Early Cardiac Rehabilitation Improves Carotid Arterial Stiffness in Patients with Myocardial Infarction.

Background: Little is known about the effect of cardiac rehabilitation (CR) on carotid arterial stiffness (CAS) in patients with myocardial infarction (MI). Patients and Methods: Rehabilitation group (B) included 90 patients with MI subjected to CR, control group (K) consisted of 30 patients with MI not participating in CR, and healthy group comprised 38 persons without cardiovascular risk factors. CAS was determined using echo-tracking before and after CR. Results: At baseline, patients with MI (B+K) presented with significantly higher mean values of CAS parameters: beta-stiffness index (7.1 vs 6.4, p = 0.004), Peterson's elastic modulus (96 kPa vs 77 kPa, p < 0.001) and PWV-beta (6.1 m/s vs 5.2 m/s, p < 0.001) than healthy persons. Age (beta: r = 0.242, p = 0.008; EP: r = 0.250, p = 0.006; PWV-beta: r = 0.224, p = 0.014) and blood pressure: SBP (EP: r = 0.388, PWV-beta: r = 0.360), DBP (AC: r = 0.225) and PP (PWV-beta: r = 0.221) correlated positively with the initial parameters of CAS. Beta-stiffness index (Rho=-0.26, p = 0.04) and PWV-beta (Rho = 0.29, p = 0.03) correlated inversely with peak exercise capacity expressed in METs. After CR, mean values of beta-stiffness index (6.2 vs 7.1, p = 0.016), EP (78 kPa vs 101 kPa, p = 0.001) and PWV-beta (5.4 m/s vs 6.2 m/s, p = 0.001) in group B were significantly lower than in group K. In group B, CAS parameters decreased significantly after CR. Univariate analysis demonstrated that the likelihood of an improvement in CAS after CR was significantly higher in patients with baseline systolic blood pressure <120 mm Hg (OR = 2.74, p = 0.009) and left ventricular ejection fraction <43% (OR = 5.05, p = 0.005). Conclusion: In patients with MI, CR exerted a beneficial effect on CAS parameters. The improvement in CAS was predicted by lower SBP and LVEF at baseline.

The Influence of Frailty Syndrome and Dementia on the Convenience and Satisfaction with Oral Anticoagulation Treatment in Elderly Patients with Atrial Fibrillation.

Background: The impact of frailty syndrome (FS) and dementia on the convenience and satisfaction with oral anticoagulation (OAC) treatment in atrial fibrillation (AF) patients is not well-known. Aim: Assessment the impact of FS and dementia on the convenience and satisfaction with OAC treatment in 116 elderly (mean age 75.2, SD = 8.2) patients with AF. Methodology: A self-administered questionnaire was used in the study to collect basic socio-demographic and clinical data. Tilburg Frailty Indicator (TFI) questionnaire was used to assess the presence of FS, Mini Mental State Examination (MMSE) to assess cognitive impairment (CI), The Perception of Anticoagulant Treatment Questionnaire Part 2 (PACT-Q2) to assess convenience and satisfaction with OAC treatment, and the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia (ASTA) to assess quality of life (QoL). Results: Multivariable analysis as a significant, negative predictor of the convenience and satisfaction domain showed the occurrence of dementia (ß = −0.34; p < 0.001, ß = −0.41; p < 0.001, respectively) and prior major bleeding (ß = −0.30; p < 0.001, ß = −0.33; p < 0.001, respectively). Analysis showed a significant relationship between convenience and satisfaction and the overall result of the ASTA (r = −0.329; p < 0.001, r = −0.372; p < 0.001, respectively). Conclusions: Elements of geriatric syndrome, such as FS and dementia, adversely affect treatment convenience and satisfaction with OAC treatment in AF. It has been shown that better convenience and satisfaction with OAC treatment translates into better QoL. There were no differences between satisfaction and convenience and the type of OAC treatment (vitamin K antagonists (VKA) vs. novel oral anticoagulants (NOAC).

Optimal medical therapy in patients with stable coronary artery disease in Poland: the ISCHEMIA trial experience.

