Clinical Characteristics, Treatment, and Short-Term Outcome in Patients with Heart Failure and Cancer.

(1) Our study aimed to look at the clinical characteristics, treatment and short-term outcomes of patients hospitalized due to heart failure with coexisting cancer. (2) Methods: Seventy one cancer (Ca) patients and a randomly selected 70 patients without Ca, hospitalized due to heart failure exacerbation in the same time period constituted the study group (Ca patient group) and controls (non-Ca group), respectively. Data on clinical characteristics were collected retrospectively for both groups. (3) Results: Cancer patients presented with a less advanced NYHA class, had more frequent HFpEF, a higher peak troponin T level, and smaller left atrium size, as compared with controls. The in-hospital deaths of Ca patients were associated with: a higher New York Heart Association (NYHA) class, lower HgB level, worse renal function, higher K and AST levels, presence of diabetes mellitus, and HFpEF. By multivariate logistic regression analysis, impaired renal function was the only independent predictor of in-hospital death in Ca patients (OR-1.15; CI 1.05; 1.27); p = 0.017). The following covariates entered the regression: NYHA class, HgB, GFR, K+, AST, diabetes mellitus t.2, and HFpEF. (4) Conclusions: The clinical picture and the course of heart failure in patients with and without cancer are different.

Cardiac Autonomic Neuropathy: Why Should Cardiologists Care about That?

BACKGROUND: Cardiac autonomic neuropathy (CAN) is a frequent but underdiagnosed complication of diabetes mellitus. It has a strong influence on various cardiac disorders including myocardial ischemia and infarction, hypertension, orthostatic hypotonia, heart failure, and arrhythmias. CAN can lead to severe morbidity and mortality and increase the risk of sudden cardiac death. METHODS: This review article summarizes the latest evidence regarding the epidemiology, pathogenesis, influence on the cardiovascular system, and diagnostic methods for CAN. The methodology of this review involved analyzing available data from recent papers relevant to the topic of diabetic autonomic neuropathy and cardiac disorders. CONCLUSIONS: The early diagnosis of CAN can improve the prognosis and reduce adverse cardiac events. Methods based on heart rate variability enable the diagnosis of CAN even at a preclinical stage. These methods are simple and widely available for use in everyday clinical practice. According to the recently published Toronto Consensus Panel on Diabetic Neuropathy, all diabetic patients should be screened for CAN. Because diabetes mellitus often coexists with heart diseases and the most common methods used for diagnosis of CAN are based on ECG, not only diabetologists but also cardiologists should be responsible for diagnosis of CAN.

Platelet reactivity and mean platelet volume as risk markers of thrombogenesis in atrial fibrillation.

Atrial fibrillation (AF) is associated with increased risk of thromboembolic complications. One of the markers of the increased risk of hypercoagulable state is platelet hyperreactivity. The aim of the study was to assess impact of arrhythmia on platelet reactivity. METHODS: The study included 36 (mean age 48,3; range 21-60) male patients with lone atrial fibrillation, with exclusion of concomitant diseases known to trigger hypercoagulable state. The AF patients underwent cardioversion to restore sinus rhythm and were subsequently under observation for 1month. Echocardiography, ECG and blood collection was performed before cardioversion (T0) and 4weeks after successful cardioversion (T1). During the study period patients have been contacted and examined every week and 24h ECG monitoring was performed. Platelet reactivity was assessed based on changes of CD62 and CD42b expression on platelet surface after stimulation with thrombin. Also changes in MPV were assessed. RESULTS: In all patients sinus rhythm was maintained at the end of the study period, however in 14 patients recurrences of AF were observed, confirmed by 24h ECG monitoring (atrial fibrillation recurrence group - AFR) and 22 patients maintained sinus rhythm throughout the whole study period (SR group). Mean fluorescence intensity (MFI) of CD62 on thrombin stimulated platelets decreased significantly 4weeks after electrical cardioversion as compared to T0 (48.04±22.42 vs 41.47±16.03; p<0.01). Also MFI of CD42b on thrombin stimulated platelets decreased significantly 4weeks after electrical cardioversion as compared to T0 (22.16±10.82 vs 12.06±5.99; p<0.0001). Platelets reactivity estimated by CD 62 expression in SR group decreased significantly after 4weeks observation (58.01±15.26 vs 46.57±13.44; p<0.001) opposite to AFR group 35.66±21.87 vs 34.54±16.4; p-ns). Moreover there were significant differences between basal reactivity during AF between SR and AFR groups (58.01±15.26 vs 35.66±21.87; p-0.01). MFI of CD42b on thrombin stimulated platelets decreased significantly both in AFR and SR groups (22.05±11.36 vs 13.8±6.03; p<0.001 and 21.87±14.18 vs 10.04±5.09; p<0005). MPV decreased significantly 4weeks after electrical cardioversion as compared to T0 (8.81±0.19 vs 8.42±0.14; p<0.0001). CONCLUSION: The changes of platelet reactivity to thrombin observed after restoration of sinus rhythm in patients prove that arrhythmia intrinsically leads to increased reactivity of platelets.

