Clinical manifestations of lead-dependent infective endocarditis: analysis of 414 cases.

It is important to identify clinical manifestations of lead-dependent infective endocarditis (LDIE), as it begins insidiously with the slow development of nonspecific symptoms. Clinical data from 414 patients with the diagnosis of LDIE according to Modified Duke Lead Criteria (MDLC) were analyzed. Patients with LDIE had been identified in a population of 1,426 subjects submitted to transvenous lead extraction (TLE) in the Reference Clinical Cardiology Center in Lublin between 2006 and 2013. The symptoms of LDIE and pocket infection were detected in 62.1 % of patients. The mean duration of LDIE symptoms prior to referral for TLE was 6.7 months. Fever and shivers were found in 55.3 % of patients, and pulmonary infections in 24.9 %. Vegetations were detected in 67.6 % of patients, and positive cultures of blood, lead, and pocket in 34.5, 46.4, and 30.0 %, respectively. The most common pathogens in all type cultures were coagulase-negative staphylococci (CNS), with Staphylococcus epidermidis domination; the second most common organism was Staphylococcus aureus. 76.3 % of patients were treated with empirical antibiotic therapy before hospitalization due to TLE. In the laboratory tests, the mean white blood cell count was 9,671 ± 5,212/µl, mean erythrocyte sedimentation rate 43 mm, C-reactive protein (CRP) 46.3 mg/dl ± 61, and procalcitonin 1.57 ± 4.4 ng/ml. The multivariate analysis showed that the probability of LDIE increased with increasing CRP. The diagnosis of LDIE based on MDLC may be challenging because of a relatively low sensitivity of major criteria, which is associated with early antibiotic therapy and low usefulness of minor criteria. The important clinical symptoms of LDIE include fever with shivering and recurrent pulmonary infections. The most specific pathogens were Staphylococcus epidermidis and Staphylococcus aureus. Laboratory tests most frequently revealed normal white blood cell count, relatively rarely elevated procalcitonin level, and significantly increased erythrocyte sedimentation rate (ESR) and CRP. This constellation of signs should prompt a more thorough search for LDIE.

Myocardial infarction in pregnant women--case reports.

Five cases of women with MI in pregnancy are presented. Their past and present heart condition, therapy and cardiovascular disease risk factors were analyzed. The mean follow-up period was 14.6 years. The observed women had an atherosclerotic etiology of MI with multiple risk factors of ischaemic heart disease. Pulmonary oedema complicating MI in presented cases had no influence on long-term prognosis.

[Differences of the clinical course and prognosis in diabetics with myocardial infarction]. / Odrebnosci w przebiegu klinicznym zawalu serca i rokowaniu odleglym u chorych z cukrzyca.

UNLABELLED: Diabetes mellitus (DM) is one of the most potent risk factor of in-hospital and long-term prognosis after myocardial infarction (MI). The study aim was to compare in-hospital management and long-term prognosis in diabetics with acute transmural MI especially in the aspect of thrombolytic therapy. We analyzed 881 patients with acute MI treated in our hospital in 1992-1996. DM was found in 21.5% of all studied patients. Data based on past history, management of in-hospital course and next ambulatory control exams in the period 2-6 years were performed using statistical methods and then compared together. Diabetics had significant more often risk factor of development of coronary artery disease. Thrombolytic therapy had received 18.0% of diabetics and 22.1% nondiabetic patients in the age under 80 years-old. Thrombolytic therapy performed at patients with DM significantly reduced in-hospital mortality. CONCLUSIONS: 1. Diabetics had worse in-hospital course of acute MI because of more frequent hemodynamic complications. The overall incidence of arrhythmia and A-V conduction disturbances did not differ from nondiabetics. 2. In-hospital mortality in all patients with DM was twofold higher than in the rest (22.2% vs 11.0% p < 0.001). Mortality among patients with thrombolytic therapy did not significantly differ between the ones (5.9% vs 6.7%). 3. Mortality rate after MI in diabetics is 1.66 times higher to compare to nondiabetic.

[Disturbances of rhythm and atrio-ventricular conduction in digitalis overdose. Case reports]. / Zaburzenia rytmu i przewodzenia przedsionkowo-komorowego wystepujace przy przedawkowaniu naparstnicy. Opis przypadków.

