Turkish Real Life Atrial Fibrillation in Clinical Practice: TRAFFIC Study

BACKGROUND

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and is associated with an increased risk of thromboembolism, ischemic stroke, impaired quality of life, and mortality. The latest research that shows the prevalence and incidence of AF patients in Türkiye was the Turkish Adults' Heart Disease and Risk Factors study, which included 3,450 patients and collected data until 2006/07.The Turkish Real Life Atrial Fibrillation in Clinical Practice (TRAFFIC) study is planned to present current prevalence data, reveal the reflection of new treatment and risk approaches in our country, and develop new prediction models in terms of outcomes.

METHODS

The TRAFFIC study is a national, prospective, multicenter, observational registry. The study aims to collect data from at least 1900 patients diagnosed with atrial fibrillation, with the participation of 40 centers from Türkiye. The following data will be collected from patients: baseline demographic characteristics, medical history, vital signs, symptoms of AF, ECG and echocardiographic findings, CHADS2-VASC2 and HAS-BLED (1-year risk of major bleeding) risk scores, interventional treatments, antithrombotic and antiarrhythmic medications, or other medications used by the patients. For patients who use warfarin, international normalized ratio levels will be monitored. Follow-up data will be collected at 6, 12, 18, and 24 months. Primary endpoints are defined as systemic embolism or major safety endpoints (major bleeding, clinically relevant nonmajor bleeding, and minor bleeding as defined by the International Society on Thrombosis and Hemostasis). The main secondary endpoints include major adverse cardiovascular events (systemic embolism, myocardial infarction, and cardiovascular death), all-cause mortality, and hospitalizations due to all causes or specific reasons.

RESULTS

The results of the 12-month follow-up of the study are planned to be shared by the end of 2023.

CONCLUSION

The TRAFFIC study will reveal the prevalence and incidence, demographic characteristics, and risk profiles of AF patients in Türkiye. Additionally, it will provide insights into how current treatments are reflected in this population. Furthermore, risk prediction modeling and risk scoring can be conducted for patients with AF.

Different Cardio-Selective ß-Blockers and the Prevention of Exaggerated Blood Pressure Response During Exercise: A Retrospective Cross-Sectional Study

OBJECTIVE

The aim of this study was to analyze the role of various ß-blockers in managing exercise-induced blood pressure escalations, referred to as exaggerated blood pressure response (eBPR). Despite the importance of this phenomenon, there is limited data on the efficacy of ß-blockers in controlling eBPR.

METHOD

Our retrospective cohort for this study comprised 2,803 individuals who underwent treadmill tests from January 2016 to February 2018. A further subgroup analysis of 1,258 patients receiving ß-blocker treatment was performed to evaluate the influence of different ß-blockers on eBPR.

RESULTS

The results demonstrated that ß-blockers play a significant role in mitigating the occurrence of eBPR (P = 0.026), irrespective of the specific type of ß-blocker. Additionally, no significant variance was observed in the development of eBPR among the different ß-blocker groups (P = 0.532 for systolic blood pressure (BP); P = 0.068 for diastolic BP). This finding remained consistent even among the 992 hypertensive patients, where no notable association was found between the type of ß-blocker and the development of eBPR (P = 0.736 for systolic BP; P = 0.349 for diastolic BP). It is noteworthy that patients using ß-blockers had unique clinical and demographic attributes.

CONCLUSION

Our study suggests that ß-blockers can potentially deter the development of eBPR during physical activity, a benefit that is consistent across all types of ß-blockers. The study sheds light on prospective randomized studies on the use of eBPR as a new treatment target.

Misperceptions and management of LDL-cholesterol in secondary prevention of patients with familial hypercholesterolemia in cardiology practice: Real-life evidence from the EPHESUS registry

BACKGROUND AND AIMS

Familial hypercholesterolemia (FH) is a common inherited disease, leading to premature atherosclerotic cardiovascular disease (ASCVD) due to elevated low-density lipoprotein cholesterol (LDL-C) levels. Achieving LDL-C goals is extremely important for preventing the complications of this fatal disease. We evaluated the management of FH patients with ASCVD in cardiology practice.

METHODS

We analyzed patients with ASCVD from the nationwide EPHESUS registry, which was conducted in 40 cardiology outpatient clinics, and compared those with and without FH.

