The outcome of peripartum cardiomyopathy patients-single center experience.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) diagnosis made by excluding identifiable causes of heart failure (HF) and occurs end of the pregnancy or during the postpartum period of five months. It presents a clinical HF spectrum with left ventricular systolic dysfunction. BACKGROUND: The purpose of this study is to retrospectively evaluate the clinical characteristics, cardiac magnetic resonance (CMR) imaging features, and end-points consisting of left ventricle recovery, left ventricular assist device implantation, heart transplantation, and all-cause mortality. METHOD: Outpatient HF records between 2008 to 2021 were screened. Thirty-seven patients were defined as PPCM. Twenty-five patients had CMR evaluation at the time of diagnosis, and six patients were re-evaluated with CMR. RESULTS: The mean age was 30.5 ± 5.6 years, and the mean LVEF was 28.2% ± 6.7%. In 13(35.7%) patients, LVEF recovered during the follow-up course. The median recovery time was 281(IQR [78-358]) days. LVEF on CMR was 35.3 ± 10.5, and three patients exhibited late gadolinium enhancement(LGE) patterns. Sub-endocardial and mid-wall uptake pattern types were detected. 18(75%) patients met the Petersen left ventricle non-compaction cardiomyopathy(LVNC) criteria. Patients with NC/C ratio lower than 2.3 had lower LVEDVi and LVESVi (124.9 ± 35.4, 86.4 ± 7.5, p = .003; 86.8 ± 34.6, 52.6 ± 7.6, p = .006), respectively. The median follow-up time was 2129 (IQR [911-2634]) days. The primary endpoint-free 1-year survival was 88.9% (event rate 11.1%), and 5-year survival was 75.7% (event rate 24.3%). CONCLUSION: In a retrospective cohort of PPCM patients, 35.7% of patients' LVEF recovered, and the primary end-point of free-5-year survival was 75%. Twenty-five patients were assessed with CMR; three of four met the Petersen CMR-derived LVNC at initial evaluation.

Endocarditis-TR: Diagnosis, treatment, and prognosis of the infective endocarditis patients admitting tertiary centres of Turkey.

BACKGROUND: Infective endocarditis (IE) is still a significant cause of morbidity and mortality among cardiovascular diseases. ENDOCARDITIS-TR study aims to evaluate the compliance of the diagnostic and therapeutic methods being used in Turkey with current guidelines. METHODS: The ENDOCARDITIS-TR trial is a multicentre, prospective, observational study consisting of patients admitted to tertiary centres with a definite diagnose of IE. In addition to the demographic, clinical, microbiological, and echocardiographic findings of the patients, adverse events, indications for surgery, and in-hospital mortality were recorded during a 2-year time interval. RESULTS: A total of 208 IE patients from 7 tertiary centres in Turkey were enrolled in the study. The study population included 125 (60.1%) native valve IE (NVE), 65 (31.3%) prosthetic IE (PVIE), and 18 (8.7%) intracardiac device-related IE (CDRIE). One hundred thirty-five patients (64.9%) were culture positive, and the most frequent pathogenic agent was methicillin-susceptible Staphylococcus aureus (MSSA) (18.3%). Among 155 (74.5%) patients with an indication for surgery, only 87 (56.1%) patients underwent surgery. The all-cause mortality rate was 29.3% in-hospital follow-up. Multivariable Cox regression analysis revealed that absence of surgery when indicated (HR: 3.29 95% CI: 0.93-11.64 p = 0.05), albumin level at admission (HR: 0.46 95% CI: 0.29-0.73 P < 0.01), abscess formation (HR: 2.11 95% CI: 1.01-4.38 p = 0.04) and systemic embolism (HR: 1.78 95% CI: 1.05-3.02 p = 0.03) were ascertained independent predictors of in-hospital all-cause mortality. DISCUSSION: The short-term results of the ENDOCARDITIS-TR trial showed the high frequency of staphylococcal IE, relatively high in-hospital mortality rates, shortage of surgical treatment despite guideline-based surgical indications and low usage of novel imaging techniques. The results of this study will provide a better insight to physicians in respect to their adherence to clinical practice guidelines.

Cardiovascular risk unawareness is common in individuals admitting to cardiology outpatient clinics in Turkey: the CVSCORE-TR study.

