Patent Foramen Ovale and Atrial Septal Aneurysm in Young Adults with Ischemic Stroke

Ischemic stroke in young adults with patent foramen ovale (PFO) and/or atrial septal aneurysm is underinvestigated. Methods: We investigated 86 such patients (age 16-49 years) with long-term follow-up. Results: Most patients recovered well, one died and 15 retired prematurely due to the index stroke. Seven patients underwent PFO closure. Few stroke recurrences occurred (4%) either on aspirin or warfarin during the 6.5 years of follow-up. Conclusions: Our data suggest good outcome, low morbidity, and low recurrence. Finding the best secondary prevention measures requires randomized trials

Prognostication in acute heart failure and cardiogenic shock : focus on electrocardiography and biomarkers

Acute heart failure (AHF) is a leading cause of hospitalizations in patients over the age of 65 worldwide, and is associated with high mortality. Cardiogenic shock (CS), the most severe form of AHF, is characterized by hypotension and end-organ hypoperfusion. Acute coronary syndrome (ACS) precipitates a third of all cases of AHF, and up to 80% of CS. Objective and timely risk assessment in AHF is challenging due to the heterogeneity in its pathophysiology and clinical picture. Risk assessment has traditionally relied on clinical parameters, which may remain subjective or become evident too late, after end-organ dysfunction has become irreversible. Considering the costs and possible adverse effects, application of the most aggressive therapies should be limited to those that most likely procure benefit. The aim of this thesis is to evaluate the prognostic value of electrocardiographic changes and biomarkers in AHF and CS. The patient data come from three cohorts of AHF and two cohorts of CS. All cohorts are independent, prospective, observational, investigator-initiated European cohorts. Study I compared the prognostic value of ventricular conduction blocks (VCB) in patients with new-onset (de novo) AHF and in patients with acutely decompensated chronic heart failure (ADCHF). Study II investigated the role of VCBs in ACS-related CS. Half the patients had a VCB in their baseline ECG, and the presence of any VCB predicted mortality independently of baseline clinical variables or angiographic findings. Studies III-IV investigated the role of two novel biomarkers, sST2 and bio-ADM, in cariogenic shock. Study III showed that sST2 provide strong and complementary prognostic value to NT-proBNP in ACS-related CS, and can help in stratification of patients into low, intermediate and high-risk groups as early as 12 hours after detection of shock. Study IV evaluated in CS patients the prognostic value and association with haemodynamic parameters of bio-ADM compared to lactate. Whereas lactate had good prognostic value in the early phase, its levels normalized during the first 24 hours in the majority of patients, with a decreasing prognostic value thereafter. In contrast, levels of bio-ADM stayed elevated in non-survivors during the first 4 days of intensive care, and bio-ADM had good prognostic value when measured on days 2 to 4. In conclusion, in patients with AHF or CS, electrocardiographic alterations may prove useful in early risk assessment on top of clinical parameters. In addition, biomarkers provide a novel approach in CS risk assessment.Akuutti sydämen vajaatoiminta on yksi yleisimmistä sairaalahoitoon johtavista sairauksista, ja siihen liittyy merkittävä kuolleisuus. Sydänperäinen sokki on akuutin vajaatoiminnan vaikein muoto; sille on tunnusomaista matala verenpaine ja yleinen elimistön verenkierron vajaus. Sepelvaltimotautikohtaus on akuutin vajaatoiminnan taustalla noin kolmasosassa tapauksista, mutta jopa 80 %:ssa tapauksista sydänperäisessä sokissa. Johtuen akuutin vajaatoiminnan kliinisen kuvan ja taustalla vaikuttavien patofysiologisten mekanismien moninaisuudesta objektiivinen ja oikea-aikainen riskinarvio on haastavaa. Varhainen riskinarvio on kuitenkin tärkeää hoitomuotojen valintaa ja ajoitusta ajatellen erityisesti sokkipotilailla. Perinteisesti riskinarvio on perustunut kliinisiin löydöksiin, joiden tulkinnassa voi kuitenkin olla subjektiivisuutta ja ne voivat ilmetä sairauden liian myöhäisessä vaiheessa, kun peruuttamattomia elinvaurioita on jo ehtinyt kehittyä. Huomioiden raskaimpien hoitomuotojen, kuten sydämen apupumppujen, korkea komplikaatioriski ja hinta, niiden käyttö tulisi rajata potilaille jotka todennäköisimmin niistä hyötyvät. Tämän väitöskirjatyön tavoitteena on määrittää sydänsähkökäyrä (EKG) –muutosten sekä uusien biomerkkiaineiden ennustearvo akuutissa sydämen vajaatoiminnassa ja sydänperäisessä sokissa. Väitöskirjatyön potilasmateriaali on peräisin kolmesta akuutin sydämen vajaatoiminnan sekä kahdesta sydänperäisen sokin potilaskohortista. Kaikki aineistot ovat eteneviä, havainnoivia, tutkijalähtöisiä eurooppalaisia potilasaineistoja. Osatyössä I tutkittiin EKG:ssa nähtävien kammiojohtumishäiriöiden yhteyttä kuolleisuuteen potilailla joilla akuutti vajaatoiminta ilmeni ensimmäistä kertaa (de novo) verrattuna potilaisiin joilla oli kroonisen sydämen vajaatoiminnan pahenemisvaihe. Osatyössä II tutkittiin kammiojohtumishäiriöitä äkillisestä sepelvaltimokohtauksesta johtuvassa sydänperäisessä sokissa. Puolella potilaista alkuvaiheen EKG:ssa oli jokin kammiojohtumishäiriö, ja kammiojohtumishäiriöt ennustivat suurempaa kuolleisuutta kliinisistä piirteistä ja sepelvaltimotaudin vaikeusasteesta riippumatta. Osatöissä III ja IV tutkittiin kahden uuden biomerkkiaineen, sST2:n ja bio-ADM:n, ennustearvoa kardiogeenisessä sokissa. Osatyö III osoitti, että sST2:lla ja NT-proBNP:llä on vahva itsenäinen ja toisiaan tukeva ennustearvo sydänperäisessä sokissa, ja niiden yhteismäärityksellä potilaat voidaan jakaa matalan, keskisuuren ja suuren riskin ryhmiin jo 12 tuntia sokin toteamisesta. Osatyö IV määritti bio-ADM:n ennustearvoa sekä yhteyttä hemodynaamisiin muuttujiin verrattuna laktaattiin sydänperäisessä sokissa. Laktaatilla oli hyvä ennustearvo ensimmäisten 24 tunnin aikana sokin toteamisesta, mutta sen pitoisuus normaalistui valtaosalla potilaista 24 tunnissa ja sen ennustearvo väheni sen jälkeen. Korkea bio-ADM pitoisuus heijasti matalaa verenpainetta ja sydämen minuuttivoluumia sekä korkeaa keskuslaskimo- ja keuhkovaltimopainetta, ja bio-ADM:n ennustearvo oli parhaimmillaan kun se mitattiin 2.-4. päivänä sokin toteamisesta. Yhteenvetona voidaan todeta, että EKG-muutoksia voidaan hyödyntää kliinisten muutosten rinnalla varhaisessa riskinarviossa akuuttia sydämen vajaatoimintaa tai sydänperäistä sokkia sairastavilla potilailla. Lisäksi uudet biomerkkiaineet mahdollistavat täysin uuden lähestymistavan sydänperäisen sokin riskinarviossa

