Fulminant adrenergic myocarditis complicated by pulmonary edema, cardiogenic shock and cardiac arrest.

Adrenergic myocarditis is an uncommon presentation of pheochromocytoma and extremely rare cause of de novo acute heart failure (AHF). We present a case of a 31-year-old Caucasian woman with a history of hypertension and recurrent occipital headaches who was admitted to the emergency department due to severe de novo AHF presenting as pulmonary edema and cardiogenic shock. During the hospital admission the patient experienced asystolic cardiac arrest and was successfully resuscitated, intubated, and mechanically ventilated. Bedside transthoracic echocardiography revealed severe diffuse left ventricular hypokinesis with ejection fraction (LVEF) of 10%. Coronary angiography disclosed normal epicardial coronary arteries. The diagnosis of fulminant myocarditis was based on clinical, laboratory and imaging findings including cardiac magnetic resonance imaging (cMRI) Lake Louise criteria. STIR-cMRI sequences revealed myocardial edema in the lateral, inferior and posterior walls of the left ventricle, whereas T1-weighted early contrast-enhanced sequences showed myocardial hyperemia and capillary leak. An ultrasound and computed tomographic scan of the abdomen disclosed a solid, heterogeneous mass (3.6×3.2×2.8-cm) in the right suprarenal area. Urinary and plasma catecholamines and metanephrines were markedly elevated. A pheochromocytoma was suspected and laparoscopic resection of the tumor was performed after pharmacological preparation with phenoxybenzamine. The histopathological findings were consistent with pheochromocytoma. Follow-up cMRI showed complete reversal of myocardial edema and hyperemia. At 12-month follow-up, the patient has remained asymptomatic and normotensive with no recurrence of cardiovascular symptoms.

The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion.

Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.

The role of NT-proBNP in the diagnostics and differentiation of cardiac and reflex syncope in adults: relative importance to clinical presentation and medical examinations.

PURPOSE: The aim of this study was to assess the clinical significance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations in the differentiation of patients with cardiac and reflex syncope. METHODS: The study included a group of 100 patients (56 women, 44 men), aged 18-77 years (mean 52.6 ± 16.7), with a history of reflex (group I) or cardiac syncope (group II). Diagnosis of syncope was performed according to the European Society of Cardiology (ESC) guidelines. In all patients, the concentration of NT-proBNP was measured. RESULTS: The assessment of NT-proBNP concentrations showed significantly higher concentrations in group II than in group I (448.7 ± 212.2 vs. 68.2 ± 64.1 pg/ml, P<0.0001). The receiver operating characteristic (ROC) curve analysis revealed that the concentration of NT-proBNP at 210.5 pg/ml may be a useful cut-off point which allows the prediction of cardiac syncope with 98 % specificity, 94 % sensitivity, and 94 % negative predictive value. In patients with cardiac arrhythmias and conduction abnormalities, the concentrations of NT-proBNP were higher in comparison to those without such disorders. CONCLUSIONS: The concentration of NT-proBNP is useful in the diagnosis of syncope and may initially guide the diagnostic process. The NT-proBNP value exceeding 200 pg/ml seems to be the most rational in determining cardiac syncope.

[Natriuretic peptides and their use in clinical practice according to the guidelines of the European Society of Cardiology]. / Peptydy natriuretyczne i ich zastosowanie w codziennej praktyce klinicznej wedlug wytycznych Europejskiego Towarzystwa Kardiologicznego.

In recent years, assay levels of natriuretic peptides are used in everyday clinical practice. The most commonly used is the assay the concentration of NT-proBNP in conjunction with the longest half-life (120 minutes) and its stability. According to the guidelines of the European Society of Cardiology determination of NT-proBNP were used in the diagnosis of acute and chronic heart failure, risk stratification in acute coronary syndromes, pulmonary embolism and in assessing the overall risk of cardiovascular patients prior to surgery. In addition, there are works whose authors have demonstrated the usefulness of NT-proBNP determination in valvular, atrial fibrillation, and syncope.

