Showing papers in "Kardiologia Polska in 2018"

[2017 ESC/EACTS Guidelines for the management of valvular heart disease].

Abstract: Authors/Task Force Members: Helmut Baumgartner* (ESC Chairperson) (Germany), Volkmar Falk* (EACTS Chairperson) (Germany), Jeroen J. Bax (The Netherlands), Michele De Bonis (Italy), Christian Hamm (Germany), Per Johan Holm (Sweden), Bernard Iung (France), Patrizio Lancellotti (Belgium), Emmanuel Lansac (France), Daniel Rodriguez Mu~ noz (Spain), Raphael Rosenhek (Austria), Johan Sjögren (Sweden), Pilar Tornos Mas (Spain), Alec Vahanian (France), Thomas Walther (Germany), Olaf Wendler (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain)

2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

Abstract: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

Oxidative stress and cardiovascular disease: new insights

Abstract: The role of oxidative stress in the onset and progression of atherosclerosis and its impact on the development of cardiovascular events has been widely described. Thus, increased oxidative stress has been described in several atherosclerotic risk factors, such as hypertension, dyslipidaemia, peripheral artery disease, metabolic syndrome, diabetes, and obesity. Among others, specific oxidative pathways involving both pro-oxidant and antioxidant enzymes seem to play a major role in the production of reactive oxidant species (ROS), such as nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, myeloperoxidase, superoxide dismutase, and glutathione peroxidase. In this review, we will discuss: 1) the most relevant enzyme systems involved in the formation and detoxification of ROS, 2) the relationship between oxidative stress and cardiovascular risk, and 3) therapeutic implications to modulate oxidative stress.

Baseline and postoperative levels of C-reactive protein and interleukins as inflammatory predictors of atrial fibrillation following cardiac surgery: a systematic review and meta-analysis.

Abstract: Background: Postoperative atrial fibrillation (POAF) is a leading arrhythmia with high incidence and serious clinical implications after cardiac surgery. Cardiac surgery is associated with systemic inflammatory response including increase in cytokines and activation of endothelial and leukocyte responses. Aim This systematic review and meta-analysis aimed to determine the strength of evidence for evaluating the association of inflammatory markers, such as C-reactive protein (CRP) and interleukins (IL), with POAF following isolated coronary artery bypass grafting (CABG), isolated valvular surgery, or a combination of these procedures. Methods: We conducted a meta-analysis of studies evaluating measured baseline (from one week before surgical procedures) and postoperative levels (until one week after surgical procedures) of inflammatory markers in patients with POAF. A compre­hensive search was performed in electronic medical databases (Medline/PubMed, Web of Science, Embase, Science Direct, and Google Scholar) from their inception through May 2017 to identify relevant studies. A comprehensive subgroup analysis was performed to explore potential sources of heterogeneity. Results: A literature search of all major databases retrieved 1014 studies. After screening, 42 studies were analysed including a total of 8398 patients. Pooled analysis showed baseline levels of CRP (standard mean difference [SMD] 0.457 mg/L, p < 0.001), baseline levels of IL-6 (SMD 0.398 pg/mL, p < 0.001), postoperative levels of CRP (SMD 0.576 mg/L, p < 0.001), postoperative levels of IL-6 (SMD 1.66 pg/mL, p < 0.001), postoperative levels of IL-8 (SMD 0.839 pg/mL, p < 0.001), and postoperative levels of IL-10 (SMD 0.590 pg/mL, p < 0.001) to be relevant inflammatory parameters significantly associated with POAF. Conclusions: Perioperative inflammation is proposed to be involved in the pathogenesis of POAF. Therefore, perioperative assessment of CRP, IL-6, IL-8, and IL-10 can help clinicians in terms of predicting and monitoring for POAF.

[The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary].

