Assessment of the incidence of fragmented QRS in electrocardiography in patients with systemic sclerosis and systemic lupus erythematosus.

OBJECTIVE: In systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) cardiac involvement is very common, and it might be asymptomatic. We aimed to assess the presence of fragmented QRS (fQRS) - possible indicator of a scar, diffuse damage or conduction system disturbances in those patients. METHODS: We examined 74 patients with SSc, 77 with SLE and 40 healthy controls. The incidence of fQRS in ECG was examined according to criteria by Das et al. Disease severity was estimated by Rodnan and SLICCC/ACRDI scores in SSc and SLE respectively. RESULTS: Patients with SSc were slightly older than those with SLE (53 ± 14 vs 46 ± 14 yrs), women constituted 91% and 88% of studied groups (p = 0.80). The duration of disease in both groups was similar (p = 0.59). Median of Rodnan and SLICCC/ACR-DI scores were 5 and 4 points, respectively. Left ventricle ejection fraction in both groups was similar (65.5 vs 65.1%, p = 0.51), hypertension incidence was lower in SSc (24 vs 48%, p = 0.004), patients with SLE presented prolonged corrected QT interval (432 vs 424 ms, p = 0.03). Of note, fQRS were observed in 34 (46%) SSc and 29 (38%) SLE patients, p = 0.33. Notched S waves were significantly more frequent in SSc (in 26% vs 10%, p = 0.02). fQRS occurred in 3 (7.5%) of healthy subjects only. CONCLUSION: The incidence of fQRS is similar in SSc and SLE, but is much more common than in healthy subjects. It is possible that fQRS may be considered an additional marker of heart involvement in these rare diseases.

Assessment of pulmonary embolism severity and the risk of early death.

Currently, venous thromboembolism, including deep vein thrombosis and acute pulmonary embolism (PE), is globally the third most frequent acute cardiovascular syndrome with rising incidence rates. The clinical presentation of PE is heterogenous: from incidental findings on imaging studies to sudden cardiac death. Hemodynamic instability identifies patients at high risk of early mortality. In hemodynamically stable patients, further stratification into intermediate- and low-risk categories is advised, preferably using a combined risk assessment strategy based on clinical parameters, laboratory findings, and imaging markers. Treatment should be tailored to the risk of early death, with more aggressive treatments reserved for patients at higher risk of complications. This review offers an update on the current strategies for assessing PE severity and the risk of early death and discusses developments in predicting mortality risk in patients with PE.

Assessment of arrhythmias and cardiac autonomic tone at a relatively young age patients with obesity class III.

There is no sufficient data on arrhythmias occurrence in obesity class III. The influence of hyperinsulinemia and insulin resistance on arrhythmias and cardiac autonomic tone is also of ongoing interest in these subjects. We prospectively studied 81 selected patients with body mass index >40 kg/m2 , aged 34 (18-65) years. Among other examinations all subjects underwent electrocardiography and Holter monitoring with heart rate variability (HRV) and turbulence (HRT) evaluation. Controls consisted of 45 healthy, sex- and aged-matched lean volunteers. In patients median BMI was 44.5 kg/m2 (40.1-58.1), benign arterial hypertension was present in 43.2% and dysglycemia in 27.2% of cases. In the group with obesity longer PR interval (P < .001) and corrected QT interval (P < .001) were observed, while in Holter monitoring no significant differences in supraventricular or ventricular arrhythmias and also bradyarrhythmias prevalence were observed in comparison to controls. In individuals with obesity HRV indices associated with sympathetic tone were significantly impaired and also abnormal HRT values (21.9 vs 0%, P = .04) were more frequently observed. There were no significant correlations between anthropometric obesity parameters and fasting insulin concentration, insulin resistance index and also HRV/HRT parameters in studied individuals. Univariate regression analysis revealed that only age influenced abnormal HRT occurrence (OR 1.69, 95%CI 1.08-2.98, P = .04). In conclusions, patients with obesity class III at a relatively young age who reported they felt healthy, do not present increased prevalence of arrhythmias, including life-threatening ones. Cardiac autonomic dysfunction is observed in these patients, however it has not been shown to be associated with anthropometric measurements.

Influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in electrocardiographic assessment of patients with systemic lupus erythematosus.

