Grzegorz Karpinski

Medical University of Warsaw, Warszawa, Masovian Voivodeship, Poland

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Publications (65)131.79 Total impact

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    ABSTRACT: Background: Oral anticoagulation is crucial for the prevention of stroke and thromboembolism in atrial fibrillation (AF). One of the comorbidities potentially affecting thromboembolic risk and anticoagulation effectiveness is obstructive sleep apnea (OSA). The objective of this study was to establish if presence of OSA is associated with poor expected benefit from vitamin K antagonist (VKA) therapy as assessed using the SAMe-TT2R2 score. Methods: We studied AF patients planned for invasive electrophysiological procedures. All patients had a whole night polygraphy performed for the diagnosis of OSA, and their SAMe-TT2R2 score was calculated. Results: We studied 211 AF patients (mean age=57.1±10.2years, 62.6% males). OSA with apnea-hypopnea index (AHI) ≥15/h was found in 48 (22.7%) patients. Mean SAMe-TT2R2 score in non-OSA patients was 1.4±0.9, compared to mild OSA patients, 1.5±0.9; moderate OSA patients, 1.9±1.1; and severe OSA patients, 2.8±0.6. A significantly higher percentage of patients with SAMe-TT2R2≥2, indicating poor predicted INR control on VKAs, was found with increasing AHI category (37% vs. 41% vs. 57% vs. 100%, respectively). Patients with poor predicted anticoagulation control (SAMe-TT2R2≥2) had a higher prevalence of OSA. There was a lower proportion of patients with TTR>70% among patients with moderate/severe OSA compared to no/mild OSA (13.6% vs. 29.6%, p=0.03). Conclusion: SAMe-TT2R2 scores in patients with OSA are substantially higher than in those without sleep-disordered breathing. The mean SAMe-TT2R2 score, as well as the percentage of patients with SAMe-TT2R2 score≥2, suggests poor predicted anticoagulation control on VKA rises along with the AHI. There was a lower proportion of patients with TTR>70% among patients with moderate/severe OSA, compared to no/mild OSA.
    No preview · Article · Nov 2015 · International journal of cardiology
  • Anna E Płatek · Grzegorz Karpiński · Filip M Szymański

    No preview · Article · Aug 2015 · Kardiologia polska
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    ABSTRACT: An 86-year-old female with aortic stenosis was qualified for invasive correction of the valvular heart disease. She developed a severe ventricular hypertrophy (LVH) and had an intermittent left bundle branch block (LBBB) and right bundle branch block (RBBB). We report the case of a single electrocardiographic examination showing changes specific for LVH, present in all forms of intraventricular conduction. The case perfectly depicts how the intracardiac vectors of depolarization change due to bundle branch blocks and how it effects QRS complex morphology. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · May 2015 · Journal of electrocardiology
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    ABSTRACT: Cardiac arrest (CA) is a complex event with a dismal survival rate. The aim of this study was to determine whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels measured on admission and serial cardiac troponin I determination in patients with in-hospital cardiac arrest (IHCA) are predictive of 30-day mortality. Out of 9877 patients hospitalized in the cardiac intensive care unit during the study, we enrolled consecutive patients experiencing cardiac arrest within 12 hours of admission. Baseline characteristics, information about circumstances of CA and cardiopulmonary resuscitation, and initial biochemical parameters were retrospectively collected. A total of 106 patients (61 male, age 71.4±12.6 years) were enrolled. Thirty-four (32.1%) had a history of myocardial infarction, and 13 (12.3%) a history of stroke. Total 30-day mortality was 60.4%. Deceased patients were older (73.7±11.9 vs. 67.8±13.0 years; p=0.01) and had lower systolic (89.4±37.0 vs. 115.0±24.0 mmHg; p=0.0001) and diastolic (53.6±24.8 vs. 66.1±15.0 mmHg; p=0.008) blood pressure on admission. Shockable initial rhythm was more often noted in the survivor group (54.8% vs. 28.1%; p=0.01). Deceased patients had higher median NT-proBNP levels (9590.0 [25-75% interquartile range (IQR), 5640.0-26450.0] vs. 3190.0 [25-75% IQR, 973.8-5362.5] pg/ml; p=0.02) on admission. There were no differences in the first two troponin I measurements, but values were higher on the third measurement in non-survivors (98.2 [25-75% IQR, 76.4-175.8] vs. 18.7 [25-75% IQR, 5.2-50.6]; p=0.009). The survival rate of patients after in-hospital CA is poor. Deceased patients have higher NT-proBNP levels on admission, along with higher troponin I concentrations on the third measurement. Those biomarkers are useful in predicting 30-day mortality in IHCA patients. Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.
