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Background: Acute ST-elevation myocardial infarction (STEMI) is an uncommon diagnosis in patients less than 40 years of age. Over the last two decades, there is an increase in the frequency of cardiovascular events among young adults. However, at present there is only limited clinical data on the clinical characteristics and outcomes of STEMI in young patients who were treated with primary percutaneous coronary intervention (pPCI). Plaque erosion is the underlying pathological mechanism leading to STEMI in the vast majority of young adults. Thrombi that complicate superficial erosion seem more platelet-rich than the fibrinous clots precipitated by plaque rupture. Mean platelet volume (MPV) is recognized as a marker of the platelet activation process and may be a better indicator of short-term prognosis than the inflammatory markers in young patients with STEMI. Therefore, we aimed to investigate clinical and angiographic characteristics, risk factors and the independent value of MPV on predicting short-term major adverse cardiovascular events (MACEs) in young adults with STEMI. Methods: A total of 349 patients aged 40 years or younger who underwent pPCI at our center between 2010–2015 with the diagnosis of STEMI were retrospectively analyzed. Results: The mean age of the patients was 36.4 ± 3.6 years and 90% of them were men. Smoking was by far the most frequent cardiovascular risk factor. MACEs were observed in 23 patients (6.6%), and according to the multivariate regression analysis, Killip IIIIV (OR 7.52, 95% CI 1.25–45.24, p = 0.03), lower admission SBP (OR 0.94, 95% CI 0.90–0.98, p

Objectives: Patients with postoperative atrial fibrillation (POAF) have increased risk of both short- and long-term mortality and morbidity; therefore, prediction of POAF is crucial in the preoperative period of the patients undergoing coronary artery bypass graft surgery. Electrocardiography (ECG) is the simplest and cost-effective tool in the preoperative workup of the patients for the prediction of POAF. A newly defined ECG parameter P wave peak time (PWPT) has been shown as a marker of atrial fibrillation development in non-surgical patients and we investigated its role in patients undergoing cardiac surgery., Method: A total of 327 patients undergoing isolated or combined cardiac surgery were involved and the primary endpoint was defined as the development of POAF. The study population was divided into two groups based on the presence or absence of POAF. Groups were compared for both standard P wave parameters and for PWPT on surface ECG. The predictors of POAF were assessed by multivariate regression analysis., Results: The frequency of POAF was 20.4% (n = 67). P wave peak time in leads D2 (65.1 ± 11.8 vs 57.2 ± 10, p < 0.01) and V1 (57.8 ± 18 vs 44.8 ± 12.3, p < 0.01) were longer in patients with POAF. In multivariate regression analysis, PWPT in leads DII and V1 were independent predictors of POAF (OR: 1.11, 95%CI: 1.02-1.21, p = 0.01, OR: 1.06, 95%CI: 1.00-1.13, p = 0.03 respectively)., Conclusion: PWPT in leads DII and V1 can predict the development of POAF in patients undergoing cardiac surgery., (© 2021. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Background: Infective endocarditis (IE) is still a significant cause of morbidity and mortality among cardiovascular diseases. ENDOCARDITIS-TR study aims to evaluate the compliance of the diagnostic and therapeutic methods being used in Turkey with current guidelines., Methods: The ENDOCARDITIS-TR trial is a multicentre, prospective, observational study consisting of patients admitted to tertiary centres with a definite diagnose of IE. In addition to the demographic, clinical, microbiological, and echocardiographic findings of the patients, adverse events, indications for surgery, and in-hospital mortality were recorded during a 2-year time interval., Results: A total of 208 IE patients from 7 tertiary centres in Turkey were enrolled in the study. The study population included 125 (60.1%) native valve IE (NVE), 65 (31.3%) prosthetic IE (PVIE), and 18 (8.7%) intracardiac device-related IE (CDRIE). One hundred thirty-five patients (64.9%) were culture positive, and the most frequent pathogenic agent was methicillin-susceptible Staphylococcus aureus (MSSA) (18.3%). Among 155 (74.5%) patients with an indication for surgery, only 87 (56.1%) patients underwent surgery. The all-cause mortality rate was 29.3% in-hospital follow-up. Multivariable Cox regression analysis revealed that absence of surgery when indicated (HR: 3.29 95% CI: 0.93-11.64 p = 0.05), albumin level at admission (HR: 0.46 95% CI: 0.29-0.73 P < 0.01), abscess formation (HR: 2.11 95% CI: 1.01-4.38 p = 0.04) and systemic embolism (HR: 1.78 95% CI: 1.05-3.02 p = 0.03) were ascertained independent predictors of in-hospital all-cause mortality., Discussion: The short-term results of the ENDOCARDITIS-TR trial showed the high frequency of staphylococcal IE, relatively high in-hospital mortality rates, shortage of surgical treatment despite guideline-based surgical indications and low usage of novel imaging techniques. The results of this study will provide a better insight to physicians in respect to their adherence to clinical practice guidelines.

