Misperceptions and management of LDL-cholesterol in secondary prevention of patients with familial hypercholesterolemia in cardiology practice: Real-life evidence from the EPHESUS registry.

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is a common inherited disease, leading to premature atherosclerotic cardiovascular disease (ASCVD) due to elevated low-density lipoprotein cholesterol (LDL-C) levels. Achieving LDL-C goals is extremely important for preventing the complications of this fatal disease. We evaluated the management of FH patients with ASCVD in cardiology practice. METHODS: We analyzed patients with ASCVD from the nationwide EPHESUS registry, which was conducted in 40 cardiology outpatient clinics, and compared those with and without FH. RESULTS: Of the 1482 consecutively enrolled patients with ASCVD, 618 (41.7%) had FH, among which 455 were categorized as 'Possible FH' and 163 as 'Probable or Definite FH'. Proposed LDL-C goals were not attained in more than 90% of the patients with FH. The proportion of those on statin therapy was 77% for possible and 91% for probable or definite FH, whereas 34.2 % and 59.4% were in use of high-intensity statins, respectively. None of the patients were on PCSK-9 inhibitors, and only 2 used ezetimibe. Adverse media coverage was the most common cause of statin discontinuation (32.5% in 'possible FH' and 45.7% in 'probable/definite FH'). The negative impact of media in the decision to stop lipid lowering therapy (LLT) was increasing with education level. CONCLUSIONS: In real life most of the FH patients with ASCVD are undertreated in cardiology practice regarding statin dosing and combined LLT. Drug discontinuation rates are notably high and are mostly media-related, and side effects very rarely cause cessation of LLT. Urgent measures are needed to increase the awareness of FH among healthcare providers and patients and to develop improved treatment strategies aimed at preventing the complications of FH.

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.

How Did the Updated 2019 European Society of Cardiology/European Atherosclerosis Society Risk Categorization for Patients with Diabetes Affect the Risk Perception and Lipid Goals? A Simulated Analysis of Real-life Data from EPHESUS Study.

BACKGROUND: The recent 2019 European Society of Cardiology/European Atherosclerosis Society practice guidelines introduced a new risk categorization for patients with diabetes. We aimed to compare the implications of the 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines with regard to the lipid-lowering treatment use, low-density lipoprotein cholesterol goal attainment rates, and the estimated proportion of patients who would be at goal in an ideal setting. METHODS: Patients with diabetes were classified into 4 risk categories according to 2019 European Society of Cardiology/European Atherosclerosis Society dyslipidemia guidelines from the database of EPHESUS (cross-sectional, observational, countrywide registry of cardiology outpatient clinics) study. The use of lipid-lowering treatment and low-density lipoprotein cholesterol goal attainment rates were then compared according to previous and new guidelines. RESULTS: This analysis included a total of 873 diabetic adults. Half of the study population (53.8%) were on lipid-lowering treatment and almost one-fifth (19.1%) were on high-intensity statins. While low-density lipoprotein cholesterol goal was achieved in 19.5% and 7.5% of patients, 87.4% and 69.6% would be on target if their lipid-lowering treatment was intensified according to 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society lipid guidelines, respectively. The new target <55 mg/dL could only be achieved in 2.2% and 8.1% of very high-risk primary prevention and secondary prevention patients, respectively. CONCLUSION: The control of dyslipidemia was extremely poor among patients with diabetes. The use of lipid-lowering treatment was not at the desired level, and high-intensity lipid-lowering treatment use was even lower. Our simulation model showed that the high-dose statin plus ezetimibe therapy would improve goal attainment; however, it would not be possible to get goals with this treatment in more than one-third of the patients.

An Evaluation of Aspirin Treatment Preferences ORIGINAL INVESTIGATION of Physicians in Hypertensive Patients in Terms of Current Guidelines: A Subgroup Analysis of the ASSOS Trial in Turkey.