Introduction: Optimal medical therapy (OMT) is the cornerstone of treatment for stable coronary disease with the ISCHEMIA trial showing similar outcomes using OMT with or without an initial invasive approach. Objectives: To describe OMT goal attainment in Polish ISCHEMIA participants compared with other countries. Patients and methods: Among 5179 trial participants, 333 were randomized in Poland. The median follow-up was 3.2 years. OMT targets were: not smoking, high-intensity statin therapy, low-density lipoprotein cholesterol (LDL-C) of less than 70 mg/dl, systolic blood pressure of less than 140 mm Hg, aspirin therapy, and ACEI / ARB, and ß-blocker therapy if indicated. Results: Compared with 36 other countries, at randomization, patients in Poland were older (67 [62­75] y vs 65 [58­71] y); P <⁠0.001), more often female (30% vs 22%; P = 0.002), with a longer history of angina (3 [1­9] y vs 1 [0­3] y; P <⁠0.001), and there were more cases of prior myocardial infarction (32% vs 18%; P <⁠0.01) and revascularization (PCI, 40% vs 19%; CABG, 11% vs 3%; P <⁠0.001 for both). The number of OMT goals attained increased from baseline to follow-up visits (5 [4­5] vs 6 [5­6]; P <⁠0.001) in Poland and other countries alike (P = 0.89 vs P = 0.14). In Poland, significant improvements were achieved regarding high-intensity statin therapy (27% vs 50%), LDL-C <⁠70 mg/dl (29% vs 65%), and systolic blood pressure of less than 140 mm Hg (63% vs 81%) (P <⁠0.001 for all), whereas not-smoking (89% vs 89%), aspirin (90% vs 88%), ACEI / ARB (93% vs 95%), and ß-blocker therapy (94% vs 90%) remained high. Conclusions: With regular surveillance and contemporary medical therapy, high OMT goal attainment was achievable among the participants of the ISCHEMIA trial in Poland relative to other countries. There is still room for improvement in LDL-C and blood pressure management.

Carotid Artery Stiffness in Metabolic Syndrome: Sex Differences.

INTRODUCTION: The effect of metabolic syndrome (MS) on carotid stiffness (CS) in the context of gender is under research. OBJECTIVE: We examined the relationship between the MS and CS in men (M) and women (W) and investigated if the impact of cardiovascular risk factors on CS is modulated by gender. PATIENTS AND METHODS: The study included 419 subjects (mean age 54.3 years): 215 (51%) with MS (109 W and 106 M) and 204 (49%) without MS (98 W and 106 M). Carotid intima-media thickness (IMT) and CS parameters (beta stiffness index (beta), Peterson's elastic modulus (Ep), arterial compliance (AC) and one-point pulse wave velocity (PWV-beta)) were measured with the echo-tracking (eT) system. RESULTS: ANCOVA demonstrated that MS was associated with elevated CS indices (p = 0.003 for beta and 0.025 for PWV-beta), although further sex-specific analysis revealed that this relationship was significant only in W (p = 0.021 for beta). Age was associated with CS in both M and W, pulse pressure (PP) and body mass index turned out to be determinants of CS solely in W, while the effect of mean arterial pressure (MAP) and heart rate was more pronounced in M. MANOVA performed in subjects with MS revealed that age and diabetes mellitus type 2 were determinants of CS in both sexes, diastolic blood pressure and MAP - solely in M and systolic blood pressure, PP and waist circumference - solely in W (the relationship between the waist circumference and AC was paradoxical). CONCLUSION: The relationship between MS and CS is stronger in W than in M. In subjects with MS, various components of arterial pressure exert different sex-specific effects on CS - with the impact of the pulsative component of arterial pressure (PP) observed in W and the impact of the steady component (MAP) observed in M.

Correction: Age-specific reference values for carotid arterial stiffness estimated by ultrasonic wall tracking.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Age-specific reference values for carotid arterial stiffness estimated by ultrasonic wall tracking.

Interaction between arterial stiffness and hypertension plays an important role in the development of cardiovascular disease. Accordingly, assessment of arterial stiffness may provide a tool for estimating cardiovascular risk and monitoring therapy in hypertensive patients. Radiofrequency-based vascular ultrasound allows accurate noninvasive assessment of local mechanical properties of large arteries, but for its use in clinical practice, reference values according to age and sex are mandatory for each vascular site. To provide reference values for common carotid artery stiffness as assessed by an echo-tracking imaging system Hitachi-Aloka, we pooled measurements collected in 1847 healthy subjects aged 3-74 years (1008 males and 839 females) recruited in 14 European centers in the E-tracking International Collaboration (ETIC). Statistical models were developed to describe relationships of different stiffness indices with age and to calculate median values and Z-scores corresponding to ± 1 and ± 2 standard deviations. In our apparently healthy population, age accounted for 53% of variability in the elastic modulus (epsilon), 39% in arterial compliance, 47% in stiffness index (ß), and 56% in local pulse wave velocity; on average, blood pressure accounted for a further 7.5% of variability. Dependence on age was not linear; changes in mean values increased at older ages, especially for epsilon and ß. There was an interaction between age and gender for arterial compliance, which was higher in males. We present nomograms and a software that can be used for the automated calculation of Z-scores for local carotid stiffness in individual patients. These tools can be used to establish prognostic indicators or surrogate targets for treatment monitoring.

