Forging Ahead in Cardiovascular Disease Management.

The common threat of cardiovascular diseases (CVDs) constantly holds a dominant position among the leading causes of global mortality [...].

Plasma Troponins Identify Patients with Very Low-Risk Acute Pulmonary Embolism.

INTRODUCTION: Although in the non-vitamin K oral anticoagulants (NOAC) era majority of low-risk acute pulmonary embolism (APE) patients can be treated at home, identifying those at very low risk of clinical deterioration may be challenging. We aimed to propose the risk stratification algorithm in sPESI 0 point APE patients, allowing them to select candidates for safe outpatient treatment. MATERIALS AND METHODS: Post hoc analysis of a prospective study of 1151 normotensive patients with at least segmental APE. In the final analysis, we included 409 sPESI 0 point patients. Cardiac troponin assessment and echocardiographic examination were performed immediately after admission. Right ventricular dysfunction was defined as the right ventricle/left ventricle ratio (RV/LV) > 1.0. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis and/or immediate surgical embolectomy in patients with clinical deterioration. RESULTS: CE occurred in four patients who had higher serum troponin levels than subjects with a favorable clinical course (troponin/ULN: 7.8 (6.4-9.4) vs. 0.2 (0-1.36) p = 0.000). Receiver operating characteristic (ROC) analysis showed that the area under the curve for troponin in the prediction of CE was 0.908 (95% CI 0.831-0.984; p < 0.001). We defined the cut-off value of troponin at >1.7 ULN with 100% PPV for CE. In univariate and multivariate analysis, elevated serum troponin level was associated with an increased risk of CE, whereas RV/LV > 1.0 was not. CONCLUSIONS: Solely clinical risk assessment in APE is insufficient, and patients with sPESI 0 points require further assessment based on myocardial damage biomarkers. Patients with troponin levels not exceeding 1.7 ULN constitute the group of "very low risk" with a good prognosis.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients.

OBJECTIVES: The presence of right heart thrombi in transit (RHTiT) in the setting of acute pulmonary embolism (PE) is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high- or intermediate-high-risk PE with coexisting RHTiT. METHODS: A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute PE with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography and laboratory tests. Eligibility criteria for surgical treatment were acute PE with RHTiT, right ventricular overload on imaging studies and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end point was hospital all-cause mortality; secondary end points were perioperative complications and long-term mortality. RESULTS: The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was 1 death in the long-term follow-up, not related to PE. CONCLUSIONS: Surgical treatment of patients with acute PE and coexisting RHTiT can provide favourable results.

Assessment of the incidence of fragmented QRS in electrocardiography in patients with systemic sclerosis and systemic lupus erythematosus.

OBJECTIVE: In systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) cardiac involvement is very common, and it might be asymptomatic. We aimed to assess the presence of fragmented QRS (fQRS) - possible indicator of a scar, diffuse damage or conduction system disturbances in those patients. METHODS: We examined 74 patients with SSc, 77 with SLE and 40 healthy controls. The incidence of fQRS in ECG was examined according to criteria by Das et al. Disease severity was estimated by Rodnan and SLICCC/ACRDI scores in SSc and SLE respectively. RESULTS: Patients with SSc were slightly older than those with SLE (53 ± 14 vs 46 ± 14 yrs), women constituted 91% and 88% of studied groups (p = 0.80). The duration of disease in both groups was similar (p = 0.59). Median of Rodnan and SLICCC/ACR-DI scores were 5 and 4 points, respectively. Left ventricle ejection fraction in both groups was similar (65.5 vs 65.1%, p = 0.51), hypertension incidence was lower in SSc (24 vs 48%, p = 0.004), patients with SLE presented prolonged corrected QT interval (432 vs 424 ms, p = 0.03). Of note, fQRS were observed in 34 (46%) SSc and 29 (38%) SLE patients, p = 0.33. Notched S waves were significantly more frequent in SSc (in 26% vs 10%, p = 0.02). fQRS occurred in 3 (7.5%) of healthy subjects only. CONCLUSION: The incidence of fQRS is similar in SSc and SLE, but is much more common than in healthy subjects. It is possible that fQRS may be considered an additional marker of heart involvement in these rare diseases.

Decreased Haemoglobin Level Measured at Admission Predicts Long Term Mortality after the First Episode of Acute Pulmonary Embolism.

