Procalcitonin: a marker of heart failure.

OBJECTIVE: Serum procalcitonin levels are associated with congestive heart failure, but are not established biomarkers of the disease. We evaluated the predictive value of serum procalcitonin levels for diagnosing heart failure and assessing its severity. METHODS AND RESULTS: This retrospective, case-control study involved 59 subjects (mean age 59.7-10.1 years; 38 males), including 21 outpa- tients and 19 inpatients with heart failure and left ventricular ejection fractions <45%, and 19 healthy controls. Serum procalcitonin levels were measured and compared among the 3 groups. Procalcitonin levels were significantly higher among inpatients (median [interquartile range], 1.45 [0.25-5.801 ng/mL) than among the outpatients (0.35 [0.001.-1.70] ng/mL; P< 0.001) or controls (0.05 [0.02-0.08] ng/mL; P< 0.0011. Using a procalcitonin cut-off level of 0.09 ng/mL, 35 (87.5%) of the 40 inpatients and outpatients were procalcitonin-positive; all control individuals were procalcitonin-negative. Serum procalcitonin levels differentiated between heart failure patients and healthy controls (sensitivity, 88.9% [95% confidence interval, 75.9-96.2%]; specificity, 100% [82.2-100.0%]; positive predictive value, 100% [91.1-100.0%]; negative predictive value, 79.2% [57.8-92.8%]). Pro calcitonin levels were >0.53 ng/mL in 4/21 (19%) outpatients and in 16/19 (84.2%) inpatients. The sensitivity and specificity of serum procalcitonin levels for differentiating between inpatients and outpatients were 84.2% and 81.0%, respectively (positive predictive value 80% [95% confidence interval, 67.6-92.4%] and 85.0% [73.9-96.1%], respectively). CONCLUSION: Serum procalcitonin levels, showing high sensitivity and specificity for diagnosing and assessing the severity of heart failure in this small study, might be considered ootential heart failure biomarkers.

[A rare complication of cardiac radiofrequency catheter ablation: Esophageal irritation]. / Kardiyak radyofrekans kateter ablasyonunun nadir bir komplikasyonu: Özofagus irritasyonu.

The complication rate of radiofrequency catheter ablation varies depending on patient characteristics and treatment, and has been reported to be approximately 3%. Esophageal irritation is one significant complication of catheter ablation, and its most common result is atrio-esophageal fistulae. However, rarely, unexpected complications and clinical variants occur due to irritation of the vagal nerve or peri-esophageal tissue without fistula formation. In this case report, attention is drawn to this rare complication in two cases, one of which occurred after paraseptal-epicardial accessory pathway ablation, and the other after atrial fibrillation ablation. Both were symptomatic with severe gag reflex.

Evaluation of atrial fibrillation (AF) management and cardiovascular risk profile in AF patients: data from Turkish patients in the international observational cross-sectional REALISE AF trial.

OBJECTIVES: To assess control of atrial fibrillation (AF) and cardiovascular (CV) risk profile of AF patients with previously established AF therapies. STUDY DESIGN: A total of 510 patients (mean (SD) age, 67.1 (12.3) years, 55.1% females) enrolled from 40 centers across Turkey were evaluated on a single-visit basis in terms of patient demographics, characteristics of underlying AF, the frequency and scoring of symptoms according to European Heart Rhythm Association AF cardiac symptoms classification, control of AF, cardiovascular (CV) risk profile, AF treatment and the consistency of current therapeutic practice with evidence-based guidelines. RESULTS: AF was controlled in 39.4% of patients based on sinus rhythm on the day of visit (10.2%) and AF with HR ≤80 bpm (29.2%). Permanent AF was the most commonly identified type of AF (56.0%). Symptoms were evident in 89.2% of patients either before V0 (78.8%) or at V0 (56.5%). Age (72.4%) and hypertension (70.0%) were the leading CV risk factors. Rate-control and rhythm-control strategies were chosen in 76.5 and 19.2% of patients at the enrollment visit. Mean (SD) of EQ-5D scores for VAS and for single index utility were 63.1 (19.8) and 0.62 (0.4), respectively. CONCLUSION: In this real life survey of AF patients from Turkey participating in the global contemporary, international, observational, cross-sectional REALISE AF survey, AF was determined to be not optimally controlled, leading patients to experience frequent symptoms, functional impairment and altered QoL,as well as frequent hospital admissions for cardiovascular events and a high requirement for procedures.

