Association between retinopathy, microalbuminuria and coronary perfusion in young patients with type 1 diabetes mellitus.

BACKGROUND: In patients with type 1 diabetes mellitus (DM) impairment of the coronary circulation has been observed. This phenomenon could be ascribed to the existence of a specific cardiomyopathy. Disturbances in other microcirculation beds--renal and ocular--are mirrored by microalbuminuria and retinopathy, respectively. The association between coronary microvascular dysfunction and the presence of microalbuminuria and retinopathy is not clear. Recognition of the interrelationships between microalbuminuria, retinopathy and the impairment of coronary circulation could allow for a simple estimation of coronary perfusion in these patients. AIM: To assess coronary blood flow velocity in young patients with type 1 DM using transoesophageal Doppler echocardiography with dipyridamole and to analyse the possible relationship between the impairment of coronary flow and retinopathy as well as microalbuminuria. METHODS: The study group consisted of 36 patients, aged from 18 to 35 (mean: 25+/-5) years with type 1 DM lasting from 8 to 27 years. Diabetes was the only disease and none of the patients had any history of cardiovascular diseases or any abnormalities in physical examination. The control group consisted of 23 age-matched healthy volunteers. All subjects underwent transoesophageal echocardiography with dipyridamole to assess coronary flow velocity reserve (CFVR). RESULTS: In the study group CFVR and maximal flow velocity after dipyridamole were significantly decreased (2.4+/-0.6 vs. 3.4+/-0.7; p <0.001 and 125.7+/-31.4 vs. 168.00+/-12.9 cm/s; p <0.001, respectively). The basal flow velocity was comparable in both groups (55.9+/-14.6 vs. 52.2+/-11.6 cm/s; p=0.32). Decrease in CFVR in the study group was associated with a smaller increase in coronary flow velocity after dipyridamole challenge. There was no relationship between coexisting microalbuminuria, retinopathy and the CFVR values. CONCLUSIONS: In young patients with type 1 DM, without any clinical cardiovascular abnormalities, decreased coronary perfusion is observed. The presence of microalbuminuria or retinopathy is not associated with the alterations in coronary perfusion.

Clinical significance of heart rate turbulence assessment in patients with chronic heart failure.

BACKGROUND: Heart rate turbulence (HRT) is modulated by the baroreceptor reflex, and it has been suggested that it could be used as a measure of autonomic dysfunction. Impaired HRT has a significant prognostic value in patients after myocardial infarction. The usefulness of HRT parameters in CHF patients has not yet been well established. AIM: To assess the relationship between HRT parameters, clinical course of CHF and selected biochemical markers with respect to their prognostic value in CHF patients. METHODS: A 64 of 100 consecutive CHF patients, in whom it was possible to calculate HRT, were divided into four groups according to NYHA class. Uric acid (UA) and brain natriuretic peptide (BNP) concentrations were measured. Heart rate turbulence was analysed from 24-hour Holter ECG and characterised by two parameters: turbulence onset (TO) and turbulence slope (TS). The results of 20 healthy persons served as a control group. Follow-up examinations were performed after 6 and 12 months. RESULTS: In patients with CHF both HRT parameters (TO and TS) were significantly impaired in comparison to TO and TS in healthy subjects. A negative correlation between these parameters was found. A strong positive correlation between TO and NYHA class and a significant negative correlation between TS and BNP and UA concentrations were observed. There were 11 deaths during one-year follow-up. Patients who died due to CHF had significantly lower TS and higher TO values in comparison to survivors. CONCLUSIONS: Heart rate turbulence is impaired in CHF patients. HRT parameters show a significant correlation with some clinical factors: NYHA class, BNP and UA concentrations. Both HRT parameters, TO and TS, seem to be significant prognostic markers in patients with CHF.

