Screening for pulmonary arterial hypertension in patients with systemic sclerosis in the era of new pulmonary arterial hypertension definitions.

OBJECTIVES: This study compares the performance of three composite pulmonary arterial hypertension (PAH) screening tools in a real-life SSc cohort, according to both the previous 2015 ESC/ERS guideline and the recent 2022 ESC/ERS guideline haemodynamic criteria. METHODS: Consecutive SSc patients without a previous diagnosis of pulmonary hypertension (PH) were screened for PAH using the European Society of Cardiology/European Respiratory Society (ESC/ERS), DETECT, and Australian Scleroderma Interest Group (ASIG) algorithms. Right heart catheterisation (RHC) referral performances for PAH were compared according to the 2022 ESC/ERS PAH criteria. RESULTS: Thirty-five of the 81 patients required RHC; 15 (18.5%) according to ESC/ERS, 27 (33.3%) according to DETECT, and 25 (31%) according to ASIG. The final diagnoses were no-PH in 17 patients, WHO group 1 PH (PAH) in 8 patients, WHO group 2 PH in 8 patients, and WHO group 3 PH in 2 patients. When the hemodynamic criteria of the previous ESC/ERS guideline were applied, only one patient was diagnosed with PAH. The sensitivities of the algorithms for the diagnosis of PAH were 62.5% for ESC/ERS, 75% for DETECT, 87.5% for ASIG according to the 2022 ESC/ERS guideline definition, and 100% for all according to the previous ESC/ERS guideline. CONCLUSIONS: With the recent criteria, PAH diagnosis in patients with SSc increased by 1.8-fold. Current algorithms for screening PAH are less sensitive with these revised criteria. Although the ASIG algorithm seems more sensitive, it can still miss the diagnosis. The multimodal/algorithmic approach seems to be the best option for predicting PAH.

Pulmonary Hypertension Due to High-Output Heart Failure: Hereditary Hemorrhagic Telangiectasia.

Pulmonary hypertension (PH) is a complex disorder that should be managed with a multidisciplinary approach. Although most of the underlying causes of left heart disease can be easily diagnosed with cardiac imaging, some pathologies might necessitate careful investigation to go beyond the obvious. High-output heart failure (HF) due to arteriovenous malformation (AVMs) is an unnoticeable cause for HF and PH. Patients with hepatic AVMs should always be carefully evaluated with regard to hereditary hemorrhagic telangiectasia (HHT) since they can have multiple signs related to the other systems without any symptoms. In this case report, we discussed a patient who was initially diagnosed as PH associated with HF with preserved ejection fraction but eventually was found to have PH associated with high-output HF due to hereditary hemorrhagic telangiectasia (HHT, or Osler Weber Rendu syndrome) after detailed evaluation.

Risk Assessment Tool Implementation in Congenital Heart Disease-Associated Pulmonary Arterial Hypertension.

BACKGROUND: Risk assessment is recommended for patients with congenital heart disease-associated pulmonary arterial hypertension. This study aims to compare an abbreviated version of the risk assessment strategy, noninvasive French model, and an abridged version of the Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management 2.0 risk score calculator, Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management Lite 2. METHODS: We enrolled a mixed prevalent and incident cohort of patients with congenital heart disease-associated pulmonary arterial hypertension (n = 126). Noninvasive French model comprising World Health Organization functional class, 6-minute walk distance, and N-terminal pro-hormone of brain natriuretic peptide or brain natriuretic peptide was used. Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management Lite 2 includes functional class, systolic blood pressure, heart rate, 6-minute walk distance, brain natriuretic peptide/N-terminal pro-hormone of brain natriuretic peptide, and estimated glomerular filtration rate. RESULTS: The mean age was 32.17 ± 16.3 years. The mean follow-up was 99.41 ± 58.2 months. Thirty-two patients died during follow-up period. Most patients were Eisenmenger syndrome (31%) and simple defects (29.4%). Most patients received monotherapy (76.2%). Most patients were World Health Organization functional class I-II (66.6%). Both models effectively identified risk in our cohort (P =.0001). Patients achieving 2 or 3 noninva-sive low-risk criteria or low-risk category by Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management Lite 2 at follow-up had a significantly reduced risk of death. Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management Lite 2 approximates noninvasive French model at discriminating among patients based on c-index. Age, high risk by Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management Lite 2, and the presence of 2 or 3 low-risk criteria by noninvasive French model emerged as an independent predictors of mortality (multivariate hazard ratio: 1.031, 95% CI: 1.005-1.058, P =.02; hazard ratio: 4.258, CI: 1.143-15.860, P =.031; hazard ratio: 0.095, CI: 0.013-0.672, P =.018, respectively). CONCLUSIONS: Both abbreviated risk assessment tools may provide a simplified and robust method of risk assessment for congenital heart disease-associated pulmonary arterial hypertension. Patients not achieving low risk at follow-up may benefit from aggressive use of available therapies.

