Prevention of cardiovascular disease in young adults: Focus on gender differences. A collaborative review from the EAS Young Fellows

A steady rise in cardiovascular morbidity and mortality has been observed in young adults within the last decades. This trend corresponds to an increasing prevalence of traditional cardiovascular risk factors such as obesity and diabetes mellitus type 2 among young adults living in developed countries. Moreover, age-specific risk factors, such as substance abuse, contraceptive medication, and pregnancy-related diseases also correlate with an increased incidence of cardiovascular diseases. In this review, we discuss the available data for young adults on the epidemiology and the rationale for the causality of traditional and newly emerging risk factors of atherosclerotic cardiovascular diseases. We focus on gender-related differences in the exposure to these risk factors, investigate the recent data regarding screening and risk stratification in the young adult population, and describe the current state of the art on lifestyle and therapeutic intervention strategies in the primary prevention setting.

QT interval alterations in epilepsy: A thorough investigation between epilepsy subtypes

OBJECTIVES

Cardiac disturbances and rhythm abnormalities which potentially lead sudden unexpected death in epilepsy, have been extensively studied in focal epilepsies. However, studies including generalized epilepsies are scarce and it is not clear whether electrocardiogram parameters reflecting vulnerability to ventricular arrhythmias differ between these groups.

METHODS

Medical records of patients who were followed in epilepsy department of a tertiary center between October 2015 and September 2016 were retrospectively reviewed. 66 generalized and 64 focal epilepsy patients with eligible electrophysiological data were analyzed. QTc interval, QTcd and other electrocardiographic indices were compared between patients with focal vs generalized epilepsy. Another analysis was performed in order to disclose any difference between patients with epilepsy (n:130) and psychogenic non-epileptic seizures. A two-tailed p value < 0.05 was considered significant.

RESULTS

There was no difference in terms of QTc and QTcd between patients with focal and generalized epilepsy [median: 406 ms vs 404 ms, p = 0.119; and median: 46 ms vs 44 ms, p = 0.497, respectively]. However patients with epilepsy were found to have longer QTc and QTcd when compared to ones with psychogenic non-epileptic seizures (p = 0.035 and p < 0.001, respectively).

CONCLUSION

Current findings demonstrate that patients with epilepsy have longer QTc and QTcd than patients with pure psychogenic non-epileptic seizures. Since there was no difference between patients with focal and generalized epilepsy; QTc interval, QTcd and potential susceptibility to cardiac arrhythmias as a result, could be a consequence of epilepsy itself regardless of origin.

Periaortic adipose tissue volume is associated with sclerotic changes in the adjacent aortic valve

Aortic sclerosis is associated with increased cardiovascular mortality and morbidity. Numerous studies have shown that visceral adiposity is associated with development of atherosclerosis, especially in the adjacent vascular wall. Considering the similar pathophysiology of aortic sclerosis and atherosclerosis, it can be hypothesized that visceral adipose tissue adjacent to aortic valve may be associated with aortic sclerosis. In this study, we investigated the relationship between periaortic adipose tissue volume and sclerotic changes in the adjacent aortic valve. In this retrospective study, 80 patients with a concurrent MSCT and echocardiography in the last 6 months were enrolled. Echocardiographic examinations were retrospectively evaluated regarding the presence of aortic sclerosis. Periaortic adipose tissue volume was calculated on a computer assisted work station (Leonardo Workstation, Siemens, Erlangen, Germany) by an experienced radiologist. Patient group (61.63 ± 8.55 years and 50% male) and the control group (61.45 ± 5.68 years, 50% male) each consisted 40 participants. Patient group had significantly higher BUN (42.50 (15.00-211.00) vs. 34.00 (12.00-107.00) mg/dL, p = 0.003), uric acid (5.40 (3.40-14.70) vs. 4.30 (2.30-6.70) ng/mL, p = 0.005) and LDL-C levels (121.50 (60.00-215.00) vs. 86.50 (49.00-209.00) mg/dL, p = 0.001) when compared to control group. Patient group had also significantly higher periaortic adipose tissue volume (32.45 (11.70-51.23) vs. 16.00 (6.29-32.96) ml, p < 0.001). Multivariate regression analysis revealed that periaortic adipose tissue volume was independently associated with the presence of aortic sclerosis (OR 0.241, 95% CI 0.143-0.946, p = 0.001). In this study, we demonstrated for the first time that periaortic adipose tissue volume was independently associated with the presence of sclerotic changes in the adjacent aortic valve.

