The role of prognostic nutritional index in predicting amputation in patients with lower extremity peripheral artery disease.

Introduction: Lower-extremity peripheral artery disease (PAD) can lead to a wide spectrum of symptoms that can progress from claudication to amputation. The prognostic nutritional index (PNI), which is calculated using the levels of albumin and lymphocyte, is an accepted indicator of immunological and nutritional status. In this study, the association between nutritional status determined using the PNI, and extremity amputation in patients with lower-extremity PAD was investigated. Methods: Lower-extremity PAD patients who had been admitted to the cardiology clinic of the Diskapi Yildirim Beyazit Training & Research Hospital with stage 2b or higher claudication, and who were technically unsuitable for revascularization or underwent unsuccessful revascularization procedure were enrolled in this retrospective study. Patients were grouped according to whether or not limb amputation had been performed previously. Potential factors were tested to detect independent predictors for amputation with logistic regression analysis. Results: A study group was formed with 266 peripheral artery patients. The amputated group (39 patients) had a higher number of hypertensive (76.9% vs 57.7%; P = 0.032) and diabetic (92.3% vs 54.2%; P <0.001) patients than those in the non-amputated group (227 patients). The median PNI value of the amputated group was lower than that of the non-amputated group (31.8 vs 39.4; P <0.001). Multivariate logistic regression showed that the PNI (OR: 0.905, 95% CI: 0.859 - 0.954; P <0.001) was independently related with amputation. Conclusion: Immune-nutritional status based on PNI was independently associated with limb amputation in patients with lower-extremity PAD.

Relationship between serum bilirubin levels and presence of fragmented QRS in patients with acute coronary syndrome.

Aim: To assess the relationship between serum bilirubin levels and fragmented QRS (fQRS), and their association with adverse events in patients with acute coronary syndrome. Methods: This study included a total of 736 patients. Laboratory results such as bilirubin levels, renal and liver function tests were obtained from the first available blood sample. Results: Left ventricular ejection fraction, end-diastolic diameter and total bilirubin level were significantly lower in fQRS (+) group than in the control group (45.0 [40.0-55.0] vs 50.0 [45.0-60.0]%; p < 0.001; 4.7 [4.6-5.1] vs 4.7 [4.5-4.9] cm; p < 0.001; 0.66 [0.49-5.1] vs 0.72 [0.53-0.97] md/dl; p = 0.017); respectively. Occurrence of adverse events was significantly higher in fQRS (+) group (32.5 vs 20.5 %; p = 0.013) during mean 1-year follow-up period. Conclusion: Total bilirubin level is an independent predictor of fQRS formation, which is associated with the presence of adverse events in patients with acute coronary syndrome.

Comparison of atrial fibrillation predictors in patients with acute coronary syndrome using ticagrelor or clopidogrel

Background/aim: Ticagrelor is a drug widely used in patients with acute coronary syndromes (ACS) that specifically increases the plasma level of adenosine, which is likely to cause atrial fibrillation (AF). Therefore, in this study we aimed to investigate the electrocardiographic and echocardiographic predictors of AF development after P2Y12 receptor antagonists in ACS patients. Materials and methods: This cross-sectional study included 831 patients with ACS (486 [58.5%] with ST elevated myocardial infarction [STEMI] and 345 [41.5%] with non-ST elevated myocardial infarction [NSTEMI]). Patients were divided into ticagrelor (n = 410) and clopidogrel (n = 421) groups. P wave properties including P wave dispersion and atrial electromechanical conduction properties were measured as AF predictors with surface ECG and tissue Doppler imaging. Results: Baseline characteristics such as age, sex, heart rate, blood pressure, and laboratory parameters were almost the same in the ticagrelor and clopidogrel groups. The statistical analysis showed no significant difference in P wave dispersion (PWD) between ticagrelor and clopidogrel groups (40.98 ± 12 ms versus 40.06 ± 12 ms, P = 0.304). Subgroups analysis according to ACS types also showed no significant difference in PWD (NSTEMI: 41.16 ± 13.8 ms versus 40.76 ± 13.55 ms, P = 0.799; STEMI: 40.9 ± 12.62 ms versus 39.19 ± 11.18 ms, P = 0.132). In addition, we did not find significant difference in atrial electromechanical delay (EMD) with tissue Doppler imaging (interatrial EMD 24.11 ± 3.06 ms versus 24.46 ± 3.23 ms, P = 0.279). Conclusion: In conclusion, we did not find any difference in detailed electrocardiographic and echocardiographic parameters as AF predictors between ticagrelor and clopidogrel groups in patients with ACS

Antithrombotic treatment patterns and stroke prevention in patients with atrial fibrillation in TURKEY: inferences from GARFIELD-AF registry.

