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.

Normal echocardiographic measurements in a Turkish population: The Healthy Heart ECHO-TR Trial.

OBJECTIVE: Normal reference values for the cardiac chambers are widely based on cohorts from European or American populations. In this study, we aimed to obtain normal echocardiographic measurements of healthy Turkish volunteers to reveal the age, gender, and geographical region dependent differences between Turkish populations and other populations. METHODS: Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination. Blood biochemical parameters were also obtained for all patients on admission. The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used to assess the echocardiographic cardiac chamber quantification. RESULTS: The study included 1154 volunteers (men: 609; women: 545), with a mean age of 33.5±11 years. Compared to men, women had a smaller body surface area, lower blood pressure and heart rate, lower hemoglobin, total cholesterol, lower low-density lipoprotein (LDL) levels, and higher high density lipoprotein (HDL) levels. Cardiac chambers were also smaller in women and their size varied with age. When we compared the regions in Turkey, the lowest values of left cardiac chamber indices were seen in the Marmara region and the highest values were observed in the Mediterranean region. Regarding the right cardiac indices, the Mediterranean region reported the lowest values, while the Black Sea region and the Eastern Anatolia region reported the highest values. CONCLUSION: This is the first study that evaluates the normal echocardiographic reference values for a healthy Turkish population. These results may provide important reference values that could be useful in routine clinical practice as well as in further clinical trials. (.

The relationship between serum apelin levels and aortic dilatation in bicuspid aortic valve patients.

OBJECTIVE: The bicuspid aortic valve (BAV) is the most common congenital heart disease. The process of aortic dilatation is not completely clear in patients with the BAV. Apelin is a peptide found at high levels in vascular endothelial cells which has a role in vascular regulation and cardiovascular function. The aim of this study was to determine the relationship between serum apelin levels and ascending aortic dilatation in adult patients with BAV. DESIGN: This cross-sectional study included 62 patients with isolated BAV and to an age, gender, and body mass index-matched control group of 58 healthy volunteers with tricuspid aortic valve. Transesophageal echocardiography was performed on all patients to determine the type of BAV. Aortic diameters of the aortic root, sinus valsalva, sinotubular junction, and ascending aorta were evaluated with echocardiography. Patients with BAV were divided into two subgroups according to the aortic diameters, as the nondilated BAV group and the dilated BAV group. Serum apelin level was analyzed with ELISA method. RESULTS: The serum apelin levels of the BAV patients were significantly lower than those of the control group (833.5, 25th-75th percentile (713.5-1745) pg/dL vs 1669 (936-2543) pg/dL; P = 0.006). In the subgroup analysis, serum apelin level was significantly different between the nondilated BAV group and the dilated BAV group [977 (790-2433) pg/dL vs 737 (693-870) pg/dL, P < 0.05] and between the dilated BAV group and the control group [737 (693-870) pg/dL vs 1669 (936-2543) pg/dL, P < 0.001]. In multivariate logistic regression analysis apelin [7.27 (95% CI: 1.73-30.42), P = 0.007] and age [1.05 (95% CI: 0.99-1.20), P = 0.049] were determined as independent predictors for ascending aortic dilatation. CONCLUSION: Low serum apelin level was associated with dilatation of ascending aortic in BAV patients. However, apelin was not relevant to BAV without aortic dilatation.

Assessment of bicuspid aortic valve phenotypes and associated pathologies: A transesophageal echocardiographic study.

