Publications by authors named "Malgorzata Lelonek"

67 Publications

Sacubitril/valsartan for heart failure with reduced ejection fraction: A first real-life observational study in Poland.

Adv Clin Exp Med 2021 Jan;30(1):67-75

Department of Invasive Cardiology, Center of Postgraduate Medical Education, Warszawa, Poland.

Background: Despite the progress in the treatment of heart failure with reduced ejection fraction (HFrEF), the prognosis remains unfavorable.

Objectives: To evaluate the effectiveness, tolerance and safety after one-year follow-up of Polish patients with stable chronic HFrEF treated with sacubitril/valsartan.

Material And Methods: This was an observational multicenter study conducted in 3 centers (Kraków, Łódź and Warszawa) specializing in heart failure (HF). We enrolled 89 HFrEF patients (aged 59.3 ±13.5 years, 82% males) in NYHA class II-IV (ambulatory). Clinical, laboratory and echocardiographic parameters were evaluated at baseline and after a one-year follow-up. The composite endpoint was defined as death or urgent HF hospitalization.

Results: After 1 year, 80% of patients used 50% or more of the target dose of sacubitril/valsartan. After a year of treatment, there were significant improvements of HF symptoms, N-terminal prohormone B-type natriuretic peptide (NT proBNP), ejection fraction (EF), and distance in six-minute walk test (6MWP) (all p < 0.001). Patients treated with the highest dose of sacubitril/valsartan exhibited the greatest benefits. The safety profile was favorable and consistent with that previously reported; however, therapy discontinuation due to side effects occurred in 11% of patients. The independent predictors for composite endpoint (n = 24, 26.9%) were history of HF hospitalization, tricuspid annular plane systolic excursion (TAPSE) and angiotensin-converting-enzyme inhibitor (ACEI)-naive patients.

Conclusions: Treatment of chronic HFrEF patients with sacubitril/valsartan is safe and is associated with significant clinical and objective improvement. The non-survivors had more advanced HF, so the initiation and uptitration of sacubitril/valsartan should be done early.
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http://dx.doi.org/10.17219/acem/128230DOI Listing
January 2021

Multicenter experiences with levosimendan therapy and its safety in patients with decompensated advanced heart failure.

Adv Clin Exp Med 2020 11;29(11):1305-1312

1st Department of Cardiology, Medical University of Gdańsk, Poland.

Background: Advanced heart failure (AdvHF) is associated with high morbidity and mortality. Patients with this clinical condition are potential candidates for heart transplantation or mechanical circulatory support. Initially, however, they are usually supported with inotropic drugs. Recent studies have suggested that levosimendan, independently of hemodynamic improvements, may lead to outcome benefits.

Objectives: To present clinical experiences concerning the indications, effectiveness, tolerance, and safety of levosimendan in the real-life therapy of patients with decompensated AdvHF in 3 cardiac centers in Poland.

Material And Methods: This is a prospective, observational, three-center study. Forty-nine patients with AdvHF admitted with decompensation were included (88% men, mean age 58 years, 65% ischemic etiology, left ventricular ejection fraction (LVEF) in median 20%) and followed up for an early (3 months) and prolonged period (1 year) after infusion of levosimendan. Patients were analyzed in relation to death.

Results: Levosimendan therapy was associated with reduced HF symptoms and signs, New York Heart Association (NYHA) class and level of B-type natriuretic peptide (BNP) at discharge. Five patients died during hospitalization, a further 10 during the three-month follow-up and 3 died during the next nine-month follow-up. During the three-month follow-up, 22 patients were re-hospitalized due to HF and in the next nine-month follow-up 8 were re-hospitalized. A multivariate analysis indicated the QRS duration at discharge (hazard ratio (HR) = 1.02; 95% confidence interval (95% CI) = 1.003-1.03; p = 0.018), high-sensitivity C-reactive protein (hsCRP) (HR = 1.01; 95% CI = 1.004-1.02; p = 0.002), and simultaneous dobutamine infusion (HR = 6.54; 95% CI = 1.4-30.5; p = 0.017) were independent risk factors for death in the one-year follow-up. There were no side effects leading to the interruption of the levosimendan infusion.

Conclusions: The use of levosimendan was safe and associated with clinical improvement and reduction in BNP level in AdvHF patients hospitalized due to HF decompensation, although the mortality and re-hospitalization rate during the one-year follow-up remains high.
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http://dx.doi.org/10.17219/acem/126301DOI Listing
November 2020

Heart failure with preserved ejection fraction after the PARAGON-HF trial results: current knowledge and future directions.

Kardiol Pol 2020 12 6;78(12):1199-1205. Epub 2020 Oct 6.

Heart failure with preserved ejection fraction (HFpEF) is an increasingly common condition, particularly in the context of the aging of the population. HFpEF is associated with high morbidity, mortality, and rate of heart failure rehospitalization as well as poor quality of life. Previous studies on HFpEF failed to reach a positive outcome. There is currently no approved treatment for HFpEF. The overall PARAGON‑HF trial population showed a 13% reduction in the primary endpoint (cardiovascular death and total heart failure hospitalizations) with sacubitril / valsartan treatment as compared with valsartan, which was of borderline statistical significance. Analyses of the secondary endpoints, including the clinical status, quality of life, and kidney function, imply that sacubitril / valsartan offers benefits compared with valsartan alone. The results of the PARAGON‑HF trial revealed that patients with HFpEF and particular clinical profiles (lower strata of ejection fraction below 57% and female sex), for whom no evidence‑based therapy is available, may benefit from treatment with sacubitril / valsartan. This review article summarizes opinions on the PARAGON‑HF results as well as a mechanistic discussion.
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http://dx.doi.org/10.33963/KP.15639DOI Listing
December 2020

Heart failure management in Polish medical centers during the coronavirus disease 2019 pandemic: results of a survey.

