[Effect of the optimal neurohormonal blockade on long-term survival in patients with chronic heart failure]. / Wplyw optymalnego hamowania neurohormonalnego na rokowanie odlegle u pacjentów z przewlekla niewydolnoscia serca.

BACKGROUND: In recent years large scale clinical trials have cleary shown that a number of pharmacological treatments can improve the outcomes of patients (pts) with chronic heart failure (CHF). AIM: The aim of this study was to assess the effect of optimal neurohormal blockade in pts with chronic heart failure on survival during 12 month follow-up. METHODS: We analyzed data on 489 pts in NYHA II-IV class of HF, referred to our Dept. (mean age was 69 +/- 12). We define doptimal neurohormonal therapy as beta-blocker and ACE-inhibitor in pts with NYHA II, and beta-blocker, ACE-Inhibitor and spironolactone in patients with NYHA III-IV class. Pts were divided into groups: group 1--optimal neurohormonal blockade (n = 232, mean age, 67 +/- 11), group 2--non-optimal neurohormonal blockade (n = 257, mean age, 70 +/- 13). Pts were followed for 12 month. RESULTS: Group with optimal therapy were frequent male gender, of ischemic aetiology, and NYHA class II (p < 0.05). Diabetes mellitus, hypertension, left ventricular ejection fraction did not differ the groups (p = NS). Pts with non-optimal therapy were more frequent with prior history of renal dysfunction and anemia at admission (p < 0.05). During 12 month follow-up 12% in optimal vs 40% in non-optimal therapy died (p < 0.005). The rehospitalisation rate during one-year was also significantly higher in pts receiving non-optimal therapy (69% vs 48%, p < 0.005). Cox multivariate analysis showed after adjusting for age, gender, etiology of HF, NYHA functional class, renal dysfunction, EF, had significantly 62% reduction in mortality and 41% reduction in cardiovascular rehospitalisation in pts receiving optimal therapy. CONCLUSIONS: The optimal neurohormonal therapy have favorable effects on outcomes in pts with CHF. This data strongly support that optimalization of care and evidence-based treatment of CHF pts can improve poor prognosis in this group.

The prognostic value of renal dysfunction in patients with chronic heart failure: 12-month follow-up.

INTRODUCTION: Renal function assessment is an important element of management and therapeutic decision-making in patients with chronic heart failure (CHF). AIM: To evaluate the prognostic value of renal dysfunction in patients with CHF in 12-month follow-up. METHODS: 639 consecutive patients hospitalised in our department from 1 July 2002 to 31 December 2003 with diagnosis of CHF (NYHA II-IV), based on medical records, were initially enrolled in the study. Patients underwent one-year follow-up. Finally, 498 patients, aged 22-98 years (mean age 69+/-12 years) in whom creatinine concentration was measured and creatinine clearance was estimated at admission with the Cockroft-Gault quotation and with long-term follow-up results obtained, were enrolled in the study. Patients were divided into two groups according to the creatinine level: Group I without renal dysfunction (creatinine level <1.4 mg/dl), and Group II--with renal dysfunction (creatinine level >1.4 mg/dl). RESULTS: Patients with renal dysfunction were significantly older and more likely to be male and in NYHA class III-IV (p <0.001). Analysis of pharmacotherapy for CHF revealed that patients with renal impairment significantly less frequently received beta-blockers (67% vs 81%, p <0.005), angiotensin-converting enzyme inhibitors (68% vs 82%, p <0.005) and combined treatment of beta-blocker and angiotensin-converting enzyme inhibitor (56% vs 71%, p <0.05), whereas loop diuretics were more frequently prescribed in this group (80% vs 70%, p <0.05). In patients with renal dysfunction, there was a significantly higher mortality rate at 30 days (32% vs 14%, p <0.001) as well as at 12 months (45% vs 20%, p <0.001). The incidence of re-hospitalisation for cardiovascular reasons (CHF worsening, myocardial infarction, stroke) was significantly higher in patients with renal dysfunction (70% vs 55%, p <0.005). Multivariate analysis of all factors affecting one-year mortality demonstrated that renal dysfunction is a strong and independent risk factor for death in patients with CHF (RR=2.13, 95% CI: 1.31-3.45; p <0.05) and it increases the risk of re-hospitalisation (RR=1.53, 95% CI: 1.01-2.14; p <0.05). CONCLUSIONS: Renal dysfunction is an independent prognostic factor in patients with CHF, which allows identification of a high-risk group and administration of optimal therapy, which in turn can result in a reduction of mortality.

