Akut miyokard infarktüsü (AMÝ) geçiren hastalarýn, ilk dakikalarý ile ilk saatlerinde elektrokardiyografilerinde görülen ST segment yüksekliði genellikle 24-48 saat içinde izoelektrik hatta dönerken T dalgasý negatifleþmektedir. Bazý hastalarda ise bu deðiþim görülmemekte, ST segment yüksekliði ve T dalga pozitifliði 72 saatten fazla devam etmektedir. AMÝ'nden sonra kollateral akým varlýðýný inceleyen çalýþmalarda, erken dönemde kollateral akým geliþiminin bazý hastalarda yeterli, bazý hastalarda ise yetersiz oluþtuðu bildirilmiþtir. Kollateral akýmýn ST segment ve T dalga deðiþimi ile iliþkisini araþtýrmak amacýyla 1995-1997 yýllarý arasýnda AMÝ tanýsýyla koroner bakým ünitesine yatýrýlarak tedavi edilen ve koroner anjiyografileri yapýlarak infarktüsten sorumlu arteri (ÝSA) tam týkalý olan 22 hasta incelendi. ST Segment yüksekliði ve T dalga pozitifliði 72 saatten daha fazla devam eden 10 hasta (Grup A) ile ST segment yüksekliði 72 saatten önce izoelektrik hatta dönerek T dalgasý negatifleþen 12 hasta (Grup B) yaþ, cins, koroner arter hastalýðý için risk faktörleri, Killip sýnýflamasýna göre kalp yetersizliði geliþme sýklýðý, preinfarktüs anjina, ventriküler taþikardi-fibrilasyon oluþumu, maksimum ve toplam ST segment yüksekliði, maksimum ve toplam resiprokal deðiþiklikler, QRS skoru, anjiyografide Rentrop sýnýflamasýna göre kollateral akým dereceleri birbirleri ile karþýlaþtýrýldý. Ýki grup arasýnda yaþ, cins, risk faktörleri, preinfarktüs anjina, maksimum ve toplam resiprokal deðiþiklik açýsýndan anlamlý fark yoktu. Toplam ST segment yüksekliði ve maksimum ST segment yüksekliði Grup A'daki hastalarda anlamlý olarak daha fazla idi (sýrasýyla p<0.01, p<0.01). QRS skoru, kalp yetersizliði, düþük ejeksiyon fraksiyonu ve duvar hareket kusuru skoru Grup A'da anlamlý olarak artmýþ bulundu (sýrasýyla p<0.05, p<0.05, p<0.01, p<0.05). Rentrop 3 kollateral akým, Grup A'da hiç yok iken Grup B'deki tüm hastalarda mevcuttu. Sonuç olarak, ST segment yüksekliði ve T dalga pozitifliði 72 saatten daha fazla devam eden hastalarda, kollateral akýmýn yetersiz olduðu hemodinamik bozulmanýn kolaylaþtýðý kanýsýna varýldý.

Following acute myocardial infaretion (AMI), some patients retain ST segment elevation and upright T waves, a pattern usually seen within minutes to hours of AMI, even, after 72 hours. It often identifies a transmural AMI which results from a persistent total obstruction of the infarct-related coronary artery and inadequate collateral flow. Twenty-two patients were studied to te st the hypothesis that absence of adequate callateral flow was responsible for pe rsistent ST elevation and that adequate collateral flow was associated with the more typical resolution of ST elevation. The study group consisted of 22 patients with AMI admitted to the coronary care u nit between 1995 and 1997 in whom a totally obstructed infarct-related artery by coronary angiography were observed. Group A consisted of 10 patients with an ECG demonstrating ST-segment elevation and upright T waves C.72 hours after AMI. Group B consisted of 12 patients with an ECG demansýrating resolution of STsegment elevation accompanied by inversion of T waves within 72 hours of the AMI. There were no significant differences between the two groups regarding age, sex, risk factors, preinfarction angina, maximum and total reciprocal changes. Total ST segment elevation, maximum ST segment elevation were higher in group A vs group B (p

