Predictors of Revascularization in Patients with Unstable Angina.

BACKGROUND: The factors that determine the necessity of coronary artery revascularization in patients with unstable angina (UA) have been supported by limited data. Therefore, this study aimed to identify the predictors of revascularization in patients with UA. METHODS: The study included the recorded data of 3668 patients with UA who underwent cardiac catheterization (age 66 ± 9.2, men 70%); 2615 of them (71%) underwent revascularization (percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), or hybrid revascularization. The remaining 1053 patients (29%) had no significant coronary stenosis and were regarded as controls. Multivariable logistic regression analysis was performed to separate the predictors of revascularization. RESULTS: It was found that severe angina (OR 2.7, 95%CI 1.9-3.7), male gender (OR 1.4, 95%CI 1.1-1.7), and hyperlipidemia were the predictors of revascularization. It was also noted that intraventricular conduction disorders including left and right bundle branch blocks and a history of previous revascularization and myocardial infarction were associated with lower odds of revascularization. CONCLUSION: Overall, however, the predictive value of the studied factors proved to be poor and may still point to the multifactorial nature of significant coronary artery stenosis and the need for revascularization in patients with UA.

Machine learning model for predicting late recurrence of atrial fibrillation after catheter ablation.

Late recurrence of atrial fibrillation (LRAF) in the first year following catheter ablation is a common and significant clinical problem. Our study aimed to create a machine-learning model for predicting arrhythmic recurrence within the first year since catheter ablation. The study comprised 201 consecutive patients (age: 61.8 ± 8.1; women 36%) with paroxysmal, persistent, and long-standing persistent atrial fibrillation (AF) who underwent cryoballoon (61%) and radiofrequency ablation (39%). Five different supervised machine-learning models (decision tree, logistic regression, random forest, XGBoost, support vector machines) were developed for predicting AF recurrence. Further, SHapley Additive exPlanations were derived to explain the predictions using 82 parameters based on clinical, laboratory, and procedural variables collected from each patient. The models were trained and validated using a stratified fivefold cross-validation, and a feature selection was performed with permutation importance. The XGBoost model with 12 variables showed the best performance on the testing cohort, with the highest AUC of 0.75 [95% confidence interval 0.7395, 0.7653]. The machine-learned model, based on the easily available 12 clinical and laboratory variables, predicted LRAF with good performance, which may provide a valuable tool in clinical practice for better patient selection and personalized AF strategy following the procedure.

Cognitive Impairment in Cardiovascular Patients after Myocardial Infarction: Prospective Clinical Study.

(1) Background: Assessment of cognitive function is not routine in cardiac patients, and knowledge on the subject remains limited. The aim of this study was to assess post-myocardial infarction (MI) cognitive functioning in order to determine the frequency of cognitive impairment (CI) and to identify factors that may influence it. (2) Methods: A prospective study included 468 patients hospitalized for MI. Participants were assessed twice: during the first hospitalization and 6 months later. The Mini-Mental State Examination was used to assess the occurrence of CI. (3) Results: Cognitive dysfunction based on the MMSE was found in 37% (N-174) of patients during the first hospitalization. After 6 months, the prevalence of deficits decreased significantly to 25% (N-91) (p < 0.001). Patients with CI significantly differed from those without peri-infarction deficits in the GFR, BNP, ejection fraction and SYNTAX score, while after 6 months, significant differences were observed in LDL and HCT levels. There was a high prevalence of non-cognitive mental disorders among post-MI patients. (4) Conclusions: There is a high prevalence of CI and other non-cognitive mental disorders, such as depression, sleep disorders and a tendency to aggression, among post-MI patients. The analysis of the collected material indicates a significant impact of worse cardiac function expressed as EF and BNP, greater severity of coronary atherosclerosis expressed by SYNTAX results, and red blood cell parameters and LDL levels on the occurrence of CI in the post-MI patient population.

TAKOTSUBO SYNDROME AND CORONARY ARTERY FISTULA: CASE REPORT AND LITERATURE REVIEW.

