Therapeutic hypothermia and postreperfusion myocardial injury in myocardial infarction.

Myocardial infarction is one of the main causes of death worldwide. Since the introduction of primary percutaneous coronary intervention (PPCI), the rate of patients who die of a myocardial infarction or suffer from numerous complications afterwards has significantly decreased. During PPCI, the patient sustains postreperfusion myocardial injury, which entails an extension of the myocardial infarct size related to ischemia. Research on the ways of limiting this phenomenon has been carried out for years. One of the investigated methods is hypothermia. The first animal studies have yielded promising results. The application of hypothermia has been proved to reduce the myocardial injury size provided that the cooling commenced before reperfusion. Moreover, the trial conducted by Götberg M. et al. showed a significant reduction of microvascular obstruction (MVO) in pigs subjected to hypothermia before reperfusion. MVO was assessed via ex vivo magnetic resonance imaging. The conducted randomized clinical trials have shown the possibility of applying mild hypothermia in conscious patients without causing significant complications. In the presented trials, hypothermia was induced and maintained using an intravascular catheter inserted into the inferior vena cava, cold saline solution infusions into peripheral veins or directly into the coronary arteries or via peritoneal hypothermia. The myocardial injury size was assessed via magnetic resonance imaging (MRI) or single photon emission computed tomography (SPECT). Despite the promising results obtained by Young-Sheng Wang et al., who applied selective intracoronary hypothermia and the myocardial infarct size (IS/MaR) was significantly reduced (p=0.022), it has not been unambiguously confirmed yet that hypothermia is effective as an adjunctive therapy for revascularization in myocardial injury size reduction during a myocardial infarction.

The Incidence, Clinical Significance, and Treatment Effects of Depression in Cardiac Resynchronization Therapy Recipients.

OBJECTIVES: Chronic heart failure (HF) is associated with significantly increased prevalence of depression. The aim of the study was to assess the incidence and clinical impact of depression as well as the effectiveness of depression treatment in HF patients. METHODS: A prospective interventional trial included 285 consecutive cardiac resynchronization therapy recipients. Patients underwent a psychiatric examination at the time of implantation and then it was routinely repeated at 3, 6, and 12 months after the procedure, and every 6 months thereafter. One hundred and thirty-five (47.4%) patients with depression were included in the depression group, whereas the control group was comprised of 150 patients free of depression. Sixty-eight (50.4%) subjects received antidepressants (treated group), whereas the observational group had 67 (49.6%) depressed patients who refused to take antidepressants. RESULTS: Depression remission was achieved in 51 (75.0%) patients from the treated group. Long-term mortality and HF hospitalization rates were significantly higher in the depression group than in the control group (20.7 vs. 11.3% and 32.6 vs. 19.2%, respectively). However, remission from depression was associated with a 40% reduction in the relative risk of major adverse cardiac events (MACE). CONCLUSIONS: Patients with HF and concomitant depression are at higher risk of MACE compared with those free of depression. Effective antidepressant treatment may significantly improve long-term outcomes in this population.

Can we rely on machines? Device-detected atrial high rates correspond well with atrial arrhythmias in cardiac resynchronization recipients.

AIMS: The aim of the study was to verify in what proportion of patients, device-detected atrial high rate (AHR) episodes are indeed atrial arrhythmias (AAs). We investigated also the reasons for inappropriate arrhythmia classification and assessed if patients with misdiagnosed arrhythmias have distinct characteristics that would help to identify them. METHODS AND RESULTS: The study population consisted of 304 consecutive patients implanted with cardiac resynchronization therapy defibrillators (CRT-Ds) and subsequently monitored via remote monitoring for a median follow-up (FU) of 30.5 months. Intracardiac electrograms of every recorded AHR episode were assessed and classified (AA vs. no AA) by two experienced cardiologists. During FU, 14 386 episodes of AHR were recorded and classified in 176 (57.9%) patients. In 89.2% of them, these episodes were true AA (94% atrial fibrillation, 62% de novo). The reasons for AHR misdiagnosis were atrial far-field signals (89.5%) and noise (10.5%). The mean per cent of day spent in AHR (54.9 vs. 5.86%; P < 0.001) and the occurrence of periods with low CRT pacing (82.8 vs. 55%; P = 0.003) were significantly higher in AA subjects than in those with misdiagnosed AHR. Episode duration of properly detected AHRs was longer than that of misdiagnosed AHRs. Higher per cent of time spent in AHR was an independent marker of appropriate arrhythmia detection [adjusted hazard ratio (HR) 1.04; P = 0.023]. CONCLUSION: Nearly two-thirds of CRT-D patients had AHR episodes within 2.5 years after implantation. Almost 90% of AHRs were indeed AA. Misdetections were caused by far-field sensing or noise. A two-step diagnostic algorithm (>9% of time spent in AHRs and episode duration >36 s) allowed for proper detection of AA with a high hit-rate and specificity.

