Elevated plasma protein carbonylation increases the risk of ischemic cerebrovascular events in patients with atrial fibrillation: association with a prothrombotic state.

INTRODUCTION: Plasma protein carbonylation that reflects oxidative stress has been demonstrated to be associated with the prothrombotic fibrin clot phenotype. However, the role of protein carbonyls (PC) in predicting ischemic stroke in atrial fibrillation (AF) is largely unknown. This study aimed to investigate whether PC increase the risk of stroke in anticoagulated AF patients during follow-up. METHODS: In 243 AF patients on anticoagulation (median age 69 years; median CHA2DS2-VASc of 4), we measured plasma PC using the assay by Becatti, along with plasma clot permeability (Ks), clot lysis time (CLT), thrombin generation, and fibrinolytic proteins, including plasminogen activator inhibitor type 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor (TAFI). Ischemic stroke, major bleeding, and mortality were recorded during a median follow-up of 53 months. RESULTS: Plasma PC levels (median, 3.16 [2.54-3.99] nM/mg protein) at baseline showed positive associations with age (P < 0.001), CHA2DS2-VASc (P = 0.003), and N-terminal B-type natriuretic peptide (P = 0.001), but not with type of AF or comorbidities except for heart failure (P = 0.007). PC levels were correlated with CLT (r = 0.342, P < 0.001), endogenous thrombin potential (r = 0.217, P = 0.001) and weakly with Ks (r = -0.145, P = 0.024), but not with fibrinogen, PAI-1, or TAFI levels. Stroke was recorded in 20 patients (1.9%/year), who had at baseline 36% higher PC levels (P < 0.001). Elevated PC (P = 0.003) at baseline were independently associated with stroke risk. CONCLUSION: Our findings suggest that in patients with AF enhanced protein carbonylation is associated with increased "residual" risk of stroke despite anticoagulation, which is at least in part due to unfavorably altered fibrin clot phenotype.

Endothelial Cell Apoptosis but Not Necrosis Is Inhibited by Ischemic Preconditioning.

This study aimed to assess the influence of ischemic preconditioning (IP) on hypoxia/reoxygenation (HR)-induced endothelial cell (EC) death. Human umbilical vein endothelial cells (HUVECs) were subjected to 2 or 6 h hypoxia with subsequent reoxygenation. IP was induced by 20 min of hypoxia followed by 20 min of reoxygenation. Necrosis was assessed by the release of lactate dehydrogenase (LDH) and apoptosis by double staining with propidium iodide/annexin V (PI/AV), using TUNEL test, and Bcl-2 and Bax gene expression measured using RT-PCR. In PI/AV staining, after 24 h of reoxygenation, 30-33% of EC were necrotic and 16-21% were apoptotic. In comparison to HR cells, IP reduced membrane apoptosis after 24 h of reoxygenation by 50% but did not influence EC necrosis. Nuclear EC apoptosis affected about 15-17% of EC after 24 h of reoxygenation and was reduced with IP by 55-60%. IP was associated with a significantly higher Bcl-2/Bax ratio, at 8 h 2-4 times and at 24 h 2-3 times as compared to HR. Longer hypoxia was associated with lower values of Bcl-2/Bax ratio in EC subjected to HR or IP. IP delays, without reducing, the extent of HR-induced EC necrosis but significantly inhibits their multi-level evaluated apoptosis.

Coronary Slow-Flow Phenomenon in Takotsubo Syndrome: The Prevalence, Clinical Determinants, and Long-Term Prognostic Impact.