Non-dominant right coronary artery (RCA) is associated with suspected inferior ischemia on SPECT in patients without significant coronary artery disease (CAD).

OBJECTIVE: There is a huge uncertainty in the medical community regarding the significance of non-dominant right coronary artery (RCA) in patients with inferior wall ischemia on myocardial perfusion single-photon emission computed tomography (SPECT). The purpose of this study is to determine the effect of non-dominant RCA on myocardial perfusion SPECT (MPS) with respect to the misleading detection of ischemia in the inferior wall of the myocardium. METHODS: This is a retrospective study of 155 patients, who had undergone elective coronary angiography owing to an indication of inferior wall ischemia by MPS between 2012 and 2017. Patients were divided into two groups based on the coronary dominance: group 1 (n = 107), if RCA is the dominant artery, and group 2 (n = 48), if there are dominance of left artery and codominance of both arteries. Obstructive CAD was diagnosed in the case of stenosis that had severity greater than 50%. The positive predictive value (PPV), which was calculated as per the correlation between the inferior wall ischemia in MPS and obstruction level in RCA, was compared in both groups. RESULTS: Majority of patients were male (109, 70%) and the mean age was 59.5 ± 10.2. There were 45 patients with obstructive RCA disease (PPV: 42%) among 107 patients in group 1, whereas there were only 8 patients with obstructive coronary artery disease (CAD) in RCA among 48 patients in group 2, (PPV: 16% and p = 0.004). CONCLUSIONS: The results demonstrated that non-dominant RCA is associated with false-positive detection of inferior wall ischemia via MPS.

Effects of obesity on arrhythmic events and survival in patients with an implantable cardioverter defibrillator.

Background    Studies have shown that increased body weight and obesity may be associated with an increased risk of arrhythmic events. The aim of this study was to evaluate the effect of obesity on the risk of arrhythmic events, hospitalization, and death in patients who received implantable cardioverter defibrillator (ICD) therapy for primary or secondary prevention.Material and Methods    A single-center, prospective, observational study was conducted. Patients with body mass index (BMI) <30 kg / m2 were classified as non-obese, and patients with BMI ≥30 kg / m2 were classified as obese. The primary endpoints were arrhythmic events and device interventions. The secondary endpoints were all-cause mortality, cardiac mortality, cardiac rehospitalization, and a composite endpoint of mortality and hospitalization.Results    Among a total of 340 patients, 78.2 % were male, and 22.1 % were obese. The mean age was 60.9 yrs. Ventricular tachycardia (VT) was more frequent in non-obese patients (HR 0.57, [CI] 0.38-0.87, p=0.009). All-cause mortality and cardiac mortality in all patients tended to be more frequent in non-obese (HR 2.71, [CI] 0.93-7.93, p= 0.069 for all-cause mortality; HR 3.29, [CI] 0.97-11.17, p=0.056 for cardiac mortality). In the subgroup analysis, VT, all-cause mortality, and cardiac mortality were more common for non-obese patients in primary prevention and ischemic heart failure (HF) groups.Conclusion    While VT was more frequent in non-obese patients, VF, ICD appropriate shock, inappropriate shock, and antitachycardia pacing were similar in obese and non-obese patients. All-cause mortality and cardiac mortality were more frequent in non-obese patients.