    Full-text · Article · Apr 2015
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    ABSTRACT: Purpose Assessment of stroke risk and implementation of appropriate antithrombotic therapy is an important issue in atrial fibrillation patients. Current risk scores do not take into consideration the comorbidities associated with elevated thromboembolic like obstructive sleep apnea (OSA). The aim of the study was to establish whether atrial fibrillation patients with coexisting OSA have higher stroke risk according to CHADS2 and CHA2DS2-VASc scores. Methods Two hundred fifty-four consecutive patients hospitalized with a primary diagnosis of atrial fibrillation participated in the study. All patients underwent whole night polygraphy and were scored in both CHADS2 and CHA2DS2-VASc according to their medical records or de novo diagnosis. Results The study population was predominantly male (65.4 %; mean age, 57.5 ± 10.0 years) with a high prevalence of hypertension (73.6 %), dyslipidemia (63.4 %), and obesity (42.9 %). OSA was present in 47.6 % of patients, who more often had history of stroke (p = 0.0007). Stroke risk profile assessed by both CHADS2 and CHA2DS2-VASc scores was higher in patients with OSA (1.2 ± 0.9 vs. 0.8 ± 0.6; p
    Full-text · Article · Aug 2014 · Sleep And Breathing
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    ABSTRACT: Background: Atrial fibrillation (AF) is the most common arrhythmia that affects the quality of life by causing deleterious health consequences, and impairing sleep quality. The severity of AF symptoms may range from very mild to the very intense which can be assessed by the European Heart Rhythm Association (EHRA) score. The aim of the study was to assess the prevalence of poor sleep quality in AF patients, in relation to the symptom severity based on the EHRA score. Methods: 177 consecutive patients, hospitalized between 2011 and 2013 with non-valvular AF and no history of myocardial infarction, stroke or decompensation of heart failure within the last 6 months, were enrolled into the study. Sleep quality was assessed by the Pittsburg Sleep Quality Index (PSQI) in all patients at admission. Medical history and data concerning AF symptoms and severity by the EHRA score were gathered by a qualified physician. Results: Poor sleep quality was present in 49.7% of patients. Patients with poor sleep quality were more often females (66.6% vs. 35.8%; P = 0.007), were older (57.9 +/- 10.1 vs. 53.9 +/- 10.0 years; P = 0.005), and had higher systolic blood pressures (134.4 +/- 16.4 vs. 129.8 +/- 17.8 mmHg; P = 0.03). Poor sleep quality was present in 33.3% of the EHRA I group, 43.9% of the EHRA II group, 58.1% of the EHRA III group, and 61.5% of the EHRA IV group (p value for trend 0.01). Conclusions: Poor sleep quality is highly prevalent in AF patients, affecting approximately half of them. It is related to the severity of symptoms, and prevalence rises with every degree of the EHRA score.
    No preview · Article · Jun 2014
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    ABSTRACT: Defuse brain injury is a key component of post-cardiac arrest syndrome reported in 30-80% of survivors of out-of-hospital cardiac arrest (OHCA). It is responsible for a high mortality rate, and is a common cause of cognitive and neurological deficits and disability. Symptom variability and dynamics and rehabilitation potential remain poorly understood.
