Beata Wożakowska-Kapłon

Efficacy of biphasic shock for transthoracic cardioversion of persistent atrial fibrillation: Can we predict energy requirements?

Although electrical cardioversion of atrial fibrillation (AF) is frequently performed, initial energy requirements for cardioversion of persistent AF is still a matter of debate. The aim of the study was to determine the efficacy of biphasic shocks for transthoracic cardioversion of persistent AF and to predict adequate initial energy. A prospective study enrolled 94 consecutive patients with persistent AF, who were referred for elective cardioversion with a biphasic waveform. The paddles were placed in the anterolateral position. A step‐up protocol was used to estimate the cardioversion threshold. The initial shock energy was 50 J, with subsequent increments to 100, 200, and 300 J in the event of cardioversion failure. The mean age of the study group was of about 65 years (6 ± 11 years) and a median duration of AF was 65 days (3–324). Sixty‐two out of 94 patients were men, 55% of the study population was classified as having well‐controlled hypertension. The overall success rate of cardioversion was 89%, with a mean 2.2 ± 1.4 shocks, and effective J 217.8 ± 113 delivered during repeated cardioversions. The success rate of low energy shocks: 50 and 50 +100 J was 51%. By logistic regression analysis the only independent predictor of success at low energy shock was shorter duration of AF (r =−0.51; P = 0.02). Patients with shorter duration of AF have a higher probability for successful cardioversion with low energy. In patients with longer AF duration, a 200 J shock should be considered for cardioversion as the initial energy. (PACE 2004; 27[Pt. I]:764–768)

Concomitant recovery of atrial mechanical and endocrine function after cardioversion in patients with persistent atrial fibrillation.

OBJECTIVES The purpose of this study was to evaluate left atrial mechanical function recovery and plasma atrial natriuretic peptide (ANP) release following successful cardioversion of persistent atrial fibrillation (AF). BACKGROUND Atrial fibrillation is characterized by functional deterioration, loss of atrial contraction, and elevation of plasma ANP levels. The response of ANP release toward atrial mechanical function after cardioversion of AF has not been fully examined. METHODS We examined 29 patients with successfully cardioverted persistent AF in whom sinus rhythm was maintained for at least 30 days after cardioversion. We assessed mechanical function of the left atrium at 24 h and 7 and 30 days after cardioversion and evaluated plasma ANP level at the same time. Atrial mechanical function was assessed during echocardiographic examination by means of the peak velocity of the transmitral A-wave, early transmitral to atrial flow velocity ratio, and atrial filling fraction (AFF). The plasma ANP level was determined by the radioimmunoassay method. RESULTS Plasma ANP levels were significantly reduced from 59.4 +/- 16.6 pg/ml to 31.1 +/- 9.2 pg/ml at 24 h after successful cardioversion. Within 30 days, we noted progressive improvement of atrial systolic function (increase in AFF from 21% to 31%, p < 0.05). At the same time, plasma ANP levels gradually increased from 31.1 +/- 9.2 pg/ml at 24 h to 36.9 +/- 12.8 pg/ml on day 30 following cardioversion (p < 0.05). CONCLUSIONS Plasma ANP levels significantly decreased in patients with persistent AF after successful cardioversion. In the 30 days after cardioversion, gradual elevation of plasma ANP concentration was observed concomitantly with an increase of AFF. Plasma ANP release after successful cardioversion of persistent AF might be due to recovery of atrial mechanical function.

Atrial natriuretic peptide level after cardioversion of chronic atrial fibrillation

UNLABELLED Heart endocrine studies concerning patients with chronic atrial fibrillation (AF) have become increasingly important. Atrial natriuretic peptide (ANP) is released from atrial myocytes. The increased level of ANP in patients with AF is probably caused by the hemodynamic effect of the arrhythmia. The aim of this study was to explore plasma ANP levels in patients with chronic AF and to describe plasma ANP concentration changes following sinus rhythm (SR) restoration. The study group was comprised of 42 patients, aged between 43 and 76 years with chronic AF (more than 1 month) and a relatively controlled ventricular response (85.8+/-11.3 beats/min). Plasma ANP levels were measured before and 24 h after AF cardioversion. The control group comprised of 11 subjects. All had normal SR without history of AF and were compatible in age, sex and concomitant diseases with the examined group. ANP level values were expressed as mean+/-standard deviation. The mean plasma ANP level in the AF group was significantly higher than in the control group (59.5+/-15.6 vs. 34.3+/-10.2 pg/ml, P<0,001). Electrical or pharmacological cardioversion was performed in 42 patients. SR was successfully restored in 35 patients. Plasma ANP concentrations decreased significantly from baseline values (from 59.4+/-16.6 to 31.4+/-15.0 pg/ml, P<0.001) 24 h after cardioversion in the successful group, while they remained unchanged (60.2+/-10.7 to 59.4+/-10.4 pg/ml, NS) in patients with an unsuccessful cardioversion. CONCLUSION The mean concentration of ANP in patients with chronic AF was nearly two-times higher than in the control group with sinus rhythm. Conversion to SR was associated with a significant decrease and normalization in plasma ANP concentrations.

