Significant Improvement of Cardiac Dysfunction After Kidney Transplant: A Case Report.

Kidney transplant is known to reverse cardiac dysfunction in patients with end-stage renal disease, and low ejection fraction in kidney transplant candidates is considered to be a contraindication for transplant. We present a significant improvement in cardiac dysfunction after successful kidney transplant in a 21-year-old male recipient. Kidney transplant may be beneficial for cardiac function in transplant recipients who have impaired cardiac function prior to the procedure and caused by uremic toxins.

Direct aortic transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical valve replacement in intermediate and even in low-risk patient cohorts. Direct aortic (DAo) route may be used in patients with severe peripheral vascular disease. Here, we present an 88-year old patient hospitalized with cardiogenic shock. Echocardiography revealed severe aortic valve stenosis with aortic valve area 0.5 cm², mean gradient of 55 mmHg, and peak gradient 92 mmHg. TAVI was considered by the Institutional Heart Team. Multislice computed tomography (MSCT) revealed severe peripheral vascular disease, decreased calibration of abdominal aorta, and multiple large vulnerable atherosclerotic plaques. The patient was scheduled for a DAo TAVI. A 26-mm Medtronic CoreValve Evolut R valve was implanted after predilatation with median sternotomy. The patient was discharged after 96 hours. Although transfemoral (TF) access is used as the default approach for TAVI, it was contraindicated in our patient owing to severe peripheral vascular disease and decreased calibration of the abdominal aorta at its narrowest point (4.5 mm) with multiple large vulnerable atherosclerotic plaques. Careful preprocedural MSCT evaluation is essential and directly affects the success of the procedure. MSCT is also mandatory to confirm the best cannulation zone that must be met for a successful DAo TAVI.

Comparison of non-vitamin K antagonist oral anticoagulants and well-controlled warfarin in octogenarians with non-valvular atrial fibrillation: Real-world data from a single tertiary center.

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, and its prevalence increases with age. Nevertheless, data about the use of oral anticoagulants (OACs) among patients with ≥80 years remains limited. This study aimed to evaluate the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in octogenarians with non-valvular AF (NVAF). METHODS: Medical records of 387 patients who were ≥80 years and diagnosed with NVAF in our hospital between January 2017 and December 2019 were evaluated retrospectively. Patients with NVAF were divided into 2 groups (NOACs and warfarin), and the incidence of stroke/systemic embolism and major bleeding were analyzed. RESULTS: A total of 322 patients were included in the study. The median follow-up duration was 10.9 months for the NOACs group and 12.1 months for the warfarin group. The primary efficacy outcome was stroke/systemic embolism, and the primary safety outcome was major bleeding. A total of 220 patients were taking NOACs, and the most preferred NOACs were apixaban (53.6%), rivaroxaban (29.5%), dabigatran (13.2%), and edoxaban (3.6%) in this order. During a mean follow-up of 302.7 patient-years, the incidence of stroke or systemic embolic events was slightly higher among patients with warfarin but the difference was not statistically significant (p=0.862). The incidence rates of major bleeding events were similar between the treatment groups (p=0.824). CONCLUSION: Our study revealed that the safety and efficacy outcomes are similar between the 2 treatment groups in octogenarians with NVAF.

Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases.

OBJECTIVE: The evolution of non-vitamin K antagonist anticoagulants (NOACs) has changed the horizon of stroke prevention in atrial fibrillation (SPAF). All 4 NOACs have been tested against dose-adjusted warfarin in well-designed, pivotal, phase III, randomized, controlled trials (RCTs) and were approved by regulatory authorities for an SPAF indication. However, as traditional RCTs, these trials have important weaknesses, largely related to their complex structure and patient participation, which was limited by strict inclusion and extensive exclusion criteria. In the real world, however, clinicians are often faced with complex, multimorbid patients who are underrepresented in these RCTs. This article is based on a meeting report authored by 12 scientists studying atrial fibrillation (AF) in diverse ways who discussed the management of challenging AF cases that are underrepresented in pivotal NOAC trials. METHODS: An advisory board panel was convened to confer on management strategies for challenging AF cases. The article is derived from a summary of case presentations and the collaborative discussions at the meeting. CONCLUSION: This expert consensus of cardiologists aimed to define management strategies for challenging cases with patients who underrepresented in pivotal trials using case examples from their routine practice. Although strong evidence is lacking, exploratory subgroup analysis of phase III pivotal trials partially informs the management of these patients. Clinical trials with higher external validity are needed to clarify areas of uncertainty. The lack of clear evidence about complex AF cases has pushed clinicians to manage patients based on clinical experience, including rare situations of off-label prescriptions.

