Anna E. Platek

Stroke Risk Factors Beyond the CHA2DS2-VASc Score: Can We Improve Our Identification of “High Stroke Risk” Patients With Atrial Fibrillation?

The prevention of stroke and other thromboembolic events plays a crucial role in the management of patients with atrial fibrillation. Not all patients with atrial fibrillation are equal in terms of thromboembolic risk; therefore, not all will benefit from oral anticoagulation treatment. The general principle is that the expected benefit of anticoagulation in reduction of thromboembolic risk must exceed the expected harm caused by possible bleeding. Some guidelines have focused on a categorical approach to stroke prevention, with a focus on identifying patients at high risk for oral anticoagulation. Various current guidelines recommend assessment of stroke risk using the CHADS2 or CHA2DS2-VASc scores to initially detect patients at low risk who require no antithrombotic therapy. However, the scores do not incorporate all possible risk factors causing a high thromboembolic risk. Factors such as impaired renal function, obstructive sleep apnea, and echocardiographic and biochemical or coagulation parameters can also predict adverse thromboembolic events. The present review aims to describe biomarkers whether blood, urine, imaging (cardiac or cerebral), or clinical that go beyond the CHA2DS2-VASc score and potentially aid stroke risk assessment. Although useful in some cases, the presented parameters should be perhaps used to further refine initial identification of patients at low risk, after which effective stroke prevention can be offered to those with ≥1 additional stroke risk factors.

Clinical characteristics, aetiology and occurrence of type 2 acute myocardial infarction

BACKGROUND Cardiovascular diseases are the leading cause of death worldwide. One of the most important diseases in this group is myocardial infarction (MI). According to the universal definition developed by the European Society of Cardiology (ESC), MI is divided into five main types based on its cause. Type 2 MI is secondary to ischaemia due to either increased demand or decreased supply of oxygen (for example due to coronary artery spasm, anaemia, arrhythmia, coronary embolism, hypertension, or hypotension). AIM To assess the occurrence and aetiology of type 2 acute MI (AMI), and to describe the clinical characteristics and prognosis of study patients. METHODS Into a retrospective study, we enrolled 2,882 patients in the Cardiology Department with an initial diagnosis of AMI between 2009 and 2012. Diagnosis of AMI was made based on ESC criteria. In all patients, coronary angiography was performed in order to exclude haemodynamically significant coronary lesions. RESULTS Among 2,882 patients hospitalised in the described time period, 58 (2%) patients were diagnosed with type 2 AMI.The mean age of the study group was 67.3 ± 13.2 years; and the majority of the study group, 60.3%, were women. Out of them, 23 (39.6%) patients experienced AMI due to coronary artery spasm, 15 (25.9%) due to arrhythmias, 11 (19%) due to severe anaemia, and nine (15.5%) due to hypertension, without significant coronary artery disease. 42 (72.4%) patients, were diagnosed as non-ST-segment elevation MI, 14 (24.1%) as ST-segment elevation MI, and two (3.5%) as AMI in the presence of ventricular paced rhythm. History of classical cardiovascular risk factors including hypertension, diabetes, dyslipidaemia, family history of heart diseases, and smoking was reported in 42 (72.4%), 14 (24.1%), 23 (39.7%), 24 (41.4%), and 16 (27.6%) cases, respectively. All-cause 30-day mortality rate was 5.2%, and six-month was 6.9%. CONCLUSIONS Type 2 AMI patients were more often female, and they were more often diagnosed as non-ST-segment elevation MI. The prevalence of classical cardiovascular risk factors in this subgroup of patients was very high. The leading cause of AMI was coronary artery spasm.

Obstructive sleep apnoea in patients with atrial fibrillation: prevalence, determinants and clinical characteristics of patients in Polish population

