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Objective: The present study was designed to determine the effects of tirofiban (Tiro) infusion on angiographic measures, ST-segment resolution, and clinical outcomes in patients with STEMI undergoing PCI. Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI), while the most effective timing of administration is still under investigation. Methods: A total of 1242 patients (83.0% males, mean (standard deviation; SD) age: 54.7 (10.9) years) with STEMI who underwent primary PCI were included in this retrospective non-randomized study in four groups, composed of no tirofiban infusion [Tiro (-); n=248], tirofiban infusion before PCI (pre-Tiro; n=720), tirofiban infusion during PCI (peri-Tiro; n=50), and tirofiban infusion after PCI (post-Tiro; n=224). In all Tiro (+) patients, bolus administration of Tiro (10 pg/kg) was followed by infusion (0.15 pg/kg/min) for a mean (SD) duration of 22.4±6.8 hours. Results: The pre-PCI Tiro group was associated with the highest percentage of patients with TIMI 3 flow (99.4%; p75% ST-segment resolution (78.1%; p

Background Vitamin D deficiency may be associated with an increased risk of renovascular disease. We assessed the correlation between vitamin D levels and contrast-induced nephropathy (CIN) in patients undergoing coronary angiography (CAG). Methods Vitamin D and parathyroid hormone (PTH) levels were assessed before CAG in 403 patients. Estimated glomerular filtration rate (eGFR) was calculated using the Cockcroft-Gault equation. Patients with eGFR 2 were hydrated with 0.9%-saline at 1 mL/kg/h for 12 hours before and after CAG. CIN was defined as serum creatinine increase of > 0.5 mg/dL or > 25% within 48-72 hours after CAG. Results CIN developed in 74 participants. Baseline eGFR, blood urea and creatinine in CIN (+) and (−) groups were not significantly different ( P = 0.14, P = 0.07, and P = 0.61, respectively). Total volume of contrast medium (CM) was higher in the CIN (+) group (132 ± 64 mL vs 90 ± 41 mL; P = 0.01). Vitamin D levels were lower (median 8.5 [range, 0.5-26.6] ng/mL vs 14.9 [range, 1.9-93.5] ng/mL; P = 0.01) and PTH levels were higher (median 73.9 [range, 22-530] pg/mL vs 44.2 [range, 5-361] pg/mL; P = 0.01) in the CIN (+) group. Multivariate logistic regression analysis revealed that lower vitamin D levels (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.11-1.26; P = 0.01) and increased CM volume (OR, 1.01; 95% CI, 1.008-1.017; P = 0.01) were independently correlated with CIN. In patients who had undergone percutaneous coronary intervention, lower levels of vitamin D were independently associated with CIN development. Conclusions Lower vitamin D levels, implying possible vitamin D deficiency, are associated with a higher incidence of CIN.

Objectives: It has been proposed that human platelet antigen- 1 (HPA-1) gene polymorphism is associated with coronary artery disease (CAD) and affects platelet function. We aimed to investigate the distribution of HPA gene polymorphism between angiographic CAD and a control group and the relation between HPA gene polymorphism and platelet aggregation. Study design: The study population consisted of 94 patients with angiographic CAD and 115 patients without angiographic CAD. Platelet aggregation was measured with impedance aggregometry on the fifth day of percutaneous coronary intervention (PCI). Platelet aggregation >480 AU*min was defined as the clopidogrel resistance group. Blood samples were obtained from all participants at discharge for investigating HPA- 1 gene polymorphism. Results: There was no significant difference in the distribution of HPA-1 gene polymorphism between the control and CAD groups (78.7% vs. 78.1% for A allele and 21.3% vs. 21.9% for B allele, p=NS). The analysis between groups with and without clopidogrel resistance revealed no significant difference in the distribution of HPA-1A and HPA-1B alleles between the groups (A allele 78.7% vs. 78.9% and B allele 21.3% vs. 21.1%, p=NS). In the CAD group, there were no significant differences in platelet aggregation between HPA-1A and HPA- 1B alleles (294+-240 vs. 259+-261 AU*min, p=NS). Conclusion: The distribution of HPA-1 gene polymorphism was not different in CAD patients compared to the control group. HPA-1 gene polymorphism was not associated with platelet aggregation or clopidogrel resistance assessed by impedance aggregometry in the CAD group.

In a randomized, double-blind, crossover study of 15 aspirin-naive patients (mean age 48.8 ± 10.2 years) with the metabolic syndrome, statin monotherapy (simvastatin 40 mg daily) was compared to combination therapy (simvastatin 40 mg and ezetimibe 10 mg daily) on biomarkers of inflammation and platelet activity. The addition of ezetimibe to simvastatin over a 4-week period was associated with reduced expression of CD141 (thrombomodulin; p = 0.02), platelet endothelial cell adhesion molecule (p < 0.0001) and CD51/61 (vitronectin receptor; p = 0.048) compared to statin monotherapy. Ezetimibe added to simvastatin improves several indices of platelet reactivity beyond statin monotherapy. However, the clinical relevance of these findings await results of the IMPROVE-IT trial (Improved Reduction of Outcomes: Vytorin Efficacy International Trial).