Gender-related differences in the progression of carotid stiffness with age and in the influence of risk factors on carotid stiffness.

BACKGROUND: In recent years, there has been growing interest in the impact of gender-related factors on the function and structure of the arterial tree. The aim of our study was to identify gender-specific differences in the progression of carotid stiffness parameters with age and in the impact of risk factors on carotid stiffness. SUBJECTS AND METHODS: The study group included 256 subjects (mean age: 54.7 years): 134 women (52%) and 122 men (48%) with cardiovascular risk factors: hypertension, type 2 diabetes mellitus, dyslipidemia, smoking, and obesity. Local parameters of carotid stiffness: ß stiffness index (ß), Peterson's elastic modulus (Ep), pulse wave velocity ß (PWV-ß) and arterial compliance (AC) were determined with ultrasound echo-tracking software application. RESULTS: Women were characterized by lower AC than men (women: 0.57 mm2/kPa vs men: 0.69 mm2/kPa, p < 0.001) and the subanalysis in three age groups revealed that the difference in AC value between genders became significant over the age of 45 years. Although no significant difference in the value of ß, Ep and PWV-ß were found between genders in the whole study group, women <45 years were characterized by lower values of ß and Ep than their men counterparts (ß: women: 5.4 vs men: 6.6, p = 0.002; Ep: women: 72 kPa vs men: 84 kPa, p = 0.015). Among analyzed risk factors, the significant determinants of carotid stiffness were age, blood pressure components (pulse pressure and mean arterial pressure), type 2 diabetes mellitus and heart rate. The relationship between carotid stiffness and pulse pressure was observed only in women and between carotid stiffness and heart rate - only in men. CONCLUSION: There are gender-related differences in the progression of carotid stiffness parameters with age and in the influence of risk factors on carotid stiffness.

Frailty syndrome and rehospitalizations in elderly heart failure patients.

BACKGROUND: Heart failure (HF) patients with frailty syndrome (FS) are at higher risk of falling, decreased mobility, ability to perform the basic activities of daily living, frequent hospitalizations, and death. AIMS: The purpose of this study was to evaluate the correlations between FS and hospital readmissions, and to assess which factors are associated with rehospitalizations. METHODS: The study included 330 patients with a mean age of 72.1 ± 7.9 years, diagnosed with HF. Frailty was measured using the Polish version of the Tilburg Frailty Indicator (TFI). Demographic, sociodemographic, and clinical data, such as the New York Heart Association (NYHA) functional class, ejection fraction (EF), number of rehospitalizations, and the medications taken, were obtained. RESULTS: Positive correlation was observed between the number of hospitalizations and FS. In the single-factor correlation analysis, treatment with diuretics, a higher NYHA class, and a lower left ventricular EF were predictors of a higher number of hospitalizations. Additionally, the physical and psychological components of the TFI, as well as the total TFI score, predisposed HF patients to more frequent hospitalizations. DISCUSSION: It seems that a deterioration of functional capabilities and an increase in symptom severity naturally lead to increased hospitalization frequency in HF. In the own study, regression analysis indicates that high NYHA classes and TFI social component scores are significant predictors of the number of hospitalizations in the studied group. CONCLUSIONS: FS is highly prevalent among elderly HF patients. Higher frailty levels in elderly patients are a determinant of more frequent rehospitalizations in HF.

Left Ventricular Function Assessed by One-Point Carotid Wave Intensity in Newly Diagnosed Untreated Hypertensive Patients.

