Prognostic importance of the extent of coronary revascularisation in patients with acute coronary syndromes and multivessel disease: one-year prospective follow-up.

BACKGROUND: Interventional treatment improves prognosis in patients with acute coronary syndromes (ACS). However, despite introduction of percutaneous coronary intervention (PCI), the risk of cardiovascular events in patients with multivessel coronary artery disease (MVD) remains significant. AIM: To evaluate the risk of complications and the prognostic value of MVD in patients with ACS during 1-year follow-up. METHODS: A group of 153 patients with ACS was followed up at a single cardiology unit with round-the-clock PCI capability. Treatment of ACS, the extent of revascularisation, and complications occurring during hospitalisation and 1-year follow-up were analysed. The end points of the study were defined as death from all causes, cardiac death, recurrent ACS and a composite end point (deaths from cardiac causes and recurrent ACS). RESULTS: During 1-year follow-up, 11 (7.2%) patients died, including 10 patients with MVD without complete revascularisation. Recurrent ACS occurred in 18 (12%) patients, including 13 patients with MVD without complete revascularisation. Presence of a residual significant coronary stenosis in incompletely revascularised patients with MVD was an important risk factor for all-cause mortality and occurrence of a composite endpoint in comparison to MVD patients who underwent complete revascularisation (p = 0.028 and p = 0.046, respectively) and patients with single-vessel disease (p = 0.006 and p = 0.003, respectively). CONCLUSIONS: Incomplete revascularisation during the acute phase of ACS was associated with an increased risk of complications and a significantly increased risk of all-cause mortality and the combined rate of cardiovascular deaths and recurrent ACS. Single-stage PCI of all significant stenoses in MVD patients resulted in better outcomes.

Combined hypotensive treatment with ≥ 3 hypotensive drugs in patients with recurrent atrial fibrillation and arterial hypertension ensures more effective arrhythmia control than using less drugs.

BACKGROUND: Combined arterial hypertension (AH) therapy ensures the effectiveness of treatment and improves haemodynamic parameters of cardiac function. AIM: The evaluation of therapeutic regimens in the prevention of recurrence of atrial fibrillation (AF) episodes in hypertensive patients with paroxysmal/persistent forms of AF. METHODS: Prospective observation included patients (n = 164), without and with AH, grade I and II, with paroxysmal (51.3%) or persistent (48.7%) recurrent form of arrhythmia. Mean duration of AF was 4.0 years, (Q1:2; Q3:7). The anti-arrhythmic drugs were ineffective in prevention of AF episodes or non tolerated and were not used. In all patients precise control of blood pressure (BP) was implemented: patients were treated with beta-blockers: 100%; ACE-I: 65%, spironolactone: 47%, thiazide diuretics: 34%, loop-diuretics: 7%, calcium antagonists: 26.5% and alpha-blockers: 14.5%. Evaluation of symptomatic and confirmed AF episodes was performed every 3 months during 1-year follow-up. RESULTS: AH, grade I and II, was diagnosed in 115, 75%, of patients; (74% men, mean age 65.5 ± 9.7 years). Persistent form of arrhythmia was more frequent in patients with AH: 83% in comparison with patients without AH: 67% (p 〈 0.05). BP values were similar in normotensive and hypertensive patients after completing the study: 123 ± 9/79 ± 4 vs. 124 ± 10/80 ± 0.5 mm Hg. One hypotensive drug was used in 6 patients, 2 drugs in 38 patients, 3 in 37, 4 in 27, 5 in 7. Patients treated with . 3 drugs had more AF episodes in 3 months prior to evaluation: 4.7 ± 0.8 vs. 2.9 ± 0.4, p = 0.0444. But during 1-year follow-up, observed in 3-months periods, they had significant reduction in every 3-months period, p = 0.0001. Patients treated with 1.2 drugs had significant reduction after 3 months: p = 0.0029, 6 months: p = 0.04 and 12 months: p = 0.0012, but not after 9 months. CONCLUSIONS: AH promotes more advanced AF forms occurrence. Combined hypotensive therapy with minimum 3 drugs, including RAA inhibitors, may be effective in terms of BP control and reduction of arrhythmia episodes.

