Safety of once- or twice-daily dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with nonvalvular atrial fibrillation: A NOAC-TR study.

Once-daily dosing of non-vitamin K antagonist oral anticoagulants (NOACs) may increase patient adherence to treatment but may also be associated with a higher risk of bleeding. In this study, we investigated the adherence to once- or twice-daily dosing of NOACs and the risk of bleeding in nonvalvular atrial fibrillation (NVAF) patients. This multicenter cross-sectional study, conducted between 1 September 2015 and 28 February 2016, included 2214 patients receiving NOACs for at least 3 months, due to NVAF. Patients receiving once-daily or twice-daily NOAC doses were 1:1 propensity score matched for baseline demographic characteristics and the presence of other diseases. The medication adherence was assessed by the 8-item Morisky Medication Adherence Scale. Risk factors were investigated in relation to minor and major bleeding. The mean age of patients was 71 ± 10 years, and 53% of the patients were women. The medication adherence was lower in patients receiving twice-daily NOAC doses compared to once-daily-dose group (47% versus 53%, p = 0.001), and there was no difference between the groups in terms of minor (15% versus 16%, p = 0.292) and major bleeding (3% versus 3%, p = 0.796). Independent risk factors for bleeding were non-adherence to medication (OR: 1.62, 95% CI: 1.23-2.14, p = 0.001), presence of 3 or more other diseases (OR: 10.3, 95% CI: 5.3-20.3, p < 0.001), and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol) score (OR: 4.84, 95% CI: 4.04-5.8, p < 0.001). In summary, the once-daily dose of NOACs was associated with increased patient adherence to medication, while it was not associated with bleeding complications.

Non-dipper hypertension is associated with slow coronary flow among hypertensives with normal coronary angiogram.

AIM: A person with a drop of more than 10% in nocturnal arterial blood pressure during the circadian rhythm is referred to as a dipper and one with a smaller decrease is referred to as a non-dipper. In our study, we aimed to compare the thrombolysis in myocardial infarction (TIMI) frame count in non-dipper and dipper hypertensive patient groups who had normal coronary artery angiography. METHODS: Patients with normal coronary arteries and with ambulatory blood pressure monitoring follow ups were retrospectively investigated and 60 patients (35%, female) were included in our study. The patients were grouped as dipper (n = 30) and non-dipper (n = 30) hypertensives. RESULTS: The TIMI frame counts in all three coronary arteries and the mean TIMI frame count in the dipper hypertensive patient group were significantly lower than those of the non-dipper hypertensives (right coronary artery TIMI frame count: 16.83 ± 3.70; 21.63 ± 3.44, p < 0.001; circumflex artery TIMI frame count: 21.28 ± 3.52; 25.65 ± 3.61, p < 0.001; left anterior descending artery TIMI frame count: 34.20 ± 2.80; 37.05 ± 3.30, p = 0.001; corrected left anterior descending artery TIMI frame count: 20.05 ± 1.63; 21.74 ± 1.95, p = 0.001; mean TIMI frame count: 19.31 ± 2.3; 22.94 ± 2.61, p < 0.001). The body mass index (BMI) was 23.79 ± 2.81 kg/m2 in the dipper patient group, while it was 25.47 ± 2.92 in the non-dippers. BMI was found to be significantly higher in the non-dipper group than in the dipper group (p = 0.027). CONCLUSION: In this study, TIMI frame count, which is a simple, productive, objective and reproducible method for determination of microvascular changes, was found to be higher in non-dipper hypertensive patients than in the dipper patients.

Clinical and microbiological findings of infective endocarditis.

INTRODUCTION: Infective endocarditis (IE) is an infection that develops on the endothelial surface of the heart. Endocarditis is a major problem for the clinicians despite of the developments in diagnostic, surgical, and medical treatment methods. In this study, we aimed to evaluate symptoms, laboratory findings, treatment options, and clinical endpoint of the patients who were diagnosed with IE in a tertiary healthcare organization according to the literature data. METHODOLOGY: Between January 2006 and March 2013, 80 IE patients who were diagnosed and treated in accordance with modified Duke criteria were enrolled in the study. Demographic features, symptoms, and laboratory and echocardiographic findings were recorded after reviewing the patient files. RESULTS: The mean age of the patients was 51.3 ± 16.0, and IE was more common in men (n = 56; 70%). Of 41 patients who had positive blood cultures, 20 patients had Staphylococcus spp. (48.7%) and 8 patients had Streptococcus spp. (19.5%). Brucella spp. was isolated from 5 patients (12.2%). While 48.7% (n = 39) of the patients had cardiac complications, 22 patients (27.5%) had embolic complication. Hospital mortality was observed in 20 patients (15%). CONCLUSIONS: In our patients, endocarditis was seen at a young age, and staphylococci were the most frequently isolated microorganism from blood culture. There were more patients with Brucella endocarditis compared to the general population. Complications are frequently seen in the course of endocarditis, and they cause problems for the clinicians during follow ups due to the high mortality rate of IE.

