Comparison of mortality prediction scores in elderly patients with ICD for heart failure with reduced ejection fraction.

BACKGROUND: This investigation aimed to examine and compare the predictive value of MADIT-II, FADES, PACE and SHOCKED scores in predicting one-year and long-term all-cause mortality in implantable cardioverter-defibrillator (ICD) implanted patients, 75 years old and older, since there has been an area of uncertainty about the utility and usefulness of these available risk scores in such cases. METHODS: In this observational, retrospective study, 189 ICD implanted geriatric patients were divided into two groups according to the presence of long-term mortality in follow-up. The baseline characteristics and laboratory variables were compared between the groups. MADIT-II, FADES, PACE and SHOCKED scores were calculated at the time of ICD implantation. One-year and long-term predictive values of these scores were compared by a receiver-operating curve (ROC) analysis. RESULTS: A ROC analysis showed that the best cutoff value of the MADIT-II score to predict one-year mortality was ≥ 3 with 87% sensitivity and 74% specificity (AUC 0.83; 95% CI 0.73-0.94; p < 0.001) and that for long-term mortality was ≥ 2 with 83% sensitivity and 43% specificity (AUC 0.68; 95% CI 0.60-0.76; p < 0.001). The predictive value of MADIT-II was superior to FADES, PACE and SHOCKED scores in ICD implanted patients who are 75 years and older. CONCLUSION: MADIT-II score has a significant prognostic value as compared to FADES, PACE and SHOCKED scores for the prediction of one-year and long-term follow-up in geriatric patients with implanted ICDs for heart failure with reduced ejection fraction.

The value of C-reactive protein-to-albumin ratio in predicting long-term mortality among HFrEF patients with implantable cardiac defibrillators.

BACKGROUND: Patients with heart failure with reduced ejection fraction (HFrEF) who received implantable cardiac defibrillator (ICD) still remain at high risk due to pump failure and prevalent comorbid conditions. The primary aim of this research was to evaluate the predictive value of C-reactive protein-to-albumin ratio (CAR) for all-cause mortality among patients with HFrEF despite ICD implantation. MATERIALS AND METHODS: Those who were implanted ICD for HFrEF in our institution between 2009 and 2019 were included. Data were extracted from hospital's database. CAR was calculated as ratio of C-reactive protein (CRP) to serum albumin concentration. Patients were grouped into tertiles in accordance with CAR at the time of the implantation. During follow-up duration of 38 [17-77] months, survival times of tertiles were compared by using Kaplan-Meier survival method. Forward Cox proportional regression model was used for multivariable analysis. RESULTS: Thousand and eleven patients constituted the study population. Ischaemic cardiomyopathy was the primary diagnosis in 92.3%, and ICD was implanted for the primary prevention among 33.9% of patients. Of those, 14.5% died after the discharge. Patients in tertile 3 (T3) had higher risk of mortality (4.2% vs 11.0% vs 28.5%) compared with those in other tertiles. Multivariable analysis revealed that when patients in T1 were considered as the reference, both those in T2 and those in T3 had independently higher risk of all-cause mortality. This finding was consistent in the unadjusted and adjusted multivariable models. CONCLUSION: Among patients with HFrEF and ICD, elevated CAR increased the risk of all-cause mortality at long term.

Prognostic nutritional index as the predictor of long-term mortality among HFrEF patients with ICD.

