Updated overview of evidence on optimal antithrombotic therapy in patients with atrial fibrillation undergoing percutanous coronary intervention.

Selection of the optimal peri- and postprocedural antithrombotic regimen in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is a common clinical problem which may pose a challenge to medical practitioners. This systematic review summarizes the updated evidence on this topic. Non-vitamin K oral anticoagulants (NOACs) at standard doses are the preferred option in most of post PCI patients with AF, except those few with a clear indication for a vitamin K antagonist (VKA). Reduced NOAC doses should be considered in dabigatran- or rivaroxaban-treated patients with a high bleeding risk, which prevail over concerns about stent thrombosis or ischemic stroke. There is insufficient evidence to favor one NOAC over another in this setting. In the early post stenting period, triple therapy comprising a NOAC, clopidogrel and aspirin is recommended. Timing of post PCI aspirin cessation should be based on a careful analysis of the bleeding and ischemic risk. There is only low quality evidence regarding the optimal approach to elective or urgent/emergency PCI procedures in patients requiring oral anticoagulation. It is suggested that there is no need of interruption of VKA and PCI procedure should be performed via radial artery access with a lower dose of unfractionated heparin. On the other hand, NOACs are usually stopped before elective PCIs, while urgent/emergency procedures may be performed with the addition of low-dose parenteral anticoagulation.

CHA2DS2-VASc score predicts atrial fibrillation recurrence after cardioversion: Systematic review and individual patient pooled meta-analysis.

BACKGROUND: Despite progresses in the treatment of the thromboembolic risk related to atrial fibrillation (AF), the management of recurrences remains a challenge. HYPOTHESIS: To assess if congestive heart failure or left ventricular systolic dysfunction (CHA2 DS2 -VASc) score is predictive of early arrhythmia recurrence after AF cardioversion. METHODS: Systematic review and individual patient pooled meta-analysis following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. INCLUSION CRITERIA: observational trials in patients with AF undergoing cardioversion, available data on recurrence of AF and available data on CHA2 DS2 -VASc score. Clinical studies of interest were retrieved by PubMed, Cochrane Library, and Biomed Central. Seven authors were contacted for joining the patient level meta-analysis, and three shared data regarding anthropometric measurements, risk factors, major comorbidities, and CHA2 DS2 -VASc score. The primary outcome was the recurrence of AF after cardioversion in patients free from antiarrhythmic prophylaxis. Univariate and multivariate logistic regression was performed. RESULTS: Overall, we collect data of 2889 patients: 61% were male, 50% with hypertension, 12% with diabetes, and 23% with history of ischemic heart disease. The median CHA2DS2-VASc score was 2.. At the multivariate analysis, chronic kidney disease (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.12-3.27; P = 0.01), peripheral artery disease (OR 1.65; 95% CI 1.23-2.19; P < 0,0001), previous use of beta blockers (OR 1.5; 95% CI 1.19-1.88; P < 0.0001), and CHA2DS2-VASc score > 2 (OR 1.37; 95% CI 1.1-1.68; P = 0.002) were independent predictors of early recurrence of AF. CONCLUSIONS: CHA2DS2-VASc score predicts early recurrence of AF in the first 30 days after electrical or pharmacological cardioversion. Protocol registration PROSPERO (CRD42017075107).

Patients with Atrial Fibrillation and Chronic Kidney Disease More Often Undergo Angioplasty of Left Main Coronary Artery - a 867 Patient Study.