Effects of Gender on Electrocardiography in Subjects with Shortened Ventricular Depolarization (QRS).

BACKGROUND: Distinctions between electrocardiograms of female and male subjects have been recognized for many years. Due to these differences, arrhythmias in each gender have a tendency to differ. In our study, we aimed to compare electrocardiography intervals between men and women with short QRS durations. METHODS: Subjects with a QRS interval of ≤80 ms were included in the study. Patients were grouped by gender and the parameters were compared. Patients with diseases that might affect QRS interval and/or who were on medications were excluded. The electrocardiogram intervals of the subjects were measured, Holter monitors were placed, and parameters of time-based heart rate variation were analyzed. RESULTS: A total of 100 patients (55% female) were included in the study. According to statistical analysis, no significant difference between the genders was observed in the heart rate or in the parameters, such as QT, JT, JTp, and TpTe intervals or heart rate-corrected QTc, JTc, JTpc, and TpTec intervals, which affect repolarization and are known to be arrhythmia precursors by shortening or elongation. No statistically significant difference was found between the two groups for the parameters of heart rate variability time measures (SDNN, SDANN, rMSSD, and pNN50). CONCLUSION: We observed that when the QRS interval gets shorter, repolarization differences between the genders disappear. New studies are required on this subject.

Diagnostic value of combining heart rate recovery and P-wave changes with exercise-induced changes in the ST segments for prediction of myocardial ischaemia.

BACKGROUND: In patients admitted to outpatient clinics with chest pain, changes in the ST-segments of electrocardiogram (ECG) readings are the most widely used criteria during treadmill ECG tests to determine myocardial ischaemia, despite its poor accuracy. In this study, we evaluated the benefit of combining elongation of P-wave duration (Pdur) and abnormal heart rate recovery (HRR) parameters in addition to changes in the ST-segments for the detection of myocardial ischaemia with treadmill ECG testing. METHODS: Patients (n = 369) with chest pain who underwent both a treadmill ECG test and myocardial perfusion scintigraphy (MPS) were enrolled. P-wave duration was measured at rest and at the end of the first minute of the recovery phase and elongation of the P-wave was calculated. Abnormal HRR was defined as the failure of a decreasing HR at the end of the first minute of the recovery phase >10% of the maximum HR reached during treadmill ECG testing. The sensitivity, specificity, positive and negative predictive values, diagnostic accuracy values, and likelihood ratios (LRs) of changes in the ST-segments, P-wave elongation, abnormal HRR, and the combination of these three variables for predicting myocardial ischaemia detected by MPS, were calculated separately-in patients without previous coronary artery disease (CAD) and in those with CAD. RESULTS: Elongation of Pdur by 20 ms or longer and abnormal HRR during treadmill ECG test were more common in patients with reversible perfusion defects in MPS than in those without perfusion defects (both P < 0.001). When patients were divided into two groups according to the presence or absence of a history of CAD, the addition of elongation of Pdur 20 ms and abnormal HRR to the development of significant changes in the ST-segments detected myocardial ischaemia with 46.7% sensitivity, 97.8% specificity, 67.2% negative predictive value, 88.9% positive predictive value, and 70% diagnostic accuracy in 77 patients with previous CAD. The LR+ of the combination of the three variables was 12.27. The addition of elongation of Pdur 20 ms and abnormal HRR to the development of significant changes in the ST-segments detected myocardial ischaemia with 52.7% sensitivity, 98.7% specificity, 89.9% negative predictive value, 90.6% positive predictive value, and 90% diagnostic accuracy in 292 patients without previous CAD. The LR+ of the combination of the three variables to detect myocardial ischaemia was calculated to be 41.48 in patients without a history of CAD. CONCLUSIONS: The addition of elongation of Pdur and abnormal HRR to the conventionally used criterion of changes in the ST-segments in patients with suspected myocardial ischaemia increased the specificity and positive and negative predictive values of treadmill ECG testing for detecting myocardial ischaemia, which might reduce the need for other expensive noninvasive techniques. The diagnostic utility of adding these two parameters was more obvious in patients with no history of CAD.

The value of aortic pulse wave velocity in predicting coronary artery disease diagnosis and severity.

OBJECTIVE: Aortic pulse wave velocity (AoPWV), one of the parameters showing arterial stiffness, has been investigated in different patient groups as a predictor of cardiovascular diseases. The purpose of our study is to investigate the correlation between AoPWV and coronary artery disease (CAD) and its severity. METHODS AND RESULTS: One hundred and three patients who were not diagnosed with CAD but who were scheduled to have coronary angiography (CAG) with CAD suspicion were included in the study. PWV was measured with tonometry device before CAG. Patients were divided into two groups: with or without CAD. The Gensini score of each patient was calculated in the CAD group by several independent specialists. The average age of the patients was 55.2 +/- 8.5 (range 33-73 years). CAD was confirmed in 59 patients (49%). Average PWV in the CAD group was statistically more significant than in the non-CAD group (8.6 +/- 2.0, 5.0 +/- 1.8; P < 0.001). A highly positive correlation was observed between CAD severity and PWV (r = 0.838, P = 0.001). In the CAD diagnosis, for an AoPWV cut-off value of 7.3 m/sec, the sensitivity was 83.1% and the specificity 86.4%. CONCLUSIONS: Various non-invasive techniques are used in CAD prognosis. Besides being simple, these techniques are also required to show a high rate of accuracy in CAD prognosis. In this respect, AoPWV gains importance as being a non-invasive method that can be performed with a tonometry device at low cost in policlinic conditions.

