Effect of air pollution exposure on risk of acute coronary syndromes in Poland: a nationwide population-based study (EP-PARTICLES study)

Background

Air pollution (AP) is linked up to 20% of cardiovascular deaths. The aim of this nationwide study was to investigate subpopulations vulnerable to AP for non-ST- (NSTEMI) and ST-elevation myocardial infarction (STEMI) incidence.

Methods

We analysed short- (lags up to seven days) and mid-term (0-30 days moving average) influence of particulate matter (PM2.5), sulphur dioxide (SO2), nitrogen dioxide (NO2) and benzo(a)pyrene (BaP) on hospitalizations due NSTEMI and STEMI in 2011-2020. Data on AP concentrations were derived using GEM-AQ model. Study included residents of five voivodeships in eastern Poland, inhabited by over 8,000,000 individuals.

Findings

Higher NO2 and PM2.5 concentrations increased mid-term risk of NSTEMI in patients aged < 65 years by 1.3-5.7%. Increased SO2 and PM2.5 concentration triggered STEMI in the short- (SO2, PM2.5) and mid-term (PM2.5) amongst those aged ≥ 65 years. In the short- and mid-term, women were more susceptible to PM2.5 and BaP influence resulting in increased STEMI incidence. In rural regions, STEMI risk was triggered by SO2, PM2.5 and BaP. Income-based stratification showed disproportions regarding influence of BaP concentrations on NSTEMI incidence based on gross domestic product (up to 1.4%).

Interpretation

There are significant disparities in the influence of air pollution depending on the demographic and socio-economic factors. AP exposure is associated with the threat of a higher risks of NSTEMI and STEMI, especially to younger people, women, residents of rural areas and those with lower income.

Funding

National Science Center and Medical University of Bialystok, Poland.

Regional antibiotic delivery for sternal wound infection prophylaxis a systematic review and meta-analysis of randomized controlled trials

Despite evidence suggesting the benefit of prophylactic regional antibiotic delivery (RAD) to sternal edges during cardiac surgery, it is seldom performed in clinical practice. The value of topical vancomycin and gentamicin for sternal wound infections (SWI) prophylaxis was further questioned by recent studies including randomized controlled trials (RCTs). The aim of this systematic review and meta-analysis was to comprehensively assess the safety and effectiveness of RAD to reduce the risk of SWI.We screened multiple databases for RCTs assessing the effectiveness of RAD (vancomycin, gentamicin) in SWI prophylaxis. Random effects meta-analysis was performed. The primary endpoint was any SWI; other wound complications were also analysed. Odds Ratios served as the primary statistical analyses. Trial sequential analysis (TSA) was performed.Thirteen RCTs (N = 7,719 patients) were included. The odds of any SWI were significantly reduced by over 50% with any RAD: OR (95%CIs): 0.49 (0.35-0.68); p < 0.001 and consistently reduced in vancomycin (0.34 [0.18-0.64]; p < 0.001) and gentamicin (0.58 [0.39-0.86]; p = 0.007) groups (psubgroup = 0.15). Similarly, RAD reduced the odds of SWI in diabetic and non-diabetic patients (0.46 [0.32-0.65]; p < 0.001 and 0.60 [0.44-0.83]; p = 0.002 respectively). Cumulative Z-curve passed the TSA-adjusted boundary for SWIs suggesting adequate power has been met and no further trials are needed. RAD significantly reduced deep (0.60 [0.43-0.83]; p = 0.003) and superficial SWIs (0.54 [0.32-0.91]; p = 0.02). No differences were seen in mediastinitis and mortality, however, limited number of studies assessed these endpoints. There was no evidence of systemic toxicity, sternal dehiscence and resistant strains emergence. Both vancomycin and gentamicin reduced the odds of cultures outside their respective serum concentrations' activity: vancomycin against gram-negative strains: 0.20 (0.01-4.18) and gentamicin against gram-positive strains: 0.42 (0.28-0.62); P < 0.001. Regional antibiotic delivery is safe and effectively reduces the risk of SWI in cardiac surgery patients.

Surgical Coronary Revascularization in Patients With Underlying Atrial Fibrillation: State-of-the-Art Review

The number of individuals referred for coronary artery bypass grafting (CABG) with preoperative atrial fibrillation (AF) is reported to be 8% to 20%. Atrial fibrillation is a known marker of high-risk patients as it was repeatedly found to negatively influence survival. Therefore, when performing surgical revascularization, consideration should be given to the concomitant treatment of the arrhythmia, the clinical consequences of the arrhythmia itself, and the selection of adequate surgical techniques. This state-of-the-art review aimed to provide a comprehensive analysis of the current understanding of, advancements in, and optimal strategies for CABG in patients with underlying AF. The following topics are considered: stroke prevention, prophylaxis and occurrence of postoperative AF, the role of surgical ablation and left atrial appendage occlusion, and an on-pump vs off-pump strategy. Multiple acute complications can occur in patients with preexisting AF undergoing CABG, each of which can have a significant effect on patient outcomes. Long-term results in these patients and the future perspectives of this scientific area were also addressed. Preoperative arrhythmia should always be considered for surgical ablation because such an approach improves prognosis without increasing perioperative risk. While planning a revascularization strategy, it should be noted that although off-pump coronary artery bypass provides better short-term outcomes, conventional on-pump approach may be beneficial at long-term follow-up. By collecting the current evidence, addressing knowledge gaps, and offering practical recommendations, this state-of-the-art review serves as a valuable resource for clinicians involved in the management of patients with AF undergoing CABG, ultimately contributing to improved outcomes and enhanced patient care.

Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry

BACKGROUND

Surgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization.

METHODS

Atrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups.

RESULTS

A total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1-8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50-0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49-0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61-1.17); P = .307, which was also consistent in the propensity score-matched analysis: 0.75 (0.39-1.43); P = .379.

CONCLUSION

To achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.

Surgical ablation, left atrial appendage occlusion or both? Nationwide registry analysis of cardiac surgery patients with underlying atrial fibrillation

OBJECTIVES

The aim of this study was to evaluate in-hospital outcomes and long-term survival of patients undergoing cardiac surgery with preoperative atrial fibrillation (AF). We compared different strategies, including no-AF treatment, left atrial appendage occlusion (LAAO) alone, concomitant surgical ablation (SA) alone or both.

METHODS

A retrospective analysis using the KROK registry included all patients with preoperative diagnosis of AF who underwent cardiac surgery in Poland between between January 2012 and December 2022. Risk adjustment was performed using regression analysis with inverse probability weighting of propensity scores. We assessed 6-year survival with Cox proportional hazards models. Sensitivity analysis was performed based on index cardiac procedure.

RESULTS

Initially, 42 510 patients with preoperative AF were identified, and, after exclusion, 33 949 included in the final analysis. A total of 1107 (3.26%) received both SA and LAAO, 1484 (4.37%) received LAAO alone, 3921 (11.55%) SA alone and the remaining 27 437 (80.82%) had no AF-directed treatment. As compared to no treatment, all strategies were associated with survival benefit over 6-year follow-up. A gradient of treatment was observed with the highest benefit associated with SA + LAAO followed by SA alone and LAAO alone (log-rank P < 0.001). Mortality benefits were reflected when stratified by surgery type with the exception of aortic valve surgery where LAAO alone fare worse than no treatment.

CONCLUSIONS

Among patients with preoperative AF undergoing cardiac surgery, surgical management of AF, particularly SA + LAAO, was associated with lower 6-year mortality. These findings support the benefits of incorporating SA and LAAO in the management of AF during cardiac surgery.

Topical vancomycin for sternal wound infection prophylaxis. A systematic review and updated meta-analysis of over 40,000 cardiac surgery patients

BACKGROUND

Despite guideline recommendations, routine application of topical antibiotic agents to sternal edges after cardiac surgery is seldom done. Recent randomized controlled trials have also questioned the effectiveness of topical vancomycin in sternal wound infection prophylaxis.

METHODS

We screened multiple databases for observational studies and randomized controlled trials assessing the effectiveness of topical vancomycin. Random effects meta-analysis and risk-profile regression were performed, and randomized controlled trials and observational studies were analyzed separately. The primary endpoint was sternal wound infection; other wound complications were also analyzed. Risk ratios served as primary statistics.

RESULTS

Twenty studies (N = 40,871) were included, of which 7 were randomized controlled trials (N = 2,187). The risk of sternal wound infection was significantly reduced by almost 70% in the topical vancomycin group (risk ratios [95% confidence intervals]: 0.31 (0.23-0.43); P < .00001) and was comparable between randomized controlled trials (0.37 [0.21-0.64]; P < .0001) and observational studies (0.30 [0.20-0.45]; P < .00001; Psubgroup = .57). Topical vancomycin significantly reduced the risk of superficial sternal wound infections (0.29 [0.15-0.53]; P < .00001) and deep sternal wound infections (0.29 [0.19-0.44]; P < .00001). A reduction in the risk of mediastinitis and sternal dehiscence risks was also demonstrated. Risk profile meta-regression showed a significant relationship between a higher risk of sternal wound infection and a higher benefit accrued with topical vancomycin (ß-coeff. = -0.00837; P < .0001). The number needed to treat was 58.2. A significant benefit was observed in patients with diabetes mellitus (risk ratios 0.21 [0.11-0.39]; P < .00001). There was no evidence of vancomycin or methicillin resistance; on the contrary, the risk of gram-negative cultures was reduced by over 60% (risk ratios 0.38 [0.22-0.66]; P = .0006).

