Relationship between disease severity and atrial fibrillation in chronic obstructive pulmonary disease.

OBJECTIVE: The aim of this study was to elucidate the relationship between atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) classification based on clinical severity determined in current guidelines. AF is the most common chronic arrhythmia that requires treatment. COPD is one of the risk factors for AF, but this relationship was only explored through respiratory function test results. METHODS: Patients who received inpatient treatment for COPD between November 2019 and January 2017 were screened. Patients with coronary artery disease, heart failure, valvular heart disease, diabetes, chronic kidney disease, hypertension, thyroid dysfunction, and sleep apnea syndrome were excluded. According to the 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, patients with COPD were divided into groups A, B, C, and D, and the relationship between AF and these groups was investigated. RESULTS: There was no difference between the two groups (depending on the presence of AF) in terms of sex and body mass index. There was a significant difference between the two groups in terms of age, left ventricular ejection fraction (LVEF), left atrium, right atrium, right ventricle, and systolic pulmonary artery pressure. When patients with COPD were classified according to clinical and symptomatic severity, the frequency of AF increased as the clinical severity increased. CONCLUSION: Regardless of the forced expiratory volume - first second (FEV1) value in the respiratory test, the incidence of AF is higher in patients with COPD with a clinically more severe picture.

Evaluation of thrombolytic treatment effect on frontal plane QRS-T angle in patients with acute pulmonary embolism : A novel marker of successful thrombolysis.

BACKGROUND: Acute pulmonary embolism (APE) patients with hypotension and/or shock should be evaluated for thrombolytic therapy, and hemodynamics often improves after thrombolytic therapy. Frontal plane QRS­T (f[QRS-T]) angle, which is between the directions QRS axis and T axis, was described as a novel marker of ventricular repolarization heterogeneity. With right ventricular pressure overload, axis of heart may be affected and thrombolytic treatment may have an effect on this situation. This study aimed to investigate thrombolytic efficiency and effect on axis of heart by using f(QRS-T) angle. METHOD: A total of 61 APE patients treated with thrombolytics and 71 APE patients treated without thrombolytics were included. Clinical findings and electrocardiogram (ECG) at diagnosis were collected. Second ECGs were included for patients with thrombolytics after 24 h, without thrombolytics after 72 h on average. RESULTS: No significant differences were observed with regard to gender, age, hypertension, diabetes and cardiovascular disease. In patients with thrombolytics, respiratory rate, heart rate and pulmonary artery systolic pressure were significantly higher; oxygen saturation (Sat O2) as well as systolic and diastolic pressure were significantly lower. f(QRS-T) was markedly higher in APE with right ventricular pressure overload and changed significantly after thrombolytic therapy. CONCLUSION: Right ventricular pressure overload in APE has an effect on f(QRS-T). In thrombolytic treatment, the change of f(QRS-T) angle may be a marker of successful thrombolysis.

Prediction of new onset atrial fibrillation in patients with acute pulmonary embolism: The role of sPESI Score.

OBJECTIVE: Acute pulmonary embolism (APE) is a serious clinical situation and atrial fibrillation (AF) is the most common arrhytmia in clinical practice. The Pulmonary Embolism Severity Index (PESI) is an accepted risk stratification tool used to predict short term mortality in APE. The aim of this study was to evaluate the relationship between the PESI score and new-onset AF in patients with APE. METHODS: The records of 869 APE patients admitted between May 2012 and December 2015 were evaluated retrospectively. The PESI score was calculated for every patient. Clinical variables associated with new-onset AF in APE were assessed after the exclusion of patients with hypertension, coronary or hemodynamically significant valvular heart disease, hepatic or renal dysfunction, chronic obstructive pulmonary disease, thyroid dysfunction, diabetes mellitus, sleep apnea, any history of inflammatory or infectious disease, or recent trauma. New-onset AF was detected in 42 (4.8%) patients. RESULTS: Age, gender, systolic and diastolic blood pressure, heart rate, fasting glucose level, serum creatinine, left ventricle ejection fraction, tricuspid annular plane systolic excursion value, and pulmonary artery systolic pressure measures were not significantly different between patients with and without AF. New-AF patients demonstrated larger LVEDD and LAD dimensions (p <0.001 for both). The PESI score was higher in the new-onset AF group (93+-23 vs.75+-17; p <0.001). LVEDD, LAD, levels of uric acid, bilirubin, albumin, and troponin, and PESI score were univariate predictors of new-onset AF. CONCLUSION: In patients with APE, the PESI score was positively correlated with new-onset AF. A PESI score greater than 82.50 may be useful to predict new-onset AF in these patients.

The relationship between right ventricular outflow tract fractional shortening and Pulmonary Embolism Severity Index in acute pulmonary embolism.

