Ryszard Targoński

Diagnostic value of mitral and tricuspid annular excursion in the diagnostics of acute pulmonary embolism patients with chronic heart failure.

causing coronary artery steal. In view of ongoing symptoms despite medical therapy the decision was made to close this vessel percutaneously. Initial attempts via the radial approach were unsuccessful due to poor guide support but a repeated attempt via the femoral arterywas successful. A 7FAL 2 guiding catheter was used, awhisper wire (Abbott, UK) was placed in the vessel and a 4 F delivery catheter was advanced into the vessel (Panel C). An Amplatzer Vascular Plug 4, (image courtesy of AGA medical corporation) (Panel D) was subsequently deployed (Panel E) and occlusion of the vessel after several minutes was confirmed by repeat angiography (Panel F). The patient experienced mild discomfort following the procedure but was otherwise well and discharged home the following morning. He was reviewed 2 months later and reported a significant improvement in his anginal symptoms, (CCS grade I) Fig. 1. The authors have no conflicts of interest to declare in relation to this manuscript. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [1].

The influence of acute pulmonary embolism on early and delayed prognosis for patients with chronic heart failure

BACKGROUND Patients with acute pulmonary embolism (APE) with concomitant chronic heart failure (CHF) are characterized by higher mortality rates than APE patients without CHF. The aim of this study is to evaluate the potential impact of APE on early and long-term prognosis in patients with CHF. METHODS This study included 87 patients with CHF with suspected APE. Patients were divided into two groups according to spiral computed tomography results: one group with confirmed APE and one with excluded APE. Total and cardiovascular mortality in patients of both groups during a 6- and 36-month follow up period was assessed. Potential risk factors for mortality in patients with CHF in short and long-term observations were identified. RESULTS APE was diagnosed in 35 patients, and excluded in the remaining 52 patients. Total and cardiovascular 6-month mortality was higher in APE patients than in patients without APE: 34.3% and 28.5% vs. 13.4% and 11.5%, p = 0.02, p = 0.02, respectively. In 6-month follow-up the only independent risk factor for mortality was the presence of APE (HR = 2.7, 95% CI 1.1-24.4, p = 0.04). However, in the 36-month follow-up APE had no effect on mortality. CONCLUSIONS Patients with CHF and acute episode of PE are characterized by a higher 6-month total and cardiovascular mortality rate following discharge from hospital compared to patients hospitalized due to acute CHF decompensation. Moreover, recent episode of PE in patients with CHF is an independent risk factor for early mortality in a 6-month follow-up.

Impact of anticoagulation on the effectiveness of loop diuretics in heart failure with cardiorenal syndrome and venous thromboembolism.

The limitations of diuretics in the treatment of acute decompensated heart failure (ADCHF) are progressive worsening of renal function and resistance to up-titrated doses. The occurrence of resistance to loop diuretics in patients with ADCHF is associated with worsening prognosis and increased mortality. In this study, we report two patients with ADCHF and resistance to loop diuretics suspected for venous thromboembolism, suggesting that heparin administered to ADCHF patients treated for venous thromboembolism with cardiorenal syndrome decreases right-ventricular overload and improves renal function. To our knowledge, these are the first reported cases describing restored responsiveness to loop diuretics in ADCHF patients after additional heparin administration.