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Bu çalýþmada egzersiz stres testi (EST) sýrasýnda prekordiyal derivasyonlarda (V1-6) ortaya çýkan T-dalga deðiþikliklerinin koroner arter hastalýðýný (KAH) belirlemedeki yeri araþtýrýldý. Bu amaçla, çalýþmaya toplam 163 hasta alýndý. Hastalarýn tümüne öncelikle EST uygulundý ve egzersiz öncesi dinlenim, zirve egzersizden hemen sonraki ve test sonrasý geç dönemdeki prekordiyal (V1-6) T-dalga yükseklikleri kaydedildi. Daha sonra hastalarýn tümüne koroner anjiyografi uygulandý ve 55 hastada normal koroner arterler (Grup-1), 73 hastada tek damar hastalýðý (Grup-2) ve 35 hastada çok damar hastalýðý (Grup-3) saptandý. EST'de kalp hýzý artýþý sonucu ortaya çýkan V1-6 prekordiyal T-dalga deðiþiklikleri incelendiðinde, koroner arterleri normal olanlarda (Grup-1) V3-6, KAH olanlarda (Grup 2 ve 3) V2-6 derivasyonlarýnda anlamlý T-dalgasý artýþý saptandý. "Cut-off" deðeri 3 mm olarak seçilip 3 mm ve üzerindeki T-dalgasý artýþlarý KAH lehinde deðerlendirildiðinde, KAH'ný saptamada en yüksek duyarlýlýk ve özgüllüðün tüm prekordiyal derivasyonlar içerisinde V2 derivasyonunda olduðu saptandý (sýrasýyla % 21 ve % 87). 3 mm ve üzerindeki T-dalga artýþýnýn tüm hastalar içinde en fazla oranda ciddi proksimal sol ön inen arter "LAD" darlýðý olan hastalarda ortaya çýktýðý (13/33, % 39) ve bu kriterin tek baþýna ele alýndýðý durumlarda, sadece özgüllük deðerinde hafif artýþ olduðu gözlenmiþtir (% 78'den % 87'ye, p>0.05). T-dalga artýþ kriteri ve ST çökme kriteri ayrý ayrý ele alýndýðýndan, duyarlýlýkta anlamlý artýþýn sadece tek damar grubunda olduðu (% 56'dan % 71'e p<0.002), tanýsal doðruluk deðerinde ise tüm hastalarda ve tek damar grubunda hafif bir artýþ olduðu saptanmýþtýr (tüm hastalarda %70'den % 74'e, tek damar grubunda % 66'dan %70'e p>0.05). Her iki kriterin ayný anda birlikte ele alýndýðý durumda ise genel duyarlýlýðýn %10'a düþmesine karþýn, özgüllüðün %78'den %96'ya çýktýðý gözlenmiþtir (p<0.005). Sonuç olarak, egzersiz ile V2 derivasyonunda ortaya çýkan 3 mm ve üzerindeki T-dalga artýþýnýn tüm hastalar içerisinde özellikle ciddi LAD darlýklarýnda belirgin olan ve ST çökmesinin yanýnda ele alýndýðýnda özellikle tek damar hastalýðýnýn tanýsal duyarlýlýðýnýn arttýrýlmasýnda, ST kriteri ile birlikte ayný anda ele alýndýðý zaman ise EST'deki yalancý pozitif sonuçlarýn azaltýlmasýnda yararlý bir kriter olabileceði düþünülmüþtür.

