Safety and efficacy of hydroxychloroquine in 152 outpatients with confirmed COVID-19: A pilot observational study.

PURPOSE: We investigated the efficacy and safety of hydroxychloroquine for empirical treatment of outpatients with confirmed COVID-19. METHODS: In this prospective, single-center study, we enrolled ambulatory outpatients with COVID-19 confirmed by a molecular method who received hydroxychloroquine. The patients were divided into low- and moderate-risk groups based on the Tisdale risk score for drug-associated QT prolongation, and the QT interval was corrected for heart rate using the Bazett formula (QTc). The QTc interval was measured by electrocardiography both pretreatment (QTc1) and 4 h after the administration of hydroxychloroquine (QTc2). The difference between the QTc1 and QTc2 intervals was defined as the ΔQTc. The QTc1 and QTc2 intervals and ΔQTc values were compared between the two risk groups. RESULTS: The median and interquartile range (IQR) age of the patients was 47.0 (36.2-62) years, and there were 78 men and 74 women. The median (IQR) QTc1 interval lengthened from 425.0 (407.2-425.0) to 430.0 (QTc2; 412.0-443.0) milliseconds (ms). However, this was not considered an increased risk of ventricular tachycardia associated with a prolonged QTc interval requiring drug discontinuation, because none of the patients had a ΔQTc of >60 ms or a QTc2 of >500 ms. Moreover, the median (quartiles; minimum-maximum) ΔQTc value was higher in patients in the moderate-risk group than those in the low-risk group (10.0 [-4.0-18.0; -75.0-51.0] vs. 7.0 [-10.5-23.5; -53.0-59.0 ms]) (p = 0.996). Clinical improvement was noted in 91.4% of the patients, the exceptions being 13 patients who presented with non-serious adverse drug reactions or who had severe COVID-19 and were hospitalized. Adverse effects related to hydroxychloroquine were non-serious and occurred in 52.8% (n = 80) of the patients. CONCLUSIONS: Our findings show that hydroxychloroquine is safe for COVID-19 and not associated with a risk of ventricular arrhythmia due to drug-induced QTc interval prolongation. Additionally, hydroxychloroquine was well tolerated, and there were no drug-related non-serious adverse events leading to treatment discontinuation in the majority of patients who were stable and did not require hospitalization.

Prognostic Value of Systemic Immune-Inflammation Index for Major Adverse Cardiac Events and Mortality in Severe Aortic Stenosis Patients after TAVI.

Background and objectives: In this study, we aimed to evaluate whether the systemic immune-inflammation index (SII) has a prognostic value for major adverse cardiac events (MACEs), including stroke, re-hospitalization, and short-term all-cause mortality at 6 months, in aortic stenosis (AS) patients who underwent transcatheter aortic valve implantation (TAVI). Materials and Methods: A total of 120 patients who underwent TAVI due to severe AS were retrospectively included in our study. The main outcome of the study was MACEs and short-term all-cause mortality at 6 months. Results: The SII was found to be higher in TAVI patients who developed MACEs than in those who did not develop them. Multivariate Cox regression analysis revealed that the SII (HR: 1.002, 95%CI: 1.001-1.003, p < 0.01) was an independent predictor of MACEs in AS patients after TAVI. The optimal value of the SII for MACEs in AS patients following TAVI was >1.056 with 94% sensitivity and 96% specificity (AUC (the area under the curve): 0.960, p < 0.01). We noted that the AUC value of SII in predicting MACEs was significantly higher than the AUC value of the C-reactive protein (AUC: 0.960 vs. AUC: 0.714, respectively). Conclusions: This is the first study to show that high pre-procedural SII may have a predictive value for MACEs and short-term mortality in AS patients undergoing TAVI.

