Relationship between left atrial functions and ambulatory blood pressure variability in patients with heart failure and preserved ejection fraction.

Aim    The aim of this study was to investigate the relationship between left atrial (LA) abnormalities and ambulatory blood pressure variability (BPV) in heart failure with preserved ejection fraction (HFpEF) patients.Material and methods    In this single-center, prospective study, we included 187 patients with HFpEF. Eighteen patients with poor image quality were excluded from the study. BPV was evaluated using 24-h ambulatory blood pressure (BP) monitoring. The standard deviation of systolic BP (SBP-SD) was calculated to assess BPV. The patients were classified into two groups according to median SBP-SD (10.5 mm Hg).Results    Overall, 169 HFpEF patients (69.2% women, mean age 69.2±11 yrs) were evaluated. There were 98 patients (57.9%) with a SBP-SD greater than 10.5 mm Hg. Patients with higher SPB-SD had significantly higher left atrial stiffness (LASt) and lower LA reservoir strain (LASr) than those with low SPB-SD. LASt was correlated with 24 hr SBP-SD in both sinus rhythm (r= 0.35, p= 0.015) and atrial fibrillation patients (r= 0.32, p= 0.005). There were significant correlations between night-time SBP-SD and LASr (r=-0.23, p=0.045) in HFpEF with sinus rhythm. For all HFpEF patients, multiple regression analyses showed that 24-hr SBP-SD was correlated with LASt (coeff.=0.40, 95%CI= 0.52-5.25, P= 0.017).Conclusions    High BPV is associated with impaired LA function, especially for LASt and LASr. This study may provide insight for larger multicenter studies to evaluate the effects on outcomes in HFpEF.

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.

Assesment of Cerebral Blood Flow Velocities with Transcranial Doppler Ultrasonography in Heart Failure Patients with Reduced Ejection Fraction.

BACKGROUND: Heart and brain interaction is a well-known entity in heart failure (HF) and left ventricular systolic dysfunction poses an increased risk for stroke and cognitive impairment. Transcranial Doppler (TCD) provides valuable information on cerebral blood flow velocities (CBFV). However, less is known about CBFV in HF patients with reduced EF. So, we aimed to evaluate CBFV by means of TCD in patients with HF and reduced ejection fraction (HFrEF). METHODS: This study included 46 HFrEF patients (mean age 65.2±11 years, mean EF 20.1±3.8%) who underwent to TCD examination. In addition, 26 healthy individuals with sinus rhythm and EF >50% were included in the study as a control group. Peak systolic, mean and end diastolic flow velocities of the both right and left middle cerebral artery (RMCA and LMCA) were analyzed. In subgroup analysis, HFrEF patients compared according to rhythm. Correlation analyses was performed in HFrEF group between EF and TCD velocities. RESULTS: The average of RMCA and LMCA peak systolic and mean flow velocities were significantly lower in HF patients than those in control group (76,06±23,7 cm/s and 48,49±16,4 cm/s in HF group vs 87,84±14,5 cm/s and 56,41±10,7 cm/s in control group, p=0,025 and p=0,016, respectively, for RMCA and 75,1±22,3 cm/s and 47,57±14.8 cm/s in HF group vs 88,73±17,7 cm/s and 57,15±12,4 cm/s in control group, p=0,009 and p=0,007, respectively, for LMCA). The average mean flow velocity of RMCA and LMCA was significantly lower in HFrEF patients with AF than HFrEF patients with sinus rhythm. (P=0.04 and P= 0.03, respectively) In correlation analysis, EF was significantly positively correlated with both LMCA and RMCA flow velocities in HFrEF group. CONCLUSION: This study showed that HFrEF patients have lower CBFV as compared to healthy controls and HFrEF patients with AF rhythm have lower CBFV compared to HFrEF with sinus rhythm which might be one of the explanations of the adverse interaction between heart and brain in HFrEF.

Assessment of fragmented QRS formation and its relationship with left ventricular hypertrophy in nonhypertensive acromegaly patients