BACKGROUND: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial has been the largest study ever conducted among patients in Turkey regarding aspirin treatment. In the subgroup analysis of the hypertensive group of the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial, we aimed to evaluate the physicians' adherence to current guidelines regarding their aspirin treatment preferences. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial is a cross-sectional and multicenter study conducted among 5007 consecutive patients aged ≥18 years. The study population consisted of outpatients on aspirin treatment (80-300 mg). The patient data were obtained from 30 different cardiology clinics of 14 cities from all over Turkey. In this subgroup analysis, patients were divided into 2 groups: the hypertensive group (n=3467, 69.3%) and the group without hypertension (n=1540, 30.7%) according to the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the Management of Arterial Hypertension. RESULTS: Aspirin use for primary prevention was higher in patients with hypertension compared to patients without hypertension [328 (21.3%); 1046 (30.2%); P < .001]. Treatment with a dose of 150 mg aspirin (n=172, 5%) was mostly preferred by internists for hypertensive patients (n =226, 6.5%); however, a daily dose of 80-100 mg aspirin therapy (n=1457, 94.6%) was mostly prescribed by cardiologists (n=1347, 87.5%) for patients without hypertension. CONCLUSION: Aspirin was found to be used commonly among patients with hypertension for primary prevention despite the current European Society of Cardiology Arterial Hypertension Guideline not recommending aspirin for primary prevention in patients with hypertension.

Inappropriate Use of Aspirin in Real-Life Cardiology Practice: Results from the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) Study.

BACKGROUND: Indications and appropriateness of aspirin use have not been well investigated in Turkey. AIMS: To investigate the prescription patterns and appropriateness of aspirin in a real-world clinical setting. STUDY DESIGN: Cross-sectional study. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) is a cross-sectional and multicenter study that included 5007 consecutive patients aged 18 or over who presented to 30 different cardiology outpatient clinics from 14 cities throughout Turkey. Only patients using aspirin (80-325 mg) were included. The study population was divided into 2 groups regarding the use of aspirin: primary prevention (PP) group and secondary prevention (SP) group. The indication of aspirin use was evaluated following the 2016 European Society of Cardiology (ESC) and the 2016 United States Preventative Services Task Force (USPTF) guidelines in the PP group. RESULTS: A total of 5007 patients (mean age 62.15 ± 11.05, 39% female) were enrolled. The PP group included 1132 (22.6%) patients, and the SP group included 3875 (77.4%) patients. Of the 1132 patients, inappropriate use of aspirin was determined in 100% of the patients according to the ESC guidelines, and 71% of the patients according to the USPTF guidelines. Multivariate logistic regression analysis showed age OR: 0.98 CI (0.97-0.99) P = .037, smoking OR: 0.60 CI (0.44-0.82) P = .001, heart failure OR: 2.11 CI (1.14-3.92) P = .017, hypertension OR: 0.51 CI (0.36-0.74) P < .001, diabetes mellitus OR: 0.34 CI (0.25-0.47) P < .001, oral anticoagulant use OR: 3.01 CI (1.10-8.25) P = .032, and female sex OR: 2.73 CI (1.96-3.80) P < .001 were independent predictors of inappropriate aspirin use in PP patients. CONCLUSION: Although there are considerable differences between the USPTF and the ESC guidelines with respect to recommendations for aspirin use in PP, inappropriate use of aspirin in Turkey is frequent in real-world practice for both guidelines. Besides, heart failure, oral anticoagulant use, and the female sex of the patients were independent predictors of inappropriate use of aspirin.

Comparison of clinical characteristics of patients with heart failure and preserved ejection fraction with atrial fibrillation versus sinus rhythm: Insights from the APOLLON registry.