RESULTS

Of the 1482 consecutively enrolled patients with ASCVD, 618 (41.7%) had FH, among which 455 were categorized as 'Possible FH' and 163 as 'Probable or Definite FH'. Proposed LDL-C goals were not attained in more than 90% of the patients with FH. The proportion of those on statin therapy was 77% for possible and 91% for probable or definite FH, whereas 34.2 % and 59.4% were in use of high-intensity statins, respectively. None of the patients were on PCSK-9 inhibitors, and only 2 used ezetimibe. Adverse media coverage was the most common cause of statin discontinuation (32.5% in 'possible FH' and 45.7% in 'probable/definite FH'). The negative impact of media in the decision to stop lipid lowering therapy (LLT) was increasing with education level.

CONCLUSIONS

In real life most of the FH patients with ASCVD are undertreated in cardiology practice regarding statin dosing and combined LLT. Drug discontinuation rates are notably high and are mostly media-related, and side effects very rarely cause cessation of LLT. Urgent measures are needed to increase the awareness of FH among healthcare providers and patients and to develop improved treatment strategies aimed at preventing the complications of FH.

Comparing the Diagnostic Performance of HFA-PEFF and H2FPEF Scoring Systems in Heart Failure with Preserved Ejection Fraction Patients: Insights from the APOLLON Registry

BACKGROUND

Heart failure with preserved ejection fraction is a complex and heterogeneous clinical syndrome, poses significant diagnostic challenges. The HFA-PEFF [Heart Failure Association of ESC diagnostic algorithm, P (Pretest Assessment), E  (Echocardiographic and Natriuretic Peptide score), F1 (Functional testing in Case of Uncertainty), F2 (Final Aetiology)] and H2FPEF [Heavy (BMI>30 kg/m2), Hypertensive (use of ≥2 antihypertensive medications), atrial Fibrillation (paroxysmal or persistent), Pulmonary hypertension (Doppler Echocardiographic estimated Pulmonary Artery Systolic Pressure >35 mm Hg), Elderly (age >60 years), Filling pressure (Doppler Echocardiographic E/e' >9)] scoring systems were developed to aid in diagnosing heart failure with preserved ejection fraction. This study aimed to assess the concordance and clinical accuracy of these scoring systems in the 'A comPrehensive, ObservationaL registry of heart faiLure with mildly reduced and preserved ejection fractiON' cohort.

METHODS

A comPrehensive, ObservationaL registry of heart faiLure with mildly reduced and preserved ejection fractiON study was conducted as a multicenter, cross-sectional, and observational study; to evaluate a group of Heart failure with mildly reduced ejection fraction and heart failure with preserved ejection fraction patients who were seen by cardiologists in 13 participating centers across 12 cities in Türkiye.

RESULTS

The study enrolled 819 patients with heart failure with preserved ejection fraction, with high probability heart failure with preserved ejection fraction rates of 40% and 26% for HFA-PEFF and H2FPEF scorings, respectively. The concordance between the 2 scoring systems was found to be low (Kendall's taub correlation coefficient of 0.242, P < .001). The diagnostic performance of both scoring systems was evaluated, revealing differences in their approach and ability to accurately identify heart failure with preserved ejection fraction patients.

CONCLUSION

The low concordance between the HFA-PEFF and H2FPEF scoring systems underscores the ongoing challenge of accurately diagnosing and managing patients with heart failure with preserved ejection fraction. Clinicians should be aware of the strengths and limitations of each scoring system and use them in conjunction with other clinical and laboratory findings to arrive at an accurate diagnosis. Future research should focus on identifying additional diagnostic factors, developing more accurate and comprehensive diagnostic algorithms, and investigating alternative methods of diagnosis or stratification of patients based on different clinical characteristics.

Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry

BACKGROUND AND AIMS

Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients.

METHODS

We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia.

RESULTS

Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P < .001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P = .06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages.