OBJECTIVES: To investigate whether newly diagnosed untreated hypertensive patients show higher left ventricular (LV) contractility, as assessed by traditional echocardiographic indices and carotid wave intensity (WI) parameters, including amplitude of the peak during early (W1 ) and late systole (W2 ). METHODS: A total of 145 untreated hypertensive patients were compared with 145 age- and sex-matched normotensive subjects. They underwent comprehensive echocardiography and WI analysis. WI analysis was performed at the level of the common carotid artery. The diameter changes were the difference between the displacement of the anterior and posterior walls, with the cursors set to track the media-adventitia boundaries 2 cm proximal to the carotid bulb and calibrated by systolic and diastolic BP. Peak acceleration was derived from blood flow velocity measured by Doppler sonography with the range-gate positioned at the center of the vessel diameter. WI was based on the calculation of (dP/dt)×(dU/dt), where dP/dt and dU/dt were the derivatives of BP (P) and velocity (U) with respect to time. One-point pulse wave velocity (PWVß) and the interval between the R wave on ECG and the first peak of WI (R-W1 ), using a high definition echo-tracking system implemented in the ultrasound machine (Aloka), were also derived. RESULTS: After adjustment for body weight, heart rate, and physical activity, the two groups had similar general characteristics and diastolic function. However, hypertensives showed significantly higher LV mass, LV ejection fraction (LVEF), circumferential and LV end-systolic stress, and one-point PWV as well as W1 (13.646 ± 7.368 vs 9.308 ± 4.675 mmHg m/s3 , P =.001) and W2 (4.289 ± 2.017 vs 2.995 ± 1.868 mmHg m/s3 , P =.001). Hypertensives were divided into tertiles according to LVEF: W1 (11.934 ± 5.836 vs 11.576 ± 5.857 vs 17.227 ± 8.889 mmHg m/s3 , P <.0001) was higher in the highest LVEF tertile along with relative wall thickness, midwall fractional shortening, endocardial fractional shortening, and R-W1 . CONCLUSIONS: Newly diagnosed hypertensives show increased LVM and LV contractility, including carotid WI parameters and R-W1 values, as compared with normotensive subjects, but no differences in LV diastolic function.

Sex-specific predictors of left ventricular diastolic dysfunction in untreated hypertension.

BACKGROUND: Little is known about the sex-specific differences in left ventricular (LV) diastolic dysfunction (DD) predictors. We hypothesized that arterial stiffness (AS) may play a different role in the etiology of LV DD in hypertensive men and postmenopausal women, acting independently from other established predictors of this condition, such as age, obesity, diabetes mellitus, LV remodeling, and systolic function. OBJECTIVES: The aim of the study was to analyze the sex-specific differences in AS and other predictors of LV DD in men and postmenopausal women with untreated hypertension (HTN). PATIENTS AND METHODS: The study included 144 patients (63 postmenopausal women and 81 men, mean age 62.7±6.7 years) with previously untreated HTN and no history of cardiovascular diseases. All patients were subjected to detailed echocardiography, vascular ultrasound, and high-resolution echotracking (eTracking) of carotid arteries. RESULTS: In the multivariate analysis, concomitant diabetes mellitus turned out to be an independent predictor of LV DD in women (P=0.02). In turn, two independent predictors of LV DD have been identified in men: S'-tissue Doppler-derived peak LV longitudinal systolic shortening velocity (P=0.001) and ß, beta stiffness index (P=0.004). CONCLUSION: There are sex differences in the predictors of LV DD in untreated HTN. In postmenopausal women, LV DD is mostly determined by diabetes, while in men, it is determined by S', reflecting LV systolic longitudinal function, and ß, a parameter of AS.

The Relationship of Carotid Arterial Stiffness and Left Ventricular Concentric Hypertrophy in Hypertension.

