Ergotamine-Induced Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a recently increasing diagnosed disease showed by transient apical or mid-apical left ventricular dysfunction. It is known as a disease of postmenopausal women, which is usually triggered by emotional or physical stress. Although the trigger is mostly endogenous, some drugs have also been reported as the cause. Published case reports of TC associated with drug usage consist of sympathomimetic drugs, inotropic agents, thyroid hormone, cocaine, and 5-fluorouracil. We present an unusual case of TC in which the possible trigger is ergotamine toxicity.

The value of aortic pulse wave velocity in predicting coronary artery disease diagnosis and severity.

OBJECTIVE: Aortic pulse wave velocity (AoPWV), one of the parameters showing arterial stiffness, has been investigated in different patient groups as a predictor of cardiovascular diseases. The purpose of our study is to investigate the correlation between AoPWV and coronary artery disease (CAD) and its severity. METHODS AND RESULTS: One hundred and three patients who were not diagnosed with CAD but who were scheduled to have coronary angiography (CAG) with CAD suspicion were included in the study. PWV was measured with tonometry device before CAG. Patients were divided into two groups: with or without CAD. The Gensini score of each patient was calculated in the CAD group by several independent specialists. The average age of the patients was 55.2 +/- 8.5 (range 33-73 years). CAD was confirmed in 59 patients (49%). Average PWV in the CAD group was statistically more significant than in the non-CAD group (8.6 +/- 2.0, 5.0 +/- 1.8; P < 0.001). A highly positive correlation was observed between CAD severity and PWV (r = 0.838, P = 0.001). In the CAD diagnosis, for an AoPWV cut-off value of 7.3 m/sec, the sensitivity was 83.1% and the specificity 86.4%. CONCLUSIONS: Various non-invasive techniques are used in CAD prognosis. Besides being simple, these techniques are also required to show a high rate of accuracy in CAD prognosis. In this respect, AoPWV gains importance as being a non-invasive method that can be performed with a tonometry device at low cost in policlinic conditions.

Severe tricuspid regurgitation mimicking constrictive pericarditis.

PATIENT: Female, 62 FINAL DIAGNOSIS: Tricuspid regurgitation Symptoms: Dyspnea exertional • fatigue • leg edema MEDICATION: - Clinical Procedure: - Specialty: Cardiology. OBJECTIVE: Challenging differential diagnosis. BACKGROUND: Tricuspid regurgitation (TR) can mimic some hemodynamic findings of constrictive pericarditis (CP), due to the restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. In this article, we report a case of severe tricuspid regurgitation in which hemodynamic findings were consistent with CP. CASE REPORT: A 62-year-old Caucasian woman presented with right heart failure symptoms. Echocardiography showed enlarged right heart chambers and severe tricuspid regurgitation. Right heart catheterization surprisingly demonstrated a constrictive physiology. Diastolic pressures of both ventricles were elevated and equalized, with a prominent deep and plateau pattern. The patient was re-evaluated with a further focus on constrictive pericarditis. However, echocardiography, thorax CT, and cardiac MRI did not demonstrate any pathological finding related to pericardium. The remaining explanation was that the severe TR itself and secondary right heart enlargement caused the restraining effect on the intact pericardium and on the left ventricle. The pericardium was normal and tricuspid annulus was severely dilated on surgical inspection. The tricuspid valve was replaced with a bioprosthetic valve. The patient did well just after the surgery, with a rapid decrease in cardiac pressures; however, she died due to respiratory failure on the 15(th) postoperative day. CONCLUSIONS: This was a case with right heart failure symptoms in which invasive hemodynamic findings were consistent with constrictive pericarditis and the noninvasive imaging modalities were not. This case illustrates that severe TR can mimic some hemodynamic findings of constrictive pericarditis, due to restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. Lack of significant respiratory changes in hemodynamic parameters that can safely be demonstrated by echocardiography and cardiac MRI suggest a normal pericardium.

The effect of strict rate control on B-type natriuretic peptide values and echocardiographic parameters in chronic atrial fibrillation.

