Karina Wierzbowska-Drabik

Prognostic value of platelet indices after acute myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND Mean platelet volume (MPV) is a strong predictor of impaired angiographic reperfusion and 6-month mortality in ST-elevation myocardial infarction (MI) treated with primary percutaneous coronary intervention (PCI). No data is available for other platelet volume indices: platelet distribution width (PDW) and platelet large cell ratio (P-LCR). The aim was to assess the impact of 3 platelet volume indices on long-term prognosis in patients treated with primary PCI in acute MI. METHODS This prospective study enrolled 538 patients who underwent primary PCI in acute MI. Admission blood samples were measured for MPV, PDW, and P-LCR. The patients were followed-up a mean period of 26 ± 11 months with regard to cardiac death, non-fatal reinfarction, re-PCI or coronary artery bypass grafting. RESULTS Kaplan-Meier survival analysis showed a significantly higher 26-month mortalityrate in patients with high MPV (≥ 11.7 fL) than in those with low MPV (< 11.7 fL) (14.6% vs. 5.5%, p = 0.0008). Similar findings were related to high P-LCR (≥ 38.1%) vs. low P-LCR (< 38.1%) - mortality 13.8% vs. 5.8%, p = 0.0025. Higher PDW values (≥ 16 fL) correlated with higher mortality rate as compared to PDW < 16 fL (17.4% vs. 6.3%, p = 0.0012). PDW was found to be an independent prognostic factor for cardiac mortality and composite endpoint. CONCLUSIONS Mean platelet volume, platelet distribution width and platelet large cell ratio measured on admission are strong, independent prognostic factors in PCI-treated acute MI.

Elevated resistin opposed to adiponectin or angiogenin plasma levels as a strong, independent predictive factor for the occurrence of major adverse cardiac and cerebrovascular events in patients with stable multivessel coronary artery disease over 1-year follow-up.

Summary Background Adipokines such as adiponectin and resistin, as well as angiogenin, may be associated with inflammation and atherosclerosis. The relationship between their levels and prognosis in high risk patients is, however, still unclear. The aim of this study was to evaluate the prognostic value of these adipokines in patients with stable multivessel coronary artery disease (MCAD). Material/Methods The study group comprised 107 MCAD patients (74% males, mean age 63±8 years). Adiponectin, resistin and angiogenin plasma levels were measured at admission and after 1-year follow-up. Primary end point (major adverse cardiac and cerebrovascular events – MACCE) was defined as cardiac death, nonfatal myocardial infarction, stroke, and hospitalization for angina or heart failure over a 1-year period. Results After 1-year follow-up, 9 (8%) patients died, all from cardiovascular causes. Primary end point was experienced by 32% of patients. Surgical treatment (CABG) was received by 51% of patients, while 49% were treated medically alone. Total cholesterol concentration levels ≥173 mg/dl were associated with a 7-fold increase (OR 7.3; 95% CI, 1.6–33.0); LDL ≥93.5 mg/dl with a 16-fold increase (OR 16.3; 95% CI, 2.8–93.8), and resistin ≥17.265 ng/ml with a 13-fold increase in MACCE risk (OR 13.5; 95% CI, 2.3–80.3). In multivariate analysis, a medical treatment strategy (p=0.001), a higher CCS class (p=0.004), resistin levels (p=0.003) and a higher Gensini score (p=0.03) were independent predictors of MACCE. Conclusions In stable patients with MCAD, elevated plasma resistin (as opposed to adiponectin or angiogenin) is a strong, independent predictive factor for the occurrence of MACCE over 1-year follow-up.

Melatonin for nondippers with coronary artery disease: assessment of blood pressure profile and heart rate variability.

The aim of this study was to assess the effects of 5 mg melatonin before sleep in patients with coronary artery disease (CAD) and with an abnormal circadian pattern of blood pressure (BP) on changes in circadian BP profile and heart rate variability (HRV). Sixty patients with CAD, nondippers aged 48–80 years (male 75%), were included. In addition to previous treatment, they were randomly allocated to melatonin or placebo. After 90 days, a second 24-h BP monitoring was carried out. Each patient had two sessions (before randomization and at the end of study) of 24-h ECG monitoring to assess the changes in HRV. Inclusion of melatonin led to BP pattern normalization in 35% of patients in the melatonin group and in 15% of controls (P=0.609). This effect was reached not only by a decrease in nighttime BP, but also by an increase in daytime BP (significant in the melatonin group). A nonoptimal effect for BP profile was observed in 12.5% of patients: extreme- or reverse dippers. In patients with conversion from nondippers to dippers (responders), an increase in standard deviation of normal-to-normal intervals between initial and final HRV analyses was observed. Nonresponders represented an increase in the mean circadian heart rate. To avoid nonoptimal effects, the inclusion of melatonin in pharmacotherapy of patients with CAD should be based on monitoring of circadian BP profile, before and during treatment. As melatonin caused not only a nocturnal decrease in BP but also a daytime increase, it should not be recommended in patients with ‘high normal’ values of BP because of the danger of induction of arterial hypertension.

