitive for identifying patients at risk for short-term serious outcomes, with scores at least as good as those provided by existing diagnostic rules, and it is easier to perform at the bedside within the Turkish population. If prospectively validated, it may offer a tool to aid physicians' decision-making.

An observational study of the effect of coronary artery disease severity on acute pacing threshold and lead impedance in patients with permanent pacemaker

OBJECTIVE

This study investigated the effect of coronary artery disease (CAD) severity, distribution and left ventricular ejection fraction (LVEF) on acute ventricular pacing threshold and lead impedance at the time of pacemaker implantation.

METHODS

One hundred and thirty-two patients who received a ventricular pacemaker or internal cardioverter-defibrilator (ICD) lead in our institution between 2007-2010 were included in this observational study. Patients were divided into ICD and anti-bradycardic pacemaker (PM) groups. Groups were compared for ventricular stimulation threshold, lead impedance and LVEF. Later, groups were sub-grouped according to the severity and distribution of CAD and subgroups were compared in both groups for ventricular stimulation threshold, lead impedance. Quantitative data of groups were compared by means of independent samples t-test.

RESULTS

Ventricular pacing thresholds were found significantly higher ICD group compared with PM group (p<0.05). Impedance and LVEF values were significantly lower in ICD group (p<0.05). Impedance and ventricular pacing thresholds were comparable in subgroups of ICD and PM groups. Our study does not confirm any relationship between pacing parameters and severity-distribution of CAD and LVEF.

CONCLUSION

Patients with ventricular ICD lead had higher pacing thresholds but lower pacing impedance values comparing with PM group. This study did not find any significant relationship between pacing parameters at implantation and LVEF, severity and distribution of CAD.

The role of nebivolol in the prevention of contrast-induced nephropathy in patients with renal dysfunction

OBJECTIVE

This prospective study was designed to evaluate the potential protective effect of nebivolol compared with metoprolol on the development of contrast-induced nephropathy (CIN) following coronary angiography in patients with renal dysfunction.

METHODS

Ninety patients with stable coronary angina pectoris with renal insufficiency (creatinine value ≥1.2 mg/dl) were included for this prospective study. Patients were divided into two groups. Patients in group 1 (n=55) received oral administration of nebivolol 5 mg/daily for coronary artery disease and/or hypertension. Group 2 consisted of 35 patients who received metoprolol 50 mg/daily for the same indications. All patients were hydrated with 0.9% NaCl at a rate of 1 mL/kg/hr for 12 hours before and 24 hours after the procedure. Patients were also given N-acetylcysteine (NAC) 600 mg twice a day, beginning 24 hours before and continuing 48 hours after the procedure. All patients underwent routine coronary angiography. Serum creatinine was assessed just before, immediately after and 48 hours after the procedure. CIN was defined as an increase in serum creatinine concentration of ≥25% within 48 hours after the procedure compared to the patient's baseline value. Tests for significance between groups were conducted using the independent sample t-test for continuous variables and Chi-square test for categorical variables.

RESULTS

Baseline serum creatinine levels were statistically comparable in two groups. Following angiography, serum creatinine levels increased in both groups. Post-angiographic creatinine levels were not statistically different in the nebivolol and the metoprolol groups. Contrast induced nephropathy developed in 13 patients (24%) of the nebivolol group and in 12 patients (33%) of the metoprolol group. The incidence of CIN was statistically significantly lower in the nebivolol group comparing with the metoprolol group (p=0.03).

CONCLUSION

The use of oral nebivolol for one week at a dose of 5 mg per day may decrease the incidence of contrast-induced nephropathy in patients who underwent coronary angiography with renal dysfunction. The small numbers of this study do not allow to draw final conclusion on the use of nebivolol in the prevention of CIN. Therefore, larger studies may be necessary to address the definite role of nebivolol in this setting.

Tricuspid annular motion in right coronary artery-related acute inferior myocardial infarction with or without right ventricular involvement

OBJECTIVE

Tricuspid annular movement and velocities before and after thrombolytic therapy were investigated for the detection of right ventricular (RV) involvement in RCA (right coronary artery)-related acute inferior myocardial infarction (IMI).

METHODS

Patients with RCA-related acute IMI were evaluated for this pilot prospective cohort study. Annular movement was measured by TAPSE (tricuspid annular plane systolic excursion), and annular velocities were measured by tissue Doppler echocardiography. Data collected before and after thrombolysis and angiography. Diagnosis of RV myocardial infarction (RVMI) was defined by co-presence of electrocardiographic and angiographic criteria. Chi-square and Student's t-tests were used in statistical analysis.

