Increased systemic arterial stiffness in patients with chronic thromboembolic pulmonary hypertension

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of venous thromboembolism (VTE) resulting from non-dissolving thromboemboli in the pulmonary arteries. Previous observations indicate a higher prevalence of atherosclerosis and cardiovascular risk factors in patients with VTE and CTEPH. The purpose of the present study was to evaluate the arterial stiffening assessed by pulse wave velocity (PWV), a marker of arterial stiffness, in CTEPH patients in comparison with a matched control group (CG).Methods: The study group consisted of 26 CTEPH patients (9 male and 17 female, age 69 ± 10 years) and 22 CG (10 male, 12 female, age 67 ± 8 years). In all subjects a physical examination, carotid-femoral PWV and transthoracic echocardiography were performed. Right heart catheterization was done in all CTEPH.Results: Chronic tromboembolic pulmonary hypertension patients had significantly higher PWV than CG (10.3 ± 2.5 m/s vs. 9 ± 1.3 m/s, p < 0.05), even though systolic blood pressure was higher in CG (120 ± 11 vs. 132 ± 14 mmHg, p = 0.002). PWV correlated only with age and pulmonary vascular resistance (PVR) in CTEPH (r = 0.45, p = 0.03 and r = 0.43, p = 0.03, respectively). Arterial stiffening defined as PWV > 10 m/s was found in 11 (42%) CTEPH patients and in 5 (23%) cases from CG (p = 0.13). CTEPH patients with PWV > 10 m/s were older (74 ± 8 vs. 66 ± 10 years, p < 0.05), had decreased oxygen saturation (SaO2 89 [73–96]% vs. 96 [85–98]%, p < 0.01) and tended to have higher PVR (8.1 [3.1–14.0] vs. 5.2 [3.1–12.7] HRU, p = 0.10).Conclusions: Arterial stiffness, assessed with PWV, is increased in CTEPH. The elevated PWV is associated with older age, lower SaO2 and higher PVR in CTEPH

Peak systolic velocity of tricuspid annulus is inferior to tricuspid annular plane systolic excursion for 30 days prediction of adverse outcome in acute pulmonary embolism

Background: Tricuspid annular plane systolic excursion (TAPSE) is an established index of right ventricular (RV) systolic function and a significant predictor in normotensive patients with pulmonary embolism (PE). Recently, Doppler tissue imaging-derived tricuspid annular systolic velocity (TV S’), a modern parameter of RV function was reported to be useful in the diagnosis and prognosis of a broad spectrum of heart diseases. Therefore, herein, is an analysis of the prognostic value of both parameters in normotensive PE patients.Methods: One hundred and thirty nine consecutive PE patients (76 female, age 56.4 ± 19.5 years) were included in this study. All patients were initially anticoagulated. Transthoracic echocardiography was performed on admission. The study endpoint (SE) was defined as PE-related 30-day mortality and/or need for rescue thrombolysis.Results: Seven (5%) patients who met the criteria for SE presented more severe RV dysfunction at echocardiography. Univariable Cox regression analysis showed that RV/LV ratio predicted SE with hazard risk (HR) 10.6 (1.4–80.0; p = 0.02); TAPSE and TV S’ showed HR 0.77 (0.67–0.89), p < 0.001, and 0.71 (0.52–0.97), p = 0.03, respectively. Area under the curve for TAPSE in the prediction of SE was 0.881; 95% CI 0.812–0.932, p = 0.0001, for TV S’ was 0.751; 95% CI 0.670–0.820, p = 0.001. Multivariable analysis showed that the optimal prediction model included TAPSE and systolic blood pressure (SBP showed HR 0.89 95% CI 0.83–0.95, p < 0.001 and TAPSE HR 0.67, 95% CI 0.52–0.87, p<0.03). Kaplan-Meier analysis showed that initially PE patients with TAPSE ≥ 18 mm had a much more favorable prognosis that patients with TAPSE < 18 mm (p < 0.01), while analysis of S’ was only of borderline statistical significance.Conclusions: It seems that TV S’ is inferior to TAPSE for 30 day prediction of adverse outcome in acute pulmonary embolism

Improvement of left ventricular diastolic function and left heart morphology in young women with morbid obesity six months after bariatric surgery

