Anna Hrynkiewicz-Szymanska

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.

The high risk of obstructive sleep apnea--an independent risk factor of erectile dysfunction in ST-segment elevation myocardial infarction patients.

INTRODUCTION Sleep-related breathing disorders are highly prevalent in patients with established cardiovascular disease. Obstructive sleep apnea (OSA) is associated with several cardiovascular conditions such as hypertension, ischemic heart disease, arrhythmias, and erectile dysfunction (ED). AIM The aim of this prospective study was to investigate the prevalence of ED in ST-segment elevation myocardial infarction (STEMI) patients at high risk of OSA, and to evaluate the leading factors that increase the risk of ED. METHODS We prospectively studied 90 consecutive male STEMI patients. MAIN OUTCOME MEASURES A risk of OSA was assessed using the Berlin questionnaire (BQ) and Epworth Sleepiness Scale (ESS). Erectile function was assessed using the International Index of Erectile Function (IIEF). RESULTS Thirty-two (35.6%) patients were at high risk of OSA. Patients were at high risk of OSA who on admission had significantly higher mean ESS score, and abnormal BQ, higher incidence of hypertension, and higher body mass index. They were also found to have significantly higher mean C-reactive protein level and higher incidence of ED. The mean IIEF score was significantly lower in patients at high risk of OSA (16.2 ± 5.4 vs. 20.5 ± 6.4; P = 0.004). In the multiple logistic regression analysis, high risk of OSA was strong and an independent risk factor of ED in STEMI patients (odds ratio 55.71, 95% confidence interval 3.36-923.81; P = 0.005). Conclusion.  ED was highly prevalent in STEMI patients at high risk of OSA. High risk of OSA was strong, independent risk factor for developing ED.

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 obstructive sleep apnea be a cause of in-stent thrombosis?

We present the case of a 45-year-old patient readmitted to Central University Hospital at 3 a.m. for acute retrosternal chest pain associated with ST-segment elevation in lead I, aVL, V1–V6 in standard 12-lead ECG performed on admission in emergency department. Coronary angiography revealed late in-stent thrombosis in left anterior descending artery. According to the new universal definition of myocardial infarction patient was finally recognized acute ST-segment elevation myocardial infarction type 4b with additional diagnosis of severe obstructive sleep apnea and overweight.

Prevalence of Erectile Dysfunction in Atrial Fibrillation Patients: A Cross‐Sectional, Epidemiological Study

Sexual dysfunctions, especially erectile dysfunction (ED), are a major problem in cardiovascular patients. They are caused by cardiovascular risk factors including low‐grade inflammation process, endothelial dysfunction, oxidative stress, and hemodynamic and vascular alterations. The same mechanisms are some of the main causes and/or consequences of atrial fibrillation (AF). To this day, literature provides no cross‐sectional data on the prevalence of sexual dysfunction in AF. The study aimed to determine the prevalence of sexual dysfunction in consecutive, young male patients with AF.

Resistant Hypertension in an Obese Patient With Obvious Obstructive Sleep Apnea and Occult Pheochromocytoma

We report the case of a 34-year-old male patient who presented with generalized weakness, poorly controlled hypertension, nocturnal hypertension spikes, and morning headaches. The history of resistant hypertension, obesity, enlarged neck size, and loud irregular snoring strongly suggested obstructive sleep apnea (OSA). To exclude other possible causes of resistant hypertension, the patient underwent an abdominal ultrasound examination, which revealed a lesion in the left adrenal gland area. A pheochromocytoma was successfully removed via laparoscopic adrenalectomy, and both his hypertension and OSA responded dramatically. This case highlights the importance of excluding all causes of resistant hypertension regardless of the initial diagnosis.

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.

Differences of psychological features in patients with heart failure with regard to gender and aetiology — Results of a CAPS-LOCK-HF (Complex Assessment of Psychological Status Located in Heart Failure) study

OBJECTIVE Objective of the study was to assess the psychological state of HF patients with reduced ejection fraction (HFrEF) with regard to gender and aetiology. METHODS 758 patients with HFrEF (mean age - 64±11years, men - 79%, NYHA class III-IV - 40%, ischemic aetiology - 61%) in a prospective Polish multicenter Caps-Lock-HF study. Scores on five different self-report inventories: CISS, MHLC, GSES, BDI and modified Mini-MAC were compared between the sexes taking into account the aetiology of HFrEF. RESULTS There were differences in the CISS and BDI score between the genders - women had higher CISS (emotion- and avoidance-oriented) and BDI (general score - 14.2±8.7 vs 12.3±8.6, P<0.05; subscale - somatic score - 7.3±3.7 vs 6.1±3.7, P<0.05). In the ischemic subpopulation, women had higher BDI (general and subscales) than men. In the non-ischemic subpopulation the differences between genders were limited to CISS scale. In a multivariable analysis with demographic and clinical data female sex, NYHA class, atrial fibrillation and diabetes mellitus determined BDI score. Similarly, in the ischemic subpopulation, the female sex, NYHA class and atrial fibrillation determined the BDI, while in the non-ischemic population NYHA class was the only factor that influenced the BDI score. Adding the psychological data made a significant additional contribution to the prediction of depression status. CONCLUSIONS There are distinct differences in psychological features with regard to gender in patients with HFrEF. Women demonstrate less favourable psychological characteristics. Gender-related differences in BDI score are especially explicit in patients with ischemic aetiology of HF. The BDI score is related to psychological predisposition.

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.