OBJECTIVE: We investigated the frequency of different bicuspid aortic valve disease (BAV) phenotypes,the associated valvular pathologies, and the aortopathy phenotypes, using 2-dimensional (2D) transthoracic, 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE. METHODS: A total of 154 patients with BAV were included. Five BAV phenotypes were detected. To better define valvular pathologies, binary classifications of BAV were used: BAV with antero-posterior commisural line (BAV-AP) and right-left commissural line (BAV-RL). Aortopathy phenotype was classified according to the involved tract(s). RESULTS: Of the patients, 53.2% had type 1, 16.2% type 2, 15.6% type 3, 1.3% type 4, and 13.6% had type 5 BAV. The prevalence of BAV-AP and BAV-RL was 68.2% and 31.8%, respectively. No difference was detected with respect to aortic regurgitation between BAV-AP and BAV-RL (p=0.9), but the BAVRL group had an increased propensity to have a stenotic aortic valve (p=0.003). The indexed aortic diameter was larger in BAV-AP cases than BAV-RL at the sinus of Valsalva (p=0.008). In patients with dilatation of the root and tubular portion, a predominance of BAV-AP versus BAV-RL was observed (85% vs 15%). A markedly low prevalence of the root phenotype (3.2%) was observed. In 90.1% of the patients, 2D TEE was sufficient to classify BAV phenotypes; further 3D imaging was needed in 9.9% of the cases. CONCLUSION: There may be racial differences in the frequency of valvular and aortopathy phenotypes in patients with BAV. BAV phenotypes differ with respect to aortic stenosis and aortopathy phenotypes. TEE may have good diagnostic utility in differentiating BAV phenotypes.

Assessment of Contributors of Aortopathy and Subclinical Left Ventricular Dysfunction in Normally Functioning Bicuspid Aortic Valves.

BACKGROUND: Left ventricular (LV) function and the dimensions of aortic valves from normally functioning bicuspid aortic valve (BAV) patients were compared with those of healthy control patients. A comparison between patients with antero-posterior BAV (BAV-AP) or right-left BAV (BAV-RL) was also performed, and the determinants of aortopathy and LV function were investigated. METHODS: Sixty-eight patients with aortic velocities <2 m/s and trivial or mild aortic regurgitation were included in the study. All patients underwent transesophageal echocardiography to diagnose BAV and identify associated phenotypes. Twodimensional (2D), Doppler echocardiographic evaluation, and strain imaging were also performed, and the results compared with those obtained from 55 age- and gender-matched healthy controls. RESULTS: The LV ejection fractions were similar between BAV patients and healthy controls, while LV global longitudinal strain (LVGLS) (p = 0.03) and LV global circumferential strain (LVGCS) (p = 0.02) were significantly lower among BAV patients. Aortic velocities and aortic dimensions at theannulus, sinus of Valsalva and sinotubular junction were significantly greater in BAV patients (all p <0.001). The diameter of the tubular ascending aorta (AA) was correlated with age (r = 0.55, p <0.001), septal E/e' (r = 0.4, p = 0.003), and LV mass index (r = 0.29, p = 0.024). Multivariate analyses revealed that the primary determinant of the AA diameter in BAV patients was age (ß = 0.38, p = 0.04), and enlargement of the AA was independent of the diastolic properties of the left ventricle and LVGLS. No significant differences were observed among the 2D or Doppler echocardiography parameters, nor among strain measurements, between BAV-AP (n = 47) and BAV-RL (n = 21) phenotypes. CONCLUSIONS: Subclinical myocardial dysfunction was observed in BAV patients with normal aortic valve function. LV dysfunction was independent of age, aortic velocity and AA diameter, which suggested the presence of intrinsic myocardial disease. Aging contributes to aortic dilatation in normally functioning BAV.

Impaired quality of life in patients with intermittent atrial fibrillation.

OBJECTIVE: The quality of life (QoL) is impaired in patients with atrial fibrillation (AF). However, the data on the perceived QoL of patients with different types of AF is limited. In this study, we investigated the QoL of patients with intermittent and chronic AF. METHODS: The study was designed as an observational cross-sectional study, and 135 consecutive patients with documented AF admitted to the cardiology outpatient clinic in a tertiary hospital were recruited. The pattern of AF was classified as intermittent or chronic AF. The European Heart Rhythm Association (EHRA) classification and symptom severity score were used to quantify the symptoms related to AF. The QoL was assessed by the Short Form-36 and the Canadian Cardiovascular Society Severity in Atrial Fibrillation (SAF) scale. RESULTS: Thirty-nine percent of the patients (n=52) had intermittent AF and 61% (n=83) had chronic AF. In the overall patient population, 92% reported having at least one of the symptoms that can be attributable to AF. Although the prevalence of symptoms were similar in patients with intermittent or chronic AF, the patients with intermittent AF perceived more severe palpitations (symptom severity score 2.4±1.7 vs. 1.5±1.5, p=0.003). Patients with intermittent AF had higher EHRA and SAF scores than the patients with chronic AF (2.6±0.9 vs. 1.9±0.8, p<0.001; 2.5±1.3 vs. 1.7±1.2, p<0.001, respectively). CONCLUSION: Outpatients with AF have a high prevalence of symptoms and impaired QoL. The impairment of subjective health-related QoL is worse in patients with intermittent AF.

