Changes over time in the prevention of recurrent coronary artery disease in everyday practice.

INTRODUCTION: Patients with coronary artery disease (CAD) are at high risk of recurrent cardiovascular events, and risk factor control is crucial in this population. OBJECTIVES: The aim of the study was to compare the implementation of the European Society of Cardiology guidelines regarding prevention of recurrent CAD in 2011 to 2013 with 2016 to 2017. PATIENTS AND METHODS: The study included 5 hospitals with cardiology departments serving the city of Kraków and its surrounding districts. Consecutive patients with established CAD were interviewed 6 to 18 months after hospitalization in the years 2011 to 2013 and 2016 to 2017. RESULTS: We examined 616 patients in 2011 to 2013 and 388 in 2016 to 2017 (mean [SD] age, 64.7 [8.8] years vs 66.4 [8.4] years; P <0.01). After adjusting for covariates, the proportion of patients with high blood pressure decreased by 8.9% (95% CI, -15.6% to -2.1%) and the proportion of patients with high level of low­ density lipoprotein cholesterol declined by 9.5% (95% CI, -16.7% to -2.2%) in 2016 to 2017 compared with 2011 to 2013, whereas the proportion of smoking patients (-0.2% [95% CI, -6% to 5.5%]) and those with high glucose levels (3.9% [95% CI, -2.2% to 10%]) and a body mass index of 25 kg/m2 or greater (3.8% [95% CI, -3.9% to 11.6%]) did not change. More patients were prescribed antiplatelets, ß­ blockers, angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, calcium antagonists, and anticoagulants in the second period. CONCLUSIONS: We observed an increase in the proportion of patients with CAD who were prescribed cardiovascular drugs, and consequently a slight improvement in the control of their blood pressure and low­ density lipoprotein cholesterol. No changes were found regarding other main risk factors.

Obesity in patients with established coronary artery disease over a 20-year period (1997-2017).

BACKGROUND: Body mass reduction in overweight and obese people so as to reduce blood pressure, low­density lipoprotein cholesterol level, and the risk of type 2 diabetes as well as to lower the risk of recurrent cardiovascular events is strongly recommended in current guidelines. OBJECTIVES: To evaluate changes in body mass index (BMI) and waist circumference in patients with established coronary artery disease over a 20­year period (1997-2017). PATIENTS AND METHODS: Consecutive patients younger than 71 years of age and hospitalized for acute coronary syndrome or myocardial revascularization procedures were recruited and interviewed 6 to 18 months after their discharge from hospital. Weight, height, and waist circumference were measured in 1997 to 1998, 1999 to 2000, 2006 to 2007, 2011 to 2013, and 2016 to 2017. The same 5 hospitals took part in the surveys each time. RESULTS: We examined 412 patients in 1997 to 1998 (survey 1), 427 in 1999 to 2000 (survey 2), 422 in 2006 to 2007 (survey 3), 462 in 2011 to 2013 (survey 4), and 272 in 2016 to 2017 (survey 5). The proportion of obese patients was 24.5% in survey 1, 27.2% in survey 2, 34.1% in survey 3, 35.9% in survey 4, and 40.4% in survey 5 (P <0.001). The proportion of patients with central obesity also increased significantly (32.5% in survey 1, 40.5% in survey 2, 51.4% in survey 3, 48.6% in survey 4, and 61.3% in survey 5; P <0.001). BMI increased significantly in men, but not in women, whereas the mean waist circumference increased in both sexes. BMI and waist circumference increased irrespective of age and education. CONCLUSIONS: The analysis of 5 multicenter surveys showed a gradual increase in BMI and waist circumference in patients with established coronary artery disease over the course of 2 decades.

Temporal changes in the secondary prevention of coronary artery disease in patients following myocardial revascularization.