Three cases of patients with symptoms of digitalis overdosage were presented. The principal manifestations included complex supraventricular dysrhythmias and atrio-ventricular conduction disturbances. In the discussion a special attention was paid to digitalis dosage. Multiple factors influencing plasma concentration of digitalis including pharmacokinetics, bioavailability and drug interactions with glycosides were described. Short review of toxic manifestations of digitalis was made and the treatment of digitalis intoxication was outlined.

[Is application of electrocardiographic exercise test always usefull in the diagnosis of coronary artery disease? Advantages and limitations of this method]. / Czy zawsze warto wykonywac elektrokardiograficzna próbe wysilkowa w rozpoznawaniu choroby wiencowej? Zalety i organiczenia metody.

UNLABELLED: To determine the diagnostic value of the electrocardiographic exercise testing (EET) in 551 patients with chest pain regarded as definite or probable stable angina pectoris (CAD), results of performed EET were compared with coronary angiography. All patients underwent exercise testing according to the Bruce protocol. The criterion for a positive exercise ST-segment response was > or = 1 mm of horizontal or down sloping depression 80 msec after J-point. The indications for cardiac catheterization in each patient were determined at the discretion of the attending physician. Clinically important coronary artery disease was defined as > 50 per cent narrowing of the diameter of at least one major vessel or > or = 50 per cent of the left main coronary artery. RESULTS: The sensitivity and specificity of EET for detection of CAD were for the entire group, in women and men respectively: 93%, 91%, 94% and 21%, 16%, 27%. CONCLUSION: 1. Indications for EET should be based on prior probability of coronary artery disease. 2. Application of higher than conventional ST depression criteria (> or = 2 mm) lowers sensitivity but increases specificity of EET. 3. Variables determining false positive results are as follows: age, sex (female), low probability of CAD, ST-segment depression in leads: II, III, aVF and mitral valve prolapse. 4. Variables determining false negative results are as follows: high probability of CAD, sex (male) and one vessel disease.

[The impact of changes in levels of calcium, phosphate and magnesium during hemodialysis on autonomic system reactivity as measured by heart rate variability analysis]. / Wplyw zmian stezenia wapnia, fosforanów i magnezu podczas hemodializy na reaktywnosc autonomicznego ukladu nerwowego mierzona parametrem HRV.

The aim of the study was to analyze the response of autonomic nervous system to dialysis related systemic volume reduction using heart rate variability (HRV) analysis. The possible relationship between changes in serum levels of calcium-phosphate balance parameters and HRV measurements results was also analyzed. The study was performed in 32 patients (20 men, 12 women) aged between 27 and 71 years (mean 44 years) treated with maintenance dialysis due to end-stage renal disease from 3 months to 15 years (mean 4.4 years). All parameters mentioned above were analyzed during 4-hour dialysis session. Mean value of LF/HF ratio at the beginning of the procedure was 5.36, with continuous increase in consecutive measurements performed 30-minute intervals to the maximal value 8.2 in 120th minute of HD session (p < 0.05). In the next measurements continuous decrease in the mentioned parameter was noticed, to the mean value 6.99 in minute 240. The values of LF/HF ratio were also lower for the whole HD session in the group of patients with initial predialytic concentration of calcium lower than 2.35 mmol/l as compared to those with initial calcium concentration higher than 2.35 mmol/l. Higher values of LF/HF ratio and bigger oscillation amplitude of this parameter were also noted in those patients, in whom the percentage reduction of magnesium level during dialysis exceeded 20%. In addition, statistically significant relationship between percentage reduction in magnesium ion concentration and LF/HF ratio during HD was found. Obtained results let us to conclude, that hemodialysis leads to important change in the activity of both components of autonomic nervous system. The factors which may adversely influence the quality of this response may be, among others, low total calcium ion concentration as well as low percentage reduction in magnesium level during hemodialysis session.

[Change of lifestyle as a relevant therapy after myocardial infarction]. / Zmiana stylu zycia jako istotna terapia po zawale serca.