Successful primary coronary angioplasty improves early and long-term outcomes in ST segment elevation acute coronary syndromes in patients above 80 years of age.

BACKGROUND: ST segment elevation myocardial infarction (STEMI) in patients above 80 years of age continues to be a therapeutic challenge. Patients in this age group are rarely included in randomised clinical trials. AIM: Comparison of the effectiveness and safety of STEMI management in octogenarians in hospitals with a 24-hour percutaneous coronary intervention (PCI) capability and hospitals without PCI access. METHODS: A retrospective analysis of medical records of 50 octogenarians who were treated with PCI (group 1) in one center and 50 patients treated noninvasively in the other 3 hospitals (group 2). We evaluated mortality and major adverse cardiac events after 10 days, 30 days and 1 year. RESULTS: There were no significant differences in the demographic characteristics of the study groups. The duration of coronary pain was similar in both groups: 318 min in group 1 vs 383 min in group 2 (NS). Mortality in group 2 was significantly higher than in group 1: 40% vs 14%, respectively, after 10 days (p = 0.0034); 48 vs 18% after 30 days (p = 0.0014); and 54% vs 24% after 1 year (p = 0.0021). Thrombolytic treatment was used in only 40% of the patients in group 2. In group 2, acute heart failure (HF) (Killip class III and IV) was diagnosed more frequently than in group 1 (28% vs 12%, p = 0.034). In patients with Killip class I/II HF, mortality in patients in group 2 and group 1 was 22% vs 9%, at 10 days; 31% vs 14% at 30 days; and 39% vs 20% at 1 year. In patients with Killip class III/IV HF, mortality was 86% vs 50%, at 10 days; 93% vs 50% at 30 days; and 93% vs 50% at 1 year, respectively (all differences NS). In multivariate analysis adjusted for the differences between groups, HF (a negative effect) and a successful PCI (a positive effect) were independent predictors of 1-year survival. CONCLUSIONS: Successful primary PCI in STEMI patients above 80 years of age resulted in a reduction of early and long-term mortality compared to the medically treated patients. The benefits of PCI treatment accrued during the follow-up. In patients treated in the tertiary reference centre in whom PCI was not successful or was not deemed feasible, prognosis was similar to that in the medically treated patients. The latter patients rarely received thrombolytic treatment.

Effect of combined spironolactone-ß-blocker ± enalapril treatment on occurrence of symptomatic atrial fibrillation episodes in patients with a history of paroxysmal atrial fibrillation (SPIR-AF study).

Angiotensin II and aldosterone are key factors responsible for the structural and neurohormonal remodeling of the atria and ventricles in patients with atrial fibrillation (AF). The aim of the present study was to evaluate the antiarrhythmic effects of spironolactone compared to angiotensin-converting enzyme inhibitors in patients with recurrent AF. A cohort of 164 consecutive patients (mean age 66 years, 87 men), with an average 4-year history of recurrent AF episodes, was enrolled in a prospective, randomized, 12-month trial with 4 treatment arms: group A, spironolactone, enalapril, and a ß blocker; group B, spironolactone and a ß blocker; group C, enalapril plus a ß blocker; and group D, a ß blocker alone. The primary end point of the trial was the presence of symptomatic AF episodes documented on the electrocardiogram. At 3-, 6-, 9-, and 12 months, a significant (p < 0.001) reduction had occurred in the incidence of AF episodes in both spironolactone-treated groups (group A, spironolactone, enalapril, and a ß blocker; and group B, spironolactone plus a ß blocker) compared to the incidence in patients treated with enalapril and a ß blocker (group C) or a ß blocker alone (group D). No significant difference was seen in AF recurrences between patients taking spironolactone and a ß blocker with (group A) and without (group B) enalapril. No significant differences were found in the systolic or diastolic blood pressure or heart rate among the groups before and after 1 year of follow-up. In conclusion, combined spironolactone plus ß-blocker treatment might be a simple and valuable option in preventing AF episodes in patients with normal left ventricular function and a history of refractory paroxysmal AF.