BACKGROUND/AIMS: Several studies have implicated atrial fibrillation (AF) as a contributing factor in chronic kidney disease (CKD) and cardiovascular events. The prevalence of coronary artery disease (CAD) in patients with AF varies substantially from 17% to 46.5%. There are only few studies concerning renal function in population with AF undergoing coronary angiography. The aim of the present study was to assess which type of AF is dominant in CKD population scheduled for coronary angiography and if it can influence patients' outcome, the association between renal impairment and the type of coronary procedures in AF patients and the influence of renal function on in-hospital mortality. METHODS: We retrospectively studied 867 patients with AF hospitalized due to coronary angiography in two year time. The cut off value of CKD was eGFR ≤ 60 ml/min./1.73m2 evaluated by CKD-EPI formula. RESULTS: A total of 867 patients with AF (44% women; mean age 72±10 years) were included in the analysis. The mean eGFR was 44±11ml/min./1.73m2 in patients with CKD and 89±18 ml/min./1.73m2 in patients with preserved renal function. Patients with CKD and AF were older (p< 0.001), had more often diabetes (p=0.009), heart failure (p< 0.001) and anaemia (p< 0.001). Patients with CKD and AF had more often permanent type of AF (p< 0.001). In CKD patients CHA2DS2VASc score was 4.3±1.5 and HAS-BLED score was 2.0±1.2 and it was significantly higher as compared to population with preserved renal function (p< 0.001, p=0.02, respectively). The use of oral anticoagulation was less frequent in CKD group (p< 0.001) although these patients had higher CHA2DS2VASc score. Patients with AF and CKD were more often admitted due to myocardial infarction (STEMI or NSTEMI) (p=0.02, p< 0.001, respectively) and more often underwent percutaneous coronary intervention (PCI) (p=0.01). Among coronary arteries the percutaneous coronary intervention (PCI) of left main artery was done more frequently in CKD patients (p=0.01). Among CKD population in-hospital mortality was significantly higher in patients with eGFR < 30 ml/min (p< 0.001). CONCLUSION: Patients with CKD had more often permanent type of AF. Percutaneous interventions of the left main coronary artery, the only elective procedures influencing patients' prognosis, were done more frequently in CKD patients with AF. In-hospital mortality was significantly higher in patients with severe renal impairment. Despite the higher risk of ischaemic stroke in CKD group the use of oral anticoagulation therapy was significantly less frequent and the patients were deprived of the confirmed benefits of such treatment.

Atrial fibrillation in dialysis patients: is there a place for non-vitamin K antagonist oral anticoagulants?

Atrial fibrillation (AF) occurs approximately in 3% of general population, with greater prevalence in elderly. Non-vitamin K-dependent oral anticoagulant agents (NOACs) according to the current European guidelines are recommended for patients with AF at high risk for stroke as a first-choice treatment. NOACs are not inferior to warfarin or some of them are better than warfarin in reducing the rate of ischemic stroke. Moreover, they significantly reduce the rate of intracranial hemorrhages, major bleedings, and mortality compared with warfarin. Nevertheless according to ESC guidelines, NOACs are not recommended in patients with creatinine clearance < 30 mL/min. Observational studies provide contradictive data. Only few new trials are ongoing. Therefore, it is not clear if NOACs should be in the future prescribed to patients with advanced CKD and those on dialysis. Moreover, the risk of stroke and bleeding is much higher in such population than in patients without end-stage renal disease (ESRD). The authors provide data on pros and cons of use of NOACs in ESRD patients with AF.

Patients with atrial fibrillation and coronary artery disease - Double trouble.

Coronary artery disease (CAD) is the most common cardiovascular disease while atrial fibrillation (AF) is the most common cardiac arrhythmia. Both diseases share associated risk factors - hypertension, diabetes mellitus, sleep apnea, obesity and smoking. Moreover, inflammation plays a causative role in both diseases. The prevalence of CAD in patients with AF is from 17% to 46.5% while the prevalence of AF among patients with CAD is low and it is estimated from 0.2% to 5%. AF is a well-established factor of poor short- and long-term prognosis in patients with acute myocardial infarction (AMI) and is associated with a marked increase in overall mortality. The arrhythmia is common after cardiac surgeries and occurs in about 20 to 40% of patients after coronary artery bypass graft (CABG) surgery. It is predicted that between 5 and 15% of AF patients will require stenting at some point in their lives and will receive triple therapy with aspirin, clopidogrel or ticagrelor and oral anticoagulation (OAC). This requires careful consideration of antithrombotic therapy, balancing bleeding risk, stroke risk, and in-stent thrombosis with subsequent acute coronary syndromes. Co-prescription of OAC with antiplatelet therapy, in particular triple therapy, increases the absolute risk of major bleeding. In addition, major bleeding is associated with an up to 5-fold increased risk of death following an acute coronary syndrome. Coexistence of AF and CAD worsens the prognosis even in carefully treated patients.

