Jacek Migaj

Does the influence of obesity on prognosis differ in men and women? A study of obesity paradox in patients with acute coronary syndrome

BACKGROUND Recent studies have reported the existence of obesity paradox in acute coronary syndromes (ACS). However, the occurrence of obesity paradox in men and women has not yet been thoroughly investigated, even though both genders differ in patterns and incidence of obesity. AIM Therefore, the aim of this study was to investigate whether obesity influence on outcomes of patients with ACS varies by gender. METHODS This retrospective study included 341 patients admitted to hospital for treatment due to ACS in 2012. They were classified according to the World Health Organisation with use of body mass index (BMI) as normal weight, overweight, and obese. All patients received standard discharge medication. All-cause mortality was assessed during a mean follow-up time of 212 ± 121 days. RESULTS There were 82 (24%) normal weight, 160 (47%) overweight, and 99 (29%) obese patients. There were 252 (73.9%) men. All-cause mortality was lower in the obese and overweight vs. normal weight male patients (1.4% vs. 3.3% vs. 13.1%, respectively, p = 0.009). There was a trend favouring the normal weight and obese vs. overweight women (4.8% vs. 3.6% vs. 17.5%, respectively, p = 0.103). In the general population, after adjustment, BMI increase by one reduced risk by 15.6% (p = 0.015), and obesity reduced risk by 50.8% (p = 0.056). Obesity reduced risk for men by 69.4% (p = 0.015), and BMI increase by one reduced risk for men by 22% (p = 0.002). BMI and obesity were independent prognostic factors in men, whereas no such phenomenon was observed in women. CONCLUSIONS Only male patients seem to contribute to the obesity paradox observed in patients with ACS. The obesity paradox does not occur in female patients when considered separately. Obesity seems to have a different influence on outcomes in both genders, and this might be worthy of further studies.

Initial clinical experience with the first drug (sacubitril/valsartan) in a new class — angiotensin receptor neprilysin inhibitors in patients with heart failure with reduced left ventricular ejection fraction in Poland

BACKGROUND Sacubitril/valsartan is the first drug from a new class of angiotensin receptor neprilysin inhibitors (ARNIs) recommended in the new European Society of Cardiology guidelines instead of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) that are used if ACEI are not tolerated. Sacubitril/valsartan is recommended for further reduction in the risk of hospitalisation or death in outpatients with heart failure with reduced ejection fraction (HFrEF) if symptoms continue despite optimal treatment with ACEI/ARB, beta-blockers, and mineralocorticoid antagonists. AIM The aim of this study is to present the initial experience with regard to the effectiveness, tolerance, and safety of sacubitril/valsartan in the outpatient cardiology practice in Poland. METHODS The study is a retrospective analysis of data obtained through a questionnaire filled in by the physicians who initiated the sacubitril/valsartan treatment in patients with HFrEF between 1 June 2016 and 30 September 2016. Patients were followed-up for three months. RESULTS The analysis included data on 28 patients aged 61 ± 16 years, of whom 85.7% were males. The drug was used in patients in New York Heart Association (NYHA) class I-III. In 25 (89.2%) patients sacubitril/valsartan was started at the lowest dose (24/26 mg BID). During follow-up the sacubitril/valsartan-treated patients had a reduction in HF symptoms assessed using the NYHA functional class (p = 0.001), a significant drop in N-terminal-pro B-type natriuretic peptide levels (mean, from 2900 to 2270 pg/mL; p = 0.008), and improved exercise tolerance, which occurred shortly after treatment initiation - after a mean of 28 days. CONCLUSIONS It was demonstrated that the use of sacubitril/valsartan in outpatients with HFrEF is safe and is associated with a significant clinical improvement.

