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Niriayo YL, Yemane B, Asgedom SW, Teklay G, Gidey K. Prevalence and predictors of poor self-care behaviors in patients with chronic heart failure. Sci Rep 2024; 14:1984. [PMID: 38263418 PMCID: PMC10805850 DOI: 10.1038/s41598-024-52611-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/21/2024] [Indexed: 01/25/2024] Open
Abstract
Despite the indispensable role of self-care behavior in managing heart failure, the practice of self-care behavior remains poor, especially in developing countries. There is a scarcity of research focusing on poor self-care behavior and its determinants within our specific context. Therefore, the objective of this study was to investigate the prevalence and predictors of poor self-care behavior among ambulatory heart failure patients. A facility-based cross-sectional study was conducted at a tertiary care hospital in Ethiopia, involving patients with heart failure. We utilized the European Heart Failure Self-Care Behavior Scale (EHFScBS-9) to evaluate adherence to self-care behaviors. Data were gathered through patient interviews and a review of medical records. A binary logistic regression analysis was performed to identify predictors of poor self-care behavior in heart failure patients. We included a total of 343 participants in the final analysis of this study. The findings revealed that a majority of the patients (73.8%) demonstrated poor overall self-care behavior. Specifically, the majority of patients did not engage in regular exercise (76.1%), failed to consult doctors in case of rapid weight gain (75.6%), did not monitor weight daily (71.5%), did not restrict fluid intake (69.9%), and did not contact doctors in case of experiencing fatigue (68.6%). Additionally, 32.4% of patients did not reach out to doctors when experiencing shortness of breath, 30% did not restrict salt intake, 29% did not adhere to prescribed medication, and only 7% did not consult doctors if edema occurred. Our findings indicated that rural residence (AOR: 5.76, 95% CI: 2.47-13.43), illiteracy (AOR: 2.64, 95% CI: 1.52-6.31), prior hospitalization (AOR: 2.09, 95% CI: 1.21-3.61), and taking five or more medications (AOR: 1.83, 1.01-3.33) were significant predictors of poor self-care behavior. In conclusion, a majority of the participants in our study demonstrated poor self-care behavior. Risk factors for this behavior included rural residence, illiteracy, prior hospitalization, and taking five or more medications. Therefore, it is crucial to prioritize these high-risk patients and implement interventional programs aimed at improving self-care behaviors and overall treatment outcomes in heart failure patients.
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Affiliation(s)
- Yirga Legesse Niriayo
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia.
| | - Bisrat Yemane
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Solomon Weldegebreal Asgedom
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Gebrehiwot Teklay
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Kidu Gidey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
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Park HW, Ozcan I, Toya T, Ahmad A, Kanaji Y, Kushwaha SS, Lerman LO, Lerman A. Invasive aortic pulse pressure is linked to cardiac allograft vasculopathy after heart transplantation. Int J Cardiol 2023; 370:167-174. [PMID: 36346255 DOI: 10.1016/j.ijcard.2022.10.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulse pressure (PP) has been linked to an increased risk of extent of coronary atherosclerosis and cardiovascular events. This study aimed to investigate the contribution of aortic PP on cardiac allograft vasculopathy (CAV) progression, and cardiovascular events after heart transplantation (HTx). METHODS A total of 330 HTx patients (mean age 49 ± 25 years, 70.0% male) undergoing routine serial coronary intravascular ultrasound (IVUS) studies and had invasive aortic PP were enrolled. The median time from HTx to first IVUS was 13.6 months. CAV progression was assessed by IVUS as the changes (Δ) in plaque volume divided by the segment length (PV/SL), adjusted for the time between IVUS (median, 3.99 years; interquartile range, 1.99-7.20 years), and was defined as ΔPV/SL ≥0.50 mm3/mm/year. Major adverse cardiovascular event (MACE) was defined as any incidence of mortality, myocardial infarction, coronary revascularization, heart failure hospitalization, or re-transplantation. RESULTS Recipient age, recipient sex, and renal dysfunction were independent determinant of high aortic PP (≥ 50 mmHg). High aortic PP was an independent determinant of CAV progression [odds ratio, 1.72; 95% confidence interval (CI), 1.01-2.93; p = 0.045]. Both high aortic PP (HR 1.46, 95% CI 1.01-2.11, p = 0.044) and high baseline CAV grade on angiogram (≥1, HR 1.50, 95% CI 1.03-2.21, p = 0.037) were independently associated with MACEs over 12 years. CONCLUSION In post-HTx patients, high aortic PP was significantly associated with plaque progression. Both aortic PP and CAV grade are independently associated with MACE during long-term follow-up. These findings suggest that arterial stiffness and CAV can be important predictors of MACEs.
