Usefulness of triglyceride-glucose index and homeostatic model assessment for predicting coronary microvascular dysfunction.

BACKGROUND: Coronary microvascular dysfunction (CMD) is a common occurrence in individuals with insulin resistance (IR). Homeostatic model assessment for insulin resistance (HOMA-IR) is a widely used surrogate marker of IR, although recent studies suggest Triglyceride-Glucose (TyG) index is a superior marker of IR that had a better accuracy to predict Type 2 Diabetes or cardiovascular outcomes than HOMA-IR. OBJECTIVES: We aimed to assess the accuracy and usefulness of TyG index and HOMA-IR for predicting CMD as assessed with echocardiographic coronary flow reserve (CFR) measurement. METHODS: All cases included in the institutional CFR registry were retrospectively reviewed, and 656 cases without epicardial coronary artery disease and without major risk factors for atherosclerosis were included. A CFR ≤2.0 was defined as CMD. RESULTS: TyG index was available in all cases, while HOMA-IR was available in 398 cases. Both TyG index and HOMA-IR were associated with CMD on univariate analyses, while after adjustment for potential confounders HOMA-IR (OR:1.38, 95 %CI:1.14-1.67, p = 0.001) but not TyG index(OR:1.48, 95 %CI:0.82-2.67, p = 0.19) was associated with CMD. The predictive accuracy of HOMA-IR (c-statistic:0.63, 95 %CI:0.54-0.72, p = 0.003) was higher than TyG index(c-statistic:0.55, 95 %CI:0.47-0.63, p = 0.13), although the difference was not statistically significant (DeLong p = 0.23). There was strong evidence favoring a true difference between CMD vs. non-CMD groups for HOMA-IR (BF10:3507) but not for TyG index(BF10:0.66). CONCLUSIONS: HOMA-IR, but not TyG index, is closely associated with CMD.

Comparison of Medical Treatments According to the Characteristics of Idiopathic Premature Ventricular Contractions: Beta-blockers or Calcium Channel Blockers?

Objective: Premature ventricular contractions (PVCs) are a common arrhythmic condition. The first approach in patients with symptomatic and frequent PVC is medical treatment, primarily beta-blockers (BB) or calcium channel blockers (CCB), but it is still unclear which of the two should be chosen. This study investigated which drug treatment would be beneficial according to patient and electrocardiography (ECG) characteristics in patients with idiopathic PVC. Methods: We retrospectively analyzed 156 patients with PVC who came to the cardiology outpatient clinic. Seventy-one patients were responsive to BB, and 85 were responsive to CCB. Their demographic and ECG characteristics were compared. Results: The male ratio was higher (p<0.001), and the left ventricular ejection fraction was lower in BB responders than in CCB responders (p<0.001). Although the mean heart rate was higher in BB responders (p<0.001), the initial PVC burden was lower in BB responders than in CCB responders (p<0.001). The PVC QRS duration was longer in BB responders than in CCB responders (p<0.001). Similarly, the coupling interval variability was higher in BB responders (p=0.006). Conclusions: The evaluation of clinical and ECG parameters in patients with frequent idiopathic PVCs may determine whether BBs or CCBs should be chosen as initial treatment. Further prospective studies are needed to verify our findings and establish their clinical applicability.