OBJECTIVES: Cardiovascular "risk" is an abstract concept that is frequently misunderstood by the general public. However, correct estimation of one's own cardiovascular risk is important as risk unawareness is associated with noncompliance with interventions aimed to reduce risk burden. Knowing the prevalence and factors linked with an increased probability of risk unawareness are therefore important to develop strategies aimed to increase risk awareness. Aims. To study prevalence of risk unawareness and to understand risk markers associated with risk underestimation and overestimation. Design. A total of 1716 participants were enrolled to the study in 33 centers across Turkey. Relevant demographic and clinical data were collected by direct interview. Cardiovascular risk of the participants was calculated using SCORE risk charts. Results. Ten-year risk for a fatal cardiovascular event was calculated as low in 633 (36.8%), intermediate in 513 (29.9%) and high-very high in 570 (33.2%) participants, respectively. According to these findings, 34.6% (n = 593) of the participants estimated their risk correctly, whereas 22.7% (n = 390) of the participants overestimated and 42.7% (n = 733) of the participants underestimated their risk. Male gender was the sole factor that was associated with an increased risk of underestimation, while having hypertension, significant valve disease or atrial fibrillation was associated with increased odds for risk overestimation. Conclusions. Only one-thirds of the sample was aware of their calculated risk for cardiovascular mortality and risk underestimation was the most common mode of risk unawareness, prompting concerns on the possible impact of the latter on adherence to the strategies aimed to reduce cardiovascular risk.

Usefulness of novel Martin/Hopkins and Sampson equations over Friedewald equation in cardiology outpatients: A CVSCORE-TR substudy.

BACKGROUND AND AIMS: The Friedewald equation (LDL-Cf) is known to produce inaccurate estimations of low-density lipoprotein cholesterol (LDL-C) when triglycerides are high (>400 mg/dL) or LDL-C is low (<70 mg/dL). The Martin/Hopkins (LDL-Cmh) and Sampson (LDL-Cs) equations were developed to overcome these limitations, but few data are available to assess whether these equations offer incremental usefulness over LDL-Cf. Our aim was to understand whether there was any incremental usefulness of novel equations on decisions regarding patient management. METHODS: Four thousand one hundred and ninety-six cardiology patients who were included in a multicentre registry database were analysed. Each patient was assigned to a cardiovascular risk class using the SCORE (Systematic COronary Risk Evaluation) algorithm, and relevant European guidelines were used to assess LDL-C targets. RESULTS: Compared with LDL-Cmh and LDL-Cs, LDL-Cf was able to correctly identify 96.9%-98.08% of patients as within or outside the LDL-C target, respectively, and 1.95%-2.8% of patients were falsely identified as being within the LDL-C target. Kappa coefficients for agreement between LDL-Cf vs LDL-Cmh and LDL-Cf vs LDL-Cs were 0.868 and 0.918 (P < .001). For patients not on cholesterol-lowering drugs, the decision to initiate treatment would be different in 1.2%-1.8% of cases if LDL-Cs or LDL-Cmh were used, respectively. For those already on cholesterol-lowering drugs, decisions regarding treatment intensification would be different in 1.5%-2.4% of cases if LDL-Cs or LDL-Cmh were used. CONCLUSIONS: In most cardiology outpatients, the Friedewald equation has excellent agreement with the novel Martin/Hopkins and Sampson equations, and treatment decisions should not change in most patients.

Cardiac autonomic dysfunctions are recovered with vitamin D replacement in apparently healthy individuals with vitamin D deficiency.

BACKGROUND: Vitamin D (VitD) has important prohormone functions in a wide range of clinical processes. Although it is known that individuals with VitD deficiency have cardiac autonomic dysfunction, there are no convincing data regarding the effect of VitD replacement. We aimed to evaluate the impact of VitD replacement on cardiac autonomic dysfunction. METHODS: Fifty-two apparently healthy subjects with VitD deficiency and 50 healthy control subjects were enrolled. Prior to VitD replacement, 24-hr Holter recordings were obtained, and HRV parameters were recorded. VitD levels were measured 2 months later after replacement, and control 24-hr Holter recordings were analyzed. RESULTS: The mean age of the patients was 36.04 ± 7.6 years, and 53.9% were female. SDNN (68.58 ± 13.53 vs. 121.02 ± 27.45 ms, p = .001), SDANN (95.96 ± 22.26 vs. 166.48 ± 32.97 ms, p = .001), RMSSD (23 vs. 59 ms, p < .001), and PNN50 (6.5% vs. 36%, p < .001) were significantly lower in patients with VitD deficiency compared with the control group. HRV parameters were improved after VitD replacement [SDNN (68.58 ± 13.53 to 119.87 ± 28.28 ms, p < .001), SDANN (95.96 ± 22.26 to 164.44 ± 33.90 ms, p < .001), RMSSD (23 to 58 ms, p < .001), and PNN50 (6.5 to 33%, p < .001)]. CONCLUSION: The present study suggested that VitD deficiency was significantly correlated with impaired cardiac autonomic functions assessed by parameters of HRV, and cardiac autonomic dysfunction improved after VitD replacement in otherwise apparently healthy individuals.

