Publications by authors named "Monika Budnik"

58 Publications

Impact of Atrial Fibrillation on Outcome in Takotsubo Syndrome: Data From the International Takotsubo Registry.

J Am Heart Assoc 2021 Aug 28;10(15):e014059. Epub 2021 Jul 28.

Department of Cardiology Intensive Care Medicine and Angiology Vincentius-Diakonissen-Hospital Karlsruhe Germany.

Background Atrial fibrillation (AF) is a major risk factor for mortality. The prevalence, clinical correlates, and prognostic impact of AF in Takotsubo syndrome (TTS) have not yet been investigated in a large patient cohort. This study aimed to investigate the prevalence, clinical correlates, and prognostic impact of AF in patients with TTS. Methods and Results Patients with TTS were enrolled from the International Takotsubo Registry, which is a multinational network with 26 participating centers in Europe and the United States. Patients were dichotomized according to the presence or absence of AF at the time of admission. Of 1584 patients with TTS, 112 (7.1%) had AF. The mean age was higher (<0.001), and there were fewer women (=0.046) in the AF than in the non-AF group. Left ventricular ejection fraction was significantly lower (=0.001), and cardiogenic shock was more often observed (<0.001) in the AF group. Both in-hospital (<0.001) and long-term mortality (<0.001) were higher in the AF group. Multivariable Cox regression analysis revealed that AF was independently associated with higher long-term mortality (hazard ratio, 2.31; 95% CI, 1.50-3.55; <0.001). Among patients with AF on admission, 42% had no known history of AF before the acute TTS event, and such patients had comparable in-hospital and long-term outcomes compared with those with a history of AF. Conclusions In patients presenting with TTS, AF on admission is significantly associated with increased in-hospital and long-term mortality rates. Whether antiarrhythmics and/or cardioversion are beneficial in TTS with AF should thus be tested in a future trial. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01947621.
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http://dx.doi.org/10.1161/JAHA.119.014059DOI Listing
August 2021

Ethnic comparison in takotsubo syndrome: novel insights from the International Takotsubo Registry.

Clin Res Cardiol 2021 May 19. Epub 2021 May 19.

Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.

Background: Ethnic disparities have been reported in cardiovascular disease. However, ethnic disparities in takotsubo syndrome (TTS) remain elusive. This study assessed differences in clinical characteristics between Japanese and European TTS patients and determined the impact of ethnicity on in-hospital outcomes.

Methods: TTS patients in Japan were enrolled from 10 hospitals and TTS patients in Europe were enrolled from 32 hospitals participating in the International Takotsubo Registry. Clinical characteristics and in-hospital outcomes were compared between Japanese and European patients.

Results: A total of 503 Japanese and 1670 European patients were included. Japanese patients were older (72.6 ± 11.4 years vs. 68.0 ± 12.0 years; p < 0.001) and more likely to be male (18.5 vs. 8.4%; p < 0.001) than European TTS patients. Physical triggering factors were more common (45.5 vs. 32.0%; p < 0.001), and emotional triggers less common (17.5 vs. 31.5%; p < 0.001), in Japanese patients than in European patients. Japanese patients were more likely to experience cardiogenic shock during the acute phase (15.5 vs. 9.0%; p < 0.001) and had a higher in-hospital mortality (8.2 vs. 3.2%; p < 0.001). However, ethnicity itself did not appear to have an impact on in-hospital mortality. Machine learning approach revealed that the presence of physical stressors was the most important prognostic factor in both Japanese and European TTS patients.

Conclusion: Differences in clinical characteristics and in-hospital outcomes between Japanese and European TTS patients exist. Ethnicity does not impact the outcome in TTS patients. The worse in-hospital outcome in Japanese patients, is mainly driven by the higher prevalence of physical triggers.

Trial Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT01947621.
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http://dx.doi.org/10.1007/s00392-021-01857-4DOI Listing
May 2021

Giant right atrial tumor in three-dimensional echocardiographic imaging.

Kardiol Pol 2021 20;79(6):714-715. Epub 2021 May 20.

1st Chair and Department of Cardiology, Medical University of Warsaw, Warszawa, Poland.

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http://dx.doi.org/10.33963/KP.15963DOI Listing
July 2021

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry.

J Clin Med 2021 Mar 24;10(7). Epub 2021 Mar 24.

1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland.

Background: We aimed to assess characteristics and treatment of AF patients with and without heart failure (HF).

Methods: The prospective, observational Polish Atrial Fibrillation (POL-AF) Registry included consecutive patients with AF hospitalized in 10 Polish cardiology centers in 2019-2020.

Results: Among 3999 AF patients, 2822 (71%) had HF (AF/HF group). Half of AF/HF patients had preserved ejection fraction (HFpEF). Compared to patients without HF (AF/non-HF), AF/HF patients were older, more often male, more often had permanent AF, and had more comorbidities. Of AF/HF patients, 98% had class I indications to oral anticoagulation (OAC). Still, 16% of patients were not treated with OAC at hospital admission, and 9%-at discharge (regardless of the presence of HF and its subtypes). Of patients not receiving OAC upon admission, 61% were prescribed OAC (most often apixaban) at discharge. AF/non-HF patients more often converted from AF at admission to sinus rhythm at discharge compared to AF/HF patients (55% vs. 30%), despite cardioversion performed as often in both groups. Class I antiarrhythmics were more often prescribed in AF/non-HF than in AF/HF group (13% vs. 8%), but still as many as 15% of HFpEF patients received them.

