The value of ECG parameters in estimating myocardial injury and establishing prognosis in patients with acute pulmonary embolism.

BACKGROUND: The electrocardiogram (ECG) is characterised by little sensitivity and specificity in the diagnostic evaluation of acute pulmonary embolism (APE). AIM: To assess the significance of ECG changes in predicting myocardial injury and prognosis in patients with APE. METHODS: The study group consisted of 225 patients (137 women and 88 men), mean age: 66.0 ± 15.2 years, in whom the diagnosis of APE was made, mostly based on computed tomography (n = 206, 92%). RESULTS: We observed 26 in-hospital deaths (mortality rate: 11.5%) and complications occurred in 58 (25.7%) patients. Elevated levels of troponin were observed in 103 (46%) patients. Logistic regression analysis showed that in-hospital mortality was associated with: coronary chest pain (0.06-0.53, OR 0.18), systolic blood pressure below 100 mm Hg (2.3-13.64, OR 5.61), heart rate above 100 bpm (1.17-15.11, OR 4.21), the S1Q3T3 sign (1.31-6.99, OR 3.02), QR in V(1) (1.60-12.32, OR 4.45), ST-segment depression in V(4)-V(6) (0.99-5.40, OR 2.31), ST-segment elevation in III (0.99-6.96, OR 2.64), ST-segment elevation in V(1) (1.74-9.49, OR 4.07); borderline (1.51-16.07, OR 4.93), moderate (1.42-17.74, OR 5.01) and severe troponin elevation (2.88-36.38, OR 10.24). In patients with cTnT(+), compared to patients with normal troponin levels, the following ECG changes were significantly more common: the S1Q3T3 sign (43 vs 21%, p = 0.003), negative T waves in V(2)-V(4) (57 vs 27%, p = 0.0001), ST-segment depression in V(4)-V(6) (40 vs 14%, p = 0.001), ST-segment elevation in III (22 vs 7%, p = 0.0006), V(1) and V(2) (43 vs 10%, p = 0.0001) and QR in V(1) (16 vs 5%, p = 0.007). CONCLUSIONS: ECG parameters are useful in predicting myocardial injury and assessing prognosis in patients with APE.

How often pulmonary embolism mimics acute coronary syndrome?

BACKGROUND: The clinical picture of acute pulmonary embolism (APE) is often uncharacteristic and may mimic acute coronary syndrome (ACS) or lung diseases, leading to misdiagnosis. In 50% of patients, APE is accompanied by chest pain and in 30-50% of the patients markers of myocardial injury are elevated. AIM: To perform a retrospective assessment of how often clinical manifestations and investigations (ECG findings and elevated markers of myocardial injury) in patients with APE may be suggestive of ACS. METHODS: We included 292 consecutive patients (109 men and 183 women) from 17 to 89 years of age (mean age 65.4 ± 15.5 years) with APE diagnosed according the ESC guidelines. RESULTS: Among the 292 patients included in the study 33 patients died during hospitalisation (mortality rate 11.3%) and 73 (25.0%) patients developed complications. A total of 75 (25.7%) patients were classified as high risk according to the ESC risk stratification, 163 (55.8%) as intermediate risk and 54 (18.5%) as low risk. Chest pain on and/or before admission was reported by 128 (43.8%) patients, including 73 (57.0%) patients with chest pain of coronary origin, 52 (40.6%) patients with chest pain of pleural origin and 3 patients with pain of undeterminable origin based on the available documentation. A total of 56 (19.2%) patients had a history of ischaemic heart disease and 5 (1.7%) had a history of myocardial infarction. A total of 8 (2.7%) patients were admitted with the initial diagnosis of ACS. The high-risk group consisted of 15 (20.6%) patients with a typical retrosternal chest pain and 60 (27.3%) patients without the typical anginal pain. Elevated troponin was observed in 103 (35.3%) patients. The ECG changes suggestive of myocardial ischaemia (inverted T waves, ST-segment depression or elevation) were observed in 208 (71.2%) patients. The following findings were significantly more common in high-risk versus non-high-risk patients: ST-segment depression in V4-V6 (42.6% vs 23.9%, p = 0.02), ST-segment elevation in V1 (46.7% vs 20.0%, p = 0.0002) and aVR (70.7% vs 40.1%, p = 0.0007). CONCLUSIONS: One third of patients with APE may present with all the manifestations (pain, elevated troponin and ECG changes) suggestive of ACS. The ECG changes suggestive of myocardial ischaemia are observed in 70% of the patients with ST-segment depression in V4-V6 and ST-segment elevation in V1 and aVR being significantly more common in high-risk vs non-high-risk patients.

