Low fasting glucose is associated with enhanced thrombin generation and unfavorable fibrin clot properties in type 2 diabetic patients with high cardiovascular risk

Objective To investigate the effect of low blood glucose on thrombin generation and fibrin clot properties in type 2 diabetes (T2DM). Methods In 165 patients with T2DM and high cardiovascular risk, we measured ex vivo plasma fibrin clot permeation [Ks], turbidity and efficiency of fibrinolysis including clot lysis time [t50%], together with thrombin generation and platelet activation markers in relation to fasting blood glucose. Results As compared to patients in medium (4.5-6.0 mmol/l, n = 52) and higher (>6.0 mmol/l, n = 75) glucose group, subjects with low glycemia (<4.5 mmol/l, n = 38) had lower Ks by 11% (p < 0.001) and 8% (p = 0.01), respectively, prolonged t50% by 10% (p < 0.001) and 7% (p = 0.016), respectively, and higher peak thrombin generation by 21% and 16%, respectively (p < 0.001 for both). There were no significant differences in Ks and t50% between patients in medium and higher glucose group. In the whole group, a J-shape relationship was observed between glycemia and the following factors: peak thrombin generation, Ks and t50%. Only in patients with HbA1c < 6.0% (42 mmol/mol) (n = 26) fasting glucose positively correlated with Ks (r = 0.53, P = 0.006) and inversely with t50% (r = −0.46, P = 0.02). By multiple regression analysis, after adjustment for age, fibrinogen, HbA1c, insulin treatment and T2DM duration, fasting glycemia was the independent predictor of Ks (F = 6.6, df = 2, P = 0.002), t50% (F = 8.0, df = 2, P < 0.001) and peak thrombin generation (F = 13.5, df = 2, P < 0.0001). Conclusions In T2DM patients fasting glycemia <4.5 mmol/l is associated with enhanced thrombin formation and formation of denser fibrin clots displaying lower lysability, especially when strict glycemia control was achieved (HbA1c<6.0%)

Knowledge gaps in patients with venous thromboembolism : usefulness of a new questionnaire

The current awareness of venous thromboembolism (VTE) and knowledge of thromboprophylaxis among patients receiving oral anticoagulation therapy (OAC) are insufficient. We sought to develop and evaluate the usefulness of the Jessa AF Knowledge Questionnaire (JAKQ), modified for VTE patients. Consecutive patients at least 1 month since the VTE event (n = 273, mean [SD] age, 51 [17] years; 52.7%, women; 55.9%, unprovoked event) were enrolled to the study. The median percentage of correct responses was 64.2% (interquartile range, 53%-73%; minimum, 12%; maximum, 100%). Younger patients had better knowledge about VTE in general, including a higher proportion of correct responses to the question about the definition of PE (71.4% vs 57.7%, P = 0.03), about the possible consequence of DVT, including PE (81.1% vs 62%, P = 0.001) and VTE risk related to long travels (78.1% vs 59.2%, P = 0.002). There was no difference in overall scoring between patients taking new oral anticoagulants and those taking vitamin K antagonists (mean [SD], 64.1% [16.3%] vs 63.9% [13.8%], respectively, P = 0.7). Regardless of the type of anticoagulants, 39.3% of patients knew that VTE is not always symptomatic, 33.6% knew what to do when they missed an OAC dose, and 50% did not know which painkillers are the safest in combination with anticoagulants. Education applied in 27 patients resulted in an increase in the median percentage of correct responses from 60% to 80% (P = 0.0001). Knowledge on VTE and anticoagulation is suboptimal among patients on VKA and NOACs. Education of VTE patients should be improved especially in older individuals on NOACs

Influence of obstructive sleep apnea on right heart structure and function

Introduction: Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep disorder associated with increased cardiovascular morbidity and mortality. This study aimed to investigate heart structure and function and their correlation with the degree of OSAS and sleep indexes in patients diagnosed with OSAS. Materials and methods: A cohort of 77patients (48 males, aged 58.1 ± 11.0 years, body mass index [BMI] = 32.4 ± 6.2) admitted to the hospital due to suspected OSAS was examined using echocardiography and polysomnography. Results: Patients with moderate-to-severe OSAS compared to patients without diagnosed OSAS or with mild OSAS had greater right ventricular outflow tract (RVOT) dimensions (32.6 ± 3.6 vs 30.9 ± 2.4 mm; p &lt; 0.05), larger right atrial area (RAA; 21.1 ± 4.8 vs 17.2 ± 3.2 mm; p = 0.002), greater right ventricular mid-cavity diameter (RVD; 35.5 ± 7.0 vs 32.2 ± 4.7 mm; p = 0.02), and diminished tricuspid annular plane systolic excursion (TAPSE, 21.9 ± 4.5 vs 25.8 ± 4.4 mm; p = 0.04), while there were no significant differences in tissue doppler imaging (TDI) parameters (S’ and E’) and in valvular regurgitation gradient for both groups. Moreover, significantly greater RVOT dimensions (31.6 ± 2.6 vs 30.9 ± 3.0 mm, p = 0.04), RVD (39.3 ± 7.0 vs 32.7 ± 5.2 mm, p = 0.003), and RAA (21.4 ± 4.4 vs 18.1 ± 4.2 mm, p = 0.02) as well as reduction in TAPSE (20.9 ± 5.3 vs 25.0 ± 4.3 mm, p = 0.01) were observed in patients having ≥ 10 episodes of obstructive apnea (OA) per hour. Conclusions: In moderate-to-severe OSAS patients, right ventricular (RV) enlargement was observed together with RV dysfunction as measured by TAPSE. Examination using TDI is not superior to standard echocardiography for the detection of heart pathology in OSAS patients. Right heart pathology is present predominantly in patients with obstructive apnea

