Early Cardiac Rehabilitation Improves Carotid Arterial Stiffness in Patients with Myocardial Infarction.

Background: Little is known about the effect of cardiac rehabilitation (CR) on carotid arterial stiffness (CAS) in patients with myocardial infarction (MI). Patients and Methods: Rehabilitation group (B) included 90 patients with MI subjected to CR, control group (K) consisted of 30 patients with MI not participating in CR, and healthy group comprised 38 persons without cardiovascular risk factors. CAS was determined using echo-tracking before and after CR. Results: At baseline, patients with MI (B+K) presented with significantly higher mean values of CAS parameters: beta-stiffness index (7.1 vs 6.4, p = 0.004), Peterson's elastic modulus (96 kPa vs 77 kPa, p < 0.001) and PWV-beta (6.1 m/s vs 5.2 m/s, p < 0.001) than healthy persons. Age (beta: r = 0.242, p = 0.008; EP: r = 0.250, p = 0.006; PWV-beta: r = 0.224, p = 0.014) and blood pressure: SBP (EP: r = 0.388, PWV-beta: r = 0.360), DBP (AC: r = 0.225) and PP (PWV-beta: r = 0.221) correlated positively with the initial parameters of CAS. Beta-stiffness index (Rho=-0.26, p = 0.04) and PWV-beta (Rho = 0.29, p = 0.03) correlated inversely with peak exercise capacity expressed in METs. After CR, mean values of beta-stiffness index (6.2 vs 7.1, p = 0.016), EP (78 kPa vs 101 kPa, p = 0.001) and PWV-beta (5.4 m/s vs 6.2 m/s, p = 0.001) in group B were significantly lower than in group K. In group B, CAS parameters decreased significantly after CR. Univariate analysis demonstrated that the likelihood of an improvement in CAS after CR was significantly higher in patients with baseline systolic blood pressure <120 mm Hg (OR = 2.74, p = 0.009) and left ventricular ejection fraction <43% (OR = 5.05, p = 0.005). Conclusion: In patients with MI, CR exerted a beneficial effect on CAS parameters. The improvement in CAS was predicted by lower SBP and LVEF at baseline.

Influence of the Apelinergic System on Conduction Disorders in Patients after Myocardial Infarction.

BACKGROUND: There is a growing body of evidence for an important role of the apelinergic system in the modulation of cardiovascular homeostasis. The aim of our study was to (1) examine the relationship between apelin serum concentration at index myocardial infarction (MI) and atrioventricular conduction disorders (AVCDs) at 12-month follow-up, and (2) investigate the association between initial apelin concentration and the novel marker of post-MI scar (Q/QRS ratio) at follow-up. METHODS: In 84 patients with MI with complete revascularization, apelin peptide serum concentrations for apelin-13, apelin-17, elabela (ELA) and apelin receptor (APJ) were measured on day one of hospitalization; at 12-month follow-up, 54 of them underwent thorough examination that included 12-lead electrocardiography (ECG), Holter ECG monitoring and echocardiography. RESULTS: The mean age was 58.9 years. At 12-month follow-up, AVCDs were diagnosed in 21.4% of subjects, with AV first-degree block in 16.7% and sinoatrial arrest in 3.7%. ELA serum concentration at index MI correlated positively with the occurrence of AVCD (p = 0.003) and heart rate (p = 0.005) at 12-month follow-up. The apelin-13 serum concentration at index MI correlated negatively with the Q/QRS ratio. CONCLUSIONS: The apelin peptide concentration during an acute phase of MI impacts the development of AVCD and the value of Q/QRS ratio in MI survivors.

Polish Multicenter Registry (Pol-LAS-SE registry). Stress echocardiography in low-gradient aortic stenosis in Poland: numbers, settings, results, complications and clinical practice.

