Transient Complete Atrioventricular Block Associated With Herbal Supplement Use.

INTRODUCTION: Increasing and easy availability of so-called natural/herbal supplements pose the unique challenge of identifying associated side effects, including arrhythmias in otherwise-healthy individuals. CASE PRESENTATION: A 25-year-old female patient presented to the emergency department with fatigue and lightheadedness. The electrocardiogram showed complete AV block with a junctional escape rhythm at 55 beats per minute with QT prolongation (542ms). One week ago, she started to use a herbal medication (Muscle Eze Advanced) for muscle cramps after workouts. Extensive cardiac testing, including complete blood count, complete metabolic panel, TSH, transthoracic echocardiography, urine drug analysis, Lyme antibody were negative. Normal sinus rhythm was restored spontaneously within 1 day of discontinuing the herbal medication. PR and corrected QT intervals returned to baseline over the next two weeks. CONCLUSION: Muscle Eze Advanced consists of seven ingredients, including Melissa officinalis and Valeriana officinalis that have negative chronotropic, negative dromotrophic and QT prolonging effects. Recognizing the association between certain over-the-counter supplements and brady-arrhythmias may circumvent need for permanent pacemakers - an important consideration especially in the young.

Evaluation of Aortic Elasticity Parameters in Survivors of COVID-19 Using Echocardiography Imaging.

OBJECTIVE: While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects lung tissue, it may cause direct or indirect damage to the cardiovascular system, and permanent damage may occur. Arterial stiffness is an early indicator of cardiovascular disease risk. The aim of our study was to establish the potential effects of SARS-CoV-2 on the vascular system evaluated by transthoracic echocardiographic examination. SUBJECTS AND METHODS: This study compared arterial stiffness between the survivors of COVID-19 and those without a history of COVID-19 infection. The difference in aortic diameter was examined using echocardiography. RESULTS: The study included 50 patients who survived COVID-19 in the last 3-6 months and 50 age- and gender-matched healthy volunteers. In surviving COVID-19 patients, aortic diastolic diameter in cm ([3.1 ± 0.2] vs. [2.9 ± 0.1], p < 0.001), pulse pressure (PP) ([43.02 ± 14.05] vs. [35.74 ± 9.86], p = 0.004), aortic distensibility ([5.61 ± 3.57] vs. [8.31 ± 3.82], p < 0.001), aortic strain ([10.56 ± 4.91] vs. [13.88 ± 5.86], p = 0.003), PP/stroke volume index ([1.25 ± 0.47] vs. [0.98 ± 0.28], p = 0.001), and aortic stiffness index ([2.82 ± 0.47] vs. [2.46 ± 0.45], p < 0.001) were statistically significant compared to the control group. CONCLUSION: SARS-CoV-2 may cause reduced or impaired aortic elasticity parameters linked to impaired arterial wall function in COVID-19 survivors compared with controls.

ST Elevation MI with Normal Coronary Arteries: A MINOCA Case.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a syndrome characterized by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography. CASE REPORT: A 35-year-old female patient presented with typical chest pain. EKG revealed sinus rhythm, 1 mm ST elevation in DI-aVL, prominent R waves in V1-V3 and ST-segment depression in DIII-aVF. She underwent emergent coronary angiography which revealed normal coronary arteries. Troponin levels peaked at 123 ng/mL. 2D Transthoracic echocardiogram showed an EF of 50 percent with lateral wall hypokinesis. A cardiac magnetic resonance imaging (CMR) showed myocardial scar tissue. Epicardial late gadolinium enhancement (LGE) was noted in the lateral left ventricular wall consistent with transmural myocardial infarction. DISCUSSION: MINOCA is not an uncommon presentation of acute MI (AMI). It is more frequent in younger women and nonwhites, is associated with fewer traditional risk factors, and usually presents with non-ST-segment elevation- myocardial infarction. Patients with MINOCA should undergo further testing to reveal the underlying etiology as treatment will vary depending on the cause. MINOCA is not a benign syndrome, with outcomes comparable to their AMI-CAD counterparts especially in younger patients.