Obstructive sleep apnea — diagnosis and treatment options

Obturacyjny bezdech senny (OSA) jest schorzeniem polegającym na powtarzających się epizodach bezdechów i spłyceń oddechu spowodowanych całkowitą bądź częściową blokadą przepływu powietrza. Głównymi objawami OSA są: nadmierna senność w ciągu dnia, nagłe wybudzenia z uczuciem zatrzymania oddechu lub duszenia się, suchość w jamie ustnej po przebudzeniu, poranne bóle głowy, trudności w koncentracji, potliwość nocna i inne. Częstość występowania OSA jest wysoka i prawdopodobnie, z powodu zwiększającej się częstości otyłości, będzie większa w przyszłości. W wielu badaniach wykazano korelacje między OSA a innymi schorzeniami, takimi jak: nadciśnienie tętnicze, przewlekła niewydolność krążenia, choroba niedokrwienna serca, arytmie, udar mózgu. Istnieje również wiele publikacji wskazujących na korzystny wpływ terapii z użyciem stałego dodatniego ciśnienia w drogach oddechowych (CPAP) na schorzenia współistniejące. „Złotym standardem” w diagnostyce OSA jest tak zwana stacjonarna polisomnografia (PSG), ale urządzenia przenośne typu 3 (z min. 4 kanałami) również są akceptowalne w diagnostyce pacjentów wyjściowo obciążonych umiarkowanym lub wysokim ryzykiem OSA. Diagnozę stawia się na podstawie wyników PSG i objawów. Na podstawie wyniku PSG można podzielić OSA na 3 grupy — łagodne, umiarkowane i ciężkie. Według aktualnych wytycznych i publikacji CPAP jest leczeniem pierwszego wyboru w umiarkowanej i ciężkiej postaci OSA. Strategia lecznicza w przypadku bezdechu łagodnego zależy od zdrowia pacjenta, schorzeń współistniejących i indywidualnych decyzji chorego. Innymi opcjami leczenia są aparaty wewnątrzustne, leczenie pozycyjne i chirurgiczne, ale żadna z tych metod nie dorównuje korzyściom wynikającym z terapii CPAP.Obstructive sleep apnea (OSA) is a disease characterized by recurrent episodes of apneas and hypopneas, caused by total or partial airway obstruction. Main symptoms of OSA are: excessive daytime sleepiness, snoring, waking up suddenly feeling like gasping or choking, dry mouth or sore throat after waking up, morning headaches, trouble concentrating, night sweats and others. Prevalence of OSA is high and probably — due to increasing prevalence of obesity — will be higher in the future. Many studies show correlation between OSA and other diseases such as hypertension, chronic heart failure, coronary artery disease, arrhythmias and stroke. There are also many publications showing positive impact of CPAP treatment on managing comorbidities. Gold standard in diagnosis of OSA is in-laboratory polysomnography (PSG), although type 3 portable monitors (with at least 4 channels) are also acceptable to diagnose patients with pre- -test moderate to high risk of OSA. Diagnosis is made based on PSG results and symptoms. Based on PSG results, we can divide OSA into 3 groups: mild, moderate and severe. Based on current guidelines and publications, continuous positive airway pressure (CPAP) is a first choice treatment in moderate and severe OSA. Treatment strategies in mild OSA depend on patient health, comorbidities and individual patient decisions. Other treatment options are oral appliances, positional treatment and surgery but none of them equals CPAP’s benefits

Polish regional differences in patient knowledge on atrial fibrillation and its management as well as in patterns of oral anticoagulant prescription

Background: The Jessa Atrial Fibrillation Knowledge Questionnaire (JAKQ) was successfully used to assess knowledge gaps in patients with atrial fibrillation (AF). Aims: To evaluate the regional differences among Polish patients in their awareness of AF diagnosis and oral anticoagulation use. Methods: A total of 1583 patients with AF at a median (IQR) age of 72 (66–79) years completed the JAKQ in 3 cardiology centers (center I, Kraków; center II, Toruń; center III, Kielce) from January 2017 to June 2018. The final analysis included 1525 patients, 32.9% were on vitamin K antagonists (VKAs) and 67.1% on non-VKA oral anticoagulants (NOACs), that is, rivaroxaban and dabigatran (28.9% each), and apixaban (9.3%). Results: The mean (SD) score on the JAKQ was 55.5% (18.4%) with better results among patients on VKAs compared with NOACs (58% [18.3%] vs 54.3% [18.4%]; P = 0.0002) with time from AF diagnosis more than 12 months (57.4% [17.5%] vs 50% [19.9%]; P &lt; 0.0001). There was a significant difference in the knowledge scores between the 3 centers (I, 59.5%; II, 48.5%; III, 54.3%; P &lt; 0.0001). In all centers the number of correct answers correlated inversely with patient’s age (r = –0.20; P &lt; 0.0001). NOACs were more frequently used in center III. The percentage of correct responses was lower in patients on reduced NOAC doses (35.4% of patients on NOACs), compared with the full-dose NOAC groups in center I (56.9% vs 62.5%; P = 0.012) and II (48.1% vs 56.2%; P = 0.003). Conclusions: Patients from a high-volume academic center showed better knowledge than their peers from district hospitals. There are large regional differences in prescription patterns of oral anticoagulants, including the preferred NOAC