An indirect effect of covid-19 on the heart: A case report.

Covid-19 virus has been recognized to develop major cardiac complications. The indirect effect of the virus though, in terms of fear for hospital admissions, constitutes a greater threat. In this case we present a 69-year old male patient who suffered from a myocardial infarction that has not been given the proper attention due to the fear of in-hospital contact with covid patients. The result was the delayed revascularization and eventually the development of heart failure. This case presents the full range of covid-19 affection to the heart and raises the public awareness for not underestimating symptoms suggesting life-threatening conditions.

Association between high on-treatment platelet reactivity to clopidogrel and hepatosteatosis in patients undergoing elective stent implantation.

OBJECTIVE: The present study is an investigation of the association between high on-treatment platelet reactivity to clopidogrel (HTPRC) and hepatosteatosis in patients who had elective stent implantation due to coronary artery disease. METHODS: A total of 190 consecutive patients who underwent an elective coronary stent implantation due to coronary artery disease were prospectively enrolled in the study. Eligible patients were given a 300 mg loading dose of clopidogrel before percutaneous coronary intervention. All of the patients underwent an ultrasound assessment for fatty liver. The patients were divided into 2 groups according to the detection of HTPRC: patients with HTPRC and patients without HTPRC. RESULTS: HTPRC was present in 54.2% (103 of 190 patients) of the total study population. The age and body mass index data were similar between the 2 groups. In all, 111 (58.6%) patients had hepatosteatosis. The HTPRC ratio was statistically higher in female patients (p=0.032). Hepatosteatosis was significantly greater in patients with HTPRC (p<0.001); 84 (81.6%) patients with HTPRC had hepatosteatosis (p=0.001). There was also a statistically significant association between the hepatosteatosis grade and HTPRC (p<0.001). The percentage of HTPRC was greater in patients with ≥grade 2 hepatosteatosis than grade 1 (p<0.001). Logistic regression analysis indicated that hepatosteatosis (odds ratio: 9.403, 95% confidence interval: 4.519-19.566; p<0.001), fasting blood glucose, and hypertension were independent predictors of HTPRC. CONCLUSION: To the best of our knowledge, this is the first study to demonstrate a relationship between hepatosteatosis and HTPRC.

Analysis of geographical variations in the epidemiology and management of non-valvular atrial fibrillation: results from the RAMSES registry.

OBJECTIVE: This study aimed to determine the differences in terms of demographic characteristics and preferred stroke prevention strategies for patients with non-valvular atrial fibrillation living in seven geographical regions of Turkey. METHODS: In total, 6273 patients were enrolled to this prospective, observational RAMSES study. The patients were divided into seven groups based on the geographical region of residence. RESULTS: In terms of the geographical distribution of the overall Turkish population, the highest number of patients were enrolled from Marmara (1677, 26.7%). All demographic characteristics were significantly different among regions. Preferred oral anticoagulants (OACs) also differed between geographical regions; non-vitamin K OACs were preceded by warfarin in East Anatolia, Aegean, Southeast Anatolia, and Black Sea. Nearly one-third of the patients (28%) did not receive any OAC therapy. However, the number of patients not receiving any OAC therapy was higher in Southeast Anatolia (51.1%) and East Anatolia (46.8%) compared with other geographical regions of Turkey. Inappropriate use of OACs was also more common in East and Southeast Anatolia. CONCLUSION: This study was the first to show that the demographic differences among the geographical regions may result in different preferences of stroke prevention strategies in Turkey. OACs are still under- or inappropriately utilized, particularly in the eastern provinces of Turkey.

Assessment of electrocardiographic parameters in adult patients undergoing extracorporeal shockwave lithotripsy.

