Prevalence of Erectile Dysfunction in Atrial Fibrillation Patients: A Cross-Sectional, Epidemiological Study.

BACKGROUND: Sexual dysfunctions, especially erectile dysfunction (ED), are a major problem in cardiovascular patients. They are caused by cardiovascular risk factors including low-grade inflammation process, endothelial dysfunction, oxidative stress, and hemodynamic and vascular alterations. The same mechanisms are some of the main causes and/or consequences of atrial fibrillation (AF). To this day, literature provides no cross-sectional data on the prevalence of sexual dysfunction in AF. The study aimed to determine the prevalence of sexual dysfunction in consecutive, young male patients with AF. MATERIAL AND METHODS: A cross-sectional survey of adult male patients with a primary diagnosis of AF was conducted at University Cardiology Departments, during the period of July 2013 to July 2014. During the enrollment process, the study participants were either electively hospitalized with a primary diagnosis of AF, or had a scheduled outpatient visit. Sexual dysfunctions were assessed using the International Index of Erectile Function. RESULTS: A total of 129 consecutive AF patients (mean age 57.0 ± 11.8 years) were analyzed. Hypertension was present in 60.5%, diabetes in 22.5% of patients, 46.5% had dyslipidemia, 18.6% were current smokers, and 45.7% had a family history of cardiovascular disease. At least one kind of sexual dysfunction was found in 86.8% of patients. ED was present in 57.4% of patients, 44.2% of patients had orgasmic dysfunction, 69.0% had lowered sexual desire, 65.1% had lowered intercourse satisfaction, and 55.8% had lowered overall satisfaction. CONCLUSIONS: Sexual dysfunctions are highly prevalent in AF patients and are not only limited to ED, but also include dysfunction of orgasmic function, desire, or general satisfaction. In part, the presence of the sexual dysfunctions is probably caused by classical cardiovascular risk factors highly prevalent in AF patients, but the impact of AF itself cannot be underestimated.

Association of the CHADS2 and CHA 2DS 2-VASc scores with left atrial enlargement: a prospective cohort study of unselected atrial fibrillation patients.

Assessment of thromboembolic risk is crucial for proper management of atrial fibrillation (AF) patients. Currently used risk score base only on scarce clinical data and do not take into consideration parameters including echocardiographic findings. The aim of this study was to evaluate if left atrium (LA) enlargement is associated with higher thromboembolic risk assessed by CHADS2 and CHA2DS2-VASc scores in a cohort of unselected non-valvular AF patients. Data from 582 AF hospitalizations occurring between November 2012 and January 2014 were analyzed. All patients underwent a standard transthoracic echocardiography and had their thromboembolic risk assessed in both CHADS2 and CHA2DS2-VASc scores. In 494 enrolled patients (48.5 % male; mean age 73.4 ± 11.5 years) AF was classified as paroxysmal in 233 (47.3 %), as persistent in 109 (22.1 %), and as permanent in 151 (30.6 %) patients. LA was enlarged in 426 (86.2 %) patients. Enlargement was classified as mild in 99 (20.0 %) patients, as moderate in 130 (26.3 %) patients, and as severe in 196 (39.7 %) patients. Patients with enlarged LA had higher mean CHADS2 score (2.0 ± 1.5 vs. 2.6 ± 1.3; p = 0.0005) and CHA2DS2-VASc (3.8 ± 2.0 vs. 4.4 ± 1.8; p = 0.02) score than patients with normal LA. The both mean scores rose along with rising LA diameter. LA enlargement is highly prevalent in AF patients. Higher thromboembolic risk assessed by both CHADS2 and CHA2DS2-VASc scores is associated with presence of LA enlargement. Echocardiographically assessed LA size may be an additional parameter useful in thromboembolic risk stratification of AF patients.

Assessment of CHADS2 and CHA 2DS 2-VASc scores in obstructive sleep apnea patients with atrial fibrillation.

