Left Ventricular Ejection Fraction Can Predict Atrial Thrombosis Even in Non-High-Risk Individuals with Atrial Fibrillation.

Background­Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, using clinical, laboratory and echocardiographic data which are usually obtained in those patients in a real-world setting. Methods­We analyzed data from electronic medical records (EMR) of consecutive AF patients referred to two university hospitals between January 2014 and December 2017 for pulmonary vein isolation (PVI) or direct current cardioversion. The primary endpoint was the presence of left atrial thrombus on TOE. Multivariable and univariable logistic regression models were computed using variables that were significantly different between the LAT and the control groups. Results­A total of 838 patients were included, of whom 132 (15.8%) had LAT. After controlling for other variables, only the left ventricle ejection fraction (LVEF) remained statistically significant with an OR of 0.956 (95% CI 0.934−0.979), p < 0.01. Regression models including LVEF had significantly higher areas under the receiver operating characteristic (ROC) curves, including in subgroups with non-high thromboembolic risk (CHA2DS2-Vasc = 0 or 1), with an area under the curve (AUC) of 0.76 (95% CI 0.71−0.81), p < 0.0001. Conclusions­The LVEF is an independent predictor of LAT, and it might improve thromboembolic risk stratification in future models. LVEF significantly increased the predictive value of the CHA2DS2-Vasc model and was able to identify LAT in non-high-risk patients.

Estrogen receptor 1 gene (TA)n polymorphism is associated with lone atrial fibrillation in men.

AIM: To determine the association between the number of thymine-adenine (TA)n dinucleotide repeats in the promoter region of the gene coding for the estrogen receptor alpha (ESR1) and the prevalence of lone atrial fibrillation (AF) in men. METHODS: We conducted a case-control study involving 89 men with lone AF and 166 healthy male controls. The ESR1 genotype was established by polymerase chain reaction and capillary electrophoresis. To assess the association of ESR1 genotype with AF, logistic regression models were built with AF as outcome. RESULTS: Men with lone AF had significantly greater number of (TA)n repeats of single alleles than controls (mean ± standard deviation, 19.2 ± 4.2 vs 18 ± 4.3, P = 0.010). After adjustment for other factors, a unit-increase in (TA)n repeat number was associated with a significantly greater likelihood of AF (odds ratio 1.069; 95% confidence interval 1.024-1.116, P=0.002). CONCLUSIONS: Our results indicate that a greater number of (TA)n repeats in the promoter region of ESR1 is associated with a significantly increased likelihood of lone atrial fibrillation in men.

Influence of in-hospital cardiac rehabilitation on psychological status after myocardial infarction in patients with D-type personality.

The aim of this study was to determine the number of D-type personality patients in the group with a history of myocardial infarction (MI) and the influence of comprehensive in-hospital cardiac rehabilitation (iCR) on their psychological status (PS). The study included 316 consecutive patients aged 18 to 65 with MI in the last six months admitted into the programme of iCR. Surgical revascularized patients, clinically unstable patients and patients with sever chronic diseases and disorders were excluded. At the beginning and in the end of iCR diagnostic exam, hematological/biochemical blood analysis, ergometric testing was conducted. At the beginning and four weeks after the finish of the iCR estimation of PS was conducted. Distress scale 14 (DS14) questioner was used for that purpose. In the period of three weeks, patients were included in the programme of comprehensive iCR. Out of 316 patients in the study group 83.2% were male, while 16.8% were female. Average age of the patient was 51.3 +/- 7.2. When being admitted to iCR 42.7% patients had characteristics of D-type personality. Those patients had substantially lower level of body mass and body mass index. In the same time there were no differences among groups in risk factors, values of clinical, laboratory and diagnostic parameters. During iCR study group had more complications in comparison to the control group. At the end of iCR substantial rise of functional capacity of patients, improvement of lipid profile and lowering of glycaemia was recorded. Also at the end of iCR antiarrhythmics and psychopharmaceutical medicaments were more often prescribed to the patients in the study group. Four weeks after the iCR share of D-type personality patients was 41% and 71% of study group patients kept their D-type structure.

Interactions of MinK and e-NOS gene polymorphisms appear to be inconsistent predictors of atrial fibrillation propensity, but long alleles of ESR1 promoter TA repeat may be a promising marker.