The usefulness of T -wave changes observed in precordial derivations (Vý.6) during exercise stress testing (EST), in detecting coronary artery disease (CAD) was evaluated in this study. For this purpose, 163 patients w ere enrolled. Precordial T -wave amplitudes were recorded before exercise, immediately after peak exercise and at Iate recovery period. Coronary angiographic exaýnination was performed later on. Normal coronary arteries in 55 patients (Group-1) , single-vessel disease in 73 patients (Group-2) and ýnulti-vesse l d isease in 35 patients (Group-3) were found. In evaluation of precordial T-wave amplitudes at base and in maximal heart rate during EST, significant T-wave amplitude increase was found in leads V3.6 in patients with normal coronary arteries (Group- i ), and in Ieads Vý.6 in patients with CAD (group 2-3). In all precordial leads. Vý had the highest sensitivity and specificity (21% and 87%, respectively) in detecting coronary artery disease when 3 ýnýn or more increase in T-wave amplitude was accepted as a positive c riterion for CAD (cut-off value=3). An increase of C.3 mm in T-wave aýnplitude was observed ýno stly in proximal LAD disease among all patients (13/33, 39%) and when only T -wave criterion was evaluated, overall specificity was increased slightly (from 78% to 87%, p>0.05). When T-wave aýnplitude increase and ST segment depression were evaluated individually, significant increase in sensitivity was detected only in the single-vessel group (from 56% to 7 1%, p<0.002) and a slight increase in diagnostic accuracy was observed in all patients and in single-vessel disease (from 70% to 74% and from 66% to 70%, respectively, p>0.05). Combining these two criteria, the overall sensitivity decreased to ýo%, however specificity increased from 78% to 96% (p<0.005). In conclusion, an increase of 3 mm or more in Twave amplitude in lead Yý during EST is evident especially in severe proximal LAD stenosis among all patients, and evaluation of this criterion on ST segment depression individually, may be useful especially in increasing sensitivity in one-vessel disease, combining these criteria with ST segment depression may be useful in diminishing falsepositive results in EST.

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Çalýþmamýzda; kardiyolojik sendrom X'li hastalarda nisoldipin ve ramiprilin anti-iskemik ve anti-anginal etkisini araþtýrdýk. Kardiyolojik sendrom X tanýsý (stabil angina pektoris, pozitif efor testi, negatif ergonovin testi ve normal koroner anjiyografi) konulan 18 hastaya (7 erkek, 11 kadýn; yaþ ortalamasý 46±10 yýl) iki haftalýk ilaçsýz dönem sonunda 2x5mg/gün nisoldipin 4 hafta süre ile verildi. Ayný hastalara 2 haftalýk ikinci ilaçsýz dönem sonunda 1x2.5 mg ramipril 4 hafta süre ile verildi. Her dönemin sonunda modifiye Bruce protokolü ile treadmill egzersiz testi uygulandý. Nisoldipin ve ramipril tedavisi sonunda angina pektoris oluþma süresi (p=0.006, p=0.02), total egzersiz süresi (p=0.0008, p=0.02) ve ortalama metabolik eþitlik (p=0.0016, p=0.01) arttý. Egzersizde 1mm ST segment çökmesi oluþma süresi (p=0.002) nisoldipin tedavisi sonunda uzadý. ST segment çökmesinin normale dönme süresi (p=0.016, p=0.012), haftalýk angina pektoris sayýsý (p=0.00, p=0.028) ve dilaltý nitrit tüketim sayýsý (p=0.00, p=0.012) nisoldipin ve ramipril tedavisi sonunda azaldý. Sonuç olarak; 10mg/gün nisoldipin ile 2.5 mg/gün ramiprilin kardiyolojik sendrom X'li hastalarda olumlu anti-iskemik ve anti-anginal etkiye sahip olduðunu saptadýk.

We investigated anti-ischaemic and anti-anginal effects of nisoldipine and ramipril in patients with the cardiological syndrome X. After a two-week wash-out period, 1 8 patients (7 men, 1 ý women; m ean age: 46± ý O years) w ith cardiological syndrome X (stable angina pectoris, positive exercise test, negative ergonovine test, and normal coronary angiography) were given nisoldipine 5 mg twice daily for four weeks. And after a second twoweek wash-out period, the same patients were given ramipril 2.5 mg daily for four weeks. Treadýnili exercise test with modified Bruce protocol was performed at the en d of each period. The time until anginal attack occurred (p=0.006 vs p=0.02), total exercise time (p=0.0008 vs p=0.02), and mean metabolic equivalent (p=O.OOý6 vs p=O.O 1) were increased significantly after nisoldipine and ramipril therapy periods. The time until ST segment depression by Imm occurred (p=0.002) was increased significantly after nisoldipine therapy. The time until ST segment de press i on recovery (p=O.O 16 vs p=O.O 1 2), the weekly number of angina pectoris (p=O.OO vs p=0.028), and the weekly number of sublingual nitroglycerin consumption (p=O.OO vs p=0.012) were decreased significantly after nisoldipine and ramipril therapy periods. We conclude that ýo mg/daily nisoldipine or 2.5 mg/daily has anti-ischaemic and anti-anginal effects in patients with cardiological syndrome X.