Abstract: Ponizszy tekst jest streszczeniem drugiej aktualizacji oryginalnego praktycznego przewodnika opublikowanego w 2013 roku. Leki przeciwkrzepliwe niebedące antagonistami witaminy K (NOAC) stanowią cenną alternatywe dla antagonistow witaminy K (VKA) w zapobieganiu udarom u pacjentow z migotaniem przedsionkow (AF) i uznano je za leki preferowane, szczegolnie dla osob rozpoczynających leczenie przeciwkrzepliwe. Zarowno lekarze, jak i pacjenci przyzwyczajają sie do ich stosowania w praktyce klinicznej, istnieje jednak wiele nierozwiązanych kwestii dotyczących optymalnego stosowania tych lekow w określonych sytuacjach klinicznych. Europejskie Stowarzyszenie Zaburzen Rytmu Serca (EHRA, European Heart Rhythm Association) podjelo sie koordynacji opracowania jednolitego sposobu komunikowania sie z lekarzami na temat stosowania roznych preparatow NOAC. Grupa określila 20 tematow zawierających konkretne scenariusze kliniczne, w odniesieniu do ktorych sformulowano praktyczne wskazowki na podstawie dostepnych dowodow. Do problemow klinicznych nalezą: 1) odpowiednia kwalifikacja pacjentow do leczenia; 2) praktyczne schematy rozpoczynania oraz monitorowania terapii za pomocą NOAC; 3) zagwarantowanie przestrzegania zalecen przyjmowania doustnych lekow przeciwkrzepliwych; 4) zmiana schematow leczenia przeciwkrzepliwego; 5) farmakokinetyka oraz interakcje lekowe; 6) stosowanie NOAC u osob z przewleklą chorobą nerek i zaawansowaną chorobą wątroby; 7) sposoby pomiaru efektu przeciwkrzepliwego NOAC; 8) pomiar stezenia NOAC w surowicy: rzadkie wskazania, środki ostrozności, potencjalne „pulapki”; 9) postepowanie w przypadku pomylki w dawkowaniu; 10) postepowanie w przypadku (podejrzenia) przedawkowania bez krwawienia lub badania krzepniecia wskazujące na potencjalne ryzyko krwawienia; 11) postepowanie w przypadku krwawienia w trakcie terapii za pomocą NOAC; 12) postepowanie u pacjentow poddanych planowym zabiegom chirurgicznym, procedurom inwazyjnym czy ablacji; 13) postepowanie u pacjentow wymagających pilnej interwencji chirurgicznej; 14) pacjenci z AF oraz chorobą wiencową; 15) unikanie pomylek w dawkowaniu NOAC w roznych wskazaniach; 16) kardiowersja u pacjenta leczonego NOAC; 17) AF u pacjentow z ostrym udarem mozgu leczonych NOAC; 18) NOAC w sytuacjach szczegolnych; 19) leczenie przeciwkrzepliwe w przypadku AF u pacjentow z nowotworami zlośliwymi; 20) optymalizacja leczenia za pomocą VKA. Dodatkowe informacje oraz materialy do pobrania, jak rowniez karty leczenia przeciwkrzepliwego w kilku jezykach mozna znaleźc na stronie internetowej EHRA (www.NOACforAF.eu).

Diagnostic and prognostic micro-RNAs in ischaemic stroke due to carotid artery stenosis and in acute coronary syndrome: a four-year prospective study

Abstract: Background: Circulating microRNAs (miRs) levels are potentially important diagnostic and prognostic biomarkers in acute coronary syndrome (ACS) or cerebral ischaemic events (CIE) resulting from internal carotid artery stenosis (ICAS). Aim: This four-year prospective study aimed to compare the levels of circulating miRs in ACS vs. CIE patients, and investigate miRs potentially associated with risk of recurrent cardiovascular events. Methods: The circulating miRs levels (miR-1-3p, miR-16-5p, miR-34a-5p, mir-122-5p, miR-124-3p, miR-133a-3p, miR-133b, miR-134-5p, miR-208b-3p, miR-375, and miR-499-5p) were compared in 43 (34 men, 57.6 ± 10.1 years) patients with ACS, and in 71 (47 men, 69.5 ± 9.6 years) with CIE due to ICAS. A four-year prospective evaluation of miRs associated with risk of cardiovascular death (CVD), myocardial infarction (MI), CIE, or all (CVD/MI/CIE) was performed. Results: In ACS vs. CIE patients, the levels of miR-124-3p (p < 0.001), miR-134-5p (p = 0.012), miR-208b-3p (p < 0.001), miR-34a-5p (p < 0.001), and miR-499-5p (p < 0.001) were higher, while levels of miR-16-5p (p < 0.001) and miR-122-5p (p < 0.001) were lower. Levels of miR-1-3p (p = 0.195), miR-133a-3p (p = 0.333), miR-133b (p = 0.056), and miR-375 (p = 0.055) were non-statistically different. During follow-up (median 57 months, Q1–Q3: 54–60), CVD/MI/CIE occurred in 23 subjects, including eight CVDs, five non-fatal CIEs, and 10 non-fatal MIs. The multivariate Cox proportional hazard analysis (relative risk [RR]; 95% confidence interval [CI]) revealed that miR-208b-3p (1.225; 1.092–1.375), miR-34a-5p (0.963; 0.935–0.992), and miR-499-5p (0.077; 0.025–0.239) were independently associated with risk of CVD/MI/CIE, as well as risk of each event. Furthermore, miR-133b (1.009; 1.003–1.015) was associated with risk of CVD. Conclusions: This study shows that although most investigated miRs levels differ significantly between patients with ACS and CIE, similar levels of circulating miR-1-3p, miR-133a-3p, miR-133b, and miR-375 were observed; furthermore, we identified several common miRs as possible risk factors for recurrent cardiovascular events.