The corner stone of atrial fibrillation therapy includes the prevention of stroke with less adverse effects. The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) study provided data to compare treatment strategies in Turkey with other populations and every-day practice of stroke prevention management with complications. METHODS: GARFIELD-AF is a large-scale registry that enrolled 52,014 patients in five sequential cohorts at >1,000 centers in 35 countries.This study initiated to track the evolution of global anticoagulation practice, and to study the impact of NOAC therapy in AF. 756 patients from 17 enrolling sites in Turkey were in cohort 4 and 5.Treatment strategies at diagnosis initiated by CHA2DS2-VASc score, baseline characteristics of patients, treatment according to stroke and bleeding risk profiles, INR values were analyzed in cohorts.Also event rates during the first year follow up were evaluated. RESULTS: AF patients in Turkey were mostly seen in young women.Stroke risk according to the CHADS2 score and CHA2DS2-VASc score compared with world data. The mean of risk score values including HAS-BLED score were lower in Turkey than world data.The percentage of patients receiving FXa inhibitor with or without an antiplatelet usage was more than the other drug groups. All-cause mortality was higher in Turkey. Different form world data when HAS-BLED score was above 3, the therapy was mostly changed to antiplatelet drugs in Turkey. CONCLUSION: The data of GARFIELD-AF provide data from Turkey about therapeutic strategies, best practices also deficiencies in available treatment options, patient care and clinical outcomes of patients with AF.

Red blood cell distribution width as a predictor of long-term mortality in patients with carbon monoxide poisoning.

OBJECTIVES: Elevated red blood cell distribution width (RDW) is an independent prognostic factor for cardiovascular events that are major causes of mortality in patients with carbon monoxide (CO) poisoning. Due to the limited number of studies, we aimed to investigate the relationship between RDW levels and long-term mortality for these patients. METHOD: This retrospective study included patients with CO poisoning, who presented to the emergency department. Baseline characteristics, laboratory results and survival status were retrieved from patients' hospital records. The severity of poisoning was determined according to COHb level and/or clinical signs and symptoms. RESULTS: The study included 571 patients (median age was 37.0 years) and less than half of these patients were male (n = 206, 36.1%). There were mild-moderate CO poisoning in 389 (68.1%) patients and severe poisoning in 182 (31.9%). At a median follow-up of 6.2 years, there were 33 deaths (5.8%). Univariate cox-regression analysis demonstrated that age, gender, presence of hypertension or diabetes mellitus, levels of hemoglobin, RDW, creatinine and alanine-aminotransferase, and white-blood-cell count were potential covariates of long-term all-cause mortality. In the multivariate analysis, the median age and RDW level remained independent predictors of mortality (age, Odds ratio [OR]: 1.070 95% confidence interval [CI]: 1.030-1.110, p = 0.001; RDW, OR: 1.221 95% CI: 1.042-1.431, p = 0.013). Patients with higher RDW levels had a significantly worse prognosis in terms of mortality than with lower RDW levels (log-rank test, p = 0.003). CONCLUSION: This study demonstrated that RDW level is an independent predictor of long-term mortality in patients with CO poisoning.

The value of transient ischemic dilation for detecting restenosis after coronary artery revascularization.