Kardiol Pol 2020 10 25;78(10):1035-1038. Epub 2020 Aug 25.

Department of Coronary Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland

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http://dx.doi.org/10.33963/KP.15584DOI Listing
October 2020

A curriculum for heart failure nurses: an expert opinion of the Section of Nursing and Medical Technicians and the Heart Failure Working Group of the Polish Cardiac Society.

Kardiol Pol 2020 06 2;78(6):647-652. Epub 2020 Jun 2.

Department of Coronary Disease and Heart Failure, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Kraków, Poland

The rates of mortality and morbidity due to heart failure (HF) are expected to significantly rise over the next 10 years owing to an ageing population and will be the highest of all rates pertaining to cardiovascular diseases. To face this rapidly progressing problem, that is, the increasing prevalence of HF and need for care of patients with this disease, an attempt was made to develop a curriculum targeted at HF nurses. The HF nurse, as a member of the therapeutic team, has to play an active role in monitoring patients' physical and mental condition, coordinating hospital care, planning intervention after discharge from the hospital, and involving the patient and / or his or her family in self‑care, effective cooperation, and communication with the therapeutic team. The curriculum was conceived to complement the knowledge of HF and improve HF nurses' educational skills. The proposed model of education, based on the guidelines of the European Society of Cardiology and led by trained educators, will enable clinicians to fully implement the principles of coordinated care and properly assess the effectiveness of educational interventions in patients with HF.
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http://dx.doi.org/10.33963/KP.15405DOI Listing
June 2020

Clinical characteristics and treatment profiles of patients after acute myocardial infarction with left ventricular ejection fraction below 40%: a short 2018-2019 report on the PL‑ACS registry.

Kardiol Pol 2020 08 19;78(7-8):766-769. Epub 2020 May 19.

3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Disease, Medical University of Silesia in Katowice, Zabrze, Poland; Department of Toxicology and Health Protection, School of Public Health in Bytom, Medical University of Silesia, Katowice, Poland

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http://dx.doi.org/10.33963/KP.15377DOI Listing
August 2020

The patient with heart failure in the face of the coronavirus disease 2019 pandemic: an expert opinion of the Heart Failure Working Group of the Polish Cardiac Society.

Kardiol Pol 2020 06 16;78(6):618-631. Epub 2020 May 16.

Department of HeartFailure and Transplantology, The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland.

Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), a new coronavirus that induces acute respiratory failure among other conditions, is the cause of the rapidly spreading coronavirus disease 2019 (COVID‑19), affecting thousands of people around the world. The present expert opinion is a synthetic summary of the current knowledge on the various aspects of heart failure in patients with COVID‑19. The aim of the paper was to provide clinicians with necessary information useful in daily clinical practice.
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http://dx.doi.org/10.33963/KP.15359DOI Listing
June 2020

Rare Case of Enormous Left Ventricular Pseudoaneurysm Complicating Transcatheter Aortic Valve Implantation.

Circ Cardiovasc Imaging 2020 05 6;13(5):e010263. Epub 2020 May 6.

Departments of Noninvasive Cardiology (M.K., M.L.), Medical University of Lodz, Poland.

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http://dx.doi.org/10.1161/CIRCIMAGING.119.010263DOI Listing
May 2020

Effects of Sacubitril-Valsartan Versus Valsartan in Women Compared With Men With Heart Failure and Preserved Ejection Fraction: Insights From PARAGON-HF.

Circulation 2020 02 17;141(5):338-351. Epub 2019 Nov 17.

Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.A.P., A.M.S., B.C., S.D.S.).

Background: Unlike heart failure with reduced ejection fraction, there is no approved treatment for heart failure with preserved ejection fraction, the predominant phenotype in women. Therefore, there is a greater heart failure therapeutic deficit in women compared with men.

Methods: In a prespecified subgroup analysis, we examined outcomes according to sex in the PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction), which compared sacubitril-valsartan and valsartan in patients with heart failure with preserved ejection fraction. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and death from cardiovascular causes. We also report secondary efficacy and safety outcomes.

Results: Overall, 2479 women (51.7%) and 2317 men (48.3%) were randomized. Women were older and had more obesity, less coronary disease, and lower estimated glomerular filtration rate and NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels than men. For the primary outcome, the rate ratio for sacubitril-valsartan versus valsartan was 0.73 (95% CI, 0.59-0.90) in women and 1.03 (95% CI, 0.84-1.25) in men ( interaction = 0.017). The benefit from sacubitril-valsartan was attributable to reduction in heart failure hospitalization. The improvement in New York Heart Association class and renal function with sacubitril-valsartan was similar in women and men, whereas the improvement in Kansas City Cardiomyopathy Questionnaire clinical summary score was less in women than in men. The difference in adverse events between sacubitril-valsartan and valsartan was similar in women and men.

Conclusions: As compared with valsartan, sacubitril-valsartan seemed to reduce the risk of heart failure hospitalization more in women than in men. Whereas the possible sex-related modification of the effect of treatment has several potential explanations, the present study does not provide a definite mechanistic basis for this finding.

Clinical Trial Registration: https://www.clinicaltrials.gov. Unique identifier: NCT01920711.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.044491DOI Listing
February 2020

Angiotensin receptor/neprilysin inhibitor-a breakthrough in chronic heart failure therapy: summary of subanalysis on PARADIGM-HF trial findings.