OBJECTIVE: Extracorporeal shock wave lithotripsy (ESWL) is a safe and effective treatment for urinary tract calculi. While serious side effects are rare, transient cardiac arrhythmias may occur. New electrocardiographic (ECG) parameters, such as P wave dispersion (PWD), QT dispersion (QTd), T peak to T end (Tp-e) interval, Tp-e interval/QT ratio, and Tp-e interval/corrected QT ratio have been defined to help predict atrial and ventricular arrhythmias. However, effect of ESWL on these ECG parameters has not been previously investigated. The present study was an examination of the effect of ESWL on ECG parameters. METHODS: Total of 40 consecutive patients who underwent ESWL were prospectively enrolled in the study. Pre-procedure ECG parameters were compared with post-procedure ECG parameters. RESULTS: PWD values were significantly longer on post-procedure ECG compared with pre-procedure ECG (p=0.017). Corrected QT duration and QTd were significantly longer on postprocedure ECG compared with pre-procedure ECG (p=0.046 and p=0.008, respectively). In addition, Tp-e interval, Tp-e interval/QT ratio, and Tp-e interval/QTc ratio were significantly longer post procedure (p=0.035, p=0.045, and p=0.022, respectively). In univariate correlation analysis, duration of procedure was significantly correlated with post-procedure PWD, QTc, and QTD values. CONCLUSION: Clinical use of ECG parameters may be helpful in monitoring of patients receiving ungated ESWL in order to detect cardiac dysrhythmia.

Real-World Clinical Characteristics and Treatment Patterns of Individuals Aged 80 and Older with Nonvalvular Atrial Fibrillation: Results from the ReAl-life Multicenter Survey Evaluating Stroke Study.

OBJECTIVES: To compare the clinical characteristics of and use of oral anticoagulant (OAC) therapy in individuals aged 80 and older with atrial fibrillation (AF) with those of individuals younger than 80 with AF in clinical practice. DESIGN: Observational study. SETTING: The ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey trial (NCT02344901), a national observational registry. PARTICIPANTS: Turkish adults with nonvalvular AF (NVAF). MEASUREMENTS: Age data were collected at the time of entry into the registry and the octogenarian subgroup included all patients aged ≥ 80 years. We compared background and management in octogenarian with non-octogenarian AF patients. RESULTS: Fifty-seven cardiology units enrolled 6,273 individuals in 3 months. Participants aged 80 and older (n = 1,170) were more likely to be female (60.7% vs 54.7%, P < .001) and had a higher prevalence of persistant or permanent AF, comorbidities, history of cerebral vascular accident, and major bleeding. As a consequence of having more comorbidities, Congestive heart failure; Hypertension; Aged 75 and older; Diabetes Mellitus; prior stroke, transient ischemic attack, or thromboembolism; Vascular disease; Aged 65 to 74; female Sex (CHA2 DS2 VASc) (4.32 ± 1.35 vs 3.04 ± 1.54, P < .001) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol (HAS-BLED) (2.14 ± 1.05 vs 1.54 ± 1.05, P < .001) scores were higher in those aged 80 and older. The mean time in therapeutic range of individuals who were taking warfarin was lower in those aged 80 and older (45.9 ± 27.9) than in those younger than 80 (54.7 ± 24.9%, P < .001). Anticoagulant therapy was prescribed for 74.8% of participants younger than 80% and 63% of those aged 80 and older (P < .001). Higher CHA2 DS2 VASc score and lower HAS-BLED score were independent predictors of OAC prescription in participants aged 80 and older. CONCLUSION: Nearly one-fifth of individuals with NVAF in this real-world sample were aged 80 and older. Participants aged 80 and older were more likely to be female and have more comorbidities than those who were younger than 80. Those aged 80 and older with AF were less likely to receive anticoagulants than those who were younger than 80, but having more comorbidities and other individual-level characteristics may explain this difference. When they were prescribed OACs, participants aged 80 and older had poorer quality of anticoagulation than those who were younger, suggesting opportunities for improvement.

Diastolic Electrocardiographic Parameters Predict Implantable Device Detected Asymptomatic Atrial Fibrillation.

