Objective: Available evidence suggests that inflammation may be associated with atrial fibrillation (AF). This prospective and observational study aimed to assess whether plasma neopterin (NPT) and interleukin-6 (IL-6) levels before and after electrical cardioversion (CV) predict AF recurrence.
Methods: The study was designed as a prospective observational trial. Blood samples were collected (24 hours before, 24 h after CV, and 7 days after CV) in 60 patients with a dual-chamber pacemakar and preserved left ventricular systolic function who underwent successful CV of persistent AF. All significant parameters associated with AF recurrence lasting ≥30 min and detected by pacemaker data logs were evaluated in multivariate logistic regression analysis. Echocardiography was performed 7 days after CV in patients with sinus rhythm. The control group included 17 subjects without AF.
Results: The analysis included 51 patients who remained in sinus rhythm 7 days after CV. During 12 months of follow-up, AF recurred in 46 patients. Baseline IL-6 levels did not differ between the two groups, but baseline NPT levels were higher in the study group than in the control group (19±7 vs. 11±5 nmol/mL, p<0.001). NPT levels of ≥14.6 nmol/L at baseline and ≥13.3 nmol/L 7 days after CV separated the patients with AF recurrence from those without arrhythmia after CV. Only left atrial emptying fraction <38% was an independent predictor of AF recurrence (p=0.03), whereas NPT levels of ≥13.3 nmol/L 7 days after CV showed borderline statistical significance (p=0.07).
Conclusion: Increased NPT level was observed in patients with persistent AF. Neither baseline IL-6 and NPT levels nor their changes within 7 days after CV were predictive of AF recurrence. Further studies are needed to establish the prognostic significance of NPT in patients with AF. (Anatol J Cardiol 2016; 16: 000-000)

Objective: This study aimed to evaluate the association between the history of stroke/transient ischemic attack (TIA) and inter- and intra-atrial electromechanical delay (EMD) in patients with paroxysmal atrial fibrillation (PAF).
Methods: Patients diagnosed with PAF were included in this retrospective study. Patients who had a history of stroke or TIA were defined as the symptomatic group, whereas those who did not have such a history were defined as the asymptomatic group. On the basis of the transthoracic echocardiographic records, atrial electromechanical coupling (time interval from the onset of the P wave on the surface electrocardiogram to the beginning of the A′ wave interval with tissue Doppler echocardiography) and intra- and interatrial EMD were measured.
Results: In this study, 160 patients were included, 52 of whom were symptomatic. While the intra-left atrial EMD was 68.2±6.1 ms in the symptomatic group, it was found to be 50.8±6.5 ms in the asymptomatic group (p<0.001). Interatrial EMD was 91.3±5.0 ms in the symptomatic group, whereas it was 71.5±7.0 ms in the asymptomatic group (p<0.001). In multiple logistic regression analysis, intra-left atrial [odds ratio (OR): 1.417, 95% confidence interval (CI): 1.193–1.684, p<0.001] and interatrial EMDs (OR: 1.398, 95% CI: 1.177–1.661, p<0.001) were found to be independently associated with the presence of stroke/TIA.
Conclusion: Prolonged inter- and intra-left atrial EMDs in patients with PAF is associated with stroke/TIA. Evaluating this parameter in addition to the CHA2DS2-VASc score in patients with PAF may be helpful in identifying patients who are at a high risk of stroke/TIA. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Atrial functions are relatively suppressed in heart failure (HF). We aimed to investigate the associations of intra- and inter-atrial electromechanical conduction delay (EMCD) with functional class and mortality over a 12-month follow-up period.
Methods: The prospective study included 65 patients with systolic HF and 65 healthy subjects with normal sinus rhythm. Left ventricular (LV) systolic functions and left atrial (LA) dimensions and volumes were evaluated by transthoracic echocardiography. Tissue Doppler imaging (TDI) signals at the lateral border of the mitral annulus (lateral PA'), septal mitral annulus (septal PA'), and tricuspid annulus (tricuspid PA') were measured. Intra- and inter-atrial EMCD were calculated.