Background/aim: It is known that the presence of fragmented QRS (fQRS) on electrocardiography (ECG) is associated with cardiovascular events. The aim of this study was the evaluation of fQRS formation and its relationship with the left ventricular hypertrophy (LVH) parameters in acromegaly patients. Materials and methods: In total, 47 previously diagnosed with non-hypertensive acromegaly patients and 48 control subjects were included in the study. ECG and transthoracic echocardiography (TTE) were performed for each participant. Acromegaly patients were divided into two groups according to the fQRS formation on the ECG. Left ventricular wall thicknesses, and left atrial diameter (LAD), left ventricular mass (LVM), left ventricular mass index (LVMi), and relative wall thickness (RWT) were obtained. Results: In control group 5 (10.4%) and in acromegaly group 17 (36.2%) patients had fQRS on ECG (p = 0.003). LAD [36.0 (34.0­38.0) vs. 38.0 (35.0­41.0) mm, p < 0.001], LVM [155.27 ± 27.00 vs. 173.0 (153.0­235.0) g, p < 0.001], LVMi [83.12 ± 13.19 vs. 92.0 (83.0­118.0) g/m², p < 0.001] and RWT [0.39 ± 0.03 vs. 0.43 (0.41­0.45), p = 0.001] were significantly higher in patients with acromegaly. Disease duration was significantly higher (11.59 ± 1.3 vs. 8.2 ± 1.8 years, p < 0.001) in the fQRS (+) group. LAD [41.0 (39.0­42.5) vs. 37.0 (34.7­38.0) mm, p < 0.001], LVM [219.0 (160.5­254.5) vs. 164.0 (153.0­188.0) g, p = 0.017], LVMi [117.0 (92.5­128.5) vs. 86.0 (82.0­100.2) g/m², p = 0.013] and RWT [0.44 (0.42­0.49) vs. 0.43 (0.40­0.44), p = 0.037] were significantly higher in fQSR (+) acromegaly patients. In multivariate logistic regression analysis, disease duration (odds ratio: 10.05, 95% CI: 1.099­92.012, p = 0.041) and LAD (odds ratio: 2.19, 95% CI: 1.030­4.660, p = 0.042) were found to be the independent predictors of fQRS formation. Conclusion: The results of our study revealed that fQRS (+) acromegaly patients had increased LVH parameters compared to fQRS (-) patients.

The association of exaggerated hypertensive response to exercise and beta-blockers use in hypertensives.

PURPOSE: An elevation in blood pressure (BP) during exercise is the normal physiological response, however an abnormally exaggerated rise in BP, in terms of hypertensive response to exercise (HRE), is seen as a prognostic factor for end-organ damage and mortality. HRE is more common in hypertensive (HT) patients and data are lacking on the effect of antihypertensive medication on HRE. In this study, we evaluated patients who underwent treadmill exercise testing (TET) to reveal the effect of antihypertensive medication on HRE. MATERIALS AND METHODS: A cohort of 2970 individuals underwent TET and data were evaluated for HRE development. HRE has been defined as a systolic BP>210 mmHg in males and >190 mmHg in females throughout the TET. To reveal the effects of antihypertensive medication on HRE, 992 HT patients were analyzed. RESULTS: HRE was observed in 11.4% (n = 113) of HT patients and 5.9% (n = 107) of non-HT individuals(p < .001). HRE was observed significantly more in males (57.6% vs. 67.3%;p = .033), and in patients with higher body mass index BMI (29.1 ± 4.5 vs. 30.3 ± 5.2;0.033). There was no significant association between medication and HRE development apart from beta-blockers. Also, gender (odds ratio:1.787; 95%CI:1.160-2.751;p = .008), BMI (odds ratio:1.070;95%CI:1.025-1.116;p = .002) and being under beta-blocker treatment (odds ratio:0.637;95%CI:0.428-0.949;p = .026) were found to be independent predictors of HRE in multivariate logistic regression analysis. CONCLUSION: HRE was associated with gender, BMI and beta-blocker use in hypertensive with male gender and higher BMI associated with higher HRE, while beta-blocker-based treatment, either mono- or combination therapy, associated with lower HRE.

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.

Effects of heart rate reduction with ivabradine on the international index of erectile function (IIEF-5) in patients with heart failure.

