Safety of once- or twice-daily dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with nonvalvular atrial fibrillation: A NOAC-TR study.

Once-daily dosing of non-vitamin K antagonist oral anticoagulants (NOACs) may increase patient adherence to treatment but may also be associated with a higher risk of bleeding. In this study, we investigated the adherence to once- or twice-daily dosing of NOACs and the risk of bleeding in nonvalvular atrial fibrillation (NVAF) patients. This multicenter cross-sectional study, conducted between 1 September 2015 and 28 February 2016, included 2214 patients receiving NOACs for at least 3 months, due to NVAF. Patients receiving once-daily or twice-daily NOAC doses were 1:1 propensity score matched for baseline demographic characteristics and the presence of other diseases. The medication adherence was assessed by the 8-item Morisky Medication Adherence Scale. Risk factors were investigated in relation to minor and major bleeding. The mean age of patients was 71 ± 10 years, and 53% of the patients were women. The medication adherence was lower in patients receiving twice-daily NOAC doses compared to once-daily-dose group (47% versus 53%, p = 0.001), and there was no difference between the groups in terms of minor (15% versus 16%, p = 0.292) and major bleeding (3% versus 3%, p = 0.796). Independent risk factors for bleeding were non-adherence to medication (OR: 1.62, 95% CI: 1.23-2.14, p = 0.001), presence of 3 or more other diseases (OR: 10.3, 95% CI: 5.3-20.3, p < 0.001), and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol) score (OR: 4.84, 95% CI: 4.04-5.8, p < 0.001). In summary, the once-daily dose of NOACs was associated with increased patient adherence to medication, while it was not associated with bleeding complications.

Comparison of left atrial volume and function in non-dipper versus dipper hypertensives: A real-time three-dimensional echocardiography study.

OBJECTIVE: Non-dipper hypertension is associated with an increased cardiovascular morbidity and mortality. Besides this, the left atrial (LA) size and functions are accepted to be prognostic factors in various cardiovascular diseases. In this study, we aimed to evaluate the effect of nondipper hypertension on LA volume and functions using real-time three-dimensional echocardiography (RT3-DE). METHODS: Forty dipper and 52 non-dipper hypertensives enrolled in this prospective cross-sectional study. Patients with any comorbidities that have a potential for causing structural cardiac alterations were excluded. Two-dimensional echocardiography (2-DE) and RT3-DE were performed to assess LA volumes and functions. The statistical tests used in this study were Shapiro-Wilk's test, Student's t-test, Mann-Whitney U test, chi-square test, Spearman's test, and Pearson's correlation test. RESULTS: LA minimal volume, LA volume before LA contraction, and LA total systolic volume were higher in non-dipper hypertensives than in dipper hypertensives (p<0.001, p=0.003, and p=0.03, respectively). Only, the 2-DE measurements of interventricular septal thickness and E/Em ratio were higher in non-dipper hypertensives (p=0.001 and p=0.03, respectively). There was a moderate correlation between LA minimal volume and LA volume before LA contraction with E/Em (r=0.31, p=0.007 and r=0.32, p=0.005, respectively). CONCLUSION: Although LA volume and passive LA systolic functions measured by RT3-DE are significantly increased in non-dipper hypertensives, the alterations in active LA systolic functions are not prominent. RT-3DE may be used to define LA volume and function alterations in conditions that have capabilities of adverse cardiac remodeling such as systemic hypertension.

CHA2DS2-VASc-HS score in non-ST elevation acute coronary syndrome patients: assessment of coronary artery disease severity and complexity and comparison to other scoring systems in the prediction of in-hospital major adverse cardiovascular events.

