The Effect of Early Administration of Hypertonic Saline Solution In Acute Decompensated Heart Failure. / O Efeito da Administração Precoce de Solução Salina Hipertônica na Insuficiência Cardíaca Descompensada Aguda.

BACKGROUND: There was no scientific evidence about the initial treatment of hypertonic saline solution (HSS) in acutely decompensated heart failure (ADHF). OBJECTIVES: This study assessed the impact of using HSS along with a loop diuretic (LD) as the first diuretic treatment for ADHF, focusing on renal function, electrolyte levels, and clinical outcomes. METHODS: In this retrospective case-control study, 171 adult patients (93 females/78 males) with ADHF were included between January 1, 2022, and December 31, 2022. Patients were allocated into two groups: upfront combo HSS+LD and standardized LD. The primary endpoint was worsening renal function (WRF). Hospitalization for HF and all-cause mortality were evaluated during 6 months of follow-up. The significance level adopted in the statistical analysis was 5%. RESULTS: The groups exhibited similarities in baseline characteristics.A significantly higher diuresis on the 1st day (3975 [3000-5150] vs. 2583 [2000-3250], p=0.001) and natriuresis on the 2nd hour (116.00 [82.75-126.00] vs. 68.50 [54.00-89.75], p=0.001) in the initial upfront combo HSS+LD were found in comparison with the standardized LD.When compared to the standardized LD, the utilization of HSS led to an increase in serum Na+ (137.00 [131.75-140.00] vs. 140.00 [136.00-142.25], p=0.001 for upfront combo HSS, 139.00 [137.00-141.00] vs. 139.00 [136.00-140.00], p=.0470 for standardized LD), while chloride (99.00 [94.00-103.25] vs. 99.00[96.00-103.00], p=0.295), GFR (48.50 [29.75-72.50 vs. 50.00 [35.50-63.50, p=0.616), and creatinine (1.20 [0.90-1.70] vs. 1.20 [1.00-1.50], p=0.218) remained stable in the upfront combo HSS group when compared to standardized LD group (Cl-: 102.00 [99.00-106.00] vs. 98.00 [95.00-103.00], p=0.001, eGFR: 56.00 [41.00-71.00] vs. 55.00 [35.00-71.00], p=0.050, creatinine:1.10 [0.90-1.40] vs. 1.20 [0.90-1.70], p=0.009). Worsening renal function (16.1% vs 35.5%, p=0.007), and length of stay in the hospital (4 days [3-7] vs. 5 days [4-7], p=0.004) were lower in the upfront combo HSS+LD in comparison with the standardized LD. In-hospital mortality, hospitalization for HF, and all-cause mortality were similar between the two groups. CONCLUSION: HSS as an initial therapy, when combined with LD, may provide a safe and effective diuresis without impairing renal function in ADHF. Therefore, HSS may lead to a shorter length of stay in the hospital for these patients.

FUNDAMENTO: Não houve evidência científica sobre o tratamento inicial com solução salina hipertônica (SSH) na insuficiência cardíaca agudamente descompensada (ICAD). OBJETIVOS: Este estudo avaliou o impacto do uso de SSH junto com um diurético de alça (DA) como o primeiro tratamento diurético para ICAD, com foco na função renal, níveis de eletrólitos e resultados clínicos. MÉTODOS: Neste estudo retrospectivo de caso-controle, 171 pacientes adultos (93 mulheres/78 homens) com ICAD foram incluídos entre 1º de janeiro de 2022 e 31 de dezembro de 2022. Os pacientes foram alocados em dois grupos: combinação inicial de SSH+DA e DA padronizada. O desfecho primário foi piora da função renal (PFR). A hospitalização por IC e a mortalidade por todas as causas foram avaliadas durante 6 meses de acompanhamento. O nível de significância adotado na análise estatística foi de 5%. RESULTADOS: Os grupos exibiram semelhanças nas características basais. Diurese significativamente maior no 1º dia (3975 [3000-5150] vs. 2583 [2000-3250], p=0,001) e natriurese na 2ª hora (116,00 [82,75-126,00] vs. 131,75-140,00] vs. 94,00-103,25] vs. 99,00 [96,00-103,00], p=0,295), TFG (48,50 [29,75-72,50 vs. 50,00[35,50-63,50, p=0,616) e creatinina (1,20 [0,90-1,70] vs. 1,20 [1,00-1,50], p=0,218) permaneceu estável no grupo SSH combinado inicial quando comparado ao grupo DA padronizado (Cl-: 102,00[99,00-106,00] vs. 98,00[95,00-103,00], p=0,001, TFGe: 56,00 [41,00-71,00] vs. 55,00[35,00-71,00], p=0,050, creatinina: 1,10[0,90-1,40] vs. 1,20 [0,90-1,70], p=0,009). A piora da função renal (16,1% vs. 35,5%, p = 0,007) e o tempo de internação hospitalar (4 dias [3-7] vs. 5 dias [4-7], p = 0,004) foram menores na combinação inicial SSH+DA em comparação com o DA padronizado. A mortalidade hospitalar, a hospitalização por IC e a mortalidade por todas as causas foram semelhantes entre os dois grupos. CONCLUSÃO: SSH como terapia inicial, quando combinada com DA, pode proporcionar uma diurese segura e eficaz sem prejudicar a função renal na ICAD. Portanto, a SSH pode levar a um menor tempo de internação hospitalar para esses pacientes.

