Supporting Role of Adequate Affected Tissue Biopsy in the Diagnostic Algorithm for Cardiac Amyloidosis.

Amyloidosis is a pathology that occurs as a result of the accumulation of various misfolded proteins in the extracellular space. It is a significant cause of morbidity and mortality due to multi-organ involvement. One of the most important determinants of mortality and morbidity is cardiac involvement. Cardiac amyloidosis (CA) may present with a variety of clinical findings. In this article, we aim to demonstrate the supportive role of cardiac and extra-cardiac tissue in the routine diagnostic pathway for CA.

Effects of an Impaired Fasting Glucose on the Left Atrial Strain Evaluated by Speckle Tracking Echocardiography.

Background and Objectives: Similar to diabetes, the presence of left ventricular (LV) diastolic function (DD) has been reported in various studies which were conducted with people with a diagnosis of an impaired fasting blood glucose (FBG). This study aimed to examine the effects of the fasting blood glucose (FBG) levels on the left atrial strain (LAS) estimated by two-dimensional echocardiography speckle tracking analyses in patients without known diabetes. Material and Methods: The study included 148 participants (74 female and 74 male) without a history of diabetes mellitus or chronic disease. The patients were divided into two groups as follows: individuals with an FBG < 100 mg/dL and those with an FBG between 100 and 125 mg/dL after at least 8 h of overnight fasting. According to these FBG levels, speckle tracking echocardiography (STE) measures were compared. Results: There was a significant decrease in the LA reservoir (52.3 ± 15 vs. 44.5 ± 10.7; p = 0.001) and conduit strain (36.9 ± 11.7 vs. 28.4 ± 9.7; p = 0.001) in the impaired FBG group. When the STE findings of both ventricles were compared, no significant difference was observed between the groups in right and left ventricular strain imaging. Conclusions: In the earliest stage of LVDD, changes in atrial functional parameters become particularly evident. Echocardiographic analyses of these parameters can help to diagnose and determine the degree of LVDD while the morphological parameters are still normal. The addition of LAS imaging to routine transthoracic echocardiography (TTE) studies in patients with an impaired FBG but without a DM diagnosis may be helpful in demonstrating subclinical LVDD or identifying patients at risk for LVDD in this patient group.

Prognostic significance of medical therapy in patients with heart failure with reduced ejection fraction.

AIMS: The use of guideline-directed medical therapy (GDMT) among patients with heart failure (HF) with reduced ejection fraction (HFrEF) remains suboptimal. The SMYRNA study aims to identify the clinical factors for the non-use of GDMT and to determine the prognostic significance of GDMT in patients with HFrEF in a real-life setting. METHODS AND RESULTS: The SMYRNA study is a prospective, multicentre, and observational study that included outpatients with HFrEF. Patients were divided into three groups according to the status of GDMT at the time of enrolment: (i) patients receiving all classes of HF medications including renin-angiotensin system (RAS) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists (MRAs); (ii) patients receiving any two classes of HF medications (RAS inhibitors and beta-blockers, or RAS inhibitors and MRAs, or beta-blockers and MRAs); and (iii) either patients receiving class of HF medications (only one therapy) or patients not receiving any class of HF medications. The primary outcome was a composite of hospitalization for HF or cardiovascular death. The study population consisted of 1062 patients with HFrEF, predominantly men (69.1%), with a median age of 68 (range: 20-96) years. RAS inhibitors, beta-blockers, and MRAs were prescribed in 76.0%, 89.4%, and 55.1% of the patients, respectively. The proportions of patients receiving target doses of guideline-directed medications were 24.4% for RAS inhibitors, 11.0% for beta-blockers, and 11.1% for MRAs. Overall, 491 patients (46.2%) were treated with triple therapy, 353 patients (33.2%) were treated with any two classes of HF medications, and 218 patients (20.6%) were receiving only one class of HF medication or not receiving any HF medication. Patient-related factors comprising older age, New York Heart Association functional class, rural living, presence of hypertension, and history of myocardial infarction were independently associated with the use or non-use of GDMT. During the median 24-month period, the primary composite endpoint occurred in 362 patients (34.1%), and 177 of 1062 (16.7%) patients died. Patients treated with two or three classes of HF medications had a decreased risk of hospitalization for HF or cardiovascular death compared with those patients receiving ≤1 class of HF medication [hazard ratio (HR): 0.65; 95% confidence interval (CI): 0.49-0.85; P = 0.002, and HR: 0.61; 95% CI: 0.47-0.79; P < 0.001, respectively]. CONCLUSIONS: The real-life SMYRNA study provided comprehensive data about the clinical factors associated with the non-use of GDMT and showed that suboptimal GDMT is associated with an increased risk of hospitalization for HF or cardiovascular death in patients with HFrEF.

Rationale, Design, and Methodology of the MORCOR-TURK Trial: Predictors of In-hospital MORtality in CORonary Care Patients in Turkey.

