Looking at the Golden Ratio from the Blood Pressure Perspective: Assessing the Hypertensive Patients and Normotensive Subjects

BACKGROUND

The representatives of mathematical concepts and indices allied to the Golden Ratio (GR) have been shown in the human body in superimposed human hands, phalangeal lengths of the digits, human ears, and the cardiovascular system. Recently, it has been demonstrated that the systolic blood pressure (SBP) to diastolic blood pressure (DBP) ratio measured by ambulatory blood pressure monitoring (ABPM) is close to GR. Accordingly, we aimed to evaluate the ratios between the SBP, DBP, and PP in normotensive and hypertensive patients who were on medical treatment or not, to assess the existence of golden proportions in 24-hour ambulatory blood pressure monitoring results.

MATERIAL AND METHOD

Five hundred and twenty-nine patients who underwent ABPM were retrospectively enrolled in the study population. The ABPM was programmed to measure blood pressure every 30 min during the daytime and 60 min night time. Based on the ABPM results, patients were classified as hypertensive (SBP/DBP≥130/80 mmHg) and normotensive (SBP/DBP<130/80 mmHg), depending on ESC/ESH 2018 guidelines. They were also divided into two subgroups: medicated and nonmedicated. Systolic to diastolic blood pressure ratio (SBP/DBP) and diastolic blood pressure to pulse pressure (DBP/PP) were calculated in the usual fashion in all study populations and subgroups.

RESULTS

After the exclusion of 133 patients who did not fulfill the inclusion criteria, 396 patients were included in the statistical analysis. Mean SBP/DBP ratios were 1.66±0.15 in all the study population, 1.63±0.11 in normotensive without medication, 1.66±0.13 in normotensive with medications, 1.62±0.15 in hypertensive without medication, and 1.76±0.20 with medications.

CONCLUSION

We have documented that SBP to DBP ratios of untreated patients, irrespective of having normal or high blood pressure, run close around the GR. However, SBP to DBP ratios of patients having antihypertensive treatment are far from the GR.

Hyponatremia and takotsubo syndrome: a review of pathogenetic and clinical implications

Hyponatremia is a common electrolyte abnormality with important prognostic and therapeutic implications. It might exert detrimental effects on various organ systems including the central nervous system (CNS), bone, and heart along with its potential association with poor quality of life. These adverse effects might be largely mediated through a variety of mechanisms including osmotic stress, dysfunctional transmembrane exchangers, and enhanced oxidative stress.Interestingly, hyponatremia might also have an important association with takotsubo syndrome (TTS) that has been universally considered as a reversible form of cardiomyopathy usually emerging in response to various stressors. In this context, severe hyponatremia was previously reported to serve as a direct trigger of TTS evolution largely through its potential impact on CNS and heart. However, pathogenetic and clinical implications of hyponatremia still need to be thoroughly evaluated in patients with TTS. This paper aims to analyze the clinical features of published cases with TTS primarily triggered by hyponatremia and also aims to discuss the association between hyponatremia and TTS from a broader perspective.

Ignored Role of Paroxysmal Atrial Fibrillation in the Pathophysiology of Cryptogenic Stroke in Patients with Patent Foramen Ovale and Atrial Septal Aneurysm

The association between cryptogenic stroke (CS) and patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) has been a debate for decades in terms of pathophysiologic processes and clinical courses. This issue has become more interesting and complex, because of the concerns associating the CS with so-called normal variant pathologies of interatrial septum, namely ASA and PFO. While there is an anatomical pathology in the interatrial septum, namely PFO and ASA, the embolic source of stroke is not clearly defined. Moreover, in patients with PFO and CS, the risk of recurrent stroke has also been associated with other PFOunrelated factors, such as hyperlipidemia, body mass index, diabetes mellitus, and hypertension, leading to the difficulty in understanding the pathophysiologic mechanism of CS in patients with PFO and/or ASA. Theoretically, the embolic source of cryptogenic stroke in which PFO and/or ASA has been involved can be categorized into three different anatomical locations, namely PFO tissue and/or ASA tissue itself, right or left atrial chambers, and venous vascular territory distal to the right atrium, i.e., inferior vena cava and lower extremity venous system. However, the possible role of paroxysmal atrial fibrillation associated with PFO and/or ASA as a source of cryptogenic stroke has never been mentioned clearly in the literature. This review aims to explain the association of cryptogenic stroke with PFO and/or ASA in a comprehensive manner, including anatomical, clinical, and mechanistic aspects. The potential role of paroxysmal atrial fibrillation and its contribution to clinical course have been also discussed in a hypothetical manner to elucidate the pathophysiology of CS and support further treatment modalities.

