The Prognostic Significance of Atrial Fibrillation and Left Atrium Size in Patients with Aortic Stenosis.

Aim    Aortic stenosis increases left atrial (LA) pressure and may lead to its remodeling. This can cause supraventricular arrhythmia. The aim of this study was to determine if the size of the LA and the presence of atrial fibrillation are related to the prognosis of patients with aortic stenosis.Material and methods    Clinical evaluation and standard transthoracic echocardiographic studies were performed in 397 patients with moderate to severe aortic stenosis.Results    In all patients, LA dimension above the median (≥43 mm) was associated with a significantly higher risk of death [HR 1.79 (CL 1.06-3.03)] and a LA volume above the median of 80 ml was associated with a significantly higher risk of death [HR 2.44 (CI 1.12-5.33)]. The presence of atrial fibrillation was significantly associated with a higher risk of death (p <0.0001). The presence of atrial fibrillation [HR 1.69 (CI 1.02-2.86)], lower left ventricular ejection fraction [HR 1.23 (CI 1.04-1.45)], higher NYHA heart failure class [HR 4.15 (CI 1.40-13.20)] and renal failure [HR 2.10 (CI 1.31-3.56)] were independent risk factors of death in patients in aortic stenosis.Conclusion    The size and volume of the LA and the occurrence of atrial fibrillation are important risk factors for death in patients with aortic stenosis. The presence of renal dysfunction, low left ventricular ejection fraction, high NYHA functional class and atrial fibrillation are independent risk factors of poor prognosis in patients with aortic stenosis.

Hemodynamic parameters of aortic valve prostheses - KRAK-AS registry analysis.

Introduction: The treatment of choice for aortic stenosis is a valve replacement. Some patients have post-procedural increased pressure gradient on the implanted prosthesis because of patient-prosthesis mismatch (PPM), known to adversely influence prognosis. The PPM risk should be initially predicted and effort made to avoid this complication, specifically in large body size patients. Aim: To assess the frequency of PPM taking into account the valvular prosthesis type in a real-life population of consecutive patients included in the Krakow aortic stenosis registry. Material and methods: The KRAK-AS registry was conducted in July-October 2016. Patients were assessed before and after valve surgery and during the 3-year follow-up. Patients who underwent aortic valve intervention were clinically and echocardiographically evaluated within a month after surgery and divided into groups depending on the implanted prosthesis type. Analysis of patients with a smaller (< 23 mm) and larger than median (≥ 23 mm) valve diameter was performed. Results: The valve implantation was performed in 229 patients (42 mechanical, 139 biological, 48 transcatheter). No differences between patient groups compared by PPM occurrence was seen at baseline. Median age was 70 years; 55.5% were men. At least moderate PPM (iEOA ≤ 0.85 cm2/m2) was observed in 40% of mechanical valves, 33% of biological valves, and was significantly less frequent (10%) in patients after transcatheter valve implantation, p = 0.0001. Severe PPM (iEOA < 0.65 cm2/m2) was found in 17.6% of mechanical valve PPM patients, 4.3% of biological ones, and no patients after transcatheter procedure. Conclusions: PPM is a frequent phenomenon in the real-life population of patients undergoing surgical aortic valve replacement, being significantly less frequent in the case of a transcatheter procedure.

THE DIETARY HABITS AND NUTRITION BELIEFS OF PATIENTS WITH AORTIC STENOSIS.