PERIOPERATIVE DISORDERS OF COAGULATION AND FIBRINOLYSIS IN PATIENTS SUBJECTED TO COLORECTAL CANCER RESECTION

Abstract Introduction Venous thromboembolism and disseminated intravascular coagulation are frequent complications of malignant neoplasia. Abnormally high coagulation activity and fibrinolytic inhibition induced by surgery are suggested to be responsible for frequent occurrences of coagulative disorders. Aim The aim of this work was to assess the influence of surgery on coagulation and fibrinolitic systems during the early postoperative period in the high risk thromboembolism population, receiving heparin prophylaxis. Materials and Methods This study was carried out in a group of 19 patients (12 males and 7 females), ages from 51 to 82 (mean 66.1), all with colorectal adenocarcinoma, who underwent scheduled elective total tumor resection. Results and Discussion Following surgical procedures the initially elevated D-dimer plasma level increased significantly. Activated partial thromboplastin time and the prothrombin time were prolonged significantly until the end of the observation period. Substantial reduction of initially normal fibrinogen concentration was revealed 6 hours after surgery, with significant increases at the 24th hour and then after 48 hours. The platelet count decreased linearly between 6 and 48 hours. The same pattern with nadir values after 48 hours was observed for antithrombin, protein C and the plasminogen plasma levels. Conclusions Colorectal cancer and surgery significantly activate the coagulation and fibrinolytic systems, despite prophylaxis with low molecular weight heparin. Elective cancer resection is accompanied by a process resembling consumptive coagulopathy with an impairment of standard coagulation markers as well as significant reduction in natural plasma anticoagulants. Further studies are required to determine whether substitutional administration of natural anticoagulants added to routine heparin treatment in case of prophylaxis failure should be considered.

The significance of mitral and tricuspid valve systolic lateral annular velocities in the diagnosis of acute pulmonary embolism in patients with chronic heart failure.

Introduction The diagnosis of acute pulmonary embolism (APE) in patients with chronic heart failure (CHF) remains a difficult task, despite the refinement of imaging techniques. The goal of this study was to assess the value of measuring tricuspid and mitral valve systolic annular velocities in CHF patients with suspected PE by tissue Doppler imaging (TDI). Material and methods The study included 75 patients with previously diagnosed CHF, admitted due to resting dyspnea, with a maximum tricuspid regurgitation pressure gradient (TRPG) of ≥ 35 mm Hg and positive D-dimer assay. Spiral computed tomography (sCT) was performed on all subjects to confirm APE. Acute pulmonary embolism was diagnosed in 35 patients (PE+), and excluded in 40 others (PE–). Tissue Doppler imaging was performed to measure maximum systolic lateral annular velocities in the mitral (SmLV) and tricuspid (SmRV) valves, as well as the SmRV/SmLV ratio. Results PE+ subjects were found to have higher SmLV than PE– subjects (6.0 cm/s (2.0–13.8 cm/s) vs. 4.2 cm/s (1.3–9.1 cm/s), p = 0.003). SmRV/SmLV ratios were 1.05 (0.50–2.50) and 1.56 (0.62–4.30), respectively (p < 0.0001). Areas under ROC curves for diagnosis of APE were 0.700 for SmLV and 0.789 for SmRV/SmLV. In multivariate logistic regression analysis, only SmRV/SmLV was statistically significant, with an odds ratio for APE of 6.26 (95% CI: 1.53–25.59; p = 0.009). Conclusions Tissue Doppler imaging of the lateral tricuspid and mitral annuli is a useful clinical tool that can help identify PE in CHF patients. Those patients who fulfill these criteria should be considered for further diagnostic studies to confirm PE.

Identification of clinical risk factors of atrial fibrillation in congestive heart failure

BACKGROUND Factors associated with the development of atrial fibrillation (AF) in general population have been described, but it is still unknown whether the same risk factors apply to heart failure (HF) patients. The aim of this study was to identify clinical factors related to various forms of AF in HF patients. METHODS The clinical and echocardiographic characteristics were assessed in 155 HF patients: 50 with sinus rhythm, 52 with non-permanent AF, and 53 with permanent AF. RESULTS Multivariate logistic regression analysis showed that the increase in the NYHA class was an independent risk factor for both forms of AF. The occurrence of permanent AF in comparison to sinus rhythm group was independently associated with hs-C-reactive protein (CRP) elevation above 1 mg/dL (OR 1.87, 95% CI 1.05-3.35), left atrial dimension above 4 cm (OR 3.78, 95% CI 1.29-11.06) and tricuspid maximal pressure gradient elevation above 35 mm Hg (OR 5.01, 95% CI 1.38-18.27). The presence of coronary disease was independently associated with less frequent occurrence of permanent AF in comparison to sinus rhythm group (OR 0.21, 95% CI 0.06-0.67). CONCLUSIONS More advanced congestive HF was associated with presence of both types of AF. Non-ischemic etiology of HF and elevated CRP are independently associated with permanent AF compared to sinus rhythm. Left ventricular diastolic dysfunction indicators (increased tricuspid maximal pressure gradient and left artial dimension) are independently associated with permanent AF.