Sydämen kroonisen vajaatoiminnan diagnostiikka

Teema : sydämen vajaatoiminta. Vertaisarvioitu. Näin tutkin.Sydämen vajaatoiminnan oireet, kuten rasitushengenahdistus, väsymys ja alaraajaturvotukset, ovat epäspesifisiä ja yleisiä etenkin vanhemmassa väestössä. Sydämen vajaatoiminta on oireyhtymä, jonka diagnoosin asettaminen vaatii, että potilaalla esiintyy sekä oireita (levossa tai rasituksessa), vajaatoimintaan liittyviä löydöksiä, että sydänkuvantamisella todettu poikkeavuus sydämen rakenteessa tai toiminnassa (pdf tiedoston taulukko 1). Anamnestisilla tiedoilla sekä perustason diagnostisilla tutkimuksilla tulee löytää ne potilaat, jotka lähetetään sydämen kaikukuvaukseen. Diagnostiikassa käytetään apuna natriureettisten peptidien määritystä; niiden suurentuminen ei ole vajaatoiminnalle spesifinen löydös, mutta normaali BNP/NT-proBNP - etenkin yhdessä normaalin EKG:n kanssa - on melko hyvä sulkemaan pois vajaatoiminnan. Sydämen kaikukuvaus on vajaatoiminnan diagnostiikan kulmakivi. Sillä voidaan varmistaa tai poissulkea vajaatoiminta, määritellä sen mekanismi, saada tietoa vajaatoiminnan syystä sekä arvioida sydämensisäisiä paineolosuhteita ja lääkevasteita. Vajaatoiminnan etiologia tulisi myös aina pyrkiä selvittämään, sillä ennusteen parantamiseksi syysairauden optimaalinen hoito on avainasemassa

