Evaluating the relationship of sleep quality and sleep duration with Framingham coronary heart disease risk score

Sleep is an important modulator of cardiovascular function and is recognized to play an important role in the pathogenesis and progression of cardiovascular disease. However, results of the studies investigating the relationship between sleep complaints and cardiovascular outcomes are still controversial. This study aimed to investigate the associations of sleep duration and sleep quality with Framingham 10-year hard coronary heart disease (CHD) risk score in Turkish adults. We included a total of 362 participants (mean age: 48.5 ± 9.0 years, 50.6% males) and measured sleep quality and sleep duration using Pittsburgh Sleep Quality Index (PSQI). Framingham risk scoring system was utilized to calculate the 10-year hard CHD risk of participants. Binary logistic regression analysis was performed to determine the association between sleep quality, sleep duration, and CHD risk. Both short sleep duration (<6 hours) (OR = 3.858, 95% CI: 1.245-11.956) and long sleep duration (≥8 hours) (OR = 2.944, 95% CI: 1.087-7.967) were identified as the predictors of 10-year hard CHD risk. However, sleep quality was not associated with 10-year CHD risk even as a categorical or continuous variable (OR = 0.864, 95% CI: 0.418-1.787 and OR = 0.985, 95% CI: 0.868-1.117, respectively). Our findings highlighted previous studies demonstrating the U-shaped relationship, with both short and long sleep durations to be associated with a higher CHD risk. Evaluation of habitual sleeping patterns may provide additional information in clinical cardiovascular risk assessment. Future research should investigate whether interventions to optimize sleep duration may help to prevent coronary events in large population-based cohorts.

Prognostic Importance of Pulmonary Artery Pulsatility Index and Right Ventricular Stroke Work Index in End-Stage Heart Failure Patients

BACKGROUND

Right ventricular (RV) failure is an important cause of morbidity and mortality in patients with left ventricular (LV) end-stage heart failure (ESHF). Pulmonary artery pulsatility index (PAPi) and right ventricular stroke work index (RVSWI) are invasive parameters related to RV function. This study aimed to investigate the prognostic impact of PAPi and RVSWI in these patients.

METHODS AND RESULTS

In this study, 416 patients with ESHF were included. The adverse cardiac event (ACE) was defined as left ventricular assist device (LVAD) implantation, urgent heart transplantation, or cardiac mortality. There were 218 ACE cases and 198 non-ACE cases over a median follow-up of 503.50 days. Patients with ACE had lower PAPi and similar RVSWI compared to those without ACE (3.1±1.9 vs. 3.7±2.3, P=0.003 and 7.3±4.9 vs. 6.9±4.4, P=0.422, respectively). According to the results of multivariate analysis, while PAPi (from 2 to 5.65) was associated with ACE, RVSWI (from 3.62 to 9.75) was not associated with ACE (HR: 0.75, 95% CI (0.55-0.95), P=0.031; HR: 0.79, 95% CI: (0.58-1.09), P=0.081, , respectively). Survival analysis revealed that PAPi ≤2.56 was associated with a higher ACE risk compared to PAPi >2.56 (HR: 1.46, 95% CI: 1.11-1.92, P=0.006). PAPi ≤2.56 could predict ACE with 56.7% sensitivity and 51.3% specificity at one year. Furthermore, the association between RVSWI and ACE was nonlinear (J-curve pattern). Low and high values seem to be associated with higher ACE risk compared to intermediate values.

CONCLUSION

The low PAPi was an independent risk for ACE and it had a linear association with it. However, RVSWI seems to be have a nonlinear association with ACE (J-curve pattern).

A seven-year single-center experience on AngioJet rheolytic thrombectomy in patients with pulmonary embolism at high risk and intermediate-high risk

BACKGROUND AND AIM

Angiojet Rheolytic thrombectomy (ART) has been utilized as a catheter-based treatment in acute pulmonary embolism (PE). In this study based on our seven-year experience on ART in patients with PE, we evaluated efficacy and safety outcomes of ART.