[Unfortunate outcome of subsequent vascular complications in female patients assigned to percutaneous coronary intervention -- case report]. / Niekorzystny przebieg kolejnych powiklan naczyniowych u chorej poddanej zabiegowi planowej angioplastyki wiencowej -- opis przypadku.

We present a case of a 58-year-old female who underwent elective PCI of the left anterior descending coronary artery. The procedure was complicated by vessel dissections and myocardial infarction. Cardiogenic shock complicated acute coronary syndrome required intraaortic balloon pumping what led to descending aortic dissection successfully treated with stent-graft implantation. However, the patient died due to intractable cardiogenic shock.

[Influence of sinus rhythm restoration and maintenance on left ventricle diameter and function in patients with persistent atrial fibrillation--one year follow-up]. / Wplyw przywrócenia i utrzymania rytmu zatokowego na wielkosc i funkcje lewej komory serca u chorych z przetrwalym migotaniem przedsionków--obserwacja roczna.

UNLABELLED: Aim of our study was to determine the dynamics of selected echocardiographic parameters after sinus rhythm (SR) restoration and maintenance in pts with persistent nonvalvular atrial fibrillation (AF) during one year follow-up period. MATERIAL AND METHODS: Our study population comprised 104 pts (F/M 33/71; mean age 60.4 +/- 7.4) assigned to SR restoration and maintenance with serial antiarrhythmic drug usage, for whom transthoracic echocardiographic (TTE) variables were recorded prior to, 2 and 12 months after cardioversion (CD). Left ventricle diastolic diameter and fractional shortening were variables of interest. RESULTS: SR was presented in 66 (63.5%) pts at one year. There was no significant differences in left ventricle diastolic diameter during the follow up. A significant increase in left ventricular fractional shortening (29.9 +/- 6.9% vs 34.5 +/- 8.9%; p < 0.001) was found in pts assigned to the sinus rhythm restoration according to intention-to-treat analysis. Such trend was noted only in pts who maintained SR during the follow up (29.9 +/- 7.6% vs 35.6 +/- 9.3%; p < 0.001). CONCLUSIONS: Among all considered variables only value of left ventricular fractional shortening increased after successful CV of persistent AF in one year follow-up.

Impact of sinus rhythm restoration and maintenance on left ventricular function and exercise tolerance in patients with persistent atrial fibrillation.

BACKGROUND: Although early improvement of haemodynamic parameters following successful cardioversion of atrial fibrillation (AF) has been well documented, the long-term benefits of sinus rhythm (SR) restoration are less obvious, mainly due to a high rate of AF relapses. AIM: To determine the impact of SR restoration and maintenance on exercise tolerance and heart failure progression in patients with persistent non-valvular AF during a one year follow-up period. METHODS AND RESULTS: We studied 104 patients (33 females, 71 males, mean age 60.4+/-7.4 years) with mild to moderate stable heart failure and persistent AF with well-controlled ventricular rate who were scheduled for cardioversion. They underwent submaximal exercise testing 24 hours before cardioversion, as well as 1 and 12 months afterwards. Exercise capacity was determined during symptom-limited exercise testing, according to a modified Bruce protocol. Heart failure symptoms were assessed at the same time-points of follow-up. RESULTS: SR was presented in 66 (63.5%) patients one year after cardioversion. In patients with SR, a significant improvement in left ventricular (LV) performance, exercise capacity and heart failure symptoms was noted. There was an increase in LV fractional shortening (29.9+/-7.6% vs 35.6+/-9.3%; p<0.001), maximal workload (4.7+/-2.3 vs 8.5+/-3.0 MET; p<0.001), exercise duration (125.3+/-115.3 vs 294.7+/-216.7 sec.; p<0.001), and improvement in the NYHA functional class (p<0.001). No such changes were observed in patients who had AF relapse during follow-up or in those who had unsuccessful cardioversion. CONCLUSIONS: Successful cardioversion of persistent AF resulted in a significant improvement of exercise capacity and a decrease in heart failure symptoms during one year follow-up period only in patients who maintained SR.

