Isoprostane-8 and GDF-15 as novel markers of post-PE syndrome: Relation with prothrombotic factors.

BACKGROUND: Post-pulmonary embolism (PE) syndrome occurs in up to 50% of PE patients. The pathophysiology of this syndrome is obscure. OBJECTIVE: We investigated whether enhanced oxidative stress and prothrombotic state may be involved in post-PE syndrome. METHODS: We studied 101 normotensive noncancer PE patients (aged 56.5 ± 13.9 years) on admission, after 5-7 days and after a 3-month anticoagulation, mostly with rivaroxaban. A marker of oxidative stress, 8-isoprostane, endogenous thrombin potential, fibrinolysis proteins, clot lysis time (CLT) and fibrin clot permeability (Ks ), along with PE biomarkers, were determined. RESULTS: Patients who developed the post-PE syndrome (n = 31, 30.7%) had at baseline 77.6% higher N-terminal brain natriuretic propeptide and 46.8% higher growth differentiation factor 15, along with 14.1% longer CLT associated with 34.4% higher plasminogen activator inhibitor-1 as compared to subjects without post-PE syndrome (all P < .05). After 5-7 days, only hypofibrinolysis was noted in post-PE syndrome patients. When measured at 3 months, prolonged CLT and reduced Ks were observed in post-PE syndrome patients, accompanied by 23.8% higher growth differentiation factor 15 and 35.8% higher plasminogen activator inhibitor-1 (all P < .05). 8-isoprostane levels ≥108 pg/ml (odds ratio=4.36; 95% confidence interval 1.63-12.27) and growth differentiation factor 15 ≥ 1529 pg/ml (odds ratio=3.89; 95% confidence interval 1.29-12.16) measured at 3 months were associated with higher risk of developing post-PE syndrome. CONCLUSIONS: Enhanced oxidative stress and prothrombotic fibrin clot properties could be involved in the pathogenesis of the post-PE syndrome. Elevated growth differentiation factor 15 assessed at 3 months might be a new biomarker of this syndrome.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms.

OBJECTIVE: Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used "standard dose protocol" and the "low dose protocol," which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15 s) in patients with a psA with sac volume of ≥1 mL. METHODS: This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1 mL and qualified for UGTI. The patients' mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol. RESULTS: The overall success rate (99.2% vs. 98.4%; p = 1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p = .85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p = .03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p = .01). CONCLUSIONS: In patients with femoral psA with sac volume of ≥1 mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Global peak left atrial longitudinal strain assessed by transthoracic echocardiography is a good predictor of left atrial appendage thrombus in patients in sinus rhythm with heart failure and very low ejection fraction - an observational study.

BACKGROUND: Peak left atrial longitudinal strain (PALS) can help identify left atrial appendage thrombus (LAAT) in patients with atrial fibrillation. Nevertheless, few studies have been performed in patients in sinus rhythm without established indications for anticoagulation but with increased risk of LAAT, such as heart failure (HF) with severe left ventricular systolic dysfunction patients. The primary aim of this study was to identify clinical and transthoracic echocardiography predictors of LAAT in HF patients with very low left ventricular ejection fraction and sinus rhythm. The secondary objective was to analyze frequencies and predictors of a composite clinical endpoint of death or hospitalization for ischemic stroke. METHODS: We included 63 patients with HF, left ventricular ejection fraction < 25%, sinus rhythm at presentation, no history of atrial fibrillation, and without any established indications for anticoagulation. We determined whether clinical and transthoracic echocardiography parameters, including left atrial strain analysis, predicted LAAT. Transesophageal echocardiography was performed in all patients. When LAAT was detected, anticoagulation was recommended. The participants were followed for a median of 28.6 months (range 4-40) to determine the composite endpoint. RESULTS: LAAT was found in 20 (31.7%) patients. Global PALS was the best independent predictor of LAAT in univariate and multivariate logistic regression analyses (Gini coefficient 0.65, area under the receiver-operating characteristic curve 0.83). A global PALS value below 8% was a good discriminator of LAAT presence (odds ratio 30.4, 95% CI 7.2-128, p <  0.001). During follow-up, 18 subjects (28.6%) reached the composite clinical endpoint. CHA2DS2-VASc score, use of angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, and body surface area were significant predictors for the composite endpoint of death or hospitalization for ischemic stroke in the multivariate regression model. CONCLUSIONS: LAAT was relatively common in our group of HF patients and PALS has shown prognostic potential in LAAT identification. Further research is needed to determine whether initiation of anticoagulation or additional screening supported by PALS measurements will improve clinical outcomes in these patients.

