Orthostatic hypotension and age-related sarcopenia.

OBJECTIVES: This study aims to determine the association of sarcopenia with orthostatic hypotension (OH) which is a significant precursor to falls and related injuries in elderly patients. PATIENTS AND METHODS: A total of 91 outpatients (18 males, 73 females; mean age 79.3±4.0 years; range, 75 to 91 years) were prospectively enrolled and those who were eligible underwent comprehensive sarcopenia assessment including measurement of muscle mass, strength, physical performance, anthropometric measurements along with frailty tests. Patients classified as sarcopenic or non-sarcopenic based on these measurements underwent supine and standing blood pressure (BP) measurements. The frequency of OH was compared between the two groups. RESULTS: Of the 91 patients, 29 (31.9%) had sarcopenia. There was no statistical difference in measurements of functional tests which consisted of gait speed, timed up-and-go test and handgrip strength. However, timed sit-to-stand test values were higher in sarcopenic patients (18.2±7.9 vs. 15.0±5.1, p=0.04). Patients with sarcopenia developed OA and intolerance more often compared to the non-sarcopenic patients (n=15 [50.0%] vs. n=14 [23.0%], p<0.01 and n=13 [44.8%] vs. n=9 [15.3%], p<0.01, respectively). The adjusted odds ratio for sarcopenia was 7.80 (95% confidence interval 1.77-34.45), p=0.007. CONCLUSION: Age-related sarcopenia increases the risk of OA in the elderly. This may in part explain the increased incidence of falls and also help identification of risky elderly patients for orthostatic BP drops.

Assessment of electrocardiographic criteria for the diagnosis of left ventricular hypertrophy in the octogenarian population.

BACKGROUND: Although there are several electrocardiographic (ECG) diagnostic criteria for identifying left ventricular hypertrophy (LVH), the sensitivity of these criteria remains low. Recently, the Peguero-Lo Presti criterion provides a higher sensitivity than the current criteria. We aimed to test this ECG criterion prospectively, in the octogenarian population. METHODS: We prospectively enrolled outpatients over 80 years of age who were referred to our echocardiography laboratory. The Peguero-Lo Presti criterion was assessed along with other established ECG criteria. Left ventricular mass was calculated by echocardiography. Performance of ECG indices in diagnosing LVH were evaluated. RESULTS: Overall, 119 patients were included in the study. The sensitivity and specificity of the Peguero-Lo Presti criterion were 62.5% and 87.3%, respectively. In addition, the highest sensitivity belonged to the Peguero-Lo Presti criterion, and the highest AUC value was also seen in this criterion (AUC: 0.787, 95% CI, 0.698-0.876, P < .001). CONCLUSION: The Peguero-Lo Presti criteria showed the highest sensitivity for LVH detection, and it outperformed the other validated criteria in this octogenarian population. The Peguero-Lo Presti criteria seemed to be more effective for diagnosing LVH in this setting.

Clinical characteristics and intermediate-term outcomes of young patients with uncomplicated myopericarditis.

OBJECTIVE: Although the long-term prognosis of myopericarditis is good, recurrence continues to be a problem. In addition, there are concerns regarding the safety of the empirical use of anti-inflammatory drugs. This study was an investigation of the clinical outcomes of young patients with uncomplicated myopericarditis, the majority of whom received both nonsteroidal anti-inflammatory drugs and colchicine. METHODS: Patients aged 18 to 40 years who were admitted between May 2015 and May 2018 due to myopericarditis and had normal left ventricular function were included in the study. The primary outcome of the research was analysis of major adverse cardiac events (MACEs): all-cause mortality, myopericarditis recurrence, development of significant arrhythmia, heart failure, and cardiac tamponade. A total of 60 patients were included in the study. The median duration of follow-up was 19 months. RESULTS: A MACE occurred in 11.7% of the patients. None of the patients experienced heart failure, significant arrhythmia, cardiac tamponade, or all-cause mortality. Recurrence of myopericarditis was the only MACE observed. Most patients were treated with both nonsteroidal anti-inflammatory drugs and colchicine (96% and 95% of the patients, respectively). Univariate cox regression analysis indicated that only the maximum in-hospital C-reactive protein (CRP) level was associated with recurrence (hazard ratio: 1.01, 95% confidence interval: 1.01-1.02; p=0.04). CONCLUSION: The intermediate-term prognosis of myopericarditis patients was excellent in terms of mortality. However, recurrence remains a challenge. The role of CRP, particularly in recurrence, should be explored further.