METHODS

Our study is based on retrospective evaluation of 56 patients with high- and intermediate-high-risk PE, age (62 years; interquartile-range (IQR): 50-73) who underwent ART.

RESULTS

High- and intermediate-high-risk were noted in 21.4 % and in 78.6 % of patients, respectively. ART duration was 304(IQR: 246-468) seconds. Measures of obstruction, right to left ventricle diameter ratio (RV/LV ratio), right to left atrial diameter ratio and pulmonary arterial pressures were improved (p<0.001 for all). During hospital stay, acute renal failure, major and minor bleeding, and mortality rates were 37.5%, 7.1%, 12.5%, and 8.9%, respectively. Aging related to post-procedural nephropathy while high-risk status was associated with in-hospital mortality (p=0.006) and long-term mortality.

CONCLUSIONS

The ART resulted in significant and clinically relevant improvements in the pulmonary arterial thrombotic burden, RV strain and hemodynamics in patients with PE at high- and intermediate-high-risk. Aging increased the risk of post-procedural nephropathy whereas baseline high-risk status predicted in-hospital and long-term mortality.

Prognostic value of main pulmonary artery diameter to ascending aorta diameter ratio in patients with advanced heart failure

OBJECTIVES AND BACKGROUND

In this study we assessed the prognostic value of main pulmonary artery diameter and its ratio to ascending aorta diameter (P/Ao ratio) in advanced heart failure patients.

METHODS

Patients with advanced heart failure who were candidates for heart transplantation were retrospectively evaluated. The clinical information, cardiac catheterisation results, and computed tomography images were gathered from institutional database system. The observed and predicted probabilities for survival were analysed in a nomogram.

RESULTS

The P/Ao ratio was found to be a strong predictor for MACE both in traditional multivariable Cox proportional hazard regression modelling (increase in P/Ao ratio per 2 SD, HR:2.72, 95% CI 1.14-6.48, p = 0.024) and ridge regression analysis (increase in P/Ao ratio per 2SD, HR:3.45, 95% CI 1.53-7.74, p = 0.003). Prediction model showed statistically significant correlation between the observed and predicted probabilities for 1-year survival.

CONCLUSION

In patients with advanced heart failure, computed tomography derived P/Ao ratio might be a prognostic predictor during follow up.

Effect of Group 2 Pulmonary Hypertension Subgroups on Outcomes: Impact of the Updated Definition of Pulmonary Hypertension

BACKGROUND

Pulmonary hypertension (PH) is a common complication of end-stage heart failure (ESHF) and associated with increased mortality. The definition of PH has recently been changed from a mean pulmonary arterial pressure (PAPm) ≥25 mmHg to a PAPm >20 mmHg. Since this change, there are no data evaluating group 2 PH subgroups on outcomes. The purpose of this study was to determine the impact of updated group 2 PH subgroups on outcomes, as well as to evaluate the clinical, echocardiographic, and haemodynamic characteristics of subgroups, and determine predictors of PH in patients with ESHF.

METHOD

A total of 416 patients with ESHF with left ventricle ejection fraction (LVEF) ≤25% were divided into three groups. Pulmonary hypertension was defined as PAPm >20 mmHg. Primary outcome was defined as left ventricular assist device (LVAD) implantation, urgent heart transplantation (HT), or death. Secondary outcome was defined as LVAD implantation and HT.

RESULTS

Over a median follow-up of 503.5 days, combined pre- and postcapillary PH (Cpc-PH) displayed greater risk of primary outcome than those with isolated postcapillary (Ipc-PH) (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.29-1.91; p<0.001) and those with no PH (HR, 2.47; 95% CI, 1.68-3.63; p<0.001). Patients with Ipc-PH demonstrated greater risk than those with no PH (HR, 1.57; 95% CI, 1.57-1.90; p<0.001). Likelihood ratios of updated PH criteria and old PH criteria (PAPm ≥25 mmHg) in identifying primary outcome were 75.6 (R²=0.179) and 72.09 (R²=0.164). Patients with PAPm 21-24 mmHg had a higher primary outcome than those with PAPm ≤20 mmHg. Severe mitral regurgitation, LVEF, grade 3 diastolic dysfunction, diabetes, and cardiac output were predictors of PH.

