Progressive bradycardia with increasing doses of dobutamine leading to stress echo interruption

Dobutamine stress testing is an important non-invasive method for evaluating patients with known or suspected coronary artery disease who are unable to adequately exercise. We present a case of a paradoxical, progressive bradycardia occurring with increasing doses of dobutamine that resulted in stress test interruption. (Cardiol J 2012; 19, 1: 79–80

Improvement of physical capacity in patients undergoing transcatheter closure of atrial septal defects

Introduction: Atrial septal defect (ASD) is the most common congenital cardiac anomaly diagnosed in adults. It often remains asymptomatic until the fourth or fifth decade of life. Significant left-to-right interatrial shunting is associated with the risk of heart failure, pulmonary hypertension and atrial fibrillation. Percutaneous ASD closure is a recognized method of treatment. Aim: To evaluate the clinical outcomes and physical capacity in patients undergoing transcatheter closure of ostium secundum ASD. Material and methods: One hundred and twenty adult patients (75 females and 45 males) with a mean age of 43.1 ±13.3 (17–78) years who underwent transcatheter device closure of ostium secundum ASD were analyzed. Clinical evaluation and transthoracic color Doppler echocardiographic study were repeated in all patients before as well as 1 and 24 months after the procedure. To assess the physical capacity symptom-limited treadmill exercise tests with respiratory gas-exchange analysis were performed in all patients before the procedure and after 24 months of follow-up. Results: The devices were successfully implanted in all patients. During 24 months of follow-up all patients showed significant clinical and spiroergometric improvement of exercise capacity, and a significant decrease of right heart chamber overload features on echocardiography. Conclusions: Transcatheter closure of ASD in patients with significant shunt resulted in significant clinical and hemodynamic improvement regardless of the baseline functional class

Alkohol w prewencji chorób układu sercowo-naczyniowego - fakty i mity

W licznych badaniach epidemiologicznych wykazano, że relacja pomiędzy konsumpcją alkoholu a ryzykiem ogólnej śmiertelności przyjmuje obraz krzywej U, a dla niektórych populacji i niektórych grup wiekowych obraz krzywej J. Zmniejszenie ryzyka wiąże się przede wszystkim ze zmniejszonym ryzykiem wystąpienia choroby niedokrwiennej serca, niedokrwiennego udaru mózgu i objawowej miażdżycy naczyń obwodowych u osób spożywających umiarkowane dawki alkoholu (1-2 drinki/dobę). Przy nadużywaniu alkoholu - powyżej 3-4 drinków/dobę - występuje zwiększone ryzyko nadciśnienia tętniczego, zaburzeń rytmu, udaru krwotocznego (60 g alkoholu/dobę), a także kardiomiopatia alkoholowa. Znane są różnorodne mechanizmy fizjologiczne odpowiedzialne za zmniejszanie ryzyka sercowo-naczyniowego przy umiarkowanym spożyciu alkoholu. Główne z nich to: zmiana profilu lipidowego (wzrost HDL), wpływ na układ krzepnięcia (fibrynoliza), modyfikacja procesu zapalnego (obniżenie CRP), poprawa insulinowrażliwości. Nie dysponujemy dziś precyzyjnie sformułowanymi zaleceniami dotyczącymi spożywania alkoholu opracowywanymi przez towarzystwa naukowe, tak jak to jest w zakresie innych czynników ryzyka sercowo-naczyniowego. Nie może dziwić ta ostrożność, bowiem ryzyko może przewyższać korzyści. W powstających wytycznych podkreśla się fakt, że istnieje wiele różnych sposobów i strategii pozwalających zmniejszyć ryzyko chorób przewlekłych, rozpoczynanie lub intensyfikacja picia alkoholu dla realizacji tych celów jest wobec tego niewskazana

Ischaemic aetiology predicts exercise dyssynchrony in patients with heart failure with reduced ejection fraction

