Autonomic neural control of the cardiovascular system in patients with Behçet's disease in the absence of neurological involvement.

Behçet's disease (BD) is a chronic multi-system disease presenting with recurrent oral and genital ulceration, and relapsing uveitis. Heart rate recovery (HRR) after exercise is a marker of parasympathetic activity. A delayed recovery of systolic blood pressure (SBP) after exercise might reflect sympathetic hyperactivity. The analysis of variations in heart rate has also been used to determine the balance between sympathetic and vagal nerve activities in the heart. Our objective was to determine HRR, the SBP response to exercise and heart rate variability (HRV) in patients with BD in the absence of neurological involvement. The study population consisted of 32 patients with BD and 30 healthy controls who were matched with respect to age, sex, and physical activity. Heart rate recovery was calculated as the difference between heart rate at peak exercise and heart rate at 1, 2, and 3 min of recovery. Blood pressure recovery indexes were determined by dividing the systolic blood pressure at 2 and 3 min in recovery to the systolic blood pressure at peak exercise. In patients with BD, mean HRR at 1 min (HRR1) were not significantly different than that of controls (21 ± 7 vs 20 ± 7 bpm, p = 0.50). Although, resting mean SBP of patients with BD was higher than controls (121 ± 13 vs 115 ± 12 mmHg, p = 0.039), the SBP recovery indices of the patients with BD at 2 and 3 min were similar to those of controls (0.84 ± 0.07 vs 0.84 ± 0.09, p = 0.89 and 0.78 ± 0.09 vs 0.78 ± 0.08, p = 0.93, respectively). Both time domain and frequency domain parameters of patients with BD were similar to that of controls. This study shows that the patients with BD have normal HRR1 and normal SBP response to exercise and normal HRV. These findings might suggest unaltered autonomic neural control of the cardiovascular system in this disorder in the absence of neurological involvement.

Short-term effects of fluvastatin therapy on plasma interleukin-10 levels in patients with chronic heart failure.

BACKGROUND: Experimental data demonstrated that inflammatory mediators, such as pro-inflammatory and anti-inflammatory cytokines and their receptors might have important role in the development and the progression of heart failure (HF). Statins were shown to downregulate inflammatory cytokines in HF. Interleukin (IL)-10 is one of the most important anti-inflammatory cytokines. The effect of statin therapy on plasma IL-10 levels is not known in patients with HF. We conducted this study to investigate the effects of fluvastatin therapy on plasma IL-10 cytokine concentration in patients with HF. METHODS: A total of 29 patients with ischemic HF were included in this prospective uncontrolled study. Patients were assigned to fluvastatin (80 mg/day) after baseline examinations. Determination of biochemical parameters including lipids, IL-10, and tumor necrosis factor-alpha were performed at baseline and 12 weeks after the initiation of fluvastatin therapy. All participants also underwent symptom-limited exercise tolerance test at baseline and 12 weeks, and heart rate recovery (HRR) was calculated. RESULTS: A significant elevation in the plasma levels of IL-10 after 12 weeks of fluvastatin treatment (4.8+ or -1.0 vs. 6.5+ or -1.3 pg/ml, P=0.002) was observed. Plasma tumor necrosis factor-alpha levels were significantly decreased after fluvastatin therapy (6.3+ or -2.3 vs. 4.8+ or -1.4 pg/ml, P=0.003). Fluvastatin therapy significantly improved HRR at 1 min after 12 weeks compared with baseline (19+ or -7 vs. 24+ or -9 bpm, P<0.001). A positive correlation between the change in the levels of IL-10 and the change in HRR at 1 min (r=0.57, P<0.001) was observed. CONCLUSION: Fluvastatin therapy might lead to an increase in plasma IL-10 levels and an associated improvement in vagal tonus as assessed by HRR at 1 min in patients with HF. These findings might partly explain the possible benefit observed in statin trials.

Short- and long-term effect of simvastatin therapy on the heterogeneity of cardiac repolarization in diabetic patients.