The Prognostic Value of the Triglyceride-Glucose Index in Forecasting Ten-Year Major Adverse Cardiovascular Events in Non-Diabetic Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

OBJECTIVE: This study aimed to explore the association between the triglyceride-glucose (TyG) index and major adverse cardiovascular events (MACE) over a ten-year period in non-diabetic patients with acute myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI). METHODS: We included 375 consecutive non-diabetic patients presenting with acute MI who underwent primary PCI. The TyG index was calculated and patients were divided based on a cut-off value of ≥ 8.84 into high and low TyG index groups. The incidence of MACE, including all-cause mortality, target vessel revascularization, reinfarction, and rehospitalization for heart failure, was assessed over 10 years. RESULTS: Over the next 10 years, patients who underwent PCI for acute MI experienced a significantly higher incidence of MACE in the group with a high TyG index (≥ 8.84) (P = 0.004). Multivariable analysis revealed that the TyG index independently predicted MACE in these patients [odds ratio = 1.64; 95% confidence interval (CI): 1.22-2.21; P = 0.002]. Analysis of the receiver operating characteristic curve indicated that the TyG index effectively predicted MACE in patients with acute MI following PCI, with an area under the curve of 0.562 (95% CI: 0.503-0.621; P = 0.038). CONCLUSION: This study established a correlation between high TyG index levels and an elevated risk of MACE in non-diabetic patients with acute MI. The findings suggest that the TyG index could be a reliable indicator of clinical outcomes for non-diabetic acute MI patients undergoing PCI.

Aortic Arch Calcification in Predicting Unfavorable Angiographic Outcomes for Patients With ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Despite all advances in treatment, no-reflow, large thrombus burden (LTB), and myocardial blush grade (MBG) are associated with adverse cardiovascular outcomes in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). Aortic arch calcification (AAC) is associated with subclinical atherosclerosis and adverse cardiovascular events. We aimed to examine the relationship between AAC and unfavorable angiographic outcomes such as no-reflow, MBG, and LTB in STEMI patients undergoing PCI. METHODS: A total of 269 consecutive patients who presented with STEMI and underwent primary PCI were included in the study prospectively. Patients were divided into 3 groups according to AAC degree: Grade 0, Grade 1, and Grade 2/3. Unfavorable angiographic results; They were divided into 2 groups according to whether there was no-reflow, 2 groups as LTB and small TB according to thrombus burden, and 4 groups according to MBG between 0-3. RESULTS: LTB, no-reflow, and MBG 0/1 were significantly higher in the Grade 2/3 AAC group compared to the Grade 0 and Grade 1 groups (all p<0.05). Moreover, Grade2/3 AAC was found to be an independent predictor for LTB, MBG 0/1, and no-reflow (OR = 2.480; 95% CI: 1.398-4.400; p = 0.002, OR = 2.364; 95% CI: 1.296-4.321, p = 0.005, OR= 4.170; 95% CI: 1.671-9.100, p=0.004, respectively). Patients were then classified according to thrombus burden, MBG, and no-reflow status. Grade 2/3 AAC was significantly higher than Grade 0/1 AAC in the LTB, MBG 0/1, and no-reflow groups (all p<0.05). CONCLUSION: AAC can be used as a reliable indicator in predicting no-reflow, MBG 0/1, and LTB in STEMI patients undergoing primary PCI.