Refractory chronic spontaneous urticaria and permanent atrial fibrillation associated with dental infection: Mere coincidence or something more to it?

Controversy surrounds the role of dental infection/inflammation in the oral cavity in chronic spontaneous urticaria (CSU) and atrial fibrillation (AF), which is mainly due to scarce literature in this area. Therefore, this case report and review of literature illustrate a possible association between the acute-phase response (APR) and clinical conditions, such as CSU and dental infection/inflammation of oral cavity and AF.We describe a 36-year-old man with an 8-year history of difficult-to-treat, uncontrolled CSU, co-existent with dental infection/inflammatory processes of oral cavity and permanent atrial fibrillation (AF). In the presented case, the most likely triggering or aggravating/maintaining factor of the symptoms was the inflammation/dental infection of the oral cavity because of rapid reduction of the urticarial symptoms, drug doses, and serum CRP levels after the dental therapy. Dental treatment may have a beneficial effect on the systemic inflammatory response, reducing/normalizing the circulating levels of APR markers. APR activation appears to worsen CSU course, early identification and treatment of infectious/inflammatory foci in the oral cavity would form the mainstay of supportive therapy for CU probably through reduction of the systemic inflammatory burden. APR associated with infectious/inflammatory foci in the oral cavity could be taken into account as a predisposing agents to AF.

Quality of life in cardiac resynchronization recipients: association with response and impact on outcome.

BACKGROUND: The prognostic impact of improvement in health-related quality of life (QoL) and its relation to response in cardiac resynchronization therapy (CRT) recipients remains unknown. AIM: To assess the correspondence between response to CRT and improvements in QoL and to verify if a change in QoL after pacing influences outcome in CRT patients. METHODS: Ninety-seven participants of the Triple-Site Versus Standard Cardiac Resynchronization Therapy Trial (TRUST CRT) randomized trial, in New York Heart Association class III-IV, QRS width ≥ 120 ms, left ventricular ejection fraction ≤ 35%, and significant mechanical dyssynchrony were included. Subjects filled out the Minnesota-QoL questionnaire prior to and 6 months after CRT with defibrillator (CRT-D) implantation. Data on major adverse cardiac events (MACEs: death, heart failure hospitalization, heart transplant) collected within the next 2.5 years and adjudicated blindly constituted the censoring variables. RESULTS: Within the first 6 months of resynchronization QoL improved in 81%, while worsening in 19% of patients. Clinical response, but not the echocardiographic one, was associated with improved QoL. During subsequent 2.5 years MACEs occurred in 37% of patients (23% died). Subjects without QoL improvement were significantly (both P < 0.05) more prone to experience MACE (61% vs 32%) and die (44% vs 18%) within the follow-up. Unimproved QoL increased the probability of future MACE by 2.7 times (95% confidence intervals [CI]: 1.26-5.83; P = 0.01) and death by 3.2 times (95% CI: 1.23-8.32; P = 0.02) independently from clinical and echocardiographic response. CONCLUSIONS: Clinical response, but not the echocardiographic one, was associated with improved QoL in CRT recipients. These preliminary data suggest that lack of improvement in QoL after CRT was associated with a strongly unfavorable prognosis, regardless of functional or echocardiographic response. Our results merit further studies with a larger number of patients.

Does atrial fibrillation still increase the risk of death? One-year follow-up results of the NOMED-AF study.