Serum troponin I and myoglobin after monophasic versus biphasic transthoracic shocks for cardioversion of persistent atrial fibrillation.

This study compared the effects of standard monophasic versus biphasic direct current shocks for cardioversion of atrial fibrillation (AF) on the release of cardiac troponin I (cTnI) and myoglobin (Myo). We randomized 48 patients with persistent AF (mean age = 61.4 +/- 10.7 years, 33 men) to monophasic (45.2%) or biphasic (54.8%) cardioversion. Plasma concentrations of cTn1 and Myo were measured before, and 6 and 24 hours after the procedure. Cardioversion was significantly more effective (88% vs 100%, P < 0.04) and required less energy (348.1 +/- 254.1 vs 187.6 +/- 105.3 J; P < 0.001) in the biphasic than the monophasic group. A significant increase in mean plasma cTnI concentration over 24 hours (0.23 +/- 0.18 vs 0.41 +/- 0.37 ng/mL, P < 0.04), and mean Myo concentration were recorded in the monophasic group over the first 6 hours following the procedure (38.2 +/- 14.2 vs 221.9 +/- 51.3 ng/mL, P < 0.001), whereas no significant increase was observed in the biphasic group. Increases in cTnI and Myo in the monophasic group correlated closely with the cumulative energy delivered (Spearman correlation coefficient r = 0.58, P = 0.004 for Myo and r = 0.67, P < 0.001 for cTnI). In addition, there was a positive correlation between cumulative cardioversion energy load and increase in Myo and cTnI indexed with left ventricular mass (r = 0.45, P < 0.02 for Myo and r = 0.47, P = 0.01 for cTnI). It is concluded that in cardioversion of AF, biphasic are more effective than monophasic and may cause less myocardial injury.

[Value of electrocardiographic treadmill test for rate control strategy in permanent atrial fibrillation]. / Przydatnosc elektrokardiograficznej próby wysilkowej podczas realizowania strategii kontroli rytmu serca u chorych z przewleklym migotaniem przedsionków.

AIM: of our study was to determine the correlation between physical activity tolerance assesed by exercise tolerance test (ETT) and dynamics of change of echocardiographic parameters of left atrium (LA) and left ventricle (LV) in standard transtoracic echocardiography (TTE) in long-term follow up of patients with persistent nonvalvular atrial fibrillation (AF). MATERIALS AND METHODS: We studied 67 patients (W/M: 23/44; mean age 63.2 +/- 7.1 years) with persistent AF lasting longer than 1 month. Rate control strategy targeted resting heart rate 70-90/min. All study subject underwent ETT in order to assess their exercise capacity. Before ETT we performed TTE in all patients and calculated the area of LA (LAar), longitudinal and saggital diameter of LA (LAlax, LAsax), LV end-diastolic diameter (LVEDD) and LV shortening fraction (FS). TTE was performed again in 2 and 12 months after beginning of observation. RESULTS: Using variation analysis we established the correlation between time of ETT in patients with persistent AF and dynamics of change of specific echocardiographic parameters in 12 months follow-up. In patients with ETT time <60 sec we observed statistically significant rise of LAar from 26.5 +/- 6.1 to 29.6 +/- 4.9 cm2 (p < 0.05; ANOVA) and deterioration of LV function assessed with FS from 35.6 +/- 5.3% on the beginning to 31.7 +/- 7.4% at the end of study (p < 0.02; ANOVA). There was no correlation between time of ETT and dynamics of change of other echocardiographic parameters in patients with time of ETT >60 sec. CONCLUSIONS: Time of exercise tolerance test limited with heart failure symptoms is an independent factor predicting dynamics of change of chosen echocardiographic parameters of left heart in long-term observation of patients with persistent atrial fibrillation.

Differences between cardiologists and internists in the management of heart failure. Medical guidelines compared with every-day practice.

