Performance of the ATRIA Bleeding Score in Predicting the Risk of In-Hospital Bleeding in Patients with ST-Elevation or Non-ST-Elevation Myocardial Infarction

INTRODUCTION

A clear assessment of the bleeding risk score in patients presenting with myocardial infarction (MI) is crucial because of its impact on prognosis. The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA score is a validated risk score to predict bleeding risk in atrial fibrillation (AF), but its predictive value in predicting bleeding after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) patients receiving antithrombotic therapy is unknown. Our aim was to investigate the predictive performance of the ATRIA bleeding score in STEMI and NSTEMI patients in comparison to the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) bleeding scores.

METHODS

A total of 830 consecutive STEMI and NSTEMI patients who underwent PCI were evaluated retrospectively. The ATRIA, CRUSADE, and ACUITY-HORIZONS risk scores of the patients were calculated. Discrimination of the three risk models was evaluated using C-statistics.

RESULTS

Major bleeding occurred in 52 (6.3%) of 830 patients during hospitalization. Bleeding scores were significantly higher in the bleeding patients than in non-bleeding patients (all P<0.001). The discriminatory ability of the ATRIA, CRUSADE, and ACUITY-HORIZONS bleeding scores for bleeding events was similar (C-statistics 0.810, 0.832, and 0.909, respectively). The good predictive value of all three scores for predicting the risk of bleeding was observed in NSTEMI and STEMI patients as well (C-statistics: 0.820, 0.793, and 0.921 and 0.809, 0.854, and 0.905, respectively).

CONCLUSION

This study demonstrated that the ATRIA bleeding score is a useful risk score for predicting major in-hospital bleeding in MI patients. This good predictive value was also present in STEMI and NSTEMI patient subgroups.

Evaluation of COVID-19 Patients According to the Survival Time

BACKGROUND

Coronavirus disease 2019 (COVID-19) was first detected as a form of atypical pneumonia. COVID-19 is a highly contagious virus, and some patients may experience acute respiratory distress syndrome (ARDS) and acute respiratory failure leading to death. We aim to evaluate the clinical, imaging, and laboratory parameters according to survival time to predict mortality in fatal COVID-19 patients.

METHODS

Fatal 350 and survived 150 COVID-19 patients were included in the study. Fatal patients were divided into three groups according to the median value of the survival days. Demographic characteristics and in-hospital complications were obtained from medical databases.

RESULTS

Of the non-survived patients, 30% (104) died within three days, 32% (110) died within 4-10 days, and 39% (136) died within over ten days. Pneumonia on computational tomography (CT), symptom duration before hospital admission (SDBHA), intensive care unit (ICU), hypertension (HT), C-reactive protein (CRP), D-dimer, multi-organ dysfunction syndrome (MODS), cardiac and acute kidney injury, left ventricular ejection fraction (LVEF), right ventricular fractional area change (RV-FAC), and Tocilizumab/Steroid therapy were independent predictors of mortality within three days compared to between 4-10 days and over ten days mortality.  A combined diagnosis model was evaluated for the age, CT score, SDBHA, hs-TnI, and D-dimer. The combined model had a higher area under the ROC curve (0.913).

CONCLUSION

This study showed that age, pneumonia on CT, SDBHA, ICU, HT, CRP, d-dimer, cardiac injury, MODS, acute kidney injury, LVEF, and RV-FAC were independently associated with short-term mortality in non-surviving COVID-19 patients in the Turkish population. Moreover, Tocilizumab/Steroid therapy was a protective and independent predictor of mortality within three days.

Assessment of myocardial performance index in patients with COVID-19: An echocardiographic follow-up study

Introduction and Objectives

Myocardial performance may be impaired in cytokine-mediated immune reactions. The myocardial performance index (MPI) is a practical parameter that reflects systolic and diastolic cardiac function. We aimed to assess the MPI in patients with COVID-19.

Methods

The study population consisted of 40 healthy controls and 40 patients diagnosed with COVID-19 who had mild pneumonia and did not need intensive care treatment. All participants underwent echocardiographic examination. First, the MPI and laboratory parameters were compared between healthy controls and patients in the acute period of infection. Second, the MPI and laboratory parameters were compared between the acute infection period and after clinical recovery.