The risk of ischemic heart disease is connected with the definite mode of life. Improper nourishment, smoking, alcohol abuse, sedentary lifestyle and excessive mental stress cause disturbances leading to development of atherosclerosis. The change of the lifestyle may prevent from coronary heart disease and may play a main role in secondary prevention, making the prognosis after myocardial infarction much better. The epidemiological and clinical studies have shown the significance of particular risk factors reduction on survival after myocardial infarction and allowed to create the optimal preventive mode of life. Therefore the change of lifestyle should become the priority in the postinfarction therapy.

An increase in plasma atrial natriuretic peptide concentration during exercise predicts a successful cardioversion and maintenance of sinus rhythm in patients with chronic atrial fibrillation.

The aim of this study was to determine the value of an increase in plasma atrial natriuretic peptide (ANP) concentrations during submaximal exercise as a predictor of return of sinus rhythm (SR), and of its maintenance over a period of 6 months after cardioversion (CV) of chronic atrial fibrillation (AF). The study group included 42 patients with AF (mean duration 7 +/- 7 months) and a controlled ventricular rate. They underwent submaximal exercise testing 24 hours before CV. Blood samples were collected at rest and at peak of exercise for measurement of plasma ANP concentrations. Thirty-five of 42 patients were successfully cardioverted to SR. At 6 months, 23 patients remained in SR, while 12 had recurrence of AF. The plasma ANP concentrations before CV increased insignificantly during exercise in patients with unsuccessful CV or with recurrence of AF (60.8 +/- 17.3 pg/mL to 64 +/- 13.5 pg/mL, NS). The mean increase in plasma ANP concentration during exercise was significantly greater in the 23 patients who remained in SR than in the 19 patients unsuccessfully cardioverted or with recurrence of AF (17.5 +/- 7.6 pg/mL vs 5.8 +/- 4.5 pg/mL, P < 0.01). In multivariate logistic regression analysis, an increase in ANP plasma concentration was independently associated with successful CV and maintenance of SR up to 6 months of observation. In patients with chronic AF an exercise-induced increase in ANP concentration predicts successful CV and maintenance of SR.

[The prognostic value of electrocardiographic exercise test in patients after acute myocardial infarction]. / Wartosc rokownicza elektrokardiograficznej próby wysilkowej u pacjentów po niepowiklanym zawale serca.

The subject of this trial were 243 patients with uncomplicated acute myocardial infarction, hospitalized in years 1992-1996, who were made an electrocardiographic exercise test in the second or third week of the in-hospital stay and whose further history in the 2-6 period after myocardial infarction (average follow-up time lasted for 4.0 +/- 1.9 years) was known. The aim of this trial was to determine the influence of the positive exercise test on the long-term prognosis after acute myocardial infarction in a group with uncomplicated acute myocardial infarction. The course of infarction and the frequency of cardiac events (cardiac death, reinfarction, revascularisation) occurrence in 78 patients with positive exercise test (group I) were compared with a group of 165 patients with negative exercise test (group II). Both groups were compared in respect to age, gender, history of myocardial infarction, risk factors and the course of the infarction in the in-hospital period. The multivariable logistic regression analyse showed that the positive exercise test did not have a statistically significant influence on the increase of post-hospital morbidity but it correlates with significantly more frequent use of the invasive treatment and reinfarction during the follow-up period in this group. Negative exercise test in patients with uncomplicated acute myocardial was a significant factor of the good long-term prognosis.

[Clinical course and long-term prognosis in patients with recurrent myocardial infarction]. / Przebieg kliniczny i rokowanie odlegle u pacjentów z powtórnym zawalem serca.

