Could Impedance Cardiography be a Non-Invasive Alternative Method of Measuring Cardiac Output in Patients with Pulmonary Hypertension?

BACKGROUND

Pulmonary hypertension guidelines recommend invasive right heart catheterization for diagnosis and clinical follow-up. Our aim was to compare non-invasive impedance cardiography with invasive techniques for cardiac index measurements and mortality prediction in patients with pulmonary hypertension.

METHODS

Between 2008 and 2018, 284 right heart catheterizations were performed for the diagnosis of pulmonary hypertension in 215 patients with mean pulmonary artery pressure >25 mm Hg, and at least 2 methods used for cardiac output measurement were included in the study retrospectively. Patients were evaluated with Pearson's correlation in 3 groups: estimated Fick (eFick) method and thermodilution (group 1), eFick method and impedance cardiography (group 2), and thermodilution and impedance cardiography (group 3). We also compared the predictive power of cardiac index measured by different methods for 1-year overall mortality and hospitalizations.

RESULTS

There were strong and moderate positive correlations in groups 1 and 3, respectively (r = 0.634, P <.001, r = 0.534, P =.001), and the weakest correlation was in group 2 (r = 0.390, P =.001). The mean difference (bias) between eFick method versus impedance cardiography, impedance cardiography vs. thermodilution, and eFick method vs. thermodilution was 0.6 mL/min, 0.47 mL/min, and -0.2 mL/min respectively, but limits of agreement were wide. In both groups, cardiac index <2.5 L/min/m2 as measured by thermodilution significantly predicted 1-year mortality. Also, impedance cardiography was better than eFick method in predicting mortality (P =.02).

CONCLUSIONS

Our single-center real-life data showed that for cardiac output and cardiac index measurements, impedance cardiography provides a moderate correlation with thermodilution and is fair with eFick method methods. Moreover, thermodilution appeared superior to both eFick method and impedance cardiography, while impedance cardiography was even better than eFick method in predicting 1-year adverse events, including total mortality and hospitalization, in patients with pulmonary hypertension.

Women, lipids, and atherosclerotic cardiovascular disease: a call to action from the European Atherosclerosis Society

Cardiovascular disease is the leading cause of death in women and men globally, with most due to atherosclerotic cardiovascular disease (ASCVD). Despite progress during the last 30 years, ASCVD mortality is now increasing, with the fastest relative increase in middle-aged women. Missed or delayed diagnosis and undertreatment do not fully explain this burden of disease. Sex-specific factors, such as hypertensive disorders of pregnancy, premature menopause (especially primary ovarian insufficiency), and polycystic ovary syndrome are also relevant, with good evidence that these are associated with greater cardiovascular risk. This position statement from the European Atherosclerosis Society focuses on these factors, as well as sex-specific effects on lipids, including lipoprotein(a), over the life course in women which impact ASCVD risk. Women are also disproportionately impacted (in relative terms) by diabetes, chronic kidney disease, and auto-immune inflammatory disease. All these effects are compounded by sociocultural components related to gender. This panel stresses the need to identify and treat modifiable cardiovascular risk factors earlier in women, especially for those at risk due to sex-specific conditions, to reduce the unacceptably high burden of ASCVD in women.

Could Heart Rate Variability Serve as a Prognostic Factor in Patients with Pulmonary Hypertension? A Single-center Pilot Study

OBJECTIVE

Heart rate variability (HRV), which is defined as cyclic changes in sinus rate with time, is used as a measure of cardiac autonomic tone. Our aim was to determine the impact of HRV on short-term prognosis in pulmonary hypertension (PH).

METHODS

We enrolled 64 PH patients and 69 healthy subjects (control group). Patients were evaluated by Holter-ECG, echocardiography, and laboratory tests. 24-h Holter-ECG monitoring was used for HRV. The development of adverse events (right heart failure, hospitalization, syncope, and death) during the 6-month follow-up was evaluated in PH group.

RESULTS

PH group (39 ± 16 years, 37.5% males) comprised of 16 patients with idiopathic pulmonary arterial hypertension (PAH) (25%), 36 patients with PAH associated with congenital heart disease (56.3%), 3 PAH associated with connective tissue disease (4.7%), 1 with portopulmonary (1.6%), and 8 chronic thromboembolic PH (12.5%). The time-dependent (standard deviation of all NN intervals for a selected time period [SDNN], standard deviation of the 5-min mean R-R intervals tabulated over an entire day [SDANN], SDNN Index, and Triangular Index) and frequency-dependent HRV indices (low frequency, high-frequency power, and total power,) were significantly reduced in those with PH. Functional class was negatively associated with SDNN, SDANN, SDNN Index, and Triangular Index. Adverse events developed in 25% of the patients during the 6-month follow-up period (200 ± 92 days) (7 patients had right-heart failure, 5 syncope, 12 patients were hospitalized, and 9 had died). All the time and frequency-dependent indices significantly associated with adverse events. Mortality correlated with SDNN (rS = -0.354, P = 0.005), SDANN (rS = -0.368, P = 0.004), SDNN Index (rS = -0.257, P = 0.045), Triangular Index (rS = -0.310, P = 0.014), and VLF (rS = -0.265, P = 0.039).

CONCLUSION

HRV is significantly depressed in patients with PH and is associated with the clinical status. HRV indices might predict clinical deterioration, adverse events, and mortality for 6 months. Non-invasive assessment of HRV through Holter-ECG may be a valuable and practical tool in risk stratification of patients with PH for short-term outcomes.

Long-Term Natural Course of Patients with Pulmonary Artery Pressures in the Range of 21-24 mmHg: Insights from a Single-Center Study

OBJECTIVE

Slightly elevated mean pulmonary artery pressure (mPAP) was previously termed as ''borderline pulmonary hypertension (PH)''. We examined the long-term prognosis of patients with mPAP values between 21 and 24 mmHg, who were referred with the suspicion of pulmonary hypertension.

METHODS

Our retrospective study included patients with moderate-to-high echocardiographic risk who underwent right heart catheterization (RHC) between 2008 and 2021 and were followed for at least 1 year. Patients with mPAP <21 mmHg and mPAP 21-24 mmHg were compared. Demographic and clinical characteristics and prognoses of the groups were compared. All-cause mortality over a mean follow-up of 5 years (min 1-max 13 years) was evaluated.

RESULTS

A total of 140 patients (mean age 53.1 ± 14.8 years, female 74.5%) with mPAP values <25 mmHg measured of the 395 diagnostic RHCs. Mean follow-up was 4.92 ± 3.13 years. NT-pro-BNP and 6-min walking distance were better in patients with mPAP <21 mmHg. Echocardiographic findings suggestive of PH were more common in mPAP 21-24 mmHg group (P < 0.05). Both the pulmonary artery wedge pressure and cardiac index values were significantly deteriorated in individuals with mPAP 21-24 mmHg (P = 0.001). All-cause mortality tended to be higher in the borderline PH group but did not reach to statistical significance.

CONCLUSION

Our single-center observational study revealed that the individuals with an mPAP of 21-24 mmHg tended to have a worser prognosis than those with mPAP of <21 mmHg for up to 13-year follow-up.

Lipid Modification to Reduce Cardiovascular Risk in Secondary Prevention Patients with Special Emphasis on PCSK9 Inhibitor Requirement: An Analysis Based on Delphi Panel Approach

OBJECTIVE

The aim of this study is to analyze the low-density lipoprotein cholesterol-lowering therapies in secondary prevention patients by analyzing their plasma low-density lipoprotein cholesterol levels, current treatment, considering their inadequate response to medications (as defined in current guidelines), and the requirement for a protein convertase subtilisin/kexin type 9 inhibitor.

