Speckle-tracking echocardiography can predict atrial fibrillation in patients with supraventricular tachycardia.

PURPOSE: Atrioventricular nodal reentry tachycardia (AVNRT) is the most common supraventriculer arrhythmia in daily clinical practice. Comorbidity of AVNRT and atrial fibrillation (AF) has been well documented in some patients and AF development has been observed more frequently in AVNRT patients during their long-term follow-up. This study was conducted in order to investigate the left atrial two-dimensional-speckle-tracking echocardiographic (STE) parametres as the predictors of the occurence of AF in long-term follow-up in patients with spontaneously developed AF during AVNRT ablation. METHODS: Two hundred and thirty two consecutive AVNRT patients who developed spontaneous AF during ablation procedure were included in the study. The patients were followed up for a mean follow-up period of 6.2 ± 2.1 years. All patients were evaluated using the 2D-STE method. AF was developed in 34 patients during the follow-up period. Cox regression analysis was performed in order to identify the independent predictors of AF occurence. RESULTS: Left atrial LA-res, LA-pump, LA-SRs, LA-SRe, and LA-SRa values were found to be significantly decreased in the group of patients that developed AF during the follow-up period (p < .001 for all aforementioned values). Multivariate cox regression analysis revealed that LA-res (hazard ratio [HR], 0.367; 95% confidence interval [CI], 0.161-0.0.683, p < .001) and SRe (HR, 0.472; 95% CI, 0.346-0.825, p = .006) were independent risk factors associated with the occurrence of AF. CONCLUSION: In conclusion, it was demonstrated for the first time with this study that 2D-STE can effectively predict the development of AF in long-term follow-up in patients with spontaneously developed AF during AVNRT ablation.

Effects of atrial electromechanical delay and ventriculoatrial conduction over the atrial functions in patients with frequent extrasystole and preserved ejection fraction.

BACKGROUND: The deterioration of left atrial and ventricular functions was demonstrated in patients with frequent ventricular extrasystole (fVES). The exact pathophysiology of left atrial dysfunction in patients with fVES is unclear. Retrograde ventriculoatrial conduction (VAC) often accompanies fVES, which may contribute to atrial dysfunction. We investigated whether atrial electromechanical delay and VAC are related to these atrial functions in patients with frequent right ventricular outflow tract (RVOT) VES and preserved ejection fraction (pEF). METHODS: This study included 21 patients with pEF (eight males, 48 ± 11 years), who had experienced more than 10 000 RVOT-VES during 24-h Holter monitoring and had undergone electrophysiological study/ablation. The study also included 20 healthy age- and sex-matched control subjects. Transthoracic echocardiography was performed on all of the subjects. Atrial conduction time was obtained by using tissue Doppler imaging. Strain analysis was performed with two-dimensional speckle tracking echocardiography. RESULTS: The peak atrial longitudinal strain was significantly impaired in patients with fVES (P = 0.01). In addition, although the interatrial and left atrial conduction delay times were significantly different between each group (P < 0.001, P < 0.001), the right atrial conduction delay times were similar. When patients with fVES were divided into groups depending on the existence of retrograde VAC, atrial deformation parameters and conduction delay time did not significantly differ between either group. CONCLUSION: Frequent RVOT-VES causes left atrial dysfunction. This information is obtained through strain analyses and recordings of left atrial conduction times in patients with pEF. Regardless, retrograde VAC is not related to atrial dysfunction.

Atrial electromechanical delay in patients undergoing heart transplantation.

BACKGROUND: We aimed to assess atrial electromechanical delay (AEMD) in patients who had undergone heart transplantation. METHODS: A total of 32 patients who underwent biatrial anastomosis heart transplantation (24 men, 8 women; mean age: 42±11 years) and 30 healthy volunteers (20 men, 10 women; mean age: 36±13 years) were included in the study. Atrial electromechanical coupling (PA), intra-AEMD, and inter-AEMD were measured. RESULTS: PA lateral (68±7 vs. 51±11 ms, p<0.01), PA septal (50±5 vs. 42±8 ms, p< 0.01) and PA tricuspid (39±6 vs. 36±9 ms, p<0.01), inter-AEMD (PA lateral-PA tricuspid) (27±7 vs. 10±4 ms, p<0.01), left intra-AEMD (PA lateral-PA septal) (18±7 vs. 10±4 ms, p<0.01), right intra-AEMD (PA septal-PA tricuspid) (13±5 vs. 5±3 ms, p<0.01) values were higher in patients who underwent heart transplantation than in a control population. CONCLUSION: Inter-AEMD and intra-AEMD were prolonged in patients who underwent heart transplantation as compared to a control population. This may explain the increased atrial fibrillation and other atrial arrhythmia incidences associated with the biatrial anastomosis heart transplantation technique and may contribute to the treatment of atrial fibrillation in this special patient group.

