Performance of the ATRIA Bleeding Score in Predicting the Risk of In-Hospital Bleeding in Patients with ST-Elevation or Non-ST-Elevation Myocardial Infarction

ABSTRACT Introduction: A clear assessment of the bleeding risk score in patients presenting with myocardial infarction (MI) is crucial because of its impact on prognosis. The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA score is a validated risk score to predict bleeding risk in atrial fibrillation (AF), but its predictive value in predicting bleeding after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) patients receiving antithrombotic therapy is unknown. Our aim was to investigate the predictive performance of the ATRIA bleeding score in STEMI and NSTEMI patients in comparison to the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) bleeding scores. Methods: A total of 830 consecutive STEMI and NSTEMI patients who underwent PCI were evaluated retrospectively. The ATRIA, CRUSADE, and ACUITY-HORIZONS risk scores of the patients were calculated. Discrimination of the three risk models was evaluated using C-statistics. Results: Major bleeding occurred in 52 (6.3%) of 830 patients during hospitalization. Bleeding scores were significantly higher in the bleeding patients than in non-bleeding patients (all P<0.001). The discriminatory ability of the ATRIA, CRUSADE, and ACUITY-HORIZONS bleeding scores for bleeding events was similar (C-statistics 0.810, 0.832, and 0.909, respectively). The good predictive value of all three scores for predicting the risk of bleeding was observed in NSTEMI and STEMI patients as well (C-statistics: 0.820, 0.793, and 0.921 and 0.809, 0.854, and 0.905, respectively). Conclusion: This study demonstrated that the ATRIA bleeding score is a useful risk score for predicting major in-hospital bleeding in MI patients. This good predictive value was also present in STEMI and NSTEMI patient subgroups.

Performance of the ATRIA Bleeding Score in Predicting the Risk of In-Hospital Bleeding in Patients with ST-Elevation or Non-ST-Elevation Myocardial Infarction.

INTRODUCTION: A clear assessment of the bleeding risk score in patients presenting with myocardial infarction (MI) is crucial because of its impact on prognosis. The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA score is a validated risk score to predict bleeding risk in atrial fibrillation (AF), but its predictive value in predicting bleeding after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) patients receiving antithrombotic therapy is unknown. Our aim was to investigate the predictive performance of the ATRIA bleeding score in STEMI and NSTEMI patients in comparison to the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) bleeding scores. METHODS: A total of 830 consecutive STEMI and NSTEMI patients who underwent PCI were evaluated retrospectively. The ATRIA, CRUSADE, and ACUITY-HORIZONS risk scores of the patients were calculated. Discrimination of the three risk models was evaluated using C-statistics. RESULTS: Major bleeding occurred in 52 (6.3%) of 830 patients during hospitalization. Bleeding scores were significantly higher in the bleeding patients than in non-bleeding patients (all P<0.001). The discriminatory ability of the ATRIA, CRUSADE, and ACUITY-HORIZONS bleeding scores for bleeding events was similar (C-statistics 0.810, 0.832, and 0.909, respectively). The good predictive value of all three scores for predicting the risk of bleeding was observed in NSTEMI and STEMI patients as well (C-statistics: 0.820, 0.793, and 0.921 and 0.809, 0.854, and 0.905, respectively). CONCLUSION: This study demonstrated that the ATRIA bleeding score is a useful risk score for predicting major in-hospital bleeding in MI patients. This good predictive value was also present in STEMI and NSTEMI patient subgroups.

Fragmented QRS in the relatives of patients with coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is one of the important causes of mortality. It has been emphasized that the risk of CAD may be increased in the relatives of CAD patients. Fragmented QRS (fQRS) is an electrocardiography (ECG) marker showing myocardial damage. METHODS: A study group of 62 symptomatic individuals (31 males, mean age 38.5 ± 7.12 years) with first-degree relatives with coronary artery disease and 64 healthy volunteers (24 males, mean age 37.9 ± 11.6 years) were included in this study. The study did not include those with known cardiac disease, metabolic disease, or drug use that may cause a change in ECG parameters. RESULTS: There was no significant difference between the groups regarding gender, heart rate, QRS complex, QTc, frontal QRS-T angle, and left ventricle ejection fraction. Compared to the control group, the QT interval and fQRS count were significantly higher in the study group (p < .05 for both). Low-density lipoprotein cholesterol (LDL-C), hemoglobin, and neutrophil counts were significantly higher in the study group compared to the control group (p < .05 for all). CONCLUSIONS: Our study showed that fQRS was increased in individuals with symptomatic first-degree relatives with coronary artery disease compared to healthy volunteers.

