-
Piotr Kukla,
Robert Długopolski,
Ewa Krupa,
Romana Furtak, Ewa Mirek-Bryniarska,
Roman Szełemej,
Marek Jastrzębski,
Jacek Nowak,
Lukasz Kulak,
Jerzy Hybel,
Krzysztof Wrabec,
Kalina Kawecka-Jaszcz,
Leszek Bryniarski
[show abstract]
[hide abstract]
ABSTRACT: The clinical picture of acute pulmonary embolism (APE) is often uncharacteristic and may mimic acute coronary syndrome (ACS) or lung diseases, leading to misdiagnosis. In 50% of patients, APE is accompanied by chest pain and in 30-50% of the patients markers of myocardial injury are elevated.
To perform a retrospective assessment of how often clinical manifestations and investigations (ECG findings and elevated markers of myocardial injury) in patients with APE may be suggestive of ACS.
We included 292 consecutive patients (109 men and 183 women) from 17 to 89 years of age (mean age 65.4 ± 15.5 years) with APE diagnosed according the ESC guidelines.
Among the 292 patients included in the study 33 patients died during hospitalisation (mortality rate 11.3%) and 73 (25.0%) patients developed complications. A total of 75 (25.7%) patients were classified as high risk according to the ESC risk stratification, 163 (55.8%) as intermediate risk and 54 (18.5%) as low risk. Chest pain on and/or before admission was reported by 128 (43.8%) patients, including 73 (57.0%) patients with chest pain of coronary origin, 52 (40.6%) patients with chest pain of pleural origin and 3 patients with pain of undeterminable origin based on the available documentation. A total of 56 (19.2%) patients had a history of ischaemic heart disease and 5 (1.7%) had a history of myocardial infarction. A total of 8 (2.7%) patients were admitted with the initial diagnosis of ACS. The high-risk group consisted of 15 (20.6%) patients with a typical retrosternal chest pain and 60 (27.3%) patients without the typical anginal pain. Elevated troponin was observed in 103 (35.3%) patients. The ECG changes suggestive of myocardial ischaemia (inverted T waves, ST-segment depression or elevation) were observed in 208 (71.2%) patients. The following findings were significantly more common in high-risk versus non-high-risk patients: ST-segment depression in V4-V6 (42.6% vs 23.9%, p = 0.02), ST-segment elevation in V1 (46.7% vs 20.0%, p = 0.0002) and aVR (70.7% vs 40.1%, p = 0.0007).
One third of patients with APE may present with all the manifestations (pain, elevated troponin and ECG changes) suggestive of ACS. The ECG changes suggestive of myocardial ischaemia are observed in 70% of the patients with ST-segment depression in V4-V6 and ST-segment elevation in V1 and aVR being significantly more common in high-risk vs non-high-risk patients.
Kardiologia polska 01/2011; 69(3):235-40. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Fabry disease is a rare X-linked recessive lysosomal storage disease, which can cause a wide range of systemic symptoms. A deficiency of the enzyme alpha galactosidase A due to mutation causes a glycolipid to accumulate within the blood vessels, other tissues, and organs. This accumulation leads to an impairment of proper heart function. Wide range of symptoms makes diagnosis difficult. We present a case of a 43 year-old male with typical Fabry disease.
Kardiologia polska 01/2011; 69(4):364-6. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A 14-year follow-up of a 69 year-old male with left ventricular aneurysm and thrombus after antero-septal myocardial infarction is presented. We describe problems with thromboembolic and bleeding complications in the context of changes in the guidelines over the period of treatment.
Kardiologia polska 01/2011; 69(4):373-6. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Electrocardiogram (ECG) in patients with acute pulmonary embolism (APE) presents many abnormalities. There are no data concerning prognostic significance of ST-elevation (STE) in lead aVR in patients with APE. Aim: To assess the prevalence of STE in aVR in patients with APE and its correlation with clinical course as well as other ECG parameters recorded at admission.
