Continuous hands-free monitoring of echocardiographic exercise test using probe fixation device.

BACKGROUND: Stress echocardiography has been widely used in clinical practice for decades and has recently gained even more importance in diagnostic approaches to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise tests. The aim herein, is to assess the feasibility of probe fixation for use during exercise echocardiography. METHODS: Forty-eight subjects (47 men, mean age 42 ± 17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). The semi-quantitative quality of acquired apical views were assessed at each stage using a four-point grading system. RESULTS: The mean time required for probe fixation was 9 ± 2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. Twenty-five patients required probe repositioning during exercise (more often on a treadmill). During peak exercise quality of images in all views declined, but for diagnostic purposes it remained sufficient in 29 patients. Thus, 76% of performed tests (60% study population) had sufficient image quality. CONCLUSIONS: Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. The device is suitable almost exclusively for male patients and in some patients requires repositioning.

Predictors of successful acetylsalicylic acid resistance suppression after percutaneous coronary revascularisation.

BACKGROUND AND AIM: There is no established management of resistance to acetylsalicylic acid (ASA) in patients with coronary artery disease (CAD). We hypothesised that simply doubling the usual daily dose of ASA could be effective in overcoming ASA resistance. METHODS: Our study comprised 40 subjects with CAD (male 67.5%, mean age 60.5 ± 8.8 years, mean body mass index 26.9 ± 2.7 kg/m² and median aspirin reaction unit [ARU] value obtained with a Verify Now Aspirin Test 612 [573-634]) with resistance to 75 mg/daily ASA defined as ARU ≥ 550. According to the overcoming of resistance or lack there of in a repeated test after four weeks of 150 mg daily ASA treatment, we defined two subsets: subjects who regained ASA sensitivity, and those who did not. RESULTS: Successful overcoming of ASA resistance was observed in 62.5% of patients. Multivariate analysis regression confirmed that two variables independently determined successful ASA resistance suppression: male gender (OR 6.88; 95% CI 1.29-36.75; p = 0.024), and ARU for 75 mg daily (OR 0.97 per unit at 75 mg; 95% CI 0.94-0.99; p = 0.039). ROC analysis indicated that the threshold value at which ARU at 75 mg ASA treatment was predictive of successful ASA resistance overcoming was ≤ 608 ARU. Using a simple point score (one point for male gender and one for initial ARU ≤ 608), we found that ASA resistance was overcome in 8%, 36% and 56% of patients, when zero, any single, or two predictors were present. CONCLUSIONS: ASA resistance overcoming by dose doubling can be achieved more often in males and in subjects with lower ARU value at ASA 75 mg.

Presence of coronary collaterals in ST-elevation myocardial infarction patients does not affect long-term outcome.

INTRODUCTION: The significance of coronary collateral circulation in the prognosis of patients after myocardial infarction remains disputable. OBJECTIVES: The aim of the study was to evaluate the effect of coronary collateral circulation, assessed by the Rentrop score, on long-term prognosis in patients treated with primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). PATIENTS AND METHODS: Coronary collateral flow was assessed by angiography in 330 patients with myocardial infarction using the Rentrop score. Patients were followed up for the mean period of 26 ±12 months with the clinical endpoints of cardiac death, nonfatal reinfarction, and repeat percutaneous or surgical revascularization. RESULTS:  Collateral circulation was graded Rentrop 0 in 39%, Rentrop 1 in 36%, Rentrop 2 in 18%, and Rentrop 3 in 7% of the patients. The mortality rate was 8.7%. Reinfarction occurred in 4.7% of the subjects, and repeat coronary revascularization was performed in 10.9% of the patients. These endpoints were not correlated with the degree of collateral circulation. A significant inverse association was observed between the Rentrop score and the infarct-related artery antegrade flow (P <0.001). CONCLUSIONS: The degree of collateral circulation assessed by the Rentrop score during primary PCI is not a useful long-term prognostic factor in the population with STEMI in the current therapeutic approach. This may result from the negative correlation between the Rentrop score and the degree of blood flow in the infarct-related artery. Thus, collateral circulation in a patient with STEMI should not discourage intensive cardiovascular risk factor control in secondary prevention of coronary artery disease.

The new oral adenosine A1 receptor agonist capadenoson in male patients with stable angina.