Anti-inflammatory therapy in atherosclerosis

Cardiovascular disease (CVD) is the leading cause of death. Although once considered merely as a lipid storage disease, studies indicate the role of inflammation in initiation and progression of atherosclerotic CVD, as well as the development of thrombotic complications. Despite significant advances in treatment of atherosclerosis, there still exists a residual risk for CVD-related morbidity and mortality. Even with optimal treatment, the rate of a new event after an index acute coronary syndrome event, such as myocardial ischemia or infarction, in the first three years has been reported to be as high as 20%. In the last decades, inflammation due to apoB-lipoproteins and other traditional risk factors, such as hypertension, diabetes and smoking, is accepted as a new target for CVD prevention. Up to now, several anti-inflammatory drugs have been tested for use in atherosclerosis. This review focuses on the current status of anti-inflammatory drug therapy for atherosclerotic CVD in humans.

P1920Long-term outcomes of pulmonary vein isolation using second-generation cryoballoon during atrial fibrillation ablation: A single-center large-scale study

Background

Currently available second-generation cryoballoon (CB2) is accepted as an effective and safe tool for pulmonary vein isolation (PVI). Although much more data exists about 1-year outcomes of CB2 ablation, data on long-term outcomes are scarce. Objective: We aimed to assess the long-term outcomes of PVI using CB2 in a large-scale symptomatic AF population at our tertiary referral center.

Methods

In this non-randomized prospective observational study, a total of 486 patients with paroxysmal (71%) or persistent (29%) AF who underwent index PVI using CB2 at our hospital between January 2013 and June 2017 were enrolled. Atrial tachyarrhythmia (ATa) free survival was defined as absence of AF, atrial flutter or atrial tachycardia recurrence >30 s following 3-months blanking period. Predictors of recurrence were evaluated by univariate and multivariate Cox proportional hazards regression models.

Results

Acute procedural success rate was 99.8% (1898/1902 PVs). Mean procedural and fluoroscopy time were 64.9±9.2 and 12.1±2.6, respectively. At median 39 (IQR: 26–56) months follow-up, ATa free survival was 78.6% after a single procedure (280/345 [81.2%] for paroxysmal AF vs 102/141 [72.3%] for persistent AF, p=0.019) and 84.4% after a mean 1.48±0.42 ablations.Cox regression analysis showed that left atrium diameter, duration of AF history and early ATa recurrence were found as the independent predictors of late recurrence. PNP was observed in 17 (3.5%) patients.

Figure 1

Conclusions

Second-generation CB based PVI is effective to maintain sinus rhythm in a significant proportion of paroxysmal and early persistent AF patients with an acceptable complication rates at long-term follow-up.

Vitamin D replacement ameliorates serum lipoprotein functions, adipokine profile and subclinical atherosclerosis in pre-menopausal women

BACKGROUND AND AIMS

Low vitamin D (vitD) has been linked to increased cardiovascular (CV) risk, but the effects of vitD supplementation are not clarified. We evaluated the impact of vitD normalization on HDL cholesterol efflux capacity (CEC), which inversely correlates with CV risk, the proatherogenic serum cholesterol loading capacity (CLC), adipokine profile and subclinical atherosclerosis.

