The Role of Osteoprotegerin as a Cardioprotective Versus Reactive Inflammatory Marker: the Chicken or the Egg Paradox

Cardiovascular disease is one of the most frequent causes of mortality and morbidity worldwide. Several variables have been identified as risk factors for cardiovascular disease. Recently, the role of receptor activator of nuclear factor kappa B, receptor activator of nuclear factor kappa B ligand, and the osteoprotegerin system has been recognized as more important in the pathogenesis of cardiovascular disease. Besides their roles in the regulation of bone resorption, these molecules have been reported to be associated with the pathophysiology of cardiovascular disease. There are conflicting data regarding the impact of osteoprotegerin, a glycoprotein with a regulatory role in the cardiovascular system. The aim of this review is to discuss the current knowledge and the role of osteoprotegerin in cardiovascular disease.

Assessment of left atrial function in patients with type 2 diabetes mellitus with a disease duration of six months.

INTRODUCTION: Changes in left atrial (LA) size and function are associated with adverse clinical events. Recently, duration of diabetes mellitus (DM2) has been found to be positively associated with increased LA volume and impaired LA function. This study was performed, using two-dimensional echocardiograpy, to evaluate the changes in LA volume and function in patients with DM2 with a disease duration of six months, and to assess the parameters that affect LA volume and function. METHODS: Fifty-six patients (28 male, age: 52.6 ± 6.5 years) with DM2 and 56 controls (24 male; age: 50.1 ± 7.0 years) were enrolled in the study. Each subject underwent conventional two-dimensional echocardiography to assess LA volume (indexed maximal LA volume: Vmax, pre-atrial contraction volume: Volp, minimal LA volume: Vmin) and LA function [passive emptying volume - passive emptying fraction (PEV - PEF), active emptying volume - active emptying fraction (AEV - AEF), total emptying volume - total emptying fraction (TEV - TEF) ]. RESULTS: LA diameter, indexed Vmax, Volp, Vmin, AEV and TEV were found to be significantly higher in the DM2 group compared with the controls (p < 0.05). Indexed Vmax, Volp and Vmin were significantly correlated with HbA1c level, body mass index (BMI), high-sensitivity C-reactive protein and uric acid levels, mitral A wave, E/E' ratio and A' wave. According to multivariate analysis, age and BMI had a statistically significant effect on LA volume. CONCLUSION: Impaired LA function may be present in patients with newly diagnosed DM2. BMI and increasing age caused LA enlargement and LA volumes that were independent of the effects of hypertension and DM2.

Treating a Patient of Dysfibrinogenemia with Acute Thromboembolism by Rivaroxaban and Cilostazol.

Congenital dysfibrinogenemia is a rare autosomal recessive bleeding disorder, which is characterized by the absence of functional fibrinogen. Patients may have bleeding and paradoxical arterial and venous thrombotic problems from early childhood. The optimal antithrombotic therapy in these patients hasn't been determined yet. In this report we present a dysfibrogenemic patient, who has suffered recurrent arterial thrombosis under aspirin treatment. Intravenous fibrinogen concentrates (fc) along with reduced doses of rivaroxaban (10 mg daily), cilostazol (50 mg bid) and aspirin (100 mg daily) were given as antithrombotic treatment. The pain and the cyanosis clinically recovered within 6 weeks. This is, to our knowledge, the first time in which a new oral anticoagulant, rivaroxaban and cilostazol combination was used in a dysfibrinogenemic patient with thrombotic episodes. We determined the type, the dosage and the duration of antithrombotic treatment according to the clinical progress of the symptoms. Rivaroxaban, cilostazol and fibrinogen concentrate replacement; combination may represent a useful alternative for the antithrombotic treatment in dysfibrinogenemic patients.

Complicated left-sided infective endocarditis in chronic hemodialysis patients: a case report.