BACKGROUND: There have been conflicting results about the role of strict rate control on cardiovascular outcomes in patients with chronic atrial fibrillation (AF). To date, large clinical studies have not shown a net clinical benefit derived from the current trend to specify the target ventricular rate according to the patient's own clinical and laboratory characteristics. Although the existing literature shows no superiority of strict rate control in clinical end points, it is difficult to assess the pure rate effect without commonly coexisting medication side effects which can also influence clinical end points. AIM: To determine the effects of strict rate control in patients with chronic AF, regarding objective parameters such as echocardiographic data and B-type natriuretic peptide (BNP) values. METHODS: 38 patients with chronic AF for whom strict rate control had been planned were enrolled in the study. Patients' echocardiographic parameters, BNP values and 24 h Holter electrocardiography findings showing the average heart rate (HR), were studied at baseline and then monthly, until the end of the 3rd month. Patients' negative dromotropic therapy was adjusted to achieve a target resting HR of below 80 bpm. Laboratory and echocardiographic parameters at baseline and at the end of the study were compared in the whole study group. The whole study group was subclassified according to the average resting HRs achieved, (group 1 with strict rate control < 80 bpm; n = 25, and group 2 without strict rate control; n = 13). RESULTS: In group 1, the average HR declined from 101 ± 16.3 bpm to 77 ± 5.2 bpm. In group 2, the average HR was 96.6 ± 6.8 bpm at baseline and there was no significant change at the end of the study (94.2 ± 5.9 bpm). In group 1, there were significant decreases in BNP, left ventricular volumes, left atrial and right atrial areas at the end of the study. In group 2, BNP values were significantly higher at the end of the study despite similar ventricular and atrial dimensions according to the baseline. Diastolic functions were assessed roughly by septal E/e', but no significant change was observed in either group. CONCLUSIONS: Strict rate control in patients with chronic AF yielded a significant decrease in BNP values as well as a reduction in volumes of cardiac chambers.

Diagnostic accuracy of mean platelet volume in prediction of clopidogrel resistance in patients with acute coronary syndrome.

OBJECTIVE: Clopidogrel therapy is the standard of care in patients with acute coronary syndrome (ACS) and stent implantation. However, concern arises because 25% of subjects are nonresponders to clopidogrel. As this nonresponsiveness is associated with increased adverse outcome, detection of these subjects in daily practice is important in order to withhold a more aggressive therapy and closer follow up. In this study we aimed to evaluate the relation between mean platelet volume (MPV) which is an indicator of platelet activation and clopidogrel nonresponsiveness. METHODS: The study was planned as a prospective cohort study. A total of 185 patients who had been on clopidogrel therapy for any acute coronary syndrome were enrolled in this study. Clopidogrel responsiveness was analyzed by Multiplate MP-0120 device by using the method of whole blood aggregometry. Blood samples were drawn 3.5 days after clopidogrel loading dose. The amount of ADP induced platelet aggregation was assessed as area under curve (AUC), and a cut-off value of 500, above which the patient is considered as clopidogrel nonresponder, was used. MPV was analyzed from the blood which were sampled at the admission of the patient by using automatic hemocounter. Independent sample t-test, ROC analyses and logistic regression analsis were used in statistical analysis. RESULTS: Among the 185 patients analyzed 41 were found to be clopidogrel nonresponder (22.1%). Mean MPV was found to be significantly higher in nonresponders compared to responders (8.7±0.82 fL vs. 8.1±0.83 fL, p<0.001). A cut-off value of 8.3 fL for MPV was detected in prediction of clopidogrel nonresponsiveness with a sensitivity of 76.6% and specificity of 68.3% (OR: 6.4; 95% CI 2.9-14.1, AUC: 0.70, p<0.001). CONCLUSION: This study showed that MPV can be used as a predictor of clopidogrel resistance in patients with ACS.

Ventricular diastolic function of ankylosing spondylitis patients by using conventional pulsed wave Doppler, myocardial performance index and tissue Doppler imaging.

OBJECTIVE: The aim of this study was to evaluate ventricular functions by using standard Doppler echocardiography (SDE), myocardial performance index (MPI), and pulsed wave tissue Doppler imaging (PW-TDI) in patients with ankylosing spondylitis (AS) and healthy controls. METHODS: Forty-nine AS patients (38 +/- 11 years, 25 M/24 F) and 33 controls (36 +/- 9 years, 17 M/16 F) were studied. Two-dimensional, M-Mode, SDE, PW-TDI echocardiography examinations were performed. Spinal mobility was assessed by the Bath ankylosing spondylitis metrology index (BASMI) measurement. Patients were also evaluated using the Bath ankylosing spondylitis functional index (BASFI) and the Bath ankylosing spondylitis disease activity index (BASDAI). RESULTS: Four control subjects and six AS patients met the left ventricular (LV) diastolic dysfunction (DD) criteria by using conventional Doppler echocardiography (p > 0.05). However, using PW-TDI method 22 patients in the AS group and six subjects in the control group were diagnosed to have LV DD (Em/Am < 1). Pseudonormalized pattern was present in 16 AS patients and two control subjects. Correlation analysis revealed significant moderate negative correlations between Em/Am and BASMI, age and body mass index (p < 0.05; r =-0.3, -0.6, and -0.4, respectively). No correlation was observed between Em/Am and disease duration, BASFI, BASDAI, CRP, and ESR. We could not detect any right ventricular function involvement either by conventional or by recently introduced echocardiography methods. The risk of developing LV DD was found to be 3.7 times higher in AS patients. CONCLUSION: When sensitive echocardiographic Doppler techniques such as MPI, TDI-derived MPI, and PW-TDI are utilized, DD can be detected in a significant proportion of patients with AS without cardiovascular (CV) disease which may contribute CV mortality in these patients.

