Role of natriuretic peptides in the assessment of aortic stenosis severity

Background/Aim. Symptom onset is a critical point in natural course of aortic stenosis and the most important indication for aortic valve replacement. The aim of the study was to evaluate the role of natriuretic peptides level in the assessment of symtomatic status of patients with severe aortic stenosis and the preserved left ventricular systolic function. Methods. In 67 patients with isolated severe aortic stenosis symptomatic status, transthoracic echocardiography, and BNP and NT-proBNP plasma level were assesed. Natriuretic peptides levels were also measured in 36 healthy controls. Results. BNP and NT-proBNP levels were significantly higher in the patients with aortic stenosis compared with the healthy controls. The symptomatic patients had a higher level of natriuretic peptides than the asymptomatic ones (BNP 118 [29-266] vs 79 [44-90] pg/mL, p < 0.001; NT-proBNP 258 [67-520], vs 79 [77- 112] pmol/L, p < 0.0001). Natriuretic peptides levels increased with the severity of NYHA class. NT-proBNP level higher than 122 pmol/L was a cutoff value for detection of symptoms in the patients with severe aortic stenosis. Conclusion. The levels of natriuretic peptides were significantly higher in the patients with symptomatic aortic stenosis, and increased with NYHA class. Measurement of natriuretic peptides levels could be important addition to clinical and echocardiographic assessment in determing optimal timing for valve replacement in aortic stenosis

Incresed inflammatory response in patients with the first myocardial infarction and nonsignificant stenosis of infarct-related artery

Introduction/Aim. Atherosclerosis presents a serial of highly specific cellular and molecular responses, and could be described as inflammatory diseases. Accordingly, for development of acute myocardial infarction (AMI), structure and vulnerability of atherosclerotic plaque are more important than the extent of stenosis of infarct-related artery. Consequently, inflammation and atherosclerosis and its complications are in good correlation. C-reactive protein (CRP) as nonspecific inflammatory marker, has prognostic significance in coronary artery diseases. The aim of this study was to establish the correlation between inflammatory response expressed as levels of CRP and fibrinogen in serum and extent of coronary artery stenosis. Methods. Study included 35 patients with acute myocardial infarction, as the first manifestation of coronary artery disease, which were treated with thrombolytic therapy according to the guidelines. All the patient had a reperfusion. The patients with acute or chronic inflammatory diseases, an increased value of sedimentation, fibrinogen, CK ≥190 U/L, early and late complications of AMI were excluded. CRP was measured on admission, after 24, 48 and 72 hrs, and 21 days latter, while fibriogen only on admission. Results. All the patients underwent coronary angiography, and were divided into two groups: the group 1 (23 patients), with significant stenosis of infarct-related artery (stenosis ≥ 75%), and the group 2 (13 patients) without significant stenosis (< 75%). Mean value of CRP serum level on admission in the group 1 was 4.4 mg/L, and in the group 2 7.2 mg/L (p < 0.001). The mean value of fibrinogen on admission in the group 1 was 2.7 g/L, and in the group 2 3.0 g/L (p < 0.001). The mean CRP value after 48 hrs in the group 1 was 21.7 mg/L, and in the group 2 42.4 mg/L. (p < 0.001). After three weeks, the mean CRP value was 4 mg/L in the group 1 and 5.5 mg/L in the group 2 (p < 0.001). There was no significant difference between the groups 1 and 2 related to gender, age, localization of AMI, CK, EF value, and risk factors for coronary artery disease. Conclusion. The patients with nonsignificant stenosis of infarct-related artery had increased inflammtory responses according to the CRP value, as a result of inflammatory process in atherosclerotic plaque and/or enhanced individual reactivity

Prognostic value of serum parathyroid hormone in ST-elevation myocardial infarction patients

Background/Aim. Parathyroid hormone (PTH) is an important messenger in the regeneration process which might influence the outcome of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the role of PTH in comparison to other traditionally used markers for the prediction of heart failure in STEMI patients. Methods. In 165 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI), blood concentrations of PTH, C-reactive protein (CRP), B-type natriuretic peptide (BNP), creatine kinase MB (CK-MB) and admission glycaemia (AG) were measured during the first three days after admission and correlated to the primary outcome - episodes of acute heart failure in the period of six months. Results. The area under the ROC curve of the maximal serum concentration of PTH was the largest among the measured biomarkers (0.867 vs 0.835 vs 0.832 vs 0.627 vs 0.619, for PTH, CRP, BNP, CK-MB and AG, respectively) for the prediction of primary outcome. The maximal PTH level adjusted to several risk factors had an independent prediction value for primary outcome (p < 0.001). In addition, PTH improved the prediction of primary outcome when added to the other markers in the model [cstatistic with BNP, CRP, CK-MB and AG was 0.908 (95% CI 0.849-0.967)], and when PTH was added, it was 0.931 (0.883-0.980), with p < 0.001 for the discrimination. Conclusion. Serum concentration of PTH early in the course of STEMI can predict acute heart failure episodes in the first six months in patients treated with primary PCI

Association between serum concentration of parathyroid hormone and left ventricle ejection fraction, and markers of heart failure and inflammation in ST elevation myocardial infarction patients treated with primary percutaneous coronary intervention

