Assessment of treatment patterns and patient awareness in atrial fibrillation patients using non-vitamin K antagonist oral anticoagulants (ASPECT-NOAC).

Background and Aim: Despite the advances in oral anticoagulation with NOACs, careful patient and dose selection is required with NOAC therapy. Our study aimed to assess treatment patterns of NOACs in AF along with patients' continuity to NOAC treatments in first year, and their knowledge level of AF and NOAC treatment. Methods: ASPECT-NOAC was designed as an observational, prospective, and multicenter study. AF patients who were prescribed NOACs within last four months were recruited from 34 outpatient cardiology clinics covering all geographic regions of Turkey. Baseline data were collected initially whereas patient awareness was evaluated at 3 to 4 weeks. Final study visit was performed at 12 months. Results: In total, 991 patients were included to the study. Mean ± standard deviation of age was 69.4 ± 10.2 years and 53.0% of patients were female. Mean duration from AF diagnosis was 24.9 ± 50.9 months. Mean CHA2DS2-VASc and HAS-BLED scores were 3.1 ± 1.5 and 1.6 ± 1.1, respectively. AF disease and NOAC treatment knowledge levels were found to be 48.9 ± 23.1% and 73.0 ± 19.3%, respectively. Among reduced dose users 71.4% of patients were prescribed inappropriate reduced doses. Through the study follow-up, 32 patients (3.2%) deceased and NOAC therapy was discontinued in 74 patients (8.7%). Conclusion: AF patients who recently started NOAC treatment in Turkey were found to have variable knowledge about their disease and anticoagulation treatment. It was observed that most of the patients continued the NOAC treatment throughout the study. Reduced dosing of NOACs was common, which was associated with higher baseline risk for bleeding as well as stroke.

Prognostic value of neutrophil-to-lymphocyte ratio in pulmonary arterial hypertension.

OBJECTIVE: To evaluate the prognostic value of baseline neutrophil-to-lymphocyte ratio (NLR) in the prediction of long-term mortality in patients with pulmonary arterial hypertension (PAH). METHODS: This prospective study recorded NLR during initial diagnostic right-sided cardiac catheterization in adult patients with PAH. Demographic, clinical, laboratory and haemodynamic variables were compared by NLR tertile. Univariate and multivariate Cox regression analyses were used to determine whether NLR was independently associated with mortality. RESULTS: Adults with PAH (n = 101) were followed-up for mean ± SD 36.8 ± 23.6 months. The number of deaths, New York Heart Association functional capacity (NYHA FC), levels of brain natriuretic peptide (BNP) or C-reactive protein (CRP) and presence of pericardial effusion increased as the NLR tertile increased, but haemoglobin and tricuspid plane annular systolic excursion (TAPSE) decreased. On univariate analysis, high NLR values were associated with mortality, but on multivariate analysis, NLR did not remain an independent predictor of mortality. Baseline NYHA FC, TAPSE, BNP level and pericardial effusion were independent predictors of mortality. CONCLUSIONS: NLR was correlated with important prognostic markers in PAH such as NYHA FC, BNP and TAPSE. This simple marker may be useful in the assessment of disease severity in patients with PAH.

Impact of Severe Tricuspid Regurgitation on Accuracy of Echocardiographic Pulmonary Artery Systolic Pressure Estimation.

