Turkiye Klinikleri Cardiovascular Sciences

.: ORIGINAL RESEARCH
The Predictors of Diabetes and Pre-Diabetes Incidentally Detected at the Time of Diagnosis of Acute Coronary Syndrome: A Cross-Sectional Study
Akut Koroner Sendrom Tanısı Sırasında Rastlantısal Olarak Saptanan Diyabet ve Prediyabetin Öngörücüleri: Bir Kesitsel Çalışma
Özlem ÖZBEKa , Mehmet Mustafa CANa
aHaseki Training and Research Hospital, Clinic of Cardiology, İstanbul, Türkiye
Turkiye Klinikleri J Cardiovasc Sci. 2023;35(3):96-106
doi: 10.5336/cardiosci.2023-99957
Article Language: EN
Full Text
ABSTRACT
 Objective: There is a strong relationship between diabetes mellitus (DM) and cardiovascular diseases-related mortality and morbidity. Patients with DM are more likely to have more serious cardiovascular diseases and have higher complication rates than nondiabetic individuals. We aimed to investigate the rates of DM and preDM that were detected incidentally at the time of index acute coronary syndrome (ACS) and the factors that could predict incidental DM and pre-DM. Also, to investigate the factors associated with major adverse cardiovascular events (MACE) due to ACS. Material and Methods: This retrospective study included 1,882 patients without known DM or pre-DM diagnoses who were hospitalized and treated for ACS. The patients were divided into the following three classes: non-DM (n=582), pre-DM (n=602), and undiagnosed DM (un-DM, n=698). Results: We found that higher age (p<0.001), female sex (p<0.001), higher body mass index (p<0.001), hyperlipidemia (p<0.001), previous peripheral artery disease (p=0.012), previous cerebrovascular disease (p=0.021), and renal diseases (p=0.017) were independently associated with pre-DM and un-DM. High age (p<0.001), renal diseases (p<0.001), ST-elevation myocardial infarction (p=0.008), un-DM (p<0.001), and pre-DM (p=0.044) were independently associated with an increased MACE risk, while hyperlipidemia (p<0.001) and antiaggregant use (p=0.012) were independently associated with a decreased MACE risk. Conclusion: The above-mentioned risk factors can be used to predict (pre)DM before ACS or to assess MACE risk after ACS. Such risk stratification may contribute to reducing cardiovascular mortality and morbidity that are increased by (pre)DM and MACE.

Keywords: Acute coronary syndrome; diabetes mellitus; major adverse cardiovascular events; pre-diabetes; ST-elevation myocardial infarction
ÖZET
 Amaç: Diabetes mellitus (DM) ile kardiyovasküler hastalıklara bağlı mortalite ve morbidite arasında güçlü bir ilişki vardır. DM'li hastaların diyabetik olmayanlara göre daha ciddi kardiyovasküler hastalıklara yakalanma ve daha yüksek komplikasyon oranlarına sahip olma olasılığı daha yüksektir. Bu çalışmada, indeks akut koroner sendrom (AKS) sırasında rastlantısal olarak saptanan DM ve pre-DM oranlarını ve rastlantısal DM ve pre-DM'yi öngörebilecek faktörleri araştırmayı amaçladık. Ayrıca AKS'ye bağlı majör advers kardiyovasküler olaylar [major adverse cardiovascular events (MACE)] ile ilişkili faktörleri araştırdık. Gereç ve Yöntemler: Bu retrospektif çalışmaya, bilinen DM veya pre-DM tanıları olmayan ve AKS nedeniyle hastaneye yatırılarak tedavi edilen 1.882 hasta dâhil edildi. Hastalar şu 3 gruba ayrıldı: DM olmayan (n=582), pre-DM (n=602) ve tanı konmamış DM [undiagnosed DM (un-DM)] (n=698). Bulgular: İleri yaş (p<0,001), kadın cinsiyet (p<0,001), beden kitle indeksi artışı (p<0,001), hiperlipidemi (p<0,001), geçirilmiş periferik arter hastalığı (p=0,012), geçirilmiş serebrovasküler hastalık (p=0,021), böbrek hastalıklarının (p=0,017) preDM ve un-DM ile bağımsız olarak ilişkili olduğu bulunmuştur. İleri yaş (p<0,001), böbrek hastalıkları (p<0,001), ST elevasyonlu miyokard infarktüsü (p=0,008), un-DM (p<0,001) ve pre-DM (p=0,044) bağımsız olarak artmış MACE riski ile ilişkiliyken, hiperlipidemi (p<0,001) ve antiagregan kullanımı (p=0,012) bağımsız olarak azalmış MACE riski ile ilişkiliydi. Sonuç: Yukarıda belirtilen risk faktörleri AKS öncesinde (pre)DM ve AKS sonrasında MACE'yi öngörmek için kullanılabilir. Bu risk faktörleri kullanılarak yapılacak risk tabakalandırması, (pre)DM ve MACE ile artan kardiyovasküler mortalite ve morbiditenin azaltılmasına katkıda bulunabilir.

