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   Table of Contents - Current issue
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April-June 2020
Volume 6 | Issue 2
Page Nos. 35-91

Online since Thursday, June 11, 2020

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REVIEW ARTICLE  

Preparticipation screening of athletic participant: A proposal for the cardiologist Highly accessed article p. 35
Ebru Ipek Turkoglu, Hasan Güngör, Oktay Ergene, Antonio Pelliccia
DOI:10.4103/IJCA.IJCA_11_20  
Hence, the sudden cardiac death (SCD) in sports activity is a rare event, it affects the community deeply. To prevent the SCD on the athletic field, screening of athletic participants is necessary. Lack of randomised controlled trials in sports-cardiology makes the decision-making process hard for the physician. Hereby, a screening model including a family and personal history, an appropriate physical examination of the athlete and 12-lead electrocardiogram, is proposed for athletic participants based on a review of current literature and in accord with the European recommendations.
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ORIGINAL ARTICLES Top

Dipping pattern of nocturnal blood pressure in hypertensive patients treated with azilsartan p. 41
P. L. N. Kapardhi, Viraj R Suvarna, Rahul Chavda, Reshma Susan Reji, Manoj A Suva
DOI:10.4103/IJCA.IJCA_23_19  
Aim: On average, blood pressure (BP) is found to be low during night than during day by approximately 10%–20%. In addition, BP decreases by >20% in some hypertensives or lowered by <10% or few patients may experience rise in BP during night compared to daytime BP. This study was performed to determine the dipping pattern of BP variability of the patients receiving azilsartan with the help of ambulatory BP monitoring (ABPM) system. Settings: This was a prospective, observational, open-label, single-center study. Materials and Methods: A total of 158 hypertensive patients (systolic BP [SBP] >140 mmHg; diastolic BP [DBP] >90 mmHg) were enrolled to performed ABPM and clinic BP monitoring with ongoing treatment with azilsartan. Statistical Analysis: Data are expressed as mean ± standard deviation. Statistical comparisons to test differences between two independent groups were by Student's t-test or Mann–Whitney's U-test as appropriate. Results: All patients monitored for 24-h BP measurement and reported to had SBP 133.76 ± 15.97 mmHg and DBP 76.16 ± 10.86 mmHg. Pulse rate was found to be 76.18 ± 11.82 bpm. BP variability was found to be high in 23.41% patients. Overall, study showed 34.17% dipper, 3.16% extreme dipper, 51.26% nondippers and 11.39% patients with reverse dipping pattern. In the present study, the dippers are classified to have 18.9% reduction in SBP, whereas 12.5% reduction in DBP. In the dippers group, only 4 patients had normal BP variation (2.53%), whereas high BP variation was found in 50 patients of the group (31.64%). Conclusions: ABPM had revealed higher SBP, BP variability (in almost one-fourth patients), dipping pattern and slightly higher pulse rates in hypertensive patients receiving azilsartan treatment. Around one-third of hypertensive patients were found to be dippers and more than half patients were non-dippers. Azilsartan has potent antihypertensive effect over 24 h and can be preferred in high-risk hypertensive patients.
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Evaluation of right ventricle functions might be a method for early recognizing cardiotoxicity in hematopoietic stem cell transplantation p. 46
Fatih Tekiner, Cennet Yildiz, Sebnem Izmir Guner
DOI:10.4103/IJCA.IJCA_1_20  
Objective: We aimed to investigate whether right ventricular (RV) functional assessment by echocardiography may help in the early diagnosis of hematopoietic stem cell transplantation (HSCT)-induced cardiotoxicity. Methods: Our study population comprised 41 autologous multiple myeloma, 25 autologous Hodgkin's lymphoma, 20 autologous and 19 allogeneic non-Hodgkin's lymphoma, 10 allogeneic acute myeloid leukemia, 12 allogeneic myelodysplastic syndrome, and 10 allogeneic aplastic anemia patients. Conventional two-dimensional echocardiographic and tissue Doppler imaging examination of the patients were performed before and after HSCT. Post-HSCT values were compared with pre-HSCT values. Results: The mean age of the patients was 46.51 ± 16.24 years, and the mean hospital length of stay and the mean leukocyte engraftment time were 30 and 11 days, respectively. The number of female and male patients was 60 (43.8%) and 77 (56.2%), respectively. There were no significant differences in echocardiographic parameters including left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular ejection fraction, RV, right atrium, pulmonary artery pressure, pulmonary velocity, Pulmonary acceleration time (PAT)/ pulmonary ejection time (PET), PAT, E, A wave velocity, E/A ratio, and DT and A' velocity before and after HSCT. Compared to pretransplant values, posttransplant values of the E' velocity, S' velocity, E'/A' ratio, and tricuspid annular plane systolic excursion showed a statistically significant decrease (0.15 ± 0.34 vs. 0.12 ± 0.04, P = 0.032; 0.19 ± 0.06 vs. 0.09 ± 0.04, P < 0.001; 0.90 ± 0.40 vs. 0.72 ± 0.37, P = 0.012; and 2.30 ± 0.39 vs. 1.63 ± 0.30, P <0.001, respectively). Conclusion: Assessment of RV functions might be useful for the prediction of early cardiotoxicity in patients undergoing HSCT.