Evaluation of Treatment Safety in Patients with Atrial Fibrillation on Edoxaban Therapy in Real-Life in Turkey Study: Design and Rationale.

OBJECTIVE: Safety and effectiveness of edoxaban was demonstrated in phase III, Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48 (ENGAGE-AF-TIMI 48) trial and is being confirmed in the post-authorization Edoxaban Treatment in routiNe clinical prActice for patients with Atrial Fibrillation in Europe (ETNA-AF-Europe) study in patients with atrial fibrillation. However, any post-authoriza tion safety study focusing on the safety of edoxaban treatment in Turkey with a prospective design has not been performed yet. The Evaluation of Treatment Safety in Patients with Atrial Fibrillation on Edoxaban Therapy in Real-Life in Turkey (ETAF-TR) study is designed to evaluate the safety and effectiveness of edoxaban treatment in atrial fibrillation in routine practice. The present article describes the design and rationale for the ETAF-TR Study. METHODS: The ETAF-TR (NCT04594915) is a national, multicenter, prospective, observational study that enrolled 858 patients from 32 centers. The primary outcome of the ETAF-TR study is any overt bleeding (consisting of major bleeding or clinically relevant nonmajor bleeding or any bleeding that does not meet this definition but is considered as overt bleeding by the par ticipating physician). Effectiveness, treatment persistence, and posology will also be evaluated in an explorative manner. The overall duration of follow-up will be 1 year; the first patient was enrolled in August 2020. CONCLUSIONS: Results of ETAF-TR will add data from clinical practice to those from ENGAGE-AF trial and also ETNA-AF study. Comparing their results will enable to test the external validity of ENGAGE-AF trial in the country conditions.

The effect of sinus rhythm restoration on high-sensitivity C-reactive protein levels and their association with long-term atrial fibrillation recurrence after electrical cardioversion.

OBJECTIVE: Recent studies have shown that high-sensitivity C-reactive protein (hs-CRP) measured before cardioversion (CV) plays a significant role in predicting atrial fibrillation (AF) relapse. The time course of changes in hs-CRP after successful electrical CV remains controversial. The aim of the present study was to assess the prognostic value of pre- and post-CV hs-CRP levels in predicting the long-term risk of AF. Additionally, we evaluated changes in hs-CRP levels over time following a successful CV. METHODS: This prospective study comprised 216 patients with persistent AF who underwent CV (mean age 51.94 ± 8.07 years; 55.6% men). hs-CRP levels were examined in all patients, and blood samples were taken prior to and 1, 2, 7 and 30 days after CV. AF relapse was determined by 24-hour ambulatory electrocardiogram (ECG) monitoring and 12-lead standard ECG during 12 months of follow-up. We further divided the study population into two groups according to their rhythm at the end of the follow-up period (group A: patients with AF at the end of follow-up; group B: patients with sinus rhythm at the end of the follow-up period). RESULTS: The AF recurrence rate was 42.2% throughout the 12-month follow-up period. The basal hs-CRP levels were higher in patients with an AF relapse than in those without (1.68 ± 0.57 vs. 1.12 ± 0.53 mg/dl; p < 0.01). The hs-CRP levels were significantly decreased at 30 days in group B, whereas there was no significant decrease in group A (from 1.12 ± 0.53 to 0.69 ± 0.33 mg/dl, p < 0.01, and from 1.68 ± 0.57 to 1.69 ± 0.76 mg/dl, p > 0.05, respectively). By multivariate Cox analysis, the independent predictors of AF relapse time points were the basal and day-2 hs-CRP levels. Receiver operating characteristic curve analysis showed that the cutoff value of hs-CRP on the 2nd day for predicting AF relapse was 1.85 mg/dl, with a sensitivity of 62%, a specificity of 82%, a positive predictive value of 85.7% and a negative predictive value of 81.6%. CONCLUSION: The hs-CRP levels both prior to and after CV predict the long-term risk of AF relapse. In the present study, hs-CRP levels were significantly decreased in patients who remained in sinus rhythm at the end of the study. In contrast, hs-CRP levels remained high throughout the follow-up in patients with an AF relapse.