Objective: The effect of malnutrition in patients with ST segment elevation myocardial infarction (STEMI) is not fully understood. In this study, we tried to investigate the prognostic consequence of the Controlling Nutritional Status (CONUT) score in patients with STEMI., Methods: In this study, we evaluated the CONUT scores of 1,028 patients with STEMI and examined its relationship with major adverse cardiovascular events (MACE) (all-cause mortality, myocardial reinfarction, and vessel revascularization) during a period of 19.9±10.3 months. Patients with CONUT score ≥5 were defined as severely malnourished. Predictors of MACE were assessed by Cox regression analysis, and p<0.05 was considered to indicate statistical significance., Results: MACE was observed in a total of 147 (14.3%) patients. MACE was more frequent in the group with a higher CONUT score (33.3% vs. 10.9%, p<0.001). CONUT score ≥5 was an independent predictor of MACE in the Cox regression analysis (hazard ratio=2.50, 95% confidence interval: 1.61-3.90, p<0.001). Low ejection fraction, Killip class ≥3 at presentation, thrombolysis in myocardial infarction flow grade <3 after intervention, left main artery involvement, and low hemoglobin levels were other independent predictors of MACE in the long-term follow-up. Kaplan-Meier curves showed decreased MACE free survival rates in the high CONUT score group at a mean 19.9±10.3 months' follow-up duration (log-rank p<0.01)., Conclusion: Malnutrition was strongly associated with poor outcomes in patients with STEMI treated using primary percutaneous coronary intervention.

Background: Despite the high proportion of octogenarians with acute pulmonary embolism, there is little information indicating the optimal management strategy, mainly therapeutic measures, such as lytic therapy., Objectives: The number of elderly patients diagnosed with acute pulmonary embolism increases constantly. However, the role of thrombolytic treatment is not clearly defined among octogenarians. Our objective is to evaluate the effectiveness of lytic therapy in octogenarian patients diagnosed with pulmonary embolism., Methods: One hundred and forty eight subjects (70.3% women, n=104) aged more than eighty years were included in the study. The patients were divided in two groups: thrombolytic versus non-thrombolytic treatment. In-hospital mortality rates and bleeding events were defined as study outcomes. P-value <0.05 was considered as statistical significance., Results: In-hospital mortality decreased significantly in the thrombolytic group compared to the non-thrombolytic group (10.5% vs. 24.2% p=0.03). Minor bleeding events were more common in the arm that received thrombolytic treatment, but major hemorrhage did not differ between the groups (35.1% vs. 13.2%, p<0.01; 7% vs. 5.5% p=0.71, respectively). High PESI score (OR: 1.03 95%CI; 1.01-1.04 p<0.01), thrombolytic therapy (OR: 0.15 95%CI; 0.01-0.25, p< 0.01) and high troponin levels (OR: 1.20 95%CI; 1.01-1.43, p=0.03) were independently associated with in-hospital mortality rates in the multivariate regression analysis., Conclusion: Thrombolytic therapy was associated with reduced in-hospital mortality at the expense of increased overall bleeding complications in octogenarians.