Effects of Obstructive Carotid Artery Disease on Ocular Circulation and the Safety of Carotid Artery Stenting.

BACKGROUND: The aims of this study were to examine the ophthalmic artery flow changes in patients with obstructive carotid artery disease, evaluate the orbital blood flow changes after carotid artery stenting and assess the safety of carotid stenting procedure by using transorbital colour and spectral Doppler sonography. METHODS: Thirty-one consecutive patients scheduled for carotid stenting with severe internal carotid artery stenosis (>60%; the study group) and 30 control subjects were included. Ophthalmic artery (OA) Doppler sonography was performed in the control group and study group before and after stenting. Peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index (RI) and systolic/diastolic ratio (S/D) in the ophthalmic artery were recorded. Statistical comparisons were made between controls and study group before stenting and before and after stenting in the study group. RESULTS: Comparison between control and study group before stenting revealed a statistically significant decrease in OA PSV (51.5±14.5 vs. 39.7±19cm/sec, p= 0.008) and EDV (15.2±4.5 vs. 11.3±5.7cm/sec, p=0.004) in the study group. Differences in PI (1.3±0.14 vs. 1.36±0.4, p=0.47), RI (0.7±0.04 vs. 0.75±0.21, p=0.19), and S/D (3.5±0.6 vs. 3.6±1, p= 0.5) ratio were not statistically significant between groups. Peak systolic velocity (39.7±18.9 vs. 51.3±22.2cm/sec, p <0.001), RI (0.75±0.21 vs. 0.81±0.13, p=0.16) and S/D ratio (3.6±1 vs. 4.6±1.5, p= 0.001) were found to be significantly increased in the study group after stenting compared to baseline. There were no statistically significant differences in EDV and RI EDV(11.3±5.7 vs. 11.7±5.7cm/sec, p=0.66), PI (1.36±0.4 vs. 1.6±0.6, p =0.047) after stenting. CONCLUSIONS: Ophthalmic artery flow parameters were significantly lower in patients with severe carotid artery stenosis compared to control, indicating compromised ocular blood flow in severe carotid stenosis. Flow indicators significantly improved after stent implantation suggesting the importance of revascularisation in restoring ocular blood flow and safety of carotid stenting.

Neutrophil to lymphocyte ratio: a novel marker for predicting hospital mortality of patients with acute type A aortic dissection.

INTRODUCTION: The inflammatory process has been reported to be associated with aortic dissection (AD) from the development to the prognosis. The aim of the study was to investigate a relationship between the neutrophil to lymphocyte ratio (NLR) and in-hospital outcomes in patients with acute aortic dissection (AAD) who underwent surgical repair. METHODS: One hundred and eighty-four patients who were admitted with the diagnosis of type A AAD who underwent surgical repair at two large tertiary hospitals. According to their NLR, 91 patients had high NLR (>6.0) and 93 patients had low NLR (⩽6.0). RESULTS: The frequency of major bleeding, hospital-related infection, multi-organ dysfunction and mortality in hospital were higher in the high NLR group compared to the low NLR group. NLR, WBC count and operation duration were found to be independent predictors for in-hospital mortality. CONCLUSIONS: The novel inflammatory marker NLR may be used to predict worse outcomes and hospital mortality in patients with AAD treated by surgical repair.

Is the presence of AA amyloidosis associated with impaired coronary flow reserve?

