Effect of air pollution exposure on risk of acute coronary syndromes in Poland: a nationwide population-based study (EP-PARTICLES study)

Background

Air pollution (AP) is linked up to 20% of cardiovascular deaths. The aim of this nationwide study was to investigate subpopulations vulnerable to AP for non-ST- (NSTEMI) and ST-elevation myocardial infarction (STEMI) incidence.

Methods

We analysed short- (lags up to seven days) and mid-term (0-30 days moving average) influence of particulate matter (PM2.5), sulphur dioxide (SO2), nitrogen dioxide (NO2) and benzo(a)pyrene (BaP) on hospitalizations due NSTEMI and STEMI in 2011-2020. Data on AP concentrations were derived using GEM-AQ model. Study included residents of five voivodeships in eastern Poland, inhabited by over 8,000,000 individuals.

Findings

Higher NO2 and PM2.5 concentrations increased mid-term risk of NSTEMI in patients aged < 65 years by 1.3-5.7%. Increased SO2 and PM2.5 concentration triggered STEMI in the short- (SO2, PM2.5) and mid-term (PM2.5) amongst those aged ≥ 65 years. In the short- and mid-term, women were more susceptible to PM2.5 and BaP influence resulting in increased STEMI incidence. In rural regions, STEMI risk was triggered by SO2, PM2.5 and BaP. Income-based stratification showed disproportions regarding influence of BaP concentrations on NSTEMI incidence based on gross domestic product (up to 1.4%).

Interpretation

There are significant disparities in the influence of air pollution depending on the demographic and socio-economic factors. AP exposure is associated with the threat of a higher risks of NSTEMI and STEMI, especially to younger people, women, residents of rural areas and those with lower income.

Funding

National Science Center and Medical University of Bialystok, Poland.

Environmental and socioeconomic determinants of heart failure

BACKGROUND

Over 1.5 million people in Poland suffer from heart failure (HF). The risk of hospitalization is related to environmental and socioeconomic factors and the organization of the healthcare system.

AIMS

The study aimed to assess the influence of environmental and socioeconomic factors on the prevalence of hospitalization for HF.

METHODS

The impact of environmental and socioeconomic factors on HF hospitalizations in Poland in 2012-2019 based on data from the National Institute of Public Health and Central Statistical Office in Poland was estimated by panel data regression techniques.

RESULTS

There were 1 618 734 HF-related hospitalizations (51.3% male; 82.6% aged >65 years). An increase in the number of physicians by 10/10 000 population and healthcare expenditure of 100 PLN per capita resulted in 3.5% (-0.035; 95% confidence interval [CI], -0.06 to -0.01; P = 0.002) and 3% (-0.029; 95% CI, -0.04 to -0.013; P <0.001) decrease in hospitalizations, respectively. For each new outpatient healthcare facility per 10 000 population, there was a 3% (-0.031; 95% CI, -0.048 to -0.014; P <0.001) decrease in hospitalizations. One percentage point increase in the proportion of green areas resulted in a 2.7% (-0.027; 95% CI, -0.042 to -0.01; P = 0.049) decrease in hospitalizations. However, an increase in cars by 1000 inhabitants and a 1 percentage point increase in the unemployment rate were associated with a 6% increase in HF hospitalizations (0.064; 95% CI, 0.008-0.121; P = 0.026).

CONCLUSIONS

The number of HF-related hospitalizations has been increasing in the last decade. This trend is most noticeable in regions with low socioeconomic development and poor medical facilities. Our study indicates that health policy measures including environmental and socioeconomic instruments may result in positive health outcomes. Additional analyses are needed to compare the impact of socioeconomic and environmental factors against the impact of healthcare alone.

Exposure to air pollution and its effect on ischemic strokes (EP-PARTICLES study)

It is well known that exceeded levels of particulate matter in the air and other air pollutants harmfully affect the cardiovascular system. Empirical analyses of the effects of these factors on stroke incidence and mortality are still limited. The main objective of our analyses was to determine the association between short-term exposure to air pollutants and stroke incidence in non-industrial areas, more specifically in north-eastern Poland. To achieve this aim, we used data from the National Health Fund on patients hospitalized for stroke between 2011 and 2020 in the largest city of the region described as the Green Lungs of Poland. The pollution levels and atmospheric conditions data were obtained from the Provincial Inspectorate for Environmental Protection and the Institute of Meteorology and Water Management. Using daily data on hospitalizations, atmospheric conditions, and pollution, as well as ordered logistic regression models the hypotheses on the impact of weather and air pollution conditions on ischemic strokes were tested. The study group included 4838 patients, 45.6% of whom were male; the average patient age was approximately 74 years. The average concentrations of PM_2.5 were 19.09 µg/m³, PM₁₀ 26.66 µg/m³ and CO 0.35 µg/m³. Analyses showed that an increase in PM_2.5 and PM₁₀ concentrations by 10 µg/m³ was associated with an increase in the incidence of stroke on the day of exposure (OR = 1.075, 95% CI 0.999-1.157, P = 0.053; OR = 1.056, 95% CI 1.004-1.110, P = 0.035) and the effect was even several times greater on the occurrence of a stroke event in general (PM_2.5: OR = 1.120, 95% CI 1.013-1.237, P = 0.026; PM₁₀: OR = 1.103, 95% CI 1.028-1.182, P = 0.006). Furthermore, a short-term (up to 3 days) effect of CO on stroke incidence was observed in the study area. An increase of 1 μg/m³ CO was associated with a lower incidence of stroke 2 days after the exposure (OR = 0.976, 95% CI 0.953-0.998, P = 0.037) and a higher incidence 3 days after the exposure (OR = 1.026, 95% CI 1.004-1.049, P = 0.022).

Comparing Atrial-Fibrillation Validated Rapid Scoring Systems in the Long-Term Mortality Prediction in Patients Referred for Elective Coronary Angiography: A Subanalysis of the Białystok Coronary Project

Rapid scoring systems validated in patients with atrial fibrillation (AF) may be useful beyond their original purpose. Our aim was to assess the utility of CHA2DS2-VASc, HAS−BLED, and 2MACE scores in predicting long-term mortality in the population of the Białystok Coronary Project, including AF patients. The initial study population consisted of 7409 consecutive patients admitted for elective coronary angiography between 2007 and 2016. The study endpoint was all-cause mortality, which occurred in 1244 (16.8%) patients during the follow-up, ranging from 1283 to 3059 days (median 2029 days). We noticed substantially increased all-cause mortality in patients with higher values of all compared scores. The accuracy of the scores in predicting all-cause mortality was also assessed using the receiver operator characteristic (ROC) curves. The greatest predictive value for mortality was recorded for the CHA2DS2-VASc score in the overall study population (area under curve [AUC] = 0.665; 95% confidence interval [95%CI] 0.645−0.681). We observed that the 2MACE score (AUC = 0.656; 95%CI 0.619−0.681), but not the HAS−BLED score, had similar predictive value to the CHA2DS2-VASc score for all-cause mortality in the overall study population. In AF patients, all scores did not differ in all-cause mortality prediction. Additionally, we found that study participants with CHA2DS2-VASc score ≥3 vs. <3 had a 3-fold increased risk of long-term all-cause mortality (odds ratio 3.05; 95%CI 2.6−3.6). Our study indicates that clinical scores initially validated in AF patients may be useful for predicting mortality in a broader population (e.g., in patients referred for elective coronary angiography). According to our findings, all compared scores have a moderate predictive value. However, in our study, the CHA2DS2-VASc and 2MACE scores outperformed the HAS−BLED score in terms of the long-term all-cause mortality prediction.

Do Muslims Living in Poland Approve of Organ Transplantation?

Background

Although the International Society for Islamic Legal Studies and the Islamic Organization for Medical Sciences have officially approved of transplantations, Muslims’ opinions on this issue are not uniform. The aim of this study was to assess the general knowledge, attitudes, and opinions concerning organ transplantation among Muslim Tatars living in North-East Poland.

Material/Methods

The study included 78 Muslim Tatars and was carried out at the Center of Muslim Culture using the diagnostic poll method.

