[Massive pulmonary embolism without echocardiographic features of right ventricular overload]. / Masywny zator tetnicy plucnej bez cech przeciazenia prawej komory w badaniu echokardiograficznym.

A case of 70-year-old patient with massive pulmonary embolism confirmed in CT, but without changes in right ventricle size and function in echocardiography is presented. This case is consistent with literature data that echocardiography has relatively low sensitivity in the diagnosis of acute pulmonary embolism.

[Pathogenesis and treatment of acute coronary syndromes]. / Patogeneza i leczenie ostrych zespolów wiencowych.

Acute coronary syndromes (ACS) include unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) and ST-segment elevation myocardial infarction (STEMI). Acute coronary syndromes lead to important epidemiological and economical problems. In polish population an estimated incidence of ACS is 250 000 cases per year. 30-day mortality in UA/NSTEMI is approximately 3.5%, and 8.4% in STEMI. The atherosclerotic plaque instability with subsequent rupture and thrombus formation is a primary mechanism of ACS. Plaque destabilization is evoked by local and systemic inflammation. The primary risk factors in ACS are: age > 65 years, diabetes, peripheral artery disease, stroke, previous myocardial infarction and elevated levels of cardiac troponins. The guidelines for treatment of ACS are based on the results of large randomized clinical trials assessing the reduction of relevant clinical end-points (death, AMI, recurrent ischaemia). The goal of treatment of UA/NSTEMI is the stabilization of the plaque, prevention and reduction of myocardial ischaemia and AMI. Inefficient medical treatment and sustained symptoms are the indication for coronary angiography and percutaneous coronary intervention (PCI). The main goal of treatment in STEMI is quick regaining of the culprit vessel patency and maintaining of sufficient myocardial perfusion. It can be done by thrombolytic therapy or primary coronary angioplasty. In comparison to fibrynolysis PCI confers the lower risk of death and recurrent AMI. New regimens of pharmacological treatment (facilitated PCI) including the half-dose of fibrynolytic and GPIIbIIIa inhibitor prior to PCI are assessed to improve the efficiency of PCI.

Age-adjustment of HRV measures and its prognostic value for risk assessment in patients late after myocardial infarction.

THE AIMS OF OUR STUDY WERE: (1) to establish the normal limit of the heart rate variability (HRV) indices in a healthy population and in its four age-related subgroups, including a new HRV index, HRV fraction; and (2) to analyse the frequency and predictive value of abnormally low HRV in a population of post-infarction patients in respect to the cut-points chosen (raw or age-adjusted). METHODS: Normal population of 296 healthy subjects (81 f, 215 m, aged 47+/-10 years) and post-infarction population of 298 patients (>3 months after acute MI, 65 f, 233 m, aged 56+/-10) were examined. The normal population was divided into 4 subsets based on age at entry: <35, 35-44, 45-54 and >54 years. Based on a 24 h ECG the standard HRV analysis was performed to obtain the following indices: mean RR interval, SDNN and SDANN. A new index of HRV, HRV fraction (HRVF, %) was calculated based on a numerical processing of the RR intervals return map. All patients were followed for 24 months. The endpoints of the study were death (of any reason) and cardiac death. RESULTS: Means and normal limits for SDNN, SDANN and HRVF were: 147+/-36 ms [95% CI 89-220], 136+/-36 ms [79-212] and 53+/-9% [35-68]. The HRV values below the lower normal limit (LNL) were observed in 20-25% of post-MI patients. During a 2 year follow-up there were 36 deaths (total mortality 12.1%), while cardiac mortality was 9.1% (27 cases). The prognostic value of the analysed indices was similar (sens approximately 53-61%, spec approximately 79-84%, PPV 22-26%, NPV 93-94%) irrespective of the cut-points chosen (calculated either for the entire population or age-related). Multivariate Cox regression analysis showed that a decrease of any index below the LNL was associated with a approximately 2.5 and approximately 4-6 times greater risk for death and cardiac death, irrespective of the cut-points chosen. CONCLUSIONS: The age-dependence of the HRV indices does not seem to significantly influence their prognostic value. Thus, a single cut-point of a particular HRV index, based on the entire population, is sufficient to be treated as a risk predictor. In the late phase of myocardial infarction the value of any global HRV index lying below the lower normal limit indicates independently an increased risk of death, especially cardiac death. The new index (HRV fraction) seems to be a promising substitute for currently used standard indices.