Comparison of mortality prediction scores in elderly patients with ICD for heart failure with reduced ejection fraction.

BACKGROUND: This investigation aimed to examine and compare the predictive value of MADIT-II, FADES, PACE and SHOCKED scores in predicting one-year and long-term all-cause mortality in implantable cardioverter-defibrillator (ICD) implanted patients, 75 years old and older, since there has been an area of uncertainty about the utility and usefulness of these available risk scores in such cases. METHODS: In this observational, retrospective study, 189 ICD implanted geriatric patients were divided into two groups according to the presence of long-term mortality in follow-up. The baseline characteristics and laboratory variables were compared between the groups. MADIT-II, FADES, PACE and SHOCKED scores were calculated at the time of ICD implantation. One-year and long-term predictive values of these scores were compared by a receiver-operating curve (ROC) analysis. RESULTS: A ROC analysis showed that the best cutoff value of the MADIT-II score to predict one-year mortality was ≥ 3 with 87% sensitivity and 74% specificity (AUC 0.83; 95% CI 0.73-0.94; p < 0.001) and that for long-term mortality was ≥ 2 with 83% sensitivity and 43% specificity (AUC 0.68; 95% CI 0.60-0.76; p < 0.001). The predictive value of MADIT-II was superior to FADES, PACE and SHOCKED scores in ICD implanted patients who are 75 years and older. CONCLUSION: MADIT-II score has a significant prognostic value as compared to FADES, PACE and SHOCKED scores for the prediction of one-year and long-term follow-up in geriatric patients with implanted ICDs for heart failure with reduced ejection fraction.

The value of C-reactive protein-to-albumin ratio in predicting long-term mortality among HFrEF patients with implantable cardiac defibrillators.

BACKGROUND: Patients with heart failure with reduced ejection fraction (HFrEF) who received implantable cardiac defibrillator (ICD) still remain at high risk due to pump failure and prevalent comorbid conditions. The primary aim of this research was to evaluate the predictive value of C-reactive protein-to-albumin ratio (CAR) for all-cause mortality among patients with HFrEF despite ICD implantation. MATERIALS AND METHODS: Those who were implanted ICD for HFrEF in our institution between 2009 and 2019 were included. Data were extracted from hospital's database. CAR was calculated as ratio of C-reactive protein (CRP) to serum albumin concentration. Patients were grouped into tertiles in accordance with CAR at the time of the implantation. During follow-up duration of 38 [17-77] months, survival times of tertiles were compared by using Kaplan-Meier survival method. Forward Cox proportional regression model was used for multivariable analysis. RESULTS: Thousand and eleven patients constituted the study population. Ischaemic cardiomyopathy was the primary diagnosis in 92.3%, and ICD was implanted for the primary prevention among 33.9% of patients. Of those, 14.5% died after the discharge. Patients in tertile 3 (T3) had higher risk of mortality (4.2% vs 11.0% vs 28.5%) compared with those in other tertiles. Multivariable analysis revealed that when patients in T1 were considered as the reference, both those in T2 and those in T3 had independently higher risk of all-cause mortality. This finding was consistent in the unadjusted and adjusted multivariable models. CONCLUSION: Among patients with HFrEF and ICD, elevated CAR increased the risk of all-cause mortality at long term.

Prognostic nutritional index as the predictor of long-term mortality among HFrEF patients with ICD.

BACKGROUND: The benefit of implantable cardiac defibrillator (ICD) in patients with heart failure and reduced ejection fraction (HFrEF) could be limited in a particular group of patients. Low prognostic nutritional index (PNI) indicates malnutrition and proinflammatory condition. We sought to investigate the value of PNI in predicting long-term mortality among HFrEF patients with ICD. METHODS: Electronic database was searched for identifying patients with HFrEF who were implanted ICD in our institution between 2009 and 2019. Demographic and clinical characteristics of included patients were recorded. PNI was calculated according to the formula: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3 ). Patients were divided into the quartiles according to PNI values. Differences between the groups were analyzed by the log-rank test. A forward Cox proportional regression model was used for multivariable analysis. RESULTS: One thousand and hundred patients were included to the study. The underlying heart failure etiology was ischemic and nonischemic in 77.3% and 22.7% of patients, respectively. Mortality rate in Q1 (5.1%) was considered as the reference. In the unadjusted model the mortality rate was 9.5% (hazard ratio [HR] 1.76, 95% confidence interval [95% CI] [0.92-3.38]) in Q2, 10.2% (HR 1.88, 95% CI 0.99-3.58) in Q3, and 39.6% (HR 8.12, 95% CI 4.65-14.17) in Q4. The same trend was consistent in the age- and sex-adjusted, comorbidities-adjusted, and covariates-adjusted models. CONCLUSION: Among patients who were implanted with ICD secondary to HFrEF, lower PNI value predicted all-cause mortality during long-term follow-up. This is the first study demonstrating the value of PNI in this population.

