Increased frequency of occurrence of bendopnea is associated with poor outcomes in heart failure outpatients.

BACKGROUND: Relationship between the frequency of occurrence of bendopnea during the daily life of heart failure (HF) outpatients and clinical outcomes has never been evaluated before. METHODS: Turkish Research Team-Heart Failure (TREAT-HF) is a network between HF centres, which undertakes multicentric observational studies in HF. Herein, the data including stable 573 HF patients with reduced ejection fraction out of seven HF centres were presented. A questionnaire was filled by the patients, with the question 'Do you experience shortness of breath while tying your shoelace?', assessing the presence and frequency of bendopnea. RESULTS: To the question related to bendopnea, 48% of the patients answered 'yes, every time', 31% answered 'yes, sometimes', and 21% answered 'No'. Patients were followed for an average of 24 ± 14 months, and the patients who answered 'yes, every time' and 'yes, sometimes' to the bendopnea question were found having increased risk for both HF-related hospitalisations (HR:3.2, p < .001- HR:2.8, p = .005) and composite outcome consisting of 'HF-related hospitalisations and all-cause death in the multi-variate analysis (HR:3.1, p < .001- HR:3.0, p < .001). Kaplan Meier analysis for HF-related hospitalisation, all-cause death, and the composite of these were provided for these three groups, yielding significant and graded divergence curves with the best prognosis in 'no' group, with the moderate prognosis in 'sometimes' group, and with the worst prognosis in the 'every time' group. CONCLUSION: For the first time in the literature, our study shows that the increased frequency of bendopnea occurrence in daily life is associated with poor outcomes in HF outpatients.

Fine vs. coarse atrial fibrillation: which one is more risky?

BACKGROUND: Atrial fibrillation (AF) is a frequent arrhythmia, associated with morbidity and mortality. It is identified by two types on surface electrocardiogram as fine and coarse AF. We aimed to search the association of subtypes of AF with clinical parameters. METHODS: Eight hundred and eleven consecutive patients, who had AF attack which lasted longer than 24 h or more, were evaluated along with clinical and laboratory data. RESULTS: Coarse AF was noticed in 51.7% (n = 419), and fine AF in 48.3% (n = 392). Sex was associated with subtype of AF such that coarse AF was present in 46.5% of male patients, but in 56.1% of female patients (p = 0.009). Coarse AF was present in 85.3% of patients with mitral stenosis, whereas it was present in 35.3% of patients with normal heart valve (p < 0.001). ). Patients having fine AF were significantly older than those having coarse AF (64 +/- 12, 57 +/- 13 years, p < 0.001). 19.6% of those with coarse AF had history of cerebrovascular event (CVE), whereas 13.5% of those with fine AF had history of CVE (p = 0.021). After controlling for age in the multivariable logistic regression analysis, presence of coarse AF (B = 1.585, p = 0.031) was found to be independently associated with the history of CVE. CONCLUSION: AF is identified by two morphological forms on the surface electrocardiogram. These two forms were found to be associated with different clinical parameters, acting on vascular endpoints differently.

Relation of coronary collateral vessel development in patients with a totally occluded right coronary artery to the metabolic syndrome.

Development of coronary collaterals (CCs) is triggered by the gradient between arteries due to obstruction and myocardial ischemia. Presence of CCs that feed the jeopardized myocardial area may limit the infarct size after coronary occlusion and may even provide a survival benefit. However, some patients develop good CCs, whereas others do not. The metabolic syndrome (MS) has been identified as a secondary target to decrease cardiovascular risk, although the effect of MS on development of CCs has not been investigated. We prospectively enrolled 596 consecutive patients (337 men and 259 women; mean age 56 +/- 8 years) who underwent coronary angiography at our center and were found to have total occlusion of the right coronary artery. Patients were then classified as having good CCs (Rentrop's grades 2 to 3) or poor CCs (Rentrop's grades 0 to 1). There were significant differences in terms of body mass index (kilograms of body weight divided by square meters of height), glucose levels, triglyceride levels, and years with angina pectoris between those with good and poor CCs. Prevalences of diabetes mellitus were 27.1% among patients with good CCs and 44% among those with poor CCs (p <0.001). Presence of MS was significantly higher in patients with poor CCs than in those with good CCs (78.4% vs 49.2%, p <0.001). In regression analysis, duration of angina pectoris (beta = 0.347, 95% confidence interval [CI] 0.266 to 0.453, p <0.001), presence of diabetes mellitus (beta = 1.829, 95% CI 1.021 to 3.279, p = 0.042), wall score (beta = 2.379, 95% CI 1.356 to 4.173, p = 0.003), and presence of MS (beta = 2.993, 95% CI 1.541 to 5.813, p = 0.001) were independent predictors of angiographically determined poor CCs. In conclusion, MS seems to be independently associated with poor CCs in patients with an occluded right coronary artery.

