Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects.

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

Evaluation of Anaesthetic Approaches in Transcatheter Aortic Valv Implantation Procedures.

Objective: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement and has become a popular treatment modality for inoperable or patients at high surgical risk with severe aortic stenosis. We aimed to evaluate our perioperative anaesthetic experiences with patients undergoing TAVI under sedation or general anaesthesia (GA). Methods: One hundred and fifty-nine patients who underwent TAVI procedures were enrolled. Effects on TAVI outcomes of sedation and GA were compared. Results: The duration of surgery and anaesthesia was significantly longer in patients who received GA. Insertion site complication and post-TAVI pacemaker implantation rates were similar between the groups, but the frequency of intraoperative complications (10% vs. 0.8%; P=0.015), intraoperative hypotension (35.3% vs. 70%; P < 0.001), and acute kidney injury (12.6% vs. 27.5%; P=0.028) was significantly higher in the GA group. Stroke occurred in seven patients, and all were in the sedation group. Conclusion: GA is related to increased procedure time and acute kidney injury; therefore, local anaesthesia and sedation may be the first option in patients undergoing TAVI.

Pleiotropy of PCSK9: Functions in Extrahepatic Tissues.

PURPOSE OF REVIEW: Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays a central role in the metabolism of LDL receptors and mainly acts in the liver. However, there are accumulating data that PCSK9 involves in several functions in different organs beyond the liver. Herein we aimed to summarize the effects of PCSK9 in tissues other than the liver. RECENT FINDINGS: PCSK9 has crucial roles in heart, brain and kidney in addition to the cholesterol metabolism. Targeting PCSK9 for the treatment of hypercholesterolemia is effective in the prevention from cardiovascular diseases and PCSK9 inhibitors are getting to be administered in more cases. Therefore understanding the effects of PCSK9 in other tissues gained importance in the use of PCSK9 inhibitors era. PCSK9 participates in cardiac, renal, and neurologic functions however, current literature reveals that use of PSCSK9 inhibitors have beneficial or neutral effects on these organs. Inhibition of PCSK9 is assigned to be associated with new onset diabetes in experimental studies whereas real world data with PCSK9 inhibitors established no relationship between PCSK9 inhibitors and new onset diabetes. PCSK9 might be used as a target for the treatment of nephrotic syndrome and heart failure in the future.

Pulmonary hypertension in Behçet's disease: echocardiographic screening and multidisciplinary approach.

BACKGROUND: Little is known about the prevalence and causes of pulmonary hypertension (PH) in Behçet's disease (BD). This study was conducted to determine the prevalence and causes of PH in BD. METHODS: In this descriptive study, we screened 154 patients with BD for PH using transthoracic echocardiography between February 2017 and October 2017. An estimated systolic pulmonary arterial pressure (sPAP ≥ 40 mmHg) was used as the cutoff value to define PH. Patients with BD were categorized into 5 groups according to organ involvement including mucocutaneous/ articular, ocular, vascular, gastrointestinal, and neurologic involvement. Additional laboratory and imaging results were obtained from hospital file records to determine the causes of PH. RESULTS: PH was detected in 17 (11%) patients. Nine (52.9%) of these patients had group II PH (due to left heart disease), 4 (23.5%) had IV PH (due to pulmonary arterial involvement), and 1 had III PH (due to chronic obstructive lung disease). The frequency of PH was higher in BD patients with vascular involvement than those without (52.9% vs 28.5%; p = 0.04). Among 10 patients with pulmonary artery involvement (PAI) 4 (40%) had PH. Although the vascular BD group had the highest rate of PH, we observed no statistically significant difference in the frequency of PH between the predefined BD subgroups. DISCUSSION: : PH is not rare in patients with BD. The majority of BD patients with PH are in group II or IV PH. Patients with vascularinvolvement carry a higher risk for the development of PH. Monitoring BD patients with PAI should be considered for the development of group IV PH.

Evaluation of machine learning algorithms for renin-angiotensin-aldosterone system inhibitors associated renal adverse event prediction.