[Natriuretic peptides. History of discovery, chemical structure, mechanism of action and the removal routes. Basis of diagnostic and therapeutic use]. / Peptydy natriuretyczne. Historia odkrycia, budowa chemiczna, mechanizm dzialania oraz metabolizm. Podstawy zastosowania diagnostycznego i leczniczego.

Natriuretic peptides (NP) are the group of proteins synthesized and secreted by the mammalian heart. All the NP are synthesized from prohormones and have 17-amino acid cyclic structures containing two cysteine residues linked by internal disulphide bond. They are characterized by a wide range of actions, mainly through their membrane receptors. The NP regulate the water and electrolyte balance, blood pressure through their diuretic, natriuretic, and relaxating the vascular smooth muscles effects. They also affect the endocrine system and the nervous system. The neurohormonal regulation of blood circulation results are mainly based on antagonism with renin--angiotensin--aldosterone system. The NP representatives are: atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), C-type natriuretic peptide (CNP), urodilatine and (DNP) Dendroaspis natriuretic peptide, not found in the human body. According to the guidelines of the European Society of Cardiology determination of NT-proBNP level have found a use in the diagnosis of acute and chronic heart failure, risk stratification in acute coronary syndromes and pulmonary embolism. There are reports found in the literature, that demonstrate the usefulness of NT-proBNP determination in valvular, atrial fibrillation, and syncopes. Recombinant human ANP--Carperitid and BNP--Nesiritid, have already found a use in the adjunctive therapy of dyspnea in acute heart failure.

Serum biomarkers and clinical outcomes in heart failure patients treated de novo with carvedilol.

BACKGROUND: The role of inflammatory and hemodynamic stress biomarkers in heart failure (HF) patients treated de novo with beta-blockers has been poorly studied. METHODS: A total of 86 patients (age 56 ± 9 years, 81 men) with left ventricular ejection fraction (LVEF) < 40% and previously not treated with beta-blockers were initiated on carvedilol. At baseline and 12 months later we performed echocardiography, cardiopulmonary exercise testing, and determined serum levels of B-type natriuretic peptide (BNP), endothelin-1 (ET-1), C-reactive protein (CRP), interleukin-6, and tumor necrosis factor alpha (TNF -a). Patients were followed up over a total period of 9 ± 3 years from baseline. RESULTS: Increased baseline CRP and its on-treatment decrease were associated with improvement of LVEF (est. coefficient per one SD: 1.6; 95% CI: -0.05,3.28; p = 0.056, and -1.80; -3.43, -0.18; p = 0.030, respectively) and diminishing of LV end-systolic volume index [mL/m2] (-6.83; -11.32; -2.34; p = 0.003, and 5.85; 1.23; -10.46; p = 0.014, respectively). Higher baseline ET-1 and on-treatment increase in TNF-a predicted frequent admissions (> 1) for cardiac complications (odds ratio per one SD: 1.98; 95% CI: 1.09-3.59; p = 0.025, and 2.07, 1.12-3.84, p = 0.021, respectively) whereas higher baseline BNP was associated with increased mortality (hazard ratio per one SD: 2.09, 95% CI: 1.26-3.45; p = 0.004). CONCLUSIONS: Serum biomarkers may have different roles in prediction of clinical outcomes among HF patients treated de novo with carvedilol.

[Evaluation of plasma renin activity in acute myocardial infarction patients treated with primary percutaneous coronary interventions]. / Ocena aktywnosci reninowej osocza u osób z ostrym zawalem miesnia sercowego leczonych pierwotna angioplastyka wiencowa.

