Maraş otu ve sigaranın kardiyak otonomi üzerine etkileri /
Yazar: MURAT AKKOYUN
Danışman: DOÇ. DR. GÜRKAN ACAR
Kahramanmaraş Sütçü İmam Üniversitesi / Tıp Fakültesi / Dahili Tıp Bilimleri Bölümü / Kardiyoloji Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2014
Konu: Kardiyoloji = Cardiology
Dizin: Kalp = Heart ; Kalp hızı = Heart rate ; Maraş otu = Maraş powder ; QT = QT ; Sigara içme = Smoking

Özet:
Giri : Sigara kardiyovask ler hastal klar a s ndan en nemli nlenebilir risk fakt r d r.
Dumans z t t n olarak bilinen ve T rkiye nin G neydo u Anadolu b lgesinde t ketilen
Mara otu nikotin ba ml l na neden olur. Mara otu sigara yerine veya sigaray b rakma
ama l bukkal mukozaya yerle tirilerek kullan l r. Mara otunun kardiyovask ler sistemi
nas l etkiledi ine dair yeterli literat r verisi yoktur.
Sigara inflamasyonu art r c etki g sterir. Total beyaz k re say s ve onun alt tipleri
olan n trofil, lenfosit ve n trofil/lenfosit oran (NLO), rik asit, gama-glutamiltransferaz ve
C-reaktif protein (CRP) sistemik inflamasyonun belirteci olarak kullan labilir. NLO ciddi
kardiyovask ler hastal olan hastalarda k t sonlan mla ili kilendirilmi tir. Ama NLO nun
sigara ve Mara otu kullan c lar ndaki rol ve anlam hakk nda hen z s n rl bilgiye sahibiz.
Kardiyak otonomik sinir sistemi (OSS) normal kardiyak elektrofizyolojinin ayarlanmas nda
ve kardiyak aktivitenin d zenlenmesinde b t nle tirici rol oynar. G nl k pratikte kardiyak
OSS yi de erlendirmemize olanak sa layan kalp h z toparlanmas (KHT), Kalp H z
De i kenli i (KHD), kronotropik yan t ve QT dinamisitesi gibi bir ok test vard r fakat bu
testler sigara ve Mara otu kullan c lar nda OSS nin de erlendirilmesinde uana kadar
kullan lmam t r.
Bu al ma sigara ve Mara otu kullan c lar nda KHT, KHD, kronotropik yan t, QT
dinamisitesi ve inflamasyon durumunu de erlendirme ama l dizayn edildi.
Y ntem: al maya 32 sa l kl g n ll , 32 sigara kullan c s ve 30 Mara otu kullan c s
olmak zere toplam 94 ki i al nd . Beyaz k re say s , rik asit, GGT ve CRP de erleri i in
kan rne i al nd . NLO n trofil y zdesinin lenfosit y zdesine b l nmesiyle elde edildi.
Kardiyak otonomik sistemin belirte leri olan KHT ve kronotropik yan t de erleri egzersiz
stres testi, KHD l mleri 24 saatlik Holter EKG parametreleri kullan larak hesapland . Tp-e
intervali ve Tp-e/QT oran 12 derivasyonlu elektrokardiyografi kullan larak hesapland , Tp-e
intervali kalp h z na g re d zeltildi. T m bu parametreler gruplar aras nda kar la t r ld .
Bulgular: NLO, rik asit ve CRP de erlerinde gruplar aras nda farkl l k saptanmad
(p>0.05). Lenfosit y zdesi ve GGT de erlerinde gruplar aras nda zay f ama nemli bir
farkl l k bulundu (p<0.05). Zirve kalp h z Mara otu kullan c lar nda di er gruplara nazaran
nemli bir ekilde d k bulundu (p=0.003). Mara otu kullan c lar nda kontrol grubuna
iv
g re nemli bir ekilde kronotropik yetersizlik y zdesi y ksek tespit edildi (p=0.02).
D zeltilmi Tp-e intervali ve Tp-e/QT oran nda gruplar aras nda farkl l k
saptanmad (p>0.05).
SDNN (T m NN intervallerinin standart sapmas )(p=0.009), RMSDD(Kom u NN
intervallerinin aras ndaki farklar n karelerinin toplam al nd ktan sonra ortalamas n n
karek k )(p=0.01) ve LF (D k frekans) (p=0.02) de erleri Mara otu kullan c lar nda
kontrol grubuna g re istatistiksel olarak farkl idi. Sigara kullan c lar nda PNN50 (24 saatlik
kay tta aras nda 50 msn den daha fazla fark olan ard k NN interval iftinin say s n n total
NN interval say s na oran ) de eri kontrol grubuna g re anlaml olarak d kt (p=0.03).
Sigara ve Mara otu kullan c lar n n SDANN (5 dakikal k segmentlerin ortalama NN
intervallerinin standart sapmas )( s ras yla p=0.012, p=0.001), HF (Y ksek frekans) (s ras yla
p=0.03, p=0.001) ve LF/HF oran (s ras yla p=0.005, p<0.0001) de erleri kontrol grubuna
g re istatistiksel olarak anlaml farkl l k g stermekte idi.
Sonu lar: Mara otu kullan c lar nda ve sigara i enlerde, kontrol grubu ile
kar la t r ld nda, 24 saatlik ritim holter EKG testi ile de erlendirilen KHD parametreleri
anlaml olarak bozuk idi. NLO, serum rik asit seviyesi ve CRP ile l len inflamatuar
durum t m gruplarda benzerdi. Ayn zamanda, ventrik ler repolarizasyonun belirteci olan
Tp-e intervali ve Tp-e/QT oran da bizim al mam zda t m gruplarda benzer bulundu.
Mara otu kullan m n n egzersize kalp h z yan t n nemli bir ekilde azalttığı tespit edildi.
Anahtar kelimeler: Kalp h z toparlanmas , Mara otu, N/L oran , sigara kullan m , Tp-e
intervali, Tp-e/QT oranı

Abstract:
Purpose: Smoking is the most preventable risk factor for cardiovascular diseases. A kind of
smokeless tobacco known as Maras powder, which is used in the southeastern region of
Turkey, causes nicotine dependence. Maras powder is used by the addicts through buccal
mucosa instead of cigarette or to give up smoking. Its negative effects on cardiovascular
system could not yet fully understood.
Smoking leads to an increased inflammatory activity. The total white blood cell count
and its subtypes, such as neutrophil, lymphocyte, and neutrophil/ lymphocyte ratio (NLR),
uric acid, gamma-glutamyltransferase (GGT) and C-reactive protein (CRP) can be used as an
indicator of systemic inflammation. NLR has been associated with poor outcomes in patients
with several cardiovascular diseases. However, there is limited data about the role of NLR in
subjects with smokers and Maras powder users. Cardiac autonomic nervous system (ANS)
plays an integral role in the modulation of normal cardiac electrophysiology and regulating
cardiac activity. In daily practice, cardiac ANS can be evaluated by several tools like heart
rate recovery (HRR), heart rate variability (HRV), chronotropic response, and QT
dynamicity; however, these methodologies has not been used to evaluate ANS in smokers
and Maras powder users.
The present study was designed to evaluate HRR, HRV, chronotropic response, QT
dynamicity, and inflammatory status in smokers and Maras powder users.
Design and Methods: Study population consisted of 92 male subjects: 32 non-smoker and
non Maras powder user healthy volunteers, 32 cigarette smokers, and 30 Maras powder users.
Blood samples were taken for total white blood cell count, uric acid, GGT and CRP. The NLR
was calculated by dividing neutrophil percentage to lymphocyte. Cardiac ANS indices
including HRR and chronotropic response were calculated from exercise stress test
parameters. HRV parameters were measured from 24-hour rhythm holter ECG. The Tp-e
interval and Tp-e/QT ratio were measured from a 12-lead electrocardiogram, and the Tp-e
interval corrected for heart rate. These parameters were compared among groups.
Results: NLR,uric acid, and CRP were not different among groups (p>0.05). The percentage
of lymphocytes and GGT levels were weakly but significantly different among groups
(p<0.05). Peak heart rate was significantly lower in Maras powder users (p=0.003). The
percentage of chronotropic incompetence in Maras powder users was significantly higher
vi
than controls (p=0.02). Corrected Tp-e interval and Tp-e/QT ratio were not different among
groups (p>0.05).
SDNN (Standard deviations of all N N intervals) (p = 0.009), RMSDD (The root
mean square of the difference in successive R R intervals) (p = 0.01) and LF (low
frequency) (p = 0.02) values were statistically different in Maras powder users than the
control group. PNN50 (the percentage of adjacent R-R intervals that varied by more than
50ms) value was significantly lower in smokers than the control group (p = 0.03).
Smoking and Maras powder users' SDANN ( the standard deviation of the averaged
normal RR intervals for all 5-min segments ) (p = 0.012, p = 0.001), HF (high frequency) (p
= 0.03, p = 0.001) and LF / HF ratio (p = 0.005, p <0.0001) parameters were statistically
different than the control group.
Conclusion: HRV parameters measured by 24-hour rhythm holter ECG in Maras powder
users and cigarette smokers, compared with the control group, were significantly impaired.
Inflammatory status measured by NLR, serum levels of uric acid, and CRP were similar in
subjects with healthy volunteers, smokers and Maras powder users. Also, Tp-e interval and
Tp-e/QT ratio as indices of ventricular repolarisation were similar in our study population.
The use of Maras powder was significantly attenuated heart rate response to exercise.
Key words: Heart rate recovery, Maras powder, N / L ratio, smoking, Tp-e interval,
Tp-e/QT ratio