Gut microbiota-derived metabolite trimethylamine N-oxide and biomarkers of inflammation are linked to endothelial and coronary microvascular function in patients with inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD), which is an umbrella term used for ulcerative colitis (UC) and Crohn's disease (CD), is associated with an increased risk for atherosclerotic cardiovascular disease (CVD). We aimed to investigate the association of local and systemic biomarkers of inflammation and gut microbiota-derived metabolite trimethylamine N-oxide (TMAO) with endothelial and coronary microvascular dysfunction in IBD. METHODS: A total of 56 patients with IBD (20 with UC and 36 with CD) and 34 age and gender matched controls were included. For all participants, samples were collected to analyze faecal calprotectin, and TMAO concentrations. Ultrasound-based examinations were done to measure flow-mediated vasodilatation (FMD) and coronary flow velocity reserve (CFVR). RESULTS: Patients with IBD had lower CFVR (2.07 (1.82-2.40)) and FMD (8.7 ± 3.7) as compared to controls (2.30 (2.07-2.74), p = 0.005 and 11.9 ± 6.8, p = 0.03). In patients with IBD, TMAO concentration (r = -0.30, p = 0.03), C-reactive protein (r = -0.29, p = 0.03) and WBC count (r = -0.37, p = 0.006) had a significant negative correlation with CFVR, and TMAO (ß = -0.27, 95 % CI: -0.23 to -0.02) and WBC count (ß = -0.31, 95 % CI: -0.56 to -0.06) were significant predictors of CFVR after multivariate adjustment. None of the biomarkers of inflammation or TMAO showed significant correlations with FMD. In patients with UC, TMAO showed a significant correlation with both CFVR (r = -0.55, p = 0.01) and FMD (r = -0.60, p = 0.005) while only WBC count had a statistically significant correlation with CFVR (r = -0.49, p = 0.004) in patients with CD. CONCLUSIONS: Gut microbiota-derived metabolite TMAO and biomarkers of systemic inflammation are associated with measures of endothelial/coronary microvascular dysfunction in patients with IBD.

Coronary flow velocity reserve is reduced in patients with an exaggerated blood pressure response to exercise.

Coronary artery disease and cardiovascular mortality are increased in patients with an exaggerated blood pressure response to exercise. The exact cause of this increase remains unknown, but previous studies have indicated the presence of endothelial dysfunction in peripheral arteries and subclinical atherosclerosis in these patients. The present study aimed to clarify whether coronary microvascular dysfunction is also present in patients with exaggerated blood pressure response to exercise. A total of 95 patients undergoing exercise testing were consecutively enrolled. Flow-mediated vasodilatation and carotid intima-media thickness were measured using standardized methods. A transthoracic echocardiography examination was performed to measure coronary flow velocity reserve. Patients with an exaggerated blood pressure response to exercise had significantly lower coronary flow velocity reserve than the controls (2.06 (1.91-2.36) vs. 2.27 (2.08-2.72), p = 0.004), and this difference was caused by a reduction in hyperemic flow velocity (57.5 (51.3-61.5) vs. 62.0 (56.0-73.0), p = 0.004) rather than a difference in basal flow (26.5 (22.3-29.8) vs. 26.0 (24.0-28.8), p = 0.95). Patients with an exaggerated blood pressure response to exercise also had a significantly greater carotid intima-media thickness and significantly lower flow-mediated vasodilatation than controls. However, an exaggerated blood pressure response to exercise remained a significant predictor of coronary microvascular dysfunction after adjusting for confounders (OR: 3.60, 95% CI: 1.23-10.54, p = 0.02). Patients with an exaggerated blood pressure response to exercise show signs of coronary microvascular dysfunction, in addition to endothelial dysfunction and subclinical atherosclerosis. This finding might explain the increased risk of coronary artery disease and cardiovascular mortality in these patients.

Quantitative assessment of left atrial functions by speckle tracking echocardiography in hypertensive patients with and without retinopathy.

PURPOSE: The association between hypertensive retinopathy and left atrial (LA) impairment is unknown. Accordingly, it was aimed to investigate the possible relationship between hypertensive retinopathy and LA phasic functions by means of two-dimensional speckle-tracking echocardiography (2D-STE). METHODS: A total of 124 hypertensive patients and 27 control subjects were included in the study. LA reservoir strain (LAS-S ), LA conduit strain (LAS-E ), and LA booster strain (LAS-A ) parameters were used to evaluate LA myocardial functions. RESULTS: Hypertensive patients (with and without retinopathy) displayed an obvious reduction in the LA reservoir strain (LAS-S ), and LA conduit strain (LAS-E ). Moreover, further impairment in LA reservoir and conduit strain was found in patients with hypertensive retinopathy than in the isolated hypertensive patients. There were no significant differences in LA booster strain (LAS-A ) among the three groups. Impaired LAS-S (OR: 0.764, CI: 0.657-0.888, and p < 0.001), LAS-E (OR: 0.754, CI: 0.634-0.897, and p = 0.001), and hypertension (HT) duration (OR: 2.345, CI: 1.568-3.507, and p < 0.001) were shown to be independent predictors of hypertensive retinopathy. CONCLUSION: Impaired LA reservoir and conduit strain may be used to predict hypertensive patients at higher risk of developing hypertensive retinopathy, and to determine which patients should be followed more closely for hypertensive retinopathy.