Coexistence of Anti-PD1-Induced Immune Myocarditis and Complete Atrioventricular Block: A Case Report

The present report describes the late recovery of an emerging complete atrioventricular (AV block) in a patient with immune check point inhibitor-related myocarditis following a period of immunosuppresive therapy. Therefore, decision-making for permanent pacemaker implantation should be implemented after a substantial period of time owing to the potential recovery of bradyarrhythmic complications in similar cases.

Integrating the Left Atrium Diameter to Improve the Predictive Ability of the Age, Creatinine, and Ejection Fraction Score for Atrial Fibrillation Recurrence After Cryoballoon Ablation

BACKGROUND

Several clinical trials have assessed predictors for atrial fibrillation recurrence following cryoballoon catheter ablation. With these predictors, a practical and new scoring system can be developed to evaluate atrial fibrillation recurrence. The present study aimed to analyze the predictive value of the age, creatinine, and ejection fraction-left atrium score for potential recurrence of atrial fibrillation following cryoballoon catheter ablation in patients with symptomatic paroxysmal or persistent atrial fibrillation.

METHODS

We retrospectively analyzed records of patients undergoing cryoballoon cath-eter ablation. atrial fibrillation recurrence was defined as an emerging atrial fibrillation episode around 12-month follow-up (with the exclusion of a 3-month blanking period). Univariate and multivariate analyses were performed to assess predictors of atrial fibrillation recurrence. In addition, receiver operating characteristic analysis was harnessed to evaluate the performance of the age, creatinine, and ejection fraction, left atrium score in determining the risk of atrial fibrillation recurrence.

RESULTS

The study population comprised 106 subjects (age 52 ± 13 years, 63.2% women) with paroxysmal (84.9%, n = 90) or persistent (15.1%, n = 16) atrial fibrillation. age, creatinine, and ejection fraction, left atrium score was significantly higher in subjects with atrial fibrillation recurrence in comparison to those with the maintenance of sinus rhythm. However, on multivariate logistic regression analysis, only the age, creatinine, and ejection fraction, left atrium score (OR = 12.93, 95% CI: 2.22-75.21, P =.004) served as an independent predictor of atrial fibrillation recurrence following cryoballoon catheter ablation.

CONCLUSION

Age, creatinine, and ejection fraction, left atrium score had an independent association with the risk of atrial fibrillation recurrence in subjects with atrial fibrillation undergoing cryoballoon catheter ablation. Therefore, this score might potentially serve as a useful tool for risk stratification of patients with atrial fibrillation.

A Stent Misplaced in the Septal Perforating Artery: Right Ventricular Fistula, Interventricular Septal Hematoma, and Right Ventricular Outflow Tract Obstruction

Coronary-cameral fistulas, though mostly regarded as congenital entities, have also been encountered as complications of major traumas and percutaneous coronary interventions (PCIs).1 On the other hand, interventricular septal (IVS) hematoma might potentially arise mostly during retrograde chronic total occlusion (CTO) interventions and has a benign course in this context.2 Herein, we describe a challenging PCI complication (and its management strategy) presenting with IVS hematoma, right ventricular fistula, and right ventricular outflow tract (RVOT) obstruction due to a misimplanted coronary stent in the septal perforating artery (SPA).

Cancer Therapy-Related Pulmonary Hypertension: A Review of Mechanisms and Implications for Clinical Practice