Interactions of MinK and e-NOS Gene Polymorphisms Appear to Be Inconsistent Predictors of Atrial Fibrillation Propensity, but Long Alleles of ESR1 Promoter TA Repeat May Be a Promising Marker. We analyzed minK, e-NOS and ESR1 gene polymorphisms in 40 patients with atrial fibrillation (AF) without major structural heart disease compared to 35 healthy controls. A missense polymorphism in the minK gene with A/G substitution at nucleotide 112 causing serine (S) to glycine (G) change, 786 T/C polymorphism in the 5' flanking region of e-NOS gene and TA polymorphism in the regulatory region of estrogen receptor ESR1 gene with long (> or = 19 TA repeats) and short alleles were examined. Only a slight increase in minK G allele frequency, but with marked excess in AG/TT combination of minK and e-NOS polymorphisms was found in the AF group. The interpretation remains tentative due to small groups precluding statistical significance of differences, possible lab flaws and inconsistencies with earlier data. However, ESR1 long allele homozygotes were strikingly more frequent in the AF than in control group, reaching statistical significance surprisingly in males (p < 0.02). Functional activity of estrogen receptors may be more critical in males than in females with abundance of circulating estrogen. Contrasting the intricate complexity of genetic polymorphisms influencing cardiac rhythm with our modest research, we would limit the conclusion to the plea for further research of ESR1 role in AF.

[Electrocardiography in the diagnostics of acute myocardial infarction with ST elevation]. / Elektrokardiografija u dijagnostici akutnog infarkta miokarda sa ST elevacijom.

After a century of clinical use, electrocardiography (ECG) remains the basic method for the diagnosis of acute myocardial infarction. Its suboptimal sensitivity can be improved by additional recording leads and device adjustment with posterior wall inverse presentation for the detection of left ventricular posterior wall and right ventricle infarcts. The addition of some ST-depression criteria equivalent to those of ST elevation is discussed, with the aim of increasing the sensitivity without a substantial loss of specificity. ECG patterns concerning myocardial infarction evolution, localization and size estimates are reviewed. PIS and EMI patterns are discussed in respect to the modes of reperfusion therapy. ECG scoring systems are commented, considering risk stratification and the choice of reperfusion therapy. In conclusion, ECG is an old diagnostic tool that should be used for new tasks.

Access site complications following cardiac catheterization assessed by duplex ultrasonography.

Access site complications are major source of morbidity following cardiac catheterization. Their incidence varies in the literature because of multiple definitions and methods of determining the presence of particular complication. The aim of this prospective study was to determine the incidence of access site complications following cardiac catheterization using arterial duplex ultrasonography. A total of 319 consecutive patients, who had cardiac catheterization underwent femoral artery duplex study 24 to 48 hours following manual hemostasis. Diagnostic angiogram had 232 (71.8%) while 87 (28.2%) had percutaneous coronary intervention (PCI). Femoral artery duplex ultrasound was normal in 247 (77.4%). Haematoma was found in 48 (15.1%), pseudoaneurysm in 17 (5.3%), AV fistula in 2 (0.6%) and dissection of the femoral artery in 5 (1.6%) patients. Baseline demografic characteristics were similar in group with normal duplex study and group with detected complication. Pseudoaneurysm and AV fistula were more commonly observed in patients following PCI than diagnostic angiogram (9.2% vs. 4.7%, p<0.001). Patients with documented complications more frequently had concomitant administration of antiplatelet and anticoagulant medication compared to the patients without complications (p=0.003). Hemodynamic disturbances (hypotension and bradycardia) during manual compression were more frequent in patients with complication (11% vs. 4.5%, p=0.047). Low threshold for use of duplex ultrasound should be exercised in patients following cardiac catheterization to establish the presence of access site complications. Special attention is needed in the setting of aggressive antiplatelet and anticoagulant therapy, interventional procedures and hemodynamic disturbances during manual hemostas.

Spontaneous and catheter-induced secondary coronary artery dissection: a single-centre experience.

