Objectives: We evaluated clinical practice in cardiovascular risk management and related patient compliance among Turkish hypertensive patients.
Study design: This noninterventional, observational study included 1023 patients (620 women, 403 men; mean age 58.4±10.6 years) with essential hypertension, from 50 centers across Turkey. Patients were evaluated at a cross-sectional phase and a follow-up phase of nine months. Data obtained at the cross-sectional phase included patient demographics, medical and past history, cardiovascular risk status, and current practice patterns regarding cardiovascular risk management.
Results: The mean duration of hypertension was 8.1±7.1 years. The mean body mass index was 30.3±5.2 kg/m2 and systolic and diastolic blood pressures (BP) were 147.8±22.4 and 88.9±12.5 mmHg, respectively. Ten-year coronary heart disease risk and risk level were significantly higher in males, and significantly increased in the presence of diabetes, metabolic syndrome, and renal disease and/or microalbuminuria (p<0.05). In past year history of cardiovascular risk management, 7.3% of the patients did not have BP measurements; no diet was recommended to 15.6%; 79.3% had high BP levels, and patient compliance with antihypertensive drug treatment and dietary recommendations were 87.7% and 62.5%, respectively. A similar profile was observed for dyslipidemia and diabetes mellitus. The physicians’ efforts to motivate the patients to quit smoking, to lose weight, and involve in physical exercise were far below satisfactory levels, and the patients’ compliance rates with these recommendations were even lower.
Conclusion: Our study demonstrates that hypertensive patients are not adequately evaluated for cardiovascular risk, which is significantly increased in the presence of various cardiovascular risk factors such as diabetes, metabolic syndrome, and renal disease.

Objectives: The impact of dialysis type on the biomarkers that reflect the severity of cardiovascular diseases is not clearly known. We aimed to investigate the effect of dialysis type on biomarkers of cardiovascular diseases in patients with end-stage renal disease (ESRD).
Study design: The study included 108 patients who had been on dialysis treatment (57 patients receiving hemodialysis, 51 patients receiving peritoneal dialysis) for ESRD for at least three months. Blood samples were collected just after the dialysis. Serum N-terminal prohormone of brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), cardiac troponin I (TnI), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and plasma fibrinogen levels were measured and compared between the two dialysis groups.
Results: The two dialysis groups were similar with respect to age and gender. The frequency of hypertension was significantly higher in patients receiving peritoneal dialysis. This group also had higher total cholesterol, HDL cholesterol, LDL cholesterol, and hemoglobin levels. Serum levels of NT-proBNP, hs-CRP, IL-6, and TNF-α, and plasma fibrinogen levels were similar in the two dialysis groups (p>0.05), but TnI was significantly higher in patients receiving peritoneal dialysis (p=0.04). Comparison of the patient subgroups based on the duration of dialysis (<12 months, 12-36 months, and >36 months) showed that longer dialysis duration was associated with significantly lower values of NT-proBNP, TNF-α, and hs-CRP (p<0.05).
Conclusion: The dialysis type does not affect serum NT-proBNP, hs-CRP, IL-6, TNF-α, and plasma fibrinogen levels, but TnI level is higher in patients treated with peritoneal dialysis.

Objectives: The underlying mechanism of slow coronary flow (SCF) has yet to be elucidated. Increased red cell distribution width (RDW) and uric acid level may be indicative of an underlying inflammatory state. We aimed to investigate RDW and serum uric acid levels in patients with normal coronary arteries and SCF without stenosis.
Study design: The study included 46 consecutive patients (25 males, 21 females; mean age 54±11 years) with angiographically normal coronary arteries but having SCF in all three coronary arteries. The control group consisted of 40 patients (18 males, 22 females; mean age 54±9 years) with angiographically normal coronary arteries without SCF. In both groups, RDW and serum uric acid levels were measured and compared.
Results: In the SCF group, TIMI frame counts measured in the left anterior descending coronary artery, left circumflex coronary artery, and right coronary artery were significantly higher compared to the control group (p<0.05). Patients with SCF exhibited significantly higher RDW (13.4±1.6% vs. 12.6±1.2%, p=0.01) and serum uric acid levels (5.3±1.6 mg/dl vs. 4.7±1.3 mg/dl, p=0.01) compared to controls. In logistic regression analysis, uric acid [Exp(B)=1.612, 95% CI 0.206-5.35, p=0.021] and RDW [Exp(B)=1.496, 95% CI 0.403-4.72, p=0.030] were found as independent predictors of SCF.
Conclusion: Our findings show that patients with SCF have significantly increased RDW and serum uric acid levels. This may help throw more light on the pathophysiological basis of SCF.

