Pericarditis and Takotsubo Syndrome-Diagnosis of Cardiac Complications of Post-Acute COVID-19 Syndrome in a 77-Year-Old Woman

The SARS-CoV-2 virus infection most often takes the form of acute COVID-19 respiratory disease, but in some patients, it turns into acute COVID-19 syndrome after a few weeks. Cardiac complications occur in the form of acute and post-acute diseases and the most common are myocarditis, pericarditis, arrhythmias, and acute coronary syndromes or Takotsubo syndrome. Cardiovascular complications are often the cause of hospitalization and death in COVID-19 patients. We present the case of a 77-year-old woman who was admitted to the clinic with suspected myocardial infarction. Coronary arteriography revealed atherosclerotic wall lesions, and echocardiography showed a good contractility of the left ventricle and fluid in the pericardial sac. Pericarditis was diagnosed. In the following days, acute kidney damage was observed, and one hemodialysis session was performed. On the sixth day of hospitalization, a sudden cardiac arrest occurred, and the patient was resuscitated. The echocardiogaphy showed abnormal contractility of the left ventricular with the ejection fraction of 15%-Takotsubo image. After a few hours, a cardiac arrest occurred again, and the patient died.

Echocardiography, Computed Tomography and Magnetic Resonance Imaging in the Differential Diagnosis of a Tumor in the Left Atrium of the Heart

Cardiac tumors are rare. Most often they are metastatic tumors, while primary tumors are much less common. In addition to proliferative changes in the heart, there are also non-neoplastic structures, such as thrombus, vegetation or inflammatory tumors. All structures with a heart tumor morphology require a lot of imaging studies in order to diagnose them and plan treatment without performing a biopsy. We present a case of a 75-year-old female patient who had moving masses in the left atrium on echocardiography. Computed tomography of the chest was performed, which did not clearly explain the nature of the structure observed in the left atrium. The Heart Team decided to perform another test—magnetic resonance imaging (MRI) of the heart in 3 months to differentiate the lesion. The examination was performed after 3 months of warfarin therapy and there were no masses in the left atrium, which confirmed that the observed tumor was a thrombus.

Fractional Flow Reserve in the Diagnosis of Ischemic Heart Disease in a Patient with Coronary Artery Ectasia

Coronary artery ectasias (CAE) are diffuse dilatations of coronary artery segments with a diameter 1.5 times greater than the largest adjacent normal segment of the vessel. They are found in 0.3–5.0% of coronary angiography. Risk factors for CAE include atherosclerosis, previous percutaneous coronary interventions, arterial inflammation and connective tissue diseases. The diagnosis of CEA in a patient is a considerable diagnostic and therapeutic problem due to the unfavorable prognosis and the lack of guidelines. We present a case of a 69-year-old male patient with a history of retrosternal pain admitted to the clinic for the diagnosis of coronary artery disease. In coronary angiography, numerous ectases of the main coronary arteries and atherosclerotic lesions causing border stenosis of the left anterior descending (LAD), diagonal (2D) and marginal branch (OM). The heart team decided to assess the significance of the changes with the fractional flow reserve (FFR). The FFR was performed and haemodynamically insignificant stenoses of the ectatically dilated coronary arteries were found. The patient was qualified for conservative treatment.

Association between air pollution and case-specific mortality in north-eastern part of Poland. Case crossover study with 4,500,000 person-years of follow-up

Background

Recent studies have reported associations between air pollution and daily mortality. The majority of them are conducted in highly polluted areas. Taking into consideration the scarce number of surveys from cities with moderate air quality we decided to conduct a study in this type of region.

Purpose

To assess the short-term impact of air pollution on cardiovascular (CVD), coronary artery-related (CAD), and cerebrovascular-related (CbVD) mortality.

Methods

The analysis with almost 4,500,000 person-years of follow-up with a time-stratified case-crossover design was performed. Results are reported as odds ratio (OR) associated with an increase in interquartile range (IQR).

Results

The analysed region was inhabited by almost 500,000 residents. From 2008 to 2017 in Bialystok, Lomza, and Suwalki we recorded 49,573 deaths – 34,005, 8,082, 7,486, respectively. The median daily concentrations of PM10 (23.8 μg/m3, IQR=16.9) was the highest in Lomza, Median daily concentration of PM2.5 was the highest in Bialystok (16.2 μg/m3, IQR=15.9). In the case of Suwalki, daily median PM2.5 concentration was 9.8 μg/m3 (IQR=8.7), and PM10 – 18.0 μg/m3 (IQR=14.3). The IQR increase in PM2.5 (OR 1.036, 95% CI 1.016–1.056, P<0.001) and PM10 concentration (OR 1.034, 95% CI 1.015–1.053, P<0.001) was associated with increased CVD mortality on lag 0 and this effect persisted on following days. The effects of PMs were more expressed in association with CAD-related mortality (OR for PM2.5 = 1.045, 95% CI 1.012–1.080, P=0.008), (OR for PM10 = 1.044, 95% CI 1.010–1.078, P=0.011) and CbVD mortality (OR for PM2.5 = 1.046, 95% CI 1.013–1.080, P=0.006), (OR=1.041 for PM10, 95% CI 1.002–1.082, P=0.038). Additionally, IQR increase in NO2 concentration was associated with increased CAD-related mortality at lag 0–1 (OR=1.055, 95% CI 1.004–1.108, P=0.032). The highest OR for PMs was noted in Suwalki compared to Bialystok and Lomza. The trend was noted regardless of the cause of death from lag 0 to lag 0–3. In a comparison of seasons, we noted higher CVD mortality OR in the cold season for PM10 in Suwalki (P=0.047) and Bialystok (p=0.001). However, the impact of NO2 (P=0.02) and PM10 (P=0.03) on CAD related mortality was higher in the warm season.

Conclusions

The impact of air pollution on CVD mortality is also observed in moderately polluted areas. PMs and NO2 had the greatest impact on CAD-related mortality. Differences in effect size and seasonality may depend on the source of air pollution.

Funding Acknowledgement

Type of funding sources: None.

Cardiac rupture – the most serious complication of Takotsubo syndrome

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).

Funding Acknowledgement

Type of funding sources: None.

Impact of air pollution on mortality due to cerebrovascular diseases

Funding Acknowledgements

Type of funding sources: None.

Background

The short-term effect of air pollution on cardiovascular mortality is well-documented but a scarce number of studies focus on cause-specific mortality in low-polluted areas.

Purpose

We decided to distinguish deaths due to cerebrovascular disease (CbVD) from a region widely known as the Green Lungs of Poland to assess the short-term effect of air pollution on CbVD mortality.

Methods

The analysis with almost 4,500,000 person-years of follow-up with a time-stratified case-crossover design was performed. Results are reported as odds ratio (OR) associated with an increase in interquartile range (IQR) of air pollution.