CONCLUSIONS

Pulmonary hypertension increases the risk of LVAD, urgent HT, or death, and Cpc-PH further increases risk in patients with ESHF. Compared to the previous definition, a new PH definition better discriminates death, going to urgent HT, or LVAD implantation for PH subgroups.

Impaired endothelium-dependent and endothelium-independent systemic vasodilatory reserve in pulmonary hypertension regardless the clinical group: A generalized dysfunction beyond the pulmonary arteries?

OBJECTIVE

Endothelium-dependent (ED) and endothelium-independent (EI) flow-mediated vasodilatation (FMD) have been used as measures of systemic arterial vasodilatory reserve. In this study, we aimed to assess both ED-FMD and EI-FMD in different groups with pulmonary hypertension (PH), and to investigate the relationship of these measures with clinical, echocardiographic, and invasive parameters of diseases severity and targeted treatment status.

METHODS

Our study population comprised 41 patients with PH [28 (68.2%) women, age 46.3±19.6 years] including idiopathic pulmonary arterial hypertension, Eisenmenger syndrome, and chronic thromboembolic PH in whom diagnosis were confirmed in accordance with current guidelines and 17 age and sex-matched healthy controls. The brachial artery (BA) was used for assessment of FMD with Duplex ultrasound, and serial changes in diameter were recorded at baseline, 1, and 3 minutes after termination of 2-minute external occlusive compression for ED-FMD, and after sublingual intake of glycerol trinitrate for EI-FMD, respectively.

RESULTS

Compared with controls, overall the PH group showed significantly lower ED-FMD (0.65±0.21 vs. 0.30±0.23 and 0.65±0.18 vs. 0.24±0.21) and EI-FMD (0.67±0.15 vs. 0.37±0.25 and 0.75±0.20 vs. 0.32±0.24) responses at 1st and 3rd min (p<0.001 for all). All these changes in the values of ED-FMD and EI-FMD were comparable among the PH subgroups. Neither ED-FMD nor EI-FMD were correlated with measures of PH severity and targeted therapy (TT) status (p>0.05).

CONCLUSION

Our results suggest an impaired BA vasodilatory reserve in patients with PH regardless of the clinical subgroup. Although these findings seem to be consistent with systemic dysfunction, acute FMD may not reflect the severity of PH and cannot be used as a potential surrogate for outcome in this setting.

Impaired endothelium-dependent and endothelium-independent systemic vasodilatory reserve in pulmonary hypertension regardless the clinical group: A generalized dysfunction beyond the pulmonary arteries?

OBJECTIVE

Endothelium-dependent (ED) and endothelium-independent (EI) flow-mediated vasodilatation (FMD) have been used as measures of systemic arterial vasodilatory reserve. In this study, we aimed to assess both ED-FMD and EI-FMD in different groups with pulmonary hypertension (PH), and to investigate the relationship of these measures with clinical, echocardiographic, and invasive parameters of diseases severity and targeted treatment status.

METHODS

Our study population comprised 41 patients with PH [28 (68.2%) women, age 46.3±19.6 years] including idiopathic pulmonary arterial hypertension, Eisenmenger syndrome, and chronic thromboembolic PH in whom diagnosis were confirmed in accordance with current guidelines and 17 age and sex-matched healthy controls. The brachial artery (BA) was used for assessment of FMD with Duplex ultrasound, and serial changes in diameter were recorded at baseline, 1, and 3 minutes after termination of 2-minute external occlusive compression for ED-FMD, and after sublingual intake of glycerol trinitrate for EI-FMD, respectively.

