Correlation between hypervolemia, left ventricular hypertrophy and fibroblast growth factor 23 in hemodialysis patients.

INTRODUCTION: Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular complications in hemodialysis (HD) patients. Hypervolemia has been accepted as an independent risk factor for progressive LVH in HD patients. Additionally, high FGF23 levels have been a significant predictor of cardiovascular mortality and morbidity in chronic kidney disease and HD patients. The aim of our study is to investigate the correlation among LVH, interdialytic volume increase and FGF-23 in the patients on a chronic hemodialysis program. DESIGN AND METHODS: A total of 97 chronic hemodialysis patients (64.43 ± 11.28 years old, M/F:47/50) were included in the study. Human FGF-23 ELISA kit was used for FGF-23 analysis of predialysis blood samples. Echocardiographic evaluation was performed in all of the patients after dialysis. Left Ventricular Mass Index (LVMI) was calculated by using the Devereux Formula. We collected the following data: LVMI, FGF-23 levels, interdialytic fluid gain, blood pressure changes, and the other biochemical and clinical parameters. RESULTS: Mean LVMI of the patients was 184.41 ± 48.62 g/m(2). LVMI of the patients with daily urine output > 250 mL was found significantly lower. Statistically significant positive correlation was found between predialysis systolic blood pressure, predialysis diastolic blood pressure, predialysis mean arterial blood pressure and LVMI measurements (p < 0.01). Mean interdialytic volume excess was correlated with LVMI measurements of the patients (r = 0.459; p < 0.01). Increased FGF-23 levels (159.79 ± 134.99 ng/L) predicted increased LVMI measurements of the patients (r = 0.322; p < 0.01). In addition, FGF-23 levels were also increased as the interdialytic fluid volume increased (r = 0.326; p < 0.05). A positive correlation was also found between FGF-23 levels and interventricular septum thickness (r = 0.238; p < 0.05). Predialysis mean arterial blood pressure, predialysis volume overload and presence of diabetes were determined to be independent risk factors on LVMI on multivariate regression analysis. CONCLUSION: Our study showed that interdialytic volume overload increased both LVMI and FGF-23 values. We can consider that interdialytic volume control exerts positive effects on increased FGF-23 levels which predict the negative cardiovascular outcomes.

Role of electrocardiographic changes in discriminating acute or chronic right ventricular pressure overload.

OBJECTIVE: Pulmonary embolism (PE) and severe pulmonary stenosis (PS) are two distinct conditions accompanied by increased pressure load of the right ventricle (RV). Despite major advances in our understanding of the mechanisms of RV adaptation to the increased pressure, substantial gaps in our knowledge remain unsettled. One of much less known aspect of pressure overload of RV is its impact on electrocardiographic (ECG) changes. In this study, we aimed to study whether acute and chronic RV overload are accompanied by different ECG patterns. METHODS: Thirty-eight patients with PE underwent ECG monitoring were compared with 20 matched patients with PS in this observational retrospective study. ECG abnormalities suggestive of RV overload were recorded and analyzed in both groups. Logistic regression analysis was used to define the predictors of chronic RV overload. RESULTS: Among the ECG changes studied, premature atrial contraction (OR-12.2, 95% CI, 1.3-107, p=0.008), right axis deviation (OR-20.4, 95% CI 4.2-98, p<0.001), indeterminate axis (OR-0.11, 95% CI 0.02-0.44, p=0.001 0.11), incomplete right bundle branch block (OR-4.2, 95% CI, 1.1-15.4, p=0.02), late R in aVR (OR-8.4, 95% CI 2.1-33.2, p=0.001), qR in V1 lead (OR-8.3, 95% CI 1.2-74.8, p=0.03) were found to be the independent predictors of chronic RV pressure overload. CONCLUSION: Our data indicate that the ECG changes that attributed to the acute RV pressure loading states may be more prevalent in chronic RV overload as compared with acute RV overload.

Advanced Age, Female Gender and Delay in Pacemaker Implantation May Cause TdP in Patients With Complete Atrioventricular Block.

