Efficacy and safety of antazoline in the rapid cardioversion of paroxysmal atrial fibrillation (the AnPAF Study).

AIMS: The aim of the study was to assess the clinical efficacy of antazoline, a first-generation anti-histaminic agent, in the rapid conversion of paroxysmal non-valvular atrial fibrillation (AF) to sinus rhythm in patients without heart failure. METHODS AND RESULTS: This study was a single center, randomized, double blind, placebo-controlled, superiority clinical trial. We enrolled patients with an AF episode lasting less than 43 h, in stable cardiopulmonary condition. Subjects who fulfilled the selection criteria were randomly assigned to receive intravenously either a placebo or up to 250 mg of antazoline. The primary end point was the conversion of AF to sinus rhythm confirmed in electrocardiogram (ECG). We enrolled 74 patients: 36 (48.6%) in the antazoline group and 38 (51.4%) in the control group. The mean age was 68 ± 12 years (range 31-90 years), 39 (53.3%) patients were male. The successful conversion of AF to sinus rhythm during the observation period was achieved in 26 (72.2%) patients treated with antazoline and 4 (10.5%) in the control group: RR 6.86 (95% CI: 2.66-17.72, P < 0.0001). Median time to conversion was 16.0 min in antazoline and 72.5 min in the control group (P = 0.0246). There were no cases of atrial tachycardia/flutter in the antazoline group. CONCLUSION: Intravenous antazoline was effective and safe in the rapid conversion of non-valvular paroxysmal atrial fibrillation to sinus rhythm in patients without heart failure. Clinical Trial Registration number: NCT01527279.

Comparative effectiveness and safety of antazoline­based and propafenone­based strategies for pharmacological cardioversion of short­duration atrial fibrillation in the emergency department.

INTRODUCTION    Numerous studies described the effectiveness and safety of antazoline in pharmacological cardioversion of short­duration atrial fibrillation (AF). However, there are no data on the comparison of antazoline and antiarrhythmic drugs listed in clinical guidelines. OBJECTIVES    The aim of the study was to assess the comparative effectiveness and safety of antazoline­based and propafenone­based strategies in pharmacological cardioversion of short­duration AF performed in our emergency department. PATIENTS AND METHODS    We conducted a retrospective case­control study based on the analysis of medical records of patients undergoing pharmacological cardioversion of short­duration AF with intravenous antazoline or propafenone at our department in the years 2008-2012. The primary endpoint was the successful cardioversion of AF. The primary safety endpoint was hospitalization due to the adverse effects of the treatment. RESULTS    We analyzed 432 cases of cardioversion. The mean age of patients was 68.9 ±9.8 years; 65% of the patients were male; 90% of the patients had a history of AF. Antazoline was administered 334 times and propafenone-98 times. The mean dose of antazoline was 172 ±65 mg, while all patients in the propafenone group received the drug at a fixed dose of 70 mg (1 vial). Cardioversion with antazoline was successful in 239 cases (71.6%) and with propafenone-in 54 patients (55.1%) (relative risk [RR], 1.30; 95% confidence interval [CI], 1.07-1.57). The rate of hospitalization due to the adverse effects of the treatment were low and similar between the study groups: 10 (3.0%) for antazoline and 4 (4.1%) for propafenone (RR, 0.73; 95% CI, 0.23-2.27). CONCLUSIONS    The antazoline­based strategy was more effective and safer in comparison with propafenone­based strategy in the pharmacological cardioversion of short­duration AF in our emergency department.

Successful primary coronary angioplasty improves early and long-term outcomes in ST segment elevation acute coronary syndromes in patients above 80 years of age.