Asymptomatic atrial fibrillation in patients with atrial fibrillation and implanted pacemaker.

INTRODUCTION: Atrial fibrillation is the most common chronic arrhythmia. Due to diagnostic difficulties, the exact prevalence of silent atrial fibrillation is not precisely defined. AIM: The main aim of the present study was to assess the prevalence of asymptomatic atrial fibrillation and the relation between clinical status and presence of symptoms of atrial fibrillation. MATERIAL AND METHODS: Fifty patients with implanted pacemaker with atrial fibrillation recording function and diagnosed paroxysmal atrial fibrillation were enrolled to the study in order to detect episodes of atrial fibrillation. Episodes lasting >1min were included into analysis. Patients were evaluated for presence of atrial fibrillation symptoms. RESULTS: A total of 870 atrial fibrillation episodes were registered, the majority (93%) were asymptomatic. Episodes occurred more often during the day than during the night (p<0.001). Asymptomatic episodes occurred 13 times more frequently than symptomatic (p<0.001). Majority of episodes lasting up to 5min were asymptomatic, while episodes lasting over 24h were usually symptomatic (p<0.001). Furthermore, there were association between silent atrial fibrillation and lower HR (p=0.003), higher percentage of atrial (p=0.01) and ventricular pacing (p<0.001), male gender (p<0.001), presence of atrioventricular block (p<0.003), lower NYHA class (p<0.002), and calcium channel blockers (p=0.033) and diuretics intake (p<0.001). CONCLUSION: In patients with bradycardia permanent pacemakers and paroxysmal atrial fibrillation, the proportion of asymptomatic episodes is very high. It was observed that shorter duration of the episodes, male gender, lower heart rate, presence of atrioventricular block, lower NYHA class, higher percentage of atrial and ventricular pacing, Ca2+ blockers, and diuretics intake predisposed to silent atrial fibrillation.

Heart rate turbulence in patients with poorly controlled diabetes mellitus type 2.

INTRODUCTION: Cardiac autonomic neuropathy (CAN) causes substantial morbidity and increased mortality in patients with diabetes mellitus (DM). Besides heart rate variability (HRV), heart rate turbulence (HRT) is an important method of assessment of cardiac autonomic regulation. The aim of the study was to assess the correlation between HRT and diabetic control. MATERIAL AND METHODS: Fifty-nine patients met the inclusion criteria - 38 males and 21 females, age 64.4 ±7.6. The patients included had inadequately controlled DM type 2 defined as glycated haemoglobin (HbA1c) > 9% (mean 11.8 ±2.7%). In all patients, intensive insulin treatment had been applied for 6 months. After 6 months, HbA1c was measured. ECG Holter monitoring was performed before and after insulin treatment to evaluate the time domain HRV and HRT parameters (turbulence onset (TO) and turbulence slope (TS)). RESULTS: After 6 months of intensive insulin treatment, HbA1c concentrations ranged from 6.3% (45 mmol/mol) to 11.2% (99 mmol/mol) - mean 8.5 ±3.8% (69 ±18 mmol/mol). Significant improvement of TO, TS and SDNN was observed. The TO and TS significantly correlated with HbA1c (r = 0.35, p = 0.006 and r = -0.31, p = 0.02 respectively). Among analyzed HRV time domain parameters such as SDNN, rMSSD and pNN50, only SDNN correlated with HbA1c (r = -0.41, p = 0.001). It was further concluded that intensive insulin therapy led to better glycemic control, resulting in improvement of HRT. CONCLUSIONS: Heart rate turbulence may be useful in monitoring changes of the autonomic nervous system functions in patients with DM, similarly to HRV parameters.

