Karabay, Can Yücel; Taşolar, Hakan; Kunak, Ayşegül Ülgen; Çap, Murat; Astarcıoğlu, Mehmet Ali; Şen, Taner; Kaplan, Mehmet; Coşgun, Muharrem Said; Ağca, Fahriye Vatansever; Arslan, Uğur

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and is associated with an increased risk of thromboembolism, ischemic stroke, impaired quality of life, and mortality. The latest research that shows the prevalence and incidence of AF patients in Türkiye was the Turkish Adults’ Heart Disease and Risk Factors study, which included 3,450 patients and collected data until 2006/07.The Turkish Real Life Atrial Fibrillation in Clinical Practice (TRAFFIC) study is planned to present current prevalence data, reveal the reflection of new treatment and risk approaches in our country, and develop new prediction models in terms of outcomes. Methods: The TRAFFIC study is a national, prospective, multicenter, observational registry. The study aims to collect data from at least 1900 patients diagnosed with atrial fibrillation, with the participation of 40 centers from Türkiye. The following data will be collected from patients: baseline demographic characteristics, medical history, vital signs, symptoms of AF, ECG and echocardiographic findings, CHADS2-VASC2 and HAS-BLED (1-year risk of major bleeding) risk scores, interventional treatments, antithrombotic and antiarrhythmic medications, or other medications used by the patients. For patients who use warfarin, international normalized ratio levels will be monitored. Follow-up data will be collected at 6, 12, 18, and 24 months. Primary endpoints are defined as systemic embolism or major safety endpoints (major bleeding, clinically relevant nonmajor bleeding, and minor bleeding as defined by the International Society on Thrombosis and Hemostasis). The main secondary endpoints include major adverse cardiovascular events (systemic embolism, myocardial infarction, and cardiovascular death), all-cause mortality, and hospitalizations due to all causes or specific reasons. Results: The results of the 12-month follow-up of the study are planned to be shared by the end of 2023. Conclusion: The TRAFFIC study will reveal the prevalence and incidence, demographic characteristics, and risk profiles of AF patients in Türkiye. Additionally, it will provide insights into how current treatments are reflected in this population. Furthermore, risk prediction modeling and risk scoring can be conducted for patients with AF.

Sancar, Kadriye Memiç; Çelik, Oğuzhan; Çil, Cem; Karaarslan, Osman; Doğan, Tolga; Yetim, Mücahit; Asoğlu, Ramazan; Çelik, Yunus; Kalkan, Sedat; Demirci, Erkan

Background: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial has been the largest study ever conducted among patients in Turkey regarding aspirin treatment. In the subgroup analysis of the hypertensive group of the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial, we aimed to evaluate the physicians’ adherence to current guidelines regarding their aspirin treatment preferences. Methods: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial is a cross-sectional and multicenter study conducted among 5007 consecutive patients aged ≥18 years. The study population consisted of outpatients on aspirin treatment (80-300 mg). The patient data were obtained from 30 different cardiology clinics of 14 cities from all over Turkey. In this subgroup analysis, patients were divided into 2 groups: the hypertensive group (n = 3467, 69.3%) and the group without hypertension (n = 1540, 30.7%) according to the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the Management of Arterial Hypertension. Results: Aspirin use for primary prevention was higher in patients with hypertension compared to patients without hypertension [328 (21.3%); 1046 (30.2%); P < .001]. Treatment with a dose of 150 mg aspirin (n = 172, 5%) was mostly preferred by internists for hypertensive patients (n =226, 6.5%); however, a daily dose of 80-100 mg aspirin therapy (n = 1457, 94.6%) was mostly prescribed by cardiologists (n = 1347, 87.5%) for patients without hypertension. Conclusion: Aspirin was found to be used commonly among patients with hypertension for primary prevention despite the current European Society of Cardiology Arterial Hypertension Guideline not recommending aspirin for primary prevention in patients with hypertension.