Atypical presentation of cardiac device related infectious endocarditis and complicated follow-up

780 pneumonia. His medical history included pre‐ vious inferior wall myocardial infarction treat‐ ed with coronary artery bypass grafting, dual chamber implantable cardioverter ‐defibrillator (ICD) implanted as secondary prophylaxis, arte‐ rial hypertension, and type 2 diabetes. Empiri‐ cal antibiotic treatment was employed (ceftriax‐ one, rifampicin, and vancomycin). Echocardiog‐ raphy performed during hospitalization suggest‐ ed vegetations on the tricuspid valve. The patient was transferred to the Department of Cardiolo‐ gy with suspicion of LDIE. On admission, he had no fever, inflammato‐ ry parameters were as follows: C ‐reactive pro‐ tein, 10.30 mg/l (mild elevation); procalcitonin, 0.06 ng/ml (within normal limits). The suspicion of LDIE was confirmed using transthoracic echo‐ cardiography, which demonstrated vegetations on Infectious endocarditis (IE) is a potentially fa‐ tal disease that is difficult to diagnose. Patients often present with unspecific signs and symp‐ toms, which delays diagnosis and proper treat‐ ment. The incidence of IE in patients with car‐ diac implantable electronic devices is estimated at 1% to 2%.1 Cardiac device–related infections vary from pocket infection and lead ‐dependent IE (LDIE) to sepsis. A 51 ‐year ‐old man presented to the Depart‐ ment of Neurology with recurrent lower back pain, which started suddenly 2 months earli‐ er, and a considerable weight loss and conflu‐ ent sweats during 6 months prior to admission. Magnetic resonance imaging (MRI) of the lum‐ bar spine showed inflammation of L4/L5 inter‐ vertebral disc and L4 and L5 vertebral bodies (FIGURE 1A), and chest X ‐ray demonstrated bilateral CLINICAL IMAGE

Left ventricular noncompaction cardiomyopathy with severe coronary artery disease in a young patient with familial hypercholesterolemia

554 mmol/l; and triglycerides, 1.19 mmol/l; moreover, the patient had elevated levels of liver enzymes (alanine transaminase, 72 U/l; aspartate transaminase, 63 U/l) and brain natriuretic peptide (527.7 pg/ml). Troponin levels were within the reference range. Transthoracic echocardiography showed enlargement of the left atrium (48 mm) and the left and right ventricles (65 mm and 33 mm, respectively), with thin walls and restrictive flow through the mitral valve, with moderate mitral regurgitation and increased trabeculation of the apex and apical and mid segments of the lateral A 34-year-old man was admitted to the hospital because of worsening of exercise tolerance and exertional dyspnea for about 3 months, without chest pain. A medical history revealed familial hypercholesterolemia (FH) diagnosed 8 years earlier (also in his brother), which was treated with rosuvastatin (20 mg) and ezetimibe, to poor effect. On admission, an electrocardiogram showed sinus rhythm and left ventricular hypertrophy (FIGURE 1A). Laboratory tests showed the following lipid levels: total cholesterol, 8.19 mmol/l; low-density lipoprotein cholesterol, 5.9 mmol/l; high-density lipoprotein cholesterol, 1.76 CLINICAL IMAGE

Patients’ knowledge of heart failure and their perception of the disease

Purpose The aim of this study was to gain a deeper insight into patients’ perception of chronic heart failure (CHF) symptoms by analyzing their compliance with nonpharmacological recommendations. Patients and methods This was a prospective, single-center survey-based registry. Patients included in this study were hospitalized between December 2014 and January 2016 at the 1st Department of Cardiology, University Hospital of Lord’s Transfiguration, Poznań University of Medical Sciences, and had been diagnosed with CHF at least 3 months prior to inclusion. Participants were divided according to New York Heart Association (NYHA) functional class into mild CHF (NYHA I and II) and severe CHF (NYHA III and IV), and according to age into young (<50 years), middle-aged (50–70 years) and old (>70 years). The survey included information about the patients’ sex, age, education, length of the illness and 12 questions about their perception of CHF. This study included 201 patients. The mean age was 58±15 years. Results The younger the patients, the more often they thought that CHF is curable. The patients presenting with severe CHF tended to think that CHF is incurable significantly more often than those with mild CHF. Most of the patients considered loss of appetite, cough and vomiting the least alarming symptoms. Significantly more patients with severe CHF exercised less and reported reduced sexual activity more often in comparison to the mild CHF patients. Most of the young patients reported no changes to their sexual activity, body mass index (BMI) or exercise after diagnosis of CHF. Most of the old patients exercised less than before diagnosis of CHF. Significantly more middle-aged patients reduced their BMI, quit smoking and reported lower sexual activity after diagnosis of CHF in comparison to the other groups. Conclusion Patients need to be better educated about the nature of CHF and the importance of lifestyle changes.

