Real-World Data on the Incidence of Stroke, Myocardial Infarction, and Mortality Among Nonvalvular Atrial Fibrillation Patients in Türkiye: New Oral Anticoagulants-TURKey Study

BACKGROUND

Atrial fibrillation (AF) is strongly associated with an increased risk of ischemic events. Anticoagulation focuses on reducing the risk of embolism. Guideline recommended CHA2DS2-VASc scoring system is most widely used; however, different scoring systems do exist. Thus, we sought to assess the impact of anticoagulant treatment and different scoring systems on the development of stroke, myocardial infarction, and all-cause mortality in patients with nonvalvular AF.

METHODS

The present study was designed as a prospective cohort study. The enrollment of the patients was conducted between August 1, 2015, and January 1, 2016. The follow-up period was defined as the time from enrollment to the end of April 1, 2017, which also provided at least 12 months of prospective follow-up for each patient.

RESULTS

A total of 1807 patients with AF were enrolled. During the follow-up, 2.7% (48) of patients had stroke, 0.8% (14) had myocardial infarction, and 7.5% (136) died. The anticoagulation and risk factors in AF (ATRIA) score had a better accuracy for the prediction of stroke compared to other scoring systems (0.729, 95% CI, 0.708-0.750, P <.05). Patients under low-dose rivaroxaban treatment had significantly worse survival (logrank P <.001). Age, CHA2DS2-VASc score, R2CHADS2 score, ATRIA score, chronic heart failure, prior stroke, and being under low-dose rivaroxaban treatment were independent predictors of clinical endpoint (P <.001).

CONCLUSION

Low-dose rivaroxaban treatment was independently and strongly associated with the combined clinical endpoint. Furthermore, the ATRIA score proved to be a stronger predictor of stroke in the Turkish population.

Long-Term Prognosis of Patients with Heart Failure: Follow-Up Results of Journey HF-TR Study Population

BACKGROUND

Despite advances in therapeutic management of patients with heart failure, there is still an increasing morbidity and mortality all over the world. In this study, we aimed to present the 3-year follow-up outcomes of patients included in the Journey HF-TR study in 2016 that has evaluated the clinical characteristics and management of patients with acute heart failure admitted to the hospital and present a national registry data.

METHODS

The study was designed retrospectively between November 2016 and December 2019. Patient data included in the previously published Journey HF-TR study were used. Among 1606 patients, 1484 patients were included due to dropout of 122 patients due to inhospital death and due to exclusion of 173 due to incomplete data. The study included 1311 patients. Age, gender, concomitant chronic conditions, precipitating factors, New York Heart Association, and left ventricular ejection fraction factors were adjusted in the Cox regression analysis.

RESULTS

During the 3-year follow-up period, the ratio of hospitalization and mortality was 70.5% and 52.1%, respectively. Common causes of mortality were acute decompensation of heart failure and acute coronary syndrome. Angiotensin receptor blockers, betablockers, statin, and sacubitril/valsartan were found to reduce mortality. Hospitalization due to acute decompensated heart failure, acute coronary syndrome, lung diseases, oncological diseases, and cerebrovascular diseases was associated with the increased risk of mortality. Implantation of cardiac devices also reduced the mortality.

CONCLUSIONS

Despite advances in therapeutic management of patients with heart failure, our study demonstrated that the long-term mortality still is high. Much more efforts are needed to improve the inhospital and long-term survival of patients with chronic heart failure.

Real-life data of major and minor bleeding events with direct oral anticoagulants in the one-year follow-up period: The NOAC-TURK study

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.

Angiotensin receptor neprilysin inhibitor for patients with heart failure and reduced ejection fraction: Real-world experience from Turkey (ARNi-TR)

OBJECTIVE

Heart failure (HF) is a growing public health problem with high morbidity and mortality. Recently, angiotensin receptor neprilysin inhibitor (ARNi) has emerged as a promising treatment for HF with reduced ejection fraction (HFrEF). Here, we shared our experience with the use of ARNi in HFrEF from multiple centers in Turkey.

