Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Temperamental and Personality Traits as Factors Related to Changes in Health Behaviors and Quality of Life in Patients With Metabolic Syndrome in Poland

Lifestyle changes in diet and physical activity are necessary for managing metabolic syndrome. The aim of this longitudinal study was to examine temperamental and personality traits as moderators of lifestyle changes prompted by motivational intervention. The sample consisted of 50 patients aged 22–65years (M=45.26; SD=9.79) who fulfilled the diagnostic criteria for metabolic syndrome and were undergoing treatment at the Military Institute of Medicine in Warsaw. There were two measurements: an initial measurement and a second 15months after motivational counseling. Each patient completed the questionnaires: Formal Characteristics of Behavior – Temperament Inventory, NEO Five Factor Inventory, Inventory of Health Behavior, and Short Form Survey SF-36. Body Mass Index (BMI), Fat Mass, Fat-free Mass, Intracellular Water, and Basal Metabolic Rate (BMR) were also measured. Data were analyzed using dependent samples t-tests to detect the changes in consecutive measurements, the hierarchical regression analysis was used to investigate temperamental and personality traits as predictors of change, the cluster analysis was used to extract the subgroups of patients with distinct profiles of temperamental and personality traits, and the analysis of variance was used to analyze extracted profiles as potential moderators of change. Three subgroups were extracted using k-means clustering: patients with higher Neuroticism, Perseveration, and Emotional Reactivity; patients higher Extraversion, Briskness, Sensory Sensitivity, Endurance, Activity, and Conscientiousness; and patients with lower Perseveration. All patients improved significantly in terms of physical quality of life (QoL), health behaviors, BMI, BMR, and Fat-free Mass (p<0.05). Regression analysis found that higher Sensory Sensitivity, lower Perseveration, and higher Agreeableness fostered positive change (p<0.05). Patients with higher Neuroticism, Perseveration, and Emotional Reactivity also improved in terms of their Emotional Quality of Life and Health Practices, reaching parity with other patients, which was verified on the basis of statistically significant interaction (p<0.05). The temperamental and personality trait profiles moderated the changes in health practices and emotional QoL. Motivational counseling was effective for patients diagnosed with metabolic syndrome in general, but patients with higher Neuroticism, Perseveration, and Emotional Reactivity benefited even more, as they were in poorer psychological condition before the motivational intervention.

Crosstalk Between Dietary Pattern, Anthropometric Parameters, and Adiponectin Concentration Among Patients with Metabolic Syndrome

Background: Adiponectin is known to mediate antidiabetic and cardioprotective metabolic effects. Current evidence suggests that diet, both its quantity and quality, affects adiponectin concentration. Methods: The purpose of this study was to evaluate the association of adiponectin with cardiometabolic risk factors, anthropometric features, and diet characteristics in obese patients with multiple cardiometabolic risk factors. The group of 113 nondiabetic patients (90 males, mean age: 48 ± 9 years) fulfilling the criteria of metabolic syndrome (IDF, 2005) was divided into 2 subgroups according to median adiponectin concentration calculated for that cohort (6.83 μg/mL)-low-adiponectin (LA) and high-adiponectin (HA) subgroup. Biochemical and anthropometric measurements were recorded and nutrients intake was assessed using 24-hr dietary recall method and diet history questionnaire. Results: No significant differences between LA and HA were noted regarding the anthropometric parameters. However, there were significant differences in biochemical indices, and HA was characterized by a more favorable insulin level, homeostasis model assessment of insulin resistance (HOMA-IR) value, and plasma lipid profile than LA. Both LA and HA subgroups were comparable in terms of energy, protein, carbohydrate, and total fat intake, but there were significant differences between the level of polyunsaturated fatty acids (PUFA) consumption (6.06 ± 1.0 and 6.37 ± 1.1, respectively) and omega-3/omega-6 ratio (as follows: 0.09 ± 0.01 and 0.16 ± 0.04). Conclusions: These results highlight interactions between diet, adiponectin concentration, and biochemical profile. Nondiabetic patients with metabolic syndrome with higher PUFA consumption, including higher omega-3/omega-6 ratio, were characterized by higher circulating adiponectin level and more favorable biochemical profile. Thus, it might be assumed that the protective role of omega-3 fatty acids might be mediated by adiponectin in patients with metabolic syndrome.

Serum microRNA in patients undergoing atrial fibrillation ablation

MicroRNAs mediate posttranscriptional gene regulation. The aim of the study was to find a microRNA predictor of successful atrial fibrillation (AF) ablation. A total of 109 patients undergoing first-time AF ablation were included. Nineteen patients were selected to undergo serum microRNA sequencing (study group). The sequencing data were used to select several microRNAs that correlated with 12-month recurrences after AF ablation. Those microRNAs were validated by digital droplet PCR in samples from remaining 90 patients. All patients underwent pulmonary vein isolation (RF ablation, contact force catheter, electroanatomical system). The endpoint of the study was the 12-month AF recurrence rate; the overall recurrence rate was 42.5%. In total, levels of 34 miRNAs were significantly different in sera from patients with AF recurrence compared to patients without AF recurrence. Six microRNAs (miR-183-5p, miR-182-5p, miR-32-5p, miR-107, miR-574-3p, and miR-144-3p) were validated in the whole group. Data from the validation group did not confirm the observations from the study group, as no significant differences were found between miRNAs serum levels in patients with and without recurrences 12 months after AF ablation.