BACKGROUND: Anti-ischaemic effect of A1 adenosine receptor agonists was shown in animal and preclinical studies. The present proof-of-concept study aimed at evaluation of the efficacy and safety of a new adenosine A1 receptor agonist capadenoson in patients with stable angina. METHODS: This was a randomized, double-blind, placebo-controlled, single dose-escalating, multicenter trial comparing the effect of capadenoson at 1, 2.5, 5, 10, and 20 mg versus placebo. For each dose step patients were randomized to receive single doses of either capadenoson or matching placebo in a 5:1 ratio. The primary efficacy variable was the absolute difference in heart rate (HR) at maximum comparable level of workload between baseline and post dose exercise tolerance test at maximum concentration of capadenoson. Capadenoson effect on total exercise time and time to 1-mm ST-segment depression were also measured. RESULTS: Sixty-two male patients with stable angina were enrolled in the study. There was a consistent trend for HR reduction at comparable maximum work load in active treatment groups, with significant differences against placebo for 10 and 20 mg (HR reduction by 12.2 and 6.8 beats per min, p = 0.0002 and p = 0.032, respectively). A statistically significant trend (p = 0.0003) for a reduction in HR with increasing doses of capadenoson was shown. Increases in total exercise time and time to 1-mm ST-segment depression were also observed. CONCLUSIONS: In patients with stable angina capadenoson lowers exercise HR at comparable maximum workload, which is associated with improved total exercise time and prolongation of time to ischaemia.

Direct comparison of the diagnostic value of point-of-care tests detecting heart-type fatty acid binding protein or glycogen phosphorylase isoenzyme BB in patients with acute coronary syndromes with persistent ST-segment elevation.

BACKGROUND: Myocardial infarction (MI) with its complications is one of the most serious challenges in contemporary cardiology. Among biochemical markers of myocardial necrosis, heart-type specific fatty acid binding protein (h-FABP) showed excellent sensitivity and specificity for the early diagnosis of an acute MI. The h-FABP is released rapidly (after 30 min) from the cardiomiocyte to the circulation in response to myocardial injury and may be useful for rapid confirmation or exclusion of MI. In recent years, glycogen phosphorylase BB (GP-BB) also emerged as a promising early specific marker of myocardial necrosis. Rapid, qualitative "point of care" tests (POCT) detecting h-FABP (Cardio Detect med) and GP-BB (Diacordon) have recently become available. AIM: To evaluate and compare qualitative POCTs detecting h-FABP and GP-BB in patients with an acute coronary syndrome (ACS). METHODS: We studied 52 patients with a strong suspicion of ACS with persistent ST-segment elevation and chest pain lasting less than 6 hours. The ultimate diagnosis of ST-segment elevation MI (STEMI) was confirmed in case of a second (6 h after admission) positive quantitative result of a cardiac troponin T (cTnT) test. On admission, POCTs to detect both h-FABP and GP-BB were performed. The study population was divided into two groups, with chest pain lasting 〈 3 h (n = 20) or 4-6 h (n = 32). All patients underwent coronary angiography and angioplasty if indicated. The sensitivity of the analysed biomarkers of myocardial necrosis was calculated. RESULTS: The sensitivity of h-FABP (84%) was superior in comparison to the other biomarkers, GP-BB and cTnT, which had sensitivity of 64% and 50%, respectively. Comparison of typical parameters of the diagnostic value of a test (sensitivity, predictive values and accuracy) in both time periods demonstrated that h-FABP was superior to GP-BB. In particular, sensitivity and accuracy of h-FABP was excellent in the group of patients with chest pain lasting 〈 3 h, with sensitivity of 79% for h-FABP and only 47% for GP-BB. Sensitivity and accuracy of cTnT were significantly lower (32% and 35%, respectively). CONCLUSIONS: The h-FABP seems to be an excellent early biomarker of cardiac necrosis in the group of patients with chest pain lasting 〈 3 h. The GP-BB can be also used as a biomarker of myocardic necrosis, but its sensitivity in the early phase of MI is limited.

[Hemorrhagic stroke in a patient requiring long-term anticoagulant treatment: how to solve a dilemma]. / Jak pogodzic sprzecznosci - udar krwotoczny u chorego wymagajacego przewleklego leczenia przeciwzakrzepowego. Opis przypadku.

Hemorrhagic stroke is a frequent cause of morbidity and mortality in Poland. It results from disruption of intracranial vessel wall continuity. We report a case of 66-years-old man with prosthetic aortic valve after three ischemic strokes treated with acenocoumarol who was admitted to hospital with vertigo and motoric aphasia. Computed tomography confirmed a hemorrhagic stroke related to anticoagulant treatment. We discussed the principles of management and therapeutic options in patients requiring long-term anticoagulation suffering from severe hemorrhagic complications.

Impact of the time to reperfusion on early outcomes in patients with acute myocardial infarction undergoing primary angioplasty.

