Cardiac troponin I after external electrical cardioversion for atrial fibrillation as a marker of myocardial injury--a preliminary report.

BACKGROUND: It is uncertain whether external electrical cardioversion (CV) of atrial fibrillation (AF) can cause myocardial injury identifiable by troponin I (cTnI). AIM: To examine whether external CV of AF can cause cTnI rise as measured with high-sensitivity assay, and to identify factors determining this elevation. METHODS: Patients with non-valvular AF selected for CV were included. Exclusion criteria were myocardial ischaemia, elevated D-dimer, heart and renal failure. Patients underwent monophasic or biphasic CV. Troponin I was measured before, and 6 and 12 hours after the procedure with TNI-ADV assay; NT-proBNP was measured before CV. Echocardiography was performed in all patients. RESULTS: Twenty-two patients were examined. Troponin I 6 and 12 hours after CV [0.04 ng/ml (0.00-0.30), 0.04 ng/ml (0.00-0.13)] was significantly higher than before [0.017 pg/ml (0.00-0.08)] (p=0.01, p=0.02). Only in one patient did cTnI exceed the cut-off for myocardial infarction after 6 hours (>0.16 ng/ml) with subsequent normalisation after 12 hours. Left ventricular end-diastolic dimension (LVEDD) was significantly higher and ejection fraction lower in the group with cTnI rise in comparison with the group with no cTnI elevation (54,2+/-6,3 vs. 47,6+/-5,7 mm, p=0,02; 56,2+/-8,9 vs. 63,2+/-7,1%, p=0,05). LVEDD=53 mm had 75% sensitivity and 72% specificity for predicting cTnI elevation after CV. Age, gender, AF duration, type of CV, energy, left atrial dimension, baseline cTnI and NT-proBNP were not predictive of cTnI increase. CONCLUSIONS: Cardioversion can lead to mild but significant cTnI rise as measured with a high-sensitivity assay. The influence of CV on cTnI elevation appears to be more pronounced in patients with relatively large LVEDD.

The prognostic value of stress tests in chronic heart failure.

Chronic heart failure is a debilitating condition with a poor prognosis despite advances in medical and invasive treatment modalities. Attempts have been made to improve risk stratification in order to single out very-high-risk patients who could benefit from invasive and costly therapies. Unfortunately clinical, echocardiographic, radiological or biochemical measurements performed at rest provide significant diagnostic information but fail to stratify the risk sufficiently. Cardiopulmonary exercise testing alone or in combination with stress echocardiography and biomarkers may offer a more profound insight into the progress of the disease and patient prognosis and aid in the choice of the most appropriate therapy. Peak oxygen consumption (pVO(2)) is the most powerful prognostic parameter obtained during cardiopulmonary exercise testing. Ventilation slopes, especially the slope of ventilation to CO(2) production (VE/VCO(2)), can have additional prognostic value or be used as a surrogate risk predictor where exercise is sub-maximal. Other cardiopulmonary parameters seem to have, at best, an auxiliary role in risk assessment. In patients with grey zone pVO(2) values the presence of contractile reserve on stress or dobutamine echocardiography can be prognostically favourable. Other echocardiographic findings, such as functional mitral regurgitation, pulmonary hypertension and right ventricle dysfunction, also yield prognostic information. Combining biomarker measurements with pVO(2) obtained during the cardiopulmonary exercise test may further improve risk assessment in heart failure patients. Two markers, B type natriuretic peptides and high sensitivity C-reactive protein (hsCRP), both with established prognostic value in heart failure and cardiovascular diseases in general, are the best candidates for combined assessment with cardiopulmonary test results. Further studies are needed to confirm this notion. (Cardiol J 2007; 14: 340-346).

[N-terminal pro-brain natriuretic peptide (NT-proBNP) and ischemia modified albumin (IMA) in exercise induced ischemia in patients with stable coronary artery disease]. / N-koncowy propeptyd natriuretyczny typu B (NT-proBNP) i albumina modyfikowana niedokrwieniem (IMA) w niedokrwieniu wysilkowym u pacjentów ze stabilna choroba wiencowa.