BACKGROUND Obstructive sleep apnoea (OSA) and atrial fibrillation (AF) are two conditions highly prevalent in the general population. OSA is known to cause haemodynamic changes, oxidative stress, and endothelial damage, and therefore promote vascular and heart remodelling which results in AF triggering and exacerbation. Coexistence of OSA and AF influences the course of both diseases, and therefore should be taken into consideration in patient management strategy planning. AIM To assess the prevalence of OSA in Polish AF patients, and to describe the clinical characteristics of patients with concomitant OSA and AF. METHODS We enrolled into the study 289 consecutive patients hospitalised in a tertiary, high-volume Cardiology Department with a primary diagnosis of AF. In addition to standard examination, all patients underwent an overnight sleep study to diagnose OSA, which was defined as apnoea-hypopnoea index (AHI) ≥ 5 per hour. RESULTS After applying exclusion criteria, the final analysis covered 266 patients (65.0% male, mean age 57.6 ± 10.1 years). OSA was present in 121 (45.49%) patients. Patients with OSA were older (59.6 ± 8.0 vs. 56.0 ± 11.4 years; p = 0.02), had higher body mass index (BMI; 30.9 ± 5.4 vs. 28.7 ± 4.4 kg/m²; p < 0.01) larger neck size (41.2 ± 3.8 vs. 39.3 ± 3.3 cm; p = 0.0001) and waist circumference (108.5 ± 13.1 vs. 107.7 ± 85.4 cm; p < 0.0001) than patients without OSA. There were no significant differences between the groups in terms of systolic and diastolic blood pressure or history of comorbidities (p > 0.05). OSA patients were less likely than non-OSA patients to have paroxysmal AF (62.0% vs. 75.9%; p = 0.02). Dividing newly diagnosed OSA patients according to the disease severity showed that mild OSA (AHI ≥ 5/h and < 15/h) was present in 27.82% of the study population, moderate OSA (AHI ≤ 15/h and ≥ 30/h) in 13.16% of patients, and severe OSA (> 30/h) in 4.51% of patients. No significant differences in terms of comorbidities and anthropometric features were seen between mild and moderate, between moderate and severe, and between mild and severe OSA. CONCLUSIONS OSA is highly prevalent in patients with AF in the Polish population, and affects approximately half of the patients. OSA patients are more likely to be older, have higher BMI, and greater waist and neck circumference. Persistent AF is the most common form of the arrhythmia in patients with OSA, while patients without OSA are more likely to have paroxysmal AF.

Usefulness of the D-Dimer Concentration as a Predictor of Mortality in Patients With Out-of-Hospital Cardiac Arrest

During cardiac arrest and after cardiopulmonary resuscitation, activation of blood coagulation occurs, with a lack of adequate endogenous fibrinolysis. The aim of the present study was to determine whether the serum D-dimer concentration on admission is an independent predictor of all-cause mortality in patients with out-of-hospital cardiac arrest. We enrolled 182 consecutive patients (122 men, mean age 64.3 ± 15 years), who had presented to the emergency department from January 2007 to July 2012 because of out-of-hospital cardiac arrest. Information about the initial arrest rhythm, biochemical parameters, including the D-dimer concentration on admission, neurologic outcomes, and 30-day all-cause mortality were retrospectively collected. Of the 182 patients, 79 (43.4%) had died. The patients who died had had lower systolic (100 ± 39.6 vs 120.5 ± 26.9 mm Hg; p = 0.0004) and diastolic (58.3 ± 24.1 vs 74 ± 16.3 mm Hg; p <0.0001) blood pressure on admission. The deceased patients more often had had a history of myocardial infarction (32.9% vs 25.2%; p = 0.04) and less often had had an initial shockable rhythm (41.8% vs 60.2%; p = 0.02). The patients who died had had a significantly higher mean D-dimer concentration (9,113.6 ± 5,979.2 vs 6,121.6 ± 4,597.5 μg/L; p = 0.005) compared with patients who stayed alive. On multivariate logistic regression analysis, an on-admission D-dimer concentration >5,205 μg/L (odds ratio 5.7, 95% confidence interval 1.22 to 26.69) and hemoglobin concentration (odds ratio 1.66, 95% confidence interval 1.13 to 2.43) were strong and independent predictors of all-cause mortality. In conclusion, patients with a higher D-dimer concentration on admission had a poorer prognosis. The D-dimer concentration was an independent predictor of all-cause mortality.

Can thromboembolic risk be associated with erectile dysfunction in atrial fibrillation patients

BACKGROUND Erectile dysfunction (ED) is highly prevalent in patients with diseases of cardiovascular system, including patients with atrial fibrillation (AF). Reasons for this high co-prevalence include endothelial dysfunction, inflammation, oxidative and emotional stress associated with AF. Association of AF-induced prothrombotic state and possible microthrombi in penile arteries with ED remains unclear. The present study aims to assess if probability of AF-associated risk of peripheral thromboembolism may be associated with ED in AF patients. METHODS Probability of thromboembolic complications was assessed with two commonly used risk scores CHADS₂ and CHA2DS₂-VASc in a group of continuous AF patients. All patients were also asked to fill an IIEF-5 questionnaire designed for screening for ED. RESULTS Mean CHADS₂ score in the whole study group was 1.1 ± 1.0 points and CHA₂DS₂- -VASc was 1.5 ± 1.4 points. ED was present in 57.4% of the 129-person study population. In patients with ED, both CHADS₂ (0.9 ± 1.0 vs. 1.3 ± 1.1; p = 0.03) and CHA₂DS₂-VASc (1.2 ± 1.1 vs. 1.8 ± 1.5; p = 0.03) scores were significantly higher than in the group without dysfunction. After dividing the patients according to age into groups younger than 65 years vs. ≥ 65 years, observed correlation was no longer significant in the younger group (p > 0.05). In patients ≥ 65 years, in whom the risk scores are routinely used, dysfunction both CHADS₂ (1.1 ± 0.9 vs. 2.0 ± 0.9; p = 0.02) and CHA₂DS₂-VASc (2.3 ± 1.1 vs. 3.4 ± 1.3; p = 0.04) scores were higher in the group with ED. CONCLUSIONS Erectile dysfunctions in AF patients are associated with elevated cardioembolic risk. We postulate that the diagnosis of ED should be considered an additional marker of prothrombotic state, and may be useful in clinical decision-making, especially in patients ≥ 65 years old.