CONCLUSIONS

In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

Assesment of Cerebral Blood Flow Velocities with Transcranial Doppler Ultrasonography in Heart Failure Patients with Reduced Ejection Fraction

BACKGROUND

Heart and brain interaction is a well-known entity in heart failure (HF) and left ventricular systolic dysfunction poses an increased risk for stroke and cognitive impairment. Transcranial Doppler (TCD) provides valuable information on cerebral blood flow velocities (CBFV). However, less is known about CBFV in HF patients with reduced EF. So, we aimed to evaluate CBFV by means of TCD in patients with HF and reduced ejection fraction (HFrEF).

METHODS

This study included 46 HFrEF patients (mean age 65.2±11 years, mean EF 20.1±3.8%) who underwent to TCD examination. In addition, 26 healthy individuals with sinus rhythm and EF >50% were included in the study as a control group. Peak systolic, mean and end diastolic flow velocities of the both right and left middle cerebral artery (RMCA and LMCA) were analyzed. In subgroup analysis, HFrEF patients compared according to rhythm. Correlation analyses was performed in HFrEF group between EF and TCD velocities.

RESULTS

The average of RMCA and LMCA peak systolic and mean flow velocities were significantly lower in HF patients than those in control group (76,06±23,7 cm/s and 48,49±16,4 cm/s in HF group vs 87,84±14,5 cm/s and 56,41±10,7 cm/s in control group, p=0,025 and p=0,016, respectively, for RMCA and 75,1±22,3 cm/s and 47,57±14.8 cm/s in HF group vs 88,73±17,7 cm/s and 57,15±12,4 cm/s in control group, p=0,009 and p=0,007, respectively, for LMCA). The average mean flow velocity of RMCA and LMCA was significantly lower in HFrEF patients with AF than HFrEF patients with sinus rhythm. (P=0.04 and P= 0.03, respectively) In correlation analysis, EF was significantly positively correlated with both LMCA and RMCA flow velocities in HFrEF group.

CONCLUSION

This study showed that HFrEF patients have lower CBFV as compared to healthy controls and HFrEF patients with AF rhythm have lower CBFV compared to HFrEF with sinus rhythm which might be one of the explanations of the adverse interaction between heart and brain in HFrEF.

P4518Cerebral blood flow is lower in heart failure patients with reduced ejection fraction

Purpose

Heart and brain interaction is a well-known entity in heart failure (HF) and left ventricular systolic dysfunction poses an increased risk for stroke and cognitive impairment. Transcranial Doppler (TCD) provides valuable information on cerebral blood flow and detects microembolic signals that can be used to determine the risk of cerebrovascular events. However, less is known about cerebral blood flow in HF patients with reduced EF. So, we aimed to evaluate cerebral blood flow rates by means of TCD in HF patients with reduced ejection fraction (EF).

Methods

This study included 46 HF patients with an EF less than 35% (mean age 65.2±11 years, mean EF 20.1±3.8%) who underwent to TCD examination. In addition, 26 healthy individuals with sinus rhythm and EF >50% (mean age 64.4±9.0 years, mean EF 63.5±2.38%) were included in the study as a control group. Minimum, maximum and mean flow velocities of the both right middle cerebral artery (RMCA) and left middle cerebral artery (LMCA) determined by TCD were analyzed.

Results

The average of RMCA maximum and mean flow velocities were found to be significantly lower in HF patients than those in control group (76,06±23,7 cm/s and 48,49±16,4 cm/s in HF group vs 87,84±14,5 cm/s and 56,41±10,7 cm/s in control group, p=0,025 and p=0,016, respectively). The average of LMCA maximum and mean flow velocities were also significantly lower in HF patients than those in control group (75,1±22,3 cm/s and 47,57±14.8 cm/s in HF group vs 88,73±17,7 cm/s and 57,15±12,4 cm/s in control group, p=0,009 and p=0,007, respectively). However, there was no significant difference in minimum RMCA or LMCA flow velocities between HF group and control groups (33,5±10,6 cm/s and 32,86±9,58 cm/s in HF group vs 36,34±9,2 cm/s and 36,53±10,4 cm/s in control group, p=0,226 and p=0,157, respectively). No significant microembolic signals were detected in HF and control groups.

Conclusions

The results of this study showed that HF patients with reduced EF have lower cerebral blood flow velocities as compared to healthy controls, which might be one of the explanations of the adverse interaction between heart and brain in HF.