6497 consecutive patients who underwent coronary angiography in our institution in a three-year period were analysed. Spontaneous coronary artery dissection was noted in five, and unexpected dissection secondary to coronary arteriography in three patients. All patients with spontaneous dissection presented clinically as myocardial infarction. Three patients (two of them with spontaneous dissection) underwent urgent coronary artery bypass grafting. Percutaneous coronary intervention was successful in two patients with spontaneous and in one with unexpected secondary dissection. One patient with spontaneous and one with secondary dissection were treated medically after failed intervention. In conclusion, spontaneous coronary artery dissection is rare, but not exceptional. Its true incidence might have been underestimated before the advent of coronary interventions in acute myocardial infarction. Survival of all our patients, in contrast to earlier reports on mortality rates up to 50%, may be attributed to the benefits of modern surgery and interventional cardiology.

Echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

We found increased systolic coronary flow in transthoracic pulsed wave (PW) Doppler in a 42-year-old patient with anomalous origin of left main coronary artery from the pulmonary artery. This is a characteristic echocardiographic finding in this anomaly in the presence of collateral circulation and coronary L-R shunt. In comparison with so far used echocardiographic criteria this parameter when present allows quick recognition of anomalous origin of left coronary artery from the pulmonary artery, and its differentiation from other potentially lethal coronary anomalies.

Heart rate variability differences in post-myocardial infarction patients based on initial treatment during acute phase of disease.

The aim of study was to asses the heart rate variability (HRV) differences in 128 post-myocardial infarction (MI) patients based on initial treatment during acute phase of disease. The patients were divided into groups: group 1 patients who underwent primary PCI, group 2 patients who received fibrinolysis and group 3 patients who were treated conservatively. In comparison with groups 2 and 3, group 1 patients had all HRV analyzed parameters higher except for LF/HF ratio. The results of study suggest that patients who were treated by primary PCI had better preserved autonomic cardiac function compared with patients who received fibrinolysis or those who were treated conservatively in the acute phase of MI.

The "Chaos Theory" and nonlinear dynamics in heart rate variability analysis: does it work in short-time series in patients with coronary heart disease?

BACKGROUND: Dynamic analysis techniques may quantify abnormalities in heart rate variability (HRV) based on nonlinear and fractal analysis (chaos theory). The article emphasizes clinical and prognostic significance of dynamic changes in short-time series applied on patients with coronary heart disease (CHD) during the exercise electrocardiograph (ECG) test. METHODS: The subjects were included in the series after complete cardiovascular diagnostic data. Series of R-R and ST-T intervals were obtained from exercise ECG data after sampling digitally. The range rescaled analysis method determined the fractal dimension of the intervals. To quantify fractal long-range correlation's properties of heart rate variability, the detrended fluctuation analysis technique was used. Approximate entropy (ApEn) was applied to quantify the regularity and complexity of time series, as well as unpredictability of fluctuations in time series. RESULTS: It was found that the short-term fractal scaling exponent (alpha(1)) is significantly lower in patients with CHD (0.93 +/- 0.07 vs 1.09 +/- 0.04; P < 0.001). The patients with CHD had higher fractal dimension in each exercise test program separately, as well as in exercise program at all. ApEn was significant lower in CHD group in both RR and ST-T ECG intervals (P < 0.001). CONCLUSIONS: The nonlinear dynamic methods could have clinical and prognostic applicability also in short-time ECG series. Dynamic analysis based on chaos theory during the exercise ECG test point out the multifractal time series in CHD patients who loss normal fractal characteristics and regularity in HRV. Nonlinear analysis technique may complement traditional ECG analysis.

Giant, dissecting, high-pressure pulmonary artery aneurysm: case report of a 1-year natural course.

We report the rare subchronic clinical course of a giant, dissecting pulmonary artery aneurysm in an oligosymptomatic middle-aged woman who had idiopathic pulmonary hypertension. Diagnosis was simple with the use of echocardiography and multislice computed tomography. Conversely, deciding on the treatment was difficult, because prominent surgeons declined to perform surgical repair of the aneurysm and recommended heart-lung transplantation. Therefore, we were forced to treat our patient medically. She survived for 1 year, including 8 months of treatment with sildenafil, and then died suddenly while awaiting transplantation. Our patient, who had a dissecting, high-pressure pulmonary artery aneurysm, had an unexpectedly stable and uneventful clinical course for 1 year, which, under more favorable circumstances, might have provided enough time for heart-lung transplantation to be performed.