Coronary artery disease (CAD) together with stroke are the leading causes of death worldwide, and together, they pre-sent a health and economic burden. Ischemic stroke survivors and patients who suffered transient ischemic attack (TIA) have a higher prevalence of coronary atherosclerosis, and they have a relatively high risk of myocardial infarcti-on and nonstroke vascular death. Pubmed was searched for studies focused on investigating coronary atherosclerosis in ischemic stroke survivors or patients who suffered TIA and their cardiovascular risk assessment. There were corona-ry plaques in 48%-70% of stroke survivors without a known history of CAD, and significant stenosis of at least one coronary artery can be found in 31% of these patients. CAD is a major cause of morbidity and mortality in stroke survivors. Detection and treatment of silent CAD may improve the long-term outcome and survival of these patients.

Kılavuzlarca önerilen güncel ST-yükselmeli/yükselmesiz miyokart enfarktüsü (STYME/ STYzME) paradigması ciddi kısıtlılıklara sahiptir. Bu paradigma önemli bir miktarda akut koroner oklüzyonu (AKO) kaçırmakta ve belirgin derecede sık gereksiz kateter laboratuvarı aktivasyonuna neden olmaktadır. STyME kriterlerinin kanıt temelinin ne derece zayıf olduğu yaygın biçimde fark edilmemektedir: Önerilen STyME değerleri AKO’su olan ve olmayan hastaları karşılaştırarak elde edilmemiş, acil reperfüzyondan kimin fayda göreceğine göre dizayn edilmemiştir. Bu makalede, STyME/STyzME paradigmasının kökeni, kanıt temeli ve sınırlılıkları gözden geçirilmekte, yeni bir oklüzyonlu ve oklüzyonsuz miyokart enfarktüsü (OME/OzME) paradigması için çağrı yapılmaktadır.

The ST-elevation myocardial infarction (STEMI)/non-STEMI paradigm per the current guidelines has important limitations. It misses a substantial proportion of acute coronary occlusions (ACO) and results in a significant amount of unnecessary catheterization laboratory activations. It is not widely appreciated how poor is the evidence base for the STEMI criteria; the recommended STEMI cutoffs were not derived by comparing those with ACO with those without and not specifically designed for distinguishing patients who would benefit from emergency reperfusion. This review aimed to discuss the origins, evidence base, and limitations of STEMI/non-STEMI paradigm and to call for a new paradigm shift to the occlusion MI (OMI)/non-OMI.

Objective: Many trials confirmed the role of sacubitril–valsartan in the treatment of patients with heart failure with reduced ejection fraction (HFrEF). However, there is no sufficient data to register the effect of compulsory discontinuation of sacubitril–valsartan, either because of finan-cial shortage or adverse effects, and shifting to the standard therapy, including angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB).
Methods: The patients with HFrEF (LVEF ≤35%) were included in the study. They received treatment with sacubitril–valsartan as a replacement for an ACEI or ARB. The patients were divided into two groups: the compliant group (n=111). The non-compliant group (n=82), whose members discontinued sacubitril–valsartan after ≥5 months but <6 months since their enrollment in the study.
Results: Initially, 199 patients with HFrEF were included in the study. All the patients were started treatment with sacubitril–valsartan in addition to the evidence-based standard therapy of heart failure. Six patients were excluded at the first follow-up visit (at 6 months). The remaining 193 patients showed initial improvement of the New York Heart Association (NYHA) class, the end-diastolic volume (EDV), and the left ventricular ejection fraction (LVEF). Five patients were excluded at the 12 months’ follow-up visit. The other 188 patients were divided into two groups: Group I (n=108) patients were compliant on sacubitril–valsartan for 12 months; Group II (n=80) patients were compliant on sacubitril–valsartan for ≥5 months, but stopped it at <6 months, and were shifted to ACEI or evidence-based ARB. Group II (n=80) patients showed worsening of their NYHA class, compared to the 6 months’ follow-up visit (p=0.001). LVEF and EDV were also shown to be worsened in these patients when we compared them to the values of the 6 months’ follow-up appointment with p=0.001 for both parameters.
Conclusion: The discontinuation of sacubitril–valsartan in patients with HFrEF leads to deterioration of the LVEF as well as worsening of the functional class. The decline in LVEF and NYHA functional class occurs despite being compliant with the optimal conventional therapy with ACEI or evidence-based ARB.