Results

In the overall analysis of the studied region PM2.5 had an impact on increased CbVD mortality at LAG 0 (OR 1.046, 95% CI 1.013 – 1.080, P = 0.006), LAG 0-1 (1.048, 1.002-1.082, P = 0.040), and LAG 0-3 (1.052, 1.015-1.090, P = 0.006). The influence of PM10 was noted at LAG 0 (1.041, 1.002-1.082, P = 0.040). CbVD mortality in Bialystok was increased by exposure to PM10 at LAG 0 (1.05, 1.00-1.09, P = 0.048) and CO at LAG 1 (1.07, 1.00-1.14, P = 0.04). Additionally, an effect of CO was observed in cold season at LAG 1 (1.09, 1.02-1.17, P = 0.02), LAG 0-1 (1.08, 1.00-1.016, P = 0.04), and LAG 0-3 (1.09, 1.01-1.18, P = 0.04). In Suwalki, an impact of PM2.5 was also observed.

Conclusions

A short-term increase in air pollutants concentrations, especially in PM2.5 and CO, had an influence on CbVD mortality. Mortality rates were significantly increased in cold season. We also found heterogeneity in the influence of major contributors on mortality between analyzed cities.

Exposure to air pollution and renal function - an underestimated threat?

Funding Acknowledgements

Type of funding sources: None.

Introduction

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 not only in respiratory, circulatory, and nervous systems but also in renal function.

Purpose

Our goal was to investigate the hypothesis indicating that we can observe the long-term and also short-term impact of air pollution on kidney function.

Methods

We reviewed medical notes of patients hospitalized between 2007-2016. 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 with 95% confidence intervals (CI).

Results

3,554 patients were included into the final analysis. The median age was 66 (IQR 15) and men were in the majority (53.2%, N = 1891). Chronic kidney disease (CKD) was diagnosed in 21.5% (N = 764). The long-term increase in annual average 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) resulted in an increased number of patients with CKD. In short-term observation the IQR increase in weekly PM2.5 concentration was associated with a 2% reduction in eGFR (OR = 0.98, 95%CI 0.97 – 0.99, P = 0.03)

Conclusions

The effects of air pollution on renal function were observed. Long- and short–term exposure to elevated air pollution levels was associated with a decrease in eGFR. The main pollutant affecting the kidneys was PM2.5.

Does climate change affect the chronobiological trends in occurrence of acute coronary syndromes?

Funding Acknowledgements

Type of funding sources: None.

Background

Acute coronary syndromes (ACS) are the leading cause of death all over the world, in the last years chronobiology of their occurrence has been changing.

Purpose

The aim of this study was to assess the influence of climate change on hospital admissions due to ACS.

Methods

Medical records of 10,529 patients hospitalized for ACS in 2008–2017 were examined. Weather conditions data were obtained from the Institute of Meteorology.

Results

Among the patients, 3537 (33.6%) were hospitalized for STEMI, 3947 (37.5%) for NSTEMI, and 3045 (28.9%) for UA. The highest seasonal mean for ACS was recorded in spring (N = 2782, mean = 2.52, SD = 1.7; OR 1.07; 95% CI 1.0-1.2; P = 0.049) and it was a season with the highest temperature changes day to day (Δ temp.=11.7). On the other hand, every 10ºC change in temperature was associated with an increased admission due to ACS by 13% (RR 1.13; 95% CI 1.04-1.3; P = 0.008). Analysis of weekly changes showed that the highest frequency of ACS occurred on Thursday (N = 1703, mean = 2.7, SD = 1.9; OR 1.16; 95% CI 1.0-1.23; P = 0.004), in STEMI subgroup it was Monday (N = 592, mean = 0.9, SD = 1.6, OR 1.2; 95% CI 1.1-1.4; P = 0.002). Sunday was associated with decreased admissions due to all types of ACS (N = 1098, mean = 1.7, SD = 1.4; OR 0.69; 95% CI 0.6-0.8, P < 0.001). In the second half of the study period (2013-2018) the relative risks of hospital admissions due to ACS were 1.043 (95%CI: 1.009-1.079, P = 0.014, lag 0) and 0.957 (95%CI: 0.925-0.990, P = 0.010, lag 1) for each 10ºC decrease in temperature; 1.049 (95% CI: 1.015-1.084, P = 0.004, lag 0) and 1.045 (95%CI: 1.011-1.080, P = 0.008, lag 1) for each 10 hPa decrease in atmospheric pressure and 1.180 (95% CI: 1.078-1.324, P = 0.007, lag 0) for every 10ºC change in temperature. For the first half of the study the risk was significantly lower.

Conclusion

We observed a shift in the seasonal peak of ACS occurrence from winter to spring which may be related to temperature fluctuation associated with climate change in this season. The lowest frequency of ACS took place on weekends. Atmospheric changes had a much more pronounced effect on admissions due to ACS in the second half of the analyzed period, which is in line with the dynamics of global climate change.

Primary Takotsubo Syndrome as a Complication of Bladder Cancer Treatment in a 62-Year-Old Woman

BACKGROUND The main causes for takotsubo syndrome (TS) in oncological patients are stress related to cancer diagnosis and treatment, pain in the course of the disease, treatment complications, and paraneoplastic syndromes. CASE REPORT An obese 62-year-old female patient, with a 3-day history of chest pain, was admitted to the hospital with a suspected acute coronary event. She had been diagnosed with high-grade bladder cancer 6 months before. After the transurethral electroresection of the tumor 5 months before and subsequent chemotherapy (gemcitabine and cisplatin), the patient was qualified for the next cancer surgery. On admission, the patient remained without chest pain. The ECG record demonstrated inverted T waves in the leads from above the anterior and lateral wall. The coronarography demonstrated minor atherosclerotic changes in the coronary arteries. The left ventriculography presented akinesis of the apex and the apical and mid-segment of the anterior wall, and the ejection fraction (EF) was 38%. Takotsubo syndrome was diagnosed. Laboratory testing revealed elevated concentration of troponin and N-terminal pro-B-type natriuretic peptide. The subsequent ECG records demonstrated deeply inverted T waves and numerous ventricular premature beats and increased QTc (528 ms). A control echocardiography showed improved left ventricular contractive function (EF - 47%). On the 4th day of hospitalization, the patient was discharged and referred for further oncological treatment. CONCLUSIONS The diagnosis of TS in oncology patients is difficult, especially in the presence of atherosclerotic lesions in coronary arteries. Takotsubo syndrome in cancer patients delays the next stages of oncological treatment, which worsens the prognosis of these patients.

Myocardial infarction triggered by exposure to air pollution – underestimated or overrated issue – 11 years study

Introduction

Currently, the greatest threat to the health and life of people and the leading cause of death in Poland are cardiovascular diseases (CVD). Air quality is a well-known risk factor for the development of them.

Purpose

The aim of this study is to assess the impact of air pollution on the frequency of hospital admissions due to acute coronary syndrome (ACS).

Methods

The medical records of 30,695 patients hospitalized in the Department of Invasive Cardiology were analyzed. Patients treated for ACS and living within the borders of the analyzed city met inclusion criteria. Weather conditions such as temperature, humidity, atmospheric pressure, wind speed and the following components of air pollution were analyzed: carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2), trioxygen (O3), particulate matter with a diameter of 2.5 μm or less (PM2.5) and with a diameter of 10 μm or less (PM10). Poisson regression was used for statistical analysis.

