Elevated factor XI is associated with recurrent left ventricular thrombus of unknown origin.

BACKGROUND: Elevated factor XI (FXI) has been shown to predispose to thromboembolism. We investigated whether it is associated with left ventricular thrombus (LVT) formation, its recurrence and subsequent thromboembolic events. METHODS: In 54 patients with prior LVT of unknown origin, who stopped anticoagulation and 54 controls, we determined FXI, along with plasma clot permeability (Ks), fibrinolysis time (CLT), endogenous thrombin potential (ETP), von Willebrand factor (vWF) and fibrinolysis proteins. During follow-up, the primary endpoint involving the recurrence of LVT a symptomatic ischemic stroke or systemic embolism was recorded. RESULTS: Elevated (>120%) FXI levels were more often observed in LVT patients when compared to the control group (14 [25.9%] vs. 6 [11.1%], p = .048) in association with the presence of active FXI. FXI correlated with age (r = .406, p = .002), Ks (r = -.542, p < .001) and CLT (r = .406, p = .002), also after adjustment for age, but not with ETP, vWF or fibrinolysis proteins. During follow-up of 77.6 ± 18.5 months the primary endpoint occurred in 17 (31.5%) LVT patients, including 11 (20.4%) recurrent LVT, and in 4 (7.4%) controls (annual incidence rate 4.9% vs. 1.1%, respectively; p = .002). On multivariate logistic regression analysis, elevated FXI was independently associated with the primary endpoint (OR 1.18; 95% CI 1.09-1.28). CONCLUSIONS: Elevated FXI in association with a prothrombotic state characterizes patients with prior LVT of unknown origin and predisposes to its recurrence and/or ischemic stroke during follow-up. It might be speculated that the measurement of FXI helps identify patients who could benefit from prolonged anticoagulation and FXI inhibitors in the future.

Effectiveness of a Standardized Combination of Intracameral Mydriatics and Anaesthetic on Mydriasis during Cataract Surgery with Coexisting Diseases.

PURPOSE: To examine the effectiveness of a standardized combination of intracameral mydriatics and anesthetic (SCIMA) on mydriasis in patients with coexisting diseases such as diabetes mellitus (DM) and pseudoexfoliation syndrome (PXF) during phacoemulsification. METHODS: Patients with cataract were included in the study if they achieved pupil dilation diameter ≥ 6.0 mm after the administration of mydriatic eyedrops (ME) during the first visit (V1). During the second visit (V2), pupil size measurements were obtained for phacoemulsification surgery with SCIMA. Effective mydriasis was defined as a pupil diameter ≥ 6.0 mm just prior to capsulorhexis without the use of additional pupil dilating agents. The measurements after ME administration during V1 and after SCIMA use during V2 were compared. RESULTS: 103 patients (103 eyes) were divided into 3 groups: cataract and DM (n = 35), cataract and PXF (n = 32), and cataract without DM or PXF (n = 36). SCIMA administration allowed the achievement of effective mydriasis (≥6.0 mm) in all groups (n = 103; 100%). Mydriasis was significantly larger (p ≤ 0.001) after ME (7.3 mm) than after SCIMA (6.8 mm) administration. CONCLUSIONS: Patients with cataract and such comorbidities as DM or PXF are likely to achieve effective pharmacological mydriasis during cataract phacoemulsification after SCIMA application. Mydriasis after ME is slower and larger, while SCIMA is faster.

Asymptomatic Caseous Calcification of the Mitral Annulus in a 66-Year-Old Woman with 3-Year Imaging Follow-Up.

BACKGROUND Caseous calcification of the mitral annulus (CCMA) is an uncommon form of mitral annular calcification and can be misdiagnosed as heart abscess, neoplasm, or other lesions occupying the atrioventricular groove. Data regarding imaging follow-up of patients with CCMA are limited. This report presents a case of CCMA with a 3-year imaging follow-up. CASE REPORT A 66-year-old asymptomatic woman was referred to our cardiology department for further evaluation of a rapidly expanding intracardiac mass observed using transthoracic echocardiography (TTE) in an outpatient setting. A neoplasm was suspected. Echocardiographic examination was normal 5 years ago, and 2 years later, TTE revealed an echodense structure (10×10 mm) occupying the atrioventricular groove. Three years later, TTE revealed an increase in the size of the lesion (21×18 mm) and a mild acoustic shadow. Cardiac magnetic resonance imaging revealed a pathological mass (20×20×37 mm) in the posterior portion of the mitral annulus that extended into the left ventricle. Using computed tomography, a round mass (20×19×39 mm) with a demarcated area of calcification was revealed in the posterior portion of the mitral annulus. Thus, the intracardiac mass was diagnosed as CCMA. Although there was a considerable increase in lesion size (doubling of lesion size within 3 years), normal intracardiac flow and asymptomatic course of the disease remained. Therefore, this patient underwent conservative management with imaging follow-up. CONCLUSIONS In cases of atypical presentation of CCMA, multimodal imaging may provide an accurate diagnosis and important information regarding the course of the disease.