Objectives: ACC/AHA/ESC guidelines recommend sublingual nitroglycerin (SNG) in patients with stable angina pectoris and coronary artery disease (CAD). However, the shelf life of SNG following first use is six months for SNG tablets and two years for SNG sprays. We investigated the frequency of prescription of SNG tablets/sprays in patients having anginal symptoms and documented CAD and the awareness levels of patients about appropriate use of SNG.
Study design: Three hundred patients (201 men, 99 women; mean age 61.7±10.8 years) with documented CAD and angina were enrolled into this study. Angina pectoris was categorized according to the functional classification system of the Canadian Cardiovascular Society. Data on cardiovascular past histories, risk factors, medications, and the use of SNG were recorded.
Results: At least one risk factor was present in 96% of the patients. Only 46% of the patients had a prescription for SNG. Of those with a prescription of SNG tablet and spray, 91.8% and 84.4% did not know the shelf life of the product, respectively. Of those who were routinely carrying SNG, 35.6% had an expired product. Of those with a prescription of SNG, only 65.9% were informed by the physician on the proper use of SNG.
Conclusion: Our results show that, despite recommendations of the guidelines, SNG is not prescribed to a substantial percentage of patients with CAD and angina, a considerable fraction of patients carry an expired product, and that patients are not adequately informed by the physicians on the use of SNG. These problems will certainly affect the optimal medical management of CAD and its efficacy.

Objectives: Although intracardiac echocardiography (ICE) has long been used for various cardiologic interventions, its utilization has been quite limited in Turkey. We assessed our experience with the use of ICE during transcatheter closure of secundum atrial septal defects (ASD).
Study design: Fourteen patients (8 females, 6 males; mean age 34 years; range 15 to 62 years) underwent transcatheter device closure of ASD with ICE guidance. Before the procedure, 13 patients were examined by transesophageal echocardiography (TEE). Intracardiac echocardiography was used to evaluate the interatrial septum, defect size, the relationship of the septal occluder with neighboring structures before its release, and residual shunts after device release.
Results: Using short- and long-axis ICE images, the anteroposterior and superoinferior rims of the ASD, coronary sinus, and pulmonary vein openings were successfully visualized in all the patients. Defect diameters measured by ICE were closely correlated with those measured by TEE (97%) and balloon sizing (95%). The defects were closed successfully in 13 patients; the procedure was terminated in one patient due to the prolapse of both discs into the left atrium. There was no procedural complication. One patient experienced gastrointestinal hemorrhage that required blood transfusion two days after the procedure. No residual shunts were observed on follow-up transthoracic echocardiographic examinations one and six months after the procedure.
Conclusion: Having high image quality and color Doppler features, ICE is quite functional in determining defect size, position of the septal occluder and its relationship with neighboring structures; thus, it is a reliable alternative to TEE which is used routinely in transcatheter closure of ASDs.

Objectives: We evaluated left ventricular (LV) myocardial functions with strain (S) and strain rate (Sr) echocardiography and tissue Doppler imaging (TDI) before and after pericardiocentesis in patients with cardiac tamponade.
Study design: The study included 27 patients (19 men, 8 women; mean age 51.4±16.3 years) who underwent pericardiocentesis following clinical and echocardiographic diagnosis of cardiac tamponade. Besides echocardiographic parameters of LV functions, S/Sr parameters and TDI velocities were measured before and five days after pericardiocentesis, including peak systolic S, peak systolic Sr (Sr-s), peak early diastolic Sr (Sr-e), peak late diastolic Sr (Sr-a), peak lateral and septal mitral annular systolic (Sm), early diastolic (E’), and late diastolic (A’) velocities.
Results: Pericardiocentesis was successful in all the patients, resulting in significant patient comfort and symptomatic improvement. In segmental analysis, there were no significant differences in peak systolic S and Sr values obtained before and after pericardiocentesis (p>0.05), except for basal lateral segment S and apical anterior segment Sr-s values (p<0.05). After pericardiocentesis, Sr-e and Sr-a values measured in all the walls and segments, and TDI-derived lateral and septal mitral E’ and A’ velocities showed significant decreases (p<0.05). All these changes demonstrated by S and Sr echocardiography corresponded well to those obtained by TDI.
Conclusion: We concluded that S and Sr echocardiography was not superior to TDI in the assessment of LV functions in patients with cardiac tamponade.

Brucella infection may cause vascular complications such as deep venous thromboembolism. This is the first report on an entrapped thrombus in a patent foramen ovale (PFO) in a patient with Brucella infection. A 43-year-old woman was admitted with complaints of fever, dyspnea, malaise, myalgia, and pretibial edema. Clinical and laboratory findings were consistent with brucellosis. Transthoracic echocardiography demonstrated a mobile, hyperechoic worm-like thrombus entrapped in a PFO. Right ventricular enlargement and elevated systolic pulmonary artery pressure (77 mmHg) showed acute pulmonary embolism. Multidetector computed tomography revealed a huge thrombus, 11.7 cm in length, in the bifurcation of the main pulmonary artery. Considering the huge size of the right heart thrombus and hemodynamically significant acute pulmonary embolism, open heart surgery was performed, during which an 11-cm thrombus was found extending from the right atrium across the PFO into the left atrium. The interatrial septum was excised en bloc together with the thrombotic mass and the PFO was closed. Pulmonary thromboendarterectomy was also performed. After surgery, systolic pulmonary artery pressure decreased to 38 mmHg and the patient was discharged without complications.