UNLABELLED: Retrospective study was based on analysis of 881 patients treated in our ward in 1992-1996. Their fate was estimated through 2-6 years after the past myocardial infarction (MI). There were among of them 147 (16.7%) with second and 20 (2.3%) with third or next MI. Then we compared in-hospital course and long-term prognosis in patients with recurrent MI (group I, n = 167) to patients with the first MI (group II, n = 714). We have also evaluated influence of the time-period between the both episodes of myocardial infarctions on the prognosis. The chi-square test was applied to identify the significance of the difference between both groups. Using the Kaplan-Meier method, figures of survival curves were created. Patients in group I were about 4.9 year-older than in group II/(median age was 64.8 +/- 10.7 vs 59.9 +/- +/- 11.3 years p < 0.05). More popular were also diabetes (30.5% vs 18.5%, p < 0.001), advanced hypertension (31.7% vs 20.5% p < 0.01) and higher ratio of current smokers (51.5%) among risk factors in patients from group I. Second myocardial infarction had more serious in-hospital course than the first one. It could be the result of anterior location and more often cardiac complications like ventricular arrhythmias including VF, disturbances of intraventricular conductions, cardiogenic shock and pulmonary oedema with especially of first hours of acute myocardial infarction. Mortality rate in the group I was 2.2 times higher to compare with group II (24.0% vs 10.9%, p < 0.001). Significance higher mortality was in the first year of follow-up and among patients with recurrent myocardial infarction within 12 months after the first one. CONCLUSION: Previous myocardial infarction is significant risk factor that elevate in-hospital course and long-term mortality rate. We observed the higher mortality rate when the recurrent myocardial infarction occurred within 12 months after the first one. The longer time-period since the first myocardial infarction the better prognosis was observed in our analysis.

[The significance of lowered ejection fraction on prognosis after myocardial infarction ]. / Znaczenie obnizonej frakcji wyrzutowej w rokowaniu po zawale serca.

The subject of this study was a group of 757 patients hospitalized because of acute myocardial infarction in years 1992-1996, who survived the in-hospital course and were under observation for 2-6 years after the infarction. During the 14-18th day of the hospital stay they were made an echocardiographic test, including the ejection fraction (EF). The aim of this study was to define the influence of the ejection fraction value lowered below 40% on the long-term prognosis in patients after acute myocardial infarction. We compared two groups of patients; group I, consisting of 130 (17.2%) patients with EF lowered below 40% and group II, which included 627 patients with EF over 40%. To estimate the statistic significance we used the chi-square and t-Student test. The morbidity curves were made with the Kaplan-Meier method. The course of the myocardial infarction was much more grave in group I than in group II, what is confirmed by a more often anterior ventricular infarction and the quantity of dangerous complications which occurred during the in-hospital phase. The multi-factor regressive analysis showed that the ejection fraction lowered below 40% raises 2.47 times (95% confidence interval 1.50-4.07) (p < 0.001) the risk of death during the first year after myocardial infarction and nearly two times during the 5 year follow-up, compared to patients with a higher EF value. The influence of the EF value lowered below 40% on the creation of an infarction was not significant. The EF value lowered below 40% in patients after acute myocardial infarction was a significant risk factor in the long-term prognosis. More than 40% of deaths during the long-term prognosis in this group were caused by heart failure.

[Diagnosis of pericarditis]. / Diagnostyka zapalenia osierdzia.

Acute pericarditis can be divided into primary pericarditis--of unknown etiology and secondary pericarditis--caused by earlier diagnosed disease. The diagnosis of acute pericarditis is based on clinical manifestations and accessory investigations, among which the most important is echocardiography. However, the etiologic diagnosis of pericarditis seems to be much more difficult, being ascertained in no more than 30%. It makes the causative treatment impossible in many cases. The good knowledge of epidemiology and symptoms of different pericardial diseases is important to make the proper choice of investigative procedures. At the beginning, usually less invasive investigations are planned to confirm etiologic diagnosis. Subsequently, more invasive procedures like pericardiocentesis, pericardiotomy and pericardial biopsy are reserved to explain the cause of pericarditis. The exceptions are cardiac tamponade and suspected purulent pericarditis, when pericardiocentesis and surgical drainage are made promptly in the therapeutic and diagnostic aim.

[A comparison of myocardial infarction clinical course and long-term prognosis in the years 1977-85 and 1992-96]. / Porównanie przebiegu zawalu serca i rokowania odleglego w latach 1977-85 i 1992-96.

This study describes comparison of the management in 997 patients treated in 1977-85 with acute transmural myocardial infarction (MI), their in-hospital and long-term mortality, with 881 patients treated in 1992-96. The study included geographically the same population treated by the same medical staff but in another decade period and the same MI criteria in both cohorts. Main changes were associated with the management of MI. Both groups were adjusted to age (59.3 +/- 11 vs. 59.9 +/- 11.7), history prior to myocardial infarction, diabetes mellitus, habit of smoking and hospital complications except rarer presence of block A-V II degrees and III degrees in the period 1992-96. The increase in percentage of female patients was noticed in the analysis (from 21% to 28.5%). The crude in-hospital mortality was statistically lower in 1992-96 than in 1977-85 (19.8% vs. 13.4% p < 0.11) and the follow up mortality in the next 2-6 years decreased from 6.97% to 4.95%. Mortality in the first year after MI in both periods was high and raised to 9.6% and 8.9%, respectively (NS). Significant diminish of mortality in next years after myocardial infarction was observed in all age adjusted groups of patients treated in 1992-96.

