Strain Echocardiographic Evaluation of Myocardial Involvement in Patients with Continuing Chest Pain after COVID-19 Infection. / Avaliação Ecocardiográfica com Strain do Envolvimento Miocárdico em Pacientes com Dor Torácica Contínua após Infecção por COVID-19.

BACKGROUND: A new clinical manifestation called post or long coronavirus disease (p/l COVID) has walked into our lives after the acute COVID-19 phase. P/l COVID may lead to myocardial injury with subsequent cardiac problems. Diagnosing these patients quickly and simply has become more important due to the increasing number of patients with p/l COVID. OBJECTIVES: We compared strain echocardiography (SE) parameters of patients who suffered from atypical chest pain and had sequel myocarditis findings on cardiac magnetic resonance (CMR). We aimed to investigate the value of SE for detection of myocardial involvement in patients with p/l COVID. METHODS: A total of 42 patients were enrolled. Our population was separated into two groups. The CMR(-) group (n = 21) had no myocardial sequelae on CMR, whereas the CMR(+) group had myocardial sequelae on CMR (n = 21). The predictive value of SE for myocarditis was also evaluated by age-adjusted multivariate analysis. P values < 0.05 were considered statistically significant. RESULTS: When compared with left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and global circumferential strain (GCS) had a stronger relationship (LVEF, p = 0.05; GLS, p < 0.001; GCS, p < 0.001) with p/l COVID associated myocardial involvement. GLS < 20.35 had 85.7% sensitivity and 81% specificity; GCS < 21.35 had 81% sensitivity and 81% specificity as diagnostic values for myocardial sequelae detected with CMR. While there was no difference between the groups in terms of inflammatory markers (C-reactive protein, p = 0.31), a difference was observed between biochemical markers, which are indicators of cardiac involvement (brain natriuretic peptide, p < 0.001). CONCLUSION: SE is more useful than traditional echocardiography for making diagnosis quickly and accurately in order not to delay treatment in the presence of myocardial involvement.

FUNDAMENTO: Tem surgido uma nova manifestação clínica chamada pós-COVID ou COVID longa (COVID p/l) após a fase aguda da COVID-19. COVID p/l pode levar à lesão miocárdica com problemas cardíacos subsequentes. Diagnosticar esses pacientes de forma rápida e simples é cada vez mais importante devido ao número crescente de pacientes com COVID p/l. OBJETIVOS: Comparamos os parâmetros de ecocardiografia com strain (ES) de pacientes que apresentaram dor torácica atípica e achados de sequelas de miocardite na ressonância magnética cardíaca (RMC). Nosso objetivo foi investigar o valor da ES para detecção de envolvimento miocárdico em pacientes com COVID p/l. MÉTODOS: Foram incluídos um total de 42 pacientes. Nossa população foi separada em 2 grupos. O grupo RMC(-) (n = 21) não apresentou sequelas miocárdicas na RMC, enquanto o grupo RMC(+) apresentou sequelas miocárdicas na RMC (n = 21). O valor preditivo da ES para miocardite também foi avaliado por análise multivariada ajustada por idade. Valores de p < 0,05 foram considerados estatisticamente significativos. RESULTADOS: Quando comparado com a fração de ejeção do ventrículo esquerdo (FEVE), o strain longitudinal global (SLG) e o strain circunferencial global (SCG) tiveram uma relação mais forte (FEVE, p = 0,05; SLG, p < 0,001; SCG, p < 0,001) com envolvimento miocárdico associado à COVID p/l. SLG < 20,35 apresentou sensibilidade de 85,7% e especificidade de 81%; SCG < 21,35 apresentou sensibilidade de 81% e especificidade de 81% como valores diagnósticos para sequelas miocárdicas detectadas com RMC. Enquanto não houve diferença entre os grupos quanto aos marcadores inflamatórios (proteína C-reativa, p = 0,31), houve diferença entre os marcadores bioquímicos, que são indicadores de envolvimento cardíaco (peptídeo natriurético cerebral, p < 0,001). CONCLUSÃO: A ES é mais útil do que a ecocardiografia tradicional para diagnosticar com rapidez e precisão, a fim de não atrasar o tratamento na presença de envolvimento miocárdico.

