Congenital Complete Heart Block-To Stimulate (When?) or Not to Stimulate?

This article presents the case of a 27-year-old female patient with idiopathic congenital complete heart block who does not consent to the implantation of a cardiac pacemaker but was referred by her primary care physician for cardiological evaluation. The conduction disturbance was recognized at the age of 6 and was asymptomatic. The professional disqualification from pacemaker implantation included a detailed history of a patient's symptoms, an echocardiographic assessment of the heart, exercise testing and ECG Holter monitoring. The aid of salbutamol administered orally was also useful.

Echocardiographic parameters as adjuncts to the Pulmonary Embolism Severity Index in predicting 30-day mortality in acute pulmonary embolism patients.

BACKGROUND: The Pulmonary Embolism Severity Index (PESI) is a validated tool to predict 30-day all-cause mortality in patients with acute pulmonary embolism (PE) but includes only clinical variables. AIMS: We aimed to determine the effectiveness of PESI extended with an echocardiographic parameter. METHODS: This cross-sectional observational study included consecutive patients with acute PE diagnosed with computed tomography pulmonary angiography. RESULTS: Of 117 subjects (57 men, 48.7%), at a median age of 69 (59-80) years, 16 patients died during the 30-day follow-up. Six modified models of PESI with an additional single echocardiographic parameter were created, which increased the predictive value of PESI (area under the curve [AUC] 0.8608): tricuspid annular plane systolic excursion (TAPSE) <18 mm, right ventricular (RV) free wall longitudinal strain (RVFWLS) >-23%, 60/60 sign, RV global longitudinal strain (RVGLS) >-16%, pulmonary ejection acceleration time (AcT) <67 ms, and thrombus in right heart cavities (AUC 0.8657 to 0.8976, respectively, all markers P <0.001). TAPSE, AcT, RVFWLS, and RVGLS showed significant correlations with the PESI score, but not a thrombus in the right heart cavity or the 60/60 sign. As PESI adjuncts, they independently predicted fatal outcomes: thrombus with hazard ratio (HR) 10.04 (95% confidence interval [CI], 2.81-37.12; P <0.001) and the 60/60 sign with HR 4.07 (95% CI, 1.27-12.81; P <0.001). CONCLUSIONS: The quantitative echocardiographic parameters of RV systolic function and pulmonary artery blood flow are associated with the PESI score and thus increase its predictive value to a limited extent. PE- specific findings: a thrombus in the right heart cavity and the 60/60 sign are effective adjuncts to the PESI score.

Indexing of Speckle Tracking Longitudinal Strain of Right Ventricle to Body Surface Area Does Not Improve Its Efficiency in Diagnosis and Mortality Risk Stratification in Patients with Acute Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism (PE) is associated with a serious mortality rate. Thus, the rapid diagnosis and identification of patients at high risk of death is pivotal. The search for echocardiographic parameters for this purpose continues. Recent publications reveal correlations between myocardial longitudinal strain (LS) and body surface area (BSA). The aim of the study was to evaluate the usefulness of indexing the right ventricular (RV) speckle tracking LS to BSA in detecting PE and stratifying the risk of 30-day all-cause mortality. METHODS: the prospective cross-sectional observational study group consisted of 167 consecutive patients (76 men, 45.5%) aged 69.5 ± 15.3 years, and they were referred for computed tomography pulmonary angiography. Patients underwent a transthoracic echocardiographic examination within 24 h of admission to the hospital ward. RVLS and their derivatives indexed to BSA were included in the analysis. RESULTS: PE was confirmed in 88 patients, while 79 patients had no radiological features of PE. The only echocardiographic parameters that differed between subgroups were pulmonary flow acceleration (Act), McConnell's sign, LS of the middle segment of the RV free wall, and its derivative indexed to BSA. During the 30-day follow-up of a subgroup of subjects with PE, 12 patients died. The mortality predictors with increasing prediction value included a RV free wall mid-segment LS (cut-off value: -21%, Area Under the Curve-AUC 0.6, p = 0.02) and its derivative indexed to BSA (-14 %/m2, AUC 0.62, p = 0.003), body mass index (24.7 kg/m2, AUC 0.63, p = 0.002), D-dimer serum concentration (3559 pg/mL, AUC 0.66, p < 0.001), Act (67 ms, AUC 0.67, p < 0.001), septal basal LS (-15%, AUC 0.68, p = 0.02), RV free wall basal segment LS (-14%, AUC 0.7, p = 0.015), age (66 years, AUC 0.74, p = 0.004), NT-proBNP (1120 pg/mL, AUC 0.75, p = 0.01), troponin T (66 ng/mL, AUC 0.78, p = 0.005), and the complex score of the Pulmonary Embolism Severity Index (AUC 0.88, p < 0.001). CONCLUSIONS: indexing of RVLS to BSA does not improve its prognostic value in patients with acute PE.