There is a tendency to avoid noncardiac surgery in patients with mechanical heart valves (MHVs) owing to the increased risk of perioperative thromboembolism, infective endocarditis, and bleeding. We aimed to determine the risk of cardiac and noncardiac complications in patients with MHVs who underwent noncardiothoracic, nonvascular surgery. A total of 140 patients with MHVs (77 aortic, 46 mitral, and 17 double valve) and 1,200 patients with native valves (control group) were prospectively followed up for a minimum of 3 months after noncardiothoracic and nonvascular surgery. Patients with bioprostheses were excluded. Those patients aged >18 years who underwent an elective, non-outpatient, open surgical procedure were enrolled. Subcutaneous enoxaparin 1 mg/kg, twice daily, was used as bridging anticoagulation. The demographics, co-morbidities, and preoperative (medications, echocardiographic findings, laboratory results) and postoperative data were evaluated for their association with the occurrence of perioperative adverse events. The incidence of perioperative adverse cardiovascular (10.8% vs 10.7%, p = 0.985) and non-cardiovascular (11.9% vs 11.4%, p = 0.989) events was similar in those patients with and without MHVs. Bleeding (18.6% vs 14.2%, p = 0.989), thromboembolism (3.6% vs 2%, p = 0.989), and mortality at 3 months (1.4% vs 1.3%, p = 0.825) were also similar for the 2 groups. In conclusion, with close follow-up and strict adherence to the guidelines, patients with MHVs and patients with native heart valves undergoing noncardiac and nonvascular surgery have a similar risk of mortality and morbidity. (C) 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;110:562-567)

Context: Extreme rates of vascular and all-cause mortality, especially in the clopidogrel arm of the PLATO (PLATelet Inhibition and Clinical Outcomes) trial, raise concerns of data accuracy and call for independent verification of vital records in the national death registries. Two recently completed acute coronary syndrome (ACS) trials, TRACER and ATLAS ACS 2 (Thrombin Receptor Antagonist for Clinical Event Reduction in ACS and Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with ACS-Thrombolysis in Myocardial Infarction), provide a valuable opportunity to match mortality numbers among 3 similar studies. Objective: To compare the rates of vascular and all-cause mortality in the PLATO, TRACER and ATLAS ACS 2 trials. Results: Despite a shorter mean follow-up (277 days) for the PLATO trial than for the TRACER (502 days) or ATLAS ACS 2 (393 days) trials, both vascular (5.1%) and all-cause (5.9%) mortality in PLATO were higher than in the TRACER (3.2 and 4.9%) or ATLAS ACS 2 (4.1 and 4.5%) control arms, respectively. Adjusting for follow-up duration, rates of vascular (0.0184/day), or all-cause (0.0213/day) mortality in PLATO differ importantly from daily death rates in TRACER (0.0063 and 0.0097) and ATLAS ACS 2 (0.0104 and 0.0115), suggesting that the risk of death in the control PLATO arm was approximately double that of the other trials. The mismatch is particularly striking considering that ATLAS ACS 2 enrolled more STEMI (ST-segment elevation in myocardial infarction) patients (50.9%) than PLATO (38.0%). Conclusions: Both overall and follow-up duration-adjusted mortality rates in PLATO far exceeded the risk of death observed in the two recent ACS trials. The background STEMI rates are not likely to be responsible for the PLATO mortality paradox. These data provide an additional reason to request an independent audit of the deceased PLATO clopidogrel cohort.

Carotid artery stenosis is the major cause of the stroke associated with ischemic origin and carries increased mortality and morbidity. Since carotid artery endarterectomy (CEA) was first performed in 1950, in conjunction with the advanced technology and increased experience under the guidance of randomized controlled trials, balloon angioplasty and carotid artery stenting, which have similar mortality and morbidity, have become comparable with CEA. Determining the optimal treatment option for each patient is the most important issue in carotid artery stenosis. Today, there have been improvements in technology and recent advances in the cardiovascular sciences. Moreover, there is increased experience, increased attention to patient selection, and a team approach to find the most suitable treatment for the patient. In this review, we briefly discuss the current treatment approaches for carotid artery stenosis under the guidance of the modern studies.

Background: Carotid intima-media thickness (CIMT) is a potential indicator of subclinical atherosclerosis in patients with metabolic syndrome (MetS). Epicardial fat thickness (EFT) is suggested as a new cardiometabolic risk factor. We investigated the association between EFT and CIMT in patients with MetS. Methods: Forty patients with MetS were compared with 40 age- and sex-matched subjects without MetS in terms of echocardiographic EFT, CIMT, anthropometric measurements, and metabolic profile in this cross-sectional study. Results: The waist circumference, total and LDL-cholesterol, fasting glucose, triglycerides, systolics and diastolic blood pressure levels, hs-CRP, and homeostasis model assessment index for insulin resistance (HOMA-IR) were significantly increased in patients with MetS. The EFT and CIMT were also increased significantly in patients with MetS compared to controls (7.2 ± 2 mm vs. 5.7 ± 1.9 mm; P = 0.001, 0.74 ± 0.1 mm vs. 0.59 ± 0.1 mm; P < 0.01, respectively). Echocardiographic EFT was the only independent predictor of CIMT in the multivariate analysis (standardized β coefficient = 0.74, P < 0.001). Conclusion: EFT is associated with increased CIMT in patients with MetS. (Echocardiography 2011;28:853-858)

Despite significant benefits including mortality advantage demonstrated with antiplatelet therapy in large clinical trials, the occurrence of adverse ischemic events, including stent thrombosis after percutaneous coronary intervention has been the challenging and devastating complication. Clopidogrel as a monotherapy, or more common in combination with aspirin, represents a cornerstone of modern pharmacotherapy in the invasive era. Although vigilance in maintenance of this dual antiplatelet treatment is mandatory, obligatory cessation of one of these agents can be observed in rare circumstances of adverse events. We describe a patient who developed recurrent acute stent thrombosis associated with clopidogrel-induced allergic reaction and discuss our therapeutic considerations.

