Non-invasive imaging techniques in patients with coronary chronic total occlusions: A key for successful diagnosis, revascularization, and post-intervention outcomes.

Coronary chronic total occlusions (CTOs) are a common finding on coronary angiograms of patients with coronary artery disease, with an incidence ranging from 15% to 25%. Despite this high incidence, the proper treatment strategy in those patients often remains unclear. There are some observational studies suggesting that successful revascularization of a CTO can reduce angina symptoms, improve quality of life, improve the left ventricular ejection fraction, and lower mortality. However, not all patients will benefit from revascularization. Pre-procedural assessment of left ventricular function, ischemic burden, and viability seems to be crucial for a good outcome of the revascularization. The aim of this review is to compare currently available non-invasive imaging modalities with regard to utility in evaluation of patients with CTOs.

A "patient-tailored" treatment of hypertension with use of impedance cardiography: a randomized, prospective and controlled trial.

BACKGROUND: Arterial hypertension might be caused by hemodynamic disturbances such as fluid retention, increased vascular resistance, and hyperdynamic function of the heart. The aim of this study was to estimate the effectiveness of antihypertensive therapy based on hemodynamic assessment by impedance cardiography in a randomized, prospective, controlled trial. MATERIAL AND METHODS: This study involved 128 patients (average age: 42.9 ± 11.1 years) with arterial hypertension, randomized into groups: (1) empiric, and (2) hemodynamic, in which treatment choice considered impedance cardiography results. Evaluation of treatment effects was performed after 12 weeks and included office blood pressure measurement and ambulatory blood pressure monitoring. RESULTS: All final blood pressure values were lower in the hemodynamic group, significantly for office systolic blood pressure (empiric vs. hemodynamic: 136.1 vs. 131.6 mmHg; p=0.036) and diastolic blood pressure (87.0 vs. 83.7 mmHg; p=0.013), as well as night-time systolic blood pressure (121.3 vs. 117.2 mmHg; p=0.023) and diastolic blood pressure (71.9 vs. 68.4 mmHg; p=0.007). Therapy based on impedance cardiography significantly increased the reduction in office systolic blood pressure (11.0 vs. 17.3 mmHg; p=0.008) and diastolic blood pressure (7.7 vs. 12.2 mmHg; p=0.0008); as well as 24-h mean systolic blood pressure (9.8 vs. 14.2 mmHg; p=0.026), daytime systolic blood pressure (10.5 vs. 14.8 mmHg; p=0.040), and night-time systolic blood pressure (7.7 vs. 12.2 mmHg; p=0.032). CONCLUSIONS: Antihypertensive treatment based on impedance cardiography can significantly increase blood pressure reduction in hypertensive patients.

Unstable angina in a young woman with Hodgkin's lymphoma.

We present the case of a 30 year-old woman - 16 months after successful treatment of Hodgkin's lymphoma (chest location) with chemotherapy (including doxorubicin) and radiotherapy - with recurrent chest pain and dyspnea. In ambulatory event telemetry, she reported nocturnal chest pain with transient ST elevation characteristic for acute cardiac ischemia. Urgent coronary angiography with intravascular ultrasound and virtual histology visualization revealed 70% fibrotic stenosis in the proximal segment of the left anterior descending artery successfully treated with a drug-eluting stent implantation. This case is especially noteworthy because of the short period from initial therapy to the symptomatic coronary artery disease that is entirely unlike the reported mean latency period of several years.

Usefulness of impedance cardiography in optimisation of antihypertensive treatment in patients with metabolic syndrome: a randomised prospective clinical trial.

BACKGROUND: The effective antihypertensive therapy is one of the main goals of treatment in metabolic syndrome (MS) because hypertensive patients with MS are of high cardiovascular risk. The impedance cardiography (ICG), as a modern technique of non-invasive haemodynamic monitoring, enables the evaluation of cardiac index (CI), thoracic fluid content (TFC) and systemic vascular resistance index (SVRI) and seems to be useful in clinical individual assessment of patients with MS. AIM: To estimate the effectiveness of the antihypertensive therapy based on ICG. METHODS: The study involved 82 hypertensive patients with MS (57 men, age 45.5 ± 10.0 years), without any major chronic diseases. After the preliminary assessment including office blood pressure measurement (OBPM), ambulatory blood pressure monitoring (ABPM) and ICG, the subjects were randomised into two groups: empirical (GE) and treated with the use of haemodynamic evaluation by ICG (HD). The effect of the therapy was estimated at 3 months follow-up. RESULTS: After 12 weeks the HD group was characterised by lower mean BP values in OBPM and ABPM, with statistical significance for night-time SBP (120.6 ± 9.1 vs 115.6 ± 8.2 mm Hg, p = 0.036). The use of ICG significantly increased the reduction of BP in OBPM - SBP (GE vs HD: change 10.7 vs 18.1 mm Hg, p = 0.012), DBP (8.9 vs 12.2 mm Hg, p = 0.037), and ABPM: in the 24-h period SBP (10.5 vs 16.7 mm Hg; p = 0.013) and day-time SBP (10.5 vs 17.2 mm Hg, p = 0.009). More patients in the HD group reached recommended BP control in OBPM (23.5 vs 36.6%, p = 0.222) and ABPM (23.5 vs 43.9%, p = 0.117). CONCLUSIONS: The antihypertensive therapy guided by ICG increased the reduction of BP in patients with MS. The assessment of haemodynamic profile by ICG guarantees better choice of antihypertensive drugs and subsequently increases the chance of recommended BP control in patients with MS.