INTRODUCTION: Well-organized, effective secondary prevention of coronary artery disease (CAD) has a potential to improve the patients' prognosis following myocardial revascularization procedures. AIM: To evaluate overtime changes in the implementation of the ESC guidelines for secondary prevention by assessing control of the main risk factors and the rate of cardioprotective drug use in patients following myocardial revascularization procedures. MATERIAL AND METHODS: Patients aged < 81 years who had been hospitalized for a myocardial revascularization procedure in five hospitals serving Krakow and surrounding districts were recruited and interviewed 6-18 months following discharge. Their personal medical history, medication use and control of the main cardiovascular risk factors were evaluated using a standard questionnaire in 2006-2007, 2011-2013, and 2016-2017. The same five hospitals took part in surveys on each occasion. RESULTS: We examined 260 patients in 2006-2007, 200 in 2011-2013 and 190 in 2016-2017. We noted a significant difference in the management of surveys participants: 62% underwent percutaneous coronary intervention (PCI) and 38% coronary artery coronary artery bypass grafting (CABG) in 2006-2007 whereas the corresponding proportions in 2016-2017 were 90% and 10%. The proportion of patients who did not achieve target blood pressure (according to ESC guidelines valid at the time of each survey) in 2006-2007, 2011-2013 and 2016-2017 was 53.5%, 52.3%, and 38.9%, respectively, the proportion of those who did not achieve the LDL cholesterol target (according to ESC guidelines valid at the time of each survey) was 36.3%, 64.0%, and 61.7%, respectively, and the proportion of those with high fasting glucose was 12.6%, 14.6%, and 19.7%, respectively. The proportion of smokers was 16.2%, 19.5%, and 16.8%, whereas 30.5%, 28.6% and 40.5% of patients were obese in 2006-2007, 2011-2013 and 2016-2017, respectively. The proportion of patients taking antiplatelets (91.8% vs. 92.0% vs. 96.3%), ß-blockers (90.3% vs. 87.5% vs. 92.6%), and lipid-lowering drugs (88.7% vs. 91.0% vs. 93.7%) did not change significantly.Conclusions: The analysis of three multicenter surveys provides evidence of the considerable potential for a further reduction in cardiovascular risk in patients following elective myocardial revascularization in Poland.

Practice setting and secondary prevention of coronary artery disease.

INTRODUCTION: Patients with established coronary artery disease (CAD) are at high risk of recurrent cardiovascular events. The aim of the analysis was to compare time trends in the extent to which cardiovascular prevention guidelines have been implemented by primary care physicians and specialists. MATERIAL AND METHODS: Five hospitals with cardiology departments serving the city and surrounding districts in the southern part of Poland participated in the study. Consecutive patients hospitalized due to an acute coronary syndrome or for a myocardial revascularization procedure were recruited and interviewed 6-18 months after hospitalization. The surveys were carried out in 1997-1998, 1999-2000, 2006-2007 and 2011-2013. RESULTS: The proportion of smokers increased from 16.0% in 1997-1998 to 16.4% in 2011-2013 among those who declared that a cardiologist in a hospital outpatient clinic decided about the treatment, from 17.5% to 34.0% (p < 0.01) among those treated by a primary care physician, and from 7.0% to 19.7% (p = 0.06) among patients treated in private cardiology practices. The corresponding proportions were 44.6% and 42.4% (p < 0.01), 47.7% and 52.8% (p = 0.53), 44.2% and 42.2% (p = 0.75) for high blood pressure, and 42.5% and 71.2% (p < 0.001), 51.4% and 79.6% (p < 0.001), 52.4% and 72.4% (p < 0.01) for LDL cholesterol level not at recommended goal. The proportion of patients prescribed cardioprotective medications increased in every analyzed group. CONCLUSIONS: The control of cardiovascular risk in CAD patients has only slightly improved since 1997/98 in all health care settings. The greatest potential for further improvement was found among patients whose post-hospital care is provided by primary care physicians. It is associated with promotion of a no-smoking policy and enhanced prescription of guideline-recommended drugs.

Factors related to the effectiveness of hypercholesterolemia treatment following hospitalization for coronary artery disease.