The Effects of Female Sex Hormones on Ventricular Premature Beats and Repolarization Parameters in Physiological Menstrual Cycle.

BACKGROUND: The effects of gender difference on cardiac electrophysiology have been well studied. In this study, we aimed to evaluate the effects of estradiol and progesteron changes occuring in physiological menstrual cycle on ventricular premature beats (VPBs) and cardiac repolarization parameters. METHODS: Women of reproductive age with VPBs were included into the study group and healthy women were recruited as the control group. During the menstruation period, a 12-lead electrocardiography, blood samples, and 24-hour rhythm Holter were applied to the study group. Similarly, all tests were repeated in the estimated ovulation period (12-14 days before menstruation) by all cases. RESULTS: The study group consisted of 20 women patients with VPB, and the control group of 18 healthy women. While the number of VPB in the menstruation period was 210 beats/day (interquartile range [IQR]: 1,144), it decreased to 86 beats/day (IQR: 251) in the ovulation period with statistical significance (P < 0.05). Average heart rate in the menstruation period was 81.4 ± 10 beats/min and it significantly increased to 84.6 ± 8 beats/min in the ovulation period (P < 0.05). There were no differences in cardiac repolarization parameters in both menstruation and ovulation periods between the study and control groups. Comparing the menstruation and the ovulation periods, J-Tpeak interval, which reflects early repolarization, was shorter in the ovulation period (193 ± 27.7 ms and 201.1 ± 28.6 ms, respectively; P < 0.05). Other repolarization parameters did not show any significant difference. CONCLUSION: VPB frequency decreases with estradiol peak in the ovulation period. This suggests that estrogen may have protective effects against ventricular arrhythmias.

Serum endocan levels as a marker of disease activity in patients with Behçet disease.

BACKGROUND: Endocan is a novel human endothelial cell-specific molecule. The central role of leukocytes and endothelial dysfunction in the development of Behçet disease (BD) led us to hypothesize that endocan might be a marker of this disease. OBJECTIVE: We investigated the relationship between serum levels of endocan and disease activity in patients with BD. METHODS: In all, 33 patients (16 active, 17 inactive) with BD and 35 healthy persons were included in the study. Endocan and C-reactive protein were measured in all subjects. RESULTS: Patients with BD had significantly higher serum endocan levels. Mean serum levels of endocan were 1.29 ± 0.60 ng/mL (range: 0.58-2.99) in patients with BD and 0.75 ± 0.16 ng/mL (range: 0.48-1.21) in control subjects (P < .001). In patients with BD, serum endocan levels correlated moderately but significantly with C-reactive protein, erythrocyte sedimentation rate, and disease activity. Receiver operating characteristic curve analysis suggested that the optimum endocan level cut-off point for patients with BD was 0.87 ng/mL, with a sensitivity and specificity of 75.8% and 80%, respectively (area under curve 0.835, 95% confidence interval 0.738-0.932). LIMITATIONS: The main limitation of our study is the relatively small sample size. CONCLUSIONS: Circulating endocan may be a marker of BD activity.

Arrhythmia risk assessment using heart rate variability parameters in patients with frequent ventricular ectopic beats without structural heart disease.

BACKGROUND: Ventricular ectopic beats (VEBs) are usually considered a benign condition that can be managed with conservative measures. Heart rate variability (HRV), which is one of the most important methods for assessing autonomic activity, is a noninvasive, quantitative method of analyzing autonomic effects on the heart. We aimed to investigate the risk of arrhythmia in patients with VEBs and without cardiovascular disease by using HRV parameters. METHODS: Patients with frequent VEBs (more than 30 times in 1 hour, according to the Lown classification) were identified. Identified patients were evaluated by 24-hour ECG recording. Our study included 43 patients with frequent VEBs and 43 controls. RESULTS: General characteristics of the study population were similar. The LF (low frequency)/HF (high frequency) ratio was significantly higher in the frequent VEBs group than in the control group (P < 0.001). The rate of paroxysmal atrial fibrillation (PAF) was higher in the frequent VEB group than in the control group (P = 0.003). The number of VEBs was correlated with LF/HF ratio and PAF (r = 0.339, P = 0.001 and r = 0.294, P = 0.006, respectively). CONCLUSIONS: Our study showed that the sympathetic nervous system is dominant in young patients with VEBs and without significant comorbidities. There is a higher risk of atrial fibrillation in patients with VEBs and they should be monitored closely for atrial fibrillation.