Prognostic value of the C-reactive protein to albumin ratio in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Background/aim: This study investigated whether baseline serum level of C-reactive protein (CRP)/albumin ratio is associated with infarct localization, number of vascular lesions, and in-hospital mortality in patients undergoing primary percutaneous coronary intervention (PCI) for acute ST elevation myocardial infarction (STEMI). Methods: The study population consisted of 116 patients diagnosed with STEMI. The CRP/albumin ratio at first admission, cardiac troponin-I (cTnI), PCI results, and clinical outcomes were recorded. Results: The mean CRP/albumin ratio, cTnI level, and mean number of vascular lesions were significantly higher in non-survivors than in survivors (p = 0.006, p = 0.004, and p = 0.007, respectively). Multivariate logistic regression analysis demonstrated that the CRP/ albumin ratio and number of coronary artery lesions were independent predictors of mortality in STEMI patients. According to these analyses, the presence of ≥ 2 vessel lesions was the most important predictor of mortality, with an odds ratio of 2.009 (95% confidence interval: 1.191­3.387, p = 0.009). Conclusion: This study demonstrates the potential utility of the CRP/albumin ratio for predicting the clinical outcome of patients with STEMI. In addition, the presence of ≥ 2 vascular lesions contributed to a 2-fold increase in mortality rate in STEMI patients.

Role of dyslipidemia in early vascular aging syndrome

Background/aim: Arterial stiffness, known as a predictor of early vascular aging, was defined as the main determinant of cardiovascular mortality and morbidity. However, the relationship between lipid profile and increased arterial stiffness is not clear. The aim of this study is to investigate the relationship between lipid profiles and increased arterial stiffness in patients with early vascular aging syndrome. Materials and methods: A total of 1582 participants ­504 (31.8%) of were male and the mean age was 52.8 ±14.2 years­ were included in the study . Patients who applied to the hospital for various reasons and who had undergone 24-h blood pressure Holter monitoring were included in this study. Patients were divided into four groups according to pulse wave velocity (PWV) quartiles (Q1 (<6.3), Q2 (6.3­7.4), Q3 (7.5­8.8), Q4 (>8.8)). Results: We found that in the highest PWV group, patients had higher systolic blood pressure (SBP), diastolic blood pressure (DBP), glucose, blood urea nitrogen (BUN), creatinine, urinary albumin excretion (UAE), uric acid(UA), total cholesterol (TC), low-density lipoprotein ( LDL-C), triglycerid (TG), and non- high-density lipoprotein (HDL-C ) levels. Additionally, diabetes mellitus (dm), age, non-HDL-C, and TG/ HDL-C levels were detected as independent risk factors of increased PWV in ordinal logistic regression analysis. Conclusion: Our study demonstrates that lipid parameters are strongly correlated with increased PWVvalue and early vascular aging. In daily clinical practice, TG\HDL-C ratio, known as atherogenic index, might be used routinely for predicted of early vascular aging and subclinical atherosclerosis.

Accessory tricuspid leaflet associated with persistent left superior vena cava.

Right atrioventricular valve is historically named as tricuspid valve. However, cases depicting multi-leaflet morphology of the right atrioventricular valve were reported. Accessory leaflet of the tricuspid valve is a rare entity and associated with congenital cardiac anomalies. We present an accessory tricuspid valve in a patient with isolated persistent left superior vena cava.

Asymptomatic Pulmonary Embolism after Ablation.

