Common polymorphisms of cyclooxygenase-2 and prostaglandin E2 receptor and increased risk for acute coronary syndrome in coronary artery disease

The arachidonic acid metabolites participate in development of coronary artery disease (CAD) and the plaque’s instability.We assessed two common genetic polymorphisms: of cyclooxyge-nase-2 (COX-2) (COX 2.8473, rs5275) and prostaglandin EP2 receptor gene (uS5, rs708494) in patients with CAD. Out of 1,368 patients screened by coronary arteriography, two groups fulfilled the entry criteria and were studied: stable coronary disease (sCAD, n=125) and acute coronary syndromes (ACS, n=63).They did not differ in the main characteristics.All patients were on aspirin at least seven days prior to the study.In 70 control subjects, the same genotypes were ascertained, expression of cyclooxygenases in peripheral blood monocytes was assessed by flow cytometry, and in-vitro biosynthesis of PGE2 was measured by mass spectrometry. COX-2 CC homozygotes (variant allele), were more common, while EP2 GG homozygotes (wild-type) were less common in ACS (p=0.03 and p=0.017) than in the sCAD group.A combined genotype characterized by the presence of the wild-type COX2.8743T allele and the wild type homozygous EP2uS5 genotype (TT or CT | GG) decreased risk ratio of ACS in CAD patients (relative risk 0.41;95% confidence interval 0.21–0.81).COX-2 polymorphism in control subjects did not affect the enzyme expression or PGE2 production by peripheral blood monocytes, but production of PGE2 increased by 40.1% in the subjects homozygous for EP2 receptor allele uS5A following lipopolysaccharide stimulation. In conclusion, the combined COX-2 (COX 2.8473) and the EP2 receptor (uS5) genotypes seem to influence CAD stability, but in peripheral blood monocytes only EP2 receptor modulates PGE2 production.

[Association of common cyclooxygenase-2 (COX-2) gene polymorphisms with clinical and angiographic characteristics of patients with coronary artery disease]

BACKGROUND

Chronic inflammation of the arterial wall plays a crucial role in the pathogenesis of atherosclerosis. Cyclooxygenase-2 (COX-2) is a key enzyme in the synthesis of proinflammatory prostanoids. At least two of the common genetic polymorphisms of the COX-2 gene have phenotypic effects: G-765C (rs20417) and T8473C (rs5275).

AIM

To assess the relation of G-765C and T8473C COX-2 polymorphisms to clinical and angiographic characteristics of patients with coronary artery disease (CAD).

MATERIAL AND METHODS

The study comprised 186 consecutive patients with angiographically defined CAD (> or =70% stenosis of > or =1 coronary artery). The study population were divided into two groups: A-123 patients with stable angina (mean age, 62.6 +/- 11.2 years; 30.1% women), and B-63 patients with unstable angina (mean age, 64.0 +/- 10.8 years; 19.0% women). The controls comprised 70 individuals without symptoms of CAD (mean age, 37.6 +/- 9.9 years; 57.1% women). Results: No significant differences were observed in -765C and 8473C allele frequencies between the patients with CAD and control subjects. In CAD patients, the studied COX-2 polymorphisms were not significantly associated with the age of the onset of symptoms and clinical presentation of CAD. In the B group, a difference was observed within the frequency of significant (>50%) left main coronary artery stenosis (LMCAS) and/or three-vessel CAD (3-CAD) between the -765C allele carriers and 765G 765G homozygotes (14.3% vs. 49.0%; p=0.044). In the CAD patients (group A and group B) the prevalence of LMCAS and/or 3-CAD was significantly lower among 365C allele carriers (22.8% vs. 40.3%:

CONCLUSIONS

There were no significant differences in -765C and 8473C allele frequencies between patients with CAD and subjects without symptoms of CAD; In patients with CAD, COX-2 G-765C and T8473C polymorphisms had no significant association with the age of the onset of symptoms and clinical presentation of ischaemic heart disease; The G-765C COX-2 polymorphism is associated with less frequent occurrence of multivessel CAD in the studied population. p=0.021

Reduced thrombin formation and altered fibrin clot properties induced by polyunsaturated omega-3 fatty acids on top of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention (OMEGA-PCI clot)

OBJECTIVE

The goal of this study was to investigate whether omega-3 polyunsaturated fatty acids (n-3 PUFA) are able to alter plasma fibrin clot properties and reduce thrombin formation in stable coronary artery disease patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

