Impact of the COVID-19 Pandemic on Pulmonary Hypertension Patients: Insights from the BNP-PL National Database.

We aimed to evaluate the clinical course and impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy in the complete Polish population of patients (pts) with pulmonary arterial hypertension (PAH-1134) and CTEPH (570 pts) treated within the National Health Fund program and reported in the national BNP-PL database. Updated records of 1704 BNP-PL pts collected between March and December 2020 were analyzed with regard to incidence, clinical course and mortality associated with COVID-19. Clinical characteristics of the infected pts and COVID-19 decedents were analyzed. The rates of new diagnoses and treatment intensification in this period were studied and collated to the proper intervals of the previous year. The incidence of COVID-19 was 3.8% (n = 65) (PAH, 4.1%; CTEPH, 3.2%). COVID-19-related mortality was 28% (18/65 pts). Those who died were substantially older and had a more advanced functional WHO class and more cardiovascular comorbidities (comorbidity score, 4.0 ± 2.1 vs. 2.7 ± 1.8; p = 0.01). During the pandemic, annualized new diagnoses of PH diminished by 25-30% as compared to 2019. A relevant increase in total mortality was also observed among the PH pts (9.7% vs. 5.9% pre-pandemic, p = 0.006), whereas escalation of specific PAH/CTEPH therapies occurred less frequently (14.7% vs. 21.6% pre-pandemic). The COVID-19 pandemic has affected the diagnosis and treatment of PH by decreasing the number of new diagnoses, escalating therapy and enhancing overall mortality. Pulmonary hypertension is a risk factor for worsened course of COVID-19 and elevated mortality.

Aging Athlete's Heart: An Echocardiographic Evaluation of Competitive Sprint- versus Endurance-Trained Master Athletes.

BACKGROUND: Sports training triggers exercise-induced cardiac remodeling (EICR). Sprint- and endurance-trained master athletes are exposed to different hemodynamic stimuli accompanied by aging. The aim of this study was to compare EICR types in light of the Morganroth hypothesis, frequency of abnormalities, and relationships between cardiac traits and age. METHODS: In this observational cross-sectional study, echocardiographic examinations were conducted in 143 sprint-trained (age range, 36-83 years) and 114 endurance-trained (age range, 38-85 years) competitive master athletes. Structural and functional characteristics were compared with population reference values, and EICR types were identified. Athletic groups were compared using t tests and χ2 tests. Relationships with age were assessed using linear regression. RESULTS: In the sprint group, 51.0% of athletes had normal cardiac geometry (nonhypertrophic heart), 4.2% had eccentric hypertrophy, 36.4% had concentric remodeling, and 8.4% had concentric hypertrophy. In their endurance-trained peers, these proportions were 22.8%, 16.7%, 36.8%, and 23.7%, respectively. Many athletes in both groups had structural abnormalities, as assessed using population norms (up to ~81% for septal thickness) but their resting cardiac function was normal. The relationships of structural and functional cardiac characteristics with age were mostly weak to moderate and did not differ between training modalities. CONCLUSIONS: Even though many endurance- and sprint-oriented master athletes exceed population norms for cardiac structure, they do not go beyond the "gray zone" and preserve normal cardiac function. Therefore, physiologic adaptations, rather than pathologic abnormalities, are expected in aging but still active athletes. Inconsistent with the Morganroth hypothesis, EICR is shifted toward normal geometry in sprinters and toward concentric remodeling and hypertrophy in endurance runners. A better understanding of the mechanisms behind cardiac remodeling during aging is needed to adequately predict EICR types in master athletes.

Characteristics and outcomes of patients with chronic thromboembolic pulmonary hypertension in the era of modern therapeutic approaches: data from the Polish multicenter registry (BNP-PL).