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Periferik arter hastalýðý saptanan kiþilerde koroner arter hastalýðý ve hipertansiyon gibi ek kardiyak hastalýklara sýklýkla rastlanmaktadýr. Özellikle koroner aterosklerozun varlýðý hastalarýn prognozunu etkileyen baþlýca faktördür. Çalýþmamýzýn amacý herhangi bir kardiyak semptom tanýmlamayan periferik arter hastalarýnda kalp kökenli ölüm ile ekokardiyografi bulgularý ve QT-D arasýndaki iliþkiyi incelemektir. Bu amaçla periferik arteriyopati nedeni ile periferik arter cerrahisi tedavisine karar verilen 35 hasta (yaþ ortalamasý 61±7, 32 erkek, 3 kadýn) ve benzer yaþ grubundaki 72 kontrol vakasý (yaþ ortalamasý 61±1, 54 erkek, 18 kadýn) çalýþma grubuna alýndý. Tüm olgularýn anamnez, fizik muayene ve laboratuar tetkikleri ile risk faktörleri deðerlendirildi. Ekokardiyografik incelemeleri yapýlarak 12 derivasyonlu elektrokardiyografileri çekildi ve QT, QTc ve QT dispersiyonu süreleri ölçüldü. Çalýþma grubu iki yýllýk dönem içerisinde izlenerek kalp kökenli ölüm oraný belirlendi. Hasta grubunun %37'sinde (13 hasta) ekokardiyografi bulgularý normal iken, %63'ünde sol ventrikül hipertrofisi ve sol ventrikül duvar kalýnlýklarýndaki artmaya eþlik eden ya da izole sol ventrikül dilatasyonu saptandý. Kontrol grubunun ise 2 kiþi dýþýnda (%3) ekokardiyografik bulgularý normaldi. QT, QTc süresi QT dispersiyonu hasta grubunda kontrol grubuna göre anlamlý olarak yüksek bulundu. QT dispersiyonu 50 ms (kontrol grubu ortalamasý + 2 SD) üzerinde saptanan kiþi sayýsý hasta grubunda 18, kontrol grubunda ise bir idi. Ýki yýllýk dönemde hasta grubunda 7 kiþi ölürken kontrol grubunda ölüm görülmedi. Hasta grubunda 50 ms üzerindeki QT dispersiyonunun kalp kökenli ölümü belirlemede duyarlýlýðý %86, özgüllüðü %57, pozitif prediktivitesi %33, negatif prediktivitesi ise %94 olarak bulundu. Ölen 7 kiþinin 5'inde sol ventrikülde dilatasyon ve 50 ms'den uzun QT-D mevcudiyeti saptandý. Sonuç olarak kalp hastalýðý yönünden asemptomatik periferik arter hastalarýnda kalp nedenli ölüm riskini belirlemede ekokardiyografi bulgularýnýn ve QT-D'nin oldukça yararlý yöntemler olduðuna karar verildi.

In patients with peripheral artery disease, additional cardiac diseases such as coronary artery disease and hypertension are frequent findings. The existence of coronary atherosclerosis is the Icading factor predicting prognosis. The aim of study was to investigate cardiac death in paticnts with peripheral artery disease without cardiac symptoms and its relation with QT dispersion. The study group consisted of 35 patients (aged 61 ±7 years, 32 males, 3 females) who underwent surgical treatmont because of peripheral arteriopathy and 72 age-matched controls (aged 61±1 years, 54 males, ý8 females). In all subjects, risk factors wcre evaluated with physical examination and laboratory findings. Echocardiographic and 12- lead electrocardiographic examinations were made and QTc interval and QT dispersion were calculated. The study group was followed for two years and cardiac deaths were recorded. Echocardiographic findings were normal in 13 patients (37%), left ventricular hypertrophy and left ventricular dilatation (isolated or accompanying an increase in left ventricular wall thickness) were detected in the remaining patients (63% ). In the control group, echocardiographic findings were normal except in 2 subjects (%3). QT, QTc interval and QT dispersion were significantly prolonged in the patients group compared with the controls. Subjects with a QT dispersion longer than 50 ms (mean of the control ± 2 SD) were 18 cases in the patients group and one in the control group. During the follow-up period, patients died due to cardiac events in the patients group, whereas nobody in the control group. In patients with peripheral artery disease, a QT dispersion of 50 ms had 86% sensitivity, 57% specificity, 33% positive predictivity and 94% negative predictivity in predicting cardiac death. In 5 of the 7 patients who died during the study period, left ventricular dilatation and a QT dispersion langer than 50 ms had been detected. It is concluded that in patients with peripheral artery disease who are asymptomatic for cardiac diseases, echocardiographic findings and QT dispersion are useful methods to predict the risk of cardiac death.