Conclusions: Over 70% of hospitalized AF patients have coexisting HF. A significant number of AF patients does not receive the recommended OAC.
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http://dx.doi.org/10.3390/jcm10071341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8036873PMC
March 2021

Transparency of TEE3D surface rendering helps to assess the scale of hidden disaster.

Echocardiography 2021 05 28;38(5):726-728. Epub 2021 Mar 28.

1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.

Presented case illustrates additional value of applying a new visualization technique - 3D Surface Rendering during the three-dimensional echocardiography.
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http://dx.doi.org/10.1111/echo.15036DOI Listing
May 2021

Prognostic impact of acute pulmonary triggers in patients with takotsubo syndrome: new insights from the International Takotsubo Registry.

ESC Heart Fail 2021 06 13;8(3):1924-1932. Epub 2021 Mar 13.

Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany.

Aims: Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes.

Methods And Results: Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In-hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long-term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long-term mortality (hazard ratio 2.12, 95% confidence interval 1.33-3.38; P = 0.002).

Conclusions: The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in-hospital course and a worse long-term outcome.
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http://dx.doi.org/10.1002/ehf2.13165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120351PMC
June 2021

Plasma Concentrations of Extracellular Vesicles Are Decreased in Patients with Post-Infarct Cardiac Remodelling.

Biology (Basel) 2021 Jan 30;10(2). Epub 2021 Jan 30.

1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland.

Background, the mechanisms underlying left ventricular remodelling (LVR) after acute myocardial infarction (AMI) remain obscure. In the course of AMI, blood cells and endothelial cells release extracellular vesicles (EVs). We hypothesized that changes in EV concentrations after AMI may underlie LVR. Methods, plasma concentrations of EVs from endothelial cells (CD146+), erythrocytes (CD235a+), leukocytes (CD45+), platelets (CD61+), activated platelets (P-selectin+), and EVs exposing phosphatidylserine after AMI were determined by flow cytometry in 55 patients with the first AMI. LVR was defined as an increase in left ventricular end-diastolic volume by 20% at 6 months after AMI, compared to baseline. Results, baseline concentrations of EVs from endothelial cells, erythrocytes and platelets were lower in patients who developed LVR ( ≤ 0.02 for all). Concentrations of EVs from endothelial cells and erythrocytes were independent LVR predictors (OR 8.2, CI 1.3-54.2 and OR 17.8, CI 2.3-138.6, respectively) in multivariate analysis. Combining the three EV subtypes allowed to predict LVR with 83% sensitivity and 87% specificity. Conclusions, decreased plasma concentrations of EVs from endothelial cells, erythrocytes and platelets predict LVR after AMI. Since EV release EVs contributes to cellular homeostasis by waste removal, decreased concentrations of EVs may indicate dysfunctional cardiac homeostasis after AMI, thus promoting LVR.
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http://dx.doi.org/10.3390/biology10020097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910841PMC
January 2021

Trends in the Prescription of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation: Results of the Polish Atrial Fibrillation (POL-AF) Registry.

J Clin Med 2020 11 5;9(11). Epub 2020 Nov 5.

Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland.

Background: Current guidelines do not suggest in which groups of patients with atrial fibrillation (AF) individual non-vitamin K antagonist oral anticoagulants (NOACs) should be used for the prevention of thromboembolic complications. The aim of this study was to evaluate the frequency of use of apixaban, dabigatran, and rivaroxaban, and attempt to identify factors predisposing their administration.

Methods: The Polish Atrial Fibrillation (POL-AF) registry is a prospective, non-interventional study, including consecutive patients with AF hospitalized in ten Polish cardiology centers during the period ranging from January to December 2019. In this study, all patients were treated with NOACs.

Results: Among the 2971 patients included in the analysis, 40.4% were treated with rivaroxaban, 32% with apixaban, and 27.6% with dabigatran. The mean age of the total population was 72 ± 11.5 years and 43% were female. A reduced dose of NOAC was used in 35% of patients treated with apixaban, 39.7% of patients treated with dabigatran, and 34.4% of patients treated with rivaroxaban. Independent predictors of the use of apixaban were previous bleeding (OR 2.37, CI 1.67–3.38), GFR < 60 mL/min (OR 1.38, CI 1.25–1.64), heart failure (OR 1.38, CI 1.14–1.67) and age (per 5 years) (OR 1.14, CI 1.09–1.19). GFR < 60 mL/min (OR 0.79, CI 0.66–0.95), female (OR 0.8, CI 0.67–0.96) and age (per 5 years) (OR 0.95, CI 0.91–0.99) diminished the chance of using dabigatran. Previous bleeding (OR 0.43, CI 0.28–0.64), vascular disease (OR 0.84, CI 0.70–0.99), and age (per 5 years) (OR 0.94, CI 0.90–0.97) diminished the chance of choosing rivaroxaban.