Freedom from pulmonary vein stenosis after multiple applications of epicardial ablation energy

OBJECTIVES

In patients undergoing cardiac surgical procedures, pulmonary vein isolation may be easily accomplished, and it is important to achieve bidirectional conduction block across created lesions. The primary aim of this study was to assess the risk of pulmonary vein stenosis (PVS) after multiple applications of epicardial bipolar radiofrequency energy.

METHODS

Thirty-five consecutive patients who were referred for off-pump coronary revascularization with concomitant pulmonary vein isolation and left atrial appendage occlusion were prospectively included in the study. The ablation protocol provided 8 standard epicardial applications of bipolar energy with additional applications until the acute bidirectional conduction block was achieved. Three to 6 months after surgery, patients underwent computed tomography to assess PVS.

RESULTS

In all patients, bidirectional conduction block was achieved across the created lesions. In 31 (89%) patients, conduction block was accomplished after the standard 8 energy applications on each side. In 4 (11%) patients, additional applications of energy were needed. All patients had computed tomography (128 total pulmonary veins) scans, which showed no evidence of PVS.

CONCLUSIONS

Multiple applications of bipolar radiofrequency energy during off-pump epicardial pulmonary vein isolation did not lead to PVS. Creating bidirectional conduction block using multiple energy applications through created lesions is feasible in all patients using the ablation protocol described.

Intraoperative epicardial focal pulmonary venous electrocardiography in patients with atrial fibrillation

OBJECTIVES

In patients referred to off-pump coronary artery bypass grafting, pulmonary vein isolation (PVI) may be used for those with persistent atrial fibrillation (AF), an alternative to the Maze procedure. However, the success rate of PVI in persistent AF is limited. The study assesses the prognostic value of focal epicardial electrocardiography of the pulmonary veins (PVs) for surgical ablation results.

METHODS

We mapped 140 PV in 35 cases undergoing off-pump coronary artery bypass grafting. Data obtained using a sensing-pacing probe before ablation were analysed. The composite study end-point consisted of the need for electrical cardioversion for in-hospital recurrence of AF and the presence of AF at hospital discharge and after 6 months follow-up confirmed by 24-h Holter electrocardiographic monitoring.

RESULTS

In patients with epicardial far-field (FF) signals recorded over at least 1 PV, the composite end-point occurred in 61% (14) vs 25% (3) of patients with no FF signal recorded over any PV (P = 0.04). The presence of FF signals in at least 1 PV significantly increased the risk of composite end-point occurrence (odds ratio 3; P = 0.04). The composite end-point occurred in 86% (6) of patients with FF signals recorded over all PVs and in 39% (11) in the remainder of the study population (P = 0.03).

CONCLUSIONS

Intraoperative epicardial focal electrocardiography of PVs revealed more than 40% of PVs had only FF atrial signals. The presence of FF signals in PVs is related to a lower early effectiveness of PVI on ablating AF. Epicardial focal electrocardiography of PVs may be a clinically effective intraoperative tool in the decision-making process between less invasive PVI and the standard Maze procedure.

Right atrium positioning for exposure of right pulmonary veins during off-pump atrial fibrillation ablation

OBJECTIVES

Concomitant surgical ablation of atrial fibrillation (AF) is recommended for patients undergoing off-pump coronary revascularization in the presence of this arrhythmia. Achievement of optimal visualization of pulmonary veins while maintaining stable haemodynamic conditions is crucial for proper completion of the ablation procedure. This study evaluates the safety and feasibility of right atrial positioning using a suction-based cardiac positioner as opposed to compressive manoeuvres for exposure during off-pump surgical ablation for AF.

METHODS

Thirty-four consecutive patients underwent pulmonary vein isolation, ganglionated plexi ablation and left atrial appendage occlusion during off-pump coronary artery bypass grafting. Right atrial suction positioning was used to visualize right pulmonary veins. Safety and feasibility end points were analysed intraoperatively and in the early postoperative course.

RESULTS

In all patients, right atrial positioning created optimal conditions to complete transverse and oblique sinus blunt dissection, correct placement of a bipolar ablation probe, detection and ablation of ganglionated plexi and conduction block assessment. In all patients, this entire right-sided ablation procedure was completed with a single exposure manoeuvre. Feasibility end points were achieved in all study patients.