INTRODUCTION    Patients with established coronary artery disease (CAD) are at high risk of recurrent cardiovascular events. OBJECTIVES    The aim of the study was to identify factors related to control of hypercholesterolemia in patients after hospitalization for CAD. PATIENTS AND METHODS    The study included consecutive patients from 5 hospitals with cardiology departments serving one city in southern Poland. Patients were hospitalized for an acute coronary syndrome or for a myocardial revascularization procedure. Interviews and examinations were conducted 6 to 18 months after hospitalization. RESULTS    Overall, 83.6% of the patients were taking statins; 2.1%, fibrates; and 0.5%, ezetimibe. A statin at a high dose (≥40 mg of atorvastatin or ≥20 mg of rosuvastatin) was taken by 36.1% of the participants. Younger age and index hospitalization in a teaching hospital were significantly associated with a higher probability of taking a statin. Overall, 28.1% of the patients had good control of hypercholesterolemia (low-density lipoprotein [LDL] cholesterol levels <1.8 mmol/l), whereas 71.9%, 38.6%, 24.4%, and 10.3% had LDL cholesterol levels of 1.8 mmol/l or higher, 2.5 mmol/l or higher, 3.0 mmol/l or higher, and 4.0 mmol/l or higher, respectively. Younger age, high blood pressure, and high fasting glucose levels were related to a higher probability of having LDL cholesterol levels of 1.8 mmol/l or higher, while younger age, shorter period of education, professional inactivity, lack of cardiac rehabilitation, and high blood pressure were related to the probability of LDL cholesterol levels of 4.0 mmol/l or higher. CONCLUSIONS    The frequency of statin use is affected by age and health care-related factors, while control of hypercholesterolemia after hospitalization due to CAD is dependent mainly on patient-related and clinical factors.

Cardiac Rehabilitation in Real Life.

Participation in cardiac rehabilitation programs (CRPs) improves prognosis in patients with coronary artery disease (CAD). However, not much is known about the effectiveness of CRP in real life. The aim of this analysis was to identify factors related to the referral to CRP following hospitalization for CAD and estimate the effectiveness of the programs in real life.Medical records of 1061 consecutive patients aged ≤80 years, hospitalized due to an acute coronary syndrome or for a myocardial revascularization procedure in 5 hospitals serving the city and surrounding counties, were reviewed and 611 patients were interviewed 6-18 months posthospitalization.Of 611 patients participating in the interview, 212 (34.7%) were referred following the hospitalization to a center providing CRP. Age, hospitalization in a teaching hospital, and index diagnosis were independently related to being granted a referral. Among the referred patients, 86.3% participated in the CRP. Participation in CRP was related to the lower probability of having high total cholesterol (23% vs 32%, P < 0.05), fasting glucose (11% vs 18%, P = 0.05), HbA1c (8% vs 16%, P = 0.05), and body mass index (27% vs 37%, P < 0.05). Generally, the effect of the CRP was significant in participants with a higher education, but not in those with a low education level. Other factors were not significantly related to the effectiveness of CRP.This study shows that CRPs are effective, but underused in Poland. The participant's education level may influence the effectiveness of CRP. Therefore, in order to increase the impact of CRP, the content of such programs should vary depending on the education level of the participants.

Relation of atrial fibrillation and right-sided cardiac thrombus to outcomes in patients with acute pulmonary embolism.

Atrial fibrillation (AF) can induce a hypercoagulable state in both the left and right atria. Thrombus in the right side of the heart (RHT) may lead to acute pulmonary embolism (APE). The aim of the study was to determine the prevalence of RHT and AF and to assess their impact on outcomes in patients with APE. The retrospective cohort included 1,006 patients (598 female), with a mean age of 66 ± 15 years. The primary end point was all-cause mortality. The secondary end point was incidence of complications (death, cardiogenic shock, cardiac arrest, vasopressor/inotrope treatment, or ventilatory support). Atrial fibrillation was detected in 231 patients (24%). RHT was observed in 50 patients (5%). The combination of AF and RHT was observed in 16 patients (2%). The overall mortality rate was significantly higher in patients with RHT compared with those without (32% vs 14%, respectively, odds ratio [OR] 3.0, 95% confidence interval [CI] 1.6 to 5.6, p = 0.001). The rate of complications was significantly higher in patients with RHT in comparison to those without (40% vs 22%, respectively, OR 2.4, 95% CI 1.3 to 4.4, p = 0.004). The mortality rate in patients with both AF and RHT was significantly higher in comparison to those with AF but without RHT (50% vs 20%, respectively, OR 3.86, 95% CI 1.3 to 11.2, p = 0.01). In multivariate analysis, RHT (p = 0.03) was an independent predictor of death. In conclusion, AF is a frequent co-morbidity in patients with APE, and the presence of RHT is not uncommon. Among patients with APE, the presence of RHT increases the mortality approximately threefold regardless of the presence of known AF.