Galectin-3 levels in patients with hypertrophic cardiomyopathy and its relationship with left ventricular mass index and function.

OBJECTIVE: Cardiac fibrosis is an important contributor to adverse left ventricular (LV) remodeling and arrhythmias in patients with hypertrophic cardiomyopathy (HCM). Galectin-3 (Gal-3) is a novel marker of cardiac fibrosis and inflammation. In this study, we investigated Gal-3 levels in patients with HCM and controls and assessed the relationship between Gal-3 level and echocardiographic indices using strain echocardiography in patients with HCM. METHODS: Forty patients with HCM in sinus rhythm and 35 healthy controls were prospectively enrolled in this case-control study. The HCM diagnosis was based on two-dimensional echocardiographic demonstration of a hypertrophied and non-dilated left ventricle (LV) with a wall thickness ≥15 mm in one or more LV myocardial segments in the absence of any cardiac or systemic disease capable of inducing LV hypertrophy. Patients with one of the followings were excluded: coronary artery disease, atrial fibrillation episodes on 24-h Holter electrocardiogram (ECG) monitoring, history of an invasive intervention to alleviate an LV outflow (LVOT) obstruction, inadequate image quality, renal disease, diabetes mellitus, hyperlipidemia, liver cirrhosis, and pulmonary fibrosis. Global LV longitudinal, circumferential strain and strain rates, peak torsion, and LV mass index (LVMI) of all subjects were assessed by echocardiography. Gal-3 levels were measured in all subjects. RESULTS: Left ventricular global longitudinal strain (-13.37±4.6% vs. -18.93±2.5%, p<0.001) and strain rate (0.66±0.22 s-1 vs. 1.08±0.14 s-1, respectively; p<0.001) values were lower in patients with HCM than in controls. Gal-3 levels were significantly higher in patients with HCM than in controls (16.9±6.64 ng/mL vs. 13.21±3.42 ng/mL, p=0.005). Gal-3 levels were associated with the thickness of the interventricular septum (r=0.444, p=0.004) and LVMI (r=0.365, p=0.021); however, they were not associated with LV global longitudinal strain (p=0.42) or strain rate (p=0.28). CONCLUSION: Gal-3 levels increased and were correlated with the degree of LV hypertrophy in patients with HCM. Gal-3 is not a good marker of decreased myocardial LV diastolic and systolic functions in these patients.

Predictors of Future Atrial Fibrillation Development in Patients with Hypertrophic Cardiomyopathy: A Prospective Follow-Up Study.

BACKGROUND: We evaluated whether left atrial (LA) phasic functions, P-wave dispersion (PWD), and plasma NT-proBNP levels could predict future development of atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM). METHODS: Seventy patients with HCM were evaluated. The LA phasic functions including the LA total emptying volume (LATEV), LA total emptying fraction (LATEF), LA active emptying volume (LAAEV), LA active emptying fraction (LAAEF), LA passive emptying volume (LAPEV), and LA passive emptying fraction (LAPEF) were evaluated. P-wave dispersion was calculated. Plasma NT-proBNP levels were measured on the same day with echocardiographic study. RESULTS: Patients were followed up 53.09 ± 1.87 months. Patients who developed AF (n = 18) had significantly higher PWD values, NT-proBNP levels, LAVI, E/E' av, and resting LVOT gradients and significantly lower LATEF and LAAEF. In multivariate analysis, LATEF (P = 0.002), LAAEF (P = 0.007), logNT-proBNP level (P = 0.022), and PWD (P = 0.018) were associated with AF development. The results of receiver operating characteristic analysis revealed that a LATEF cutoff value 49% with 72% sensitivity and 81% specificity, a LAAEF cutoff value of 36% with 72% sensitivity and 71% specificity, and an NT-proBNP cutoff value of 720 pg/mL predicted future AF development with 72% sensitivity and 60% specificity. A PWD cutoff value of 47.5 msecond predicted future AF development with 78% sensitivity and 72% specificity. CONCLUSION: In patients with HCM, LA phasic functions, PWD, and NT-proBNP levels predict future development of AF. Assessment of LA phasic functions during routine echocardiographic evaluation and measuring NT-proBNP levels and PWD values of patients with HCM during daily practice may provide important data in predicting those at high risk of AF occurrence.