[Evaluation of epidemiologic data, concomitant cardiovascular risk factors, treatment strategies and the current atrial fibrillation registry: RealiseAF]. / Atriyal fibrilasyonun epidemiyolojik verileri, eslik eden kardiyovasküler risk faktörleri, tedavi stratejilerinin degerlendirilmesi ve güncel atriyal fibrilasyon kayit çalismasi: RealiseAF.

As a supraventricular arrhythmia characterized by uncoordinated atrial activation and consequent loss of atrial mechanical function, atrial fibrillation (AF) has been considered to be a significant public health problem with its age-dependent demographic trend for both patients and health care system. Randomized trials on electrophysiological mechanisms, treatment with antiarrhyhtmic/anticoagulant drugs and non-pharmacological treatment have provided considerable insight into the nature and treatment of the disease leading to novel promising therapeutic options in the management of patients with AF. Comprehension of the epidemiology and natural course of AF seems to be crucial in developing new treatment strategies to limit burden of the disease on the population and also for fair distribution of resources. The aim of this review was to evaluate AF in terms of its incidence, prevalence, concomitant cardiovascular risk factors, and treatment strategies with special emphasis on current real-life challenges in disease management.

Impact of image integration on clinical and procedural outcomes of radiofrequency catheter ablation of atrial fibrillation: A meta-analysis of randomized controlled trials.

BACKGROUND: The purpose of this meta-analysis was to evaluate the impact of image integration technique on clinical and procedural outcomes in patients undergoing radiofrequency catheter ablation of atrial fibrillation with a three-dimensional electroanatomic mapping system. METHODS: Randomized controlled trials were identified through a systematic literature search of PubMed and CENTRAL databases from inception to April 2020. The primary outcome was arrhythmia recurrence during the follow-up period. The secondary outcomes were the difference in total procedural time and fluoroscopy time. RESULTS: Four studies with a total of 749 patients were included. The pooled result showed no statistically significant difference between the groups with respect to arrhythmia recurrence (RR, 0.75; 95% CI, 0.47-1.21), fluoroscopy time (MD, -6 minutes; 95% CI, -23.4 to 11.3), and total procedural time (MD, 1.1 minutes; 95% CI, -31.8 to 34.1). CONCLUSION: Image integration to guide radiofrequency catheter ablation for patients with atrial fibrillation does not improve clinical and procedural outcomes.

Inappropriate sinus tachycardia - successful treatment with ivabradine.

Inappropriate sinus tachycardia (IST) is characterised by an exaggerated increase of heart rate in response to normal physiologic demands. Therapeutic options including medical and radiofrequency ablation interventions are still under debate. Ivabradine inhibits spontaneous pacemaker activity of the sinus node by selectively blocking If channels of pacemaker cells. Here we present a case of a patient with IST, who was successfully treated with ivabradine after various ineffective therapeutic approaches.

A rare complication of radiofrequency catheter ablation of left atrial tachycardia: atrial septal dissection and left atrial hematoma formation.

A 52-year-old man with left atrial tachycardia underwent radiofrequency catheter ablation. A steerable 4-mm-tip ablation catheter was advanced into the left atrium through a patent foramen ovale without transseptal puncture. However, the tip of the catheter was stuck in a structure. A pull-back maneuver rendered the catheter free and the procedure was cancelled. Transthoracic and transesophageal echocardiograms obtained immediately after the procedure showed intimal layer dissection in the interatrial septum and intramural hematoma formation throughout the anterior left atrial wall. The patient was in stable condition. Therefore, he was followed-up conservatively with serial echocardiographic examinations. The dissected intimal layer disappeared in 10 days and the hematoma underwent near-complete resolution in three months. This case highlights a rare complication of catheter ablation procedure that all interventionists should be familiar with.