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Atriyoventriküler nodal reentrant takikardi (AVNRT), atriyoventriküler (AV) iletimde ikili yol fizyolojisi bulunanlarda ortaya çýkmaktadýr. Ancak ikili AV iletim fizyolojisi (ÝAVÝF) hastalarýn önemli bir kýsmýnda gösterilememektedir. AVNRT'li hastalarda hýzlý atriyal uyarý ("pacing") sýrasýnda, 1:1 AV iletimin saðlanabildiði maksimum hýzlarda, PR intervalinin sýklýkla atriyal uyarý siklus uzunluðunu geçtiði gösterilmiþtir. PR>RR olarak tanýmlanan bu bulgunun antegrad yavaþ yol iletiminin bir göstergesi olduðu ve ÝAVÝF gösterilemeyen AVNRT'li hastalarda yavaþ yol ablasyonunun baþarýsýný deðerlendirmede yararlý olabileceði öne sürülmüþtür. Biz de bu prospektif çalýþmada hýzlý atriyal uyarý sýrasýnda elde edilen PR>RR bulgusunun yavaþ yol iletiminin ve AVNRT'nin bir göstergesi olarak tanýsal deðerini araþtýrdýk. Hýzlý atriyal uyarý sýrasýnda 1:1 AV iletimin saðlanabildiði maksimum hýzlarda iki grup hastada PR ve RR intervalleri ölçüldü. Grup 1: AVNRT'si olan hastalar (n=20), grup 2: Kontrol grubu (n=21). Grup 1 hastalarýnýn hepsine radyofrekans kateter ablasyon yöntemi ile yavaþ yol ablasyonu yapýldý. Ablasyon iþleminden sonra grup 1 hastalarýnda çalýþma protokolü tekrarlandý. Grup 1'deki 20 hastanýn 10'unda (%50) ve grup 2'deki 21 hastanýn 2'sinde (%.95, p=0.006) PR>RR bulgusu saptandý. Grup 1 hastalarýnýn tümünde yavaþ yol ablasyonu sonrasýnda PR>RR bulgusu ortadan kalktý. PR>RR bulgusunun AVNRT için sensitivitesi %50, spesifitesi %90, negatif prediktif deðeri %66, pozitif prediktif deðeri %84 olarak bulundu. Sonuç olarak PR>RR bulgusunun AVNRT için sensitivitesinin düþük olmasýna raðmen, spesifitesinin ve pozitif prediktif deðerinin yüksek olmasý nedeniyle takikardi indüklenmesinde güçlükle karþýlaþýlan ve ÝAVÝF gösterilemeyen olgularda yavaþ yol ablasyonunun baþarýsýný deðerlendirmede yardýmcý bir kriter olarak kullanýlabileceði izlenimi doðmuþtur.