Objective: Despite wide usage of digoxin for various diseases in cardiology practice, its benefit is controversial and moreover it had been associated with unfavorable outcomes in some previous studies. The aim of this present study was to demonstrate whether digoxin usage was related with worse outcomes or not in patients with acute pulmonary embolisms., Methods: A total number of 1215 patients retrospectively enrolled for the study. Basic demographic features, pulmonary embolism severity index (PESI) scores, laboratory parameters and medications of patients who had been diagnosed with acute pulmonary embolism were recorded. Short (30 days) and long-term mortality were reported as the clinical outcomes., Results: Total mortality was 15.4% in the study population and 78 of these subjects died within the first 30 days. The frequency of digoxin treatment was 8% and most of these patients were prior users. According to the binary logistic regression analyses the PESI score, right ventricle (RV) diastolic diameter, systolic pulmonary arterial pressure (sPAP), brain natriuretic peptide (BNP), troponin and digoxin therapy (odds ratio, OR: 2.82 95% confidence interval, CI: 1.39-8.31, P = 0.03) were found as independent predictors of short-term mortality. Beside these findings; sPAP, PESI score, RV diastolic diameter and digoxin therapy (hazard ratio, HR: 2.11 95%CI: 1.22-7.31, P = 0.03) were determined as independent predictors of long-term mortality in Cox regression analyses. In subgroup analysis, we determined significantly greater increase in short-term mortality with use of digoxin among patients who had chronic renal disease, among patients under thrombolytic therapy and under high dosage of digoxin therapy and among female patients., Conclusion: Digoxin has been used extensively for decades in the treatment of heart failure and arrhythmias despite some controversies over its benefit. For the first time in the literature, we have demonstrated independent association of digoxin therapy with short-term and long-term mortality in patients with acute pulmonary embolism., (© 2020. Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Digoxin treatment has come under scrutiny in recent years after reports from several studies that it is associated with increased mortality in patients with atrial fibrillation (AF). The clinical effects of digoxin on mortality were closely related to serum digoxin concentrations (SDC) in these studies. In the present work, we evaluated the role of the SAMe-TT 2 R 2 and modified SAMe-TT 2 R 2 scores in predicting the therapeutic range of digoxin therapy., Methods: Medical records from our institution were screened for patients who were under digoxin treatment between 2008 and 2018. A total of 2418 patients for whom SDC were recorded were included in the study. An SDC of <0.5 or >1.2 ng/ml was defined as being out of the therapeutic range (oTR)., Results: In multivariable regression analyses, abnormal body mass index (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.29-1.95, p < 0.01), white blood cell count (OR: 1.12, 95% CI: 1.01-1.27, p < 0.01), and the modified SAMe-TT 2 R 2 score (OR: 4.19 95% CI: 3.71-4.72, p < 0.01) were determined to be independent predictors of oTR. A modified SAMe-TT 2 R 2 score greater than 3 predicted oTR with a sensitivity of 86% and a specificity of 65% (AUC: 0.825, p < 0.01)., Conclusion: Digoxin is still widely used in the treatment of heart failure and AF despite concerns about the increased risk of mortality when levels are oTR. In the present study, the modified SAMe-TT 2 R 2 score was found to be an independent predictor of oTR. This score may aid clinicians in identifying patients who are more likely to benefit from digoxin therapy., (© 2020. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: In this study, we aimed to determine if neutrophil to lymphocyte ratio could predict long term morbidity and mortality in patients who hospitalized for non-ST segment elevation acute coronary syndrome (NSTE-ACS) and had coronary slow flow on coronary angiography. Methods: In this observational study, 111 patients who presented with NSTE-ACS and diagnosed with coronary slow flow phenomenon on angiographic examination were included. Neutrophil to lymphocyte ratio (NLR) calculated as the ratio of the number of neutrophils to the number of lymphocytes. Patients classified into three groups according to NLR values. The term coronary slow flow phenomenon was depicted by calculating Thrombolysis in Myocardial Infarction frame count.Patients were followed up and the occurrence of recurrent angina, recurrent myocardial infarction, and long-term mortality was determined using medical records, phone calls, or face-to-face interviews. P values <0.05 considered to indicate statistical significance. Results: Recurrent angina and myocardial infarction occurred more frequently in the highest NLR tertile compared with middle and lowest NLR tertiles. High NLR group (NLR≥ 3.88 n=38) was significantly associated with younger age and smoking status. WBC, troponin I and CRP levels increased as the NLR tertile increased. Recurrent myocardial infarction and angina showed strong relationship with increasing NLR values. In multivariate regression analyses smoking and high NLR levels were independent predictors of recurrent myocardial infarction (HR:4.64 95%CI 0.95-22.52 P=0.04, HR: 1.48 95%CI 1.16-1.90 P<0.01 respectively) in the long term follow up. Conclusion: Our study demonstrated that high NLR values can be a valuable prognostic tool in the long term follow up of patients who presented with NSTE-ACS and diagnosed with slow flow phenomenon on coronary angiography., (© 2021 The Author(s).)

Background: Lead aVR provides prognostic information in various settings for patients with cardiovascular diseases. The present study aimed to investigate the prognostic value of a positive T wave in lead aVR (TaVR) for patients with acute pulmonary embolism (APE). Methods: We screened a total of 412 consecutive patients who were hospitalised with a diagnosis of APE between 2008 and 2018. We investigated electrocardiograms (ECGs) for the presence of a positive TaVR and classified other abnormal ECG findings. Additionally, clinical data, such as echocardiographic findings were recorded, and pulmonary embolism severity index (PESI) scores were calculated. The predictors of mortality at 30 days were investigated as the clinical outcome by logistic regression analysis. Results: In our study population, 54 patients (13.1%) died within 30 days. The prevalence of female gender, congestive heart failure, chronic obstructive pulmonary disease, and mean PESI scores were significantly higher in patients with a positive TaVR compared to those without it. Systolic blood pressure of patients with positive TaVR was significantly lower than that of patients without positive TaVR. In multivariate regression analysis; PESI scores (OR: 1.03; 95% CI: 1.01-1.04, p  < .01), Right ventricular end-diastolic diameter (RVEDD) (OR: 1.07 95% CI: 1.01-1.13, p  = .02), and a positive TaVR (OR: 4.41; 95% CI: 1.63-11.96, p  < .01) were independently correlated with mortality. Conclusion: Positive TaVR, PESI scores, and RVEDD at hospital admission may have prognostic value in patients with APE. Positive T wave in lead aVR could be a useful marker in early risk stratification of pulmonary embolism.

Background: Because myocardial infarction in young adults is rare, there has been limited research on the condition in this patient group. Very few data are available regarding the long-term outcomes of patients under 40 years of age with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing invasive treatments. The prognostic value of uric acid (UA) in young patients with NSTEMI who undergo percutaneous coronary intervention (PCI) has also not been studied. The purpose of this study was to evaluate the long-term clinical outcomes of this specific subset of young patients. In addition, we aimed to identify the role of serum UA in predicting the long-term prognosis of young patients with NSTEMI who have undergone PCI., Methods: We performed a retrospective analysis of 213 young adult patients (≤40 years old) with NSTEMI who underwent PCI during their hospitalization at our tertiary referral center., Results: The mean age of the 213 patients was 36.8 ± 3.3 years (range, 21-40 years). The median follow-up was 930 days. Our patients were predominantly male (88.3%) and the most frequent traditional cardiovascular risk factors were smoking and dyslipidemia. Baseline TIMI flow 0-1, estimated glomerular filtration rate (eGFR), and UA were found to be independently correlated with long-term major adverse cardiovascular events (MACEs) in multivariate Cox regression analysis., Conclusion: In the present study, baseline TIMI flow 0-1, admission eGFR, and UA levels were correlated with MACEs during long-term follow-up in young patients with NSTEMI.