OBJECTIVE: We recently described the CHA2DS2-VASc-HS score as a novel predictor of coronary artery disease (CAD) severity in stable CAD patients. We aimed to assess the accuracy of the CHA2DS2-VASc-HS score in the determination of CAD severity and complexity and its availability in the risk stratification of in-hospital major adverse cardiovascular events (MACE) in non-ST elevation acute coronary syndrome (NSTE-ACS) patients. METHODS: We prospectively analyzed the clinical and angiographic data of consecutive NSTE-ACS patients in our clinic. Patients were classified into three tertiles according to their SYNTAX score (SS): tertile 1 had an SS of 0-22; tertile 2 had an SS of 23-32; and tertile 3 had an SS of >32. There were no specific exclusion criteria except for previous coronary artery bypass grafting (CABG) because SS was validated for only native coronary arteries for this study. We used the following analyses: χ2 or Fisher's exact tests, one-way analysis of variance or Kruskal-Wallis tests, Pearson's or Spearman's tests, the receiver operating characteristics (ROC) curve analysis, the area under the curve (AUC) or C-statistic, and pairwise comparisons of the ROC curves. RESULTS: A total of 252 patients were enrolled. There were 131 patients in tertile 1, 79 in tertile 2, and 42 in tertile 3. The number of diseased vessels was correlated with the Global Registry for Acute Coronary Events (GRACE) (p<0.001), Thrombolysis in Myocardial Infarction (TIMI) (p<0.001), and CHA2DS2-VASc-HS (p<0.001) scores. In the ROC curve analyses, the cut-off value of the CHA2DS2-VASc-HS score in the prediction of in-hospital MACE was >5 with a sensitivity of 69.6% and specificity of 90.3% (AUC: 0.804, 95%: CI 0.750-0.851, p<0.001). We also compared the diagnostic accuracy of the CHA2DS2-VASc-HS score with the TIMI and GRACE risk scores in the determination of the in-hospital MACE and found no differences. CONCLUSION: The CHA2DS2-VASc-HS score was positively correlated with the severity and complexity of CAD. We also found that CHA2DS2-VASc-HS was comparable with other risk scores for the risk stratification of the in-hospital MACE of NSTE-ACS patients. Therefore, it may play an important role as a predictive model of NSTE-ACS patients in clinical practice.

Assessment of left atrial volume and mechanical functions using real-time three-dimensional echocardiography in patients with mitral annular calcification.

OBJECTIVE: Mitral annular calcification (MAC) is degeneration of the fibrous annular ring of the mitral valve. Left atrial (LA) function and volume have been evaluated by many methods; however, none have used real-time three-dimensional echocardiography (RT3DE) in patients with MAC. Our study is the first to evaluate LA volume and mechanical function using RT3DE in patients with MAC. METHODS: Our study was a prospective cross-sectional study. In total, 32 patients with echocardiographic evidence of MAC and 30 volunteers without MAC were enrolled in the study. Kolmogorov-Smirnov test, Student's t-test, Mann-Whitney U test, chi-square test, Pearson's correlation test, and multiple linear regression analyses were used in this study. RESULTS: LA diameter was significantly higher in patients with MAC (38.5±3.8 vs. 31.1±2.9, p<0.001). Maximum LA volume (49.6±11.2 vs. 35.6±2.5, p<0.001), minimum LA volume (23.8±7.9 vs. 12.6±2.3, p<0.001), and LA volume index (LAVI) (26.9±6.1 vs. 20.5±2.4, p<0.001) were also higher in the MAC group. LAVI was correlated with age (p<0.001), blood urea nitrogen levels (p=0.089), total cholesterol levels (p=0.055), left ventricular systolic myocardial velocity (p=0.048), E/A ratio (p<0.001), and MAC (p<0.001). Multiple linear regression analyses revealed that age (ß=0.390, p<0.001) and MAC (ß=0.527, p<0.001) were independent predictors of LAVI. CONCLUSION: We found that LA mechanical function was impaired in patients with MAC. Furthermore, age and MAC were independent predictors of increased LAVI according to our RT3DE examination.

Transradial Percutaneous Coronary Intervention in a Patient with a Rare Coronary Anomaly: Twin Circumflex Arteries.