BACKGROUND: Pulmonary embolism (PE) is a life-threatening event with a broad presentation spectrum ranging from asymptomatic cases to sudden cardiac arrest. It is unclear if right atrial emboli cause PE in patients with atrial fibrillation (AF) or if mild PE itself increases right cardiac pressure provoking AF. OBJECTIVE: To determine the incidence and predictors of asymptomatic PE in patients undergoing AF ablation. METHOD AND RESULTS: Patients (n = 93) were screened and those with previous or current symptomatic PE or venous thromboembolism, pulmonary hypertension, increased right heart pressures detected on echocardiography, a history of stroke, transient ischemic attack, coagulopathy or cancer and inappropriate contrast for the evaluation of pulmonary arterial tree were excluded. The remaining AF patients (n = 71) underwent guided ablation controlled with 3-dimensional, left atrial and pulmonary venous computed tomography. The asymptomatic PE was defined by using the modified Miller score by 2 independent assessors in 6 patients. Univariate logistic regression showed that age (OR: 1.094, 95% CI 1.007-1.188, p = 0.033), diabetes (OR: 12.000, 95% CI 1.902-75.716, p = 0.008), CHA2DS2-VASc score (OR: 2.800, 95% CI 1.304-6.013, p = 0.008), and pulmonary artery diameter (OR: 1.221, 95% CI 1.033-1.444, p = 0.019) were significantly associated with PE. However, multivariate analysis revealed that the CHA2DS2-VASc score (p = 0.047) remained the exclusive significant predictor for asymptomatic PE. CONCLUSION: The incidence of random asymptomatic PE in AF patients is high (>8%). The CHA2DS2-VASc score can predict silent PE. Since patients with a high CHA2DS2-VASc score are already anticoagulated, our results do not change clinical practice but are noteworthy in terms of the cause-effect relationship between AF and PE.

Increased level of red cell distribution width is associated with poor coronary collateral circulation in patients with stable coronary artery disease.

OBJECTIVES: Previous studies have shown the association between various hematological parameters and cardiovascular diseases, and their prognostic value. In this study, we compared red cell distribution width (RDW), neutrophil lymphocyte ratio (NLR) and mean platelet volume (MPV) measurements among patients with poor coronary collateral circulation (CCC) and well-developed CCC. STUDY DESIGN: 326 patients with stable coronary artery disease (CAD) were evaluated retrospectively. CCC was graded by using the Rentrop classification. The poor CCC group included patients with Rentrop 0-1 CCC, and the good CCC group included Rentrop 2-3 CCC. RESULTS: There were 171 subjects (84% male; mean age 56.6±10.4 years) in the poor CCC group, and 155 subjects (89% male; mean age 57.6±9.7 years) in the good CCC group. The total number of vessels with >95% stenosis (1.1±0.5 vs. 1.0±0.4; p=0.64) and Gensini scores (84.4±38.8 vs. 83.3±37.4; p=0.83) was not higher in the poor CCC group compared to the good CCC group. RDW was significantly higher in the poor CCC group compared to the good CCC group (14.19±1.36% vs. 13.89±1.19%; p=0.04). In multivariate logistic regression analysis, elevated levels of RDW and LDL were found to be independent predictors of poor CCC (OR 1.73, 95% CI: 1.30-2.29, p=0.01 and OR 1.01 95% CI 1.002-1.02; p=0.02, respectively). CONCLUSION: In the present study, poor CCC was found to be independently correlated with RDW, but not with any other hematological parameters in patients with stable CAD.

Comparison of the Effects of Recent Coronavirus 2019 Infection and Vaccination on the Prognosis of Acute Coronary Syndrome: A Retrospective Study Conducted in a Single Center in Türkiye.

BACKGROUND: We aimed to examine the effects of COVID-19 infection versus vaccination within the month prior to acute coronary syndrome (ACS) diagnosis with respect to their impact on the development of mortality or major adverse cardiovascular events (MACE). METHODS: This retrospective cohort study included patients hospitalized with a diagnosis of ACS between June 2020 and December 2022. Patients diagnosed with ACS were grouped according to the presence of COVID-19 infection (post-COVID), vaccination (post-vaccine), or non-exposure during the month prior to ACS diagnosis. Patients with and without MACE were also compared separately. RESULTS: We analyzed 1890 ACS patients (mean age 57.43 ± 11.53 years, 79.15% males). Of these, 319 (16.88%) were in the post-vaccine group, and 334 (17.67%) were in the post-COVID group. Major adverse cardiovascular events occurred in 569 (30.11%) patients. Mortality was recorded in 271 (14.34%) patients. In the post-COVID group, the frequencies of MACE and mortality and length of stay in hospital were significantly higher (vs. post-vaccine and vs. non-exposure groups; both P <.001). High age, ST-elevation myocardial infarction, having suffered from Post-COVID ACS, and high glucose were independently associated with increased MACE risk; whereas, hyperlipidemia, 3 or more COVID vaccinations, receipt of the Biontech vaccine, and high estimated glomerular filtration rate were independently associated with decreased MACE risk. CONCLUSION: Acute coronary syndrome patients who have recently had COVID-19 infection may have a worse prognostic course compared to those with recent vaccination, necessitating continuing care for pandemic-related risk factors as well as previously known factors impacting MACE and prognosis.