BACKGROUND: Coronary care units are sophisticated clinics established to reduce deaths due to acute cardiovascular events. Current data on coronary care unit mortality rates and predictors of mortality in Turkey are very limited. The MORtality predictors in CORonary care units in TURKey (MORCOR-TURK) trial was designed to provide information on the mortality rates and predictors in patients followed in coronary care units in Turkey. METHODS: The MORCOR-TURK trial will be a national, observational, multicenter, and noninterventional study conducted in Turkey. The study population will include coronary care unit patients from 50 centers selected from all regions in Turkey. All consecutive patients admitted to coronary care units with cardiovascular diagnoses between 1 and 30 September 2022 will be prospectively enrolled. All data will be collected at one point in time, and the current clinical practice will be evaluated (ClinicalTrials.gov number NCT05296694). In the first step of the study, admission diagnoses, demographic characteristics, basic clinical and laboratory data, and in-hospital management will be assessed. At the end of the first step, the predictors and rates of in-hospital mortality will be documented. The second step will be in cohort design, and discharged patients will be followed up till 1 year. Predictors of short- and long-term mortality will be assessed. Moreover, a new coronary care unit mortality score will be generated with data acquired from this cohort. RESULTS: The short-term outcomes of the study are planned to be shared by early 2023. CONCLUSION: The MORCOR-TURK trial will be the largest and most comprehensive study in Turkey evaluating the rates and predictors of in-hospital mortality of patients admitted to coronary care units.

The impact of complete versus partial preservation of the sub-valvular apparatus on left ventricular function in mitral valve replacement.

INTRODUCTION: In mitral valve replacement (MVR), sudden increases in afterload and disruption of the annular-chordal-papillary-left-ventricular wall causes left ventricular (LV) dysfunction in the early postoperative period. Preservation of the posterior mitral leaflet apparatus (MVR-P) has a favorable outcome on LV function. However, there is paucity of data on the impact of complete preservation of the sub-valvular apparatus (MVR-C). OBJECTIVE: We investigated the impact of MVR-P and MVR-C on baseline and 3-months postoperative LV ejection fraction (EF) and global longitudinal strain (GLS). METHODS: We retrospectively analyzed a cohort of 29 MVR-P and 19 MVR-C patients with complete echocardiography data at our unit, who were operated between 2008 and 2017. Between-group changes in LVEF and GLS were compared using independent sample T-test. RESULTS: Median age was 59 years (IQR 50-69 years). Baseline LVEF was 58% (51%- 60%). Baseline GLS was -18.4 (-21.2 to -15.5). There were no significant between-group differences between all baseline demographics and echocardiographic markers. There was significantly higher absolute postoperative LVEF in MVR-C patients (p = 0.029). There was also significant worsening in LVEF (p = 0.0121) and GLS (p < 0.0001) after MVR-P and not MVR-C, suggesting no reduction in LV function post-MVR-C but a reduction post-MVR-P. There was significantly less postoperative worsening of GLS per patient in MVR-C group as compared to the MVR-P group (p = 0.023), indicating better preservation of LV function. There was also a smaller decline in LVEF per patient in the MVR-C as compared to the MVR-P group, although not statistically significant (p = 0.23). CONCLUSION: MVR with complete preservation of the sub-valvular apparatus shows a favorable impact on the longitudinal function of the heart at 3 months. Further studies with larger patient numbers are indicated to investigate the long-term results of this surgical approach.

Incidental finding of accessory mitral valve tissue on routine adult echocardiography.

Accessory mitral valve tissue is a rare congenital cardiac abnormality that sometimes can cause left ventricular outflow tract obstruction. We herein present the case of a 55-year-old male with an incidental finding of accessory mitral valve tissue on transthoracic echocardiography. The patient was managed conservatively as accessory tissue was not causing left ventricular outflow obstruction and there were no hemodynamic consequences.

Usefulness of novel Martin/Hopkins and Sampson equations over Friedewald equation in cardiology outpatients: A CVSCORE-TR substudy.

BACKGROUND AND AIMS: The Friedewald equation (LDL-Cf) is known to produce inaccurate estimations of low-density lipoprotein cholesterol (LDL-C) when triglycerides are high (>400 mg/dL) or LDL-C is low (<70 mg/dL). The Martin/Hopkins (LDL-Cmh) and Sampson (LDL-Cs) equations were developed to overcome these limitations, but few data are available to assess whether these equations offer incremental usefulness over LDL-Cf. Our aim was to understand whether there was any incremental usefulness of novel equations on decisions regarding patient management. METHODS: Four thousand one hundred and ninety-six cardiology patients who were included in a multicentre registry database were analysed. Each patient was assigned to a cardiovascular risk class using the SCORE (Systematic COronary Risk Evaluation) algorithm, and relevant European guidelines were used to assess LDL-C targets. RESULTS: Compared with LDL-Cmh and LDL-Cs, LDL-Cf was able to correctly identify 96.9%-98.08% of patients as within or outside the LDL-C target, respectively, and 1.95%-2.8% of patients were falsely identified as being within the LDL-C target. Kappa coefficients for agreement between LDL-Cf vs LDL-Cmh and LDL-Cf vs LDL-Cs were 0.868 and 0.918 (P < .001). For patients not on cholesterol-lowering drugs, the decision to initiate treatment would be different in 1.2%-1.8% of cases if LDL-Cs or LDL-Cmh were used, respectively. For those already on cholesterol-lowering drugs, decisions regarding treatment intensification would be different in 1.5%-2.4% of cases if LDL-Cs or LDL-Cmh were used. CONCLUSIONS: In most cardiology outpatients, the Friedewald equation has excellent agreement with the novel Martin/Hopkins and Sampson equations, and treatment decisions should not change in most patients.