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Affiliation(s)
- Hyun Woong Park
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Department of Cardiology in Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, South Korea
| | - Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Department of Internal Medicine, Saint Luis University School of Medicine, Saint Louis, MO, USA
| | - Ali Ahmad
- Division of Cardiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Letsou GV, Bolch CM, Hord EC, Altman WC, Leschinsky B, Criscione JC. The CorInnova Implantable Cardiac Assist System for Direct Cardiac Compression. Rev Cardiovasc Med 2022; 23:211. [PMID: 39077181 PMCID: PMC11273667 DOI: 10.31083/j.rcm2306211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/05/2022] [Accepted: 05/10/2022] [Indexed: 07/31/2024] Open
Abstract
The CorInnova cardiac compression device (CorInnova, Inc., Houston, TX, USA) is designed to provide direct biventricular support, increase cardiac output, and improve ventricular unloading in patients with heart failure. Placed within the pericardium and surrounding both ventricles, the device has two concentric sets of thin-film polyurethane chambers: (1) inner (epicardial) saline-filled chambers that conform intimately to the epicardial surface, eradicating any gaps in the interface between the device and the heart; and (2) outer air-filled chambers cycled to provide epicardial compression during systole and negative epicardial pressure during diastole, consistent with physiological cardiac contraction and relaxation. A superelastic, collapsible Nitinol frame gives the device structure, enables minimally invasive self-deployment, and enhances diastolic filling. Preclinical testing has been extremely promising, with improvements in cardiac output and other cardiac parameters in animal heart failure models. This potentially transformative technology is moving rapidly toward first-in-human use. The CorInnova device may provide an effective device-based solution for patients with heart failure who currently have few or limited mechanical cardiac support options, including patients with biventricular cardiac failure, those with right heart failure, those who are older, and those who are of smaller size. It can be removed easily and requires minimal maintenance. An important, unique feature of this technology is that it provides mechanical cardiac assistance without blood contact or need for anticoagulation. The CorInnova device may be particularly important for those patients who have contraindications to anticoagulation due to allergy, neurological bleeds, or preexisting hemorrhage. No other mechanical circulatory support device addresses these underserved heart-failure populations.
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Affiliation(s)
| | | | | | | | | | - John C. Criscione
- CorInnova, Inc., Houston, TX 77021, USA
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77843, USA
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Baker E, Facultad JL, Slade H, Lee G. A new tool to measure acuity in the community: a case study. Br J Community Nurs 2021; 26:482-492. [PMID: 34632789 DOI: 10.12968/bjcn.2021.26.10.482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The provision of acute healthcare within patients own home (i.e. hospital in the home) is an important method of providing individualised patient-centred care that reduces the need for acute hospital admissions and enables early hospital discharge for appropriate patient groups. The Hospital in the Home (HitH) model of care ensures that this approach maximises patient safety and limits potential risk for patients. As HitH services have seen record numbers of patient referrals in the past 2 years, there is now a greater need to measure and understand the acuity and dependency levels of the caseload. Through an expert clinician development process at one NHS trust, aspects of procedural complexity, interdisciplinary working, risk stratification and comorbidities were used to quantify acuity and dependency. This paper uses a case study approach to present a new method of measuring this important concept.
