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Wiskott-Aldrich syndrome (WAS) is a rare X-linked primary immunodeficiency disorder that is characterized by a triad of microthrombocytopenia, severe immunodeficiency, and eczema. We report the case of a 7-year-old male patient with chronic thrombocytopenia that was diagnosed as WAS after dilatation of the ascending aorta was noticed. WAS is rare, and it is a disease that requires high suspicion for diagnosis. We recommend periodic echocardiography and magnetic resonance imaging examinations to evaluate aortic aneurysms in children with WAS and that surgical intervention should not be delayed when aneurysm is detected.

In heart failure with reduced ejection fraction (HFrEF) patients, myocardial blood flow (MBF), myocardial energy expenditure (MEE), myocardial efficiency has been poorly evaluated because of the necessity of invasive procedures in the determination of these parameters. Transthoracic echocardiography (TTE) can provide reliable data for MEE, MBF (via coronary sinus (CS) flows). Also, myocardial efficiency can be evaluated by the MEE to MBF ratio. We aim to assess MBF, MEE and energy efficiency and the prognostic value of these parameters in HFrEF. In this prospective study, a total of 80 patients with HFrEF due to either ischemic or non-ischemic etiology and 20 healthy control subjects were included. Median follow-up duration was 901 (27-1004) days. MBF was calculated via coronary sinus blood flow. MEE was measured from circumferential end-systolic stress, stroke volume and left ventricular ejection time. MEE to MBF ratio was determined as MEf. Primary composite end-point (CEP) was cardiovascular mortality, heart transplantation or mechanical circulatory support. MEE and MEf were lower and MBF per minute was higher in HF group compared to control subjects whereas MBF per 100 g left ventricular mass was not different. MEE and MEf have significantly negative correlation with troponin I, BNP, uric acid and positive correlation with epicardial fat thickness. In Cox regression analysis, per one calorie decrease of MEE was associated 4.3 times increased risk [HR 4.396 (95% CI 1.230-15.716)] and per one percent decrease of MEf was associated 3.3 times increased risk of CEP [HR 3.343 (95% CI 1.025-10.905)]. Our study demonstrated that while MEE and MEf diminished in HFrEF, MBF preserved with the symptomatic progression of HF. MEE and MEf were found to be associated with important prognostic markers and independent predictors of CEP in HFrEF. Evaluation of MEE, MBF and MEf with echocardiography may provide an additional data regarding prognostic assessment of HFrEF population.

WOS: 000257946700009, PubMed ID: 17705053, Background: Acute coronary syndromes, characterized by the rupture of unstable plaque and the subsequent thrombotic process involving platelets, have been increasing in relative frequency. The central role of platelet activation has long been noticed in this pathophysiology; hence, many therapies have been directed against it. In this study, we have aimed to search prospectively the value of mean platelet volume (MPV), which is a simple and accurate measure of the functional status of platelets, in patients hospitalized with diagnosis of acute coronary syndromes (ACS). Materials and methods: A total of 216 consecutive patients (156 male, 60 female) hospitalized with the diagnosis of non-ST segment elevation (NSTE) ACS within the first 24 h of their chest pain were enrolled. One hundred and twenty patients, matched according to sex and age, with stable coronary heart disease (CHD) (85 male, 35 female) were enrolled as a control group. Patients were classified into two group: those with unstable angina (USAP, n = 105) and those with non-ST segment elevation myocardial infarction (NSTEMI, n = 111). Results: MPVs were 10.4 +/- 0.6 fL, 10 +/- 0.7 fL, 8.9 +/- 0.7 fL consecutively for NSTEMI, USAP and stable CHD with significant differences. Patients with ischemic attacks in the first day of hospitalization accompanied by > 0.05 mV ST segment shift had significantly higher MPV compared to those without such attacks (P = 0.001). Multivariable logistic regression analysis yielded that MPV (P = 0.016), platelet count (P < 0.001), and the presence of > 0.05 mV ST segment depression at admission (P = 0.002) were independent predictors of development of NSTEMI in patients presenting with NSTE ACS. Conclusion: In patients presenting with NSTE ACS, higher MPV, though there are overlaps among subgroups, indicates not only more risk of having NSTEMI but also ischemic complications.

WOS: 000242209100008, PubMed ID: 16943646, Background: Atrial fibrillation (AF) is a frequent arrhythmia, associated with morbidity and mortality. It is identified by two types on surface electrocardiogram as fine and coarse AF. We aimed to search the association of subtypes of AF with clinical parameters. Methods: Eight hundred and eleven consecutive patients, who had AF attack which lasted longer than 24 h or more, were evaluated along with clinical and laboratory data. Results: Coarse AF was noticed in 51.7% (n = 419), and fine AF in 48.3% (n = 392). Sex was associated with subtype of AF such that coarse AF was present in 46.5% of male patients, but in 56.1% of female patients (p = 0.009). Coarse AF was present in 85.3% of patients with mitral stenosis, whereas it was present in 35.3% of patients with normal heart valve (p < 0.001).). Patients having fine AF were significantly older than those having coarse AF (64 +/- 12, 57 +/- 13 years, p < 0.001). 19.6% of those with coarse AF had history of cerebrovascular event (CVE), whereas 13.5% of those with fine AF had history of CVE (p = 0.021). After controlling for age in the multivariable logistic regression analysis, presence of coarse AF (B = 1.585, p = 0.031) was found to be independently associated with the history of CVE. Conclusion: AF is identified by two morphological forms on the surface electrocardiogram. These two forms were found to be associated with different clinical parameters, acting on vascular endpoints differently. Copyright (c) 2007 S. Karger AG, Basel.