UNLABELLED: The aim of this study was evaluation of plasma renin activity (PRA) in patients with acute ST-segement elevation myocardial infarction (STEMI) treated with primary percutaneous coronary interventions (PCI). We observed 40 patients (30 men, 10 woman) aged 29-69 yrs (mean age 53.9 SD 10.9) with first ST-segment elevation myocardial infarction. Patients were treated with primary percutaneous coronary intervention (PCI) with implantation of bare metal stent in the period up to 6 hours after the onset of chest pain. Plasma renin activity was evaluated on 1st, 3rd and 5th day and 1st and 3rd month after STEMI in all patients. Values of PRA were compared between men and women during a 3-month follow-up. Echocardiography examinations with left ventricular parameter measurements (included ventricular ejection fraction) were performed at 3rd day, 1st and 3rd month after STEMI. In all patients Troponin I level was measured in the first day of STEMI. In addition, the level of NTproBNP and hsCRP in plasma were measured in all patients at 1st day, 1st and 3rd month after STEMI. Changes of PRA levels within 3-months follow-up were evaluated in relation to the age, BMI, serum levels of NTproBNP, hsCRP, lipids and left ventricular function. RESULTS: Median value of the PRA was 1.4 ng/ml/h at 1st day (N:1.46 +/- 0.23 ng/ml/h); 2.3 ng/ml/h at 3rd day; 3.9 ng/ml/h at 5th day; 2.1 ng/ml/h at 1 month, and 2.7 ng/ml/h at 3 months after STEMI. Peak value of PRA was observed between 5th day and 1st month after STEMI. PRA was significantly higher in men than in women at 1st day after STEMI (1.8 vs. 0.8 ng/ml/h; p = 0.002). There were no differences of PRA between men and women during the rest of the followup (3rd day - 3.3 vs. 2.0 ng/ml/h; 5th day 7.3 vs. 3.5 ng/ml/h; 1st month 4.1 vs. 2.1 ng/ml/h, 3rd month 3.5 vs. 2.2 ng/ml/h. There was no significant correlation between PRA and age, BMI, serum levels of NTproBNP, hsCRP, lipids and left ventricular function. CONCLUSIONS: 1. Values of PRA change within early period after STEMI. The peak value was achieved between 5th day and 1st month after STEMI treated with primary PCI. 2. Plasma renin activity was significantly higher in men than in women at 1st day of STEMI treated with primary PCI.

[Prevalence of age, gender and body weight on the frequency of hypertension and diabetes mellitus in patients hospitalized in cardiology department]. / Wplyw wieku, plci oraz masy ciala na czestosc wystépowania nadcisnienia tetniczego oraz cukrzycy, u pacjentów hospitalizowanych na oddziale kardiologicznym.

UNLABELLED: Overweight and obesity are a major medical problems of the twenty-first century. According to the World Health Organization (WHO) in the world are about 1.6 billion people with overweight and at least 400 million adults are obese. The aim of this study was to analyze the effects of age, sex, and selected anthropometric parameters on the incidence of hypertension and diabetes mellitus in patients hospitalized in the cardiology department. The study included 1188 patients aged 18 - 94 years (mean age 66.9 years, SD 13.2), including 610 men (mean age 65.9 years, SD 12.7) and 578 women (mean age 67.9 years, SD 13.7), hospitalized in the Department of Cardiology Specialist Hospital Louis Rydygier in Krakow in 2009. All patients defined age, height and weight. Based on these results calculated body mass index (BMI). All patients were collected history on the prevalence of hypertension and type 2 diabetes mellitus. Then performed a statistical analysis of the incidence of hypertension and diabetes mellitus compared to sex, median age, BMI. RESULTS: In the study population normal blood pressure and hypertension grade 2 occurred significantly more often in men. Grade 3 hypertension occurred significantly more often in women. The median age was 67 years. In the older group occurred more frequently hypertension 2 and Grade 3. Also, diabetes mellitus was more common among older people. In obese people (BMI> 30) and overweight (BMI 25-29.99) occurred significantly more grade 3 hypertension compared to those of normal weight. CONCLUSIONS: 1. Diabetes mellitus and hypertension are more common in postmenopausal women compared to men the same age. 2. Obesity and overweight predisposes to hypertension grade 3 and diabetes mellitus.

[Epidemiology of pulmonary embolism in patients with cardiac department]. / Epidemiologia zatorowosci plucnej u pacjentów oddzialu kardiologicznegom.

