Association between PDW and Long Term Major Adverse Cardiac Events in Patients with Acute Coronary Syndrome.

BACKGROUND: The aim of the present study was to perform a preliminary evaluation of the potential association between platelet distribution width (PDW) and frequency of major adverse cardiovascular events (MACEs) development in an observational study of acute coronary syndrome (ACS) patients. METHODS: A total of 679 consecutive patients with ACS (498 (73.3%) males; mean age was 63.31±11.2 years; study population composed of 320 patients with acute myocardial infarction and 359 patients with unstable angina pectoris) subjected to primary percutaneous coronary intervention with transradial approach (TRA) were retrospectively enrolled to the study. Tertiles were formed based on PDW levels. The associations between PDW and in-hospital and long-term MACEs were analysed. RESULTS: The frequencies of in-hospital instent thrombosis (P=0.05), long-term instent restenosis (P=0.005) and long-term total MACEs (P=0.008) were higher in tertiles having a high PDW value. In multivariate analyses, PDW was an independent predictor of in-hospital and long-term MACEs (odds ratio 1.081, 95% confidence interval 1.003-1.165; p=0.042). The projected Kaplan-Meier incidence of a MACEs in the PDW tertiles groups were 12.8%, 12.1%, and 21.6% at 40 months (respectively, p=0.003). CONCLUSIONS: The pre-procedural PDW may be an independent predictor of both in-hospital and long-term adverse outcomes in patients with ACS.

Clinical Characteristics and Outcome of Cardiovascular Implantable Electronic Device Infections in Turkey.

Infection is one of the most devastating outcomes of cardiovascular implantable electronic device (CIED) implantation and is related to significant morbidity and mortality. In our country, there is no evaluation about CIED infection. Therefore, our aim was to investigate clinical characteristics and outcome of patients who had infection related to CIED implantation or replacement. The study included 144 consecutive patients with CIED infection treated at 11 major hospitals in Turkey from 2005 to 2014 retrospectively. We analyzed the medical files of all patients hospitalized with the diagnosis of CIED infection. Inclusion criteria were definite infection related to CIED implantation, replacement, or revision. Generator pocket infection, with or without bacteremia, was the most common clinical presentation, followed by CIED-related endocarditis. Coagulase-negative staphylococci and Staphylococcus aureus were the leading causative agents of CIED infection. Multivariate analysis showed that infective endocarditis and ejection fraction were the strongest predictors of in-hospital mortality.

Epicardial Fat Tissue Predicts Increased Long-Term Major Adverse Cardiac Event in Patients With Moderate Cardiovascular Risk.

We investigated the relationship between epicardial fat volume (EFV) measured by multislice computed tomography (MDCT) and long-term major adverse cardiac events (MACEs). Consecutive patients (n = 564) were enrolled in this retrospective study. Patients were divided into tertiles according to EFV. Patients were followed up for an average of 18 months. Patients in each tertile were similar in terms of gender and risk factors. Patients with greater EFV in the third group were more likely to be overweight (P = .001) and older (P = .001). High-density lipoprotein cholesterol levels were relatively lower in the third tertile (45 ± 9, 45 ± 11, and 43 ± 9 mg/dL, respectively; P = .018). The third group had a significantly higher rate of myocardial infarction (0.6%, 1.1%, and 3.7%, respectively; P = .043). The incidence of MACEs during the follow-up period was highest in the third group 15.9% (4.1%, 7.7%, and 15.9%, respectively; P = .001). Epicardial fat volume measured by MDCT was associated with increased long-term cardiovascular risk.

The Utility of the Platelet-Lymphocyte Ratio for Predicting No Reflow in Patients With ST-Segment Elevation Myocardial Infarction.