Long-term outcomes in patients with acute myocardial infarction and no ischemic changes on electrocardiogram.

BACKGROUND: Acute myocardial infarction (MI) is commonly associated with ischemic abnormalities on electrocardiography (ECG). However, a significant proportion of patients present with no ischemic changes (NIC), and their baseline characteristics and management differ considerably from those with other ECG patterns. In the era of rapid troponin assays, the exact prognostic effects of normal ECGs remain unclear. OBJECTIVES: This study aimed to compare the outcomes of patients with MI without ischemic changes and those with other ECG patterns. METHODS: Between 2012 and 2018, 155,073 patients with MI were enrolled in the prospective nationwide Polish Registry of Acute Coronary Syndromes (PL-ACS). The patients were assigned to one of the following groups: NIC, ST-segment elevation (STE), ST-segment depression (STD), T-wave inversion (TWI), and other ST-T abnormalities (STT). RESULTS: The NIC group accounted for 9.56% of all patients. The in-hospital risk of death was lower in the TWI group than in the NIC group. In the STE, STD, and STT groups, the short-term results were substantially worse. During the 12-month observation period, TWI had the best prognosis. The worst long-term prognoses were associated with STT and STD. The outcomes of the STE and NIC groups were similar (12-month death rate 9.0% vs. 8.7%, respectively; P=0.534), despite the fact STE was an independent predictor of 12-month prognosis. CONCLUSIONS: The prognosis of patients with MI and NIC is not as favorable as previously thought. Their long-term outcomes were equal to those of the TWI and STE MI groups.

Choosing a treatment method for post-catheterization pseudoaneurysms guided by the late to early velocity index.

Ultrasound-guided thrombin injection (UGTI) is often the first-line treatment for iatrogenic post-catheterization pseudoaneurysms (psA). There are also first reports of the use of biologically derived tissue glues (TG) instead of sole thrombin especially when UGTI was unsuccessful or in case of psA recurrence. Previously, we have established that a late to early velocity index (LEVI) < 0.2 could be a predictor of an increased risk of psA recurrence after standard UGTI. In this paper, we report our first experiences when the choice of the first-line treatment method was based on LEVI assessment. From May 2017 till January 2020 we included 36 patients with psA. Of them, 10 had LEVI < 0.2 and they underwent ultrasound-guided tissue glue injection (UGTGI) with biological TG and 26 had LEVI > 0.2 and they underwent UGTI. The injection set containing human thrombin and fibrinogen was used for UGTGI. Bovine thrombin was used for UGTI. The success rate was 100% and no psA recurrence was detected during a 2-week follow-up. It was significantly better when compared to the expected recurrence rates based on our previous 14 years of experience (0% vs. 13%, p = 0.01). All complications (10% in the UGTGI group and 15% in the UGTI group) were mild and transient and included clinical symptoms of paresthesia, numbness, tingling, or pain. Their rates were comparable to the rates we previously reported. No significant differences in other characteristics were observed. The approach to choose the first-line treatment method for iatrogenic psA based on LEVI is encouraging. It may increase the success rate and avoid unnecessary repetition of the procedure, without increasing complication rate while keeping costs of the procedure reasonable.

ST-segment elevation myocardial infarction with non-obstructive coronary arteries: Score derivation for prediction based on a large national registry.