BACKGROUND: The diagnostic workup of low-gradient aortic stenosis (LG AS) is a challenge in clinical practice. AIMS: Our goal was to assess the diagnostic value of stress echocardiography (SE) performed in patients with undefined LG AS with low and preserved ejection fraction (EF) and the impact of its result on therapeutic decisions in Polish third level of reference. METHODS: All the patients with LG AS and with SE performed were recruited in 16 Polish cardiology departments between 2016 and 2019. The main exclusion criteria were as follows: moderate or severe aortic or mitral regurgitation and mitral stenosis. RESULTS: The study group included 163 patients (52% males) with LG AS who underwent SE for adequate diagnostic and therapeutic decision. In 14 patients DSE was non-diagnostic. The mean aortic valve (AV) pressure gradient was 24.1 (7.3) mm Hg, while an AV area was 0.86 (0.2) cm2. Among 149 patients with conclusive DSE, severe AS was found in 59.8%, pseudo-severe in 22%, and moderate AS in 18%. There were no cases of death or vascular events related to DSE. Among 142 patients 63 (44%) patients had an aortic valve intervention in a follow-up (median: 208 days; lower-upper quartile: 73-531 days). Based on the result of the DSE test, severe AS was significantly more often associated with qualification to interventional treatment compared to the moderate and pseudo-severe subgroups (P <0.0001). CONCLUSIONS: The DSE test in severe AS is a valuable diagnostic tool in patients with LG AS in Poland.

Prospective multicenter Polish Stress Echocardiography Registry (PolStress-Echopro) - the role in clinical practice.

BACKGROUND: Stress echocardiography (SE) is becoming an increasingly frequently performed diagnostic examination in Poland. After the published retrospective PolSTRESS Registry, this prospective study is the first one available so far. OBJECTIVES: The aim of the study was to analyze SE tests, taking into account the clinical characteristics of the patients, indications, applied protocols, and diagnostic and therapeutic decisions. MATERIAL AND METHODS: Reference cardiological centers in Poland were asked for a 1-month prospective analysis of the data obtained. The study included 189 SE examinations. To evaluate coronary artery disease (CAD) (178 tests), all 17 centers performed dobutamine SE (DSE) (100%), 3 centers (17%) performed pacing, while cycle ergometer and treadmill SE were performed by 1 (5%) and 2 (11%) centers, respectively. In patients with valvular heart disease (VHD) (11 tests), 3 centers (16%) performed SE to evaluate low-flow/low-gradient aortic stenosis (AS), 4 (22%) in asymptomatic AS and 1 (5%) to evaluate mitral regurgitation. RESULTS: For CAD assessment, a positive result was found in 37 (20%) patients, negative in 109 (61%) and nondiagnostic in 32 (19%). In the CAD group, coronarography was performed in 41 (23%) people. The analysis of the significance of the SE results for decision-making on interventional measures revealed that 30 patients (from the total study population of 189) were referred for the intervention. CONCLUSIONS: The most commonly used SE is the DSE. Negative test results allowed in almost half of the patients to resign from invasive coronarography. Stress echocardiography should be more frequently used in patients with VHD in the qualification for invasive treatment.

Polish Stress Echocardiography Registry (Pol-STRESS registry) - a multicentre study. Stress echocardiography in Poland: numbers, settings, results, and complications.

BACKGROUND: Stress echocardiography (SE) is widely used in Europe. No collective data have been available on the use of SE in Poland until now. AIM: To evaluate the number of SE investigations performed in Poland, their settings, complications, and results. METHODS: In this retrospective survey, referral cardiology centres in Poland were asked to fill in a questionnaire regarding SE examinations performed from May 1, 2014 to May 1, 2015. RESULTS: The study included data from 17 university hospitals and large community hospitals, which performed 4611 SE exa-minations, including 4408 tests in patients investigated for coronary artery disease (CAD) and 203 tests to evaluate valvular heart disease (VHD). To evaluate CAD, all centres performed dobutamine SE (100%), 10 centres performed pacing SE (58.8%), while cycle ergometer SE and treadmill SE were performed by six (35.3%) and five (29.4%) centres, respectively. Dipyridamole SE was performed in one centre. All evaluated centres (100%) performed SE to evaluate low-flow/low-gradient aortic stenosis, eight (47%) performed SE to evaluate asymptomatic aortic stenosis, and also eight (47%) performed SE to evaluate mitral regurgitation. The mean number of examinations per year was 271 per centre. Most centres performed more than 100 examinations per year (11 centres, 64.7%). We did not identify any cardiac death during SE examination in any of the centres. Myocardial infarction occurred in three (0.07%) patients. Non-sustained ventricular tachycardia occurred in 52 (1.1%) SE examinations. The rates of minor complications were low. SE to evaluate CAD was more commonly performed in the hospital settings using cycle ergometer (72.6%), treadmill (87.6%), and low-dose dobutamine (68.0%), while a dipyridamole test was more frequently employed in ambulatory patients (77.6%). No significant differences between the rates of examina-tions performed in the ambulatory and hospital settings were found for high-dose dobutamine and pacing SE. Examinations to evaluate VHD were significantly more frequently performed in the hospital settings. SE examinations accounted for more than one third of all stress tests performed in the surveyed centres over the study period. CONCLUSIONS: Stress echocardiography is a safe diagnostic method, and major complications are very rare. Despite European recommendations, SE examinations to evaluate CAD are performed less frequently than electrocardiographic exercise tests, although they already comprise a significant proportion of all stress tests. It seems reasonable to promote SE further for the evaluation of both CAD and VHD.