Erol, Mustafa Kemal; Kayikçioglu, Meral; Yavuzgil, Oguz; Kiliçkap, Mustafa; Güler, Arda; Öztürk, Önder; Tuncay, Burcu; Inci, Sinan; Balaban, Ismail; Tatar, Fatih Pasa

Objective: In this study, we aimed to analyze the TURKMI registry to identify the factors associated with delays from symptom onset to treatment that would be the focus of improvement efforts in patients with acute myocardial infarction (AMI) in Turkey. Methods: The TURKMI study is a nation-wide registry that was conducted in 50 centers capable of 24/7 primary percutaneous coronary intervention (PCI). All consecutive patients (n=1930) with AMI admitted to coronary care units within 48 hours of symptom onset were prospectively enrolled during a predefined 2-week period between November 1, 2018, and November 16, 2018. All the patients were examined in detail with regard to the time elapsed at each step from symptom onset to initiation of treatment, including door-to-balloon time (D2B) and total ischemic time (TIT). Results: After excluding patients who suffered an AMI within the hospital (2.6%), the analysis was conducted for 1879 patients. Most of the patients (49.5%) arrived by self-transport, 11.8% by emergency medical service (EMS) ambulance, and 38.6% were transferred from another EMS without PCI capability. The median time delay from symptom-onset to EMS call was 52.5 (15-180) min and from EMS call to EMS arrival 15 (10-20) min. In ST-segment elevation myocardial infarction (STEMI), the median D2B time was 36.5 (25-63) min, and median TIT was 195 (115-330) min. TIT was significantly prolonged from 151 (90-285) min to 250 (165-372) min in patients transferred from non-PCI centers. The major significant factors associated with time delay were patient-related delay and the mode of hospital arrival, both in STEMI and non-STEMI. Conclusion: The baseline evaluation of the TURKMI study revealed that an important proportion of patients presenting with AMI within 48 hours of symptom onset reach the PCI treatment center later than the time proposed in the guidelines, and the use of EMS for admission to hospital is extremely low in Turkey. Patient-related factors and the mode of hospital admission were the major factors associated with the time delay to treatment.

Kocabaş, Umut; Kıvrak, Tarık; Öztekin, Gülsüm Meral Yılmaz; Tanık, Veysel Ozan; Özdemir, İbrahim; Kaya, Ersin; Yüce, Elif İlkay; Demir, Fulya Avcı; Doğduş, Mustafa; Altınsoy, Meltem

Objective: Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ≤40%). Methods: The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019. Results: The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin–angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter–defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279). Conclusion: The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy.

Erol, Mustafa Kemal; Kayıkçıoğlu, Meral; Kılıçkap, Mustafa; Arın, Can Baba; Kurt, İbrahim Halil; Aktaş, İbrahim; Güneş, Yılmaz; Özkan, Eyüp; Şen, Taner; İnce, Orhan

Objective: The TURKMI registry is designed to provide insight into the characteristics, management from symptom onset to hospital discharge, and outcome of patients with acute myocardial infarction (MI) in Turkey. We report the baseline and clinical characteristics of the TURKMI population. Methods: The TURKMI study is a nation-wide registry that was conducted in 50 centers capable of percutaneous coronary intervention selected from each EuroStat NUTS region in Turkey according to population sampling weight, prioritized by the number of hospitals in each region. All consecutive patients with acute MI admitted to coronary care units within 48 hours of symptom onset were prospectively enrolled during a predefined 2-week period between November 1, 2018 and November 16, 2018. Results: A total of 1930 consecutive patients (mean age, 62.0±13.2 years; 26.1% female) with a diagnosis of acute MI were prospectively enrolled. More than half of the patients were diagnosed with non-ST elevation MI (61.9%), and 38.1% were diagnosed with ST elevation MI. Coronary angiography was performed in 93.7% and, percutaneous coronary intervention was performed in 73.2% of the study population. Fibrinolytic therapy was administered to 13 patients (0.018%). Aspirin was prescribed in 99.3% of the patients, and 94% were on dual antiplatelet therapy at the time of discharge. Beta blockers were prescribed in 85.0%, anti-lipid drugs in 96.3%, angiotensin converting enzyme inhibitors in 58.4%, and angiotensin receptor blockers in 7.9%. Comparison with European countries revealed that TURKMI patients experienced MI at younger ages compared with patients in France, Switzerland, and the United Kingdom. The most prevalent risk factors in the TURKMI population were hypercholesterolemia (60.2%), hypertension (49.5%), smoking (48.8%), and diabetes (37.9%). Conclusion: The nation-wide TURKMI registry revealed that hypercholesterolemia, hypertension, and smoking were the most prevalent risk factors. TURKMI patients were younger compared with patients in European Countries. The TURKMI registry also confirmed that current treatment guidelines are largely adopted into clinical cardiology practice in Turkey in terms of antiplatelet, anti-ischemic, and anti-lipid therapy.