The aim of the study was to evaluate the utility of the preprocedural platelet-lymphocyte ratio (PLR) for predicting no reflow in patients undergoing primary percutaneous intervention (PCI) for the treatment of ST-segment elevation myocardial infarction. The thrombolysis in myocardial infarction (TIMI) flow grades of 287 patients treated with primary PCI were assessed retrospectively. Patients were divided into 3 tertiles based upon preprocedural PLR. Pre- and postprocedural TIMI flow grades were evaluated. No reflow developed in 6, 14, and 43 patients in the lower, middle, and higher tertiles, respectively (P < .001). After multivariate analysis, PLR remained a significant predictor of no reflow together with neutrophil-lymphocyte ratio (NLR). A cutoff value of 160 for PLR and 5.9 for NLR predicted no reflow with sensitivities and specificities of 75% and 71% and 74% and 70%, respectively. In conclusion, high preprocedural PLR and NLR levels are significant and independent predictors of no reflow in patients undergoing primary PCI.

Predictors of anticoagulant treatment in patients with nonvalvular atrial fibrillation: results from atrial fibrillation in Turkey: epidemiologic registry.

The aim of the study was to assess the factors associated with the anticoagulation treatment in patients with atrial fibrillation (AF). A total of 2242 consecutive patients who had been admitted with AF on their electrocardiogram were included in the study. After excluding valvular AF, 1745 patients with nonvalvular AF were analyzed. Mean CHA2DS2-VASc score [cardiac failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 -74 and sex category (female)], frequency of persistent/permanent AF, hypertension, diabetes mellitus (DM), stroke history, body mass index, and left atrial diameter were significantly higher in patients receiving anticoagulant therapy. Stroke history, persistent/permanent AF, hypertension, DM, age, heart failure, and left atrial diameter were independent predictors of warfarin prescription. Labile international normalized ratio was the only independent negative predictor of effective treatment with warfarin. In this study, we demonstrated that stroke history, persistent/permanent AF, hypertension, DM, and left atrial diameter were positive predictors, whereas advanced age and heart failure were negative predictors of oral anticoagulant use in patients with nonvalvular AF.

[Assessment of right ventricular systolic function in patients with chronic renal failure before and after hemodialysis by means of various echocardiographic modalities]. / Kronik böbrek yetersizligi olan hastalarda hemodiyaliz öncesi ve sonrasi sag ventrikül sistolik fonksiyonlarinin farkli ekokardiyografi yöntemleri ile degerlendirilmesi.

OBJECTIVES: The goal of the study was to determine the effect of decreased preload on right ventricular systolic function, as measured by new and old echocardiographic parameters in chronic renal failure (CRF) patients. STUDY DESIGN: A total of 30 CRF patients (mean age 48±15 years, 11 male and 19 female) undergoing hemodialysis were included in the study. Echocardiography was used to determine left ventricular ejection fraction (LVEF), left atrial volume, right atrial area, right ventricular end-diastolic area, systolic pulmonary artery pressure, right ventricular fractional area change (RV FAC), right ventricular myocardial performance index (Tei index), right ventricular tissue Doppler S' (RV S') velocity, isovolumic myocardial acceleration (IVA), tricuspid annular plane systolic excursion (TAPSE) and right ventricular outflow tract systolic excursion (RVOT SE) before and after hemodialysis. RESULTS: The RV S' velocity and RVOT SE parameters, which are indicators of right ventricular systolic function, did not change significantly after hemodialysis (p=0.919, p=0.186). However, the RV FAC, Tei index, IVA and TAPSE values were significantly increased (p<0.001 for all). TAPSE was found to be the only parameter that had a positive correlation with the amount of fluid removed (p=0.041 and r=0.375). CONCLUSION: Although RV S' velocity and RVOT SE, was found to be independent of preload, RV FAC, Tei index, IVA and TAPSE values were dependent on preload. In addition, TAPSE correlated with the amount of fluid removed.

New inflammatory predictors for non-valvular atrial fibrillation: echocardiographic epicardial fat thickness and neutrophil to lymphocyte ratio.