BACKGROUND: Atrial fibrillation is the most common clinically significant arrhythmia. It is now established that atrial high-rate episodes are highly correlated with atrial fibrillation. AIMS: To investigate the relation between diastolic electrocardiographic parameters and subclinical atrial fibrillation detected by cardiac implantable electronic devices. STUDY DESIGN: Ccross-sectional study. METHODS: A total of 203 patients who had a dual-chamber, rate-modulated pacing pacemaker implanted due to sinus node dysfunction were prospectively enrolled in this study. Atrial high-rate episodes were defined as any lasting more than 5 min with an atrial rate of ≥220 beats per minute during the previous year. Patient groups were categorized on the basis of pacemaker interrogation as the absence of atrial high-rate episodes [atrial high-rate episodes (-)] and the presence of atrial high-rate episodes [atrial high-rate episodes (+)]. Episodes related to atrial over sensing were excluded. Twelve-lead surface electrocardiography was independently analyzed by two experienced readers for the measurement of diastolic electrocardiography parameters. RESULTS: Among 203 patients (mean age: 67.5±9.1, 60.1% male), 51 (25.1%) with atrial high-rate episodes were defined as group 1 and 152 (74.9%) without atrial high-rate episodes were defined as group 2. Both groups were similar in terms of demographic characteristics and cardiovascular risk factors. Tend-Q and Tend-P were significantly longer in group 2. PQ interval was statistically longer in group 1. Corrected QT interval was significantly longer in group 1. Diastolic electrocardiography index, heart rate and PQ and QT intervals were the only independent predictors of atrial high-rate episodes in patients with dual pacemakers in multivariate analysis. CONCLUSION: Abnormal diastolic electrocardiography parameters are powerful predisposing factors for the initiation of incident atrial fibrillation. Diastolic electrocardiography parameters and a novel diastolic index predict atrial high-rate episodes. Evaluating these parameters enables clinicians to identify patients who are at high risk and who may benefit from prophylactic treatment.

Guideline-adherent therapy for stroke prevention in atrial fibrillation in different health care settings: Results from RAMSES study.

OBJECTIVE: No studies have been conducted in Turkey to compare the quality of stroke prevention therapies provided in different healthcare settings in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate possible differences between secondary (SH) and tertiary hospital (TH) settings in the effectiveness of implementing AF treatment strategies. METHODS: Baseline characteristics of 6273 patients with non-valvular AF enrolled in the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke Prevention Strategies in Turkey) study were compared. RESULTS: Of the study population, 3312 (52.8%) patients were treated in THs and 2961 (47.2%) patients were treated in SHs. Patients treated in the SH setting were older (70.8±9.8 vs. 68.7±11.4years, p<0.001), had a lower socioeconomic status, had a higher CHA2DS2VASc and HASBLED scores (3.4±1.4 vs. 3.1±1.7, p<0.001 and 1.7±1.0 vs. 1.6±1.1, p<0.001 respectively), and had more comorbidities than patients treated in THs. Inappropriate oral anticoagulant use was more prevalent in SHs than THs (31.4% vs. 25.6%, p<0.001). When over- and undertreatment rates were compared among hospital types, overtreatment was more prevalent in THs (7.6% vs. 0.9%, p<0.001) while undertreatment was more common in SHs (30.5% vs. 17.9%, p<0.001). CONCLUSION: This study demonstrates the marked disparity between patient groups with AF presenting at SHs and THs. The use of guideline-recommended therapy is not adequate in either type of centre, overtreatment was more prevalent in THs and undertreatment was more prevalent in SHs.

Interatrial block predicts atrial high rate episodes detected by cardiac implantable electronic devices.