UNLABELLED: Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a embolic material. ZP is usually a manifestation of venous thromboembolism (VTE), which in addition to the ZP includes deep vein thrombosis. The aim of this study was to analyze the epidemiology of pulmonary embolism in patients in the cardiology department with regard to gender and age. Material for the study was the medical documentation of patients hospitalized in the Department of Cardiology Hospital Louis Rydygiera in Cracow in the period of 7 years (1 I 2004 - 31 December 2010). During this time 11,435 patients were hospitalized. The study included 67 (1.23%) patients (31 men, 36 women) aged 30 - 93 years (mean 70.3 years, SD 13.3) who were diagnosed with acute pulmonary embolism. Collected information on gender, age, body weight and coexisting disease. An analysis of the documentation in terms of symptoms on admission and the cause of pulmonary embolism. RESULTS: The study included 67 patients, aged 30 - 93 years (mean age 70.3 years, SD 13.3) including 31 males (mean age 71.7 years, SD 13.8) and 36 women (average age 69.1 years, SD 12.9). The incidence of pulmonary embolism was 6 people per 1000 hospital admissions (0.58%). The average age of women was lower compared to men (69.1 +/- 12.9 vs. 71.7 +/- 13.8 years). Among the most common coexisting diseases were coronary heart disease (44.8%), hyperlipidemia (40.3%) and varicose veins of the lower limbs (49.3%). The most common symptoms on admission were dyspnea (88.1%), chest pain (59.7%) and hypotension (44.8%). Among the predisposing factors for pulmonary embolism occurs most frequently in the history of surgery (55.2%), venous thrombosis of lower limbs (50.7%), smoking (34.3%). The median age was 70.3 years. Pulmonary embolism was significantly more common among older people (37.3% vs. 62.7%, p = 0.04) and in men (35.5% vs. 64.5%, p = 0.04) and women (38.9% vs. 61.1%, p = 0.04). Pulmonary embolism was reported most frequently in the age group between 70-79 years of age in the study group (43.3%). CONCLUSIONS: 1. Pulmonary embolism occurs in 6 per 1000 patients hospitalized in the cardiology department. 2. Pulmonary embolism occurs most frequently in the age group 70-79 years. 3. The most common factors that causes pulmonary embolism are state after surgery and a history of deep vein thrombosis.

Altered fibrin clot properties in patients with chronic heart failure and sinus rhythm: a novel prothrombotic mechanism.

BACKGROUND: Thromboembolic complications occur more frequently in patients with chronic heart failure (CHF) than in the general population. Formation of a compact fibrin clot resistant to lysis has been shown in arterial and venous thrombosis. OBJECTIVE: To investigate fibrin clot properties in patients with CHF. METHOD: Plasma clot permeability, compaction, turbidity and fibrinolysis were assessed in 36 consecutive patients with stable CHF (30M, 6F; aged 64+/-10 years, left ventricular ejection fraction (LVEF) 34.9+/-6.7%) and 36 controls matched for age, sex, cardiovascular risk factors and medication. Exclusion criteria were LVEF >40%, anticoagulant therapy, previous thromboembolic events, atrial fibrillation. RESULTS: Clots obtained from plasma of patients with CHF had 23% lower clot permeability (p<0.0001), 13% less clot compaction (p<0.001), 15% faster fibrin polymerisation (p<0.0001) and tended to have prolonged fibrinolysis time (p=0.1) compared with controls. C-reactive protein and fibrinogen were associated inversely with clot permeability (R(2)=0.84, p<0.0001 and R(2)=0.79, p<0.0001, respectively) and positively with fibrinolysis time (R(2)=0.88, p<0.0001 and R(2)=0.80, p<0.0001, respectively) in patients with CHF. Plasma thrombin-antithrombin complex concentrations were inversely correlated with clot permeability (R(2)=0.88, p<0.0001) and positively with fibrinolysis time (R(2)=0.91, p<0.0001). Left atrium diameter, but not LVEF, correlated with fibrinolysis time (R(2)=0.61, p=0.027). CONCLUSIONS: Patients with CHF with sinus rhythm are characterised by faster formation of compact plasma fibrin clots, which might predispose to thromboembolic complications.

Restrictive left ventricular filling pattern and its effect on the clinical course of systolic heart failure in patients receiving carvedilol.