BACKGROUND AND AIMS: Systemic amyloid A protein (AA) amyloidosis may occur as a complication of many chronic inflammatory disorders. Patients receiving inadequate anti-inflammatory and immunosuppressive therapies have an increased risk of developing systemic AA amyloidosis. Inflammation plays a role in all stages and the thrombotic complications of atherosclerosis. In the absence of epicardial coronary stenosis, coronary flow reserve (CFR) reflects coronary microvascular dysfunction. In the present study, we hypothesized that amyloid advanced subclinical inflammation in chronic inflammatory diseases (CID) patients may further affect coronary microcirculation. METHODS: Thirty-two patients with biopsy-diagnosed renal AA, 73 patients with non-amyloid CID, and a group of healthy volunteers were included in the study. The measurements of coronary flow velocity were performed by a single investigator with expertise in transthoracic Doppler harmonic echocardiography (TTDE). RESULTS: The AA amyloidosis subgroup had significantly lower CFR values than other non-amyloid CID patients and the control individuals (1.8 (1.5-2.1) vs. 2.1 (2.0-2.4) and 3.0 (2.8-3.2), p < 0.001). Multivariate logistic regression analysis indicated that the presence of AA amyloidosis and elevated hs - CRP independently predict impairment of the CFR (p < 0.05). CONCLUSIONS: The presence of AA amyloidosis is related to decreased CFR values and the presence of AA amyloidosis and elevated hs - CRP independently predict impairment of the CFR. Therefore, patients with AA amyloidosis may have an increased risk of developing coronary artery diseases.

Comparison of Right Ventricle Systolic Function between Long-Term Anabolic-Androgenic Steroid User and Nonuser Bodybuilder Athletes: A Study of Two-Dimensional Speckle Tracking Echocardiography.

BACKGROUND: Right ventricular (RV) effects of long-term use of anabolic-androgenic steroids (AAS) are not clearly known. The aim of this study was to assess RV systolic functions by two-dimensional speckle tracking echocardiography (2DSTE) in AAS user and nonuser bodybuilders. METHODS: A total of 33 competitive male bodybuilders (15 AAS users, 18 AAS nonusers) were assessed. To assess RV systolic functions, all participants underwent standard two-dimensional and Doppler echocardiography, and 2DSTE. RESULTS: Interventricular septal thickness, left ventricle posterior wall thickness, relative wall thickness, and left ventricle mass index were significantly higher in AAS users than nonusers. While standard diastolic parameters were not statistically different between the groups, tissue Doppler parameters including RV E' and E'/A' were lower in AAS users than nonusers (10.1 ± 2.0 vs. 12.7 ± 2.1; P = 0.001, 1.1 ± 0.1 vs. 1.5 ± 0.4; P = 0.009, respectively). Tricuspid annular plane systolic excursion, RV fractional area change, and RV S' were in normal ranges. However, RV S' was found to be lower in users than nonusers (12.2 ± 2.2 vs. 14.6 ± 2.8, P = 0.011). RV free wall longitudinal strain and strain rate were decreased in AAS users in comparison with nonusers (-20.2 ± 3.1 vs. -23.3 ± 3.5; P = 0.012, -3.2 ± 0.1 vs. -3.4 ± 0.1; P = 0.022, respectively). In addition, there were good correlations between 2DSTE parameters and RV S', E', and E'/A'. CONCLUSION: Despite normal standard systolic echo parameters, peak systolic RV free wall strain and strain rate were reduced in AAS user bodybuilders in comparison with nonusers. Strain and strain rate by 2DSTE may be useful for early determination of subclinical RV dysfunction in AAS user bodybuilders.

Comparison of uninterrupted warfarin and bridging therapy using low-molecular weight heparin with respect to the severity of bleeding after dental extractions in patients with prosthetic valves.

OBJECTIVE: The management of anticoagulated patients with warfarin during dental extraction is an intricate issue. We carefully designed the current study so that the amount of bleeding was measured with objective methods and the data from the same patient in different dental extraction appointments could be compared, eliminating the bleeding diathesis differences of patients. METHODS: This prospective and controlled study was conducted in 36 adult patients with prosthetic valve requiring multiple tooth extractions. The first dental extraction was performed without the discontinuation of warfarin therapy, and the second procedure was performed with a discontinuation of warfarin and bridging with low-molecular weight heparin (LMWH). The two dental extraction protocols in the same patient group were compared. The total amount of bleeding was calculated as the difference between the weights of gauze swabs used before and after the tamponade; the number of gauze swabs used for bleeding control in the first 48 h was recorded. RESULT: The median number of used gauze swabs was 2.5 (IQR: 1-5) and 3.0 (IQR: 2-7) in the first and second dental extraction procedures, respectively. The median bleeding time was 50.0 (IQR: 20-100) in the first procedure compared with 60.0 (IQR: 40-140) min in the second procedure. The mean amounts of bleeding were 2194±1418 mg in the first dental extraction procedure and 2950±1694 mg in the second dental extraction procedure. The median number of used gauze swabs, the median bleeding time, and the mean amount of bleeding were statistically higher in the second dental extraction procedure (P<0.001). CONCLUSION: Continued warfarin treatment at the time of dental extractions reduces the total amount of bleeding compared with bridging therapy in patients with prosthetic valves.