Differences in knowledge among patients with atrial fibrillation receiving non-vitamin K antagonist oral anticoagulants and vitamin K antagonists

Abstract: Background: Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF) worldwide. Few articles have compared current understanding of AF patients about the disease and anticoagulant therapy in relation to the medications used. Aim: We sought to compare the knowledge of AF and anticoagulation between AF patients treated with NOACs and those on vitamin K antagonists (VKAs). Methods: We used the Jessa AF Knowledge Questionnaire (JAKQ), developed and validated in Belgium. Patients were re­cruited at a tertiary centre in Krakow, Poland. Results: A total of 479 AF patients completed the JAKQ. Patients on NOACs (n = 276, 57.6%) compared with those on VKAs (n = 175, 36.5%) did not differ regarding demographic and clinical variables. The mean score of the JAKQ was very similar in the NOAC and VKA group (60.7 ± 17.0% vs. 61.6 ± 17.1%; p = 0.4, respectively). The differences in the proportion of correct responses referred to three questions. Consequences of AF, such as blood clots and cerebral infarction, were more obvious for patients on NOACs compared with those on VKAs (81.5% vs. 70.9%; p = 0.01). The patients on NOACs (78.7% vs. 67.6%; p = 0.009) more frequently considered consulting a physician for advice concerning anticoagulant treatment before surgery, while fewer patients on NOACs were aware of the need to take their medication even if they did not feel AF (76.1% vs. 89.7%; p = 0.0004). Only 25.9% of the VKA patients and 49.3% of the NOAC users knew what to do if they missed a dose of the anticoagulant. Conclusions: The knowledge of arrhythmia and anticoagulation is better regarding the safety issues among subjects on NOACs compared with those on VKAs. Irrespective of the type of oral anticoagulation therapy, education of AF patients should be improved.

Catheter ablation of atrial fibrillation: current status, techniques, outcomes and challengesCatheter ablation of atrial fibrillation: current status, techniques, outcomes, and challenges

Abstract: Atrial fibrillation (AF) is the most common human arrhythmia. Interventional treatment with catheter ablation is an established technique that is increasingly applied and has become one of the main treatment modalities in patients with AF. Ablation results in significant improvement of symptoms and the quality of life. There is as yet no clear evidence of any impact of the procedure on hard clinical endpoints, except in patients with heart failure, who seem to benefit significantly from ablation. The cornerstone of the procedure is the achievement of pulmonary vein isolation. Radiofrequency energy is the main applied energy source, but cryoballoon ablation has emerged as a safe and effective alternative to radiofrequency ablation. Additional ablation strategies and novel technical features have been proposed but without unequivocal proof of clinical benefit. The most promising of these seems to be substrate mapping of the left atrium with substrate modification in areas with low voltage as an adjunct to pulmonary vein isolation. Complication rates remain considerable despite accumulated experience and can be partly reduced by application of preventive measures.

Reperfusion treatment in acute myocardial infarction in elderly patients.

Abstract: In this paper the current knowledge of reperfusion therapy in elderly patients with an ST-segment elevation acute myocardial infarction (STEMI) is summarised. Placebo-controlled trials of fibrinolytic agents, direct comparative trials of fibrinolytic agents and antithrombotic co-therapies, and randomised trials of primary percutaneous coronary intervention (PCI) versus fibrinolytic therapy as well as registries are briefly reviewed, focusing on the impact of age. The benefit and risk of a combined pharma-cological and mechanical approach is presented. Important differences between a "facilitated PCI" and a "pharmaco-invasive strategy", particularly in older STEMI patients, are highlighted. It will become clear at the end of this review that the knowledge about the benefit and risk of reperfusion therapy in the elderly is still incomplete and that more clinical trials in the elderly are needed. Practical recommendations for elderly patients with STEMI based on the current knowledge have been provided.

The usefulness of C-reactive protein for the prediction of post-infarct left ventricular systolic dysfunction and heart failure

Abstract: Acute myocardial infarction (MI) provokes a systemic inflammatory response that may contribute to the development of left ventricular systolic dysfunction (LVSD) and heart failure (HF). Patients with post-infarct HF with concomitant LVSD have the most unfavourable long-term prognosis. Measurement of C-reactive protein (CRP) concentration reflecting an involvement of inflammatory pathways in post-infarct myocardial damage offers an attractive strategy to improve risk stratification and clinical decision-making for early management of high-risk patients. Despite growing evidence for the prognostic value of CRP both as a single factor and as a component of multi-marker approach in MI, CRP measurement is not yet incorporated into current guidelines. This may be due to conflicting results reported in existing studies related to various limitations in study designs, such as retrospective case control design, prior myocardial damage, CRP measurement with low-sensitivity assays, non-homogenous populations with acute coronary syndromes, different treatment strategies, small sample sizes, and the lack of left ventricular ejection fraction assessment and long-term clinical and echocardiographic monitoring. As a result, previous studies have not provided conclusive evidence of the prognostic value of CRP for post-infarct LVSD or HF. Future studies with an adequate design including upstream mediators of inflammation as inflammatory markers are needed to identify the best biomarker-based strategies for identifying high-risk patients. Further clinical trials involving anti-inflammatory therapies target-ing different pathways of inflammatory activation in MI should test the inflammatory hypothesis of post-infarct LVSD and HF. Identifying high-risk patients with persistent post-infarct inflammatory response may allow incorporation of pathophysiological guidance for implementation of personalised treatment approaches.

Cardioneuroablation using an anatomical approach: a new and promising method for the treatment of cardioinhibitory neurocardiogenic syncope.