Altered Fibrin Clot Properties Predict Stroke and Bleedings in Patients With Atrial Fibrillation on Rivaroxaban.

Background and Purpose- We investigated whether clot permeability can predict clinically relevant outcomes in patients with atrial fibrillation (AF) treated with rivaroxaban. Methods- In the cohort study, we enrolled 232 consecutive patients with AF on rivaroxaban 20 mg/d (76.3%) or 15 mg/d (23.7%) for at least 3 months. Plasma clot permeability (Ks), a measure of fibrin network density, was determined 24 to 30 hours since the intake of rivaroxaban at undetectable drug's levels. Ischemic cerebrovascular events and bleedings were recorded. Results- During a median follow-up of 48 months, patients with Ks below median (6.8 cm2·10-9) had higher prevalence of stroke (5.84 versus 0.88% per year; P<0.0001) and relevant bleeding (7.06 versus 0.88% per year; P<0.0001) compared with those above median. The mortality rate was 1.53% per year and was not associated with Ks. Lower Ks predicted cerebrovascular ischemic events (hazard ratio, 6.64; 95% CI, 2.2-20.1) and relevant bleedings (hazard ratio, 7.38; 95% CI, 2.58-21.10). Minor bleeds (32.8% of patients) were observed more often in patients with Ks above median (50.9 versus 14.7%; P<0.0001). Multivariate Cox regression analysis showed that in AF patients on rivaroxaban lower Ks increased the risk of stroke (hazard ratio, 6.51; 95% CI, 2.14-19.75) and relevant bleedings (hazard ratio, 9.68; 95% CI, 3.21-29.18). Conclusions- Decreased clot permeability in AF patients can predict thromboembolic and clinically relevant bleeding events during therapy with rivaroxaban, while looser clot networks predispose to minor bleeds.

Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and Thrombocytopenia.

AIMS: Thrombocytopenia was one of the exclusion criteria in randomized trials in which non-vitamin K antagonist oral anticoagulants (NOACs) were tested. The safety of NOACs in patients with atrial fibrillation (AF) and thrombocytopenia remains unclear. METHODS: We studied 62 patients with AF aged from 53 to 85 (mean 70.5) years with platelet count from 50 to 100 × 109/L who were treated with rivaroxaban 15 mg once daily (33.9%), dabigatran 110 mg twice daily (bid) (54.8%), or apixaban 2.5 mg bid (11.3%). Age- and sex-matched AF patients with normal platelet count and similar CHA2DS2-VASc scores who were treated with the recommended doses of NOACs served as a reference group. RESULTS: Patients were followed for a mean of 55 months (range, 23-64 months). In the thrombocytopenia group bleeding risk was higher (mean HAS-BLED score 2.0, vs. 1.0, P < 0.0001). During follow-up in thrombocytopenic and normocytopenic patients, we observed similar rates of major bleeding (1.8%/year vs. 2.7%/year, P = 0.49), clinically relevant nonmajor bleeding (CRNMB) (1.5%/year vs. 1.1%/year, P = 0.74), ischemic stroke and transient ischemic attacks (1.8%/year vs. 1.5%/year, P = 0.8), and death (1.06%/year vs. 1.11%/year, P = 0.96). The risk of bleeding and stroke was unaffected by the type of the NOAC used in both groups. Major bleedings and clinically relevant nonmajor bleeding in thrombocytopenic patients on NOACs were predicted only by age (hazard ratio 1.1, 95% confidence interval 1.0-1.3, P = 0.04). CONCLUSIONS: Our findings indicate that in AF patients with mild thrombocytopenia, anticoagulation with NOAC at reduced doses seems to be safe and effective.

