Objective: Endothelial dysfunction is an early marker of atherosclerosis. Angiotensin II and nitric oxide have important roles in maintaining the vascular tone. The existence of the angiotensin converting enzyme (ACE) gene polymorphisms has been known, and deletion (D) of the allele has been associated with coronary artery disease. As ACE genotype affects endothelial functions in the patients with risk factors for coronary artery disease, it may also be a determinant of atherosclerosis. In this study, the relationship between endothelial function and ACE gene polymorphisms was investigated in healthy young subjects. Methods: Forty-six healthy young subjects were included in this cross-sectional, randomized study. Participants were further divided into three groups according with ACE genotypes: DD genotype - 24 subjects, DI genotype - 13 subjects and II genotype - 9 subjects. All patients underwent brachial artery ultrasonographic examination. We analyzed ACE insertion (I) and D allele frequencies in all subjects. Kruskal-Wallis test was used to compare continuous variables, and the Chi-square test was used to compare proportions among groups. Results: Demographic features were similar except gender between the groups according to the ACE genotypes. Total cholesterol levels were lower in the DD genotype comparing with the others (pİ0.05). High-density lipoprotein cholesterol levels, baseline brachial artery diameter, baseline blood flow and the increase in the blood flow during the reactive hyperemia were also similar. The changes in flow-mediated dilatation (endothelium dependent) were 4.9±1.3% in DD genotype, 5.5±1.7% in DI genotype and 5.5±1.9% in II genotype groups. Flow mediated dilatation was lower in DD genotype group as compared with ID and II genotype groups, however, this result did not reach statistical significance (p>0.05). Endothelium independent dilatations were similar among different ACE genotypes. Conclusion: Our data showed that ACE genotype has no effect on endothelial functions in patients without risk factors for coronary artery disease.

Objective: The arginine- to-glutamine change at codon 3500 of the apolipoprotein B-100 (apo B) is a well- known genetic cause of hypercholesterolemia. Since increased cholesterol levels lead to atherosclerosis, identification of the carries of the apo B-3500 mutation is an important step in the risk stratification of individuals and families with hypercholesterolemia. The prevalence of this mutation in Turkish population is not well known. We aimed to investigate the frequency of apo B-100 mutations (codon 3500) C9774T (Arg 3500→Trp) and G9775A (Arg 3500 →Gln) in patients with atherosclerosis in comparison with healthy subjects. Methods: This cross-sectional study included 442 unrelated subjects living on the West coast of Turkey. Subgroups consisted of 165 patients with coronary artery disease, 163 patients with ischemic stroke, and 114 healthy control subjects. Results: We did not find any apo B-100 mutation both in the patient and control groups. Conclusion: As it is hypothesized that this mutation arose within the Central European region from a common ancestor approximately 7000 years ago and spread across Europe, our result of the absence of the R3500Q mutation in Turkish patients give an important information about the geographical distribution of the apo B-R3500Q, that the mutation has not reached to Anatolia.

Objective: Albuminuria is a predictor of cardiovascular morbidity and mortality in patients with diabetes (DM). In this study, we tested the hypothesis suggesting that the presence of albuminuria reflects impaired aortic elastic properties in type 2 DM.
Methods: Overall 140 patients with type 2 DM without obvious renal impairment (serum creatinine <1.5 mg/dl) were included in this cross-sectional study. Patients were divided into 3 groups based on amount of albuminuria: Group 1 - patients with no signs of albuminuria (16 men, 34 women, mean age 51±11 years); Group 2 - patients with microalbuminuria (15 men, 35 women, mean age 52±9 years); Group 3 - patients with macroalbuminuria (14 men, 26 women, mean age 56±8 years). Each patient underwent transthoracic two-dimensional and Doppler echocardiography with assessment of diastolic function, aortic strain and aortic root distensibility. Statistical analysis was performed using ANOVA analysis for comparison of variables between 3 groups. The relationship of albuminuria with clinical variables, parameters of left ventricular mass, diastolic function, aortic strain and distensibility was assessed using multivariate regression analysis.
Results: A significant stepwise decrease in the aortic strain and distensibility was seen across Group 1 to Group 3. Similar findings were noted in left ventricular diastolic functions with longer deceleration time (DT) and lower peak early to late transmitral filling velocity ratios (E/A) in groups with albuminuria. Aortic distensibility significantly correlated with DT (r=-0.35, p<0.001), isovolumic relaxation time (r=-0.31, p<0.005) and left ventricular mass/ height2.7 (r =-0.26, P<0.005). In multivariate analysis, the amount of albumin was significantly associated with aortic distensibility (standardized β coefficient -0.23, p<0.01) and DT (standardized β coefficient 0.26, p<0.005).
Conclusion: Our results suggest increased urinary albumin excretion is significantly correlated with impaired aortic elastic properties and left ventricular diastolic dysfunction in type 2 diabetes, which may contribute to the relation of albuminuria and increased rate of cardiovascular events among diabetics. (Anadolu Kardiyol Derg 2008; 8: 10-5)

