Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry.

BACKGROUND AND AIMS: Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients. METHODS: We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia. RESULTS: Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P < .001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P = .06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages. CONCLUSIONS: In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

Prognostic value of C-reactive protein/albumin ratio in hypertensive COVID-19 patients.

OBJECTIVES: The aim of this study was to investigate the relationship between the C-reactive protein/albumin ratio and the prognosis of hypertensive COVID-19 patients. METHODS: It was designed as a single center retrospective study. PCR positive COVID-19 patients who were followed up in the intensive care unit (ICU) and received antihypertensive treatment were included in the study. The patients were divided into two groups as survivor and non-survivor. C-reactive protein/albumin (CAR) ratios of the patients were compared. The cut-off value was determined as a mortality predictor. The effect of CAR on mortality was evaluated using Logistic Regression analysis. RESULTS: 281 patients were included in the study. Groups consisted of 135 (non-survivor) and 146 (survivor) patients. CAR was significantly higher in the non-survivor group (p<0.001). The area under the ROC curve for CAR for mortality was 0.807, with sensitivity of 0.71 and specificity of 0.71. The cut-off value for CAR was calculated as 56.62. In logistic regression analysis, CAR increases mortality 4.9 times compared to the cut-off value. CONCLUSION: CAR is a powerful and independent prognostic marker for predicting mortality and disease progression in hypertensive COVID-19 patients.

Clinical features of heart failure with mid-range and preserved ejection fraction in octogenarians: Results of a multicentre, observational study.

OBJECTIVES: To compare real-world characteristics and management of individuals aged 80 and older with heart failure (HF) and mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) derived from a large cohort of survey and to compare them with those younger than 80 from the same survey. METHODS: This is an observational, multicentre and cross-sectional study conducted in Turkey (NCT03026114). Consecutive 1065 (mean age of 67.1 ± 10.6 years) patients admitted to the cardiology outpatient units with HFmrEF and HFpEF were included. RESULTS: Participants aged 80 and older (n = 123, 11.5%) were more likely to be female (66.7% vs 52.5%, P = 0.003), had a higher prevalence of atrial fibrillation (49.6% vs 34%, P = 0.001), and anaemia (46.3% vs 33.4%, P = 0.005) than those who were younger than 80. N-terminal pro B-type natriuretic peptide levels were higher in those aged 80 and older than in those younger than 80 (1037 vs 550 pg/ml, P < 0.001). The prescription rates of HF medications (including in ACE-Is/ARBs, ß-blockers, MRAs, digoxin, ivabradine and diuretics) were similar (P > 0.05) in both groups. Octogenarians did not significantly differ from younger patients in the prevalence of HFmrEF (24.4% vs 22.9%) and HFpEF (75.6% vs 77.1%). Coronary artery disease was associated with HFmrEF (P < 0.05), whereas atrial fibrillation was associated with HFpEF (P < 0.05) in octogenarians. CONCLUSIONS: This study revealed that nearly 12% of the individuals with HFmrEF and HFpEF in this real-world sample were aged 80 and older. Participants aged 80 and older are more likely to be female and have more comorbidities than those who were younger than 80. However, HF medication profiles were similar in both groups. This study also showed that associated factors with HFmrEF and HFpEF were differ in octogenarians.

The reasons of poor lipid target attainment for secondary prevention in real life practice: Results from EPHESUS.

OBJECTIVE: There are lack of studies considering the suboptimal management of dyslipidemia especially in cardiology outpatient clinics. This study was conducted to assess the patient adherence to cholesterol treatment recommendations and attainment of low-density-lipoprotein cholesterol (LDL-C) goals. METHODS: EPHESUS (NCT02608645) is a national, observational and multicenter registry which has been designed as a cross-sectional study to allow inclusion of all consecutive patients with hypercholesterolemia in cardiology outpatient clinics. The present subgroup analyses of the EPHESUS trial included patients with known peripheral artery disease or atherosclerotic cerebrovascular disease, and coronary heart disease namely secondary prevention. RESULTS: The present analysis of the EPHESUS study included 1482 patients (62.79 ± 10.4 years, 38.2% female) with secondary prevention from 40 sites in Turkey. Regarding recommended lipid targets for LDL-C, only 267 patients (18%) were below the target of 70 mg/dL. Females were significantly more off-target when compared with male patients (396, 85.5% vs 67, 14.5%; P = 0.017). Moreover, the achievement of LDL-C goal was significantly decreased with illiteracy (233, 19.2% vs 35, 13.1%; P = 0.02). Patients who think that the cholesterol treatment should be terminated when the cholesterol level of a patient has normalised were higher in the off-target group (34.0% vs 24.7%, P < 0.001). Besides, physician perceptions about LDL-C goal for secondary prevention were significantly related with LDL-C target attainment. CONCLUSIONS: EPHESUS is an important study with large population in terms of representing real-life practice of the adherence to dyslipidemia guidelines in secondary prevention patients in Turkey. Perceptions, knowledge, and compliance with the guidelines for secondary prevention have increased, but it is far below from the desired levels even in cardiology outpatient clinics. There is a need for patients' and physicians' education regarding the treatment of hyperlipidemia.