Postmyocardial infarction ventricular septal defect (VSD) carries a high mortality and, even after successful surgery, residual defect is common. A 75-year-old woman was admitted with the diagnosis of hyperacute anterior myocardial infarction. Primary percutaneous intervention was performed by stenting of a totally obstructed segment in the proximal left anterior descending artery. The patient’s condition deteriorated on the second postprocedural day with a 3/6 pansystolic murmur at the mesocardium. Echocardiography revealed an apical anteroseptal VSD and moderate pulmonary hypertension. She underwent surgical VSD closure with a Gore-Tex patch and coronary artery bypass grafting to the left anterior descending and circumflex arteries. The patient’s condition continued to be unstable due to septicemia and hemodynamically significant residual VSD. After medical management of septicemia, the residual defect was successfully closed using a 10-mm Cardio-O-Fix septal occluder under fluoroscopic and transesophageal echocardiographic guidance. The clinical condition of the patient was then stabilized and there was no significant residual shunt on echocardiography on the third postprocedural day.

Chylothorax and chylous ascites are very rare clinical entities generally caused by obstruction and disruption of the thoracic duct. A 60-year-old man presented with exertional dyspnea, fatigue, and chest discomfort of 18-month history. Physical examination revealed S4, bilateral pretibial edema, and moderate amount of ascites. Computed tomography and X-ray of the thorax showed left-sided pleural effusion. Abdominal imaging showed normal liver and spleen structure with intraperitoneal effusion and periportal edema. Thoracentesis and paracentesis yielded a milky, lipemic fluid of exudative nature. Biochemical analysis of the fluids showed a high triglyceride content and elevated lymphocyte count, typical of chylous fluid. All laboratory analyses for possible etiologies including neoplasms, tuberculosis, and cirrhosis were negative. Positron-emission tomography did not show any pathological uptake. Transthoracic echocardiographic examination showed bilateral atrial enlargement, left ventricular hypertrophy, anteroseptal hypokinesia and akinesia, and moderate mitral and tricuspid regurgitation, with an ejection fraction of 25%. Coronary arteries were normal on angiography. The patient was diagnosed with severe congestive heart failure accompanied by chylothorax and chylous ascites. Despite appropriate treatment, there was little change in congestion and no change in symptoms. He died during ultrafiltration therapy due to hemodynamic collapse and asystole.

Crossed pulmonary arteries are an uncommon anomaly in which the left pulmonary artery originates superiorly and to the right of the right pulmonary artery, and the two pulmonary arteries cross each other. This anomaly may accompany other cardiac anomalies. We encountered this anomaly during echocardiographic examination of a 21-month-old boy. He had mesocardia, tetralogy of Fallot, right aortic arch, and malposition of the branch pulmonary arteries. Cardiac angiography confirmed intracardiac anomalies and showed the ostium of the left pulmonary artery lying superiorly and to the right of the right pulmonary artery and their crisscross.

Persistent left superior vena cava (LSVC) with absent right superior vena cava (RSVC) is a very rare congenital anomaly. Its isolated existence is even rarer. Persistent LSVC is usually asymptomatic and discovered incidentally. We present persistent LSVC with absent RSVC in two asymptomatic patients, namely, a 52-year-old woman and 65-year-old man. The diagnosis was confirmed by cardiac computed tomography in both cases.

Intravascular ultrasound (IVUS) is widely used to assess the severity of coronary artery lesions. Fracture of the IVUS catheter in the coronary artery is very rare and embolization of a fractured segment into other organs has not been reported. A 41-year-old male patient underwent IVUS imaging for further assessment of a lesion detected angiographically in the left main coronary artery. During the procedure, the distal tip of the IVUS catheter fractured in the left main coronary artery. Percutaneous retrieval of the broken fragment was attempted using a coronary snare, but the fragment freed from the snare and embolized into the right renal artery. After placement of a right coronary guide wire catheter in the right renal artery, the fractured tip was captured with a coronary snare and was successfully retrieved.

The prevalence of carotid artery diseases increases with age and exposure to cardiovascular risk factors. Significant carotid artery stenosis is closely associated with the development of stroke and cerebrovascular events. Doppler ultrasound imaging is a noninvasive and useful modality for the examination of carotid and vertebral arteries. However, proper investigation of the carotid artery system requires sufficient technical knowledge and experience. This review gives information about the techniques of appropriate examination of the carotid artery system.