Lipid Modification to Reduce Cardiovascular Risk in Secondary Prevention Patients with Special Emphasis on PCSK9 Inhibitor Requirement: An Analysis Based on Delphi Panel Approach.

OBJECTIVE: The aim of this study is to analyze the low-density lipoprotein cholesterol-lowering therapies in secondary prevention patients by analyzing their plasma low-density lipoprotein cholesterol levels, current treatment, considering their inadequate response to medications (as defined in current guidelines), and the requirement for a protein convertase subtilisin/kexin type 9 inhibitor. METHODS: Delphi panel is used to seek expert consensus of experienced 12 cardiologists. A questionnaire consisting of 6 main questions is used to reflect the opinion of the expert panelists on the practices of low-density lipoprotein cholesterol-lowering therapies of patients with high and very high cardiovascular risk. Patients with atherosclerotic cardiovascular disease are covered in this present analysis. RESULTS: According to expert opinion data, 18.6% of the patient population with atherosclerotic cardiovascular disease is estimated to have experienced recurrent vascular events. The current treatment of the patient population is 39.7% on high dose, 36.9% on low/moderate dose of statin, 13.1% on maximum tolerated dose statin+ezetimibe, and 1.2% on maximum tolerated dose statin+ezetimibe+protein convertase subtilisin/kexin type 9 inhibitor. The percentage of atherosclerotic cardiovascular disease patients with inadequate treatment response is estimated to be 20.2% in those using "maximum tolerated dose statin+ezetimibe." The proportion of patients who will need to be treated with a protein convertase subtilisin/kexin type 9 inhibitor increases as their low-density lipoprotein cholesterol levels rises from 9.1% in 70-99 mg/dL to 50.8% in ≥160 mg/dL for these patients. CONCLUSION: According to expert opinion, although a substantial proportion of patients with secondary prevention have not achieved low-density lipoprotein cholesterol goals, the use of protein convertase subtilisin/kexin type 9 inhibitors is very low. Since the questionnaire subject to panel discussion did not include any question elaborating the issue, the discrepancy between the recommendation of the related guidelines and Turkish practice needs further studies for the explanation.

The validation of left atrial strain imaging for the assessment of diastolic functions in patients with ST-segment elevation myocardial infarction.

Assessment of left ventricular filling pressure (LVFP) is crucial in patients with ST-segment elevation myocardial infarction (STEMI). Since current guideline recommended echocardiographic parameters have limited value, more comprehensive assessment methods are required in this patient subset.In this study, we aimed to investigate the clinical utility of left atrial reservoir strain (LARS) imaging in patients treated with primary percutaneous coronary intervention (pPCI). Patients who underwent successful pPCI were included. Left ventricular end-diastolic pressure (LVEDP) was measured invasively following pPCI. Left atrial strain imaging was performed following pPCI within 24 h of pPCI. Normal LARS value was accepted as above 23%. We prospectively enrolled 69 patients; there were 18 patients with LARS below 23% who were included into group 1 and rest of the study population included into group 2. There was no significant difference between groups in terms of comorbidities.Troponin and pro-BNP levels were significantly higher in group 1 (p: 0.036 and 0.047 respectively). Left atrial volume and tricuspid regurgitation velocity were similar between groups (p: 0.416 and p: 0.351 respectively). Septal tissue velocity was higher (p: 0.001) and Septal E/e' ratio was lower (p: 0.004) in group 2. Left ventricular (LV) global longitudinal strain value was higher in group 1 which is consistent with observed lower ejection (LVEF) fraction in group 1 (p: 0.001 for LV strain and p: 0.001 for LVEF). Estimated mean LVFP was also higher in group 1 (p: 0.003).Correlation analyses revealed moderate correlation between LARS and LVEDP (r: - 0.300). Our results indicate that left atrial strain imaging is a promising tool for the assessment of left atrial pressure in patients with STEMI.

A 19-Year-Old Pregnant Woman With Pulmonary Hypertension With Progressive Dyspnea.