OBJECTIVES Several studies have shown that psychosocial risk factors such as stress and depression make substantial contribution to the pathogenesis of coronary artery disease. This study aimed to investigate acute stress factors prior to acute myocardial infarction (AMI), and stress, depression, and anxiety levels during the subacute period in AMI patients aged ≤ 40 years, in comparison with AMI patients aged >40 years. STUDY DESIGN The study included 200 first-time AMI patients aged ≤ 40 years (n=100; mean age 35 ± 4 years) and >40 years (n=100; mean age 54 ± 9 years). The DASS 21 scale (Depression Anxiety Stress Scales) was administered via face-to-face interviews in the early recovery period of AMI. The patients were also questioned whether they had experienced acute stress factors such as severe emotional or physical stressful events within two hours before the onset of chest pain. In addition, coronary angiography results were assessed based on the two age groups. RESULTS Comparison of the two age groups showed significantly higher frequencies of family history of CAD and smoking in the younger group, and significantly higher frequencies of hypertension, diabetes mellitus, and dyslipidemia in the older group (p

A 61-year-old man underwent successful percutaneous revascularization of both lower limbs with multiple stent implantations. Paralysis of right lower limb was noticed after completion of procedure when transferring the patient from angiography table. Since hematoma compressing lumbosacral neural plexus could be a fatal complication, computed tomography (CT) image was taken. CT showed bulge of distended bladder compressing stent struts. Following placement of Foley catheter, condition improved and he was subsequently discharged uneventfully.

A 47-year-old man presented to the outpatient clinic complaining of dyspnea. Physical examination was unremarkable. Electrocardiogram was normal. Chest x-ray showed distortion of the right cardiac silhouette by a large mass (Figure A). Transthoracic echocardiogram showed significant compression of the right atrium due to a large mass measuring 10x10 cm (Figure B, C). Positron emission tomography/computed tomography (PET/CT) displayed increased heterogeneous F-18 fluorodeoxyglucose (FDG) uptake with standardized uptake value (SUV) max 8.6 and hypometabolic areas, suggesting presence of necrotic tissue (Figure D). A 15x15x15-cm and 890-g giant mass with capsule invasion was successfully resected with partial pericardiectomy. Intrapericardial, intravascular, and lung invasion were not observed. Histopathological examination revealed type B1 thymoma, according to World Health Organization classification. Chemotherapy was administered. Control PET/CT performed on fourth postoperative month showed no increased FDG uptake in surgical or other sites. Thymomas and lymphomas comprise the majority of anterior mediastinal masses. While frequently asymptomatic, they may present with chest pain, dyspnea, or vena cava syndrome, depending on the dissemination of the tumor. In addition to displaying the anatomy of the tumor, PET/CT shows heterogeneous metabolic activity of the thymoma. Resection remains the first option when a tumor aggressively invades the cardiac and vascular structures, or causes significant compression, as in the present case. 353

Familial hyperlipidemia (FH) is an inherited metabolic disorder caused by low-density lipoprotein (LDL) receptor abnormality. The delayed clearance of serum LDL results in severe hypercholesterolemia, which leads to the accumulation of LDL-derived cholesterol in skin, tendons, and arterial walls.In homozygous form of the disease, severely atheromatous involvement of the aorta extending to the coronary ostia is almost always present, and particular surgical strategy is required to prevent atheroembolic events.

OBJECTIVES The serum alkaline phosphatase (ALP) level has shown to be a prognostic factor in myocardial infarction and peripheral vascular disease by its promoting effect on vascular calcification. A few recent studies also showed that elevated ALP levels were associated with mortality and unfavorable prognosis in coronary artery disease (CAD). Herein, we aimed to investigate the correlation between serum ALP levels and the severity of CAD by assessing the Gensini score. MATERIALS AND METHODS A total of 470 patients with stable angina pectoris were evaluated retrospectively.Upon admission, their ALP levels were measured with an automated analyzer by the enzymatic method, and the severity of CAD was documented for each patient according to their Gensini score. Patients with a Gensini score greater than 40 were defined to have an advanced CAD. Serum ALP levels higher than 129 mg/dl in men and higher than 104 mg/dl in women were defined as the elevated ALP groups. RESULTS The mean ALP level was 97.3±56.4, ranging from 15 to 485 U/l with 66.0/82.5/106.0 U/l percentile values, and elevated ALP levels were obtained in 79 cases (16.8%). In 70% of the patients (n=329), advanced CAD was diagnosed. The mean Gensini score was 85.6±29.4 in the advanced CAD group and 12.8±15.8 in the remainder of the patients. The advanced CAD group included more men, patients with diabetes mellitus, hypertension, and a reduced left ventricular ejection fraction, and patients with lower levels of high-density lipoprotein cholesterol and higher levels of creatinine, red cell distribution width, and mean platelet volume. ALP levels (105.4±60.7 vs. 78.4±38.7 U/l, P