BACKGROUND: ST segment elevation myocardial infarction (STEMI) in patients above 80 years of age continues to be a therapeutic challenge. Patients in this age group are rarely included in randomised clinical trials. AIM: Comparison of the effectiveness and safety of STEMI management in octogenarians in hospitals with a 24-hour percutaneous coronary intervention (PCI) capability and hospitals without PCI access. METHODS: A retrospective analysis of medical records of 50 octogenarians who were treated with PCI (group 1) in one center and 50 patients treated noninvasively in the other 3 hospitals (group 2). We evaluated mortality and major adverse cardiac events after 10 days, 30 days and 1 year. RESULTS: There were no significant differences in the demographic characteristics of the study groups. The duration of coronary pain was similar in both groups: 318 min in group 1 vs 383 min in group 2 (NS). Mortality in group 2 was significantly higher than in group 1: 40% vs 14%, respectively, after 10 days (p = 0.0034); 48 vs 18% after 30 days (p = 0.0014); and 54% vs 24% after 1 year (p = 0.0021). Thrombolytic treatment was used in only 40% of the patients in group 2. In group 2, acute heart failure (HF) (Killip class III and IV) was diagnosed more frequently than in group 1 (28% vs 12%, p = 0.034). In patients with Killip class I/II HF, mortality in patients in group 2 and group 1 was 22% vs 9%, at 10 days; 31% vs 14% at 30 days; and 39% vs 20% at 1 year. In patients with Killip class III/IV HF, mortality was 86% vs 50%, at 10 days; 93% vs 50% at 30 days; and 93% vs 50% at 1 year, respectively (all differences NS). In multivariate analysis adjusted for the differences between groups, HF (a negative effect) and a successful PCI (a positive effect) were independent predictors of 1-year survival. CONCLUSIONS: Successful primary PCI in STEMI patients above 80 years of age resulted in a reduction of early and long-term mortality compared to the medically treated patients. The benefits of PCI treatment accrued during the follow-up. In patients treated in the tertiary reference centre in whom PCI was not successful or was not deemed feasible, prognosis was similar to that in the medically treated patients. The latter patients rarely received thrombolytic treatment.

Effect of combined spironolactone-ß-blocker ± enalapril treatment on occurrence of symptomatic atrial fibrillation episodes in patients with a history of paroxysmal atrial fibrillation (SPIR-AF study).

Angiotensin II and aldosterone are key factors responsible for the structural and neurohormonal remodeling of the atria and ventricles in patients with atrial fibrillation (AF). The aim of the present study was to evaluate the antiarrhythmic effects of spironolactone compared to angiotensin-converting enzyme inhibitors in patients with recurrent AF. A cohort of 164 consecutive patients (mean age 66 years, 87 men), with an average 4-year history of recurrent AF episodes, was enrolled in a prospective, randomized, 12-month trial with 4 treatment arms: group A, spironolactone, enalapril, and a ß blocker; group B, spironolactone and a ß blocker; group C, enalapril plus a ß blocker; and group D, a ß blocker alone. The primary end point of the trial was the presence of symptomatic AF episodes documented on the electrocardiogram. At 3-, 6-, 9-, and 12 months, a significant (p < 0.001) reduction had occurred in the incidence of AF episodes in both spironolactone-treated groups (group A, spironolactone, enalapril, and a ß blocker; and group B, spironolactone plus a ß blocker) compared to the incidence in patients treated with enalapril and a ß blocker (group C) or a ß blocker alone (group D). No significant difference was seen in AF recurrences between patients taking spironolactone and a ß blocker with (group A) and without (group B) enalapril. No significant differences were found in the systolic or diastolic blood pressure or heart rate among the groups before and after 1 year of follow-up. In conclusion, combined spironolactone plus ß-blocker treatment might be a simple and valuable option in preventing AF episodes in patients with normal left ventricular function and a history of refractory paroxysmal AF.

Flow disturbances in carotid and vertebral arteries in symptomatic patients referred for pacemaker implantation.