RESULTS

Compared with controls, overall the PH group showed significantly lower ED-FMD (0.65±0.21 vs. 0.30±0.23 and 0.65±0.18 vs. 0.24±0.21) and EI-FMD (0.67±0.15 vs. 0.37±0.25 and 0.75±0.20 vs. 0.32±0.24) responses at 1st and 3rd min (p<0.001 for all). All these changes in the values of ED-FMD and EI-FMD were comparable among the PH subgroups. Neither ED-FMD nor EI-FMD were correlated with measures of PH severity and targeted therapy (TT) status (p>0.05).

CONCLUSION

Our results suggest an impaired BA vasodilatory reserve in patients with PH regardless of the clinical subgroup. Although these findings seem to be consistent with systemic dysfunction, acute FMD may not reflect the severity of PH and cannot be used as a potential surrogate for outcome in this setting.

Effect of non-dipper pattern on echocardiographic myocardial work parameters in normotensive individuals

BACKGROUND

It is known that non-dipper pattern (NDP) is associated with adverse outcomes in hypertensive patients. However, there is insufficient data on the outcome of NDP in normotensive individuals. Using myocardial work (MW) analysis, as a new echocardiographic examination method, this study aimed to determine the early myocardial effects of NDP in normotensive individuals.

METHODS

This study included 70 normotensive individuals who were followed by ambulatory blood pressure monitoring (ABPM). The subjects were divided into two groups according to dipper pattern (DP) and NDP. Conventional, strain, and MW findings were compared between the groups by making echocardiographic evaluations.

RESULTS

The demographic characteristics, laboratory parameters, and measurements of cardiac chambers, and left ventricular (LV) walls were similar between the groups. There was no statistical difference between the groups in terms of LV 3-2-4 chambers strains and global longitudinal strain (GLS) values. LVMW parameters, global work index (GWI), and global constrictive work (GCW) were not statistically different between groups (2012 ± 127, 2069 ± 137, p = 0.16; 2327 ± 173, 2418 ± 296, p = 0.18, respectively). However, global waste work (GWW) and global work efficiency (GWE) parameters were different between the groups (144 ± 63.9, 104 ± 24.8, p < 0.001; 93.2 ± 3.17, 95.4 ± 1.28, p < 0.001, respectively). In regression analysis, GWW was independently associated with NDP. GWW model showed better results with higher likelihood chi-square and R² values than GLS model in discriminating the predictable capability for NDP status.

CONCLUSION

The results of MW analysis in this study showed that GWW values were higher and the GWE values were lower in normotensive individuals with NDP.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure

BACKGROUND

Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure.

METHODS

This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development.

RESULT

Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia.

CONCLUSION

The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Prognostic significance of malnutrition scores in elderly patients for the prediction of contrast-induced acute kidney injury

BACKGROUND

Malnutrition reflects the general condition of a patient including physical condition, protein turnover, and immune competence. Contrast-induced acute kidney injury (CI-AKI) is a disorder that adversely affects the prognosis of older adults. In our study, we aimed to show the relationship between CI-AKI and malnutrition status in elderly patients over 65 years of age with chronic coronary artery disease (CAD).

METHODS

Study enrolled 360 consecutive patients with coronary angiography performed because of chronic coronary artery disease. Patients pre-procedural and post-procedural blood samples were taken and prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, and geriatric nutritional risk index (GNRI) malnutrition scores were calculated.

RESULTS

The median age of the patients included in the study was 69 (67-72, IQR) and CI-AKI was seen in 91 (25.2%) patients. Univariate regression analysis showed that age, diabetes mellitus, baseline creatinine, body weight-adapted contrast agent, haemoglobin, left ventricular ejection fraction, CONUT score, PNI score, and GNRI score were independent predictors of CI-AKI. In model 1, increase in CONUT score (2 to 5) (OR: 3.21 (2.11-4.88), in model 2, increase in PNI score (37.4 to 45) (OR: 0.34, (0.24-0.49)), and in model 3, increase in GNRI score (89.5 to 103.8) (OR: 0.55, (0.38-0.81)) were independently associated with the presence of CI-AKI. PNI showed better results than other models in discriminating the predictable capability for CI-AKI.