METHODS AND RESULTS

Healthy premenopausal women with vitD deficiency (n = 31) underwent supplementation. Subclinical atherosclerosis was evaluated by flow-mediated dilation (FMD), pulse wave velocity (PWV) and augmentation index (AIx), measured with standard techniques. HDL CEC and serum CLC were measured by a radioisotopic and fluorimetric assay, respectively. Malondialdehyde (MDA) in HDL was quantified by the TBARS assay. Pre-β HDL was assessed by 2D-electrophoresis. Serum adipokines were measured by ELISA. VitD replacement restored normal levels of serum 25-hydroxyvitamin D (25OHD) and significantly improved FMD (+4%; p < 0.001), PWV (-4.1%: p < 0.001) and AIx (-16.1%; p < 0.001). Total CEC was significantly improved (+19.5%; p = 0.003), with a specific increase in the ABCA1-mediated CEC (+70.8%; p < 0.001). HDL-MDA slightly but significantly decreased (-9.6%; p = 0.027), while no difference was detected in pre-β HDL. No change was observed in aqueous diffusion nor in the ABCG1-mediated CEC. Serum CLC was significantly reduced (-13.3%; p = 0.026). Levels of adiponectin were increased (+50.6%; p < 0.0001) and resistin levels were decreased (-24.3%; p < 0.0001). After vitD replacement, an inverse relationship was found linking the ABCA1-mediated CEC with pre-β HDL (r² = 0.346; p < 0.001) and resistin (r² = 0.220; p = 0.009).

CONCLUSION

Our data support vitD supplementation for CV risk prevention.

Anti-Hyperglycemic Agents for the Treatment of Type 2 Diabetes Mellitus: Role in Cardioprotection During the Last Decade

Type 2 diabetic patients are known to have a tendency to develop cardiovascular (CV) disease (CVD), and related unfavourable outcomes such as heart failure, myocardial infarction (MI), cerebrovascular events (e.g. stroke), and related mortality. Long- term clinical trials have revealed contradictory findings regarding the relationship between glycemic control and CV benefits due to variations in the key characteristics of the study population. During the last decade, number of pharmacological agents used for glucose- lowering in the treatment of type 2 diabetes mellitus (T2DM) has increased owing to the introduction of dipeptidyl peptidase- IV (DPP- IV) inhibitors, glucagon- like peptide- 1 (GLP- 1) receptor agonists, and sodium-glucose co-transporter 2 (SGLT- 2) inhibitors. This review aims to focus on the mechanisms of action of these drugs in the cardiovascular system and the trials evaluating their impact on CVD. Furthermore, trials in the last decade evaluating the impact of traditional glucose- lowering drugs on CVD are included. For this purpose, we searched PubMed for articles in English using the search terms "type 2 diabetes mellitus, glucose- lowering drugs, antidiabetic medications, cardiovascular, cardiovascular disease, cardiovascular system" between inception to September 2016. We also searched separately for each medication in addition to the keyword "cardiovascular disease" on PubMed. To identify further articles, we hand searched related citations in review articles and commentaries.

Enhanced serum levels of matrix Gla protein and bone morphogenetic protein in acute coronary syndrome patients

BACKGROUND

Vascular calcification has been found to be associated with increased risk of cardiovascular (CV) morbidity and mortality. Various bone-associated proteins have been suggested to be related with this process. In this study, we aimed to evaluate whether serum levels of bone morphogenic protein-4 (BMP-4) and matrix Gla protein (MGP) differed in patients who were found to have normal epicardial coronary arteries or a culprit lesion in the coronary angiography leading to acute coronary syndrome (ACS).

METHODS

Patients admitted to emergency department with the diagnosis of ACS who underwent primary percutaneous coronary intervention (PCI) between October 2015 and April 2016 were consecutively recruited as the patient group. Age and gender-matched subjects who underwent coronary angiography following non-invasive ischemia assessment made the control group.

RESULTS

A total of 90 subjects (63.00±14.02 years, 70% male) were included in this study. MGP (<0.001) and BMP-4 (<0.001) levels were significantly elevated when compared to subjects with normal coronary arteries. Fasting blood glucose (P=.024), HDL-cholesterol (P=.002), C-reactive protein (CRP) (P=.001) levels, and left ventricular ejection fraction (LVEF) (P=.021) were significantly correlated with serum MGP levels. HDL-cholesterol (P=.001) and CRP (P=.030) levels were also significantly correlated with serum BMP-4 levels. In the model including HDL-cholesterol, CRP, MGP, and BMP-4 levels, only MGP (odds ratio[OR]: 1.018, P=.019) and BMP-4 (OR: 1.313, P=.023) were found to be independently associated with ACS.