[Evaluation of quality of life using the Umea 22 questionnaire among patients with atrioventricular nodal tachycardia undergoing successful radiofrequency ablation treatment]. / Basarili radyofrekans ablasyon islemi uygulanan atriyoventriküler nodal reentran tasikardili hastalarda yasam kalitesinin Umea 22 anketi ile degerlendirilmesi.

OBJECTIVE: Atrioventricular nodal reentrant tachycardia (AVNRT) attacks is one of the common arrhythmias adversely affecting quality of life. The Umea 22 (U22) is a questionnaire developed for the assessment of symptoms associated with supraventricular tachycardia (SVT), and it is found to be effective in evaluation of quality of life after radiofrequency ablation. Using this questionnaire, the study aimed to assess quality of life among Turkish patients with ANRT before and after the successful RFA. METHODS: The study was conducted between January 2011 and September 2013, and included 57 patients who had undergone RFA due to AVNRT. The U22 questionnaire was administered pre-procedure and at 6 months post-procedure. The participants were asked to report on their general well-being, arrhythmia effects on their wellbeing, and intensity of discomfort associated with episodes. They were asked to provide a score from 1 to 10 in order to determine to severity of discomfort, and the quantity of symptoms was then assessed according to the visual analogue scale (VAS). RESULTS: Patients' general wellbeing (7.5±2.3 vs. 8.7±1.8, p<0.001), the effects of arrhythmia episodes on general well-being (8.1±1.7 vs. 1.0±2.1, p<0.001), frequency of symptoms (2.8±0.8 vs. 0.4±0.9, p<0.001) and duration of symptoms were reduced significantly after RFA. The rate of drug use among patients also decreased after RFA (70% vs. 23%, p=0.017). CONCLUSION: Treatment success was high in patients undergoing RFA due to AVNRT according to the U22 quality of life questionnaire. General and arrhythmia-associated quality of life had improved significantly by the 6th month post-procedure.

To Be or Not to Be Patent: The Relationship Between Migraine and Patent Foramen Ovale.

OBJECTIVE/BACKGROUND: Migraine is a common neurological disorder with an uncertain pathogenesis. A pathophysiological link has been proposed between the migraine headache and patent foramen ovale (PFO). However, the data about the association of migraine with the presence of PFO are conflicting. The study aims to prospectively investigate the prevalence of PFO in patients with migraine compared with that of control subjects. METHODS: A total of 203 migraineous patients and 212 control subjects with similar demographic characteristics to that of case subjects regarding age and gender were included in the study. Transthoracic echocardiography with agitated saline injection was used to evaluate the presence of PFO. PFO was judged to be present if any microbubble was seen in the left cardiac chambers within the first 5 cardiac cycles from the maximum right atrial opacification at rest or after provocative maneuvers. RESULTS: Mean age of the patients was 37.2 ± 9.8 years and 93% were female. Migraine with aura was present in 32% (n = 65) of the patients. The prevalence of PFO was similar in patients with migraine and the control subjects (42% vs 44%; odds ratio 0.90, 95% confidence interval 0.61-1.33, P = .61). Likewise, the prevalence of PFO was similar in migraineurs patients with or without aura (41% vs 42%; odds ratio 0.95, 95% confidence interval 0.51-1.76, P = .87). CONCLUSION: This study suggest that PFO is not more common in patients with migraine compared with healthy subjects. Therefore, our findings suggest that the relationship between migraine headache and the presence of PFO is questionable.

Relationships between P wave dispersion, atrial electromechanical delay, left atrial remodeling, and NT-proBNP levels, in patients with hypertrophic cardiomyopathy.