Atrial fibrillation in kidney transplant recipients: is there a place for the novel drugs?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia of high clinical importance, occurring in 2% of the general population and in 19-24% in patients with chronic kidney disease. It is a well-known risk factor for cardiovascular morbidity and mortality. Kidney transplant recipients with a history of AF were associated with significantly higher rate of ischaemic strokes, graft failure and post-transplant mortality. AF occurs in over 7% of kidney transplant recipients in the first 3 years after transplantation and is associated with reduced graft and patient survival. The incidence of stroke in patients after kidney transplantation (KTx) is higher than the general population, but markedly lower than those on dialysis. Oral anticoagulation (OAC) therapy is recommended in AF patients at high risk of stroke. There are no randomized studies assessing OAC in patients after KTx and there are no specific recommendations and guidelines on therapeutic strategies in these patients. KTx recipients are a vulnerable population, exposed to variations in renal function, being at higher risk of bleeding and thrombotic complications, with possible interactions with immunosuppression. Surely, there is a place for novel oral anticoagulants (NOACs) in this group of patients as long as the summary of product characteristics is followed, as they are a valuable anticoagulation therapy. On one hand, they are at least as effective as warfarin; on the other hand NOACs are safer, especially when it comes to intracranial haemorrhages. However, NOACs seem to be underused in this population as they are excreted via kidney, may interact with immunosuppressive therapy and physicians need more experience and confidence in their administration. Percutaneous left atrial appendage occlusion procedure may also be considered as an opportunity for this group of patients, in particular in the presence of contraindications to anticoagulation.

Adhering to the principles of clinical pharmacology - the correct fixed combinations of antihypertensive drugs.

INTRODUCTION: Hypertension is one of the primary modifiable risk factor for cardiac and renal diseases with the prevalence around 30-45% of the general population, with a steep increase with ageing. The administration of blood pressure-lowering drugs is to reduce the risk of major clinical cardiovascular outcomes. Hypertension guidelines recommend combination therapy in patients with high cardiovascular risk and with subclinical organ damage as well as when monotherapy fails. Areas covered: As the etiology of essential hypertension is multifactorial, combination therapy using different classes of antihypertensive agents have greater effect than each on its own (synergistic effect), may have better tolerability (two components minimizing each other's side effects) and lead to improved patient compliance. Several studies assess the hypotensive efficacy on drug combination; there are also studies on triple drug combination. Expert commentary: At present, dual and triple combination therapy is available to hypertensive patients with good clinical outcomes, compliance and low profile of side effects. It is critical as patients' adherence to the pharmacological therapy significantly decreases the risk of long-term adverse events including mortality. It appears that combinations not only of hypotensive drugs but also with statins (as well as antidiabetics) will be widely used.

CHA2 DS2 VASc score predicts unsuccessful electrical cardioversion in patients with persistent atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia occurring in 2% of the population. It is known that AF increases morbidity and limits quality of life. The CHA2 DS2 VASc score (congestive heart failure/left ventricular dysfunction, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65-74 and sex category (female)) is widely used to assess thrombotic complications. The CHA2 DS2 VASc score was not used until now in predicting the effectiveness of electrical cardioversion. AIM: To assess the value of CHA2 DS2 VASc score in predicting unsuccessful electrical cardioversion. METHODS: We analysed 258 consecutive patients with persistent AF who underwent electrical cardioversion between January 2012 and April 2016 in a Cardiology University Centre in Poland. RESULTS: Out of 3500 hospitalised patients with AF, 258 (mean age 64 ± 11 years, 64% men) underwent electrical cardioversion. The CHA2 DS2 VASc score in analysed population (258 patients) was 2.5 ± 1.7 (range 0-8), and the HAS-BLED (hypertension, abnormal liver or renal function, stroke, bleeding, labile international normalised ratio, elderly, drugs or alcohol) was 1 ± 0.9 (range 0-4). Electrical cardioversion was unsuccessful in 12%. Factors associated with unsuccessful cardioversion were age (P = 0.0005), history of ischaemic stroke (P = 0.04), male gender (P = 0.01) and CHA2 DS2 VASc score (P = 0.002). The CHA2 DS2 VASc score in patients who had unsuccessful cardioversion was higher compared to patients who had successful cardioversion - 3.5 versus 2.4 (P = 0.001). In the logistic regression model, if the CHA2 DS2 VASc score increases by 1, the odds of unsuccessful cardioversion increase by 39% (odds ratio (OR) 1.39; confidence interval (CI): 1.12-1.71; P = 0.002). The odds of unsuccessful cardioversion are three times higher in patients with a CHA2 DS2 VASc score ≥ 2 than in patients with a CHA2 DS2 VASc score of 0 or 1 (OR 3.06; CI: 1.03-9.09; P = 0.044). CONCLUSION: The CHA2 DS2 VASc score routinely used in thromboembolic risk assessment may be a simple, easy and reliable scoring system that can be used to predict unsuccessful electrical cardioversion.