Late saphenous vein graft occlusion in patients with coronary bypass: possible role of aspirin resistance.

BACKGROUND: Late venous graft thrombosis, leading to recurrent ischemia, is frequently encountered in old, degenerated vein grafts with advanced atherosclerotic plaque formation. Aspirin has been indicated to maintain venous graft patency in the post-operative period. However, there is considerable evidence that aspirin resistance is of concern in patients with venous grafts. MATERIAL AND METHOD: Prospectively enrolled 14 patients (11 male, 3 female, Group 1), who were shown to have at least one occluded saphenous vein graft on their late control coronary angiogram after bypass operation, were compared for the presence of aspirin resistance by PFA-100 with age- and sex-matched 14 patients (10 male, 4 female, Group 2), who were found patent and well-functioning vein grafts without wall irregularities on late post-operative coronary angiograms (mean 6.5+/-2.5 years), enrolled as a control group. RESULTS: Mean CT of collagen/epinephrine cartridge in Group 1 was 197+/-85 s and significantly less than in Group 2 (279+/-44 s; p=0.011). It was found that 50% of patients in Group 1 were so-called aspirin resistant, whereas in Group 2, this ratio was 7.1% (p=0.033). BMI (p=0.038, Beta=-0.322), uric acid level (p=0.023, Beta=-0.355), and CT by collagen/epinephrine cartridge (p=0.008, Beta=0.431) were independently predicting late occlusion of saphenous vein graft. CONCLUSION: Aspirin resistance is highly prevalent in patients with occluded venous grafts at a relatively late period.

Metabolic syndrome is associated with extension of coronary artery disease in patients with non-ST segment elevation acute coronary syndromes.

BACKGROUND: Metabolic syndrome (MS) comprises a group of factors that are associated with increased risk for cardiovascular events. Acute coronary syndromes account for the most important part of cardiovascular events with considerable morbidity and mortality. We aimed to investigate the association of MS with extension of coronary artery disease in patients presenting with non-ST segment elevation (NSTE) acute coronary syndromes (ACS). METHODS: Three hundred and six consecutive patients (220 men, 86 women patients) with the diagnosis of NSTE ACS, who were hospitalized within the first 24 h of their chest pain in the coronary care unit, were prospectively enrolled into our study. Patients with elevation of troponins (T or I) were classified as NSTE myocardial infarction (MI) and otherwise as unstable angina pectoris (USAP). Components of MS were noted as previously identified. Coronary angiograms were evaluated by two authors, who were blinded to the study plan and each other, via Sullivan's method. RESULTS: MS was noted in 49% of all patients, and was significantly more common in women than in men (62.8 versus 43.6%, P=0.003). The mean total stenosis score of patients with MS was significantly higher than for those without MS (16+/-6 versus 12+/-5, P<0.001), and the mean extension score of patients with MS was significantly higher than for those without MS (63+/-29 versus 44+/-26, P<0.001). The presence of MS together with some clinical factors and poor total cholesterol/high-density lipoprotein cholesterol ratio, hypertension and diabetes mellitus, was found to be independently predictive of extension of coronary artery disease (CAD) in a group of patients presenting with NSTE ACS. CONCLUSIONS: MS is independently associated with CAD extension, and hence, might account for poor cardiovascular outcomes through CAD extension in patients with NSTE ACS.

Lipid profile of patients with aortic stenosis might be predictive of rate of progression.