UNLABELLED: Coronary artery anomalies are rare in population and most of them are found incidentally during coronary angiography. Percutaneous treatment of critical lesions on anomalous arteries may lead to difficulties due to their abnormal origin or course. Herein, we report a 65-year-old male patient presented with recent onset chest pain. Electrocardiogram and transthoracic echocardiography were in normal range. Treadmill exercise test revealed ST segment depression in lead V4-V6. Angiography revealed an unusual coronary anomaly: twin circumflex arteries originating from left main coronary artery and same orifice of right coronary artery, respectively. There was a significant stenosis on the right sided circumflex artery, which was treated percutaneously via transradial access. KEY WORDS: Coronary artery anomalies; Percutaneous coronary intervention; Transradial access; Twin circumflex arteries.

Mitral annular plane systolic excursion in the assessment of left ventricular diastolic dysfunction in obese adults.

OBJECTIVE: Mitral annular plane systolic excursion (MAPSE) is a simple way to assess left ventricle (LV) function. MAPSE is also correlated to parameters, illustrating the close relation between systolic and diastolic function of LV. In this study, we evaluated whether MAPSE could help us in the determination the LV diastolic dysfunction (DD) in obese adults. METHODS: Our study was a prospective cross-sectional study. Obese patients who were referred from the endocrinology clinic were enrolled into this study. The participants included 40 obese patients with early-stage DD (grade I and II) and 40 obese patients with normal diastolic function, with an equal number of males and females. The patients with DD were further divided into Obese DD+I, who had grade I DD, and Obese DD+II, who had grade II DD. Student t-test, Mann-Whitney U test, one-way analysis of variance, ROC curve analysis, and pairwise comparisons of the ROC curves were used for statistical analysis. RESULTS: MAPSE was different in all groups, with the lowest value in the Obese DD+II group (p<0.001). E/Em ratio was also different among all groups and was highest in the Obese DD+II group (p<0.001). Furthermore, MAPSE was negatively correlated with E/Em ratio (r=-0.368, p=0.020). The optimal threshold point of MAPSE in the diagnosis of left ventricle diastolic dysfunction (LVDD) was ≤1.45 cm, with 92.5% sensitivity (95% CI 79.6-98.4) and 77.5% specificity (95% CI 61.5-89.2) in the ROC curve analysis. There was no difference in the pairwise comparisons of the ROC curves of MAPSE and E/Em ratio in the diagnosis of DD [area under the ROC curve 0.902 (0.033) vs. 0.927 (0.027); p=0.54]. CONCLUSION: Consequently, we found significantly a close relationship between MAPSE with conventional echocardiographic parameters, especially with E/Em, in the detection of left ventricle diastolic dysfunction (LVDD) in obese adults with normal LV ejection fraction. We think that MAPSE is a simple, easily acquired and less time consuming measurement and may help us in the stratification of LVDD in obese adults.

Effects of the coronary collateral circulation on the Tp-e interval and Tp-e/QT ratio in patients with stable coronary artery disease.

BACKGROUND: The clinical utility of the Tp-e interval and Tp-e/QT ratio in the risk stratification of ventricular arrhythmic events is controversial. Therefore, we investigated the impact of CCC on these electrocardiographic indexes in the course of stable CAD. METHODS: Two hundred three consecutive patients with stable CAD who underwent coronary angiography and had documented total occlusion of one of the major coronary arteries were enrolled in this prospective cross-sectional study. The Tp-e interval and Tp-e/QT ratio were measured by 12-lead electrocardiogram. RESULTS: The Tp-e interval, cTp-e interval, Tp-e/QT ratio, and cTp-e/QT ratio were lower in the grade 3 CCC group compared with the others in all leads. Multivariate linear regression analyses was performed to identify the clinical factors affecting the cTp-e interval and was indicated that age (ß = 0.261, P < 0.001), male sex (ß = 0.334, P < 0.001), poor Rentrop grade (ß = -0.228, P < 0.001), and NLR (ß = 0.137, P = 0.027) were independent predictors of a prolonged cTp-e interval. CONCLUSION: It could be concluded that the decreased dispersion of ventricular repolarization might contribute to the lower incidence of ventricular arrhythmias and SCD in CAD patients with a good CCC.

Increased epicardial adipose tissue thickness on transthoracic echocardiography in patients with Behçet disease.