Unclassified pleomorphic and spindle cell pulmonary neoplasm with brain metastases after prasugrel.

BACKGROUND: There was an excess of new solid neoplasms (112 vs. 69), and cancer deaths (24 vs. 15) after prasugrel in the TRITON (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition). These cancers usually occur after 4 months following prasugrel, and women are especially at risk. The hypothesis has been offered that prasugrel, but not aspirin or clopidogrel, causes indirect modulation of tumor growth, and/or enhanced metastatic dissemination due to instability of platelet-tumor cell aggregates via the inability to keep cancer locally within the platelet thrombi due to excessive chronic platelet inhibition. CASE REPORT: A 70-year old female diabetic patient underwent drug-eluting stent implantation. The patient received a loading dose of prasugrel (60 mg), followed by prasugrel 10 mg/daily as well as aspirin (81 mg/daily). After 4 months on dual antiplatelet therapy she expectorated blood when coughing. A lung X-ray and CT scan revealed numerous lung nodules later diagnosed as unclassified pleomorphic and spindle cell malignant solid neoplasm. The patient died following multiple brain metastasis. CONCLUSION: Female gender, duration of prasugrel exposure, rare unclassified neoplasm pathology type and a tumor of a highly metastatic and aggressive nature in the index patient should be regarded with caution. The effects of novel antiplatelet agents on the onset of cancer should be tested in future mega-trials.

Gastrointestinal adverse events after dual antiplatelet therapy: clopidogrel is safer than ticagrelor, but prasugrel data are lacking or inconclusive.

Current guidelines offer a choice of P2Y12 receptor antagonist among clopidogrel, prasugrel or ticagrelor on top of aspirin (ASA) for dual antiplatelet therapy (DAPT) in patients after acute coronary syndromes (ACS). However, the comparative risks of gastrointestinal (GI) adverse events during DAPT are not clear. Two large ACS trials (TRITON and PLATO) provide a valuable opportunity to directly match the risks of GI complications among current antiplatelet regimens. We compared the rates of GI adverse events after prasugrel and ticagrelor versus clopidogrel based on the Food and Drug Administration (FDA) clinical safety reviews. When compared with ticagrelor, clopidogrel is safer with regard to GI-related risks including fewer overall GI/anal bleeding events and spontaneous GI hemorrhagic episodes, less nausea, vomiting, dyspepsia and diarrhea, and a lower rate of presence of Helicobacter pylori. Among GI symptoms, only constipation was more common after clopidogrel than following ticagrelor. There were extrahepatic risks observed with ticagrelor but not with prasugrel when compared to clopidogrel. Prasugrel unquestionably caused more bleeding from the GI tract and GI malignancies than clopidogrel. However, the entire spectrum of GI effects of prasugrel is much less well known and mostly based on sponsor analysis rather than FDA-verified numbers. Among 3 DAPT options on top of ASA, clopidogrel seems to represent the safest alternative, although comprehensive data on direct prasugrel-associated GI effects are lacking or inconclusive.

[Relationship between human platelet antigen-1 gene polymorphism and clopidogrel resistance in patients with coronary artery disease]. / Koroner arter hastalarinda insan trombosit antijen-1 gen polimorfizmi ile klopidogrel direnci iliskisi.

