The Prognostic Significance of Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio for Long-Term Survival in Patients With Severe Left Ventricular Dysfunction and Implantable Cardioverter Defibrillator.

Introduction: Systemic inflammation resulting from comorbidities such as arterial hypertension, diabetes, and obesity is responsible for the pathogenesis of myocardial structural and functional changes in heart failure. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are novel biomarkers of inflammation. The aim of this study was to evaluate the relationship between blood NLR and PLR levels and one-year cardiac mortality in primary prevention patients with left ventricular ejection fraction (LVEF) ≤35%, using an intracardiac defibrillator. METHODS: A total of 180 compensated heart failure patients with LVEF<35% (ischemic or nonischemic) and implantable cardioverter-defibrillator (ICD) therapy for primary prevention who applied to the cardiology outpatient clinic of Zonguldak Bülent Ecevit Üniversitesi Hospital, Zonguldak, Türkiye, between March 2018 and June 2019 were consecutively included. The patients were followed for one year after the application. RESULTS: In the multivariate logistic regression analysis model, only NLR (OR: 1.328; 95%CI: 1.129-1.563; p <0.01) was found independently associated with the risk of one-year cardiovascular mortality. Based on the NLR, levels were 2.69 ng/ml, and the area under the curve was found to be 0.795 (95%CI: 0.729-0.862) in the evaluation made with the receiver operating characteristic curve. CONCLUSION: High NLR ratio levels independently predicted one-year cardiac mortality in patients with LVEF<35% and ICD for secondary protection. Large-scale randomized studies are needed to fully demonstrate the relationship between NLR levels and cardiovascular mortality in patients with severe left ventricular dysfunction and ICD.

Comparison of Atherosclerotic Plaque Compositions in Diabetic and Non-diabetic Patients.

INTRODUCTION: Diabetes mellitus is one of the major risk factors for coronary artery disease. Intravascular ultrasound (IVUS) imaging has an important role in the evaluation of atherosclerotic coronary artery disease. The aim of the study was to investigate the potential link between diabetes mellitus and plaque vulnerability in patients with coronary artery disease. METHODS: In total, 26 patients with acute coronary syndrome (eight with diabetes mellitus) and 34 with stable angina pectoris (16 with diabetes mellitus) constituted the study population. Patients underwent IVUS ultrasound and virtual histology (VH)-IVUS imaging during routine diagnostic catheterization procedures. A total of 70 plaques in 60 patients were examined. RESULTS: Patients with diabetes mellitus had a significantly greater percentage of fibrofatty components in the minimal lumen area (MLA) (17 ± 12 in diabetics; 12 ± 6 in non-diabetics; p=0.06). Thin-cap fibroatheromas were more frequent in patients with diabetes mellitus (72% versus 45%; p=0.012). There was a positive correlation between the presence of attenuated plaque and hemoglobin A1C (HbA1c) levels as well (7.09 ± 1.66 versus 6.02 ± 1.00; p=0.011). Patients with HbA1C ≥7.5% also had the highest prevalence of attenuated plaque. CONCLUSION: As shown by VH-IVUS, the prevalence of vulnerable plaques in patients with diabetes mellitus was much higher than that in non-diabetic patients. The presence of attenuated plaque detected in grayscale intravascular ultrasonography was associated with high HbA1C levels in diabetic patients. Diabetes mellitus may cause cardiovascular vulnerability by changing the plaque morphology.

Comparing the Diagnostic Performance of HFA-PEFF and H2FPEF Scoring Systems in Heart Failure with Preserved Ejection Fraction Patients: Insights from the APOLLON Registry.