RESULTS

Thirty-one patients were included. Before thrombolysis, annular velocities and TAPSE were found significantly higher in patients without RVMI than in patients with RVMI. Comparison of tricuspid systolic velocity (Sa) and movement before and after thrombolytic therapy in patients without RVMI revealed no significant difference (21.6±2.1 mm vs. 21.8±2.0 mm p>0.05 and 136.1±8.8 mm/s vs. 137.5±9.0 mm/s p>0.05, for TAPSE and Sa respectively). Contrarily, in patients with RVMI, TAPSE and systolic velocity increased significantly after thrombolysis compared with pre-thrombolysis (16.2±2.0 mm vs. 17.6±1.8 mm p=0.001 and 110.0±12.6 mm/s vs. 113.08±12.7 mm/s p=0.027 for TAPSE and Sa respectively). Diastolic velocities did not change significantly after thrombolysis in patients with RVMI.

CONCLUSION

Tricuspid annular movement and velocity measurement by echocardiography may contribute to echocardiographic diagnosis of RV involvement in RCA-related IMI. Patients without RVMI have significantly higher annular velocities and TAPSE than in patients with RVMI before thrombolysis. Only in IMI patients with RVMI, significant increases in TAPSE and Sa were observed after thrombolysis.

[Value of interatrial conduction time and P wave dispersion in the prediction of atrial fibrillation following coronary bypass surgery]

OBJECTIVE

This prospective observational study investigated predictive power of interatrial conduction time (IACT) and P wave dispersion (PWD), in addition to other atrial fibrillation (AF) predictors, in patients undergoing coronary artery bypass surgery (CABG).

METHODS

Eighty-one patients undergoing CABG were enrolled. Before surgery, IACT and PWD were measured. Time interval from electrocardiographic P wave to echocardiographic transmitral a wave was defined as IACT. Rhythm monitorization was used for AF detection. Continuous and categorical data were compared with independent samples t test and Chi-square statistics. Multiple logistic regression analysis was used to identify independent AF predictors.

RESULTS

During a follow-up period of 6.4 ± 2.1 days, AF developed in 14 patients (17%). There were no significant differences between patients with or without AF according to age, gender, number of bypass grafts, cross-clamp duration, systolic function, and left atrial diameter. Significantly increased PWD and IACT were found in AF group (PWD: 37 ± 9 ms vs 24 ± 8 ms, p=0.005 and IACT: 129 ± 11 ms vs 117 ± 11 ms, p=0.01) as compared to group without AF. Increased PWD (OR 1.17; 95% CI 1.04-1.31; p=0.02), absence of beta-blocker treatment (OR 8.88; 95% CI 1.62-48.45; p=0.01), diabetes (DM) and hypertension (HT) combination (OR 1.45; 95% CI 1.15-4.22; p=0.01) were independent AF predictors. However, IACT predictive power had borderline significance (OR 1.03; 95% CI 0.95-1.12; p=0.06).

CONCLUSION

Increased PWD, absence of beta-blocker therapy, HT-DM combination were independent AF predictors following CABG. There was significant difference between groups according to IACT, however predictive value of IACT was nonsignificant. Other studies are needed to establish predictive power of IACT.

[The effect of atrial pacing on left ventricular diastolic function and BNP levels in patients with DDD pacemaker]

OBJECTIVE

We aimed to investigate the effect of atrial pacing on left ventricular diastolic function and brain natriuretic peptide (BNP) levels in patients with DDD pacemaker.

METHODS

Thirty patients with complete atrio-ventricular (AV) block and DDD pacemaker were included. All patients had normal left ventricular systolic function. Echocardiographic diastolic function parameters (transmitral and tissue Doppler velocities during early (E and E') and late (A and A') filling) and NT-pro-BNP levels were evaluated prospectively during atrial sensing and pacing periods. Echocardiographic data were compared with paired sample t test and NT-pro-BNP levels were compared with Wilcoxon test.