Conclusions: In hospitalized patients with AF, the most frequently chosen NOAC was rivaroxaban. Apixaban was chosen more often in patients after bleeding, and in those who were advanced in years, with heart failure and impaired renal function. Impaired renal function and female gender were factors that diminished the chance of using dabigatran. Previous bleeding and vascular disease was the factor that diminished the chance of using rivaroxaban. Dabigatran and rivaroxaban have been used less frequently in elderly patients.
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http://dx.doi.org/10.3390/jcm9113565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694480PMC
November 2020

Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban.

Cardiol Res Pract 2020 17;2020:1206402. Epub 2020 Sep 17.

Collegium Medicum, The Jan Kochanowski University, Kielce 25-369, Poland.

Left atrial appendage thrombus (LAAT) may be detected by transesophageal echocardiography (TOE) in patients with atrial fibrillation (AF) despite continuous anticoagulation therapy. We examined the factors predisposing to LAAT in patients treated with the anticoagulants dabigatran and rivaroxaban. We retrospectively evaluated 1,256 AF patients from three centres who underwent TOE before electrical cardioversion ( = 611, 51.4%) or catheter ablation ( = 645, 48.6%) from January 2013 to December 2019 and had been on at least three weeks of continuous dabigatran ( = 603, 48%) or rivaroxaban ( = 653, 52%) therapy. Preprocedural TOE diagnosed LAAT in 51 patients (4.1%), including 30 patients (5%) treated with dabigatran and 21 patients (3.2%) treated with rivaroxaban (=0.1145). In multivariate logistic regression, predictors of LAAT in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF) (OR = 6.2, =0.015), heart failure (OR = 3.22, =0.003), and a eGFR <60 ml/min/1.73 m (OR = 2.65, =0.012); the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) (OR = 5.73, =0.0221) and heart failure (OR = 3.19, =0.116). In ROC analysis of the dabigatran group, the area under the curve (AUC) for the CHADS-VASc-RAF score was significantly higher (0.78) than those for the CHADS, CHADS-VASc, and RCHADS scores (0.67, 0.70, and 0.72, respectively). In the rivaroxaban group, the CHADS-VASc-RAF score also performed significantly better (AUC of 0.77) than the CHADS, CHADS-VASc, and RCHADS scores (AUC of 0.66, 0.64, and 0.67, respectively). The risk of LAAT was the same for patients in both treatment groups. In all patients, non-paroxysmal AF or heart failure, and in patients treated with dabigatran an eGFR <60 ml/min/1.73 m, were independent predictors of LAAT. The new CHADS-VASc-RAF scale had the highest predictive value for LAAT in the entire study population.
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http://dx.doi.org/10.1155/2020/1206402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519465PMC
September 2020

Prevalence and risk factors of left atrial thrombus in patients with atrial fibrillation and lower class (IIa) recommendation to anticoagulants.

Cardiovasc Diagn Ther 2020 Aug;10(4):717-724

Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland.

Background: Oral anticoagulation therapy (OAT) prevents ischaemic incidents in patients with atrial fibrillation (AF). CHADS-VASc risk score of ≥2 points in men and ≥3 in women is a class I indication for OAT. OAT should also be considered as a prevention of thromboembolism in AF men with a CHADS-VASc score of 1 point and women with 2 points, but the class of recommendation is lower (IIa). This study aims to assess the occurrence of left atrial appendage thrombus (LAAT) and risk factors of its formation in patients with lower class recommendation to oral antiocoagulation treatment.

Methods: The study group consisted of 1,858 patients: 555 patients with class IIa indication to OAT (IIa group) and 1,303 patients with class I indication as a control group (I group). Patients were admitted to three cardiology departments. All subjects underwent transoesophageal echocardiography.

Results: The incidence of LAAT was comparable in both IIa and I group: LAAT was confirmed in 30 (5.4%) subjects of IIa group and in 77 (5.9%) of I group. The prevalence of LAAT in IIa group was higher on treatment with VKAs (in comparison to NOACs) (8.4% 3.4%, P=0.010), and lower in case of paroxysmal AF (in comparison to non-paroxysmal AF) (2.4% 9.8%, P=0.0002). Multivariate logistic regression revealed the following variables as the independent predictors of LAAT in IIa group: treatment with VKAs (OR 2.99, 95% CI: 1.33-6.69; P=0.007), paroxysmal AF (OR 0.26, 95% CI: 0.11-0.62; P=0.002) and eGFR <60 mL/min/1.73 m (OR 3.19, 95% CI: 1.42-7.16; P=0.005).

Conclusions: The prevalence of LAAT in AF patients with lower class (IIa) recommendation to anticoagulants was comparable to higher (I). Treatment with VKAs, along with non-paroxysmal type of AF and eGFR <60 mL/min/1.72 m were identified as the strongest predictors of LAAT in IIa group.
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http://dx.doi.org/10.21037/cdt-20-151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487402PMC
August 2020

Vascular disease in patients with atrial fibrillation. A report from Polish participants in the EORP-AF General Long-Term Registry.

Int J Clin Pract 2021 Mar 20;75(3):e13701. Epub 2020 Sep 20.

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

Aims: This study aimed to (1) define the prevalence of vascular disease (VD; coronary (CAD) and/or peripheral artery disease (PAD)) and associated risk factors in patients with atrial fibrillation (AF); (2) establish the relationship of VD and associated treatment patterns on adverse events in AF.

