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Heart failure (HF) has been classified as reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF) by the recent HF guidelines. In addition, HF with improved ejection fraction has been defined as a subgroup of HFrEF. In HFrEF, diagnostic workup and evidence-based pharmacological and device-based therapies have been well established. However, HFpEF, which comprises almost half of the HF population, represents significant uncertainties regarding its pathophysiology, clinical phenotypes, diagnosis and treatment. Diagnostic criteria of HFpEF have been changed a few times over the years and still remained a matter of debate. New paradigms including a prominent role of co-morbidities, inflammation, endothelial dysfunction have been proposed in its pathophysiology. As a complex, multifactorial syndrome HFpEF consists of many overlapping clinical and hemodynamic phenotypes. In contrast to HFrEF, clinical outcomes of HFpEF have not improved over the last decades due to lack of proven effective therapies. Although HFrEF and HFpEF have different clinical spectrums and proposed pathophysiological mechanisms, there is no clear defining syndrome postulated for HFmrEF. Clinical characteristics and risk factors of HFmrEF overlap with HFrEF and HFpEF. HFmrEF is also referred as a transitional zone for dynamic temporal changes in EF. So, HFpEF and HFmrEF, both namely HF with non-reduced ejection fraction (HF-NEF), have some challenges in the management of HF. The purpose of this paper is to provide a comprehensive review including epidemiology, pathophysiology, clinical presentation and phenotypes of HF-NEF and to guide clinicians for the diagnosis and therapeutic approaches based on the available data in the literature.

Hyperkalemia is a common electrolyte abnormality in heart failure (HF) that can cause potentially life-threatening cardiac arrhythmias and sudden cardiac death. HF patients with diabetes, chronic kidney disease and older age are at higher risk of hyperkalemia. Moreover, hyperkalemia is also often associated with the use of renin-angiotensin-aldosterone system inhibitors (RAASi) including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists and sacubitril-valsartan. In clinical practice, the occurrence of hyperkalemia is a major concern among the clinicians and often limits RAASi use and/or lead to dose reduction or discontinuation, thereby reducing their potential benefits for HF. Furthermore, recurrent hyperkalemia is frequent in the long-term and is associated with an increase in hyperkalemia-related hospitalizations. Therefore, management of hyperkalemia has a special importance in HF patients. However, treatment options in chronic management are currently limited. Dietary restriction of potassium is usually ineffective with variable adherence. Sodium polystyrene sulfonate is commonly used, but its effectiveness is uncertain and reported to be associated with intestinal toxicity. New therapeutic options such as potassium binders have been suggested as potentially beneficial agents in the management of hyperkalemia. This document discusses prevalence, predictors and management of hyperkalemia in HF, emphasizing the importance of careful patient selection for medical treatment, uptitration of the doses of RAASi, regular surveillance of potassium and treatment options of hyperkalemia.

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

Objective: The aim of this study was to determine the relationship of left atrial appendage (LAA) mechanics assessed using 2-dimensional (2D)-strain analysis of the gray scale images obtained during transesophageal echocardiography (TEE) to the conventional LAA functional parameters, CHA2DS2-VASc score, and the presence of spontaneous echo contrast (SEC) and/or LAA thrombus in patients with non-valvular atrial fibrillation (AF)., Methods: The study included 126 patients with AF and 30 controls with a sinus rhythm who were referred for TEE. The global, medial, lateral and apical LAA longitudinal 2D-strain of all patients and the CHA2DS2-VASc score of AF patients were evaluated., Results: The global, medial, lateral, and apical LAA longitudinal 2D-strain results of AF patients were significantly lower than those of the controls and revealed moderate but significant correlations with LAA flow velocity and LAA area change. Patients with a CHA2DS2-VASc score of 0 or 1 had the highest LAA 2D-strain values and the results revealed that the LAAemptying velocity and LAA lateral and medial 2D-strain values were independent correlates of CHA2DS2-VASc score. SEC was detected in 84 patients, of whom, 42 had dense SEC and 27 had thrombus in the LAA. Multivariate analysis indicated that LAA emptying velocity, LAA area change, and LAA medial 2D-strain were independently associated with the presence of dense SEC/thrombus. In ROC analysis, cut-off values for global, medial, apical, and lateral 2D-strain for the presence of dense SEC/ thrombus were 6.0% p=0.011), 8.0% (p=0.032), 6.0% (p=0.033), and 5.4% (p=0.004), respectively., Conclusion: Global and regional LAA mechanics were significantly related to conventional LAA functional parameters and to the presence of LAA-dense SEC/thrombus in patients with AF and may be useful as complementary data for estimating future thromboembolism.

