Background and objective Atrial fibrillation (AFib) is the most common supraventricular arrhythmia occurring after myocardial infarction (MI). Height, body weight, waist and hip circumference, and body mass index (BMI) are considered potential risk factors for the development of AFib. The aim of this study was to investigate the effect of BMI and waist circumference on the incidence of AFib in patients with acute MI. Methods This prospective, cross-sectional, observational study was conducted in the coronary intensive care unit (CICU) of a tertiary care university hospital between July 2014 and February 2016. Patients diagnosed with ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) were included. Demographic, clinical, echocardiographic, and laboratory data, past medical history, and anthropometric measurements were recorded. Continuous electrocardiography (ECG) monitoring was performed for following up on the occurrence of AFib. Then, AFib predictors were identified using multiple regression analysis. Results AFib developed in 31 (9.3%) patients in the cohort. No significant difference was observed between patients with or without AFib in terms of BMI and waist circumference values (p=0.686 vs. p=0.728, respectively). Factors associated with AFib development as per the multivariate analyses included age (OR: 1.051, 95% CI: 1.013-1.09; p=0.008), pulse rate (OR: 1.043, 95% CI: 1.018-1.069; p=0.001), peak troponin T value (OR: 1.356, 95% CI: 1.135-1.619; p=0.001), and length of CICU stay (OR: 2.247, 95% CI: 1.163-4.340; p=0.016). Conclusion BMI and waist circumference measurements were similar in patients with and without AFib during acute MI. Age, pulse rate, peak troponin T, and duration of CICU stay were identified as independent predictors of AFib development.

Objective: Heart failure (HF) has a high prevalence and mortality rate in elderly patients; however, there are few studies that have focused on patients older than 80 years. The aim of this study is to describe and compare the age-specific demographics and clinical features of Turkish elderly patients with HF who were admitted to cardiology clinics. Methods: The Epidemiology of Cardiovascular Disease in Elderly Turkish population (ELDER-TURK) study was conducted in 73 centers in Turkey, and it recruited a total of 5694 patients aged 65 years or older. In this study, the clinical profile of the patients who were aged 80 years or older and those between 65 and 79 years with HF were described and compared based on the ejection fraction (EF)-related classification: HFrEF and HFpEF (is considered as EF: >= 50%). Results: A total of 1098 patients (male, 47.5%; mean age, 83.5 +/- 3.1 years) aged 80 years and 4596 patients (male, 50.2 %; mean age, 71.1 +/- 4.31 years) aged 65-79 years were enrolled in this study. The prevalence of HF was 39.8% for patients who were >= 80 years and 27.1% for patients 65-79 years old. For patients aged >= 80 years with HF, the prevalence rate was 67% for hypertension (HT), 25.6% for diabetes mellitus (DM), 54.3% for coronary artery disease (CAD), and 42.3% for atrial fibrilation. Female proportion was lower in the HFrEF group (p=0.019). The prevalence of HT and DM was higher in the HFpEF group (p<0.01), whereas CAD had a higher prevalence in the HFrEF group (p=0.02). Among patients aged 65-79 years, 43.9% (548) had HFpEF, and 56.1% (700) had HFrEF. In this group of patients aged 65-79 years with HFrEF, the prevalence of DM was significantly higher than in patients aged >= 80 years with HFrEF (p<0.01). Conclusion: HF is common in elderly Turkish population, and its frequency increases significantly with age. Females, diabetics, and hypertensives are more likely to have HFpEF, whereas CAD patients are more likely to have HFrEF.

Correspondence: Kadir Çeviker, MD. Süleyman Demirel Üniversitesi Tıp Fakültesi Kalp ve Damar Cerrahisi Anabilim Dalı, 32260 Çünür, Isparta, Turkey. e-mail: drkadirce@yahoo.com 1Department of Cardiovascular Surgery, Süleyman Demirel University Medical Faculty, Isparta, Turkey 2Medical Student, Süleyman Demirel University Medical Faculty, Isparta, Turkey 3Department of Cardiology, Süleyman Demirel University Medical Faculty, Isparta, Turkey 4Department of Radiology, Süleyman Demirel University Medical Faculty, Isparta, Turkey