High concentrations of B-type natriuretic peptide and left ventricular diastolic dysfunction in patients with paroxysmal/persistent atrial fibrillation as possible markers of conversion into permanent form of arrhythmia: 1-year prospective evaluation.

BACKGROUND: Atrial fibrillation (AF) may cause electrical and structural atrial remodelling, leading to progression from paroxysmal to permanent form of arrhythmia. Predictors of such a transition have not yet been well established. AIM: To assess the role of B-type natriuretic peptide (BNP) and left ventricular (LV) diastolic impairment in prediction of progression from paroxysmal/persistent AF to permanent AF. METHODS: The study group consisted of 154 patients (84 males, mean age 65.8 +/- 10 years) with paroxysmal (51%) or persistent (49%) AF and normal LV systolic function. All patients had BNP level and echocardiographic parameters of diastolic LV dysfunction measured at baseline and after one-year follow up. RESULTS: After one-year follow-up, 15 (9.5%) patients developed permanent AF. These patients had significantly higher baseline and one-year BNP values than the remaining patients (96.0 v. 41 pg/mL, p < 0.005, and 151.1 v. 32.5 pg/mL, p < 0.0001, respectively). Also echocardiographic indices of LV diastolic dysfunction were abnormal in patients who developed permanent AF. Stepwise logistic regression analysis revealed that baseline BNP level had independent prognostic value in predicting permanent AF development (OR 1.06, CI 1.01-1.12, p < 0.0162). The area under ROC curve was 0.787. CONCLUSIONS: Patient with normal systolic LV function and paroxysmal or persistent AF are likely to progress into permanent AF when they have increased BNP levels and echocardiographic signs of LV diastolic dysfunction.

Success rate of transvenous left ventricular lead implantation for cardiac resynchronisation therapy - recent experience of a single centre.

BACKGROUND: Implantation of a left ventricular (LV) lead for cardiac resynchronisation therapy (CRT) may be challenging. Wider use of various implantation techniques increases the success rate of CRT. AIM: Short-term analysis of the success rate of transvenous LV lead implantation for CRT. METHODS: All CRT procedures performed in 2009 with first-time LV lead implantation attempt were analysed in terms of efficacy, total number of procedures, procedure and fluoroscopy time, complications, and reinterventions. Final LV lead location and the number of tested sites were analysed. Complex procedures were defined and described. RESULTS: We studied 122 patients aged 67.6 +/- 10.6 years (98 males/80%) selected for CRT. The CRT implantation was an upgrade procedure in 17 patients. Fifty-six (46%) patients had coronary artery disease and 111 (91%) patients were in NYHA class III. The mean LV ejection fraction was 27% (range 10-35%). The implantation success rate was 97.5%. There were 87 (73%) CRT-D systems implanted and 32 (27%) CRT-P systems. Mean procedure time was 118 +/- 41 min, and fluoroscopy time was 15.9 +/- 12.1 min. An optimal location of the LV lead was achieved in 107 (90%) patients. More than one LV lead sites were tested in 42 (35.3%) patients. Complex procedures were performed in 4 (3.4%) patients. Early LV lead reintervention (< 30 days) was necessary in 10 (8.4%) patients (11 procedures), and epicardial lead placement was performed in one patient. The LV lead location in the antero-lateral branch demonstrated the lowest reintervention rate (1/22, 4.5%) v. other sites (great cardiac vein: 1/8, 12.5%, lateral branches: 9/86, 10.5%, p = NS). The LV lead-related reinterventions and initial procedure failure were associated with the upgrade procedures. No serious periprocedural complications were recorded. In one patient, the CRT system was explanted due to pocket infection. One patent died three months after CRT implantation due to progressive end-stage congestive heart failure. CONCLUSIONS: 1. In a tertiary centre, CRT implantation success rate is high and implantation procedures are safe. 2. Achieved LV lead location is optimal in a vast majority of patients. 3. We noted a significant rate of early reinterventions related to LV lead dislodgement. 4. The LV lead implantation failure and reinterventions occurred more frequently in subjects with upgrade- to-CRT procedures. A similar trend was also noted in patients after cardiac surgery. 5. In selected cases, advanced techniques must be used to achieve successful CRT implantation.