[Heparin-induced thrombocythopenia in a patient with massive pulmonary embolism and dilated cardiomyopathy, successfuly treated with fondaparinux - a case report]. / Maloplytkowosc indukowana heparyna w przebiegu leczenia masywnej zatorowosci plucnej u kobiety z kardiomiopatia rozstrzeniowa skutecznie leczona fondaparynuksem - opis przypadku.

Heparin-induced thrombocythopenia (HIT) is a potentially serious complication of heparin treatment, rarely observed in cardiological wards. We present a case of a 38-year-old woman with dilated cardiomyopathy and massive pulmonary embolism treated with alteplase and unfractionated heparin. On 12th day an unexpected fall in platelet count was observed, without new signs of thrombosis. The HIT type II was diagnosed. Patient was treated effectively and safely by 7.5 mg of fondaparinux given subcutaneously once daily for 10 days.

[Usefulness of Tco99m-IBI myocardial perfusion SPECT in coronary artery disease diagnosis in women]. / Przydatnosc scyntygrafii perfuzyjnej serca SPECT z uzyciem technetu Tc99m-mIBI w rozpoznawaniu choroby niedokrwiennej serca u kobiet.

UNLABELLED: Coronary artery disease (CAD) in women remains a difficult diagnostic problem. The usefulness of exercise electrocardiography (EXT) in these patients is limited. The value of other noninvasive tests including Tc99m-MIBI single photon emission computed tomography (SPECT), is still to be determined. Aim of the study was to assess the usefulness of Tc99m-MIBI SPECT in the diagnosis of CAD in women in comparison to EXT MATERIAL AND METHODS: 48 women age 38-64 years (mean 50 +/- 6) with symptoms of CAD were included to the study. EXT ECG and Tc99m-MIBI SPECT with dipyridamole were performed in all patients. The diagnostic value of the tests was assessed in comparison to coronary angiography. Sensivity, specifity and accuracy were calculated according to the generally accepted rules. RESULTS: In 21 patients (44%) significant stenosis (> 50% diameter narrowing) in coronary angiography was found. In 18 (38%) of them single-vessel disease was detected. In 2 pts (4%) vasoconstriction was observed. EXT was positive in 28, negative in 17 and undiagnostic in 3 women with sensivity 72%, specificity 46% and an accuracy 58%. Perfusion defects were detected in 15 pts at rest and in 30 after dipyridamole infusion. MIBI SPECT had sensivity 91%, a specifity 60% and accuracy 74%. Evaluating tests enhanced sensivity to 100%, specifity to 71% and accuracy to 86%. SPECT sensivity was related to the localisation of coronary vessels changes: LAD 100%, Cx 66%, RCA 88% in case of single-vessel disease. CONCLUSION: Tc99m-MIBI SPECT proved to be a highly useful test in the diagnosis of CAD in women. Its diagnostic sensivity and accuracy is further enhanced by combination with ECG EXT. It has particular value in detection of one vessel disease.

A new programme of multidisciplinary care for patients with heart failure in Poznan: one-year follow-up.

INTRODUCTION: Recent trials have demonstrated the effectiveness of multidisciplinary care (MDC) for patients with chronic heart failure (CHF). However, results of the assessment of different programmes in individual countries could be different because of local specificities of health care systems. AIM: We sought to determine whether MDC for patients with CHF has an influence on mortality, rate of rehospitalisation, quality of life (QoL) and self-care (SC) during a one-year study period. METHODS: 160 patients with CHF treated in our unit were randomly assigned to receive either MDC or routine care (RC). Patients from the MDC group (n=80; mean age 67+/-10.2 years) attended follow-up visits at the heart failure clinic after 14 days and 3, 6, 9 and 12 months after discharge. They were cared for by a team which consisted of a cardiologist, a heart failure nurse (HF nurse), a psychologist and a physiotherapist. This group of patients received comprehensive education from the HF nurse and the cardiologist. Telephone counselling and home-based interventions by the HF nurse were also available daily. Patients from the RC group (n=80, mean age 69.5+/-10.7 years) were cared for by their primary care physician only. In both groups QoL and SC scores were calculated based on a 21 and 12-item questionnaire completed by the patients at discharge and after one year. RESULTS: After one-year follow-up the two groups did not differ in terms of either total and HF mortality or number of sudden deaths. In the MDC group when compared to the RC group we observed a significant decrease in the total number of hospital readmissions (by 37%, p <0.05), a decrease in hospital admissions due to HF (by 48%; p <0.05) and decreased length of stay during both all-cause readmissions and those due to HF (p <0.05). After one year of follow-up both QoL and SC scores were significantly lower in the MDC group than in the RC group (p <0.001), indicating improved QoL in the MDC group. CONCLUSIONS: The one-year multidisciplinary care programme for patients with chronic heart failure in Poznan demonstrated significant improvement of treatment results in terms of frequency of readmissions and length of hospital stay as well as improved Qol. A tendency to decreased total and heart failure related mortality and decreased number of sudden deaths was also observed.