Matrix Metalloproteinase Neutrophil Gelatinase-Associated Lipocalin Complex Predicts Atrial Fibrillation Recurrence after Electrical Cardioversion in Obese Patients.

BACKGROUND: There is not much data on matrix metalloproteinase neutrophil gelatinase-associated lipocalin (MMP-NGAL) complex in patients with atrial fibrillation (AF). AIM: The aim of the study was to assess the value of MMP-NGAL complex in predicting AF recurrence after electrical cardioversion. METHODS: The serum levels of NGAL, cystatin C, interleukin-6, high-sensitivity C-reactive protein, copeptin, MMP-NGAL complex, matrix metalloproteinase 2, tissue inhibitor of metalloproteinase 1, Von Willebrand factor, B-type natriuretic peptide and the urinary level of NGAL were evaluated before cardioversion. RESULTS: A total of 83 patients with persistent AF were enrolled in the study. Left atrial diameter (LA) ≥4.5 cm was significantly associated with AF recurrence at follow-up (p = 0.009). In selected 39 obese patients, MMP-NGAL complex was associated with AF recurrence (p = 0.03). If the concentration of MMP-NGAL complex increased by 1 ng/ml, the odds of AF recurrence increased by 4% (OR 1.04; CI: 1.00-1.08; p = 0.03). MMP-NGAL complex did not correlate with AF recurrence in patients with a first episode of AF, in patients ≥65 years of age and in patients with a LA ≥4.5 cm or with chronic kidney disease. CONCLUSIONS: It is known that the greater the BMI at baseline, the higher the likelihood of progression from paroxysmal to permanent AF. However, European Society of Cardiology (ESC) guidelines do not consider obese patients a population with a low likelihood of success of cardioversion. That is why we need a sensitive marker to predict sinus rhythm maintenance in such a population. We found that MMP-NGAL complex may predict AF recurrence after successful cardioversion in obese patients.

Management of patients with atrial fibrillation and chronic kidney disease in light of the latest guidelines.

Atrial fibrillation (AF) frequently occurs in patients with chronic kidney disease (CKD), and the rate reaches even 30% in patients with end-stage renal disease (ESRD). Patients with AF and CKD have a significantly higher risk of thrombotic complications, particularly ischemic stroke, and at the same time, a higher bleeding risk (proportionally to the grade of renal failure). In addition, AF and CKD share a number of comorbidities and risk factors, which results in increased mortality rates. Moreover, disturbances in hemostasis are common complications of kidney disease. Their occurrence and severity correlate with worsening renal function, including ESRD. At present, the incidence of bleeding is declining, while thrombotic complications have become the predominant cause of mortality. Prophylactic antithrombotic treatment reduces the rate of stroke and other thrombotic complications. Vitamin K antagonists (VKAs) have long been used in anticoagulant therapy, and more recently, non-vitamin K oral anticoagulants (NOACs) have been introduced, which are direct thrombin inhibitors. NOACs are a valuable anticoagulant option in this group of patients as long as a summary of product characteristics is followed. They are at least as effective as warfarin, while being safer, especially when it comes to intracranial hemorrhage. Renal function should be evaluated before initiation of NOACs and reevaluated when clinically indicated. Importantly, disturbances in hemostasis in patients with CKD and ESRD may lead to unexpected complications, such as extensive bleeding. If anticoagulation is administered to patients on dialysis, effects of an individual dialysis modality as well as interactions with other drugs given (eg, heparin) should be considered.