Results

The study included 3,325 inhabitants of analyzed city (mean age 66.2 years, SD=12.2), male in majority (60.3%). The number of patients admitted for ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA) was 1002, 1265, and 1058, respectively. An increase of CO concentration by 1 g/m3 was associated with a higher number of admissions due to NSTEMI (RR 1.74; 95% CI, 1.08–2.8; P=0.02), this effect was more noticeable in the female population (RR - 2.8; 95% CI, 1.39–5.65; P=0.004). In male subjects an increase in the concentration of PM2.5 by 10 μg/m3 was associated with a 0.5% increase in the number of admissions for NSTEMI (RR 1.05, 95% CI 1.02–1.22; P=0.02) and UA (OR 1.14, 95% CI 1.02–1.25; P=0.014). An increase in the concentration of SO2 by 1 μg/m3 affected the frequency of admissions in men due to NSTEMI (0.5% increase, RR 1.04, 95% CI 1.01–1.07; P=0.007) and UA (OR 1.17, 95% CI 1.02–1.36; P=0.031). The concentration of 03 and NO2 did not affect admissions rate due to ACS.

Conclusions

Air quality had an impact on the occurrence of ACS among residents of Bialystok. Increased exposure to air pollution, in particular, elevated PM2.5, SO2 and CO levels, was associated with a higher incidence of NSTEMI and UA. This effect was more noticeable in the male population.

Funding Acknowledgement

Type of funding source: None

Gender differences in association between air pollution and daily mortality in Green Lungs of Poland – population-based study with almost 3,000,000 person-years of observation

Introduction

Air pollution is considered to be one of the main risk factors for public health, in particular its impact on the disorders of the pulmonary and cardiovascular system and the related mortality.

Purpose

This study was carried out to assess the influence of the atmospheric conditions and air pollutants on mortality in the population of the big city in the eastern Poland.

Materials and methods

Based on the data from the Central Statistical Office, the number and causes of the deaths of the city 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. Multivariate Poisson regression was used for statistical analysis.

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). The main causes of deaths in the female population were chronic ischemic heart disease (N=1683; 10.42%) and cerebral infarction (N=1617; 10.01%), while in the male population, in addition to chronic ischemic heart disease (N=1530; 8.57%), deaths were caused mainly by malignant neoplasm of the bronchus and lung (N=1555; 8.71%). During the analysis, it was observed that the 1-day norm of sulfur dioxide (SO2) recommended by the World Health Organization (WHO) guidelines was sporadically exceeded (N=18, 0.50% of analyzed days), while the daily norm for the particulate matter with a diameter of 2.5 μm or less (PM2.5) was exceeded on 688 days (23.60% of analyzed days). In the female group, excluding the seasonal impact, an increase of SO2 concentration by 1-μg/m3 (RR 1.05, 95% confidence interval (CI) 1.01–1.10; P=0.009) and a 10°C decrease of temperature (RR 1.04, 95% CI 1.02–1.07; P=0.003) were related to an increase in the number of daily deaths. In the male group, a stronger effect of SO2concentration on mortality was noted; the RR for 1-μg/m3 increase of SO2 was 1.10 (95% CI 1.04–1.18; P=0.002). In the subgroup analysis of cardiovascular deaths, the main pollutant that was found to have an effect on daily mortality was PM2.5; the RR for 10-μg/m3 increase of PM2.5 was 1.07 (95% CI 1.02–1.12; P=0.01).

Conclusions

Air quality and atmospheric conditions had an impact on the mortality of Białystok residents, and this effect was more pronounced in the male population. The main air pollutants that influenced the rate of mortality were SO2and PM2.5. In the female population, an additional factor that influenced the total mortality and mortality due to cardiovascular diseases was temperature. It is worth emphasizing that the impact of SO2 on mortality was clear within “safe” range recommended by WHO. More research on that topic is necessary, but our results bring questions whether the recommended norms should be stricter, or is there a safe concentration of SO2 in the air at all.

Funding Acknowledgement

Type of funding source: None

The GRACE scale in the prognosis of patients with Takotsubo syndrome

Background

The prognosis of Takotsubo syndrome (TTS) is comparable to that of the non-ST-elevation myocardial infarction (NSTEMI). The GRACE scale is used to assess the risk of premature and long-term mortality in patients with NSTEMI in order to select the most favorable treatment strategy.

Methods

101 patients with TTS were hospitalized in 4 centers of invasive cardiology in Podlaskie Voivodeship during the period 2008–2012 were included in the study. The patients were divided into 2 groups: I – 52 patients (GRACE ≤140 points) and II – 49 patients (GRACE >140 points).

Results

The mean GRACE score in study group was 138.66. The course of Takotsubo in the patients with higher GRACE scores was associated with higher incidence of pneumonia (36,7% vs 7,69%, p=0,0004), rhythm abnormalities (17,3% vs 3,85%, p=0,026) and serious complications (cardiogenic shock, pulmonary edema, and sudden cardiac arrest) (30,6% vs 5,77%, p=0,001).

The mean observation period was 7.2 years. A significantly higher risk of 6-month (18,37% vs 3,85%, p=0,019),1-year (22,45 vs 3,85%, p=0,005), 3-year (40,82 vs 3,85%, p<0,0001), 5-year (42,86% vs 3,85%, p<0,0001) and 7-year mortality (53,06% vs 9,62%, p<0,0001) was observed in the group of patients with a GRACE score ≥140. The death risk factors in the multivariate analysis performed were low BMI, low eGFR, and a higher GRACE score

The ROC curve presents the discriminatory scores of the GRACE scale for the follow-up prognosis. The area under ROC curve (AUC) for the GRACE scale was 0.805 (95% CI - 0.718–0.892, p<0.001), with a cut-off value of 153 points, sensitivity of 74%, and specificity of 77% for TTS.

Conclusion

The GRACE scale is highly valuable for the prognosis of death risk in patients with TTS in the early and follow-up period.

Funding Acknowledgement

Type of funding source: None

Effectiveness of Levosimendan in an 84-Year-Old Patient with Takotsubo Syndrome Complicated by Acute Heart Failure

BACKGROUND Although takotsubo syndrome (TTS) is usually mild, severe complications such as acute heart failure may occur in the acute phase. Because of the etiology of TTS, typical catecholamines are not recommended; the use of inotropic drugs with a different mechanism of action is recommended, mainly levosimendan. CASE REPORT An 84-year-old patient with cardiovascular risk factors, hospitalized in a city hospital because of exacerbation of chronic obstructive pulmonary disease (COPD), was transferred to the clinic with suspected myocardial infarction. At the time of admission, the patient was hemodynamically stable. The coronarography indicated insignificant atherosclerotic lesions in the coronary arteries. The echocardiography revealed apical akinesis and hypokinesis of the apical and middle left ventricular segments (LV). The ejection fraction (EF) was 40%. TTS was diagnosed. After 12 h of hospitalization, the patient developed symptoms of acute heart failure, with deterioration of the LV systolic function (EF 30%). Levosimendan was included in the treatment, which led to an increased blood pressure and clinical improvement after several hours. Over the next few days, the patient's condition improved and he was transferred to the referral center, from which he was discharged to home. CONCLUSIONS In patients with COPD, exacerbation of the disease may be a trigger for TTS. In acute heart failure complicating TTS, administration of levosimendan improves the clinical condition of patients.

Hepcidin - Potential biomarker of contrast-induced acute kidney injury in patients undergoing percutaneous coronary interventions

PURPOSE

Contrast-induced acute kidney injury (CI-AKI) is a common and potentially serious complication of percutaneous coronary interventions (PCI). In this study, we tested the hypothesis whether serum and urinary hepcidin could represent early biomarkers of CI-AKI in patients with normal serum creatinine undergoing PCI. In addition, we assessed serum and urinary neutrophil gelatinase-associated lipocalin (NGAL), cystatin C, eGFR and serum creatinine in these patients.

