Takotsubo cardiomyopathy in the setting of multiple sclerosis: a multifaceted phenomenon with important implications.

Dear Editor, Takotsubo cardiomyopathy (TTC) has been universally regarded as a unique form of reversible myocardial dysfunction associated with a variety of emotional and physical stressors. In their recently published elegant article, Dell'Aquila et al. have reported an interesting case of TTC triggered by an exacerbation of relapsing-remitting multiple sclerosis (MS). However, we would like to comment on this interesting case and its particular implications...

An epidemiological study to evaluate the use of vitamin K antagonists and new oral anticoagulants among non-valvular atrial fibrillation patients in Turkey- AFTER-2 study design.

OBJECTIVES: Atrial fibrillation (AF) is one of the most common causes of preventable ischemic stroke and is related to increased cardiovascular morbidity and mortality. There is a lack of data in Turkey on the use of new oral anticoagulants (NOACs), and time in therapeutic INR range (TTR) in vitamin K antagonist users and AF management modality. In this multi-center trial, we aimed to analyze, follow and evaluate the epidemiological data in non-valvular AF patients. STUDY DESIGN: Four thousand one hundred consecutive adult patients from 42 centers with at least one AF attack identified on electrocardiography will be included in the study. Patients with rheumatic mitral valve stenosis and prosthetic valve disease will be excluded from the study. At the end of one year, the patients will be evaluated in terms of major cardiac end points (death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding and hospitalization). RESULTS: First results are expected in June 2015. Data about major cardiovascular end-points will be available in January 2016. CONCLUSION: The rates and kind of oral anticoagulant use, TTR in vitamin K antagonist users and main management modality applied in non-valvular AF patients will be determined by AFTER-2 study. In addition, the rate of major adverse events (MACEs) and the independent predictors of these MACEs will be detected (AFTER-2 Study ClinicalTrials.gov number, NCT02354456.).

Which aerobic exercise is more effective in Parkinson's patients? Cycle ergometer versus body weight-supported treadmill.

Objectives: The study aimed to evaluate the effects of aerobic exercise applied with bodyweight-supported treadmill (BWSTT) or cycle ergometer (CE) in Parkinson's patients. Patients and methods: In the prospective single-blind study, 38 Parkinson's patients with Hoehn-Yahr Stage 1-3 were randomized into the CE and BWSTT groups between May 2019 and March 2020. Evaluations before and after six weeks of treatment included a six-min walking test with a software device as the primary outcome and functional balance tests (Tinetti balance and gait test, one-leg stance balance test) as secondary outcomes. Both groups received 40 min of aerobic exercise three days per week with conventional rehabilitation and various methods. CE and BWSTT groups were created. The aerobic exercise program was designed based on treatment recommendations for Parkinson's patients of the American College of Sports Medicine (CE test, with the Karvonen formula, 40-60% reserve). Posttreatment and pretreatment evaluations were compared within and between groups. Results: The six-week aerobic exercise program was completed by 16 participants (9 males, 7 females; mean age: 65.9±8.1; range, 47 to 78 years) in the CE group and 15 participants (9 males, 6 females; mean age: 62.5±7.5; range, 49 to 79 years) in the BWSTT group. The demographic characteristics of the patients were similar. Primary and secondary outcomes were significantly different after treatment than before treatment in both groups. There were no significant differences between the groups in outcomes. Conclusion: The results showed that both methods are effective and not superior to each other. Aerobic exercise programs led by experienced clinicians can benefit patients.

Baseline Characteristics of a Patient Cohort and Predictors of In-hospital MORtality in CORonary Care Units (MORCOR-TURK) Trial in Türkiye.