Background: Decreased hemoglobin concentration was reported to predict long term prognosis in patients various cardiovascular diseases including congestive heart failure and coronary artery disease. We hypothesized that hemoglobin levels may be useful for post discharge prognostication after the first episode of acute pulmonary embolism. Therefore, the aim of the current study was to evaluate a potential prognostic value of a decreased hemoglobin levels measured at admission due to the first episode of acute PE for post discharge all cause mortality during at least 2 years follow up. Methods: This was a prospective, single-center, follow-up, observational, cohort study of consecutive survivors of the first PE episode. Patients were managed according to ESC current guidelines. After the discharge, all PE survivors were followed for at least 24 months in our outpatient clinic. Results: During 2 years follow-up from the group of 402 consecutive PE survivors 29 (7.2%) patients died. Non-survivors were older than survivors 81 years (40−93) vs. 63 years (18−97) p < 0.001 presented higher sPESI 2 (0−4) vs. 1 (0−5), p < 0.001 driven by a higher frequency of neoplasms (37.9% vs. 16.6%, p < 0.001); and had lower hemoglobin (Hb) level at admission 11.7 g/dL (6−14.8) vs. 13.1 g/dL (3.1−19.3), p < 0.001. Multivariable analysis showed that only Hb and age significantly predicted all cause post-discharge mortality. ROC analysis for all cause mortality showed AUC for hemoglobin 0.688 (95% CI 0.782−0.594), p < 0.001; and for age 0.735 (95% CI 0.651−0.819) p < 0.001. A group of 59 subjects with hemoglobin < 10.5 g/dL showed mortality rate of 16.9% (OR for mortality 4.19 (95% CI 1.82−9.65), p-value < 0.00, while among 79 patients with Hb > 14.3 g/dL only one death was detected. Interestingly, patients in age > 64 years hemoglobin levels < 13.2 g/dL compared to patients in the same age but with >13.2 g/dL showed OR 3.6 with 95% CI 1.3−10.1 p = 0.012 for death after the discharge. Conclusions: Lower haemoglobin measured in the acute phase especially in patients in age above 64 years showed significant impact on the prognosis and clinical outcomes in PE survivors.

Prevalence of Obesity and Severe Obesity among Professionally Active Adult Population in Poland and Its Strong Relationship with Cardiovascular Co-Morbidities-POL-O-CARIA 2016-2020 Study.

For several decades, a steady increase in the percentage of overweight and obese people has been observed all over the world. There are many studies available in the literature emphasizing the relationship of overweight and obesity with the occurrence of other diseases. The aim of this study is to characterize the prevalence of obesity and severe obesity, as well as their changes over time, among professionally active adults who underwent occupational medicine examinations in Poland in 2016−2020, for the POL-O-CARIA 2016−2020 study. In total, the results of 1,450,455 initial, control and periodic visits as part of the occupational medicine certificate were analyzed. Statistical calculations were performed with the use of IBM SPSS Statistics 25. In both groups (men/women), a significant decrease was observed every year for people who had normal body weight. In addition, the tendency to increase in people with I and III degrees of obesity was more strongly observed in the male group. A significant relationship was also observed between BMI categories and the occurrence of all analyzed comorbidities: hypertension, type 2 diabetes, lipid disorders and coronary artery disease (chi2 (70) = 12,228.11; p < 0.001). Detailed results showed that in the group of patients diagnosed with hypertension or lipid disorders, significant differences were observed between all groups; it turned out that as the BMI level increased (I, I, III), there was an increase in the percentage of occurrence of hypertension (38.1%, 41% and 45.3%, respectively) and type 2 diabetes (3.2%, 4.6% and 5.8%, respectively) (p < 0.001). Our analysis indicates that the prevalence of adult obesity and severe obesity will continue to increase nationwide, with an accompanying large increase in comorbidities.

An expert opinion of the Polish Cardiac Society Working Group on Pulmonary Circulation on screening for chronic thromboembolic pulmonary hypertension patients after acute pulmonary embolism: Update.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism (APE). Both pharmacological and invasive treatments for CTEPH are available in Poland, and awareness of the disease among physicians is growing. It has been suggested that the COVID-19 pandemic may increase the incidence of CTEPH and facilitate disease detection during more advanced stages of the illness. Thus, the Polish Cardiac Society's Working Group on Pulmonary Circulation, in cooperation with independent experts in this field, launched the updated statement on the algorithm to guide a CTEPH diagnosis in patients with previous APE. CTEPH should be suspected in individuals after APE with dyspnea, despite at least 3 months of effective anticoagulation, particularly when specific risk factors are present. Echocardiography is the main screening tool for CTEPH. A diagnostic workup of patients with significant clinical suspicion of CTEPH and right ventricular overload evident on echocardiography should be performed in reference centers. Pulmonary scintigraphy is a safe and highly sensitive screening test for CTEPH. Computed tomography pulmonary angiography with precise detection of thromboembolic residues in the pulmonary circulation is important for the planning of a pulmonary thromboendarterectomy. Right heart catheterization definitively confirms the presence of pulmonary hypertension and direct pulmonary angiography allows for the identification of lesions suitable for thromboendarterectomy or balloon pulmonary angioplasty. In this document, we propose a diagnostic algorithm for patients with suspected CTEPH. With an individualized and sequential diagnostic strategy, each patient can be provided with suitable and tailored therapy provided by a dedicated CTEPH Heart Team.