BACKGROUND: Significant achievements in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) have provided effective therapeutic options for most patients. However, the true impact of the changed landscape of CTEPH therapies on patients' management and outcomes is poorly known. We aimed to characterize the incidence, clinical characteristics, and outcomes of CTEPH patients in the modern era of CTEPH therapies. METHODS: We analyzed the data of CTEPH adults enrolled in the prospective multicenter registry. RESULTS: We enrolled 516 patients aged 63.8 ± 15.4 years. The incidence rate of CTEPH was 3.96 per million adults per year. The group was burdened with several comorbidities. New oral anticoagulants (n = 301; 58.3%) were preferred over vitamin K antagonists (n = 159; 30.8%). Pulmonary endarterectomy (PEA) was performed in 120 (23.3%) patients and balloon pulmonary angioplasty (BPA) in 258 (50%) patients. PEA was pretreated with targeted pharmacotherapy in 19 (15.8%) patients, and BPA in 124 (48.1%) patients. Persistent CTEPH was present in 46% of PEA patients and in 65% of patients after completion of BPA. Persistent CTEPH after PEA was treated with targeted pharmacotherapy in 72% and with BPA in 27.7% of patients. At a mean time period of 14.3 ± 5.8 months, 26 patients had died. The use of PEA or BPA was associated with better survival than the use of solely medical treatment. CONCLUSIONS: The modern population of CTEPH patients comprises mostly elderly people significantly burdened with comorbid conditions. This calls for treatment decisions that are tailored individually for every patient. The combination of two or three methods is currently a frequent approach in the treatment of CTEPH. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov/ct2/show/NCT03959748.

Thrombocytopenia During Prostacyclin Analogue Therapies of Pulmonary Arterial Hypertension-Possible Pathomechanisms and Implications.

Pulmonary arterial hypertension is a quite rare, but problematic disease in everyday cardiologists' practice. Prostanoids are the most important group of drugs used in this disease. One of the biggest problems encountered during treatment with analogs of prostacyclin is thrombocytopenia. Based on hematological guidelines we suggest common therapeutic schemes depending on the number of platelets or the severity of bleeding conducting the therapy.

Characterization of Patients with Pulmonary Arterial Hypertension: Data from the Polish Registry of Pulmonary Hypertension (BNP-PL).

Current knowledge of pulmonary arterial hypertension (PAH) epidemiology is based mainly on data from Western populations, and therefore we aimed to characterize a large group of Caucasian PAH adults of Central-Eastern European origin. We analyzed data of incident and prevalent PAH adults enrolled in a prospective national registry involving all Polish PAH centers. The estimated prevalence and annual incidence of PAH were 30.8/mln adults and 5.2/mln adults, respectively and they were the highest in females ≥65 years old. The most frequent type of PAH was idiopathic (n = 444; 46%) followed by PAH associated with congenital heart diseases (CHD-PAH, n = 356; 36.7%), and PAH associated with connective tissue disease (CTD-PAH, n = 132; 13.6%). At enrollment, most incident cases (71.9%) were at intermediate mortality risk and the prevalent cases had most of their risk factors in the intermediate or high risk range. The use of triple combination therapy was rare (4.7%). A high prevalence of PAH among older population confirms the changing demographics of PAH found in the Western countries. In contrast, we found: a female predominance across all age groups, a high proportion of patients with CHD-PAH as compared to patients with CTD-PAH and a low use of triple combination therapy.

Treatment of chronic thromboembolic pulmonary hypertension in a multidisciplinary team.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) may be treated with pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapy (MT). Assessment in a multidisciplinary team of experts (CTEPH team) is currently recommended for treatment decision making. The aim of the present study was to report the effects of such an interdisciplinary concept. METHODS AND RESULTS: A total of 160 patients were consulted by the CTEPH team between December 2015 and September 2018. Patient baseline characteristics, CTEPH team decisions and implementation rates of diagnostic and therapeutic procedures were analysed. Change in World Health Organization (WHO) functional class and survival rates were evaluated by treatment strategy. A total of 51 (32%) patients were assessed as operable and 109 (68%) were deemed inoperable. Thirty-one (61% of operable patients) underwent PEA. Patients treated with PEA, BPA(+MT) and MT alone were 50.9 ± 14.7, 62.9 ± 15.1 and 68.9 ± 12.7 years old, respectively. At the follow-up, PEA patients had the highest WHO functional class improvement. Patients treated with BPA(+MT) had significantly better survival than PEA (p = 0.04) and MT patients (p = 0.04; 2-year survival of 92%, 79% and 79%, respectively). CONCLUSIONS: The CTEPH team ensures that necessary diagnostic procedures are performed. A relatively low proportion of patients was assessed by the CTEPH team as operable and underwent surgery, which in survivors resulted in the best functional improvement. Although patients undergoing BPA(+MT) were older than patients treated with PEA, their survival was better than patients subjected to PEA or MT alone. The reviews of this paper are available via the supplemental material section.