Infective endocarditis (IE) is a serious infectious condition with high morbidity and mortality in patients with end-stage renal disease (ESRD). It has been particularly associated with recurrent bacteremia due to vascular access via lumen catheters. The most common pathogen is Staphylococcus (S.) aureus, and most affected valve is mitral valve, which frequently calcified. Two patients with ESRD who received hemodialysis treatment via tunneled catheters, aged 56 and 88 years, were admitted with fever and high troponin level. Blood cultures revealed growth of S. aureus. Good quality transthoracic echocardiography (TTE) displayed calcified mitral and aortic valves with no vegetation or abscess formation. Myocardial necrosis as result of catheter infection was considered. Both patients had persistent positive blood cultures 3 and 5 days after initiation of antibiotic treatment. Therefore, transesophageal echocardiogram (TEE) was scheduled. Results revealed perivalvular abscess in the older patient, and highly mobile vegetation in the younger patient. The older patient refused surgery and died soon after due to refractory shock. Mitral valve surgery was planned for the other patient; however, she developed left ventricular failure and bleeding, and also subsequently died as result of refractory shock. Patient evaluations were particularly unfavorable: they had catheter infection as primary focus, and TTE did not detect vegetation or annular abscess. Diagnosis of IE in patients with ESRD using Duke criteria is problematic; we have to keep use of TEE in mind to detect vegetation or abscess formation when there is clinical suspicion regarding ESRD patients even after good quality TTE.

Early Changes in Atrial Electromechanical Coupling in Patients with Hypertension: Assessment by Tissue Doppler Imaging.

BACKGROUND: Hypertension (HT) is associated with atrial electrophysiological abnormalities. Echocardiographic pulsed wave tissue Doppler imaging (TDI) is one of the noninvasive methods for evaluation of atrial electromechanical properties. The aims of our study were to investigate the early changes in atrial electromechanical conduction in patients with HT and to assess the parameters that affect atrial electromechanical conduction. METHODS: Seventy-six patients with HT (41 males, mean age 52.6 ± 9.0 years) and 41 controls (22 males, mean age 49.8 ± 7.9 years) were included in the study. Atrial electromechanical coupling at the right (PRA), left (PLA), interatrial septum (PIS) were measured with TDI. Intra- (right: PIS-PRA, left: PLA-PIS) and inter-atrial (PLA-PRA) electromechanical delays were calculated. Maximum P-wave duration (Pmax) was calculated from 12-lead electrocardiogram. RESULTS: Atrial electromechanical coupling at PLA (76.6 ± 14.1 ms vs. 82.9 ± 15.8 ms, P = 0.036), left intra-atrial (10.9 ± 5.0 ms vs. 14.0 ± 9.7 ms, P = 0.023), right intra-atrial (10.6 ± 7.8 ms vs. 14.5 ± 10.1 ms, P = 0.035), and interatrial electromechanical (21.4 ± 9.8 ms vs. 28.3 ± 12.7 ms, P = 0.003) delays were significantly longer in patients with HT. The linear regression analysis showed that left ventricular (LV) mass index and Pmax were significantly associated with PLA (P = 0.001 and P = 0.002, respectively), and the LV mass index was the only related factor for interatrial delay (P = 0.001). CONCLUSIONS: Intra- and interatrial electromechanical delay, PLA were significantly prolonged in hypertensive patients. LV mass index and Pmax were significantly associated with PLA, and the LV mass index was the only related factor for interatrial delay. The atrial TDI can be a valuable method to assess the early changes of atrial electromechanical conduction properties in those patients.

Aortic flow propagation velocity, epicardial fat thickness, and osteoprotegerin level to predict subclinical atherosclerosis in patients with nonalcoholic fatty liver disease.

