The Role of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) in Atrial Fibrillation: Treatment Management Based on Patient and Drug Characteristics.

Data from Turkey revealed that atrial fibrillation patient percentage under adequate anti- coagulation in Turkey is less than that in other countries due to multiple parameters such as treatment adherence problems, failure to follow guideline recommendations, negative perspective on the use of new drugs, drug costs, and payment conditions. The aim of this article is to provide physicians with a compiled resource that focuses on the differences between non-vitamin K antagonist oral anticoagulants and heterogeneity of atrial fibrilla- tion patients by reviewing the global and national data from a multidisciplinary perspective and provide guidance on the choice of non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients. A gastroenterologist, 2 neurologists, and 11 cardiologists from university and training and research hospitals in Turkey who are experienced in atrial fibrillation and non-vitamin K antagonist oral anticoagulant treatments gathered in 3 separate meetings to identify the review topics and evaluate the outcomes of the systematic literature search. Based on the pharmacological characteristics, clinical studies, and real-world data compari- sons, it has been revealed that non-vitamin K antagonist oral anticoagulants are not similar. Thromboembolism and bleeding risks, renal and hepatic functions, coexisting conditions, and concomitant drug usage have been shown to affect the levels of benefits gained from non-vitamin K antagonist oral anticoagulant in atrial fibrillation patients. Although Turkish patients with atrial fibrillation have been observed to be younger, they are more likely to have coexisting cardiovascular conditions compared to the atrial fibrillation patients in other countries. Selection of an appropriate non-vitamin K antagonist oral anticoagulant in line with the available evidence and recent guidelines will provide substantial benefits to atrial fibrillation patients.

Assessment of the relationship between semaphorin4D level and recurrence after catheter ablation in paroxysmal atrial fibrillation.

OBJECTIVE: Semaphorin4D (Sema4D), a novel integral membrane glycoprotein, plays a role in atherosclerosis, angiogenesis and chronic inflammation. Elevated levels of sema4D were presented in myocardial infarction, heart failure and atrial fibrillation. Aim of the study was to investigate the relation between sema4D and recurrence after catheter ablation (CA) in paroxysmal AF. METHODS: The present study included 161 paroxysmal AF patients (PAF) (101 patients undergone CA) and 60 healthy subjects. Serum levels of sema4D were measured and study participants were followed-up for 3 months and 1 year since CA in terms of recurrence respectively. RESULTS: Sema4D levels were significantly elevated in the recurrent group compared to the non-recurrent PAF patients (p < 0.001). Sema4D was importantly positively correlated with both left atrial volume index (r = 0.51, p < 0.013) and high sensitive C-reactive protein (r = 0.38), p < 0.011). In multivariate analysis, sema4D [odds ratio (OR) = 1.23, 95% CI 1.11-1.42; p < 0.001] and left atrial diameter (OR = 1.13, 95% CI 1.02-1.23; p = 0.012) were found to be significant independent risk parameters for recurrence. CONCLUSIONS: Sema4D is a novel biomarker that may help to identify individuals with recurrence after CA procedure in long term period in PAF.

Transcatheter treatment of partial anomalous pulmonary venous connection to left subclavian vein.

Reports of transcatheter treatment for dual drainage of an abnormal pulmonary venous connection are rare. Presently described is the case of a 27-year-old female with exertional dyspnea and a partial anomalous pulmonary venous connection of the left upper pulmonary vein with dual drainage to a vertical vein (VV) and the left atrium. The patient was evaluated with a balloon occlusion test to determine whether closing the anomalous VV connection would increase pulmonary pressure. The results of this test are an important guide to treatment decisions. A 12x9 mm Amplatzer Vascular Plug II device was successfully used to occlude the anomalous pulmonary venous connection using a transcatheter technique. This is a less invasive option than surgical repair and can be an appropriate choice in suitable cases.

Neutrophil to lymphocyte ratio is associated with proximal/middle segment of the LAD lesions in patients with ST segment elevation infarction.

