Jan Błażejewski

Relationship between B-type natriuretic peptide serum level, echocardiographic TEI index and the degree of diastolic dysfunction in patients with heart failure with preserved systolic function

Introduction The growing number of heart failure (HF) patients is becoming an important issue in cardiology. B-type natriuretic peptide (BNP) is a recognized marker of HF, including in patients with preserved systolic function. The TEI index is an indicator of left ventricular function. The aim of the study was to evaluate the relationship between BNP serum level, TEI index and the degree of diastolic dysfunction in patients with HF symptoms and preserved systolic function. Material and methods Hundred patients with arterial hypertension and preserved systolic function were enrolled in the study. The study group consisted of 51 individuals with impaired diastolic function and HF symptoms. Fourty-nine hypertensive individuals without HF symptoms were assigned to the control group. B-type natriuretic peptide and echocardiographic examination were performed. Patients were divided into 4 subgroups – with normal diastolic function, impaired relaxation, pseudonormalization and restriction. Results Median value of BNP in patients with normal diastolic function was 28.36 pg/ml, 87.10 pg/ml in patients with impaired relaxation, 212.75 pg/ml and 461.56 pg/ml in the pseudonormalization and restriction group respectively (p < 0.0001). The median value of the TEI index was: 0.386 in patients with normal diastolic function, 0.507 in individuals with impaired relaxation, 0.639 and 0.725 in the pseudonormalization and restriction group respectively. All the differences were statistically significant (p < 0.0001). A significant positive correlation (r = 0.80, p < 0.001) between BNP and the TEI index was found. Conclusions In hypertensive patients with HF symptoms and preserved left ventricular systolic function a highly significant increase in BNP serum level and in the TEI index values related to the deterioration of diastolic dysfunction was found.

Short-term alcohol consumption may have detrimental effect on fibrinolysis and endothelial function: preliminary report of prospective randomised study

BACKGROUND AND AIM This study was designed to clarify the impact of the short-term consumption of different types of alcoholic beverages on haemostatic factors, C-reactive protein (hsCRP) and endothelin-1 (E-1) plasma levels. METHODS The study group consisted of 57 healthy male volunteers, aged 20-29 years. Subjects were randomised to consume 300 mL of red wine, white wine, 12% ethanol, black currant juice or water for five days. Blood samples were collected for CRP, tissue type plasminogen activator antigen (t-PA:Ag), plasminogen activator inhibitor antigen (PAI-1:Ag) and E-1 at baseline, on day 2, and on day 6. RESULTS A significant increase in PAI-1:Ag concentration was observed in the red wine drinking group (day 1: 44.98; day 2:56.86; day 6: 47.44 ng/mL; p = 0.05). A similar increase of E-1 level was found in the 12% ethanol group (day 1: 0.53; day 2:1.65; day 6: 1.11 fmol/mL; p = 0.01). Dividing the whole study group according to ethanol content of consumed beverages revealed significant changes in tPA:Ag, PAI-1:Ag and E-1 levels. In the alcohol drinking group, significant increases of PAI-1:Ag (day 1: 44.75; day 2: 54.07; day 6: 44.80 ng/mL; p < 0.05); tPA:Ag level (day 1: 3.65; day 2: 4.17; day 6: 5.03 ng/mL;p < 0.02) and E-1 (day 1: 0.42; day 2: 1.01; day 6: 0.97 fmol/mL; p < 0.002) were observed. CONCLUSIONS Short-term alcohol consumption increases tPA:Ag, PAI:Ag and E-1 plasma levels. This effect may have an unfavourable impact on the fibrinolytic system and endothelial function.

Bone morphogenetic protein 6—a possible new player in pathophysiology of heart failure

Derangement of bone morphogenetic protein (BMP) signalling was observed in cardiovascular disorders. The present study assesses the diagnostic and prognostic value of BMP6 plasma concentration in chronic heart failure (CHF). 130 CHF patients and 32 controls participated in the study. BMP6 plasma level was measured at baseline. During 12‐month follow‐up death and hospitalisation with CHF exacerbation were recorded. BMP6 was significantly increased in CHF patients with highest concentration in most advanced disease. Individuals with pulmonary congestion or peripheral oedema had higher levels of BMP6 than isovolemic patients. BMP6 was not a predictor of all‐cause mortality or CHF hospitalisation. BMP6 may be involved in pathophysiology of systolic CHF. BMP6 plasma level is related to the disease severity and signs of exacerbation.