Background: The main objective of the current study is to find out if any association exists between specific inflammatory markers such as homocysteine (Hcy) and pentraxin-3 (PTX-3) and cardiac involvement determined by means of echocardiographic parameters in patients with Behçet disease (BD). Methods: From January 2011 to January 2012, a total of 62 Behçet's patients were enrolled in the study. Thirty-two healthy subjects constituted the control group. The diagnosis of BD was made as proposed by International Study Group of BD. Results: The mean PTX-3, Hcy, and C-reactive protein levels were significantly higher in patients with BD compared to the control group. The electromechanical delay (EMD) times were found to be prolonged in patients with BD. Also, the aortic stiffness index (SI) and elastic modulus (Ep) were significantly higher, while the aortic dispensibility was significantly lower in patients with BD. The left atrial volume, left atrial volume index, E/A ratio, E/E' septal, IRight-EMD, PA'-ML, PA'-MS, PA'-TL, SI, and Ep were correlated with PTX-3 levels. In addition, the E/A, PA'-ML, PA'-MS, SI, and Ep displayed correlation with Hcy levels in patients having BD. Conclusion: Elevated levels of PTX-3 and Hcy were found to be correlated with cardiac involvement determined by means of echocardiographic parameters in patients with BD.

Introduction: In-stent restenosis (ISR) still constitutes a major problem after percutaneous vascular interventions and the inflammation has a pivotal role in the pathogenesis of such event. The C-reactive protein/albumin ratio (CAR) is a newly identified inflammatory biomarker, and it may be used as an indicator to predict ISR in subjects with coronary artery stenting. In light of these data, our main objective was to investigate the relationship between the preprocedural CAR and ISR in patients undergoing successful iliac artery stent implantation. Methods: In total, 138 consecutive patients who had successful iliac artery stent implantation in a tertiary heart center between 2015 and 2018 were enrolled in the study. The study population was categorized into two groups; patients with ISR and those without ISR during follow-up. The CAR was determined by dividing CRP by serum albumin. Results: In the multivariable regression analysis; the CAR (HR: 2.66, 95% CI: 1.66-4.25, P < 0.01), stent length (HR: 1.01, 95% CI: 0.99-1.02, P = 0.04), and HbA1c levels (HR: 1.22, 95% CI: 0.99-1.51, P = 0.04) were independently related with ISR. A receiver operating curve analysis displayed that the CAR value of >0.29 predicted ISR with sensitivity of 97.5% and specificity of 88.8% (AUC 0.94, P < 0.01). Conclusion: Our findings provide evidence that the CAR may be an applicable inflammatory biomarker in predicting ISR in subjects undergoing iliac artery stenting for the treatment of peripheral artery disease (PAD). Also, the stent length and poor glycemic control were found to be associated with ISR., (© 2020 The Author(s).)

Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

Background: An increased risk of ischemic stroke has been reported in patients with Parkinson's disease (PD). Atrial fibrillation (AF) is strongly associated with ischemic stroke. Prolonged atrial electromechanical delay (EMD) is an independent predictor for the development of AF., Aims: The aim of the present study was to evaluate the atrial conduction parameters in patients with PD and to assess their relation with the severity of PD., Study Design: We prospectively enrolled 51 consecutive patients with newly diagnosed PD and 31 age- and sex-matched non-PD subjects., Methods: To assess atrial electromechanical coupling (PA), the time intervals from the onset of p wave on ECG to the late diastolic wave at the septal (PAs) and lateral (PAl) mitral annulus and lateral tricuspid annulus (PAt) were measured on Tissue Doppler Echocardiography (TDE). The difference between PAs-PAl, PAs-PAt, and PAl-PAt were defined as left intra-atrial, right intra-atrial, and interatrial EMD, respectively. P-wave dispersion (PWD) was calculated from the 12-lead ECG., Results: PWD, PAs, PAl, and PAt durations were significantly prolonged in the PD group (all p < 0.001). Interatrial, right, and left intra-atrial EMD were also significantly longer in PD patients ( p < 0.001, p < 0.001 and p =0.002, resp.). There were significant positive correlations between disease severity (UPDRS score) and PWD ( r =0.34, p =0.041), left intra-atrial ( r =0.39, p =0.005), and interatrial EMD ( r =0.35, p =0.012). By multivariate analysis, PWD (OR: 1.13, 95% CI: 1.02-1.25; p =0.017), LA volume index (OR: 1.19, 95% CI: 1.02-1.37; p =0.021), left intra-atrial (OR: 1.12, 95% CI: 1.01-1.24; p =0.041), and interatrial EMD (OR: 1.08, 95% CI: 1.01-1.16; p =0.026) were found as independent predictors of PD., Conclusion: Atrial conduction times were longer and correlated with the severity of disease in PD patients. Prolonged inter- and intra-atrial-EMD intervals were also found as independent correlates of PD. These findings may suggest an increased predisposition to atrial fibrillation in PD.