CONCLUSION

Topical vancomycin effectively reduces the risk of sternal wound infection in cardiac surgery patients.

Hyperuricemia as a Risk Factor in Hypertension among Patients with Very High Cardiovascular Risk

Hypertension remains a global threat to public health, affecting the worldwide population. It is one of the most common risk factors for cardiovascular disease. Today's treatments focus on creating a hypotensive effect. However, there is a constant search for additional factors to reduce the potential of developing hypertension complications. These factors may act as a parallel treatment target with a beneficial effect in specific populations. Some studies suggest that uric acid may be considered such a factor. This study investigated the potential effect of uric acid concentrations over 5 mg/dL on the incidence of hypertension complications among patients with very high cardiovascular risk. A total of 705 patients with hypertension and very high cardiovascular risk were selected and included in the analysis. The patients were divided and compared according to serum uric acid levels. The study showed a higher occurrence of heart failure (OR = 1.7898; CI: 1.2738-2.5147; p = 0.0008), atrial fibrillation (OR = 3.4452; CI: 1.5414-7.7002; p = 0.0026) and chronic kidney disease (OR = 2.4470; CI: 1.3746-4.3558; p = 0.0024) among individuals with serum uric acid levels over 5 mg/dL, males and those with a BMI > 25 kg/m2. These findings suggest that even serum uric acid concentrations over 5 mg/dL may affect the prevalence of hypertension-related complications among patients with very high cardiovascular risk.

Validation of EuroSCORE II in atrial fibrillation heart surgery patients from the KROK Registry

The study aimed to validate the European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) in patients with atrial fibrillation (AF). All data were retrieved from the National Registry of Cardiac Surgery Procedures (KROK). EuroSCORE II calibration and discrimination performance was evaluated. The final cohort consisted of 44,172 patients (median age 67, 30.8% female, 13.4% with AF). The in-hospital mortality rate was 4.14% (N = 1830), and 5.21% (N = 2303) for 30-day mortality. EuroSCORE II significantly underestimated mortality in mild- and moderate-risk populations [Observed (O):Expected (E)-1.1, 1.16). In the AF subgroup, it performed well [O:E-0.99), whereas in the very high-risk population overestimated mortality (O:E-0.9). EuroSCORE II showed better discrimination in AF (-) [area under curve (AUC) 0.805, 95% CI 0.793-0.817)] than in AF (+) population (AUC 0.791, 95%CI 0.767-0.816), P < 0.001. The worst discriminative performance for the AF (+) group was for coronary artery bypass grafting (CABG) (AUC 0.746, 95% CI 0.676-0.817) as compared with AF (-) population (AUC 0.798, 95% CI 0.774-0.822), P < 0.001. EuroSCORE II is more accurate for patients with AF. However, it underestimated mortality rates for low-to-moderate-risk patients and had a lower ability to distinguish between high- and low-risk patients with AF, particularly in those undergoing coronary artery bypass grafting.

Tricuspid intervention for less-than-severe regurgitation simultaneously with minimally invasive mitral valve surgery in patients with atrial fibrillation

BACKGROUND

While tackling moderate tricuspid regurgitation (TR) simultaneously with left-side heart surgery is recommended by the guidelines, the procedure is still seldom performed, especially in the minimally invasive setting. Atrial fibrillation (AF) is a known marker of both mortality and TR progression after mitral valve surgery.

AIMS

This study aimed to investigatev the safety of performing tricuspid intervention and minimally invasive mitral valve surgery (MIMVS) in patients with preoperative AF.

METHODS

We retrospectively analyzed data from the Polish National Registry of Cardiac Surgery Procedures collected between 2006 and 2021. We included all patients who underwent MIMVS (mini-thoracotomy, totally thoracoscopic, or robotic surgery) and had presented with moderate tricuspid regurgitation and AF preoperatively. The primary endpoint was death from any cause at 30 days and at the longest available follow-up after MIMVS with tricuspid intervention vs. MIMVS alone. We used propensity score (PS) matching to account for baseline differences between groups.

RESULTS

We identified 1545 patients with AF undergoing MIMVS, 54.7% were men aged 66.7 (mean [standard deviation, SD], 9.2) years. Of those, 733 (47.4%) underwent concomitant tricuspid valve intervention. At 13 years of follow-up, the addition of tricuspid intervention was associated with 33% higher mortality as compared to MIMVS alone (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.05-1.69; P = 0.02). PS matching resulted in identifying 565 well-balanced pairs. Concomitant tricuspid intervention did not influence long-term follow-up (HR, 1.01; 95 CI, 0.74-1.38; P = 0.94).

CONCLUSIONS

After adjusting for baseline confounders, the addition of tricuspid intervention for moderate tricuspid regurgitation to MIMVS did not increase perioperative mortality nor influence long-term survival.

Rindera graeca (A. DC.) Boiss. & Heldr. (Boraginaceae) In Vitro Cultures Targeting Lithospermic Acid B and Rosmarinic Acid Production

The in vitro cultures of Rindera graeca, a rare endemic plant, were developed as a sustainable source of phenolic acids. Various shoot and root cultures were established and scaled up in a sprinkle bioreactor. A multiplication rate of 7.2 shoots per explant was achieved. HPLC-PDA-ESI-HRMS analysis revealed the presence of rosmarinic acid (RA) and lithospermic acid B (LAB) as the main secondary metabolites in both the shoot and root cultures. The maximum RA (30.0 ± 3.2 mg/g DW) and LAB (49.3 ± 15.5 mg/g DW) yields were determined in root-regenerated shoots. The strongest free radical scavenging activity (87.4 ± 1.1%), according to 2,2-diphenyl-1-picrylhydrazyl-hydrate assay, was noted for roots cultivated in a DCR medium. The highest reducing power (2.3 µM ± 0.4 TE/g DW), determined by the ferric-reducing antioxidant power assay, was noted for shoots cultivated on an SH medium containing 0.5 mg/L 6-benzylaminopurine. A genetic analysis performed using random amplified polymorphic DNA and start codon targeted markers revealed genetic variation of 62.8% to 96.5% among the investigated shoots and roots. This variability reflects the capacity of cultivated shoots and roots to produce phenolic compounds.

Out-of-hospital cardiac arrest: Do we have to perform coronary angiography?

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of global mortality, while survivors are burdened with long-term neurological and cardiovascular complications. OHCA management at the hospital level remains challenging, due to heterogeneity of OHCA presentation, the critical status of OHCA patients reaching the return of spontaneous circulation (ROSC), and the demands of post ROSC treatment. The validity and optimal timing for coronary angiography is one important, yet not fully defined, component of OHCA management. Guidelines state clear recommendations for coronary angiography in OHCA patients with shockable rhythms, cardiogenic shock, or in patients with ST-segment elevation observed in electrocardiography after ROSC. However, there is no established consensus on the angiographic management in other clinical settings. While coronary angiography may accelerate the diagnostic and therapeutic process (provided OHCA was a consequence of coronary artery disease), it might come at the cost of impaired post-resuscitation care quality due to postponing of intensive care management. The aim of the current statement paper is to discuss clinical strategies for the management of OHCA including the stratification to invasive procedures and the rationale behind the risk-benefit ratio of coronary angiography, especially with patients in critical condition.

Multi-City Analysis of the Acute Effect of Polish Smog on Cause-Specific Mortality (EP-PARTICLES Study)

Polish smog is a specific type of air pollution present in Eastern Poland, which may cause particularly adverse cardiovascular effects. It is characterized primarily by high concentrations of particulate matter (PM) and different favorable conditions of formation. Our study aimed to assess whether PM and nitrogen dioxide (NO₂) have a short-term impact on mortality due to acute coronary syndrome (ACS) and ischemic stroke (IS). The study covered the years 2016-2020, a total of 6 million person-years from five main cities in Eastern Poland. To evaluate the association between air pollution and cause-specific mortality, a case-crossover study design with conditional logistic regression was used at days with LAG from 0 to 2. We recorded 87,990 all-cause deaths, including 9688 and 3776 deaths due to ACS and IS, respectively. A 10 μg/m³ increase in air pollutants was associated with an increase in mortality due to ACS (PM_2.5 OR = 1.029, 95%CI 1.011-1.047, p = 0.002; PM₁₀ OR = 1.015, 95%CI 1-1.029, p = 0.049) on LAG 0. On LAG 1 we recorded an increase in both IS (PM_2.5 OR = 1.03, 95%CI 1.001-1.058, p = 0.04) and ACS (PM_2.5 OR = 1.028, 95%CI 1.01-1.047, p = 0.003; PM₁₀ OR = 1.026, 95%CI 1.011-1.041, p = 0.001; NO₂ OR = 1.036, 95%CI 1.003-1.07, p = 0.04). There was a strong association between air pollution and cause-specific mortality in women (ACS: PM_2.5 OR = 1.032, 95%CI 1.006-1.058, p = 0.01; PM₁₀ OR = 1.028, 95%CI 1.008-1.05, p = 0.01) and elderly (ACS: PM_2.5 OR = 1.03, 95%CI 1.01-1.05, p = 0.003; PM₁₀ OR = 1.027, 95% CI 1.011-1.043, p < 0.001 and IS: PM_2.5 OR = 1.037, 95%CI 1.007-1.069, p = 0.01; PM₁₀ OR = 1.025, 95%CI 1.001-1.05, p = 0.04). The negative influence of PMs was observed on mortality due to ACS and IS. NO₂ was associated with only ACS-related mortality. The most vulnerable subgroups were women and the elderly.