Coronary microvascular dysfunction is common in patients hospitalized with COVID-19 infection.

BACKGROUND AND AIMS: Microvascular disease is considered as one of the main drivers of morbidity and mortality in severe COVID-19, and microvascular dysfunction has been demonstrated in the subcutaneous and sublingual tissues in COVID-19 patients. The presence of coronary microvascular dysfunction (CMD) has also been hypothesized, but direct evidence demonstrating CMD in COVID-19 patients is missing. In the present study, we aimed to investigate CMD in patients hospitalized with COVID-19, and to understand whether there is a relationship between biomarkers of myocardial injury, myocardial strain and inflammation and CMD. METHODS: 39 patients that were hospitalized with COVID-19 and 40 control subjects were included to the present study. Biomarkers for myocardial injury, myocardial strain, inflammation, and fibrin turnover were obtained at admission. A comprehensive echocardiographic examination, including measurement of coronary flow velocity reserve (CFVR), was done after the patient was stabilized. RESULTS: Patients with COVID-19 infection had a significantly lower hyperemic coronary flow velocity, resulting in a significantly lower CFVR (2.0 ± 0.3 vs. 2.4 ± 0.5, p < .001). Patients with severe COVID-19 had a lower CFVR compared to those with moderate COVID-19 (1.8 ± 0.2 vs. 2.2 ± 0.2, p < .001) driven by a trend toward higher basal flow velocity. CFVR correlated with troponin (p = .003, r: -.470), B-type natriuretic peptide (p < .001, r: -.580), C-reactive protein (p < .001, r: -.369), interleukin-6 (p < .001, r: -.597), and d-dimer (p < .001, r: -.561), with the three latter biomarkers having the highest areas-under-curve for predicting CMD. CONCLUSIONS: Coronary microvascular dysfunction is common in patients with COVID-19 and is related to the severity of the infection. CMD may also explain the "cryptic" myocardial injury seen in patients with severe COVID-19 infection.

The relationship between triglyceride/high-density lipoprotein cholesterol ratio and coronary slow-flow phenomenon.

In this study, we aimed to investigate the relationship between high triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) ratio and coronary slow flow phenomenon (CSFP) in patients undergoing elective coronary angiography for suspected coronary artery disease. This prospective study included a total of 84 CSFP patients and 83 controls with normal coronary flow, as evidenced by coronary angiography. The Thrombolysis in Myocardial Infarction (TIMI) frame count (TFC) was used to measure the coronary blood flow velocity. The lipid profiles were analyzed and TG/HDL-C ratio were calculated dividing absolute TG levels by absolute HDL-C levels in peripheral blood. The median TG/HDL-C ratio was higher in the CSFP group than the control group (3.4 [2.6 to 4.9] vs. 2.3 [1.8 to 3], respectively; p < 0.001). The multivariate logistic regression analysis revealed that TG/HDL-C ratio was an independent predictor of CSFP (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.59-2.32; p = 0.001) and TG/HDL-C ratio was positively correlated with the TFC in the CSFP group (r = 0.311, p < 0.001). The area under the receiver operating characteristic curve of TG/HDL-C for the diagnosis of CSFP was 0.73 (95% CI 0.65-0.81; p < 0.001). If a cut-off value of 2.75 was used, higher levels of TG/HDL-C ratio could predict the presence of CSFP with 72% sensitivity and 71% specificity. Our study results suggest that TG/HDL-C ratio is associated with CSFP and may be a useful biomarker for predicting CSFP and its severity.

Prognostic Value of Inflammatory Biomarkers in Patients with Severe COVID-19: A Single-Center Retrospective Study.

