Procalcitonin: a marker of heart failure.

OBJECTIVE: Serum procalcitonin levels are associated with congestive heart failure, but are not established biomarkers of the disease. We evaluated the predictive value of serum procalcitonin levels for diagnosing heart failure and assessing its severity. METHODS AND RESULTS: This retrospective, case-control study involved 59 subjects (mean age 59.7-10.1 years; 38 males), including 21 outpa- tients and 19 inpatients with heart failure and left ventricular ejection fractions <45%, and 19 healthy controls. Serum procalcitonin levels were measured and compared among the 3 groups. Procalcitonin levels were significantly higher among inpatients (median [interquartile range], 1.45 [0.25-5.801 ng/mL) than among the outpatients (0.35 [0.001.-1.70] ng/mL; P< 0.001) or controls (0.05 [0.02-0.08] ng/mL; P< 0.0011. Using a procalcitonin cut-off level of 0.09 ng/mL, 35 (87.5%) of the 40 inpatients and outpatients were procalcitonin-positive; all control individuals were procalcitonin-negative. Serum procalcitonin levels differentiated between heart failure patients and healthy controls (sensitivity, 88.9% [95% confidence interval, 75.9-96.2%]; specificity, 100% [82.2-100.0%]; positive predictive value, 100% [91.1-100.0%]; negative predictive value, 79.2% [57.8-92.8%]). Pro calcitonin levels were >0.53 ng/mL in 4/21 (19%) outpatients and in 16/19 (84.2%) inpatients. The sensitivity and specificity of serum procalcitonin levels for differentiating between inpatients and outpatients were 84.2% and 81.0%, respectively (positive predictive value 80% [95% confidence interval, 67.6-92.4%] and 85.0% [73.9-96.1%], respectively). CONCLUSION: Serum procalcitonin levels, showing high sensitivity and specificity for diagnosing and assessing the severity of heart failure in this small study, might be considered ootential heart failure biomarkers.

[A rare complication of cardiac radiofrequency catheter ablation: Esophageal irritation]. / Kardiyak radyofrekans kateter ablasyonunun nadir bir komplikasyonu: Özofagus irritasyonu.

The complication rate of radiofrequency catheter ablation varies depending on patient characteristics and treatment, and has been reported to be approximately 3%. Esophageal irritation is one significant complication of catheter ablation, and its most common result is atrio-esophageal fistulae. However, rarely, unexpected complications and clinical variants occur due to irritation of the vagal nerve or peri-esophageal tissue without fistula formation. In this case report, attention is drawn to this rare complication in two cases, one of which occurred after paraseptal-epicardial accessory pathway ablation, and the other after atrial fibrillation ablation. Both were symptomatic with severe gag reflex.

Transcatheter coil embolization of a coronary artery-left ventricular fistula associated with single coronary artery anomaly.

Single coronary artery anomaly associated with coronary fistula is a rare entity. Transcatheter coil embolization is the treatment of choice for coronary artery fistulas. In this case report, we describe a patient with both single coronary artery anomaly and coronary fistula who was successfully treated with coil embolization.

Soluble endothelial protein C receptor levels and protein C activity in patients with acute ST-segment elevation myocardial infarction.

OBJECTIVES: In contrast to its membrane-bound form, soluble endothelial protein C receptor (sEPCR) expresses procoagulant activity through binding to protein C. We aimed to investigate the relationship between sEPCR levels and protein C activity in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: The study population included 60 STEMI patients who had undergone a primary percutaneous coronary intervention and 29 patients with stable angina pectoris (SAP) with significant coronary stenosis on angiography. Preprocedural sEPCR levels and protein C activity were determined in all study patients. RESULTS: In the STEMI group, the baseline sEPCR level was significantly higher (172.0±89.3 vs. 107.1±39.2 ng/ml, P<0.001) and protein C activity was significantly lower (91.9±26.4 vs. 124.5±16.2%, P<0.001) compared with patients with SAP. There was a significant negative correlation between protein C activity and sEPCR in the STEMI group (r=-0.38, P=0.002); however, no significant correlation was observed in the SAP group (r=0.02, P=0.91). Angiographic thrombus load and the incidence of no-reflow phenomenon were significantly higher in STEMI patients with protein C activity under the median level. CONCLUSION: The ratio of sEPCR levels to protein C activity is high, with a significant negative correlation in patients with STEMI. Lower protein C activity is associated with the development of no-reflow in STEMI patients. However, the sEPCR level has no relation to the development of no-reflow. The clinical significance of elevated sEPCR level in STEMI should be evaluated in larger studies.

