Kardiomiopatia przerostowa u bezobjawowej 24-letniej kobiety w ciąży — postępowanie według wytycznych ESC

We present the case of a 24-years old asymptomatic pregnant woman in 18hbd with hypertrophic cardiomyopathy (HCM). An echocardiogram revealed the hypertrophy of all walls of left ventricle (LV), except for the posterolateral wall, from 21mm to 31mm and septal hypertrophy up to 36mm. During the first 48-h-ECG monitoring 5 episodes of slowVT consisted of 3 ExV up to 108/min were recorded. The 5-year HCM SCD (sudden cardiac death) risk score revealed the low risk of 2,25% - implantable cardioverter-defibrylator (ICD) not indicated. After a C-section delivery in 37hbd the control echocardiography revealed the enlargement of LV wall hypertrophy up to 38mm. In 48h-ECG monitoring 2 episodes of asymptomatic nsVT consisted of 4 and 7 ExV up to 162/min were registered. The 5-year HCM SCD risk came up to intermediate level: 5,91% (ICD may be considered, class IIb B of recommendations). Based on the clinical and echocardiographic findings with dynamic progress in the LV hypertrophy, exacerbation of ventricular arrhythmias and increase of NT-proBNP, the ICD was implanted. As presented by Maron & Maron at ESC Congress in London 2015, an MRI scanning with the late gadolinium enhancement (LGE) estimation may be helpful in making the decision on the ICD implantation, especially within the group of the intermediate 5-year risk of SCD (4-6%) with massive LV hypertrophy. Authors suggest the extensive LGE (≥15%) as a primary SCD risk factor and also as a potential risk factor when conventional evaluation of the ICD implantation indications is ambiguous.Zaprezentowano opis przypadku 24-letniej kobiety z kardiomiopatią przerostową bez objawów w 18. tygodniu ciąży.W echokardiografii przezklatkowej (TTE) uwidoczniono przerost wszystkich ścian lewej komory (LV) poza tylno-boczną,od 21 mm do 31 mm, oraz przerost przegrody międzykomorowej do 36 mm. W 48-godzinnym badaniu elektrokardiograficznym(EKG) metodą Holtera stwierdzono 5 epizodów częstoskurczu komorowego złożonych z 3 pobudzeń o częstoścido 108/min. Wyliczono 5-letnie ryzyko nagłego zgonu sercowego (SCD) jako niskie — na poziomie 2,25% (wszczepialnykardiowerter-defibrylator [ICD] nie jest zalecany). Po porodzie drogą cięcia cesarskiego w 37. tygodniu ciąży w TTEuwidoczniono progresję przerostu mięśnia LV do 38 mm. W 48-godzinnym badaniu EKG metodą Holtera stwierdzono2 epizody bezobjawowego nieutrwalonego częstoskurczu komorowego z 4 oraz 7 pubudzeń o częstości do 162/min.Wyliczone 5-letnie ryzyko SCD zwiększyło się do 5,91% (klasa zaleceń IIb B dla ICD). Ze względu na całość obrazuklinicznego i echokardiograficznego, progresję przerostu ścian LV, nasilenie arytmii komorowej i zwiększenie stężeniaN-końcowego propeptydu natriuretycznego typu B pacjentce wszczepiono ICD. U pacjentów z pośrednim 5-letnim ryzykiemSCD w kardiomiopatii przerostowej (4–6%), zgodnie z doniesieniem Maron i Maron z kongresu EuropejskiegoTowarzystwa Kardiologicznego (Londyn, 2015), ocena późnego wzmocnienia kontrastowego (LGE) w badaniu rezonansumagnetycznego może być pomocna w podjęciu decyzji o implantacji ICD. Autorzy wskazują na LGE większe lub równe15% jako czynnik ryzyka SCD kwalifikujący do implantacji ICD, a także czynnik rozstrzygający w przypadku niejednoznacznychwskazań do wszczepienia ICD

Czynniki prognostyczne w obserwacji rocznej w przewlekłej niewydolności serca u chorych po 80. roku życia