Clinical characteristics of atrial fibrillation in nonagenarian population and relationship with mortality.

BACKGROUND: There is a considerable amount of literature available on well-known risk factors for atrial fibrillation (AF); however, available data specifically focused on the ninth decade are scarce. The main objective of this study was to assess the demographic and clinical characteristics of AF and sinus rhythm in a nonagenarian population. METHODS: All individuals aged >90 years who were admitted to the Cardiology outpatient clinic between April 2018 and January 2019 were enrolled in the study. The demographic and clinical characteristics of all patients were recorded. All deaths that occurred during the two-year follow-up period were recorded. RESULTS: In total, 112 nonagenarian individuals were included in the study. Of these patients, 50 (44.6%) had AF. The groups showed similarities in demographic and clinical characteristics. During a mean follow-up period of 596±44 days, 39 patients (78%) in the AF group and 35 patients (56.5%) in the sinus group died. Patients with AF showed a lower overall survival distribution than those with sinus rhythm (P=0.005, log-rank test χ2=7.734). AF was associated with an increased risk of mortality (P=0.002, hazard ratio [HR] =2.104, 95% confidence interval [CI] = 1.326-3.339) in multivariate Cox regression analysis, while waist circumference and total cholesterol (P=0.003, HR=0.969, 95% CI=0.949-0.989 and P=0.046, HR=0.993, 95% CI=0.986-1.000, respectively) showed a decreased risk of mortality. CONCLUSIONS: Atrial fibrillation is very common in individuals over the age of 90 years (44.6%). Well-known risk factors do not appear to be effective in this age group, and AF is associated with a 2.1-fold increase in the risk of mortality.

Impact of triglyceride-glucose index on intracoronary thrombus burden in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

BACKGROUND AND AIMS: We aimed to investigate the relationship between triglyceride glucose (TyG) index and intracoronary thrombus burden in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: A total of 468 consecutive patients who were admitted with STEMI and underwent primary PCI were included in the study. TyG index was calculated as ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2]. According to the angiographic reclassified thrombolysis in myocardial infarction (TIMI) thrombus grade, patients were divided into two groups as small thrombus burden (STB) with TIMI thrombus grade 0-3, and large thrombus burden (LTB) with TIMI thrombus grade 4-5. TyG index was significantly higher in the LTB group than in the STB group (9.11 ± 0.86 vs 8.89 ± 0.62; p = 0.002). In multivariate analysis, TyG index was found to be an independent predictor of LTB in STEMI patients who underwent primary PCI [OR (95 % CI): 1.470 (1.090-1.982), p = 0.012]. The area under the curve (AUC) of TyG index predicting LTB was 0.568 (95 % CI 0.506-0.631; p = 0.023), with the best cut-off value of 8.87. In the classification according to TyG index cut-off value, the frequency of LTB was found to be significantly higher in the high TyG index group than in the low TyG index group (33.6 % vs 21.2 %; p = 0.003). CONCLUSION: TyG index, a valid surrogate marker of insulin resistance, is an independent predictor of LTB in STEMI patients who underwent primary PCI and can be used as an indicator of increased intracoronary thrombus burden.

Combined use of frontal plane QRS-T angle and platelet-to-lymphocyte ratio in the risk prediction of ischemic cardiomyopathy in STEMI.

