Phenotypes of Polish primary care patients using hierarchical clustering: Exploring the risk of mortality in the LIPIDOGEN2015 study cohort.

BACKGROUND: Comorbidities in primary care do not occur in isolation but tend to cluster together causing various clinically complex phenotypes. This study aimed to distinguish phenotype clusters and identify the risks of all-cause mortality in primary care. METHODS: The baseline cohort of the LIPIDOGEN2015 sub-study involved 1779 patients recruited by 438 primary care physicians. To identify different phenotype clusters, we used hierarchical clustering and investigated differences between clinical characteristics and mortality between clusters. We then performed causal analyses using causal mediation analysis to explore potential mediators between different clusters and all-cause mortality. RESULTS: A total of 1756 patients were included (mean age 51.2, SD 13.0; 60.3% female), with a median follow-up of 5.7 years. Three clusters were identified: Cluster 1 (n = 543) was characterised by overweight/obesity (body mass index ≥ 25 kg/m2), older (age ≥ 65 years), more comorbidities; Cluster 2 (n = 459) was characterised by non-overweight/obesity, younger, fewer comorbidities; Cluster 3 (n = 754) was characterised by overweight/obesity, younger, fewer comorbidities. Adjusted Cox regression showed that compared with Cluster 2, Cluster 1 had a significantly higher risk of all-cause mortality (HR 3.87, 95% CI: 1.24-15.91), whereas this was insignificantly different for Cluster 3. Causal mediation analyses showed that decreased protein thiol groups mediated the hazard effect of all-cause mortality in Cluster 1 compared with Cluster 2, but not between Clusters 1 and 3. CONCLUSION: Overweight/obesity older patients with more comorbidities had the highest risk of long-term all-cause mortality, and in the young group population overweight/obesity insignificantly increased the risk in the long-term follow-up, providing a basis for stratified phenotypic risk management.

Association of body mass index and long-term mortality in patients from nationwide LIPIDOGRAM 2004-2015 cohort studies: no obesity paradox?

BACKGROUND: An obesity paradox has been described in relation to adverse clinical outcomes (e.g., mortality) with lower body mass index (BMI). AIMS: We sought to evaluate the association between BMI and weight loss with long-term all-cause mortality in adult populations under the care of family physicians. METHODS: LIPIDOGRAM studies were conducted in primary care in Poland in 2004, 2006, and 2015 and enrolled a total of 45,615 patients. The LIPIDOGRAM Plus study included 1627 patients recruited in the LIPIDOGRAM 2004 and repeated measurements in 2006 edition. Patients were classified by BMI categories as underweight, normal weight, overweight and class I, II, or III (obesity). Follow-up data up to December 2021 were obtained from the Central Statistical Office. Differences in all-cause mortality were analyzed using Kaplan‒Meier and Cox regression analyses. RESULTS: Of 45,615 patients, 10,987 (24.1%) were normal weight, 320 (0.7%) were underweight, 19,134 (41.9%) were overweight, and 15,174 (33.2%) lived with obesity. Follow-up was available for 44,620 patients (97.8%, median duration 15.3 years, 61.7% females). In the crude analysis, long-term all-cause mortality was lowest for the normal-weight group (14%) compared with other categories. After adjusting for comorbidities, the highest risk of death was observed for the class III obesity and underweight categories (hazard ratio, HR 1.79, 95% CI [1.55-2.05] and HR 1.57, 95% CI [1.22-2.04]), respectively. The LIPIDOGRAM Plus analysis revealed that a decrease in body weight (by 5 and 10%) over 2 years was associated with a significantly increased risk of death during long-term follow-up-HR 1.45 (95% CI 1.05-2.02, p = 0.03) and HR 1.67 (95% CI 1.02-2.74, p < 0.001). Patients who experienced weight loss were older and more burdened with comorbidities. CONCLUSIONS: Being underweight, overweight or obese is associated with a higher mortality risk in a population of patients in primary care. Patients who lost weight were older and more burdened with cardiometabolic diseases, which may suggest unintentional weight loss, and were at higher risk of death in the long-term follow-up. In nonsmoking patients without comorbidities, the lowest mortality was observed in those with a BMI < 25 kg/m2, and no U-curve relationship was observed.

Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP).