BACKGROUND: The benefit of implantable cardiac defibrillator (ICD) in patients with heart failure and reduced ejection fraction (HFrEF) could be limited in a particular group of patients. Low prognostic nutritional index (PNI) indicates malnutrition and proinflammatory condition. We sought to investigate the value of PNI in predicting long-term mortality among HFrEF patients with ICD. METHODS: Electronic database was searched for identifying patients with HFrEF who were implanted ICD in our institution between 2009 and 2019. Demographic and clinical characteristics of included patients were recorded. PNI was calculated according to the formula: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3 ). Patients were divided into the quartiles according to PNI values. Differences between the groups were analyzed by the log-rank test. A forward Cox proportional regression model was used for multivariable analysis. RESULTS: One thousand and hundred patients were included to the study. The underlying heart failure etiology was ischemic and nonischemic in 77.3% and 22.7% of patients, respectively. Mortality rate in Q1 (5.1%) was considered as the reference. In the unadjusted model the mortality rate was 9.5% (hazard ratio [HR] 1.76, 95% confidence interval [95% CI] [0.92-3.38]) in Q2, 10.2% (HR 1.88, 95% CI 0.99-3.58) in Q3, and 39.6% (HR 8.12, 95% CI 4.65-14.17) in Q4. The same trend was consistent in the age- and sex-adjusted, comorbidities-adjusted, and covariates-adjusted models. CONCLUSION: Among patients who were implanted with ICD secondary to HFrEF, lower PNI value predicted all-cause mortality during long-term follow-up. This is the first study demonstrating the value of PNI in this population.

The predictive value of the CHA2DS2-VASc score in patients with mechanical mitral valve thrombosis.

Prosthetic valve thrombosis (PVT) is a potentially life-threatening complication associated with high morbidity and mortality. The CHA2DS2-VASc is a clinical score used to determine thromboembolism risk in non-valvular atrial fibrillation patients. Therefore; in this study, we aimed to determine predictive value of the CHA2DS2-VASc score for development of PVT in patients with mechanical prosthetic valve. This was a retrospective study included 417 consecutive patients with mechanic prosthetic valve in whom transesophageal echocardiography (TEE) was performed due to different clinical indications from January 2004 to June 2016. After evaluation according to exclusion criteria, 267 patients with mechanic prosthetic valve were enrolled in the study. The definitive diagnosis of the PVT was made as proposed by TEE finding. The study population was divided into two groups; PVT patients (154 patients) and control group (113 patients) with functional prosthetic valve. The CHA2DS2-VASc score was calculated for each patient from the hospital electronic database. The mechanical mitral valve thrombosis predictive value of variables including CHA2DS2-VASc score was tested in our study. The mean CHA2DS2-VASc score was significantly higher in PVT patients compared to control patients (2.51 ± 1.54 vs. 1.13 ± 1.21, p < 0.01). Both on univariate and multivariate analysis demonstrated that the CHA2DS2-VASc score is independently associated with PVT (p < 0.001 and p < 0.001, respectively). The patients whose CHA2DS2-VASc score ≥ 1-3 had 6.20 times higher risk for thrombus formation, and patients whose CHA2DS2-VASc score ≥ 4 had 16.6 times higher risk for thrombus formation compared to patients with CHA2DS2-VASc score = 0 (p < 0.001 and p < 0.001, respectively). The CHA2DS2-VASc score may be a significant independent predictor of PVT in patients with prosthetic valve and the CHA2DS2-VASc score ≥ 2.5 or more was associated with increased PVT in patients with prosthetic valve. Thus; it may be an applicable risk scoring system to assess the risk of development of PVT in patients with prosthetic valve.

Interatrial block predicts atrial high rate episodes detected by cardiac implantable electronic devices.