BACKGROUND: The current knowledge about novel coronavirus-2019 (COVID-19) indicates that the immune system and inflammatory response play a crucial role in the severity and prognosis of the disease. In this study, we aimed to investigate prognostic value of systemic inflammatory biomarkers including C-reactive protein/albumin ratio (CAR), prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) in patients with severe COVID-19. METHODS: This single-center, retrospective study included a total of 223 patients diagnosed with severe COVID-19. Primary outcome measure was mortality during hospitalization. Multivariate logistic regression analyses were performed to identify independent predictors associated with mortality in patients with severe COVID-19. Receiver operating characteristic (ROC) curve was used to determine cut-offs, and area under the curve (AUC) values were used to demonstrate discriminative ability of biomarkers. RESULTS: Compared to survivors of severe COVID-19, non-survivors had higher CAR, NLR, and PLR, and lower LMR and lower PNI (P < .05 for all). The optimal CAR, PNI, NLR, PLR, and LMR cut-off values for detecting prognosis were 3.4, 40.2, 6. 27, 312, and 1.54 respectively. The AUC values of CAR, PNI, NLR, PLR, and LMR for predicting hospital mortality in patients with severe COVID-19 were 0.81, 0.91, 0.85, 0.63, and 0.65, respectively. In ROC analysis, comparative discriminative ability of CAR, PNI, and NLR for hospital mortality were superior to PLR and LMR. Multivariate analysis revealed that CAR (⩾0.34, P = .004), NLR (⩾6.27, P = .012), and PNI (⩽40.2, P = .009) were independent predictors associated with mortality in severe COVID-19 patients. CONCLUSIONS: The CAR, PNI, and NLR are independent predictors of mortality in hospitalized severe COVID-19 patients and are more closely associated with prognosis than PLR or LMR.

Anxiety Disorder Associated with the COVID-19 Pandemic Causes Deterioration of Blood Pressure Control in Primary Hypertensive Patients.

OBJECTIVE: The new coronavirus disease (COVID-19) has spread rapidly all over the world and caused anxiety disorders. Recent studies have also shown that the prevalence of depression and anxiety increased during the COVID-19 outbreak. We aimed to evaluate the anxiety and depression levels during the pandemic and identify the effect of pandemic-related stress on blood pressure (BP) control in primary hypertensive patients. METHOD: A total of 142 patients with primary hypertension (HT) who continued to use the same antihypertensive drugs before and during the pandemic were included in the study. Twenty-four -hour Ambulatory Blood Pressure Monitoring (ABPM) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were applied to patients. We retrospectively reviewed 24-h ABPM records of the same patients for the year before the pandemic. RESULTS: Daytime, nighttime and 24 -hour-systolic blood pressure (SBP) levels as well as daytime, nighttime, and 24- hour-diastolic blood pressure (DBP) levels , were significantly elevated during the COVID-19 outbreak compared to the pre-pandemic period (p<0.001). Higher HADS-A scores (HADS-A ≥7) were significantly associated with much greater increase in BP compared to the patients with lower HADS-A scores. CONCLUSION: Psychological stress due to the COVID-19 outbreak led to worsening of the regulation of BP in controlled hypertensive patients whose antihypertensive treatments did not change.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure.

BACKGROUND: Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure. METHODS: This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development. RESULT: Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia. CONCLUSION: The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Presence of fragmented QRS is associated with left ventricular systolic dysfunction after surgery in patients with severe aortic regurgitation.

