Bartosz Puchalski

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.

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.

Evaluation of endothelial function and arterial stiffness in HIV-infected patients: a pilot study.

BACKGROUND In the era of combination antiretroviral therapy (cART), life expectancy of HIV-infected patients is the same as that of the general population, resulting in increasing prevalence of cardiovascular disease in this patient group. AIM To assess the prevalence of endothelial dysfunction in HIV-infected patients and to identify factors which affect endothelial function and arterial stiffness. METHODS Thirty-seven adult HIV-infected patients, regardless of the fact and the type of cART, were enrolled into the study. In patient, reactive hyperaemia peripheral arterial tonometry assessment was performed using the Endo-PAT2000 device (ITAMAR®). This method allows evaluation of endothelial function ant arterial stiffness. RESULTS Final analysis included 37 patients (median age 38 years, range 32-45 years), including 89.2% men. Endothelial dysfunction was found in 13 (35.1%) HIV-infected patients. We found no differences in demographic and clinical characteristics, laboratory data, and cardiovascular drug therapy between patients with or without endothelial dysfunction, except for platelet count which was higher in patients with endothelial dysfunction (174 [119-193] × 10³/mm3 vs. 222 [168-266] × 10³/mm³, p = 0.03). No demographic or clinical variables were identified as predictors of endothelial dysfunction in HIV-infected patients. In addition, no association was found between factors related to HIV infection, chronic drug therapy and the risk of endothelial dysfunction. Statistically significant correlations were found between arterial stiffness and age (rs = 0.53, p < 0.001), red blood cell count (rs = -0.39, p = 0.018), and platelet count (rs = 0.42, p = 0.009). CD4+ and CD8+ lymphocyte count and viral load were similar in patients with or without endothelial dysfunction. Arterial stiffness was significantly higher in patients with higher viral load (rs = -0.39, p = 0.0018) and in those with established AIDS (9.5 [1.0-16.0] vs. -5 [-10-5], p = 0.009). cART had no effect on endothelial dysfunction, while arterial stiffness was higher in patients treated with cART (10 [0-15] vs. -5 [-10-3], p = 0.014). CONCLUSIONS Endothelial dysfunction is common in HIV-infected patients. In general, none of the analysed factors had an effect on endothelial function but cART had a negative effect on arterial stiffness.

The prevalence of sexual dysfunction before myocardial infarction in population of Polish men: a retrospective pilot study.

BACKGROUND AND AIM To assess the frequency of sexual dysfunction in men before myocardial infarction (MI). METHODS Sixty-two men with cardiovascular disease risk factors who were admitted to the hospital because of a first MI, were asked to fill the IIEF-15 questionnaire to assess sexual dysfunction before MI. RESULTS Erectile dysfunction (ED), decreased orgasmic function, decreased sexual desire, decreased intercourse satisfaction, and decreased overall satisfaction were reported by 51.6%, 14.5%, 50%, 69.4%, and 48.4% of men, respectively. Men with ED had significantly higher serum C-reactive protein (CRP) levels than men without ED (5.8 mg/L, 95% confidence interval [CI] 8.3-21.7) vs. 4.6 mg/L, 95% CI 3.0-11.3; p = 0.01). Men with decreased orgasmic function had significantly higher serum triglyceride levels (259.5 mg/dL, 95% CI 176.9-362.1 vs. 150 mg/dL, 95% CI 146.8-187.4; p = 0.01), and men with normal sexual desire had significantly higher serum high-density lipoprotein (HDL) cholesterol levels than men with decreased sexual desire (41 mg/dL, 95% CI 39.9-47.8 vs. 36 mg/dL, 95% CI 34.1-40.5; p = 0.01). Men with decreased sexual desire had significantly higher serum CRP levels (7 mg/L, 95% CI 7.7-21.4 vs. 5 mg/L, 95% CI 3.6-12.1; p = 0.03). CONCLUSIONS 1. ED was present in more than half of men before MI and it may be the first symptom of coronary artery disease. 2. Men with ED and decreased sexual desire have higher serum CRP levels in the acute peri-infarction period. 3. Serum triglyceride level is a factor that significantly affects orgasmic function, and serum HDL cholesterol level is a factor that significantly affects sexual desire.

Long QT interval in a patient after out-of-hospital cardiac arrest with hypocalcaemia, undergoing therapeutic hypothermia

A 53-year-old woman was hospitalized after out-of-hospital cardiac arrest due to ventricular fibrillation. Initial electrocardioagram showed sinus rhythm of 117 beats per minute, 452 ms QTc interval, ST-segment depression up to 1 mm in V(2)-V(6), and ST-elevation in lead aVR. Patient was treated with primary coronary angioplasty and therapeutic hypothermia, during which QTc interval prolonged up to 616 ms and Osborn wave was seen in lead V(4), along with elevation of ST-segment in I, II, III, aVF, V(5) and V(6); negative T waves in I, II, aVL, aVF, and V(2)-V(6). Laboratory test results showed hypocalcaemia. After rewarming and ion correction QT abnormalities resolved.

