Pleiotropic effects of HDL subfractions and HDL-associated enzymes on protection against coronary artery disease.

OBJECTIVE: High-density lipoprotein cholesterol (HDL-C) levels are inversely related to the risk of coronary artery disease (CAD). Alterations in HDL-C subclass distribution and HDL-associated enzyme activities may be more important than total HDL levels for the progression of CAD. We intended to investigate the relationship of HDL-C subclass distribution and HDL-associated enzyme activities with CAD. METHOD AND RESULTS: Our study included 101 patients with stable coronary artery disease, and 64 healthy subjects. Serum levels of HDL lipoprotein-associated-phospholipase A2 (HDL-LpPLA2), paraoxonase 1 (PON1), and HDL subfraction distribution were measured. We found increased small HDL (sHDL) subfractions in patients with one-vessel disease (P < 0.001). We also found a reverse correlation between total HDL-C levels and affected vessel number (P < 0.05). Plasma HDL-Lp PLA2 enzyme level was higher in each vessel disease category compared to the control group (P < 0.001). However, PON1 enzyme activity in patients with CAD was not statically significant. Plasma sHDL, HDL-Lp PLA2 enzyme and Lp(a) were significantly different between subjects with CAD and control participants. CONCLUSIONS: We demonstrated decreased sHDL particles and a lower cardioprotective HDL-LpPLA, enzyme activity in all patient subgroups compared to controls. Measurement of total HDL-C level only may not be sufficient to predict CAD risk.

Esophageal rupture complicated by acute pericarditis.

Esophageal perforation is a serious condition with a high mortality rate. Delayed detection of esophageal perforation may result in devastating complications such as mediastinitis and pericarditis. Esophageal perforation is rarely due to aspiration of foreign bodies. Here we report the case of a 59-year-old male patient with complicated esophageal perforation due to ingestion of a chicken bone, whose first signs are considered to be acute non-specific pericarditis.

Successful thrombolysis using recombinant tissue plasminogen activator in cases of severe pulmonary embolism with mobile thrombi in the right atrium.

Hereby, we report two cases of acute pulmonary embolism with concomitant right-sided thrombus, which were successfully treated using recombinant tissue plasminogen activator (rtPA). These patients had life-threatening acute right ventricular failure, which dramatically improved within hours following thrombolysis. These cases emphasize the clinical utility of rtPA for the treatment of life-threatening pulmonary embolism.

Epicardial adipose tissue thickness and NGAL levels in women with polycystic ovary syndrome.

BACKGROUND: Polycystic ovary syndrome (PCOS) is associated with an increased cardiovascular disease (CVD) risk and early atherosclerosis. Epicardial adipose tissue thickness (EATT) is clinically related to subclinical atherosclerosis. In the present study, considering the major role of neutrophil gelatinase-associated lipocalin (NGAL) which is an acute phase protein rapidly releasing upon inflammation and tissue injury, we aimed to evaluate NGAL levels and EATT in PCOS patients and assess their relationship with cardiometabolic factors. METHODS: 64 patients with PCOS and 50 age- and body mass index-matched healthy controls were included in the study. We evaluated anthropometric, hormonal and metabolic parameters. EATT was measured by echocardiography above the free wall of the right ventricle. Serum NGAL and high-sensitive C- reactive protein (hsCRP) levels were measured by ELISA. RESULTS: Mean EATT was 0,38 +/-0,16 mm in the PCOS group and 0,34 +/-0,36 mm in the control group (p = 0,144). In the obese PCOS group (n = 44) EAT was thicker compared to the obese control group (n = 41) (p = 0.026). Mean NGAL levels of the patients with PCOS were 101,98 +/-21,53 pg/ml, while mean NGAL levels were 107,40 +/-26,44 pg/ml in the control group (p = 0,228). We found a significant positive correlation between EATT and age, BMI, waist circumference, fasting insulin, HOMA-IR, triglyceride and hsCRP levels in PCOS group. CONCLUSIONS: Thickness of the epicardial adipose tissue can be used to follow the risk of CVD development in obese PCOS cases. However serum NGAL levels do not differ in patients with PCOS and control group.

Cholesterol forms and traditional lipid profile for projection of atherogenic dyslipidemia: lipoprotein subfractions and erythrocyte membrane cholesterol.