The interlead variability of QT interval in the 12-lead electrocardiogram, QT dispersion (QTd), has been shown to reflect dispersion of ventricular refractoriness and may provide a measure of arrhythmogenic potential in diabetic patients. QTd and heart rate corrected QTd (QTcd) were also proposed to be accurate predictors of cardiac death in patients with diabetes. In recent years, experimental and clinical evidence demonstrates that statins exert antiarrhythmic properties. Therefore, in the present study, we have examined whether simvastatin treatment has any effect on the QTd and QTcd in patients with diabetes mellitus. Sixty type 2 diabetic patients without known coronary artery disease and low-density lipoprotein cholesterol >100mg/dl and 30 age and sex-matched non-diabetic controls were included in a prospective study. Out of 60 diabetic patients, 30 were treated with simvastatin 40 mg/day for 1 year and the remaining 30 subjects were served as diabetic controls. No lipid lowering therapy was administered to the diabetic and the non-diabetic controls. QTd and QTcd of treated diabetics and the non-diabetic controls were measured at baseline, 6, 12 weeks and at 1 year. QTd and QTcd of the diabetic controls were obtained at baseline, 6 and 12 weeks. Both QTd and QTcd were significantly greater in patients with the diabetes than in the non-diabetic controls at baseline (52+/-13 ms vs. 41+/-12 ms, p<0.001 and 62+/-17 ms vs. 42+/-11 ms, p<0.001, respectively). Simvastatin therapy significantly decreased both QTd and QTcd at the end of first year compared to baseline (51+/-15 ms vs. 33+/-11 ms, p<0.001 and 60+/-18 ms vs. 38+/-12 ms, p<0.001, respectively). No significant change were found in QTd and QTcd in the non-diabetic (p=0.29 and p=0.87 by ANOVA, respectively) and in the diabetic controls (p=0.72 and p=0.57, by ANOVA, respectively). This study suggests for the first time that simvastatin treatment in diabetic patients with hyperlipidemia is associated with an improvement in the heterogeneity of cardiac repolarization. This may be one of the mechanisms for the reduction in clinical events reported in the survival studies with statins. Further prospective randomized studies are warranted to confirm our findings.

Altered autonomic neural control of the cardiovascular system in patients with polycystic ovary syndrome.

PURPOSE: Polycystic ovary syndrome (PCOS) is frequently accompanied by the presence of cardiovascular risk factors. It has also been recognized that there is a significant relationship between the autonomic nervous system and adverse cardiac events. Heart rate recovery (HRR) after exercise is a marker of parasympathetic activity and attenuation of this parameter has been shown to be associated with increased cardiac mortality. A delayed recovery of systolic blood pressure (SBP) after peak exercise has been found to have diagnostic value and might reflect sympathetic hyperactivity. The analysis of variations in heart rate has also been used to determine the balance between sympathetic and vagal nerve activities in the heart. Our objective was to determine HRR, the SBP response to exercise and heart rate variability (HRV) in patients with PCOS. METHODS: The study population consisted of 26 untreated patients with PCOS and 24 healthy controls who were matched with respect to age, body mass index and physical activity. All subjects underwent symptom-limited exercise tolerance test according to a modified Bruce protocol. Following peak exercise, subjects walked a 2-min cool-down period. Heart rate recovery was calculated as the difference between heart rate at peak exercise and heart rate at the relevant minute of recovery. Blood pressure recovery indexes were determined by dividing the systolic blood pressure at 1, 2 and 3 min in recovery to the systolic blood pressure at peak exercise. RESULTS: HRR at 1 min (HRR1) of the patients with PCOS were significantly lower than that of controls (20+/-4 vs 28+/-8 bpm, p<0.0001). Although, resting SBP of the two groups were similar (117+/-7 vs 117+/-10 mmHg, p=0.663), the SBP of the patients with PCOS at peak exercise were significantly higher when compared to controls (172+/-12 vs 156+/-14 mmHg, p<0.0001). In addition, the SBP of the patients with PCOS remained significantly elevated when compared to controls at the first, second and third minute of recovery (168+/-13 vs 148+/-15 mmHg, 162+/-13 vs 136+/-16 mmHg, 152+/-17 vs 127+/-15 mmHg, respectively, p<0.0001 for all three). The SBP recovery index at 2 and 3 min of the patients with PCOS were significantly higher than that of controls (0.93+/-0.04 vs 0.87+/-0.07, p<0.0001 and 0.87+/-0.07 vs 0.82+/-0.09, p=0.017, respectively). Both time domain and frequency domain parameters of patients with PCOS were significantly lower than that of controls. CONCLUSION: This study shows that the patients with PCOS have attenuated HRR1, exaggerated SBP response to exercise which is delayed to recover and a depressed HRV. These findings might also suggest alterations in autonomic neurol control of the cardiovascular system in this disorder.