Erol, Mustafa Kemal; Kayıkçıoğlu, Meral; Kılıçkap, Mustafa; Güler, Arda; Yıldırım, Abdullah; Kahraman, Fatih; Can, Veysi; İnci, Sinan; Baysal, Sadettin Selçuk; Er, Okan

Objective: Delayed admission of myocardial infarction (MI) patients is an important prognostic factor. In the present nationwide registry (TURKMI-2), we evaluated the treatment delays and outcomes of patients with acute MI during the Covid-19 pandemic and compaired with a recent pre-pandemic registry (TURKMI-1). Methods: The pandemic and pre-pandemic studies were conducted prospectively as 15-day snapshot registries in the same 48 centers. The inclusion criteria for both registries were aged ≥18 years and a final diagnosis of acute MI (AMI) with positive troponin levels. The only difference between the 2 registries was that the pre-pandemic (TURKMI-1) registry (n=1872) included only patients presenting within the first 48 hours after symptom-onset. TURKMI-2 enrolled all consecutive patients (n=1113) presenting with AMI during the pandemic period. Results: A comparison of the patients with acute MI presenting within the 48-hour of symptom-onset in the pre-pandemic and pandemic registries revealed an overall 47.1% decrease in acute MI admissions during the pandemic. Median time from symptom-onset to hospital-arrival increased from 150 min to 185 min in patients with ST elevation MI (STEMI) and 295 min to 419 min in patients presenting with non-STEMI (NSTEMI) (p-values <0.001). Door-to-balloon time was similar in the two periods (37 vs. 40 min, p=0.448). In the pandemic period, percutaneous coronary intervention (PCI) decreased, especially in the NSTEMI group (60.3% vs. 47.4% in NSTEMI, p<0.001; 94.8% vs. 91.1% in STEMI, p=0.013) but the decrease was not significant in STEMI patients admitted within 12 hours of symptom-onset (94.9% vs. 92.1%; p=0.075). In-hospital major adverse cardiac events (MACE) were significantly increased during the pandemic period [4.8% vs. 8.9%; p<0.001; age- and sex-adjusted Odds ratio (95% CI) 1.96 (1.20-3.22) for NSTEMI, p=0.007; and 2.08 (1.38-3.13) for STEMI, p<0.001]. Conclusion: The present comparison of 2 nationwide registries showed a significant delay in treatment of patients presenting with acute MI during the COVID-19 pandemic. Although PCI was performed in a timely fashion, an increase in treatment delay might be responsible for the increased risk of MACE. Public education and establishing COVID-free hospitals are necessary to overcome patients' fear of using healthcare services and mitigate the potential complications of AMI during the pandemic.

Çelik, Oğuzhan; Çil, Cem; Özlek, Bülent; Özlek, Eda; Doğan, Volkan; Başaran, Özcan; Demirci, Erkan; Bekar, Lütfü; Kalçık, Macit; Karaarslan, Osman

Objective: The aim of this study was to describe the current status of aspirin use and the demographic characteristics of patients on aspirin for primary and secondary prevention of cardiovascular diseases. Methods: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) trial was a multicenter, cross-sectional, and observational study conducted in Turkey. The study was planned to include 5000 patients from 14 cities in Turkey. The data were collected at one visit, and the current clinical practice regarding aspirin use was evaluated (ClinicalTrials.gov number NCT03387384). Results: The study enrolled all consecutive patients who were admitted to the outpatient cardiology clinics from March 2018 until June 2018. Patients should be at least 18 years old, have signed written informed consent, and on aspirin (80–325 mg) therapy within the last 30 days. Cardiologists from the hospital participates in the study. Patients were divided into 2 categories according to presence or absence of atherosclerotic cardiovascular disease, namely secondary prevention group and primary prevention group, respectively. The appropriate use of aspirin in the primary and secondary prevention groups was assessed according to the European Society of Cardiology guidelines and US Preventive Services Task Force. The patients’ gastrointestinal bleeding risk factors and colorectal cancer risk were evaluated. Conclusion: The ASSOS registry will be the most comprehensive and largest study in Turkey evaluating the appropriateness of aspirin use. The results of this study help understand the potential misuse of aspirin in a real-world setting.

