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Behcet's disease (BD) may present with life threating complications including neurological and cardiovascular involvement. Neuro-Behcet's disease (NBD) is one of the most important causes of morbidity and mortality in patients with BD. The aim of the present study is to investigate whether patients with NBD are different than BD patients with other manifestations in terms of subclinical myocardial dysfunction.Forty patients with NBD (23 female, mean age: 42.4 ± 9.4 years), 40 patients with BD (9 female, mean age: 39.7 ± 9.0 years) and 40 controls (20 male, mean age: 41.8 ± 6.5 years) were consecutively included in the study. All subjects underwent a transthoracic echocardiography for evaluation of left ventricular (LV) and atrial (LA) functions with two-dimensional (2D) speckle tracking echocardiography (STE).Baseline characteristics, clinical data, LV dimensions, systolic and diastolic functions were all in normal range among the groups. LV global longitudinal strain (LV-GLS) was significantly lower in patients with NBD and BD patients without neurologic involvement compared to controls. LA conduit strain was significantly lower in patients with NBD compared to controls. Patients with both parenchymal NBD and vascular NBD manifestations had significantly lower LV-GLS and LA conduit strain compared to controls. Linear regression analysis demonstrated that among cardiovascular risk factors only presence of NBD was the independent predictor of LV-GLS.BD is associated with impaired LV and LA functions. LV-GLS and LA conduit strains of the patients with NBD were lower. NBD was an independent predictor of LV-GLS, suggesting a link between neurological manifestations and cardiac dysfunction in BD patients.

Purpose Insomnia is a common sleep disorder which has high comorbidity with a number of cardiovascular diseases (CVD). As a possible risk factor for the CVDs, arterial stiffness may be assessed non-invasively by pulse wave velocity (PWV) and augmentation index (AI). The aim of this study was to evaluate any relation between insomnia and arterial stiffness. Methods Patients with insomnia were included in the study after the exclusion of other sleep disorders by polysomnography. Sleep quality and the degree of insomnia symptoms were evaluated by the Pittsburgh sleep quality index (PSQI) and insomnia severity index (ISI), respectively. PWV and AI were assessed by Mobil-O-Graph arteriograph system. Results Consecutive patients with insomnia (n = 72, 56 women, mean age 55.8 +/- 9.1 years) were included. Patients were grouped as those with severe ISI scores (22-28) and those with mild to moderate ISI scores (8-21). Despite no significant difference in characteristics and clinical data, patients with severe ISI scores had significantly higher total PSQI scores and NREM-2 with significantly lower REM duration. They also had significantly higher systolic blood pressure, mean blood pressure, pulse pressure, PWV, and AI compared to patients with mild and moderate ISI scores. Correlation analysis revealed that PWV and AI were significantly correlated with the ISI score and PSQI score. Conclusion There is a close relation between arterial stiffness and insomnia suggesting a risk for CVD in patients with insomnia.

This recent Turkish Myocardial Infarction registry reported that guidelines are largely implemented in patients with acute myocardial infarction (MI) in Turkey. We aimed to obtain up-to-date information for short- and midterm outcomes of acute MI. Fifty centers were selected using probability sampling, and all consecutive patients with acute MI admitted to these centers (between November 1 and 16, 2018) were enrolled. Among 1930 (mean age 62 ± 13 years, 26% female) patients, 1195 (62%) had non-ST segment elevation myocardial infarction (NSTEMI) and 735 (38%) had ST segment elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) was performed in 94.4% of patients with STEMI and 60.2% of those with NSTEMI. Periprocedural mortality occurred in 4 (0.3%) patients. In-hospital mortality was significantly higher in STEMI than in patients with NSTEMI (5.4% vs 2.9%, respectively; P = .006). However, the risk became slightly higher in the NSTEMI group at 1 year. Women with STEMI had a significantly higher in-hospital mortality compared with men (11.2% vs 3.8%; P < .001); this persisted at follow-up. In conclusion, PCI is performed in Turkey with a low risk of complications in patients with acute MI. Compared with a previous registry, in-hospital mortality decreased by 50% within 20 years; however, the risk remains too high for women with STEMI.

Preeclampsia is a maternal disorder of pregnancy characterized by concomitant increase in preload and afterload with end organ dysfunction. The aim of our study is to evaluate left ventricular (LV) and right ventricular (RV) functions with speckle tracking echocardiography in preeclamptic patients. Fifty-five preeclamptic (mean age: 30.7 ± 5.9 years) and 35 healthy pregnant women (mean age: 28.8 ± 5.7 years) of the same race, similar age and gestational week were consecutively included. The diagnosis of preeclampsia was based on the criteria proposed by the American College of Obstetricians and Gynecologists. LV and RV functions were assessed by both conventional and speckle tracking echocardiography after the 30th gestational week and at the postpartum 6th months. The preeclamptic patients had significantly larger left atrium, thicker interventricular septum, higher systolic pulmonary artery pressure and mitral E/e′ ratio compared to controls during pregnancy while LV ejection fraction was similar. Preeclamptic patients had significantly lower LV and RV global longitudinal strain (GLS) during pregnancy compared to controls (− 18.0 ± 2.6% vs. − 19.8 ± 2.1% p = 0.001 and − 26.7 ± 3.3% vs. 28.9 ± 3.3% p = 0.002, respectively). In the postpartum period, while LVGLS values of preeclamptic patients increased significantly (− 18.0 ± 2.6% vs. − 20.4 ± 2.4% p

Background: Coronary artery disease (CAD) and ischemic stroke share the same risk factors. Objective: The aim of the study was to explore the prevalence and predictors of concomitant CAD in acute ischemic stroke patients. Methods: One hundred and five patients (64.3 ± 15.0 years, 61 male) presenting with acute ischemic stroke documented by neuroimaging were consecutively included. All patients were carefully evaluated to determine their cardiovascular disease risk scores. The patients who had been previously shown to have ≥50% stenosis in at least one of the major coronary arteries by coronary angiography were grouped as CAD patients. Results: Of the 105 stroke patients, 27 patients had documented concomitant CAD. The stroke patients with CAD had higher cardiovascular risk scores and troponin I levels and carotid plaques were more prevalent. ROC analysis determined cut-off values as ≥22% for Framingham Heart Study Risk Score, ≥0.05 ng/mL for Troponin I, and ≥0.80 mm for carotid artery intima-media thickness to predict concomitant CAD. During 6 months of follow-up, among the 78 stroke patients without documented CAD, 16 patients had experienced major cardiovascular events including myocardial infarction, recurrent stroke, or cardiovascular death. These patients had higher Framingham Heart Study Risk Score and high-sensitive C reactive protein levels. Conclusion: Our study suggests stroke patients with higher Framingham Heart Study Risk Score and troponin I levels and carotid plaques be further investigated for the presence of concomitant CAD.

