Jadwiga Nessler

Omega-3 Polyunsaturated Fatty Acids Increase Plasma Adiponectin to Leptin Ratio in Stable Coronary Artery Disease

BackgroundGrowing evidence suggests a cardioprotective role of omega-3 polyunsaturated fatty acids (PUFA). However, the exact mechanisms underlying the effects of omega-3 PUFA in humans have not yet been fully clarified.PurposeWe sought to evaluate omega-3 PUFA-mediated effects on adipokines in patients with stable coronary artery disease (CAD) undergoing elective percutaneous coronary intervention (PCI).MethodsWe conducted a prospective, double-blind, placebo-controlled, randomized study, in which adiponectin, leptin and resistin were determined at baseline, 3–5xa0days and 30xa0days during administration of omega-3 PUFA 1xa0g/day (nu2009=u200920) or placebo (nu2009=u200928).ResultsAs compared to controls administration of omega-3 PUFA resulted in increase of adiponectin by 13.4xa0% (Pu2009<u20090.0001), reduction of leptin by 22xa0% (Pu2009<u20090.0001) and increase of adiponectin to leptin (A/L) ratio by 45.5xa0% (Pu2009<u20090.0001) at 30xa0days, but not at 3–5xa0days. Compared with placebo adiponectin was 12.7xa0% higher (Pu2009=u20090.0042), leptin was 16.7xa0% lower (Pu2009<u20090.0001) and A/L ratio was 33.3xa0% higher (Pu2009<u20090.0001) in the omega-3 PUFA group at 30xa0days. Resistin decreased similarly in both groups after 1xa0month, without intergroup differences (Pu2009=u20090.32). The multivariate model showed that the independent predictors of changes in adiponectin at 1xa0month (Pu2009<u20090.001) were: omega-3 PUFA treatment, baseline platelet count, total cholesterol and those in leptin (Pu2009<u20090.0001) were: omega-3 PUFA treatment and waist circumference. Independent predictors of A/L ratio changes (Pu2009<u20090.0001) were: assigned treatment, current smoking and hyperlipidemia.ConclusionsIn high risk stable coronary patients after PCI omega-3 PUFA supplementation improves adipokine profile in circulating blood. This might be a novel, favourable mechanism of omega-3 PUFA action.

The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion

Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.

Long-Term Incremental Prognostic Value of Cardiovascular Magnetic Resonance After ST-Segment Elevation Myocardial Infarction: A Study of the Collaborative Registry on CMR in STEMI

OBJECTIVESnThis study sought to investigate whether early post-infarction cardiac magnetic resonance (CMR) parameters provide additional long-term prognostic value beyond traditional outcome predictors in ST-segment elevation myocardial infarction (STEMI) patients.nnnBACKGROUNDnLong-term prognostic significance of CMR in STEMI patients has not been assessed yet.nnnMETHODSnThis was a longitudinal study from a multicenter registry that prospectively included STEMI patients undergoing CMR after infarction. Between May 2003 and August 2015, 810 revascularized STEMI patients were included. CMR was performed at a median of 4 days after STEMI. Infarct size, microvascular obstruction (MVO), and left ventricular (LV) volumes and function were measured. Primary endpoint was a composite of all death and decompensated heart failure (HF).nnnRESULTSnDuring median follow-up of 5.5 years (range 1.0 to 13.1 years), primary endpoint occurred in 99 patients (39xa0deaths and 60 HF hospitalization). MVO was a strong predictor of the composite endpoint after correction for important clinical, CMR, and angiographic parameters, including age, LV systolic function, and infarct size. The independent prognostic value of MVO was confirmed in all multivariate models irrespective of whether it was included as axa0dichotomous (presence of MVO, hazard ratio [HR]: 1.985 to 1.995), continuous (MVO extent as % LV, HR: 1.095 to 1.097), or optimal cutoff value (MVO extentxa0≥2.6% of LV; HR: 3.185 to 3.199; pxa0< 0.05 for all). MVO extentxa0≥2.6% of LV was a strong independent predictor of all death (HR: 2.055; 95% confidence interval: 1.076 to 3.925; pxa0= 0.029) and HF hospitalization (HR: 5.999; 95% confidence interval: 3.251 to 11.069; pxa0< 0.001). Finally, MVO extentxa0≥2.6% of LV provided incremental prognostic value over traditional outcome predictors (net reclassification improvement index: 0.16xa0to 0.30; pxa0< 0.05 for all models).nnnCONCLUSIONSnEarly post-infarction CMR-based MVO is a strong independent prognosticator in revascularized STEMI patients. Remarkably, MVO extentxa0≥2.6% of LV improved long-term risk stratification over traditional outcome predictors.

