Blood pressure control in anticoagulated hypertensive patients.

OBJECTIVE: To compare the methods of office blood pressure (BP) measurement and ambulatory blood pressure monitoring (ABPM) to ensure optimal BP control in hypertensive anticoagulated patients. PATIENTS AND METHODS: Seventy-eight patients who were receiving antihypertensive drugs and warfarin in a dose-adjusted approach to achieve therapeutic international normalized ratio because of the association of atrial fibrillation were enrolled in the study. Twenty-four hour ABPM was applied to all patients. For the assessment of optimal BP control, office BP measurements were compared with ABPM recordings. All patients were divided into 'good control' and 'poor control' groups with a cut-off level of 140 mmHg systolic blood pressure (SBP). The groups of patients with 'good control' and 'poor control' were further subdivided into four groups according to the cardiovascular outcome on the basis of ABPM reference threshold levels: 'true good control' or 'seemingly good control' and 'true poor control' or 'seemingly poor control' (white coat effect). Positive and negative predictive values of the office BP measurement method versus ABPM were estimated. RESULTS: According to office measurements, 56.9% of all cases were in the 'good control' group and 43.1% were in the 'poor control' group. When we reclassified patients according to daytime and night-time mean SBP, we realized that they were in 'true good control', 'seemingly good control', 'true poor control', and 'seemingly poor control' groups with ratios of 25.5, 31.4, 21.6, and 21.6% on the basis of daytime systolic mean values and 19.6, 37.3, 35.3, and 7.8% on the basis of night-time systolic mean values, respectively. When we considered ABPM as a reference method, sensitivity, specificity, and positive and negative predictive values of office SBP measurements were 40.74, 54.17, 50.00, and 44.83% for daytime SBP mean values and 48.65, 71.43, 81.82, and 34.48% for night-time SBP mean values, respectively. CONCLUSION: Poor control of SBP in patients with anticoagulant therapy may result in fatal events such as intracranial bleeding; thus, they are still under significant risk, although they are considered to have controlled BP with office measurements. ABPM is an essential method for accurate BP control in contrast to office BP measurement in anticoagulated patients.

A hammock in the left atrium.

Shone's anomaly describes a complex involving multiple left sided cardiac obstructions, namely, parachute deformity of the mitral valve, supravalvular ring of the left atrium, subaortic stenosis and aortic coarctation. We are reporting a case of Shone's anomaly characterised by aortic recoarctation, mitral supravalvular membrane, bicuspid aortic valve, complicated complete atrioventricular block and bradycardia-induced nonsustained polymorphic ventricular tachycardia. We revealed mitral supravalvular membrane by 3D transoesophageal echocardiography.

The influence of dipper and nondipper blood pressure patterns on left ventricular functions in hypertensive patients: a tissue Doppler study.

OBJECTIVES: We investigated the effect of dipper and non-dipper blood pressure patterns on left ventricular diastolic filling parameters in hypertensive patients. STUDY DESIGN: Fifty-five hypertensive patients (37 women, 18 men; mean age 55+/-10 years) were evaluated with echocardiography and ambulatory 24-hour blood pressure monitoring. All the patients received antihypertensive drug therapy for at least three months prior to the evaluations. Tissue Doppler-derived systolic and diastolic parameters were compared. RESULTS: Dipper and nondipper blood pressure patterns were found in 22 patients (40%) and 33 patients (60%), respectively. Both groups had similar left ventricular systolic and diastolic diameters. Dipper patients had significantly lower values for left atrial diameter (p<0.0001), interventricular septum (p=0.001) and posterior wall (p=0.012) thickness, left ventricular mass (p=0.017) and mass index (p=0.021). Both groups had similar mitral E and A waves, E/A ratio, E-wave deceleration time, isovolumetric relaxation time, and tissue Doppler-derived A' wave. Dipper patients had a significantly lower E/E' ratio (10.8+/-3.4 vs. 14.1+/-3.6; p=0.002) and significantly higher systolic (S') (p=0.05) and early diastolic (E') (p=0.027) tissue velocities. Based on the E/E' ratios being <15 or = or >15, the frequency of dipper hypertension was significantly higher in patients with E/E' <15 (48.8% vs. 9.1%; p=0.019). The frequency of dippers was also higher among patients having an E/E' ratio of <8, compared to those having an E/E' ratio of = or >8 to <15 (90% vs. 35.3%; p=0.019). CONCLUSION: Nondipper blood pressure pattern may be associated with increased left ventricular mass, impaired left ventricular systolic and diastolic dysfunction, and higher left ventricular filling pressures.