The effect of sinus rhythm restoration on high-sensitivity C-reactive protein levels and their association with long-term atrial fibrillation recurrence after electrical cardioversion.

OBJECTIVE: Recent studies have shown that high-sensitivity C-reactive protein (hs-CRP) measured before cardioversion (CV) plays a significant role in predicting atrial fibrillation (AF) relapse. The time course of changes in hs-CRP after successful electrical CV remains controversial. The aim of the present study was to assess the prognostic value of pre- and post-CV hs-CRP levels in predicting the long-term risk of AF. Additionally, we evaluated changes in hs-CRP levels over time following a successful CV. METHODS: This prospective study comprised 216 patients with persistent AF who underwent CV (mean age 51.94 ± 8.07 years; 55.6% men). hs-CRP levels were examined in all patients, and blood samples were taken prior to and 1, 2, 7 and 30 days after CV. AF relapse was determined by 24-hour ambulatory electrocardiogram (ECG) monitoring and 12-lead standard ECG during 12 months of follow-up. We further divided the study population into two groups according to their rhythm at the end of the follow-up period (group A: patients with AF at the end of follow-up; group B: patients with sinus rhythm at the end of the follow-up period). RESULTS: The AF recurrence rate was 42.2% throughout the 12-month follow-up period. The basal hs-CRP levels were higher in patients with an AF relapse than in those without (1.68 ± 0.57 vs. 1.12 ± 0.53 mg/dl; p < 0.01). The hs-CRP levels were significantly decreased at 30 days in group B, whereas there was no significant decrease in group A (from 1.12 ± 0.53 to 0.69 ± 0.33 mg/dl, p < 0.01, and from 1.68 ± 0.57 to 1.69 ± 0.76 mg/dl, p > 0.05, respectively). By multivariate Cox analysis, the independent predictors of AF relapse time points were the basal and day-2 hs-CRP levels. Receiver operating characteristic curve analysis showed that the cutoff value of hs-CRP on the 2nd day for predicting AF relapse was 1.85 mg/dl, with a sensitivity of 62%, a specificity of 82%, a positive predictive value of 85.7% and a negative predictive value of 81.6%. CONCLUSION: The hs-CRP levels both prior to and after CV predict the long-term risk of AF relapse. In the present study, hs-CRP levels were significantly decreased in patients who remained in sinus rhythm at the end of the study. In contrast, hs-CRP levels remained high throughout the follow-up in patients with an AF relapse.

Long-Term Survival Following Cardiac Arrest Without Implantable Defibrillator Protection in a Hypertrophic Cardiomyopathy Patient.

Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death in young people. Implantable cardioverter defibrillator (ICD) is the optimal therapy in patients with HCM, both for primary or secondary prevention of sudden death. Left ventricular systolic function in HCM is usually normal. However, in few patients, HCM has been reported to progress to a state that is characterized by left ventricular dilation and systolic dysfunction, resembling dilated cardiomyopathy (DCM). Although arrhythmias are common in HCM, advanced or complete atrioventricular block (AV) is very rare. This case report describes a HCM patient who progressed to DCM with advanced AV block and survived 31 years following cardiac arrest without ICD protection.

Inappropriate sinus tachycardia - successful treatment with ivabradine.