Can Glypican-6 Levels Be Used to Determine Right Ventricular Remodeling After Non-ST Segment Elevation Myocardial Infarction?

OBJECTIVE: Myocardial infarction is associated with right ventricular (RV) remodeling. Glypican-6 (GPC6), a member of the membrane proteoglycan family, plays a significant role in cardiac remodeling. This study aims to determine if GPC6 can predict RV remodeling after percutaneous coronary intervention (PCI) in patients with non-ST segment elevation myocardial infarction (NSTEMI). METHODS: The study enrolled 164 consecutive patients with NSTEMI and controls. It compared baseline plasma GPC6 levels, echocardiography, and laboratory parameters between the RV remodeling and non-RV remodeling groups with NSTEMI. Echocardiographic data were measured at baseline and at six months. RESULTS: GPC6 levels were higher in the NSTEMI group 11.06 ng/mL (4.61-18.17) vs. 5.98 ng/mL (3.81-9.83) compared to the control group in the initial phase. RV remodeling, defined as a ≥ 20% increase in RV end-diastolic area (RV EDA), was observed in 23 patients (30%). After six months, RV EDA increased significantly from baseline 18.68 ± 1.20 cm2 vs. 24.91 ± 1.08 cm2, P < 0.001. GPC6 was a significant independent predictor of RV remodeling (hazard ratio [HR]: 1.546, 95% confidence interval [CI]: 1.056-2.245, P < 0.001). Receiver operating characteristic curve (ROC) analyses showed that GPC6 values > 15.5 ng/mL (area under the curve [AUC] = 0.828, sensitivity: 70%, specificity: 74%, P < 0.001) were strong predictors of RV remodeling. CONCLUSION: NSTEMI patients should be closely monitored for RV remodeling. GPC6 appears useful in detecting RV remodeling following NSTEMI in patients undergoing PCI.

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.

Relationship of Frontal QRS-T Angle with Coronary Flow Grade and Adverse Events Before Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Myocardial Infarction.

OBJECTIVE: Electrocardiography is used in the initial risk assessment of patients with non-ST-elevation myocardial infarction. The frontal QRS-T angle is an electrocardiography parameter that may be affected by the alterations in the coronary blood flow. This study aimed to explore the relationship of the frontal QRS-T angle with coronary flow grade and adverse events in non-ST-elevation myocardial infarction patients. METHODS: A total of 191 non-ST-elevation myocardial infarction patients were divided into 2 groups based on the thrombolysis in myocardial infarction (TIMI) flow level on coronary angiography before revascularization, namely TIMI 0/1 and TIMI 2/3. The frontal QRS-T angle obtained before revascularization was compared between the groups and its relationship with adverse events was examined. In-hospital all-cause mortality, repeat target lesion revascular-ization, new-onset heart failure, ventricular arrhythmias, and atrial fibrillation were defined as adverse events. RESULTS: Frontal QRS-T angle was wider in the patients with TIMI 0/1 flow compared to the patients with TIMI 2/3 flow (P  <  0.001). The frontal QRS-T angle was determined to be a predictor of TIMI flow grade 0/1 before revascularization in patients with non-ST-elevation myocardial infarction (odds ratio: 1.51; 95% CI: 1.30-1.75; P < 0.001). The frontal QRS-T angle was a predictor of the adverse events during hospitalization in the patients with non-ST-elevation myocardial infarction (odds ratio: 1.11; 95% CI: 1.04-1.19; P = 0.002). The cut-off values of the frontal QRS-T angle for TIMI flow grade and adverse events were determined to be 73.5°, based on receiver operating characteristic curve analysis. CONCLUSION: Increased frontal QRS-T angle may be a useful electrocardiography parameter for determining TIMI flow grade and the need for an early invasive strategy in patients with non-ST-elevation myocardial infarction.