Objective: Left bundle branch block (LBBB), which is associated with underlying cardiac disease, is believed to play a role in the pathogenesis of cardiomyopathy through delays in interventricular conduction, leading to dyssynchrony. However, this has not been established in previous studies. It is unclear whether LBBB indicates clinically advanced cardiac disease or is an independent factor responsible for increased mortality and the development of heart failure. We investigated the natural history of isolated LBBB without any associated structural heart disease in order to determine its clinical significance.
Methods: We performed a retrospective chart review on consecutive patients who fulfilled the 12-lead electrocardiographic (ECG) criteria for complete LBBB and had a normal echocardiogram with no evidence of structural heart disease and left or right ventricular systolic dysfunction within three months of the initial ECG between January 1, 2000 and December 31, 2009. We excluded patients with documented coronary artery disease (CAD) at any time, any structural heart disease, or cardiac devices. We evaluated the primary endpoints of mortality and incidence of cardiomyopathy, as well as any heart failure hospitalizations over a 1- and 10-year period.
Results: We identified 2522 eligible patients. The mean follow-up duration was 8.4±3.2 years. The one-year mortality rate was 7.8%, with a 10-year mortality rate of 22.0%. The incidence of cardiomyopathy over one year was 3.2% and over 10 years was 9.1%. There was no significant difference in QRS duration between patients who were alive and those that were deceased at 10 years (141+/−18 vs. 141+/−17 ms; p=0.951) and patients with and without cardiomyopathy at 10 years (142±17 vs. 141±17 ms; p=0.532).
Conclusion: Isolated LBBB occurring without structural heart disease, ventricular dysfunction, or CAD is associated with a low mortality rate and incidence of cardiomyopathy.

Objective: Distal radial artery access or trans-snuffbox access (TSA) is a novel, safe, and feasible technique for coronary artery interventions wherein its vascular hemostasis is still concerned. So, this study aimed to compare two homeostasis methods comprising manual and mechanical compression approaches in patients undergoing coronary angiography (CAG) via TSA.
Methods: In a prospective nonrandomized clinical trial, a total of 80 patients undergoing diagnostic CAG by TSA were divided into two equal groups: manual compression and mechanical compression (using radial TR band), the main end point of which was primary hemostasis time. Other variables were patient satisfaction, puncture site pain severity, hospitalization time, and local neurovascular complication during the 30-day follow-up.
Results: The mean age of the patients was 57.1±8.0 years, with 40 of them (54.1%) being male. The primary hemostasis time was significantly shorter in the manual compression approach [15.0±5.9 minutes with median 15 (9–20)] than in the TR band group [25.7±4.9 minutes with median 25 (20–30)] (p<0.001). No significant difference was noted in the patient’s satisfaction and puncture site pain severity as well as hospitalization time between the two methods (p>0.050). The neurovascular complication, including hematoma, numbness, and dRA occlusion, rates had also no significant difference between the two groups (p>0.050).
Conclusion: The manual compression approach on the puncture site reduces hemostasis time in patients undergoing CAG via TSA when compared with the mechanical compression method.

AMAÇ
COVİD-19 tanısı alan hafif ve orta derecede semptomatik hastalarda COVİD-19'un hidroksiklorokin, antiviral ve antibiyotik içeren üçlü kombinasyon tedavisi tam olarak anlaşılamamış olup netlik kazanmamıştır. Hafif ve orta şiddette semptomatik COVID-19 hastalarında üçlü kombinasyon tedavisinden sonra değerlendirilen EKG parametrelerindeki değişiklikleri araştırmayı amaçladık.

GEREÇ ve YÖNTEM
Bu retrospektif tek merkezli olgu serisinde, 1 Nisan 2020 - 30 Nisan 2020 tarihleri arasında...................... Hastanesi, Ankara, Türkiye’de COVID-19 tanısı alan hafif ila orta derecede semptomatik 91 hasta analiz edildi. 43 hasta hidroksiklorokin + oseltamivir + azitromisin (Grup 1) ile tedavi edildi ve 48 hasta hidroksiklorokin + oseltamivir + levofloksasin (Grup 2) ile tedavi edildi. Kalp hızı, P dalga süresi, P dalga dispersiyonu, PR aralığı, QRS süresi, QTc, QTD, delta QTc, Tp-e, Tp-e dispersiyonu ve Tp-e / QTc oranı bazal ve tedavi sonrası 12 derivasyonlu EKG kayıtlarından hesaplanmıştır.

BULGULAR
QTc, QRS süresi, Tp-e, PR aralığı ve P dalga süresinin tedaviden sonra anlamlı olarak arttığı izlendi (p <0.001). Tedavi sonrası CRP değeri, Grup 1'de anlamlı olarak düşüktü (p = 0.014). Hastaların % 30'unda başvuru sırasında QT uzaması vardı, % 4.3'ünde QT süresi> 500 msn idi. QTc aralığı (p <0.001 vs. p <0.001), QRS süresi (p = 0.006 vs. p = 0.014), Tp-e (p = 0.036 vs. p <0.001), PR aralığının(p = 0.002 vs. p = 0.05) her iki grupta da anlamlı derecede uzadığı görüldü. QTD Grup 1'de anlamlı olarak düşük izlendi (p <0.001). Takip edilen hiçbir hastada aşikar ventriküler aritmi gözlenmedi.