Avaliação Ecocardiográfica com Strain do Envolvimento Miocárdico em Pacientes com Dor Torácica Contínua após Infecção por COVID-19 / Strain Echocardiographic Evaluation of Myocardial Involvement in Patients with Continuing Chest Pain after COVID-19 Infection

Resumo Fundamento Tem surgido uma nova manifestação clínica chamada pós-COVID ou COVID longa (COVID p/l) após a fase aguda da COVID-19. COVID p/l pode levar à lesão miocárdica com problemas cardíacos subsequentes. Diagnosticar esses pacientes de forma rápida e simples é cada vez mais importante devido ao número crescente de pacientes com COVID p/l. Objetivos Comparamos os parâmetros de ecocardiografia com strain (ES) de pacientes que apresentaram dor torácica atípica e achados de sequelas de miocardite na ressonância magnética cardíaca (RMC). Nosso objetivo foi investigar o valor da ES para detecção de envolvimento miocárdico em pacientes com COVID p/l. Métodos Foram incluídos um total de 42 pacientes. Nossa população foi separada em 2 grupos. O grupo RMC(-) (n = 21) não apresentou sequelas miocárdicas na RMC, enquanto o grupo RMC(+) apresentou sequelas miocárdicas na RMC (n = 21). O valor preditivo da ES para miocardite também foi avaliado por análise multivariada ajustada por idade. Valores de p < 0,05 foram considerados estatisticamente significativos. Resultados Quando comparado com a fração de ejeção do ventrículo esquerdo (FEVE), o strain longitudinal global (SLG) e o strain circunferencial global (SCG) tiveram uma relação mais forte (FEVE, p = 0,05; SLG, p < 0,001; SCG, p < 0,001) com envolvimento miocárdico associado à COVID p/l. SLG < 20,35 apresentou sensibilidade de 85,7% e especificidade de 81%; SCG < 21,35 apresentou sensibilidade de 81% e especificidade de 81% como valores diagnósticos para sequelas miocárdicas detectadas com RMC. Enquanto não houve diferença entre os grupos quanto aos marcadores inflamatórios (proteína C-reativa, p = 0,31), houve diferença entre os marcadores bioquímicos, que são indicadores de envolvimento cardíaco (peptídeo natriurético cerebral, p < 0,001). Conclusão A ES é mais útil do que a ecocardiografia tradicional para diagnosticar com rapidez e precisão, a fim de não atrasar o tratamento na presença de envolvimento miocárdico.

Abstract Background A new clinical manifestation called post or long coronavirus disease (p/l COVID) has walked into our lives after the acute COVID-19 phase. P/l COVID may lead to myocardial injury with subsequent cardiac problems. Diagnosing these patients quickly and simply has become more important due to the increasing number of patients with p/l COVID. Objectives We compared strain echocardiography (SE) parameters of patients who suffered from atypical chest pain and had sequel myocarditis findings on cardiac magnetic resonance (CMR). We aimed to investigate the value of SE for detection of myocardial involvement in patients with p/l COVID. Methods A total of 42 patients were enrolled. Our population was separated into two groups. The CMR(-) group (n = 21) had no myocardial sequelae on CMR, whereas the CMR(+) group had myocardial sequelae on CMR (n = 21). The predictive value of SE for myocarditis was also evaluated by age-adjusted multivariate analysis. P values < 0.05 were considered statistically significant. Results When compared with left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and global circumferential strain (GCS) had a stronger relationship (LVEF, p = 0.05; GLS, p < 0.001; GCS, p < 0.001) with p/l COVID associated myocardial involvement. GLS < 20.35 had 85.7% sensitivity and 81% specificity; GCS < 21.35 had 81% sensitivity and 81% specificity as diagnostic values for myocardial sequelae detected with CMR. While there was no difference between the groups in terms of inflammatory markers (C-reactive protein, p = 0.31), a difference was observed between biochemical markers, which are indicators of cardiac involvement (brain natriuretic peptide, p < 0.001). Conclusion SE is more useful than traditional echocardiography for making diagnosis quickly and accurately in order not to delay treatment in the presence of myocardial involvement.