CONCLUSIONS

This report documents the safety and feasibility of right atrial exposure using a suction-based cardiac positioner to complete ablation for AF concomitant with off-pump coronary revascularization. This technique may be widely adopted to create stable haemodynamic conditions and optimal visualization of the right pulmonary veins.

Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation

INTRODUCTION:

Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence.

METHODS:

The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads.

RESULTS:

Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003).

CONCLUSION:

Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Echocardiographic assessment and N-terminal pro-brain natriuretic peptide in hypertensives with metabolic syndrome

BACKGROUND

N-terminal pro-brain natriuretic peptide (NT-proBNP) release is associated with left ventricular expansion and pressure overload. Elevation of serum levels of natriuretic peptides is observed in patients with impaired as well as preserved left ventricular systolic function. High NT-proBNP has been shown to be related not only to preload but also to increased afterload, especially blood pressure and arterial stiffness.

OBJECTIVES

The aim of the study was to evaluate the association of NT-proBNP and echocardiographic parameters in hypertensives with metabolic syndrome.

MATERIAL AND METHODS

The study group comprised 133 patients (99 men; mean age 45.9 ± 9.4 years) with at least a 3-month history of arterial hypertension (stages 1 and 2) and fulfilling the diagnostic criteria for metabolic syndrome. Following initial clinical assessment, which included NT-proBNP levels, they underwent two-dimensional echocardiography.

RESULTS

Echocardiographic abnormalities were observed in 60 subjects (45.1%), including left ventricular diastolic dysfunction (LVDdf) in 41 (30.8%) and left ventricular hypertrophy (LVH) in 35 (26.3%). Higher NT-proBNP concentrations were observed in patients with LVH, especially in the presence of LVDdf. Further analysis demonstrated that NT-proBNP correlated negatively with septal E' (r = -0.38; p = 0.015) and heart rate (r = -0.42; p = 0.006) in patients with LVDdf, and positively with left ventricular end diastolic diameter (r = 0.46; p = 0.006) and left ventricular mass index (r = 0.49; p = 0.005) in subjects with LVH. However, the analysis of ROC curves revealed no NT-proBNP level of good sensitivity and specificity in diagnosing LVDdf/LVH (maximal area under the curve 0.571).

CONCLUSIONS

Even a relatively low NT-proBNP concentration can be a useful marker of left ventricular hypertrophy and end-diastolic wall stretch. However, in the present study there was no NT-proBNP level of satisfactory predictive value to diagnose LV abnormalities.

Cushing's Disease: Subclinical Left Ventricular Systolic and Diastolic Dysfunction Revealed by Speckle Tracking Echocardiography and Tissue Doppler Imaging

OBJECTIVE

Novel echocardiographic techniques, such as speckle tracking echocardiography (STE) and tissue Doppler imaging, are sensitive tools for assessing left ventricular (LV) performance. LV global longitudinal strain (GLS), assessed by STE, is a sensitive marker of myocardial systolic function. Cardiovascular complications in patients with Cushing's disease (CD) determine a higher mortality than that in an age- and gender-matched population. Cardiac systolic dysfunction may be detected in early stages by STE. Thus, the aim of this study was to investigate the usefulness of STE in detecting subclinical LV dysfunction in three groups of patients: CD group, arterial hypertension group (AHG), and healthy volunteers (HV).

METHODS

Echocardiographic assessments of LV systolic and diastolic function were performed in 171 subjects (CD: 22, AHG: 114, HV: 35) with no symptoms of heart failure. A statistical comparison included separate analyses for men and women.

RESULTS

CD patients showed good blood pressure (BP) control (below 140/90 mmHg in 82% of cases). However, in comparison AHG and HV groups they exhibited: (1) significantly lower LV contractility expressed by GLS (CD group: -17.7%, AHG group: -19.2%, HV: -20.0%; p = 0.004) and (2) higher prevalence of LV diastolic dysfunction (45.0, 14.2, 0.0%, respectively; p < 0.00001). Men with CD showed significantly more pronounced LV diastolic dysfunction. Cortisol excess in women was related to impaired LV systolic function.

CONCLUSION

CD, even with well-controlled BP, is associated with LV dysfunction which depends individually on sex. These hemodynamic alterations can be detected by modern non-invasive diagnostic tools and may become potential therapeutic objectives.

Association of Central Sleep Apnea with Impaired Heart Structure and Cardiovascular Hemodynamics in Patients with Chronic Heart Failure

Background

Advanced heart failure (HF) is commonly accompanied by central sleep apnea (CSA) with Cheyne-Stokes respiration (CSR). The aim of this study was to evaluate the relationship between CSA/CSR and other clinical features of HF, with particular emphasis on cardiovascular hemodynamics.