OBJECTIVE: The MORtality in CORonary Care Units in Türkiye (MORCOR-TURK) trial is a national registry evaluating predictors and rates of in-hospital mortality in coronary care unit (CCU) patients in Türkiye. This report describes the baseline demographic characteristics of patients recruited for the MORCOR-TURK trial. METHODS: The study is a multicenter, cross-sectional, prospective national registry that included 50 centers capable of 24-hour CCU service, selected from all seven geographic regions of Türkiye. All consecutive patients admitted to CCUs with cardiovascular emergencies between September 1-30, 2022, were prospectively enrolled. Baseline demographic characteristics, admission diagnoses, laboratory data, and cardiovascular risk factors were recorded. RESULTS: A total of 3,157 patients with a mean age of 65 years (range: 56-73) and 2,087 (66.1%) males were included in the analysis. Patients with arterial hypertension [1,864 patients (59%)], diabetes mellitus (DM) [1,184 (37.5%)], hyperlipidemia [1,120 (35.5%)], and smoking [1,093 (34.6%)] were noted. Non-ST elevation myocardial infarction (NSTEMI) was the leading cause of admission [1,187 patients (37.6%)], followed by ST elevation myocardial infarction (STEMI) in 742 patients (23.5%). Other frequent diagnoses included decompensated heart failure (HF) [339 patients (10.7%)] and arrhythmia [272 patients (8.6%)], respectively. Atrial fibrillation (AF) was the most common pathological rhythm [442 patients (14%)], and chest pain was the most common primary complaint [2,173 patients (68.8%)]. CONCLUSION: The most common admission diagnosis was acute coronary syndrome (ACS), particularly NSTEMI. Hypertension and DM were found to be the two leading risk factors, and AF was the most commonly seen pathological rhythm in all hospitalized patients. These findings may be useful in understanding the characteristics of patients admitted to CCUs and thus in taking precautions to decrease CCU admissions.

Impact of chronic total occlusion in a non-infarct-related coronary artery on contrast-associated nephropathy in acute ST-elevation myocardial infarction.

OBJECTIVES: Co-existing chronic total occlusion (CTO) in a non-infarct-related artery (IRA) might serve as an important trigger of adverse outcomes in ST-segment elevation myocardial infarction (STEMI). Therefore, we planned to analyse the potential impact of non-IRA CTO on the evolution of contrast-associated nephropathy (CAN) in STEMI patients managed with primary percutaneous coronary intervention (P-PCI). METHODS: A total of 537 subjects with STEMI undergoing P-PCI during the first 12 h after the onset of their symptoms were enrolled in this retrospective study. The subjects were categorised based on the angiographic presence of non-IRA CTO. Moreover, the subjects were also divided into 2 groups based on their CAN status following P-PCI (CAN (+) and CAN (-)). RESULTS: Co-existing non-IRA CTO was demonstrated in 86 subjects (16%). During the hospitalisation period, we identified 81 (15.1%) subjects with CAN. Subjects with non-IRA CTO had a significantly higher incidence of CAN compared with those without (56 [12.4%] vs 25 [29.1%], respectively, p < 0.001). In a logistic regression analysis, an existing non-IRA CTO (odds ratio: 2.840, 95%CI: 1.451-5.558, p = 0.002), as well as age, haemoglobin, diabetes mellitus, creatinine, and white blood cell count, were independent of predictors of CAN. CONCLUSION: In STEMI patients managed with P-PCI, a co-existing non-IRA CTO had an independent association with the evolution of CAN.

Integrating the Left Atrium Diameter to Improve the Predictive Ability of the Age, Creatinine, and Ejection Fraction Score for Atrial Fibrillation Recurrence After Cryoballoon Ablation.

BACKGROUND: Several clinical trials have assessed predictors for atrial fibrillation recurrence following cryoballoon catheter ablation. With these predictors, a practical and new scoring system can be developed to evaluate atrial fibrillation recurrence. The present study aimed to analyze the predictive value of the age, creatinine, and ejection fraction-left atrium score for potential recurrence of atrial fibrillation following cryoballoon catheter ablation in patients with symptomatic paroxysmal or persistent atrial fibrillation. METHODS: We retrospectively analyzed records of patients undergoing cryoballoon cath-eter ablation. atrial fibrillation recurrence was defined as an emerging atrial fibrillation episode around 12-month follow-up (with the exclusion of a 3-month blanking period). Univariate and multivariate analyses were performed to assess predictors of atrial fibrillation recurrence. In addition, receiver operating characteristic analysis was harnessed to evaluate the performance of the age, creatinine, and ejection fraction, left atrium score in determining the risk of atrial fibrillation recurrence. RESULTS: The study population comprised 106 subjects (age 52 ± 13 years, 63.2% women) with paroxysmal (84.9%, n = 90) or persistent (15.1%, n = 16) atrial fibrillation. age, creatinine, and ejection fraction, left atrium score was significantly higher in subjects with atrial fibrillation recurrence in comparison to those with the maintenance of sinus rhythm. However, on multivariate logistic regression analysis, only the age, creatinine, and ejection fraction, left atrium score (OR = 12.93, 95% CI: 2.22-75.21, P =.004) served as an independent predictor of atrial fibrillation recurrence following cryoballoon catheter ablation. CONCLUSION: Age, creatinine, and ejection fraction, left atrium score had an independent association with the risk of atrial fibrillation recurrence in subjects with atrial fibrillation undergoing cryoballoon catheter ablation. Therefore, this score might potentially serve as a useful tool for risk stratification of patients with atrial fibrillation.