Contrast-induced nephropathy (CIN) accounts for 10% of hospital-acquired renal failure, causes a prolonged in-hospital stay and represents a powerful predictor of poor clinical outcome. The underlying mechanism of the CIN development remains unclear and seems to be multifactorial. The potential link between platelet indices such as mean platelet volume (MPV) and platelet distribution width (PDW) with CIN is unknown. Herein, we aimed to investigate the correlation between MPV and PDW levels with the development of CIN. The incidence of CIN (20.5%) was prospectively evaluated in 430 patients with diagnosis of acute coronary syndrome. Initial creatinine (1.13 ± 0.25 vs. 1.05 ± 0.27 mg/dl, P = 0.01) and PDW (40.1 ± 20.2 vs. 34.5 ± 19.9%, P = 0.02) levels and the total volume of contrast media used (121 ± 61 vs. 94 ± 42 ml, P = 0.01) were higher in patients who developed CIN. MPV was similar between the two groups (P = 0.80). In a univariate regression analysis, age, increased creatinine, uric acid, phosphate, PDW levels and higher total volume of contrast media used were significantly correlated with CIN incidence. However, in a multivariate analysis, only total volume of CM used [odds ratio (OR) 1.011, 95% confidence interval (CI) 1.006-1.016; P = 0.01], increased age (OR 1.026, 95% CI 1.00-1.052; P = 0.05) and increased PDW levels (OR 1.009, 95% CI 1.00-1.022; P = 0.04) remained as the independent predictors of CIN. Among platelet indices, PDW, but not MPV, was associated with CIN development. The clinical significance of such link remains unclear, but may indicate involvement of platelet activation in CIN pathogenesis.

Background Pulmonary arterial hypertension (PAH) is a chronic progressive disease characterized by persistent elevation of pulmonary artery pressure. Regardless of the initial trigger, the elevated pulmonary arterial pressure and vascular resistance in patients with PAH are primarily caused by remodeling and thrombosis of small- and medium-sized pulmonary arteries and arterioles, as well as sustained vasoconstriction. Recent studies have emphasized the relevance of several biomarkers of hemostasis in the PAH progression. However, there is no agreement whether hemostatic indices are indeed distinguishing PAH patients from controls. Methods Plasma fibrinogen, D-dimer, platelet count, and mean platelet volume, and platelet aggregation induced by ADP and collagen were serially measured in 34 patients with PAH, and 34 matched by age and sex normal volunteers. Results Hemostatic indices were significantly higher for fibrinogen (p = 0.0001), D-dimer (p = 0.001), mean platelet volume (p = 0.001), and platelet aggregation induced by ADP-, and collagen (p = 0.0001 for both) in PAH pstients when compared to healthy controls. In contrast, platelet counts were almost identical between both groups. Conclusions Patients with PAH exhibit activation of hemostatic indices compared to healthy controls. These data support previous observations that hemostatic abnormalities including platelet activation may directly impact pathogenesis of PAH, and need to be confirmed in larger randomized studies with more comprehensive assessment of hemostatic indices for justification of antithrombotic strategies.

Takotsubo cardiomyopathy is recently defined reversible left ventricular dysfunction and apical ballooning resembling acute myocardial infarction. Although electrocardiographic, echocardiographic, biochemical and clinical findings indicate a possible acute coronary syndrome, coronary angiography reveals normal epicardial coronary arteries without any obstructing lesion. Here we describe a 52 year old woman admitted with chest pain and ST elevation with mildly increased cardiac enzymes. She was diagnosed as Takotsubo cardiomyopathy after 1 week of hospital stay and evaluation.

Background The aim of this study was to determine the incidence rate, identify the risk factors, and describe the clinical outcome of perioperative acute kidney injury (AKI) in patients undergoing noncardiac, nonvascular surgery (NCS). Methods A total of 1,200 adult consecutive patients undergoing NCS were prospectively evaluated. Patients with pre-existing renal dysfunction were excluded. The primary outcome of this study was perioperative AKI defined by the RIFLE (risk, injury, failure, loss of function, and end-stage kidney disease) criteria. Results Eighty-one patients (6.7%) met the AKI criteria. Multivariate analysis identified age, diabetes, revised cardiac risk index, and American Society of Anesthesiologists physical status as independent predictors of AKI. Patients with AKI had more cardiovascular (33.3% vs 11.3%, P

Objective To investigated the relationship between epicardial fat volume (EFV) and coronary collateral circulation (CCC) in patients with stable coronary artery disease (CAD). Methods The study population consisted of 152 consecutive patients with CAD who underwent coronary angiography and were found to have at least 95% significiant lesion in at least one major coronary artery. EFV was assessed utilizing 64-multislice computed tomography. The patients were classifield into impaired CCC group (Group 1, Rentrop grades 0−1, n = 58), or adequate CCC (Group 2, Rentrop grades 2−3, n = 94). Results The EFV values were significantly higher in paitients with adequate CCC than in those with impaired CCC. In multivariate logistic regression analysis, EFV (OR = 1.059; 95% CI: 1.035−1.085; P = 0.001); and presence of angina were independent predictors of adequate CCC. In receiver-operating characteristic curve analysis, the EFV value > 106.5 mL yielded an area under the curve value of 0.84, with the test sensitivity of 49.3%, and with 98.3% specifity. Conclusions High EFV, and the presence of angina independently predict adequate CCC in patients with stable coronary artery disease. This association offers new diagnostic opportinities to assess collateral flow by conventional ultrasound techniques.