METHODS

Delphi panel is used to seek expert consensus of experienced 12 cardiologists. A questionnaire consisting of 6 main questions is used to reflect the opinion of the expert panelists on the practices of low-density lipoprotein cholesterol-lowering therapies of patients with high and very high cardiovascular risk. Patients with atherosclerotic cardiovascular disease are covered in this present analysis.

RESULTS

According to expert opinion data, 18.6% of the patient population with atherosclerotic cardiovascular disease is estimated to have experienced recurrent vascular events. The current treatment of the patient population is 39.7% on high dose, 36.9% on low/moderate dose of statin, 13.1% on maximum tolerated dose statin+ezetimibe, and 1.2% on maximum tolerated dose statin+ezetimibe+protein convertase subtilisin/kexin type 9 inhibitor. The percentage of atherosclerotic cardiovascular disease patients with inadequate treatment response is estimated to be 20.2% in those using "maximum tolerated dose statin+ezetimibe." The proportion of patients who will need to be treated with a protein convertase subtilisin/kexin type 9 inhibitor increases as their low-density lipoprotein cholesterol levels rises from 9.1% in 70-99 mg/dL to 50.8% in ≥160 mg/dL for these patients.

CONCLUSION

According to expert opinion, although a substantial proportion of patients with secondary prevention have not achieved low-density lipoprotein cholesterol goals, the use of protein convertase subtilisin/kexin type 9 inhibitors is very low. Since the questionnaire subject to panel discussion did not include any question elaborating the issue, the discrepancy between the recommendation of the related guidelines and Turkish practice needs further studies for the explanation.

Relationship Between Work Mode, Time of Admission, and Mortality in St-Segment Elevation Myocardial Infarction: Results From the TURKMI Registry

Treatment of acute myocardial infarction has evolved steadily. However, limited studies exist regarding the effect of all innovations on mortality. We aimed to investigate the effect of time of admission and work mode on 1-year outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). Based on the TURKMI registry, we analyzed 735 STEMI patients recruited consecutively and prospectively from 50 PCI-capable cardiology clinics within a prespecified two-week period. Centers were categorized as "on-call" and "on-duty" according to their work mode. At 1-year follow-up, all-cause mortality and cardiovascular mortality were the primary outcomes. The secondary outcome was a composite of coronary revascularization, re-infarction/stroke, and recurrent angina. One-fifth of the participants (19.5%) were treated in the on-call group. All-cause mortality (7.9 vs 10.5%, aHR: 1.16, P = .650) and cardiovascular mortality rates (6.1 vs 9.1%, aHR: 1.35, P = .413) were similar between centers' modes of work. Likewise, both groups were equally likely to undergo coronary revascularization (P = .278), re-MI/stroke (P = .280), recurrent angina (P = .175), and the composite outcome of these components (P = .482). No significant difference was observed in primary outcomes between weekend and weekday admissions. In conclusion, we observed similar outcomes between the on-call and on-duty groups among STEMI patients.

Long-Term Clinical Consequences of Patients Hospitalized for COVID-19 Infection

Background

Coronavirus disease 2019, putatively caused by infection with severe acute respiratory coronavirus 2, often involves injury to multiple organs and there are limited data regarding the mid- to long-term consequences of coronavirus disease 2019 after discharge from the hospital. The study aimed to describe the mid- to long-term consequences of coronavirus disease 2019 in hospitalized patients after discharge.

Methods

This single-center, prospective study enrolled coronavirus disease 2019 patients who were discharged uneventfully from our center. All participants underwent face-to-face interviews by trained physicians and were asked to complete a series of questionnaires on third and sixth months’ follow-up visits.

Results

A total of 406 consecutive discharged coronavirus disease 2019 patients were enrolled in this study. Patients were divided into 3 groups according to World Health Organization classification as follows: World Health Organization-3 (n = 83); World Health Organization-4 (n = 291); and World Health Organization-5,6 (n = 32). Length of hospital stay was highly, significantly increased in the higher World Health Organization groups (World Health Organization-3 vs. World Health Organization-4, P < .0001; World Health Organization-3 vs. World Health Organization-5,6, P < .0001; World Health Organization-4 vs. World Health Organization-5,6, P < .0001), whereas the length of intensive care unit stay was highly, significantly increased only in World Health Organization-5,6 group compared to other groups (World Health Organization-3 vs. World Health Organization-5,6, P < .0001; World Health Organization-4 vs. World Health Organization-5,6, P < .0001). The most frequent complaints were chest pain (39%), and the frequency of complaints decreased during the 3-6 months follow-up period. Multiple logistic regression analysis indicated that age, coronary artery disease, fibrinogen, C-reactive protein, troponin I, D-dimer, use of steroid and/or low molecular weight heparin, and World Health Organization class were found to be independent predictors of ongoing cardiovascular symptoms.

Conclusions

The current data demonstrated that persistent symptoms were common after coronavirus disease 2019 among hospitalized patients. This should raise awareness among healthcare professionals regarding coronavirus disease 2019 aftercare.

Clinical Presentation and Outcomes in Real-Life Management of Elderly Patients Aged ≥75 Years Presenting with Acute Myocardial Infarction

Background: The aim of this study was to provide insight into the real-life clinical presentation and outcomes of the elderly presenting with acute myocardial infarction from the Turkish Myocardial Infarction registry database.

Methods: TURKMI was a nationwide, multicenter, observational, 15-day snapshot registry conducted to address the management of acute myocardial infarction patients admitted to percutaneous intervention-capable hospitals. The present analysis included the comparison of consecutively enrolled acute myocardial infarction patients aged ≥75 and <75 years.

Results: Of the overall 1930 patients, 362 patients were aged ≥75 years. Elderly patients were more likely to have hypertension and renal failure and less likely to have hypercholesterolemia. Elderly patients were admitted to hospitals almost 1 hour later mainly due to a late call to emergency medical service. At discharge, medical therapies were significantly less prescribed to the elderly. The proportion of patients undergoing coronary angiography was significantly lower in elderly (81.8% vs. 96.4%, P < .001). Both in-hospital and 1-year mortality were significantly higher in elderly patients (9.1% vs. 2.7% and 22.7% vs. 5.8%, P < .001 respectively). The adjusted risk of 1-year mortality was 4-fold in elderly (hazard ratio and 95% CI 4.0 [2.9-5.6], P < .001). In multivariate analysis, every 5-beat/min increase in heart rate increased mortality by 7%. Higher heart rate and use of antiplatelet agents on admission were predictors of mortality in elderly.

Conclusion: In real-life settings, elderly patients presenting with acute myocardial infarction are prone to prolonged total ischemic time and are subjected to less-intensive medical treatment and interventional approaches. Besides age, the increased heart rate could be the major determinant of mortality.

Can serum 8-hydroxy-2'-deoxyguanosine levels reflect the severity of pulmonary arterial hypertension?

OBJECTIVE

Oxidative stress plays a pivotal role in the pathogenesis of pulmonary arterial hypertension. 8-Hydroxy-2'-deoxyguanosine is a sensitive biomarker that reflects the degree of oxidative damage to DNA. We investigated whether serum 8-Hydroxy-2'-deoxyguanosine is a clinically useful biomarker for the severity of pulmonary arterial hypertension.