The objective of this study was to investigate the relationship of echocardiographic epicardial fat thickness (EFT) and neutrophil to lymphocyte ratio (NLR) with different types of non-valvular atrial fibrillation (AF) in a clinical setting. A total of 197 consecutive patients were enrolled in the study. Seventy-one patients had paroxysmal non-valvular AF, 63 patients had persistent/permanent non-valvular AF, and 63 patients had sinus rhythm (control group). EFT was measured with echocardiography, while NLR was measured by dividing neutrophil count by lymphocyte count. EFT was significantly higher in patients with paroxysmal non-valvular AF compared with those in the sinus rhythm group (6.6 ± 0.7 vs. 5.0 ± 0.9 mm, p < 0.001). Persistent/permanent non-valvular AF patients had a significantly larger EFT compared with those with paroxysmal AF (8.3 ± 1.1 vs. 6.6 ± 0.7 mm, p < 0.001). EFT had a significant relationship with paroxysmal non-valvular AF (odds ratio 4.672, 95 % CI 2.329-9.371, p < 0.001) and persistent/permanent non-valvular AF (OR 24.276, 95% CI 9.285-63.474, p < 0.001). NLR was significantly higher in those with paroxysmal non-valvular AF compared with those in the sinus rhythm group (2.5 ± 0.6 vs. 1.8 ± 0.4, p < 0.001). Persistent/permanent non-valvular AF patients had a significantly larger NLR when compared with paroxysmal non-valvular AF patients (3.4 ± 0.6, vs. 2.5 ± 0.6, p < 0.001). NLR (>2.1) had a significant relationship with non-valvular AF (OR 11.313, 95% CI 3.025-42.306, b 2.426, p < 0.001). EFT and NLR are highly associated with types of non-valvular AF independent of traditional risk factors. EFT measured by echocardiography and NLR appears to be related to the duration and severity of AF.

Relationship Between Red Cell Distribution Width and the GRACE Risk Score With In-Hospital Death in Patients With Acute Coronary Syndrome.

The aim of this study was to evaluate the relationship between red cell distribution width (RDW) and Global Registry of Acute Coronary Events (GRACE) risk score in patients with unstable angina pectoris (UAP) and non-ST elevation myocardial infarction (NSTEMI). We retrospectively enrolled 193 patients with UAP/NSTEMI (mean age 63.6 ± 12.6 years; men 57%) in this study. Higher RDW values were associated with increased in-hospital mortality (P = .001). There is a significant correlation between RDW and GRACE score (P < .001). In multivariate logistic regression analysis, RDW was found to be an independent predictor of high GRACE score (odds ratio: 1.513, 95% confidence interval: 1.116-2.051, P = .008). A cutoff value of >15.74 for RDW predicted high GRACE score, with a 64% sensitivity and 65% specificity. Our study results demonstrated that high RDW was an independent predictor of high GRACE score, and it is associated with in-hospital mortality in UAP/NSTEMI.

Epidemiology, anticoagulant treatment and risk of thromboembolism in patients with valvular atrial fibrillation: Results from Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER).

BACKGROUND: The aim of this study was to perform a multicenter, prospective investigation regarding the epidemiology, the current effectiveness of therapeutic anticoagulation, and the risk of thromboembolism in patients with valvular atrial fibrillation (AF) based on the records of the Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study. METHODS: Patients were selected from a total of 2,242 consecutive admissions that presented with AF diagnosed via electrocardiogram. Those diagnosed with non-valvular AF were excluded from the AFTER study population, which left 497 patients with valvular AF for analysis. RESULTS: The etiology of valvular AF in patients was either attributed to rheumatic mitral valve stenosis (n = 217) or possessing a prosthetic heart valve (n = 280). Out of all the patients with valvular AF, 83.1% were taking warfarin for anticoagulation. Only 36.1% demonstrated a therapeutic international normalized ratio (INR), and among those patients it was found that 19.1% exhibited a labile INR. Multivariate analysis revealed that age was the only independent predictor of thromboembolic events in patients with valvular AF. CONCLUSIONS: Many valvular AF patients are not maintained at therapeutic INR levels, which poses a threat to patient health as they age and are at greater risk for thromboembolism.

Association between neutrophil to lymphocyte ratio and pulmonary arterial hypertension.