Barriers to implementation of evidence-based electrical therapies and the need for outcome research: role of European registries.

Although clinical trial results and the implementation of current guidelines appear to have encouraged progress in the treatment of arrhythmias, great discrepancies still exist between European Society of Cardiology (ESC) member countries. Guidelines are not adhered to for a variety of reasons. This cannot be explained only by economic factors, although these obviously play a substantial role. Other factors responsible for adequate guideline implementation appear to be the lack of trained personnel, the lack of infrastructure, or different health insurance systems. In this complex scenario, the data based on European registries are useful for creating standards and harmonizing the treatment of arrhythmias. Moreover, a summary of registry data, such as presented in the European Heart Rhythm Association (EHRA) White Book, can provide the opportunity to share and exchange information among ESC member countries on specific needs for improvements, reimbursement policy, and training issues.

Determinants of geographic variations in implantation of cardiac defibrillators in the European Society of Cardiology member countries--data from the European Heart Rhythm Association White Book.

AIMS: Sudden cardiac death (SCD) is a major health concern in developed countries. Many studies have demonstrated the efficacy of implantable cardioverter defibrillator (ICD) therapy in the prevention of SCD and total mortality reduction. However, the high individual costs and the reimbursement policy may limit widespread ICD utilization. METHODS AND RESULTS: This study analyzed the temporal and the geographical trends of the ICD implantation rate. Data were gathered from two editions of the European Heart Rhythm Association (EHRA) White Books published in 2008 and 2009. The analysis revealed significant differences in the rates of ICD implantation per million capita between the countries, but the median implantations was constantly increasing. The number of ICD implantations correlated with gross domestic product (GDP), GDP per capita, expenditure on health, life expectancy, and the number of implanting centres. CONCLUSION: There are great number of differences in the ICD-implanting rates between EHRA member countries, consequent to the increase in the number of ICD implantations. The ICD implantation rates are related to national economic status and healthcare expenses.

Endothelial function and left ventricular remodeling in diabetic and non-diabetic patients after acute coronary syndrome.

BACKGROUND: Endothelial dysfunction is an independent predictor of future cardiac events. MATERIAL/METHODS: We evaluated the relationship between flow-mediated dilation (FMD) in brachial artery and coronary risk factors in 93 patients (70 males, mean age: 62 ± 8 years) with ACS treated with primary angioplasty (PCI). The patients were divided into 2 subgroups: 43 patients with diabetes mellitus type 2 (DM) and 50 non-diabetics (non-DM). Patients were examined on the 3rd day after ACS and after 6 months. FMD on the 3rd day were significantly lower in DM than in non-DM (5.8 ± 2.2% vs. 8.8 ± 4.9%, p=0.0007) and after 6 months (6.2 ± 2.6% vs. 9.4 ± 4.4%, p<0.0001). It was also observed that the improvement of FMD in both groups after a 6-month follow-up inversely correlated with the increase of left ventricular end-diastolic volume (LVEDV) (r=-0.41, p<0.001). RESULTS: There was an inverse relationship between FMD and age (r=-0.26, p<0.01), BMI (r=-0.26, p<0,005), total cholesterol (r=-0.56, p<0.001) and LDL cholesterol (r=-0.53, p<0.001). There was no relationship between triglycerides, hypertension and history of smoking. In the DM group, FMD negatively correlated with HbA1c (r=-0.68, p<0.001). Restenosis rate was significantly higher in the DM group (19% vs. 6%, p<0.001) but there was no relationship between FMD and restenosis. CONCLUSIONS: Impaired FMD is more significant in diabetics than in non-diabetic patients with ACS. Lack of improvement of FMD after acute coronary syndrome can be a predictor of detrimental left ventricular remodeling in patients with ACS.