INTRODUCTION: Although atrial fibrillation (AF) is a well­known risk factor for ischemic stroke and hospitalization, its effect on mortality has not been clearly established. OBJECTIVES: We aimed to assess whether AF is an independent risk factor for death. A secondary objective was to evaluate the role of oral anticoagulation in the prevention of stroke and death in 1­year follow­up of patients included in the NOMED­AF (Noninvasive Monitoring for Early Detection of Atrial Fibrillation) study. PATIENTS AND METHODS: The NOMED­AF study included 3014 patients. The participants underwent continuous long­term electrocardiographic monitoring using a wearable vest for up to 30 days. The present analysis involved 2795 patients who completed the 1­year follow­up. The median (interquartile range) follow­up time was 365 (365-365) days. AF was diagnosed in 617 participants. RESULTS: Independent risk factors for death in the patients who completed the 1­year follow­up were AF, age equal to or above 65 years, and chronic kidney disease. The individuals with diagnosed AF had an almost 2­fold higher risk of death (odds ratio [OR], 1.7; 95% CI, 1.18-2.44; P <0.001) and a 2.5­fold higher risk of stroke (OR, 2.53; 95% CI, 1.41-4.44; P <0.001), as compared with those without an AF diagnosis. The participants with AF who received oral anticoagulants had an almost 5­fold lower risk of death than those who were not on anticoagulation (2.9% vs 14.2%, respectively; P <0.001). CONCLUSIONS: AF is an independent risk factor for death and cardiovascular hospitalization. The risk of death and stroke in patients with AF is significantly higher than in the patients without this arrhythmia. Oral anticoagulation in patients with AF significantly reduces the rates of death and stroke; however, its use is suboptimal in this group of patients.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures.

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Predictive factors of left ventricular ejection fraction improvement after myocardial infarction treated invasively.

Introduction: One indication for the implantation of a cardioverter-defibrillator is a reduction in the left ventricular ejection fraction (LVEF) ≤ 35%. However, in certain patients following an acute myocardial infarction (AMI) a gradual improvement in LVEF has been observed. The factors determining this increase in LVEF have not been conclusively determined. Aim: To ascertain the independent predictors associated with the improvement of LVEF in patients following AMI who underwent invasive treatment, while observing their progress over a 6-month follow-up period. Material and methods: Among 665 patients with AMI, a population with LVEF ≤ 35% was selected. After 6 months, a follow-up echocardiogram was performed. Further analysis compared patients with at least 5% improvement in LVEF (Group I) with those without an increase (Group II). Results: Group I consisted of 34 individuals out of 80 patients (43%) with LVEF ≤ 35%. The factors linked to a reduced probability of LVEF improvement were: higher levels of cardiac troponin T (cTnT) (OR 0.841 for 1 ng/ml increase in cTnT, CI 0.715-0.989; p = 0.037), presence of diabetes mellitus (OR = 0.217, 95% CI: 0.058-0.813, p = 0.023) and moderate or severe mitral regurgitation (OR = 0.178, 95% CI: 0.053-0.597; p = 0.005). Conclusions: The study findings indicate that the presence of severe or moderate mitral regurgitation is the most significant factor contributing to the lack of LVEF improvement following AMI. Moreover, the extent of myocardial damage, as indicated by elevated cTnT values, along with compromised adaptation to hypoxia in patients with diabetes, are identified as independent factors associated with reduced chances of an increase in LVEF.

Predictors of ventricular tachyarrhythmia in patients with implantable cardioverter-defibrillator and non-ischemic systolic heart failure.