Objective: Aortic stiffness is an important cardiovascular risk marker, which can be determined using different noninvasive techniques. Aortic propagation velocity (APV) has recently been established as a novel echocardiographic parameter of aortic stiffness. This study aimed to investigate the association between APV and the classical echocardiography-derived aortic stiffness parameters, aortic distensibility (AD) and aortic strain (AS), in a group of otherwise healthy individuals. Methods: In total, 97 consecutive healthy subjects were recruited in this observational study. APV was measured using color M-mode echocardiography from the suprasternal window in the descending aorta. AS and AD were calculated using clinical blood pressure and the M-mode echocardiography-derived aortic diameters. Correlation analyses were performed between cardiovascular risk factors related to increased aortic stiffness (age, obesity, and blood pressure) and measured stiffness parameters (APV, AS, and AD). Correlation analyses were also performed among the measured stiffness parameters. Results: Good correlation of age, blood pressure, and BMI with AS and AD was observed. One-on-one correlation of age, blood pressure, and BMI with APV was not observed. No correlation was observed between APV and AS (r=-0.05, p=0.6) or between APV and AD (r=-0.17, p=0.8). Conclusion: Although APV has been proposed as a novel and practical echocardiographic parameter of aortic stiffness, especially in patients with coronary artery disease, correlations between classical stiffness parameters (AS and AD) and APV were absent in healthy individuals at low-intermediate risk. The clinical and research applicability of APV should be further evaluated.

Atrial fibrillation (AF) is the most common supraventricular arrhythmia following ST elevation myocardial infarction (STEMI). Oxidative stress and inflammation may cause structural and electrical remodeling in the atria making these critical processes in the pathology of AF. In this study, we aimed to evaluate the association between total oxidative status (TOS), total antioxidative capacity (TAC) and high-sensitivity C-reactive protein (hs-CRP) in the development of AF in patients presenting with STEMI. This prospective cohort study consisted of 346 patients with STEMI. Serum TAC and TOS were assessed by Erel's method. Patients were divided into two groups: those with and those without AF. Predictors of AF were determined by multivariate regression analysis. In the present study, 9.5% of patients developed AF. In the patients with AF, plasma TOS and oxidative stress index (OSI) values were significantly higher and plasma TAC levels were significantly lower compared to those without AF (p=.003, p=.002, p<.0001, respectively). Multivariate regression analysis results showed that, female gender (Odds ratio[OR]=3.07; 95% Confidence Interval[CI]=1.26-7.47; p=.01), left atrial diameter (OR =1.28; 95% CI =1.12-1.47; p<.0001), hs-CRP (OR =1.02; 95% CI =1.00-1.03; p=.001) and OSI (OR =1.10; 95% CI =1.04-1.18; p=.001) were associated with the development of AF in patients presenting with STEMI. The main finding of this study is that oxidative stress and inflammation parameters were associated with the development of AF in patients presenting with STEMI. Other independent predictors of AF were female gender, left atrial diameter and hs-CRP.

BACKGROUND AND AIM OF THE STUDY:Prosthetic valve thrombosis (PVT) is a rare but serious complication of the prosthetic heart valve. Although recent guidelines generally recommend surgical treatment as the main option for patients with obstructive left-sided PVT, thrombolytic therapy (TT) may offer another attractive approach. There is also no consensus on the type, dose and route of administration of thrombolytic agents. The present study included a small series of patients with low-dose, slow infusion tissue-type plasminogen activator (tPA) to treat PVT in the mitral position.METHODS:Eight consecutive episodes of mitral PVT (one woman was pregnant) in seven patients were treated with low-dose (25 mg), slow infusion (within 6 h) tPA, if needed, with repeat sessions of TT (with the same protocol up to a total dose of 150 mg) until a satisfactory result was achieved.RESULTS:The cause of PVT was inadequate anticoagulation with warfarin or low-molecular-weight heparin in all patients on admission. A complete resolution of hemodynamic instability and echocardiographic abnormalities was observed in all cases, without mortality. In addition, there were no thromboembolic and major hemorrhagic complications in the case series.CONCLUSION:These findings suggest that low-dose, slow infusion tPA may be applicable to bileaflet mitral PVT in relatively stable patients, and may represent a therapeutic option to surgery.