Results

Compared with healthy controls, patients with COVID-19 had a significantly higher MPI (0.56±0.09 vs. 0.41±0.06, p<0.001), longer isovolumic relaxation time (IRT) (112.3±13.4 vs. 90.6±11.2 ms, p<0.001), longer deceleration time (DT) (182.1±30.6 vs. 160.8±42.7 ms, p=0.003), shorter ejection time (ET) (279.6±20.3 vs. 299.6±34.7 ms, p<0.001) and higher E/A ratio (1.53±0.7 vs. 1.21±0.3, p<0.001). Statistically significantly higher MPI (0.56±0.09 vs. 0.44±0.07, p<0.001), longer IRT (112.3±13.4 vs. 91.8±12.1 ms, p<0.001), longer DT (182.1±30.6 vs. 161.5±43.5 ms, p=0.003), shorter ET 279.6±20.3 vs. 298.8±36.8 ms, p<0.001) and higher E/A ratio (1.53±0.7 vs. 1.22±0.4, p<0.001) were observed during the acute infection period than after clinical recovery. Left ventricular ejection fraction was similar in the controls, during the acute infection period and after clinical recovery.

Conclusions

Subclinical diastolic impairment without systolic involvement may be observed in patients with COVID-19. This impairment may be reversible on clinical recovery.

Plasma atherogenic indices are independent predictors of slow coronary flow

Background

Although the pathophysiology of coronary slow flow (CSF) has not been fully elucidated, emerging data increasingly support potential role for subclinical diffuse atherosclerosis in the etiology of CSF. We aimed to investigate relationship between atherogenic indices and CSF.

Methods

130 patients with CSF diagnosed according to Thrombolysis in Myocardial Infarction (TIMI)-frame count (TFC) method and 130 controls who had normal coronary flow (NCF) were included in this retrospective study. Atherogenic indices (atherogenic index of plasma [AIP], Castelli risk indices I and II [CRI-I and II]) were calculated using conventional lipid parameters.

Results

The logistic regression analyses demonstrated that AIP (OR, 5.463; 95% confidence interval [CI], 1.357–21.991; p = 0.017) and CRI-II (OR, 1.624; 95% CI, 1.138–2.319; p = 0.008) were independent predictors of CSF. Receiver operating characteristic analysis showed that the optimal cutoff value to predict the occurrence of CSF was 0.66 for AIP (sensitivity, 59%; specificity, 73%; area under curve [AUC], 0.695; p < 0.001) and 3.27 for CRI-II (sensitivity, 60%; specificity, 79%; AUC, 0.726; p < 0.001).

Conclusions

AIP and CRI-II levels were independent predictors of CSF. Prospective studies in larger cohorts of patients may elucidate the role of atherogenic dyslipidemia in the pathophysiology of CSF.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients after Anterior Myocardial Infarction

BACKGROUND

The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior.

METHODS

The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (<40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI.

RESULTS

Transthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively.

CONCLUSIONS

We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients after Anterior MI

Background

The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction. Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential.

Purpose

We aimed to compare the Two-Dimensional Echocardiography (2DE), contrast-2DE and Real-time Three-Dimensional Echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior.

Methods

The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (&lt;40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and Magnetic Resonance Imaging (MRI) were performed to all patients within one month after anterior MI.

Results

Transthoracic 2DE detected thrombi in 29 patients, contrast 2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast 2DE and RT-3DE, respectively.

Conclusion

We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Funding Acknowledgement

Type of funding sources: None.

Multilayer global longitudinal strain assessment of subclinical myocardial dysfunction related to insulin resistance

 

Myocardial tissue is sensitive to insulin resistance (IR) due to its interactions with insulin levels. Previous studies demonstrated that heart failure prevalence was higher in IR patients. Evaluation of myocardial deformation by multilayer global longitudinal strain (MGLS) might provide more information about IR related left ventricular dysfunction. In this study, we aimed to investigate subclinical LV dysfunction with MGLS in patients with IR. The study was designed as a prospective cross-sectional study. The present study included 64 patients with IR(+), and 54 subjects without IR(−) prospectively. The homeostasis model of insulin resistance (HOMA-IR) was used to quantify insulin resistance. Specific analysis for endocardial, mid-myocardial and epicardial layers were performed by two-dimensional (2D) speckle tracking echocardiography (STE) for multilayer global longitudinal strain. MGLS (Endocard-Mid-myocard-Epicard) values were significantly lower in the IR(+) group compared to IR(−) group ((GLS-endocard; −15.1±1.5 vs. −18.7±1.3, p&lt;0.001), (GLS-mid-myocard; −16.0±2.0 vs. −18.0±2.0, p&lt;0.001), (GLS-epicard; −17.0±1.7 vs. −18.01±1.94, p=0.004)). GLS-endocard levels were significantly and positively correlated with HOMA-IR levels (r=0.643, p&lt;0.001). HOMA-IR and age were found to be independent factors in detecting a decrease in GLS-endocard level in regression analysis. In conclusion, our data reveal that IR(+) patients had significantly lower strain values compared to IR(−) group. Besides, we presented that the HOMAIR value was an independent predictor of subclinical left ventricular dysfunction.