CONCLUSION

This study shows that serum BMP-4 and MGP are independently associated with ACS occurrence when adjusted for other CV risk factors. These biomarkers may have a diagnostic potential in ACS patients.

Management of Blood Pressure and Heart Rate in Acute Decompensated Heart Failure with Volume Overload

BACKGROUND

Heart failure (HF) is a global health problem. Like most chronic diseases, HF also courses with acute exacerbations, which have been found to be associated with significant morbidity and mortality. A substantial proportion of acute decompensated heart failure (ADHF) patients clinically present with volume overload.

METHODS

The goal of this work was to review the current literature and recent guidelines of European Society of Cardiology and American Heart Association/ American College of Cardiology regarding the management strategies in patients with ADHF and volume overload.

RESULTS

In the setting of ADHF and volume overload, prompt diagnosis of the disease should be made. Underlying pathologies should be identified and corrected if possible. Specific approaches may be necessary depending on the etiology.

DISCUSSION

Current guidelines direct clinicians on the appropriate principles of management in this group of patients; however, approach should be individualized.

Serum galectin-3 level as a marker of thrombogenicity in atrial fibrillation

BACKGROUND

Left atrial appendage flow velocity (LAAFV) and presence of spontaneous echo contrast (SEC) have been reported to be predictors of thromboembolism in atrial fibrillation (AF) patients. Galectin-3 is a biomarker reflecting pro-inflammatory status, whose role in AF has recently drawn attention, particularly in persistent AF population.

AIM

In this study we aimed to investigate the association between serum galectin-3 levels and echocardiographic predictors of thromboembolism in persistent AF patients.

METHODS

We included 65 persistent AF patients (55.50±10.67 years, 46.15% male). Transesophageal echocardiography (TEE) was performed to assess LAAFV and presence of left atrial (LA)/LA appendage (LAA)-located SEC and thrombus prior to direct current cardioversion or catheter ablation for AF.

RESULTS

Median galectin-3 level was 0.63 ng/mL. Serum galectin-3 levels were significantly correlated with LAAFV (r=-.440, P<.001). Serum galectin-3 levels were associated with presence of SEC (P<.001), and LA thrombus (P=.008). Receiver operating characteristic analysis revealed that a serum galectin-3 greater or equal to the cut-off value of 0.69 predicted presence of SEC with a sensitivity and specificity of 91.00% and 79.00%, respectively (P<.001).

CONCLUSION

In conclusion, in the setting of persistent AF, serum galectin-3 levels are associated with presence of SEC and LAAFV on TEE. Our findings suggest that serum galectin-3 level may have a place in thromboembolism risk stratification in persistent AF patients.

Enhanced S100A9 and S100A12 expression in acute coronary syndrome

AIMS

In this study, we aimed to investigate whether serum S100A8, S100A9 and S100A12 levels were markers of acute coronary syndrome (ACS).

MATERIALS & METHODS

Patients who underwent coronary angiography and/or percutaneous coronary interventions between June 2015-October 2015 were consecutively recruited in this study and categorized three groups each containing 30 patients (normal coronary arteries, stable coronary artery disease, and acute coronary syndrome). Baseline characteristics, including co- morbidities and medications, were recorded and serum S100A8, S100A9, S100A12, and C- reactive protein levels were measured besides routine laboratory tests.

RESULTS

A total of 90 patients (63.00 [56.00-73.00] years, 62.89% male) have been included. None of the groups differed from each other regarding baseline characteristics (p > 0.05). S100A9 levels were elevated in ACS when compared with the normal coronary arteries (p = 0.033) and S100A12 levels were found to be elevated in ACS when compared with both patients with normal coronary arteries and stable coronary artery disease (p = 0.001). S100A12 was identified as an independent associate of ACS (p = 0.002).

CONCLUSION

These results suggest that S100A12 may serve as a marker of coronary plaque instability, and may have a therapeutic implication in ACS treatment.