CASE PRESENTATION: A 19-year-old pregnant woman at week 32 of gestation was referred to our clinic with progressive shortness of breath for the further evaluation and treatment of high-risk pregnancy. Her complaints had been existing since her childhood. Two years prior to her admission, she had been diagnosed with heart failure with preserved ejection fraction due to cardiomyopathy and associated pulmonary hypertension. The patient had no family history of any cardiac disease. She had never smoked or drunk alcohol. Her clinical condition had deteriorated progressively with the pregnancy.

Echocardiographic assessment of left ventricular filling pressure in patients with acute ST elevation myocardial infarction: an invasive validation study.

Backgrounds Assessment of left ventricular filling pressure (LVFP) is of clinical importance in patients with ST elevation myocardial infarction (STEMI). Although several echocardiographic parameters are recommended for the assessment of LVFP, validation of these parameters in patients with STEMI is missing. We aimed to investigate the clinical utility of these parameters in acute settings. Methods: We prospectively included consecutive patients with STEMI. LV end-diastolic pressure (LVEDP) was measured following primary PCI and echocardiographic examination was performed within 24 hours. Mean left atrial pressure (mLAP) was calculated both invasively using Yamamoto's formula and non-invasively using Naugeh's formula. Mean LAP was considered increased when exceeded 18 mmHg. Results: Patients were grouped according to LVEDP, group 1(41 patients) and group 2(114 patients).There was no significant difference between groups in terms of comorbidities. NT pro-BNP levels (p < 0.001) and peak level of Hs-TnT (p-value: 0.002) were significantly higher in group 2. Average E/e' ratio was significantly higher in group 2 (10.19 ± 3.15 vs. 12.04 ± 4.83, p: 0.046). Isovolumetric relaxation time was longer in group 2 (p < 0.001) and left atrial volume index (LAVI) was also significantly higher in group 2 (p < 0.001). Regression analyses revealed that septal, lateral and average E/e' ratio, tricuspid regurgitation velocity, LAVI and left ventricular volume are correlated with mLAP. Among group 2 patients only 14 Patients fulfilled the increased LVFP criteria suggested by current guidelines. Conclusions Echocardiographic parameters indicating increased LVFP require validation and may need to be modified in patients with STEMI. Moreover, current algorithms underestimate the actual number of patients with increased LVFP.

Dual antithrombotic therapy with dabigatran in patients with atrial fibrillation after percutaneous coronary intervention for ST-segment elevation myocardial infarction: a post hoc analysis of the randomised RE-DUAL PCI trial.

BACKGROUND: Little is known about the optimal antithrombotic therapy in patients with atrial fibrillation undergoing PCI for ST-elevation myocardial infarction (STEMI). AIMS: The aim of this study was to investigate the safety and efficacy of dabigatran dual therapy (110 or 150 mg twice daily, plus clopidogrel or ticagrelor) versus warfarin triple therapy in patients with atrial fibrillation and STEMI. METHODS: In the RE-DUAL PCI trial, 305 patients with STEMI were randomised to dabigatran 110 mg (n=113 versus 106 warfarin) or 150 mg (n=86 versus 84 warfarin). The primary endpoint was the time to first major/clinically relevant non-major bleeding event (MBE/CRNMBE). The thrombotic endpoint was a composite of death, thromboembolic events, or unplanned revascularisation. RESULTS: In STEMI patients, dabigatran 110 mg (HR 0.39, 95% CI: 0.20-0.74) and 150 mg (0.43, 0.21-0.89) dual therapy reduced the risk of MBE/CRNMBE versus warfarin triple therapy (p for interaction vs all other patients=0.31 and 0.16). The risk of thrombotic events for dabigatran 110 mg (HR 1.61, 95% CI: 0.85-3.08) and 150 mg (0.56, 0.20-1.51) had p interactions of 0.20 and 0.33, respectively. For net clinical benefit, the HRs were 0.74 (95% CI: 0.46-1.17) and 0.49 (0.27-0.91) for dabigatran 110 and 150 mg (p for interaction=0.80 and 0.12), respectively. CONCLUSIONS: After PCI for STEMI, patients on dabigatran dual therapy had lower risks of bleeding events versus warfarin triple therapy with similar risks of thromboembolic events, supporting dabigatran dual therapy even in patients with high thrombotic risk.