Background We aimed to investigate the circadian rhythm on left ventricular (LV) function and infarct size, according to the onset of ST elevation myocardial infarction (STEMI), with echocardiography in patients with first STEMI successfully revascularised with primary percutaneous coronary intervention (PCI).Methods We conducted a retrospective analysis of 252 STEMI patients. Patients were divided into the four, six-hour periods of the day. Conventional and tissue Doppler imaging (TDI) echocardiography were performed within 48 hours after onset of chest pain. The average of peak systolic myocardial velocities (Sm) in each of the four myocardial segments and LV ejection fraction (LVEF) were calculated.Results A negative linear correlation was shown between CK-MB levels and Sm (r= -0.209, p = 0.001). There was an oscillation between time of day and average of Sm. The lowest Sm and largest infarct size were in the period of 06: 00-noon compared with period of noon-18: 00 and 18: 00-midnight (p = 0.029 and p = 0.031, respectively). A secondary analysis showed that both LVEF and Sm were lower in the midnight-noon group compared with the noon-midnight group (44.9 +/- 7.3% versus 47.3 +/- 7.9%, p = 0.018, and 7.6 +/- 1.4 cm/s versus 8.2 +/- 1.6 cm/s, p= 0.003, respectively).Conclusions This study has shown that there was a circadian rhythm of infarct size and LV function evaluated by echocardiography according to time of STEMI onset. The largest infarct size and poor LV function occurred in the midnight-noon period, in particular in the 06: 00-noon period.

Hyponatremia is frequently seen in heart failure patients and has a high mortality rate. If not treated adequately, acute and chronic hyponatremia may worsen the prognosis of heart failure. Despite its high incidence in heart failure patients, other underlying conditions that possibly lead to the incidence of hyponatremia may be underestimated, thus making its treatment more difficult. In this case study, we describe a rare case of levetiracem-induced and tolvaptan-resistant hyponatremia.

Answer: 683 A 55-year-old male patient was admitted to an emergency department of a secondary care hospital with left forearm pain and numbness of fingers lasting for 6 h. He did not state any kind of chest pain and has not had any cardiac disease history and risk factors except smoking for 30 years. Electrocardiography (ECG) demonstrated negative P waves and ST-segment elevation in inferior leads and minimal ST-segment depression in D1 and aVL, and heart rate was 101 bpm (Fig. 1). His cardiac examination and vital signs were normal. He was transported to our hospital for primary percutaneous coronary intervention with the diagnosis of inferior myocardial infarction (MI). Which of the following is not included in your first differential diagnosis in light of the clinical and electrocardiographic findings?

Associations between metabolic syndrome (MS) and major depressive disorder (MDD) are well documented although the underlying biological mechanisms for this relationship are less studied. Paraoxonase (PON1) is a high-density lipoprotein (HDL)-associated enzyme, with demonstrated evidence of strong antioxidant activity. Oxidative stress has been implicated in the pathophysiology of MS and MDD. PON1 activity has been studied to some extent in patients with MS and less in MDD. The aim of this study was to compare serum PON1 activity in patients with MS and MDD, MS without MDD, and normal control groups in the context of the biological mechanism of the association between MS and MDD. In this case-control study, 67 patients with MS and 25 healthy controls from the hospital–university staff were recruited. All patients and healthy controls were assessed by a semi-structured psychiatric interview. Patients with MDD were diagnosed according to the DSM-IV criteria for MDD. Serum PON1 activity was determined with a spectrophotometric method, and the activity was compared between patients with MS and MDD, with MS but without MDD, and control groups. Serum PON1 activity levels were lower in patients with MS and MDD group compared to those in the patients with MS and without MDD group and control group (69.5 ± 24.2, 84.3 ± 34.6, and 97.1 ± 40.8 U/ml, p = 0.03, respectively). Post hoc analysis showed that PON1 activity was statically significantly lower in the MS with MDD group than in the control group (p = 0.02). Impaired PON1 activity, in the context of enhanced oxidative stress, could be one of the possible underlying biological mechanisms of the MS–MDD association.