Heart Fail Rev 2020 05;25(3):393-402

Department of Noninvasive Cardiology, Medical University of Lodz, ul. Żeromskiego 113, 90-549, Lodz, Poland.

It is over 4 years since the Prospective Comparison of angiotensin receptor/neprilysin inhibitor (ARNI) with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial was published in New England Journal of Medicine. The PARADIGM-HF trial was the one that contributed to the official approval to use ARNI simultaneously with cardiac resynchronisation therapy (CRT) or implantable cardioverter-defibrillator (ICD) in patients who receive optimal medical treatment and still presented NYHA II-IV class symptoms according to the 2016 European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure. The aim of this article is to summarise current knowledge on the activity of ARNI in a selected group of patients with heart failure with reduced ejection fraction (HFrEF) based on a recent PARADIGM-HF subanalysis in the field of renal function in patients with and without chronic kidney disease, glycaemia control in patients with diabetes, ventricular arrhythmias and sudden cardiac death and health-related quality of life. This article includes also recently announced findings on the TRANSITION study which revealed that HFrEF therapy with ARNI might be safely initiated after an acute decompensated heart failure episode, including patients with heart failure de novo and ACEI/ARB naïve, both hospitalised or shortly after discharge, in contrary to the PARADIGM-HF trial, where patients had to be administered a stable dose of an ACEI/ARB equivalent to enalapril 10 mg a day for at least 4 weeks before the screening.
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http://dx.doi.org/10.1007/s10741-019-09879-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181555PMC
May 2020

Pregnant Women With Uncorrected Congenital Heart Disease: Heart Failure and Mortality.

JACC Heart Fail 2020 02 11;8(2):100-110. Epub 2019 Sep 11.

Erasmus Medical Center, Rotterdam, the Netherlands. Electronic address:

Objectives: The purpose of this work was to study maternal and fetal outcomes of women with uncorrected congenital heart disease (CHD).

Background: Globally, CHD is an important cause of maternal morbidity and mortality in women reaching reproductive stage. Data are lacking from larger cohorts of women with uncorrected CHD.

Methods: The 10-year data from the European Society of Cardiology EORP ROPAC (EURObservational Research Programme Registry of Pregnancy and Cardiac disease) registry of women with uncorrected CHD were analyzed.

Results: Of 5,739 pregnancies in 53 countries, 3,295 women had CHD, 1,059 of which were uncorrected cases. Of these, 41.4% were from emerging countries. There were marked differences between the cardiac defects in uncorrected cases versus those in corrected CHD cases with primary shunt lesions (44.7% vs. 32.4%, respectively), valvular abnormalities (33.5% vs. 12.6%, respectively), and Tetralogy of Fallot and pulmonary atresia (0.8% vs. 20.3%, respectively; p < 0.001). In patients with uncorrected CHD, 6.8% were in modified World Health Organization risk class IV, approximately 10% had pulmonary hypertension (PH), and 3% were cyanotic prior to pregnancy. Maternal mortality and heart failure (HF) in the women with uncorrected CHD were 0.7% and 8.7%, respectively. Eisenmenger syndrome was associated with a very high risk of cardiac events (65.5%), maternal mortality (10.3%), and HF (48.3%). Coming from an emerging country was associated with higher pre-pregnancy signs of HF, PH, and cyanosis (p < 0.001) and worse maternal and fetal outcomes, with a 3-fold higher rate of hospital admissions for cardiac events and intrauterine growth retardation (p < 0.001).

Conclusions: Marked differences between cardiac conditions in pregnant women with uncorrected CHD and those in corrected CHD were found, with a markedly worse outcome, particularly in women with Eisenmenger syndrome and from emerging countries.
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http://dx.doi.org/10.1016/j.jchf.2019.09.001DOI Listing
February 2020

Angiotensin-Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction.

N Engl J Med 2019 10 1;381(17):1609-1620. Epub 2019 Sep 1.

From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.).

Background: The angiotensin receptor-neprilysin inhibitor sacubitril-valsartan led to a reduced risk of hospitalization for heart failure or death from cardiovascular causes among patients with heart failure and reduced ejection fraction. The effect of angiotensin receptor-neprilysin inhibition in patients with heart failure with preserved ejection fraction is unclear.

Methods: We randomly assigned 4822 patients with New York Heart Association (NYHA) class II to IV heart failure, ejection fraction of 45% or higher, elevated level of natriuretic peptides, and structural heart disease to receive sacubitril-valsartan (target dose, 97 mg of sacubitril with 103 mg of valsartan twice daily) or valsartan (target dose, 160 mg twice daily). The primary outcome was a composite of total hospitalizations for heart failure and death from cardiovascular causes. Primary outcome components, secondary outcomes (including NYHA class change, worsening renal function, and change in Kansas City Cardiomyopathy Questionnaire [KCCQ] clinical summary score [scale, 0 to 100, with higher scores indicating fewer symptoms and physical limitations]), and safety were also assessed.