METHODS

The ARNi-TR is a multicenter, noninterventional, retrospective, observational study. Overall, 779 patients with HF from 22 centers in Turkey who were prescribed sacubitril/valsartan were examined. Initial clinical status, biochemical and echocardiographic parameters, and New York Heart Association functional class (NYHA-FC) values were compared with follow-up values after 1 year of ARNi use. In addition, the effect of ARNi on number of annual hospitalizations was investigated, and the patients were divided into 2 groups, depending on whether ARNi was initiated at hospitalization or under outpatient clinic control.

RESULTS

N-terminal pro-brain natriuretic peptide (NT-proBNP), left-ventricle ejection fraction (LV-EF), and NYHA-FC values improved significantly in both groups (all parameters, p<0.001) within 1-year follow-up. In both groups, a decrease in hemoglobin A1c (HbA1c) values was observed in ARNi use (p<0.001), and a decrease in daily diuretic doses and hospitalizations owing to HF were observed after ARNi use (all comparisons, p<0.001). Hypertension (16.9%) was the most common side effect in patients using ARN.

CONCLUSION

The ARNi-TR study offers comprehensive real-life data for patients using ARNi in Turkey. The use of ARNi has shown significant improvements in FC, NT-proBNP, HbA1c levels, and LV-EF. Likewise, reductions in the number of annual hospitalizations and daily furosemide doses for HF were seen in this study.

MicroRNA and Cardiovascular Diseases

Cardiovascular diseases are one of the most common causes of death in both developing and developed countries worldwide. Even though there have been improvements in primary prevention, the prevalence of cardiovascular diseases continues to increase in recent years. Hence, it is crucial to both investigate the molecular pathophysiology of cardiovascular diseases in-depth and find novel biomarkers regarding the early and proper prevention and diagnosis of these diseases. MicroRNAs, or miRNAs, are endogenous, conserved, single-stranded non-coding RNAs of 21-25 nucleotides in length. miRNAs have important roles in various cellular events such as embryogenesis, proliferation, vasculogenesis, apoptosis, cell growth, differentiation, and tumorigenesis. They also have potential roles in the cardiovascular system, including angiogenesis, cardiac cell contractility, control of lipid metabolism, plaque formation, the arrangement of cardiac rhythm, and cardiac cell growth. Circulating miRNAs are promising novel biomarkers for purposes of the diagnosis and prognosis of cardiovascular diseases. Cell or tissue specificity, stability in serum or plasma, resistance to degradative factors such as freeze-thaw cycles or enzymes in the blood, and fast-release kinetics, provide the potential for miRNAs to be surrogate markers for the early and accurate diagnosis of disease and for predicting middle- or long-term prognosis. Moreover, it may be a logical approach to combine miRNAs with traditional biomarkers to improve risk stratification and long-term prognosis. In addition to their efficacy in both diagnosis and prognosis, miRNA-based therapeutics may be beneficial for treating cardiovascular diseases using novel platforms and computational tools and in combination with traditional methods of analysis. microRNAs are promising, novel therapeutic agents, which can affect multiple genes using different signaling pathways. miRNAs therapeutic modulation techniques have been used in the settings of atherosclerosis, acute myocardial infarction, restenosis, vascular remodeling, arrhythmias, hypertrophy and fibrosis, angiogenesis and cardiogenesis, aortic aneurysm, pulmonary hypertension, and ischemic injury. This review presents detailed information about miRNAs regarding structure and biogenesis, stages of synthesis and functions, expression profiles in serum/plasma of living organisms, diagnostic and prognostic potential as novel biomarkers, and therapeutic applications in various diseases.

Is there a gender gap in secondary prevention of coronary artery disease in Turkey?

OBJECTIVE

It has been reported that women receive fewer preventive recommendations regarding pharmacological treatment, lifestyle modifications, and cardiac rehabilitation compared with men who have a similar risk profile. This study was an investigation of the impact of gender on cardiovascular risk profile and secondary prevention measures for coronary artery disease (CAD) in the Turkish population.

METHODS

Statistical analyses were based on the European Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE)-IV cross-sectional survey data obtained from 17 centers in Turkey. Male and female patients, aged 18 to 80 years, who were hospitalized for a first or recurrent coronary event (coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or acute myocardial ischemia) were eligible.