Cardiac defibrillator implantation via persistent left superior vena cava - sometimes this approach is facile. A case report.

We report a case of persistent left superior vena cava (PLSVC) incidentally recognized during the implantation of a cardioverter-defibrillator. PLSVC is the most common venous anomaly of the thorax and drains into the right atrium. There are a lot of publications reporting success of pacemaker or defibrillator lead implantations via PLSVC. In this article we present the technique of approaching the right ventricle and right atrium via PLSVC; sometimes this method can be as straightforward as the classical way. Therefore, if PLSVC is recognized intra-operatively, we suggest continuing left-sided implantation, and considering a right venous access only in case of failure.

The effect of diabetic autonomic neuropathy on P-wave duration, dispersion and atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is the most common sustained arrhythmia. Diabetic autonomic neuropathy (DAN) is a frequent complication of diabetes mellitus and has a negative impact on the cardiovascular system. There are no data about the occurrence of paroxysmal atrial fibrillation (PAF) in the population with DAN. MATERIAL AND METHODS: We analysed the data of 100 patients with PAF. The study population was divided into three groups: group I: 28 patients with diabetes mellitus (DM) and DAN, group II: 34 patients with DM without DAN, and group III: 38 patients without DM. P-wave duration (FPD) and dispersion (PWD) were measured during sinus rhythm and AF episodes were counted during 12 months of follow-up. RESULTS: Recurrence of PAF was higher in group I (47 episodes/year) compared to groups II and III (26 and 22 episodes/year) - p<0.01. The FPD was longer in group I (137.4 ±12.0 ms vs. 126 ±23.0 ms in II group and 129 ±18.3 ms in group III; p<0.001). The PWD was longer in patients with DAN (53 ±19 ms vs. 36 ±18 ms and 34 ± 20 ms, p<0.001). CONCLUSIONS: The results showed that the presence of DAN caused a significant increase in P-wave duration and dispersion, which might be responsible for the recurrence of AF.

Recurrence of ventricular arrhythmias in patients with non-ischaemic dilated cardiomyopathy: evidence-based predictors.

BACKGROUND: Ventricular arrhythmia (VA) is the most frequent cause of sudden death among patients with non-ischaemic dilated cardiomyopathy (DCM). AIM: To identify the important VA risk factors in patients with DCM. METHODS AND RESULTS: Eighty-five DCM patients (73 males, mean age 54 years) with DCM and implantable cardioverter defibrillators (ICD) were followed for 21+/-19 months after ICD implantation. The mean follow-up was 21 months. Data from 55 patients with VA recorded in the ICD memory and requiring ICD intervention during follow-up were compared with 30 patients without arrhythmia. Cox regression analysis identified the following univariate predictors of VA: alcoholic aetiology of DCM (0.05), diuretic treatment (0.003), history of cardiac arrest (0.03), right ventricular diastolic diameter (0.001). Both ACE inhibitor (ACEI) and statin treatments were associated with a tendency towards decreased risk of VA. Multivariate logistic analysis identified four predictors as significantly related to VA: alcoholic aetiology (HR 4.8, p=0.008), ACEI treatment (HR 0.4, p=0.01), diuretic treatment (HR 2.6, p=0.015), and statin treatment (HR 0.1, p=0.03). CONCLUSIONS: The majority of patients with DCM and ICD have recurrences of VA. Alcoholic aetiology of DCM is associated with an increase in the incidence of arrhythmias. Treatment with ACEI and statins is associated with a reduction of arrhythmias.

[Value and circadian variations of QT dispersion in patients with diabetes mellitus and coronary artery disease]. / Wartosc dyspersji QT i jej zmiennosc dobowa u chorych na cukrzyce i chorobe wiencowa.