METHODS

We measured serum 8-Hydroxy-2'-deoxyguanosine levels in 25 patients (age 37±13 years, 68% women) diagnosed with idiopathic pulmonary arterial hypertension, familial pulmonary arterial hypertension, or pulmonary arterial hypertension associated with congenital heart disease. The severity of pulmonary arterial hypertension was evaluated by six-min walking distance, World Health Organization functional class, and serum brain natriuretic peptide levels. Age and gender-matched 22 healthy subjects served as the control group.

RESULTS

The comparison of 8-Hydroxy-2'-deoxyguanosine levels between patients and controls was not statistically different [(19.86±9.79) versus (18.80±3.94) ng/mL, p=0.622)]. However, there was a significant negative correlation between 8-Hydroxy-2'-deoxyguanosine levels and six-min walking distance (r= -0.614, p=0.001). Additionally, serum 8-Hydroxy-2'-deoxyguanosine levels in patients with functional class III-IV were significantly higher than those with functional class I-II (functional class III-IV 32.31±10.63 ng/mL versus functional class I-II 16.74±6.81 ng/mL, respectively, p=0.003).

CONCLUSION

The 8-Hydroxy-2'-deoxyguanosine levels were significantly correlated with exercise capacity (six-min walking distance) and symptomatic status (functional class), both of which show the severity of pulmonary arterial hypertension in patients.

Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry

BACKGROUND AND AIMS

Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients.

METHODS

We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia.

RESULTS

Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P < .001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P = .06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages.

CONCLUSIONS

In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

Time delays in each step from symptom onset to treatment in acute myocardial infarction: Results from a nation-wide TURKMI registry

OBJECTIVE

In this study, we aimed to analyze the TURKMI registry to identify the factors associated with delays from symptom onset to treatment that would be the focus of improvement efforts in patients with acute myocardial infarction (AMI) in Turkey.

METHODS

The TURKMI study is a nation-wide registry that was conducted in 50 centers capable of 24/7 primary percutaneous coronary intervention (PCI). All consecutive patients (n=1930) with AMI admitted to coronary care units within 48 hours of symptom onset were prospectively enrolled during a predefined 2-week period between November 1, 2018, and November 16, 2018. All the patients were examined in detail with regard to the time elapsed at each step from symptom onset to initiation of treatment, including door-to-balloon time (D2B) and total ischemic time (TIT).

RESULTS

After excluding patients who suffered an AMI within the hospital (2.6%), the analysis was conducted for 1879 patients. Most of the patients (49.5%) arrived by self-transport, 11.8% by emergency medical service (EMS) ambulance, and 38.6% were transferred from another EMS without PCI capability. The median time delay from symptom-onset to EMS call was 52.5 (15-180) min and from EMS call to EMS arrival 15 (10-20) min. In ST-segment elevation myocardial infarction (STEMI), the median D2B time was 36.5 (25-63) min, and median TIT was 195 (115-330) min. TIT was significantly prolonged from 151 (90-285) min to 250 (165-372) min in patients transferred from non-PCI centers. The major significant factors associated with time delay were patient-related delay and the mode of hospital arrival, both in STEMI and non-STEMI.

CONCLUSION

The baseline evaluation of the TURKMI study revealed that an important proportion of patients presenting with AMI within 48 hours of symptom onset reach the PCI treatment center later than the time proposed in the guidelines, and the use of EMS for admission to hospital is extremely low in Turkey. Patient-related factors and the mode of hospital admission were the major factors associated with the time delay to treatment.

Monozygotic twins with familial hypercholesterolemia and high lipoprotein(a) levels leading to identical cardiovascular outcomes: Case report and review of the literature

Homozygous familial hypercholesterolemia (HoFH) is a rare, autosomal dominant disease that leads to premature cardiovascular disease (CVD). Since monozygotic twins share the intrauterine environment and have the same age and gene profile, they could represent a very special resource for the investigation of the causes and the natural course of FH. This report is a description of 36-year-old monozygotic twin brothers with almost identical early coronary artery involvement due to FH concomitant with high lipoprotein(a) (Lpa) levels and a review of the literature. Sequence analysis revealed that the twins were homozygous for the LDLR c.1060+10G>A (rs12710260) mutation and heterozygous for the LDLR c.542C>T (rs557344672) mutations. Both were also homozygous for the c.1060+7T>C (rs2738442) and c.1586+53A>G (rs1569372) mutations in the LDLR gene as well as c.4265A>T (rs568413) mutations in the APOB gene. In the literature, there are 7 twin cases with reported FH, but none with high Lpa levels. The HoFH twins in this case report had lower low-density lipoprotein (LDL) cholesterol levels than expected (before treatment 204 and 223 mg/dL), with almost identical coronary involvement. Both had an extremely high Lpa level (308 and 272 nmol/L) with a very low coronary calcium score (16 AU) and a good response to statins (>60%). There was a history of the first CVD event occurring at nearly the same age (32-34 years) in the family. This could be an important aspect of FH families as a result of the similar timing of cumulative LDL exposure exceeding the threshold of CVD events. In conclusion, this first report of monozygotic HoFH twins with elevated Lpa levels and almost identical early coronary artery involvement at the same age provides evidence to substantiate the hypothesis of lifetime cholesterol burden/exposure.

Hepatic and splenic sonographic and sonoelastographic findings in pulmonary arterial hypertension

Purpose

The aim of this study was to evaluate the associations of sonographic and sonoelastographic parameters with clinical cardiac parameters, as well as to assess their value in predicting survival in patients with pulmonary arterial hypertension (PAH).

Methods

Thirty-six patients with PAH and normal liver function were prospectively enrolled in this prospective study along with 26 healthy controls, all of whom underwent ultrasound and point shear wave elastography examinations. Additionally, the portal vein pulsatility index (PVPI), inferior vena cava collapsibility index, and clinical cardiac variables were obtained in PAH patients. The values of hepatic (LV_s) and splenic shear wave velocity (SV_s) were compared between PAH patients and controls. The relationships between all sonographic and clinical parameters in the PAH patients were analyzed. Furthermore, their prognostic value in predicting survival was investigated.

Results

LV_s values in PAH patients (median, 1.62 m/s) were significantly higher than in controls (median, 0.99 m/s), while no significant difference was observed in SV_s values. Patients with higher grades of tricuspid regurgitation (TR) had significantly different values of PVPI (P=0.010) and sonoelastographic parameters (P<0.001 for LV_s and P=0.004 for SV_s) compared to those with less severe TR. Tricuspid annular plane systolic excursion values were the only investigated parameter found to be associated with survival (hazard ratio, 0.814; 95% confidence interval, 0.694 to 0.954; P=0.011).

Conclusion

Our results demonstrated a direct association between cardiac congestion (i.e., the severity of TR) and liver stiffness, which should be kept in mind during the assessment of fibrosis in patients with PAH.

Cumulative non-HDL-cholesterol burden in patients with hypertriglyceridemia receiving long-term fibrate therapy: Real life data from a lipid clinic cohort

OBJECTIVE

Though epidemiological data suggest that an elevated triglyceride (TG) level may be a risk factor for coronary artery disease (CAD), there is still insufficient clinical evidence. This study was designed to evaluate the real-life efficacy and side effects of fibrate treatment for hypertriglyceridemia seen in a lipid clinic, as well as cardiovascular and diabetic outcomes.

METHODS

This retrospective study evaluated patients who were followed-up for a diagnosis of hypertriglyceridemia at the lipid outpatient clinic of the Ege University Cardiology Department between 1997 and 2018. Data of demographic and clinical characteristics were obtained from hospital records. All patients (n=240) with at least 1 year of follow-up were included in the analysis. During follow-up, patients were treated with fenofibrate, and less frequently, gemfibrozile (14 patients), at different doses according to the TG level and disease severity.