INTRODUCTION: Preliminary data indicate that B type natriuretic peptides' levels may rise in exercise induced myocardial ischemia in patients with stable coronary artery disease. Such findings hint at a potential broader application of these markers reaching beyond its present use in chronic heart failure and acute coronary syndromes. Ischemia modified albumin (IMA) is a novel diagnostic marker in acute coronary syndromes as its value increases in states of myocardial ischemia and necrosis. The role of this marker in the assessment of exercise induced myocardial ischemia in stable coronary artery disease has not been extensively investigated and remains unknown. AIM: To examine changes in N-terminal pro-brain natriuretic peptide (NT-proBNP) and ischemia modified albumin (IMA) during an ECG stress test in patients with stable coronary artery disease and to assess the potential of these markers to detect exercise induced myocardial ischemia. PATIENTS AND METHODS: Patients with angiographically confirmed coronary atherosclerosis were included into the study. In all of them prognostic ECG stress test according to Bruce protocol was performed. The test was considered true positive (ischemia present) in case of significant ST-segment depression in the presence of significant coronary stenosis. The test was considered true negative (ischemia absent) when no significant ST depression was noted in the absence of significant coronary stenosis. In all patients echocardiography was performed and blood was drawn for NT-proBNP, IMA, serum albumin and creatinine before and within the first five minutes after exercise. RESULTS: 41 patients with unequivocal stress test result corresponding to coronary angiogram were included in the final analysis (out of 51 examined patients). 21 patients demonstrated ischemia during exercise, 20 did not. NT-proBNP concentration was significantly higher after the stress test than before in the whole group: 127.9 (10.7-994.2) pg/ml and 110 (10.5-990.2) pg/ml respectively; p < 0.0001. NT-proBNP increase was higher in the ischemic than in the non-ischemic group; however, the difference was not statistically significant: deltaNT-proBNP 12.3 (1.0-172.3) pg/ml and 4.2 (1.0-77.1) pg/ml respectively; p = 0.09. This manifested itself in poor sensitivity and specificity of NT-proBNP in detecting exercise induced myocardial ischemia: 62 and 55% respectively (AUC 0.589). In the whole group the increase of NT-proBNP depended on baseline NT-proBNP concentration (r = 0.54; p = 0.0003), the magnitude of ST-segment depression (r = 0.38; p = 0.01), creatinine concentration (r = 0.34; p= 0.03) and history of myocardial infarcion: log deltaNT-proBNP in post-MI patients and in patients without prior MI 1.19 ( +/- 0.54) i 0.61 ( +/- 0.57) respectively; p = 0.004. In multiple regression analysis the only factor independently determining NT-proBNP increase during exercise was the history of myocardial infarction (beta = 0.342; p = 0.01) but not left ventricle ejection fraction. IMA decreased during exercise in all patients significantly--the mean value before and after exercise was 88.20 (7.72) and 78.05 (8.33) U/ml respectively; p = 0.0001. Decrease in IMA correlated only with increase in albumin concentration measured before and after exercise (r = -0.6; p < 0.0001). CONCLUSIONS: Exercise induced myocardial ischemia has little influence on NT-proBNP increase. The test measuring it has therefore insufficient ability to detect exercise induced ischemia in stable coronary artery disease. In patients with stable coronary artery disease without severe impairment of left ventricular function the history of myocardial infarction is the main factor determining NT-proBNP increase during exercise. Changes in serum albumin concentration during exercise seem to exclude the use of IMA in the assessment of exercise induced myocardial ischemia.

[Correlation of high-sensitivity CRP concentration with the extent of coronary atherosclerosis in men with symptoms of ischemic heart disease]. / Korelacja stezenia bialka C-reaktywnego mierzonego metoda o wysokiej czulosci z nasileniem zmian miazdzycowych w tetnicach wiencowych u mezczyzn z objawami choroby niedokrwiennej serca.