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Much of these diseases burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that with respect to low density lipoprotein cholesterol (LDL-C), "lower is better for longer", and the recent data have strongly emphasized the need of also "the earlier the better". In addition to statins, which have been available for several decades, the availability of ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) are additional very effective approach to LLT, especially for those at very high and extremely high cardiovascular risk. LLT is initiated as a response to an individual's calculated risk of future ASCVD and is intensified over time in order to meet treatment goals. However, in real-life clinical practice goals are not met in a substantial proportion of patients. This Position Paper complements existing guidelines on the management of lipids in patients following ACS. Bearing in mind the very high risk of further events in ACS, we propose practical solutions focusing on immediate combination therapy in strict clinical scenarios, to improve access and adherence to LLT in these patients. We also define an 'Extremely High Risk' group of individuals following ACS, completing the attempt made in the recent European guidelines, and suggest mechanisms to urgently address lipid-medicated cardiovascular risk in these patients.

Cardiac magnetic resonance in the assessment of hypertrophic cardiomyopathy phenotypes and stages - pictorial review.

The aim of this paper is to present recent advances in hypertrophic cardiomyopathy (HCM) diagnosis and treatment based on a literature review. Special emphasis has been placed on the role of cardiac magnetic resonance imaging (CMR) for the assessment of morphological and functional consequences of different stages of HCM including prognostication. The text is illustrated with the images and data of the HCM patients diagnosed with CMR study in our hospital. CMR is an important tool, particularly relevant in novel risk factors and LV dysfunction groups. The HCM group with overt left ventricular dysfunction is underrecognized, often labelled by clinicians as dilated cardiomyopathy. Advanced diagnostic and management strategies effectively influence the natural history of HCM.

Bioresorbable polymer-coated thin strut sirolimus-eluting stent vs durable polymer-coated everolimus-eluting stent in daily clinical practice: Propensity matched one-year results from interventional cardiology network registry.

OBJECTIVES: We sought to determine the 1-year clinical follow-up in patients treated with the thin strut (71 µm) bioabsorbable polymer-coated sirolimus-eluting stent (BP-SES) vs durable coating everolimus eluting stent (DP-EES) in daily clinical routine. BACKGROUND: Presence of durable polymers may be associated with late/very late stent thrombosis occurrence and the need for prolonged dual antiplatelet therapy. Bioabsorbable polymers may facilitate stent healing, thus enhancing clinical safety. METHODS: Interventional Cardiology Network Registry is a prospective, multicenter, observational registry of 21,400 consecutive patients treated with PCI since 2010. We analyzed 4,670 patients treated with either a BP-SES (ALEX, Balton, Poland) or DP-EES (XIENCE, Abbott, USA) with available 1-year clinical follow-up using propensity-score matching. Outcomes included target vessel revascularization (TVR) as efficacy outcome and all cause death, myocardial infarction (MI), and definite/probable stent thrombosis as safety outcomes. RESULTS: After propensity score matching, 1,649 patients treated with BP-SES and 1,649 patients treated with DP-EES were selected. Procedural and clinical characteristics were similar between both groups. There was no significant difference between tested groups in in-hospital mortality. One-year follow-up demonstrated comparable efficacy outcome, TVR (BP-SES 5.9% vs DP-EES 4.6% P = 0.45), as well as comparable safety outcomes, all cause death, MI and definite/probable stent thrombosis. CONCLUSIONS: In this multicenter registry, the BP-SES thin strut biodegradable polymer-coated sirolimus-eluting stent demonstrated comparable clinical outcomes at 1-year after implantation to the DP-EES. These data support the relative safety and efficacy of DP-SES in a broad range of patients undergoing percutaneous coronary intervention.

Epidemiological analysis of hospitalisations due to recurrent stroke in the Silesian Province, Poland, between 2009 and 2015.