Evaluation of myocardial performance index in patients with COVID-19: An echocardiographic follow-up study.

Introduction and Objectives: Myocardial performance may be impaired in cytokine-mediated immune reactions. The myocardial performance index (MPI) is a practical parameter that reflects systolic and diastolic cardiac function. We aimed to assess the MPI in patients with COVID-19. Methods: The study population consisted of 40 healthy controls and 40 patients diagnosed with COVID-19 who had mild pneumonia and did not need intensive care treatment. All participants underwent echocardiographic examination. First, the MPI and laboratory parameters were compared between healthy controls and patients in the acute period of infection. Second, the MPI and laboratory parameters were compared between the acute infection period and after clinical recovery. Results: Compared with healthy controls, patients with COVID-19 had a significantly higher MPI (0.56±0.09 vs. 0.41±0.06, p<0.001), longer isovolumic relaxation time (IRT) (112.3±13.4 vs. 90.6±11.2 ms, p<0.001), longer deceleration time (DT) (182.1±30.6 vs. 160.8±42.7 ms, p=0.003), shorter ejection time (ET) (279.6±20.3 vs. 299.6±34.7 ms, p<0.001) and higher E/A ratio (1.53±0.7 vs. 1.21±0.3, p<0.001). Statistically significantly higher MPI (0.56±0.09 vs. 0.44±0.07, p<0.001), longer IRT (112.3±13.4 vs. 91.8±12.1 ms, p<0.001), longer DT (182.1±30.6 vs. 161.5±43.5 ms, p=0.003), shorter ET 279.6±20.3 vs. 298.8±36.8 ms, p<0.001) and higher E/A ratio (1.53±0.7 vs. 1.22±0.4, p<0.001) were observed during the acute infection period than after clinical recovery. Left ventricular ejection fraction was similar in the controls, during the acute infection period and after clinical recovery. Conclusions: Subclinical diastolic impairment without systolic involvement may be observed in patients with COVID-19. This impairment may be reversible on clinical recovery.

Introducão e objetivos: O desempenho miocárdico pode ser prejudicado em reações imunes mediadas por citocinas. O índice de performance miocárdico (IPM) é um parâmetro que reflete a função cardíaca sistólica e diastólica. O nosso objetivo foi avaliar o IPM em doentes com COVID-19. Métodos: O presente estudo consistiu em analisar 40 casos controlo saudáveis e 40 doentes com diagnóstico de COVID-19 que apresentavam pneumonia ligeira e não necessitavam de tratamento intensivo. Todos os participantes foram submetidos a avaliação ecocardiográfica. Primeiro, o IPM e os parâmetros laboratoriais foram comparados entre os casos controlo saudáveis e os doentes com período agudo de infeção. Em segundo lugar, o IPM e os parâmetros laboratoriais foram comparados entre o período agudo de infeção e após a recuperação clínica. Resultados: Em comparação com os casos controlo saudáveis, os doentes com COVID-19 tiveram um IPM significativamente maior (0,56±0,09 versus 0,41±0,06, p<0,001), tempo de relaxamento isovolumétrico (TRI) mais longo (112,3±13,4 versus 90,6±11, 2 ms, p<0,001), tempo de desaceleração maior (TD) (182,1±30,6 versus 160,8±42, 7 ms, p=0,003), tempo de ejeção (TE) menor (279,6±20,3 versus 299,6±34, 7 ms, p<0,001) e razão E/A maior (1,53±0,7 versus 1,21±0,3, p<0,001). Um IPM superior estatisticamente significativo (0,56±0,09 versus 0,44±0,07, p<0,001), um TRI mais longo (112,3±13,4 versus 91,8±12, 1 ms, p<0,001), um TD mais longo (182,1±30,6 versus 161,5±43,5 ms, p=0,003), um TE mais curto (279,6±20,3 versus 298,8±36,8 ms, p<0,001) e razão E/A mais elevada (1,53±0,7 versus 1,22±0,4, p<0,001) foram observados durante o período agudo de infeção em comparação com aqueles após a recuperação clínica. A fração de ejeção do ventrículo esquerdo foi semelhante nos casos controlo saudáveis, período agudo de infeção e após a recuperação clínica. Conclusão: A disfunçao diastólica subclínica sem difunção sistólica pode ser observada em doentes com COVID-19. Esta deficiência pode ser reversível na recuperação clínica.