Anahtar Kelimeler: Akut koroner sendrom; diabetes mellitus; majör advers kardiyovasküler olay; prediyabet; ST elevasyonlu miyokard infarktüsü
REFERENCES:
  1. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1736-88. Erratum in: Lancet. 2019;393(10190):e44. Erratum in: Lancet. 2018;392(10160):2170. [PubMed]  [PMC] 
  2. Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano RP. Acute coronary syndromes. Lancet. 2022;399(10332):1347-58. [Crossref]  [PubMed]  [PMC] 
  3. Grech ED, Ramsdale DR. Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction. BMJ. 2003;326(7401):1259-61. [Crossref]  [PubMed]  [PMC] 
  4. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021;143(8):e254-e743. [Crossref]  [PubMed] 
  5. Dagenais GR, Leong DP, Rangarajan S, Lanas F, Lopez-Jaramillo P, Gupta R, et al. Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study. Lancet. 2020;395(10226):785-94. Erratum in: Lancet. 2020;395(10226):784. [Crossref]  [PubMed] 
  6. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1223-49. [PubMed]  [PMC] 
  7. Katz P, Leiter LA, Mellbin L, Rydén L. The clinical burden of type 2 diabetes in patients with acute coronary syndromes: prognosis and implications for short- and long-term management. Diab Vasc Dis Res. 2014;11(6):395-409. [Crossref]  [PubMed] 
  8. Grant PJ, Cosentino F. The 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: New features and the 'Ten Commandments' of the 2019 Guidelines are discussed by Professor Peter J. Grant and Professor Francesco Cosentino, the Task Force chairmen. Eur Heart J. 2019;40(39):3215-7. [Crossref]  [PubMed] 
  9. IDF Atlas I. International Diabetes Federation. IDF diabetes atlas. 6th ed. Belgium: International Diabetes Federation; 2013. [Link] 
  10. Patsouras A, Farmaki P, Garmpi A, Damaskos C, Garmpis N, Mantas D, et al. Screening and risk assessment of coronary artery disease in patients with type 2 diabetes: an updated review. In Vivo. 2019;33(4):1039-49. [Crossref]  [PubMed]  [PMC] 
  11. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al; ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111-88. Erratum in: Eur Heart J. 2020;41(44):4255. [Crossref]  [PubMed] 
  12. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604-12. Erratum in: Ann Intern Med. 2011;155(6):408. [Crossref]  [PubMed]  [PMC] 
  13. Morbitzer KA, Jordan JD, Dehne KA, Durr EA, Olm-Shipman CM, Rhoney DH. Enhanced renal clearance in patients with hemorrhagic stroke. Crit Care Med. 2019;47(6):800-8. [Crossref]  [PubMed] 
  14. Arslan F, Damman P, Zwart B, Appelman Y, Voskuil M, de Vos A, et al. 2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation : Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups. Neth Heart J. 2021;29(11):557-65. [Crossref]  [PubMed]  [PMC] 
  15. Damman P, van 't Hof AW, Ten Berg JM, Jukema JW, Appelman Y, Liem AH, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: comments from the Dutch ACS working group. Neth Heart J. 2017;25(3):181-5. [Crossref]  [PubMed]  [PMC] 
  16. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-77. [PubMed] 
  17. O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. [PubMed] 
