Oktay Gulcu

The Risk of Atrial Fibrillation With Ivabradine Treatment: A Meta-analysis With Trial Sequential Analysis of More Than 40000 Patients.

Recent trials reported that risk of atrial fibrillation (AF) is increased in patients using ivabradine compared with controls. We performed this meta‐analysis to investigate the risk of AF association with ivabradine treatment on the basis of data obtained from randomized controlled trials (RCTs). We searched PubMed, EMBASE, Scopus, and the Cochrane Library for RCTs that comprised >100 patients. The incidence of AF was assessed. We obtained data from European Medicines Agency (EMA) scientific reports for the RCTs in which the incidence of AF was not reported. We used trial sequential analysis (TSA) to provide information on when we had reached firm evidence of new AF based on a 15% relative risk increase (RRI) in ivabradine treatment. Three RCTs and 1 EMA overall oral safety set (OOSS) pooled analysis (included 5 RCTs) were included in the meta‐analysis (N = 40 437). The incidence of AF was 5.34% in patients using ivabradine and 4.56% in placebo. There was significantly higher incidence of AF (24% RRI) in the ivabradine group when compared with placebo before (RR: 1.24, 95% confidence interval: 1.08‐1.42, P = 0.003, I 1980 = 53%) and after excluding OOSS (RR: 1.24, 95% confidence interval: 1.06‐1.44, P = 0.008). In the TSA, the cumulative z‐curve crossed both the traditional boundary (P = 0.05) and the trial sequential monitoring boundary, indicating firm evidence for ≥15% increase in ivabradine treatment when compared with placebo. Study results indicate that AF is more common in the ivabradine group (24% RRI) than in controls.

Massive pulmonary embolism mimicking electrocardiographic pattern of Brugada syndrome.

Brugada syndrome is an inherited heart disease without structural abnormalities that is thought to arise as a result of accelerated inactivation of Na channels and predominance of transient outward K current to generate a voltage gradient in the right ventricular layers. Brugada syndrome occurs in patients with structurally normal heart and predisposes patients to malignant ventricular arrhythmias. Acute pulmonary embolism has been associated with a variety of electrocardiograms,and rarely, it may mimic electrocardiographic pattern of Brugada syndrome and this condition was defined as Brugada phenocopy.

Comparison of the three conventional methods for the postoperative atrial fibrillation prediction

Although various risk factors have been defined for the development of postoperative atrial fibrillation (PAF), these parameters have not been adequately verified and validated. We investigated the atrial fibrillation detection capabilities of echocardiographic parameters in PAF developing and the determination of predictive values for clinical use.

Apical hypertrophic cardiomyopathy mimicking acute coronary syndrome.