Cancer therapy-related pulmonary hypertension is a rare yet potentially fatal cardiotoxicity. However, it is a reversible cause of pulmonary hypertension if detected in its early stages. Cancer therapy-related pulmonary hypertension has been encountered in patients using tyrosine kinase inhibitors, particularly dasatinib. However, it is also well known that many agents used in cancer treatment such as alkylating agents, proteasome inhibitors, thoracic radiation exposure, and immune checkpoint inhibitors are particularly associated with pulmonary hypertension evolution. In case that history, symptoms, and clinical findings suggest a potential cancer therapy-related pulmonary hypertension, echocardiography is considered as the initial tool to detect pulmonary hypertension. If the possibility of pulmonary hypertension is high based on echocardiographic data, cancer treatment, as the initial step, should be discontinued due to its potential risks and other causes for pulmonary hypertension should be investigated thoroughly. Right heart catheterization should be the next step to establish the final diagnosis, and medical management, where appropriate, should be started without delay in these patients according to their pulmonary hypertension subgroup. There exists limited information regarding the diagnostic and management strategies of cancer therapy-related pulmonary hypertension in the current guidelines. In this review article, we aim to present current literature data on the mechanisms and management of cancer therapy-related pulmonary hypertension along with its follow-up algorithm in the setting of cardio-oncology practice.

Serum Copeptin in Cardiooncology Practice: Review of Pathophysiological and Clinical Implications

In cardiooncology practice, "early cardiotoxicity" refers to an emerging subclinical myocardial dysfunction/injury in response to certain chemotherapeutic regimens. This condition can progress to overt cardiotoxicity in time and hence warrants proper and timely diagnostic and preventive strategies. Current diagnostic strategies for "early cardiotoxicity" are largely based on conventional biomarkers and certain echocardiographic indices. However, a significant gap still exists in this setting, warranting further strategies to improve diagnosis and overall prognosis in cancer survivors. Copeptin (surrogate marker of the arginine vasopressine axis) might serve as a promising adjunctive guide for the timely detection, risk stratification, and management of early cardiotoxicity on top of conventional strategies largely due to its multifaceted pathophysiological implications in the clinical setting. This work aims to focus on serum copeptin as a marker of "early cardiotoxicity" and its general clinical implications in patients with cancer.

Balloon Shaft Fracture: A Nightmare Scenario in the Setting of Percutaneous Coronary Intervention

These images illustrate an attempt to pull back the balloon of an implanted proximal stent swiftly (before it was completely deflated) just following unplanned disengagement of the guiding catheter from the right coronary ostium. This maneuver resulted in abrupt balloon shaft fracture (outside the guiding catheter), leading to a freely swinging shaft appearance in the descending aorta. Unfortunately, several attempts to retrieve the swinging fragment of the shaft failed. Moreover, intracoronary snare technique in an effort to grasp the distal portion of the shaft also failed. Finally, the shaft fragment was surgically removed along with a bypass graft operation for the severely stenotic circumflex artery.

Impact of chronic total occlusion in a non-infarct-related coronary artery on contrast-associated nephropathy in acute ST-elevation myocardial infarction

OBJECTIVES

Co-existing chronic total occlusion (CTO) in a non-infarct-related artery (IRA) might serve as an important trigger of adverse outcomes in ST-segment elevation myocardial infarction (STEMI). Therefore, we planned to analyse the potential impact of non-IRA CTO on the evolution of contrast-associated nephropathy (CAN) in STEMI patients managed with primary percutaneous coronary intervention (P-PCI).

METHODS

A total of 537 subjects with STEMI undergoing P-PCI during the first 12 h after the onset of their symptoms were enrolled in this retrospective study. The subjects were categorised based on the angiographic presence of non-IRA CTO. Moreover, the subjects were also divided into 2 groups based on their CAN status following P-PCI (CAN (+) and CAN (-)).

RESULTS

Co-existing non-IRA CTO was demonstrated in 86 subjects (16%). During the hospitalisation period, we identified 81 (15.1%) subjects with CAN. Subjects with non-IRA CTO had a significantly higher incidence of CAN compared with those without (56 [12.4%] vs 25 [29.1%], respectively, p < 0.001). In a logistic regression analysis, an existing non-IRA CTO (odds ratio: 2.840, 95%CI: 1.451-5.558, p = 0.002), as well as age, haemoglobin, diabetes mellitus, creatinine, and white blood cell count, were independent of predictors of CAN.

CONCLUSION

In STEMI patients managed with P-PCI, a co-existing non-IRA CTO had an independent association with the evolution of CAN.

Serum Prealbumin: a potential predictor of Right Ventricular Dysfunction in patients receiving programmed hemodialysis

OBJECTIVE

Prealbumin has been a reliable marker to predict protein energy malnutrition and hypercatabolic state. In this analysis, we particularly aimed to investigate the potential association between serum prealbumin levels and right ventricular dysfunction in patients receiving programmed hemodialysis.