Abstract: INTRODUCTION Neurally mediated syncope (NMS) is the most common cause of syncope and is brought about by enhanced vagal tone leading to asystole, sinus bradycardia, or atrioventricular block (AVB) [1]. According to the current guidelines, dual-chamber cardiac pacing may be considered in patients > 40 years old, when the correlation between syncopal episodes and asystole is documented. In younger patients, pacemaker implantation may be considered only in very selected cases [1]. Recently, endocardial biatrial ablation of ganglionated plexi (GP) has been shown to provide excellent shortand long-term results in the treatment of syncope caused by cardioinhibitory reflex syncope or functional AVB [2–4]. However, this method, called cardioneuroablation (CNA), is still evolving, and more data are needed to establish its role in the treatment of NMS. We present three patients with frequent syncopal episodes due to cardioinhibitory mechanism, who underwent CNA in order to improve symptoms and avoid pacemaker implantation.

Metabolic syndrome in HIV infected adults in Poland.

Abstract: Background: Metabolic syndrome (MS) is usually diagnosed based on the presence of abdominal obesity, elevated blood pres­sure (BP), elevated fasting plasma glucose, high serum triglycerides (TG), and low high-density lipoprotein (HDL) cholesterol levels. Whether HIV is associated with a higher prevalence of MS than in the general population remains unclear. Aim: The aim of the study was to determine the incidence of MS in the population of HIV-infected adults and its association with clinical, virological, and biochemical features. Methods: Two hundred and seventy HIV-infected Caucasian adult patients were enrolled in the study and evaluated based on clinical records in the years 2013–2015. Results: Metabolic syndrome was diagnosed in 60 of 270 (22%) patients, 47 (24%) males and 13 (17%) females, mostly (72%) aged above 40 years. The percentage of patients with diagnosed MS in specific age groups in comparison to the general Polish population for females aged 30 kg/m2 in 29%, waist circumference exceeding 94 cm in men and 80 cm in woman — 87.5%, TG ≥ 150 mg/dL — 82%, HDL cholesterol 100 mg/dL — 42%. In stepwise multivariate logistic regression analysis, age (odds ratio [OR] 1.052, 95% con­fidence interval [CI] 1.018–1.088, p = 0.003) and nadir CD4 < 350 cells/mm3 (OR 3.576, 95% CI 1.035–12.355, p = 0.04) were associated with MS. Patients with MS compared with those without this disorder had low, intermediate, high, and very high cardiovascular risk in 10% vs. 23%, 73% vs. 70%, 7% vs. 5%, and 10% vs. 2%, respectively (p = 0.006). Conclusions: Prevalence of MS in the HIV-infected population is higher than in the general Polish population. Age and low nadir CD4 were found to be associated with MS.

Hybrid versus traditional cardiac rehabilitation models: a systematic review and meta-analysis

Abstract: Background: The common drawbacks of standard cardiac rehabilitation (CR) models include low participation rate, high cost, and dependence on on-site exercise sessions. Therefore, hybrid CR protocols have been developed. Aim: We aimed to test whether hybrid CR models are superior or equivalent to the traditional CR models in patients after myocardial infarction, heart failure, and cardiac surgery, using a meta-analysis framework. Methods: Data from relevant original studies indexed in the Medline, Scopus, Cochrane Central, and Web of Science data­bases were extracted and analysed. The standardised mean difference (SMD) was used as a summary effect estimate, along with 95% confidence interval (CI). Results: Based on data from 1195 patients, the summary effect size showed similar improvement in functional capacity in hybrid and standard CR programmes (SMD = –0.04, 95% CI –0.18 to 0.09, p = 0.51). No significant difference was detected between the two models in terms of changes in exercise duration (SMD = –0.14, 95% CI –0.51 to 0.24, p = 0.47), systolic (SMD = –0.01, 95% CI –0.14 to 0.12, p = 0.91), and diastolic (SMD = –0.03, 95% CI –0.16 to 0.11, p = 0.7) blood pres­sure, or health-related quality of life (SMD = –0.08, 95% CI –0.23 to 0.07, p = 0.27). In terms of blood lipids, no significant difference was noted between hybrid and traditional CR models in all assessed lipid profile parameters, except for triglycerides (favouring the traditional CR model). Conclusions: Hybrid CR protocols showed comparable efficacy to the traditional model. Further well-designed studies are required to validate these findings, especially regarding the long-term outcomes.

Rotational atherectomy in everyday clinical practice. Association of Cardiovascular Interventions of the Polish Society of Cardiology (Asocjacja Interwencji Sercowo-Naczyniowych Polskiego Towarzystwa Kardiologicznego - AISN PTK): Expert opinion.