Inappropriate sinus tachycardia (IST) is characterised by an exaggerated increase of heart rate in response to normal physiologic demands. Therapeutic options including medical and radiofrequency ablation interventions are still under debate. Ivabradine inhibits spontaneous pacemaker activity of the sinus node by selectively blocking If channels of pacemaker cells. Here we present a case of a patient with IST, who was successfully treated with ivabradine after various ineffective therapeutic approaches.

[A case of asymptomatic Brugada syndrome with type 1 ECG pattern and cardiac arrest: an evaluation of the prognostic value of electrophysiologic study]. / Asemptomatik, tip 1 EKG bulgulari olan ve ani kalp durmasi gelisen Brugada sendromlu bir olgu: Elektrofizyolojik çalismanin prognoz belirleme üzerine etkisinin irdelenmesi.

Brugada syndrome is characterized by ST-segment elevation in the leads V1-3 of electrocardiography (ECG) in the absence of a structural heart disease. A 26-year old male patient was admitted with sudden cardiac arrest. Cardiopulmonary resuscitation was successful and he was referred to the reanimation unit due to unconsciousness. A year before, he was diagnosed as having Brugada syndrome with type 1 ECG pattern at another center, at which time electrophysiologic study (EPS) was not performed due to lack of symptoms and a family history of sudden cardiac death. In addition, family screening revealed two asymptomatic brothers having Brugada syndrome with type 1 ECG pattern. Medical follow-up was recommended to one of them. The other sibling underwent EPS at a different center where ventricular fibrillation was induced. An implantable cardioverter defibrillator (ICD) was recommended, but the patient refused. A further analysis of the family made at our center showed type 2 ECG changes in the father and in one of the cousins. Due to the development of persistent brain injury and an expected survival of less than a year, an ICD was not considered in the patient. The prognostic value of EPS is still controversial in asymptomatic patients with type 1 Brugada syndrome, without a family history of sudden cardiac death.

Acute type A aortic dissection with diastolic prolapse of intimal flap into the left ventricle.

A 45-year-old man presented to the emergency department with acute oppressive chest pain. On physical examination, a loud decrescendo diastolic murmur of grade 2-3/6 was audible on the left sternal edge. The electrocardiogram was within normal limits and there were no signs of myocardial ischemia. Transthoracic echocardiography revealed an acute type A aortic dissection with an intimal flap prolapsing into the left ventricular outflow tract through the aortic valve during diastole. Color Doppler examination showed severe aortic regurgitation of grade 3. The aortic valve had three leaflets with normal thickness. Aortic diameter was 50 mm at the sinus of Valsalva and 66 mm after the sinotubular junction. The left and right ventricles were normal in size and function. Dynamic thorax and abdominal computed tomography demonstrated that the dissection flap extended from the ascending aorta to the proximal segments of the common iliac arteries. The patient underwent successful ascending aorta replacement with preservation of the aortic valve.

Migration of the breakthrough: the advantage of noncontact mapping in targeting inappropriate sinus tachycardia.

We report on a 42-year-old female patient with inappropriate sinus tachycardia (IST), in whom an effective sinus node modification was made by using the noncontact mapping system. The patient was admitted with palpitations and a heart rate between 90-110 beats per minute (bpm). Her heart rate increased to 150 bpm during minimal exercise. After confirming the diagnosis of IST by an electrophysiological study, radiofrequency catheter ablation was performed. A color-coded isopotential map was created when the heart rate was 95 bpm and the initial breakthrough of the sinus node (SNB) was labeled. After administration of isoproterenol, a new color-coded map recording was created when the heart rate reached 160 bpm, showing a new breakthrough 24 mm away from the SNB. Radiofrequency was delivered to this region and the heart rate decreased to 120 bpm. After another infusion of isoproterenol, the maximum heart rate reached 140 bpm and another isopotential map recording was created, which demonstrated migration of the breakthrough 16 mm away from the SNB. Radiofrequency was delivered to the second site and the heart rate decreased to 90 bpm and increased to a maximum of 120 bpm after a new isoproterenol infusion. A subsequent infusion caused no increase in the heart rate, and the ablation procedure was terminated. During a follow-up of one year, the patient was in sinus rhythm with a mean heart rate of 80 bpm.