Traditional and Alternative Therapies for Refractory Angina

Refractory angina (RFA) is an unfavourable condition that is characterized with persistent angina due to reversible myocardial ischemia in patients with coronary artery disease that remains uncontrollable despite an optimal combination of pharmacological agents and revascularization. Despite significant advances in revascularization techniques and agents used in pharmacological therapy, there is still a significant population suffering from RFA and the global prevalence is even increasing. Anti- anginal treatment and secondary risk-factor modification are the traditional approaches for this group of patients. Furthermore, now there is still a large number of alternative treatment options. In order to review traditional and alternative treatment strategies in patients with RFA, we searched Pubmed for articles in English using the search terms "pharmacological therapy, refractory angina", "alternative therapy, refractory angina" between inception to June 2016. We also went through separately for each alternative treatment modality on Pubmed. To identify further articles, we handsearched related citations in review articles and commentaries. We also included data from the European Society of Cardiology (2013), and the Canadian Society of Cardiology/ Canadian Pain Society (2012) guidelines. Data show that besides traditional pharmacological agents, such as nitrates, beta- blockers or calcium channel blockers, novel antiischemic drugs and if symptoms persist, several non- invasive and/ or invasive alternative strategies may be considered. Impact of some pharmacological agents, such as rho- kinase inhibitors, and novel alternative treatment modalities, such as coronary sinus reducers, stem cell therapy, gene and protein therapy, on outcomes are still under investigation.

Role of Micronutrients on Subclinical Atherosclerosis Micronutrients in Subclinical Atherosclerosis

Atherosclerotic cardiovascular disease (CVD) leading to coronary heart disease is the leading cause of morbidity and mortality in the world. Nutrition is one of the key factors in the etiology of atherosclerosis. Micronutrient supplements are widely used to prevent many chronic diseases including atherosclerosis. However, scientific evidence regarding this issue is still insufficient and current data on the association of dietary micronutrients and CVD risk is contradictory. Most of the randomized studies have failed to demonstrate beneficial effects of micronutrient supplementation on markers of subclinical atherosclerosis. In this review, role of each micronutrient on subclinical atherosclerosis will be evaluated thoroughly.

Enhanced Platelet Toll-like Receptor 2 and 4 Expression in Acute Coronary Syndrome and Stable Angina Pectoris

Evidence is accumulating that toll-like receptors (TLR) are involved in the initiation and progression of cardiovascular disease. Enhanced expression of these receptors on monocytes has been shown in patients with acute coronary syndrome (ACS). However, expression on platelets in this group of patients has not been evaluated yet. We aimed to demonstrate the possible relationship of platelet TLR-2 and TLR-4 expressions with stable coronary artery disease and ACS pathogenesis. In this observational case-control study, 40 patients diagnosed with ACS (unstable angina pectoris, non-ST-segment elevation and ST-segment elevation ACS), 40 patients diagnosed with stable coronary artery disease, and 40 age- and gender-matched subjects with normal coronary arteries were involved. Platelet TLR-2 and TLR-4 expressions were evaluated by flow cytometry in peripheral venous blood samples obtained before coronary angiography. A total of 120 patients (60.7 ± 12.3 years, 50% men) were included. Median platelet TLR-2 and TLR-4 expressions were greater in patients with ACS compared to those with stable angina pectoris and normal coronary arteries (29.5% vs 10.5% vs 3.0%, p <0.001 and 40.5% vs 11.5% vs 3.0%, p <0.001, respectively). Median platelet TLR-2 and TLR-4 expressions were also greater in patients with stable angina pectoris compared to those with normal coronary arteries (p <0.05). In conclusion, this is the first study demonstrating enhanced TLR-2 and TLR-4 expressions on platelets in patients with ACS. These findings may suggest that platelet TLR expression as a novel potential prophylactic and therapeutic target in ACS.

Lone AF: is There a Rationale?

