ISSN 1016-5169 | E-ISSN 1308-4488
Archives of the Turkish Society of Cardiology - Turk Kardiyol Dern Ars: 45 (7)
Volume: 45  Issue: 7 - October 2017
EDITORIAL
1. Message From the Editor-in-Chief
Dilek Ural
Page VII

EDITORIAL COMMENT
2. What is new in 2017 European Society of Cardiology ST Elevation Myocardial Infarction guideline?
Aylin Yıldırır
PMID: 28990937  doi: 10.5543/tkda.2017.92566  Pages 579 - 583
Abstract |Full Text PDF

3. The new changes in the European Society of Cardiology 2017 Guidelines for the Management of Valvular Heart Disease
Recep Demirbağ
PMID: 28990938  doi: 10.5543/tkda.2017.79359  Pages 584 - 589
Abstract |Full Text PDF

ORIGINAL ARTICLE
4. Tenth categories of total and HDL cholesterol fail to independently predict death risk in middle-aged Turkish adults
Altan Onat, Günay Can, Muhammed Keskin, Volkan Çamkıran, Ahmet Okan Uzun, Hüsniye Yüksel
PMID: 28990939  doi: 10.5543/tkda.2017.38085  Pages 590 - 598
Objective: The aim of this study was to delineate in detail the longitudinal association of total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) levels with overall mortality in middle-aged participants of the biennial Turkish Adult Risk Factor study.
Methods: Baseline lipid variables were analyzed in sex-specific deciles. A baseline age of 45 to 84 years as an inclusion criterion led to the enrollment of 2121 men and women. Cox regression analyses were performed.
Results: Deaths were recorded in 237 and 306 women and men, respectively, during a mean 8.85±4.4 years of follow-up. After adjustment for age, smoking status, lipid-lowering and antihypertensive drug usage, prevalent diabetes, and coronary heart disease, and using the lowest decile as referent, neither TC (p trend=0.94 and 0.96, respectively), nor HDL-C categories (p trend=0.20 and 0.31, respectively) were significantly predictive of mortality in either gender. TC deciles exhibited a gender difference insofar as hazard ratios in females tended to be reciprocal to those in males in deciles 2 through 5.
Conclusion: The findings on TC deciles may be attributed to a comparatively higher death rate in the female (compared with male) bottom decile, reflecting the autoimmune process-induced elevated risk in the lowest decile. Observations on HDL-C confirmed presumed pro-inflammatory conversion in levels >50 mg/dL. These results have important clinical implications.

5. Are oxidative stress markers helpful for diagnosing the disease and determining its complexity or extent in patients with stable coronary artery disease?
Mustafa Yılmaz, Cihan Altın, Afag Özyıldız, Haldun Müderrisoğlu
PMID: 28990940  doi: 10.5543/tkda.2017.80733  Pages 599 - 605
Objective: The aim of this study was to investigate the relationship between oxidative/antioxidative stress markers and the diagnosis and complexity of coronary artery disease (CAD) in patients with stable CAD.
Methods: A total of 145 patients were enrolled in the study. Based on coronary angiography results, the patients were categorized into 2 groups: those without CAD (Group 1) and those with CAD (Group 2). The patients in Group 2 were also categorized into low score and moderate/high score groups according to their SYNTAX score. The serum malondialdehyde (MDA) and total antioxidant capacity (TAOC) levels of Group 1 and Group 2 were compared. Finally, MDA and TAOC levels were compared between the moderate/high-risk and low-risk groups formed according to SYNTAX score.
Results: There was a significant difference with respect to both serum TAOC and MDA levels between Group 1 and Group 2 (p=0.036 and p=0.029, respectively). The groups with a SYNTAX score 1-22 and with a SYNTAX score >22 were not significantly different with respect to serum TAOC or MDA level (p=0.582 and p=0.85, respectively).
Conclusion: The serum MDA level was significantly higher and the TAOC level was significantly lower in patients with stable CAD compared to those without; however, these molecule levels failed to predict disease complexity in patients with stable CAD.