BACKGROUND: Heart failure with preserved ejection fraction is a complex and heterogeneous clinical syndrome, poses significant diagnostic challenges. The HFA-PEFF [Heart Failure Association of ESC diagnostic algorithm, P (Pretest Assessment), E  (Echocardiographic and Natriuretic Peptide score), F1 (Functional testing in Case of Uncertainty), F2 (Final Aetiology)] and H2FPEF [Heavy (BMI>30 kg/m2), Hypertensive (use of ≥2 antihypertensive medications), atrial Fibrillation (paroxysmal or persistent), Pulmonary hypertension (Doppler Echocardiographic estimated Pulmonary Artery Systolic Pressure >35 mm Hg), Elderly (age >60 years), Filling pressure (Doppler Echocardiographic E/e' >9)] scoring systems were developed to aid in diagnosing heart failure with preserved ejection fraction. This study aimed to assess the concordance and clinical accuracy of these scoring systems in the 'A comPrehensive, ObservationaL registry of heart faiLure with mildly reduced and preserved ejection fractiON' cohort. METHODS: A comPrehensive, ObservationaL registry of heart faiLure with mildly reduced and preserved ejection fractiON study was conducted as a multicenter, cross-sectional, and observational study; to evaluate a group of Heart failure with mildly reduced ejection fraction and heart failure with preserved ejection fraction patients who were seen by cardiologists in 13 participating centers across 12 cities in Türkiye. RESULTS: The study enrolled 819 patients with heart failure with preserved ejection fraction, with high probability heart failure with preserved ejection fraction rates of 40% and 26% for HFA-PEFF and H2FPEF scorings, respectively. The concordance between the 2 scoring systems was found to be low (Kendall's taub correlation coefficient of 0.242, P < .001). The diagnostic performance of both scoring systems was evaluated, revealing differences in their approach and ability to accurately identify heart failure with preserved ejection fraction patients. CONCLUSION: The low concordance between the HFA-PEFF and H2FPEF scoring systems underscores the ongoing challenge of accurately diagnosing and managing patients with heart failure with preserved ejection fraction. Clinicians should be aware of the strengths and limitations of each scoring system and use them in conjunction with other clinical and laboratory findings to arrive at an accurate diagnosis. Future research should focus on identifying additional diagnostic factors, developing more accurate and comprehensive diagnostic algorithms, and investigating alternative methods of diagnosis or stratification of patients based on different clinical characteristics.

Cyclophilin A and D Levels in Acute Coronary Syndrome and Their Relationship with Cardiovascular Risk Factors.

OBJECTIVE: Our objective was to evaluate cyclophilin levels in patients with acute coronary syndrome (ACS) and their association with the clinical characteristics of these patients. METHODS: We enrolled 150 patients with ACS (n=75 ST-elevation myocardial infarction [STEMI], n = 75 non-ST-elevation myocardial infarction [NSTEMI]). For comparison, 25 healthy volunteers were included in the study. Levels of cyclophilin A, cyclophilin D, and C-reactive protein (CRP) were measured in both the acute myocardial infarction (AMI) groups and the healthy group. We examined the effects of cardiovascular risk factors, including diabetes mellitus, hypertension, dyslipidemia, age, gender, and smoking on these parameters. RESULTS: Cyclophilin A levels were significantly lower in the STEMI group, while cyclophilin D and CRP levels were significantly higher in all AMI groups (P < 0.05). A negative correlation existed between cyclophilin A and troponin T and CK-MB (respectively r = -0.287, P < 0.001; r = -0.231, P = 0.005). However, there was no correlation between cyclophilin D and the cardiac markers. A positive correlation was observed between cyclophilin D and CRP (r = 0.219, P = 0.004). Cyclophilin A was associated with hypertension, whereas cyclophilin D was associated with the female gender and dyslipidemia (P < 0.05). CONCLUSION: Our findings suggest that a decrease in cyclophilin A indicates a more severe disease in STEMI and an increase in cyclophilin D in both STEMI and NSTEMI may be valuable markers. Therefore, further detailed studies are warranted to monitor their changes and interactions in ACS patients.

The relationship between a combination of vitamin D deficiency and hyperuricemia and the severity of coronary artery disease in myocardial infarction patients.