Polish Stress Echocardiography Registry (Pol-STRESS registry) — a multicentre study. Stress echocardiography in Poland: numbers, settings, results, and complications

BACKGROUND Stress echocardiography (SE) is widely used in Europe. No collective data have been available on the use of SE in Poland until now. AIM To evaluate the number of SE investigations performed in Poland, their settings, complications, and results. METHODS In this retrospective survey, referral cardiology centres in Poland were asked to fill in a questionnaire regarding SE examinations performed from May 1, 2014 to May 1, 2015. RESULTS The study included data from 17 university hospitals and large community hospitals, which performed 4611 SE exa-minations, including 4408 tests in patients investigated for coronary artery disease (CAD) and 203 tests to evaluate valvular heart disease (VHD). To evaluate CAD, all centres performed dobutamine SE (100%), 10 centres performed pacing SE (58.8%), while cycle ergometer SE and treadmill SE were performed by six (35.3%) and five (29.4%) centres, respectively. Dipyridamole SE was performed in one centre. All evaluated centres (100%) performed SE to evaluate low-flow/low-gradient aortic stenosis, eight (47%) performed SE to evaluate asymptomatic aortic stenosis, and also eight (47%) performed SE to evaluate mitral regurgitation. The mean number of examinations per year was 271 per centre. Most centres performed more than 100 examinations per year (11 centres, 64.7%). We did not identify any cardiac death during SE examination in any of the centres. Myocardial infarction occurred in three (0.07%) patients. Non-sustained ventricular tachycardia occurred in 52 (1.1%) SE examinations. The rates of minor complications were low. SE to evaluate CAD was more commonly performed in the hospital settings using cycle ergometer (72.6%), treadmill (87.6%), and low-dose dobutamine (68.0%), while a dipyridamole test was more frequently employed in ambulatory patients (77.6%). No significant differences between the rates of examina-tions performed in the ambulatory and hospital settings were found for high-dose dobutamine and pacing SE. Examinations to evaluate VHD were significantly more frequently performed in the hospital settings. SE examinations accounted for more than one third of all stress tests performed in the surveyed centres over the study period. CONCLUSIONS Stress echocardiography is a safe diagnostic method, and major complications are very rare. Despite European recommendations, SE examinations to evaluate CAD are performed less frequently than electrocardiographic exercise tests, although they already comprise a significant proportion of all stress tests. It seems reasonable to promote SE further for the evaluation of both CAD and VHD.

Ocena wartości rokowniczej wybranych parametrów ergospirometrycznych u chorych z przewlekłą skurczową niewydolnością serca kwalifikowanych wstępnie do transplantacji serca, w obserwacji 12-miesięcznej

Introduction. Despite recent advances in diagnosis and pharmacological treatment of cardiovascular diseases, chronic heart failure (HF) carries a poor prognosis. The identification of patients at highest risk for early death from HF is of special importance. Ergospirometric test is known to be useful in predicting survival and oxygen consumption (maximal/peak VO2) and minute ventilation-carbon dioxide production relationship (VE/VCO2slope) are the most frequently analyzed cardiopulmonary exercise test parameters. The aim of this study was to assess the ability of peak VO2 and VE/VCO2slope to predict cardiac-related mortality and cardiac-related hospitalization (MACE, major adverse cardiac event) in patients with chronic systolic HF, pre-qualified for heart transplantation. Material and methods. Forty-five patients (38 men; age 50 ± 8 years) with stable chronic HF (21 coronary artery disease, 24 dilated cardiomyopathy), in New York Heart Association functional class II (n. 16)–III (n. 29), with left ventricular ejection fraction (LVEF) below 35% (mean LVEF = 22.7 ± 5.1%), underwent cardiopulmonary exercise testing between 2006 and 2012 year. Results. At the end of follow-up, 5 (11%) patients had died and 17 (38%) had a hospitalization due to CHF exacerbation. Peak VO2 was 14.5 ± 5.7 mL/kg/min, VE/VCO2 slope was 35.1 ± 6.1. MACE(+) group had a lower peak VO2 (13.9 ± 6.9 mL/kg/min vs 15.1 ± 4.3, p = NS) and higher VE/VCO2slope (37.2 + 6.0 vs. 33.1 ± 5.6, p = 0.021) than MACE(–) group. MACE(+) death group had a lower peak VO2 than MACE(–) group (10.9 ± 1.3 vs. 15.1 ± 4.3, p = 0.045). The areas under the receiver operating characteristic curves for predicting MACE at 1 year were 0.68 for peak VO2 and 0.70 for VE/VCO2slope. The results of Kaplan-Meier analysis revealed a 1-year MACE free survival of 33% in patients with VE/VCO2slope > 34.9 and 67% in those with VE/VCO2slope 11.9 mL/kg/min (p = 0.0085). Conclusions. Both VO2 and VE/VCO2slope, are good prognostic parameters for serious cardiovascular events and improve the risk stratification of chronic HF patients.