Assessment of right ventricular systolic function in heart transplant patients: Correlation between echocardiography and cardiac magnetic resonance imaging. Investigation of the accuracy and reliability of echocardiography.

BACKGROUND: Right ventricular (RV) function has great impact on the survival of heart transplantation recipients; therefore, careful evaluation is of high clinical importance. However, there is no standard conventional echocardiographic parameter to assess RV systolic function. Herein, we evaluated the correlation between echocardiographic parameters of RV systolic function and ejection fraction assessed by cardiac magnetic resonance imaging (MRI RVEF) in heart transplantation recipients. METHOD AND RESULTS: Forty-three patients with at least 6-month heart transplantation history were included in this study. Each patient had conventional echocardiography and cardiac MRI evaluation, followed by endomyocardial biopsy and right heart catheterization, which were performed in six hours. Echocardiographic parameters of RV systolic function, RV fractional area change (RV FAC), tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index, and RV global longitudinal strain, were compared with MRI RVEF (P values were <0.001, <0.3, <0.9, and <0.4, respectively). RV FAC was the only parameter to strongly correlate with MRI RVEF (r=0.747, P<0.001); and RV FAC 48.5% value had 90.5% sensitivity and 90.5% specificity to predict the pathologic reference value of MRI RVEF ≤50% (AUC:0.96; 95% CI, 0.908-1.013). CONCLUSION: To our knowledge, this is the first prospective study to evaluate the correlation between the echocardiographic parameters for RV systolic function and MRI RVEF in heart transplantation recipients. RV FAC is the only parameter to correlate well with MRI RVEF, and its routine use in the follow-up of heart transplantation recipients should be considered.

Lymphocytopenia is associated with poor NYHA functional class in chronic heart failure patients with reduced ejection fraction.

OBJECTIVE: In heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients. METHODS: The Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms. RESULTS: Patient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients. CONCLUSION: The present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.

Antiplatelet Treatment Preferences of a Group of Cardiologists from Türkiye: A Survey Research Study.

OBJECTIVE: Deciding on the optimal duration of dual antiplatelet treatment (DAPT) remains a complex decision. This survey aims to explore the preferences for antiplatelet therapy and the daily routine regarding DAPT duration in coronary artery disease among a group of cardiologists in Türkiye. METHOD: Using an online questionnaire with 38 questions, the preferences of 314 cardiologists were collected. Qualitative descriptive characteristics of the answers received from the participants were examined. RESULTS: Participating cardiologists mostly worked in training and research hospitals (51.59%) and university hospitals (21.66%). Participants primarily favored ticagrelor in patients undergoing PCI with a diagnosis of STEMI and NSTE-ACS (69.75% and 55.73% respectively). Clopidogrel was the most preferred P2Y12 treatment in patients with chronic coronary syndrome (CCS) after PCI (94.90%). Pre-treatment with a loading dose of a P2Y12 receptor inhibitor was administered to 57.01% of patients with NSTE-ACS, irrespective of the planned treatment strategy. In NSTE-ACS patients with low bleeding risk treated with PCI, 83.12% of participants recommended DAPT for 12 months and 14.65% for >12 months. In high-bleeding-risk NSTE-ACS patients treated with PCI, DAPT durations of six months (74.52%), three months (19.75%), and one month (5.73%) were chosen. Among CCS patients treated with PCI without an increased risk of bleeding, 12 months of DAPT was preferred by 68.15% of participants. Most participants (70.70%) were switching to a more potent P2Y12 receptor inhibitor therapy in emergency department clopidogrel-loaded patients with ACS. CONCLUSION: The aim of this survey to capture a snapshot of the preferences of a group of cardiologists in Türkiye regarding DAPT treatment and duration. The responses were both in accordance and in conflict with the current guidelines.