Results

Transplantation from living donors was accepted by 96.1% of respondents, and from dead donors by 88.8% of respondents. Consent to the removal of organs after the death of a close relative was approved of by 57.7%, and 1/5 of respondents objected to it. Removal of their organs after death was approved of by 70.5% of respondents, more often by persons with higher education and vocational education than among those with only elementary education. Only 2.2% of respondents had reported their objection to the Central Objection Register. Almost 40% of men and women informed their family members about their willingness to be an organ donor. Most (71.8%) respondents had a positive attitude to transplantation, 25.6% had a negative attitude, and 2.6% were neutral. Approximately 72% of respondents believed that the final decision concerning the removal of organs from dead donors should be made by the family, and according to 8.9%, it should be prescribed by the law.

Conclusions

Muslim Tatars living in Poland mostly accept the removal of organs both from live donors and from dead bodies. Gender and education level had a considerable impact on the decision concerning organ donation.

Exposure to air pollution and renal function

Air pollution contributes to the premature death of approximately 428,000 citizens of Europe every year. The adverse effects of air pollution can be observed in respiratory, circulatory systems but also in renal function. We decide to investigate the hypothesis indicating that we can observe not only long- but also short-term impact of air pollution on kidney function. We used linear, log-linear, and logistic regression models to assess the association between renal function and NO2, SO2, and PMs. Results are reported as beta (β) coefficients and odds ratios (OR) for an increase in interquartile range (IQR) concentration. 3554 patients (median age 66, men 53.2%) were included into final analysis. Chronic kidney disease (CKD) was diagnosed in 21.5%. The odds of CKD increased with increase in annual concentration of PM2.5 (OR for IQR increase = 1.07; 95% CI 1.01-1.15, P = 0.037) and NO2 (OR for IQR increase = 1.05; 95% CI 1.01-1.10, P = 0.047). The IQR increase in weekly PM2.5 concentration was associated with 2% reduction in expected eGFR (β = 0.02, 95% CI - 0.03; - 0.01). Medium- and short-term exposure to elevated air pollution levels was associated with a decrease in eGFR and development CKD. The main pollutants affecting the kidneys were PM2.5 and NO2.

Impact of short-term air pollution exposure on acute coronary syndrome in two cohorts of industrial and non-industrial areas: A time series regression with 6,000,000 person-years of follow-up (ACS - Air Pollution Study)

BACKGROUND

There is a lack of studies directly comparing the effect of air pollution on acute coronary syndrome (ACS) occurrence in industrial and non-industrial areas.

OBJECTIVES

A comparison of association of air pollution exposure with ACS in two cohorts of industrially different areas.

MATERIALS AND METHODS

The study covered 6,000,000 person-years of follow-up and five pollutants between 2008 and 2017. A time series regression analysis with 7-lag was used to assess the effects air pollution on ACS.

RESULTS

A total of 9046 patients with ACS were included in the analysis, of whom 3895 (43.06%) had ST-elevation myocardial infarction (STEMI) - 45.39% from non-industrial area, and 42.37% from industrial area; and 5151 (56.94%) had non-ST-elevation myocardial infarction (NSTEMI) - 54.61% from non-industrial area and 57.63% from industrial area. The daily concentrations of PM_2.5, PM₁₀, NO₂, SO₂, CO were higher in industrial than in non-industrial area (P < 0.001). In non-industrial area, an increase of 10 μg/m³ of NO₂ concentration (Odds Ratio (OR) = 1.126, 95%CI = 1.009-1.257; P = 0.034, lag-0) and an increase of 1 mg/m³ in CO concentration (RR = 1.055, 95%CI = 1.010-1.103; P = 0.017, lag-0) were associated with an increase in the number of hospitalization due to NSTEMI (for industrial area increase of 10 μg/m³ in NO₂ (OR = 1.062, 95%CI = 1.020-1.094; P = 0.005, lag-0), SO₂ (OR = 1.061, 95%CI = 1.010-1.116; P = 0.018, lag-4), PM₁₀ (OR = 1.010, 95%CI = 1.001-1.030; P = 0.047, lag-6). In STEMI patients in industrial area, an increased hospitalization was found to be associated with an increase of 10 μg/m³ in SO₂ (OR = 1.094, 95%CI = 1.030-1.162; P = 0.002, lag-1), PM_2.5 (OR = 1.041, 95%CI = 1.020-1.073; P < 0.001, lag-1), PM₁₀ (OR = 1.030, 95%CI = 1.010-1.051; P < 0.001, lag-1). No effects of air pollution on the number of hospitalization due to STEMI were noted from non-industrial area.

CONCLUSION

The risk of air pollution-related ACS was higher in industrial over non-industrial area. The effect of NO₂ on the incidence of NSTEMI was observed in both areas. In industrial area, the effect of PMs and SO₂ on NSTEMI and STEMI were also observed. A clinical effect was more delayed in time in patients with NSTEMI, especially after exposure to PM₁₀. Chronic exposure to air pollution may underlie the differences in the short-term effect between particulate air pollution impact on the incidence of STEMI.

Cardiac Rupture-The Most Serious Complication of Takotsubo Syndrome: A Series of Five Cases and a Systematic Review

Background: The most serious complication of the acute Takotsubo phase is a myocardial perforation, which is rare, but it usually results in the death of the patient. Methods: In the years 2008–2020, 265 patients were added to the Podlasie Takotsubo Registry. Cardiac rupture was observed in five patients (1.89%), referred to as the Takotsubo syndrome with complications of cardiac rupture (TS+CR) group. The control group consisted of 50 consecutive patients with uncomplicated TS. The diagnosis of TS was based on the Mayo Clinic Criteria. Results: Cardiac rupture was observed in women with TS aged 74–88 years. Patients with TS and CR were older (82.20 vs. 64.84; p = 0.011), than the control group, and had higher troponin, creatine kinase, aspartate aminotransferase, and blood glucose levels (168.40 vs. 120.67; p = 0.010). The TS+CR group demonstrated a higher heart rate (95.75 vs. 68.38; p < 0.0001) and the Global Registry of Acute Coronary Events (GRACE) scores (186.20 vs. 121.24; p < 0.0001) than the control group. In patients with CR, ST segment elevation was recorded significantly more often in the III, V4, V5 and V6 leads. Left ventricular free wall rupture was noted in four patients, and in one case, rupture of the ventricular septum. In a multivariate logistic regression, the factors that increase the risk of CR in TS were high GRACE scores, and the presence of ST segment elevation in lead III. Conclusions: Cardiac rupture in TS is rare but is the most severe mechanical complication and is associated with a very high risk of death. The main risk factors for left ventricular perforation are female gender, older age, a higher concentration of cardiac enzymes, higher GRACE scores, and ST elevations shown using electrocardiogram (ECG).

Impact of chronic kidney disease on long-term outcome of patients with valvular heart defects

INTRODUCTION

Valvular heart diseases (VHD) are becoming a significant problem in the Polish population. Coexistence of chronic kidney disease (CKD) in patients with VHD increases the risk of death and affects further therapeutic strategy.

AIM

Analysis impact of CKD on long-term prognosis in patients with VHD.

MATERIAL AND METHODS

The inclusion criteria were met by 1025 patients with moderate and severe VHD. Mean observation time was 2528 ± 1454 days.

RESULTS

The average age of the studied population was 66.75 (SD = 10.34), male gender was dominant 56% (N = 579). Severe aortic valve stenosis (AVS) occurred in 28.2%, severe mitral valve insufficiency (MVI) in 20%. CKD occurred in 37.1% (N = 380) patients mostly with mitral stenosis (50%, N = 16) and those with severe MVI (44.8%, N = 94). During the observational period, 52.7% (N = 540) deaths were noted. Increased risk of mortality was associated mostly with age (OR: 1.02, 95% CI: 1.00-1.03, p < 0.001), creatinine (OR:1.27, 95% CI: 1.12-1.43, p < 0.001), CKD (OR: 1.30, 95% CI: 1.17-1.44, p < 0.001), reduced ejection fraction (EF) (OR: 0.98, 95% CI: 0.97-0.99, p = 0.01) and coexisting of AVS (OR: 1.19, 95% CI: 1.04-1.35, p = 0.01).

CONCLUSIONS

Mitral valve defects more often than aortic valve defects coexist with chronic kidney disease. Regardless of the stage, chronic kidney disease is an additional factor affecting the prognosis in patients with heart defects. Factors increasing the risk of death were age, creatinine concentration and reduced EF. The monitoring of renal function in patients with VHD should be crucial as well as the implementation of treatment at an early stage.