BACKGROUND: Acute myocardial infarction with ST-segment elevation (STEMI) and obstructive coronary arteries (MI-CAD) are treated with primary percutaneous coronary interventions (pPCI), while patients with STEMI and non-obstructive coronary arteries (MINOCA), usually require non-invasive therapy. The aim of the study is to design a score for predicting suspected MINOCA among an overall group of STEMI patients. MATERIALS AND METHODS: Based on the Polish national registry of PCIs, we evaluated patients between 2014 and 2019, and selected 526,490 subjects treated with PCI and 650,728 treated using only coronary angiography. These subjects were chosen out of 1,177,218 patients who underwent coronary angiography. Then, we selected 124,663 individuals treated with pPCI due to STEMI and 5,695 patients with STEMI and MINOCA. The score for suspected MINOCA was created using the regression model, while the coefficients calculated for the final model were used to construct a predictive model in the form of a nomogram. RESULTS: Patients with MINOCA differ significantly from those in the MI-CAD group; they were significantly younger, less often males and demonstrated smaller burden of concomitant diseases. The model allowed to show that patients who scored more than 600 points had a 19% probability of MINOCA, while for those scoring more than 650 points, the likelihood was 71%. The other end of the MINOCA probability scale was marginal for patients who scored less than 500 points (< .2%). CONCLUSIONS: Based on the created MINOCA score presented in the current publication, we are able to distinguish MINOCA from MI-CAD patients in the STEMI group.

Late to early velocity index as a predictor of iatrogenic femoral artery pseudoaneurysm recurrence in patients treated with ultrasound-guided thrombin injection.

INTRODUCTION: Ultrasound-guided thrombin injection (UGTI) is the preferred treatment of pseudoaneurysms (psA). The potential risk of complications increases with the number of UGTI treatments needed for complete psA obliteration. Identification of risk factors for recurrent psA is needed. MATERIAL AND METHODS: In total, 508 patients with femoral artery psA underwent UGTI, followed by ultrasound examination repeated twice, at 1-week intervals, to assess UGTI effectiveness. In cases of psA recurrence, the procedure was repeated. Clinical and ultrasound data were prospectively collected. RESULTS: The psA recurrence occurred in 76 (15%) patients. UGTI was repeated twice in 49 (64%), three times in 15 (20%) and more than three times in 12 (16%) patients. The median thrombin dose was 150 IU (80-250 IU), and was lower in initial procedures than repeated UGTI (p = 0.025). The median psA volume was 2.26 ml (0.86-5.47 ml). The median length of the communicating channel was 4 mm (0-12 mm). A time interval between vessel catheterization and UGTI greater than 7 days (p < 0.001), a late to early velocity index (LEVI) of < 0.2 identified during the outflow phase (p < 0.001), a psA volume > 5 ml (p = 0.032), and a short communicating channel between the psA and the artery (p = 0.037) predicted psA recurrence. Antiplatelet and anticoagulant agents did not increase the risk. CONCLUSIONS: The LEVI and time interval between artery cannulation and UGTI treatment are strong parameters identifying patients at risk of psA recurrence. The psA volume and communicating channel length are less substantial risks, but still significant. Concomitant antiplatelet and anticoagulant therapy do not affect the success rate of UGTI.

Ultrasound-guided thrombin injection as a preferable method of treatment for iatrogenic pseudoaneurysms after invasive cardiovascular procedures - a single-center experience.

INTRODUCTION: Arterial cannulation is inherently associated with a risk of vascular complications including pseudoaneurysm (psA) that are encountered in both radial and femoral artery access. Among various methods of treatment of pseudoaneurysm the most popular are: watchful waiting for a spontaneous resolution, ultrasound-guided compression, ultrasound-guided thrombin injection (UGTI) and surgical treatment. In many previous reports nonsurgical methods appeared to be effective in most cases. AIM: To evaluate the incidence, characteristics as well as treatment scheme of iatrogenic pseudoaneurysms in a single high-volume cardiovascular intervention center. MATERIAL AND METHODS: The study is a prospective analysis of femoral artery and radial artery pseudoaneurysm cases in a 6-year period (2015-2020) in Swietokrzyskie Cardiology Centre in Kielce, Poland. Analysis of baseline characteristics, treatment and outcomes of all pseudoaneurysm cases was performed. RESULTS: Among a total number of 7268 cardiovascular procedures, with 49.2% being of the radial approach, we diagnosed 113 cases of psA. Global prevalence of femoral artery pseudoaneurysm was 1.29% and that of radial artery pseudoaneurysm was 0.30%. Only 2 patients with femoral puncture were primarily qualified for surgical treatment due to large size of the pseudoaneurysm. The vast majority of patients underwent successful nonsurgical therapy with the major predominance of the UGTI procedure. Effectiveness of the first thrombin injection was as high as 90% in RPA and 85% in FPA, whereas all of the consecutive attempts were successful. CONCLUSIONS: UGTI is nowadays a very effective and safe method of iatrogenic pseudoaneurysm treatment that prevents further necessary surgical procedures.