Enlarged Left Atrium Is a Simple and Strong Predictor of Poor Prognosis in Patients after Myocardial Infarction

Background and Aim: Patients after myocardial infarction (MI) differ according to the extend of myocardial damage and prognosis. Diastolic function impairment may have great impact on development of heart failure and outcomes. We evaluated the prognostic value of various echocardiographic measurements in 18‐month and 3‐year observation after MI. Methods: 60 patients after MI (44 male, mean age 60 ± 11) were examined by transthoracic echocardiography with the assessment of wide spectrum of parameters. Mortality and combined end points (cardiac deaths and heart failure exacerbation) were assessed after 18‐month and 3‐year observation and groups with and without end points were compared. Optimal cutoff values were estimated by receiver operating characteristic (ROC) analysis and resulting Kaplan–Meier curves were compared. Results and Conclusions: After 18 months, 11 deaths occurred and 20 subjects experienced hospitalization caused by heart failure exacerbation. Although the group with cardiac events showed a greater enlargement of the left ventricle and lower ejection fraction, the highest relative risk of poor outcome (RR = 5.0) was related to the left atrial enlargement above 44 mm. Although restrictive or pseudonormal inflows were connected with 2.1 relative risk of combined end point, all patients with E deceleration time ≤130 ms experienced heart failure exacerbation or death. Despite tissue Doppler and propagation parameters describing elevated end‐diastolic pressure differed between groups with various outcomes in multivariate analysis, only enlarged left atrium was an independent predictor for both combined end point and cardiac death. Further 3‐year follow‐up solely confirmed the role of above described predictors.

Severe Obesity Impairs Systolic and Diastolic Heart Function – The Significance of Pulsed Tissue Doppler, Strain, and Strain Rate Parameters

We assessed the impact of morbid obesity on systolic and diastolic heart function in severely obese, but otherwise healthy subjects and age‐matched controls.

Echocardiographic indices of left ventricular hypertrophy and diastolic function in hypertensive patients with preserved LVEF classified as dippers and non-dippers

Introduction Long-lasting arterial hypertension causes left ventricular hypertrophy (LVH) and impairs left ventricular diastolic function. Our aim was to compare echocardiographic parameters between hypertensive patients defined as dippers and non-dippers during ambulatory blood pressure (BP) monitoring. Material and methods We analysed 61 consecutive subjects with treated hypertension undergoing 24-h BP monitoring and transthoracic echocardiographic examination and included in the study patients with preserved left ventricular ejection fraction (EF ≥ 50%). Echocardiographic and arterial pressure parameters were compared between the group classified as dippers (n = 26, 57 ±13 years, 16 males) and non-dippers (n = 35, 60 ±12 years, 24 males) according to present or absent decrease of BP during the night > 10%. Echocardiographic data were compared between both groups and control subjects without hypertension. Results Dippers had lower average systolic, diastolic and mean arterial pressure during the night hours but did not differ according to the mean pressure calculated from a 24-hour period. All echocardiographic parameters were similar in dippers and non-dippers. All patients with arterial hypertension presented with larger dimension of both ventricles and left atrium, thicker left ventricular walls, higher LV mass and mass index and preserved EF and E/A ratio as compared with normotensive controls. Normal geometry, concentric remodelling and eccentric hypertrophy were similarly distributed in both groups. Concentric hypertrophy was more prevalent in non-dippers as compared to the dippers (71.4% vs. 38.5%, p < 0.043). Conclusions The concentric type of LVH is the prevalent pattern in non-dippers. Non-dipping blood pressure pattern may be responsible for the development of left ventricular concentric hypertrophy secondary to hypertension.