Takotsubo syndrome (TTS) has been reported in various clinical conditions. Coronary artery fistula (CAF) is diagnosed in 0.2- 0.4% of patients undergoing coronary angiography. Pathologic communication between coronary artery (e.g., left anterior de¬scending coronary artery - LAD) and cardiac chambers (e.g., left ventricle - LV) is cameral type of CAF which particularly predis¬pose to myocardial ischemia due to a steal syndrome. Eight cases of coexistent TTS and CAF have been reported so far; in 6 of them LAD cameral fistulas drained LV, in 2 others communications between coronary arteries and pulmonary artery were found. The authors describe a case of a 75-year-old female, admitted due to chest pain and dyspnea. Her clinical picture with ST-segment elevation in ECG, moderately increased troponin I and apical ballooning in echocardiography, was more typical for TTS than for myocardial infarction; besides that, color doppler imaging was suggestive of multiple CAF to LV. Coronary angiography showed communication between all (normal) coronary arteries and LV. Throughout the conservative therapy, first, an improve¬ment and then normalization of LV function were observed after 2 and 6 days, respectively. Chest x-ray and computed tomogra¬phy revealed mediastinal tumor (eventually diagnosed as lung cancer). Cardiac magnetic resonance performed after one month did not show late gadolinium enhancement. During the course of 24 months follow-up, she was taking bisoprolol and ramipril and her cardiologic state remained stable, even during chemotherapy and radiotherapy. The authors collected the clinical data of all 9 cases with concomitant TTS and CAF. Specific TTS triggering factors/predisposing conditions were present in all patients, which has indicated that coexistence of TTS and CAF is rather coincidental.

A Review of Acute Coronary Syndrome and its Potential Impact on Cognitive Function.

According to the World Health Organization (WHO) forecasts, in 2030, the number of people suffering from dementia will reach 82 million people worldwide, representing a huge burden on health and social care systems. Epidemiological data indicates a relationship between coronary heart disease (CHD) and the occurrence of cognitive impairment (CI) and dementia. It is known that both diseases have common risk factors. However, the impact of myocardial infarction (MI) on cognitive function remains controversial and largely unknown. The main goal of this study is to attempt to summarize and discuss selected scientific reports on the causes, mechanisms and effects of CI in patients after acute coronary syndrome (ACS), especially after MI. The risk of CI can increase in patients after ACS, and can therefore also adversely affect the further course of treatment. A late diagnosis of CI can lead to serious clinical implications, such as an increase in the number of hospitalizations and mortality.

Impact of genetic variants of selected cytochrome P450 isoenzymes on pharmacokinetics and pharmacodynamics of clopidogrel in patients co-treated with atorvastatin or rosuvastatin.

PURPOSE: Impaired antiplatelet effect of clopidogrel (CLP) can result from drug-drug interactions and genetic polymorphisms of drug-metabolizing enzymes. The aim of the study was to evaluate the effect of genetic polymorphisms of ABCB1 and the selected cytochrome P450 isoenzymes on the pharmacodynamics and pharmacokinetics of CLP and its metabolites in patients co-treated with atorvastatin or rosuvastatin. METHODS: The study involved 50 patients after coronary angiography/angioplasty treated with CLP and atorvastatin (n = 25) or rosuvastatin (n = 25) for at least 6 months. Plasma concentrations of CLP, diastereoisomers of thiol metabolite (inactive H3 and active H4), and inactive CLP carboxylic acid metabolite were measured by UPLC-MS/MS method. Identification of the CYP2C19*2, CYP2C19*17, CYP3A4*1G, CYP1A2*1F, and ABCB1 C3435T genetic polymorphisms was performed by PCR-RFLP, while platelet reactivity units (PRU) were tested using the VerifyNow P2Y12 assay. RESULTS: There were significant differences in the pharmacokinetic parameters of the H4 active metabolite of CLP in the atorvastatin and rosuvastatin group divided according to their CYP2C19 genotype. There were no significant associations between CYP3A4, CYP1A2, and ABCB1 genotypes and pharmacokinetic parameters in either statin groups. In the multivariate analysis, CYP2C19*2 genotype and non-genetic factors including BMI, age, and diabetes significantly affected platelet reactivity in the studied groups of patients (P < 0.01). In the atorvastatin group, CYP2C19*2, CYP3A4*1G, and ABCB1 C3435T TT genotypes were independent determinants of PRU values (P < 0.01). CONCLUSION: The CYP2C19*2 allele is the primary determinant of the exposition to the H4 active metabolite of clopidogrel and platelet reactivity in patients co-treated with atorvastatin or rosuvastatin.

Characteristics of circulating endothelial cells obtained from non-ST-segment elevation myocardial infarction patients with additional diastolic dysfunction of left ventricle observed in echocardiography.