Polyunsaturated omega-3 fatty acids reduce lipoprotein-associated phospholipase A2 in patients with stable angina

BACKGROUND AND AIMSnIncreased consumption of omega-3 polyunsaturated fatty acids (PUFA) together with lifestyle measures and medications is recommended for the prevention of cardiovascular diseases. However, the exact mechanisms underlying observed benefits are not well defined. To this aim, we evaluated the effects of omega-3 PUFA in stable coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) on lipoprotein associated phospholipase A2 (Lp-PLA2) mass and activity and their relation to oxidized low-density lipoproteins (oxy-LDL).nnnMETHODS AND RESULTSnIn a prospective, double-blind, placebo-controlled, randomized study Lp-PLA2, oxy-LDL, myeloperoxidase and interleukin-6 were determined at baseline, 3-5 days and 30 days during administration of omega-3 PUFA 1xa0g/day (nxa0=xa030) or placebo (nxa0=xa024). Treatment with omega-3 PUFA resulted in reduction of Lp-PLA2 mass by 10.7%, activity by 9.3 (pxa0=xa00.026 for both) and oxy-LDL by 10.9% (pxa0=xa00.014) at 30 days, with no change in myeloperoxidase and interleukin-6. Compared with placebo, patients receiving omega-3 PUFA had lower Lp-PLA2 mass by 9.42%, activity by 9.2 (pxa0=xa00.041 for both) and oxy-LDL by 12.3% (pxa0=xa00.10) after one month, but not at 3-5 days. There were no correlations between Lp-PLA2 and both myeloperoxidase and oxy-LDL throughout the study. The multivariate model showed that only treatment with omega-3 PUFA and baseline myeloperoxidase levels were independent predictors of Lp-PLA2 mass changes at one month (R(2)xa0=xa00.37, Pxa0=xa00.005).nnnCONCLUSIONSnAdministration of omega-3 PUFA can decrease Lp-PLA2 in patients with stable angina undergoing PCI. This novel effect may contribute to the benefits derived from omega-3 PUF.

Age, sex, and secondary prevention of ischaemic heart disease in everyday practice

BACKGROUNDnMany researchers have studied age- and sex-related differences in the management of patients with coronary artery disease. However, the results are inconsistent.nnnAIMnTo assess sex- and age-related bias in the secondary prevention in patients hospitalised due to ischaemic heart disease.nnnMETHODSnFive hospitals with departments of cardiology serving a city and surrounding districts in southern Poland participated in the study. Consecutive patients hospitalised from 1 April 2005 to 31 July 2006 due to acute coronary syndrome or for a myocardial revascularisation procedure and aged ≤ 80 years were recruited and interviewed 6-18 months after hospitalisation.nnnRESULTSnThe hospital records of 640 patients were reviewed and 513 (80.2%) patients participated in the follow-up interview. Women were older and less educated than their male counterparts. Sex was not independently associated with the control of major risk factors in the post-discharge period, whereas age was related to a higher probability of having high blood pressure and a lower chance of smoking. Multivariate analysis showed that females were prescribed calcium antagonists (odds ratio [OR] 2.13; 95% confidence intervals [CI] 1.34-3.39) and diuretics (OR 1.52; 95% CI 1.00-2.31) more often than males. Age was independently related to the prescription rate of diuretics (≥ 70 years vs. < 60 years; OR 1.61; 95% CI 1.19-2.20). The prescription rate of antiplatelets, beta-blockers, angiotensin converting enzyme-inhibitors/sartans, lipid-lowering drugs, and anticoagulants was not related to age or sex.nnnCONCLUSIONSnWe found no major sex-related difference in the frequency of achieving recommended goals in secondary prevention, whereas age was related to a lower prevalence of smoking and a higher probability of having high blood pressure in subjects after hospitalisation for coronary artery disease.

Distribution of selected elements in calcific human aortic valves studied by microscopy combined with SR-μXRF: influence of lipids on progression of calcification.

Calcified heart valves display a significant imbalance in tissue content of trace and essential elements. The valvular calcification is an age-related process and there are data suggesting involvement of lipids. We studied elemental composition and lipid distribution in three distinct regions of calcified human aortic valves, representing successive stages of the calcific degeneration: normal, thickened (early lesion) and calcified (late lesion), using SR-μXRF (Synchrotron Radiation Micro X-Ray Fluorescence) for elemental composition and Oil Red O (ORO) staining for demonstration of lipids. Two-dimensional SR-μXRF maps and precise point spectra were compared with histological stainings on consecutive valve sections to prove topographical localization and colocalization of the examined elements and lipids. In calcified valve areas, accumulation of calcium and phosphorus was accompanied by enhanced concentrations of strontium and zinc. Calcifications preferentially developed in lipid-rich areas of the valves. Calcium concentration ratio between lipid-rich and lipid-free areas was not age-dependent in early lesions, but showed a significant increase with age in late lesions, indicating age-dependent intensification of lipid involvement in calcification process. The results suggest that mechanisms of calcification change with progression of valve degeneration and with age.