[New multidisciplinary heart failure care program (six-month preliminary observation)]. / Nowy wielodyscyplinarny program opieki nad chorymi z niewydolnoscia serca (szesciomiesieczna obserwacja wstepna).

UNLABELLED: In the last years multidisciplinary care (MDC) of patients with chronic heart failure has proved to be effective. Because of specificity of the medical care organization in different countries the outcome of the programs may be various. The aim of this study was to evaluate the effect of MDC on patients' survival, hospitalization rate and stay. MATERIAL AND METHODS: 129 chronic heart failure patients admitted to Department of Cardiology were randomized to MDC or routine care (RC) groups. All patients were referred to their primary care physicians. In 64 patients from MDC group, aged 68 +/- 10.5 years, a follow-up was performed on 14 day, 3 and 6 months, on the basis of heart failure clinic, by cardiologist, heart failure nurse, psychologist and physiotherapist. Patients received heart failure nurse and cardiologist broad educational program systematically. Every day heart failure nurse telephone counseling and home-based interventions were also available to the patients. 65 patients from RC group, aged 72 +/- 11.5 years, were referred only to their primary care physicians. RESULTS: There was the lower duration of hospitalization in MDC than in RC group (8.3 +/- 5.31 vs 13.5 +/- 6.99 days; p < 0.05). A tendency to the lower duration of heart failure hospitalization and frequency of total and heart failure hospitalization in MDC group was observed (9.8 +/- 5.46 vs 12.1 +/- 6.23 days, 18.8 vs 25.0, and 12.5 vs 16.9% respectively). No significant differences were found between MDC and RC total and heart failure mortality (15.6 vs 16.9%, and 10.9 vs 12.3%, respectively). CONCLUSION: Six months multidisciplinary care of chronic heart failure patients has appeared more efficient than routine primary care.

What primary care physicians know about diagnosis and treatment of chronic heart failure.

BACKGROUND: The majority of patients with chronic heart failure (CHF) are treated by primary care physicians. Recent studies have shown that their knowledge about diagnosis and treatment of CHF is not satisfactory. AIM: To evaluate the knowledge of primary care physicians on the diagnosis and treatment of patients with CHF. METHODS: The survey consisting of 23 questions on the diagnosis and treatment of CHF, was filled in by 116 primary care physicians, practising in the city of Poznan. The questions dealt with the most typical characteristics of CHF, including history, physical examination, diagnosis of diastolic CHF and medical treatment, according to the recent guidelines of the European Society of Cardiology. RESULTS: More than 90% of physicians regarded history and physical examination as the most important elements required for establishing the diagnosis of CHF. Ankle oedema, dyspnea and fatigue were listed as the most typical CHF symptoms. Almost 80% of surveyed physicians routinely performed ECG and chest radiogram in order to diagnose CHF. Echocardiography was used by only 20% of physicians, and the term "diastolic CHF" was familiar to only one third of them. Angiotensin converting enzyme inhibitors (ACEI) were used by more than two thirds of doctors, and beta-blockers--by one third. The correct initial recommended dose of enalapril was known to more than half of the physicians, and the target dose--to only one fourth of them. The correct initial recommended dose of carvedilol was known to almost half of the physicians, and the target dose--to only 3% of them. Diuretics were prescribed by 62% of physicians, spironolactone--by half of them, and digitalis--by one third of them. CONCLUSIONS: Primary care physicians practising in the Poznan area diagnose CHF mainly on the basis of history, physical examination, ECG and chest radiogram. Echocardiography is underused which may hamper the accuracy of CHF diagnosis. ACEI and beta-blockers are also underused. These findings demonstrate that knowledge about diagnosis and treatment of CHF is insufficient among primary care physicians and indicate the need for educational and systematic changes, including a wider access to echocardiography.