BACKGROUND AND AIM: There is a lack of recent epidemiological studies on recurrent stroke (RS) in Poland. The aim of this study was to analyse all hospitalisations related to RS in Silesia - an industrial region covering 12% of the Polish population. MATERIAL AND METHODS: We carried out statistical analysis of data contained in stroke questionnaires transferred to the Polish National Health Fund by hospitals in Silesia, Poland, between 2009 and 2015. RESULTS: In the analysed period, the number of RS hospitalisations in Silesia was 18,063 (22.2% of all acute strokes). The percentage of RS significantly decreased during the period under consideration (p < 0.001). The same observation concerned recurrent ischaemic stroke (RIS), but not recurrent haemorrhagic stroke (RHS). The median hospitalisation time was 14 days for RHS, and 11 days for RIS. Large-artery atherosclerosis and cardioembolisms were significantly more often recognised in RIS than in first-ever ischaemic stroke (FIS) (consecutively, 38.2% vs 36.0%, and 21% vs 18.1%; p < 0.001). The in-hospital mortality rate was significantly higher for RS than for first-ever stroke (18.4% vs 17.2%; p < 0.001). The same observation was done for RIS vs FIS (16.2% vs 13.9%; p < 0.001), and for RHS vs FHS (39.8% vs 36%; p = 0.004). The rtPA therapy was applied to 5.3% of FIS and 3.2% of RIS patients (p < 0.001). CONCLUSIONS: This is the first such comprehensive and long-term analysis of recurrent stroke in Silesia, Poland. It could help in the implementation of appropriate educational programmes, and thus help to improve the health status of society.

Levosimendan ­ a valuable player in the treatment of a right-sided heart failure

A 66 year-old obese man, suffering from type 2 diabetes, high blood pressure, chronic nephropathy in stage 4, permanent atrial fibrillation accompanied by bradycardia was admitted to a cardiology ward with the signs and symptoms of acute right-sided heart failure. A standard therapy was used including combined diuretics therapy. In spite of the applied methods and pharmaceuticals, no significant reduction of the body weight neither improvement in cardiovascular capacity or renal parameters were observed. Due to the ineffectiveness of the standard combined pharmacotherapy applied in the case of the acute circulatory failure, the resistance to diuretics was recognized and as a result of the above, infusion of levosimendan was decided to be applied. This therapy resulted in rich diuresis, significant loss in body weight and considerable improvement in cardiovascular capacity which allowed to continue further diagnostics and appropriate invasive treatment. The article describes current knowledge on the place of levosimendan and its application in the treatment of an right-sided heart failure.

[Niewydolnosc serca - problem medyczny, ekonomiczny i spoleczny].

Heart failure has accompanied mankind since the dawn of time. The first mentions of the disease, which today we describe as heart failure, come from ancient times. Epidemiology of symptomatic heart failure is well known , especially in Europe. Heart failure affects approximately 2% of the adult population in Europe. The article presents: definition, epidemiology and prognosis of patients with heart failure. The article presents current methods of pharmacotherapy and treatment of heart failure. An important element in the management of patients with heart failure is medical rehabilitation and the prevention of cardiovascular diseases, according to the ESC guidelines. The topic also discussed in the article is the analysis of socio-economic costs of heart failure. The article concludes that: heart failure is a medical problem, because despite the introduction of new treatment methods, it is a disease that is still characterized by poor prognosis; heart failure is an economic problem because its treatment is expensive and absorbs 2% of all costs of healthcare; heart failure is a social problem because it is a disorder affecting mainly elderly people, leading to a significant reduction in their ability to live independently, which results in their exclusion from social life.

[Heart failure in opole voivodeship - epidemiology and future perspectives].

Heart failure appears in 2% of the adult population in Europe. One in five people aged 40 years will develop heart failure during their lifetime. Heart failure touch 20,000 people in the Opole province. Heart failure is the second, after acute coronary syndromes, urgent cause of admissions to the Clinic of Cardiology at the University Hospital in Opole. The paper presents the prognosis of hospitalization of patients with heart failure for the years 2015-2050 taking into account the processes of depopulation taking place in our region. The analysis makes it possible to predict that the age group particularly exposed to heart failure in the coming decades will be people who today belong to teenagers and young adults. The article presents current methods of treatment of heart failure. Improvement in the prognosis of patients with heart failure can occur through the implementation of the guidelines for treatment of heart failure recommended by the ESC. This goal is to be achieved by introducing the "Comprehensive care for patients with heart failure (KONS)" program in our country. The shift of the burden of care for patient with heart failure to outpatient unit will result in a significant reduction in the number of hospitalizations.