T-wave inversion in patients with acute pulmonary embolism: prognostic value.

INTRODUCTION: T-wave inversion (TWI) is a common ECG finding in patients with acute pulmonary embolism (APE). OBJECTIVES: To determine the prevalence of TWI in patients with APE and to describe their relationship to outcomes. METHODS: Retrospective study of 437 patients with APE. TWI patterns were described in two distributions: inferior (II, III, aVF) and precordial (V1-V6). RESULTS: TWI was observed in 258 (59%) patients. The mortality rate was significantly higher in the group with TWI in the inferior AND precordial leads compared to the group without TWI (OR: 2.74; p = 0.024) and the group with TWI in the inferior OR precordial leads (OR: 2.43; p = 0.035). As compared those with TWI in <5 leads, patients with TWI in ≥5 leads experienced significantly higher rates of death (17.1% vs. 6.6%, OR: 2.92; p = 0.002) and complications. CONCLUSIONS: TWI and the quantitative assessment thereof can be useful to risk stratify patients with APE.

Secondary prevention of coronary artery disease in contemporary clinical practice.

BACKGROUND: The highest priority in preventive cardiology was given to patients with established coronary artery disease (CAD). The aim of the study was to assess the implementation of guidelines for secondary prevention in everyday clinical practice by evaluating control of the main risk factors and the cardioprotective medication prescription rates for patients, following their hospitalization for CAD. METHODS: Five hospitals with cardiology departments serving the city and its surround-ing districts in southern part of Poland participated in the study. Consecutive patients aged ≤ 80 years, hospitalized from January 1 2010 to April 31 2012 due to an acute coronary syndrome or for a myocardial revascularization procedure were recruited and interviewed 6-18 months after hospitalization. RESULTS: The medical records of 595 patients (mean age: 62.8 ± 9.0 years, 397 men and 198 women) were reviewed and included in the analyses. Proportions of medical records with available information on risk factors were high with the exception of total cholesterol levels as well as weight and height measurements, which were available in less than 80% of the hospital records. The prescription rate at discharge for antiplatelets was 99%, beta-blockers (BB)--85%, angiotensin converting enzyme inhibitors (ACEI) or sartans--85%, and lipid-lowering drugs--94%. Patients scheduled for coronary artery bypass grafting were significantly less often prescribed BB, ACEI or sartans, and lipid-lowering drugs. The proportion of patients with high blood pressure (≥ 140/90 mm Hg) 6-18 months after hospitalization was 47%, with high LDL cholesterol level (≥ 1.8 mmol/L) 73%, and with a high HbA1c level (≥ 7.0%) 14%, whereas 20% of participants were smokers and 80% were overweight. The proportion of patients taking an antiplatelet agent 6-18 months after hospitalization was 90%, BB--82%, ACEI--or sartan 78%, and lipid-lowering drug--82%. Overall, 33.9% of the study participants declared that they had been advised to participate in a rehabilitation/secondary prevention program following their hospitalization and 30.5% participated in a rehabilitation/secondary prevention program. However, only 28.2% took part in at least half of the planned sessions. Using a multivariate analysis we showed that, in general, risk factors control and the prescription rates of cardioprotective medications were related to the patients' age, education, and participation in a rehabilitation/secondary prevention program following their hospitalization due to CAD. CONCLUSIONS: Our data provide evidence that there is a considerable potential for further reduction of cardiovascular risk in CAD patients. Our results suggest that increasing patient participation rates in rehabilitation/secondary prevention programs may improve the implementation of the secondary prevention.

Use of ischemic ECG patterns for risk stratification in intermediate-risk patients with acute PE.