Outcomes of Transcatheter Aortic Valve Implantation Comparing Medtronic's Evolut PRO and Evolut R: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become a broadly acceptable alternative to AV surgery in patients with aortic stenosis (AS). New valve designs are becoming available to address the shortcomings of their predecessors and improve clinical outcomes.

METHODS

A systematic review and meta-analysis was carried out to compare Medtronic's Evolut PRO, a new valve, with the previous Evolut R design. Procedural, functional and clinical endpoints according to the VARC-2 criteria were assessed.

RESULTS

Eleven observational studies involving N = 12,363 patients were included. Evolut PRO patients differed regarding age (p < 0.001), sex (p < 0.001) and STS-PROM estimated risk. There was no difference between the two devices in terms of TAVI-related early complications and clinical endpoints. A 35% reduction of the risk of moderate-to-severe paravalvular leak (PVL) favoring the Evolut PRO was observed (RR 0.66, 95%CI, [0.52, 0.86] p = 0.002; I2 = 0%). Similarly, Evolut PRO-treated patients demonstrated a reduction of over 35% in the risk of serious bleeding as compared with the Evolut R (RR 0.63, 95%CI, [0.41, 0.96]; p = 0.03; I2 = 39%), without differences in major vascular complications.

CONCLUSIONS

The evidence shows good short-term outcomes of both the Evolut PRO and Evolut R prostheses, with no differences in clinical and procedural endpoints. The Evolut PRO was associated with a lower rate of moderate-to-severe PVL and major bleeding.

Environmental and socioeconomic determinants of heart failure

BACKGROUND

Over 1.5 million people in Poland suffer from heart failure (HF). The risk of hospitalization is related to environmental and socioeconomic factors and the organization of the healthcare system.

AIMS

The study aimed to assess the influence of environmental and socioeconomic factors on the prevalence of hospitalization for HF.

METHODS

The impact of environmental and socioeconomic factors on HF hospitalizations in Poland in 2012-2019 based on data from the National Institute of Public Health and Central Statistical Office in Poland was estimated by panel data regression techniques.

RESULTS

There were 1 618 734 HF-related hospitalizations (51.3% male; 82.6% aged >65 years). An increase in the number of physicians by 10/10 000 population and healthcare expenditure of 100 PLN per capita resulted in 3.5% (-0.035; 95% confidence interval [CI], -0.06 to -0.01; P = 0.002) and 3% (-0.029; 95% CI, -0.04 to -0.013; P <0.001) decrease in hospitalizations, respectively. For each new outpatient healthcare facility per 10 000 population, there was a 3% (-0.031; 95% CI, -0.048 to -0.014; P <0.001) decrease in hospitalizations. One percentage point increase in the proportion of green areas resulted in a 2.7% (-0.027; 95% CI, -0.042 to -0.01; P = 0.049) decrease in hospitalizations. However, an increase in cars by 1000 inhabitants and a 1 percentage point increase in the unemployment rate were associated with a 6% increase in HF hospitalizations (0.064; 95% CI, 0.008-0.121; P = 0.026).

CONCLUSIONS

The number of HF-related hospitalizations has been increasing in the last decade. This trend is most noticeable in regions with low socioeconomic development and poor medical facilities. Our study indicates that health policy measures including environmental and socioeconomic instruments may result in positive health outcomes. Additional analyses are needed to compare the impact of socioeconomic and environmental factors against the impact of healthcare alone.

Exposure to air pollution and its effect on ischemic strokes (EP-PARTICLES study)

It is well known that exceeded levels of particulate matter in the air and other air pollutants harmfully affect the cardiovascular system. Empirical analyses of the effects of these factors on stroke incidence and mortality are still limited. The main objective of our analyses was to determine the association between short-term exposure to air pollutants and stroke incidence in non-industrial areas, more specifically in north-eastern Poland. To achieve this aim, we used data from the National Health Fund on patients hospitalized for stroke between 2011 and 2020 in the largest city of the region described as the Green Lungs of Poland. The pollution levels and atmospheric conditions data were obtained from the Provincial Inspectorate for Environmental Protection and the Institute of Meteorology and Water Management. Using daily data on hospitalizations, atmospheric conditions, and pollution, as well as ordered logistic regression models the hypotheses on the impact of weather and air pollution conditions on ischemic strokes were tested. The study group included 4838 patients, 45.6% of whom were male; the average patient age was approximately 74 years. The average concentrations of PM_2.5 were 19.09 µg/m³, PM₁₀ 26.66 µg/m³ and CO 0.35 µg/m³. Analyses showed that an increase in PM_2.5 and PM₁₀ concentrations by 10 µg/m³ was associated with an increase in the incidence of stroke on the day of exposure (OR = 1.075, 95% CI 0.999-1.157, P = 0.053; OR = 1.056, 95% CI 1.004-1.110, P = 0.035) and the effect was even several times greater on the occurrence of a stroke event in general (PM_2.5: OR = 1.120, 95% CI 1.013-1.237, P = 0.026; PM₁₀: OR = 1.103, 95% CI 1.028-1.182, P = 0.006). Furthermore, a short-term (up to 3 days) effect of CO on stroke incidence was observed in the study area. An increase of 1 μg/m³ CO was associated with a lower incidence of stroke 2 days after the exposure (OR = 0.976, 95% CI 0.953-0.998, P = 0.037) and a higher incidence 3 days after the exposure (OR = 1.026, 95% CI 1.004-1.049, P = 0.022).

Do Patients with Atrial Fibrillation and a History of Ischemic Stroke Overuse Reduced Doses of NOACs?-Results of the Polish Atrial Fibrillation (POL-AF) Registry

BACKGROUND

The aim of our study was to assess if patients with AF (atrial fibrillation) and a history of ischemic stroke (IS) excessively receive reduced doses of NOACs (non-vitamin K antagonist oral anticoagulants).

METHODS

The Polish AF (POL-AF) registry is a prospective, observational, multicenter study, including patients with AF from 10 cardiology hospital centers. In this study we focused on patients with IS in their past.

RESULTS

Among 3999 patients enrolled in the POL-AF registry, 479 (12%) had a previous history of IS. Compared to patients without IS history, post-stroke subjects had a higher CHA₂DS₂-VASc score (median score 7 vs. 4, p < 0.05). Of these subjects, 439 (92%) had anticoagulation therapy, 83 (18.9%) were treated with a vitamin K antagonist (VKA), 135 (30.8%) with rivaroxaban, 112 (25.5%) with dabigatran, and 109 (24.8%) with apixaban. There were a significant number of patients after IS with reduced doses of NOACs (48.9% for rivaroxaban, 45.5% for dabigatran, and 36.7% for apixaban). In many cases, patients were prescribed reduced doses of NOACs without any indication for reduction (28.8% of rivaroxaban use, 56.9% of dabigatran use, and 60.0% of apixaban use-out of reduced dosage groups, p = 0.06).

CONCLUSIONS

A significant proportion of AF patients received reduced doses of NOAC after ischemic stroke in a sizeable number of cases, without indication for dose reduction.

Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER): protocol for a prospective observational nationwide study

INTRODUCTION

Atrial fibrillation (AF) is a prevalent disease considerably contributing to the worldwide cardiovascular burden. For patients at high thromboembolic risk (CHA₂DS₂-VASc ≥3) and not suitable for chronic oral anticoagulation, owing to history of major bleeding or other contraindications, left atrial appendage occlusion (LAAO) is indicated for stroke prevention, as it lowers patient's ischaemic burden without augmentation in their anticoagulation profile.

METHODS AND ANALYSIS

Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER) will be conducted in 10 heart surgery and cardiology centres across Poland to assess the outcomes of LAAO performed by fully thoracoscopic-epicardial, percutaneous-endocardial or hybrid endo-epicardial approach. The registry will include patients with nonvalvular AF at a high risk of thromboembolic and bleeding complications (CHA2DS2-VASc Score ≥2 for males, ≥3 for females, HASBLED score ≥2) referred for LAAO. The first primary outcome is composite procedure-related complications, all-cause death or major bleeding at 12 months. The second primary outcome is a composite of ischaemic stroke or systemic embolism at 12 months. The third primary outcome is the device-specific success assessed by an independent core laboratory at 3-6 weeks. The quality of life (QoL) will be assessed as well based on the QoL EQ-5D-5L questionnaire. Medication and drug adherence will be assessed as well.

ETHICS AND DISSEMINATION

Before enrolment, a detailed explanation is provided by the investigator and patients are given time to make an informed decision. The patient's data will be protected according to the requirements of Polish law, General Data Protection Regulation (GDPR) and hospital Standard Operating Procedures. The study will be conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the local Bioethics Committee of the Upper-Silesian Medical Centre of the Silesian Medical University in Katowice (decision number KNW/0022/KB/284/19). The results will be published in peer-reviewed journals and presented during national and international conferences.