Differences Between Two Distinct Hypertrophic Cardiac Conditions: Fabry Disease versus Hypertrophic Cardiomyopathy. / Diferenças entre Duas Condições Cardíacas Hipertróficas Distintas: Doença de Fabry Versus Cardiomiopatia Hipertrófica.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) and Fabry disease (FD) are genetically inherited diseases with left ventricular hypertrophy (LVH) phenotype characteristics that cause adverse cardiac outcomes. OBJECTIVES: To investigate the demographic, clinical, biochemical, electrocardiographic (ECG), and echocardiographic (ECHO) differences between HCM and FD. METHODS: 60 HCM and 40 FD patients were analyzed retrospectively as a subanalysis of the 'LVH-TR study' after excluding patients with atrial fibrillation, pace rhythm, bundle branch blocks, and second and third-degree atrioventricular (AV) blocks. The significance level was accepted as <0.05. RESULTS: Male gender (p=0.048) and creatinine (p=0.010) are significantly higher in favor of FD; however, ST depression (p=0.028), QT duration (p=0.041), interventricular septum thickness (IVSd) (p=0.003), posterior wall thickness (PWd) (p=0.009), moderate-severe mitral regurgitation (MR) (p=0.013), and LV mass index (LVMI) (p=0.041) are significantly higher in favor of HCM in the univariate analyses. In multivariate analysis, statistical significance only continues in creatinine (p=0.018) and QT duration (0.045). FD was positively correlated with creatinine (rho=0.287, p=0.004) and HCM was positively correlated with PWd (rho=0.306, p=0.002), IVSd (rho=0.395, p<0.001), moderate-severe MR (rho=0.276, p<0.005), LVMI (rho=0.300, p=0.002), relative wall thickness (RWT) (rho=0.271, p=0.006), QT duration (rho=0.213, p=0.034) and ST depression (rho=0.222, p=0.026). CONCLUSION: Specific biochemical, ECG, and ECHO characteristics can aid in the differentiation and early diagnosis of HCM and FD.

FUNDAMENTO: A cardiomiopatia hipertrófica (CMH) e a doença de Fabry (DF) são doenças herdadas geneticamente com características fenotípicas de hipertrofia ventricular esquerda (HVE) que causam resultados cardíacos adversos. OBJETIVOS: Investigar as diferenças demográficas, clínicas, bioquímicas, eletrocardiográficas (ECG) e ecocardiográficas (ECO) entre CMH e DF. MÉTODOS: 60 pacientes com CMH e 40 pacientes com DF foram analisados retrospectivamente como uma subanálise do "estudo LVH-TR" após exclusão de pacientes com fibrilação atrial, ritmo de estimulação, bloqueios de ramo e bloqueios atrioventriculares (AV) de segundo e terceiro graus. O nível de significância foi aceito como <0,05. RESULTADOS: O sexo masculino (p=0,048) e a creatinina (p=0,010) são significativamente maiores a favor da DF; entretanto, infradesnivelamento do segmento ST (p=0,028), duração do QT (p=0,041), espessura do septo interventricular (SIVd) (p=0,003), espessura da parede posterior (PWd) (p=0,009), insuficiência mitral moderada a grave (IM) (p=0,013) e o índice de massa ventricular esquerda (IMVE) (p=0,041) são significativamente maiores a favor da CMH nas análises univariadas. Na análise multivariada, a significância estatística apenas permanece na creatinina (p=0,018) e na duração do intervalo QT (0,045). A DF foi positivamente correlacionada com a creatinina (rho=0,287, p=0,004) e a CMH foi positivamente correlacionada com o PWd (rho=0,306, p=0,002), IVSd (rho=0,395, p<0,001), IM moderada-grave (rho= 0,276, p<0,005), IMVE (rho=0,300, p=0,002), espessura relativa da parede (ERP) (rho=0,271, p=0,006), duração do QT (rho=0,213, p=0,034) e depressão do segmento ST (rho =0,222, p=0,026). CONCLUSÃO: Características bioquímicas, ECG e ECO específicas podem auxiliar na diferenciação e no diagnóstico precoce da CMH e da DF.

Physicians' attitudes toward beta-blockers for the treatment of hypertension in Italy, Poland, and Turkey.

Despite substantial progress in understanding the complex pathophysiology, hypertension remains a serious public health challenge affecting over 1.2 billion adults aged 30-79 years worldwide. Appropriate knowledge of the different pharmaceutical classes of antihypertensive agents and an understanding of the characteristics of individual molecules are essential to optimize clinical outcomes in patients with hypertension. We conducted a computer-assisted web interviewing (CAWI) quantitative survey in Italy, Poland, and Turkey to investigate physicians' prescriptions, knowledge, and perceptions of antihypertensive drugs with a focus on ß-blockers, to assess antihypertensive usage patterns and the reasons underlying prescription choices. The survey findings show that ß-blockers retain a pivotal role in the management of hypertension and are prescribed more often for patients with cardiovascular comorbidities than for patients with diabetic comorbidities. In all three countries, nebivolol is the only ß-blocker among the ones analyzed which is consistently prescribed to 20% or more of patients and is overall the most prescribed one for the population with comorbid diabetes. In terms of specific ß-blockers' features, this study revealed knowledge gaps that underline the need for educational activities focused on the differences among ß-blockers, which are important in choosing the most suitable agent for individualized antihypertensive therapy.