Objectives: We aimed to evaluate left ventricular (LV) and right ventricular (RV) systolic performance in patients with sepsis or septic shock and possible functional alteration on in-hospital mortality. Patients and Methods: Thirty-seven consecutive patients with the diagnosis of sepsis or septic shock were included in the study. All patients underwent comprehensive transthoracic echocardiographic examination. Data of patients discharged from the intensive care unit was compared with data of patients who died in the hospital. Results: Fifteen patients (40.5%) survived, while 22 patients were died in the hospital (59.5%). A significant difference was detected between survivor and non-survivor groups regarding before discharge or death level of inflammatory markers such as CRP (p=0.05) and procalcitonin (p=0.03) besides BNP (p=0.01) and SOFA (p=0.009) score. There were two patients (5.4%) with EF value less than %50 in the study population. Eight patients (21.6%) displayed hypokinesia on the apical segment, and four patients (10.8%) had TAPSE values below 17 mm. One patient (6.6%) in the survivor group, but seven patients (31.8%) in the non-survivor group had apical hypokinesia with a trend towards significance (p=0.068). One patient in the survivor group (6.6%) and three patients (13.6%) in the non-survivor group had RV systolic dysfunction (p: 0.51). Conclusion: We found a much lower rate of LV and RV systolic dysfunction in patients with sepsis or septic shock compared with previous studies. None of the myocardial dysfunction types was associated with in-hospital mortality. Apical hypokinesia was also more prevalent in non-survivors despite borderline significance.

PURPOSE Systemic sclerosis (SSc) is associated with right ventricle (RV) remodeling and dysfunction. The primary aim of this study was to evaluate RV dyssynchrony (RV-Dys) in SSc patients using two-dimensional speckle tracking echocardiography (2D-STE). METHODS Fifty-five SSc patients with functional class I-II and 45 healthy controls were consecutively included and underwent 2D-STE. RV-Dys was defined as the standard deviation of time to peak strain of mid and basal segments of RV free wall and interventricular septum. SSc group was further classified according to the presence of pulmonary arterial hypertension (PAH). Patients with tricuspid regurgitant velocity >2.8 m/s with additional echocardiographic PAH signs were defined as SSc PAH (+). RESULTS SSc patients had lower RV longitudinal strain (RV-LS) (-17.6 ± 4.6% vs. -20.8 ± 2.8%, p

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease of pulmonary hypertension (PH) as a consequence obstructive of pulmonary arteries with thromboembolism. Augmented pulmonary vascular resistance and pulmonary artery pressure (PAP) can ultimately lead to the right ventricular dysfunction, which leads to adaptive and maladaptive changes. Right ventricle (RV) remodeling can cause clinical deterioration and RV failure. Aims and Objectives: We aimed to evaluate the RV functions with a new diagnostic modality 2-deoxy-2-(18F)-fluoro-D-glucose (FDG)-positron emission tomography (PET) in patients with CTEPH. Materials and Methods: We included 53 patients diagnosed with CTEPH who were planned to have pulmonary thromboendarterectomy (PEA) and did not have any contraindication for cardiac PET/computed tomography (CT). We performed transthoracic echo, cardiac PET/CT, 6-minute walk distance (6-MWT), and right heart catheterization 1 week before PEA surgery. Results: The patients divided into two groups according to RV/left ventricle (LV) FDG-PET uptake ratio, RV/LV ≤1, and RV/LV >1. Six-MWD was significantly higher in the RV/LV ≤1 group (P = 0.005). Pro-BNP was considerably higher in the RV/LV >1 group (P = 0.041). Conclusion: The present study aims to demonstrate the RV/LV FDG-PET uptake ratio could be used in the noninvasive diagnostic method in diagnosing, treatment strategy, and clinical follow-up in patients with CTEPH.

PURPOSE Epicardial adipose tissue thickness (EATT) is considered to be a surrogate for visceral fat and a novel cardiovascular risk indicator. Hyperprolactinemia has been shown to be associated with increased cardiovascular risk. The aim was to evaluate the association between EATT, carotid intima media thickness (CIMT), and cardiac functions in patients with prolactinoma. METHODS Patients with the diagnosis of prolactinoma were included. The control group consisted of healthy age matched individuals with normal prolactin levels. Prolactin, fasting blood glucose (FBG), insulin, hemoglobin A1c (HbA1c), alanine aminotransferase (ALT), total cholesterol, triglycerides, and high (HDL) and low density lipoprotein (LDL) cholesterol were measured. EATT, CIMT, cardiac systolic, and diastolic functions were determined using echocardiography. RESULTS We evaluated 67 patients with prolactinoma (aged 40.7 ± 11.9 years, F/M: 51/16) and 57 controls (aged 42.5 ± 7.4 years, F/M: 36/21). Of the 67 patients, 24 had normal prolactin levels. FBG level was higher in prolactinoma patients than in controls. Patients and controls had similar HbA1c, HOMA-IR, ALT, total, HDL, LDL cholesterol, and triglycerides levels, and similar cardiac systolic and diastolic functions. Prolactinoma patients had greater EATT (3.0 ± 0.5 mm vs. 2.6 ± 0.4 mm, p

Purpose The aim of this study was to evaluate right ventricle (RV) dyssynchrony and its relation with mortality using speckle-tracking echocardiography (STE) in patients with acute inferior myocardial infarction (IMI). Methods One hundred and fifty-eight consecutive patients with acute IMI treated with primary percutaneous coronary intervention, and 44 healthy subjects were included. RV myocardial involvement (RVMI) was defined as an elevation >1 mm in V1 or V4R and/or the presence of a culprit lesion at the proximal portion of the first RV marginal branch after reviewing coronary angiography. Patients were followed for 3 years to determine the cardiovascular mortality. Results Overall, 70 patients with IMI had RVMI. IMI patients had significantly higher RV peak systolic longitudinal strain dyssynchrony (PLSSD) index, lower peak longitudinal systolic strain (PLSS), longer time to PLSS, and time to PLSS differences compared to healthy controls while the patients with RVMI had significantly worse values compared to patients without RVMI and healthy controls. Twenty-seven patients (17.1%) died within 2 years. RVMI was more prevalent in mortality group, and they had significantly higher RV PSSD index, whereas they had lower RV free wall PLSS and longer time to PLSS differences. Receiver operating characteristics (ROC) analysis revealed that a RV PLSSD index > 65 ms predicted mortality with a sensitivity of 88.9% and specificity of 71.8% in IMI patients. Conclusions Intra- and inter-ventricular dyssynhcrony may develop in patients with acute IMI, especially in those with RV involvement, which might have a negative effect on the prognosis of these patients.