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Affiliation(s)
- Edward Baker
- Lecturer in Applied Technology for Clinical Care, King's College London, King's College Hospital NHS Foundation Trust
| | - Jose Loreto Facultad
- Associate Chief Nurse-Workforce Transformation and Professional Practice, Buckinghamshire Healthcare NHS Trust
| | - Harriet Slade
- Clinical Development Matron, @home service, Guy's and St Thomas' NHS Foundation Trust
| | - Geraldine Lee
- Reader in Applied Technology for Clinical Care, King's College London
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Chen Y, Zhou S, Zhang A, Huang J, Zhang G, Cui L. Temporal changes and prognostic value of plasma ghrelin level in patients with acute heart failure: a prospective study. Heart Vessels 2021; 37:419-425. [PMID: 34533592 DOI: 10.1007/s00380-021-01935-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Plasma ghrelin levels can be elevated in patients with acute heart failure (AHF). This study aimed to analyze the temporal changes and prognostic value of ghrelin levels in patients with AHF. METHODS This prospective study included patients with AHF at the Cardiology Department, Weifang People's Hospital (May 2018-October 2019), and age- and sex-matched healthy controls. Plasma ghrelin levels were measured. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were used to evaluate whether ghrelin levels could predict major cardiac adverse events (MACEs) during a 1-year follow-up. RESULTS Finally, 92 patients with AHF and 50 healthy controls were enrolled. Ghrelin levels were higher in patients with AHF at 1, 3, 12, and 24 h compared with controls (all P < 0.01). Ghrelin levels in the AHF group were higher at 3 and 12 h than at 1 and 24 h (P < 0.001). Ghrelin level at 3 h in patients with AHF was negatively correlated with the left ventricular end-diastolic diameter and left ventricular ejection fraction (both P < 0.05). MACEs occurred in 48 patients with AHF. Ghrelin levels were higher in the MACE group than in the non-MACE group at 1 (P = 0.011) and 3 h (P = 0.034). Multivariable regression showed that ghrelin level at 3 h was independently associated with MACEs [OR = 0.629, 95% confidence interval (CI): 0.515-0.742, P = 0.010], but the area under the ROC curve was only 0.629 (95% CI 0.515-0.742). CONCLUSIONS Plasma ghrelin levels are elevated in AHF and patients with MACEs during follow-up.
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Affiliation(s)
- Yanbo Chen
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China.,Department of Cardioangiology, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Sani Zhou
- Central Sterile Supply Department, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Aiyuan Zhang
- Department of Cardioangiology, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Jing Huang
- Department of Cardioangiology, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Guangfang Zhang
- Department of Cardioangiology, Weifang People's Hospital, Weifang, 261041, Shandong, China
| | - Lianqun Cui
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China.
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Shabani F, Mohammadi Shahboulaghi F, Dehghan Nayeri N, Hosseini M, Maleki M, Naderi N, Chehrazi M. Optimization of Heart Failure Patients Discharge Plan in Rajaie Cardiovascular Medical and Research Center: An Action Research. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2021; 9:199-214. [PMID: 34222541 PMCID: PMC8242409 DOI: 10.30476/ijcbnm.2021.87770.1461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic heart failure can lead to frequent hospitalizations. Improving the discharge planning is an approach to reduce hospitalization. Since there has not been enough structured and effective discharge plan in Iranian hospitals, the present study was designed to optimize this program. METHOD This is a participatory action research based on Hart and Bond's framework, conducted in a cardiovascular center in Iran from June 2016 to April 2018 during two cycles. Based on the optimization strategies obtained through semi-structured interviews with 15 participants, three focus group discussions and six expert panels, the operational discharge plan, including three areas of patient empowerment, telephone follow-up and home visit, was designed, implemented for three months and evaluated for 23 patients. European Heart Failure Self-Care Behavior Scale and information registration form to record the number of hospitalization and length of hospital stay were used to collect the quantitative data. The non-parametric Wilcoxon test was used to analyze the data by SPSS 16. Qualitative participatory evaluation was performed during a group discussion and analyzed based on qualitative content analysis method with conventional approach P<0.05 was statistically significant. RESULTS Considering the solutions provided by the participants, the operational discharge plan was designed and implemented with the cooperation of relevant stakeholders. Evaluation showed significant effects of designed discharge plan on self-care behavior (P<0.001), number of hospitalizations (P<0.001), and length of hospital stay (P<0.001). CONCLUSION Changes were made to improve the heart failure patients' discharge plan using action research, which resulted in reduced re-hospitalization and improved self-care behavior.