Serum troponin I and myoglobin after monophasic versus biphasic transthoracic shocks for cardioversion of persistent atrial fibrillation.

This study compared the effects of standard monophasic versus biphasic direct current shocks for cardioversion of atrial fibrillation (AF) on the release of cardiac troponin I (cTnI) and myoglobin (Myo). We randomized 48 patients with persistent AF (mean age = 61.4 ± 10.7 years, 33 men) to monophasic (45.2%) or biphasic (54.8%) cardioversion. Plasma concentrations of cTn1 and Myo were measured before, and 6 and 24 hours after the procedure. Cardioversion was significantly more effective (88% vs 100%, P < 0.04) and required less energy (348.1 ± 254.1 vs 187.6 ± 105.3 J; P < 0.001) in the biphasic than the monophasic group. A significant increase in mean plasma cTnI concentration over 24 hours (0.23 ± 0.18 vs 0.41 ± 0.37 ng/mL, P < 0.04), and mean Myo concentration were recorded in the monophasic group over the first 6 hours following the procedure (38.2 ± 14.2 vs 221.9 ± 51.3 ng/mL, P < 0.001), whereas no significant increase was observed in the biphasic group. Increases in cTnI and Myo in the monophasic group correlated closely with the cumulative energy delivered (Spearman correlation coefficient r = 0.58, P = 0.004 for Myo and r = 0.67, P < 0.001 for cTnI). In addition, there was a positive correlation between cumulative cardioversion energy load and increase in Myo and cTnI indexed with left ventricular mass (r = 0.45, P < 0.02 for Myo and r = 0.47, P = 0.01 for cTnI). It is concluded that in cardioversion of AF, biphasic are more effective than monophasic and may cause less myocardial injury.

An Increase in Plasma Atrial Natriuretic Peptide Concentration During Exercise Predicts a Successful Cardioversion and Maintenance of Sinus Rhythm in Patients with Chronic Atrial Fibrillation

The aim of this study was to determine the value of an increase in plasma atrial natriuretic peptide (ANP) concentrations during submaximal exercise as a predictor of return of sinus rhythm (SR), and of its maintenance over a period of 6 months after cardioversion (CV) of chronic atrial fibrillation (AF). The study group included 42 patients with AF (mean duration 7 ± 7 months) and a controlled ventricular rate. They underwent submaximal exercise testing 24 hours before CV. Blood samples were collected at rest and at peak of exercise for measurement of plasma ANP concentrations. Thirty‐five of 42 patients were successfully cardioverted to SR. At 6 months, 23 patients remained in SR, while 12 had recurrence of AF. The plasma ANP concentrations before CV increased insignificantly during exercise in patients with unsuccessful CV or with recurrence of AF (60.8 ± 17.3 pg/mL to 64 ± 13.5 pg/mL, NS). The mean increase in plasma ANP concentration during exercise was significantly greater in the 23 patients who remained in SR than in the 19 patients unsuccessfully cardioverted or with recurrence of AF (17.5 ± 7.6 pg/mL vs 5.8 ± 4.5 pg/mL, P < 0.01). In multivariate logistic regression analysis, an increase in ANP plasma concentration was independently associated with successful CV and maintenance of SR up to 6 months of observation. In patients with chronic AF an exercise‐induced increase in ANP concentration predicts successful CV and maintenance of SR.

The Influence of Left Ventricle Diastolic Function on Natriuretic Peptides Levels in Patients with Atrial Fibrillation

Background: The diagnosis of the impaired left ventricle (LV) diastolic function during atrial fibrillation (AF) using traditional methods is very difficult. Natriuretic peptides seem to be useful for assessment of diastolic function in patients with AF.

A Decrease in Serum Aldosterone Level is Associated with Maintenance of Sinus Rhythm after Successful Cardioversion of Atrial Fibrillation

Background: The activation of the renin–angiotensin–aldosterone system has been implicated in the progression of atrial structural remodeling during atrial fibrillation (AF). However, consequences of the changes of aldosterone in AF have not been evaluated.

Changes in plasma natriuretic peptide levels in patients with atrial fibrillation after cardioversion

UNLABELLED The aim of the study was to assess changes in plasma natriuretic peptide (NP) levels after spontaneous or electrical cardioversion (CV) in patients with paroxysmal or persistent atrial fibrillation (AF). METHODS Patients with paroxysmal or persistent AF with normal left ventricular function and controlled heart rate, referred for electrical CV, were enrolled prospectively. NP concentrations were measured by means of radioimmunoassay method. RESULTS We studied 23 patients with paroxysmal and 77 with persistent AF, spontaneously or electrical cardioverted to sinus rhythm. The mean plasma NP levels were increased in AF patients, ANP: 249±88.3 pg/ml and 258±89.7 pg/ml vs 67±21.2 pg/ml; (p<0.001) and BNP: 99.6±29.8 pg/ml and 82.3±33 pg/ml vs 37.5±13 pg/ml; in the paroxysmal, persistent, and control group, respectively. The mean ANP and BNP levels decreased after sinus restoration from 249.0±88.3 pg/ml to 70.1±13 pg/ml, and from 99.6±29.8 pg/ml to 37.4±8.4 pg/ml, respectively, in the paroxysmal group; from 257.7±89.7 pg/ml to 150.0±87.2 pg/ml and from 82.3±33 pg/ml to 63.7±28.6 pg/ml in the persistent AF group. NP levels remained stable for the next 30 days in the group of patients who remained in sinus rhythm. CONCLUSION Plasma NP concentrations are significantly reduced or normalized after sinus rhythm restoration in patients with paroxysmal and persistent AF and remain stable within 4 weeks of follow-up, provided that AF does not recur.