[Treprostinil therapy for distal chronic thromboembolic pulmonary hypertension]. / Obwodowa postac przewleklego zakrzepowo-zatorowego nadcisnienia plucnego. Trudnosci diagnostyczne, nowe mozliwosci terapeutyczne.

We present a case of a 77-year-old female with distal chronic thromboembolic pulmonary hypertension. Diagnostic and therapeutic difficulties are discussed. Clinical and haemodynamic benefits resulting from treprostinil therapy added to continuous anticoagulation are shown.

Results of one-year anticoagulation in patients with newly detected chronic thromboembolic pulmonary hypertension not treated with pulmonary endarterectomy.

INTRODUCTION: Currently pulmonary endarterectomy is considered the method of choice in patients with chronic thromboembolic pulmonary hypertension (CTEPH). It is not known if this option should be recommended in all suitable patients as it is highly variable with respect to prognosis. There is also doubt about selection of adequate time to refer patients with CTEPH for surgery. AIM: To establish whether some patients with CTEPH may clinically benefit from isolated anticoagulation with drugs and if the use of anticoagulation may have any impact on the time of patient referral for pulmonary endarterectomy. METHODS: The prospective analysis involved 29 patients (9 male, 20 female) aged 37 to 82 years, with pulmonary arterial systolic pressure ranging from 39 to 133 mmHg and newly diagnosed CTEPH who had not been treated with pulmonary endarterectomy and were not receiving anticoagulation. Survival, functional status according to NYHA classification, duration of thromboembolism, exercise tolerance and echocardiographic parameters of right ventricular overload before and at one year after initiation of therapy with anticoagulants were evaluated. RESULTS: During follow-up, 3 patients with PASP ranging from 120 to 133 mmHg died. In 26 patients with PASP 39-115 mmHg, who survived, improvement in echocardiographic parameters of right ventricular overload, better exercise tolerance as well as functional status according to NYHA classification was observed. In 12 survivors, pulmonary pressure returned to normal. CONCLUSIONS: The results of this study suggest that favourable effects of isolated anticoagulation are likely in patients with newly detected CTEPH, mild and moderate baseline pulmonary hypertension and acceptable exercise tolerance. They also indicate the necessity of anticoagulation in these patients prior to possible referral for pulmonary endarterectomy.

[One-year controlled therapy with doxazosin in patients with pulmonary hypertension due to chronic obstructive pulmonary disease]. / Roczna, kontrolowana ocena stosowania doksazosyny u chorych na nadcisnienie plucne na tie przewlekle j obturacyjnej choroby pluc.

UNLABELLED: It was shown recently that a thirty day doxazosin therapy, that was undertaken to prove alpha1-adrenergic hypothesis for pulmonary hypertension, resulted in a significant improvement of pulmonary hemodynamics in patients with hypoxic pulmonary hypertension (HPH) due to COPD. AIM OF THE STUDY: The objective of this study was to learn if 12 months long therapy with 2 mg of doxazosin daily (dosage effective in recent research) may result in persistent hemodynamical and clinical benefits. MATERIAL AND METHODS: To this end, baseline and after 1 year results of echocardiography, symptom-limited maximal exercise test, and arterial blood gaseous analysis were evaluated at baseline and after 12-month study in 32 patients with HPH randomized either to doxazosin treated group (16 patients, aged 60.2 +/- 12 years, or to control group (16 patients, aging 60.5 +/- 4 years). At baseline doxazosin treated COPD patients had less advanced disease than COPD control patients (FVC 2.4 +/- 0.7 vs 1.3 +/- 0.31, p<0,001 and FEV1 1.6 +/- 0.6 vs 0.7 +/- 0.31, p<0,001). RESULTS: This study showed that results of tricuspid gradient, acceleration time, right ventricular enddiastolic diameter, left ventricular enddiastolic diameter and left ventricular ejection fraction did not differ significantly in both groups between baseline and 1-year assessment. The number of METs achieved during exercise test and results of PaO2 and PaCO2 did not change significantly in both groups either. CONCLUSION: The study indicates lack of hemodynamical and clinical improvement during a 1-year doxazosin therapy in patients with HPH due to COPD.