BACKGROUND: Left ventricular hypertrophy (LVH) and geometry patterns vary in different hemodynamic profiles The concentric hypertrophy (CH) pattern has been proved to have the worst prognosis. OBJECTIVES: The aim of the study was to test the hypothesis that carotid artery stiffness, as a marker of vascular damage, is associated with CH, independently of other potential determinants such as demographic factors (age, sex, BMI), clinical parameters (smoking, diabetes, creatinine level) and hemodynamic variables (blood pressure, pulse pressure [PP]). MATERIAL AND METHODS: The study involved 262 subjects (89 men): 202 patients with hypertension (153 untreated, 49 on medication), aged 55.7 ± 10 years, and 60 age-matched normal controls. The subjects were examined by echocardiography and carotid ultrasound with a high-resolution echo-tracking system. Based on the left ventricular mass index (LVMI) and relative wall thickness (RWT), the patients with hypertension were divided into four patterns of LVH and geometry: normal geometry (N, n = 57), concentric remodeling (CR, n = 48), concentric hypertrophy CH (n = 62) and eccentric hypertrophy (EH, n = 35). Intima-media thickness (IMT) and the parameters of arterial stiffness were also assessed using the ß stiffness index (ß), Young elastic modulus (Ep), arterial compliance (AC), one-point pulse wave velocity (PWVß) and the wave reflection augmentation index (AI). RESULTS: Univariate analysis showed that the following variables are significant in determining CH: ß > 8.4, Ep > 136 kPa, PWVß > 7.1 m/s, AI > 21.9%, systolic BP > 151 mm Hg, PP > 54, IMT > 0.56 and the presence of diabetes. However, by multivariate analysis only AI (OR 3.65, p = 0.003), PWVß > 7.1 m/s (OR 2.86, p = 0.014), systolic BP (OR 3.12, p = 0037) and the presence of diabetes (OR 3.75, p = 0.007) were associated independently with the occurrence of CH. CONCLUSIONS: Concentric hypertrophy in hypertension is strongly associated with carotid arterial stiffness and wave reflection parameters, independently of the influence of systolic blood pressure and diabetes.

Sex differences in the quality of life of patients with acute coronary syndrome treated with percutaneous coronary intervention after a 3-year follow-up.

BACKGROUND: The aims of this study were to analyze the dynamics of quality of life (QoL) changes after 36 months from the percutaneous coronary intervention (PCI) depending on sex and identify baseline predictors of the follow-up QoL of patients hospitalized for acute coronary syndrome (ACS) and subjected to PCI. METHODS AND RESULTS: The study included 137 patients, females (n=67) and males (n=70), with ACS who underwent PCI. The QoL was assessed using the MacNew Heart Disease Health-Related Quality of Life questionnaire. The group of females scored lower in all the domains of the MacNew Heart Disease Health-Related Quality of Life questionnaire in the initial measurement (B 1), in the measurement after 6 months (B 2), and in the long-term follow-up measurement (36 months - B 3). Despite the fact that both groups achieved improved QoL, its values were higher in the males. The average growth rate of the QoL score in the period from the sixth month to 36th month was higher in females than in males. In the univariate and multivariate analyses, significant independent predictors with a negative influence on the long-term QoL score included female sex (ρ=-0.190, ß=-0.21), age >60 years (ρ=-0.255, ß=-0.186), and diabetes (ρ=-0.216, ß=-0.216). CONCLUSION: In a 36-month follow-up of ACS patients treated with PCI, there were no statistically significant differences in QoL between sexes. In the entire cohort, there was improvement in QoL, which was higher in the case of the females studied. For the entire group, significant independent determinants of lower QoL 3 years after ACS included female sex, age >60 years, and diabetes.

Impact of cardiovascular risk factors on carotid intima-media thickness: sex differences.

BACKGROUND AND PURPOSE: There has been growing interest in the sex-related differences in the impact of cardiovascular (CV) risk factors on carotid intima-media thickness (CIMT). Therefore, we aimed at examining the influence of CV risk factors on CIMT in men and women and identifying differences between males and females in the risk profiles affecting CIMT. PATIENTS AND METHODS: The study group consisted of 256 patients (mean age 54.7 years), including 134 females (52%), with the following CV risk factors: arterial hypertension, type 2 diabetes mellitus, dyslipidemia, nicotine addiction, overweight, and obesity. Subjects with the history of any overt CV disease were excluded. CIMT was measured through B-mode ultrasound examination of the right common carotid artery. In the analysis of CIMT values at different ages, the patients were divided into three age groups: 1) <45 years, 2) 45-60 years, and 3) >60 years. Regression analysis was used to examine the influence of CV risk factors on CIMT in men and women. RESULTS: CIMT increased with age in both men and women. Women had lower values of CIMT than men (0.54 mm vs 0.60 mm, P=0.011). The analysis in three age subgroups revealed that CIMT values were comparable in men and women in group 1 (0.48 mm vs 0.48 mm, P=0.861), but over the age of 45 years, CIMT values became significantly lower in women compared to men (group 2: 0.51 mm vs 0.63 mm, P=0.005; group 3: 0.63 mm vs 0.72 mm, P=0.020). Significant differences were observed between the sexes in terms of risk factor impact on CIMT. In men, only three factors significantly affected CIMT: age (b=+0.009, P<0.0001), hypertension (b=+0.067, P<0.05), and type 2 diabetes (b=+0.073, P<0.05). In women, apart from age (b=+0.008, P<0.0001) and type 2 diabetes (b=+0.111, P<0.01), significant factors were pulse pressure (PP; b=+0.005, P<0.0001), body mass index (b=+0.007, P<0.05), increased waist circumference (b=+0.092, P<0.01), and metabolic syndrome (b=+0.071, P<0.05). In the multiple regression analysis, independent CIMT determinants for the entire group were age (ß=0.497, P<0.001) and body mass index (ß=0.195, P=0.006). For males, age was the only independent determinant of CIMT (ß=0.669, P<0.001). For females, these were PP (ß=0.317, P=0.014), age (ß=0.242, P=0.03), and increased waist circumference (ß=0.207, P=0.048). CONCLUSION: CIMT values are lower in women than in men, which is most pronounced over the age of 45 years. There are sex-related differences in the profile of CV risk factors affecting CIMT: in males, CIMT is mostly determined by age, while in females, by age, PP, and increased waist circumference.