Heart Failure Awareness Survey in a Turkish Population: HFAS-TR.

OBJECTIVE: Heart failure is a leading cause of death and the most common diagnosis leading to hospitalization. Its awareness is lower than that of other cardiovascular diseases, both in the general population and among patients with heart failure (HF). This study aimed to establish the current level of knowledge about HF in patients with HF with reduced ejection fraction (HFrEF) and mildly reduced ejection fraction (HFmrEF) in Türkiye. METHODS: This questionnaire-based survey study is multicenter, conducted across 34 centers from December 2021 to July 2022. We performed a survey consisting of two sets of questions focusing on individual characteristics of the patients and HF-related knowledge. RESULTS: The study included a total of 2,307 outpatient HF patients, comprising 70.5% males and 29.5% females with a mean age of 64.58 ± 13 (56-74) years and a mean body mass index value of 32.5 ± 10 kg/m2. HFrEF and HFmrEF were determined in 74.7% and 25.3% of patients, respectively. Thirty percent of the patients were unaware that they had HF. While 28.7% of the patients thought that they had sufficient information about HF, 71.3% believed they lacked adequate knowledge. In the study, 25.2% of the participants identified dyspnea, 22% identified tiredness, and 25.4% identified leg edema as the most common symptoms of HF. Only 27.4% of patients recognized all three typical symptoms of HF. CONCLUSION: We found that the study population's knowledge about HF symptoms and the nature of the disease was poor. Educational and awareness activities are necessary to optimize outcomes and benefits.

Obstructive - Nonobstructive hypertrophic cardiomyopathy: differences and predictors.

INTRODUCTION: Hypertrophic cardiomyopathy(HCM) is a genetic cardiomyopathy with a prevalence of 1/500 and causes adverse outcomes, usually due to left ventricular outflow tract obstruction. AIM: In this study, we aimed to determine the possible differences and predictors of obstructive hypertrophic cardiomyopathy HCM (Obs-HCM) and nonobstructive HCM (Nonobs-HCM) by electrocardiographic (ECG) and echocardiographic (ECHO) evaluations with clinical, demographic, and biochemical characteristics. METHODS: This study is a subgroup analysis of a multicentre, national, and observational 'LVH-TR study' that included 886 left ventricular hypertrophy(LVH) patients in 22 centres between February 2020 and August 2021. After excluding six patients with atrial fibrillation, pace rhythm, bundle branch blocks, and second, and third-degree atrioventricular(AV) block, 60 HCM patients were included, 23 of whom were obstructive, and 37 were nonobstructive. RESULTS: Body surface area(BSA) (2.01 ± 0.17, 1.89 ± 0.19; p = .01), ST-segment depression (%82.6, %54.1; p = .02), QT and QTc durations (436.3 ± 58.3, 398.0 ± 65.5; p = .02/470.6 ± 58.7, 432.8 ± 74.7; p = .04), left ventricular mass index(LVMI) (176.4 ± 47.0, 152.7 ± 10.2; p = .004), and systolic anterior motion(SAM) rates (%82.6, %18.9; p < 0.001) were significantly higher in the obstructive HCM compared to nonobstructive HCM. Furthermore, the significance of ST-segment depression, QT duration, LVMI, and SAM continued in the univariate analyses to assess obstruction prediction (all p values < .05). CONCLUSION: In multivariate and correlation analyses, ST segment depression (rho = 0.29), QT prolongation (rho = 0.34), and SAM (rho = 0.62) are found as predictors for obstruction (all p values < .05). Our study will guide future studies since it has detailed ECG and ECHO comparisons of Obs-HCM and Nonobs-HCM patients over 18 are made.

Gender-Related Differences in Patients with Acute Heart Failure: Observation from the Journey Heart Failure-Turkish Population Study.