PURPOSE: Assessment of stroke risk and implementation of appropriate antithrombotic therapy is an important issue in atrial fibrillation patients. Current risk scores do not take into consideration the comorbidities associated with elevated thromboembolic like obstructive sleep apnea (OSA). The aim of the study was to establish whether atrial fibrillation patients with coexisting OSA have higher stroke risk according to CHADS2 and CHA2DS2-VASc scores. METHODS: Two hundred fifty-four consecutive patients hospitalized with a primary diagnosis of atrial fibrillation participated in the study. All patients underwent whole night polygraphy and were scored in both CHADS2 and CHA2DS2-VASc according to their medical records or de novo diagnosis. RESULTS: The study population was predominantly male (65.4%; mean age, 57.5 ± 10.0 years) with a high prevalence of hypertension (73.6%), dyslipidemia (63.4%), and obesity (42.9%). OSA was present in 47.6% of patients, who more often had history of stroke (p = 0.0007). Stroke risk profile assessed by both CHADS2 and CHA2DS2-VASc scores was higher in patients with OSA (1.2 ± 0.9 vs. 0.8 ± 0.6; p < 0.0001 and 2.2 ± 1.7 vs. 1.5 ± 1.1; p = 0.001) than without it. Differences in the stroke risk remained significant across different age strata, and the trend for point values in CHADS2 and CHA2DS2-VASc scores rose along with OSA severity according to the apnea-hypopnea index (AHI; p for trend <0.001). CONCLUSIONS: OSA was highly prevalent in atrial fibrillation patients. Patients with OSA have higher CHADS2 and CHA2DS2-VASc scores. Mean CHADS2 and CHA2DS2-VASc scores rise with OSA severity. Future studies should prospectively research on potential inclusion of OSA to stroke prediction models.

Presence and severity of obstructive sleep apnea and remote outcomes of atrial fibrillation ablations - a long-term prospective, cross-sectional cohort study.

BACKGROUND: Prior studies suggested that obstructive sleep apnea (OSA) promotes recurrence of arrhythmia in patients after atrial fibrillation (AF) ablation. METHODS: In this prospective, long-term, observational study, we enrolled 290 consecutive patients admitted for AF ablation. Prior to the ablation, all patients underwent a polygraphy sleep study for the diagnosis of OSA. After the procedure, patients were followed up for mean time of 30 months for AF reoccurrence. OSA was diagnosed when apnea-hypopnea index (AHI) was ≥5. Patients were subsequently divided into groups according to the OSA severity: mild OSA (AHI 5-15/h), moderate OSA (AHI >15 and ≤30/h), and severe (AHI >30/h). RESULTS: After excluding patients disqualified from the procedure, and those with central sleep apnea, the study population consisted of 251 patients, mean age 57.6 years [163 (64.9%) male]. OSA was present in 115 (45.8%) patients, while in 137 (54.6%) cases, we observed reoccurrence of AF. Recurrence was more often in patients with, than without, OSA (65.2 vs. 45.6%; p = 0.003). We also observed that along with rising OSA severity rose also the number of patients in whom AF was detected during the follow-up period (45.6 vs. 66.2 vs. 57.6 vs. 81.8%; p = 0.005; for non-OSA, mild, moderate, and severe, respectively). CONCLUSIONS: OSA is highly prevalent in AF patients. The presence of OSA lowers chances on successful AF ablation. Early screening, and treatment for OSA in AF patients, may improve low success rates of AF ablation procedures.

The high risk of obstructive sleep apnea--an independent risk factor of erectile dysfunction in ST-segment elevation myocardial infarction patients.