Predictors of functional mitral regurgitation improvement during a short-term follow-up after cardiac resynchronisation therapy.

BACKGROUND AND AIM: The study was undertaken to assess the predictive role of myocardial contractile reserve for functional mitral regurgitation (FMR) improvement after cardiac resynchronisation therapy (CRT), and to define other predictors of FMR improvement (FMRI) and the impact of FMRI on left ventricular (LV) reverse remodelling. METHODS AND RESULTS: Among 90 patients in whom echocardiography was performed one day before and six weeks after CRT implantation, 66 with at least FMR(2+) in a four-point scale (mean age 64 ± 10 years, mean LV ejection fraction [LVEF] 25.7 ± 6%, ischaemic aetiology 48%) were included. FMRI was defined as the reduction of the FMR severity by at least one grade. The patients were divided into groups: A with FMRI (n = 30) and B without FMRI (n = 36). Contractile reserve was evaluated using low-dose dobutamine stress-echo before CRT implantation and was defined as a relative improvement in LVEF of more than 20% and segmental contractility improvement. Reverse remodelling was defined as the reduction of the LV end-systolic volume (LVESV) by at least 15%. Cox regression multivariate analysis revealed the following predictors for FMRI: contractile reserve preserved in more than three segments with an OR = 5.7 (95% CI 1.81-17.97, p = 0.005, sensitivity 65.5%, specificity 72.2%, AUC = 0.727) and LV end-diastolic diameter ≤ 74 mm with an OR = 2.09 (95% CI 0.75-5.78, p < 0.05, sensitivity 80.0%, specificity 47.2%, AUC = 0.632). FMRI was associated with greater reduction of LVESV (p = 0.002), greater increase in LVEF (p < 0.001) and higher incidence of the LV reverse remodelling (p < 0.001). CONCLUSIONS: Preserved contractile reserve and lesser degree of LV dilation were predictive factors of short-term FMR improvement after CRT implantation. FMR improvement was associated with higher incidence of the LV reverse remodelling early, already in the six weeks after CRT implantation.

Predictors of left atrial appendage thrombogenic milieu in patients subjected to transesophageal echocardiography prior to cardioversion of persistent atrial fibrillation.

INTRODUCTION: Evidence of left atrial appendage thrombogenic milieu (LAA TM) on transesophageal echocardiography (TEE) is recognized as a surrogate marker for an increased stroke risk. Although the CHA2DS2-VASc scale is commonly used as a measure of thromboembolic risk in patients with atrial fibrillation (AF), it was shown to have only low-to-moderate ability to predict the presence of LAA TM. The potential role of transthoracic echocardiography (TTE) in the refinement of clinical scales for the detection of LAA TM in patients with AF has been readdressed recently. OBJECTIVES: The aim of the study was to identify the predictors of LAA TM among the components of the CHA2DS2-VASc scale and TTE parameters in patients scheduled for electrical cardioversion due to persistent AF. PATIENTS AND METHODS: We conducted a retrospective analysis of demographic, clinical, laboratory, echocardiographic, and medication data of 202 patients (123 men and 79 women; mean age, 65.6 years) with persistent AF, who underwent TEE before electrical cardioversion. RESULTS: Duration of AF exceeding 1 year (odds ratio [OR] = 13.9; P = 0.02), left atrial diameter exceeding 51 mm (OR = 3.98; P = 0.009), left ventricular end-diastolic dimension (LVEDd) exceeding 52 mm (OR = 2.42; P = 0.01), and radiographic evidence of aortic plaques (OR = 2.97; P = 0.007) were shown to be independent predictors of LAA TM in a multivariate regression analysis. CONCLUSIONS: The CHA2DS2-VASc scale did not predict the presence of LAA TM on TEE in patients scheduled for electrical cardioversion due to persistent AF. Of the CHA2DS2-VASc components, only radiographic evidence of aortic plaques, and of TTE parameters, only left atrial enlargement and LVEDd were independent predictors of LAA TM. A comprehensive clinical and echocardiographic assessment of individual risk is indicated in patients before electrical cardioversion due to persistent AF.