BACKGROUND: The ACC/AHA guidelines for management of patients with ST-elevation myocardial infarction (STEMI) have recommended primary PCI (pPCI) as the preferred reperfusion therapy, when it can be performed in a timely fashion, within 90-110 min from the first contact with medical personnel. The impact of treatment delays on outcomes in patients undergoing pPCI has been controversial. AIM: To evaluate the impact of time delays on in-hospital mortality and on the frequency of cardiac events during 30 days after STEMI. METHODS: 1723 patients were stratified on the basis of their time delays: from symptom onset until balloon inflation. The patients were divided into 4 groups: group 1 (311 patients) - time from symptom onset <90 min; group 2 (731 patients) - time delays of 90-180 min; group 3 (535 patients) - time delays of 180-360 min, and group 4 (146 patients) - time from symptom onset >360 min. RESULTS: The median time delay was 268.5+/-206 min, the median door to balloon time was 36.12+/-11.2 min. The patients with longer time delays (group 4) were older, more often were women, and had a higher frequency of diabetes, anterior MI and Killip class 4. During hospitalisation, 70 (4.1%) patients died. In-hospital mortality was significantly higher in group 4 (13.6%) than in other groups. Complications of STEMI such as cardiogenic shock considerably influenced mortality (45.6%). During a 30-day follow- -up, the patients with cardiogenic shock and the elderly had an increased risk of cardiac events. Also, time delays >360 min and failed pPTCA were independent adverse risk factors in multivariate regression analysis. CONCLUSION: Delays in time to pPCI have an impact on outcomes, especially in those treated >6 hours from the onset of symptoms.

[Cardiotoxic properties of interferon: aggravation of atrio-ventricular block during treatment of chronic hepatitis C with peginterferon--a case report]. / Kardiotoksyczne dzialanie interferonu: Opis przypadku nasilenia zaburzen przewodzenia przedsionkowo-komorowego w czasie leczenia przewleklego zapalenia watroby typu C interferonem pegylowanym.

The authors reviewed cardiac adverse events during interferon therapy. The significance of preexisting cardiac disease (coronary artery disease, heart failure or cardiac arrhythmias) should be considered in patient selection for this treatment. A case of a 55-year old woman with chronic hepatitis C, qualified to peginterferon therapy in our hospital, is presented. No cardiac diseases were diagnosed in this patient previously. Atrio-ventricular (AV) conduction disturbances in the form of second-degree AV block were diagnosed during peginterferon therapy. The intensity of these disturbances diminished when treatment was interrupted. A pacemaker had to be implanted to enable the patient continuation of treatment without these side effects.

Doxorubicin-induced ventricular arrhythmia treated by implantation of an automatic cardioverter-defibrillator.

Anthracyclines are a group of potent antitumour agents and cardiotoxicity is an important factor limiting their therapeutic effectiveness. Although cardiomyopathy is the most widely recognized type of cardiotoxic reaction, early arrhythmia following anthracycline administration may be of clinical significance as well. We report a case of ventricular tachycardia causing cardiac arrest in a female treated with doxorubicin as adjuvant therapy of breast cancer. Due to recurrence of the arrhythmia and a desire to continue chemotherapy, an automatic cardioverter-defibrillator was implanted with excellent effect.

Elderly and patients with sick sinus syndrome have lower chances for appropriate pacemaker mode selection, according to the Polish Cardiac Society recommendations -- a single-centre retrospective analysis.

BACKGROUND: The Polish Cardiac Society recommendations for permanent heart pacing have been valid since 1999. The clinical use of these guidelines is, however, still limited. AIM: To analyse whether the chosen pacing strategy is consistent with the Polish Cardiac Society recommendations and to estimate the effects of analysed factors on selecting optimal or suboptimal pacing modes. METHOD: Retrospective analysis of medical records and procedure protocols of 1052 patients who underwent pacemaker implantation between 1 January 2000 and 31 December 2004 was performed. In each case, the applied pacing mode was compared against the optimal one defined according to the guidelines of the Polish Cardiac Society. A number of demographic and clinical factors associated with the procedure were analysed and correlated with the optimal pacing mode selection. RESULTS: During the analysed period, 59.3% of patients received optimal pacing. The percentage of patients with optimal pacing increased in the consecutive years from 40.2% in 2000 to 68.5% in 2005. In a univariate regression analysis, patients above the age of 70 years, with sick sinus syndrome as an indication for pacing, as well as cardiac heart failure and obesity, received optimal pacing significantly less frequently. In a multivariate analysis, advanced age and sick sinus syndrome were found to be independent predictors of suboptimal pacing. CONCLUSIONS: About 60% of patients had their pacemakers implanted with the optimal pacing mode selection according to the valid recommendations. Patients over the age of 70 years, as well as patients with sick sinus syndrome, had significantly lower chances of receiving optimal pacing.