Migration of the breakthrough: the advantage of noncontact mapping in targeting inappropriate sinus tachycardia.

We report on a 42-year-old female patient with inappropriate sinus tachycardia (IST), in whom an effective sinus node modification was made by using the noncontact mapping system. The patient was admitted with palpitations and a heart rate between 90-110 beats per minute (bpm). Her heart rate increased to 150 bpm during minimal exercise. After confirming the diagnosis of IST by an electrophysiological study, radiofrequency catheter ablation was performed. A color-coded isopotential map was created when the heart rate was 95 bpm and the initial breakthrough of the sinus node (SNB) was labeled. After administration of isoproterenol, a new color-coded map recording was created when the heart rate reached 160 bpm, showing a new breakthrough 24 mm away from the SNB. Radiofrequency was delivered to this region and the heart rate decreased to 120 bpm. After another infusion of isoproterenol, the maximum heart rate reached 140 bpm and another isopotential map recording was created, which demonstrated migration of the breakthrough 16 mm away from the SNB. Radiofrequency was delivered to the second site and the heart rate decreased to 90 bpm and increased to a maximum of 120 bpm after a new isoproterenol infusion. A subsequent infusion caused no increase in the heart rate, and the ablation procedure was terminated. During a follow-up of one year, the patient was in sinus rhythm with a mean heart rate of 80 bpm.

[A case of asymptomatic Brugada syndrome with type 1 ECG pattern and cardiac arrest: an evaluation of the prognostic value of electrophysiologic study]. / Asemptomatik, tip 1 EKG bulgulari olan ve ani kalp durmasi gelisen Brugada sendromlu bir olgu: Elektrofizyolojik çalismanin prognoz belirleme üzerine etkisinin irdelenmesi.

Brugada syndrome is characterized by ST-segment elevation in the leads V1-3 of electrocardiography (ECG) in the absence of a structural heart disease. A 26-year old male patient was admitted with sudden cardiac arrest. Cardiopulmonary resuscitation was successful and he was referred to the reanimation unit due to unconsciousness. A year before, he was diagnosed as having Brugada syndrome with type 1 ECG pattern at another center, at which time electrophysiologic study (EPS) was not performed due to lack of symptoms and a family history of sudden cardiac death. In addition, family screening revealed two asymptomatic brothers having Brugada syndrome with type 1 ECG pattern. Medical follow-up was recommended to one of them. The other sibling underwent EPS at a different center where ventricular fibrillation was induced. An implantable cardioverter defibrillator (ICD) was recommended, but the patient refused. A further analysis of the family made at our center showed type 2 ECG changes in the father and in one of the cousins. Due to the development of persistent brain injury and an expected survival of less than a year, an ICD was not considered in the patient. The prognostic value of EPS is still controversial in asymptomatic patients with type 1 Brugada syndrome, without a family history of sudden cardiac death.

[Arrhythmogenic right ventricular cardiomyopathy mimicking right ventricular outflow tract tachycardia]. / Sag ventrikül çikis yolu tasikardisini taklit eden aritmojenik sag ventrikül kardiyomiyopatisi.

Ventricular tachycardia may be mistaken for right ventricular outflow tract tachycardia in patients with arrhythmogenic right ventricular cardiomyopathy. A 27-year-old man had complaints of palpitation and syncope. The admission electrocardiogram (ECG) showed sustained monomorphic ventricular tachycardia with left bundle branch block and inferior axis morphology. The ECG obtained during sinus rhythm was normal. Transthoracic echocardiography showed both ventricles in normal function and size. During electrophysiologic study, ventricular tachycardia was induced consistent with the clinical tachycardia. It was thought to originate from the left ventricular outflow tract and was terminated by radiofrequency ablation. However, the patient presented again, after a year, complaining of palpitations. The admission ECG was similar to that obtained before with sustained ventricular tachycardia, whereas the ECG during sinus rhythm showed negative T waves in leads V1-3. During electrophysiologic study, another ventricular tachycardia was induced with left bundle branch block and horizontal axis morphology as well as that consistent with the clinical tachycardia. The former was terminated spontaneously. The presence of a different morphology and negative T waves on the ECG suggested arrhythmogenic right ventricular cardiomyopathy. On angiography, the right ventricle was dilated and hypocontractile. Cardiac magnetic resonance imaging confirmed the diagnosis by showing decreased wall thickness and wall motion abnormality in the right ventricle.