Complications of percutaneous thrombin injection in patients with postcatheterization femoral pseudoaneurysm.

PURPOSE: To study the complications of ultrasound-guided thrombin injection of pseudo-aneurysms occurring after interventional cardiovascular procedures. METHOD: We prospectively studied 353 patients who developed post-catheterization femoral artery pseudo-aneurysms and were treated with ultrasound-guided thrombin injection. RESULTS: Arterial micro-embolization occurred in 53 patients (15%) and pulmonary embolism in 1 patient (0.3%). None of the patients developed significant peripheral arterial embolism. The length of the communicating channel between the arterial lumen and the pseudo-aneurysm was inversely correlated with the risk of embolization (p < 0.0001). A 4.6 mm increase in channel length decreased the odds of embolization by 14%, and patients with a channel less than 2 mm long were at greater risk. Repeated thrombin injection also increased the risk of embolization (p = 0.02). CONCLUSION: Thrombin injection for the treatment of post-catheterization femoral pseudo-aneurysm is feasible and safe, but it must be performed with caution, especially when the sac is directly communicating with the artery, or when success cannot be achieved with a single injection.

[Modern pharmacotherapy in heart failure with reduced ejection fraction: is further improvement in prognosis possible?].

A growing number of patients with chronic heart failure (CHF) is a combined result of aging and, paradoxically, the progress in management of cardiovascular diseases. The modern pharmacotherapy of HF with reduced ejection fraction (HFrEF) is based on the understanding of excessive neurohormonal activation as a key point in the pathophysiology and progression of HFrEF. The introduction of neurohormonal modifiers decreased significantly the mortality, survival and acute cardiac death rate. However, the rate of hospitalization increased and the quality of life is still poor. There is a large body of evidence on disease progression and mechanical heart failure as a main cause of death. The improvement in survival and decreasing the hospitalization rate remain a real challenge. The risk of death is the highest in the first weeks following hospitalization due to HF. The maintenance of stable patient condition is the priority of management. Pharmacotherapy at discharge should be optimized according to the prognostic factors to modify the clinical course of disease. Data from registries suggest that target doses are not reached and dose titration is not performed in outpatient clinics as it should be done according to guidelines. Taken together, the system of complex management of patients with HF focused on the management on discharge and early post-discharge period seems to be the best solution to identify the HF progression factors (suboptimal therapy, lack of revascularization, arrhythmia, concomitant diseases) and to improve the prognosis and the quality of life and to decrease the hospitalization rate.

[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.

[Acute myocardia infarction associated with pregnancy]. / Zawal serca u kobiet w ciazy.

Pregnancy-associated myocardial infarction is rare but potentially fatal. Clinical course is different from nonpregnant patients. As it is predominantly non-atherosclerotic in origin, optimal treatment is not unequivocally established. Common anterior wall involvement results in developing of heart failure and its complications. There is a high risk of coronary artery dissection during percutaneous interventions. Pharmacological treatment, beneficial for mother, may be harmful for fetus. Long term prognosis is unclear.

[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.

[Influenza infection in intensive cardiac care unit patients]. / Infekcja wirusem grypy u pacjentów oddzialu intensywnej terapii kardiologicznej.

Infection with influenza type A virus may cause serious cardiovascular complications, such as myocarditis, heart failure, acute myocardial infarction. Also infection with influenza type AH1N1 may contribute to aggravation of cardiac disorders, i.e. acute coronary syndrome, heart failure, cardiogenic shock, severe ventricular arrythmias. One of the most fatal complication of influenza is pneumonia leading to acute respiratory insufficiency requiring artifitial ventilation. Symptoms of respiratory tract infections durnig influenza epidemy should always be treated with a high index of suspicion. Early diagnosis and adequate antiviral treatment may prevent those complications. A series of four cases of patients hospitalised in intensive cardiac care unit due to suspected cardiac dyspnea and finally diagnosed as a cardiac disease complicated by influenza pneumonia is presented.