BACKGROUND: A marked progress in the treatment of chronic heart failure (CHF) took place during the last decade. Large, randomised studies documented the role of angiotensin-converting enzyme inhibitors (ACE-I) and beta-blockers in the reduction of mortality and morbidity in CHF. AIM: To assess differences in the management of CHF patients between cardiologists and internists. METHODS: Medical records of 433 patients with CHF, aged 38-98 years, hospitalised between October 2000 and May 2002 in an academic centre, were retrospectively analysed. Cardiologists treated 241 patients, and internists - 192 patients. In addition, 12 randomly selected physicians who treated CHF patients, filled-in a questionnaire concerning CHF treatment. Next, the answers were compared with the actual treatment, documented in patients medical files. RESULTS: There were significant differences in the CHF treatment between cardiologists and internists. Cardiologists significantly more often prescribed ACE-I in NYHA class III patients (77% vs 58%, p=0.003), beta-blockers in all NYHA classes (80% vs 57%, p<0.001), loop diuretics in NYHA classes III and IV (76% vs 42%, p<0.001 and 91% vs 44%, p=0.005), and thiazides in NYHA class III patients (36% vs 11%, p<0.001). Internists more often used loop diuretics (37% vs 15%, p<0.001), digoxin (28% vs 7%, p<0.001) and aldosterone antagonists (24% vs 13%, p=0.022) in NYHA class II patients. All cardiologists and almost half of internists declared combined usage of ACE-I and beta-blockers at increasing dosages as the treatment was continued. The highest concordance between declared and actual medication concerned the concomitant use of ACE-I and beta-blockers. CONCLUSIONS: Cardiologists used more often ACE-I and beta-blockers than internists in the treatment of CHF patients. A satisfactory knowledge of treatment guidelines was not associated with widespread usage of ACE-I and beta-blockers in every-day practice.

[Myoglobin and troponin I as markers of myocardial damage during cardioversion of atrial fibrillation]. / Mioglobina i troponina I jako markery uszkodzenia miesnia sercowego podczas kardiowersji migotania przedsionków.

UNLABELLED: We performed direct comparison of safety and efficacy of monophasic and biphasic shock cardioversion (CV) of atrial fibrillation (AF). Troponin I (cTnl) and myoglobin (My) were used as markers of potential myocardial and skeletal muscle damage during the procedure. METHODS: 63 patients (p.t.s.) with persistent, nonvalvular AF (F/M 18/45; mean age 61.6 +/- 11.4 years) were randomized to CV either with monophasic (F/M 10/24, Group I) or biphasic (F/M 8/21, Group II) shock. Plasma levels of cTnl and My were measured before CV, 6 hours and 24 hours after CV. RESULTS: The efficacy of CV was significantly higher in Group II (93% vs 85%, p < 0.04). Sinus rhythm restoration required lower total energy used during procedure with biphasic shock (379.8 +/- 301.5 vs 192.8 +/- 100.6 J; p 0.001). There was no significant difference in mean values of cTnl before CV in both groups (0.3 +/- 0.2 vs 0.2 +/- 0.1 ng/mL, p > 0.15). In 14 pts (41%) from Group I and 3 pts (10%) from Group II plasma cTnl concentration above discriminatory level (0.9 ng/mL) were noted. There was a significant increase in mean plasma cTnl level (0.3 +/- 0.2 vs 1.9 +/- 0.9 ng/mL, p < 0.04) 24 hours after the procedure in Group I. We did not observed significant differences in cTnl plasma concentration 6 and 24 hours after CV in Group II (0.2 +/- 0.1 vs 0.4 +/- 0.2 ng/mL, p > 0.15). Both study groups did not significantly differ in mean serum My level at baseline (39.1 +/- 14.2 vs 43.1 +/- 20.9 ng/mL). In Group I mean My serum concentration increased during the first 6 hours after CV (43.1 +/- 20.9 vs 247.9 +/- 53.3 ng/mL, p < 0.02) and there was a significant decreasing in My serum level during the further observation (247.9 +/- 53.3 vs 104.5 +/- 46.1 ng/mL, p < 0.03). Mean serum My concentration remained within normal ranges during the 24 hour follow-up after the biphasic shock CV (43.1 +/- 20.9 vs 43.6 +/- 29.1 ng/mL). Increased of cTnl and My in Group I may be due to myocardial and skeletal muscle damage and correlate closely with cumulative energy delivered (Spearmann correlation index (r) = 0.55, p < 0.01 for My and r = 0.66, p < 0.01 for cTnl). In Group I positive correlation between cumulative energy used during CV and increase of studied markers indexed with left ventricular mass (r = 0.6, p < 0.05 for My and r = 0.74, p < 0.04 for cTnl) was observed. There was no significant correlation between delivered energy and increase of heart markers in Group II noted. CONCLUSIONS: We observed the significant increase in mean serum cTnl and My level 24 hours after CV with monophasic shock and its positive correlation with total energy used during the procedure. There is a conclusion that biphasic shock used during CV of AF is more efficient and may cause less myocardial and skeletal muscle damage due to lower energy delivered.