Purpose Hypertension is associated with left ventricular (LV) hypertrophy, impaired LV relaxation, and left atrial (LA) enlargement. Cardiac rehabilitation (CR) improves clinical outcomes in a broad spectrum of cardiac disease. The aim of our study was to determine the effect of CR on blood pressure (BP), and on LA and LV functions in hypertensive patients. Methods Thirty consecutive hypertensive patients who would undergo CR program, and 38 hypertensive patients who refused to undergo CR program were included. All patients underwent ambulatory BP monitoring and transthoracic echocardiography, which were repeated after completion of the CR program, or 12 weeks later in the control group. LA and LV functions were assessed by both speckle tracking and 3-dimensional echocardiography. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were assessed before and after CR. Results Although initial ambulatory BP values and NT-proBNP levels were similar between the groups, daily, day-time, and night-time BP and NT-proBNP were significantly lower in the CR group after rehabilitation. LA reservoir strain and LV global longitudinal strain of the CR group significantly increased after CR while no significant increase was observed in controls. Conclusion CR improves LA and LV strain while lowering BP and should be encouraged in routine management of hypertensive patients.

PURPOSE Antiretroviral therapy (ART) has dramatically changed the clinical manifestation of human immunodeficiency virus (HIV) associated cardiomyopathy from severe left ventricular (LV) systolic dysfunction to a pattern of subclinical cardiac dysfunction. The aim of this study was to evaluate by speckle tracking echocardiography (STE) LV, right ventricular (RV), and biatrial functions in HIV-infected patients under different ART combinations. METHODS We consecutively included 128 HIV-infected patients (mean age 44.2 ± 10.1 years, 110 males) and 100 controls (mean age 42.1 ± 9.4 years, 83 males). Ventricular and atrial functions were assessed by both conventional and STE. RESULTS Although there was not any significant difference in conventional echocardiographic variables, HIV-infected patients had significantly lower LV global longitudinal strain (GLS), RV GLS, left atrial (LA) reservoir and conduit strain, and right atrial conduit strain. HIV patients receiving integrase strand transfer inhibitors and protease inhibitors (PI) had significantly lower LV GLS and LA conduit strain, while patients receiving non-nucleoside reverse transcriptase inhibitors and PI had significantly lower RV GLS than controls. CD4 count at the time of echocardiography was strongly correlated with LV GLS (r = .619, P

BACKGROUND Right ventricle (RV) involvement causes acute systolic and diastolic functional alterations in the RV in patients after inferior myocardial infarction (IMI), which may result in an increase in left ventricle (LV) end-diastolic and right atrial (RA) pressure. In our study, we sought to evaluate RA volumes and mechanical functions using real-time three-dimensional echocardiography (RT3DE) in IMI patients with or without RV involvement. METHODS Ninety-six consecutive patients with IMI (mean age: 59.7 ± 10.2 years, 60 female) were included. RV myocardial involvement (RVMI) was defined as the presence of a culprit lesion at the proximal portion of the first RV marginal branch in coronary angiography. The study population was divided into two groups: IMI (58.3%) and IMI + RVMI (41.7%). Patients were evaluated using conventional two-dimensional echocardiography (2DE) and RT3DE. RESULTS In RT3DE measurements, IMI + RVMI patients had significantly higher RA phasic volumes and worse conduit mechanical function. A receiver operating characteristic (ROC) curve analysis revealed that an RT3DE RA maximum volume (Vmax) index > 27.9 mL/m2 was an independent predictor of RV involvement in patients after acute IMI, with a sensitivity of 80.0% and a specificity of 89.3%. CONCLUSIONS Right ventricle involvement may cause an increase in RA phasic volumes and deterioration of conduit function in patients with acute IMI.

A double-chambered right ventricle (DCRV) is a heart defect, typically congenital, in which the right ventricle is separated into a proximal high-pressure (anatomically lower) chamber and distal low-pressure (anatomically higher) chamber. Commonly ventricular septal defect is found concomitantly in patients with DRCV. In this case report, we present a 20-year- -old female patient who was found to have a DRCV without any concomitant congenital heart disorder.

Our aim was to evaluate left ventricular (LV) systolic and diastolic functions of primary hyperparathyroidism (pHPT) patients with detailed echocardiographic analysis and investigate the effect of parathyroidectomy on echocardiographic parameters. A total of 22 eligible consecutive patients with pHPT who underwent parathyroidectomy operation were recruited to the study. Another 22 subjects with similar age, gender and frequency of cardiovascular risk factors compared to patients were used as a control group. Echocardiographic parameters of patients scheduled for parathyroidectomy were compared to healthy matched controls. Echocardiographic parameters measured 6 months after the operation were also compared with preoperative values for each patient. Patients had higher LV mass index compared with controls. There were no significant differences between groups regarding 2D echocardiographic parameters reflecting LV systolic function and tissue Doppler velocities; however, 2D echocardiographic parameters demonstrated impairment in LV diastolic functions compared with controls. Speckle tracking echocardiography (STE) demonstrated similar LV global longitudinal systolic strain; however, left atrial conduit and reservoir functions were significantly reduced in patients with pHPT. In general, there were no significant differences between baseline and postoperative state regarding parameters reflecting LV systolic and diastolic functions; however, STE demonstrated significantly increased LV global longitudinal strain after surgery (22.3 ± 3.3% vs 20.3 ± 2.9%, p = 0.026). Patients with pHPT displayed higher LV mass and impairment in LV diastolic function compared with controls. Parathyroidectomy did not lead to significant improvements in LV mass or LV diastolic function; however, subtle but not apparent increases in LV systolic function were observed 6 months after surgery.

Depression is an independent risk factor in cardiovascular diseases. Changes in the cardiac autonomic functions and pro-inflammatory processes are potential biological factors. Endothelial dysfunction plays an important role in the etiopathogenesis of atherosclerosis. Our objective was to evaluate the impact of major depression on heart rate variability and endothelial dysfunction in patients with stable CAD.The study group included 65 CAD patients with a diagnosis of major depression and 54 CAD patients without major depression. All study population underwent transthoracic echocardiography, measurement of flow mediated dilatation (FMD) and 24-h holter recording for heart rate variability (HRV). Blood samples were drawn to determine the inflammatory parameters. Severity of depressive episode was assessed by Montgomery-Asberg Depression Scale (MADRS).The distribution of age and sex was similar in the patient and control groups (P=0.715, 0.354, respectively). There was no significant difference in medications used between the groups. Echocardiographic parameters were similar between the groups. Inflammatory parameters were also similar between the groups. HRV parameters were significantly lower in the patient group than controls. The absolute FMD value and percentage FMD were significantly lower in the patient group than controls (P0.001). The MADRS score correlated with pNN50 in both groups (P0.05), and with FMD in the control group (P0.001), even after adjusting for age and gender (P0.001).MADRS score was an independent predictor of pNN50 level, percentage and absolute FMD values regardless of age and gender. Clinician should pay more attention for evaluation of depressive patients with CAD.

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) has been associated with an increased arterial stiffness. However, the question as to whether an association exists between the extent of vascular and liver stiffness in patients with biopsy-proven NAFLD remains open. In this study, we sought to investigate whether pulse wave velocity (PWV) and augmentation index (AIx) - two common indices of arterial stiffness - are associated with (a) liver stiffness measurement (LSM) on transient elastography (TE) and (b) histological liver fibrosis. PATIENTS AND METHODS We examined 125 patients with biopsy-proven NAFLD and 55 age-matched and sex-matched controls. Arterial stiffness of the brachial artery was measured using a Mobil-O-Graph arteriography system. LSM was assessed using TE, whereas the presence of advanced fibrosis (F ≥ 3) was determined on histology. RESULTS Patients with NAFLD had higher PWV [median: 7.2 (6.3-8.2) and 6.2 (5.5-6.7) m/s, respectively, P

Androgen-deprivation therapy (ADT) is a treatment option for locally advanced and metastatic prostate cancer (PCA). The aim of the study was to evaluate the effect of ADT on left ventricular (LV) functions assessed by speckle-tracking echocardiography (STE) in prostate cancer (PCA) patients. Forty-nine consecutive PCA patients (mean age 71.5 ± 6.7 years) who would be treated with radiotherapy and ADT and 32 consecutive PCA patients (mean age 71.9 ± 7.0 years) who would be treated with radical or partial prostatectomy and 42 age-matched healthy men (mean age 70.5 ± 9.1 years) were included in our study. The left ventricular functions were assessed by both conventional echocardiography and STE at baseline and 6 months later. There were not any significant difference in characteristics of the patients and controls. There were not any significant differences in conventional echocardiographic measures at baseline and at 6th month among the PCA patients and controls. Although there were not any significant differences in STE measures at baseline among the PCA patients and controls, the strain measures of the PCA patients receiving ADT decreased significantly at the 6th month and were significantly lower compared to strain measures of PCA patients undergoing prostatectomy and controls. There was not any statistically significant difference in baseline and 6th-month strain measures of the PCA patients undergoing prostatectomy. ADT might be associated with decrease in LV longitudinal, circumferential, and radial strain measures in patients with PCA. STE might be useful for early identification of LV subclinical impairment in PCA patients treated with ADT.

Background Postoperative atrial fibrillation (POAF) may develop after coronary artery bypass grafting (CABG). The aim of the study was to explore the relationship between preoperative left atrial function and atrial fibrosis and POAF after CABG. Methods Forty-eight consecutive patients undergoing CABG (mean age: 61.6 ± 8.9 years, 39 male) were included. All patients were in sinus rhythm during surgery. Patients were followed by continuous electrocardiography monitoring and daily electrocardiogram. Left atrial function was assessed by both conventional and speckle tracking echocardiography. Atrial fibrosis was determined by samples taken from right atrium. Results Postoperative atrial fibrillation was detected in 13 patients. Female sex and number of bypassed vessels were significantly higher and cardiopulmonary bypass time was significantly longer in patients with POAF. Left atrial volume index (LAVI) was significantly higher while left atrial reservoir strain was significantly lower in POAF patients. The percentage of patients with severe fibrosis was higher in the POAF group. Regression analysis revealed fibrosis and LAVI as independent predictors of POAF. Left atrial volume index ≥36 mL/m2 predicted POAF with a sensitivity of 84.6% and specificity of 68.6% in our cohort. Conclusion Patients who developed POAF after CABG had more fibrosis, increased LAVI and lower left atrial reservoir strain. Preoperative echocardiography might be helpful in discriminating these patients.

Objective To determine the frequency of subclinical atherosclerosis in patients with systemic sclerosis (SSc; scleroderma) compared to healthy subjects (HS) and rheumatoid arthritis (RA) patients and to determine the ability of cardiovascular (CV) risk indices in detecting SSc patients with subclinical atherosclerosis. Methods A total of 110 SSc patients (102 females and 8 males, mean ± SD age 50.5 ± 11.9 years), 110 age- and sex-matched RA patients, and 51 HS without CV disease were examined with ultrasonography (US). Carotid intima-media thickness (cIMT) >0.90 mm and/or carotid plaques were used as the gold standard for subclinical atherosclerosis (US+). Systematic Coronary Risk Evaluation (SCORE), QRisk II, and 2013 American College of Cardiology (ACC)/American Heart Association (AHA) CV risk indices were calculated. Results Twenty-one (19.1%) SSc patients, 24 (21.8%) RA patients, and 3 (5.9%) HS had subclinical atherosclerosis (SSc versus RA: P = 0.62, SSc versus HS: P = 0.029). cIMT in SSc was higher compared to HS (0.68 ± 0.15 mm versus 0.61 ± 0.10 mm; P = 0.008) but similar to RA patients (0.66 ± 0.14 mm; P = 0.82). Subclinical atherosclerosis in SSc was associated with age (odds ratio [OR] 1.07, P = 0.013), elevated erythrocyte sedimentation rate (OR 3.4, P = 0.045), and pulmonary arterial hypertension (OR 4.27, P = 0.012). Concerning CV risk indices, of the 21 US+ SSc patients only 0, 3 (14.2%), and 6 (28.6%) were classified as high CV risk according to SCORE, QRisk II, and ACC/AHA risk indices, respectively. Conclusion Subclinical atherosclerosis in SSc patients is more frequent than in HS, but is as frequent as in RA patients in which accelerated atherosclerosis is clearly defined. CV risk indices for the general population are considerably insufficient to detect SSc patients with atherosclerosis.

Objective: Pre- and postoperative changes in echocardiographic parameters and results of 6-minute walking test (6-MWT) were investigated in the present study. Methods: Seventy-six patients (32 males, 44 females; mean age 45.9 +/- 15.1 years) were included. Before and after surgery, 6-MWT and echocardiography were performed. Changes in postoperative parameters were compared to basal walking test and other basal parameters. Results: Distance covered in 6-MWT significantly increased after surgery (p

Background Warfarin treatment is crucial to prevent thrombolytic complications after the heart valve replacement (HVR) operation. Our purpose was to investigate the prevalence of CYP2C9 *2 and *3 gene polymorphisms, which are essential in warfarin metabolism in patients with and without HVR surgery prescribed with warfarin. Material and method 47 patients with and without HVR were genotyped for the CYP2C9*2 (rs1799853, 430 C>T), CYP2C9*3 (rs1057910, 1075 A>C) polymorphisms by PCR-RFLP assay. Results Homozygous wild (CC), heterozygous and homozygous polymorphic (CT+TT) genotype frequencies of CYP2C9 *2 were determined respectively as 69.6% and 30.4% for patients with HVR; 79.2% and 20.8% for patients without HVR. Homozygous wild (AA) and heterozygous (AC) genotype frequencies of CYP2C9 *3 polymorphism were determined respectively as 73.9% and 26.1%f for patients with HVR; 79.2% and 20.8% for patients without HVR. CYP2C9 *2 and *3 genotype frequencies did not show any statistically significant difference between with and without HVR groups. Conclusion In the present study, no significant difference was observed between patients with and without HVR with respect to CYP 2C9 *2 and *3 gene polymorphisms in Turkish subjects. Further studies with higher number of patients are needed to evaluate the importance of CYP 2C9 *2 and *3 pharmacogenetic testing in patients with HVR using warfarin.

Background: Although right ventricular (RV) dysfunction in pulmonary diseases has been associated with increased morbidity, tools for RV dysfunction identification are not well defined. Objective: The aim of this study was to evaluate the magnitude of RV dysfunction by means of speckle tracking echocardiography (STE) in patients with chronic obstructive pulmonary disease (COPD) and to investigate whether STE could be used as an index of RV improvement after a pulmonary rehabilitation (PR) program. Methods: Forty-six patients with COPD undergoing PR program and 32 age-sex matched healthy subjects were enrolled. RV function was evaluated at admission and after PR program by conventional two-dimensional echocardiography (2DE) and STE. In addition, exercise tolerance of subjects was evaluated using the six-minute walk test (6MWT). Results: COPD patients had worse RV function according to STE and 2DE as well. STE was more sensitive than conventional 2DE in determining RV improvement after PR program - RV global longitudinal strain (LS): 20.4 ± 2.4% vs. 21.9 ± 2.9% p < 0.001 and RV free wall LS: 18.1 ± 3.4% vs. 22.9 ± 3.7%, p < 0.001). RV free wall LS was directly related to distance walked at baseline 6MWT (r = 0.58, p < 0.001) and to the change in the 6MWT distance (6MWTD ∆) (r = 0.41, p = 0.04). Conclusions: We conclude that STE might be as effective as 2DE for evaluation of global and regional RV functions. STE may become an important tool for assessment and follow-up of COPD patients undergoing PR program to determine the relationship between RV function and exercise tolerance. Resumo Fundamento: Embora a disfunção do ventrículo direito (VD) nas doenças pulmonares tenha sido associada ao aumento da morbidade, as ferramentas para a identificação da disfunção do VD não estão bem definidas. Objetivo: O objetivo deste estudo foi avaliar a disfunção do VD por ecocardiografia speckle tracking (STE) em pacientes com doença pulmonar obstrutiva crônica (DPOC), e se a STE pode ser usada como indicador de melhora da função ventricular direita após um programa de reabilitação pulmonar (RP). Métodos: Quarenta e seis pacientes com DPOC submetidos ao programa de RP e 32 controles sadios pareados por sexo e idade foram incluídos no estudo. A função do VD foi avaliada na admissão e após o programa de RP por ecocardiografia bidimensional convencional e por STE. Além disso, a tolerância ao exercício foi avaliada pelo teste de caminhada de seis minutos (TC6M). Resultados: Pacientes com DPOC apresentaram pior função do VD segundo STE e ecocardiografia bidimensional convencional. Em comparação ao método convencional, a STE mostrou maior sensibilidade em determinar melhora da função ventricular direita após o programa de RP - strain longitudinal (SL) global do VD: 20,4 ± 2,4% vs. 21,9 ± 2,9% p < 0,001; SL da parede livre do VD: 18,1 ± 3,4% vs. 22,9 ± 3,7%, p < 0,001. O SL da parede livre do VD relacionou-se diretamente com a distância percorrida no TC6M basal (r = 0,58, p < 0,001) e com a variação no TC6M ∆ (TC6M) (r = 0,41, p = 0,04). Conclusões: Concluímos que a STE pode ser tão eficaz como a ecocardiografia bidimensional convencional na avaliação das funções globais e regionais do VD. Ainda, a STE pode se tornar uma importante ferramenta de avaliação e acompanhamento de pacientes com DPOC submetidos à RP para determinar a relação entre função ventricular direita e tolerância ao exercício.

Background Right ventricular (RV) involvement in inferior myocardial infarction (MI) increases in-hospital morbidity and mortality. Hypothesis RV systolic dysfunction assessed by 2-dimensional speckle tracking echocardiography (STE) might be a predictor of early mortality in patients with acute inferior MI. Methods Eighty-one consecutive patients with acute inferior MI (mean age, 60.8 ± 12.7 years; 18 females) were included. RV myocardial involvement was defined as an elevation >1 mm in V1 or V4 R within 12 hours of symptom onset. RV function was assessed by STE. Patients were followed for 30 days for all-cause mortality. Results Thirty-eight patients had RV myocardial involvement, and they had significantly lower tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (RVS), and left ventricular (LV) and RV global longitudinal strain (GLS). Nine patients (11%) died within 30 days. The mean age of mortality group was higher with more female frequency. They had significantly higher pro-BNP, hs-troponin T, and creatinine levels, but lower hemoglobin levels. TIMI 3 flow was significantly less achieved in mortality group. RV myocardial involvement was more frequent in the mortality group, and they had significantly lower TAPSE, RVS, and LV and RV GLS. Multivariate analysis revealed that age and RV GLS were independent predictors of early mortality. RV GLS ≤ -14% predicted early mortality in patients with acute inferior MI with a sensitivity of 88.9% and a specificity of 62.5% (AUC: 0.817, P = 0.002). Conclusions RV GLS may be useful in predicting early mortality in patients with acute inferior MI.

The aim of this study was to assess the right ventricular and right atrial functions in patients with nonischemic dilated cardiomyopathy by novel echocardiographic measures. In all, 40 patients with nonischemic dilated cardiomyopathy and 26 healthy subjects were consecutively included. Left ventricular, right ventricular, and right atrial functions were assessed by tissue Doppler imaging and two-dimensional speckle tracking echocardiography. Right ventricular systolic dysfunction was accepted moderated to severe when tissue Doppler peak systolic velocity of tricuspid lateral annulus was

Objective: The aim of the present study was to evaluate left atrial (LA) volume and functions using real-time three-dimensional echocardiography (RT3DE) and speckle tracking in systemic sclerosis (SSc) patients. Methods: The study was designed as a cross-sectional observational study. We studied 41 consecutive SSc patients (38 females, mean age: 49.5±11.6 years) and 38 healthy controls (35 females, mean age: 48.5±10.8 years). Patients with evidence or history of cardiovascular disease and patients with risk factors as hypertension, diabetes and chronic renal failure were excluded from the study. All study subjects underwent standard echocardiography; LA speckle tracking and RT3DE was performed to assess LA volume and phasic functions. Differences between numeric variables were tested using the independent sample Student’s t-test or Mann-Whitney U test, where appropriate. Results: There were no significant differences between SSC patients and controls regarding left ventricular (LV) systolic functions and two-dimensional (2-D) atrial diameters. Presence of LV diastolic dysfunction (LVDD) was evaluated and graded according to recommendations of the American Society of Echocardiography. Accordingly, LVDD was observed to be significantly more frequent in SSc patients; 16 SSc patients (39%) and 5 controls (12.8%) were observed to have LVDD (p=0.007). With regard to results obtained from RT3DE, LA maximum, minimum, and before atrial contraction volumes were significantly higher (40.5±14.6 vs. 32.6±8.9, 15.5±8.4 vs. 9.9±3.5 and 28.7±11.7 vs. 21.4±7.0 mL respectively, p

Although sleep deprivation (SD) affects cardiovascular system in many ways, physio-pathological changes in cardiac chamber volume and function have not been described well. The aim of the present study was to investigate the effect of SD on left atrial (LA) and ventricular function with three-dimensional (3D) echocardiography. Thirty-two healthy individuals (12 females, mean age 33.25 ± 8.18) were evaluated. Echocardiographic examination was performed once after a night of regular sleep and a night of sleep debt. Beside conventional parameters, 3D phasic volumes and function were measured using a commercially available 3D echocardiography system and offline analysis software. Mean sleep duration of the study group was 8.15 ± 2.19 h in the day of regular sleep and 2.56 ± 2.25 h in the day of sleep deprivation. There was a significant prolongation in deceleration time (180.83 ± 15.34 vs. 166.44 ± 26.12; p = 0.044) and increase in E/e’ (6.95 ± 1.26 vs. 6.38 ± 0.85; p = 0.005). Among 3D measurements, the difference in left ventricular ejection fraction (EF), LA EF, LA reservoir function and LA active EF were not significant. Mean LA passive EF of the individuals was significantly lower after night shift (24.10 ± 7.66 vs. 31.49 ± 7.75; p = 0.006). Acute SD is associated with a reduction in LA passive emptying function in healthy adults. 3D-derived indices were sufficient to show subclinical diastolic dysfunction according to impairment in passive phase of LA ejection. Prospective large-scale studies are needed to enlighten this issue.

Heart failure is an important clinical problem worldwide. There is great interest in evaluating the relationship between electrocardiographic variations and dilated cardiomyopathy (DCM) since it has been used as a predictor of increased morbidity and mortality. The presence of fragmentation in the QRS complexes on 12-lead electrocardiogram (ECG) was reported as a marker of depolarization abnormality in patients with DCM. Previous studies have investigated the relation between QRS morphology and DCM. QRS morphology and duration are associated with clinical deterioration and increased mortality in patients with DCM. Although surface ECG provides valuable information on prognosis of these patients, echocardiographic methods have been used for further investigation of patients with DCM. The aim of the present review is to provide an overview of the pathophysiological links, echocardiographic characteristics and clinical implications of QRS morphology in patients with DCM.

Sarcoidosis is a systemic inflammatory disease with unknown etiology involving several organs. Myocardial involvement, pericarditis, severe rhythm abnormalities, and heart valve disease due to papillary muscle dysfunction are some of the cardiac manifestations. Conventional echocardiographic methods remain insufficient for the determination of subclinical myocardial dysfunction in patients with sarcoidosis. In our study, we investigated the impact of sarcoidosis on bi-ventricular and atrial functions using two-dimensional (2D) speckle tracking echocardiography (STE). Forty patients with sarcoidosis and 20 age and sex-matched controls were recruited into study. All subjects underwent a transthoracic echocardiography for the evaluation of ventricular and atrial functions with 2D STE. Left ventricular (LV) dimensions, LV ejection fraction, and right ventricular (RV) systolic velocity were similar between the two groups. Left atrial (LA) diameter was significantly higher in sarcoidosis patients than controls. Eighteen (45 %) patients in the sarcoidosis group and 1 (5 %) patient in the control group had LV diastolic dysfunction. LV global longitudinal, radial, circumferential strain, twist, untwists, and RV global longitudinal strain values were significantly lower in sarcoidosis patients compared to controls. LA and RA reservoir functions were also significantly lower in sarcoidosis patients than controls. Although impaired LV diastolic function was detected using conventional parameters, only novel advanced echocardiographic modalities demonstrated impaired bi-ventricular and atrial mechanical functions in patients with sarcoidosis.

Introduction: There is limited data in the literature regarding the association between hyperlipidemia and heart rate variability (HRV). The aim of the present study is to investigate the association between HRV and hyperlipidemia by retrospectively evaluating the recordings of subjects free of any apparent cardiovascular or systemic disease. Patients and Methods: Medical records of patients to whom 24 hour-Holter recording was performed in our clinic between January 2012 and May 2013 were retrospectively examined. Data of subjects who were determined to be free of any cardiovascular or systemic disease were used in the analysis. Results: Data of 37 subjects were used. There were 20 subjects with hyperlipidemia (10 male, age: 44.5 ± 11.1 years) and 17 subjects with normal lipid profile (5 male, age: 33.4 ± 10.6 years; p= 0.18 for gender and p=0.004 for age). Majority of HRV parameters were found to be significantly depressed in group with hyperlipidemia; however, there were no significant difference between groups regarding prevalence of arrhythmias. Out of components of the lipid profile, linear regression analysis revealed serum triglyceride level to be independently associated variable with RMSSD, PNN50 and LF/HF ratio (in respective order; beta= -0.40, p= 0.02; beta= -0.41, p= 0.012 and beta= -0.31, p= 0.05). Conclusion: Subjects with hyperlipidemia were observed to have significantly depressed HRV compared to subjects with normal lipid profile in our retrospective study. Based on our observations, it may be suggested that patients with hyperlipidemia, in particular with hypertriglyceridemia display higher subtle cardiac sympathetic activity which may be associated with increased cardiovascular morbidity and mortality.

Vitamin D deficiency is associated with impaired myocardial deformation parameters and cardiovascular disease (CVD). Increased epicardial fat thickness (EFT) is also associated with increased risk of CVD. The aim of the study is to evaluate the effect of vitamin D deficiency and supplementation on myocardial deformation parameters and EFT. The study population consisted of 50 patients with vitamin D deficiency who were free of cardiovascular risk (mean age: 42.6 ± 8.9 years, 37 female). Patients were treated with oral administration of vitamin D3. Myocardial deformation parameters and EFT were evaluated before and after treatment of those patients. Vitamin D levels significantly increased after treatment (30.5 ± 10.5 vs. 9.9 ± 5.3 nmol/l, p < 0.001). There was no significant difference between conventional echocardiographic parameters before and after treatment. Baseline EFT was significantly higher than post-treatment measurements (35.2 ± 8.0 vs. 27.5 ± 5.6 mm, p < 0.001). Post-treatment myocardial deformation parameters were also significantly higher than baseline measurements. Baseline vitamin D levels correlated with baseline EFT and left ventricular global longitudinal strain (LV-GLS). Post-treatment vitamin D levels also correlated with post-treatment EFT, body mass index, and LV-GLS. Baseline vitamin D level was an independent predictor of baseline LV-GLS (p = 0.002). Patients with impaired LV-GLS had significantly lower vitamin D levels than patients with normal LV-GLS (6.6 ± 3.8 vs. 11.0 ± 5.3 nmol/l, p = 0.005). Baseline vitamin D level was also an independent predictor of baseline impaired LV-GLS (p = 0.010). Vitamin D supplementation has beneficial effects on myocardial deformation parameters and EFT. Moreover, baseline vitamin D levels are a predictor of impaired LV-GLS.

Background Obstructive sleep apnea (OSA) is characterized by reductions in breathing amplitude during sleep caused by an obstructed or collapsed upper airway. The neutrophil to lymphocyte ratio (NLR) has been proposed as a novel biomarker for systemic inflammatory response. The aim of the present study was to evaluate the relationship between NLR and OSA. Methods The study population consisted of 195 consecutive patients with clinical suspicion of OSA. Full night polysomnography was performed for all patients. Patients with an apnea hypopnea index (AHI) ≥ 5 were considered to have OSA. NLR was calculated as the ratio of neutrophil count to lymphocyte count. Results While 130 patients (91 male, mean age: 49.9±9.8 years) had OSA, 65 patients (42 male, mean age: 48.7 ± 10.2 years) had normal findings according to AHI scores. Cardiovascular risk factors such as hypertension, hyperlipidemia, diabetes mellitus and smoking were more common in patients with OSA. Patients with OSA had significantly higher NLR than controls (1.87±0.80 vs 1.49±0.48, p=0.005). AHI score was significantly correlated with NLR (r=0.228, p=0.001). NLR and presence of hyperlipidemia were independent predictors of OSA (OR: 2.451, 2.850, p=0.001, 0.004, respectively). NLR of 1.62 or higher predicted OSA with a sensitivity of 56.2 % and specificity of 63.1 %. Conclusions NLR was higher and also correlated with AHI score in patients with OSA which has not been reported previously. NLR more than 1.62 was an independent predictor of OSA. A simple, cheap white blood cell count may also give an idea about the presence and severity of OSA (Tab. 3, Fig. 3, Ref. 30).

Objective: Non-alcoholic fatty liver disease (NAFLD) is associated with atherosclerosis and reduced vascular compliance. The purpose of this study was to examine the relationships between arterial stiffness measures, the histological severity of NAFLD, and epicardial fat thickness (EFT). Methods: A total of 100 patients with biopsy-proven NAFLD and 50 age- and sex-matched controls were enrolled. The histological severity was assessed in all NAFLD patients. Measurements of arterial stiffness [pulse-wave velocity (PWV) and augmentation index (AIx)] were carried out using a Mobil-O-Graph arteriograph system. EFT was assessed by means of echocardiography. Results: Compared with controls, NAFLD patients had significantly higher PWV and AIx values. Stepwise linear regression analysis demonstrated that the liver fibrosis score and EFT were independent predictors of both PWV and AIx values in NAFLD patients. Conclusions: Patients with NAFLD have an increased arterial stiffness, which reflects both the severity of liver fibrosis and increased EFT values.