Paroxysmal Sustained Ventricular Tachycardia with Cardiac Arrest and Myocardial Infarction in 29-Year-Old Man Addicted to Medical Marijuana-It Never Rains but It Pours.

This article presents the case of a 29-year-old male patient, addicted to prescribed medical marijuana administered for mixed anxiety and depressive disorder and without classic cardiovascular risk factors and history of myocarditis, suffering from episodes of paroxysmal hemodynamically unstable ventricular tachycardia. Cardiovascular magnetic resonance imaging of the heart revealed disseminated non-ischemic myocardial injury lesions of subepicardial and intramuscular location. Additionally, the individual experienced myocardial infarction without ST segment elevation following marijuana intake. Treatment required implantation of a cardioverter-defibrillator and ablation of the myocardial areas responsible for the origin of the arrhythmia, as well as appropriate pharmacotherapy and marijuana addiction treatment.

Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK): A novel independent predictor of 30-day mortality in patients with acute pulmonary embolism.

BACKGROUND: The most commonly used parameter of right ventricular (RV) systolic function - tricuspid annular plane systolic excursion (TAPSE) - is unavailable for some patients. Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) has been proposed as its alternative. AIM: The study aimed to assess the feasibility of SEATAK use in patients with acute pulmonary embolism (PE) and its value in prognosis after PE. METHODS: The observational study included 164 consecutive patients (45.7% men; average age, 70 years) with a high clinical probability of PE referred for computed tomography pulmonary angiography. RESULTS: SEATAK was unavailable due to inadequate quality of echocardiogram in 2.8% of patients, whereas TAPSE could not be calculated in 4.9%, both parameters were not estimated only in 0.6%. SEATAK and TAPSE values did not differ between groups of patients with PE (n = 82) and without (n = 82). In the whole study, SEATAK correlated positively with TAPSE (r = 0.71; 95% confidence interval [CI], 0.62-0.78; P < 0.001), fractional area change of the RV, left ventricular ejection fraction, and peak systolic tricuspid annular velocity assessed with tissue Doppler imaging. There were only 3 echocardiographic predictors of 30-day all-cause mortality in patients with with PE (n = 10): SEATAK, pulmonary acceleration time, and the 60/60 sign. SEATAK predicted 30-day all-cause mortality with AUC (area under the curve) 0.726 (95% CI, 0.594-0.858; P = 0.01) and 30-day PE-related mortality (n = 4) with AUC, 0.772 (95% CI, 0.506-0.998; P = 0.03). CONCLUSIONS: SEATAK is a promising practicable echocardiographic parameter reflecting RV systolic function and might be an accurate alternative to TAPSE. Moreover, SEATAK could be an independent predictor of all-cause and PE-related 30-day mortality in patients with acute PE.

Nicotine affects hydrogen sulfide concentrations in mouse kidney and heart but not in brain and liver tissues.

