Barbara Uznańska-Loch

Left Atrial Dysfunction Assessed by Two-Dimensional Speckle Tracking Echocardiography in Patients with Impaired Left Ventricular Ejection Fraction and Sleep-Disordered Breathing.

To evaluate the relationship between left atrial (LA) structure and deformation obtained by two‐dimensional speckle tracking echocardiography (2DSTE): peak longitudinal systolic strain (LAs), peak longitudinal systolic strain rate (LAS‐SR), peak longitudinal early diastolic strain rate (LAE‐SR), peak longitudinal late diastolic strain rate (LAA‐SR), and sleep‐disordered breathing (SDB) estimated by means of apnea–hypopnea index (eAHI).

Evaluation of the impact of atmospheric pressure in different seasons on blood pressure in patients with arterial hypertension.

OBJECTIVES Atmospheric pressure is the most objective weather factor because regardless of if outdoors or indoors it affects all objects in the same way. The majority of previous studies have used the average daily values of atmospheric pressure in a bioclimatic analysis and have found no correlation with blood pressure changes. The main objective of our research was to assess the relationship between atmospheric pressure recorded with a frequency of 1 measurement per minute and the results of 24-h blood pressure monitoring in patients with treated hypertension in different seasons in the moderate climate of the City of Łódź (Poland). MATERIAL AND METHODS The study group consisted of 1662 patients, divided into 2 equal groups (due to a lower and higher average value of atmospheric pressure). Comparisons between blood pressure values in the 2 groups were performed using the Mann-Whitney U test. RESULTS We observed a significant difference in blood pressure recorded during the lower and higher range of atmospheric pressure: on the days of the spring months systolic (p = 0.043) and diastolic (p = 0.005) blood pressure, and at nights of the winter months systolic blood pressure (p = 0.013). CONCLUSIONS A significant inverse relationship between atmospheric pressure and blood pressure during the spring days and, only for systolic blood pressure, during winter nights was observed. Int J Occup Med Environ Health 2016;29(5):783-792.

Circumferential strain of carotid arteries does not differ between patients with advanced coronary artery disease and group without coronary stenoses

PURPOSE Speckle tracking echocardiography is widely used for the analysis of myocardial function. Recently, circumferential strain (CS) of carotid arteries was postulated as novel indicator of vascular function. Our aim was to characterize and compare CS of carotid arteries in patients with advanced coronary artery disease and controls without significant coronary stenoses. PATIENTS/METHODS We compared CS of both common carotid arteries (CCA) in the 25 patients with three-vessel coronary artery disease (3VD) (mean age 69±9 years, 9 male) and in 16 age-matched subjects without significant coronary lesions (C) (69±8 years, 7 male). Additionally in 11 patients we estimated pulse wave velocity (PWV) and assessed the correlation between PWV and CS. Short-axis images of arteries were acquired for strain analysis with linear probe of echocardiograph. The assessment of CS was performed off-line by two observers. RESULTS The intraobserver variability for the CS (coefficient of variation) were 4.9 and 5.4% for left and right CCA and interobserver variability were 11.7% and 12.5%, respectively. The mean CS for left and right CCA did not differ between compared groups. We did not find correlation between CS strain and PWV. The only difference was related to the more prevalent plaque presence and thicker intima-media complex (IMT) in 3VD (p=0.0039 for IMT of left CCA and p=0.016 for IMT of right CCA). CONCLUSIONS The global CS of CCA, contrary to IMT, did not allow for differentiation between 3VD and C subjects. Despite good feasibility and concordance of CS measurements its clinical significance remains to be established.

Cardiotoxic effect due to accidental ingestion of an organic solvent.

Toxic myocardial injury can be misdiagnosed as a myocardial infarction, resulting in the patient undergoing standard treatment for cardiac rehabilitation. However, such inadequate therapeutic strategies can lead to cardiovascular complications including dilated cardiomyopathy. This study presents a case of a 65-year-old man after accidental ingestion of organic solvents (toluene and xylene), whose condition demonstrated all the criteria for diagnosis of myocardial infarction. The qualitative determinations of the above mentioned volatile organic compounds (VOCs) in whole blood were carried out using a headspace sampling by means of gas chromatography. Cardiac catheterization revealed no specific coronary lesions, only a muscular bridge causing a 30-50% stenosis in the middle of the circumflex branch of the left coronary artery.

Non-invasive detection of concomitant coronary artery anomaly and atherosclerotic coronary disease using transthoracic Doppler echocardiography.