Background: Warfarin-related nephropathy (WRN) is a complication of warfarin over-anticoagulation that is associated with acute and/or chronic renal dysfunction and increased mortality. The long-term effects of warfarin on renal function has not been adequately studied in patients with a mechanical prosthetic valve (MPV)., Aim: To study the time-dependent effects of over-anticoagulation on renal function in patients with a MPV., Methods: A total of 193 patients who underwent MPV implantation and were followed up in this study were eligible for inclusion. Time above therapeutic international normalized ratio (INR) range (TATR) was calculated by dividing the number of INR measurements above target in a year by the total number of INR measurements within a year. Patients were divided into quartiles according to average TATR at 60 months., Results: At 60 months more patients within the 4th quartile had a ≥20% reduction in the estimated glomerular filtration rate (eGFR, 25.0%, p = 0.04) and chronic kidney disease (CKD, 33.0%, p = 0.07) compared to patients within the 1st quartile. High TATR remained a significant determinant for reduction in eGFR (odds ratio OR: 7.50, 95% confidence interval CI:1.55-36.32) and CKD (OR:5.15, 95% CI: 1.26-20.62) after adjusting for other variables. Longitudinal analysis revealed that the change in eGFR was related to the duration of warfarin use (p < 0.001) and the interaction between the duration of warfarin use and TATR (p = 0.03). Similar findings were observed in patients without CKD at baseline, but not in those with CKD before the index operation., Conclusion: Anticoagulation over targeted INR values is associated with a steeper decline in eGFR and an increased frequency of CKD in patients with a MPV.

Objective: An intra-aortic balloon pump (IABP) is a mechanical support device that is used in addition to pharmacological treatment of the failing heart in intensive cardiac care unit (ICCU) patients. In the literature, there are limited data regarding the clinical characteristics and in-hospital outcomes of acute coronary syndrome patients in Turkey who had an IABP inserted during their ICCU stay. This study is an analysis of the clinical characteristics and outcomes of these acute coronary syndrome patients., Methods: The data of patients who were admitted to the ICCU between September 2014 and March 2017 were analyzed retrospectively. The data were retrieved from the ICCU electronic database of the clinic. A total of 142 patients treated with IABP were evaluated in the study. All of the patients were in cardiogenic shock following percutaneous coronary intervention, at the time of IABP insertion., Results: The mean age of the patients was 63.0±9.7 years and 66.2% were male. In-hospital mortality rate of the study population was 54.9%. The patients were divided into 2 groups, consisting of survivors and non-survivors of their hospitalization period. Multivariate analysis after adjustment for the parameters in univariate analysis revealed that ejection fraction, Thrombolysis in Myocardial Infarction flow score of ≤2 after the intervention, chronic renal failure, and serum lactate and glucose levels were independent predictors of in-hospital mortality., Conclusion: The mortality rate remains high despite IABP support in patients with acute coronary syndrome. Patients who are identified as having a greater risk of mortality according to admission parameters should be further treated with other mechanical circulatory support devices.

Background: Acute pulmonary embolism (PE) is a serious clinical disease characterized by a high mortality rate. The aim of this study was to assess the prognostic value of international normalized ratio (INR) in acute PE patients not on anticoagulant therapy., Methods: The study included 244 hospitalized acute PE patients who were not receiving previous anticoagulant therapy. Based on their 30-day mortality, patients were categorized as survivors or non-survivors. INR was measured during the patients' admission, on the same day as the diagnosis of PE but before anticoagulation started., Results: Thirty-day mortality occurred in 39 patients (16%). INR was higher in non-survivors than in survivors (1.3±0.4 vs 1.1±0.3, P=.003). In multivariate analysis, INR (HR: 3.303, 95% CI: 1.210-9.016, P=.020) was independently associated with 30-day mortality from PE. Inclusion of INR in a model with simplified pulmonary embolism severity index (sPESI) score improved the area under the receiver operating characteristics (ROC) curve from 0.736 (95% CI: 0.659-0.814) to 0.775 (95% CI: 0.701-0.849) (P=.028). Also, the addition of INR to sPESI score enhanced the net reclassification improvement (NRI=8.8%, P<.001) and integrated discrimination improvement (IDI=0.043, P=.027)., Conclusion: Elevated INR may have prognostic value for 30-day mortality in acute PE patients not on anticoagulation. Combining INR with sPESI score improved the predictive value for all-cause mortality. However, further large-scale studies are needed to confirm it's prognostic role., (© 2017 Wiley Periodicals, Inc.)