WOS: 000234323900007, PubMed ID: 16374140, Background Coronary artery bypass grafting has been performed for a long period utilizing saphenous vein grafts, the fate of which might be crucial to prognosis following the operation. Metabolic syndrome, on the other hand, has become an increasingly important part of cardiovascular practice. We examined whether there was any negative effect of metabolic syndrome on saphenous vein graft patency in a relatively short term (

BACKGROUND The development of coronary collateral vessels is the physiological response of myocardial tissue to hypoxia or ischemia, which results in an increase in blood supply to the tissue. However, a lack of collateral vessels or the presence of poor collateralization in some patients despite the presence of significant coronary stenosis or obstruction and evidence of myocardial ischemia suggest that some other factors may affect the development of collateral circulation. In the present study we aimed to evaluate coronary collateral circulation in patients with metabolic syndrome with advanced coronary artery disease and compare the results with those of patients without metabolic syndrome. METHOD The study population comprised 102 patients with metabolic syndrome and advanced coronary artery disease (>or=90% diameter stenosis in at least one major epicardial coronary artery) and 102 control participants without metabolic syndrome who also had >or=90% diameter stenosis in at least one major epicardial coronary artery. The diagnosis of metabolic syndrome was based on the National Cholesterol Education Program Adult Treatment Panel III clinical definition. Coronary collateral vessels were analysed according to the Cohen and Rentrop grading system. Both groups were also divided into two additional groups according to the Rentrop collateral score as patients with poor collateral circulation (Rentrop score 0-1) and good collateral circulation (Rentrop score 2-3). RESULTS The mean Rentrop collateral score for patients with metabolic syndrome was significantly lower than for those without metabolic syndrome (1.38+/-0.79 compared with 1.99+/-1.08, respectively, P

P-wave dispersion (PWD), has been defined as the difference between maximum and minimum P-wave duration. Prolonged P-wave duration and increased PWD have been reported to be related with increased risk for atrial fibrillation (AF). AF is the most common sustained arrhythmia encountered in patients with rheumatic mitral stenosis (MS). Beta-blockers are the mainstay of therapy in patients with rheumatic MS to control ventricular rate both during sinus rhythm and AF. In the present study, we aimed to evaluate the effect of long-term beta-blocker therapy on P-wave duration and PWD in patients with rheumatic MS.Study population includes 46 patients (group I, 8 men, 38 women, mean age = 34+/-8 years) with newly diagnosed moderate-to-severe rheumatic MS who have not taken any medication before and prescribed oral beta-blocker therapy and 46 healthy control subjects without any cardiovascular disease (group II, 8 men, 38 women, mean age = 35+/-7 years). Mitral valve area, maximum and mean diastolic mitral gradients, left atrial diameter, and systolic pulmonary artery pressure were evaluated by transthoracic echocardiography before initiation of beta blocker therapy and repeated at the end of the first month. Baseline maximum and minimum P-wave duration and PWD were determined on 12-lead electrocardiogram recorded for each patient and control subject and repeated at the end of the first month after initiation of beta-blocker therapy in patient group.Maximum P-wave duration and PWD were found to be significantly higher in patients with MS than those in control subjects (Maximum P-wave duration: 128+/-7 ms vs. 104+/-4 ms and PWD: 52+/-6 ms vs. 27+/-3 ms, p0.001 for both). Both groups had comparable minimum P-wave duration (75+/-4 ms vs. 76+/-4 ms, p = 0.093). Maximum P-wave duration and PWD were found to be significantly decreased by long-term beta blocker therapy (Maximum P-wave duration; 128+/-7 ms vs. 122+/-6 ms, p0.001, PWD; 52+/-6 ms vs. 47+/-5 ms, p0.001). However, there was no significant difference between the values of minimum P wave duration measured before and at the end of the first month of beta-blocker therapy (75+/-4 ms vs. 75+/-3 ms, p = 0.678). Statistically significant decrease were detected on maximum and mean mitral gradient and systolic pulmonary artery pressure and resting heart rate at the end of the first month of beta-blocker therapy. However, only the change in resting heart rate was found to be significantly correlated with the decrease in maximum P-wave duration and PWD (Maximum P-wave duration: r = 0.327, p = 0.026, PWD: r = 0.378, p = 0.01).We have shown for the first time that long-term beta-blocker therapy causes a significant decrease in maximum P-wave duration and PWD in patients with rheumatic MS.

A 63-year-old man was admitted to our emergency department with the complaint of syncope. An electrocardiogram showed complete atrioventricular block with a low ventricular rate. He was hospitalized and a temporary transfemoral pacemaker was inserted under direct fluoroscopy urgently. Immediate postprocedural electrocardiogram in the paced mode showed right bundle branch block morphology that led to suggestion of abnormal lead location. A transthoracic echocardiogram revealed that the pacemaker lead was directly inserted from the right atrium into the left ventricle through the junction of the interatrial and interventricular septums. Because severe multivessel coronary artery disease was diagnosed angiographically in his subsequent hospital course, coronary artery bypass grafting and surgical extraction of the misplaced lead was performed at the same time. Clinical implications, diagnosis, and therapeutic options of left ventricular pacemaker lead malposition are discussed.

Statins are frequently prescribed drugs for patients with coronary heart disease according to evidence-based medicine. However, compliance with these agents has still been far from ideal, since they require long term, probably life long therapy. We conducted a survey on patients who were already on statin treatment and evaluated their level of awareness of prescribed statins.236 participants (117 male, 119 female), who had been on treatment with statins for at least three months, were enrolled in our study after giving informed consent. Patients were asked close-ended survey questions.Only 5.5% of participants were on statin treatment for primary prevention, and 16.1% of them had a CHD equivalent, defined as those with clinical manifestations of noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, carotid artery disease) and diabetes mellitus. Most participants (70%) stated that they had been using statins to decrease cholesterol, whereas 16.5% stated that they had no idea. More than half of the participants (58%) stated that they did not know how long they would have to keep using their statins, whereas 21% replied that they would use them continuously. One fifth of participants had some idea about side effects. Participants in whom statin therapy was started during hospitalisation for coronary angiography and/or PCI more frequently answered that statins should be used continuously (49% vs. 12% not hospitalised, p0.01). Also, therapy adjustment by the physician led to a better understanding of the need for continuous use (55% vs. 31% without medication change, p0.001), as was the case for patients with2 co-medications (36% vs. 17% with2 co-medications, p 0.002). Presence of other risk factors did not have any impact on level of awareness.Comprehensive information at initial prescription, initiation of statins during hospitalization, dose adjustment during follow up, and as little co-medication as possible seem to increase the level of awareness of the benefits of long-term statin treatment. This might result in better compliance rates.