Funding Acknowledgement

Type of funding sources: None.

The relationship between CHA2DS2-VASc score and isolated coronary artery ectasia

INTRODUCTION

Coronary artery ectasia (CAE) is defined as localized or diffuse dilatation of the epicardial coronary arteries. We aimed to elucidate the relationship between the CHA₂DS₂-VASc score and CAE.

METHODS

The study population consisted of 122 patients with isolated CAE and 87 sex- and age-matched control subjects. The demographic, clinical, and laboratory profiles and CHA₂DS₂-VASc scores of patients with CAE and the control group were compared. The Markis classification was used to determine the extent of CAE. Coronary arteries in which ectasia was localized were identified. CHA₂DS₂-VASc scores were calculated for all patients. Parameters predicting the development of CAE were analyzed with multivariate logistic regression.

RESULTS

The majority of patients with CAE were male (76, 62%) and their mean age was 58.4 ± 8.3. The CHA₂DS₂-VASc score of the CAE group was significantly higher than that of the control group (2.41 ± 1.12 vs 1.52 ± 0.73, P < 0.001). Multivariate regression analysis showed that the CHA₂DS₂-VASc score (odds ratio [OR] = 1.607, P = 0.004), left ventricular ejection fraction (OR = 0.953, P = 0.044), uric acid (OR = 1.569, P = 0.003), white blood cell count (OR = 1.001, P < 0.001), highly sensitive C-reactive protein level (OR = 1.115, P = 0.010), and smoking (OR = 2.019, P = 0.043) were independent predictors of CAE.

CONCLUSION

High CHA₂DS₂-VASc scores were associated with isolated CAE; therefore, the score might be a useful predictor of coronary thrombus development in patients with isolated CAE.

Evaluation of index of cardiac electrophysiological balance in COVID-19 patients

AIM

The aim of the current study was to evaluate the index of Cardiac Electrophysiological Balance (iCEB) in hospitalized COVID-19 patients receiving Hydroxychloroquine / azithromycin (HCQ / AZ) combination therapy to determine the susceptibility to ventricular arrhythmia among these patients.

METHOD

Sixty-seven COVID-19 patients admitted to the ward were included in the study. Electrocardiograms (ECGs) were obtained from all patients before the initiation of treatment and on treatment day 5. QT/QRS (iCEB) and QTc/QRS (iCEBc) ratios were calculated.

RESULTS

QRS, QT and QTc intervals were significantly prolonged on day 5 measurements compared to pre-treatment period (p <0.05). Overall, mean iCEB was 3.6±0.4 before treatment and 3.8±0.4 on day 5 in the study population (p <0.001). Considering the iCEBc values, a significant increase was observed in patients receiving HCQ/AZ treatment compared to pre-treatment period (4.1±0.5 vs 4.4±0.6; p <0.001).

CONCLUSIONS

To the best of our knowledge, this was the first study to investigate iCEB and iCEBc parameters in patients with COVID-19 on HCQ/AZ therapy. In this study, we demonstrated significantly increased iCEB and iCEBc values following HCQ/AZ treatment in COVID-19 patients. iCEB and iCEBc may serve as a noninvasive, simple, and novel biomarker for detecting increased pro-arrhythmia risk in COVID-19 patients (Tab. 3, Fig. 3, Ref. 36).

Prognostic Significance of Fragmented QRS in Patients with Acute Ischemic Stroke

OBJECTIVES

There are studies in the literature showing the clinical importance of fragmented QRS (fQRS) in many systemic diseases. In this study, we aimed to investigate the frequency and prognostic value of fQRS on electrocardiogram (ECG) in patients with acute ischemic stroke.

MATERIALS AND METHODS

We prospectively enrolled 241 patients with acute ischemic stroke between January 2018 and January 2020. ST depression and elevation, QRS duration, PR interval, RR interval, QTc interval, QTc dispersion (QTcd), T negativity, Q wave, and fQRS were evaluated on ECG. Brain computed tomography (CT) and diffusion magnetic resonance imaging (MRI) images were obtained in the acute period and the National Institute of Health Stroke Scale (NIHSS) score was calculated for each patient. Patients were followed up for a period of two years.

RESULTS

The 241 patients comprised 121 (50.2%) men and 120 (49.8%) women with a mean age of 67.52 ± 13.00 years. In Cox regression analysis, age, NIHSS, QTcd, and fQRS were found to be independent predictors of mortality (age, hazard ratio [HR]: 1.063, p < 0.001; NIHSS, HR: 1.116, p = 0.006; QTcd, HR: 1.029, p = 0.042; fQRS, HR: 2.048, p = 0.037). Two-year mortality was higher in patients with fQRS than in patients without fQRS (31% vs. 9%, p = 0.001).

