Arkadiusz Niklas

A marked fall in nocturnal blood pressure is associated with the stage of primary open-angle glaucoma in patients with arterial hypertension

Abstract Introduction. The aim of this study was to assess blood flow in the vessels of the eyeball and changes in the optic nerve in patients with arterial hypertension and primary open-angle glaucoma. Material and Methods. The patients were divided into groups: 1 (night blood pressure, BP, fall, NBPF, not more than 10%; non-dippers); 2 (NBPF 10–15%, dippers) and 3 (NBPF>15%; extreme dippers). Results. In the group of dippers and extreme dippers, perfusion pressure was significantly lower than that in the non-dippers group, there was reduced thickness of the nerve fibers and a greater decrease in the visual field. Significant relationships between peak systolic, end-diastolic flow in the ophthalmic and central retinal arteries and night perfusion pressure, thickness of nerve fibers, and a loss of visual field were observed. Conclusion. In patients with glaucoma and well-controlled hypertension, a nocturnal BP fall of more than 10% is associated with a greater visual field defect and greater degeneration of the optic nerve fibers. Low minimum diastolic pressure and the level of nocturnal BP fall, but not the absolute value of average arterial BP at night, should be included in the group of specific risk factors in patients with hypertension and open-angle glaucoma. These findings also suggest avoiding excessive lowering of BP at night in this group.

Multi-centre National Population Health Examination Survey (WOBASZ II study): assumptions, methods, and implementation.

BACKGROUND Cardiovascular diseases (CVDs) are the main cause of morbidity and mortality in developed countries. Despite the progress in diagnostics and treatment, it is expected that CVD will still be the main cause of death worldwide until at least 2030. From 1991 CVD mortality in Poland systematically decreased, but it is still higher than the average in Western Europe. In 2013 CVDs were the cause of 46% of all deaths in Poland (40.9% in men and 51.1% in women) and 26.9% of deaths among persons under 65 years of age. The epidemiologic assessment of prevalence, control and treatment of CVD risk factors, and monitoring of healthy behaviour and morbidity due to diseases like coronary artery disease, hypertension and diabetes is very important for health policy planning. The WOBASZ II is the newest Polish population based survey, performed in 2013-2014 to evaluate prevalence, control, treatment, and morbidity. The study was the continuation of WOBASZ (2003-2005). AIM To describe the goals and methods of the WOBASZ II study and to present the results of the recruitment. METHODS The WOBASZ II study was planned as a cross-sectional survey of a random sample of Polish residents aged over 20 years. The selection, using the National Identity Card Registry of the Ministry of Internal Affairs, was made as a three-stage sampling, stratified according to administrative units (voivodeships), type of urbanisation (commune), and gender. The study protocol consisted of a questionnaire used in face-to-face interviews, physical examination, and blood samples. WOBASZ II was coordinated by the Department of Epidemiology, Cardiovascular Diseases Prevention and Health Promotion of the Institute of Cardiology in Warsaw in cooperation with medical universities in Gdansk, Katowice, Krakow, Lodz, and Poznan. RESULTS Out of 15,120 persons, 1557 persons were not eligible. Out of eligible persons, 6170 (2760 men and 3410 women) were examined (the response rate 45.5%). The highest response rates were observed in Warminsko-Mazurskie (64.2%), Zachodniopomorskie (58.1%), and Kujawsko-Pomorskie (53.1%). CONCLUSIONS The importance of the WOBASZ study for the monitoring of the health state of Polish society, and for the as-sessment of prophylaxis efficiency and treatment of CVD and metabolic diseases, as well as for the evaluation of the actions in the field of health promotion, is difficult to overstate.

Rheumatic diseases induced by drugs and environmental factors: the state-of-the-art – part one

The majority of rheumatic diseases belong to the group of autoimmune diseases and are associated with autoantibody production. Their etiology is not fully understood. Certain medications and environmental factors may have an influence on the occurrence of rheumatic diseases. Establishing a cause-effect relationship between a certain factor and disease induction is not always simple. It is important to administer the drug continuously or monitor exposure to a given factor in the period preceding the onset of symptoms. The lack of previously diagnosed autoimmune disease, or finally the lack of symptoms within a few weeks/months after discontinuation of the drug/cessation of exposure, is also important. The most frequently mentioned rheumatic diseases caused by drugs and environmental factors include systemic lupus erythematosus, scleroderma, systemic vasculitis, polymyositis, dermatomyositis, and Sjögrens syndrome. The objective of this study is to summarize current knowledge on rheumatic diseases induced by drugs and environmental factors.