Significant stenosis of the left anterior descending artery in a young woman without cardiovascular risk and with above-average physical activity

Address for correspondence: Marta Kałużna-Oleksy, MD, PhD, 1st Department of Cardiology, University of Medical Sciences, ul. Długa 1/2, 61–848 Poznań, Poland, e-mail: marta.kaluzna@wp.pl Conflict of interest: none declared Kardiologia Polska Copyright

Is there a Place for the Fullerton Test in Evaluation of Heart Failure Patients? The Relationship between Exertional Gas Exchange Parameters and Functional Fitness in Patients with Heart Failure: A Pilot Study

Background: To minimize the effect of heart failure (HF) on quality of life and to reduce the economic burden, it is necessary to provide means of rehabilitation and prognosis evaluation for patients. Patients with severe HF might not be able to perform the most commonly used cardiopulmonary exercise test (CPET), even using the easiest protocols. The Fullerton functional fitness test, developed for the elderly, might be suitable for evaluation of such patients. Our aim was to determine relationship between functional fitness and exertional gas exchange parameters in HF patients, and if they performed worse in functional fitness tests than patients without HF. Methods: Twenty-one male patients were included in this prospective registry; twelve with HF and nine without. They underwent the standard Fullerton test; the six-minute-walk test (6MWT; patient walks for six minutes along a corridor, and the distance covered is measured; it is a submaximal exercise test for healthy individuals) was modified by using a portable CPET device to record exertional gas exchange parameters. Results: The HF patients had lower left ventricular ejection fraction and were younger; they presented significantly worse “chair sit-and-reach” results (-0.18 vs. 1.81 cm, p=0.041) and 6-minute walking distance (334.8 vs. 508.4 m, p=0.002), less exercise repetitions in “chair stand” (10.7 vs. 15.1, p<0.001) and “arm curl” (13 vs. 16.8, p<0.001), longer time to perform “8-foot up-and-go” (7.1 vs. 5.6 s, p=0.030), higher VE/VCO2 slope (34.1 vs. 29, p=0.005), and tended to present lower peak oxygen uptake parameters (VO2/kg 11.8 vs. 14, p=0.13; VO2 0.99 vs. 1.22, p=0.10; VO2 as percentage of predicted 43.1 vs. 55.4, p=0.14). 6 MWT, “chair stand” and “arm curl” showed the strongest correlations with AT VE/VCO2 (r=-0.58, p=0.006; r=-0.57, p=0.007; r=-0.62, p=0.003 respectively) and VE/VCO2 slope (r=-0.60, p=0.004; r=-0.52, p=0.015; r=-0.50, p=0.021 respectively) and VO2 as percentage of predicted (r=0.59, p=0.005; r=0.55, p=0.009; r=0.47, p=0.031 respectively); 6MWT correlated strongly with VO2/kg (r=0.61, p=0.004). Conclusion: HF patients perform worse in the Fullerton test than patients without HF. Physical fitness is related to CPET parameters taken during 6MWT. Lower physical fitness is related to lower exercise capacity and worse ventilatory efficiency. The Fullerton test may be useful in complex evaluation of HF patients.

Pierwsze doświadczenia kliniczne z przedstawicielem nowej grupy leków ARNI (sakubitril/walsartan) u pacjentów z niewydolnością serca z obniżoną frakcją wyrzutową lewej komory w Polsce

BACKGROUND Sacubitril/valsartan is the first drug from a new class of angiotensin receptor neprilysin inhibitors (ARNIs) recommended in the new European Society of Cardiology guidelines instead of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) that are used if ACEI are not tolerated. Sacubitril/valsartan is recommended for further reduction in the risk of hospitalisation or death in outpatients with heart failure with reduced ejection fraction (HFrEF) if symptoms continue despite optimal treatment with ACEI/ARB, beta-blockers, and mineralocorticoid antagonists. AIM The aim of this study is to present the initial experience with regard to the effectiveness, tolerance, and safety of sacubitril/valsartan in the outpatient cardiology practice in Poland. METHODS The study is a retrospective analysis of data obtained through a questionnaire filled in by the physicians who initiated the sacubitril/valsartan treatment in patients with HFrEF between 1 June 2016 and 30 September 2016. Patients were followed-up for three months. RESULTS The analysis included data on 28 patients aged 61 ± 16 years, of whom 85.7% were males. The drug was used in patients in New York Heart Association (NYHA) class I-III. In 25 (89.2%) patients sacubitril/valsartan was started at the lowest dose (24/26 mg BID). During follow-up the sacubitril/valsartan-treated patients had a reduction in HF symptoms assessed using the NYHA functional class (p = 0.001), a significant drop in N-terminal-pro B-type natriuretic peptide levels (mean, from 2900 to 2270 pg/mL; p = 0.008), and improved exercise tolerance, which occurred shortly after treatment initiation - after a mean of 28 days. CONCLUSIONS It was demonstrated that the use of sacubitril/valsartan in outpatients with HFrEF is safe and is associated with a significant clinical improvement.