Associations of changes in patient characteristics and management with decrease in mortality rates of men and women with ST-elevation myocardial infarction - a propensity score-matched analysis.

INTRODUCTION: The aim of this study is to estimate how much of the recent decrease in mortality among patients with myocardial infarction with ST-segment elevation (STEMI) can be attributed to improved treatment strategies, and how much it is related to changes in baseline clinical characteristics, and to compare these findings for men and women. MATERIAL AND METHODS: This was a retrospective analysis of 32,790 patients with STEMI from the Polish Registry of Acute Coronary Syndromes PL-ACS hospitalised in 2005 and 2011. Changes in treatment strategies including pharmacotherapy were analysed. Observed in-hospital and 12-month mortality rates were compared with the outcomes in the groups matched on the propensity scores. RESULTS: There was a substantial improvement in STEMI patient management between 2005 and 2011 in Poland. It included greater use of percutaneous coronary interventions and other guideline-based adjunctive therapies, and it was associated with a significant decline in in-hospital mortality. Relative 12-month mortality reduction rates were less pronounced and more related to changes in patients' clinical characteristics. Higher mortality risk reductions were observed in women and were driven by relatively more positive changes in their baseline risk profiles when compared to men. CONCLUSIONS: The progress in the treatment strategies has helped to achieve better survival rates in STEMI patients. However, the ongoing changes in clinical characteristics of patients also played an important role, especially in women. Clinicians should focus on modifiable risk factors and post-discharge management to possibly prolong the positive aspects of in-hospital efforts.

Clinical presentation and 3-year outcomes of patients with acute coronary syndromes and non-obstructive coronary arteries on angiography.

BACKGROUND: With the emerging interest in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA), there is a need to define an even broader group of patients with the syndrome of myocardial ischemia with non-obstructive coronary arteries (INOCA). There are limited data on the clinical characteristics and prognoses of such patients who present with symptoms of acute coronary syndrome (ACS) and undergo urgent coronary angiography that reveals no significant lesions. The aim of this observational study was to compare patients with ACS INOCA and those with ACS with obstructive coronary artery disease (OCAD) both within unadjusted cohorts and with propensity score matched controls. METHODS AND RESULTS: This observational study was based on the data from the Polish National Registry of Invasive Cardiology Procedures. Of 9744 patients included, 7624 had OCAD and 2120 had ACS INOCA. In unadjusted cohorts, the overall survival and incidence of major adverse cardiovascular events (MACE: death, cardiac arrest, myocardial infarction, stroke, and heart failure hospitalization) until 36 months were higher in patients with ACS OCAD. Following propensity matching, higher win ratios of death (p = 0.02), additional revascularizations by percutaneous coronary intervention or coronary artery bypass graft surgery (p<0.001), and cardiac hospitalization (p<0.001) were observed in these patients. In contrast, the win ratios of myocardial infarction (p = 0.74), heart failure hospitalization (p = 0.86), and MACE (p = 0.07) were not significantly different between the groups. CONCLUSIONS: The prognosis of patients with ACS INOCA was more favorable than that of patients with ACS OCAD; however, the differences diminished after adjustments for the initial clinical profiles. An ACS incident should not be judged as trivial even when cardiac markers remain stable and no significant lesions are found on angiography.

The progress in outcomes of the management of patients with non-ST-segment elevation myocardial infarction between 2005 and 2014 in Poland - a propensity score matching analysis from the PL-ACS registry.

