Adem Adar

Fragmented QRS is associated with subclinical left ventricular dysfunction in patients with chronic kidney disease.

Objective We aimed to investigate the association of fragmented QRS (fQRS) with subclinical left ventricular (LV) dysfunction in patients with chronic kidney disease (CKD). Methods and results Patients with CKD who had a normal LV ejection fraction (≥ 50%) were enrolled. The tissue Doppler-derived Tei index was measured for all patients. A Tei index of ≥ 0.5 was considered abnormal. Subclinical LV dysfunction was defi ned as the presence of an abnormal Tei index in the absence of impaired LV ejection fraction (< 50%). The fQRS was defi ned as the presence of an additional R wave (R’) or notching of R or S wave or the presence of fragmentation in two contiguous ECG leads. The study group consisted of 82 patients (45 male, mean age 54 ± 14 years). Overall, prevalence of fQRS was 60% among CKD patients who had a preserved LV ejection fraction. Of these, 52 (63%) had an abnormal (≥ 0.5) and 30 (37%) a normal Tei index (< 0.5). The prevalence of fQRS was signifi cantly higher in patients with an abnormal Tei index than in patients with a normal Tei index (71% vs. 40%, P= 0.006). Patients with an abnormal Tei index had a lower E/A ratio as compared to patients with a normal Tei index (P = 0.03). Groups were similar with respect to all other variables. In multivariate logistic regression analysis, the presence of fQRS was independently associated (OR 3.52, 95% CI 1.28-9.64) with the presence of an abnormal Tei index after adjustment for potential confounders. Conclusion Fragmented QRS is independently associated with subclinical LV dysfunction in patients with CKD and normal ejection fraction.

Onychomycosis is associated with subclinical atherosclerosis in patients with diabetes.

BACKGROUND We aimed to investigate the association of toenail onychomycosis with subclinical atherosclerosis in patients with diabetes mellitus. PATIENTS AND METHODS Consecutive diabetic patients who were seen at our outpatient clinic were enrolled. The carotid intima-media thickness (CIMT) was assessed and toenail onychomycosis was diagnosed with microscopic evaluation. RESULTS We investigated 127 patients with diabetes melltus type 2. Overall, the prevalence of toenail onychomycosis was 37.8 % (48 of 127). Of the 127 patients, 60 (47.2 %) had subclinical atherosclerosis (CIMT ≥ 1 mm). Prevalence of male gender (43.3 % vs. 22.4 %, p = 0.012) and onychomycosis (53.3 % vs. 23.9 %, p = 0.001) was significantly higher in patients with subclinical atherosclerosis. Among biochemical parameters, low-density lipoprotein (122 ± 38 mg/dL vs. 108 ± 36 mg/dL, p = 0.039) and glycosylated hemoglobin levels (median 8.4 %, IQR: 2.1 % vs. median 7.5 %, IQR: 1.6 %, p = 0.002) were significantly higher in patients with subclinical atherosclerosis. Study groups were similar with respect to all other demographic, clinical, and laboratory parameters. After adjustment for all potential confounders, the presence of onychomycosis was independently associated with subclinical atherosclerosis (OR 2.77, 95 % CI 1.16 to 6.30) in multivariate logistic regression analysis. CONCLUSIONS Presence of onychomycosis in patients with diabetes is associated with subclinical atherosclerosis. Onychomycosis may be a marker of atherosclerotic arterial involvement.

Relationship between fragmented QRS complex and left ventricular systolic and diastolic function in kidney transplant patients

Background Kidney transplant is a most important replacement therapy. It reduces cardiovascular mortality and morbidity but does not fully correct impairments in cardiac function. Fragmented QRS (fQRS) complex includes various RSR′ patterns with different QRS complex morphologies on electrocardiograms. Objective To analyze fQRS frequency and the relationship between fQRS and left ventricular function in kidney transplant patients. Method After demographic data on 39 kidney transplant patients were recorded and biochemical parameters were investigated, electrocardiograms were evaluated for the presence of fQRS. Left ventricular ejection fraction, mitral annular plane systolic excursion, peak early diastolic mitral annular velocities, late diastolic mitral annular velocities, and systolic mitral annular velocity were analyzed. Results Fragmented QRS was detected in 16 patients. A history of hypertension was associated with the presence of fQRS. Patients with fQRS had significantly lower systolic and peak early diastolic mitral annular velocities, mitral annular plane systolic excursion, and left ventricular ejection fraction than did patients without fQRS (P = .03, .01, < .001, and .03, respectively). Conclusion Detection of fQRS on electrocardiograms may be useful in predicting systolic and diastolic dysfunction of the left ventricle in kidney transplant patients.

Aortic arch calcification is strongly associated with coronary artery calcification.

