Real-World Data on the Incidence of Stroke, Myocardial Infarction, and Mortality Among Nonvalvular Atrial Fibrillation Patients in Türkiye: New Oral Anticoagulants-TURKey Study

BACKGROUND

Atrial fibrillation (AF) is strongly associated with an increased risk of ischemic events. Anticoagulation focuses on reducing the risk of embolism. Guideline recommended CHA2DS2-VASc scoring system is most widely used; however, different scoring systems do exist. Thus, we sought to assess the impact of anticoagulant treatment and different scoring systems on the development of stroke, myocardial infarction, and all-cause mortality in patients with nonvalvular AF.

METHODS

The present study was designed as a prospective cohort study. The enrollment of the patients was conducted between August 1, 2015, and January 1, 2016. The follow-up period was defined as the time from enrollment to the end of April 1, 2017, which also provided at least 12 months of prospective follow-up for each patient.

RESULTS

A total of 1807 patients with AF were enrolled. During the follow-up, 2.7% (48) of patients had stroke, 0.8% (14) had myocardial infarction, and 7.5% (136) died. The anticoagulation and risk factors in AF (ATRIA) score had a better accuracy for the prediction of stroke compared to other scoring systems (0.729, 95% CI, 0.708-0.750, P <.05). Patients under low-dose rivaroxaban treatment had significantly worse survival (logrank P <.001). Age, CHA2DS2-VASc score, R2CHADS2 score, ATRIA score, chronic heart failure, prior stroke, and being under low-dose rivaroxaban treatment were independent predictors of clinical endpoint (P <.001).

CONCLUSION

Low-dose rivaroxaban treatment was independently and strongly associated with the combined clinical endpoint. Furthermore, the ATRIA score proved to be a stronger predictor of stroke in the Turkish population.

Misperceptions and management of LDL-cholesterol in secondary prevention of patients with familial hypercholesterolemia in cardiology practice: Real-life evidence from the EPHESUS registry

BACKGROUND AND AIMS

Familial hypercholesterolemia (FH) is a common inherited disease, leading to premature atherosclerotic cardiovascular disease (ASCVD) due to elevated low-density lipoprotein cholesterol (LDL-C) levels. Achieving LDL-C goals is extremely important for preventing the complications of this fatal disease. We evaluated the management of FH patients with ASCVD in cardiology practice.

METHODS

We analyzed patients with ASCVD from the nationwide EPHESUS registry, which was conducted in 40 cardiology outpatient clinics, and compared those with and without FH.

RESULTS

Of the 1482 consecutively enrolled patients with ASCVD, 618 (41.7%) had FH, among which 455 were categorized as 'Possible FH' and 163 as 'Probable or Definite FH'. Proposed LDL-C goals were not attained in more than 90% of the patients with FH. The proportion of those on statin therapy was 77% for possible and 91% for probable or definite FH, whereas 34.2 % and 59.4% were in use of high-intensity statins, respectively. None of the patients were on PCSK-9 inhibitors, and only 2 used ezetimibe. Adverse media coverage was the most common cause of statin discontinuation (32.5% in 'possible FH' and 45.7% in 'probable/definite FH'). The negative impact of media in the decision to stop lipid lowering therapy (LLT) was increasing with education level.

CONCLUSIONS

In real life most of the FH patients with ASCVD are undertreated in cardiology practice regarding statin dosing and combined LLT. Drug discontinuation rates are notably high and are mostly media-related, and side effects very rarely cause cessation of LLT. Urgent measures are needed to increase the awareness of FH among healthcare providers and patients and to develop improved treatment strategies aimed at preventing the complications of FH.

Real-life data of major and minor bleeding events with direct oral anticoagulants in the one-year follow-up period: The NOAC-TURK study

OBJECTIVE

This study aimed to evaluate the safety of direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF) during daily clinical practice.

METHODS

This was a prospective study conducted between January 01, 2016, and April 01, 2017, in patients aged ≥18 years with a diagnosis of NVAF. We performed the study in 9 clinical centers from different regions of Turkey, and the mean follow-up period was 12+2 months. We investigated major and minor bleeding events of DOAC.