CONCLUSIONS

The fQRS is associated with poor prognosis in patients with acute ischemic stroke.

Aortic flow propagation velocity and neutrophil-to-lymphocyte ratio in coronary slow flow

AIM

A useful tool for determining the presence of systemic inflammation is the neutrophil-to-lymphocyte ratio (NLR). Chronic inflammation causes more microvascular resistance, which is known to be involved with coronary slow flow (CSF). Aortic flow propagation velocity (APV) can be used to evaluate the aorta's rigidity. We hypothesized that NLR and APV might be related to CSF. Therefore, we aimed to evaluate the NLR and APV in CSF patients.

METHOD

Eighty-six CSF patients and 43 subjects with normal coronary flow were enrolled in this study. We utilized the Thrombolysis in Myocardial Infarction (TIMI) frame count (TFC) method for determining each enrolled patient's coronary flow rate. APV values were determined via color M-mode Doppler echocardiography. Differences in NLR and APV values were determined in CSF and control groups.

RESULTS

Patients with CSF had lower APV values and higher NLR values than the normal controls (39.9±11.4 vs 48.0±10.6, p<0.01; 3.3±2.8 vs 2.3±1.2, p=0.03). TFC was significantly higher in CSF patients compared to controls (29.8±5.0 vs 12.9±2.6; p<0.01). TFC and APV were negatively correlated in CSF patients (r=-0.338 p=0.001). APV was independently associated with CSF (OR: 1.164, CI: 1.078-1.257, p=0.001).

CONCLUSIONS

APV was significantly associated with TFC, and it is independently associated with CSF (Tab. 4, Fig. 3, Ref. 30). Text in PDF www.elis.sk Keywords: coronary slow flow, neutrophil-to-lymphocyte ratio, aortic flow propagation velocity, atherosclerosis, inflammation.

The Association of Glomerular Filtration Rate With Echocardiographic Parameters in Chronic Kidney Disease

Background

Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in chronic kidney disease (CKD) patients. Aortic propagation velocity (APV), epicardial fat thickness (EFT) and carotid intima-media thickness (CIMT) measurements could provide additional information on assessing renal decline in CKD patients. The study aimed to evaluate EFT, AVP and CIMT in CKD patients and then investigate the association among those parameters.

Methods

A total of 170 CKD consecutive subjects were enrolled in the study. Patients were divided into five groups according to their estimated glomerular filtration rate (eGFR) values. Each patient underwent complete transthoracic echocardiography examination. APV, EFT and CIMT were measured for analyses. A multivariate linear regression model was used for analysis to determine the independent predictors of eGFR.

Results

The lowest APV was observed in stage IV-V, and the highest APV was observed in stage I-II (P < 0.001). Stage IV-V patients had the highest EFT and stage I-II patients had the lowest EFT (P < 0.001). Moreover, the lowest CIMT was observed in stage III, and the highest CIMT was observed in stage V (P < 0.001). eGFR was significantly and positively correlated with APV and negatively correlated with EFT and CIMT. In multivariate analyses, APV (odds ratio (OR): 0.289, P < 0.001), EFT (OR: -0.135, P < 0.001) and CIMT (OR: -0.388, P < 0.001) were independent predictors of eGFR.

Conclusion

We found that APV decreased, and EFT and CIMT increased as CKD progress. The present study suggests that APV, EFT and CIMT might be incorporated with the examination of CKD patients in daily practice.

The evaluation of myocardial performance index in patients with COVID-19: An echocardiographic follow-up study

Funding Acknowledgements

Type of funding sources: None.

Introduction

The epidemic of pneumonia caused by a new coronavirus rapidly spread all over the world. World Health Organization called the condition as coronavirus disease 2019 (COVID-19). COVID-19 has become a life-threatening public health emergency internationally. COVID-19 mostly presents by respiratory tract symptoms including fever, dry cough, and dyspnea. The disease progression causes pneumonia and acute respiratory distress syndrome. Pathophisyology of cardiovascular effects of COVID-19 have not been well known yet. Myocardial dysfunction may occur in cytokine-originated immune reactions. Myocardial performance index (MPI) is a feasible parameter that reflects systolic and diastolic cardiac functions.

Purpose

We aimed to evaluate the MPI in patients with COVID-19.