Objective: In this study we aimed to determine the relation of presence and severity of coronary artery disease with microalbuminuria, fasting insulin levels and the classical risk factors in non-diabetic patients. Methods: We enrolled 100 non-diabetic patients that had an indication for coronary angiography. Group 1 consisted of 55 patients with coronary artery disease, and 45 patients without coronary artery disease were included in Group 2. The study was cross-sectional and case-controlled. In all patients 24-hour microalbuminuria, serum total, high density lipoprotein (HDL), low density lipoprotein (LDL) cholesterol and lipoprotein a, triglyceride, fasting blood sugar levels were obtained. Fasting insulin levels were determined and routine urinary tests were performed. Gensini scoring was done for determination of the severity of coronary artery disease. Statistical analysis was performed using unpaired t test, Mann-Whitney U test, Chi-square test, ROC analysis and multiple logistic regression analysis. Results: Microalbuminuria levels (p<0.001), fasting insulin levels (p<0.001), mean age (p=0.01), pulse pressure (p=0.014), LDL cholesterol levels (p=0.004), lipoprotein a levels (p<0.001) were significantly higher and HDL cholesterol levels were significantly lower (p=0.015) in Group 1 compared to the Group 2. Male gender was more frequent in Group 1 (p<0.001). With cut-off values defined by ROC analysis microalbuminuria (18 µgr/min, sensitivity: 91%, specificity: 45%, area under the curve: 0.790, 95% CI 2.43-15.96, p<0.001) increased probability of coronary artery disease by 6.2-fold and fasting insulin level higher than 10 µIU/ml by 11 folds at multivariate logistic regression analysis. When the cases were evaluated according to the Gensini scoring there was a significant association of coronary artery disease and microalbuminuria (r=0.52, p<0.001). Conclusion: We concluded that in non-diabetic cases microalbuminuria and increased fasting insulin levels were predictors of presence and the severity of coronary artery disease and can be suggested as risk factors.

Objective: The aim of the present study was to assess obesity as a risk of adverse outcomes following cardiac surgery. Methods: The data of 324 consecutive patients who underwent elective procedures requiring cardiopulmonary bypass in a single cardiac center in South-Western Anatolia were retrospectively analyzed. There were 250 males and 74 females. Median age was 58.8 years (range 17 to 90 years). A body mass index (BMI)≥30 kg/m2 was defined as obesity. Adverse outcomes analyzed included in-hospital mortality, chest tube drainage, reopening, inotropic support, arrhythmias, deep sternal wound infection, superficial surgical site infection and hospital stay duration. Multiple logistic regression analysis was performed to assess the relationship of obesity with clinical outcomes after cardiac surgery. Covariates considered in the logistic model included age, gender, pulmonary disease, cerebrovascular disease, smoking, hypertension, and diabetes. Results: Fourteen percent of patients (47/324) were obese and this ratio is quite smaller than reported for industrialized countries. The results of multiple regression analysis demonstrated that obesity was a risk factor only for superficial sternal or harvesting site infection (odds ratio - 4.5, 95% CI- 1.404-14.679, p=0.012). Conclusion: Obesity was associated with increased risk of superficial surgical wound infections following cardiac surgery. In comparison with industrialized countries, obesity may account for fewer adverse events in patients undergoing open-heart surgical procedures in South-Western Anatolia, a developing country sample.