Development of ST Elevation Myocardial Infarction and Atrial Fibrillation after an Electrical Injury.

Electrical energy is a type of energy that is commonly used in daily life. Ventricular premature beats, ventricular tachycardia, ventricular fibrillation, atrial tachycardia, atrial fibrillation, bundle branch blocks, and AV block are arrhythmic complications that are encountered in case of electric shocks. Myocardial infarction is one of the rarely seen complications of electric shocks yet it has fatal outcomes. Coronary arteries were detected to be normal in most of the patients who had myocardial infarction following an electric shock. So, etiology of myocardial infarction is thought to be unrelated to coronary atherosclerosis in these cases. Coronary artery vasospasm is thought to be the primary etiological cause. In our case report, we presented a patient who developed ST elevation MI with atrial fibrillation after an electric shock.

Parameters of heart rate variability can predict prolonged asystole before head-up tilt table test.

BACKGROUND: We aimed to evaluate whether heart rate variability (HRV) could predict prolonged asystole before head-up tilt table test (HUTT) by comparing time domain HRV parameters of patients with type 2B vasovagal syncope (VVS) and patients with other types of VVS. METHODS: Ninety-eight patients who examined with 24-hour Holter electrocardiogram monitoring before HUTT and diagnosed with VVS were enrolled. Patients were divided into two groups in accordance with their VVS type as group 1 (n = 43) consisting of patients with type 2B VVS and group 2 (n = 57) consisting of patients with other types of VVS. Time domain HRV parameters (SDNN, SDANN, SDNN index, RMSSD, pNN50) of two groups were compared. ROC curve analysis was performed to predict best cutoff values that could prognosticate occurrence of prolonged asystole during HUTT. RESULTS: SDNN, SDANN, SDNN index values were significantly longer for group 1 compared to group 2 (P = 0.009, P = 0.006, P = 0.004; respectively). While a SDNN cutoff value of ≥151 ms predicted occurrence of type 2B VVS before HUTT with 69% sensitivity and 56% specificity, a SDANN value of ≥164 ms had 47% sensitivity and 87% specificity and a SDNN index value of ≥102 ms showed 40% sensitivity and 85% specificity. CONCLUSIONS: In our study, we tried to demonstrate prediction of prolonged asystole by analyzing HRV parameters before HUTT. We found out that time domain HRV parameters were longer in patients with type 2B VVS than patients with other types of VVS. Our results need to be supported by extensive studies.

Central venous obstruction and clinical predictors in patients with permanent pacemaker.

OBJECTIVE: This study investigated the proportion of silent venous obstruction in patients who underwent pacemaker or lead reimplantation for various reasons. We also investigated independent predictors or risk factor of venous obstruction in this patient population. METHODS: Seventy-three patients who underwent pacemaker pulse generator and/or lead reimplantation in our institution between 2007 and 2010 were enrolled for this retrospective case-control study. Prior to procedure, patients underwent ipsilateral venography. Patients' venographies were classified as non-significant obstruction (stenosis ≤70%, including normal venogram), significant obstruction (stenosis >70%) and complete obstruction. Continuous and categorical data were compared with Mann-Whitney U test and Chi-square statistics respectively. Logistic regression analysis was used to identify independent predictors of venous obstruction. RESULTS: Complete or significant silent central venous obstruction (CVO) proportion was detected as 9.5% (n=7). Basal characteristics of patients with or without CVO were comparable. Significantly increased pacemaker pocket erosion incidence (57% vs 0%, p=0.001, in groups with and without CVO respectively) and significantly higher mean pacemaker age (15.3 ± 10.2 years vs 10.4 ± 5.1 years, p=0.047, in groups with and without CVO respectively) were found in group with CVO. Pacemaker pocket erosion (OR 3.00; 95% CI 1.024-9.302; p=0.001), higher pacemaker age (OR 1.33; 95% CI 1.026-1.733; p=0.02) were found as independent CVO predictors in multiple logistic regression analysis. Correlation analysis also revealed a significant correlation between previous or current pacemaker pocket erosion and CVO (r=0.80, p=0.001). CONCLUSION: Ipsilateral venography is a useful procedure prior to pacemaker or lead reimplantation to detect CVO. In addition to the increased pacemaker age, current or past history of erosion and infection at pacemaker pocket are probable clinical conditions related to CVO. These clinical conditions create a predisposition to CVO with unknown mechanisms, according to the results of this preliminary study.