RESULTS

Of the study population, 23% had CAD, 21% were diabetic, and 52% were obese. On admission, 20% were using fibrates and 17% were on statins. The mean admission lipid levels were TG: 281±194 mg/dL, low-density lipoprotein cholesterol: 115±37 mg/dL, high-density lipoprotein (HDL) cholesterol: 43±13 mg/dL, and non-HDL cholesterol: 166±42 mg/dL. The mean length of follow-up was 5.3±4.7 years (range: 1-16 years). A total of 8 (4.3%) patients had adverse effects during follow-up (1 on statin combination and 7 on fibrates alone). The side effects observed were an elevation of liver enzymes in 3, myalgia in 2, insomnia in 1, malaise in 1, and a skin rash in 1 patient. No rhabdomyolysis or myopathy was seen. During follow-up, diabetes developed in 14 and cardiovascular disease (CVD) in 14 patients. The cumulative non-HDL cholesterol level was significantly high in patients who developed diabetes or CVD. Receiver operating curve analysis indicated that a cumulative non-HDL cholesterol value of 1016 mg/dL was predictive of the development of diabetes mellitus or CVD with 85% sensitivity and 70% specificity.

CONCLUSION

In real life, long-term fibrate use is effective and safe. The cumulative non-HDL cholesterol burden can be used to assess the efficacy of treatment as a simple and easily calculated method. Large studies are needed to further clarify the value of this parameter in predicting the development of both diabetes and CVD.

[Turkish Cardiology Association Consensus Report: COVID-19 Pandemic and Cardiovascular Diseases (May 13, 2020)]

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

[Consensus Report from Turkish Society of Cardiology: COVID-19 and Cardiovascular Diseases. What cardiologists should know. (25th March 2020)]

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

Evaluation of perceptions, knowledge and compliance with guidelines in real-life practice: A survey on the under-treatment of hypercholesterolemia

OBJECTIVE

Few studies have directly assessed suboptimal management of dyslipidemia in Turkey. This study was conducted to assess patients' understanding and perceptions of high cholesterol as well as physicians' knowledge and awareness of lipid management strategies.

METHODS

This was a multicenter, observational study (ClinicalTrials.gov identifier: NCT02608645). Consecutive patients admitted to the participating cardiology clinics who were at least 18 years of age and who had been classified in a secondary prevention (SP) group or a high-risk primary prevention (PP) group were enrolled. The study population included 1868 patients from 40 sites in Turkey. Two-thirds (67.5%) of the patients in the SP group had been prescribed a statin, whereas only 30.1% of the PP group patients received statin therapy (p<0.001).

RESULTS

It was determined that 18% of the SP patients and 10.6% of the PP patients had a low-density lipoprotein cholesterol level at the recommended level (p<0.001). A patient survey revealed that almost half of the patients in the PP and in the SP groups were aware that their cholesterol levels were high. Negative information about statin treatment disseminated by media programs was the most common reason (9.4%) given for treatment discontinuation.

CONCLUSION

Perceptions, knowledge and compliance with the guidelines for PP and SP patients in real-life practice have increased, but it remains far below the desired level. Patients and physicians should have more information about the treatment of hyperlipidemia. More accurate media programming could help to prevent the dissemination of misinformation.

The reasons of poor lipid target attainment for secondary prevention in real life practice: Results from EPHESUS

OBJECTIVE

There are lack of studies considering the suboptimal management of dyslipidemia especially in cardiology outpatient clinics. This study was conducted to assess the patient adherence to cholesterol treatment recommendations and attainment of low-density-lipoprotein cholesterol (LDL-C) goals.

METHODS

EPHESUS (NCT02608645) is a national, observational and multicenter registry which has been designed as a cross-sectional study to allow inclusion of all consecutive patients with hypercholesterolemia in cardiology outpatient clinics. The present subgroup analyses of the EPHESUS trial included patients with known peripheral artery disease or atherosclerotic cerebrovascular disease, and coronary heart disease namely secondary prevention.

RESULTS

The present analysis of the EPHESUS study included 1482 patients (62.79 ± 10.4 years, 38.2% female) with secondary prevention from 40 sites in Turkey. Regarding recommended lipid targets for LDL-C, only 267 patients (18%) were below the target of 70 mg/dL. Females were significantly more off-target when compared with male patients (396, 85.5% vs 67, 14.5%; P = 0.017). Moreover, the achievement of LDL-C goal was significantly decreased with illiteracy (233, 19.2% vs 35, 13.1%; P = 0.02). Patients who think that the cholesterol treatment should be terminated when the cholesterol level of a patient has normalised were higher in the off-target group (34.0% vs 24.7%, P < 0.001). Besides, physician perceptions about LDL-C goal for secondary prevention were significantly related with LDL-C target attainment.

CONCLUSIONS

EPHESUS is an important study with large population in terms of representing real-life practice of the adherence to dyslipidemia guidelines in secondary prevention patients in Turkey. Perceptions, knowledge, and compliance with the guidelines for secondary prevention have increased, but it is far below from the desired levels even in cardiology outpatient clinics. There is a need for patients' and physicians' education regarding the treatment of hyperlipidemia.

Cardiac amyloidosis: Recent advances in the diagnosis and therapy

Cardiac amyloidosis (CA) is a progressive cardiomyopathy in which misfolded endogenous proteins form amyloid fibrils that deposit in the heart as well as kidneys, liver, gastrointestinal tract and soft tissues. The most common forms of CA include immunoglobulin light chain (AL) amyloidosis and transthyretin (TTR) amyloidosis. Although cardiac amyloidosis is thought to be a very rare disease, emerging data suggested that 13% of heart failure patients with preserved ejection fraction and 16-26% of advanced aged patients with severe aortic stenosis may have TTR-CA. Amyloidosis with cardiac involvement shows poor prognosis with a median survival of 6 months in AL-CA and 26-43 months in TTR-CA. Early diagnosis and novel therapeutic options have been shown to significantly improve prognosis. Recent diagnostic techniques such as cardiac MR or nuclear scintigraphy using bone isotopes as well as increasingly wide use of echocardiography, genetic testing, biopsy and histopathological analysis allow the clinicians to make early diagnosis of CA. The aim of this paper is to provide a comprehensive review including etiology, clinical presentation, diagnosis and management of CA and to address recent important advances in noninvasive cardiac imaging techniques and novel therapeutic approaches based on the available data in the literature.

Is there a gender gap in secondary prevention of coronary artery disease in Turkey?

OBJECTIVE

It has been reported that women receive fewer preventive recommendations regarding pharmacological treatment, lifestyle modifications, and cardiac rehabilitation compared with men who have a similar risk profile. This study was an investigation of the impact of gender on cardiovascular risk profile and secondary prevention measures for coronary artery disease (CAD) in the Turkish population.

METHODS

Statistical analyses were based on the European Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE)-IV cross-sectional survey data obtained from 17 centers in Turkey. Male and female patients, aged 18 to 80 years, who were hospitalized for a first or recurrent coronary event (coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or acute myocardial ischemia) were eligible.

RESULTS

A total of 88 (19.7%) females and 358 males (80.3%) were included. At the time of the index event, the females were significantly older (p=0.003) and had received less formal education (p<0.001). Non-smoking status (p<0.001) and higher levels of depression and anxiety (both p<0.001) were more common in the female patients. At the time of the interview, conducted between 6 and 36 months after the index event, central obesity (p<0.001) and obesity (p=0.004) were significantly more common in females. LDL-C, HDL-C or HbA1c levels did not differ significantly between genders. The fasting blood glucose level was significantly higher (p=0.003) and hypertension was more common in females (p=0.001). There was no significant difference in an increase in physical activity or weight loss after the index event between genders, and there was no significant difference between genders regarding continuity of antiplatelet, statin, beta blocker or ACEi/ARB II receptor blocker usage (p>0.05).