RESULTS

A total of 1807 patients with NVAF were enrolled. The mean age of the patients was 73.6±10.2 years, CHA2DS2-VASc score was 3.6±1.4, and HAS-BLED score was 2±1.2. The most frequently prescribed DOAC was dabigatran 110 mg bid in 409 (22.6%) patients. The patients on apixaban 2.5 mg bid were older (p<0.001). Patients on rivaroxaban 15 mg od also had a higher prevalence of chronic renal failure, 46 (16.7%) patients. A total of 205 (11.4%) bleeding events were observed; among these, 34 (1.9%) patients had major bleeding and 171 (9.4%) patients had minor bleeding. The major and minor bleeding events were 2/273 (0.7%) and 30/273 (10.9%) in patients receiving dabigatran 150 mg bid, 13/409 (3%) and 44/409 (10.7%) in patients receiving dabigatran 110 mg bid, 4/385 (1%) and 42/385 (10.9%) in patients receiving rivaroxaban 20 mg od, 8/276 (2.9%) and 27/276 (9.7%) in patients receiving rivaroxaban 15 mg od, 3/308 (0.9%) and 14/308 (4.5%) in patients receiving apixaban 5 mg bid, 4/156 (2.5%) and 14/156 (9%) in patients receiving apixaban 2.5 mg bid, respectively. The total bleeding events were 17 (5.6%) in patients receiving apixaban 5 mg, less than those receiving other DOACs. On multivariate analyses, rivaroxaban 20 mg od (p=0.002), ATRIA and HAS-BLED scores, and peripheral artery disease were independent indicators of bleeding. The most frequent location of major bleeding was the gastrointestinal system (GIS) [17 (0.9%) patients], and the most frequent location of minor bleeding was the gingiva [45 (2.5%) patients].

CONCLUSION

This study showed that similar results as the previous real-life study; however, we had some different results, such as the GIS tract bleeding was more frequent in patients receiving dabigatran 110 mg bid. The major and intracranial bleeding events were similar for different DOACs; and among DOACs, only rivaroxaban 20 mg od was associated with a high risk of bleeding.

Evaluation of contrast nephropathy in percutaneous treatment of chronic total occlusions

Background

Contrast-induced nephropathy (CIN) is a leading cause of morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI). Chronic total occlusions (CTO) are frequently observed among patients undergoing coronary angiography.

Methods

A total of 128 CTO patients were included. Mehran score, lesion characteristics, interventional procedure, serological specimens and devices were recorded. The first group was administered with 1 ml · kg^-1 · h^-1 saline (0.9% NaCl) infusion that started 12 h before the procedure and continued 12 h post procedure as recommended by the guidelines. The second group was administered with saline infusion of 12 ml · kg^-1 · h^-1 only during CTO-PCI procedure, which is called as intensive infusion.

Results

CIN development was similar in two groups (four patients in standard hydration group and five patients in intensive hydration group). The amount of saline was significantly higher in the standard group (1,767 ± 192.2 vs. 1,043.6 ± 375; p < 0.001). Patients with higher creatinine levels prior to PCI had a higher rate of CIN development after procedure. Interestingly, age, left ventricular ejection fraction, and diabetes mellitus independently predicted CIN.

Conclusion

Intensive hydration administration appears to be an effective and cost-effective method in CTO-PCI patients, especially in patients without left ventricular function failure.

Association between SYNTAX II score and electrocardiographic evidence of no-reflow in patients with ST-segment elevation myocardial infarction

OBJECTIVE

This study was performed to examine the association between the SYNTAX II score (SS-II) and no-reflow observed on electrocardiography and examine their use in the evaluation of risk of an in-hospital major adverse cardiovascular event (MACE) in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

A total of 126 consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) were recruited. The SS-II was derived using angiographic and basic patient clinical features. The difference in the sum of Stsegment elevations measured between before the pPCI and the assessment determined approximately 60 minutes after the pPCI was interpreted as the sum of ST-segment resolution (ΣSTR). MACE is a composite endpoint frequently used in cardiovascular research and usually includes endpoints reflecting safety and effectiveness. ΣSTR <50% was defined as incomplete ΣSTR (no-reflow group; n=44), while ΣSTR <50% was defined as complete ΣSTR (normal-flow group, n=82).

RESULTS

The SS-II was significantly higher in the no-reflow group (p<0.001). SS-II and no-reflow findings were associated with MACE. Logistic regression analysis demonstrated significant predictive values of SS-II (Odds ratio [OR]: 1.169; 95% confidence interval [CI]: 1.084-1.260; p<0.001) and ΣSTR (OR: 0.764; 95% CI: 0.632-0.924; p=0.006) for in-hospital MACE.

CONCLUSION

SS-II was significantly associated with no-reflow as assessed by electrocardiography. In patients with STEMI, SS-II and no-reflow (incomplete ΣSTR) may be important predictive factors for in-hospital MACE.