BACKGROUND: Frontal plane QRS-T angle (fQRS-T) and platelet-to-lymphocyte ratio (PLR) are highly important parameters that well-predict unfavorable outcomes in patients with ST-elevated myocardial infarction (STEMI).There are limited data on the predictive significance of ischemic cardiomyopathy (I-CMP) from the combination of fQRS-T and PLR in STEMI, compared to using fQRS-T and PLR alone. AIM: We aimed to evaluate the ability of the combination of fQRS-T and PLR routinely obtained on admission to identify STEMI patients at risk of I-CMP. METHOD: Six hundred and thirty-eight consecutive patients with STEMI who underwent primary percutaneous coronary intervention between 2018 and 2021 were included. The assessment of I-CMP was conducted through two-dimentional (2D)-echocardiography 6 weeks post-STEMI and I-CMP was defined as a left ventricular ejection fraction (LVEF) of 50% or less. Multivariate logistic regression analysis and receiver operating curve (ROC) analysis were performed to predict the development of I-CMP. RESULTS: In ROC analysis, the cut-off values of fQRS-T and PLR for best predicting I-CMP were 66.72° and 101.23, respectively. The model using the combination of two markers was the most powerful predictor of I-CMP risk (OR: 3.183, 95% CI: 1.971-5.139, p = .001) when included in a single variable such as high fQRS-T or high PLR (OR: 1.422, 95% CI: 0.870-0.232, p = .160). Additionally, the concomitant presence of high fQRS-T and high PLR exhibited the highest specificity (77%) for I-CMP relative to the individual presence of high fQRS-T (66%) or PLR (49%). CONCLUSION: The combination of fQRS-T and PLR, which is a simple and cost-effective risk assessment, may serve as a more reliable prognosticator for I-CMP as opposed to the use of fQRS-T and PLR alone for STEMI.

An interesting observation: prolonged green urine can be a combined effect of decreased liver and renal function in a patient with heart failure-a case report.

Background: The administration of propofol and methylene blue (MB) can be associated with the appearance of prolonged green urine discoloration, particularly in patients with heart failure (HF) concomitant with renal and liver dysfunction. Understanding the reasons behind this phenomenon is of clinical significance. Case summary: A 79-year-old woman with a history of HF experienced dyspnoea and persistent green urine discoloration for a week, leading to her hospitalization for acutely decompensated HF. A recent dual-chamber rate-modulated-pacemaker implantation had necessitated propofol sedation and the administration of 100 mg of MB due to methaemoglobinaemia. Upon admission, the patient exhibited elevated levels of brain natriuretic peptide (BNP) and liver function tests, as well as a significant decrease in glomerular filtration rate (GFR). Initial therapy with intravenous furosemide yielded an inadequate response, requiring the initiation of combined diuretic therapy (CDT). The patient's condition improved with CDT, resulting in the normalization of BNP, liver function tests, and GFR, along with the restoration of normal urine colour lasting 12 days. Discussion: Our case report sheds light on the complex interaction between drug metabolic pathways and their potential for prolonged side effects, particularly in patients with multiorgan dysfunction. The association between propofol, MB, and green urine discoloration in the context of HF warrants further investigation, emphasizing the need for increased awareness of drug interactions and their implications in complex clinical scenarios.

Evaluation of the relationship between para-aortic adipose tissue and ascending aortic diameter using a new method.

BACKGROUND: Para-aortic adipose tissue (PAT) is the local adipose tissue that externally surrounds the aorta. It contributes significantly to aortic atherosclerosis and enlargement. Studies conducted with computed tomography and magnetic resonance have shown that individuals with aortic aneurysm had more PAT than healthy individuals. In this study, we measured PAT using transthoracic echocardiography (TTE). The aim of this study is to investigate the possible relationship of TTE measured PAT with ascending aortic width. METHODS: PAT was defined as the hypoechoic space in front of ascending aortic 2 cm above the sinotubular junction at the end of the systole. Patients were divided into 2 groups according to the presence of dilatation in the ascending aorta using Roman's classification (aortic size index, ASI). ASI of less than 21 was considered no aortic dilation and an ASI of 21 mm/m2 or greater was considered to have aortic dilation. RESULTS: A total of 321 unselected patients were divided into the ascending aortic dilatation (AAD) group (n = 96) and the normal ascending aorta diameter group (n = 225 patients). PAT was significantly higher in the AAD group compared with the non-ADD group (0.9 (0.48) vs. 0.7 (0.91) mm, p < 0.0001). Univariate and multivariate logistic regression analysis revealed that PAT (OR: 3.005, 95%CI (1.445-6.251)) were significantly associated with AAD. CONCLUSIONS: This is the first study which evaluated PAT measured by TTE. We found a significant association between PAT measured by TTE and ascending aorta width.