Association of cardiac adaptations with NT-proBNP levels after percutaneous closure of atrial septal defect.

OBJECTIVE: The aim of this study was to evaluate the early effects of transcatheter closure of secundum atrial septal defect (ASD) on atrial and ventricular diameters and functions evaluated by transthoracic echocardiography, and to assess the relation of morphological changes to N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. METHODS: Twenty-two patients with secundum-type ASD referred for percutaneous closure were included in the study as well as 22 healthy individuals who served as a control group. TTE and concurrent blood sampling were performed prior to and 24 hours and 30 days after the closure procedure. RESULTS: At follow-up 24 hours and 30 days after the closure, the right atrial (RA) area, right ventricular (RV) area, RV end-diastolic volume (EDV), and RV end-systolic volume (ESV) decreased, while left ventricle (LV) EDV (LVEDV), LVESV, and LV stroke volume (LVSV) increased. Global RV systolic and diastolic function indices, such as the tricuspid annular plane systolic excursion, the tricuspid E/A and E/e' ratio decreased immediately after the closure. The NT-proBNP value increased in the 24 hours following closure, and after 30 days, it was still higher than the measurement recorded before the transcatheter closure. The LV structural and functional parameters were significantly correlated with the NT-proBNP value (LVEDV: r=0.37, p=0.02; LVESV: r=0.38, p=0.01; left atrium area: r=0.46, p=0.002; mitral E/e': r=0.28, p=0.04). CONCLUSION: Percutaneous ASD closure can lead to both early and sustained changes in cardiac anatomy and function involving both sides of the heart. The NT-proBNP level had increased at 24 hours post procedure, and was also notably increased 30 days after the percutaneous ASD closure, which is associated with increased LV diameter and volume.

The effect of perindopril on echocardiographic parameters, NYHA functional class and serum NT-proBNP values in patients with diastolic heart failure.

INTRODUCTION: Growing evidence has demonstrated that diastolic heart failure occurs in about half of heart failure (HF) patients. We investigated the effects of perindopril on echocardiographic parameters, New York Heart Association (NYHA) functional class and serum N-terminal pro B-type natriuretic peptide (NT-proBNP) levels in patients with diastolic heart failure. METHODS: In total, 108 diastolic heart failure patients aged ≥ 50 years, who had diastolic dysfunction with an ejection fraction ≥ 50%, were enrolled and randomised to one of the two study groups. Perindopril was initiated in the study group and the control group was given standard therapy. Echocardiographic parameters, NT-proBNP levels and NYHA classes were recorded. The patients were followed for 11 (three to 16) months. Eighty-eight patients completed the study. RESULTS: Although diastolic parameters were not changed, A' (septal) velocity (10.8 vs 9.9 cm/s) and Sm (septal) velocity (8.5 vs 7.6 cm/s) were significantly increased in the perindopril compared to the control group. A significant increase in A' (septal) velocity (+0.61 vs -0.28 cm/s, p = 0.04) and a slight increase in Sm (septal) velocity (+0.99 vs 0.36 cm/s, p = 0.054) were noted in the perindopril group. CONCLUSIONS: Tissue Doppler septal late diastolic velocities and septal systolic myocardial velocities increased in the perindopril group but NT-proBNP levels, and NYHA class was not changed in this study population.

Transvenous extraction of pacemaker and implantable cardioverter defibrillator leads using Evolution® mechanical dilator sheath: a single center confirmatory experience.