ST Depression, No ST Change, or ST Elevation in Inferior Derivations: Which Has the Worst Outcomes in Acute Anterior Myocardial Infarction?

OBJECTIVE: The combination of electrical phenomena and remote myocardial ischemia is the pathophysiological mechanism of ST segment changes in inferior leads in acute anterior myocardial infarction (MI). We investigated the prognostic value of ST segment changes in inferior derivations in patients with first acute anterior MI treated with primary percutaneous coronary intervention (PCI). METHODS: In this prospective single-center analysis, we evaluated the prognostic impact of ST segment changes in inferior derivations on 354 patients with acute anterior MI. Patients were divided into the following 3 groups according to admission ST segment changes in inferior derivations: ST depression (group 1), no ST change (group 2), and ST elevation (group 3). RESULTS: In-hospital multivariate analysis revealed notably high rates of in-hospital death for patients in group 3 compared to patients in group 2 (OR 2.5; 95% CI 1.6-7.6, p < 0.001). Group 1 and group 2 had similar in-hospital and long-term mortality rates. After adjusting for confounding baseline variables, group 3 had higher rates of 18-month mortality (HR 3.3; 95% CI 1.5-8.2, p < 0.001). CONCLUSION: In patients with a first acute anterior MI treated with primary PCI, ST elevation in inferior leads had significantly worse short-term and long-term outcomes compared to no ST change or ST segment depression.

The prognostic significance of early and late right precordial lead (V4 R) ST-segment elevation in patients with acute anterior myocardial infarction.

BACKGROUND: The predictive significance of ST-segment elevation (STE) in lead V4 R in patients with anterior ST-segment elevation myocardial infarction (STEMI) has not been well-understood. In this study, we evaluated the prognostic value of early and late STE in lead V4 R in patients with anterior STEMI. METHODS: A total 451 patients with anterior STEMI who treated with primary percutaneous coronary intervention (PPCI) were prospectively enrolled in this study. All patients were classified according to presence of STE (>1 mm) in lead V4 R at admission and/or 60 min after PPCI. Based on this classification, all patients were divided into three subgroups as no V4 R STE (Group 1), early but not late V4 R STE (Group 2) and late V4 R STE (Group 3). RESULTS: In-hospital mortality had higher rates at group 2 and 3 and that had 2.1 and 4.1-times higher mortality than group 1. Late V4 R STE remained as an independent risk factor for cardiogenic shock (odds ratio [OR] 2.6; 95% confidence interval [CI] 1.9-4.3; p < .001) and in-hospital mortality (OR 2.3; 95% CI 1.8-4.1; p < .001). The 12-month overall survival for group 1, 2, and 3 were 91.1%, 82.4%, and 71.4% respectively. However, the long-term mortality also had the higher rate at group 3; late V4 R STE did not remain as an independent risk factor for long-term mortality (OR 1.5; 95% CI 0.8-4.1; p: .159). CONCLUSION: Late V4 R STE in patients with anterior STEMI is strongly associated with poor prognosis. The record of late V4 R in patients with anterior STEMI has an important prognostic value.

Which admission electrocardiographic parameter is more powerful predictor of no-reflow in patients with acute anterior myocardial infarction who underwent primary percutaneous intervention?

BACKGROUND: Acute transmural ischemia due to left anterior descending artery (LAD) occlusion changes precordial R and Q wave durations owing to depressed intramyocardial activation. We investigated the prognostic value of sum of precordial Q wave duration/sum of precordial R wave duration ratio (Q/R) in patients with first acute anterior myocardial infarction (AAMI) treated with primary percutaneous coronary intervention (PPCI). METHODS: In this prospective analysis, we evaluated the no-reflow predictive value of Q/R on 403 patients with first AAMI. Patients were divided into two as no-reflow group (n=32) and control (n=371) group according to post-PPCI flow status. RESULTS: The patients in the no-reflow group had significantly higher Q/R on admission electrocardiography (ECG) compared to patients in the control group (p<0.001). When admission ECG parameters were compared according to no-reflow prediction, Q/R was stronger than other well-accepted parameters. The best cut-off value of the Q/R to predict no-reflow was 1.08 with 76% sensitivity and 73% specificity (AUC: 0.78; 95% CI: 0.72-0.83; p<0.001). CONCLUSION: In patients with first AAMI treated with PPCI, Q/R in admission ECG may have a role as an independent predictive marker of no-reflow.

A simple independent prognostic electrocardiography parameter in first acute anterior myocardial infarction; Precordial total Q wave/precordial total R wave.