Altered cardiac autonomic function after recovery from COVID-19.

BACKGROUND: Autonomic dysfunction may occur during the acute phase of COVID-19. Heart rate variability (HRV) is a useful tool for the assessment of cardiac sympathetic and parasympathetic balance. We aimed to evaluate cardiac autonomic function by using HRV in subjects after recovery from COVID-19 who had previously symptomatic and were followed outpatiently. METHODS: The study group composed of 50 subjects with a confirmed history of COVID-19 and the control group composed of 50 healthy subjects without a history of COVID-19 and vaccination. All the study participants underwent 2-dimensional, pulsed- and tissue-Doppler echocardiographic examinations and 24-hour Holter monitoring for HRV analysis. RESULTS: Time domain parameters of SDNN, SDANN, SDNNi, RMSSD, pNN50, and HRV triangular index were all decreased in the study group when compared with the control group. Frequency domain parameters of TP, VLF, LF, HF, and HFnu were also decreased in the study group in comparison with the control group. LFnu was similar between groups. Nonlinear parameters of HRV including α1 and α2 decreased in the study group. By contrast, Lmax, Lmean, DET, REC, and Shannon entropy increased in the study population. Approximate and sample entropies also enhanced in the study group. CONCLUSIONS: The present study showed that all three domain HRV significantly altered in patients after recovery from COVID-19 indicating some degree of dysfunction in cardiac autonomic nervous system. HRV may be a useful tool for the detection of preclinical autonomic dysfunction in this group of patients.

Plasma atherogenic indices are independent predictors of slow coronary flow.

BACKGROUND: Although the pathophysiology of coronary slow flow (CSF) has not been fully elucidated, emerging data increasingly support potential role for subclinical diffuse atherosclerosis in the etiology of CSF. We aimed to investigate relationship between atherogenic indices and CSF. METHODS: 130 patients with CSF diagnosed according to Thrombolysis in Myocardial Infarction (TIMI)-frame count (TFC) method and 130 controls who had normal coronary flow (NCF) were included in this retrospective study. Atherogenic indices (atherogenic index of plasma [AIP], Castelli risk indices I and II [CRI-I and II]) were calculated using conventional lipid parameters. RESULTS: The logistic regression analyses demonstrated that AIP (OR, 5.463; 95% confidence interval [CI], 1.357-21.991; p = 0.017) and CRI-II (OR, 1.624; 95% CI, 1.138-2.319; p = 0.008) were independent predictors of CSF. Receiver operating characteristic analysis showed that the optimal cutoff value to predict the occurrence of CSF was 0.66 for AIP (sensitivity, 59%; specificity, 73%; area under curve [AUC], 0.695; p < 0.001) and 3.27 for CRI-II (sensitivity, 60%; specificity, 79%; AUC, 0.726; p < 0.001). CONCLUSIONS: AIP and CRI-II levels were independent predictors of CSF. Prospective studies in larger cohorts of patients may elucidate the role of atherogenic dyslipidemia in the pathophysiology of CSF.