Background: Left ventricular (LV) dyssynchrony is common in patients with heart failure with reduced ejection fraction (HFREF). However, various conditions including exercise may alter its presence. LV dyssynchrony at exercise (ExDYS) has been associated with lower cardiac performance and exercise capacity but with higher cardiac resynchronization therapy (CRT) response. Therefore, understanding mechanisms underlying ExDYS may improve patient selection for CRT. Aims: To investigate for predictors of ExDYS among patients with HFREF and prolonged QRS duration. Methods: Consecutive patients with stable, chronic HF, LVEF<35%, sinus rhythm and QRS≥120ms were eligible. 2D echocardiography and tissue-Doppler were performed at rest and peak cyclo-ergometer exercise to assess LV systolic (LVEF) and diastolic function [mitral E-to-e’-wave velocities (E/e’)] and dyssynchrony. Dyssynchrony was defined as a maximal difference between time-to-peak systolic velocities of≥65ms from opposing basal segments. Results: We included 48 patients (aged 63.7±12.2, 81.3% male). Ischaemic aetiology (ICM) was present in 23 (47.9%). Dyssynchrony at rest (rDYS) was present in 32 (66.6%) patients, while ExDYS in 23 (47.9%). ExDYS correlated with ICM, lower LVEF and higher E/e’ ratio. ICM remained significant predictor of ExDYS in multiple regression model (OR:4.3, 95%CI:1.2–15.7, p=003). On exercise, 19 (39.5%) patients changed the rDYS status. While, exercise-induced dyssynchronization was observed only in ICM patients, exercise-induced resynchronization was more likely in patients with lower rest E/e’ ratio (OR:0.85, 95%CI:0.75–0.97, p=0.02). Conclusions: Ischaemic aetiology of HFREF is an important predictor of ExDYS. Restoration of LV synchronicity during exercise is more likely in patients with less advanced LV diastolic dysfunction

Predictive factors of myocardial reperfusion in patients with anterior wall acute myocardial infarction

Background: The no-reflow phenomenon due to microvasculature damage is sometimes observed in patients despite patency of the infarct-related artery. The study aimed to assess the predictive value of clinical, hemodynamic and electrocardiographic parameters for the development of the no-reflow phenomenon in patients after successful coronary reperfusion. Methods: Eighty-six patients, mean age 58.4 ± 11.2, underwent primary percutaneous coronary intervention (PCI) for acute anterior myocardial infarction (AMI). Angiographic parameters, i.e. TIMI grade flow, cTFC, TMPG, wall motion score index (WMSI), ST-segment resolution and segmental perfusion, were estimated by myocardial contrast echocardiography (MCE). Results: As evidenced by MCE, 54 patients were classified as the reflow ones and 32 as no- reflow. Patients from the no-reflow group showed a higher creatine kinase peak (p = 0.0034), higher kinase-MB (p = 0.0033) and higher troponin level (p = 0.062), longer time span between the onset of pain and reperfusion (p = 0.0003), worse baseline WMSI (p = 0.0022), inferior flow in the infarct-related artery and ST-segment resolution. Univariate analysis revealed that age, time span between the onset of chest pain to PCI, all angiographic parameters, WMSI and ST-segment resolution were related to the no-reflow phenomenon. Multivariate logistic regression analysis revealed that lack of preservation of normal or nearnormal flow before PCI and significant impairment of left ventricle contractility were independent predictive factors of the no-reflow phenomenon. Conclusions: MCE yields vital information about the outcome of coronary intervention in patients with AMI. Development of a no-reflow phenomenon is correlated with the severity of myocardial damage and poor flow through the infarct-related artery before PCI. (Cardiol J 2008; 15: 57-62

ECG Markers of Hemodynamic Improvement in Patients with Pulmonary Hypertension

Introduction. Several diagnostic tests have been recommended for risk assessment in pulmonary hypertension (PH), but the role of electrocardiography (ECG) in monitoring of PH patients has not been yet established. Therefore the aim of the study was to evaluate which ECG patterns characteristic for pulmonary hypertension can predict hemodynamic improvement in patients treated with targeted therapies. Methods. Consecutive patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) were eligible to be included if they had had performed two consecutive right heart catheterization (RHC) procedures before and after starting of targeted therapies. Patients were followed up from June 2009 to July 2017. ECG patterns of right ventricular hypertrophy according to American College of Cardiology Foundation were assessed. Results. We enrolled 80 patients with PAH and 11 patients with inoperable CTEPH. The follow-up RHC was performed within 12.6±10.0 months after starting therapy. Based on median change of pulmonary vascular resistance, we divided our patients into two subgroups: with and without significant hemodynamic improvement. RV1, max⁡RV1,2 + max⁡SI,aVL-SV1, and PII improved along with the improvement of hemodynamic parameters including PVR. They predicted hemodynamic improvement with similarly good accuracy as shown in ROC analysis: RV1 (AUC: 0.75; 95% CI: 0.63–0.84), PII (AUC: 0.67, 95% CI: 0.56–0.77), and max⁡RV1,2+max⁡SI,aVL-SV1 (0.73; 95% CI: 0.63–0.82). In Cox regression only change in RV1 remained significant mortality predictor (HR: 1.12, 95% CI: 1.01–1.24). Conclusion. Electrocardiogram may be useful in predicting hemodynamic effects of targeted therapy in precapillary pulmonary hypertension. Decrease of RV1, max⁡RV1,2+max⁡SI,aVL-SV1, and PII corresponds with hemodynamic improvement after treatment. Of these changes a decrease of R wave amplitude in V1 is associated with better survival