Mehmet Eyuboglu

Usefulness of fragmented QRS in hypertensive patients in the absence of left ventricular hypertrophy

In the absence of left ventricular hypertrophy, importance of fragmented QRS complex (fQRS) in individuals with hypertension is unknown. The authors aimed to evaluate the relationship between blood pressure levels and fQRS in the absence of left ventricular hypertrophy. A total of 548 never‐treated patients who underwent 24‐hour ambulatory blood pressure monitoring were enrolled. The frequency of fQRS was significantly higher in patients with hypertension than normotension (36.4% vs 17.6%, P<.05). Multivariate logistic regression analysis revealed that systolic blood pressure is significantly associated with presence of fQRS on electrocardiography (odds ratio, 0.931; 95% CI, 0.910–0.9521 [P<.001]) even after adjusting for other confounding factors. Receiver operating characteristic analysis revealed a cutoff value of 147.65 mm Hg for systolic blood pressure to predict presence of fQRS (sensitivity: 51%, specificity: 99%, area under the curve=0.764; 95% CI, 0.717–0.811 [P<.001]). fQRS may be a sign of increased blood pressure and may predict higher fibrotic burden in patients with hypertension.

Body mass index is a predictor of presence of fragmented QRS complexes on electrocardiography independent of underlying cardiovascular status

BACKGROUND Fragmented QRS (fQRS) as a sign of myocardial fibrosis indicates adverse outcomes in various cardiovascular diseases. However, there are no clear data regarding relationship between obesity and fQRS. We aimed to investigate whether high body mass index (BMI) predicts fQRS on electrocardiography (ECG) independent of underlying cardiovascular status. METHODS A total of 1530 patients were included into the study. Patients were divided into three groups according to BMI (normal, overweight and obese). Groups were compared regarding frequency of fQRS on ECG and we investigated the correlation between BMI and fQRS. RESULTS Among study population, 841 patients had normal BMI, 402 patients were overweight, and 287 patients were obese. Obese patients had significantly higher frequency of fQRS on ECG compared to non-obese patients (p < 0,001). Furthermore, multivariate logistic regression analysis revealed that BMI is an independent predictor of presence of fQRS on ECG (OR:1,220, 95% CI: 1,177-1,266, p < 0.0001). CONCLUSION BMI predicts fQRS independent of underlying cardiovascular status. Similar to cardiovascular diseases, BMI should be taken into consideration when using fQRS as a prognostic marker.

Accurate Patient Selection for Percutaneous Coronary Intervention for Coronary Chronic Total Occlusions

Chronic total occlusions (CTOs) are not uncommon in catheterization laboratory practice and are considered as high-risk complex cases. The clinical benefit of percutaneous coronary intervention (PCI) for CTO remains controversial. PCI may provide prognostic benefit in accurately selected patients with CTO; however, routine treatment with PCI may not be useful and may even be harmful in most cases. Recently, Kranjec et al concluded that performing a successful CTO PCI may be associated with similar clinical outcomes in patients with single-vessel non-CTO successful PCI and provides better long-term clinical outcomes compared with patients in whom CTO PCI failed. On the other hand, patients undergoing CTO PCI carry a risk of hazardous complications that may affect prognosis, irrespective of procedure success. Therefore, some important issues should be clearly addressed before deciding to perform PCI in patients with CTO. Unsuccessful CTO PCI is associated with higher frequency of periprocedural serious complications including erythrocyte transfusions, tamponade, and stroke and is associated with higher incidence of major adverse cardiovascular events (MACEs) and mortality. Importantly, since the Occluded Artery Trial demonstrated that PCI did not reduce the longterm occurrence of MACE and mortality in stable patients with CTO, there is no robust evidence indicating superiority of routine PCI over optimal medical therapy in patients with CTO. Another option may be surgical revascularization; however, the literature on prognostic value of surgical revascularization of isolated CTO is also limited. Nevertheless, coronary artery bypass graft surgery may be the best revascularization option in terms of improvement in clinical outcomes in selected patients with CTO and with left main coronary artery disease, multivessel disease, and viable myocardium. Additionally, in the absence of a large burden of ischemia or viable myocardium, there is lack of evidence regarding prognostic benefit of CTO PCI. Therefore, in the study by Kranjec et al, arbitrary patient selection and failed CTO PCI-related adverse events may have an effect on higher frequency of MACE, irrespective of revascularization. Also, PCI seems to be unsuccessful in terms of improving the clinical outcomes of many patients with stable coronary artery disease compared with optimal medical therapy. Hence, prognostic value of successful and failed CTO PCI should be compared with optimal medical therapy. The authors should provide information regarding treatment with essential medications and optimal medical therapy for each group. In conclusion, CTO PCI may improve the clinical outcomes in carefully selected patients. However, it is a high-risk intervention, and the predictors of improvement in clinical outcomes should be investigated more comprehensively before the procedure. In the absence of predictors of improvement in clinical outcomes, this procedure may not be useful, and failed CTO PCI may cause adverse outcomes irrespective of revascularization.

Factors Related to Epicardial Adipose Tissue Thickness.