Treatment of Simultaneous Thromboembolism of the Right and Left Coronary Arteries with Thrombus Aspiration in a Patient with a Prosthetic Mitral Valve.

Prosthetic heart valve thrombosis is a rare, difficult-to-treat condition that increases morbidity and mortality by leading to systemic embolism. Clinically, it presents mainly in the form of stroke, though an embolism be observed in many systems. Acute coronary syndrome, which is rarely observed in patients with a prosthetic heart valve, mostly occurs as non-ST segment elevation myocardial infarction (MI). There is no specific recommendation for the treatment of this condition. Revascularization success rates have been shown to be variable in cases wherein thrombolytic therapy, balloon angioplasty, stent implantation, and a combination of all of these techniques are used. Herein are presented details of the successful revascularization of a patient with ST segment elevation MI presenting with simultaneous right and left coronary system embolism, and without embolism in any other system. In cases of acute coronary syndrome in patients with a prosthetic heart valve with no known coronary artery disease, starting the procedure with thrombus aspiration may prevent unnecessary stent and balloon angioplasty procedures being required, by accelerating the revascularization process.

Evaluation of Subtle Left Ventricular Systolic Dysfunction by Longitudinal Systolic Strain in Patients with Human Immunodeficiency Virus.

BACKGROUND: Although left ventricular systolic dysfunction (LVSD) is a major cause of morbidity in human immunodeficiency virus (HIV)-infected patients, there is limited data on cardiac functions of these patients. Compared to the conventional echocardiography, the global longitudinal strain (GLS) can detect subclinical myocardial dysfunction at an earlier stage. OBJECTIVES: In our study, we aimed to evaluate left ventricular systolic functions using the GLS in HIV-infected patients and to investigate the effect of cluster of differentiation 4 T-cell values on LVSD. METHODS: This prospective, case-control study included a total of 65 HIV-infected patients and 48 healthy volunteers. Conventional and strain echocardiography were performed on all participants. In HIV-infected patients, CD4 T-cell counts and HIV-ribonucleic acid (HIV-RNA) values were measured. RESULTS: The median CD4 T-cell count was 529.65 cells/mm3 in the HIV-infected patients and median duration of living with HIV was 16.25 (range: 2 to 120) months. Baseline characteristics and left ventricular ejection fraction values were similar in both groups. However, there was a significant difference in the low-density lipoprotein cholesterol, triglycerides, interventricular septum, left ventricular posterior wall, and GLS between the groups (p = 0.013, p = 0.005, 0.041, p = 0.013, and p = 0.003, respectively). There was a positive correlation between GLS and CD4 levels (r = 0.463, p < 0.001). CONCLUSIONS: Our study results suggest that reduced CD4 T-cell counts in HIV-infected patients may cause myocardial dysfunction and GLS can be useful to show subtle LVSD asymptomatic cases.

Persistent smoking rate after coronary revascularization and factors related to smoking cessation in Turkey.