Methods: Data from 701 Polish AF patients enrolled in the EORP-AF General Long-Term Registry in the years 2013-2016 were included in this analysis. During the one-year follow-up, the occurrence of major adverse events (MAE; all-cause death, thromboembolic event, myocardial infraction) and its components was evaluated.

Results: VD was recorded in 293 (44%) patients and based on multivariate logistic analysis was associated with age >75, diabetes, hypercholesterolemia, heart failure (HF). There was no significant difference in rates of MAE between patients with and without VD based on Fisher's exact test (8.8% vs 5.7%, P = .16), as well as between patients with concomitant CAD and PAD, PAD and CAD alone based on the Chi-square test (21% vs 7.5% vs 6.7%; P = .09). A higher risk of MAE was associated with HF, chronic kidney disease (in all study group), age >75, HF, diabetes (VD group),chronic obstructive pulmonary disease (non-VD group) based on the multivariate logistic analysis. Relative to patients with VD on vitamin K antagonists (VKA), those treated with non-VKA-oral anticoagulants (NOAC) had lower absolute rate of MAE according to Fisher's exact test (1.4% vs 10%, P = .02) but similar risks for thromboembolic and hemorrhagic events. The concomitant use of triple therapy was associated with increased risk of MAE as compared with those on OAC alone or dual therapy based on the Chi-square test (20% vs 4.8%, 3.2%, P = .02).

Conclusion: VD was prevalent in almost two-fifths of AF patients. The incidence of MAE was higher in patients with VD on VKA (vs NOAC) and on triple therapy (vs dual therapy, OAC alone) within one-year follow-up.
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http://dx.doi.org/10.1111/ijcp.13701DOI Listing
March 2021

Echocardiographic photorealistic imaging of leiomyomatosis intravascularis.

Int J Cardiovasc Imaging 2021 Jan 2;37(1):109-111. Epub 2020 Aug 2.

Medical University of Warsaw, Warsaw, Poland.

We present a case of patient with leiomyomatosis intravascularis. To diagnose, we used 3D photorealistic imaging which allowed us better visualisation of pathological structures as well as planning the surgical procedure in greater detail. The main advantage of this technique is the possibility to move the virtual light source and thus visualize the specific part of the heart.
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http://dx.doi.org/10.1007/s10554-020-01951-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878218PMC
January 2021

Serum copeptin and copeptin/NT-proBNP ratio - new tools to differentiate takotsubo syndrome from acute myocardial infarction.

Folia Med Cracov 2020 ;60(1):5-14

1st Chair and Department of Cardiology, Medical University of Warsaw, Poland.

Background: Today no established biomarkers are available for the early diagnosis of takotsubo syndrome and its differentiation from ST-segment elevation myocardial infarction. We hypothesized that copeptin and copeptin/NT-proBNP ratio may serve a routine marker combination for non-invasive differentiation.

Methods: The study compared the serum concentrations of copeptin, troponin I (TnI) and NT-proBNP in 19 consecutive women diagnosed with takotsubo syndrome according to the Mayo Clinic criteria and 10 consecutive women diagnosed with ST-segment elevation myocardial infarction.

Results: Copeptin concentrations were significantly lower in patients with takotsubo syndrome than in patients with ST-segment elevation myocardial infarction. The diagnostic accuracy to distinguish takotsubo syndrome from ST-segment elevation myocardial infarction is highest for copeptin/NTproBNP ratio, copeptin/TnI at admission ratio and copeptin alone (AUC 0.8713, 0.8538, 0.8480, respectively).

Conclusions: The serum copeptin to NTproBNP ratio could be an additional tool in the non-invasive differentiation between takotsubo syndrome and ST-segment elevation myocardial infarction. However, further researches are needed.
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http://dx.doi.org/10.24425/fmc.2020.133481DOI Listing
October 2020

Decreased left atrial appendage emptying velocity as a link between atrial fibrillation type, heart failure and older age and the risk of left atrial thrombus in atrial fibrillation.

Int J Clin Pract 2020 Nov 4;74(11):e13609. Epub 2020 Aug 4.

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

Introduction: Decreased left atrial appendage emptying velocity (LAAV) is a known predictor of LAA thrombus in atrial fibrillation (AF). The aim of our study was to identify which of the clinical risk factors for LAA thrombus are associated with decreased LAAV.

Methods: The study included 1476 consecutive AF patients who underwent transesophageal echocardiography (TEE) before AF direct current cardioversion or ablation in two high-reference cardiology departments. Patients were divided into two groups: 71 (4.8%) patients with LAAV < 20 cm/s and 1405 patients (95%) with LAAV ≥ 20 cm/s.