BACKGROUND: The benefit derived from implantable cardioverter-defibrillators (ICD) in subjects with non-ischemic systolic HF (NICM) is less well-established. AIM: The study aimed to determine the incidence, predictors, and prognostic impact of ventricular arrhythmias in patients with ICD and NICM. METHODS: The study sample included 377 consecutive patients with ICD or cardiac resynchronization cardioverter-defibrillators (CRT-D, 74% of patients) and NICM implanted and monitored remotely in a university hospital. RESULTS: During the median (interquartile range [IQR]) follow-up of 1645 (960-2675) days, sustained ventricular arrhythmia occurred in 92 patients (24.4%). Of those, ventricular fibrillation (VF), ventricular tachycardia (VT), and both VT and VF occurred in 10 (10.9%), 72 (78.3%), and 10 (10.9%) patients, respectively. Patients with vs. those without ventricular arrhythmia differed concerning sex, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular ejection fraction (LVEF), post-inflammatory etiology, atrial fibrillation/flutter occurrence, and supraventricular arrhythmia (SVT) other than AF/AFL during follow-up. In multivariable Cox regression, LVEDD (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.003-1.09; P = 0.03), AF/AFL (HR, 1.86; 95% CI, 1.21-2.85; P = 0.004), and SVT (HR, 1.77; 95% CI, 1.10-2.87; P = 0.02) were independent predictors of sustained VT, while AF/AFL (HR, 1.65; 95% CI, 1.07-2.56; P = 0.02) was independent predictor of VF. All-cause mortality in patients with VT/VF was significantly higher than in subjects without sustained ventricular arrhythmias (35.9% vs. 22.4%; P = 0.01). CONCLUSIONS: Ventricular arrhythmia occurred in every fourth patient with NICM and ICD during 4.5 years of observation and was associated with significantly worse prognosis than in subjects free of VT/VF. Higher LVEDD, atrial fibrillation/atrial flutter, and supraventricular tachycardia flag patients at risk of ventricular arrhythmia.

Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure: study protocol for a LAAC-SBI trial.

BACKGROUND: Left atrial appendage closure (LAAC) procedures prevent cardioembolic stroke in patients with atrial fibrillation who have contraindications to oral anticoagulant medications. However, these procedures carry certain risks of peri-procedural complications. One such complication is silent brain infarcts (SBI), which can lead to cognitive impairment and mood disturbances. The implementation of mechanical neuroprotection systems during LAAC procedures may reduce the risk of SBI and associated cognitive and mood disorders. METHODS: The LAAC-SBI trial is a prospective, multicenter, randomized, and double-blind interventional study. The study aims to enroll a total of 240 patients, with 120 patients allocated to each group. The study group will evaluate the use of the Sentinel CPS during LAAC, while the control group will undergo LAAC procedures without the Sentinel CPS. The primary endpoint of the study is the number of new SBIs or stroke foci detected by diffusion-weighted magnetic resonance imaging (DW MRI). Secondary endpoints include deterioration of cognitive function, development of dementia syndrome, and occurrence of depressive disorders. These endpoints will be assessed using questionnaire tools such as the Montreal Cognitive Assessment (MoCA), Trail Making Test (TMT), Controlled Oral Word Association Test (COWAT), and Hospital Anxiety and Depression Scale (HADS). The observational period for patients in the study is 2 years. DISCUSSION: If the study demonstrates a favorable outcome with reduced incidence of SBI and improved cognitive and mood outcomes in patients receiving cerebral protection devices during LAAC, it will have significant implications for clinical management standards. This would support the use of neuroprotection devices not only for LAAC but also in procedures such as atrial fibrillation ablation or transcatheter mitral valve interventions, where the risk of embolic events and subsequent brain injury may also be present. TRIAL REGISTRATION: ClinicalTrials.gov NCT05369195. Registration on 11.05.2022.

The prognostic value of different glucose abnormalities in patients with acute myocardial infarction treated invasively.

BACKGROUND: Diabetes (DM) deteriorates the prognosis in patients with coronary heart disease. However, the prognostic value of different glucose abnormalities (GA) other than DM in subjects with acute myocardial infarction (AMI) treated invasively remains unclear. AIMS: To assess the incidence and impact of GA on clinical outcomes in AMI patients treated with percutaneous coronary intervention (PCI). METHODS: A single-center, prospective registry encompassed 2733 consecutive AMI subjects treated with PCI. In all in-hospital survivors (n = 2527, 92.5%) without the history of DM diagnosed before or during index hospitalization standard oral glucose tolerance test (OGTT) was performed during stable condition before hospital discharge and interpreted according to WHO criteria. The mean follow-up period was 37.5 months. RESULTS: The incidence of GA was as follows: impaired fasting glycaemia - IFG (n = 376, 15%); impaired glucose tolerance - IGT (n = 560, 22%); DM (n = 425, 17%); new onset DM (n = 384, 15%); and normal glucose tolerance - NGT (n = 782, 31%). During the long-term follow-up, death rate events for previously known DM, new onset DM and IGT were significantly more frequent than those for IFG and NGT (12.3; 9.6 and 9.4 vs. 5.6 and 6.4%, respectively, P < 0.05). The strongest and common independent predictors of death in GA patients were glomerular filtration rate < 60 ml/min/1,73 m^2 (HR 2.0 and 2.8) and left ventricle ejection fraction < 35% (HR 2.5 and 1.8, all P < 0.05) respectively. CONCLUSIONS: Glucose abnormalities are very common in AMI patients. DM, new onset DM and IGT increase remote mortality. Impaired glucose tolerance bears similar long-term prognosis as diabetes.