BACKGROUND: Renin-angiotensin-aldosterone system inhibitors (RAASi) are commonly used medications. Renal adverse events associated with RAASi are hyperkalemia and acute kidney injury. We aimed to evaluate the performance of machine learning (ML) algorithms in order to define event associated features and predict RAASi associated renal adverse events. MATERIALS AND METHODS: Data of patients recruited from five internal medicine and cardiology outpatient clinics were evaluated retrospectively. Clinical, laboratory, and medication data were acquired via electronic medical records. Dataset balancing and feature selection for machine learning algorithms were performed. Random forest (RF), k-nearest neighbor (kNN), naïve Bayes (NB), extreme gradient boosting (xGB), support vector machine (SVM), neural network (NN), and logistic regression (LR) were used to create a prediction model. RESULTS: 409 patients were included, and 50 renal adverse events occurred. The most important features predicting the renal adverse events were the index K and glucose levels, as well as having uncontrolled diabetes mellitus. Thiazides reduced RAASi associated hyperkalemia. kNN, RF, xGB and NN algorithms have the highest and similar AUC (≥ 98%), recall (≥ 94%), specifity (≥ 97%), precision (≥ 92%), accuracy (≥ 96%) and F1 statistics (≥ 94%) performance metrics for prediction. CONCLUSION: RAASi associated renal adverse events can be predicted prior to medication initiation by machine learning algorithms. Further prospective studies with large patient numbers are needed to create scoring systems as well as for their validation.

Role of echocardiography on early diagnosis of atrial remodelling and fibrosis in elite athletes.

There is emerging data indicating that long-standing vigorous exercise may be associated with atrial structural remodelling. This remodelling process is may be the cause of the increasing frequency of atrial arrythmias in athletes. Early diagnosis of atrial remodelling by atrial imaging could have a role in management of atrial arrythmias in elite athletes. In this study we aimed to diagnose early phases of atrial remodelling in elite athletes. Two groups of athletes including professional weight lifters (n = 33), professional marathoners (n = 32) and sedentary participants (n = 30) were enrolled. We also studied patients who received cardiotoxic chemotherapy (n = 10) for comparison. Serum TGF-beta level as a marker of fibrosis was measured. Both left atrial (LA) 3D volume and strain values were analysed. There was a positive correlation between serum TGF-beta levels and LA volumes and negative correlation between TGF-beta levels and strain values. TGF-beta levels were higher among chemotherapy and weight lifter groups, compared to control and marathoner groups [mean 0.57 ± 0.3 and 0.55 ± 0.2 vs. 0.45 ± 0.2 and 0.47 ± 0.2, respectively, p = 0.005]. LA volumes were higher among chemotherapy and weight lifter groups [median 33 (26-38) and 31 (23-36) respectively, p = 0.005], and strain values were lower in these two groups [mean 20.3 ± 2.5 and 24.6 ± 4.5, respectively, p < 0.005] compared to control and marathoner groups. Total exercise volume was higher in weight lifter group compared to marathoners [13,780 (2496-36,400) vs. 4732 (780-44928), respectively, p = 0.001]. There wasn't any difference between any group regarding left ventricular systolic and diastolic functions. Vigorous exercise causes atrial remodelling and fibrosis in elite athletes. Strength exercise carries higher risk for atrial fibrosis than endurance exercise. Burden of exercise is correlated with the severity of cardiac fibrosis. Echocardiographic evaluation of the left atrium and TGF-beta levels may help to detect subclinical cardiac remodelling and fibrosis.

Single Center Experience of Percutaneous Septal Ablation in Patients With Hypertrophic Cardiomyopathy With A Novel Agent: Polidocanol.