Relationship of carotid arterial functional and structural changes to left atrial volume in untreated hypertension.

ABSTRACT: The contribution of arterial functional and structural changes to left ventricular (LV) diastolic dysfunction has been the area of recent research. There are some studies on the relationship between arterial stiffness (a.s.) and left atrial (LA) remodelling as a marker of diastolic burden. Little is known about the association of arterial structural changes and LA remodelling in hypertension (H). AIM: The aim of this study was to examine the relationship between carotid a.s. and intima-media thickness (IMT) and LA volume in subjects with H. The study included 245 previously untreated hypertensives (166 women and 79 men, mean age 53.7 ± 11.8 years). Each patient was subjected to echocardiography with measurement of LA volume, evaluation of left ventricular hypertrophy (LVH) and LV systolic/diastolic function indices, integrated assessment of carotid IMT and echo-tracking of a.s. and wave reflection parameters. RESULTS: Univariate regression analysis revealed significant correlations between indexed LA volume and selected clinical characteristics, echocardiographic indices of LVH and LV diastolic/systolic function and a.s./wave reflection parameters. The following parameters were identified as independent determinants of indexed LA volume on multivariate regression analysis: diastolic blood pressure (beta = -0.229, P < 0.001), left ventricular mass index (LVMI; beta = 0.258, P < 0.001), E/e' index (ratio of early mitral flow wave velocity ­ E to early diastolic mitral annular velocity ­ e'; beta = 0.266, P = 0.001), augmentation index (AI; beta = 0.143, P = 0.008) and body mass index (BMI; beta = 0.132, P = 0.017). No correlations between indexed LA volume and IMT were found. CONCLUSION: There is a significant relationship between carotid arterial stiffness but not intima-media thickness and LA volume in patients with untreated hypertension.

Predictors of left atrial appendage thrombogenic milieu in patients subjected to transesophageal echocardiography prior to cardioversion of persistent atrial fibrillation.

INTRODUCTION: Evidence of left atrial appendage thrombogenic milieu (LAA TM) on transesophageal echocardiography (TEE) is recognized as a surrogate marker for an increased stroke risk. Although the CHA2DS2-VASc scale is commonly used as a measure of thromboembolic risk in patients with atrial fibrillation (AF), it was shown to have only low-to-moderate ability to predict the presence of LAA TM. The potential role of transthoracic echocardiography (TTE) in the refinement of clinical scales for the detection of LAA TM in patients with AF has been readdressed recently. OBJECTIVES: The aim of the study was to identify the predictors of LAA TM among the components of the CHA2DS2-VASc scale and TTE parameters in patients scheduled for electrical cardioversion due to persistent AF. PATIENTS AND METHODS: We conducted a retrospective analysis of demographic, clinical, laboratory, echocardiographic, and medication data of 202 patients (123 men and 79 women; mean age, 65.6 years) with persistent AF, who underwent TEE before electrical cardioversion. RESULTS: Duration of AF exceeding 1 year (odds ratio [OR] = 13.9; P = 0.02), left atrial diameter exceeding 51 mm (OR = 3.98; P = 0.009), left ventricular end-diastolic dimension (LVEDd) exceeding 52 mm (OR = 2.42; P = 0.01), and radiographic evidence of aortic plaques (OR = 2.97; P = 0.007) were shown to be independent predictors of LAA TM in a multivariate regression analysis. CONCLUSIONS: The CHA2DS2-VASc scale did not predict the presence of LAA TM on TEE in patients scheduled for electrical cardioversion due to persistent AF. Of the CHA2DS2-VASc components, only radiographic evidence of aortic plaques, and of TTE parameters, only left atrial enlargement and LVEDd were independent predictors of LAA TM. A comprehensive clinical and echocardiographic assessment of individual risk is indicated in patients before electrical cardioversion due to persistent AF.