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Affiliation(s)
- Fidan Shabani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Nahid Dehghan Nayeri
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadali Hosseini
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Naderi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Chehrazi
- Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
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Lv H, Yang X, Wang B, Wang S, Du X, Tan Q, Hao Z, Liu Y, Yan J, Xia Y. Machine Learning-Driven Models to Predict Prognostic Outcomes in Patients Hospitalized With Heart Failure Using Electronic Health Records: Retrospective Study. J Med Internet Res 2021; 23:e24996. [PMID: 33871375 PMCID: PMC8094022 DOI: 10.2196/24996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/04/2021] [Accepted: 03/16/2021] [Indexed: 01/16/2023] Open
Abstract
Background With the prevalence of cardiovascular diseases increasing worldwide, early prediction and accurate assessment of heart failure (HF) risk are crucial to meet the clinical demand. Objective Our study objective was to develop machine learning (ML) models based on real-world electronic health records to predict 1-year in-hospital mortality, use of positive inotropic agents, and 1-year all-cause readmission rate. Methods For this single-center study, we recruited patients with newly diagnosed HF hospitalized between December 2010 and August 2018 at the First Affiliated Hospital of Dalian Medical University (Liaoning Province, China). The models were constructed for a population set (90:10 split of data set into training and test sets) using 79 variables during the first hospitalization. Logistic regression, support vector machine, artificial neural network, random forest, and extreme gradient boosting models were investigated for outcome predictions. Results Of the 13,602 patients with HF enrolled in the study, 537 (3.95%) died within 1 year and 2779 patients (20.43%) had a history of use of positive inotropic agents. ML algorithms improved the performance of predictive models for 1-year in-hospital mortality (areas under the curve [AUCs] 0.92-1.00), use of positive inotropic medication (AUCs 0.85-0.96), and 1-year readmission rates (AUCs 0.63-0.96). A decision tree of mortality risk was created and stratified by single variables at levels of high-sensitivity cardiac troponin I (<0.068 μg/L), followed by percentage of lymphocytes (<14.688%) and neutrophil count (4.870×109/L). Conclusions ML techniques based on a large scale of clinical variables can improve outcome predictions for patients with HF. The mortality decision tree may contribute to guiding better clinical risk assessment and decision making.
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Affiliation(s)
- Haichen Lv
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaolei Yang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Bingyi Wang
- Medical Department, Yidu Cloud (Beijing) Technology Co Ltd, Beijing, China
| | - Shaobo Wang
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, China.,AI Lab, Yidu Cloud (Beijing) Technology Co Ltd, Beijing, China
| | - Xiaoyan Du
- Medical Department, Yidu Cloud (Beijing) Technology Co Ltd, Beijing, China
| | - Qian Tan
- Medical Department, Happy Life Technology Co Ltd, Beijing, China
| | - Zhujing Hao
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jun Yan
- AI Lab, Yidu Cloud (Beijing) Technology Co Ltd, Beijing, China
| | - Yunlong Xia
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Wood C. Fluid management: An update for perioperative practitioners. J Perioper Pract 2021; 31:71-79. [PMID: 33472531 DOI: 10.1177/1750458920964174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An interprofessional team approach is required to achieve optimum fluid balance for patients during the perioperative period. Incorrect management of fluid assessment and monitoring is associated with adverse outcomes. The scientific understanding of perioperative fluid balance has improved over recent years leading to changes in clinical practice with regard to volume and choice of intravenous fluid. It is important that perioperative practitioners have an understanding of intravenous fluid, fluid compartmentalisation, fluid mechanics and intravascular fluid control mechanisms. Optimum fluid status not only shortens hospital stay but also reduces the incidence of postoperative nausea and vomiting and complication profiles. This article aims to provide perioperative practitioners with a comprehensive overview of fluid management. It will cover important issues surrounding physiological control of fluid balance, choice of intravenous fluid therapy, methods to monitor intravascular volume and factors which influence delivery.