BACKGROUND: Gender-related clinical variations in patients with acute heart failure have been described in previous studies. However, there is still a lack of research on gender differences in patients hospitalized for acute heart failure in Türkiye. The aim of this study is to compare the clinical features, in-hospital approaches, and outcomes of male and female patients hospitalized for acute heart failure. METHODS: Differences in clinical characteristics, medication prescription, hospital management, and outcomes between males and females with acute heart failure were investigated from the Journey Heart Failure-Turkish Population study. RESULTS: Nine hundred eighteen patients (57.2%) were men and 688 (42.8%) were women. Women were older than men (70.48 ± 13.20 years vs. 65.87 ± 12.82 years; P <.001). The frequency of comorbidities such as hypertension (72.7% vs. 62.4%, P <.001), diabetes (46.5% vs. 38.5%, P = .001), atrial fibrillation (46.5% vs. 33.4%, P <.001), New York Heart Association class III-IV symptoms (80.6% vs. 71.2%, P =.001), and dyspnea in the rest (73.8% vs. 68.3%, P =.044) were more common in women on admission. Male patients were more frequently hospitalized with reduced left ventricular ejection fraction (51.0% vs. 72.4%, P <.001). In-hospital mortality was higher among female patients (9.3% vs. 6.4%, P =.022). Higher New York Heart Association class, lower estimated glomerular filtration rate, higher N-terminal pro-B type natriuretic peptide on admission, and mechanical ventilation usage were the independent parameters of in-hospital mortality, whereas the female gender was not. CONCLUSION: Our study clearly demonstrated the diversity in presentation, management, and in-hospital outcomes of acute heart failure between male and female patients. Although left ventricular systolic functions were better in female patients, in-hospital mortality was higher. Recognizing these differences in the management of heart failure in different sexes will serve better results in clinical practice.

Long-Term Prognosis of Patients with Heart Failure: Follow-Up Results of Journey HF-TR Study Population.

BACKGROUND: Despite advances in therapeutic management of patients with heart failure, there is still an increasing morbidity and mortality all over the world. In this study, we aimed to present the 3-year follow-up outcomes of patients included in the Journey HF-TR study in 2016 that has evaluated the clinical characteristics and management of patients with acute heart failure admitted to the hospital and present a national registry data. METHODS: The study was designed retrospectively between November 2016 and December 2019. Patient data included in the previously published Journey HF-TR study were used. Among 1606 patients, 1484 patients were included due to dropout of 122 patients due to inhospital death and due to exclusion of 173 due to incomplete data. The study included 1311 patients. Age, gender, concomitant chronic conditions, precipitating factors, New York Heart Association, and left ventricular ejection fraction factors were adjusted in the Cox regression analysis. RESULTS: During the 3-year follow-up period, the ratio of hospitalization and mortality was 70.5% and 52.1%, respectively. Common causes of mortality were acute decompensation of heart failure and acute coronary syndrome. Angiotensin receptor blockers, betablockers, statin, and sacubitril/valsartan were found to reduce mortality. Hospitalization due to acute decompensated heart failure, acute coronary syndrome, lung diseases, oncological diseases, and cerebrovascular diseases was associated with the increased risk of mortality. Implantation of cardiac devices also reduced the mortality. CONCLUSIONS: Despite advances in therapeutic management of patients with heart failure, our study demonstrated that the long-term mortality still is high. Much more efforts are needed to improve the inhospital and long-term survival of patients with chronic heart failure.

Prevalence of Fabry Disease in patients with left ventricular hypertrophy in Turkey: Multicenter study (LVH-TR subgroup analysis).

PURPOSE: In this prospective study we aimed to determine the rate of Fabry Disease (FD) in patients with left ventricular hypertrophy (LVH), and to evaluate the clinical presentations of patients with FD in a comprehensive manner. In addition, we aimed to raise awareness about this issue by allowing early diagnosis and treatment of FD. METHODS: Our study was planned as national, multicenter, observational. Totally 22 different centers participated in this study. A total of 886 patients diagnosed with LVH by echocardiography (ECHO) were included in the study. Demographic data, biochemical parameters, electrocardiography (ECG) findings, ECHO findings, treatments and clinical findings of the patients were recorded. Dry blood samples were sent from male patients with suspected FD. The α-Gal A enzyme level was checked and genetic testing was performed in patients with low enzyme levels. Female patients suspected of FD were genetically tested with the GLA Gene Mutation Analysis. RESULTS: FD was suspected in a total of 143 (16.13%) patients included in the study. The α-Gal-A enzyme level was found to be low in 43 (4.85%) patients whom enzyme testing was requested. GLA gene mutation analysis was positive in 14 (1.58%) patients. Male gender, E/e' mean ,and severe hypertrophy are important risk factor for FD. CONCLUSION: In daily cardiology practice, FD should be kept in mind not only in adult patients with unexplained LVH but also in the entire LVH population. Dry blood test (DBS) should be considered in high-risk patients, and mutation analysis should be considered in required patients.

Awareness and Knowledge of Pneumococcal Vaccination in Cardiology Outpatient Clinics and the Impact of Physicians' Recommendations on Vaccination Rates.