BACKGROUND: Interatrial block which is defined as P wave duration longer than 120 milliseconds is underappreciated but highly prevalent electrocardiographic abnormality and associated with atrial tachyarrhythmias and ischemic stroke. Impaired left atrial mechanics and atrial fibrillation are potential mechanisms contributing to the embolic events associated with interatrial block. Detection of atrial high rate episodes by cardiac implantable electronic devices provides clinicians to diagnose asymptomatic atrial fibrillation. The relation between interatrial block and asymptomatic atrial fibrillation can provide an insight to the increased risk of ischemic stroke in patients with interatrial block. METHODS: We prospectively evaluated 367 patients who were implanted dual chamber pacemaker due to sinus node dysfunction (SND) between January 2015 and December 2015. Twelve lead electrocardiograms were analyzed to diagnose interatrial block before pacemaker implantation. Six months after the implantation, pacemakers were interrogated to detect atrial high rate episodes. Patients were divided into two groups in terms of presence or absence of atrial high rate episodes. RESULTS: Atrial high rate episodes were detected in 107 (30.1%) patients during their device interrogation. Interatrial block was found in 115 (32.4%) patients out of total study population. Sixty-seven (27.0%) patients in AHRE (-) group had interatrial block while 48 (44.9%) patients had in AHRE (+) group. Prevalence of interatrial block was statistically significantly higher in AHRE (+) patients (P<0.01). CONCLUSION: Occurrence of atrial high rate episodes, a surrogate for asymptomatic atrial fibrillation, is statistically significantly higher in patients with interatrial block.

The effect of serum potassium level on in-hospital and long-term mortality in ST elevation myocardial infarction.

Current studies evaluating the effect of serum potassium levels on mortality in patients with ST elevation myocardial infarction (STEMI) are lacking. We analyzed retrospectively 3760 patients diagnosed with STEMI. Mean serum potassium levels were categorized accordingly: <3.0, 3.0 to <3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, 5.0 to <5.5, and ≥5.5mEq/L. The lowest mortality was determined in patients with serum potassium level of 4 to <4.5mEq/L whereas mortality was higher in patients with serum potassium levels of ≥5.0 and <3.5mEq/L. In a multivariable Cox-proportional regression analysis, the mortality risk was higher for patients with serum potassium levels of ≥5mEq/L [hazard ratio (HR), 2.11; 95% confidence interval (CI) 1.23-4.74 and HR, 4.20; 95% CI 1.08-8.23, for patients with potassium levels of 5 to <5.5mEq/L and ≥5.5mEq/L, respectively]. In-hospital and long-term mortality risks were also higher for patients with serum potassium levels of ≤3.5mEq/L. Conversely, ventricular arrhythmias were higher only for patients with serum potassium level of ≤3.5mEq/L. Furthermore, a significant relationship was found between the patient with serum potassium levels of ≤3.5mEq/L and ventricular arrhythmias.

Assessment of Prognostic Value of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Patients with Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism is a serious medical condition that has a substantial global impact. Inflammation plays a role in the pathophysiology and prognosis of acute pulmonary embolism (APE). The aim of the present study was to investigate the prognostic value of admission parameters for complete blood count (CBC) in APE. METHODS: A total of 203 patients who were hospitalized with diagnosed APE were retrospectively enrolled in the study. Clinical data, PESI scores, admission CBC parameters, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were all recorded. The clinical outcomes of study subjects were determined by the reported patient 30-day mortality and long-term mortality. RESULTS: During a median follow-up period of 20 months [interquantile range 17], 34 subjects in the study population (17%) died. NLR and PLR levels were significantly higher in patients who died within the 30 days (n = 14) [9.9 (5.5) vs. 4.5 (4.1), p = 0.01 and 280 (74) vs. 135 (75), p = 0.01, respectively] and during the long-term follow-up (n = 20) [8.4 (2.9) vs. 4.1 (3.8), p = 0.01 and 153 (117) vs. 133 (73), p = 0.03, respectively] when compared to the patients that survived. In Cox regression analysis, age, systolic blood pressure, systolic pulmonary arterial pressure, PESI scores (HR 1.02 95%CI 1.01-1.04, p = 0.01), elevated levels of NLR (HR 1.13 95%CI 1.04-1.23, p = 0.01) and PLR (HR 1.002 95%CI 1.001-1.004, p = 0.01) were independently correlated with total mortality. CONCLUSIONS: Admission NLR and PLR may have prognostic value in patients with APE.

The first six-month clinical outcomes and risk factors associated with high on-treatment platelet reactivity of clopidogrel in patients undergoing coronary interventions.