The significance of heart rate turbulence in predicting major cardiovascular events in patients after myocardial infarction treated invasively.

INTRODUCTION: The role of heart rate turbulence (HRT) related to baroreflex sensitivity in predicting mortality after myocardial infarction (MI) has been confirmed by several investigators. However, the significance of HRT in predicting major adverse cardiovascular events (MACE) following acute MI is unknown. PURPOSE: To analyze the prognostic value of HRT and other independent risk factors associated with autonomic regulation of MACE. METHODS: HRT was assessed based on 24-hour Holter recordings in 500 patients (pts) with acute MI treated invasively (352 M, aged 60.58 years). Turbulence onset (TO,%), slope (TS, ms/RR interval) and timing (TT) were calculated. TO ≥ 0, TS ≤ 2.5 and TT ≥ 10 were considered abnormal; classic and own categories were defined. Time domain heart rate variability (HRV) parameters were also calculated. Within 30.1 ± 15.1 months of follow-up, MACE occurred in 116 pts. RESULTS: Abnormal TO, TS, and TT were significantly more frequent in patients with MACE (P < 0.05 for each parameter, classic and own categories). In long-term follow-up, the largest differences in MACE were observed in patients with own category comprising abnormal TO, TS, and TT. Combining HRT parameters with SDNN (total HRV index) augmented their predictive value. Independent risk factors for MACE were TT, SDNN and rMSSD (a parasympathetic activity index) (HR 2.44, 1.71 and 1.69 respectively; P < 0.05). CONCLUSION: Abnormal HRT distinguishes patients at risk of MACE after MI. Own category encompassing three abnormal HRT parameters best differentiates patients at risk of MACE. Turbulence timing is a strong independent risk factor for MACE following MI.

The prognostic impact of therapeutic hypothermia after a sudden cardiac arrest in the course of myocardial infarction.

BACKGROUND: Mild therapeutic hypothermia (MTH) is one of the treatment methods recommended in post-sudden cardiac arrest (SCA) patients who remain unconscious after cardiopulmonary resuscitation. The present study aimed at assessing the prognostic impact of intravascular MTH on invasively treated patients with an acute myocardial infarction complicated by SCA. METHODS: The presented data were collected via a single-center retrospective analysis of the hospitalization and follow-up of 54 patients with post-myocardial infarction complicated by SCA. The patients were treated in the years 2014-2020 and the average follow-up period was 1141 ± 163 days. The population was divided into two groups: 28 patients treated with MTH (a therapeutic hypothermia [TH] group) and 26 patients treated without MTH (a non-TH group). RESULTS: The results indicate a trend toward improved in-hospital prognosis in the TH group, but the differences did not reach statistical significance: TH 25.0% vs. non-TH 34.5%, p = 0.554. An additional analysis of younger patients (under 60 years of age) revealed no significant differences between the TH and non-TH subgroups concerning in-hospital survival (in-hospital mortality rate: TH 6.7% vs. non-TH 30.0%, p = 0.267). Still, TH patients aged < 60 achieved a significantly better rate of follow-up survival (p = 0.041). The older (≥ 60) patient group showed no in-hospital mortality rate differences (TH 46.2% vs. non-TH 37.5%, p = 0.638). However, in-hospital bleeding frequency was significantly higher in patients aged ≥ 60 from the hypothermia group (TH 50.0% vs. non-TH 6.7%, p = 0.011). CONCLUSIONS: Intravascular MTH may improve the follow-up prognosis in patients aged < 60 with SCA in the early phase of myocardial infarction.