OBJECTIVE: Nonalcoholic fatty liver disease is the most common cause of liver dysfunction in Western countries and an independent risk factor for atherosclerotic heart disease. Appropriate noninvasive parameters are lacking for optimal risk stratification of cardiovascular disease in these patients. We evaluated several recently discovered noninvasive parameters for atherosclerosis in patients with nonalcoholic fatty liver disease: epicardial fat thickness, aortic flow propagation velocity, and osteoprotegerin level. METHODS: Forty-one patients (27 men and 14 women; mean age, 37.9±8.9 years) with nonalcoholic fatty liver disease and 37 control subjects (17 men and 20 women; mean age, 34.5±8.6 years) were enrolled in this observational case-control study. Patients with nonalcoholic fatty liver disease diagnosed at a gastroenterology outpatient clinic were included. Patients with cardiac pathology other than hypertension were excluded. Epicardial fat thickness and aortic flow propagation velocity were measured by echocardiography. The serum concentration of osteoprotegerin was measured using a commercial enzyme-linked immunosorbent assay kit. RESULTS: Nonalcoholic fatty liver disease patients exhibited a significantly lower aortic flow propagation velocity (155.17±30.00 vs. 179.00±18.14 cm/s, p=0.000) and significantly higher epicardial fat thickness (0.51±0.25 vs. 0.29±0.09 cm, p=0.000) than control subjects. Osteoprotegerin levels were higher, but not significant, in patients with nonalcoholic fatty liver disease (28.0±13.0 vs. 25.2±10.8 pg/mL, p=0.244). Binary logistic regression analysis showed that aortic flow propagation velocity (OR, -0.973; 95% CI, 0.947-0.999) and waist circumference (OR, -1.191; 95% CI, 1.088-1.303) were independent predictors of nonalcoholic fatty liver disease. CONCLUSION: In this study, epicardial fat thickness and osteoprotegerin level were higher and aortic flow propagation velocity was lower in patients with nonalcoholic fatty liver disease. Early detection of abnormal epicardial fat thickness and aortic flow propagation velocity may warrant a search for undetected cardiovascular disease in patients with nonalcoholic fatty liver disease.

Cardiotoxicity following cyclophosphamidetherapy: a case report.

INTRODUCTION: Cardiac toxicity is one of the life-threatening complications of cancer therapy. Systemic anticancer treatments may exert their own toxic effects or can aggravate adverse effects of other drugs. We report a case of cyclophosphamide-induced cardiotoxicity in a patient with normal cardiac functions before chemotherapy. CASE PRESENTATION: A 66-year-old Caucasian woman with a mediastinal mass diagnosed with Burkitt lymphoma underwent chemotherapy with rituximab-hyperfractionated-cyclophosphamide-vincristine-doxorubicin-dexamethasone. On the seventh day of chemotherapy, she developed dyspnea. An electrocardiogram demonstrated low voltage in the limb and precordial leads. It also showed diffusely increased myocardial echogenicity, mild pericardial and pleural effusion, generally impaired biventricular systolic functions with a left ventricular ejection fraction of 31%, and right ventricular mid-apical akinesia, even though she had normal biventricular functions before chemotherapy. Cyclophosphamide-induced cardiotoxicity was suspected and she was given treatment for congestive heart failure. Her dyspnea decreased and she was discharged on the tenth day with a left ventricular ejection fraction of 37% and normal right ventricular function. After 1 month, echocardiography showed normal biventricular functions with a left ventricular ejection fraction of 60%. CONCLUSIONS: Drug-induced cardiotoxicity, therefore, should be taken into consideration when using cyclophosphamide therapy, especially when anthracyclines are co-administered. Close communication between hematologists and cardiologists is required.

Carotid Artery Intima Media Thickness and HsCRP; Predictors for Atherosclerosis in Prediabetic Patients?

OBJECTIVE: We aimed to assess carotid intima media thickness (CIMT) and serum high-sensitivity C-reactive protein (hs-CRP) levels as estimated markers of subclinical atherosclerosis and inflammation in prediabetic patients. METHODOLOGY: One hundred and ten patients were defined as prediabetic and seventy-six subjects (age and sex matched) were assigned as control group in our cross sectional study. Bilateral CIMT measurements and hs-CRP levels were evaluated. RESULTS: The prevalance of hypertension, hyperlipidemia, angiotensin receptor blockers and antihyperlipidemic medication use were statistically higher in the prediabetic group. Serum hs-CRP levels, left, right and maximum CIMT were statistically higher among prediabetics compared to control group. There was a positive, significant correlation between left, right, maximum CIMT and fasting blood glucose, HbA1c, hs-CRP levels and BMI. CONCLUSION: Recognising and focusing on the intervention of prediabetic state as early as possible and identifying the susceptible patients who may benefit from more aggressive preventive therapy is an important issue of primary prevention of diabetes and cardiovascular diseases.