OBJECTIVE: In recent years there has been an increase in clinical situations requiring lead extraction procedures of implanted cardiac devices. In our clinic, extraction procedures are performed with Evolution® mechanical lead extraction system. In this manuscript we aimed to evaluate our lead extraction procedures. METHODS: We retrospectively evaluated lead extraction procedures carried out on 41 patients [30 male, 11 female patient; mean age 61.5 ± 18.5 median 67 (23-85)] between 2008 and 2015 using Evolution® system. Procedural success, major and minor complications are determined according to previously published guidelines. RESULTS: Mean duration of the lead implantation was 88.4 ± 62.5 months (6-240). Implanted device was a pacemaker in 27 (65.8 %) and ICD in 14 (34.2 %) of patients. Total 67 leads were extracted from the patients, 22 (32.8 %) were atrial, 30 (44.2 %) were ventricular, 14 (21.5 %) were dual coil defibrillator and 1 (1.5 %) was coronary sinus lead. Indications for lead removal were pacemaker decubitis and infection in 29 (70.8 %), lead dysfunction in 11 (26.8 %) and subclavian vein thrombosis in 1 (2.4 %) patient. Success rate with Evolution® system without using snare was 85.3 %. Clinical success rate was 97.5 % procedural success rate was 95.1 % and failure occured in one patient. Major complications occured in 2 (4.8 %) patients, 1 (2.4 %) was procedure related mortality. Minor complications were seen in 5 (12.2 %) of patients. CONCLUSIONS: In our single center study it is shown that extraction of pacemaker and defibrillator leads of relatively long implantation duration and in an older age patient group may be successfully carried out using the Evolution® system. However due to potentially serious complications it is adviced to be done by experienced operators in centers with cardiovascular surgery backup.

[Evaluation of lead extraction procedures using the Evolution Mechanical Dilatator Sheath lead extraction system: A single centre experience]. / Evolution mekanik dilatör kilifli elektrot çikarma sistemi ile yapilan elektrot çikarma islemlerinin degerlendirilmesi: Tek merkez deneyimi.

OBJECTIVE: In recent years, there has been an increase in clinical situations requiring extraction of leads of implanted cardiac devices. This study aimed to evaluate the Evolution Mechanical Dilator Sheath system, presently in use in our clinic for lead extraction procedures. METHODS: Lead extraction procedures carried out on 20 patients (14 men, 6 women; mean age 61±19; range 23 to 85 years) between 2008 and 2013 using the Evolution system were retrospectively evaluated. Procedural success, and major and minor complications were determined by previously published guidelines. RESULTS: Mean implantation duration of the leads was 97±65 months (8-204). Fifteen (75%) patients had undergone pacemaker implantation and 5 (25%) had been implanted with a defibrillator. A total of 35 leads were removed from the patients. Seventeen (49%) were ventricular and 12 (34%) were atrial. Five (14%) were defibrillator coils and 1 a coronary sinus lead. Indications for lead extraction were device infection in 18 (90%) patients and lead dysfunction in 2 (10%). Complete procedural success was 95%. Failure occurred in 1 patient. The major complication rate was 5% and minor complications were seen in 25% of patients. No case of mortality was present. CONCLUSION: In this single centre study, it was shown that extraction of pacemaker and defibrillator leads of longer implant duration may be successfully carried out using the Evolution system. However, due to potentially serious complications it is advised that extraction be done by an experienced operator in centres with cardiovascular surgery facilities.

Quality of life of patients with atrial septal defect following percutaneous closure.