[The effect of admission mean platelet volume on TIMI frame count measured after fibrinolytic therapy in patients with acute ST-segment elevation myocardial infarction]. / ST-Segment yükselmeli akut miyokart enfarktüslü hastalarda basvuru sirasindaki ortalama trombosit hacminin fibrinolitik tedavi sonrasi TIMI kare sayisi üzerine etkisi.

OBJECTIVES: Mean platelet volume has been reported as a predictor of unfavorable prognosis in patients with ST-segment elevation myocardial infarction (MI). We evaluated the relationship between admission mean platelet volume and the response to fibrinolytic therapy using the TIMI frame count in patients with acute ST-segment elevation MI. STUDY DESIGN: The study included 87 patients (58 males, 29 females; mean age 55+/-11 years) who received fibrinolytic therapy within the first 12 hours of symptom onset for acute ST-segment elevation MI. Venous blood samples were obtained to determine admission mean platelet volume and fibrinolytic therapy was administered. Coronary angiography was performed within the first 72 hours and the TIMI frame count was measured for infarct-related artery. TIMI frame counts of <40 and >or=40 were defined as complete and incomplete reperfusion, respectively. RESULTS: Reperfusion was complete in 35 patients (40.2%) and incomplete in 52 patients (59.8%). The mean TIMI frame counts were 31.8+/-5.9 and 61.2+/-15.3 in patients with complete and incomplete reperfusion, respectively (p<0.01). Patients with complete reperfusion had a significantly lower mean platelet volume (9.4+/-0.4 fl vs. 9.7+/-0.3 fl; p=0.016). There was a highly significant correlation between mean platelet volume and incomplete reperfusion (r=0.742, p<0.0001). CONCLUSION: High levels of admission mean platelet volume might be associated with insufficient reperfusion response to fibrinolytic therapy in patients with acute ST-segment elevation MI.

Platelet to lymphocyte ratio predicts all-cause mortality in patients with carotid arterial disease.

BACKGROUND: Platelet to lymphocyte ratio (PLR) has been demonstrated as a risk and prognostic marker in many of cardiovascular diseases. A relationship between PLR and severity of carotid stenosis has been shown. The aim of our study was to investigate the relationship between PLR and all cause mortality in patients with carotid arterial disease. METHODS: This retrospective study included 146 patients who had been performed selective carotid angiography. Carotid stenosis were graded by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Platelet to lymphocyte ratio was calculated as the ratio of platelets to lymphocytes. The end point of the study was all-cause mortality. RESULTS: During median follow-up of 16 months (0-65 months) 15 (10.3%) patients suffered all-cause mortality. 50 patients (34.2%) underwent carotid endarterectomy and 69 patients (47.3%) had non-carotid cardiac surgery. 38 patients (26.02%) had cerebrovascular events (stroke/transient ischemic attack) at admission. NASCET grades were not different between survivors and non-survivors. Non-survivors had significantly lower hemoglobin (Hb) levels (12.7 ± 1.6 g/dL vs. 13.7 ± 1.7 g/dL, p = 0.031) and they were older than survivors (74.2 ± 8.4 years vs. 68.6 ± 8.5 years, p = 0.029). Non-survivors had significantly higher PLR values compared with survivors (190.3 ± 85.6 and 126.8 ± 53.8, p = 0.017). In multivariate analysis, only PLR predicted all-cause mortality in patients with carotid artery stenosis. CONCLUSION: In our study, higher PLR was associated with increased all-cause mortality.