Comment on Modifying Effect of Body Mass Index on Survival in Elderly Type 2 Diabetic Patients: Hong Kong Diabetes Registry and Reverse Epidemiology of Traditional Cardiovascular Risk Factors in the Geriatric Population

To the Editor: Cheung et al1 have recently published an intriguing study showing an association between body mass index (BMI) and mortality in the elderly with type 2 diabetes. It appears that high BMI protects against mortality in patients aged 65 years and older, especially in patients 75 years old and older. What is most noticeable is that this fact is the subject of interest more and more often lately. Also recently, Ahmadi et al2 have provided a very fascinating review of how BMI, serum cholesterol, and blood pressure are associated with death risk in the general and the geriatric population. Among the elderly, these traditional risk factors are linked to lower, not higher, risk of death. This phenomenon called “reverse epidemiology” or “risk factor paradox” is also observed in some chronic states such as end-stage renal disease requiring dialysis, chronic heart failure (CHF), rheumatoid arthritis, and AIDS. In September 2015, Piotrowski et al3 published data on 2 random populations, under and above 65 years of age (Wieloo srodkowe Ogólnopolskie Badanie Stanu Zdrowia Ludno sci [WOBASZ] andWOBASZ Senior Studies, both held in Poland), in the context of 15 risk factors of death, both of general and cardiovascular causes. One of the conclusions was that classic risk factors provided by the European Society of Cardiology in Heart Score scale were highly predictive of death in Caucasian population from Poland less than 65 years of age, and it related particularly to serum cholesterol, low-density lipoprotein cholesterol, BMI, abdominal obesity, hypertension, smoking, diabetes, and the male sex. In contrast, those risk factors in the population aged above 74 years did not predict similar cardiovascular and all-cause mortality results as in the WOBASZ Study. In that group, apart from the age, only creatinine level turned out to be a significantly prognostic risk factor of global mortality. Similar conclusions were drawn from Systolic Heart failure treatment with the If inhibitor ivabradine Trial (SHIFT) trial analysis, which covered patients with ischemic etiology of CHF with left ventricular ejection fraction 35% and aged 60.9 11.4 years. Specifically, higher than normal serum cholesterol was not related to global or cardiovascular cause of death as in the WOBASZ Senior Study. In the SHIFT trial as well as in the WOBASZ Senior Study, apart from the age, the elevated creatinine serum level turned out to be the most distinctive independent risk factor of death. In both the SHIFT trial and in the Ahmadi’s review, lower BMI and lower blood pressure were linked to higher risk of death in elderly populations. Similar trend was observed in WOBASZ Senior Study, in comparison with a younger WOBASZ cohort. As seen in before-mentioned reports, the prognostic value of traditional risk factors changes with age in a significant manner. What is also important in chronic states, such as CHF or renal failure, is that reverse epidemiology is observed in younger populations. A recurrent relation between increased creatinine level and mortality in all aforementioned studies may suggest a necessity of search for other risk factors, perhaps among the ones assessing microcirculation function. A question appears whether the elevated serum creatinine as a predictive risk factor is just an epiphenomenon or a key to changing a way of understanding the process of impaired microcirculation among the elderly and in chronic conditions. Moreover, as the reverse epidemiology is reported to revert back to classic epidemiologic relationships in patients after successful heart or kidney transplantation, it cannot be denied that what leads to that change in epidemiology is an improved microcirculation after both mentioned procedures. Because of the reverse epidemiology of traditional risk factors, it remains questionable whether some modifications of treatment should be recommended in particular groups of patients, at least in the elderly. As for patients with CHF, apart from the study provided by Horwich et al,4 statins intake did not result in a significant improvement of survival.5e7 Especially valuable is that Ahmadi et al mention the latest American College of Cardiology/American Heart Association guideline on the treatment of blood cholesterol, which indicates not recommending routine initiation of statins for primary prevention of atherosclerotic cardiovascular disease among all individuals older than 75 years.8 Considering WOBASZ Study and WOBASZSenior Study results, thequestion remainswhether this age threshold should not be lowered in the general geriatric population. Our believe is that further studies will both explicate the pathology of reverse epidemiology phenomenon, perhaps considering the aspect of microcirculation disturbances, as well as provide convincing evidence for the treatment standards.

