ECG patterns to predict pulmonary arterial hypertension in patients with severe tricuspid regurgitation

INTRODUCTION

Echocardiographic evaluation of tricuspid regurgitation (TR) velocity is a key measure in screening for pulmonary hypertension. Based on its value and additional features of right ventricle overload patients are classified into low, intermediate or high probability of pulmonary hypertension which transfers into decisions of further invasive evaluation. However, in the presence of severe TR echocardiography underestimates pulmonary artery pressure and therefore pulmonary hypertension may be overlooked in some patients. Accordingly, in the present study we aimed to assess the role of electrocardiography in predicting the presence of pulmonary arterial hypertension (PAH) in patients with severe TR.

RESULTS

We analysed 83 consecutive patients with severe TR who were diagnosed in our centre between February 2008 and 2021 and who underwent right heart catheterization. Of them 58 had PAH while 25 had isolated TR (iTR). We found that the following ECG criteria supported the diagnosis of PAH as opposed to the diagnosis of iTR: R:SV1 > 1.0, max RV1 or 2 + max S I or aVL -SV1 > 6 mm, SI/RI > 1 in I. For these parameters using ROC analysis we found that the optimal thresholds suggesting the presence of pulmonary hypertension were: R:SV1 > 1.5 (AUC = 0.74, p = 0.0004, sensitivity 57.1%,specificity of 85%), max RV1 or 2 + max S I or aVL - SV1 > 3 mm (AUC = 0.76, p < 0.0001, sensitivity 91.4%, specificity of 60%) and for SI:RI > 0.71 (AUC = 0.79, p < 0.0001, sensitivity 82.5%,specificity of 70.8%). Presence of atrial fibrillation predicted iTR with 76% sensitivity and 81% specificity.

CONCLUSIONS

ECG analysis can improve the diagnostic process for patients with severe TR. The presence of atrial fibrillation facilitates the diagnosis of isolated tricuspid regurgitation (iTR), while increased values of R:SV1, R:SI, and increased max RV1 or 2 + max SI or aVL - SV1 favor the diagnosis of TR secondary to PAH.

Timing for First-in-Minor Clinical Trials of New Cancer Drugs

OBJECTIVES

To describe the delay for first-in-minor cancer clinical trials and its relationship with the Food and Drug Administration (FDA) approval.

STUDY DESIGN

We used ClinicalTrials.gov to create a sample of pediatric-relevant cancer drugs starting efficacy testing in adults from 2006 through 2011. We characterized the delay between first-in-adult efficacy trials and first-in-minor trials. We also assessed the proportion of drugs evaluated in minors that failed to gain approval, the proportions that were not evaluated in minors before receiving the FDA approval, and whether shorter delay was associated with larger effect sizes or greater probability of regulatory approval.

RESULTS

Thirty-four percent of the 185 drugs in our cohort were evaluated in minors; the median delay to clinical trials was 4.16 years. Of all drugs, 17% received the FDA approval, 41% of which were never tested in minors before licensing. Of the 153 drugs not attaining approval, 78% were not evaluated in minors. Earlier testing did not significantly predict greater response rates (P = .13). Drugs not attaining regulatory approval were evaluated significantly earlier (3.0 for drugs not approved vs 5.4 years delayed testing for approved drugs, P = .019).

CONCLUSIONS

New cancer drugs were typically evaluated in minors years after adult efficacy evaluation. This delay likely eliminated some drugs lacking desirable pharmacology before pediatric testing. However, some drugs that were eliminated may have had activity in pediatric indications. Approaches for prioritizing drugs for pediatric testing warrants further consideration.

Impact of diabetes mellitus on disease severity and patient survival in idiopathic pulmonary arterial hypertension: data from the Polish multicentre registry (BNP-PL)

BACKGROUND

Recent studies revealed that alterations in glucose and lipid metabolism in idiopathic pulmonary arterial hypertension (IPAH) are associated with disease severity and poor survival. However, data regarding the impact of diabetes mellitus (DM) on the prognosis of patients with IPAH remain scarce. The aim of our study was to determine that impact using data from a national multicentre prospective pulmonary hypertension registry.

METHODS

We analysed data of adult patients with IPAH from the Database of Pulmonary Hypertension in the Polish population (BNP‑PL) between March 1, 2018 and August 31, 2020. Upon admission, clinical, echocardiographic, and haemodynamic data were collected at 21 Polish IPAH reference centres. The all-cause mortality was assessed during a 30-month follow-up period. To adjust for differences in age, body mass index (BMI), and comorbidities between patients with and without DM, a 2-group propensity score matching was performed using a 1:1 pairing algorithm.