Gemifloxacin-Induced Allergic Myocardial Infarction: A Case Report.

BACKGROUND: Gemifloxacin given once daily for 5-7 days has been shown to be non-inferior to, or in some instances superior to, comparator agents for the treatment of common lower respiratory tract infections. Gemifloxacin is generally well tolerated and is as safe as many frequently empirically prescribed antimicrobials. CASE REPORT: We report a case of a 46-year-old woman given gemifloxacin for an upper respiratory tract infection who developed allergic myocardial infarction 15 min after taking an oral dose of 320 mg gemifloxacin. To our knowledge, this is the first case of allergic myocardial infarction associated with gemifloxacin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although anaphylactoid/anaphylactic reactions are rare adverse effects of fluoroquinolones, clinicians should be aware of this potentially fatal event. Electrocardiographic interpretation is a critical skill of the emergency physician. Awareness of Kounis syndrome and its specific electrocardiogram findings may help facilitate further testing that will aid in timely diagnosis and interventions. A diagnosis of Kounis syndrome should be considered in young, healthy patients with no atherosclerotic risk factors when they develop an acute coronary syndrome after administration of a potentially allergic agent.

Impact of preoperative cardiology consultation prior to intermediate-risk surgical procedures.

BACKGROUND: Patients undergoing noncardiac, nonvascular surgery (NCNVS) are at risk of perioperative cardiovascular events. However, benefits of cardiology consultation (CC) in patients with known or suspected cardiac disease undergoing intermediate-risk NCNVS is unknown. METHODS: The study group included 700 consecutive patients referred for CC before intermediate-risk NCNVS in a tertiary-care teaching hospital. The control group included 1200 age-matched and sex-matched consecutive patients proceeded to the intermediate-risk surgery without preoperative CC during the same period. Patients older than 18 years who underwent an elective, NCNVS were enrolled. Requests for consultation were made either by surgeon or an attending anaesthesiologist. All patients underwent a complete preoperative clinical evaluation. RESULTS: Of the 700 patients who were referred for CC in the study group, 530 patients (75.7%) had no additional recommendations, and 170 patients (24.3%) underwent additional preoperative tests or had a change in preoperative therapy. Only 20 (2.8%) patients' NCNVS were delayed based on the cardiologists' recommendation and 680 patients eventually had their surgeries. Major cardiovascular and noncardiovascular complication rates were similar in the study and in the control groups (12.9% vs 13.6%, P = 0.273 and 25.2% vs 26%, P = 0.432 respectively). CONCLUSIONS: Preoperative CC in patients who underwent intermediate-risk NCNVS does not affect either perioperative management or outcome of surgery.

The Role of Left Atrial Volume Index in Patients with a First-ever Acute Ischemic Stroke.

BACKGROUND: Although an enlarged left atrium has recently emerged as a marker of adverse outcomes in various diseases, its discriminatory value and prognostic role in acute ischemic stroke (AIS) are not well studied. We studied whether left atrial volume index (LAVI) predicts mortality and discriminates stroke subtypes after AIS. METHODS: We prospectively followed 310 consecutive first-ever AIS patients aged 50 years or older who were admitted to the hospital within 24 hours of the onset of stroke symptoms. The type of AIS was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. All of the patients underwent transthoracic echocardiography within the first 24 hours. LAVI was measured with the biplane area-length method and categorized as 28 mL/m2 or lower (normal), 28.1-32 mL/m2, 32.1-36 mL/m2, and >36 mL/m2. The patients were followed for 1 year or until death, whichever came first. RESULTS: The LAVI of the cardioembolic group was significantly higher than that of the noncardioembolic group (32.4 ± 4.0 versus 29.7 ± 3.4 mL/m2, respectively; P < .001). The optimal cutoff value, sensitivity, and specificity of LAVI to distinguish cardioembolic stroke from noncardioembolic stroke were 30 mL/m2, 81%, and 64%, respectively. Mortality in each LAVI category was 4%, 7.8%, 25.9%, and 70.9%, respectively (P = .026). Kaplan-Meier analysis showed that there was a stepwise increase in risk of mortality with each increment of LAVI category. CONCLUSIONS: The LAVI can distinguish cardioembolic stroke from noncardioembolic stroke and provides an independent information over clinical and other echocardiographic variables for predicting mortality in patients with first-ever AIS.