Agnieszka Bednarek

Twenty-four-Hour Profile of Central Blood Pressure and Central-to-Peripheral Systolic Pressure Amplification

BACKGROUND The significant difference in central and peripheral blood pressure (BP) values has only recently been widely recognized. Ambulatory BP monitoring has been shown to have advantages over office BP measurements because ambulatory monitoring can provide important information not available when only office BP is measured. The aim of this study was to assess the 24-hour central systolic pressure (CSP) profile, CSP short-term variability, and 24-hour systolic pressure amplification profile. METHODS The study group comprised 50 hypertensive subjects and 50 normotensive subjects. All participants underwent 24-hour peripheral and central pressure monitoring. RESULTS CSP was lower than peripheral pressure levels during the day (124.1 ± 15.7 mm Hg vs 133.9 ± 16.3 mm Hg; P < 0.001) and night hours (114.4 ± 14.5 mm Hg vs 121.5 ± 15.2 mm Hg; P < 0.001). The CSP nocturnal fall was lower than the peripheral pressure fall in normotensive subjects as well as in hypertensive subjects. Although 24-hour systolic pressure amplification was similar in subjects with and without hypertension (9.2 ± 3.1 mm Hg and 8.3 ± 2.4 mm Hg; P = NS), it was significantly lower during the night than during the day in both groups. The nocturnal fall in systolic pressure amplification was correlated with the day-night difference in heart rate (r = 0.70; P < 0.001). CONCLUSIONS Central pressure differs significantly from peripheral pressure during regular daily activity as well as during night hours. Moreover, it appears that systolic pressure amplification varies throughout the 24-hour period and that the main factor determining nocturnal fall in systolic pressure amplification is nocturnal drop in the heart rate. More studies are required to demonstrate advantage of this novel technique over traditional pressure monitoring in clinical practice.

Acute hyperglycaemia and inflammation in patients with ST segment elevation myocardial infarction

BACKGROUND Acute hyperglycaemia in patients with acute coronary syndromes (ACS) is associated with increased cardiovascular (CV) risk among both diabetic and non-diabetic patients although the mechanisms underlying this association are not clearly understood. Acute hyperglycaemia in patients with ACS may be associated with increased systemic inflammation. Leukocytes are the major cellular mediators of inflammation and their elevated count is associated with higher CV event rate in ACS patients. Thus, it is possible that there is a relationship between acute hyperglycaemia and high leukocyte count and concomitant presence of these two conditions may contribute to increased CV risk among patients with ST segment elevation myocardial infarction (STEMI). AIM To investigate the relationship between acute hyperglycaemia and high leukocyte count and to evaluate its association with outcomes in patients with STEMI. METHODS Glucose level and leukocyte count on admission were measured in 246 patients with STEMI admitted in 2004- -2007 to the First Department of Cardiology and Hypertension at the University Hospital in Cracow who were treated with an early invasive management strategy. Patients were divided into two groups, with acute hyperglycaemia (glycaemia on admission ≥ 7.8 mmol/L) and with normoglycaemia (glycaemia on admission < 7.8 mmol/L). Leukocyte count was defined as high when it was greater than or equal to the median in the overall study group. RESULTS Acute hyperglycaemia was noted in 136 (55.3%) patients. Median leukocyte count on admission in the overall study group was 10.8 × 103/mm3 (interquartile range: 8.5-13.0). Significantly higher in-hospital mortality (11.8% vs. 1.8%, p = 0.0029) and higher rates of cardiogenic shock (10.3% vs. 0.9%, p = 0.0022), Killip class > 1 heart failure (HF; 44.1% vs. 20.0%, p < 0.0001), atrial fibrillation (11.0% vs. 3.6%, p = 0.0308), ventricular fibrillation (5.9% vs. 0.9%, p = 0.0389), repeated percutaneous coronary angioplasty (5.2% vs. 0.0%, p = 0.0158), the primary endpoint defined as death and/or cardiogenic shock (16.9% vs. 1.8%, p = 0.0001), and the secondary endpoint defined as atrial fibrillation and/or second or third degree atrioventricular block and/or HF and/or stroke/transient ischaemic attack (53.7% vs. 23.6%, p < 0.0001) were noted in the acute hyperglycaemia group in comparison with the normoglycaemic group. Adverse events were associated with high leukocyte count in all patients and in both diabetic and non-diabetic subgroups. Mean leukocyte count was higher in patients who died (13.3 ± 4.01 vs. 11.0 ± 3.56 [103/mm3], p = 0.0115; 14.2 ± 1.59 vs. 10.8 ± 3.18 [103/mm3], p = 0.0210; and 13.5 ± 4.79 vs. 11.1 ± 3.72 [103/mm3], p = 0.0363 in the overall study group, diabetics and non-- diabetics, respectively), in patients with cardiogenic shock (14.0 ± 4.56 vs. 11.0 ± 3.52 [103/mm3], p = 0.0019; and 15.4 ± 4.93 vs. 11.0 ± 3.66 [103/mm3], p = 0.0007 in the overall study group and non-diabetics, respectively), and in patients with HF (12.1 ± 3.78 vs. 10.8 ± 3.51 [103/mm3], p = 0.0083; and 12.1 ± 3.39 vs. 10.3 ± 2.90 [103/mm3], p = 0.0159 in the overall study group and diabetics, respectively) as compared to patients without respective adverse events. Glucose level on admission correlated positively with the on-admission leukocyte count. This correlation was statistically significant in the overall study group (r = 0.25, p < 0.0001), in diabetics (r = 0.27, p = 0.021), and in non-diabetics (r = 0.35, p < 0.0001). Patients with both acute hyperglycaemia and the leukocyte count greater than or equal to the median in the overall study group had a higher in-hospital risk of death and/or cardiogenic shock (odds ratio 17.6, 95% CI 1.9-165.3, p = 0.0122). CONCLUSIONS Acute hyperglycaemia is associated with worse in-hospital outcomes in patients with STEMI. More severe inflammation (defined as leukocyte count on admission) is noted in STEMI patients with adverse events. A significant positive correlation can be seen between glucose level and leukocyte count on admission, and concomitant presence of both acute hyperglycaemia and more severe inflammation in patients with STEMI was found to be an independent predictor of poor in-hospital outcomes.