Trends in hypertension prevalence, awareness, treatment, and control among Polish adults 75 years and older during 2007–2014

BACKGROUND The aim of this study was to assess changes in the prevalence, awareness, and treatment of hypertension and its effectiveness between 2007 (WOBASZ Senior study) and 2013-2014 (WOBASZ II) in a sample of the Polish population over the age of 75 years. METHODS Sampling had three stages, stratified according to voivodeships, type of community, and gen-der. Finally, the WOBASZ II study included 467 persons (290 women and 177 men). For a comparison of the data, 1096 persons (538 women and 554 men) examined in the WOBASZ Senior study were used. RESULTS Systolic and diastolic blood pressures significantly decreased from 153.0 ± 23.9 mmHg to 142.9 ± 22.3 mmHg and from 85.2 ± 11.9 mmHg to 78.4 ± 11.3 mmHg, respectively, from 2007 to 2014 (p < 0.0001). Prevalence of hypertension among people included in WOBASZ studies slightly decreased from 83.8% to 77.9% (rate ratio [RR]: 0.95; 95% confidence interval [CI]: 0.78-1.16) in men, and from 75.4% to 71.8% (RR: 0.93; 95% CI: 0.8-1.09) in women. Hypertension awareness was improved from 59.2% to 72.9% (RR: 1.23; 95% CI: 0.97-1.56) in men, and from 74,8% to 93% (RR: 1.26; 95% CI: 1.01-1.58) in women. The proportion of men and women, with implemented hypertension treatment, increased from 48.4% to 61.1% (RR: 1.26; 95% CI: 1.01-1.58), and from 63.2% to 82.0% (RR: 1.3; 95% CI: 1.1-1.53), respectively. The effectiveness of the treatment was improved over two-fold, there was an increase from 10.3% to 26.8% (RR: 2.65; 95% CI: 1.81-3.89) in men, and from 13.8% to 33.5% in women (RR: 2.44; 95% CI: 1.81-3.3). CONCLUSIONS The prevalence of hypertension in Polish seniors remains high, but has decreased slightly in the perspective of the last 7 years. Although treatment and control has improved over the last decade, it remains below expectations. Efforts to improve the diagnosis and effective treatment of hypertension in Polish seniors should be intensified.

Prevalence, awareness, treatment and control of hypertension in the adult Polish population – Multi-center National Population Health Examination Surveys – WOBASZ studies

Introduction Hypertension is one of the main risk factors of cardiovascular diseases. The first aim of the study was to evaluate the prevalence, awareness and treatment of hypertension as well as treatment effectiveness (blood pressure < 140/90 mm Hg) in a representative sample of the Polish population over the age of 19, examined in the WOBASZ II program. The second aim was to assess the changes in these parameters between 2003–2005 (WOBASZ study) and 2013–2014 in adults aged 20–74. Material and methods Sampling was performed in three stages, stratified according to voivodeship (province), type of commune, and gender. Finally, the study included 6163 persons (3406 women and 2757 men) examined in the years 2013–2014 (aged ≥ 19 years). For comparison the data from 14 755 persons (7783 women and 6452 men aged 20–74 years) examined in the years 2003–2005 were used. Results In the years 2013–2014, the age-standardized prevalence of hypertension, awareness, treatment and control was 42.7%, 59.3%, 46.1%, and 23% respectively. In the last decade an increase in the prevalence of hypertension (relative ratio (RR) 1.12; 95% confidence interval (CI): 1.07–1.18), treatment (RR = 1.26; 95% CI: 1.17–1.36) and control (RR = 2.16; 95% CI: 1.9-12.45) was found. In contrast, the awareness decreased nonsignificantly (RR = 0.98; 95% CI: 0.92–1.05). Conclusions The prevalence of hypertension in Poland is high, and increased by about 12% in 10 years. Although the number of treated patients and blood pressure control improved nearly twofold over the last decade, this is still below expectations. Efforts to improve the diagnosis and effective treatment of hypertension in Poland should still be intensified.