The effect of serum uric acid levels on the long-term prognosis of patients with non-ST-elevation myocardial infarction

BACKGROUND

Cardiovascular diseases (CVD) are the leading cause of death worldwide. Many studies have reported an association between serum uric acid (sUA) and CVD, and its role as a risk marker for mortality.

OBJECTIVES

To assess the relationship between sUA levels and the long-term prognosis of patients with non-ST-elevation myocardial infarction (NSTEMI).

MATERIAL AND METHODS

The study was conducted at the Clinical Hospital of Białystok (Poland). Based on medical records, 9328 patients were hospitalized between 2011 and 2013, of which 726 had NSTEMI. The exclusion criteria were: any diagnosed neoplasms and estimated glomerular filtration rate (eGFR) <15 mL/min. The average observation time was 2324 days.

RESULTS

A total of 549 patients were qualified for the analysis; men were in the majority (69.03%, n = 379), and the mean age was 68.42 years (standard deviation (SD) = 11.66). The sUA norm was exceeded in 137 of the patients (24.95%). Hyperuricemia is more likely to occur in women (risk ratio (RR) = 1.52, 95% confidence interval (95% CI) = 1.016-2.288, p = 0.042), in patients with chronic kidney disease (CKD) (RR = 3.452, 95% CI = 2.432-4.854, p < 0.001) and in patients with higher body mass index (BMI)s (RR = 1.048, 95% CI = 1.008-1.090, p = 0.018). In the whole study group, during the study, 178 of the patients died (32.41.9%), more often those with hyperuricemia: (60/137 patients (43.8%)) compared to patients with normal sUA values (118/412 values (28.64%)); p < 0.001). There was a significant correlation between an increase in sUA levels and an increase in mortality (p < 0.001). Independent risk factors of death were age (RR = 1.086, 95% CI = 1.065-1.108, p < 0.001), sUA (RR = 1.245, 95% CI = 1.131-1.370, p = 0.041), ejection fraction (EF) (RR = 0.928, 95% CI = 0.910-0.946, p < 0.001) and hemoglobin concentration (RR = 0.685, 95% CI = 0.611-0.768, p < 0.001).

CONCLUSIONS

Serum UA concentration is an independent risk factor of long-term mortality in patients who have undergone NSTEMI, and is associated with higher in-hospital death rates. Secondary prevention after NSTEMI should entail management of the patients' sUA levels.

Impact of renal function on patients with acute coronary syndromes: 15,593 patient-years study

Introduction

Coexistence of chronic kidney disease (CKD) in the case of acute coronary syndromes (ACS) significantly worsens the outcomes.

Aim

The aim of our study was to assess renal function impact on mortality among patients with ACS.

Materials and methods

The study was based on records of 21,985 patients hospitalized in the Medical University of Bialystok in 2009–2015. Inclusion criteria were ACS. Exclusion criteria were: death within 24 h of admission, eGFR <15 ml/min/1.73 m², hemodialysis. Mean observation time was 2296 days.

Results

Criteria were met by 2213 patients. CKD occurred in 24.1% (N = 533) and more often affected those with NSTEMI (26.2 (337) vs. 21.2 (196), p = .006). STEMI patients had higher incidence of post-contrast acute kidney injury (PC-AKI) (5 (46) vs. 4.1 (53), p < .001). During the study, 705 people died (31.9%), more often with NSTEMI (33.2% (428) vs. 29.95% (277), p < .001). However, from a group of patients suffering from PC-AKI 57.6% died. The risk of PC-AKI increased with creatinine concentration (RR: 2.990, 95%CI: 1.567–5.721, p < .001), occurrence of diabetes mellitus (RR: 2.143, 95%CI: 1.029–4.463, p = .042), atrial fibrillation (RR: 2.289, 95%CI: 1.056–4.959, p = .036). Risk of death was greater with an increase in postprocedural creatinine concentration (RR: 2.254, 95%CI: 1.481–3.424, p < .001).

Conclusion

PC-AKI is a major complication in patients with ACS, occurs more frequently in STEMI and may be a prognostic marker of long-term mortality in patients undergoing percutaneous coronary intervention (PCI). More attention should be given to the prevention and diagnosis of PC-AKI but necessary PCI should not be withheld in fear of PC-AKI.

Exposure to air pollution-a trigger for myocardial infarction? A nine-year study in Bialystok-the capital of the Green Lungs of Poland (BIA-ACS registry)

OBJECTIVES

This study aimed to assess the effect of air pollution and weather conditions on the frequency of hospital admissions due to acute coronary syndrome (ACS) in the population of Bialystok, known as the capital of the Green Lungs of Poland.

MATERIALS AND METHODS

The study analyzed the medical records of 2,645 patients living within the borders of Bialystok who were treated for ACS between 2009 and 2017 and the data on air pollutants-nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter with a diameter of 2.5 μm or less (PM_2.5) and 10 μm or less (PM₁₀)-and the basic meteorological factors (temperature, humidity, and atmospheric pressure). A time-stratified case-crossover study design was applied to assess the effects of particulate matter, the concentration of gases, and weather conditions on ACS.

RESULTS

The number of patients admitted for ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA) was 791, 999, and 855, respectively. The daily concentration norm for PM_2.5 recommended by the World Health Organization (WHO) was exceeded in 692 days (i.e., 24.58% of the observation period). The significant increase in the number of ACS hospitalizations was associated with an interquartile-range increase in NO₂ concentration, with an odds ratio of 1.08 (95% confidence interval (CI): 1.02-1.15, P = 0.01), 1.09 (95% CI: 1.01-1.18, P = 0.03), and 1.11 (95% CI: 1.00-1.22, P = 0.048) for patients with ACS, NSTEMI, and UA, respectively.

CONCLUSION

The study showed that the effects of air pollution and weather conditions on the number of ACS hospitalizations are also observed in cities with moderately polluted or good air quality. NO₂ was identified as the main air pollutant affecting the incidence of ACS.

Opinions of Followers of Judaism Residing in the Northeastern Part of Poland on Organ Donation

BACKGROUND

Families of deceased potential donors often object to organ harvesting on religious grounds. The aim of this study was to learn the attitudes and opinions of Judaism followers regarding organ donation.

MATERIAL AND METHODS

The study included 97 Judaism followers living in the northeastern part of Poland. The research used the diagnostic survey method.

RESULTS

A fairly large percentage (approximately 92%) of respondents accepted treatment using organ transplantation. The removal of organs for transplantation from a loved one after his death was accepted by about 90%. After his death, 14.43% expressed opposition to organ removal. About one-third of respondents did not talk to the family about their organ donation attitude. The average age of people who talked to their family about their will to donate was 49.69 ± 13.95 years. In total, 91.75% of the respondents had a positive attitude toward organ transplantation, 6.19% negative, and 2.06% indifferent. According to respondents, the most common reasons for a family's refusal to collect organs from the deceased are death-related emotions (53.61%), religious beliefs (36.08%), and fear of misuse of organs (22.68%).

CONCLUSION

Judaism believers mostly accept treatment with organs taken from living and deceased people. In a larger percentage, young people with higher and secondary education more often accepted organ donation.

Gender Differences in Association between Air Pollution and Daily Mortality in the Capital of the Green Lungs of Poland-Population-Based Study with 2,953,000 Person-Years of Follow-Up

(1) Introduction: air pollution is considered to be one of the main risk factors for public health. According to the European Environment Agency (EEA), air pollution contributes to the premature deaths of approximately 500,000 citizens of the European Union (EU), including almost 5000 inhabitants of Poland every year. (2) Purpose: to assess the gender differences in the impact of air pollution on the mortality in the population of the city of Bialystok-the capital of the Green Lungs of Poland. (3) Materials and Methods: based on the data from the Central Statistical Office, the number-and causes of death-of Białystok residents in the period 2008-2017 were analyzed. The study utilized the data recorded by the Provincial Inspectorate for Environmental Protection station and the Institute of Meteorology and Water Management during the analysis period. Time series regression with Poisson distribution was used in statistical analysis. (4) Results: A total of 34,005 deaths had been recorded, in which women accounted for 47.5%. The proportion of cardiovascular-related deaths was 48% (n = 16,370). An increase of SO2 concentration by 1-µg/m3 (relative risk (RR) 1.07, 95% confidence interval (CI) 1.02-1.12; p = 0.005) and a 10 °C decrease of temperature (RR 1.03, 95% CI 1.01-1.05; p = 0.005) were related to an increase in the number of daily deaths. No gender differences in the impact of air pollution on mortality were observed. In the analysis of the subgroup of cardiovascular deaths, the main pollutant that was found to have an effect on daily mortality was particulate matter with a diameter of 2.5 μm or less (PM2.5); the RR for 10-µg/m3 increase of PM2.5 was 1.07 (95% CI 1.02-1.12; p = 0.01), and this effect was noted only in the male population. (5) Conclusions: air quality and atmospheric conditions had an impact on the mortality of Bialystok residents. The main air pollutant that influenced the mortality rate was SO2, and there were no gender differences in the impact of this pollutant. In the male population, an increased exposure to PM2.5 concentration was associated with significantly higher cardiovascular mortality. These findings suggest that improving air quality, in particular, even with lower SO2 levels than currently allowed by the World Health Organization (WHO) guidelines, may benefit public health. Further studies on this topic are needed, but our results bring questions whether the recommendations concerning acceptable concentrations of air pollutants should be stricter, or is there a safe concentration of SO2 in the air at all.

