Jacek Kowalczyk

Mid-term outcomes of triple-site vs. conventional cardiac resynchronization therapy: a preliminary study.

BACKGROUND The primary objectives of this study were to compare the implantation course of triple-site (double left-single right) and conventional cardiac resynchronization devices. The secondary target was to assess mid-term outcomes of both types of cardiac resynchronization therapy (CRT). METHODS Fifty-four patients with NYHA classes III-IV, left ventricular EF<or=35% and QRS>or=120 ms were included; 27 received triple-site pacemakers (TRIV group), 27 conventional CRT devices (BIV group). Procedural course, clinical data, QRS duration, echocardiographic parameters, peak oxygen consumption (VO2max) and 6-minute walking distance (6MWD) were screened for inter-group differences. RESULTS Procedure duration was higher in TRIV than in BIV group (197.6 vs. 137.6 min, P<0.001), fluoroscopy exposure and complication-rates were similar. After 3 months of CRT, triple-site pacing was associated with a more significant (P<0.05) NYHA class reduction (by 1.4 vs. 1.0 class, respectively), increase in VO(2) max (2.9 vs. 1.1 mL/kg/min) and 6MWD (98.7 vs. 51.6 m) than conventional CRT. A higher EF and more improved intraventricular synchrony were observed in the TRIV than in the BIV group. The response rate in the TRIV group was 96.3% vs. 62.9% in the conventional group (P=0.002). Triple-site stimulation was an independent predictor of response to CRT (adjusted odds ratio 26.4, P=0.01). CONCLUSIONS Triple-site resynchronization appears to be more beneficial than conventional CRT. Upgrade to triple-site CRT may be considered in non-responders to standard resynchronization.

Effect of Anemia in High-Risk Groups of Patients With Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention

The significance of anemia in patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention (PCI) remains controversial. The aim of the present study was to evaluate the effect of anemia on the short- and long-term prognosis of patients with AMI treated with PCI, including high-risk subgroups. The study group consisted of 1,497 consecutive patients with AMI treated in the acute phase with PCI. Anemia was defined using World Health Organization criteria (hemoglobin level <13 g/dl for men and <12 g/dl for women). The study population was divided into 2 major groups (patients with [n = 248, 16.6%] and without [n = 1,249, 83.4%] anemia) and 6 subgroups (diabetes mellitus, impaired renal function, age >70 years, left ventricular dysfunction, incomplete revascularization, and multivessel disease). A comparative analysis was performed between both groups within the whole population and within the particular subgroups. Significantly greater 30-day (13.2% vs 7.3%), 1-year (20.5% vs 11.3%), and total (24.1% vs 12.7%; all p <0.05) mortality rates were observed in the anemic group. Multivariate analysis identified anemia as an independent predictor of any-cause death in the whole population during the observation period (covariate-adjusted hazard ratio 1.46, 95% confidence interval 1.31 to 1.61, p <0.05). Anemia was significantly associated with excessive long-term mortality in the multivessel disease group (adjusted hazard ratio 1.54, 95% confidence interval 1.34 to 1.74) and in the incomplete revascularization group (hazard ratio 1.67, both p <0.05). In conclusion, anemia on admission in patients with AMI treated in the acute phase with PCI was independently associated with increasing short- and long-term mortality, especially in the subgroups with incomplete revascularization and multivessel disease.

A Common Variant in Low-Density Lipoprotein Receptor–Related Protein 6 Gene (LRP6) Is Associated With LDL-Cholesterol

Objective—A rare mutation in low-density lipoprotein receptor-related protein 6 gene (LRP6) was identified as the primary molecular defect underlying monogenic form of coronary artery disease. We hypothesized that common variants in LRP6 could predispose subjects to elevated LDL-cholesterol (LDL-C). Methods and Results—Twelve common (minor allele frequency ≥0.1) single nucleotide polymorphisms in LRP6 were genotyped in 703 individuals from 213 Polish pedigrees (Silesian Cardiovascular Study families). The family-based analysis revealed that the minor allele of rs10845493 clustered with elevated LDL-C in offspring more frequently than expected by chance (P=0.0053). The quantitative analysis restricted to subjects free of lipid-lowering treatment confirmed the association between rs10845493 and age-, sex-, and BMI-adjusted circulating levels of LDL-C in families as well as 2 additional populations − 218 unrelated subjects from Silesian Cardiovascular Study replication panel and 1138 individuals from Young Men Cardiovascular Association cohort (P=0.0268, P=0.0476, and P=0.0472, respectively). In the inverse variance weighted meta-analysis of the 3 populations each extra minor allele copy of rs10845493 was associated with 0.14 mmol/L increase in age-, sex-, and BMI-adjusted LDL-C (SE=0.05, P=0.0038). Conclusions—Common polymorphism in the gene underlying monogenic form of coronary artery disease impacts on risk of LDL-C elevation.