Platelet function analysis with two different doses of aspirin.

OBJECTIVES: We aimed to compare the level of platelet inhibition using the platelet function analyzer (PFA)-100 in patients receiving low and medium doses of aspirin. STUDY DESIGN: On a prospective basis, 159 cardiology outpatients (83 men, 76 women; mean age 60.9 ± 9.9 years) taking 100 mg/day or 300 mg/day aspirin at least for the previous 15 days were included. Of these, 79 patients (50%) were on 100 mg and 80 patients (50.3%) were on 300 mg aspirin treatment. Blood samples were collected between 09:30 and 11:00 hours in the morning. Platelet reactivity was measured with the PFA-100 system. Incomplete platelet inhibition was defined as a normal collagen/epinephrine closure time (< 165 sec) despite aspirin treatment. RESULTS: Baseline clinical and laboratory characteristics of the patient groups taking 100 mg or 300 mg aspirin were similar. The overall prevalence of incomplete platelet inhibition was 22% (35 patients). The prevalence of incomplete platelet inhibition was significantly higher in patients treated with 100 mg of aspirin (n = 24/79, 30.4%) compared with those treated with 300 mg of aspirin (n = 11/80, 13.8%) (p = 0.013). In univariate analysis, female sex (p = 0.002) and aspirin dose (p = 0.013) were significantly correlated with incomplete platelet inhibition. In multivariate analysis, female sex (OR: 0.99; 95% CI 0.9913-0.9994; p = 0.025) and aspirin dose (OR: 3.38; 95% CI 1.4774-7.7469; p = 0.003) were found as independent factors predictive of incomplete platelet inhibition. CONCLUSION: Our findings suggest that treatment with higher doses of aspirin can reduce incomplete platelet inhibition especially in female patients.

The clinical significance of aspirin resistance in patients with chest pain.

BACKGROUND: There are conflicting data in the literature about the clinical significance of aspirin resistance. HYPOTHESIS: We aimed to prospectively evaluate the prevalence of biochemical aspirin resistance in patients on aspirin therapy who were admitted to the emergency clinic with chest pain. We also aimed to evaluate the relation between acute coronary syndromes (ACS) and aspirin resistance. METHODS: A total of 338 patients were included in the study. Platelet reactivity was measured with the PFA-100 system (Dade Behring Inc, Deerfield, IL). Aspirin resistance determined by the PFA-100 was defined as a normal collagen and/or epinephrine closure time despite aspirin treatment (<165 s). RESULTS: Patients were divided into 4 groups: stable angina pectoris (SAP), unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), ST-elevation myocardial infarction (STEMI), and rule out ACS. Aspirin resistance was found in 81 (24%) patients in all groups. Patients with ACS had significantly more aspirin resistance than patients with rule out ACS or patients with SAP (P < .001). In the SAP group, 31 (19.6%) patients; in the UA/NSTEMI group, 19 (35.8%) patients; in the STEMI group, 14 (50%) patients; and in the rule out ACS group, 17 (17.2%) patients had aspirin resistance (P < .001). In the multivariate analysis, cardiac biomarker elevation on admission to emergency department and platelet count appeared as independent factors predictive of aspirin resistance. CONCLUSIONS: We demonstrated that incidence of aspirin resistance was significantly higher in patients who were finally diagnosed as ACS, especially in aspirin-taking patients admitted to the emergency clinic with STEMI.

Mitral valve aneurysm associated with aortic valve regurgitation.

Mitral valve aneurysm (MVA) is uncommon and occurs most commonly in association with infective endocarditis involving the aortic valve. A 66-year-old man with anterior MVA is presented. Two-dimensional transthoracic echocardiography and transesophageal echocardiography revealed a saccular structure in the anterior mitral leaflet that bulged into the left atrium throughout the cardiac cycle, a localized aneurysmal lesion of the aortic valve, and severe mitral and aortic regurgitation. There were neither vegetations nor atrial thrombi and his medical record was not suggestive of any episode of infective endocarditis. The mitral and aortic valves were replaced with mechanical protheses. Pathologic examination of the excised valves showed inflammation and cultures were negative. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. In this case, MVA is likely to result from previous infective endocarditis of the aortic valve leading to aneurysm formation and severe aortic regurgitation.