Results: Compared with patients with LAAV ≥ 20 cm/s, those with decreased LAAV were older, more often had non-paroxysmal AF, were burdened with more concomitant diseases (including hypertension, diabetes, vascular disease, and heart failure [HF]) with higher median CHA DS -VASc score (3 [2-4] vs 2 [1-3], P < .0001), and had lower glomerular filtration rate (GFR). Prevalence of LAA thrombus was higher in patients with decreased LAAV compared with those with LAAV ≥ 20cm/s (20% vs 4.6%, P < .0001). In patients with decreased LAAV, there was no difference in the frequency of LAA thrombus between those treated with VKA and those receiving NOAC, while in patients with LAAV ≥ 20 cm/s a trend was observed towards a benefit with NOAC. In multivariate logistic regression, non-paroxysmal AF, HF and age ≥ 65 years predicted both LAAV < 20 cm/s and LAA thrombus, while GFR < 60 mL/min/1.73 m predicted only the presence of LAA thrombus.

Conclusion: One in five AF patients with decreased LAAV had LAA thrombus, regardless of the type of OAC. Non-paroxysmal AF, HF and age ≥ 65 years might increase LAA thrombus risk via reduced LAAV.
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http://dx.doi.org/10.1111/ijcp.13609DOI Listing
November 2020

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

Medicine (Baltimore) 2020 Jun;99(25):e20570

Collegium Medicum, the Jan Kochanowski University.

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ± 1.2 vs 1.2 ± 0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ± 4.4 vs 3.7 ± 2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.
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http://dx.doi.org/10.1097/MD.0000000000020570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310852PMC
June 2020

NT-proBNP increase during stress echocardiography predicts significant changes in ischemic mitral regurgitation severity in patients qualified for surgical revascularization.

Cardiol J 2020 Jun 9. Epub 2020 Jun 9.

1st Chair and Department of Cardiology, Medical University of Warsaw, Poland, Warsaw.

Background: In many patients, significant changes in ischemic mitral regurgitation (IMR) severity during exercise can be observed independent of the degree of IMR at rest. This study aimed to investigate the correlations between N-terminal fragment B-type natriuretic peptide (NT-proBNP) and echocardiography measurements at rest and at peak exercise in patients with moderate IMR who qualified for surgical revascularization.

Methods: A total of 100 patients eligible for coronary artery bypass grafting, were included in this prospective study. All patients underwent exercise echocardiography. Additionally, the levels of NT-proBNP were measured at rest and after peak exercise.

Results: A positive correlation of absolute NT-proBNP levels with effective regurgitant orifice area (EROA) were observed and with tricuspid regurgitant peak gradient (TRPG) at peak exercise. Absolute ∆NT-proBNP during exercise and the tenting area at rest were independent predictors of severe IMR at peak exercise. The level of absolute ∆NT-proBNP during exercise and coaptation height at rest were the most important predictors of significant increases in TRPG. The best cutoff value for ∆NT-proBNP as a predictor for increases in EROA at peak exercise was 68.9 pg/mL and to predict an increase in TRPG ≥ 50 mmHg at peak exercise was 68 pg/mL.

Conclusions: The level of ∆NT-proBNP during exercise was the most important parameter in predicting significant changes in IMR severity and pulmonary pressure. Based on the present data, it can be speculated that integration of the assessment of NT-proBNP at rest and at exercise might improve patient selection for valve surgery.
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http://dx.doi.org/10.5603/CJ.a2020.0078DOI Listing
June 2020

Coexistence and outcome of coronary artery disease in Takotsubo syndrome.

Eur Heart J 2020 09;41(34):3255-3268

Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland.

Aims: Takotsubo syndrome (TTS) is an acute heart failure syndrome, which shares many features with acute coronary syndrome (ACS). Although TTS was initially described with angiographically normal coronary arteries, smaller studies recently indicated a potential coexistence of coronary artery disease (CAD) in TTS patients. This study aimed to determine the coexistence, features, and prognostic role of CAD in a large cohort of patients with TTS.

Methods And Results: Coronary anatomy and CAD were studied in patients diagnosed with TTS. Inclusion criteria were compliance with the International Takotsubo Diagnostic Criteria for TTS, and availability of original coronary angiographies with ventriculography performed during the acute phase. Exclusion criteria were missing views, poor quality of angiography loops, and angiography without ventriculography. A total of 1016 TTS patients were studied. Of those, 23.0% had obstructive CAD, 41.2% had non-obstructive CAD, and 35.7% had angiographically normal coronary arteries. A total of 47 patients (4.6%) underwent percutaneous coronary intervention, and 3 patients had acute and 8 had chronic coronary artery occlusion concomitant with TTS, respectively. The presence of CAD was associated with increased incidence of shock, ventilation, and death from any cause. After adjusting for confounders, the presence of obstructive CAD was associated with mortality at 30 days. Takotsubo syndrome patients with obstructive CAD were at comparable risk for shock and death and nearly at twice the risk for ventilation compared to an age- and sex-matched ACS cohort.

Conclusions: Coronary artery disease frequently coexists in TTS patients, presents with the whole spectrum of coronary pathology including acute coronary occlusion, and is associated with adverse outcome.

Trial Registration: ClinicalTrials.gov number: NCT01947621.
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http://dx.doi.org/10.1093/eurheartj/ehaa210DOI Listing
September 2020

Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants in clinical practice-A multicenter registry.

J Cardiovasc Electrophysiol 2020 08 11;31(8):2005-2012. Epub 2020 Jun 11.

1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland.

Background: The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF) who have been treated with non-vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non-valvular AF treated with NOACs for at least 3 weeks.

Methods: Consecutive patients with non-valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high-reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE.