Assessment of pulmonary embolism severity and the risk of early death.

Currently, venous thromboembolism, including deep vein thrombosis and acute pulmonary embolism (PE), is globally the third most frequent acute cardiovascular syndrome with rising incidence rates. The clinical presentation of PE is heterogenous: from incidental findings on imaging studies to sudden cardiac death. Hemodynamic instability identifies patients at high risk of early mortality. In hemodynamically stable patients, further stratification into intermediate- and low-risk categories is advised, preferably using a combined risk assessment strategy based on clinical parameters, laboratory findings, and imaging markers. Treatment should be tailored to the risk of early death, with more aggressive treatments reserved for patients at higher risk of complications. This review offers an update on the current strategies for assessing PE severity and the risk of early death and discusses developments in predicting mortality risk in patients with PE.

Association between the geographic region and the risk of familial atrioventricular nodal reentrant tachycardia in the Polish population.

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the most common regular supraventricular arrhythmias referred for catheter ablation (CA). In Poland, several families with familial AVNRT (FAVNRT) were reported in Podkarpacie Province (PP). Objectives: We aimed to determine the frequency of FAVNRT in PP compared with other south-eastern provinces of Poland. Patients and methods: Clinical data of 1544 patients with AVNRT diagnosed by invasive electrophysiological study between 2010 and 2019 were screened for FAVNRT. From January 2017 to June 2019, patients were asked to provide details on family history and origin to obtain 3-generation pedigrees. Families with at least 2 members with previous CA of AVNRT were divided into those from south-eastern provinces (SEPs; including PP and bordering provinces [BPs]) and the remaining parts of Poland (RPP). Results: There were 932 patients from SEPs and 612 from RPP. FAVNRT was reported in 45 patients (2.91%) from 27 families, with a higher frequency in SEPs than RPP (4.02% vs 1.17%; P = 0.002) and the highest frequency in PP (6.33% vs 2.47% in BPs; P = 0.004). The risk of FAVNRT was higher in PP compared with BPs (odds ratio, 2.67; 95% CI, 1.36­5.23; P = 0.004) and similar in BPs compared with RPP (odds ratio, 2.14; 95% CI, 0.86­5.34; P = 0.1). Conclusions: A relationship exists between the geographic region and frequency of FAVNRT. A greater distance from PP was associated with less frequent FAVNRT. International cooperation and genetic testing are needed to confirm the genetic impact of FAVNRT in this part of Central Europe.

, , ACUTE PULMONARY EMBOLISM BY AMNIOTIC FLUID - A RARE COMPLICATION OF PERINATAL PERIOD THAT SHOULD NOT BE FORGOTTEN.

OBJECTIVE: Amniotic fluid embolism (AFE) is a diagnostically challenging type of pulmonary embolism that occurs when amniotic fluid enters maternal circulation during delivery or postpartum. This obstetric complication is very rare but characterized by high mortality rate. The main symptoms are dyspnea, cardiovascular collapse, disseminated intravascular coagulation (DIC) and even sudden cardiac death. The aim of the article is to draw attention to AFE as a rare but possible and catastrophic complication of perinatal period. The authors present a 28-year-old woman who was admitted to obstetric ward during the first stage of labour. The patient developed sudden deterioration of her medical state with acute respiratory distress symptoms. An emergency cesarean section was performed, complicated by excessive bleeding. After a detailed assessment of the patient's condition and evaluation of the results of additional tests, we diagnosed AFE as the cause of the patient's deterioration. CONCLUSION: Conclusions: The case study shows how unpredictable, unpreventable and dangerous is AFE. It is still one of the main causes of maternal deaths in developed countries. Four diagnostic criteria proposed by the Society for Maternal-Fetal Medicine (SMFM) may accelerate diagnosis. AFE as a medical emergency, requires immediate multidisciplinary response and aggressive treatment. The initial medical care may be facilitated by the application of the general guidelines recommended by SMFM. The case report also emphasizes the need for further research on this disease, in particular on early detection and prevention.