Objective: The effects of body mass index (BMI) on ventricular repolarization in young men have not been studied in detail. The QT and JT intervals are measured to estimate the duration of the ventricular repolarization. As new repolarization parameters, the time intervals between the J point to the apex of the T wave (JTa), the apex and the end of T wave (TaTe) may be associated with arrhythmogenesis in clinical conditions. The aim of this study was to compare ventricular repolarization parameters in overweight and normal weight healthy young men. Methods: Thirty-six overweight men (BMI - 26.3±1.5 kg/m2, mean age - 20.6±1.5 years) and 149 men within normal limits (BMI - 21.9±1.5 kg/m2, mean age - 20.4±1.4 yrs) were included in this cross-sectional controlled study. The body mass index of 25 to 29.9 kg/m2 was defined as overweight and scores of 18.5 to 24.9 kg/m2 were accepted as normal. Ventricular repolarization parameters including QT, JT, JTa, TaTe, RR intervals duration and heart rate-corrected values of QT (QTc), JT (JTc), JTa (JTac), and TaTe (TaTec) intervals duration were obtained from lead V2 and considered to be representative of the ventricular repolarization process. Results: We found similar ventricular repolarization parameters (QT, JT, JTa, TaTe, RR, QTc, JTc, JTac, and TaTec) in overweight and normal groups. Uncorrected and corrected ventricular repolarization parameters were not correlated with BMI. Conclusion: Ventricular repolarization features in young men who are overweight in terms of BMI seem to show no significant difference when compared to normal weight men.

Objective: The aim of this case-controlled, cross-sectional study is to investigate the tendency towards arrhythmia using noninvasive arrhythmia markers (QT dispersion and heart rate variability) in children with Eisenmenger syndrome. Methods: We studied 23 patients, whose pulmonary-to-systemic resistance ratio was calculated to be greater than 0.75, and who were diagnosed as Eisenmenger syndrome between 1990 and 2001. Twenty healthy children were studied as the control group. Electrocardiographic recordings with calculation of QT dispersion, Holter monitoring, echocardiographic studies and heart rate variability (HRV) analysis were performed in both groups. Catheterization records were analyzed in all the patients. Results: QT and QTc dispersion were higher (p=0.007 and p=0.006, respectively) and PR interval was longer (p=0.009) in the patients with Eisenmenger syndrome, than those in the control group. In addition, low frequency component, high frequency component, very low frequency component, and total power, obtained from HRV analysis were significantly lower in the patients with Eisenmenger syndrome (p=0.001, p=0.006, p=0.009 and p=0.011, respectively). Evaluation of Holter recordings revealed pathologic findings in 21.7% of the patients with Eisenmenger syndrome. Pulmonary-to-systemic resistance ratio of the patients with pathologic Holter findings were higher than in the patients with normal Holter recordings (p=0.011). It was also shown that there was a positive correlation between OT dispersion and pulmonary-to-systemic resistance ratio (p=0.048, r=0.416) and between QT dispersion and PR interval (p=0.009, r=0.532) in the patients with Eisenmenger syndrome. Conclusion: Dispersion of repolarization, being associated with high pulmonary-to-systemic resistance ratio, is increased and autonomic modulation of heart rate is impaired in patients with Eisenmenger syndrome. These findings suggest that arrhythmia risk for patients with Eisenmenger syndrome is higher than in normal controls.

Objective: The Epiclose®-T, a novel closure device for arterial access sites, is designed as a double-balloon device that applies direct pressure on the arteriotomy site, allowing natural coagulation and leaving no artificial material behind. We assessed prospectively the initial safety and efficacy of the Epiclose®-T after diagnostic cardiac catheterization, and evaluated patient comfort. Methods: In our randomized, controlled, prospective study, the study group consisted of 32 patients (17 male, mean age 52.8±11.0 years) treated with Epiclose®-T device. The control group included 39 patients (20 male, mean age 55.5±11.0 years) treated with manual compression. Results: Hemostasis was achieved successfully in 90.6% of the study group. For the 30-day follow-up, there were no statistically significant differences between the groups in the rate of major and minor complications. No bleeding requiring transfusion was seen in both groups. However, the number of major complications, including large hematoma (0 vs. 1 patient-2.6%) and pseudoaneursym (0 vs. 1 patient-2.6%), occurred more often in the control group. The number of small hematomas was 3 (7.7%) in the compression group and 2 (6.9%) in the Epiclose®-T group. In the failure group (3 patients), body-mass-index was somewhat lower than that of the success group (median - 26 (25-33) kg/m2 vs. 27 (24-32) kg/m2, p=0.07). Most patients were satisfied by the Epiclose®-T closure device and grade it as excellent or good. Conclusion: Hemostasis can be easily and safely achieved by Epiclose®-T device with no significant minor and major complications with patients’ total satisfaction.