OBJECTIVE: The aim of this study was to assess the clinical characteristics of patients with heart failure and preserved ejection fraction (HFpEF) and atrial fibrillation (AF) and compare them with those of HFpEF patients without AF. METHODS: This study was a sub-group analysis of a multicenter, observational, and cross-sectional registry conducted in Turkey (ClinicalTrials.gov identifier: NCT03026114). Patients with HFpEF were divided into 2 groups: HFpEF with AF and HFpEF with sinus rhythm (SR), and the clinical characteristics of the groups were compared. RESULTS: In a total of 819 HFpEF patients (median age: 67 years; 58% women), 313 (38.2%) had AF. Compared to the patients with SR, those with AF were older (70 years vs 66 years; p<0.001) and more symptomatic, with a higher rate of classification as New York Heart Association functional class III-IV, paroxysmal nocturnal dyspnea, orthopnea, palpitations, fatigue, pulmonary crepitations, and peripheral edema. The hospitalization rate for heart failure was higher (28.4% vs 12.6%; p<0.001) in patients with AF, and participants with AF had higher level of N-terminal pro-B-type natriuretic peptide (887 pg/mL vs 394.8 pg/mL; p<0.001) and higher left atrial volume index level. Patients without AF had a higher burden of diabetes mellitus, obstructive sleep apnea, and coronary artery disease. The prescription rate of nondihydropyridine calcium blockers, digoxin, loop diuretics, and anticoagulant drugs was higher in the AF group. CONCLUSION: The results of this study revealed that in a large Turkish cohort with HFpEF, significant clinical differences were present between those with and without AF and. Further prospective studies are needed to clarify the prognostic implications of AF in this growing heart failure population in our country.

Implications of continuous positive airway pressure on heart rate variability in patients with obstructive sleep apnea: Does gender matter?

OBJECTIVE: This study was designed to determine the effectiveness of continuous positive airway pressure (CPAP) treatment on the improvement of heart rate variability (HRV) and whether gender plays a role in HRV in patients with mode-rate to severe obstructive sleep apnea syndrome (OSAS). METHODS: Consecutive patients with recently diagnosed moderate to severe OSAS underwent continuous synchronized electrocardiographic monitoring and were prospectively considered for inclusion in the study. HRV was analyzed before starting CPAP therapy and 1 year thereafter. The effects of CPAP on HRV were evaluated in men and women separately to ascertain whether there are gender differences in the clinical manifestations of OSAS and whether female HRV responses to CPAP are similar to those of men. RESULTS: A total of 18 patients (10 men, median age: 56 years) were included in the study. There were no significant differences in the baseline clinical characteristics of the male and female patients. After 1 year of CPAP treatment, heart rate decreased (p<0.05) and time domain parameters increased (p<0.05) in both men and women. None of the frequency domain parameters changed in women (p<0.05), whereas the high frequency power measured increased (p<0.05) and the ratio of low frequency to high frequency decreased (p<0.05) in men after 1 year of CPAP treatment. The increase in HRV after 1 year of CPAP therapy was significantly higher in men than in women (p<0.05). CONCLUSION: CPAP therapy reduced enhanced cardiac sympathetic nerve activity in patients with OSAS assessed according to HRV. The beneficial effect of long-term CPAP therapy on HRV was more pronounced in men.

Predictors of early and delayed recovery in peripartum cardiomyopathy: a prospective study of 52 Patients.

Background: Predictors of early or delayed recovery are unclear in peripartum cardiomyopathy (PPCM). Therefore, we aimed to assess the prognostic value of serial assessment of clinical, echocardiographic, and biochemical markers in patients with PPCM.Methods: Fifty-two consecutive women with PPCM were enrolled in this prospective study. Each patient underwent transthoracic echocardiography, B-type natriuretic peptide (BNP) and C-reactive protein (CRP) measurement at admission, and every 3 months. Early recovery was defined as resolution of heart failure at 6 months postdiagnosis, delayed recovery was defined if the length of time required for recovery of left ventricular function was longer than 6 months, and persistent left ventricular dysfunction (PLVD) was defined as an ejection fraction of less than 50% at the end of follow-up.Results: Thirty patients (57.7%) recovered completely, 10 died (19.2%), and 12 (23.1%) had PLVD. There were no significant differences in baseline BNP and CRP values between patients who recovered completely and who did not recover. However, patients with complete recovery were more likely to have a higher left ventricular ejection fraction, smaller left ventricle end-systolic dimensions at baseline, and lower CRP and BNP levels at follow-up. Elevated levels of BNP and CRP on follow up at 3 and 6 months were associated with nonrecovery. Third and sixth month BNP values were significantly lower in patients with rapid recovery, compared to patients with delayed recovery. Bromocriptine therapy was also associated with early recovery.Conclusions: Persistent elevation of plasma CRP and BNP levels at follow-up portend a slower response or nonrecovery in patients with PPCM. Bromocriptine therapy was an independent predictor of early recovery.