Physiological changes in pregnancy

Physiological changes occur in pregnancy to nurture the developing foetus and prepare the mother for labour and delivery. Some of these changes influence normal biochemical values while others may mimic symptoms of medical disease. It is important to differentiate between normal physiological changes and disease pathology. This review highlights the important changes that take place during normal pregnancy.http://www.cvja.co.zaam2016Obstetrics and Gynaecolog

Glottal flow characteristics in vowels produced by speakers with heart failure

Heart failure (HF) is one of the most life-threatening diseases globally. HF is an under-diagnosed condition, and more screening tools are needed to detect it. A few recent studies have suggested that HF also affects the functioning of the speech production mechanism by causing generation of edema in the vocal folds and by impairing the lung function. It has not yet been studied whether these possible effects of HF on the speech production mechanism are large enough to cause acoustically measurable differences to distinguish speech produced in HF from that produced by healthy speakers. Therefore, the goal of the present study was to compare speech production between HF patients and healthy controls by focusing on the excitation signal generated at the level of the vocal folds, the glottal flow. The glottal flow was computed from speech using the quasi-closed phase glottal inverse filtering method and the estimated flow was parameterized with 12 glottal parameters. The sound pressure level (SPL) was measured from speech as an additional parameter. The statistical analyses conducted on the parameters indicated that most of the glottal parameters and SPL were significantly different between the HF patients and healthy controls. The results showed that the HF patients generally produced a more rounded glottal pulse and a lower SPL level compared to the healthy controls, indicating incomplete glottal closure and inappropriate leakage of air through the glottis. The results observed in this preliminary study indicate that glottal features are capable of distinguishing speakers with HF from healthy controls. Therefore, the study suggests that glottal features constitute a potential feature extraction approach which should be taken into account in future large-scale investigations in studying the automatic detection of HF from speech.Peer reviewe

Prevalence, Temporal Evolution and Impact on Survival of Ventricular Conduction Blocks in Patients with Acute Coronary Syndrome and Cardiogenic Shock

Changes in QRS duration and pattern are regarded to reflect severe ischemia in acute coronary syndromes (ACS), and ventricular conduction blocks (VCBs) are recognized high-risk markers in both ACS and acute heart failure. Our aim was to evaluate the prevalence, temporal evolution, association with clinical and angiographic parameters, and impact on mortality of VCBs in ACS-related cardiogenic shock (CS). Data of 199 patients with ACS-related CS from a prospective multinational cohort were evaluated with electrocardiogram data from baseline and day 3. VCBs including left or right bundle branch block, right bundle branch block and hemiblock, isolated hemiblocks, and unspecified intraventricular conduction delay were assessed. Fifty percent of patients had a VCB at baseline; these patients were older, had poorer left ventricular function and had more often left main disease compared with those without VCB. One-year mortality was over 2-fold in patients with VCB compared with those without VCB (68% vs 32%, pPeer reviewe

The automatic detection of heart failure using speech signals

Heart failure (HF) is a major global health concern and is increasing in prevalence. It affects the larynx and breathing - thereby the quality of speech. In this article, we propose an approach for the automatic detection of people with HF using the speech signal. The proposed method explores mel-frequency cepstral coefficient (MFCC) features, glottal features, and their combination to distinguish HF from healthy speech. The glottal features were extracted from the voice source signal estimated using glottal inverse filtering. Four machine learning algorithms, namely, support vector machine, Extra Tree, AdaBoost, and feed-forward neural network (FFNN), were trained separately for individual features and their combination. It was observed that the MFCC features yielded higher classification accuracies compared to glottal features. Furthermore, the complementary nature of glottal features was investigated by combining these features with the MFCC features. Our results show that the FFNN classifier trained using a reduced set of glottal + MFCC features achieved the best overall performance in both speaker-dependent and speaker-independent scenarios. (C) 2021 The Author(s). Published by Elsevier Ltd.Peer reviewe

Circulating levels of microRNA 423-5p are associated with 90 day mortality in cardiogenic shock