Atrioventricular nodal reentrant tachycardia (A VNRT) occurs ýn patients with dua! atrioventricular (AV) nodal physiology. However, dua! AV nodal physiology cannot be demonstrated in a signifýcant proportion of patients w ith A VNRT. During rapid atrial pacing at the maximum rate with consistený 1:1 AV conduction, PR interval often exeecds the pacing cycle Jength in patients with A VNRT. This finding, deseribed as PR>RR, was proposed to be consistent with antegrade slow pathway conduction and useful method for evaluating the success of slow pathway ablation in patients with A VNRT and without demosýrable dua! AV nodal physiology. The purpose of this prospective study was to determine the diagnostic value of the PR>RR find ing as an indicator of antegrade slow pathway conduction and A VNRT. The PR and RR intervals were measured during rapid atrial pacing at the maximum rate with consistent 1:1 AV conduction in 2 groups of patients. Group 1: patients w ith A VNRT (n=20) and Group 2: control subjects (n=2 1 ). Radiofrequency catheter ablation of the slow pathway was performed in all Group 1 patients. After slow pathway ablation, the study protocol was repeated in Group 1 patients. PR>RR finding was present in ýo of 20 Group 1 patients (50%) and 2 of 2ý Group 2 patients (9.5%, p=0.006). After slow pathway ablation, PR>RR finding was no longer preseni in any Group ý patients. The finding of PR>RR had a sensitiviýiy of 50 % for A VNRT, a specificity of 90%, a negative predictive value of 66% and a positive predictive value of 84%. In conclusion, although the sensiýivity of PR>RR finding for AVNRT is low, because of its high specificity and positive predictive value, this finding may be usefuý for evaluating the success of slow pathway ablation in patients with A VNRT in whom tachycardia inducýion is not reproducibe and dua! AV nodal physiology cannot be demonstrated.

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Insülin rezistansý koroner arter hastalýðý için risk faktörleri olan hiperinsülinemi, glukoz intoleransý, obezite ve dislipidemi gibi metabolik bozukluklarýn patogenezinde önemli rol oynar. Birçok çalýþmada insülin rezistansý ile koroner arter hastalýðý arasýnda baðýmsýz bir iliþki gösterilerek, insülin rezistansýnýn koroner arter hastalýðý için bir risk faktörü olduðu öne sürülmüþtür. Bu çalýþmada koroner anjiyografi ile koroner arter hastalýðý saptanan 35 yaþýndan küçük tümü erkek 16 hasta (Grup 1) ve 16 saðlýklý bireyde (Grup 2) hiperinsülinemik öglisemik glukoz klemp tekniði ile insülin rezistansý araþtýrýldý. Hasta grubunda M deðeri ortalama 4.37 ± 1.1 mg/kg/dk bulunurken, kontrol grubunda ise 7.9±1.1 mg/kg/dk olarak bulundu. (p<0.001). Grup 1'deki 16 hastanýn 7'sinde insülin rezistansý saptanýrken Grup 2'de hiçbir hastada insülin rezistansý saptanmadý. (p<0.05). Hastalarýn trigliserid, total ve LDL kolesterol, insülin ve C peptid düzeyleri de kontrol grubuna göre anlamlý derecede yüksekti (p<0.05). Çalýþmamýz diðer çalýþmalardan farklý olarak ilk defa "koroner arter hastalýðý tanýsý konan genç yaþ olgularda" insülin rezistansýnýn gösterilmesi açýsýndan önemlidir. Sonuç olarak prematüre koroner arter hastalýðýnda insülin rezistansý önemli bir risk faktörüdür.

Insulin resistance has an important role in the pathogenesis of metabolic disorders such as hyperinsulinemia, glucose intolcrance, obcsity, and dyslipidemia, all established risk factors for coronary artery disease (CAD). In a number of prospective studies, an independent relationship was noted between CAD and hyperinsulinemia and insulin resistance; and has been suggcsted that insulin resistance isa risk factor for CAD. In this study, insulin res istance was studied by the hyperinsulinemic euglysemic glucose c lamp technique in ý6 male patients w ith CAD (Group ý), diagnosed all by coronary angiography and in 16 male healthy controls (Group 2), younger than 35 years. In our study, "M" value was found as a 4.37± 1.1 mg/kg/min in Group 1, and 7 .9± 1.1 mg/kg/min in Group 2. Insulin resistance was found in 7 of 16 in Group 1. w hile Group 2 no insulin resistance w as found, (p<0.05). In the patient group triglyceride, total and LDLcholesterol, insulin and C-peptide levels were statistically higher than controls (p<0.05). W e found that young patients with newly diagnosed CAD, did show insulin resistance, in variance from other studies. As a result, insulin resistance is an important risk factor in premature CAD.