Are changes in heart rate, observed during dobutamine stress echocardiography, associated with a response to cardiac resynchronisation therapy in patients with severe heart failure? Results of a multicentre ViaCRT study.

BACKGROUND: According to current European Society of Cardiology guidelines for the diagnosis and treatment of heart failure (HF), cardiac resynchronisation therapy (CRT) is indicated in patients suffering from HF with reduced ejection fraction (EF) with significantly widened QRS complexes. The presence of vital myocardium proven by dobutamine stress echocardiography (DSE) is considered as a good prognostic factor for responsiveness to this treatment. Chronotropic incompetence is, on the other hand, a known factor of unfavourable outcome in HF. AIM: The aim of this study was to analyse the relationship between heart rate (HR) response during DSE and resultant changes in echocardiographic parameters determined prior to CRT and six weeks post-implantation of the CRT system. METHODS: The study included 72 men and 25 women with chronic HF and markedly deteriorated left ventricular (LV) sys-tolic function (EF < 35%). Low-dose DSE was performed prior to the CRT system implantation. Baseline echocardiographic parameters determined before CRT were compared to those measured six weeks after implantation. RESULTS: Implantation of the CRT system resulted in an improvement of LV systolic function. DSE showed a significant in-crease in HR, by 16.3 bpm on average. Patients with the least prominent increase in HR during DSE (< 7 bpm) presented with significantly greater end-diastolic LV dimension and volume, as well as with significantly lower EF than the subjects with the most evident increase in HR (> 24 bpm). Improvement in EF at six weeks was associated with lower baseline HR and its greater absolute and relative increase during DSE. Greater absolute increase in HR during DSE was also associated with more prominent decrease in systolic/diastolic LV volumes. CONCLUSIONS: Patients with better chronotropic response during DSE show significant improvement in LV parameters determined by echocardiography within six weeks of CRT. Chronotropic response to pharmacologic stress test may serve as a predictive factor in patients qualified for CRT.

Prognostic value of selected echocardiographic, impedance cardiographic, and hemodynamic parameters determined during right heart catheterization in patients qualified for heart transplantation.

The aim of the study was to verify prognostic value of selected echocardiographic (UKG), impedance cardiography (ICG), and right heart catheterization (RHC) parameters in systolic heart failure (HF). UKG, ICG, and RHC were performed in 46 patients with chronic HF with ejection fraction <35%. During a 1-year follow-up, composite endpoint (death or hospitalization due to HF exacerbation) was achieved by 23 (50.0%) patients. Analysis of receiver operating characteristic (ROC) curves identified UKG parameters: inferior vena cava diameter on inspiration (IVCinsp) >13 mm [area under curve (AUC), 0.791], right atrial (RA) >5.2 cm (AUC 0.710) and ventricular dimension (RVD) >3.5 cm (AUC 0.717), tricuspid annular plane systolic excursion (TAPSE) <17 mm (AUC 0.682), and its velocity (S'RV) <6.07 cm/s (AUC 0.716) as unfavorable prognostic factors. RHC parameters: low values of cardiac index (CI < 2.1 L/min; AUC 0.846) and high pulmonary capillary wedge pressure (PCWP > 24 mmHg; AUC 0.773) turned out to be the most accurate single predictors of worse outcome. Prognostic value of non-invasive parameters was improved due to the use of their composite measures: IVC% × TAPSE (<430%/mm; AUC 0.826), RVSP/TAPSE (>2.4 mmHg/mm; AUC 0.800), IVC% × SBP (>2097% mmHg; AUC 0.826), and RA × IVCinsp/S'RV (>11.8 cm s; AUC 0.839). In conclusion, composite measures based on non-invasive parameters, such as IVC%/TAPSE, RVSP/TAPSE and RA × IVCinsp/S'RV, may provide equally accurate prognosis as the invasive examination. PCWP and CI determined during RHC were the best individual predictors of the composite endpoint. In addition, echocardiographic parameters: RVD, RA, IVC, TAPSE, and S'RV are accurate predictors of the unfavorable outcome.