BACKGROUND: We evaluated the associations among the well-known atrial fibrillation (AF) predictors including P-wave dispersion (PWD), intra- and inter-atrial electromechanical dyssynchrony (EMD), left atrial (LA) phasic functions, and plasma N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) levels, in patients with hypertrophic cardiomyopathy (HCM). METHODS: Seventy patients with HCM and age and sex matched 70 subjects were enrolled. PWD, LA total emptying fraction (LATEFr), active emptying fraction (LAAEFr), passive emptying fraction (LAPEFr), expansion index (LAEI) intra- and inter-atrial EMD were calculated. Levels of NT-proBNP of all subjects were determined. RESULTS: Higher PWD (p = 0.006), significantly decreased LAEI (p < 0.001), LATEFr, and LAPEFr (both p values < 0.001) values and significantly increased inter-atrial (p < 0.001), LA (p = 0.001), and right atrial dyssynchrony (p < 0.001) were observed in the HCM group compared to controls. PWD was negatively correlated with LAEI (r = -0.236, p = 0.005) and LATEFr (r = -0.242, p = 0.04), however not with LAPEFr (p = 0.7), or LAAEFr (p = 0.3). Except for the LA lateral wall PA' (r = 0.283, p = 0.02), PWD was not correlated with any atrial EMD parameter. Inter-atrial dyssynchrony was related to LAEI (r = -0.272, p = 0.001), LATEFr (r = -0.256, p = 0.03), and LAPEFr (r = -0.332, p = 0.006), but not, however, to LAAEFr (p = 0.4). The plasma NT-proBNP levels of patients were not correlated with either PWD (p = 0.927) or inter-atrial dyssynchrony (p = 0.102). CONCLUSIONS: PWD and inter-atrial dysynchrony seem to independently promote AF, although both are associated with LA reservoir function in HCM populations. The NT-proBNP level is not associated with these two AF predictors in patients with HCM. NT-proBNP seems to be a poor marker of atrial electrical remodeling in HCM patients.

The left atrial phasic functions and the relationship with plasma N-terminal pro-B-type natriuretic peptide levels and symptomatic states in patients with hypertrophic cardiomyopathy.

OBJECTIVE: We aimed to evaluate left atrium (LA) phasic functions and relation with N-terminal pro-B- type natriuretic peptide (NT-proBNP) levels and symptomatic states of the patients with hypertrophic cardiomyopathy (HCM). METHODS: Left atrial volume was calculated at end-systole (Vmax), end-diastole and pre-atrial contraction by echocardiography in 75 patients with HCM and 75 control subjects. Left atrial ejection fraction (LAEF), expansion index (LAEI), active emptying volume index (LAAEVI) and fraction (LAAEFr), passive emptying volume index (LAPEVI) and fraction (LAPEFr) were calculated. NT-proBNP levels were measured. RESULTS: Left atrial active emptying volume (LAAEV) positively correlated with Vmax (r=0.343, p=0.003) up to a point, but then reached a plateau with larger LA volumes in HCM group. The LAAEFr was the only variable which was similiar between asymptomatic patients and controls, but was significantly decreased in symptomatic patients (p<0.05). NT-proBNP was correlated with LAEF (r=-0.32, p=0.005), LAEI (r=-0387, p=0.001), and LAAEFr (r=-0.25, p=0.035) but not related with LAPEFr (p=0.4). In receiver operating characteristic curve analysis an NT-proBNP cut-off value of 1415 pg/mL identified reduced LAEF with 87% specificity and 59% sensitivity [AUC=0.77 (95% CI: 0.65-0.89), p=0.004], a cut-off value of 820 pg/mL predicted impaired LAEI with 81% specificity ve 67% sensitivity [AUC=0.78 (95% CI: 0.66-0.9), p<0.001]; while a cut-off value of 1320 pg/mL predicted impaired LAAEFr with 76% specificity and 67% sensitivity [AUC=0.79 (95% CI: 0.68-0.91), p=0.02]. CONCLUSION: In HCM, LA phasic functions alter according to the Frank-Starling mechanism indicating occurrence of a secondary atrial myopathy. Impairment of LA booster pump function seems to be associated with appearance of symptoms and NT-proBNP levels predict the deterioration of LA reservoir and pump functions in HCM population.