Oral health status and the occurrence and clinical course of myocardial infarction in hospital phase: A case-control study

BACKGROUND Periodontitis may contribute to destabilization of atherosclerotic plaque leading to acute coronary syndrome and myocardial infarction (MI). The aim of the paper was to evaluate the state of the oral cavity and test the association between chosen parameters of acute, hospital phase MI in patients aged 60 and younger. METHODS We examined patients with acute MI, age 60. Control group consisted of matched group of patients with stable angina. Patients enrolled in the study underwent dental, cardiovascular and biochemical examination. Left ventricular ejection fraction (LVEF) was measured during echocardiographic examination, intima-media thickness (IMT) was assessed by ultrasonographic examination at the same time. RESULTS The case group included 112 hospital patients with acute MI. Patients with acute MI were characterized by higher level of cardiovascular disease risk factors and poor oral health status in comparison to the control group. There was higher prevalence of edentulousness (p = 0.0039) and advanced periodontal disease (APD) (p < 0.0001) in the case group than in the control group. Patients with edentulousness and APD were characterized by the highest levels of fi brinogen, interleukine-6, tumor necrosis factor-a, increased IMT and numerous atherosclerotic plaques. Logistic regression analysis revealed association between biomarkers of myocardial injury, LVEF and chosen periodontal parameter (API, CAL, PDI, BI) and edentulousness. CONCLUSIONS Poor oral health status, especially periodontal disease may infl uence on the occurrence and clinical course of MI.

Clinical and angiographic characteristics of coronary artery disease in young adults: a single centre study

BACKGROUND Coronary artery disease (CAD) in young adults under 40 years of age is a growing medical, social, psychological and economical problem, related to the prevalence of civilization-related diseases and unhealthy lifestyle. The problem of CAD in young people has not been characterised as well as in older individuals, as the available data mostly come from case reports and small series, often related to genetic aspects and familial occurrence of the disease. AIM To assess clinical and angiographic characteristics of young adults with CAD and to evaluate in-hospital and long-term mortality in this patient group. The study combined a retrospective and a prospective approach. METHODS A total of 239 patients aged 40 years or younger who underwent coronary angiography (CAG) in the Swietokrzyskie Centre of Cardiology in Kielce in 2001-2008 were included in this study. Demographic characteristics, risk factor profile, laboratory test results, electrocardiographic and echocardiographic findings, CAG findings, and in-hospital mortality were assessed retrospectively in the selected groups. During the second stage of the study, clinical and mortality data were obtained prospectively in 130 patients (54.4% of the study group) during up to 5 years of follow-up. RESULTS The mean patient age was 35.1 ± 4.4 years. Men made up 86.2% of the study sample, and the proportion of rural area residents was 54.8%. Among young patients with acute coronary syndromes (ACS), the most common presentation (52.8%) was ST segment elevation myocardial infarction (STEMI). Angiographically normal coronary arteries were found in 37.2% of CAD patients and in 16.9% of patients with the diagnosis of ACS. The mean degree of coronary artery lumen stenosis was 75.4% in the group with significant atherosclerotic coronary lesions (50-90%) and 95.9% in the group demonstrating a critical coronary obstruction (≥ 90%). Single-vessel disease was identified in 61.9% of patients with a positive result of CAG (stenosis > 50%, CORO(+) group). The most common location of significant atherosclerotic coronary lesions was the left anterior descending artery (61.6%) followed by the right coronary artery (27.4%). The most prevalent conventional cardiovascular risk factors were lipid abnormalities, cigarette smoking and an increased body mass index ≥ 25 kg/m2, followed by a family history of CAD and hypertension. The proportion of patients with abnormal lipid profile, cigarette smoking and overweight or obesity was particularly high in the CORO(+) group (85.6%, 83.9%, and 64.4%, respectively). In-hospital mortality rate was low, at 0.7% among ACS patients. Long-term mortality during up to 5 years of follow-up was not so favourable, at 7.75% in ACS patients and 8.5% in the CORO(+) group. CONCLUSIONS The population of young patients with CAD is predominantly male, rural, and characterised by a low socio-economic status. The aetiology of CAD in this patient group differs significantly from that in older patients and it is often associated with an unhealthy lifestyle related to rapid civilization changes. The rates of CAD risk factors in young adults are high and the most important risk factors are dyslipidaemia, smoking, and overweight/obesity. Single vessel disease and STEMI presentation were predominant in young patients. Short-term prognosis in young ACS patients is excellent, but long-term prognosis is significantly worse. Further studies on CAD in young adults are warranted, particularly in larger patient populations.