Early and One-Year Outcomes of Acute Stroke in the Industrial Region of Poland During the Decade 2006-2015: The Silesian Stroke Registry.

BACKGROUND: Poland, classified as a high-income country, is still considered to have a high cardiovascular risk population. During the last decade, the standards of care in acute stroke (AS) had markedly improved; thus, we aimed to assess whether and how it translated into early and late outcomes. METHODS: Silesian Stroke Registry was created from the administrative database of the public, obligatory, health -insurer in Poland. The AS cases were selected based on primary diagnosis coded in ICD-10 as I60-I64 for years 2006-2015 (n = 120,844). Index hospitalization together with data on re-hospitalizations, procedures, ambulatory visits, rehabilitation and all-cause deaths in a 1-year follow-up were analyzed. RESULTS: The rates of admissions per 100,000 adult population varied between 41-47 for haemorrhagic and 257-275 for ischaemic stroke with substantial decrease in almost all age groups except for the oldest patients. In ischaemic stroke, thrombolytic therapy raised from 0 to 8.8% in 2015, along with significant trends of decreasing 30-day (from 20 to 16%) and 12-month (from 35 to 31%) case fatality. In haemorrhagic stroke, case fatality had not changed. After ischaemic stroke, 12-month readmissions due to AS declined from 11-12% in 2006-2009 to 9% in 2010-2014. The percentage of patients benefiting from rehabilitation increased from 24 to 32%. CONCLUSIONS: In a large population of industrial province, we showed recent, positive trends in AS admissions, treatment and 1-year outcomes. Development of stroke unit networks and increase in thrombolytic treatment were at least in part responsible for survival improvement and reduction of recurrence of AS. However, case-fatality and stroke recurrence remain high compared to those of other developed countries.

Diagnostics, treatment and secondary prevention of ischemic stroke in the Silesian Province, Poland between 2009 and 2015.

BACKGROUND: The available data on diagnostics and treatment of ischemic stroke (IS) in Poland come mainly from non-representative cohorts or are outdated. OBJECTIVE: Therefore, the current study was done to access the most recent data on IS in the industrial region that covers 12% of the country's population. MATERIALS & METHODS: Analysis of the data from stroke questionnaires, obligatory for all patients hospitalized due to acute stroke and administered by the National Health Fund (the only public health insurer in Poland) between 2009 and 2015 (n=81,193). RESULTS: The number of hospitalizations due to IS in the Silesian Province was 69,403 and constituted 85.5% of all stroke cases reported to the NHF between 2009 and 2015. Neuroimaging of the brain (CT/MRI) was performed in 68,696 (99%) subjects, while ultrasonography of extra- and/or intracranial arteries in 57,886 (83.4%). The rtPA therapy was applied in 3282 patients (4.7% of all IS subjects). The rate of patients treated with rtPA gradually increased (1.2% in 2009, 9.3% in 2015). Among all patients with IS, 57,636 (83.1%) subjects were administered antiplatelet drugs, 16,199 (23.3%) - oral anticoagulants, and 55,971 (80.7%) - antihypertensive drugs. Also, 2260 (3.3%) patients were referred for vascular intervention. In subjects with cardioembolic stroke etiology, 37.8% were treated with anticoagulants. CONCLUSIONS: There has been observed a significant improvement in the quality of diagnosis and treatment of acute ischemic stroke during recent years. However, further actions are required both in terms of reperfusion treatment (thrombolysis and/or thrombectomy) and secondary prevention of stroke.

Characteristics of hospitalizations due to acute stroke in the Silesian Province, Poland, between 2009 and 2015.