INTRODUCTION: Sleep-related breathing disorders are highly prevalent in patients with established cardiovascular disease. Obstructive sleep apnea (OSA) is associated with several cardiovascular conditions such as hypertension, ischemic heart disease, arrhythmias, and erectile dysfunction (ED). AIM: The aim of this prospective study was to investigate the prevalence of ED in ST-segment elevation myocardial infarction (STEMI) patients at high risk of OSA, and to evaluate the leading factors that increase the risk of ED. METHODS: We prospectively studied 90 consecutive male STEMI patients. MAIN OUTCOME MEASURES: A risk of OSA was assessed using the Berlin questionnaire (BQ) and Epworth Sleepiness Scale (ESS). Erectile function was assessed using the International Index of Erectile Function (IIEF). RESULTS: Thirty-two (35.6%) patients were at high risk of OSA. Patients were at high risk of OSA who on admission had significantly higher mean ESS score, and abnormal BQ, higher incidence of hypertension, and higher body mass index. They were also found to have significantly higher mean C-reactive protein level and higher incidence of ED. The mean IIEF score was significantly lower in patients at high risk of OSA (16.2 ± 5.4 vs. 20.5 ± 6.4; P = 0.004). In the multiple logistic regression analysis, high risk of OSA was strong and an independent risk factor of ED in STEMI patients (odds ratio 55.71, 95% confidence interval 3.36-923.81; P = 0.005). Conclusion. ED was highly prevalent in STEMI patients at high risk of OSA. High risk of OSA was strong, independent risk factor for developing ED.

Can obstructive sleep apnea be a cause of in-stent thrombosis?

We present the case of a 45-year-old patient readmitted to Central University Hospital at 3 a.m. for acute retrosternal chest pain associated with ST-segment elevation in lead I, aVL, V1-V6 in standard 12-lead ECG performed on admission in emergency department. Coronary angiography revealed late in-stent thrombosis in left anterior descending artery. According to the new universal definition of myocardial infarction patient was finally recognized acute ST-segment elevation myocardial infarction type 4b with additional diagnosis of severe obstructive sleep apnea and overweight.

[Cardiogenic shock secondary to the tako-tsubo syndrome in young male patient]. / Wstrzas kardiogenny w przebiegu zespolu tako-tsubo u mlodego mezczyzny.

Tako-tsubo's syndrome is usually induced by sudden stress reaction, however symptoms may also occur without any cause. Most reported cases of this syndrome, more than 95%, affect women older than 60 years. We present a case of a 45 year-old man in good health with severe cardiovascular complication due to "simple" laryngological surgery using systemic anaesthesia. On the basis of clinical features and results of additional tests we recognize tako-tsubo syndrome.

A study to evaluate the prevalence and determinants of stress coping strategies in heart failure patients in Poland (CAPS-LOCK-HF sub-study).

BACKGROUND AND AIM: We aimed to evaluate the prevalence and determinants of different stress coping strategies in Polish patients suffering from heart failure with reduced ejection fraction (HFREF). METHODS: This manuscript is a sub-study of the CAPS-LOCK-HF multicentre psychological status assessment of patients with HFREF. Patients with > six-month history of HFREF and clinical stability for ≥ three months and left ventricular ejection fraction (LVEF) < 45% were enrolled in the study. Demographic and clinical variables were obtained from medical records, while a standardised Coping Inventory for Stressful Situations (CISS) was applied to all subjects. RESULTS: The study comprised 758 patients (599 men; 79%) with a median age of 64 years (IQR 58-71). Median LVEF was 33% (25-40). Subjects most commonly used task-oriented coping strategies (median CISS score 55 points; IQR 49-61), followed by avoidance (45 points; 39-50) and emotion-oriented coping strategies (41 points; 34-48). Distraction-based avoidance coping strategies (20 points; 16-23) were more pronounced than social diversion strategies (16 points; 14-19). Multiple regression analysis showed that higher New York Heart Association (NYHA) class and lower systolic blood pressure were independent predictors of task-oriented style. Emotion-oriented coping was more common among females and higher NYHA classes, and in patients who did not take angiotensin-converting enzyme inhibitors. Patients who used avoidance-oriented strategies were more frequently those in sinus rhythm on assessment and those who had less history of neoplastic disease. CONCLUSIONS: Patients with HFREF most commonly use favourable task-oriented coping strategies. However, female patients and those with higher NYHA classes tend to use potentially detrimental emotion-oriented coping strategies.

Differences of psychological features in patients with heart failure with regard to gender and aetiology - Results of a CAPS-LOCK-HF (Complex Assessment of Psychological Status Located in Heart Failure) study.