   Background: Obesity contributes to left ventricular (LV) diastolic dysfunction (LVDD) and may lead to diastolic heart failure. Weight loss (WL) after bariatric surgery (BS) may influence LV morphology and function. Using echocardiography, this study assessed the effect of WL on LV diastolic function (LVDF) and LV and left atrium (LA) morphology 6 months after BS in young women with morbid obesity. Methods: Echocardiography was performed in 60 women with body mass index ≥ 40 kg/m², aged 37.1 ± ± 9.6 years prior to and 6 months after BS. In 38 patients, well-controlled arterial hypertension was present. Heart failure, coronary artery disease, atrial fibrillation and mitral stenosis were exclusion criteria. Parameters of LV and LA morphology were obtained. To evaluate LVDF, mitral peak early (E) and atrial (A) velocities, E-deceleration time (DcT), pulmonary vein S, D and A reversal velocities were measured. Peak early diastolic mitral annular velocities (E’) and E/E’ were assessed. Results: Mean WL post BS was 35.7 kg (27%). A postoperative decrease in LV wall thickness, LV mass (mean 183.7 to 171.5 g, p = 0.001) and LA parameters (area, volume) were observed. LVDD was diagnosed in 3 patients prior to and in 2 of them subsequent to the procedure. An improvement in LVDF Doppler indices were noted: increased E/A, D and E’ lateral, and decreased S/D and lateral E/E’. None of the patients showed increased LV filling pressure. No significant correlations between hypertension and echo-parameters were demonstrated. Conclusions: Six months after BS weight loss resulted in the improvement of LVDF and left heart morphology in morbidly obese women. (Cardiol J 2018; 25, 1: 97–105

A Novel Doppler TRPG/AcT Index Improves Echocardiographic Diagnosis of Pulmonary Hypertension after Pulmonary Embolism

Background: We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). Methods: We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. Results: Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100–2.197) vs. 0.208 (0.026–0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731–0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25–1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. Conclusions: A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH

Fire Safety of Healthcare Units in Conditions of Oxygen Therapy in COVID-19: Empirical Establishing of Effects of Elevated Oxygen Concentrations

Large-scale usage of oxygen therapy (OT) may lead to increased oxygen concentrations (OC) in places where COVID-19 patients are treated. The aim of the study was to establish in an empirical way the OC in COVID-19 at the patient’s bedside and to assess the relationships and reactions that occur during OT in an uncontrolled oxygen-enriched environment. We analyzed and took into account the OC, the technical conditions of the buildings and the air exchange systems. Based on the results, we performed a Computational Fluid Dynamics analysis to assess evacuation conditions in the event of a fire outbreak in the COVID-19 zone. A total of 337 measurements of OC were carried out, and three safety thresholds were then defined and correlated with fire effects. The highest ascertained oxygen concentration was 25.2%. In the event of a fire outbreak at 25.2% oxygen in the atmosphere, the response time and evacuation of medical staff and patients is no longer than 2.5 min. Uncontrolled oxygen enrichment of the environment threatens the safety of medical staff and patients in COVID-19 hospitals

High prevalence of severe coronary artery disease in elderly patients with non-operable chronic thromboembolic pulmonary hypertension referred for balloon pulmonary angioplasty

Introduction : Balloon pulmonary angioplasty (BPA) is a new emerging catheter-based alternative treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Aim : To show that all elderly CTEPH patients referred for BPA are at higher risk of obstructive coronary artery disease and that, in daily practice, they should undergo invasive coronary angiography. Material and methods : Eleven patients at the age of at least 65 years (6 males, 5 females, 77.2 ±5.9 years) with confirmed non-operable type II or type III CTEPH, considered for BPA, underwent elective coronary angiography. Severe obstructive coronary artery disease (CAD) was diagnosed when stenosis of left main coronary artery ≥ 50% or stenosis of ≥ 70% of epicardial arteries was angiographically confirmed. We also screened for CAD consecutive age- and sex-matched 114 PE survivors (52 males, 62 females, 74.8 ±7.2 years) with excluded CTEPH. Results : Severe CAD was more frequent in elderly patients with non-operable type II or type III CTEPH candidates for BPA than in elderly acute PE survivors with excluded CTEPH (54.5% vs. 16.7%, p < 0.01), and therefore elderly CTEPH patients referred for BPA were at higher risk of CAD (OR = 5.9, 95% CI: 1.64–21.46, p = 0.007) when compared to elderly survivors after acute PE with excluded CTEPH. Conclusions : All elderly CTEPH patients referred for BPA are at higher risk of severe CAD and should routinely undergo invasive coronary angiography before BPA

Leczenie riwaroksabanem w porównaniu ze standardową terapią powoduje skrócenie okresu hospitalizacji pacjentów z ostrą zatorowością płucną: doświadczenia ośrodka akademickiego