Temporal trends in secondary prevention in myocardial infarction patients discharged with left ventricular systolic dysfunction in Poland

Background The proportion of patients discharged after myocardial infarction with left ventricular systolic dysfunction remains high and the prognosis is unfavourable. The aim of this study was to analyse the temporal trends in the treatment and outcomes of a nationwide cohort of patients. Methods and results Data from the Polish Registry of Acute Coronary Syndromes and Acute Myocardial Infarction in Poland Registry were combined to achieve complete information on inhospital course, treatment and outcomes. An all-comer population of patients discharged with left ventricular ejection fraction of 40% or less formed the sample population (nu2009=u200928,080). The patients were analysed for the incidence of significant temporal trends and their possible consequences. The implementation of guideline-based treatment at discharge was high. In the post-discharge course a trend towards a higher frequency of percutaneous coronary intervention and a lower prevalence of planned coronary artery bypass grafting procedures was observed. The number of implantable cardioverter defibrillator/cardiac resynchronisation therapy defibrillator implantations was increasing. Cardiac rehabilitation was performed in 19–23% cases. The post-discharge outpatient care was based on general practitioner visits, with only 47.9–48.1% of patients attending an ambulatory cardiology specialist visit. In 12 months of observation the frequency of heart failure rehospitalisations was 17.5–19.1%, while the prevalence of rehospitalisations due to myocardial infarction decreased (8.3% in 2009 to 6.7% in 2013, Pu2009<u20090.001). A trend towards lower all-cause mortality was observed. Assessment of composite outcomes (death, myocardial infarction, stroke or heart failure rehospitalisation) adjusted for sex and age at 12 months revealed a significant decreasing trend. Conclusion The overall prognosis in this population is improving slowly. This may be due to the increasing prevalence of guideline-based forms of secondary prevention. Efforts aimed at maintaining these trends are essential, as overall compliance with these guideline remains suboptimal.

Secondary prevention in patients after hospitalisation due to coronary artery disease: what has changed since 2006?

BACKGROUNDnThe evidence concerning the quality of secondary prevention of coronary artery disease (CAD) in Poland in recent years is scarce.nnnAIMnTo compare the implementation of secondary prevention guidelines into everyday clinical practice between 2006-2007 and 2011-2012 in patients after hospitalisation due to CAD.nnnMETHODSnFive hospitals with departments of cardiology serving a city and its surrounding districts in the southern part of Poland participated in the study. Consecutive patients aged ≤ 80 years, hospitalised from April 1, 2005 to July 31, 2006 (first survey) and from April 1, 2010 to June 30, 2011 (second survey) due to acute coronary syndrome or for a myocardial revascularisation procedure were recruited and interviewed 6-18 months after hospitalisation.nnnRESULTSnMedical records of 640 patients were reviewed and included in the first survey and 466 in the second survey. The proportion of medical records with available information on smoking did not differ between the surveys, whereas the proportion of medical records with available information on blood pressure and total cholesterol was lower in patients hospitalised in 2010-2011. The prescription rate of β-blockers at discharge decreased from 90% to 84% (p < 0.05), whereas the prescription rates at discharge of other drug classes did not change significantly. The proportion of patients with high blood pressure (≥ 140/90 mm Hg) one year after hospitalisation decreased in 2011-2012 compared to 2006-2007 (from 48% to 35%, p < 0.05), whereas the proportion of subjects with high LDL cholesterol, high fasting glucose, and obesity did not change significantly. We did not note a significant difference in the smoking rate. The proportions of patients taking an antiplatelet agent (90% vs. 91%), a β-blocker (87% vs. 79%), an ACE inhibitor or a sartan (79% vs. 76%), a calcium antagonist (22% vs. 25%), a diuretic (35%vs. 45%), and a lipid-lowering drug (86% vs. 87%) one year after discharge did not change significantly (all p > 0.05).nnnCONCLUSIONSnWe noted a modest improvement in the implementation of CAD secondary prevention guidelines in everyday clinical practice: blood pressure was better controlled, although the control of all other main risk factors did not change significantly. Our data provides evidence that there is a considerable potential for further reduction of cardiovascular risk in CAD patients.