AIM: We aimed to report the clinical features related to torsades de pointes (TdP) in patients with complete AV block (CAVB). METHODS: Patients with CAVB who were admitted to our instituition between January 2007 and January 2010 were retrospectively evaluated in terms of the occurence of TdP. The clinical features were compared in patients with and without TdP using the software of SPSS. RESULTS: Sixty-four patients were determined to have CAVB. Three of them had documented episodes of TdP. All three patients experiencing TdP were females, whereas 48% of the patients with CAVB were females. The mean age of patients with TdP was significantly greater than the mean age of the other patients (85 ±3 vs. 78±7.6, respectively; p<0.05). In our archives, bradycardia exposure time could be determined in only 49 patients without TdP. Among them, just 10 patients had been exposed to bradycardia over 48 hours, whereas all of the 3 patients with TdP had been exposed to bradycardia over 48 hours (p<0.05). Additionally, in two patients with TdP, we demonstrated that QT and QTc prolongation increases as the duration of bradycardia is extended. Furthermore, all patients with TdP had notched T waves in the ECG on the occurrence day of TdP, whereas they did not have any notched T wave in their ECG on the admission day. CONCLUSION: Among the patients with CAVB, elderly females are more susceptible to development of TdP. Delay in institution of physiological heart rate leads to further QT prolongation and thereby to TdP. Besides QT prolongation, the finding of T wave notching on ECG may also have a predictive value for TdP.

Noninvasive assessment of impaired endothelial function in psoriasis.

The objectives of this study are noninvasive assessment of endothelial dysfunction (ED) and diagnosing the possible early vascular development of atherosclerosis in psoriasis disease (PD). Twenty-eight PD patients (study group) without any obstructive vascular involvement were compared with 28 healthy controls (control group) in terms of ED utilizing endothelium-dependent dilation as well as endothelium-independent dilation, which was assessed by measuring changes in brachial artery diameter following sublingual glyceryl trinitrate (400 microg Nitrolingual spray). All patients underwent a complete transthoracic echocardiographic and tissue Doppler study. A standard form was utilized for the documentation of the presence or absence of the known risk factors for atherosclerotic vascular disease. Statistical analysis was performed by utilizing SPSS version 11. There was no difference between patients and controls in terms of echocardiographic and tissue Doppler parameters as well as baseline brachial artery diameters. Flow-mediated dilation showed 37% impairment in study group compared with control (p < 0.05). Endothelium-independent NTG dilatation did not differ in both groups. Noninvasive methods such as ultrasonography, saving time and cost-effective, can be utilized for following outpatient PD patients for the risk of ED, which may preclude to atherosclerosis.

Serum prohepcidin in pulmonary tuberculosis.

AIM: Anemia of chronic disease is the second most encountered anemia following iron deficiency in patients who develop acute or chronic immune activation. Pulmonary tuberculosis is an infectious disease which results in an inflammatory response frequently causing anemia. We investigated whether prohepcidin can be used successfully to disclose the cause of anemia and to monitor the result of the therapy in patients with pulmonary tuberculosis. MATERIAL AND METHODS: The study was performed in 40 male patients and 15 healthy controls that had a diagnosis of tuberculosis with a positive sputum smear and did not receive any previous treatment. They were treated for 6 months. RESULTS: The study revealed a significant elevation of prohepcidin in patients with tuberculosis in comparison to those of healthy control subjects. Additionally, prohepcidin levels significantly decreased after treatment in the patient group but remained high in comparison to control group. CONCLUSION: We conclude that prohepcidin is high in pulmonary tuberculosis and might be a marker for monitoring the response to treatment.

The effect of the content of the knowledge on adherence to medication in hypertensive patients.