OBJECTIVE: This study attempted to fill the gaps in evidence related to response to clopidogrel treatment in the Turkish population. The study aimed to determine the prevalence, associated risk factors, and clinical outcomes of high on-treatment platelet reactivity (HTPR) of clopidogrel in patients undergoing percutaneous coronary intervention (PCI) in a tertiary cardiovascular hospital in Turkey. METHODS: In this prospective studied a total of 1.238 patients undergoing PCI were included in the present study. Blood samples were analyzed using a Multiplate analyzer. All patients were examined in the outpatient clinics at the end of the first and sixth months for recording drug therapy compliance and study endpoints. RESULTS: Among the study population, 324 (30.2%) patients were found to have HTPR (mean age 58.03±11.88 years, 71.7% men). The incidence of HTPR was higher amongst females than amongst males (38.3% vs. 27%, p=0.010). Hypertension and diabetes mellitus were more frequently observed in the HTPR group (57.7% vs. 48.7%, p=0.004; 35% vs. 29.1%, p=0.040, respectively). When the recorded data were analyzed using multinomial regression analysis, hypertension, hemoglobin level, platelet, lymphocyte, and eosinophil count were independently associated with HTPR. CONCLUSION: On the basis of the results obtained from our study, we conclude that 30.2% of the Turkish population has HTPR. Our results also led us to believe that hypertension is an associated risk factor and decreased hemoglobin level as well as increased platelet counts are laboratory parameters that are strongly associated with the presence of HTPR. However, no differences were observed with regard to cardiovascular mortality and stent thrombosis.

The awareness, efficacy, safety, and time in therapeutic range of warfarin in the Turkish population: WARFARIN-TR.

OBJECTIVE: The awareness, time in therapeutic range (TTR), and safety of warfarin therapy were investigated in the adult Turkish population. METHODS: This multicenter prospective study includes 4987 patients using warfarin and involved regular international normalized ratio (INR) monitoring between January 1, 2014 and December 31, 2014. TTR was calculated according to F.R. Roosendaal's algorithm. Awareness was evaluated based on the patients' knowledge of warfarin's affect and food-drug interactions. RESULTS: The mean TTR of patients was 49.52±22.93%. The patients with hypertension (55.3%), coronary artery disease (23.2%), congestive heart failure (24.5%), or smoking habit (20.8%) had significantly lower TTR levels than the others. Of the total number of patients, 42.6% had a mechanical valve, 38.4% had non-valvular atrial fibrillation (AF), and 19% had other indications for warfarin. Patients with other indications had lower TTR levels than those with mechanical valve and non-valvular AF (p=0.018). Warfarin awareness decreased in higher age groups. The knowledge of warfarin's food-drug interactions was 55%. People with higher warfarin awareness had higher TTR levels. Patients with ≤8 INR monitoring/year had lower TTR levels (46.4±25.3 vs. 51.1±21.3, respectively, p<0.001) and lower awareness (44.6% vs. 60.6%, p<0.001) than patients with ≥8 INR monitoring/year. In this study, 20.1% of the patients had a bleeding event (major bleeding 15.8%, minor bleeding 84.2%) within a year. CONCLUSION: Both the mean TTR ratios and awareness of the Turkish population on warfarin therapy were found to be low. It was thought that low TTR levels of the Turkish population may be caused by the low awareness of warfarin, warfarin's food-drug interactions, and high rates of concomitant diseases.

A Retained Bullet in Pericardial Sac: Penetrating Gunshot Injury of the Heart.

Penetrating cardiac trauma is rarely seen but when present there is a short time lag to keep the patients alive. Cardiac gunshot injuries are exceptional and it occurs mostly during interpersonal disagreements casualties or a mistakenly fired gun nowadays. Here we present a case of cardiac gunshot injury from the war of Kobani, Syria. The patient was mistakenly diagnosed to have a sole bullet in the left shoulder while he had a penetrating cardiac trauma with a bullet in the heart and pericardial effusion possibly giving rise to pericardial tamponade. Luckily the cardiac gunshot injury was noticed one day later and the patient was referred to a tertiary hospital. Intrapericardial bullet was conservatively followed up. The patient was discharged one week later after resection of the bullet in the shoulder.