Topal, İsmail; Bilgin, Aslı Özbek; Çimen, Ferda Keskin; Kurt, Nezahat; Süleyman, Zeynep; Bilgin, Yasin; Özçiçek, Adalet; Altuner, Durdu

Objective: Cisplatin is an anticancer drug used for treating childhood solid tumors. Symptoms related to cisplatin-induced cardiovascular adverse effects may be mild or severe. Rutin (vitamin P1) has many properties, including as antioxidant, anticancer, antidiabetic, antimicrobial, antiulcer, and tissue renewal properties. Therefore, we aimed to biochemically, histopathologically, and immunohistochemically demonstrate the effect of rutin on cisplatin-induced cardiotoxicity in rats. Methods: The rats included in our study were divided into four groups: Healthy group (HE), 5-mg/kg cisplatin group (CP), 50 mg/kg rutin+5-mg/kg cisplatin (CR-50), 100-mg/kg rutin+5-mg/kg cisplatin (CR-100) group. Results: CP group administered cisplatin had significantly increased blood, serum, and cardiac tissue malondialdehyde (MDA), interleukin 1 beta (IL-1β), tumor necrosis factor alpha (TNF-α), troponin I, creatine kinase (CK), and CK-MB levels compared to the HE group, whereas there was a significant decrease in the total glutathione (tGSH) levels. Rutin was observed to prevent the increase in MDA, IL-1β, TNF-α, troponin I, CK, and CK-MB levels as well as prevent the decrease in tGSH levels more significantly when administered at a 100-mg/kg dose than at a 50-mg/kg dose. Histopathologically, cardiac necrosis, dilated/congested blood vessels, hemorrhage, polymorphonuclear leukocyte, edema, and cells with pyknotic nuclei were observed in the CP group. Rutin was shown to prevent cisplatin-induced cardiac damage more effectively when used at a100-mg/kg dose than at a 50-mg/kg dose. Conclusion: These results suggest that rutin is useful for preventing cisplatin-related cardiovascular damage.

Aşılar, Rabia HacıhasanoğLu; Gözüm, Sebahat; Çapık, Cantürk; Morisky, Donald E.

Objective: The aim of this study is to evaluate the reliability and validity of the Turkish version of the 8-item Morisky medication adherence scale. Methods: The study was conducted as a methodological design. The study included 196 patients with hypertension who applied to the Family Health Centers in three different regions of Turkey. Data were collected from February-June 2012.; Methods used in the analysis included factor analysis, assessment of Cronbach’s α test and item-total correlation in order to perform psychometric measurements. Variables influencing scores of medication adherence were determined using logistic regression analysis.; Results: Factor loadings of all items in the scale were above 0.40, and the variation explained was determined to be 42.4. The Turkish form consisted of a single domain. The Cronbach’s α coefficient of the items in the scale was 0.79. Item-total correlations of items in the scale were between 0. 30 and 0. 62. Scores of medication adherence were observed to be affected by low economic condition and city where said individuals reside.; Conclusion: It was determined that levels of reliability and validity of Turkish version of 8-item Morisky medication adherence scale is acceptable.

Aşılar, Rabia Hacıhasanoğlu; Gozum, Sebahat; Capik, Canturk

Objective: Study purpose was to examine the validity of a 13-item short form of the Medication Adherence Self-Efficacy Scale-Short Form (MASES-SF) in an independent sample of 150 hypertensive Turkish patients. Methods: This is a methodological study and 150 adult patients, who are receiving medication for hypertension in the last one year, were included as the study sample. The sample of the study was chosen with the method of simple random sampling. The study was conducted between October 25, 2010 and December 31, 2010 at Family Health Center (FHC). In this study, exploratory and confirmatory factor analyses were used for psychometric evaluation. Cronbach s alpha coefficient was used to evaluate the reliability of the scale. Results: Confirmatory factor analysis showed that all goodness indexes were at acceptable quality: &amp;#967;2=61.72, df=65, p&gt;0.05, GFI=0.99, CFI=1.00, RMSA=0.00. Reliability coefficient of the Turkish adaptation of MASES-SF was found as 0.94 and item-total correlations ranged between 0.13 - 0.52. Patients with uncontrolled hypertension had lower self-efficacy scores compared to those with normal blood pressure. Conclusion: This result indicated that the preliminary criterion validity is adequate. Psychometric testing demonstrated satisfactory internal consistency and validity of the instrument for patients in the study group. It can be used confidently in determining and testing interventions to improve medication adherence self-efficacy perceptions and behaviors in hypertensive Turkish patients. The MASES-SF is brief, quick to administer, and capture useful data on medication adherence self-efficacy in hypertensive patients. (Anadolu Kardiyol Derg 2012; 12: 241-8)