RESULTS

A total of 532 patients with IPAH were included in the study and 25.6% were diagnosed with DM. Further matched analysis was performed in 136 patients with DM and 136 without DM. DM was associated with older age, higher BMI, more advanced exertional dyspnea, increased levels of N-terminal pro-brain natriuretic peptide, larger right atrial area, increased mean right atrial pressure, mean pulmonary artery pressure, pulmonary vascular resistance, and all-cause mortality compared with no DM.

CONCLUSIONS

Patients with IPAH and DM present with more advanced pulmonary vascular disease and worse survival than counterparts without DM independently of age, BMI, and cardiovascular comorbidities.

Percutaneous aspiration of a right atrial thrombus with the AngioVac system

< p > < /p >.

Lung transplantation in patients with pulmonary arterial hypertension: The opinion of the Polish Cardiac Society Working Group on Pulmonary Circulation

Pulmonary arterial hypertension is a rare but progressive disease that leads to death. Modern drug treatment slows the progression of the disease and prolongs patients' lives, but often, even maximal treatment with parenteral prostacyclin does not prevent deterioration. In the case of inadequate clinical response to drug treatment, lung transplantation (LTx) should be considered. This article aims to analyze thoroughly indications to refer a patient for consultation with a transplant center, the optimal timing of listing for LTx, contraindications for the procedure, bridging techniques, as well as tests needed before and after transplantation. We outline the technique of the procedurę and evaluate psychological aspects of LTx.

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: a multicentre registry

BACKGROUND

Balloon pulmonary angioplasty (BPA) is a promising therapy for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are ineligible for pulmonary endarterectomy.

AIMS

The present study aimed to evaluate the safety and efficacy of BPA for CTEPH using the first multicentre registry of a single European country.

METHODS

Data were obtained from the Database of Pulmonary Hypertension in the Polish Population (NCT03959748), a prospective, multicentre registry of adult and paediatric pulmonary arterial hypertension (PAH) and CTEPH, for a total of 236 patients with confirmed CTEPH (124 women; mean age 67 years) who underwent 1,056 BPA procedures at eight institutions in Poland.

RESULTS

In 156 patients who underwent follow-up assessments after a median of 5.9 (IQR: 3.0-8.0) months after final BPA, the mean pulmonary arterial pressure decreased from 45.1±10.7 to 30.2±10.2 mmHg (p<0.001) and pulmonary vascular resistance from 642±341 to 324±183 dynes (p<0.001), and the six-minute walking test (6MWT) improved from 341±129 to 423±136 m (p<0.001). Pulmonary injury related to the BPA procedure occurred in 6.4% of all sessions. Eighteen patients (7.6%) died during follow-up, including 4 (1.7%) who died within 30 days after BPA. Overall survival was 92.4% (95% confidence interval [CI]: 87.6%-94.9%) three years after the initial BPA procedure.

CONCLUSIONS

This multicentre registry confirmed significant improvement of haemodynamic, functional, and biochemical parameters after BPA. Complication rates were low and overall survival comparable to the results of another registry. Therefore, BPA may be an important therapeutic option in patients with CTEPH in Poland.

Characteristics and outcomes of patients with chronic thromboembolic pulmonary hypertension in the era of modern therapeutic approaches: data from the Polish multicenter registry (BNP-PL)

Background:

Significant achievements in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) have provided effective therapeutic options for most patients. However, the true impact of the changed landscape of CTEPH therapies on patients’ management and outcomes is poorly known. We aimed to characterize the incidence, clinical characteristics, and outcomes of CTEPH patients in the modern era of CTEPH therapies.

Methods:

We analyzed the data of CTEPH adults enrolled in the prospective multicenter registry.

Results:

We enrolled 516 patients aged 63.8 ± 15.4 years. The incidence rate of CTEPH was 3.96 per million adults per year. The group was burdened with several comorbidities. New oral anticoagulants (n = 301; 58.3%) were preferred over vitamin K antagonists (n = 159; 30.8%). Pulmonary endarterectomy (PEA) was performed in 120 (23.3%) patients and balloon pulmonary angioplasty (BPA) in 258 (50%) patients. PEA was pretreated with targeted pharmacotherapy in 19 (15.8%) patients, and BPA in 124 (48.1%) patients. Persistent CTEPH was present in 46% of PEA patients and in 65% of patients after completion of BPA. Persistent CTEPH after PEA was treated with targeted pharmacotherapy in 72% and with BPA in 27.7% of patients. At a mean time period of 14.3 ± 5.8 months, 26 patients had died. The use of PEA or BPA was associated with better survival than the use of solely medical treatment.

Conclusions:

The modern population of CTEPH patients comprises mostly elderly people significantly burdened with comorbid conditions. This calls for treatment decisions that are tailored individually for every patient. The combination of two or three methods is currently a frequent approach in the treatment of CTEPH.