Results: Mitral inflow velocities were studied using pulsed-wave Doppler after placing the sample volume at the leaflets’ tips. The peak early (E wave) and late (A wave) velocities were measured. The septal annular E/E' ratio was relatively higher and lateral, septal, and right ventricular S, E', and A' waves were significantly lower in the HF group than in the control group (12.49±6.03 – 7.16±1.75, pE/E' <0.0001). Intra-atrial EMCD was detected as 117.5 ms and inter-atrial EMCD as 127.5 ms in patients with prolonged atrial EMCD. A significant increase was found in prolonged intraand inter-atrial EMCD according to functional capacity increase (p=0.012 and p=0.031, respectively). The incidence of mortality was significantly higher in patients with prolonged atrial EMCD (p=0.025), and 5 patients in the HF group died during the study over the 12-month follow-up period.
Conclusions: In this study, we found a relationship between prolonged atrial conduction time and increased functional class and mortality in patients with systolic HF. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Changes in left atrial (LA) function can be observed in type 1 diabetes mellitus (T1DM). Three-dimensional (3-D) speckle tracking echocardiography (STE) seems to be a promising tool for volumetric and functional evaluation of LA. The objective of the present study was to compare 3DSTE-derived LA volumetric and strain parameters between T1DM patients and matched healthy controls.
Methods: This prospective study consists of 17 subcutaneous insulin pump-treated non-obese patients with T1DM (mean age: 33.5±8.2 years, 8 males). To exclude possible cardiovascular disease, patients with complaints of chest pain, dyspnea, or signs of cerebrovascular disease or peripheral artery disease were not included. Their results were compared with 20 age-matched and gender-matched healthy controls (mean age: 36.9±11.0 years, 9 males). Independent sample Student t-test and Fisher’s exact test were used for comparisons. Bland–Altman method was used for evaluating intraobserver and interobserver correlations.
Results: Anemia and impaired renal function were not confirmed in T1DM patients. Calculated LA maximum and minimum volumes and LA volume before atrial contraction were significantly increased in T1DM patients. Total atrial stroke volume was increased (23.6±6.9 mL vs. 19.6±4.6 mL, p=0.04), whereas mean segmental circumferential peak strain was decreased (28.9%±11.4% vs. 37.3%±12.5%, p=0.04). Segmental basal longitudinal and area strains were increased, whereas segmental superior circumferential and area strains and midatrial 3-D strain were decreased in T1DM.
Conclusion: Both 3DSTE-derived volumetric and strain analysis confirmed alterations in LA function, suggesting early LA remodeling in patients with T1DM. (Anatol J Cardiol 2016; 16: 000-00)

Objective: The awareness, time in therapeutic range (TTR), and safety of warfarin therapy were investigated in the adult Turkish population.
Methods: This multicenter prospective study includes 4987 patients using warfarin and involved regular international normalized ratio (INR) monitoring between January 1, 2014 and December 31, 2014. TTR was calculated according to F.R. Roosendaal’s algorithm. Awareness was evaluated based on the patients’ knowledge of warfarin’s affect and food–drug interactions.
Results: The mean TTR of patients was 49.52±22.93%. The patients with hypertension (55.3%), coronary artery disease (23.2%), congestive heart failure (24.5%), or smoking habit (20.8%) had significantly lower TTR levels than the others. Of the total number of patients, 42.6% had a mechanical valve, 38.4% had non-valvular atrial fibrillation (AF), and 19% had other indications for warfarin. Patients with other indications had lower TTR levels than those with mechanical valve and non-valvular AF (p=0.018). Warfarin awareness decreased in higher age groups. The knowledge of warfarin’s food–drug interactions was 55%. People with higher warfarin awareness had higher TTR levels. Patients with ≤8 INR monitoring/year had lower TTR levels (46.4±25.3 vs. 51.1±21.3, respectively, p<0.001) and lower awareness (44.6% vs. 60.6%, p<0.001) than patients with ≥8 INR monitoring/year. In this study, 20.1% of the patients had a bleeding event (major bleeding 15.8%, minor bleeding 84.2%) within a year.