INTRODUCTION: Quality of life has become an important outcome measure in addition to mortality and morbidity in patients with congenital heart disease. Atrial septal defect is a common congenital heart disease, and transcatheter atrial septal defect closure has become an accepted treatment modality. The aim of this study is to assess the quality of life of patients with atrial septal defect who underwent percutaneous closure. MATERIALS AND METHODS: We examined the quality of life of 69 patients with atrial septal defect and 69 healthy controls matched according to age, sex, educational level, and economic, marital, and employment status. Quality of life was investigated using the Turkish version of Short Form-36. RESULTS: The mean age of the patients was 39.7 ± 14.2 and 26% were male. The quality of life assessment was performed at a mean follow-up time of 18.0 ± 13.8 months after the intervention. The mean scores of the domains of the Short Form-36, namely, physical functioning, role functioning, social functioning, mental health, vitality, pain, and general health, were similar in patients with atrial septal defect who underwent percutaneous closure and the control group. CONCLUSION: Adult patients who underwent percutaneous atrial septal defect closure perceive their quality of life to be as good as their healthy counterparts.

Evaluation of aortic elastic properties in patients with exaggerated systolic blood pressure response to exercise testing.

We aimed to evaluate the aortic elastic properties in subjects with hypertensive response to exercise stress test (HRE). Sixty-six patients were divided into two groups (33 patients in HRE group and 33 patients in normotensive group). Baseline demographic characteristics were similar. The mean aortic stiffness index (ASI) was significantly higher (p=0.001) whereas aortic distensibility (AD) was significantly lower (p=0.029) in patients suggesting HRE. The C-reactive protein levels of patients with HRE was higher in the HRE group (p=0.03). AD was significantly correlated with age (r=-0.406, p<0.001), pre-test systolic blood presure (SBP) (r=-0.427, p<0.001), peak exercise SBP (r=-0.307, p=0.01), peak exercise diastolic blood presure (DBP) (r=-0.315, p=0.008), and recovery time (3 min) SBP (r=-0.497, p=0.004). Age (ß=-0.506, p=0.003) and peak DBP (ß=-0.322, p=0.049) were independent predictors of decreased AD. In conclusion, we found a deterioration in arterial elastic properties in patients with HRE.

[A case of occurring hemodynamic deterioration and ST-segment elevation during transcatheter aortic valve implantation]. / Kateter yoluyla aort kapagi yerlestirilmesi sirasinda hemodinamik bozukluk ve ST-segment yükselmesi gelisen bir olgu.

Transcatheter aortic valve implantation is becoming increasingly popular as an alternative treatment technique for symptomatic patients with severe aortic stenosis, who are at high risk for surgery. However, with this revolutionary treatment modality, some fatal complications have also emerged. One of these fatal complications is the occlusion of the left main coronary artery at the time of procedure. In this case report, we report a case of a transcatheter aortic valve implantation complicated by acute left main trunk subtotal occlusion and hemodynamic collapse, which was successfully recovered by balloon angioplasty and stent implantation.

Decline in mean platelet volume in patients with patent foramen ovale undergoing percutaneous closure.

INTRODUCTION: The presence of patent foramen ovale (PFO) is considered a possible cause for cryptogenic stroke. The mechanism underlying the ischaemic neurological events in the presence of PFO has not been firmly established. The purpose of this study was to compare: (1) the mean platelet volume levels in PFO patients with and without a cryptogenic stroke, and (2) pre- and post-procedural mean platelet volumes (MPV) in patients undergoing percutaneous PFO closure. METHODS: Sixteen PFO patients undergoing percutaneous closure to prevent recurrent ischaemic events and 15 asymptomatic patients with PFO were enrolled in the study. Mean platelet volume was compared between patients with and without a history of stroke. We also compared pre- and post-procedural MPV levels in patients undergoing percutaneous PFO closure. RESULTS: Mean platelet volume, which is a marker for platelet activity, was similar in PFO patients with and without stroke (9.34 ± 1.64 vs 9.1 ± 1.34 fl; p = 0.526). Interestingly, MPV decreased significantly after percutaneous closure compared to pre-procedural levels (9.34 ± 1.64 vs 8.3 ± 1.12 fl; p = 0.001). CONCLUSION: Our findings suggest interatrial communication through a PFO may be related to increased MPV and increased platelet activity.