AIM: Transient ischemic dilation (TID) is a marker of severe coronary artery disease (CAD). We aimed to assess the incremental value of TID in a cohort of patients with known significant CAD who had recurrence of symptoms after revascularization. METHODS: We identified in our databases 104 patients who had recent coronary revascularization and recurrence of symptoms. 62 patients had PCI (75 arteries) and 42 patients had CABG (104 arteries). All had follow-up stress SPECT MPI and repeat coronary angiography. Myocardial perfusion findings of ischemia and TID were correlated with presence of significant obstructive CAD (>70% stenosis). RESULTS: Follow-up stress Tc-99m Sestamibi SPECT MPI revealed inducible ischemia in 38 patients (36.5%) and TID > 1.20 in 49 patients (47%). Subsequent coronary angiography showed significant obstructive CAD in 44 patients (42%). The sensitivity for detecting obstructive CAD was 61% for SPECT MPI alone, but increased significantly to 93% by the addition of TID as a diagnostic criterion (P < 0.0001). CONCLUSIONS: In this selected patient cohort with prior coronary revascularization, TID is an important marker of obstructive CAD and has incremental value over SPECT MPI alone.

Pulmonary arterial hemodynamic assessment by a novel index in systemic lupus erythematosus patients: pulmonary pulse transit time.

OBJECTIVE: Systemic lupus erythematosus (SLE) is a chronic, inflammatory, and autoimmune connective tissue disease. One of the leading causes of mortality among SLE patients is pulmonary hypertension. The aim of this study was to evaluate the association between echocardiographic findings, including the pulmonary pulse transit time and pulmonary hypertension parameters, in SLE patients. METHODS: Thirty SLE patients (aged 39.9±11 years, 28 females) as the study group and 34 age- and sex-matched healthy volunteers (aged 37.9±11.5 years, 31 females) as the control group were included in the study. After detailed medical histories were recorded, 12-lead electrocardiography, blood tests, and echocardiography were performed in the groups. In addition to basic echocardiographic measurements, other specialized right ventricular indicators [i.e, Tricuspid Annular Plane Systolic Excursion (TAPSE), estimated pulmonary artery systolic pressure (ePASP), right ventricular dimensions, and myocardial performance index (MPI)] were measured. The pulmonary pulse transit time was defined as the time interval between the R-wave peak in ECG and the corresponding peak late-systolic pulmonary vein flow velocity. RESULTS: The mean disease duration was 121.1±49.9 months. The mean age at diagnosis was 35.0±15.4 years. The mean RV MPI was higher (p=0.026), mean TAPSE measurements were shorter (p=0.021), and mean ePASP was higher (p=0.036) in the SLE group than in the control group. In addition, pPTT was significantly shorter in the SLE group (p=0.003). pPTT was inversely correlated with disease duration (p<0.001), MPI (p=0.037), and ePASP (p=0.02) and positively correlated with TAPSE (p<0.001). CONCLUSION: SLE patients have higher pPTT values than controls. Further, pPTT shows an inverse correlation with disease duration, MPI, and ePASP and a positive correlation with TAPSE.

Early changes in atrial conduction times in hypertensive patients with elevated pulse pressure.

OBJECTIVE: Pulse pressure (PP) is the difference between systolic and diastolic blood pressure, and is an independent predictor of atrial fibrillation (AF). In this study we investigated the relationship between PP and atrial conduction times. METHODS: The study included 157 patients with essential hypertension. PP of 60 mmHg or more was regarded as elevated (n=56). Atrial electromechanical delay (EMD) was assessed with tissue Doppler echocardiography and P-wave dispersion (Pd) was calculated from the electrocardiogram. RESULTS: Left atrial volume index (23.6±4.9 ml/m2 vs. 25.2±6.5 ml/m2, p=0.141), left ventricular mass index (77.3±13.5 g/m2 vs. 80.9±19.6 g/m2, p=0.180) and grade I diastolic dysfunction (42% vs. 53%, p=0.242) were similar between groups. Inter-atrial (33.6±9.2 ms vs. 41.5±11.3 ms, p<0.001), intra-left atrial (23.0±8.8 ms vs. 28.2±10.6 ms, p=0.001) and intra-right atrial (10.5±5.8 ms vs. 13.2±4.9 ms, p=0.004) EMD were found to be higher in patients with elevated PP. P-maximum (108±8 ms vs. 114±9 ms, p<0.001) and Pd (30±13 ms vs. 38±13 ms, p<0.001) were also prolonged in patients with elevated PP. Multivariate linear regression analysis revealed that PP was independently associated with inter-atrial EMD (ß=0.379, t=4.088, p<0.001). CONCLUSION: This study showed that elevated PP is associated with prolonged atrial EMD and Pd. Atrial conduction is disturbed in hypertensive patients with elevated PP before the development of significant structural remodeling.