Patients with takotsubo syndrome (TTS) may present coronary slow flow (CSF) in angiography performed in the acute myocardial infarction (MI). However, the detailed clinical relevance and its long-term impact remain poorly understood. Among 7771 MI patients hospitalized between 2012 and 2019, TTS was identified in 82 (1.1%) subjects. The epicardial blood flow was assessed with thrombolysis in myocardial infarction (TIMI) scale and corrected TIMI frame count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). CSF was defined as TIMI-2 or corrected TFC > 27 frames in at least one epicardial vessel. CSF was identified in 33 (40.2%) TTS patients. In the CSF-TTS versus normal-flow-TTS group, lower values of left ventricular ejection fraction on admission (33.5 (25-40) vs. 40 (35-45)%, p = 0.019), more frequent midventricular TTS (27.3 vs. 8.2%, p = 0.020) and the coexistence of both physical and emotional triggers (9.1 vs. 0%, p = 0.032) were noted. Within a median observation of 55 months, higher all-cause mortality was found in CSF-TTS compared with normal-flow TTS (30.3 vs. 10.2%, p = 0.024). CSF was identified as an independent predictor of long-term mortality (hazard ratio 10.09, 95% confidence interval 2.12-48.00, p = 0.004). CSF identified in two-fifths of TTS patients was associated with unfavorable long-term outcomes.

Rare instances of concomitant acute myocardial infarction and stroke.

Cardio-cerebral infarction (CCI) is a term coined to describe concomitant myocardial infarction and acute ischemic stroke. Acute myocardial infarction and stroke, as separate events, constitute some of the most important causes for disability and mortality in aging societies. Stroke can either occur simultaneously with myocardial infarction or become a serious complication of myocardial infarction and/or its treatment. The frequency of CCI has been reported at a 0.009% incidence rate in stroke patients and is associated with an extremely high mortality. Because of the rare occurrence of CCI, there are currently no guidelines for assessing its diagnosis and optimal treatment. Therefore, currently, the management of CCI cases needs to be individualized. Hopefully, in the future, the results of large clinical trials or prospective registries are expected to enhance our understanding of managing concomitant acute MI and stroke. In this review we have focused on the current literacy in the diagnosis and treatment of CCIs. The paper illustrates potential distinct scenarios of CCI through the analysis of three patient cases (Fig. 5, Ref. 65). Text in PDF www.elis.sk Keywords: myocardial infarction, stroke, cardio-cerebral infarction, carotid artery stenting, cardiac surgery.

Screening diagnosis of dementia in patients following heart failure decompensation is associated with a higher relative wall thickness.

BACKGROUND: The usefulness of echocardiographic characteristics for dementia prediction in patients with heart failure decompensation (HFD) is not determined. Therefore, we sought to investigate the echocardiographic features of patients with HFD and screening diagnosis of dementia (SDD). METHODS: 139 patients aged over 65 years were hospitalized with the diagnosis of HFD. Clinical characteristics and echocardiographic characteristics were recorded during hospitalization. SDD was defined based on the result of ALFI- MMSE of <17 points. RESULTS: Patients with SDD were older (p=0.013), had thicker IVSd (p=0.021), thicker PWd (p=0.005) and had a higher RWT (0.40 vs 0.35, p=0.004) than patients without SDD, without differences in LVMI (p=0.13). There was no correlation between RWT and LVMI (r=-0.01, p=0.88). In the multivariate analysis, an older age (ß=-0.116, 95% CI -0.224 - -0.008, p=0.035, per year) and a higher RWT (ß=-0.069, 95% CI -0.137 - -0.002, p=0.045, per 0.01) influenced a lower ALFI-MMSE. For a prediction of SDD, the RWT reached the area under a ROC curve of 0.67 (95% CI 0.56-0.77, p=0.004 with sensitivity of 60% and specificity of 70% for RWT of ≥0.375). CONCLUSIONS: Apart from age, RWT reflecting left ventricular geometry changes but not hypertrophy was independently but moderately associated with SDD in patients following HFD (Tab. 4, Fig. 1, Ref. 35).

Typical variant of takotsubo cardiomyopathy in oncological patients. Two case reports and review of the literature.