The reasons of poor lipid target attainment for secondary prevention in real life practice: Results from EPHESUS

OBJECTIVE

There are lack of studies considering the suboptimal management of dyslipidemia especially in cardiology outpatient clinics. This study was conducted to assess the patient adherence to cholesterol treatment recommendations and attainment of low-density-lipoprotein cholesterol (LDL-C) goals.

METHODS

EPHESUS (NCT02608645) is a national, observational and multicenter registry which has been designed as a cross-sectional study to allow inclusion of all consecutive patients with hypercholesterolemia in cardiology outpatient clinics. The present subgroup analyses of the EPHESUS trial included patients with known peripheral artery disease or atherosclerotic cerebrovascular disease, and coronary heart disease namely secondary prevention.

RESULTS

The present analysis of the EPHESUS study included 1482 patients (62.79 ± 10.4 years, 38.2% female) with secondary prevention from 40 sites in Turkey. Regarding recommended lipid targets for LDL-C, only 267 patients (18%) were below the target of 70 mg/dL. Females were significantly more off-target when compared with male patients (396, 85.5% vs 67, 14.5%; P = 0.017). Moreover, the achievement of LDL-C goal was significantly decreased with illiteracy (233, 19.2% vs 35, 13.1%; P = 0.02). Patients who think that the cholesterol treatment should be terminated when the cholesterol level of a patient has normalised were higher in the off-target group (34.0% vs 24.7%, P < 0.001). Besides, physician perceptions about LDL-C goal for secondary prevention were significantly related with LDL-C target attainment.

CONCLUSIONS

EPHESUS is an important study with large population in terms of representing real-life practice of the adherence to dyslipidemia guidelines in secondary prevention patients in Turkey. Perceptions, knowledge, and compliance with the guidelines for secondary prevention have increased, but it is far below from the desired levels even in cardiology outpatient clinics. There is a need for patients' and physicians' education regarding the treatment of hyperlipidemia.

Geographical Variations in Patients with Heart Failure and Preserved Ejection Fraction: A Sub-Group Analysis of the APOLLON Registry

Background:

Clinical characteristics of patients with heart failure may vary geographically. However, limited data are available regarding the geographical differences of patients with heart failure and preserved ejection fraction.

Aims:

The present subgroup analysis aims to investigate the geographical differences in clinical characteristics, management, and primary etiology of patients with heart failure and preserved ejection fraction in Turkey.

Study Design:

A cross-sectional study.

Methods:

A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON (APOLLON) is a multicenter and observational study conducted in seven regions of Turkey (NCT03026114). The present study is a post-hoc analysis of the APOLLON registry. In this substudy, we compared the clinical characteristics of 819 consecutive patients with heart failure and preserved ejection fraction (mean age, 67 years; 57.8% women) admitted to cardiology outpatient units in different geographical regions.

Results:

Based on the geographical distribution of the entire Turkish population, the highest number of patients enrolled were from Marmara (271 patients, 33.1%). All demographical characteristics, clinical and laboratory findings, comorbidities, primary etiology, and medications prescribed were significantly different between the regions. Furthermore, inter-regional gender differences were identified. Comparatively, the Aegean and Mediterranean regions had older patients with heart failure and preserved ejection fraction (p<0.001), and the Black Sea, Southeast, and East Anatolia regions had predominantly male patients (51.2, 54.5, and 56.9%, respectively; p=0.002). Notably, the Mediterranean and Southeast Anatolia had more symptomatic patients, and history of hospitalization for heart failure was more prevalent in Southeast Anatolia (33.3%, p<0.001). Prevalence of atrial fibrillation was higher in the Mediterranean and Southeast Anatolia regions (51 and 48.5%, p<0.001), and patients with heart failure and preserved ejection fraction had a higher prevalence of hypertension in the Mediterranean, Southeast Anatolia, and Black Sea regions (p=0.002). Angiotensin-converting enzyme inhibitors were more frequently prescribed in East Anatolia (52.3%, p=0.001), and the prevalence of patients with heart failure and preserved ejection fraction using loop diuretics (48.8%, p=0.003) was higher in the Black Sea region.