BACKGROUND We aimed to investigate the association between aortic arch and coronary artery calcification (CAC). We postulated that low- and high-risk CAC scores could be predicted with the evaluation of standard chest radiography for aortic arch calcification (AAC). PATIENTS AND METHODS Consecutive patients who were referred for a multidetector computerized tomography (MDCT) examination were enrolled prospectively. All patients were scanned using a commercially available 64-slice MDCT scanner for the evaluation of CAC score. A four-point grading scale (0, 1, 2 and 3) was used to evaluate AAC on the standard posterior-anterior chest radiography images. RESULTS The study group consisted of 248 patients. Median age of the study group was 52 (IQR: 10) years, and 165 (67 %) were male. AAC grades (r = 0.676, p < 0.0001) and age (r = 0.518, p < 0.0001) were significantly and positively correlated with CAC score. Presence of AAC was independently associated with the presence of CAC (OR: 11.20, 95 % CI 4.25 to 29.52). An AAC grade of ≥ 2 was the strongest independent predictor of a high-risk CAC score (OR: 27.42, 95 % CI 6.09 to 123.52). Receiver operating characteristics curve analysis yielded a strong predictive ability of AAC grades for a CAC score of ≥ 100 (AUC = 0.892, P < 0.0001), and ≥ 400 (AUC = 0.894, P < 0.0001). Absence of AAC had a sensitivity, specificity and accuracy of 90 %, 84 % and 89 %, respectively, for a CAC score of < 100. An AAC grade of ≥ 2 predicted a CAC score of ≥ 400 with a sensitivity, specificity and accuracy of 68 %, 98 % and 95 %, respectively. CONCLUSIONS AAC is a strong and independent predictor of CAC. The discriminative performance of AAC is high in detecting patients with low- and high-risk CAC scores.

Association of Fragmented QRS with Subclinical Left Ventricular Dysfunction in Patients with Obstructive Sleep Apnea

Objective: We aimed to investigate whether fragmented QRS (fQRS) is associated with subclinical left ventricular (LV) dysfunction in patients with obstructive sleep apnea (OSA). Subjects and Methods: A total of 141 patients with OSA who had normal LV ejection fraction (LVEF) were included in the study. The fQRS was defined as the presence of an additional R wave, notching of R or S wave or the presence of fragmentation in 2 contiguous electrocardiography (ECG) leads. Subclinical LV dysfunction was defined as the presence of a tissue Doppler-derived Tei index of ≥0.5 in the absence of impaired LVEF (<50%) as assessed by transthoracic echocardiography. Results: Of the 141 patients, 71 (50.4%) had subclinical LV dysfunction. Overall, the prevalence of the fQRS was 61% (86/141). Patients with fQRS had significantly higher Tei indices than those without fQRS [median 0.66, interquartile range (IQR) 0.39 vs. median 0.40, IQR 0.15, p < 0.001]. The presence of fQRS on ECG predicted subclinical LV dysfunction in univariate logistic regression analysis [odds ratio (OR) 6.69, 95% confidence interval (CI) 3.10-14.43]. The association remained significant after adjusting for all potential confounders (OR 4.59, 95% CI 1.94-10.87). Conclusion: fQRS on ECG was an independent predictor of subclinical LV dysfunction in patients with OSA. This simple tool might help to identify OSA patients who could be at risk for developing overt cardiac dysfunction.

Radiotherapy Induces Development of Fragmented QRS in Patients with Breast Cancer

Background: Myocardial fibrosis is a well-known side effect of radiotherapy. Fragmented QRS (fQRS) has been shown to be a marker of myocardial fibrosis. We postulated that radiotherapy induces development of fQRS in breast cancer patients. Patients and Methods: Breast cancer patients receiving locoregional radiotherapy were enrolled. Patients who had fQRS on electrocardiography (ECG) before radiotherapy were excluded. All patients were revaluated for the development of fQRS at 1-year follow-up. An age-matched healthy group served as controls. Results: A total of 52 breast cancer patients receiving locoregional radiotherapy were included (median age 49 years, interquartile range (IQR) 13). Of these, 19 (37%) had developed fQRS at 1-year follow-up. Compared with the control group, prevalence of fQRS was significantly higher in the irradiated group (37 vs. 12%; p < 0.002). Median total cardiac radiation dose was significantly higher in patients who had developed fQRS (5 Gy, IQR 5.2 vs. 1.7 Gy, IQR 4.4; p = 0.003). Cardiac radiation dose, entered either as a continuous variable (odds ratio (OR) 1.35, 95% confidence interval (CI) 104-1.74) or as a dichotomized variable (≥ 2.2 Gy, OR 6.48, 95% CI 1.47-28.61), was independently associated with the development of fQRS at 1-year follow-up. Conclusion: Radiotherapy for breast cancer induces development of fQRS on ECG. Cardiac radiation dose is independently associated with the development of fQRS.

Pregbalin induced recurrent syncopal attacks with prolong QT interval

Long QT syndrome may lead to fatal dysrhythmia. Prolongation of QT interval due to pregabalin has been shown in rats and no data is available in humans. We report a 80‐year‐old female patient using pregabalin. She was presented to emergency room with syncope attacks. Her admission electrocardiography demonstrated prolonged QT interval. After excluding the possible causes of the long QT syndrome, we attributed prolonged QT interval to pregabalin therapy. After discontinuation of pregabalin QT interval returned to normal range and patient experienced no further syncope attacks. It is first time for documentation of prolonged QT due to pregabalin in humans.

Recurrent ST-elevation Myocardial Infarction in a Patient with Systemic Lupus Erythematosus

Increased atherosclerosis and thrombosis in patients with systemic lupus erythematosus (SLE) commonly cause cardiovascular complications such as myocardial infarction. Mechanism of myocardial infarction is different: Some immunological and genetic causes such as antiphospholipid syndrome, increased inflammation, immune complexes, elevated homocysteine level and Factor V Leiden mutation, play pivotal role in this group of patients. So its treatment shows difference too. Anticoagulant drugs are not recommended for treatment of myocardial infarction in current practice however, main treatment protocol should contain oral anticoagulants such as warfarin after myocardial infarction in this group of patients. Herein, we present a 30 year old SLE patient with recurrent STelevation myocardial infarction due to lack of oral anticoagulant treatment. With the initiation of anticoagulation, the patient has not experienced myocardial infarction again. In this case, we underline the importance of oral anticoagulant therapy after myocardial infarction in patients with SLE.