Usefulness of the SAME-TT2R2 score to predict anticoagulation control on VKA in patients with atrial fibrillation and obstructive sleep apnea

BACKGROUND Oral anticoagulation is crucial for the prevention of stroke and thromboembolism in atrial fibrillation (AF). One of the comorbidities potentially affecting thromboembolic risk and anticoagulation effectiveness is obstructive sleep apnea (OSA). The objective of this study was to establish if presence of OSA is associated with poor expected benefit from vitamin K antagonist (VKA) therapy as assessed using the SAMe-TT2R2 score. METHODS We studied AF patients planned for invasive electrophysiological procedures. All patients had a whole night polygraphy performed for the diagnosis of OSA, and their SAMe-TT2R2 score was calculated. RESULTS We studied 211 AF patients (mean age = 57.1 ± 10.2 years, 62.6% males). OSA with apnea-hypopnea index (AHI) ≥ 15/h was found in 48 (22.7%) patients. Mean SAMe-TT2R2 score in non-OSA patients was 1.4 ± 0.9, compared to mild OSA patients, 1.5 ± 0.9; moderate OSA patients, 1.9 ± 1.1; and severe OSA patients, 2.8 ± 0.6. A significantly higher percentage of patients with SAMe-TT2R2 ≥ 2, indicating poor predicted INR control on VKAs, was found with increasing AHI category (37% vs. 41% vs. 57% vs. 100%, respectively). Patients with poor predicted anticoagulation control (SAMe-TT2R2 ≥ 2) had a higher prevalence of OSA. There was a lower proportion of patients with TTR > 70% among patients with moderate/severe OSA compared to no/mild OSA (13.6% vs. 29.6%, p = 0.03). CONCLUSION SAMe-TT2R2 scores in patients with OSA are substantially higher than in those without sleep-disordered breathing. The mean SAMe-TT2R2 score, as well as the percentage of patients with SAMe-TT2R2 score ≥ 2, suggests poor predicted anticoagulation control on VKA rises along with the AHI. There was a lower proportion of patients with TTR > 70% among patients with moderate/severe OSA, compared to no/mild OSA.

Should cardiologist routinely screen and evaluate patients for sleep disordered breathing

We report a case of a 61-year-old male patient who presented with reduced exercise capacity, dyspnea, lower limbs oedema,irregular heart rhythm, loud, irregular snoring, history of poorly controlled hypertension, nocturnal hypertension spikes, andmorning headaches. Patient underwent ECG Holter monitoring and polygraphy, which revealed severe obstructive sleepapnea. In ECG Holter monitoring atrial fibrillation with pauses to 6.5 s were observed. Patient was referred for continuouspositive airway pressure (CPAP) treatment. Three-months of CPAP therapy resulted in significant decrease in apnea-hypopneaindex (31.6/h vs. 5.1/h) and better control of hypertension and heart failure. CPAP treatment allowed us to reduce patients cardiovascular risk. Cardiologist should routinely screen and evaluate patients for sleep disordered breathing, especially when patients are obese, have hypertension and/or arrhythmias.

OSACS score-a new simple tool for identifying high risk for Obstructive Sleep Apnea Syndrome based on clinical parameters.

