Grzegorz Karpinski

The incidence of asymptomatic paroxysmal atrial fibrillation in patients treated with propranolol or propafenone

Anti-arrhythmic therapy for paroxysmal atrial fibrillation leads to complete symptomatic relief in a number of patients. The elimination of symptoms may be associated either with a complete elimination of arrhythmia or with a conversion of symptomatic atrial fibrillation into asymptomatic episodes of arrhythmia. The aim of the study was to evaluate the occurrence of asymptomatic paroxysmal atrial fibrillation in 52 patients treated with propafenone (35 drug trials) or propranolol (34 drug trials) by means of ambulatory ECG Holter monitoring. Propafenone was clinically effective (complete relief of symptoms) in 26 (74%) patients. However, in 7 cases (27%) asymptomatic episodes of arrhythmia were still recorded when awake. In patients treated with propranolol clinical symptoms were absent in 18 (53%). However, in 4 (22%) patients attacks of paroxysmal atrial fibrillation were present. The mechanism of drug-induced conversion of symptomatic episodes of atrial fibrillation into asymptomatic spells of arrhythmia was a marked shortening in duration of episodes in 7 patients (from 2215 +/- 3843 s to 16 +/- 10 s, N.S.) or by a significant slowing of ventricular response during atrial fibrillation in 4 patients (from 125 +/- 27 to 84 +/- 8 beats/min, P = 0.05). In conclusion, in a significant proportion of patients with symptomatic paroxysmal atrial fibrillation asymptomatic episodes of arrhythmia may occur while on anti-arrhythmic drug therapy. Some of these patients, particularly those with other risk factors for stroke such as advanced age or the presence of organic heart disease, may require anti-coagulant therapy or change in anti-arrhythmic treatment, and can be selected on the basis of ambulatory ECG monitoring.

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.

Drug-Induced Long-QT Syndrome With Macroscopic T-Wave Alternans

A 51-year-old woman was admitted after resuscitation from cardiac arrest at home. She was defibrillated 5 times by an emergency team because of ventricular fibrillation. At admission, the patient was unconscious, intubated, and breathing sufficiently on her own. Blood pressure was 100/50 mm …

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.

Admission ST-segment elevation in lead aVR as the factor improving complex risk stratification in acute coronary syndromes

This study aimed to analyze the prognostic value of the presence of ST elevation in lead aVR [aVR(+)] in initial standard electrocardiogram (ECG) performed on admission in combination with clinical variables and Thrombolysis in Myocardial Infarction (TIMI) risk score for unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). In 205 consecutive patients with UA/NSTEMI, we retrospectively evaluated admission ECG for aVR(+) of more than 0.5 mm. With the use of multivariate analysis, admission aVR(+) was found to be a strong and independent predictor of 30-day mortality. Mortality also increased with the severity of aVR(+): 2.2%, 10.8%, 13.8%, 22.2%, 50% (P value for trend <.0001). In prespecified low-risk groups by clinical factors, those with aVR(+) had higher death rates than those without aVR(+): 16.1% vs 2.2% (P = .04), 13.9% vs 1.1% (P = .001), 12.4% vs 1.1% (P = .002), 9.6% vs 1.2% (P = .02), and 6.7% vs 0% (P = .05) for patients with negative troponin, heart rate of 110 beats per minute or less, systolic blood pressure greater than 90 mm Hg, Killip I class on admission, and age 70 years or younger, respectively. Patients with aVR(+) compared to patients without aVR(+) had higher death rates in the low- and intermediate-risk groups by TIMI risk score. Our findings suggest that aVR(+) has significant prognostic value in patients with UA/NSTEMI and may provide an additional prognostic value to the conventional cardiovascular risk factor, particularly in patients in the low-risk and intermediate-risk groups.

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.

Does time delay between the primary cardiac arrest and PCI affect outcome

Objectives — In patients with acute ST-segment elevation acute myocardial infarction (AMI), no data are available on the prognostic value of cardiac arrest (CA) due to ventricular fibrillation (VF) before, during, and after percutaneous coronary intervention (PCI).The aim of our study was to determine differences in prognosis between patients with CA before, during, and after PCI. Methods — Among 448 patients with first ST-segment elevation AMI, we selected 34 (7.6%) with primary CA due to VF and 6 (1.3%) with secondary CA. The patients with primary CA were categorized into groups according to the time of the first episode of the primary CA, either before [12 (35.3%)], during [18 (52.9%)], or after [4 (11.8%)] PCI procedure.The 30-day all-cause mortality rate was analysed. Results — Short-term mortality was: (i) in patients without CA: 7.1% (29/408); (ii) in patients with primary CA 35.3% (12/34); (iii) in patients with secondary CA 50% (3/6); (P < 0.001). Mortality was 8.3% (1/12) in patients with primary CA before PCI; 44.4% (8/18) in patients with primary CA during PCI; 75% (3/4) in patients with primary CA after PCI procedure; (P = 0.007). Conclusions — Patients with a primary CA have the same poor prognosis as patients with a secondary CA. The prognosis worsened according to the time of the occurrence of the primary CA. It might be reasonable to isolate subgroups of ST-segment elevation AMI patients treated with PCI with primary CA according to time of primary CA.This could help to better stratify the risk of these patients.

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.

Prognostic value of B-type natriuretic peptide levels on admission in patients with acute ST elevation myocardial infarction

Objective — To assess the relation between B-type natriuretic peptide (BNP) levels on admission in ST elevation myocardial infarction (STEMI) and short-term, all-cause mortality. Methods and results — Blood samples for BNP determination were obtained on admission in 88 patients (mean age 60.6 ± 10.7 years old) with STEMI. In a 15-minute period, BNP was measured by using simple bedside test for rapid quantification of BNP. Thirty days follow-up was performed. During the period of follow-up 12 (13.6%) patients died. Mean BNP was 228.74 ± 269.98 pg/ml.The lowest value was 5 pg/ml, the highest value 1300 pg/ml due to limitations of the method.The baseline level of BNP was higher among patients who died than among those who were alive at 30 days (mean, 545.6 vs. 178.7 pg/ml; P = 0.001). Mortality increased among patients in increasing quartiles (p = 0.009). The unadjusted odds ratio for 30-day risk of death in the fourth quartile was 5.6 (95 percent confidence interval, 1.6 to 20.5; P < 0.001).When BNP was added to a multivariate Cox regression model including clinical and electrocardiographic variables, BNP levels were independently associated with the prognosis. Conclusions — BNP levels obtained on admission are a powerful, independent indicator of shortterm mortality in patients with STEMI. Rapid tests for BNP assay seem to be a new tool in risk stratification of patients with STEMI.