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Kronik Konjestif Kalp yetersizliðinin tedavisinde sýklýkla kullanýlan anjiyotensin dönüþtürücü enzim (ADE) inhibitörleri, akut kardiyojenik pulmoner ödem tedavisinde de kullanýlabilirler. Çünkü bu epizodlar sýrasýnda ortaya çýkan önyük ve ardyük yükselmesini önleyebilecekleri gibi, yine bu epizodlar sýrasýnda oluþan yüksek renin düzeylerini de azaltarak etkili olabilirler. Bu konuda yapýlan çalýþmalar sýnýrlý sayýdadýr. Bu çalýþmanýn amacý, akut kardiyojenik pulmoner ödem tablosundaki olgularda intravenöz enalaprilatýn etkinliðini ve güvenilirliðini göstermektedir. Çalýþma akut kardiyojenik pulmoner ödem tanýsý konulan 12 olgu (7 erkek, 5 kadýn; ortalama yaþ 57.2±7.4) üzerinde yapýlmýþtýr. Tedavi öncesi düþük olan kalp debisi, kalp indeksi ve atým hacmi tedavi sonrasý yükselirken (p<0.01-0.001); tedavi öncesi yüksek olan sistemik vasküler direnç, pulmoner vasküler direnç, pulmoner ve sistemik arter basýncý düþtü, kalp hýzý ve solunum sayýsý azaldý (p<0.01-0.0001). Çalýþmaya alýnan olgularýn tamamýnda klinik ve hemodinamik iyileþmeler saðlandý; hiç bir hastada önemli bir yan etki gözlenmedi. Sonuç olarak bu çalýþma, intravenöz enalaprilatýn akut kardiyojenik pulmoner ödem tedavisinde etkili ve güvenilir bir seçenek olduðunu düþündürmektedir.

Angiotensin-converting enzyme (ACE) inhibitors which have been used for the treatment of chronic congestive heart failure, can also be used for the treatment of acute cardiogenic pulmonary edema. In this condition, patients are hemodynamically unstable and have high renin levels. The studies in this area are limited. The purpose of this study was to evaluate the efficacy and safety of intravenous enalaprilat in patients with acute cardiogenic pulmonary edema. The study was performed in 12 patients (7 men, 5 women; mean age 57.2±7.4 years) with acute cardiogenic pulmonary edema due to dilated cardiomyopathy, coronary artery disease, hypertensive heart disease or coronary and/or hypertensive heart disease. Hemodynamic and elinical parameters were measured and evaluated before and 1 O minutes after infusion of enalaprilat. Enalaprilat increased cardiac output, cardiac index and stroke volume (p

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Týp alanýnda Türkiye'den kaynaklanan uluslararasý yayýnlarýn gidiþini deðerlendirmek amaciyle, Science Citation Index'in taradýðý dergilerdeki Türkiye adresli tüm yayýnlar gözden geçirildi. 1997 yýlýný kapsayan SCI CD-ROM'larýnda bulunan ve hekimliði ilgilendiren tüm kaynaklar ayýklandý. Ortak yayýnlar için bir kredi sistemi uygulandý. Anýlan yýlda sýrasiyle 1643 toplam yayýn ile 1012 tam metinli makale mevcuttu. Bu artýþ bir önceki yýla göre %20-25 gibi çok hýzlý olup 1988'den beri gözlenen aþamanýn sürdüðünü göstermektedir. Týp yayýnlarýnda dünyadaki payýmýz binde 5'e ulaþmýþtýr. Yayýnda artýþýn editöre mektupta deðil de, özellikle makale, editoryal, derleme türlerinde belirgin olmasý, geliþmenin saðlýklý olduðunu düþündürmekteydi. Üstelik temel bilimlerde daha göze çarptý. Üniversite-dýþý kuruluþlar ile bazý nisbeten yeni fakülteler yayýn artýþýnda aslan payýný aldýlar. Ege Týp Fakültesi 4'üncü sýraya yerleþti. Kardiyovasküler týp alanýnda da 1997'de toplam 52 makale yayýna girmiþ ve dünyadaki payýmýz binde 4'ü geçmiþtir.