[Normal coronary angiogram in patient with diagnosis of acute coronary syndrome with ST segment elevation. Was it possible to recognise acute pulmonary embolism earlier?]. / Prawidlowy wynik koronarografii u pacjenta z rozpoznaniem ostrego zespolu wiencowego z uniesieniem ST zakwalifikowanego do przezskórnej interwencji wiencowej. Czy mozna bylo wczesniej rozpoznac ostra zatorowosc plucna?

A case of a 48 year old male scheduled for early invasive treatment of acute coronary syndrome with ST segment elevation is presented. Clinical suspicion of acute pulmonary embolism was undertaken because of normal coronary angiogram and was confirmed by pulmonary angiography. Differential diagnosis based on medical history, electrocardiogram and laboratory findings was discussed.

[Characteristics of acute, hemodynamically stable pulmonary embolism presenting as a syncope]. / Charakterystyka ostrej, hemodynamicznie stabilnej zatorowosci plucnej ujawniajacej sie omdleniem.

Syncope (S) occurs in approximately 10% patients with acute pulmonary embolism (APE) and is commonly ascribed to the massive, hemodynamically instable APE. The aim of the study was to assess the occurrence and significance of S revealing hemodynamically stable APE. We found syncope in 6 of 21 (29%) consecutive patients (16 females, 5 males; age from 46-87 years, mean age of 71 years) who were diagnosed with APE and in whom other reasons for S were excluded. All patients were treated with anticoagulation. They all survived hospitalization and no APE recurrences were found during in-hospital period. Patients with APE-S compared to patients with APE and without S had smaller baseline RVED (21.2 +/- 2 vs. 27.3 +/- 5.6, p = 0.01), however both groups did not differ statistically in baseline vital signs, angiographic, hemodynamic, other echocardiographic parameters as well as in the results of laboratory findings. It is concluded, that S signals hemodynamically stable APE more frequently than is quoted. APE-S patients could not be clearly discriminate from APE patients without S on the basis of the parameters studied and S did not impact the course of APE during in- hospital period.

[Cardiac tamponade due to angiosarcoma--was surgical treatment necessary? A case report]. / Tamponada serca wywolana miesakiem naczyniowym--czy nalezalo wykonac zabieg kardiochirurgiczny?

We present a case of a 49-year-old patient with cardiac tamponade due to haemopericardium. The decision to perform surgery, although controversial, allowed to diagnose cardiac angiosarcoma with metastases to pericardium, vena cava superior and pulmonary trunk. Consequently, chemotherapy was instituted and was initially effective, however, the patient died 12 months later due to the progression of the disease.

[Bronchial adenocarcinoma mimicking acute pulmonary embolism -- a case report]. / Gruczolowy rak oskrzelikowy nasladujacy ostra zatorowosc plucna.

A case of a 31-year-old male with medical history, clinical symptoms and additional diagnostic tests strongly suggesting diagnosis of acute pulmonary embolism is presented. However, pulmonary emboli were not seen during pulmonary angiography. At autopsy bronchial carcinoma was found and this definitive diagnosis was confirmed by the results of histopathological study.

[Impact of 30 day therapy with doxazosin--alpha1 adrenergic blocker on pulmonary hemodynamics in patients with secondary pulmonary hypertension due to chronic obstructive pulmonary disease]. / Wplyw 30-dniowego leczenia alpha1 adrenolitykiem--doksazosyna--na hemodynamike plucna u chorych z nadcisnieniem plucnym w przebiegu przewleklej obturacyjnej choroby pluc.