METHODS

Serum and urinary hepcidin and NGAL, serum cystatin C, were evaluated before, and after 2, 4, 8, 24 and 48 h after PCI using commercially available kits. Serum creatinine was assessed before, 24 and 48 h after PCI.

RESULTS

We found a significant rise in serum hepcidin as early as after 4 and 8 h when compared to the baseline values. Serum NGAL increased after 2, 4 and 8 h, and in urinary NGAL after 4, 8 and 24 h after PCI. We found a significant fall in urinary hepcidin after 8 and 24 h after PCI. Serum cystatin C increased significantly 8 h after PCI, reaching peak 24 h after PCI and then decreased after 48 h. The prevalence of CI-AKI was 8%. Urine hepcidin was significantly lower 8 and 24 h after PCI in patients with CI-AKI, while serum and urine NGAL were significantly higher in patients with CI-AKI.

CONCLUSIONS

Our findings suggest that serum hepcidin might be an early predictive biomarker of ruling out CI-AKI after PCI, thereby contributing to early patient risk stratification. However, our data needs to be validated in large cohorts with various stages of CKD.

Patients with Atrial Fibrillation and Chronic Kidney Disease More Often Undergo Angioplasty of Left Main Coronary Artery - a 867 Patient Study

BACKGROUND/AIMS

Several studies have implicated atrial fibrillation (AF) as a contributing factor in chronic kidney disease (CKD) and cardiovascular events. The prevalence of coronary artery disease (CAD) in patients with AF varies substantially from 17% to 46.5%. There are only few studies concerning renal function in population with AF undergoing coronary angiography. The aim of the present study was to assess which type of AF is dominant in CKD population scheduled for coronary angiography and if it can influence patients' outcome, the association between renal impairment and the type of coronary procedures in AF patients and the influence of renal function on in-hospital mortality.

METHODS

We retrospectively studied 867 patients with AF hospitalized due to coronary angiography in two year time. The cut off value of CKD was eGFR ≤ 60 ml/min./1.73m2 evaluated by CKD-EPI formula.

RESULTS

A total of 867 patients with AF (44% women; mean age 72±10 years) were included in the analysis. The mean eGFR was 44±11ml/min./1.73m2 in patients with CKD and 89±18 ml/min./1.73m2 in patients with preserved renal function. Patients with CKD and AF were older (p< 0.001), had more often diabetes (p=0.009), heart failure (p< 0.001) and anaemia (p< 0.001). Patients with CKD and AF had more often permanent type of AF (p< 0.001). In CKD patients CHA2DS2VASc score was 4.3±1.5 and HAS-BLED score was 2.0±1.2 and it was significantly higher as compared to population with preserved renal function (p< 0.001, p=0.02, respectively). The use of oral anticoagulation was less frequent in CKD group (p< 0.001) although these patients had higher CHA2DS2VASc score. Patients with AF and CKD were more often admitted due to myocardial infarction (STEMI or NSTEMI) (p=0.02, p< 0.001, respectively) and more often underwent percutaneous coronary intervention (PCI) (p=0.01). Among coronary arteries the percutaneous coronary intervention (PCI) of left main artery was done more frequently in CKD patients (p=0.01). Among CKD population in-hospital mortality was significantly higher in patients with eGFR < 30 ml/min (p< 0.001).

CONCLUSION

Patients with CKD had more often permanent type of AF. Percutaneous interventions of the left main coronary artery, the only elective procedures influencing patients' prognosis, were done more frequently in CKD patients with AF. In-hospital mortality was significantly higher in patients with severe renal impairment. Despite the higher risk of ischaemic stroke in CKD group the use of oral anticoagulation therapy was significantly less frequent and the patients were deprived of the confirmed benefits of such treatment.

Matrix Metalloproteinase Neutrophil Gelatinase-Associated Lipocalin Complex Predicts Atrial Fibrillation Recurrence after Electrical Cardioversion in Obese Patients

BACKGROUND

There is not much data on matrix metalloproteinase neutrophil gelatinase-associated lipocalin (MMP-NGAL) complex in patients with atrial fibrillation (AF).

AIM

The aim of the study was to assess the value of MMP-NGAL complex in predicting AF recurrence after electrical cardioversion.

METHODS

The serum levels of NGAL, cystatin C, interleukin-6, high-sensitivity C-reactive protein, copeptin, MMP-NGAL complex, matrix metalloproteinase 2, tissue inhibitor of metalloproteinase 1, Von Willebrand factor, B-type natriuretic peptide and the urinary level of NGAL were evaluated before cardioversion.

RESULTS

A total of 83 patients with persistent AF were enrolled in the study. Left atrial diameter (LA) ≥4.5 cm was significantly associated with AF recurrence at follow-up (p = 0.009). In selected 39 obese patients, MMP-NGAL complex was associated with AF recurrence (p = 0.03). If the concentration of MMP-NGAL complex increased by 1 ng/ml, the odds of AF recurrence increased by 4% (OR 1.04; CI: 1.00-1.08; p = 0.03). MMP-NGAL complex did not correlate with AF recurrence in patients with a first episode of AF, in patients ≥65 years of age and in patients with a LA ≥4.5 cm or with chronic kidney disease.

CONCLUSIONS

It is known that the greater the BMI at baseline, the higher the likelihood of progression from paroxysmal to permanent AF. However, European Society of Cardiology (ESC) guidelines do not consider obese patients a population with a low likelihood of success of cardioversion. That is why we need a sensitive marker to predict sinus rhythm maintenance in such a population. We found that MMP-NGAL complex may predict AF recurrence after successful cardioversion in obese patients.

Takotsubo cardiomyopathy: serious early complications and two-year mortality - a 101 case study

Background

Takotsubo cardiomyopathy (TTC) is characterised by transient contractility disturbances of the apex of the left ventricle.

Methods

We enrolled 101 patients from the northern-eastern part of Poland in the years 2008–2012 who were hospitalised for TCC. The control group consisted of female patients diagnosed with anterior myocardial infarction with ST-segment elevation (anterior STEMI) (n = 101).

Results

89 % of the study group were women. Patients with TTC had diabetes (12.6 % vs 29.7 %; p = 0.002) and hyperlipidaemia (36.8 % vs 64.4 %; p = 0.0001) significantly less frequently, and better kidney function assessed by estimated glomerular filtration rate versus patients with anterior STEMI (74.52 % vs 64.30 %; p = 0.004). In the TTC group there were more patients with chronic obstructive pulmonary disease (11.6 % vs 1.0 %; p = 0.002) and thyroid disturbances, especially hyperthyroidism (23.4 % vs 11.0 %; p = 0.021). In patients with TTC sudden cardiac arrest, pulmonary oedema and cardiogenic shock were observed less frequently than in the control group (14.7 % vs 30.7 %; p = 0.0078). Hospitalisations in TTC patients were less frequently complicated by pneumonia (20.0 % vs 35.6 %; p = 0.0148) and urinary infection (4.2 % vs 21.8 %; p = 0.0003). Cardiac rupture occurred in 3 patients with TTC and in 1 with anterior STEMI. In-hospital mortality was significantly lower in the group with TTC. Also, mortality at 30 days, 3 months, 1 year and 2.5 years was significantly lower in patients with TTC than in patients with MI (p = 0.035; p = 0.0226; p = 0.0075; p = 0.009).