OBJECTIVE: Vitamin D deficiency has been shown to be associated with coronary artery disease (CAD). In addition, there are studies suggesting that hyperuricemia is an independent risk factor for atherosclerosis, whereas the relationship between the combination of these 2 parameters and severity of CAD remains unclear. The aim of this study was to investigate the association between the combination of vitamin D deficiency and hyperuricemia and the extent of CAD. METHODS: A total of 502 patients who had experienced myocardial infarction (MI) were included in this cross-sectional study. The 25-hydroxyvitamin D (25OHD) and serum uric acid (SUA) levels were measured in blood samples taken at the time of admission. A 2x2 factorial design was used to create groups according to the presence of hyperuricemia (>7 mg/dL) and vitamin D deficiency (<20 ng/mL). All of the patients underwent coronary angiography and the severity of CAD was determined using the Gensini score, SYNTAX score, and the number of diseased vessels. RESULTS: Both vitamin D deficiency and hyperuricemia were present in 83 patients (16.5%). Patients with hyperuricemia/vitamin D deficiency had more multivessel disease (24.1% vs 8.5%), and a higher SYNTAX score and Gensini score compared with the control group (13.9±8.0 vs. 9.5±6.3, 54.8±24.0 vs. 40.5±19.9, respectively). Age, male sex, presence of diabetes mellitus, family history of CAD, and levels of SUA and 25OHD were independent predictors of the severity of CAD. Moreover, the hyperuricemia/vitamin D deficiency group had 4 times greater odds of severe CAD than the control group. CONCLUSION: The combination of hyperuricemia and vitamin D deficiency appears to be an independent predictor of severe CAD in MI patients.

Geographical Variations in Patients with Heart Failure and Preserved Ejection Fraction: A Sub-Group Analysis of the APOLLON Registry

Background: Clinical characteristics of patients with heart failure may vary geographically. However, limited data are available regarding the geographical differences of patients with heart failure and preserved ejection fraction. Aims: The present subgroup analysis aims to investigate the geographical differences in clinical characteristics, management, and primary etiology of patients with heart failure and preserved ejection fraction in Turkey. Study Design: A cross-sectional study. Methods: A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON (APOLLON) is a multicenter and observational study conducted in seven regions of Turkey (NCT03026114). The present study is a post-hoc analysis of the APOLLON registry. In this substudy, we compared the clinical characteristics of 819 consecutive patients with heart failure and preserved ejection fraction (mean age, 67 years; 57.8% women) admitted to cardiology outpatient units in different geographical regions. Results: Based on the geographical distribution of the entire Turkish population, the highest number of patients enrolled were from Marmara (271 patients, 33.1%). All demographical characteristics, clinical and laboratory findings, comorbidities, primary etiology, and medications prescribed were significantly different between the regions. Furthermore, inter-regional gender differences were identified. Comparatively, the Aegean and Mediterranean regions had older patients with heart failure and preserved ejection fraction (p<0.001), and the Black Sea, Southeast, and East Anatolia regions had predominantly male patients (51.2, 54.5, and 56.9%, respectively; p=0.002). Notably, the Mediterranean and Southeast Anatolia had more symptomatic patients, and history of hospitalization for heart failure was more prevalent in Southeast Anatolia (33.3%, p<0.001). Prevalence of atrial fibrillation was higher in the Mediterranean and Southeast Anatolia regions (51 and 48.5%, p<0.001), and patients with heart failure and preserved ejection fraction had a higher prevalence of hypertension in the Mediterranean, Southeast Anatolia, and Black Sea regions (p=0.002). Angiotensin-converting enzyme inhibitors were more frequently prescribed in East Anatolia (52.3%, p=0.001), and the prevalence of patients with heart failure and preserved ejection fraction using loop diuretics (48.8%, p=0.003) was higher in the Black Sea region. Conclusion: This study was the first to show geographical differences in clinical characteristics of patients with heart failure and preserved ejection fraction in Turkey. Determination of the clinical characteristics of the heart failure and preserved ejection fraction population based on the geographical region may enables physicians to adopt a region-specific clinical approach toward heart failure and preserved ejection fraction.