Factors associated with glucose metabolism disorders after kidney transplantation.

INTRODUCTION: Post-transplant diabetes mellitus (PTDM), pre-diabetes-impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are frequent complications after organ transplantation. The aim of this study was to assess the frequency of PTDM, IFG and IGT in a group of renal transplant recipients, to compare the frequency of glucose metabolism disorders in subjects treated with tacrolimus and with cyclosporine, and to establish the influence of different risk factors on the development of glucose metabolism disorders. MATERIAL AND METHODS: We examined 206 non-diabetic kidney allograft recipients (age 46.4 ± 12.3 years, time since transplantation 45.5 ± ± 33.6 months, BMI 26.3 ± 4.5 kg/m2). Glucose metabolism disorders were diagnosed using an oral glucose tolerance test. Logistic regression was used to assess the influence of each risk factor (age, BMI, waist circumference, physical activity, the presence of cardiovascular disease, positive family history of diabetes, cholesterol and triglycerides concentration) on the development of glucose metabolism disorders. RESULTS: In 103 patients (50%), we diagnosed glucose metabolism disorders. 19% of patients had PTDM, 14% IFG, and 17% IGT. We did not find any differences in the frequency of glucose metabolism disorders between patients treated with tacrolimus and with cyclosporine. Multivariate analysis identified BMI and a family history of diabetes as independent risk factors of glucose metabolism disorders. CONCLUSIONS: We found a high prevalence of glucose metabolism disorders in the examined group. This suggests that kidney transplant recipients should be screened for these disturbances. Patients with higher BMI and with first-degree relatives with diabetes had an increased risk of glucose metabolism disorders after kidney transplantation.

[Difficulties in the diagnosis of ACTH-dependent Cushing's syndrome in a patient after left adrenalectomy and treated with glucocorticoids]. / Trudnosci w diagnostyce ACTH-zaleznego zespolu Cushinga u chorej po lewostronnej adrenalektomii i leczonej glikokortykosteroidami.

Cushing's syndrome (CS), that is a consequence of chronic excess of corticosteroides, is most frequently of iatrogenic origin. Corticotropin secreting pituitary adenomas are responsible for most cases of endogenous Cushing' s syndrome. Difficulties in the diagnosis and treatment of ACTH-dependent Cushing's syndrome concern with localization of the source of pathological ACTH secretion, particularly when magnetic resonance imaging is unable to identify the pituitary microadenoma. In this paper we present the case of a patient with symptoms of Cushing's syndrome and describe problems with localization of the source of hypercortisolemia. The diagnostic process was additionally complicated by the treatment with corticosteroids, occasionally applied due to concomitant diseases. This delayed the right diagnosis and treatment.

Patterns of post-MI left ventricular volume changes - clinical implications.

