Comprehensive geriatric assessment in primary care practices: a multi-centered, cross-sectional study in Krakow, Poland.

BACKGROUND: Comprehensive geriatric assessment (CGA), as a complex diagnostic process, allows medical specialists to recognize the capabilities and limitations of the patient in older age. This study aimed to evaluate the prevalence and severity of deficits typical of seniors and find relationships between CGA results and selected factors. METHODS: A cross-sectional questionnaire study was performed in Krakow among patients aged 65 years and over visiting their general practitioners (GPs). CGA was conducted using eight scales: the Activities of Daily Living (ADL), Mini-Mental State Examination, Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale, Timed Up and Go Test, Mini Nutritional Assessment Short Form, Clinical Frailty Scale, and Athens Insomnia Scale. RESULTS: Four hundred and thirty-eight patients, aged between 65 and 96 years, were examined. Most of them received high scores in the assessed aspects. The most common abnormalities were sleep disorders (42 %), symptoms of frailty (33 %), and depressive tendency (32 %). Age correlated with every aspect assessed in CGA and worsened as patients grew older (in all cases p <0.05). Male gender reduced the chance of depressive disorders [odds ratio (OR) =0.6 (0.39-0.92); p =0.02]. The strongest association was found between ADL and IADL scales [OR =153.56 (34.86-676.48); p <0.001]. CONCLUSIONS: Even though patients who attended general practices were functioning well in everyday life, after analysis, they manifested deficits in some areas of CGA. The most widespread problems in the geriatric population were depressive symptoms, frailty, and insomnia, and that is why GPs should ask about sleep and mood disorders during visits and assess the occurrence of frailty. HIPPOKRATIA 2020, 24(4): 173-181.

LV mechanical dispersion as a predictor of ventricular arrhythmia in patients with advanced systolic heart failure : A pilot study.

BACKGROUND: Myocardial mechanical dyssynchrony induced by the presence of postinfarction scar and/or conduction abnormalities in patients with a left ventricular ejection fraction (LVEF) of < 35 % may be associated with a greater propensity toward inducing serious ventricular arrhythmia [(ventricular tachycardia (VT), ventricular fibrillation (VF)] and sudden cardiac death. The assessment of regional myocardial function using tissue Doppler echocardiography (TDE) allows for noninvasive analysis of regional mechanical dysfunction (LV mechanical dispersion). AIM: The aim of this study was to evaluate the TDE-based mechanical dispersion as a potential echocardiographic predictor of VT/VF. METHODS: The study group consisted of 47 consecutive ambulatory patients with implanted cardiac resynchronization therapy-defibrillator (CRT-D) devices who were divided into two groups: Group 1 (n = 29) comprised patients with recorded episodes of VT/VF, in whom baseline TDE data were available, and group 2 (n = 18) comprised patients without registered VT/VF in the device memory within 4 years after implantation. LV mechanical dispersion was defined as the standard deviation of the time measured from the beginning of the QRS complex to the peak longitudinal strain in apical four-chamber and two-chamber views. A retrospective quantitative assessment of LV regional deformation was based on the color tissue velocity recordings. RESULTS: The average time to event after implantation was 345 days. Patients with electrical events demonstrated greater mechanical dispersion: 99.14 ± 33.60 vs. 72.98 ± 19.70, p=0.002. CONCLUSION: During the 4-year follow-up, patients with documented VT/VF were characterized by significantly higher LV mechanical dispersion as compared with patients without electrical events. Measurement of LV mechanical dispersion might be helpful in determining the risk of sudden cardiac death.

[Tachycardia-induced cardiomyopathy]. / Arytmogenna kardiomiopatia rozstrzeniowa.