Results: There were 894 primary events in 526 patients in the sacubitril-valsartan group and 1009 primary events in 557 patients in the valsartan group (rate ratio, 0.87; 95% confidence interval [CI], 0.75 to 1.01; P = 0.06). The incidence of death from cardiovascular causes was 8.5% in the sacubitril-valsartan group and 8.9% in the valsartan group (hazard ratio, 0.95; 95% CI, 0.79 to 1.16); there were 690 and 797 total hospitalizations for heart failure, respectively (rate ratio, 0.85; 95% CI, 0.72 to 1.00). NYHA class improved in 15.0% of the patients in the sacubitril-valsartan group and in 12.6% of those in the valsartan group (odds ratio, 1.45; 95% CI, 1.13 to 1.86); renal function worsened in 1.4% and 2.7%, respectively (hazard ratio, 0.50; 95% CI, 0.33 to 0.77). The mean change in the KCCQ clinical summary score at 8 months was 1.0 point (95% CI, 0.0 to 2.1) higher in the sacubitril-valsartan group. Patients in the sacubitril-valsartan group had a higher incidence of hypotension and angioedema and a lower incidence of hyperkalemia. Among 12 prespecified subgroups, there was suggestion of heterogeneity with possible benefit with sacubitril-valsartan in patients with lower ejection fraction and in women.

Conclusions: Sacubitril-valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among patients with heart failure and an ejection fraction of 45% or higher. (Funded by Novartis; PARAGON-HF ClinicalTrials.gov number, NCT01920711.).
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http://dx.doi.org/10.1056/NEJMoa1908655DOI Listing
October 2019

Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study.

Eur J Heart Fail 2019 08 27;21(8):998-1007. Epub 2019 May 27.

Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain.

Aims: To assess tolerability and optimal time point for initiation of sacubitril/valsartan in patients stabilised after acute heart failure (AHF).

Methods And Results: TRANSITION was a randomised, multicentre, open-label study comparing two treatment initiation modalities of sacubitril/valsartan. Patients aged ≥ 18 years, hospitalised for AHF were stratified according to pre-admission use of renin-angiotensin-aldosterone system inhibitors and randomised (n = 1002) after stabilisation to initiate sacubitril/valsartan either ≥ 12-h pre-discharge or between Days 1-14 post-discharge. Starting dose (as per label) was 24/26 mg or 49/51 mg bid with up- or down-titration based on tolerability. The primary endpoint was the proportion of patients attaining 97/103 mg bid target dose after 10 weeks. Median time of first dose of sacubitril/valsartan from the day of discharge was Day -1 and Day +1 in the pre-discharge group and the post-discharge group, respectively. Comparable proportions of patients in the pre- and post-discharge initiation groups met the primary endpoint [45.4% vs. 50.7%; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.79-1.02]. The proportion of patients who achieved and maintained for ≥ 2 weeks leading to Week 10, either 49/51 or 97/103 mg bid was 62.1% vs. 68.5% (RR 0.91; 95% CI 0.83-0.99); or any dose was 86.0% vs. 89.6% (RR 0.96; 95% CI 0.92-1.01). Discontinuation due to adverse events occurred in 7.3% vs. 4.9% of patients (RR 1.49; 95% CI 0.90-2.46).

Conclusions: Initiation of sacubitril/valsartan in a wide range of heart failure with reduced ejection fraction patients stabilised after an AHF event, either in hospital or shortly after discharge, is feasible with about half of the patients achieving target dose within 10 weeks.

Clinical Trial Registration: ClinicalTrials.gov ID: NCT02661217.
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http://dx.doi.org/10.1002/ejhf.1498DOI Listing
August 2019

The journey of the heart failure patient, based on data from a single center.

Adv Clin Exp Med 2019 Apr;28(4):489-498

Department of Noninvasive Cardiology, Chair of Internal Medicine and Cardiology, Medical University of Lodz, Poland.

Background: Care for patients with heart failure (HF) in Poland requires improvement.

Objectives: The aim of this study was to define the journey of the HF patient, taking into account the specialization of the hospital ward and further, highly specialized outpatient care.

Material And Methods: Using the medical system CliniNET®, we analyzed 214 consecutive patients hospitalized due to HF (International Statistical Classification of Diseases and Health Related Problems - ICD-10: I50) in the period from September 1 to December 31, 2015, and also the data from post-discharge outpatient care in a 3-month period. To fairly compare the management of care and outcomes of patients hospitalized in the internal medicine (IM) ward and in the cardiac ward, propensity score matching was performed. The multivariate regression analysis was performed to determine the independent predictors of the hospital ward selection and the risk of rehospitalization due to HF and/or death.

Results: The majority of patients were hospitalized due to HF for the first time (72%) and in the cardiac ward (65%). For 55% of rehospitalized patients, the subsequent admission was within 3 months after initial discharge. The independent predictors of a higher risk of rehospitalization due to HF and/or death were ischemic heart disease, atrial fibrillation (AF), chronic kidney disease (CKD), mineralocorticoid antagonism (MRA) therapy, and hospitalization in the last year (for all, p < 0.05). Internal medicine ward patients differed from cardiac ward patients in: mode of admission (urgent 100% vs 83.5%; p < 0.001), length of hospitalization (median: 8 days vs 5 days; p = 0.001), death rate (24% vs 4.3%; p < 0.001), echocardiography (43% vs 98%; p < 0.001), and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) measurements (43% vs 96%; p < 0.001). The burden of 5-9 accompanying diseases enhanced the choice of the cardiac ward (p < 0.05), while age and urgent mode of hospitalization decreased the chance of being referred to the cardiac ward (p < 0.01). Cardiac patients were more likely to receive β-blockers, diuretics, angiotensin receptor blockers (ARB), and MRA. Over 90% of cardiac ward patients were referred to cardiac ambulatory care after discharge from hospital, while among patients discharged from the IM ward, this rate was 60% (p < 0.001).