Fibrinogen-to-albumin ratio predicts mortality in COVID-19 patients admitted to the intensive care unit.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is an inflammatory disease, and serum albumin and fibrinogen are two important factors in systemic inflammation. We aimed to investigate the relationship between the fibrinogen-to-albumin ratio (FAR) and in-hospital mortality in COVID-19 patients admitted to the intensive care unit (ICU). MATERIAL AND METHODS: Patients diagnosed with COVID-19 admitted to the Adiyaman Training and Research Hospital from August to November 2020 were enrolled in this retrospective cohort study. They were divided into 2 groups based on in-hospital mortality: a survivor group (n = 188) and a non-survivor group (n = 198). FAR was calculated by dividing the fibrinogen value by the albumin value. Mortality outcomes were followed up until December 15, 2020. RESULTS: The average age of the patients was 71.2 ± 12.9 years, and 54% were male. On multivariate logistic analysis, diabetes mellitus (OR: 1.806; 95% CI: 1.142-2.856; p = 0.011), troponin I levels (OR: 1.776; 95% CI: 1.031-3.061; p = 0.038), and FAR (OR: 1.004; 95% CI: 1.004-1.007; p = 0.010) at ICU admission were independent predictors of in-hospital mortality in patients with COVID-19. CONCLUSIONS: The FAR at admission was associated with mortality in patients infected with SARS-CoV-2 in the ICU.

Effects of eight weeks exercise training on serum levels of adropin in male volleyball players.

OBJECTIVES: To evaluate the effects of an eight week exercise program on the lipid profile in serum, serum levels of adropin, systolic blood pressure (SBP), and diastolic blood pressure (DBP) in male volleyball players. METHODS: Sixteen healthy male volleyball players participated in this study. Subjects performed eight weeks of aerobic and resistance training, and body mass index (BMI), body fat ratio, total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), adropin, SBP, and DBP values were measured at the start (untrained) and end (trained) of training. Non-HDL-C was calculated by subtracting HDL-C from TC. RESULTS: Body fat percentage and BMI values decreased significantly after eight weeks of exercise training. There was a statistically significant decrease in the post-test values of LDL-C, TG, non-HDL-C, and DBP compared to pre-test measurements. There was a significant increase in the trained levels of adropin and HDL-C compared to untrained levels. Pearson's correlation analyses revealed a negative and significant relationship between changes in DBP and adropin levels before and after exercise. CONCLUSIONS: Eight weeks of exercise training decreased LDL-C, TG, non-HDL-C, and DBP and an increased serum levels of adropin in male volleyball players.

Effects of regular exercise on inflammatory biomarkers and lipid parameters in soccer players.

Since chronic dyslipidemia and inflammation play a major role in the etiopathogenesis of atherosclerotic plaque, we investigated the effects of a 7-week exercise on the serum lipid profile, plasma atherogenic index (PAI), and inflammatory biomarkers interleukin (IL), tumor necrosis factor (TNF)-α, and monocyte chemoattractant protein (MCP)-1 in male soccer players. Methods: The participants in this study were 22 healthy male soccer players aged 19-25 years. IL-1ß, IL-6, IL-10, TNF-a, MCP-1, and lipid profile were recorded before and after the program. PAI was calculated as log (TG/HDL-C), where TG is triglyceride and HDL-C is high-density lipoprotein cholesterol. Results: There were significant decreases in post-exercise IL-6, TNF-α, and MCP-1 (for all, p< .05). Compared to the pretest values, there were significant decreases in posttest total cholesterol (TC), TGs, low-density lipoprotein (LDL), non- high-density lipoprotein cholesterol (non-HDL-C), and PAI (for all, p< .05). In contrast, HDL-C values increased after exercise (p< .001). After exercise training TC, TGs, LDL-C, non-HDL-C, and PAI decreased and HDL-C increased, indicating improvement in parameters of dyslipidemia. The decreases in IL-6, TNF-α, and MCP-1 suggest a decrease in systemic inflammation.

Correction to: Evaluation of Index of Cardio-Electrophysiological Balance in Patients With Atrial Fibrillation on Antiarrhythmic-Drug Therapy.

[This corrects the article DOI: 10.14740/cr1185.].

Evaluation of Index of Cardio-Electrophysiological Balance in Patients With Atrial Fibrillation on Antiarrhythmic-Drug Therapy.