Aims The role of microRNAs has not been studied in cardiogenic shock. We examined the potential role of miR-423-5p level to predict mortality and associations of miR-423-5p with prognostic markers in cardiogenic shock. Methods and results We conducted a prospective multinational observational study enrolling consecutive cardiogenic shock patients. Blood samples were available for 179 patients at baseline to determine levels of miR-423-5p and other biomarkers. Patients were treated according to local practice. Main outcome was 90 day all-cause mortality. Median miR-423-5p level was significantly higher in 90 day non-survivors [median 0.008 arbitrary units (AU) (interquartile range 0.003-0.017) vs. 0.004 AU (0.002-0.009), P = 0.003]. miR-423-5p level above median was associated with higher lactate (median 3.7 vs. 2.4 mmol/L, P = 0.001) and alanine aminotransferase levels (median 68 vs. 35 IU/L, P <0.001) as well as lower cardiac index (1.8 vs. 2.4, P = 0.04) and estimated glomerular filtration rate (56 vs. 70 mL/min/1.73 m(2), P = 0.002). In Cox regression analysis, miR-423-5p level above median was associated with 90 day all-cause mortality independently of established risk factors of cardiogenic shock [adjusted hazard ratio 1.9 (95% confidence interval 1.2-3.2), P = 0.01]. Conclusions In cardiogenic shock patients, above median level of miR-423-5p at baseline is associated with markers of hypoperfusion and seems to independently predict 90 day all-cause mortality.Peer reviewe

Association of miR-21-5p, miR-122-5p, and miR-320a-3p with 90-Day Mortality in Cardiogenic Shock

Cardiogenic shock (CS) is a life-threatening emergency. New biomarkers are needed in order to detect patients at greater risk of adverse outcome. Our aim was to assess the characteristics of miR-21-5p, miR-122-5p, and miR-320a-3p in CS and evaluate the value of their expression levels in risk prediction. Circulating levels of miR-21-5p, miR-122-5p, and miR-320a-3p were measured from serial plasma samples of 179 patients during the first 5–10 days after detection of CS, derived from the CardShock study. Acute coronary syndrome was the most common cause (80%) of CS. Baseline (0 h) levels of miR-21-5p, miR-122-5p, and miR-320a-3p were all significantly elevated in nonsurvivors compared to survivors (p < 0.05 for all). Above median levels at 0h of each miRNA were each significantly associated with higher lactate and alanine aminotransferase levels and decreased glomerular filtration rates. After adjusting the multivariate regression analysis with established CS risk factors, miR-21-5p and miR-320a-3p levels above median at 0 h were independently associated with 90-day all-cause mortality (adjusted hazard ratio 1.8 (95% confidence interval 1.1–3.0), p = 0.018; adjusted hazard ratio 1.9 (95% confidence interval 1.2–3.2), p = 0.009, respectively). In conclusion, circulating plasma levels of miR-21-5p, miR-122-5p, and miR-320a-3p at baseline were all elevated in nonsurvivors of CS and associated with markers of hypoperfusion. Above median levels of miR-21-5p and miR-320a-3p at baseline appear to independently predict 90-day all-cause mortality. This indicates the potential of miRNAs as biomarkers for risk assessment in cardiogenic shock

Association of miR-21-5p, miR-122-5p, and miR-320a-3p with 90-Day Mortality in Cardiogenic Shock

Cardiogenic shock (CS) is a life-threatening emergency. New biomarkers are needed in order to detect patients at greater risk of adverse outcome. Our aim was to assess the characteristics of miR-21-5p, miR-122-5p, and miR-320a-3p in CS and evaluate the value of their expression levels in risk prediction. Circulating levels of miR-21-5p, miR-122-5p, and miR-320a-3p were measured from serial plasma samples of 179 patients during the first 5–10 days after detection of CS, derived from the CardShock study. Acute coronary syndrome was the most common cause (80%) of CS. Baseline (0 h) levels of miR-21-5p, miR-122-5p, and miR-320a-3p were all significantly elevated in nonsurvivors compared to survivors (p < 0.05 for all). Above median levels at 0h of each miRNA were each significantly associated with higher lactate and alanine aminotransferase levels and decreased glomerular filtration rates. After adjusting the multivariate regression analysis with established CS risk factors, miR-21-5p and miR-320a-3p levels above median at 0 h were independently associated with 90-day all-cause mortality (adjusted hazard ratio 1.8 (95% confidence interval 1.1–3.0), p = 0.018; adjusted hazard ratio 1.9 (95% confidence interval 1.2–3.2), p = 0.009, respectively). In conclusion, circulating plasma levels of miR-21-5p, miR-122-5p, and miR-320a-3p at baseline were all elevated in nonsurvivors of CS and associated with markers of hypoperfusion. Above median levels of miR-21-5p and miR-320a-3p at baseline appear to independently predict 90-day all-cause mortality. This indicates the potential of miRNAs as biomarkers for risk assessment in cardiogenic shock