RESULTS

Echocardiographic E/A, E'/A', E/E' ratios were calculated as 0.72+/-0.34, 0.61+/-0.21 and 8.76+/-2.58 during atrial sensing period. Same parameters were found as 0.71+/-0.23, 0.64+/-0.16 and 8.93+/-3.16 respectively during atrial pacing period. Echocardiographic left ventricular diastolic function parameters were not significantly different during atrial pacing and atrial sensing periods. Median plasma NT-pro-BNP levels were measured as 142 pg/ml (min-max 47-563 pg/ml) and 147 pg/ml (min-max 33-1035 pg/ml) during atrial sensing and pacing periods respectively. These levels were not significantly different (p=0.86).

CONCLUSION

The result of this study has shown that, atrial pacing has not any additional detrimental effect on left ventricular diastolic function parameters in paced patients with normal left ventricular systolic function.

[Retrospective analysis of 1650 permanent pacemaker implantations experience over two different consecutive time periods in a single cardiology clinic]

OBJECTIVE

Indications for pacing, pacing modes, and demographics of patients who underwent pacemaker implantation between two different time periods were compared in this study.

METHODS

Pacemaker registry of our cardiology department was used to evaluate these changes from 1986 to 2007 (First period: 1986-1996, second period: 1997-2007) retrospectively.

RESULTS

Registry revealed 776 implantations in the first and 874 implantations in the second period. The percentages of first implantation were 89% and 70.1% respectively. Nearly 50% of the patients in both periods were female. Main indications for pacing were atrioventricular (AV) block, sick sinus syndrome (SSS) and slow ventricular rate during atrial fibrillation in both periods. Implantation of VVI-AAI pacemakers have decreased (77.8%/1.5% to 51%/0.3%, p=0.05) and implantation of DDD-VDD pacemakers have increased (19.3%/1.3% to 42.3%/6.3%, p=0.05) during the second period compared to the first period. Permanent pacemaker implantation for SSS has decreased significantly from 31.1% in the first period to 12.0% (p=0.05) in the second period. Implantation for AV block has increased significantly from 63.3% to 79.7% (p=0.05) in the second period.

CONCLUSION

Our data revealed temporal changes in pacemaker implantation practice during last twenty years in the cardiology department of a teaching hospital. Implantation of VVI-AAI pacemakers have decreased significantly during the second period. Permanent pacemaker implantation for AV block has also decreased during the last period.

Progression of conduction system disease in a paced patient with Kearns-Sayre syndrome

The Kearns-Sayre syndrome is a rare condition characterized by external ophthalmoplegia, retinal pigmentary degeneration and progressive impairment of cardiac conduction. We report a patient with the permanent pacemaker. The spontaneous cardiac impulse formation disappeared during long-term follow-up in this patient with Kearns-Sayre Syndrome.

Should we revascularize before implanting a pacemaker?

BACKGROUND

The effect of coronary revascularization on disappearance of the severe conduction disturbances is still unclear.

HYPOTHESIS

We sought to determine whether revascularization may induce recovery of sinus rhythm in patients with significant coronary artery disease and complete atrioventricular block (AVB).

METHODS

Fifty-three patients who had third-degree AVB and significant coronary artery disease were enrolled. Patients with acute coronary syndromes were excluded. Thirty-three (62%) patients were men and the mean age was 65 +/- 10 y. All patients received a permanent dual-mode, dual-pacing, dual-sensing (DDD) pacemaker. Coronary disease was treated medically in 16 (30%) patients due to patient preference or ineligibility. Thirty-seven (70%) patients underwent a revascularization procedure (coronary artery bypass grafting [CABG]: 16, percutaneous coronary intervention [PCI]: 21 pts). Mean follow-up was 36 +/- 6 mo and patients were evaluated every 3 mo according to their resting electrocardiograms (ECGs) at each visit.

RESULTS

In the medically treated group, 13 (81%) patients still had third-degree AVBs at the end of the follow-up period, while 3 (19%) patients returned to normal sinus rhythm. On the other hand, 27 out of 37 patients (73%) who were revascularized were still in complete AVB, and 10 patients from this group (27%) had returned to normal sinus rhythm. There was no statistically significant difference between the revascularized and medically treated groups in terms of need for a pacemaker.

CONCLUSIONS

Patients who have concomitant severe conduction disturbances and significant coronary disease may well receive a pacemaker before a revascularization procedure. Our data shows that coronary revascularization has little, if any, impact on returning to normal AV conduction.