The impact of unsuccessful percutaneous coronary intervention on short- and long-term prognosis in STEMI and NSTEMI.

OBJECTIVES: To compare the impact of the efficacy of percutaneous coronary intervention (PCI) on prognosis in ST and non-ST elevation myocardial infarction (STEMI and NSTEMI) patients with respect to infarct-related artery (IRA). BACKGROUND: The significance of the efficacy of PCI in STEMI and NSTEMI depending on the type of IRA has yet to be clarified. METHODS: Study population consisted of 2,179 STEMI and 554 NSTEMI consecutive patients treated with urgent PCI. The efficacy of PCI (TIMI [thrombolysis in myocardial infarction] 3 vs. TIMI < 3) was assessed with regard to the type of IRA (left anterior descending artery, circumflex artery [Cx] or right coronary artery). The mean follow-up was 37.5 months. RESULTS: The rate of unsuccessful PCI was similar in STEMI and NSTEMI irrespectively of IRA (14.1 vs. 17.7%; P = 0.062). In STEMI, unsuccessful PCI was associated with significantly higher early (23.1 vs. 5.6%; P < 0.001) and late (29.9 vs. 12.8%; P < 0.001) mortality regardless of IRA. In NSTEMI, the inefficacious PCI significantly increased early (19.0% vs. 0.9%; P < 0.001) and late (27.3% vs. 6.3%; P < 0.001) mortality only in patients with Cx-related infarction. Unsuccessful PCI of IRA was an independent risk factor for death in STEMI (HR 1.64; P < 0.05), but not in NSTEMI (P = 0.64). Further analysis showed that whilst unsuccessful PCI of any vessel in STEMI is an independent risk factor for death, in NSTEMI this applies to unsuccessful PCI of Cx only. CONCLUSIONS: The significance of unsuccessful PCI of IRA seems to be different in STEMI and NSTEMI. Unsuccessful PCI is an independent risk factor for death in STEMI regardless of IRA and in NSTEMI with the involvement of Cx.

A common variant in low-density lipoprotein receptor-related protein 6 gene (LRP6) is associated with LDL-cholesterol.

OBJECTIVE: A rare mutation in low-density lipoprotein receptor-related protein 6 gene (LRP6) was identified as the primary molecular defect underlying monogenic form of coronary artery disease. We hypothesized that common variants in LRP6 could predispose subjects to elevated LDL-cholesterol (LDL-C). METHODS AND RESULTS: Twelve common (minor allele frequency > or =0.1) single nucleotide polymorphisms in LRP6 were genotyped in 703 individuals from 213 Polish pedigrees (Silesian Cardiovascular Study families). The family-based analysis revealed that the minor allele of rs10845493 clustered with elevated LDL-C in offspring more frequently than expected by chance (P=0.0053). The quantitative analysis restricted to subjects free of lipid-lowering treatment confirmed the association between rs10845493 and age-, sex-, and BMI-adjusted circulating levels of LDL-C in families as well as 2 additional populations - 218 unrelated subjects from Silesian Cardiovascular Study replication panel and 1138 individuals from Young Men Cardiovascular Association cohort (P=0.0268, P=0.0476, and P=0.0472, respectively). In the inverse variance weighted meta-analysis of the 3 populations each extra minor allele copy of rs10845493 was associated with 0.14 mmol/L increase in age-, sex-, and BMI-adjusted LDL-C (SE=0.05, P=0.0038). CONCLUSIONS: Common polymorphism in the gene underlying monogenic form of coronary artery disease impacts on risk of LDL-C elevation.

Prospective evaluation of diagnostic work-up in syncope patients: results of the PL-US registry.