The retrospective analysis of 293 patients with APE diagnosed according to the ESC guidelines (182 females, 111 males, mean age 65.4 ± 15.5 years).
The STE in lead aVR was observed in 133 (45.3%) patients. In comparison with patients without STE, patients with STE in lead aVR (STaVR[+]) had significantly more often systolic blood pressure 〈 90 mm Hg on admission (27% vs 10%, p 〈 0.001) and positive troponin level (64.8% vs 27.9%, p 〈 0.001). Thrombolytic therapy (14.3% vs 5.6%, p = 0.009) and catecholamines (29.3% vs 7.5%, p 〈 0.001) were more frequently used in patients with STaVR(+). The overall mortality (16.5% vs 6.9%, p = 0.009) and complication rates during hospitalisation (38.3% vs 12.5%, p 〈 0.001) were significantly higher in patients with STaVR(+). The STaVR(+) was significantly more frequent in patients with negative T-waves in inferior leads (59.4% vs 39.4%, p 〈 0.001), STE in lead III (24% vs 5.6%, p 〈 0.001), STE in lead V1 (46.6% vs 7.5%, p 〈 0.001), ST depression in lead V(4)-V(6) (48.9% vs 7.5%, p 〈 0.001), right bundle branch block (15.8% vs 8.1%, p = 0.04), QR sign in lead V1 (18% vs 6.2%, p 〈 0.001) and SI-QIII-TIII (46.6% vs 21.2%, p 〈 0.001).
The presence of STE in lead aVR in patients with APE is associated with poor prognosis. The presence of STE in lead aVR could be an easily obtainable and noninvasive ECG parameter, helpful in risk stratification of patients with APE.
Kardiologia polska 01/2011; 69(7):649-54. · 0.51 Impact Factor
-
Michał Owsiak,
Agnieszka Pelc-Nowicka,
Leszek Badacz,
Jacek Dubiel,
Dariusz Dudek,
Grzegorz Gajos,
Janusz Grodecki,
Piotr Jankowski,
Kalina Kawecka-Jaszcz, Ewa Mirek-Bryniarska,
Jadwiga Nessler,
Piotr Podolec,
Jerzy Sadowski,
Wiesława Tracz,
Michał Zabojszcz,
Krzysztof Żmudka,
Leszek Bryniarski
[show abstract]
[hide abstract]
ABSTRACT: Antiplatelet drugs currently constitute the basic treatment of coronary artery disease (acute coronary syndrome [ACS], stable angina and patients treated with percutaneous coronary interventions [PCI]). The number of patients with indication for dual antiplatelet therapy with comorbidities with high thrombo-embolic risk (such as atrial fibrillation [AF], venous thrombotic disease, valvular diseases) is increasing. That is why the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common recently. The AF is the most common indication for chronic anticoagulation. Because of the lack of large randomised trials regarding triple therapy, characteristics of this group has not been well established.
To assess the presence of cardiovascular (CV) risk factors and concomitant diseases in patients with ACS requiring triple therapy.
Retrospective analysis included 2279 patients diagnosed with ACS who were admitted to the Departments of Cardiology in Cracow in 2008. In this group, 365 (16%) patients had indications for chronic anticoagulation. Demographic and clinical characteristics of these patients were compared with those of patients included in other published registries.
Patients requiring triple therapy were aged 73.2 ± 9.5 years. Hypertension was diagnosed in 80%, hyperlipidaemia in 63%, smoking in 36%, prior myocardial infarction in 33%, prior stroke in 15%, previous treatment with PCI in 13%, coronary artery bypass grafting in 7%, diabetes in 36%, heart failure in 46%, anaemia in 33% and chronic ulcer disease or gastroesophageal reflux disease in 9%. The mean left ventricular ejection fraction was 46 ± 15%. Compared with other registries of patients without indications for triple therapy, our patients had significantly more frequently hypertension, diabetes and were older.
Patients after an ACS requiring triple therapy have more often a history of comorbidities and CV risk factors when compared with the group of patients with ACS without indication for triple therapy.