Evaluation of perceptions, knowledge and compliance with guidelines in real-life practice: A survey on the under-treatment of hypercholesterolemia.

OBJECTIVE: Few studies have directly assessed suboptimal management of dyslipidemia in Turkey. This study was conducted to assess patients' understanding and perceptions of high cholesterol as well as physicians' knowledge and awareness of lipid management strategies. METHODS: This was a multicenter, observational study (ClinicalTrials.gov identifier: NCT02608645). Consecutive patients admitted to the participating cardiology clinics who were at least 18 years of age and who had been classified in a secondary prevention (SP) group or a high-risk primary prevention (PP) group were enrolled. The study population included 1868 patients from 40 sites in Turkey. Two-thirds (67.5%) of the patients in the SP group had been prescribed a statin, whereas only 30.1% of the PP group patients received statin therapy (p<0.001). RESULTS: It was determined that 18% of the SP patients and 10.6% of the PP patients had a low-density lipoprotein cholesterol level at the recommended level (p<0.001). A patient survey revealed that almost half of the patients in the PP and in the SP groups were aware that their cholesterol levels were high. Negative information about statin treatment disseminated by media programs was the most common reason (9.4%) given for treatment discontinuation. CONCLUSION: Perceptions, knowledge and compliance with the guidelines for PP and SP patients in real-life practice have increased, but it remains far below the desired level. Patients and physicians should have more information about the treatment of hyperlipidemia. More accurate media programming could help to prevent the dissemination of misinformation.

Rationale, design, and methodology of the EPIC (Epidemiology of Polypharmacy and Potential Drug-Drug Interactions in Elderly Cardiac Outpatients) study.

OBJECTIVE: The aim of this study is to assess the prevalence of polypharmacy, inappropriate drug use, and drug-drug interactions (DDIs) in elderly patients presenting at outpatient cardiology clinics in Turkey. METHODS: The EPIC (Epidemiology of Polypharmacy and Potential Drug-Drug Interactions in Elderly Cardiac Outpatients) study will be an observational, real-world, multicenter study conducted to evaluate DDIs and polypharmacy in elderly cardiac outpatients. All consecutive patients (aged ≥65 years) admitted to outpatient cardiology clinics between July 30, 2018 and July 30, 2019 who provide written, informed consent will be enrolled. A total of approximately 5000 patients are to be enrolled in this non-interventional study. All of the data will be collected at one point in time and current clinical practice will be evaluated (ClinicalTrials.gov NCT03370523). RESULTS: Patient demographics, comorbid disease characteristics, laboratory test results, and details of medication use will be collected using self-reports and medical records. The severity of comorbid disease will be recorded and scored according to Charlson Comorbidity Index (CCI) and patients will be divided into 3 groups: mild, those with a CCI score of 1-2; moderate, those with a CCI score of 3-4; and severe, those with a CCI score of ≥5. Polypharmacy will be defined as the use of 5 or more medications at one time. DDIs will be determined using the Lexicomp Online drug interaction screening tool and potentially inappropriate medications will be defined based on the 2015 update of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Severe drug interactions will be defined as those in category D or X. CONCLUSION: EPIC will be the first large-scale study in Turkey to evaluate polypharmacy, potentially inappropriate medications, and DDIs in elderly cardiac outpatients in a real-world clinical setting.

The reasons of poor lipid target attainment for secondary prevention in real life practice: Results from EPHESUS.