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C-reactive protein/albumin ratio designates advanced heart failure among outpatients with heart failure p. 51
Oguzhan Yucel, Hakan Günes, Murat Kerkütlüoglu, Mehmet Birhan Yılmaz
DOI:10.4103/IJCA.IJCA_49_19  
Background: Exercise intolerance has a relation with poor prognosis for patients with heart failure (HF). The high C-reactive protein (CRP) levels have prognostic effects on many cardiovascular diseases such as HF, coronary artery disease, and ischemic stroke. The low serum albumin levels are related with poor prognosis in patients with HF. We aimed to investigate whether the assessment of CRP/albumin ratio would enable clinicians to identify patients with advanced HF. Materials and Methods: This retrospective study included 102 HF patients with reduced ejection fraction (≤40%). The mean age of patients was 44 ± 13 years. Advanced HF (New York Heart Association [NYHA] Functional Class III–IV) was observed in 27 patients (26.5%). Results: CRP/albumin ratio was on average higher in patients with NYHA functional Classes III and IV than in patients with NYHA functional Classes I and II (0.4 [0.02–1.97] vs. 0.12 [0.02–1.63], P < 0.001). In multiple logistic regression model with forward stepwise method, CRP/albumin ratio (odds ratio [OR]: 3.084, P: 0.036, 95.0% confidence interval [CI]: 1.074–3.855) and brain natriuretic peptide >500 pg/ml (OR: 3.526, P: 0.014, 95.0% CI: 1.290–9.637) remained associated with advanced HF. Conclusions: For the first time in the literature, we showed that elevated CRP/albumin ratio was found to be independently associated with advanced HF. We have also shown that high CRP/albumin ratio was associated with poor hemodynamic parameters.
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Effect of no-reflow/reflow on P-wave time indexes in patients with acute myocardial infarction undergoing percutaneous coronary intervention p. 57
Ahmet Karakurt, Cennet Yildiz, Doğan Iliş
DOI:10.4103/IJCA.IJCA_58_19  
Aim: The aim of this study was to investigate the relationship between no-reflow (no-RF), reflow (RF), and the P-wave time index in patients undergoing percutaneous coronary intervention (PCI) with a diagnosis of acute myocardial infarction (AMI) due to total occlusion. Methods: This study included a total of 272 AMI patients with no-RF (110 patients) and RF (162 patients). Results: The no-RF group had higher values of mean maxPWTpostPCI(94.95 ± 15.61 vs. 117.86 ± 12.06, P < 0.001), minPWTpostPCI(54.21 ± 12.13 vs. 67.31 ± 11.79, P < 0.001), and PWDpostPCI(39.14 ± 12.55 vs. 50.91 ± 11.9, P < 0.001) during the post-PCI period. According to multivariate logistic regression analysis, maxPWTpostPCI(odds ratio [OR]: 1.103, 95% confidence interval [CI]: 1.049–1.160, P < 0.001), minPWTpostPCI(OR: 1.055, 95% CI: 1.011–1.101, P = 0.0014), and PWDpostPCI(OR: 1.107, 95% CI: 1.037–1.181, P = 0.002) were the independent predictors of RF after PCI. ROC curve analyses demonstrated that the optimal cutoff values for maxPWTpostPCI, minPWTpostPCI, and PWDpostPCIfor predicting no-RF were 112.95 ms (area under the curve [AUC]: 0.852, 95% CI: 0.807–0.898, P < 0.001, sensitivity 70%, specificity 85.2%), 62.66 ms (AUC: 0.650, 95% CI: 0.585–0.716, P < 0.001, sensitivity 54.5%, specificity 72.8%), and 43.43 ms (AUC: 0.782, 95% CI: 0.727–0.837, P < 0.001, sensitivity 75.5%, specificity 60.5%), respectively. Conclusions: Prolonged maxPWTpostPCI, maxPWTpostPCI,and PWDpostPCIare independent predictors that differentiate no-RF from RF in patients with AMI after PCI and can be used in the follow-up of no-RF patients during the post-PCI period.