Herein we comment on the article by Szymanski et al. (1) entitled “OSACS score-a new simple tool for identifying high risk for Obstructive Sleep Apnea Syndrome based on clinical parameters.” published in Anatol J Cardiol 2015; 15: 50-5. They proposed a scoring system based on clinical and echocardiographic data to screen the risk of obstructive sleep apnea (OSA) immediately after an acute coronary syndrome (ACS) episode. The authors identified independent risk factors using clinical and echocardiographic parameters in a logistic regression model. Additionally, all risk factors were used to create a final model to predict OSA risk among ACS patients. OSA diagnosis and treatment are important procedures for the secondary prevention of cardiovascular diseases. OSA independently increases the risk of ACS, and majority of ACS patients develop OSA as a comorbidity (2). Glantz et al. (3) evaluated 662 patients undergoing percutaneous coronary revascularization. They found that OSA, defined as an apnea–hypopnea index equal to or greater than 15/h (moderate to severe cases), was found in 422 (63.7%) patients. This prevalence was higher than hypertension (55.9%), obesity (body mass index≥30 kg/m2; 25.2%), diabetes (22.1%), and current smoking (18.9%) (3). However, OSA gold standard diagnosis by polysomnography is rarely available in hospital settings and cost ineffective by means of general screening tool, which brings relevance for diverse proposals to stratify the risk of OSA, offering more effective resources for an appropriate and selective strategy to decide which patient should be submitted for the complete diagnostic procedure. Hence, we value the authors’ initiative for the development of this screening tool to identify a high risk of OSA among ACS patients. Previous OSA screening tools, such as the Berlin questionnaire and overnight auto-CPAP with low pressure for the identification of apnea– hypopnea index through its algorithm, have been tested in similar settings (4). The Berlin questionnaire depends on subjective data derived from the patients’ self-reports. A more precise decision-making process can be achieved using objective information as used by this investigation, which built a prediction model based only on clinical and echocardiographic parameters, achieving a high accuracy level. Future studies may consider a subsequent analysis to assess multicollinearity in the regression models for defining the OSACS score predictors. Most independent variables included in the OSACS score are possibly correlated with each other, which can influence the model’s robustness, reducing the capacity of some potential predictors to significantly explain the high risk for OSA. As an example, obesity (BMI>30 kg/m2) is associated with the risk of both ACS and OSA, regardless of other predictors (5). This study presents a promising tool for the stratification of OSA risk in patients with cardiovascular disease. Because clinical and echocardiographic data from hospitalized ACS patients are easily available, the screening process has low cost and no adverse effects. We encourage the design of future studies addressing the validity of this new score in other populations across different settings and the investigation of whether OSA presence and its effective treatment impact ACS severity and extension of myocardial lesions.

Prognostic value of troponin I and NT-proBNP concentrations in patients after in-hospital cardiac arrest.

OBJECTIVES Cardiac arrest (CA) is a complex event with a dismal survival rate. The aim of this study was to determine whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels measured on admission and serial cardiac troponin I determination in patients with in-hospital cardiac arrest (IHCA) are predictive of 30-day mortality. METHODS Out of 9877 patients hospitalized in the cardiac intensive care unit during the study, we enrolled consecutive patients experiencing cardiac arrest within 12 hours of admission. Baseline characteristics, information about circumstances of CA and cardiopulmonary resuscitation, and initial biochemical parameters were retrospectively collected. RESULTS A total of 106 patients (61 male, age 71.4±12.6 years) were enrolled. Thirty-four (32.1%) had a history of myocardial infarction, and 13 (12.3%) a history of stroke. Total 30-day mortality was 60.4%. Deceased patients were older (73.7±11.9 vs. 67.8±13.0 years; p=0.01) and had lower systolic (89.4±37.0 vs. 115.0±24.0 mmHg; p=0.0001) and diastolic (53.6±24.8 vs. 66.1±15.0 mmHg; p=0.008) blood pressure on admission. Shockable initial rhythm was more often noted in the survivor group (54.8% vs. 28.1%; p=0.01). Deceased patients had higher median NT-proBNP levels (9590.0 [25-75% interquartile range (IQR), 5640.0-26450.0] vs. 3190.0 [25-75% IQR, 973.8-5362.5] pg/ml; p=0.02) on admission. There were no differences in the first two troponin I measurements, but values were higher on the third measurement in non-survivors (98.2 [25-75% IQR, 76.4-175.8] vs. 18.7 [25-75% IQR, 5.2-50.6]; p=0.009). CONCLUSIONS The survival rate of patients after in-hospital CA is poor. Deceased patients have higher NT-proBNP levels on admission, along with higher troponin I concentrations on the third measurement. Those biomarkers are useful in predicting 30-day mortality in IHCA patients.

Myocardial Infarction Type 4b in Human Immunodeficiency Virus-Infected Patient

We report a case of a 52-year-old human immunodeficiency virus (HIV)-infected male patient receiving combined antiretroviral therapy (cART), who presented with acute ST-elevation myocardial infarction (STEMI). He was properly treated (e.g., prescribed anti-coagulation drugs: aspirin, clopidogrel, enoxaparin) and discharged. After 1.5 months, another STEMI related with in-stent thrombosis took place. The cART scheme was altered, resulting in no further cardiac events in the follow-up period, with undetectable levels of HIV ribonucleic acid. This case highlights the association between HIV infection and the specific drugs of cART, and the risk of cardiovascular disease development.