CONCLUSION

Achievement of ideal body weight, fasting blood glucose and blood pressure targets was lower in women despite similar reported medication use. This highlights the importance of the implementation of lifestyle measures and adherence to medications in women.

Insulin resistance in children with familial hyperlipidemia

Background The aim of the study was to investigate whether there is insulin resistance in children with familial hyperlipidemia (FHL) and to determine the factors affecting insulin resistance. Methods Hyperlipidemic children aged between 4 and 18 years and followed up with an FHL diagnosis were included in the study. The children of adults followed up with an FHL diagnosis were also recruited after the screening period. The scanned children were divided into two groups as hyperlipidemic and normolipidemic. A total of 77 patients of whom 52 were hyperlipidemic and 25 were normolipidemic were assessed in the study. Insulin resistance was evaluated (homeostatic model assessment of insulin resistance [HOMA-IR]) by performing the oral glucose tolerance test (OGTT). Results Of the patients, 36 were male and 41 were female; the average age was 11.6±3.9 years, and the body mass index (BMI) was established to be 20.3±4.4. In hyperlipidemic and normolipidemic patients, the following were determined: fasting insulin: 10.6 (±0.89) μU/mL, 4.9 (±0.45) μU/mL (p=0.000); 2-h insulin: 28.7 (±12.7) μU/mL, 18.9 (±10.5) μU/mL (p=0.000); and HOMA-IR: 1.9 (±0.17), 0.86 (±0.7) (p=0.000). No relationship was identified between lipid profiles and insulin resistance. Nevertheless, there was a positive correlation between insulin resistance and apolipoprotein B (Apo B) levels (0.52), and a negative correlation was determined in carnitine levels (-0.64). Conclusions Insulin resistance was established to be higher in children with FHL compared to normolipidemic children. Insulin resistance was not related to lipid phenotypes, but to Apo B levels and carnitine levels. Insulin resistance should be a routine method of evaluation in the follow-up of children with FHL.

[Data on prevalence of dyslipidemia and lipid values in Turkey: Systematic review and meta-analysis of epidemiological studies on cardiovascular risk factors]

OBJECTIVE

Dyslipidemias, primarily hypercholesterolemia, are independent and strong predictors of cardiovascular (CV) events. The frequency of dyslipidemia is very important in terms of determining CV prevention policies. In order to determine the up-to-date frequency of CV risk factors in Turkey, a meta-analysis of the epidemiologic studies carried out in the last 15 years was performed. This article presents the results on the dyslipidemia data including hypercholesterolemia principally.

METHODS

Epidemiological studies conducted during the last 15 years and having the potential to represent the general population in Turkey were searched in databases (Ovid Medline, Web of Science Core Collection, and Turkish Academic Network and Information Center [ULAKBIM]) and web pages (Ministry of Health, Turkey Statistical Institute, Turkish Society of Cardiology, Nephrology and Endocrinology Associations). A total of 7 studies including lipid data were found. Systematic review and meta-analysis of the studies with low bias score were performed. Crude values of the prevalence of hypercholeterolemia, hypertriglyceridemia and low HDL and mean lipid levels were calculated. Random effects model was used in meta-analysis.

RESULTS

The prevalence of hypercholesterolemia defined as a LDLcholesterol >130 and/or ≥130 mg/dL, was 29.1% (95% CI 23.6-35.0) in the general population, 30.2% in females (%95 CI 24.7-36.1), and 27.8% in males (95% CI 22.3-33.6). The prevalence of low HDLcholesterol (≤50 mg/dL for females and ≤40 mg/dL for males) was calculated as 46.1% (95% CI 42.4-49.9) in the whole group, 50.7% (95% CI 47.7-53.6) in females and 41.1% (95% CI 36.1-46.3) in males. The prevalence of hypertriglyceridemia (>150 mg/dL) was 36.5% (95% CI 30.6-42.5) in general, 32.0% (95% GA 26.6-37.8) in females and 41.3% (95% CI 34.9-47.8) in males.

CONCLUSION

Dyslipidemia constitutes a major public health problem in Turkey. In the adult population, almost 3 of 10 have hypercholesterolemia, one of 2 has a low HDL-cholesterol, and 1 of 3 has high triglycerides levels.

[Temporal changes in the epidemiology of diabetes mellitus in Turkey: A systematic review and meta-analysis]

OBJECTIVE

Diabetes mellitus (DM) is a serious public health problem. Despite various epidemiological studies reporting prevalence of DM in Turkey, there is no meta-analysis or systematic review evaluating these studies as a whole and assessing temporal changes in the prevalence of DM. In this meta-analysis, the studies that have been conducted in the last 15 years and which provide information on the prevalence of DM in our country are examined.

METHODS

Epidemiological studies on cardiovascular risk factors in adult Turkish population that had been conducted within the last 15 years and having the capacity of either representating or potentially representing the country, were searched through Ovid, Medline and Web of Science Core Collection the Turkish Academic Network and Information Center (ULAKBIM) databases. Additionally, websites of Ministry of Health and related societies were investigated for additional studies. Random effects model was used in meta-analysis of low bias risk studies. Meta-regression was performed to evaluate the temporal change in DM prevalence.

RESULTS

There were 8 studies which provided information with regard to DM prevalence (n=84656). Four of these studies (n=56853) had low bias risk and four had high bias risk (n=27803). When compared with low bias risk studies, those with high bias risk had very large variation of DM prevalence (between 4% to 15%). Meta-analysis of the low bias risk group yielded a crude DM prevalence of 13.5% (95% CI: 11.6-15.5%) in the whole group, 14.2% (95% CI: 12.3-16.2%) in females, 12.6% (95% CI: 10.5-14.9%) in males. In meta-regression analysis of low bias risk group, mean age difference among the studies and the time period in which the study was undertaken were partially able to explain the inter-study heterogeneity (R2 values were 52% and 78%).

CONCLUSION

This meta-analysis shows that DM is a highly prevalent public health problem in our country. Contrary to studies, which compare the recent studies with previous ones and report an increasing prevalence of DM, the present meta-analysis-despite its limitations-provides findings that the temporal increase of DM prevalence is at least paused over time. This situation underlines the need for new studies.

[Data on prevalence of hypertension and blood pressure in Turkey: Systematic review, meta-analysis and meta-regression of epidemiological studies on cardiovascular risk factors]

OBJECTIVE

Cardiovascular risc factors may show significant changes over the years. A systematic review and meta-analysis of epidemiological studies conducted in Turkey was performed to assess the latest profile and temporal changes in cardiovascular risk factors. Presented here are the data on hypertension (HT) and blood pressure (BP).

METHODS

Ovid Medline, the Web of Science Core Collection, and the Turkish Academic Network and Information Center (ULAKBIM) were searched for epidemiological studies conducted in Turkey during the last 15 years. In addition, the web pages of the Ministry of Health, the Turkish Statistical Institute, and associations of cardiology, nephrology, and endocrinology were searched for appropriate studies. Regional studies were excluded. The studies included were assessed with a bias score developed by our team, then categorized as having a low risk or a high risk of bias. The crude values of HT prevalence and BP were pooled using a random effects model. Meta-regression was performed to explain heterogeneity and to assess temporal changes.