CONCLUSION

Malnutrition assessment of elderly patients before performing diagnostic or interventional coronary procedures could help clinicians to identify patients with elevated risk for CI-AKI.

Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension is an underdiagnosed and potentially fatal subgroup of pulmonary hypertension, if left untreated. Clinical signs include exertional dyspnea and non-specific symptoms. Diagnosis requires multimodality imaging and heart catheterization. Pulmonary endarterectomy, an open heart surgery, is the gold standard treatment of choice in selected patients in specialized centers. Targeted medical therapy and balloon pulmonary angioplasty can be effective in high-risk patients with significant comorbidities, distal pulmonary vascular obstructions, or recurrent/persistent pulmonary hypertension after pulmonary endarterectomy. Currently, there is a limited number of data regarding novel coronavirus-2019 infection in patients with chronic thromboembolic pulmonary hypertension and the changing spectrum of the disease during the pandemic. Challenging times during this outbreak due to healthcare crisis and relatively higher case-fatality rates require convergence; that is an ultradisciplinary collaboration, which crosses disciplinary and sectorial boundaries to develop integrated knowledge and new paradigms. Management strategies for the "new normal" such as virtual care, preparedness for further threats, redesigned standards and working conditions, reevaluation of specific recommendations, and online collaborations for optimal decisions for chronic thromboembolic pulmonary hypertension patients may change the poor outcomes.

Pulmonary arterial hypertension associated with congenital heart disease: lessons learnt from the large Turkish Nationwide Registry (THALES)

Pulmonary hypertension is a group of diseases, including pulmonary arterial hypertension associated with congenital heart disease (APAH-CHD), characterized by progressive deterioration in pulmonary hemodynamics associated with substantial morbidity and mortality risk. THALES is a national multicenter, prospective observational registry, providing data on patients with APAH-CHD. The study comprised APAH-CHD patients (>3 months of age) with confirmed diagnosis of right heart catheterization or echocardiographic findings. Initial and follow-up data were collected via regular hospital visits. Descriptive statistics are used for definitive purposes. Overall, 1034 patients aged 3 months–79 years (median 11.2 [Q1–Q3: 2.2–24.3] years) with APAH-CHD were enrolled at 61 centers, 50.3% being retrospectively enrolled. Most had either Eisenmenger's syndrome (49.2%) or systemic-to-pulmonary shunts (42.7%). Patients were mostly in functional class I–II at the time of diagnosis (46.6%). Mean 6-min walk distance (6MWD) was 369 ± 120 m. Mean pulmonary arterial pressure was 54.7 ± 22.2 mmHg for the whole group, and was highest in patients with Eisenmenger's syndrome. Targeted therapies were noted in 398 (38.5%) patients (monotherapy in 80.4%). Follow-up data were available in 506 patients. Survival at 140 months was 79% and was associated with baseline 6MWD >440 m (p = 0.009), brain natriuretic peptide level < 300 ng/L (p < 0.001). Follow-up 6MWD >165 m (p < 0.0001), brain natriuretic peptide level <300 ng/L (p = 0.031), and targeted therapies (p = 0.004) were also predictive of survival. THALES is the largest registry dedicated to APAH-CHD to date and provides important contributions on demographics, clinical characteristics, and gaps in disease management.

How does severe functional mitral regurgitation redefined by European guidelines affect pulmonary vascular resistance and hemodynamics in heart transplant candidates?

OBJECTIVE

Increased pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) are important prognostic factors in patients with heart transplantation (HT). It is well known that severe mitral regurgitation increases pulmonary pressures. However, the European Society of Cardiology and the 6th World Symposium of pulmonary hypertension (PH) task force redefined severe functional mitral regurgitation (FMR) and PH, respectively. We aimed to investigate the effect of severe FMR on PAP and PVR based on these major redefinitions in patients with HT.