BACKGROUND: We investigated the prognostic value of precordial total Q wave amplitude/precordial total R wave amplitude ratio (Q/R) in patients with first acute anterior MI treated with primary percutaneous coronary intervention (PPCI). METHODS: We evaluated the in-hospital prognostic impact of Q/R on 354 patients with first acute anterior MI. Patients were stratified by tertiles of admission Q/R, clinical outcomes were compared between those groups. RESULTS: In-hospital univariate analysis revealed notably higher rates of in-hospital death for patients in tertile 3, as compared to patients in tertile 1 (OR 9.7, 95% CI 2.8-33.5, p. CONCLUSION: Q/R in admission ECG in patients with first acute anterior MI provide an independent prognostic marker of in-hospital outcomes.

What is the predictive value of ST segment depression in inferior leads in first acute anterior myocardial infarction?

BACKGROUND: Electrical phenomenon and remote myocardial ischemia are the main factors of ST segment depression in inferior leads in acute anterior myocardial infarction (AAMI). We investigated the prognostic value of the sum of ST segment depression amplitudes in inferior leads in patients with first AAMI treated with primary percutaneous coronary intervention. (PPCI). METHODS: In this prospective analysis, we evaluated the in-hospital prognostic impact of the sum of ST segment depression in inferior leads on 206 patients with first AAMI. Patients were stratified by tertiles of the sum of admission ST segment depression in inferior leads. Clinical outcomes were compared between those tertiles. RESULTS: Univariate analysis revealed higher rate of in-hospital death for patients with ST segment depression in inferior leads in tertile 3, as compared to patients in tertile 1 (OR 9.8, 95% CI 1.5-78.2, p<0.001). After adjustment for baseline variables, ST segment depression in inferior leads in tertile 3 was associated with 5.7-fold hazard of in-hospital death (OR: 5.7, 95% CI 1.2-35.1, p<0.001). Spearman rank correlation test revealed correlation between the sum of ST segment depression amplitude in inferior leads and the sum of ST segment elevation amplitude in V1-6, L1 and aVL. Multivessel disease and additional RCA stenosis were also detected more often in tertile 3. CONCLUSION: The sum of ST segment depression amplitude in inferior leads of admission ECG in patients with first AAMI treated with PPCI provide an independent prognostic marker of in-hospital outcomes. Our data suggest the sum of ST segment depression amplitude to be a simple, feasible and clinically applicable tool for rapid risk stratification in patients with first AAMI.

Single right coronary artery with absence of the left main coronary artery, left anterior descending artery, and circumflex artery.

Single coronary artery is an extremely rare congenital coronary anomaly in which the entire coronary arterial system arises from a solitary ostium. The Lipton's classification is used for single coronary artery anomalies. Herein, we present a 72-year-old woman with single coronary artery anomaly admitted with atypical chest pain. Coronary angiography and multidetector computed tomography coronary angiography findings were shared.

Catheter ablation of ventricular arrhythmia originating in the tricuspid annulus in a patient with biventricular noncompaction: a case report.

It is rare for ventricular tachycardia arising from the right ventricle to originate in the tricuspid annulus, and the clinical presentation and cardiac abnormalities associated with this type of arrhythmia have not been clearly established. This report describes a case of biventricular noncompaction presenting with ventricular arrhythmia originating in the tricuspid annulus and successfully treated with radiofrequency ablation.

The relationship between fragmentation on electrocardiography and in-hospital prognosis of patients with acute myocardial infarction.

BACKGROUND: In patients with acute ST elevation myocardial infarction (STEMI), QRS fragmentation was determined as one of the indicators of mortality and morbidity. The development of fragmented QRS (fQRS) is related to defects in the ventricular conduction system and is linked to myocardial scar and fibrosis. MATERIAL AND METHODS: We prospectively enrolled 355 consecutive patients hospitalized in the coronary intensive care unit of our hospital with STEMI between the years 2010 and 2012 and their electrocardiographic features and the frequency of in-hospital cardiac events were evaluated. RESULTS: There were 217 cases in the fQRS group and 118 cases in the control group. QRS fragmentation was found to be a predictor for major cardiac events. In the fragmented QRS group, the frequency of in-hospital major cardiac events (MACE) and death were higher (MACE p<0.001; death p<0.003). In the fragmented QRS group, the cardiac enzymes (Troponin-I, CK-MB) were significantly higher than in the control group (p<0.001). In subgroup analyses, apart from the presence of fragmentation, the presence of more than 1 type of fragmentation and the number of fragmented deviations were also found to be related with MACE. A significant negative correlation was observed with the ejection fraction and, in particular, the number of fragmented deviations. CONCLUSIONS: Fragmented QRS has emerged as a practical and easily identifiable diagnostic tool for predicting in-hospital cardiac events in acute coronary syndromes. Patients who present with a fragmented QRS demonstrate increased rates of major cardiac events, death risk, and low ejection fraction. In patients with STEMI, the presence of fQRS on the ECG and number of fQRS derivations are a significant predictor of in-hospital major cardiac events.

