Prognostic value of myocardial fibrosis in severe aortic stenosis:Study protocol for a prospective observational multi-center study (FIB-AS)

BACKGROUND: Adverse cardiac remodeling with a myocardial fibrosis as a key pathophysiologic component may be associated to worse survival in aortic stenosis (AS) patients. Therefore, with the application of advanced cardiac imaging we aim to investigate left ventricular myocardial fibrosis in severe AS patients undergoing aortic valve replacement (AVR) and determine its impact with post-intervention clinical outcomes. METHODS: In a prospective, observational, cohort study patients with severe AS scheduled either for surgical or transcatheter AVR will be recruited from two tertiary heart centers in Denmark and Lithuania. All patients will receive standard of care in accordance with the current guidelines and will undergo additional imaging testing before and after AVR: echocardiography with deformation analysis and cardiovascular magnetic resonance (CMR) with T1 parametric mapping. Those undergoing surgical AVR will also have a myocardial biopsy sampled at the time of a surgery for histological validation. Patients will be recruited over a 2-year period and followed up to 2 years to ascertain clinical outcomes. Follow-up CMR will be performed 12 months following AVR, and echocardiography with deformation analysis will be performed 3, 12, and 24 months following AVR. The study primary outcome is a composite of all-cause mortality and major adverse cardiovascular events. DISCUSSION: Despite continuous effort of research community there is still a lack of early predictors of left ventricular decompensation in AS, which could improve patient risk stratification and guide the optimal timing for aortic valve intervention, before irreversible left ventricular damage occurs. Advanced cardiac imaging and CMR derived markers of diffuse myocardial fibrosis could be utilized for this purpose. FIB-AS study is intended to invasively and non-invasively assess diffuse myocardial fibrosis in AS patients and investigate its prognostic significance in post-interventional outcomes. The results of the study will expand the current knowledge of cardiac remodeling in AS and will bring additional data on myocardial fibrosis and its clinical implications following AVR. ETHICS/DISSEMINATION: The study has full ethical approval and is actively recruiting patients. The results will be disseminated through scientific journals and conference presentations. TRIAL REGISTRATION: ClinicalTrials.govNCT03585933. Registered on 02 July 2018

Unusual presentation of chest pain

Rupture of pulmonary abscess and subsequent pleural empyema with pneumothorax is unusual acute chest pain cause. Brief history, physical examination, simple chest X-ray makes rupture of pulmonary abscess to pleural cavity quickly recognizable. Patient vital signs can deteriorate rapidly, thus depending on findings chest tube placement is crucial and can be lifesaving. In this report we present clinical case of 56 male who presents to rural Emergency Department (ED) complaining worsening dyspnea and sharp severe pain in right chest side, one month ago he was treated in the hospital for Community Acquired Pneumonia

Type 2 myocardial infarction

Myocardial infarction is the leading cause of death in many countries around the world. The use of troponin in clinical practice as „gold standard” improved diagnostic of myocardial infarction without coronary artery occlusion. In 2007, the Task Force for the Universal Definition of Myocardial Infarction published an international consensus document, where 5 myocardial infarction subtypes were defined. Type II myocardial infarction brought confusion in clinical practice. There are the lack of data about differences between type I and II myocardial infarction frequency, symptoms and clinical outcomes. The aims of our study were to evaluate the clinical onset, course, treatment and outcome differences between patients with type I and II myocardial infarction. Study methods: Retrospective study was conducted to analyze data of 1583 patients with MI diagnosis registered in the database of Acute coronary syndromes monitoring system during the year 2011-2015 in Vilnius University clinics Santaros. Patients with type I and II myocardial infarction were analyzed. Demographic parameters, laboratory tests, interventional and medical treatment and disease outcomes were examined. Study results: Type I myocardial infarction was diagnosed for 1467 patients (87.95%), type II – 116 patients (6.95%). Comparing groups of patients with type II and I myocardial infarction significant differences were found between the number of patients with anemia, tachycardia, new onset atrial fibrillation and significantly (<100 m.) impaired functional capacity – all parameters were worse in patients with type II myocardial infarction. Group of patients with type II myocardial infarction also had lower troponin concentration, lower number of damaged coronary arteries and a lower degree of stenosis. Coronarography, percutaneous coronary intervention and antiplatelet treatment (54% vs. 76%; p<0.001) were applied less often for these patients. Group of patients with type II MI stood out with higher hospital mortality (10% vs. 4%; p=0.049). Conclusions: Type II MI is diagnosed almost 12 times less frequent than type I MI, however patients with type II MI have higher hospital mortality. Type II MI patients are more frequently diagnosed with anemia, tachycardia, new onset atrial fibrillation, significantly impaired functional capacity and lower troponin concentration than those with type I MI. Interventional and antiplatelet treatment is applied less often in type II MI patients