BACKGROUND: Electrocardiographic abnormalities and clinical symptoms are used as indications for cardiac pacing. Syncope, faints and other neurological symptoms are of multi-factorial origin and are due to reduced brain perfusion. AIM: To examine the carotid and vertebral artery blood flow and to assess whether stenosis of these arteries is associated with symptoms of cerebral hypoperfusion in patients undergoing pacemaker implantation. METHODS: In 152 consecutive patients (84 men, age 70.6+/-10 years), admitted for pacemaker implantation from January 2003 to June 2004, ultrasonographic and colour Doppler examinations of the carotid and vertebral arteries were performed. The patient's medical history and symptoms, conduction disturbances, and modes of pacing were evaluated using a uniform questionnaire. Clinical manifestations of atherosclerosis were present in 21% (remote myocardial infarction) and 8% (stroke) of patients. Patients were divided into 2 groups: asymptomatic subjects (25%) and those with symptoms of cerebral hypoperfusion (75%). RESULTS: There were no significant differences in indications and modes of pacing between the groups; only second degree atrioventricular block was significantly more frequent in patients without symptoms (p=0.0163). Prevalence of either common or internal carotid artery stenosis>50% was higher in symptomatic than asymptomatic patients (32 vs. 16, p<0.05). Multivariate analysis revealed a 3.5 times higher probability of Stokes-Adams attacks and syncope in patients with confirmed atherosclerotic lesions (OR 3.5, 95% CI 1.2-13.4; p=0.0351). Blood flow disturbances in vertebral arteries were more frequent in symptomatic patients: 26 vs. 11%, p=0.0438. The lowest risk of loss of consciousness was observed in patients with second degree atrioventricular block, with no atherosclerotic lesions: (OR 0.2; 95% CI 0.03-0.06; p=0.0102). CONCLUSIONS: Prevalence of atherosclerotic lesions in carotid and vertebral arteries is higher in symptomatic patients referred for pacemaker implantation. The lowest risk of symptoms was found in patients with a second degree atrioventricular block and no atherosclerotic lesions. Ultrasonographic examination of carotid and vertebral arteries should be considered in all symptomatic patients with indications for pacemaker implantation.

High monthly temperature as a possible risk factor of local vascular bleeding complications during percutaneous coronary interventions evaluated by ultrasonography - retrospective analysis.

BACKGROUND: Bleeding complications are a very important issue in the era of percutaneous coronary interventions (PCI). Effective antiplatelet therapy increases the rate of successful interventions but the risk of bleeding complications, among them local vascular complications, may be higher. Other factors may also be important in the development of local bleeding complications. AIM: To examine the relationship between air temperature and local haemorrhagic complications. METHODS: The retrospective analysis of ultrasonographic examinations performed during the last 5 years (2003-2007) in 10 548 consecutive patients undergoing cardiac catheterisation due to acute coronary syndromes or elective coronary angiography was performed. The relationship between mean monthly temperature, other factors and the rate of local bleeding complications was examined. RESULTS: Mean number of treated patients was 2708 +/- 377/year (2113-3089), of whom 1692 +/- 362/year had coronary angiography and 1345 +/- 281/year had PCI. Yearly rate of all femoral bleeding complications was 3.0 +/- 0.5%. There were more haematomas than pseudoaneurysms: 2.2 +/- 0.4 vs. 0.8 +/- 0.1%, p < 0.0001. Higher mean monthly air temperatures were positively correlated with the number of complications (r = 0.11, p < 0.05), both in males and females (r = 0.13, p < 0.05). A positive correlation between number of haematomas and air temperature values was detected in women. Yearly rate of all vascular complications, haematomas and pseudoaneurysms was higher in women than in men 4.3 +/- 0.9 vs. 2.3 +/- 0.3% (p < 0.0001), 3.0 +/- 0.7 vs. 1.7 +/- 0.3% (p < 0.0001) and 1.3 +/- 0.2 vs. 0.6 +/- 0.1% (p < 0.0005) respectively. In spite of more aggressive antiplatelet therapy, higher clopidogrel loading doses and abciximab use introduced during the analysed period, the rate of local vascular bleeding complications did not increase. CONCLUSIONS: High air temperature during the post-intervention period, besides female gender and advanced age, may be another risk factor for local bleeding complications. This risk remains low (3%), in spite of growing intensity of antiplatelet treatment.