The Elevated Soluble ST2 Predicts No-Reflow Phenomenon in ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

AIM: The primary percutaneous procedure resulted in a significant improvement in the prognosis of myocardial infarction. However, no-reflow phenomenon restrains this benefit of the process. There are studies suggesting that soluble suppression of tumorigenicity (sST2) can be valuable in the diagnosis and progression of heart failure and myocardial infarction. In this study, we aimed to investigate the effect of sST2 on no-reflow phenomenon in ST-elevated myocardial infarction (STEMI). METHOD: This study included 379 patients (258 men; mean age, 60±11 years) who underwent primary percutaneous treatment for STEMI. sST2 levels were measured from blood samples taken at admission. Patients were divided into two groups according to Thrombolysis in Myocardial Infarction(TIMI) flow grade: group 1 consists of TIMI 0,1,2, accepted as no-reflow, and group 2 consists of TIMI 3, accepted as reflow. RESULTS: No-reflow phenomenon occurred in 60 patients (15.8%). The sST2 level was higher in the no-reflow group (14.2±4.6 vs. 11.3±5.0, p=0.003). Moreover, regression analysis indicated that diabetes mellitus, lower systolic blood pressure, multivessel vascular disease, high plaque burden, and grade 0 initial TIMI flow rate were other independent predictors of the no-reflow phenomenon in our study. Besides, when the patients were divided into high and low sST2 groups according to the cut-off value from the Receiver operating characteristics analysis, being in the high sST2 group was associated with 2.7 times increased odds for no-reflow than being in the low sST2 group. CONCLUSION: sST2 is one of the independent predictors of the no-reflow phenomenon in STEMI patients undergoing primary percutaneous coronary intervention.

Clinical features of heart failure with mid-range and preserved ejection fraction in octogenarians: Results of a multicentre, observational study.

OBJECTIVES: To compare real-world characteristics and management of individuals aged 80 and older with heart failure (HF) and mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) derived from a large cohort of survey and to compare them with those younger than 80 from the same survey. METHODS: This is an observational, multicentre and cross-sectional study conducted in Turkey (NCT03026114). Consecutive 1065 (mean age of 67.1 ± 10.6 years) patients admitted to the cardiology outpatient units with HFmrEF and HFpEF were included. RESULTS: Participants aged 80 and older (n = 123, 11.5%) were more likely to be female (66.7% vs 52.5%, P = 0.003), had a higher prevalence of atrial fibrillation (49.6% vs 34%, P = 0.001), and anaemia (46.3% vs 33.4%, P = 0.005) than those who were younger than 80. N-terminal pro B-type natriuretic peptide levels were higher in those aged 80 and older than in those younger than 80 (1037 vs 550 pg/ml, P < 0.001). The prescription rates of HF medications (including in ACE-Is/ARBs, ß-blockers, MRAs, digoxin, ivabradine and diuretics) were similar (P > 0.05) in both groups. Octogenarians did not significantly differ from younger patients in the prevalence of HFmrEF (24.4% vs 22.9%) and HFpEF (75.6% vs 77.1%). Coronary artery disease was associated with HFmrEF (P < 0.05), whereas atrial fibrillation was associated with HFpEF (P < 0.05) in octogenarians. CONCLUSIONS: This study revealed that nearly 12% of the individuals with HFmrEF and HFpEF in this real-world sample were aged 80 and older. Participants aged 80 and older are more likely to be female and have more comorbidities than those who were younger than 80. However, HF medication profiles were similar in both groups. This study also showed that associated factors with HFmrEF and HFpEF were differ in octogenarians.

Patients with HFpEF and HFmrEF have different clinical characteristics in Turkey: A multicenter observational study.