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Traditional warfarin (Coumadin) therapy usage experience on nonvalvular atrial fibrillation before non-Vitamin K antagonists (new oral anticoagulants) era from a center in Turkey p. 66
Emre Ozdemir, Ozgen Safak, Sadik Volkan Emren, Mehmet Serdar Bayata
DOI:10.4103/IJCA.IJCA_61_19  
Introduction: Atrial fibrillation (AF) is the most common arrhythmia with a prevalence that increases by aging. AF causes morbidity and mortality due to thromboembolic events. In developing countries, the use of new generation medications can be delayed. Objective: We evaluated nonvalvular AF patients without effective oral anticoagulation (OAC) when non- vitamin K antagonists (NOACs) were mostly unavailable in Turkey before 2012–2013. The results were compared with what would happen if NOAC was available in use. Patients and Methods: Two-hundred and five patients in AF with adequate information were detected 123 of these patients were nonvalvular AF, (92 patients in these 123 ones were not taking OAC or on ineffective INR range) were included in the study. Results: Thirty-one (25.2%) of these patients were already on effective warfarin therapy. Ninety-two (74.8%) patients were not on warfarin therapy or on out of effective therapeutic range. About 52.2% of participants were female. The mean age was 70.62 ± 11.8 years. Eighteen (19.5%) patients had a recurrent stroke. Conclusion: OACs are recommended for patients with high stroke risk according to CHA2DS2-VASc score. OAC therapy significantly decreases mortality, morbidity, and also especially stroke risk. The only OAC therapy was warfarin over the decades until NOACs have been found. In our study, if NOACs could be available before 2012 in Turkey, 74.8% of our cohort would be under the effective anticoagulation and 19.5% of patients may have avoided from stroke. This is important for patients' lives and also for their costs.
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Effect of exercise on left atrial mechanical functions in professional wrestlers p. 70
Hasan Gungor, Alper Kartal, Abraham Samuel Babu, Sercan Çayırlı, Esin Ergin
DOI:10.4103/IJCA.IJCA_62_19  
Background: The adaptation of the cardiovascular system to exercise differs according to the type of sport. The aim of this study is to evaluate the effect of regular exercise on left atrial (LA) mechanical functions in professional wrestlers at internationally competitive level versus controls. Methods: Twenty professional male wrestlers (mean age, 21.90 + 2.49 years) and twenty male controls (mean age, 22.3 + 1.49 years) participated in this study. Echocardiographic assessments were performed using the criteria of the American Society of Echocardiography. The following LA volumes (LAVs) were measured: maximal volume (Vmax), minimal volume (Vmin), and LAV before atrial contraction (VpreA) at the onset of the pulsed wave of the simultaneously recorded electrocardiogram. LA ejection fraction (LAEF), LA expansion index (LAEI), LA active emptying volume index (LAAEVI) and fraction (LAAEFr), and LA passive emptying volume index (LAPEVI) and fraction (LAPEFr) were calculated. Results: Body mass index and LA diameter were statistically significantly higher in the wrestlers' group (P < 0.05). Other baseline characteristics, demographics, and echocardiographic parameters did not show any statistically significant difference between the groups. With regard to LAVs, Vminindex and VpreAindex were lower in wrestlers (P < 0.05), whereas LAEF, LAPEVI, and LAPEFr were higher in wrestlers' groups (P < 0.05). LAEI, LAAEVI, and LAAEFr were higher in wrestlers but were not statistically significant. Conclusion: Wrestling may be associated with morphologic alterations in LA mechanical functions. Deterioration in the mechanical function of the LA can be detected even earlier, especially if the volume is preserved in the early period.