The prevalence of coronary artery anomalies (CAA) is reported to be 1% in the general population [1]. The symptoms vary from clinically silent course to angina pectoris, syncope, arrhythmias, myocardial infarction and sudden cardiac death. Although coronary angiography remains a gold standard for the evaluation of coronary anatomy, modern echocardiography offers additional diagnostic opportunities, including assessment of proximal coronary anatomy, flow and coronary flow reserve in a variety of clinical conditions [2–6]. However, experience with echocardiography in patients with concomitant coronary anomalies and atherosclerotic diseases is rather limited. We report a case of a 69-year-old man, with angina and ventricular arrhythmia, in whom we successfully applied echocardiographic imaging modalities to demonstrate an abnormal course of the circumflex coronary artery and identify coronary stenosis-related flow abnormalities. A 69-year-old man was admitted to our hospital in February 2007 with chest pain on minor exertion, radiating to left arm and to the back, aggravating over the last month. Similar, less intense pain had been observed for 3 months. Concomitant history included pharmacologically controlled hypertension, type 2 diabetes mellitus with polyneuropathy, hypercholesterolaemia, peripheral artery disease, depression and benign prostatic hypertrophy. Admission ECG was unremarkable except for a few ventricular premature beats. Admission blood pressure was 130/85. Echocardiography revealed a minor systolic dysfunction: hypokinesis of mid- and apical segments of the lateral and posterior wall, with left ventricular ejection fraction of 58%. The left atrium was enlarged to 45 mm and the left ventricular mass index was increased to 141 g/m2. Mitral inflow was pseudonormal with E/A ratio 1.2. There was a mild commissural fusion of the aortic valve cusps, without significant motion impairment, a peak velocity of 1.7 m/s and trace of regurgitation. Serum concentrations of troponin I and CK-MB were within normal limits. Exercise treadmill test (Bruce procedure) elicited no angina but was electrographically positive with ST segment depression in leads V4-6 at 7 METS workload. In 24-h Holter ECG monitoring 6518 ventricular premature beats but neither complex arrhythmia nor significant ST segment changes were recorded. Transthoracic echocardiography (GE, Vivid 7 Dimension; transducer M4S) of coronary arteries showed abnormal findings in the left coronary ostium, with calcifications and accelerated turbulent flow consistent with high-degree stenosis (Figure 1). Diastolic flow was accelerated to 1.3 m/s. Non-invasive Doppler transthoracic coronary flow reserve (CFR) was measured according to the standard technique, in the distal left anterior descending (LAD) coronary artery during 12 mg adenosine injection, yielding an abnormally low value of 1.4. Figure 1 The arrows indicate stenosis of the left coronary ostium, detected in angiography and transthoracic echocardiography. In the panel below – normal distal left anterior descending coronary artery LAD – left anterior descending coronary artery, ... Subsequently, the abnormal coronary artery ostium was visualized in the right sinus of Valsalva, continuous with a vessel running retroaortically, consistent with the anomalous circumflex coronary artery course (Figure 2). Distal circumflex stenosis was not detectable using transthoracic echocardiography (TTE). Figure 2 The arrows show anomalous circumflex coronary artery running retroaortically, in the right panels the flow detected by Doppler echocardiography. Below: angiography of the circumflex coronary artery originating next to the right coronary artery and separate ... Coronary angiography revealed 90% ostial stenosis of the left coronary artery, with the absence of origin of the circumflex branch (CX); the distal LAD coronary artery was normal. The circumflex coronary artery originated next to the right coronary artery, running in an inferior direction, reaching its proper course after 3-4 cm; the CX was narrowed to 90%. The right coronary artery was narrow and tortuous.The patient was referred to cardiac surgery for coronary artery bypass grafting. Our report indicates that state-of-the-art, high-end TTE allows the evaluation of coronary anatomy and coronary flow reserve, facilitating the assessment of anomalous coronary arteries combined with advanced coronary artery disease. Non-invasive data are complementary to standard angiographic findings. Angiography remains a gold standard for the evaluation of coronary anatomy. However, in some cases, echocardiography may suggest an initial diagnosis. State-of-the-art transthoracic examination is nowadays powerful enough to aid in the assessment of coronary anomalies as the ostia and proximal course can usually be visualized [7–9]. Carefully performed investigation may identify coronary disease in clinically silent or unclear cases, especially in proximal arterial segments. Coronary artery anomalies may be clinically silent but often cause symptoms such as angina pectoris, syncope, arrhythmias, myocardial infarction, and sudden cardiac death. Importantly, coronary anomalies constitute the second most common cause of sudden cardiac death in young athletes. Particularly dangerous and potentially lethal variants involve Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery), with 80-85% mortality in the first year of life or CX coursing between the aorta and pulmonary trunk as well as the right coronary artery originating from the left sinus of Valsalva. Circumflex branch originating from the right coronary artery (RCA) or the right sinus of Valsalva is the most common CAA, found in 0.48% of the population of patients undergoing angiography [10]. Abnormal CX may begin with a separate (37%) or common (23%) origin with the RCA or arise from a proximal segment of the RCA (40%) [11]. Abnormal retroaortic segment of the vessel seems to be particularly predisposed to atherosclerosis but may be successfully treated with coronary angioplasty. On the other hand, CX origin from non-coronary sinus is a unique anomaly, detectable by transoesophageal echocardiography, which has been reported as a useful method allowing tomographic visualization of proximal coronary arteries. Preliminary diagnosis of coronary artery anomaly on the basis of echocardiographic examination allows one to reduce contrast and radiation exposure during angiography and thus possibly avoid some complications including contrast-induced nephropathy [12]. Patients with clinically significant type of CAA may benefit from appropriate medical or surgical treatment. Transthoracic echocardiography may be used for efficient postoperative outcome evaluation and long-term follow-up. High-quality echocardiographic visualization of the stenotic arterial site allows quantification based on turbulent flow detection, velocity [13, 14] and lumen diameter measurement, and functional tests (stress echocardiography). Transthoracic examination is proven to be an accurate method to evaluate coronary artery diameter in patients with healthy coronary arteries [15]. At least doubling of maximal flow velocity within stenosis with regard to maximal flow velocity proximal to stenosis or local maximal flow velocity > 1.5 m/s is proposed to be a reliable sign of > 50% coronary artery stenosis. When coronary angiography reveals LAD stenosis of intermediate severity, the measurement of CFR using transthoracic Doppler provides assessment of its functional importance with CFR value > 2 justifying postponement of interventional treatment. Coronary flow reserve is thus a useful method for functional assessment of complex coronary pathophysiology. The limitations of our report include the lack of invasive assessment of fractional flow reserve (FFR) in the LAD and CX, which would be interesting to compare with echocardiographic CFR measurements. It must be noted that distal CX stenosis was not detectable in transthoracic echocardiography. In conclusion, coronary angiography remains a gold standard for the evaluation of coronary anatomy. Nevertheless, carefully performed transthoracic echocardiographic examination of coronary arteries may be considered as a complementary non-invasive method providing extended physiological information and enabling non-invasive follow-up in selected patients.