Clinical Trial Registration:

clinicaltrials.gov/ct2/show/NCT03959748

Hemodynamic Effects of Ultrasound-Assisted, Catheter-Directed, Very Low-Dose, Short-Time Duration Thrombolysis in Acute Intermediate-High Risk Pulmonary Embolism (from the EKOS-PL Study)

Ultrasound-assisted, catheter-directed, low-dose thrombolysis (USAT) at an average alteplase dose of 20 mg infused over 12 to 24 hours reversed right ventricular disfunction and improved pulmonary hemodynamics in intermediate-high-risk pulmonary embolism patients. As bleeding risk increases with the thrombolytic dose, establishing a minimal effective USAT dosing regimen is of clinical importance. We aimed to investigate hemodynamic effects and safety of a very low-alteplase-dose USAT of 10 mg administered within 5 hours. We included 12 consecutive intermediate-high-risk pulmonary embolism patients with symptoms duration of <14 days and proximal thrombi location in pulmonary arteries. Pulmonary Embolism Response Team decision-based fixed, bilateral ultrasound-assisted alteplase infusions at the rate of 1mg/hour/catheter for 5 hours through EKOS system catheters were made. The primary efficacy measure was the change in invasive systolic and mean pulmonary arteries pressure, and in cardiac index from USAT start to termination. Safety measures were 180-day all-cause death or cardiopulmonary decompensation and bleeding complications. The systolic pulmonary arteries pressure and mean pulmonary arteries pressure decreased from 53 (45.5 to 59) to 37.5 (27.5 to 40.5) mm Hg (p = 0.02) and from 29.5 (27.5 to 32) to 21.5 (15.5 to 25) mm Hg (p = 0.02), respectively. The cardiac index increased from 1.6 (1.5 to 1.8) to 2.2 (1.9 to 2.4) l/min/m², (p = 0.02). No deaths, decompensations, or need for therapy intensification occurred. There was 1 episode of access-site bleeding, which subsided after conservative management. No intracranial hemorrhages appeared. In conclusion, reduced dose and duration USAT improved pulmonary hemodynamics and cardiac function leading to cardiopulmonary stabilization in intermediate-high risk pulmonary embolism patients at a low periprocedural risk.

Pregnancy in a Patient With Chronic Thromboembolic Pulmonary Hypertension After Successful Treatment with Balloon Pulmonary Angioplasty

Pulmonary hypertension has been recognized as a contraindication to pregnancy. Recently, several groups have shown promising results with the use of balloon pulmonary angioplasty (BPA) in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) patients with distally located organized thrombi who were not candidates for pulmonary endarterectomy. We present the case report of a 26-year-old woman who became pregnant after successful treatment of severe CTEPH with the use of BPA. We conclude that patients undergoing effective BPA for CTEPH can consider becoming pregnant if followed closely by a multidisciplinary team, including experts in thrombosis, pulmonary hypertension, and obstetrics.

Prognostic role of traditional cardiovascular risk factors in patients with idiopathic pulmonary arterial hypertension

INTRODUCTION

Metabolic alterations have been recently associated with onset and progression of idiopathic pulmonary arterial hypertension (IPAH). We aimed to determine the prevalence and prognostic role of cardiovascular risk factors in patients with IPAH.

MATERIAL AND METHODS

Between February 2009 and January 2015 we recruited consecutive IPAH patients. Clinical assessment included medical history, fasting glucose, lipid profile, N-terminal pro-brain natriuretic peptide concentration, 6-minute walk test distance, WHO functional class and hemodynamic evaluation. Patients' risk was estimated based on the Swedish PAH Register grading system.

RESULTS

The study group included 61 IPAH patients, and the control group included 2413 Polish residents. When compared to the general population, IPAH patients had lower low-density lipoprotein cholesterol (LDL-C) and a higher triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio. Female patients were characterized by elevated glucose level, higher prevalence of diabetes and lower HDL-C than controls. PAH severity grade correlated positively with age and TG/HDL-C ratio (R = 0.29, p = 0.02) and inversely with LDL-C (R = -0.28, p = 0.03) and HDL-C (R = -0.39, p = 0.02) concentrations. After a follow-up of 48 (23-79) months we recorded 28 deaths in the IPAH group. In the regression analysis lower LDL-C (p = 0.002) and HDL-C (p = 0.0002) levels, and higher TG/HDL-C ratio (p = 0.003) and glucose level (p = 0.003) were associated with all-cause mortality after adjustment for age, sex or PAH severity grade.

