Evaluation of subclinical left ventricular systolic dysfunction using two-dimensional speckle-tracking echocardiography in patients with non-alcoholic cirrhosis.

INTRODUCTION: Cirrhosis is associated with certain abnormalities in left ventricular (LV) structure and function. Two-dimensional speckle-tracking echocardiography (2D-STE) enables a rapid and accurate analysis of regional LV systolic mechanics in the longitudinal, radial and circumferential directions. The aim of this study was to precisely assess the differences among the 3 directions in the early impairment of LV myocardial contraction in non-alcoholic cirrhotic patients with preserved LV pump function. METHODS: A total of 75 subjects, including 38 cirrhotic patients and 37 healthy individuals, were enrolled. Using 2D-STE, the strain (S) and systolic strain rate (SRS) values belonging to the radial (R), circumferential (C), and longitudinal (L) functions of the LV were measured. RESULTS: In the cirrhotic group, the LS (20.57 ± 2.1 vs. 28.7 ± 43.1, p<0.001) and LSR-S (1.1 ± 0.24 vs. 1.6 ± 0.3) values were found to be lower, whereas the CS (24.82 ± 2.57 vs. 19.16 ± 4.58, p<0.001) and CSRS (1.41 ± 0.3 vs. 1.2 ± 0.4, p<0.004) values were found to be higher than in the healthy control group. The RS and RSR-S values did not differ among the groups. A relationship was observed between the MELD score, which shows the severity of the disease, and the CS value (â: 0.211, p<0.01, 95%CI: 0.086-0.503). CONCLUSION: LV myocardial contraction was impaired in the longitudinal direction. However, LV pump function was augmented by the circumferential shortening during the ventricular systole. Using the 2D-STE method for the regional evaluation of the LV, the LV damage can be detected in the subclinical phase in cirrhotic patients.

Determination of right ventricular dysfunction using the speckle tracking echocardiography method in patients with obstructive sleep apnea.

BACKGROUND: The speckle tracking echocardiography (STE) method shows the presence of right ventricular (RV) dysfunction before the advent of RV failure and pulmonary hypertension in patients with cardiopulmonary disease. We aimed to assess subclinical RV dysfunction in obstructive sleep apnea (OSA) using the STE method. METHOD: Twenty-one healthy individuals and 58 OSA patients were included. According to severity as determined by the apnea-hypopnea index (AHI), OSA patients were examined in three groups: mild, moderate and severe. RV free wall was used in STE examination. RESULTS: Right ventricle strain (ST %) and systolic strain rate (STR-S 1/s) were decreasing along with the disease severity (ST - healthy: -34.05 ± -4.29; mild: -31.4 ± -5.37; moderate: -22.75 ± -4.89; severe: -20.89 ± -5.59; p < 0.003; STR-S - healthy: -2.93 ± -0.64; mild: -2.85 ± -0.73; moderate: -2.06 ± -0.43; severe: -1.43 ± -0.33; p < 0.03). Correlated with the disease severity, the RV early diastolic strain rate (STR-E) was decreasing and the late diastolic strain rate was increasing (STR-E - healthy: 2.38 ± 0.63; mild: 2.32 ± 0.84; moderate: 1.66 ± 0.55; severe: 1 ± 0.54; p < 0.003; STR-A - healthy: 2.25 ± 0.33; mild: 2.32 ± 0.54; moderate: 2.79 ± 0.66; severe: 3.29 ± 0.54; p < 0.03). The STR-E/A ratio was found to be in a decreasing trend along with the disease severity (healthy: 1.08 ± 0.34; mild: 1.06 ± 0.46; moderate: 0.62 ± 0.22; severe: 0.34 ± 0.23; p < 0.03). CONCLUSIONS: Subclinical RV dysfunction can be established in OSA patients even in the absence of pulmonary hypertension and pathologies which could have adverse effects on RV functions. In addition to the methods of conventional, Doppler and tissue Doppler echocardiography, using the STE method can determine RV dysfunction in the subclinical phase.

Aortic valve endocarditis and cerebral mycotic aneurysm due to brucellosis.

Brucellosis is an infectious disease caused by Gram-negative coccobacilli. Direct contact with the infected tissue or blood, consumption of infected dairy products, and inhalation of infectious aeresol particles can transmit the disease. Brucella endocarditis is rare but the most fatal complication of brucellosis. The most commonly involved valve is aortic valve. Mycotic aneurysms result as an involvement of central nervous system and can lead to serious complications. Herein we present a case with mycotic aneurysmal rupture and aortic insufficency and sinus valsalva fistula caused by brucella endocarditis. There were rare cases with brucella endocarditis and mycotic aneursymal rupture secondary to neurobrucellosis in the literature. Relevant complications are treated with aortic valve surgery and peripheral endovascular intervention.