OBJECTIVES: It has been proposed that human platelet antigen-1 (HPA-1) gene polymorphism is associated with coronary artery disease (CAD) and affects platelet function. We aimed to investigate the distribution of HPA gene polymorphism between angiographic CAD and a control group and the relation between HPA gene polymorphism and platelet aggregation. STUDY DESIGN: The study population consisted of 94 patients with angiographic CAD and 115 patients without angiographic CAD. Platelet aggregation was measured with impedance aggregometry on the fifth day of percutaneous coronary intervention (PCI). Platelet aggregation >480 AU*min was defined as the clopidogrel resistance group. Blood samples were obtained from all participants at discharge for investigating HPA-1 gene polymorphism. RESULTS: There was no significant difference in the distribution of HPA-1 gene polymorphism between the control and CAD groups (78.7% vs. 78.1% for A allele and 21.3% vs. 21.9% for B allele, p=NS). The analysis between groups with and without clopidogrel resistance revealed no significant difference in the distribution of HPA-1A and HPA-1B alleles between the groups (A allele 78.7% vs. 78.9% and B allele 21.3% vs. 21.1%, p=NS). In the CAD group, there were no significant differences in platelet aggregation between HPA-1A and HPA-1B alleles (294±240 vs. 259±261 AU*min, p=NS). CONCLUSION: The distribution of HPA-1 gene polymorphism was not different in CAD patients compared to the control group. HPA-1 gene polymorphism was not associated with platelet aggregation or clopidogrel resistance assessed by impedance aggregometry in the CAD group.

Evaluation of subclinical atherosclerosis in rosacea patients by flow-mediated dilatation method.

BACKGROUND: Rosacea may contribute to the development of cardiovascular (CV) diseases by causing endothelial dysfunction (ED), which is known to be the initial step of atherosclerosis, due to its inflammatory features. OBJECTIVE: This study aimed to assess ED in rosacea patients using the flow-mediated dilatation (=dilation) (FMD) method. METHODS: Seventy-three rosacea patients and 73 age, gender-matched healthy volunteers were enrolled. Individuals with cardiac risk factors, pregnant, and lactating women were excluded. Demographic, clinical data and anthropometric measurements were recorded. FMD measurement was performed ultrasonographically by a cardiologist. Systolic and diastolic blood pressures (BP) were measured and hemogram, erythrocyte sedimentation rate (ESR), C-Reactive Protein (CRP), total cholesterol, triglyceride, low-density lipoprotein (LDL), high-density lipoprotein (HDL), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), mean platelet volume (MPV), and fasting blood glucose values were assessed. RESULTS: The FMD value was statistically lower in rosacea patients compared with healthy controls (p = 0.000). Metabolic syndrome, systolic and diastolic BPs, and plasma NLR were higher in the rosacea group (p = 0.009, p = 0.000, p = 0.000, p = 0.000, respectively). According to the multivariate linear regression analysis, rosacea type significantly predicted FMD. CONCLUSIONS: Rosacea is not only a disease limited to the skin, but it may also have systemic involvement. A significant difference was found between FMD values measured in between the case and control groups, suggesting rosacea may have an atherogenic effect. Possible cardiac risks should be considered in rosacea patients, and further evaluation could be warranted.

Mortality in the TRACER and ATLAS ACS 2 trials: two more reasons to audit vital records in PLATO.