INTRODUCTION: The available data on acute stroke (AS) in Poland come mainly from non-representative cohorts or are outdated. Therefore, the current study was done to access the most recent data on AS in the industrial region that covers 12% (4.6mln) of the country's population. OBJECTIVE: To evaluate the epidemiological data of AS in the Silesian Province, Poland. PATIENTS AND METHODS: Analysis of the data from stroke questionnaires, obligatory for all patients hospitalized due to AS and administered by the only public health insurer in Poland (the National Health Fund) between 2009 and 2015 (n=81,193). RESULTS: The annual number of hospitalizations due to AS in the analyzed period was between 239 and 259 per 100,000 inhabitants of the Silesian Province. Haemorrhagic stroke constituted 13.3%, ischaemic stroke - 85.5%, and unspecified stroke - 1.2%. The average age of patients was 71.6±12.2 years (M 68.2±11.9, F 74.8±11.9, P<0.05). The mean duration of hospitalization was 17±16 days for haemorrhagic stroke, and 14±11 days for ischaemic stroke. Large-artery atherosclerosis (36.1%) and cardioembolism (18.7%) constituted the main causes of ischaemic stroke. Overall hospital mortality for AS was 18% (haemorrhagic - 40.8%, ischaemic - 14.9%). A decreasing trend in mortality was observed in ischaemic but not in haemorrhagic stroke. In-hospital mortality was significantly higher in women than in men (P<0.05). CONCLUSIONS: This comprehensive long-term analysis of the epidemiological situation related to AS in the industrial region of Poland should encourage further development of educational and treatment programmes for improvement in the health status of the population.

[Definition and treatment of stroke over the centuries].

Stroke was already diagnosed in the ancient times. For hundreds of years the treatment of this disease has changed radically. According to the current WHO definition, stroke is a clinical syndrome caused by focal or generalized brain injury that lasts more than 24 hours or leads to death and has no other cause than vascular. Stroke constitutes a big social and economic problem, as it can lead to death or disability. In the highly developed countries stroke is the third most common cause of adult deaths, the second leading cause of dementia, and the most common cause of disability. The consequences of stroke also include epilepsy and depression. In the twentieth century, stroke was only treated symptomatically and rehabilitation was limited to passive exercises. The first breakthrough in ischemic stroke therapy was the introduction of aspirin (ASA), followed by intravenous thrombolysis using recombinant tissue plasminogen activator (rtPA), initially available in our country only in the drug programs, and since 2009 it has been reimbursed by the National Health Fund (NFZ). Gradually invasive stroke treatment has been developed. Mechanical thrombectomy is currently only performed in selected centers, giving hope for more effective stroke treatment. The purpose of this work was to show how stroke treatment has changed over the centuries.

The association of functional polymorphisms in genes encoding growth factors for endothelial cells and smooth muscle cells with the severity of coronary artery disease.

BACKGROUND: Despite the important roles of vascular smooth muscle cells and endothelial cells in atherosclerotic lesion formation, data regarding the associations of functional polymorphisms in the genes encoding growth factors with the severity of coronary artery disease (CAD) are lacking. The aim of the present study is to analyze the relationships between functional polymorphisms in genes encoding basic fibroblast growth factor (bFGF, FGF2), epidermal growth factor (EGF), insulin-like growth factor-1 (IGF-1), platelet derived growth factor-B (PDGFB), transforming growth factor-ß1 (TGF-ß1) and vascular endothelial growth factor A (VEGF-A) and the severity of coronary atherosclerosis in patients with stable CAD undergoing their first coronary angiography. METHODS: In total, 319 patients with stable CAD who underwent their first coronary angiography at the Silesian Centre for Heart Diseases in Zabrze, Poland were included in the analysis. CAD burden was assessed using the Gensini score. The TaqMan method was used for genotyping of selected functional polymorphisms in the FGF2, PDGFB, TGFB1, IGF1 and VEGFA genes, while rs4444903 in the EGF gene was genotyped using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. The associations between the selected polymorphisms and the Gensini were calculated both for the whole cohort and for a subgroup of patients without previous myocardial infarction (MI). RESULTS: There were no differences in the distribution of the Gensini score between the genotypes of the analyzed polymorphisms in FGF2, EGF, IGF1, PDFGB, and TGFB1 in the whole cohort and in the subgroup of patients without previous MI. The Gensini score for VEGFA rs699947 single-nucleotide polymorphism (SNP) in patients without previous myocardial infarction, after correction for multiple testing, was highest in patients with the A/A genotype, lower in heterozygotes and lowest in patients with the C/C genotype, (p value for trend = 0.013, false discovery rate (FDR) = 0.02). After adjustment for clinical variables, and correction for multiple comparisons the association between the VEGFA genotype and Gensini score remained only nominally significant (p = 0.04, FDR = 0.19) under the dominant genetic model in patients without previous MI. CONCLUSIONS: We were unable to find strong association between analyzed polymorphisms in growth factors and the severity of coronary artery disease, although there was a trend toward association between rs699947 and the severity of CAD in patients without previous MI.