INTRODUCTION: Neutrophil to lymphocyte ratio (NLR) was revaled to have a close relation with atherosclerotic cardiovascular disease. The relationship between NLR and culprit plaque localization has never been studied. AIM OF THE STUDY: To evaluate the association between NLR and unstable plaque localization of left anterior descending artery (LAD) in anterior miyocardial infarction patients. MATERIAL AND METHODS: Patients admitted to our hospital with acute anterior STEMI were included. Fifhy-eight patients who have single-vessel disease at LAD and their hematological parameters were analyzed retrospectively. Proximal segment of LAD lesions were groupped as Group I and mid segment of the LAD lesion groupped as Group II. The groups were compared according to their NLR and other parameters. RESULTS: Between group I (n = 41, mean age 52.5 ±12.7) and group II (n = 17, mean ages 52.0 ±10.8); NLR, were significantly higher in group I compared to the group II (6.9 ±5.6 vs. 3.3 ±2.0, p = 0.01). In group I, left ventricular ejection fraction (LVEF) was significantly lower (p = 0.02). In correlation analyzes, NLR was positively correlated with CK MB (r = 0.32, p = 0.01) and negatively correlated with LVEF (r = -0.28, p = 0.03). CONCLUSIONS: The present study demonstrated that anterior myocardial infarction patients with high NLR had a greater possibility having proximal culprit lesion on the LAD. Therefore NLR can be used as a useful tool to culprit plaque localization in patients with acute miyocardial infarction patients.

High tenascin-C levels cause inadequate myocardial blush grade in patients with acute myocardial infarction.

AIM: Coronary artery disease (CAD) and its serious clinical form, ST segment elevated myocardial infarction (STEMI) has been the leader within the death causes around the world and in our country. In STEMI, the main objective is providing the myocardial reperfusion. In our study, it was aimed to investigate the predictive value of tenascin-C level for the degree of myocardial reperfusion in patients with STEMI. METHODS: In our study, 58 patients admitted to our hospital with acute anterior STEMI were included. All the patients had underwent primary percutaneous intervention for the single-vessel disease at left anterior descending coronary artery. After admission to coronary care unit tenascin-C levels were measured. Subjects were classified according to their myocardial blush grades (MBG); MBG 0, MBG 1 and MBG 2 were groupped as Group I, MBG 3 was groupped as Group II. The groups were compared according to their tenascin-C levels and other parameters. RESULTS: Between group I (n = 31, mean age 55 ± 12.5) and group II (n = 27, mean ages 49.3 ± 11.1); tenascin-C, troponin I and CK-MB levels were significantly higher in group I compared to the group-II (P < 0.001; P < 0.001 and P < 0.05; respectively). In group I, left ventricular ejection fraction (LVEF) was significantly lower (P < 0.001), left ventricular end-diastolic volume and left ventricular end-systolic volume were significantly higher (P = 0.03) as compared to group II. In group I, ST-segment resolution at ECG was worse (P = 0.003). In correlation analyzes, tenascin-C was significantly positively correlated with troponin-I (r = 0.596; P < 0.001) and CRP (r = 0.615, P < 0.001). Tenascin-C was significantly negatively correlated with MBG, LVEF and ST-segment resolution (r = -0.626, P < 0.001, r = -0.411, P = 0.002 and r = -0.631; P < 0.001, respectively). CONCLUSION: Based on our study, it can be estimated that in patients with high tenascin-C levels myocardial reperfusion was inadequate, even underwent successfull PCI. In this context, increased tenascin-C may help predict not only left ventricular remodelling and prognosis but also the effectiveness of primary PCI.

Mean platelet volume levels in the presence of angiographically documented peripheral artery disease.