METHODS

A total of 212 patients with HT were divided into 2 groups: those with severe FMR (n=70) and without severe FMR (n=142). Severe FMR was defined as effective orifice regurgitation area ≥20 mm2 and regurgitation volume ≥30 mL where the mitral valve was morphologically normal. A mean PAP of >20 mm Hg was accepted as PH. Patients with left ventricular ejection fraction ≤25% were included in the study.

RESULTS

The systolic PAP, mean PAP, and PVR were higher in patients with severe FMR than in those without severe FMR [58.5 (48.0-70.2) versus 45.0 (36.0-64.0), p<0.001; 38.0 (30.2-46.6) versus 31.0 (23.0-39.5), p=0.004; 4.0 (2.3-6.8) versus 2.6 (1.2-4.3), p=0.001, respectively]. Univariate analysis revealed that the severe FMR is a risk factor for PVR ≥3 and 5 WU [odds ratio (OR): 2.0, 95% confidence interval (CI): 1.1-3.6, p=0.009; and OR: 3.2, 95% CI: 1.5-6.7, p=0.002]. The multivariate regression analysis results revealed that presence of severe FMR is an independent risk factor for PVR ≥3 WU and presence of combined pre-post-capillary PH (OR: 2.23, 95% CI: 1.30-3.82, p=0.003 and OR: 2.30, 95% CI: 1.25-4.26, p=0.008).

CONCLUSION

Even in the updated definition of FMR with a lower threshold, severe FMR is associated with higher PVR, systolic PAP, and mean PAP and appears to have an unfavorable effect on pulmonary hemodynamics in patients with HT.

The prognostic role of cardiac troponin in hospitalized COVID-19 patients

BACKGROUND AND AIMS

Myocardial injury defined by elevation of cardiac troponins (cTn) in the course of coronavirus disease 2019 (COVID-19) pandemic has been reported, though not fully characterized yet. Using the Turkish nationwide centralized COVID-19 database, we sought to determine whether cTn measured within 24 h of admission may help identify 30-day all-cause mortality in hospitalized patients.

METHODS

This retrospective cohort study was conducted at all hospitals in Turkey between March 11, 2020, and June 22, 2020. All hospitalized COVID-19 patients (≥18 years) who had cTn measurements within 24 h of admission were included. The primary outcome was 30-day all-cause mortality.

RESULTS

A total of 14,855 COVID-19 patients (median age 49 years and 54% male) from 81 provinces of Turkey were included. Of these, 2020 patients (13.6%) were transferred to intensive care unit, 1165 patients (7.8%) needed mechanical ventilation, and 882 patients (5.9%) died during hospitalization. The prevalence of cTn positivity was 6.9% (n = 1027) in the hospitalized patients. cTn positivity was 5% in those patients alive at 30-day, and 44% in those who died. In multivariable Cox proportional hazard regression model, age, lactate dehydrogenase, and cTn were the strongest predictors of 30-day mortality, irrespective of cTn definition as a continuous, ordinal variable, or dichotomic variables.

CONCLUSIONS

A single measurement of cTn at admission in patients with COVID-19 is associated with 30-day all-cause mortality and may have an important prognostic role for optimizing risk stratification.

Unicuspid aortic valve with false aortic dissection appearance: A case report

Unicuspid aortic valve (UAV) is a rare congenital anomaly that usually presents with aortic stenosis or mixed stenosis and regurgitation early in life. Ascending aortic aneurysm and aortic dissection are important complications of UAVs. A 27-year-old man presented to the emergency department with a complaint of acute chest pain. Bedside transthoracic echocardiography (TTE) showed dilatation of ascending aorta (47 mm) and mild aortic regurgitation; computed tomography (CT) angiography revealed a suspicious dissection flap within ascending aorta. A cardiovascular surgeon, a radiologist, and a cardiologist were immediately consulted. TTE performed by the cardiologist revealed a unicuspid unicommissural aortic valve and dilated ascending aorta with no signs of dissection. Aortic dissection image on CT angiogram was interpreted by an experienced radiologist and the cardiovascular surgeon as superior pericardial recess and considered as a false-positive dissection image. Given the patient was pain-free, the CT image was considered false positive and as TTE clearly visualized the ascending aorta, the heart team decided that no further imaging is required. After excluding acute aortic syndrome, acute coronary syndrome, and other causes of acute chest pain, the patient was discharged with close follow-up. Diagnosis of aortic dissection is based on noninvasive imaging modalities, and CT is the first-line imaging choice in most emergency departments. Depending on a single imaging modality may cause false interpretations and lead to unnecessary surgical explorations.