Chronic thromboembolic pulmonary hypertension in patients with persistent chest symptoms after acute pulmonary embolism.

OBJECTIVE: This study aimed to analyze the role of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with persistent chest symptoms after acute PE. METHODS: Patients aged between 18 and 80 years who were followed up for acute PE were screened for chest symptoms which persisted after the anticoagulation treatment. Patients suffering other types of pulmonary hypertension (PH) or metastatic malignancies were excluded in this study. Demographic and functional data of patients included this study were collected. The patients underwent transthoracic echocardiography and ventilation/perfusion (VQ) scans. Also, invasive hemodynamic studies were done to patients with intermediate/high probability of VQ scans. RESULTS: Of the 140 patients screen for this study, 29 patients (Female/Male=16/13) with mean age of 56.1±11.2 years and follow-up time of 35.1±17.7 months met the inclusion criteria. The mean systolic pulmonary artery blood pressure (sPAP) on transthoracic echocardiography was 28.9±4.9 mm Hg (range=20-40 mm Hg). Furthermore, intermediate or high probability of VQ scans was detected in 2 patients, who were subsequently diagnosed with CTEPH (6.9%) via right heart catheterization. CONCLUSION: CTEPH was diagnosed at a low rate in patients with persistent chest symptoms after the anticoagulation treatment for PE. CTEPH is still an elusive entity, which requires a multidisciplinary and invasive approach.

The impact of lesion complexity on no-reflow phenomenon and predictors of reversibility in patients treated with primary percutaneous intervention.

OBJECTIVES: Complex coronary lesions are more prone to complications; however, the relationship between complex coronary lesions and no-reflow phenomenon in patients undergoing primary percutaneous intervention (pPCI) is still not clarified. Previous studies reported the association of total coronary artery complexity with no-reflow; however, impact of culprit lesion complexity on no-reflow is not known. In this study, we aimed to investigate the impact of culprit lesion complexity on no-reflow phenomenon. Furthermore, we aimed to investigate the factors that are related to reversibility of no-reflow. METHODS: We prospectively included 424 patients treated with pPCI. Patients' baseline characteristics and clinical variables were recorded. Reversibility of no-reflow was decided according to final angiography or ST resolution during the first hour following pPCI. There were 90 patients with a diagnosis of no-reflow constituted group 1 and patients without no-reflow constituted group 2. Complexity of coronary artery disease was assessed with SYNTAX score and culprit lesion complexity was assessed with both American College of Cardiology/Society of Cardiovascular Angiography and Interventions lesion classification and SYNTAX score. RESULTS: Complexity of culprit lesion was significantly higher in group 1 patients (type C lesion 76.6 vs. 27.8%; P < 0.001 and SYNTAX score 8.7 ± 3.0 vs. 6.2 ± 2.6; P < 0.001, respectively, group 1 vs. 2). Multivariate analyses revealed that lesion complexity is independently associated with no-reflow. Among 90 patients of group 1, 43 patients were classified as reversible no-reflow. Logistic regression analysis revealed that only ischaemia duration is independently associated with reversibility of no-reflow. CONCLUSION: Our study demonstrated that culprit lesion complexity is independently associated with no-reflow phenomenon and short ischaemic duration is significantly associated with reversibility of no-reflow.

Management of periprocedural anticoagulant therapy: a novel individualized approach-a transeusophageal echocardiographic study.