A new and simple parameter for diagnosis pulmonary edema: Expiratory air humidity.

PURPOSE: Acute pulmonary edema is characterized by increased levels of fluid in the interstitial and alveolar space of the lung and requires emergency treatment. In acute pulmonary edema, the amount of fluid in the intra-alveolar, interstitial space, and pleural space vary considerably and this fluid will evaporate in different amounts compared to the physiological fluid. The aim of this study was to compare the humidity rates of expiratory air measured before and after pulmonary edema induced by α-naphthylthiourea (ANTU) in rats. METHODS: The study included twenty healthy adult rats divided equally into a healthy control group and a pulmonary edema group. Pulmonary edema was induced by administering ANTU intraperitoneally in the rats in the study group. Humidity, temperature, lung weight, pleural effusion, and histopathological changes in the respiratory system due to pulmonary edema were examined in the ANTU group. Control measurments were taken before administration of ANTU and again 4 h after administration of ANTU when lung damage was considred to be at maximum levels. RESULTS: Mean expiratory air humidity was 71.22±3.59% before ANTU and 56.28±3.94% after administration of ANTU. The mean humidity difference of -14.94±5.96% was considered statistically different (p = 0.01). CONCLUSION: Humidity rate in expiratory air was significantly lower in rats with acute pulmonary edema compared to healthy rats. This result supports the hypothesis that humidity in expiratory air can be considered an important parameter in patients during clinical are follow-up for pulmonary edema.

The diagnostic value of 2D-speckle tracking echocardiography for identifying subclinical ventricular dysfunction in subjects with early repolarization pattern.

INTRODUCTION: Early repolarization pattern (ERP) can exist a silent substrate for arrhytmic events in accordance with the previous studies which have shown there has been evidence of morphological changes in left ventricle (LV) in ERP subjects. Despite structural changes in ERP subjects, it has not exactly known whether a change in LV functional parameters occur in ERP. The aim of our study was to investigate LV functional parameters in ERP athletes evaluated by 2D- speckle tracking echocardiography (2D-STE). METHOD: In this study, athletes with ERP (n = 50) and athletes without ERP (n = 50) were recruited between April 2018 and September 2018. For each case, 2D- TTE and 2D- STE evaluation were performed by the same cardiologist. RESULTS: Left ventricle mean global longitudinal strain (GLS) (P < .001) and GLS at all apical chamber views (P < .001), longitudinal peak systolic strain rate (SRS) at A3C (P: .011), early diastolic strain rate (SRE) at A3C (P < .001) and late diastolic strain rate (SRA) at A3C (P: .034) in the ERP athletes were significantly lower than those in the athletes without ERP. LV basal segment circumferential SRS (P: .002) and SRE (P: .006) were significantly lower in ERP athletes compared to athletes without ERP. LV mechanical dispersion was significantly higher in ERP athletes compared to athletes without ERP (P < .001). CONCLUSION: Our study suggests ERP can be more associated with impaired LV longitudinal function than circumferential function. In addition, both LV inferolateral region and basal segment can be more affected functionally in ERP athletes.

Could aortic arch calcification help in detection of hypertensive retinopathy?