Although atrial fibrillation (AF) development has been demonstrated to be associated with underlying cardiovascular conditions such as hypertension, valvular heart disease or diabetes mellitus; in a subset of relatively younger patients, no cardiopulmonary disease diagnosis can be established. AF patients younger than 60 years without clinical or echocardiographic evidence of cardiopulmonary disease are defined as lone AF patients. Despite the decrease in lone AF prevalence due to advances in understanding of AF pathogenesis, there are still issues yet to be resolved. Future studies are needed to demonstrate the cost- effectiveness of the routine use of more advanced diagnostic tools, such as non- invasive assessment of endothelial function, autoimmune markers or genetic screening and whether they would have clinical implications on treatment of lone AF. This review focuses on the suggested mechanisms in lone AF initiation and maintenance.

Preoperative frontal QRS-T angle is an independent correlate of hospital length of stay and predictor of haemodynamic support requirement following off-pump coronary artery bypass graft surgery

OBJECTIVES

With the adoption of novel operative techniques and aggressive care protocols that facilitate earlier extubation and mobilization of patients, postoperative length of stay (LOS) following coronary artery bypass graft surgery (CABG) has declined. However, there is paucity of information regarding preoperative electrocardiographic predictors of LOS following CABG. In this study, we investigated whether frontal QRS-T angle, which is an abnormal repolarization marker in prediction of various cardiovascular events, was an independent correlate of postoperative hospital LOS for off-pump CABG. Furthermore, we evaluated independent predictors of vasopressor agent/intra-aortic balloon pump (IABP) support requirement following off-pump CABG.

METHODS

In this observational study, 78 patients with stable angina, who were scheduled for elective coronary artery bypass surgery following diagnosis of obstructive coronary artery disease by conventional angiography, were enrolled.

RESULTS

Left ventricular ejection fraction (LVEF) was significantly lower and vasopressor agent/IABP support requirement and incidence of sustained atrial or ventricular arrhythmias was higher in patients with wide QRS-T angle (P < 0.05). Postoperative hospital LOS was also longer in this group. From the preoperative characteristics, wide frontal QRS-T angle was found to be an independent correlate of postoperative hospital LOS (B ± SD: 11.97 ± 0.62, P ≤ 0.01). Wide frontal QRS-T angle was also found to be an independent predictor of vasopressor agent/IABP support requirement postoperatively (OR: 7.87, P ≤ 0.01).

CONCLUSIONS

Prediction of the hospital LOS and patient outcome following CABG is of great importance. Being easily obtainable via standard 12-lead electrocardiogram and its low cost may make frontal QRS-T angle a beneficial marker for reducing both patient-based morbidity and economic burden.

Periatrial epicardial adipose tissue thickness is an independent predictor of atrial fibrillation recurrence after cryoballoon-based pulmonary vein isolation

BACKGROUND

Epicardial adipose tissue (EAT) is a metabolically active fat depot. Studies have investigated the effect of EAT thickness on outcomes of radiofrequency catheter ablation of atrial fibrillation (AF). However, data on the relationship between EAT thickness and outcome of cryoballoon-based pulmonary vein isolation (PVI) are lacking.

OBJECTIVE

In this study, we investigate the association between EAT thickness and AF recurrence after cryoballoon-based PVI.

METHODS

Patients with symptomatic paroxysmal or persistent AF despite ≥1 antiarrhythmic drug(s) were scheduled for cryoballoon-based PVI for AF per the recent recommendations. Periatrial, periventricular, and total EAT thickness measurements were obtained from preprocedural multidetector CT scans.

RESULTS

A total of 249 patients (55.6 ± 10.7 years; 48.2% male; 18.5% persistent AF) were involved in the study. Patients were followed-up for 29 months (8-48 months). When blanking period was considered, freedom from AF after the ablation procedure was 75.9% at a median follow-up of 29 months. Total periatrial EAT thickness (18.1 ± 6.2 vs. 14.7 ± 4.7 mm; P < .001) was greater in patients with late AF recurrence when compared to those without. On the other hand, periventricular or total EAT thickness measurements did not differ between both groups (P > .05). Multivariate Cox proportional hazard regression analysis showed that periatrial EAT thickness (hazard ratio, 1.086; P = .001) and left atrial volume index (hazard ratio, 1.144; P < .001) were independent predictors for late AF recurrence.