Background: Although smoking is an established risk factor for coronary artery disease, smoking cessation efforts, as part of a lifestyle change, have been disappointing so far. Therefore, assessing current smoking trends and identifying patients who are at risk of smoking continuation is of paramount importance. In this study, our aim was to assess current smoking rates after coronary revascularization as of 2017, and to define factors that potentially affect smoking cessation. Methods: Overall, 350 patients who had undergone coronary revascularization, either by percutaneous coronary intervention or bypass surgery were included in this cross-sectional, observational study. Patients were queried for various sociodemographic characteristics and smoking habits. Disease related data were obtained from the hospital archives. Results: The overall smoking rate was 57% after coronary revascularization. Age, bypass surgery and the occurrence of in-hospital adverse events were found to be independent predictors of smoking cessation in multivariate analysis. Conclusions: Despite efforts, smoking rates after coronary intervention remain substantially high. Therefore, a multidisciplinary approach to smoking cessation that incorporates cardiac rehabilitation programs and medications should be implemented in clinical practice.

Relationship between a fragmented QRS and microalbuminuria in patients with type 2 diabetes mellitus.

INTRODUCTION: Microalbuminuria (MAU), a complication of diabetes, is closely related to cardiovascular events. A fragmented QRS (fQRS) in the electrocardiogram (ECG) was found to be strongly associated to cardiovascular morbidity and mortality. OBJECTIVE: The aim of this study was to assess the association between a fQRS and MAU in patients with type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS: One hundred and twenty-seven patients (mean age, 50.49 years; 44.01% male) with T2DM of at least six months duration and at least two urine albumin/creatinine ratios (ACRs) available were enrolled into the study between December 2015 and May 2016. All patients underwent ECG and echocardiography, and were taken blood and urine samples. Patients were divided into two groups according to presence of fQRS (group 1) or absence of fQRS (group 2). RESULTS: Both groups had similar baseline characteristics. MAU and glycosylated hemoglobin (HbA1c) levels and left ventricular end-diastolic diameter (LVEDd) were increased in patients with a fQRS in the ECG (p=0.002, p=0.02, and p=0.007, respectively). Univariate and multivariate logistic regression analysis showed MAU and an increased LVEDd to be independent risk factors for the presence of a fQRS in the ECG of T2DM patients. DISCUSSION AND CONCLUSIONS: In this study, a fQRS was associated to MAU. In T2DM, MAU may be related to subclinical diastolic and systolic dysfunction.

Four-Dimensional Speckle Tracking Echocardiography in Patients with Hypertrophic Cardiomyopathy.

OBJECTIVE: Abnormal left ventricular (LV) deformational mechanics have been demonstrated in patients with hypertrophic cardiomyopathy (HCM) using two-dimensional (2D) speckle tracking echocardiography, but there is not enough information about the four-dimensional speckle tracking echocardiography (4DSTE) in these patients. The objective of the study was to identify and quantify the left ventricular contractility in patients with HCM using 4DSTE. METHODS: Thirty patients [age, 54.6 ± 12.1 years; 12 (40%) women] with diagnosis of nonobstructive HCM and 20 healthy controls [age, 47.42 ± 11.43 years; 8 (40%) women] underwent 4DSTE measurement of longitudinal, radial, circumferential, and area strains. RESULTS: Patients with HCM showed lower longitudinal (-13.5% vs. -20.3%, P < 0.001) and radial (33.4% vs. 43.6%, P < 0.001) strain, but higher circumferential (-22.7% vs. -15.9%, P < 0.001) and area (-30.7% vs. -22.1%, P < 0.001) strain than control subjects. Peak LV twist showed significantly higher values in patients with HCM (13.7 ± 5.3 vs. 11.3 ± 4.8, P < 0.005). CONCLUSIONS: Patients with HCM have reduced longitudinal and radial strain but increased circumferential and area strain on 4DSTE. These results are found appropriate with previous 2DSTE studies. Thus, 4DSTE is useful to determine LV deformational mechanics.

Value of stress echocardiography in mitral stenosis.

Mitral stenosis (MS) is a common disease that causes substantial morbidity. Timely recognition and treatment of the mitral stenotic lesion is very important. Stress echocardiography plays an important role in evaluating asymptomatic patients with significant mitral stenosis and symptomatic patients with only mild disease at rest. In patients with mitral stenosis, stress echocardiography protocols assess for the change in the mean transmitral pressure gradient and a peak pulmonary artery systolic pressure during exercise. In this review, clinical use of stress echocardiography in patients with mitral stenosis is summarized.