OBJECTIVES: Pulmonary hypertension (PH) is composed of a heterogeneous group of disorders marked by increased pulmonary artery resistance leading to right heart failure, with high mortality. Evidence is increasing to propose that inflammation plays a significant role in the pathophysiological mechanism. Increased prevalence of PH in patients with systemic inflammatory diseases is already known. Herein, we sought to evaluate the association between neutrophil to lymphocyte ratio (N/L ratio) and pulmonary arterial hypertension (PAH). STUDY DESIGN: Twenty-five patients with PAH and 25 controls were evaluated. Baseline clinical and echocardiographic variables were obtained. Complete blood counts in all patients and controls were reviewed retrospectively. RESULTS: The N/L ratio was higher in patients with PAH compared to healthy volunteers (p=0.05). A cut-off value of 1.65 for N/L ratio predicted the presence of PAH with 72% sensitivity and 69% specificity. After multivariate analysis, only N/L ratio remained a significant predictor of PAH. CONCLUSION: We showed for the first time that N/L ratio was significantly increased in patients with PAH compared to controls.

[A second percutaneous closure due to residual mitral paravalvular leak and successful treatment of device embolization]. / Kalinti mitral paravalvüler kaçagi nedeniyle ikinci kez yapilan perkütan kapatma islemi ve olusan cihaz embolisinin basarili tedavisi.

Paravalvular leak (PVL) is a common complication after surgical valve replacement. Most PVLs remain clinically silent; however, some may require reoperation due to symptomatic PVL. Surgical closure of PVL remains the most common therapy for these defects; however, redo surgery has some disadvantages, including a high recurrence rate as well as high morbidity and mortality rates. Percutaneous closure of PVLs has emerged as an alternative to surgical closure. A 42-year-old male patient underwent a second percutaneous closure due to residual mitral paravalvular leak. During the procedure, the closure device embolized in the descending aorta. The device was captured with a snare and successfully retrieved, and then PVL was successfully occluded with another device.

Relation of epicardial fat thickness and brachial flow-mediated vasodilation with coronary artery disease.

OBJECTIVE: The purpose of this study is to investigate the presence of a statistical association between epicardial fat thickness (EFT) and coronary artery disease (CAD) and between flow-mediated vasodilation (FMD) and CAD. METHODS: We measured the EFT and FMD in 64 subjects with suspected stable angina pectoris. The patients were separated into two groups according to their coronary angiography results: 34 patients with CAD and 30 patients with normal coronary arteries (NCA). RESULTS: EFT was significantly higher in the patients with CAD than the NCA group (6.43 ± 0.90 mm vs. 5.35 ± 0.75 mm, p<0.001) while FMD was significantly lower in the patients with CAD than those in the NCA group (6.41 ± 2.51% vs. 8.33 ± 3.45%, p=0.015). No significant correlation was found between EFT and FMD. After adjustment for EFT, FMD, age, sex, ejection fraction, glucose, and low-density lipoprotein cholesterol through multivariate logistic regression analysis, EFT (odds ratio: 6.325, 95% confidence interval 2.289-17.476, p<0.001) and age (odds ratio: 1.093, 95% confidence interval 1.008-1.185, p=0.032) remained significant predictors of CAD. A cut-off value of EFT≥5.8mm predicted the presence of CAD with 77% sensitivity and 70% specificity. CONCLUSION: An echocardiographic EFT assessment is independently associated with the presence of CAD. Thus, EFT may be helpful in cardiometabolic risk stratification and therapeutic interventions.

Epidemiology of atrial fibrillation in Turkey: preliminary results of the multicenter AFTER study.

OBJECTIVES: Although atrial fibrillation (AF) is one of the most common rhythm disorders observed in clinical practice, a multicenter epidemiological study has not been conducted in our country. This study aimed to assess our clinical approach to AF based upon the records of the first multicenter prospective Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study. STUDY DESIGN: Taking into consideration the distribution of the population in our country, 2242 consecutive patients with at least one AF attack determined by electrocardiographic examination in 17 different tertiary health care centers were included in the study. Inpatients and patients that were admitted to emergency departments were excluded from the study. Epidemiological data of the patients and the treatment administered were assessed. RESULTS: The mean age of the patients was determined as 66.8 ± 12.3 years with female patients representing 60% of the study population. While the most common AF type in the Turkish population was non-valvular AF (78%), persistent/permanent AF was determined in 81% of all patients. Hypertension (%67) was the most common co-morbidity in patients with AF. While a stroke or transient ischemic attack or history of systemic thromboembolism was detected in 15.3% of the patients, bleeding history was recorded in 11.2%. Also, 50% of the patients were on warfarin treatment and 53% were on aspirin treatment at the time of the study. The effective INR level was detected in 41.3% of the patients. The most frequent cause of not receiving anticoagulant therapy was physician neglect. CONCLUSION: These results demonstrate the necessity for improved quality of physician care of patients with AF, especially with regards to antithrombotic therapy.