Takotsubo syndrome - fatal prognosis of patients with low body mass index in 5-year follow-up

INTRODUCTION

The clinical courses of takotsubo syndrome (TS) and of acute coronary syndromes (ACS) seem to be very similar. However, there is limited knowledge about risk factors of poor outcomes. Low body mass index worsens the prognosis of patients with cardiovascular diseases, especially those undergoing surgical treatment. The aim of the study was to evaluate the influence of the body mass index (BMI) on the prognosis in patients diagnosed with TS.

MATERIAL AND METHODS

Eighty patients aged 15-89 (mean: 67.9 years), 74 women and 6 men with TS diagnosis according to Mayo Clinic diagnostic criteria were divided into 3 groups: low body mass (BMI < 18.5 kg/m²), normal body mass (18.5 ≥ BMI < 25 kg/m²) and excessive body mass (BMI ≥ 25 kg/m²).

RESULTS

Patients with low BMI were older, but with less prevalent risk factors such as hypertension, hypercholesterolemia and positive family history of coronary artery disease and more frequent risk factors such as cigarette smoking, chronic obstructive pulmonary disease (COPD), depressive and anxiety disorders as well as malignancy. They also had higher haemoglobin, lower troponin, creatine kinase, C-reactive protein and lipid fractions. The highest annual, 3-year and 5-year mortality was observed in the group with BMI < 18.5 kg/m². None of the patients with low BMI survived the 5-year follow-up period (100% vs. 25% vs. 15.2%; p < 0.0001). In group III, mortality among overweight patients (25 ≥ BMI < 30 kg/m²) was 8.3%, and in obese people (BMI ≥ 30 kg/m²) 1 out 5 patients died during follow-up.

CONCLUSIONS

The majority of typical cardiovascular risk factors are less frequently observed in patients with TS and low body mass. Early prognosis for TS patients and low BMI is relatively favourable, whereas the 5-year follow-up is associated with extremely high mortality. Overweight patients have the best prognosis in the long-term follow-up.

Acute coronary syndromes and atherosclerotic plaque burden distribution in coronary arteries among patients with valvular heart disease (BIA-WAD registry)

INTRODUCTION

Valvular heart diseases (VHD) are a significant problem in the Polish population. Coexistence of coronary artery disease (CAD) in patients with VHD increases the risk of death and affects the further therapeutic strategy.

AIM

Analysis of atherosclerotic plaque burden distribution in coronary arteries and long-term prognosis among patients with VHD.

MATERIAL AND METHODS

Inclusion criteria were met by 1025 patients with moderate and severe VHD. Mean observation time was 2528 ±1454 days.

RESULTS

Severe aortic valve stenosis (AVS) occurred in 28.2%, severe mitral valve insufficiency (MVI) in 20%. CAD with severe angiographic stenoses was noted in 42.3% (n = 434). Among patients with severe MVI, CAD was noted in 47.1% of cases, and prior acute coronary syndromes (ACS) in 27.1% of patients (n = 58). In severe AVS patients, significant angiographic atherosclerotic changes were observed in 29.6% (n = 86), and prior ACS in 7.6% (n = 22) of patients. During the observation 52.7% of patients died, including 62.9% of patients with severe MVI and 51.6% of those with severe AVS. Age (OR = 1.038; 95% CI: 1.005-1.072; p = 0.022) and coexisting aortic valve insufficiency (AVI) (OR = 2.39, 95% CI: 5.370-11.065, p = 0.035) increased the mortality rate.

CONCLUSIONS

Severe AVS is starting to be the most prevalent VHD. CAD is one of the most significant factors deteriorating prognosis of patients with VHD. AVI and age were significant risk factors for mortality. The worst prognosis was observed in severe MVI, which may result from more frequent occurrence of CAD in this group. A lesser burden of CAD and ACS in the group of patients with severe AVS did not affect survival.

Effect of air pollution on the number of hospital admissions for acute coronary syndrome in elderly patients

INTRODUCTION

Air pollution is a documented risk factor for cardiovascular diseases.

OBJECTIVES

The aim of the study was to assess the effect of air pollution on the number of hospital admissions for acute coronary syndrome (ACS) in elderly patients.

PATIENTS AND METHODS

The medical records of 26 695 patients hospitalized for ACS between 2008 and 2017 were examined. Weather conditions and the following components of air pollution were analyzed: sulfur dioxide, nitrogen dioxide, and particulate matter with a diameter of 2.5 μm or less (PM2.5) and a diameter of 10 μm or less (PM10).

RESULTS

The study included 1618 inhabitants of Białystok in Poland (mean [SD] age, 75 [6.4] years; men, 52.6%). The norm for PM2.5 was exceeded on 23.5% of days, while for PM10, on 5.3% of days. Elevated PM10 levels were associated with a higher number of hospitalizations for ACS on the day of exposure (mean [SD], 0.61 [0.78] vs 0.44 [0.69]; P <0.001), and this effect persisted in the subsequent days (mean [SD], 1.07 [1.07] vs 0.88 [1.00]; P = 0.02). An increase of PM10 concentrations by 10 μg/m3 was associated with an increase in the number of hospitalizations due to unstable angina, and significant effects were observed even after 6 days (rate ratio, 1.16; 95% CI, 1.03-1.32; P = 0.02).

CONCLUSIONS

Increased exposure to air pollution, in particular, elevated PM10 levels, is associated with a higher incidence of ACS both on the day of exposure and over the following days.

Acute kidney injury in elderly patients

INTRODUCTION

In the elderly, impairment of kidney function occurs. Renal diseases overlap with anatomic and functional changes related to age-related involutionary processes. Mortality among patients with acute renal injury is approximately 50%, despite advances in treatment and diagnosis of AKI.

THE AIM

To assess the incidence of acute kidney injury in elderly patients and to analyze the causes of acute renal failure depending on age.

MATERIAL AND METHODS

A retrospective analysis included medical documentation of patients hospitalized in the Nephrology Clinic during the 6-month period. During this period 452 patients were hospitalized in the clinic. A group of 77 patients with acute renal failure as a reason for hospitalization was included in the study.

RESULTS

The prerenal form was the most common cause of AKI in both age groups. In both age groups, the most common cause was dehydration; in the group of patients up to 65 years of age, dehydration was 29.17%; in the group of people over 65 years - 43.39%. Renal replacement therapy in patients with AKI was used in 14.29% of patients. In the group of patients up to 65 years of age hemodialysis was 16.67% and above 65 years of age. -13.21% of patients. The average creatinine level in the group of younger patients at admission was 5.16 ± 3.71 mg / dl, in the group of older patients 3.14 ± 1.63 mg / dl. The size of glomerular filtration GFR in the group of younger patients at admission was 21.14 ± 19.54 ml / min, in the group of older patients 23.34 ± 13.33 ml / min.

CONCLUSIONS

The main cause of acute kidney injury regardless of the age group was dehydration. Due to the high percentage of AKI in the elderly, this group requires more preventive action, not only in the hospital but also at home.

Vitamin D deficiency and anemia is highly prevalent and dependent on the etiology of heart failure: A pilot study

BACKGROUND

Anemia and vitamin D deficiency are common factors in chronic heart failure (CHF). The aim of this study was to assess vitamin D levels as well as its binding protein and anemia in relation to a cause of CHF: coronary heart disease, valvular disease and cardiomyopathy.