[The diagnostic value of resting electrocardiography in stable coronary artery disease]. / Wartosc diagnostyczna spoczynkowego badania elektrokardiograficznego w rozpoznawaniu stabilnej choroby wiencowej.

The relation of resting electrocardiographic (ECG) patterns to angiographic features was assessed in 566 patients with chest pain regarded as definite or probable stable angina pectoris. The indications for catheterization in each patient were determined at the discretion of the attending physician. All patients underwent diagnostic coronary angiography (clinically important coronary artery disease was defined as > or = 70 per cent narrowing of the diameter of at least one major vessel or > or = 50 per cent of the left main coronary artery) and standard 12 lead electrocardiography which was interpreted by 2 cardiologists independently in coordinating centre. The signs of impaired coronary blood flow were assessed by abnormalities of repolarization (among others S-T segment, the T wave), depolarization and presence of disturbances of cardiac rythm. The resting routine electrocardiogram was assigned to one of three categories: normal, nonspecific abnormalities or typical for coronary insufficiency. The typical pattern for ischemia was present in 104 patients (18%), nonspecific abnormalities were present in 185 patients (33%) and electrocardiogram was normal in 277 patients (49%). Sensitivity and specificity of the typical for coronary insufficiency resting ECG was calculated: 23% and 87% respectively for the entire group, 33% and 81% in women, 20% and 93% in men. In the group with normal resting electrocardiographic pattern 55% of patients have significant stenosis in at least one major coronary artery.

[Should sinus rhythm be restored in patients with chronic atrial fibrillation? Preliminary results from the Polish "Hot Cafe" study]. / Czy przywracac rytm zatokowy u chorych z przewleklym migotaniem przedsionków? Wstepne wyniki polskiego badania "Hot Cafe".

Atrial fibrillation (AF) is the most common arrhythmia occurring in clinical practice. It is the most frequent cause of hospitalization in cardiac rhythm disturbance. Despite comprehensive progress in the research into electrophysiological mechanisms leading to this loss of normal rhythm and new procedures dealing with it, the main problem being the conversion to and maintaining the normal sinus rhythm (SR) has not been solved. The polish study "Hot Cafe" is trying to evaluate the advantages and risks of the two procedures widely used in clinical practice in patients (pts) with chronic AF, i.e. conversion and maintaining SR vs leaving pts with the arrhythmia. Pts with non-valvular chronic AF fulfilling the criteria for including them into the sample are randomly assigned to two procedures: conversion to SR by means of direct current cardioversion and maintaining it or leaving pts with AF. Pts left with AF are treated by rate control and antithrombotic treatment. The project is of prospective kind and it will be carried out by many medical institutions. It is planned to include 200 pts. The observation period will last at least 12 months. Preliminary results after inclusion of the first 121 pts are shown.

[Risk factors for in-hospital course and long-term outcome in myocardial infarction]. / Czynniki obciazajace rokowanie szpitalne i odlegle w zawale serca.

The aim of the present study is to separate the most important in-hospital and long term outcome risk factors in patients with myocardial infarction. We analysed 251 women and 630 men hospitalised for acute myocardial infarction between 1992-96. We compared history data, in-hospital course and long term observation within 2-6 years in a group of patients who died versus group of patients who survived. The most important risk factors of in-hospital death were: cardiogenic shock--with mortality rate--6.2, pulmonary oedema--2.8, ventricular fibrillation--2.7, third degree A-V block--2.5, supraventricular arrhythmia (atrial flutter, atrial fibrillation--2.4, previous myocardial infarction--2.4, diabetes--2.0, disturbances of intraventricular conduction--1.8. The most important risk factors of long term outcome were: congestive heart failure--III, IV class of NYHA at discharge--mortality rate--3.0, ejection fraction < 40%--2.7, disturbances of intraventricular conduction--2.2, in-hospital cardiogenic shock and/or oedema pulmonum--2.0, prior myocardial infarction--1.9, diabetes--1.7, in-hospital ventricular fibrillation--1.6, supraventricular arrhythmia--1.6. Better predictors of survival we can obtain using multivariate analysis. This analysis allows to separate groups of patient with good, mean and poor prognosis which finally simplify choice of efficient kind of therapy.