Background: In the elderly the most common cause of hospitalisation and the leading cause of death is heart failure (HF). Aim: The purpose was to determine prognostic factors in chronic HF (CHF) in octogenarians and nonagenarians. Methods: The analysis included 197 consecutive patients over 80 years old (mean age 83.63 ± 3.01 years; 46.19% men) hospitalised in 2010–2013 due to CHF. Sixty-two parameters were investigated, such as: age, gender, New York Heart Asso­ciation functional class, body mass index, blood pressure, other comorbidities, the parameters of the 12-lead resting electro­cardiography and the echocardiography, the results of basic laboratory tests, and selected biomarkers, including N-terminal pro-B-type natriuretic peptide, high-sensitive troponin T (hs-TnT), and high-sensitive C-reactive protein. Participants remained in a prospective follow-up for 12 months. We defined the primary endpoint as death due to cardiovascular causes and the composite endpoint, which consisted of: death due to cardiovascular causes and/or hospitalisation for exacerbation of CHF. Follow-up concerning the deaths was performed in 189 patients, composite endpoint in 168 and hospitalisation in 166. The uni- and multivariate logistic regression stepwise analysis was performed for the entire population, according to left ventricular ejection fraction (LVEF < 45% and ≥ 45%) and in the group with glomerular filtration rate (GFR) < 60 mL/min. Results: Patients who died constituted 11.1% of the study population (21/189). In multivariate analysis four variables were independently associated with the primary endpoint: GFR (OR = 0.92), hypertension (OR = 0.19), lung diseases (OR = 9.36), and vascular diseases (OR = 6.07). In turn, in the group of patients who reached the composite endpoint (55/168; 32.7%), the only statistically significant independent variable was anaemia (OR = 4.71). In the subpopulation of patients with LVEF < 45% the prognostics for each endpoint were vascular diseases and lung diseases, and they increased the risk from 10- to 24-fold. In the subgroup of patients with LVEF ≥ 45% the independent variable associated with the composite endpoint was haemoglobin (OR = 0.61), in turn for death the prognostics were: white blood cell count, hs-TnT, and vascular diseases (respectively OR = 1.30; OR = 1.04; OR = 3.96). In the population with GFR < 60 mL/min variables with prognostic importance for the composite endpoint were red blood cell parameters: red blood cell distribution width (OR = 1.42) and anaemia (OR = 3.79), while for occurrence of death they were the same as for the entire population — vascular (OR = 5.16) and lung diseases (OR = 4.72). Conclusions: In patients over 80 years old with CHF, comorbidities are of important prognostic value for annual prognosis. The most aggravating factor in studied subgroups was lung disease.Wstęp: U osób w wieku podeszłym najczęstszą przyczyną hospitalizacji i główną przyczyną zgonu jest niewydolność serca (HF). Cel: Celem pracy było określenie czynników prognostycznych w przewlekłej HF dla 80-latków i 90-latków. Metody: Analizą objęto 197 kolejnych pacjentów powyżej 80. rż. (średni wiek wynosił 83,63 ± 3,01 roku; 46,19% mężczyzn) hospitalizowanych w latach 2010–2013 z powodu przewlekłej HF. Analizowano 62 parametry, m.in.: wiek, płeć, klasę funkcjonalną wg New York Heart Association, wskaźnik masy ciała, ciśnienie tętnicze krwi, obciążenia innymi chorobami współistniejącymi, parametry z 12-odprowadzeniowego spoczynkowego zapisu elektrokardiograficznego oraz echokardiografii, a także wyniki podstawowych badań laboratoryjnych i wybrane biomarkery, w tym N-końcowy propeptyd natriuretyczny typu B, wysokoczułą troponinę T (hs-TnT), wysokoczułe białko C-reaktywne. Pacjenci byli objęci obserwacją prospektywną przez rok. Wyznaczono pierwszorzędowy punkt końcowy — zgon z przyczyn sercowo-naczyniowych oraz złożony punkt końcowy, na który składał się zgon z przyczyn sercowo-naczyniowych i/lub hospitalizacja związana z zaostrzeniem przewlekłej HF. Informacje o pierwszorzędowym punkcie końcowym udało się uzyskać od 189 osób, o złożonym punkcie końcowym — od 168, a o hospitalizacjach — od 166 chorych. Przeprowadzono jedno- i wieloczynnikową analizę metodą regresji logistycznej krokowej postępującej dla całej populacji, w zależności od frakcji wyrzutowej lewej komory (LVEF < 45% i ≥ 45%), oraz w grupie z współczynnikiem filtracji kłębuszkowej (GFR) < 60 ml/min. Wyniki: Chorzy, którzy zmarli, stanowili 11,1% badanej populacji (21/189). Z analizy wieloczynnikowej uzyskano 4 zmienne niezależnie powiązane z wystąpieniem pierwszorzędowego punktu końcowego: GFR (OR = 0,92), nadciśnienie tętnicze (OR = 0,19), choroby płuc (OR = 9,36) i choroby naczyniowe (OR = 6,07). Wśród pacjentów, u których wystąpił złożony punkt końcowy (55/168; 32,7%), jedyną istotną statystycznie zmienną niezależną okazała się niedokrwistość (OR = 4,71). U osób z obniżoną LVEF < 45% dla każdego punktu końcowego prognostyczne okazały się choroby naczyniowe i choroby płuc, które zwiększały ryzyko od 10- do 24-krotnie. W podgrupie pacjentów z zachowaną LVEF ≥ 45% niezależną zmienną powiązaną z wystąpieniem złożonego punktu końcowego okazała się hemoglobina (OR = 0,61), natomiast dla wystąpienia zgonu prognostyczne były: liczba krwinek białych, hs-TnT i choroby naczyniowe (odpowiednio OR = 1,30; OR = 1,04 i OR = 3,96). W populacji z GFR < 60 ml/min zmiennymi mającymi znaczenie prognostyczne dla wystąpienia złożonego punktu końcowego były parametry czerwonokrwinkowe: wskaźnik zmienności objętości krwinek czerwonych (OR = 1,42) i niedokrwistość (OR = 3,79), natomiast dla wystąpienia zgonu, podobnie jak dla całej populacji, choroby naczyniowe (OR = 5,16) i choroby płuc (OR = 4,72). Wnioski: W populacji pacjentów po 80. rż. z przewlekłą HF choroby współistniejące miały istotne znaczenie prognostyczne dla rocznego rokowania. W badanym materiale czynnikiem najbardziej obciążającym były choroby płuc