CONCLUSIONS

Patients with IPAH are characterized by an altered profile of lipid and glucose metabolism. Lowered levels of LDL-C and HDL-C and increased TG/HDL-C ratio correlate with disease severity and together with elevated plasma glucose level predict poor survival in IPAH.

High‑density lipoprotein cholesterol levels and pulmonary artery vasoreactivity in patients with idiopathic pulmonary arterial hypertension

Introduction Metabolic dysregulation has been recognized as a prognostic marker in idiopathic pulmonary arterial hypertension (IPAH). Objectives We aimed to investigate the association between cardiometabolic risk factors and vascular reactivity of pulmonary arteries in patients with IPAH. Patients and methods Between June 2009 and January 2015, we recruited 66 consecutive patients with IPAH. We assessed main cardiometabolic risk factors, inflammatory markers, and markers of IPAH severity. Hemodynamic evaluation included pulmonary vasoreactivity testing with the use of inhaled nitric oxide. Reduced mean pulmonary artery pressure was considered a marker of acute vasoreactivity. Acute responders were treated with calcium channel blockers and classified as long‑term responders if they had sustained vasoreactivity (near‑normal hemodynamics and World Health Organization functional class I or II) for at least 1 year. Results Thirteen patients (19.7%) showed a positive response to acute pulmonary vasoreactivity testing; however, only 9 (13.6%) remained vasoreactive at follow‑up. Machine‑learning algorithms indicated 4 variables associated with acute vasoreactivity of pulmonary arteries: high‑density lipoprotein cholesterol (HDL‑C), right atrial pressure, cardiac index, and creatinine level, and 4 predictors of long‑term vasoreactivity: HDL‑C, 6‑minute walking distance, creatinine level, and high‑sensitive C‑reactive protein level. Conclusions HDL‑C level is associated with pulmonary vasoreactivity in acute testing and predicts long‑term responsiveness to calcium channel blockers in patients with IPAH.

A systematic review of how patients value COPD outcomes

Our objective was to summarise systematically all research evidence related to how patients value outcomes in chronic obstructive pulmonary disease (COPD).We conducted a systematic review (systematic review registration number CRD42015015206) by searching PubMed, Embase, PsycInfo and CINAHL, and included reports that assessed the relative importance of outcomes from COPD patients' perspective. Two authors independently determined the eligibility of studies, abstracted the eligible studies and assessed risk of bias. We narratively summarised eligible studies, meta-analysed utilities for individual outcomes and assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.We included 217 quantitative studies. Investigators most commonly used utility measurements of outcomes (n=136), discrete choice exercises (n=13), probability trade-off (n=4) and forced choice techniques (n=46). Patients rated adverse events as important but on average, less so than symptom relief. Exacerbation and hospitalisation due to exacerbation are the outcomes that COPD patients rate as most important. This systematic review provides a comprehensive registry of related studies.

Electrocardiogram reading: a randomized study comparing 2 e‑learning methods for medical students

INTRODUCTION    Interpretation of the electrocardiogram (ECG) is an essential skill in most medical specialties; however, the best method of teaching how to read ECGs has not been determined. OBJECTIVES    The aim of the study was to compare the effectiveness of collaborative (C‑eL) and self (S‑eL) e‑learning of ECG reading among medical students. PATIENTS AND METHODS    A total of 60 fifth‑year medical students were randomly assigned to the C‑eL and S‑eL groups. S‑eL students received 15 ECG recordings with a comprehensive description by email (one every 48 hours), while C‑eL students received the same ECG recordings without description. C‑eL students were expected to analyze each ECG together within the subgroups using an internet platform and to submit the interpretation within 48 hours. Afterwards, they received a description of each ECG. C‑eL students' activity was assessed based on the number of words written on the internet platform during discussion. A final test consisted of 10 theoretical questions and 10 ECG recordings. The final score was a sum of points obtained for the interpretation of ECG recordings. The main endpoint of the study was the number of students whose final score was 56% or higher. RESULTS    The final test was completed by 53 students (88.3%). The main endpoint was achieved in 20 C‑eL students (77%) and in 13 S‑eL students (48.1%), P = 0.03. The final score was 6.4 (interquartile range [IQR], 5.8-7.6) in the C‑eL group and 5.6 (IQR, 4.2-7.2) in the S‑eL group, P = 0.04. It correlated with the results of the theoretical test and students' activity during C‑eL (r = 0.42, P = 0.002 and r = 0.4, P = 0.04, respectively). CONCLUSIONS    C‑eL of ECG reading among fifth‑year medical students is superior to S‑eL.

Right atrium enlargement predicts clinically significant supraventricular arrhythmia in patients with pulmonary arterial hypertension

BACKGROUND

Right atrial (RA) enlargement is a common finding in patients with pulmonary arterial hypertension (PAH) and an important predictor of mortality, however its relation to the risk of atrial arrhythmias has not been assessed.