The relationship between monocyte/high-density lipoprotein ratio and Selvester QRS score in patients with STEMI

OBJECTIVE

The ratio of monocytes to high-density lipoprotein (MHR) has recently been recommended as a new prognostic factor in cardiovascular disease. Studies have documented the value of the Selvester QRS score for prediction of prognosis of ST-elevation myocardial infarction (STEMI). However, no study has examined the association between the QRS score and MHR in patients with STEMI. The present study analyzed the relationship between MHR and QRS score in patients with STEMI.

METHODS

A cohort of 99 consecutive patients who experienced STEMI between June and September 2016 was retrospectively evaluated. Serial electrocardiogram, monocyte count, and lipid panel measurements (day 1, day 2, and after discharge) were performed in all patients, and MHR was calculated. The patients were classified into 2 groups based on the median values according to the estimated infarct size: QRS score <6 and QRS score ≥6.

RESULTS

The MHR was higher in the high QRS score group on day 1 in hospital (p=0.001). The MHR value was associated with QRS score in univariate logistic regression analysis and was found to be an independent predictor of the QRS score (Odds ratio: 0.390, 95% Confidence interval: 0.252-0.605; p<0.001).

CONCLUSION

A higher MHR serves as an indicator of inflammation and oxidative stress and was reported to be associated with a high QRS score. In addition, it was found to be an independent predictor of such scores during follow-up in patients with STEMI.

Comparison of the Predictive Roles of Risk Scores of In-Hospital Major Adverse Cardiovascular Events in Patients with Non-ST Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

OBJECTIVE

We evaluated the relationship between various risk scores (SYNTAX score [SS], SYNTAX score-II [SS-II], thrombolysis in myocardial infarction [TIMI] risk scores, and Global Registry of Acute Coronary Events [GRACE] risk scores) and major adverse cardiovascular events (MACE) in non-ST elevation myocardial infarction (NSTEMI) patients undergoing percutaneous coronary intervention (PCI).

SUBJECTS AND METHODS

The study population were selected from among 589 patients who underwent coronary angiography with a diagnosis of NSTEMI. TIMI and GRACE risk scores were calculated. SS and SS-II were calculated in all patients, and points were added according to the predefined algorithm, taking into account the other 6 clinical variables being monitored (age, sex, left ventricular ejection fraction, creatinine clearance, chronic obstructive pulmonary disease, and peripheral artery disease). Patients were classified into tertile 1 (SS < 22), tertile 2 (SS 23-32), and tertile 3 (SS > 32).

RESULTS

The group with high SS-II for PCI values in the risk scores were observed from tertile 1 to tertile 3 (from 25.0 ± 7.7 to 31.6 ± 9.4, p < 0.001, respectively). The SS-II score in patients with PCI was an independent predictor of MACE, in-hospital mortality, nonfatal myocardial infarction, and stent thrombosis (OR 1.082, 95% CI 1.036-1.131, p < 0.001). The overall MACE, in-hospital mortality, and nonfatal myocardial infarction rates were significantly higher in the high SS-II for PCI group (p < 0.001).

CONCLUSION

TIMI and GRACE risk scores were able to predict MACE. In addition to these, SS-II was also able to predict in-hospital mortality, nonfatal myocardial infarction, and stent thrombosis.

Comparison of the effects of metoprolol or carvedilol on serum gamma-glutamyltransferase and uric acid levels among patients with acute coronary syndrome without ST segment elevation

Objective:

Serum gamma-glutamyltransferase (GGT) and uric acid levels measured in patients with acute coronary syndrome without ST segment elevation (NSTEMI) are important in diagnosis and in predicting the prognosis of the disease. There is a limited number of clinical studies investigating the effects of beta-blockers on GGT and uric acid levels in these patients. In our study, we aimed to investigate the effects of beta-blocker therapy on GGT and uric acid levels.

Methods:

We conducted a randomized, prospective clinical study. Hundred patients with NSTEMI were included in this study, and they were divided into two groups. Fifty patients were administered metoprolol succinate treatment (1 × 50 mg), whereas the remaining 50 patients were administered carvedilol treatment (2 × 12.5 mg). Thereafter, all of the patients underwent coronary angiography. Blood samples were taken at the time of admission, at the 1^st month, and 3^rd month to detect GGT and uric acid levels.

Results:

There was no statistically significant difference among the metoprolol or carvedilol groups in terms of the GGT levels measured at the baseline, 1^st month, and 3^rd month (p=0.904 and p=0.573, respectively). In addition, there was no statistically significant difference among the metoprolol or carvedilol groups in terms of uric acid levels measured at the baseline, 1^st month, and 3^rd month (p=0.601 and p=0.601, respectively).

Conclusion:

We found that GGT and uric acid levels did not show any change compared to the baseline values, with metoprolol and carvedilol treatment initiated in the early period in patients with NSTEMI.