TRIAL REGISTRATION NUMBER

NCT05144958.

Comparing Atrial-Fibrillation Validated Rapid Scoring Systems in the Long-Term Mortality Prediction in Patients Referred for Elective Coronary Angiography: A Subanalysis of the Białystok Coronary Project

Rapid scoring systems validated in patients with atrial fibrillation (AF) may be useful beyond their original purpose. Our aim was to assess the utility of CHA2DS2-VASc, HAS−BLED, and 2MACE scores in predicting long-term mortality in the population of the Białystok Coronary Project, including AF patients. The initial study population consisted of 7409 consecutive patients admitted for elective coronary angiography between 2007 and 2016. The study endpoint was all-cause mortality, which occurred in 1244 (16.8%) patients during the follow-up, ranging from 1283 to 3059 days (median 2029 days). We noticed substantially increased all-cause mortality in patients with higher values of all compared scores. The accuracy of the scores in predicting all-cause mortality was also assessed using the receiver operator characteristic (ROC) curves. The greatest predictive value for mortality was recorded for the CHA2DS2-VASc score in the overall study population (area under curve [AUC] = 0.665; 95% confidence interval [95%CI] 0.645−0.681). We observed that the 2MACE score (AUC = 0.656; 95%CI 0.619−0.681), but not the HAS−BLED score, had similar predictive value to the CHA2DS2-VASc score for all-cause mortality in the overall study population. In AF patients, all scores did not differ in all-cause mortality prediction. Additionally, we found that study participants with CHA2DS2-VASc score ≥3 vs. <3 had a 3-fold increased risk of long-term all-cause mortality (odds ratio 3.05; 95%CI 2.6−3.6). Our study indicates that clinical scores initially validated in AF patients may be useful for predicting mortality in a broader population (e.g., in patients referred for elective coronary angiography). According to our findings, all compared scores have a moderate predictive value. However, in our study, the CHA2DS2-VASc and 2MACE scores outperformed the HAS−BLED score in terms of the long-term all-cause mortality prediction.

The Expression Profiles of the Salvia miltiorrhiza 3-Hydroxy-3-methylglutaryl-coenzyme A Reductase 4 Gene and Its Influence on the Biosynthesis of Tanshinones

Salvia miltiorrhiza is a medicinal plant that synthesises biologically-active tanshinones with numerous therapeutic properties. An important rate-limiting enzyme in the biosynthesis of their precursors is 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGR). This study presents the organ-specific expression profile of the S. miltiorrhiza HMGR4 gene and its sensitivity to potential regulators, viz. gibberellic acid (GA₃), indole-3-acetic acid (IAA) and salicylic acid (SA). In addition, it demonstrates the importance of the HMGR4 gene, the hormone used, the plant organ, and the culture environment for the biosynthesis of tanshinones. HMGR4 overexpression was found to significantly boost the accumulation of dihydrotanshinone I (DHTI), cryptotanshinone (CT), tanshinone I (TI) and tanshinone IIA (TIIA) in roots by 0.44 to 5.39 mg/g dry weight (DW), as well as TIIA in stems and leaves. S. miltiorrhiza roots cultivated in soil demonstrated higher concentrations of the examined metabolites than those grown in vitro. GA₃ caused a considerable increase in the quantity of CT (by 794.2 µg/g DW) and TIIA (by 88.1 µg/g DW) in roots. In turn, IAA significantly inhibited the biosynthesis of the studied tanshinones in root material.

Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting for Treating In-Stent Restenosis in Unprotected-Left Main: LM-DRAGON-Registry

Background

Data regarding management of patients with unprotected left main coronary artery in-stent restenosis (LM-ISR) are scarce.

Objectives

This study investigated the safety and effectiveness of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) for the treatment of unprotected LM-ISR.

Methods

Consecutive patients who underwent PCI or CABG for unprotected LM-ISR were enrolled. The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE), defined as cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), and stroke.

Results

A total of 305 patients were enrolled, of which 203(66.6%) underwent PCI and 102(33.4%) underwent CABG. At 30-day follow-up, a lower risk of cardiac death was observed in the PCI group, compared with the CABG-treated group (2.1% vs. 7.1%, HR 3.48, 95%CI 1.01–11.8, p = 0.04). At a median of 3.5 years [interquartile range (IQR) 1.3–5.5] follow-up, MACCE occurred in 27.7% vs. 29.6% (HR 0.82, 95%CI 0.52–1.32, p = 0.43) in PCI- and CABG-treated patients, respectively. There were no significant differences between PCI and CABG in cardiac death (9.9% vs. 18.4%; HR 1.56, 95%CI 0.81–3.00, p = 0.18), MI (7.9% vs. 5.1%, HR 0.44, 95%CI 0.15–1.27, p = 0.13), or stroke (2.1% vs. 4.1%, HR 1.79, 95%CI 0.45–7.16, p = 0.41). TVR was more frequently needed in the PCI group (15.2% vs. 6.1%, HR 0.35, 95%CI 0.15–0.85, p = 0.02).

Conclusions

This analysis of patients with LM-ISR revealed a lower incidence of cardiac death in PCI compared with CABG in short-term follow-up. During the long-term follow-up, no differences in MACCE were observed, but patients treated with CABG less often required TVR.

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Registration

https://www.clinicaltrials.gov; Unique identifier: NCT04968977.

Long-term outcomes following drug-eluting balloons vs. thin-strut drug-eluting stents for treatment of recurrent restenosis in drug-eluting stents

BACKGROUND

There is limited data on the optimal revascularization strategy in patients with recurrent in-stent restenosis (R-ISR).

AIMS

To compare the long-term outcomes of patients treated with either a thin-strut drug-eluting stent (thin-DES) or a drug-eluting balloon (DEB) for R-ISR in a drug-eluting stent (DES).

METHODS

A multicenter DEB-DRAGON registry was used to retrospectively identify patients with R-ISR who received either a thin-DES or a DEB. Propensity score matching was applied to adjust for baseline differences. The primary outcome was target lesion revascularization (TLR).

RESULTS

Out of 311 patients (mean age, 67 years; 63% male) with R-ISR, 86 (27.7%) were treated with a thin-DES and 225 (72.3%) with a DEB. Median follow-up was 2.6 years. TLR occurred in 18 (20.9%) patients who received thin-DES and 61 (27.1%) patients treated with DEB (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33-0.98; log-rank P = 0.04). The difference remained significant in a propensity score-matched cohort of 57 patients treated with thin-DES and 57 patients treated with a DEB (17.5 vs. 33.3%, respectively; HR, 0.38; 95% CI, 0.17-0.86; P = 0.01). The risks of device-oriented adverse cardiac events and all-cause mortality were similar after thin-DES or DEB in both unadjusted and propensity score-matched cohorts. In a multivariable Cox proportional hazard model, the treatment with a thin-DES was an independent predictor of a TLR-free survival (HR, 0.33; 95% CI 0.13-0.84; P = 0.02).

CONCLUSIONS

In patients with R-ISR implantation of a thin-DES is associated with a lower risk of repeated revascularization compared with angioplasty with a DEB.

Intravascular Lithotripsy for the Treatment of Stent Underexpansion: The Multicenter IVL-DRAGON Registry

Background: Whereas the efficacy and safety of intravascular lithotripsy (IVL) have been confirmed in de novo calcified coronary lesions, little is known about its utility in treating stent underexpansion. This study aimed to investigate the impact of IVL in treating stent underexpansion. Methods and Results: Consecutive patients with stent underexpansion treated with IVL entered the multicenter IVL-Dragon Registry. The procedural success (primary efficacy endpoint) was defined as a relative stent expansion >80%. Thirty days device-oriented composite endpoint (DOCE) (defined as a composite of cardiac death, target lesion revascularization, or target vessel myocardial infarction) was the secondary endpoint. A total of 62 patients were enrolled. The primary efficacy endpoint was achieved in 72.6% of patients. Both stent underexpansion 58.5% (47.5−69.7) vs. 11.4% (5.8−20.7), p < 0.001, and the stenotic area 82.6% (72.4−90.8) vs. 21.5% (11.1−37.2), p < 0.001, measured by quantitative coronary angiography improved significantly after IVL. Intravascular imaging confirmed increased stent expansion following IVL from 37.5% (16.0−66.0) to 86.0% (69.2−90.7), p < 0.001, by optical coherence tomography and from 57.0% (31.5−77.2) to 89.0% (85.0−92.0), p = 0.002, by intravascular ultrasound. Secondary endpoint occurred in one (1.6%) patient caused by cardiac death. There was no target lesion revascularization or target vessel myocardial infarction during the 30-day follow-up. Conclusions: In this real-life, largest-to-date analysis of IVL use to manage underexpanded stent, IVL proved to be an effective and safe method for facilitating stent expansion and increasing luminal gain.