Takotsubo cardiomyopathy (TCM) represents an acute systolic left ventricular dysfunction typically triggered by severe psychological or physical stress. Oncological patients due to emotional distress of the diagnosis, proinflammatory and prothrombotic nature of cancer and also physical stress often following complex anticancer therapies are at high-risk of TCM. Moreover, there are also few reports of TCM associated with oncological treatment, mostly chemotherapy. Recent data from large registries indicate a surprisingly high incidence of malignancy in TCM, significant differences in clinical characteristics and unfavorable short- and long-term clinical outcomes in this specific group of patients. Therefore, we present two case reports of TCM that occurred during active anticancer therapy. Both women were admitted with suspicion of acute coronary syndrome. The first patient underwent mastectomy two years before due to hormone receptor-positive breast cancer and on admission she was during adjuvant hormonotherapy with tamoxifen. The admission of the second patient was preceded by fifteen fractions of adjuvant external beam radiotherapy due to intermediate-risk endometrial cancer after radical hysterectomy. Based on coronary angiography type I of acute coronary syndrome was excluded. Both patients negated stressful situations in the period immediately before the symptoms onset. Within hospital course baseline apical ballooning observed in both cases fully recovered and enabled subsequent completion of oncological treatment in accordance with adopted treatment protocols without recurrence of TCM. To our knowledge, presented cases are the first reports showing direct relationship between TCM and adjuvant hormonotherapy with tamoxifen or pelvic radiotherapy.

The awareness and knowledge about heart failure in Poland - lessons from the Heart Failure Awareness Day and internet surveys.

BACKGROUND: Heart failure (HF) is a life-threatening condition which affects up to 2% of contemporary populations. Generally, it is a chronic and progressive disease, however in many cases it can be prevented or treated. Nevertheless, effective control of this disease requires awareness of symptoms in the society. AIMS: The aim of the study was to assess the level of HF knowledge in the Polish population. METHODS: The questionnaire concerning knowledge about HF prepared by the Competence Network HF under the patronage of the European Heart Failure Association of the ESC, was used. The survey included 534 contributors who formed three groups: medical students - in vast majority at first half of the study course (MS) - 198 (37.1%), HF Awareness Day participants (HFDP) - 134 (25.1%) and other (OP) - 202 (37.8%). RESULTS: Study groups differed in terms of gender, age and level of education. As predicted, MS achieved the highest score (22.5 [20.0-24.0]), compared to HFDP (20.0 [17.0-22.0], P <0.001) and OP (19.0[16.0-21.0], P <0.001). Knowledge on typical HF symptoms was alarmingly low in the analyzed groups - dyspnea (MS - 96.0%, HFDP - 78.4%, OP - 74.6%), ankle edema (MS - 79.8%, HFDP - 50.6%, OP - 32.2%), body weight gain (MS - 14.1%, HFDP - 17.2%, OP - 4.5%). By multivariate model medical education (ß 3.372, 95% CI 2.738-4.005) and own illness or having relatives or friends with HF (ß 0.654, 95% CI 0.066-1.242) independently affected the score of awareness questionnaire. CONCLUSIONS: The basic knowledge on HF in Poland is not sufficient. It is moderately better among MS. Further campaigns improving HF awareness are necessary.

Clinical characteristics and long-term outcomes of patients with heart failure with improved ejection fraction. First Polish experience from LECRA-HF registry.