The effects of CD4 nadirs on vessel stiffness in HIV patients undergoing antiretroviral therapy

BACKGROUND There are many factors associated with human immunodeficiency virus (HIV) patients having a greater risk of cardiovascular diseases (CVD). HIV damages vessel endothelium through chronic inflammation, which, combined with dys-lipidaemia, arterial hypertension, and antiretroviral therapy leads to the progression of atherosclerotic changes. AIM Our goal was to determine if a CD4 nadir along with immunological, inflammatory, biochemical, and metabolic mark-ers can be associated with higher vessel stiffness and therefore an increased risk of CVD in patients undergoing antiretroviral therapy for HIV. METHODS Endothelial damage was evaluated in 20 patients (including four female) during successful antiretroviral therapy. We assessed the endothelial stiffness by recording the reactive hyperaemia of peripheral arteries using an Endo-PAT2000 (ITAMAR®) device. This device allowed us to measure the arterial tonometry and to determine the augmentation index for a pulse rate of 75/min (AI@75). We set the normal value for vessel stiffness at reactive hyperaemia index (RHI) > 1.67, as recommended by the manufacturer. Additionally, we recorded the length of antiretroviral therapy, number of CD4 lymphocytes, CD4 nadir, HIV viremia, and biochemical and immunologic results. Finally, we compared patients with normal and dysfunctional endothelium. RESULTS The only parameter significantly differentiating between the group with and group without endothelium dysfunction was platelet count (p = 0.012). CONCLUSIONS We were not able to confirm the significance of a CD4 nadir in the progression of endothelial stiffness in HIV patients. However, platelet values could be an important complementary marker for assessing the risk for CVD amongst HIV patients undergoing antiretroviral treatment.

Acute myocarditis complicated by pulmonary embolism

Zapalenie mieśnia sercowego jest chorobą, ktora moze prowadzic do ciezkiej niewydolności serca (HF). Objawy ze strony ukladu sercowo-naczyniowego zazwyczaj są poprzedzone infekcją. Procesy autoimmunologiczne toczące sie w miokardium prowadzą do uszkodzenia kardiomiocytow i aktywacji wielu procesow zapalnych. Rozpoznanie ustala sie na podstawie danych z wywiadu, badania przedmiotowego i badan obrazowych: echokardiografii oraz rezonansu magnetycznego serca (CMR). Biopsje endomiokardialną wykonuje sie w sytuacji podejrzenia zapalenia olbrzymiokomorkowego, braku odpowiedzi na standardową terapie oraz w przypadkach o piorunującym przebiegu. Mezczyzne w wieku 28 lat przyjeto do Kliniki z powodu narastającej duszności i ograniczenia tolerancji wysilku. Z wywiadu wynikalo, ze chory przebyl prawostronne zapalenie pluc 2 miesiące przed przyjeciem. W badaniach laboratoryjnych stwierdzono nieznacznie podwyzszone parametry stanu zapalnego: bialko C-reaktywne 13,2 mg/l. W zapisie elektrokardiograficznym (EKG) stwierdzono rytm zatokowy miarowy, ujemne zalamki T w odprowadzeniach II, III, aVF, V3–V6. W badaniu echokardiograficznym (ECHO) uwidoczniono zaburzenia kurczliwości pod postacią akinezy ściany przedniej i dolnej, cześci przegrody miedzykomorowej oraz hipokineze pozostalych ścian lewej komory (LV), z frakcją wyrzutową LV (LVEF) 18%, a takze krew echogenną w LV. Na podstawie wyniku CMR rozpoznano zapalenie mieśnia sercowego w fazie aktywnej. Do leczenia wlączono prednizolon, karwedilol, ramipril, eplerenon, suplementacje potasu i kwas acetylosalicylowy, uzyskując poprawe stanu ogolnego pacjenta. W kontrolnym ECHO stwierdzono poprawe kurczliwości mieśnia LV i wzrost LVEF do 35%. W ramach dalszej diagnostyki wykonano tomografie klatki piersiowej z kontrastem, stwierdzając drobne skrzepliny w obrebie tetnic segmentalnych — rozpoznano zatorowośc plucną niskiego ryzyka. W czasie kolejnej hospitalizacji, ktora miala miejsce po okolo miesiącu od poprzedniej, wykonano koronarografie, w ktorej nie uwidoczniono zmian miazdzycowych w tetnicach wiencowych. W kontrolnych ECHO stwierdzono uogolnioną hipokineze mieśnia LV, z LVEF 19%, oraz umiarkowaną, czynnościową niedomykalnośc mitralną (ERO 0,2 cm2, MRvol 22 ml, VC 4–5 mm). W 24-godzinnym monitorowaniu pracy serca metodą Holtera zarejestrowano liczne komorowe zaburzenia rytmu pod postacią par, bigeminii, trigeminii komorowych oraz epizodow nieutrwalonych czestoskurczow komorowych (ryc. 1). Wszczepiono uklad kardiowertera-defibrylatora w ramach prewencji pierwotnej naglego zgonu sercowego. W badaniu ergospirometrycznym wykazano obnizoną wydolnośc fizyczną wynikającą z HF, a na podstawie parametrow VE/VCO2slope (31,5) oraz PETCO2 (32 mm Hg) stwierdzono podwyzszone ryzyko sercowo-naczyniowe. Pacjenta wypisano w stanie poprawy z zaleceniem stalej opieki w Poradni Kardiologicznej. Zapalenie mieśnia sercowego moze miec rozny przebieg kliniczny: od niewielkiej dysfunkcji skurczowej miokardium az do ciezkiej HF wymagającej transplantacji narządu. U wiekszości chorych reakcja autoimmunologiczna na patogen zostaje stlumiona, jednak u niektorych osob trwające procesy zapalne mogą doprowadzic do pozapalnej postaci kardiomiopatii rozstrzeniowej. Związek miedzy infekcjami wirusowymi powodującymi reakcje zapalne a wystepowaniem zatorowości plucnej przedstawiono w pracy Abgueguena i wsp. (Clin Infect Dis, 2013; 36: 134–139), w ktorej omowiono 2 przypadki infekcji wirusem cytomegalii w powiązaniu z zatorowością plucną. Interesujących spostrzezen dokonano w badaniu obejmującym 22 pacjentow z zatorowością plucną, u ktorych stwierdzono obecnośc komorek zapalnych w mieśniu prawej i lewej komory, z towarzyszącymi cechami miocytolizy charakterystycznymi dla zapalenia mieśnia sercowego.