BACKGROUND: Interatrial block which is defined as P wave duration longer than 120 milliseconds is underappreciated but highly prevalent electrocardiographic abnormality and associated with atrial tachyarrhythmias and ischemic stroke. Impaired left atrial mechanics and atrial fibrillation are potential mechanisms contributing to the embolic events associated with interatrial block. Detection of atrial high rate episodes by cardiac implantable electronic devices provides clinicians to diagnose asymptomatic atrial fibrillation. The relation between interatrial block and asymptomatic atrial fibrillation can provide an insight to the increased risk of ischemic stroke in patients with interatrial block. METHODS: We prospectively evaluated 367 patients who were implanted dual chamber pacemaker due to sinus node dysfunction (SND) between January 2015 and December 2015. Twelve lead electrocardiograms were analyzed to diagnose interatrial block before pacemaker implantation. Six months after the implantation, pacemakers were interrogated to detect atrial high rate episodes. Patients were divided into two groups in terms of presence or absence of atrial high rate episodes. RESULTS: Atrial high rate episodes were detected in 107 (30.1%) patients during their device interrogation. Interatrial block was found in 115 (32.4%) patients out of total study population. Sixty-seven (27.0%) patients in AHRE (-) group had interatrial block while 48 (44.9%) patients had in AHRE (+) group. Prevalence of interatrial block was statistically significantly higher in AHRE (+) patients (P<0.01). CONCLUSION: Occurrence of atrial high rate episodes, a surrogate for asymptomatic atrial fibrillation, is statistically significantly higher in patients with interatrial block.

Long-Term Antiarrhythmic Effects of Thrombolytic Therapy in Pulmonary Embolism.

BACKGROUND: The role of thrombolytic therapy in acute pulmonary embolism patients is still controversial considering the occurrence of arrhythmias. Short-term effects of thrombolytics are well-known whereas long-term effects on cardiac electrophysiology have not been reported before. The objective of our study was to assess the arrhythmic differences in pulmonary embolism patients who received thrombolytics followed by anticoagulation or anticoagulation alone. METHODS: Sixty patients who received thrombolytic therapy followed by anticoagulation (group 1) and 60 patients who received anticoagulation alone (group 2) were included in this retrospective, single-centre observational study. Twenty-four-hour ambulatory electrocardiography was performed 31 ± 9 months after pulmonary embolism hospitalisation in order to compare arrhythmias originating from both ventricles and atria. RESULTS: The age and gender distribution of the patients were statistically similar. Ventricular arrhythmias were found to be the same between t-PA and non t-PA groups. All types of atrial arrhythmias were found to be increased in non t-PA group even though left and right atrial volume indexes were statistically identical between the two groups. CONCLUSION: In long-term pulmonary embolism, follow-up thrombolytic therapy was demonstrated to have atrial antiarrhythmic effects.

Left Ventricular Perforation Due to Radiofrequency Catheter Ablation for Incessant Ventricular Tachycardia in a Post-Myocardial Infarction Patient.

Left ventricular (LV) myocardial perforation is a rare complication following ventricular tachycardia (VT) ablation with radiofrequency (RF); this complication should be diagnosed and treated promptly. LV free wall rupture after elective RF ablation for sustained VT refractory to medical treatment is rarely reported in the medical literature. Herein we discuss an interesting case which contributes to the ongoing literature, regarding a patient who developed LV perforation due to RF ablation for VT which was resistant to pharmacotherapy and repeated cardioversion attempts after acute myocardial infarction.

Catheter ablation of ventricular arrhythmia originating in the tricuspid annulus in a patient with biventricular noncompaction: a case report.

It is rare for ventricular tachycardia arising from the right ventricle to originate in the tricuspid annulus, and the clinical presentation and cardiac abnormalities associated with this type of arrhythmia have not been clearly established. This report describes a case of biventricular noncompaction presenting with ventricular arrhythmia originating in the tricuspid annulus and successfully treated with radiofrequency ablation.