CONTEXT: Extreme rates of vascular and all-cause mortality, especially in the clopidogrel arm of the PLATO (PLATelet Inhibition and Clinical Outcomes) trial, raise concerns of data accuracy and call for independent verification of vital records in the national death registries. Two recently completed acute coronary syndrome (ACS) trials, TRACER and ATLAS ACS 2 (Thrombin Receptor Antagonist for Clinical Event Reduction in ACS and Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with ACS-Thrombolysis in Myocardial Infarction), provide a valuable opportunity to match mortality numbers among 3 similar studies. OBJECTIVE: To compare the rates of vascular and all-cause mortality in the PLATO, TRACER and ATLAS ACS 2 trials. RESULTS: Despite a shorter mean follow-up (277 days) for the PLATO trial than for the TRACER (502 days) or ATLAS ACS 2 (393 days) trials, both vascular (5.1%) and all-cause (5.9%) mortality in PLATO were higher than in the TRACER (3.2 and 4.9%) or ATLAS ACS 2 (4.1 and 4.5%) control arms, respectively. Adjusting for follow-up duration, rates of vascular (0.0184/day), or all-cause (0.0213/day) mortality in PLATO differ importantly from daily death rates in TRACER (0.0063 and 0.0097) and ATLAS ACS 2 (0.0104 and 0.0115), suggesting that the risk of death in the control PLATO arm was approximately double that of the other trials. The mismatch is particularly striking considering that ATLAS ACS 2 enrolled more STEMI (ST-segment elevation in myocardial infarction) patients (50.9%) than PLATO (38.0%). CONCLUSIONS: Both overall and follow-up duration-adjusted mortality rates in PLATO far exceeded the risk of death observed in the two recent ACS trials. The background STEMI rates are not likely to be responsible for the PLATO mortality paradox. These data provide an additional reason to request an independent audit of the deceased PLATO clopidogrel cohort.

Comparison of transthoracic and transesophageal 2-dimensional speckle tracking echocardiography.

OBJECTIVES: Two-dimensional (2D) strain imaging has been established as a reliable and reproducible technique for the assessment of left and right ventricular function using transthoracic echocardiography (TTE). However, the reproducibility of transesophageal echocardiographic (TEE) 2D strain imaging and the agreement with TTE 2D strain imaging remains unclear. In the present study, the authors studied the reproducibility of TEE 2D strain imaging parameters. DESIGN: A comparative, observational clinical study. SETTING: The echocardiography laboratory of the tertiary referral center. PARTICIPANTS: Healthy individuals with a suspected patent foramen ovale. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients were included in the study. None of the patients had any structural cardiovascular disease. TTE and TEE images of the subjects were recorded and analyzed offline (EchoPAC 6.1; GE Vingmed Ultrasound AS, Horten, Norway). Longitudinal strain and strain rate measurements of the 4 chambers, the apical long axis, 2 chambers, and the right ventricle were obtained for each record of TTE and TEE. The mean age of the patients in this study was 36 ± 9.2 years. Bland-Altman analysis showed that there were generally good agreements between strain and strain rate measurements on TEE and TTE. The inter- and intraobserver agreement for TEE parameters was good. CONCLUSIONS: Transesophageal 2D strain imaging is a reproducible method to measure ventricular function and has a good agreement with TTE 2D strain imaging.

Epicardial fat thickness is associated with non-dipper blood pressure pattern in patients with essential hypertension.

OBJECTIVE: Epicardial fat tissue reflects visceral adiposity and is a suggested cardiometabolic risk factor. Patients with abdominal obesity have an increased prevalence of the non-dipper blood pressure (BP) pattern, but it is unclear whether the same is true of patients with increased epicardial fat thickness (EFT). The association between EFT and circadian BP changes in patients with recently diagnosed essential hypertension was examined. METHODS: Sixty hypertensive patients underwent echocardiography, treadmill stress testing, and 24 hours of ambulatory BP monitoring. Epicardial fat thickness and left ventricular mass (LVM) index were measured by using transthoracic echocardiography. The patients were categorized into two groups according to their BP pattern (group 1, non-dippers; group 2, dippers). RESULTS: The mean EFT and LVM of patients in group 1 (n = 24) (EFT, 7.6 ± 2.1 mm; LVM, 130 ± 31.2 g/m(2)) were significantly greater than those of group 2 (n = 36) (EFT, 5.5 ± 1.2 mm, P = .0001; LVM, 107 ± 23.7 g/m(2), P = .002). The average systolic BP over 24 hours (BP(s) 24) and average diastolic BP over 24 hours (BP(d) 24) of group 1 (BP(s) 24, 151.1 ± 17.6 mm Hg; BP(d) 24, 94.1 ± 16.5 mm Hg) were significantly higher than those of group 2 (BP(s) 24, 136.7 ± 11.9 mm Hg, P = .0001; BP(d) 24, 84.6 ± 10.6 mm Hg; P = .008). Multivariate backward logistic regression analysis demonstrated that the non-dipper BP pattern was associated with EFT (standardized ß coefficient = 0.87, P = .005) and LVM (standardized ß coefficient = 0.43, P = .016). An EFT ≥ 7 mm was associated with the non-dipper BP pattern with 44% sensitivity and 94% specificity (receiver operating characteristic area under curve of 0.72, 95% CI [0.59-0.83], P = .0007). CONCLUSIONS: Epicardial fat thickness was above average in newly diagnosed, untreated hypertensive patients with non-dipper BP pattern. The echocardiographic measurement of EFT may be used to indicate increased risk of hypertension-related adverse cardiovascular events.