The prevalence of abnormal echocardiographic findings in a sample of urban adult population

BACKGROUNDnEchocardiography has emerged as the test of choice for the evaluation of cardiac diseases.nnnAIMnTo assess the prevalence of a spectrum of cardiac abnormalities detected by echocardiography in a representative sample of an urban adult population.nnnMETHODSnTransthoracic echocardiography was performed in a random sample of 511 men (47%) and women (53%) aged 48-76 years selected from population registers in Krakow. Body surface area (BSA) was used to adjust echocardiographic parameters for variations in body size. Disease history and cardiovascular risk factors were assessed in all patients.nnnRESULTSnMen smoked more frequently than women and had higher blood pressure and triglycerides and lower high density lipoprotein cholesterol. The most common finding was increased left ventricular (LV) end-diastolic diameter (EDd) (37%), followed by mitral (32%), aortic (24%), or tricuspid (17%) regurgitations, LV posterior wall (24.1%) and interventricular septum (17.5%) thickening, increased indexed LVEDd (23%), increased left atrial diameter (LAd; 15.7%), reduced LV ejection fraction (LVEF; 15.3%), segmental wall motion abnormalities (13.9%), increased indexed LAd (8.8%), dilation of the ascending aorta (8%), enlargement of the right ventricle (RV) (2%) and elevation of RV systolic pressure (0.6%). When adjusted for main cardiovascular risk factors and the presence of coronary artery disease, male sex was associated with a higher prevalence of enlargement of LV (LVEDd/BSA): OR = 1.8 (1.1-2.9), dilation of ascending aorta (aortic diameter/BSA): OR = 2.7 (1.3-5.8), and LA (LA/BSA) = OR 2.7 (1.3-5.6), as well as a decrease of LVEF: OR = 3.6 (1.9-6.5).nnnCONCLUSIONSnApproximately a quarter of urban adults aged 48 to 76 can be expected to have some abnormalities on echocardiographic examination. Some of these abnormalities such as aortic dilation, LA enlargement, LV enlargement and decreased LVEF are more frequently found in males than in females, even after adjustment for BSA, main cardiovascular disease risk factors, and the presence of coronary artery disease. The use of raw instead of indexed LAd and LVEDd over estimates the prevalence of LA and LV enlargement.

Secondary prevention of coronary artery disease in contemporary clinical practice

BACKGROUNDnThe highest priority in preventive cardiology was given to patients with established coronary artery disease (CAD). The aim of the study was to assess the implementation of guidelines for secondary prevention in everyday clinical practice by evaluating control of the main risk factors and the cardioprotective medication prescription rates for patients, following their hospitalization for CAD.nnnMETHODSnFive hospitals with cardiology departments serving the city and its surround-ing districts in southern part of Poland participated in the study. Consecutive patients aged ≤ 80 years, hospitalized from January 1 2010 to April 31 2012 due to an acute coronary syndrome or for a myocardial revascularization procedure were recruited and interviewed 6-18 months after hospitalization.nnnRESULTSnThe medical records of 595 patients (mean age: 62.8 ± 9.0 years, 397 men and 198 women) were reviewed and included in the analyses. Proportions of medical records with available information on risk factors were high with the exception of total cholesterol levels as well as weight and height measurements, which were available in less than 80% of the hospital records. The prescription rate at discharge for antiplatelets was 99%, beta-blockers (BB)--85%, angiotensin converting enzyme inhibitors (ACEI) or sartans--85%, and lipid-lowering drugs--94%. Patients scheduled for coronary artery bypass grafting were significantly less often prescribed BB, ACEI or sartans, and lipid-lowering drugs. The proportion of patients with high blood pressure (≥ 140/90 mm Hg) 6-18 months after hospitalization was 47%, with high LDL cholesterol level (≥ 1.8 mmol/L) 73%, and with a high HbA1c level (≥ 7.0%) 14%, whereas 20% of participants were smokers and 80% were overweight. The proportion of patients taking an antiplatelet agent 6-18 months after hospitalization was 90%, BB--82%, ACEI--or sartan 78%, and lipid-lowering drug--82%. Overall, 33.9% of the study participants declared that they had been advised to participate in a rehabilitation/secondary prevention program following their hospitalization and 30.5% participated in a rehabilitation/secondary prevention program. However, only 28.2% took part in at least half of the planned sessions. Using a multivariate analysis we showed that, in general, risk factors control and the prescription rates of cardioprotective medications were related to the patients age, education, and participation in a rehabilitation/secondary prevention program following their hospitalization due to CAD.nnnCONCLUSIONSnOur data provide evidence that there is a considerable potential for further reduction of cardiovascular risk in CAD patients. Our results suggest that increasing patient participation rates in rehabilitation/secondary prevention programs may improve the implementation of the secondary prevention.