Missed opportunities for coronary heart disease diagnoses: primary care experience.

AIM: To investigate missed opportunities to reveal existing but not formerly diagnosed coronary heart disease cases and related risk factors in primary health care. METHODS: The study comprised 850 people aged over 30 years with no known history of coronary heart disease, receiving health services from a primary care center located in a suburban area of Antalya, Turkey. Data on their age, gender, education level, health insurance status, income, smoking behavior, and physical activities were collected. Undiagnosed coronary heart disease patients were determined by the Rose questionnaire, physical examination, and electrocardiogram. Height and weight, blood pressure, serum glucose and cholesterol levels were measured, and body-mass index and waist-hip ratio calculated. Each patient was given a risk score regarding age, smoking behavior, systolic blood pressure, and cholesterol levels. Estimated risk ratio of each person for developing coronary heart disease in the next decade was determined. RESULTS: The number of formerly undiagnosed coronary heart disease cases was 126 (14.8%). Overall mean (+/-standard deviation) risk score for developing coronary heart disease in the next decade in study group was 6.1+/-6.8. Diseases facilitating development of coronary heart disease: hypertension, diabetes, and hypercholesterolemia were present in 255 (30.4%), 70 (8.2%), and 364 (43.4%) participants, respectively. Obesity was detected in 315 (37.1%) subjects and there were 222 (26.1%) current smokers. For patients who attended primary health care, the estimated percentage risk for developing coronary heart disease in the next ten years was 7 to 45% in men and 2 to 45% in women. CONCLUSION: Opportunities to reveal coronary heart disease and its risk factors are being missed in primary care. Measures should be taken to ensure timely diagnosis of coronary heart disease and related risk factors.

Prescribing pattern of antihypertensive drugs in primary care units in Turkey: results from the TURKSAHA study.

OBJECTIVES: The prescribing pattern of drugs used for treating hypertension changes over time in response to changes in recommended guidelines and innovations in drug formulations, among others. In addition, the classes of antihypertensive drugs used vary among the countries. The aim of this study was to investigate the practice of antihypertensive medications in primary care units in Turkey. METHOD: TURKSAHA is a cross-sectional screening study conducted in 1000 primary care units considered to be representative of primary care in Turkey, with the purpose of defining the demographic characteristics, clinical features, rate of blood pressure control achieved and the antihypertensive drugs prescribed for the hypertensive patients treated in these centers. In this analysis, we investigated the agents used in the treatment regimen. RESULTS: Of the 16,270 patients considered to be eligible for inclusion in the study, 15,187 (93.3%) were on an antihypertensive treatment, and 1083 (6.7%) were receiving no treatment. Patients who received treatment but whose antihypertensive medication was not specified (2290 patients) were subsequently excluded, and the trial was carried out with the remaining 12,897 patients. The mean age of the patients was 60 +/- 11 years (60.2% female). Of the 12,897 patients, 75.7% were receiving monotherapy, 19.7% two drugs, 4.1% three drugs and 0.5% four or more drugs. The rate of successful blood pressure control (<140/90 mmHg; for diabetics <130/80 mm Hg) in relation to the number of drugs received was 26.3, 25.9, 24.5 and 26.2%, respectively. Among the patients receiving monotherapy, the most frequently used antihypertensive drug class was angiotensin-converting enzyme inhibitors (30.1%), followed by beta-blockers (20.6%), calcium-channel blockers (17.9%), diuretics (15.4%) and angiotensin-receptor blockers (14%). CONCLUSION: As in other European countries, the rate of successful blood pressure control was low among hypertensive patients receiving treatment, and despite the inadequacy of monotherapy to control blood pressure, many of the patients continued this treatment regimen. Consistent with the global trend, the most frequently prescribed anti-hypertensives were angiotensin blockers.

Assessment of percutaneous coronary intervention on regional and global left ventricular function in patients with chronic total occlusions.