[Ventricular and supraventricular arrhythmias in women]. / Nadkomorowe i komorowe zaburzenia rytmu--skala problemu u kobiet.

There are few gender-related differences in electrophysiology regarding occurrence, clinical symptoms and prognosis of arrhythmias. Women tend to have higher incidence of sinus tachycardia and atrio-ventricular nodal re-entry tachycardia. Atrial fibrillation is more frequent among men, but women have worse prognosis as their mortality is higher, "rhythm control" strategy is less favorable and the thromboembolic risk is greater. Ventricular arrhythmias are less common in women and their significance is smaller. As women have longer QTc interval and torsade de pointes is typical women's arrhythmia, physicians must be very careful ordering QT-elongating drugs. Coronary heart disease (CHD) is seldom background for ventricular tachycardia and women with CHD and arrhythmias have better prognosis than men. Sex hormones play important role in women's electrophysiology. Pregnancy increase risk of supraventricular tachycardia and decrease occurrence of torsade de pointes.

[Therapeutic approach and mortality in men and women with ST-segment elevation myocardial infarction]. / Strategia leczenia a smiertelnosc kobiet i mezczyzn z zawalem serca z uniesieniem odcinka.

UNLABELLED: The benefit of immediate reperfusion in the treatment of ST-segment elevation myocardial infarction (STEMI) is indisputable. Unfortunately, no reperfusion therapy is applied to nearly 30% of patients without contraindication to such treatment. We aimed to analyze the impact of therapeutic approach on the prognosis after acute phase of STEMI. MATERIAL AND METHODS: The study group consisted of 26035 consecutive STEMI patients (8989 females, 34.4%) hopitalized in 456 sites during one year. Data were available from the Polish Registry of Acute Coronary Syndromes (PL-ACS) launched in Silesian Center for Heart Diseases, Zabrze. RESULTS: Patiens treated with primary percutaneous intervention (pPCI) had the best outcome. All therapeutic strategies resulted in worse prognosis in women when compared to men. Women had greater 12-month mortality in the conservative, fibrinolytic and interventional treatment group: 33.1% vs 23.2%; p < 0.0001; 24.3% vs 16.2%; p < 0.0001 i 11.4% vs 8.2%, p < 0.0001, respectively. Differences in the surgically treated group were insignificant (men: 25%, women: 8%, p = 0.42). CONCLUSIONS: The outcome of conservative, fibrinolytic and interventional treatment was worse in the female group. Primary coronary angioplasty was the most benefical therapeutic strategy.

Loeffler's endomyocarditis: from cardiac arrest to complete recovery.

Hypereosinophilic syndromes are rare diseases; however, cardiac involvement is frequently seen. When diagnosed promptly, the prognosis is relatively good; however, a final diagnosis is made by ruling out many conditions leading to secondary eosinophilia. We present a case of Loeffler's endomyocarditis primarily misdiagnosed as an acute coronary syndrome, complicated by low output heart failure and cardiac arrest. After hypereosinophilic syndrome was confirmed and treatment with prednisone initiated, the patient responded well to therapy, and her further recovery was complete and uneventful.

[Does permanent cardiac stimulation through B - type natriuretic peptide secretion influence the basic parameters of renal function?]. / Czy wszczeplenle na stale stymulatora serca przez wydzielanie do krwi peptydu natriuretycznego typu B wplywa na czynnosc nerek?

UNLABELLED: Aberrant waveform during artificial pacing increases secretion of natriuretic peptides, mainly B-type natriuretic peptide (BNP). The aim of the study was to investigate whether renal function is modified through increased BNP secretion during artificial pacing. MATERIAL AND METHODS: A total of 117 patients with pacemaker implanted were included (pacing mode: AAI/R - 21, DDD/R - 59, VVWl/R - 37) and 48 healthy volunteers served as controls. Serum BNP, creatinine and urea, levels were measured prior to, three and six months after pacemaker implantation. RESULTS: Three and six months after implantation BNP level significantly increased in DDD/R group, urea level increased in AAI/R group whereas creatinine level increased in DDD/R and WI/R group. CONCLUSIONS: In patients after pacemaker implantation BNP level increases in DDD/R pacing mode group whereas in other modes it remains stable. Pacemaker implantation leads to changes in renal function. B-type natriuretic peptide level may serve as a useful parameter forrenal and cardiac function assessment after pacemaker implantation.