Bone morphogenetic protein 6-a possible new player in pathophysiology of heart failure.

Derangement of bone morphogenetic protein (BMP) signalling was observed in cardiovascular disorders. The present study assesses the diagnostic and prognostic value of BMP6 plasma concentration in chronic heart failure (CHF). 130 CHF patients and 32 controls participated in the study. BMP6 plasma level was measured at baseline. During 12-month follow-up death and hospitalisation with CHF exacerbation were recorded. BMP6 was significantly increased in CHF patients with highest concentration in most advanced disease. Individuals with pulmonary congestion or peripheral oedema had higher levels of BMP6 than isovolemic patients. BMP6 was not a predictor of all-cause mortality or CHF hospitalisation. BMP6 may be involved in pathophysiology of systolic CHF. BMP6 plasma level is related to the disease severity and signs of exacerbation.

Use of transthoracic impedance cardiography and tissue Doppler echocardiography in the cardiovascular assessment of atrial fibrillation patients subjected to electroversion.

BACKGROUND: Atrial fibrillation (AF) is the commonest complex cardiac arrhythmia, affecting approximately 2% of the general population. AIM: To describe cardiovascular changes in tissue Doppler echocardiography (TDE) and impedance cardiography (ICG) in AF patients subjected to cardioversion. METHODS: Forty-one patients (22 males and 19 females) with acute or persistent AF were examined by means of TDE and transthoracic ICG before electroversion, and then one week following the restoration of sinus rhythm. Additionally, the preand post-cardioversion serum levels of B-type natriuretic peptide (BNP) were determined. RESULTS: The restoration of sinus rhythm was reflected by a significant increase in the following ICG parameters (average changes are presented): stroke volume (+25 mL), stroke volume index (+11.8 m/m²), contractility index (+12.6/s), end-diastolic index (+12.3 mL/m²), acceleration index (+6/s²), and left ventricular ejection time (+56 ms). These changes were accompanied by a significant increase in the TDE parameters of tricuspid annular systolic velocity and mitral annular systolic velocities. Moreover, a significant decrease in early diastolic velocities was also observed following the restoration of sinus rhythm, along with significantly lower levels of BNP. CONCLUSIONS: Both TDE and ICG are modern, valuable diagnostic methods that complementarily explain changes occurring in the cardiovascular system of AF patients subjected to electroversion.

Short-term alcohol consumption may have detrimental effect on fibrinolysis and endothelial function: preliminary report of prospective randomised study.

BACKGROUND AND AIM: This study was designed to clarify the impact of the short-term consumption of different types of alcoholic beverages on haemostatic factors, C-reactive protein (hsCRP) and endothelin-1 (E-1) plasma levels. METHODS: The study group consisted of 57 healthy male volunteers, aged 20-29 years. Subjects were randomised to consume 300 mL of red wine, white wine, 12% ethanol, black currant juice or water for five days. Blood samples were collected for CRP, tissue type plasminogen activator antigen (t-PA:Ag), plasminogen activator inhibitor antigen (PAI-1:Ag) and E-1 at baseline, on day 2, and on day 6. RESULTS: A significant increase in PAI-1:Ag concentration was observed in the red wine drinking group (day 1: 44.98; day 2:56.86; day 6: 47.44 ng/mL; p = 0.05). A similar increase of E-1 level was found in the 12% ethanol group (day 1: 0.53; day 2:1.65; day 6: 1.11 fmol/mL; p = 0.01). Dividing the whole study group according to ethanol content of consumed beverages revealed significant changes in tPA:Ag, PAI-1:Ag and E-1 levels. In the alcohol drinking group, significant increases of PAI-1:Ag (day 1: 44.75; day 2: 54.07; day 6: 44.80 ng/mL; p < 0.05); tPA:Ag level (day 1: 3.65; day 2: 4.17; day 6: 5.03 ng/mL;p < 0.02) and E-1 (day 1: 0.42; day 2: 1.01; day 6: 0.97 fmol/mL; p < 0.002) were observed. CONCLUSIONS: Short-term alcohol consumption increases tPA:Ag, PAI:Ag and E-1 plasma levels. This effect may have an unfavourable impact on the fibrinolytic system and endothelial function.