BACKGROUND: To determine and compare the demographic characteristics, clinical profile and management of patients with heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) in a Turkish cohort. METHODS: The APOLLON trial (A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON) is an observational and multicenter study conducted in Turkey. Consecutive patients admitted to the cardiology clinics who were at least 18 years of age and had HFmrEF or HFpEF were included (NCT03026114). RESULTS: The study population included 1065 (mean age of 67.1 ±â€¯10.6 years, 54% women) patients from 12 sites in Turkey. Among participants, 246 (23.1%) had HFmrEF and 819 (76.9%) had HFpEF. Compared to patients with HFpEF, those with HFmrEF were more likely to be male (57.7 vs 42.2%; p < 0.001), had higher N-terminal pro-B-type natriuretic peptide levels (853 vs 528 pg/ml, p < 0.001), were more likely to have ECG abnormalities (72.4 vs 53.5%, p < 0.001) and hospitalization history for heart failure (28 vs 18.6%; p = 0.002). HFmrEF patients were more likely to use ß-blockers (69.9 vs 55.2%, p < 0.001), aldosterone receptor antagonists (24 vs 14.7%, p = 0.001), statins (37 vs 23%, p < .001), and loop diuretics (39.8 vs 30.5%, p = 0.006) compared to patients with HFpEF. CONCLUSIONS: The results of APOLLON study support that the basic characteristics and etiology of HFmrEF are significantly different from HFpEF. This registry also showed that the patients with HFmrEF and HFpEF were younger but undertreated in Turkey compared to patients in western countries.

The relationship of Charlson comorbidity index with stent restenosis and extent of coronary artery disease.

OBJECTIVES: The objective of this study is to investigate the effect of comorbid conditions [Charlson comorbidity index (CCI)] on stent restenosis who underwent coronary angioplasty earlier. METHODS: Patients were divided into two groups; patients with critical restenosis [recurrent diameter stenosis >50% at the stent segment or its edges (5-mm segments adjacent to the stent) (Group 1; n = 53, mean age: 63.8 ± 9.9 years)] and patients with no critical restenosis [<50% obstruction (Group 2; n = 94, mean age: 62.1 ± 9.1 years)]. The CCI and modified CCI were used for the presence of comorbid conditions. The Gensini scoring system was used to assess the extent of coronary artery disease (CAD). RESULTS: Group 1 had a significantly greater CCI and modified CCI score compared to Group 2 (7.1 ± 3.7 vs. 5.6 ± 1.6, p = 0.006; 6.9 ± 3.6 vs. 4.5 ± 1.5, p = 0.008, respectively). There was a weak correlation, albeit significant, between the modified CCI score and restenosis percentage (r = 0.29, p < 0.001; r = 0.25, p = 0.003, respectively). CONCLUSIONS: In conclusion, the CCI score is greater among patients with stent restenosis than those without. CCI score is higher among patients with a more diffuse CAD than with a milder disease extent.

Galectin-3: A Novel Biomarker Predicts Sudden Cardiac Death in Hypertrophic Cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy is a primary cardiac disease characterized by left ventricular hypertrophy, myocyte hypertrophy and irregularities and interstitial fibrosis in the absence of any cardiac or systemic diseases and may lead to sudden cardiac death (SCD). Galectin-3 is a ß-galactoside-binding lectin that has been associated with cardiac fibrosis and inflammation. In this study, we aimed to investigate the relationship between serum galectin-3 levels and the criteria for 5-year sudden death risk, recently defined in the European Society of Cardiology guidelines (2014), in patients with hypertrophic cardiomyopathy. MATERIALS AND METHODS: A total of 52 hypertrophic cardiomyopathy patients were enrolled in the study. Patients were questioned for sudden death risk predictors as outlined in the 2014 European Society of Cardiology guideline. A standardized clinical evaluation was carried out on the basis of previously described prognostic variables to calculate the 5-year risk of SCD. Blood samples were taken from all patients to measure serum galectin-3 levels. A statistical significance level of P < 0.05 was accepted in all tests. RESULTS: We found that there was a significant correlation between the estimated 5-year risk of SCD and serum levels of galectin-3. CONCLUSIONS: Galectin-3 may be an inexpensive and easily accessible parameter to predict arrhythmia risk. In addition, it can be used to determine antiarrhythmic prophylaxis as a predictor of an arrhythmia storm in implantable cardioverter defibrillator-implanted patients who are not available for magnetic resonance imaging.