[Markers of coagulation and fibrinolysis do not detect or predict the presence of left atrial appendage thrombus in patients with atrial fibrillation]. / Atriyal fibrilasyonu olan hastalarda pihtilasma ve fibrinolizis belirteçleri sol atriyal trombüs varligini belirleyemiyor veya öngöremiyor.

OBJECTIVE: This study was designed to evaluate the role of hemostatic variables in arterial blood serum in left atrial thrombosis and to define any hemostatic variables, such as serum biomarkers, that could potentially reduce the need for transesophageal echocardiography. METHODS: This study included patients with non-valvular asymptomatic atrial fibrillation (AF), either paroxysmal, persistent, or chronic. The presence of an left atrial appendix (LAA) thrombus was used to form 2 groups: thrombus (+) and thrombus (-). The serum levels of the thrombotic/fibrinolytic markers including beta-thromboglobulin, prothrombin fragment 1+2, thrombin/antithrombin complex, human plasminogen activator inhibitor-1/tissue plasminogen activator complex, and D-dimer were compared between 2 groups. RESULTS: The mean age of the study population was 65.6±12.2 years (range: 30-96 years), and 33 (61.1%) patients were male. Fourteen (25.9%) patients had an LAA thrombus and 40 patients did not. Two groups did not differ significantly with regard to any of the coagulation/fibrinolysis markers. The LAA thrombus (+) group had significantly higher rates of heart failure, peripheral artery disease, coronary artery disease, and chronic obstructive pulmonary disease (<0.05). Neither the serum levels of the study markers nor demographic and clinical parameters were predictive of an LAA thrombus in binary logistic regression analysis. CONCLUSION: The arterial blood serum markers did not differ significantly between groups with and without an LAA thrombus and did not predict an LAA thrombus in patients presenting with AF.

Incidence of Cardiovascular Events After Renal Transplantation.

OBJECTIVES: Renal transplant recipients may present with transplant-specific risk factors related to end-stage renal disease. Although cardiovascular disease-related deaths may be reduced in renal transplant recipients, this disease is still the leading cause of death in patients with a functioning allograft. In this study, our aim was to determine the incidence of cardiovascular events after renal transplant. MATERIALS AND METHODS: This observational retrospective cohort study analyzed renal transplant recipients seen at Baskent University Hospital from 2014 to 2017. Posttransplant cardiovascular events were defined as presence of myocardial infarction, percutaneous coronary interventions, new-onset angina, and death. Patient characteristics, traditionals cardiovascular risk factors, routine biochemistry, and other comorbidities were included in our analyses. RESULTS: In total, 56 renal transplant recipients older than 18 years were included (mean age of 48.4 ± 11.3 years; 21.4% were female patients). In the patient group, 14.2% had coronary artery disease pre-transplant, and 1 patient had an acute myocardial infarction. Mean time from transplant to incidence of cardiovascular events (as shown by coronary angiography) was 9.34 ± 5.2 years. Thirty-six recipients (64.2%) had a cardiovascular event during this posttransplant period, and 6 patients who developed cardiovascular events were women. Five patients (8.9%) required bypass surgery after coronary angiography. Stent implantations were needed in 14 patients. The remaining patients received medical treatment decisions. Twenty-one patients had no acute or chronic cardiovascular events. One patient died because of noncardiac reasons (pulmonary aspergillosis). Two patients died after cardiac surgery, and 1 patient died because of decompensated heart failure. CONCLUSIONS: The presence of symptoms of cardiovascular disease is an important prognostic marker that requires cardiac evaluation. As with the general population, modifiable risk factors can reduce the incidence of cardiovascular events in renal transplant recipients.