Atherothrombosis is a generalized disease process that affects large- and medium-diameter arteries throughout the arterial tree. In this study, we aimed to evaluate the correlation between collaterals in different vascular beds. Patients who had undergone digital subtraction angiography for symptomatic lower extremity peripheral arterial disease and coronary angiography after an acute anterior myocardial infarction (MI) were compared with a control group composed of those patients who were hospitalized for acute anterior MI and underwent coronary angiography but had no claudication and had an ankle-brachial index of greater than 0.9 in both legs. In claudicants, stenosis in the left anterior descending artery (LAD) (90.3 +/- 17.5 vs 78.6 +/- 13.8, P = 0.005) was greater compared with the patients without claudication. The collaterals to the LAD (88% vs 37.5%, P = 0.001) and the collateral grades (1.7 +/- 0.7 vs 0.7 +/- 0.9, P = 0.001) were higher in the patients with claudication compared with those without claudication. A previous history of angina (52.2% vs 16.3%, P = 0.001), claudication (39.1% vs 4.6%, P = 0.001), and peripheral collaterals (45.7% vs 6.9%, P = 0.001) were higher in the patients with coronary collaterals than in those without. The factors affecting the development of coronary collaterals were claudication [relative risk (RR): 8.8; 95% confidence interval (CI): 2.1-39.8], peripheral collaterals (RR: 1.1; 95% CI: 1.1-1.3), and LAD stenosis (RR: 1.2; 95% CI: 0.03-29.1). Our results suggest that the presence of collateralization or angiogenesis in one vascular bed highly predicts collateralization in another arterial bed.

Long-term moderate or strenuous physical activity is associated with a considerable reduction in cardiovascular morbidity and mortality. However acute exercise leads to a transient activation of the thrombotic system. Healthy individuals can react this by increasing their fibrinolytic capacity acutely. However, patients with ischemic heart disease, lacking fibrinolytic potential, may be at considerable risk for acute ischemic events if exposed to heavy physical exertion. Platelet size has been shown to reflect platelet activity. The mean platelet volume (MPV) can reflect changes in either the level of platelet stimulation or rate of platelet production.We evaluated Treadmill exercise test (TMET) and compared MPV values (fl) before and after TMET in 63 consecutive patients who, then, underwent coronary angiography and found to have significant coronary artery disease in more than one coronary artery (70% diameter stenosis in left anterior descending, right coronary or circumflex artery and50% diameter stenosis in left main coronary artery). Sixty-three male patients were enrolled as a patient group with a mean age of 52.43 +/- 4.08 years and with strongly positive exercise test (or =2 mm ST segment depression, horizontal or down-sloping). Thirty-five patients without significant coronary artery disease were selected as a control group with a mean age of 52.66 +/- 4.39 years having undergone TMET.In the patient and control groups, mean MPV values before TMET were the same, 8.52 +/- 0.63 and 8.45 +/- 0.58 respectively. Following TMET within 30 minutes, mean MPV were 10.03 +/- 0.96 and 8.50 +/- 0.45 respectively ( p0.001). When pre and post-TMET MPV values were evaluated together, the patient group had a significant increase in the MPV ( p0.001), whereas, the control group had no significant increase in the MPV ( p = 0.379). It was concluded that exercise possibly makes patients with significant coronary artery disease, more susceptible to a thrombotic event through various routes, one of that is platelet activation that could be measured indirectly via MPV. Healthy subjects react this thrombotic process by increasing their fibrinolytic capacity acutely. Patients with ischemic heart disease, particularly those with significantly narrowed coronary arteries, known to lack fibrinolytic capacity and have high shear stress, on the other hand, might face ischemic events, including sudden death following acute exercise.

A true dissection of the descending thoracic aorta resulting from blunt chest trauma is a relatively rare injury compared with aortic transsection and occurs mostly in the region of the aortic isthmus. It is a life-threatening condition that requires rapid and accurate diagnosis. In this case, we report a patient with Stanford type B aortic dissection caused by decelerating trauma of the chest in a motor vehicle accident causing near total occlusion of the aortic lumen. The diagnosis was made by transthoracic echocardiography and confirmed by aortography.

The predisposition to atrial fibrillation (AF) in mitral stenosis (MS) has been demonstrated with several electrocardiographic (increased P-wave dispersion) and echocardiographic parameters (atrial electromechanical delay). Despite the improvement in P-wave dispersion after percutaneous mitral balloon valvuloplasty (PMBV), the changes in echocardiographic parameters related to AF risk are unknown. In this study we aimed to investigate the acute effect of PMBV on atrial electromechanical delay (EMD) assessed by tissue Doppler echocardiography in addition to electrocardiographic parameters. This single-center study consisted of 30 patients with moderate or severe MS (23 females and seven males, aged 36.5 ± 8.5 years, with a mean MVA of 1.1 ± 0.2 cm2) who underwent successful PMBV without complication at our clinic and 20 healthy volunteers from hospital staff as a control group (16 females and four males, aged 35.4 ± 6 years). We compared the two groups in regard to clinical, electrocardiographic and echocardiographic features. The patients with MS were also evaluated after PMBV within 72 h of the procedure. The P-wave dispersion was calculated from12-lead ECG. Interatrial and intra-atrial EMDs were measured by tissue Doppler echocardiography. These ECG and echocardiographic parameters after PMBV were compared with previous values. The maximum P-wave duration (138 ± 15 vs. 101 ± 6 ms, p