AIM: We aimed to evaluate the awareness of pneumococcal vaccination (PCV13, PPSV23) in general cardiology outpatient clinics and impact of physicians' recommendations on vaccination rates. METHODS: This was a multicenter, observational, prospective cohort study. Patients over the age of 18 from 40 hospitals in different regions of Turkey who applied to the cardiology outpatient clinic between September 2022 and August 2021 participated. The vaccination rates were calculated within three months of follow-up from the admitting of the patient to cardiology clinics. RESULTS: The 403 (18.2%) patients with previous pneumococcal vaccination were excluded from the study. The mean age of study population (n = 1808) was 61.9 ± 12.1 years and 55.4% were male. The 58.7% had coronary artery disease, hypertension (74.1%) was the most common risk factor, and 32.7% of the patients had never been vaccinated although they had information about vaccination before. The main differences between vaccinated and unvaccinated patients were related to education level and ejection fraction. The physicians' recommendations were positively correlated with vaccination intention and behavior in our participants. Multivariate logistic regression analysis showed a significant correlation between vaccination and female sex [OR = 1.55 (95% CI = 1.25-1.92), p < 0.001], higher education level [OR = 1.49 (95% CI = 1.15-1.92), p = 0.002] patients' knowledge [OR = 1.93 (95% CI = 1.56-2.40), p < 0.001], and their physician's recommendation [OR = 5.12 (95% CI = 1.92-13.68), p = 0.001]. CONCLUSION: To increase adult immunization rates, especially among those with or at risk of cardiovascular disease (CVD), it is essential to understand each of these factors. Even if during COVID-19 pandemic, there is an increased awareness about vaccination, the vaccine acceptance level is not enough, still. Further studies and interventions are needed to improve public vaccination rates.

[Changes in etiology, cause of death, survival, and mortality rates in cardiac transplant patients from 1998 to 2011]. / 1998-2011 arasi dönemde kalp nakli hastalarinda etyoloji, ölüm nedenleri, sagkalim ve mortalite oranlarindaki degisim.

OBJECTIVES: We retrospectively analyzed changes in heart failure etiology, causes of death, mortality and survival rates in cardiac transplant patients from 1998 to 2011. STUDY DESIGN: A total of 144 patients (112 men, 32 women; mean age 40.2±14.3 years) underwent cardiac transplantation between February 1998 and January 2011. The patients were divided into two groups; hence, 63 patients (group 1; mean age 42.5±12.6 years) receiving transplantation up to January 2006, and 81 patients (group 2; mean age 38.4±15.3 years) receiving transplantation from 2006 to 2011. In the latter period, a ventricular assist device was used in 17 patients before transplantation. RESULTS: Dilated cardiomyopathy was the main cause of heart transplantation in both groups (71.4% vs. 74.1%). Overall mortality, in-hospital mortality (<30 days), and late mortality (≥30 days) rates were 39.6% (n=57), 13.9% (n=20), and 25.7% (n=37), respectively. Survival rates for 1, 2, 5, and 10 years were 76%, 69%, 59%, and 46%, respectively. The second group had significantly lower rates of overall mortality and late mortality compared to group 1 (29.6% vs. 52.4%, p=0.005; 16.0% vs. 38.1%, p=0.002, respectively), whereas early mortality rates were similar. Survival rates were also higher in the second group, but these differences did not reach significance (1-year, 76.1% vs. 74.6%; 2-year, 73.0% vs. 65.1%; 5-year, 63.8% vs. 55.6%; log rank 0.33). In both groups, infections (30.3% vs. 33.3%), right ventricular failure (12.1% vs. 29.2%), and sudden cardiac death (15.2% vs. 16.7%) were the leading causes of death. CONCLUSION: Our data show that overall and late mortality rates show significant decreases in cardiac transplant patients from 1998 to 2011.

Heart failure with non-reduced ejection fraction: Epidemiology, pathophysiology, phenotypes, diagnosis and treatment approaches.

Heart failure (HF) has been classified as reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF) by the recent HF guidelines. In addition, HF with improved ejection fraction has been defined as a subgroup of HFrEF. In HFrEF, diagnostic workup and evidence-based pharmacological and device-based therapies have been well established. However, HFpEF, which comprises almost half of the HF population, represents significant uncertainties regarding its pathophysiology, clinical phenotypes, diagnosis and treatment. Diagnostic criteria of HFpEF have been changed a few times over the years and still remained a matter of debate. New paradigms including a prominent role of co-morbidities, inflammation, endothelial dysfunction have been proposed in its pathophysiology. As a complex, multifactorial syndrome HFpEF consists of many overlapping clinical and hemodynamic phenotypes. In contrast to HFrEF, clinical outcomes of HFpEF have not improved over the last decades due to lack of proven effective therapies. Although HFrEF and HFpEF have different clinical spectrums and proposed pathophysiological mechanisms, there is no clear defining syndrome postulated for HFmrEF. Clinical characteristics and risk factors of HFmrEF overlap with HFrEF and HFpEF. HFmrEF is also referred as a transitional zone for dynamic temporal changes in EF. So, HFpEF and HFmrEF, both namely HF with non-reduced ejection fraction (HF-NEF), have some challenges in the management of HF. The purpose of this paper is to provide a comprehensive review including epidemiology, pathophysiology, clinical presentation and phenotypes of HF-NEF and to guide clinicians for the diagnosis and therapeutic approaches based on the available data in the literature.