METHODS

One hundred and sixteen consecutive patients (36 females and 80 males) with CHF were admitted for percutaneous coronary interventions (PCI). Hemoglobin concentration, serum creatinine, B-type natriuretic peptide (BNP), 25-hydroxyvitamin D [25(OH)D] and its binding protein-VDBP were measured.

RESULTS

The prevalence of anemia was 22%. BNP was the highest in the group with coronary artery disease. Ejection fraction was the lowest in cardiomyopathy group. 25(OH)D was lowest in valvular disease group, significantly lower than in the coronary artery group. A similar pattern of change showed vitamin D binding protein. The prevalence of vitamin D deficiency (level below 20 ng/mL) in the whole group was 95%, in 49% of the patients 25(OH)D was below 10 ng/mL. In univariate analysis 25(OH)D correlated with hemoglobin, red blood cell count, hematocrit, mean corpuscular volume and BNP in patients with CHF in the whole group. In multiple regression analysis, predictors of 25(OH)D were estimated, glomerular filtration rate, BNP and valvular disease.

CONCLUSIONS

25(OH)D deficiency is common in CHF patients. Valvular disease is associated the most severe vitamin D deficiency and worsened kidney function. A higher prevalence of anemia in CHF due to coronary heart disease may be associated with wider use of angiotensin converting enzyme inhibitors and acetylsalicylic acid. Heart and kidney function are predictors of 25(OH)D level in the patients of this study.

Takotsubo syndrome and chronic kidney disease: a deadly duet in long-term follow-up

Introduction The prognosis of takotsubo syndrome (TTS) was recognized as benign. However, patients with TTS and chronic kidney disease (CKD) more often experience severe complications in the acute phase of the disease, particularly sudden cardiac arrest. Objectives We aimed to assess the impact of CKD on early and long-term outcomes, including mortality, among 95 patients with TTS. Patients and methods All patients underwent coronary angiography. Clinical, biochemical, and other medical data were recorded. Estimated glomerular filtration rate was assessed using the CKD‑EPI formula. Results CKD was diagnosed in 32% of the patients. Contrast‑induced acute kidney injury (CI‑AKI) was not reported in any of the patients. Patients with CKD were older but had a lower prevalence of positive cardiovascular family history as well as higher creatine kinase activity and concentrations of inflammatory parameters. During hospitalization, sudden cardiac arrest was more common in CKD patients. In‑hospital, 1‑year, and long‑term mortality rates were the highest in CKD patients, reaching 33.3% in long‑term follow‑up. Predictors of death in a multivariate analysis were body mass index, ejection fraction, and serum creatinine concentrations. Conclusions CKD is a novel and still underestimated risk factor for TTS. It may trigger TTS but, more importantly, it adversely affects the outcomes. Thus, it is important to assess kidney function in all patients with TTS to evaluate the risk of morbidity and mortality in follow‑up, as well as to adjust drug doses and implement preventive measures to avoid CI‑AKI when coronary angiography or contrast‑enhanced computed tomography is performed.

Hyperglycemia and diabetes have different impacts on outcome of ischemic and hemorrhagic stroke

INTRODUCTION

Stroke is the second leading cause of long-term disability and death worldwide. Diabetes and hyperglycemia may impact the outcome of stroke. We examined the impact of hyperglycemia and diabetes on in-hospital death among ischemic and hemorrhagic stroke patients.

MATERIAL AND METHODS

Data from 766 consecutive patients with ischemic (83.15%) and hemorrhagic stroke were analyzed. Patients were classified into four groups: ischemic and diabetic; ischemic and non-diabetic; hemorrhagic and diabetic; and hemorrhagic and non-diabetic. Serum glucose was measured on admission at the emergency department together with biochemical and clinical parameters.

RESULTS

Mean admission glucose in ischemic stroke patients with diabetes was higher than in non-diabetic ones (p < 0.001) and in hemorrhagic stroke patients with diabetes than in those without diabetes (p < 0.05). Mean admission glucose in all patients who died was significantly higher than in patients who survived. In multivariate analysis, the risk factors for outcome in patients with ischemic stroke and without diabetes were age, admission glucose level and estimated glomerular filtration rate (eGFR), while in diabetics they were female gender, admission glucose level, and eGFR; in patients with hemorrhagic stroke and without diabetes they were age and admission glucose levels. The cut-off value in predicting death in patients with ischemic stroke and without diabetes was above 113.5 mg/dl, while in diabetics it was above 210.5 mg/dl.

CONCLUSIONS

Hyperglycemia on admission is associated with worsened clinical outcome and increased risk of in-hospital death in ischemic and hemorrhagic stroke patients. Diabetes increased the risk of in-hospital death in hemorrhagic stroke patients, but not in ischemic ones.

[Vitamin D – from the past antirachitic factor to new pleiotropic substance]

Vitamin D is known for almost 100 years. Since time of its discovery, numerous studies on vitamin D function in the human body were performed. Considered from the beginning as an important factor in rickets prevention, thanks to the continuous development of knowledge, vitamin D is regarded now as an important factor from the point of view of the whole body homeostasis. Newly-find features of vitamin D allow to use this substance concentration in serum as a biomarker of general health and create opportunities of vitamin D use in the prevention and treatment of many diseases. The aim of this article is to present basic function of vitamin D in human body, sources of this substance, its metabolism and molecular mechanism of action, taking into account the evolution of the state of knowledge about Vitamin D - from early researches leading to its discovery, through the finding of its basic functions to the present studies on vitamin D mechanisms of action at molecular and genomic level.

[Klotho not only antiageing protein]

Klotho, the gene encoding the antiaging protein, was discovered in 1997 and named after a Greek Goddes who spun the thread of life. Numerous experiments on mice confirmed that destruction of the klotho gene or loss of klotho function leads to an accelerated aging and premature death. In addition to shortened life span, klotho-deficient mice demonstrated changes in functioning of multiple organs, ectopic calcification, enhanced development of arteriosclerosis, osteoporosis and atrophy of skin. In contrast, overexpression of a gene in mice inhibited aging and prolonged survival. The multisystemic phenotype induced by Klotho deficiency indicates that Klotho works on a variety of organs. Klotho is highly expressed in the kidney, brain, and to a lesser extent in other organs. Protein Klotho exists in two forms: membrane and secreted which play different functions. Membrane Klotho function as an obligate co-receptor required for signaling for the phosphaturic factor FGF23, regulates calcium-phosphate homeostasis through renal ion transport in addition to modulation of PTH and 1,25(OH)2D3. Soluble klotho functions as a humoral factor and regulates the activity of several ion channels and transporters. The secreted Klotho can also inhibit oxydative stres and the insulin and insulin-like growth factor 1 (IGF-1) pathways. The discovery of the protein klotho led to the identification of new axes connecting endocrine disturbances in the homeostasis of the calcium-phosphate to the aging of the organism. Klotho deficiency may not only be a trigger for accelerated aging but also in development of age- -associated diseases, including hypertension, osteoporosis, cardiovascular disease, and CKD. Conceivably, better understanding of Klotho protein might provide a novel treatment strategy for aging and age-associated diseases.

Searching for patent foramen ovale in a 44-year-old female patient after ischemic stroke - diagnostic problems

Patent foramen ovale (PFO) is associated with the occurrence of cryptogenic strokes in young patients. Transesophageal echocardiography with contrast is the established standard in PFO diagnostics. We present the case of a 44-year-old female patient after ischemic stroke, in whom PFO was not detected by echocardiography; the defect was ultimately diagnosed by right heart catheterization.

Opinions and knowledge about organ donation and transplantation of residents of selected villages in Podlaskie Voivodeship

BACKGROUND

In recent years, transplantation, a specific area of medicine, has achieved more and more support and acceptance among different nations around the world. However, there are still many ethical, moral, and legal barriers related to this form of treatment of end-stage organ failures. The aim of this study was to investigate the knowledge and opinions of rural residents about organ transplantation.

MATERIAL AND METHODS

The research method is a diagnostic survey of 395 rural residents of selected villages of the region of Podlasie, located in north-east Poland. The research tool used to carry out the study was the authors' questionnaire.

RESULTS

Organs procurement and transplantation from deceased donors are accepted by 72.6% of respondents. About 60% of the respondents would agree to organ donation for transplantation from the members of their family after death and 65.3% of the residents would be donors after their death. Half of the respondents (55.9%) believe that the final decision as to the donation of organs from a deceased person should be taken by the family. A positive attitude towards organ transplantation was expressed by 67.6% of respondents.