Valsartan is known to inhibit platelet activity in both in vitro and ex vivo clinical setting, whereas aliskiren in vitro modulates antithrombin-III in plasma. The authors tested how aliskiren and valsartan combination versus aliskiren monotherapy will affect hemostatic biomarkers in mild-to-moderate hypertensive diabetics in the frame of the Aliskiren and Valsartan Impact in Diabetics (AVID) trial. A total of 52 patients with type 2 diabetes and mild-to-moderate hypertension were equally randomized to aliskiren (150-300 mg/d) and valsartan (160 mg/d) versus aliskiren (150-300 mg/d) alone for 4 weeks. A total of 25 biomarkers were serially measured, of which 16 are related to platelet function, 6 to coagulation, and 3 to fibrinolysis. Aliskiren monotherapy has no significant impact on any of the assessed biomarkers. In contrast, valsartan on top of aliskiren provided significant inhibition of ADP-induced platelet aggregation (P=0.032), decreased shear-induced activation measured with PFA-100 analyzer (P=0.041), and diminished expression of GP IIb/IIIa activity (P=0.027) measured by PAC-1 antibody, GP Ib (CD42b, P=0.033), vitronectin receptor (CD51/61, P=0.046), P-selectin (CD62p, P=0.026), lysosome-associated membrane protein (CD107a, P=0.042), and CD40-ligand (CD154, P=0.048). In AVID trial, valsartan in combination with aliskiren mildly but significantly inhibited platelets, confirming previous observations. In contrast, aliskiren monotherapy does not enhance antithrombin activity, suggesting that previous data probably represent a laboratory artifact. Importantly, these randomized data were generated on top of low-dose daily aspirin, supporting extra benefit for combination use of angiotensin receptor blockers and renin inhibitors in high-risk diabetic population.

Current guidelines offer a choice of P2Y12 receptor antagonist among clopidogrel, prasugrel or ticagrelor on top of aspirin (ASA) for dual antiplatelet therapy (DAPT) in patients after acute coronary syndromes (ACS). However, the comparative risks of gastrointestinal (GI) adverse events during DAPT are not clear. Two large ACS trials (TRITON and PLATO) provide a valuable opportunity to directly match the risks of GI complications among current antiplatelet regimens. We compared the rates of GI adverse events after prasugrel and ticagrelor versus clopidogrel based on the Food and Drug Administration (FDA) clinical safety reviews. When compared with ticagrelor, clopidogrel is safer with regard to GI-related risks including fewer overall GI/anal bleeding events and spontaneous GI hemorrhagic episodes, less nausea, vomiting, dyspepsia and diarrhea, and a lower rate of presence of Helicobacter pylori. Among GI symptoms, only constipation was more common after clopidogrel than following ticagrelor. There were extrahepatic risks observed with ticagrelor but not with prasugrel when compared to clopidogrel. Prasugrel unquestionably caused more bleeding from the GI tract and GI malignancies than clopidogrel. However, the entire spectrum of GI effects of prasugrel is much less well known and mostly based on sponsor analysis rather than FDA-verified numbers. Among 3 DAPT options on top of ASA, clopidogrel seems to represent the safest alternative, although comprehensive data on direct prasugrel-associated GI effects are lacking or inconclusive.

P wave dispersion (PWD) has been shown to be a noninvasive predictor for the development of atrial fibrillation (AF). Atorvastatin is a 3 hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitor that lowers blood cholesterol levels. The beneficial effect of atorvastatin on atrial arrhythmias is controversial. Aim of this study was to investigate the effect of atorvastatin treatment on PWD in hyperlipidemic patients.Seventy-nine newly diagnosed hyperlipidemic patients and 30 normolipidemic healthy subjects were enrolled in this study. All hyperlipidemic patients received atorvastatin 20-40 mg/ day according to their cholesterol levels and hypolipidemic diet treatment. Twelve-lead surface electrocardiogram (ECG) were recorded from hyperlipidemic patients before and after 6-months of atorvastatin therapy and from control group at their first visit. The P-wave duration measurements were calculated from these surfaces of ECG.When pretreatment PWD, P maximum and P minimum values were compared with post-treatment values, a statistically significant decrease was found after 6 months (p less than 0.001, p=0.012 and p=0.007, respectively).Atorvastatin lowered PWD significantly, so this finding may be important in the prevention of AF in hyperlipidemic patients.

Amaç: Sağ ventrikül (SV) fonksiyonu birçok kardiyopulmoner hastalıklarda klinik sonlanım olarak önemli rol oynar. Pulmoner emboli (PE) ve ciddi pulmoner darlık (PD) SV basınç yüklenmesi ile seyreden iki ayrı hastalıktır. SV’ nin artmış basınç yüklenmesine karşı verdiği uyum mekanizmaları iyi bilinmesine karşın hala bazı tanımlanmamış boşluklar devam etmektedir. SV basınç yüklenmesinin elektrokardiyografik (EKG) olarak nasıl bir deği- şiklik yaptığı pek bilinmemektedir. Çalışmamızdaki amaç akut ve kronik basınç yüklenmesini EKG olarak ayrımının yapılabileceğini araştırmaktır. Yöntemler: Bu retrospektif gözlemsel çalışmamıza 20 PD ve 38 PE tanısı kesinleşmiş hasta dahil edildi. SV yüklenmesini gösterdiği daha önceki çalışmalarda kabul edilmiş EKG kriterleri her iki grupta araştırıldı. Logistic regression analysis was used to define the predictors of chronic RV overload. Bulgular: Bakılan EKG değişikliklerinden, prematür atriyal atım (OR-12.2, %95 CI, 1.3-107, p0.008), sağ aks deviasyonu (OR-20.4, %95 CI 4.2-98, p0.001), indetermine aks (OR-0.11, %95 CI 0.02-0.44, p0.001), inkomplet sağ dal bloğu (OR-4.2, %95 CI, 1.1-15.4, p0.02), aVR de geç R dalgası (OR-8.3, %95 CI 1.2-74.8, OR-8.4, %95 CI 2.1-33.2 p0.001), V1’ de qR dalgası (OR-8.3, %95 CI 1.2-74.8 p0.02) SV kronik basınç yüklenmesini gös- teren bağımsız prediktörlerdir. Sonuç: PE için kabul edilen EKG kriterleri PD grubunda daha sık saptandı. Daha da ötesi istatiksel olarak anlamı bulunan EKG kriterlerin basınç yüklenmesinin zamanlaması hakkında sınırlı tanısal değeri olduğu saptandı. Objective: Pulmonary embolism (PE) and severe pulmonary stenosis (PS) are two distinct conditions accompanied by increased pressure load of the right ventricle (RV). Despite major advances in our understanding of the mechanisms of RV adaptation to the increased pressure, substantial gaps in our knowledge remain unsettled. One of much less known aspect of pressure overload of RV is its impact on electrocardiographic (ECG) changes. In this study, we aimed to study whether acute and chronic RV overload are accompanied by different ECG patterns. Methods: Thirty-eight patients with PE underwent ECG monitoring were compared with 20 matched patients with PS in this observational retrospective study. ECG abnormalities suggestive of RV overload were recorded and analyzed in both groups. Logistic regression analysis was used to define the predictors of chronic RV overload. Results: Among the ECG changes studied, premature atrial contraction (OR-12.2, 95% CI, 1.3-107, p0.008), right axis deviation (OR-20.4, 95% CI 4.2-98, p