Presence of sigma shaped right coronary artery is an indicator of poor prognosis in patients with inferior myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: The effectiveness of primary percutaneous coronary intervention (PCI) in ST segment elevation myocardial infarction (STEMI) is well established. The clinical variables associated with poor prognosis in patients with STEMI have been extensively investigated. Right coronary artery (RCA) has two anatomical variations detected on coronary angiography namely C-shaped and sigma shaped RCA. The clinical importance of the shape of RCA in patients with STEMI has not been investigated before. PURPOSE: To investigate the prognostic value of RCA shape in patients with inferior STEMI treated with primary PCI. METHODS: Angiographic data of patients with inferior STEMI who were treated with primary PCI were retrospectively recruited. The differentiation of sigma and C-shaped RCAs was shown using single-frame angiograms, obtained during end-diastole of cardiac cycle in the left anterior oblique projection at 25° to 35° with no cranio-caudal angulation. Cardiovascular events at 30-days and on follow up were obtained through review of hospital records and telephone contact with the patient or the patient's relatives. Patients with C-shaped RCAs served as the control group. RESULTS: A total number of 824 patients with inferior STEMI who were treated with primary PCI for RCA were included. Sigma shaped RCA was observed in 15.1% of the subjects. In the sigma shaped RCA group, the door-to-balloon times were longer (32.5 ± 5.1 vs. 27.8 ± 4.6 min; P = 0.01) and TIMI 3 flow restoration rates were lower (76.8% vs. 94.1%; p=0.01) compared to the controls. Mean SYNTAX scores were significantly higher in patients with sigma shaped RCA. Four patients (3.2%) in the sigma shaped RCA group and 23 patients (3.3%) in the control group died by day 30. The incidence of stent thrombosis, recurrent MI, and target lesion revascularization, were similar between the groups. During the follow-up (mean 37.6 ± 13.4 months) 15 patients (12.3%) from the sigma shaped RCA group and 28 (4.1%) patients from the control group died (P = 0.01). The incidence of recurrent MI (27.2% vs. 13.7%; P = 0.01) and major adverse cardiovascular events (29.7% vs. 16.3%; P = 0.01) were significantly higher in the sigma shaped RCA group. In multivariate analysis, age, Killip class of >1, the presence of sigma shaped RCA, post PCI TIMI flow <3 and decreased left ventricular ejection fraction were the independent predictors of long term mortality. CONCLUSION: Presence of sigma shaped RCA is associated with more severe form of coronary artery disease and worse clinical outcome in patients with inferior STEMI.

Elevated levels of RDW is associated with non-valvular atrial fibrillation.

Red cell distribution width (RDW) and neutrophil/lymphocyte ratio (NLR) have been found to be associated with cardiovascular diseases. Only a few trials have investigated the correlation of these parameters with postoperative atrial fibrillation (AF). However, the correlation of these parameters in non-valvular AF is still unclear. We retrospectively analyzed consecutive AF patients from medical records and included 117 non-valvular AF patients (103 paroxysmal and 14 chronic AF). All subjects underwent physical examination and echocardiographic imaging. Complete blood counts (CBCs) were analyzed for hemoglobin, RDW, neutrophil and lymphocyte counts as well as mean corpuscular volume. Results of CBC tests within the previous year were also included and the averages were used. The demographic and echocardiographic properties of non-valvular AF group were comparable to the control group except for left atrial volumes which were increased in AF (median 33.1, IQR 26.3-41.1 cm(3) vs. median 26.4, IQR 24.2-28.9 cm(3); p = 0.01). RDW levels were significantly higher in the AF group (median 13.4 %, IQR 12.9-14.1 %) compared to the control (median 12.6 %, IQR 12.0-13.1 %; p = 0.01). NLR was not statistically different in the AF group and the controls (2.04 ± 0.94 vs. 1.93 ± 0.64, respectively; p = 0.32). Hs-CRP levels were higher in the AF group compared to the controls (median 0.84, IQR 0.30-1.43 mg/L vs. median 0.29, IQR 0.18-0.50 mg/L, respectively; p = 0.01). Multivariate logistic regression analysis revealed RDW (OR 4.18, 95 % CI 2.15-8.15; p = 0.01), hs-CRP (OR 3.76, 95 % CI 1.43-9.89; p = 0.01) and left atrial volume (OR 1.31, 95 % CI 1.06-1.21; p = 0.01) as the independent markers of non-valvular AF. Multivariate linear regression analysis revealed that hemoglobin levels (standardized ß coefficient = -0.252; p = 0.01) and the presence of AF (standardized ß coefficient = 0.336; p = 0.01) were the independent correlates of RDW levels. Elevated RDW levels, not NLR, may be an independent risk marker for non-valvular AF.