A Novel Risk Assessment Model Using Urinary System Contrast Blush Grading to Predict Contrast-Induced Acute Kidney Injury in Low-Risk Profile Patients

Contrast-induced acute kidney injury (CI-AKI) can occur after coronary interventions despite protective measures. We evaluated the effect of urinary system contrast blush grading for predicting post-procedure CI-AKI in 486 patients with chronic coronary artery disease. Patient characteristics and blood samples were collected. Urinary system contrast blush grade was recorded during the coronary angiography and interventions. Post-procedure third to fourth day blood samples were collected for diagnosis of CI-AKI. The median age of the patients was 61 years (53-70, interquartile range), and 194 (39.9%) participants were female. Contrast-induced acute kidney injury occurred in 78 (16%) patients. By comparing full and reduced models with the likelihood ratio test, it was observed that in the reduced model, factors such as age, diabetes mellitus, body weight-adapted contrast media (CM), hemoglobin, and urinary system blush were associated with CI-AKI presence. The probability of CI-AKI presence increased slightly from grade 0 to 1 blush, but it increased sharply grade from 1 to 2 blush. According to our results, an increase in body weight-adapted CM and urinary blush grading were the main predictors of CI-AKI. These findings suggest that when body weight-adapted CM ratio exceeds 3.5 mL/kg and urinary contrast blush reaches grade 2, the patients should be followed up more carefully for the development of CI-AKI.

Development and validation of clinical prediction model to estimate the probability of death in hospitalized patients with COVID-19: Insights from a nationwide database

In the current study, we aimed to develop and validate a model, based on our nationwide centralized coronavirus disease 2019 (COVID‐19) database for predicting death. We conducted an observational study (CORONATION‐TR registry). All patients hospitalized with COVID‐19 in Turkey between March 11 and June 22, 2020 were included. We developed the model and validated both temporal and geographical models. Model performances were assessed by area under the curve‐receiver operating characteristic (AUC‐ROC or c‐index), R², and calibration plots. The study population comprised a total of 60,980 hospitalized COVID‐19 patients. Of these patients, 7688 (13%) were transferred to intensive care unit, 4867 patients (8.0%) required mechanical ventilation, and 2682 patients (4.0%) died. Advanced age, increased levels of lactate dehydrogenase, C‐reactive protein, neutrophil–lymphocyte ratio, creatinine, albumine, and D‐dimer levels, and pneumonia on computed tomography, diabetes mellitus, and heart failure status at admission were found to be the strongest predictors of death at 30 days in the multivariable logistic regression model (area under the curve‐receiver operating characteristic = 0.942; 95% confidence interval: 0.939–0.945; R² = .457). There were also favorable temporal and geographic validations. We developed and validated the prediction model to identify in‐hospital deaths in all hospitalized COVID‐19 patients. Our model achieved reasonable performances in both temporal and geographic validations.

Incidence of symptomatic venous thromboembolism following hospitalization for coronavirus disease 2019: Prospective results from a multi-center study

Background

Thrombosis and pulmonary embolism appear to be major causes of mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. However, few studies have focused on the incidence of venous thromboembolism (VTE) after hospitalization for COVID-19.

Methods

In this multi-center study, we followed 1529 COVID-19 patients for at least 45 days after hospital discharge, who underwent routine telephone follow-up. In case of signs or symptoms of pulmonary embolism (PE) or deep vein thrombosis (DVT), they were invited for an in-hospital visit with a pulmonologist. The primary outcome was symptomatic VTE within 45 days of hospital discharge.