INTRODUCTION: Transthoracic Doppler echocardiography (DE) is recommended for screening and monitorization of pulmonary arterial hypertension (PAH). However, some recent studies have suggested that Doppler echocardiographic pulmonary artery systolic pressure (PASP) estimates may frequently be inaccurate. Some hemodynamic and echocardiographic factors are known to contribute to discordant results. The aim of this study was to determine whether severe tricuspid regurgitation (TR) has any impact on true estimation of PASP by DE. MATERIALS AND METHODS: We retrospectively identified all PAH patients who underwent right heart catheterization (RHC) and had an echocardiogram within the same hospitalization period. Patients were divided into two groups according to the presence of severe TR: Group 1 consisted of 36 patients with mild-moderate TR and group 2 of 36 patients with severe TR. For these two groups, the agreement between echocardiographic and catheterization PASP measurements was evaluated by Bland-Altman analysis, separately. RESULTS: In group 1, the bias for the echocardiographic estimates of the PASP was 2.5 mmHg and 62.5% of the echocardiographic estimates were accurate (≤10 mmHg difference with RHC measurement). In group 2, the bias was 16.25 mmHg and echocardiography was accurate in 37.5% of the patients. To clarify the association between PASP overestimation on DE and the presence of severe TR, regression analysis was performed. Severe TR was found as the only independent predictor of PASP overestimation on echocardiography after multivariate analysis. CONCLUSION: The results of the study show that in patients with PAH, the presence of severe TR is associated with an overestimated PASP measurement on echocardiography.

Rapid retraction of a post-infarction intramyocardial dissecting hematoma.

A 60-year-old male with a recent anterior myocardial infarction (MI) was referred to our hospital for implantable cardioverter defibrillator (ICD) implantation. He was on the 42nd day of MI and clinically stable on admission. Electrocardiography showed right bundle branch block with QS pattern on anterior leads. Transthoracic echocardiographic examination revealed an ejection fraction of 25% with akinesis of the apex and mid-apical segments of anterior and septal walls. In the apical-septal region, a pulsatile cavity with systolic expansion surrounded by a thin endomyocardial border was visualized. Color-Doppler interrogation did not demonstrate any flow within that structure. These findings suggested an intramyocardial dissecting hemorrhage formed after MI. Cardiac magnetic resonance imaging also confirmed an intramyocardial hematoma in the mid-apical anteroseptal region. A conservative approach was assumed as the patient was hemodynamically stable. The planned ICD implantation was postponed due to the high risk of perforation. Subsequently, oral anticoagulant therapy with warfarin was initiated against risk of intracardiac thrombus formation. The existing dual antiplatelet therapy was also continued. One week after hospital discharge, he was rehospitalized due to a very high INR of 6.3. The repeated transthoracic echocardiography revealed an almost complete resolution of the intramyocardial dissecting hematoma and adhesion of the surrounding myocardial layers. Oral anticoagulant therapy was discontinued. Echocardiographic examinations showed no change compared to the last examination during hospitalization. This case illustrates a conservatively managed intramyocardial dissecting hematoma case, in which anticoagulant and antiaggregant therapy yielded a rapid retraction without any complication.

Diagnostic accuracy of mean platelet volume in prediction of clopidogrel resistance in patients with acute coronary syndrome.

OBJECTIVE: Clopidogrel therapy is the standard of care in patients with acute coronary syndrome (ACS) and stent implantation. However, concern arises because 25% of subjects are nonresponders to clopidogrel. As this nonresponsiveness is associated with increased adverse outcome, detection of these subjects in daily practice is important in order to withhold a more aggressive therapy and closer follow up. In this study we aimed to evaluate the relation between mean platelet volume (MPV) which is an indicator of platelet activation and clopidogrel nonresponsiveness. METHODS: The study was planned as a prospective cohort study. A total of 185 patients who had been on clopidogrel therapy for any acute coronary syndrome were enrolled in this study. Clopidogrel responsiveness was analyzed by Multiplate MP-0120 device by using the method of whole blood aggregometry. Blood samples were drawn 3.5 days after clopidogrel loading dose. The amount of ADP induced platelet aggregation was assessed as area under curve (AUC), and a cut-off value of 500, above which the patient is considered as clopidogrel nonresponder, was used. MPV was analyzed from the blood which were sampled at the admission of the patient by using automatic hemocounter. Independent sample t-test, ROC analyses and logistic regression analsis were used in statistical analysis. RESULTS: Among the 185 patients analyzed 41 were found to be clopidogrel nonresponder (22.1%). Mean MPV was found to be significantly higher in nonresponders compared to responders (8.7±0.82 fL vs. 8.1±0.83 fL, p<0.001). A cut-off value of 8.3 fL for MPV was detected in prediction of clopidogrel nonresponsiveness with a sensitivity of 76.6% and specificity of 68.3% (OR: 6.4; 95% CI 2.9-14.1, AUC: 0.70, p<0.001). CONCLUSION: This study showed that MPV can be used as a predictor of clopidogrel resistance in patients with ACS.