Conclusion:

This study was the first to show geographical differences in clinical characteristics of patients with heart failure and preserved ejection fraction in Turkey. Determination of the clinical characteristics of the heart failure and preserved ejection fraction population based on the geographical region may enables physicians to adopt a region-specific clinical approach toward heart failure and preserved ejection fraction.

Clinical features of heart failure with mid-range and preserved ejection fraction in octogenarians: Results of a multicentre, observational study

OBJECTIVES

To compare real-world characteristics and management of individuals aged 80 and older with heart failure (HF) and mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) derived from a large cohort of survey and to compare them with those younger than 80 from the same survey.

METHODS

This is an observational, multicentre and cross-sectional study conducted in Turkey (NCT03026114). Consecutive 1065 (mean age of 67.1 ± 10.6 years) patients admitted to the cardiology outpatient units with HFmrEF and HFpEF were included.

RESULTS

Participants aged 80 and older (n = 123, 11.5%) were more likely to be female (66.7% vs 52.5%, P = 0.003), had a higher prevalence of atrial fibrillation (49.6% vs 34%, P = 0.001), and anaemia (46.3% vs 33.4%, P = 0.005) than those who were younger than 80. N-terminal pro B-type natriuretic peptide levels were higher in those aged 80 and older than in those younger than 80 (1037 vs 550 pg/ml, P < 0.001). The prescription rates of HF medications (including in ACE-Is/ARBs, β-blockers, MRAs, digoxin, ivabradine and diuretics) were similar (P > 0.05) in both groups. Octogenarians did not significantly differ from younger patients in the prevalence of HFmrEF (24.4% vs 22.9%) and HFpEF (75.6% vs 77.1%). Coronary artery disease was associated with HFmrEF (P < 0.05), whereas atrial fibrillation was associated with HFpEF (P < 0.05) in octogenarians.

CONCLUSIONS

This study revealed that nearly 12% of the individuals with HFmrEF and HFpEF in this real-world sample were aged 80 and older. Participants aged 80 and older are more likely to be female and have more comorbidities than those who were younger than 80. However, HF medication profiles were similar in both groups. This study also showed that associated factors with HFmrEF and HFpEF were differ in octogenarians.

Patients with HFpEF and HFmrEF have different clinical characteristics in Turkey: A multicenter observational study

BACKGROUND

To determine and compare the demographic characteristics, clinical profile and management of patients with heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) in a Turkish cohort.

METHODS

The APOLLON trial (A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON) is an observational and multicenter study conducted in Turkey. Consecutive patients admitted to the cardiology clinics who were at least 18 years of age and had HFmrEF or HFpEF were included (NCT03026114).

RESULTS

The study population included 1065 (mean age of 67.1 ± 10.6 years, 54% women) patients from 12 sites in Turkey. Among participants, 246 (23.1%) had HFmrEF and 819 (76.9%) had HFpEF. Compared to patients with HFpEF, those with HFmrEF were more likely to be male (57.7 vs 42.2%; p < 0.001), had higher N-terminal pro-B-type natriuretic peptide levels (853 vs 528 pg/ml, p < 0.001), were more likely to have ECG abnormalities (72.4 vs 53.5%, p < 0.001) and hospitalization history for heart failure (28 vs 18.6%; p = 0.002). HFmrEF patients were more likely to use β-blockers (69.9 vs 55.2%, p < 0.001), aldosterone receptor antagonists (24 vs 14.7%, p = 0.001), statins (37 vs 23%, p < .001), and loop diuretics (39.8 vs 30.5%, p = 0.006) compared to patients with HFpEF.

CONCLUSIONS

The results of APOLLON study support that the basic characteristics and etiology of HFmrEF are significantly different from HFpEF. This registry also showed that the patients with HFmrEF and HFpEF were younger but undertreated in Turkey compared to patients in western countries.

Effects of heart rate reduction with ivabradine on the international ındex of erectile function (IIEF-5) in patients with heart failure

INTRODUCTION

The presence of concomitant erectile dysfunction (ED) with heart failure (HF) is not surprising, because endothelial dysfunction is pathophysiologic signature of both ED and HF. ED significantly and adversely affects quality of life in patients with HF. It was demonstrated that ivabradine treatment can improve endothelial function and ED in experimental models. In this study, we aimed to determine the effect of ivabradine treatment on ED in patients with HF via International Index of Erectile Function (IIEF-5) questionaire.