Beta-myosin heavy-chain mutations R403QLW, V606M, K615N and R663H in patients with hypertrophic cardiomyopathy.

OBJECTIVE: Hypertrophic cardiomyopathy (HCM) is a disease of the myocardium with an autosomal-dominant pattern of inheritance mainly caused by single heterozygous mutations in sarcomere genes. In this study we aimed to detect the presence of R403QLW, V606M, K615N, and R663H mutations in beta-myosin heavy-chain gene (MYH7) and figure out the genotype-phenotype correlations in Turkish patients with HCM. METHODS: This case-control study based on genotype-phenotype correlation included 69 patients (mean age, years: 50±13.16) diagnosed with HCM constituting the study group and 50 healthy individuals (mean age, years: 52±1.4) constituting the control group. DNA was extracted from peripheral blood and the genotyping of mutations was performed by real-time PCR technique and high resolution melting analysis. Associations between categoric variables were determined using chi-square tests. Differences between two groups were compared with unpaired Student's t-test for continuous variables. RESULTS: None of the patients in the HCM group were carrying the index mutations. One healthy individual was found to be heterozygous for the R663H mutation with mildly abnormal IVS and LVPW thickness. The allele frequency for R663H (G>A) mutation was found to be 0.01% in control group. CONCLUSION: We performed a mutational screening of 6 HCM-associated mutations in 69 Turkish HCM patients (not previously studied except R403Q). There was no significant difference in the prevalence of the mutations between the patients with HCM and the healthy controls (p>0.05).

The effects of iodixanol and iopamidol on adhesion molecule serum levels in patients with angina pectoris undergoing coronary angiography: a randomized study.

OBJECTIVE: To compare intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) serum levels between patients with stable (SAP) and unstable angina pectoris (USAP) undergoing coronary angiography (CAG), investigate effects of CAG on ICAM-1, VCAM-1 levels in SAP, USAP patients; probable different effects of non-ionic radiocontrast media (RCM), iso-osmotic iodixanol and low osmolar iopamidol, on these adhesion molecules (AM). METHODS: In this randomized, prospective study, 2 groups consisting of patients with SAP (n=22) and USAP (n=22) undergoing CAG were included. For halves of each group iopamidol, for the other halves iodixanol were used as RCM, in turn for randomization. The patients were divided into 4 subgroups according to clinical presentations and used RCM(SAP-iodixanol, SAP-iopamidol USAP-iodixanol, USAP-iopamidol). ICAM-1, VCAM-1 levels were measured just before and 12 hours after CAG. Repeated measurements were compared with two-way ANOVA test. RESULTS: Baseline VCAM-1 concentration was higher in USAP group than SAP group (p=0.001). ICAM-1, VCAM-1 concentrations increased significantly following CAG in SAP, USAP groups. ICAM-1, VCAM-1 concentration increments; didn't reach statistical significance in SAP-iodixanol subgroup, reached a borderline significance in SAP-iopamidol subgroup (p=0.06). In USAP-iodixanol subgroup; only VCAM-1 (p<0.001), in USAP-iopamidol subgroup; ICAM-1 (p=0.009), VCAM-1 (p=0.006) levels increased significantly following CAG. No complication was observed. CONCLUSION: To our knowledge, this is the first study indicating ICAM-1, VCAM-1 inducing effect of CAG in patients with SAP, USAP and differential effects of iodixanol and iopamidol on ICAM-1, VCAM-1 serum levels. Further studies are needed to clarify the effects of CAG and different RCM on vascular inflammation, vessel injury, serum AM levels and their clinical significance. This study should be taken as a pilot, hypothesis-generating study.

Rate of blood pressure control and antihypertensive treatment approaches in diabetic patients with hypertension.