Kardiologia polska 01/2011; 69(9):907-12. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The electrocardiogram (ECG) is characterised by little sensitivity and specificity in the diagnostic evaluation of acute pulmonary embolism (APE).
To assess the significance of ECG changes in predicting myocardial injury and prognosis in patients with APE.
The study group consisted of 225 patients (137 women and 88 men), mean age: 66.0 ± 15.2 years, in whom the diagnosis of APE was made, mostly based on computed tomography (n = 206, 92%).
We observed 26 in-hospital deaths (mortality rate: 11.5%) and complications occurred in 58 (25.7%) patients. Elevated levels of troponin were observed in 103 (46%) patients. Logistic regression analysis showed that in-hospital mortality was associated with: coronary chest pain (0.06-0.53, OR 0.18), systolic blood pressure below 100 mm Hg (2.3-13.64, OR 5.61), heart rate above 100 bpm (1.17-15.11, OR 4.21), the S1Q3T3 sign (1.31-6.99, OR 3.02), QR in V(1) (1.60-12.32, OR 4.45), ST-segment depression in V(4)-V(6) (0.99-5.40, OR 2.31), ST-segment elevation in III (0.99-6.96, OR 2.64), ST-segment elevation in V(1) (1.74-9.49, OR 4.07); borderline (1.51-16.07, OR 4.93), moderate (1.42-17.74, OR 5.01) and severe troponin elevation (2.88-36.38, OR 10.24). In patients with cTnT(+), compared to patients with normal troponin levels, the following ECG changes were significantly more common: the S1Q3T3 sign (43 vs 21%, p = 0.003), negative T waves in V(2)-V(4) (57 vs 27%, p = 0.0001), ST-segment depression in V(4)-V(6) (40 vs 14%, p = 0.001), ST-segment elevation in III (22 vs 7%, p = 0.0006), V(1) and V(2) (43 vs 10%, p = 0.0001) and QR in V(1) (16 vs 5%, p = 0.007).
ECG parameters are useful in predicting myocardial injury and assessing prognosis in patients with APE.
Kardiologia polska 01/2011; 69(9):933-8. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess the influence of electrocardiographic (ECG) pattern on prognosis and complications of patients hospitalized with acute pulmonary embolism (APE).
We performed a retrospective analysis of 292 patients who had confirmed APE. There were 183 females and 109 males, the age range was 17 to 89 years, and the mean age was 65.4 ± 15.5 years.
In our study group, there were 33 deaths (mortality rate, 11.3%), and 73 (25%) patients developed complications during hospitalization. Based on European Society of Cardiology risk stratification, we classified 75 (25.7%) patients as high risk, 163 (55.8%) patients as intermediate risk, and 54 (18.5%) patients as low risk. A comparison between patients with complicated APE and those with no complications during hospitalization indicated that the following ECG parameters were more common in patients who had complications: atrial fibrillation, S1Q3T3 sign, negative T waves in leads V2-V4, ST segment depression in leads V4-V6, ST segment elevation in leads III, V1 and aVR, qR in lead V1, complete right bundle branch block (RBBB), greater number of leads with negative T waves, and greater sum of the amplitude of negative T waves. In multivariate analysis, the sum of negative T waves (OR 0.88; p = 0.22), number of leads with negative T waves (OR 1.46; p = 0.001), RBBB (OR 2.87; p = 0.02) and ST segment elevation in leads V1 (OR 3.99; p = 0.00017) and aVR (OR 2.49; p = 0.011) were independent predictors of complications during hospitalization. In turn, in multivariate analysis, only the sum of negative T waves (OR 0.81; p = 0.0098), number of leads with negative T waves [OR 1.68; p = 0.00068] and ST segment elevation in lead V1 (OR 4.47; p = 0.0003) were independent predictors of death during hospitalization.
In our population of APE patients, the sum of negative T waves, the number of leads with negative T waves and the ST segment elevation in lead V1 were independent predictors of death during hospitalization. In turn, the sum of negative T waves, the number of leads with negative T waves, and RBBB and ST segment elevation in leads V1 and aVR were independent predictors of complications during hospitalization. We conclude that ECG analysis may be a useful noninvasive method for risk stratification of patients with APE.