Wartość oznaczania stężeń antygenu nowotworowego Ca 125 i kopeptyny w monitorowaniu terapii chorych z zaawansowaną niewydolnością serca

Introduction. A search continues for new markers and new monitoring methods that would be useful in the management of patients with advanced heart failure (HF). Recent studies have shown increased levels of cancer antigen 125 (Ca 125) and copeptin in patients with HF which implies that they may be used as markers of HF. Material and methods. The aim of the study was to evaluate levels of potential HF markers in relation to established biochemical markers. The study included 60 patients who were admitted due to exacerbation of chronic New York Heart Association class III or IV systolic HF. Before administration of initial intravenous diuretic dose, blood samples were collected to determine levels of conventional prognostic factors (uric acid, B-type natriuretic peptide [BNP]) and novel HF biomarkers (Ca 125, copeptin). Results. On admission, BNP level (median 1166.50 pg/mL [636.00–2068.50]) and uric acid level (9.497 ± 2.426 mg/ dL) in patients with HF was significantly higher compared to respective normal values. Ca 125 level (median 88.71 U/mL [29.28–169.00]) was also significantly increased, and copeptin level was significantly higher compared to the control group (median 96.55 vs 7.05 pg/mL, p < 0.0001). In additional, a statistically significant correlation between baseline BNP and Ca 125 levels (r = 0.48, p < 0.001) was observed. No correlations were found between baseline levels of copeptin and BNP or uric acid. Conclusion. In patients with chronic HF, several pathomechanisms are operating, which may be indicated by increased levels of several markers, including both conventional and new ones. Higher levels of Ca 125 were observed in patients with acute decompensated HF, even though these patients did not have a malignancy. However, Ca 125 did not exceed the prognostic value of BNP due to its low specificity. Despite different pathomechanisms of BNP and Ca 125 level elevations, a correlation was found between these markers, which might indicate a complex pathophysiology of HF in the studied group.

Echokardiograficzna ocena prawych jam serca w praktyce klinicznej w świetle zaleceń ekspertów z 2015 roku

Cardiac imaging is crucial in diagnostics and monitoring of cardiovascular diseases. Among all imaging techniques, studies, echocardiography is a method of choice considering its availability, accuracy, safety and cost effectiveness. Significant prognostic value of the right ventricular function makes its evaluation an indispensable part of daily practice. Another updated edition of guidelines on optimal echocardiographic methodology providing new set of reference values confirms the importance of the right heart assessment in clinical setting. These new recommendations on adult echocardiography were endorsed by American Society of Echocardiography and European Association of Cardiovascular Imaging and published in 2015. The document underlines the need for right heart evaluation during each and every echocardiographic examination using all available acoustic windows and combining the findings with clinical data. Detailed choice of methods is individualized with regard to the clinical situation, symptoms, equipment, skills and echocardiographers’ experience. The guidelines highlight the need to relate echocardiographic findings to the individual features, especially in case of extreme values (body size), to eliminate potential interpreting mistakes in individuals with extreme weight and height. The guidelines organize the methodology of echocardiographic examination significantly and increase its clinical value.

Prognostic significance of red cell distribution width and other red cell parameters in patients with chronic heart failure during two years of follow-up.