OBJECTIVES: We aimed to analyze acute clinical, echocardiographic, and hemodynamic results and long-term event-free survival of percutaneous mitral balloon valvuloplasty (PMBV) in the treatment of hemodynamically significant mitral stenosis (MS). STUDY DESIGN: We retrospectively reviewed 577 patients (454 females, 123 males; mean age 38±11 years) who underwent PMBV for moderate or severe MS. Acute procedural success was defined as the achievement of mitral valve area (MVA) >1.5 cm2 and absence of grade 3-4 mitral regurgitation. In addition, 489 patients were interrogated by phone calls for event-free survival (death, redo PMBV, mitral valve replacement) after at least one year (mean 54 months) of the procedure. RESULTS: The procedure was successful in 547 patients (94.8%) and unsuccessful in 30 patients (5.2%). Among baseline echocardiographic and hemodynamic parameters, MVA was significantly lower (p=0.0001) and moderate/severe tricuspid regurgitation was significantly more common (p=0.031) in patients with failure. The mean Wilkins scores were similar in the two groups (p>0.05). Failure was related to suboptimal valve opening (MVA

Amaç: Renal bozukluğun kardiyovasküler olaylar için yüksek riskle bağlantılı olduğu gösterilmiştir. Kreatinin yüksekliğinin hafif formları bile kötü kardiyovasküler sonuçlarla ilişkilidir. Aşikar renal bozukluğun olmadığı hastalarda kreatinin düzeyleri ile koroner arter hastalığının anjiyografik yaygınlığının ilişkisini araştırmak için retrospektif bir çalışma tasarlandı. Yöntemler: Tipik kararlı anjina pektoris ile Türkiye Yüksek İhtisas hastanesine başvuran ve diyaliz öyküsü olmadan kreatinin düzeyi ?3 mg/dl olan 892 ardışık hasta (ortalama yaşı 62±10 yıl olan 311’i kadın ve ortalama yaşı 56±11 yıl olan 581 erkek) retrospektif olarak tarandı. Aşikar renal hastalığı olmayan hastalar kreatinin düzeyine göre 3 gruba ayrıldı (Grup A: Kr50%) ve düşük skor gruplarına ayrıldılar. Yüksek darlık ve yaygınlık skorlarının klinik öngördürücülerini belirlemek amacı ile lojistik regresyon analiz yapıldı. Bulgular: Kreatinin düzeyine göre ayrılan her bir grubun koroner arter hastalığının anjiyografik yaygınlığı farklıydı (p, Objective: Renal dysfunction has been shown to be linked to high risk for cardiovascular events. Even milder forms of creatinine elevation are associated with poor cardiovascular outcomes. We designed a retrospective study and searched the association of angiographic extent of coronary artery disease and creatinine levels in patients without overt renal dysfunction. Methods: We retrospectively reviewed 892 consecutive patients with typical stable angina pectoris (311 female with mean age of 62±10 years, 581 male with mean age of 56±11 years) at Türkiye Yüksek İhtisas Hospital and creatinine level ≤3 mg/dl without history of hemodialysis. Patients without overt renal disease were divided into 3 groups according to level of creatinine (Group A: Cr level 50%) versus low stenosis and low extension scores. Logistic regression analysis was performed to establish the clinical predictors of high total stenosis and high extension scores. Results: Each group of patients according to level of creatinine showed marked difference in terms of angiographic extent of coronary artery disease (p

WOS: 000294311800008, PubMed ID: 21821502, Objective: Percutaneous mitral balloon valvuloplasty (PMBV) is the method of choice in treatment of patients with hemodynamically significant mitral stenosis. We aimed to analyze acute and long-term clinical and echocardiographic consequences of PMBV. Methods: In this retrospective cohort study; 311 patients who underwent PMBV in our Cardiology Clinic at Turkiye Yuksek Ihtisas Education and Research Hospital between January 2000 and March 2004 were evaluated for acute procedural outcomes and primary endpoints (death, rePMBV, mitral valve replacement (MVR)). All 311 patients were contacted by phone call or letter at least five years after the procedure. Of the 311 patients, 87 who defined NYHA class II-IV symptoms were invited for a control visit and detailed echocardiographic evaluation. Sixty-three patients out of 87 who completed follow-up were enrolled for long-term consequences. Those 63 patients were subclassified into two groups as those without any negative event (n=26) (Group 1) and those with mitral valve area (MVA) (< 1.5 cm(2)), rePMBV or referral to MVR (n=37) (Group 2) on follow up to 6.4 +/- 1.6 years. Results: In the analysis of 311 patients, acute post procedural success, which was defined as mitral valve area (MVA) cm2 without severe mitral regurgitation, was 94% and was only associated with preprocedural MVA (p=0.008). In the logistic regression analysis, preprocedural MVA was the only independent parameter, associated with acute procedural success (Exp beta=0.004, 95%CI 0.0001-0.234, p=0.008). In the long-term follow up of 63 patients, the patients with uneventful course (Group 1) had significantly higher MVA (p < 0.001), lower mean (p=0.001) and peak (p < 0.001) transmitral gradients immediately after the procedure when we compared to the patients in Group 2. It was also noticed that patients with at least 60% improvement in MVA experienced composite end point much less frequently compared to those with less than 60% improvement in MVA (5% vs. 30.4%, p=0.009). Kaplan-Meier analysis yielded significantly diverging cumulative survival curves for those with and without at least 60% improvement in MVA (p=0.003). Conclusion: Concerning long-term follow up data of patients undergoing PMBV in a single center, it seems only acute postprocedural MVA was significantly associated with long-term consequences. (Anadolu Kardiyol Derg 2011; 11:515-20)

WOS: 000265432300009, PubMed ID: 18413331, In this study, factors leading to the failure of internal mammary artery grafting was investigated among patients with coronary bypass. In all, 1323 patients were evaluated. It was found that lower grade diameter stenosis in the native vessel during postoperative angiogram and wall motion score index independently affected the fate of internal mammary artery as a graft. Grafting with internal mammary artery to native vessels with lower grade stenosis and to myocardium with poor wall score might not be a rational approach.

