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.

Thyroid Functions Are Associated with All-Cause Long-Term Mortality in Elderly Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

OBJECTIVE: Our aim in this study was to show the relationship between long-term all-cause mortality and thyroid functions in the elderly patient group that underwent primary percuta-neous coronary intervention with the diagnosis of ST-segment elevation myocardial infarction. METHODS: Two-hundred seventy patients over 65 years of age who underwent primary percutaneous coronary intervention with the diagnosis of ST-segment elevation myocardial infarction were analyzed retrospectively. After applying the exclusion criteria, 198 patients were included in the study. The patients were divided into 2 groups according to their out-of-hospital mortality status. Angiographic, laboratory, echocardiographic, and electrocardiographic data were analyzed. RESULTS: The mean age of 198 patients in the study was 72.5 ± 6.6 years, and the median follow-up time was 101.7 months. Age was higher in the deceased group (70.4 ± 5.4 vs. 74.5 ± 6.9, P < 0.001). In multivariate analysis, age (odds ratio: 1.59, P = 0.003), insulin (odds ratio: 2.561, P = 0.016), angina balloon time (odds ratio: 1.134, P = 0.002), number of serious stenoses (odds ratio: 1.702, P = 0.003), creatinine (odds ratio: 3.043, P < 0.001), and fT4 (odds ratio: 2.026, P = 0.026) were determined as independent predictors of mortality. The fT4 level was correlated with the uric acid level (R: 0.182, P = 0.02) and the fT3 level was correlated with albumin (R: -0.253, P = 0.001) and creatinine (R: -0.224, P = 0.003) levels. A fT4 level cutoff value of 0.99 ng/mL had a sensitivity of 76%, a specificity of 54%, and an area under the curve of 0.675 in predicting mortality. In Kaplan-Meier analysis, fT4 elevation was strongly associated with mortality (P = 0.01). CONCLUSION: In our study, subclinical values in thyroid functions were found to be associated with increased mortality, apart from known factors in elderly patients who underwent primary PTCA with the diagnosis of ST-segment elevation myocardial infarction.

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.

The Relationship Between Coronary Anatomy and Angina Pectoris During Stent Balloon Dilatation in Patients Undergoing Percutaneous Coronary Intervention.

OBJECTIVE: Angina pectoris (AP) is defined as a clinical symptom characterized by sensations such as pressure-heaviness, burning, squeezing, or discomfort in different parts of the body, including the retrosternum, chest, jaw, neck, shoulders, and back. Limited publications exist on the impact of coronary artery disease localization on the placement, character, and severity of AP. This study aimed to investigate the relationship between the frequency of AP development due to myocardial ischemia during percutaneous coronary intervention (PCI), its character, severity, localization, and coronary anatomy. METHODS: A total of 128 patients were included in the study, with 146 lesions treated among them. RESULTS: Among patients who underwent PCI of the right coronary artery (RCA), 31.1% reported no complaints. Similar rates were observed in patients undergoing PCI of the left anterior descending (LAD) and circumflex (Cx) arteries, at 23.7% and 19.1%, respectively. Pressure-heaviness was frequently observed in PCI of the LAD and Cx arteries, while burning was the dominant symptom description in PCI of the RCA. The isolated retrosternal and left thoracic regions were the most common localizations in all main coronary arteries. Epigastric localization occurred most frequently in PCI of the RCA. In terms of the severity of angina, no significant difference was observed between the three coronary arteries. CONCLUSION: Pressure-heaviness angina was commonly observed during PCI of the LAD and Cx, while burning angina was frequent during PCI of the RCA. The severity of AP was similar across the three main coronary arteries.

Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry.

BACKGROUND AND AIMS: Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients. METHODS: We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia. RESULTS: Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P < .001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P = .06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages. CONCLUSIONS: In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

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.

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.

Reprogramming the tachycardia parameters with long-detection strategy in patients with pre-existing implantable cardioverter-defibrillator.

Background: A long-detection interval (LDI) programming has been proved to reduce shock therapy in patients who underwent de novo implantable cardioverter defibrillator (ICD) implantation. We aimed to evaluate effectiveness and safety of this new strategy in old ICD recipients. Methods: We included 147 primary prevention patients with ischaemic and non-ischaemic aetiology. Conventional setting parameters (18 of 24 intervals to detect ventricular arrhythmias (VA's)) were reprogrammed with LDI strategy (30 of 40 intervals to detect VA's). One monitoring zone (between 360 and 330 ms) and two therapy zones were programmed, treating all rhythms of cycle length <330 ms that met the duration criterion of 30/40 intervals and were discriminated as ventricular tachycardia/ventricular fibrillation (VT/VF). The supraventricular tachycardia (SVT) discriminators were used in all patients. Results: At a median follow-up of 24 months, 12.9% (n = 19) of patients received shock therapies (± antitachycardia pacing (ATP)). Appropriate and inappropriate shocks occurred in 7.5 and 5.4% of patients during follow-up, respectively. Only one patient experienced an arrhythmic syncope during the follow-up period. There was no death related to LDI programming. The LDI programming helped to stop unnecessary in 10 patients (6.8%), who otherwise would have been treated in the conventional programming. Conclusions: LDI programming was found safe and effective. Hence, old ICD recipients will benefit from this strategy.

