The prevalence of hypertension, valve calcification and left ventricular hypertrophy and geometry in peritoneal dialysis patients.

BACKGROUND/AIMS: Cardiac valve calcification (CVC) and left ventricular (LV) abnormalities are common indicators of a poor prognosis in dialysis patients. We determined the prevalence of hypertension, CVC, LV hypertrophy (LVH) and LV geometry in peritoneal dialysis (PD) patients. METHODS: Eighty-seven patients (50 female; mean age 42 ± 13 years; mean dialysis duration 46 ± 24 months) on strict salt and volume restriction, none of whom were receiving antihypertensives, were included in the study. Blood pressure (BP), biochemical parameters, CVC, LVH and LV geometry were determined. RESULTS: Most patients were normotensive. CVC of the mitral and aortic valves and of both valves were noted in 22, 23 and 15% of patients, respectively. Patients with CVC had significantly higher diastolic BP (p = 0.023), cardiothoracic index (CTI; p = 0.037) and LV mass index (LVMI; p = 0.002). LVH, noted overall in 44% of cases, was present in 62 and 36% of the patients with and without CVC, respectively (p = 0.028). Of the whole group, only 50.6% had normal LV geometry. LVH was associated with lower serum albumin (p = 0.002), higher CTI (p = 0.027) and more frequent CVC (p = 0.028). LVMI was greater in patients with CVC (p = 0.002). CONCLUSION: Strict salt restriction and the achievement of ideal dry weight result in normotension in PD patients. CVC is associated with LVH, both of which are lower in normotensive patients.

Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a systemic disease with a rising incidence. Cardiac dysfunction may occur as an early complication of AP. B type natriuretic factor (BNP) is a diagnostic and prognostic indicator of cardiac disorders. Therefore, in this study we aimed to assess the relationship between serum BNP concentrations and severity of AP. METHODS: Patients with AP who were admitted to gastroenterology clinic of our center, were included in this study. BNP measurements were performed twice, once on admission to the hospital and another after clinical and laboratory remission of the disease. All patients underwent echocardiography, abdominal ultrasonography and/or computed tomography chest X-ray and routine biochemical assays. Disease severity was determined by Ranson, Balthazar and Glasgow scoring systems. RESULTS: A total of 55 patients with AP (33 male, 60%) were enrolled in the study. Causes of AP were biliary in 32 patients (58%), alcoholic in 10 (18%), idiopathic in 8 (15%), hyperlipidemic in 4 (7%) and ERCP related in one patient (2%), respectively. Serum BNP levels in first 2 days of admission and after the clinical and laboratory remission of disease were 444 ± 295.9 and 124 ± 109.5 pg/ml, respectively (p<0.001). Increased serum BNP levels were positively correlated with severity of the disease (p<0.001). We could not find a difference between serum BNPe levels of edematous and necrotizing patients (P = 0.683). CONCLUSION: Increased serum BNP levels might be a plausible indicator of severity of AP during the course of the disease.

[The effect of levosimendan and dobutamine treatment on QT dispersion in patients with decompensated heart failure: a prospective study]. / Levosimendan ve dobutamin tedavilerinin akut dekompanse kalp yetersizlikli hastalarda QT dispersiyonu üzerine etkisi: Prospektif bir çalisma.

OBJECTIVE: We investigated the effect of intravenous levosimendan on QT dispersion compared with intravenous dobutamine in patients with acute decompensated heart failure. METHODS: This prospective cohort study included 38 patients who were admitted with acute decompensated heart failure (New York Heart Association functional class III-IV). Twenty-five patients (11 men, 14 women; mean age 70.5 ± 11.13 years) were treated with levosimendan infusion and 13 patients (5 men, 8 women; mean age 71.08 ± 6.86 years) were treated with dobutamine infusion. Intravenous levosimendan was administered with an initial bolus dose of 12 µg/kg for 10 min, followed by a continuous infusion of 0.1 µg/kg/min for 1 hour and 0.1 µg/kg/min 23 hours. Intravenous dobutamine was administered with a continuous dose of 10 µg/kg /min for 24 hours. Transthoracic echocardiography was performed and electrocardiograms were obtained before and after drug infusions. QTc dispersion was defined as the difference between the maximum and the minimum QT intervals and the value was corrected for heart rate. Chi-square test, Wilcoxon test and Mann-Whitney U tests were used for data analysis. RESULTS: No significant differences were found before and after treatment of both levosimendan and dobutamine with respect to minimum QT intervals, maximum QT and QT dispersions. (Pretreatment and 24th hour values of levosimendan group were; 0.43 ± 0.04 s, 0.44 ± 0.04s; 0.49 ± 0.05s, 0.50 ± 0.05s; 0.06 ± 0.03s, 0.06 ± 0.03s; in dobutamine group values are - 0.39 ± 0.05 s, 0.41 ± 0.05s; 0.45 ± 0.05s, 0.48 ± 0.05s; 0.06 ± 0.04s, 0.06 ± 0.04s, respectively) (p>0.05). No side effects related to drugs were seen during follow-up in all two treatment groups. CONCLUSION: Our results suggest that, therapeutic doses of levosimendan infusion do not have a significant effect on QT parameters - the predictors of arrhythmias-, in patients with decompensated heart failure when compared with dobutamine infusion.