[Knowledge of primary care physicians, cardiologists from cardiology clinics, internal and cardiology department physicians about chronic heart failure diagnosis and treatment]. / Porównanie wiedzy lekarzy rodzinnych, kardiologów oraz lekarzy szpitalnych oddzialów wewnetrznych i kardiologicznych o diagnostyce i leczeniu przewleklej niewydolnosci serca.

UNLABELLED: Last studies have shown unsatisfactory diagnosis and treatment of chronic heart failure (CHF) patients. The aim of this study was to compare the knowledge of primary care physicians (PCP), cardiologists from cardiology clinics (CARC), internal and cardiology department physicians (INTD and CARD) about CHF diagnosis and treatment. MATERIAL AND METHODS: A questionnaire consisting of 23 questions related to above issues was filled out by 153 physicians (64 PCP, 24 CARC, 44 INTD and 21 CARD) from the urban district. Similarly to other physicians, PCP suspected CHF on the ground of ankle oedema (88%), dyspnoea (75%) and basal pulmonary crepitations (44%). Most questioned doctors ordered a chest X-ray (58-86%) to establish the diagnosis. Echocardiography was underused by PCP (19%) in comparison to other doctors (68-86%). Under-utilization of angiotensin converting enzyme inhibitors (ACEI) (-68 to -79%; NS) and, especially, beta-blockers (-35% by PCP to -51% by CARD; p < 0.05) was observed. The recommended target dose of enalapril knew more CARD (52%) and INTD (45%) than PCP (25%) (p < 0.05 and p < 0.01, respectively). The appropriate target dose of carvedilol knew 3% of PCP, 8% of CARC, 9% of INTD and 14% of CARD (PCP vs. CARD; p < 0.01). CONCLUSIONS: Most CHF patients from the urban region are diagnosed by PCP and other doctors on the basis of symptoms, signs and a chest X-ray. The misdiagnosis of CHF may depend on the small direct access of PCP to echocardiography. Under-utilization and under-dosing of ACEI and beta-blockers creates the necessity to introduce broad educational programs and some organisational changes (implementation of CHF clinics).

Polymorphism in intron 23 of the endothelial nitric oxide synthase gene (NOS3) is not associated with hypertension.

Nitric oxide (NO) is synthesised in the vascular endothelium by nitric oxide synthase (NOS3) and is an important factor in the regulation of blood pressure. Impaired synthesis of NO due to mutations in the NOS3 gene is associated with hypertension. To date several allelic variants of the NOS3 gene have been identified and their possible linkage with hypertension investigated. We studied the distribution of genotypes and frequency of alleles of the G11T polymorphism in intron 23 of the NOS3 gene in patients with hypertension and in a control group of healthy individuals. The polymorphism was determined by PCR-RFLP analysis. The distribution of genotypes in the patients with hypertension and in the healthy individuals did not differ significantly from the values predicted from Hardy-Weinberg equilibrium for the general population. No major differences in the distribution of the G11T polymorphism in the patients and healthy individuals were found (P > 0.05).