Nicotine, a potent parasympathomimetic alkaloid with stimulant effects, is contributing to addictive properties of tobacco smoking and is though used in the smoking cessation therapy. Hydrogen sulfide (H2S) is involved in physiology and pathophysiology of various systems in mammals. The interactions between nicotine and H2S are not fully recognized. The aim of the study is to assess the influence of nicotine on the H2S tissue concentrations in different mouse organs. Adult CBA male mice were administered intraperitoneally 1.5 mg/kg b.w. per day of nicotine (group D1, n = 10) or 3 mg/ kg b.w. per day of nicotine (group D2, n = 10). The control group (n = 10) received physiological saline. The measurements of the free and acid-labile H2S tissue concentrations were performed with the Siegel spectrophotometric modi ed method. ere was a significant increase in H2S concentrations in both nicotine doses groups in the kidney (D1 by 54.2%, D2 by 40.0%). In the heart the higher nicotine dose caused a marked decrease in H2S tissue level (by 65.4%), while the lower dose did not affect H2S content. Nicotine administration had no effect on H2S concentrations in the brain and liver. In conclusion, nicotine affects H2S tissue concentrations in kidney and heart but not in the liver and brain tissues.

Right-sided aortic arch with aberrant left subclavian artery and hearing loss in patient with abnormal cardiomediastinal contours in routine chest X-ray.

Although the development of technologically advanced imaging techniques has progressively reduced the use of chest X-ray in clinical practice, it is still an invaluable tool to evaluate different diseases of the respiratory and cardiovascular systems. We are presenting a case of a 55-year-old male with arterial hypertension, severe mixed hearing loss who was referred to an internal medicine ward due to abnormal mediastinal and cardiac contours observed in a routine chest X-ray. The finding was linked to an anomalous aortic course what was confirmed within transthoracic echocardiography. The computed tomography angiography of the whole aorta revealed the right sided aortic arch (RSAA) with four large arteries arising from the aortic arch, including the aberrant left subclavian artery compressing the esophagus causing though no symptoms. Since RSAA might be associated with other cardiovascular diseases and genetic disorders including 22q11.2 deletion syndrome, we have conducted a complex diagnostics which showed additionally a decreased level of lymphocytes. The patient did not consent to genetic diagnostics and was qualified for conservative treatment of his disorders. In conclusion, a plain chest radiograph with the assessment of heart silhouette must not be neglected in cardiologic diagnostics. The identification of even asymptomatic aortic anatomic variant should be followed by the whole aorta angiography and a detailed assessment of the patient. RSAA bears potential risk of tracheostomy bleeding, unforeseen problems in transradial coronary procedures and potential problems during thyroid surgery, also because of abnormal recurrent laryngeal nerves' course.

Echocardiographic assessment of right ventricular function in responders and non-responders to cardiac resynchronization therapy.

INTRODUCTION: The aim of this study was to determine whether baseline right ventricular (RV) function assessed by standard echocardiography may indicate patients who will respond to cardiac resynchronization therapy (CRT). MATERIAL AND METHODS: The data of 57 patients (54 men, 95%), aged 66.4 ±8.7 years with heart failure (HF) having a CRT device implanted were collected. All patients had left ventricular ejection fraction (LVEF) ≤ 35% and QRS complex duration ≥ 120 ms. Echocardiographic examination with tissue Doppler imaging techniques and complex RV evaluation were performed at baseline and three months after CRT onset. RESULTS: Three months after CRT implantation, patients responding to CRT, defined as a reduction of left ventricle end-systolic volume (LVESV) of at least 10% (n = 34), compared to patients with a reduction of LVESV of less than 10% (n = 23), had at baseline a smaller right atrium diameter (47.85 ±11.33 mm vs. 52.65 ±8.69 mm; p = 0.028), higher TAPSE (14.56 ±2.57 mm vs. 13.04 ±2.93 mm; p = 0.030) and lower grade of tricuspid valve regurgitation (1.82 ±0.97 vs. 2.3 ±0.88; p = 0.033). CONCLUSIONS: This study showed that there are differences in baseline right ventricular function between responders and non-responders to CRT. Yet in our study, none of the baseline RV parameters provided any value in identifying patients who would respond to CRT.