6. Influence of coronary calcification patterns on hemodynamic outcome of coronary stenoses and remodeling
Ahmet Demirkıran, Ozan Çakır, Adem Atıcı, Emre Aslanger, Cansu Akdeniz, Berrin Umman, Sabahattin Umman, Zehra Bugra, Murat Sezer
PMID: 28990941  doi: 10.5543/tkda.2017.94493  Pages 606 - 613
Objective: The histological characteristics of plaque may affect the hemodynamic outcome of a given coronary stenosis. In particular, the potential effect of volumetric calcium content and the topographical distribution in the lesion segment on physiological outcome has not yet been investigated. The aim of this study was to identify any potential correlation between patterns of calcification and the fractional flow reserve (FFR) and the coronary remodeling index (RMI).
Methods: A total of 26 stable angina pectoris and 34 acute coronary syndrome patients without persistent ST-segment elevation constituted the study population. FFR was used to assess 70 intermediate coronary stenosis lesions. After obtaining hemodynamic measurements, quantitative grayscale and virtual histology-intravascular ultrasound analyses were performed. The depth, length, and circumferential distribution of calcification of the lesions were also recorded.
Results: Within the analyzed segment (area of interest, lesion segment), FFR was correlated with maximal thickness of deep calcification (r=-0.285; p=0.021) and calcification angle (r=-0.396; p=0.001). In lesions with a calcification angle >180°, the mean FFR value was significantly lower compared with those <180° (0.64±0.17 vs. 0.78±0.08; p=0.024). RMI was correlated with maximal angle of superficial (r=-0.437; p<0.001) and deep (r=0.425; p<0.001) calcification. RMI was correlated with maximal thickness of superficial (r=-0.357; p=0.003) and deep (r=0.417; p<0.001) calcification. RMI was also correlated with FFR (r=-0.477; p<0.001).
Conclusion: This study demonstrated that the geometry, location, and amount of calcification of a plaque could affect hemodynamic and anatomical outcome measures in functionally significant stenoses by affecting vessel wall compliance.

7. Herbal supplement usage in cardiac patients
Neslihan Pınar, Meyli Topaloğlu, Cahit Özer, Harun Alp
PMID: 28990942  doi: 10.5543/tkda.2017.79160  Pages 614 - 622
Objective: Complementary and alternative medicine (CAM) has become more and more widespread around the world. CAM is a broad term that refers to all medical healthcare services, methods, and practices that are not part of standard medical care, as well as the accompanying theories and beliefs. The aim of the present study was to investigate the use of herbal medicinal products in cardiac patients, as well as the methods of administration of the products.
Methods: This descriptive cross-sectional study included 199 patients aged over 18 years who were hospitalized in the Defne Hospital department of cardiology and volunteered to participate in a 20-item survey between April 2016 and June 2016.
Results: The study results indicated that 28.6% (n=57) of patients were using herbal products and 71.6% (n=142) said they did not. Only 14.03% (n=8) of those who used herbal products said they used them in consultation with their physician; 85.9% (n=49) had used herbal medicine without consulting their doctor. Of the participants with hypertension, 35.7% of them reported using herbal medicinal products. Of these, 22.5% of them were consuming lemon, 17.5% pomegranate syrup, and 17.5% green tea. Of the participants with cardiovascular diseases, 23.5% of them stated that they were taking herbal products. Of these, 25% were consuming green tea, 25% ginger, and 18.8% sage.
Conclusion: Herbal medicinal supplements were used by a large portion of the cardiac patients in this study. Furthermore, most of the patients stated that they were using these products without informing their physician, a practice that can have unwanted consequences.