High monthly temperature as a possible risk factor of local vascular bleeding complications during percutaneous coronary interventions evaluated by ultrasonography - retrospective analysis.

BACKGROUND: Bleeding complications are a very important issue in the era of percutaneous coronary interventions (PCI). Effective antiplatelet therapy increases the rate of successful interventions but the risk of bleeding complications, among them local vascular complications, may be higher. Other factors may also be important in the development of local bleeding complications. AIM: To examine the relationship between air temperature and local haemorrhagic complications. METHODS: The retrospective analysis of ultrasonographic examinations performed during the last 5 years (2003-2007) in 10 548 consecutive patients undergoing cardiac catheterisation due to acute coronary syndromes or elective coronary angiography was performed. The relationship between mean monthly temperature, other factors and the rate of local bleeding complications was examined. RESULTS: Mean number of treated patients was 2708 +/- 377/year (2113-3089), of whom 1692 +/- 362/year had coronary angiography and 1345 +/- 281/year had PCI. Yearly rate of all femoral bleeding complications was 3.0 +/- 0.5%. There were more haematomas than pseudoaneurysms: 2.2 +/- 0.4 vs. 0.8 +/- 0.1%, p < 0.0001. Higher mean monthly air temperatures were positively correlated with the number of complications (r = 0.11, p < 0.05), both in males and females (r = 0.13, p < 0.05). A positive correlation between number of haematomas and air temperature values was detected in women. Yearly rate of all vascular complications, haematomas and pseudoaneurysms was higher in women than in men 4.3 +/- 0.9 vs. 2.3 +/- 0.3% (p < 0.0001), 3.0 +/- 0.7 vs. 1.7 +/- 0.3% (p < 0.0001) and 1.3 +/- 0.2 vs. 0.6 +/- 0.1% (p < 0.0005) respectively. In spite of more aggressive antiplatelet therapy, higher clopidogrel loading doses and abciximab use introduced during the analysed period, the rate of local vascular bleeding complications did not increase. CONCLUSIONS: High air temperature during the post-intervention period, besides female gender and advanced age, may be another risk factor for local bleeding complications. This risk remains low (3%), in spite of growing intensity of antiplatelet treatment.

Pre-hospital delay of treatment in patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: experience of cardiac centre located in the vicinity of the centre of Warsaw.

BACKGROUND: Early reperfusion therapy with primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) improves left ventricular function and reduces mortality. AIM: To assess the time delay in treatment of patients with STEMI referred to a twenty-four-hour interventional centre located in the vicinity of the centre of Warsaw. METHODS: We analysed 350 consecutive STEMI patients admitted to our Department between October 2005 and September 2006. The majority of the patients - 244 (69.7%), were admitted via hospitals without an interventional department. Sixty-two (17.7%) patients were transported directly by ambulance from home, 34 (9.7%) from a community health centre and 10 patients (2.9%) came by themselves from home or work. A detailed interview concerning the time of symptom onset was conducted in 342 patients (97.7%). RESULTS: Sixty-two (18%) patients arrived at the interventional centre within the first 2 hours from symptom onset: 6 women (5.5% of all women in the study population) and 56 (24.1%) men (p <0.0001). Within the first 2 hours, 32 (13.1%) patients were admitted via another hospital and 20 (32.2%) directly by ambulance (p <0.001). During the first 7 days of hospitalisation the following patients died: 2 (3.2%) patients admitted within the first 2 hours via another hospital, 6 (3.4%) patients among 178 admitted between 2 and 6 hours after pain onset, 4 (8.3%) among 48 admitted between 6 and 12 hours and 8 (14.8%) among 54 patients with the pain duration over 12 hours (p <0.02). During the first 7 days of hospitalisation 8 (3.3%) patients admitted within the first 6 hours after pain onset died compared with 12 (11.8%) admitted later (p <0.003). CONCLUSIONS: In the interventional centre located near the centre of Warsaw symptom-onset-to-door time was 120 minutes only in 18% of patients with STEMI. Almost 70% of patients underwent interhospital transfer for primary PCI. Prolongation of the time from onset of symptoms to successful PCI worsened prognosis. When transporting patients with acute coronary syndrome, efforts should be made to avoid district hospitals without a catheterisation laboratory. Direct transportation by ambulance or helicopter with educated staff equipped with ECG teletransmission data, which may substantially shorten time to treatment, should be preferred.