Conclusion: Both the mean TTR ratios and awareness of the Turkish population on warfarin therapy were found to be low. It was thought that low TTR levels of the Turkish population may be caused by the low awareness of warfarin, warfarin’s food–drug interactions, and high rates of concomitant diseases. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Chronic obstructive pulmonary disease (COPD) is a risk factor for cardiovascular disease (CVD). Carotid intima-media thickness (CIMT) is the sign of subclinical atherosclerosis. Therefore, the aim of this study was to evaluate whether CIMT measurement is related with significant coronary artery disease (CAD) in patients with COPD, similar to those without COPD.
Methods: One hundred and eight patients with previously diagnosed COPD and 78 patients without COPD who underwent coronary angiography (CAG) were enrolled in this prospective cross-sectional study. Carotid artery ultrasonography was performed on all patients after coronary angiography by another operator who was blind to the CAG results. The patients were divided into four subgroups as follows: group 1: COPD (−) and CAD (−); group 2: COPD (−) and CAD (+); group 3: COPD (+) and CAD (+); and group 4: COPD (+) and CAD (−). Patients with previous coronary revascularization, carotid artery disease, and lung disease other than COPD were not enrolled in this study. The student’s t-test, chi-square analysis, multiple logistic regression analysis, and receiver operating characteristic (ROC) curve were used for statistical analysis.
Results: CIMT was found to be highest in patients with both significant CAD and COPD (group 3) (p<0.05). Among the 108 COPD patients, the odds ratio associated with the CIMT >1.25 mm to predict CAD was 12.4. The area under the ROC curve for a cut-off value of 1.25 mm for CIMT to predict CAD in COPD patients was calculated as 0.913, with a sensitivity of 89.7% and specificity of 86.7%.
Conclusion: CIMT has a predictive value for the presence of CAD in patients with COPD. Further studies are needed to validate our results. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Functional capacity is one of the cardinal determinants of morbidity and mortality in patients with coronary artery disease (CAD). We hypothesized that baseline cardiovascular mechanics, including cardiac systolic and diastolic functions, arterial mechanics, and ventriculoarterial interaction, may play a role in predicting exercise capacity in patients with CAD.
Methods: Fifty consecutive patients with CAD who were referred to cardiac rehabilitation were prospectively included in the study. Patients with non-sinus rhythms or severe valvular disease were excluded. Full left ventricular pressure–volume loops were constructed and arterial mechanics was evaluated using echocardiographic and tonometric measurements. Cardiopulmonary exercise tests were performed to measure exercise capacity.
Results: Fifty patients were enrolled in the study. Ventriculo-arterial coupling showed a moderate correlation with peak oxygen consumption (VO2) (r=0.410, p=0.04) in patients with reduced left ventricular ejection fraction (LVEF). Only left ventricular volume at 15 mm Hg (r=0.514, p<0.01) in diastolic parameters (stiffness constant, p=0.75; ventricular compliance, p=0.17) and arterial compliance (r=0.467, p=0.01) in arterial parameters [arterial elastance, p=0.27; systemic vascular resistance, p=0.45; augmentation pressure, p=0.85; augmentation index (AIx), p=0.63; heart rate-corrected AIx, p=0.68] emerged as significant factors correlated with peak VO2 in patients with normal LVEF.
Conclusion: Comprehensive evaluation of resting cardiovascular mechanics can give clues about exercise-recruited reserves of the cardiovascular system. Optimization of ventriculo-arterial coupling in patients with reduced LVEF and arterial compliance in patients with normal LVEF should be the main target in patients with CAD and limited functional capacity. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Cardiac syndrome X (CSX) is characterised by typical exertional chest pain, a positive response to exercise testing, and a normal coronary angiography. The relationship of CSX with myocardial fibrosis and ischemia has been clearly demonstrated in previous studies. In addition, fragmented QRS (fQRS) has been reported in the literature as an indicator of myocardial fibrosis. The aim of this study was to investigate the frequency of fQRS in patients with CSX.
Methods: This prospective case-control study included 37 patients (CSX group) with typical complaints of angina, ischemia on an exercise test, and normal coronary arteries as detected by angiography and 47 patients (control group) with normal coronary arteries. Echocardiographic examinations were performed according to the recommendations of the American Society of Echocardiography. Continuous variables were expressed as mean±standard deviation (SD), and the qualitative variables were expressed as a percentage or ratio. Data were compared statistically with Shapiro–Wilk test, Student’s t-test, Mann-Whitney U, chi-square and Fisher exact test.