Predictors of mortality in patients with prosthetic valve infective endocarditis: a nation-wide multicenter study.

BACKGROUND: Our aim was to investigate the clinical and prognostic features of the patients with prosthetic valve endocarditis (PVE) in a multicenter nation-wide study. METHODS: The present nation-wide study consisted of 75 consecutive patients with PVE treated at 13 major hospitals in Turkey from 2005 to 2012. RESULTS: The patients who died during follow-up were significantly older than the survivors and had higher C-reactive protein (CRP), creatinine, poor NYHA functional class and large vegetations. High creatinine level (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.14-6.13), poor functional status (OR 24.5; 95% CI 3.1-196.5) and high CRP (OR 1.02; 95% CI1.00-1.03) measured on admission were independent risk associates for in-hospital mortality. CONCLUSIONS: High creatinine level, poor functional status and high CRP measured on admission were independent risk associates for in-hospital mortality, whereas a NYHA class ofIII/IV and high CRP reflected independent risk for stroke/mortality end point.

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.

[Percutaneous closure of ventricular septal defects in adult patients: our initial experience]. / Eriskinlerdeki ventriküler septal defektlerin perkütan kapatilmasinda ilk deneyimlerimiz.

OBJECTIVES: We evaluated our initial experience with percutaneous closure of ventricular septal defects (VSD) in adult patients. STUDY DESIGN: Percutaneous closure of VSDs in adult patients was launched in 2007 in our center. This study included the first five patients (3 women, 2 men; mean age 32.6 years; range 17 to 44 years) with a perimembranous (n=4) or muscular (n=1) VSD. Before percutaneous intervention, all the patients were assessed by transthoracic (TTE) and, when necessary, transesophageal (TEE) echocardiography, heart catheterization, and ventriculography. Percutaneous closure was performed under fluoroscopy and TEE or TTE guidance using the Amplatzer device (perimembranous asymmetric VSD occluder in perimembranous VSDs and muscular VSD occluder in muscular VSD). RESULTS: The mean VSD diameter was 7.4 mm (range 5 to 11 mm) by echocardiography, and 8.2 mm (range 6 to 11 mm) by ventriculography. The mean left ventricular end-diastolic diameter was 47.2 mm, and the mean distance between the VSD and the aorta was 5.6 mm. Percutaneous closure was successful in all the patients. Ventriculography obtained immediately after the procedure showed minimal passage from the interventricular septum in three patients, but there was no passage on control TTE examination on the first day after the procedure. Aortic, tricuspid, and mitral valves showed normal function. No rhythm problems were seen. All the patients were discharged within one or two days after the procedure. CONCLUSION: Percutaneous closure of VSDs has become a good alternative to surgical repair in recent years, with high success rates and low morbidity. The results of percutaneous closure of VSDs are also successful in adult patients.

[Oral anticoagulant use in patients with atrial fibrillation]. / Atriyal fibrilasyonlu hastalarda oral antikoagülan kullanimi.