Apical hypertrophic cardiomyopathy (HCM) is a phenotypic variant of nonobstructive HCM in which hypertrophy of the myocardium predominantly involves the left ventricular apex. Hypertrophic cardiomyopathy in patients is associated with the risk for sudden death, heart failure, and peripheral thromboembolism [1–3]. A 65-year-old male patient without a family history of heart disease presented to the emergency department with progressive chest pain suggestive of unstable angina. A physical examination revealed an irregular heart rate of 70 beats perminute and blood pressure of 120/50mm Hg. His ECGon admission revealed T-wave inversions in inferior and lateral leads (Fig. 1)with elevated cardiac biomarkers. Acute coronary syndromewas suspected, and because of the high-risk score, we performed coronary angiography. Coronary angiography revealed evidence of nonobstructive coronary artery disease, and therewas complete obliteration of the left ventricular cavity from the midportion to the apex during systole with “ace-of-spades” sign characteristic of apical HCM. A transthoracic echocardiogram showed apical hypertrophy (Fig. 2 and Movie 1), and Doppler imaging showed a dagger-shaped late-peaking systolic gradient, consistentwith HCM. After transthoracic echocardiography, the patient underwent a cardiac magnetic resonance imaging (MRI). The MRI confirmed the diagnosis of the apical HCM (Fig. 3). The patient was treated with β-blocker indefinitely and discharged to hospital 4 days from admission, and at 1-year follow-up, he was asymptomatic. Physicians should be aware of apical HCM in case of patients who have similar electrocardiographic changes and symptoms with coronary artery disease, and sometimes, further examinations may be considered [1–5]. ☆ Conflict of interest: There is no conflict of interests. 0735-6757/© 2015 Elsevier Inc. All rights reserved. Please cite this article as: Topcu S, et al, Apical hypertrophic cardiomyop http://dx.doi.org/10.1016/j.ajem.2015.11.054 Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2015.11.054. Selim Topcu MD Oktay Gulcu MD Atatürk University Faculty of Medicine Department of Cardiology Erzurum, Turkey Uğur Aksu MD Kars State Hospital Department of Cardiology, Kars, Turkey Corresponding author. Tel.: +90 4423448427 E-mail address: aksuuu001@msn.com Serdar Sevimli MD Atatürk University Faculty of Medicine Department of Cardiology Erzurum, Turkey http://dx.doi.org/10.1016/j.ajem.2015.11.054 References [1] Maron BJ, Bonow RO, Seshagiri TN, Roberts WC, Epstein SE. Hypertrophic cardiomyopathy with ventricular septal hypertrophy localized to the apical region of the left ventricle (apical hypertrophic cardiomyopathy). Am J Cardiol 1982;49:1838–48. [2] Lin CS, Chen CH, Ding PY. Apical hypertrophic cardiomyopathymimicking acute myocardial infarction. Int J Cardiol 1998;64:305–7. [3] Olearczyk B, Gollol-Raju N, Menzies DJ. Apical hypertrophic cardiomyopathymimicking acute coronary syndrome: a case report and review of the literature. Angiology 2008;59:629–31. [4] Sayin T, Kocum T, Kervancioglu C. Apical hypertrophic cardiomyopathy mimics acute coronary syndrome. Int J Cardiol 2001;80:77–9. [5] Gupta T, Paul N, Palaniswamy C, Balasubramaniyam N, Aronow WS, Kolte D, et al. Sudden cardiac arrest in a patient with apical hypertrophic cardiomyopathy: case report and a brief review of literature. Am J Ther 2015 [Epub ahead of print]. athy mimicking acute coronary syndrome, Am J Emerg Med (2015), Fig. 1. Electrocardiography shows negative T waves in inferior and lateral leads. Fig. 2.MRI demonstrates typical ace-of-spade–like appearance. Fig. 3.MRI demonstrates asymmetrical left ventricular apical thickening. 2 S. Topcu et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx Please cite this article as: Topcu S, et al, Apical hypertrophic cardiomyopathy mimicking acute coronary syndrome, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.11.054

Efficacy of coronary fractional flow reserve using contrast medium compared to adenosine

Introduction Coronary fractional flow reserve (FFR) is recommended as the gold standard method in evaluating intermediate coronary stenoses. However, there are significant debates concerning the agents and the timing of the measurement. Aim To compare the contrast medium induced Pd/Pa ratio (CMR) with the FFR. Material and methods We enrolled 28 consecutive patients with 34 intermediate lesions who underwent coronary FFR measurement by intracoronary (i.c.) adenosine. After baseline Pd/Pa was calculated, a single contrast medium (Iomeron) injection of 6 ml (3 ml/s) was performed manually. Within 10 s after the contrast medium injection, the CMR was calculated. Bolus injection of i.c. adenosine was performed to induce maximal hyperemia (from 60 µg to 600 µg), and when it was ≤ 0.80, the intermediate lesion was considered as significant. Results After bolus i.c. adenosine, 12 lesions of 34 (35.3%) were identified as significant. The CMR value was 0.86 ±0.06 (range: 0.71–0.97). There were no significant differences between FFR and CMR values (p = 0.108). A substantial positive correlation between adenosine and contrast values was detected (0.886 and p < 0.001). Good agreement in Bland-Altman analysis was revealed (mean bias was 0.027, 95% confidence interval 0.038–0.092). Receiver operating characteristics curve analysis showed 90.9% sensitivity and 91.7% specificity for a cut-off value of 0.85 for the CMR compared to FFR (≤ 0.80). Conclusions Our study showed that measuring the CMR is a feasible method compared to FFR. The CMR may be used in situations where adenosine cannot be administered.