Results: A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2-VASc score ≥2 points (OR = 2.11; 95% CI, 1.15-3.88; P = .0161), non-paroxysmal AF (OR = 6.30; 95% CI, 2.22-17.91; P = .0005), and GFR <60 mL/min/1.73 m (OR = 2.05; 95% CI, 1.14-3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs.

Conclusions: In non-valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2-VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.
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http://dx.doi.org/10.1111/jce.14589DOI Listing
August 2020

Left Ventricular Ejection Fraction Is Associated with the Risk of Thrombus in the Left Atrial Appendage in Patients with Atrial Fibrillation.

Cardiovasc Ther 2020 24;2020:3501749. Epub 2020 Apr 24.

1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.

Introduction: Atrial fibrillation (AF) is associated with high risk of ischemic stroke. The most frequent thrombus location in AF is the left atrial appendage (LAA). Transthoracic echocardiography (TTE) is a basic diagnostic examination in patients (pts) with AF.

Objectives: To analyse the relations between basic echocardiographic features, well-established stroke risk factors, type of AF, and anticoagulation therapy with the incidence of left atrial appendage thrombus (LAAT). . The study group consisted of 768 pts with AF (mean age, 63 years), admitted to three high-reference cardiology departments. Five hundred and twenty-three pts were treated with non-vitamin K antagonist oral anticoagulants (NOACs) and 227 (30%) with vitamin K antagonists (VKAs). The subjects underwent TTE and transesophageal echocardiography (TEE) before cardioversion or ablation.

Results: LAAT was significantly more frequent in pts with reduced left ventricular ejection fraction (LVEF): in 10.6% (7 pts) with LVEF < 40% and in 9.0% (9 pts) with LVEF 40-49%, while only in 5.5% (33 pts) with LVEF > 50%. Compared to pts without LAAT, those with LAAT presented with lower LVEF and higher left atrial diameter (LAD). Multivariate logistic regression revealed the following variables as independent predictors of LAAT: previous bleeding, treatment with VKA, and LVEF.

Conclusion: LAAT is related to lower LVEF and higher LAD. LVEF is one of the independent predictors of LAAT. Even in the case of adequate anticoagulant therapy, it might be prudent to consider TEE before cardioversion or ablation in patients with low LVEF and LA enlargement, especially in the coexistence of other thromboembolic risk factors.
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http://dx.doi.org/10.1155/2020/3501749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201491PMC
July 2020

Isoprenaline induced Takotsubo syndrome: Histopathological analyses of female rat hearts.

Cardiol J 2020 Apr 24. Epub 2020 Apr 24.

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

Background: Takotsubo syndrome (TTS) is a stress-induced disorder affecting mostly postmenopausal women. The aim of the study was to evaluate isoprenaline (ISO) dependent female rat model and histopathological characteristics in TTS.

Methods: Forty-nine Sprague Dawley female rats, 12 weeks old, were injected intraperitoneally with a single dose of ISO at doses 50 (n = 8), 75 (n = 6), 100 (n = 3), 150 (n = 27) and 200 (n = 5) mg/kg body weight (bw). The control group (n = 6) was injected with physiological saline. The echocardiographic examination to assess wall motion abnormalities took place 24, 48, 72 h, and 7 days post-ISO. Histopathological analysis was performed on the basis of hematoxylin-eosin staining.

Results: The total mortality rate was 3/49 (6.12%). The optimum dose of ISO to induce TTS was 150 mg/kg bw and 21/27 (77.77%) rats showed apical ballooning. Histopathological analysis revealed focal necrosis/apoptosis of cardiomyocytes with inflammatory and fibroblast-like cell infiltration. Foci were the most numerous in the central muscle layer with apical-basal gradient 24,48,72 h post-ISO (p < 0.05). Significant differences were noted 48 h post-ISO in the central layer in apical vs basal segments (p = 0.0032), in the endocardial layer in apical vs basal segments (0.00024) and in mid-cavital vs. basal segments (p = 0.0483). The number of foci in endocardium of apical region differ 48 h post-ISO in rats with a dose of 150 vs. 200 mg/kg bw (p = 0.0084).

Conclusions: The ISO female rat model of TTS is associated with higher optimum dose and lower mortality in comparison with the male TTS model. TTS presents as a singles cardiomyocyte disorder, foci concerned mainly central muscle layer with apical-basal gradient.
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http://dx.doi.org/10.5603/CJ.a2020.0057DOI Listing
April 2020

Age-Related Variations in Takotsubo Syndrome.

J Am Coll Cardiol 2020 04;75(16):1869-1877

Krankenhaus "Maria Hilf" Medizinische Klinik, Stadtlohn, Germany.

Background: Takotsubo syndrome (TTS) occurs predominantly in post-menopausal women but is also found in younger patients.

Objectives: This study aimed to investigate age-related differences in TTS.

Methods: Patients diagnosed with TTS and enrolled in the International Takotsubo Registry between January 2011 and February 2017 were included in this analysis and were stratified by age (younger: ≤50 years, middle-age: 51 to 74 years, elderly: ≥75 years). Baseline characteristics, hospital course, as well as short- and long-term mortality were compared among groups.