Results: There was no significant difference between the CRX and control groups with respect to basic characteristics such as age and sex. fQRS and the frequency of its presentation with stable angina pectoris at the clinic were significantly higher in the CSX group than in the control group (p values: 0.001 and <0.001, respectively).
Conclusion: A close follow-up would be useful in CSX patients in whom fQRS is detected in an electrocardiogram (ECG) because of the association between fQRS and poor prognosis with respect to the prevention of late complications. We believe that the presence of fQRS in the ECG aids in the diagnosis of CSX in clinical practice and in the recognition of this group of patients. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) is a transcriptional coactivator that has been proposed to play a protective role in mouse models of cardiac ischemia and heart failure, suggesting that PGC-1α could be relevant as a prognostic marker. Our previous studies showed that the estimation of peripheral mRNA PGC-1α expression was feasible and that its induction correlated with the extent of myocardial necrosis and left ventricular remodeling in patients with myocardial infarction. In this study, we sought to determine if the myocardial and peripheral expressions of PGC-1α are well correlated and to analyze the variability of PGC-1α expression depending on the prevalence of some metabolic disorders.
Methods: This was a cohort of 35 consecutive stable heart failure patients with severe aortic stenosis who underwent an elective aortic valve replacement surgery. mRNA PGC-1α expression was simultaneously determined from myocardial biopsy specimens and blood samples obtained during surgery by quantitative PCR, and a correlation between samples was made using the Kappa index. Patients were divided into two groups according to the detection of baseline expression levels of PGC-1α in blood samples, and comparisons between both groups were made by chi-square test or unpaired Student’s t-test as appropriate.
Results: Based on myocardial biopsies, we found that mRNA PGC-1α expression in blood samples showed a statistically significant correlation with myocardial expression (Kappa index 0.66, p<0.001). The presence of higher systemic PGC-1α expression was associated with a greater expression of some target genes such as silent information regulator 2 homolog-1 (x-fold expression in blood samples: 4.43±5.22 vs. 1.09±0.14, p=0.044) and better antioxidant status in these patients (concentration of Trolox: 0.40±0.05 vs. 0.34±0.65, p=0.006).
Conclusions: Most patients with higher peripheral expression also had increased myocardial expression, so we conclude that the non-invasive estimation of mRNA PGC-1α expression from blood samples provides a good approach of the constitutive status of the mitochondrial protection system regulated by PGC-1α and that this could be used as prognostic indicator in cardiovascular disease. (Anatol J Cardiol 2016; 16: 000-00)

Objective: Although sudden cardiac death is rare in children, an intracardiac defibrillator system is indicated in children with various types of cardiomyopathy, primary electrical diseases, and after surgical repair of congenital heart defects. The use of transvenous defibrillator lead systems is limited in pediatric patients because of a small body size and/or limited vascular access. Subcutaneous array leads combined with an abdominally placed generator can enable implantation.
Method: This is a retrospective study of 13 patients who underwent subcutaneous defibrillator implantation between September 2010 and March 2015. The subcutaneous system was preferred because patients were not amenable to transvenous lead placement.
Results: The median patient age was 4.1 years, and the median patient weight was 12.1 kg. Diagnoses of patients were long-QT syndrome in 6, aborted cardiac arrest with left ventricular non-compaction in 3, hypertrophic cardiomyopathy with sustained ventricular tachycardia in 3, and arrythmogenic right ventricular cardiomyopathy in 1. Revision of the subcutaneous lead was required in 5 patients 2–26 months after the implantation. Appropriate shocks were observed in three patients. Inappropriate shock and lead fractures were observed in one patient during the follow-up period. The failure of therapy was observed in one patient. There were no perioperative complications and no early or late deaths.
Conclusion: Subcutaneous defibrillator systems are safe and effective in pediatric patients when the transvenous method is risky and contraindicated. Because the high growth rate in this population leads to lead failures, a close follow-up of this population is essential. (Anatol J Cardiol 2016; 16: 000-00)