OBJECTIVES

To assess whether RA enlargement is associated with supraventricular arrhythmias (SVA) and whether it predicts new clinically significant SVA (csSVA).

METHODS

Patients with PAH were recruited between January 2010 and December 2014 and followed until January 2017. csSVA was diagnosed if it resulted in hospitalization. To assess predictors of new csSVA, only patients without a history of SVA at baseline were analyzed.

RESULTS

Among 97 patients, any SVA was observed in 45 (46.4%) and included permanent atrial fibrillation(AF, n = 8), paroxysmal AF (n = 10), permanent atrial flutter (AFl, n = 1), paroxysmal AFl (n = 2) or other types of supraventricular tachycardia (n = 24). Patients with SVA as compared to patients without SVA were characterized by older age, lower distance in a 6-minute test, higher NT-proBNP, higher RA area index (RAai), left atrial area index, mean right atrial pressure (mRAP) and were more commonly treated with β-blocker. Eighty five patients who were in sinus rhythm at baseline assessment and had no history of significant SVA were observed for 37 ± 19.9 months. During that time csSVA occurred in 15.3%. In univariate models, the occurrence of csSVA were predicted by age, right ventricular ejection fraction, right ventricular end diastolic index, RAai and mRAP, but in multivariate model only RAai remained significant predictor for csSVA (HR of 1.23, 95%CI: 1.11-1.36, p < 0.001). The optimal threshold for RA enlargement as discriminator of csSVA was 21.7 cm2/m2.

CONCLUSIONS

In PAH patients RA enlargement is associated with increased prevalence of SVA. RAai is an independent predictor of hospitalization due to csSVA.

Assessment of knowledge on cardiovascular disease risk factors by postal survey in residents of Małopolska Voivodeship. Małopolska CArdiovascular PReventive Intervention Study (M-CAPRI)

[b]Introduction.[/b] Education is a key tool in the prevention of cardiovascular disease (CVD). Education programmes require monitoring of their effectiveness. [b]Objectives. [/b]1) to introduce postal screening for the assessment of knowledge on CVD risk factors (RFs) for the Polish population, 2) to assess this knowledge in adult residents of Małopolska Voivodeship, and 3) to assess whether knowledge on RFs is related to age, gender, place of residence, level of education and family history of CVD. [b]Materials and method.[/b] Anonymous questionnaires were posted to a random sample of 5,000 residents of Małopolska Voivodeship in Poland. Results were presented as proportions of participants who listed RFs correctly. A series of multiple logistic regression models was used to assess the associations of knowledge on RFs with the potential determinants. [b]Results.[/b] 1,126 completed questionnaires were returned. Over 35% of respondents could not list a single RF and 14 % listed only 1-2 RFs. About 40% named 3-5 and only 12% listed 6 or more RFs. About a half of the respondents listed incorrectly from 1-8 characteristics as being associated with higher risk of CVD. In the multivariate analysis, knowledge on RFs was not significantly associated with age. Level of education was the strongest determinant of knowledge. Male rural and small town residents had less knowledge, whereas women with a family history of CVD had more knowledge on some CVD RFs. [b]Conclusions.[/b] Using a postal questionnaire for the assessment of knowledge of CVD RFs in the population of Małopolska Voivodeship appeared to have serious limitations due to low participation in the study. Despite this, the results of the study indicate that knowledge on CVD RFs is insufficient. Female gender and higher education were related to more prevalent knowledge on RFs. Family history of CVD was related to better knowledge in women only. Male residents of rural areas and small towns had slightly less knowledge on CVD RFs.

Fibrin structure in organized thrombotic material removed during pulmonary artery endarterectormy: the effect of vessel calibre

Pulmonary endarterectomy (PEA) is a curative therapeutic approach in patients with chronic thromboembolic pulmonary hypertension (CTEPH). The location-dependent structural differences of thrombotic material found in pulmonary arteries in CTEPH are poorly investigated. We present the case of a 47-year-old woman with antiphospholipid syndrome, diabetes mellitus and abnormal fibrin phenotype, who underwent PEA for CTEPH. Intravascular material removed bilaterally during PEA (from lobar, segmental and sub-segmental arteries) has been studied using light and scanning electron microscopy (SEM). Light microscopy showed tighter fibrous network in the portions of intraluminal thrombotic material facing the vessel wall, which contained collagen and fibrin fibers, and abundant cells. Cells, evaluated by immunostaining, were present in the whole removed material. Tissue factor expression was also observed with the highest values in the portions of intravascular material facing the vessel wall. In the main pulmonary arteries, SEM images revealed thick fibers of fibrous proteins loosly meshed and few erythrocytes and platelets between them (both dysmorphic "wedged" and fresh cells were present). In the fibrotic layers, containing mainly collagen and fibrin, removed from the lobar/segmental pulmonary arteries we found a stepwise increase in fiber density with decreasing vessel calibre, followed by denser fibrous networks composed of thinner fibers. Elastic fibers in the lobar and segmental arteries were aligned along the blood flow vector. These findings demonstrate differences in the structure of endarterectomized PEA material dependent on the vessel calibre and might contribute to understanding of CTEPH pathophysiology.