Conclusions: There were significant differences among the 2 wards in relation to the course of hospitalization and post-discharge outpatient care.
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http://dx.doi.org/10.17219/acem/78688DOI Listing
April 2019

Baseline Characteristics of Patients With Heart Failure and Preserved Ejection Fraction in the PARAGON-HF Trial.

Circ Heart Fail 2018 07;11(7):e004962

British Heart Foundation Cardiovascular Research Centre (J.J.V.M.).

Background: To describe the baseline characteristics of patients with heart failure and preserved left ventricular ejection fraction enrolled in the PARAGON-HF trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in HFpEF) comparing sacubitril/valsartan to valsartan in reducing morbidity and mortality.

Methods And Results: We report key demographic, clinical, and laboratory findings, and baseline therapies, of 4822 patients randomized in PARAGON-HF, grouped by factors that influence criteria for study inclusion. We further compared baseline characteristics of patients enrolled in PARAGON-HF with those patients enrolled in other recent trials of heart failure with preserved ejection fraction (HFpEF). Among patients enrolled from various regions (16% Asia-Pacific, 37% Central Europe, 7% Latin America, 12% North America, 28% Western Europe), the mean age of patients enrolled in PARAGON-HF was 72.7±8.4 years, 52% of patients were female, and mean left ventricular ejection fraction was 57.5%, similar to other trials of HFpEF. Most patients were in New York Heart Association class II, and 38% had ≥1 hospitalizations for heart failure within the previous 9 months. Diabetes mellitus (43%) and chronic kidney disease (47%) were more prevalent than in previous trials of HFpEF. Many patients were prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (85%), β-blockers (80%), calcium channel blockers (36%), and mineralocorticoid receptor antagonists (24%). As specified in the protocol, virtually all patients were on diuretics, had elevated plasma concentrations of N-terminal pro-B-type natriuretic peptide (median, 911 pg/mL; interquartile range, 464-1610), and structural heart disease.

Conclusions: PARAGON-HF represents a contemporary group of patients with HFpEF with similar age and sex distribution compared with prior HFpEF trials but higher prevalence of comorbidities. These findings provide insights into the impact of inclusion criteria on, and regional variation in, HFpEF patient characteristics.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01920711.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.118.004962DOI Listing
July 2018

Initial clinical experience with the first drug (sacubitril/valsartan) in a new class - angiotensin receptor neprilysin inhibitors in patients with heart failure with reduced left ventricular ejection fraction in Poland.

Kardiol Pol 2018 1;76(2):381-387. Epub 2017 Dec 1.

1st Department of Cardiology, University of Medical Sciences, Poznan, Poland.

Background: Sacubitril/valsartan is the first drug from a new class of angiotensin receptor neprilysin inhibitors (ARNIs) recommended in the new European Society of Cardiology guidelines instead of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) that are used if ACEI are not tolerated. Sacubitril/valsartan is recommended for further reduction in the risk of hospitalisation or death in outpatients with heart failure with reduced ejection fraction (HFrEF) if symptoms continue despite optimal treatment with ACEI/ARB, beta-blockers, and mineralocorticoid antagonists.

Aim: The aim of this study is to present the initial experience with regard to the effectiveness, tolerance, and safety of sacubitril/valsartan in the outpatient cardiology practice in Poland.

Methods: The study is a retrospective analysis of data obtained through a questionnaire filled in by the physicians who initiated the sacubitril/valsartan treatment in patients with HFrEF between 1 June 2016 and 30 September 2016. Patients were followed-up for three months.

Results: The analysis included data on 28 patients aged 61 ± 16 years, of whom 85.7% were males. The drug was used in patients in New York Heart Association (NYHA) class I-III. In 25 (89.2%) patients sacubitril/valsartan was started at the lowest dose (24/26 mg BID). During follow-up the sacubitril/valsartan-treated patients had a reduction in HF symptoms assessed using the NYHA functional class (p = 0.001), a significant drop in N-terminal-pro B-type natriuretic peptide levels (mean, from 2900 to 2270 pg/mL; p = 0.008), and improved exercise tolerance, which occurred shortly after treatment initiation - after a mean of 28 days.

Conclusions: It was demonstrated that the use of sacubitril/valsartan in outpatients with HFrEF is safe and is associated with a significant clinical improvement.
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http://dx.doi.org/10.5603/KP.a2017.0230DOI Listing
December 2018

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease.

Heart 2018 05 1;104(9):745-752. Epub 2017 Nov 1.

Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.

Objective: Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease.

Methods: The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient-centre-country).

Results: A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate.

Conclusion: While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome.
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http://dx.doi.org/10.1136/heartjnl-2017-311910DOI Listing
May 2018

Soluble ST2 protein and hospitalizations due to worsening chronic heart failure during a one-year follow-up in a population with reduced ejection fraction.

Adv Clin Exp Med 2017 Sep;26(6):931-938

Department of Noninvasive Cardiology, Medical University of Lodz, Poland.

Background: Hospitalizations due to worsening chronic heart failure (CHF) are common. However, the relationship between a single measurement of soluble ST2 protein (sST2) and the necessity of hospitalization in CHF is still unclear.

Objectives: The aim of this study was to determine the association between a single measurement of sST2 concentration and hospitalizations due to worsening CHF during a one-year follow-up.

Material And Methods: The study involved 167 consecutive patients (mean age 63 years, 83% males) with CHF in stable NYHA classes I-III with left ventricular ejection fraction (LVEF) ≤ 45% (median 29.65%, range 13-45%). Fifty-six variables were analyzed (clinical factors, basic laboratory results on admission, standard 12-lead ECG, echocardiography and coronary arteriography results). Information about hospitalizations due to worsening CHF was obtained during telephone interviews conducted 12 months after discharge from the cardiac ward. In order to define factors associated with hospitalization, uniand multivariate regression analyses were performed.