Abstract: The common use of stents, including antiproliferative drug-eluting stents, has been a major breakthrough in invasive cardiology. Nowadays, a change in the clinical presentation of patients treated with percutaneous coronary intervention (PCI) is observed. The typical clinical characteristics now include advanced age, diabetes, chronic kidney disease, heart failure, and multilevel atherosclerosis. Age, diabetes, and chronic kidney disease are the main predictors of coronary artery calcifications. Severe coronary artery calcifications are the main factor limiting the efficacy of PCI. Successful stent implantation is challenging in the presence of calcifications, because it is difficult to achieve full stent expansion and proper stent apposition. Therefore, it is necessary to adequately prepare the lesion before stent implantation. This document presents the technique of rotational atherectomy (rotablation) as well as indications for and contraindications to the procedure, along with its possible complications and their prevention. Training in rotablation for operators as well as reimbursement policy for the procedure in Poland are also discussed.

miR-1, miR-21, and galectin-3 in hypertensive patients with symptomatic heart failure and left ventricular hypertrophy

Abstract: INTRODUCTION Left ventricular hypertrophy (LVH) is known as an independent risk factor for coronary heart disease, heart failure (HF), stroke, and sudden cardiac arrest. LVH implicates changes in the architecture of myocardial tissue, which consist of perivascular and myocardial fibrosis, as well as medial thickening of intramyocardial coronary arteries, in addition to cardiomyocyte hypertrophy [1–3]. The impact of miR-1 level on cardiac hypertrophy and cardiomyocyte apoptosis has been recently suggested [3, 4]. Also, the association between miR-21 and galectin-3 (gal-3) levels and maladaptive cardiac remodelling, fibrosis, and inflammation has been described [5, 6]. Nevertheless, the synergistic role of these molecules in LVH has not been explained to date. We analysed the expressions of miR-1, miR-21, and gal-3 concentration in patients with symptomatic HF (SHF) and a history of hypertension and LVH revealed in echocardiography.

Association of cardiac troponin I with prothrombotic alterations in atrial fibrillation

Abstract: INTRODUCTION Atrial fibrillation (AF) increases the risk of stroke and systemic thromboembolism. A hypercoagulable state in AF is reflected by elevated von Willebrand factor (vWF), D-dimer, and thrombin generation (TG), as well as increased platelet activation [1]. The usefulness of several biomarkers in stroke and bleeding risk prediction among AF patients, in particular N-terminal pro–B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I (cTnI-hs), has been demonstrated, although practical implications of this strategy are uncertain [2]. We sought to assess the relations of four such markers: cTnI-hs, cystatin C, vWF, and NT-proBNP, with prothrombotic alterations in AF patients.

The influence of metformin and the presence of type 2 diabetes mellitus on mortality and hospitalisation in patients with heart failure.

Abstract: Background: Metformin is one of the antihyperglycaemic drugs, reducing the risk of major cardiovascular events, including fatal ones. Although it is formally contraindicated in moderate and severe functional stages of heart failure (HF), it is commonly used in patients with concomitant type 2 diabetes mellitus (T2DM). Aim: We sought to evaluate the effect of metformin and T2DM on total mortality and hospitalisation rates in patients with HF. Methods: This retrospective analysis included 1030 adult patients (> 18 years) with HF from the Polish section of the HF Long-Term Registry (enrolled between 2011 and 2014). Patients with T2DM (n = 350) were identified and divided into two groups: those receiving metformin and those not. Both groups were subjected to one-year follow-up. Results: Mean patient age was 65.3 ± 13.5 years, with the predominance of male sex (n = 726) and obesity (mean body mass index 30.3 ± 5.5 kg/m2) and mean left ventricular ejection fraction was 34.3% ± 14.1%. Among patients with T2DM (n = 350) only 135 (38.6%) were treated with metformin. During one-year follow-up, 128 patients with HF died, of whom 53 had T2DM (15.1% vs. 10.9%, hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.87–0.91, p = 0.045). Metformin was associated with a lower mortality rate compared to other antihyperglycaemic agents (9.6% vs. 18.6%, HR 0.85; 95% CI 0.81–0.89, p = 0.023). There were no significant differences in the hospitalisation rate, including that due to HF decompensation, among patients treated with metformin and the remainder (53.5% vs. 40.0%, respectively HR 0.93, 95% CI 0.82–1.04, p = 0.433). Conclusions: Metformin treatment in patients with different degrees of HF and T2DM is associated with a reduction in mortality and does not affect the hospitalisation rate.

Green tea polyphenol epigallocatechin-3-gallate increases atherosclerotic plaque stability in apolipoprotein E-deficient mice fed a high-fat diet

Abstract: Background: Epigallocatechin-3-gallate (EGCG), which is the principal component of green tea, has been shown to prevent atherosclerosis. However, the effect of EGCG on atherosclerotic plaque stability remains unknown. Aim: This study aimed to assess whether EGCG can enhance atherosclerotic plaque stability and to investigate the underlying mechanisms. Methods: Apolipoprotein E-deficient mice fed a high-fat diet were injected intraperitoneally with EGCG (10 mg/kg) for 16 weeks. Cross sections of the brachiocephalic arteries were stained with haematoxylin and eosin for morphometric analyses or Masson’s trichrome for collagen content analyses. Immunohistochemistry was performed to evaluate the percentage of macrophages and smooth muscle cells (SMCs). Protein expression and matrix metalloproteinase (MMP) activity were assayed by Western blot and gelatin zymography, respectively. Serum inflammatory cytokine levels were quantified by enzyme-linked immunosorbent assays. Results: After 16 weeks of feeding the high-fat diet, there were clear atherosclerotic lesions in the proximal brachiocephalic artery segments according to HE staining. EGCG treatment significantly increased the thickness of the fibrous cap. In the atherosclerotic plaques of the EGCG group, the relative macrophage content was decreased, whereas the relative SMC and collagen contents were increased. The expression levels of MMP-2, MMP-9, and extracellular matrix metalloproteinase inducer (EMMPRIN) were significantly decreased by EGCG treatment. In addition, EGCG treatment decreased the circulat­ing tumour necrosis factor-α, interleukin-6, monocyte chemoattractant protein-1, and interferon-γ levels in apolipoprotein E-deficient mice. Conclusions: EGCG promotes atherosclerotic lesion stability in apolipoprotein E-deficient mice. Potentially, these effects are mediated through the inhibition of inflammatory cytokine, MMPs and EMMPRIN expression.