Clinical outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention stratified according to duration of pain-to-balloon time and type of myocardial infarction.

BACKGROUND: Based on the clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), treated with primary percutaneous coronary intervention (pPCI), this study intended to assess mortality and major adverse cardiac and cerebrovascular event (MACCE) rates according to duration of pain-to-balloon (PTB) time and type of MI. METHODS: This is a retrospective cohort study based on the prospectively collected ORPKI registry which covers PCIs performed in Poland chosen between January 2014 and December 2017. Under assessment were 1,994 STEMI and 923 NSTEMI patients. Study endpoints included mortality and MACCE rates (in-hospital, 30-day, 12- and 36-month). Predictors of all-cause mortality in the overall group, STEMI and NSTEMI were assessed by multivariable analysis. RESULTS: Kaplan-Meier survival curve analysis did not reveal significant differences between the STEMI and NSTEMI group for all-cause mortality or MACCE at the 36-month follow-up. While in the long PTB time group, MACCE rate was significantly greater in STEMI patients when compared to NSTEMI (p = 0.004). Among STEMI patients, the short, medium and long PTB time groups differed significantly in the rate of all-cause mortality (p = 0.006) and MACCE (p = 0.04) at 1,095 days of follow-up, which were the greatest in the long PTB time group. CONCLUSIONS: Before considering the length of PTB time, there were no statistically significant differences in mortality or MACCE frequency between the STEMI and NSTEMI group at 36-month follow-up. Longer PTB times are related to significantly greater mortality at the 36-month follow-up in the STEMI, but not in the NSTEMI group.

[Early invasive strategy in patients with myocardial infarction and intraventricular conduction disturbances and plasma B-type natriuretic peptide levels assessed 6 months after myocardial infarction]. / Wczesna strategia inwazyjna u chorych z zawalem serca i zaburzeniami przewodzenia sródkomorowego a stezenie peptydu natriuretycznego typu B w surowicy oceniany 6 miesiecy po zawale serca.

UNLABELLED: The aim of the study was to assess plasma B-type natriuretic peptide (BNP) levels in patients after myocardial infarction (MI) with intraventricular conduction defects (IVCD) and to define relationship between BNP level, treatment strategy and left ventricular performance. MATERIAL AND METHODS: Four types of IVCD were noted: left bundle branch block (LBBB), right bundle branch block (RBBB), left anterior hemiblock (LAH) and left posterior hemiblock (LPH). A total of 158 patients six months after MI treated either invasively or conservatively were included. Of them 126 had IVCD (group A): LBBB-31, RBBB-36, LAH-130, LPH-29, whereas 32 patients without IVCD served as controls (group B). Plasma BNP levels were measured using an immunoenzymatic method. All subjects underwent echocardiography to evaluate left ventricular function. RESULTS: In group A significantly lower plasma BNP levels (186.3 vs 355.3 pg/mL; p < 0.01) and significantly higher left ventricular ejection fraction (EF) (48.4 vs 42.4%; p < 0.05) were noted in favour of invasive treatment. In group B differences between plasma BNP level and echocardiographic parameters of left ventricle function were insignificant. In patients with LBBB plasma BNP levels were significantly lower in those treated invasively (163.9 vs 528.9; p < 0.01). Also, left ventricular EF and myocardial performance index (MPI) were comparable, whereas E/A value was lower as compared with patients treated conservatively (p < 0.05). There were no significant differences in BNP levels in groups with RBBB, LAH and LPH. Multifactorial regression analysis showed that BNP levels were most strongly correlated with magnitude of the ejection fraction EF (p < 0.001). Other parameters which affect significantly BNP level were MPI: OR 9.07 (95% CI 1.03-79.58; p < 0.05) and E/A: OR 6.58 (95% CI 1.01-42.76; p < 0.05). CONCLUSIONS: Invasive strategy in MI with IVCD, especially with LBBB, correlates with lower plasma BNP levels six months after index procedure. In patients with IVCD post MI plasma BNP level is better marker of dysfunction of the left ventricle than its ejection fraction.