Material/Methods

In 161 stable HF patients with left ventricular ejection fraction (LVEF) ≤45% (NYHA class I–III; mean LVEF 32.8%) the clinical evaluation included: LVEF; left and right ventricular end-diastolic diameter (LVDd, RVDd); ratio of early transmitral flow velocity to early diastolic septal mitral annulus velocity (E/e’) assessed by echocardiography; stroke index (SI); heart rate (HR); cardiac index (CI); and systemic vascular resistance index (SVRI) assessed by impedance cardiography (ICG). The comparison was performed between 2 subgroups: one with moderate/severe CSA/CSR - CSR_ [+] (n=51), and one with mild or no CSA/CSR – CSR_ [−] (n=110).

Results

CSR_ [+] patients presented more advanced NYHA class (p<0.001) and more frequently had permanent atrial fibrillation (p=0.018). Moreover, they had: lower LVEF (p<0.0001); higher LVDd (p<0.0001), RVDd (p<0.001), and E/e’ (p<0.001); lower SI (p<0.001) and CI (p=0.009); and higher HR (p=0.044) and SVRI (p=0.016). The following predictors of CSR_ [+] were identified: NYHA class (OR=3.34 per class, p<0.001, which was the only independent predictor); atrial fibrillation (OR=2.29, p=0.019); RV enlargement (OR=2.75, p=0.005); LVEF<35% (OR=3.38, p=0.001); E/e’ (OR=3.15; p=0.003); and SI<35 ml/m² (OR=2.96, p=0.003).

Conclusions

Presence of CSA/CSR in HF is associated with NYHA class, atrial fibrillation and more advanced impairment of cardiovascular structure and hemodynamics. Patient functional state remains the main determinant of CSR.

The effect of hemodynamically-guided hypotensive therapy in one-year observation: Randomized, prospective and controlled trial (FINEPATH study)

BACKGROUND

The use of impedance cardiography (ICG) revealed to provide beneficial blood pressure (BP) lowering effect. However, the follow-up in previous trials was short and brachial BP was the only evaluated hemodynamic variable. Thus, we aimed to estimate the influence of ICG-guided therapy on brachial and central BP, impedance-derived hemodynamic profile and echocardiographic features after 12 months in a randomized, prospective and controlled trial (NCT01996085).

METHODS

One hundred and forty-four hypertensives were randomly assigned to groups of empiric (GE) and ICG-guided therapy (HD). Office BP, ambulatory BP monitoring, central BP and echocardiography (left ventricular hypertrophy and diastolic function assessment) were performed before and after 12 months of treatment.

RESULTS

Blood pressure reduction was higher in HD (office BP: 21.8/14.1 vs. 19.9/11.8 mm Hg; mean 24-h BP: 19.0/10.9 vs. 14.4/9.2 mm Hg). However, the only statistically significant differences were: percentage of patients achieving BP reduction of minimum 20 mm Hg for of-fice diastolic BP (27.3% vs. 12.1%; p = 0.034) and mean 24-h systolic BP (49.1% vs. 27.3%; p = 0.013). More pronounced improvement in the left ventricular diastolic dysfunction (delta E/A 0.34 vs. 0.12, p = 0.017) was the only other beneficial hemodynamic effect.

CONCLUSIONS

Beneficial BP lowering effect of hemodynamically-guided pharmacotherapy, observed previously in short-term observation, persists over time. Hemodynamic effects of such a treatment approach, especially those of prognostic value (central BP, myocardial hypertrophy), should be evaluated in further studies including patients with resistant hypertension, heart failure, diabetes mellitus and chronic kidney disease.

Who benefits more from hemodynamically guided hypotensive therapy? The experience from two randomized, prospective and controlled trials

OBJECTIVES

Arterial hypertension (AH) may be related to fluid retention, increased vascular resistance or hyperdynamic heart function. Impedance cardiography (ICG) is shown to be useful in the individualization of antihypertensive therapy but little is known about who most benefits from this therapeutic approach. The aim of this analysis was to estimate the effectiveness of ICG-guided antihypertensive therapy with respect to baseline blood pressure (BP) from the perspective of 12 weeks' observation in randomized, prospective and controlled trials.

METHODS

This analysis involved 272 patients (average age: 44.1 ± 10.8 years) with AH. After baseline evaluation, including: office BP measurement (systolic, SBP; diastolic, DBP; mean, MBP) and ambulatory BP monitoring (mean 24-h SBP, mean 24-h DBP) the subjects were randomly assigned to groups of empiric [GE] and ICG-guided antihypertensive therapy [HD]. The results were evaluated separately in subgroups derived from median of MBP (110 mmHg): with slightly increased ('SI_BP') and more increased BP ('MI_BP'). The comparative analysis included absolute change in BP (d_OSBP, d_ODBP, d_24-h SBP, d_24-h DBP) and the percentage of patients with reduction of BP ⩾ 10 mmHg (d10_OSBP, d10_ODBP, d10_24-h SBP, d10_24-h DBP).

