Anna Borowiec

Effect of Combined Spironolactone–β-Blocker ± Enalapril Treatment on Occurrence of Symptomatic Atrial Fibrillation Episodes in Patients With a History of Paroxysmal Atrial Fibrillation (SPIR-AF Study)

Angiotensin II and aldosterone are key factors responsible for the structural and neurohormonal remodeling of the atria and ventricles in patients with atrial fibrillation (AF). The aim of the present study was to evaluate the antiarrhythmic effects of spironolactone compared to angiotensin-converting enzyme inhibitors in patients with recurrent AF. A cohort of 164 consecutive patients (mean age 66 years, 87 men), with an average 4-year history of recurrent AF episodes, was enrolled in a prospective, randomized, 12-month trial with 4 treatment arms: group A, spironolactone, enalapril, and a β blocker; group B, spironolactone and a β blocker; group C, enalapril plus a β blocker; and group D, a β blocker alone. The primary end point of the trial was the presence of symptomatic AF episodes documented on the electrocardiogram. At 3-, 6-, 9-, and 12 months, a significant (p < 0.001) reduction had occurred in the incidence of AF episodes in both spironolactone-treated groups (group A, spironolactone, enalapril, and a β blocker; and group B, spironolactone plus a β blocker) compared to the incidence in patients treated with enalapril and a β blocker (group C) or a β blocker alone (group D). No significant difference was seen in AF recurrences between patients taking spironolactone and a β blocker with (group A) and without (group B) enalapril. No significant differences were found in the systolic or diastolic blood pressure or heart rate among the groups before and after 1 year of follow-up. In conclusion, combined spironolactone plus β-blocker treatment might be a simple and valuable option in preventing AF episodes in patients with normal left ventricular function and a history of refractory paroxysmal AF.

Prospective assessment of cytokine IL-15 activity in patients with refractory atrial fibrillation episodes

AIMS Inflammatory state is considered a risk factor of atrial fibrillation (AF) occurrence. The aim of this study was a prospective evaluation of the inflammation parameters in patients with different forms of AF without structural heart disease. METHODS AND RESULTS One hundred fifty-eight patients with paroxysmal/persistent AF (87; 55.1% men, mean age 65.8±9.6 years) without structural heart disease were enrolled in the study. Inflammatory parameters: WBC, ESR, hs-CRP, IL-6, IL-15 and TNF-alpha were measured at baseline and after one year follow-up. Despite frequent AF episodes median values of WBC, ESR and C-reactive protein at baseline and after follow up were within normal ranges. There were no significant differences between WBC, ESR and hs-CRP regarding AF types. In patients who developed permanent AF form (n=14) hs-CRP concentrations were higher at baseline: 0.35 (IQR1: 0.09 IQR: 0.61) vs 0.15 (IQR1: 0.07 IQR: 0.29), p<0.01. Nevertheless, after one years observation these differences were not significant. Among all cytokines were studied only IL-15 was significantly correlated with the number of AF episodes (r=0.26), mean (IQ1-IQ3): 10 (3-30) vs 60 (50-100), p=0.00681. CONCLUSION Basic inflammatory markers were not changed in patients with refractory atrial fibrillation episodes in prospective one years observation. Only cytokine IL-15 was correlated to numbers of AF episodes. Its potential role as a marker of arrhythmia deserves further evaluation.

Osteoprotegerin in patients with degenerative aortic stenosis and preserved left-ventricular ejection fraction.

