Blood pressure variability: Epidemiological and clinical issues

Blood pressure variability (BPV) is a classical physiological phenomenon. This paper describesmajor epidemiological and clinical issues of BPV which may be important to understand thebackground of this interesting feature. In healthy subjects, BPV is a measure of hemodynamiccondition and refl ects function of autonomic nervous system. BP fl uctuations result from thecomplex interaction between environmental stimulation, genetic factors and cardiovascularcontrol mechanisms. Abnormal BPV is recognized in persons with a blurred dipping pattern(i.e. extreme dipping, non-dipping, reverse-dipping, morning surge of BP) or increased variationsof day-time or night-time BP (high BP lability). Inappropriate BPV worsens the outcome,including increase in all-cause and cardiac mortality and incidence of cardiovascular events,and advance in target organ damage. Abnormal BPV may be softened or removed with suitabletime-dependent administration of anti-hypertensive agents, especially those acting on therenin–angiotensin system

Bayesian analysis in diagnosing origins of elevated blood pressure

Analiza bayesowska to metoda wnioskowania statystycznego, będąca alternatywą dla tzw. analizy tradycyjnej. Twierdzenie Bayesa pozwala na weryfikację subiektywnego przypuszczenia na temat istnienia choroby w obliczu znajomości obiektywnych wyników testów diagnostycznych. Z matematycznego punktu widzenia teoria ta mówi, że prawdopodobieństwo występowania badanego punktu końcowego, zwanego prawdopodobieństwem a posteriori, jest wprost proporcjonalnie zależne od wartości wstępnego prawdopodobieństwa jego istnienia (tzw. prawdopodobieństwo a priori) i wartości współczynnika wiarygodności (likelihood ratio). Z analizy bayesowskiej można z powodzeniem korzystać w codziennej praktyce klinicznej, także w odniesieniu do diagnostyki objawowego nadciśnienia tętniczego, bazując na wynikach różnego rodzaju testów diagnostycznych, w tym badania podmiotowego i przedmiotowego oraz badań dodatkowych - laboratoryjnych czy obrazowych. W artykule opisano użyteczność wykorzystania wnioskowania bayesowskiego w rozpoznawaniu podwyższonych wartości ciśnienia tętniczego występujących w przebiegu pierwotnego hiperaldosteronizmu oraz zwężenia tętnicy nerkowej.Bayesian analysis is a statistical method that is alternative for traditionally implemented ‘frequentist approach’. Bayes’ theorem is a formula that shows how existing and subjective beliefs are modified by objective results of diagnostic tests. From mathematical point of view, Bayes’ theorem states that the probability of outcome occurrence after new information is obtained, called a posteriori probability, depends directly on an a priori probability and the value of likelihood ratio associated with a given test result. Bayesian analysis may be successfully used in everyday clinical practice, also in relation to diagnosis of origins of secondary hypertension. Then, it is based on the results of various diagnostic procedures, including signs and symptoms of the disease, lab findings and imaging techniques. This paper describes usefulness of bayesian analysis in diagnosis of elevated blood pressure values resulting from primary aldosteronism and renal artery stenosis

Effect of fluid resuscitation with balanced solutions on platelets: In vitro simulation of 20% volume substitution

   Background: Fluid resuscitation in massive bleeding may cause coagulation disorders by dilution of platelets and clotting factors or by the impact on their function. The aim of this study was to investigate the effects of balanced crystalloid and colloid solutions on platelets in vitro using complex assessment of coagulation. Methods: The study group was comprised of 32 American Society of Anesthesiologists physical status class I male volunteers, aged 21–35 (29 ± 4) years, weighting 59–103 (81.2 ± 9.8) kg. Whole blood samples were diluted at a 4:1 ratio with the following fluids: balanced crystalloid (Plasmalyte®), 6% hydroxyethyl starch 130/0.4 (Volulyte®) and succinylated gelatin (Geloplasma®). Coagulation was as­sessed using standard morphology, rotational thromboelastometry and aggregometry. Results: Dilution with all fluids caused statistically significant drop in the number of platelets (p < 0.01) but the effect did not differ between solutions (p > 0.05 for all). Other platelet parameters, such as platelet distribution width, mean platelet volume and platelet-large cell ratio were not affected by the solutions. Hemodilution had no effect on platelet function (p = 0.1). Decreased platelet component of clot strength was found for all three fluids (p < 0.05), although the effect for colloids was more pronounced. Conclusions: The effect of balanced crystalloids and colloids on platelet aggregation was insignificant, even after 20% volume substitution with the resuscitation fluids.