Predictors of functional mitral regurgitation improvement during a short-term follow-up after cardiac resynchronisation therapy.

BACKGROUND AND AIM: The study was undertaken to assess the predictive role of myocardial contractile reserve for functional mitral regurgitation (FMR) improvement after cardiac resynchronisation therapy (CRT), and to define other predictors of FMR improvement (FMRI) and the impact of FMRI on left ventricular (LV) reverse remodelling. METHODS AND RESULTS: Among 90 patients in whom echocardiography was performed one day before and six weeks after CRT implantation, 66 with at least FMR(2+) in a four-point scale (mean age 64 ± 10 years, mean LV ejection fraction [LVEF] 25.7 ± 6%, ischaemic aetiology 48%) were included. FMRI was defined as the reduction of the FMR severity by at least one grade. The patients were divided into groups: A with FMRI (n = 30) and B without FMRI (n = 36). Contractile reserve was evaluated using low-dose dobutamine stress-echo before CRT implantation and was defined as a relative improvement in LVEF of more than 20% and segmental contractility improvement. Reverse remodelling was defined as the reduction of the LV end-systolic volume (LVESV) by at least 15%. Cox regression multivariate analysis revealed the following predictors for FMRI: contractile reserve preserved in more than three segments with an OR = 5.7 (95% CI 1.81-17.97, p = 0.005, sensitivity 65.5%, specificity 72.2%, AUC = 0.727) and LV end-diastolic diameter ≤ 74 mm with an OR = 2.09 (95% CI 0.75-5.78, p < 0.05, sensitivity 80.0%, specificity 47.2%, AUC = 0.632). FMRI was associated with greater reduction of LVESV (p = 0.002), greater increase in LVEF (p < 0.001) and higher incidence of the LV reverse remodelling (p < 0.001). CONCLUSIONS: Preserved contractile reserve and lesser degree of LV dilation were predictive factors of short-term FMR improvement after CRT implantation. FMR improvement was associated with higher incidence of the LV reverse remodelling early, already in the six weeks after CRT implantation.

[Novel paradigms for heart failure with preserved ejection fraction].

Patients with heart failure with preserved ejection fraction (HFpEF) constitute a heterogenous group with significant differences in clinical phenotypes, comorbidities and profiles between men and women. Diastolic dysfunction plays a key role in HFpEF; both left ventricular relaxation disturbances and the increase of passive ventricular stiffness may result in left ventricular filling abnormalities at rest and during exercise. However additional factors such as increased arterial stiffness and abnormal ventricular-arterial coupling, chronotropic incompetency, blunted arterial vasodilator's reactivity and pulmonary hypertension have been considered in the pathophysiology of HFpEF recently. Novel paradigms for HFpEF assume that myocardial remodeling and diastolic dysfunction are the result of the cumulation of comorbidities that induce systemic inflammation with coronary endothelial dysfunction and reduced activity of protein kinase G. Inflammatory process with dysfunction of endothelium and decreased bioavailability of nitric oxide, resulting in structural and functional myocardial changes, constitute a mechanistic link between comorbidities and evolution and progression of HFpEF. The paper presents novel paradigms for HFpEF with the heterogeneity of clinical phenotypes in subjects with this feature of hearl failure.

Frailty in patients with acute coronary syndrome: comparison between tools for comprehensive geriatric assessment and the Tilburg Frailty Indicator.