Objective: Psychological factors may influence the development and prognosis of coronary heart disease. The purpose of this study was to measure levels of depression, anxiety, and panic agoraphobia in patients who had been treated for acute coronary syndrome (ACS). We attempted to evaluate the relationship of the scores of depression, anxiety and panic agoraphobia, coronary risk factors, some clinical variables and coronary heart disease. Methods: We evaluated the levels of depression, anxiety, and panic agoraphobia of patients who had been treated for ACS, using the Hamilton depression (HAM-D), the Hamilton anxiety (HAM-A), and the Hamilton panic agoraphobia (HAM-PA) rating scales in 82 patients underwent treatment for acute coronary syndrome in this cross-sectional observational study. The relationship of these psychological variables with gender, presence of diabetes mellitus, hypercholesterolemia and coronary revascularization were assessed. Statistical analysis was performed using unpaired t test for independent samples and Chi-square test Results: The majority of the patients were male (54 males and 28 females); the mean age of the patients was 61.9 ± 12.1 years; 46% were admitted for unstable angina, 37.8% for acute myocardial infarction (MI) with ST elevation, and 16.7% with non–ST-elevation MI. Depressive symptoms (HAM-D score>8) were present in 87.8% of the patients. The HAM-D score was closely related to the HAM-A and the HAM-PA scores (p<0.001). The HAM-D, HAM-A, and HAM-PA scores were significantly higher in female patients (p<0.001). After controlling for sex, both the HAM-D score (21.05 ± 7.72 vs 15.10 ± 7.3; p=0.02) and the HAM-A score (19.17 ± 9.50 vs 12.96 ± 7.77; p=0.03) were significantly higher in diabetic patients. The mean HAM-D score was also significantly higher in patients with hypercholesterolemia (18.10 ± 8.23 vs 13.97 ± 6.38; p=0.02), as well as in those with a previous history of cerebrovascular disease (CVD) (23.20 ± 9.62 vs 15.89 ± 7.45; p=0.02). Patients who had undergone coronary artery bypass grafting (CABG) showed significantly lower HAM-D (12.5 ± 7.8 vs 16.6 ± 8.1; p=0.03) and HAM-A (9.6 ± 6.3 vs 15.6 ± 8.5; p=0.01) scores. Conclusion: Higher scores of depression, anxiety, and panic agoraphobia were particularly common findings in female patients and in those patients with diabetes mellitus, hypercholesterolemia, and CVD. Depression and anxiety disorder may be prevalent in patients who had been treated for ACS. We believe that patients should be carefully followed and treated for depression and anxiety disorder after ACS treatment to prevent adverse outcomes.

Cardiac rehabilitation is a multidisciplinary rehabilitation program established to assist individuals with heart disease in achieving optimal physical, psychological and social status within limits of their disease. It is useful to divide cardiac rehabilitation to four phases: inhospital care, the early postdischarge period, exercise training period and long-term follow up. Although cardiac rehabilitation has been recommended to all patients with stable heart disease, most of studies cover rehabilitation issues in coronary artery disease. It is also beneficial for patients with congestive heart failure, heart transplantation and heart valve surgery. This article discusses the topics on exercise programme in cardiac rehabilitation, the benefits of cardiac rehabilitation and the importance of cardiac rehabilitation in the setting of different cardiac diseases (congestive heart failure, heart transplantation, heart valve surgery and two important diseases that trigger coronary heart diseases; diabetes and hypertension).

An increasing number of patients are found to be unsuitable for revascularization by conventional approaches to the epicardial vessels. Transmyocardial laser revascularization (TMR) is a treatment choice for patients who have refractory angina pectoris when bypass surgery or percutaneous transluminal angioplasty is not indicated. Transmyocardial laser revascularization leads to significant improvements in angina. It also improves quality of life, reduces hospital readmission rates and may improve exercise tolerance. However, the technique does not effect survival, ejection fraction, cardiac events and myocardial perfusion with nuclear studies. Further results from ongoing trials are awaited with interest.