Is coronary vein angioplasty necessary to provide cardiac resynchronization in selected patients? A case report.

Cardiac resynchronization therapy (CRT) has become a recommended method for patients with congestive heart failure (CHF) and cardiac dyssynchrony. In some cases, CRT implantation procedure can be complicated because of anatomic and technical reasons. Some reports describe balloon angioplasty of stenotic heart veins as a method to achieve the target vessel. We present a case of a 58-year-old male with permanent atrial fibrillation and CHF who was referred for CRT. During the implantation of the pacemaker, the diaphragmatic obstacle in coronary sinus (CS) has been passed after many attempts using a balloon catheter with no inflation. The aim of the report is to discuss, in short, the real necessity of venous angioplasty in the CS bed during CRT implantation.

Primary coronary intervention in diabetic octogenarians with acute ST elevation myocardial infarction.

BACKGROUND: Diabetic patients with acute coronary syndrome (ACS) have higher mortality risk than non-diabetic patients. No data are available on long-term results of interventional treatment of ACS in diabetic patients aged > or =80 years. AIM: To compare the effects of primary angioplasty (pPCI) on short- and long-term outcome in diabetic patients > or =80 years with ST-elevation myocardial infarction (STEMI) compared to those without diabetes mellitus (DM) of similar age. METHODS: In 63 consecutive patients (22% with diabetes mellitus) aged 80-93 years (mean 83+/-3) with ST elevation ACS (ACS-STE) coronary angiography was performed. Severity of coronary atherosclerosis, effects of pPCI, one-day mortality, in-hospital mortality and one-year mortality were studied. RESULTS: Severity of coronary atherosclerosis measured by angiographic Gensini score and author's own score was similar in diabetic and non-diabetic patients (23.25+/-9.6 vs. 20.6+/-10.2; NS, and 9.1+/-6.0 vs. 8.1+/-5.4; NS, respectively). In 78.6% of diabetic subjects and in 69.4% of those without DM, pPCI was performed. Successful pPCI, defined as TIMI 3 flow and residual infarct related stenosis <20%, was obtained in 92.2% of patients with DM compared to 83.7% of non-diabetics (NS). One-day mortality was 7.1 vs. 6.1% (NS), in-hospital mortality was 7.1 vs. 17.4% (NS). Successful pPCI reduced 30-day mortality threefold (OR=0.31; p <0.05). Contrast-induced nephropathy occurred in 35.7% of diabetic patients compared to 26.5% of those without diabetes (NS) Contrast-induced nephropathy increased risk for in-hospital mortality fivefold (p <0.02). No significant correlation between DM or baseline glucose level and in-hospital mortality was found. During one-year follow-up mortality rate in diabetic patients was 38.5% compared to 7.3% of those without diabetes (p <0.01). One-year mortality predictors were: age (OR=1.27; p=0.0047), metabolic syndrome (OR=4.4; p <0.04), type 2 diabetes (OR=5.25; p <0.02), insulin treatment (OR=5.7; p <0.03), baseline glucose level (OR=1.01; p <0.007), maximum CK-mass level (OR=1.006; p <0.05), noninvasive STEMI management (OR=5.0; p <0.02), and stroke (OR=7.5; p <0.006). Stroke (OR=40.0; p <0.005) and diabetes (OR=6.2; p <0.01) were identified by multivariable analysis as independent risk factors of one-year mortality. CONCLUSIONS: In patients with DM aged > or =80 years with ACS-STE, severity of coronary atherosclerosis and in-hospital prognosis after pPCI seems to be similar to subjects in the same age without DM. Diabetes mellitus is an independent risk factor of one-year mortality after successful pPCI.