BACKGROUND: Index of cardio-electrophysiological balance (iCEB) has been described as a novel risk marker for predicting malignant ventricular arrhythmia. There remains limited evidence on the effects of amiodarone and propafenone used for sinus rhythm maintenance on iCEB in patients with atrial fibrillation (AF). The aim of this study was to evaluate iCEB in patients with AF on antiarrhythmic-drug therapy. METHODS: A total of 108 patients with AF (68 patients using amiodarone and 40 patients using propafenone) and 50 healthy subjects were included in the study. All groups underwent a standard 12-lead surface electrocardiogram. QRS duration, QT, T wave peak-to-end (Tp-e) intervals, iCEB (QT/QRS) and iCEBc (heart rate-corrected QT (QTc)/QRS) rates were calculated from the electrocardiogram and compared between groups. RESULTS: QT, Tp-e intervals and Tp-e/QT ratio were significantly longer in the amiodarone group than the propafenone and control groups (P < 0.001, for all). iCEB was similar in the amiodarone and control groups (4.4 ± 0.6 and 4.2 ± 0.4; P > 0.05), while iCEB values in the propafenone group were significantly lower than the amiodarone group and control groups (3.9 ± 0.5; P < 0.001). There was a significantly difference in iCEBc values among the amiodarone, control and propafenone groups (4.8 ± 0.6, 4.6 ± 0.4 and 4.3 ± 0.6; P < 0.001, respectively). CONCLUSIONS: In this study, higher iCEBc parameters were observed in patients using amiodarone, while iCEBc values were lowest among patients with AF using propafenone. Further studies are needed to determine whether these electrophysiological changes are associated with ventricular arrhythmias for patients with AF on antiarrhythmic-drug therapy.

A spontaneous cervical spinal epidural hematoma in a male patient receiving treatment for acute coronary syndrome: A case report.

Although spontaneous spinal epidural hematoma is a rare entity with an unknown origin, it may occur secondary to the use of anticoagulant and/or antiplatelet agents, which are particularly used for the treatment of cardiovascular and cerebrovascular diseases. Since it occurs rarely and its initial symptoms are usually non-specific, early and accurate diagnosis can be challenging which affects survival rate and the quality of life. Herein, we present a 65-year-old male case who developed acute severe neck pain and headache on the third day of acute coronary syndrome treatment, followed by neurological deficits in bilateral upper and lower extremities.

Effects of Short-Term Hydroxychloroquine Plus Moxifloxacin Therapy on Corrected QT Interval and Tp-e Interval in Patients With COVID-19.

BACKGROUND: Limited data are available regarding hydroxychloroquine (HCQ) and moxifloxacin (MOX) in patients with possible coronavirus disease 2019, (COVID-19). Both drugs may increase risk of malignant ventricular arrhythmias associated with prolongation of QT interval. METHODS: A total of 76 subjects with chest tomography findings compatible with COVID-19 pneumonia were enrolled in the study. Standard 12-lead electrocardiogram (ECG) was repeated on days 2 and 5 in patients receiving a combination of HCQ + MOX. Heart rate, QT interval, Tp-e interval, and Tp-e/QT ratio were measured. RESULTS: The mean age of the patients was 61.7 ± 14.8 years and 54% had hypertension. Compared to day 2, ECG on day 5 showed significant increases in QT interval (370.8 ± 32.5 vs. 381.0 ± 29.3, respectively, P = 0.001), corrected QT (QTc) interval (424 (403 - 436) vs. 442 (420 - 468), respectively, P < 0.001), Tp-e interval (60 (55 - 70) vs. 65 (57 - 75), respectively, P < 0.001), cTp-e interval (72.2 ± 12.9 vs. 75.4 ± 12.7, respectively, P < 0.001). Moreover, a slight decrease in Tp-e/QT ratio was observed (0.17 ± 0.03 vs. 0.17 ± 0.02, P = 0.030). QTc was > 500 ms in 5% of the patients, and 8% of patients had an increase in QTc interval > 60 ms. Tp-e/QT ratio was > 0.23 in 4% of patients. Five patients died due to pulmonary failure without evidence of ventricular arrhythmia. No ventricular arrhythmia events, including torsades de pointes (TdP), were observed. CONCLUSIONS: HCQ + MOX combination therapy led to increases in QTc interval, Tp-e interval, and cTp-e interval. However, this therapy did not cause ventricular arrhythmia in the short-term observation.

Evaluation of TP-E Interval and TP-E/QT Ratio in Panic Disorder.