Results: A total of 53 patients from the study group (38%) were hospitalized due to worsening CHF. They included a higher percentage of males (p = 0.042), higher concentrations of sST2 (p = 0.049), and glucose (p = 0.010). The multivariate analysis (for model χ2 = 17.235; p < 0.001) revealed that glucose and sST2 were independently associated with hospitalization due to worsening CHF during the 1-year observation (p < 0.001).

Conclusions: In patients with stable mild to moderate CHF with reduced EF, a single measurement of sST2 protein and glucose were independent variables for hospitalization due to worsening CHF over a 1-year follow-up period. The defined prognostic model including sST2 and fasting glucose better identified patients without HF-related hospitalizations.
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http://dx.doi.org/10.17219/acem/63005DOI Listing
September 2017

The need to apply the best therapy in heart failure - the era after PARADIGM-HF.

Arch Med Sci 2017 Aug 5;13(5):1244-1248. Epub 2016 May 5.

Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland.

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http://dx.doi.org/10.5114/aoms.2016.59711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575206PMC
August 2017

Adherence to the guidelines on the management of systolic heart failure in ambulatory care in Poland. Data from the international QUALIFY survey.

Pol Arch Intern Med 2017 10 8;127(10):657-665. Epub 2017 Aug 8.

INTRODUCTION    Adherence to guidelines is associated with improved patient prognosis. OBJECTIVES    The aim of this study was to evaluate adherence to guidelines on the management of heart failure (HF) in ambulatory care in Poland. PATIENTS AND METHODS    The study included 209 outpatients with HF who participated in the prospective, observational QUALIFY survey. The inclusion criteria were as follows: age of 18 years or older, systolic HF with left ventricular ejection fraction of 40% or lower, and hospitalization for HF exacerbation within the previous 1 to 15 months. We assessed prescription of medications for HF and dose selection (classified as a target dose or as 50% or more of the target dose). The adherence score was calculated on the basis of the use of angiotensin‑converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β‑blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine. The use of all indicated medications was scored as good adherence; of more than half of the medications, as moderate adherence; and of half of the medications or fewer, as poor adherence.  RESULTS    The mean (SD) age of the patients was 67.4 (10.9) years; men constituted 77.0% of the population. Almost 92.0% of the patients were prescribed ACEIs or ARBs, of whom only 27.4% and 4.0%, respectively, reached the target doses. Nearly 97.0% of the patients received β‑blockers, with only 17.7% reaching the target dose. MRAs were prescribed in 73.2% of the patients, of whom 66.0% reached the target dose. Ivabradine was prescribed in 13.9% of the patients, but the target dose was attained only in 13.8%. The adherence was good in 72.2%, moderate in 23.9%, and poor in 3.8% of the study population. CONCLUSIONS    Most patients with HF in Poland receive adequate treatment, but the proportion of patients reaching the target doses is suboptimal.
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http://dx.doi.org/10.20452/pamw.4083DOI Listing
October 2017

Diagnostic utility of biomarkers of left ventricular stress in patients with aortic stenosis and preserved left ventricular ejection fraction.

Kardiochir Torakochirurgia Pol 2017 Jun 30;14(2):93-98. Epub 2017 Jun 30.

Department of Noninvasive Cardiology, Medical University of Lodz, Poland.

Introduction: Aortic stenosis (AS) is the most common acquired valvular heart disease. The early identification of patients with severe AS is crucial. NT-proBNP is a well-known biomarker of pressure overload, and its role in patients with AS has been demonstrated in previous studies. Another, less well-known biomarker of pressure overload is sST2 protein, and its role in AS is unclear.

Aim: To evaluate the utility of sST2 protein, NT-proBNP and selected clinical parameters in the assessment of degenerative AS severity in a population with preserved left ventricular ejection fraction (LVEF).

Material And Methods: Sixty-nine consecutive patients (mean age: 68.42 ±12.58 years, 55.07% male) with symptomatic degenerative AS and preserved LVEF ≥ 45% were prospectively included. At enrollment complete transthoracic echocardiographic examination, ECG analysis, and standard laboratory tests including NT-proBNP were performed and blood samples for sST2 were obtained.

Results: There were 43 (62.32%) patients with severe AS. The multivariate stepwise linear regression models revealed that only systolic blood pressure (SBP), Sokolow-Lyon index and left ventricular end-diastolic diameter (LVEDD) were independently associated with severe AS. Spearman correlation coefficients analysis showed no correlations between sST2 levels and a mild to moderate correlation between NT-proBNP concentration and parameters of AS severity. However, levels of NT-proBNP ( = 0.1857) and sST2 ( = 0.7851) did not differentiate patients according to severity of AS.

Conclusions: In the study population with degenerative AS and preserved LVEF neither the NT-proBNP nor sST2 concentrations can be used to differentiate patients according to the severity of AS.
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http://dx.doi.org/10.5114/kitp.2017.68737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5519833PMC
June 2017

Annual prognostic factors in chronic heart failure in patients over 80 years old.

Kardiol Pol 2017 7;75(2):164-173. Epub 2016 Oct 7.

Chair of Cardiology, Cardiac Surgery and Vascular Diseases Medical University of Lodz.

Background: In the elderly the most common cause of hospitalisation and the leading cause of death is heart failure (HF).