Prognostic Significance of Hyperuricemia in Patients with Different Types of Renal Dysfunction and Acute Myocardial Infarction Treated with Percutaneous Coronary Intervention

Aim: This study evaluated the impact of hyperuricemia (HUR) on outcome in patients with different types of impaired renal function (IRF) and acute myocardial infarction (AMI) treated invasively. Methods: Out of 3,593 consecutive AMI patients treated invasively, 1,015 IRF patients were selected. The IRF group consisted of patients with baseline kidney dysfunction (BKD group) and/or patients with contrast-induced nephropathy (CIN group). HUR was defined as a serum uric acid concentration (SUAC) >420 µmol/l (>7 mg/dl). Independent predictors of death and major adverse cardiovascular events (MACE) were selected by the multivariate Cox-regression model. Results: Remote mortality rates were higher in HUR patients: IRF (32.7 vs. 18.6%), BKD (41.3 vs. 25.9%), CIN (35.4 vs. 16.7%); all p < 0.001. HUR was an independent predictor of death in BKD (hazard ratio (HR) 1.38, p < 0.05). Each 100-µmol/l increase in SUAC was associated with a significant increase of HR for mortality: 1.087 in IRF patients, 1.108 in BKD patients, 1.128 in CIN patients; all p < 0.05. Remote major adverse cardiovascular event rates were higher in HUR patients: IRF (55.4 vs. 48.9%), CIN (56.8 vs. 48%); both p < 0.05. Conclusions: In AMI patients treated invasively, an increase in SUAC is an independent predictor of death within all types of renal dysfunction; HUR defined as SUAC >420 µmol/l (>7 mg/dl) is a predictor only in BKD patients.

Effect of Type of Atrial Fibrillation on Prognosis in Acute Myocardial Infarction Treated Invasively

To assess the incidence of atrial fibrillation (AF) and the clinical impact of AF types on outcomes in patients with acute myocardial infarction (AMI) treated invasively, we analyzed 2,980 consecutive patients with AMI admitted to our department from 2003 through 2008. Data collected by the insurer were screened to identify patients who died during the median follow-up of 41 months. AF was recognized in 282 patients (9.46%, AF group); the remaining 2,698 patients (90.54%) were free of this arrhythmia (control group). The AF group was divided into 3 subgroups: prehospital paroxysmal AF (n = 92, 3.09%), new-onset AF (n = 109, 3.66%), and permanent AF (n = 81, 2.72%). In-hospital and long-term mortalities were significantly higher (p <0.001 for the 2 comparisons) in the AF than in the control group (14.9% vs 5.3%, 37.2% vs 17.0%, respectively). Long-term mortality was significantly higher (p <0.001 for the 2 comparisons) in the new-onset AF (35.8%) and permanent AF (54.3%) groups than in the control group but did not differ significantly between the prehospital AF and control groups (21.7% vs 17.0%, p = NS). Considering types of arrhythmia separately, only permanent AF (hazard ratio 2.59) was an independent risk factor for death in the studied population. In conclusion, AF occurs in 1 of 10 patients with AMI treated invasively, with nearly equal distributions among prehospital, new-onset, and permanent forms. Although arrhythmia is a marker of worse short- and long-term outcomes, only permanent AF is an independent predictor for death in this population.

The prognostic value of different glucose abnormalities in patients with acute myocardial infarction treated invasively

BackgroundDiabetes (DM) deteriorates the prognosis in patients with coronary heart disease. However, the prognostic value of different glucose abnormalities (GA) other than DM in subjects with acute myocardial infarction (AMI) treated invasively remains unclear.AimsTo assess the incidence and impact of GA on clinical outcomes in AMI patients treated with percutaneous coronary intervention (PCI).MethodsA single-center, prospective registry encompassed 2733 consecutive AMI subjects treated with PCI. In all in-hospital survivors (n = 2527, 92.5%) without the history of DM diagnosed before or during index hospitalization standard oral glucose tolerance test (OGTT) was performed during stable condition before hospital discharge and interpreted according to WHO criteria. The mean follow-up period was 37.5 months.ResultsThe incidence of GA was as follows: impaired fasting glycaemia - IFG (n = 376, 15%); impaired glucose tolerance - IGT (n = 560, 22%); DM (n = 425, 17%); new onset DM (n = 384, 15%); and normal glucose tolerance – NGT (n = 782, 31%). During the long-term follow-up, death rate events for previously known DM, new onset DM and IGT were significantly more frequent than those for IFG and NGT (12.3; 9.6 and 9.4 vs. 5.6 and 6.4%, respectively, P < 0.05). The strongest and common independent predictors of death in GA patients were glomerular filtration rate < 60 ml/min/1,73 m^2 (HR 2.0 and 2.8) and left ventricle ejection fraction < 35% (HR 2.5 and 1.8, all P < 0.05) respectively.ConclusionsGlucose abnormalities are very common in AMI patients. DM, new onset DM and IGT increase remote mortality. Impaired glucose tolerance bears similar long-term prognosis as diabetes.

Stroke and death prediction with CHA2DS2-vasc score after myocardial infarction in patients without atrial fibrillation.