BACKGROUND: The improvement of regional and global ventricular function following percutaneous coronary intervention (PCI) with reperfusion of the artery supplying the infarct area in acute myocardial infarction is well-described. However, little is known of the potential effects of late recanalization of chronic coronary artery occlusion on left ventricular function. OBJECTIVE: To determine whether PCI improves regional and global left ventricular function in patients with chronic coronary artery occlusions. PATIENTS AND METHODS: Thirty-five patients having at least one coronary artery occluded for six weeks or longer were included in the present prospective study. Exercise thallium-201 myocardial perfusion scintigraphy, multiple-gated acquisition ventriculography and two-dimensional echocardiography were performed in 19 patients (16 men; mean age of 58+/-5 years) who underwent a successful PCI to assess both regional and global left ventricular function before and six weeks following the procedure. RESULTS: The mean ejection fractions before and after reperfusion were 51+/-7% and 58+/-6% using Simpson's method (P<0.001) by echocardiography, and 45+/-1% and 53+/-1% (P=0.01) by multiple-gated acquisition ventriculography, respectively. The echocardiographic wall motion score was 24+/-9 before and 15+/-6 after PCI (P<0.001). The exercise perfusion score (21+/-1 and 14+/-1 [P=0.01]), rest perfusion score (15+/-1 and 12+/-1 [P=0.02]) and reinjection perfusion score (14+/-1 and 11.1+/-1 [P=0.07]) also improved after PCI. The presence of angina was strongly associated with an improvement in left ventricular function and wall motion score (P<0.01). CONCLUSIONS: PCI significantly improved the regional and global left ventricular function in patients with chronic total coronary occlusion. This procedure may provide symptom benefits in selected patients.

Primary percutaneous coronary interventions in acute myocardial infarction in diabetic versus non-diabetic patients. In-hospital and long-term results.

BACKGROUND: It has been well established that in the pre-thrombolytic era diabetic patients had poorer clinical outcome after acute myocardial infarction (AMI) compared to non-diabetic patients. Less is known about the impact of diabetes on early and late clinical outcomes in patients with AMI undergoing primary percutaneous coronary interventions (PCI). AIM: To compare the in-hospital and long-term clinical outcomes of AMI patients with and without diabetes. METHODS: Seven hundred seventy-four patients who underwent primary PCI for AMI in our institution between 1997 and 2001 were included in the study. We compared the angiographic and clinical outcomes of 633 (81.8%) non-diabetic (aged 55.9+/-10.6 years; 82.6% male) and 141 (18.2%) diabetic (aged 56.8+/-11.7 years; 63.1% male) patients. RESULTS: Diabetic patients had a higher incidence of hypertension, hyperlipidemia, and unstable hemodynamic status compared to non-diabetic patients (p=0.001, 0.003, 0.001, respectively). Smoking and male gender rates were significantly more frequent in non-diabetic patients (p=0.001, 0.001, respectively). Angiographic success and prominent clinical improvement were achieved in 96.4% and 90.7% of diabetics vs 96.7% and 95.1% of non-diabetics (p=NS and 0.04, respectively). Diabetic patients had a higher incidence of in-hospital deaths and overall events (p=0.028). At one-month follow-up, diabetic patients required more target vessel revascularisation (5.6% vs 1.6%; p=0.006), which accounted for the majority of major cardiac events at one month (20.6% vs 7.4%; p=0.003). At a mean follow-up of 7.2+/-2.7 months, 92.9% of non-diabetic and 88% of diabetic patients were still alive (p=0.05). Overall survival without any major cardiac event (death, new MI or target vessel revascularisation) at 7.2+/-2.7 month follow-up was 75.8% for non-diabetics and 58.1% for diabetic patients (p<0.01). In the multivariate analysis age, diabetes, shock, hemodynamic instability and female gender were the most important predictors for the development of early and late major cardiovascular events. CONCLUSIONS: Primary PCI in acute MI is effective in restoring TIMI 3 coronary flow both in diabetic and non-diabetic patients. This procedure may reduce mortality in both groups, particularly in diabetic patients in whom this benefit is more prominent compared to thrombolytic therapy. Nevertheless, early and long-term event rates are significantly higher in diabetics than in non-diabetic patients.

Treatment of mild-to-moderate hypertension with calcium channel blockers: a multicentre comparison of once-daily nifedipine GITS with once-daily amlodipine.