The influence of subclinical hyperthyroidism on blood pressure, heart rate variability, and prevalence of arrhythmias.

BACKGROUND: The impact of subclinical hyperthyroidism (sHT) on the cardiovascular system still needs to be elucidated. The aim of the study was to prospectively assess blood pressure (BP), variability in heart rate, and the prevalence of arrhythmias in patients with sHT, both before and after they are restored to the euthyroid state. METHODS: The study group consisted of 44 normotensive patients (37 women, 7 men), aged 22-65 years (mean±SD: 45.9±11.0) with sHT. Enrolled patients were drawn from 1080 patients referred to our department for treatment of hyperthyroidism. Study patients were treated with radioiodine treatment to restore the euthyroid state. Ambulatory BP monitoring and Holter electrocardiography were performed (i) when sHT was diagnosed and (ii) at least 6 months after they became euthyroid. RESULTS: sHT in comparison to the euthyroid state was associated with higher (109.3±7.1 vs. 107.1±7.7 mmHg) nocturnal systolic mean BP (p=0.035) and BP load (14.8 vs. 10.2%, p=0.033), mean diastolic BP (66.4±6.6 vs. 64.8±6.6 mmHg, p=0.047), and mean arterial pressure (80.8±43.1 vs. 79.3±43.6 mmHg, p=0.049). Moreover, significant changes in both the time and frequency domain measures of heart rate variability (HRV) were observed: decrease of the square root of the mean squared differences of successive NN intervals (rMSSD) (45.68±34.1 vs. 65.09±50.6 ms, p=0.03) and the low frequency power (LF) (5.71±0.99 vs. 6.0±1.01 ms(2), p=0.049) as well as increase of QT interval dispersion (58.25±28.5 vs. 46.90±12.1 ms, p=0.020). This was accompanied by a clinically insignificant increase in the frequency of ventricular extrasystoles (VES) (3.1±7.4 vs. 0.6±1.2 per hour, p=0.048) and increased mean heart rate (78.4±6.8 vs. 76.0±8.0 beats/min, p=0.004). Some of the parameters correlated positively with thyroid hormones: nocturnal diastolic BP with free triiodothyronine (FT(3)) (r=0.397, p=0.008), rMSSD with free thyroxine (FT(4)) (r=0.389, p=0.013), and QT interval dispersion with FT(4) (r=0.450, p=0.004). CONCLUSIONS: The study suggests that sHT in comparison to euthyroid status may be associated with a statistically significant but probably clinically insignificant increase of QT interval dispersion, prevalence of VES, elevated nocturnal arterial BP, and changes in HRV. These findings broaden our understanding of the cardiovascular effects of sHT.

The effects of cardiac rehabilitation on haemodynamic parameters measured by impedance cardiography in patients with heart failure.

BACKGROUND: Cardiac rehabilitation (CR) is an important element of heart failure (HF) treatment although the mechanisms of its beneficial effects remain debatable. AIM: To evaluate the haemodynamic effects of CR measured by impedance cardiography in patients with HF. METHODS: Study group included 50 HF patients (aged 56.2 ± 8.8 years, NYHA class II and III, left ventricular ejection fraction ≤ 40%) who underwent 8-week CR. Clinical and haemodynamic assessment was performed before and after CR. RESULTS: As a result of CR, exercise tolerance improved significantly as measured by peak VO(2) (18.7 ± 4.4 vs 20.8 ± 4.7 mL/kg/min; p = 0.025), six-minute walking test distance (6-MWT; 417.8 ± 103.6 vs 467.7 ± 98.4 m, p = 0.016) and NYHA class (change to the lower NYHA class in 30% of subjects). A significant reduction of the left atrial diameter was observed in echocardiography (4.55 ± 0.63 vs 4.43 ± 0.59 cm, p = 0.017). Impedance cardiography revealed a significant change in diastolic to systolic wave ratio (O/C ratio; 54.8 ± 24.0 vs 47.9 ± 20.8%, p = 0.021). A significant change in the haemodynamic profile of the left ventricular blood ejection was also observed. Before CR, transthoracic fluid content (TFC) correlated with stroke index (SI; R = 0.37, p < 0.01), compared to no correlation after CR (R = 0.00, NS). Reduction in TFC correlated with prolongation of the 6-MWT (R = -0.32, p = 0.06), and increase in systolic time ratio (STR) correlated with increase in peak VO(2)(R = 0.40, p = 0.006). Subjects who benefited from CR tended to have lower heart rate (61.4 ± 9.0 vs 67.7 ± 10.7 1/min, p = 0.07), longer pre-ejection period (PEP; 12.2 ± 11.6 ms vs -2.6 ± 23.1 ms, p = 0.018) and non-significantly higher STR (0.423 ± 0.123 vs 0.377 ± 0.102, p = 0.37). CONCLUSIONS: Impedance cardiography revealed beneficial effects of CR, manifested by reduced fluid retention and a reduced effect of preload on left ventricular relaxation and ejection.