The effects of short time right ventricular pacing on left atrial mechanical functions.

OBJECTIVES: Left atrium (LA) plays an important role in left ventricular filling. It is well known that right ventricular apical pacing has unfavorable effects on ventricular systolic and diastolic performance. The aim of this study is to evaluate the LA mechanical functions with 2D echocardiography in patients with a permanent pacemaker after short time ventricular pacing. DESIGN: Echocardiographic examination was performed in 38 patients (mean age 63.0+/- 10.9, 18 female) with dual chamber pacemakers or defibrillators (< 20% ventricular pacing within previous 6 months, all of them on sinus rhythm) before and after 4 hours > 90% ventricular pacing at 70 beats per minute in DDD mode with an optimal AV interval. Left atrial volumes (LAV) including at the time of mitral valve opening (Vmax), at closure (Vmin), and at the onset of atrial systole (Volp) were measured. The passive emptying, conduit, active emptying and total emptying volume, stroke volumes were also calculated. RESULTS: No significant differences were noted at baseline and after pacing for absolute Vmax, Volp, passive emptying, conduit, active emptying, total emptying volumes as well as the volumes indexed to body surface area (p >0.05). CONCLUSIONS: Short - time RV pacing seems to have no acute effects on left atrial mechanical functions.

Tissue Doppler study of the right ventricle with a multisegmental approach: comparison with cardiac magnetic resonance imaging.

OBJECTIVE: We investigated whether systolic right ventricular (RV) function and myocardial performance index (MPI) studied with a multisegmental approach improve the accuracy of RV function estimation based on tricuspid lateral annulus. METHODS: Systolic and isovolumic contraction velocities, isovolumic acceleration, regional MPI from the tricuspid lateral and septal annulus, and basal and apical RV free wall and blood pool MPI were obtained in 69 patients and compared with RV ejection fraction (EF) by cardiac magnetic resonance. RESULTS: Average systolic velocity from 2 annular sites had the highest correlation to the RVEF (r = 0.74; P < .001) and highest accuracy to estimate RVEF > 45% (cutoff = 7.0 cm/s; area under the curve 0.908; 95% confidence interval, 0.84-0.98; sensitivity 83%; specificity 86%; P < .0001). Average annular systolic velocity correlated with the RVEF more strongly than the lateral annular systolic velocity in patients with and without dilated RVs and in patients with and without pulmonary arterial hypertension. Four-region average MPI correlated with the RVEF (r = 0.70; P < .001) more strongly than regional MPI and blood pool MPI, with a higher accuracy to estimate RVEF > 45% (cutoff = 0.66; area under the curve 0.849; 95% CI, 0.76-0.94; sensitivity 86%; specificity 75%; P < .0001). Lateral annular measurements were mostly determined by the RVEF, whereas septal annular measurements were almost equally influenced by RVEF and left ventricular ejection fraction (LVEF). Consequently, when the RVEF and LVEF were discordant, only the lateral annular systolic velocity and MPI determined RVEF. CONCLUSION: Average systolic velocity from 2 tricuspid annular sites provides the most accurate estimate of RVEF if the RVEF and LVEF are not discordant.

Lipoma of the right atrium.

A 66-year-old asymptomatic woman was admitted to our hospital with the diagnosis of a right atrial mass detected on an outside transthoracic echocardiogram and confirmed on transesophageal echocardiography. Physical examination and basal electrocardiogram were normal. Transthoracic echocardiography revealed a 3.8 x 2.5 cm echogenic mass in the right atrium. A multislice CT examination demonstrated a right atrial mass with a fat density ranging from -80 to -110 HU. The patient had a successful surgical excision of the mass, and the diagnosis of lipoma was confirmed on histopathological examination.

Adenosine-induced ventricular arrhythmias in patients with supraventricular tachycardias.