Determinanty zapalenia mięśnia sercowego u młodych dorosłych — 3-letnie doświadczenia jednego ośrodka

Introduction. Myocarditis is a challenging diagnosis due to the heterogeneity of clinical presentations. This inflammatory myocardial disease should be diagnosed based on established clinical, laboratory and imaging criteria.Material and methods. We studied consecutive patients aged 18–40 years admitted to an emergency department (ED) with the diagnosis of an acute coronary syndrome (ACS) between January 01, 2011 and December 31, 2013. Demographic, clinical and laboratory data were analysed. The patients were diagnosed with myocarditis based on the history of a respiratory or gastrointestinal tract infection, clinical symptoms of reduced exercise tolerance, chest pain, arrhythmias or new onset symptoms of heart failure, with abnormal electrocardiographic and/or echocardiographic findings and elevated markers of myocardial necrosis. All subjects underwent coronary angiography to exclude or confirm an ACS.Results. Patients with myocarditis were younger (median age 30.5 years, interquartile range [IQR] 20.5–32) compared to ACS patients (median age 39 years, IQR 35–39.5; (p = 0.001). All young adults with myocarditis had a history of infection within 4 weeks and it was the strongest determinant of myocarditis (odds ratio [OR] 113.7, 95% confidence interval [CI] 5.64–2289.7; p < 0.001). Compared to ACS patients, those with myocarditis were more likely to report a history of fever (OR 17.22; 95% CI 0.9–330.5; p = 0.06) and have an elevated white blood cell count (median 9.95, IQR 8.3–11.95 vs. 8.2, IQR 6.4–10.32; p = 0.07), elevated high-sensitivity C-reactive protein level (OR 29.3; 95% CI 1.14–748.6; p = 0.04), higher left ventricular ejection fraction (median 60, IQR 60–65 vs. 55, IQR 50–55; p = 0.001),and elevated creatine kinase activity (OR 7.94; 95% CI 1.41–44.8; p = 0.02). Dyslipidaemia was less frequent in young adults with myocarditis (OR 0.03; 95% CI 0.003–0.3; p = 0.002).Conclusions. Infection-related parameters are key determinants of myocarditis in young adults with chest pain. These easily accessible clinical and laboratory parameters should guide further clinical decision-making in ED.Wstęp. Zapalenie mięśnia sercowego jest często wyzwaniem diagnostycznym ze względu na niejednoznaczny obrazkliniczny. Ta zapalna choroba mięśnia sercowego powinna być rozpoznawana na podstawie określonych kryteriów klinicznych, laboratoryjnych i wyników badań obrazowych.Materiał i metody. Do badania włączano kolejnych chorych w wieku 18–40 lat, kierowanych na szpitalny oddział ratunkowy z rozpoznaniem ostrego zespołu wieńcowego (ACS) w okresie od 1 stycznia 2011 roku do 31 grudnia 2013 roku. Obok szczegółowego wywiadu chorobowego u każdego pacjenta oznaczano laboratoryjne markery uszkodzenia mięśnia sercowego i wykładniki stanu zapalnego oraz wykonywano elektrokardiografię (EKG) i echokardiografię (UKG). U wszystkich chorych wykonano angiografię naczyń wieńcowych. Rozpoznania zapalenia mięśnia sercowego dokonywano z wykluczenia, na podstawie charakterystycznego wywiadu, objawów klinicznych, zmian w obrazach EKG i UKG oraz wyników badań laboratoryjnych, przy prawidłowym wyniku koronarografii.Wyniki. Osoby z zapalenia mięśnia sercowego były znamiennie statystycznie młodsze (mediana wieku [Me] = 30,5; zakres międzykwartylowy [IQR] 20,5–32) niż chorzy z ACS (Me = 39; IQR 35–39,5) (p = 0,001). Wszyscy młodzi dorośli z rozpoznanym zapalenia mięśnia sercowego w ostatnich 4 tygodniach przebyli infekcję, najczęściej dróg oddechowych. Był to najsilniejszy determinant zapalenia mięśnia sercowego (iloraz czans [OR] = 113,7; 95-proc. przedział ufności [CI] 5,64–2289,7; p < 0,001). Czas trwania infekcji wynosił 4 (IQR 3,5–7) dni. Osoby z zapaleniem mięśnia sercowego cechowały się ponadto częstszym występowaniem gorączki w wywiadzie (OR = 17,22; 95% CI 0,9–330,5; p = 0,06), większą liczbą leukocytów w morfologii krwi obwodowej (Me = 9,95; IQR 8,3–11,95 v. Me = 8,2; IQR 6,4–10,32; p = 0,07) oraz podwyższonym stężeniem wysokoczułego białka C-reaktywnego (OR = 29,3; 95% CI 1,14–748,6; p = 0,04). Osoby z ACS cechowała znamiennie gorsza frakcja wyrzutowa lewej komory (Me = 60; IQR 60–65 v. Me = 55; IQR 50–55; p = 0,001), jednak nie przekładało się to na różnicę między grupami pod względem odsetka osób z obniżoną poniżej 50% funkcją (OR = 0,34; 95% CI 0,03–4,2; p = 0,8). Obciążenie klasycznymi czynnikami ryzyka sercowo-naczyniowego nie różniło się między grupami, z wyjątkiem dyslipidemii, która u osób z zapaleniem mięśnia sercowego występowała znacznie rzadziej (OR = 0,03; 95% CI 0,003–0,3; p = 0,002).Wnioski. U młodych osób dorosłych czynnikami różnicującymi przyczynę stenokardii są infekcja w wywiadzie, podwyższone parametry stanu zapalnego oraz obecność dyslipidemii