    Full-text · Article · May 2014 · Kardiologia polska
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    ABSTRACT: Obstructive sleep apnea (OSA) and atrial fibrillation (AF) are two conditions highly prevalent in the general population. OSA is known to cause hemodynamic changes, oxidative stress, and endothelial damage, and therefore promote vascular and heart remodelling which results in triggering and exacerbating AF. Coexistence of OSA and AF influences course of both diseases, and therefore should be taken into consideration in patient management strategy planning. The aim of the study was to /1/ asses the prevalence of OSA in Polish AF patients, and to /2/ describe clinical characteristics of patients with concomitant OSA and AF. We : enrolled in the : study : 289 consecutive patients hospitalized in a tertiary, high-volume Cardiology Department with a primary diagnosis of atrial fibrillation. In addition to standard examination all patients underwent an over-night sleep study to diagnose OSA, which was defined as apnea-hypopnea index (AHI) ≥ 5 per hour. After applying exclusion criteria, final analysis covered 266 patients (65.0% males, mean age 57.6 ± 10.1 years). OSA was present in 121 (45.49%) patients. Patients with OSA were older (59.6 ± 8.0 vs. 56.0 ± 11.4 years; p=0.02), had higher BMI (30.9 ± 5.4 vs. 28.7 ± 4.4 kg/m²; p < 0.01) and bigger neck (41.2 ± 3.8 vs. 39.3 ± 3.3 cm; p = 0.0001) and waist circumference (108.5 ± 13.1 vs. 107.7 ± 85.4 cm; p < 0.0001) than patients without OSA. There were no significant differences between the groups in terms of SBP, DBP or history of comorbidities (p > 0.05). OSA patients were also less likely than non-OSA patients to have paroxysmal AF (62.0% vs. 75.9%; p = 0.02). Dividing newly diagnosed OSA patients according to the disease severity showed that mild OSA (AHI ≥ 5 and < 15 per hour) to mild OSA was present in 27.82% of the study population patients, moderate OSA (AHI ≤ 15 and ≥ 30 per hour) in 13.16% patients, and severe OSA (> 30 per hour) in 4.51% patients. No significant differences in terms of comorbidities and anthropometric features were seen between mild and moderate, between moderate and severe, and between mild and severe OSA. OSA is highly prevalent in patients with AF in Polish population, and affects approximately half of this population. OSA patients are more likely to be older, have higher BMI, higher waist, and neck circumference. Persistent AF is the more common form of the arrhythmia in patients with OSA, while patients without OSA are more likely to have paroxysmal AF.
    Full-text · Article · Mar 2014 · Kardiologia polska

  • No preview · Article · Mar 2014
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    ABSTRACT: Sleep duration and sleep quality affect patients' general condition and self-reported health status. The aims of this study were: (1) to describe the clinical characteristic of ST-elevation myocardial infarction patients who sleep too little or too much; and (2) to determine whether sleep duration is independently associated with higher risk of all-cause mortality. We enrolled into the study 407 consecutive patients admitted with diagnosis of ST-elevation myocardial infarction (STEMI). All patients were asked for sleep duration in the first three months after being discharged from the hospital. According to the sleep duration, we divided patients into three groups: A) the reference category defined as 6-8 sleep hours, B) short sleep with <6 h and C) long sleep with >8 h. The final analysis covered 379 patients [271 males; mean age 59.4±10.61]. 36 (9.5%) patients slept less than 6 hours, 26 (6.9%) slept more than 8 hours per night. The all-cause 3-year mortality was 1.9% in the reference category, 13.9% in patients who slept less than 6 hours, and 30.8% in patients who slept more than 8 hours per night (p<0.0001). In the multiple logistic regression analysis, short (odds ratio 10.2, 95% CI 2.1-50;p=0.004) and long sleep duration (odds ratio 33.3, 95% CI 6.8-163.4; p<0.001) were strong and independent predictors of all-cause mortality. Too short and especially too long duration of sleep in first months after myocardial infarction are strong, independent predictors of all-cause mortality.
    No preview · Article · Feb 2014 · Kardiologia polska
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    ABSTRACT: Objective: Obstructive sleep apnea syndrome (OSAS) is a cardiovascular risk factor associated with clinical complications like hypertension, ischaemic heart disease or thrombosis. The aim of this study was to develop a new scoring system, based on objective clinical and echocardiographic parameters. Methods: One hundred fifty-eight consecutive acute coronary syndrome (ACS) patients underwent standard clinical, laboratory and echocardiography assessment after ACS, and their risk of OSAS was assessed using Berlin Questionnaire and Epworth Sleepiness Scale. Creation of OSACS (Obstructive Sleep Apnea in Acute Coronary Syndrome patients) score was attempted, with risk factors evaluated in multiple logistic regression model. Results: In 34.2% patients, who were at high risk of OSAS left ventricular diastolic diameter, left atrial diameter, and intrventricular septal thickness were elevated. In multiple logistic regression analysis: history of hypertension (Odds Ratio 4.42; 95% CI 0.96-20.5, p=0.06), body mass index (OR 6.82; 95% CI 2.33-20; p<0.001), diastolic blood pressure (OR 6.4; 95% CI 1.58-25.9; p=0.01), left ventricular diastolic diameter (OR 3.5; 95% CI 1.05-11.6; p=0.04), left ventricular mass index (OR 0.26; 95% CI 0.07-0.94; p=0.04), interventricular septal thickness (OR 4.44; 95% CI 1.15-17.1; p=0.03) were independent risk factors for high risk of OSAS. All independent risk factor were implemented into risk prediction model called OSACS. The area under the ROC curve for the OSACS score was 0.87. Conclusion: OSAS is highly prevalent in ACS patients. The new OSACS score has a high predictive value in assessment of risk of OSAS in these patients, and it can be used as an objective tool, and an alternative for the Berlin Questionnaire.