Conclusions

Previously considered to be a benign syndrome, TTC should be reconsidered as a clinical condition at risk for serious complications such as cardiac arrest, cardiogenic shock, pulmonary oedema and cardiac rupture leading to death and causing substantial early hazard. The prognosis in TTC is significantly better than in patients with anterior STEMI.

Do CHA2 DS2 VASc and HAS-BLED scores influence 'real-world' anticoagulation management in atrial fibrillation? 1556 patient registry from the reference cardiology centre

INTRODUCTION

Although recommendations for the antithrombotic management of atrial fibrillation (AF) are based on strong evidence, the European guidelines are not fully implemented into practice.

OBJECTIVES

The objective of this study is to analyse antithrombotic treatment in AF in Poland after the publication of the European Society of Cardiology Guidelines in 2012.

PATIENTS AND METHODS

We retrospectively studied 1556 patients with AF from the Reference Cardiology University Centre in Poland in 2012-2014.

RESULTS

CHA2 DS2 VASc and HAS-BLED scores were 3.5 ± 1.7 and 2.4 ± 1.1. Anti-vitamin K agent were prescribed in 59%, with non-vitamin K antagonist oral anticoagulants in 12%, acetylsalicylic acid (ASA) alone in 18%. Older patients (p < 0.0001) and with paroxysmal AF were less likely to receive oral anticoagulation (OAC, p < 0.0001). The risk of stroke according to CHA2 DS2 VASc score was higher in patients who did not receive OAC (p < 0.0001). The use of OAC increased with increasing CHA2 DS2 VASc score but was less frequent in score ≥ 4. The risk of bleeding was higher in patients without OAC (p < 0.0001). The odds of non-vitamin K antagonist oral anticoagulants use were lower for older patients, patients with ischaemic heart disease, chronic heart failure, anaemia, HAS-BLED ≥ 3 and valvular AF. ASA was given in 39% of the patients, especially in paroxysmal AF (p < 0.0001). The odds of ASA alone were higher for older patients, with ischaemic heart disease and history of myocardial infarction (p < 0.0001). The odds of use of ASA as the only treatment were 5.5 times higher for HAS-BLED ≥ 3 (p < 0.0001).

CONCLUSIONS

Antithrombotic management in AF is well implemented in Polish conditions, but we show the lack of pattern concerning who is being treated with OAC and ASA when it comes to the risk of stroke and bleeding.

Significant narrowing of the circumflex artery leads to worse outcomes than right coronary artery narrowing in patients with anterior myocardial infarction treated invasively

BACKGROUND

Occlusion of the circumflex artery (Cx) often does not present signs in the ECG. It can lead to delayed angiography during ST-elevation myocardial infarction (STEMI). The aim of this analysis was to determine if Cx narrowing is related to diverse outcomes in comparison with right coronary artery (RCA) stenosis in patients with STEMI, treated with percutaneous coronary intervention (PCI) of the left descending artery (LAD).

METHODS AND RESULTS

Inclusion criteria were as follows: first STEMI treated with PCI of the LAD and additional significant (≥ 70 %) Cx or RCA narrowing-two-vessel disease. A total of 234 consecutive patients with STEMI were included. Total mortality was estimated during long-term follow-up, at mean 639 (± 224) days after STEMI. Patients with Cx narrowing constituted 46 % (N = 108) of the study population, and patients with RCA narrowing amounted to 54 % (N = 126). Patients with narrowing of the Cx had worse long-term outcomes in terms of mortality than patients with RCA narrowing (22 vs. 11 %, p < 0.05, respectively). Multiple regression analysis showed independent risk factors for death during long-term follow-up such as: age, ejection fraction and Cx narrowing.

CONCLUSION

Significant Cx narrowing leads to worse outcomes than RCA narrowing in patients with STEMI treated with PCI of the LAD.

Renalase, kidney and cardiovascular disease: are they related or just coincidentally associated?

Cardiovascular diseases, including hypertension are the leading cause of death in the developed countries. Diabetes and chronic kidney disease became also more prevalent reaching almost the level of epidemy. Researchers are looking eagerly for the new risk and/or pathogenetic factors, as well as therapeutic option in these disease. It has been suggested that human kidney releases a protein named renalase into the bloodstream. It is supposed to be an enzyme which breaks down catecholamines in the blood circulation and regulate blood pressure. However, there were several doubts whether renalase exerts monoaminooxidase activity, or if it is monoaminooxidase at all. Recently, a hypothesis that it is also a cytokine was postulated. Studies on renalase polymorphisms in hypertension, cardiovascular disease or diabetes are inconsistent. Similarly, there are several discrepancies in the animal on the possible role of renalase in hypertension and cardiovascular diseases. Some studies report a protective role of renalase in acute kidney injury, whereas others showed that renalase levels were mainly dependent on kidney function, indicating rather a role of kidney in excretion of this substance. Moreover, validated assays are needed to evaluate renalase levels and activity. On one hand a deeper and more accurate link between renalase and cardiovascular diseases require further profound research, on the other hand whether or not renalase protein could be a new therapeutic target in these pathologies should also be considered. Whether renalase, discovered in 2005, might be a Holy Grail of hypertension, linking kidney and cardiovascular diseases, remains to be proven.

Cardiovascular disease and kidney transplantation‑evaluation of potential transplant recipient

Cardiovascular evaluation of a potential kidney transplant recipient remains controversial. The burning issue is the lack of clear guidelines as well as the fact that patients with a low probability of cardiovascular disease undergo numerous unnecessary screening procedures and false‑positive results are common. In general, the standard procedure involves clinical data collection, physical examination, electrocardiography, chest‑X ray, measurement of the lipid profile and fasting glycemia, cardiac ultrasonography, followed by coronary angiography. An exercise tolerance test is not recommended because it has low sensitivity and is difficult to perform and interpret. Cardiac ultrasonography should be performed after a hemodialysis session to avoid an effect on hypervolemia. All noninvasive diagnostic imaging and isotope tests are usually of limited value and, to a large extent, are facility- and operator‑dependent. Coronary angiography should be considered in patients with positive exercise tolerance test results and a history of acute coronary syndrome, unstable coronary artery disease, and high cardiovascular risk. However, a decision regarding therapy, ie, percutaneous coronary intervention, stenting (type of stent), or coronary artery bypass grafting should be made during the meeting of a cardiac team. The guidelines also discuss cardiac contraindications to kidney transplantation. It should be stressed that a patient scheduled for a kidney transplant is sick at the time of evaluation and that his or her condition may change after several years on the waiting list. Therefore, cardiac reevaluation may be needed. Preemptive transplantation as well as short dialysis therapy before transplantation (<6 months) are associated with better patient and graft survival and thus with lower incidence of cardiovascular complications and better quality of life. The current review discusses the available guidelines on the evaluation of the potential kidney transplant recipient.