Effects of carvedilol therapy on arrhythmia markers in patients with congestive heart failure.

The aim of this study was investigate the effects of carvedilol therapy on ventricular repolarization characteristics as assessed by QT dispersion (QTd) and heart rate variability (HRV) in patients with heart failure. Thirty-one patients with heart failure (mean age, 63.9 years) were included in the study. Carvedilol was administered in addition to standard therapy for CHF at a dose of 6.25 mg/day and uptitrated to the maximum tolerated dose. Control group consisted of 14 patients with heart failure (mean age, 69.4 years) who could not take carvedilol due to several reasons. All patients were followed-up 6 months. QT dispersion (QTd), and corrected QTd (QTcd) values were calculated at baseline and at the end of follow-up. Time domain and frequency domain heart rate variability analysis were performed with ambulatory Holter ECG. Mean carvedilol dose was 23.9 +/- 13.9 mg. Significant reductions were observed in the QTd (P = 0.016) and QTcd (P = 0.001) with carvedilol therapy, whereas QTd (P = 0.47) and QTcd (P = 0.43) did not change significantly in the control group. The QT maximum value did not change significantly but the QT minimum value (P = 0.03) was significantly increased after carvedilol therapy. Although the mean SDANN value was improved (P = 0.039), other HRV parameters such as mean SDNN (P = 0.32), rMSSD (P = 0.74), and the LF/HF ratio (P = 0.35) did not change significantly after carvedilol therapy. This prospective controlled study shows that carvedilol therapy decreased QT dispersion and improved ventricular repolarization characteristics but did not change autonomic dysfunction in patients with heart failure.

Five chambered heart: a case report and brief review of literature.

We present a patient with chest pain and suspicious findings in electrocardiography and myocardial perfusion scintigraphy for myocardial ischemia. Coronary angiography and then echocardiography and magnetic resonance imaging revealed a dilated left anterior descending coronary artery, which has fistulous communication with a large, separate chamber that occupies the infero-apical interventricular septum. This is a challenging congenital anomaly for a clinician in many aspects, which are discussed in the report.

Suppression of angioplasty-related inflammation by pre-procedural treatment with trimetazidine.

Percutaneous transluminal coronary angioplasty (PTCA) has been recognized as a reliable treatment procedure for acute reversible ischemia and reperfusion. Ischemic reperfusion cycle in PTCA leads to the systemic inflammation and extensive tissue injury by the production of reactive oxygen species including nitric oxide (NO) radicals. In patients with coronary artery disease, undergoing PTCA, the effects of trimetazidine (TMZ), a piperazine-derivative anti-anginal drug, were studied on several indirect markers of systemic inflammatory response: tumor necrosis factor-alpha (TNF-alpha), C-reactive protein (CRP) and NO products (nitrite and nitrate). Patients (n = 11 each group) were untreated or pre-treated with TMZ (20 mg per orally three times a day), begun three days prior to PTCA, and marker levels were measured before the start of TMZ therapy (baseline), just before PTCA (0 hr), and 4, 24, and 48 hrs after PTCA. The baseline levels of markers were not significantly different between the untreated and pre-treated patients. In contrast, all parameters were lower in the TMZ-treated group than those in the matched control group in the pre- and post-angioplasty periods. Interestingly, in the TMZ group, CRP and nitrite levels were significantly lower than in the control group at each time point of the pre- and post-angioplasty periods, but the TNF-alpha levels were significantly decreased only in the post-angioplasty period. Pre-procedural treatment with oral TMZ for three days significantly suppressed the elevation of inflammatory markers before and shortly after PTCA. We suggest the usefulness of TMZ in preventing inflammatory cardiovascular events after PTCA.

Left atrial appendage-flow velocity predicts cardioversion success in atrial fibrillation.