The Usefulness of Admission Plasma NT-pro BNP Level to Predict Left Ventricular Aneurysm Formation after Acute ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Left ventricular aneurysm (LVA) is an important complication of acute myocardial infarction. In this study, we investigated the role of N- Terminal pro B type natriuretic peptide level to predict the LVA development after acute ST-segment elevation myocardial infarction (STEMI). METHODS: We prospectively enrolled 1519 consecutive patients with STEMI. Patients were divided into two groups according to LVA development within the six months after index myocardial infarction. Patients with or without LVAs were examined to determine if a significant relationship existed between the baseline N- Terminal pro B type natriuretic peptide values and clinical characteristics. A p-value < 0.05 was considered statistically significant. RESULTS: LVA was detected in 157 patients (10.3%). The baseline N- Terminal pro- B type natriuretic peptide level was significantly higher in patients who developed LVA after acute MI (523.5 ± 231.1 pg/mL vs. 192.3 ± 176.6 pg/mL, respectively, p < 0.001). Independent predictors of LVA formation after acute myocardial infarction was age > 65 y, smoking, Killip class > 2, previous coronary artery bypass graft, post-myocardial infarction heart failure, left ventricular ejection fraction < 50%, failure of reperfusion, no-reflow phenomenon, peak troponin I and CK-MB and NT-pro BNP > 400 pg/mL at admission. CONCLUSIONS: Our findings indicate that plasma N- Terminal pro B type natriuretic peptide level at admission among other variables provides valuable predictive information regarding the development of LVA after acute STEMI.

[Clinical importance of cardiac troponins]. / Kardiyak troponinlerin klinik önemi.

Cardiac troponins (cTn) are highly sensitive and specific markers of myocardial injury. Elevated cTn levels have considerable significance in both prognosis and guidance of the therapy of acute coronary syndrome. Thus, cTn measurements are commonly utilized in coronary care units and emergency departments to diagnose acute coronary syndrome. However, it must be considered that cTn elevations may be seen in many diseases other than acute coronary syndrome. In this article, we reviewed the clinical syndromes associated with elevated cTn levels.

[Obstructive sleep apnea syndrome and cardiac arrhythmias]. / Obstrüktif uyku apnesi sendromu ve kardiyak aritmi.

Obstructive sleep apnea syndrome (OSAS) refers to recurring episodes of upper respiratory track obstruction and frequent decreases in arterial oxygen saturation due to repetitive occlusions of the posterior pharynx during sleep. Its prevalence in adult population is 4% in men and 2% in women. The most important causes of morbidity and mortality in affected patients are traffic accidents and cardiovascular complications including systemic arterial hypertension, coronary artery disease, congestive heart failure, and cardiac arrhythmias. The initial phases of apnea are associated with a transient increase in the parasympathetic activity resulting in bradyarrhythmias, followed by tachycardias due to increased sympathetic activity and arousal after the end of apnea episodes. The most frequent arrhythmia in OSAS is cyclic variation of heart rate. Most of the arrhythmias seen in OSAS are secondary to OSAS and disappear with OSAS treatment, without any electrophysiological conduction system abnormalities.

Single coronary artery anomaly: a report of three cases.

We presented three cases of anomalous single coronary artery detected incidentally during routine coronary angiography. The presenting symptoms were chest pain, angina pectoris, and exertional chest pain, respectively. In one case (male, 69 years), the single coronary artery gave off branches to the left anterior descending artery, left circumflex (LCx) artery, and right coronary artery (RCA) (type L-I). There were no atherosclerotic lesions. The patient's chest pain was thought to have a noncardiac origin and it did not recur during a 12-month follow-up. In another case (male, 65 years), the single coronary artery originated from the right sinus of Valsalva, and gave off branches to the RCA and the left coronary system (type R-I). The patient underwent coronary artery bypass surgery for significant stenotic lesions in the LCx and RCA. He was free of angina pectoris within 12 months after surgery. In the third case (female, 48 years), a single coronary ostium gave branches to the right and left coronary systems (type R-II-B). As the course of the coronary artery was between the aorta and pulmonary artery, surgery was recommended, but the patient refused surgery.