Giant post-infarction pseudoaneurysm of the left ventricle manifesting as severe heart failure.

A 57 year-old female was admitted for chronic heart failure (HF) with NYHA class IV symptoms. Transthoracic echocardiography revealed ruptured left ventricular (LV) lateral and posterior wall between their basal and middle segments resulting in giant, round pseudoaneurysm formation with a diameter of 12 cm. Bidirectional flow through a 2.9 cm orifice between the LV and the pseudoaneurysm cavity was shown. A 12-cm diameter pseudoaneurysm was resected and the orifice was closed with a Dacron patch. Twelve months after the diagnosis, the patient is in a stable condition with NYHA class II HF symptoms.

[Recurrent cardiac tamponade and sepsis in a patient with rheumatoid arthritis]. / Nawracajaca tamponada serca i posocznica u pacjenta z reumatoidalnym zapaleniem stawów.

Exudative pericarditis is found in 30-50% of the patients with rheumatoid arthritis (RA), particularly in later stages of the disease. Most cases present with no or few symptoms. We report a case of a 68 year-old male with a history of mild RA who developed exudative pericarditis leading to recurrent cardiac tamponade requiring repeated pericardiocenteses. Treatment with glucocorticosteroids, methotrexate and colchicine proved ineffective in preventing the recurrences. Immunosuppression contributed to the development of sepsis caused by Enterobacter cloacae and resulting in the patient's death.

[Successful therapy and rehabilitation following stroke in a pregnant woman with prosthetic aortic valve]. / Pomyslna terapia i rehabilitacja udaru u ciezarnej ze wszczepiona sztuczna zastawka aortalna.

This report describes a case of a 40 year-old woman with implanted aortic prosthetic valve, who experienced thrombo-embolic complication in a form of ischaemic stroke in 15 week of pregnancy. At the beginning of the event, the patient suffered from mixed aphasia, right-side paresis and depressive syndrome. Thanks to cooperation of many specialists, especially rehabilitation team, she restored overall physical efficiency, speaking ability, delivered a healthy child, and returned to normal family and social activity. Problems of anti-thrombotic therapy during pregnancy in patients with prosthetic valves are discussed.

[Severe, thromboembolic pulmonary hypertension with recurrent pulmonary embolism and right heart thrombi in a patient with past myocardial infarction, cerebral ischaemic stroke and small intestine necrosis]. / Ciezkie, zakrzepowo−zatorowe nadcisnienie plucne z nawracajaca zatorowoscia plucna i skrzeplinami w prawych jamach serca u pacjenta z przebytymi zawalami serca, udarem pnia mózgu oraz martwica jelita cienkiego.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a chronic progressive disease of pulmonary circulation characterised by indistinct ethiopathogenesis. We present a case of a 50 year-old male with thrombophilia of unknown origin leading to the formation of multiple thrombi within venous circulation followed by episodes of acute pulmonary embolism resulting ultimately in acute heart failure in the course of developing CTEPH. Unfortunately, despite the wide range of haemostasis laboratory tests we were not able to define the type of coagulation abnormality. Owing to the efficient cooperation between cardiologists and cardiosurgeons it was possible to save patient's life.

Relationship between B-type natriuretic peptide serum level, echocardiographic TEI index and the degree of diastolic dysfunction in patients with heart failure with preserved systolic function.