Methods

The study consisted of 40 patients diagnosed with COVID-19 who had mild pneumonia and had not needed intensive care treatment. Transthoracic echocardiographic examination was performed in all patients at the acute stage of infection and after clinical recovery. The average time interval between the baseline and recovery echocardiography exam was about 28 ± 3,4 days. Blood samples were studied on day 0 and on days 7, 14, 21, and 28.  Immunofluorescence assay was used for COVID-19 antibody titers.  Respiratory secretions were sent for RT-PCR tests.

Results

The mean age was 54 ± 11 years ( male 26 (65% ) ). Statistically significant higher MPI (0.56 ± 0.09 versus 0.44 ± 0.07, p < 0.001), longer isovolumic relaxation time (112.3 ± 13.4 versus 91.8 ± 12.1ms, p < 0.001), longer deceleration time (182.1 ± 30.6 versus 161.5 ± 43.5ms, p = 0.003), shorter ejection time (279.6 ± 20.3 versus 298.8 ± 36.8ms, p < 0.001) and higher E/A ratio (1.53 ± 0.7 versus  1.22 ± 0.4, p < 0.001), were observed during acute period of  infection compared to ones after clinical recovery. Compared with basal values, no significant change in left ventricular systolic ejection fraction was observed after clinical recovery (60.3± 3.2% versus 61.7 ± 2.4%, p > 0.05). Isovolumic contraction time was similar at acute infection and after clinical recovery ( 44.3 ± 7.8 versus 40.6 ± 9.7ms, p > 0.05)

Conclusion

In conclusion, our study suggests global reversible LV dysfunction in COVID-19 patients with preserved LV systolic function based on tissue Doppler derived MPI. This could be due to isolated subclinical diastolic dysfunction. To our knowledge, this study is the first echocardiographic follow-up study that evaluated the systolic and diastolic function of the left ventricle in COVID -19 patients. The underlying mechanism and its clinical significance can be established by further studies.

Evaluation of Index of Cardio-Electrophysiological Balance in Patients With Atrial Fibrillation on Antiarrhythmic-Drug Therapy

BACKGROUND

Index of cardio-electrophysiological balance (iCEB) has been described as a novel risk marker for predicting malignant ventricular arrhythmia. There remains limited evidence on the effects of amiodarone and propafenone used for sinus rhythm maintenance on iCEB in patients with atrial fibrillation (AF). The aim of this study was to evaluate iCEB in patients with AF on antiarrhythmic-drug therapy.

METHODS

A total of 108 patients with AF (68 patients using amiodarone and 40 patients using propafenone) and 50 healthy subjects were included in the study. All groups underwent a standard 12-lead surface electrocardiogram. QRS duration, QT, T wave peak-to-end (Tp-e) intervals, iCEB (QT/QRS) and iCEBc (heart rate-corrected QT (QTc)/QRS) rates were calculated from the electrocardiogram and compared between groups.

RESULTS

QT, Tp-e intervals and Tp-e/QT ratio were significantly longer in the amiodarone group than the propafenone and control groups (P < 0.001, for all). iCEB was similar in the amiodarone and control groups (4.4 ± 0.6 and 4.2 ± 0.4; P > 0.05), while iCEB values in the propafenone group were significantly lower than the amiodarone group and control groups (3.9 ± 0.5; P < 0.001). There was a significantly difference in iCEBc values among the amiodarone, control and propafenone groups (4.8 ± 0.6, 4.6 ± 0.4 and 4.3 ± 0.6; P < 0.001, respectively).

CONCLUSIONS

In this study, higher iCEBc parameters were observed in patients using amiodarone, while iCEBc values were lowest among patients with AF using propafenone. Further studies are needed to determine whether these electrophysiological changes are associated with ventricular arrhythmias for patients with AF on antiarrhythmic-drug therapy.

Multilayer global longitudinal strain assessment of subclinical myocardial dysfunction related to insulin resistance

Myocardial tissue is sensitive to insulin resistance (IR) due to its interactions with insulin levels. Previous studies demonstrated that heart failure prevalence was higher in IR patients. Evaluation of myocardial deformation by multilayer global longitudinal strain (MGLS) might provide more information about IR related left ventricular dysfunction. In this study, we aimed to investigate subclinical LV dysfunction with MGLS in patients with IR. The study was designed as a prospective cross-sectional study. The present study included 64 patients with IR (+), and 54 subjects without IR (-) prospectively. The homeostasis model of insulin resistance (HOMA-IR) was used to quantify insulin resistance. Specific analysis for endocardial, mid-myocardial and epicardial layers were performed by two-dimensional (2D) speckle tracking echocardiography (STE) for multilayer global longitudinal strain. MGLS (Endocard-Mid-myocard-Epicard) values were significantly lower in the IR (+) group compared to IR (-) group ((GLS-endocard; - 15.1 ± 1.5 vs. - 18.7 ± 1.3, p < 0.001), (GLS-mid-myocard; - 16.0 ± 2.0 vs. - 18.0 ± 2.0, p < 0.001), (GLS-epicard; - 17.0 ± 1.7 vs. - 18.01 ± 1.94, p = 0.004)). GLS-endocard levels were significantly and positively correlated with HOMA-IR levels (r = 0.643, p < 0.001). HOMA-IR and age were found to be independent factors in detecting a decrease in GLS-endocard level in regression analysis. In conclusion, our data reveal that IR (+) patients had significantly lower strain values compared to IR (-) group. Besides, we presented that the HOMA-IR value was an independent predictor of subclinical left ventricular dysfunction.