RESULTS

ICG-guided therapy was shown to be superior to the empiric approach, especially in MI_BP. In this subgroup, the BP reduction in HD was higher than in GE: d_OSBP (23.3 ± 10.8 versus 18.5 ± 13.9 mmHg; p = 0.035), d_ODBP (16.0 ± 6.3 versus 11.6 ± 9.6 mmHg; p = 0.003), d_24-h SBP (17.7 ± 10.8 versus 13.1 ± 13.1 mmHg; p = 0.035). This benefit was also confirmed by a higher percentage of patients with significant BP reduction: d10_OSBP (87.7% versus 69.1%; p = 0.012), d10_ODBP (69.2% versus 47.3%; p = 0.012) and d10_24-h SBP (72.3% versus 52.7%; p = 0.012). The comparison in the SI_BP subgroup did not reveal such significant differences.

CONCLUSIONS

The hemodynamically guided pharmacotherapy results in greater BP reduction. This effect is more pronounced in patients with higher baseline BP, while in those with slightly increased BP the empiric approach seems comparable to ICG.

What does impedance cardiography add more to the assessment of left ventricular diastolic function in essential hypertension?

Left ventricular diastolic dysfunction (LVDdf) and arterial stiffness are associated with increased mortality in patients with arterial hypertension.

THE AIM

of the study was to evaluate the relation between left ventricular diastolic function and hemodynamic profile assessed by impedance cardiography (ICG).

MATERIAL AND METHODS

In 209 hypertensives clinical evaluation, echocardiography and ICG were performed to evaluate i.e. septal annulus early diastolic velocity (e'), mitral flow ratio (E/A), stroke index (SI), acceleration index (ACI), velocity index (VI), Heather index (HI), total arterial compliance.

RESULTS

Left ventricular diastolic dysfunction was associated with lower SI (p=0.049), VI (p=0.002), ACI (p=0.014), HI (p=0.002) and higher SVRI (p=0.004). There were no significant differences in age, blood pressure, BMI, sex distribution. Males with LVDdf characterized with lower SI (p=0.011), VI (p<0.00001), ACI (p=0.0005), HI (p=0.00005) and higher SVRI (p=0.008). No such relevant differences were observed in women. In the analysis of the relations between clinical/hemodynamic features and echocardiographic indices of left ventricular diastolic function the significant correlations were observed in males, the most relevant for: age vs E/A (-0.45; p<0.001), VI vs e' (0.30; p<0.001), VI vs E/A (0.30; p<0.001), and SVRI vs e' (-0.28; p<0.001).

CONCLUSIONS

Impedance cardiography revealed to be useful in the evaluation of impaired left ventricular performance and increased arterial stiffness related to LVDdf in young and middle-aged hypertensives. Sex may influence cardiovascular hemodynamics resulting in slightly different ventricular-vascular interactions that should be considered in therapeutic strategies.

Association of N-terminal pro-brain natriuretic peptide and hemodynamic parameters measured by impedance cardiography in patients with essential hypertension

The aim of this study was to evaluate the association of NT-proBNP with clinical and hemodynamic assessment in 156 patients with arterial hypertension. NT-proBNP correlated positively with, i.e. age (r=0.310, p=0.00008), mean blood pressure (MBP; r=0.199, p=0.0136), Heather index (HI; r=0.375, p<0.00001) and negatively with thoracic fluid content (TFC; r=-0.300, p=0.0002). The patients with higher NT-proBNP were older (46.1 versus 40.6 years, p=0.001), with higher MBP (102.6 versus 98.5 mm Hg, p=0.0043), HI (14.54 versus 11.93 Ohm s2, p=0.009) and lower TFC (27.5 versus 29.4 1/kOhm, p=0.0032). The independent predictors of higher NT-proBNP were: age, MBP and HI.

ST-segment elevation in the recovery phase of nuclear exercise stress test with ⁹⁹mTc-sestamibi in a patient with critical RCA stenosis and subtle systolic dysfunction in speckle tracking imaging

An asymptomatic Caucasian male patient underwent coronary artery disease diagnostics. Standard exercise treadmill test was inconclusive, and Holter ECG study didn't show any significant abnormalities. Considering the high risk of ischemic heart disease nuclear exercise stress test was performed,which revealed ST-segment elevation in the recovery phase of the treadmill exercise test. Single photon emission computed tomography (SPECT/CT) showed myocardial perfusion abnormalities in the inferior and lateral walls of the left ventricle. Furthermore,speckle tracking imaging showed subtle left ventricle dysfunction. Finally critical stenosis in the second segment of right coronary artery was diagnosed in coronary angiography.

[The influence of weather conditions on the occurrence of paroxysmal atrial fibrillation]

The effect of the changing weather conditions on the incidence of the paroxysmal atrial fibrillation (PAF) has not been documented before.

MATERIAL AND METHODS

This analysis retrospectively assessed the influence of the weather conditions on 1153 PAF cases over the period of 10 years. The average age of the studied population was 64.9 +/- 9.2 years. There was 60% males in the group. The majority (84%) had an existing heart disease, the remaining part was diagnosed as the lone PAF.