BACKGROUND: Aortic stenosis is one of the most commonly encountered valvular pathology requiring surgery in developed countries. There are similarities between risk factors for coronary atherosclerosis and the development of aortic stenosis. We designed a retrospective study, evaluated the lipid profile and previous echocardiographic recordings of patients with aortic stenosis, and searched the association of rate of progression and lipid profile. METHODS AND RESULTS: The annual rates of progression in the peak and mean aortic gradients were 8.5 +/- 3.2 and 6.7 +/- 2.2 mm Hg/year, respectively. We classified the annual rate of progression of peak aortic gradient into 2 groups, group 1 with <10 mm Hg ("slow progressors") and group 2 with > or =10 mm Hg annual rate of progression ("fast progressors"). The annual rate of progression in group 1 was significantly higher than that in group 2, both in peak and mean aortic gradients (12 +/- 2 mm Hg and 6.4 +/- 1.6 mm Hg; 9 +/- 1.3 mm Hg and 5.2 +/- 1.1 mmHg; P <.001 for both). There was a highly significant difference between group 1 and group 2 for total cholesterol/high-density lipoprotein (HDL) cholesterol level ratio (7.1 +/- 1.4 vs 5.2 +/- 1.3, P <.001). There was a significant correlation between annual rate of progression in peak gradient and total cholesterol/HDL cholesterol level ratio (r = 0.399, P =.009). Smoking (P =.024, Beta = 0.26), presence of coronary heart disease (P =.011, Beta = 0.31), and total cholesterol/HDL cholesterol level ratio (P =.004, Beta = 1.98) were independently predictive of fast progression of the peak aortic gradient in the regression analysis. CONCLUSION: In a small group of patients from Turkey with aortic stenosis, there seems to be an association between the rate of progression and total cholesterol/HDL cholesterol level ratio, with fast progression occurring in the group with higher ratios.

Serum creatinine is independently associated with angiographic extent of coronary artery disease in patients with stable angina pectoris.

OBJECTIVE: Renal dysfunction has been shown to be linked to high risk for cardiovascular events. Even milder forms of creatinine elevation are associated with poor cardiovascular outcomes. We designed a retrospective study and searched the association of angiographic extent of coronary artery disease and creatinine levels in patients without overt renal dysfunction. METHODS: We retrospectively reviewed 892 consecutive patients with typical stable angina pectoris (311 female with mean age of 62 ± 10 years, 581 male with mean age of 56 ± 11 years) at Türkiye Yüksek Ihtisas Hospital and creatinine level ≤ 3 mg/dl without history of hemodialysis. Patients without overt renal disease were divided into 3 groups according to level of creatinine (Group A: Cr level <1.2 mg/dl, Group B: Cr level ≥ 1.2 and <1.5 mg/dl and Group C: Cr level ≥ 1.5 -≤ 3 mg/dl). Additionally after evaluation of coronary angiograms, patients were also classified according to those with high stenosis (stenosis score ≥ 16) and high extension scores (extension score >50%) versus low stenosis and low extension scores. Logistic regression analysis was performed to establish the clinical predictors of high total stenosis and high extension scores. RESULTS: Each group of patients according to level of creatinine showed marked difference in terms of angiographic extent of coronary artery disease (p<0.001). Those in the highest creatinine group (≥ 1.5 mg/dl, but not above 3 mg/dl) had the highest total stenosis (17 ± 6, p<0.001) and extension (78 ± 25, p<0.001) scores irrespective of age and gender. Creatinine was shown to be significantly correlated with both stenosis and extension scores. Age (OR:1.035, 95% CI:1.016-1.054, p<0.0001), being male (OR:1.746, 95% CI: 1.135-2.685, p=0.011), presence of hypertension (OR:1.507, 95%CI: 1.005-2.25 p=0.047), presence of diabetes mellitus (OR: 1.865, 95%: 1.250-2.783, p=0.002), previous history of myocardial infarction (OR: 1.624, 95%CI: 1.094-2.413, p=0.016), wall motion score index (OR:1.203, 95%CI: 1.108-1.305, p<0.0001) and creatinine (OR:4.037, 95%CI: 2.530-6.443, p<0.0001) level were found to be independent predictors of high total stenosis score. Furthermore, age (OR:1.042, 95%CI: 1.026-1.059, p<0.0001), being male (OR:2.587, 95%CI: 1.794-3.731, p<0.0001), presence of hypertension (OR:1.536, 95% CI:1.100-2.147, p=0.012), previous myocardial infarction (OR:6.183, 95%CI: 4.340-8.807, p<0.0001), total cholesterol/HDL ratio (OR:1.215, 95%CI: 1.114-1.327, p<0.0001) and creatinine (OR:3.814, 95%CI: 2.149-6.768, p<0.0001) were found to be independent predictors of high extension score. CONCLUSION: Serum creatinine seems to denote severity of angiographic extent of coronary artery disease in patients with typical chest pain.