Effects of Short-Term Hydroxychloroquine Plus Moxifloxacin Therapy on Corrected QT Interval and Tp-e Interval in Patients With COVID-19

Background

Limited data are available regarding hydroxychloroquine (HCQ) and moxifloxacin (MOX) in patients with possible coronavirus disease 2019, (COVID-19). Both drugs may increase risk of malignant ventricular arrhythmias associated with prolongation of QT interval.

Methods

A total of 76 subjects with chest tomography findings compatible with COVID-19 pneumonia were enrolled in the study. Standard 12-lead electrocardiogram (ECG) was repeated on days 2 and 5 in patients receiving a combination of HCQ + MOX. Heart rate, QT interval, Tp-e interval, and Tp-e/QT ratio were measured.

Results

The mean age of the patients was 61.7 ± 14.8 years and 54% had hypertension. Compared to day 2, ECG on day 5 showed significant increases in QT interval (370.8 ± 32.5 vs. 381.0 ± 29.3, respectively, P = 0.001), corrected QT (QTc) interval (424 (403 - 436) vs. 442 (420 - 468), respectively, P < 0.001), Tp-e interval (60 (55 - 70) vs. 65 (57 - 75), respectively, P < 0.001), cTp-e interval (72.2 ± 12.9 vs. 75.4 ± 12.7, respectively, P < 0.001). Moreover, a slight decrease in Tp-e/QT ratio was observed (0.17 ± 0.03 vs. 0.17 ± 0.02, P = 0.030). QTc was > 500 ms in 5% of the patients, and 8% of patients had an increase in QTc interval > 60 ms. Tp-e/QT ratio was > 0.23 in 4% of patients. Five patients died due to pulmonary failure without evidence of ventricular arrhythmia. No ventricular arrhythmia events, including torsades de pointes (TdP), were observed.

Conclusions

HCQ + MOX combination therapy led to increases in QTc interval, Tp-e interval, and cTp-e interval. However, this therapy did not cause ventricular arrhythmia in the short-term observation.

Serum Asymmetric Dimethylarginine Levels in Patients with Vasovagal Syncope

Background and Objectives: Vasovagal syncope (VVS) is the most common cause of syncope and has multiple pathophysiological mechanisms. Asymmetric dimethylarginine (ADMA) is the major inhibitor of nitric oxide (NO). In this study, we aimed to investigate the relationship between plasma ADMA levels and syncope during the head-up tilt (HUT) test. Materials and Methods: Overall, 97 patients were included in this study. They were above 18 years of age and were admitted to our clinic with the complaint of at least one episode of syncope consistent with VVS. The HUT test was performed in all patients. Patients were divided into the following two groups based on the HUT test results: group 1 included 57 patients with a positive HUT test and group 2 included 35 patients with a negative HUT test. Blood samples were taken before and immediately after the HUT test to measure ADMA levels. Results: No significant intergroup differences were observed concerning gender and age (female gender 68% vs 60%; mean age 24.85 ± 4.01 vs 25.62 ± 3.54 years, respectively, for groups 1 and 2). ADMA values were similar between groups 1 and 2 before the HUT test [ADMA of 958 (544–1418) vs 951 (519–1269); p = 0.794]. In the negative HUT group, no significant differences were observed in ADMA levels before and after the HUT test [ADMA of 951 (519–1269) vs 951 (519–1566); p = 0.764]. However, in the positive HUT group, ADMA levels were significantly decreased following the HUT test [pretest ADMA of 958 (544–1418) vs post-test ADMA of 115 (67–198); p < 0.001]. Conclusion: ADMA levels significantly decreased after the HUT test in patients with VVS.

The relationship between galectin-3 levels and fragmented QRS (fQRS) in patients with heart failure with reduced left ventricular ejection fraction

BACKGROUND

Fragmented QRS (fQRS) complex is an electrocardiographic pattern which reflects myocardial scarring. We aimed to investigate the relationship between the presence of fragmented QRS (fQRS) on electrocardiogram (ECG) and plasma galectin-3 levels in patients with heart failure (HF) and severely decreased left ventricular ejection fraction (LVEF ≤ 35%).