Blood pressure changes in patients with chronic heart failure undergoing slow breathing training

Abstract Background. Slow breathing training (SBT) has been proposed as a new non-pharmacological treatment able to induce favorable effects in patients with chronic heart failure (CHF). However, no information is available regarding its effects on orthostatic blood pressure (BP) changes in these patients, an issue of practical relevance given the reported BP-lowering effect of SBT. The aim of this study is to evaluate the influence of SBT on BP and whether SBT induces orthostatic hypotension (OH) or changes in quality of life (QoL) in CHF patients. Methods. The analysis was performed as part of an ongoing crossover open trial aimed at assessing the clinical effectiveness of SBT in treated patients with CHF. The patients underwent 10–12 weeks of SBT with the RESPeRATE device and 10–12 week follow-up under usual care. Patients were randomly divided into two groups: group I began with SBT, followed by usual care; group II began with usual care, followed by SBT. Patients undergoing SBT were asked to perform each day two separate 15 min sessions of device-guided SBT at a breathing frequency of 6 breaths/min. In all patients, before the enrollment and after each study phase, clinical data collection and BP measurements in sitting, supine and standing position were performed. OH was defined as a decrease of ≥ 20 mmHg in systolic blood pressure (SBP) or ≥ 10 mmHg in diastolic blood pressure (DBP) within 3 min of standing. QoL was assessed three times at the beginning, and after each phase of the study by the Minnesota Living with Heart Failure (MLHF) questionnaire. Results. Forty patients (two equal groups) completed the study, with the following baseline characteristics: 32 males/eight females, age 63.3 ± 13.4 years, 25 with ischemic CHF, 37 in New York Heart Association class II and three in class III, left ventricular ejection fraction 30.8 ± 6.7%, mean BP 138.7 ± 16.5/83.1 ± 11.5 mmHg, 23 with arterial hypertension and four with a history of stroke. There were no significant differences between the groups in clinical characteristics, SBP and DBP at rest, while seated and before and after standing up. OH prevalence was low and did not change during the study (10% vs 10%). No significant difference in average SBP and DBP changes secondary to body position were found when comparing the two study phases. Decrease in MLHF score was observed in group I during SBT (p = 0.002), but not in group II. Conclusions. Our data indicate that SBT is safe, does not affect the prevalence of OH in CHF patients and shows a non-significant tendency to improve QoL. These results should be confirmed in a larger sample of patients to support the safety of SBT and its possible benefits as a novel component of cardiorespiratory rehabilitation programs in CHF.

Half of coronary patients are not instructed how to respond to symptoms of a heart attack

BACKGROUND The delayed treatment of acute coronary syndrome has a significant impact on survival. Due to improved organization and the use of reperfusion therapies, inhospital delay has been shortened in recent years. However, the time between the onset of chest pain and the call for medical help is still too long. The aim of this study was to assess the proportion of coronary patients instructed how to behave in case of chest pain and to find what factors relate to a lower probability of being counselled. METHODS Patients aged < 80 years, hospitalized due to coronary artery disease (CAD) were identified retrospectively on the basis of a medical records review and were invited for a follow-up examination. Two hundred and nineteen patients agreed to participate in the study. Data on the prehospital delay was obtained using a standard questionnaire. RESULTS The study group consisted of 149 men and 70 women. The mean time between discharge and the follow-up examination was 1.1 ± 0.4 years. Of 219 study participants, 106 (48.4%) declared they had been instructed about the symptoms of a heart attack and how to respond to it. Men, smokers, non-diabetics, and those with previously diagnosed CAD had been instructed more frequently. The independent predictors of being instructed were: percutaneous coronary intervention during the index hospitalization, diabetes, smoking, male sex and previously diagnosed CAD. CONCLUSIONS About half of patients after hospitalization due to CAD are not instructed how to respond to heart attack symptoms. This has not changed over the last decade and may contribute to the lack of shortening of prehospital delay.