Objective: Dyslipidemias, primarily hypercholesterolemia, are independent and strong predictors of cardiovascular (CV) events. The frequency of dyslipidemia is very important in terms of determining CV prevention policies. In order to determine the up-to-date frequency of CV risk factors in Turkey, a meta-analysis of the epidemiologic studies carried out in the last 15 years was performed. This article presents the results on the dyslipidemia data including hypercholesterolemia principally., Methods: Epidemiological studies conducted during the last 15 years and having the potential to represent the general population in Turkey were searched in databases (Ovid Medline, Web of Science Core Collection, and Turkish Academic Network and Information Center [ULAKBIM]) and web pages (Ministry of Health, Turkey Statistical Institute, Turkish Society of Cardiology, Nephrology and Endocrinology Associations). A total of 7 studies including lipid data were found. Systematic review and meta-analysis of the studies with low bias score were performed. Crude values of the prevalence of hypercholeterolemia, hypertriglyceridemia and low HDL and mean lipid levels were calculated. Random effects model was used in meta-analysis., Results: The prevalence of hypercholesterolemia defined as a LDLcholesterol >130 and/or ≥130 mg/dL, was 29.1% (95% CI 23.6-35.0) in the general population, 30.2% in females (%95 CI 24.7-36.1), and 27.8% in males (95% CI 22.3-33.6). The prevalence of low HDLcholesterol (≤50 mg/dL for females and ≤40 mg/dL for males) was calculated as 46.1% (95% CI 42.4-49.9) in the whole group, 50.7% (95% CI 47.7-53.6) in females and 41.1% (95% CI 36.1-46.3) in males. The prevalence of hypertriglyceridemia (>150 mg/dL) was 36.5% (95% CI 30.6-42.5) in general, 32.0% (95% GA 26.6-37.8) in females and 41.3% (95% CI 34.9-47.8) in males., Conclusion: Dyslipidemia constitutes a major public health problem in Turkey. In the adult population, almost 3 of 10 have hypercholesterolemia, one of 2 has a low HDL-cholesterol, and 1 of 3 has high triglycerides levels.

Objective: Obesity is the most important epidemic of the 21st century and its incidence is increasing steadily in Turkey. The aim of this study was to assess the current status and temporal change in the prevalence of obesity in Turkey with a systematic review and metaanalysis of epidemiological studies conducted in the last 15 years., Methods: Ovid Medline, the Web of Science Core Collection and the Turkish Academic Network and Information Center (ULAKBIM) databases, as well as the web pages of the Turkish Ministry of Health, the Turkish Statistical Institute, and cardiology, nephrology and endocrinology associations were searched for epidemiological studies conducted within Turkey the last 15 years. Research focusing on local data was excluded. Studies included in the analysis were assessed with a special bias score and categorized as having low or high risk of bias. Body mass index (BMI), waist circumference, obesity and prevalence of abdominal obesity were calculated as crude values. Meta-regression analysis was performed to assess heterogeneity and change over time., Results: The agreement between the two investigators on the selection and bias scoring of the studies was excellent (kappa=0.95), but the heterogeneity between the studies was high. BMI (10 studies, n=93.554) was calculated as 28.2 kg/m2 for women and 26.5 kg/m2 for men. The prevalence of obesity (12 trials, n=106.553) was 33.2% in females and 18.2% in males. In 6 studies (n=66.591) that included a measurement of waist circumference, the values were 89.72 cm in women and 93.57 cm in men. Especially in women, the prevalence of abdominal obesity (5 studies, n=62331) was greater than that of general obesity (50.8% in women vs 20.8% in men). Meta-regression analysis revealed that the variance of the obesity prevalence between the studies could partly be explained by the age differences, but there was no temporal change in the prevalence of obesity during the years the studies were conducted., Conclusion: The prevalence of obesity, especially abdominal obesity, is considerably high in Turkish women and increases with advancing age. This finding points out that nationwide action plans against obesity, especially for women, should be designed and implemented by health policy makers.

Objective: Cardiovascular risc factors may show significant changes over the years. A systematic review and meta-analysis of epidemiological studies conducted in Turkey was performed to assess the latest profile and temporal changes in cardiovascular risk factors. Presented here are the data on hypertension (HT) and blood pressure (BP)., Methods: Ovid Medline, the Web of Science Core Collection, and the Turkish Academic Network and Information Center (ULAKBIM) were searched for epidemiological studies conducted in Turkey during the last 15 years. In addition, the web pages of the Ministry of Health, the Turkish Statistical Institute, and associations of cardiology, nephrology, and endocrinology were searched for appropriate studies. Regional studies were excluded. The studies included were assessed with a bias score developed by our team, then categorized as having a low risk or a high risk of bias. The crude values of HT prevalence and BP were pooled using a random effects model. Meta-regression was performed to explain heterogeneity and to assess temporal changes., Results: The agreement between the 2 authors on the selection and bias scoring of the studies was perfect (Kappa ≥0.95). There were 7 (n=73218) studies providing HT prevalence data, and 8 (n=75879) studies with BP data. The heterogeneity between the studies was high. Meta-analysis of the studies with a low risk of bias indicated that the crude prevalence of HT is higher in women, but that BP levels were similar in both sexes. The HT prevalence and BP value decreased between 2003 and 2012; however, the number of hypertensives stabilized at approximately 15 million, and the number of uncontrolled hypertensives, despite some decrease, was around 11 million., Conclusion: Despite some improvement, HT is still an important public health problem in Turkey.