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Uyar H, Yesil E, Karadeniz M, Orscelik O, Ozkan B, Ozcan T, Cicek Yilmaz D, Celik A. The Effect of High Lactate Level on Mortality in Acute Heart Failure Patients With Reduced Ejection Fraction Without Cardiogenic Shock. Cardiovasc Toxicol 2021; 20:361-369. [PMID: 32048133 DOI: 10.1007/s12012-020-09563-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND We aimed to determine the effect of blood lactate levels on cardiovascular (CV) death and hospitalization for heart failure (HF) in acute HF patients with reduced left ventricular ejection fraction (EF). METHODS Eighty-five acute HF patients with reduced ejection fraction were divided into two groups according to admission blood lactate levels. 48 of them had low blood lactate levels (< 2 mmol/l) and 37 of them had high blood lactate levels (≥ 2 mmol/l). Patients with acute coronary syndrome, cardiogenic shock, sepsis and low blood pressure at admission were excluded from the study. Primary endpoint is the composite of cardiovascular (CV) death and hospitalization for heart failure (HHF) in 6-month follow-up. Secondary endpoint is the change in NT-proBNP levels from admission to 72 h. RESULTS Baseline characteristics of patients were similar in two groups. On baseline echocardiographic evaluation; patients with high lactate revealed a higher mitral E/A ratio (2.34 [0.43-3.31], p = 0.008) and a lower TAPSE ratio (14 [10-27], p = 0.008) than patients with low lactate levels. Over a median follow-up period of 6 months, the primary end point occurred in 28 (75.7%) of 37 patients assigned to high lactate group and in 20 (41.7%) of 48 patients assigned to low lactate group (p = 0.006). High lactate levels significantly increased the risk of CV death and HHF at 6 months by nearly 5.35-fold in acute HF patients with reduced EF. The change in NT-proBNP levels at 72nd hour after admission were similar between two groups. CONCLUSION Higher lactate levels at admission related with higher HHF at 6 months and may be related with higher risk of CV death in acute HF patients with reduced EF.
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Affiliation(s)
- Hakan Uyar
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey
| | - Emrah Yesil
- Department of Cardiology, Toros State Hospital, Mersin, Turkey
| | - Muzaffer Karadeniz
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey
| | - Ozcan Orscelik
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey
| | - Bugra Ozkan
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey
| | - Turkay Ozcan
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey
| | - Dilek Cicek Yilmaz
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey
| | - Ahmet Celik
- Department of Cardiology, Mersin University Medical Faculty, 33343, Mersin, Turkey.
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Duyan M, Ünal AY, Özturan İU, Günsoy E. Contribution of caval index and ejection fraction estimated by e-point septal separation measured by emergency physicians in the clinical diagnosis of acute heart failure. Turk J Emerg Med 2020; 20:105-110. [PMID: 32832729 PMCID: PMC7416849 DOI: 10.4103/2452-2473.290065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/19/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Although the reliability of e-point septal separation (EPSS) and caval index (CI) is proven in the diagnosis of acute heart failure (AHF), how much they contribute to the initial clinical impression is unclear. This study aimed to determine the diagnostic contribution of EPSS and CI to the initial clinical impression of AHF. METHODS This is a prospective observational study conducted in an academic emergency department (ED). The patients admitted to the ED with acute undifferentiated dyspnea were included. Primary diagnosis was made after an initial clinical evaluation, and a secondary diagnosis was made after EPSS and CI measurements. Independent cardiologists made the final diagnosis. The primary outcome was the diagnostic contribution of EPSS and CI to the primary diagnosis. RESULTS A total of 182 patients were included in the study. The primary diagnosis was found with a sensitivity of 0.55 and specificity of 0.84 and the secondary diagnosis was determined with a sensitivity of 0.78 and specificity of 0.83 in predicting the final diagnosis. The agreement coefficient between the primary and final diagnosis was 0.44 and between the secondary diagnosis and the final diagnosis was 0.61. When the primary diagnosis was coherent with secondary diagnosis, sensitivity and specificity were found to be 0.74 and 0.90, respectively. CONCLUSION Although a detailed history and physical examination are the essential factors in shaping clinical perception, CI and EPSS combined significantly contribute to the initial clinical impression.