BACKGROUND: To analyze differences in brain natriuretic peptide (BNP) levels depending on mitral flow pattern (MFP) and to assess the effects of carvedilol on changes in MFP, left ventricular function and exercise capacity. METHODS AND RESULTS: The study population consisted of 73 patients with symptomatic heart failure in NYHA classes II and III and LVEF < 40% without prior beta-blockade. In all patients at baseline, before carvedilol, and then at 3 and 12 months after initiation of treatment, the following parameters were assessed: HR(s), serum BNP, echocardiographic parameters, and exercise capacity with gas monitoring during cardiopulmonary stress test. Before carvedilol there was a positive correlation between BNP and E/A (r = 0.17; p = 0.05). BNP was significantly higher in patients with restrictive MFP (rMFP) as compared with nonrestrictive MFP (nrMFP) (541.5 +/- 206.7 vs. 412.6 +/- 207.2; p = 0.009), and lower VO(2peak) in rMFP as compared with nrMFP (12.5 +/- 3.7 vs. 16.5 +/- 4.7; p = 0.001). After initiation of carvedilol, the patients with rMFP had reduced E/A (2.9 vs. 1.4; p = 0.003), and rMFP was changed to nrMFP in 60.8% of patients. Respective BNP concentrations were 342.16 +/- 284.31 vs. 326.40 +/- 264.6; NS. In patients with rMFP VO(2peak) , %N increased significantly from 42.4 +/- 10.2 to 52.4 +/- 14.4; p = 0.012. CONCLUSIONS: In patients with systolic congestive heart failure, the presence of rMFP is related to higher BNP levels and reduced VO(2peak). Chronic treatment with carvedilol replaces rMFP with nrMFP and improves exercise capacity in some patients.

Concentration of BNP, endothelin 1, pro-inflammatory cytokines (TNF-alpha, IL-6) and exercise capacity in patients with heart failure treated with carvedilol.

BACKGROUND: Recent studies on the pathophysiology of heart failure indicate the role of neurohormones and immune and inflammatory processes as potential mechanisms involved in the pathogenesis and clinical course of chronic heart failure (CHF). AIM: To analyse the relationship between concentrations of brain natriuretic peptide (BNP), endothelin-1 (ET-1), inflammatory cytokines (TNF-alpha, IL-6) and cardiopulmonary stress test parameters, and to evaluate their changes during carvedilol treatment. METHODS: The study included 86 patients (81 men and 5 women) aged from 35 to 70 years (56.8+/-9.19) with symptomatic heart failure and left ventricular ejection fraction <40%, receiving an inhibitor of angiotensin II converting enzyme, diuretic and/or digoxin but not beta-blockers. All patients at baseline, and then at 3 and 12 months after treatment, underwent a panel of studies to assess functional capacity according to NYHA, echocardiographic and cardiopulmonary stress test (CPX) parameters, and serum concentrations of BNP, ET-1, TNF-alpha and IL-6. Before introducing carvedilol we found a weak relationship between concentrations of BNP, ET-1, IL-6 and decreased VO2 peak. RESULTS: At 12 months exercise tolerance was significantly improved (exercise stress testing prolonged by 143.9 s, p=0.001) and an increase in metabolic equivalent (MET) by 1.41 (p=0.001) was observed. The VO2 peak was nonsignificantly increased by a mean of 0.9 ml/kg/min. In patients with baseline VO2 peak <14 ml/kg/min the concentrations of ET-1 and TNF-alpha were significantly higher than in the remaining ones, and after treatment they were significantly reduced. In these patients VO2 peak%N was also significantly increased (39.5+/-7.5 vs. 50.1+/-15,0; p=0.013). The number of patients with VO2 peak <14 ml/kg/min also significantly decreased from 39 to 21 (p=0.013). CONCLUSIONS: In patients with HF decreased value of VO2 peak is associated with LV systolic function disorders and increased levels of BNP, ET-1, TNF-alpha and IL-6. Chronic treatment with carvedilol improves LV systolic function, exercise tolerance and peak oxygen consumption and is associated with significant decrease of BNP, ET-1, TNF-alpha and IL-6 concentrations.