Knowledge of rare diseases among health care students – the effect of targeted education

BACKGROUND

Poor knowledge on rare diseases (RD) results in a significant delay in their diagnosis and treatment. So far there are no standards of university education in RD. We assessed knowledge on RD among healthcare students and the effectiveness of targeted education.

METHODS

We conducted an internet-based survey among students of the faculty of medicine, pharmacy and health sciences. Questions regarded personal information, definition and epidemic data on RD. The survey was used to assess the effect of targeted education about RD in an additional group of students.

RESULTS

We enrolled 270 students (females: n=181; 67%), aged 22±1.7 years. Most of them (87.8%) declared to be familiar with the term RD. However only 20.7% knew the correct definition of RD, 14% knew that RD affect a significant (6-8%) proportion of population, 21.4% that there are 5-8 thousands of different RD’ entities, 73.7% recognized the most common cause of RD. 12.6% knew, that the RD most frequently occur in the adulthood. Targeted education applied in the additional group of 18 students resulted in a significant improvement of students’ knowledge on RD: definition (by 33%; p=0.007), percentage of population affected by RD (by 67%; p=0.001 ), total number of different RD (by 61%; p=0.003), time of onset of RD (by 61% p=0.003).

CONCLUSIONS

Despite the declared recognition of the term: RD, knowledge on RD among medical students is poor independently on the year of study. However it can be improved with use of targeted education.

Research in disaster settings: a systematic qualitative review of ethical guidelines

BACKGROUND

Conducting research during or in the aftermath of disasters poses many specific practical and ethical challenges. This is particularly the case with research involving human subjects. The extraordinary circumstances of research conducted in disaster settings require appropriate regulations to ensure the protection of human participants. The goal of this study is to systematically and qualitatively review the existing ethical guidelines for disaster research by using the constant comparative method (CCM).

METHODS

We performed a systematic qualitative review of disaster research ethics guidelines to collect and compare existing regulations. Guidelines were identified by a three-tiered search strategy: 1) searching databases (PubMed and Google Scholar), 2) an Internet search (Google), and 3) a search of the references in the included documents from the first two searches. We used the constant comparative method (CCM) for analysis of included guidelines.

RESULTS

Fourteen full text guidelines were included for analysis. The included guidelines covered the period 2000-2014. Qualitative analysis of the included guidelines revealed two core themes: vulnerability and research ethics committee review. Within each of the two core themes, various categories and subcategories were identified.

CONCLUSIONS

Some concepts and terms identified in analyzed guidelines are used in an inconsistent manner and applied in different contexts. Conceptual clarity is needed in this area as well as empirical evidence to support the statements and requirements included in analyzed guidelines.

[Prevalence and knowledge of modifiable cardiovascular risk factors among patients of primary health care. Małopolska CArdiovascular Preventive Intervention Study (M-CAPRI)]

INTRODUCTION

Cardiovascular diseases (CVD) are the main cause of death in Poland. The prevalence of CVD risk factors is regionally differentiated. Awareness of their presence in the population is crucial for identification of high-risk patients and implementation of appropriate preventive intervention. Therefore, the aim of our study was to assess the prevalence and knowledge of modifiable CVD risk factors among patients of primary health care in Malopolska.

MATERIAL AND METHODS

The study was conducted among participants of Małopolska CArdiovascular Preventive Intervention Study (M-CAPRI). Standardized questionnaire and clinical evaluation was conducted in a total of 978 consecutive patients (aged 45.7±13.0) without known CVD in randomly selected primary care units in Małopolska.

RESULTS

The most common major modifiable CVD risk factor was hypercholesterolemia (648; 66.3%) while predisposing was incorrect nutrition (890; 91.0%). The prevalence of hypertension, hypercholesterolemia, diabetes and obesity was increased with age but cigarette smoking, low physical activity and poor nutrition remain unchanged. CVD risk assessed using Pol-SCORE charts was high or very high in 104 (16.9%) and moderate in 369 (59.5%) patients. Each of the modifiable CVD risk factors was often identified by people with higher education and educated beforehand by a doctor or nurse. The presence of a particular CVD risk factor was not associated with better knowledge of it except for diabetes (OR 3.44, 95% CI 0.996-11.863).

