Evaluation of the impact of warfarin time in therapeutic range on outcomes of patients with atrial fibrillation in Turkey: Perspectives from the observational, prospective WATER Registry

Background: Warfarin is highly efficacious in reducing stroke risk in patients with atrial fibrillation (AF). However, its safety and efficacy in stroke prevention is markedly influenced by its time in therapeutic range (TTR). The quality of anticoagulant therapy varies considerably among countries. Representative data concerning the quality of anticoagulant therapy and its effects on clinical outcomes in Turkey are lacking. Methods: Warfarin in Therapeutic Range (WATER) registry is a prospective, observational study which followed 572 AF patients (mean age 67.3 ± 12 years; females 60%; 71% non-valvular AF) treated with warfarin. Results: At a median of 22-month follow-up, the mean TTR value was 42.3 ± 18% (median: 40%) for the whole population and lower in non-valvular AF su group than valvular AF subgroup (40.3 ± 18 vs. 46.9 ± 19, respectively, p < 0.001). Death, cardiac hospital­ization and minor bleeding rates were higher in the group with TTR value < 40% than the group with > 40% (3.4% vs. 5.9%; 28.6% vs. 35.4%; 36.5% vs. 41.7%, respectively, all of them p < 0.001). A correlation analysis showed a negative correlation between age and TTR value (r = –0.178, p < 0.001). Mean CHA2DS2VASc score was 3.63 ± 1.5 and mean HASBLED score was 2.38 ± 1.01 in the non-valvular AF group. A negative correlation was observed between TTR levels and CHA2DS2VASc score. Conclusions: WATER provides insight into the anticoagulation control status of AF patients in Turkey. The quality of anticoagulation was poor. Strategies should be undertaken by clinicians and patients to improve TTR. New oral anticoagulant agents may be perfect alternatives for non-valvular AF patients

How we eat may be as important as what we eat: eating behaviour and heart rate variability

Objective Diet exerts a crucial role on cardiovascular health. Evidence is mainly based on the content and the amount of dietary intakes. Some recent reports demonstrated that eating behaviour may also be of significant importance in cardiovascular health. In this study we aimed to investigate the effects of eating behaviour on heart rate variability (HRV) in healthy subjects

Severe tricuspid regurgitation mimicking constrictive pericarditis

Objective: Challenging differential diagnosis Background: Tricuspid regurgitation (TR) can mimic some hemodynamic findings of constrictive pericarditis (CP), due to the restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. In this article, we report a case of severe tricuspid regurgitation in which hemodynamic findings were consistent with CP. Case Report: A 62-year-old Caucasian woman presented with right heart failure symptoms. Echocardiography showed enlarged right heart chambers and severe tricuspid regurgitation. Right heart catheterization surprisingly demonstrated a constrictive physiology. Diastolic pressures of both ventricles were elevated and equalized, with a prominent deep and plateau pattern. The patient was re-evaluated with a further focus on constrictive pericarditis. However, echocardiography, thorax CT, and cardiac MRI did not demonstrate any pathological finding related to pericardium. The remaining explanation was that the severe TR itself and secondary right heart enlargement caused the restraining effect on the intact pericardium and on the left ventricle. The pericardium was normal and tricuspid annulus was severely dilated on surgical inspection. The tricuspid valve was replaced with a bioprosthetic valve. The patient did well just after the surgery, with a rapid decrease in cardiac pressures; however, she died due to respiratory failure on the 15th postoperative day. Conclusions: This was a case with right heart failure symptoms in which invasive hemodynamic findings were consistent with constrictive pericarditis and the noninvasive imaging modalities were not. This case illustrates that severe TR can mimic some hemodynamic findings of constrictive pericarditis, due to restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. Lack of significant respiratory changes in hemodynamic parameters that can safely be demonstrated by echocardiography and cardiac MRI suggest a normal pericardium. © Am J Case Rep, 2014

OPERATOR DEPENDENCY OF THE RADIATION EXPOSURE IN CARDIAC INTERVENTIONS: FEASIBILITY OF ULTRA LOW DOSE LEVELS

Introduction: Mean radiation exposure in invasive cardiology varies greatly between different centres and interventionists. The International Commission on Radiological Protection and the EURATOM Council stipulate that, despite reference values, ` All medical exposure for radiodiagnostic purposes shall be kept as low as reasonably achievable' (ALARA). The purpose of this study is to establish the effects of the routine application of ALARA principles and to determine operator and procedure impact on radiation exposure in interventional cardiology. Materials and methods: A total of 240 consecutive cardiac interventional procedures were analysed. Five operators performed the procedures, two of whom were working in accordance with ALARA principles (Group 1 operators) with the remaining three working in a standard manner (Group 2 operators). Radiation exposure levels of these two groups were compared. Results: Total fluoroscopy time and the number of radiographic runs were similar between groups. However, dose area product and cumulative dose were significantly lower in Group 1 when compared with Group 2. Radiation levels of Group 1 were far below even the reference levels in the literature, thus representing an ultra-low-dose radiation exposure in interventional cardiology. Conclusion: By use of simple radiation reducing techniques, ultra-low-dose radiation exposure is feasible in interventional cardiology. Achievability of such levels depends greatly on operator awareness, desire, knowledge and experience of radiation protection