INTRODUCTION: Dynamic changes both in clinical profile and treatment strategy of non ST-segment elevation myocardial infarction (NSTEMI) patients have been observed recently. The exact impact of them on prognosis in a wide national population remains unclear. AIM: To evaluate the impact of treatment advances between 2005 and 2014 on the outcomes of NSTEMI cases. MATERIAL AND METHODS: NSTEMI patients from the Polish Registry of Acute Coronary Syndromes (PL-ACS) were included to the analysis. The mortality rate in a hospital observation as well as in 12-month follow-up was evaluated. RESULTS: The frequency of diabetes, hypertension, prior coronary artery interventions (especially percutaneous coronary intervention) raised. A frequency of invasive procedures increased remarkably (coronary angiography from 35.8% to 90.7%; p < 0.05 and percutaneous coronary intervention from 25.7% to 63.6%; p < 0.05). The usage of P2Y12 - inhibitors raised substantially from 56% to 93%; p < 0.05. In-hospital mortality decreased by fifty percent (in women from 6.6% to 3.3%; p < 0.001 and in men from 4.9% to 2.5%; p < 0.001, respectively). Similarly, 12-month mortality decreased up to one third (in women from 21.6% to 15.1%; p < 0.001 and in men from 17.8% to 12.8%; p < 0.001, respectively). Invasive strategy appeared to be the strongest factor decreasing mortality. Into in-hospital observation it reduces triple mortality risk whereas in 12-month follow up twice. Using propensity score matching analysis the impact of the treatment improvements on relative risk reduction was estimated on over 60%. CONCLUSIONS: In last decade the outcomes of NSTEMI in Poland improved substantially. The predominant impact on it had a routine invasive strategy.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms.

OBJECTIVE: Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used "standard dose protocol" and the "low dose protocol," which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15 s) in patients with a psA with sac volume of ≥1 mL. METHODS: This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1 mL and qualified for UGTI. The patients' mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol. RESULTS: The overall success rate (99.2% vs. 98.4%; p = 1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p = .85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p = .03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p = .01). CONCLUSIONS: In patients with femoral psA with sac volume of ≥1 mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Global peak left atrial longitudinal strain assessed by transthoracic echocardiography is a good predictor of left atrial appendage thrombus in patients in sinus rhythm with heart failure and very low ejection fraction - an observational study.

BACKGROUND: Peak left atrial longitudinal strain (PALS) can help identify left atrial appendage thrombus (LAAT) in patients with atrial fibrillation. Nevertheless, few studies have been performed in patients in sinus rhythm without established indications for anticoagulation but with increased risk of LAAT, such as heart failure (HF) with severe left ventricular systolic dysfunction patients. The primary aim of this study was to identify clinical and transthoracic echocardiography predictors of LAAT in HF patients with very low left ventricular ejection fraction and sinus rhythm. The secondary objective was to analyze frequencies and predictors of a composite clinical endpoint of death or hospitalization for ischemic stroke. METHODS: We included 63 patients with HF, left ventricular ejection fraction < 25%, sinus rhythm at presentation, no history of atrial fibrillation, and without any established indications for anticoagulation. We determined whether clinical and transthoracic echocardiography parameters, including left atrial strain analysis, predicted LAAT. Transesophageal echocardiography was performed in all patients. When LAAT was detected, anticoagulation was recommended. The participants were followed for a median of 28.6 months (range 4-40) to determine the composite endpoint. RESULTS: LAAT was found in 20 (31.7%) patients. Global PALS was the best independent predictor of LAAT in univariate and multivariate logistic regression analyses (Gini coefficient 0.65, area under the receiver-operating characteristic curve 0.83). A global PALS value below 8% was a good discriminator of LAAT presence (odds ratio 30.4, 95% CI 7.2-128, p <  0.001). During follow-up, 18 subjects (28.6%) reached the composite clinical endpoint. CHA2DS2-VASc score, use of angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, and body surface area were significant predictors for the composite endpoint of death or hospitalization for ischemic stroke in the multivariate regression model. CONCLUSIONS: LAAT was relatively common in our group of HF patients and PALS has shown prognostic potential in LAAT identification. Further research is needed to determine whether initiation of anticoagulation or additional screening supported by PALS measurements will improve clinical outcomes in these patients.

Long-term clinical outcomes in patients with unstable angina undergoing percutaneous coronary interventions in a contemporary registry data from Poland.