Lipoprotein(a): A New Intensive Care Unit Admission Predictor in Coronavirus Disease 2019 Patients.

OBJECTIVE: Endothelium-related events in patients with coronavirus disease 2019 are linked to a poor prognosis. Lipoprotein(a) plays a role in vascular endothelial cell dysfunction. This research aims to investigate whether baseline serum lipoprotein(a) levels could be a predictor for intensive care unit admission and related clinical parameters in coronavirus disease 2019 patients. MATERIAL AND METHODS: The research covers 126 patients who were hospitalized in intensive care unit or the non-intensive care unit in our hospital. This prospective cohort study was conducted from January 2021 to June 2021. The patients who were positive for severe acute respiratory syndrome coronavirus 2 according to real-time polymerase chain reaction test results were included in the study. Two groups were created according to the status of intensive care unit admission. Lipoprotein(a) was studied from blood samples taken at the time of hospital admission. RESULTS: According to the results of the first clinical evaluation, 46 patients were admitted to the intensive care unit and 80 patients were admitted to non-intensive care unit in the hospital. Patients with intensive care unit admission had significantly higher serum lipoprotein(a) levels than patients without intensive care unit admission (40.9 ng/mL and 17.4 ng/mL, P < .001, respectively). The regres- sion analysis revealed that serum lipoprotein(a) levels were independently related to intensive care unit admission (odds ratio 1.242, 95% CI 1.109-1.391, P < .001). In receiver operating characteristic curve analysis, lipoprotein(a) level ≥31.42 ng/mL had 82.6% sensitivity and 72.5% specificity in predicting intensive care unit admission. The risk of intensive care unit admission was seen to be 12.522-fold higher in cases with lipoprotein(a) level ≥31.42. CONCLUSION: Lipoprotein(a) could be used as a useful biomarker for the triage of coronavirus disease 2019 patients. Baseline serum lipoprotein(a) levels may serve as a useful prognostic biomarker in patients hospitalized for coronavirus disease 2019.

Patients with Achilles Tendon Rupture Are Prone to Develop Ventricular Arrhythmia.

BACKGROUND AND OBJECTIVES: This study aimed to examine the ventricular repolarization (VR) disturbances of patients operated on for acute spontaneous Achilles tendon ruptures (ATRs), by comparing them with a healthy individual control group. MATERIALS AND METHODS: Between June 2014 and July 2020, a total of 29 patients (28 males, 1 female; mean age: 40 ± 9.78 years; range, 21-66 years) who presented to the emergency department within the first three weeks of injury, and were diagnosed with acute spontaneous ATRs and treated with an open Krackow suture technique, were retrospectively analyzed. Fifty-two healthy individuals (47 males, 5 females; mean age: 39 ± 11.45 years; range, 21-66 years) were recruited as a control group from the cardiology outpatient clinic. Clinical data (demographic features and laboratory parameters (serum glucose, creatinine, hemoglobin, white blood cell count, and lipid profile)) and electrocardiograms (ECGs) were collected from medical records. ECGs were evaluated for heart rate and VR parameters of QRS width, QTc interval, cQTd interval, Tp-e interval, and Tp-e/QT ratio. The clinical data and these ECG parameters were compared between groups. RESULTS: There was no statistically significant difference between groups, regarding clinical data (all p < 0.05). Among ECG parameters, heart rate, QRS width, QTc interval, and cQTd interval were similar between groups (all p < 0.05). There were two important statistically significant findings of this research: The mean Tp-e interval was longer (ATR group: 72.4 ± 24.7, control group: 58.8 ± 14.5, p: 0.01), and the Tp-e/QT ratio was higher (ATR group: 0.2 ± 0.1, control group: 0.16 ± 0.4, p: 0.027) in the ATR group. CONCLUSIONS: According to the ventricular repolarization disturbances found in this study, patients with ATR may be at a higher risk of ventricular arrhythmia than healthy people. As a result, ATR patients should be assessed for ventricular arrhythmia risk by an expert cardiologist.