Dear Editor, We read the article by Akyüz et al. [1] with great interest. In their study, the authors concluded that the amount of epicardial adipose tissue (EAT) was higher in subjects with xanthelasma than in subjects without. We appreciate their investigation concerning the relationship between xanthelasma and EAT thickness. However, a number of well-known factors may independently affect EAT thickness. These include the metabolic syndrome independent of body mass index, and the correlation between visceral adipose tissue and waist circumference [2, 3] . EAT thickness is significantly higher in patients with nonalcoholic fatty liver disease compared to controls [4] , and patients with subclinical hypothyroidism seem to have a significantly increased EAT thickness [5] . Treatment with statins could induce EAT regression independentPublished online: January 20, 2016

Occupational exposure to hand-arm vibration

a Siyami Ersek Thoracic and Cardiovascular Surgery, Training and Research Hospital, Department of Cardiology, Istanbul, Turkey b Department of Cardiology, Special Izmir Avrupa Medicine Center, Karabaglar, Izmir, Turkey c Gulhane Military Medical Academy, Haydarpasa Training Hospital Department of Cardiology, Istanbul, Turkey d Gulhane Military Medical Academy, Department of Cardiology, Ankara, Turkey

Delay in Revascularization and Prognosis After Myocardial Infarction

In the article ‘‘Women Undergoing Coronary Angiography for Myocardial Infarction or Who Present With Multivessel Disease Have a Poorer Prognosis Than Men’ by Gijsberts et al,’’ the investigators reported that major adverse cardiovascular events (MACEs) occurred more often in women than in men who presented with myocardial infarction (MI). Gijsberts et al identified the prognostic significance of gender difference in particular in patients with MI. However, because of the presence of some confounding factors, we would like to emphasize some points. Total ischemic time is an important prognostic factor in MI. In the study by Gijsberts et al, there are no data about total ischemic time, door-to-balloon time, and time to revascularization for patients with MI. Delay in primary percutaneous coronary intervention is an independent predictor of MACEs in patients with ST-segment elavation MI. Additionally, early invasive strategy may have beneficial effects on prognosis in selected patients with non–ST-segment elevation acute coronary syndrome. Hence, longer time to revascularization, door-to-balloon time, and total ischemic time may be reasons for higher MACEs rates in women with MI. The investigators should state the time to revascularization and total ischemic time for each group to confirm the real significance of gender difference for the prognosis after MI.

Prognostic value of low QRS voltage in patients with acute coronary syndrome

☆ Study design: A letter to the editor about the article QRS voltage on the admission electrocardiogram in ac Cardiol. 2015;190:34-9. ☆☆ Prior publication: This article is an original letter an submitted for publication elsewhere, in whole or in part, ★ Address for reprints: Reprints not available from the ★★ Copyright constraints: The article does not include an E-mail address: mhmtybgl@gmail.com.

How can we detect the low risk patients for ischemic etiology in heart failure population

akinetic, hypokinetic and dyskinetic wall segments. In HFERF patients, the presence of regional wall motion abnormalities may be a significant indicator of CAD.Therefore, it mayaffecttheresultsof thepresentstudy of Silva et al. and the presence of higher levels of wall motion score indexesmayoverestimatetheincidenceofCADinHFERFpatientswithout angina and risk factors. In this sense, it may be a wrong approach to include these patients into the low risk patient group for ischemic etiology. Additionally, a novel echocardiographic calcification scores was found to be an independent indicator of significant CAD in a recent study [5], and it may be useful to identify low risk HFREF patients for ischemic etiology who may benefit from CA and revascularization. In conclusion, the prevalence of CAD in HFREF patients without angina and risk factors may be overestimated in the present study of Silva et al. Actually, HFREF patients without angina and risk factors which are defined as low risk patient group for ischemic etiology, may not be a low risk group because of inadequate screening. Despite CAD being the most common etiology in patients with heart failure, there is a significant proportion of HFREF patients without ischemic etiology. Therefore, we should use all non-invasive diagnostic methods to eliminate unnecessary CA.

Effects of Renin-Angiotensin-Aldosterone System Blockers and Renoprotective Regimens on Contrast-Induced Nephropathy.

In the article ‘‘Platelet-to-lymphocyte ratio predicts contrastinduced nephropathy in patients with non-ST-segment elevation acute coronary syndrome’’ by Kocas et al, the authors reported that platelet-to-lymphocyte ratio (PLR) was found to be an independent predictor of contrast-induced nephropathy (CIN) after coronary angiography in patients with non-ST segment elevation acute coronary syndrome. The study of Kocas et al includes patients with near-normal renal functions. However, there are no data about incidence of patients treated with chronic renin–angiotensin–aldosterone system (RAAS) blockers and periprocedural renoprotective treatments. Chronic usage of RAAS blockers increases the risk of CIN in patients with near normal renal functions who underwent coronary procedures. Additionally, periprocedural hydration with sodium bicarbonate plays a protective role against CIN while performing coronary procedures. The authors reported that patients in CIN group had higher prevalence of diabetes mellitus, hypertension, and chronic kidney disease. Therefore, higher incidence of treatment with chronic RAAS blockers and less treatment with renoprotective regimens may play a significant role for higher incidence of CIN in the Kocas et al study. Higher PLR levels may be an indicator for the development of CIN. To define its exact role, we should be sure that both patient groups have similar incidence of chronic RAAS blockers usage and treatment with periprocedural renoprotective regimens. It would be worth assessing if renal function indices were diferent in patients taking RAAS blockers before and after coronary angiography even if they did not develop CIN.