OBJECTIVE: Hypertension-induced end-organ damage is one of the important determinants of morbidity and mortality in patients with hypertension. All types of hypertension-induced end-organ damages start with vascular damage. Vascular calcification is a marker of vascular damage and aortic arch calcification (AAC) is one of the easily identifiable types of vascular calcification. We hypothesized that AAC predicts retinopathy in hypertensive patients. METHODS: Consecutive hypertensive patients without diabetes mellitus were included. Chest radiography in the posterior-anterior was used to assess the presence of AAC. All patients underwent ophthalmologic examination for retinopathy. RESULTS: We included 495 hypertensive patients in this study. Of these, 306 (62%) had hypertensive retinopathy. Patients with hypertensive retinopathy had significantly higher prevalence of AAC as compared to the patients without hypertensive retinopathy (88% vs. 22%, P < 0.001). We found a strong and positive correlation between hypertensive retinopathy and AAC grades (r = 639, P < 0.001). Receiver operator characteristics curve analysis yielded a strong predictive ability of AAC for the presence of hypertensive retinopathy [area under curve = 0.814, 95% confidence interval (CI): 0.775-0.853, P < 0.0001]. In multivariate logistic regression analysis, presence of AAC [odds ratio (OR) 13.128; CI: 7.894-21.832] and serum glucose levels (OR 1.020; CI: 1.003-1.037) were strongly and independently associated with hypertensive retinopathy. CONCLUSION: Presence of AAC on chest radiograph is strongly and independently associated with retinopathy in nondiabetic hypertensive patients. This simple, inexpensive and widely available tool may help in early detection of retinopathy in patients with hypertension.

Aortic Arch Calcification on Routine Chest Radiography is Strongly and Independently Associated with Non-Dipper Blood Pressure Pattern / A Calcificação no Arco Aórtico na Radiografia de Tórax de Rotina está Forte e Independentemente Associada ao Padrão Não-Dipper de Pressão Arterial

Abstract Background: Non-dipper blood pressure (NDBP) is one of the important causes of hypertension-related target organ damage and future cardiovascular events. Currently, there is no practical tool to predict NDBP pattern. Objectives: The aim of this study was to investigate the relationship between aortic arch calcification (AAC) on chest radiography and NDBP pattern. Methods: All patients referred for ambulatory BP monitoring test were approached for the study participation. NDBP was defined as the reduction of ≤10% in nighttime systolic BP as compared to the daytime values. AAC was evaluated with chest radiography and inter-observer agreement was analyzed by using kappa statistics. Univariate and multivariate logistic regression analysis was conducted to assess the association of AAC and NDBP pattern. A 2-tailed p-value < 0.05 was considered statistically significant. Results: A total of 406 patients (median age: 51.3) were included. Of these, 261(64%) had NDBP pattern. Overall, the prevalence of AAC was 230 (57%). Non-dipper group had significantly higher prevalence of AAC (70% vs. 33%, p < 0.0001) as compared to the dipper group. Presence of AAC was a strong and independent predictor of NDBP pattern (OR 3.919, 95%CI 2.39 to 6.42) in multivariate analysis. Conclusions: Presence of AAC on plain chest radiography is strongly and independently associated with the presence of NDBP pattern.

Resumo Fundamento: A pressão arterial não-dipper é uma das causas mais importantes de lesão de órgão-alvo da hipertensão e de eventos cardiovasculares futuros. Atualmente, não há uma ferramenta prática para prever o padrão não-dipper de pressão arterial. Objetivos: O objetivo deste estudo foi investigar a relação entre a calcificação no arco aórtico detectada no raio de tórax e o padrão não-dipper de pressão arterial. Métodos: Todos os pacientes encaminhados para monitorização ambulatorial da pressão arterial foram abordados para participação no estudo. A pressão arterial não-dipper foi definida como a redução de ≤10% da pressão arterial sistólica noturna quando comparada com os valores diários. A calcificação no arco aórtico foi avaliada através de radiografia do tórax e a concordância interobservador foi analisada utilizando a estatística kappa. Análises de regressão logística uni e multivariada foram realizadas para avaliar a associação entre a calcificação no AA e o padrão PADV. Valores de p bicaudais < 0,05 foram considerados estatisticamente significativos. Resultados: Ao todo, 406 pacientes (idade mediana: 51,3) foram incluídos. Desses, 261(64%) apresentavam padrão não-dipper de pressão arterial. De modo geral, a prevalência de calcificação no arco aórtico foi de 230 (57%). O grupo não-dipper apresentou prevalência significativamente maior de calcificação no arco aórtico (70% vs. 33%, p < 0,0001) em relação ao grupo dipper. A presença de calcificação no arco aórtico foi um preditor forte e independente de padrão não-dipper de pressão arterial (OR = 3,919; IC: 95% 2,39-6,42) em análise multivariada. Conclusões: A presença de calcificação no arco aórtico em raio-x de tórax simples está forte e independentemente associada à presença de padrão não-dipper de pressão arterial.