Impact of diabetes on mortality and complications after coronary artery by-pass graft operation in patients with left main coronary artery disease

PURPOSE

Left main disease (LMD) is a severe form of coronary artery disease (CAD). Fifty percent of patients with LMD treated conservatively die within 3-5 years of diagnosis. The aim of the study was to assess the influence of type 2 diabetes on early and late (2-year) prognosis and the risk of complications after coronary artery by-pass graft (CABG) surgery in patients with LMD.

MATERIAL/METHODS

We enrolled 257 patients diagnosed with LMD. 169 (67%) underwent CABG, 19 (8%) percutaneous coronary intervention (PCI) without left main stem protection. 30 (12%) patients had CABG previously. Patients treated with CABG were divided into two groups - with and without diabetes. There were 43 (25.4%) patients with diabetes and 126 (74.6%) without diabetes.

RESULTS

We observed more complications with wound healing (40.5% vs. 12.8%, p<0.001) and sternal dehiscence (23.8% vs. 4.0%, p<0.001) after CABG in patients with diabetes. There were no differences in 7-day, 30-day, 3-month and 1-year mortality. 2-Year mortality was also similar in both groups (11.6% vs. 11.1%, p=0.928). Patients with diabetes were more frequently hospitalized due to other reasons than angina (39.5% vs. 20.6%, p=0.014).

CONCLUSIONS

Patients with diabetes and LMD had more often complications with wound healing and sternal dehiscence after CABG than patients without diabetes. Type 2 diabetes did not influence early and late mortality in patients with LMD treated with cardiac surgery, but the presence of diabetes was associated with more frequent hospitalizations.

Biomarkers of Contrast-Induced Nephropathy: Which Ones and What Is Their Clinical Relevance?

Contrast-induced nephropathy, or contrast-induced acute kidney injury (AKI), is an acute impairment of renal function as manifested by an increase in serum creatinine. Different urinary and serum proteins have been intensively investigated as possible biomarkers for the early diagnosis of AKI. Promising candidate biomarkers have the ability to detect an early and graded increase in tubular epithelial cell injury and to distinguish prerenal causes of AKI from acute tubular necrosis. In this article new, emerging biomarkers of contrast-induced AKI are presented and described, of which serum neutrophil gelatinase-associated lipocalin appears to be the most promising.

Pharmacologic treatment in dialysis patients hospitalized for cardiovascular reasons: do we follow the guidelines?

AIM

The aim was to assess if the pharmacological treatment due to cardiovascular causes in dialysis patients is compliant with the European Guidelines.

METHODS

In total, 110 consecutive end-stage renal disease (ESRD) patients on regular dialysis were enrolled into the study. We divided the population into subgroups with coronary artery disease (CAD), chronic heart failure (CHF) and diabetes mellitus (DM).

RESULTS

We gathered information about drugs from 99 patients. The mean age was 61.8 ± 12.9 years (70% of males). There were 37 patients with CAD. Acetylsalicylic acid (ASA) was taken by 89% of the patients with CAD, clopidogrel by 25%, beta-blockers by 70%, angiotensin converting enzyme inhibitors (ACEIs) by 50%, angiotensin receptor blockers (ARBs) by 8%, and statins by 41%. Dual antiplatelet therapy was used after stent implantation (35%). There were 24 patients with CHF. Beta-blockers were taken by 71% of the patients, ACEIs by 45%, statins by 54%, and diuretics by 21% with CHF. There were 36 patients with DM. ASA was taken by 89% of the patients, clopidogrel and ticlopidine by 34%, beta-blockers were taken by 67%, ACE-inhibitors by 55%, and statins by 38% of the population with DM. The patients with DM were taking more ACEIs than those without DM (p = 0.033). DM was associated with a statistically 21% higher odds of ACEI/ARB use, but CHF was associated with no increase in the odds of beta-blocker use and no increase in ACEI/ARB use.

CONCLUSIONS

Dialysis patients with cardiovascular diseases are given less cardioprotective drugs such as ASA, beta-blockers, ACEIs, ARBs, and statins than they should be given according to the guidelines.

Which method of GFR estimation has the best prognostic value in patients treated with primary PCI: Cockcroft-Gault formula, MDRD, or CKD-EPI equation?--A 6-year follow-up

BACKGROUND/AIMS

The aim of this study was to determine the correlation between renal function and 6-year mortality in patients with acute myocardial infarction (AMI), treated successfully with primary percutaneous coronary intervention (PCI), and to examine whether Cockcroft-Gault (C-G) formula or Modification of Diet in Renal Disease (MDRD) study equation or CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation is the best predictor of very late mortality.

METHODS

A prospective cohort study with 6-year follow-up of a homogenous group of 193 patients, with ST-segment elevation AMI treated with successful primary PCI. Glomerular filtration rate (GFR) estimated by C-G formula, MDRD, and CKD-EPI equation were analyzed.

RESULTS

The patients with chronic kidney disease (CKD) had a much lower cumulative survival rate than those without it (p < 0.05). A larger area under the receiver-operating characteristic curve for death with respect to GFR for C-G formula was observed. In the multivariate analysis, only GFR ≥ 55 mL/min according to C-G formula was independently associated with lower mortality.

CONCLUSION

CKD is associated with higher mortality after a successful primary PCI during a 6-year follow-up. C-G formula is better than MDRD and CKD-EPI equations at predicting mortality after AMI.

Left ventricular morphology and function in diabetic and nondiabetic hemodialyzed patients

Morbidity in end-stage renal disease (ESRD) diabetic patients is worse than in patients without diabetes mellitus (DM). This study aims to compare clinical, laboratory, and echocardiographic features between the ESRD patients with and without DM. Fifty-eight ESRD patients on dialysis were prospectively divided into two groups according to the presence of DM. Demographic, clinical, laboratory, and echocardiographic features (ejection fraction and wall motion score index) were compared between the two groups. Overall, 20 out of 58 patients (37.8%) with ESRD had DM. There were no significant differences between the patients with DM and those without DM when it comes to age (60.6 ± 10.6 vs. 59.0 ± 10.6 years, P = 0.665), ejection fraction (52.6% ± 12.8% vs. 54.2% ± 12.8%, P = 0.59), and wall motion score index (1.21 ± 0.3 vs.1.15 ± 0.3, P = 0.37). In multivariant analysis of the interventricular septum, posterior wall thickness and left atrium size correlated positively with DM. There was also no statistical difference in myocardial perfusion disturbances on real-time contrast echocardiography between the groups with and without DM (12 (60%) patients vs. 14 patients (36.8%), P = 0.079). Among diabetics 77.8% had significant atherosclerotic changes, while in the group without DM, only 38.1%, P = 0.01. From the laboratory parameters ferritin and high-sensitivity C-reactive protein levels were significantly higher in the group with DM, P = 0.014 and P = 0.026, respectively. Patients with ESRD and DM have significantly bigger left atrial size, thicker left ventricular walls, and higher serum ferritin and high-sensitivity C-reactive protein levels than the patients without DM. The aforementioned features may be possible risk factors for the development of adverse cardiac events in patients on hemodialysis.

Markers of kidney function in the elderly in relation to the new CKD-EPI formula for estimation of glomerular filtration rate

INTRODUCTION

Neutrophil gelatinase-associated lipocalin (NGAL) has been recently proved useful in the quantitation of chronic kidney disease (CKD). The aim of the study was to assess prevalence of CKD according to the Modification of Diet in Renal Disease (MDRD), Cockcroft-Gault, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulae in 412 patients with normal serum creatinine and markers of kidney function/injury such as NGAL, cystatin C, and kidney injury molecule-1 (KIM-1) in these patients in relation to age (below and over 65 years).