Factors affecting the quality of anticoagulation with warfarin: experience of one cardiac centre

INTRODUCTION: The risk of complications in anticoagulation therapy can be reduced by maximising the percentage of time spent by the patient in the optimal therapeutic range (TTR). However, little is known about the predictors of anticoagulation control. The aim of this paper was to assess the quality of anticoagulant therapy in patients on warfarin and to identify the factors affecting its deterioration. MATERIAL AND METHODS: We studied 149 patients who required anticoagulant therapy with warfarin due to non-valvular atrial fibrillation and/or venous thromboembolism. Each patient underwent proper training regarding the implemented treatment and remained under constant medical care. RESULTS: The mean age of the patients was 68.8 ± 12.6 years, and 59% were male. A total of 2460 international normalised ratio (INR) measurements were collected during the 18-month period. The mean TTR in the studied cohort was 76 ± 21%, and the median was 80%. The level at which high-quality anticoagulation was recorded for this study was based on TTR values above 80%. Seventy-five patients with TTR ≥ 80% were included in the stable anticoagulation group (TTR ≥ 80%); the remaining 74 patients constituted the unstable anticoagulation group (TTR < 80%). According to multivariate stepwise regression analysis, the independent variables increasing the risk of deterioration of anticoagulation quality were: arterial hypertension (OR 2.74 [CI 95%: 1.06-7.10]; p = 0.038), amiodarone therapy (OR 4.22 [CI 95%: 1.30-13.70]; p = 0.017), and obesity (OR 1.11 [CI 95%: 1.02-1.21]; p = 0.013). CONCLUSIONS: The presence of obesity, hypertension, or amiodarone therapy decreases the quality of anticoagulation with warfarin. High quality of anticoagulation can be achieved through proper monitoring and education of patients

Prognosis of elderly patients hospitalized in the cardiac ward

Abstract Introduction Cardiovascular diseases affect nearly 80% of the elderly, and they are the major cause of death in this population. The aim was to evaluate the clinical profile and prognostic factors for patients aged 80 years and more who have been hospitalized for cardiologic reasons. Material and Methods The study included 100 patients aged 80–91 years (46% men) referred to the Department of Cardiology. We analyzed the reasons and length of hospitalization, clinical factors, results of basic laboratory tests, echocardiography, angiography, comorbidities and number of deaths during the hospitalization and in one year of follow-up. Patients were divided and analyzed, depending on the total mortality rate.Results The most common causes of hospitalization were myocardial infarction (67%) and heart failure (10%). Coronary angiography was performed in 72% of patients and percutaneous coronary intervention in 81%. The most common cause of hospital deaths was myocardial infarction (67%). The proportion of deaths in hospital was 8%, and during a year of observation it was 26%. Deaths were found to be related to ventricular conduction blocks (OR=4.0; P=0.03) and atrial fibrillation (OR=11.15; P=0.04). Conclusions In the elderly hospitalized in cardiac wards, myocardial infarction was the most common cause of hospitalization and hospital death. The mortality rate was high and associated with ventricular conduction blocks and atrial fibrillation.</jats:p