Exercise-induced ST-segment elevation in leads aVR and V1 for the prediction of left main disease.

BACKGROUND: This study investigated the value of exercise-induced ST-segment elevation in lead aVR with or without concomitant ST-segment elevation in lead V(1) for detection of left main (LM) coronary artery disease in patients with Duke treadmill score

Rheumatic mitral valve stenosis is associated with impaired flow-mediated dilatation.

It has been demonstrated that rheumatic mitral valve stenosis (RMVS) is associated with an increase in markers of endothelial dysfunction. It is not known whether this association indicates an impairment of flow-mediated dilatation (FMD) of the vascular endothelium. Thirty patients with RMVS and 30 healthy subjects were studied. FMD in patients with RMVS was significantly smaller than in healthy controls (11.9+/-0.4% vs 15.4+/-0.70%, p=0.003). The absolute change in brachial artery diameter in patients with RMVS was also significantly smaller than in healthy subjects (0.42+/-0.26 mm vs 0.64+/-0.32 mm, p<0.001). These findings suggest that vascular endothelial function is altered in patients with RMVS.

Effect of female gender on the outcome of coronary artery bypass surgery for left main coronary artery disease.

OBJECTIVE: Early mortality after coronary artery bypass grafting is generally higher in women than in men. This study analyzes the effect of female gender on early mortality of coronary artery bypass grafting particularly for left main coronary artery disease. METHODS: Study population consisted of 144 consecutive patients (33 women, 111 men) undergoing coronary artery bypass grafting for left main coronary artery disease. Mean follow-up was 25.1 +/- 14.0 months. Data were collected retrospectively and presented as mean +/- standard deviation. Survival analysis was done using Kaplan-Meier actuarial curve method with the log rank univariate test, followed by Cox's proportional rate multivariate model. RESULTS: Overall mortality was 7% in the patient population. Cox regression analysis revealed that the independent predictors of increased total mortality were female gender (HR 8.34, 95% CI 1.79 - 38.76, p=0.007), advanced age (HR 1.12, 95% CI 1.02-1.23, p=0.014), degree of left main coronary artery stenosis (HR 1.068, 95%CI 1.005-1.135, p=0.03), and left ventricular ejection fraction (HR 0.93, 95% CI 0.87-0.99, p=0.03). Female gender was found to be the only independent predictor of increased early mortality (HR 13.18, 95%CI 1.444-120.343, p=0.02). After discharge from the hospital, female gender was no more a predictor of increased mortality. CONCLUSION: According to these data, we may assume that female gender is related with increased mortality in coronary artery surgery for left main disease in the pre-discharge period however after discharge from hospital, long-term benefit of female survivors of coronary artery bypass grafting operated on for left main coronary artery disease might be as good as in men.

Coronary and systemic stent embolization during percutaneous coronary interventions: a single center experience.

OBJECTIVE: In this study, we attempted to analyze the incidence and outcomes of systemic and coronary stent embolizations during percutaneous coronary interventions and have described the treatment and retrieval methods used. METHODS: We retrospectively studied 24,038 consecutive coronary angiography procedures carried out at The Baskent University Adana Hospital from 1998 to present to determine the total number of stent embolization events. RESULTS: Among them, 4,797 were consecutive coronary stent operations and embolization was encountered in 14 cases (0.29%; 95% CI = 0.14-0.44%, P < 0.0001). The mean age of the patients was 61 +/- 8 years and 78% were men. Stent embolization occurred more frequently in cases with significant proximal angulation. Calcified lesions were not noted in any of the cases. In 7 out of 14 cases, stent embolization occurred at an unknown location and the clinical course was uneventful thereafter. Treatment and retrieval methods of the other 7 cases included the following: 1. Emergency cardiac bypass surgery (3 cases, 43%) 2. Advancement of a low profile delivery balloon through the stent, inflating the balloon, and replacing the stent at the lesion site (3 cases, 43%) 3. Crushing the stent against the coronary wall using another stent (1 case, 14%) 4. 4-loop snare (1 case, failed) None of the cases had bleeding that required transfusion. The stent was not crushed or deployed in the coronary artery causing major cardiac complication in any case. CONCLUSION: Systemic and coronary embolizations of stent procedures are rare. Consequences of coronary stent embolization can lead to prompt cardiac bypass surgery if the retrieval or deployment methods fail. Stent deployment or crushing techniques may be attempted before retrieval in patients who do not suffer from coronary thrombosis and myocardial infarction due to stent embolization.