PURPOSE: Heart failure (HF) with improved ejection fraction (HFimpEF) is a new category of HF introduced in the newest European Society of Cardiology guidelines. However, clinical characteristics and long-term outcomes of HFimpEF patients remain insufficiently elucidated. We sought to characterize Polish HFimpEF patients and determine their long-term mortality. MATERIAL AND METHODS: Of 1186 patients enrolled in the single-center Lesser Poland Cracovian Heart Failure (LECRA-HF) registry between 2009 and 2019 and hospitalized due to HF decompensation, 340 (28.7%) were those with HF with reduced ejection fraction (HFrEF). Based on follow-up echocardiography, 61 (17.9%) of them were classified as HFimpEF and the remaining as HFnon-impEF. RESULTS: HFimpEF patients were more frequently females (P â€‹< â€‹0.001), had higher baseline left ventricular ejection fraction (LVEF, P â€‹< â€‹0.001), had less often a history of diabetes (P â€‹= â€‹0.024), severe chronic kidney disease (P â€‹= â€‹0.026) or prior myocardial infarction (P â€‹= â€‹0.008) than HFnon-impEF patients. By multivariable analysis the HFimpEF diagnosis was independently predicted by baseline NYHA I/II (odds ratio [OR] 2.347, 95% confidence interval [95%CI] 1.020-5.405), non-ischemic etiology (OR 3.096, 95%CI 1.587-6.024), lack of diabetes mellitus (OR 2.016, 95%CI 1.059-3.846) and higher baseline LVEF (OR 1.084, 95%CI 1.042-1.126, per 1%). Within the median 49 (25-77) months all-cause mortality was lower in HFimpEF than in HFnon-impEF (10.8 vs 16.4%/year, P â€‹= â€‹0.004). CONCLUSIONS: Our findings indicate that every sixth Polish patient with HFrEF has a chance to improve LVEF during follow-up and to become a HFimpEF patient. Baseline characteristics of HFimpEF patients are different from HFnon-impEF. Simultaneously, the HFimpEF diagnosis is associated with higher long-term survival.

Effect of high-dose statin therapy on coagulation factors: Lowering of factor XI as a modifier of fibrin clot properties in coronary artery disease.

BACKGROUND: Multiple pleiotropic effects of statins include antithrombotic properties with formation of looser fibrin networks more susceptible to lysis. Recently, rosuvastatin 20 mg/d has been reported to decrease coagulation factors (F) VII, FVIII and FXI in venous thrombosis patients. OBJECTIVES: We investigated how high-dose statin therapy recommended in coronary artery disease (CAD) alters plasma levels of coagulation factors and if such changes might affect fibrin clot properties. METHODS: We studied 130 advanced CAD patients, who initially did not achieve the target low-density lipoprotein cholesterol (LDL-C). Before high-dose statin therapy (rosuvastatin 40 mg/d or atorvastatin 80 mg/d) and 6-12 months after its initiation, FII, FV, FVII, FVIII, FIX, FX, FXI and fibrinogen were assessed. We evaluated the impact of statin-induced alterations to the factors on plasma fibrin clot permeability (Ks) reflecting a fibrin pore size, and clot lysis time (CLT) reflecting fibrinolytic potential. RESULTS: At baseline LDL-C (median 3.2, interquartile range 2.7-3.7 mmol/L) was independently associated solely with FXI (ß = 0.58, P < 0.001). Median LDL-C reduction by 25% (P < 0.001) on high-dose statin treatment was accompanied by lowering of FVII, FVIII, and FXI (for all P < 0.001). On high-dose statin treatment, Ks (R = 0.65, P < 0.001) inversely associated with CRP (ß = -0.41, P < 0.001), LDL-C (ß = -0.26, P = 0.001), and FXI (ß = -0.18, P = 0.016). In turn, CLT (R = 0.45, P < 0.001) was positively associated with LDL-C (ß = 0.19, P = 0.043) and FXI (ß = 0.17, P = 0.049). CONCLUSIONS: High-dose statin therapy in CAD patients decreases FVII, FVIII, and FXI. The statin-induced reduction in FXI may contribute to less prothrombotic fibrin clot phenotype, indicating additional antithrombotic effect of high-dose statins.

Thin-cap fibroatheroma and increased coronary intima-media thickness are associated with an altered balance of arginine metabolites.

INTRODUCTION: Arginase inhibition increases plasma citrulline and citrulline / ornithine (C/O) ratio, and reduces plasma ornithine and ornithine / arginine (O/A) ratio in an animal model of myocardial infarction (MI). OBJECTIVES: We hypothesized that the presence of thin­cap fibroatheroma (TCFA) in the culprit lesion and increased non­culprit intima­media thickness of an infarct­related artery (IRA) are associated with an altered balance of arginine metabolites. PATIENTS AND METHODS: Arginine and its metabolites were measured using liquid chromatography and tandem mass spectrometry in 100 consecutive MI patients upon admission and at 6­month follow­up. TCFA and adjacent to culprit lesion proximal and distal 10­mm segments were assessed with optical coherence tomography in the acute phase. Twenty five patients without coronary lesions on angiography served as controls. RESULTS: The C/O ratio increased 5.33 times (P <0.001), while the O/A ratio decreased 2.53 times (P <0.001) at the 6­month follow­up, as compared with the acute phase of MI. The patients with (n = 75) vs without (n = 25) TCFA had lower C/O ratio by 29% (P = 0.003), while the mean intima­media diameter of adjacent non­culprit region correlated with the follow­up O/A ratio (R = 0.337; P = 0.003). In a multivariable analysis, a higher acute phase C/O ratio was associated with a lower risk of TCFA presence (odds ratio, 0.978; 95% CI, 0.962-0.994; P = 0.006), whereas a higher follow­up O/A ratio correlated with larger intima­media diameter of the adjacent segments (ß coefficient, 0.227; 95% CI for ß coefficient, 0.045-0.409; P = 0.018). CONCLUSIONS: Enhanced arginase activity over nitric oxide synthase following ischemia was associated with the presence of TCFA in the culprit lesion, while a similar metabolic shift in the chronic phase correlated with a greater thickness of the intima­media in the adjacent non­culprit IRA segments.

Intracranial hemorrhages associated with meningiomas: Own experience and literature review.

Intracranial hemorrhage associated with meningioma is rare. Relatively, few such cases are described in the source literature, and it is estimated that intracranial meningiomas presenting with hemorrhage account for about one percent of all meningiomas. Hemorrhage can occur in both meningioma tissue and on the tumor surface. It can lead to intracerebral, subdural and subarachnoid hematoma. This can in turn cause high intracranial pressure with rapid neurological deterioration. Urgent neurosurgical intervention is often necessary. In our department, three patients with meningioma-related hemorrhage were treated surgically from 2006 to 2020. One patient was operated on as an emergency, due to the patient's poor neurological condition, while the two others underwent surgery following supplementary diagnosis several days following their admission. The outcomes of the three patients were good. The three meningiomas associated with hemorrhage described in the present manuscript constitute 2.2% of all 136 meningiomas treated surgically from 2006 to 2020 at our department. All three hemorrhages described in this study were associated with WHO I convexity meningiomas. Similar data can be found in some sources also describing meningioma WHO I-related hemorrhages; nevertheless, other literature references indicate a higher risk of bleeding into meningiomas of a higher degree of malignancy. The hemorrhage mechanism remains unclear; however, the proposed mechanism is rupture of defective intratumoral blood vessels and stretching of the superficial veins including bridge veins by the growing tumor, leading to their rupture. Our observations regarding the incidence of meningioma hemorrhage and tumor location are consistent with the source literature data.

Clinical Characteristics and Long-Term Outcomes of MINOCA Accompanied by Active Cancer: A Retrospective Insight Into a Cardio-Oncology Center Registry.

Background: Clinical characteristics and long-term outcomes of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and cancer are insufficiently elucidated. Objectives: We sought to characterize these patients hospitalized in a tertiary cardio-oncology center and to find the potential determinants affecting their long-term mortality. Methods: MINOCA was diagnosed in 72 of the 1,011 patients with consecutive myocardial infarction who underwent coronary angiography. Mortality rates and their determinants were analyzed within a median follow-up of 69.2 (37.8-79.9) months. Results: Active cancer was identified in 21 (29.2%) of patients with MINOCA and in 113 (12.0%) patients with myocardial infarction and obstructive coronary artery disease (MI-CAD) (p < 0.001). MINOCA patients with cancer were characterized by a higher incidence of anemia (47.6 vs. 21.6%, p = 0.03) and more frequently Takotsubo syndrome (19.1 vs. 2.0%, p = 0.01) than in non-cancer MINOCA. The troponin T/hemoglobin ratio was higher in both cancer MINOCA and MI-CAD groups when compared with their respective non-cancer patients (both p < 0.05). The age and sex-standardized mortality rates were significantly higher in cancer MINOCA (26.7%/year) when compared with non-cancer MINOCA (2.3%/year, p = 0.002) and in cancer MI-CAD (25.0%/year) vs. non-cancer MI-CAD (3.7%/year, p < 0.001). Active cancer (HR 3.12, 95% CI 2.41-4.04) was independently associated with higher long-term mortality, while higher hemoglobin levels (HR 0.93, 95% CI 0.88-0.99, per g/dl) and a MINOCA diagnosis (HR 0.69, 95% CI 0.47-0.97) improved long-term survival. Conclusion: Patients with MINOCA were comorbid with cancer more frequently than MI-CAD. In turn, an active malignancy was associated with an unfavorable long-term survival both in MI-CAD population and in patients with MINOCA.

Scraping nasal cytology in the diagnostics of rhinitis and the comorbidities.

Nasal scraping cytology is a non-invasive tool used in the diagnostics of allergic and non-allergic rhinitis. The study aimed to analyze to what extent the cytological picture of the nasal mucosa coincides with the diagnosis of a given disease, taking into account the content of eosinophils. Retrospective analysis of the cytograms performed in 842 patients was carried out in relation to the disease entities and the content of eosinophils. Significant relationship between the Epith:Infl ratio and the four groups of diseases (Chi2 = 9.6488; p = .014) was confirmed. The more intensive inflammation was found, the higher percentage of patients had manifested the increased level of eosinophils (> 1% in the inflammatory cells). The value of 20% of eosinophils in all counted cells corresponds to around 45% of eosinophils in the inflammatory cells in patients with the evident inflammatory picture. Allergic rhinitis presents a different cytological picture regarding the eosinophilic reaction against the background of the inflammation process: the higher degree of inflammation observed, the lower amount of eosinophils detected, with the exception of allergic rhinitis provoked by pollen allergens.

Prognostic Values of Combined Ratios of White Blood Cells in Glioblastoma: A Retrospective Study.

In some malignant tumours, the changes in neutrophil counts in relation to other blood cells are connected with unfavourable prognosis. Nevertheless, the prognostic value of the combinations of the haematological components in glioblastoma (GBM) remains under dispute. The clinical significance of the neutrophil-to-lymphocyte ratio (NLR), systemic immune inflammation index (SII), and systemic inflammation response index (SIRI) was investigated in our study. We retrospectively studied 358 patients (males n = 195; females n = 163) aged 59.9 ± 13.5 yrs with newly diagnosed glioma and admitted to the Neurosurgery Centre. Routine blood tests and clinical characteristics were recorded within the first hour of hospital admission. The inflammatory variables: NLR, SII and SIRI exceeded the reference values and were significantly elevated in Grade 3 and Grade 4 tumour. The Cox model analysis showed that the age ≥ 63 years, NLR ≥ 4.56 × 103/µL, SII ≥ 2003 × 103/µL and SIRI ≥ 3.03 × 103/µL significantly increased the risk of death in Grade 4 tumour patients. In the inflammatory variables, NLR demonstrated the highest impact on the survival time (HR 1.56; 95% CI 1.145-2.127; p = 0.005). In the first Polish study including GBM patients, the age in relation to simple parameters derived from complete blood cell count were found to have prognostic implications in the survival rate.

Statin Use in Cancer Patients with Acute Myocardial Infarction and Its Impact on Long-Term Mortality.

Statin use and its impact on long-term clinical outcomes in active cancer patients following acute myocardial infarction (MI) remains insufficiently elucidated. Of the 1011 consecutive acute MI patients treated invasively between 2012 and 2017, cancer was identified in 134 (13.3%) subjects. All patients were observed within a median follow-up of 69.2 (37.8−79.9) months. On discharge, statins were prescribed less frequently in MI patients with cancer as compared to the non-cancer MI population (79.9% vs. 91.4%, p < 0.001). The most common statin in both groups was atorvastatin. The long-term mortality was higher in MI patients not treated vs. those treated with statins, both in non-cancer (29.5%/year vs. 6.7%/year, p < 0.001) and cancer groups (53.9%/year vs. 24.9%/year, p < 0.05), respectively. Patient's age (hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.03−1.05, p < 0.001, per year), an active cancer (HR 2.42, 95% CI 1.89−3.11, p < 0.001), hemoglobin level (HR 1.14, 95% CI 1.09−1.20, p < 0.001, per 1 g/dL decrease), and no statin on discharge (HR 2.13, 95% CI 1.61−2.78, p < 0.001) independently increased long-term mortality. In MI patients, simultaneous diagnosis of an active cancer was associated with less frequently prescribed statins on discharge. Irrespective of cancer diagnosis, no statin use was found as an independent predictor of increased long-term mortality.

Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research.

Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.

Atypical Course of Vertebral Artery Outside the Cervical Spine: Case Report and Review of the Literature.

BACKGROUND: The vertebral arteries are branches of the subclavian arteries supply blood to the posterior part of the encephalon, forming vertebrobasilar circulation. Disorders of vertebrobasilar circulation have significant clinical implications. Symptoms of these disorders include dizziness, vomiting, collapse, vision and cerebellar disorders. The vertebral artery usually ascends in the transverse foramina of the cervical vertebrae to reach the posterior cranial cavity by entering the magnum foramen. Although most often the vertebral artery enters the C6 transverse process, anatomic variation may occur. CASE DESCRIPTION: In this case, a 16-year-old male patient with casuistic anatomic variant of vertebral artery course is described. In this case report, left vertebral artery ascended outside the transverse foramina of cervical vertebrae C6-C3 and entered transverse foramen of axis. The patient suffered from collapse and dizziness during neck and head movements as a result of arterial folding. After rehabilitation and posture and proper movement learning, the frequency of symptoms subsided. CONCLUSIONS: Variability of the vertebral arteries may have clinical implications, and knowledge of its topography is important for mechanism of vertebrobasilar circulatory disorder understanding and for surgical approach to the cervical spine and neck anatomic structures.

A Peer-Based Educational Intervention Effects on SARS-CoV-2 Knowledge and Attitudes among Polish High-School Students.

To support high school students to develop knowledge they need to adhere to control measures during the pandemic, a peer-based educational intervention on SARS-CoV-2 was developed and its impact was evaluated. Multistage random sampling was used. The 50 min peer-based intervention was conducted by final year medical students. Baseline and post-intervention knowledge and attitudes were assessed. Significance was tested by McNemar's/Wilcoxon rank tests. Of 518 participants (mean age 17.8 years ± 0.43), 81.0% did not receive any school-based education on SARS-CoV-2. After intervention, the knowledge score improved from 65.2% to 81.6%, attitudes from 63.2% to 70.8% (both p < 0.0001). The effect size after the intervention compared to pre-intervention showed moderate improvement of knowledge, but not attitudes (d = 0.46 and d = 0.18, respectively). Pre- and post-intervention, females, students in non-science programs, living in cities < 250,000 inhabitants had lower knowledge, while fewer males, non-science program students, living in smaller cities presented positive attitudes. Before intervention, 67.0% students correctly named SARS-CoV-2 preventive methods and 73.6% were concerned COVID-19 is a serious disease; these improved after intervention (to 80.1% and 86.3%; p < 0.0001). The intervention was not very successful in increasing the intent to vaccinate for COVID-19 (pre-intervention 52.9%, post-intervention 56.4%; p < 0.007). Peer-based teaching for high school students can be effective in increasing SARS-CoV-2 knowledge and awareness. More efforts are needed to improve attitudes and enhance acceptance of vaccination against COVID-19.

Dementia screening in elderly high-risk patients following heart failure decompensation may predict unfavorable long-term clinical outcomes.

BACKGROUND: Recently heart failure (HF) has been found to be a new dementia risk factor; nevertheless, their relations in patients following HF decompensation remain unknown. We sought to investigate whether a screening diagnosis for dementia (SDD) in this high-risk population may predict unfavorable long-term clinical outcomes. METHODS: One hundred forty-two patients following HF decompensation requiring hospitalization were enrolled. Within a median time of 55 months all patients were screened for dementia with ALFI-MMSE scale whereas their compliance was assessed with the Morisky Medication Adherence Scale. Any incidents of myocardial infarction, coronary revascularization, stroke or transient ischemic attack (TIA), revascularization, HF hospitalization and bleedings during follow-up were collected. RESULTS: SDD was established in 37 patients (26%) based on the result of an ALFI-MMSE score of <17 points. By multivariate analysis the lower results of the ALFI-MMSE score were associated with a history of stroke/TIA (ß=-0.29, P<0.001), peripheral arterial disease (PAD) (ß=-0.20, P=0.011) and lower glomerular filtration rate (ß=0.24, P=0.009). During the follow-up, patients with SDD were more often rehospitalized following HF decompensation (48.7% vs. 28.6%, P=0.042) than patients without SDD, despite a similar level of compliance (P=0.25). Irrespective of stroke/TIA history, SDD independently increased the risk of rehospitalization due to HF decompensation (HR 2.22, 95% CI: 1.23-4.01, P=0.007). CONCLUSIONS: In patients following decompensated HF, a history of stroke/TIA, PAD and impaired renal function independently influenced SDD. In this high-risk population, SDD was not related with patients' compliance but irrespective of the stroke/TIA history it was associated with the increased risk of HF rehospitalization.

Worse long-term prognosis in myocardial infarction occurring at weekends or public holidays with insight into myocardial infarction with nonobstructive coronary arteries.

INTRODUCTION: The weekend effect in Polish patients with myocardial infarction (MI) treated in the current network of catheterization laboratories is poorly understood. OBJECTIVES: We sought to investigate long­term prognosis of patients with MI admitted at weekends or public holidays (NWDs) and on working days (WDs). PATIENTS AND METHODS: We enrolled 865 patients with MI hospitalized between 2012 and 2017. The long­term mortality within the median (IQR) time of 68.5 (36.7-78.4) months was determined in 223 patients (25.8%) admitted on NWDs and in 642 (74.2%) on WDs. RESULTS: Patients admitted on NWDs more often had ST­segment elevation MI (41.3% vs 30.8%; P = 0.005), left anterior descending artery as an infarct­related artery (38.1% vs 30.2%; P = 0.031) and incomplete reperfusion expressed as Thrombolysis in Myocardial Infarction flow grade 0/1 following primary angioplasty (6.8% vs 1.6%; P <0.001) as compared with those hospitalized on WDs. Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurred less often on NWDs (4% vs 9%, P = 0.019). The all­cause long­term mortality was higher in NWD patients as compared with those admitted on WDs (36.3% vs 28.4%; P = 0.037). By the Cox proportional hazards model with time­dependent covariates, MI on NWDs (hazard ratio, 1.027; 95% CI, 1.022-1.032; P <0.001) but not MINOCA (hazard ratio, 0.971; 95% CI, 0.595-1.583; P = 0.91) was independently associated with long­term mortality. CONCLUSIONS: Patients hospitalized on NWDs as compared with those admitted on WDs had a larger ischemic territory and more often had transmural MI with incomplete epicardial reperfusion, which resulted in a higher long­term mortality. The latter outcome was not influenced by MINOCA.