METHODS

We prospectively enrolled 125 symptomatic HF patients (NYHA class II-III) with severely reduced LVEF (≤35%). fQRS was identified in ECG. Galectin-3 and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were measured. Patients were divided into two groups based on the presence (n = 40) or absence (n = 85) of a fQRS on ECG.

RESULTS

Majority of patients were male (87.70%), and mean age was 65.1 ± 11.6. Galectin-3 and NT-proBNP levels were found to be significantly higher in the fQRS (+) group compared with the fQRS (-) group (NT-proBNP 5,362 ± 701 pg/ml vs. 4,452 ± 698 pg/ml; p < 0.001, galectin-3 607 ± 89.8 pg/ml vs. 509.4 ± 63.5 pg/ml; p < 0.001). Multivariate analyses revealed galectin-3 and NT-proBNP levels are the presence of fQRS on ECG (p < 0.001 and p < 0.001, respectively). The area under the curve using the galectin-3 level for fQRS was 0.819.

CONCLUSIONS

fQRS and serum galectin-3 levels are associated with myocardial fibrosis and are associated with poor prognosis in heart failure. In our study, a positive correlation was found between serum galectin-3 levels and fQRS on ECG.

Multilayer longitudinal strain can help predict the development of no-reflow in patients with acute coronary syndrome without ST elevation

No-reflow (NR) is one of the major complications of primary percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We aim to assess the value of multilayer longitudinal strain parameter to predict NR in patients with NSTEMI and preserved ejection fraction. 230 consecutive patients who were admitted to the emergency department and diagnosed with NSTEMI were prospectively included in this study. Echocardiography was performed 1 h before angiography. Specific analysis for endocardial, mid-myocardial and epicardial layers were performed by two-dimensional (2D) speckle tracking echocardiography (STE) for multilayer longitudinal strain. NR was described as flow grade of ≤ TIMI 2 when mechanical occlusions like dissection, intimal tear, arterial spasm and thromboembolism during angiography were excluded. 49 of 168 patients admitted to the study had NR. No significant differences were observed between the groups regarding age and gender. Multilayer longitudinal strain imaging (endocard, midmyocard and epicard) revealed lower strain values particularly in endocardial layer in patients with NR (GLS-endocard: - 14.14 ± 1.39/- 17.41 ± 2.34, p < 0.001; GLS-midmyocard: - 14.81 ± 1.40/17.81 ± 2.22, p < 0.001; GLS-epicard: - 16.14 ± 1.38/18.22 ± 2.00, p < 0.001). GLS-endocard, GLS-midmyocard, GLS-epicard and ST depression were found to be statistically significant independents parameters respectively to predict NR phenomenon (GLS-endocard: OR: 2.193, p < 0.001; GLS-midmyocard: OR: 1.510, p: 0.016; GLS-epicard: OR: 1.372, p: 0.035; ST depression: OR: 3.694, p: 0.014). We revealed that left ventricular strain study with speckle tracking echocardiography predicts NR formation. This noninvasive method may be useful for detecting NR formation in patients with NSTEMI.

Three-dimensional 123I-meta-iodobenzylguanidine cardiac innervation maps to assess substrate and successful ablation sites for ventricular tachycardia: feasibility study for a novel paradigm of innervation imaging

BACKGROUND

Innervation is a critical component of arrhythmogenesis and may present an important trigger/substrate modifier not used in current ventricular tachycardia (VT) ablation strategies.

METHODS AND RESULTS

Fifteen patients referred for ischemic VT ablation underwent preprocedural cardiac (123)I- meta-iodobenzylguanidine ((123)I-mIBG) imaging, which was used to create 3-dimensional (3D) innervation models and registered to high-density voltage maps. 3D (123)I-mIBG innervation maps demonstrated areas of complete denervation and (123)I-mIBG transition zone in all patients, which corresponded to 0% to 31% and 32% to 52% uptake. (123)I-mIBG denervated areas were ≈2.5-fold larger than bipolar voltage-defined scar (median, 24.6% [Q1-Q3, 18.3%-34.4%] versus 10.6% [Q1-Q3, 3.9%-16.4%]; P<0.001) and included the inferior wall in all patients, with no difference in the transition/border zone (11.4% [Q1-Q3, 9.5%-13.2%] versus 16.6% [Q1-Q3, 12.0%-18.8%]; P=0.07). Bipolar/unipolar voltages varied widely within areas of denervation (0.8 mV [Q1-Q3, 0.3-1.7 mV] and 4.0 mV [Q1-Q3, 2.9-5.6 mV]) and (123)I-mIBG transition zones (0.8 mV [Q1-Q3, 0.4-1.8 mV] and 4.6 mV [Q1-Q3, 3.2-6.3 mV]). Bipolar voltages in denervated areas and (123)I-mIBG transition zones were <0.5 mV, 0.5 to 1.5 mV, and >1.5 mV in 35%, 36%, and 29%, as well as 35%, 35%, and 30%, respectively (P>0.05). Successful ablation sites were within bipolar voltage-defined scar (7%), border zone (57%), and areas of normal voltage (36%), but all ablation sites were abnormally innervated (denervation/(123)I-mIBG transition zone in 50% each).