    Preview · Article · Jan 2014 · Anadolu kardiyoloji dergisi: AKD = the Anatolian journal of cardiology
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    ABSTRACT: We report a case of a 52-year-old human immunodeficiency virus (HIV)-infected male patient receiving combined antiretroviral therapy (cART), who presented with acute ST-elevation myocardial infarction (STEMI). He was properly treated (e.g., prescribed anti-coagulation drugs: aspirin, clopidogrel, enoxaparin) and discharged. After 1.5 months, another STEMI related with in-stent thrombosis took place. The cART scheme was altered, resulting in no further cardiac events in the follow-up period, with undetectable levels of HIV ribonucleic acid. This case highlights the association between HIV infection and the specific drugs of cART, and the risk of cardiovascular disease development.
    Full-text · Article · Jan 2014 · Korean Circulation Journal
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    ABSTRACT: Cardiovascular disease are the leading cause of death worldwide. One of the most important diseases in this group is myocardial infarction. According to the Universal Definition developed by the European Society of Cardiology (ESC) myocardial infarction is divided into five main types basing on its cause. Type 2 myocardial infarction is secondary to ischemia due to either increased demand or decreased supply of oxygen (in example due to coronary artery spasm, anaemia, arrhythmia, coronary embolism, hypertension, or hypotension). The aim of the study was (1) to assess the occurrence and etiology of type 2 acute myocardial infarction (AMI), and (2) to describe the clinical characteristics and prognosis of study patients. Into the retrospective study we enrolled 2882 patients in Cardiology Department with an initial diagnosis of AMI between 2009 and 2012. Diagnosis of AMI was made basing on ESC criteria. In all patient coronary angiography was performed in order to exclude hemodynamically significant coronary lesions. Among 2882 patients hospitalized in the described time period, 58 (2%) patients were diagnosed with type 2 AMI. Mean age of the study group was 67.3±13.2 years; and the majority of the study group 60.3% were women. Out of them 23 (39.6%) patients experienced AMI due to coronary artery spasm, 15 (25.9%) due to arrhythmias, 11 (19%) due to severe anaemia and 9 (15.5%) due to hypertension, without significant coronary artery disease. Majority of patients - 42 (72.4%) was diagnosed as non-ST-segment elevation myocardial infarction, while 14 (24.1%) as ST-segment elevation myocardial infarction, and 2 (3.5%) as AMI in the presence of ventricular paced rhythm. History of classical cardiovascular risk factors including hypertension, diabetes, dyslipidemia, family history of heart diseases, and smoking was reported in 42 (72.4%), 14 (24.1%), 23 (39.7%), 24 (41.4%), 16 (27.6%) cases, respectively. All-cause, 30-day mortality rate was 5.2%, and 6-month was 6.9%. Type 2 AMI patients were more often female, and they were more often diagnosed as non-ST-segment elevation myocardial infarction. The prevalence of classical cardiovascular risk factors in this subgroup of patients was very high. The leading cause of AMI was coronary artery spasm.