Elevated levels of vitamin B12 in chronic stable heart failure: a marker for subclinical liver damage and impaired prognosis.

BACKGROUND: Elevated vitamin B12 is a sign for liver damage, but its significance in chronic stable heart failure (HF) is less known. The present study investigated the clinical correlates and prognostic significance of vitamin B12 levels in stable systolic HF. METHODS: A total of 129 consecutive patients with HF and 50 control subjects were enrolled. Data regarding demographics, clinical signs, therapeutic and conventional echocardiographic measurements were recorded for all patients. Right-sided HF was defined as the presence of at least one of the typical symptoms (ankle swelling) or specific signs (jugular venous distention or abdominojugular reflux) of right HF. Cox proportional hazards regression analyses were performed to determine the independent prognostic determinants of mortality. RESULTS: Baseline B12 levels in HF patients (n=129) with and without right sided HF were significantly higher compared to healthy controls (n=50): Median 311 pg/mL and 235 pg/mL vs 198 pg/mL, respectively (P=0.005). Folic acid levels were similar between the study groups. Age, ejection fraction, left atrial size, estimated glomerular filtration rate, and direct and indirect bilirubin levels were significantly correlated to serum B12 level in univariate analysis. In multivariate analysis, independent correlates of B12 were direct bilirubin (R=0.51, P<0.001) and age (R=0.19, P=0.028). Patients with HF were followed-up for a median period of 32 months. Median B12 levels were significantly higher in patients who subsequently died (n=35) compared to survivors, but folic acid was not different between the two groups. ROC analysis showed that B12 values ≥270 pg/mL had 80% sensitivity and 58% specificity for predicting all-cause mortality (area under the curve=0.672, 95% CI=0.562-0.781; P=0.003). However, in Cox regression analysis, only left atrial diameter, level of direct bilirubin, and the presence of abdominojugular reflux were independent predictors of death. CONCLUSION: Increased B12 in stable HF patients is associated with increased direct bilirubin due to right HF, indicating a cardiohepatic syndrome, but neither B12 nor folic acid are independently associated with mortality.

Surface electrogram-guided left ventricular lead placement improves response to cardiac resynchronization therapy.

OBJECTIVE: Failure to select the optimal left ventricular (LV) segment for lead implantation is one of the most important causes of unresponsiveness to the cardiac resynchronization therapy (CRT). In our study, we aimed to investigate the echocardiographic and clinical benefits of LV lead implantation guided by an intraoperative 12-lead surface electrocardiogram (ECG) in patients with multiple target veins. METHODS: We included 80 [42 (62.5%) male] heart failure patients who successfully underwent CRT defibrillator (CRT-D) implantation. Patients were divided into two groups. In group 1, LV lead was positioned at the site with the shortest biventricular-paced (BiV-paced) QRS duration (QRSd), as intraprocedurally measured using surface ECG. In group 2 (control), we included patients who underwent the standard unguided CRT. ECG, echocardiogram, and functional status were evaluated before and 6 months after CRT implantation in all patients. RESULTS: In group 1, BiV-paced QRSd measurements were successfully performed in 112 of 120 coronary sinus branches during CRT and an LV lead was successfully placed at the optimal site in all patients. Compared with group 2, group 1 had a significantly higher rate (85% vs. 50%, p=0.02) of response (>15% reduction in LV end-systolic volume) to CRT as well as a shorter QRSd (p<0.001) and a greater QRS shortening (ΔQRS) associated with CRT compared with baseline (p<0.001). The mean New York Heart Association functional class was significantly improved in both groups, and no significant differences were found in clinical response to CRT (85% vs. 70%, p=0.181). CONCLUSION: Surface ECG can be used to guide LV lead placement in patients with multiple target veins for improving response to CRT. Thus, it is a safe, feasible, and economic approach for CRT-D implantation.

A large biatrial thrombus entrapped by patent foramen ovale in a case with massive pulmonary embolism.

Thrombus development in cardiac chambers increases the risk of mortality, compared to pulmonary embolism alone, and can require change in therapy. In the presence of patent foramen ovale, paradoxical systemic embolization can occur associated with a higher incidence of death and embolic complications. Herein, we present a case of pulmonary embolism concomitant a right atrial huge thrombus entrapped in patent foramen ovale and prolapsing into the left heart chambers.