Genetic variants in a Polish population of patients with pulmonary arterial hypertension: sequencing of BMPR2, ALK1, and ENG genes

BACKGROUND Pulmonary arterial hypertension (PAH) is a rare disease with a very serious prognosis. It seems that mutations in genes related to transforming growth factor-b signalling pathway are often related to the development of the disease. No study covers this problem in a Polish population. AIM To screen for genetic mutations in a Polish cohort of patients with pulmonary hypertension, especially with idiopathic PAH, treated in a single hospital in Poland. METHODS DNA sequencing method was used. Samples from 50 patients with pulmonary hypertension were screened for mutations in type 2 bone morphogenetic protein receptor of the transforming growth factor-b superfamily gene (BMPR2). Samples from 20 patients with idiopathic PAH (11 men, mean age 55 years) were also screened for mutations in activin A receptor-like type 1 gene (ALK1) and endoglin gene (ENG). RESULTS No genetic variations were found for the BMPR2 gene. In all 20 samples from idiopathic pulmonary hypertension patients we found heterozygosity of single nucleotide polymorphism (SNP) rs 372023206 in ALK1 gene. Three samples from these patients showed variations of ENG gene: we found one sample with heterozygosity of SNP rs 200525684, one with heterozygosity of SNP rs 3739817, and one with both. CONCLUSIONS We detected benign polymorphisms or genetic variants of unknown importance. It is possible that the Polish population of PAH patients differs from the previously described populations of other countries in terms of the frequency and importance of mutations in BMPR2, ALK1 and ENG genes.