CONCLUSIONS

Inhabitants of rural areas mostly agree with procurement of organs from the deceased and also from living donors. However, the enthusiasm and goodwill associated with the transplantation of organs after death diminished when the problem affects members of the family. Positive attitude about transplantation is related to age and level of the education.

[Acute kidney injury in patients with acute respiratory distress]

Acute respiratory distress together with hypoxia could be an indication for admission to intensive care unit. It may also lead to acute kidney injury. In addition, mechanical ventilation may be an additional factor for development of acute kidney injury. The aim of the work was to assess the prevalence of acute kidney injury, including the need for renal replacement therapy in patients with acute respiratory distress treated in intensive care unit. In addition, the effect of acute kidney injury on outcome of patients with acute respiratory distress was evaluated. The studies were performed on 100 patients with acute respiratory distress treated in intensive care unit of the regional hospital. Patients were divided into 2 groups in respect to the presence or absence of acute kidney injury. Acute kidney injury was diagnosed in 22% of patients with acute respiratory distress, while 12% required renal replacement therapy, it was more often observed in patients with estimated GFR < 60 ml/min/1.73m2. Length of stay was similar irrespective of kidney function, however, the mortality was significantly higher in patients with eGFR < 60 ml/min/1.73 m2, particularly in those on hemodialyses. In addition, mortality was associated with older age and sepsis.

[Suicides among patients with mental disorders - case studies]

INTRODUCTION

Suicides around the world are a major public health problem. They are the most serious causes of death among patients with mental disorders. In many European countries, national programs and strategies for suicide prevention were developed. The progress of civilisation, changes in political and economic life, a too fast pace of life negatively affect human, causing the liberation of self-destructive behaviours.

AIM

The aim of this study, which was based on medical records, was to analyse the course of psychiatric disorders, that ended with suicide.

MATERIAL AND METHODS

Descriptions of the course of mental disorders which ended with suicide and self-harm codes according to ICD-10 in randomly selected patients have been presented. 1. A 68 year old patient with schizophrenia - the intending self-harm by hanging (X70); 2. A 46 years old patient with a diagnosis of schizoaffective disorder - the intentional self-harm by drug poisoning (X61); 3. A 51 years old patient with a diagnosis of bipolar disorder - suicide death under the wheels of the train (X8 1).

CONCLUSIONS

Risk of suicide in mental disorders requires the implementation conduct standards in a suicide crisis. In each case, it is necessary to assess the risk on the basis of the identification of suicide risk factors. Evaluation of risk factors is the basis of therapeutic action and determines how to support patients with a risk of suicidal death. Despite advances in the treatment of mental disorders, in some cases, there is still limited effectiveness of suicide preventio.

Do overweight patients have a better five years prognosis after an acute myocardial infarction treated with coronary intervention?

BACKGROUND

Obesity and overweight alone may confer a survival benefit after myocardial infarction, independent of age, medical care or therapy.

AIM

To evaluate the impact of body mass index (BMI) on long-term mortality in ST-segment elevation acute myocardial infarction (STEMI) patients treated by primary angioplasty (PCI).

METHODS

We prospectively studied a homogenous group of 131 patients who had suffered STEMI, and subsequently exhibited a TIMI 3 flow after primary PCI. The patients (41 women, 90 men, mean age 58.3 ± 10.8 years) were analysed in two groups: Group 1 - 30 (23%) patients with BMI 〈 25 kg/m(2) and Group 2 - 101 (77%) patients with BMI ≥ 25 kg/m(2).

RESULTS

Altogether, 19 (14.5%) patients died during the five-year follow-up period - nine out of 30 (30%) were patients with BMI 〈 25 kg/m(2), and ten out of 101 (10%) were patients with BMI ≥ 25 kg/m(2) (p 〈 0.001). Individuals with BMI ≥ 25 kg/m(2) had lower five-year mortality, and this was independent of other potentially confounding variables. Area under the receiver-operating characteristic (ROC) curves for death with respect to weight on ROC analysis was significantly different than for a random model (p 〈 0.05). There were no significant differences in 30-day mortality and one-year mortality (p = 0.6517 and p = 0.3573, respectively).

CONCLUSIONS

Patients after primary angioplasty for STEMI with BMI 〈 25 kg/m(2) and patients with BMI ≥ 25 kg/m(2) have no difference in 30-day or one-year mortality, but individuals with BMI ≥ 25 kg/m(2) have a better five year prognosis, and this is independent of other potentially confounding variables.

[Rotational atherectomy in a patient with non-ST elevation acute coronary syndrome]

Rotational atherectomy is a valuable technique complementary to PCI in complex calcified coronary artery stenoses. A case of a 65 year-old man with non-ST elevation acute myocardial infarction (NSTEMI) treated with PCI with rotational atherectomy followed by two drug eluting stents (DES) implantation is presented.

[Nephrology complications in cardiology]

Heart disease and renal failure occurring together, constitute a potential threat to life, especially in the elderly. Diseases of the cardiovascular system are the main factor in morbidity and mortality in patients with chronic kidney disease. On the other hand, chronic kidney disease is considered a risk factor for cardiovascular diseases. Identified major nephrological problems, especially chronic renal disease and acute kidney damage, as the most aggravating cardiac patients. Stressed the importance of clinical, preventive measures and prognosis in contrast nephropathy

The influence of renal function and selected cardiovascular risk factors on the thickness of the intima-media complex in the peripheral arteries

BACKGROUND

Measurement of the intima-media thickness (IMT) in the peripheral arteries leads to better stratification of cardiovascular risk. This is of great importance in patients with chronic renal insufficiency, who are particularly vulnerable to developing atherosclerotic lesions. The aim of the study was to evaluate whether parameters of renal insufficiency and selected risk factors of atherosclerosis influence IMT in the peripheral arteries.

METHODS

The study population comprised 231 patients submitted to coronary angiography with ultrasonographic assessment of the common carotid artery (CCA), carotid artery bulb (CB) and common femoral artery (CFA) made contemporaneously with evaluation of IMT and atherosclerotic plaques. Renal function as well as selected clinical and biochemical risk factors of atherosclerosis were assessed. Two subgroups were analysed: 200 patients with coronary heart disease confirmed angiographically (study group) and 31 patients without coronary lesions (control group).

RESULTS

Significant negative correlation was found between glomerular filtration rate and IMT values in CCA (p < 0.001) as well as in CB (p < 0.05). Patients with abnormal glucose metabolism had significantly higher IMT values in CCA (0.95 +/- 0.30 vs. 0.87 +/- 0.20; p = 0.034). Hypercholesterolaemia did not influence the IMT values in CCA and CFA. There was no correlation between body mass index and IMT.

CONCLUSIONS

Patients with chronic renal insufficiency presented higher values of IMT in CCA. The measurement of IMT appears to be a valuable non-invasive method of diagnosing preclinical stages of atherosclerosis in the described group of patients. (Cardiol J 2007; 14: 59-66).

[Obesity as a risk factor of chronic kidney disease in patients undergoing primary angioplasty]