RESULTS

The agreement between the 2 authors on the selection and bias scoring of the studies was perfect (Kappa ≥0.95). There were 7 (n=73218) studies providing HT prevalence data, and 8 (n=75879) studies with BP data. The heterogeneity between the studies was high. Meta-analysis of the studies with a low risk of bias indicated that the crude prevalence of HT is higher in women, but that BP levels were similar in both sexes. The HT prevalence and BP value decreased between 2003 and 2012; however, the number of hypertensives stabilized at approximately 15 million, and the number of uncontrolled hypertensives, despite some decrease, was around 11 million.

CONCLUSION

Despite some improvement, HT is still an important public health problem in Turkey.

[Data on prevalence of metabolic syndrome in Turkey: Systematic review, meta-analysis and meta-regression of epidemiological studies on cardiovascular risk factors]

OBJECTIVE

The incidence of metabolic syndrome varies greatly in developed and developing countries. In the last 10 to 15 years, important studies have been performed examining the incidence of metabolic syndrome in Turkey. This article is a meta-analysis of the studies that investigated the incidence of metabolic syndrome this country.

METHODS

Epidemiological studies from the last 15 years that provided information about the incidence of metabolic syndrome in Turkey were screened in the Ovid Medline, the Web of Science Core Collection, and the Turkish Academic Network and Information Center (ULAKBIM) databases. In addition, web pages of the Ministry of Health, the Turkish Statistical Institute, and the associations of the related medical discipilnes were screened for appropriate studies. A bias tool that is developed by our team was used to categorize the included studies as having low- or high risk of bias. A random effects model was used in the meta-analysis. Linear and nonlinear meta-regression analyses were performed to evaluate heterogeneity and temporal variations in prevalence rates.

RESULTS

Four studies (n=34893) were identified that provided information about the status of metabolic syndrome in Turkey using the Adult Treatment Panel III definition. There was excellent interobserver agreement regarding the selection of studies and the scoring of the selected research with respect to bias. The metaanalysis revealed a prevalence of 32.9% (95% confidence interval [CI]: 30.2-35) overall, 38.3% (95% CI: 35.8-40.8) in women, and 26.8% (95% CI: 23.4-30.3) in men. Two studies (n=8568) provided data according to the International Diabetes Federation definition of metabolic syndrome. The random effects model used in the metaanalysis of these studies demonstrated a prevalence of metabolic syndrome of 43.3% (95% CI: 41.9-44.7) overall, 50.4% (95% CI: 49.0-51.9) in women, and 35.4% (95% CI: 32.5-38.5) in men.

CONCLUSION

In Turkey, the incidence of metabolic syndrome is 1 in every 4 men, and 1 in every 3 women. The rate is particularly high among women. Studies designed to prevent the development of metabolic syndrome are needed.

[Data on prevalence of obesity and waist circumference in Turkey: Systematic review, meta-analysis and meta regression of epidemiological studies on cardiovascular risk factors]

OBJECTIVE

Obesity is the most important epidemic of the 21st century and its incidence is increasing steadily in Turkey. The aim of this study was to assess the current status and temporal change in the prevalence of obesity in Turkey with a systematic review and metaanalysis of epidemiological studies conducted in the last 15 years.

METHODS

Ovid Medline, the Web of Science Core Collection and the Turkish Academic Network and Information Center (ULAKBIM) databases, as well as the web pages of the Turkish Ministry of Health, the Turkish Statistical Institute, and cardiology, nephrology and endocrinology associations were searched for epidemiological studies conducted within Turkey the last 15 years. Research focusing on local data was excluded. Studies included in the analysis were assessed with a special bias score and categorized as having low or high risk of bias. Body mass index (BMI), waist circumference, obesity and prevalence of abdominal obesity were calculated as crude values. Meta-regression analysis was performed to assess heterogeneity and change over time.

RESULTS

The agreement between the two investigators on the selection and bias scoring of the studies was excellent (kappa=0.95), but the heterogeneity between the studies was high. BMI (10 studies, n=93.554) was calculated as 28.2 kg/m2 for women and 26.5 kg/m2 for men. The prevalence of obesity (12 trials, n=106.553) was 33.2% in females and 18.2% in males. In 6 studies (n=66.591) that included a measurement of waist circumference, the values were 89.72 cm in women and 93.57 cm in men. Especially in women, the prevalence of abdominal obesity (5 studies, n=62331) was greater than that of general obesity (50.8% in women vs 20.8% in men). Meta-regression analysis revealed that the variance of the obesity prevalence between the studies could partly be explained by the age differences, but there was no temporal change in the prevalence of obesity during the years the studies were conducted.

CONCLUSION

The prevalence of obesity, especially abdominal obesity, is considerably high in Turkish women and increases with advancing age. This finding points out that nationwide action plans against obesity, especially for women, should be designed and implemented by health policy makers.

Frequency of pulmonary hypertension in transthoracic echocardiography screening is not increased in Takayasu arteritis: Experience from a single center in Turkey

OBJECTIVE

Pulmonary hypertension (PH) may occur in Takayasu arteritis (TA), mostly due to pulmonary arteritis, but also due to left heart disease and/or chronic thromboembolism (CTE). Using transthoracic echocardiography (TTE), we investigated the frequency of PH caused by pulmonary arteritis.

METHODS

This cross-sectional study included 70 patients with TA fulfilling the 1990 ACR criteria, 68 healthy controls, and 67 patients with systemic sclerosis (SSc) fulfilling the 1980 ACR criteria representing the disease control group. Patients with severe left heart disease or CTE were excluded. The ESC-ERS guideline definition was considered for diagnosis of PH.

RESULTS

The mean systolic pulmonary artery pressure (SPAP) values in TA, SSc, and healthy control groups were 20.93±6.06, 31.57±12.75, and 18.88±5.39 mmHg, respectively. While the SPAP values were similar between TA and healthy groups, the SPAP values in the SSc group were significantly higher than in other groups. Based on conventional and/or magnetic resonance angiography findings, pulmonary arteritis was present in 4 out of 70 TA patients; however, PH was not detected in any patients with TA, including those with pulmonary arteritis.

CONCLUSION

The TTE findings suggested that the frequency of PH was not increased in TA. However, a low frequency of pulmonary arteritis in our series might have affected our results.

Data on smoking in Turkey: Systematic review, meta-analysis and meta-regression of epidemiological studies on cardiovascular risk factors

OBJECTIVE

Smoking is one of the most important public health problems and preventable causes of mortality in Turkey. Major healthcare policies have been implemented to combat this problem over the past 10 years. The aim of this study was to conduct a systematic review and meta-analysis of epidemiological studies performed in the country in the last 15 years to determine the prevalence of smoking in Turkey.

METHODS

Ovid Medline, the Web of Science Core Collection, and the Turkish Academic Network and Information Center (ULAKBIM), as well as the websites of the Ministry of Health and the Turkish Statistical Institute were searched for the appropriate epidemiological studies. Studies included in the analysis were evaluated by a selfdeveloped bias score regarding their potential to represent Turkey and standardization of measurements. The meta-analysis and metaregression analysis were performed using a random effects model.

RESULTS

Ten epidemiological studies (n=122383) that included data about smoking were found. Eight of them (all with low bias score) included separate data about the smoking habit of women (n=49524) and men (n=37684). The smoking prevalence was determined to be 30.5% for the whole group, 15.7% for women, and 46.1% for men, when occasional smokers were included. Although the change observed in crude prevalence values over time was not statistically significant, when the data of the 3 studies that gave prevalence values according to age categories were standardized according to age, the incidence of smoking between 2003 and 2012 decreased 6.8% (20.2%) when occasional smokers were included and 8.4% (26.3%) when they are excluded.