OBJECTIVE: Objective of the study was to assess the psychological state of HF patients with reduced ejection fraction (HFrEF) with regard to gender and aetiology. METHODS: 758 patients with HFrEF (mean age - 64±11years, men - 79%, NYHA class III-IV - 40%, ischemic aetiology - 61%) in a prospective Polish multicenter Caps-Lock-HF study. Scores on five different self-report inventories: CISS, MHLC, GSES, BDI and modified Mini-MAC were compared between the sexes taking into account the aetiology of HFrEF. RESULTS: There were differences in the CISS and BDI score between the genders - women had higher CISS (emotion- and avoidance-oriented) and BDI (general score - 14.2±8.7 vs 12.3±8.6, P<0.05; subscale - somatic score - 7.3±3.7 vs 6.1±3.7, P<0.05). In the ischemic subpopulation, women had higher BDI (general and subscales) than men. In the non-ischemic subpopulation the differences between genders were limited to CISS scale. In a multivariable analysis with demographic and clinical data female sex, NYHA class, atrial fibrillation and diabetes mellitus determined BDI score. Similarly, in the ischemic subpopulation, the female sex, NYHA class and atrial fibrillation determined the BDI, while in the non-ischemic population NYHA class was the only factor that influenced the BDI score. Adding the psychological data made a significant additional contribution to the prediction of depression status. CONCLUSIONS: There are distinct differences in psychological features with regard to gender in patients with HFrEF. Women demonstrate less favourable psychological characteristics. Gender-related differences in BDI score are especially explicit in patients with ischemic aetiology of HF. The BDI score is related to psychological predisposition.

Perception of health control and self-efficacy in heart failure.

BACKGROUND: The issue of self-perceived health control and related sense of self-efficacy has not received any attention in patients with heart failure (HF), although these psychological features have been established to determine the patients' approach towards healthcare professionals and their recommendations, which strongly affects compliance. METHODS: A total of 758 patients with systolic HF (age: 64 ± 11 years, men: 79%, NYHA class III­IV: 40%, ischaemic aetiology: 61%) were included in a prospective Polish multicentre Caps-Lock-HF study. A Multidimensional Health Locus of Control (MHLC) scale was used to assess subjective perception of health control in three dimensions (internal control, external control by the others, and by chance); the Generalised Self Efficacy scale (GSES) was used to estimate subjective sense of self-efficacy; and the Beck Depression Inventory (BDI) was used to determine depressive symptoms. RESULTS: The majority of patients perceived the external control (by the others) and internal control of their health as high (77% and 63%, respectively) or moderate (22% and 36%, respectively), whereas self-efficacy was perceived as high or moderate (63% and 27%), which was homogenous across the whole spectrum of the HF cohort, being unrelated to HF severity, HF duration, the presence of co-morbidities, and the applied treatment. The stronger the perception of internal health control, the higher the self-efficacy (p < 0.05); both features were related to less pronounced depressive symptoms (p < 0.05). CONCLUSIONS: The established pattern of self-perceived control of own health and self-efficacy indicates that patients with HF acknowledge the role of others (i.e. healthcare providers) and themselves in the process of the management of HF, and are convinced about the high efficacy of their undertaken efforts. Such evidence supports implementation of a partnership model of specialists' care of patients with HF.