Atherogenic dyslipidemia characterized by abnormal changes in plasma lipid profile such as low high-density lipoprotein (HDL) and increased triglyceride (TG) levels is strongly associated with atherosclerotic diseases. We aimed to evaluate the levels of pro- and antiatherogenic lipids and erythrocyte membrane cholesterol (EMC) content in normo- and dyslipidemic subjects to investigate whether EMC content could be a useful marker for clinical presentation of atherogenic dyslipidemia. Low-density lipoprotein (LDL), HDL and their subfraction levels and erythrocyte lipid content were determined in 64 normolipidemic (NLs), 42 hypercholesterolemic (HCs) and 42 mixed-type dyslipidemic subjects (MTDs). Plasma atherogenic lipid indices [small-dense LDL (sdLDL)/less-dense HDL (LHDL), TC/HDL-C, TG/HDL-C and Apo B/AI] were higher in MTDs compared to NLs (p < 0.001). The highest sdLDL level was observed in HCs (p < 0.01). Despite a slight increase in EMC level in dyslipidemic subgroups, the difference was not statistically significant. A significant negative correlation, however, was observed between EMC and sdLDL/LHDL in HCs (p < 0.035, r = -0.386). Receiver operating characteristic curves to predict sdLDL level showed that TG and EMC levels had higher area under curve values compared to other parameters in HCs. We showed that diameters of larger LDL and HDL particles tend to shift toward smaller values in MTDs. Our results suggest that EMC content and TG levels may be a useful predictor for sdLDL level in hypercholesterolemic patients.

A rare complication: Undeflatable balloon of the stent.

Percutaneous coronary intervention is an important modality in the treatment of coronary artery disease. These procedures are usually completed successfully, but occasionally serious complications are encountered. In this paper, we present the case of an undeflatable stent balloon, which is an extremely rare complication that has not been described in the literature.

Epicardial adipose tissue is independently associated with increased left ventricular mass in untreated hypertensive patients: an observational study.

OBJECTIVE: Epicardial adipose tissue (EAT) secretes various inflammatory mediators and growth factor, and has endocrine and paracrine effects on myocardium and body. We planned the present study in order to evaluate the possible relationship between EAT and left ventricular mass (LVM), a potent predictor of cardiovascular mortality and morbidity, independent of age, blood pressure and the metabolic parameters in patients with hypertension (HT). METHODS: The present study was cross-sectional and observational, including consecutive 107 untreated essential hypertensive patients who underwent a complete transthoracic echocardiographic examination as well as measurements of LVM and EAT. Blood pressure, routine blood chemistry, C-reactive protein, and patient characteristics were also recorded. Univariate and then multiple linear regression analyses were used for analysis of independent variables associated with EAT. RESULTS: LVM significantly correlated with waist circumference, EAT, glucose, uric acid, high-density lipoprotein (HDL) cholesterol, and systolic and diastolic blood pressure. When we divided study population into two groups according to median mean blood pressure (BP) (Mean BP ≤116 vs. >116 mmHg), EAT was the only associated factor for LVM in patients below median BP (Beta: 0.518, p<0.001). Linear regression analyses revealed EAT to be independently associated with LVM (Beta: 0.419; p<0.001) and LVM index (Beta: 0.384, p<0.001) as well as high-density lipoprotein (Beta: -0.264, p=0.006). CONCLUSION: EAT was related to increased LVM independent of BMI, waist circumference, weight, systolic and diastolic blood pressure and other risk parameters, in patients with HT. Determination of increased EAT by echocardiography may have an additional value as an indicator of cardiovascular risk and total visceral adipose tissue.

Premature hair whitening is an independent predictor of carotid intima-media thickness in young and middle-aged men.

OBJECTIVE: Premature graying or whitening of the hair may possibly represent premature atherosclerotic changes as a surrogate marker of different host responses to cardiovascular risk factors (CVRFs). This study was undertaken to test whether carotid artery intima-media thickness (CIMT) as a validated surrogate marker of the severity and extent of coronary artery disease (CAD) is higher in subjects with prominent signs of hair whitening, independent of chronological age and other CVRFs. METHODS: The current study was conducted in young and middle-aged patients (<55 years age) without a history of cardiovascular disease. Two hundred and two eligible patients consecutively admitted to our outpatient clinic for CVRF management were included. A gray/white-hair scale was used to determine the percentage of hair whitening. RESULTS: In the groups determined according to the degree of hair whitening, age (p<0.001), waist circumference (p=0.011), the presence of hypertension (p=0.003), the uric acid levels (p=0.008), the C - reactive protein levels (p=0.002) and CIMT (p<0.001) were significantly different. When we performed multivariate analyses to determine the independent predictors of CIMT and hair whitening, CIMT was found to be related to age, waist circumference, the levels of uric acid, bilirubin and gamma-glutamyl transpeptidase, the presence of a family history of CAD and hair whitening, while hair whitening was found to be related to age, hypertension, the bilirubin level and CIMT. CONCLUSION: Our findings suggest that premature hair whitening intensity is independently related to CIMT. In cumulative assessments of CVRFs on the human body, the presence of premature hair whitening may be useful in identifying individuals with an increased risk of cardiovascular disease.

Non-dipping pattern in untreated hypertensive patients is related to increased pulse wave velocity independent of raised nocturnal blood pressure.

BACKGROUND: Non-dipper pattern, characterized by diminished nocturnal decline in blood pressure (BP), is associated with an increase in cardiovascular events. Carotid-femoral pulse wave velocity (CF-PWV) has been accepted as the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. In this study, we investigated the association between PWV as the surrogate of arterial stiffness and non-dipper pattern in untreated hypertensive patients. METHODS: The present study was cross-sectional and observational. Hypertensive patients were diagnosed according to ambulatory BP measurements (mean BP ≥ 130/80 mmHg). Eighty-four hypertensive patients, consulted for initial evaluation of hypertension, were enrolled. CF-PWV as the indicator of arterial stiffness was measured by a validated tonometry system (SphygmoCor). Patients with the history of any cardiovascular disease were excluded from the study. RESULTS: Fifty-six patients had non-dipper pattern and 28 patients had dipper pattern in the study. Baseline characteristics were not significantly different between the two groups, except the CF-PWV (non-dipper vs dipper; 8.91 ± 2.53 vs 7.66 ± 1.08 m/s, p = 0.002), female gender (55% vs 32%, p = 0.045) and nocturnal BP measurements (for mean BP; 106 ± 11 vs 92 ± 8 mmHg, p < 0.001). Multiple logistic regression analysis including age, gender, BP and PWV measurements, revealed female gender (odds ratio, OR = 5.112, 95% confidence interval, CI 1.282-20.4, p = 0.021), nocturnal mean BP (OR = 1.243, 95% CI 1.107-1.396, p < 0.001) and CF-PWV (OR = 1.992, 95% CI 1.240-3.198, p = 0.004) as the independent predictors of non-dipper hypertensive pattern. CONCLUSION: Our results suggest that diminished nocturnal decline in BP is independently associated with PWV and nocturnal BP rather than daytime BP. Non-dipper pattern, mainly related to increased PWV and impaired modulation of vascular smooth muscle tone during the night, may justify an increased cardiovascular risk in these patients.

Independent determinants of ascending aortic dilatation in hypertensive patients: smoking, endothelial dysfunction, and increased epicardial adipose tissue.

BACKGROUND: Ascending aortic aneurysm is an uncommon condition with lethal consequences. Lately, epicardial adipose tissue (EAT) is acknowledged as an organ with important effects on the vascular system. In this study, we aimed to investigate whether EAT, cardiovascular risk factors, and vascular structure and functions are independently related to ascending aortic dilatation. METHODS AND RESULTS: Vascular structure and functions were determined by carotid intima-media thickness, pulse wave velocity, and brachial artery flow-mediated dilation. Study parameters were compared between 46 patients with a dilated ascending aorta (diameter ≥ 37 mm) and 58 individuals with a normal aortic diameter of <37 mm. Ascending aortic diameter significantly correlated with age (r=0.420, P<0.001), waist circumference (r=0.235, P=0.032), EAT (r=0.507, P<0.001), mean carotid intima-media thickness (r=0.354, P<0.001), flow-mediated dilation (r=-0.513, P<0.001), and diastolic blood pressure (r=0.365, P<0.001). Although C-reactive protein was related to BMI (r=0.485, P<0.001), waist circumference (r=0.368, P=0.001), and EAT (r=0.315, P=0.003), it was not correlated with ascending aortic diameter (r=0.092, P=0.403). Linear regression analysis revealed EAT thickness (ß: 0.483, P<0.001), smoking (ß: 0.366, P=0.002), and flow-mediated dilation (ß: -0.332, P=0.007) as the determinants of ascending aortic dilatation. CONCLUSION: On the basis of our findings, smoking, endothelial dysfunction, and increased EAT may be suggested as risk factors for ascending aortic dilation due to local or systemic effects in hypertensive patients.