BACKGROUND: Circulating endothelial cells (CEC) may be used to find new strategies for the early di-agnosis of cardiovascular diseases. The major objective of the project is to broaden knowledge of CEC biology by determining their phenotypic characteristics. The additional aim is to clarify whether on the basis of these information it is possible to identify the origin of CEC release (from various cardiovascular compartments). METHODS: Circulating endothelial cells were collected from arterial blood prior to angiography, as well as from arterial and venous blood obtained after angiography/coronary angioplasty, from 18 patients with non-ST-segment elevation myocardial infarction (NSTEMI). CECs were quantified by flow cytometry and defined as Syto16 (dye)+, CD45dim/neg, CD31+ and CD146+. The additional CD36+ was establish as a marker of endothelial cells released from small vessels of the microcirculation. RESULTS: The total number of CECs increased significantly after the percutaneous transluminal coronary angioplasty (PTCA) in the arterial system. Number of CECs isolated at similar time points (after invasive procedure) did not differ significantly between arteries and veins, but the number of CD36+ CECs after coronary angioplasty was significantly higher in the venous system, than in the arterial system. CONCLUSIONS: The number of CD36+ in artery samples obtained after coronary angioplasty (PTCA) had tendency to be decreased (in comparison to the sample obtained before angiography). It was major difference between those who had PTCA performed vs. those who had not.

Transient left ventricular hypertrophy in a 30-year-old female with chronic emotional stress and depression treated with venlafaxine.

Transient left ventricular hypertrophy or thickening (TLVH/T) is a phenomenon rarely observed in some patients with myocarditis and stress-induced takotsubo syndrome (TTS). Initial presentation on echocardiography can mimic hypertrophic cardiomyopathy (HCM), sometimes with a decreased ejection fraction (EF). A CASE REPORT: The authors describe TLVH/T in a 30-year-old female with a history of chronic emotional stress and depression treated with venlafaxine (75 mg twice a day). She suffered from spinocerebellar ataxia (SCA) and, because of a family conflict, was living alone with a daughter who was diagnosed with maple syrup urine disease (MSUD). At admission, she presented with advanced heart failure with pulmonary congestion, moderately elevated blood pressure, ECG signs of LV hypertrophy (with negative T waves in leads: I-III, aVF, V4- 6) and with mild troponin I and high BNP elevation. Echocardiography revealed hypertrophy of the LV myocardium, systolic dysfunction and a small pericardial effusion. She denied any chest pain; there were no clinical features of infection or connective tissue disorder. Genetic nature of the patient's SCA and of her daughter's MSUD gave rise to a suspicion that she had coexistent HCM. She received therapy with ramipril, carvedilol and diuretics; venlafaxine was not discontinued. Cardiac magnetic resonance (CMR) performed a month later showed LV thickening to be a little smaller, absence of late gadolinium enhancement and an improvement of EF; T2-weighted images were not studied. Unexpectedly, after several months, LV hypertrophy disappeared in subsequent ECG, echocardiography and CMR; simultaneously, EF as well as regional and longitudinal strain returned to normal values.

Takotsubo syndrome in a patient with adrenal insufficiency, severe hyponatremia and coexistent coronary artery disease.

Some endocrine disorders, including primary and secondary adrenal insufficiency (AI), predispose to takotsubo syndrome (TTS). Hyponatremia is a frequent feature seen in adrenal crisis; however, TTS cases preceded by low serum sodium associated with other diseases are also reported. A CASE REPORT: The authors describe a case of a 72-year-old female with primary AI (Addison's disease) after adrenalectomy due to adrenal hypertrophy she underwent in childhood. Before admission, she missed a few doses of replacement therapy with prednisone and fludrocortisone. On admission, she presented with hypotension, severe heart failure (HF) and hyponatremia. Negative T-waves in ECG and left ventricular (LV) apical ballooning in echocardiography were suggestive of TTS. Restarted replacement therapy and symptomatic HF treatment resulted in gradual LV function normalization within 6 days. Cardiac magnetic resonance (CMR) performed after 4 weeks was normal and did not reveal any late gadolinium enhancement (LGE). However, elective coronary angiography made a month later showed critical stenosis of the left anterior descending coronary artery which was treated with coronary angioplasty. The authors suggest that each patient with adrenal crisis as well as with severe hyponatremia should be evaluated by echocardiography. The case presented confirms a possible coexistence of TTS and obstructive coronary artery disease.