Radon measurements in the Catalagzi Thermal Power Plant, Turkey

The Catalağzi Thermal Power Plant (CTPP) (41(0)30'48.4('')N and 0.31(0)53'41.5('')E) is located at nearly 13 km North-east of Zonguldak city, which is located at the West Black Sea coast in Turkey. The middling products with high ash content of bituminous coals are used in this plant. Seasonal radon concentration measurements have been carried out by using CR-39 plastic track detectors in and around the CTPP. The annual average radon concentration has been found to vary from a minimum of 39.8 +/- 28.9 Bq m(-3) in the ash area to a maximum of approximately 75.0 +/- 15.7 Bq m(-3) in the service building of the power plant. The annual average radon concentration in the dwellings of the thermal power plant colony of the plant is 71.0 +/- 33.4 Bq m(-3). The effective dose has been found to vary from 0.38 to 0.71 mSv y(-1) with a mean value of 0.56 mSv y(-1), which is lower than the effective dose values 3-10 mSv given as the range of action levels recommended by International Commission on Radiological Protection: Protection against radon-222 at home and at work, ICRP Publication 65 (1993).

Is there an association between left bundle branch block and coronary slow flow in patients with normal coronary arteries?

Slow flow in angiographically normal coronary arteries is not a rarely seen problem. It is unknown whether it is related with conduction disorders. In this study we investigated the frequency of conduction disorders in patients with normal coronary artery and slow flow. The study included 36 (22 female; mean age 63 +/-11 years) patients who have normal coronary arteries and slow flow in coronary angiography. Patients' 12-lead electrocardiograms were analyzed for the presence of bundle branch block. Twenty-two of 36 patients (61%) demonstrated left bundle branch block. Twelve patients (33%) had normal intraventricular conduction. Only 2 of 36 patients (6%) had right bundle branch block. Microvascular disease has been implicated in coronary slow flow. However, according to the results of this study there is a close association between especially left bundle branch block and coronary slow flow. A causal relation should be sought between them with future studies.

The Brugada syndrome: can we predict the risk?

Since its introduction in 1992, the Brugada syndrome has attracted great interest because of increased risk of sudden cardiac death. Risk stratification aimed at the identification of patients at risk for sudden death is an important goal of current research. Controversy exists on risk stratification particularly in asymptomatic individuals. The predictive value of the inducibility of ventricular tachyarrhythmias is also discussed controversially. Currently, an implantable cardioverter defibrillator is the only proven effective treatment for the disease.

Impact of diabetic and pre-diabetic state on development of contrast-induced nephropathy in patients with chronic kidney disease

BACKGROUND

The aim of the present study was to assess the influence of diabetic and pre-diabetic state on the development of contrast-induced nephropathy (CIN) in chronic kidney disease patients undergoing coronary angiography.

METHODS

A total of 421 patients with Cockcroft clearance between 15 and 60 ml/min were divided into three groups [diabetes mellitus (DM), n = 137; pre-diabetes (pre-DM), n = 140; and normal fasting glucose (NFG), n = 144]. CIN was defined as an increase of > or =25% in creatinine over baseline within 48 h of angiography, DM as glucose > or =126 mg/dl, pre-DM as glucose between 100 and 125 mg/dl and NFG as glucose <100 mg/dl.

RESULTS

CIN occurred in 20% of the DM [relative risk (RR) 3.6, P = 0.001], 11.4% of the pre-DM (RR 2.1, P = 0.314) and 5.5% of the NFG group. The decrease of glomerular filtration rate (GFR) was higher in DM and pre-DM (P = 0.001 and P = 0.002, respectively). GFR < or =30 ml/min (RR 19.22), multivessel involvement (RR 7.59), hyperuricaemia (RR 3.95), use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker (RR 2.70) and DM (RR 2.34) were predictors of CIN. Length of hospital stay was 2.45 +/- 1.45 day in DM, 2.27 +/- 0.68 day in pre-DM and 1.97 +/- 0.45 day in NFG (P < 0.001, DM vs NFG and P = 0.032, pre-DM vs NFG). The rate of major adverse cardiac events was 8.7% in DM, 5% in pre-DM and 2.1% in NFG (P = 0.042, DM vs NFG). Haemodialysis was required in 3.6% of DM and 0.7% in pre-DM (P = 0.036, DM vs NFG), and the total number of haemodialysis sessions during 3 months was higher in DM and pre-DM (P < 0.001). Serum glucose > or =124 mg/dl was the best cut-off point for prediction of CIN.

CONCLUSION

Our data support that patients with DM are at a higher risk of developing CIN, but patients with pre-DM are not at as high a risk for developing CIN as diabetes patients.