Delayed longitudinal myocardial function recovery after dobutamine challenge as a novel presentation of myocardial dysfunction in type 2 diabetic patients without angiographic coronary artery disease

AIMS Since myocardial dysfunction in diabetic patients without coronary artery disease (CAD) is subtle at rest, the assessment during dobutamine stress echocardiography (DSE) may be more sensitive for detection of myocardial involvement. We assessed systolic function of the left ventricle during all stages of DSE in 3 diabetic patients free of significant CAD using state-of-the-art speckle-tracking quantification. METHODS AND RESULTS We performed DSE in 250 patients with angina recording views during baseline (0), peak (1), and recovery phase (2). All patients had coronary anatomy verified with ≥ 50% stenosis in left main and ≥ 70% in other arteries considered as significant. In this analysis, we included 25 subjects with diabetes mellitus (DM) but without CAD (mean age 62 ± 8) and compared them with an age- and sex-matched group of 85 controls without DM and CAD (mean age 60 ± 9). Global peak systolic longitudinal strain (PSLS) of the left ventricle was obtained by automated function imaging (AFI) at rest, peak, and recovery phase of DSE. The global PSLS was similar in both groups at baseline (-17.3 ± 4.0% in diabetics vs. -18.7 ± 3.3% in controls, P = ns) and at peak stage of DSE (-16.4 ± 4.5% in diabetics vs. -17.9 ± 4.2% in controls, P = ns), whereas at recovery absolute value was lower in patients with DM (-15.3 ± 3.2% vs. -17.2 ± 3.3%, P = 0.01). CONCLUSION Peak systolic longitudinal strain measured by AFI during recovery of DSE was impaired in diabetic patients. It may reflect longer time needed for full restoration of myocardial systolic function in this group of subjects.

Assessment of Mitral Inflow During Standardized Valsalva Maneuver in Stratification of Diastolic Function

Background: We assessed the changes of mitral inflow during Valsalva maneuver (VM) in patients with different stages of left ventricular dysfunction and evaluated their value for the differentiation between normal and pseudonormal filling pattern. Methods: A total of 190 patients (120 with coronary artery disease, and 70 healthy subjects) were examined by transthoracic echocardiography. Mitral E/A ratio, early wave deceleration time (Edt), and pulmonary vein flow (especially atrial reversal parameters (Ar)), were used for the initial stratification to normal, delayed relaxation, pseudonormal, and restrictive profiles. Changes of mitral inflow during VM were compared between 54 normal (N) and 15 pseudonormal (PN). Results: During VM, a similar decrease in early wave peak velocity (–30 ± 18 vs –35 ± 17 cm/sec), peak velocity of atrial wave (–6 ± 16 vs –8 ± 17 cm/sec), and E/A ratio (–0.4 ± 0.4 vs –0.4 ± 0.4) was observed in both groups. Only two filling variables, related to atrial phase of inflow, changed in the opposite direction. In normal pattern, the duration and velocity‐time integral of atrial wave diminished during VM as opposed to pseudonormal subjects (ΔAt –7 ± 39 vs 20 ± 44 msec; P < 0.05 and ΔA vti –0.7±1.8 vs 0.4±2 cm; P < 0.05). Increase in peak atrial velocity and marked decrease in E/A ratio during VM were specific for the restrictive group. Conclusions: Changes of mitral inflow during VM have a moderate diagnostic value for the differentiation of normal and pseudonormal pattern. Increased duration of atrial phase but not increase in atrial velocity allowed the diagnosis of pseudonormalization.

Anomalous circumflex origin from the right coronary artery forming 'bleb sign' in transoesophageal echocardiography.

A 76-year-old man with mild mitral valve disease (mitral valve area of ∼1.5 cm2 and first grade of regurgitation) and atrial fibrillation was admitted to echocardiography laboratory for transoesophageal examination (TEE) before planned cardioversion. The examination did not revealed thrombi in heart chambers, especially in the left atrial appendage, detected persistent foramen ovale, and indicated atypically …

The Prevalence and the Prognostic Value of Microvolt T‐Wave Alternans in Patients with Hypertrophic Cardiomyopathy

Background: Nonsustained ventricular tachycardia (nVT) may have ominous implications for patients with hypertrophic cardiomyopathy (HCM). The microvolt T‐wave alternans (TWA) has been proposed as a noninvasive tool‐identifying patients at risk of sudden cardiac death and ventricular tachycardia/fibrillation (VT/VF). The aim of the study was to determine the significance of TWA in predicting nVT episodes and compare how other electrocardiographic parameters can predict the occurrence of nVT.