[Prognostic value of early dipyridamole stress echocardiography in patients with first uncomplicated myocardial infraction]. / Ocena wartosci prognostycznej echokardiograficznego testu z dipirydamolem wykonywanego u chorych po pierwszym, niepowiklanym zawale miesnia sercowego.

Detection of contractility abnormalities during stress echocardiography could affect prognosis after myocardial infarction (MI). The aim of the study was to examine the prognostic value of dipyridamole stress echocardiography (E-DIP) in patients (pts) who survived the first Q-wave uncomplicated MI. The study group consisted of 137 pts--124 males and 13 females--mean age 54 years, range (32-75). E-DIP was performed between 10-17 day after MI. Cardiac events: death, myocardial infarction, unstable angina, angioplasty or coronary artery bypass grafting, were in 1 year follow-up observed. In-group with positive result of E-DIP (63 pts) the frequency of cardiac events was significantly higher compared to the group with negative result of E-DIP.

[Captopril in the treatment of acute myocardial infarction. Hypotension as an important clinical problem]. / Kaptopryl w leczeniu zawalu miesnia sercowego. Podcisnienie tetnicze jako istotny problem kliniczny.

The aim of study was to analyze the effect of captopril (C) on blood pressure in patients with acute myocardial infarction (AMI) during 1 year treatment. Patients less then 70 years old with systolic blood pressure (sBP) > or = 100 mm Hg were qualified to the study. Administration of C was started during the first 4 days of AMI (mean 21 +/- 24 h). 50 pts treated with C and control group of 43 pts were finally analyzed. Doses of C were gradually increased from 3.125 t.i.d. on the first day till 25 mg t.i.d. on the 4th day. Significant decrease of sBP after administration of C was observed at 60 and 120 min after the 1st, 2nd and 3rd dose on the first day, and after 30-120 min after first C dose on the 4th day. dBP decreased only at 60-120 min after the 1st dose on first day and at 90 min after the first dose on 4th day. Hypotension after 1st and 2nd dose of C on the first day caused exclusion of 3 pts (6%) from the study. In conclusion, hypotension seems to be quite often encountered during captopril therapy of early phase of AMI. It appears not only after the first but also after the following doses. The initial dose of 3.125 mg seems to be safe and sufficient to assess its hypotensive action.

Heart rate turbulence in patients with obstructive sleep apnea syndrome.

BACKGROUND: Heart rate turbulence (HRT) assessment is used as noninvasive method based on physiological sinus node response to the premature ventricular beat. Blunted HRT may indicate the autonomic nervous system impairment and can be helpful in identifying high-risk patients. Obstructive sleep apnea syndrome (OSAS) leads to cardiovascular complications. Autonomic nervous system and baroreflex dysfunctions may play the main role in the development of cardiovascular diseases. In the present study we aimed to assess HRT parameters in OSAS patients with and without coronary artery disease (CAD) in comparison to control group. METHODS: HRT analysis (TO--turbulence onset and TS--turbulence slope) was performed in 22 OSAS patients (confirmed by polisomnography, apnea-hypopnea index >or= 15) and 21 healthy persons, obtained from 24-hour ECG recordings. CAD was confirmed in 10 OSAS patients, by positive exercise test ECG and coronary angiography. RESULTS: TS was significantly lower in OSAS patients in comparison to control group (1.14 +/- +/- 2.83 vs. 21.28 +/- 16.2, p < 0.001). TO didn't differ in both group. Significant negative correlation between TS and apnea-hypopnea index was observed (r = 0.49, p < 0.01). There were no significant HRT changes in OSAS and CAD patients vs. OSAS without CAD patients, although tendency to more impaired HRT in OSAS and CAD patients was observed. CONCLUSIONS: In OSAS patients, blunted HRT (especially TS) was observed. This may indicate baro-reflex dysfunction correlated with the severity of sleep disorders. The additional diagnosis of CAD did not significantly influence HRT parameters.