Results: Of 2,098 TTS patients, 242 (11.5%) patients were ≤50 years of age, 1,194 (56.9%) were 51 to 74 years of age, and 662 (31.6%) were ≥75 years of age. Younger patients were more often men (12.4% vs. 10.9% vs. 6.3%; p = 0.002) and had an increased prevalence of acute neurological (16.3% vs. 8.4% vs. 8.8%; p = 0.001) or psychiatric disorders (14.1% vs. 10.3% vs. 5.6%; p < 0.001) compared with middle-aged and elderly TTS patients. Furthermore, younger patients had more often cardiogenic shock (15.3% vs. 9.1% vs. 8.1%; p = 0.004) and had a numerically higher in-hospital mortality (6.6% vs. 3.6% vs. 5.1%; p = 0.07). At multivariable analysis, younger (odds ratio: 1.60; 95% confidence interval: 0.86 to 3.01; p = 0.14) and older age (odds ratio: 1.09; 95% confidence interval: 0.66 to 1.80; p = 0.75) were not independently associated with in-hospital mortality using the middle-aged group as a reference. There were no differences in 60-day mortality rates among groups.

Conclusions: A substantial proportion of TTS patients are younger than 50 years of age. TTS is associated with severe complications requiring intensive care, particularly in younger patients.
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http://dx.doi.org/10.1016/j.jacc.2020.02.057DOI Listing
April 2020

Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease.

Cardiol J 2020 Apr 27. Epub 2020 Apr 27.

Chair and Department of Cardiology, Medical University of Warsaw.

Background: Atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values.

Methods: This study included 1962 patients who underwent transesophageal echocardiographic examination (TEE) prior to cardioversion or ablation in the years 2014-2018 in three cardiac centers.

Results: More than a quarter of AF patients had decreased eGFR ( < 60 mL/min/1.73 m²) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR ( < 30, 30-59 and > 60 mL/min/1.73 m², respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA₂DS₂-VASc < 2.

Conclusions: Despite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation.
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http://dx.doi.org/10.5603/CJ.a2020.0036DOI Listing
April 2020

Assessing sex differences in patients with takotsubo syndrome requires homogeneous cohorts. Authors' reply.

Pol Arch Intern Med 2020 01 31;130(1):88. Epub 2020 Jan 31.

1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland

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http://dx.doi.org/10.20452/pamw.15168DOI Listing
January 2020

Trends in antithrombotic management of patients with atrial fibrillation. A report from the Polish part of the EURObservational Research Programme - Atrial Fibrillation General Long-Term Registry.

Pol Arch Intern Med 2020 03 24;130(3):196-205. Epub 2020 Jan 24.

1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland

Introduction: Data on antithrombotic treatment among patients with atrial fibrillation (AF) in Poland are limited.

Objectives: We aimed to describe antithrombotic management within the Polish part of the EUROobservational Research Programme on Atrial Fibrillation General Long-Term Registry.

Patients And Methods: We analyzed data collected at baseline and at 1‑year follow‑up from 701 Polish patients treated at 25 Polish centers between 2013 and 2016.

Results: Any antithrombotic therapy was administered to 94% of patients (vitamin K antagonists [VKAs], 53%; non‑VKA oral anticoagulants [NOACs], 36%; antiplatelet therapy [APT], 4.8%). However, 78% of patients considered as "low‑risk" (CHA2DS2‑VASc = 0 in men or 1 in women) were prescribed oral anticoagulants and 12% were on APT. Independent predictors of NOAC and VKA use were first‑detected AF and device therapy. Predictors of VKA use were lone AF, history of ischemic stroke, and pulmonary embolism or deep vein thrombosis; of NOAC use, permanent AF; of APT use, history of hemorrhagic events and first‑detected or persistent AF; and of no antithrombotic treatment, young age. Incorrect NOAC prescription was more common in the reduced‑dose group than in the full‑dose group (30% vs 7%). During follow‑up, the all‑cause mortality rate was 5.2%, 0.8%, 15%, and 7% (P <0.0001) and the risk of thromboembolic events was 0.4%, 0.5%, 6.2%, and 0% (P = 0.04) in patients on VKA, NOAC, APT, and no treatment, respectively.

Conclusions: Patients with the lowest stroke risk are often overtreated. The choice of proper antithrombotic strategy does not depend solely on factors incorporated in the CHA2DS2‑VASc score. Higher mortality is observed among APT‑treated patients and those without antithrombotic treatment.
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http://dx.doi.org/10.20452/pamw.15157DOI Listing
March 2020

Do older patients get takotsubo syndrome differently?

J Geriatr Cardiol 2019 Dec;16(12):909-910

1 st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.

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http://dx.doi.org/10.11909/j.issn.1671-5411.2019.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6938741PMC
December 2019

Ticagrelor attenuates the increase of extracellular vesicle concentrations in plasma after acute myocardial infarction compared to clopidogrel.

J Thromb Haemost 2020 03 9;18(3):609-623. Epub 2020 Jan 9.

First Chair and Department of Cardiology, Medical University of Warsaw, Poland.

