The Usefulness of Questionnaires in Assessing the Risk of Obstructive Sleep Apnea in Patients in the Managed Care after Acute Myocardial Infarction Program-The Results of a Cross-Sectional Study.

Obstructive sleep apnea (OSA) worsens prognosis after myocardial infarction (MI) but often remains undiagnosed. The study aimed to evaluate the usefulness of questionnaires in assessing the risk of OSA in patients participating in managed care after an acute myocardial infarction program. Study group: 438 patients (349 (79.7%) men) aged 59.92 ± 10.92, hospitalized in the day treatment cardiac rehabilitation department 7-28 days after MI. OSA risk assessment: A 4-variable screening tool (4-V), STOP-BANG questionnaire, Epworth sleepiness scale (ESS), and adjusted neck circumference (ANC). The home sleep apnea testing (HSAT) was performed on 275 participants. Based on four scales, a high risk of OSA was found in 283 (64.6%) responders, including 248 (56.6%) based on STOP-BANG, 163 (37.5%) based on ANC, 115 (26.3%) based on 4-V, and 45 (10.3%) based on ESS. OSA was confirmed in 186 (68.0%) participants: mild in 85 (30.9%), moderate in 53 (19.3%), and severe in 48 (17.5%). The questionnaires' sensitivity and specificity in predicting moderate-to-severe OSA were: for STOP-BANG-79.21% (95% confidence interval; CI 70.0-86.6) and 35.67% (95% CI 28.2-43.7); ANC-61.39% (95% CI 51.2-70.9) and 61.15% (95% CI 53.1-68.8); 4-V-45.54% (95% CI 35.6-55.8) and 68.79% (95% CI 60.9-75.9); ESS-16.83% (95% CI 10.1-25.6) and 87.90% (95% CI 81.7-92.6). OSA is common in post-MI patients. The ANC most accurately estimates the risk of OSA eligible for positive airway pressure therapy. The sensitivity of the ESS in the post-MI population is insufficient and limits this scale's usefulness in risk assessment and qualification for treatment.

Transient out-of-range impedance in "hybrid" implantable cardioverter-defibrilator system: A case series.

A retrospective analysis of 60 patients with hybrid implantable cardioverter-defibrilator (ICD) systems: Boston Scientific device paired with non-Boston leads. In 10 (17%) patients transient, out-of-range peaks of ventricular pace impedance trend were observed. Probable cause is header-lead interaction incompatibility. This matter is known mainly for pacemakers systems but not for ICDs. Investigation this issue is crucial because consequences in ICD systems are unpredictable and risk might be higher than in pacing systems.

Left ventricular global longitudinal strain in predicting CRT response: one more J-shaped curve in medicine.

The aim of the study was: (1) to verify the hypothesis that left ventricular global longitudinal strain (LVGLS) may be of additive prognostic value in prediction CRT response and (2) to obtain such a LVGLS value that in the best optimal way enables to characterize potential CRT responders. Forty-nine HF patients (age 66.5 ± 10 years, LVEF 24.9 ± 6.4%, LBBB 71.4%, 57.1% ischemic aetiology of HF) underwent CRT implantation. Transthoracic echocardiography was performed prior to and 15 ± 7 months after CRT implantation. Speckle-tracking echocardiography was performed to assess longitudinal left ventricular function as LVGLS. The response to CRT was defined as a ≥ 15% reduction in the left ventricular end-systolic volume (∆LVESV). Thirty-six (73.5%) patients responded to CRT. There was no linear correlation between baseline LVGLS and ∆LVESV (r = 0.09; p = 0.56). The patients were divided according to the percentile of baseline LVGLS: above 80th percentile; between 80 and 40th percentile; below 40th percentile. Two peripheral groups (above 80th and below 40th percentile) formed "peripheral LVGLS" and the middle group was called "mid-range LVGLS". The absolute LVGLS cutoff values were - 6.07% (40th percentile) and - 8.67% (80th percentile). For the group of 20 (40.8%) "mid-range LVGLS" patients mean ΔLVESV was 33.3 ± 16.9% while for "peripheral LVGLS" ΔLVESV was 16.2 ± 18.8% (p < 0.001). Among non-ischemic HF etiology, all "mid-range LVGLS" patients (100%) responded positively to CRT (in "peripheral LVGLS"-55% responders; p = 0.015). Baseline LVGLS may have a potential prognostic value in prediction CRT response with relationship of inverted J-shaped pattern. "Mid-range LVGLS" values should help to select CRT responders, especially in non-ischemic HF etiology patients.

Regional Strain Pattern Index-A Novel Technique to Predict CRT Response.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves outcome in patients with heart failure (HF) however approximately 30% of patients still remain non-responsive. We propose a novel index-Regional Strain Pattern Index (RSPI)-to prospectively evaluate response to CRT. METHODS: Echocardiography was performed in 49 patients with HF (66.5 ± 10 years, LVEF 24.9 ± 6.4%, QRS width 173.1 ± 19.1 ms) two times: before CRT implantation and 15 ± 7 months after. At baseline, dyssynchrony was assessed including RSPI and strain pattern. RSPI was calculated from all three apical views across 12 segments as the sum of dyssynchronous components. From every apical view, presence of four components were assessed: (1) contraction of the early-activated wall; (2) prestretching of the late activated wall; (3) contraction of the early-activated wall in the first 70% of the systolic ejection phase; (4) peak contraction of the late-activated wall after aortic valve closure. Each component scored 1 point, thus the maximum was 12 points. RESULTS: Responders reached higher mean RSPI values than non-responders (5.86 ± 2.9 vs. 4.08 ± 2.4; p = 0.044). In logistic regression analysis value of RSPI ≥ 7 points was a predictor of favorable CRT effect (OR: 12; 95% CI = 1.33-108.17; p = 0.004). CONCLUSIONS: RSPI could be a valuable predictor of positive outcome in HF patients treated with CRT.

Patients with atrial fibrillation and low risk of stroke: do they really need anticoagulation?

Atrial fibrillation (AF) significantly increases the risk of thromboembolic events, in particular the risk of stroke. Anticoagulation therapy has been shown to reduce this risk; therefore, the treatment should be lifelong. However, the risk in patients with nonvalvular AF is not equally distributed, and there is a population of patients at low risk. According to the current guidelines, the decision on the need of anticoagulation is primarily dependent on whether the patient is at low risk. The CHA2DS2-VASc is currently the most commonly recommended scheme for assessing thromboembolic risk in patients with nonvalvular AF. In a large group of nontreated patients with a CHA2DS2-VASc of 0 (1 in women), the annual risk of stroke was 0.49%; ischemic stroke, 0.43%; bleeding, 1.08%; intracranial bleeding, 0.15%; and death, 3.87%. In patients on warfarin, the frequency of ischemic stroke was similar. Patients with a CHA2DS2-VASc of 0 (1 in women) are low-risk patients who do not benefit from anticoagulation. The low-risk group is also defined as patients younger than 65 years of age without structural cardiovascular disease, regardless of sex. They represent from 6% to 10% of patients with nonvalvular AF. Thromboembolic risk in patients with a score of 1 (2 in women) is much more controversial, as reflected by several recently published cohort studies. In a Swedish study, the risk was found to be low, while in Danish and Taiwanese studies-as significantly higher. Another analysis has shown that the use of vitamin K antagonists is appropriate when the risk of stroke is higher than 1.7%/year. Owing to a lower risk of intracranial bleeding, anticoagulation with nonvitamin K antagonist oral anticoagulants may be considered already at an annual risk of stroke exceeding 0.9%. Patients at low risk do not require chronic anticoagulation.