OBJECTIVE: Right ventricular (RV) functions are clinically important in acute pulmonary embolism (APE). Measurement of systolic function of the right ventricular outflow tract (RVOT) with echocardiography is a simple method to evaluate RV function. The aim of this study was to determine the relationship between RVOT systolic function and the Pulmonary Embolism Severity Index (PESI). METHODS: A total of 151 patients diagnosed with APE by pulmonary computed tomography angiography or ventilation/perfusion scintigraphy were included. Patients were assigned to 2 groups based on the simplified PESI (sPESI): sPESI <1 (n=85) and sPESI ≥1 (n=66). RV conventional parameters, RVOT dimensions, and fractional shortening (RVOT-FS) were also measured. RESULTS: Mean age was similar between sPESI <1 and >1 patients (58.7±12.9 years vs. 61.1±12.7 years, respectively). Frequency of male gender was significantly higher in PESI <1 group (61.2% vs. 40.2%, p=0.013). No significant differences were found between the groups in fasting glucose, serum creatinine, hemoglobin, C-reactive protein, erythrocyte sedimentation rate, troponin, and D-dimer levels, and left ventricular ejection fraction. RVOT-FS was higher in patients with sPESI <1 than in patients with sPESI ≥1 (34.41±3.56 vs. 22.98±4.22), and this difference was significant (p<0.001). Tricuspid annular plane systolic excursion values were lower and pulmonary artery systolic pressure values were higher in the sPESI ≥1 group, which was also statistically significant (p<0.05). Mortality occurred in 7 patients with sPESI <1 and in 16 patients with sPESI ≥1. The mortality rate was higher in patients with lower RVOT-FS, and a RVOT-FS <0.22 predicted mortality with a sensitivity of 54.5% (AUC: 0.674, 95% CI 0.552-0.796; p=0.009). CONCLUSION: The RVOT-FS is a noninvasive measurement of RV systolic function, is well-correlated with the sPESI score, and associated with mortality in patients with APE. This easily applied measurement may be used to predict short-term mortality in patients with APE.

Association between fractional flow reserve and Duke treadmill score in patients with single-vessel disease.

BACKGROUND: Duke treadmill score (DTS) is an index that provides prognostic information calculated at exercise stress test. Fractional flow reserve (FFR) is an invasive method used to evaluate intermediate coronary stenosis. The direct relation of DTS and FFR has not been studied to date. AIM: The present study aims to investigate the relationship between the DTS and FFR. METHODS: The study population consisted of a total of 106 patients with single-vessel disease, as confirmed by coronary angiography performed following EST, and whose FFRs were measured. The patients were separated into three groups according to the DTS values: low risk (DTS ≥ +5), intermediate risk (-10 ≤ DTS ≤ +4), and high risk (DTS ≤ -11). According to the FFR values, the patients were separated into two groups: FFR < 0.80 and FFR ≥ 0.80. RESULTS: Angina symptoms and chronic heart failure were more frequent in the group with FFR < 0.80 than the group with FFR ≥ 0.80; respectively, 95% vs. 69.8%, p = 0.020 and 15% vs. 3.5%, p = 0.045. The mean DTS value was lower in the group with FFR < 0.80 than the group with FFR ≥ 0.80 (1.60 vs. 5.07; p = 0.011). However, there were no statistically significant differences in the DTS risk groups among the FFR groups (p = 0.070). A weak positive correlation was found between the numerical DTS and FFR values (r = 0.139; p = 0.156). When the patients with high-risk were excluded, a statistically significant relationship was determined between the FFR and in the groups with low- and intermediate-risk in terms of the DTS values (p = 0.029). CONCLUSION: In conclusion, our study results showed an association with FFR and in the groups with low and intermediate risk in terms of the DTS values. DTS levels can be useful to determine patients who require invasive management.

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.

The relationship between fragmented QRS and functional significance of coronary lesions.

BACKGROUND: Recently fragmented QRS (fQRS) on electrocardiography (ECG) has been introduced as a predictor of myocardial scarring and myocardial ischemia in coronary artery disease (CAD). OBJECTIVE: The aim of this study was to investigate the relationship between fQRS and fractional flow reserve (FFR) results in patients with the intermediate degree of coronary artery stenosis. METHODS: A total of 301 consecutive patients who underwent coronary angiography (CAG) and FFR measurement for intermediate coronary artery stenosis were included in the study. The study patients were divided into two groups: the low FFR group (FFR value of ≤0.80) and normal FFR (FFR value of >0.80) group. Both groups were compared in terms of the presence of fQRS. RESULTS: Of 301 patients, fQRS was detected in 128 (42.5%) and low FFR was detected in 115 (38.2%). In the low FFR group, fQRS was significantly higher (P<0.001). Multivariate analysis showed that fQRS was an independent predictor of myocardial ischemia in patients with intermediate coronary stenosis (OR=7.202, CI 95%, 4.195-12.367; p<0.001). The presence of fQRS had 70% sensitivity and 74% specificity for the prediction of FFR≤0.80. CONCLUSION: In clinical practice, the presence of fQRS on ECG is associated with myocardial ischemia in patients with intermediate coronary stenosis.