AIM: Increased mean platelet volume (MPV) have been shown to be associated with peripheral artery disease (PAD). However in these studies, noninvasive methods for the diagnosis of PAD was used. In the literature, there is no studies examining the values of MPV in the angiographically documented PAD. We aimed to evaluate the relationship between angiographically documented PAD and MPV levels in the peripheral blood samples. METHODS: In this study, retrospective analysis of 1386 patients was performed who underwent peripheral angiography at the cardiology service of the our hospital, between 2006 and 2012 for a suspected diagnosis of lower extremity peripheral arterial disease. Patients with a stenosis percent of 50% or above in the peripheral angiography were considered as having peripheral arterial disease. MPV values are affected by many factor. Only 84 patients who complied with the inclusion criteria were detected. The study patients were divided into 2 groups according to the results of peripheral angiography. 56 patients diagnosed with PAD based on the specified criteria were grouped into Group I (mean age 59 ± 10 years) while 28 patients without peripheral arterial disease were grouped into Group II (mean age 60 ± 11 years). Blood tests and angiographic images were analyzed from patients' data. RESULTS: Both groups were similar in terms of basic parameters of anemia including hemoglobin, hematocrit and red cell distribution width levels. There were no significant differences between MPV levels in both groups (8.08 ± 0.91 vs 8.28 ± 1.16, P > 0.05). Mean corpuscular volume and mean corpuscular hemoglobin levels, on the other hand, were significantly higher in Group I (P < 0.05). CONCLUSIONS: In our study, we did not found any significant changes in the MPV levels of angiographically documented PAD diseases. The use of MPV level as a risk factor for peripheral arterial disease is impractical due to the fact that MPV is affected by a lot of factors and there are several technical factors. Because of this, in the real life, we are not recommend to use MPV values as an indicator for peripheral artery disease.

An epidemiological study to evaluate the use of vitamin K antagonists and new oral anticoagulants among non-valvular atrial fibrillation patients in Turkey- AFTER-2 study design.

OBJECTIVES: Atrial fibrillation (AF) is one of the most common causes of preventable ischemic stroke and is related to increased cardiovascular morbidity and mortality. There is a lack of data in Turkey on the use of new oral anticoagulants (NOACs), and time in therapeutic INR range (TTR) in vitamin K antagonist users and AF management modality. In this multi-center trial, we aimed to analyze, follow and evaluate the epidemiological data in non-valvular AF patients. STUDY DESIGN: Four thousand one hundred consecutive adult patients from 42 centers with at least one AF attack identified on electrocardiography will be included in the study. Patients with rheumatic mitral valve stenosis and prosthetic valve disease will be excluded from the study. At the end of one year, the patients will be evaluated in terms of major cardiac end points (death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding and hospitalization). RESULTS: First results are expected in June 2015. Data about major cardiovascular end-points will be available in January 2016. CONCLUSION: The rates and kind of oral anticoagulant use, TTR in vitamin K antagonist users and main management modality applied in non-valvular AF patients will be determined by AFTER-2 study. In addition, the rate of major adverse events (MACEs) and the independent predictors of these MACEs will be detected (AFTER-2 Study ClinicalTrials.gov number, NCT02354456.).

Evaluation of Tp-Te interval and Tp-Te/QTc ratio in patients with coronary artery ectasia.

AIM: Coronary artery ectasia (CAE) is commonly defined as local or generalized dilatation of a coronary vessel up to 1.5 times the diameter of an adjacent vessel. Tp-Te interval and Tp-Te/QT ratio have emerged as novel electrocardiographic markers of increased dispersion of ventricular repolarization. The aim of this study was to evaluate ventricular repolarization by using Tp-Te interval and Tp-Te/QT ratio in patients with CAE. MATERIALS AND METHODS: Patients' records were retrospectively analyzed. Electrocardiogram of 28 patients, who were diagnosed as CAE were obtained and scanned. T wave peak to end interval, QT and corrected QT intervals and some other ECG intervals were measured. Electrocardiograms of age and sex matched 22 control individuals were also analyzed for comparison. Patients with critical coronary stenosis, moderate or severe valve disease, left and/or right heart failure, left and/or right ventricle hypertrophy, atrial fibrillation, moderate or severely abnormal electrolytes, right or left bundle block or patients who got pacemaker or ICD implanted and who undergo hemodialyses were excluded. RESULTS: Baseline characteristics and QT, QTc intervals were similar in both groups. Tp-Te (97.71 ± 8.7 vs 85.23 ± 7.1; p < 0.001) and Tp-Te/QT (0.22 ± 0.0 vs 0.20 ± 0.0; p < 0.001) were significantly worse in CAE group. CONCLUSIONS: T wave peak to end interval is a measure of transmural dispersion of repolarization in the left ventricle and accepted as a surrogate for increased ventricular arrhythmogenesis risk. Tp-Te and Tp-Te/QT are relatively new markers which also indicate repolarization defects. Our results show that CAE patients significantly higher values of Tp-Te and Tp-Te/QT than controls. These measurements may indicate increased arrhythmogenesis risk for individuals with CAE.