Patients with non-valvular atrial fibrillation who are under chronic oral anticoagulant therapy (OAC) treatment frequently require interruption of OAC treatment. By examining the presence of left atrial/left atrial appendage (LA/LAA) thrombus or dense spontaneous echo contrast (SEC) with transesophageal echocardiography (TEE) we aimed to develop an individualized strategy. To test the validity of CHA2DS2VASc score based recommendations was our secondary purpose. In this prospective study patients with non-valvular atrial fibrillation on OAC therapy were included. Patients' baseline characteristics, CHA2DS2VASc and HASBLED scores, medications, type of invasive procedures and clinical events were recorded. Each patient underwent to TEE examination prior to the invasive procedure. Bridging anticoagulation was recommended only to patients with LA/LAA thrombus. We included 155 patients and mean CHA2DS2VASc score of the study population was 3.4 ± 1.4. Seventy-one of them had LA/LAA thrombi or SEC on TEE examination and bridging anticoagulation was applied. OAC treatment was not bridged in 8 of 11 patients with prior cerebrovascular accident and 17 of 31 patients with CHA2DS2VASc score of > 4. 57 of 124 patients with CHA2DS2VASc score of ≤ 4 required bridging anticoagulation. There were 14 major bleedings decided according to ISTH bleeding classification. Major bleeding was observed only in patients underwent to high-risk bleeding procedure. In conclusion CHA2DS2VASc score by itself is not enough for decision-making regarding ischemic risk. Furthermore, since major bleedings occurred only in patients underwent to high-risk bleeding surgery, TEE-based individualisation may be a feasible approach particularly for those with high thromboembolic risk undergoing high-bleeding risk procedure.

Left atrial thrombus in patients with atrial fibrillation and under oral anticoagulant therapy; 3-D transesophageal echocardiographic study.

Ischemic stroke is the major complication of atrial fibrillation (AF) and only proven preventive therapy is oral anticoagulant therapy (OAC). Previous studies reported the presence of thrombus in the left atrium (LA) or left atrial appendage (LAA) despite anticoagulant therapy. We aim to investigate the predictors of LA/LAA thrombus in patients under OAC therapy and long-term clinical impact of thrombus. We prospectively enrolled consecutive patients with permanent AF under OAC therapy. Patients baseline characteristics were recorded. Transesophageal echocardiographic study performed after complete transthoracic echocardiographic study. 3-D evaluation of LAA was made using 3-D zoom mode and thrombus was defined when echo reflecting, mobile mass detected. Patients clinical outcomes were decided according to hospital records or via phone calls. Among 184 patients, 28 LAT were detected. Mean CHA2DS2-VASc score was significantly higher in patients with LAT in comparison to patients without LAT. CHA2DS2-VASc score (p: 0.001), left atrial volume (p: 0.001), left atrial flow velocity (p: 0.006) and left ventricular ejection fraction (p: 0.014) were independently associated with LAT. Among the parameters in CHA2DS2-VASc score, the previous history of stroke and age were independently related to LAT. After 12 months of follow-up, patients with LAT had more ischemic stroke than patients without LAT (7.1% vs 4.4%, p: 0.001 respectively). Although oral anticoagulation is the default treatment strategy for prevention of LAT and thromboembolism in patients with non-valvular AF, LAT still can be detected especially in patients with a high CHA2DS2-VASc score. Furthermore, the presence of LAT is significantly associated with future ischemic stroke.

[Evaluation of statin use on LDL cholesterol levels in Turkey: A systematic review]. / Türkiye'de statin kullaniminin LDL-kolesterol düzeyleri üzerine etkisinin degerlendirildigi sistematik derleme.