Background: CHA 2 DS 2 -VASc score has been validated in risk prediction for stroke and thromboembolism in patients with atrial fibrillation (AF). Association of CHA 2 DS 2 -VASc score with higher risk of venous thromboembolism and pulmonary embolism (PE) has also been shown. In this study, we investigated the long-term prognostic value of CHA 2 DS 2 -VASc score in patients with acute pulmonary embolism (APE)., Methods: Consecutive patients with APE presenting to our emergency department were retrospectively recruited. Patients with AF and who died secondary to causes other than PE were excluded from the study. The CHA 2 DS 2 -VASc score and pulmonary embolism severity index (PESI) were calculated., Results: Two hundred seventy seven participants were included in the study. The mortality rate was 18.7%. Twenty-two cases died within 30 days, and 30 cases died during the follow-up period (median: 13 months). The mean CHA 2 DS 2 -VASc score was significantly higher in dead patients compared to survivors (3.61 ± 1.35 vs 1.95 ± 1.52, P < .01). In multivariate regression analysis, systolic pulmonary artery pressure (hazard ratio [HR]: 1.03, 95% confidence interval [CI]: 1.01-1.06, P = .02), PESI score (HR: 1.010, 95% CI: 1.004-1.017, P < .01), and CHA 2 DS 2 -VASc score (HR: 1.67, 95% CI: 1.19-2.16, P < .01) were found to be independently correlated with mortality. The patients whose CHA 2 DS 2 -VASc score was between 1 and 3 had 5.67 times and patients whose CHA 2 DS 2 -VASc score was ≥4 had 16.8 times higher risk of mortality compared to patients with CHA 2 DS 2 -VASc score = 0., Conclusion: Patients with higher CHA 2 DS 2 -VASc scores had higher rates of mortality after APE.

Background: Coronary artery anomalies are a heterogeneous group of congenital disorders presenting with a wide spectrum of symptoms, ranging from vague chest pain to sudden cardiac death. Despite available data, there is no consensus about the classification, nomenclature, and outcomes of coronary anomalies in the normally connected heart. In this study, we aimed to investigate clinical and angiographic characteristics of coronary arterial anomalies, as well as the frequency of atherosclerotic involvement in anomalous coronaries, diagnosed at a tertiary referral centre., Methods: We retrospectively reviewed coronary angiograms performed between 2011 and 2015 for the presence of a coronary anomaly. A total of 111 patients with a final diagnosis of coronary anomaly were included in the study group. We also recruited 110 age- and sex-matched patients who underwent coronary angiography because of symptomatic coronary artery disease as controls., Results: Among 36,893 coronary angiograms, 111 (0.30%) major coronary anomalies were found. Compared with controls, the prevalence of significant atherosclerotic coronary disease was lower in patients with coronary anomalies and stable symptoms (p=0.02); however, the prevalence of significant coronary atherosclerosis was similar among patients admitted with unstable angina or myocardial infarction (p>0.05). Compared with controls, patients with an anomalous left anterior descending coronary artery had significantly less atherosclerotic involvement than those in whom the left anterior descending artery was not anomalous (p=0.005)., Conclusions: Although coronary artery anomalies are cited as a cause for myocardial ischaemia, atherosclerotic coronary artery disease is also frequent and may offer an alternative explanation to ischaemic symptoms. No predisposition to accelerated atherosclerosis was found, however, and atherosclerotic involvement was less frequent in some anomalous vessels.

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.

Background: Contrast induced nephropathy (CIN) has been proven as a clinical condition related to adverse cardiovascular outcomes. However, relationship between CIN and stent restenosis (SR) remains unclear. In this study, we aimed to investigate the association of CIN with SR rates after primary percutaneous coronary intervention (PCI) and bare metal stent (BMS) implantation., Methods: A total number of 3225 patients who had undergone primary PCI for STEMI were retrospectively recruited. The medical reports of subjects were searched to find whether the patients had a control coronary angiogram (CAG) and 587 patients with control CAG were included in the study. The laboratory parameters of 587 patients were recorded and patients who developed CIN after primary PCI were defined. Contrast induced nephropathy was defined as either a 25% increase in serum creatinine from baseline or 0.5 mg/dL increase in absolute value, within 72 h of intravenous contrast administration., Results: The duration between primary PCI and control CAG was median 12 months [8-24 months]. The rate of SR was significantly higher in CIN (+) group compared to CIN (-) group (64% vs. 46%, p < 0.01). In multivariate Cox regression analysis, male gender, stent length, admission WBC levels and presence of CIN (HR 1.39, 95% CI 1.06-1.82, p < 0.01) remained as the independent predictors of SR in the study population., Conclusion: Gender, stent length, higher serum WBC levels and presence of CIN are independently correlated with SR in STEMI patients treated with BMS implantation.