Sudden cardiac death risk factors in patients with heart failure treated with carvedilol.

BACKGROUND: Chronic heart failure (CHF) is associated with a high risk of sudden cardiac death (SCD). Most frequently SCD occurs in patients with NYHA class II and III. AIM: To evaluate the influence of prolonged carvedilol therapy on SCD risk in CHF patients. METHODS: The study included 86 patients (81 men and 5 women) aged 56.8+/-9.19 (35-70) years with CHF in NYHA class II and III receiving an ACE inhibitor and diuretics but not beta-blockers. At baseline and after 12 months of carvedilol therapy the following risk factors for SCD were analysed: in angiography - occluded infarct-related artery; in echocardiography - left ventricular ejection fraction (LVEF) <30%, volume of the left ventricle (LVEDV) >140 ml; in ECG at rest - sinus heart rate (HRs) >75/min, sustained atrial fibrillation, increased QTc; in 24-hour ECG recording - complex arrhythmia, blunted heart rate variability (SDNN <100 ms) and abnormal turbulence parameters (TO and TS or one of them); in signal-averaged ECG - late ventricular potentials and prolonged fQRS >114 ms. The analysis of SCD risk factors in basic examination in patients who suddenly died was also performed. RESULTS: During one-year carvedilol therapy heart transplantation was performed in 2 patients; 5 patients died. At 12 months the following risk factors for SCD were significantly changed: HRs >75/min (50 vs. 16 patients, p=0.006), LVEF <30% (37 vs. 14 patients, p=0.01), SDNN <100 ms (19 vs. 9 patients, p=0.04). At 12 months the number of risk factors for SCD in each patient was significantly reduced (p=0.001). In patients who suddenly died we found a greater amount of SCD risk factors in basic examination (7 vs. 5) as compared to alive patients. CONCLUSIONS: Prolonged beta-adrenergic blockade reduces risk of sudden cardiac death through significant LVEF increase, reduction of HR at rest and improvement of HRV.

[Cardiac tamponade as the first symptom of oesophageal carcinoma -- a case report]. / Tamponada serca jako pierwszy objaw raka przelyku -- opis przypadku.

We present a case of a 56-year-old male who was admitted to our hospital due to cardiac tamponade. A 600 ml of purulent fluid was evacuated from the pericardium. The patient received antibiotics, however, due to recurrent pericardial effusion a pericardial drainage was required. Esophagoscopy and computerised tomography revealed oesophageal carcinoma with oesophago-pericardial fistula.

[Cardiac arrest in a 17-year-old boy--a case report].

Cardiac arrest (CA) refers to abrupt cessation of cardiac pump function. Most sudden deaths in young people are of cardiac origin, at the same time most patients have unrecognised prior heart disease. We report a case of a 17-year-old boy with cardiac arrest induced by ventricular fibrillation. Sinus rhythm was restored after one hour's resuscitation. Based upon elevated necrotic markers, ECG changes and echocardiographic examinations the diagnosis of anterolateral myocardial infarction was established. Coronary angiography revealed only a small myocardial bridge. The patient in a poor general and unconscious state was transferred to the Coronary Care Unit of the Department of Coronary Disease. The patient improved after treatment and without neurological deficit or circulatory insufficiency continued cardiac rehabilitation in a spa hospital. The paper reviews differential diagnosis of cardiac arrest, treatment modalities and describes the course of hospitalisation.

Value of lead aVR in the detection of significant left main coronary artery stenosis in acute coronary syndrome.