OBJECTIVE: The aim of this study was to examine and present the effect of statin treatment on the low-density lipoprotein (LDL) cholesterol level of patients in Turkey by evaluating the data of studies conducted in the country. METHODS: Manuscripts published between January 1, 2008 and December 31, 2017 with terms 'LDL' and 'TURK' in the title or abstract and reporting LDL cholesterol data of patients treated with statins were evaluated for inclusion in the study. From the initial search result a total of 1795 papers, 39 manuscripts with 63 study arms were selected for analysis and the data of 3486 patients were included. Descriptive analysis was used to assess the data. Weighted averages of the data were also calculated. RESULTS: The female/male ratio was 42/58. The mean age was 52.9±10.1 years. The proportion of patients with the recommended LDL cholesterol level of <70 mg/dL after treatment with statins was 15.3%;. In all, 10.2% of the patients who were prescribed a low-dose statin and 28.0% of those who were prescribed a high-dose statin had an LDL cholesterol of <70 mg/dL after treatment. Among patients who were being treated with statins for ≤2 months, 25.7% achieved an LDL cholesterol level of <70 mg/dL. Among those who were being treated with statins for 2-4 months and >4 months the proportion was 11.4% and 9.7%, respectively. The percentage of patients at the target level was 21.8%, 21.7%, 17.9%;, 8.6%, and 0.8% among those using atorvastatin, simvastatin, rosuvastatin, fluvastatin, and pravastatin, respectively. CONCLUSION: In Turkey, only 15% of the patients who had received statin therapy had a LDL cholesterol level of <70 mg/dL. Revision of the current treatment should be considered to reach the target levels recommended in the guidelines, especially for patients with high cardiovascular risk.

The clinical significance of premature atrial contractions: How frequent should they become predictive of new-onset atrial fibrillation.

BACKGROUND: Although previous studies reported frequent premature atrial contractions(fPACs) increased the risk of adverse cardiovascular outcomes, especially atrial fibrillation(AF), there is a substantial inconsistency between reports concerning the definition of fPAC. In this study, we aimed to investigate the relationship between fPAC and cardiovascular outcomes, especially AF. We further searched for a cutoff value of fPAC for prediction of AF. METHODS: We retrospectively analyzed the ambulatory 24-hr Holter monitoring records and 392 patients included. Frequent PAC was defined as more than 720 PAC/24 hr as used for frequent ventricular premature beats. Patients' baseline characteristics, echocardiographic variables and medical history were recorded. RESULTS: There were 189 patients with fPAC and 203 patients without fPAC. Patients with fPAC had more comorbidities in terms of hypertension, diabetes mellitus, coronary artery disease and congestive heart failure. CHA2DS2-VaSc was higher in patients with fPAC. Mean follow-up duration was 31 months, and the number of patients with new-onset AF during follow-up was significantly higher in fPAC group (22% vs. 5%, p < .001). fPAC was significantly and independently associated with new-onset AF and predicted AF with a cutoff value of 3,459 PAC/24 hr, and the risk of AF was 11-fold higher than those with <3,000 PAC/24 hr. In addition, an increased CHA2DS2-VaSc score was also associated with new-onset atrial fibrillation. CONCLUSION: In our study, we have demonstrated that fPAC is significantly associated with new-onset AF, and this association is the strongest among those patients who have more than 3,000 PAC in 24 hr.

The impact of atherosclerotic risk factors on disease progression in patients with previously diagnosed nonobstructive coronary artery disease: factors affecting coronary artery disease progression.

OBJECTIVE: Since coronary artery disease (CAD) is a slow progressive disease, management and appropriate follow-up of patients with nonobstructive coronary artery disease (NOCAD) remains challenging, and there are no clear guidelines recommending a follow-up strategy and indications for repeat invasive coronary angiography (ICA). We investigated the predictors of the development of obstructive CAD in patients with previously diagnosed NOCAD. METHODS: We prospectively included 186 patients who previously received a diagnosis of NOCAD with invasive coronary angiogram and underwent repeat ICA. Patients' demographics, clinical characteristics, biochemical analyses were recorded. Obstructive CAD is defined as >50% luminal narrowing in any epicardial coronary artery with a diameter of >2 mm. RESULTS: A total of 186 patients (105 male) were assigned into our study. Mean age was 64.77 ± 10.31 in patients with obstructive CAD (n = 60) vs. 61.87 ± 9.94 in NOCAD patients (n = 126) (P value: 0.068). The median time interval between index and follow-up coronary angiograms was 8 (5-10) years. There was no significant difference between groups with respect to LDL and Hs-CRP levels (P value: 461 and 354, respectively). Although patients with obstructive CAD have more comorbidities, multivariate analyses revealed that there was no significant difference between groups. On the contrary, the total number of risk factors were significantly associated with the development of obstructive CAD during follow-up. Receiver operating characteristic analyses revealed with a cut-off value of 3.5 risk factors, the sensitivity of 71%, the specificity of 61% and the area under the curve was 0.71 for prediction of obstructive CAD. CONCLUSION: Our results indicate that no single risk factor alone is related with development of obstructive CAD; however, patients with high number of multiple risk factors are more prone to develop obstructive disease and require closer follow-up.