Heartfelt sepsis: microvascular injury due to genomic storm

Abstract: Sepsis is one of the ten leading causes of death in developed and developing countries. In the United States, sepsis mortality approaches that of acute myocardial infarction and exceeds deaths from stroke. Neonates and the elderly are the most vulner­able patients, with these groups suffering from the highest sepsis mortality. In both groups, many survivors respectively display serious developmental disabilities and cognitive decline. The National Institute of Health/National Heart, Lung, and Blood Institute Panel redefined sepsis as a “severe endothelial dysfunction syndrome in response to intravascular and extravascular infections causing reversible or irreversible injury to the microcirculation responsible for multiple organ failure.” Microvas­cular endothelial injury in sepsis due to microbial inflammation encompasses small blood vessels (< 100 μm in diameter). While the lungs remain the principal organ of interest due to sepsis-associated acute respiratory distress syndrome, “septic heart” or “septic cardiomyopathy” accelerates sepsis’ transition to potentially lethal septic shock. This review analyses both new advances in understanding the septic mechanism and possible resolutions of sepsis. The concept of a “genomic storm,” caused by microbes triggering florid production of inflammatory mediators, is based on septic reprogramming of the human genome. This genomic storm leads to microvascular endothelial injury, persistent hypotension, and organ failure. While very early control of sepsis-causing bacterial, fungal and viral infections remains crucial for the treatment of sepsis, supportive measures are likewise necessary to maintain blood pressure, respiration, and kidney function. New evidence indicates that preadmission b-blockers may reduce sepsis-associated mortality. The fundamental role of nuclear signalling in the progres­sion and resolution of sepsis was established with a new class of cell-penetrating nuclear transport modifiers (NTMs). NTMs target the translocation of proinflammatory and metabolic transcription factors to the cell’s nucleus while also enhancing bacterial clearance in experimental polymicrobial sepsis models. The result is a 700-fold reduction in the bacterial burden of the lungs and improvement of sepsis-associated thrombocytopaenia and blood markers of endothelial injury. When added to anti-microbial therapy, NTM has increased survival from 30% to 55%, when compared to antimicrobial therapy alone. Yet, the prevention of sepsis remains the most rational and beneficial path. Anti-pneumococcal vaccination has reduced the incidence of pneumonia and sepsis caused by increasingly antibiotic-resistant Streptococcus pneumoniae in all age groups. Similarly, the incidence of meningococcal sepsis known as “purpura fulminans” has been reduced by a recently approved vaccine thereby preventing hearing loss, neurologic damage, and limb amputations in young survivors of septic outbreaks. We urgently need further preventive, diagnostic, and therapeutic measures as the tide of sepsis rises in the United States and around the world.

Comparison of clinical characteristics of real-life atrial fibrillation patients treated with vitamin K antagonists, dabigatran, and rivaroxaban: results from the CRAFT study