UNLABELLED: Atherogenesis is combined with inflammation of low intensity within endothelium. To-date studies have demonstrated that C-reactive protein is the best marker of this type of inflammation because its concentrations not only reflect the intensity of the process but they also carry prognostic information in apparently healthy general population as well as in patients with symptomatic atherosclerosis. The aim of this study was to evaluate the correlation between high-sensitivity CRP (hsCRP) and the extent of coronary atherosclerosis in men undergoing coronary angiography. The secondary aim was to assess the influence of statin treatment on hsCRP levels by comparing these levels in statin-treated and statin-naive patients. MATERIALS AND METHODS: 112 men with symptoms of ischemic heart disease were included in the study. In 98 cases coronary angiography was performed 52 patients were treated with statins. The extent of atherosclerosis in the coronary bed was evaluated according to four indexes: Gensini score (G), Friesinger score (F), Number of Vessels Diseased (NVD) and Arterial Segment Score (ASS). Concentrations of hsCRP concentrations were obtained with NB100 Dade-Behring kit. Pearson correlation coefficient was calculated for CRP concentrations following their logarithmic transformation. Correlation evaluation was confined to statin-naive patients due to convincing data about the influence of statins on CRP levels. RESULTS: A significant correlation between levels of hsCRP and extension of coronary atherosclerosis was found with all used indexes (G: R=0.335; p=0.0151, F: R=0.406; p=0.0028, NVD: R=0.0338; p=0.0142, ASS=0.368; p=0.071). The mean concentration of hsCRP was 27.7% lower in the patients on statins than in statin-naive patients within the low and moderate range of concentrations (up to 70th percentile, 2.4 mg/l) (p<0.02). In 25% of study subjects hsCRP exceeded the level of 3.0 mg/l which is the cut-off value for increased risk of atherothrombotic complications. CONCLUSIONS: The study showed a significant correlation between hsCRP and the extent of coronary atherosclerosis in men with symptoms of ischemic heart disease. A significantly lower concentration of hsCRP was observed in the group of patients treated with statins compared to statin-naive patients, which may result from the proposed CRP reducing influence of these drugs. A quarter of study subjects had hsCRP levels exceeding the cut-off value for increased cardiovascular risk.

[Troponin I levels after uncomplicated, elective percutaneous coronary intervention in patients with stable coronary heart disease]. / Stezenia troponin po niepowiklanych zabiegach planowanej angioplastyki wiencowej u chorych ze stabilna choroba wiencowa.

UNLABELLED: Percutaneous coronary intervention is a proven method of treatment of significant number of patients with coronary artery disease. Sometimes it is accompanied by increases of troponin levels. Frequency and degree of these phenomena are not well known. THE AIM: of the present study was to establish frequency and a degree of the increase of cardiac troponin I (cTnI) in patients with stable coronary artery disease who underwent elective PTCA without complications during hospitalization. MATERIAL AND METHODS: Our study included 99 patients fulfilling the above mentioned criteria. Average patients' age was 58,7 years (range 37-82 years). In 67 patients PTCA was performed on one artery, in 27 on two and in five on 3 arteries. In 36 patients standard stents were implanted, in the remaining (63 patients) only PTCA was performed. In the group with stents 29 patients had 1 stent implanted, 6 patients had 2 stents and one had 3 stents implanted. In all the patients cTnI (Abbott AxSYM Immunoassay) were determined before PTCA, 12 and 24 hours after PTCA. RESULTS: After 12 hours percentage of cTnI results above 1.22 microg/L (cut-point for spontaneous infarction according to the new definition of heart infarction) amounted to 35% and above 2.0 microg/L (cut-off according WHO infarction definition) 28%. After 24 hours the percentages were similar. Typical cTnI results (90%) after PTCA were below 10 microg/L. cTnI levels were weakly but statistically significantly correlated with number of vessels, which underwent PTCA. CONCLUSION: Moderate increases in troponin I after PTCA seem to correspond to minimal, in general, cardiac injury.