Coronary Angiography for Follow-up of Heart Transplant Recipients: Usefulness of the Gensini Score.

OBJECTIVES: Posttransplant cardiac allograft vasculo-pathy affects long-term survival after heart transplant. Because cardiac transplant recipients do not feel angina pectoris as a result of denervation of the transplanted heart graft, early diagnosis is difficult. The Gensini score, a widely used and simple scoring system, can determine the severity of coronary artery disease by angiography. Although this system has been widely used to evaluate natural coronary atherosclerosis, its use in heart transplant recipients has not been studied. Here, we evaluated cardiac allograft vasculo-pathy using the Gensini score. MATERIALS AND METHODS: We retrospectively analyzed 105 heart transplant patients seen between February 2004 and April 2018, including their immunosuppressive therapies. The Gensini score was calculated to determine severity score for each coronary stenosis according to degree of luminal narrowing and location. RESULTS: Of 105 heart transplant patients, 21 were diagnosed with cardiac allograft vasculopathy. Most patients received tacrolimus, prednisolone, and mycophenolate mofetil as standard therapy. Of 63 included patients, 21 (33.3%) showed cardiac allograft vasculopathy on coronary angiography. In accordance with the International Society of Heart and Lung Transplantation rating system, 42 of 63 patients (66.6%) were rated as 0 (no detectable angiographic lesions). Mean Gensini score was 34.8 ± 26. In the 21 patients with cardiac allograft vasculopathy, Gensini score showed mild cardiac allograft vas-culopathy (score ≤ 10) in 8 patients (38%), moderate (score > 10 and ≤ 40) in 6 patients (28.5%), and severe (score > 40) in 7 patients (33.3%). Angiographic coronary artery disease burden using Gensini was strongly correlated with cardiac allograft vasculopathy severity. CONCLUSIONS: The Gensini score could provide valid assessment of cardiac allograft vasculopathy burden for use in clinical practice. However, more research is needed to identify and treat cardiac allograft vasculopathy for successful long-term survival of heart transplant patients.

Pulmonary Artery Distensibility is Worsened in Obstructive Sleep Apnea Syndrome.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) leads to right ventricular (RV) dysfunction and pulmonary hypertension (PH) in the later stages. Early determination of these conditions is very important. OBJECTIVES: We aimed to evaluate the correlations of pulmonary artery distensibility, right pulmonary artery fractional shortening (RPA-FS), and pulmonary artery stiffness (PAS) with PH among newly diagnosed OSAS patients. METHODS: We prospectively evaluated 34 newly diagnosed OSAS patients and 28 controls. The study subgroups were determined according to the apnea-hypopnea index (AHI). All patients underwent a transthoracic echocardiographic examination. Conventional RV parameters, PAS, and RPA-FS parameters were measured. RESULTS: RPA-FS was significantly lower in the OSAS group (p < 0.001) and positively correlated with tricuspid annular systolic excursion (TAPSE) (p = 0.047) and pulmonary acceleration time (PAT) (p = 0.006), and inversely correlated with systolic pulmonary artery pressure (sPAP) (p = 0.013), and PAS (p < 0.001). Consistent with this result, PAS was significantly worse in the patients with OSAS compared to the controls (27.1 ± 3.5 to 15.8 ± 2.7, p < 0.001), and inversely correlated with RPA-FS (p < 0.001), PAT (p = 0.001), and TAPSE (p = 0.035). PAS was positively correlated with sPAP (p = 0.001). There were statistically significant differences for both PAS and RPA-FS among the OSAS subgroups with regards to the severity of disease (p < 0.001). The correlation analyses showed a significantly positive correlation between RPA-FS and mean O2 saturation. RPA-FS was also inversely correlated with AHI. Similarly, PAS was positively correlated with AHI and arousal index. CONCLUSIONS: PAS and RPA-FS are worsened in patients with OSAS, and are correlated with PH and severity of OSAS.