Cardiology journal 01/2011; 18(6):648-53. · 1.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Dual antiplatelet therapy for 12 months is currently recommended for all patients with acute coronary syndrome (ACS), both for those treated pharmacologically or with percutaneous coronary interventions (PCI). Recently, the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common. However, in addition to intensifying antiplatelet treatment, the risk of haemorrhagic complications is also significantly increased with triple therapy.
To assess the in-hospital use of triple therapy in patients with ACS, who have indications for long-term anticoagulation, and to define the reasons for not administering such a therapy.
The analysis included 298 patients diagnosed with ACS who were admitted to our department. Analysis of recommended treatment was conducted upon discharge from hospital after ACS and during hospitalisation. The reason for discontinuation or non-compliance with oral anticoagulant (OAC) therapy was also assessed.
Out of 298 patients diagnosed with ACS, 53 (17.8%) had indications for long-term anticoagulation. The largest group consisted of patients with unstable angina who were treated pharmacologically (51.7%). The most common indication for chronic anticoagulation was paroxysmal atrial fibrillation (AF) (62%). At discharge from hospital, only 15.1% of patients received triple therapy. There was no significant association between the mode of treatment (triple therapy vs. lack of it) and indication for antiplatelet treatment (p = 0.18) or anticoagulation (p = 0.27). Among risk factors for bleeding, only prior episode of bleeding [p = 0.0002; odds ratio (OR) 4.17] and treatment with PCI (p = 0.02; OR impossible to assess because of too small group) were significantly associated with withdrawal of triple therapy.
The use of triple therapy in patients presenting with ACS and indications for long-term anticoagulation is insufficient. The reasons for not prescribing triple therapy are not clear. One explanation could be excessive concerns about haemorrhagic complications. There is a lack of equivocal guidelines and large randomised trials which would clearly define the optimal management strategy for patients presenting with ACS and indications for long-term anticoagulation therapy.
Kardiologia polska 12/2009; 67(12):1335-41. · 0.51 Impact Factor
-
Andrzej Pajak,
Piotr Jankowski,
Kalina Kawecka-Jaszcz,
Sławomir Surowiec,
Renata Wolfshaut,
Magdalena Loster,
Katarzyna Batko,
Leszek Badacz,
Jacek S Dubiel,
Janusz Grodecki,
Tomasz Grodzicki,
Janusz Maciejewicz, Ewa Mirek-Bryniarska,
Wiesław Piotrowski,
Wanda Smielak-Korombel,
Wiesława Tracz
[show abstract]
[hide abstract]
ABSTRACT: Both in the European and Polish guidelines, the highest priority for preventive cardiology was given to patients with established coronary artery disease (CAD). The Cracovian Program for Secondary Prevention of Ischaemic Heart Disease was introduced in 1996 to assess and improve the quality of clinical care in secondary prevention. Departments of cardiology of five participating hospitals serving the area of the city of Kraków and surrounding districts (former Kraków Voivodship) inhabited by a population of 1 200 000 took part in the surveys. In 1999/2000 and 2006/2007 the same hospitals joined the EUROASPIRE (European Action on Secondary Prevention through Intervention to Reduce Events) II and III surveys. The goal of the EUROASPIRE surveys was to assess to what extent the recommendations of the Joint Task Force of International Scientific Societies were implemented into clinical practice.
To compare the quality of secondary prevention in the post-discharge period in Kraków in 1997/1998, 1999/2000 and 2006/2007.
Consecutive patients hospitalised from 1 July 1996 to 31 September 1997 (first survey), from 1 March 1998 to 30 March 1999 (second survey), and from 1 April 2005 to 31 July 2006 (third survey) due to acute myocardial infarction, unstable angina or for myocardial revascularisation procedures, below the age of 71 years were identified and then followed up, interviewed and examined 6-18 months after discharge.