MATERIAL AND METHODS

We included in the study 1005 patients with coronary artery disease and normal serum creatinine. However, markers of kidney function/injury were assessed in 412 patients. The NGAL, cystatin C and KIM-1, were assessed using commercially available kits.

RESULTS

Patients over 65 years had significantly lower estimated glomerular filtration rate (eGFR) than their younger counterparts despite identical creatinine. They also had significantly lower haematocrit, despite similar Hb, lower platelet count, higher serum fibrinogen, higher systolic (SBP) and lower diastolic blood pressure, higher serum NGAL and cystatin C, but similar urinary NGAL and KIM-1. Serum NGAL correlated with age, haematocrit, leukocyte, platelet and erythrocyte count, eGFR, creatinine, fasting glucose, HbA(1c), fibrinogen, SBP, and diabetes duration. In multiple regression analysis kidney function (eGFR, creatinine clearance or creatinine), cystatin C and SBP were predictors of serum NGAL.

CONCLUSIONS

In our study we found a very high prevalence of CKD up to 61% in elderly patients with coronary artery disease and normal serum creatinine. Neutrophil gelatinase-associated lipocalin could be a sensitive marker of kidney function, particularly in elderly patients with another risk factor for kidney damage, i.e. hypertension.

Impact of diabetes mellitus on survival in patients with end-stage renal disease: a three-year follow-up

BACKGROUND/AIMS

To assess the impact of diabetes mellitus (DM) on clinical outcome in patients with end-stage renal disease (ESRD) on a 3-year follow-up.

METHODS

58 ESRD patients were divided into 2 groups according to the presence of DM. We analyzed following end points: death, cardiac arrest, myocardial infarction, stroke, hospitalizations due to cardiovascular causes, revascularization, and combined end point.

RESULTS

Among diabetics, 14 (77.8%) had significant atherosclerotic changes, in the group without DM only 8 (38.1%), p = 0.01. In the group without DM, 14 (46.7%) patients reached combined end point, while in the group with DM 16 (53.3%) patients, p = 0.0013. There were no statistical differences in mortality (p = 0.423).

CONCLUSION

Survival of hemodialyzed diabetic patients is not inferior to nondiabetics; however, morbidity is significantly higher due to adverse cardiac events.

Prevalence of chronic kidney disease and anemia in patients with coronary artery disease with normal serum creatinine undergoing percutaneous coronary interventions: relation to New York Heart Association class

BACKGROUND

Kidney disease and cardiovascular disease seem to be lethally synergistic and both are approaching the epidemic level. A reduced glomerular filtration rate is associated with increased mortality risk in patients with heart failure. Many patients with congestive heart failure are anemic. Anemia is very often associated with chronic kidney disease.

OBJECTIVES

To assess--in relation to New York Heart Association class--the prevalence of anemia and chronic kidney disease in patients with normal serum creatinine in a cohort of 526 consecutive patients with coronary artery disease undergoing percutaneous coronary interventions.

METHODS

GFR was estimated using the simplified MDRD formula, the Cockcroft-Gault formula, the Jeliffe and the novel CKD-EPI formula.

RESULTS

According to the WHO definition the prevalence of anemia in our study was 21%. We observed a progressive decline in GFR and hemoglobin concentration together with a rise in NYHA class. Significant correlations were observed between eGFR and systolic blood pressure, diastolic blood pressure, age, NYHA class, complications of PCI, including bleeding, and major adverse cardiac events.

CONCLUSIONS

The prevalence of anemia and chronic kidney disease is high in patients undergoing PCI despite normal serum creatinine, particularly in higher NYHA class. Lower eGFR and hemoglobin are associated with more complications, including bleeding after PCI and higher prevalence of major adverse cardiac events. In patients with risk factors for cardiovascular disease, GFR should be estimated since renal dysfunction and subsequent anemia are important risk factors for cardiovascular morbidity and mortality.

Serum neutrophil gelatinase-associated lipocalin as a marker of renal function in non-diabetic patients with stage 2-4 chronic kidney disease

The current Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines advocate creatinine-based equations for estimating GFR to identify patients with potential kidney disease and classify them into different stages due to the fact that serum creatinine is very insensitive to changes in the glomerular filtration rate. Very few biomarkers exist for monitoring chronic kidney disease. The aim of the study was to assess whether NGAL could represent a novel, sensitive marker of kidney function in adult patients with CKD. The study was performed on 92 non-diabetic patients with CKD stages 2-4. Serum and urinary NGAL as well as serum cystatin C were measured using commercially available kits. Serum NGAL was related, in univariate analysis, to serum creatinine, urinary NGAL, hemoglobin, hematocrit, leukocyte count, eGFR, and cystatin C. Urinary NGAL correlated with age, hemoglobin, hematocrit, serum creatinine, and eGFR. In multiple regression analysis, predictors of serum NGAL were creatinine (beta value = 0.97, p = 0.005), cystatin C (beta = 0.34, p = 0.01), and eGFR (beta value = 1.77, p = 0.001). In the healthy volunteers, serum NGAL correlated with age, serum creatinine, eGFR, leukocyte count, and cystatin C. Taking into consideration the fact that the recent DOQI (Dialysis Outcomes Quality Initiative) states that individuals with reduced GRF (glomerular filtration rate) are at greater risk for CVD and cardiac deaths, precise evaluation of renal function is important in order to select the appropriate strategy to reduce the cardiovascular risk. NGAL should be investigated as a potential early and sensitive marker of kidney impairment/injury.

Serum neutrophil gelatinase-associated lipocalin as a marker of renal function in hypertensive and normotensive patients with coronary artery disease

AIM

Hypertension is one of the risk factors for cardiovascular diseases. The kidneys could be a victim and/or culprit of hypertension. Recently, the value of neutrophil gelatinase-associated lipocalin (NGAL) was highlighted as a novel marker for early detection of acute renal damage. Therefore, the aim of the study was to assess whether hypertension could affect NGAL and cystatin C levels in patients with normal serum creatinine (lower than 1.5 mg/dL in males and 1.2 mg/dL in females) and stable coronary artery disease.

METHODS

Serum, urinary NGAL, cystatin C and estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease study (MDRD) and Cockcroft-Gault formulas) were evaluated in hypertensive, normotensive patients with stable coronary heart disease and healthy volunteers.

RESULTS

Normotensives had significantly lower NGAL than hypertensives. Serum cystatin C was significantly lower in normotensives than in hypertensives. Urinary NGAL did not differ significantly between these groups. Despite similar serum creatinine levels, eGFR (MDRD and Cockcroft-Gault formulas) was significantly higher in normotensives than in hypertensives. Serum NGAL was related, in univariate analysis, to serum creatinine, urea, urinary NGAL, haemoglobin, haematocrit, duration of hypertension, age, eGFR by MDRD and Cockcroft-Gault, and cystatin C.

CONCLUSION

Hypertension is associated with kidney injury as reflected by elevated serum NGAL and cystatin C. It is noteworthy that despite normal serum creatinine, eGFR is relatively low suggesting impaired renal function. Therefore, NGAL needs to be investigated as a potential early marker for impaired kidney function/kidney injury, especially in patients with another risk factor for kidney damage, namely coronary artery disease.