The relationship between 24-hour ambulatory blood pressure load and neutrophil-to-lymphocyte ratio.

INTRODUCTION AND OBJECTIVE: The neutrophil-to-lymphocyte ratio (NLR) is established as a reliable marker of systemic inflammation. Low-grade inflammation has a key role in the pathogenesis and progression of hypertension (HTN). Blood pressure (BP) load, defined as the percentage of abnormally elevated BP readings, is a good marker of HTN severity. We aimed to evaluate the relationship between HTN severity and NLR using averaged ambulatory BP readings and BP load. METHODS: A total of 300 patients with untreated essential HTN were included in this cross-sectional study. Patients were divided into quartiles according to NLR values (first: <1.55; second: 1.55-1.92; third: 1.92-2.48; and fourth: >2.48). Averaged ambulatory BP values and BP load were assessed for each quartile. RESULTS: In the interquartile evaluation there were no differences between quartiles in terms of baseline demographic, clinical and echocardiographic characteristics (p>0.05). Daytime systolic BP (SBP), 24-hour diastolic BP (DBP), daytime DBP, daytime SBP load, 24-hour DBP load and daytime DBP load were found to be significantly higher in the upper two quartiles (p<0.05 for all). In correlation analysis, log NLR values were found to be positively correlated with 24-hour SBP, DBP, SBP load and DBP load (Pearson coefficients of 0.194, 0.197, 0.157 and 0.181, respectively; p<0.01 for all). In multivariate analysis, log NLR had an independent association with 24-hour SBP and DBP and 24-hour SBP and DBP load. CONCLUSION: This study showed for the first time that increased NLR is independently associated with HTN severity in untreated essential HTN patients.

Sleep related bradyarrhythmic events and heart rate variability in apparently healthy individuals.

OBJECTIVE: It is thought that abnormal cardiac impulses of the autonomic nervous system during sleep are responsible for sleep-related bradyarrhythmias. Despite a proposed common etiopathogenesis and having common name of "sleep-related bradyarrhythmias," precise importance of sinoatrial or atrioventricular (AV) node involvement remains elusive. This study aimed to determine whether there is a difference in sleeprelated bradyarrhythmias from the point of view of heart rate variability (HRV). METHODS: Patients were evaluated using 24-hour Holter electrocardiogram monitor. After careful medical evaluation, apparently healthy individuals with sleep-related sinus pauses ≥2 seconds on at least 1 occasion or those in whom Mobitz type I AV block occurred were included. Frequency and time domain analyses were conducted for daytime, nighttime, and 24-hour period. RESULTS: Total of 37 patients with sinus pause(s), 40 patients with Mobitz type I AV block(s), and 40 healthy controls were included. On HRV analyses, all time and frequency domain parameters were better in sinus pause group for daytime, nighttime, and 24-hour average (p<0.05 for all). Results of heart rate-corrected HRV analyses still showed significantly better total power (TP) and very low frequency (VLF) in the sinus pause group compared with AV block group (TP: 7.1x10-3 vs. 5.4x10-3, p=0.011; VLF: 4.9x10-3 vs. 3.7x10-3, p=0.007). CONCLUSION: Despite proposed common autonomic mechanisms, sleep-related sinus pause cases demonstrated better HRV profile in comparison with Mobitz type I AV block.

Comparison of coronary artery dimensions in patients with chronic aortic regurgitation or stenosis.