Septal reduction therapy is recommended in patients with obstructive hypertrophic cardiomyopathy (HCM) who remain symptomatic under maximally tolerated optimal medical treatment. Alcohol septal ablation is a favorable option, especially in patients with high surgical risk or who refuse surgery. Alcohol; causes scar-related ventricular arrhythmias and advanced heart blocks more frequently than surgical myectomy. Therefore, novel, safer agents are required for percutaneous septal ablation therapy. All the patients who underwent percutaneous septal ablation between January 2017 and June 2021 with polidocanol because of ongoing symptoms related to HCM despite maximally tolerated medical treatment were enrolled. Data were obtained retrospectively from the hospital electronic database. A total of 28 patients were included. Median age was 61 years (43.5-67), and 19 (67.8%) patients were male. Most of the patients underwent index procedures; however, only 2 cases had history of previous septal ablation. Median follow-up was 3.5 months (0.25 to 12.25). Median left ventricular outflow tract (LVOT) gradient at rest was 68.5 (37-80) mm Hg, and after Valsalva maneuver median LVOT gradient was 95.5 (75-125) mm Hg. Median volume of polidocanol used in procedures was 2 (2-3.37) ml, and mean procedure time was 28.1 ± 2.5 minutes. LVOT gradient invasively measured was significantly reduced (mean 76.5 mm Hg vs mean 30 mm Hg; p <0.001) immediately after the septal ablation. Conduction defects developed in 18 patients (64.2%); however, de novo permanent cardiac implantable electronic device implantation was required in only 4 (14.3%) cases. Leakage of polidocanol and mortality did not occur in any cases. Pericardial effusion developed in only 1 case, and it resolved with medical treatment. After mean 3.5 months follow-up, both LVOT gradient and New York Heart Association functional class parameters were better than baseline values. In conclusion, polidocanol is a safe and effective agent for septal ablation in patients with HCM. Outcomes and complication rates are similar with alcohol septal ablation.

Association between oxygen delivery and digital ulcers in systemic sclerosis.

OBJECTIVE: Tissue hypoxia due to microvasculopathy is the main cause of digital ulcers (DUs) in systemic sclerosis (SSc). Reduced oxygen delivery (DO2) to the tissues may also contribute to the development of DU. This study was conducted to investigate the association between DO2 and DUs in patients with SSc. METHODS: In all, 111 patients and 30 healthy controls were enrolled. DO2 was calculated by using the formula; DO2 = Cardiac output × arterial oxygen saturation (SpO2) × serum haemoglobin level × 1.39 × 10. Both right index finger SpO2 measurements (index-SpO2) and highest value of SpO2 (maximum SpO2) obtained among the fingers of the subjects were used for the calculations and DO2 results were adjusted both for weight and body surface area (BSA). RESULTS: Mean DO2 was lower in SSc patients as compared to controls in all 4 different calculations but the difference was only statistically significant when using index-SpO2 and adjusting for BSA (498 mL/min/m2 vs 549 mL/min/m2, p = 0.03). There was a strong positive correlation between cardiac output and DO2 calculated by using the index-SpO2 (r = 0.903; p < 0.001). Of the SSc patients, 46 (41.4 %) had DUs within the last 12 months. Patients with DUs had higher mean mRSS, lover mean FVC and more frequently diffuse disease, interstitial lung disease, anti-SCL70 antibody positivity (p < 0.05 for all). No difference was observed in DO2 among DU positive or DU negative groups by any calculation (p > 0.05 for all). CONCLUSIONS: DO2 in SSc patients seems to be lower than healthy controls. However, DO2 is similar between the patients with and without DUs. Our results suggest that the contribution of DO2 is negligible to the development of DU and support the major role of microvasculopathy in SSc patients with DUs.

Long-term outcomes of left atrial appendage isolation using cryoballoon in persistent atrial fibrillation.