[Effects of different statins, ezetimibe/simvastatin combination on hsCRP levels in unstable angina pectoris and non-ST elevation myocardial infarction patients: a randomized trial]. / Kararsiz anjina pektoris ve ST-elevasyonsuz miyokart enfarktüslü hastalarda degisik statinlerin, ezetimib/simvastatin kombinasyonunun hsCRP düzeyleri üzerine etkileri: randomize bir çalisma.

OBJECTIVE: The aim of our study was to evaluate the effects of two different statins and a statin/ezetimibe combination on high sensitive C-reactive protein (hsCRP) values, which were given at high doses in the early period of acute coronary syndromes. METHODS: A total of 150 patients with non-ST elevation myocardial infarction and unstable angina pectoris were enrolled to our prospective, randomized, single-blind study. Patients were divided into three groups by block randomization method. One group received 20 mg/day atorvastatin, one group received 10 mg/day rosuvastatin and the other group received 10 mg/day ezetimibe/simvastatin combination therapy, which was initiated within the first 24 hours of admission. Follow-up duration was 2 months . Biochemical investigations and hsCRP levels (by nephelometric method) were performed with 138 patients evaluated at baseline, 10th and 60th days of therapy. Decreases of hsCRP levels were analyzed with one-way MANOVA and repeated measures of ANOVA methods. Post-hoc Tukey HSD test was performed for finding the different group, when the difference was detected between the groups. RESULTS: Tenth day hsCRP levels in ezetimibe/simvastatin group was significantly lower than the other groups (p<0.001). Further, after 60 days of follow-up a significant reduction was seen in hsCRP levels in ezetimib/simvastatin group (in ezetimibe/simvastatin group the mean hsCRP was reduced from 38.4±15.0 mg/L to 2.4±1.3 mg/L, in atorvastatin group the mean hsCRP was reduced from 27.3±11.7 mg/L to 4.1±2.4 mg/L and in rosuvastatin group the mean hsCRP was reduced from 22.0±6.9 mg/L to 3.6±1.7 mg/L (F (1.1, 148.2) = 746.9, p<0.01 and the difference between drugs; F (2.2, 148.2) = 32.1, p<0.01). No side effects related to drugs were seen during follow-up in all three treatment groups. CONCLUSION: This study showed that ezetimibe/simvastatin 10 mg/day combination treatment was superior to atorvastatin 20 mg/day and rosuvastatin 10 mg/day treatment in reducing the inflammatory markers when high dose statins was started in the early period of unstable angina and non ST elevation myocardial infarction.

Electrocardiographic changes and importance of repolarization changes in cases with acute pancreatitis.

BACKGROUND/AIMS: Acute pancreatitis is a systemic disease with high mortality. The most common electrocardiography finding in acute pancreatitis cases is reported to be nonspecific repolarization changes in the literature. Recently, it is reported that repolarization changes carry high mortality risk. In this study, we aimed to investigate the association between repolarization changes and prognosis in acute pancreatitis cases. METHODS: Patients with acute pancreatitis referred to gastroenterohepatology clinic between 2009 and 2010 were included into the study. Echocardiography, electrocardiography, chest graph, abdominal sonography and/or computerized tomography, Ranson's and Glasgow's parameters and routine biochemistry tests of all patients were evaluated. RESULTS: A total of 55 cases [F/M: 22 (40%) / 33 (60%)] were included into the study. Thirty-nine of acute pancreatitis cases (70%) had electrocardiography changes. Electrocardiography changes were seen most frequently in cases with biliary (73%) and alcohol dependant pancreatitis cases (21%). The most frequently seen electrocardiographic finding was lateral early repolarization. There was a significant correlation between lateral early repolarization and Ranson score (p = 0.005). CONCLUSION: Early repolarization is the most common electrocardiographic findings and consistent with severity of acute pancreatitis cases.