Restoration of sinus rhythm by electrical cardioversion is a therapeutic option in appropriately selected patients with atrial fibrillation. It is important to determine predictors of electrical cardioversion outcome in patients with atrial fibrillation. Predictive value of clinical and conventional echocardiographic parameters for predicting cardioversion outcome is limited. The role of left atrial appendage (LAA) function, which may reflect left atrial contractile function, for prediction of cardioversion outcome remains unclear. We conducted a single center prospective study to evaluate the role of LAA function for prediction of cardioversion success in patients with atrial fibrillation. One hundred sixty three patients with atrial fibrillation underwent transthoracic and transesophageal echocardiography (TEE) before electrical cardioversion. LAA functions, including LAA peak flow velocity, LAA area and LAA ejection fraction, were examined. Cardioversion was successful in 133 patients and unsuccessful in 30 patients. Mean LAA peak emptying flow velocity was significantly higher in the patients with successful cardioversion than in those with unsuccessful cardioversion (0.34 +/- 0.14 vs 0.27 +/- 0.1 m/sec; p = 0.013). At multivariate logistic regression analysis, only LAA flow velocity (> 0.28 m/sec, odds ratio = 2.8 ; p = 0.03) proved to be an independent predictor of cardioversion success. LAA area (p = 0.18) and LAA ejection fraction (p = 0.52) were not different between successful and unsuccessful cardioversion groups. Therefore, measurement of LAA flow velocity provides valuable information for prediction of cardioversion outcome in patients with atrial fibrillation before TEE guided cardioversion.

Evaluation of left ventricular diastolic dysfunction with conventional and current Doppler techniques in Behcet's disease.

Behcet's disease (BD) is a systemic vasculitis characterized by genital and oral ulcers, uveitis, and other organs' involvement. Left ventricular (LV) diastolic dysfunction has been documented in BD. However, conventional echocardiographic techniques have serious limitations like its dependence on preload, afterload and heart rate. Recently, new techniques like colour M-mode and tissue Doppler imagining (TDI) have provided additional concept in the assessment of diastolic function. The aim of the present study was to investigate the LV diastolic dysfunction with conventional and new echocardiographic techniques in BD. Forty-eight patients with BD (25 women, 23 men) and 26 healthy volunteers (15 women, 11 men) were enrolled in the study. LV diastolic functions were examined with mitral inflow pulse wave Doppler, TDI and mitral flow propagation rate (MFPR). The following were accepted as diastolic dysfunction: in mitral inflow pulse wave Doppler, E/A<1, isovolumic relaxation time (IVRT)>110 ms and deceleration time of E wave (DT)>240 ms; in TDI of mitral ring with pulse wave, E'/A'<1; and in MFPR, velocity slope (Vp)<45 cm/s. The two groups were comparable in age, sex, heart rate, body mass index, smoking, hyperlipidemia and basic echocardiographic measurements. LV diastolic dysfunction was significantly higher in BD group according to E/A<1 (p<0.05). When echocardiographic measurements were compared one by one for two groups, As' (late diastolic TDI wave in septal wall) was found to be significantly higher in BD group (p<0,0001). IVRT was longer in BD group than in controls, but it did not reach statistical significance (p=0,06). Diastolic dysfunction of LV is more frequent in patients with BD than in control according to E/A and As'. Conventional and current techniques like TDI and colour M-mode Doppler echocardiography could be used to investigate diastolic functions in BD.

Head-up tilt table testing with low dose sublingual isosorbide dinitrate in the evaluation of unexplained syncope: a comparison with isoproterenol infusion.

OBJECTIVES: To investigate the value of head-up tilt table testing (HUTT) with low-dose isosorbide dinitrate (ISDN) in the evaluation of patients with unexplained syncope and to compare the results of HUTT with ISDN and HUTT with isoproterenol. PATIENTS AND METHODS: Forty-three patients with unexplained syncope (21 women, with a mean age of 45.4 18 years) and 18 control subjects without syncope (eight women, with a mean age of 45.8 12 years) were tilted (80 ) for 30 min (passive period). When this period was negative, 2.5 mg sublingual ISDN was administered and patients were observed for an additional 15 min (ISDN period). The first 25 patients studied (10 women, with a mean age of 46.2 18 years) were tested again after a mean period of three weeks using the isoproterenol protocol. After the passive period, intravenous isoproterenol was administered (1 to 3 g/min) to patients lying in the supine position, and they were tilted again (80 ) for 10 min (isoproterenol period). RESULTS: During the passive period, 10 of 43 patients (23%) had a positive response compared with none in the control group. Syncope was observed in another 14 patients and in two control subjects during the ISDN period. The positivity rate (sensitivity) and specificity of HUTT with low dose ISDN were 56% and 89%, respectively. Among the patients (n=25) tested with the isoproterenol protocol, 14 (56%) patients had syncope. The agreement rate between the protocols was 78.9%. CONCLUSIONS: The total positivity rate of HUTT significantly increased with the use of the low dose ISDN, while specificity remained high. Due to its simplicity and tolerability, the ISDN protocol can be chosen when the results of the passive period tilt testing are negative.

Primary stenting in a patient with acute myocardial infarction and primary antiphospholipid syndrome.

We present a patient who had recurrent coronary thrombosis due to primary antiphospholipid syndrome. The patient was treated with streptokinase during the first myocardial infarction and primary stenting during reinfarction. To our knowledge, this is the first case in which the occluded right coronary artery was treated with primary stent implantation.