8. Do Turkish reimbursement recommendations cover current European Lipid Guidelines? A retrospective analysis of patients presenting with first acute coronary syndrome
Deniz Demirci, Duygu Ersan Demirci, Murat Esin, Özkan Kayhan, Şakir Arslan
PMID: 28990943  doi: 10.5543/tkda.2017.22796  Pages 623 - 629
Objective: This study was a comparison of the statin therapy protocol issued by the European Society of Cardiology (ESC) and the Ministry of Health’s Health Implementation Directive (SUT) in Turkey, performed in order to assess the adequacy of hyperlipidemia treatment indications for primary prevention.
Methods: A total of 582 patients with first acute coronary syndrome were included in the study. Patients with noncritical stenosis observed on coronary angiography or a history of atherosclerotic disease were excluded. The risk calculation was determined using age, sex, smoking status, presence of diabetes mellitus, total cholesterol, and lipoprotein levels. Statin treatment indications were evaluated according to the ESC guidelines (2016) and the SUT (2016).
Results: Statin treatment was indicated for 96% of diabetic patients, and according to the ESC, it was appropriate for 13.5% of nondiabetic patients, while the SUT recommendation included 13.3% of nondiabetic patients (p<0.05). For patients younger than 60 years of age, the SUT had more guidelines than the ESC; however, for patients aged 70 to 90, the ESC had more guidelines than the SUT. For patients over 90, the indications were the same. For patients with low-density lipoprotein-cholesterol (LDL-C) >190 mg/dL there was greater discrepancy between the SUT and ESC guidelines. According to the SUT, all patients >190 mg/dL are to receive treatment. The ESC had more guidelines than the SUT for cases of LDL-C <160 mg/dL.
Conclusion: The scope of the SUT guidelines is generally not narrower than the ESC indications. However, the indications for patients >60 years of age and those with LDL-C >160 mg/dL should be reassessed, as they are more limited than those of the ESC. A new treatment algorithm should be defined.

9. The opinion of Turkish cardiologists on current malpractice system and an alternative patient compensation system proposal: PCS study group
Ayhan Olcay, Sadık Volkan Emren, Gamze Babür Güler, Ekrem Güler, Vedat Ertunç, Rida Berilgen, Abdullah Aslan, Ersin Çağrı Şimşek, Şükriye Ebru Gölcük, Kıvanç Yalın
PMID: 28990944  doi: 10.5543/tkda.2017.39455  Pages 630 - 637
Objective: Cardiologists participate in the diagnosis and interventional treatment of numerous high-risk patients. The goal of this study was to investigate how the current malpractice system in Turkey influences cardiologists’ diagnostic and interventional behavior and to obtain their opinions about an alternative patient compensation system.
Methods: The present cross-sectional study assessed the practice of defensive medicine among cardiologists who are actively working in various types of workplace within the Turkish healthcare system. A 24-item questionnaire was distributed to cardiology residents, specialists, and academics in Turkey in print format, by electronic mail, or via cell phone message.
Results: A total of 253 cardiologists responded to the survey. Among them, 29 (11.6%) had been sued for malpractice claims in the past. Of the cardiologists who had been sued, 2 (6.9%) had been ordered to pay financial compensation, and 1 (3.4%) was given a sentence of imprisonment due to negligence. In all, 132 (52.8%) of the surveyed cardiologists reported that they had changed their practices due to fear of litigation, and 232 (92.8%) reported that they would prefer the new proposed patient compensation system to the current malpractice system. Among the cardiologists surveyed, 78.8% indicated that malpractice fear had affected their decision-making with regard to requesting computed tomography angiography or thallium scintigraphy, 71.6% for coronary angiography, 20% for stent implantation, and 83.2% for avoiding treating high-risk patients.
Conclusion: The results of this survey demonstrated that cardiologists may request unnecessary tests and perform unneeded interventions due to the fear of malpractice litigation fear. Many also avoid high-risk patients and interventions. The majority indicated that they would prefer the proposed alternative patient compensation system to the current malpractice system.

CASE REPORT
10. An alternative treatment for iatrogenic right ventricular puncture in primary percutaneous intervention
Hasan Arı, Alper Karakuş, Selma Arı, Sencer Çamcı, Mehmet Melek
PMID: 28990945  doi: 10.5543/tkda.2017.72823  Pages 638 - 640
Right ventricle perforation is an uncommon, but potentially fatal, possible complication of pericardiocentesis. We presented a case of right ventricular perforation that developed during urgent pericardiocentesis due to tamponade. This case was successfully treated with the incremental removal of the drainage catheter, replacing it with a smaller catheter at 10-minute intervals. This may be an alternative option to treat iatrogenic right ventricle puncture occurring during pericardiocentesis without cardiac surgery or a vascular closure device.