Abstract: Background: The first-line drugs for the treatment of non-valvular atrial fibrillation (AF) are non-vitamin K antagonist oral anticoagulants (NOACs), which are preferred over vitamin K antagonists (VKAs). There is some evidence that there are dis-crepancies between everyday clinical practice and the guidelines. Aim: The study aimed to compare the characteristics of patients on VKAs, dabigatran, and rivaroxaban in everyday practice (i.e. baseline characteristics, drug doses, risk factors for bleeding and thromboembolic events). Additionally, we assessed the frequency of prescription of different oral anticoagulants (OACs) in recent years. Methods: This study consisted of data from the multicentre CRAFT (MultiCentre expeRience in AFib patients Treated with OAC) study (NCT02987062). This was a retrospective analysis of hospital records of AF patients (hospitalised in the years 2011–2016) treated with VKAs (acenocoumarol, warfarin) and NOACs (dabigatran, rivaroxaban). A total of 3528 patients with non-valvular AF were enrolled in the CRAFT study. Results: The total cohort consisted of 1973 patients on VKA, 504 patients on dabigatran, and 1051 patients on rivaroxaban. Patients on rivaroxaban were older (70.5 ± 13.1 years) and more often female (47.9%), compared with those on VKAs (67.0 ± 12.8 years, p < 0.001; 35.5%, p < 0.001) and on dabigatran (66.0 ± 13.9 years, p < 0.001; 38.9%, p = 0.001). Among NOACs, patients with persistent and permanent AF were more likely to receive rivaroxaban (54.7% and 73.4%, re-spectively) than dabigatran (45.3%, p < 0.001 and 26.6%, p = 0.002, respectively). Patients on rivaroxaban had higher risk of thromboembolic events (CHA2DS2VASc 3.9 ± 2.0, CHADS2 2.2 ± 1.4) than those on VKAs (3.3 ± 2.0, 1.9 ± 1.3) and on dabigatran (3.1 ± 2.0, 1.8 ± 1.3). Patients on rivaroxaban had also a higher rate of prior major bleeding (11.2%) than those on VKAs (6.7%, p < 0.001) and on dabigatran (7.3%, p = 0.02). Patients on lower doses of dabigatran and rivaroxaban had a significantly higher risk of thromboembolic and bleeding events. Use of VKAs in the year 2011 was reported in over 96% of patients on OACs, but this proportion decreased to 34.6% in 2016. In the last analysed year (2016) AF patients were treated mainly with NOACs — dabigatran (24.2%) and rivaroxaban (41.3%). Conclusions: The prescription of VKAs declined significantly after the introduction of NOACs. Patients treated with different OACs demonstrated a distinct baseline clinical profile. The highest risk of thromboembolic events and incidence of major bleedings was observed in patients on rivaroxaban, in comparison to patients on VKAs and dabigatran. Among NOACs, patients treated with lower doses of dabigatran and rivaroxaban were older and had a significantly higher risk of thromboembolic and bleeding events.

EQ-5D studies in cardiovascular diseases in eight Central and Eastern European countries: a systematic review of the literature.

Abstract: Background: The measurement of health-related quality of life (HRQoL) by validated generic instruments, such as EQ-5D, has become an increasingly important tool for the assessment of health care in a wide range of diagnoses. Aim: We aimed to systematically review EQ-5D literature on cardiovascular diseases in eight Central and Eastern European (CEE) countries. Methods: A structured literature search was conducted in MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, Cochrane Library, and the EuroQol website up to November 2016. Original cardiovascular-related studies that reported EQ-5D results were included. Results: Of the 36 papers, 17 reported EQ-5D index scores. Most studies were performed in Poland (n = 24, 67%). The most common diagnosis regarding the number of publications and population size was ischaemic heart disease (n = 13, N = 6394), followed by atrial fibrillation (n = 4, N = 1052). The average EQ-5D index scores ranged from 0.61 to 0.88 and from 0.66 to 0.95 for patients before and after cardiac procedure/surgery, respectively (including angioplasty, coronary artery bypass grafting, ablation, surgical correction of septal defects, transcatheter aortic valve implantation [TAVI]). In all studies baseline scores were lower than the repeated assessments after the procedure, with the most substantial improvement of 0.24 in high-risk elderly patients after TAVI. Studies which did not assess invasive treatment reported mean EQ-5D index scores ranging from 0.18 to 0.80. Conclusions: The number of cardiovascular-related studies reporting HRQoL using EQ-5D has consistently increased in CEE countries over the past decade and is outstanding compared with other clinical fields. The EQ-5D index and EQ VAS scores varied based on the disease severity, patient characteristics, and treatment protocol.

Number of erythrocytes as a prognostic marker in patients undergoing heart valve surgery.

Abstract: INTRODUCTION Anaemia is defined by the Word Health Organisation as a haemoglobin level < 130 g/L for men and < 120 g/L for women [1]. It has been shown that lower haemoglobin levels are associated with increased mortality and morbidity among the elderly, and in patients with chronic heart failure or myocardial infarction [2–4]. The role of haemoglobin or haematocrit as independent predictors of mortality and morbidity in patients undergoing cardiac surgery has been described primarily in patients with coronary artery disease undergoing coronary artery bypass grafting [5, 6], as well as in patients undergoing heart valve surgery or congenital heart defects surgery [7–9]. In contrast, the predictive role of the red blood cell count (RBC) in patients undergoing valvular cardiac surgery has not been described. Given this gap in knowledge, we decided to assess a predictive value of the individual parameters of blood cell counts in patients undergoing heart valve surgery.

Clinical anatomy of human heart atria and interatrial septum - anatomical basis for interventional cardiologists and electrocardiologists. Part 1: right atrium and interatrial septum.

Abstract: INTRODUCTION Interventional cardiology together with interventional electrocardiology are nowadays one of the fastest developing branches of medicine and latterly, indications for transcatheter interventions have been extended to more and more folded cases. In recent decades, rapid progression in treatment of various types of atrial arrhythmias, particularly atrial fibrillation and atrial flutter, has been observed. Ablation within the cavotricuspid and other parts of the right atrium, as well as cardiac resynchronisation therapy, has become a standard approach. The right atrium (RA) and the interatrial septum are not only the direct targets of various interventions but also enable access to left heart chambers. The RA consists of many unique anatomical structures whose presence and morphology not only may trigger the abnormal electric activity of the heart, but also hinder the course of procedures. Precise understanding of heart anatomy and the most frequently observed anatomical variants of atrial structures seems to be crucial for achieving satisfying results, and minimising or avoiding complications during interventional procedures. This comprehensive summary presents in a thorough but uncomplicated way a detailed macroscopic morphology of RA and interatrial septum. It also provides the anatomical background for the most common atrial arrhythmias and invasive cardiological procedures.