Increased epicardial adipose tissue in patients with slow coronary flow phenomenon.

BACKGROUND: Slow coronary flow (SCF) is an angiographic finding characterised by delayed opacification of epicardial coronary arteries without obstructive coronary disease. Epicardial adipose tissue (EAT), localised beneath the visceral pericardium, is a metabolically active endocrine and paracrine organ with possible interactions within the heart. EAT and low-grade inflammation play major roles in the atherosclerotic vascular processes and may be important in other coronary pathologies such as SCF. AIM: To investigate whether EAT and C-reactive protein (CRP) are increased in patients with isolated SCF compared to normal subjects. METHODS: The present study was cross-sectional and observational, consisting of 66 individuals who underwent coronary angiography with a suspicion of coronary artery disease and who had angiographically normal coronary arteries of varying coronary flow rates. The relationship between EAT, CRP and SCF phenomenon was investigated. Thirty-three patients with isolated SCF (mean age: 56 ± 10 years) and 33 age- and gender-matched control participants with normal coronary flow (NCF), but without SCF, (mean age: 55 ± 10 years) were included in the study. RESULTS: EAT thickness was significantly increased in the SCF group compared to the NCF group (7.1 ± 2.7 vs. 4.7 ± 1.9 mm, p < 0.001). Body mass index (BMI, p < 0.001) and the percentage of isolated SCF (p = 0.002) were significantly higher in patients with increased EAT thickness. CRP was not related to SCF. When we performed multiple logistic regression analysis, only increased EAT thickness was related to the presence of SCF (OR 1.720, 95% CI 1.175-2.516, p = 0.005) independent of BMI and CRP. CONCLUSIONS: This study revealed, for the first time, a significant increase in EAT thickness in patients with SCF compared to NCF. We believe that further studies are needed to clarify the role of adipose tissue in patients with SCF.

The independent relationship between systemic inflammation and fragmented QRS complexes in patients with stable angina pectoris.

BACKGROUND: QRS complex fragmentations can frequently be seen on routine ECG with narrow or wide QRS complex. Fragmented QRS complexes (fQRS) are defined as various RSR' patterns (≥ 1 R' or notching of S wave or R wave) in two contiguous leads corresponding to a major coronary artery territory. In previous studies, fQRS has been associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. The causative relationship between fQRS and cardiac fibrosis has been shown, but it has not been extensively studied whether there are different mechanisms for the development of fQRS AIM: To interrogate the relationship between systemic inflammation and the presence of fQRS in patients with stable angina pectoris. METHODS: A total of 353 eligible patients who underwent coronary angiography with a suspicion of coronary artery disease (CAD) at our institution between April 2010 and December 2010 were enrolled consecutively. All patients had angina pectoris or angina equivalent symptoms with either a positive treadmill test or myocardial perfusion study. Patients with recent acute coronary syndrome either with or without ST-segment elevation, significant organic valve disease, and patients having any QRS morphology with QRS duration ≥ 120 ms, as well as patients with permanent pacemakers, were excluded from the study. RESULTS: Patients with fQRS had older age (p = 0.01), higher C-reactive protein (CRP) (p 〈 0.001), longer QRS time (p 〈 0.001) and more severe CAD (p 〈 0.001) compared to patients with non-fragmented QRS. When we performed multiple logistic regression analysis, we found that the fragmentations in QRS complexes were positively related with increased CRP (OR: 3.8, 95% CI 1.573.9.278, p = 0.003), and QRS duration (OR: 1.1, 95% CI 1.008.1.101, p = 0.019) and negatively related with left ventricular ejection fraction [%] (OR: 1.0, 95% CI 0.914.0.992, p = 0.020). CONCLUSIONS: In our study, we found that fQRS was independently related with increased CRP and QRS duration as well as left ventricular systolic dysfunction. Fragmented QRS, which may come about as an end effect of inflammation at cellular level, can represent increased cardiac risk by different causative mechanisms in patients with stable CAD. In addition, fragmentations on ECG may be useful for identifying patients who should be investigated and treated for their increased inflammatory status and possible chronic infections.

Relationship of fragmented QRS complexes with inadequate coronary collaterals in patients with chronic total occlusion.