OBJECTIVES: Oral anticoagulant therapy has been shown to decrease the risk for vascular complications in patients with atrial fibrillation (AF). We evaluated the frequency of oral anticoagulant use in patients with AF, whether oral anticoagulant use was associated with effective INR values, and the reasons for not including an anticoagulant in the treatment. STUDY DESIGN: The study included 426 consecutive patients (256 women, 170 men; mean age 66+/-11 years) who presented with a diagnosis of AF between October 2007 and November 2008. The patients were inquired about whether they were using warfarin and/or aspirin and the reasons for not taking an oral anticoagulant. The INR levels were measured in those receiving warfarin. RESULTS: Permanent AF was present in 72.8%, and paroxysmal AF was present in 27.2%. Patients = or >75 years of age accounted for 32.4%. The risk for stroke was high in 69.3%, moderate in 21.8%, and low in 8.9%, hypertension being the most frequent risk factor (66.7%). Inquiry about medications showed that 107 patients (25.1%) were taking aspirin and warfarin, 21 patients (4.9%) and 237 patients (55.6%) were taking warfarin and aspirin alone, respectively, while 61 patients (14.3%) used none. The incidence of oral anticoagulant use was 30.1%, being significantly low in patients = or >75 years of age (p=0.0001), and having hypertension (p=0.023) or coronary artery disease (p=0.004). Effective INR values recommended by the guidelines were attained in 47.7% (n=61) of patients receiving warfarin. Sex, age, clinical risk factors, and socioeconomic parameters were not associated with achievement of target INR values. The most frequent reason for not starting anticoagulant treatment was the low tendency of physicians to prescribe the drug (74.3%), followed by the presence of contraindications (9.8%). CONCLUSION: The most important factor for inadequate oral anticoagulant use especially in patients having a high risk for stroke is the low incidence of prescription of the drug by the physicians, suggesting low influence of the guidelines on the clinical practice.

Additive prognostic value of NT-proBNP over TIMI risk score in intermediate-risk patients with acute coronary syndrome.

OBJECTIVES: We evaluated the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) for further risk stratification of intermediate-risk patients with non-ST elevation acute coronary syndromes (NSTE-ACS). STUDY DESIGN: The study included 137 intermediate-risk patients (85 men, 52 women; mean age 62+/-11 years) with ACS, based on the TIMI risk score (scores 3 to 5). Serum NT-proBNP levels were measured 12 hours after the last anginal episode. The patients were divided into four groups according to the following NT-proBNP quartiles: 17-310 pg/ml (n=34), 313-688 pg/ml (n=35), 724-2,407 pg/ml (n=34), and 2,575-24,737 pg/ml (n=34). Primary endpoint of the study was mortality. The mean follow-up was 21.8+/-7.1 months. RESULTS: There were 27 deaths (19.7%), 14 of which were in the 4th quartile (4th vs 1st, 2nd, and 3rd quartiles: p=0.02, p=0.01, and p<0.01, respectively). The first three quartiles did not differ significantly in this respect. In Kaplan-Meier analysis, patients in the 4th quartile had the lowest cumulative survival (log rank test, 4th vs 1st, 2nd, and 3rd quartiles: p=0.041, p=0.026, and p=0.009, respectively). NT-proBNP level was significantly higher in nonsurvivors than in survivors (p=0.01). In univariate analysis, mortality was also associated with the TIMI risk score, ejection fraction, and age. Patients who died were older (65.6+/-11.9 years vs 60.7+/-11.0 years; p=0.048) and had a lower ejection fraction (46.3+/-11% vs 54.1+/-9.8%; p<0.001) than patients who survived. Mortality rates corresponding to TIMI risk scores of 3, 4, and 5 were 25.9%, 29.6%, and 44.4%, respectively (p=0.58 for TIMI 3 vs 4; p=0.001 for TIMI 3 vs 5; p=0.013 for TIMI 4 vs 5). Cox proportional hazards regression analysis showed that only TIMI risk score was an independent predictor of mortality (hazard ratio 2.3, 95% confidence interval 1.4-3.8, p=0.001). CONCLUSION: NT-proBNP has an additive predictive value over TIMI risk score in predicting long-term mortality in intermediate-risk patients with ACS.

A late presentation of tetralogy of Fallot with pulmonary atresia and coronary-pulmonary artery collateral and a congenital aortic stenosis.

We report a 40-year-old man with an unoperated tetralogy of Fallot with pulmonary atresia and congenital aortic valvular stenosis. A well-developed coronary-pulmonary arterial collateral arising from the left main coronary artery was also demonstrated. Although rare cases of tetralogy of Fallot with congenital aortic stenosis has been reported, this is the first particular case demonstrating a triad of these abnormalities.