Takotsubo cardiomyopathy in a 52 year old patient.

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.

N-terminal pro brain natriuretic peptide to predict prognosis in dilated cardiomyopathy with sinus rhythm.

AIMS: To assess the value of plasma NT proBNP levels for predicting adverse outcomes in patients with dilated cardiomyopathy (DCM). METHODS: Seventy-eight patients with DCM (EF <40%) with sinus rhythm were enrolled. All patients had undergone echocardiographic examination, coronary angiography, and cardiac catheterisation. Blood samples for plasma NT proBNP levels were taken at rest following echocardiographic examination. Patients were followed up for 660+/-270 days for clinical endpoints defined as; death from worsening heart failure, sudden cardiac death and heart transplantation (Tx). RESULTS: Clinical end points were observed in 19 patients (5 Tx, 4 sudden cardiac death, 10 death from worsening heart failure). Variables associated with an increased hazard of clinical endpoints in univariate analysis were log NT proBNP, age, NYHA functional class, left ventricle ejection fraction, mitral valve effective regurgitation orifice area, and E wave deceleration time. The plasma level of NT proBNP (Hazard ratio=2.5 [95% CI: 1.3-4.7], p=0.0024) and age (hazard ratio=0.94 [95% CI: 0.90-0.98], p=0.0005) were the independent variables associated with an increased risk of clinical endpoints. NT proBNP plasma level >4500 pg/ml detected patients with clinical endpoints with a sensitivity, and specificity of 72%, 80%, respectively. The event free survival was found to be significantly lower in patients with NT proBNP levels >4500 pg/ml. CONCLUSION: NT proBNP seems to be a strong predictor of adverse outcomes in patients with DCM with sinus rhythm and may be used as a reliable biological marker in risk stratification.

Acute anterior myocardial infarction due to aortosaphenous vein graft occlusion with very large thrombus burden.

A 75-year-old man, with a previous history of myocardial infarction and three-vessel coronary artery bypass grafting, presented with an acute anterior ST-elevation myocardial infarction. The vein graft to the left anterior descending artery was occluded with heavy thrombus burden, and the other grafts were patent. After administering a bolus dose of tirofiban and then undergoing percutaneous coronary intervention without stenting to the left anterior descending artery saphenous vein graft, intracoronary thrombolytic infusion was performed to maintain the patency of the vein graft. The patient was asymptomatic after medical follow-up. This may be an effective treatment option in patients with large thrombus burden and requires further investigation through large-scale trials.

Effect of percutaneous mitral balloon valvuloplasty on left atrial appendage function: a Doppler tissue study.

The aim of this study was to compare left atrial appendage (LAA) functions by Doppler tissue imaging (DTI) before and after percutaneous balloon mitral valvuloplasty (PBMV). Twenty patients with symptomatic rheumatic mitral stenosis who underwent PBMV were included in this study. LAA functions were measured before and after PBMV. To determine LAA functions, LAA late filling (LAALF) velocity, LAA late emptying (LAALE) velocity, and area change of LAA percent were measured. In the DTI records, the first positive wave identical to the LAALE wave after the P wave was accepted as LAA late systolic wave, and the second negative wave identical to the LAALF flow was accepted as late diastolic wave. There was no difference in LAALF velocity and area change of LAA percent after PBMV. LAALE velocity increased after PBMV compared with baseline (P = .005). Late emptying, systolic, and diastolic wave values measured by DTI were found to be increased after PBMV compared with baseline (P = .023, P = .002, and P = .002, respectively). LAALE velocity measured by standard Doppler was increased after PBMV compared with baseline (P = .005), but there was no change in area change of LAA percent or LAALF. Spontaneous echocontrast was present in 7 of the 20 patients before procedure. It completely disappeared (4 patients) or decreased (3 patients) after procedure. In patients with spontaneous echocontrast, LAALE and late emptying, systolic, and diastolic wave values measured by DTI were found to be increased after PBMV compared with baseline. Our results suggest that PBMV improves LAA functions and, thereby, may have a favorable influence on future thromboembolic complications.