RESULTS

A total of 88 (19.7%) females and 358 males (80.3%) were included. At the time of the index event, the females were significantly older (p=0.003) and had received less formal education (p<0.001). Non-smoking status (p<0.001) and higher levels of depression and anxiety (both p<0.001) were more common in the female patients. At the time of the interview, conducted between 6 and 36 months after the index event, central obesity (p<0.001) and obesity (p=0.004) were significantly more common in females. LDL-C, HDL-C or HbA1c levels did not differ significantly between genders. The fasting blood glucose level was significantly higher (p=0.003) and hypertension was more common in females (p=0.001). There was no significant difference in an increase in physical activity or weight loss after the index event between genders, and there was no significant difference between genders regarding continuity of antiplatelet, statin, beta blocker or ACEi/ARB II receptor blocker usage (p>0.05).

CONCLUSION

Achievement of ideal body weight, fasting blood glucose and blood pressure targets was lower in women despite similar reported medication use. This highlights the importance of the implementation of lifestyle measures and adherence to medications in women.

[EUROASPIRE-IV: European Society of Cardiology study of lifestyle, risk factors, and treatment approaches in patients with coronary artery disease: Data from Turkey]

OBJECTIVE

Data from EUROASPIRE-IV Turkey report investigating risk factors and adherence to guidelines in patients hospitalized for coronary artery disease are presented and results are compared with those of EUROASPIRE-III Turkey and EUROASPIRE-IV Europe.

METHODS

Study was performed in 24 European countries, including Turkey (17 centers). Patients (18-80 years old) hospitalized for coronary (index) event during preceding 3 years were identified from hospital records and interviewed ≥6 months later. Patient information regarding index event was acquired from hospital records. Anamnesis was obtained during the interview, and physical examination and laboratory analyses were performed.

RESULTS

Median age at the index coronary event was 58.8 years, and it was significantly decreased compared with last EUROASPIRE-III study (60.5 years), which was conducted at the same centers 6 years earlier (p=0.017). Of all patients, 19.3% were under 50 years of age and mean age was lower than that of EUROASPIRE-IV Europe (62.5 years). Comparing EUROASPIRE-IV Turkey with EUROASPIRE-III Turkey, rate of smokers increased to 25.5% from 23.1% (p=0.499), obesity increased to 40.7% from 35.5% (p=0.211), total cholesterol level increased to 49.6% from 48.3% (p=0.767), and diabetes rate increased to 39.7% from 33.6% (p=0.139), however none of the differences reached a level of statistical significance. Only 11.7% of the smokers quit after coronary event. Rates for these factors were lower in EUROASPIRE-IV Europe (16% for smoking, 37.6% for obesity, and 26.8% for diabetes).

CONCLUSION

EUROASPIRE-IV Turkey data revealed that secondary prevention was unsatisfactory and had progressed unfavorably compared with last EUROASPIRE study, some risk factors were more uncontrolled than overall European average, and coronary artery events at young age remain an important problem.

The Time in Therapeutic Range and Bleeding Complications of Warfarin in Different Geographic Regions of Turkey: A Subgroup Analysis of WARFARIN-TR Study

Background:

The time in therapeutic range values may vary between different geographical regions of Turkey in patients vitamin K antagonist therapy.

Aims:

To evaluate the time in therapeutic range percentages, efficacy, safety and awareness of warfarin according to the different geographical regions in patients who participated in the WARFARIN-TR study (The Awareness, Efficacy, Safety and Time in Therapeutic Range of Warfarin in the Turkish population) in Turkey.

Study Design:

Cross-sectional study.

Methods:

The WARFARIN-TR study includes 4987 patients using warfarin and involved regular international normalized ratio monitoring between January 1, 2014 and December 31, 2014. Patients attended follow-ups for 12 months. The sample size calculations were analysed according to the density of the regional population and according to Turkish Statistical Institute data. The time in therapeutic range was calculated according to F.R. Roosendaal’s algorithm. Awareness was evaluated based on the patients’ knowledge of the effect of warfarin and food-drug interactions with simple questions developed based on a literature review.