Background: The prognostic value of baseline SYNTAX (SS) and clinical SYNTAX (cSS) scores has been shown in different populations with coronary artery disease. However, their prognostic value has not been compared in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease., Methods: Patients who had undergone a primary percutaneous coronary intervention (PCI) for STEMI and had at least one critical lesion other than the culprit artery were recruited retrospectively. SS and cSS were calculated from medical records and angiograms and were compared in coronary artery by-pass grafting (CABG) and PCI groups. Long-term major adverse cardiac events (MACE) were defined as mortality, reinfarction, and target vessel revascularization., Results: A total of 460 patients (214 in the CABG group and 246 in the PCI group) were analyzed. The baseline SS and the cSS were significantly higher in the CABG group compared with the PCI group (30.1±6.7 vs. 22.5±5.6; P<0.01 and 41.4±21.2 vs. 27.2±15.9; P<0.01, respectively). During a follow-up period of 32±8 months, 15 patients from the CABG group and 12 patients from the PCI group died (P=0.33), but the rate of MACE was higher in the PCI group (31 vs. 20%, P<0.01). Receiver operating curve analysis and univariate Cox regression analysis indicated that SS and cSS have prognostic value in the CABG group, but not in the PCI group. In the CABG group, SS and cSS showed significant discriminative power for long-term mortality (for SS>33 sensitivity 73.3%, specificity 71.4% and for cSS>38.4 sensitivity 93.3%, specificity 58.3%) and for MACE (for SS>34.5 sensitivity 50%, specificity 81.4% and for cSS>43.5 sensitivity 66.7%, specificity 73.8%)., Conclusion: SS and cSS scores have prognostic value in STEMI patients with multivessel disease treated with CABG surgery. cSS may be superior to SS for prediction of long-term adverse events in CABG patients.

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.

Background: Serum cholesterols play an important role in pathophysiology and prognosis of acute thrombotic diseases. The aim of the present study was to investigate the prognostic value of serum lipid parameters in acute pulmonary embolism (APE)., Methods: From January 2008 to January 2014 a total of 275 patients who were hospitalised with a diagnosis of APE were retrospectively screened. Clinical data, laboratory parameters, serum cholesterol levels were recorded and pulmonary embolism severity index (PESI) scores were calculated. Mortality rate at 30 days was investigated as the clinical outcome., Results: In our study population, 24 patients (8.7%) died within 30 days. Serum total cholesterol, LDL-C, HDL-C and triglyceride levels were significantly lower in deceased patients when compared to the survived patients (3.1 ± 0.6 vs. 4.7 ± 1.2 mmol/L, p < 0.01; 1.8 ± 0.9 vs. 2.9 ± 0.9 mmol/L, p < 0.01; 0.9 ± 0.3 vs. 1.2 ± 0.3 mmol/L, p < 0.01; 1.4 ± 0.7 vs. 1.7 ± 0.6 mmol/L, p = 0.04, respectively). In multivariate regression analysis; PESI scores (OR: 1.06 95% CI: 1.01-1.11, p < 0.01), right ventricular diameter (OR: 11.31 95% CI: 3.25-52.64, p < 0.01), total cholesterol (OR: 1.09 95% CI: 1.02-1.17, p < 0.01), LDL-C (OR: 1.06 95% CI: 1.01-1.12, p = 0.02), HDL-C (OR: 1.21 95% CI: 1.04-1.41, p < 0.01) and triglyceride (OR: 1.03 95% CI: 1.01-1.05, p < 0.01) levels were independently correlated with mortality., Conclusions: Serum total cholesterol, LDL-C, HDL-C and triglyceride levels, obtained within the first 24hours of hospital admission, may have prognostic value in patients with APE., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Type IV dual left anterior descending artery (LAD) anomaly constitutes a rare subset of coronary anomalies in which the anterior and anterolateral wall of the left ventricle is supplied by a short LAD originating from the left coronary artery along with a long LAD that originates from the right sinus of Valsalva. Albeit rare, the angiographic presentation is challenging since the appearance of the short LAD is similar to a total occlusion beyond first few diagonal or septal branches. Here, we present a series of four cases with type IV dual LAD anomaly with different clinical and angiographic presentations.

Objectives: New-onset atrial fibrillation (NOAF) during hospitalization is considered a frequent complication associated with worse outcomes in the setting of ST-segment elevation myocardial infarction (STEMI). We aimed to investigate the association of admission serum laboratory parameters, neutrophil to lymphocyte ratio (NLR), and monocyte to high-density lipoprotein ratio (MHR) with NOAF in STEMI patients treated with a primary percutaneous coronary intervention (PCI)., Patients and Methods: A total of 621 patients who were hospitalized with a diagnosis of STEMI and treated with primary PCI were retrospectively enrolled in the study. NOAF during index hospitalization and overall mortality were reported as the clinical outcomes., Results: In our study population, 40 (6.4%) patients developed NOAF during index hospitalization. Monocyte counts, mean platelet volume (MPV), red cell distribution width (RDW), NLR, MHR, C-reactive protein (CRP), creatinine, glucose, and uric acid levels were higher in the NOAF+ group compared with the NOAF- group. In multivariate regression analysis, age, left-ventricular ejection fraction, left atrial volumes, admission heart rate, multivessel disease, increased levels of CRP, MPV, RDW, uric acid, NLR, and MHR independently predicted NOAF. In addition, NOAF was found to be an independent predictor of overall mortality in the study population., Conclusion: For the first time in the literature, admission serum levels of MPV, RDW, uric acid, NLR, and MHR were found to be correlated independently with NOAF after primary PCI.