Effect of non-dipper and dipper blood pressure patterns on Tp-Te interval and Tp-Te/QT ratio in patients with metabolic syndrome.

The purpose of this study was to evaluate the effect of blood pressure (BP) rhythm on the values of Tp-Te interval and Tp-Te/QT ratio in patients with metabolic syndrome. Seventy patients with newly diagnosed hypertension who fulfilled the metabolic syndrome criteria according to the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP/ATP-III) were evaluated with 24-hour blood pressure holter monitoring. According to blood pressure rhythm, 35 patients with dipper blood pressure pattern and 35 patients with non-dipper blood pressure pattern were enrolled as two groups in our study. QT, corrected QT (QTc), Tp-Te interval and Tp-Te/QT ratio were measured from the 12-lead electrocardiogram. These parameters were compared between the groups. The nocturnal systolic and diastolic blood pressures were significantly higher in non-dipper patients than the dipper group. Baseline characteristics and QT, QTc intervals were similar in both groups. Tp-Te (91±12.24 vs 74±9.96; p < 0.001), Tp-Te/QT (0.24±0.027 vs 0.20±0.025; p < 0.001) and Tp-Te/QTc (0.22±0.023 vs 0.18±0.023; p < 0.001) were significantly increased in non-dipper group. These findings suggest that Tp-Te interval, Tp-Te/QT ratio end Tp-Te/QTc ratio were prominently increased in non-dipper hypertensive patients than dippers with metabolic syndrome.

The Relationship between Non-Dipper Blood Pressure and Thoracic Aortic Diameter in Metabolic Syndrome.

OBJECTIVE: Non-dipper hypertension is associated with increased cardiovascular morbidity and mortality. The purpose of this study was to evaluate the association of non-dipping hypertension with aortic diameter in patients with metabolic syndrome. MATERIALS AND METHODS: This study included 70 hypertensive patients with metabolic syndrome. These patients were evaluated with 24-h blood pressure Holter monitoring and divided into two groups of 35 patients each. Aortic diameter was measured by M-mode and two-dimensional echocardiography. These parameters were compared between the two groups. RESULTS: In the dipper group, there were 26 female and 9 male patients with a mean age of 55±11 years. In the non-dipper group, there were 25 female and 10 male patients with a mean age of 56±11 years. No significant difference was found between the two groups in terms of basic characteristics. Non-dipper hypertensive patients had a higher thoracic aortic diameter value than dipper patients (35.6±2.4 and 33.23±1.1, p<0.01). CONCLUSION: These findings suggest that thoracic aortic diameter value is higher in patients with non-dipper hypertension.

Left atrial mechanical functions in patients with the metabolic syndrome.