AIMS: Syncope is a common problem. Demographic and clinical characteristics of patients admitted to different types of centres may vary, physician's adherence to the guidelines has been examined only in a few studies, and the requirements for implantable loop recorders (ILR) have not been well defined. The aim of this study was to (i) compare demographic and clinical characteristics of patients with syncope diagnosed and treated in tertiary electrophysiology cardiac centres and those attending syncope units or general hospitals, (ii) assess how physicians adhere to the published guidelines, and (iii) calculate the requirement for ILR insertion. METHODS AND RESULTS: In total, 669 consecutive patients with syncope, admitted to 18 electrophysiological cardiac tertiary centres over a mean of 3 months (range 1-10 months), entered a special Internet database called the PL-US (Polish patients with Unexplained Syncope) registry. Detailed demographic and clinical characteristics of the patients, including the results of all diagnostic tests performed, were analysed. Adherence to the guidelines was assessed, based on the published recommendations. The ILR implantation was indicated when (i) all other tests were inconclusive (unexplained syncope) and (ii) syncope associated with injury or presence of organic heart disease or past medical history and ECG suggesting arrhythmic syncope. Syncope of cardiac/arrhythmic origin was the most frequent diagnosis (53%), followed by reflex syncope (33%). Adherence to the guidelines was less than satisfactory-measurement of blood pressure in an upright position, carotid sinus massage, exercise testing, and electrophysiological study were underused, whereas prolonged ECG monitoring and neurological consultations were overused. Unexplained syncope had 58 (9%) patients, and 42 (72%) of them had indication for ILR which accounts for 6% of the whole study population. The calculated need for ILR was 222 implants/million inhabitants/year. CONCLUSION: Patients with syncope admitted to the tertiary electrophysiology cardiac centres are a highly selected group of patients with syncope and differ in their characteristics as well as underlying diseases to those managed at general hospitals, outpatient clinics, or special syncope units. In Poland, the adherence to the published guidelines is far from satisfactory. At least 6% of all consecutive patients with syncope are candidates for ILR insertion.

Prognostic significance of hyperuricemia in patients with different types of renal dysfunction and acute myocardial infarction treated with percutaneous coronary intervention.

AIM: This study evaluated the impact of hyperuricemia (HUR) on outcome in patients with different types of impaired renal function (IRF) and acute myocardial infarction (AMI) treated invasively. METHODS: Out of 3,593 consecutive AMI patients treated invasively, 1,015 IRF patients were selected. The IRF group consisted of patients with baseline kidney dysfunction (BKD group) and/or patients with contrast-induced nephropathy (CIN group). HUR was defined as a serum uric acid concentration (SUAC) >420 µmol/l (>7 mg/dl). Independent predictors of death and major adverse cardiovascular events (MACE) were selected by the multivariate Cox-regression model. RESULTS: Remote mortality rates were higher in HUR patients: IRF (32.7 vs. 18.6%), BKD (41.3 vs. 25.9%), CIN (35.4 vs. 16.7%); all p < 0.001. HUR was an independent predictor of death in BKD (hazard ratio (HR) 1.38, p < 0.05). Each 100-µmol/l increase in SUAC was associated with a significant increase of HR for mortality: 1.087 in IRF patients, 1.108 in BKD patients, 1.128 in CIN patients; all p < 0.05. Remote major adverse cardiovascular event rates were higher in HUR patients: IRF (55.4 vs. 48.9%), CIN (56.8 vs. 48%); both p < 0.05. CONCLUSIONS: In AMI patients treated invasively, an increase in SUAC is an independent predictor of death within all types of renal dysfunction; HUR defined as SUAC >420 µmol/l (>7 mg/dl) is a predictor only in BKD patients.

Heart rate turbulence for prediction of heart transplantation and mortality in chronic heart failure.

BACKGROUND: Previous studies have shown conflicting results about the value of heart rate turbulence (HRT) for risk stratification of patients (pts) with chronic heart failure (CHF). We prospectively evaluated the relation between HRT and progression toward end-stage heart failure or all-cause mortality in patients with CHF. METHODS: HRT was assessed from 24-hour Holter recordings in 110 pts with CHF (54 in NYHA class II, 56 in class III-IV; left ventricular ejection fraction (LVEF) 30%+/- 10%) on optimal pharmacotherapy and quantified as turbulence onset (TO,%), turbulence slope (TS, ms/RR interval), and turbulence timing (beginning of RR sequence for calculation of TS, TT). TO > or = 0%, TS < or = 2.5 ms/RR, and TT >10 were considered abnormal. End point was development of end-stage CHF requiring heart transplantation (OHT) or all-cause mortality. RESULTS: During a follow-up of 5.8 +/- 1.3 years, 24 pts died and 10 required OHT. TO, TS, TT, and both (TO and TS) were abnormal in 35%, 50%, 30%, and 25% of all patients, respectively. Patients with at least one relatively preserved HRT parameter (TO, TS, or TT) (n = 98) had 5-year event-free rate of 83% compared to 33% of those in whom all three parameters were abnormal (n = 12). In multivariate Cox regression analysis, the most powerful predictor of end point events was heart rate variability (SDNN < 70 ms, hazard ratio (HR) 9.41, P < 0.001), followed by LVEF < or = 35% (HR 6.23), TT > or = 10 (HR 3.14), and TO > or = 0 (HR 2.54, P < 0.05). CONCLUSION: In patients with CHF on optimal pharmacotherapy, HRT can help to predict those at risk for progression toward OHT or death of all causes.