Aim: The purpose was to determine prognostic factors in chronic HF (CHF) in octogenarians and nonagenarians.

Methods: The analysis included 197 consecutive patients over 80 years old (mean age 83.63 ± 3.01 years; 46.19% men) hospitalised in 2010-2013 due to CHF. Sixty-two parameters were investigated, such as: age, gender, New York Heart Asso-ciation functional class, body mass index, blood pressure, other comorbidities, the parameters of the 12-lead resting electro-cardiography and the echocardiography, the results of basic laboratory tests, and selected biomarkers, including N-terminal pro-B-type natriuretic peptide, high-sensitive troponin T (hs-TnT), and high-sensitive C-reactive protein. Participants remained in a prospective follow-up for 12 months. We defined the primary endpoint as death due to cardiovascular causes and the composite endpoint, which consisted of: death due to cardiovascular causes and/or hospitalisation for exacerbation of CHF. Follow-up concerning the deaths was performed in 189 patients, composite endpoint in 168 and hospitalisation in 166. The uni- and multivariate logistic regression stepwise analysis was performed for the entire population, according to left ventricular ejection fraction (LVEF < 45% and ≥ 45%) and in the group with glomerular filtration rate (GFR) < 60 mL/min.

Results: Patients who died constituted 11.1% of the study population (21/189). In multivariate analysis four variables were independently associated with the primary endpoint: GFR (OR = 0.92), hypertension (OR = 0.19), lung diseases (OR = 9.36), and vascular diseases (OR = 6.07). In turn, in the group of patients who reached the composite endpoint (55/168; 32.7%), the only statistically significant independent variable was anaemia (OR = 4.71). In the subpopulation of patients with LVEF < 45% the prognostics for each endpoint were vascular diseases and lung diseases, and they increased the risk from 10- to 24-fold. In the subgroup of patients with LVEF ≥ 45% the independent variable associated with the composite endpoint was haemoglobin (OR = 0.61), in turn for death the prognostics were: white blood cell count, hs-TnT, and vascular diseases (respectively OR = 1.30; OR = 1.04; OR = 3.96). In the population with GFR < 60 mL/min variables with prognostic importance for the composite endpoint were red blood cell parameters: red blood cell distribution width (OR = 1.42) and anaemia (OR = 3.79), while for occurrence of death they were the same as for the entire population - vascular (OR = 5.16) and lung diseases (OR = 4.72).

Conclusions: In patients over 80 years old with CHF, comorbidities are of important prognostic value for annual prognosis. The most aggravating factor in studied subgroups was lung disease.
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http://dx.doi.org/10.5603/KP.a2016.0132DOI Listing
July 2017

Thirty-year risk of cardiovascular disease in senior medical students - based on the StudHeart study.

Kardiochir Torakochirurgia Pol 2016 Jun 30;13(2):172-7. Epub 2016 Jun 30.

Department of Cardiology, Chair of Cardiology and Cardiac Surgery, Medical University of Lodz, Poland.

Introduction: Long-term risk functions highlight the need of prophylaxis in youth before the first symptoms of cardiovascular disease (CVD) occur.

Aim: On the basis of data obtained in the StudHeart study, the aim of this report was to evaluate the 30-year risk of CVD based on the risk scale developed by the Framingham Heart Study (FHS).

Material And Methods: Seven hundred and one students aged 22-27 (mean age: 24 ±1.42) from the 5(th) and 6(th) year of the medical faculties of the Medical University of Lodz were included in the study. The StudHeart study was based on an anonymous survey comprising 12 questions. Based on the answers the authors evaluated the 30-year risk of CVD in each respondent using an on-line calculator that allows one to evaluate: general CVD risk including coronary death, myocardial infarction, coronary insufficiency, angina, ischemic stroke, hemorrhagic stroke, transient ischemic attack, peripheral artery disease, heart failure and hard CVD risk including coronary death, myocardial infarction and stroke.

Results: Elevated general 30-year CVD risk occurred in 23.18% of students, while hard CVD risk was elevated in 16.91% of respondents. In both cases elevated risk occurred more often in men (general CVD risk: 43.46% male vs. 8.93% female, p < 0.001 and hard CVD risk: 29.33% male vs. 8.19% female, p < 0.001). Elevation of the risk was mainly caused by overweight, obesity and smoking cigarettes.

Conclusions: Based on FHS 30-Year CVD risk, elevated risk occurred in almost one-fourth of students. Prophylactic actions should be performed, especially in men.
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http://dx.doi.org/10.5114/kitp.2016.61059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971280PMC
June 2016

Fludrocortisone for the Prevention of Vasovagal Syncope: A Randomized, Placebo-Controlled Trial.

J Am Coll Cardiol 2016 07;68(1):1-9

Division of Cardiology, Department of Cardiac Sciences, University of Calgary, Calgary, Canada.

Background: There is limited evidence whether being on fludrocortisone prevents vasovagal syncope.

Objectives: The authors sought to determine whether treatment with fludrocortisone reduces the proportion of patients with recurrent vasovagal syncope by at least 40%, representing a pre-specified minimal clinically important relative risk reduction.

Methods: The multicenter POST 2 (Prevention of Syncope Trial 2) was a randomized, placebo-controlled, double-blind trial that assessed the effects of fludrocortisone in vasovagal syncope over a 1-year treatment period. All patients had >2 syncopal spells and a Calgary Syncope Symptom Score >-3. Patients received either fludrocortisone or matching placebo at highest tolerated doses from 0.05 mg to 0.2 mg daily. The main outcome measure was the first recurrence of syncope.