Influence of statin treatment on pharmacokinetics and pharmacodynamics of clopidogrel and its metabolites in patients after coronary angiography/angioplasty.

Possible interaction between clopidogrel and CYP3A4-metabolised atorvastatin or non-CYP3A4-metabolised rosuvastatin was investigated based on pharmacokinetic parameters of clopidogrel and its metabolites as well as the platelet reactivity test in patients undergoing coronary angiography/angioplasty. The study involved 50 patients (62.7 ±â€¯7.8 years old) who underwent coronary angiography/angioplasty and were treated with clopidogrel and atorvastatin or rosuvastatin during the six months after the procedure. The P2Y12 reaction units (PRU) and pharmacokinetic parameters of clopidogrel, diastereoisomers of thiol metabolite (inactive H3 and active H4), and inactive carboxylic metabolite were measured 12-18 h and six months after the coronary angiography/angioplasty. There were no significant differences in concentrations of clopidogrel and its metabolites including the H4 active metabolite in plasma of patients co-treated with clopidogrel and atorvastatin or rosuvastatin. The use of statins did not affect the pharmacokinetic parameters of the studied compounds. A significant correlation was found between the Cmax and AUC0-t of the active H4 isomer and platelet aggregation in a group of patients treated with rosuvastatin but not in the atorvastatin group. No significant differences in PRU values were observed between the atorvastatin and rosuvastatin groups at the beginning of the study (171.4 ±â€¯54.3 vs 146.3 ±â€¯48.1 PRU, p = 0.192) as well as at six months (173.7 ±â€¯45.8 vs 157.3 ±â€¯54.9 PRU, p = 0.562). However, in a small group of patients, who were discharged from atorvastatin to rosuvastatin, an increase in the PRU values accompanied by a decreased AUC of the H4 active isomer was observed. The study confirmed that the systemic exposure to clopidogrel and its active H4 isomer of thiol metabolite, as well as the antiplatelet effect of the drug, were not negatively affected by co-administration of atorvastatin as compared with rosuvastatin.

Transient left ventricular dysfunction due to coronary spasm after spinal anesthesia with bupivacaine - a case report.

Bupivacaine is a long-acting local anesthetic (LA) used for cutaneous infiltration, peripheral nerve blocks, epidural and spinal anesthesia. However, its application may result in cardiovascular complications such as: hypotension, bradycardia, cardiac arrest and toxic myocardial injury. The authors describe a 53-year-old male with a history of cigarette smoking, admitted for an elective inguinal hernia surgery. Before surgery, the patient received subarachnoid injection of bupivacaine (20 mg). After the operation, he developed transient hypotension. Blood pressure returned to normal after gelofusine infusion; no sympathomimetics were administered. The male denied chest pain; however, ECG showed ST segment elevation coexisting with left ventricular anterolateral hypokinesia and decreased longitudinal strain in echocardiography. A significant increase in troponin I level was suggestive rather of myocardial infarction than of takotsubo cardiomyopathy. Urgent coronary angiography revealed left anterior descending artery spasm, which remitted after intracoronary nitroglycerin injection. Normalization of ECG and echocardiography was observed within a few days. The authors indicate that the presented atypical adverse effect of bupivacaine manifested itself with delay and that coronary spasm proceeded without angina. A close observation of the patient after anesthetic procedure with LA should be extended over the postoperative period.

[Rivaroxaban-resistant right ventricular thrombus, successfully treated with vitamin K antagonist in a patient with dilated cardiomyopathy]. / Oporna na rywaroksaban skrzeplina w prawej komorze, skutecznie leczona antagonista witaminy K u chorego z kardiomiopatia rozstrzeniowa.

Rivaroxaban, a selective inhibitor of active factor X belongs to the group of direct-acting oral anticoagulants (DOAC), more and more often replacing vitamin K antagonists (VKA) in venous thromboembolic disease and nonvalvular atrial fibrillation. Attempts are also being made to use DOAC to treat locally formed intracardiac thrombi, mainly in the left atrium and its appendage, in atrial fibrillation and in heart failure. Rarely diagnosed local right ventricular thrombus (RVT) may be a complication of dilated cardiomyopathy (DCM). CASE REPORT: The authors present a case of a 40-year-old male with DCM and RVT located in the apex, which was imaged in echocardiography, magnetic resonance and multislice computed tomography. During treatment with rivaroksaban (2x15 mg: 4 weeks; 1x20 mg: 4 months) diminishing of RVT was not observed. After 2 months of VKA use complete resolution of RVT was noted. The case presented is probably the first described RVT treated with rivaroxaban. The authors conclude that in some cases, anticoagulation with VKA may be more effective than DOAC in intracardiac thrombi therapy, especially when it is meticulously monitored. Overlapping effect on RVT due to anticoagulants use with a different mechanism of action cannot be excluded.