Too Late Allergic Reaction in a Patient with Permanent Pacemaker.

Contact allergy to cardiac implantable electronic devices is a rare problem in patients. Clinical evaluation and patch tests have an important place in its diagnosis. Also in this case, the diagnosis is supported by ultrasonography. It has been reported in the literature that allergic dermatitis developed after permanent pacemaker implantation in the first few days until the current year. In our case report, we showed that the allergic reaction in the patient was too late. In this article, we present a 94-year-old male patient with a permanent pacemaker who came to us with the complaint of redness and itching in the left chest area and was diagnosed with contact allergy.

Serum Prealbumin: a potential predictor of Right Ventricular Dysfunction in patients receiving programmed hemodialysis.

OBJECTIVE: Prealbumin has been a reliable marker to predict protein energy malnutrition and hypercatabolic state. In this analysis, we particularly aimed to investigate the potential association between serum prealbumin levels and right ventricular dysfunction in patients receiving programmed hemodialysis. METHODS: A total of 57 subjects were included in the analysis. The subjects were then categorized into two groups: right ventricular dysfunction (n=18) and non-right ventricular dysfunction (n=39) groups. In all patients, detailed transthoracic echocardiography (following hemodialysis) were performed along with the evaluation of complete blood count, routine biochemistry parameters, and, in particular, serum prealbumin levels. RESULTS: Mortality rate at 3 years was found to be significantly higher in the right ventricular dysfunction group (p=0.042). Serum prealbumin levels were also significantly lower in the right ventricular dysfunction group compared with the non-right ventricular dysfunction group (23.83±8.50 mg/dL versus 31.38±6.81 mg/dL, p=0.001). In the receiver operating characteristics curve analysis, a prealbumin cutoff value of <28.5 mg/dL was found to predict right ventricular dysfunction, with a sensitivity of 67% and a specificity of 62% (area under the curve: 0.744). In the correlation analysis, a moderate yet significant positive correlation was demonstrated between serum prealbumin and tricuspid annular plane systolic excursion (r=0.365, p=0.005). CONCLUSION: This study suggests that low serum prealbumin might serve as a potential predictor of right ventricular dysfunction (and its clinical consequences) in patients receiving programmed hemodialysis.

Risk of premature coronary atherosclerosis in patients with nonalcoholic fatty liver disease.

OBJECTIVE: In the current literature, there are few studies investigating the relationship between premature coronary atherosclerosis and nonalcoholic fatty liver disease. We aimed to evaluate the relationship between nonalcoholic fatty liver disease and premature coronary atherosclerosis. METHODS: In this cross-sectional study, female patients aged <55 years and male patients aged <50 years were enrolled. Both male and female patients underwent coronary angiography and abdomen ultrasonography between 2014 and 2019. A stepwise binary logistic regression analysis was carried out to evaluate the independent variables related to premature coronary atherosclerosis and nonalcoholic fatty liver disease. A p-value<0.05 was considered statistically significant. RESULTS: nonalcoholic fatty liver disease was present in 44% of patients (n=377). Notably, 62% of the patients were female and the mean age was 44.5 (39-49) years. In a multivariate analysis, nonalcoholic fatty liver disease was shown to be an independent risk factor of premature coronary atherosclerosis (OR 1.438; 95%CI, 1.050-1.969; p=0.024). CONCLUSIONS: The presence of nonalcoholic fatty liver disease is an important independent risk factor for the development of premature coronary atherosclerosis.