An expert opinion of the Polish Cardiac Society Working Group on Pulmonary Circulation and the Polish Society for Rheumatology on the diagnosis and treatment of pulmonary hypertension in patients with connective tissue disease.

Systemic connective tissue diseases (CTDs) comprise a large group of diseases that are auto-immune in nature and characterized by the involvement of multiple systems and organs. Pul-monary hypertension (PH) of various etiologies may develop in the course of CTD, including pulmonary arterial hypertension (PAH), PH secondary to the lung disease, postcapillary PH in the course of left heart disease, and chronic thromboembolic pulmonary hypertension (CTEPH). In addition, the different forms of PH may coexist with each other. Among patients with CTD, PAH occurs most commonly in those with systemic sclerosis, where it affects ap-proximately 8%-12% of patients. The prognosis in patients with untreated PAH is very poor. It is particularly important to identify the high-risk CTD-PAH population and to perform effi-cient and accurate diagnostics so that targeted therapy of the pulmonary arteries can be intro-duced. Echocardiography is used to screen for PH, but clinical and echocardiographic suspicion of PH always requires confirmation by right heart catheterization. Confirmation of PAH ena-bles the initiation of life-prolonging pharmacological treatment in this group of patients, which should be administered in referral centers. Drugs available for pharmacological management include endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostacyclins.

Holter-Derived Autonomic Function, Arrhythmias and Carbohydrate Metabolism in Patients with Class III Obesity Treated with Laparoscopic Sleeve Gastrectomy.

The effects of weight loss following bariatric surgery on autonomic balance, arrhythmias and insulin resistance are still of interest. We prospectively investigated 50 patients with BMI > 40 kg/m2, aged 36.5 (18-56) years who underwent laparoscopic sleeve gastrectomy. Among other examinations, all subjects had 24-h Holter monitoring with heart rate variability (HRV) and heart rate turbulence (HRT) evaluation. After a median of 15 months, BMI decreased from 43.9 to 29.7 kg/m2, the incidence of hypertension decreased from 54 to 32% (p = 0.04) and any carbohydrate disorders decreased from 24 to 6% (p = 0.02). Fasting insulin concentration and insulin resistance index improved significantly (p < 0.001). Improvements in HRV parameters related to the sympathetic autonomic division were also observed (p < 0.001), while HRT evaluation was not conclusive. The enhancement of autonomic tone indices was correlated with reduction of BMI (SDNN-I r = 0.281 p = 0.04; SDNN r = 0.267 p = 0.05), but not with reduction of waist circumference, and it was also associated with decrease of mean heart rate (OR 0.02, 95%CI 0.0-0.1, p < 0.001). The incidence of arrhythmias was low and similar before and after follow-up. In conclusion, improvement of homeostasis of carbohydrate metabolism and autonomic function is observed in relatively young patients after weight loss due to laparoscopic sleeve gastrectomy.

Echocardiography during the coronavirus disease 2019 pandemic - the impact of the vaccination program. A 2021 update of the expert opinion of the Working Group on Echocardiography of the Polish Cardiac Society.

The coronavirus disease 2019 (COVID-19) pandemic resulted in an urgent need to reorganize the work of echocardiography laboratories in order to ensure the safety of patients and the protection of physicians, technicians, and other staff members. In the previous Expert Opinion of the Working Group on Echocardiography of Polish Cardiac Society we provided recommendations for the echocardiographic services, in order to ensure maximum possible safety and efficiency of imagers facing epidemic threat. Now, with much better knowledge and larger experience in treating COVID-19 patients and with introduction of vaccination programs, we present updated recommendations for performing transthoracic and transesophageal examinations, including information on the potential impact of personnel and the patient vaccination program, and growing numbers of convalescents on performance of echocardiographic laboratories, with the goal of their ultimate reopening.

Left ventricular diastolic dysfunction and diseases severity contribute to impaired exercise capacity in systemic lupus erythematosus.