The Influence of Comorbid Conditions on Graft Stenosis in Patients with Coronary Artery Bypass Graft Operation / A influência das condições comórbidas na estenose do enxerto em pacientes com coronariopatia Operação de enxerto de artéria

The primary goal of coronary artery bypass grafting is to achieve complete revascularization with grafts that will remain patent throughout the patient's lifetime. This study investigated the association between bypass graft patency and comorbidity burden determined by Charlson comorbidity index (CCI) among patients with previous bypass operation who underwent a control angiography. One-hundred and two patients who had undergone CABG in the past were included to the study. Critical stenosis was defined as 50% or greater coronary luminal obstruction of any coronary vessel or its lateral branch. Patients were divided into 2 groups group 1; critical graft stenosis; (54 pts; 41M, mean age 66.5 ± 7.8 years), group 2; graft patent (48 pts; 31M, mean age; 65.9 ± 8.2 years). Charlson comorbidity index (CCI) and modified CCI scores were used for detecting comorbidities. The comparison of continuous variables between the control and critical CAD groups was performed by the independent sample test. A p value less than 0.05 was considered statistically significant. The two groups were statistically similar with respect to demographic properties, time since bypass operation, cardiovascular risk factors, systolic blood pressure, heart rate, medications used, complete blood counts parameters, and lipid profiles. CCI was significantly higher in Group 1 compared to Group 2 (7.14 ± 2.02 vs4.72 ± 1.58; p < 0.001). Modified CCI scores were also higher in Group 1 than in Group 2 (6.14 ± 2.02 vs 3.73 ± 1.60; p < 0.001). Graft occlusion was more common among patients with a high comorbidity burden. CCI scoring system may be helpful for determining patients at increased risk at both the preoperative and postoperative periods

Rationale, Design, and Methodology of the APOLLON trial: A comPrehensive, ObservationaL registry of heart faiLure with midrange and preserved ejectiON fraction.

OBJECTIVE: Although almost half of chronic heart failure (HF) patients have mid-range (HFmrEF) and preserved left-ventricular ejection fraction (HFpEF), no studies have been carried out with these patients in our country. This study aims to determine the demographic characteristics and current status of the clinical background of HFmrEF and HFpEF patients in a multicenter trial. METHODS: A comPrehensive, ObservationaL registry of heart faiLure with mid range and preserved ejectiON fraction (APOLLON) trial will be an observational, multicenter, and noninterventional study conducted in Turkey. The study population will include 1065 patients from 12 sites in Turkey. All data will be collected at one point in time and the current clinical practice will be evaluated (ClinicalTrials.gov number NCT03026114). RESULTS: We will enroll all consecutive patients admitted to the cardiology clinics who were at least 18 years of age and had New York Heart Association class II, III, or IV HF, elevated brain natriuretic peptide levels within the last 30 days, and an left ventricular ejection fraction (LVEF) of at least 40%. Patients fulfilling the exclusion criteria will not be included in the study. Patients will be stratified into two categories according to LVEF: mid-range EF (HFmrEF, LVEF 40%-49%) and preserved EF (HFpEF, LVEF ≥50%). Regional quota sampling will be performed to ensure that the sample was representative of the Turkish population. Demographic, lifestyle, medical, and therapeutic data will be collected by this specific survey. CONCLUSION: The APOLLON trial will be the largest and most comprehensive study in Turkey evaluating HF patients with a LVEF ≥40% and will also be the first study to specifically analyze the recently designated HFmrEF category.