The number of patients with chronic kidney disease-CKD is still growing. Overweight and obesity present also an important problem of world public health. However, there are not many data showing possible association between obesity and incresing risk of development of renal failure recently it has been demonstrated that in obese patients secondary focal segmental glomerulosclerosis and glomerular hypertrophy appear more frequently. The aim of this study was to estimate glomerular filtration rate-GFR in patients with normal serum creatinine concentration undergoing primary angioplasty according to body mass index. The study included 1413 patients udergoing primary angioplasty for acute myocardial infarction. The following parameters were assessed: age, gender, family history of cardiovascular disease, risk factors of cardiovascular disease (hypertension, diabetes mellitus, obesity etc.), previous myocardial infarction, pre-existing heart failure, treatment given, localization of infarct, coronary stenting, serum creatinine before angioplasty, cholesterol, LDL, HDL, triglycerides, glucose, blood pressure. Of a total of 1413 patients, 1337 (94.62%, 943 M, 394 F) had correct serum creatinine concentration (below 1.5 mg/dl for men, below 1.2 mg/dl for women). Glomerular filtration rate was calculated from serum creatinine levels by using the simplified Modification of Diet in Renal Disease Study formula--MDRD, Cockcroft-Gault equation and Jeliffe formula. An average value of GFR in study group was 79.94 +/- 24.51 ml/min (Cockcroft-Gault equation), 73.02 +/- 21.96 ml/min (Cockcroft-Gault adjusted to weight), 90.37 +/- 25.1 ml/min (MDRD equation) and 77.67 +/- 21.65 ml/min (Jeliffe formula). A significant lower serum creatinine levels and GFR (assessed by 3 formulas and Cockcroft-Gault using adjusted weight) were observed in women group. In the whole study group (with normal serum creatinine levels) substantial correlation was found between age and serum creatinine concentration (r = 0.13, p > 0.001), GFR (MDRD, r = -0.37, p < 0.001, Cockcroft-Gault, r = -0.62, p < 0.001, adjusted to weight r = -0.64, p < 0.001, Jeliffe r = -0.61, p < 0.001) and also between BMI and GFR (MDRD r = 0.28, p < 0.001, Cockcroft-Gault, r = 0.31, p < 0.001, adjusted to weight r = 0.08, p < 0.001, Jeliffe r = 0.341, p < 0.001), but not with serum creatinine concentration (r = 0.03, p = 0.3). In patients with normal serum creatinine levels percentage of patients with GFR below 60 ml/min ranges from 4.79% up to 30.74%. In patients with higher BMI, higher GFR may be partially caused by glomerular hyperfiltration. Overweight or obesity are significant, but potentially changeable risk factors for development of chronic renal failure. However, chronic kidney disease is one of the complications of obesity.

[Antiphospholipid antibodies in patients with coronary heart disease and the disturbances of glucose tolerance]

Experimental and clinical reports suggest the role of antiphospholipid antibodies (aPL) in the pathogenesis of atherosclerosis and arterial thrombosis. The aim of our study was to evaluate IgM and IgG anti-beta2-glycoprotein I (anti-beta2-GPI), as well as IgG antiphosphatydylserine (aPS) antibodies in 80 consecutive patients (mean age 58.6+/-8.3 years) referred for coronary angiography, dependent on the extent of atherosclerotic lesions in coronary vessels and the disturbances of glucose tolerance. Antiphospholipid antibodies were measured by ELISA. The mean values of aPS and anti-beta2-GPI did not differ significantly between patients with 1- (n = 17), 2- (n = 15) or 3-vessel disease (n = 14) and subjects without significant changes in coronary arteries (n = 34), as well as between patients with unstable (n = 12) and effort angina (n = 68). Significantly higher levels of IgG anti-beta2-GPI were found in the subgroup with type 2 diabetes in comparison with the subjects with impaired glucose tolerance (median 3,8 (1.9 -9.3) U/ml vs 2,8 (1.5-5.0) U/ml, p = 0.027). Current smokers (n = 11) had significantly higher values of aPS than non smokers (55.8 +/- 30.7 - 64.7) U/ml vs 38.7 (5.7 +/- 82.6) U/ml, p = 0.017). Abnormal aPS values were found in 34 subjects (42,5%): 16 (6 diabetics) with normal angiograms (47.0%), 9 (26.5%) with 1-vessel disease, 3 (8,8%) with 2-vessel disease and 6 (17,6%) with 3- vessel disease. Increased IgG anti- (2-GPI levels were found in 8 (10%), and IgM anti-beta2-GPI - in 4 patients (5%). All subjects with high IgM anti-beta2-GPI values, as well as 5 persons with high IgG anti-beta2-GPI levels (62.5%) had significant coronary artery lesions. Multiple regression analysis revealed that factors independently influencing the levels of aPS were: patient's age (Beta = -0.8417, p = 0.0003) and glycaemia 120 min. after glucose load (Beta = 0.6453, p = 0.025).

CONCLUSIONS

our results do not confirm an association between aPS or/and anti-beta2-GPI antibodies and the extent of atherosclerotic lesions in coronary vessels, although they suggest an increased membrane phospholipids immunogenicity in relatively young patients with elevated postload glycaemia, as well as cigarette smokers.

Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD?

BACKGROUND

Gastro-esophageal reflux disease (GERD) may cause chest pain. The aim was to determine the correlation between ischemia and gastro-esophageal reflux in patients with CAD and to assess the influence of short-term "anti-reflux" therapy on the ischemia in patients with GERD and CAD.

METHODS

Fifty patients with angiographically proven CAD underwent simultaneous 24-h continuous ECG and esophageal pH monitoring. We assessed the number of ST-segment depression episodes (ST dep.) and total duration of ischemic episodes, expressed as total ischemic burden (TIB). In pH-metry, we assessed: time percentage of pH lower than 4, total time of pH lower than 4 and the number of pathological refluxes (PR). Patients fulfilling the GERD criteria received a 7-day therapy with omeprazole 20 mg bid. On the 7th day of therapy, simultaneous Holter and esophageal pH monitoring was repeated.

RESULTS

Total number of 224 PRs in 42 patients (84%) was recorded during esophageal pH-metry. GERD criteria were fulfilled in 23 patients (46%). Out of 218 episodes of ST dep., 45 (20.6%) correlated with PR. GERD patients had larger TIB and higher number of ST dep. (p<0.015 and p<0.035, respectively). The anti-reflux therapy reduced all analyzed parameters of esophageal pH monitoring (p<0.0022) as well as the number of ST dep. (p<0.012) and TIB (p<0.05).

CONCLUSIONS

Gastro-esophageal reflux disease is common in patients with CAD and may provoke myocardial ischemia. Short-term proton pump inhibitors therapy that restores normal esophageal pH significantly reduces myocardial ischemia, possibly due to elimination of acid-derived esophago-cardiac reflex compromising coronary perfusion-the phenomenon known as "linked angina".

Is transport with platelet GP IIb/IIIa inhibition for primary percutaneous coronary intervention more efficient than on-site thrombolysis in patients with STEMI admitted to community hospitals? Randomised study. Early results

INTRODUCTION

The advantage of primary percutaneous coronary intervention (pPCI) in the management of ST-elevation myocardial infarction (STEMI) over thrombolytic therapy has been demonstrated. However, an optimal medical treatment of STEMI patients admitted to regional hospitals without catheterisation facilities has not yet been established. Delay in initiation of pPCI resulting from transportation to the catheterisation laboratory may diminish the benefits of such therapy in comparison with thrombolysis administered in a regional hospital. Early initiation of therapy with platelet glycoprotein IIb/IIIa receptor inhibitor, which provides protection for the transportation, may be a reasonable solution to maintain the advantage of pPCI over thrombolysis alone in STEMI patients.

METHODS

The studied group comprised patients with STEMI (infarct duration time <12 hours, typical clinical and electrocardiographic criteria of MI) who were randomly assigned in 13 regional hospitals located 20 to 150 km from invasive centre to one of two subgroups, either to thrombolysis in the community hospital or to transport after thrombolysis initiation with platelet GP IIb/IIIa receptor inhibitor (tirofiban; 10 mg/kg in intravenous bolus in the emergency room of the community hospital followed by continuous intravenous infusion of 0.1 mg/kg/min during transport as well as coronary procedure) in order to receive pPCI. All patients with cardiogenic shock on admission were routinely treated with PCI and were excluded from the study.

RESULTS

341 patients were included in the study (169 were randomised to receive thrombolytic therapy and 172--transport with intention to perform PCI). Mean time between onset of MI and randomisation was similar in the transport and thrombolysis groups, (139+/-133 min. vs 143+/-117 min., respectively, p=0.94). Mean infusion time of tirofiban to the beginning of PCI in the transport group was 121+/-36 min. Anterior MI was present in 42.6% of patients in the PCI group and in 41.5% in the thrombolytic group (p=0.085). Mean time from randomisation to pPCI was 158+/-60 min., and to thrombolysis initiation in 44+/-43 min. (p <0.0001). None of the patients died during transfer. In a 30-day follow-up we noted (pPCI vs thrombolytic group, respectively): mortality 3.49% vs 8.88% (p=0.04); reinfarction 1.16% vs 5.92% (p=0.02), stroke 0.58% vs 1.18% (p=0.55). In-hospital stay was significantly shorter in the transport group (9+/-3 days vs 14+/-7 days, p <0.0001). During hospitalisation, 17 (10.05%) patients initially assigned to thrombolysis alone had to be transferred to the catheterisation laboratory to undergo PCI (rescue PCI or PCI for postinfarction angina). Combined end-point (death/reinfarction/stroke) was reached more frequently in the thrombolytic group (15.98% vs 5.23%, p=0.001).