OBJECTIVE: It was suggested that knowledge might influence the adherence to treatment in hypertension. Accordingly, in this study, we investigated the effects of content of knowledge on medication adherence and knowledge-based predictors of adherence to treatment in hypertensive patients. METHODS: This cross-sectional study included 227 hypertensive patients (70% female;mean age: 57+/-12 years), who were followed by cardiology and internal medicine clinics. The patients were asked to fulfill a questionnaire including 40 items. Besides the demographic and disease-related questions, the patients were also asked (1) the name of the drug, (2) the duration of the drug use;(3) the reason of using the drug;(4) the cause of hypertension;(5) the target level of hypertension;(6) the result of hypertension;(7) the side effects of antihypertensive medicines. Statistical analyses were performed using Chi-square, Fischer exact, Mann Whitney U tests and logistic regression analysis. RESULTS: It was found that 163 (72%) were adherent and 64 (28%) were nonadherent to the treatment. Angiotensin-II receptor antagonist use (OR=4.405;95%CI: 1.561-12.365, p=0.022) and hypertension duration > or =5 years (OR=0.446;95%CI: 0.246-0.811, p=0.006) was found to be independently related to adherence. Among the knowledge-based variables, knowing the duration of use of the medicine (OR=6.822;95% CI: 1.478-31.241, p=0.075), the reason of use of medicine (OR=2.828;95% CI: 1.445-5.543, p=0.018), the cause of the hypertension (OR=3.447;95% CI: 1.889-6.290, p=0.037) and the target level of blood pressure (OR=12.859;95% CI: 5.045-32.640, p<0.001) significantly increased the adherence rates. On the other hand, knowing the name of the medicine (p=0.112) or the results of hypertension (p=0.719) had no effect on adherence, while knowing the side effects of the medicine (OR=0.607;95% CI: 0.340-1.084, p=0.005) had negative effect. The total number of correct answers was also higher in patients with adherence to treatment (p=0.002). CONCLUSION: Patient knowledge about hypertension and medications is associated with higher adherence rates. However, it should be taken into consideration that the possible effects of knowledge may differ according to its content.

Does harvesting of radial artery in the early postoperative period perturb the palmar blood supply and functions?

OBJECTIVE: The aim of this prospective study was to assess whether the removal of the radial artery (RA) caused any alteration in the function or power of hand on postoperative 15th day. METHODS: The study group included 25 patients with objective or subjective complaints on postoperative 15th day regarding harvest site following coronary bypass surgery by using RA. Patients were examined for bilateral forearm function (soft touch and pin-prick neural sensation, handgrip power). The ulnar artery and palmar arcus Doppler measurements such as peak systolic and end-diastolic velocity, and radius of the arteries have been measured both at rest and following handgrip test. The operated arm was evaluated and compared with the opposite arm. Wilcoxon test was used to compare continuous variables. RESULTS: Among 18 patients complained a loss of sense in the RA excised arm, the sensory defects were documented in 5. Among 7 patients presented with a feel of strength loss, handgrip power revealed a nonsignificant decrease of strength in the harvested arm. After squeezing test, ipsilateral ulnar artery peak systolic velocity increased from 86+/- 15 to 105+/- 15 cm/sec (<0.001), end-diastolic flow velocity from 28+/- 5 to 36+/- 8 cm/sec (<0.001) without any change in the ulnar artery radius. In contrast, no significant change in the flow velocity and the diameter of palmar arcus was noted before and after squeezing test. The comparison of the ulnar artery radius and blood flow velocity parameters in the RA excised arm to those of contralateral one after exercise test demonstrated no difference. CONCLUSIONS: With an assumption of appropriate selection, removal of RA does not change the forearm blood supply and functions with little sensory disturbances in the early postoperative period.

Rapid normalization of a highly thickened pericardium by chemotherapy in a patient with T-cell acute lymphoblastic lymphoma.

The most common tumor that affects the pericardium is malign lymphoma. T-cell lymphoblastic lymphoma (TLL) is a rare type of malign lymphomas. In this manuscript, we are reporting a patient with TLL with pericardial involvement diagnosed incidentally during the evaluation of pleural effusion. Echocardiographic examination showed thickened pericardium and pericardial effusion. The pericardial thickness was found to be 13 mm by computerized tomography and confirmed by echocardiography. The patient had systemic chemotherapy for TLL. On day 30 of chemotherapy, computerized tomography of the thorax and echocardiographic examination revealed normal pericardial thickness and minimal pericardial effusion.