[Transient psychiatric abnormalities in patients with acute myocardial infarction]. / Przemijajace zaburzenia psychiczne u pacjentów z ostrym zespolem wiencowym z uniesieniem odcinka ST.

UNLABELLED: Psychiatric abnormalities (PA) are often observed in patients (pts) in the Coronary Care Units. The origin of such abnormalities is not always clear, but it is known that they may aggravate patients status and interfere with further treatment. The aim of this study was to analyze the factors potentially predisposing to the occurrence of PA in pts with acute myocardial infarction (AMI). MATERIAL: The study group consisted of 200 consecutive pts hospitalized due to AMI. In 63 of them (Group A) the in-hospital course was complicated by PA (agitation, anxiety, hallucinations). Sex- and age-matched 63 pts of the remaining 137 pts which had not PA were control group (Group B). METHODS: The data related to coronary artery disease history, AMI diagnosis and treatment were withdrawn from hospital reports. Second group of parameters was focused on history of central nervous system (CNS) diseases, vision and audition ability, stimulant or drug addiction. The data about patient's employment and familial status, level of education, self-estimation of quality of life (QoL) in hospital were the third group of parameters. The second and third group of data were questionnaire-based information. RESULTS: There were no significant differences between groups in arrhythmias, localization of AMI, percentage of pts with high level of education, neither living alone or with family, jobless, retired or employed ones. Also self-evaluation of QoL was distributed similarly. The parameters which differed Group A versus Group B were respectively: history of CNS diseases (48% vs 20%, p<0,05), in particular--CNS traumas (18% vs 2,3%, p<0,05) and ischemic episodes (10% vs 0%, p = 0,039), thrombolytic (non-percutaneous interventional) treatment 23,8 vs 4,6%, p<0,05), handicap of visual ability (16% vs 0%, p--0,012), nicotinism (30% vs 9,1%, p<0,05), left ventricle ejection fraction <40% (34% vs 5%, p<0,05), treatment with atropine (12,7% vs 0%, p = 0,012) or amiodarone (16,7% vs 0%, p = 0,037). CONCLUSION: History of neurological diseases, thrombolytic treatment, left ventricle ejection fraction <40%, handicap of visual ability, nicotinism and amiodarone or atropine in pharmacological treatment are factors which may be helpful to predict PA in pts with AMI. Cumulation of such factors increases a risk of occurrence of transient psychiatric abnormalities. Proper psychoactive pretreatment should be applied in pts with such profile in purpose to avoid behavior related complications.

[Persistent left superior vena cava]. / Przetrwala zyla glówna górna lewa.

Persistent left superior vena cava -- a case report. A case of a 72-year-old female admitted for pacemaker implantation is presented. During the procedure, persistent left superior vena cava was found. Pacemaker was inserted via right subclavicular vein.

Myocardial ischemia and autonomic activity in dippers and non-dippers with coronary artery disease: assessment of normotensive and hypertensive patients.

OBJECTIVES: The aim of this study was to assess the relations between the circadian variations of blood pressure (BP) and the pattern of ischemia and autonomic activity in normotensive and hypertensive patients with coronary artery disease (CAD). PATIENTS AND METHODS: On the basis of the results of ambulatory BP monitoring, 115 patients with stable CAD were divided into Group 1 (with arterial hypertension) and Group 2 (normotensives). Groups were subdivided into dippers and non-dippers. Holter monitoring was performed to assess the occurrence and circadian pattern of ischemic episodes. Time domain and frequency domain HRV analyses were performed to evaluate the autonomic activity. RESULTS: The total number of ischemic episodes was similar in dippers and non-dippers. Non-dippers had a greater number of silent episodes and a different circadian pattern of ischemia with more night episodes. Among the time-domain HRV parameters, only SDNN was similar in dippers and non-dippers. Non-dippers had lower pNN50 and rMSSD-the parameters expressing parasympathetic activity. Differences between diurnal and nocturnal results of spectral HRV analysis were observed in dipper patients only. They presented an elevation of HF power and a decline of LF power at night. All differences between dippers and non-dippers were of similar significance in both hypertensives and normotensives. CONCLUSIONS: A lack of a nocturnal fall in BP is present in normotensive and hypertensive patients with CAD. Non-dippers with CAD had silent and nighttime ischemia more often. They also had an abnormal pattern of autonomic activity with higher sympathetic and lower parasympathetic modulation.