A simple discharge risk model for predicting 1-year mortality in hospitalised acute decompansated heart failure patients with reduced ejection fraction.

OBJECTIVE: The risk stratification for prognosis in heart failure is very important for optimal disease management and decision making. The aim of this study was to establish a simple discharge 1-year mortality prediction model by integrating data obtained from demographic characteristics, clinical evaluation, laboratory biomarkers and echocardiographic evaluation of hospitalised heart failure with reduced ejection fraction (HFrEF) patients with acute decompensation. METHODS AND RESULTS: A risk score model was developed based on ß-coefficient number of variables in a multivariable logistic regression model which was created with the use of data on clinical, laboratory, imaging and therapeutic findings of 670 patients (65.4% males, 65 ± 11 years) who was hospitalised with acute decompensated HFrEF. The mean left ventricular ejection fraction (LVEF) was 26 ± 9%. Independent predictors of mortality were: age ≥75 years, sodium <130 mEq/L, hepatomegaly at admission, unable to use beta-blocker at discharge and LVEF ≤20%. The 1-year mortality rate was 7.8% in the study population. The existence of each predictor was scored as 1 point and the discharge risk score identified patients into low (0-1 points), intermediate (2-3 points) and high (4-5 points) risk individuals with 3, 15.6 and 44.4% 1-year mortality rates, respectively. The model performance evaluated by concordance index was 0.74. CONCLUSIONS: This simple discharge risk score model for hospitalised acute decompensated HFrEF patients using easily determined demographic characteristics, clinical signs, echocardiographic and laboratory data is a valuable and an easy risk assessment tool to use at point-of-care.

A massive left-to-right shunt due to delayed spontaneous perforation of polyvinyl alcohol membrane of atrial septal occluder.

Percutaneous closure of an atrial septal defect (ASD) has emerged as an alternative to surgery. A 54-yearold woman with a history of percutaneous ASD closure with a 30-mm Cardia Ultrasept septal occluder (Cardia Inc., Eagan, MN, USA) comprising 2 discs made of Nitinol wire mesh covered with polyvinyl alcohol (PVA) membrane, was admitted to the hospital with unstable angina pectoris. In a routine examination, transthoracic echocardiography revealed a left-to-right shunt through the device. Transesophageal echocardiography (TEE) also demonstrated significant left-to-right shunt through the central portion of the prosthesis. Coronary angiography was performed, which disclosed severe stenosis in the right and left anterior descending coronary arteries. Threedimensional TEE showed multiple perforations of the PVA membrane with intact nitinol frame. Surgical removal of failing device and closure of the ASD with a pericardial patch was performed together with coronary artery bypass graft surgery. On perioperative view, the device appeared to have been correctly implanted, and the device frame was completely intact; however, the PVA membrane of both the right and left discs had almost completely disappeared and there was incomplete endothelialization around the frame. Surgeons must be aware of this rarely seen complication and they should re-examine all patients implanted with Cardia devices in regular follow-up examinations for a long period of time.

Mid-Term Outcomes of Stent Overlap in Long Total Occluded Lesions of Superficial Femoral Artery.

BACKGROUND Superficial femoral artery chronic total occlusion (SCTO) is a common type of peripheral arterial disease (PAD). Endovascular therapy is a treatment approach that has a poor long-term success rate in this group. The aim of this study was to compare the mid-term results of two different uses of nitinol stents in long SCTO lesions (>100 mm): the use of one long stent or two shorter stents. MATERIAL AND METHODS Of 154 patients who underwent percutaneous infrainguinal interventions from 2011 to 2014, a total of 170 CTO lesions were selected for this retrospective study analysis. The mean age of the study population was 63.4±10.4 years (range 29-89 years); 71.8% of the patients were male. RESULTS Patients were divided into two groups according to the number of stents used. Patients treated with a single stent were placed into group A and patients treated with two stents were placed into group B. The stent fracture rate was significantly higher in group B compared to group A (29.2% vs. 42%). Type 1 and 2 fracture rates were higher in group A, but type 3 and 5 fracture rates were significantly higher in group B. The rate of stent restenosis was significantly higher in group B compared to group A (45.1% vs. 54.5%, p=0.05). CONCLUSIONS Mid-term patency rate was low in patients with long totally occluded superficial femoral artery (SFA) lesions. Using a long single stent had an acceptable mid-term patency rate compared to using a two stent strategy. Stent fracture seemed to be the main reason for in-stent restenosis in cases of multiple stenting. A long single stent strategy may be more appropriate and reasonable than a two stent strategy in the treatment of long SFA lesions.