CONCLUSION

Quantification of EAT thickness from preprocedural multidetector CT scans may serve as a beneficial parameter for prediction of AF recurrence after cryoballoon-based PVI.

Effects of persistent atrial fibrillation on serum galectin-3 levels

Galectin-3 is known to play an important role in a number of fibrotic conditions, including cardiac fibrosis. Many studies have focused on the association between galectin-3 levels and cardiac fibrosis in heart failure. However, the role of galectin-3 in the pathogenesis of atrial fibrillation (AF) has not been evaluated thoroughly yet. The aim of this study was to determine whether serum galectin-3 levels were elevated in patients with AF and preserved left ventricular function. Seventy-six patients with paroxysmal or persistent AF and preserved left ventricular systolic function and 75 age- and gender-matched control subjects were enrolled in this observational study. Galectin-3 levels were measured by enzyme-linked immunosorbent assay. Serum galectin-3 (median 0.6 ng/ml [interquartile range 0.2 to 1.4] vs 0.5 ng/ml [interquartile range 0.1 to 0.7], p <0.001) and left atrial volume index (LAVI) (mean 29.5 ± 3.5 vs 26.5 ± 2.5 ml/m(2), p <0.001) were significantly greater in patients with AF compared with the control group. Serum galectin-3 levels were also significantly higher in patients with persistent AF than those with paroxysmal AF (median 0.8 ng/ml [interquartile range 0.4 to 1.4] vs 0.5 ng/ml [interquartile range 0.2 to 0.9], p <0.001). Multivariate regression analysis demonstrated that serum galectin-3 (odds ratio 87.53, 95% confidence interval 6.06 to 1,265.03, p = 0.001) and LAVI (odds ratio 1.38, 95% confidence interval 1.19 to 1.60, p <0.001) were independent predictors of AF. Only LAVI was independently correlated with serum galectin-3 levels in patients with AF in linear regression analysis. In conclusion, serum galectin-3 is significantly elevated and is also significantly correlated with LAVI in patients with AF with preserved left ventricular function.

M2-muscarinic acetylcholine receptor autoantibody levels predict left atrial fibrosis severity in paroxysmal lone atrial fibrillation patients undergoing cryoablation

AIMS

Atrial fibrosis has been found to be associated with recurrent atrial fibrillation (AF) following catheter ablation. Autoantibodies against M2-muscarinic receptors (anti-M2-R) may play a role in the development of AF by inducing left atrial (LA) fibrosis. In this study, we aim to compare anti-M2-R levels between paroxysmal lone AF patients and healthy control subjects and to investigate the relationship between pre-ablation anti-M2-R level, LA fibrosis quantified by delayed enhancement magnetic resonance imaging (DE-MRI), and AF recurrence following cryoablation.

METHODS AND RESULTS

Thirty-one patients with paroxysmal lone AF (53.4 ± 8.0 years, 61% male), who underwent cryoballoon-based ablation, along with 31 healthy control subjects were included. Enzyme-linked immunosorbent assay tests to measure serum anti-M2-R levels were performed in both groups and DE-MRI was done to quantify LA fibrosis prior to the ablation in the patients. Anti-M2-R levels were higher in the study population when compared with control subjects [212.4 (103.2-655.5) vs. 73.0 (39.5-299.1) ng/mL, P < 0.001]. Anti-M2-R level predicted moderate-extensive LA fibrosis independent of other measures [odds ratio: 1.26 (95% confidence interval (CI): 1.04-1.53), P = 0.017]. At a mean follow-up of 35.2 ± 3.5 months, nine patients (29.0%) had AF recurrence. In the Cox regression model including pre-ablation anti-M2-R level, LA diameter, LA volume index, and moderate-extensive LA fibrosis, only moderate-extensive LA fibrosis predicted late AF recurrence independent of other measures [hazard ratio: 29.41 (95% CI: 3.52-250.00), P = 0.002].