SONUÇ
Bildiğimiz kadarıyla bu çalışma, üçlü kombinasyon tedavisi uygulanan bir hasta popülasyonunda QT uzamasını araştıran ilk çalışmadır. Azitromisin ile üçlü tedavi alan hastalarda tedaviden sonra QTD'de anlamlı bir azalma olduğunu saptadık.

Objective: The effects of treatment of coronavirus disease 2019 (COVID-19) with a triple combination composed of hydroxychloroquine, an an-tiviral, and an antibiotic on electrocardiography (ECG) parameters in patients with mild-to-moderate symptoms are not wholly understood. We aimed to explore the changes in ECG parameters after treatment with triple combination therapy in patients with mild-to-moderate symptomatic COVID-19.
Methods: This retrospective, single-center case series analyzed 91 patients with mild-to-moderate symptomatic COVID-19 at Ankara Gazi Mus-tafa Kemal State Hospital of Ankara City, Turkey, from April 1, 2020, to April 30, 2020. Forty-three patients were treated with hydroxychloroquine+oseltamivir+azithromycin (Group 1) and 48 patients were treated with hydroxychloroquine+oseltamivir+levofloxacin (Group 2). Heart rate, P wave duration, P wave dispersion, PR interval, QRS duration, corrected QT interval (QTc), QTc dispersion (QTD), delta QTc, Tp-e, Tp-e dispersion, and Tp-e/QTc ratio were all calculated from the baseline and posttreatment 12-lead ECG recordings.
Results: The QTc, QRS duration, Tp-e, PR interval, and P wave duration were significantly increased after treatment (p<0.001; p<0.001; p<0.001; p=0.001; p=0.001). The posttreatment C-reactive protein level was significantly lower than at baseline in Group 1 (p=0.014). At admission, 30% of patients had QT prolongation, and 4.3% of them had a QT duration >500 ms. Both Group 1 and Group 2 showed significant prolongation of the QTc interval (Group 1; p<0.001 vs. Group 2; p<0.001), QRS duration (Group 1; p=0.006 vs. Group 2; p=0.014), Tp-e (Group 1; p=0.036 vs. Group 2; p<0.001), and PR interval (Group 1; p=0.002 vs. Group2; p=0.05). The QTD was significantly decreased in Group 1 (p<0.001). None of the patients experienced any overt ventricular arrhythmia.
Conclusion: To the best of our knowledge, this study is the first to investigate QT prolongation in a population of COVID-19 patients treated with triple combination therapy. We found that there was a significant decrease in the QTD after the treatment in patients who were taking triple therapy including azithromycin.

Amaç: Protez kapak hastalarında klinik bulgu veren serebrovasküler olay risk artışı bilinmektedir, ancak sessiz serebral iskemi (SSİ) riskine dair veriler oldukça sınırlıdır. Serum nöron spesifik enolaz (NSE), nöronal hasar derecesini belirleme açısından fikir verici, geçerli bir biyobelirteç olarak değerlendirilmektedir. Amacımız protez mitral kapak hastalarında, olası yeni SSI’nin belirteci olarak NSE yüksekliğini test etmekti.
Metod: Hastanemiz polikliniğine ayaktan rutin değerlendirme için başvuran 103 protez mitral kapak hastasında NSE değerleri ölçüldü. INR ve terapötik aralıkta olma oranları (TTR) antikoagülasyon kalitesi belirteçleri olarak kaydedildi.
Bulgular: Hastaların %58’i kadın ve yaş ortalaması 65 idi. Hastaların %24’ünde, yeni geçirilmiş SSİ göstergesi olan NSE>12 ng/mL düzeyi saptandı. Kabüldeki INR düzeyi ile NSE arasında negatif korelasyon mevcuttu (r= -0.307, p=0.002). Çok değişkenli analizde subterapötik INR ve optimal olmayan TTR düzeylerinin SSİ için bağımsız belirteçler olduğu gösterildi (sırasıyla; odds oranı [OR] 5.420; 95% güvenlik aralığı [CI] 1.589 - 18.483; p=0.007, ve [OR] 4.149; 95%[CI] 1.019 - 16.949; p=0.047). Aktif sigara içiciliği OR] 10.798; 95% [CI] 2.520 -46.272; p=0.001), büyük sol atrium ([OR] 6.763; 95% [CI] 2.253 - 20.302; p=0.001) ve aspirin kullanmıyor olmak ([OR] 10.526; 95% [CI] 1.298 -83.333; p=0.027) diğer bağımsız belirteçlerdi.
Sonuç: Verilerimiz protez kapak hastalarında SSİ’nin oldukça sık olduğunu göstermektedir, sonuç rutin poliklinik hastalarında dört kişiden biri oranındadır. Bu yüksek değer yetersiz antikoagülasyon düzeyi ile kısmen açıklanabilmektedir.