Impact of volume status on blood pressure and left ventricle structure in patients undergoing chronic hemodialysis.

In this study, we aimed to examine the impact of volume status on blood pressure (BP) and on left ventricular mass index (LVMI) in chronic hemodialysis (HD) patients. This study enrolled 74 patients (F/M: 36/38, mean age 53.5 ± 15.3 years, mean HD time 41.5 ± 41 months) that were on HD treatment for at least 3 months. Demographics, biochemical tests, hemogram and C-reactive protein levels, mean interdialytic weight gain (IDWG), mean percentage of ultrafiltration (UF), and intradialytic complications such as hypotension and cramps were determined. Mean values of predialysis and postdialysis BP measurements were recorded a month before echocardiographic examination. On the day after a midweek dialysis session, 24 h ambulatory BP monitoring (ABPM) and echocardiographic examination were made concurrently. The patients were classified into two groups according to volume status: normovolemic (group 1; 14F/24M, mean age 50 ± 16.7 years, mean dialysis time 47.7 ± 47.7 months) and hypervolemic (group 2; 15F/21M, mean age 57.3 ± 12.7 years, mean dialysis time 34.9 ± 32 months). HD duration, IDWG, UF, and interdialytic complication rates were similar between the two groups (p < 0.05). Eleven patients (28.9%) of group 1 and 8 patients (22.2%) of group 2 showed dipper (p = 0.50). Valvular damage was more common in group 2 (p = 0.002). Whereas 33 patients (91.7%) had left ventricular hypertrophy (LVH) in group 2, 21 patients of the group 1 (55.3%) had LVH (p < 0.001). Although LVMI showed a significant positive correlation with cardiothoracic index, predialysis and postdialysis BP, IDWG, UF, daytime and nighttime BP measurements of 24 h ABPM, a significant negative correlation was seen with Kt/V urea and serum albumin levels. In conclusion, increased IDWG and UF and elevated BP are independent predictors of LVH for HD patients. Increased volume status leads to IDWG and elevated BP and eventually causes severe LVMI increases.

Comparison of epicardial adipose tissue (EAT) thickness and anthropometric measurements in metabolic syndrome (MS) cases above and under the age of 65.

EAT is a new index of cardiac and visceral obesity. Waist circumference (WC) measurement is not fully reliable in the determination of visceral adipose tissue (VAT), especially in elderly individuals. Studies on the reflection of the intra-abdominal fat mass by the EAT mass surrounding the heart were performed. Our purpose in this study was to determine the relation between the MS criteria and EAT in MS cases and especially to compare anthropometric measures between non-geriatric patients under the age of 65, and geriatric ones over the age of 65 years. The study was performed during the years 2008 and 2009 on 120 cases; 66.7% of them were under the age of 65 and 33.3% of the cases were 65-year old or older. All of the patients were diagnosed as MS by the International Diabetes Federation (IDF) criteria. They were randomized as per the application order and included to the study. Each subject underwent transthoracic two-dimensional (2D) guided M-mode echocardiogram. We measured epicardial fat thickness on the 1/3 section close to the ventricle basis adjacent to the free wall of right ventricle from both the parasternal long axis (LA) and parasternal short axis (SA) views. Multiple regression analysis showed that WC, systolic blood pressure (SBP) and age were the strongest independent variables correlated with EAT (p<0.001). We also determined a significant correlation between low-density lipoprotein-cholesterol (LDL-C) and EAT (p<0.05). Our data show that EAT-measurement by echocardiography is an efficient method in determination of visceral adiposity and shall be taken into consideration especially when advanced age groups are in question.

A rare cause of acute abdomen: ruptured adrenal pheochromocytoma.