To prove alpha1-adrenergic hypothesis for pulmonary hypertension we studied 6 patients aged 63.3 +/- 8 (range 50-75) years with stable, advanced chronic obstructive pulmonary disease (COPD), FEV=1.51 +/- 0.3 I and with pulmonary hypertension, mean pulmonary artery pressure 28.3 +/- 8 (range 21-40) mm Hg. a1 blocker, doxazosin was administered per os in a daily dose of 2-3 mg. Pulmonary hemodynamics was performed before and after 30 day of treatment. After therapy, compared to baseline results, pulmonary artery systolic pressure decreased from 48.6 +/- 14 to 42.5 +/- 13 mm Hg, p=0.003, pulmonary artery diastolic pressure from 14.5 +/- 6 to 7 +/- 4 mm Hg, p=0.02), mean pulmonary artery pressure from 28.3 +/- 8 to 21.1 +/- 5 mm Hg, p=0.01 and pulmonary vascular resistance from 389.6 +/- 14 to 234.6 +/- 73 dyn x s x cm5. No significant changes in pulmonary artery wedge pressure, cardiac output, arterial oxygen content, percent saturation of hemoglobin with oxygen and oxygen delivery were found. In summary, the results of 30 day doxazosin therapy support alpha1 adrenergic hypothesis for pulmonary hypertension and suggest potential clinical benefits during long term treatment in patients with pulmonary hypertension due to COPD.

Electrocardiographic signs of right ventricular overload in patients who underwent pulmonary embolism event(s). Are they useful in diagnosis of chronic thromboembolic pulmonary hypertension?

Diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) remains a major clinical problem. An attempt was made to learn whether electrocardiography has the potential to alleviate that problem. Sensitivity, specificity, negative and positive predictive value as well as a likelihood ratio of electrocardiogram (ECG) signs of right ventricular overload (RVO) were determined in 56 patients with chronic pulmonary embolism and a mean pulmonary artery pressure (mPAP) ranging from 15 to 80 mm Hg. CPE was recognized as the only disease in 44 patients (Group A) whereas the remaining 12 CPE patients suffered from concomitant cardiac and pulmonary diseases (Group B). Thirty three (59%) of the patients were diagnosed with CTEPH (mPAP exceeding 30 mm Hg). Twelve ECG signs of RVO were identified in the entire population of patients. At least a single ECG sign of RVO was found in 72% of the patients and 7 ECG signs were found exclusively in CTEPH patients. Negative T wave in precordial V1-V5 leads, negative T wave in II, III, aVF, pulmonary P wave and right axis deviation >90% occurred with the highest incidence that was determined to be 43%, 32%, 30%, and 30% respectively. These ECG signs of RVO had positive predictive value of those signs ranged from 80 to 100% in Group A and 25 to 75% in Group B, whereas their negative predictive value ranged from 44 to 76% and from 66.5 to 87.5% respectively. It is concluded that ECG signs of RVO appear to have the potential to aid in diagnosing CTEPH in the patients who underwent acute embolic event in the past.

[Infective endocarditis--still a great challenge. Two case reports]. / Infekcyjne zapalenie wsierdzia - wciaz wielkie wyzwanie. Opis dwóch przypadków.

We present two patients with aortic valve disease who developed acute infective endocarditis. In both patients the disease started with infection of the upper respiratory tract. The patients were treated with antibiotics due to pneumonia. The diagnosis of infective endocarditis was established 4 months and 9 weeks after the onset of infection. The first patient died whereas the second underwent successful aortic valve replacement.

[Acute myocardial infarction in a patient with normal coronary arteries--a case report]. / Ostry zawal serca przy niezmienionych angiograficznie tetnicach wiencowych.

A case of a 72-year-old female who was admitted for elective dual-chamber pacemaker implantation, is presented. A few hours after the procedure the patient developed chest pain with ST-segment elevation in ECG and a significant increase in the troponin I level. An acute myocardial infarction was diagnosed. Urgent coronary angiography revealed normal coronary arteries without spasm. Possible causes of acute myocardial infarction following pacemaker implantation are discussed.