Methyl Jasmonate Activates the 2C Methyl-D-erithrytol 2,4-cyclodiphosphate Synthase Gene and Stimulates Tanshinone Accumulation in Salvia miltiorrhiza Solid Callus Cultures

The present study characterizes the 5′ regulatory region of the SmMEC gene. The isolated fragment is 1559 bp long and consists of a promoter, 5′UTR and 31 nucleotide 5′ fragments of the CDS region. In silico bioinformatic analysis found that the promoter region contains repetitions of many potential cis-active elements. Cis-active elements associated with the response to methyl jasmonate (MeJa) were identified in the SmMEC gene promoter. Co-expression studies combined with earlier transcriptomic research suggest the significant role of MeJa in SmMEC gene regulation. These findings were in line with the results of the RT-PCR test showing SmMEC gene expression induction after 72 h of MeJa treatment. Biphasic total tanshinone accumulation was observed following treatment of S. miltiorrhiza solid callus cultures with 50–500 μM methyl jasmonate, with peaks observed after 10–20 and 50–60 days. An early peak of total tanshinone concentration (0.08%) occurred after 20 days of 100 μM MeJa induction, and a second, much lower one, was observed after 50 days of 50 μM MeJa stimulation (0.04%). The dominant tanshinones were cryptotanshinone (CT) and dihydrotanshinone (DHT). To better understand the inducing effect of MeJa treatment on tanshinone biosynthesis, a search was performed for methyl jasmonate-responsive cis-active motifs in the available sequences of gene proximal promoters associated with terpenoid precursor biosynthesis. The results indicate that MeJa has the potential to induce a significant proportion of the presented genes, which is in line with available transcriptomic and RT-PCR data.

Atrial fibrillation is a predictor of nonobstructive coronary artery disease in elective angiography in old age: a cross-sectional study in Poland and Russia

BACKGROUND

Significant changes in the coronary vessels are not confirmed in a large proportion of patients undergoing cardiac catheterization.

AIMS

The present study aimed to determine correlates and independent predictors of nonobstructive coronary artery disease (CAD) in older adults referred for elective coronary angiography.

METHODS

A cross-sectional study was conducted involving 2,214 patients referred to two medical centers (in Poland and Russia) between 2014 and 2016 for elective coronary angiography due to exacerbated angina, despite undergoing optimal therapy for CAD. The median age was 72 years (IQR: 68-76), and 49.5% patients were women.

RESULTS

Significant stenosis (defined as stenosis of 50% or more of the diameter of the left main coronary artery stem or stenosis of 70% or more of the diameter of the remaining major epicardial vessels) was diagnosed only in 1135 (51.3%) patients. Female sex (odds ratio [OR], 3.01; 95% confidence interval [CI], 2.44-3.72; p < 0.001) and atrial fibrillation (OR, 1.87; 95% CI 1.45-2.40; p < 0.001) were the main independent predictors of nonobstructive CAD. Significantly lower ORs were observed for diabetes (OR, 0.75; 95% CI 0.59-0.95; p = 0.02), chronic kidney disease (OR, 0.76; 95% CI 0.61-0.96; p = 0.02), and anemia (OR, 0.69; 95% CI 0.50-0.95; p = 0.02) after controlling for age, chronic heart failure, BMI, and study center.

DISCUSSION AND CONCLUSIONS

The results confirmed that nonobstructive CAD occurs in a high percentage of older patients referred for elective coronary angiography. This suggests the need to improve patient stratification for invasive diagnosis of CAD, especially for older women and patients with atrial fibrillation. Trial registration number and date of registration: NCT04537507, September 3, 2020.

The effect of different light treatments on morphogenesis, phenolic compound accumulation and antioxidant potential of Dracocephalum forrestii transformed shoots cultured in vitro

The aim of this study was to evaluate the effects of wavelengths of light emitted from LEDs on cultured in vitro transformed shoots of Dracocephalum forrestii. The shoots were grown on MS agar medium with 0.5 mg/l BPA (N-benzyl-9-(tetrahydropyranyl)-adenine) and 0.2 mg/l IAA (indole-3-acetic acid) under four light environments: blue, red, red/blue (7:3) and white (control). After four weeks of culture, shoot multiplication rate, biomass and morphology were evaluated, as well as bioactive phenolic content, antioxidant capacities and antioxidant enzyme activities. The hydromethanolic extracts from shoots were analyzed using UHPLC method, and antioxidant potential was evaluated using radical scavenging (1,1-diphenyl-2-picrohydrazyl and superoxide anion), and ferric reducing antioxidant power (FRAP), and enzymatic methods, i.e. sodium dismutase (SOD), catalase (CAT) and peroxidase (POD) activity. It was found that the blue and red/blue light had the strongest effect on morphogenesis and shoot propagation; in these conditions, more than five new shoots were obtained per explant. The blue light cultures demonstrated the highest fresh (0.41 g/tube FW) and dry weights (0.045 g/tube DW), the highest levels of polyphenols (99.7 mg/g DW), i.e. almost three times greater than under white light (35.4 mg/g DW), as well as the highest antioxidant potential. Therefore, LED culture appears to be a beneficial strategy for enhancing the production of the medicinal value of transformed D. forrestii shoot culture.

Predicting Mortality in Patients with Atrial Fibrillation and Obstructive Chronic Coronary Syndrome: The Bialystok Coronary Project

Over the next decades, the prevalence of atrial fibrillation (AF) is estimated to double. Our aim was to investigate the causes of the long-term mortality in relation to the diagnosis of atrial fibrillation (AF) and chronic coronary syndrome (CCS). The analysed population consisted of 7367 consecutive patients referred for elective coronary angiography enrolled in a large single-centre retrospective registry, out of whom 1484 had AF and 2881 were diagnosed with obstructive CCS. During follow-up (median = 2029 days), 1201 patients died. The highest all-cause death was seen in AF(+)/CCS(+) [194/527; 36.8%], followed by AF(+)/CCS(−) [210/957; 21.9%], AF(−)/CCS(+) [(459/2354; 19.5%)] subgroups. AF ([HR]_AC = 1.48, 95%CI, 1.09–2.01; HR_CV = 1.34, 95%CI, 1.07–1.68) and obstructive CCS (HR_AC = 1.90, 95%CI, 1.56–2.31; HR_CV = 2.27, 95%CI, 1.94–2.65) together with age, male gender, heart failure, obstructive pulmonary disease, diabetes were predictors of both all-cause and CV mortality. The main findings are as follow among patients referred for elective coronary angiography, both AF and obstructive CCS are strong and independent predictors of the long-term mortality. Mortality of AF without CCS was at least as high as non-AF patients with CCS. CV deaths were more frequent than non-CV deaths in AF patients with CCS compared to those with either AF or CCS alone.

Long-Term Outcomes Following Drug-Eluting Balloons Versus Thin-Strut Drug-Eluting Stents for Treatment of In-Stent Restenosis (DEB-Dragon-Registry)

[Figure: see text].

Novel Iron Parameters in Patients with Type 2 Diabetes Mellitus in Relation to Kidney Function

BACKGROUND/AIMS

Anemia of chronic disease is a common feature in diabetes and chronic kidney disease. Hepcidin is the key element involved in iron metabolism; however, studies on new indices of iron status are still ongoing. The aim of the study was to assess novel iron parameters in patients with type 2 diabetes mellitus in relation to kidney function.

METHODS

The study included 80 type 2 diabetic patients and 23 healthy volunteers. Standard laboratory measurements were used to measure the iron status, complete blood count, creatinine, the estimated glomerular filtration rate (eGFR), serum lipids, and brain natriuretic peptides (BNPs). Commercially available kits were used to measure hepcidin-25, the soluble transferrin receptor (sTfR), growth differentiation factor-15 (GDF-15), and hypoxia-inducible factor-1 alpha.

RESULTS

Anemia was present in 65% of the studied patients. The control group was found to have significantly higher hepcidin, sTfR, and GDF-15, and lower hemoglobin and iron. When compared with patients with eGFR values ≥60 mL/min/1.73 m² and <60 mL/min/1.73 m², we found that patients with higher eGFR had higher hemoglobin, ferritin, and HIF-1 alpha, lower BNP, and were younger. We found that levels of HIF-1 alpha are negligible in the studied population and were related to age only in patients with eGFR values ≥60 mL/min/1.73 m².

CONCLUSION

A comprehensive assessment of iron status is rarely performed. Novel biomarkers of iron metabolism are not generally related to kidney function. Whether the assessment of HIF-1 alpha would be a marker of efficient anemia therapy with HIF-prolyl hydroxylase inhibitors is still a matter for further study.

Exposure to air pollution and renal function

Air pollution contributes to the premature death of approximately 428,000 citizens of Europe every year. The adverse effects of air pollution can be observed in respiratory, circulatory systems but also in renal function. We decide to investigate the hypothesis indicating that we can observe not only long- but also short-term impact of air pollution on kidney function. We used linear, log-linear, and logistic regression models to assess the association between renal function and NO2, SO2, and PMs. Results are reported as beta (β) coefficients and odds ratios (OR) for an increase in interquartile range (IQR) concentration. 3554 patients (median age 66, men 53.2%) were included into final analysis. Chronic kidney disease (CKD) was diagnosed in 21.5%. The odds of CKD increased with increase in annual concentration of PM2.5 (OR for IQR increase = 1.07; 95% CI 1.01-1.15, P = 0.037) and NO2 (OR for IQR increase = 1.05; 95% CI 1.01-1.10, P = 0.047). The IQR increase in weekly PM2.5 concentration was associated with 2% reduction in expected eGFR (β = 0.02, 95% CI - 0.03; - 0.01). Medium- and short-term exposure to elevated air pollution levels was associated with a decrease in eGFR and development CKD. The main pollutants affecting the kidneys were PM2.5 and NO2.