Renal Function and Outcomes With Dabigatran Dual Antithrombotic Therapy in Atrial Fibrillation Patients After PCI.

OBJECTIVES: The study sought to evaluate the effect of dabigatran dual therapy versus warfarin triple therapy across categories of renal function in the RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy with Dabigatran versus Triple Therapy with Warfarin in Patients with Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) trial. BACKGROUND: The RE-DUAL PCI (NCT02164864) trial of patients with atrial fibrillation undergoing percutaneous coronary intervention reported that dabigatran dual therapy (110 or 150 mg twice daily, plus clopidogrel or ticagrelor) reduced the primary endpoint of major bleeding events (MBE) or clinically relevant nonmajor bleeding events (CRNMBE) compared with warfarin triple therapy, with noninferiority in overall thromboembolic events. METHODS: Risk of a first MBE or CRNMBE and the composite of death or thromboembolic event (DTE) or unplanned revascularization were evaluated in 2,725 patients according to baseline creatinine clearance (CrCl) categories: 30 to <50, 50 to <80, and ≥80 ml/min. RESULTS: Compared with warfarin, dabigatran 110 mg dual therapy reduced risk of MBE or CRNMBE across all categories of CrCl (p for interaction = 0.19). Dabigatran 150 mg dual therapy reduced risk of MBE or CRNMBE regardless of the CrCl category (p for interaction = 0.31). Risk of DTE or unplanned revascularization was similar to warfarin triple therapy for dabigatran 110 mg dual therapy across all CrCl categories. Dabigatran 150 mg dual therapy versus warfarin triple therapy had similar risk for DTE or unplanned revascularization in patients with CrCl 30 to <80 ml/min and lower risk at CrCl ≥80 ml/min (p for interaction = 0.02). CONCLUSIONS: In the RE-DUAL PCI trial, dabigatran dual therapy reduced bleeding events versus warfarin triple therapy irrespective of renal function, with overall similar risks of thromboembolic events but lower risks with dabigatran 150 mg in patients with normal CrCl.

Risk assessment and survival of patients with pulmonary hypertension: Multicenter experience in Turkey.

OBJECTIVE: Risk stratification continues to evolve in pulmonary arterial hypertension (PAH). Our aim was to further confirm the risk assessment strategy in our cohort and to determine the most reliable model. METHODS: We enrolled incident patients with idiopathic PAH (IPAH), heritable, drug-induced, congenital heart disease (CHD), connective tissue diseases (CTD) subsets, and chronic thromboembolic pulmonary hypertension (CTEPH) from January 2008 to February 2018. Data from the baseline and subsequent follow-ups within 1 year of diagnosis were included. An abbreviated risk assessment strategy was applied using the following variables: functional class (FC), 6-minute walk distance (6 MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP) or BNP, right atrial (RA) area, pericardial effusion, the mean RA pressure, cardiac index, and mixed venous oxygen saturation. Three different methods were applied to categorize patients. RESULTS: A total of 189 subjects (46+-17 years, 23% male) were included. Sixty-one patients had died. The survival differed significantly between the risk groups both at diagnosis and during the follow-up. Patients with a low-risk profile had a better survival rate. An abbreviated risk assessment tool predicted mortality at early follow-up in the entire group and CHD, CTD subsets, and CTEPH, separately. An overall mortality among risk categories was significantly different according to each categorization method. The most reliable model comprised FC, 6 MWD, NT pro-BNP/BNP, and the RA area at the follow-up. CONCLUSION: The abbreviated risk assessment tool may be valid for the PAH subsets and CTEPH. Echocardiographic variables do matter. A model comprising FC, 6 MWD, NT pro-BNP/BNP, and the RA area at the follow-up could be useful for better prognostication.