UNLABELLED: The frequency of onset of acute coronary syndromes and sudden cardiac death has been reported to have circadian variations, with a peak incidence in early morning hours. It has also been known that acute ischemia is a potent stimulus to increased dispersion of repolarization and development of malignant arrhythmias. QT dispersion (QTd) is used as an index of heterogenity of the ventricular repolarization and increases in patients with ischemic heart disease. The aim of the study was to investigate diurnal variations of QTd in patient with triple-vessel coronary artery disease (CAD) with and without diabetes mellitus type 2 (DM). MATERIAL AND METHODS: We investigated of 28 patients with stable triple-vessel CAD and 32 patients with similar advancement of changes in coronary circulation with co-existing DM. We excluded patients with prior myocardial infarction, taking oral medications which might alter QT interval and patients in which measurements of QT were difficult to perform or impossible. QTd measurements were taken semi-automatically every hour from 24 hours 12 leads Holter monitoring system (SUPRIMA 12). Measurements were verified independently by three observers. RESULTS: CAD patients without DM had QTd significantly greater in the morning hours (6 a.m. to 9 a.m.) in comparison with the other times (p < 0.01). The shortest QTd was measured during the night between 10 p.m. and 1 a.m. We did not observed circadian variations of QTd in patients with co-existent DM and values of QTd in this group was significantly greater then in CAD without DM group (p < 0.001). CONCLUSIONS: Our data proved that QTd in patients with CAD had a circadian variation with a peak value in the morning hours shortly after awakening. Patients with DM and CAD had not circadian variation of QTd but QTd values, during whole day and night, were significantly greater then patients without DM.

[Effect of the acetylosalicyd acid (ASA) and ticlopidine therapy on clinical condition and parameters of blood platelets in patients with peripheral arterial occlusive disease (PAOD)]. / Ocena wplywu terapii kwasem acetylosalicylowym i tiklopidyna na stan kliniczny oraz parametry plytek krwi u chorych na miazdzyce zarostowa konczyn dolnych (arteriosclerosis obliterans).

UNLABELLED: Hyperreactivity of platelets is one of the agents promoting atherosclerosis and its organ complications THE AIM: To assess antiplatelet therapy with acetylsalicylic acid (ASA) and ticlopidine on clinical condition and chosen parameters of blood platelet activity and reactivity in patients with PAOD. MATERIAL AND METHODS: Twenty eight patients, aged 40-65 years, were enrolled to the study after clinically and echographically established diagnosis. The patients were randomly divided into two groups: 13 were treated with ASA 300 mg daily and 15 with ticlopidine 2 x 250 mg daily. The therapy lasted two months. Clinical stress tests were done on moving track according to thB modified Bruce's protocol and blood platelets activity parameters on flow-cytometer. Percentage of spontaneous platelet aggregates, microplatelets and platelets expressing CD62P, Cd42b and CD41 were tested. RESULTS: Supplementation therapy with ASA or ticlopidine to the standard therapy with pentoxyphylline resulted in a marked increase in the distance of claudication evaluated subjectively and objectively on moving track and revealed silent myocardial ischemia in 4 PAOD patients. In platelet activation tests, both at rest and after the stress test, independently of the antiplatelet agent used, we observed significant drop in the percentage of platelet aggregates and symptoms of vWF receptor activation. No effect of the therapy on CD62P expression, reflecting platelet release reaction and CD41 expression (the fragment of receptor for fibrynogen) were noted. CONCLUSIONS: Both antiplatelet drugs have beneficial effect on clinical condition of PAOD patients and the effect may results from their anti-aggregative and anti-adhesive properties.

Heart rate and arrhythmia in patients with psoriasis vulgaris.

BACKGROUND: Psoriasis is a chronic inflammatory disease involving 1-3% of the human population worldwide. Many systemic diseases including cardiovascular disturbances have been described in psoriatic patients. However, there is a scarcity of data on heart rate, heart rate variability, arrhythmia and conduction abnormalities in this group of patients. METHODS: The study comprised 32 patients with chronic psoriasis vulgaris and negative personal history of heart problems. Severity of the disease was evaluated by Psoriasis Area and Severity Index (PASI). Twenty-four-h continuous electrocardiographic monitoring (24-h Holter ECG) was performed in all patients. RESULTS: Heart rate was significantly higher both during the day and at night in patients with psoriasis vulgaris than in the control group (p < 0.0001). There was a positive correlation between the increased heat rate, both during the day and at night, in psoriatic patients and severity of the disease expressed as PASI. Single supraventricular beats were significantly more frequently observed in psoriatic patients vs. the control group (p < 0.0001). CONCLUSIONS: An active inflammatory process observed in psoriasis seems to exert its influence on increased heart rate and supraventricular beats development. However, to confirm the above findings, further studies on larger groups of psoriatic patients, presenting different types of the disease are mandatory.