Polymyositis induced by atorvastatin

We present the case of a 61-year-old female who developed polymyositis after atorvastatin treatment. She was admitted to hospital in July 2014 with fever, weight loss, myalgia, and limb weakness. Additionally in anamnesis, the following are seen: diabetes type 2, hypertension, and hypercholesterolaemia (treated with atorvastatin 20 mg daily for 6 months). In physical examination muscle weakness was observed (upper limbs 4° and lower limbs 3° in Lovett scale). Laboratory tests revealed increased levels of creatine kinase (CK) — 3977 U/L, alanine aminotransferase (ALT) — 176 U/L and aspartate aminotransferase (AST) — 128 U/l. In electromyography myogenic-dominant damage was described. Atorvastatin was withdrawn. Methylprednisolone pulse therapy was started (3 × 500 mg). Then the patient, with a diagnosis of myopathy, was sent (in August 2014) to the Department of Rheumatology for continuation of treatment. The muscle weakness was still observed (upper limbs 4° and lower limbs 3° in Lovett scale) and laboratory results were as follows: CK 1299.7 U/L, ALT 133.2 U/L, AST 50.5 U/L, aldolase 15.6 U/L, lactate dehydrogenase (LDH) — 742 U/L. Antinuclear antibodies were negative. The presence of anti-SS-A antibodies was observed (Fig. 1). The myositis profile was negative (Fig. 2). In spite of such results the clinical diagnosis of atorvastatin-induced polymyositis was made. Treatment with methylprednisolone pulse (3 × 500 mg) was continued with subsequent oral prednisone therapy (25 mg daily). In control after 1 month a slight improvement of lower limbs muscle strength was observed (4° in Lovett scale, upper limbs remain constant). Laboratory tests revealed the following: CK 873.5 U/L, ALT 77.6 U/L, AST 39 U/L, LDH 704 U/L, aldolase 9.7 U/L. We continued treatment with methylprednisolone pulse (3 × 500 mg). Subsequently the oral prednisone dose was reduced to 20 mg daily. The latest observation was made in November 2014. The upper limbs muscle strength was normal and lower limbs remained constant (4° in Lovett scale). Laboratory results were as follows: CK 259.3 U/L, ALT 40.5 U/L, AST 23 U/L, LDH 401 U/L. The treatment with methylprednisolone pulse was continued, but the dose was reduced (3 × 250 mg). Oral prednisone dose was also decreased to 17.5 mg. Because of permanent hypercholesterolaemia ezetimibe was prescribed. Now patient is under our observation with planned control. Our case describes patients who develop polymyositis after atorvastatin therapy. Because of the non-autoimmune origin of the disease the patient did not reveal a characteristic immunological pattern. Withdrawing the drug did not improve the symptoms. Immunosuppressive therapy with corticosteroids was necessary. Statins may be a cause of the whole spectrum of muscle damage, but full-blown polymyositis or dermatomyositis are rather rare. It is crucial to establish any association with a drug as soon as possible because a key role in the treatment is played by the elimination of any agent causing the disease.

Intra-atrial course of the right coronary artery: an uncommon anomaly diagnosed by coronary computed tomography angiography.