BACKGROUND: Electrocardiographic lead aVR is usually ignored in patients with chest pain. ST segment elevation in aVR may have diagnostic value in patients with acute coronary syndrome (ACS) and significant stenosis or obstruction of the left main coronary artery (LMCAS), especially when accompanied by ST segment elevation in lead V(1). AIM: To asses the value of lead aVR and V1 for the detection of LMCAS in patients with ACS. METHODS: The study group consisted of 150 patients (mean age 60.6+/-9.5 years, range 33-78 years) with ACS, including 46 with LMCAS and 104 without LMCAS. ECG recordings obtained on admission were compared between these two groups. RESULTS: In patients with LMCAS, ST segment elevation in lead aVR was two times more frequent than in remaining patients (69.6% vs 34.6% p=0.0001) whereas there were no differences in lead V(1). Sensitivity of ST elevation in aVR in detection of LMCAS was 69.6%, specificity - 65.4%, positive predictive value - 47.1%, and negative predictive value - 82.9%. In patients with LMCAS, ST segment depression was significantly more often present in ECG leads other than aVR (45.6% vs 23.1% p<0.01). Patients with LMCAS more often had hypertension (95.6% vs 77.9% p<0.05) and three-vessel disease (78.3% vs 31.8%, p<0.0001). CONCLUSIONS: The assessment of lead aVR in patients with ACS may indicate LMCAS. Additional analysis of lead V(1) does not improve diagnostic accuracy.

[Variant angina pectoris associated with Morgagni-Adams-Stokes syndrome--case report]. / Wazospastyczna postac dusznicy bolesnej z towarzyszacym zespolem Morgagniego- Adamsa-Stokesa--opis przypadku.

We report a case of Prinzmetal angina initially manifested with short losses of consciousness in a 55-year-old man hospitalized in the Department of Coronary Artery Disease, Institute of Cardiology, Jagiellonian University Medical College in Cracow. Clinical symptomatology of the presented case, causes and mechanism of loss of consciousness in variant angina as well as treatment methods are discussed.

[Cardiopulmonary stress test in patients with heart failure and atrial fibrillation]. / Wysilkowy test spiroergometryczny u chorych z niewydolnoscial serca i migotaniem przedsionków.

BACKGROUND: The cardiopulmonary stress test (CPST) allows the objective assessment of stress capacity in patients (pts) with heart failure (HF). There are a small number of studies concerning CPST in pts with HF and AF. AIM: to assess the influence of AF on CPST parameters in pts with HF. MATERIAL: The study group consisted of 56 males aged 35-65 years (x = 57.3 year) with diagnosed HF lasting at least 3 months, in the II and I NYHA functional class and with l eft ventricular ejection fraction(EF) below 40%. 12 pts had an idiopathic cardiomyopathy and 44--cardiomyopathy of ischemic origin. All study pts were divided into two groups: group I (gr. I) - with persistent AF and group II (gr. II)--with sinus rhythm. METHODS: The BNP ad IL-6 levels were measured and transthoracic echocardiography and CPST were performed in all study pts.We have analysed the echocardiographic and CPST parameters in both study groups. RESULTS: We found no significant differences in age, BMI, ethiology, left ventricular echocardiographic parameter values and NYHA functional class between both groups. In pts with AF (gr. I) we found significantly higher LA diameter (mm) 49.5, SD = 6.7 vs. 44.8, SD = 6.7 (p = 0.01), significantly higher BNP level (pg/ml) 582.75, SD = 179.36 vs. 442.94, SD = 213.75 (p = 0.03) and IL-6 level (pg/ml) 13.55, SD = 10.94 vs. 8.6, SD = 7.83 (p = 0.05). We also found significant differences in: HRmin (bpm) (gr. I--98.45, SD = 21.70, gr. II--80.48, SD = 15.25 p = 0.001), HRmax (bpm) (gr. I--146.82, SD = 16.14, gr. II--123,14, SD = 16.69 p = 0.001), tmax (sec) (gr. I--414.0, SD = 252.33, gr. II--618.11, SD=268,69, p = 0.02), METS (gr. I--2.09 SD = 1.04, gr. II--4.42, SD = 2.15 p = 0.002) and VO2peak (ml/kg/min) (gr. I--11.52, SD = 1.86, gr. II - 15,03, SD = 4.42, p = 0.01). CONCLUSIONS: (1) Persistent atrial fibrillation in pts with HF is associated with 23% lower VO2peak and lower stress tolerance as compared to pts with sinus rhythm. (2) Higher IL-6 level in pts with HF and AF indicates the sympatethic system's overactivation and the presence of inflammatory reaction in these pts.