WOS: 000265432300004, PubMed ID: 18445613, Obesity is a growing pandemic. Among obese patients with significant coronary artery stenosis, development of coronary collaterals was investigated. Consecutive 104 obese patients with stable angina pectoris were enrolled. Coronary collaterals were assessed according to the Cohen and Rentrop grading system and classified into 2 as those with poor collaterals (grade 0-1, Group 1) and those with good collaterals (grade 2-3, Group 2). Group I had higher body mass index, shorter duration of angina pectoris than Group 2. Poor collaterals were present in 82.3% and 59.5% of patients with and without (P = .019) metabolic syndrome, respectively. Metabolic syndrome score (sum of each component) was found to be negatively correlated with Rentrop score (r = -691; P < .001). After controlling for symptom duration and body mass index, metabolic syndrome kept independent association with poor collaterals among obese patients (P = .043, B = 1.8). Metabolic syndrome appears to influence the development of coronary collaterals among obese patients with stable coronary artery disease.

Objective: Coronary slow flow (CSF) is an angiographic phenomenon characterized by delayed opacification of coronary arteries in the absence of obstructive coronary disease. Recently, increased aortic pulse pressure (PP) and aortic pulsatility were both linked to the presence of angiographic coronary artery disease. In this study aortic PP and aortic pulsatility, derived from the invasively measured ascending aortic pressure waveform, were analyzed in patients with CSF and otherwise normal epicardial coronary arteries and compared with those with completely normal coronary arteries. Methods: Fifty consecutive patients with CSF (35 men, mean age: 51.7 ± 10 years) and fifty age and gender-matched controls (34 men, 51.1 ± 9 years) were included in the study. For determination of coronary flow, the thrombosis in myocardial infarction (TIMI) frame count method was used. Blood pressure waveforms of the ascending aorta were measured during cardiac catheterization with a fluid-filled system. Aortic pulsatility was estimated as the ratio of aortic PP to mean pressure. Results: Study groups were well matched with respect to age, gender and atherosclerotic risk factors. Although systolic, diastolic and mean pressures of the ascending aorta were similar, aortic PP (60.5 ± 19 vs. 51.7 ± 14 mm Hg, p = 0.01) and aortic pulsatility (0.63 ± 0.1 vs. 0.54 ± 0.1, p = 0.006) were significantly higher in patients with CSF compared with the controls. Besides, in all subjects, corrected TIMI frame counts of all three coronary arteries correlated with both ascending aorta PP and aortic pulsatility values. No association was found between corrected TIMI frame counts of coronary arteries and aortic mean blood pressure or brachial blood pressure parameters. Conclusion: Our findings suggest that CSF is, as with obstructive coronary artery disease, associated with more diffuse vascular disease rather than being an isolated finding.

BACKGROUND Metabolic syndrome (MS) comprises a group of factors that are associated with increased risk for cardiovascular events. Acute coronary syndromes account for the most important part of cardiovascular events with considerable morbidity and mortality. We aimed to investigate the association of MS with extension of coronary artery disease in patients presenting with non-ST segment elevation (NSTE) acute coronary syndromes (ACS). METHODS Three hundred and six consecutive patients (220 men, 86 women patients) with the diagnosis of NSTE ACS, who were hospitalized within the first 24 h of their chest pain in the coronary care unit, were prospectively enrolled into our study. Patients with elevation of troponins (T or I) were classified as NSTE myocardial infarction (MI) and otherwise as unstable angina pectoris (USAP). Components of MS were noted as previously identified. Coronary angiograms were evaluated by two authors, who were blinded to the study plan and each other, via Sullivan's method. RESULTS MS was noted in 49% of all patients, and was significantly more common in women than in men (62.8 versus 43.6%, P=0.003). The mean total stenosis score of patients with MS was significantly higher than for those without MS (16+/-6 versus 12+/-5, P

Background Association of valvular heart disease and lipid profile might be important as in the case of aortic stenosis. However, it has not been so far considered in detail the probable association of other valvular diseases, particularly of mitral stenosis (MS) with lipid profile. In our study, we aimed to search possible association of echocardiographic mitral valve score, evaluated according to Wilkins score, with lipid parameters in a group of patients with mitral stenosis, who were referred for possible percutaneous balloon valvuloplasty. Material and Method We retrospectively reviewed 401 patients (316 female, 85 male), who were referred as possible candidates for PMBV, with moderate to severe MS of predominantly rheumatic origin. Mitral valve was evaluated according to Wilkins score by an experienced author as indicated. Results Mean age of all patients was 36.6±11.3 years, and was not different in both genders. Mean mitral valve area was 1±0.1 mm 2 . Considering all patients, total Wilkins score was significantly, but mildly correlated with ratio of total/HDL cholesterol ratio ( r =0.174, p =0.02). Presence of more than one recurrent attack of rheumatic fever, narrow mitral valve area, high total/HDL cholesterol and being male were independent predictors of poor echocardiographic Wilkins score (>8). Conclusion We think that Wilkins echocardiographic score of mitral stenosis, particularly of leaflet thickening, might well be associated with serum lipids, probably as the same extent does aortic stenosis.