Understanding the Burden of Atrial Fibrillation and Importance of Screening: A Global Perspective and Recommendations for Turkey.

Considering the aging population, the increase in predisposing factors, and the improvement in healthcare with increased survival rates, atrial fibrillation has been the most common cardiac arrhythmia in adults with a rise in the estimated lifetime risk over recent years. While aging is a powerful risk factor for atrial fibrillation, the leading prevalent comorbidities are hypertension, heart failure, obesity, obstructive sleep apnea, diabetes mellitus, and chronic kidney disease. Atrial fibrillation is associated with substantial morbidity, impaired quality of life, and increased mortality and healthcare costs. As a significant proportion of the total atrial fibrillation population is asymptomatic or mildly symptomatic, early identification and initiation of appropriate treatment for atrial fibrillation may prevent potentially detrimental outcomes such as stroke and heart failure and decrease all-cause mortality. Although screening via evolving health technologies has recently been emerging, verification of the electrocardiogram track recording over at least 30 seconds by a physician with expertise is still required for a definite diagnosis. Based on the global and national data and the current healthcare environment in Turkey, this targeted review with cardiology, neurology, and family physicians' perspectives highlights the importance of early detection by implementing the advancing screening modalities as well as the need for raised awareness of both patients and healthcare professionals and establishment of a multidisciplinary clinical approach for a better outcome in atrial fibrillation management.

Characteristics and long-term survival of patients with left ventricular non-compaction cardiomyopathy.

AIMS: Left ventricular non-compaction cardiomyopathy (LVNC) is a poorly understood entity resulting in heart failure. Whether it is a distinct form of cardiomyopathy or an anatomical phenotype is a subject of discussion. The current diagnosis is based on morphologic findings by comparing the compacted to non-compacted myocardium. The study aimed to compare demographic and prognostic variables of patients with dilated cardiomyopathy (DCM) and LVNC. Emphasis was given to cardiac magnetic resonance (CMR) imaging analysis. Data on survival were also assessed. METHODS AND RESULTS: We retrospectively evaluated the characteristics and outcomes of 262 non-ischaemic cardiomyopathy patients with LVNC and DCM phenotypes. Petersen's CMR criteria of non-compacted to the compacted myocardial ratio 2.3 were used to diagnose LVNC. The primary endpoint was a composite endpoint of major adverse cardiovascular events comprising cardiovascular-related death, left ventricular assisted device implantation, or heart transplantation. A total of 262 patients with CMR data were included in the study. One hundred fifty-five patients who fulfilled CMR criteria were diagnosed as LVNC. CMR findings revealed that LVNC patients had higher left ventricular end-diastolic (137.2 ± 51.6, 116.8 ± 44.6, P = 0.002) and systolic volume index (98.4 ± 49.5, 85.9 ± 42.7, P = 0.049). Cardiac haemodynamics, cardiac output (5.61 ± 2.03, 4.96 ± 1.83; P = 0.010), stroke volume (73.9 ± 28.8, 65.1 ± 25.1; P = 0.013), and cardiac index (2.85 ± 1.0, 2.37 ± 0.72; P < 0.0001), were higher in LVNC patients. Of all the 249 patients, 102 (40.9%) patients demonstrated late gadolinium enhancement (LGE). According to Petersen's criteria, the Kaplan-Meier survival outcome did not reveal significant differences (hazard ratio [HR]: 1.53, 95% confidence interval [CI]: [0.89-2.63], P = 0.11). The presence or pattern of LGE did not show significant importance for endpoint-free survival. Most of the sub-epicardial LGE pattern was found in LVNC patients (94.4%). When receiver operator characteristics analysis was applied to NC/C ratio to discriminate the primary endpoint, a higher NC/C ratio of 2.57 was associated with adverse events (HR: 1.90, 95% CI: [1.12-3.24], P = 0.016). CONCLUSIONS: Our study questions the criteria being used for the diagnosis of LVNC. Further evaluation of CMR variables and association of these findings with demographic variables and survival is mandatory.