BACKGROUND: Adenosine is widely used for the diagnosis and the termination of supraventricular arrhythmias. There are many case reports and few series about the proarrhythmic potential of adenosine. We sought to evaluate the proarrhythmic potential of adenosine used to terminate the supraventricular arrhythmias. METHODS: The records of all patients that received adenosine for the termination of supraventricular tachycardia were reviewed retrospectively and those with a continuous electrocardiographic (ECG) recording during adenosine administration were included to the study. RESULTS: Our search identified 52 supraventricular episodes of 46 patients with a continuous ECG recording during adenosine administration. Following adenosine administration, premature ventricular contraction (PVC) or ventricular tachycardia (VT) developed in 22 (47.8%) patients and in 26 (50%) tachycardia episodes. No patient had a sustained VT. Nonsustained VT developed in eight (17.4%) patients. All VT episodes were polymorphic, short, and self-terminating. When the basal and demographic properties of patients with PVC or VT and those without PVT or VT were compared, there was no significant difference. CONCLUSIONS: Adenosine is a quite safe and effective drug for the termination of narrow QRS complex tachycardia but it often induces nonsustained VT or PVC that are clinically insignificant in the absence of other accompanying heart disease.

The effects of prior calcium channel blocker therapy on creatine kinase-MB levels after percutaneous coronary interventions.

BACKGROUND: Use of intracoronary calcium channel blockers (CCBs) during percutaneous coronary intervention (PCI) has been shown to have favorable effects on coronary blood flow. We aimed to investigate the effects of CCBs administrated perorally on creatine kinase-MB (CK-MB) levels in patients undergoing elective PCI. METHODS: A total of 570 patients who underwent PCI were evaluated for CK-MB elevation. Patients who were on CCB therapy when admitted to the hospital constituted the CCB group. No CCBs were given to the rest of the patients during the periprocedural period and these patients served as the control group. Blood samples for CK-MB were obtained before and at 6 h, 24 h, and 36 h after the procedure. RESULTS: 217 patients were in the CCB group (mean age 60.2 +/- 9.3 years, 162 males), and 353 were in the control group (mean age 60.0 +/- 10.1 years, 262 males). CK-MB levels increased above the normal values in 41 patients (18.9%) of the CCBs group and in 97 patients (27.5%) of the control group (p = 0.02). Median CK-MB levels were significantly higher in the control group for all studied hours (for all p < 0.05). CONCLUSIONS: Prior oral CCB therapy may have favorable effects in preventing myocyte necrosis after elective PCI.

Effects of persistent platelet reactivity despite aspirin therapy on cardiac troponin I and creatine kinase-MB levels after elective percutaneous coronary interventions.

BACKGROUND: Creatinine kinase-MB (CK-MB) and cardiac troponin I (cTnI) elevations are highly specific for myonecrosis after percutaneous coronary intervention (PCI). Aspirin is used to prevent thrombotic complications. Several studies have shown that some individuals exhibit a reduced or completely missing antiplatelet response to aspirin. The aim of this study is to investigate the effects of platelet reactivity despite aspirin therapy on CK-MB and cTnI levels after elective percutaneous coronary interventions despite 600 mg loading dose of clopidogrel. METHODS: One hundred fourteen (mean age 61.2+/-9.3 years, 78.1% male) patients receiving 300 mg daily enteric coated aspirin for at least 7 days with documented coronary artery disease were included in the study. Platelet reactivity despite aspirin was measured by platelet function analyzer (PFA)-100 collagen/epinephrine cartridge. Blood samples for CK-MB and cTnI were obtained before and at 6, 24, and 36 h after the PCI. Persistent platelet reactivity was defined when collagen/epinephrine closure time<165 s. RESULTS: A total of 87 (76.4%) patients were noted to have normal platelet reactivity (Group A), and 27 (23.6%) had persistent platelet reactivity (Group B). The elevations of CK-MB and cTnI levels were statistically significant within the groups (both P<0.001). However, there were no significant differences in the CK-MB and cTnI levels of the groups at baseline and after PCI for all studied hours. CONCLUSION: Persistent platelet reactivity was not associated with increased risk of CK-MB, cTnI elevations in low-to-intermediate risk PCI patients.

Comparison of C-reactive protein levels in patients who do and do not develop atrial fibrillation during electrophysiologic study.