Improvement in left ventricular intrinsic dyssynchrony with cardiac resynchronization therapy.

OBJECTIVE: Cardiac resynchronization therapy (CRT) has been shown to induce a structural and electrical remodeling; the data on whether left ventricle (LV) reverse remodeling is associated with restitution of intrinsic contraction pattern are unknown. In this study, we investigated the presence of improvement in left ventricular intrinsic dyssynchrony in patients with CRT. METHODS: A total of 45 CRT recipients were prospectively studied. Dyssynchrony indexes including interventricular mechanical delay (IVMD) and tissue Doppler velocity opposing-wall delay (OWD) as well as QRS duration on 12-lead surface electrocardiogram were recorded before CRT device implantation. After 1 year, patients with chronic biventricular pacing were reprogramed to VVI 40 to allow the resumption of native conduction and contraction pattern. After 4-6 h of intrinsic rhythm, QRS duration and all echocardiographic measurements were recorded. Dyssynchrony was defined as IVMD >40 ms and OWD >65 ms. CRT response was defined by a ≥15% reduction in left ventricular end-systolic volume (LVESV) at a 12-month follow-up. RESULTS: Thirty-two patients (71%) showed response to CRT. The native QRS duration reduced significantly from 150±12 ms to 138±14 ms (p<0.001), and dyssynchrony indexes showed a significant improvement only in responders. The mean OWD reduced from 86±37 ms to 50±29 ms (p<0.001), and the mean IVMD decreased from 55±22 ms to 28±22 ms (p<0.001) in responders. The reduction in LVESV was significantly correlated with ΔOWD (r=0.47, p=0.001), ΔIVMD (r=0.45, p=0.001), and ΔQRS (r=0.34, p=0.022). CONCLUSION: Chronic CRT significantly improves LV native contraction pattern and causes reverse remodeling in dyssynchrony.

Associations Between Neutrophil Gelatinase Associated Lipocalin, Neutrophil-to-Lymphocyte Ratio, Atrial Fibrillation and Renal Dysfunction in Chronic Heart Failure.

BACKGROUND Atrial fibrillation (AF) and renal dysfunction are two common comorbidities in patients with chronic heart failure with reduced ejection fraction (HFrEF). This study evaluated the effect of permanent AF on renal function in HFrEF and investigated the associations of atrial fibrillation, neutrophil gelatinase-associated lipocalin (NGAL), and neutrophil-to-lymphocyte ratio (NLR) with adverse clinical outcome. MATERIAL AND METHODS Serum NGAL levels measured by ELISA and NLR were compared between patients with sinus rhythm (HFrEF-SR, n=68), with permanent AF (HFrEF-AF, n=62), and a healthy control group (n=50). RESULTS Mean eGFR levels were significantly lower, and NLR and NGAL levels were significantly higher in the HFrEF patients than in the control patients but the difference between HFrEF-SR and HFrEF-AF was not statistically significant (NGAL: 95 ng/mL in HFrEF-SR, 113 ng/mL in HFrEF-AF and 84 ng/mL in the control group; p<0.001). Independent associates of baseline eGFR were age, hemoglobin, NLR, triiodothyronine, and pulmonary artery systolic pressure. In a mean 16 months follow-up, adverse clinical outcome defined as progression of kidney dysfunction and composite of all-cause mortality and re-hospitalization were not different between HFrEF-SR and HFrEF-AF patients. Although NGAL was associated with clinical endpoints in the univariate analysis, Cox regression analysis showed that independent predictors of increased events were the presence of signs right heart failure, C-reactive protein, NLR, triiodothyronine, and hemoglobin. In ROC analysis, a NLR >3 had a 68% sensitivity and 75% specificity to predict progression of kidney disease (AUC=0.72, 95% CI 0.58-0.85, p=0.001). CONCLUSIONS Presence of AF in patients with HFrEF was not an independent contributor of adverse clinical outcome (i.e., all-cause death, re-hospitalization) or progression of renal dysfunction. Renal dysfunction in HFrEF was associated with both NLR and NGAL levels, but systemic inflammation reflected by NLR seemed to be a more important determinant of progression of kidney dysfunction.

Rare multiple fistulas with large saccular aneurysms originating from left anterior descending artery and left main coronary artery.

A 49-year-old female patient consulted us for a cardiac evaluation before undergoing colon adenocarcinoma surgery. Three years prior, the patient underwent coronary angiography for dyspnea. The coronary angiography examination revealed a fistula originating from the left anterior descending artery and left main coronary artery, which had soft aneurysmal sacs and most likely drained into the pulmonary artery. Parasternal short axis echocardiography revealed a color flow that could be related to the fistula, but the other echocardiographic findings were normal. The patient did not accept the proposed examination and invasive treatment.