OBJECTIVE: Metabolic syndrome (MS) is a cluster of risk factors leading to cardiometabolic diseases.The aim of the present study was to investigate the effect of MS on left atrial function, which is an important determinant of left ventricular filling. METHODS: Left atrial (LA) volumes were measured echocardiographically in 32 MS patients and 32 age- and sex-matched controls. LA volumes were determined at the time of mitral valve opening (maximal, Vmax), at the onset of atrial systole (p wave on the electrocardiogram, Vp) and at the mitral valve closure (minimal, Vmin) according to the biplane area-length method in apical 4-chamber and 2-chamber view. All volumes were corrected to the body surface area, and following left atrial emptying functions were calculated. LA passive emptying volume =Vmax- Vp LA passive emptying fraction = LA passive emptying volume/Vmax . Conduit volume= LV stroke volume - (Vmax- Vmin), LA active emptying volume =Vp- Vm,, LA active emptying fraction= LA active emptying volume/Vp, LA total emptying volume = (Vmax -Vmin), LA total emptying fraction = LA total emptying volume/Vmax. RESUITS: LA maximal volume and LA presystolic volume were significantly higher in MS patients than in controls (P <0.001). But LA minimum volume was significantly lower in MS patients than in controls (P <0.001). Although LA passive emptying volume (P <0.03), LA passive emptying fraction (P <0.001) and conduit volume (P <0.001) were found to be significantly lower in MS patients than in controls, LA active emptying volume (P <0.001) and LA active emptying fraction (P< 0.001) were significantly greater in MS patients than in controls. Conclusion In our study, metabolic syndrome was associated with increased left atrial volume, decreased left atrial passive emptying function and increased pump function. Increased left atrial pump function represents a compensatory mechanism in patients with MS.Thus, these results underline the importance of maintaining a sinus rhythm in these patients.

The effect of non-dipper and dipper blood pressure patterns on aortic elasticity in patients with metabolic syndrome.

The purpose of this study was to evaluate the effect of blood pressure (BP) rhythm on aortic functions in patients with metabolic syndrome. Seventy patients with newly diagnosed hypertension who fulfilled the metabolic syndrome criteria according to the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP/ATP-III) were evaluated with 24-hour BP holter monitoring. According to BP rhythm, 35 patients with dipper BP pattern and 35 patients with non-dipper BP pattern were enrolled as two groups in our study. Systolic and diastolic diameters of the ascending aorta were measured by M-mode echocardiography and aortic functions (aortic strain, distensibility, and stiffness index) were calculated. The nocturnal systolic and diastolic BPs were significantly higher in non-dipper patients than the dipper group. According to clinical parameters including age, gender, height, weight, body mass index, waist circumference, clinical systolic, and diastolic BPs, we did not find significantly difference between the two groups. Aortic strain was significantly higher (6.63 ± 3.37 vs. 1.81 ± 0.92; P < .0001) and aortic distensibility was lower (2.38 ± 1.18 cm(-2)/dyn/10(-6) and 6.66 ± 3.67 cm(-2)/dyn/10(-6); P < .001) in non-dipper group. These findings suggest that aortic functions were prominently deteriorated in non-dipper hypertensive patients than dippers with metabolic syndrome.

The time interval from the initiation of the P-wave to the start of left atrial appendage ejection flow: does it reflect interatrial conduction time?

UNLABELLED: Recurrence of atrial fibrillation is more common in patients with atrial conduction delay. In the present study, we evaluated whether findings obtained from transesophageal echocardiography (TEE), a semi-invasive method, correlate with those from an invasive method, electrophysiologic study (EPS), in measuring interatrial conduction time. METHODS AND RESULTS: We compared two methods of calculating interatrial conduction time in a group of 33 patients. The origin of the P-wave on the surface electrocardiogram (ECG) was taken as the onset of atrial activation. The time interval from this point to the commencement of the left atrial appendage ejection flow (P-LAA) was measured by TEE. Meanwhile, simultaneous recordings of the left atrial appendage were obtained with a catheter positioned in the LAA, and an invasive interatrial conduction time was measured from the origin of the surface's earliest P-wave (I-IACT). The mean I-IACT (46.27 +/- 13.25 ms) correlated strongly with the mean P-LAA (49.91 +/- 12.72 ms; r = 0.839, P < 0.0001). CONCLUSION: The interatrial conduction time can be estimated with a relatively noninvasive method using P-LAA measurements. This technique can be applied widely in predicting AF recurrence, and appropriate therapy may be applied.