BACKGROUND: Fragmented QRS (fQRS) complexes are defined as various RSR' patterns (≥1 R' or notching of S wave or R wave) in two contiguous leads corresponding to a major coronary artery territory. In previous studies, fQRS has been associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events (CVEs). The causative relationship between fQRS and cardiac fibrosis has been shown in prior studies. The association between inadequate (poor) coronary collaterals and presence of fQRS has not comprehensively been studied in patients with chronic total occlusion (CTO) until now. We tested the hypothesis that the presence of fQRS is associated with inadequate coronary collateral growth. METHODS: This study had a cross-sectional observational design. The study population consisted of patients who underwent coronary angiography with the suspicion of coronary artery disease at our institution in an outpatient manner. Patients who had CTO in at least one major epicardial coronary artery were included. Coronary angiograms of 148 eligible patients from our database were analyzed again. Ninety-three patients had good and 55 had poor collateral development according to the Cohen-Rentrop method. RESULTS: Patients with poor collateral development had higher plasma glucose (130 ±â€Š54 vs. 116 ±â€Š33 mg/dl, P = 0.047) and an older age (65 ±â€Š10 vs. 61 ±â€Š10  years, P = 0.042) in comparison to patients with good collateral growth. The presence and number of fQRS were higher in the poor collateral group than the good collateral group (64 vs. 32%, P < 0.001 and 2.3 ±â€Š2.4 vs. 1.2 ±â€Š2.0, P = 0.002, respectively). Left ventricular ejection fraction was significantly lower in the poor collateral group than the good collateral group (45 ±â€Š11 vs. 51 ±â€Š13, P = 0.014). There was a significant correlation between number of fQRSs and the echocardiographic wall-motion abnormality score (r = 0.662, P < 0.001). In multivariate analysis, only the presence of fQRS was independently related to poor collateral development (odds ratio, 3.559; 95% confidence interval, 1.708-7.415, P = 0.001). CONCLUSION: We found that fQRS was independently related to inadequate coronary collaterals in patients with CTO. fQRS, which may be derived from the effects of myocardial ischemia or scar on myocardial electricity at the cellular level, can represent inadequate coronary collateral development in patients with CTO.

Increased epicardial adipose tissue thickness is correlated with ascending aortic diameter.

Epicardial adipose tissue (EAT), localized beneath the visceral pericardium, is a metabolically active endocrine and paracrine organ with possible interactions within the heart. Recent studies identified possible roles of uric acid (UA)-induced oxidative stress and increased inflammatory status in the pathogenesis of ascending aortic dilatation. The aim of this study was to investigate whether EAT is an independent factor for ascending aortic dilatation. The patients were evaluated by a complete transthoracic echocardiographic examination including measurements of EAT and aortic dimensions. Serum levels of UA and C-reactive protein and EAT thicknesses were compared in 38 patients with dilated ascending aorta (DAA) (the diameter ≥ 37 mm) vs. 107 subjects with normal aortic diameter (AD) of < 37 mm. EAT thickness was significantly higher in DAA group compared to normal AD group (8.3 ± 2.7 vs. 5.4 ± 2.2 mm, p < 0.001) as well as age (53 ± 10 vs. 48 ± 9 years, p = 0.004), the presence of hypertension (54% vs. 30%, p = 0.009) and UA levels (6.0 ± 1.4 vs. 5.2 ± 1.1 mg/dL, p < 0.001). There was a strong correlation between EAT thickness and ascending aortic diameter (r = 0.521, p < 0.001). In multiple logistic regression analysis, EAT thickness (OR: 1.429, p = 0.006), body mass index (OR: 1.169, p = 0.014) and UA levels (OR: 1.727, p = 0.023) were independently correlated to ascending aortic dilatation. We therefore propose that increased EAT thickness is an independent predictor of ascending aortic dilation.

Prominent ST-segment elevation in leads V1-V4 due to isolated right ventricular branch occlusion after primary percutaneous coronary intervention for right coronary artery.

Isolated right ventricular myocardial infarction (RVMI) rarely occurs. It accounts for only 3% of all infarctions. In the literature, there are several reported isolated RVMI cases with precordial ST-segment elevation. We describe a 55-year-old man with prominent ST-segment elevation in leads V1-V4 in whom isolated RVMI developed due to occlusion of the right ventricular branch during primary percutaneous coronary intervention to the right coronary artery for acute inferior myocardial infarction.