Risk factors distribution in patients with symptomic vitamin K antagonist overdose

Aim of the study. To determine risk factors for bleeding, major bleeding and death in patients with overdose of vitamin K antagonists. Methods. The retrospective study examined patients, who have overdosed vitamin K antagonists and were admitted to Vilnius university Santariškės hospital between 2010-01-01and 2016- 10-31. Age, sex and bleeding risk factors were compared between groups with bleeding events and without bleeding events. Results. Total of 518 patients’ data were analysed, 253 (48,8%) were men, 265 (51,2%) women, average age was 73,2±11,2 years old. 298 (57,5%) had bleeding event, 149 (50%) were women, average age was 72,3±11,7 years old. Group with bleeding event were more likely to have gastrointestinal bleeding history:16 (5,4%) vs. 3 (1,4%) (p=0,017. 162 patients had major bleeding, average age was 72,8±11,8 years old, 88 (54,3%) were women. Major bleeding group also had more common gastrointestinal bleeding history - 10 (6,2%) vs. 9 (2,5%) (p=0,04). 56 (10,8% ) patients died, average age was 74,8±11,2 years old, 27 (48,2%) were women . Patients with lethal outcomes had kidney disease history more often (creatinine was over 200mmol/l) -17 (30,4%) vs. 64 (13,9%) (p=0,001). Conclusions. Patients who had symptomic warfarin overdose with bleeding or major bleeding were more likely to have gastrointestinal bleeding history. 9,4% of all bleeding event were lethal. Patients who died during hospitalization and had warfarin overdose were more likely to have kidney diseases and creatinine value over 200 mmol/l. These risk factors might be prognostic to predict if warfarin overdose will be symptomic, but futher investigation is required

Hospitalization and treatment analysis after vitamin K antagonists overdose

Aim of the study – to find risk factors for longer hospitalization and additional treatment for patients with vitamin K antagonist overdose and to describe how hospitalization length and treatment quantities change after bleeding occurs. Methods. Following information about patients with vitamin K antagonists (warfarin) overdose was analysed: bleeding risk factors, overdose outcomes, hospitalization length, bleeding treatment. Results. 116 (77,3%) patients with bleeding and 48 (43,5%) without bleeding needed additional treatment for bleeding and/or following complications. (p<0,001). Patients with bleeding event needed more red blood cell units (p<0,001), fresh frozen plasma units (p<0,001), vitamin K (p=0,03). These differences are even bigger in group with major bleeding event (p<0,001). Previously diagnosed anaemia is a risk factor for additional treatment need during hospitalization (p<0,001). Average hospitalization length was longer for patients with anaemia (p=0,05), thrombocytopenia (p=0,05) or liver disease history (p=0,04), hospitalization length was significantly longer for patients with bleeding event (p=0,003), 11,8±8,7 days and 9,1±4,6 days respectively. The average hospitalization length for patients with haemorrhagic stroke was 23,3±18,2 days. Conclusions. Vitamin K antagonists overdose requires additional treatment and longer hospitalization: average hospitalization length is 3 days longer after bleeding occurs, and red blood cell units consumption has grown 10 times over five year

Išeičių po perkutaninės koronarinės intervencijos ir aortokoronarinių jungčių suformavimo operacijos palyginimas tarp vyresnio amžiaus pacientų