C-reactive protein (CRP) was increased in patients with atrial fibrillation (AF). The aim of this study was to evaluate CRP after inducing AF in 39 patients undergoing electrophysiologic study (EPS). After a diagnostic EPS, programmed atrial stimulation with 3 extra stimuli from the right atrium was performed in all patients. CRP was measured before and 6 and 24 hours after the procedure. Patients in whom AF was induced were monitored for 24 hours. AF was induced in 18 of 39 patients. Twenty-one patients without a tachyarrhythmia constituted the control group. Groups were similar with regard to age, gender, incidences of hypertension and diabetes, and history of coronary artery disease. On average, AF lasted 4.8 hours, and spontaneous conversion to sinus rhythm was observed in all patients. There were no statistically significant differences with respect to baseline and 6-hour CRP values between groups. However, mean CRP at 24 hours was significantly higher in patients with AF compared with controls (10 +/- 11 and 3.9 +/- 4.2 mg/L; p = 0.04). In conclusion, induction of AF during EPS led to increased CRP. This finding suggested that increased CRP may be the consequence of AF.

C-reactive protein levels increase after exercise testing in patients with increased platelet reactivity.

Aspirin has the potential to influence C-reactive protein (CRP) levels, an inflammatory marker, by its anti-inflammatory activity. Persistently increased platelet reactivity, however, can be detected with different laboratory methods despite aspirin therapy in some patients. The aim of this study was to investigate the effects of increased platelet reactivity on CRP levels at rest and after exercise in patients with documented or suspected coronary artery disease. Blood samples were collected from 100 patients (age, 58.1+/-8.5 years; 63.0% men) who were treated with 100 or 300 mg/day enteric-coated aspirin for at least 7 days, before and immediately after treadmill test for CRP analyses. Platelet reactivity was measured by the standardized platelet function analyzer-100, and increased platelet reactivity was defined as a normal collagen/epinephrine closure time (<165 s). Of the 100 patients, 82 had normal platelet reactivity (group A) and 18 had increased platelet reactivity (group B). The CRP levels increase was statistically significant after exercise in patients with increased platelet reactivity [group A: 2.3 (1.4-4.3) to 2.8 (1.6-4.9) mg/l, P=0.09; group B: 3.3 (2.0-4.5) to 4.7 (2.9-8.5) mg/l, P=0.02]. Detecting increased platelet reactivity is associated with an increase in CRP levels. The clinical significance of this finding needs to be further investigated.

Noninvasive estimation of right ventricular filling pressure by ratio of early tricuspid inflow to annular diastolic velocity in patients with and without recent cardiac surgery.

BACKGROUND: Few data are available on the evaluation of right ventricular (RV) diastolic function and filling pressures by echocardiography. We aimed to determine whether the ratio of early tricuspid inflow to annular diastolic velocity (E/E') could be used to estimate RV filling pressure in patients with and without recent cardiac surgery. METHODS: In all, 101 data sets including invasive and echocardiographic measurements (42 after recent cardiac surgery) were simultaneously obtained from patients in the intensive care department. Tissue Doppler measurements were performed from the tricuspid annulus. E/E' was related to catheter right atrial pressure (RAP) measurements. RESULTS: E/E' correlated only moderately with RAP early after cardiac surgery (r = .41, P = .007), whereas E/E' correlated strongly with RAP in patients without cardiac surgery (r = .83, P < .0001). The sensitivity and specificity of E/E' 4 or greater were 88% and 85% for RAP 10 mm Hg or greater in patients who were not in the postcardiac surgery status (receiver operating characteristic area 0.93 [95% confidence interval: 0.86-0.99]) but 44% and 73% early after cardiac surgery (receiver operating characteristic area 0.56 [95% confidence interval: 0.37-0.75]). E/E' correlated more strongly with RAP when the RV systolic function was impaired. In repeated measurements from 12 patients, an increase of greater than 2 in E/E' was associated with an increase of 5 mm Hg or more in the RAP with a sensitivity of 67% and a specificity of 89%. CONCLUSIONS: E/E' is useful for noninvasive estimation of RV filling pressure and to detect serial changes in a wide range of clinical conditions but is a weak correlate of RAP early after cardiac surgery and in patients with normal RV function.