Lack of ST-segment depression normalization after PCI is a predictor of 5-year mortality in patients with ST-elevation myocardial infarction

BACKGROUND

The significance of dynamic changes in a depressed ST-segment in the reciprocal changes after percutaneous coronary intervention (PCI) of patients with ST-elevation myocardial infarction (STEMI) is unknown, so the aim of this study was to evaluate the significance of reciprocal ST-segment depression normalization (STN) on long-term mortality in patients with STEMI treated with primary PCI.

METHODS AND RESULTS

Data for 247 consecutive patients with STEMI were analyzed; 84 patients were excluded because of exclusion or incomplete inclusion criteria, so finally, 163 patients successfully treated with primary PCI were included. The study group was divided into 3 subgroups according to percentage of STN: poor STN (<30%), partial STN (30-70%), complete STN (>70%). Complete STN occurred in 63%, partial in 24% and poor in 13% of patients. STN correlated with late mortality (15% vs 28% vs 38% respectively, p=0.012). Patients who died during the follow-up period had a lower mean percentage reduction of initial ST-segment depression after PCI (50% vs 75%, p=0.001). Percentage reduction of initial ST-segment depression after PCI was a significant and independent risk factor of long-term mortality (odds ratio 1.01; 95% confidence interval: 1.00-1.02; p=0.02).

CONCLUSIONS

These data revealed the use of reciprocal changes normalization as a novel tool for assessment of long-term risk of death in patients after successful primary PCI for STEMI.

Could neutrophil-gelatinase-associated lipocalin and cystatin C predict the development of contrast-induced nephropathy after percutaneous coronary interventions in patients with stable angina and normal serum creatinine values?

The value of neutrophil-gelatinase-associated lipocalin (NGAL) was highlighted as a novel biomarker for the detection of acute renal failure. We tested the hypothesis whether NGAL could represent an early biomarker of contrast-induced nephropathy (CIN) in 100 patients with normal serum creatinine values undergoing percutaneous coronary interventions (PCI). In addition, we assessed serum and urinary NGAL in relation to cystatin C, estimated glomerular filtration rate, and serum and urinary creatinine in these patients. We measured urinary and serum NGAL values before and 2, 4, 8, 24, and 48 h after the PCI. We found a significant rise in serum NGAL levels 2, 4, and 8 h after the PCI and in urinary NGAL values 4, 8, and 24 h after a PCI procedure. Cystatin C rose significantly 24 h after the procedure. The prevalence of CIN was 11%. The NGAL levels were significantly higher 2 h after the PCI (serum NGAL) or 4 h after the PCI (urinary NGAL), whereas the cystatin C values were higher only 8 and 24 h after a PCI procedure in patients with CIN. In multivariate analysis, only serum creatinine was a predictor of serum NGAL before a PCI. NGAL may represent a sensitive early biomarker of renal impairment after PCI. Serum creatinine level, the presence of diabetes, and the duration of the PCI may affect serum NGAL values and kidney function following a PCI procedure.

Transfer with GP IIb/IIIa inhibitor tirofiban for primary percutaneous coronary intervention vs. on-site thrombolysis in patients with ST-elevation myocardial infarction (STEMI): a randomized open-label study for patients admitted to community hospitals

AIMS

Our study aimed to compare two reperfusion strategies in patients with ST-elevation myocardial infarction (STEMI) admitted initially to a community hospital without catheterization facilities.

METHODS AND RESULTS

Four hundred and one patients with STEMI admitted to community hospital (13 hospitals, radius 20-150 km from cath-lab) were randomized to on-site thrombolysis or to transport with tirofiban (10 microg/kg bolus i.v. + i.v. infusion 0.1 microg/kg/min) for primary PCI in single invasive centre. Primary endpoints were total mortality, recurrent MI (re-AMI), and stroke during 1 year follow-up. Delay to reperfusion defined as interval between admission and start of fibrinolysis or primary PCI was 35 and 145 min (P < 0.0001). Mean time of tirofiban administration to PCI in transfer group was: 122.3 +/- 35.7 min. Mortality was not different during hospitalization and at 30th-day, with trend towards lower mortality at 1 year in transport group (12.5 vs. 7.0%, P = 0.061). There were no differences in the rate of re-AMI and stroke, with trend towards lower incidence of re-AMI in transfer group at 1 year (7.5 vs. 3.5%, P = 0.073). Composite of death/re-AMI/stroke was higher in on-site group during follow-up (15.5 vs. 8.0%, P = 0.019; 21.5 vs. 11.4%, P = 0.006, respectively, at 30th-day and 1 year).

CONCLUSION

Outcomes at 1 year follow-up suggest that transportation with adjunctive therapy with GP IIb/IIIa inhibitor tirofiban for primary PCI is superior to on-site thrombolysis for patient with STEMI presenting to hospital without catheterization facilities.

NGAL (neutrophil gelatinase-associated lipocalin) and cystatin C: are they good predictors of contrast nephropathy after percutaneous coronary interventions in patients with stable angina and normal serum creatinine?

The aim of the study was to assess whether NGAL and cystatin C could predict contrast-induced nephropathy in non-diabetic patients (n=60, mean age 60+/-11 years) with normal serum creatinine undergoing elective PCI. We found a significant rise in serum NGAL after 2, 4 and 8 h, and in urinary NGAL after 4, 8 and 24 h after PCI. Cystatin C rose significantly 8 and 24 h after the procedure. Prevalence of CIN was 10%. We found 90% sensitivity and 74% specificity of serum and 76% sensitivity and 80% specificity of urinary NGAL increase. NGAL may represent a sensitive early biomarkers of renal impairment after PCI.

Undiagnosed renal impairment in patients with and without diabetes with normal serum creatinine undergoing percutaneous coronary intervention

HYPOTHESIS

The recent Dialysis Outcome Quality Initiative publication on the evaluation, classification and stratification of chronic kidney disease (CKD) states that individuals with a reduced glomerular filtration rate (GFR) is at greater risk for cardiovascular diseases and cardiac deaths.

AIM

To determine the prevalence of kidney dysfunction in a cohort of 1390 patients with and without diabetes with normal serum creatinine undergoing percutaneous coronary intervention.

METHODS

Kidney function was estimated using simplified MDRD, Cockcroft-Gault and Jeliffe formulas.

RESULTS

Normal serum creatinine was observed in 93% patients. Mean estimated GFR in 1068 non-diabetic patients was significantly higher than in 322 diabetic patients (all formulas). Diabetic females had significantly lower creatinine and estimated GFR, higher high-density lipoprotein and platelet count than diabetic males. A very high prevalence of CKD up to 77% was found in studied diabetic patients. Clinically significant CKD (as defined by GFR < 60 mL/min) was found in 13.0-33.8% patients depending on the formula used to estimate GFR.

CONCLUSION

The prevalence of CKD (stages 2-3) is high in diabetic patients undergoing percutaneous coronary intervention despite normal creatinine. The risk of contrast nephropathy with worse outcomes is enhanced in these patients, particularly in elderly and females. Evaluation of renal function is important in order to select the appropriate strategy to reduce the cardiovascular risk.