Objective: Although patients with prosthetic heart valves have an increased risk of clinically overt cerebrovascular events, evidence for the risk of silent cerebral infarction (SCI) is scarce. Serum neuron-specific enolase (NSE) is suggested to be a valid biomarker that allows for the quantification of the degree of neuronal injury. We aimed to assess whether NSE is elevated as a marker of recent SCI in patients with a prosthetic mitral valve.
Methods: We measured the NSE levels in 103 patients with a prosthetic mitral valve (PMV), admitted to our outpatient clinics for routine evaluation. International normalized ratio (INR) and time in target therapeutic range (TTR) were noted as anticoagulation quality measures.
Results: Most of the patients were females (58%), and a mean age was 65 years. NSE values of >12 ng/mL, suggesting a recent SCI, was detected in 25 patients (24%). NSE was negatively correlated with admission INR (r=−0.307, p=0.002). Multivariate analyses demonstrated subtherapeutic INR (INR <2.5) and suboptimal TTR as independent predictors of SCI [odds ratio (OR) 5.420; 95% confidence interval (CI) 1.589 to 18.483; p=0.007, and OR 4.149; 95% CI 1.019 to 16.949; p=0.047, respectively]. Being a current smoker (OR 10.798; 95% CI 2.520 to 46.272; p=0.001), large left atrium (OR 6.763; 95% CI 2.253 to 20.302; p=0.001), and not using aspirin (OR 10.526; 95% CI 1.298 to 83.333; p=0.027) were other independent predictors.
Conclusion: Our data suggest that silent brain infarcts are very prevalent among patients with a PMV, as one fourth of them had the event during their routine outpatient visit. Poor quality of anticoagulation partly explains the increased prevalence.

Öz.
Amaç: Nonvalvüler atrial fibrilasyon (NVAF) hastalarında direkt oral antikoagülanların güvenilirliğinin değerlendirilmesi.
Metod: Ocak 2016 ve Nissan 2017 tarihleri arasında yapılan prospektif çalışmada,18 yaşından büyük, direkt oral antikoagulan tedavi altındaki NVAF tanılı hastalar incelendi.Türkiyenin farklı bölgerlerinde yapılan çalışmada ortalama takip süresi 12±2 aydı.Mayor ve minor kanama olayları araştırıldı.
Bulgular: Toplamda 1807 katılımcı kaydedildi. Ortalama yaş (age=73.6 ± 10.2, 39% male, mean CHA2DS2-VASc score =3.6 ± 1.4, HAS-BLED score=2 ± 1.2).En sık reçete edilen DOAK dabigatran 110 mg bid idi 409 (22.6%).Apiksaban 2.5 mg bid alan hastalar en yaşlı gruptu(p<0.001). Rivaroksaban 15 mg alan hastalarda, kronik böbrek yetersizliği oranı daha fazla idi 46(16.7%)). Toplam 205(11.4%) hastada kanama olayı gözlendi. Bunların arasından 34 tanesi (1.9%) major, 171 tanesi (9.4%) minör kanama idi. Sırası ile dabigatran 150 mg alan grupta kanama olayı 2/273(0.7%) major, 30/273(10.9%) minör, dabigatran 110 mg’da major 13/409(3%) ve minör 44/409(10.7%). Rivaroksaban 20 mg’da 42/385(10,9%) ve 4/385(1%), rivaroksaban 15 mg’da 8/276(2.9%) ve 27/276 (9.7%). Apiksaban 5 mg’da 3/308(0.9%) ve 14/308(4.5%), apiksaban 2.5 mg’da 4/156(2.5%) ve 14/156(9%). Apiksaban 5mg ile olan toplam kanama 17(5.6%) diğer DOAK’lardan daha azdı. Ancak bu ilişki çok değişkenli analizde gösterilemedi. Dabigatran 110 mg da toplam kanama ve gastrointestinal sistem (GIS) kanama oranı daha yüksekti. Çok değişkenli analizde,rivaroksaban 20 mg kanama riski için bağımsız bir göstergeydi (HR=1.760, (CI=1.228 - 2.524) P=0.002). ATRIA ve HAS-BLED skorları ile periferik arter hastalığı kanama riski için diğer bağımsız göstergelerdi. Çalışmamızda en sık major kanama odağı GIS 17 (0.9 %) iken, gingiva (45 (2.5%) ise en sık minör kanama odağı idi.
Sonuç: Bu çalışma, gerçek yaşam çalışmalarına benzer sonuçlar göstermekteydi. Rivaroksaban 20 mg, kanama için bağımsız bir risk faktörüydü.

 

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.