Aortic Arch Calcification on Routine Chest Radiography is Strongly and Independently Associated with Non-Dipper Blood Pressure Pattern.

BACKGROUND: Non-dipper blood pressure (NDBP) is one of the important causes of hypertension-related target organ damage and future cardiovascular events. Currently, there is no practical tool to predict NDBP pattern. OBJECTIVES: The aim of this study was to investigate the relationship between aortic arch calcification (AAC) on chest radiography and NDBP pattern. METHODS: All patients referred for ambulatory BP monitoring test were approached for the study participation. NDBP was defined as the reduction of ≤10% in nighttime systolic BP as compared to the daytime values. AAC was evaluated with chest radiography and inter-observer agreement was analyzed by using kappa statistics. Univariate and multivariate logistic regression analysis was conducted to assess the association of AAC and NDBP pattern. A 2-tailed p-value < 0.05 was considered statistically significant. RESULTS: A total of 406 patients (median age: 51.3) were included. Of these, 261(64%) had NDBP pattern. Overall, the prevalence of AAC was 230 (57%). Non-dipper group had significantly higher prevalence of AAC (70% vs. 33%, p < 0.0001) as compared to the dipper group. Presence of AAC was a strong and independent predictor of NDBP pattern (OR 3.919, 95%CI 2.39 to 6.42) in multivariate analysis. CONCLUSIONS: Presence of AAC on plain chest radiography is strongly and independently associated with the presence of NDBP pattern.

An unusual cause of lacunar infarcts: Lambl's excrescences on aortic valve shown in detail by 3D transesophageal echocardiography.

Lambl's excrescences (LE) are rare cardiac structures. They are associated with catastrophic thromboembolic and coronary events. Despite resulting in such important events, 2D echocardiographic imaging modalities may overlook LE owing to very thin cardiac structures. So, 3D echocardiographic imaging modalities may fully offer this cardiac mass and provide us to more accurately guess the complication rate related to LE due to the fact that 3D echocardiographic imaging techniques have higher spatial resolution and are not based on the geometric assumption. Indeed, another benefit of 3D echocardiographic imaging modalities in this population is that these imaging modalities clearly provide the relationship to adjacent structures of LE and its movement over a cardiac cycle in 3D space. In our case report, we aim to present the usefulness of 3D echocardiography as a modality to clearly offer all features of LE, furthermore to give valuable information about management in patients with thromboembolic events leading to LE.

Presence of fragmented QRS may be associated with complex ventricular arrhythmias in patients with essential hypertension.

BACKGROUND: Ventricular arrhythmias (VAs) are frequent in hypertensive patients. Myocardial fibrosis is one of the components of left ventricular hypertrophy secondary to hypertension. Fragmented QRS (fQRS) on electrocardiography (ECG) has been shown to be a marker of myocardial fibrosis. In this study, we aimed to investigate the association between fQRS and complex VAs in patients with essential hypertension. METHODS: Two hundreds consecutive patients who were diagnosed with hypertension were included in the study. The control group consisted of 153 age and sex matched healthy individuals. ECG and transthoracic echocardiography were performed to all patients. fQRS was defined as additional R' wave or notching/splitting of S wave in two contiguous ECG leads. All patients underwent 24-hour Holter monitoring and VAs were classified using Lown's scoring system. Lown class ≥3 VAs were considered as complex VAs. RESULTS: There was no significant difference with respect to age (52 ±â€¯8 vs 52 ±â€¯6 years, p = 0.836) and gender distribution (female: 64% vs 63%, p = 0.907) between the groups. As compared to the healthy individuals, prevalence of fQRS (67% vs 9.2%, p < 0.001) and complex VAs (19% vs 0%, p < 0.001) were significantly higher in patients with hypertension. Furthermore, complex VAs (25.4% vs 6.1%, p = 0.001) were significantly higher in hypertensive patients with fQRS. In multiple logistic regression analysis, left ventricular ejection fraction (OR: 1.11, 95%CI: 1.025 to 1.183; p = 0.006), left ventricular mass index (OR: 1.04, 95%CI: 1.021 to 1.107; p = 0.001) and presence of fQRS (OR: 5.605, 95%CI: 1.427 to 22.019; p = 0.014) were independent predictors for complex VAs. CONCLUSION: The presence of fQRS may be associated with complex VAs in patients with essential hypertension. Therefore, fQRS may be used in risk stratification of complex VAs and sudden cardiac death especially in hypertensive patients with left ventricular hypertrophy.