Red cell distribution width is increased in patients with ascending aortic dilatation.

OBJECTIVES: The prognostic importance of red cell distribution width (RDW) and neutrophil/lymphocyte ratio (NLR) in cardiovascular diseases has been shown. Ascending aortic dilatation (AAD) is a common cardiovascular disease and is associated with aortic wall inflammation and cystic degeneration. In this study, we aimed to investigate the relationship between serum levels of RDW, NLR and the presence of AAD. STUDY DESIGN: Two-hundred consecutive patients with AAD diagnosed by transthoracic echocardiography were prospectively recruited and were compared to 170 age-gender- matched subjects with normal aortic diameters. Complete blood counts (CBCs) were analyzed for hemoglobin, RDW and NLR counts, as well as mean corpuscular volume (MCV). If possible, results of CBC tests within the previous two years were also included and the averages were used. RESULTS: RDW [median 13.9, interquartile range (IQR) 1.40 vs. median 13.3, IQR 1.05%, p=0.01], NLR (median 2.04, IQR 1.09 vs. median 1.78, IQR 0.90, p=0.01) and high-sensitive C-reactive protein (hs-CRP) (median 0.60, IQR 0.80 vs. median 0.44, IQR 0.68 mg/L, p=0.01) levels were significantly higher in the AAD group compared to the control group. In univariate correlation analysis, ascending aortic diameters were correlated with RDW levels (r=0.31, p=0.01), NLR levels (r=0.15, p=0.01) and hs-CRP levels (r=0.12, p=0.03). In multivariate logistic regression analysis, increased levels of RDW and hs-CRP remained as the independent correlates of AAD in the study population. Receiver operating characteristic (ROC) curve analysis revealed that a RDW measurement higher than >13.8% predicted AAD with a sensitivity of 49.5% and a specificity of 82.8% (area under the curve [AUC] 0.681, p=0.01). CONCLUSION: In patients with AAD, RDW and hs-CRP levels are increased, which may indicate the role of inflammation in the pathogenesis of AAD.

Management of patients with drug-induced atrioventricular block.

OBJECTIVE: To identify the frequency of atrioventricular (AV) conduction improvement after discontinuation of the culprit drug in patients with AV block. BACKGROUND: AV blockers are considered as reversible causes of AV block that do not require pacemaker (PM) implantation. However, controversial reports declared that a major part of these drug-induced AV blocks are persistent or recurrent. METHODS: Of 668 consecutive patients with symptomatic type II second- or third-degree AV block, 2:1 AV block, atrial fibrillation, and bradyarrhythmia, 108 patients (62 patients enrolled prospectively) using AV blockers without myocardial infarction, electrolyte abnormalities, digitalis toxicity, and vasovagal syncope were enrolled into the present study. The level of AV block (AV-nodal or infranodal) was defined according to electrocardiographic characteristics. RESULTS: The most frequent culprit medications were ß-blockers followed by digoxin. Drug discontinuation was followed by resolution of AV block in 72% of cases, whereas spontaneous resolution of AV block occurred in only 6.6% of patients who had AV block in the absence of medications. However, 27% of patients with improved AV conduction experienced a recurrence of AV block despite discontinuation of the culprit drug. Twenty-one of 24 carvedilol-induced AV blocks resolved after discontinuation of the drug and never recurred, whereas 24 of 36 metoprolol-induced AV blocks persisted or recurred. A digoxin-induced AV block usually improved (28 of 39) after withdrawal of the drug. Roughly half of the patients with drug-induced AV block underwent permanent PM implantation. CONCLUSION: Drug-induced AV block is a serious disease that requires a permanent PM for almost half of the patients.

Predictors for early mortality in patients with implantable cardiac defibrillator for heart failure with reduced ejection fraction.