  18. Yilmaz S, Adali MK, Kilic O, Til A, Yaylali YT. Effect of invasive strategy on long-term mortality in elderly patients presenting with acute coronary syndrome. Cardiovasc J Afr. 2020;31(5):252-6. [Crossref]  [PubMed]  [PMC] 
  19. Açar B, Ozeke O, Karakurt M, Ozen Y, Özbay MB, Unal S, et al. Association of Prediabetes with higher coronary atherosclerotic burden among patients with first diagnosed acute coronary syndrome. Angiology. 2019;70(2):174-80. [Crossref]  [PubMed] 
  20. World Health Organization. WHO Guidelines Approved by the Guidelines Review Committee. Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus: Abbreviated Report of a WHO Consultation. Geneva: World Health Organization; 2011. [Link] 
  21. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S13-s28. [Crossref]  [PubMed] 
  22. Aboyans V. Introducing the 2019 ESC Guidelines on Diabetes, Pre-Diabetes, and CVD. Eur Heart J. 2019;40(39):3217-19. [Crossref]  [PubMed] 
  23. Albers AR, Krichavsky MZ, Balady GJ. Stress testing in patients with diabetes mellitus: diagnostic and prognostic value. Circulation. 2006;113(4):583-92. [Crossref]  [PubMed] 
  24. Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339(4):229-34. [Crossref]  [PubMed] 
  25. Farhan S, Redfors B, Maehara A, McAndrew T, Ben-Yehuda O, De Bruyne B, et al. Impact of pre-diabetes on coronary plaque composition and clinical outcome in patients with acute coronary syndromes: an analysis from the PROSPECT study. JACC Cardiovasc Imaging. 2019;12(4):733-41. [Crossref]  [PubMed] 
  26. He C, Lin P, Liu W, Fang K. Prognostic value of hyperuricemia in patients with acute coronary syndrome: A meta-analysis. Eur J Clin Invest. 2019;49(4):e13074. [Crossref]  [PubMed] 
  27. Huang Z, Chan TM, Dong W. MACE prediction of acute coronary syndrome via boosted resampling classification using electronic medical records. J Biomed Inform. 2017;66:161-70. [Crossref]  [PubMed] 
  28. Uskela S, Kärkkäinen JM, Eränen J, Siljander A, Mäntylä P, Mustonen J, et al. Percutaneous coronary intervention with drug-coated balloon-only strategy in stable coronary artery disease and in acute coronary syndromes: An all-comers registry study. Catheter Cardiovasc Interv. 2019;93(5):893-900. [Crossref]  [PubMed] 
  29. Bush N, Sharma YP, Prasad K, Kumar P, Mehrotra S. Comparison of demographic profile, risk factors, and in-hospital outcome in young and old patients with acute coronary syndrome: A single-center experience. J Family Med Prim Care. 2021;10(2):871-6. [Crossref]  [PubMed]  [PMC] 
  30. Wang L, Cong HL, Zhang JX, Hu YC, Wei A, Zhang YY, et al. Triglyceride-glucose index predicts adverse cardiovascular events in patients with diabetes and acute coronary syndrome. Cardiovasc Diabetol. 2020;19(1):80. [Crossref]  [PubMed]  [PMC] 
  31. Puricel S, Lehner C, Oberhänsli M, Rutz T, Togni M, Stadelmann M, et al. Acute coronary syndrome in patients younger than 30 years--aetiologies, baseline characteristics and long-term clinical outcome. Swiss Med Wkly. 2013;143:w13816. [Crossref]  [PubMed] 
  32. Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, et al; ESC Scientific Document Group. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020;41(2):255-23. Erratum in: Eur Heart J. 2020;41(45):4317. [Crossref]  [PubMed] 

.: Up To Date

.: Process List

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com