BACKGROUND: Both unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) are still classified together in non-ST-elevation acute coronary syndromes despite the fact they substantially differ in both clinical profile and prognosis. The aim of the present study was to evaluate contemporary clinical characteristics and outcomes of unstable angina patients after percutaneous coronary intervention (PCI) in comparison with stable angina and NSTEMI in Swietokrzyskie District of Poland in years 2015-2017. METHODS: A total of 7187 patients after PCI from ORPKI Registry (38% with diagnosis of unstable angina) were included into the analysis. Impact of clinical presentation (unstable angina, stable angina, NSTEMI, STEMI) on three-year outcomes were determined. RESULTS: Unstable angina patients were older than stable angina but younger than NSTEMI individuals. In unstable angina group, the percentage of previous myocardial infarction (MI), PCI or coronary artery bypass grafting (CABG) was the highest among all analyzed groups. In three-year observation, the risk of death as well as MI and MACE in unstable angina after PCI was higher than stable angina angina but considerably lower than in the NSTEMI group. Multivariate analysis confirmed that prognosis in NSTEMI was substantially worse in comparison with unstable angina [relative risk (RR) 1.365, 95% confidence interval (CI): 1.126-1.655, P = 0.0015]. On the contrary in unstable angina and stable angina patients, the impact of diagnosis on mortality risk was similar (RR 1.189, 95% CI: 0.932-1.518, P = 0.1620). Parallel results were observed in respect of MI and MACE. Independent predictors of death or MACE were: age, kidney disease, hypertension, diabetes, previous stroke or previous PCI. CONCLUSION: Three-year prognosis in unstable angina was considerable better in comparison with NSTEMI. On the contrary, after adjustment for baseline differences, the outcomes (death, MI, MACE) in unstable angina and stable angina patients were comparable.

Survival benefit from recent changes in management of men and women with ST-segment elevation myocardial infarction treated with percutaneous coronary interventions.

BACKGROUND: Nowadays, the majority of patients with myocardial infarction with ST-segment elevation (STEMI) are treated with primary percutaneous coronary interventions (PCI). In recent years, there have been ongoing improvements in PCI techniques, devices and concomitant pharmacotherapy. However, reports on further mortality reduction among PCI-treated STEMI patients remain inconclusive. The aim of this study was to compare changes in management and mortality in PCI-treated STEMI patients between 2005 and 2011 in a real-life setting. METHODS: Data on 79,522 PCI-treated patients with STEMI from Polish Registry of Acute Coronary Syndromes (PL-ACS) admitted to Polish hospitals between 2005 and 2011 were analyzed. First, temporal trends of in-hospital management in men and women were presented. In the next step, patients from 2005 and 2011 were nearest neighbor matched on their propensity scores to compare in-hospital, 30-day and 1-year mortality rates and in-hospital management strategies and complications. RESULTS: Some significant changes were noted in hospital management including shortening of median times from admission to PCI, increased use of drug-eluting stents, potent antiplatelet agents but also less frequent use of statin, beta-blockers and angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. There was a strong tendency toward preforming additional PCI of non-infarct related arteries, especially in women. After propensity score adjustment there were significant changes in inhospital but not in 30-day or 1-year mortality rates between 2005 and 2011. The results were similar in men and women. CONCLUSIONS: There were apparent changes in management and significant in-hospital mortality reductions in PCI-treated STEMI patients between 2005 and 2011. However, it did not result in 30-day or 1-year survival benefit at a population level. There may be room for improvement in the use of guideline-recommended pharmacotherapy.

Left atrial longitudinal strain in dilated cardiomyopathy patients: is there a discrimination threshold for atrial fibrillation?

To determine the left atrial longitudinal strain discrimination threshold of atrial fibrillation (AF) in patients with dilated cardiomyopathy (DCM). A total of 100 DCM patients and LVEF < 25% were included. Of them, 50 had sinus rhythm (SR), and 50 had AF. Patients with significant valvular disease, cardiac pacemakers and prosthetic valves were excluded. Speckle tracking echocardiography was performed to visualize the inferior and lateral walls of the left atrium as well as the interatrial septum. The Q-Analysis software was used to assess left atrial contractile strain (εCT) during the atrial systole and left atrial conduit strain (εCD) during the atrial filling. In SR patients analysis was P-wave timed. In AF patients the reference point was at 200 ms before the QRS complex on the surface ECG. The εCD was significantly higher in SR patients than in those with AF (9.68% vs. 4.7%; p = 0.0003). ROC analysis demonstrated that εCD less than 5.43% (AUC 0.95; 95% CI 0.905-0.995; p < 0.0001) together with εCT below - 1.97% (AUC = 0.97; 95% CI 0.46-1.00; p < 0.0001) identified patients with AF. In patients with LVEF < 25% and AF left atrial contractile strain analysis is feasible. In these patients both contractile and conduit strain values are significantly lower than in patients with preserved SR, and εCD below 5.43% and εCT less than - 1.97% distinguish SR from AF patients with LVEF < 25%.