Do CHA2 DS2 VASc and HAS-BLED scores influence 'real-world' anticoagulation management in atrial fibrillation? 1556 patient registry from the reference cardiology centre.

INTRODUCTION: Although recommendations for the antithrombotic management of atrial fibrillation (AF) are based on strong evidence, the European guidelines are not fully implemented into practice. OBJECTIVES: The objective of this study is to analyse antithrombotic treatment in AF in Poland after the publication of the European Society of Cardiology Guidelines in 2012. PATIENTS AND METHODS: We retrospectively studied 1556 patients with AF from the Reference Cardiology University Centre in Poland in 2012-2014. RESULTS: CHA2 DS2 VASc and HAS-BLED scores were 3.5 ± 1.7 and 2.4 ± 1.1. Anti-vitamin K agent were prescribed in 59%, with non-vitamin K antagonist oral anticoagulants in 12%, acetylsalicylic acid (ASA) alone in 18%. Older patients (p < 0.0001) and with paroxysmal AF were less likely to receive oral anticoagulation (OAC, p < 0.0001). The risk of stroke according to CHA2 DS2 VASc score was higher in patients who did not receive OAC (p < 0.0001). The use of OAC increased with increasing CHA2 DS2 VASc score but was less frequent in score ≥ 4. The risk of bleeding was higher in patients without OAC (p < 0.0001). The odds of non-vitamin K antagonist oral anticoagulants use were lower for older patients, patients with ischaemic heart disease, chronic heart failure, anaemia, HAS-BLED ≥ 3 and valvular AF. ASA was given in 39% of the patients, especially in paroxysmal AF (p < 0.0001). The odds of ASA alone were higher for older patients, with ischaemic heart disease and history of myocardial infarction (p < 0.0001). The odds of use of ASA as the only treatment were 5.5 times higher for HAS-BLED ≥ 3 (p < 0.0001). CONCLUSIONS: Antithrombotic management in AF is well implemented in Polish conditions, but we show the lack of pattern concerning who is being treated with OAC and ASA when it comes to the risk of stroke and bleeding.

Management of patients with valvular and non-valvular atrial fibrillation in Poland: Results from Reference Cardiology University Center.

BACKGROUND: Information on epidemiology of atrial fibrillation (AF) in Middle European Countries such as Poland is limited. METHODS: We studied 1,556 patients with AF. We focused on different types of AF in terms of clinical features and management. RESULTS: CHA2DS2-VASc score was 3.5 ± 1.7 and HAS-BLED score--2.4 ± 1.1. In-hospital mortality was 2%. The CHA2DS2-VASc score was the highest in permanent AF (p < 0.001) and the HAS-BLED score was the highest in paroxysmal and permanent AF (p < 0.001). The CHA2DS2-VASc score ≥ 2 was found in the majority of non-valvular AF patients. Permanent AF was associated with the highest thromboembolic risk (p < 0.001). Valvular AF was more commonly observed in patients with permanent AF (p = 0.004). Seventy-one percent of patients who had CHA2DS2-VASc > 2 received antithrombotic therapy. Acetylsalicylic acid alone was most common in paroxysmal AF (p < 0.001). Patients with valvular AF had more often permanent AF (p < 0.004). Valvular AF patients were more often prescribed antithrombotic therapy (p = 0.001). The in-hospital mortality did not differ between patients with valvular and non-valvular AF (p = 0.3). In multivariate logistic regression, odds of in-hospital death were higher for patients > 75 years old (OR = 6.26, p = 0.001, 95% CI 2.06-19.02) and with ejection fraction < 35% (OR = 5.25, p < 0.001, 95% CI 2.24-12.32). CONCLUSIONS: Our population with AF have similar risk of stroke and bleeding as in European registries. The need for anticoagulation in AF patients is well established in daily medical care in Poland similarly to Western Europe. Patients with valvular AF are more frequently prescribed antithrombotic therapy than patients with non-valvular AF. In-hospital mortality is relatively low in both valvular and non-valvular AF patients and is connected with old age and diminished ejection fraction.