11. Stent and implantable cardioverter defibrillator implantation in medically resistant vasospastic angina patient
Nil Özyüncü, Hüseyin Göksülük, Veysel Kutay Vurgun, Onur Yıldırım, Türkan Seda Tan Kürklü
PMID: 28990946  doi: 10.5543/tkda.2017.44756  Pages 641 - 645
Vasospastic angina, also known as Prinzmetal’s angina, is thought to occur due to vascular hyper-reactivity to various stimuli. Response to medical therapy is usually good; however, 1 out of 5 patients has resistant symptoms. Rarely, potentially lethal arrhythmias can occur due to vasospasm, and those patients are reported to have a poorer prognosis. Presently described is a case of resistant vasospastic angina with persistent symptoms under calcium channel blocker and nitrate treatment. The patient presented with hemodynamically unstable rapid-rate ventricular tachycardia, which was quite resistant to recurrent cardioversion. She was treated with stent implantation for definite vasospastic segments of the coronaries, in combination with medical therapy. An implantable cardioverter defibrillator was also implanted for secondary prevention of ventricular arrhythmia, as vasospasm was considered to be a diffuse disease without a certain definitive treatment.

12. Ablation of epicardial premature ventricular contractions in a patient with ischemic cardiomyopathy and implementation of cardiac resynchronization therapy in the same procedure
Veysel Kutay Vurgun, Başar Candemir, Ali Timuçin Altın, Ömer Akyürek
PMID: 28990947  doi: 10.5543/tkda.2017.17776  Pages 646 - 649
Premature ventricular contractions (PVCs) can cause clinical deterioration in patients with heart failure and increase the frequency of shocks delivered by an implantable cardioverter defibrillator (ICD). Epicardial PVC/ventricular tachycardia (VT) is seen less often in ischemic cardiomyopathy. Radiofrequency catheter ablation is the most effective treatment option for the management of PVC/VT and can improve cardiac function. Presently described is a patient with ischemic cardiomyopathy and frequent PVCs and VT runs with multiple ICD therapies who was treated with simultaneous radiofrequency catheter ablation in the anterior interventricular vein and cardiac resynchronization therapy defibrillator upgrade in the same procedure.

13. Case series of three different scenarios with drug-induced Brugada patterns: fact or fiction?
Serkan Asil, Uğur Canpolat, Ergün Barış Kaya, Kudret Aytemir, Giray Kabakçı
PMID: 28990948  doi: 10.5543/tkda.2017.02717  Pages 650 - 654
Brugada syndrome is an inherited cardiac arrhythmia condition characterized by coved-type ST elevation and J point elevation of at least 2 mm in at least 2 of the right precordial electrocardiogram (ECG) leads (V1–3). An increasing number of noncardiac agents, including psychotropic and anesthetic drugs, have been shown to induce a characteristic Brugada ECG pattern, predisposing the patient to fatal ventricular arrhythmias. However, there are scarce data regarding the clinical significance. In this case series, a typical Brugada pattern was unmasked by lithium, valproic acid, and thiocolchicoside; however, the clinical scenario was different in all 3 cases, ranging from an asymptomatic patient to sudden cardiac arrest.

14. Exceptional cause of chest pain: idiopathic ascending aortitis
Mert İlker Hayıroğlu, Muhammed Keskin, Hüseyin Kuplay, Tolga Sinan Güvenç, Barış Güngör
PMID: 28990949  doi: 10.5543/tkda.2017.68484  Pages 655 - 659
Idiopathic ascending aortitis is an insidious disease most often encountered during an evaluation for other cardiovascular and connective tissue diseases. To the best of our knowledge, admission to an emergency department with chest pain due to idiopathic ascending aortitis has not been reported before. Herein, the case of a 46-year-old man with chest and back pain symptoms that were discovered to be secondary solely to idiopathic ascending aortitis is described.