    Full-text · Article · Oct 2013 · Kardiologia polska
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    ABSTRACT: The risk of a cardiovascular event increases with the number of cardiovascular risk factors. The aim of this study was to identify patients with acute coronary syndromes (ACS) who were at high clinical suspicion for obstructive sleep apnea syndrome (OSAS). We also report the clinical characteristics of ACS patients at high clinical suspicion for OSAS. We studied 158 consecutive patients who satisfied the entry criteria (mean age 57.1 ± 8.7 years, 68% males) and were admitted to a tertiary university hospital. The risk of OSAS was assessed using the Berlin questionnaire. In addition, all patients were required to have excessive sleepiness as demonstrated by a score >10 on the Epworth Sleepiness Scale (ESS). Fifty four (34.2%) patients were at high clinical suspicion. On admission, patients at clinical suspicion for OSAS had significantly more often a history of hypertension (92.6% vs. 55.8%, p<0.0001) or diabetes mellitus (37% vs. 15.4%, p=0.0049); significantly higher mean ESS (14.83 ± 3.02 vs. 5.83 ± 3.33, p<0.0001), systolic blood pressure (149.9 ± 34.2 vs. 128.4 ± 23.6 mmHg, p<0.0001), diastolic blood pressure (87.7 ± 17.4 vs. 76.2 ± 12.1 mmHg, p<0.0001), and body mass index (32.3 ± 4.6 vs. 27 ± 3.8 kg/m(2), p<0.0001); and a lower glomerular filtration rate (79.5 ± 21.2 vs. 87.5 ± 22.2 ml/min/1.73 m(2), p=0.048). Patients at high clinical suspicion for OSAS more often had onset of acute chest pain between midnight and 5.59 am compared to the patients at low clinical suspicion (42.6% vs. 26%; p<0.05). The mortality (7.4% vs. 1%; p=0.03) was greater in patients at high clinical suspicion. This study demonstrates that one out of every three ACS patients was diagnosed with a high clinical suspicion for OSAS. The prevalence of cardiovascular risk factors among ACS patients at high clinical suspicion for OSAS was high when compared with patients at low clinical suspicion. This finding calls for physicians to perform routine screening and individual evaluation of myocardial infarction patients for sleep disorders, especially when they are obese, or have hypertension or chest pain in the night hours.
    No preview · Article · Oct 2013
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    ABSTRACT: We report a case of a 54-year-old obese, loudly snoring male, who presented to the hospital with typical ischemic chest pain of early morning onset, and high blood pressure values. A standard 12-lead ECG performed on admission showed ST-segment elevation in leads II, III, aVF, V1 and ST-segment depression in leads I, aVL, V2 to V4, but coronary angiography revealed no evidence of plaque rupture or erosion in an epicardial coronary vessel. Performed polysomnography confirmed severe obstructive sleep apnea (OSA). According to the universal definition of myocardial infarction patient was diagnosed with acute ST-segment elevation myocardial infarction type 2, caused probably by sudden blood pressure rise secondary to apnea episode in the course of OSA. Patient was treated with continuous positive airway pressure device and suffered no further adverse cardiovascular event during 12 months of follow-up. The case highlights importance of further investigation of novel risk factors such as OSA, and possibly listing it as one of the causes of acute myocardial infarction type 2.
    No preview · Article · Oct 2013 · Cor et vasa
  • Filip M Szymański · Grzegorz Karpiński · Anna E Płatek · Grzegorz Opolski
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    ABSTRACT: We report a case of a 61-year-old male patient who presented with reduced exercise capacity, dyspnea, lower limbs oedema,irregular heart rhythm, loud, irregular snoring, history of poorly controlled hypertension, nocturnal hypertension spikes, andmorning headaches. Patient underwent ECG Holter monitoring and polygraphy, which revealed severe obstructive sleepapnea. In ECG Holter monitoring atrial fibrillation with pauses to 6.5 s were observed. Patient was referred for continuouspositive airway pressure (CPAP) treatment. Three-months of CPAP therapy resulted in significant decrease in apnea-hypopneaindex (31.6/h vs. 5.1/h) and better control of hypertension and heart failure. CPAP treatment allowed us to reduce patient's cardiovascular risk. Cardiologist should routinely screen and evaluate patients for sleep disordered breathing, especially when patients are obese, have hypertension and/or arrhythmias.
    No preview · Article · Sep 2013 · Kardiologia polska
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    ABSTRACT: A 53-year-old woman was hospitalized after out-of-hospital cardiac arrest due to ventricular fibrillation. Initial electrocardioagram showed sinus rhythm of 117 beats per minute, 452 ms QTc interval, ST-segment depression up to 1 mm in V(2)-V(6), and ST-elevation in lead aVR. Patient was treated with primary coronary angioplasty and therapeutic hypothermia, during which QTc interval prolonged up to 616 ms and Osborn wave was seen in lead V(4), along with elevation of ST-segment in I, II, III, aVF, V(5) and V(6); negative T waves in I, II, aVL, aVF, and V(2)-V(6). Laboratory test results showed hypocalcaemia. After rewarming and ion correction QT abnormalities resolved.