CONCLUSIONS

A strategy of invasive therapy involving transport with GP IIb/IIIa receptor inhibitor and pPCI in STEMI patients admitted to hospital without catheterisation facilities was found to be more effective than thrombolytic therapy alone employed in the regional hospitals.

[No-reflow phenomenon occurring during elective angioplasty performed due to in-stent restenosis -- a case report]

The no-reflow phenomenon is an impairment of microcirculation after successful percutaneous coronary interventions (PCI). The no-reflow phenomenon is usually observed during acute myocardial infarction. This case-report describes no-reflow phenomenon in a patient undergoing elective PCI in the right coronary artery, occluded due to restenosis in implanted stent. After deflation of balloon during angioplasty in restenosed stent, no-reflow phenomenon occurred, followed by asystolia. The patient was successfully resuscitated. During resuscitation procedures, abciximab was administered what improved myocardial perfusion. This case demonstrates that no-reflow phenomenon can be a serious problem during elective PCI, leading even to a cardiac arrest. It shows also the necessity for administration of drugs improving tissue perfusion when no-reflow phenomenon occurs.

Changes in C-reactive protein levels following coronary stent implantation depend on the extent of periprocedural arterial injury

BACKGROUND

Coronary stenting is associated with acute inflammation within the arterial wall followed by neointimal growth. Acute inflammatory response is expressed by a marked systemic elevation of the inflammatory biomarker C-reactive protein (CRP). It has been shown that the degree and extent of CRP increase may be related to clinical presentation or periprocedural treatment.

AIM

To investigate whether an increase in CRP level is associated with the extent of arterial injury during stent deployment.

METHODS

CRP levels were measured with a high-sensitivity CRP (hsCRP) assay. Seventy-three patients (51 males) with normal baseline plasma CRP (<3 mg/L) underwent percutaneous coronary intervention (PCI) with stent implantation for stable coronary disease. Blood samples for hsCRP were drawn before the intervention, and 6, 12 and 24 hours after the procedure. Both quantitative (single vs multivessel coronary intervention) and qualitative analyses (including lesion classification according to the ACC/AHA grading system) were performed in all patients. The examined angiographic parameters and procedural data obtained included reference diameter, lesion location, lesion length, total stented segment length, diameter of stent after deployment, maximal deployment pressure, total inflation number and duration.

RESULTS

The mean hsCRP level increased in all patients between baseline and 24 hours (1.36+/-0.93 mg/L and 4.34+/-3.3 mg/L, p <0.0001). Single vessel procedure was performed in 51 patients and multivessel coronary intervention in 22 patients. Mean hsCRP was similar at baseline and after 6 hours in both groups and the increase after 12 and 24 hours was higher among patients with multivessel coronary intervention compared to patients with single vessel procedure (2.69+/-2.48 vs 4.15+/-3.17; p=0.039 and 3.76+/-3.13 vs 5.69+/-3.38; p=0.021, respectively). There was no correlation between hsCRP and the degree of lesion complexity. Multiple regression analysis showed that the total stented segment length (p=0.01) contributed to the hsCRP increase after 24 hours.

CONCLUSIONS

The inflammatory response expressed by hsCRP levels is higher in patients with multivessel coronary intervention with longer total segment stented.

[Thrombus in the left atrium -- is it always treated properly?]

A case of a 61-year-old female with a history of stroke in a course of mitral stenosis with atrial fibrillation is reported. Mitral commissurotomy was conducted eight years after the diagnosis. The chest X-ray revealed large calcified mass in the left atrium. During surgical mitral valve replacement the mass has been removed and identified as calcified thrombus. Despite numerous risk factors, anticoagulation has not been introduced until a few months before the operation.

[Estimation of renal function in patients with normal serum creatinine undergoing primary percutaneous coronary intervention]

Kidney disease and cardiovascular disease seem to be lethally synergistic and both approach level of epidemy. On the other hand, patients with ischemic heart disease often exhibit renal dysfunction due to concomitant diabetes, hypertension, congestive heart failure and dyslipidemia. Patients with chronic kidney disease are at increased risk of death after acute MI.

AIM

Assessment of prevalence of kidney dysfunction in patients with normal serum creatinine using estimated GFR in a cohort of 922 consecutive patients undergoing primary PCI due to acute myocardial infarction.

RESULTS

Normal serum creatinine (less than 1.5 mg/dL in males and less than 1.2 mg/dL in females) was observed in 857 (93%) patients. Mean GFR was 69.0 +/- 21.15 ml/min (Cockcroft-Gault formula), 85.18 +/- 24.17 ml/min (MDRD) or 72.25 +/- 21.65 ml/min (Jeliffe). According to Cockcroft-Gault formula stage 2 chronic kidney disease-CKD i.e. GFR 60-89 ml/min was found in 378 patients (44.11%) and stage 3 CKD i.e. GFR 30-59 ml/min was found in 283 (33.02%) patients with normal serum creatinine. According to MDRD formula stage 2 CKD was found in 440 patients (51.32%) and stage 3 CKD was found in 71 (8.29%) patients, whereas according to Jeliffe formula stage 2 CKD was found in 405 patients (47.25%) and stage 3 CKD was found in 194 (22.63%) patients with normal serum creatinine.

CONCLUSION

The prevalence of chronic kidney disease is high, up to almost 80% patients undergoing primary PCI despite normal serum creatinine. The risk of contrast nephropathy with worse outcomes is enhanced in these patients. In patients with risk factors for cardiovascular disease, GFR should be estimated since renal dysfunction is one more important risk for cardiovascular morbidity and mortality.

Plasma adiponectin and E-selectin concentrations in patients with coronary heart disease and newly diagnosed disturbances of glucose metabolism

PURPOSE

Adiponectin is a fat derived hormone, which enhances insulin sensitivity. In experimental studies adiponectin was shown to have antiatherogenic properties by suppressing endothelial expression of adhesion molecules. Therefore, the aim of the study was to evaluate plasma adiponectin and E-selectin concentrations in patients with coronary artery disease and impaired glucose metabolism and evaluation of their relationship with selected anthropometric, biochemical and clinical parameters.

MATERIAL AND METHODS

The study group consisted of 62 patients with coronary heart disease, without previous diagnosis of diabetes mellitus (mean age 48.6 +/- 6.0 years; mean BMI 28.6 +/- 3.13 kg/m2). In the studied group the OGTT with glucose and insulin estimation was performed and insulin resistance index (HOMA-IR) was calculated. In the fasting state, the plasma adiponectin, soluble form of E-selectin, HbA1c and lipid parameters were estimated.

RESULTS

Adiponectin concentration was not different in patients with type 2 diabetes mellitus and impaired glucose tolerance (n = 36) in comparison to the group with normal glucose tolerance (n = 26). There was also no difference in adiponectin concentration in relation to atherosclerosis progression. There was no significant correlation between adiponectin and calculated insulin resistance index, while there was marked inverse correlation between adiponectin and BMI (r = -0.30; p = 0.018), body weight (r = -0.33; p = 0.008), E-selectin (r = -0.263; p = 0.039), TG concentration (r = -0.27; p = 0.036), duration of coronary heart disease (r = -0.33; p = 0.009) and borderline significance with ejection fraction (r = -0.268; p = 0.06).

CONCLUSIONS

Our study supports the hypothesis that adiponectin could be recognised as a protective protein for the development of atherosclerosis.

[Repeated administration of t-PA and abciximab in a patient with anterior myocardial infarction--a case report]

Repeated administration of t-PA and abciximab in a patient with anterior myocardial infarction - a case report. A case of a 40-year-old male with acute anterior myocardial infarction (MI) is presented. Due to the angiographic equipment failure, the patient did not undergo primary angioplasty and received heparin and 100 mg of t-PA. This treatment was associated with clinical and ECG signs of reperfusion, however, 30 minutes after completion of t-PA infusion, the patient developed clinical and ECG signs of re-occlusion. The decision was made to transfer the patient to a catheterisation laboratory for further invasive treatment, however, it was located 200 km from our centre. Because of that, the patient received another dose of 50 mg of t-PA and abciximab before transportation. Further course was uncomplicated and the patient underwent successful stent implantation in the other centre.