Background Excess mortality especially in the clopidogrel arm of the PLATO trial raise concerns of data integrity, and call for independent verification of vital records in the national death registries. Recently published data focused on outcomes in patients after non-invasive strategies yielded from the PLATO (PLATO-NIS) and TRILOGY ACS trials allowing comparison of all cause mortality (ACM) between trials. Methods To compare the prorated over follow-up duration rates of ACM in the clopidogrel arms of PLATO-NIS cohort and TRILOGY ACS trial. Results The background clinical characteristics indicate similar if not higher mortality should be expected in TRILOGY ACS. PLATO trial was almost half the duration with a mean follow-up of 277days compared to TRILOGY ACS (513days). Matching prorated over follow-up duration of ACM rates in the clopidogrel arm revealed 0.027/day or 9.86% yearly mortality in PLATO-NIS cohort (195 fatalities among 2615 patients enrolled). The ACM rates in TRILOGY ACS (409/4663) were only 0.017/day or 6.2% annually after clopidogrel, suggesting that the risk to die in the control PLATO-NIS group was 63% higher and barely missed significance (p=0.051) compared to TRILOGY ACS. Conclusions Prorated over length of follow-up PLATO-NIS mortality rates after clopidogrel far exceeded those observed in a similar medically managed patients in a TRILOGY ACS trial. The background clinical differences between trials are not responsible for the elevated PLATO-NIS mortality numbers. These data further challenge the death paradox reported in the overall PLATO trial and call for the urgent independent verification of vital records.

Background: There was an excess of new solid neoplasms (112 vs. 69), and cancer deaths (24 vs. 15) after prasugrel in the TRITON (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition). These cancers usually occur after 4 months following prasugrel, and women are especially at risk. The hypothesis has been offered that prasugrel, but not aspirin or clopidogrel, causes indirect modulation of tumor growth, and/or enhanced metastatic dissemination due to instability of platelet-tumor cell aggregates via the inability to keep cancer locally within the platelet thrombi due to excessive chronic platelet inhibition. Case Report: A 70-year old female diabetic patient underwent drug-eluting stent implantation. The patient received a loading dose of prasugrel (60 mg), followed by prasugrel 10 mg/daily as well as aspirin (81 mg/daily). After 4 months on dual antiplatelet therapy she expectorated blood when coughing. A lung X-ray and CT scan revealed numerous lung nodules later diagnosed as unclassified pleomorphic and spindle cell malignant solid neoplasm. The patient died following multiple brain metastasis. Conclusion: Female gender, duration of prasugrel exposure, rare unclassified neoplasm pathology type and a tumor of a highly metastatic and aggressive nature in the index patient should be regarded with caution. The effects of novel antiplatelet agents on the onset of cancer should be tested in future mega-trials.

To compare heart rate variability (HRV) indices between pulmonary arterial hypertension (PAH) patients and controls, and to investigate whether therapy improves heart rhythm.Thirty-eight patients and 20 controls underwent Holter monitoring. HRV was analyzed before and after PAH therapy. Various time, and frequency domain indices of HRV analysis including standard deviation of all normal-to-normal intervals, standard deviation of mean values for all normal-to-normal intervals over 5 min, and square root of the mean square differences of successive RR intervals were recorded and analyzed before and after 1 year of PAH therapy.Significant differences with regard to diminished physical capacity, impared cardiac output, increased BNP in PAH cohort; HRV indices were diminished compared to controls and no differences between before and after PAH therapy with respect to analysis of HRV. Patients exhibited depressed HRV and therapy failed to improve HRV indices suggesting urgent unmet need for better therapeutic options.Patients with PAH exhibit severely depressed HRV. Surprisingly, PAH specific therapy for 1 year with phosphodiesterase- 5 inhibitor, prostacyclin analogue, endhotelin receptor antagonist, or their combination failed to improve HRV indices suggesting urgent unmet need for better therapeutic options.