A search was made of medical publications arising from institutions in Turkey appearing in medical periodicals covered by the Science Citation Index and comprised in the ISf CD-ROM 1997 Annual. This revealed a total of 1640 medical items making up almost half of all scientific publications originating from Turkey. When adjusted for publications jointly materialized with foreign medical centers and with nonmedical Turkish faculties (which constituted roughly 8% of the total), and when letters to the editar and meeting abstracts w ere exeluded, ý O ý O artieles in full text remained (ineluding editarials and reviews). This represented 0.5% of share in the respective world medical publications and a rise of 25% over the previous year. Thus Turkey doubled her output of international medical publications each 3 years over the past decade - a remarkable feat. The rise pertained to publications in basic (preclinical) fields as well as in elinical disciplines. The seven medical faculties (located in the three big cities) which produced 5 ý % of all medical publications were as follows: Hacettepe. Ankara, Ýstanbul, Aegean, Cerrahpaþa, Gazi and September 9th. The most significant trend over the previous years was a diversification of the publishing centers, in particular the rise to 17% of the share of nonacademic institutions. In cardiovascular medicine, 52 artieles in full text appeared in 1997 which represents a share of more than 0.4% in the world. References of each of these art ieles are provided as an appendix.

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Týptaki geliþmeler ve çok sayýdaki çalýþmaya raðmen konjestif kalp yetersizliði tedavisi hala sorun olup yeni ilaç ve tedavi yöntemlerine ihtiyaç duyulmaktadýr. Son yýllarda konjestif kalp yetersizliði fizyopatolojisine yönelik araþtýrmalar nörohumoral aktivitenin prognostik önemini ortaya koymuþtur. ACE inhibitörleriyle renin anjiotensin sistemi inhibisyonuyla semptomatik yarar saðlanacaðý ve mortalitenin azalacaðý gösterilmiþtir. Çalýþmalarda kronik kalp yetersizliðinde aþýrý uyarýlmýþ sempatik sistemin zararlý etkilerinin beta blokerlerle giderilebileceðine dair deliller elde edilmiþtir. Çok sayýda kontrollu, çok merkezli araþtýrma sonuçlarý da beta blokerlerin özellikle dilate kardiyomiyopatiye baðlý kalp yetersizliðinin tedavisinde kullanýlmalarýnýn yerinde olacaðýný düþündürmektedir. Carvedilolle elde edilen mortalite yararýna ait veriler de umut vericidir. Bununla beraber, konjestif kalp yetersizlikli tüm hastalarda rutin kullaným için deðiþik etiyolojili çok sayýda hastada planlanmýþ ve sürdürülmekte olan çalýþmalarýn sonucunu beklemek yerinde olacaktýr.

Despite basic and elinical research in congestive heart failure, this disorder continues to remain a major challenge therapeutically and there is a need for innovative drugs that alter the prognosis of heart failure. In recent years, research directed toward understanding of the pathophysiology of congestive heart failure showed that the level of neurohumoral activation is the predictor of survival. Clinical studies documented that the inhibition of overactivated renin-angiotensin-aldosteron system by angiotensin-converting enzyme inhibitors may improve symptoms and mortality. There is also inercasing evidence of beneficial effects of beta blacking drugs which counteract the long-term deleterious effects of overstimulated sympathetic nervous system. Several trials strongly suggest that beta-blockers should be used for the manageýnent of heart failure, especially in patients with dilated cardiomyopathy. Mortality data from the carvedilol studies are also encouraging. However, there is stili a need to await the result of planned large-scale trials in larger numbers of patients with different etiologies for routine usage of beta blackers in all patients with congestive heart failure.

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A graduate of Bologna Medical Faculty in 1653, and later prof. of medicine (1662), Malpighi pionecrcd the experimental study of living organisms and founded the science of microscopy. He discovered the capillary circulation (166 1 ), red blood corpuscles (1666), deseribed the structure of the ski n (M. la yer), papillae of the tongue, bodies in the spleen and kidneys (M. bodies and corpuscles) and the pulmonary alveoli. Microscopic exaýnination in frogs while the heart was beeting, revealed opposite direction of blood in adjacent vessels and he observed further that blood broke into the eýnpty space and was collected again by a gaping vessel. Two stamps and a posta! cancellatian depicting his portrait are presented.

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