The atrial fibrillation in Turkey: Epidemiologic Registry (AFTER).

BACKGROUND: AFTER (Atrial Fibrillation in Turkey: Epidemiologic Registry) is a prospective, multicenter study designed with the aim of describing the prevalence and epidemiology of AF practice in Turkey. This study aims to evaluate stroke risk in non-valvular atrial fibrillation (AF) and anticoagulant drug utilization within conformity to AF guidelines. METHODS: Patients were recruited in 17 referral hospitals reflecting all the population of 7 geographical regions of Turkey. 2242 consecutive patients who had been admitted with AF on ECG were included in the study. 1745 of these patients, who had non-valvular AF, were included in the statistical evaluation. Stroke risk was evaluated with the CHA2DS2-VASc score. RESULTS: The average age of participants was determined to be 69.2 ± 11.5 years (56% female). Persistent-permanent AF was found to be the most common type of non-valvular AF (78%). The most common comorbid disorder was hypertension (73%). It was found that oral anticoagulant therapy was used by 40% of all patients, 37% of whom had effective INR (2.0-3.0). Upon multivariate analysis, age was found to be the only independent predictor of stroke among the variables' effects on thromboembolic events that created CHA2DS2-VASc abbreviations (OR 1.026, p < 0.001). CONCLUSIONS: These results suggest that stroke risk scores should be thoroughly heeded based on guidelines, and that anticoagulation must be applied according to their guidance.

Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study design.

OBJECTIVE: Atrial fibrillation (AF) is an important health problem in Turkey. However, no prospective, multicenter, large trial reflecting national data has been published so far. Therefore, the aim of this study was to follow, analyze and evaluate patients with AF in a large multicenter nation-wide trial. METHODS: Two thousand three hundred consecutive patients with AF in their electrocardiogram, reflecting all the population of seven geographical regions of Turkey will be included in the study. The patients will be followed up for two years and death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding, hospitalization will be recorded as the primary end-point. RESULTS: Will be available at the end of the study; preliminary results will be due December 2012. CONCLUSION: General risk profile of patients with AF, frequency of anticoagulation, frequency of effective treatment and risks of bleeding will be evaluated according to the current guidelines. Major adverse events and their independent predictors will be determined.

Assessment of left ventricular systolic and diastolic function with conventional and tissue Doppler echocardiography imaging techniques in patients administered tyrosine kinase inhibitor.

OBJECTIVES: The aim of this study was to use echocardiographic techniques to determine the possible cardiotoxic effects of low molecular weight tyrosine-kinase inhibitors (TKI) in patients receiving the therapy for the first time. STUDY DESIGN: Thirty patients (17 females; 13 males; mean age 49±16; range 22 to 76 years) who met the exclusion criteria and were diagnosed as having malignancy were enrolled. All patients underwent conventional echocardiography and tissue Doppler imaging (TDI) prior to the treatment. The conventional echocardiogram was repeated 2 months later as the patients were concurrently receiving therapy. Myocardial Performance Index was obtained by conventional echocardiography and by TDI techniques to evaluate left ventricular systolic and diastolic function. RESULTS: Statistically significant increase occurred in mean left ventricle (LV) end-systolic volume. However, there was significant decrease in both mean LV ejection fraction and LV stroke volume values (64±3, 62±4, p=0.000 and 67±13, 61±13, p=0.000, respectively). Anterior wall Em/Am ratio measured by using the TDI technique was significantly decreased at the end of two months (0.99±0.49, 0.90±0.41, p=0.03). In addition, decreases were determined in Sm values obtained from all of four LV walls and also in mean Sm value, but this decrease was significant only for the lateral wall Sm measurement (12.8±2.9, 11.6±2.3, p=0.004). CONCLUSION: Tyrosine-kinase inhibitors therapy can be administered safely to patients without predisposing factors for cardiotoxicity in short treatment intervals, and low molecular TKIs may cause subtle or clinically significant cardiotoxicity following the treatment period even in patients without predisposing factors for cardiotoxicity, so clinicians should consider this possibility.