Evaluation of plasma PCSK9 concentrations, transcript of LDL receptor, as well as the total number of monocyte LDL receptors in acute coronary syndrome patients.

BACKGROUND: Before our study, there were no data concerning complex evaluation of: plasma PCSK9 concentrations, transcript LDL receptor (LDLR), as well as the total amount of monocytes' LDLR in acute coronary syndrome (ACS) patients. PCSK9 levels in a few cohort studies were found to correlate with the number of white blood cells (WBC) or platelets (PLT). The study aims to evaluate PCSK9-LDLR concentrations, as well as to find any association between PCSK9 and WBC or PLT. METHODS: The study group included 95 consecutive patients with acute myocardial infarction, in whom angiography/angioplasty of the culprit vessel was performed. The control group consisted of 10 healthy young volunteers. Thirty patients from the studied group were qualified for further percutaneous revascularization after 3 months. Laboratory tests were performed using commercially available kits. LDLR expression on monocyte surface was measured by flow cytometry, but the mRNA level for LDLR was established by real time polymerase chain reaction. The PCSK9 plasma concentration was measured by ELISA kits. RESULTS: Higher concentration of PCSK9 and amount of LDLR on monocytes surface were observed in patients with ACS compared with healthy young volunteers (number of LDLRs on monocytes [reaction units] 10.8 ± 9.6 vs. 41.8 ± 11.8, p < 0.001, PCSK9 [ng/mL] 295.4 ± 76.4 vs. 213 ± 63.2, p < 0.001). A similar relationship was observed after application of 3-month intensive lipid-lowering therapy in patients with ACS (n = 30, PCSK9 [ng/mL] 281.1 ± 59.5 vs. 358.5 ± 74.7, p < 0.001, LDLR transcript [reaction units] 0.6 ± 0.32 vs. 1.87 ± 0.24, p < 0.001, number of LDLRs on monocytes [reaction units] 5.9 ± 3.1 vs. 22.3 ± 3.8, p < 0.001). There were no significant differences in levels of PCSK9, LDLR between patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). There was no relation of the PCSK9 with WBC as well as with PLT. CONCLUSIONS: We observed significantly higher concentration of PCSK9, and significantly higher levels of mRNA LDLR transcript in patients with ACS compared with healthy young volunteers. A similar pattern was observed after 3 months of intensive statin therapy among patients with ACS. There were no differences in these parameters between patients with STEMI vs. NSTEMI. The results of the study require confirmation in a larger population of patients.

Highly upregulated expression of CD36 and MSR1 in circulating monocytes of patients with acute coronary syndromes.

Acute Coronary Syndromes (ACS) are a group of disorders caused by the significant reduction of circulation in coronary arteries. The most common reason of the dysfunction is a blood clot formed in place of plaque rupture. The role of scavenger receptors in development and progression of atherosclerosis has been confirmed in many animal experiments, however the knowledge about contribution of the receptors in the development of ACS symptoms in humans still remains insufficient. The aim of this work was to define the expression of two scavenger receptors: CD36 and MSR1 in monocytes of patients with ACS after the onset of symptoms and after the 6 months of treatment. The analysis of CD36 and MSR1 expression was carried out with the use of real-time PCR and flow cytometry. Analyses of lipid and glucose concentration in blood and the level of inflammatory markers in plasma were performed additionally for all ACS patients. All data obtained during the research were analyzed using statistical tests, such as Mann Whitney test, Wilcoxon test, or correlation. In all patients with symptoms of ACS the amount of CD36 and MSR1 mRNA in circulating monocytes, as well as the density of both receptors on the cells surface was significantly higher. Re-analysis of subjects after 6 months of treatment, showed a significant decrease in the CD36 and MSR1 expression in all patients who received atorvastatin. The results of presented studies demonstrate that both investigated receptors are involved in the development and/or progression of ACS.