Intracardiac Thrombus in Behçet's Disease.

Behçet's disease (BD) is a chronic multisystem disease that presents with recurrent oral and genital ulceration and recurrent uveitis. The patients are often diagnosed in the range of 20-30 years of age and BD are more common in men.[1] BD has a worldwide distribution, but it is mainly observed in Mediterranean areas and Japan.[2] Involvement of skin, joints, nervous, respiratory, gastrointestinal, and cardiovascular systems is also recognised.[34] Although the vascular lesions are frequently observed in this disease, the cardiac involvement is rare and is associated with the poor prognosis.[5].

Cardiac Rehabilitation Improves the QRS Fragmentation in Patients With ST Elevation Myocardial Infarction.

INTRODUCTION: We aimed to evaluate the effect of exercise-based cardiac rehabilitation (CR) on the fragmented QRS (fQRS) in patients with ST elevation myocardial infarction (STEMI). METHODS: Ninety-seven patients with STEMI participated CR and 81 patients as a control group were included to the study. The trained patients were grouped according to the presence and persistence of QRS fragmentation on the electrocardiogram (ECG) before and after CR. If the fragmentation was present on the ECG at the beginning of the CR but not on the ECG at the end of CR; the transient group, if the fQRS persists after CR; the persistent fQRS group. ECGs obtained from the control group were grouped according to the presence of a fQRS on ECG. RESULTS: Among the trained patients, 45 (46%) did not have a fQRS before CR, whereas 52 (54%) presented a fQRS before CR, which was persistent in 35 patients (the persistent fQRS group) and transient in 17 patients (the transient fQRS group). Among 81 patients included in the control group, fQRS was persistent in 41 patients. Presence of fQRS on the ECG was significantly decreased with CR and it is better in trained group than the control group (P = .034). There were not significant correlations with other characteristics, except hypertension. CONCLUSION: The existence of the fQRS decreases after CR in patients with STEMI especially in hypertensive individuals, which may be related to improved electrical stability in the myocardium as a predictor of increase in survival and decrease in major cardiac events.

Retrobulbar blood flow and carotid intima-media thickness alteration may relate to subclinic atherosclerosis in patients with chronic inflammatory diseases.

OBJECTIVE: AA amyloidosis occurs in the setting of longstanding inflammation. An increased incidence of coronary artery disease (CAD) was noted in patients with chronic inflammatory disease (CID). Retrobulbar blood flow predicts future macrovascular events including CAD. Increase in carotid artery intima-media thickness is regarded as a marker for early atherosclerosis. The relationship between chronic inflammation and atherosclerosis is well known; however, the connection between amyloidosis-advanced CIDs and retrobulbar microvascular function and carotid intima-media thickness (CIMT) is unidentified. We aimed to investigate whether retrobulbar microcirculation and CIMT were impaired or not in amyloidosis-advanced CID patients compared to normal subjects. METHODS: Fourteen patients with renal AA amyloidosis and a group of healthy volunteers were included in the study. Measurement of CIMT and retrobulbar blood flow velocities was performed with ultrasound scanner and color Doppler ultrasonography. RESULTS: The CIMT of patients with renal amyloidosis was significantly thicker than that of the normal population (p < 0.001). The resistivity index of the ophthalmic artery (OA) of patients with renal amyloidosis was significantly higher than the study group (p < 0.001). CONCLUSION: This study demonstrates that accelerated atherosclerosis which can be shown by increased OA resistivity index and CIMT are found in amyloidal-related CID patients.

The relationship between rheumatoid factor levels and coronary artery lesion complexity and severity in patients with stable coronary artery disease.