OBJECTIVES: Patients with systemic lupus erythematosus (SLE) have a higher risk of myocardial involvement, which can result in ventricular dysfunction. The aim of our study was to estimate potential relationship between exercise capacity assessed by six minute walk test (6MWT) and echocardiographic parameters of left and right ventricular function in SLE patients. METHODS: We prospectively studied 66 SLE patients (57 F, age 44 (20-75) years) and 27 age matched healthy subjects. In addition to routine evaluation, 6MWT and transthoracic echocardiography including LV diastolic dysfunction parameters (E/A, E/É) were performed. RESULTS: While E/A was similar in both groups, E/E' was higher in patients with SLE than in controls, 7.5 (4-22) vs 6.8 (1.6-9.4), p = 0.018. The mean 6MWT distance was significantly shorter in SLE (561.6 ± 150.7 vs 682.6 ± 98.1 m, p < 0.002). Among SLE patients only 53 (80.3%) were capable to walk at least 450 m, while in controls 27 (100%) (p = 0.013). We observed significant correlations between 6MWT distance and SLICC/ACR-DI (rho=-0.44, p < 0.001), E/A (rho = 0.30, p = 0.004), E/E' (rho=-0.36, p < 0.001) in SLE patients. Univariable logistic regression models revealed that SLICC/ACR-DI, E/E', tricuspid regurgitant peak gradient (TRPG), and right ventricular systolic pressure (RVSP) were associated with 6MWT distance lower than < 450 m. ROC curves shown high predictive value of E/E' ratio, TRPG, RVSP in the prediction for 6MWT distance < 450 m. CONCLUSION: Impaired exercise tolerance seems to result mainly from the severity of SLE and LV diastolic dysfunction.

Assessment of arrhythmias and cardiac autonomic tone at a relatively young age patients with obesity class III.

There is no sufficient data on arrhythmias occurrence in obesity class III. The influence of hyperinsulinemia and insulin resistance on arrhythmias and cardiac autonomic tone is also of ongoing interest in these subjects. We prospectively studied 81 selected patients with body mass index >40 kg/m2 , aged 34 (18-65) years. Among other examinations all subjects underwent electrocardiography and Holter monitoring with heart rate variability (HRV) and turbulence (HRT) evaluation. Controls consisted of 45 healthy, sex- and aged-matched lean volunteers. In patients median BMI was 44.5 kg/m2 (40.1-58.1), benign arterial hypertension was present in 43.2% and dysglycemia in 27.2% of cases. In the group with obesity longer PR interval (P < .001) and corrected QT interval (P < .001) were observed, while in Holter monitoring no significant differences in supraventricular or ventricular arrhythmias and also bradyarrhythmias prevalence were observed in comparison to controls. In individuals with obesity HRV indices associated with sympathetic tone were significantly impaired and also abnormal HRT values (21.9 vs 0%, P = .04) were more frequently observed. There were no significant correlations between anthropometric obesity parameters and fasting insulin concentration, insulin resistance index and also HRV/HRT parameters in studied individuals. Univariate regression analysis revealed that only age influenced abnormal HRT occurrence (OR 1.69, 95%CI 1.08-2.98, P = .04). In conclusions, patients with obesity class III at a relatively young age who reported they felt healthy, do not present increased prevalence of arrhythmias, including life-threatening ones. Cardiac autonomic dysfunction is observed in these patients, however it has not been shown to be associated with anthropometric measurements.

Evaluation of the InterTAK Diagnostic Score in differentiating Takotsubo syndrome from acute coronary syndrome. A single center experience.

BACKGROUND: The aim of this study was to evaluate the usefulness of a novel clinical score - the InterTAK Diagnostic Score in differentiating Takotsubo syndrome (TTS) from acute coronary syndrome (ACS). METHODS: Medical records of 40 consecutive patients with ACS and 20 patients with TTS were managed and retrospectively analyzed at the documented center. Each patient was evaluated using the Inter- TAK Diagnostic Score. To illustrate the diagnostic ability of the score, a receiver operating characteristic (ROC) curve was performed. RESULTS: Takotsube syndrome patients were more often female compared to the ACS group (70% vs. 27.5%, p = 0.002), an emotional trigger was more prevalent among the TTS group (65% vs. 7.5%, p < 0.001). The area under the curve (AUC) for the score was 0.885 (95% confidence interval [CI] 0.78-0.97). Using a cut-off value of 45 points, the sum of sensitivity and specificity was the highest. However, when patients with a score of ≥ 50 were diagnosed as TTS, 85% were diagnosed correctly. When patients with score ≤ 31 were diagnosed as ACS, 92% were diagnosed correctly. CONCLUSIONS: The InterTAK Diagnostic Score might help in differentiating TTS from ACSs with high sensitivity and specificity. This finding requires further investigation to confirm its clinical utility.