BACKGROUND: European recommendations on the management of acute pulmonary embolism (APE) divide patients into 3 risk categories: high, intermediate, and low. Mortality has previously been estimated at 3% to 15% in the intermediate group. The aim of this study was to use a new metric "ischemic electrocardiographic (ECG) patterns" to more precisely estimate the risk (complications or death) of APE patients identified as "intermediate risk" by current European Society of Cardiology (ESC) criteria. METHODS: The study group consisted of 500 consecutive patients (290 females), with a mean age 66.3 ± 15.2 years, and 245 (72.8%) patients were initially classified as intermediate risk. Four ischemic ECG patterns were studied: (i) ST-segment ischemic pattern (STIP), (ii) global ischemic pattern (GIP), (iii) negative T wave pattern, and (iv) control group consisting of patients with no ischemic changes. RESULTS: Predictors of death in univariate analysis included elevated troponin concentration (odds ratio [OR], 6.8; 95% confidence interval [CI], 1.28-169; P = 0.02]) and ischemic ECG patterns: STIP (OR, 6.3; 95% CI, 1.6-46.0; P = 0.007). Patients with right ventricular dysfunction (RVD) who were STIP (+) experienced significantly higher mortality rate compared to RVD patients who were STIP(-) (11.4% vs 1.6%; OR, 7.26; 95% CI, 1.82-52.8; P = 0.004). In patients with STIP (+) as compared to STIP (-), rate of death (OR, 6.35; P = 0.007) and rate of complications (OR, 4.19; P = 0.002) were significantly higher. Neither presence of negative T-waves nor GIP pattern was associated with a worse prognosis. CONCLUSIONS: In patients with APE, an ischemic ECG pattern on hospital admission, when identified in addition to classic risk markers, is an independent risk factor for worse in-hospital outcomes.

Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) is a predictor of poor prognosis in patients with acute pulmonary embolism (APE). OBJECTIVES: The aim of this study was to compare electrocardiography (ECG) parameters in patients with APE presenting with or without CS. METHODS: A 12-lead ECG was recorded on admission at a paper speed of 25 mm/s and 10 mm/mV amplification. All ECGs were examined by a single cardiologist who was blinded to all other clinical data. All ECG measurements were made manually. RESULTS: Electrocardiographic data from 500 patients with APE were analyzed, including 92 patients with CS. The following ECG parameters were associated with CS: S1Q3T3 sign, (odds ratio [OR]: 2.85, P<.001), qR or QR morphology of QRS in lead V1, (OR: 3.63, P<.001), right bundle branch block (RBBB) (OR: 2.46, P=.004), QRS fragmentation in lead V1 (OR: 2.94, P=.002), low QRS voltage (OR: 3.21, P<.001), negative T waves in leads V2 to V4 (OR: 1.81, P=.011), ST-segment depression in leads V4 to V6 (OR: 3.28, P<.001), ST-segment elevation in lead III (OR: 4.2, P<.001), ST-segment elevation in lead V1 (OR: 6.78, P<.01), and ST-segment elevation in lead aVR (OR: 4.35, P<.01). The multivariate analysis showed that low QRS voltage, RBBB, and ST-segment elevation in lead V1 remained statistically significant predictors of CS. CONCLUSIONS: In patients with APE, low QRS voltage, RBBB, and ST-segment elevation in lead V1 were associated with CS.

Population of Polish patients participating in the Heart Failure Pilot Survey (ESC-HF Pilot).

BACKGROUND: Heart failure (HF) is currently one of the main causes of cardiovascular mortality. In order to collect current epidemiological data on patients with HF, the Heart Failure Pilot Survey (ESC-HF Pilot) registry was initiated. AIM: Primary objective of the study was to compare clinical epidemiology of outpatients and inpatients with HF and investigate currently used diagnostic and therapeutic modalities in Poland and 11 other European countries. METHODS: The ESC-HF Pilot Survey study was a prospective multicentre observational registry conducted in 2009-2011 in 136 cardiology centres in 12 European countries selected to represent different health systems and care attitudes across Europe. All outpatients with HF and patients admitted due to acute decompensated HF were included into the registry during the enrolment period (1 day per week for 8 consecutive months). Researchers completed detailed medical data questionnaires for all HF patients recruited to the study. RESULTS: In all participating centres across Europe, 6108 patients were recruited, including 1159 patients from Poland (19% of the survey population). The majority of Polish participants were admitted due to acute HF (73%), while ambulatory chronic HF patients predominated in the remaining European centres (69%). Polish patients develop HF at a younger age compared to other European countries (proportion of patients above 65 years: 54 vs. 65%, respectively) and they are more severely ill (NYHA class III: 44 vs. 34%, respectively; NYHA class IV: 18 vs. 11%; mean BNP level 910 vs. 773 pg/mL). Angiographically documented coronary artery disease was the major aetiology of HF in Poland (39 vs. 33%) which explains a higher rate of invasive revascularisation procedures in the Polish population (13 vs. 7%). In Poland, therapy with implantable cardioverter- -defibrillators was used more frequently during the initial hospitalisation (7 vs. 4%), but the rate of cardiac resynchronisation therapy device implantation was smaller than in other European countries (4 vs. 7%). Drug therapy used in our country was comparable to the rest of Europe, except for more frequent use of aldosterone antagonists. Despite significant differences in the clinical characteristics seen between Polish and other European patients participating in the ESC-HF Pilot study, mortality at 3 months did not differ between Polish and other European centres (2.5 vs. 3%). CONCLUSIONS: The ESC-HF Pilot Survey findings indicate a very high standard of inpatient HF treatment but at the same time unsatisfactory current ambulatory HF therapy in Poland.