Is there association between changes in eGFR value and the risk of permanent type of atrial fibrillation? Analysis of valvular and non-valvular atrial fibrillation population.

BACKGROUND/AIMS: There are no data concerning renal function in population with valvular and non-valvular atrial fibrillation (AF). To assess renal function in patients with AF, the association between eGFR and AF perpetuation, in-hospital mortality. METHODS: We studied 1523 patients with AF. Patients with chronic kidney disease (CKD) were compared to population with preserved renal function. RESULTS: CKD was more frequently observed in patients with valvular AF(p=0.009). In non-valvular AF patients eGFR <60 ml/min./1,73 m2 had more often permanent AF (p<0.0001). In patients with CKD CHA2DS2VASc score was 4.1±1.5 and HAS-BLED score was 2.1±1.2 and it was higher as compared to population with preserved renal function (p<0.0001 vs. p<0.0001). The odds of permanent AF in patients with non-valvular AF and CKD were increased 1.82 times (OR=1.82, p<0.0001, 95% CI:1.46-2.27). The odds of permanent AF in patients with valvular AF and CKD were not significantly increased (OR=1.46, p=0.2,95% CI:0.86-2.5). In non-valvular AF, if eGFR decrease by 10 ml/min, odds of permanent AF are increased by 10% (OR=1.1 p<0.0001, 95% CI 1.05-1.15). In multivariate logistic regression, in non-valvular AF, odds of in-hospital death were higher for patients >75 years old (OR=3.70, p=0.01, 95% CI 1.33-10.28), with CKD (OR=2.61, p=0.03, 95% CI 1.09-6.23). The type of AF had no significant influence on in-hospital mortality(OR=0.71, p=0.45,95% CI 0.30-1.70). CONCLUSIONS: CKD is more often observed in patients with valvular AF. In population with non-valvular AF decreased eGFR is associated with permanent type of AF and with higher CHA2DS2VASc and HAS-BLED score. Among valvular AF patients there are no differences in type of AF between patients with and without CKD. There is the correlation between CKD and AF perpetuation but only in non-valvular population.

Does admission anaemia still predict mortality six years after myocardial infarction?

BACKGROUND: Anaemia is present in 12-30% of patients with acute coronary syndromes (ACS). Many studies have shown that admission anaemia is an independent predictor of in-hospital or short-term mortality in patients with ACS. However, there is limited data on the long-term prognostic importance of anaemia in this group of patients. AIM: To establish the relation between haemoglobin concentration on admission and six-year all-cause mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated invasively. METHODS: We retrospectively studied 551 patients with the diagnosis of STEMI referred to the catheterisation laboratory of our hospital and treated with successful primary percutaneous coronary intervention. Patients were divided into two groups according to admission haemoglobin concentration (< 13 g/dL in males and < 12 g/dL in females). RESULTS: A total of 551 patients with STEMI (164 female, 30%) were included in the analysis, mean age was 63 ± 12 years. Anaemia on admission was present in 11% (n = 61) of the patients. Of the entire cohort, renal failure was present in 25% (n = 138), and diabetes in 16% (n = 88). Admission haemoglobin concentration was significantly associated with age (r = -0.2663, p < 0.05), blood pressure (systolic blood pressure [SBP]: r = 0.1940, diastolic blood pressure [DBP]: r = 0.2023, p < 0.05), glucose concentration (r = -0.1218, p < 0.05), white blood cells count (r = 0.1230, p < 0.05), cholesterol concentration (r = 0.1253,p < 0.05), estimated glomerular filtration rate (eGFR; r = 0.1819, p < 0.05), Killip-Kimball class (r = -0.1387, p < 0.05) and TIMI risk score for STEMI (r = -0.2647, p < 0.05). During follow-up, 27% (n = 130) of the patients died. The mortality rate was significantly higher in the patients with admission anaemia (47% vs. 24%, p = 0.0002). The patients with anaemia were older (p = 0.0007), had lower blood pressure (SBP: p = 0.007; DBP: p = 0.01), higher heart rate (p = 0.03), higher glycaemia concentration (p = 0.003), higher C-reactive protein concentration (p = 0.0007) and lower white blood cells count (p = 0.03). Patients with anaemia had more frequently renal failure (eGFR < 60 mL/min/1.73 m²) (p = 0.02) and a significantly higher TIMI risk score for STEMI (p = 0.01). In multivariate analysis, all-cause mortality was associated with: anaemia on admission (OR = 2.29; 95% CI 1.20-4.36; p = 0.011), low ejection fraction (OR = 2.97; 95% CI 1.78-4.96; p < 0.001) and age (OR = 1.65 [per 10 years]; 95% CI 1.34-2.03; p < 0.001). Anaemia on admission remained an independent predictor of six-year mortality. CONCLUSIONS: Admission anaemia significantly influences all-cause mortality in patients with STEMI treated invasively ina six-year follow-up and may be used for risk stratification in this population.