Secondary prevention of cardiovascular diseases: current state of the art.

Abstract: Prevention strategies for cardiac events depend of the risk for such an event. A very high risk is defined as a risk > 10% over 10 years. For example, a patient with known coronary artery disease has such a very high risk of death. However, a patient with diabetes and severe hypertension without known coronary artery disease carries the same risk. Here, secondary preven-tion and primary prevention overlap. Prevention guidelines include a number of general recommendations, such as changes in behaviour, nutrition, body weight, and physical activity as well as smoking intervention strategies. Drug treatment-based prevention strategies address diabetes mellitus, hypercholesterolaemia, platelet aggregation, and arterial hypertension. Follow-ing hospitalisation for heart failure or acute coronary syndrome, participation in a centre-based or home-based rehabilitation programme is recommended. There are a number of new treatment options with a promising potential to reduce the rate of events in patients with cardiovascular diseases and in patients with cardiovascular risk factors. Very recent treatment strategies include the PCSK9 inhibitors for hypercholesterolaemia and the SGLT2 inhibitors for reduction of cardiovascular events in patients with diabetes mellitus and increased cardiovascular risk.

[Coordinated heart failure care in Poland: towards optimal organisation of the health care system].

Abstract: Heart failure has becoming an increasing medical, economic, and social problem globally. The prevalence of this syndrome is rising, and despite unequivocal positive effects of modern therapy, reduction of mortality has been achieved at the cost of more frequent hospitalisations. Unlike in many European countries, in Poland heart failure is usually recognised later, at a more advanced stage of the disease, leaving less time for ambulatory treatment and resulting in a high number of hospitalisations. The current paper presents the most important data regarding morbidity and mortality due to heart failure in Poland. The experts in the field focus on the key source of high costs of therapy and highlight several critical organisational deficits present in the Polish health care system. This background information builds a basis for a concept of coordinated care for patients with heart failure. The paper discusses the fundamental elements of the system of coordinated care for patients with heart failure necessary to enhance the diagnosis, improve therapeutic effects, and reduce medical, economic, and social costs.

Acetylsalicylic acid and clopidogrel hyporesponsiveness following acute coronary syndromes

Abstract: This review discusses the response variability to acetylsalicylic acid (ASA) and particularly to clopidogrel, and their relation to adverse recurrent ischaemic events in patients with arterial diseases. The higher rate of ASA resistance reported in the literature may be mainly due to the cyclooxygenase-1 non-specific assays, non-compliance, and underdosing. Clopidogrel response variability and non-responsiveness are established concepts. Moreover, high platelet reactivity (HPR) to adenosine diphosphate during clopidogrel therapy is now a known risk factor for recurrent ischaemic events in high-risk percutaneous coronary intervention/acute coronary syndrome patients. Variable active metabolite generation is the primary explanation for clopidogrel response variability and non-responsivenes. Variable levels of active metabolite generation following clopidogrel administration could be mainly explained by functional variability in hepatic cytochrome (CYP)P450 isoenzyme activity that is influenced by drug–drug interactions and single nucleotide polymorphisms of specific genes encoding CYP450 isoenzymes. Treatment with more potent P2Y12 receptor blockers, such as prasugrel and ticagrelor are credible alternative strategies to overcome HPR during clopidogrel therapy.

Lead-related complications after DDD pacemaker implantation.

Abstract: Background: Pacing leads remain the weakest link in pacemaker systems despite advances in manufacturing technology. Aim: The aim of the study was to assess the long-term pacing lead performance in an unselected real-life cohort following primary DDD pacing system implantation. Methods: A single-centre retrospective analysis of patients who underwent DDD pacing system implantation between October 1984 and December 2014 and were followed-up until August 2016 was conducted. The inclusion criterion was at least one follow-up visit after post-implant discharge. The performance of each atrial and ventricular lead implanted was evaluated during the follow-up period, and the incidence of, and predictive factors for, lead dislodgement and failure were analysed. Results: The data of 3771 patients and 24,431.8 patient-years of follow-up were analysed. The mean follow-up of patients was 77.7 ± 61.8 months. During the study period, 7887 transvenous atrial and right ventricular pacing leads were implanted. Lead dislodgement occurred in 94 (1.2%) leads (92 [2.4%] patients), perforation in 11 (0.1%) leads (10 [0.3%] patients), and lead failure in 329 (4.2%) leads (275 [7.3%] patients). Atrial lead position was a predictive factor for lead dislodgement, while age at implantation, polyurethane 80A insulation, subclavian vein access, unipolar lead construction, and lead manufacturer were multivariate predictors of lead failure. Conclusions: Leads with polyurethane 80A insulation, unipolar construction, and those implanted via subclavian vein puncture exhibited the worst long-term performance.