Harvesting of the radial artery: subfasciotomy or full skeletonization: a comparative study.

BACKGROUND: Long fasciotomy of the posterior aspect of the radial artery (RA) for the purpose of sympathectomy is one of the surgical techniques for the preparation of this graft. We compared the early results of this technique with those of the RA graft harvested as a pedicle in the conventional fashion. METHODS: The study patients have been selected from the patients who underwent coronary artery bypass grafting (CABG) using the RA graft harvested either with a long posterior fasciotomy (group 1) or as a whole with a pedicle in the classical manner (group 2). Only the patients with a flow study have been included. The flow index was described as the bleeding amount of the RA in a minute per body surface area (mL/m2 min). The flow index has been performed before and after fasciotomy in group 1, and after full skeletonization in group 2. The clinical and demographic parameters and flow indices were measured and compared between the groups, and in group 1, before and after fasciotomy. RESULTS: From 218 patients with CABG using the RA between January 1998 and August 2005, a total of 57 patients were recruited into the study. Group 1 consisted of 25 patients. Thirty-two patients constituted group 2. Subfascial dissection of the RA increased the blood flow index from 48 +/- 20 mL/m2 min to 51 +/- 19 mL/m2 min (p < 0.001). The comparison of the clinical, perioperative characteristics of the patients was not different between the groups. CONCLUSIONS: The necessity of total skeletonization of the RA should not be the only option when the aim is to reduce the spasm. While subfascial dissection (sympathectomy) of the pediculed RA alone provides a satisfactory increase in the blood flow index, it also reduces the manipulation time as well as the risk of injury to the graft.

Noninvasive assessment of impaired endothelial dysfunction in mucocutaneous Behçet's disease.

Noninvasive assessment of endothelial dysfunction (ED) and diagnosing the early vascular development of atherosclerosis in active mucocutaneous Behçet's disease. Twenty-nine active BD patients (study group) without any obstructive vascular involvement were compared with twenty-nine healthy controls (control group) in terms of ED utilizing endothelium-dependent dilation as well as endothelium-independent dilation (FMD), which was assessed by measuring changes in brachial artery diameter following sublingual glyceril trinitrate (400 microg Nitrolingual spray). All patients underwent a complete transthoracic echocardiographic and tissue Doppler study. A standard form was utilized for the documentation of the presence or absence of the known risk factors for atherosclerotic vascular disease. Statistical analysis was performed by utilizing SPSS version 11. There was no difference between patients and controls in terms of echocardiographic and tissue Doppler parameters as well as baseline brachial artery diameters. Flow-mediated dilation showed 38% impairment in study group compared with control (P<0.05). Endothelium-independent NTG dilatation did not differ in both groups. Ultrasonography is an easily applicable noninvasive method for following BD patients for the risk of ED, which may preclude to atherosclerosis, save time and cost-effective.

[Does accompanying metabolic syndrome contribute to heart dimensions in hypertensive patients?]. / Hipertansiyonlu hastalarda metabolik sendrom varliginin kalp boyutlarina katkisi var midir?

OBJECTIVES: Metabolic syndrome (MetS) is associated with increased risk for cardiovascular events. We evaluated heart dimensions in hypertensive patients with MetS. STUDY DESIGN: The study included 75 hypertensive patients (34 males, 41 females; mean age 51+/-9 years) without coronary artery disease. Patients were evaluated in two groups depending on the presence or absence of MetS. Age- and gender-matched 20 healthy subjects (9 males, 11 females; mean age 50+/-5 years) comprised the control group. The diagnosis of MetS was based on the presence of at least three of five MetS criteria. Hypertension was defined as arterial blood pressure exceeding 140/85 mmHg on three consecutive measurements or the use of antihypertensive drugs. Echocardiographic measurements included interventricular septal thickness, left ventricular internal diameter, posterior wall thickness, aortic diameter, left atrial diameter, relative wall thickness, and left ventricular mass. RESULTS: Metabolic syndrome was present in 32 hypertensive patients (42.7%; 18 males, 14 females). The mean number of MetS criteria was 2.6+/-1.0 in the hypertensive group. Compared to the control group, patients with or without MetS exhibited significantly increased interventricular septum and posterior wall thickness, left atrial diameter, relative wall thickness, and left ventricular mass (p<0.05). The only significant difference between the two patient groups was that MetS was associated with a greater left atrial diameter (p=0.019). Left atrial diameter was correlated with the number of MetS criteria (r=0.51; p<0.001). CONCLUSION: Left ventricular dimensions are not influenced by MetS. Rather than MetS, hypertension is primarily responsible for changes in left ventricular dimensions. However, left atrial enlargement is more prominent in patients with MetS, suggesting that each MetS criterion contributes to left ventricular diastolic dysfunction.