Diabetes as an independent predictor of left ventricular longitudinal strain reduction at rest and during dobutamine stress test in patients with significant coronary artery disease

Aims Diabetes (DM) is a strong cardiovascular risk factor modifying also the left ventricular (LV) function that may be objectively assessed with echocardiographic strain analysis. Although the impact of isolated DM on myocardial deformation has been already studied, few data concern diabetics with coronary artery disease (CAD), especially in all stages of dobutamine stress echocardiography (DSE). We compared LV systolic function during DSE in CAD with and without DM using state-of-the art speckle-tracking quantification and assessed the impact of DM on LV systolic strain. Methods and results DSE was performed in 250 patients with angina who afterwards had coronarography with ≥50% stenosis in the left main artery and ≥70% in other arteries considered as significant. In this analysis, we included 127 patients with confirmed CAD: 42 with DM [DM(+); mean age 64 ± 9 years] and 85 patients without DM [DM(-); mean age 63 ± 9 years]. The severity of CAD and LV ejection fraction (EF) were similar in both groups. Global and regional LV peak systolic longitudinal strain (PSLS) revealed in all DSE phases lower values in DM(+) group: 14.5 ± 3.6% vs. 17.4 ± 4.0% at rest; P = 0.0001, 13.8 ± 3.9% vs. 16.7 ± 4.0% at peak stress; P = 0.0002, and 14.2 ± 3.1% vs. 15.5 ± 3.5% at recovery; P = 0.0432 for global parameters, although dobutamine challenge did not enhance further resting differences. LV EF, body surface area, and diabetes were independent predictors for strain in 16-variable model (R2 = 0, 51, P < 0.001). Conclusion PSLS although diminished in both groups with CAD was lower in diabetics at all DSE stages, and DM was an independent predictor of this impairment. However, the dobutamine challenge did not deepen the resting differences, suggesting that the direct impact of coronary stenoses effaces the influence of DM during DSE. The comparison with our previous data revealed synergistic, detrimental effect of coexisting CAD and DM on myocardial strain.

Arrhythmic manifestation of peripartum cardiomyopathy-Case report

We report a case of 26‐year‐old woman, with arrhythmic manifestation of peripartum cardiomyopathy with moderate heart failure. Ventricular arrhythmia recorded in ambulatory Holter ECG (premature ventricular contractions) was most severe during pregnancy, reduced when beta‐blocker therapy was initiated and almost completely resolved after delivery. Then, 1 year after hospitalization in Cardiology Department, recurrence was observed with recorded short episode of nonsustained ventricular tachycardia.

HOPE-3 — „nowa nadzieja” dla polypill?

Opisano wyniki waznego badania HOPE-3 (Heart Outcomes Prevention Evaluation), w ktorym testowano efekty leczenia stalą dawką leku hipolipemizującego (rosuwastatyna 10 mg) i polączenia kandesartanu i hydrochlorotiazidu o dzialaniu hipotensyjnym w grupie pacjentow cechujących sie średnim ryzykiem sercowo-naczyniowym. Wyniki potwierdzają bezpieczenstwo i skutecznośc obnizenia stezenia cholesterolu frakcji LDL statyną, a korzyści z terapii hipotensyjnej, zgodnie z oczekiwaniami, byly zawezone do jedynie 1/3 pacjentow z wyzszymi wartościami ciśnienia tetniczego.

Advanced and traditional electrocardiographic risk factors in pulmonary arterial hypertension: the significance of ventricular late potentials

BACKGROUND Whether non-invasive electrocardiographic parameters may be of similar relevance in pulmonary arterial hy-pertension (PAH) as in left ventricular heart failure (LVHF) remains unclear. AIM To examine a profile of electrocardiographic parameters in PAH and to determine their prognostic significance. Com-parison of profile in patients with pulmonary hypertension secondary to left ventricular dysfunction was planned in order to put PAH group results into context. METHODS We included 41 patients with type 1.1/1.4.4 (according to the European Society of Cardiology) PAH and 31 patients with LVHF and type 2.1 pulmonary hypertension. All patients underwent 24-h ambulatory electrocardiography monitoring. RESULTS Among heart rate variability parameters, only RMSSD was different (mean, 75 ms [PAH] vs. 112 ms [LVHF], p = 0.016). In PAH, fewer patients had ventricular tachycardia (15% vs. 48%, p = 0.004), abnormal deceleration capacity (54% vs. 84%, p = 0.011), positive heart rate turbulence (11% vs. 48%, p = 0.003), severe autonomic failure (10% vs. 39%, p = 0.005), and ventricular late potentials (LP) (19% vs. 62%, p = 0.001). In PAH, four deaths occurred in 42 months. In univariate analysis, the risk factors for death were: LP (hazard ratio 13.55, 95% confidence interval 1.41-130.72; p = 0.024), age, N-terminal prohormone of B-type natriuretic peptide, while the protective factors were minimal and mean heart rate, as well as the six-minute walk test (6MWT) distance. In multivariate analysis, the influence of LP and the 6MWT distance remained significant. CONCLUSIONS Ventricular LP were present in 19% of PAH patients and were the most powerful risk factor of mortality .