  Background: Depending on the severity of clinical condition, acute pulmonary embolism (APE) is treated with unfraction­ated heparin (UFH), low-molecular weight heparin (LMWH), oral anticoagulants or, in the most severe form, with fibrinolytic agents. Following APE, patients require prolonged anticoagulant therapy for 3–6 months or in some cases indefinitely. Treatment options in this period include vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) including rivaroxaban. The most recent European Society of Cardiology guidelines on the diagnosis and management of APE recommend use of NOAC in patients at a low-to-moderate risk of early mortality (a class I B recommendation). Rivaroxaban may be used in haemodynamically stable patients since the first day of therapy and was approved for this indication in Poland in December 2012. Aim: To evaluate the rate of rivaroxaban use, characterise patients with APE treated with rivaroxaban, and evaluate potential reduction of the duration of hospitalisation in patients treated with rivaroxaban compared to those receiving VKA. Methods: We evaluated hospital and postdischarge treatment in 215 consecutive APE patients (105 men, 110 women) at the mean age of 65.0 (range: 19.5–91.9) years. The study included patients hospitalised from January 2013 to November 2014, i.e. in the period immediately following approval of rivaroxaban for the treatment of APE in Poland. In the acute phase, patients were treated with LMWH, UFH, or rivaroxaban, and the treatment was continued with VKA, LMWH, or rivaroxaban. The timing of initiation of oral therapy depended on the haemodynamic stability of the patient. Results: Our study group of 215 APE patients included 157 (73%) moderate-risk patients, 51 (24%) low-risk, and 7 (3.3%) high-risk patients. Treatment was initiated with UFH or LMWH in 208 (96.7%) patients, and with rivaroxaban in 7 (3.3%) patients. In 33 (16.5%) patients, rivaroxaban was started after up to 3 days of heparin therapy. Chronic therapy prescribed at discharge in­cluded VKA in 64 (30.5%) patients, rivaroxaban in 82 (39%) patients, and LMWH in 64 (30.5%) patients. Five patients died during hospital, for the total mortality of 2.3%. Acute high-risk PE was diagnosed on admission in 2 of these patients, and moderate-risk PE in 3 patients. Treatment in this group included enoxaparin in 4 patients and UFH in 1 patient. Patients who were discharged on rivaroxaban stayed in hospital for a significantly shorter time compared to patients discharged on VKA (6 [2–22] vs. 8 [2–17] days, p = 0.0005). Duration of hospital stay was significantly shorter in APE patients with sPESI of 0 who were treated with rivaroxaban compared to those with sPESI of 0 treated with VKA (5 [2–11] vs. 6 [2–12] days, p = 0.002). A significant difference in the duration of hospital stay was also noted in patients with sPESI of ≥ 1 treated with rivaroxaban compared to those treated with VKA (7 [3–22] vs. 9 [3–17] days, p = 0.015). Patients with sPESI of ≥ 1 treated with rivaroxaban were hospitalised for a sig­nificantly longer time compared to those with sPESI of 0 treated with rivaroxaban (7 [3–22] vs. 5 [2–11] days, p = 0.00005). Conclusions: Rivaroxaban therapy is a useful therapeutic option in patients with APE. Compared to standard therapy, use of rivaroxaban has been associated with a significant reduction of the duration of hospital stay.Wstęp: W ostrej fazie, w zależności od zaawansowania klinicznego, ostra zatorowość płucna (APE) jest leczona heparyną niefrakcjonowaną (UFH) lub drobnocząsteczkową (LMWH), antykoagulantami doustnymi, a w swej najcięższej postaci — fi­brynolitycznie. Pacjenci po przebytej APE wymagają przedłużonego leczenia przeciwkrzepliwego, które należy stosować przez 3–6 miesięcy, a u niektórych pacjentów bezterminowo. Do leków stosowanych w tym okresie należą doustne antykoagulanty: antagoniści witaminy K (AVK) lub leki niebędące antagonistami witaminy K (NOAC), a wśród nich riwaroksaban. W najnowszych zaleceniach Europejskiego Towarzystwa Kardiologicznego dotyczących rozpoznawania i leczenia APE rekomenduje się stosowanie NOAC u chorych z grupy