An interesting septic embolism.

Septic pulmonary embolism is a rare disease but mortality and morbidity of it is high. Septic pulmonary emboli comes from infected heart valves, thrombophlebitis, and pulmonary artery catheter or infected pacemaker wires as many sources [1,2]. In recent years, pacemaker is a common treatment of the bradiarrhythmia that is persisted in the etiology of septic embolism, its applications has started to pick up [3]. There is the growing number of patients with pacemaker, according to this the frequency of pacemaker lead infection and the number of patients at risk for right-sided endocarditis increase [4]. The patients don't have specific clinical and radiological features because of this it is very difficult to define, so the diagnosis is often delayed [5]. A detailed medical history, a detailed physical examination in diagnosis and evaluation of good additional imaging methods is very important. Early diagnosis and proper treatment, the implementation of the management, can provide good results.

Evaluation of left ventricular diastolic function according to new criteria and determinants in acromegaly.

Left ventricular diastolic dysfunction (LVDD) develops in the early stages of acromegaly. The purpose of this study was to identify LVDD analyzing by new echocardiograpic criteria as well as to evaluate determinants of the LVDD in acromegaly. This cross-sectional study examined 42 patients with acromegaly; 16 in active disease (AA) and 26 cured/ well controlled (CA), and compared them with 30 healthy controls (CG). Ventricular systolic and diastolic functions were studied by conventional and tissue Doppler imaging based on the E/Em ratio and myocardial performance index (MPI). Other clinical parameters possibly contributing to LVDD in acromegaly were also investigated. The prevalence of LV hypertrophy (33%) and LVDD (35.7%) were increased in acromegaly, however, there were no differences between the AA and CA groups. Acromegalic patients had higher LV volumes and LV mass, and septal E/Em ratio compared to CG, whereas LV ejection fraction and MPI were not different. The presence of acromegaly (r = 0.29, P = 0.013), diabetes mellitus (DM) (r = 0.41, P < 0.001), hypertension (r = 0.35, P = 0.002), and sleep apnea (r = 0.56, P = 0.003) were found to be correlated with LVDD, whereas duration and activity of acromegaly were not. In regression analysis, advanced age (OR: 8.53, P = 0.006) and DM (OR: 25.9, P = 0.007) were found to be independent risk factors for LVDD. The risk of LVDD according to new criteria increases in acromegaly. However, it seems to be related to the presence of DM and advanced age and is independent of disease duration and activity.

The association of beta-fibrinogen 455 G/A gene polymorphism with left atrial thrombus and severe spontaneous echo contrast in atrial fibrillation.

OBJECTIVE: The role of coagulation parameters left atrial thrombus formation in atrial fibrillation has not been investigated before. We aimed to investigate the association between the beta-fibrinogen gene polymorphism or glycoprotein IIIa gene polymorphism and presence of left atrial (LA) thrombus or spontaneous echo contrast (SEC) in patients with atrial fibrillation (AF). METHODS: Forty-seven patients with AF, in whom transesophageal echocardiography was performed, were included to this cross-sectional observational study. Patients were divided in two groups; those with LA thrombus (n=24) were assigned to group 1 and those without thrombus in group 2 (n=23). DNA analysis was conducted to determine gene polymorphism in all patients. Mann-Whitney U test or Chi-square tests were used for statistical analysis. RESULTS: There were no significant differences between groups regarding to demographic and clinical characteristics. The frequency of beta-fibrinogen 455 G/A polymorphism was higher (37.5%) in group 1 as compared to group 2 (15.1%) but it did not reach statistical difference (p=0.23). When we added patients with severe SEC in the study group (patients with severe SEC and/or thrombus n=27) the difference (44.40%-10%) reached the statistical difference (p=0.01). Glycoprotein IIIa Pl A1/A2 polymorphism was not different between groups with (p=0.82) or without SEC (p=0.73). CONCLUSION: In patients with atrial fibrillation, beta-fibrinogen 455 G/A gene polymorphism is associated with the presence of left atrial thrombus and severe SEC. Beta-fibrinogen 455 G/A gene polymorphism may be a promising marker for the prediction of thromboembolism risk in patients with atrial fibrillation.

Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial.

BACKGROUND: Several protective therapies have been developed to prevent contrast-induced nephropathy (CIN). We aimed to investigate the efficacy of sodium bicarbonate by comparing 2 other regimens, including combination of N-acetylcysteine (NAC) plus sodium chloride and sodium chloride alone, to prevent CIN in patients undergoing cardiovascular procedures. METHODS: We prospectively enrolled 264 patients who were scheduled for cardiovascular procedures and had a baseline creatinine level >1.2 mg/dL. The patients were assigned 1 of 3 prophylactic regimens: infusion of sodium bicarbonate, sodium chloride, sodium chloride plus oral NAC (600 mg bid). Contrast-induced nephropathy was defined as an increase in serum creatinine level >25% or 0.5 mg/dL after 48 hours. RESULTS: There were no significant differences among groups regarding baseline demographic properties and nephropathy risk factors. The change in creatinine clearance was significantly better in the sodium bicarbonate group than other 2 groups (P = .007). The incidence of CIN was significantly lower in the sodium bicarbonate group (4.5%) compared with sodium chloride alone (13.6%, P = .036) and tended to be lower than in the combination group (12.5%, P = .059). After adjusting the Mehran nephropathy risk score, the risk of CIN significantly reduced with sodium bicarbonate compared with sodium chloride alone (adjusted risk ratio 0.29, P = .043). CONCLUSIONS: Hydration with sodium bicarbonate provides better protection against CIN than the sodium chloride infusion does alone. Combination therapy of NAC plus sodium chloride did not offer additional benefit over hydration with sodium chloride alone.

Effects of carvedilol therapy on arrhythmia markers in patients with congestive heart failure.

The aim of this study was investigate the effects of carvedilol therapy on ventricular repolarization characteristics as assessed by QT dispersion (QTd) and heart rate variability (HRV) in patients with heart failure. Thirty-one patients with heart failure (mean age, 63.9 years) were included in the study. Carvedilol was administered in addition to standard therapy for CHF at a dose of 6.25 mg/day and uptitrated to the maximum tolerated dose. Control group consisted of 14 patients with heart failure (mean age, 69.4 years) who could not take carvedilol due to several reasons. All patients were followed-up 6 months. QT dispersion (QTd), and corrected QTd (QTcd) values were calculated at baseline and at the end of follow-up. Time domain and frequency domain heart rate variability analysis were performed with ambulatory Holter ECG. Mean carvedilol dose was 23.9 +/- 13.9 mg. Significant reductions were observed in the QTd (P = 0.016) and QTcd (P = 0.001) with carvedilol therapy, whereas QTd (P = 0.47) and QTcd (P = 0.43) did not change significantly in the control group. The QT maximum value did not change significantly but the QT minimum value (P = 0.03) was significantly increased after carvedilol therapy. Although the mean SDANN value was improved (P = 0.039), other HRV parameters such as mean SDNN (P = 0.32), rMSSD (P = 0.74), and the LF/HF ratio (P = 0.35) did not change significantly after carvedilol therapy. This prospective controlled study shows that carvedilol therapy decreased QT dispersion and improved ventricular repolarization characteristics but did not change autonomic dysfunction in patients with heart failure.

Are complex coronary lesions more frequent in patients with diabetes mellitus?