Electrocardiography and prognosis of patients with acute pulmonary embolism.

BACKGROUND: To assess the influence of electrocardiographic (ECG) pattern on prognosis and complications of patients hospitalized with acute pulmonary embolism (APE). METHODS: We performed a retrospective analysis of 292 patients who had confirmed APE. There were 183 females and 109 males, the age range was 17 to 89 years, and the mean age was 65.4 ± 15.5 years. RESULTS: In our study group, there were 33 deaths (mortality rate, 11.3%), and 73 (25%) patients developed complications during hospitalization. Based on European Society of Cardiology risk stratification, we classified 75 (25.7%) patients as high risk, 163 (55.8%) patients as intermediate risk, and 54 (18.5%) patients as low risk. A comparison between patients with complicated APE and those with no complications during hospitalization indicated that the following ECG parameters were more common in patients who had complications: atrial fibrillation, S1Q3T3 sign, negative T waves in leads V2-V4, ST segment depression in leads V4-V6, ST segment elevation in leads III, V1 and aVR, qR in lead V1, complete right bundle branch block (RBBB), greater number of leads with negative T waves, and greater sum of the amplitude of negative T waves. In multivariate analysis, the sum of negative T waves (OR 0.88; p = 0.22), number of leads with negative T waves (OR 1.46; p = 0.001), RBBB (OR 2.87; p = 0.02) and ST segment elevation in leads V1 (OR 3.99; p = 0.00017) and aVR (OR 2.49; p = 0.011) were independent predictors of complications during hospitalization. In turn, in multivariate analysis, only the sum of negative T waves (OR 0.81; p = 0.0098), number of leads with negative T waves [OR 1.68; p = 0.00068] and ST segment elevation in lead V1 (OR 4.47; p = 0.0003) were independent predictors of death during hospitalization. CONCLUSIONS: In our population of APE patients, the sum of negative T waves, the number of leads with negative T waves and the ST segment elevation in lead V1 were independent predictors of death during hospitalization. In turn, the sum of negative T waves, the number of leads with negative T waves, and RBBB and ST segment elevation in leads V1 and aVR were independent predictors of complications during hospitalization. We conclude that ECG analysis may be a useful noninvasive method for risk stratification of patients with APE.

Increased prevalence of cardiovascular risk factors in patients with acute coronary syndrome and indications for treatment with oral anticoagulation.

BACKGROUND: Antiplatelet drugs currently constitute the basic treatment of coronary artery disease (acute coronary syndrome [ACS], stable angina and patients treated with percutaneous coronary interventions [PCI]). The number of patients with indication for dual antiplatelet therapy with comorbidities with high thrombo-embolic risk (such as atrial fibrillation [AF], venous thrombotic disease, valvular diseases) is increasing. That is why the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common recently. The AF is the most common indication for chronic anticoagulation. Because of the lack of large randomised trials regarding triple therapy, characteristics of this group has not been well established. AIM: To assess the presence of cardiovascular (CV) risk factors and concomitant diseases in patients with ACS requiring triple therapy. METHODS: Retrospective analysis included 2279 patients diagnosed with ACS who were admitted to the Departments of Cardiology in Cracow in 2008. In this group, 365 (16%) patients had indications for chronic anticoagulation. Demographic and clinical characteristics of these patients were compared with those of patients included in other published registries. RESULTS: Patients requiring triple therapy were aged 73.2 ± 9.5 years. Hypertension was diagnosed in 80%, hyperlipidaemia in 63%, smoking in 36%, prior myocardial infarction in 33%, prior stroke in 15%, previous treatment with PCI in 13%, coronary artery bypass grafting in 7%, diabetes in 36%, heart failure in 46%, anaemia in 33% and chronic ulcer disease or gastroesophageal reflux disease in 9%. The mean left ventricular ejection fraction was 46 ± 15%. Compared with other registries of patients without indications for triple therapy, our patients had significantly more frequently hypertension, diabetes and were older. CONCLUSIONS: Patients after an ACS requiring triple therapy have more often a history of comorbidities and CV risk factors when compared with the group of patients with ACS without indication for triple therapy.