INTRODUCTION: The presence of concomitant erectile dysfunction (ED) with heart failure (HF) is not surprising, because endothelial dysfunction is pathophysiologic signature of both ED and HF. ED significantly and adversely affects quality of life in patients with HF. It was demonstrated that ivabradine treatment can improve endothelial function and ED in experimental models. In this study, we aimed to determine the effect of ivabradine treatment on ED in patients with HF via International Index of Erectile Function (IIEF-5) questionaire. MATERIAL AND METHODS: Consequently, 29 patients, between 18 and 70 years of age, male with chronic HF known for at least 1 year, New York Heart Association functional class I-II, left ventricule ejection fraction less than 40%, in sinus rhythm with a resting HR of at least 70 beats per minute (b.p.m.), who were intended to be treated with ivabradine according to the decision of their physicians were evaluated to determine ED. We used the Turkish version of the IIEF-5 questionnaire to evaluate ED on the last 6-month period. Twenty-four of 29 patients who scored ≤21 were considered to have ED and included to the study. IIEF-5 scores for each question and domains were calculated for all responders at baseline and at 6-month follow-up visit in order to determine any effect of ivabradine treatment on ED in patients with HF. RESULTS: According to the data of survey, Cronbach's alpha coeffient for all of the patients who were included into the study were 0.84 and detected highly reliable. IEFF-5 questionnaire scores increased significantly (p = .003) after the ivabradine treatment, on the contrary, significant decrease in HR was revealed as expected. HR is decreased steadily after ivabradine treatment and mean decrease in HR was 11.5 ± 9.4 in this study population. Likewise, negative correlation was demonstrated between decrease in HR (p < .001) and increase in IEFF-5 scores (p = .003). CONCLUSION: Although lack of patients with HF have been evaluated in this study population, initial results seem promising that ivabradine has favorable effects on ED. These findings were postulated to be dependent exclusively on HR reduction. As a sequel, cardiologist should avoid neglecting ED to improve medical compliance as well as quality of life in patients with heart failure. This pilot study provide some data for further randomized controlled studies.

Cutaneous microvascular reactivity and aortic elasticity in coronary artery disease: Comparison of the laser Doppler flowmetry and echocardiography.

BACKGROUND AND AIM: Decreased vascular reactivity in atherosclerosis was previously shown. In our study, it was aimed to demonstrate the decreased vascular functions in both microvascular and macrovascular tissues and to estimate any correlation between them. METHODS: Twenty-five control outpatients with no coronary artery disease (CAD) history and 26 outpatients with CAD history were enrolled in the study. Local cutaneous post-occlusive reactive hyperemia (PORH) responses after three minutes of brachial occlusion with a pneumatic cuff were recorded noninvasively by a Perimed Periflux 5010 laser Doppler flow system. Aortic distensibility and stiffness indexes were recorded noninvasively by a two-dimensional Doppler echocardiography machine (Vivid S6 GE Medical System, Horten, Norway). RESULTS: Except for the medication history of subjects, there were no significant demographic differences between the CAD and control groups. Peak flow (PF), resting flow (RF) and biological zero(BZ) laser Doppler measurements were not decreased, but PF-RF/RF (%), PF-BZ/BF (%), hyperemia repayment and PORH indexes were significantly decreased in the CAD group (P=0.005, P=0.024, P=0.017, P=0.006, respectively) with laser Doppler measurements. Aortic strain (%) and aortic distensibility (cm3/dyn-1) measurements were significantly decreased in the CAD group (P=0.005, P=0.013). However, there was no correlation between microvascular indexes (hyperemia repayment index, PORH index) and macrovascular indexes (aortic strain and aortic distensibility). DISCUSSION: Different corrupted vascular tonus regulator systems in arteries of varying diameter, different major reactive responses to the stimuli or, finally, the lack of a number of subjects to obtain a significant level may be responsible for the irrelevant correlation analysis. CONCLUSION: The differences in arterial beds (both aorta and microcirculation) may be examined to assess the cardiovascular risk in patients with history of CAD.

Effects of creatine supplementation on cardiac autonomic functions in bodybuilders.

Bodybuilder-type workouts may affect heart rate variability (HRV), which has considerable potential to assess the role of autonomic nervous system (ANS). A scientifically designed approach is necessary for bodybuilders to achieve better results while protecting their health. In this study, we aimed to investigate HRV parameters in bodybuilders compared to healthy control subjects and effects of creatine supplementation. A total of 48 male participants (16 controls, 16 supplement (-), 16 supplement (+)) were evaluated in our study. Bodybuilders who were taking creatine supplementation were enrolled in supplement (+) group. HRV parameters were measured from 24-hour Holter recordings of all participants. When mean heart rates were compared with control group (71.5 ± 12.6 beats/min), statistically significant difference was revealed in supplement (-) group (61.8 ± 6.8 beats/min; P = 0.022) unlike supplement (+) group (69.63 ± 14.1 beats/min; P = 0.650). HRV analyses revealed significant parasympathetic shift in supplement (-) group. No significant difference was demonstrated on HRV parameters, except high frequency (P = 0.029) in supplement (+) group. Conclusively, elevated parasympathetic modulation, which is favorable cardiovascular outcome of exercise, was demonstrated in bodybuilders. However, our study also revealed that creatine supplementation attenuates this favorable effect in ANS by limiting elevation of parasympathetic modulation. Although the sympathetic slight shift is attributed to creatine supplementation, it cannot be discriminated from the effects of over training.