Utstein-style reporting of out-of-hospital cardiac arrest in the Bielsko-Biała county

Introduction. Out-of-hospital cardiac arrest (OHCA) is one of the most severe medical emergencies, with significantly high both pre- and in-hospital mortality rates. The aim of the study was to assess the quality of reporting OHCA data by the Emergency Medical Service teams (EMS) in the Bielsko-Biała county, using standard ambulance dispatch cards. Material and methods. The study included adult inhabitants of Bielsko-Biała county who suffered from OHCA in 2013. Data were retrieved from standardised PRM forms, and compared to the Utstein style template. The study group comprised 272 patients, 190 (70%) males and 82 (30%) females, with a median age of 71 years (IQR 60–80). The pre-hospital mortality rate was 76.5% (75.3% in men and 79.3% in women). Results. The potential cause of OHCA was least known, with only 22% of forms including any information concerning this issue. Suboptimal reporting on the data enabling patient identification was noted in 12% cases. There was no association between reporting style and time and place of the OHCA. Conclusions. The overall quality of reporting of OHCA by PMR in Bielsko-Biała was good. The greatest concern was inability to identify the potential cause of the event, which can significantly influence application of adequate treatment

Diagnostic value of flow mediated dilatation measurement for coronary artery lesions in men under 45 years of age

Background: In those without symptoms of coronary artery disease (CAD), the incidence of coronary events is still high. The aim of this study was to evaluate whether flow mediated dilatation (FMD) is a useful tool in identifying those with CAD in who are under 45 years of age. Methods and results: Seventy five men below 45 years of age, hospitalized in order to perform elective coronary angiography, were enrolled into the study. Based on coronary angiography findings, they were divided into two groups: study group (Group A, n = 55) with obstructive coronary lesions and the control group (Group B, n = 20) without significant lesions in coronary arteries. In all subjects atherosclerosis risk factors were analyzed. Endothelial dysfunction was assessed in ultrasound via FMD. FMD was significantly lower in the study group than in the control group (3.92 &#177; 1.1 vs 6.51 &#177; 1.1, p < 0.001). FMD, as well as age, diabetes and positive family history, appeared to be statistically significant CAD risk factors. AUROC for FMD was 0.957 (p < 0.001), meaning this model had an almost complete ability to predict the presence of CAD. AUROC for CAD diagnosis on the basis of significant clinical parameters was 0.992 (p < 0.001), also representing almost complete ability of this model to identify asymptomatic subjects with CAD risk. Conclusions: The evaluation of endothelial function by the use of FMD in the population of men below 45 years of age with diabetes and positive family history can help in identifying subjects at high risk of coronary artery disease. (Cardiol J 2010; 17, 3: 288-292