CONCLUSIONS

Educated patients have better knowledge on CVD risk factors. Identification of CVD risk factors and education about them should be implemented during visits in primary health care.

Effectiveness of single medical advice on emergency phone number knowledge in urban adult population--"Health, Alcohol and Psychosocial Factors in Eastern Europe" substudy

INTRODUCTION

Early access to Emergency Medical Services determines survival in out-of-hospital cardiac arrest. However, a significant proportion of adults do not know the emergency phone number (EN) and no intervention has been proposed to improve it. Therefore, we aimed to assess prospectively the effectiveness of single advice from a physician on knowledge of the EN in adult population.

MATERIALS AND METHODS

The study was conducted among participants of "Health, Alcohol and Psychosocial Factors in Eastern Europe" study. A total of 942 persons (aged 48-82 years) randomly selected from an urban population registry were interviewed and then instructed about the correct EN (the intervention group). After 12 months knowledge of the EN was assessed in the intervention group (n=716) and in matched control group (n=435).

RESULTS

The correct EN was given by 498 (69.6%) participants at baseline and in 550 (76.8%) participants 12 months afterwards (p<0.001). At follow-up the knowledge of EN was higher by in intervention group than in controls (76.8% vs 70.6%, p=0.02). Factors associated with better educational effect were male sex (OR 1.49; 95% CI 1.04-2.1) and secondary or higher level of education (OR 1.44; 95% CI 1.08-1.91).

CONCLUSIONS

We concluded that a single instruction about the EN from a physician increases its long-term knowledge and should be offered during medical visits.

Markers of thrombogenesis and fibrinolysis and their relation to inflammation and endothelial activation in patients with idiopathic pulmonary arterial hypertension

Background

Chronic anticoagulation is a standard of care in idiopathic pulmonary arterial hypertension (IPAH). However, hemostatic abnormalities in this disease remain poorly understood. Therefore, we aimed to study markers of thrombogenesis and fibrinolysis in patients with IPAH.

Methods

We studied 27 consecutive patients (67% female) with IPAH aged 50.0 years (IQR: 41.0 - 65.0) and 16 controls without pulmonary hypertension. Prothrombin fragment 1+2 (F1+2) and thrombin-antithrombin (TAT) complexes were measured to assess thrombogenesis; tissue-type plasminogen activator (tPA) antigen and plasmin-anti-plasmin complex to characterize activation of fibrinolysis; plasminogen activator inhibitor 1 (PAI-1) to measure inhibition of fibrinolysis; and endothelin-1 (ET-1) and interleukin-6 (IL-6) to assess endothelial activation and systemic inflammation, respectively. In addition, in treatment-naive IPAH patients these markers were assessed after 3 months of PAH-specific therapies.

Results

TPA (10.1[6.8-15.8] vs 5.2[3.3-7.3] ng/ml, p<0.001), plasmin-anti-plasmin (91.5[60.3-94.2] vs 55.8[51.1-64.9] ng/ml, p<0.001), IL-6 (4.9[2.5-7.9] vs 2.1[1.3-3.8] pg/ml, p=0.001) and ET-1 (3.7 [3.3-4.5] vs 3.4[3.1-3.5], p= 0.03) were higher in patients with IPAH than in controls. In IPAH patients plasmin-anti-plasmin and tPA correlated positively with IL-6 (r=0.39, p=0.04 and r=0.63, p<0.001, respectively) and ET-1 (r=0.55, p=0.003 and r=0.59, p=0.001, respectively). No correlation was found between tPA or plasmin-anti-plasmin and markers of thrombogenesis. Plasmin-anti-plasmin decreased after 3 months of PAH specific therapy while the other markers remained unchanged.

Conclusions

In the present study we showed that markers of fibrynolysis were elevated in patients with IPAH however we did not find a clear evidence for increased thrombogenesis in this group of patients. Fibrinolysis, inflammation, and endothelial activation were closely interrelated in IPAH.

The prevalence of abnormal echocardiographic findings in a sample of urban adult population

BACKGROUND

Echocardiography has emerged as the test of choice for the evaluation of cardiac diseases.

AIM

To assess the prevalence of a spectrum of cardiac abnormalities detected by echocardiography in a representative sample of an urban adult population.

METHODS

Transthoracic echocardiography was performed in a random sample of 511 men (47%) and women (53%) aged 48-76 years selected from population registers in Krakow. Body surface area (BSA) was used to adjust echocardiographic parameters for variations in body size. Disease history and cardiovascular risk factors were assessed in all patients.