The relationship between chronic kidney disease and SYNTAX score.

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease and death. We evaluated the association between CKD and severity of coronary artery stenosis by calculating SYNTAX Score in patients with left main coronary artery and/or 3-vessel coronary artery disease. Coronary angiograms of 217 patients were assessed. Chronic kidney disease was staged using the estimated glomerular filtration rate (eGFR, mL/min per 1.73 m(2)) prior to coronary angiography. Patients were divided into 5 groups according to the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines (14). Patients with eGFR >90 mL/min per 1.73 m(2) (group 1), patients with eGFR 60 to 89 mL/min per 1.73 m(2) (group 2), patients with eGFR 30 to 59 mL/min per 1.73 m(2) (group 3), patients with eGFR >15 to < 30 per 1.73 m(2) and dialysis patients with eGFR < 15 per 1.73 m(2) were combined as group 4. The risk of significant lesion complexity increased progressively with decreasing kidney function (P = .001). Estimated glomerular filtration rate was a strong predictor of higher SYNTAX Score.

Immediate and follow-up results of repeat percutaneous mitral balloon commissurotomy for restenosis after a succesful first procedure.

BACKGROUND: The widespread use of percutaneous mitral commissurotomy (PMC) has led to an increase in restenosis cases. The data regarding follow-up results of repeat PMC are quite limited. The aim of this retrospective analysis is to evaluate the immediate and midterm results of the second PMC, in patients with symptomatic mitral restenosis after a succesful first procedure. METHODS: Twenty patients (95% female, mean age 37 ± 4 years) who have undergone a second PMC, 6.3 ± 2.5 years after a first successful intervention built the study group. All were in sinus rhythm, with a mean Wilkins score of 8.5 ± 1.2. RESULTS: The valve area increased from 1.2 ± 0.2 to 1.9 ± 0.2 cm(2) and mean gradient decreased from 10.5 ± 3.4 to 6.1 ± 1.1 mmHg. There were no complications except for a transient embolic event without sequela (5%) and two cases (10%) of severe mitral regurgitation. The immediate success rate was 90%. The mean follow-up was 70 ± 29 months (36-156 months). The 5-year restenosis and intervention (repeat PMC or valve replacement) rates were 9.1 ± 5.2% and 3.6 ± 3.3%, respectively. The intervention free 5-year survival in good functional capacity (New York Heart Association [NYHA] I-II) was 95.1 ± 5.5% and restenosis and intervention free 5-year survival with good functional capacity was 89.7 ± 6.8%. CONCLUSIONS: Although from a limited number of selected patients, these findings indicate that repeat PMC is a safe and effective method, with follow-up results similar to a first intervention and should be considered as the first therapeutic option in suitable patients.

Clear depiction of inflammatory abdominal aortic aneurysm with diffusion-weighted magnetic resonance imaging.

We report the case of an inflammatory abdominal aortic aneurysm incidentally detected clearly with diffusion-weighted magnetic resonance imaging (DW-MRI) during the examination of a patient with myelofibrosis with myeloid metaplasia that later converted to acute myeloid leukemia. DW-MRI revealed a hyperintense halo surrounding the abdominal aorta with aneurysmatic dilatation, establishing the diagnosis.

Recurrent thrombotic RCA occlusions due to exaggerated stent protrusion into the aorta.

We report a case with exaggerated stent protrusion from the right coronary ostium into the aorta leading to recurrent inferoposterior and right ventricular myocardial infarctions due to stent thrombosis, which were treated successfully with fibrinolysis. The stent was removed via transverse aortotomy and two bypass grafts were performed. Stents protruding from the aorta may not only cause technical difficulties but also carry a high risk of thrombosis.