Evaluation of heart rhythm variability and arrhythmia in children with systemic and localized scleroderma.

OBJECTIVE: To evaluate possible disturbances in autonomic regulation and cardiac arrhythmias in children with localized and systemic scleroderma. METHODS: There were 40 children included in the study: 20 with systemic and 20 with localized scleroderma. The control group comprised 20 healthy children. RESULTS: In 24-hour Holter recording, the average rate of sinus rhythm was significantly higher in the groups with systemic and localized scleroderma than in the control group, but there was no significant difference between them. The variability of heart rhythm in both groups was significantly decreased. In the group with systemic scleroderma, single supraventricular ectopic beats were observed in 20% and runs were seen in 40% of patients. In the group with localized scleroderma, supraventricular single ectopic beats occurred in 35% of patients and runs in 45% of those studied. Ventricular arrhythmia occurred in 2 children with systemic scleroderma, but in 1 child, it was complex. CONCLUSION: The most frequent cardiac arrhythmias in both types of scleroderma in children were of supraventricular origin, whereas ventricular arrhythmias did not occur very often. There were no significant differences in autonomic disturbances manifesting as a higher heart rate and decreased heart rate variability between localized and systemic scleroderma.

Primary coronary intervention in diabetic octogenarians with acute ST elevation myocardial infarction.

BACKGROUND: Diabetic patients with acute coronary syndrome (ACS) have higher mortality risk than non-diabetic patients. No data are available on long-term results of interventional treatment of ACS in diabetic patients aged > or =80 years. AIM: To compare the effects of primary angioplasty (pPCI) on short- and long-term outcome in diabetic patients > or =80 years with ST-elevation myocardial infarction (STEMI) compared to those without diabetes mellitus (DM) of similar age. METHODS: In 63 consecutive patients (22% with diabetes mellitus) aged 80-93 years (mean 83+/-3) with ST elevation ACS (ACS-STE) coronary angiography was performed. Severity of coronary atherosclerosis, effects of pPCI, one-day mortality, in-hospital mortality and one-year mortality were studied. RESULTS: Severity of coronary atherosclerosis measured by angiographic Gensini score and author's own score was similar in diabetic and non-diabetic patients (23.25+/-9.6 vs. 20.6+/-10.2; NS, and 9.1+/-6.0 vs. 8.1+/-5.4; NS, respectively). In 78.6% of diabetic subjects and in 69.4% of those without DM, pPCI was performed. Successful pPCI, defined as TIMI 3 flow and residual infarct related stenosis <20%, was obtained in 92.2% of patients with DM compared to 83.7% of non-diabetics (NS). One-day mortality was 7.1 vs. 6.1% (NS), in-hospital mortality was 7.1 vs. 17.4% (NS). Successful pPCI reduced 30-day mortality threefold (OR=0.31; p <0.05). Contrast-induced nephropathy occurred in 35.7% of diabetic patients compared to 26.5% of those without diabetes (NS) Contrast-induced nephropathy increased risk for in-hospital mortality fivefold (p <0.02). No significant correlation between DM or baseline glucose level and in-hospital mortality was found. During one-year follow-up mortality rate in diabetic patients was 38.5% compared to 7.3% of those without diabetes (p <0.01). One-year mortality predictors were: age (OR=1.27; p=0.0047), metabolic syndrome (OR=4.4; p <0.04), type 2 diabetes (OR=5.25; p <0.02), insulin treatment (OR=5.7; p <0.03), baseline glucose level (OR=1.01; p <0.007), maximum CK-mass level (OR=1.006; p <0.05), noninvasive STEMI management (OR=5.0; p <0.02), and stroke (OR=7.5; p <0.006). Stroke (OR=40.0; p <0.005) and diabetes (OR=6.2; p <0.01) were identified by multivariable analysis as independent risk factors of one-year mortality. CONCLUSIONS: In patients with DM aged > or =80 years with ACS-STE, severity of coronary atherosclerosis and in-hospital prognosis after pPCI seems to be similar to subjects in the same age without DM. Diabetes mellitus is an independent risk factor of one-year mortality after successful pPCI.