The use of an automated external defibrillator in a victim of car accident

Early identification of the emergency, early cardiopulmonary resuscitation (CPR), and early defibrillation are crucial for improving survival rates of out-of-hospital cardiac arrest. Various educational programmes and campaigns have been implemented to improve knowledge of basic life support techniques in the general public. Alongside education comes technological advances. Automated external defibrillators (AED) are now more widely available in public spaces including shopping malls, train stations, airports etc. Many paramedical organisations such as volunteer mountain rescue services or other uniformed services have their cars equipped with AED. Statistics show that an increasing number of bystanders, even without any medical training, are using AEDs in emergency settings, performing, in many cases successful, CPR. We report the case of a 37-year-old male who was hit by a car on a pedestrian crossing at dusk. Help was immediately introduced by bystanders, one of whom was a uniformed services officer whose vehicle was equipped with an AED. As a result of the accident, the victim suffered cardiac arrest. Witnesses immediately took steps of basic life support protocol (chest compressions and mouth-to-mouth ventilation), and used AED. The device correctly recognised a shockable rhythm (ventricular tachycardia) and issued appropriate voice commands. After charging the capacitor, the AED delivered energy of 120 J, after which the bystanders, according to the recommendations of the AED, immediately began indirect heart massage. AED-assisted CPR lasted for a total of 15 min, until paramedics arrived on the scene and introduced advanced life support. Other recorded cardiac arrest rhythms showed that defibrillation should not be performed and finally resuscitation was unsuccessful, which was later shown to be due to multiorgan damage and massive blood loss. Fragments of electrocardiogram recorded by AED are shown in Figures 1 and 2. Guidelines of the European Resuscitation Council strongly stress the role of the ‘Chain of Survival’ in the management of cardiac arrest patients. The first three links in the Chain: recognition with a call for help, CPR, and defibrillation, are extremely time-sensitive. With every minute of delay, the chances of a favourable outcome drop dramatically. Early recognition and introduction of CPR by bystanders can be improved solely by the education of people, but the third link depends strongly on availability of defibrillator. Since their introduction in 1979, AEDs have slowly become part of the urban landscape. They have been shown to be extremely safe, with a close-to-zero rate of inappropriate intervention, and have dramatically improved survival rates when they are implemented early. The use of AED is reasonable in all cases of cardiac arrest including traumatic and non-traumatic reasons. In traffic accidents, victims’ potential causes of cardiac arrest include cardiac combustion (for example by blunt trauma caused by the steering wheel), pulmonary oedema or blood loss. In many cases, these causes are potentially treatable and reversible, especially in young, otherwise healthy individuals. The present case, even though CPR was finally unsuccessful, illustrates that increasing the availability of AEDs in public spaces, and as in this case in uniformed services vehicles, is necessary and can potentially save lives.