Adequacy of infective endocarditis prophylaxis before dental procedures among solid organ transplant recipients.

Infective endocarditis (IE) is a life-threatening condition with high morbidity and mortality. The current IE guidelines recommend antibiotic prophylaxis only in patients with certain cardiac conditions and before certain dental procedures. However, there is not enough data about solid organ transplant (SOT) recipients. In this study, we aimed to investigate the IE prophylaxis in general dental and periodontal surgical procedures among our SOT recipients. Medical records of 191 SOT recipients (32 liver transplant recipients, 54 heart transplant recipients, and 105 kidney transplant recipients) who were admitted to our hospital between January 2016 and January 2018 were evaluated. A total of 65 patients who underwent dental procedures were included in the study. We investigated the adequacy of IE prophylaxis according to the current guidelines. Two groups were created according to whether they received antibiotic prophylaxis or not. The mean age was 44.2 ± 13.6 years, and 66.1% were male. The majority of patients (67.6%) received antibiotic prophylaxis. The most commonly used antibiotic was amoxicillin (48.8%). Among the procedures, 23.1% were classified as invasive and 76.9% were classified as noninvasive. No complication was observed after invasive and noninvasive dental procedures. There were no complications in both antibiotic prophylaxis and no-prophylaxis groups. According to our results, IE prophylaxis has been used appropriately in SOT recipients in our center. No serious infection has been reported. In addition, no complication due to antibiotic use was also observed.

The Novel CHA2DS2-VASC-FSH Score is Predictive of Severe Coronary Artery Disease on Coronary Angiography in Patients with Atrial Fibrillation and Unstable Symptoms.

OBJECTIVE: AF may create confusion about the presence of severe or unstable coronary artery disease in cases with unstable symptoms. Novel scores and markers are needed to determine severe coronary artery disease in such patients. We aimed to test the newly developed CHA2DS2-VASc-FSH score, developed by adding family history for coronary artery disease, hyperlipidemia, and smoking to the original CHA2DS2-VASc score, in the prediction of severe CAD in patients with AF and unstable symptoms. MATERIALS AND METHODS: We retrospectively analyzed 72 patients presenting to Baskent Universtiy School of Medicine Hospital between April 2011 and January 2016. The CHA2DS2VASc-FSH score was assessed for the prediction of severe CAD. RESULTS: Seventy-two patients aged 65.7±11.2 years were enrolled. Thirty-five (48.6%) patients had severe CAD and 11 (15.3%) had unstable CAD. patients with severe coronary artery disease had a significantly greater CHA2DS2VASC-FSH score (5 (1-8) vs 3(0-7); p<0.05). The CHA2DS2VASC-FSH score independently predicted severe CAD, with a CHA2DS2VASc-FSH score of 3 or greater having a sensitivity of 77.1% and a specificity of 56.8% for severe CAD. CONCLUSION: Among patients with AF and unstable symptoms, the CHA2DS2VASc-FSH score independently predicts severe CAD.

Successful Treatment of a Rare Complication in a Heart Transplant Recipient: Spontaneous Axillary Artery Bleeding.

Spontaneous atraumatic axillary artery bleeding is an unusual clinical entity. Axillary artery bleeding is associated with a high mortality rate. Vascular fragility is defined as a decrease in blood vessel resistance, and increased vascular fragility is one of the reasons for arterial bleeding. In this report, we present a case of spontaneous axillary artery bleeding in a heart transplant recipient.

Fragmented QRS on 12-Lead Electrocardiogram Is Correlated With Severe Coronary Artery Disease and Abnormal Myocardial Perfusion Scintigraphy Results in Renal Transplant Candidates.