RESULTS

The following factors favoured the FAP occurrence: high air temperature (> 25 Centigrade) for more than 3 days, low temperature (< 8 Centigrade), water vapor pressure > 16.5 kPa, accelerated increase of the air pressure > 8hPa over 2 days.

CONCLUSIONS

The following weather conditions such as: temperature, air humidity and pressure have a definite impact on the occurrence of the paroxysmal atrial fibrillation episodes in 87% of patients especially those with co-existing coronary heart disease, hypertension or older age.

[Clinical and angiographic correlates of coronary calcium scoring in multislice computed tomography (MSCT)]

BACKGROUND

The MSCT calcium scoring allows to identify patients with increased coronary event risk or at early stages of coronary artery disease (CAD).

AIM

The aim of the study was to find the correlation of calcium score with various clinical features and degree of coronary stenosis.

METHODS

40 consecutive patients (10 women) with angiographically proven coronary artery disease were assessed for coronary calcium score by means of MSCT not later than 48 hours after the angiography. The acquisition parameters were as follows: 3.2 mm slice thickness, 1.6 mm increment, pitch 1.25, 120 kV, 200 mAs, rotation time of 500 ms, supine patients during single breath-hold. The calcium score was semiautomatically calculated taking into account the size and density higher than 130 Hounsfield units. The clinical features such as the presence of hypertension, diabetes, dyslipidaemia, obesity (body mass index), smoking, CCS angina score, previous myocardial infarction, CAD duration, degree of stenosis and diffused disease were also analysed by means of Spearman's test.

RESULTS

The calcium score in the left anterior descending artery (LAD) 271 + 598 showed good correlation with the degree of stenosis in the LAD 69 +/- 37 (r = 0.591, p<0.0001) and angina score (median 2, p<0.001). It was also correlated as well as calcium score in the LMA 55 +/- 147 with the CAD duration of 9 +/- 9 years and diabetes (p<0.01). The CS in the RCA 102 +/- 362 was associated with the diabetes, dyslipidaemia and obesity with the p<0.03. The score in the LCX 282 +/- 797 was correlated with the degree of stenosis in every artery (p<0.001 for the LCX = 56 +/- 39). The total calcium score 675 +/- 1462 was associated with the angina score, CAD duration (p<0.001), diffused disease and the stenosis in the LAD and LCX (p<0.0001).

CONCLUSION

The total and the LAD coronary calcium score may be associated with the severity of symptoms, degree of stenosis in the LAD and disease extent. The calcium deposits in the RCA may be more frequent in patients with metabolic disorders.

[Genes and cardiovascular diseases]

In recent years there has been observed a relatively fast progress of explaining genetic mechanisms of development of many cardiovascular system diseases, mainly diseases conditioned by the mutation of single genes. The situation is different when analyzing the dependencies of complex cardiovascular system diseases whose development has many stages depending on exogenous or hereditary factors. The development of those diseases is due to interactions between particular environmental factors, individual differences in response to environmental factors and often complex genetic relations. The complexity of etiopathogenesis and clinical differentiation are the result of superposition of the effects of the action of single genes responsible for the development, predisposing and/or modulating the course. The analysis of genetic causes of cardiovascular system diseases is made on the basis of models and multigene polymorphisms.

[Left ventricular function in rheumatoid arthritis patients]

BACKGROUND

The disproportion between the absence of clinical manifestations of circulatory system involvement and serious lesions in the heart found on post mortem examinations, more frequently diagnosed congestive circulatory failure and also higher mortality rate of patients with rheumatoid arthritis (RA), encouraged the authors to study the subject. THE AIM OF THE STUDY WAS: Echocardiographic assessment of the effect of rheumatoid process on left ventricular structure, and systolic and diastolic function in patients with RA without clinically overt features of heart disease.

METHODS

The study was conducted in 50 patients with RA diagnosed on the basis of the ACR criteria and in 50 persons matched with the patients with respect to age, gender, body area and body mass index, heart rate and arterial pressure. Persons with manifestations and/or history of cardiovascular diseases were excluded from the study.

RESULTS

The authors found that: in RA, the involvement of the myocardium by the pathological process was manifested as increased wall thickness, increased mass and mass index of the left ventricle with impairment of its diastolic function and normal systolic function. With progressing rheumatoid process, left ventricular systolic function impairment was observed. Left ventricular diastolic dysfunction in the course of rheumatoid arthritis usually was not manifested clinically.

Autonomic nervous system and left ventricular hypertrophy in essential hypertension

BACKGROUND

Patients with essential hypertension (EH) and left ventricular hypertrophy (LVH) have an increased risk of cardio-vascular complications. Alterations in the autonomic nervous system (ANS) activity may play a role in the development of serious cardiac arrhythmias and mortality in these patients.