RESULTS

Men smoked more frequently than women and had higher blood pressure and triglycerides and lower high density lipoprotein cholesterol. The most common finding was increased left ventricular (LV) end-diastolic diameter (EDd) (37%), followed by mitral (32%), aortic (24%), or tricuspid (17%) regurgitations, LV posterior wall (24.1%) and interventricular septum (17.5%) thickening, increased indexed LVEDd (23%), increased left atrial diameter (LAd; 15.7%), reduced LV ejection fraction (LVEF; 15.3%), segmental wall motion abnormalities (13.9%), increased indexed LAd (8.8%), dilation of the ascending aorta (8%), enlargement of the right ventricle (RV) (2%) and elevation of RV systolic pressure (0.6%). When adjusted for main cardiovascular risk factors and the presence of coronary artery disease, male sex was associated with a higher prevalence of enlargement of LV (LVEDd/BSA): OR = 1.8 (1.1-2.9), dilation of ascending aorta (aortic diameter/BSA): OR = 2.7 (1.3-5.8), and LA (LA/BSA) = OR 2.7 (1.3-5.6), as well as a decrease of LVEF: OR = 3.6 (1.9-6.5).

CONCLUSIONS

Approximately a quarter of urban adults aged 48 to 76 can be expected to have some abnormalities on echocardiographic examination. Some of these abnormalities such as aortic dilation, LA enlargement, LV enlargement and decreased LVEF are more frequently found in males than in females, even after adjustment for BSA, main cardiovascular disease risk factors, and the presence of coronary artery disease. The use of raw instead of indexed LAd and LVEDd over estimates the prevalence of LA and LV enlargement.

Changes in exercise capacity and cardiac performance in a series of patients with Eisenmenger's syndrome transitioned from selective to dual endothelin receptor antagonist

BACKGROUND

Differences in clinical effects between selective and dual endothelin (ET) receptor antagonists (ERA) in patients with pulmonary arterial hypertension (PAH) are currently unknown. We aimed to assess prospectively how transition from selective (sitaxsentan) to dual (bosentan) ERA affected exercise capacity and cardiocirculatory performance in patients with Eisenmenger's syndrome.

METHODS

A series of seven stable patients with Eisenmenger's syndrome aged 40.0 (30.0-56.0) years old treated with sitaxsentan were assessed before and three months after transition to bosentan. Six minute walk test and magnetic resonance to assess LV and RV mass, volume and ejection fraction, and pulmonary flow, and laboratory tests were performed.

RESULTS

We observed an increase in LV mass [96.5 (66.0-116.0) vs. 123.0 (93.0-146.0)g; p=0.03], LV ejection fraction [55.0 (44.0-63.0) vs. 65.0 (58.0-70.0)%; p=0.02)], and pulmonary flow [64 (53.0-71.0) vs. 69.0 (55.0-84.0)ml/beat; p=0.046]. This was accompanied by an increase of oxygen saturation, elongation of 6MWD [435.0 (378.0-482.3) vs. 474 (405.0-534.7); p=0.02], decrease of NTproBNP level and increase of ET-1 level.

CONCLUSIONS

Three month follow-up of stable patients with Eisenmenger's syndrome transitioned from sitaxsentan to bosentan revealed improvement of exercise capacity despite significant elevation of ET-1 level. Concurrent increase of LV ejection fraction and pulmonary flow might have contributed to these favourable effects.

Electrocardiogram for the diagnosis of right ventricular hypertrophy and dilation in idiopathic pulmonary arterial hypertension

BACKGROUND

Currently, there are no data on the association between right ventricular (RV) structure and ECG changes specific for idiopathic pulmonary arterial hypertension (IPAH). Therefore, we aimed to assess the accuracy of the recommended ECG criteria for predicting RV hypertrophy (RVH) and dilation in patients with IPAH.

METHODS AND RESULTS

Twelve-lead ECG and cardiovascular magnetic resonance imaging (CMR) were performed in 23 consecutive patients with IPAH aged 49.8±16.3 years. ECG criteria were referred to RV mass index and RV end-diastolic volume index as measured by CMR. Only the ECG voltage criteria based on R wave amplitude in lead V1, R wave amplitude in aVR, P wave amplitude in II and ventricular activation time in V1 were useful for differentiating between patients with and without RVH. A ventricular activation time in lead V1 of <0.01 s excluded RVH, whereas R in V1 >6 mm, R:S in V1 >1, R in aVR >4 mm, R:S in V5 to R:S in V1 <0.04 and P in II >2.5 mm confirmed the diagnosis. Only the ventricular activation time in V1 correlated with RV dilation and when >0.045s confirmed its diagnosis.

CONCLUSIONS

Only a few of the recommended ECG criteria proved to be useful in the diagnosis of RVH or RV dilation in patients with IPAH. Changes in the cut-off values improved their accuracy.