OBJECTIVES: Coronary artery disease is a major cause of mortality and morbidity after renal transplant. Fragmented QRS on standard 12-lead electrocardiograms has been proposed as a marker of myocardial scar, mainly due to coronary artery disease. Here, we aimed to investigate fragmented QRS to detect severe coronary artery disease in renal transplant candidates. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 534 patients with end-stage renal failure who were on the deceased-donor renal transplant wait list at Baskent University Faculty of Medicine due to having no living kidney donor available. We evaluated patients with standard 12-lead electrocardiograms, myocardial perfusion scintigraphy, and coronary angiography. We compared fragmented QRS prevalence versus myocardial perfusion scintigraphy abnormalities and severe coronary artery disease. Correlations among these were analyzed. RESULTS: Of 92 renal transplant candidates (median age of 56.5 y; range, 24-80 y), 87 patients (94.6%) had myocardial perfusion defects and 72 (78.3%) had myocardial wall motion abnormalities on myocardial perfusion scintigraphy. Forty-four patients (47.8%) had severe coronary artery disease on coronary angiography, and 51 patients (55.4%) had fragmented QRS. Fragmented QRS was significantly more common among patients with myocardial scar. Coronary artery disease was significantly more common in patients with fragmented QRS (P = .042) and in those with fragmented QRS combined with myocardial perfusion defects (P < .01). Fragmented QRS was significantly correlated with presence of myocardial scar and any perfusion defects. When combined with myocardial perfusion defects, fragmented QRS was significantly correlated with severe coronary artery disease (P < .05). CONCLUSIONS: Fragmented QRS was significantly correlated with abnormal myocardial perfusion scintigraphy and severe coronary artery disease in renal transplant candidates. This simple parameter can provide valuable information on severe coronary artery disease and help to prevent excess patient morbidity and mortality from this disease after renal transplant.

Posttransplant Pulmonary Hypertension Is Correlated With Acute Rejection and Death Among Cardiac Transplant Recipients: A Single Center Study.

OBJECTIVES: Endomyocardial biopsy sampling is used to check acute rejection after cardiac transplant. However, it may lead to tricuspid valve injury and cardiac perforation; therefore, less invasive tools may be useful. Right heart catheterization provides valuable information about cardiac hemodynamics. Herein, we aimed to determine the correlation of right heart catheterization parameters with acute rejection and death during cardiac transplant follow-up. MATERIALS AND METHODS: We retrospectively evaluated follow-up right heart catheterization and endomyocardial biopsy results from 47 adult patients who underwent cardiac transplant at Baskent University Faculty of Medicine between 2004 and 2016. Right heart catheterization parameters were compared between deceased and surviving patients and were correlated with acute cellular and humoral rejection. Averaged right heart catheterization parameters were correlated with death. We used Cox regression analysis to determine risk of death and acute cellular rejection and Kaplan-Meier survival analysis to determine any survival differences associated with pulmonary hypertension. RESULTS: There were 47 patients (38 males, 9 females) with a mean age of 44 ± 10 years at transplant. In our patient group, 18 patients (38.3%) died at a median time of 11.2 months. Ninety endomyocardial biopsy samples (22.1%) showed cellular rejection, and 61 samples (4.5%) showed humoral rejection. The deceased patients had significantly greater mean and systolic pulmonary artery pressures, which were significantly correlated with acute cellular rejection. Death was significantly correlated with averaged values of mean and systolic pulmonary artery pressures. Our Cox regression analysis revealed that pulmonary hypertension was significantly associated with risk of death and acute cellular rejection. A Kaplan-Meier survival analysis revealed that pulmonary hypertension was associated with a significantly lower median survival. CONCLUSIONS: Pulmonary artery pressures are significantly correlated with acute cellular rejection and death after cardiac transplant. Pulmonary hypertension significantly increases the risk of death and shortens survival after cardiac transplant.

Prevalence and Angiographic Characteristics of Coronary Vasospasm Detected at Surveillance Coronary Angiograms Among Patients With Heart Transplants.