Trends in sex differences in clinical characteristics, treatment strategies, and mortality in patients with ST-elevation myocardial infarction in Poland from 2005 to 2011.

INTRODUCTION: During the last decade, there has been an increased awareness of sex differences in the clinical characteristics, management, and mortality in myocardial infarction. Many previous studies have found that women with ST-elevation myocardial infarction (STEMI) have a poorer baseline risk profile, are less intensively treated, and have worse outcomes. OBJECTIVE: To evaluate whether sex disparities in STEMI have changed in recent years. METHODS: This is a retrospective analysis of data on 111 148 STEMI patients enrolled in the Polish Registry of Acute Coronary Syndromes between 2005 and 2011. Temporal trends in the clinical presentation, treatment strategies, and mortality rates between men and women are compared. RESULTS: Throughout the study, women were, on average, older than men, and more frequently presented with hypertension, diabetes, or obesity. These differences showed a tendency for narrowing. The percentage of smokers increased in both sexes. Despite a reduction in prehospital delays, they remained longer in women. Sex differences in prehospital cardiac arrest and cardiogenic shock at admission disappeared. In 2011, women were still less likely to undergo coronary angiography with subsequent revascularization, but it was mainly driven by patients older than 70 years of age who also had a higher in-hospital mortality. Despite the greater relative risk reductions, the crude mortality rates remained significantly higher in women. Female sex was not an independent predictor of mortality. CONCLUSION: Sex differences in STEMI patients were narrowing from 2005 to 2011 in Poland. However, more attention needs to be focused on increasing smoking prevalence, the longer times from symptoms onset to hospital admission in women and the lower frequencies of the use of an invasive treatment strategy in older women, and their worse in-hospital outcomes.

[Risk factors and treatment of patients with ST-segment elevation myocardial infarction with cardiogenic shock].

Aim: To assess risk factors and prognosis in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS) in Poland. Methods: Data from The Polish Registry of Acute Coronary Syndromes (PL-ACS) were analysed in 2008-2012. A total of 57400 consecutive STEMI patients included. The results of treatment and prognosis of patients with and without CS were compared. An additional analysis of the prognosis of men and women with CS was performed. Results: There were 34.2% of women and 65.8% of men. CS was diagnosed in 3589 (6.3%) patients (females 7.3% vs. males 5.7%, p<0.003). In multivariate analysis CS was the strongest factor affecting both inhospital (OR 2.51; 95%CI 2.25-2.80; p<0.0001) and 12-month (OR 2.09; 95%CI 1.96-2.24; p<0.0001) mortality. The worst prognosis was associated with pulmonary edema, advanced age, left or right bundle branch block, atrial fibrillation, and anterior MI. An early invasive strategy up to six hours from the symptom onset were the only factors reducing in-hospital and 12-month mortality. Despite of high female ratio in the group with CS and higher mortality in the female group, the female sex did not influence the in-hospital prognosis. Conclusion: In spite of enormous progress in the treatment of STEMI cardiogenic shock remains an important complication affecting the in-hospital and long-term prognosis. A symptom onset-to-treatment time is the key element in the management of patients with CS. Proper diagnosis and management including wide interventional strategy implementation increase the survival chance. An intensive study on novel treatment modalities and on effective identification methods of patients at risk and are warranted.

Pregnancy after myocardial infarction and coronary artery bypass grafting - is it safe?

Pregnancy after myocardial infarction (MI) and coronary artery bypass grafting (CABG), although still rare, is slowly becoming a challenge in everyday clinical practice. In recent decades MI has been observed to occur more frequently in young women. Concurrently an increasing number of women decide to become pregnant at more advanced age. Although pregnancy after MI and CABG may be possible and safe, a multidisciplinary approach involving careful evaluation by the cardiac and obstetric team in each individual is mandatory. Two cases of pregnant women with a history of MI treated with CABG are presented and their management is discussed.