An Evaluation of Aspirin Treatment Preferences ORIGINAL INVESTIGATION of Physicians in Hypertensive Patients in Terms of Current Guidelines: A Subgroup Analysis of the ASSOS Trial in Turkey.

BACKGROUND: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial has been the largest study ever conducted among patients in Turkey regarding aspirin treatment. In the subgroup analysis of the hypertensive group of the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial, we aimed to evaluate the physicians' adherence to current guidelines regarding their aspirin treatment preferences. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial is a cross-sectional and multicenter study conducted among 5007 consecutive patients aged ≥18 years. The study population consisted of outpatients on aspirin treatment (80-300 mg). The patient data were obtained from 30 different cardiology clinics of 14 cities from all over Turkey. In this subgroup analysis, patients were divided into 2 groups: the hypertensive group (n=3467, 69.3%) and the group without hypertension (n=1540, 30.7%) according to the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the Management of Arterial Hypertension. RESULTS: Aspirin use for primary prevention was higher in patients with hypertension compared to patients without hypertension [328 (21.3%); 1046 (30.2%); P < .001]. Treatment with a dose of 150 mg aspirin (n=172, 5%) was mostly preferred by internists for hypertensive patients (n =226, 6.5%); however, a daily dose of 80-100 mg aspirin therapy (n=1457, 94.6%) was mostly prescribed by cardiologists (n=1347, 87.5%) for patients without hypertension. CONCLUSION: Aspirin was found to be used commonly among patients with hypertension for primary prevention despite the current European Society of Cardiology Arterial Hypertension Guideline not recommending aspirin for primary prevention in patients with hypertension.

Fontan Circulation Might be Associated with Peripartum Cardiomyopathy: A Review of Mechanistic and Clinical Aspects.

Fontan operation has been defined as a palliative surgery connecting systemic venous return and pulmonary circulation in patients with certain forms of complex congenital heart disease (CHD). Fortunately, it has improved overall survival and chance of successful pregnancies among these patients. However, Fontan circulation (FC), as a potential trade-off, might be associated with specific late or post-gestational complications, including peripartum cardiomyopathy (PPCM) largely through its adverse effects on the placenta and inflammation-oxidation stress. Importantly, diagnosis of superimposed PPCM in women with FC might be a diagnostic challenge, requiring a high index of suspicion. Accordingly, the present paper aims to highlight the potential association of FC with PPCM evolution largely based on certain mechanistic and clinical perspectives.

Acute effect of outflow tract premature ventricular complex ablation on QT dispersion, Tp-e interval and Tp-e/QT ratio.

BACKGROUND: There is limited data regarding the effect of idiopathic premature ventricular complexes (PVC) on myocardial repolarisation. Most of PVC's originate from right and left ventricular outflow tracts (RVOT and LVOT). AIM: The aim of this study is to evaluate the acute effect of outflow tract PVC ablation on electrocardiographic repolarisation markers. METHODS: A total of 180 patients (49.2 ± 13.6 years, 74 male) without any exclusion criteria who had undergone outflow tract PVC ablation between 1 January 2015 and 1 November 2018 constituted our study population. Electrocardiographic recordings that had been obtained before and after ablation procedure on the same day were retrospectively evaluated for the QTc dispersion, Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio. Significance of difference between pre- and postablation values was tested. RESULTS: There was no significant difference regarding QTc dispersion between pre- and post-ablation state (36.5 ± 20.9 vs. 35.3 ± 16.4 ms, p: NS). However, Tp-e and Tp-e/QT values in all lateral precordial derivations were observed to decrease significantly after PVC ablation (in the respective order on derivation V5: 104.0 ± 21.6 ms vs. 91.1 ± 14.8 ms, p<.001 and 0.26 ± 0.05 vs. 0.23 ± 0.04, p<.001). CONCLUSIONS: Based on these observations, it may be suggested that frequent outflow tract PVC's increase transmural dispersion of repolarisation and this effect is attenuated by catheter ablation in the acute phase. Results of further prospective studies are required for evaluation of the long term effects of PVC ablation on myocardial repolarisation.