[Clinical outcome of patients after transmyocardial laser revascularization alone and combined with coronary artery bypass grafting]. / Kliniczna ocena efektu przezsercowej rewaskularyzacji laserowej polaczonej lub niepolaczonej z pomostowaniem aortalno-wiencowym.

The aim of the study was to assess the effect of transmyocardial laser revascularization (TMLR) alone and in combination with coronary artery bypass grafting (CABG) on the angina score (CCS--Canadian Cardiovascular Society class), exercise tolerance and left ventricular function 6 months after the procedures. Sixty two patients were subjected to revascularization, 38 to sole TMLR procedure and 24 to combination CABG and TMLR (CABG/TMLR group). The angina score and exercise stress test together with radionuclide ventriculography were performed before and 6 months after the operation. The angina class and exercise tolerance were similar in both groups preoperatively. After the operation the improvement was seen in both groups with no statistical difference. The left ventricular ejection fraction were 61 +/- 8% and 54 +/- 8% (p < 0.05) before operation and after 6 months respectively. Transmyocardial laser revascularisation alone and in combination with coronary artery bypass grafting may relieve the angina and improve the exercise tolerance. However the left ventricular ejection fraction may drop significantly.

[C-reactive protein as a new risk factor of coronary heart disease in the population of young Polish males]. / Bialko C-reaktywne jako nowy czynnik zagrozenia choroba niedokrwienna serca w populacji mlodych zdrowych Polaków.

UNLABELLED: The aim of this study was to measure the levels of C-reactive protein (CRP) and examine their relationship with traditional risk factors of the coronary heart disease. Methods and participants. We examined a group of 150 males aged between 18 and 24. Each participant underwent physical examination and gave his previous medical history which included the place of residence, family background and current medication. In each case blood pressure was measured and body mass index (BMI) as well as waist/hip (W/H) ratio were established. The following biochemical parameters were measured in the serum of each participant: glucose, total cholesterol, HDL-cholesterol, triglycerides, apolipoproteins A-I and B (Apo A, Apo B), uric acid and C-reactive protein. LDL-cholesterol level was obtained from Friedewald's formula. High sensitivity C-reactive protein (hs-CRP) was measured by automatic DADE-Behring nefelometer. RESULTS: The results underwent variation, correlation and regression analyses. The mean age of participants was 20.5 +/- 1.2 years. The mean BMI, W/H ratio, systolic and diastolic blood pressure as well as traditional coronary heart disease risk factors (total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, uric acid, Apo A, Apo B) were within reference range. The mean CRP level was 0.135 +/- 0.24 mg/dl. There was statistically significant positive correlation between CRP level and W/H ratio. There was statistically significant negative correlation between CRP level and HDL-cholesterol and Apo-A levels. There was no statistically significant correlation between CRP level and smoking. CONCLUSIONS: Our study confirmed findings by other authors that there is a relationship between CRP level and other coronary heart disease factors such as W/H ratio and HDL-cholesterol. The lack of relationship between CRP level and smoking remains consistent with previous findings of Onat and Mendall. The mean CRP level in our study group was similar to CRP levels observed in large European populations.

[Transmyocardial laser revascularization]. / Przezsercowa rewaskularyzacja laserowa.

This review describes the transmyocardial laser revascularization (TMLR) which is a method used to treat patients with end-stage coronary heart disease who have been excluded from standard invasive treatments (coronary artery by-pass grafting, percutaneous transluminal coronary angioplasty) and no longer benefit from maximum medical therapy. TMLR consists in reestablishing blood flow to the ischaemic myocardium by creating a number of laser-drilled channels which are thought to allow a direct contact between the left ventricle and the myocardial plexus. This paper also presents a review of the available evidence of the efficacy of the procedure.