Impact of short-term air pollution exposure on acute coronary syndrome in two cohorts of industrial and non-industrial areas: A time series regression with 6,000,000 person-years of follow-up (ACS - Air Pollution Study)

BACKGROUND

There is a lack of studies directly comparing the effect of air pollution on acute coronary syndrome (ACS) occurrence in industrial and non-industrial areas.

OBJECTIVES

A comparison of association of air pollution exposure with ACS in two cohorts of industrially different areas.

MATERIALS AND METHODS

The study covered 6,000,000 person-years of follow-up and five pollutants between 2008 and 2017. A time series regression analysis with 7-lag was used to assess the effects air pollution on ACS.

RESULTS

A total of 9046 patients with ACS were included in the analysis, of whom 3895 (43.06%) had ST-elevation myocardial infarction (STEMI) - 45.39% from non-industrial area, and 42.37% from industrial area; and 5151 (56.94%) had non-ST-elevation myocardial infarction (NSTEMI) - 54.61% from non-industrial area and 57.63% from industrial area. The daily concentrations of PM_2.5, PM₁₀, NO₂, SO₂, CO were higher in industrial than in non-industrial area (P < 0.001). In non-industrial area, an increase of 10 μg/m³ of NO₂ concentration (Odds Ratio (OR) = 1.126, 95%CI = 1.009-1.257; P = 0.034, lag-0) and an increase of 1 mg/m³ in CO concentration (RR = 1.055, 95%CI = 1.010-1.103; P = 0.017, lag-0) were associated with an increase in the number of hospitalization due to NSTEMI (for industrial area increase of 10 μg/m³ in NO₂ (OR = 1.062, 95%CI = 1.020-1.094; P = 0.005, lag-0), SO₂ (OR = 1.061, 95%CI = 1.010-1.116; P = 0.018, lag-4), PM₁₀ (OR = 1.010, 95%CI = 1.001-1.030; P = 0.047, lag-6). In STEMI patients in industrial area, an increased hospitalization was found to be associated with an increase of 10 μg/m³ in SO₂ (OR = 1.094, 95%CI = 1.030-1.162; P = 0.002, lag-1), PM_2.5 (OR = 1.041, 95%CI = 1.020-1.073; P < 0.001, lag-1), PM₁₀ (OR = 1.030, 95%CI = 1.010-1.051; P < 0.001, lag-1). No effects of air pollution on the number of hospitalization due to STEMI were noted from non-industrial area.

CONCLUSION

The risk of air pollution-related ACS was higher in industrial over non-industrial area. The effect of NO₂ on the incidence of NSTEMI was observed in both areas. In industrial area, the effect of PMs and SO₂ on NSTEMI and STEMI were also observed. A clinical effect was more delayed in time in patients with NSTEMI, especially after exposure to PM₁₀. Chronic exposure to air pollution may underlie the differences in the short-term effect between particulate air pollution impact on the incidence of STEMI.

Procedural and 1-year outcomes following large vessel coronary artery perforation treated by covered stents implantation: Multicentre CRACK registry

Background

Data regarding the clinical outcomes of covered stents (CSs) used to seal coronary artery perforations (CAPs) in the all-comer population are scarce. The aim of the CRACK Registry was to evaluate the procedural, 30-days and 1-year outcomes after CAP treated by CS implantation.

Methods

This multicenter all-comer registry included data of consecutive patients with CAP treated by CS implantation. The primary endpoint was the composite of major adverse cardiac events (MACEs), defined as cardiac death, target lesion revascularization (TLR), and myocardial infarction (MI).

Results

The registry included 119 patients (mean age: 68.9 ± 9.7 years, 55.5% men). Acute coronary syndrome, including: unstable angina 21 (17.6%), NSTEMI 26 (21.8%), and STEMI 26 (21.8%), was the presenting diagnosis in 61.3%, and chronic coronary syndromes in 38.7% of patients. The most common lesion type, according to ACC/AHA classification, was type C lesion in 47 (39.5%) of cases. A total of 52 patients (43.7%) had type 3 Ellis classification, 28 patients (23.5%) had type 2 followed by 39 patients (32.8%) with type 1 perforation. Complex PCI was performed in 73 (61.3%) of patients. Periprocedural death occurred in eight patients (6.7%), of which two patients had emergency cardiac surgery. Those patients were excluded from the one-year analysis. Successful sealing of the perforation was achieved in 99 (83.2%) patients. During the follow-up, 26 (26.2%) patients experienced MACE [7 (7.1%) cardiac deaths, 13 (13.1%) TLR, 11 (11.0%) MIs]. Stent thrombosis (ST) occurred in 6 (6.1%) patients [4(4.0%) acute ST, 1(1.0%) subacute ST and 1(1.0%) late ST].

Conclusions

The use of covered stents is an effective treatment of CAP. The procedural and 1-year outcomes of CAP treated by CS implantation showed that such patients should remain under follow-up due to relatively high risk of MACE.

Primary Takotsubo Syndrome as a Complication of Bladder Cancer Treatment in a 62-Year-Old Woman

BACKGROUND The main causes for takotsubo syndrome (TS) in oncological patients are stress related to cancer diagnosis and treatment, pain in the course of the disease, treatment complications, and paraneoplastic syndromes. CASE REPORT An obese 62-year-old female patient, with a 3-day history of chest pain, was admitted to the hospital with a suspected acute coronary event. She had been diagnosed with high-grade bladder cancer 6 months before. After the transurethral electroresection of the tumor 5 months before and subsequent chemotherapy (gemcitabine and cisplatin), the patient was qualified for the next cancer surgery. On admission, the patient remained without chest pain. The ECG record demonstrated inverted T waves in the leads from above the anterior and lateral wall. The coronarography demonstrated minor atherosclerotic changes in the coronary arteries. The left ventriculography presented akinesis of the apex and the apical and mid-segment of the anterior wall, and the ejection fraction (EF) was 38%. Takotsubo syndrome was diagnosed. Laboratory testing revealed elevated concentration of troponin and N-terminal pro-B-type natriuretic peptide. The subsequent ECG records demonstrated deeply inverted T waves and numerous ventricular premature beats and increased QTc (528 ms). A control echocardiography showed improved left ventricular contractive function (EF - 47%). On the 4th day of hospitalization, the patient was discharged and referred for further oncological treatment. CONCLUSIONS The diagnosis of TS in oncology patients is difficult, especially in the presence of atherosclerotic lesions in coronary arteries. Takotsubo syndrome in cancer patients delays the next stages of oncological treatment, which worsens the prognosis of these patients.

Impact of chronic kidney disease on long-term outcome of patients with valvular heart defects

INTRODUCTION

Valvular heart diseases (VHD) are becoming a significant problem in the Polish population. Coexistence of chronic kidney disease (CKD) in patients with VHD increases the risk of death and affects further therapeutic strategy.

AIM

Analysis impact of CKD on long-term prognosis in patients with VHD.

MATERIAL AND METHODS

The inclusion criteria were met by 1025 patients with moderate and severe VHD. Mean observation time was 2528 ± 1454 days.

RESULTS

The average age of the studied population was 66.75 (SD = 10.34), male gender was dominant 56% (N = 579). Severe aortic valve stenosis (AVS) occurred in 28.2%, severe mitral valve insufficiency (MVI) in 20%. CKD occurred in 37.1% (N = 380) patients mostly with mitral stenosis (50%, N = 16) and those with severe MVI (44.8%, N = 94). During the observational period, 52.7% (N = 540) deaths were noted. Increased risk of mortality was associated mostly with age (OR: 1.02, 95% CI: 1.00-1.03, p < 0.001), creatinine (OR:1.27, 95% CI: 1.12-1.43, p < 0.001), CKD (OR: 1.30, 95% CI: 1.17-1.44, p < 0.001), reduced ejection fraction (EF) (OR: 0.98, 95% CI: 0.97-0.99, p = 0.01) and coexisting of AVS (OR: 1.19, 95% CI: 1.04-1.35, p = 0.01).

CONCLUSIONS

Mitral valve defects more often than aortic valve defects coexist with chronic kidney disease. Regardless of the stage, chronic kidney disease is an additional factor affecting the prognosis in patients with heart defects. Factors increasing the risk of death were age, creatinine concentration and reduced EF. The monitoring of renal function in patients with VHD should be crucial as well as the implementation of treatment at an early stage.

The effect of serum uric acid levels on the long-term prognosis of patients with non-ST-elevation myocardial infarction

BACKGROUND

Cardiovascular diseases (CVD) are the leading cause of death worldwide. Many studies have reported an association between serum uric acid (sUA) and CVD, and its role as a risk marker for mortality.

OBJECTIVES

To assess the relationship between sUA levels and the long-term prognosis of patients with non-ST-elevation myocardial infarction (NSTEMI).

MATERIAL AND METHODS

The study was conducted at the Clinical Hospital of Białystok (Poland). Based on medical records, 9328 patients were hospitalized between 2011 and 2013, of which 726 had NSTEMI. The exclusion criteria were: any diagnosed neoplasms and estimated glomerular filtration rate (eGFR) <15 mL/min. The average observation time was 2324 days.