Transapical aortic valve implantation - a rescue procedure for patients with aortic stenosis and "porcelain aorta".

Surgical aortic valve replacement (AVR) still remains the treatment of choice in symptomatic significant aortic stenosis (AS). Due to technical problems, extensive calcification of the ascending aorta ("porcelain aorta") is an additional risk factor for surgery and transapical aortic valve implantation (TAAVI) is likely to be the only rescue procedure for this group of patients. We describe the case of an 81-year-old woman with severe AS and "porcelain aorta", in whom the only available life-saving intervention was TAAVI.

Effects of therapy based on tilt testing results on the long-term outcome in patients with syncope.

BACKGROUND: The use of tilt testing (TT) in guiding therapy in patients with syncope remains controversial. AIM: To assess the long-term effectiveness of TT-based therapy in patients with syncope of unknown origin. METHODS: The study group consisted of 340 patients (182 females, mean age 38.2+/-16.5 years, range 15-78 years) with at least two syncopal episodes during 6 months preceding the study. TT was performed at 60 degrees angle for 20 min, followed by sublingual nitroglycerine (NTG) challenge (250 microg) when necessary. After positive baseline TT and returning to supine position, 0.1 mg/kg of propranolol was intravenously administered and a second TT was performed. All patients with positive TT were advised to take propranolol, midodrine or fludrocortisone for 6 months -- the choice of agent was based on standard criteria. The time to first syncope was an indicator of the efficacy of treatment and a recurrence of syncope was the end-point of the study. In patients who did not faint during follow-up, the last date of contact was taken as the end of observation period. RESULTS: Out of 340 patients who underwent TT, 148 with positive TT and propranolol challenge were included in the study; 82 patients (group I) received long-term therapy whereas 66 did not (group II). During a 12.8+/-0.9 month follow-up, syncope recurred in 86 patients - 40 (49%) from group I and 46 (70%) from group II (p<0.01). Survival analysis showed that medical therapy was associated with a significant reduction of the risk of syncope recurrence (RRR: 36%, 95% CI: 23-47). The greatest benefit from long-term treatment was documented in patients taking propranolol (RRR: 42%; 95% CI: 18-58; p<0.008), particularly in those in whom intravenous propranolol prevented TT-induced syncope (RRR: 50%; 95% CI: 23-67; p<0.012). Risk reduction in patients treated with midodrine or fludrocortisone was moderate (RRR: 22%; 95% CI: 11-34; p>0.09). CONCLUSIONS: Carefully selected and TT-based long-term pharmacological treatment is associated with a 36% risk reduction of syncope recurrences in patients with syncope of unknown origin.

Haemodynamic indices of the early phase of the tilt test: does measurement predict outcome?

INTRODUCTION: Tilt testing (TT) is a well-established tool in the diagnosis of syncope. However, it is time-consuming. Therefore, identification of parameters that could shorten the duration of TT is desirable. AIM: To identify and assess the usefulness of early haemodynamic parameter changes in prediction of the tilt test results in a group of patients with syncope of unknown aetiology. METHODS: The study involved a group of 105 patients, including 61 women and 44 men, with a mean age of 34.2+/-13.7 (from 13 to 82) years, with at least two episodes of syncope in the last 6 months. The head-up tilt test was carried out according to protocol 60/20 min and if necessary was continued after administration of sublingual nitroglycerine in a dose of 250 g. The assessment of haemodynamic indices was performed employing the beat-to-beat method using the Portapres M2 device. Systolic (SBP) and diastolic (DBP) arterial pressure, heart rate (HR), cardiac output (CO) and stroke volume (SV), and total peripheral vascular resistance (TPR) were analysed. The measured values of haemodynamic indices were calculated by means of averaging 10-second intervals within 3-minute studied periods either before or after tilting a patient. Mean baroreceptor sensitivity (BRS) for the same 3-minute-long intervals was evaluated using the xBRS (cross-correlation) method. In the analysis, differences (Rx) of the haemodynamic values between the beginning of tilting a patient and the rest period were also calculated. RESULTS: Loss of consciousness was noted in 47 (46%) of the studied patients - group I. The remaining subjects (58 patients, 54%) did not develop syncope during TT (group II). The univariate and multivariate logistic analyses of regression revealed that the mean vascular resistance difference (meanRTPR) <-10 dyn.s/cm8 was an independent risk factor of syncope (chi2=3.4; p<0.0008). The presence of this risk factor was associated with a significantly higher risk of a positive response during the tilt test (65% vs 39%; RR: 1.7, 95% CI: 1.2-3.2). In predicting a positive TT result, sensitivity of this parameter was 65%, specificity was 61% and the prognostic value of the positive and negative result was 32% and 86%, respectively. CONCLUSIONS: In patients with syncope of unknown origin, an early (within first 3 minutes of TT) asymptomatic fall in total peripheral vascular resistance is a significant predictor of a positive final result of the test.