Simvastatin improves the attenuated heart rate recovery of type 2 diabetics.

Heart rate recovery at 1min (HRR1) is a strong predictor of all-cause mortality. The effects of statins on the autonomic nervous system may account for their beneficial effects in survival. Our aim was to determine if statin therapy improves heart rate recovery in hypercholesterolemic patients with type 2 diabetes mellitus. Thirty type 2 diabetic patients without known coronary artery disease and low density lipoprotein cholesterol>100mg/dl and 30 age and sex matched non-diabetic controls were included in a prospective study. Patients with diabetes were treated with simvastatin 40mg/day for 1 year. No lipid-lowering therapy was administered to the control group. Exercise testing with 2min cool-down period was performed at baseline, 6, 12 weeks and at 1 year. The diabetics had significantly lower HRR1 compared with non-diabetics at baseline (19.2+/-5.4bpm versus 24.2+/-4bpm, p<0.0001). Simvastatin therapy significantly improved HRR1 after 12 weeks compared to baseline (19.2+/-5.4bpm versus 24+/-5bpm, p<0.0001) and this improvement remained significant at 1 year (26+/-4.4bpm, p<0.0001 compared to baseline). HRR1 did not change in the control group (p=0.39 by ANOVA). This study demonstrates that treatment with simvastatin might improve the attenuated heart rate recovery of diabetic subjects. In patients with diabetes, the mortality benefit provided by statins might involve their effects on the autonomic nervous system.

An experience on radial versus femoral approach for diagnostic coronary angiography in Turkey.

OBJECTIVE: The radial approach has been increasingly used as an alternative to femoral access. The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach (TRA) for diagnostic coronary angiography, and to describe the difficulties associated with the technique as compared with transfemoral approach (TRF). METHODS: A series of 180 consecutive patients were divided to TRA or TFA groups by two operators. We compared the groups regarding procedural time, access time, fluoroscopy time, procedural failure, complications, contrast volume, length of hospital stay, and number of used coronary catheters. RESULTS: The number of used coronary catheters was not different between the two groups (p = 0.6). Total hospital length of stay was significantly shorter in the radial group (p <0.0001) than in femoral one. We found differences between the radial and femoral groups in the success rate (p<0.0001), contrast volume (p = 0.012), procedural time (p<0.0001), access time (p<0.0001), and fluoroscopy time (p<0.0001). We did not find any major complication in the radial group. There was a major bleeding in the femoral group. CONCLUSION: The TRA is a safe alternative to femoral catheterization although with lesser procedural success, longer procedural access, and radiation time, and more contrast volume.

Slow coronary flow is associated with carotid artery dilatation.

Slow coronary flow (SCF) in a normal coronary angiogram is a well-recognized clinical entity, but its etiopathogenesis remains unclear. Carotid intima-media thickness (CIMT) is a noninvasive marker of atherosclerosis. The aim of this study was to investigate the CIMT and diameter of carotid and coronary artery in relation to SCF. Twenty-four patients with angiographically diagnosed SCF (51 +/- 7 years), and 26 age-matched subjects with normal coronary flow (NCF) (52 +/- 8 years) in the coronary angiography were enrolled. Coronary flow rates were documented by thrombolysis in myocardial infarction (TIMI) frame count (TFC), a simple method for evaluating coronary blood flow. Carotid and coronary artery diameters and CIMT were measured. Mean TFC was significantly higher in patients with SCF than in patients with NCF (p < 0.001). There were no significant differences regarding maximum (p = 0.84) and mean CIMT (p = 0.61). On the other hand, carotid lumen (p = 0.03) and coronary artery diameters (p = 0.001) were significantly greater in patients with SCF than in subjects with NCF. There was a significant relation between mean coronary artery diameter and TFC (p = 0.004, 95% CI for OR: 1.61-11.87). In conclusion, these findings suggest that CIMT is not altered in patients with SCF as compared with those with NCF. However, carotid and coronary artery diameters are increased in patients with SCF as compared to those with NCF. Because the common carotid artery can be assessed in nearly every patient, carotid artery dilatation may be used as an early indicator for SCF.