BACKGROUND AND AIM OF THE STUDY: Chronic severe aortic regurgitation (AR) is associated with progressive accumulation of interstitial fibrosis and disruption of myocardial structure. After aortic valve replacement (AVR), the negative remodeling process reverses, and left ventricular ejection fraction (LVEF) improves but not in all patients. In this study, we aimed to investigate the association of fragmented QRS (F-QRS), which is a possible marker of myocardial fibrosis, with postoperative left ventricular (LV) systolic dysfunction. METHODS: A total of 147 consecutive patients with AVR were included in this study. F-QRS was identified by the presence of various RSR' patterns (QRS duration <120 ms) such as additional R wave (R prime)or notching of the R or S wave in at least two consecutive leads. Patients were compared in two groups based on the presence or absence of F-QRS. A logistic regression model was used to determine independent predictors of postoperative LV systolic dysfunction (LVEF <50%). RESULTS: Patients with F-QRS were associated with poor recovery of LV systolic function after AVR compared to the patients without F-QRS, regardless of preoperative LVEF (p = .008). F-QRS was found to be an independent predictor of postoperative LV systolic dysfunction (LVEF <50%). Lower preoperative LVEF and increased LV end diastolic diameter index were also found as independent risk factors for postoperative LV systolic dysfunction. CONCLUSIONS: As a possible marker of myocardial fibrosis, F-QRS was associated with postoperative LV systolic dysfunction. Therefore, as a simple and convenient clinical parameter, F-QRS may be used to predict poor recovery of LVEF after AVR.

Prognostic significance of cardiac injury in COVID-19 patients with and without coronary artery disease.

OBJECTIVE: COVID-19 is a disease with high mortality, and risk factors for worse clinical outcome have not been well-defined yet. The aim of this study is to delineate the prognostic importance of presence of concomitant cardiac injury on admission in patients with COVID-19. METHODS: For this multi-center retrospective study, data of consecutive patients who were treated for COVID-19 between 20 March and 20 April 2020 were collected. Clinical characteristics, laboratory findings and outcomes data were obtained from electronic medical records. In-hospital clinical outcome was compared between patients with and without cardiac injury. RESULTS: A total of 607 hospitalized patients with COVID-19 were included in the study; the median age was 62.5 ± 14.3 years, and 334 (55%) were male. Cardiac injury was detected in 150 (24.7%) of patients included in the study. Mortality rate was higher in patients with cardiac injury (42% vs. 8%; P < 0.01). The frequency of patients who required ICU (72% vs. 19%), who developed acute kidney injury (14% vs. 1%) and acute respiratory distress syndrome (71%vs. 18%) were also higher in patients with cardiac injury. In multivariate analysis, age, coronary artery disease (CAD), elevated CRP levels, and presence of cardiac injury [odds ratio (OR) 10.58, 95% confidence interval (CI) 2.42-46.27; P < 0.001) were found to be independent predictors of mortality. In subgroup analysis, including patients free of history of CAD, presence of cardiac injury on admission also predicted mortality (OR 2.52, 95% CI 1.17-5.45; P = 0.018). CONCLUSION: Cardiac injury on admission is associated with worse clinical outcome and higher mortality risk in COVID-19 patients including patients free of previous CAD diagnosis.

Combined past preeclampsia and gestational diabetes is associated with a very high frequency of coronary microvascular dysfunction.

BACKGROUND: A history of preeclampsia (pPE) and gestational diabetes (pGDM) are female-specific risk markers for atherosclerosis and future cardiovascular risk. In addition to increasing the risk of established risk factors for atherosclerosis, such as hypertension or diabetes, evidence suggests that pregnancy-related complications can also directly accelerate atherosclerosis by inducing endothelial dysfunction. A combination of both conditions is seen in a subset of patients with pregnancy, though it is not known whether this combination increases the overall risk for cardiovascular events. AIMS: Present study aimed to find the impact of combined pPE/pGDM on the prevalence of coronary microvascular dysfunction (CMD). METHODS: A total of 24 patients with combined pPE/pGDM, 19 patients with isolated pPE and 63 patients with pGDM were included to the present study and a further 36 healthy women with no previous pregnancy-related complications served as controls. Coronary flow reserve was measured using echocardiography and CMD was defined as a coronary flow reserve ≤2.5. RESULTS: Patients with combined pPE/pGDM had a high prevalence of CMD (91%), which was significantly higher than controls (5.6%, p < 0.001) and patients with pGDM (55%, p = 0.01). A history of pPE on top of pGDM was associated with an increased risk of CMD (HR:6.28, 95%CI:1.69-23.37, p = 0.006) after multivariate adjustment, but pGDM did not increase the odds for CMD in those with pPE. CONCLUSIONS: Combined pPE/pDM is associated with a very high prevalence of CMD, which may indicate an increased risk for future cardiovascular events.