OBJECTIVES The aim of the present study was to evaluate value of osteoprotegerin (OPG) in patients with degenerative aortic stenosis and preserved left-ventricular ejection fraction. METHODS We have prospectively followed 70 patients with aortic stenosis (mean aortic gradient ≥15 mmHg) and preserved left-ventricular ejection fraction for 1 year. In all patients, echocardiography and blood tests (OPG, lipids, high-sensitivity C-reactive protein) were performed at baseline and after 1 year of follow-up. Detailed medical history including atherosclerotic risk factors was obtained. The control group consisted of 20 healthy individuals with normal echocardiographic findings. Rapid progression of aortic stenosis was defined as more than 7 mmHg increase in mean aortic gradient per year. RESULTS Osteoprotegerin concentrations were significantly higher in patients with aortic stenosis (P < 0.0001) and correlated with the degree of aortic stenosis. In multivariable regression model analysis, age (β = 0.015, P < 0.0001), mean aortic gradient (β = 0.04, P = 0.0078) and presence of coronary artery disease (β = 0.111, P = 0.0408) were the only independent determinants of plasma OPG concentrations. There was no association between OPG concentrations and coronary artery disease risk factors: male sex, smoking, hypertension and hypercholesterolemia. Concentrations of high-sensitivity C-reactive protein correlated positively with OPG levels only in nonsurgical patients (with lower degree of stenosis) (r = 0.34, P = 0.01). Aortic stenosis progression was related to body mass, diabetes, triglyceride concentrations, metabolic syndrome and left-ventricular systolic volume. In multivariate analysis, only metabolic syndrome was an independent predictor of aortic stenosis progression. CONCLUSION Osteoprotegerin concentrations are linked to the presence and severity of aortic stenosis. Metabolic syndrome was the only independent predictor of degenerative aortic stenosis progression.

Cardiac manifestations in antineutrophil cytoplasmic autoantibody (ANCA) — associated vasculitides

Katarzyna Życińska, MD, PhD, Professor graduated from the Medical University of Warsaw and is board certified in internal medicine and family medicine. Professor Życińska is currently the Head of Chair and Department of Family Medicine, Medical University of Warsaw. She is a member of the Polish Internal Medicine Society and a board member of Polish Family Medicine Society. She is also a member of the College of Family Physicians in Poland and of the Association of Medical Education in Europe. Her main research areas are systemic vasculitis and nephrology. She is published in leading international medical journals.

Atherosclerosis in antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis

Katarzyna Życińska, MD, PhD, Professor graduated from the Medical University of Warsaw and is board certified in internal medicine and family medicine. Professor Życińska is currently the Head of Chair and Department of Family Medicine, Medical University of Warsaw. She is a member of the Polish Internal Medicine Society and a board member of the Polish Family Medicine Society. She is also a member of the College of Family Physicians in Poland and of the Association of Medical Education in Europe. Her main research areas are systemic vasculitis and nephrology. She has been published in leading international medical journals.

Echocardiographic Assessment in Patients with Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis (GPA) is one of the most common forms of systemic vasculitis, which usually involves the upper and lower respiratory tract, but it may affect also multiple organs. The aim of the study was an echocardiographic evaluation of cardiac involvement in GPA patients during remission. Eighty eight patients with GPA were evaluated in the study. The control group consisted of 40 age and sex-matched patients without a previous history of cardiovascular disease. We found that there were no differences between GPA and control groups regarding left atrial enlargement and interventricular septal hypertrophy. In one GPA patient, all heart chambers were enlarged. Left ventricle systolic function was decreased (LVEF ≤ 50%) in eight patients with GPA, and left ventricle wall motion abnormalities were observed in 12 patients. Left ventricle relaxation dysfunction, mitral valve and tricuspid valve regurgitation were observed with the same frequency in both GPA and control groups. Aortic regurgitation was the single abnormality that occurred significantly more often in the GPA group than in controls (28% vs. 7.5%; p = 0.03). Pericardial effusion was observed in three GPA patients and in none from the control group. We conclude that the most common echocardiographic manifestation in GPA patients in remission was aortic valve regurgitation. However, cardiac involvement in such patients is rather rare and in the majority of cases clinically insignificant.