Three-dimensional echocardiographic imaging of biventricular false tendons mimicking hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is characterized by hypertrophy of the left ventricle, with variable clinical manifestations and morphologic and hemodynamic abnormalities. False tendons (FTs) are discrete, fibromuscular structures of varying length and thickness that tranverse either left and right ventricular cavities. Left and right ventricular FTs were giving a false impression of HCM. Misdiagnosis of HCM can lead to undue anxiety, unnecessary medication, and further evaluation. Three-dimensional (3D) transthoracic echocardiography is additive to conventional two-dimensional imaging in these patients in terms of 3D perspective and anatomically correct examination. We present a 32-year-old male who was misdiagnosed as asymetrical septal hypertrophy.

The impact of mitral stenosis on left atrial function assessed by two-dimensional speckle tracking echocardiography.

AIMS: The aim of this study is to investigate the effect of mitral stenosis (MS) on left atrial (LA) function using two-dimensional speckle tracking echocardiography (2DSTE). METHODS AND RESULTS: The study subjects consisted of 52 patients with asymptomatic MS and 52 control subjects. LA function was assessed using prototype speckle tracking software and manual tracking method. Maximal LA volume (LAVmax) and minimal LA volume (LAVmin) and LA volume before atrial contraction (LAVpre-a) were measured. Using these volumes, LA reservoir, conduit and booster pump fuction parameters were calculated. Indexed LAVmax, LAVmin, and LAVpre-a measurements via speckle tracking were highly correlated with manual tracing methods in both groups. Expansion index (67.8 ± 36.4 vs. 148.3 ± 44.2), diastolic emptying index (37.7 ± 12.9 vs. 58.0 ± 8.5), passive emptying (37.3 ± 14.1 vs. 70.4 ± 10.4) and passive emptying index (13.3 ± 6.3 vs. 41.3 ± 10.6) were decreased significantly in MS patients (P < 0.001). In contrast active emptying index (62.6 ± 4.1 vs. 29.5 ± 10.1) increased in MS group (P < 0.001) while active emptying (28.1 ± 13.0 vs. 28.3 ± 6.9) remained same among both groups. CONCLUSIONS: This is the first study relating LA volumes and function assessed by 2DSTE to MS. 2D speckle tracking analysis of LA volume is relatively easy and provides more detailed information regarding the changes in LA volumes during the cardiac cycle.

Effect of Treatment Regimen on Long-Term Mortality of Geriatric Patients Diagnosed With Stable Coronary Artery Disease.

Background Increased life expectancy across the world has resulted in an increase in the proportion of the elderly population who are lost to heart diseases. Advanced age and comorbidities are believed to change the response to treatments. In this study, we aimed to investigate the effects of surgical and medical treatments on the mortality of stable coronary diseases. Methods A total of 150 geriatric patients who underwent coronary angiography (CAG) were followed up in our cardiology clinic. Patients who decided to undergo coronary artery bypass graft (CABG) surgery after CAG and were willing to undergo the operation were assigned to group 1, whereas those who were unwilling to undergo the operation were not eligible for percutaneous coronary intervention and were followed up medically, and were assigned to group 2. Keeping the primary goal as mortality rates, both the groups were compared using medical records for three years after the treatment. Results After three years, the overall mortality rate included six patients (16%) in the CABG group versus 63 patients (55%) in the medical therapy group (p < 0.001). The CABG therapy was found to be significantly and independently associated with first- and third-year mortality (risk ratio: 0.064, 95% confidence interval: 0.009-0.467, p = 0.007; risk ratio: 0.305, 95% confidence interval: 0.151-0.615, p < 0.001, respectively). Kaplan-Meier analysis for first- and third-year all-cause mortality rates led to significant results and curves between the groups. Conclusion Our study revealed that compared to CABG surgery in the treatment of coronary artery disease in geriatric patients, medical treatment is associated with poor outcomes in terms of mortality in long-term follow-up.