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.

Dabigatran for stroke prevention in real life in a sample of population from Turkey: D-SPIRIT registry

OBJECTIVE

The D-SPIRIT registry is designed to investigate the safety and effectiveness of dabigatran etexilate in patients with atrial fibrillation in routine clinical practice.

METHODS

D-SPIRIT is the first national, multicenter, prospective, observational, postmarketing registry that investigates the usage of dabigatran in real life. A total of 326 noveloral anticoagulant-eligible patients with atrial fibrillation who have been taking dabigatran etexilate therapy for stroke prevention at least 6 months from 9 different centers were enrolled into the registry. Patients were followed up for 2 years to evaluate the effectiveness and safety of the treatment. All adverse clinical events including bleeding, thromboembolic events, stroke, systemic embolism, transient ischemic attack, myocardial infarction, and all-cause death were recorded.

RESULTS

The mean age was 71.1±9.6 years, and 57.4% of the study participants were female. The mean CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65-74 years, sex category) score was 3.4±1.6. The cumulative adverse clinical events rate was 6.30% per year. The rate for embolic events including TIA, ischemic stroke, and peripheral embolism was 1.26% per year. The rate for major bleeding was 2.20% per year, and the mortality rate was 0.94% per year.

CONCLUSION

This registry obtained an important overview of the current safety and effectiveness of the dabigatran etexilate in Turkey. Our results indicate similar rates of thromboembolic and bleeding events with pivotal phase 3 trial and other real-life registries. However, rate of undertreatment usage of dabigatran etexilate in real life was found to be considerable.

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.

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.

Spontaneous spinal epidural hematoma developing after percutaneous coronary intervention: early diagnosis, early intervention, and good outcome

A 56-year-old female patient hospitalized with diagnosis of acute coronary syndrome underwent early coronary intervention. Anticoagulant and antithrombotic treatment was administered, including acetylsalicylic acid, clopidogrel, and heparin in periprocedural period. Severe back pain and rapidly progressing paraplegia developed in early period of follow-up. The patient underwent surgery immediately after diagnosis of spontaneous spinal epidural hematoma (SSEH) causing pressure, and decompression was performed. The patient rapidly improved without recurrence through early diagnosis and early surgical intervention. A common problem encountered by interventional cardiologists is back pain in patients who have undergone interventions in the femoral region and have lain in the same position for an extended period. Clinical onset of SSEH includes similar complaints, a fact of which cardiologists should be aware. Early diagnosis and early intervention may provide a good outcome, as is reported in the present case.

OPERATOR DEPENDENCY OF THE RADIATION EXPOSURE IN CARDIAC INTERVENTIONS: FEASIBILITY OF ULTRA LOW DOSE LEVELS

INTRODUCTION

Mean radiation exposure in invasive cardiology varies greatly between different centres and interventionists. The International Commission on Radiological Protection and the EURATOM Council stipulate that, despite reference values, 'All medical exposure for radiodiagnostic purposes shall be kept as low as reasonably achievable' (ALARA). The purpose of this study is to establish the effects of the routine application of ALARA principles and to determine operator and procedure impact on radiation exposure in interventional cardiology.

MATERIALS AND METHODS

A total of 240 consecutive cardiac interventional procedures were analysed. Five operators performed the procedures, two of whom were working in accordance with ALARA principles (Group 1 operators) with the remaining three working in a standard manner (Group 2 operators). Radiation exposure levels of these two groups were compared.

RESULTS

Total fluoroscopy time and the number of radiographic runs were similar between groups. However, dose area product and cumulative dose were significantly lower in Group 1 when compared with Group 2. Radiation levels of Group 1 were far below even the reference levels in the literature, thus representing an ultra-low-dose radiation exposure in interventional cardiology.

CONCLUSION

By use of simple radiation reducing techniques, ultra-low-dose radiation exposure is feasible in interventional cardiology. Achievability of such levels depends greatly on operator awareness, desire, knowledge and experience of radiation protection.

Karşıyaka Prevalance and Awareness of Hypertension Study (KARHIP)

<p><strong>Background: </strong>The study<strong> </strong>was planned to assess potential differences in hypertension prevalance and hypertension related demographic properties in a urban area with relatively higher income and cultural population compared to national average. <strong>Methods: </strong>Field work was done by educated personel at Karşıyaka Municipality Building by one by one interviewing poll, blood pressure measurement, rhythm and body composition analysis in February 2014. Hypertension was defined as  average  systolic blood pressure ≥140 mmHg or  average diastolic blood pressure ≥90 mmHg. <strong>Results: </strong>Out of total 1417 (627 males and 790 females) people enrolled, 780 people hypertensive(prevalence 55%). Hypertension prevalence in middle age group( age 35-65) was 46%, in geriatric age group(age&gt;65) %79. 216 out of 780 hypertensive  (27.7%) people were not aware of their disease. Ratio of people under antihypertensive treatment was 69.4% and ratio of people under control was 34.7%, whereas control rate was 50.1% in 541 patients who were aware of their diseases.<strong>Conclusions: </strong>Hypertension prevalances in our study were similar to PatenT2 trial prevalances, which were  46 % for middle age group and 78% for geriatric age group. Compared to PatenT 2 data, rate of hypertension awareness (54.7% vs 72.3%) and rate of being under treatment (47.5% vs 69.4%) were higher. Rate of controlled hypertension was a little big higher (28.7 % vs 34.7% )in our group, whereas  control rates  in aware and treated groups were similar (53.9 % and 50.1 %) in both study. <strong>Keywords: </strong>Hypertension, Prevalance, Awareness, Treatment</p><p> </p>