Contrast-enhanced 64-slice computed tomography in detection and evaluation of anomalous coronary arteries.

Anomalous coronary artery (ACA) has either an unusual origin or different anatomical course and is associated with sudden cardiac death. The absence or nonspecific symptoms of ACA make its diagnosis difficult. Mostly, ACA is diagnosed coincidentally during invasive coronary angiogram (ICA). A conventional computed tomography (CT) cannot provide detailed images of coronary arteries of the moving heart, but 64-slice CT, with its short acquisition time, can provide detailed anatomy of coronary arteries non-invasively. In this study, we assessed the validity of contrast-enhanced 64-slice CT in the evaluation of ACA. ICA was performed in 7,574 patients for the diagnosis or evaluation of occlusive coronary artery disease and detected coronary anomalies in 56 patients (0.7%). We then performed 64-slice CT in 53 patients out of the 56 patients with demonstrated or suspected coronary anomaly, showing the origin and the course of the ACA along with stenosis, except for one patient who could not be evaluated due to image distortion artifacts. Contrast-enhanced 64-slice CT was also performed in 374 patients with vague signs and symptoms, detecting coronary anomalies in 7 patients (1.2%). Thus, in the total of 59 patients undergone 64-slice CT, we were able to visualize the entire abnormal coronary tree with a high diagnostic image quality. This is the first study to demonstrate the utility of 64-slice CT in a large series of ACA. Contrast-enhanced 64-slice CT is superior to ICA to identify the presence and course of ACA and should be the first line diagnostic tool in the evaluation of ACA.

Eleven-year experience in diagnosis and surgical therapy of right atrial masses.

BACKGROUND: Tumors arising from the right atrium are quite rare, and require special care during differential diagnosis for their management. A review of surgical experience with right atrial tumors in 11 patients from our institution has been presented in this article. METHODS: Eleven cases, operated for a tumor mass in the right atrium in our institution between January 1993 and December 2004, were retrospectively reviewed for their clinical presentation, diagnostic workup, method of surgical procedure, and histopathologic findings. Electrocardiogram, transthoracic, and transesophageal echocardiography, computerized tomography, and nuclear magnetic resonance imaging were available for all patients during the diagnostic evaluation. Surgical procedure notes, photos, and file recordings were reviewed when available. The surgeons were also interviewed when necessary. RESULTS: Right atrial tumors were diagnosed in 11 patients (6 males and 5 females). The average age of the patients was 34 +/- 11 years (ranging between 21 and 65 years). The histopathological examination of the surgically removed specimen revealed a benign tumor in eight patients (73%), and a malignant process in three (23%). In eight patients with a benign tumor, atrial myxoma was the leading cause in half of the cases. Hydatid cyst (n = 2), lipoma (n = 1), and right atrial thrombus (n = 1) were detected in the remaining four patients. One patient died of heart failure after surgery. The diameters of the excised masses were 2 +/- 0.5 cm versus 7 +/- 1 cm. CONCLUSIONS: Tumors of the right atrium are rarely seen, and necessitate a unique attention during the process of diagnosis and surgical treatment. We present our surgical experience of 11 patients with right atrial mass. The differentiation of the right atrial tumors with the diagnostic tools before surgery, the determination of the spreading, and the structural properties of the mass may designate surgical approach and prognosis.