OBJECTIVE: Aim: The analysis of dietary knowledge and habits of patients with aortic stenosis, both prior to and post valve implantation. PATIENTS AND METHODS: Materials and methods: Patient with diagnosed moderate or severe aortic stenosis were included into the study. Telephonic dietary interview was performed. It was based on the standard KomPAN questionnaire developed and validated by the Behavioural Nutrition Team, Committee of Human Nutrition of Polish Academy of Sciences. RESULTS: Results: The analysis was conducted in 94 consecutive patients. The pro-health diet index was 4.87 points (3.7; 5.96), while the optimal level was defined as 20 points. The 12.8% of the respondents had low knowledge about nutrition, 79.8% - moderate and 7.4% - good. From 94 patients, 37 had the patientprosthesis mismatch and overweight. The 35.1% of patients with the patient-prosthesis mismatch and overweight considered their nutritional habits as bad, 62.2% as moderate and 2.7% as good. In a group of patients without the patient-prosthesis mismatch the self-opinion about diet was bad in 20.8%, moderate in 72.9% and good in 6.3%. CONCLUSION: Conclusions: Dietary habits and nutritional knowledge in patients with aortic stenosis are inadequate. However, awareness of bad dietary habits in patients who are overweight and have patient-prosthesis mismatch is better compared to the remaining group of patients. The proper dietary education is needed in all patients with aortic stenosis.

A quasi-experimental study examining a nurse-led educational program to improve disease knowledge and self-care for patients with acute decompensated heart failure with reduced ejection fraction.

BACKGROUND: Nurse-led education can improve heart failure (HF) knowledge and self-care behaviors, and consequently lead to better patient outcomes. OBJECTIVES: To assess the effectiveness of "The Weak Heart" educational model in enhancing the level of disease knowledge and self-care behaviors among patients hospitalized with acute decompensated heart failure with reduced ejection fraction (HFrEF). MATERIAL AND METHODS: An evidence-based, standardized educational program was implemented for HF patients in Poland. We compared the initial level of HF knowledge - as rated using a self-developed questionnaire and self-care behaviors, evaluated according to the 9-item European Heart Failure Self-care Behavior Scale (9-EHFScBS) - to the results obtained at the 3-month follow-up period with a sample of patients (n = 231) hospitalized with acute decompensated HF (ADHF). RESULTS: The results showed a significant increase in total score of HF knowledge test depending on the time of measurement (χ2 = 356.526, p < 0.001) and in all individual questions on HF. The significant change of the 9-EHFScBS self-care questionnaire was also found in total score (Z = -7.317, p < 0.001), in all domains: autonomous-based adherence (Z = -5.870, p < 0.001); consulting behavior (Z = -7.238, p < 0.001); provider-based adherence (Z = -4.162; p < 0.001) and in relation to all individual statements except statement 7 ("I eat a low salt diet") and statement 9 ("I exercise regularly"). Within 3 months of hospital discharge, 84% (193 out of 231) of participants visited their primary care physician and 79% (183 out of 231) visited a cardiologist in accordance with their individual treatment plan. CONCLUSIONS: "The Weak Heart" educational model is effective in enhancing the level of HF knowledge and self-care behaviors among patients with decompensation of HFrEF.

Stable patient with heart failure - the fact or the myth?

A treated patient with heart failure (HF), whose signs and symptoms have remained generally unchanged for at least 1 month is said to be 'stable'. Majority of patients with heart failure who are properly treated complain of slight symptoms described as functional class I and II NYHA. There is a belief that oligosymptomatic patients with heart failure have a good prognosis. Nevertheless, results of registries and randomized trials (e.g. ESC-HF-LT-R, CHARM, EMPHASIS-HF, PARADIGM-HF) disclosed that there is high risk of death and hospitalization for heart failure. Consequently, risk of every patient with heart failure should be evaluated with the use of validated scales - for example MAGGIC. Even in mild symptoms, remodeling of a left ventricle and dysfunction of the heart is progressing. It was revealed in the TRED-HF trial that withdrawal of guideline-directed medical therapy causes deterioration of clinical state in patients who were devoid of HF symptoms and presented improvement of echocardiographic parameters (left ventricle ejection fraction, left ventricle end diastolic volume) and laboratory parameters (N-terminal pro-B-type natriuretic peptide). This fact indicates that a chronic therapy in HF is necessary even in a situation where symptoms disappear, and heart function normalizes. An analysis of QUALIFY and ESC-HF-LT-R registries revealed that minority of patients with HF are treated according to current guidelines and doses of medications are not optimized. This management leads to deterioration of patient's prognosis. In addition to standard therapies (beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, ivabradine), novel drugs (e.g. sacubitril/valsartan) and individualized medical procedures should be applied in therapy.

Low triiodothyronine syndrome and serum selenium status in the course of acute myocardial infarction.

Both glutathione peroxidase and deiodinases are selenoproteins requiring selenium. Oxidative stress accompanying acute myocardial infarction (MI) may lead to activation of peroxidase and relative selenium deficiency. That may impair conversion of tetraiodothyronine (T4) to triiodothyronine (T3). AIM: The aim of the study was the evaluation of the prevalence of low T3 syndrome in MI, in relation to selenium deficiency. MATERIALS AND METHODS: The study group consisted of 59 consecutive patients hospitalized due to STEMI or NSTEMI, treated with primary percutaneous coronary intervention. Exclusion criteria: thyroid dysfunction, severe systemic disease, treatment with amiodarone, steroids or propranolol. Group A consisted of 7 patients with low fT3 concentration, Group B consisted of remaining 52 patients with normal fT3 levels. RESULTS: The prevalence of low T3 syndrome was 11.9%. The prevalence of selenium deficiency was 71.2%. Patients with low T3 syndrome had higher heart rate at admission and more often needed intravenous diuretics or inotropic agents. Low fT3 group presented higher levels of NT-proBNP, hsCRP, WBC, admission CKMB levels. There was a nonsignificant trend towards lower selenium levels in A group. We demonstrated correlations between fT3 and hsTnT, CKMB, NT-proBNP, hsCRP, MAPSE but we did not find correlation between fT3 and selenium or LVEF. CONCLUSIONS: Selenium deficiency was found in majority of MI patients, while low T3 was identified in 11.9% of patients. fT3 levels correlate with markers of infarction severity and inflammatory markers. Se deficiency alone does not explain the reason of low fT3 concentration.

Correction to: Low triiodothyronine syndrome and selenium deficiency - undervalued players in advanced heart failure? A single center pilot study.

After publication of the original article [1], the authors have notified us of a typing error in spelling Dr. Kabat's name. The original publication has been corrected.

Low triiodothyronine syndrome and selenium deficiency - undervalued players in advanced heart failure? A single center pilot study.

BACKGROUND: The function of deiodinases - selenoproteins converting thyroid hormones may be disturbed by oxidative stress accompanying heart failure. Selenium (Se) may be used by glutathione peroxidase, leading to a lack of deiodinase and triiodothyronine (T3). The aim of the study was the evaluation of the prevalence and clinical significance of low T3 syndrome in heart failure and the assessment of the association of low fT3 and Se deficiency. METHODS: The study group consisted of 59 consecutive patients hospitalized due to decompensated HFrEF NYHA III or IV. Exclusion criteria were: thyroid dysfunction, severe systemic disease, treatment with amiodarone, steroids or propranolol. Group A included 9 patients with low free T3 (fT3) concentration below 3.1 pmol/L. Group B consisted of the remaining 50 patients with normal fT3 levels. RESULTS: The prevalence of low T3 syndrome was 15.3%. The prevalence of Se deficiency was 74.6%. We demonstrated correlations between fT3 and main clinical variables (i.e. NT-proBNP, LVEF, hsCRP), but we did not find correlation between fT3 and the Se level. Kaplan-Meier survival analysis showed lower survival probability in patients with low fT3 (p < 0.001). CONCLUSIONS: Low T3 syndrome is frequently found in patients with HFrEF and is associated with a poor outcome. We did not identify any significant correlation between Se and fT3 level.

Selenium deficiency and the dynamics of changes of thyroid profile in patients with acute myocardial infarction and chronic heart failure.

BACKGROUND: Selenium (Se) is incorporated in 25 enzymes, for example, glutathione peroxidase (activatedb by oxidative stress) and deiodinases (converting thyroid hormones). Oxidative stress present in heart failure (HF) and myocardial infarction (MI) might cause Se deficiency and decreased thyroxine to triiodothyronine conversion. AIMS: We sought to evaluate Se levels in Polish patients with MI, HF, and healthy volunteers in relation to thyroid hormone levels. METHODS: The study group consisted of 143 participants: 54 patients with MI, 59 patients with decompensated HF, and 30 healthy matched volunteers. The patients underwent echocardiography and laboratory tests on admission and 5 months later. RESULTS: Se levels were lower in patients with MI and HF than in controls (median [interquartile range, IQR], 65.9 [55.2-76.1] µg/l and 59.7 [47.7-70.7] µg/l vs 93.2 [84.2-99.1] µg/l, respectively; P <0.001). The Se deficiency was very common in patients with MI and HF, while it was rare in controls (70.37% and 74.58% vs 10%, respectively; P <0.001). Patients with MI and HF presented lower free triiodothyronine (FT3) levels and lower FT3 to free thyroxine (FT4) ratio in comparison with controls (median [IQR], 3.90 [3.60-4.38] pmol/l and 4.25 [3.57-4.60] pmol/l vs 4.92 [4.50-5.27] pmol/l; P <0.001; and 0.25 [0.23-0.29] and 0.25 [0.21-0.28] vs 0.32 [0.29-0.37]; P <0.001, respectively). There was a weak to moderate correlation between Se level, FT3 level, and the FT3/FT4 ratio. At follow­up, the FT3/FT4 ratio tended to normalize in patients with MI and remained decreased in patients with HF (mean [SD], 0.31 [0.06] vs 0.27 ([0.05]; P <0.001. CONCLUSIONS: Se deficiency is very common in Polish patients with MI and HF. Thyroid hormones disturbances were more transient in patients with MI, but more chronic in those with HF.

[Evaluation of sleep apnea, detected by 24-hour ECG Holter monitoring analysis in patients with stable coronary artery disease and ischemic heart failure - correlations with clinical data]. / Ocena zaburzen oddychania w czasie snu na podstawie 24-godzinnego monitorowaniu EKG metoda Holtera u chorych ze stabilna choroba wiencowa oraz u chorych z niewydolnoscia serca ­ korelacje z danymi klinicznymi.

Obstructive sleep apnoea (OSA) is frequently undiagnosed in patients with heart failure (HF) and coronary artery disease (CAD). Simple and widely available screening tests are needed to diagnose patients with SA. Measurements of thoracic impedance and heart rate variability during 24-hour ECG Holter (H-EKG) monitoring allows to calculate estimated apnoea-hypopnoea index (eAHI). AIM: The aim of the research was to assess prevalence of OSA evaluated with the use of H-EKG and determination of its clinical relevance in patients with CAD and ischeamic HF. MATERIALS AND METHODS: The study groups comprised of: 30 consecutive patients with ischeamic HF with reduced LVEF (HFrEF) (group A) and 30 patients with CAD (group B). Control group (C) comprised of 30 patients with arterial hypertension but no CAD nor HF. H-ECG monitoring was performed and eAHI was calculated. On the basis of AHI result group A was subdivided to subgroups A1 (eAHI <15) and A2 (eAHI ≥15). RESULTS: Study groups differed with eAHI values (27,9±19,9 vs. 21,8±17,3 vs. 15,7±12,2; p=0,022). Post hoc analysis revealed that eAHI in group A was higher in comparison to group C (27,9±19,9 vs. 15,7±12,2; p=0,006). SA prevalence was higher in group A compared to group C (70,0% vs. 40,0%; p=0,019). Significant but weak correlation between eAHI and LVEDD was found (r=0,282; p<0,05). Subgroups A1 and A2 did not differ in terms of clinical and demographical parameters, HF symptoms, LVEF and NT-proBNP levels. CONCLUSIONS: OSA coexists more frequently with HF than with arterial hypertension Significant but weak correlation between eAHI and LVEDD was demonstrated. However, in patients with symptomatic ischeamic heart failure eAHI ≥15 was not related to NYHA class, lower LVEF and higher NT-proBNP levels.