Sodium Hydrosulfide Exerts a Transitional Attenuating Effect on Spermatozoa Migration in Vitro.

Hydrogen sulfide (H2S) has been shown to have a prominent role in the regulation of reproductive system function and fertility. The aim of the study was to assess the effect of a H2S donor, sodium hydrosulfide (NaHS), on mouse sperm migration in vitro. Special plates with 4 corner wells filled with balanced salt solution (control) and various NaHS solutions in concentrations of 2.5 mmol/l, 5 mmol/l or 10 mmol/l were applied. Spermatozoa from each male mouse were injected (the experiment was repeated with ten BALB/c 5-month old males) into the central pocket, connected with the wells with ducts. After 1 h, 2 h and 4 h of incubation, the number of spermatozoa in each well was determined using Bürker's counting chambers. The number ofspermatozoa in all corner wells were summed and the number of the cells in each well was treated as the percentage share of all the migrated spermatozoa. At the time points of 1 hour and 4 hours, no differences regarding chemotactic features of spermatozoa to the utilized solutions were observed. After two hours of incubation the attenuating effect of NaHS medium and high level solutions on spermatozoa migration was observed, but not for the low concentration mixture: H(3, N = 40) = 9.65, P = 0.022; control group vs 5 mmol/l NaHS solution: 36.0% vs 18.5%, P = 0.023; control group vs 10 mmol/l NaHS solution group: 36.0% vs 17.0%, P 0.011. In conclusion, NaHS has a transitional attenuating effect on spermatozoa migration in vitro.

Awareness of cardiovascular risk factors in ambulatory cardiology patients.

Cardiovascular diseases (CVD) are the leading cause of mortality. The majority of CVD risk factors are modifiable and controllable so the knowledge of them might prevent circulatory diseases development and improve already diagnosed CVD outcomes. The aim of the study was to assess the awareness of risk factors for CVD in ambulatory patients of cardiology offices. A specially designed questionnaire was used by trained physicians in a structured technique of face-to-face interview in 284 consecutive patients (men - 47.9%, aged 64.1 ± 11.2 years). As many as 6.3% of the study participants did not name any CVD risk factor, whereas only 7.4% of patients knew at least 3 of them. Smoking and high cholesterol were best recognized (33.1% and 27.4%, respectively) while the least often quoted old age was identified only by 2.5% of the individuals. The average number of the listed CVD risk factors equaled 1.38 ± 0.77. In the multiple regression analysis the factors significantly associated with knowledge of CVD risk factors comprised the level of education (b = 0.55, p < 0.0001) and age (b = -0.02, p < 0.0001). The patients with family history of CVD diseases were more often aware of the fact that family history of CVD is a risk factor for CVD as compared to individuals with no relatives affected by CVD (21.9% vs 10.1%, p = 0.0061). To the contrary, respondents with hypercholesterolemia less often knew that dyslipidemia is a CVD risk factor than patients with normal cholesterol levels (24.1% vs 41.1%, p = 0.0108). In conclusion, the awareness of cardiovascular risk factors in ambulatory cardiology patients is very low. The perception of CVD risk factors is affected by the level of education and age.

Non-steroidal anti-inflammatory drugs and paracetamol in self-therapy of various disorders in students of different fields of study.

Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol are most commonly the first-line pharmacotherapy in combating different pain and inflammatory disorders and fever. Unfortunately, those drugs might have serious side effects, especially when they are used in an inappropriate way. The aim of the study was to explore various aspects of NSAIDs and paracetamol use in the self-therapy of miscellaneous disorders in young adults. The questionnaire-based survey comprised 250 consecutive students aged 22.1 ± 1.9 years (189 women) of diverse fields of study. The drugs were applied in clinical conditions in which they should be avoided including asthma attack (1.2%), vomiting (2.4%), malaise and depression (3.6%), in autumn and winter as a preventive measure against infections (14.0%), heart-burn (2.0%) and during food poisoning (16.0%). As many as 6.0% of the students claimed that studied medications are ultimately free of adverse reactions. Men more frequently than women used NSAIDs and paracetamol during alcohol consumption (49.2% vs 30.7%, p = 0.009, respectively) but less often were aware that there are maximum doses of medications which should not be exceeded (57.4% vs 76.7%, p = 0.003, respectively). The students of medical-related degree courses (n = 82) compared with individuals of other subjects (n = 168) declared they more often have the custom of always reading medications' leaflets (46.3% vs 31.0%, p = 0.017, respectively). Side effects of medicines were reported by 65 participants - 26.0%. In conclusion, students' knowledge about NSAIDs and paracetamol is low. Participants do not search for information on drug related endangerments, the medication group choice for the given disorder is often inappropriate and the drugs are applied in conditions in which they are contraindicated.

Selected apoptotic markers in serum of patients with chronic viral hepatitis C.

BACKGROUND: In chronic viral hepatitis C, hepatocytes inflammation, necrosis and apoptosis occur. To evaluate hepatocyte apoptotic rate, a serum concentration of proapoptotic FaS protein and its ligand (FaS/FaSL) as well tumor necrosis factor-alpha (TNF-alpha) and antiapoptotic hepatocyte growth factor (HGF) may be used. The aim of the study was to evaluate the hepatic apoptosis rate in patients with hepatitis virus C infection and its correlations with the degree of liver inflammation and staging, biochemical tests, viral load and the duration of the infection. PATIENTS AND METHODS: 60 adults (30 chronic hepatitis C patients and 30 controls) were included into the study. Serum levels of FaS/FaSL, TNFalpha and HGF were evaluated using the ELISA method. The results were correlated with viral load, biochemical tests, as well ultrasonographic and histopathological (grading, staging) examinations. RESULTS: TNF-alpha level in HCV-infected patients was significantly higher than in the controls (11.0 +/- 19.3 pg/ml vs. 3.3 +/- 2.8 pg/ml, p = 0.04). FaS/ FaSL and HGF did not differ significantly in both groups. TNF-alpha level was higher in patients with low staging (fibrosis F-0) than in those with higher staging (F-1, F-2, F-3)--according to the Batts-Ludwig scale. Other markers (FaS/FaSL and HGF) did not differ in groups with variant staging. No significant differences were observed in relation to grading. CONCLUSIONS: The measurement of FaSIFaSL, TNF-alpha and HGF does not allow for the assessment about apoptotic rate in patients with chronic hepatitis C. Explanation of this problem need follow-up studies on larger groups with the use of more complex methods.

Acute pulmonary embolism mimicking STEMI. Do the potential benefits of pulmonary artery angiography support the decision to perform the procedure?

This case report concerns a 68 year old male with, type 2 diabetes, stage 3 hypertension, hypercholesterolemia, myocardial infarction (MI) 20 years ago. He was admitted to the catheterization laboratory with suspected acute inferior wall MI. Angiography of pulmonary arteries revealed massive thrombosis.

Heart rate variability in the course of ST--segment elevation myocardial infarction treated with primary percutaneous transluminal coronary angioplasty in elderly and younger patients.