[Treatment of heart failure: guidelines compared to clinical practice]. / Leczenie niewydolnosci serca--standardy kliniczne a praktyka lekarska.

UNLABELLED: Last decade brought great development in the treatment of patients with heart failure (HF). General use of angiotensin-converting-enzyme inhibitors (ACE-I) in patients with asymptomatic left ventricular dysfunction or with HF significantly reduced morbidity and mortality. The aim of this study was to assess how the specialists from Cardiology Department and Gastroenterology Department think that heart failure should be managed, how they implement their knowledge and if it is consistent with the recommendation of European Society of Cardiology (ESC) and whether differences exists in practice between specialists. In the first phase the specialists, cardiologists and diabetologists, answered the questions about the management of different stages of HF. In second phase we analysed medical documentation of 345 patients aged between 38 and 98 years, hospitalised in Cardiology and Gastroenterology Departments from October 2000 to February 2002 by reason of coronary artery disease, hypertension and dilated cardiomyopathy. In the third phase we compared the knowledge of heart failure management from questionnaire and its implementation, the compliance with ESC recommendation and finally whether differences in clinical practice exist between cardiologist and diabetologists. RESULTS: ACE-I were prescribed in all NYHA classes of HF. In over 50% patients in II NYHA class to 94% in IV NYHA class in Cardiology Department. Differences between the Departments in prescribing of ACE-I were observed. Beta-blockers (BB) were used with the same frequency in all NYHA classes, more often in Cardiology Department. Frequency of the administration of digoxin, diuretics, aldosterone receptor blocker was increasing starting with II NYHA class. The highest compliance between declarations from questionnaire and clinical practice concerned the use of BB and ACE-I combination.

[Role amiodarone in sinus rhythm maintenance after successful cardioversion in patients with chronic non-valvular atrial fibrillation]. / Rola amiodaronu w utrzymaniu rytmu zatokowego po skutecznej kardiowersji elektrycznej u chorych z przetrwalym migotaniem przedsionków.

UNLABELLED: Antiarrhythmic drugs prophylaxis may improve late outcome of electrical cardioversion (CV) in persistent atrial fibrillation (AF). We conducted a prospective study of the efficacy of sequential antiarrhythmic drug therapy in sinus rhythm (SR) maintenance after a successful elective CV in patients (pts) with persistent nonvalvular AF. Investigated group and methods. 104 pts (60.4 +/- 7.9 years old) with persistent AF underwent CV. Following SR restoration pts received one of these antiarrhythmic drugs (Drug I): propafenone, sotalol, disopyramide. In case of arrhythmia recurrence we performed a second CV and pts received another drug from the mentioned before (Drug II). If treatment proved to be unsuccessful pts received amiodarone (Drug III) and a third CV was attempted. Following an unsuccessful first CV pts received loading dose amiodarone and another CV was attempted. In case of SR restoration amiodarone was administered continuously. RESULTS: First CV was successful in 53.8% pts. Following 1 year 27 pts (48.2%) presented with SR treated with Drug I (median not exist); Drug II proved to be effective in 2 pts (7.0%) (median 14 days). Amiodarone as the third antiarrhythmic agent (Drug III), administered in pts who had previously AF recurrence during the first two antiarrhythmic agents, occurred effective in additional 13 pts (median 307 days) who remained free from AF for one year from the initiation of sequential antiarrhythmic therapy. 48 pts in whom the first CV was ineffective, received amiodarone. During the loading period SR was restored in 10 pts (20.8%). The remaining 38 pts underwent repeated CV and SR was restored in 24 (62.3%) of them. Long-term amiodarone treatment maintained SR during the follow-up period in 24 (70.6%) pts. In total, amiodarone helped to maintain SR in 56.0% of pts. CONCLUSIONS: Sequential antiarrhythmic drug therapy improve arrhythmia prognosis in AF within a 12 months observation period. Amiodarone seems to be the most effective antiarrhythmic drug also in pts who required a second CV proceeded by amiodarone treatment to restore SR.