    No preview · Article · Sep 2013 · The American journal of emergency medicine
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    ABSTRACT: To compare the long-term prediction value of the six risk scores in a 7-year follow-up of acute coronary syndrome (ACS) patients. We followed 906 patients diagnosed with ACS for 7 years prospectively. Following risk scores (RS) were calculated: TIMI STEMI, TIMI NSTEMI, GRACE, SIMPLE, ZWOLLE and BANACH. Based on the survival data the prediction value for each RS was calculated with receiver operating characteristics (ROC) curve analysis and presented as area under curve (AUC). The 7-year survival was 71%. The RS showed diverse long-term prediction values and AUC. The best estimation was demonstrated by the TIMI STEMI (0.779 [95% CI 0.743 to 0.812]), GRACE RS (0.766 [95% CI 0.737 to 0.794]) and BANACH RS (0.743 [95% CI 0.713 to 0.771]). Other scores presented were SIMPLE (0.714 [95% CI 0.683 to 0.743], TIMI NSTEMI (0.635 [95% CI 0.580 to 0.688]) and ZWOLLE (0.739 [95% CI 0.697 to 0.779]. The prediction values of currently recommended RS are good for long-term perspective (7-year). RS with high usability, such as BANACH RS demonstrates accuracy similar to the more advanced RS.
    No preview · Article · Aug 2013 · Kardiologia polska

  • No preview · Article · Aug 2013 · Kardiologia polska
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    ABSTRACT: During cardiac arrest and after cardiopulmonary resuscitation, activation of blood coagulation occurs, with a lack of adequate endogenous fibrinolysis. The aim of the present study was to determine whether the serum D-dimer concentration on admission is an independent predictor of all-cause mortality in patients with out-of-hospital cardiac arrest. We enrolled 182 consecutive patients (122 men, mean age 64.3 ± 15 years), who had presented to the emergency department from January 2007 to July 2012 because of out-of-hospital cardiac arrest. Information about the initial arrest rhythm, biochemical parameters, including the D-dimer concentration on admission, neurologic outcomes, and 30-day all-cause mortality were retrospectively collected. Of the 182 patients, 79 (43.4%) had died. The patients who died had had lower systolic (100 ± 39.6 vs 120.5 ± 26.9 mm Hg; p = 0.0004) and diastolic (58.3 ± 24.1 vs 74 ± 16.3 mm Hg; p <0.0001) blood pressure on admission. The deceased patients more often had had a history of myocardial infarction (32.9% vs 25.2%; p = 0.04) and less often had had an initial shockable rhythm (41.8% vs 60.2%; p = 0.02). The patients who died had had a significantly higher mean D-dimer concentration (9,113.6 ± 5,979.2 vs 6,121.6 ± 4,597.5 μg/L; p = 0.005) compared with patients who stayed alive. On multivariate logistic regression analysis, an on-admission D-dimer concentration >5,205 μg/L (odds ratio 5.7, 95% confidence interval 1.22 to 26.69) and hemoglobin concentration (odds ratio 1.66, 95% confidence interval 1.13 to 2.43) were strong and independent predictors of all-cause mortality. In conclusion, patients with a higher D-dimer concentration on admission had a poorer prognosis. The D-dimer concentration was an independent predictor of all-cause mortality.
    No preview · Article · May 2013 · The American journal of cardiology

Publication Stats

321 Citations
131.79 Total Impact Points

Institutions

  • 2004-2015
    • Medical University of Warsaw
      • Department of Cardiology
      Warszawa, Masovian Voivodeship, Poland
  • 2013
    • University of Warsaw
      Warszawa, Masovian Voivodeship, Poland
  • 2007-2009
    • Central Clinical Hospital of the Ministry of Interior in Warsaw
      Warszawa, Masovian Voivodeship, Poland
  • 2004-2005
    • Cardinal Wyszynski National Institute of Cardiology
      Warszawa, Masovian Voivodeship, Poland