Endothelium plays an important role in regulating coronary vascular tone. In addition, several of cardiovascular risk factors that are associated metabolic syndrome have been reported to be associated with endothelial dysfunction. In the present study we aimed to evaluate the coronary blood flow in patients with metabolic syndrome by means of the Thrombolysis in Myocardial Infarction (TIMI) frame count.Forty-two patients with metabolic syndrome (group I) and 42 control subjects without metabolic syndrome (group II) were included in the study. All subjects had angiographically proven normal coronary arteries. Diagnosis of metabolic syndrome was based on the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines published in 2001. Coronary flow rates of all subjects were documented by TIMI frame count method.TIMI frame counts for each of the major epicardial coronary arteries were found to be significantly higher in patients with metabolic syndrome compared with control subjects (corrected TIMI frame count for left anterior descending coronary artery: 35 +/- 7 vs 25 +/- 7, respectively; left circumflex coronary artery: 32 +/- 9 vs 25 +/- 7, respectively; right coronary artery: 31 +/- 9 vs 24 +/- 5, respectively; P.001 for all). Statistically significant independent relationships were found between TIMI frame count and body mass index (R(2) = 0.480, P = .009), waist circumference (R2 = 0.551, P = .001), and triglyceride level (R2 = 0.434, P = .036).We have shown for the first time that patients with metabolic syndrome and angiographically normal coronary arteries have higher TIMI frame counts for all 3 coronary vessels, indicating impaired coronary blood flow, compared to control subjects without metabolic syndrome.

OBJECTIVE As the endothelium and inflammatory cells play a crucial role in the development of collaterals after a sudden or slowly progressing stenosis of coronary arteries, the levels of soluble endothelial adhesion molecules (CAMs) including vascular cell adhesion molecule (VCAM-1) intercellular adhesion molecule-1 (ICAM-1) and E-selectin were compared between patients with poor coronary collaterals and patients with well-developed collaterals. METHODS In the study, 97 non-diabetic subjects with single-vessel disease were included. Collateral supply to the stenotic coronary artery was determined by angiographic grading system of 0-3 (Rentrop et al. J Am Coll Cardiol 1985; 5:587-592). Serum levels of adhesion molecules were measured by enzyme-linked immunosorbent assay. RESULTS Patients were divided into two groups according to the collateral degree (group A: 50 patients with grade 0 and 1; group B: 47 patients with grade 2 and 3 collaterals). The groups were well matched with respect to baseline clinical and angiographic characteristics. Levels of soluble VCAM-1 (mean+/-SEM; 875+/-26.6 versus 742.7+/-35.1 ng/ml; P=0.004), ICAM-1 (322.4+/-12.4 versus 269.4+/-13.3 ng/ml; P=0.005), and E-selectin (43.6+/-2.6 versus 33+/-2.4 ng/ml; P=0.004) were found to be significantly higher in group A in comparison with group B. In addition, when patients were divided into four groups according to the collateral degree, patients with grade 0 collaterals had the highest values and those with grade 3 collaterals had the lowest values for all these molecules. CONCLUSIONS We concluded that poor collateral circulation is associated with increased levels of soluble CAMs in patients with obstructive coronary artery disease. However, further studies are needed to elucidate the exact role of these inflammatory markers in the setting of poor collateral circulation.

Background: Mitral stenosis may increase sympathetic nervous activity by increasing left atrial pressure and reducing cardiac output. And elevated sympathetic nerve activity may be a risk factor for the development of clinical manifestations of mitral stenosis. In this study, we assessed the autonomic nervous system activity in patients with mitral stenosis by heart rate variability analysis and defined factors affecting autonomic functions. Methods and Results: Fifty-four patients with rheumatic mitral stenosis were compared with an age- and gender-matched control group composed of 42 healthy individuals. SDNN, RMSSD, PNN50, and HF were lower; mean heart rate (HR), LF and LF/HF ratio were higher in the patients with mitral stenosis compared to the control group. SDNN was correlated positively with left ventricle ejection fraction (LVEF), negatively with mitral valve area, left atrial (LA) diameter, and duration of symptoms. RMSSD was correlated positively with mean transmitral gradient, negatively correlated with age; PNN50 was correlated negatively with mitral valve area and positively correlated with transmitral gradient. LF was positively and HF was negatively correlated with LA diameter; LF was correlated positively, and HF was negatively correlated with duration of symptoms. LF/HF ratio was positively correlated with LA diameter and duration of symptoms, negatively with LVEF and mean valve area. Conclusion: As a result, sympathetic nervous system activity is increased in patients with mitral stenosis and sympathetic overactivity worsens their symptoms. Most significant factors that affect autonomic functions in these patients are left atrial dilatation and mitral valve area.

Elevated sympathetic nerve activity in patients with mitral stenosis (MS) may be an index of the severity of the disease. Percutaneous mitral balloon commissurotomy (PMBC) is now a standard treatment for many patients with symptomatic MS. We aimed to show the effects of PMBC on autonomic nervous system activity in the patients with MS by heart rate variability (HRV) analysis. Fifty-four consecutive patients with mitral stenosis and sinus rhythm who underwent percutaneous mitral commissurotomy were enrolled. Apart from significant haemodynamic improvements, mean heart rate (HR), LF day, LF night, LF/HF day and night significantly decreased and SDNN, RMSSD, PNN50, HF day and night significantly increased in the early period after PMBC and these changes were preserved for up to one month. SDNN was positively correlated with left ventricle ejection fraction (LVEF) but negatively correlated with mean valve area (MVA), left atrial (LA) diameter and pressure, right atrial (RA) pressure; LF/HF day ratio was positively correlated with LA diameter and pressure, mean transmitral gradient and negatively correlated with LVEF; LF/HF night ratio was positively correlated with LA pressure and mean transmitral gradient. The increase in SDNN was correlated with the change in LA and RA pressure. The decrease in LF/HF ratio after PMBC was significantly correlated with the changes in the mean transmitral gradient, LA pressure and RA pressure. As a result, the heart rate variability and autonomic nervous system function in patients with mitral stenosis are correlated with the atrial pressures and left ventricular function. These parameters significantly change in the early period after PMBC and are preserved at one month. The improvement in the heart rate variability and sympatho-vagal balance are significantly affected by the early changes in atrial pressures after PMBC.