Results:

The Turkey-wide time in therapeutic range was reported as 49.5%±22.9 in the WARFARIN-TR study. There were statistically significant differences between regions in terms of time in therapeutic range (p<0.001). The highest rate was reported in the Marmara region (54.99%±20.91) and the lowest was in the South-eastern Anatolia region (41.95±24.15) (p<0.001). Bleeding events were most frequently seen in Eastern Anatolia (41.6%), with major bleeding in the Aegean region (5.11%) and South-eastern Anatolia (5.36%). There were statistically significant differences between the regions in terms of awareness (p<0.001).

Conclusion:

Statistically significant differences were observed in terms of the efficacy, safety and awareness of warfarin therapy according to different geographical regions in Turkey.

The assessment of the relationship between variations in the apelin gene and coronary artery disease in Turkish population

Objective:

Apelin is a novel endogenous peptide with inotropic and vasodilatory properties and is the ligand for the angiotensin receptor-like 1 (APJ) receptor. The aim of the study was to investigate the association of 2 single-nucleotide polymorphisms (SNPs) in the apelin gene with susceptibility to coronary artery disease (CAD) in the Turkish population.

Methods:

The present observational case-control study consisted of 244 subjects (134 angiographically proven CAD patients and 110 healthy controls) aged 30-65 years. The association of 2 SNPs (rs3115758 and rs3115759) in the apelin gene and CAD risk was investigated. Real-time polymerase chain reaction (RT-PCR) was used to analyze the 2 SNPs in both the CAD and the healthy subjects. Allele and genotype frequencies between patients and control groups were compared using the Chi-square (χ²) test. The relationships of the 2 polymorphisms with the presence of CAD were determined with multiple binary logistic regression analysis after adjustment for CAD risk factors.

Results:

TT and AA risk genotypes of the rs3115758 and rs3115759 variants in the apelin gene were found to be significantly related with the risk of CAD with the same power (OR: 6.36, 95% CI: 1.41-28.6) (p=0.007). After adjustments for traditional CAD risk factors, the homozygous TT genotype for rs3115758 and AA genotype for rs3115759 increased the CAD risk, both with an OR of 5.91.

Conclusion:

Genetic variants in the apelin gene are significantly associated with the risk of CAD in the Turkish population.

Evaluation of association between common genetic variants on chromosome 9p21 and coronary artery disease in Turkish population

Objective:

Coronary artery disease (CAD), which develops from complex interactions between genetic and enviromental factors, is a leading cause of death worldwide. Based on genome-wide association studies (GWAS), the chromosomal region 9p21 has been identified as the most relevant locus presenting a strong association with CAD in different populations. The aim of the present study was to investigate the association of two SNPs on chromosome 9p21 on susceptibility to CAD and the effect of these SNPs along with cardiovascular risk factors on the severity of CAD in the Turkish population.

Methods:

This study had an observational case-control design. We genotyped 460 subjects, aged 30-65 years, to investigate the association of 2 SNPs (rs1333049, rs2383207) on chromosome 9p21 and CAD risk in Turkish population. Real-time polymerase chain reaction (RT-PCR) was used to analyze the 2 SNPs in CAD patients and healthy controls. The genotype and allelic variations of these SNPs with the severity of CAD was also assessed using semi-quantitative methods such as the Gensini score. Student’s t test and multiple regression analysis were used for statistical analysis.

Results:

The SNPs rs1333049 and rs2383207 were found to be associated with CAD with an adjusted OR of 1.81 (95% Cl 1.05-3.12) and 2.12 (95% CI 1.19-4.10) respectively. After adjustment of CAD risk factors such as smoking, family history of CAD and diabetes, the homozygous AA genotype for rs2383207 increased the CAD risk with an OR 3.69. Also a very strong association was found between rs1333049 and rs2383207 and Gensini scores representing the severity of CAD (p<0.001).

Conclusion:

The rs2383207 and rs1333049 SNPs on 9p21 chromosome were significantly associated with the risk and severity of CAD in the Turkish population.