OBJECTIVES: Coronary vasospasm in heart transplant recipients occurs through various mechanisms. It has been linked to allograft rejection and coronary vasculopathy, which can result in mortality during follow-up. Here, we investigated the prevalence of coronary vasospasm among heart transplant recipients undergoing surveillance coronary angiography procedures. MATERIALS AND METHODS: This study was prospectively performed at Baskent University Faculty of Medicine by retrospectively analyzing medical information of patients who underwent bicaval heart transplant between 2003 and 2016 and subsequently had coronary angiography to rule out allograft vasculopathy. We analyzed prevalence of coronary vasospasm, affected vessels, underlying vessel properties, and treatment modalities. Coronary vasospasm was defined as transient diffuse or localized luminal narrowing, either spontaneously or catheter-induced, relieved spontaneously or with nitroglycerine. RESULTS: Forty-one coronary angiography procedures were performed using the standard Judkins technique. Among these, 5 patients showed coronary vasospasm a mean of 2 years after cardiac transplant. All vasospasm episodes involved the left anterior descending artery, with 2 also involving the circumflex artery and 1 involving the right coronary artery. The degree of luminal narrowing ranged from mild to severe. Episodes that involved the left anterior descending artery more often diffusely involved most of the vessel. In 3 patients, vasospasms were recurrent. Three patients had underlying coronary artery disease, which was relieved in 2 patients who progressed by stent implant. Neither ischemic events nor reduction of ejection fraction was observed during follow-up. There were also no occurrences of cellular or humoral rejection or death in any of the patients with vasospasm. CONCLUSIONS: Coronary vasospasm is common in heart transplant recipients. It may be diffuse or localized and occur spontaneously or because of underlying coronary artery disease. Factors, including allograft vasculopathy, associated with coronary vasospasm remain to be determined, and further related research is needed.

Plasma osteopontin concentration is elevated in patients with coronary bare metal stent restenosis.

OBJECTIVE: Osteopontin is a component of atherosclerotic lesions, secreted by monocytes, macrophages and endothelial and vascular smooth muscle cells, which together are responsible for neointimal proliferation. We examined whether elevated plasma osteopontin concentration was associated with in-stent restenosis in patients with coronary artery disease. SUBJECTS AND METHODS: We enrolled 91 patients who underwent coronary artery stenting, and 60 control patients with normal findings on coronary angiography, between June 2012 and September 2013. For patients with stents, we measured plasma osteopontin concentration at the first follow-up coronary angiogram. For controls, plasma osteopontin concentration was measured at the time of angiography. RESULTS: Of the 91 patients who had undergone coronary artery stenting, 31 (34.1%) had developed in-stent restenosis and the mean time passed to control coronary angiography was 36.7 months (±SD 35.1 months). Mean plasma osteopontin concentration in this group was 2721.4 ± 1787.8 pg/ml, significantly higher than the 60 patients (65.9%) with no in-stent restenosis (1770.4 ± 1208.2 pg/ml, p = .011) and the 60 patients with a normal coronary angiogram (1572.4 ± 904.8 pg/ml, p = .002). There was no significant difference in mean osteopontin concentration between the patients with no in-stent restenosis and the control group (p = .312). CONCLUSIONS: Elevated plasma osteopontin concentration is associated with in-stent stenosis in patients with coronary artery disease. Further studies will be needed to establish whether osteopontin can predict in-stent restenosis and guide clinical management strategies.

Preoperative Cardiac Risk Assessment in Patients Undergoing Liver Transplant Due to Hepatocellular Carcinoma: Should It Be Different?