Femoral rather than carotid artery ultrasound imaging predicts extent and severity of coronary artery disease.

BACKGROUND: Pathological, epidemiological and clinical studies indicate that there is coexistence between peripheral vascular disease and coronary artery disease (CAD). B-mode ultrasound of superficial arteries is a non-invasive, valid and reproducible method of directly visualising and assessing carotid and femoral intima-media thickness (IMT) and focal atherosclerosis. AIM: To evaluate the prognostic importance of carotid and femoral vascular changes in predicting CAD severity. METHODS: 410 patients--300 (73.2%) males and 110 (26.8%) females--aged 29-75 years (mean age 55.9+/-9.5 years), referred for elective coronary arteriography, were studied. Clinical examination and laboratory tests were performed, and ultrasound assessments of IMT and atherosclerotic plaque thickness in the common carotid arteries and common femoral arteries were evaluated. RESULTS: Coronary angiography revealed CAD in 81% of patients (85% of males, 70% of females). Cox multiple hazards regression analyses showed a significant relationship between size of atherosclerotic plaques in peripheral arteries and CAD. Odds ratio of CAD associated with every 1-mm plaque thickening ranged from 1.7 to 3.0 (p <0.001) depending on examined artery. Using multiple stepwise regression analysis, the following parameters were found to be independent predictors of one-vessel CAD: myocardial infarction (MI) in anamnesis (OR=22.3; 95% CI 4.0-122.9), typical chest pain (OR=6.4; 95% CI 1.2-34.2), femoral IMT (OR=5.0; 95% CI 1.4-18.4), ex-smoking (OR=5.6; 95% CI 1.1-28.7), and pulse pressure (OR=1.8; 95% CI 1.0-3.2). Independent predictors of multi-vessel CAD were: MI (OR=3.7; 95% CI 1.8-7.5), typical angina (OR=3.3; 95% CI 1.7-6.5), age (OR=1.05; 95% CI 1.01-1.08), number of cigarettes smoked (OR=0.8; 95% CI 0.6-0.9), total cholesterol level (OR=1.1; 95% CI 1.0-1.2), and left femoral plaque thickness (OR=1.4; 95% CI 1.0-2.0). CONCLUSION: Femoral IMT is an independent predictor of a single-vessel disease, whereas femoral atherosclerotic plaque presence indicates advanced CAD.

[Acute myocardial infarction complicated by cardiogenic shock in a patient with Leriche syndrome--a case report]. / Swiezy zawal serca powiklany wstrzasem u chorego z zespolem Leriche'a.

Acute myocardial infarction complicated by cardiogenic shock in a patient with Leriche syndrome - a case report. A 46-year-old male with atherosclerosis obliterans was admitted to the hospital due to chest pain lasting for two hours and signs of cardiogenic shock. ECG revealed postero-inferior myocardial infarction. The patient was successfully treated with primary angioplasty of RCA. Due to atherosclerosis obliterans angioplasty was performed by transulnar approach. After 22 days of treatment and rehabilitation he was discharged home.

[Myocardial infarction in a patient with hemophilia A--a case report]. / Zawal serca u chorego z hemofilia typu A.

A 43-year-old men with hemophilia A was admitted to CCU due to anginal pain lasting for sixteen hours. ECG revealed anterior wall myocardial infarction and elevated CK and MB-CK levels confirmed the diagnosis. Exercise test performed later was positive and the patient underwent elective coronary angiography which showed 90% stenosis of left anterior descending (LAD) and closed circumflex coronary artery. Next, angioplasty of LAD, preceded by antihemophilic globulin (factor VIII) administration, was successfully performed.