Acute Fulminant Myocarditis Successfully Bridged to Recovery with Left Ventricular Assist Device and Complicated by Flail Mitral Valve.

Acute fulminant myocarditis is a life-threatening inflammatory disease of the myocardium characterized by the rapid deterioration of the hemodynamic status of the affected individual. With prompt recognition and appropriate management, complete recovery of ventricular function is likely within a few weeks. We introduce a 28-year-old man with acute fulminant myocarditis, who experienced circulatory collapse following acute angina and dyspnea. The patient had high troponin levels with low ejection fraction and normal coronary arteries. He was successfully bridged to recovery with a left ventricular assist device but was complicated by flail mitral valve. Perioperative myocardial biopsy was also compatible with myocarditis. At 4 months' follow-up, the patient was stable with functional capacity I according to the New York Heart Association's classification. A possible mechanism for this very rare complication is the rupture of the chordal structure secondary to the fragility of an inflamed subvalvular apparatus stretched by a recovered ventricle.

The classical "R-on-T" phenomenon.

The polymorphic ventricular tachycardia (PVT) is uncommon arrhythmia with multiple causes and has been classified according to whether they are associated with long QT interval or normal QT. Whereas "Torsade de pointes (TdP)" is an uncommon and distinctive form of PVT occurring in a setting of prolonged QT interval, which may be congenital or acquired (congenital or acquired), "PVT with normal QT" is associated with myocardial ischemia, electrolyte abnormalities (hypokalemia), mutations of the cardiac sodium channel (Brugada syndrome), and the ryanodine receptor (catecholaminergic PVT). This distinction is crucial because of the differing etiologies and management of these arrhythmias. Moreover, the PVT in the setting of acute MI generally occurs during the hyperacute phase, is related to ischemia ("ischemic PVT") and is not associated with QT prolongation. It is triggered by ventricular extrasystoles with very short coupling interval (the "R-on-T" phenomenon) and is not pause-dependent. However, recently there has been described a new PVT during the "healing phase" of MI in patients with no evidence of ongoing ischemia and following excessive QT prolongation, the electrophysiologic abnormality being a "pause-dependent infarct-related TdP" due to a LQTS in healing MI patients. Therefore, "ischemic PVT" differs from "infarct-related TdP" in terms of pathophysiology and ECG manifestations.

Left ventricular pseudoaneurysm after mitral valve replacement: Review of pseudoaneurysms late after mitral valve replacement.

Left ventricular pseudoaneurysm (LVPA) due to incomplete or late rupture after mitral valve replacement is a rare condition but can be life threatening if it develops into perdicardial tamponade. LVPA may develop de novo after the surgical procedure or may be a sequela of an earlier rupture. Clinical presentation includes shortness of breath, heart failure, chest pain, endocarditis, and pericardial tamponade. However, it can also have an asymptomatic course. The recommended treatment for LVPA is surgical repair. Conservative follow-up is an alternative for patients who refuse surgical treatment or are considered high risk for re-operation. We conducted a review of all the available literature on cases of LVPA after mitral valve replacement and present the findings here.

An alternative noninvasive technique for the treatment of iatrogenic femoral pseudoaneurysms: stethoscope-guided compression.

OBJECTIVE: latrogenic femoral pseudoaneurysm is a well-known vascular access site complication. Many invasive and noninvasive techniques have been proposed for the management of this relatively common complication. In this study, we aimed to evaluate efficiency and safety of stethoscope-guided compression as a novel noninvasive technique in the femoral pseudoaneurysm treatment. METHODS AND RESULTS: We prospectively included 29 consecutive patients with the diagnosis of femoral pseudoaneurysm who underwent coronary angiography. Patients with a clinical suspicion of femoral pseudoaneurysm were referred to colour Doppler ultrasound evaluation. The adult (large) side of the stethoscope was used to determine the location where the bruit was best heard. Then compression with the paediatric (small) side of the stethoscope was applied until the bruit could no longer be heard and compression was maintained for at least two sessions. Once the bruit disappeared, a 12-hour bed rest with external elastic compression was advised to the patients, in order to prevent disintegration of newly formed thrombosis. Mean pseudoaneurysm size was 1.7 +/- 0.4 cmx 3.0 +/- 0.9 cm and the mean duration of compression was 36.2 +/- 8.5 minutes.Twenty-six (89.6%) of these 29 patients were successfully treated with stethoscope-guided compression. In 18 patients (62%), the pseuodoaneurysms were successfully closed after 2 sessions of 15-minute compression. No severe complication was observed. CONCLUSION: Stethoscope-guided compression of femoral pseudoaneurysms is a safe and effective novel technique which requires less equipment and expertise than other contemporary methods.