Aims The CHA2DS2-VASc score is widely used to stratify the risk of stroke in patients with nonvalvular atrial fibrillation. The aim of the study was to assess whether the CHA2DS2-VASc score might be useful to identify patients at a high risk of ischemic stroke and death among individuals after acute myocardial infarction and with no history of atrial fibrillation. Methods We analysed consecutive patients with acute myocardial infarction admitted to our centre between 2003 and 2008. On the basis of the CHA2DS2-VASc score, four groups were distinguished: low-risk (1 point), intermediate-risk (2–3 points), high-risk (4–5 points) and very high-risk (>5 points). Data on long-term follow-up were screened to identify patients who experienced stroke or died during remote observation. Results Out of 2980 registry participants, 333 were excluded because of atrial fibrillation and/or ongoing therapy with oral anticoagulants. Finally, 2647 individuals were included into the analysis. An ischemic stroke occurred in 71 (2.68%) patients, whereas 439 (16.58%) died during a median follow-up of 41.5 months. The risk of stroke and death increased four-fold in the high-risk group compared with the low-risk group (P < 0.001). Every point in the CHA2DS2-VASc score was independently associated with 41% increase in stroke risk and 23% increase in mortality rate (for both P < 0.001). Conclusion The mortality rate and risk of stroke were strongly associated with the CHA2DS2-VASc scores. Hence, this scoring system could be useful to identify high-risk patients with no history of atrial fibrillation, in whom additional preventive measures might be beneficial to improve the outcome.

Prospective evaluation of diagnostic work-up in syncope patients: results of the PL-US registry

AIMS Syncope is a common problem. Demographic and clinical characteristics of patients admitted to different types of centres may vary, physicians adherence to the guidelines has been examined only in a few studies, and the requirements for implantable loop recorders (ILR) have not been well defined. The aim of this study was to (i) compare demographic and clinical characteristics of patients with syncope diagnosed and treated in tertiary electrophysiology cardiac centres and those attending syncope units or general hospitals, (ii) assess how physicians adhere to the published guidelines, and (iii) calculate the requirement for ILR insertion. METHODS AND RESULTS In total, 669 consecutive patients with syncope, admitted to 18 electrophysiological cardiac tertiary centres over a mean of 3 months (range 1-10 months), entered a special Internet database called the PL-US (Polish patients with Unexplained Syncope) registry. Detailed demographic and clinical characteristics of the patients, including the results of all diagnostic tests performed, were analysed. Adherence to the guidelines was assessed, based on the published recommendations. The ILR implantation was indicated when (i) all other tests were inconclusive (unexplained syncope) and (ii) syncope associated with injury or presence of organic heart disease or past medical history and ECG suggesting arrhythmic syncope. Syncope of cardiac/arrhythmic origin was the most frequent diagnosis (53%), followed by reflex syncope (33%). Adherence to the guidelines was less than satisfactory-measurement of blood pressure in an upright position, carotid sinus massage, exercise testing, and electrophysiological study were underused, whereas prolonged ECG monitoring and neurological consultations were overused. Unexplained syncope had 58 (9%) patients, and 42 (72%) of them had indication for ILR which accounts for 6% of the whole study population. The calculated need for ILR was 222 implants/million inhabitants/year. CONCLUSION Patients with syncope admitted to the tertiary electrophysiology cardiac centres are a highly selected group of patients with syncope and differ in their characteristics as well as underlying diseases to those managed at general hospitals, outpatient clinics, or special syncope units. In Poland, the adherence to the published guidelines is far from satisfactory. At least 6% of all consecutive patients with syncope are candidates for ILR insertion.

Sleep apnoea as a predictor of mid- and long-term outcome in patients undergoing cardiac resynchronization therapy

AIMS To assess the impact of baseline apnoea-hypopnoea index (AHI) on mid-term outcome and its change after 6 months of cardiac resynchronization therapy (CRT) on remote outcome. METHODS AND RESULTS In 71 patients with CRT devices, Holter-derived AHI was assessed before and 6 months after the procedure. Baseline AHI >20 was considered abnormal. After 6 months of CRT, a 50% decrease of baseline AHI was considered significant and stratified patients into AHI dippers and non-dippers, except those who preserved normal AHI. Prognostic value of baseline AHI and its change were assessed in relation to mortality and major cardiac events (MACE). More patients with an abnormal AHI died during 6 months follow-up (P = 0.02), especially due to sudden cardiac death. MACE-rate was insignificantly higher in abnormal AHI patients. Significantly higher mortality (P = 0.001), especially due to heart failure progression and higher MACE-rate (P < 0.001) during further observation were observed in AHI non-dippers. In multivariate analysis, the absence of AHI reduction was an independent predictor of mortality [hazard ratio (HR) 6.56, P = 0.015)] and MACE (HR 6.05, P = 0.002). CONCLUSIONS Abnormal baseline AHI identifies patients prone to death during mid-term observation. Lack of AHI reduction after 6 months of CRT is an independent risk factor of death and MACE during further follow-up.

Quality of Life in Cardiac Resynchronization Recipients: Association with Response and Impact on Outcome

The prognostic impact of improvement in health‐related quality of life (QoL) and its relation to response in cardiac resynchronization therapy (CRT) recipients remains unknown.