Background and Objectives: The autonomic nervous system (ANS) is involved in panic disorders. ANS dysfunction has been shown to be associated with ventricular arrhythmia and increased heterogeneity of ventricular repolarization. However, there remains limited evidence of the relationship between panic disorders and ventricular depolarization markers, including the Tp-e interval and Tp-e/QT ratio. This study aimed to evaluate ventricular repolarization parameters in patients with panic disorder. Materials and Methods: In total, 40 patients with panic disorder, diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, were included in the study group. The control group comprised of 50 age- and sex-matched healthy individuals. A standard 12 lead electrocardiogram was recorded on all participants, and heart rate, QT interval, QRS duration, Tp-e interval, and Tp-e/QT ratio were measured. Results: QRS durations and QT intervals were similar in the study and control groups. Compared to the control group, QTd, Tp-e, and cTp-e intervals as well as Tp-e/QT and Tp-e/QTc ratios were significantly increased in patients with panic disorder (p < 0.05 for all). In the study group, the Severity Measure for Panic Disorder-Adult score had a significant positive correlation with the Tp-e interval (r = 0.369, p < 0001), cTp-e interval (r = 0.531, p < 0.001), Tp-e/QT ratio (r = 0.358, p = 0.001), and Tp-e/QTc ratio (r = 0.351, p = 0.001). Conclusion: These findings indicate that panic disorders are associated with increased ventricular repolarization heterogeneity, which may be attributed to ANS dysregulation.

The effect of idiopathic premature ventricular complexes on left ventricular ejection fraction.

AIM: Current literature lacks a definitive threshold of idiopathic premature ventricular complex (PVC) burden for predicting cardiomyopathy (CMP). The main objective of the present study was to evaluate relationship between the PVC burden and left ventricular ejection fraction (LVEF). METHOD: This multicenter, cross-sectional study included 341 consecutive patients with more than 1,000 idiopathic PVC in 24 hr of Holter monitoring admitted to the cardiology clinics between January 2019 and May 2019 in the nineteen different centers. The primary outcome was the LVEF measured during the echocardiographic examination. RESULT: Overall, the median age was 50 (38-60) and 139 (49.4%) were female. Percentage of median PVC burden was 9% (IQR: 4%-17.4%). Median LVEF was found 60% (55-65). We used proportional odds logistic regression method to examine the relationship between continuous LVEF and candidate predictors. Increase in PVC burden (%) (regression coefficient (RE) -0.644 and 95% CI -1.063, -0.225, p < .001), PVC QRS duration (RE-0.191 and 95% CI -0.529, 0.148, p = .049), and age (RE-0.249 and 95% CI -0.442, -0.056, p = .018) were associated with decrease in LVEF. This inverse relationship between the PVC burden and LVEF become more prominent when PVC burden was above 5%. A nomogram developed to estimate the individual risk for decrease in LVEF. CONCLUSION: Our study showed that increase in PVC burden %, age, and PVC QRS duration were independently associated with decrease in LVEF in patients with idiopathic PVC. Also, inverse relationship between PVC burden and LVEF was observed in lower PVC burden than previously known.

The Time in Therapeutic Range and Bleeding Complications of Warfarin in Different Geographic Regions of Turkey: A Subgroup Analysis of WARFARIN-TR Study.

BACKGROUND: The time in therapeutic range values may vary between different geographical regions of Turkey in patients vitamin K antagonist therapy. AIMS: To evaluate the time in therapeutic range percentages, efficacy, safety and awareness of warfarin according to the different geographical regions in patients who participated in the WARFARIN-TR study (The Awareness, Efficacy, Safety and Time in Therapeutic Range of Warfarin in the Turkish population) in Turkey. STUDY DESIGN: Cross-sectional study. METHODS: The WARFARIN-TR study includes 4987 patients using warfarin and involved regular international normalized ratio monitoring between January 1, 2014 and December 31, 2014. Patients attended follow-ups for 12 months. The sample size calculations were analysed according to the density of the regional population and according to Turkish Statistical Institute data. The time in therapeutic range was calculated according to F.R. Roosendaal's algorithm. Awareness was evaluated based on the patients' knowledge of the effect of warfarin and food-drug interactions with simple questions developed based on a literature review. RESULTS: The Turkey-wide time in therapeutic range was reported as 49.5%±22.9 in the WARFARIN-TR study. There were statistically significant differences between regions in terms of time in therapeutic range (p>0.001). The highest rate was reported in the Marmara region (54.99%±20.91) and the lowest was in the South-eastern Anatolia region (41.95±24.15) (p>0.001). Bleeding events were most frequently seen in Eastern Anatolia (41.6%), with major bleeding in the Aegean region (5.11%) and South-eastern Anatolia (5.36%). There were statistically significant differences between the regions in terms of awareness (p>0.001). CONCLUSION: Statistically significant differences were observed in terms of the efficacy, safety and awareness of warfarin therapy according to different geographical regions in Turkey.