BACKGROUND: Hypertension is one of the most important causes of cardiovascular disease, and treatment of hypertension leads to a significant reduction in cardiovascular mortality and morbidity. Although calcium channel blockers are regarded as an important part of the therapeutic armamentarium against cardiovascular diseases, and are among the most frequently prescribed antihypertensive medications, concern has been aroused about these drugs, particularly the short-acting dihydropyrldine derivatives. However, the value of nifedipine GITS(Adalat-Crono), the long-acting dihydropyrldine, is in need of being re-established. OBJECTIVE: To compare the effectiveness, safety and tolerability of once-daily nifedipine and amlodipine treatment in patients with mild-to-moderate essential hypertension. DESIGN: Randomised multicentre trial with an open comparison of treatments for 12 weeks, with a preceding placebo run-in period of 2 weeks (patients on beta-blockers at the time of enrollment entered a mandatory 2-week wash-out period before being allowed In the placebo run-in period;this wash-out period was one week for patients using any antihypertensive medication other than beta-blockers). SETTING: Nine centres (all university hospitals) in Turkey. PATIENTS: 155 patients with essential hypertension(diastolic blood pressure 95-109 mmHg). INTERVENTIONS: Initial treatment (step 1) consisted of 30 mg nifedipine GlTS (n = 76; (Adalat-Crono tablets), or 5 mg amlodipine (n = 79; Norvasct5-mg tablets), either administered once daily, as a morning dose, or f the blood pressure was not below 140/90 mmHg, or the reduction In diastolic blood pressure was lower than 10 mmHg after a treatment period of 6 weeks, the dose was increased (Step 2) to 60 mg once daily in the nifedipine group, or 10 mg once daily in the amlodipine group. MAIN EFFICACY PARAMETER: Diastolic blood pressure at trough after 12 weeks of active compound therapy adjusted to baseline. RESULTS: After 12 weeks of treatment, the mean diastolic blood pressure was 83.1 and 81.9 mmHg,in the nifedipine and amlodipine groups, respectively (p = 0.436). The mean decrease in systolic blood pressure (28.5 +/- 11.9 and 28.2 +/- 11.2 mmHg in the nifadipine and amlodipine groups, respectively) and the mean decrease in diastolic blood pressure (16.4A +/- 7.0 and 17.5 +/- 6.9 mmHg in the nifedipine and amlodipine groups, respectively), as well as the responder rates (88.1%and 92.1%, in the nifediplne and amlodipine groups, respectively) were comparable at the end of the study. No significant differences between groups were detected In the efficacy parameters assessed in this study. Both drugs were well tolerated. The overall incidence of adverse events was 7.9% in the nifadipine group and 10.1% In the amlodipine group. However, more patients discontinued treatment prematurely in the amlodipine group (13 patients; 19.7%), than in the nifedipine group (four patients; 5.6%). CONCLUSIONS: The results of this study demonstrated that once-daily nifedipine in GITS formation and amlodipine are comparably safe and effective treatment options in patients with mild-to-moderate essential hypertension.

Comparison of initial efficacy and long-term follow-up of heparin-coated Jostent with conventional NIR stent.

The implantation of heparin-coated stents was reported to be well tolerated, but there are conflicting results about acute in-hospital complications. (sub)acute thrombosis rates, and long-term follow-up compared to uncoated stents. We compared the angiographic and clinical results after coronary placement of two stent models: the heparin-coated premounted Jostent and the uncoated premounted NIR stent. Of 710 patients revascularized, a total of 426 patients received Jostent (n = 230) or NIR stent (n = 196) implantation. The primary end points were acute or subacute thrombosis, urgent CABG, AMI or death, while the secondary end points were the comparison of the restenosis rates of the stents at the 6th month and of the functional angina classification of the stent groups at the 1st, 6th and 12th months. There were no significant differences between the Jostent and NIR stent groups regarding angiographic and procedural success. Acute thrombosis rates in the Jostent and NIR stent groups were similar while no subacute thrombosis was observed in either group. The major adverse cardiac event rates of the groups also did not differ. Angiographic restenosis occurred in 17% of the Jostent group and 16% of the NIR stent group (NS). The combined clinical and angiographic restenosis rate was also similar between the Jo and NIR groups (19% and 18%, respectively). Comparison of functional angina classes at the 1st, 6th and 12th months revealed no significant difference between the study groups. In conclusion, when compared with implantation of an uncoated premounted NIR stent, implantation of a heparin-coated premounted Jostent does not provide any more benefit with respect to initial efficacy, sub(acute) thrombosis and 6-month restenosis rates and 12-month clinical outcomes.

Cardiac relapse of squamous cell carcinoma of the maxillary sinus.

An unusual case of maxillary sinus carcinoma presenting with heart metastasis is reported. The epicardium, myocardium and endocardium were infiltrated with the tumor, but no evidence of recurrent maxillary sinus carcinoma and other organ metastasis was found. Surgical excision was not possible due to massive invasion of the heart by the tumor mass. The right ventricular inflow tract obstruction was relieved by surgical dilatation.