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Affiliation(s)
- Murat Duyan
- Department of Emergency Medicine, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | | | | | - Ertuğ Günsoy
- Department of Emergency Medicine, Sivas Numune Hospital, Sivas, Turkey
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Li Y, Yuan H, Chen C, Chen C, Ma J, Chen Y, Li Y, Jian Y, Liu D, Ou Z, Ou J. Concentration of circulating microparticles: a new biomarker of acute heart failure after cardiac surgery with cardiopulmonary bypass. SCIENCE CHINA-LIFE SCIENCES 2020; 64:107-116. [PMID: 32548691 DOI: 10.1007/s11427-020-1708-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/12/2020] [Indexed: 12/28/2022]
Abstract
Acute heart failure (AHF) is a severe complication after cardiac surgery with cardiopulmonary bypass (CPB). Although some AHF biomarkers have been used in clinic, they have limitations when applied in the prediction and diagnosis of AHF after cardiac surgery with CPB, and there are still no effective and specific biomarkers. We and other researchers have shown that circulating microparticles (MPs) increased in a variety of cardiovascular diseases. However, whether the concentration of circulating MPs could be a new biomarker for AHF after cardiac surgery remains unknown. Here, 90 patients undergoing cardiac surgery with CPB and 45 healthy subjects were enrolled. Patients were assigned into AHF (n=14) or non-AHF (n=76) group according to the diagnosis criteria of AHF. The concentrations of circulating MPs were determined before, as well as 12 h and 3 days after operation with nanoparticle tracking analysis technique. MPs concentrations in patients before surgery were significantly higher than those of healthy subjects. Plasma levels of MPs were significantly elevated at 12 h after surgery in patients with AHF, but not in those without AHF, and the circulating MPs concentrations at 12 h after surgery were higher in AHF group compared with non-AHF group. Logistic regression analysis indicated that MPs concentration at postoperative 12 h was an independent risk factor for AHF. The area under receiver operating characteristic curve for MPs concentration at postoperative 12 h was 0.81 and the best cut-off value is 5.20×108 particles mL-1 with a sensitivity of 93% and a specificity of 10%. These data suggested that the concentration of circulating MPs might be a new biomarker for the occurrence of AHF after cardiac surgery with CPB.
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Affiliation(s)
- Yuquan Li
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Haoxiang Yuan
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Caiyun Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Chao Chen
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Jian Ma
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Yating Chen
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Yan Li
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Yupeng Jian
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Donghong Liu
- Department of Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Zhijun Ou
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China.,Division of Hypertension and Vascular Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Jingsong Ou
- Division of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China. .,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China. .,NHC key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China. .,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China. .,Guangdong Provincial Key Laboratory of Brain Function and Disease, Guangzhou, 510080, China.
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12
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Harada R, Mantha Y, Hieda M. Back to Basics: Key Physical Examinations and Theories in Patients with Heart Failure. Heart Fail Clin 2020; 16:139-151. [PMID: 32143759 DOI: 10.1016/j.hfc.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Heart failure (HF) is a leading cause of hospitalization. Suitable pharmacologic management is critical. Distinct physical findings such as congestion and peripheral hypoperfusion need to be considered in selecting pharmacologic therapy. By applying the pretest probability and likelihood ratios of unique physical findings of HF to a Markov model, a definite posttest probability can be obtained. This article focuses on the findings of S3, jugular venous pressure, proportional pulse pressure, bendopnea, trepopnea, and various heart murmurs. Incorporating statistical precision in physical assessments, diagnoses of HF can be further refined, providing a sophisticated approach to evaluate patients hemodynamics status noninvasively.
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Affiliation(s)
- Rakushumimarika Harada
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Yogamaya Mantha
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Michinari Hieda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Dallas, TX 75231, USA.