Comparison of left atrial volume and function in non-dipper versus dipper hypertensives: A real-time three-dimensional echocardiography study.

OBJECTIVE: Non-dipper hypertension is associated with an increased cardiovascular morbidity and mortality. Besides this, the left atrial (LA) size and functions are accepted to be prognostic factors in various cardiovascular diseases. In this study, we aimed to evaluate the effect of nondipper hypertension on LA volume and functions using real-time three-dimensional echocardiography (RT3-DE). METHODS: Forty dipper and 52 non-dipper hypertensives enrolled in this prospective cross-sectional study. Patients with any comorbidities that have a potential for causing structural cardiac alterations were excluded. Two-dimensional echocardiography (2-DE) and RT3-DE were performed to assess LA volumes and functions. The statistical tests used in this study were Shapiro-Wilk's test, Student's t-test, Mann-Whitney U test, chi-square test, Spearman's test, and Pearson's correlation test. RESULTS: LA minimal volume, LA volume before LA contraction, and LA total systolic volume were higher in non-dipper hypertensives than in dipper hypertensives (p<0.001, p=0.003, and p=0.03, respectively). Only, the 2-DE measurements of interventricular septal thickness and E/Em ratio were higher in non-dipper hypertensives (p=0.001 and p=0.03, respectively). There was a moderate correlation between LA minimal volume and LA volume before LA contraction with E/Em (r=0.31, p=0.007 and r=0.32, p=0.005, respectively). CONCLUSION: Although LA volume and passive LA systolic functions measured by RT3-DE are significantly increased in non-dipper hypertensives, the alterations in active LA systolic functions are not prominent. RT-3DE may be used to define LA volume and function alterations in conditions that have capabilities of adverse cardiac remodeling such as systemic hypertension.

Left atrial volume and function in patients with white-coat hypertension assessed by real-time three-dimensional echocardiography.

BACKGROUND: White-coat hypertension (WCH) is a disease based on the disparity of a patient's blood pressure measurements between the physician's office and the patient's home environment. The aim of the present study is to evaluate the left atrial (LA) volume and functions in WCH. METHODS: In total, this study included 37 WCH (17 women, 20 men, mean age 48.4±5.7 years) and 30 healthy individuals (18 women, 20 men, mean age 47.9±7.5 years). All patients underwent real-time three-dimensional and comprehensive two-dimensional echocardiography (2DE) with tissue Doppler evaluation to estimate left atrial volumes and mechanical functions. RESULTS: LA diameters were significantly higher in the patients compared with the controls (37±2.8 vs. 35±3.1 mm, P=0.017). LA total systolic volume and LA maximal volume were significantly higher in the patients. (41.1±6.9 vs. 35.5±3.7 ml, P<0.001; 25.8±5.4 vs. 21.3±3.3 ml, P<0.001, respectively). LA volume before LA contraction and LA active stroke volume were significantly higher in the patients with WCH than in the normotensives (24.4±6.3 vs. 20.9±2 ml, P=0.002; 9.1±4.8 vs. 6.7±2.5 ml, P=0.007, respectively). Moreover, the LA expansion index was significantly higher in the patients with WCH than in the normotensives (178.7±53.6 vs. 155.3±36.3, P=0.037). However, the total emptying volume fraction of the LA was similar between the two groups. CONCLUSION: We showed that LA structural functions and volumes were increased in the WCH group. Although increased LA volume has been observed in many diseases, structural changes in LA may be accepted as an early sign for clinical cardiac remodeling in patients with WCH, suggesting the necessity of early intervention for preventing clinical cardiovascular disease.