OBJECTIVES: Liver transplant is a high-risk surgery for cardiac events. The risk of 30-day major cardiac adverse events is estimated at more than 5%. In this retrospective study, we evaluated our preoperative cardiac risk assessment approach. MATERIALS AND METHODS: We evaluated 58 adult patients who underwent liver transplant between May 2011 and May 2015. Preoperative cardiac risk factors and results of diagnostic tests were noted. Patients were divided into 2 groups: patients with or without hepatocellular carcinoma. Electrocardiogram, echocardiogram, and treadmill tests were performed for preoperative cardiac evaluation in all candidates for liver transplant. Results of these tests showed our preference for myocardial perfusion scintigraphy and/or coronary angiography and heart catheterization. RESULTS: Mean age of patients was 46.5 ± 14.5 years. The most common cardiovascular risk factor was family history of coronary artery disease (24.1%) in all patients. Diabetes mellitus (15.5%) was the most common risk factor in the patient group without hepatocellular carcinoma. Three patients had already known coronary artery disease (5.2%). Of 16 patients (27.6%) who underwent coronary angiography, 4 were in the hepatocellular carcinoma group. Coronary revascularization by stent implantation was necessary for 1 patient in the hepatocellular carcinoma group; 1 patient in the group without hepatocellular carcinoma underwent preoperative coronary bypass surgery. CONCLUSIONS: No consensus exists for cardiovascular risk stratification and preoperative cardiovascular evaluation of liver transplant candidates. Noninvasive stress tests are not always feasible for all liver transplant candidates because of poor mobility and poor exercise capacity. With early diagnoses of cardiovascular conditions and preventive recommendations, liver transplant can be performed safely before spread of the disease, which is essential for carcinoma patients. Angiographic evaluation of liver transplant candidates for hepatocellular carcinoma is strongly recommended.

Comparison of application of 2013 ACC/AHA guideline and 2011 European Society of Cardiology guideline for the management of dyslipidemias for primary prevention in a Turkish cohort.

OBJECTIVE: Atherosclerotic cardiovascular disease is a major global cause of death. The common approach in primary prevention of cardiovascular disease is to identify patients at high risk for cardiovascular disease. This article analyzes and compares the application of 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline and the 2011 European Society of Cardiology (ESC) guideline for the management of dyslipidemias for primary prevention in Turkish population. METHODS: The study included 833 patients (482 women and 351 men). Risk scores were calculated according to both guidelines and indications for statin treatment were determined according to sex and age group. Variables are presented as mean±SD or median with interquartile range for continuous data and as proportions for categorical data. Variables were analyzed by unpaired t-test, Mann-Whitney U test, chi-square or Fischer's exact test as appropriate. RESULTS: The ACC/AHA would suggest statin treatment in 415 patients out of 833 (49.5%), while ESC would recommend statin for 193 patients out of 833 (23.1%)(p<0.001). Statins would be recommended for 40.4% of women and 62.6% of men for primary prevention by the ACC/AHA, while this figure was 12% for women and 38.4% for men according to the ESC guideline (p<0.001 for both). CONCLUSION: When compared to the ESC guideline, the ACC/AHA guideline suggests augmented statin treatment for primary prevention in Turkish population.

Demographics, Management Strategies, and Problems in ST-Elevation Myocardial Infarction from the Standpoint of Emergency Medicine Specialists: A Survey-Based Study from Seven Geographical Regions of Turkey.

BACKGROUND: This study aimed to explore the ST segment elevation myocardial infarction (STEMI) management practices of emergency medicine specialists working in various healthcare institutions of seven different geographical regions of Turkey, and to examine the characteristics of STEMI presentation and patient admissions in these regions. METHODS: We included 225 emergency medicine specialists working in all geographical regions of Turkey. We e-mailed them a 20-item questionnaire comprising questions related to their STEMI management practices and characteristics of STEMI presentation and patient admissions. RESULTS: The regions were not significantly different with respect to primary percutaneous coronary intervention (PCI) resources (p = 0.286). Sixty six point two percent (66.2%) of emergency specialists stated that patients presented to emergency within 2 hours of symptom onset. Forty three point six percent (43.6%) of them contacted cardiology department within 10 minutes and 47.1% within 30 minutes. In addition, 68.3% of the participants improved themselves through various educational activities. The Southeastern Anatolian region had the longest time from symptom onset to emergency department admission and the least favorable hospital admission properties, not originating from physicians or 112 emergency healthcare services. CONCLUSION: Seventy point seven percent (70.7%) of the emergency specialists working in all geographical regions of Turkey comply with the latest guidelines and current knowledge about STEMI care; they also try to improve themselves, and receive adequate support from 112 emergency healthcare services and cardiologists. While inter-regional gaps between the number of primary PCI capable centers and quality of STEMI care progressively narrow, there are still issues to address, such as delayed patient presentation after symptoms onset and difficulties in patient admission.