OBJECTIVE: Effects of various conditions on coronary artery dimensions is an important research topic, and data regarding effect of aortic valvular diseases are limited. Aim of the present study was to investigate effects of aortic regurgitation (AR) and aortic stenosis (AS) on coronary artery dimensions. METHODS: Coronary dimensions of 95 patients (35 with isolated AR, 30 with isolated AS, and 30 without any valvular disease) were calculated. Patients with severe coronary artery disease and concurrent moderate to severe additional valvular disease were excluded. Mean diameter of major coronary arteries was determined using quantitative coronary angiography. RESULTS: The 3 study groups were similar in terms of baseline characteristics. Diameter of left main coronary artery was found to be greater in AR group than AS group (2.66±0.57 mm/m2 vs 2.36±0.49 mm/m2; p=0.015). Mean diameter of left anterior descending and left circumflex arteries were found to be similar in AR and AS groups, and greater than control group. Mean diameter of right coronary artery was found to be greater in AR group compared with controls; however, no significant difference was found in same measurement between AS group and controls. CONCLUSION: Present study findings indicate that coronary dimensions in AR group tend to be greater than AS group. Further studies investigating factors that affect coronary dimensions would be beneficial in order to demonstrate mechanisms and differences in AR and AS groups.

Neutrophil-to-lymphocyte ratio predicts hemodynamic significance of coronary artery stenosis.

OBJECTIVE: Coronary artery disease is closely linked with inflammation, and the neutrophil-to-lymphocyte ratio (NLR) has emerged as a new inflammatory marker. Fractional flow reserve (FFR) is a well-established method for determining hemodynamic significance of coronary artery stenosis. In this study, we aimed to investigate the relationship between NLR and hemodynamic significance of coronary artery lesion as assessed by FFR. METHODS: A total of 134 patients with FFR measurement between January 2012 and December 2013 were enrolled in this retrospective study. Patients with single intermediate-grade coronary artery stenosis were enrolled, and those with second intermediate or severe coronary artery stenosis were excluded from study. Patients' NLR were calculated. An FFR value of ≤0.80 was accepted for hemodynamic significance. Statistical analysis was performed by the chi-square test, Student's t-test, Mann-Whitney U test, logistic regression analysis, and ROC curve analysis. RESULTS: Patients with hemodynamically significant lesions had higher NLR values (3.3±1.2 vs. 2.0±0.9, p<0.001). White blood cell count, male gender, high-density lipoprotein levels, platelet-to-lymphocyte ratio, and NLR were found to be possible confounding factors predicting hemodynamically significant coronary artery stenosis. In multiple logistic regression analysis, NLR remained as the only independent predictor for hemodynamically significant coronary artery stenosis. An NLR value of 2.4 had 87.5% sensitivity and 78.4% specificity for prediction of hemodynamically significant coronary artery stenosis. CONCLUSION: In present study, we showed that NLR was significantly higher in patients with hemodynamically significant coronary artery stenosis. We also found NLR to be an independent predictor of hemodynamically significant coronary artery stenosis as measured by FFR. Further studies are needed to find a causal relationship.

Relationship between neutrophil to lymphocyte ratio and slow coronary flow.

OBJECTIVES: We evaluated the relationship between neutrophil to lymphocyte ratio (NLR) and slow coronary flow (SCF). METHODS: A total of 180 participants were recruited to the present study. Of all the participants, 82 patients were with SCF and 98 participants were with normal coronary arteries. Basal characteristics were recorded. Coronary flow was quantified by thrombolysis in myocardial infarction frame count. RESULTS: Basal characteristics were similar between the 2 groups. The NLR was significantly higher in the SCF group when compared to the control group (2.3 ± 0.8 and 1.5 ± 0.4 respectively, P < .001). In multiple logistic regression analysis, NLR remained as the independent predictor of SCF (P < 0.001). CONCLUSIONS: Our findings showed that NLR was significantly higher in the SCF group when compared to the control group with normal coronary arteries. We also showed that NLR was related to the presence of SCF rather than the extent of SCF. Besides these findings, we also showed the NLR as an independent predictor of SCF.

Can Admission Neutrophil to Lymphocyte Ratio Predict Infarct-Related Artery Patency in ST-Segment Elevation Myocardial Infarction.