Evaluating the Association Between the Three Different Ejection Fraction Measurement Techniques and Left Ventricle Global Strain

Objective The prognosis of cardiovascular diseases (CVDs) is directly associated with systolic function based on the measurement of ejection fraction (EF), and many studies have indicated that the left ventricular global strain (LVGS) provides better predictivity than the EF measurement in the diagnosis, prognosis, survival, and CVD staging. However, these studies did not investigate the correlation between the EF measurement and the LVGS parameters, or which parameters are better correlated with LVGS, but we analyzed the association between three EF measurement methods and LVGS. Materials and Methods This study included 62 patients that applied to the clinic between October 2015 and March 2016. An echocardiography examination of these patients was performed. The exclusion criteria were atrial fibrillation and suboptimal image quality. Results Sixty-two patients (the average age 61.0±12.6 years; 56% male and 44% female) were enrolled in the study. A statistically significant association was found between the visual EF and Simpson EF measurements and the LVGS parameters (p<0.001). While the visual EF was moderately correlated with the LVGS parameters (r=0.44), there was a good correlation between the Simpson EF and the LVGS parameters (r=0.710). Conclusion In this study, we demonstrate that the Simpsons rule LVEF correlates better with LVGS than the Teicholtz method or visual EF and that it has a better area under the curve value for determining an abnormal LVGS. Therefore, we recommend the use of the Simpson EF for the EF measurement that has a better correlation with the LVGS values in the patients whose ventricle functions should be evaluated.

The effect of dialysis type on left atrial functions in patients with end-stage renal failure: A propensity score-matched analysis

Despite the widespread use of both hemodialysis (HD) and peritoneal dialysis (PD), there is no study comparing the effects of these dialysis methods on the left atrial (LA) volume and functions. In this study, we investigated the impact of different dialysis methods on the LA volume and function in the patients exposed to chronic pressure overload and volume overload.

Aortic valve sclerosis is associated with the extent of coronaryartery disease in stable coronary artery disease

BACKGROUND/AIM Aortic valve sclerosis (AVS) is characterized by lipid deposition and calcific infiltration on the edge of aortic leaflets without significant restriction of motion. The SYNTAX Score (SS) is an important method for evaluating coronary artery disease (CAD). Many studies showed that there is an important relation between the SS and undesired cardiac outcomes. In our study, we investigated the correlation between the SS and AVS by including both ACS and stable CAD cases. MATERIALS AND METHODS We enrolled 543 patients with CAD who underwent coronary angiography into this cross-sectional study between September 2013 and September 2014. RESULTS The study population was divided into two groups according to SS values above and below 22. Diabetes mellitus (DM) incidence was greater in the group with high SS values (26.3% vs. 19.2%, P = 0.052.). Left ventricular ejection fraction (LVEF) and glomerular filtration rate were lower. Low-density lipoprotein cholesterol and triglyceride levels were lower while platelet counts were higher. In multivariate analysis, for the stable coronary artery group AVS existence, platelet count, LVEF value, and chronic obstructive pulmonary disease were found as independent predictors. CONCLUSION Our study results demonstrated that AVS is significantly associated with the complexity of CAD, especially in patients with stable CAD. This study provides new information regarding the role of AVS in CAD complexity.

The association of the Syntax score II with carotid intima media thickness and epicardial fat tissue

Aim Syntax score II (SSII) is a highly predictive scoring system, which is used to improve individualized assessment of patients with complex coronary artery disease and facilitates clinical decision making. Surrogate markers [carotid intima-media thickness (CIMT), epicardial fat tissue (EFT)] are also used for risk assessment, but their relation with SSII is not well established. Method We enrolled 543 consecutive patients, who underwent coronary angiography for stable angina pectoris and acute coronary syndrome, in the study. SSII was calculated for each patient and the patients were divided into two groups as low SSII group and high SSII group according to their median SSII. Results The average age of the patients was 61.4 years and 75% of the patients were male. The multivariate analysis indicated that only EFT (p: 0,035), CIMT (p:0,04) and Hypertension (HT) (p: 0,014) were independently associated with high SSII. Discussion EFT and CIMT, the surrogate markers which can be simply and non-invasively determined, are of the independent predictors of high SSII. The inclusion of these parameters in the risk classification may provide additional clinical benefit.