UNEXPECTED POSITIVE EFFECT OF FRESH FROZEN PLASMA ON STANDARD ANTICOAGULATION IN THE CASE OF PULMONARY EMBOLISM ACCOMPANIED BY SEPSIS - A CASE REPORT

Abstract Introduction . In recent years there have been significant advances in the diagnosis and management of venous thromboembolism. This has resulted in the establishment of detailed diagnostic and therapeutic guidelines. Despite the benefits coming from their implementations, a clinical outcome of thromboembolic complications in particular patients poses a number of diagnostic difficulties. Treatment results and prognosis, despite following commonly recognized therapeutic standards, are difficult to predict. Aim . This paper aimed at presenting an atypical course of high-risk pulmonary embolism (PE) and the remote outcome of its treatment in a surgical patient with an initial low risk of thrombotic complications. Case study . The patient was a 58-year old female with a history of primary arterial hypertension who was electively operated on for euthyreotic polynodular goiter. On the 2nd postoperative day, she had to be resuscitated due to PE accompanied by sepsis with disseminated intravascular coagulation and shock. As shock symptoms did not subside despite the administration of typical treatment (Dextran, intravenous infusion fluids, dopamine, heparin, broad-spectrum antibiotics), and because of gastrointestinal bleeding suspicion, the patient was also administered fresh frozen plasma. Following resuscitation, lasting 2.5 hours, long-term improvement in hemodynamic parameters occurred. After respiratory therapy, lasting several hours, a gradual improvement of the patients general condition was observed. She regained consciousness, dyspnea subsided, and features of acute right ventricular overload gradually subsided in electrocardiogram. Results and discussion . On the one hand, the effectiveness of a combined treatment employing heparin and fresh frozen plasma could have resulted from its effect on improving tissue hypoperfusion secondary to the shock; and, on the other hand, because of the coexisting intravascular coagulation process. Fresh frozen plasma, apart from its commonly known procoagulative effect, may also enhance fibrinolytic processes. The potential influence of endogenous anticoagulants contained in plasma with respect to the course of PE has been discussed. It may have contributed to the regression of PE symptoms, despite the fact that in the acute phase the patient was on heparin only. Conclusions . Fresh frozen plasma, due to its endogenous anticoagulation activity, may positively influence the course of high-risk PE.

Indapamide-induced hyponatremia or the syndrome of inappropriate antidiuretic hormone secretion: a case report

We report a case of an apparently well-documented indapamide-induced hyponatremia. The initial diagnosis was made on the basis of dechallenge and rechallenge performed on two occasions. Further course of the disease, which proved inconsistent with our expectations, prompted us to look for another aetiology leading to the final diagnosis of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) complicated by indapamide treatment.

Evaluation of selected lipid parameters and blood pressure in ethnically-homogenous population of middle-aged persons, depending on gender, age and body mass

The study is a retrospective analysis of data obtained from a cardiovascular disease prevention program financed by the National Health Fund (Poland). The aim of the study was to evaluate the population to demonstrate the prevalence of favourable and unfavourable lipid parameters and blood pressure values depending on age and BMI. A total of 2,616 subjects were included in the study (811 men and 1805 women aged between 35 and 55 years of age) who perceived themselves as completely healthy individuals and in whom no cardiovascular disease or diabetes mellitus had been diagnosed. We evaluated blood pressure values, body weight, height, BMI, fasting glucose, total cholesterol, triglycerides, HDL and LDL in the serum of venous blood. The above-mentioned parameters were compared in women and men depending on BMI and age. It was demonstrated that the epidemiological situation of women in the analysed age group, regardless of the studied parameter and method of its evaluation, is much more favourable than that of men. We have demonstrated that evaluation of the analysed lipid parameters and blood pressure should be performed with consideration to gender and age. Otherwise conclusions may be obtained which are not satisfied by 75-95% of the population in a given age group. Obesity was highlighted as a factor triggering further lipid disturbances and blood pressure increase.