Anxiety, Depression, and General Psychological Distress in Patients with Coronary Slow Flow.

BACKGROUND: The relationship between psychiatric illness and heart disease has been frequently discussed in the literature. The aim of the present study was to investigate the relationship between anxiety, depression and overall psychological distress, and coronary slow flow (CSF). METHODS: In total, 44 patients with CSF and a control group of 50 patients with normal coronary arteries (NCA) were prospectively recruited. Clinical data, admission laboratory parameters, and echocardiographic and angiographic characteristics were recorded. Symptom Checklist 90 Revised (SCL-90-R), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) scales were administered to each patient. RESULTS: The groups were comparable with respect to age, sex, and atherosclerotic risk factors. In the CSF group, BAI score, BDI score, and general symptom index were significantly higher than controls (13 [18.7] vs. 7.5 [7], p = 0.01; 11 [14.7] vs. 6.5 [7], p = 0.01; 1.76 [0.81] vs. 1.1[0.24], p = 0.01; respectively). Patients with CSF in more than one vessel had the highest test scores. In univariate correlation analysis, mean thrombolysis in myocardial infarction (TIMI) frame counts were positively correlated with BAI (r = 0.56, p = 0.01), BDI (r = 0.47, p = 0.01), and general symptom index (r = 0.65, p = 0.01). The psychiatric tests were not correlated with risk factors for atherosclerosis. CONCLUSION: Our study revealed higher rates of depression, anxiety, and overall psychological distress in patients with CSF. This conclusion warrants further studies.

Assessment of electrocardiographic parameters in patients with electrocution injury.

BACKGROUND: Electrocution injury (EI) is a major problem in developing countries. The aim of this study is to investigate the effect of EI on electrocardiographic (ECG) parameters. METHODS: A total of 43 patients hospitalized with diagnosis of EI were prospectively enrolled. Admission ECGs were compared with follow-up ECGs obtained one month after the event. RESULTS: Maximum P wave duration (Pmax), minimum P wave duration (Pmin), P wave dispersion (PWD), PR interval, QRS complex duration, corrected QT duration (QTc), QT dispersion (QTD), T peak to T end (Tp-e) interval were longer and Tp-e interval/QT and Tp-e interval/QTc ratios were higher on admission ECGs compared to follow-up ECGs. Frontal QRS-T angle and frequency of patients with fragmented QRS were also higher on admission ECGs. CONCLUSION: Our study revealed that EI causes significant deterioration of admission ECG parameters. The clinical use of these parameters in prediction of arrhythmias after EI warrants further studies.

The independent association of plateletcrit with long-term outcomes in patients undergoing primary percutaneous coronary intervention.

PURPOSE: Platelets play a key role in the genesis of thrombosis. Plateletcrit (PCT) provides complete information on total platelet mass. The relationship between PCT values and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary angioplasty is not known. We sought to determine the effect of PCT values on the outcomes of primary angioplasty for STEMI. METHODS: Overall, 2572 consecutive STEMI patients (mean age, 56.6±11.8 years) undergoing primary percutaneous coronary intervention were enrolled retrospectively into the present study. Plateletcrit at admission was measured as part of the automated complete blood count. Patients were classified into 2 groups: high PCT (>0.237, n=852) and nonhigh PCT (<0.237, n=1720). Clinical characteristics and in-hospital and long-term (median, 21 months) outcomes of primary angioplasty were analyzed. RESULTS: A higher in-hospital shock rate was observed among patients with high PCT values compared with those with nonhigh PCT values (6.5 vs 3.8%, respectively; P=.003). The long-term cardiovascular prognosis was worse for patients with high PCT values (Kaplan-Meier, log-rank test; P=.007). We used Cox proportional hazard models to examine the association between PCT and adverse clinical outcomes. High PCT values were also an independent predictor of cardiovascular mortality (hazard ratio, 1.85; 95% confidence interval, 1.061-3.22; P=.03). CONCLUSION: High PCT values on admission are independently associated with long-term adverse outcomes in patients with STEMI who undergo primary angioplasty.