Initial clinical experience with the first drug (sacubitril/valsartan) in a new class — ARNIs in patients with heart failure with reduced left ventricular ejection fraction in Poland

BACKGROUND Sacubitril/valsartan is the first drug from a new class of angiotensin receptor neprilysin inhibitors (ARNIs) recommended in the new European Society of Cardiology guidelines instead of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) that are used if ACEI are not tolerated. Sacubitril/valsartan is recommended for further reduction in the risk of hospitalisation or death in outpatients with heart failure with reduced ejection fraction (HFrEF) if symptoms continue despite optimal treatment with ACEI/ARB, beta-blockers, and mineralocorticoid antagonists. AIM The aim of this study is to present the initial experience with regard to the effectiveness, tolerance, and safety of sacubitril/valsartan in the outpatient cardiology practice in Poland. METHODS The study is a retrospective analysis of data obtained through a questionnaire filled in by the physicians who initiated the sacubitril/valsartan treatment in patients with HFrEF between 1 June 2016 and 30 September 2016. Patients were followed-up for three months. RESULTS The analysis included data on 28 patients aged 61 ± 16 years, of whom 85.7% were males. The drug was used in patients in New York Heart Association (NYHA) class I-III. In 25 (89.2%) patients sacubitril/valsartan was started at the lowest dose (24/26 mg BID). During follow-up the sacubitril/valsartan-treated patients had a reduction in HF symptoms assessed using the NYHA functional class (p = 0.001), a significant drop in N-terminal-pro B-type natriuretic peptide levels (mean, from 2900 to 2270 pg/mL; p = 0.008), and improved exercise tolerance, which occurred shortly after treatment initiation - after a mean of 28 days. CONCLUSIONS It was demonstrated that the use of sacubitril/valsartan in outpatients with HFrEF is safe and is associated with a significant clinical improvement.

Digoxin is associated with increased risk of death in heart failure patients treated with beta-blockers. Results from Polish part of ESC HF Long-Term Registry

BACKGROUND Digoxin is used in the treatment of atrial fibrillation (AF) and heart failure (HF). It was reported to increase the risk of death in HF. Studies on digoxin are based mainly on patients treated some years ago, before the era of common b-blocker use. AIM This study aims to show the influence of digoxin in a modern cohort of HF patients on top of the contemporary guideline-directed treatment. METHODS This study retrospectively analyses the Polish part of the European Society of Cardiology Heart Failure Long-Term Registry. It includes 912 patients treated for HF between February 2012 and January 2013, and followed until May 2014. At baseline, 19.1% took digoxin, 89.6% angiotensin convertase enzyme inhibitors or angiotensin receptor blockers, 91.9% b-blockers, and 69.4% mineralocorticoid receptor antagonists. RESULTS Digoxin is associated with increased risk of death after adjustment for significant covariates in patients who have HF with reduced ejection fraction (HFrEF) but no AF history (hazard ratio [HR] 2.52, 95% confidence interval [CI] 1.23-5.19; p = 0.011), and it does not influence significantly the risk of hospitalisation (adjusted HR 1.46, 95% CI 1.05-1.72; p = 0.11). Digoxin use shows no significant association with the risk of death or hospitalisation in patients with AF and HFrEF or HF with preserved ejection fraction (HFpEF). Patients on digoxin present a significantly worse clinical status with lower left ventricular ejection fraction and higher New York Heart Association class, and fewer of them received the guideline-directed treatment. CONCLUSIONS Digoxin is associated with increased risk of death in HFrEF patients without AF history receiving the guideline- -directed treatment. Digoxin seems to be employed in patients with worse clinical status, which may at least partially explain its association with increased risk of death.