The number of patients who participated in the follow-up examinations was 418 (78.0%) in the first survey, 427 (82.9%) in the second and 427 (79.1%) in the third survey. The use of cardioprotective medication increased significantly: antiplatelets from 76.1% (1997/1998) to 86.9% (1999/2000) and 90.1% (2006/2007), beta-blockers from 59.1% (1997/1998) to 63.9% (1999/2000) and 87.5% (2006/2007), and ACE inhibitors/sartans from 45.9% (1997/1998) to 79.0% (2006/2007). The proportion of patients taking lipid lowering agents increased from 34.0% (1997/1998) to 41.9% (1999/2000) and 86.8% (2006/2007). Simultaneously, a significant improvement in the control of hyperlipidemia could be noted. In 2006/07, over 60% had a serum LDL cholesterol < 2.5 mmol/l. No significant change was found in the proportion of subjects with well-controlled hypertension or diabetes. In 2006/2007, elevated blood pressure was found in 46.6% of participants and glucose > 7 mmol/l in 13.4%. There was no significant change in smoking rates (16.3 vs. 15.9 vs. 19.2%). The proportion of obese patients increased reaching 33.9% in 2006/2007.
The implementation of CAD prevention guidelines into clinical practice over the decade from 1997/1998 to 2006/2007 changed significantly. The use of cardioprotective drugs increased largely but among risk factors a significant improvement could be found only in the case of hypercholesterolemia. No improvement in the control of hypertension and diabetes, no change in smoking rates and increasing prevalence of obesity suggest insufficient lifestyle modifications in CAD patients.
Kardiologia polska 12/2009; 67(12):1353-9. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Acute pulmonary embolism (APE) is a life-threatening disease. Mortality in APE still remains very high in spite of progress in diagnostic tools. Mortality rate is about 30% in patients with unrecognised APE. APE is one of the main causes of in-hospital mortality.
To asses management of patients with APE in the Małopolska region.
This registry consists of 205 consecutive patients who were hospitalised in 6 cardiology departments between 1 January 2005 and 30 September 2007, with the mean age of 65.1 +/- 15.3 years (124 females and 81 males). Mean hospitalisation duration 14.6 days (1-52 days).
During hospitalisation 23 (11.2%) patients died. Complications (death, cardiogenic shock, cardiac arrest, use of catecholamines, respiratory therapy and ventilation) during in-hospital stay were observed in 57 (27.8%) patients. Fifty-three patients were haemodynamically unstable (cardiogenic shock or hypotension). The troponin I or T level was assessed in 147 (71.7%) patients and in 50 (34.0%) was positive. In patients with positive troponin we observed 11 (22.0%) deaths, while in patients with normal troponin T or I level 6 (6.2%) deaths occurred. In patients with normal blood pressure we observed a significant difference in mortality in patients with elevated vs. normal troponin level (14.3 vs. 2.5%, p = 0.02). Thrombolytic therapy was used in 20 (9.8%) patients. In patients treated with thrombolytic therapy 9 (45%) deaths were observed. We divided patients according to the ESC 2008 guidelines risk stratification. The 'non-high risk' group consisted of 152 (74.1%) patients, and mortality was 3.9%. The 'high-risk' group consisted of 53 (26.8%) patients. The 'non-high risk' group was divided into the following subgroups: 1. moderate-high (with 2 risk factors: both RV dysfunction and positive injury markers) mortality - 8.1%; 2. moderate subgroup with one risk factor, mortality - 3.6%; 3. low risk - no risk factors - 0% mortality.
1. In our registry mortality rate in patients with APE was 11%. 2. In about 30% of patients APE was under mask of acute coronary syndrome or syncope, 34% of patients had elevated troponin level, and 30% of patients had complication during hospitalisation. 3. In patients treated with thrombolytics mortality rate was 45%. 4. Reperfusion strategy (trombolysis or embolectomy) in the high risk group was used in only 41% of patients. 5. Elevated troponin level in normotensive patient was associated with 4-fold times higher risk of death. 6. New risk stratification according to the ESC guidelines 2008 correctly predicts prognosis in everyday clinical practise.