RESULTS

A total of 549 patients were qualified for the analysis; men were in the majority (69.03%, n = 379), and the mean age was 68.42 years (standard deviation (SD) = 11.66). The sUA norm was exceeded in 137 of the patients (24.95%). Hyperuricemia is more likely to occur in women (risk ratio (RR) = 1.52, 95% confidence interval (95% CI) = 1.016-2.288, p = 0.042), in patients with chronic kidney disease (CKD) (RR = 3.452, 95% CI = 2.432-4.854, p < 0.001) and in patients with higher body mass index (BMI)s (RR = 1.048, 95% CI = 1.008-1.090, p = 0.018). In the whole study group, during the study, 178 of the patients died (32.41.9%), more often those with hyperuricemia: (60/137 patients (43.8%)) compared to patients with normal sUA values (118/412 values (28.64%)); p < 0.001). There was a significant correlation between an increase in sUA levels and an increase in mortality (p < 0.001). Independent risk factors of death were age (RR = 1.086, 95% CI = 1.065-1.108, p < 0.001), sUA (RR = 1.245, 95% CI = 1.131-1.370, p = 0.041), ejection fraction (EF) (RR = 0.928, 95% CI = 0.910-0.946, p < 0.001) and hemoglobin concentration (RR = 0.685, 95% CI = 0.611-0.768, p < 0.001).

CONCLUSIONS

Serum UA concentration is an independent risk factor of long-term mortality in patients who have undergone NSTEMI, and is associated with higher in-hospital death rates. Secondary prevention after NSTEMI should entail management of the patients' sUA levels.

Effectiveness of Levosimendan in an 84-Year-Old Patient with Takotsubo Syndrome Complicated by Acute Heart Failure

BACKGROUND Although takotsubo syndrome (TTS) is usually mild, severe complications such as acute heart failure may occur in the acute phase. Because of the etiology of TTS, typical catecholamines are not recommended; the use of inotropic drugs with a different mechanism of action is recommended, mainly levosimendan. CASE REPORT An 84-year-old patient with cardiovascular risk factors, hospitalized in a city hospital because of exacerbation of chronic obstructive pulmonary disease (COPD), was transferred to the clinic with suspected myocardial infarction. At the time of admission, the patient was hemodynamically stable. The coronarography indicated insignificant atherosclerotic lesions in the coronary arteries. The echocardiography revealed apical akinesis and hypokinesis of the apical and middle left ventricular segments (LV). The ejection fraction (EF) was 40%. TTS was diagnosed. After 12 h of hospitalization, the patient developed symptoms of acute heart failure, with deterioration of the LV systolic function (EF 30%). Levosimendan was included in the treatment, which led to an increased blood pressure and clinical improvement after several hours. Over the next few days, the patient's condition improved and he was transferred to the referral center, from which he was discharged to home. CONCLUSIONS In patients with COPD, exacerbation of the disease may be a trigger for TTS. In acute heart failure complicating TTS, administration of levosimendan improves the clinical condition of patients.

Atrial fibrillation is more frequently associated with nonobstructive coronary lesions: the Bialystok Coronary Project

INTRODUCTION

Atrial fibrillation (AF) and chronic coronary syndrome (CCS) share common risk factors and frequently coexist. Additionally, AF symptoms may mimic CCS.

OBJECTIVES

The aim of the study was to investigate the hypothesis indicating absence of significant coronary lesions in patients with AF as compared with those with sinus rhythm.

PATIENTS AND METHODS

We conducted a single‑center retrospective study including consecutive patients referred for elective coronary angiography between 2007 and 2016.

RESULTS

The study population included 8288 patients out of whom 1674 had AF. There were substantial differences between groups with and without AF. Patients with AF were significantly older, more often were men and had diabetes, and more frequently were diagnosed with both chronic kidney disease and heart failure. On the other hand, they had history of hyperlipidemia less often. CCS was less frequently detected in patients with AF as compared with those with sinus rhythm (37.5% vs 41.1%; P <0.001). Additionally, the latter group more often underwent subsequent coronary angioplasty (19.2% vs 22.3%; P = 0.004). Multivariable analysis identified AF as an independent factor associated with absence of significant coronary lesions (odds ratio, 1.57; 95% CI, 1.32-1.87; P <0.001). Moreover, a comparison between patients with and without angiographically significant CCS revealed a higher prevalence of AF in the latter group (18.7% vs 21.2%; P = 0.006).

CONCLUSIONS

In our study, AF was associated with the absence of significant coronary lesions on angiography, reflecting difficulties with qualifying patients with AF for invasive CCS diagnostic workup. Our findings suggest the need for more efficacious noninvasive diagnostic approach for patients with AF and suspected CCS.

Transformed Shoots of Dracocephalum forrestii W.W. Smith from Different Bioreactor Systems as a Rich Source of Natural Phenolic Compounds

Transformed shoots of the Tibetan medicinal plant Dracocephalum forrestii were cultured in temporary immersion bioreactors (RITA and Plantform) and in nutrient sprinkle bioreactor (NSB) for 3 weeks in MS (Murashige and Skoog) liquid medium with 0.5 mg/L BPA (N-benzyl-9-(2-tetrahydropyranyl)-adenine) and 0.2 mg/L IAA (indole-3-acetic acid). The greatest biomass growth index (GI = 52.06 fresh weight (FW) and 55.67 dry weight (DW)) was observed for shoots in the RITA bioreactor, while the highest multiplication rate was found in the NSB (838 shoots per bioreactor). The levels of three phenolic acids and five flavonoid derivatives in the shoot hydromethanolic extract were evaluated using UHPLC (ultra-high performance liquid chromatography). The predominant metabolite was rosmarinic acid (RA)—the highest RA level (18.35 mg/g DW) and total evaluated phenol content (24.15 mg/g DW) were observed in shoots grown in NSB. The NSB culture, i.e., the most productive one, was evaluated for its antioxidant activity on the basis of reduction of ferric ions (ferric reducing antioxidant power, FRAP) and two scavenging radical (O₂^•– and DPPH, 1,1-diphenyl-2-picrylhydrazyl radical) assays; its antibacterial, antifungal, and antiproliative potential against L929 cells was also tested (3-[4,5-dimethylthiazole-2-yl]-2,5-diphenyltetrazolium bromide (MTT) test). The plant material revealed moderate antioxidant and antimicrobial activities and demonstrated high safety in the MTT test—no cytotoxicity at concentrations up to 50 mg/mL was found, and less than a 20% decrease in L929 cell viability was observed at this concentration.

Impact of renal function on patients with acute coronary syndromes: 15,593 patient-years study

Introduction

Coexistence of chronic kidney disease (CKD) in the case of acute coronary syndromes (ACS) significantly worsens the outcomes.

Aim

The aim of our study was to assess renal function impact on mortality among patients with ACS.

Materials and methods

The study was based on records of 21,985 patients hospitalized in the Medical University of Bialystok in 2009–2015. Inclusion criteria were ACS. Exclusion criteria were: death within 24 h of admission, eGFR <15 ml/min/1.73 m², hemodialysis. Mean observation time was 2296 days.

Results

Criteria were met by 2213 patients. CKD occurred in 24.1% (N = 533) and more often affected those with NSTEMI (26.2 (337) vs. 21.2 (196), p = .006). STEMI patients had higher incidence of post-contrast acute kidney injury (PC-AKI) (5 (46) vs. 4.1 (53), p < .001). During the study, 705 people died (31.9%), more often with NSTEMI (33.2% (428) vs. 29.95% (277), p < .001). However, from a group of patients suffering from PC-AKI 57.6% died. The risk of PC-AKI increased with creatinine concentration (RR: 2.990, 95%CI: 1.567–5.721, p < .001), occurrence of diabetes mellitus (RR: 2.143, 95%CI: 1.029–4.463, p = .042), atrial fibrillation (RR: 2.289, 95%CI: 1.056–4.959, p = .036). Risk of death was greater with an increase in postprocedural creatinine concentration (RR: 2.254, 95%CI: 1.481–3.424, p < .001).

Conclusion

PC-AKI is a major complication in patients with ACS, occurs more frequently in STEMI and may be a prognostic marker of long-term mortality in patients undergoing percutaneous coronary intervention (PCI). More attention should be given to the prevention and diagnosis of PC-AKI but necessary PCI should not be withheld in fear of PC-AKI.

Exposure to air pollution-a trigger for myocardial infarction? A nine-year study in Bialystok-the capital of the Green Lungs of Poland (BIA-ACS registry)

OBJECTIVES

This study aimed to assess the effect of air pollution and weather conditions on the frequency of hospital admissions due to acute coronary syndrome (ACS) in the population of Bialystok, known as the capital of the Green Lungs of Poland.

MATERIALS AND METHODS

The study analyzed the medical records of 2,645 patients living within the borders of Bialystok who were treated for ACS between 2009 and 2017 and the data on air pollutants-nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter with a diameter of 2.5 μm or less (PM_2.5) and 10 μm or less (PM₁₀)-and the basic meteorological factors (temperature, humidity, and atmospheric pressure). A time-stratified case-crossover study design was applied to assess the effects of particulate matter, the concentration of gases, and weather conditions on ACS.