CONCLUSION

Serum anti-M2-R levels may be associated with the severity of LA fibrosis and may be implicated in the pathophysiology of AF recurrence following cryoablation. Detection of anti-M2-R levels may help select appropriate patients for the procedure.

Epicardial Fat Thickness is Increased in Vitamin D Deficient Premenopausal Women and does not Decrease after Short-term Replacement

AIM

Vitamin D deficiency, which is prevalent among young women in Middle Eastern populations, has been linked to cardiovascular disease. Epicardial adipose tissue (EAT) has also been found to be associated with coronary artery disease. However, data on the relationship between vitamin D status and epicardial adiposity is limited. This study aims to investigate the effect of vitamin D deficiency and replacement therapy on EAT thickness in healthy, young premenopausal women.

METHODS

Thirty-one premenopausal women with vitamin D deficiency and 31 age-matched women with normal vitamin D levels were enrolled in this study. EAT thickness was measured echocardiographically. Measurements were performed at baseline in both groups and were repeated at the 6-month follow-up in vitamin D deficient subjects after vitamin D replacement therapy.

RESULTS

The baseline plasma 25-hydroxyvitamin D levels were lower in the vitamin D deficient group compared to the control group and were significantly improved following replacement therapy. EAT thickness was significantly higher in the vitamin D deficient group, and no significant change occurred following replacement therapy. In the linear regression analysis, waist circumference (β=0.031 [0.005-0.057], p=0.020) and 25(OH)D level (β=－0.020 [(－0.028)－(－0.013)], p＜0.001) independently correlated with EAT thickness.

CONCLUSION

Vitamin D deficiency is associated with a significant increase in EAT thickness in premenopausal women; however, a net beneficial response to adequate replacement therapy was not observed during the short period of therapy during our study. Longer periods of replacement therapy and follow-up may be useful to demonstrate the potential beneficial effects of vitamin D replacement on epicardial adiposity.

Red blood cell distribution width predicts outcome of cryoballoon-based atrial fibrillation ablation

PURPOSE

Elevated red blood cell distribution width (RDW) has been associated with atrial fibrillation (AF) in cross-sectional and prospective studies. In this study, we aim to evaluate the relation of preablation RDW levels to late AF recurrence following cryoablation.

METHODS

A total of 299 patients with symptomatic paroxysmal or persistent AF despite ≥ 1 antiarrhythmic drug(s) who were scheduled for cryoballoon-based AF ablation were enrolled in this prospective study.

RESULTS

A total of 299 patients (55.40 ± 10.60 years, 49.20 % male) were involved and followed up at a median time of 24 (6-44) months. Patients with late AF recurrence had higher RDW levels (14.30 ± 0.93 vs. 13.52 ± 0.93 %, p < 0.001). Multivariate Cox proportional hazard regression analysis showed that RDW level was an independent predictor for late AF recurrence (HR 1.88, 95 % CI 1.41-2.50, p < 0.001) along with left atrial (LA) diameter (HR 3.09, 95 % CI 1.81-5.27, p < 0.001), duration of AF (HR 1.04, 95 % CI 1.01-1.07, p = 0.02), and early AF recurrence (HR 6.39, 95 % CI 3.41-11.97, p < 0.001). A cut-off level of 13.75 % for RDW predicted late AF recurrence following cryoballoon-based pulmonary vein isolation (PVI) with a sensitivity and specificity of 78.00 and 70.00 %, respectively.

CONCLUSION

These findings suggest that elevated RDW may be a predictor of late recurrence following cryoballoon-based AF ablation. Further studies are needed to establish its exact pathophysiologic and prognostic roles.

A young boy with affected heart and mind: arterial involvement in a patient with undiagnosed Behçet's disease

Behçet's disesase is a vasculitis that manifests with oral and genital ulcerations, skin lesions, uveitis, vascular, central nervous system and gastrointestinal involvement. While most patients develop mucocutaneous and genital ulcers along with eye disease, other patients may also present with arthritis, frank vasculitis, thrombophlebitis and central nervous system disease. This is the first case in the literature, where the diagnosis of Behçet's disease was made secondary to concomitant involvement of coronary and carotid arteries.