[Carotid endarterectomy versus stenting: where do we stand today?]. / Karotis arter endarterektomisine karsi karotis artere stent: Bugün nerede duruyoruz?

Carotid artery stenosis is the major cause of the stroke associated with ischemic origin and carries increased mortality and morbidity. Since carotid artery endarterectomy (CEA) was first performed in 1950, in conjunction with the advanced technology and increased experience under the guidance of randomized controlled trials, balloon angioplasty and carotid artery stenting, which have similar mortality and morbidity, have become comparable with CEA. Determining the optimal treatment option for each patient is the most important issue in carotid artery stenosis. Today, there have been improvements in technology and recent advances in the cardiovascular sciences. Moreover, there is increased experience, increased attention to patient selection, and a team approach to find the most suitable treatment for the patient. In this review, we briefly discuss the current treatment approaches for carotid artery stenosis under the guidance of the modern studies.

Prognostic value of the TyG index for in-hospital mortality in nondiabetic COVID-19 patients with myocardial injury.

OBJECTIVE: The purpose of this study was to explore the efficacy of the triglyceride glucose (TyG) index on in-hospital mortality in nondiabetic coronavirus disease 2019 (COVID-19) patients with myocardial injury. METHODS: This was a retrospective study, which included 218 nondiabetic COVID-19 patients who had myocardial injury. The TyG index was derived using the following equation: log [serum triglycerides (mg/dL) ×fasting blood glucose (mg/dL)/2]. RESULTS: Overall, 49 (22.4%) patients died during hospitalization. Patients who did not survive had a higher TyG index than survivors. In multivariate Cox regression analysis, it was found that the TyG index was independently associated with in-hospital death. A TyG index cutoff value greater than 4.97 was predicted in-hospital death in nondiabetic COVID-19 patients with myocardial damage, with 82% sensitivity and 66% specificity. A pairwise evaluation of receiver operating characteristic (ROC) curves demonstrated that the TyG index (AUC: 0.786) had higher discriminatory performance than both triglyceride (AUC: 0.738) and fasting blood glucose (AUC: 0.660) in predicting in-hospital mortality among these patients. CONCLUSIONS: The TyG index might be used to identify high-risk nondiabetic COVID-19 patients with myocardial damage.

Recurrent acute stent thrombosis due to allergic reaction secondary to clopidogrel therapy.

Despite significant benefits including mortality advantage demonstrated with antiplatelet therapy in large clinical trials, the occurrence of adverse ischemic events, including stent thrombosis after percutaneous coronary intervention has been the challenging and devastating complication. Clopidogrel as a monotherapy, or more common in combination with aspirin, represents a cornerstone of modern pharmacotherapy in the invasive era. Although vigilance in maintenance of this dual antiplatelet treatment is mandatory, obligatory cessation of one of these agents can be observed in rare circumstances of adverse events. We describe a patient who developed recurrent acute stent thrombosis associated with clopidogrel-induced allergic reaction and discuss our therapeutic considerations.

Severity of mitral stenosis and left ventricular mechanics: a speckle tracking study.

BACKGROUND: It has been shown that mitral stenosis (MS) impairs left ventricular (LV) systolic function; however, this issue has not been studied comprehensively. We aimed to evaluate the role of 2D strain in the assessment of subclinical LV systolic dysfunction in patients with MS. METHODS: Seventy-two patients with isolated MS (mild, moderate and severe) and 31 healthy control subjects constituted the study population. 2D echocardiography images were obtained from LV apical 4-chamber (4C), long axis (LAX), and 2-chamber (2C) views. Peak longitudinal strain and strain rate (Sr) were obtained from 4C, LAX, and 2C views. Global strain and Sr were calculated by averaging the three apical views. RESULTS: There were no significant differences in LV ejection fraction and LV systolic or diastolic dimensions between the groups. Patients with MS had significantly lower LV longitudinal strain and Sr measurements than the control group. In addition, there were no significant differences in MS subgroups with respect to LV strain and Sr measurements. CONCLUSION: We demonstrated that patients with MS had lower LV functions using 2D strain imaging, and this is independent of the hemodynamic severity of MS. In the detection of subclinical LV dysfunction in patients with MS, 2D strain imaging appears to be useful.

Echocardiographic epicardial fat thickness is related to altered blood pressure responses to exercise stress testing.

OBJECTIVE: Hypertensive response at peak exercise and blunted blood pressure (BP) recovery, altered BP responses obtained from exercise stress testing, have been suggested as risk factors for future onset of hypertension in previous studies. Epicardial fat, a new cardiometabolic risk factor, has been linked to hypertension in some recent studies. In this study, we tested the primary hypothesis suggesting that the epicardial fat thickness (EFT) is related to altered BP responses to treadmill exercise testing. We also evaluated the sensitivity and specificity of the EFT as a predictor of hypertensive response to peak exercise. METHODS: Normotensive subjects underwent to treadmill stress testing and transthoracic echocardiography. Hypertensive response to peak treadmill exercise testing was defined as ≥ 210/105 mmHg and ≥ 190/105 mmHg at peak exercise in males and females, respectively. BP recovery index (BPRI) was defined as the ratio of the BP at the 3rd minute of the recovery phase to BP at peak exercise. EFT was measured by echocardiography. Thirty-two subjects with hypertensive response to peak exercise constituted Group 1 and 48 subjects with normal response constituted Group 2. RESULTS: The mean EFT of subjects in Group 1 was significantly higher (8.2 ± 1.1 mm vs 5.1 ± 1.5 mm; p = 0.0001) than subjects in Group 2. In correlation analysis performed in Group 1, EFT was found to be significantly correlated with BPRI (r = 0.51, p < 0.003). An EFT of ≥ 6.5 mm predicted the hypertensive response to peak exercise test with 68.8% sensitivity and 87.5% specificity (receiving operator characteristic area under curve: 0.879, 95% CI 0.793-0.965, p < 0.001). Patients with EFT ≥ 6.5 mm showed a significantly increased BPRI (0.89 ± 0.07 vs 0.74 ± 0.09, p < 0.0001) and peak systolic BP (198.4 ± 15.3 mmHg vs 169.4 ± 19.8 mmHg, p < 0.0001). There were significant differences in metabolic equivalents, maximum heart rate, homeostatic model assessment of insulin resistance, high-density lipoprotein-cholesterol, waist circumference and age values between two patients groups dichotomized according to the cut-off value of EFT. BPRI was the only independent variable related to EFT in the multivariate analysis (odds ratio = 1.4, 95% CI 2.75-7.16, p = 0.001). CONCLUSIONS: EFT was found to be related to altered BP responses to exercise stress testing. The echocardiographic measurement of EFT may serve as a useful non-invasive indicator of heightened risk of future hypertension.