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13
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Long B, Koyfman A, Gottlieb M. Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review. West J Emerg Med 2019; 20:875-884. [PMID: 31738714 PMCID: PMC6860389 DOI: 10.5811/westjem.2019.9.43732] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023] Open
Abstract
Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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14
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Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med 2018; 55:635-646. [DOI: 10.1016/j.jemermed.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/09/2018] [Accepted: 08/03/2018] [Indexed: 12/21/2022]
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15
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Wu T, Chen Y, Du Y, Tao J, Li W, Zhou Z, Yang Z. Circulating exosomal miR-92b-5p is a promising diagnostic biomarker of heart failure with reduced ejection fraction patients hospitalized for acute heart failure. J Thorac Dis 2018; 10:6211-6220. [PMID: 30622793 DOI: 10.21037/jtd.2018.10.52] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Circulating microRNA (miRNA) biomarkers have been extensively reported in cardiovascular diseases (CVDs). However, serum exosomal miRNA (exo-miRNA) as biomarker in patients with heart failure (HF) with reduced ejection fraction (HFrEF) remain largely unexplored. We sought to investigate the potential of three types of serum exo-miRNAs as biomarkers for diagnosis in HFrEF patients who were admitted in hospital because of acute heart failure (AHF). Methods A total of 28 HFrEF patients hospitalized for AHF, including de novo AHF and acute decompensated HF, and 30 volunteers as control group (CG) from 2015 to 2017 were enrolled in this study. Serum exo-miRNAs were extracted and analyzed by NaNOZS-90, electron microscopy, and western blotting. Three types of serum exo-miRNAs (exo-miR-92b-5p, -192-5p, and -320a) were assessed by quantitative real time polymerase chain reaction (qRT-PCR). Results The particle size was confirmed as 40-150 nm using NaNOZS-90 and transmission electron microscopy. Exosomal biomarkers CD63 and Hsp70 were readily detected. The expression level of serum exo-miRNAs were transformed into log2-delta CT in the qPCR assay. The data showed that exo-miR-92b-5p was elevated in HFrEF patients compared with controls. Moreover, exo-miR-92b-5p was inversely correlated with the left ventricular fraction shortening (LVFS) and left ventricular ejection fraction (LVEF), whereas it was positively correlated with left atrial diameter (LAD), left ventricular diastolic diameters (LVDD) and systolic diameters (LVSD). A receiver operating characteristic (ROC) curve was generated for discrimination between HFrEF patients and controls based on exo-miR-92b-5p (P<0.001, sensitivity =71.4%, specificity =83.3%). Conclusions Exo-miR-92b-5p levels in the serum may serve as a marker for HFrEF diagnosis.
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Affiliation(s)
- Tao Wu
- Department of Cardiovascular, the Affiliated Hospital of Medical School of Ningbo University, Ningbo 315020, China
| | - Yichen Chen
- Ningbo Institute of Medical Science, Ningbo 315020, China
| | - Yantao Du
- Ningbo Institute of Medical Science, Ningbo 315020, China
| | - Jin Tao
- Zhejiang Pharmaceutical College, Ningbo 315000, China
| | - Wei Li
- Ningbo Emergency Medical Center, Ningbo 315020, China
| | - Zhong Zhou
- Department of Cardiovascular, the Affiliated Hospital of Medical School of Ningbo University, Ningbo 315020, China
| | - Zhuo Yang
- Department of Cardiovascular, the Affiliated Hospital of Medical School of Ningbo University, Ningbo 315020, China
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16
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Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
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Clinical utility of early use of tolvaptan in very elderly patients with acute decompensated heart failure. Anatol J Cardiol 2017; 18:206-212. [PMID: 28777097 PMCID: PMC5689052 DOI: 10.14744/anatoljcardiol.2017.7628] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: The establishment of an optimal strategy for elderly patients with acute decompensated heart failure (ADHF) is currently an important issue. Particularly in very elderly (VE) patients, ADHF is associated with a poor prognosis. We therefore aimed to evaluate the efficacy and safety of the early use of tolvaptan (TLV) in VE patients. Methods: Of 245 patients with ADHF admitted between March 2013 and July 2014, we prospectively enrolled 111 patients with TLV first administered within 24 h of hospitalization. These were divided into two groups according to the age: VE (≥85 years, n=45) and not very elderly (NVE, <85 years, n=66). The endpoints were the incidence of worsening renal function, death by any cause, or the length of hospital stay. Results: There were no significant differences between the two groups in the incidence of worsening renal function (26.7% in VE vs. 25.8% in not VE, p=0.92), dose of TLV after hospitalization (7.4±0.7 vs. 7.5±1.3 mg/day, p=0.63), mean duration of the use of TLV (4.3±3.5 vs. 5.4±4.8 days, p=0.17), or mean length of hospital stay (16.5±7.8 vs. 15.7±8.0 days, p=0.64). Conclusion: TLV shows similar efficacy and safety in both VE and NVE groups. Even for VE patients with ADHF, initiation of TLV with standard diuretic treatment may have the potential not to increase the incidence of worsening renal function.