Background: Patients with atrial septal defect (ASD) have an increased risk for atrial fibrillation (AF). Previously it was shown that maximum P wave duration and P wave dispersion in 12-lead surface electrocardiograms are significantly increased in individuals with a history of paroxysmal AF. We studied P maximum and P dispersion in adult patients with ASD during normal sinus rhythm. In addition, the impact of surgical closure of ASD on these variables within 1 year after surgery was evaluated. Methods: Thirty-four patients (21 women, 13 men; mean age: 35 ± 11 years) operated on for ostium secundum type ASD and 24 age-matched healthy subjects (13 women, 11 men; mean age: 37 ± 10 years) were investigated. P maximum, P minimum, and P dispersion (maximum – minimum P wave duration) were measured from the 12-lead surface electrocardiography. Results: P maximum was found to be significantly longer in patients with ASD as compared to controls (115.2 ± 9 vs 99.3 ± 14 ms; P < 0.0001). In addition, P dispersion of the patients was significantly higher than controls (37 ± 9 vs 29.8 ± 10 ms; P = 0.003). P minimum was not different between the two groups (P = 0.074). After surgical repair of ASD, 10 patients (29%) experienced one or more episodes of paroxysmal AF. Patients with postoperative AF were older (45 ± 6 vs 30 ± 10 years; P = 0.001), and had a higher preoperative pulmonary artery peak systolic pressure as compared to those without postoperative AF (51 ± 11 vs 31 ± 9 mmHg; P < 0.0001). No significant difference in the pulmonary-to-systemic flow ratio was observed preoperatively between the two groups (P = 0.56). P maximum and P dispersion were significantly higher in patients with postoperative paroxysmal AF at baseline and at postoperative first month, sixth month, and first year as compared to those without it (for P maximum P = 0.027, P = 0.014, P = 0.001, P < 0.0001, respectively; for P dispersion P = 0.037, P = 0.026, P = 0.001, P < 0.0001, respectively). In addition, in patients with postoperative AF, no significant changes were detected in both of these P wave indices during postoperative follow-up. However, in the other group, P maximum and P dispersion were found to be significantly decreased at postoperative 6 months and 1 year as compared to baseline. P minimum was similar throughout the postoperative follow-up as compared to baseline in both groups. Conclusions: Mechanical and electrical changes in atrial myocardium may cause greater P maximum and P dispersion in patients with ASD. Surgical closure of the ASD can regress these pathological changes of atrial myocardium with a result in decreased P maximum and P dispersion. However, higher P maximum and P dispersion at baseline, which have not decreased after surgery, may be associated with postoperative paroxysmal AF, especially for older patients.

Elevated plasma levels of homocysteine are currently considered a major, independent risk factor for cardiovascular diseases. Recently, several investigators have suggested that even mild elevation in plasma homocysteine level can severely disturb vascular endothelial function and subsequently impair coronary blood flow. Accordingly, we investigated plasma homocysteine level in patients with slow coronary flow.Study population included 53 patients with angiographically proven normal coronary arteries and slow coronary flow in all three coronary vessels (group I, 21 females, 32 males, mean age=48+/-9 years), and 50 subjects with angiographically proven normal coronary arteries without associated slow coronary flow (group II, 22 females, 28 males, mean age=50+/-8 years). Coronary flow rates of all patients and control subjects were documented by Thrombolysis In Myocardial Infarction frame count (TIMI frame count). All patients in group I had TIMI frame counts greater than two standard deviations above those of control subjects (group II) and, therefore, were accepted as exhibiting slow coronary flow. The mean TIMI frame count for each patient and control subject was calculated by adding the TIMI frame counts for each major epicardial coronary artery and then dividing the obtained value into 3. Plasma homocysteine level was measured in all patients and control subjects using commercially available homocysteine kits.There was no statistically significant difference between two groups in respect to age, gender, hypertension, diabetes mellitus, hyperlipidemia and cigarette smoking (p0.05). Plasma homocysteine level of patients with slow coronary flow were found to be significantly higher than those of control subjects (15.5+/-5.7 vs. 8.7+/-4.2 microM/l, respectively, p0.001). Moreover, we found a significant positive correlation between plasma homocysteine level and mean TIMI frame count (r=0.660, p0.001).We have shown that patients with slow coronary flow have raised level of plasma homocysteine compared to control subjects with normal coronary flow. This data suggests that elevated level of plasma homocysteine may play a role in the pathogenesis of slow coronary flow.

P-wave dispersion (PWD) is a new electrocardiographic marker that reflects discontinuous and inhomogeneous propagation of sinus impulses, which has been studied in some cardiac conditions as a useful predictor of paroxysmal atrial fibrillation (AF). The aim of the peresent study was to compare P-wave duration and PWD in patientsor =45 versusor =65 years of age. The study consisted of 2 groups. Group I included 118 patients agedor =65 years (86 men, 32 women, mean age= 69 +/- 4 years). Group II included 72 patients agedor =45 years (53 men, 19 women, mean age= 41 +/- 4 years). All patients were selected from those who were undertaken coronary angiography in our hospital with a suspicion of coronary artery disease and detected as having angiographically normal coronary arteries. All patients were undertaken transthoracic echocardiography to evaluate the presence of any structural and functional cardiac abnormality. Maximum and minimum P-wave durations and PWD were calculated from 12-lead surface electrocardiogram. Maximum P-wave duration and PWD were significantly higher in group I patients than in group II patients (P.001). However, there was no statistically significant difference between group I patients and group II patients regarding minimum P-wave duration (p=0.9). Left atrial diameter, left ventricular wall thicknesses, mitral A velocity, deceleration time and isovolumic relaxation time were significantly higher in group I patients than in group II patients. However, mitral E velocity were significantly lower in group I patients than in group II patients. A significant positive correlation was detected between PWD and age, left atrial diameter, mitral A velocity, deceleration time and isovolumic relaxation time. In addition, we found a significant negative correlation between PWD and mitral E velocity. PWD, indicating increased risk for paroxysmal AF, was found to be significantly higher in patientsor =65 years of age than in thoseor =45 years of age. Further prospective studies that include larger series and long term follow-up are needed to clarify the clinical utility of PWD as a predictor of increased risk for paroxysmal AF in old patients.