Pheochromocytoma is a tumor of the chromaffin cells which secretes catecholamines and 90% of it originates from adrenal medulla. The main symptoms and signs are hypertension, tachycardia, sweating and headache. Rarely, acute abdomen may occur as a result of the rupture of tumoral mass or bleeding inside the mass. Here we present a 43 year old male patient who applied with acute abdominal syndrome and severe hypertension. Abdominal MRI showed a large mass hemorrhagic in nature above the right kidney. At laparotomy, ruptured adrenal mass was seen and excised successfully. The histological evaluation confirmed the diagnosis as pheochromocytoma. Ruptured adrenal pheochromocytoma is a mortal situation potentially and it should be considered in patients who present with an acute abdominal syndrome and hypertension or shock. It should be known that early diagnosis and surgery with proper preoperative treatment is a life saver.

Recurrent pericarditis as the initial manifestation of Familial Mediterranean fever.

BACKGROUND: Familial Mediterranean fever is an autosomal recessive disease largely restricted to certain ethnic groups and presenting with recurrent febrile serositis attacks. Peritonitis, pleuritis, and synovitis are common manifestations; however, the pericardium is rarely affected. CASE REPORT: In this case report, we describe a 25-year-old Turkish woman who presented with recurrent pericarditis of no obvious cause, which eventually responded to colchicine therapy. Using gene mutation analysis to detect the MEFV gene, the patient's condition was finally diagnosed as Familial Mediterranean fever. CONCLUSIONS: Familial Mediterranean fever should be considered in patients with idiopathic recurrent pericarditis unresponsive to nonsteroidal anti-inflammatory medications and corticosteroids. Mutation analyses should be done.

Effects of coronary collateral vessels in left ventricular segmental motions and myocardial viability using color kinesis dobutamine stress echocardiography.

OBJECTIVE: To detect the functional importance of coronary collaterals, which develop after acute myocardial infarctions (AMI). METHODS: Forty patients with acute AMI whose coronary angiography demonstrated a total occlusion of the left anterior descendant (LAD) artery were included in the study, between January 2003 and June 2004. All of the study patients underwent coronary angiography and left ventriculography using standard Judkins techniques (Phillips Integris-3000). Left ventricular (LV) free walls were divided into 5 segments, and all of these segments motions were evaluated then LV free wall motion score index (WMSI) was calculated. The study patients were divided into 2 groups: good (Rentrop 3; group I; n = 14) and poor coronary collateral circulation (Rentrop 0-2; group II; n = 26) according to the Rentrop grading. Then, color kinesis dobutamine stress echocardiography (CK-DSE) was performed to all patients with standard techniques 6 weeks after AMI. RESULTS: There were no significant differences for age, gender, risk factors for the coronary artery disease and use of the fibrinolytic therapy between the groups. There were no significant statistical differences for angiographic WMSI, left ventricular ejection fraction (LVEF), end-diastolic volume, end-systolic volume and end-diastolic pressures between the 2 groups. No difference was detected between Group I and II for initial EF, WMSI and peak dose WMSI in CK-DSE procedure. Viability was determined in all of the 14 patients in group I (100%) and 12 of 26 patients in group II (46%) (p = 0.03). CONCLUSION: In early periods of an AMI genesis of the coronary collateral circulation does not affect left ventricular global and regional systolic functions, but increase viability quite significantly. According to our findings early revascularization could be carried out in patients with good coronary collateral circulation without doing any test for viability.

After myocardial infarction carvedilol improves insulin resistance compared to metoprolol.

PRINCIPLES: Both carvedilol and metoprolol have cardioprotective effects and decrease infarct size in myocardium. We compared effects of carvedilol and metoprolol on insulin resistance and serum lipid levels after myocardial infarction. METHODS: Fifty-nine patients aged between 30 and 70 and BMI = 25-30 kg/m2, who were diagnosed with myocardial infarction with ST segment elevation, were considered to be eligible for the study. Patients were randomly allocated to two different therapy protocols. Metoprolol 100 mg bid or carvedilol 25 mg bid was added to their standardized therapy regimen. Baseline to week 4 and 12, fasting blood glucose, serum lipid profile, BMI, C-peptide, insulin and homeostasis model assessment of insulin resistance (HOMA-IR) were measured. RESULTS: After 12 weeks of metoprolol therapy HOMA-IR, insulin and C-peptide levels were significantly higher (p < 0.05 for all) and total cholesterol and triglyceride levels decreased significantly (p < 0.05 for all) compared to baseline. After 12 weeks of carvedilol therapy HOMA-IR, insulin and C-peptide (p < 0.05 for all), total cholesterol and triglyceride (p = 0.001 for all) decreased significantly compared to baseline. Carvedilol provided more decrease in total cholesterol and LDL levels than metoprolol (p = 0.043 and p = 0.021, respectively). CONCLUSIONS: In patients after myocardial infarction, carvedilol added to background therapy improved insulin resistance and lipid profile.