[Effect of a 2-year pulmonary rehabilitation on the 7-year prognosis in patients with advanced chronic obstructive pulmonary disease]. / Wplyw 2-letniej rehabilitacji oddechowej na 7-letnie rokowanie u chorych z zaawansowana przewlekla obturacyjna choroba pluc.

Pulmonary rehabilitation (PR) improve the quality of life in COPD patients, however, little has been known whether it may improve the survival. We assessed 7-year prognosis in 46 patients with advanced COPD, 27 of which completed successfully 2-year course of PR whereas 19 COPD patients made a control (C) group. At the end of 7-year observation 41.3% of total number of patients survived, among them 12 (42.8%) PR patients and 7 (38%) C patients. COPD progression was the main (80%) reason of mortality in both groups. The survivors had better results of baseline FVC, FEV1 and treadmill exercise test. They did not differ from non-survivors with age, baseline results of the weight, PaO2, PaCO2 and the number of PR patients. The Cox proportional hazard analysis showed that neither of baseline parameters influenced significantly the 7-year prognosis in this group of COPD patients. In conclusion, PR failed to improve 7-year prognosis in the studied group of patients with advanced COPD.

[Acute myocardial infarction treated with primary PCI complicated by pulmonary embolism--a case report]. / Pierwotna interwencja wiencowa w swiezym zawale serca powiklana zatorowoscia plucna.

A case of 53-year-old male who was admitted to the hospital due to a chest pain, is presented. ECG showed ST elevation in precordial leads. The patient was successfully treated with primary angioplasty. On the third day of hospitalization, he collapsed with hypotension. Routine echocardiographic examination revealed signs of pulmonary embolism. An adequate pharmacotherapy was implemented and the patient improved. After 10 days of treatment and rehabilitation he was discharged home. The present case report points out on pulmonary embolism as a rare but potentially life-threatening complication of coronary angioplasty.

[Repeated coronary angioplasty due to restenosis and disease progression - a case report]. / Nawroty zwezen po angioplastyce i postep choroby wymuszaja czeste interwencje. Dylematy postepowania.

We present a case of a 71-year-old male with exercise angina and two-vessel coronary artery disease (CAD). As the first step of treatment, the patient underwent successful coronary angioplasty with a stent implantation in the circumflex artery and remained free from angina for the following month. After this period, the patient underwent elective angioplasty of left anterior descending (LAD) coronary artery which was complicated by dissection, requiring implantation of two stents. Because of recurrent angina the patient underwent three months later another coronary angiography which revealed in-stent restenosis in LAD. The patient underwent repeated angioplasty with a good angiographic results, however, without cessation of angina Clinical and angiographic indications for percutaneous coronary interventions, according to the recent ACC/AHA guidelines, are discussed.

[Coronary angiography is not always helpful in differential diagnosis between perimyocarditis and myocardial infarction - four case reports]. / Czy zmiany ST-T elektrokardiogramu sa wynikiem zapalenia osierdzia i miesnia sercowego - czy zawalu serca. Koronarografia nie zawsze rozstrzyga watpliwosc. Opis 4 przypadków.

Four males aged 17-42 years with ST-T segment changes suggesting perimyocarditis or non-Q acute myocardial infarction are presented. Coronary angiography was performed to establish the final diagnosis. Three patients had normal coronary arteries; two of them had typical clinical signs of perimyocarditis whereas the third patient had less typical changes. The fourth patient was a smoker, had a family history of coronary heart disease and left ventricular dysfunction due to a non-Q wave apical infarction. In this patient coronary angiography revealed small atheromatous plaques in the distal part of left anterior descending artery as well as left main and right coronary artery spasm. Angiospastic aetiology of infarction and probable endothelial dysfunction due to myocarditis were diagnosed. The authors conclude that coronary angiography is not always helpful if clinical, electrocardiographic and biochemical signs of perimyocarditis are observed.