BACKGROUND: The aim of the study was to appraise time domain heart rate variability (HRV) parameters in patients with ST-segment elevation myocardial infarction (STEMI) in different age groups. MATERIAL AND METHODS: Retrospective analysis included 357 consecutive patients in sinus rhythm without diabetes, aged 27-87 years (mean age--63.0 +/- 11.8 years, 243 men) treated with primary percutaneous transluminal coronary angioplasty (PTCA) due to first in their life STEMI. Each patient had an echocardiographic examination and 24-hour ECG monitoring results interpreted. Participants were divided in the analysis applying the WHO old age criterion into two groups: group A < 65 years old (n = 188) and B aged > or = 65 years (n = 169). RESULTS: In the whole study group age negatively correlated with SDNN, SDANNI, SDNNI and EF, whereas positive correlation between EF and SDANN, and EF and SDNNI was observed. Elderly patients as compared to the younger individuals had significantly diminished SDNN, SDANN, SDNNI and more often SDNN < 70 ms (33.7% vs 20.7%, p < 0.0001). When the circumflex artery lesion was the cause of myocardial infarction SDNN and SDANN were significantly lower in the group B, whereas in case of PTCA of RCA, apart from decreased SDNN and SDANN, EF was also compromised in this group. CONCLUSIONS: Elderly patients with myocardial infarction with ST-segment elevation treated with primary PTCA, compared to the younger age group, are characterized by increased sympathetic activation assessed by heart rate variability and heart rate in 24-hour ECG monitoring.

Safety and tolerability of the use of atorvastatin 40 mg in common daily practice in short-term observation in 3,227 patients.

BACKGROUND: Statins reduce cardiovascular morbidity and mortality but their administration is associated with a broad array of potential adverse effects. The aim of the study was to assess the safety and tolerability of the use of atorvastatin in the dose of 40 mg a day during short-term observation in daily practice--in outpatient clinics, specialized individual practice offices and in-patient health care units. MATERIAL AND METHODS: A prospective authorial interviewer questionnaire-based study comprised 3,227 consecutive patients who were already administered 40 mg of atorvastatin a day or just started the therapy. The mean follow-up was 38 +/- 13 days. RESULTS: Fifty two patients (1.6% of all study participants) interrupted atorvastatin therapy due to drug-related adverse effects, which comprised mainly increased liver transaminases (0.4%) and myalgia (0.5%). In many of those patients complex side reactions were observed concerning mostly gastrointestinal disturbances (1.2%). No cases of rhabdomyolysis were reported. As many as 160 individuals (5.0%) did not continue the therapy due to economical issues, personal belief or low awareness of cardiovascular diseases and their potential complications. CONCLUSIONS: Atorvastatin in daily dose of 40 mg is a safe and well tolerable medication for the treatment for dyslipidemic disorders in patients of different clinic profile and cardiovascular risk groups in common medical practice.

Medication adherence in hypertensive patients of different cardiovascular risk treated in primary health care.

BACKGROUND: The execution of the dosing regimen in Polish primary health care is unknown. The aim of the study was to appraise the medication adherence in patients with hypertension of various cardiovascular risk. MATERIAL AND METHODS: A prospective interviewer questionnaire-based study included 1,467 consecutive patients with arterial hypertension with the pharmacotherapy containing ramipril in the daily dose of 10 mg. The mean observation period was 30.3 +/- 7.0 days (20-56 days). At the followup visit the study participants filled the Morisky-Green test appraising the medication non-adherence. RESULTS: As many as 60.9% of the study participants have ever forgotten to take their medicine, 60.7% are sometimes neglectful in regard to their medicine hours, 32.4% skip their medicine hours when they are feeling well and 37.4% skip the drugs when they feel badly due to the medicine. Drug adherence was observed in 26.0% of patients. The level of adherence varied between different cardiovascular risk groups and was higher in the groups of lower cardiovacular risk. A very weak correlation between cardiovascular risk level and non-adherence to medication assessed with Morisky-Green scale was observed (r = 0.078, p = 0.047). No relation of non-compliance to medication to age and gender was noted. CONCLUSIONS: Drug adherence in patients with hypertension treated in Polish primary healthcare is very low regardless of the cardiovascular risk level.