Background: Monocyte count to high-density lipoprotein ratio (MHR) has recently emerged as an indicator of inflammation and oxidative stress in the literature. We aimed to investigate the prognostic value of MHR in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI)., Methods: A total of 513 patients who were hospitalized with diagnosis of acute ST-segment elevation myocardial infarction and treated with primary PCI were retrospectively enrolled in the study. Demographic and clinical data, admission laboratory parameters, and MHR values were recorded. Inhospital major adverse cardiac events (MACE) and mortality were reported as the clinical outcomes., Results: Twenty-six patients (5%) died, and MACE was observed in 86 patients (17%) during hospital follow-up. Patients were categorized in 3 groups according to tertiles of admission MHR. The rates of inhospital mortality and MACE were significantly higher in tertile 3 group compared to tertile 1 group (10% vs 1%, 27% vs 11%; P < .01 and P < .01). In multivariate regression analysis, age, sex, presence of Killip 3 or 4, left ventricular ejection fraction, troponin I, C-reactive protein, and increased MHR levels (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P < .01) independently predicted inhospital mortality; age, presence of Killip 3 or 4, troponin I, and increased MHR levels (odds ratio, 1.02; 95% confidence interval, 1.01-1.04; P < .01) independently predicted MACE., Conclusion: Admission MHR values were found to be independently correlated with inhospital MACE and mortality after primary PCI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Blood pressure variability (BPV) is a novel parameter related to adverse cardiovascular findings and events, especially in hypertensive patients. The aim of the present study was to investigate the relationship between short-term BPV and ascending aortic dilatation (AAD)., Hypothesis: Hypertensive patients with AAD may exhibit higher short-term BPV compared to hypertensive patients with normal diameter ascending aorta and BPV may be correlated with aortic sizes., Methods: Seventy-six hypertensive patients with AAD and 181 hypertensive patients with a normal-diameter ascending aorta were retrospectively enrolled in the study. Clinical data, echocardiographic characteristics, and 24-hour ambulatory blood pressure monitoring characteristics were compared between the 2 groups. Standard deviation (SD) and Δ of BP were used as parameters of BPV., Results: Although 24-hour mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were similar between the 2 groups, the SD of SBP and SD of DBP values were significantly higher in AAD patients (17.2 ± 6.8 vs 13.8 ± 3.5, P < 0.01; and 12.1 ± 5.1 vs 10.7 ± 3.1, P = 0.02, respectively). Daytime SD of SBP values were higher in AAD patients, whereas nighttime SD of SBP values did not differ between groups. In multivariate linear regression analysis, 24-hour SD of SBP, 24-hour Δ SBP, daytime SD of SBP, daytime Δ SBP, and left ventricular mass index were independently correlated with aortic size index., Conclusions: Our study revealed higher levels of short-term BPV in hypertensive patients with AAD. This conclusion warrants further study., (© 2015 Wiley Periodicals, Inc.)

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.

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., (Copyright © 2015. Published by Elsevier Inc.)

Congenital anomalies of the mitral valve apparatus are rare. Of such cases, congenital mitral stenosis, atresia, accessory valvular tissue, and cleft mitral valve are more common. Descriptions of unileaflet mitral valves (either partial or complete leaflet agenesis/hypoplasia) are extremely rare and largely limited to a few case reports. We report herein a 45-year-old nulliparous woman presenting to our outpatient clinic with chest discomfort and dyspnea on minimal exertion. Mitral valve with a single leaflet leading to a significant obstruction in left ventricular outflow was seen on transthoracic echocardiography and confirmed with transesophageal two- (2D) and three-dimensional (3D) echocardiography. Metoprolol was prescribed to relieve obstruction and symptoms.

Background and Aim: The aim of this study was to evaluate the effect of atorvastatin and rosuvastatin on erectile dysfunction in hypercholesterolaemic patients., Methods: Ninety consecutive male hypercholesterolaemic patients (mean age 50.4 ± 7.9 years) who were otherwise healthy were included into the study prospectively. None of the patients had any cardiovascular risk factors except hypercholesterolaemia.The patients were divided into two groups. One group received atorvastatin while the other group was given rosuvastatin. All patients were followed for six months and International Index of Erectile Function-5 (IIEF-5) score and blood samples were re-evaluated., Results: Patients were in similar ages in both groups. There were also no statistical differences in terms of blood glucose levels, total cholesterol, low density lipoprotein, high density lipoprotein, triglyceride and mean IIEF score in both groups at the beginning. After six months, no IIEF score changes were observed in the rosuvastatin group after the medication. However, the IIEF score was significantly lower in the atorvastatin group (p = 0.019)., Conclusions: Rosuvastatin showed no effect on erectile dysfunction, while we observed increased erectile dysfunction with atorvastatin. Our study reveals that different statin types may have different effects on erectile dysfunction.

Emboli are among the most feared complications of interventional cardiology. Although surgery is needed in most cases for the removal of peripheric foreign body emboli, some may be extracted by percutaneous intervention. We present a case of retrieval of a femoral sheath fragment via contralateral femoral access, wiring of the sheath fragment, and retrieval with an 'anchoring balloon' system.