CONCLUSION

Despite implementation of major healthcare policies and some success in decreasing rate of smoking, one-third of the Turkish population aged over 15 years and nearly half of the men are smokers. It is essential to continue and to strengthen measures to combat smoking.

The rationale and design of the national peripartum cardiomyopathy registries in Turkey: The ARTEMIS-I and ARTEMIS-II studies

OBJECTIVE

Peripartum cardiomyopathy (PPCM) is left ventricular (LV) systolic dysfunction with an ejection fraction of ≤45% occurring in the later stages of pregnancy or soon after delivery. Although various risk factors have been identified, the exact cause of the disease is unknown. Unlike most countries in the European region, Turkey has yet to determine the current PPCM burden. A registry for this purpose does not exist. To close this gap, the A RegisTry of pEripartuM cardIomyopathy in Turkish patientS (ARTEMIS-I and ARTEMIS-II), was planned and endorsed by the Turkish Society of Cardiology. The aim of this manuscript is to describe the rationale and design of the ARTEMIS-I and ARTEMIS-II registries.

METHODS

ARTEMIS was designed to be the nationwide PPCM registry of Turkey, with the goal of identifying problems and opportunities while improving quality and consistency in the medical care of PPCM patients. A second goal is to determine the clinical characteristics pertinent to patients in this region. The ARTEMIS registry will consist of 2 arms. All secondary and tertiary cardiology centers have been electronically invited to participate in ARTEMIS-I, which will be conducted to assess the current standard of care and outcome measures. Centers will be asked to enroll PPCM patients admitted to their clinic in last 5 years retrospectively. Eligibility criteria will consist of pregnant or early postpartum woman without a previous history of heart failure (HF) or known pathology associated with HF, LV ejection fraction ≤45%, and exclusion of other causes of LV systolic dysfunction. ARTEMIS-II will consist of the prospective enrollment of patients.

CONCLUSION

The nationwide PPCM registries, ARTEMIS-I and ARTEMIS-II, are designed to determine the current status of medical care, provide insights into nature of the disease, and suggest solutions on how to improve care and outcomes in these patients.

The role of specialized prevention clinics for the short term follow-up of acute coronary syndromes

OBJECTIVE

This study aimed to investigate the effect of specialized prevention clinics and standard clinics follow-ups on secondary protection after acute coronary syndrome (ACS) on cardiovascular risk factors.

METHODS

A total of 118 patients who received thrombolytic therapy after being diagnosed with ST-segment elevation myocardial infarction were followed up for 6 months. After ACS, patients in a specialized prevention clinic (Group 1) (n=67) and those in a standard clinic (Group 2) (n=51) were compared in terms of the change in their lifestyle, management of risk factors, and drug compliance.

RESULTS

No significant difference was found between groups in terms of baseline clinical and laboratory findings except for triglyceride level (Group 1: median 174 mg/dL; Group 2: median 136 mg/dL; p=0.039). Six months after indexing, smoking cessation (72.4% vs. 50%, p=0.037), diet compliance (43% vs.19.6%, p=0.012), and exercise rates (31% vs. 13.7%, p=0.044) were significantly higher in Group 1. Although the weight control rate was higher in Group 1, no significant difference was noted between the groups (27% vs. 15.6%, p=0.219). The rate of systolic and diastolic blood pressures >140/90 mmHg was significantly higher in Group 2 (23.5% vs. 9%, p=0.029) at 6 months. The median low-density lipoprotein cholesterol (LDL-C) value was significantly lower in Group 1 patients (Group 1: 91 mg/dL; Group 2: 102 mg/dL; p=0.042). Moreover, the rate of LDL-C ≤70 mg/dL or ≥50% reduction compared with baseline was significantly higher in Group 1 (32.8% vs. 13.7%, p=0.016). Although the recommended treatments were similar in both groups, the statin use rate was significantly higher in Group 1 (95.5% vs. 80.3%, p=0.021) at 6 months.

CONCLUSION

The results of the study showed that specialized prevention clinics were more effective during the management of cardiovascular risk factors after ACS.

Achievement of low-density lipoprotein cholesterol goals in 18 countries outside Western Europe: The International ChoLesterol management Practice Study (ICLPS)

Background

Little is known about the achievement of low density lipoprotein cholesterol (LDL-C) targets in patients at cardiovascular risk receiving stable lipid-lowering therapy (LLT) in countries outside Western Europe.

Methods

This cross-sectional observational study was conducted in 452 centres (August 2015−August 2016) in 18 countries in Eastern Europe, Asia, Africa, the Middle East and Latin America. Patients (n = 9049) treated for ≥3 months with any LLT and in whom an LDL-C measurement on stable LLT was available within the previous 12 months were included.

Results

The mean±SD age was 60.2 ± 11.7 years, 55.0% of patients were men and the mean ± SD LDL-C value on LLT was 2.6 ± 1.3 mmol/L (101.0 ± 49.2 mg/dL). At enrolment, 97.9% of patients were receiving a statin (25.3% on high intensity treatment). Only 32.1% of the very high risk patients versus 51.9% of the high risk and 55.7% of the moderate risk patients achieved their LDL-C goals. On multivariable analysis, factors independently associated with not achieving LDL-C goals were no (versus lower dose) statin therapy, a higher (versus lower) dose of statin, statin intolerance, overweight and obesity, female sex, neurocognitive disorders, level of cardiovascular risk, LDL-C value unknown at diagnosis, high blood pressure and current smoking. Diabetes was associated with a lower risk of not achieving LDL-C goals.

Conclusions

These observational data suggest that the achievement of LDL-C goals is suboptimal in selected countries outside Western Europe. Efforts are needed to improve the management of patients using combination therapy and/or more intensive LLTs.

Rationale, design, and methodology of the Evaluation of Perceptions, Knowledge, and Compliance with the Guidelines in Real Life Practice: A Survey on the Under-treatment of Hypercholesterolemia

OBJECTIVE

A wide gap exists between dyslipidemia guidelines and their implementation in the real world, which is primarily attributed to physician and patient compliance. The aim of this study is to determine physician and patient adherence to dyslipidemia guidelines and various influential factors.

METHODS

The Evaluation of Perceptions, Knowledge, and Compliance with the Guidelines in Real Life Practice: A Survey on the Under-treatment of Hypercholesterolemia (EPHESUS) trial (ClinicalTrials.gov number NCT02608645) will be an observational, multicenter, non-interventional study. The study targets enrollment of 2000 patients from 50 locations across Turkey. All of the data will be collected in a single visit and current clinical practice will be evaluated. A cross-sectional survey of public perception and knowledge of cholesterol treatment among Turkish adults will be performed. All consecutive patients admitted to cardiology clinics who are in the secondary prevention group (coronary heart disease, peripheral artery disease, atherosclerotic cerebrovascular disease) and who are in the high-risk primary prevention group (type 2 diabetes mellitus with no prior known coronary heart disease; patients who had markedly elevated single risk factors, in particular, cholesterol >8 mmol/L [>310 mg/dL], blood pressure ≥180/110 mmHg, a calculated Systematic Coronary Risk Evaluation [SCORE] ≥5%, or <10% 10-year risk of fatal cardiovascular disease) will be included. Demographic, lifestyle, medical, and therapeutic data will be collected with a survey designed for the study.

CONCLUSION

The EPHESUS registry will be the largest study conducted in Turkey evaluating the adherence to dyslipidemia guidelines both in secondary and high-risk primary prevention patients.