INTRODUCTION: The relation between serum rheumatoid factor levels and the extent, severity, and complexity of coronary artery disease has not been adequately studied. AIM: Therefore, we assessed the relationship between the severity of coronary artery disease assessed by SYNTAX score and serum rheumatoid factor levels in patients with stable coronary artery disease. MATERIAL AND METHODS: We enrolled 268 consecutive patients who underwent coronary angiography. Patients with acute coronary syndrome and chronic immune disorders were excluded. Baseline serum rheumatoid factor levels were measured and the SYNTAX score was calculated from the study population. RESULTS: Patients were divided into two groups. Group 1 was defined as low SYNTAX score < 22, and group 2 was defined as intermediate and high SYNTAX score > 22. Serum rheumatoid factor levels were significantly higher in the intermediate and high-SYNTAX score group than in the low-SYNTAX score group (16.4 ±9 IU/mlvs. 11.36 ±5 IU/ml, p < 0.001). Also, there was a significant correlation between rheumatoid factor and CRP levels with the SYNTAX score r = 0.411; p < 0.001 and r = 0.275; p < 0.001, respectively. On multivariate linear regression analysis, rheumatoid factor (ß = 0.101, p < 0.001) was an independent risk factor for intermediate and high SYNTAX score in patients with stable coronary artery disease. In receiver operator characteristic curve analysis, optimal cut-off value of rheumatoid factor to predict high SYNTAX score was found to be 10.5 IU/ml, with 69% sensitivity and 61% specificity. CONCLUSIONS: The rheumatoid factor level was independently associated with the extent, complexity, and severity of coronary artery disease assessed by SYNTAX score in patients with stable coronary artery diseases.

The Effect of Chronic Anabolic-Androgenic Steroid Use on Tp-E Interval, Tp-E/Qt Ratio, and Tp-E/Qtc Ratio in Male Bodybuilders.

BACKGROUND: The chronic consumption of androgenic anabolic steroids has shown to cause atrial arrhythmias. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate repolarization dispersion measured from the 12-lead surface electrocardiogram (including Tp-e interval, Tp-e/QT ratio, and Tp-e/cQT ratio) in bodybuilders who are using anabolic androgenic steroids (AAS). METHODS: We selected a population of 33 competitive bodybuilders, including 15 actively using AAS for ≥ 2 years (users) and 18 who had never used AAS (nonusers), all men. RESULTS: QT, cQT, QTd, cQTd, JT, and cJT were significantly increased in AAS users bodybulders compared to the nonusers (all P < 0.001). Tp-e interval, Tp-e/QT ratio, and Tp-e/cQT ratio were also significantly higher in AAS user group compared to the nonuser group (all P < 0.001). QRS duration was not different between the groups. There were negative correlation between E(m) and Tp-e, Tp-e/QT ratio, Tp-e/cQT ration (r = -0.657, P < 0.01; r = -0.607, P = 0.02; r = -0.583, P = 0.02; respectively).There were also negative correlation between S(m) and Tp-e, Tp-e/QT ratio, Tp-e/cQT ration (r = -0.681, P < 0.01; r = -0.549, P = 0.03; r = -0.544, P = 0.023; respectively). CONCLUSION: In conclusion, we have presented a strong evidence suggesting that Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were increased in AAS users, which suggest that there might be a link between AAS use and ventricular arrthymias and sudden death.

Evaluation of the effect of cardiac rehabilitation on left atrial and left ventricular function and its relationship with changes in arterial stiffness in patients with acute myocardial infarction.

BACKGROUND: The main aim of this study was to detect the possible early effect of cardiac rehabilitation (CR) on left atrium (LA) and left ventricle (LV) function and relation to aortic stiffness in patients with acute myocardial infarction (AMI). METHODS: Fifty-four patients with AMI were enrolled in this study. Left atrial strain analysis was performed by two-dimensional speckle tracking echocardiography. The deceleration time (DT) was measured by pulsed-wave Doppler. The ratio of E/e' to LA peak strain was used to estimate the LA stiffness (Stiffnessstrain ) Aortic elasticity parameters were calculated using the formulas including aortic systolic and diastolic diameter with M-Mode echocardiography and blood pressure. Anterior wall aortic expansion velocity was measured by tissue Doppler imaging. RESULTS: Left ventricle ejection fraction (EF) and LA functional parameters were significantly better in trained subjects. Also in training group, the LV diastolic functional parameters were better in CR group than the control group. Aortic elasticity parameters were better with CR. CONCLUSIONS: In patients with CR, an increase in LA strain was correlated with increase in aortic strain and improved aortic distensibility, likely indicating favorable LA and aortic interactions with exercise training.