OBJECTIVE: There are lack of studies considering the suboptimal management of dyslipidemia especially in cardiology outpatient clinics. This study was conducted to assess the patient adherence to cholesterol treatment recommendations and attainment of low-density-lipoprotein cholesterol (LDL-C) goals. METHODS: EPHESUS (NCT02608645) is a national, observational and multicenter registry which has been designed as a cross-sectional study to allow inclusion of all consecutive patients with hypercholesterolemia in cardiology outpatient clinics. The present subgroup analyses of the EPHESUS trial included patients with known peripheral artery disease or atherosclerotic cerebrovascular disease, and coronary heart disease namely secondary prevention. RESULTS: The present analysis of the EPHESUS study included 1482 patients (62.79 ± 10.4 years, 38.2% female) with secondary prevention from 40 sites in Turkey. Regarding recommended lipid targets for LDL-C, only 267 patients (18%) were below the target of 70 mg/dL. Females were significantly more off-target when compared with male patients (396, 85.5% vs 67, 14.5%; P = 0.017). Moreover, the achievement of LDL-C goal was significantly decreased with illiteracy (233, 19.2% vs 35, 13.1%; P = 0.02). Patients who think that the cholesterol treatment should be terminated when the cholesterol level of a patient has normalised were higher in the off-target group (34.0% vs 24.7%, P < 0.001). Besides, physician perceptions about LDL-C goal for secondary prevention were significantly related with LDL-C target attainment. CONCLUSIONS: EPHESUS is an important study with large population in terms of representing real-life practice of the adherence to dyslipidemia guidelines in secondary prevention patients in Turkey. Perceptions, knowledge, and compliance with the guidelines for secondary prevention have increased, but it is far below from the desired levels even in cardiology outpatient clinics. There is a need for patients' and physicians' education regarding the treatment of hyperlipidemia.

Gender disparities in heart failure with mid-range and preserved ejection fraction: Results from APOLLON study.

OBJECTIVE: This study aimed to examine gender-based differences in epidemiology, clinical characteristics, and management of consecutive patients with heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF). METHODS: The APOLLON trial (A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON) is a multicenter, cross-sectional, and observational study. Consecutive patients with HFmrEF or HFpEF who were admitted to the cardiology clinics were included (NCT03026114). Herein, we performed a post-hoc analysis of data from the APOLLON trial. RESULTS: The study population included 1065 (mean age of 67.1+-10.6 years, 54% women) patients from 11 sites in Turkey. Compared with men, women were older (68 years vs. 67 years, p<0.001), had higher body mass index (29 kg/m2 vs. 27 kg/m2, p<0.001), and had higher heart rate (80 bpm vs. 77.5 bpm, p<0.001). Women were more likely to have HFpEF (82% vs. 70.9%, p<0.001), and they differ from men having a higher prevalence of hypertension (78.7% vs. 73.2%, p=0.035) and atrial fibrillation (40.7% vs. 29.9%, p<0.001) but lower prevalence of coronary artery disease (29.5% vs. 54.9%, p<0.001). Women had higher N-terminal pro-B-type natriuretic peptide (691 pg/mL vs. 541 pg/mL, p=0.004), lower hemoglobin (12.7 g/dL vs. 13.8 g/dL, p<0.001), and serum ferritin (51 ng/mL vs. 64 ng/mL, p=0.001) levels, and they had worse diastolic function (E/e'=10 vs. 9, p<0.001). The main cause of heart failure (HF) in women was atrial fibrillation, while it was ischemic heart disease in men. CONCLUSION: Clinical characteristics, laboratory findings, and etiological factors are significantly different in female and male patients with HFmrEF and HFpEF. This study offers a broad perspective for increased awareness about this patient profile in Turkey.

Gemifloxacin-Induced Allergic Myocardial Infarction: A Case Report.

BACKGROUND: Gemifloxacin given once daily for 5-7 days has been shown to be non-inferior to, or in some instances superior to, comparator agents for the treatment of common lower respiratory tract infections. Gemifloxacin is generally well tolerated and is as safe as many frequently empirically prescribed antimicrobials. CASE REPORT: We report a case of a 46-year-old woman given gemifloxacin for an upper respiratory tract infection who developed allergic myocardial infarction 15 min after taking an oral dose of 320 mg gemifloxacin. To our knowledge, this is the first case of allergic myocardial infarction associated with gemifloxacin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although anaphylactoid/anaphylactic reactions are rare adverse effects of fluoroquinolones, clinicians should be aware of this potentially fatal event. Electrocardiographic interpretation is a critical skill of the emergency physician. Awareness of Kounis syndrome and its specific electrocardiogram findings may help facilitate further testing that will aid in timely diagnosis and interventions. A diagnosis of Kounis syndrome should be considered in young, healthy patients with no atherosclerotic risk factors when they develop an acute coronary syndrome after administration of a potentially allergic agent.

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.

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.