Background: Platelet P2Y12 antagonist ticagrelor reduces mortality after acute myocardial infarction (AMI) compared to clopidogrel, but the underlying mechanism is unknown. Because activated platelets, leukocytes, and endothelial cells release proinflammatory and prothrombotic extracellular vesicles (EVs), we hypothesized that the release of EVs is more efficiently inhibited by ticagrelor compared to clopidogrel.

Objectives: We compared EV concentrations and EV procoagulant activity in plasma of patients after AMI treated with ticagrelor or clopidogrel.

Methods: After percutaneous coronary intervention, 60 patients with first AMI were randomized to ticagrelor or clopidogrel. Flow cytometry was used to determine concentrations of EVs from activated platelets (CD61 , CD62p ), fibrinogen , phosphatidylserine (PS ), leukocytes (CD45 ), endothelial cells (CD31 , 146 ), and erythrocytes (CD235a ) in plasma at randomization, after 72 hours and 6 months of treatment. A fibrin generation test was used to determine EV procoagulant activity.

Results: Concentrations of platelet, fibrinogen , PS , leukocyte, and erythrocyte EVs increased 6 months after AMI compared to the acute phase of AMI (P ≤ .03). Concentrations of platelet EVs were lower on ticagrelor compared to clopidogrel after 6 months (P = .03). Concentrations of fibrinogen , PS , and leukocyte EVs were lower on ticagrelor compared to clopidogrel both after 72 hours and 6 months (P ≤ .03). Concentrations of endothelial EVs and EV procoagulant activity did not differ between patient groups and over time (P ≥ .17).

Conclusions: Ticagrelor attenuates the increase of EV concentrations in plasma after acute myocardial infarction compared to clopidogrel. The ongoing release of EVs despite antiplatelet therapy might explain recurrent thrombotic events after AMI and worse clinical outcomes on clopidogrel compared to ticagrelor.
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http://dx.doi.org/10.1111/jth.14689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065161PMC
March 2020

Association of Galectin-3 and Soluble ST2, and Their Changes, with Echocardiographic Parameters and Development of Heart Failure after ST-Segment Elevation Myocardial Infarction.

Dis Markers 2019 10;2019:9529053. Epub 2019 Oct 10.

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

Purpose: To investigate the association of galectin-3 (Gal-3) and soluble ST2 (sST2) and their follow-up changes with the development of heart failure (HF) and echocardiographic parameters of HF (ejection fraction, atrial and ventricular size, left ventricular hypertrophy, e', and E/e') in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI).

Methods: A prospective, observational study, BIOSTRAT (Biomarkers for Risk Stratification After STEMI), enrolled 117 patients between October 2014 and April 2017. Gal-3 and sST2 serum collection and echocardiography were performed twice (during index hospitalization and on a control visit at one-year follow-up). The primary endpoint was HF onset at one-year follow-up. Secondary assessments included associations of biomarker concentration with echocardiographic indices of systolic and diastolic dysfunction at baseline and at one year.

Results: Mean baseline concentrations of Gal-3 and sST2 (7.5 and 26.4 ng/mL, respectively) were significantly increased at one-year follow-up (8.5 ng/mL and < 0.001 and 31.4 ng/mL and = 0.001, respectively). Patients who reached the primary endpoint (50 patients (48%)) had significantly higher baseline concentrations of both biomarkers and a higher Gal-3 level at one year compared to patients who did not. Both Gal-3 and sST2 were predictors of the primary endpoint in univariate logistic regression analysis, but only Gal-3 remained significant in multivariate analysis. There was no clear association between both biomarkers and echocardiographic parameters.

Conclusions: Baseline, but not one-year, changes of Gal-3 and sST2 concentrations may be useful for risk stratification after STEMI. However, only Gal-3 was the independent predictor of HF development at one-year observation. This trial is registered with NCT03735719.
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http://dx.doi.org/10.1155/2019/9529053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6811795PMC
April 2020

Determination of left ventricular ejection fraction by gated 99mTc-MIBI G-SPECT in patients with takotsubo syndrome - comparison with echocardiography.

Folia Med Cracov 2019 ;59(2):75-80

1st Chair and Department of Cardiology, Medical University of Warsaw, Poland.

Background: Echocardiography is the first exam to establish the myocardial function in patients with takotsubo syndrome (TTS). However, ECG-Gated Myocardial Single-Photon Emission Tomography (G-SPECT) also allows to calculate left ventricular ejection fraction (LVEF) and can be useful in early stadium of TTS.

Aim: To compare LVEF obtained from 99mTc-MIBI G-SPECT and echocardiography in patients with TTS.

Material And Methods: Study population:20 patients in medium age 77(62-89) with TTS were included. In all patients 99mTc-MIBI G-SPECT and echocardiography was performed on the same day.

Results: LVEF measured by G-SPECT and echocardiography ranged from 34 to 83% and 38 to 69%, respectively. The LVEF values for ECHO were significantly lower than for SPECT. The correlation between the LVEF was r = 0.76. The calculated correlation coefficient (r) for linear regression analysis was 0.64. The following equation shows the approximate interdependence of both LVEF calculations: LVEF GSPECT = 10.35 + 0.93 * LVEF Echo.

Conclusions: G-SPECT tends to overerestimate LVEF compared to echocardiography so these imaging techniques should not be used interchangeably. Calculated equation should be used for comparison of LVEF.
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April 2020
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