OBJECTIVES: Hypertension is a common co-morbidity in patients with type 2 diabetes. Management of hypertension is of paramount importance in reducing macro- and microvascular complications of diabetes. The aim of this study is to determine the rate of blood pressure control (<140/85 mmHg) in diabetic patients with hypertension, and to evaluate the prescribing pattern of antihypertensive medications. STUDY DESIGN: This was a prospective, cross-sectional, observational study conducted in a tertiary centre in Turkey. Of 707 patients with diabetes, 500 hypertensive patients were evaluated to determine control of hypertension and treatment attitudes. Logistic regression analysis was used to evaluate the likelihood of prescription of each class of antihypertensive medications for the presence of macro- and microvascular complications. RESULTS: Most of the patients (95%) were on antihypertensive therapy. Only 41% achieved target blood pressure values (<140/85 mmHg). Renin angiotensin system (RAS) blockers were the most frequently (82.4%) prescribed antihypertensive agents, and a combination of RAS blockers and diuretics were the most commonly preferred combination therapy. Most of the patients were on 1 antihypertensive drug or a combination of 2 drugs (39.5% and 44.7%, respectively). Patients with coronary artery disease were more likely to receive beta blockers (Odds ratio=3.6, 95% confidence interval=2.3-5.6; p<0.001). CONCLUSION: Although most of the diabetic hypertensive patients were on hypertensive therapy, more than half had uncontrolled blood pressure.

The validity and reliability of the Turkish version of the University of Toronto Atrial Fibrillation Severity Scale.

BACKGROUND/AIM: There are various instruments to assess quality of life (QoL) in patients with atrial fibrillation (AF). The aim of this study is to determine the reliability and validity of the Turkish version of the University of Toronto Atrial Fibrillation Severity Scale (AFSS). MATERIALS AND METHODS: The AFSS and Short Form-36 (SF-36) were completed by 130 patients with documented AF. The Canadian Cardiovascular Society Severity in Atrial Fibrillation (SAF) scale and European Heart Rhythm Association (EHRA) scale were also utilized by the attending physicians. To assess test-retest reliability, the AFSS was readministered to 47 clinically stable patients at a 1-month follow-up visit. Internal consistency reliability, test-retest reproducibility, and construct validity were evaluated. RESULTS: The mean age of the patients was 63.1 + 10.9 years and 58.5% of patients were male. The outcome scores of the Turkish version of the AFSS showed good correlations with theoretically related SF-36 domains. Additionally, AFSS outcome scores showed a linear correlation with the SAF and EHRA scores. Cronbach's alpha values for internal consistency were consistent and similar with the English language version of the AFSS. Intraclass correlation coefficients for reproducibility exceeded 0.80 for every item. CONCLUSION: Convergent-divergent and known-groups validity and reliability were established for the Turkish version of the University of Toronto AFSS.

Assessment of left atrial appendage function during sinus rhythm in patients with hypertrophic cardiomyopathy: transesophageal echocardiography and tissue doppler study.

BACKGROUND: The incidence of systemic thromboembolism is high in patients with hypertrophic cardiomyopathy (HCM). The authors hypothesized that vulnerability to such vascular events could be caused by depressed left atrial appendage (LAA) function during normal sinus rhythm (SR). The aim of this cross-sectional study was to investigate LAA contractile function during SR in patients with HCM. METHODS: LAA function was assessed in 62 patients with HCM in SR and compared with that in 53 age-matched and sex-matched controls. Patients with histories of atrial fibrillation and documented episodes of paroxysmal atrial fibrillation on 24-hour Holter monitoring and depressed left ventricular ejection fractions (<50%) were excluded. Multiplane transesophageal echocardiography was performed for determination of the morphology and function of the LAA. RESULTS: LAA thrombi were present in five patients (8%) with HCM. LAA emptying and filling Doppler velocities were significantly depressed in the HCM group. LAA emptying and filling velocities were negatively correlated with age in controls (r = -0.4, P = .005), but these velocities were not associated with age in the HCM group. Moreover, LAA velocities were not associated with left ventricular mass index, left ventricular outflow tract gradient, or the degree of diastolic dysfunction in the HCM group. All Doppler tissue imaging velocities obtained from LAA walls were also significantly depressed in the HCM group. CONCLUSIONS: LAA thrombus formation was not rare in this patient population. The significantly depressed LAA filling and emptying velocities in SR may predispose patients with HCM to thromboembolic events. The depressed Doppler tissue imaging LAA parameters in patients with HCM may indicate the presence of a possible intrinsic atrial myopathy. Thromboembolic risk should be taken into account, and the evaluation of LAA morphology and function by transesophageal echocardiography might become a component of routine workup in patients with HCM in the future.