OSACS score-a new simple tool for identifying high risk for Obstructive Sleep Apnea Syndrome based on clinical parameters.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is a cardiovascular risk factor associated with clinical complications like hypertension, ischaemic heart disease or thrombosis. The aim of this study was to develop a new scoring system, based on objective clinical and echocardiographic parameters. METHODS: One hundred fifty-eight consecutive acute coronary syndrome (ACS) patients underwent standard clinical, laboratory and echocardiography assessment after ACS, and their risk of OSAS was assessed using Berlin Questionnaire and Epworth Sleepiness Scale. Creation of OSACS (Obstructive Sleep Apnea in Acute Coronary Syndrome patients) score was attempted, with risk factors evaluated in multiple logistic regression model. RESULTS: In 34.2% patients, who were at high risk of OSAS left ventricular diastolic diameter, left atrial diameter, and intrventricular septal thickness were elevated. In multiple logistic regression analysis: history of hypertension (Odds Ratio 4.42; 95% CI 0.96-20.5, p=0.06), body mass index (OR 6.82; 95% CI 2.33-20; p<0.001), diastolic blood pressure (OR 6.4; 95% CI 1.58-25.9; p=0.01), left ventricular diastolic diameter (OR 3.5; 95% CI 1.05-11.6; p=0.04), left ventricular mass index (OR 0.26; 95% CI 0.07-0.94; p=0.04), interventricular septal thickness (OR 4.44; 95% CI 1.15-17.1; p=0.03) were independent risk factors for high risk of OSAS. All independent risk factor were implemented into risk prediction model called OSACS. The area under the ROC curve for the OSACS score was 0.87. CONCLUSION: OSAS is highly prevalent in ACS patients. The new OSACS score has a high predictive value in assessment of risk of OSAS in these patients, and it can be used as an objective tool, and an alternative for the Berlin Questionnaire.

Stroke Risk Factors Beyond the CHA2DS2-VASc Score: Can We Improve Our Identification of "High Stroke Risk" Patients With Atrial Fibrillation?

The prevention of stroke and other thromboembolic events plays a crucial role in the management of patients with atrial fibrillation. Not all patients with atrial fibrillation are equal in terms of thromboembolic risk; therefore, not all will benefit from oral anticoagulation treatment. The general principle is that the expected benefit of anticoagulation in reduction of thromboembolic risk must exceed the expected harm caused by possible bleeding. Some guidelines have focused on a categorical approach to stroke prevention, with a focus on identifying patients at high risk for oral anticoagulation. Various current guidelines recommend assessment of stroke risk using the CHADS2 or CHA2DS2-VASc scores to initially detect patients at low risk who require no antithrombotic therapy. However, the scores do not incorporate all possible risk factors causing a high thromboembolic risk. Factors such as impaired renal function, obstructive sleep apnea, and echocardiographic and biochemical or coagulation parameters can also predict adverse thromboembolic events. The present review aims to describe biomarkers whether blood, urine, imaging (cardiac or cerebral), or clinical that go beyond the CHA2DS2-VASc score and potentially aid stroke risk assessment. Although useful in some cases, the presented parameters should be perhaps used to further refine initial identification of patients at low risk, after which effective stroke prevention can be offered to those with ≥1 additional stroke risk factors.

Prognostic value of troponin I and NT-proBNP concentrations in patients after in-hospital cardiac arrest.

OBJECTIVES: Cardiac arrest (CA) is a complex event with a dismal survival rate. The aim of this study was to determine whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels measured on admission and serial cardiac troponin I determination in patients with in-hospital cardiac arrest (IHCA) are predictive of 30-day mortality. METHODS: Out of 9877 patients hospitalized in the cardiac intensive care unit during the study, we enrolled consecutive patients experiencing cardiac arrest within 12 hours of admission. Baseline characteristics, information about circumstances of CA and cardiopulmonary resuscitation, and initial biochemical parameters were retrospectively collected. RESULTS: A total of 106 patients (61 male, age 71.4±12.6 years) were enrolled. Thirty-four (32.1%) had a history of myocardial infarction, and 13 (12.3%) a history of stroke. Total 30-day mortality was 60.4%. Deceased patients were older (73.7±11.9 vs. 67.8±13.0 years; p=0.01) and had lower systolic (89.4±37.0 vs. 115.0±24.0 mmHg; p=0.0001) and diastolic (53.6±24.8 vs. 66.1±15.0 mmHg; p=0.008) blood pressure on admission. Shockable initial rhythm was more often noted in the survivor group (54.8% vs. 28.1%; p=0.01). Deceased patients had higher median NT-proBNP levels (9590.0 [25-75% interquartile range (IQR), 5640.0-26450.0] vs. 3190.0 [25-75% IQR, 973.8-5362.5] pg/ml; p=0.02) on admission. There were no differences in the first two troponin I measurements, but values were higher on the third measurement in non-survivors (98.2 [25-75% IQR, 76.4-175.8] vs. 18.7 [25-75% IQR, 5.2-50.6]; p=0.009). CONCLUSIONS: The survival rate of patients after in-hospital CA is poor. Deceased patients have higher NT-proBNP levels on admission, along with higher troponin I concentrations on the third measurement. Those biomarkers are useful in predicting 30-day mortality in IHCA patients.