The value of ECG parameters in estimating myocardial injury and establishing prognosis in patients with acute pulmonary embolism.

BACKGROUND: The electrocardiogram (ECG) is characterised by little sensitivity and specificity in the diagnostic evaluation of acute pulmonary embolism (APE). AIM: To assess the significance of ECG changes in predicting myocardial injury and prognosis in patients with APE. METHODS: The study group consisted of 225 patients (137 women and 88 men), mean age: 66.0 ± 15.2 years, in whom the diagnosis of APE was made, mostly based on computed tomography (n = 206, 92%). RESULTS: We observed 26 in-hospital deaths (mortality rate: 11.5%) and complications occurred in 58 (25.7%) patients. Elevated levels of troponin were observed in 103 (46%) patients. Logistic regression analysis showed that in-hospital mortality was associated with: coronary chest pain (0.06-0.53, OR 0.18), systolic blood pressure below 100 mm Hg (2.3-13.64, OR 5.61), heart rate above 100 bpm (1.17-15.11, OR 4.21), the S1Q3T3 sign (1.31-6.99, OR 3.02), QR in V(1) (1.60-12.32, OR 4.45), ST-segment depression in V(4)-V(6) (0.99-5.40, OR 2.31), ST-segment elevation in III (0.99-6.96, OR 2.64), ST-segment elevation in V(1) (1.74-9.49, OR 4.07); borderline (1.51-16.07, OR 4.93), moderate (1.42-17.74, OR 5.01) and severe troponin elevation (2.88-36.38, OR 10.24). In patients with cTnT(+), compared to patients with normal troponin levels, the following ECG changes were significantly more common: the S1Q3T3 sign (43 vs 21%, p = 0.003), negative T waves in V(2)-V(4) (57 vs 27%, p = 0.0001), ST-segment depression in V(4)-V(6) (40 vs 14%, p = 0.001), ST-segment elevation in III (22 vs 7%, p = 0.0006), V(1) and V(2) (43 vs 10%, p = 0.0001) and QR in V(1) (16 vs 5%, p = 0.007). CONCLUSIONS: ECG parameters are useful in predicting myocardial injury and assessing prognosis in patients with APE.

The prognostic value of ST-segment elevation in the lead aVR in patients with acute pulmonary embolism.

BACKGROUND: Electrocardiogram (ECG) in patients with acute pulmonary embolism (APE) presents many abnormalities. There are no data concerning prognostic significance of ST-elevation (STE) in lead aVR in patients with APE. AIM: To assess the prevalence of STE in aVR in patients with APE and its correlation with clinical course as well as other ECG parameters recorded at admission. METHODS: The retrospective analysis of 293 patients with APE diagnosed according to the ESC guidelines (182 females, 111 males, mean age 65.4 ± 15.5 years). RESULTS: The STE in lead aVR was observed in 133 (45.3%) patients. In comparison with patients without STE, patients with STE in lead aVR (STaVR[+]) had significantly more often systolic blood pressure 〈 90 mm Hg on admission (27% vs 10%, p 〈 0.001) and positive troponin level (64.8% vs 27.9%, p 〈 0.001). Thrombolytic therapy (14.3% vs 5.6%, p = 0.009) and catecholamines (29.3% vs 7.5%, p 〈 0.001) were more frequently used in patients with STaVR(+). The overall mortality (16.5% vs 6.9%, p = 0.009) and complication rates during hospitalisation (38.3% vs 12.5%, p 〈 0.001) were significantly higher in patients with STaVR(+). The STaVR(+) was significantly more frequent in patients with negative T-waves in inferior leads (59.4% vs 39.4%, p 〈 0.001), STE in lead III (24% vs 5.6%, p 〈 0.001), STE in lead V1 (46.6% vs 7.5%, p 〈 0.001), ST depression in lead V(4)-V(6) (48.9% vs 7.5%, p 〈 0.001), right bundle branch block (15.8% vs 8.1%, p = 0.04), QR sign in lead V1 (18% vs 6.2%, p 〈 0.001) and SI-QIII-TIII (46.6% vs 21.2%, p 〈 0.001). CONCLUSIONS: The presence of STE in lead aVR in patients with APE is associated with poor prognosis. The presence of STE in lead aVR could be an easily obtainable and noninvasive ECG parameter, helpful in risk stratification of patients with APE.