Preliminary results from a nationwide adult cardiology perspective for pulmonary hypertension: RegiStry on clInical outcoMe and sUrvival in pulmonaRy hypertension Groups (SIMURG)

OBJECTIVE

The present study was designed to evaluate the characteristics of pulmonary hypertension (PH) and adult cardiology practice patterns for PH in our country.

METHODS

We evaluated preliminary survey data of 1501 patients with PH (females, 69%; age, 44.8±5.45) from 20 adult cardiology centers (AdCCs).

RESULTS

The average experience of AdCCs in diagnosing and treating patients with PH was 8.5±3.7 years. Pulmonary arterial hypertension (PAH) was the most frequent group (69%) followed by group 4 PH (19%), group 3 PH (8%), and combined pre- and post-capillary PH (4%). PAH associated with congenital heart disease (APAH-CHD) was the most frequent subgroup (47%) of PAH. Most of the patients' functional class (FC) at the time of diagnosis was III. The right heart catheterization (RHC) rate was 11.9±11.6 per month. Most frequently used vasoreactivity agent was intravenous adenosine (60%). All patients under targeted treatments were periodically for FC, six-minute walking test, and echo measures at 3-month intervals. AdCCs repeated RHC in case of clinical worsening (CW). The annual rate of hospitalization was 14.9±19.5. In-hospital use of intravenous iloprost reported from 16 AdCCs in CWs. Bosentan and ambrisentan, as monotreatment or combination treatment (CT), were noted in 845 and 28 patients, respectively, and inhaled iloprost, subcutaneous treprostinil, and intravenous epoprostenol were noted in 283, 30, and four patients, respectively. Bosentan was the first agent used for CT in all AdCCs and iloprost was the second. Routine use of antiaggregant, anticoagulant, and pneumococcal and influenza prophylaxis were restricted in only two AdCCs.

CONCLUSION

Our nationwide data illustrate the current status of PH regarding clinical characteristics and practice patterns.

[Cardiovascular prevention and pitavastatin]

HMG-CoA reductase inhibitors (statins) represent the most effective class of LDL lowering drugs with an overall positive safety and tolerability profile. They have also consistent benefit in terms of reduced cardiovascular (CV) events in both primary and secondary prevention. Pitavastatin is a new member of the statin class. This review provides a current overview of pravastatin's role in CV risk reduction. In brief pitatastatin has pleitrophic effects as the other statins. It has been shown that it reduces plaque atheroma volume in acute coranary settings. Also the 'real life' evidence gained with pitavastatin in LIVES study, a longterm postmarketing surveillance study in more than 20,000 patients in Japan, denotes an effective CV risk reduction with this new statin.

[Fabry disease: An overlooked diagnosis in adult cardiac patients]

Fabry disease is a rare, X-linked, lysosomal glycosphingolipid storage disorder. A deficiency of the enzyme alpha-galactosidase results in intracellular accumulation of globotriaosylceramide in multiple cell types, such as those of the nerves, kidneys, cardiac, and cutaneous tissues, leading to a multisystem disease. Male patients are more severely affected; however, heterozygous female patients may also be afflicted, though often the symptoms develop later. Cardiac involvement can include left ventricular hypertrophy, conduction abnormalities, arrhythmias, valvular abnormalities, and heart failure. A variant of the disease affects only cardiac tissue and mostly manifests as unexplained ventricular hypertrophy. Presently described are 2 cases of Fabry disease and the signs and symptoms of cardiac involvement, as well as the importance of early diagnosis to start enzyme replacement therapy before the development of irreversible tissue damage.

[EUROASPIRE-IV: European Society of Cardiology study of lifestyle, risk factors, and treatment approaches in patients with coronary artery disease: Data from Turkey]

OBJECTIVE

Data from EUROASPIRE-IV Turkey report investigating risk factors and adherence to guidelines in patients hospitalized for coronary artery disease are presented and results are compared with those of EUROASPIRE-III Turkey and EUROASPIRE-IV Europe.

METHODS

Study was performed in 24 European countries, including Turkey (17 centers). Patients (18-80 years old) hospitalized for coronary (index) event during preceding 3 years were identified from hospital records and interviewed ≥6 months later. Patient information regarding index event was acquired from hospital records. Anamnesis was obtained during the interview, and physical examination and laboratory analyses were performed.

RESULTS

Median age at the index coronary event was 58.8 years, and it was significantly decreased compared with last EUROASPIRE-III study (60.5 years), which was conducted at the same centers 6 years earlier (p=0.017). Of all patients, 19.3% were under 50 years of age and mean age was lower than that of EUROASPIRE-IV Europe (62.5 years). Comparing EUROASPIRE-IV Turkey with EUROASPIRE-III Turkey, rate of smokers increased to 25.5% from 23.1% (p=0.499), obesity increased to 40.7% from 35.5% (p=0.211), total cholesterol level increased to 49.6% from 48.3% (p=0.767), and diabetes rate increased to 39.7% from 33.6% (p=0.139), however none of the differences reached a level of statistical significance. Only 11.7% of the smokers quit after coronary event. Rates for these factors were lower in EUROASPIRE-IV Europe (16% for smoking, 37.6% for obesity, and 26.8% for diabetes).

CONCLUSION

EUROASPIRE-IV Turkey data revealed that secondary prevention was unsatisfactory and had progressed unfavorably compared with last EUROASPIRE study, some risk factors were more uncontrolled than overall European average, and coronary artery events at young age remain an important problem.

ScreenPro FH - Screening Project for Familial Hypercholesterolemia in Central, Southern and Eastern Europe: Basic Epidemiology

INTRODUCTION

Despite great recent progress, familial hypercholesterolemia (FH) is still underestimated, under-diagnosed and thus undertreated worldwide. We have very little information on exact prevalence of patients with FH in the Central, Eastern and Southern Europe (CESE) region. The aim of the study was to describe the epidemiological situation in the CESE region from data available.

METHODS

All local leaders of the ScreenPro FH project were asked to provide local data on (a) expert guess of FH prevalence (b) the medical facilities focused on FH already in place (c) the diagnostic criteria used (d) the number of patients already evidenced in local database and (e) the availability of therapeutic options (especially plasma apheresis).

RESULTS

With the guess prevalence of FH around 1 : 500, we estimate the overall population of 588 363 FH heterozygotes in the CESE region. Only 14 108 persons (2.4 %) were depicted in local databases; but the depiction rate varied between 0.1 % and 31.6 %. Only four out of 17 participating countries reported the the LDL apheresis availability.

CONCLUSION

Our data point to the large population of heterozygous FH patients in the CESE region but low diagnostic rate. However structures through the ScreenPro FH project are being created and we can hope that the results will appear soon.Key words: diagnosis - epidemiology - familial hypercholesterolemia - screening.

ScreenPro FH - Screening Project for Familial Hypercholesterolemia in Central, Southern and Eastern Europe: Rationale and Design

Familial hypercholesterolemia (FH) is a genetic disorder with well-known genetic transmission and clinical course. Despite great recent progress, FH is still underestimated, under-diagnosed and thus undertreated. Furthermore it represents a significant healthcare challenge as a common risk factor for the premature development of coronary heart disease. The ScreenPro FH Project is an international network project aiming at improving complex care - from timely screening, through diagnosis to up-to-date treatment of familial hypercholesterolemia in Central, Eastern and Southern Europe. An important task for the project is to harmonise and unify diagnostic and therapeutic approaches in participating countries, where the situation differs from country to country. Countries with more experience should serve as a model for countries developing the FH network.Key words: diagnosis - familial hypercholesterolemia - screening - treatment optimization.