[The effect of admission mean platelet volume on TIMI frame count measured after fibrinolytic therapy in patients with acute ST-segment elevation myocardial infarction]. / ST-Segment yükselmeli akut miyokart enfarktüslü hastalarda basvuru sirasindaki ortalama trombosit hacminin fibrinolitik tedavi sonrasi TIMI kare sayisi üzerine etkisi.

OBJECTIVES: Mean platelet volume has been reported as a predictor of unfavorable prognosis in patients with ST-segment elevation myocardial infarction (MI). We evaluated the relationship between admission mean platelet volume and the response to fibrinolytic therapy using the TIMI frame count in patients with acute ST-segment elevation MI. STUDY DESIGN: The study included 87 patients (58 males, 29 females; mean age 55+/-11 years) who received fibrinolytic therapy within the first 12 hours of symptom onset for acute ST-segment elevation MI. Venous blood samples were obtained to determine admission mean platelet volume and fibrinolytic therapy was administered. Coronary angiography was performed within the first 72 hours and the TIMI frame count was measured for infarct-related artery. TIMI frame counts of <40 and >or=40 were defined as complete and incomplete reperfusion, respectively. RESULTS: Reperfusion was complete in 35 patients (40.2%) and incomplete in 52 patients (59.8%). The mean TIMI frame counts were 31.8+/-5.9 and 61.2+/-15.3 in patients with complete and incomplete reperfusion, respectively (p<0.01). Patients with complete reperfusion had a significantly lower mean platelet volume (9.4+/-0.4 fl vs. 9.7+/-0.3 fl; p=0.016). There was a highly significant correlation between mean platelet volume and incomplete reperfusion (r=0.742, p<0.0001). CONCLUSION: High levels of admission mean platelet volume might be associated with insufficient reperfusion response to fibrinolytic therapy in patients with acute ST-segment elevation MI.

Comparison of antithyroid drugs efficacy on P wave changes in patients with Graves' disease.

OBJECTIVE: Some precursor P wave changes on electrocardiogram (ECG) before the atrial fibrillation (AF) episodes occur in the hyperthyroidism. Our aim was to compare the effect of two antithyroid drugs (ATD) on P wave duration and dispersion (PWD) in patients with hyperthyroidism. METHODS: Fifty patients (13 men, 37 women; mean age 39.2+/-13.2 years) with newly diagnosed overt hyperthyroid patients with Graves' disease (GD) were enrolled in the prospective, randomized study. The maximum P wave duration (Pmax) and the minimum P wave duration (Pmin) were measured in all 12-lead surface ECGs. The patients were consecutively randomized to propylthiouracil (PTU) (n=24) and methimazole (MMZ) (n=26) groups. Electrocardiogram was repeated within euthyroid state after the 18-month ATD treatment. Student t-test, Mann-Whitney U and Pearson Chi-square tests were used for comparisons of the data between groups. The differences between pre- and post-treatment measurements within groups were evaluated by Wilcoxon Sign Rank test. The correlation of data was tested by using Spearman correlation analysis. RESULTS: The maximum P wave duration (Pmax) was 90 (80-110) and 90 (90-110) msec, (p=0.586), and PWD was 35 (22.5-48.7) and 40 (30-40) msec, respectively (p=0.952) in PTU and MMZ groups. After euthyroidism was achieved, Pmax was 80 (80-90) and 87.5 (80-90) msec (p=0.676), and PWD was 27.5 (20-35) and 27.5 (20-30) msec in PTU and MMZ groups, respectively (p=0.540). After ATD treatment PWD decreased (p=0.009 and p<0.001, respectively) in both of PTU and MMZ groups. However effects of ATD on PWD change were similar (p=0.486). CONCLUSION: P wave duration and PWD are found to be prolonged in hyperthyroid patients with GD. Both propylthiouracil and methimazole reduce the P wave duration and dispersion. Thus, we can conclude that improvements in atrial conduction properties are not associated with the type of ATD but with only achievement of euthyroidism.