Dilated cardiomyopathy induces circulatory insufficiency with poor prognosis. Persistent tachyarrhythmias may be the cause of this disease. At particular high risk for heart damage and insufficiency are young people and children. The group of most dangerous arrhythmias consist of: incessant tachycardia in patients with preexcitation syndrome and supraventricular tachyarrhythmias (atrial flutter and fibrillation, ectopic atrial tachycardia) with high rate of ventricles. The result of arrhythmias is dilatation of the heart and thinness of ventricular walls with hemodynamic disorders. The effective therapy of arrhythmias--ablation of the accessory pathway in patients with pre-excitation syndrome or reversion to sinus rhythm (pharmacological or electric cardioversion) in patients with atrial fibrillation and flutter, often leads to normalisation of heart ejection function and diameter. Therefore it exist important question: is dilated cardiomyopathy the cause or consequence of tachyarrhythmias? Causative antiarrhythmic therapy in these second cases gives a possibility to improve the prognosis in patients with such a disease.

[Atrial flutter: causes, electrophysiological characteristics, treatment with radiofrequency catheter ablation]. / Trzepotanie przedsionków--przyczyny, charakterystyka elektrofizjologiczna, leczenie za pomoca ablacji pradem o czestotliwosci radiowej.

Atrial flutter (TP) is one of the most common supraventricular tachyarrhythmias. Because of its influence on hemodynamics of the circulation, prolonged episode of paroxysmal TP can lead in as many as 1/3-1/2 patients to clinical signs of coronary insufficiency, decompensation of the circulatory system, or even such life-threatening states, like cardiac arrest. Patients with preexcitation syndrome, hyperthyroidism, as well as children, whose atrio-ventricular (AV) node can conduct in a 1:1 fashion, are in the group of particularly high risk of complications. Recurrent episodes of TP are also associated with frequent occurrence of thromboembolic events. Based on the electrocardiographic (ECG) pattern TP is divided into common type, with negative "sawtooth" in leads II, III, aVF, and uncommon type, which is characterised by other ECG morphologies. Experimental and clinical data have revealed, that common and some part of uncommon type are due to clockwise or counterclockwise reentry in the right atrium. These forms of TP can be treated with high success-rate with radiofrequency (CR) ablation. Because of difficulties in pharmacological conversion of the arrhythmia to the sinus rhythm and high frequency of recurrences, CR ablation seems to be a high effective method of treatment in patients with common and some forms of uncommon TP.

[Radiofrequency ablation of accessory pathway's atrial insertion site]. / Ablacja pradem o czestotliwosci radiowej ujscia przedsionkowego dodatkowych szlaków przewodzenia.

Brought into clinical practice in 80, method of radiofrequency catheter ablation (RFCA) enabled possibility of causative treatment in patients with preexcitation syndrome. RFCA may be performed utilizing various techniques, choice of one of them depends on experience and preference of the operator. Aim of the study was assessment of efficacy and safety of RFCA targeting accessory pathway's atrial insertion site with help of unipolar signals from ablation-catheter with regard to various localizations of accessory pathways. Material and method studied population consisted of consecutive 149 patients with symptomatic, drug-resistant WPW-syndrome, which were admitted to our Center for electrophysiologic study and RFCA. From the studied population two groups were subdivided: patients with left-sided (group I, n = 112) and right-sided (group II, n = 37) accessory pathway. Every patient underwent electrophysiological study with use of four diagnostic electrodes and after preexcitation was confirmed RFCA was undertaken. In case of left-sided accessory pathway transseptal puncture was performed. Analyzed parameters were: total duration, fluoroscopy-time, number of current-applications during RFCA, as well as success-rate, complications and recurrences after successful ablation. Patient in both groups did not differ significantly with respect to age and sex. Success-rate was insignificantly higher in gr.I (92.8%) than in gr.II (86.5%), as was RFCA-duration (136.4 min versus 123.6 min). We found significant differences in fluoroscopy-time, which was longer in gr.I (37.2 min versus 28.4 min, p < 0.05). Complications occurred in 1 patient in each group. RFCA aiming at accessory pathway's atrial insertion site with use of unipolar tracings from ablation-catheter is safe and effective method of treatment in WPW-patients.