BACKGROUND: Coronary atherosclerotic burden is excessive in diabetic patients. Diabetes mellitus (DM) is an independent predictor for both death and myocardial infarction. It is not known whether the prevalence of complex coronary lesions, such as bifurcation and ostial lesions, is different in diabetics from nondiabetics. OBJECTIVE: The aim of present study was to investigate the prevalence of these lesions in patients with DM. METHODS: One thousand fourteen consecutive patients (mean age 61.3+/-10.7 years) were investigated. Coronary angiograms were examined for bifurcation and ostial lesions using a digital quantitative system. Patients were classified as diabetic (n=281) or nondiabetic (n=733). RESULTS: Patient mean age, and rates of hypertension and hyperlipidemia were significantly higher in the diabetic group than in the nondiabetic group (P<0.0001), although smoking was significantly lower (P=0.001). Reasons for coronary angiography and treatment were comparable between the two groups. The prevalence of bifurcation lesions and ostial lesions was significantly greater in the diabetic group than in the nondiabetic group (9.8% versus 4.3% [P=0.001] and 38.4% versus 29.2% [P=0.003] in the diabetic group versus the nondiabetic group). The presence of DM and greater age were found to be independent predictors for bifurcation lesions (OR=2.27 [P=0.004] and OR=1.03 [P=0.01], for DM and age, respectively) and ostial lesions (OR=1.40 [P=0.027] and OR=1.02 [P=0.001], for DM and age, respectively) in multivariate analysis. CONCLUSIONS: Complex coronary lesions such as bifurcation and ostial lesions were significantly more common in diabetic patients than in nondiabetic patients. Greater age and the presence of DM were independent predictors for these complex lesions. These results may help to explain the poor prognosis of coronary artery disease among diabetic patients.

Five chambered heart: a case report and brief review of literature.

We present a patient with chest pain and suspicious findings in electrocardiography and myocardial perfusion scintigraphy for myocardial ischemia. Coronary angiography and then echocardiography and magnetic resonance imaging revealed a dilated left anterior descending coronary artery, which has fistulous communication with a large, separate chamber that occupies the infero-apical interventricular septum. This is a challenging congenital anomaly for a clinician in many aspects, which are discussed in the report.

Left atrial appendage-flow velocity predicts cardioversion success in atrial fibrillation.

Restoration of sinus rhythm by electrical cardioversion is a therapeutic option in appropriately selected patients with atrial fibrillation. It is important to determine predictors of electrical cardioversion outcome in patients with atrial fibrillation. Predictive value of clinical and conventional echocardiographic parameters for predicting cardioversion outcome is limited. The role of left atrial appendage (LAA) function, which may reflect left atrial contractile function, for prediction of cardioversion outcome remains unclear. We conducted a single center prospective study to evaluate the role of LAA function for prediction of cardioversion success in patients with atrial fibrillation. One hundred sixty three patients with atrial fibrillation underwent transthoracic and transesophageal echocardiography (TEE) before electrical cardioversion. LAA functions, including LAA peak flow velocity, LAA area and LAA ejection fraction, were examined. Cardioversion was successful in 133 patients and unsuccessful in 30 patients. Mean LAA peak emptying flow velocity was significantly higher in the patients with successful cardioversion than in those with unsuccessful cardioversion (0.34 +/- 0.14 vs 0.27 +/- 0.1 m/sec; p = 0.013). At multivariate logistic regression analysis, only LAA flow velocity (> 0.28 m/sec, odds ratio = 2.8 ; p = 0.03) proved to be an independent predictor of cardioversion success. LAA area (p = 0.18) and LAA ejection fraction (p = 0.52) were not different between successful and unsuccessful cardioversion groups. Therefore, measurement of LAA flow velocity provides valuable information for prediction of cardioversion outcome in patients with atrial fibrillation before TEE guided cardioversion.