Kruchość chorych kierowanych na operacje kardiochirurgiczne — badanie pilotażowe

Introduction. Frailty has been recently approved in many surgical fields as the acknowledged preoperative predictor of adverse postoperative complications. Several methods are available to assess frailty assessment which focus on different patient-related data. The aims of the study were: 1) to verify whether frailty may predict early postoperative complications in cardiac surgery; and 2) to investigate the agreement between objective and subjective assessment of frailty. Material and methods. This prospective study included 54 consecutive patients (32 men; median age 75 years) hospitalized between December 2015 and February 2016. Frailty was assessed using the Edmonton Frail Scale (EFS, subjective tool) and the Modified Frailty Index (MFI, objective tool). Complications were evaluated based on medical records. Results. The median EFS was 6 (IQR 5–7) points. Frailty was observed in 15% and vulnerability in 49% of subjects. The median MFI was 0.45 (IQR 0.36–0.56). We found a weak correlation between frailty and the length of hospital stay (EFS: r = 0.22; P = 0.1; MFI: r = 0.324; P = 0.02). Neither tools could predict the occurrence of postoperative complications (EFS: AUROC = 0.602; 95% CI 0.459–0.732; P = 0.2; MFI: AUROC = 0.532; 95% CI 0.389–0.670; P = 0.2). We found no correlation between EFS and MFI (r = 0.05, P = 0.7). Conclusions. Although many elderly cardiac surgical patients are at risk of frailty, none of the evaluated methods could predict postoperative complications. Available diagnostic tools to assess frailty cannot be used interchangeably. Subjective assessment (by a patient) should be verified by objective evaluation (by a treating physician) and conclusions should be drawn based on the overall clinical picture

Nagłe zatrzymanie krążenia u młodej osoby dorosłej — studium przypadku

Sudden cardiac arrest (SCA) is an unexpected loss of heart function. It rarely occurs in young adults, but if already does, it is characterized by a higher mortality rate compared to patients being 40 years of age or older. Although SCA can happen in apparently healthy persons, it is usually triggered by cardiac disorders. Generally it has no characteristic prodromal symptoms. In this paper we describe a case of SCA in a young woman that was the first symptom of a single-vessel coronary artery disease.Nagłe zatrzymanie krążenia (NZK) jest definiowane jako nieoczekiwane ustanie funkcji serca. Rzadko dotyczy ono osób młodych, natomiast jeśli już wystąpi, to cechuje się u nich większą śmiertelnością niż u osób po 40. roku życia. Choć NZK może wystąpić u pozornie zdrowych osób, to zwykle ma podłoże kardiologiczne. Z reguły poprzedza je wystąpienie niecharakterystycznych objawów prodromalnych. Celem pracy jest opis przypadku NZK u młodej kobiety, które było pierwszym objawem jednonaczyniowej choroby wieńcowej

Regression towards the mean in studies of arterial blood pressure

Regresja w kierunku wartości średniej (RTM, regression towards the mean) jest zjawiskiem statystycznym, które występuje w badaniach ciśnienia tętniczego niezależnie od analizowanego problemu badawczego, wieku badanych, metody pomiaru lub czasu prowadzonej obserwacji. Problem ten pojawia się zawsze, gdy dobór uczestników do grupy badanej nie jest randomizowany. Regresja w kierunku wartości średniej jest tym większa, im słabsza jest korelacja między ocenianymi zmiennymi. Spostrzeżenie to ma istotne implikacje w badaniach populacyjnych wykorzystujących pomiar przygodnego ciśnienia tętniczego, gdyż w największym stopniu może skutkować błędną interpretacją otrzymanych rezultatów. Wartość RTM stanowi problem zwłaszcza w ocenie skuteczności terapii hipotensyjnej oraz w ocenie rozpowszechnienia nadciśnienia tętniczego. Mimo że eliminacja efektu RTM nie jest często możliwa, warto uwzględnić ten problem w metodologii i odnieść się do niego w dyskusji uzyskanych wyników.Regression towards the mean (RTM) is a statistical phemonenon that occurs in blood pressure studies independently of the problem or duration of the research, age of the studied population, or the method being used. RTM is observed whenever the study group is not randomized. It is assumed that the less correlated the two variables are the greater the RTM is. The infuence of RTM should be considered mostly in casual blood pressure measurements because of imprecise assessment of the results. Consequently, RTM may be mistakenly attributed to a treatment effect and the prevalence of hypertension. Despite the entire elimination of RTM can be impossible, it is suggested to remind this problem to the reader either in the section of &#8222;materials and methods&#8221; or &#8222;discussion&#8221;