P-wave dispersion and its relationship to aortic stiffness in patients with acute myocardial infarction after cardiac rehabilitation.

BACKGROUND: The aim of our study was to investigate the P-wave dispersion from standard electrocardiograms (ECGs) in patients with acute myocardial infarction (AMI) after cardiac rehabilitation (CR) and determine its relation to arterial stiffness. METHODS: This is a prospective study included 33 patients with AMI and successfully re-vascularized by percutaneous coronary intervention (PCI) underwent CR. Left ventricular ejection fraction (LVEF) was measured by biplane Simpson's method. Left atrium (LA) volume was calculated. The maximum and minimum durations of P-waves (Pmax and Pmin, respectively) were detected, and the difference between Pmax and Pmin was defined as P-wave dispersion (Pd = Pmax-Pmin). Aortic elasticity parameters were measured. RESULTS: LVEF was better after CR. The systolic and diastolic blood pressures decreased after CR, these differences were statistically significant. With exercise training, LA volume decreased significantly. Pmax and Pd values were significantly shorter after the CR program. The maximum and minimum P-waves and P-wave dispersion after CR were 97 ± 6 ms, 53 ± 5 ms, and 44 ± 5 ms, respectively. Aortic strain and distensibility increased and aortic stiffness index was decreased significantly. Aortic stiffness index was 0.4 ± 0.2 versus 0.3 ± 0.2, P = 0.001. Aortic stiffness and left atrial volume showed a moderate positive correlation with P-wave dispersion (r = 0.52, P = 0.005; r = 0.64, P < 0.001, respectively). CONCLUSION: This study showed decreased arterial stiffness indexes in AMI patient's participated CR, with a significant relationship between the electromechanical properties of the LA that may raise a question of the preventive effect of CR from atrial fibrillation and stroke in patients with acute myocardial infarction.

Association between restless leg syndrom and slow coronary flow.

OBJECTIVE: Restless legs syndrome (RLS) is a common sleep disorder in which patients feel unpleasent leg sensations and urge to move the legs during rest, especially at night, and symptoms are improved by leg movement. Prior studies analyzing the associations between cardiovascular disease and restless legs syndrome has shown controversial results. The goal of the study was to estimate the relationship between restless legs syndrome and slow coronary flow (SCF). METHODS: The present study was cross-sectional and observational and consists of 176 individuals who underwent coronary angiography and had angiographically normal coronary arteries of varying coronary flow rates. The study included 86 patients with isolated SCF and 90 control participants with normal coronary flow (NCF). RLS was assessed the day after the coronry flow was evaluated, using a self-administered questionnaire based on the International Restless Legs Study Group criteria. The following question was asked: "Do you have unpleasant leg sensations (like crawling, paraesthesia, or pain) combined with motor restlessness and an urge to move?" The possible responses were as follows: no, less than once/month, 2-4 times/month, 5-14 times/month, and 15 or more times per month. Those who answered that they had these feelings were asked the following two more questions: 1) "Do these symptoms occur only at rest and does moving improve them?" and 2) "Are these symptoms worsen in the evening/at night compared with the morning?" RLS is considered to be probable if the participant has answered "yes" for all three of the above questions, and has a frequency of ≥5 times/month. Student's t-test, Mann-Whitney U test, multiple logistic regression analysis were used for statistical analysis. RESULTS: The prevalence of restless legs syndrome was 48 (27%) and increased significantly with age. Patients with SCF have more likely had RLS than the control group (p<0.001). The age-adjusted prevalence odds of SCF were 3.11 times higher (95% CI: 1.54-6.29; P<0.001) among patients with RLS symptoms. Significant associations between RLS and SCF did not materially change after further adjustment for other potential covariates, such as sex, BMI, BMI squared, smoking. CONCLUSION: Our study concluded that there is a strong link between SCF and RLS.