pośredniego i niskiego ryzyka wczesnego zgonu (klasa zaleceń I B). Riwaroksaban można stosować u stabilnych hemodynamicznie pacjentów od pierwszego dnia terapii; został on zarejestrowany w Polsce w tym wskazaniu w grudniu 2012 roku. Cel: Celem pracy była ocena częstości stosowania riwaroksabanu i charakterystyka grupy chorych z APE leczonych tym lekiem, a także ocena potencjalnego skrócenia czasu hospitalizacji u pacjentów poddanych terapii riwaroksabanem w porównaniu z osobami otrzymującymi VKA. Metody: Analizowano leczenie szpitalne i poszpitalne 215 kolejnych pacjentów (105 mężczyzn, 110 kobiet) w wieku 65,0 (19,5–91,9) lat z APE. U każdego chorego poza badaniem przedmiotowym wykonywano badania echokardiograficzne i laboratoryjne (stężenie biomarkerów odzwierciedlających uszkodzenie/przeciążenie prawej komory: troponina T, NT-proBNP), a także oceniano ryzyko 30-dniowego zgonu w celu oszacowania stopnia ciężkości APE (skala sPESI). Do badania włączono chorych hospitalizowanych w okresie 01.2013–11.2014, a więc bezpośrednio po zarejestrowaniu w Polsce riwaroksabanu do leczenia APE. APE wysokiego ryzyka wczesnego zgonu rozpoznawano, gdy przy przyjęciu stwierdzano wstrząs lub hipotonię spowodowaną APE. APE pośredniego ryzyka rozpoznawano wówczas, gdy systemowe ciśnienie skurczowe przy przyjęciu wynosiło ≥ 90 mm Hg oraz stwierdzano echokardiograficzne, tomograficzne lub laboratoryjne cechy przeciążenia/uszkodzenia prawej komory. APE niskiego ryzyka rozpoznawano u normotensyjnych chorych bez cech przeciążenia/uszkodzenia prawej komory. W ostrej fazie pacjenci przyjmowali UFH, LMWH lub riwaroksaban. Terapię kontynuowano za pomocą VKA, UFH lub riwaroksabanu. Czas rozpoczęcia terapii lekami doustnymi zależał od stabilności hemodynamicznej chorego. Wyniki: W badanej grupie 215 chorych z APE u 157 (73%) pacjentów rozpoznano APE pośredniego ryzyka, u 51 (24%) niskiego ryzyka, a u 7 (3,3%) stwierdzono APE wysokiego ryzyka. 208 (96,7%) chorych leczono wstępnie UFH lub LMWH, u 7 (3,3%) od pierwszego dnia terapii włączono riwaroksaban, w 33 (16,5%) przypadkach po maksymalnie 3 dniach leczenia heparynami zastosowano riwaroksaban. W 4 (1,9%) przypadkach w trakcie hospitalizacji zastosowano leczenie fibrynolityczne. Po wypisaniu ze szpitala jako terapię przewlekłą u 64 (30.5%) pacjentów zalecono stosowanie VKA włączanych w trakcie hospitalizacji, u 82 (39%) riwaroksabanu, a u 64 (30.5%) UFH. W trakcie hospitalizacji zmarło 5 chorych, śmiertelność całkowita wynosiła 2,3%. U 2 pacjentów przy przyjęciu rozpoznano APE wysokiego ryzyka, a u 3 — APE pośredniego ryzyka. W tej grupie 4 chorych było leczonych enoksaparyną, a 1 za pomocą UFH. Przyczyną zgonów u 4 osób była zaawansowana cho­roba nowotworowa, a u 1 pacjentki niepoddające się leczeniu zapalenie dolnych dróg oddechowych. W przypadku żadnego ze zgonów nie stwierdzono poważnego krwawienia. Pacjenci, którzy zostali wypisani do domu z zaleceniem przyjmowania riwaroksabanu, byli hospitalizowani istotnie krócej niż chorzy, którzy otrzymali VKA (6 [2–22] vs. 8 [2–17] dni, p = 0,0005). W grupie chorych z APE i sPESI = 0 pkt. leczonych riwaroksabanem czas hospitalizacji był istotnie krótszy niż u badanych z sPESI = 0 pkt. leczonych VKA (5 [2–11] vs. 6 [2–12] dni, p = 0,002). U badanych z sPESI ≥ 1 pkt leczonych riwaroksabanem i VKA wykazano również istotną statystycznie różnicę długości trwania hospitalizacji (7 [3–22] vs. 9 [3–17] dni, p = 0,015). Stwierdzono istotnie dłuższy czas hospitalizacji pacjentów z sPESI ≥ 1 pkt leczonych riwaroksabanem w porównaniu z badanymi z sPESI = 0 pkt. leczonych tym lekiem (7 [3–22] vs. 5 [2–11] dni, p = 0,00005). Ponadto w badanej grupie chorych zaobserwowano 3 przypadki poważnych krwawień. Pacjenci z tej grupy stosowali leczenie enoksaparyną. Wnioski: Leczenie riwaroksabanem jest przydatną opcją terapeutyczną u chorych z APE. W porównaniu ze standardową terapią zastosowanie riwaroksabanu wiąże się z istotnym skróceniem okresu hospitalizacji

Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism

Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p &gt; 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development