Predictive value of admission electrocardiogram for multivessel disease in acute anterior and anterior-inferior myocardial infarction.

BACKGROUND: Our aim was to investigate the correlation between admission ECG and coronary angiography findings in terms of predicting the culprit vessel responsible for the infarct or multivessel disease in acute anterior or anterior-inferior myocardial infarction (AMI). METHODS: We investigated 101 patients with a diagnosis of anterior AMI with or without ST-segment elevation or ST-segment depression in at least two leads in DII, III, aVF. The patients were classified as those with vessel involvement in the left anterior descending (LAD) coronary artery and patients with multivessel disease. Vessel involvement in LAD + circumflex artery (Cx) or LAD + right coronary artery (RCA) or LAD + Cx + RCA were considered as multivessel disease. Thus, (a) anterior AMI patients with reciprocal changes in inferior leads, (b) anterior AMI patients with inferior elevations, (c) all anterior AMI patients according to the ST-segment changes in the inferior region were analyzed according to the presence of LAD or multivessel involvement. RESULTS: Presence of ST-segment depression in aVL and V6 was significantly correlated with the presence of multivessel disease in anterior AMI patients with reciprocal changes in the inferior leads (P = 0.005 and P = 0.003, respectively). No statistically significant difference between the leads were detected in terms of ST-segment elevation in predicting vessel involvement in the two groups of anterior AMI patients with inferior elevations. When all the patients with anterior AMI were analyzed, the presence of ST-segment depression in leads aVL, V4, V5 and V6 were significantly associated with the presence of multivessel disease (P = 0.035, P = 0.010, P = 0.011, P = 0.001, respectively). CONCLUSIONS: The presence of ST-segment depression in anterolateral leads in the admission ECG of anterior AMI patients with reciprocal changes in inferior leads was associated with multivessel disease.

Automatic backscatter analysis of regional right ventricular systolic function using colour kinesis in patients with inferior wall acute myocardial infarction with or without right ventricular involvement.

BACKGROUND: In patients with inferior acute myocardial infarction (AMI), right ventricular (RV) function is an important determinant of global cardiac performance, prognosis, and exercise capacity. Several echocardiographic methods for quantifying RV function have been developed over the years but the usefulness of colour kinesis (CK) and acoustic quantification (AQ) have not yet been investigated. AIM: To test whether AQ and CK may provide quantitative assessment of global and regional RV function in patients with inferior AMI. METHODS: Thirty two consecutive patients with recent inferior AMI with or without RV involvement (n=17 and n=15, respectively), and 15 age- and gender-matched controls were studied. The graphs of RV fractional area change were displayed along with ECG and the concurrent cross sectional image. CK digitised end-systolic images of RV and were evaluated by reviewing the stored loops obtained from normal subjects and patients. To evaluate the entire RV systolic endocardial excursion, further quantitative CK analysis was performed by measuring the systolic segmental endocardial motion (SEM). RESULTS: In comparison with the control group, patients with inferior AMI with or without RV involvement had reduced RV fractional area change (30+/-7%, 36+/-6%,45+/-6%, p<0.05, p<0.01 respectively), reduced mean free wall SEM (3.9+/-1.1 mm, 5.2+/-1.3 mm, 6.3+/-1.4 mm, p<0.05, p<0.01 respectively) and mean septal wall SEM (4.9+/-1.2 mm, 6.4+/-1.5 mm, 7.2+/-1.4 mm, p<0.05, p<0.05, respectively). CONCLUSIONS: Our results confirmed that RV systolic functions are significantly more altered in patients with inferior AMI than in controls, and that RV abnormalities are more pronounced in patients with rather than without RV involvement. AQ and CK are able to detect wall motion disturbances in patients with inferior AMI with RV involvement.