Objective: Iron deficiency (ID) is the most common nutritional deficiency, and iron metabolism becomes further deteriorated in the presence of certain conditions, such as heart failure (HF). Atrial fibrillation (AF) has many similarities to HF, including a chronic inflammatory pathophysiology; however, the prevalence of ID and other hematinic deficiencies in AF patients have not been determined., Methods: In this study, the prevalence of iron (serum ferritin <100 µg/L or ferritin 100-299 µg/L with transferrin saturation <20%), vitamin B12 (<200 pg/mL), and folate deficiency (<4.0 ng/mL) was evaluated in 101 patients with non-valvular AF with preserved left ventricular ejection fraction and no signs of HF, and the results were compared with 35 age- and gender-matched controls., Results: Anemia was detected in 26% of the patients. A total of 48 (47.6%) patients had ID, 10 (9.9%) had a vitamin B12 deficiency, and 13 (12.9%) had a folate deficiency. The prevalence of ID was similar in the controls and the paroxysmal AF patients, but increased gradually in persistent and permanent AF. Univariate logistic regression analysis demonstrated that permanent vs. paroxysmal AF [Odds ratio (OR): 2.17; 95% confidence interval (CI): 0.82-5.69; p=0.011], high sensitive C-reactive protein (OR: 1.47; 95% CI: 0.93-2.36; p=0.019), N-terminal pro b-type natriuretic peptide (OR: 1.24; 95% CI: 0.96-1.71; p=0.034), and white blood cell count (OR: 1.21; 95% CI: 0.95-1.58; p=0.041) were associated with ID. In multivariable analysis, permanent AF remained as an independent clinical associate of ID (OR: 4.30; 95% CI: 0.83-12.07; p=0.039)., Conclusion: ID is common in permanent AF, as in HF. Inflammation and neurohormonal activation seem to contribute to its development.

Objective: Peripartum cardiomyopathy (PPCM) is left ventricular (LV) systolic dysfunction with an ejection fraction of ≤45% occurring in the later stages of pregnancy or soon after delivery. Although various risk factors have been identified, the exact cause of the disease is unknown. Unlike most countries in the European region, Turkey has yet to determine the current PPCM burden. A registry for this purpose does not exist. To close this gap, the A RegisTry of pEripartuM cardIomyopathy in Turkish patientS (ARTEMIS-I and ARTEMIS-II), was planned and endorsed by the Turkish Society of Cardiology. The aim of this manuscript is to describe the rationale and design of the ARTEMIS-I and ARTEMIS-II registries., Methods: ARTEMIS was designed to be the nationwide PPCM registry of Turkey, with the goal of identifying problems and opportunities while improving quality and consistency in the medical care of PPCM patients. A second goal is to determine the clinical characteristics pertinent to patients in this region. The ARTEMIS registry will consist of 2 arms. All secondary and tertiary cardiology centers have been electronically invited to participate in ARTEMIS-I, which will be conducted to assess the current standard of care and outcome measures. Centers will be asked to enroll PPCM patients admitted to their clinic in last 5 years retrospectively. Eligibility criteria will consist of pregnant or early postpartum woman without a previous history of heart failure (HF) or known pathology associated with HF, LV ejection fraction ≤45%, and exclusion of other causes of LV systolic dysfunction. ARTEMIS-II will consist of the prospective enrollment of patients., Conclusion: The nationwide PPCM registries, ARTEMIS-I and ARTEMIS-II, are designed to determine the current status of medical care, provide insights into nature of the disease, and suggest solutions on how to improve care and outcomes in these patients.

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors´ Network of the European Society of Cardiology.