Does neutrophil gelatinase-asociated lipocalin have prognostic value in patients with stable angina undergoing elective PCI? A 3-year follow-up study.

BACKGROUND: Neutrophil gelatinase-associated lipocalin (NGAL), a widely accepted diagnostic marker of acute renal injury (AKI) may be involved in the development of atherosclerosis. PURPOSE: To assess the prognostic significance of serum and urinary NGAL and serum cystatin C in patients with stable angina undergoing percutaneous coronary intervention (PCI) on a 3-year follow-up. METHODS: We included patients with stable angina undergoing PCI. Serum NGAL and cystatin C were evaluated before and 4h, 8h after PCI. Urinary NGAL was evaluated before and 12h and 24h after the procedure. The primary end-point was all-cause mortality on a 3-year follow-up. RESULTS: Among 132 patients there were 63% of males (mean age 64,5±9,8 years). Mean eGFR was 86.2±28.5 ml/min. During follow-up 8% of the patients died. All-cause mortality was significantly higher in patients with increased urinary NGAL concentration 12h after PCI (p=0.04). Urinary NGAL 12h after PCI correlated with eGFR (p<0.05), with serum NGAL evaluated before and 4h and 8h after PCI (p<0.05) and with increased serum cystatin C evaluated 4 hours after PCI (p<0.05). CONCLUSIONS: Increased urinary NGAL concentration is a strong predictor of mortality in patients with stable angina who undergo PCI and may be used for the risk stratification in this population.

[Giant thrombus in the left atrium after mitral bioprosthesis implantation: is standard oral anticoagulation always sufficient?]. / Gigantyczna skrzeplina w lewym przedsionku po implantacji biologicznej protezy mitralnej: czy standardowa antykoagulacja jest zawsze wystarczajaca?

We present a case of 70-year old male after coronary by-pass surgery and mitral bioprosthesis implantation due to infective endocarditis, with continuous atrial fibrillation, who was admitted to the hospital due to the worsening of the heart failure. He was on oral antivitamine K agents with therapeutic value of INR. On echocardiography we found enlargement of all cavities with extremely big left atrium (9.5 cm) and poor contractile left ventricular function (EF 25%). An enormously big old thrombus was found in the left atrium. The patient was disqualified from surgical treatment. Treatment with unfractionated heparin was unsuccessful. We discuss if standard antithrombotic treatment is always sufficient in such unusual cases.

[Is establishing diagnosis of perivalvular abscess still difficult?]. / Czy rozpoznanie ropnia w przebieguinfekcyjnego zapalenia wsierdzia pozostaje nadal trudne?

We report the case of 42-year-old male, who developed infective endocarditis on bicuspid aortic valve due to infection of the central line with Staphylococcus aureus MSSA. The patient was hospitalised several times in district hospitals because of worsening of heart failure. He had a few transthoracic (TTE) and one transesophageal (TEE) echocardiography which did not reveal early stages of perivalvular abscess and was disqualified from surgical procedures due to bad left ventricular systolic function. The second TEE done a month after the first one showed an abscess with perforation to the right ventricle. The patient died disqualified again from surgical procedure due to multiorgan failure.