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Clinical indications for requesting high-sensitivity troponin I in the emergency department p. 75
Abdulhalim Jamal Kinsara, Ziad A Taher, Abdullah Altalhi, Moaffaq Mahdi, Abdulrahman Aldainy, Atif Alqubbany, Aida Darwish
DOI:10.4103/IJCA.IJCA_65_19  
Objectives: The aim of this study is to evaluate the presenting symptoms, risk factors and cardiac origin of high-sensitivity troponin I (Hs-TnI), the tendency of emergency physicians to use Hs-TnI in a general emergency room (ER) and the validity of requesting an Hs-TnI routinely. Methodology: A retrospective cohort study with 904 patients presenting at a tertiary hospital ER with an Hs-TnI requested. The study was conducted for 15 months. Results: Of the sample, 20.4% (n = 184) presented with dyspnea, 18.03% (n = 163) with chest pain and a small proportion (12.94%, n = 117) with epigastric abdominal pain. Patients presenting with chest pain and a history of dyslipidemia were at a higher risk of developing acute coronary syndrome compared to the group without dyslipidemia (relative risk [RR] = 1.62 [1.01–2.58] P = 0.044). Diabetes and hypertension were the most prevalent chronic comorbidities in patients with dyspnea with a risk of (RR = 5.19 (0.68–39.27) P < 0.068). Patients who presented with epigastric pain and had a history of dyslipidemia had a risk of (RR = 5.23 (1.33–20.54) P = 0.009). Conclusion: The presenting symptoms should be taken into consideration by the emergency department physician to support the request for an Hs-TnI laboratory test. The yield and risk were both low in random screening.
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Association between stasis dermatitis and length of stay in heart failure hospitalizations p. 80
Ozge Kaya, Anıl Sahin, Hakki Kaya
DOI:10.4103/IJCA.IJCA_12_20  
Background: Stasis dermatitis (SD) is caused by venous hypertension that can be associated with peripheral congestion due to heart failure (HF). Length of stay (LOS) is the primary driver of HF hospitalization costs. Therefore, it is important to determine those patients who will have longer LOS. We aimed to investigate the relationship between the SD and LOS in HF patients. Methods: A total of 308 patients, who were hospitalized between January 2012 and January 2014 due to acute decompensated HF (ADHF) in our center, were evaluated in this retrospective observational cohort study. Patients' baseline clinical characteristics and presence of SD diagnosis within the past 3 months prior the HF hospitalization were assessed by a review of cardiology and dermatology clinics medical records. Results: A total of 237, acutely decompensated, HF patients were enrolled in the study. The median LOS was 5 days, and the mean LOS was 5.4 ± 2 days. Prolonged LOS was defined as LOS >5 days, and the patients were classified into two groups: Those with LOS ≤5 days (Group I) and those with LOS >5 days (Group II, longer LOS). The presence of SD diagnosis was higher in Group II compared to patients in Group I (22% vs. 46%, P < 0.001). In the multivariate logistic regression model, presence of SD diagnosis, presence of moderate-to-severe tricuspid regurgitation, presence of atrial fibrillation, left atrial diameter, creatinine level, sodium level remained associated with longer LOS after adjustment for age, gender and for the variables found to be statistically significant in univariate analysis and correlated with LOS. Conclusions: This was the first time in the literature that a study demonstrated that the presence of SD was associated with an increased the risk of prolonged hospitalization independent of other factors in patients with reduced ejection fraction heart failure admitted for ADHF.
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CASE REPORTS Top

Coronary artery bypass graft surgery in a rare case of coronary artery anomaly – Single coronary artery originating from the right aortic sinus p. 86
Anshuman Darbari, Devender Singh, Anish Gupta, Barun Kumar
DOI:10.4103/IJCA.IJCA_54_19  
Single coronary artery (SCA) is a very rare congenital anomaly, in which the entire coronary system arises from the solitary ostium with the incidence of 0.024%–0.066% in the general population undergoing coronary angiography. It is usually considered a benign entity but may cause chest pain, hemodynamic abnormalities, myocardial ischemia, or sudden cardiac death owing to its course arising between the pulmonary artery and aorta. The diagnosis of congenital coronary artery anomalies is usually made by conventional coronary angiography and very few cases have been reported in the literature. To the best of our knowledge, we report this as a first case, in which successful off-pump coronary artery bypass grafting was done for a SCA system.
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Right atrial mass imitating the catheter p. 89
Aysu Oktay, Feyza Aksu, Mustafa Caliskan
DOI:10.4103/IJCA.IJCA_59_19  
Catheter-related thrombosis is a relatively common complication of central venous catheter insertion. The catheter-related complications (malfunctions, infections, and thrombosis) cause serious problems in these patients. In patients presenting with fever and a history of venous catheterization, the right heart cavities and venous system should be carefully evaluated due to the procedure that may form a basis for infective endocarditis even if the catheter is removed. In this article, we report a case of right atrial mass mimicking a catheter in a patient with a history of recurrent venous catheterization due to hemodialysis.
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