Usefulness of preprocedural soluble CD40 ligand for predicting restenosis after percutaneous coronary intervention in patients with stable coronary artery disease.

CD40-CD40 ligand interaction is involved in the inflammatory pathogenesis of atherosclerosis but clinical data about its role in stent restenosis are still limited. We investigated the effect of preprocedural CD40 ligand (sCD40L) on stent restenosis. We enrolled 36 patients (mean age 61.4 +/- 8.5 years) with stable angina who underwent successful stent implantation. Control angiograms were performed in all patients after 6 months. Plasma sCD40L and high-sensitive C-reactive protein levels were measured before stent implantation and at 1 and 6 months after the procedure. Angiographically proven restenosis rate was 27.8%. Plasma sCD40L levels were significantly higher (preprocedural 0.74 +/- 0.79) and more prolonged in patients with stent restenosis compared with patients without stent restenosis (0.02 +/- 0.22 ng/ml, p < 0.001). According to receiver-operator characteristic analysis, sCD40L > 0.41 ng/ml was the best distinguished parameter between patients with and without restenosis. At the multivariate logistic regression analysis, preprocedural sCD40L was an independent predictor (RR 39.4, 95% confidence interval 4.05 to 383.8, p = 0.002) of stent restenosis after adjusting for confounding variables, including diabetes, reference vessel diameter, lesion length, stent diameter, stent length, and baseline high-sensitive C-reactive protein. Sensitivity, specificity, and positive and negative predictive values and likelihood ratio of preprocedural sCD40L levels in stent restenosis were 78%, 92%, 78%, 92%, and 9.37%, respectively. In conclusion, enhanced inflammation of plaque (increased sCD40L) before percutaneous coronary intervention may increase the rate of stent restenosis. Increased preprocedural sCD40L level is an independent predictor of stent restenosis. We can use this marker for the assessment of risk stratification before planning stent implantation.

Successful thrombolytic therapy for prosthetic mitral valve thrombosis with hemodynamic obstruction: case report and review of the literature.

Prosthetic valve thrombosis (PVT) is a serious complication of mechanical valves. The use of thrombolytic therapy to relieve thrombotic prosthetic valve obstruction is accepted for right-sided valves, but its role in left-sided valves and hemodynamically stable patients awaits clarification. The case is presented of a patient in whom prosthetic heart valve thrombosis was treated successfully with streptokinase under transesophageal echocardiographic guidance.

Cardioversion under the guidance of transesophageal echochardiograhy in persistent atrial fibrillation: results with low molecular weight heparin.

BACKGROUND: Transesophageal echocardiography (TEE) guided cardioversion to restoration of sinus rhythm is a therapeutic option in patients with atrial fibrillation (AF). Anticoagulation at the time of and after cardioversion is necessary to prevent formation of new thrombus during atrial stunning period. We aimed to evaluate the efficacy and safety to TEE guided cardioversion with low molecular weight heparin (LMWH) in patients with atrial fibrillation. METHODS: We followed up 208 patients with persistent AF (mean age: 65.5+/-10.2 years) who were attempted TEE guided cardioversion. LMWH were used as an anticoagulant and warfarin therapy was continued. RESULTS: Cardioversion were performed in 183 patients. Sinus rhythm restored in 144 patients (78.7%). Mean follow up duration was 155 days. No cardiac death occurred. In the early follow up period (within 30 day) one thromboembolic event (0.54%) occurred in a patient who was cardioverted. Two patients who had not been cardioverted because of left atrial thrombus presented embolic stroke, one in early and another in late follow up period. All embolic complications occurred in patients who had been taking warfarin and whose INR level was subtherapeutic at the time of stroke. Sinus rhythm was maintained in 64% and total hemorrhagic complications occurred in 4.8% of the patients in long-term follow-up. CONCLUSION: TEE guided cardioversion with a short-term anticoagulation protocol using low molecular weight heparin is a safe and effective method in restoring and maintaining sinus rhythm and enables us to make earlier cardioversion in atrial fibrillation.