Background/Aim. Previous studies have shown increased serum concentration of parathyroid hormone (PTH) in acute myocardial infarction and heart failure. In this study we examined the relation-ships between parathyroid hormone status and biochemical markers of myocardial injury and heart failure, as well as electrocardio-graphic (ECG) and echocardiographic indicators of infarction size and heart failure. Methods. In 390 consecutive patients with ST segment elevation myocardial infarction (STEMI), average age 62 ± 12 years, laboratory analysis of serum concentrations of creatine kinase MB isoenzyme (CK-MB), C-reactive protein (CRP) and in-tact PTH and plasma concentration of brain natriuretic peptide (BNP) were done during the first three days after admission. All patients were treated with primary percutaneous coronary intervention (PCI). Exclusion criterion was severe renal insufficiency (glomerular filtration rate ≤ 30 mL/min). Serum concentration of PTH was measured on the 1st, 2nd and, in some cases, on the 3rd morning after admission and maximum level of PTH was taken for analysis. Patient cohort was divided into four groups according to quartiles of PTH maximum serum concentration (I ≤ 4.4 pmol/L; II > 4.4 pmol/L and < 6.3 pmol/L; III ≥ 6.3 pmol/L and < 9.2 pmol/L; IV ≥ 9.2 pmol/L). Selvester’s ECG score, left ventricle ejection fraction and wall motion index (WMSI) were determined at discharge between 5–14 days after admission. Results. We found that LVEF at discharge significantly decreased (p < 0.001) and WMSI at discharge and ECG Selvester´s score significantly increased across the quartiles of PTH max. level (p < 0.001 for both parameters). BNP, CRP and CK-MB isoenzyme level significantly increased across the quartiles of PTH max. level (p < 0.001; p < 0.001 and p = 0.004, retrospectively). Conclusion. The patients in the 4th quartile of PTH had significantly lower LVEF and higher WMSI and Selvester’s ECG score at discharge. This group of patients also had higher levels of BNP, CRP and CK-MB in blood in the early course of STEMI

Association of different electrocardiographic patterns with shock index, right ventricle systolic pressure and diameter, and embolic burden score in pulmonary embolism

Background/Aim. Some electrocardiographic (ECG) patterns are characteristic for pulmonary embolism but exact meaning of the different ECG signs are not well known. The aim of this study was to determine the association between four common ECG signs in pulmonary embolism [complete or incomplete right bundle branch block (RBBB), S-waves in the aVL lead, S1Q3T3 sign and negative T-waves in the precordial leads] with shock index (SI), right ventricle diastolic diameter (RVDD) and peak systolic pressure (RVSP) and embolic burden score (EBS). Methods. The presence of complete or incomplete RBBB, S waves in aVL lead, S1Q3T3 sign and negative T-waves in the precordial leads were determined at admission ECG in 130 consecutive patients admitted to the intensive care unit of a single tertiary medical center in a 5-year period. Echocardiography examination with measurement of RVDD and RVSP, multidetector computed tomography pulmonary angiography (MDCT-PA) with the calculation of EBS and SI was determined during the admission process. Multivariable regression models were calculated with ECG parameters as independent variables and the mentioned ultrasound, MDCT-PA parameters and SI as dependent variables. Results. The presence of S-waves in the aVL was the only independent predictor of RVDD (F = 39.430, p < 0.001; adjusted R2 = 0.231) and systolic peak right ventricle pressure (F = 29.903, p < 0.001; adjusted R2 = 0.185). Negative T-waves in precordial leads were the only independent predictor for EBS (F = 24.177, p < 0.001; R2 = 0.160). Complete or incomplete RBBB was the independent predictor of SI (F = 20.980, p < 0.001; adjusted R2 = 0.134). Conclusion. In patients with pulmonary embolism different ECG patterns at admission correlate with different clinical, ultrasound and MDCT-PA parameters. RBBB is associated with shock, Swave in the aVL is associated with right ventricle pressure and negative T-waves with the thrombus burden in the pulmonary tree

The role of lung transthoracic ultrasound in clinical practice

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Left ventricular noncompaction in a patient presenting with a left ventricular failure

Introduction. Left ventricular noncompaction (LVNC) is a congenital disorder characterised by prominent trabeculations in the left ventricular myocardium. This heart condition very often goes completely undetected, or is mistaken for hypertrophic cardiomyopathy or coronary disease. Case report. A middle-aged female with a positive family history of coronary disease was admitted with chest pain, electrocardiography (ECG) changes in the area of the inferolateral wall and elevation in cardiac specific enzymes. Initially, she was suspected of having acute coronary syndrome. However, in the left ventricular apex, especially alongside the lateral and inferior walls, cardiac ultrasound visualised hypertrabeculation with multiple trabeculae projecting inside the left ventricular cavity. A short-axis view of the heart above the papillary muscles revealed the presence of two layers of the myocardium: a compacted homogeneous layer adjacent to the epicardium and a spongy layer with trabeculae and sinusoids under the endocardium. The thickness ratio between the two layers was 2.2:1. The same abnormalities were corroborated by multislice computed tomography (MSCT) of the heart. Conclusion. Left ventricular noncompaction is a rare, usually hereditary cardiomyopathy, which should be considered as a possibility in patients with myocardial hypertrophy. It is very often mistaken for coronary disease owing to ECG changes and elevated cardiac specific enzymes associated with myocardial hypertrophy and heart failure