[Radiofrequency catheter ablation of two accessory pathways in patients with WPW Syndrome]. / Ablacja pradem o czestotliwosci radiowej dwóch dróg dodatkowych u chorego z zespolem preekscytacji.

In 10-30% patients with WPW syndrome more than one accessory pathway in electrophysiology study is observed. These patients make a group of higher atrial fibrillation and coming next ventricle fibrillation risk. We present the 39 years old patient with symptomatic WPW syndrome, without preexcitation signs in ECG at rest. In medical history--palpitations was observed from childhood with one episode of atrial fibrillation with high ventricle response required cardioversion. Electrophysiology study: without preexcitation signs at rest, two ortodromic AV reentrant tachycardias were induced--200 and 166/min. Two accessory pathways were diagnosed, left lateral and left midseptal. Radiofrequency catheter ablation of both accessory pathways was made during tachycardia, first lateral, next septal. In six month follow-up the patient was asymptomatic.

[Arrhythmogenic dysplasia of the right heart ventricle]. / Arytmogenna dysplazja prawej komory serca.

Arrhythmogenic right ventricular dysplasia (ARVD) is a heart muscle disease in which muscle tissue has been partially replaced by adipose or fibro-adipose tissue. Morphologic changes in the right ventricle and ventricular arrhythmias are characteristic. Pathomorphological changes should be confirmed by NMR or endomyocardial biopsy. Morphological changes ought to be found by ultrasound methods or angiographic examination. ECG exercise test, Holter monitoring, late potentials, total ventricular activation time and programmed stimulation of right ventricle are used to evaluate the risk of sudden death due to ventricular arrhythmias which is the most important problem. Those methods indicate pharmacologic or invasive therapy (RF ablation, implanted cardioverter-defibrillators), and are used to establish the effectiveness of treatment.

Use of changes in ST segment elevation for prediction of infarct artery recanalization in acute myocardial infarction.

BACKGROUND: The role of the ECG in evaluating reperfusion status after thrombolytic treatment in acute myocardial infarction is not clear. Dramatic ST segment changes have been observed during recanalization of an infarct-related artery, but ST criteria have not been definitively established for prediction of coronary artery patency. Differences in ST segment changes in relation to infarct localization have not been evaluated, and further investigation is required into reciprocal ST depression, which provides information independent from ST elevation. Therefore, the aim of this study was to evaluate how early changes in ST segment elevations and depressions predict vessel patency after fibrinolysis for patients with anterior and inferior/lateral infarcts. METHODS AND RESULTS: Two hundred patients with a Pardee wave in the ECG and chest pain of less than 6 h duration were given thrombolytic treatment. The result of the therapy was assessed simultaneously with coronary angiography. Patients were divided into two groups: I (50 patients) without recanalization (TIMI grade 0, 1 or 2), and II (150 patients) with successful recanalization (TIMI grade 3). Before and after therapy, analysis of the 12 lead ECG included maximum ST elevation measurement (H1, H2 respectively), the sum of ST elevations (sigma H1, sigma H2), the sum of ST segment depressions (sigma h1, sigma h2), and the ratios of ST segment changes (R1 = H2:H1, R2 = sigma H2:sigma H1, R3 = sigma h2:sigma h1). The mean interval from the first to the second ECG was 3.5 +/- 1 h. Successive values of R1 and R2 were examined to find that which best distinguished between the two groups. The best values for prediction of reperfusion were: (1) For anterior wall infarct [table: see text] (2) For inferior and lateral infarct [table: see text] In 13 patients with a complete right or left bundle branch block in the first or second ECG, the result of treatment was predicted in 11 patients using criteria for factor R1 and in 12 patients using criteria for R2. Analysis of ST segment depressions revealed a significant correlation between normalization of ST segment depressions and elevations (R3 vs R1: r = 0.60, P < 0.05; R3 vs R2 r = 0.59, P < 0.05). Multivariate discriminant analysis showed an independent value of R3 for discrimination between the two groups, but only in patients with inferior/lateral infarcts. The overall accuracy of the common algorithm in predicting reperfusion was significantly better in patients with inferior/lateral infarcts (Chi2 test, P = 0.0078). When separate algorithms were used, there was no significant difference between patients with anterior or inferior/lateral infarcts because of the significant improvement in prediction of reperfusion in patients with anterior infarcts (McNemar's test: P = 0.041). CONCLUSIONS: We conclude that analysis of ST segments on the standard 12-lead ECG offers valuable help in the early identification of successful recanalization of infarct-related arteries after thrombolytic therapy in patients with acute myocardial infarction. Use of the ratio of ST segment normalization according to the separate criteria for anterior and inferior/lateral infarcts gives the test a high sensitivity and specificity, even in the presence of interventricular conduction disturbances.