Pregnancy Outcomes in Women After Arterial Switch Operation for Transposition of the Great Arteries: Results From ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Programme

Background In the past 3 decades, the arterial switch procedure has replaced the atrial switch procedure as treatment of choice for transposition of the great arteries. Although survival is superior after the arterial switch procedure, data on pregnancy outcomes are scarce and transposition of the great arteries after arterial switch is not yet included in the modified World Health Organization classification of maternal cardiovascular risk. Methods and Results The ROPAC (Registry of Pregnancy and Cardiac disease) is an international prospective registry of pregnant women with cardiac disease, part of the European Society of Cardiology EURObservational Research Programme. Pregnancy outcomes in all women after an arterial switch procedure for transposition of the great arteries are described. The primary end point was a major adverse cardiovascular event, defined as combined end point of maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischemic coronary events, and thromboembolic events. Altogether, 41 pregnant women (mean age, 26.7±3.9 years) were included, and there was no maternal mortality. A major adverse cardiovascular event occurred in 2 women (4.9%): heart failure in one (2.4%) and ventricular tachycardia in another (2.4%). One woman experienced fetal loss, whereas no neonatal mortality was observed. Conclusions Women after an arterial switch procedure for transposition of the great arteries tolerate pregnancy well, with a favorable maternal and fetal outcome. During counseling, most women should be reassured that the risk of pregnancy is low. Classification as modified World Health Organization risk class II seems appropriate. </jats:sec

Health status after invasive or conservative care in coronary and advanced kidney disease

BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of &lt;30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, 120.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, 122.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, 121.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, 122.2 to 3.4). CONCLUSIONS Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy

Management of coronary disease in patients with advanced kidney disease

BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction

Evaluating the Appropriate Use Criteria for Coronary Revascularization in Stable Ischemic Heart Disease Using Randomized Data From the ISCHEMIA Trial

BACKGROUND: The appropriate use criteria for revascularization of stable ischemic heart disease have not been evaluated using randomized data. Using data from the randomized ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches; July 2012 to January 2018, 37 countries), the health status benefits of an invasive strategy over a conservative one were examined within appropriate use criteria scenarios. METHODS: Among 1833 participants mapped to 36 appropriate use criteria scenarios, symptom status was assessed using the Seattle Angina Questionnaire-7 at 1 year for each scenario and for each of the 6 patient characteristics used to define the scenarios. Coronary anatomy and SYNTAX(Synergy between percutaneous coronary intervention with Taxus and cardiac surgery) scores were measured using coronary computed tomography angiography. Treatment effects are expressed as an odds ratio for a better health status outcome with an invasive versus conservative treatment strategy using Bayesian hierarchical proportional odds models. Differences in the primary clinical outcome were similarly examined. RESULTS: The mean age was 63 years, 81% were male, and 71% were White. Diabetes was present in 28% and multivessel disease in 51%. Most clinical scenarios favored invasive for better 1-year health status. The benefit of an invasive strategy on Seattle Angina Questionnaire angina frequency scores was reduced for asymptomatic patients (odds ratio [95% credible interval], 1.16 [0.66-1.71] versus 2.26 [1.75-2.80]), as well as for those on no antianginal medications. Diabetes, number of diseased vessels, proximal left anterior descending coronary artery location, and SYNTAX score did not effectively identify patients with better health status after invasive treatment, and minimal differences in clinical events were observed. CONCLUSIONS: Applying the randomization scheme from the ISCHEMIA trial to appropriate clinical scenarios revealed baseline symptoms and antianginal therapy to be the primary drivers of health status benefits from invasive management. Consideration should be given to reducing the patient characteristics collected to generate appropriateness ratings to improve the feasibility of future data collection