To survey the dentists in Central Eastern Turkey, testing their knowledge on coronary interventions and assessing perception of antecedent dual antiplatelet therapy.Two hundred and ninety-eight dentists were surveyed face-to-face by completing questionnaires, including 16 structured questions focused on general knowledge of coronary stents, and assessing periprocedural practice with regard to antiplatelet therapy.All respondents were aware of such devices as coronary stents, but only one-third of the respondents knew the differences between a bare metal and a drug-eluting stent design, and associated vascular outcomes. Awareness about stent thrombosis was limited to 34%, while consequences of interrupting antiplatelet therapy were known to only 30% of surveyed dentists. Importantly, the attitudes of surveyed respondents differed substantially depending on the location of their practice, where dentists working in the urban environment (population over 10 000) were more aware of antiplatelet recommendations when compared to their colleagues from the rural areas.Knowledge about coronary stents, associated clinical outcomes, and current guidelines with regard to surgical management of antecedent antiplatelet therapy in Central Eastern Turkey is inconsistent, and heavily dependent on the location of dental practice. Rural areas around the globe should be in a focus of continuous medical education to improve the quality of medical care.

Background. Epicardial fat tissue, another form of visceral adiposity, has been proposed as a new cardiometabolic risk factor, and the possible association of epicardial fat with hypertension has been shown in some recent studies. Although epicardial fat thickness (EFT) is associated with hypertension, the relationship between preeclampsia and EFT is still unknown. The purpose of this paper is to investigate the association between the echocardiographic EFT and the severity of preeclampsia in pregnant women. Methods. Forty women with preeclampsia were recruited and thirty-five normal pregnant women were matched for both maternal age and gestastional age served as control. The materials were collected immediately after delivery of the fetus, before placenta expulsion and before clamping of the umblical cord in patients and controls whom were in fasting state. Total cholesterol, high-density lipoprotein cholesterol (HDL), and triglyceride levels (TG) and low-density-lipoprotein cholesterol (LDL), and homeostatic model assessment of insulin resistance (HOMA-IR) levels were assessed. EFT was measured by using transthoracic echocardiography. Results. Among the preeclamptic women, 12 were diagnosed with severe preeclampsia and 28 mild preeclampsia. There were no statistically significant differences between patients with preeclampsia and normal pregnancy except when they are divided according to systolic and diastolic blood pressure, proteinuria levels, and parity and EFT levels. Among women with preeclampsia (n=40), 30% had severe disease. Women with mild and severe preeclampsia had significiantly higher blood pressures at delivery and earlier gestational ages in comparison to control subjects. Although TG, VLDL and LDL, HDL, and HOMA-IR levels (P>0.05) were comparable between preeclampsia and normal pregnancies, EFT levels were significiantly higher in patients with preeclampsia. Moreover, in subgroup analysis, patients with severe preeclampsia had higher EFT levels (P<0.05) in comparison with mild preeclampsia. Conclusions. EFT levels measured at delivery were increased in patients with preeclampsia, and patients with increased levels of EFT levels had a substantially higher probability of the disease severity in comparison to those with mild preeclampsia and controls.

Acute alcohol consumption can cause atrial fibrillation in patients with, and without, heart disease. Increased atrial electromechanical delay (EMD) has been associated with atrial fibrillation. We evaluated the atrial conduction properties by tissue Doppler imaging (TDI) echocardiography in healthy men following acute alcohol intake.Thirty healthy male volunteers were included in this study. Baseline ECG, heart rate, blood pressure, and TDI echocardiographic findings were compared to readings taken one hour after drinking six 12-oz cans of beer (76.8 g of ethanol).Although the blood pressure and heart rate remained similar before and one hour after alcohol intake, Pmax and Pd values were significantly prolonged (114.2 ± 10.4 vs 100.8 ± 10.6, p = 0.002; 50.6 ± 9.6 vs 34.5 ± 8.8, p0.0001). Interatrial EMD was significantly increased after drinking alcohol compared to the baseline (19.8 ± 9.2 vs 14.0 ± 5.5 ms, p0.0002).Acute moderate alcohol intake was associated with an increased interatrial EMD obtained by TDI echocardiography. This finding may help explain how these patients express increased susceptibility to atrial fibrillation.

Epicardial fat tissue reflects visceral adiposity and is a suggested cardiometabolic risk factor. Patients with abdominal obesity have an increased prevalence of the non-dipper blood pressure (BP) pattern, but it is unclear whether the same is true of patients with increased epicardial fat thickness (EFT). The association between EFT and circadian BP changes in patients with recently diagnosed essential hypertension was examined.Sixty hypertensive patients underwent echocardiography, treadmill stress testing, and 24 hours of ambulatory BP monitoring. Epicardial fat thickness and left ventricular mass (LVM) index were measured by using transthoracic echocardiography. The patients were categorized into two groups according to their BP pattern (group 1, non-dippers; group 2, dippers).The mean EFT and LVM of patients in group 1 (n = 24) (EFT, 7.6 ± 2.1 mm; LVM, 130 ± 31.2 g/m(2)) were significantly greater than those of group 2 (n = 36) (EFT, 5.5 ± 1.2 mm, P = .0001; LVM, 107 ± 23.7 g/m(2), P = .002). The average systolic BP over 24 hours (BP(s) 24) and average diastolic BP over 24 hours (BP(d) 24) of group 1 (BP(s) 24, 151.1 ± 17.6 mm Hg; BP(d) 24, 94.1 ± 16.5 mm Hg) were significantly higher than those of group 2 (BP(s) 24, 136.7 ± 11.9 mm Hg, P = .0001; BP(d) 24, 84.6 ± 10.6 mm Hg; P = .008). Multivariate backward logistic regression analysis demonstrated that the non-dipper BP pattern was associated with EFT (standardized β coefficient = 0.87, P = .005) and LVM (standardized β coefficient = 0.43, P = .016). An EFT ≥ 7 mm was associated with the non-dipper BP pattern with 44% sensitivity and 94% specificity (receiver operating characteristic area under curve of 0.72, 95% CI [0.59-0.83], P = .0007).Epicardial fat thickness was above average in newly diagnosed, untreated hypertensive patients with non-dipper BP pattern. The echocardiographic measurement of EFT may be used to indicate increased risk of hypertension-related adverse cardiovascular events.