Clinical characteristics, aetiology and occurrence of type 2 acute myocardial infarction.

BACKGROUND: Cardiovascular diseases are the leading cause of death worldwide. One of the most important diseases in this group is myocardial infarction (MI). According to the universal definition developed by the European Society of Cardiology (ESC), MI is divided into five main types based on its cause. Type 2 MI is secondary to ischaemia due to either increased demand or decreased supply of oxygen (for example due to coronary artery spasm, anaemia, arrhythmia, coronary embolism, hypertension, or hypotension). AIM: To assess the occurrence and aetiology of type 2 acute MI (AMI), and to describe the clinical characteristics and prognosis of study patients. METHODS: Into a retrospective study, we enrolled 2,882 patients in the Cardiology Department with an initial diagnosis of AMI between 2009 and 2012. Diagnosis of AMI was made based on ESC criteria. In all patients, coronary angiography was performed in order to exclude haemodynamically significant coronary lesions. RESULTS: Among 2,882 patients hospitalised in the described time period, 58 (2%) patients were diagnosed with type 2 AMI.The mean age of the study group was 67.3 ± 13.2 years; and the majority of the study group, 60.3%, were women. Out of them, 23 (39.6%) patients experienced AMI due to coronary artery spasm, 15 (25.9%) due to arrhythmias, 11 (19%) due to severe anaemia, and nine (15.5%) due to hypertension, without significant coronary artery disease. 42 (72.4%) patients, were diagnosed as non-ST-segment elevation MI, 14 (24.1%) as ST-segment elevation MI, and two (3.5%) as AMI in the presence of ventricular paced rhythm. History of classical cardiovascular risk factors including hypertension, diabetes, dyslipidaemia, family history of heart diseases, and smoking was reported in 42 (72.4%), 14 (24.1%), 23 (39.7%), 24 (41.4%), and 16 (27.6%) cases, respectively. All-cause 30-day mortality rate was 5.2%, and six-month was 6.9%. CONCLUSIONS: Type 2 AMI patients were more often female, and they were more often diagnosed as non-ST-segment elevation MI. The prevalence of classical cardiovascular risk factors in this subgroup of patients was very high. The leading cause of AMI was coronary artery spasm.

Clinical characteristics of patients with acute coronary syndrome at high clinical suspicion for obstructive sleep apnea syndrome.

INTRODUCTION: The risk of a cardiovascular event increases with the number of cardiovascular risk factors. The aim of this study was to identify patients with acute coronary syndromes (ACS) who were at high clinical suspicion for obstructive sleep apnea syndrome (OSAS). We also report the clinical characteristics of ACS patients at high clinical suspicion for OSAS. METHODS: We studied 158 consecutive patients who satisfied the entry criteria (mean age 57.1 ± 8.7 years, 68% males) and were admitted to a tertiary university hospital. The risk of OSAS was assessed using the Berlin questionnaire. In addition, all patients were required to have excessive sleepiness as demonstrated by a score >10 on the Epworth Sleepiness Scale (ESS). RESULTS: Fifty four (34.2%) patients were at high clinical suspicion. On admission, patients at clinical suspicion for OSAS had significantly more often a history of hypertension (92.6% vs. 55.8%, p<0.0001) or diabetes mellitus (37% vs. 15.4%, p=0.0049); significantly higher mean ESS (14.83 ± 3.02 vs. 5.83 ± 3.33, p<0.0001), systolic blood pressure (149.9 ± 34.2 vs. 128.4 ± 23.6 mmHg, p<0.0001), diastolic blood pressure (87.7 ± 17.4 vs. 76.2 ± 12.1 mmHg, p<0.0001), and body mass index (32.3 ± 4.6 vs. 27 ± 3.8 kg/m(2), p<0.0001); and a lower glomerular filtration rate (79.5 ± 21.2 vs. 87.5 ± 22.2 ml/min/1.73 m(2), p=0.048). Patients at high clinical suspicion for OSAS more often had onset of acute chest pain between midnight and 5.59 am compared to the patients at low clinical suspicion (42.6% vs. 26%; p<0.05). The mortality (7.4% vs. 1%; p=0.03) was greater in patients at high clinical suspicion. CONCLUSIONS: This study demonstrates that one out of every three ACS patients was diagnosed with a high clinical suspicion for OSAS. The prevalence of cardiovascular risk factors among ACS patients at high clinical suspicion for OSAS was high when compared with patients at low clinical suspicion. This finding calls for physicians to perform routine screening and individual evaluation of myocardial infarction patients for sleep disorders, especially when they are obese, or have hypertension or chest pain in the night hours.