The acute effect of bi-level positive airway pressure on heart rate variability in chronic obstructive pulmonary disease patients with hypercapnic respiratory failure.

OBJECTIVE: Non-invasive mechanical ventilation (NIMV) has the potential to improve sympathovagal control of heart rate. The aim of this study was to investigate the acute effects of NIMV on heart rate variability (HRV) in chronic obstructive pulmonary disease (COPD) patients with hypercapnic respiratory failure (HRF). METHODS: In this prospective study 28 COPD patients (64+/-10 years) with HRF underwent electrocardiographic Holter monitorization. Both time domain (TD) and frequency domain (FD) means of HRV analysis were measured for two hours before and during NIMV application. For the TD, mean-RR, SDNN, SDANN, SDNN index, RMSSD, pNN50 and HRV triangular index were measured. For FD, high frequency (HF) and low frequency (LF) were detected. To compare HRV parameters before and during bi-level positive airway pressure (BiPAP) application; paired sample t test was used for normally distributed variables and Wilcoxon signed rank test was used for the variables that were not normally distributed. Pearson correlation test was used to analyze the correlation between HRV and blood gas parameters during BiPAP application. RESULTS: High frequency power of HRV (39 (18-65) ms2 vs. 28 (12-50) ms2, p<0.05), HRV triangular index (9 (3-17) units vs. 6 (2-13) units, p<0.05) and pNN50 (59% (13-110) vs. 42% (5-84), p<0.05), were higher during NIMV than before noninvasive mechanical ventilation. CONCLUSIONS: We think that NIMV may improve heart rate variability indices of parasympathetic modulation of heart rate in COPD cases with HRF and decrease arrhythmic potential.

Is there any relationship between metabolic parameters and left ventricular functions in type 2 diabetic patients without evident heart disease?

BACKGROUND: The aim of the present study was to evaluate left ventricle (LV) systolic and diastolic function, using tissue Doppler echocardiography (TDE) and color M-mode flow propagation velocity, in relation to blood glucose status in normotensive patients with type 2 diabetes mellitus (T2DM) who had no clinical evidence of heart disease. METHODS: Seventy-two patients with T2DM (mean age 49.1 +/- 9.8 years) without symptoms, signs or history of heart disease and hypertension, and 50 ages matched healthy controls (mean age 46.1 +/- 9.8 years) had echocardiography. Systolic and diastolic LV functions were detected by using conventional echocardiography, TDE and mitral color M-mode flow propagation velocity (V(E)). Fasting blood glucose level (FBG) after 8 hours since eating a meal, postprandial blood glucose level (PPG), and HbA(1C) level were determined. The association of FBG, PPG and HbA(1C) with the echocardiographic parameters was investigated. RESULTS: It was detected that although systolic functions of two groups were similar, diastolic functions were significantly impaired in diabetics. No relation of FBG and PPG with systolic and diastolic functions was determined. However, HbA(1C) was found to be related to diastolic parameters such as E/A, Em/Am, V(E) and E/V(E) (beta=-0.314, P = < 0.05; beta=-0.230, P < 0.05; beta=-0.602, P < 0.001, beta= 0.387, P < 0.005, respectively). In addition to HbA(1C), LV, diastolic functions were also correlated with age and diabetes duration. CONCLUSION: Diastolic LV dysfunction may develop even in absence of ischemia, hypertension, and LVH in T2DM. FBG and PPG have no effect on LV functions, but HbA(1C) levels may affect diastolic parameters.