BACKGROUND: Left ventricular (LV) enlargement - the main discriminant of postinfarction remodelling - is dynamic and not necessarily progressive. The magnitude of the remodelling process is directly proportional to infarct size (IS), although it is significantly influenced by other factors. AIM: To assess the clinical implications of different patterns of LV volume changes in 1-year echocardiographic follow-up after myocardial infarction (MI) and to determine early predictors of adverse remodelling. METHODS: The study group consisted of 132 patients (pts) (mean age 55.7+/-12 years) with their first MI (STEMI) (67% pts treated with fibrinolysis). In the consecutive ECHO examinations (S1, first day; S2, at discharge; S3, 6 months; and S4, one year after MI) the following parameters were assessed: WMSI, EDVI, ESVI, LVEF, LV sphericity index (WSF), index of infarct expansion (EXP), restrictive pattern of mitral flow (RP), grade of mitral regurgitation (MR). The criterion of significant LV dilatation was EDVI > or =85 ml/m2 and/or DEDVI > or =20% between two succeeding ECHO. At S3 pts were classified into groups: group 1 with no LV dilatation (n=68), group 2 with early transient LV dilatation (S1 and/or S2) (n=26), group 3 with progressive (S1 - S2 - S3) LV dilatation (n=28). The prognostic value of the following parameters was assessed: anterior infarct location, Q-wave MI, Killip-Kimball class l2, lack of noninvasive assessed reperfusion R(-), EXP(+), CK > or =3000 IU, WMSIS2 > or =1.5, EDVIS2 > or=80 ml/m2, ESVIS2 > or =40 ml/m2, EFS2 <45%, RPS2 and baseline LV hypertrophy (S1). RESULTS: Patients in group 3 had significantly larger IS (WMSI) than in group 1 (p <0.01) and group 2 (p <0.05). Infarct expansion was found only in group 3. One year after MI in group 3 compared to groups 1 and 2 adverse remodelling was observed: lower EFS4 (p <0.001), more spherical LV (WSFS4) (p <0.001), higher rate of MRS4 > or =2 (p <0.001) and RPS4 (p <0.001). Within each group LVEFS1-S4 was stable in one-year follow-up. In group 3 incidence of heart failure (HF) was significantly higher than in groups 1 and 2 (respectively 57 vs. 2 vs. 4%; p <0.001). Cardiac death (CD) was observed only in group 3 (25% of pts). Increased EDVI > or =80 ml/m2 at discharge was the most powerful independent predictor of progressive LV dilatation. Large IS (CK >/=3000 IU and/or WMSI > or =1.5) was not an independent predictor of adverse remodelling. CONCLUSIONS: 1) During the first 6 months after MI the progression of LV dilatation was a useful sign identifying adverse remodelling, even in the absence of LVEF evolutionary changes. Progressive LV dilatation was associated with more spherical LV and higher rate of MR > or =2 degrees . 2) Patients with progressive LV were at higher risks of HF and CD in one-year follow-up. 3) Increased EDVI > or =80 ml/m2 at discharge was the most powerful independent predictor of adverse postinfarction remodelling. Large IS was not an independent predictor. 4) Echocardiographic monitoring after MI is of great clinical importance - it enables pts at higher risk of HF and CD to be identified.

Early predictors of adverse left ventricular remodelling after myocardial infarction treated by primary angioplasty.

BACKGROUND: Progressive left ventricular dilatation (PLVD) occurs after myocardial infarction (MI), and this may take place in the area of primary percutaneous coronary intervention (PCI). The factors predicting PLVD after primary PCI still need to be clarified. The aim of the study was to assess the prevalence and to define the baseline clinical and echocardiographic predictors of PLVD in patients with STEMI treated by primary PCI. METHODS: Of the 90 patients initially selected for the study 88 (29 women and 59 men, mean age 67.1 +/- 5.6 years) with first ST-elevation myocardial infarction (STEMI) treated with primary PCI were examined. Echocardiographic examination was performed in all patients at discharge (M1) and after 6 months (M2). The following factors influencing PLVD were evaluated: type of infarct-related artery (IRA), infarct size expressed as wall motion score index (WMSI) >/= 1.5, left ventricular end-diastolic volume index (LVEDVI) >/= 80 ml/m(2), ejection fraction (EF) /= 125 g/m(2) and coronary risk factors. RESULTS: The overall prevalence of PLVD (according to the criterion of 20% LVEDVI increase from M1 to M2) was 24%. Univariate regression analysis revealed that the following were the significant baseline M1 predictors of adverse PLVD: left anterior descending as IRA (relative risk: rr = 2.3, p < 0.05), WMSI >/= 1.5 (rr = 4.29, p < 0.005), EF /= 1.5. CONCLUSIONS: Both regional and global left ventricular systolic dysfunction indices as well as severe left ventricular diastolic abnormalities but not left ventricular dilatation at discharge are significant predictors of adverse cardiac remodelling after STEMI in patients treated with primary PCI. However the only independent determinant of PLVD was WMSI >/= 1.5 expressing the infarct size. (Cardiol J 2007; 14: 238-245).