Evaluation of acute alterations in electrocardiographic parameters after cryoballoon ablation of atrial fibrillation and possible association with recurrence.

OBJECTIVE: This study aimed to evaluate the acute effect of cryoballoon ablation (CB-A) on electrocardiographic parameters that have been suggested to reflect heterogeneity in atrial conduction and ventricular repolarization. METHODS: A total of 67 patients (52.6±13.2 years, 43 men) without any exclusion criteria who had undergone CB-A for atrial fibrillation (AF) between January 01, 2015, and December 31, 2018, constituted our study population. Electrographic recordings obtained before and after the ablation procedure on the same day were retrospectively evaluated for the P-wave dispersion, QTc dispersion, Tp-Te interval, and Tp-Te/QT ratio. The pre- and post-ablation values were tested for significant differences. The association of the possible CB-A-related changes in these parameters with AF recurrence during follow-up was evaluated. RESULTS: P dispersion (30.1±6.8 vs. 35.9±9.4 ms, p<0.001), QT dispersion (20.7±7.5 vs. 24.0±8.8 ms, p<0.001), Tp-Te duration (on V5 83.6±8.1 vs. 110.2±9.5 ms, p<0.001), and Tp-Te/QT ratio (on V5 0.22±0.03 vs. 0.28±0.02, p<0.001) were observed to increase significantly after CB-A. There was no association between the magnitudes of change in any parameter and AF recurrence. CONCLUSION: CB-A had significant effects on electrocardiographic parameters related to atrial conduction and ventricular repolarization in the acute phase after CB-A. Further prospective studies are required to examine the time-related course of these alterations and their impact on clinical outcomes.

Fluoroscopy time and scattered radiation during electrophysiology procedures: analysis of one-year data of a laboratory providing electrophysiology training.

OBJECTIVES: Patients and medical staff expose to significant radiation during electro-physiological (EP) procedures. There are few data regarding the leading factors of longer fluoroscopy time and higher scattered radiation in a laboratory giving EP training during those interventions. MATERIAL AND METHODS: The patients' recordings that underwent EP procedure in a single centre arrhythmia unit from February 2019 to January 2020 were examined. Prospectively collected data regarding procedure duration, fluoroscopy time and total air kerma, demographic characteristics of the patients, type of procedure, success of ablation and the use of electro anatomic mapping were retrospectively evaluated. Predictors of total air kerma were analysed with linear regression analysis. RESULTS: Study population consisted of 437 patients with a median age of 47 (39-56); 184 (42.1%) were male. Median fluoroscopy time was 768 (420-1320) seconds and median cumulative air kerma was 369 (191-750) mGy. Fluoroscopy time and cumulative air kerma were significantly lower in diagnostic EP studies compared to other procedures. There was no difference in terms of total air kerma between the procedures other than the diagnostic EP study. In multivariable linear regression analysis; body surface area, fluoroscopy time, not using the electro-anatomical mapping, unsuccessful ablation and atrial flutter ablation were predictors of total air kerma in EP studies performed by trainees. CONCLUSION: Scattered radiation during EP procedures performed by in-training operators is related with some factors. Awareness about those may help to effort reducing the harmful effect of ionising radiation.

Late Versus Early Myocardial Remodeling After Acute Myocardial Infarction: A Comparative Review on Mechanistic Insights and Clinical Implications.

In the setting of acute myocardial infarction (AMI), adverse myocardial remodeling (AMR) has been universally regarded as an early-onset phenomenon generally arising within the first few weeks (usually within days in the infarct zone) following myocardial injury. On the other hand, onset of cardiac morphological changes in this setting may potentially extend far beyond this time frame (usually beyond several months after the index AMI), suggesting a prolonged latent period in certain cases. In clinical practice, this delayed form of post-AMI remodeling, namely late AMR, has emerged as an interesting and underrecognized phenomenon with poorly understood mechanisms. Notably, systemic inflammation and associated growth factors seem to play a pivotal role in this setting. Accordingly, the present article primarily aims to discuss potential mechanisms and clinical implications of late AMR (in a comparative manner with its classical early counterpart) among AMI survivors along with a particular emphasis on potential benefits of certain anti-inflammatory strategies in this setting.