Improvement of exercise tolerance in cardiopulmonary testing with sustained safety after regular training in outpatients with systolic heart failure (NYHA III) and an implantable cardioverter-defibrillator. Prospective 18-month randomized study

Introduction The aim of the study was to evaluate the impact of individual training on the level of physical capacity and echocardiographic parameters in patients with systolic heart failure (SHF), NYHA III and an implantable cardioverter-defibrillator (ICD). Material and methods The study included 84 patients with SHF, randomly assigned to one of two groups: with regular training (ICD-Ex) and a control group (ICD-control). The ICD-Ex group participated in a hospital rehabilitation program which after discharge was individually continued for 6 months in an outpatient setting. The ICD-control group participated in a training program during hospitalization, but after discharge did not perform any controlled activities. Prior to discharge, at 6 and 18 months cardiopulmonary exercise testing (CPX), standard echocardiographic examination and the 6-minute walk test (6-MWT) were performed in all patients. Results After 18 months in the ICD-Ex group most of the CPX parameters improved significantly (VO2 peak, ml/kg/min: 13.0 ±4.1 vs. 15.9 ±6.1, p < 0.0017; VCO2 peak, l/min: 1.14 ±0.34 vs. 1.58 ±0.65, p < 0.0008; Watt: 74.5 ±29.7 vs. 92.6 ±39.1, p < 0.0006; METs 3.72 ±1.81 vs. 4.35 ±1.46, p < 0.0131). In the ICD-control group no significant improvement of any parameter was observed. Left ventricular systolic dimensions remained significantly lower at 18 months only in the ICD-Ex group (49.5 ±11.0 vs. 43.4 ±10.0, p < 0.011). Left ventricular ejection fraction in both groups significantly increased at 6 and 18 months compared to baseline (ICD-Ex: 25.07 ±5.4 vs. 31.4 ±9.2, p < 0.001, vs. 30.9 ±8.9, p < 0.002, ICD-C: 25.1 ±8.3 vs. 29.2 ±7.7, p < 0.012 vs. 30.1 ±9.1, p < 0.005). Distance of the 6-MWT was significantly improved after 6 and 18 months in the ICD-Ex group and was overall longer than in the ICD-control group (491 ±127 vs. 423 ±114 m, p < 0.04). Conclusions An individual, 6-month training program, properly controlled in patients with SHF and an implanted ICD, was safe and resulted in a significant improvement of exercise tolerance and capacity and echocardiographic parameters.

Clinical, echocardiographic, and pacing parameters affecting atrial fibrillation burden in patients with tachycardia-bradycardia syndrome

BACKGROUND The influence of various factors on atrial fibrillation (AF) development in the population of tachycardia-bradycardia syndrome (TBS) patients remains unclear. There are no data on the impact of different right ventricular pacing percentage (RVp%) profiles. AIM The purpose of the study was to evaluate the relationship between the AF burden (AFB) and various clinical, echocardiographic, and pacing parameters in TBS patients. METHODS We performed a prospective, one-year registry of TBS patients with documented AF referred for dual-chamber pacemaker (DDD) implantation. RESULTS The data of 65 patients were analysed. The median 12-month RVp% and AFB was 9.4% and 1.0%, respectively. During the follow-up 14% of patients had no AF (p = 0.003), and the withdrawal of AF symptoms was observed in 49% of patients (p < 0.0001). The AFB was related to the left atrium diameter (r = 0.31, p = 0.02), especially in the subjects with left ventricular ejection fraction < 60% (r = 0.44, p = 0.04). Based on the relative change of RVp%, three groups of various RVp% profile were established: stable, decreasing, and increasing RVp%. In the stable RVp% group (n = 21) there was a quadratic correlation between the 12-month RVp% and AFB (r = 0.71, p = 0.0003). In the stable RVp% > 20% subgroup there was a significant increase of AFB in comparison to the RVp% ≤ 20% subgroup (ΔAFB 1.8% vs. 0.0%, p = 0.03, respectively). In the increasing RVp% group (n = 28) the AFB increased whereas in the decreasing RVp% (n = 16) it remained stable (ΔAFB 0.67% vs. 0.0%, p = 0.034, respectively). CONCLUSIONS DDD implantation in TBS patients is related to a significant reduction in AF symptoms, and left atrial diameter correlates with cumulative AFB in the mid-term observation. Stable RVp% > 20% is associated with AF progression whereas lower stable RVp% may stabilise AF development. Increasing RVp% may be associated with the AFB increase in comparison to the decreasing RVp% subgroup in which AFB remains stable.