15. A rare complication of chronic granulomatous disease in a child: constrictive aspergillus pericarditis
Emrah Şişli, Yasemin Özdemir Şahan, Mehmet Fatih Ayık, Deniz Nart, Yüksel Atay
PMID: 28990950  doi: 10.5543/tkda.2017.52284  Pages 660 - 663
A 3-year-old girl with the diagnosis of chronic granulomatous disease (CGD) was hospitalized for bronchopneumonia and congestive heart failure. Her medical history included methylprednisolone medication for autoimmune gastric outlet obstruction. Computed tomography revealed pneumonic infiltrations and pericardial thickening. A pulsed-wave Doppler recording revealed E/A >1. During a pericardiectomy, multiple islands of thick, firm-walled, fibrinous exudate-containing, small abscess formations were observed. Histopathological evaluation of pericardial tissue revealed granulomatous inflammation. Aspergillus fumigatus was cultured from the abscess. In conclusion, development of constrictive aspergillus pericarditis should be considered in patients with CGD because immediate initiation of anti-fungal management with aggressive surgical treatment is life-saving.

INVITED REVIEW
16. Testosterone replacement therapy and cardiovascular events
Alp Burak Çatakoğlu, Muammer Kendirci
PMID: 28990951  doi: 10.5543/tkda.2017.00531  Pages 664 - 672
A low testosterone level and hypogonadism are associated with cardiovascular disease. Aging, chronic health problems, and obesity are all associated with a low testosterone level as well as the presence and severity of cardiovascular disease. Testosterone is increasingly prescribed for patients with clinical hypogonadism and a low testosterone level. The information we have is still contradictory regarding testosterone replacement therapy (TRT) and its association with adverse cardiovascular events. Older patients and patients who are susceptible to cardiovascular diseases could be at risk with a testosterone prescription. This is a review of the literature to discuss the cardiovascular safety of TRT.

CASE IMAGE
17. Delayed therapy and syncope due to excessive charging time in a patient with implantable defibrillator during a fast ventricular tachycardia episode
Uğur Canpolat, Metin Okşul, Kudret Aytemir, Giray Kabakçı
PMID: 28990952  doi: 10.5543/tkda.2017.50405  Page 673
Abstract |Full Text PDF | Video

18. Assessment of isolated cleft mitral valve by live/real-time three-dimensional transesophageal echocardiography
Begüm Uygur, Aydın Yıldırım
PMID: 28990953  doi: 10.5543/tkda.2017.44957  Page 674
Abstract |Full Text PDF | Video

19. Cardiac metastasis of cervical cancer
Özge Akgün, Muzaffer Kahyaoğlu, Çetin Geçmen, Arzu Kalaycı Karabay, İbrahim Akın İzgi
PMID: 28990954  doi: 10.5543/tkda.2017.36504  Page 675
Abstract |Full Text PDF | Video

20. Acute coronary syndrome accompanying transient ischemic attack: an unusual presentation of myxoma
Abdulkadir Uslu, Cem Doğan
PMID: 28990955  doi: 10.5543/tkda.2017.15143  Page 676
Abstract |Full Text PDF | Video

LETTER TO EDITOR
21. To extract, or not to extract: that is the question
Aysenur Ekizler, Serkan Cay, Ozcan Ozeke, Firat Ozcan, Dursun Aras, Serkan Topaloglu
PMID: 28990956  doi: 10.5543/tkda.2017.57681  Page 677
Abstract |Full Text PDF

22. Authors reply
Ahmet Hakan Ateş, Uğur Arslan
PMID: 28990957  doi: 10.5543/tkda.2017.54545  Page 678
Abstract |Full Text PDF

OTHER ARTICLES
23. Kardiyoloji yayınlarında gündem ve yorumlar
Ertan Ural
Page 679
Abstract |Full Text PDF



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