BACKGROUND: There are no data on the influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in 24-hour Holter monitoring in systemic lupus erythematosus (SLE). METHODS: Consecutive 92 SLE and 51 healthy subjects were studied. The standard 12-lead electrocardiography (ECG), Holter monitoring with heart rate turbulence (HRT) and QT, Tp-e and Tp-e/QT ratio assessment (including corrected values) were performed. Subjects with conditions causing repolarization abnormalities or insufficient number of beats suitable for QT evaluation were excluded (17 SLE and 8 controls). RESULTS: Finally, 75 SLE and 43 sex- and age-matched controls were included to the study. In SLE patients, the median disease severity score (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI)) was 3.0. The mean values of QTc, cTp-e and cTp-e/QTc were significantly higher in SLE patients than in controls. QTc ≥ 460 ms was observed in 18.7% of patients using standard ECG and in 58.7% using Holter monitoring. With Holter monitoring, patients with SLICC/ACR-DI >3.0 presented longer QTc than those with SLICC/ACR-DI ≤3.0 (418±15 vs. 409 ± 16, p = 0.04), while cTp-e and cTp-e/QTc values were similar. Patients with abnormal HRT presented longer cTp-e and higher cTp-e/QTc than those with normal HRT (92 ± 52 vs. 71 ± 16 ms, p = 0.04; 0.244 ± 0.126 vs. 0.187 ± 0.035, p = 0.03), while QTc values were similar. No differences in QT and Tp-e parameters were observed according to disease duration. CONCLUSION: In SLE patients, Holter monitoring revealed QTc prolongation more frequently than standard ECG. Longer QTc values were observed in patients with more advanced disease, while increased cTp-e and cTp-e/QTc were related to cardiac autonomic dysfunction expressed by abnormal HRT.

Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary circulation in patients with systemic sclerosis.

PURPOSE: Pulmonary hypertension (PH) is an ominous complication in systemic sclerosis patients (SSc) and echocardiography is a screening tool for its detection. The goal of this study was to assess the reliability of resting and exercise echo Doppler parameters with data obtained by right heart catheterization (RHC). MATERIAL AND METHODS: We included 91 patients (84 F, 53.3 ± 15.2 years) with SSc. Transthoracic echocardiography followed by exercise Doppler-echocardiography (EDE) were performed. A positive EDE was defined as a ≥20 mmHg increase in tricuspid regurgitation peak gradient (TRPG). RHC with exercise was performed in positive EDE patients and/or in subjects with resting TRPG > 31 mmHg. RESULTS: Finally, RHC was performed in 20 patients. The correlation for the echocardiography and invasive measurement of systolic (sPAP) and mean (mPAP) pulmonary artery pressure was r = 0.66 (p = 0.001) and r = 0.7 (p = 0.001), respectively. We also found significant correlation between echocardiography and invasive measurement of exercise sPAP r = 0.68 (p = 0.001) and exercise mPAP r = 0.67 (p = 0.002). There was a correlation between pulmonary vascular resistance (PVR) assessed by echocardiography and measured by RHC r = 0.49, p = 0.027. The equation derived within our population was: PVR by echocardiography = 9.6*TRV/TVIRVOT+0.068. We also performed ROC analysis to predict PVR > 2 WU. Our results highlight that sPAP has the highest AUC (0.802, 95% CI 0.585-1). CONCLUSION: Doppler resting and exercise echocardiography may provide a reliable, noninvasive method for determining resting and exercise sPAP, mPAP, and PVR in SSc patients, although it may underestimate or overestimate these values in some individuals. Doppler echocardiography does not replace RHC for definite hemodynamic assessment of suspected PH.

Comparison of non-invasive assessment of arrhythmias, conduction disturbances and cardiac autonomic tone in systemic sclerosis and systemic lupus erythematosus.

Systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) are connective tissue diseases presenting cardiac complications including different arrhythmias, then direct electrocardiographic comparison may be useful in everyday clinical decision making. We examined 86 adult SSc patients, 76 with SLE and 45 healthy controls. Among other examinations all subjects underwent 24-h Holter monitoring with time-domain heart rate variability and heart rate turbulence evaluation. Patients with various co-existing conditions which might markedly influence arrhythmias and autonomic modulation were excluded from further analysis (SSc n = 12, SLE n = 6). Finally, 76 SSc and 70 SLE subjects were eligible for this study, mean age 51.9 ± 13.1 and 46.5 ± 12.7 years (p = 0.11), with median disease duration 6.0 and 8.5 years (p = 0.15), respectively. As compared to SLE, patients with SSc were characterised by more frequent incidence of various supraventricular and ventricular arrhythmias. As compared to SSc, patients with SLE presented prolonged corrected QT intervals and also significant correlations between corrected QT length and heart rate variability indices. Both SSc and SLE subjects presented impaired sympathetic cardiac autonomic modulation, while indices associated with parasympathetic activity in SLE were not diminished. Disease duration was not associated with arrhythmias' occurrence (except for ventricular tachycardia in SSc, p = 0.02) and also with autonomic function in both groups of patients. Patients with SSc and SLE differ in terms of arrhythmias, conduction disturbances and cardiac autonomic tone. Regular Holter monitoring should be considered as a part of routine evaluation in connective tissue diseases patients, especially in systemic sclerosis.

The assessment of platelet function using multiple electrode aggregometry in practical procedures in anaesthesia.

BACKGROUND: Platelets are responsible for primary haemostasis. Patients with suspected platelet dysfunction require prompt clinical assessment when qualifying for emergency surgical procedures. The purpose of this article is to present our experience in platelet function assessment using whole-blood multiple electrode aggregometry (MEA) in various clinical conditions. CASE REPORTS: Retrospective analysis of three patients with thrombocytopathy associated with normal platelet counts was performed using standard laboratory tests complemented by MEA. In two cases, platelet dysfunction was due to antiplatelet drugs, while in one other case it was caused by chronic kidney disease. CONCLUSIONS: Anaesthesiologists strive to make the perioperative period as safe as possible. Platelet function assessment should be considered in every patient in whom haemostatic disturbances are suspected. MEA provides support for clinical decision-making, especially in patients who undergo haemodialysis or require antiplatelet therapy, and are in need of emergency surgery.

d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism.

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology--Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension--Technique, safety and efficacy of 50 consecutive angioplasties.

BACKGROUND/OBJECTIVES: Balloon pulmonary angioplasty (BPA) is an emerging therapeutic method in CTEPH. We aimed to prove the safety and efficacy of refined BPA driven by combined assessment of intra-arterial anatomy (IVUS/OCT) and physiology (pulmonary pressure ratio, PPR) in non-operable distal CTEPH. METHODS: 11 pts (mean age 76, 59­84, 7 males) were enrolled in the BPA program according to the following inclusion criteria: 1. Non-operable CTEPH; 2. RHC with mPAP > 30 mm Hg; 3. At least one segmental perfusion defect at lung scintigraphy; 4. WHO class > II. Overall, 9 pts underwent 27 BPA sessions (mean 3 sessions per patient, range 1­5), 50 pulmonary arteries were dilated (mean 6 vessels per patient, range 3­9; 2.03 dilated arteries per session). All the angioplasties were performed according to an algorithm, which incorporated anatomical and functional assessment of targeted lesions. RESULTS: We performed BPA of 32 web lesions, 5 ring-like stenosis and 13 complete obstructions. BPA resulted in clinical and hemodynamic improvement. WHO class improved from pre-BPA to post-BPA (p = 0.018), and 6 MWD increased from 304 m to 384 m (p = 0.03), NT-proBNP dropped from 1248 pg/ml to 730 pg/ml (p < 0.001). Mean PAP and PVR decreased (p = 0.01), while CO and CI increased (p = 0.01). All dilated arteries were patent at angiographic reassessment. No significant complications occurred and all treated patients are still alive. Insignificant transient reperfusion pulmonary oedema occurred in only 2 patients, who responded well to supplemental oxygen. CONCLUSIONS: Refined BPA with assessment of intrapulmonary physiology using a pressure wire and precise evaluation of anatomy with IVUS and OCT provides hemodynamic and functional improvement, with minimal complications in distal non-operable CTEPH. This observation requires further validation in a large prospective study.

Heart rate turbulence assessment in systemic sclerosis: the role for the detection of cardiac autonomic nervous system dysfunction.

OBJECTIVE: To assess the heart rate turbulence (HRT) in patients with SSc as a method of assessment for cardiac autonomic nervous function. METHODS: We prospectively studied 68 consecutive patients with SSc before inclusion in the study. After a detailed clinical evaluation, including echocardiography, 45 subjects [aged 54.6 (14.7) years; 40 women] underwent 24-h Holter monitoring for HRT and time- and frequency-domain heart rate variability (HRV) assessment. Results were compared with those in 30 age- and sex-matched healthy controls. RESULTS: As compared with controls, HRT was impaired in SSc patients: the median turbulence onset (TO) was higher (P = 0.0001) and the median turbulence slope (TS) was lower (P = 0.0003). Abnormal HRT (TO > or =0.0% and/or TS < or =2.5 ms/RR) was found in 42% of SSc patients. Moreover, SSc duration correlated negatively with values of TS (r = -0.3; P = 0.045). HRT did not differ between diffuse and limited SSc groups. All estimated time- and the majority of frequency-domain values of HRV parameters in SSc were significantly lower than in controls. Significant correlations were also demonstrated between HRT and HRV parameters. CONCLUSIONS: HRT, like HRV assessment, indicates a frequent impairment of the cardiac autonomic nervous system in SSc patients, irrespective of the SSc type.

Is it possible to use standard electrocardiography for risk assessment of patients with pulmonary embolism?

BACKGROUND: Risk stratification of patients with acute pulmonary embolism (APE) is crucial for appropriate treatment selection. Shock and hypotonia are known indications for aggressive management. However, in the haemodynamically stable group the best prognosis strategy is still being sought. Acute pulmonary embolism often provokes changes in electrocardiography recordings (ECG). AIM: To assess whether ECG features recorded on admission can be useful for risk stratification during hospitalisation. METHODS: We analysed 12-lead ECG and echocardiography of 56 patients (22 males, age: 64.3 +/- 17.9 years) with diagnosed APE. The diagnosis of APE was confirmed by spiral computer tomography. The ECG analysis was based on the 21-point ECG score including: the presence of tachycardia (> 100 beats/min), right bundle branch block, negative S waves in lead I, negative Q or T waves in lead III, S1Q3T3 complex and depth of negative T waves in leads V1-V4. ECG features were scored from 0 to 21 points. Complicated in-hospital course was defined as need for vasopressor, thrombolysis, embolectomy or resuscitation and the presence of shock index > 1 (heart rate/systolic blood pressure). RESULTS: Four (7.1%) patients died during hospitalisation and in 8 (14.3%) others complications occurred. Patients with complications had higher mean sum of 21-ECG score compared to subjects with uneventful course [8 (1-17) vs. 3 (0-18); p = 0.04]. Right ventricular contractility dysfunction (RVD) in echocardiography was found in 13 (23.2%) patients, who had higher ECG score compared to patients without RVD [8 (3-17) vs. 2 (0-18); p = 0.004]. The area under the ROC curve to assess the usefulness of 21-ECG score to predict RVD was 0.794 (95% CI 0.665-0.891) and for PPH 0.727 (95% CI 0.591-0.837). The sensitivity and specificity, positive and negative predictive value for the value > 3 points in 21-ECG score to predict RVD were: 92, 65, 44, 97% and for PPH: 75, 46, 19, 92%, respectively. CONCLUSIONS: 21-ECG score is a simple and cheap method which can be used to predict RVD and serious complications in patients with APE. A value L 3 points in the 21-ECG score can exclude RVD with high probability and limit the need of echocardiography to 23% of haemodynamically stable patients.

Assessment of left and right ventricular diastolic function in patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is a connective tissue disease characterised by vascular changes and immunologically induced fibrosis of the skin and internal organs. Systemic sclerosis may be associated with both right (RV) and left ventricular (LV) diastolic dysfunction. AIM: To analyse RV and LV myocardial diastolic function in patients with SSc and its relation to exercise capacity. METHODS: We prospectively studied 51 consecutive patients (47 females, 4 males, age 53.3+/-15.2 years) with SSc (mean disease duration 9+/-12.4 years) and a group of 31 age-matched healthy subjects (28 females, 3 males, age 52.68+/-12.1 years). In addition to conventional investigation, transthoracic echocardiography (TTE) for assessment of RV and LV myocardial diastolic function and 6-minute walking test (6MWT) were performed. RESULTS: Abnormal LV filling, as expressed by an inverted mitral E/A ratio (Mit E/A <1), was detected in 28 (55%) SSc patients and in 8 (25%) controls (p <0.001). The mean value of Mit E/A in the SSc group was lower than in controls (1.0+/-0.3 vs. 1.2+/-0.3, p=0.04). There were no differences in pulmonary venous flow between SSc patients and controls. The mean value of Tei index for the LV was higher in SSc than in controls (0.44+/-0.08 vs. 0.38+/-0.05, p <0.001). Abnormal RV filling, as expressed by an inverted tricuspid E/A ratio (TR E/A <1), was detected in 16 (31%) SSc patients and in 5 (16%) controls (p <0.001). Patients with SSc were found to have an inverted Tr E/A ratio (Tr E/A <1), indicating abnormal RV filling. The mean value of Tr E/A in SSc was lower than in controls (1.0+/-0.2 vs. 1.2+/-0.3, p=0.04). The mean value of Tei index for the RV was higher in SSc patients than in controls (0.35+/-0.07 vs. 0.29+/-0.03, p <0.001). In multiple regression analysis Tr E/A ratio was independently correlated with Mit E/A ratio (r=0.65, p=0.01). The mean 6MWT distance was shorter in the SSc group than in controls (528+/-100.6 vs. 617.7+/-80 m, p <0.001) and the mean saturation of capillary blood after the 6-MWT was lower in SSc patients (92.7+/-4.9 vs. 97.2+/-1.2%, p <0.001). Mean desaturation after test and D sat was significantly more pronounced in the SSc group than in controls (3.4+/-3.1 vs. 0.7+/-0.9, p <0.001). The Tr E/A ratio and Mit E/A ratio correlated positively with 6MWT distance (r=0,49, p=0.01 and r=0.48, p=0.02). CONCLUSIONS: Impaired RV and LV relaxation is observed in a significant percentage of SSc patients and is associated with decreased exercise capacity.