MATERIAL AND METHODS

Consequently, 29 patients, between 18 and 70 years of age, male with chronic HF known for at least 1 year, New York Heart Association functional class I-II, left ventricule ejection fraction less than 40%, in sinus rhythm with a resting HR of at least 70 beats per minute (b.p.m.), who were intended to be treated with ivabradine according to the decision of their physicians were evaluated to determine ED. We used the Turkish version of the IIEF-5 questionnaire to evaluate ED on the last 6-month period. Twenty-four of 29 patients who scored ≤21 were considered to have ED and included to the study. IIEF-5 scores for each question and domains were calculated for all responders at baseline and at 6-month follow-up visit in order to determine any effect of ivabradine treatment on ED in patients with HF.

RESULTS

According to the data of survey, Cronbach's alpha coeffient for all of the patients who were included into the study were 0.84 and detected highly reliable. IEFF-5 questionnaire scores increased significantly (p = .003) after the ivabradine treatment, on the contrary, significant decrease in HR was revealed as expected. HR is decreased steadily after ivabradine treatment and mean decrease in HR was 11.5 ± 9.4 in this study population. Likewise, negative correlation was demonstrated between decrease in HR (p < .001) and increase in IEFF-5 scores (p = .003).

CONCLUSION

Although lack of patients with HF have been evaluated in this study population, initial results seem promising that ivabradine has favorable effects on ED. These findings were postulated to be dependent exclusively on HR reduction. As a sequel, cardiologist should avoid neglecting ED to improve medical compliance as well as quality of life in patients with heart failure. This pilot study provide some data for further randomized controlled studies.

Rationale, design, and methodology of the Evaluation of Perceptions, Knowledge, and Compliance with the Guidelines in Real Life Practice: A Survey on the Under-treatment of Hypercholesterolemia

OBJECTIVE

A wide gap exists between dyslipidemia guidelines and their implementation in the real world, which is primarily attributed to physician and patient compliance. The aim of this study is to determine physician and patient adherence to dyslipidemia guidelines and various influential factors.

METHODS

The Evaluation of Perceptions, Knowledge, and Compliance with the Guidelines in Real Life Practice: A Survey on the Under-treatment of Hypercholesterolemia (EPHESUS) trial (ClinicalTrials.gov number NCT02608645) will be an observational, multicenter, non-interventional study. The study targets enrollment of 2000 patients from 50 locations across Turkey. All of the data will be collected in a single visit and current clinical practice will be evaluated. A cross-sectional survey of public perception and knowledge of cholesterol treatment among Turkish adults will be performed. All consecutive patients admitted to cardiology clinics who are in the secondary prevention group (coronary heart disease, peripheral artery disease, atherosclerotic cerebrovascular disease) and who are in the high-risk primary prevention group (type 2 diabetes mellitus with no prior known coronary heart disease; patients who had markedly elevated single risk factors, in particular, cholesterol >8 mmol/L [>310 mg/dL], blood pressure ≥180/110 mmHg, a calculated Systematic Coronary Risk Evaluation [SCORE] ≥5%, or <10% 10-year risk of fatal cardiovascular disease) will be included. Demographic, lifestyle, medical, and therapeutic data will be collected with a survey designed for the study.

CONCLUSION

The EPHESUS registry will be the largest study conducted in Turkey evaluating the adherence to dyslipidemia guidelines both in secondary and high-risk primary prevention patients.

Evaluation of increase in intraventricular gradient and dynamic obstruction during exercise stress test in competitive runners

OBJECTIVE

Sudden cardiac death in athletes is one of the most tragic health events seen both in our country and all over the world. In some of those athletes, there is no obvious structural abnormality. Dynamic changes in intracardiac hemodynamics during exercise may be a cause for sudden death in these athletes, the impact of exercise on intracardiac gradient and cardiac hemodynamic parameters in athletes was compared with healthy controls.

METHODS

A total of 21 professional male athletes and 21 healthy male controls were included in the study. Transthoracic echocardiography was performed in all participants both at rest and maximal exercise level to assess the intraventricular gradient (IVG) and cardiac systolic and diastolic functions. Abnormal IVG was defined as gradient of >30 mm Hg at peak exercise level.