A 54-year-old woman who underwent surgical resection of the subaortic membrane 10 years earlier presented with new onset dyspnea. Cardiovascular examination revealed 3-4/6 pansystolic murmur at the apex. She was found to have severe mitral regurgitation (MR) with transthoracic echocardiography; 2D and real-time-3D transesophageal echocardiography demonstrated severe MR through anterior mitral leaflet perforation with precise localization. The patient was treated with surgery in which the perforated segment was closed by direct suture technique and discharged on postoperative 5th day. .

A 59-year-old woman presented with a recent onset of dyspnea and chest pain. Past medical history and cardiovascular examination were completely normal. Electrocardiography demonstrated sinus rhythm with left bundle branch block pattern. Transthoracic echocardiography (TTE) revealed a slightly reduced ejection fraction with hypokinetic septal and anterior walls. Parasternal short-axis imaging displayed a small saccular echo-free space associated with the aorta, and no color flow turbulence was observed with color flow Doppler imaging (Fig. 1a). Subsequently, two-dimensional transesophageal echocardiography (2D-TEE) revealed a normal long-axis view and similar short-axis findings to transthoracic imaging. Real-time 3D-TEE (RT-3D-TEE) provided better imaging and indicated that the saccular body was a round-shaped small aneurysm that was relevant to the left main coronary artery (LMCA) take-off location (Fig. 1b; Video 1). Aortography depicted a round-shaped saccular aneurysm, 8×9 mm in size, originating from the proximal LMCA that was approximately 2–3 mm next to the LMCA ostium (Fig. 2a; Video 2). Coronary angiography revealed an aneurysm associated with proximal LMCA (Fig. 2b; Video 3). Although TTE can provide valuable information regarding the diagnosis of coronary aneurysm in pediatric patients with Kawasaki disease, its validity is limited in adults because of the declining image quality. Nevertheless, proximal segments of the coronary arteries can be assessed with TEE. RT-3-D-TEE can provide even better information regarding the location, size, shape, and relation to adjacent tissue in LMCA aneurysm, as in our case. In this report, we presented an isolated saccular LMCA aneurysm diagnosed by echocardiography, which is rarely encountered in coronary angiography.

Acute stent thrombosis may result from many causes. Bee sting is a very rare cause of this situation. As bee venom activates some inflammatory and vascular events resulting in occlusion in vessels or diseases in electrical system of heart, it may cause myocardial infarction or atrial fibrillation. This problem may be temporary or fatal. Because of its pathologic effects, to be able to catch on and treat them shortly is very important.

Several studies showed that high-density lipoprotein cholesterol (HDL-C) has anti-inflammatory effect. The neutrophil–lymphocyte ratio (NLR) is a new biomarker of systemic inflammation. The aim of this study was to assess the NLR in healthy participants with low HDL-C. We studied 69 patients with low HDL-C (≤35 mg/dL) and 59 control participants (HDL-C >35 mg/dL) with similar cardiovascular risk factors. Hematological indices were measured in all patients with low HDL-C and control participants. The HDL-C was significantly lower among the patients with low HDL-C than that of the control group (31.7 ± 2.7 vs 50.7 ± 5.0 mg/dL, respectively; P < .001). The NLR was significantly higher among the patients with low HDL-C than that of the control group (2.6 ± 0.8 vs 1.6 ± 0.4, respectively; P < .001). The NLR was negatively correlated with HDL-C ( P < .001, r = −.53). The NLR is significantly elevated in patients with low HDL-C when compared with control participants.

A low high-density lipoprotein cholesterol (HDL-C) level is a predictor of increased cardiovascular risk. We assessed the mean platelet volume (MPV) in patients with low HDL-C. We studied 59 patients with low HDL-C (HDL-C ≤35 mg/dL) and 56 control participants (HDL-C levels >35 mg/dL) with similar cardiovascular risk factors. As expected, HDL-C was significantly lower among the patients with low HDL-C than that of the control group (32 ± 3 vs 51 ± 5 mg/dL, respectively; P < .001). Platelet count was significantly lower among the patients with low HDL-C than that of the control group (213 ± 60 vs 285 ± 75 × 109/L, respectively; P < .001). The MPV was significantly higher among the patients with low HDL-C than that of the control group (8.7 ± 0.6 vs 7.1 ± 0.5 fL, respectively; P < .001). We have shown that MPV was significantly elevated in patients with low HDL-C compared with control participants.