Carotid intima-media thickness (CIMT) is a potential indicator of subclinical atherosclerosis in patients with metabolic syndrome (MetS). Epicardial fat thickness (EFT) is suggested as a new cardiometabolic risk factor. We investigated the association between EFT and CIMT in patients with MetS.Forty patients with MetS were compared with 40 age- and sex-matched subjects without MetS in terms of echocardiographic EFT, CIMT, anthropometric measurements, and metabolic profile in this cross-sectional study.The waist circumference, total and LDL-cholesterol, fasting glucose, triglycerides, systolics and diastolic blood pressure levels, hs-CRP, and homeostasis model assessment index for insulin resistance (HOMA-IR) were significantly increased in patients with MetS. The EFT and CIMT were also increased significantly in patients with MetS compared to controls (7.2 ± 2 mm vs. 5.7 ± 1.9 mm; P = 0.001, 0.74 ± 0.1 mm vs. 0.59 ± 0.1 mm; P0.01, respectively). Echocardiographic EFT was the only independent predictor of CIMT in the multivariate analysis (standardized β coefficient = 0.74, P0.001).EFT is associated with increased CIMT in patients with MetS.

OBJECTIVE Neutrophil gelatinase-associated lipocalin (NGAL) is a novel marker for early detection of renotubular deterioration. Despite the limited data concerning the NGAL in heart failure (HF), significance of NGAL in right-sided HF remains unknown. We assessed serum and urinary NGAL in left and right-sided HF due to non-ischemic cardiomyopathy (NICMP) and severe pulmonary arterial hypertension (PAH). METHODS In this cross-sectional observational study, we compared three groups; 35 patients with NICMP, 28 patients with PAH and 27 healthy controls. None had a serum creatinine ≥1.5 mg/dL. Plasma brain natriuretic peptide (BNP) levels, estimated glomerular filtration rate (eGFR) by Cockroft-Gault (CG) and Modification of Diet in Renal Disease Study formulas, echocardiographic measures of left and right ventricles (LV, RV) and non-invasive measurement of cardiac index (CI) by echocardiography and impedance cardiography were assessed. Differences among the groups for continuous variables were evaluated by the ANOVA and the Kruskal-Wallis test as appropriate. The Chi-square test was used for comparison of categorical variables. RESULTS Despite eGFR with CG formula was lower in NICMP and PAH subsets as compared to those in controls (102±27 and 99.4±29.4 vs 122.4±25.9 mL/min, p

We investigated the prevalence and indications of digoxin use in elderly patients presenting to a cardiology outpatient clinic of a tertiary hospital in Turkey.On a prospective basis, the study included 800 consecutive patients aged 70 or over (mean age 77 ± 6 years) who presented to our cardiology outpatient clinic. There were 124 patients (15.5%) receiving digoxin. All the patients underwent transthoracic echocardiography. Digoxin use was considered inappropriate if the patient had normal left ventricle systolic function or if there was no atrial fibrillation (AF).The reasons for use of long-term digoxin were persistent AF (n=55, 44.4%), heart failure (HF) (n=51, 41.1%), and paroxysmal AF (n=8, 6.5%). The exact reason could not be determined in 10 patients (8.1%). Digoxin use was based on appropriate indications in 76 patients (61.3%), whereas 48 patients (38.7%) were taking digoxin with inappropriate indications. Of 51 patients for whom HF was the only reason for digoxin therapy, diagnosis of HF was incorrect in 30 patients (24.2%). Other inappropriate indications were paroxysmal AF and undetermined indication for digoxin prescription. Concerning digoxin dose, 24 patients (19.4%) received one tablet (0.25 mg) and 30 patients (24.2%) received a half tablet (0.125 mg) on a daily basis, while 10 patients (8.1%) used six tablets per week with one day off (0.214 mg/day) and 60 patients (48.4%) took five tablets per week with two days off (0.179 mg/day). The median daily dose was 0.182 mg/day. Digoxin dose was higher than the recommended doses for elderly patients in 75.8% of the patients.Our findings show that nearly 40% of elderly patients receive digoxin with inappropriate indications and 75% of these patients take digoxin at higher doses than the recommended doses for this age group.

Background: It has been shown that mitral stenosis (MS) impairs left ventricular (LV) systolic function; however, this issue has not been studied comprehensively. We aimed to evaluate the role of 2D strain in the assessment of subclinical LV systolic dysfunction in patients with MS. Methods: Seventy-two patients with isolated MS (mild, moderate and severe) and 31 healthy control subjects constituted the study population. 2D echocardiography images were obtained from LV apical 4-chamber (4C), long axis (LAX), and 2-chamber (2C) views. Peak longitudinal strain and strain rate (Sr) were obtained from 4C, LAX, and 2C views. Global strain and Sr were calculated by averaging the three apical views. Results: There were no significant differences in LV ejection fraction and LV systolic or diastolic dimensions between the groups. Patients with MS had significantly lower LV longitudinal strain and Sr measurements than the control group. In addition, there were no significant differences in MS subgroups with respect to LV strain and Sr measurements. Conclusion: We demonstrated that patients with MS had lower LV functions using 2D strain imaging, and this is independent of the hemodynamic severity of MS. In the detection of subclinical LV dysfunction in patients with MS, 2D strain imaging appears to be useful.