CONCLUSIONS

(123)I-mIBG innervation defects are larger than bipolar voltage-defined scar and cannot be detected with standard voltage criteria. Thirty-six percent of successful VT ablation sites demonstrated normal voltages (>1.5 mV), but all ablation sites were within the areas of abnormal innervation. (123)I-mIBG innervation maps may provide critical information about triggers/substrate modifiers and could improve understanding of VT substrate and facilitate VT ablation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01250912.

Differences in quantitative assessment of myocardial scar and gray zone by LGE-CMR imaging using established gray zone protocols

Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging is the gold standard for myocardial scar evaluation. Heterogeneous areas of scar ('gray zone'), may serve as arrhythmogenic substrate. Various gray zone protocols have been correlated to clinical outcomes and ventricular tachycardia channels. This study assessed the quantitative differences in gray zone and scar core sizes as defined by previously validated signal intensity (SI) threshold algorithms. High quality LGE-CMR images performed in 41 cardiomyopathy patients [ischemic (33) or non-ischemic (8)] were analyzed using previously validated SI threshold methods [Full Width at Half Maximum (FWHM), n-standard deviation (NSD) and modified-FWHM]. Myocardial scar was defined as scar core and gray zone using SI thresholds based on these methods. Scar core, gray zone and total scar sizes were then computed and compared among these models. The median gray zone mass was 2-3 times larger with FWHM (15 g, IQR: 8-26 g) compared to NSD or modified-FWHM (5 g, IQR: 3-9 g; and 8 g. IQR: 6-12 g respectively, p < 0.001). Conversely, infarct core mass was 2.3 times larger with NSD (30 g, IQR: 17-53 g) versus FWHM and modified-FWHM (13 g, IQR: 7-23 g, p < 0.001). The gray zone extent (percentage of total scar that was gray zone) also varied significantly among the three methods, 51 % (IQR: 42-61 %), 17 % (IQR: 11-21 %) versus 38 % (IQR: 33-43 %) for FWHM, NSD and modified-FWHM respectively (p < 0.001). Considerable variability exists among the current methods for MRI defined gray zone and scar core. Infarct core and total myocardial scar mass also differ using these methods. Further evaluation of the most accurate quantification method is needed.

Serum ceruloplasmin levels in acute decompensated heart failure

BACKGROUND

Ceruloplasmin (Cp) is a serum protein that belongs to the family of α2-globulins and it is increased in patients with after acute myocardial infarction complicated with heart failure. Aim of the study was to investigate levels of serum Cp in patients with acute decompensated heart failure.

MATERIALS AND METHODS

The present cross-sectional observational study consists of three groups: Fifty patients with decompensated heart failure (Group 1) and same 50 patients after compensation (Group 2); 50 control patients group with comparable age and sex without heart failure (Group 3). Demographic, echocardiographic and biochemical data of patients were collected. Serum Cp level was determined spectrophotometrically.

RESULTS

Serum ceruloplasmin was significantly increased in Groups 1 (820.8 ± 78.5 IU/dL) and 2 (873.5 ± 121.0 IU/dL) compared, to Group 3 (640.6 ± 132.4 IU/dL) (p<0.001). In the sub-group analysis, this difference was due to the difference between Groups 3, Group 1 and 2 (both p=0.0001) whereas no significant difference was present between Group I and Group 2 (p>0.063). A positive correlation was found between Cp and female sex, heart rate, systolic and diastolic blood pressure, acetylsalisilic acid and diuretic use, left ventricular systolic and diastolic diameter, mitral regurgitation, and negative correlation was found between Cp and ejection fraction (p<0.05 for all) whereas none of the parameters were independently associated with serum Cp level (p>0.05).

CONCLUSIONS

Findings of the present study suggest that serum Cp level is increased in both decompensated and compensated HF compared to controls. Further large scale studies are needed to elucidate the pathophysiological mechanisms of increased Cp in HF.