Coronary artery disease detected by coronary computed tomography angiography is associated with red cell distribution width.

OBJECTIVE: Increased red blood cell distribution width (RDW) is associated with severity of coronary artery disease (CAD). The aim of the present study was to retrospectively evaluate the relationship between CAD detected by coronary computed tomography angiography (CCTA) and RDW. METHODS: Records of 291 patients who underwent 16-slice CCTA due to the presence of angina-like chest pain were retrospectively evaluated. Exclusion criteria were applied. Clinical characteristics, risk factors for CAD, and RDW values on CCTA were noted. RESULTS: RDW levels in patients with CAD were significantly higher than in those with normal coronary arteries (NCAs) (15.50±1.57 compared to 14.80±1.41, p=0.001). Diabetes mellitus, hypertension, and history of smoking were significantly more common in the CAD group (p=0.018, p=0.007, and p=0.013, respectively). On multivariate logistic regression analysis, RDW (p=0.009 [odds ratio (OR): 1.352; 95% confidence interval (CI): 1.081-1.683]), age (p<0.001 [OR: 1.063; 95% CI 1.031-1.090]), and history of smoking (p=0.003 [OR: 2.672; 95% CI: 1.360-5.232]) were shown to be independent predictors for CAD detected by CCTA. CONCLUSION: The present results suggest that higher RDW levels are independently associated with presence of CAD detected by CCTA in patients without known CAD. Further studies are warranted to clarify the exact role of RDW in risk stratification.

Predictive Value of Hematologic Parameters for Detecting Asymptomatic Graft Rejection After Heart Transplant: Preliminary Results.

OBJECTIVES: Hematologic parameters, such as mean platelet volume, red-cell distribution width, and neutrophil-to-lymphocyte ratio, have prognostic value in multiple cardiac conditions such as stable angina pectoris, acute coronary syndromes, and heart failure. However, no previous studies have evaluated the association between hematologic parameters and asymptomatic graft rejection after heart transplant. We evaluated the role of hematologic parameters for detecting asymptomatic graft rejection after heart transplant. MATERIALS AND METHODS: We retrospectively evaluated medical records of 47 adult patients who underwent orthotopic heart transplant between February 25, 2005, and July 6, 2014, in our hospital, noting their hematologic parameters before each biopsy. Two groups were created according to biopsy results: rejection and no-rejection. RESULTS: We excluded 4 patients who died during the first month posttransplant owing to early complications. We evaluated 422 endomyocardial biopsy results of 43 adult patients (mean age, 43.4 ± 11.4 y; 14 women). Mean follow-up was 33 months. A total of 109 biopsies performed because of clinical suspicion of rejection were excluded. Red-cell distribution width levels were similar between groups (17.2% ± 2.6% in the rejection group and 17.1% ± 2.5% in the no-rejection group; P = .856). Neutrophil-to-lymphocyte ratio was similar between groups (7.8 ± 9.9 in the rejection group and 8.2 ± 9.7 in the no-rejection group; P = .791). Mean platelet volume levels were significantly lower in the rejection group (8.3 ± 1.3 fL) than in the no-rejection group (8.8 ± 1.8 fL) (P = .037) (Table 1). CONCLUSIONS: According to our results, only lower mean platelet volume levels were significantly associated with asymptomatic graft rejection in patients with a transplanted heart. More detailed analyses are needed to exclude the effects of immunosuppressant drugs, and further studies are needed to clarify the exact role of hematologic parameters for detecting asymptomatic rejection after heart transplant.