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Baydemir C, Ural D, Karaüzüm K, Balcı S, Argan O, Karaüzüm I, Kozdağ G, Ağır AA. Predictors of Long-Term Mortality and Frequent Re-Hospitalization in Patients with Acute Decompensated Heart Failure and Kidney Dysfunction Treated with Renin-Angiotensin System Blockers. Med Sci Monit 2017; 23:3335-3344. [PMID: 28690311 PMCID: PMC5515119 DOI: 10.12659/msm.902786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 01/02/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Assessment of risk for all-cause mortality and re-hospitalization is an important task during discharge of acute heart failure (AHF) patients, as they warrant different management strategies. Treatment with optimal medical therapy may change predictors for these 2 end-points in AHF patients with renal dysfunction. The aim of this study was to evaluate the predictors for long-term outcome in AHF patients with kidney dysfunction who were discharged on optimal medical therapy. MATERIAL AND METHODS The study was conducted retrospectively. The study group consisted of 225 AHF patients with moderate-to-severe kidney dysfunction, who were hospitalized at Kocaeli University Hospital Cardiology Clinic and who were prescribed beta-blockers and ACE-inhibitors or angiotensin II receptor blockers at discharge. Clinical, echocardiographic, and biochemical predictors of the composite of total mortality and frequent re-hospitalization (≥3 hospitalizations during the follow-up) were assessed using Cox regression and the predictors for each end-point were assessed by competing risk regression analysis. RESULTS Incidence of all-cause mortality was 45.3% and frequent readmissions were 49.8% in a median follow-up of 54 months. The associates of the composite end-point were age, NYHA class, respiration rate on admission, eGFR, hypoalbuminemia, mitral valve E/E' ratio, and ejection fraction. In competing risk regression analysis, right-sided HF, hypoalbuminemia, age, and uric acid appeared as independent associates of all-cause mortality, whereas NYHA class, NT-proBNP, mitral valve E/E' ratio, and uric acid were predictors for re-hospitalization. CONCLUSIONS Predictors for all-cause mortality in AHF with kidney dysfunction treated with optimal therapy are mainly related to advanced HF with right-sided dysfunction, whereas frequent re-hospitalization is associated with volume overload manifested by increased mitral E/E' ratio and NT-proBNP levels.
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Affiliation(s)
- Canan Baydemir
- Department of Biostatistics and Medical Informatics, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Dilek Ural
- Department of Cardiology, Koç University, School of Medicine, Istanbul, Turkey
| | - Kurtuluş Karaüzüm
- Department of Cardiology, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Sibel Balcı
- Department of Biostatistics and Medical Informatics, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Onur Argan
- Department of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey
| | - Irem Karaüzüm
- Department of Cardiology, Izmit Seka State Hospital, Kocaeli, Turkey
| | - Güliz Kozdağ
- Department of Cardiology, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Ayşen A. Ağır
- Department of Cardiology, Kocaeli University, School of Medicine, Kocaeli, Turkey
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