RESULTS

The number of patients admitted for ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA) was 791, 999, and 855, respectively. The daily concentration norm for PM_2.5 recommended by the World Health Organization (WHO) was exceeded in 692 days (i.e., 24.58% of the observation period). The significant increase in the number of ACS hospitalizations was associated with an interquartile-range increase in NO₂ concentration, with an odds ratio of 1.08 (95% confidence interval (CI): 1.02-1.15, P = 0.01), 1.09 (95% CI: 1.01-1.18, P = 0.03), and 1.11 (95% CI: 1.00-1.22, P = 0.048) for patients with ACS, NSTEMI, and UA, respectively.

CONCLUSION

The study showed that the effects of air pollution and weather conditions on the number of ACS hospitalizations are also observed in cities with moderately polluted or good air quality. NO₂ was identified as the main air pollutant affecting the incidence of ACS.

Gender Differences in Association between Air Pollution and Daily Mortality in the Capital of the Green Lungs of Poland-Population-Based Study with 2,953,000 Person-Years of Follow-Up

(1) Introduction: air pollution is considered to be one of the main risk factors for public health. According to the European Environment Agency (EEA), air pollution contributes to the premature deaths of approximately 500,000 citizens of the European Union (EU), including almost 5000 inhabitants of Poland every year. (2) Purpose: to assess the gender differences in the impact of air pollution on the mortality in the population of the city of Bialystok-the capital of the Green Lungs of Poland. (3) Materials and Methods: based on the data from the Central Statistical Office, the number-and causes of death-of Białystok residents in the period 2008-2017 were analyzed. The study utilized the data recorded by the Provincial Inspectorate for Environmental Protection station and the Institute of Meteorology and Water Management during the analysis period. Time series regression with Poisson distribution was used in statistical analysis. (4) Results: A total of 34,005 deaths had been recorded, in which women accounted for 47.5%. The proportion of cardiovascular-related deaths was 48% (n = 16,370). An increase of SO2 concentration by 1-µg/m3 (relative risk (RR) 1.07, 95% confidence interval (CI) 1.02-1.12; p = 0.005) and a 10 °C decrease of temperature (RR 1.03, 95% CI 1.01-1.05; p = 0.005) were related to an increase in the number of daily deaths. No gender differences in the impact of air pollution on mortality were observed. In the analysis of the subgroup of cardiovascular deaths, the main pollutant that was found to have an effect on daily mortality was particulate matter with a diameter of 2.5 μm or less (PM2.5); the RR for 10-µg/m3 increase of PM2.5 was 1.07 (95% CI 1.02-1.12; p = 0.01), and this effect was noted only in the male population. (5) Conclusions: air quality and atmospheric conditions had an impact on the mortality of Bialystok residents. The main air pollutant that influenced the mortality rate was SO2, and there were no gender differences in the impact of this pollutant. In the male population, an increased exposure to PM2.5 concentration was associated with significantly higher cardiovascular mortality. These findings suggest that improving air quality, in particular, even with lower SO2 levels than currently allowed by the World Health Organization (WHO) guidelines, may benefit public health. Further studies on this topic are needed, but our results bring questions whether the recommendations concerning acceptable concentrations of air pollutants should be stricter, or is there a safe concentration of SO2 in the air at all.

The Stimulatory Effect of Purine-Type Cytokinins on Proliferation and Polyphenolic Compound Accumulation in Shoot Culture of Salvia Viridis

The present study demonstrates hormonal control of Salvia viridis growth and development using four different purine-type cytokinins at different concentrations. The addition of cytokinins significantly increased biomass of cultures, proliferation rate, and, interestingly, secondary metabolite production. The best response in terms of multiplication ratio was recorded on Murashige and Skoog medium supplemented with 0.5 mg/L BPA (N-benzylotetrahydropyranyl adenine), while the greatest biomass accumulation was achieved when supplemented with 1 mg/L m-T (meta-topoline). Quantitative UPLC-DAD analysis of the hydromethanolic extract from S. viridis culture revealed the presence of 12 polyphenols: seven phenolic acids and five phenylethanoids. The highest total content of polyphenolic compounds was found in shoots cultivated on medium with 2 mg/L BPA (18.66 mg/g DW): almost twice that of control shoots. The medium was also the most optimal for the biosynthesis of rosmarinic acid, the predominant phenolic acid. However, the greater phenylethanoid accumulation was stimulated by 1 mg/L m-T: the metabolite content was above three times higher than that found in shoots grown on the control medium (8.03 mg/g DW vs. 2.37 mg/g DW). Hence, it was demonstrated that phytohormones are capable of influencing not only vital physiological processes, but therapeutic potential of plants as well. Therefore, the cytokinin-based sage cultures may be also considered as the alternative sources of bioactive compounds.

The effect of purine-type cytokinin on the proliferation and production of phenolic compounds in transformed shoots of Dracocephalum forrestii

Dracocephalum forrestii is a perennial, endemic to China plant with a number of pharmaceutical properties. Transformed shoots of the species spontaneously regenerated from hairy roots induced by Agrobacterium rhizogenes. The transgenic nature of the shoots was confirmed by polymerase chain reaction (PCR). The shoot culture was multiplied on Murashige and Skoog (MS) medium with 0.2 mg/l IAA and 0.2, 0.5, 1.0, 2.0 or 5.0 mg/l purine-type cytokinins (mT, BAR, BPA or BAP). The highest multiplication rate (about thirteen shoot or buds per explant) was obtained on MS medium with 0.2 mg/l mT after four weeks of culture. The phenolic compounds present in the hydromethanolic extracts from the D. forrestii transgenic shoots were characterized using UPLC-PDA-ESI-MS. The shoots were found to biosynthesize three phenolic acids and five flavonoid glycosides. UHPLC analysis of the hydromethanolic extracts found the predominant phenolic acid to be rosmarinic acid, with its highest content observed in shoots cultivated with 5.0 mg/l BPA. In contrast, the greatest production of flavonoid derivatives (especially acacetin derivatives) was observed in the medium supplemented with 2 mg/l BPA.

Acute coronary syndromes and atherosclerotic plaque burden distribution in coronary arteries among patients with valvular heart disease (BIA-WAD registry)

INTRODUCTION

Valvular heart diseases (VHD) are a significant problem in the Polish population. Coexistence of coronary artery disease (CAD) in patients with VHD increases the risk of death and affects the further therapeutic strategy.

AIM

Analysis of atherosclerotic plaque burden distribution in coronary arteries and long-term prognosis among patients with VHD.

MATERIAL AND METHODS

Inclusion criteria were met by 1025 patients with moderate and severe VHD. Mean observation time was 2528 ±1454 days.

RESULTS

Severe aortic valve stenosis (AVS) occurred in 28.2%, severe mitral valve insufficiency (MVI) in 20%. CAD with severe angiographic stenoses was noted in 42.3% (n = 434). Among patients with severe MVI, CAD was noted in 47.1% of cases, and prior acute coronary syndromes (ACS) in 27.1% of patients (n = 58). In severe AVS patients, significant angiographic atherosclerotic changes were observed in 29.6% (n = 86), and prior ACS in 7.6% (n = 22) of patients. During the observation 52.7% of patients died, including 62.9% of patients with severe MVI and 51.6% of those with severe AVS. Age (OR = 1.038; 95% CI: 1.005-1.072; p = 0.022) and coexisting aortic valve insufficiency (AVI) (OR = 2.39, 95% CI: 5.370-11.065, p = 0.035) increased the mortality rate.

CONCLUSIONS

Severe AVS is starting to be the most prevalent VHD. CAD is one of the most significant factors deteriorating prognosis of patients with VHD. AVI and age were significant risk factors for mortality. The worst prognosis was observed in severe MVI, which may result from more frequent occurrence of CAD in this group. A lesser burden of CAD and ACS in the group of patients with severe AVS did not affect survival.

Effect of air pollution on the number of hospital admissions for acute coronary syndrome in elderly patients

INTRODUCTION

Air pollution is a documented risk factor for cardiovascular diseases.

OBJECTIVES

The aim of the study was to assess the effect of air pollution on the number of hospital admissions for acute coronary syndrome (ACS) in elderly patients.

PATIENTS AND METHODS

The medical records of 26 695 patients hospitalized for ACS between 2008 and 2017 were examined. Weather conditions and the following components of air pollution were analyzed: sulfur dioxide, nitrogen dioxide, and particulate matter with a diameter of 2.5 μm or less (PM2.5) and a diameter of 10 μm or less (PM10).

RESULTS

The study included 1618 inhabitants of Białystok in Poland (mean [SD] age, 75 [6.4] years; men, 52.6%). The norm for PM2.5 was exceeded on 23.5% of days, while for PM10, on 5.3% of days. Elevated PM10 levels were associated with a higher number of hospitalizations for ACS on the day of exposure (mean [SD], 0.61 [0.78] vs 0.44 [0.69]; P <0.001), and this effect persisted in the subsequent days (mean [SD], 1.07 [1.07] vs 0.88 [1.00]; P = 0.02). An increase of PM10 concentrations by 10 μg/m3 was associated with an increase in the number of hospitalizations due to unstable angina, and significant effects were observed even after 6 days (rate ratio, 1.16; 95% CI, 1.03-1.32; P = 0.02).

CONCLUSIONS

Increased exposure to air pollution, in particular, elevated PM10 levels, is associated with a higher incidence of ACS both on the day of exposure and over the following days.