PURPOSE: It is a known fact that age is a strong predictor of adverse events in acute coronary syndrome (ACS). In this context, the main risk factor in elderly patients, ie, frailty syndrome, gains special importance. The availability of tools to identify frail people is relevant for both research and clinical purposes. The purpose of this study was to investigate the correlation of a scale for assessing frailty - the Tilburg Frailty Indicator (TFI) and its domains (mental and physical) - with other research tools commonly used for comprehensive geriatric assessment in patients with ACS. PATIENTS AND METHODS: The study covered 135 people and was carried out in the cardiology ward at T Marciniak Lower Silesian Specialist Hospital in Wroclaw, Poland. The patients were admitted with ACS. ST segment elevation myocardial infarction and non-ST segment elevation myocardial infarction were defined by the presence of certain conditions in reference to the literature. The Polish adaptation of the TFI was used for the frailty syndrome assessment, which was compared to other single measures used in geriatric assessment: the Mini-Mental State Examination (MMSE), the Hospital Anxiety and Depression Scale (HADS), and Katz Index of Independence in Activities of Daily Living (ADLs). RESULTS: The mean TFI value in the studied group amounted to 7.13±2.81 (median: 7, interquartile range: 5-9, range [0, 14]). Significant correlations were demonstrated between the values of the TFI and other scales: positive for HADS (r=0.602, P<0.001) and the reverse for MMSE (r=-0.603, P<0.001) and IADL (r=-0.462, P<0.001). Patients with a TFI score ≥5 revealed considerably higher values on HADS (P<0.001) and considerably lower values on the MMSE (P<0.001) and IADL scales (P=0.001). CONCLUSION: The results for the TFI comply with the results of other scales (MMSE, HADS, ADL, IADL), which confirm the credibility of the Polish adaptation of the tool. Stronger correlations were observed for mental components and the mental scales turned out to be independently related to the TFI in a multidimensional analysis.

Frailty Syndrome in cardiovascular disease: clinical significance and research tools.

Frailty Syndrome is one of the key health problems in geriatrics, strongly affecting poor prognosis. There is a growing interest in the relevance of this syndrome in cardiovascular disease. The diagnosis of Frailty Syndrome in the elderly cardiac population is essential for an accurate risk stratification and for making therapeutic decisions. Most risk assessment systems used in cardiology are based on chronological age, which does not always reflect the biological age of a patient, therefore making an inadequate risk estimation. This paper discusses the definitions of Frailty Syndrome and research tools used to identify it. We specifically address the role of Frailty Syndrome in cardiovascular disease and the diagnostic and therapeutic difficulties in patients with Frailty Syndrome, emphasizing the role of the identification of Frailty Syndrome in making therapeutic decisions and the stratification of cardiovascular risk in patients with cardiologic conditions.

Arterial-atrial coupling in untreated hypertension.

Recently, there has been growing interest in an interplay of vascular mechanics and heart function (arterial-ventricular-atrial coupling). The contribution of arterial stiffness (AS) to left atrial (LA) enlargement is unclear. The aim of this study was to verify whether the association between carotid AS and LA volume in untreated arterial hypertension is independent of such confounders as age, sex, body mass index (BMI), blood pressure, left ventricular hypertrophy (LVH), left ventricular (LV) diastolic and systolic function. The study included 133 patients, among them 107 individuals with hypertension (51 men and 56 women, mean age 56.8 ± 10.3 years) and 26 matched controls. Each patient was subjected to echocardiography, ultrasonographic measurement of mean carotid intima-media thickness (IMT) and echo-tracking assessment of AS and wave reflection. LA volume was calculated by ellipsoid method. The indexed LA volume showed significant linear correlations with age (r = 0.32; p < 0.05), BMI (r = 0.21; p < 0.05), pulse pressure (r = 0.26; p < 0.05), B-type natriuretic peptide (r = 0.64; p < 0.05), LV end-diastolic volume (r = 0.42; p < 0.05), LV mass index (LVMI; r = 0.58; p < 0.05), septum thickness (r = 0.40; p < 0.05), posterior wall thickness (r = 0.34; p < 0.05), early filling wave of mitral inflow (E; r = 0.30; p < 0.05), early diastolic myocardial velocity of mitral annulus (e'; r = - 0.22; p < 0.05), E/e' ratio (r = 0.45; p < 0.05), IMT (r = 0.26; p < 0.05) and augmentation index (AI; r = 0.27; p < 0.05). Progressive multivariate analysis identified LVMI, age, AI and BMI as independent determinants of indexed LA volume in patients with arterial hypertension. The study showed the significant relationship between wave reflection expressed by AI and LA structural remodeling, which supports the hypothesis of arterial-atrial coupling in hypertension.