OBJECTIVES: Owing to the fact that the potential frequency of endothelial dysfunction and early atherosclerosis might be higher in Behçet disease, characterized by acute and chronic inflammatory attacks, it may lead to impairment in flow-mediated dilatation and an increase in epicardial adipose tissue thickness. Therefore, we aimed to evaluate whether epicardial adipose tissue thickness and brachial artery flow-mediated dilatation as markers of early atherosclerosis and endothelial dysfunction were associated with Behçet disease. METHODS: Thirty-five patients with Behçet disease and 35 healthy volunteers were included in this study. Epicardial adipose tissue was identified as an anechoic space between epicardial layers on 2-dimensional images, and its thickness was measured on the free wall of the right ventricle. Right brachial artery flow-mediated dilatation was assessed according to recent guidelines. RESULTS: Serum γ-glutamyl transferase (GGT) levels and epicardial adipose tissue thickness were significantly higher (P = .001; P < .001 respectively), whereas flow-mediated, endothelium-dependent dilatation was significantly lower in the Behçet disease group than controls (P < .001). There was a significant negative association between epicardial adipose tissue thickness and flow-mediated dilatation (P < .001). Epicardial adipose tissue thickness was also positively correlated with Behçet disease activity (P< .001), Behçet disease duration (P< .001), and waist circumference (P< .001). Flow-mediated dilatation was negatively correlated with GGT (P< .001), Behçet disease activity (P< .001), and age (P< .001). There was also a significant association between GGT and Behçet disease activity (P < .001). CONCLUSIONS: We found that epicardial adipose tissue thickness was significantly higher and flow-mediated dilatation was significantly lower in patients with Behçet disease than in controls. We suggest that identification of increased epicardial adipose tissue might aid in the diagnosis and treatment of possible coronary artery disease in patients with Behçet disease.

Effect of smoking on Tp-e interval, Tp-e/QT and Tp-e/QTc ratios as indices of ventricular arrhythmogenesis.

BACKGROUND: Smoking may lead to ventricular arrhythmias and sudden cardiac death via altering ventricular recovery time dispersion indices such as QT interval and QT dispersion (QTd). The Tp-e/QT and Tp-e/QTc ratios are also known as predictors of ventricular arrhythmogenesis. The aim of this study was to evaluate the relationship between cigarette smoking and ventricular repolarisation dispersion using these novel electrocardiographic parameters. METHODS: One hundred and twenty-one chronic smokers and 70 age- and sex-matched non-smoker controls were included in our study. The Tp-e interval and Tp-e/QT ratio were measured by 12-lead electrocardiogram, and corrected for heart rate. RESULTS: QTd (34.2 ± 8.4, 27.2 ± 10.4, P<0.001) and corrected QTd (37.3 ± 8.9, 29.8 ± 11.2, P<0.001) were significantly increased in the smokers compared to the non-smoker control group. The Tp-e interval (76.5 ± 6.3, 70.3 ± 6.8, P<0.001), cTp-e interval (83.5 ± 8.0, 77.1 ± 8.7, P<0.001), Tp-e/QT (0.20 ± 0.03, 0.19 ± 0.02, P<0.001) and Tp-e/QTc ratios (0.19 ± 0.02, 0.17 ± 0.02, P<0.001) were increased in the patient group when compared to the controls. Significant positive correlations were also found between the level of smoking with the cTp-e interval (r=0.836, P<0.001), and Tp-e/QT (r=0.714, P<0.001) and Tp-e/QTc ratios (r=0.448, P<0.001). CONCLUSION: We found in our study that cTp-e interval, Tp-e/QT and Tp-e/QTc ratios were increased in smokers and significantly correlated to the amount of smoking.

Large thrombus formation from right atrial incision site after closure of atrial septal defect.

Atrial septal defect (ASD) is the common congenital anomaly which requires surgical interventions. Right atrial thrombus formations after primary suture repairs of the ASD and evidences of thromboembolic complications are extremely rare. Specifically, the cases of thromboembolic complications have high mortality and morbidity risks. Two cases of giant intra-atrial thrombus formation detected in the late stage after primary repairs of ASDs are being discussed.