AIMS: There is an increasing trend evaluating the role of non-pulmonary vein (PV) triggers to improve ablation outcomes in persistent atrial fibrillation (AF) as pulmonary vein isolation (PVI) strategy alone has modest outcomes. We investigated the long-term safety and efficacy of left atrial appendage isolation (LAAi) in addition to PVI using cryoballoon (CB) in persistent AF. METHODS AND RESULTS: In this multicentre retrospective analysis, we included a total of 193 persistent AF patients (mean age: 60 ± 11 years, 50.3% females) who underwent PVI and LAAi using CB. Baseline and follow-up data including electrocardiography (ECG), 24 h Holter ECGs, and echocardiography were recorded for all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as the detection of AF, atrial flutter, or atrial tachycardia (≥30 s) after a 3-month blanking period. At a median follow-up of 55 (36.5-60.0) months, 85 (67.9%) patients with PVI + LAAi were in sinus rhythm after the index procedure. Ischaemic stroke/transient ischemic attack occurred in 14 (7.2%) patients at a median of 24 (2-53) months following catheter ablation. Multivariate regression analysis revealed heart failure with preserved ejection fraction [hazard ratio (HR) 2.29, 95% confidence interval (CI) 1.04-5.02; P = 0.038], male gender (HR 0.53, 95% CI 0.29-0.96; P = 0.037), and LA area (HR 1.04, 95% CI 0.53-1.32; P = 0.023) as independent predictors of ATa recurrence. CONCLUSION: Our findings demonstrated that the LAAi + PVI strategy using CB had acceptable long-term outcomes in patients with persistent AF. Systemic thrombo-embolic events are an important concern throughout the follow-up, which were mostly observed in case of non-adherence to anticoagulants.

Sarcopenia and anthracycline cardiotoxicity in patients with cancer.

BACKGROUND: Several studies have suggested that sarcopenia is associated with an increased treatment toxicity in patients with cancer. The aim of this study is to evaluate the relationship between sarcopenia and anthracycline-related cardiotoxicity. METHODS: Patients who received anthracycline-based chemotherapy between 2014 and 2018 and had baseline abdominal CT and baseline and follow-up echocardiography after anthracycline treatment were included. European Society of Cardiology ejection fraction criteria and American Society of Echocardiography diastolic dysfunction criteria were used for definition of cardiotoxicity. Sarcopenia was defined on the basis of skeletal muscle index (SMI) and psoas muscle index (PMI) calculated on CT images at L3 and L4 vertebra levels. RESULTS: A total of 166 patients (75 men and 91 women) were included. Sarcopenia was determined in 33 patients (19.9%) according to L3-SMI, in 17 patients (10.2%) according to L4-SMI and in 45 patients (27.1%) according to PMI. 27 patients (16.3%) developed cardiotoxicity. PMI and L3-SMI were significantly associated with an increased risk of cardiotoxicity (L3-SMI: HR=3.27, 95% CI 1.32 to 8.11, p=0.01; PMI: HR=3.71, 95% CI 1.58 to 8.73, p=0.003). CONCLUSIONS: This is the first study demonstrating a significant association between CT-diagnosed sarcopenia and anthracycline-related cardiotoxicity. Routine CT scans performed for cancer staging may help clinicians identify high-risk patients in whom closer follow-up or cardioprotective measures should be considered.

Breast artery calcification as an opportunistic predictor of cardiovascular disease.

BACKGROUND: Atherosclerotic cardiovascular disease is still the leading cause of mortality for women. Breast cancer screening with mammography is recommended in all women aged over 40 years. AIMS: Whether breast artery calcification (BAC) is associated with cardiovascular disease is not clear. We aimed to evaluate the association between BAC and the presence of coronary atherosclerosis determined by CT. METHODS: All patients who underwent both mammography and coronary CT angiography between January 2010 and December 2016 were screened, and patients with a duration of less than 12 months between CT and mammography were included. RESULTS: A total of 320 women were included and BAC was detected in 47 (14.6%) patients. BAC was correlated with age and CT coronary calcium score. Both the frequency of critical coronary artery stenosis (34% vs 10.6%; p = 0.001) and CT coronary calcium score (5.5 vs 0; p = 0.001) was significantly higher in patients with BAC. The absence of BAC was a strong predictor of the absence of significant coronary artery disease (p = 0.001). BAC was independently associated with all-cause mortality after excluding patients with breast cancer (HR: 5.32; p = 0.013). CONCLUSION: Breast artery calcification is associated with coronary calcium score and significant coronary stenosis. A high BAC score is related to increased mortality.