Kardiologia polska 08/2009; 67(7):735-41. · 0.51 Impact Factor
-
Piotr Jankowski,
Kalina Kawecka-Jaszcz,
Andrzej Pajak,
Stawomir Surowiec,
Renata Wolfshaut,
Magdalena Loster,
Leszek Badacz,
Jacek S Dubiel,
Janusz Grodecki,
Tomasz Grodzicki,
Janusz Maciejewicz, Ewa Mirek-Bryniarska,
Wiesław Piotrowski,
Wanda Smielak-Korombel,
Wiesława Tracz
[show abstract]
[hide abstract]
ABSTRACT: Both in the European and Polish guidelines the highest priority for preventive cardiology was given to patients with established cardiovascular disease. The Cracovian Program for Secondary Prevention of Ischaemic Heart Disease was initiated in 1996. The main goal of the program was to assess and improve the quality of clinical care in the secondary prevention of ischaemic heart disease. Later, the same centres joined the EUROASPIRE (European Action on Secondary and Primary Prevention Intervention to Reduce Events) II and III surveys.
To compare the quality of secondary prevention in Krakow cardiac departments in 1996/1997, 1998/1999 and 2005/2006.
Five hospitals serving the area of the city of Krakow and surrounding districts (former Krakow Voivodship), inhabited by 1,200,000 persons, took part in the surveys. Consecutive patients hospitalised from July 1, 1996 to September 31, 1997 (first survey), from March 1, 1998 to March 30, 1999 (second survey), and from April 1, 2005 to July 31, 2006 (third survey) due to acute myocardial infarction, unstable angina or for myocardial revascularisation procedures, below the age of <71 years were recruited and included to the present analysis. All medical records were reviewed by trained reviewers using standardised data collection forms.
Medical records of 536 patients treated in 1996/1997, 515 treated 1998/1999, and 540 treated in 2005/2006 were reviewed and analysed. Proportions of medical records with available information on risk factors prior to hospitalisation as well as proportions of medical records with available information on blood pressure (by 10%, p < 0.05) and lipids (by over 30%, p < 0.05) measurements during the first 24 h of hospitalisation as well as on weight and height measurements (by 16%, p < 0.05) increased significantly from 1996/1997 to 2005/2006. Antiplatelets prescription rate at discharge increased from 87% to 97% (p < 0.05), prescription rate for beta-blockers increased from 66% to 91% (p < 0.05), ACE inhibitors/sartans from 50% to 89% (p < 0.05), and lipid lowering drugs from 27% to 96% (p < 0.05) between 1996/1997 and 2005/2006, respectively.
The implementation of secondary prevention guidelines into clinical practice in the Krakow cardiac departments improved in 2005/2006 as compared to 1996/1997 and 1998/1999. Our results suggest that recent decade brought significant improvement in the approach to secondary prevention of ischaemic heart disease in hospital practice.
Kardiologia polska 08/2009; 67(8A):970-7. · 0.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Dual antiplatelet therapy is currently recommended for all patients with acute coronary syndromes, independent of whether they receive pharmacological treatment or undergo percutaneous coronary intervention. Antiplatelet agents are the cornerstone of pharmacological treatment in interventional cardiology. However, there is a clear need for randomized trials to assess the treatment strategy of dual antiplatelet therapy in patients who also need long-term antithrombotic treatment (such as those with atrial fibrillation, prosthetic heart valve, mitral valve regurgitation or stenosis, deep vein thrombosis, pulmonary embolism, or pulmonary hypertension). In this paper we discuss trials and analyses on the use of dual antiplatelet treatment in combination with antithrombotic therapy in particular diseases, with a focus on the risk of hemorrhagic events connected with this treatment, as well as recent guidelines of the European Society of Cardiology, the American College of Cardiology, and the American Heart Association.
Cardiology journal 02/2009; 16(2):179-89. · 1.31 Impact Factor