METHODS

A total of 57 subjects were included in the analysis. The subjects were then categorized into two groups: right ventricular dysfunction (n=18) and non-right ventricular dysfunction (n=39) groups. In all patients, detailed transthoracic echocardiography (following hemodialysis) were performed along with the evaluation of complete blood count, routine biochemistry parameters, and, in particular, serum prealbumin levels.

RESULTS

Mortality rate at 3 years was found to be significantly higher in the right ventricular dysfunction group (p=0.042). Serum prealbumin levels were also significantly lower in the right ventricular dysfunction group compared with the non-right ventricular dysfunction group (23.83±8.50 mg/dL versus 31.38±6.81 mg/dL, p=0.001). In the receiver operating characteristics curve analysis, a prealbumin cutoff value of <28.5 mg/dL was found to predict right ventricular dysfunction, with a sensitivity of 67% and a specificity of 62% (area under the curve: 0.744). In the correlation analysis, a moderate yet significant positive correlation was demonstrated between serum prealbumin and tricuspid annular plane systolic excursion (r=0.365, p=0.005).

CONCLUSION

This study suggests that low serum prealbumin might serve as a potential predictor of right ventricular dysfunction (and its clinical consequences) in patients receiving programmed hemodialysis.

Systolic Blood Pressure to Diastolic Blood Pressure Ratios in Diabetic and Non-diabetic Patients: Deviation from Golden Ratio

INTRODUCTION

Cardiovascular measures like, systolic to diastolic time intervals on ECG recordings, end-diastolic to end-systolic diameters of the left ventricle on echocardiography, pulmonary and systemic hemodynamic measures have gained an interest in terms of Golden ratio or Golden proportions. Ratio of SBP to DBP as a reflection of GR has been recently evaluated in patients who have undergone ABPM to assess the presence of hypertension.

AIM

To assess and compare the ratios of SBP to DBP as a reflection of GR in 24 h ABPM recordings in patients with and without DM who were not on medical treatment.

METHODS

Six hundred and thirty two patients who underwent ABPM were retrospectively screened and enrolled in the study population in between October 2020 and March 2021. After exclusion of 378 who did not meet the inclusion criteria, 254 patients were enrolled in statistical analysis. Systolic blood pressure and diastolic blood pressure measurements were also averaged for the day and the night spans according to the patients' reported time of waking up and going to bed. The ABPM was programmed to measure blood pressure every 45 min during both the day time and night time periods RESULTS: Among those 254 patients included in statistical analysis, 212 patients were classified as non-diabetic and 42 patients as diabetic. SBP/DBP ratios were significantly higher in diabetics compared to those of non-diabetics in all time spans (1.698 vs 1.631, p = 0.041 for 24 h; 1.689 vs 1.618 p = 0.032 for day-time; 1.74 vs 1.66 p = 0.037 for night time). In non-diabetic patients interestingly day time SBP/DBP gave almost the same value of GR i.e 1.618, likewise the 24 h value of SBP/DBP gave the value of 1.631 which was so close to GR. On the other hand SBP/DBP ratios for all time spans were deviated far from the 1.618 in diabetic patients CONCLUSION: We have shown that systolic to diastolic blood pressure ratios of patients with DM are significantly higher than those without DM. These differences are mainly to due to the lower DBP of diabetic patients compared to non-diabetic patients. Beyond these differences SBP/DBP ratio of non-diabetic patients has shown close proximity to 1.618 known as golden ratio.

Fontan Circulation Might be Associated with Peripartum Cardiomyopathy: A Review of Mechanistic and Clinical Aspects

Fontan operation has been defined as a palliative surgery connecting systemic venous return and pulmonary circulation in patients with certain forms of complex congenital heart disease (CHD). Fortunately, it has improved overall survival and chance of successful pregnancies among these patients. However, Fontan circulation (FC), as a potential trade-off, might be associated with specific late or post-gestational complications, including peripartum cardiomyopathy (PPCM) largely through its adverse effects on the placenta and inflammation-oxidation stress. Importantly, diagnosis of superimposed PPCM in women with FC might be a diagnostic challenge, requiring a high index of suspicion. Accordingly, the present paper aims to highlight the potential association of FC with PPCM evolution largely based on certain mechanistic and clinical perspectives.