Intra-atrial course of the right coronary artery (RCA) is a very rare anomaly. The frequency of anomalous course of RCA through the right atrium in the population is approximately 0.1%. Intracavitary course of RCA was first described by McAlpine in 1975 [McAlpine WA ed. Heart and coronary arteries. An anatomical atlas for clinical diagnosis, radiological investigation, and surgical treatment. Springer-Verlag, New York 1975]. The growing clinical use of cardiac computed tomography (CT) is enabling accurate assessment of the morphology and location of anomalous vessel course. We present the case of a 78-year-old female who was referred to cardiac CT to rule out ischaemic heart disease. The patient came to the cardiology outpatient clinic with non-specific chest pain, low tolerance of physical effort, dry cough, and raised blood pressure (BP) to 200/100 mm Hg. In anamnesis: hypertension for 6 years, and an acute coronary syndrome 2 years ago without hospitalisation but with pharmacological treatment. In physical examination: regular heart rate (HR) of 68/min with normal heart sounds and normal breath sounds over the lungs, BP 140/80 mm Hg. In resting electrocardiogram: regular HR of 68/min and left branch bundle block. In echocardiography: global hypokinesis with ejection fraction of about 45%. On account of her age and the non-specific cardiac trouble, a cardiac CT was recommended. The origin and proximal segment of the RCA was normal with an epicardial course in the right atrioventricular groove. RCA passed through the anterior right atrial wall (Fig. 1). The mid-segment of RCA had 2 cm of intra-atrial course. The distal segment of RCA exited from the right atrium. This divided into a posterolateral ventricular branch and a posterior descending artery which runs to the heart apex in the posterior interventricular groove. Previously published case reports of intra-atrial RCA evaluated by CT angiography have shown variable lengths of 1.5 to 5.5 cm, which run inside the cavity of the right atrium (Fig. 2). The left main coronary artery, including the left anterior descending and the left circumflex, had normal origin and epicardial course. The above arteries were unobstructed, with numerous soft and mixed plaques causing less than 50% stenosis. The patient was given a dose of 90 mL iodinated contrast medium 400 mg/mL, followed by saline solution. HR during examination was 54–56/min. Multi-detector CT (MDCT) provides a high-quality, noninvasive technique which can help diagnose and visualise the origin and course of anomalous coronary arteries by a 3D display of anatomy. Recognition of such anomalies may help prevent unsafe consequences during interventional procedures or bypass surgery. Anomalous intracavitary RCA may be damaged during procedures including inferior vena cava cannulation, right heart catheterisation, coronary sinus cannulation, pacemaker implantation, invasive electrophysiology testing, ablation of atrial dysarrhythmias arising in the right atrium, transseptal puncture for left atrial access and coronary artery bypass surgery. Therefore, identifying this anomalous course provides significant information to the interventional cardiologist or cardiothoracic surgeon. The detection of these abnormalities is improving with the growing use of cardiac CT. MDCT angiography enabled better and noninvasive visualisation of the anomalous course of coronary artery and associated findings. CT is the diagnostic method for detecting coronary anomalies associated with a low risk of complications. The course of an anomalous coronary artery can be identified with very high accuracy.

Altered course of non-affected left coronary artery as a reason for symptoms of coronary artery disease

Anomalies of coronary arteries are rare (about 0.3–1.3% of patients undergoing a coronary angiography procedure), and left coronary artery (LCA) going from the right sinus of Valsalva (RSV) is described in 0.09–0.15% of cases. We present the case of a 61-year-old female who complained of typical angina symptoms for two years. A cardiac stress test was performed with positive result. The patient was admitted to hospital for coronary catheterisation. Electrocardiogram (ECG) revealed: sinus rhythm 66/min, with T-wave inversion in leads III and aVF and ST depression in leads V4–V6. Echocardiography showed: no segmental wall motion abnormalities and ejection fraction 65%. A coronary angiography was performed. Anomalous origin of LCA from the RSV was observed. Apart from that, the coronary arteries were not affected. Because coronary angiography reveals only two-dimensional views, coronary computed tomography angiography was performed to evaluate the detailed anatomy and course of the coronary arteries. A study was performed with ECG gating at 56–61 bpm using a retrospective acquisition technique. Anatomy and patency of coronary arteries was evaluated using dedicated coronary software. Coronary arteries and their braches were free of plaques, which might have caused significant stenoses and related symptoms. RSV was a source of short common trunk, which bifurcated into the right coronary artery (RCA) and LCA (Fig. 1). The RCA followed its typical anatomical course, and the LCA ran to the left, initially between the right ventricular outflow tract and ascending aorta, and subsequently within the basal anterior segment of the intraventricular septum (Fig. 2A, B). Intramuscular segment supplied the branch corresponding with the diagonal (D1) branch of left anterior descending artery (LAD) and a tiny branch that seemed to supply the intraventricular septum. Further segments of the LCA anatomically corresponding to the LAD ran in epicardial fat tissue giving an origin to the left circumflex artery and its obtuse marginal branches. The type of anomalous course of LCA described in our patient (inter-arterial) has the worst prognosis and is associated with sudden cardiac death (> 50%), especially connected with exercise. For that reason the case of our patient is also unusual. As a young woman she practiced athletics for several years. Her professional work was connected with great physical effort. And finally she gave birth to three children (forces of nature). None of these situations provoked any symptoms. At the time of writing, the state of the patient is stable, so she has been offered optimal medical treatment.