Fate of internal mammary artery grafted to left anterior descending artery is influenced by native vessel stenosis and viable myocardium.

In this study, factors leading to the failure of internal mammary artery grafting was investigated among patients with coronary bypass. In all, 1323 patients were evaluated. It was found that lower grade diameter stenosis in the native vessel during postoperative angiogram and wall motion score index independently affected the fate of internal mammary artery as a graft. Grafting with internal mammary artery to native vessels with lower grade stenosis and to myocardium with poor wall score might not be a rational approach.

Association of lipid profile with echocardiographic Wilkins score in patients with moderate to severe mitral stenosis: possible impact on prognosis.

BACKGROUND: Association of valvular heart disease and lipid profile might be important as in the case of aortic stenosis. However, it has not been so far considered in detail the probable association of other valvular diseases, particularly of mitral stenosis (MS) with lipid profile. In our study, we aimed to search possible association of echocardiographic mitral valve score, evaluated according to Wilkins score, with lipid parameters in a group of patients with mitral stenosis, who were referred for possible percutaneous balloon valvuloplasty. MATERIAL AND METHOD: We retrospectively reviewed 401 patients (316 female, 85 male), who were referred as possible candidates for PMBV, with moderate to severe MS of predominantly rheumatic origin. Mitral valve was evaluated according to Wilkins score by an experienced author as indicated. RESULTS: Mean age of all patients was 36.6+/-11.3 years, and was not different in both genders. Mean mitral valve area was 1+/-0.1 mm2. Considering all patients, total Wilkins score was significantly, but mildly correlated with ratio of total/HDL cholesterol ratio (r=0.174, p=0.02). Presence of more than one recurrent attack of rheumatic fever, narrow mitral valve area, high total/HDL cholesterol and being male were independent predictors of poor echocardiographic Wilkins score (>8). CONCLUSION: We think that Wilkins echocardiographic score of mitral stenosis, particularly of leaflet thickening, might well be associated with serum lipids, probably as the same extent does aortic stenosis.

Level of awareness of on-treatment patients about prescribed statins.

BACKGROUND: Statins are frequently prescribed drugs for patients with coronary heart disease according to evidence-based medicine. However, compliance with these agents has still been far from ideal, since they require long term, probably life long therapy. We conducted a survey on patients who were already on statin treatment and evaluated their level of awareness of prescribed statins. METHODS: 236 participants (117 male, 119 female), who had been on treatment with statins for at least three months, were enrolled in our study after giving informed consent. Patients were asked close-ended survey questions. RESULTS: Only 5.5% of participants were on statin treatment for primary prevention, and 16.1% of them had a CHD equivalent, defined as those with clinical manifestations of noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, carotid artery disease) and diabetes mellitus. Most participants (70%) stated that they had been using statins to decrease cholesterol, whereas 16.5% stated that they had no idea. More than half of the participants (58%) stated that they did not know how long they would have to keep using their statins, whereas 21% replied that they would use them continuously. One fifth of participants had some idea about side effects. Participants in whom statin therapy was started during hospitalisation for coronary angiography and/or PCI more frequently answered that statins should be used continuously (49% vs. 12% not hospitalised, p < 0.01). Also, therapy adjustment by the physician led to a better understanding of the need for continuous use (55% vs. 31% without medication change, p < 0.001), as was the case for patients with < 2 co-medications (36% vs. 17% with > 2 co-medications, p 0.002). Presence of other risk factors did not have any impact on level of awareness. CONCLUSION: Comprehensive information at initial prescription, initiation of statins during hospitalization, dose adjustment during follow up, and as little co-medication as possible seem to increase the level of awareness of the benefits of long-term statin treatment. This might result in better compliance rates.