[Arrhythmogenic right ventricular cardiomyopathy mimicking right ventricular outflow tract tachycardia]. / Sag ventrikül çikis yolu tasikardisini taklit eden aritmojenik sag ventrikül kardiyomiyopatisi.

Ventricular tachycardia may be mistaken for right ventricular outflow tract tachycardia in patients with arrhythmogenic right ventricular cardiomyopathy. A 27-year-old man had complaints of palpitation and syncope. The admission electrocardiogram (ECG) showed sustained monomorphic ventricular tachycardia with left bundle branch block and inferior axis morphology. The ECG obtained during sinus rhythm was normal. Transthoracic echocardiography showed both ventricles in normal function and size. During electrophysiologic study, ventricular tachycardia was induced consistent with the clinical tachycardia. It was thought to originate from the left ventricular outflow tract and was terminated by radiofrequency ablation. However, the patient presented again, after a year, complaining of palpitations. The admission ECG was similar to that obtained before with sustained ventricular tachycardia, whereas the ECG during sinus rhythm showed negative T waves in leads V1-3. During electrophysiologic study, another ventricular tachycardia was induced with left bundle branch block and horizontal axis morphology as well as that consistent with the clinical tachycardia. The former was terminated spontaneously. The presence of a different morphology and negative T waves on the ECG suggested arrhythmogenic right ventricular cardiomyopathy. On angiography, the right ventricle was dilated and hypocontractile. Cardiac magnetic resonance imaging confirmed the diagnosis by showing decreased wall thickness and wall motion abnormality in the right ventricle.

The comparison of the effects of standard 20 mg atorvastatin daily and 20 mg atorvastatin every other day on serum LDL-cholesterol and high sensitive C-reactive protein levels.

OBJECTIVE: In this study, we aimed at comparing the effects of standard once daily 20 mg atorvastatin treatment with that of atorvastatin 20 mg administered every other day on serum lipids and high sensitive C-reactive protein (hs-CRP) levels. METHODS: Sixty-one patients with serum total cholesterol levels of above 200 mg/dl and low density lipoprotein (LDL)--cholesterol levels of above 130 mg/dl were included in this prospective, randomized study. The patients were randomized into daily treatment of 20 mg atorvastatin (standard treatment) and 20 mg atorvastatin every other day (every other day treatment) groups. Before the treatment and at each visit, serum lipids and hs-CRP levels of all the patients were measured. Statistical analyses were performed Chi-square, unpaired t and two-way repeated measurements ANOVA tests. RESULTS: In the every other day treatment group, there was a 36.1% reduction in LDL-cholesterol levels by the end of first month (p<0.01). At the end of three months there was further decrease of 10.2% in LDL-cholesterol levels when compared to 1 month levels (p>0.05). The LDL cholesterol levels of the group receiving 20 mg atorvastatin every day was reduced by %41 by the end of 1 month (p<0.01). At the end of three months, the difference between the changes in the all lipid parameters of the two groups was not found to be of statistical significance. In the group receiving the medication every other day, there was a 21% decrease in hs-CRP levels compared to the basal measurements at the end of first month (p<0.05). In the group, receiving the medication every day the decrease in hs-CRP levels at the end of one month was more striking (37%, p<0.05). However, the effects of both treatment arms on hs-CRP levels, did not differ significantly (p>0.05). CONCLUSIONS: Alternate-day dosing of atorvastatin causes a significant lipid-lowering and antiinflammatory effects similar to that of daily administration and yet may provide some cost savings.