AIM

To examine the activity of ANS in patients with established EH in relation to the presence of LVH.

METHODS

The study group consisted of 70 subjects: 50 patients with untreated EH (mean age 44.4+/-12.7 years, 28 patients without LVH and 22 with LVH), and 20 age-matched healthy volunteers. ANS reactivity was assessed using heart rate variability (HRV) analysed during tilt table testing at 60 degrees. The following 5-min time-periods were analysed: (A) before tilting (supine position), (B) initial period of tilting, (C) last 5 min of tilting, and (D) immediately after completion of tilt test (after return to supine position).

RESULTS

Patients with EH without LVH had a higher increase of LF/HF values (period B versus period C) compared with controls (p<0.05). The change from tilt to supine position caused significantly lower change in lnHF values in patients with EH and LVH than in controls (p<0.01) or patients with EH without LVH (p<0.005). In patients with EH and LVH a significant correlation between HF and LVmass/height (r=-0.5, p<0.01) was noted. Compared with healthy controls, patients with EH and LVH had significantly lower HRV parameters [lnLF values were significantly lower in all analysed periods, (p<0.05), and lnHF - during period D, (p<0.01)] whereas LF/HF ratio assessed during period D was significantly higher (p<0.05).

CONCLUSIONS

In patients with EH without LVH a relative dominance of sympathetic activity is present. LVH in EH leads to a decrease in vagal drive and progressive inhibition of parasympathetic activity, both of which decrease HRV. These changes may play an important role in the electrical instability of hypertrophied myocardium.

[Norms of arterial blood pressure for 24 hours based on biological activity]

So far there is no unambiguous universally accepted standards for 24 ABPM. Aim of this study was to establish standard values of systolic and diastolic blood pressures, taking into account minimal night values, corresponding with basic biological activity. 1204 patients were tested. In 707 of them, (mean age 42.5 +/- 14.7 years), arterial hypertension was recognized. Basic on our results we determined borderline values (112/69 mmHg) which are diagnostic for arterial hypertension. Those norms eliminate influence of environmental factors on values of blood pressure. They correspond with homeostasis in hypertensive patients.

[Examination of skin microcirculation with laser-Doppler flowmetry in patients with essential hypertension]

The estimation of microcirculatory parameters in patients with essential hypertension and in normotensic control group was the aim of this study. The study group consisted of 14 patients with essential hypertension confirmed by 24-hours ABP. 10 healthy patients served as control group. The flow in the skin microcirculation was measured by laser-Doppler flowmeter (PF-3, PERIMED) on dorsal part of the palm. Microcirculatory indices were registered in resting conditions, during one-minute occlusion reaction and during reactive hyperemia. The following indices were calculated: resting flow, biological zero, maximal flow, time to maximal flow, ratio of maximal to resting flow, ratio of resting flow to biological zero and ratio of maximal flow to biological zero. Skin microcirculation was highly disturbed in patients with essential hypertension. It was expressed by significantly higher biological zero and longer time to maximal flow.

[Late cellular potentials in patients after myocardial infarction--a result of left ventricular diastolic disfunction?]

The link between left ventricular dysfunction and arrhythmogenesis is commonly known. However, so far, only the systolic left ventricular dysfunction has been evaluated. Because of the controversial results of those studies, we decided to assess if is there a link between late potentials (LP) and left ventricular diastolic dysfunction. Our material consisted of 56 patients: 11 women and 45 men, mean age was 61.12 +/- 10.07 years. Signal averaged ECG and ECHO were performed in each patient, 2-3 months after myocardial infarction. For high pass filter of 40 Hz, LP were defined as 2 or 3 abnormal SAECG variables (the averaged QRS > 114 ms, the low amplitude signal duration LAS > 38 ms and root mean square voltage of the terminal 40 ms RMS40 < 20 microV). During ECHO study, we assessed E and A waves E/A ratio, left ventricular end-diastolic volume (LVEDV), ejection fraction (EF), acceleration (AT) and deceleration times (DT). The patients were divided into 2 groups: group I-30 patients LP positive and group II-26 patients LP negative. There were no significant differences between the groups in terms of age, EF, and heart rate. We presented significant differences between group I and II in terms of E wave velocity (0.75 +/- 0.19 vs 0.64 +/- 0.19 p < 0.03) E/A ratio (2.13 +/- 1.56 vs 1.0 +/- 0.5 p < 0.05) respectively. We did not confirm significant differences as regards A wave velocity, AT, isovolumetric time (IVRT) and LVEDV between both tested groups. In group I we revealed a significant correlation between E wave (r = 0.45), E/A ratio (r = 0.62), AT (r = -0.42) E/A ratio (r = 0.56), DT (r = 0.55) and QRS, as well as DT and LPD (r = 0.40) and between IVRT and RMS40 (r = -0.43). The results of our study suggest that in patients after myocardial infarction: 1/incidence of LP depends on the degree of left ventricular filling pattern like in impaired relaxion, quite well correlated with filtered QRS time 3/in LP positive patients there was predominance of restrictive left ventricular filling pattern, quite well correlation with RMS40 amplitude.