A female pattern of ischemic heart disease--a new look at an old problem.

Diseases of the circulatory system are the most common cause of death among women. It should be emphasized that this problem is still underestimated in daily practice. As women are less likely to have significant stenosis in coronary angiography than men, they are regarded to be at smaller risk. At the same time, numerous studies prove that the prognosis of women with ischemic heart disease is serious. Therefore, some researchers suggest distinguishing the so-called "female pattern" of ischemic heart disease, characterized by persistent, often atypical chest pain, positive results for noninvasive tests evaluating ischemia and no significant changes in coronary angiography. It is relevant in the diagnosis of women to assess the global risk, taking into consideration such parameters as inflammation indicators, endothelial dysfunction and microvascular reactivity. There is still no data on optimal treatment, but there seems to be a clear benefit from intensive modification and elimination of risk factors, as well as typical pharmacotherapy with angiotensin-converting enzyme inhibitors, beta-blockers and statins.

Left atrial appendage thrombus in patients referred for electrical cardioversion for atrial fibrillation: a prospective single­center study.

INTRODUCTION: Left atrial appendage thrombus (LAAT) is a risk factor for stroke; however, the actual health risk associated with LAAT in patients with atrial fibrillation (AF) on chronic anticoagulation is unknown. OBJECTIVES: We aimed to assess the prevalence and predictors of LAAT, and its predictive role in relation to mortality, stroke, and systemic thromboembolic events among consecutive AF patients on oral anticoagulation (OAC) admitted for electrical cardioversion. PATIENTS AND METHODS: This was a prospective, single­ center cohort study. The participants underwent transesophageal echocardiography before electrical cardioversion. A total of 296 patients were enrolled. The primary outcome was the presence of LAAT. All participants were followed for 12 months to evaluate the incidence of systemic thromboembolic events, stroke, and death. RESULTS: Despite uninterrupted OAC in patients with AF of above 48-hour duration scheduled for cardio-version, we found a high prevalence of LAAT, reaching 14.5%. There was no difference in the prevalence of thrombi between different types of OAC (P = 0.26). The independent predictors of LAAT were chronic obstructive pulmonary disease, heart failure, prior myocardial infarction, greater left atrial diameter, lower left ventricular ejection fraction, higher CHA2DS2­VASc score, and reduced dabigatran dose. The optimal cutoff values for the prediction of LAAT were the age of at least 74 years, left atrial diameter equal or greater than 52 mm, left ventricular ejection fraction equal or lower than 40%, and CHA2DS2­VASc score equal or greater than 3. No strokes or systemic thromboembolic events occurred over the follow­up period. CONCLUSIONS: The presence of LAAT had no practical value for predicting stroke, thromboembolic events, or death in patients with AF and on chronic anticoagulation.

Comparison of safety and effectiveness between the right and left radial artery approach in percutaneous coronary intervention.

INTRODUCTION AND OBJECTIVES: There is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in "real-world" patients with either stable angina or acute coronary syndrome (ACS). METHODS: To overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry). RESULTS: The rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0±947.1 mGy vs 1007.4±983.5 mGy, P=.001; ACS: 1212.7±1005.5 mGy vs 1053.5±1029.7 mGy, P=.001). More contrast was used in LRA procedures but only in ACS patients (174.2±75.4mL vs 167.2±72.1mL, P=.001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P=.008), no-reflow phenomenon (0.65% vs 0.49%, P=.005), and puncture site bleeding (0.09% vs 0.05%, P=.04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P=.90). CONCLUSIONS: Our finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients.