Relation of atrial fibrillation and right-sided cardiac thrombus to outcomes in patients with acute pulmonary embolism.

Atrial fibrillation (AF) can induce a hypercoagulable state in both the left and right atria. Thrombus in the right side of the heart (RHT) may lead to acute pulmonary embolism (APE). The aim of the study was to determine the prevalence of RHT and AF and to assess their impact on outcomes in patients with APE. The retrospective cohort included 1,006 patients (598 female), with a mean age of 66 ± 15 years. The primary end point was all-cause mortality. The secondary end point was incidence of complications (death, cardiogenic shock, cardiac arrest, vasopressor/inotrope treatment, or ventilatory support). Atrial fibrillation was detected in 231 patients (24%). RHT was observed in 50 patients (5%). The combination of AF and RHT was observed in 16 patients (2%). The overall mortality rate was significantly higher in patients with RHT compared with those without (32% vs 14%, respectively, odds ratio [OR] 3.0, 95% confidence interval [CI] 1.6 to 5.6, p = 0.001). The rate of complications was significantly higher in patients with RHT in comparison to those without (40% vs 22%, respectively, OR 2.4, 95% CI 1.3 to 4.4, p = 0.004). The mortality rate in patients with both AF and RHT was significantly higher in comparison to those with AF but without RHT (50% vs 20%, respectively, OR 3.86, 95% CI 1.3 to 11.2, p = 0.01). In multivariate analysis, RHT (p = 0.03) was an independent predictor of death. In conclusion, AF is a frequent co-morbidity in patients with APE, and the presence of RHT is not uncommon. Among patients with APE, the presence of RHT increases the mortality approximately threefold regardless of the presence of known AF.

Use of ischemic ECG patterns for risk stratification in intermediate-risk patients with acute PE.

BACKGROUND: European recommendations on the management of acute pulmonary embolism (APE) divide patients into 3 risk categories: high, intermediate, and low. Mortality has previously been estimated at 3% to 15% in the intermediate group. The aim of this study was to use a new metric "ischemic electrocardiographic (ECG) patterns" to more precisely estimate the risk (complications or death) of APE patients identified as "intermediate risk" by current European Society of Cardiology (ESC) criteria. METHODS: The study group consisted of 500 consecutive patients (290 females), with a mean age 66.3 ± 15.2 years, and 245 (72.8%) patients were initially classified as intermediate risk. Four ischemic ECG patterns were studied: (i) ST-segment ischemic pattern (STIP), (ii) global ischemic pattern (GIP), (iii) negative T wave pattern, and (iv) control group consisting of patients with no ischemic changes. RESULTS: Predictors of death in univariate analysis included elevated troponin concentration (odds ratio [OR], 6.8; 95% confidence interval [CI], 1.28-169; P = 0.02]) and ischemic ECG patterns: STIP (OR, 6.3; 95% CI, 1.6-46.0; P = 0.007). Patients with right ventricular dysfunction (RVD) who were STIP (+) experienced significantly higher mortality rate compared to RVD patients who were STIP(-) (11.4% vs 1.6%; OR, 7.26; 95% CI, 1.82-52.8; P = 0.004). In patients with STIP (+) as compared to STIP (-), rate of death (OR, 6.35; P = 0.007) and rate of complications (OR, 4.19; P = 0.002) were significantly higher. Neither presence of negative T-waves nor GIP pattern was associated with a worse prognosis. CONCLUSIONS: In patients with APE, an ischemic ECG pattern on hospital admission, when identified in addition to classic risk markers, is an independent risk factor for worse in-hospital outcomes.

Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) is a predictor of poor prognosis in patients with acute pulmonary embolism (APE). OBJECTIVES: The aim of this study was to compare electrocardiography (ECG) parameters in patients with APE presenting with or without CS. METHODS: A 12-lead ECG was recorded on admission at a paper speed of 25 mm/s and 10 mm/mV amplification. All ECGs were examined by a single cardiologist who was blinded to all other clinical data. All ECG measurements were made manually. RESULTS: Electrocardiographic data from 500 patients with APE were analyzed, including 92 patients with CS. The following ECG parameters were associated with CS: S1Q3T3 sign, (odds ratio [OR]: 2.85, P<.001), qR or QR morphology of QRS in lead V1, (OR: 3.63, P<.001), right bundle branch block (RBBB) (OR: 2.46, P=.004), QRS fragmentation in lead V1 (OR: 2.94, P=.002), low QRS voltage (OR: 3.21, P<.001), negative T waves in leads V2 to V4 (OR: 1.81, P=.011), ST-segment depression in leads V4 to V6 (OR: 3.28, P<.001), ST-segment elevation in lead III (OR: 4.2, P<.001), ST-segment elevation in lead V1 (OR: 6.78, P<.01), and ST-segment elevation in lead aVR (OR: 4.35, P<.01). The multivariate analysis showed that low QRS voltage, RBBB, and ST-segment elevation in lead V1 remained statistically significant predictors of CS. CONCLUSIONS: In patients with APE, low QRS voltage, RBBB, and ST-segment elevation in lead V1 were associated with CS.

Electrocardiography and prognosis of patients with acute pulmonary embolism.

BACKGROUND: To assess the influence of electrocardiographic (ECG) pattern on prognosis and complications of patients hospitalized with acute pulmonary embolism (APE). METHODS: We performed a retrospective analysis of 292 patients who had confirmed APE. There were 183 females and 109 males, the age range was 17 to 89 years, and the mean age was 65.4 ± 15.5 years. RESULTS: In our study group, there were 33 deaths (mortality rate, 11.3%), and 73 (25%) patients developed complications during hospitalization. Based on European Society of Cardiology risk stratification, we classified 75 (25.7%) patients as high risk, 163 (55.8%) patients as intermediate risk, and 54 (18.5%) patients as low risk. A comparison between patients with complicated APE and those with no complications during hospitalization indicated that the following ECG parameters were more common in patients who had complications: atrial fibrillation, S1Q3T3 sign, negative T waves in leads V2-V4, ST segment depression in leads V4-V6, ST segment elevation in leads III, V1 and aVR, qR in lead V1, complete right bundle branch block (RBBB), greater number of leads with negative T waves, and greater sum of the amplitude of negative T waves. In multivariate analysis, the sum of negative T waves (OR 0.88; p = 0.22), number of leads with negative T waves (OR 1.46; p = 0.001), RBBB (OR 2.87; p = 0.02) and ST segment elevation in leads V1 (OR 3.99; p = 0.00017) and aVR (OR 2.49; p = 0.011) were independent predictors of complications during hospitalization. In turn, in multivariate analysis, only the sum of negative T waves (OR 0.81; p = 0.0098), number of leads with negative T waves [OR 1.68; p = 0.00068] and ST segment elevation in lead V1 (OR 4.47; p = 0.0003) were independent predictors of death during hospitalization. CONCLUSIONS: In our population of APE patients, the sum of negative T waves, the number of leads with negative T waves and the ST segment elevation in lead V1 were independent predictors of death during hospitalization. In turn, the sum of negative T waves, the number of leads with negative T waves, and RBBB and ST segment elevation in leads V1 and aVR were independent predictors of complications during hospitalization. We conclude that ECG analysis may be a useful noninvasive method for risk stratification of patients with APE.

The value of ECG parameters in estimating myocardial injury and establishing prognosis in patients with acute pulmonary embolism.

BACKGROUND: The electrocardiogram (ECG) is characterised by little sensitivity and specificity in the diagnostic evaluation of acute pulmonary embolism (APE). AIM: To assess the significance of ECG changes in predicting myocardial injury and prognosis in patients with APE. METHODS: The study group consisted of 225 patients (137 women and 88 men), mean age: 66.0 ± 15.2 years, in whom the diagnosis of APE was made, mostly based on computed tomography (n = 206, 92%). RESULTS: We observed 26 in-hospital deaths (mortality rate: 11.5%) and complications occurred in 58 (25.7%) patients. Elevated levels of troponin were observed in 103 (46%) patients. Logistic regression analysis showed that in-hospital mortality was associated with: coronary chest pain (0.06-0.53, OR 0.18), systolic blood pressure below 100 mm Hg (2.3-13.64, OR 5.61), heart rate above 100 bpm (1.17-15.11, OR 4.21), the S1Q3T3 sign (1.31-6.99, OR 3.02), QR in V(1) (1.60-12.32, OR 4.45), ST-segment depression in V(4)-V(6) (0.99-5.40, OR 2.31), ST-segment elevation in III (0.99-6.96, OR 2.64), ST-segment elevation in V(1) (1.74-9.49, OR 4.07); borderline (1.51-16.07, OR 4.93), moderate (1.42-17.74, OR 5.01) and severe troponin elevation (2.88-36.38, OR 10.24). In patients with cTnT(+), compared to patients with normal troponin levels, the following ECG changes were significantly more common: the S1Q3T3 sign (43 vs 21%, p = 0.003), negative T waves in V(2)-V(4) (57 vs 27%, p = 0.0001), ST-segment depression in V(4)-V(6) (40 vs 14%, p = 0.001), ST-segment elevation in III (22 vs 7%, p = 0.0006), V(1) and V(2) (43 vs 10%, p = 0.0001) and QR in V(1) (16 vs 5%, p = 0.007). CONCLUSIONS: ECG parameters are useful in predicting myocardial injury and assessing prognosis in patients with APE.

The prognostic value of ST-segment elevation in the lead aVR in patients with acute pulmonary embolism.

BACKGROUND: Electrocardiogram (ECG) in patients with acute pulmonary embolism (APE) presents many abnormalities. There are no data concerning prognostic significance of ST-elevation (STE) in lead aVR in patients with APE. AIM: To assess the prevalence of STE in aVR in patients with APE and its correlation with clinical course as well as other ECG parameters recorded at admission. METHODS: The retrospective analysis of 293 patients with APE diagnosed according to the ESC guidelines (182 females, 111 males, mean age 65.4 ± 15.5 years). RESULTS: The STE in lead aVR was observed in 133 (45.3%) patients. In comparison with patients without STE, patients with STE in lead aVR (STaVR[+]) had significantly more often systolic blood pressure 〈 90 mm Hg on admission (27% vs 10%, p 〈 0.001) and positive troponin level (64.8% vs 27.9%, p 〈 0.001). Thrombolytic therapy (14.3% vs 5.6%, p = 0.009) and catecholamines (29.3% vs 7.5%, p 〈 0.001) were more frequently used in patients with STaVR(+). The overall mortality (16.5% vs 6.9%, p = 0.009) and complication rates during hospitalisation (38.3% vs 12.5%, p 〈 0.001) were significantly higher in patients with STaVR(+). The STaVR(+) was significantly more frequent in patients with negative T-waves in inferior leads (59.4% vs 39.4%, p 〈 0.001), STE in lead III (24% vs 5.6%, p 〈 0.001), STE in lead V1 (46.6% vs 7.5%, p 〈 0.001), ST depression in lead V(4)-V(6) (48.9% vs 7.5%, p 〈 0.001), right bundle branch block (15.8% vs 8.1%, p = 0.04), QR sign in lead V1 (18% vs 6.2%, p 〈 0.001) and SI-QIII-TIII (46.6% vs 21.2%, p 〈 0.001). CONCLUSIONS: The presence of STE in lead aVR in patients with APE is associated with poor prognosis. The presence of STE in lead aVR could be an easily obtainable and noninvasive ECG parameter, helpful in risk stratification of patients with APE.

How often pulmonary embolism mimics acute coronary syndrome?

BACKGROUND: The clinical picture of acute pulmonary embolism (APE) is often uncharacteristic and may mimic acute coronary syndrome (ACS) or lung diseases, leading to misdiagnosis. In 50% of patients, APE is accompanied by chest pain and in 30-50% of the patients markers of myocardial injury are elevated. AIM: To perform a retrospective assessment of how often clinical manifestations and investigations (ECG findings and elevated markers of myocardial injury) in patients with APE may be suggestive of ACS. METHODS: We included 292 consecutive patients (109 men and 183 women) from 17 to 89 years of age (mean age 65.4 ± 15.5 years) with APE diagnosed according the ESC guidelines. RESULTS: Among the 292 patients included in the study 33 patients died during hospitalisation (mortality rate 11.3%) and 73 (25.0%) patients developed complications. A total of 75 (25.7%) patients were classified as high risk according to the ESC risk stratification, 163 (55.8%) as intermediate risk and 54 (18.5%) as low risk. Chest pain on and/or before admission was reported by 128 (43.8%) patients, including 73 (57.0%) patients with chest pain of coronary origin, 52 (40.6%) patients with chest pain of pleural origin and 3 patients with pain of undeterminable origin based on the available documentation. A total of 56 (19.2%) patients had a history of ischaemic heart disease and 5 (1.7%) had a history of myocardial infarction. A total of 8 (2.7%) patients were admitted with the initial diagnosis of ACS. The high-risk group consisted of 15 (20.6%) patients with a typical retrosternal chest pain and 60 (27.3%) patients without the typical anginal pain. Elevated troponin was observed in 103 (35.3%) patients. The ECG changes suggestive of myocardial ischaemia (inverted T waves, ST-segment depression or elevation) were observed in 208 (71.2%) patients. The following findings were significantly more common in high-risk versus non-high-risk patients: ST-segment depression in V4-V6 (42.6% vs 23.9%, p = 0.02), ST-segment elevation in V1 (46.7% vs 20.0%, p = 0.0002) and aVR (70.7% vs 40.1%, p = 0.0007). CONCLUSIONS: One third of patients with APE may present with all the manifestations (pain, elevated troponin and ECG changes) suggestive of ACS. The ECG changes suggestive of myocardial ischaemia are observed in 70% of the patients with ST-segment depression in V4-V6 and ST-segment elevation in V1 and aVR being significantly more common in high-risk vs non-high-risk patients.

[Prevalence of age, gender and body weight on the frequency of hypertension and diabetes mellitus in patients hospitalized in cardiology department]. / Wplyw wieku, plci oraz masy ciala na czestosc wystépowania nadcisnienia tetniczego oraz cukrzycy, u pacjentów hospitalizowanych na oddziale kardiologicznym.

UNLABELLED: Overweight and obesity are a major medical problems of the twenty-first century. According to the World Health Organization (WHO) in the world are about 1.6 billion people with overweight and at least 400 million adults are obese. The aim of this study was to analyze the effects of age, sex, and selected anthropometric parameters on the incidence of hypertension and diabetes mellitus in patients hospitalized in the cardiology department. The study included 1188 patients aged 18 - 94 years (mean age 66.9 years, SD 13.2), including 610 men (mean age 65.9 years, SD 12.7) and 578 women (mean age 67.9 years, SD 13.7), hospitalized in the Department of Cardiology Specialist Hospital Louis Rydygier in Krakow in 2009. All patients defined age, height and weight. Based on these results calculated body mass index (BMI). All patients were collected history on the prevalence of hypertension and type 2 diabetes mellitus. Then performed a statistical analysis of the incidence of hypertension and diabetes mellitus compared to sex, median age, BMI. RESULTS: In the study population normal blood pressure and hypertension grade 2 occurred significantly more often in men. Grade 3 hypertension occurred significantly more often in women. The median age was 67 years. In the older group occurred more frequently hypertension 2 and Grade 3. Also, diabetes mellitus was more common among older people. In obese people (BMI> 30) and overweight (BMI 25-29.99) occurred significantly more grade 3 hypertension compared to those of normal weight. CONCLUSIONS: 1. Diabetes mellitus and hypertension are more common in postmenopausal women compared to men the same age. 2. Obesity and overweight predisposes to hypertension grade 3 and diabetes mellitus.

[Epidemiology of pulmonary embolism in patients with cardiac department]. / Epidemiologia zatorowosci plucnej u pacjentów oddzialu kardiologicznegom.

UNLABELLED: Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a embolic material. ZP is usually a manifestation of venous thromboembolism (VTE), which in addition to the ZP includes deep vein thrombosis. The aim of this study was to analyze the epidemiology of pulmonary embolism in patients in the cardiology department with regard to gender and age. Material for the study was the medical documentation of patients hospitalized in the Department of Cardiology Hospital Louis Rydygiera in Cracow in the period of 7 years (1 I 2004 - 31 December 2010). During this time 11,435 patients were hospitalized. The study included 67 (1.23%) patients (31 men, 36 women) aged 30 - 93 years (mean 70.3 years, SD 13.3) who were diagnosed with acute pulmonary embolism. Collected information on gender, age, body weight and coexisting disease. An analysis of the documentation in terms of symptoms on admission and the cause of pulmonary embolism. RESULTS: The study included 67 patients, aged 30 - 93 years (mean age 70.3 years, SD 13.3) including 31 males (mean age 71.7 years, SD 13.8) and 36 women (average age 69.1 years, SD 12.9). The incidence of pulmonary embolism was 6 people per 1000 hospital admissions (0.58%). The average age of women was lower compared to men (69.1 +/- 12.9 vs. 71.7 +/- 13.8 years). Among the most common coexisting diseases were coronary heart disease (44.8%), hyperlipidemia (40.3%) and varicose veins of the lower limbs (49.3%). The most common symptoms on admission were dyspnea (88.1%), chest pain (59.7%) and hypotension (44.8%). Among the predisposing factors for pulmonary embolism occurs most frequently in the history of surgery (55.2%), venous thrombosis of lower limbs (50.7%), smoking (34.3%). The median age was 70.3 years. Pulmonary embolism was significantly more common among older people (37.3% vs. 62.7%, p = 0.04) and in men (35.5% vs. 64.5%, p = 0.04) and women (38.9% vs. 61.1%, p = 0.04). Pulmonary embolism was reported most frequently in the age group between 70-79 years of age in the study group (43.3%). CONCLUSIONS: 1. Pulmonary embolism occurs in 6 per 1000 patients hospitalized in the cardiology department. 2. Pulmonary embolism occurs most frequently in the age group 70-79 years. 3. The most common factors that causes pulmonary embolism are state after surgery and a history of deep vein thrombosis.

Acute pulmonary embolism registry in the Malopolska region - clinical course.

BACKGROUND: Acute pulmonary embolism (APE) is a life-threatening disease. Mortality in APE still remains very high in spite of progress in diagnostic tools. Mortality rate is about 30% in patients with unrecognised APE. APE is one of the main causes of in-hospital mortality. AIM: To asses management of patients with APE in the Malopolska region. METHODS: This registry consists of 205 consecutive patients who were hospitalised in 6 cardiology departments between 1 January 2005 and 30 September 2007, with the mean age of 65.1 +/- 15.3 years (124 females and 81 males). Mean hospitalisation duration 14.6 days (1-52 days). RESULTS: During hospitalisation 23 (11.2%) patients died. Complications (death, cardiogenic shock, cardiac arrest, use of catecholamines, respiratory therapy and ventilation) during in-hospital stay were observed in 57 (27.8%) patients. Fifty-three patients were haemodynamically unstable (cardiogenic shock or hypotension). The troponin I or T level was assessed in 147 (71.7%) patients and in 50 (34.0%) was positive. In patients with positive troponin we observed 11 (22.0%) deaths, while in patients with normal troponin T or I level 6 (6.2%) deaths occurred. In patients with normal blood pressure we observed a significant difference in mortality in patients with elevated vs. normal troponin level (14.3 vs. 2.5%, p = 0.02). Thrombolytic therapy was used in 20 (9.8%) patients. In patients treated with thrombolytic therapy 9 (45%) deaths were observed. We divided patients according to the ESC 2008 guidelines risk stratification. The 'non-high risk' group consisted of 152 (74.1%) patients, and mortality was 3.9%. The 'high-risk' group consisted of 53 (26.8%) patients. The 'non-high risk' group was divided into the following subgroups: 1. moderate-high (with 2 risk factors: both RV dysfunction and positive injury markers) mortality - 8.1%; 2. moderate subgroup with one risk factor, mortality - 3.6%; 3. low risk - no risk factors - 0% mortality. CONCLUSIONS: 1. In our registry mortality rate in patients with APE was 11%. 2. In about 30% of patients APE was under mask of acute coronary syndrome or syncope, 34% of patients had elevated troponin level, and 30% of patients had complication during hospitalisation. 3. In patients treated with thrombolytics mortality rate was 45%. 4. Reperfusion strategy (trombolysis or embolectomy) in the high risk group was used in only 41% of patients. 5. Elevated troponin level in normotensive patient was associated with 4-fold times higher risk of death. 6. New risk stratification according to the ESC guidelines 2008 correctly predicts prognosis in everyday clinical practise.

[Tuberculous pericarditis--diagnostic difficulties. A case report]. / Gruzlicze zapalenie osierdzia--trudnosci diagnostyczne. Opis przypadku.

A 17-year-old male developed four times in a three month period treatment resistant infectious pericarditis. Etiology of the disease was established on the bases of chest computed tomography (CT) end effective trial of antituberculous treatment.