A 66-year-old male presented with fatigue, weakness, haemoptysis and severe dyspnoea for two weeks. On physical examination, heart rate was 80 beats/min, blood pressure was 110/80 mmHg and bilateral crepitant rales up to the mid zone of the lungs. Surface ECG showed sinus rhythm. Transthoracic echocardiography revealed moderate depression of left ventricular function (ejection fraction: 40%) and left atrial mass. To confirm the diagnosis, we also performed a transoesophageal echocardiography and demonstrated a lobulated mass with a diameter of 30x25 mm in the left atrium and compression of the mass to superior vena cava (Figure 1A, 1B). Cardiac magnetic resonance imaging (CMRI) confirmed the findings in the transoesophageal echocardiography (Figure 1C). Thoracic computed tomography demonstrated a mass with a diameter of 52x36 mm in the

Time in therapeutic range (TTR) of international normalized ratio is crucial for the safety and efficacy of anticoagulation with warfarin and it is influenced by many factors. There are limited data about the quality of warfarin therapy and its effects on clinical outcomes in Turkey. The aim of this study is to demonstrate the quality of anticoagulant therapy with warfarin and evaluate the parameters that affect the quality of warfarin therapy. A total of 170 patients with atrial fibrillation (AF; mean age: 62.2 ± 13.3; 69.2% female) treated with warfarin were included in this study. The mean follow-up period was 20 ± 8.4 months. The mean TTR levels of all patients were found to be 54.2% ± 21.4%. The TTR levels were similar in patients with valvular AF (VAF) and nonvalvular AF (NVAF). Logistic regression analysis revealed that elderly, heart failure (HF), and renal dysfunction were independent predictors of lower TTR. There were no significant differences between the VAF and NVAF subgroups regarding the incidence of mortality, stroke, and myocardial infarction. Cox regression analysis revealed that HF, coronary artery disease, and renal dysfunction were independent predictors of clinical outcomes in addition to lower TTR. Our results provide data regarding the quality of anticoagulation with warfarin from a single tertiary center in Istanbul, Turkey. The questions remain in seeking quality improvement in anticoagulation.

Variant angina (VA) is a clinical syndrome caused by spontaneous vasospasm of the epicardial coronary artery which is characterized by episodes of angina. Endothelial dysfunction and neurohormonal hyperactivity are important factors in pathogenesis of VA. Although patient prognosis is good, VA may be one of the reasons of sudden cardiac death (SCD) in case of persistent ST segment elevation and malignant arrhythmias. Therefore, early treatment of VA is crucial for prevention of malignant arrhythmias and SCD. In this case report we describe a case of VA presented with cardiogenic shock and malignant ventricular arrhythmia.

Although ulcerative colitis (UC) shows obvious similarities with other autoimmune diseases, cardiac consequences have not adequately introduced. The aim of our study was to evaluate left ventricular (LV) function in UC patients by using novel echocardiographic parameters. Forty-five UC patients (mean age 37, 18 female) and 90 age- and sex-matched healthy volunteers (mean age 40, 38 female) included in the study. The mean disease activity score according to partial Mayo score was 2.16 ± 2.13. Mean global longitudinal strain (GLS) and global longitudinal strain rate (GLSR) measurements were significantly lower (−21.16 ± 2.71 vs. −23.36 ± 3.34; p

Objective: Previous prospective studies have reported depression as an independent risk factor for myocardial infarction and cardiovascular mortality. Anxiety disorders are also known to be associated with coronary artery disease (CAD. Psychological factors may also affect the course and outcome of CAD through behavioral mechanisms such as smoking, decreased physical activity, poor diet, and reduced compliance to treatment. The aim of this study was to explore the anxiety and depression levels and to determine the atherosclerotic risk factors in patients admitted for elective coronary angiography due to suspected CAD.Methods: The study population consisted of 116 patients, who were consecutively admitted for elective coronary angiography. Findings were classified into two major groups: normal or abnormal coronary angiography. Abnormal coronary angiography was suggested in patients with atherosclerotic disease (equal to or greater than 50% stenosis) and/or slow blood flow in coronary arteries. Anxi...

Published reports demonstrate improved myocardial reperfusion with adjunctive thrombus aspiration in ST-elevation myocardial infarction (STEMI). However, implementation of this procedure without angioplasty or stent implantation is not clear. In this report, we present an octogenarian with inferior STEMI who was treated with thrombus aspiration alone. Another important feature of our case is trapped thrombus material in the guiding catheter during thrombus aspiration. Operators should avoid thrombus re-injection by controlling the system carefully during aspiration procedure.

Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are associated with worse outcome in various diseases. Non-dipping blood pressure pattern is associated with higher cardiovascular mortality. The aim of this study was to explore the association between NLR and PLR in patients with dipper versus non-dipper hypertension.The study included 166 patients with hypertension. Eighty-three patients (40 male, mean age: 49.1 ± 10.5 years) had dipper hypertension, while 83 patients (41 male, mean age: 52.3 ± 12.7 years) had non-dipper hypertension.Baseline demographic characteristics were similar in both groups. Patients with non-dipper hypertension had significantly higher NLR compared to dipper hypertension (2.3 ± 0.9 versus 1.8 ± 0.5, p 0.001). Patients with non-dipper hypertension had significantly higher PLR compared to dipper hypertension (117.7 ± 35.2 versus 100.9 ± 30.5, p = 0.001). In univariate analysis, hyperlipidemia, smoking, presence of diabetes, PLR more than 107 and NLR more than 1.89 were among predictors of dipper and non-dipper status. In logistic regression analyses, only hyperlipidemia (odds ratio: 2.96, CI: 1.22-7.13) and PLR more than 107 (odds ratio: 2.62, CI: 1.13-6.06) were independent predictors of dipper and non-dipper status. A PLR of 107 or higher predicted non-dipper status with a sensitivity of 66.3% and specificity of 68.7%.We demonstrated that patients with non-dipper hypertension had significantly higher NLR and PLR compared to dipper hypertension, which has not been reported previously. Moreover PLR more than 107 but not NLR was independent predictor of non-dipper status.

Paradoxical embolization through the patent foramen ovale (PFO) is the major cause of most cryptogenic stroke cases. However, the presence of PFO may simply be an incidental finding in these patients, and endothelial dysfunction may be the underlying reason of ischemic stroke. The aim of this study was to compare the endothelial function of cryptogenic stroke patients according to the presence of PFO. Sixty consecutive patients with cryptogenic stroke referred for transesophageal echocardiography (TEE) and 39 consecutive nonstroke patients referred for TEE examination because of suspected PFO were included in the study. Endothelial functions were assessed by brachial artery ultrasonography. PFO was diagnosed by the presence of right-to-left passage of contrast bubbles during TEE. Stroke and nonstroke patients were further subdivided into two groups according to the presence of PFO. Stroke patients had significantly lower flow-mediated dilation (FMD) values than nonstroke patients (8.36 ± 4.38 % vs. 12.57 ± 4.90 %, p