[Cardiogenic shock. Coronary angioplasty after failed intravenous thrombolysis]. / Wstrzas kardiogenny. Koronaroplastyka przy niepowodzeniu trombolizy dowiencowej.

Rescue coronary angioplasty (PTCA) was employed as reperfusion strategy after unsuccessful intracoronary infusion of streptokinase in 13 patients with AMI complicated by cardiogenic shock (CS). Reperfusion defined as reestablishment of TIMI 3 degree flow in the infarct related artery and reduction in luminal narrowing to less than 50% was achieved in 8 patients (61.5%). The failure of PTCA was caused by: inability to cross occlusion in 2 patients and recurrent thrombosis despite repeated dilatations resulting in hemodynamic instability requiring cardiopulmonary resuscitations during the procedure in 3 patients. There was no significant differences in mean age, sex, time from onset of symptoms, LVEF, artery involved, extent of coronary disease and incidence of cardiopulmonary resuscitations during the procedures. There where 4 in-hospital deaths among patients with failed PTCA (80%) compared to 25% mortality in reperfused group. We conclude that PTCA is an effective method of achieving reperfusion in patients with CS complicating AMI after failed thrombolysis with intracoronary streptokinase and that it improves in-hospital survival.

[Acute myocardial infarction with shock. Intracoronary thrombolysis]. / Ostry zawal serca ze wstrzasem. Tromboliza dowiencowa.

UNLABELLED: Of 932 pts with acute myocardial infarction (AMI) who underwent reperfusion therapy (RT) by intracoronary streptokinase (IC.STK), 32 pts had cardiogenic shock (CS). Shock was defined as systolic blood pressure (BP) < or = 80 mmHg without inotropic support or BP < or = 90 mmHg with inotropic or balloon counterpulsation support and left ventricular end diastolic pressure < 18 mmHg and clinical symptoms of hypoperfusion. Time from onset of symptoms to initiation of therapy was less than 6 hours. Reperfusion was defined as reestablishment of antegrade TIMI-2 or 3 flow in occluded artery. Comparison revealed no significant differences in sex, age, time after onset of symptoms, artery involved, history of previous AMI, left ventricular ejection fraction and in extent of coronary disease between pts with successful and failed thrombolysis. IC.STK was successful in 12 pts with CS (37.5%) and in 67.2% of pts without CS (p < or = 0.001). Mortality rate in pts with CS was 25% in reperfused and 81.8% among nonreperfused (p = 0.0095). CONCLUSIONS: 1. IC.STK gives a considerably lower rate of reperfusion in pts with AMI complicated by CS. 2. No influence on the frequency of effective reperfusion with respect to the analyzed clinical and angiographical data was found. 3. The high mortality in the group with unsuccessful reperfusion as well as the low effectiveness of the IC STK indicates the necessity to apply more effective methods of reperfusion in pts with AMI complicated by CS.