Prognosis in diabetic patients with acute myocardial infarction treated invasively is related to renal function.

BACKGROUND: The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) is rapidly increasing. Both comorbidities are considered significant risk factors for cardiovascular complications. The aim of the study was to evaluate the impact of DM with and without CKD on prognosis in patients with acute myocardial infarction (AMI) treated invasively. MATERIAL/METHODS: This single-center prospective study encompassed 3334 AMI-patients without cardiogenic shock, who were divided into 2 major groups: 999 patients with type 2 DM diagnosed prior to or during index hospitalization, and 2335 non-diabetics. All diabetic patients were divided with respect to their renal status into: diabetics with CKD (DM-CKD; n=264) and without (DM-nCKD; n=735). Short- and long-term outcomes were compared between study groups. Independent predictors of death and composite end-point were selected with multivariate Cox-regression model. RESULTS: Mortality rates were significantly higher in DM group compared to nDM in all observation periods. DM-CKD was associated with excessive total mortality (35.6%) when compared to DM-nCKD (11.6%, P<0.001) and to nDM (9.8%, P<0.001). Mortality and major adverse cardiovascular event rates did not differ significantly between DM-nCKD and nDM groups. Diabetes coexisting with CKD was one of the strongest independent risk factors for death (hazard ratio 1.93; confidence interval 1.79-2.07; P<0.001). CONCLUSIONS: The prognosis in diabetics with AMI is significantly related to renal function. Diabetics without CKD had similar prognosis to non-diabetics. Multivariate analyses showed that unlike diabetes without renal dysfunction, DM-CKD was an independent risk factor for cardiovascular complications and total mortality.

Comparison of the everolimus-eluting bioresorbable vascular scaffold versus the everolimus-eluting metallic stent in real-world patients with ST-segment elevation myocardial infarction.

INTRODUCTION: Despite the withdrawal of the ABSORB bioresorbable vascular scaffold (BVS) from clinical use, continuous observation of BVS-treated patients is necessary. In the vast majority of clinical trials, patients with ST-segment elevation myocardial infarction (STEMI) were excluded from the analysis. AIM: To compare the early and long-term outcomes of the BVS with the everolimus-eluting metallic stent (EES) in patients with STEMI. MATERIAL AND METHODS: Consecutive patients treated with BVS or EES in our center were screened. For analysis, only patients with STEMI were enrolled. The primary endpoint was a comparison of the target lesion failure at 12 and 24 months. The secondary endpoints encompass occurrence of the patient-oriented cardiovascular endpoint (PoCE), stent thrombosis (ST), device, and procedural success. RESULTS: Between 2012 and 2016, 2,137 patients were hospitalized for STEMI. Of these, 123 patients received the BVS (163 scaffolds; 151 lesions), whereas in 141 patients the EES (203 stents; 176 lesions) was implanted. The median follow-up was 931 ±514 days. The primary endpoint at 12 months occurred in 9.7% in the BVS group and in 8.5% in the EES group (hazard ratio (HR) = 2.61; 95% confidence interval (CI): 0.90-7.56; p = 0.076). At 24 months the incidence of the primary endpoint was 15.2% in the BVS group and 14.9% in the EES group (HR = 2.46; 95% CI: 0.85-7.07; p = 0.095). The rates of PoCE, ST, device, and procedural success were also comparable in both groups. CONCLUSIONS: STEMI patients treated with the BVS showed statistically similar rates of primary and secondary endpoints compared with the EES.