[Evaluation of blood pressure changes by 24-hours ambulatory blood pressure monitoring (ABPM) in young, normotensive patients with diabetes mellitus type I]. / Ocena zmian cisnienia tetniczego metoda 24-godzinnego ambulatoryjnego monitorowania cisnienia (ABPM) u mlodych, normotensyjnych chorych na cukrzyce typu 1.

UNLABELLED: The aim of this study was to evaluate usefulness of ambulatory blood pressure monitoring (ABPM) to examine circadian patterns of blood pressure (BP) alterations in young, normotensive patients with type I diabetes mellitus (DM1). MATERIAL AND METHODS: We studied 43 patients with DM1 aged 18-28 years, with 9-23 years of DM1, without long-term complications. Control group consisted of 32 healthy persons, matched to the DM1 group. 24h ABPM was performed by a Spacelab 90207 device to obtain daytime (7 AM to 11 PM, readings at 20-min interval) and nighttime (11 PM to 7 AM, readings at 30-min interval) measurements in both groups. RESULTS: During the daytime systolic BP (sBP) and diastolic BP (dBP) were not significantly different from the control group. We noted nighttime sBP and dBP higher in DM1 group: sBE 119.7+/-12.6 mmHg vs. 103.817.1; p = 0.001 l dBP 65.5+/-6.2 vs. 61.5+/-3.1; p = 0.001. The loss of fall in BP ('non-dippers') was more prevalent in DM1 group: 49% vs. 9%; p = 0.003. Pulse pressure (PP) was significantly higher in DM1 patients: 50.9+/-6.9 mmHg vs. 44.8+/-5.6 mmHg; p = 0.0001. CONCLUSIONS: ABPM is a useful method in detecting early BP alterations in young normotensive patients with diabetes mellitus type 4 1. Increased PP and suppressed diurnal BP variations could represent a increased risk of cardiovascular complications in young patients with diabetes mellitus type 1.

[Application of heart rate variability in prognosis of patients with diabetes mellitus]. / Zastosowanie analizy zmiennosci rytmu zatokowego w ocenie prognostycznej u chorych na cukrzyce.

The ECG based heart rate variability (HRV) measurements has become an important method of assessment of the cardiac autonomic regulation. There is a large body of clinical and experimental evidences indicating that reduced HRV is a predictor of death in patients after myocardial infarction and with heart failure. Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes. Cardiovascular autonomic neuropathy (CAN) is the most studied and clinically important form of DAN. Published data demonstrate that CAN is strongly associated with an increased risk of myocardial ischaemia, serious arrhythmias, exercise intolerance and mortality. The determination of the presence of CAN is usually based on Ewing's tests. Measurement of HRV is readily available method and serves to establish diagnosis of autonomic dysfunction. The reduction in parameters of HRV seems not only to carry negative prognostic value in patients with diabetes but also to precede the clinical expression of autonomic neuropathy HRV evaluation in diabetes can encourage physician to improve further therapy.

[Automatic blood pressure monitoring for verification of earlier diagnosis of treatment-resistant hypertension: a case report]. / Zastosowanie 24-godzinnego automatycznego monitorowania cisnienia tetniczego do weryfikacji rozpoznania nadcisnienia tetniczego opornego na leczenie (opis przypadku).

We present a case of 68-year old woman with long-term diagnosis of arterial hypertension resistant to treatment. Despite multiple treatment modifications and intensification the blood pressure values were poorly controlled. We observed the high lability of the blood pressure measured during 10 to 20 minutes intervals. 24 h automatic blood pressure monitoring (ABPM) was performed using Holter's method. The examination revealed normal or even low values of the arterial blood pressure. We established diagnosis of "white coat effect" and corrected the therapy.