[Cardiac involvement in Fabry's disease - typical disease course and diagnostic problems]. / Choroba Fabry'ego z zajeciem serca - typowy przebieg i trudnosci diagnostyczne.

Fabry disease is a rare X-linked recessive lysosomal storage disease, which can cause a wide range of systemic symptoms. A deficiency of the enzyme alpha galactosidase A due to mutation causes a glycolipid to accumulate within the blood vessels, other tissues, and organs. This accumulation leads to an impairment of proper heart function. Wide range of symptoms makes diagnosis difficult. We present a case of a 43 year-old male with typical Fabry disease.

[Patient with left ventricular aneurysm and thrombus after myocardial infarction - long-term observation]. / Chory z pozawalowym tetniakiem lewej komory ze skrzeplina - wieloletnia obserwacja.

A 14-year follow-up of a 69 year-old male with left ventricular aneurysm and thrombus after antero-septal myocardial infarction is presented. We describe problems with thromboembolic and bleeding complications in the context of changes in the guidelines over the period of treatment.

How often pulmonary embolism mimics acute coronary syndrome?

BACKGROUND: The clinical picture of acute pulmonary embolism (APE) is often uncharacteristic and may mimic acute coronary syndrome (ACS) or lung diseases, leading to misdiagnosis. In 50% of patients, APE is accompanied by chest pain and in 30-50% of the patients markers of myocardial injury are elevated. AIM: To perform a retrospective assessment of how often clinical manifestations and investigations (ECG findings and elevated markers of myocardial injury) in patients with APE may be suggestive of ACS. METHODS: We included 292 consecutive patients (109 men and 183 women) from 17 to 89 years of age (mean age 65.4 ± 15.5 years) with APE diagnosed according the ESC guidelines. RESULTS: Among the 292 patients included in the study 33 patients died during hospitalisation (mortality rate 11.3%) and 73 (25.0%) patients developed complications. A total of 75 (25.7%) patients were classified as high risk according to the ESC risk stratification, 163 (55.8%) as intermediate risk and 54 (18.5%) as low risk. Chest pain on and/or before admission was reported by 128 (43.8%) patients, including 73 (57.0%) patients with chest pain of coronary origin, 52 (40.6%) patients with chest pain of pleural origin and 3 patients with pain of undeterminable origin based on the available documentation. A total of 56 (19.2%) patients had a history of ischaemic heart disease and 5 (1.7%) had a history of myocardial infarction. A total of 8 (2.7%) patients were admitted with the initial diagnosis of ACS. The high-risk group consisted of 15 (20.6%) patients with a typical retrosternal chest pain and 60 (27.3%) patients without the typical anginal pain. Elevated troponin was observed in 103 (35.3%) patients. The ECG changes suggestive of myocardial ischaemia (inverted T waves, ST-segment depression or elevation) were observed in 208 (71.2%) patients. The following findings were significantly more common in high-risk versus non-high-risk patients: ST-segment depression in V4-V6 (42.6% vs 23.9%, p = 0.02), ST-segment elevation in V1 (46.7% vs 20.0%, p = 0.0002) and aVR (70.7% vs 40.1%, p = 0.0007). CONCLUSIONS: One third of patients with APE may present with all the manifestations (pain, elevated troponin and ECG changes) suggestive of ACS. The ECG changes suggestive of myocardial ischaemia are observed in 70% of the patients with ST-segment depression in V4-V6 and ST-segment elevation in V1 and aVR being significantly more common in high-risk vs non-high-risk patients.