OBJECTIVES: In this study, we aimed to investigate the relationship between neutrophil to lymphocyte ratio (NLR) and infarct-related artery (IRA) patency in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: A total of 349 patients with STEMI were recruited to this retrospective study. Baseline characteristics were reviewed. Patency of IRA was evaluated by thrombolysis in myocardial infarction flow grade. RESULTS: Of all patients, 293 patients formed the occluded IRA group and 56 patients formed the patent IRA group. The NLR was significantly higher in occluded IRA group (4.4 ± 4.1 vs 1.9 ± 1.1, P < .001). Glucose levels were also higher in occluded IRA group (171.3 ± 78.0 vs 144.7 ± 49.7, P = .022). Regression analysis demonstrated admission NLR and plasma glucose levels as independent predictors of IRA patency. CONCLUSION: In this study, we found that admission NLR and glucose levels were higher in patients with occluded IRA than in patients with STEMI. We also found that NLR and glucose levels were independent predictors of IRA patency. Because hemogram is a cheap, fast, and widely available test, it can be used in daily practice as a predictor of IRA patency.

[Prevalence and clinical features of microfistulas between the coronary artery and left ventricle: single-center experience]. / Koroner arter ile sol ventrikül arasindaki mikrofistüllerin sikligi ve klinik özellikleri: tek merkez deneyimi.

OBJECTIVES: Coronary artery fistula is an infrequent malformation, and the prevalence was reported as approximately 0.1-0.4% in previous studies. However, the number of studies about microfistulas from coronary arteries to the left ventricle is inadequate, especially in the Turkish population. The purpose of this study was to evaluate the prevalence and clinical features of microfistulas in subjects undergoing coronary angiography for the assessment of coronary artery disease. STUDY DESIGN: In this retrospective study, we researched the cardiac catheterization laboratory database between January 2008 and July 2013. The presence of microfistulas was established according to the following criteria: 1) direct filling of the heart cavity during selective coronary injection without interposing "capillary" phase or venous filling, and 2) visualization of small vessels interposed between the epicardial coronary vessels and the heart cavity and emptying into the heart. RESULTS: Microfistulas were found in 12 (0.11%) of the 11403 coronary angiographies. There were 7 (58.3%) female patients (mean age, 70.2±10.8 years), and contemporary severe coronary artery stenosis was noted in 2 (16.7%) patients. Chest pain was the most frequently encountered complaint, followed by dyspnea. Microfistulas originated from the left anterior descending artery (100%), circumflex artery (66.7%), and right coronary artery (58.3%). In addition, multiple microfistulas were seen in 6 (50%) patients, bilateral microfistulas in 3 (25%) patients and unilateral microfistula in 3 (25%) patients, and all of them terminated in the left ventricle. CONCLUSION: Our study found an overall incidence of microfistulas of 0.11%. Microfistula is a rare cardiac anomaly that sometimes causes cardiac symptoms; otherwise, it is detected during routine coronary angiography.

An invasive but simple and accurate method for ascending aorta-femoral artery pulse wave velocity measurement.

INTRODUCTION: Pulse wave velocity (PWV) is an emerging predictor in the assessment of cardiovascular risk in diseased and healthy populations. We suggest a novel method for the accurate measurement of PWV. METHOD: PWV is calculated from pulse transit time using two separate pulse recordings over a known distance. 8F sheaths were placed in the right femoral arteries and routine coronary angiographies were performed with 5F diagnostic catheters. Ascending aorta pressures were measured with right diagnostic catheter tip in the ascending aorta and synchronous femoral artery pressures were measured with the sheath in the femoral artery. The distance between the two pressure sites was calculated as follows: total length of the right diagnostic catheter-length of the catheter outside the sheath-Sheath length. RESULTS: We evaluated the PWV measured using the catheter method in 24 subjects. PWV correlated positively and independently with age (p = 0.004), coronary artery disease (p = 0.04), ascending aorta systolic pressure (p = 0.006), femoral artery systolic pressure (p = 0.008), ascending aorta pulse pressure (p = 0.003) and femoral artery pulse pressure (p = 0.04). In coronary artery disease patients, the mean PWV value was significantly higher than in patients with normal coronary arteries (12.61 ± 6.31 m/s vs 7.58 ± 2.26 m/s p = 0.04). CONCLUSION: We describe a novel and accurate but invasive method for measurement of PWV. Our results may serve as a reference for non-invasive assessment of aorta-femoral artery PWV.