The risk of diabetes development in long-term observation of patients with acute hyperglycaemia during myocardial infarction

BACKGROUND Acute hyperglycemia in patients with myocardial infarction is an unfavorable predictive factor. However, there are limited data regarding the relationship between acute hyperglycemia and the incidence of new onsets diabetes in long-term observation. AIM We studied the relationship between admission glycemia in patients with myocardial infarction and the future development of diabetes. METHODS In 190 patients admitted during 2004-2007 years with myocardial infarction diabetes was excluded on the basis of oral glucose tolerance test (OGTT) performed at the end of hospitalization. Patients were divided into three groups according to admission glucose level: G1 <7.8 mmol/l (<140 mg/dl); G2: 7.8-11.0 mmol/l (140-199 mg/dl); G3 ≥11.1 mmol/l (≥200 mg/dl). RESULTS The groups consisted of 80 (42.1%), 94 (49.5%) and 16 (8.4%) patients, respectively for G1, G2 and G3. The mean age was 61.3±11.3 years. ST-segment elevation myocardial infarction (STEMI) was diagnosed in 158 patients (83.2%) and non-ST-segment elevation myocardial infarction (NSTEMI) in 32 patients (16.8%). A total of 15 cases (7.9% of the study group) of newly diagnosed diabetes mellitus were registered during a mean follow-up of 48.2±13.9 months. Higher incidence of new diabetes diagnosis was noticed in patients with higher glucose level on admission (5.0% vs. 7.4% vs. 25.0%, p=0.0249). Regression analysis showed two independent risk factors of diabetes development in observational period: admission glucose level considered as continuous variable with OR 1.2 (95% CI 1.0-1.4, p=0.03) and occurrence of IGT with OR 3.6 (95% CI 1.0-12.0, p=0.04). CONCLUSIONS Patients with acute hyperglycemia during myocardial infarction are more likely to have diabetes in future. This group of patients requires a close monitoring of glucose metabolism after myocardial infarction.

His-bundle pacing as a standard approach in patients with permanent atrial fibrillation and bradycardia

His‐bundle (HB) pacing is the most physiological method of ventricular pacing. However, it is also considered a demanding procedure with a low success rate and has suboptimal pacing parameters. There is a scarcity of data concerning HB pacing as a standard approach in patients with symptomatic bradycardia. Our goal was to compare acute and chronic results of two approaches to pacing in patients with permanent atrial fibrillation, narrow QRS complexes, and symptomatic bradycardia: right ventricular myocardial pacing versus HB pacing.

Effects of device-guided slow breathing training on exercise capacity, cardiac function, and respiratory patterns during sleep in male and female patients with chronic heart failure

INTRODUCTION Slow breathing training (SBT) has been proposed as a new nonpharmacologic treatment in patients with chronic heart failure (CHF). OBJECTIVES The aim of this study was to assess the effects of SBT on exercise capacity, hemodynamic parameters, and sleep respiratory patterns in a relatively large sample of CHF patients. PATIENTS AND METHODS A crossover open study was conducted. Patients completed, in a random order, 10- to 12‑week SBT, with 2 15‑minute sessions of device‑guided SBT each day, reaching 6 breaths/ min, and a 10- to 12‑week follow‑up under standard care. Clinical data collection, polysomnography, echocardiography, 6‑minute walk test (6MWT), and laboratory tests were performed. RESULTS A total of 96 patients (74 men, 22 women) in New York Heart Association classes I-III, with an average age of 65 years and an ejection fraction (EF) of 31%, completed the study. Home‑based SBT was safe. After training, EF and 6MWT distance improved (EF: 31.3% ±7.3% vs 32.3% ±7.7%; P = 0.030; 6MWT: 449.9 ±122.7 m vs 468.3 ±121.9 m; P <0.001), and the apnea-hypopnea index decreased (5.6 [interquartile range (IQR), 2.1; 12.8] vs. 5.4 [IQR, 2.0; 10.8]; P = 0.043). CONCLUSIONS SBT improved physical capacity and systolic heart function; it also diminished sleep disturbances. The results support the benefits of SBT as a novel component of cardiorespiratory rehabilitation programs in patients with CHF.

His bundle pacing: Still much to learn

1. A 3D mapping system was not used during implantation in our cohort. Perhaps in the failed cases it could be useful for our redo procedures. We have no experience with such an approach. However, our intuition is that failures in atrial fibrillation patients are mainly due to a lack of proper tools to reach the His bundle area in cases with enlarged/rotated hearts rather than due to the inability to map the His bundle when it is within reach of the C315/C304 sheaths. Our intention was to follow a simplified His bundle pacing implantation technique so it could be considered to be a true alternative to the standard pacemaker implantation procedure. Although 3D mapping can potentially increase the success rate, such a procedure would be quite far from a standard pacemaker implantation approach.