Patient with advanced coronary artery disease and psoriasis

A 67-year-old patient was admitted to the hospital due to the retrosternal pain appearing during moderately physical activity. An interview revealed the following: symptomatic angina pectoris, hypertension, diabetes type 2, and psoriasis with psoriatic arthritis for several years (Fig. 1). Laboratory results showed the following: elevated C-reactive protein, total cholesterol, and glycated haemoglobin. Electrocardiogram revealed the following: regular sinus rhythm, 68/min. Echocardiography: enlargement of the left ventricle with hypokinesis of the basal segment of the inferior wall and the septum, and ejection fraction 60%. Coronary angiography revealed the following: left main artery: minor changes; left anterior descending artery (LAD): aneurysmal extended, distally closed (Fig. 2), diagonal branch: closed; left circumflex artery: aneurysmal extended; 90% narrowing in first marginal branch (Fig. 3); right coronary artery: dominant, wide, 90% distally narrowing (Fig. 4); and posterior descending artery: closed. After the heart team consultation, the changes in coronary arteries were treated conservatively. Doppler ultrasound showed unobstructed both carotid arteries and intima–media thickness of 0.6 mm. An inflammatory process and hyperlipidaemia play roles in the development of atherosclerosis. Psoriasis is a chronic inflammatory disease that belongs to the dermatosis group. Its aetiology includes: genetic factors, vascular changes, and immunological phenomena, as well as environmental factors. The pathophysiology is associated with the inflammatory pathway response of cytokines released by Th1 and Th17 lymphocytes. Patients with psoriasis have increased risk of coronary artery disease (CAD); in this group the probability of myocardial infarction is significantly increased. Moreover, in coronary angiography up to 84% of patients had atherosclerotic lesions vs. 75% observed in the control group. Atherosclerotic lesions in LAD were observed more frequently compared with the general population, and their intensity correlated with the duration of the psoriasis. The inflammatory process is the connecting element between these two diseases. In the pathogenesis of psoriasis one of the main roles is played by the immune processes with the cascade of cytokines released by Th1 and Th17 lymphocytes (TNF-a, IFN-g, IL-17, IL-12, IL-2, and IL-23). The activation of Th1 and its mediators (INF-g, TNF-a, IL-1, IL-12, and IL-18) play a role in the pathogenesis of atherosclerosis. IL-12 and IFN-g are the elements connecting these diseases. European Society of Cardiology guidelines list psoriasis as an independent risk factor for CAD. A key role is attributed to the immune process, especially T-helper response. Patients with concomitant psoriasis and CAD represent an uncommon and complicated group of patients who require significant cardiovascular prevention. It is also worth noting that such patients are good candidates for omega-3 fatty acids supplementation, which is known for both cardiovascular prevention and improvement of psoriasis symptoms. Figure 1. Psoriasis in the joints and nails of both hands

Effect of unilateral catheter-based renal sympathetic denervation in a patient with resistant hypertension.

A 52-year-old woman was admitted to the Department of Hypertension with resistant hypertension coexistent with type 2 diabetes mellitus, two episodes of transient ischaemic attack in the past, and obesity. The patient’s arterial hypertension was uncontrolled on six antihypertensive medications. A denervation procedure Simplicity cathether (Medtronic) was applied. In the main left renal artery, six ablations were performed without any complications. During the first ablation of the main right renal artery, oedema of the arterial wall with a significant stenosis of 80% occurred. Due to the above, no further ablations were attempted. A follow-up arteriography of the right renal artery was performed 24 h later, showing a minimal stenosis in the previously affected area. On the qualification visit, the average office blood pressure (BP) was 203.33/107.66 mm Hg, and on ambulatory BP monitoring mean BP was 189/109 mm Hg in the day and 139/77 mm Hg in the night. In the central BP measurement (Sphygmocor, AtCor Medical), systolic BP was 172 mm Hg, diastolic BP — 98 mm Hg, augmentation index (AIx) — 40, AIx standarised to a heart rate of 75 bpm (AIx@HR75) — 40% (Fig. 1A). In the follow-up visits after six and 12 months, we observed significant falls in all measured parameters (Table 1, Fig. 1B). There was no modification of antihypertensive therapy in the follow up. There are just a few publications concerning unilateral renal denervation, and the presented results are contradictory. The measurement of central BP in hypertensive patients is of increasing interest because of both its predictive value for cardiovascular events and the differential effect of antihypertensive therapies compared to brachial BP. In our opinion, central BP should be considered as a valuable and objective marker of the effectiveness of invasive therapies. Our case shows that even unilateral renal ablation can be fully successful and decrease BP values to a remarkable extent in a 12 month observation.