Design and rationale of dabigatran's stroke prevention in real life in Turkey (D-SPIRIT)

OBJECTIVE

The D-SPIRIT registry is designed to investigate the safety and efficacy of dabigatran etexilate in patients with nonvalvular atrial fibrillation (NVAF) and to collect data on outcomes in clinical practice.

METHODS

The D-SPIRIT is a national, prospective, observational, post-marketing registry involving patients with NVAF who have been taking dabigatran etexilate therapy for stroke prevention for a minimum of 6 months prior to enrollment. The registry will collect and analyze data from routine care, enrolling up to 600 patients in 9 centers. Patients will be followed up for 2 years to evaluate effectiveness and safety. A sample size of 600 subjects is proposed based on the following assumptions; Two-sided significance level of 0.05 (1-sided significance level of 0.025), ischemic stroke incidence rate of 0.768%-1.111%, hemorrhagic stroke incidence rate of 0.109%-0.130%, transient ischemic attack incidence rate of 0.722%-0.623%, therapy discontinuation incidence rate of 40% at day 730, and duration of enrollment period of 12 months with non-uniformed enrollment rate. Ethics approval was given by Dokuz Eylül University Ethics Committee of Clinical Research (2014/54) and approved by the Turkish Ministry of Health.

CONCLUSION

Potential results of D-SPIRIT registry will add data from clinical practice to those from the RE-LY trial to expand knowledge of dabigatran etexilate treatment in patients with NVAF.

Association of overhydration and cardiac dysfunction in patients have chronic kidney disease but not yet dialysis

BACKGROUND/AIM

Fluid overload and cardiac dysfunction is well established in hemodialysis patients. But in predialysis chronic kidney disease, the association of fluid overload and cardiac dysfunction is relatively unknown. In this study, we aimed to investigate the relationship between fluid overload and cardiac dysfunction in predialysis chronic kidney disease patients.

METHOD

We enrolled 107 consecutive patients in our study. Fluid overload was assessed via body composition monitor. Patients were dichotomized according to the fluid overload status. The patients with FO < 1.1L were determined as normovolemic and those with FO ≥ 1.1L as hypervolemic according to the previously reported physiologic model. Left atrial volume index (LAVI), left ventricular end-diastolic-end-systolic index (LVEDVI, LVESVI), E/e', LVMI and global longitudinal left ventricular left ventricular strain (GLS-%) were evaluated in each patient as markers of cardiac dysfunction. Arterial stiffness was also assessed by Mobil-O-Graph(®) 24h pulse wave analysis monitor and pWV values were recorded.

RESULTS

Fifty-five patients were normovolemic and 52 patients were hypervolemic. LAVI, LVMI, LDEDVI, LVEDSVI, E/e' were increased in hypervolemic patients. Also in hypervolemic patients pulse wave velocity was increased and GLS was decreased. Multivariate analysis showed that FO was independently associated with GLS which is the most specific echo-parameter for left ventricular dysfunction.

CONCLUSION

FO was independently associated with cardiac dysfunction in patients with chronic kidney disease not ongoing dialysis. Effective treatment of hypervolemia may be important in these patients to avoid further cardiac damage.

Impact of anxiety level on circadian rhythm of blood pressure in hypertensive patients

INTRODUCTION

Considering the high prevalence rates and growing incidences of hypertension (HT) and anxiety disorders in the modern world, a full understanding of anxiety's relationship to HT is crucial. In this study we aimed to investigate the effects of anxiety level on circadian rhythm of blood pressure (BP) in hypertensive patients.

MATERIAL AND METHOD

This cross-sectional study included 160 previously diagnosed essential hypertensive patients (80 female, 80 male, mean age: 55.3±15.1 years). All participants underwent 24 h ambulatory blood pressure monitoring (ABPM) and filled State-Trait Anxiety Inventory (STAI) (trait) Questionnaire. The study population was divided into 2 groups according to their STAI scores; an anxiety group (n=97; STAI ≥45) and a control group (n=63; STAI<44). Clinical characteristics, laboratory findings and ABPM measurements were compared between the groups.

RESULTS

There was no significant difference between the groups for ABPM parameters except morning blood pressure surge (MBPS). Anxiety group had a significantly higher MBPS compared to control group (14.4±17.0 vs 9.1±11.9 mmHg, P:0.03). Multivariate analysis showed that duration of HT and STAI score were the only independent predictors of MBPS.

CONCLUSION

Patients' anxiety level is associated with MBPS which is an independent risk factor for cardiovascular complications. Assessment and control of anxiety seems to be worthy in effective treatment of hypertension.