[Risk factors and treatment of patients with ST-segment elevation myocardial infarction with cardiogenic shock].

Aim: To assess risk factors and prognosis in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS) in Poland. Methods: Data from The Polish Registry of Acute Coronary Syndromes (PL-ACS) were analysed in 2008-2012. A total of 57400 consecutive STEMI patients included. The results of treatment and prognosis of patients with and without CS were compared. An additional analysis of the prognosis of men and women with CS was performed. Results: There were 34.2% of women and 65.8% of men. CS was diagnosed in 3589 (6.3%) patients (females 7.3% vs. males 5.7%, p<0.003). In multivariate analysis CS was the strongest factor affecting both inhospital (OR 2.51; 95%CI 2.25-2.80; p<0.0001) and 12-month (OR 2.09; 95%CI 1.96-2.24; p<0.0001) mortality. The worst prognosis was associated with pulmonary edema, advanced age, left or right bundle branch block, atrial fibrillation, and anterior MI. An early invasive strategy up to six hours from the symptom onset were the only factors reducing in-hospital and 12-month mortality. Despite of high female ratio in the group with CS and higher mortality in the female group, the female sex did not influence the in-hospital prognosis. Conclusion: In spite of enormous progress in the treatment of STEMI cardiogenic shock remains an important complication affecting the in-hospital and long-term prognosis. A symptom onset-to-treatment time is the key element in the management of patients with CS. Proper diagnosis and management including wide interventional strategy implementation increase the survival chance. An intensive study on novel treatment modalities and on effective identification methods of patients at risk and are warranted.

[Myocardial infarction due to the left main coronary artery disease in men and women--does accompanying multivessel disease matter?]. / Zawal serca spowodowany choroba pnia lewej tatnicy wiencowej u kobiet i mezczyzn--czy towarzyszaca wielonaczyniowa choroba wiencowa ma znaczenie?

AIMS: The prognosis in men and women with myocardial infarction due to left main coronary artery disease (LM) in relation to the presence of isolated LM disease or accompanying one-, two- or multivessel disease. MATERIALS AND METHODS: A total of 643 consecutive patients (184 females, 459 males) with acute myocardial infarction due to LM stenosis or occlusion were enrolled. Data on clinical presentation, management and in-hospital mortality derived from the Polish Registry of Acute Coronary Syndromes PL-ACS, data on 12-month mortality derived from the Civil Registry. Patients with isolated LM disease were compared with patients in whom significant stenosis in artery another than LM was present. In-hospital, 30-day, 6- and 12-month mortality in both genders were analyzed. RESULTS: The disease severity was similar in men and women. No difference in mortality between all subgroups was observed. A non-significant trend towards higher mortality in patients with multivessel disease accompanying to LM disease when compared to patients with isolated LM disease (34.2% vs. 25.2%; p log rank = 0.06). CONCLUSIONS: There was no difference in in-hospital and long-term mortality between patients with isolated LM disease vs. patients with accompanying multivessel disease. No difference in mortality between genders was noticed. A longer follow-up is needed to confirm the significance of higher mortality in patients with multivessel disease.

[Non ST-segment elevation myocardial infarction in men and women with diabetes mellitus]. / Zawal serca bez uniesienia odcinka ST u kobiet i mezczyzn z cukrzyca.

BACKGROUND: Diabetes is a significant risk factor in patients with non ST-segment elevation myocardial infarction (NSTEMI). Sex-related differences in clinical course of NSTEMI have not been extensively studied. MATERIAL AND METHODS: During one year all consecutive patients presenting with NSTEMI and diabetes were enrolled. A total of 298 (158 women and 140 men) were analyzed. Clinical presentation, applied treatment and prognosis were compared between women and men. RESULTS: Women tended to be older. More men smoked cigarettes. Pharmacological approach was similar in both groups. Men underwent revascularization more often. Despite those differences both short- and long-term mortality were comparable. CONCLUSION: Despite the common knowledge on negative influence of diabetes and female sex in NSTEMI patients, in multivariate analysis only age and three or four Killip class on admission were significant.

The obesity paradox in acute coronary syndrome: a meta-analysis.