Background: Paroxysmal atrial arrhythmias especially atrial fibrillation (AF) are frequently encountered in adult patients with atrial septal defect (ASD). Previously it was shown that maximum P wave duration and P wave dispersion in 12-lead surface electrocardiograms are significantly increased in individuals with a history of paroxysmal AF. The aim of this study was to determine whether P maximum and P dispersion in adult patients with ASD and without AF are increased as compared to healthy controls. In addition, the relationship of pulmonary to systemic flow ratio (Qp/Qs) and these P wave indices were investigated. Methods and results: Sixty-two consecutive patients [39 women, 23 men; mean age 33±13 years (range 16 to 61 years)] with ostium secundum type ASD and 47 healthy subjects [25 women, 22 men; mean age 36.6±9.5 years (range 18 to 50 years)] were investigated. P maximum, P minimum and P dispersion (maximum minus minimum P wave duration) were measured from the 12-lead surface ECG. There were no significant differences with respect to age (P=0.08), gender (P=0.3), heart rate (P=0.3), left atrial diameter (P=0.5) and left ventricular ejection fraction (P=0.3) between patients and controls. Pulmonary artery peak systolic pressure was significantly higher in patients with ASD as compared to controls (P

Background: P-wave dispersion (PWD), defined as the difference between the maximum and minimum P-wave duration, has been proposed as being useful for the prediction of paroxysmal atrial fibrillation (AF). AF is the most common arrhythmia and an important prognostic indicator for clinical deterioration in patients with aortic stenosis (AS). The aim of the present study was to evaluate PWD in patients with AS. Methods: The study population consisted of two groups: Group I consisted of 98 patients with AS (76 men, 22 women; aged 63 ± 8 years) and group II consisted of 98 healthy subjects (same age and sex) without any cardiovascular disease. A 12-lead electrocardiogram was recorded for each subject. The P-wave duration was calculated in all leads of the surface electrocardiogram. The difference between the maximum and minimum P-wave duration was calculated and was defined as the PWD. All patients and control subjects were also evaluated by echocardiography to measure the left atrial diameter, left ventricular ejection fraction, left ventricular wall thicknesses, and the maximum and mean aortic gradients. Patients were also evaluated for the presence of paroxysmal AF. Results: Maximum P-wave duration and PWD of group I were found to be significantly higher than those of group II. In addition, patients with paroxysmal AF had significantly higher PWD than those without paroxysmal AF. There was no significant difference between the two groups regarding minimum P-wave duration. In addition, there was no significant correlation between echocardiographic variables and PWD. Conclusion: PWD, indicating increased risk for paroxysmal AF, was found to be significantly higher in patients with AS than in those without it. Further assessment of the clinical utility of PWD for the prediction of paroxysmal AF in patients with severe AS will require longer prospective studies.

Adhesion molecules play an important role in the development and course of coronary atherosclerosis. In this study, soluble forms of vascular cell adhesion molecule (VCAM-1) intercellular adhesion molecule-1 (ICAM-1), E-selectin and P-selectin were evaluated in patients with various clinical presentations of coronary atherosclerosis and compared them to those with angiographically documented normal coronary arteries. Venous plasma samples were collected from 43 patients with acute myocardial infarction (AMI), 45 with unstable angina pectoris (UNP), 34 with stable angina pectoris (SAP) and 29 subjects with normal coronary arteries (control). The VCAM-I level was significantly higher in patients with AMI (mean+/-SEM; 799.8+/-26.3 ng/ml) than those with UAP (644.2+/-26.7 ng/ml) and SAP (526+/-32.5 ng/ml) and controls (270+/-26.8 ng/ml). In patients with UAP, VCAM-I was found to be significantly elevated as compared to the SAP group and controls. VCAM-l level was also higher in SAP group than the controls. Serum levels ICAM-1 were similar among patients with AMI (424.1+/-15.2 ng/ml), UAP (403+/-12.3 ng/ml) and SAP (381.2+/-16.2 ng/ml); however, levels of ICAM- I was significantly elevated in these groups as compared to the controls (244.3+/-11). The mean level of E-selectin was not different in AMI and UAP groups (47.2+/-2.2 vs. 42.6+/-2.1 ng/ml; respectively). However, it was significantly higher in acute coronary syndrome groups as compared to SAP (33.4+/-2.3 ng/ml) and control subjects (30.7+/-1.9 ng/ml). Serum levels of E-selectin were similar in SAP group and controls. For P-selectin, no significant difference was observed between AMI and UAP groups (187.5+/-7.2 vs. 181.7+/-4.7 ng/ml; respectively), however, it was significantly higher in both groups as compared to SAP group (146.1+/-7.4 ng/ml) and controls (108+/-6.6 ng/ in]). Serum level of P-selectin was significantly higher in patients with SAP than the control group. In conclusion, determination of serum VCAM-I. E-selectin and P-selectin levels seems more useful for detecting coronary plaque destabilization. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

The changes in serum concentrations of cytokines such as interleukin-1 (IL-1) beta, interleukin- 6 (IL-6), tumor necrosis factor (TNF) alpha and a soluble-intercellular adhesion molecule (sICAM- 1) has been investigated in patients with stable angina and acute myocardial infarction. Thirty- four patients with stable angina (SA), 15 with acute myocardial infarction (AMI), and 20 subjects in the control (C) group were included in the study. The mean serum concentrations of sICAM-1, IL-1-beta, IL-6, and TNF-alpha differed signif icantly among the three groups. Serum concentrations of IL-1 beta, sICAM-1, and TNF-alpha were comparable in the AMI and SA groups and higher than those found in the C group (p