INTRODUCTION: The growing number of heart failure (HF) patients is becoming an important issue in cardiology. B-type natriuretic peptide (BNP) is a recognized marker of HF, including in patients with preserved systolic function. The TEI index is an indicator of left ventricular function. The aim of the study was to evaluate the relationship between BNP serum level, TEI index and the degree of diastolic dysfunction in patients with HF symptoms and preserved systolic function. MATERIAL AND METHODS: Hundred patients with arterial hypertension and preserved systolic function were enrolled in the study. The study group consisted of 51 individuals with impaired diastolic function and HF symptoms. Fourty-nine hypertensive individuals without HF symptoms were assigned to the control group. B-type natriuretic peptide and echocardiographic examination were performed. Patients were divided into 4 subgroups - with normal diastolic function, impaired relaxation, pseudonormalization and restriction. RESULTS: Median value of BNP in patients with normal diastolic function was 28.36 pg/ml, 87.10 pg/ml in patients with impaired relaxation, 212.75 pg/ml and 461.56 pg/ml in the pseudonormalization and restriction group respectively (p < 0.0001). The median value of the TEI index was: 0.386 in patients with normal diastolic function, 0.507 in individuals with impaired relaxation, 0.639 and 0.725 in the pseudonormalization and restriction group respectively. All the differences were statistically significant (p < 0.0001). A significant positive correlation (r = 0.80, p < 0.001) between BNP and the TEI index was found. CONCLUSIONS: In hypertensive patients with HF symptoms and preserved left ventricular systolic function a highly significant increase in BNP serum level and in the TEI index values related to the deterioration of diastolic dysfunction was found.

[The case of surgically treated severe thromboemboic pulmonary hypertension developing in the course of recurrent pulmonary embolism]. / Ciezkie zakrzepowo-zatorowe nadcisnienie plucne w przebiegu nawracajacej zatorowosci plucnej leczone operacyjnie.

A case of a patient with surgically treated progressive thromboembolic pulmonary hypertension in the course of recurrent pulmonary embolism resulting from deep vein thrombosis is presented. Acute embolic episode seems to have crucial role as an initiating factor triggering the cascade of unfavorable changes in pulmonary vasculature. The paper stresses the role of systematic clinical and echocardiographic control of patients after pulmonary embolism in order to diagnose developing complications as soon as possible. It would allow to introduce efficient treatment and improve prognosis.

Relationship between thoracic fluid content and natriuretic peptide type B in patients with systolic heart failure.

BACKGROUND: Thoracic fluid content (TFC) is one of the basic parameters measured by impedance cardiography (ICG). The B-type natriuretic peptide (BNP) is a neuroendocrine mediator produced in the ventricular myocardium and released in response to the increase of wall tension. AIM: To determine the relationship between TFC measured by ICG and BNP serum level in patients with systolic heart failure (HF). METHODS: The study population included 50 patients: a group of 30 patients with systolic HF in functional NYHA class II and III [27 males and 3 females, aged 53 +/- 6 years, with mean left ventricular ejection fraction (LVEF) 23 +/- 6%], and 20 controls without HF symptoms and preserved LVEF. The TFC and BNP serum level were measured on the same day. RESULTS: Mean BNP serum concentration was 521 +/- 882 pg/ml in HF patients and 44 +/- 36 pg/ml in healthy controls (p = 0.02). The TFC values did not differ significantly between the two groups (27.3 +/- 4.5 1/kW in the study group versus 26.3 +/- 2.8 1/kW in control subjects, NS). A significant correlation between TFC and BNP was found in patients with overt HF (r = 0.57, p = 0.001); however, after excluding one patient with exacerbation of HF symptoms, the correlation was non-significant (r = 0.24, p = 0.22). No correlation between these parameters was observed in healthy controls (r = 0.17, p = 0.51). CONCLUSIONS: There was no significant correlation between TFC measured by ICG and BNP serum level in haemodynamically stable patients with HF symptoms. The usefulness of ICG measurements in patients with exacerbated chronic HF needs further investigations.