Acute aortic regurgitation with myocardial infarction: an important clue for aortic dissection.

BACKGROUND: Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis. OBJECTIVES: To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection. CASE REPORT: An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation. CONCLUSION: Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.

Management of patients with drug-induced atrioventricular block.

OBJECTIVE: To identify the frequency of atrioventricular (AV) conduction improvement after discontinuation of the culprit drug in patients with AV block. BACKGROUND: AV blockers are considered as reversible causes of AV block that do not require pacemaker (PM) implantation. However, controversial reports declared that a major part of these drug-induced AV blocks are persistent or recurrent. METHODS: Of 668 consecutive patients with symptomatic type II second- or third-degree AV block, 2:1 AV block, atrial fibrillation, and bradyarrhythmia, 108 patients (62 patients enrolled prospectively) using AV blockers without myocardial infarction, electrolyte abnormalities, digitalis toxicity, and vasovagal syncope were enrolled into the present study. The level of AV block (AV-nodal or infranodal) was defined according to electrocardiographic characteristics. RESULTS: The most frequent culprit medications were ß-blockers followed by digoxin. Drug discontinuation was followed by resolution of AV block in 72% of cases, whereas spontaneous resolution of AV block occurred in only 6.6% of patients who had AV block in the absence of medications. However, 27% of patients with improved AV conduction experienced a recurrence of AV block despite discontinuation of the culprit drug. Twenty-one of 24 carvedilol-induced AV blocks resolved after discontinuation of the drug and never recurred, whereas 24 of 36 metoprolol-induced AV blocks persisted or recurred. A digoxin-induced AV block usually improved (28 of 39) after withdrawal of the drug. Roughly half of the patients with drug-induced AV block underwent permanent PM implantation. CONCLUSION: Drug-induced AV block is a serious disease that requires a permanent PM for almost half of the patients.

Predictors for early mortality in patients with implantable cardiac defibrillator for heart failure with reduced ejection fraction.

Implantable cardioverter defibrillators (ICD) are recommended in heart failure with reduced ejection fraction (HFrEF) patients to reduce arrhythmic deaths. This study aimed to identify risk factors associated with mortality within one-year following the ICD. The data from our hospital's electronic database system was extracted for patients who were implanted ICD secondary to HFrEF between 2009 and 2019. Overall, 1107 patients were included in the present analysis. Mortality rate at one-year following the device implantation was 4.7%. In multivariate analysis; age, atrial fibrillation, New York Heart Association classification >2, blood urea nitrogen, pro-brain natriuretic peptide and albumin independently predicted one year mortality.

[Primary angioplasty in women with ST-elevation myocardial infarction: in-hospital and long-term clinical results]. / ST yükselmeli miyokart enfarktüslü kadinlarda primer anjiyoplasti: Hastaneiçi ve uzun dönem klinik sonuçlar.

OBJECTIVES: We evaluated in-hospital and long-term clinical results of female patients following primary angioplasty for ST-elevation myocardial infarction (STEMI), in comparison with male patients. STUDY DESIGN: We reviewed 2,644 patients (2,188 males, 456 females) who underwent primary angioplasty for STEMI between October 2003 and March 2008. Data on female patients concerning demographic and clinical characteristics, primary angioplasty results, in-hospital and 25-month follow-up results were compared with those of male patients. RESULTS: Hypertension, diabetes mellitus, anemia, shock, and renal failure were more common in female patients, while smoking was more frequent in males (p<0.05). The mean age was higher in female patients (63.9±11.7 vs. 55.2±11.3 years, p<0.001). Females also presented with higher values of glucose, mean platelet volume, and platelet count, and lower hemoglobin and hematocrit values (p<0.05). The frequencies of multivessel disease and procedure failure were significantly higher, and pain-to-balloon time was significantly longer in females (p<0.05). Mortality associated with cardiovascular causes occurred in 148 patients (5.6%), being significantly higher in females (9.4% vs. 4.8%, p<0.001). In-hospital mortality, major cardiac events, stroke, cardiogenic shock, and major bleeding were more frequent in women (p<0.05). Long-term mortality rate was also significantly higher in females (10% vs. 4.5%, p<0.001). Multivariate analysis showed female gender as one of the independent predictors of mortality (odds ratio=1.75, 95% CI 1.02-2.99; p<0.04). CONCLUSION: Female patients with STEMI undergoing primary angioplasty have a higher risk profile and poorer in-hospital and follow-up clinical results. Therefore, female patients should be treated more aggressively.