Rapid retraction of a post-infarction intramyocardial dissecting hematoma

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

OPERATOR DEPENDENCY OF THE RADIATION EXPOSURE IN CARDIAC INTERVENTIONS: FEASIBILITY OF ULTRA LOW DOSE LEVELS

Introduction: Mean radiation exposure in invasive cardiology varies greatly between different centres and interventionists. The International Commission on Radiological Protection and the EURATOM Council stipulate that, despite reference values, ` All medical exposure for radiodiagnostic purposes shall be kept as low as reasonably achievable' (ALARA). The purpose of this study is to establish the effects of the routine application of ALARA principles and to determine operator and procedure impact on radiation exposure in interventional cardiology. Materials and methods: A total of 240 consecutive cardiac interventional procedures were analysed. Five operators performed the procedures, two of whom were working in accordance with ALARA principles (Group 1 operators) with the remaining three working in a standard manner (Group 2 operators). Radiation exposure levels of these two groups were compared. Results: Total fluoroscopy time and the number of radiographic runs were similar between groups. However, dose area product and cumulative dose were significantly lower in Group 1 when compared with Group 2. Radiation levels of Group 1 were far below even the reference levels in the literature, thus representing an ultra-low-dose radiation exposure in interventional cardiology. Conclusion: By use of simple radiation reducing techniques, ultra-low-dose radiation exposure is feasible in interventional cardiology. Achievability of such levels depends greatly on operator awareness, desire, knowledge and experience of radiation protection

Zależności między wskaźnikami płytkowymi a obrazem klinicznym choroby wieńcowej

Background: Platelets play a key role in the development and progression of cardiovascular disease. The degree of platelet activation may be assessed by platelet indices such as platelet count, mean platelet volume (MPV) and platelet distribution width (PDW).Aim: To evaluate the relationship between platelet indices and clinical features of coronary artery disease (CAD).Methods: Our population is represented by a total of 441 consecutive patients undergoing coronary angiography. Patients were divided into three groups according to their clinical presentation: Patients with stable angina (Group I), with acute coronary syndrome (Group II), and with a normal coronary angiogram (Group III). All demographic and clinical features were collected retrospectively. Platelet indices were measured in all patients.Results: There was no statistical difference for platelet count, MPV and PDW values among the groups. Correlation analysis showed a positive association between platelet count and Gensini scoring (Kendall’s tau b, r = 0.312, p = 0.037, two-tailed)and also age (Kendall’s tau b, r = 0.518, p = 0.001, two-tailed) in patients with CAD. However, there was no significant correlation between Gensini scoring and MPV or PDW values in these patients.Conclusions: PDW and MPV may not be related to the clinical features or presentation and extent of CAD. Our study findings add to the conflicting results of previous studies in this area. Prospective trials with longer follow-up periods and largersamples are warranted to conclusively define the role of platelet indices in CAD.Wstęp: Płytki krwi odgrywają ważną rolę w rozwoju i progresji chorób układu sercowo-naczyniowego. Stopień aktywacji płytek można ocenić na podstawie wskaźników płytkowych, takich jak liczba płytek krwi, średnia objętość płytek (MPV) i szerokość rozkładu płytek (PDW).Cel: Celem badania była ocena zależności między wskaźnikami płytkowymi a obrazem klinicznym choroby wieńcowej (CAD).Metody: Badaniem objęto 441 kolejnych pacjentów poddanych angiografii wieńcowej. Chorych podzielono na trzy grupy w zależności od charakterystyki klinicznej: osoby ze stabilną dławicą piersiową (grupa I), osoby z ostrym zespołem wieńcowym (grupa II) i osoby z prawidłowym obrazem w angiografii wieńcowej (grupa III). Wszystkie dane demograficzne i kliniczne zbierano w sposób retrospektywny. U wszystkich chorych zmierzono wskaźniki płytkowe.Wyniki: Nie stwierdzono statystycznych różnic między grupami pod względem liczby płytek krwi i wartości MPV oraz PDW. Analiza korelacji wykazała dodatnie zależności między liczbą płytek krwi a punktacją w skali Gensiniego (współczynnik tau-bKendalla r = 0,312; p = 0,037; test dwustronny) oraz wiekiem (współczynnik tau-b Kendalla, r = 0,518; p = 0,001; testdwustronny) u pacjentów z CAD. Nie wykazano jednak u tych chorych istotnych korelacji między punktacją w skali Gensiniegoa wartościami MPV lub PDW.Wnioski: Wartości PDW i MPV mogą się nie wiązać z obrazem klinicznym ani charakterem zmian miażdżycowych lub rozległością CAD. Wyniki te są rozbieżne z danymi uzyskanymi we wcześniejszych badaniach na ten temat. Należy przeprowadzić prospektywne badania z dłuższym okresem obserwacji i większą liczebnością próby, aby jednoznacznie ustalić znaczenie wskaźników płytkowych w CAD

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

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

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

Objective To evaluate the prognostic value of baseline neutrophil-to-lymphocyte ratio (NLR) in the prediction of long-term mortality in patients with pulmonary arterial hypertension (PAH)