[Perindopril in monotherapy of primary hypertension--6 month observation]

We evaluated effects of perindopril (Prestarium-SERVIER) in the treatment of the primary hypertension in 41 patients (mean age 41.6) in the I or II degrees WHO using 24 ambulatory blood pressure measurement and echocardiography. Investigation were performed before and after 3 and 6 months of the treatment. Initially 4 mg of perindopril was given and individually was increased after 3 months to 8 mg according to 24 ambulatory blood pressure measurement results. We obtained significant decrease of blood pressure in 3 (134.6/86.6 mm Hg) and in 6 (135/88, 9 mm Hg) months of treatment in comparison to baseline values (141.8/91.1 mm Hg), decrease of left ventricular mass to 244.4 g in 3 and 248.8 g after 6 months (baseline 258.5 g), as well as index of left ventricular mass, wall thickness and left ventricular end diastolic volume. There was no significant differences in: ejection, heart rate, left ventricular inflow on the successive investigations. Good effect of perindopril we observed in 31 patients (75.6%) after 6 months of treatment. We did not observe any serious side effects of perindopril.

CONCLUSION

Perindopril in treatment hypertension effectively reduces the level of blood pressure (systolic, diastolic and mean) without any effect on heart rate. Prestarium reduces left ventricular mass, intraseptal wall thickness and left ventricular end diastolic volume. There is no influence on inflow to the left ventricle as well as on ejection fraction.

Parasympathetic withdrawal precedes spontaneous blood pressure elevations in women with primary hypertension

Exaggerated sympathetic activity is widely accepted as one of the fundamental mechanisms leading to primary hypertension and being responsible for frequent episodes of blood pressure elevation in hypertensive patients. Some data suggest also that basal parasympathetic tone in this entity is lowered. However, the effects of autonomic nervous activity on heart rate variability during spontaneous blood pressure elevations have not been yet evaluated. That is why we present the preliminary results of 24-hour electrocardiogram and blood pressure monitoring in 13 women with mild primary hypertension and with 25 episodes of blood pressure elevations. Time- and frequency domain measurements of heart rate variability found during the 24- and 10- hour daily periods were compared with those obtained during four 5-min records: 25-20, 15-10 min and immediately before, as well as immediately after the recording of blood pressure elevation. Significant decrease in parameters representing vagal tone was found during 5-min periods not only immediately preceding or following blood pressure elevations, but also 10 and 20 min before these episodes. Moreover, low-frequency component of heart rate variability was significantly lowered 10 min before and immediately after the recording of blood pressure elevation. These results suggest that among various pathogenetic mechanisms of spontaneous blood pressure elevations in women with primary hypertension, sudden withdrawal of parasympathetic tone should be taken into account.

Heart rate variability before sudden blood pressure elevations or complex cardiac arrhythmias in phaeochromocytoma

In phaeochromocytoma, sudden hypertensive or arrhythmic episodes are believed to be associated with excessive free catecholamine excretion. However, lack of correlation between blood pressure (BP) and plasma catecholamine levels has been reported. Therefore an attempt was made to assess the sympathovagal balance before and during episodes of BP elevation or complex cardiac arrhythmias in this disease. Ten patients with phaeochromocytoma and 10 matched controls with essential hypertension underwent simultaneous 24 h Holter ECG and BP monitoring. BP elevation was diagnosed when the BP exceeded the mean 24 h values by 40 mm Hg systolic or 30 mm Hg diastolic, respectively. Heart rate variability (HRV) was measured for 5 min periods 1 h before, 15 min before and during 13 episodes of BP elevation in phaeochromocytoma and 13 episodes in the control group, as well as at 1 h, 15 min and immediately before five arrhythmic events in phaeochromocytoma. In phaeochromocytoma, vagal activity measured 1 h before BP elevation was markedly higher than in control hypertensives. However, in both groups at 15 min before and during the hypertensive events, the vagal tone decreased significantly. In contrast, just before the arrhythmic events HRV remained unaltered with a slight insignificant increase in sympathetic activity. We conclude that in phaeochromocytoma, pronounced BP elevations during daily activities are preceded by a parasympathetic withdrawal, similar to the findings in essential hypertension. Such a sequence does not seem to precede sudden complex arrhythmic events in phaeochromocytoma.

Heart rate variability in pheochromocytoma

The results of our study show that parasympathetic tone was higher in patients with pheochromocytoma than in patients with primary hypertension. An unusual spectral form of vagal activity was seen during excessive beta-adrenergic stimulation, while persistent hypertension with an excessive alpha-adrenergic stimulation was responsible for low cardiac sympathetic tone, probably due to desensitization of beta-adrenergic receptors.