Heart failure is an important community health problem. Prevalence and incidence of heart failure have continued to rise over the years. Despite recent advances in heart failure therapy, prognosis is still poor, rehospitalization rate is very high, and quality of life is worse. Co-morbidities in heart failure have negative impact on clinical course of the disease, further impair prognosis, and add difficulties to treatment of clinical picture. Therefore, successful management of co-morbidities is strongly recommended in addition to conventional therapy for heart failure. One of the most common co-morbidities in heart failure is presence of iron deficiency and anemia. Current evidence suggests that iron deficiency and anemia are more prevalent in patients with heart failure and reduced ejection fraction, as well as those with heart failure and preserved ejection fraction. Moreover, iron deficiency and anemia are referred to as independent predictors for poor prognosis in heart failure. There is strong relationship between iron deficiency or anemia and severity of clinical status of heart failure. Over the last two decades, many clinical investigations have been conducted on clinical effectiveness of treatment of iron deficiency or anemia with oral iron, intravenous iron, and erythropoietin therapies. Studies with oral iron and erythropoietin therapies did not provide any clinical benefit and, in fact, these therapies have been shown to be associated with increase in adverse clinical outcomes. However, clinical trials in patients with iron deficiency in the presence or absence of anemia have demonstrated considerable clinical benefits of intravenous iron therapy, and based on these positive outcomes, iron deficiency has become target of therapy in management of heart failure. The present report assesses current approaches to iron deficiency and anemia in heart failure in light of recent evidence.

Objective: Depression frequently occurs in patients with heart failure as similar pathophysiological mechanisms present in both these diseases. Patients with dilated cardiomyopathy (DCM) have a high incidence of clinically asymptomatic silent cerebral infarction (SCI). This study aimed to evaluate the relation between SCI and major depressive disorder (MDD), and between MDD and clinical and biochemical parameters in DCM patients., Methods: Patients with ischemic and non-ischemic DCM who had chronic heart failure (CHF) (39 male, 10 female, age 60±10 years) were included in the study. Mean patient ejection fraction (EF) was 34±10%. Patients had no localized neurological symptoms or stroke history. The etiology of DCM was ischemic in 40 and non-ischemic in 9 patients. Twenty-five age-matched healthy volunteers served as a control group for comparison of SCI and MDD prevalence., Results: Patients had mild to severe CHF symptoms. Prevalence of SCI and MDD was significantly higher in patients with DCM than in the control group; 63% vs 8%; p<0.001, and 52% vs 20%; p<0.001 respectively. Patients with SCI had a higher prevalence of MDD than patients without SCI in DCM (61% vs 27%, p=0.02)., Conclusion: CHF patients have an increased prevalence of SCI and MDD. Patients with SCI have a higher prevalence of MDD compared to patients without SCI in CHF.

Objective: In heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients., Methods: The Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms., Results: Patient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients., Conclusion: The present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.

Objectives: Chronic heart failure (CHF) has been associated with an increased risk of poorer cognitive performance in older adults. Reversibility of cognitive impairment after medical treatment has been reported, although the restorative effects of enhanced external counterpulsation (EECP) on cognitive performance have not been studied. We investigated the effect of EECP on cognitive functions in CHF patients., Study Design: Thirty-six individuals (mean age: 66±8 years) who were diagnosed with CHF and were New York Heart Association (NYHA) Class II-III and Canadian Cardiovascular Society (CCS) Class II-III participated in this study. Neuropsychological assessment was performed in these patients., Results: Patients in the EECP treatment group showed a statistically significant improvement in spontaneous naming (p=0.011) and forward row score of the attention subset among domains of cognition (p=0.020) and interference time of executive function (p=0.012)., Conclusion: Enhanced external counter pulsation resulted in improvement in all domains of cognitive functions except verbal and visual memory tests.

Women are under-represented in landmark clinical trials that form the basis of evidence based management of cardiovascular diseases. Differences among male and female patients emerged in effectiveness and safety of therapeutics in some diseases. Especially in dyslipidemia, ischemic heart diseases and heart failure, trials in which women are better represented and guidelines that evaluate findings in women more detailed are needed. This article evaluates differences among men and women in some landmark trials that are used among main references in management guidelines.

The inhibition of renin-angiotensin system (RAS) has an effect beyond reducing blood pressure in the treatment of cardiovascular diseases; it also reduces mortality and morbidity. Although the classic RAS blockage is effective, due to blockage of negative feedback inhibition, it increases plasma renin activity and as a result generates a residual cardiovascular risk. Different from ACE-i and ARB treatments, aliskiren, a direct renin inhibitor, is the only pharmacologic agent that noticeably reduces the plasma renin activity, an independent cardiovascular risk factor. This creates a new option in RAS blockage. The efficacy and safety of aliskiren in the treatment of hypertension has been well established. The effect of aliskiren on cardiovascular mortality and morbidity is being researched. At this point there are many experimental and clinical studies to answer questions on this subject.

Stenosis in the coronary veins can cause failure of left ventricular pacemaker lead implantation, which is the cornerstone of cardiac resynchronization therapy. There are several case reports in which left ventricular pacing could be possible after successful elimination of coronary vein stenosis by stent implantation or cutting balloon angioplasty. We report two cases of left ventricular pacemaker lead implantation after successful balloon angioplasty for posterolateral and posterior vein stenoses, respectively.