Implantable cardioverter defibrillators (ICD) are recommended in heart failure with reduced ejection fraction (HFrEF) patients to reduce arrhythmic deaths. This study aimed to identify risk factors associated with mortality within one-year following the ICD. The data from our hospital's electronic database system was extracted for patients who were implanted ICD secondary to HFrEF between 2009 and 2019. Overall, 1107 patients were included in the present analysis. Mortality rate at one-year following the device implantation was 4.7%. In multivariate analysis; age, atrial fibrillation, New York Heart Association classification >2, blood urea nitrogen, pro-brain natriuretic peptide and albumin independently predicted one year mortality.

Effects of high altitude and sea level on mean platelet volume and platelet count in patients with acute coronary syndrome.

A relationship exists between exposure to high altitude and increased coagulability. Mean platelet volume is a parameter of platelet functions and may be a marker for increased platelet aggregability. The aim of this study was to compare the mean platelet volumes and platelet counts in patients who experienced an acute coronary event at moderately high altitude and at sea altitude. Four hundred and one patients who experienced an acute coronary event were enrolled, of them 211 were born and had been living at the sea level, while 190 were born and had been living at high altitude (at least 2,000 m above the sea level). Patients were compared regarding the mean platelet volumes and platelet counts. The mean platelet volumes were significantly higher in patients living in high altitude (P = 0.001). No statistically significant differences were found among the groups regarding the platelet counts. As a result, this increased MPV values in highlanders who experienced an acute coronary event may reflect increased platelet aggregability.

Natriuretic Peptides in Clinical Practice.

Natriuretic peptides have long been introduced into clinical practice. These biomarkers have certainly been shown to provide useful information in the diagnosis, prognosis and risk stratification in heart failure and also may have a role in the guidance of heart failure therapy. Although, there are some limitations in using of these markers such as lack of specificity, aging, renal dysfunction or obesity, among the huge number of candidates for heart failure biomarkers, only natriuretic peptides are currently widely used in daily clinical practice in heart failure. Recent heart failure guidelines recognize natriuretic peptides as an essential tool in the new diagnostic and therapeutic algorithms. Furthermore, natriuretic peptides are not only used in the diagnosis or prognosis of heart failure, but also these biomarkers are referred to have some potential role in primary prevention, cardio-oncology, advanced heart failure, assessment of response to cardiac resynchronization therapy, pulmonary arterial hypertension, acute coronary syndromes, atrial fibrillation and valvular heart disease. In this article, natriuretic peptides have been reviewed for their updated information and new recommendations in heart failure and also potential role of these biomarkers in the management of various clinical conditions have been addressed in the form of expert opinion based on the available data in the literature.

Glue (toluene) abuse: increased QT dispersion and relation with unexplained syncope.

Exposure to toluene, one of the major components of glue, can lead to cardiac arrhythmias and sudden sniffing death syndrome. QT dispersion is a useful risk marker for cardiac arrhythmias and sudden cardiac death. The aim of this study was to investigate the effects of glue abuse on QT interval and QT dispersion. The study included 44 patients with inhalant abuse and 34 healthy controls. Patients were divided into three groups: glue abusers with history of unexplained syncope (n = 20), asymptomatic glue abusers (n = 24), and healthy control subjects (n = 34). QT intervals, QT dispersion, and corrected QT dispersion values were measured. QT and corrected QT duration were greater in the symptomatic group than in at the symptomatic group and greater in the asymptomatic group than in controls. QT and corrected QT dispersion in both symptomatic and asymptomatic group were significantly greater than controls (p= .001), and also QT and corrected QT dispersion in symptomatic group was greater in asymptomatic group (p = .001). These findings demonstrate that QT interval and corrected QT dispersion increase in symptomatic or asymptomatic toluene abusers. The QT and QTc dispersion were also found to be longer in the symptomatic group than those in the asymptomatic group.