[Myocardial infarction in pregnancy]. / Zawal serca w czasie ciazy.

We report two cases of pregnant women who developed an acute myocardial infarction. The proposed cause of massive myocardial anterior and interventricular wall infarction of the first patient appears to be bacterial intracoronary thrombus during the course of bacterial endocarditis. Acute insufficiency of the mitral valve caused by rupture chordae tendineae of the anterior mitral left was another complication. Labor contractions occurred on the 13th day of treatment. On the next day the patient gave birth to a healthy child by elective cesarean section. She was also qualified for an operation because of increased signs of left ventricular heart failure. Preoperative coronary angiography revealed occlusion of the anterior descending branch and reconstruction of its periphery. Other vessels were not changed. The patient was subjected to implantation of artificial valve, an aortocoronary by-pass and repair of atrial septal defect. Eighteen months follow up was uneventful. The second case was a 29 year-old pregnant woman who had previously undergone mitral commissurotomy admitted because of an acute myocardial infarction in the II trimester. No complication of the disease was observed.

[Surgical treatment of bacterial endocarditis of the tricuspid valve]. / Bakteryjne zapalenie wsierdzia zastawki trójdzielnej leczone operacyjnie.

We present a rare case of bacterial endocarditis of tricuspid valve caused by temporary intracardiac pacing. The 48-year old male patient developed complete a-v block during the 1st day of acute inferior myocardial infarction. Intracardiac electrode was inserted for temporary pacing. After 4 days signs of bacterial endocarditis developed. Patient was markedly febrile, moderate tachycardia with gallop rhythm and systolic murmur of tricuspid valve insufficiency were present. Dullness to percussion was audible at the base of right lung. Hepato- and splenomegaly appeared during the second month of hospitalization. Laboratory tests revealed: elevated ESR, leukocytosis with a shift to the left, several blood cultures were positive to Staphylococcus aureus. On repeated chest X-ray patchy infiltrates with thin-walled translucent pools were visible. Transthoracic and transoesophageal++ echocardiography provided more precise informations. Bacterial vegetations were visualised on the tricuspid valve. Coronary angiography revealed proximal occlusion of the right coronary artery and 75-80% stenosis of the left circumflex artery. Antibacterial treatment guided by blood cultures was begun: vancomycin combined with netilmycin, then tienamycin and diflucan--after 10 weeks treatment was decided to be unsuccessful and the decision about surgical treatment was made. In extracorporeal circulation posterior left leaflet together with granular bacterial growths was excised. Septal and anterior leaflets were found normal. Cultures made of excised tissue were positive for Staphylococcus aureus and subsequent treatment with fluoroquinolones gave satisfactory result. Postoperative echocardiography revealed only small tricuspid valve insufficiency. Coronary by-pass surgery was performed later because of the high risk of simultaneous operation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long QT syndrome after organophosphate insecticide poisoning]. / Zespól wydluzonego QT w przebiegu zatrucia zwiazkami fosforoorganicznymi.

A case of prolonged QT syndrome (PQTS) caused by unintentional poisoning with organic phosphate pesticides is reported in a 73 year old farmer. PQTS developed and coexisted with other symptoms of poisoning such as low levels of cholinesterase, vomitus, diarrhoea, miosis, hypersalivation and occurred with typical symptoms. Despite concomitant with PQTS advanced ventricular extrasystoles the most dangerous form of them--ventricular tachycardia "torsades de pointes"--wasn't observed what was attributed among other things to scrupulous control and replenishment of potassium++ and magnesium and avoidance of typical antiarhytmic drugs in ventricular arrhythmia+ treatment. Acquired (most often after drug treatment, toxic and resulting from electrolytic disturbances) forms of PQTS are discussed stressing their heterogeneity and necessity of preventive treatment (different, dependent on etiology).