Results

Of 1529 COVID-19 patients discharged from hospital, a total of 228 (14.9%) reported potential signs or symptoms of PE or DVT and were seen for an in-hospital visit. Of these, 13 and 12 received Doppler ultrasounds or pulmonary CT angiography, respectively, of whom only one patient was diagnosed with symptomatic PE. Of 51 (3.3%) patients who died after discharge, two deaths were attributed to VTE corresponding to a 45-day cumulative rate of symptomatic VTE of 0.2% (95%CI 0.1%–0.6%; n = 3). There was no evidence of acute respiratory distress syndrome (ARDS) in these patients. Other deaths after hospital discharge included myocardial infarction (n = 13), heart failure (n = 9), and stroke (n = 9).

Conclusions

We did not observe a high rate of symptomatic VTE in COVID-19 patients after hospital discharge. Routine extended thromboprophylaxis after hospitalization for COVID-19 may not have a net clinical benefit. Randomized trials may be warranted.

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In a large multi-center study, the incidence of venous thromboembolism in COVID-19 patients followed for 45 days after hospitalization was relatively low.

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Routine extended thromboprophylaxis in COVID-19 patients who have been discharged from the hospital may not have a net clinical benefit.

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Older age, history of recent cancer, and history of recent diabetes were associated with higher risk of mortality after hospital discharge

Syncope in relation to pulmonary arterial obstructive burden, hemodynamic status and short- and long-term outcome in patients with acute pulmonary embolism

Background and aims

Although syncope (S) has been reported as one of the presenting findings in patients (pts) with acute pulmonary embolism (APE), its clinical and haemodynamic correlates and impacts on the long-term outcome in this setting remains to be determined. In this single-centre study we evaluated the clinical and haemodynamic significance of S in APE in initial asessment, and during short- and long-term follow-up period.

Methods

Our study was based on the retrospective and prospective analysis of the overall 641 pts (age 65 (51–74 IQR) yrs, 56.2% female) with diagnosis of documented APE who underwent anticoagulant (n=207), thrombolytic (n=164), utrasound-facilitated thrombolysis (UFT) (n=218) or rheolytic thrombectomy (RT) (n=52). The systematic work- up including multidetector computed tomography (MDCT), Echo, biomarkers, and PE severity indexes were performed in all pts, and Qanadli score (QS) was used as the measure of the thrombotic burden in the pulmonary arteries (PA).

Results

The S as the presenting symptom In 30.2% of pts with APE. At baseline assessment, S(+) vs S(−) APE subgroups had a significantly shorter symptom-diagnosis interval, a higher risk status according to the significant elevations in troponin T, D-dimer, the higher PE severity indexes, a more deteriorated right ventricle/left ventricle ratio (RV/LV r), right atrial/left atrial ratio (LA/RAr) and RV longitudinal function indexes including tricuspid annular planary excursion (TAPSE) and tissue velocity (St), a significantly higher PA obstructive burden as assessed by QS and PA pressures. Thrombolytic therapy (36.2% vs 21%, p&lt;0.001) and RT (11.9% vs 6.47%, p=0.037) were more frequently utilized S(+) as compared to S(−) group. However, all these differences between two subgroups were found to disappear after evidence-based APE treatments. In-hospital mortality (IHM) (12.95% vs 6%, p=0.007) and minor bleeding (10.36% vs 2.9%, p&lt;0.001) were significantly higher in S(+) pts as compared to those in S(−) subgroup. Binominal logistic regression analysis revealed that PESI score and RV/LVr independently associated with S while IHM was only predicted by age and heart rate. The COX proportional hazard method showed that RV/LVr at discharge and malignancy were independently associated with cumulative mortality during follow-up duration of 620 (200–1170 IQ) days.

Conclusions

The presence of S in pts with APE was found to be asociated with a higher PA obstructive burden, a more deteriorated RV function and haemodynamics and higher risk status which may need more agressive reperfusion treatments. However, in the presence of the optimal treatments, S did not predict neither in-hospital outcome, nor long-term mortality.

Funding Acknowledgement

Type of funding source: None