Differential diagnosis of apical hypertrophic cardiomyopathy and apical displacement of the papillary muscles: a multimodality imaging point of view.

Apical hypertrophic cardiomyopathy (ApHCM) and apical displacement of papillary muscles (ADPM) are two different pathologies with a number of similar imaging findings that may hamper adequate diagnosis. While ApHCM is associated with increased rate of mortality, ADPM commonly presents with a benign course and differential diagnosis is of great importance. Clinical assessment and 2D echocardiography cannot sufficiently differentiate these conditions, however, and advanced echocardiographic methods may facilitate diagnosis. Although echocardiography is the first-line imaging method in the diagnostic algorithm, cardiac magnetic resonance imaging (CMRI) is the gold standard for evaluating patients due to good spatial resolution and myocardial tissue characterization abilities. When CMRI is contraindicated, cardiac computed tomography may be an alternative reliable method that can also give information about the coronary anatomy. Nuclear imaging may also provide supplementary data regarding hypertrophy and coronary arteries when there is a suspicion of ischemia.

Gender-related clinical and management differences in patients with chronic heart failure with reduced ejection fraction.

AIM: Gender-related differences have been described in the clinical characteristics and management of patients with chronic heart failure with reduced ejection fraction (HFrEF). However, published data are conflictive in this regard. METHODS: We investigated differences in clinical and management variables between male and female patients from the ATA study, a prospective, multicentre, observational study that included 1462 outpatients with chronic HFrEF between January and June 2019. RESULTS: Study population was predominantly male (70.1%). In comparison to men, women with chronic HFrEF were older (66 ± 11 years vs 69 ± 12 years, P < .001), suffered more hospitalisations and presented more frequently with NYHA class III or IV symptoms. Ischaemic heart disease was more frequent in men, whereas anaemia, thyroid disease and depression were more frequent in women. No difference was seen between genders in the use rate of renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or ivabradine, or in the proportion of patients achieving target doses of these drugs. Regarding device therapies, men were more often treated with an implantable cardioverter-defibrillator (ICD) and women received more cardiac resynchronisation therapy. CONCLUSION: In summary, although management seemed to be equivalent between genders, women tended to present with more symptoms, require hospitalisation more frequently and have different comorbidities than men. These results highlight the importance of gender-related differences in HFrEF and call for further research to clarify the causes of these disparities. Gender-specific recommendations should be included in future guidelines in HFrEF.

Adherence to guideline-directed medical and device Therapy in outpAtients with heart failure with reduced ejection fraction: The ATA study.

OBJECTIVE: Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ≤40%). METHODS: The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019. RESULTS: The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin-angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279). CONCLUSION: The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy.

Normal echocardiographic measurements in a Turkish population: The Healthy Heart ECHO-TR Trial.

OBJECTIVE: Normal reference values for the cardiac chambers are widely based on cohorts from European or American populations. In this study, we aimed to obtain normal echocardiographic measurements of healthy Turkish volunteers to reveal the age, gender, and geographical region dependent differences between Turkish populations and other populations. METHODS: Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination. Blood biochemical parameters were also obtained for all patients on admission. The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used to assess the echocardiographic cardiac chamber quantification. RESULTS: The study included 1154 volunteers (men: 609; women: 545), with a mean age of 33.5±11 years. Compared to men, women had a smaller body surface area, lower blood pressure and heart rate, lower hemoglobin, total cholesterol, lower low-density lipoprotein (LDL) levels, and higher high density lipoprotein (HDL) levels. Cardiac chambers were also smaller in women and their size varied with age. When we compared the regions in Turkey, the lowest values of left cardiac chamber indices were seen in the Marmara region and the highest values were observed in the Mediterranean region. Regarding the right cardiac indices, the Mediterranean region reported the lowest values, while the Black Sea region and the Eastern Anatolia region reported the highest values. CONCLUSION: This is the first study that evaluates the normal echocardiographic reference values for a healthy Turkish population. These results may provide important reference values that could be useful in routine clinical practice as well as in further clinical trials. (.