RESULTS

Both groups reached the level of predicted maximum exercise. There was no exercise limiting symptom among participants during exercise test. The athletes revealed a higher maximum peak systolic IVG at baseline and after exercise in comparison with the control group. None of the participants showed an abnormal IVG level.

CONCLUSION

Our results showed that there was no dynamic intraventricular obstruction with aerobic exercise in subjects with a structurally normal heart.

Rationale, design and methodology of the RAMSES Study: ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies

OBJECTIVE

Atrial fibrillation is the most common arrhythmia and is associated with a five- fold increased risk of thromboembolic events. Vitamin K antagonists (VKAs) have been the mainstay of oral anticoagulant prophylaxis and the data on stroke prevention strategies are limited to VKA era. The purpose of this study is to evaluate the use of VKA, non-Vitamin K antagonist oral anticoagulants (NOAC), and antiplatelet agents in patients with non-valvular atrial fibrillation (NVAF).

METHODS

The ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey (RAMSES) is an observational, multicenter, prospective study of patients with NVAF. The study targeted enrollment of 7835 patients from 68 sites in Turkey. All the data will be collected at one point in time and current clinical practice will be evaluated. (ClinicalTrials.gov number NCT02344901).

RESULTS

Baseline characteristics of patients, antithrombotic therapies, transition to NOACs and rate/rhythm control strategies will be evaluated.

CONCLUSION

The RAMSES registry will be the largest study in Turkish NVAF patients. The study will provide insights into real-world problems and anticoagulant treatment in patients with NVAF.

Effects of creatine supplementation on cardiac autonomic functions in bodybuilders

Bodybuilder-type workouts may affect heart rate variability (HRV), which has considerable potential to assess the role of autonomic nervous system (ANS). A scientifically designed approach is necessary for bodybuilders to achieve better results while protecting their health. In this study, we aimed to investigate HRV parameters in bodybuilders compared to healthy control subjects and effects of creatine supplementation. A total of 48 male participants (16 controls, 16 supplement (-), 16 supplement (+)) were evaluated in our study. Bodybuilders who were taking creatine supplementation were enrolled in supplement (+) group. HRV parameters were measured from 24-hour Holter recordings of all participants. When mean heart rates were compared with control group (71.5 ± 12.6 beats/min), statistically significant difference was revealed in supplement (-) group (61.8 ± 6.8 beats/min; P = 0.022) unlike supplement (+) group (69.63 ± 14.1 beats/min; P = 0.650). HRV analyses revealed significant parasympathetic shift in supplement (-) group. No significant difference was demonstrated on HRV parameters, except high frequency (P = 0.029) in supplement (+) group. Conclusively, elevated parasympathetic modulation, which is favorable cardiovascular outcome of exercise, was demonstrated in bodybuilders. However, our study also revealed that creatine supplementation attenuates this favorable effect in ANS by limiting elevation of parasympathetic modulation. Although the sympathetic slight shift is attributed to creatine supplementation, it cannot be discriminated from the effects of over training.

[A case with tricuspid valve brucella endocarditis presenting with acute right heart failure]

Although the presence of brucella endocarditis is encountered rarely, it is the most fetal complication of brucellosis, which is shown to affect the aortic valve primarily and the mitral valve secondarily. Involvement of the tricuspid valve is extremely rare. A 62-year-old female was admitted with complaints of fever, fatigue, difficulty in breathing, and swellings in her legs. A transthoracic echocardiogram was performed since acute right heart failure was considered due to her symptoms. The echocardiogram showed enlarged right heart chambers, serious tricuspid valve insufficiency, and a mass on the tricuspid valve compatible with a vegetation moving in and out of the right ventricle. Although no growths were observed in the blood culture, antibody titration for brucellosis was found to be 1/640 (+) in the serological examination. The patient was diagnosed with brucella endocarditis and placed on doxycycline, rifampicin, and ceftriaxone treatment for eight weeks. At the end of the eight-week treatment, the symptoms of right heart failure receded and the patient recovered from the endocarditis. Tricuspid valve brucella endocarditis should be considered in patients suffering from acute right heart failure accompanied by systemic infection findings since brucellosis is presently endemic in Turkey.