Background. The data on long-term outcomes for elderly patients with coronary artery disease who undergo invasive treatment is limited. This study aimed to assess long-term outcomes and risk factors for patients over 80 years of age who underwent revascularisation. Methods. This single-centre retrospective study included ≥80-year-old patients who underwent coronary angiography between 2012 and 2014. Among 590 study patients, 411 patients had significant angiographic changes and had either a percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) performed. Baseline patient characteristics, including demographics, comorbidities, survival to hospital discharge, and long term mortality were analysed. Three-year mortality was assessed. Results. Three hundred sixty-nine (89.8%) patients underwent PCI and in 42 (10.2%) CABG was performed. Significant differences between groups were detected in heart failure (PCI – 51.2% vs. CABG – 78.6%; p = 0.001), previous CABG (11.4% vs. 0%; p = 0.014), cardiogenic shock (12.2% vs. 0%; p = 0.008). Hospital mortality rate in the PCI group – 10.6%, CABG – 7.1%; p = 0.787. A median 3-year survival rate in the PCI group – 66.1%, CABG – 66.7%; p = 1.000. Chronic heart failure (OR 2.442; 95% CI: 1.530–3.898, p < 0.001), atrial fibrillation (OR 0.425; 95% CI: 0.261–0.692, p < 0.001), cardiogenic shock (OR 0.120; 95% CI: 0.054–0.270, p = 0.001), and LMCA stenosis (OR 2.104; 95% CI: 1.281–3.456, p = 0.003) were identified as independent 3-year all-cause mortality predictors in multivariate regression analysis. Conclusions. There was no significant difference in hospital mortality and survival rates between elderly patients who underwent PCI or CAGB. The majority of elderly patients underwent a PCI and these patients appeared to experience cardiogenic shock more frequently

Prognostic significance of biomarkers in predicting in-hospital all-cause mortality in elderly patients with acute myocardial infarction

Background: AMI is a common cause of death in elderly patients. Therefore, prognostic prediction has become crucially important part of the treatment process. Aim: We aimed to investigate prognostic significance of biomarkers and other clinical factors in predicting all-cause in-hospital mortality in patients older than 75 years with AMI. Materials and Methods: 2059 consecutive patients were retrospectively included in single center study. Participants were divided into groups based on their in-hospital mortality. The prognostic ability of biomarkers peak values was evaluated by using ROC curve and binary logistic regression analysis. Results: Among 2059 patients enrolled in this study, 1141 (55.4%) were woman, and 1060 (51.5%) were with a diagnosis of non-ST segment elevation myocardial infarction. The mean age (SD) of the study population was 81.97 (4.33) years. In-hospital mortality rate in our study was 13.3%. Peak Troponin I, BNP and hs-CRP concentrations were significantly higher in deceased patients (all p824.3 ng/l and hs-CRP level >78.7 g/l were disclosed as the best thresholds for mortality prediction in this age group. Using binary logistic regression, hs-CRP level >78.7 g/l (OR (95% CI), 2.68 (1.89-3.81)), stroke history (OR (95%CI), 2.3 (1.53-3.47)), BNP level >824.3 ng/l (OR (95% CI), 2.04 (1.43- 2.91)), in-hospital bleeding complications (OR (95% CI), 2.04 (1.27-3.28)) were identified as strongest independent predictors of in-hospital all-cause mortality. Conclusion: In-hospital mortality in elderly patients with acute myocardial infarction is 13.3%. Troponin I is the least useful biomarker in predicting mortality. Increased levels of hs-CRP, BNP, stroke history and the presence of any in-hospital bleeding complications were identified as reliable predictors of in-hospital mortality in the elderly population with acute myocardial infarction

High-Sensitivity Cardiac Troponin Impact on the Differential Diagnosis of Non-ST Segment Elevation Coronary Syndromes&mdash;Is It Helping?

Background and Objectives: Increased levels of high-sensitivity cardiac troponin (hs-cTn) are the main criteria that differentiate non-ST segment elevation myocardial infarction (NSTEMI) from unstable angina (UA). How are these implemented in clinical practices? This study aims to detect cases of misdiagnosed UA instead of NSTEMI. Materials and Methods: We analysed discharge summaries of 840 patients admitted to Vilnius University Hospital Santaros Klinikos with the diagnosis of UA in 2017&ndash;2018. We retrospectively checked symptoms, levels of hs-cTn, coronary angiography and electrocardiogram changes with an aim to differentiate UA and type 1 NSTEMI, according to the Fourth Universal Definition of Myocardial Infarction. We excluded patients with missing hs-cTn levels or coronary angiography. Results: We found that 46.71% (n = 334) of patients met the diagnostic criteria of UA according to the Fourth Universal Definition, whereas 19.16% of patients (n = 137) could have been diagnosed with type 1 NSTEMI instead of UA. In the group of patients who could be reclassified to type 1 NSTEMI, the median level of hs-cTn was 184.32 [226.15] ng/L on admission. The median of the lowest level during the hospitalization was 114.0 [207.4] ng/L. Median highest&mdash;304.0 [257.6] ng/L. Myocardial infarction with non-obstructive coronary arteries could have been diagnosed in 3.36% (n = 24) of patients. Conclusions: Only less than half of patients met the diagnostic UA criteria. Almost one-fifth of patients with a diagnosis of UA could be reclassified to type 1 NSTEMI