Relationship between ST-Segment Shifts in Lead aVR and Coronary Complexity in Patients with Acute Coronary Syndrome.

BACKGROUND: ST-segment shifts in lead aVR are associated with increased coronary atherosclerosis. However, there is insufficient data about the relationship between ST-segment shifts in lead aVR and coronary complexity. The aim of this study was to investigate this relationship. METHODS: This prospective, observational study included 236 patients with acute coronary syndrome who underwent coronary angiography. Electrocardiograms on presentation were reviewed in terms of ST-segment shifts in lead aVR. Inter-observer agreement was analyzed using kappa statistics for the presence of aVR lead ST segment shifts. The patients were divided into two groups according to their Sx scores (≤ 22 and > 22). RESULTS: The mean age of the study population was 62.19 ± 12 years. Eighty-seven patients (37%) had complex coronary artery disease as defined by intermediate-high Sx scores, and 130 patients (55%) had ST-segment shifts in lead aVR. In multivariate logistic regression analysis, ST-segment elevation or depression ≥ 1 mm were independently associated with intermediate-high Sx scores. CONCLUSIONS: In patients with acute coronary syndrome, the presence of ST-segment elevation or depression ≥ 1 mm in lead aVR may indicate coronary complexity.

A strong and reliable indicator for early postoperative major cardiac events after elective orthopedic surgery: Aortic arch calcification.

BACKGROUND: Cardiovascular events after orthopedic surgery may result in mortality. Therefore, predictors of early cardiovascular events after elective orthopedic surgery are required. AIM: The aim of this study is to investigate the relationship between aortic arch calcification and 30-day major adverse cardiac events following elective orthopedic surgery. METHODS: Patients who had undergone orthopedic surgery were screened. Preoperative detailed anamnesis was taken. Echocardiography and standard chest x-ray were performed.Patients were followed in terms of perioperative 30-days major cardiac events and were classified into two groups according to development of perioperative major adverse cardiac events.Aortic arch calcification was evaluated by two cardiologists, blinded to study findings and was graded as 0 to 3 on chest x-ray. RESULTS: A total of 1060 patients were approached for the study participation. Of these 714 were included in the study (mean age: 70.43, 65% female). Cardiovascular events occurred in 33 patients. As compared to the patients without cardiac events, the prevalence of aortic arch calcification, coronary artery disease, hypertension, and smoking were higher in patients with cardiac events. In addition, Lee index, left ventricular end-systolic, end-diastolic and left atrial diameter were significantly higher, GFR values were significantly lower in the group with cardiac events.Multivariate regression analysis showed that smoking (OR 5.031, 95% CI 1.602 to 15.794), presence of hypertension (OR 5.133, 95% CI 1.297 to 20.308) and aortic arch calcification (OR 6.920, 95% CI 3.890 to 12.310) are independent predictors of major cardiac events within 30-day of elective orthopedic surgery. CONCLUSIONS: Presence of aortic arch calcification is associated with development of major cardiac events within 30-days after elective orthopedic surgery.

Development of Pacemaker Lead Thrombosis in a Patient with Atrial Fibrillation during Apixaban Treatment.

Apixaban was introduced in clinical use for nonvalvular atrial fibrillation as an alternative to warfarin. There is a dearth of information regarding apixaban use in patients suffering from atrial fibrillation with intracardiac foreign bodies such as pacemaker leads. In this report, we describe a 72-year-old female patient with a complaint of weakness in both legs of a few days' duration. She was detected to have a thrombus over the pacemaker lead and inside the left atrial appendage during apixaban treatment. After the discontinuation of apixaban and the commencement of warfarin, the thrombus was resolved. Our case is the first report to show that apixaban treatment (5 mg, twice daily) may not prevent the development of pacemaker lead thrombosis in patients with atrial fibrillation.