Optimal treatment of unligated side branch of internal mammary artery: Coil, amplatzer vascular plug or graft stent? A case report and literature review

Coronary artery steal syndromes may occur following coronary artery bypass grafting as a result of the presence of large side-branches arising from the internal mammary artery (IMA). Coil embolization, Amplatzer Vascular Plug and graft stents are all used for the treatment of such syndromes. The literature contains limited data on the long-term success of these treatment methods. There is no large series regarding occluded IMA side branches causing coronary steal phenomena, and data on long-term follow-up of this treatment method is also very limited. This report presented two cases and their treatment, and reviewed the advantages and disadvantages of treatment methods and the factors that affect successful treatment.

Evaluation of the impact of warfarin time in therapeutic range on outcomes of patients with atrial fibrillation in Turkey: perspectives from the observational, prospective WATER Registry

BACKGROUND

Warfarin is highly efficacious in reducing stroke risk in patients with atrial fibrillation (AF). However, its safety and efficacy in stroke prevention is markedly influenced by its time in therapeutic range (TTR). The quality of anticoagulant therapy varies considerably among countries. Representative data concerning the quality of anticoagulant therapy and its effects on clinical outcomes in Turkey are lacking.

METHODS

Warfarin in Therapeutic Range (WATER) registry is a prospective, observational study which followed 572 AF patients (mean age 67.3 ± 12 years; females 60%; 71% non-valvular AF) treated with warfarin.

RESULTS

At a median of 22-month follow-up, the mean TTR value was 42.3 ± 18% (median: 40%) for the whole population and lower in non-valvular AF su group than valvular AF subgroup (40.3 ± 18 vs. 46.9 ± 19, respectively, p < 0.001). Death, cardiac hospital-ization and minor bleeding rates were higher in the group with TTR value < 40% than the group with > 40% (3.4% vs. 5.9%; 28.6% vs. 35.4%; 36.5% vs. 41.7%, respectively, all of them p < 0.001). A correlation analysis showed a negative correlation between age and TTR value (r = -0.178, p < 0.001). Mean CHA2DS2VASc score was 3.63 ± 1.5 and mean HASBLED score was 2.38 ± 1.01 in the non-valvular AF group. A negative correlation was observed between TTR levels and CHA2DS2VASc score.

CONCLUSIONS

WATER provides insight into the anticoagulation control status of AF patients in Turkey. The quality of anticoagulation was poor. Strategies should be undertaken by clinicians and patients to improve TTR. New oral anticoagulant agents may be perfect alternatives for non-valvular AF patients.

Anomalous origin of the right vertebral artery from the ascending aorta in the presence of an aberrant right subclavian artery

We present a case of a 63-year-old man who was admitted to the hospital due to an acute coronary syndrome. Angiographic and magnetic resonance angiography examination showed an abnormal right vertebral artery originating from the ascending aorta, just above the left coronary sinus Valsalva in addition to aberrant retro-esophageal right subclavian artery. The variations and the incidence of various abnormal origins of the right vertebral artery are also reviewed.

The relationship between angiotensin converting enzyme gene polymorphism, coronary artery disease, and stent restenosis: the role of angiotensin converting enzyme inhibitors in stent restenosis in patients with diabetes mellitus

Patients with diabetes mellitus (DM) have advanced atherosclerosis compared with nondiabetics. Restenosis after intracoronary stent implantation occurs frequently in diabetic patients. Angiotensin II is an important growth factor for the development of neointimal hyperplasia after vascular injury. The aim of our study was to evaluate the relationships between angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and coronary artery disease (CAD) and stent restonosis in diabetic patients. One hundred and thirty consecutive patients with CAD and 47 consecutive patients (14 males, mean age, 58.0 +/- 10.0) without CAD were enrolled in the study. All patients had type 2 (noninsulin dependent) DM. The patients with CAD underwent percutaneous transluminal coronary angioplasty (PTCA) and stenting. Ninety-four (59 males, mean age, 60.3 +/- 9.8) underwent control coronary angiography at the end of the follow-up period (mean duration, 9.1 +/- 2.9 months). ACE gene I/D genotyping was identified in all patients. No significant difference was found among patients with and without CAD with respect to ACE gene I/D polymorphism (P = 0.460). In the control coronary angiography, stent restenosis and new lesion development were comparable in each genotyping subgroup. However, a significant relationship was observed between restenosis and the use of ACE inhibitors (ACEI) in patients with D allele (ACEI ratio, 43.5% in the restenosis group and 56.5% in non-restenotic group, P < 0.05). We did not find any relationship between ACE gene I/D polymorphism and CAD and stent restenosis and new lesion development in diabetic patients. On the other hand, ACEI treatment may reduce stent restenosis in type 2 diabetic patients with D allele (DD or ID).

[Raynaud syndrome. A case report]

Symptomatology, diagnosis, treatment, and clinical course of a Raynaud syndrome in a sixteen-year old patient beginning in the second year of his life are described. He lost all distal phalanges of both hands and big toes at the age of nine. Remarkable was the laboratory finding of an extremely high serum IgE concentration. A combined therapy of plasmapheresis, immunosuppression and corticosteroids improved the clinical and laboratory findings.