Results: The authors randomized 210 patients (71% female, median age 30 years) with a median 15 syncopal spells over a median of 9 years equally to fludrocortisone or placebo. Of these, 96 patients had ≥1 syncope recurrences, and only 14 patients were lost to follow-up before syncope recurrence. There was a marginally nonsignificant reduction in syncope in the fludrocortisone group (hazard ratio [HR]: 0.69: 95% confidence interval [CI]: 0.46 to 1.03; p = 0.069). In a multivariable model, fludrocortisone significantly reduced the likelihood of syncope (HR: 0.63; 95% CI: 0.42 to 0.94; p = 0.024). When the analysis was restricted to outcomes after 2 weeks of dose stabilization, there was a significant benefit due to fludrocortisone (HR: 0.51; 95% CI: 0.28 to 0.89; p = 0.019).

Conclusions: The study did not meet its primary objective of demonstrating that fludrocortisone reduced the likelihood of vasovagal syncope by the specified risk reduction of 40%. The study demonstrated a significant effect after dose stabilization, and there were significant findings in post hoc multivariable and on-treatment analyses. (A randomised clinical trial of fludrocortisone for the prevention of vasovagal syncope; ISRCTN51802652; Prevention of Syncope Trial 2 [POST 2]; NCT00118482).
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http://dx.doi.org/10.1016/j.jacc.2016.04.030DOI Listing
July 2016

Factors affecting the quality of anticoagulation with warfarin: experience of one cardiac centre.

Kardiochir Torakochirurgia Pol 2015 Dec 30;12(4):334-40. Epub 2015 Dec 30.

Department of Cardiology, Medical University of Lodz, Lodz, Poland.

Introduction: The risk of complications in anticoagulation therapy can be reduced by maximising the percentage of time spent by the patient in the optimal therapeutic range (TTR). However, little is known about the predictors of anticoagulation control. The aim of this paper was to assess the quality of anticoagulant therapy in patients on warfarin and to identify the factors affecting its deterioration.

Material And Methods: We studied 149 patients who required anticoagulant therapy with warfarin due to non-valvular atrial fibrillation and/or venous thromboembolism. Each patient underwent proper training regarding the implemented treatment and remained under constant medical care.

Results: The mean age of the patients was 68.8 ± 12.6 years, and 59% were male. A total of 2460 international normalised ratio (INR) measurements were collected during the 18-month period. The mean TTR in the studied cohort was 76 ± 21%, and the median was 80%. The level at which high-quality anticoagulation was recorded for this study was based on TTR values above 80%. Seventy-five patients with TTR ≥ 80% were included in the stable anticoagulation group (TTR ≥ 80%); the remaining 74 patients constituted the unstable anticoagulation group (TTR < 80%). According to multivariate stepwise regression analysis, the independent variables increasing the risk of deterioration of anticoagulation quality were: arterial hypertension (OR 2.74 [CI 95%: 1.06-7.10]; p = 0.038), amiodarone therapy (OR 4.22 [CI 95%: 1.30-13.70]; p = 0.017), and obesity (OR 1.11 [CI 95%: 1.02-1.21]; p = 0.013).

Conclusions: The presence of obesity, hypertension, or amiodarone therapy decreases the quality of anticoagulation with warfarin. High quality of anticoagulation can be achieved through proper monitoring and education of patients.
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http://dx.doi.org/10.5114/kitp.2015.56784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4735535PMC
December 2015

EuroSCORE II does not show better accuracy nor predictive power in comparison to original EuroSCORE: a single-centre study.

Kardiol Pol 2016;74(5):469-475. Epub 2015 Nov 17.

Medical University of Lodz, Department of Cardiology, Chair of Cardiology and Cardiac Surgery.

Background: EuroSCORE is used to predict postoperative mortality in patients undergoing cardiac surgery. Its updated version was published in 2011.

Aim: To assess whether EuroSCORE II (ESII) predicts more accurately postoperative mortality after cardiac surgery in comparison with additive (addES) and logistic EuroSCORE (logES).

Methods: A total of 461 patients (aged 21-88 years, 63.4% of men) who underwent cardiac surgery (December 2010 - June 2011) were included into the prospective research. For each patient ESII, addES and logES were calculated. Accuracy, calibration, and clinical performance of these models were assessed with receiver operating characteristics analyses using the area under the curve and the Hosmer-Lemeshow test. Out of this population, a group of 300 coronary artery bypass grafting (CABG) patients (aged 42-85 years, 73% of men) was selected and statistically analysed using the same methods.

Results: The mortality rate was 5.21%. Predicted mortality rates were as follows: addES 4.68%, logES 4.57%, and ESII 1.89%; the accuracy was: 0.589, 0.728, and 0.726, respectively. Only logES presented good predictive power (Hosmer-Lemeshow test: c2 = 12.79, p = 0.12). In the CABG patients, the postoperative mortality rate was 5.33%. Predicted mortality rates were as follows: addES 4.69%, logES 4.59%, and ESII 1.88%; the accuracy was: 0.512, 0.691, and 0.687, respectively. In the Hosmer-Lemeshow test also logES presented good predictive power (c2 = 10.72, p = 0.218).

Conclusions: EuroSCORE II did not estimate mortality risk better in comparison to its previous versions, in the entire studied population or in the CABG patients. On the basis of the analysed data, it seems that the closest to the actual risk of death for the Polish population is the EuroSCORE logistic model.
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http://dx.doi.org/10.5603/KP.a2015.0215DOI Listing
April 2017