Usefulness of the D-dimer concentration as a predictor of mortality in patients with out-of-hospital cardiac arrest.

During cardiac arrest and after cardiopulmonary resuscitation, activation of blood coagulation occurs, with a lack of adequate endogenous fibrinolysis. The aim of the present study was to determine whether the serum D-dimer concentration on admission is an independent predictor of all-cause mortality in patients with out-of-hospital cardiac arrest. We enrolled 182 consecutive patients (122 men, mean age 64.3 ± 15 years), who had presented to the emergency department from January 2007 to July 2012 because of out-of-hospital cardiac arrest. Information about the initial arrest rhythm, biochemical parameters, including the D-dimer concentration on admission, neurologic outcomes, and 30-day all-cause mortality were retrospectively collected. Of the 182 patients, 79 (43.4%) had died. The patients who died had had lower systolic (100 ± 39.6 vs 120.5 ± 26.9 mm Hg; p = 0.0004) and diastolic (58.3 ± 24.1 vs 74 ± 16.3 mm Hg; p <0.0001) blood pressure on admission. The deceased patients more often had had a history of myocardial infarction (32.9% vs 25.2%; p = 0.04) and less often had had an initial shockable rhythm (41.8% vs 60.2%; p = 0.02). The patients who died had had a significantly higher mean D-dimer concentration (9,113.6 ± 5,979.2 vs 6,121.6 ± 4,597.5 µg/L; p = 0.005) compared with patients who stayed alive. On multivariate logistic regression analysis, an on-admission D-dimer concentration >5,205 µg/L (odds ratio 5.7, 95% confidence interval 1.22 to 26.69) and hemoglobin concentration (odds ratio 1.66, 95% confidence interval 1.13 to 2.43) were strong and independent predictors of all-cause mortality. In conclusion, patients with a higher D-dimer concentration on admission had a poorer prognosis. The D-dimer concentration was an independent predictor of all-cause mortality.

Resistant hypertension in an obese patient with obvious obstructive sleep apnea and occult pheochromocytoma.

We report the case of a 34-year-old male patient who presented with generalized weakness, poorly controlled hypertension, nocturnal hypertension spikes, and morning headaches. The history of resistant hypertension, obesity, enlarged neck size, and loud irregular snoring strongly suggested obstructive sleep apnea (OSA). To exclude other possible causes of resistant hypertension, the patient underwent an abdominal ultrasound examination, which revealed a lesion in the left adrenal gland area. A pheochromocytoma was successfully removed via laparoscopic adrenalectomy, and both his hypertension and OSA responded dramatically. This case highlights the importance of excluding all causes of resistant hypertension regardless of the initial diagnosis.

[Stroke in young diver with patent foramen ovale]. / Udar mózgu u mlodego nurka z droznym otworem owalnym.

Patent foramen ovale (PFO) is the most common cause of right-to-left shunt which carries a significant risk for stroke when associated with venous thrombosis, coagulation abnormalities or other conditions. We present a young male in whom diving was associated with stroke in a subject with otherwise clinically silent PFO.