In the general population, the lowest mortality risk is considered to be for the body mass index (BMI) range of 20-24.9 kg/m(2). In chronic diseases (chronic kidney disease, chronic heart failure or chronic obstructive pulmonary disease) the best survival is observed in overweight or obese patients. Recently above-mentioned phenomenon, called obesity paradox, has been described in patients with coronary artery disease. Our aim was to analyze the relationship between BMI and total mortality in patients after acute coronary syndrome (ACS) in the context of obesity paradox. We searched scientific databases for studies describing relation in body mass index with mortality in patients with ACS. The study selection process was performed according to PRISMA statement. Crude mortality rates, odds ratio or risk ratio for all-cause mortality were extracted from articles and included into meta-analysis. 26 studies and 218,532 patients with ACS were included into meta-analysis. The highest risk of mortality was found in Low BMI patients--RR 1.47 (95 % CI 1.24-1.74). Overweight, obese and severely obese patients had lower mortality compared with those with normal BMI-RR 0.70 (95 % CI 0.64-0.76), RR 0.60, (95 % CI 0.53-0.68) and RR 0.70 (95 % CI 0.58-0.86), respectively. The obesity paradox in patients with ACS has been confirmed. Although it seems to be clear and quite obvious, outcomes should be interpreted with caution. It is remarkable that obese patients had more often diabetes mellitus and/or hypertension, but they were younger and had less bleeding complications, which could have influence on their survival.

Mortality in cardiogenic shock complicating acute myocardial infarction due to left main coronary artery disease: does gender matter?

AIMS: To assess prognosis in men and women with myocardial infarction (MI) complicated with cardiogenic shock (CS) due to critical stenosis of the unprotected left main coronary artery (ULMCA). METHODS AND RESULTS: A total of 643 (females 28.6%, males 71.4%) consecutive patients with critical ULMCA stenosis and acute MI were included. Data were obtained from the Polish Registry of Acute Coronary Syndromes (PL-ACS). Study end-points were defined as in-hospital death, mortality at 30 days, 6 and 12 months. Of all patients 103 (16.0%) developed CS. Basic characteristics and treatment strategy were similar in both sexes. As many as 95% of patients in CS were treated invasively with PCI. In-hospital mortality among women in CS was lower than among men (43.3% vs. 64.4%, p = 0.049). Mortality at 30 days and 12 months in CS group as well as in patients without CS did not differ significantly between men and women. In multivariate analysis age and CS, but not a female gender, were independent factors of increased mortality whereas only a successful PCI significantly reduced mortality. CONCLUSION: Cardiogenic shock and pulmonary edema were independent factors of mortality. There were no differences in mortality between men and women in subgroups with and without CS. Emergency PCI seems to be a useful and beneficial option in this subset of patients.

Percutaneous transaxillary approach through the first segment of the axillary artery for the Impella-supported PCI Versus TAVR.

Percutaneous transaxillary approach (PTAX) through the first segment of the axillary artery is not widely recognized as a safe method. Furthermore, PTAX has never been directly compared between Impella-supported percutaneous coronary interventions (Impella-PCI) and transcatheter aortic valve replacement (TAVR). This study evaluated the feasibility and safety of PTAX through the first axillary segment in Impella-PCI versus TAVR. In cases where standard imaging guidance was insufficient, a technique involving puncturing the axillary artery "on-the-balloon" was employed. The endpoints were bleeding and vascular complications, as defined by BARC and VARC-3 criteria. PTAX was successfully performed in all 46 attempted cases: 23 for Impella-PCI and 23 for TAVR. Strict adherence to BARC and VARC-3 criteria led to the frequent identification of major bleeding (57%) and a moderately frequent diagnosis of vascular complications (17%). These incidences were primarily based on post-procedural hemoglobin reduction (> 3 g/dl) but not overt bleeding. The Impella group exhibited a higher rate of BARC 3b bleeding due to a greater hemoglobin decline resulting from the prolonged implant duration and PCI itself. Left axillary access was linked to smaller blood loss. Bleeding and vascular complications, as per BARC and VARC-3 definitions, did not affect short-term prognosis, with only 3 Impella patients succumbing to heart failure unrelated to the procedures during one-month follow-up period.