BACKGROUND Studies published during the last decade seem to indicate red blood cell parameters as inexpensive, rapidly available, and simple tools for the assessment of prognosis in patients with chronic heart failure (CHF). AIM To evaluate the prognostic value of red cell parameters determined in a routine blood count in patients with CHF. METHODS The study group included 165 patients with the New York Heart Association (NYHA) class II-IV CHF hospitalised in the 2nd Department of Cardiology in Bydgoszcz. On the first day of hospitalisation, all patients in the study group underwent a complete blood count with an assessment of haemoglobin (Hb) level, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and red blood cell distribution width (RDW). Follow-up was carried over 24 months by phone calls every 3 months. RESULTS MCV, MCH and MCHC were not shown to be significant predictors of mortality in CHF patients at 1 and 2 years of follow-up. In univariate analysis at 1-year follow-up, the following variables were significantly associated with the occurrence of the study endpoint: Hb level (p = 0.022; HR = 0.80), RDW (p = 0.004; HR = 1.257), and N-terminal pro-B-type na-triuretic peptide (NT-proBNP) level (p = 0.0001; HR = 1). At 2 years of follow-up, the following variables were significantly associated with the occurrence of the study endpoint: left ventricular ejection fraction (p = 0.018; HR = 0.956), NYHA class (p = 0.007; HR = 0.378), RDW (p = 0.044; HR = 1.175), and NT-proBNP level (p < 0.001; HR = 1). Multivariate analysis for 1-year follow-up showed that RDW and NT-proBNP level were independent significant predictors of mortality, while NT-proBNP level (p = 0.006; HR = 1) and NYHA class (p = 0.024; HR = 0.439) were significant predictors of mortality at 2 years of follow-up. Based on receiver operating characteristic curve analysis, the cut-off RDW was 15.00% (AUC = 0.63; 0.523-0.737), at 12 months of follow-up and 14.00% (AUC = 0.6; 0.504-0.697), at 24 months of follow-up. The cut-off for Hb level was 13.9 g/dL (AUC = 0.662; 0.553-0.77), at 12 months of follow-up and 12.2 g/dL (AUC = 0.581; 0.482-0.681), at 24 months of follow-up. CONCLUSIONS Baseline RDW and Hb level in patients hospitalised with the diagnosis of NYHA class II-IV CHF seem to be important predictors of mortality in this population. Among the red blood cell parameters, only RDW was shown to be an independent prognostic factor at 1 year of follow-up but it appeared to lose its significance during longer-term follow-up.

Churg-Strauss syndrome with endocardial injury, clot formation in heart’s chambers, and neurological complications

Address for correspondence: Robert Bujak, MD, PhD, 2nd Chair and Clinic of Cardiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, ul. Ujejskiego 75, 85–168 Bydgoszcz, Poland, e-mail: robertbujak@wp.pl Conflict of interest: none declared Kardiologia Polska Copyright

Czy zmiany częstości rytmu serca obserwowane podczas próby obciążeniowej z wykorzystaniem dobutaminy korelują z odpowiedzią na terapię resynchronizującą serce u pacjentów z ciężką skurczową niewydolnością serca? Wyniki badania wieloośrodkowego ViaCRT

BACKGROUND According to current European Society of Cardiology guidelines for the diagnosis and treatment of heart failure (HF), cardiac resynchronisation therapy (CRT) is indicated in patients suffering from HF with reduced ejection fraction (EF) with significantly widened QRS complexes. The presence of vital myocardium proven by dobutamine stress echocardiography (DSE) is considered as a good prognostic factor for responsiveness to this treatment. Chronotropic incompetence is, on the other hand, a known factor of unfavourable outcome in HF. AIM The aim of this study was to analyse the relationship between heart rate (HR) response during DSE and resultant changes in echocardiographic parameters determined prior to CRT and six weeks post-implantation of the CRT system. METHODS The study included 72 men and 25 women with chronic HF and markedly deteriorated left ventricular (LV) sys-tolic function (EF < 35%). Low-dose DSE was performed prior to the CRT system implantation. Baseline echocardiographic parameters determined before CRT were compared to those measured six weeks after implantation. RESULTS Implantation of the CRT system resulted in an improvement of LV systolic function. DSE showed a significant in-crease in HR, by 16.3 bpm on average. Patients with the least prominent increase in HR during DSE (< 7 bpm) presented with significantly greater end-diastolic LV dimension and volume, as well as with significantly lower EF than the subjects with the most evident increase in HR (> 24 bpm). Improvement in EF at six weeks was associated with lower baseline HR and its greater absolute and relative increase during DSE. Greater absolute increase in HR during DSE was also associated with more prominent decrease in systolic/diastolic LV volumes. CONCLUSIONS Patients with better chronotropic response during DSE show significant improvement in LV parameters determined by echocardiography within six weeks of CRT. Chronotropic response to pharmacologic stress test may serve as a predictive factor in patients qualified for CRT.