In an investigator-initiated, prospective, double-blind, placebo-controlled, randomized study, patients undergoing PCI who received standard pharmacotherapy were assigned to the treatment with 1 g/day n-3 PUFA (n = 30) or placebo (n = 24) for 1 month. Plasma fibrin clot permeability (K(s)); lysis time (t(50%)); prothrombin fragment 1.2; and peak thrombin generation from automated thrombogram, 8-isoprostaglandin F(2α) (8-iso-PGF(2α), an oxidative stress marker), and C-reactive protein were determined at baseline, 3 to 5 days after randomization, and 30 days after randomization. At baseline, both treatment groups did not differ significantly. A 1-month treatment with n-3 PUFA compared with placebo was associated with 15.3% higher K(s), indicating larger pores in the fibrin network (P = 0.0005); 14.3% shorter t(50%), indicating increased susceptibility to fibrinolysis (P<0.0001); 33.8% lower prothrombin fragment 1.2 (P = 0.0013); 13.4% lower peak thrombin generation (P = 0.04); and 13.1% lower 8-iso-PGF(2α) (P = 0.009). Treatment with n-3 PUFA had no effect on fibrinogen and C-reactive protein. After 1 month of treatment, fibrinogen (r = -0.53, P<0.0001), treatment assignment (r = 0.29, P = 0.006) and 8-iso-PGF(2α) (r = -0.27, P = 0.015) were independently associated with clot permeability (P<0.0001, R(2) = 0.66).

CONCLUSIONS

Adding n-3 PUFA to standard therapy in stable patients undergoing PCI significantly decreases thrombin formation and oxidative stress and favorably alters fibrin clot properties. These findings indicate novel antithrombotic effects induced by n-3 PUFA in humans.

Life-threatening cardiac manifestations of primary antiphospholipid syndrome

We report a rare case of primary antiphospholipid syndrome (APS) in a 43-year-old man presenting as recurrent acute coronary stent thrombosis and complicated by three myocardial infarctions. As illustrated in this report, in APS patients recurrent life-threatening arterial thrombotic events may occur in spite of recommended anticoagulant therapy. We conclude that the APS should be considered as a potential cause of acute coronary syndrome, particularly in young individuals with a history of recurrent thrombotic events and/or with abnormal coagulation test results. Further studies are needed to determine the best therapeutic strategy for APS patients with acute coronary syndrome.

Common polymorphisms of cyclooxygenase-2 and prostaglandin E2 receptor and increased risk for acute coronary syndrome in coronary artery disease

The arachidonic acid metabolites participate in development of coronary artery disease (CAD) and the plaque's instability. We assessed two common genetic polymorphisms: of cyclooxygenase-2 (COX-2) (COX2.8473, rs5275) and prostaglandin EP2 receptor gene (uS5, rs708494) in patients with CAD. Out of 1,368 patients screened by coronary arteriography, two groups fulfilled the entry criteria and were studied: stable coronary disease (sCAD, n = 125) and acute coronary syndromes (ACS, n = 63). They did not differ in the main characteristics. All patients were on aspirin at least seven days prior to the study. In 70 control subjects, the same genotypes were ascertained, expression of cyclooxygenases in peripheral blood monocytes was assessed by flow cytometry, and in-vitro biosynthesis of PGE(2) was measured by mass spectrometry. COX-2 CC homozygotes (variant allele), were more common, while EP2 GG homozygotes (wild-type) were less common in ACS (p = 0.03 and p = 0.017) than in the sCAD group. A combined genotype characterized by the presence of the wild-type COX2.8743T allele and the wild type homozygous EP2uS5 genotype (TT or CT | GG) decreased risk ratio of ACS in CAD patients (relative risk 0.41; 95% confidence interval 0.21-0.81). COX-2 polymorphism in control subjects did not affect the enzyme expression or PGE(2) production by peripheral blood monocytes, but production of PGE(2) increased by 40.1% in the subjects homozygous for EP2 receptor allele uS5A following lipopolysaccharide stimulation. In conclusion, the combined COX-2 (COX2.8473) and the EP2 receptor (uS5) genotypes seem to influence CAD stability, but in peripheral blood monocytes only EP2 receptor modulates PGE(2) production.

Effect of atorvastatin on endothelial function and inflammation in long-duration type 1 diabetic patients without coronary heart disease and arterial hypertension

AIM

We evaluated the ability of atorvastatin, an HMG-CoA reductase inhibitor, to affect endothelial function and inflammation in long-duration (>10 years) type 1 diabetes mellitus (T1DM) patients without coronary heart disease (CHD) and arterial hypertension (AH).

METHODS AND RESULTS

We randomized 204 Caucasians with long-duration T1DM into either the atorvastatin 40 mg/day plus hypolipaemic diet group (n = 154) or the placebo plus hypolipaemic diet group (n = 50) for 6 months. Endothelium-dependent flow-mediated (FMD) and endothelium-independent flow-mediated vasodilatation, serum levels of plasminogen activator inhibitor-1 (PAI-1), von Willebrand factor (vWF) and high sensitivity C-reactive protein (hs-CRP) were estimated before and after treatment. After 6 months of therapy, FMD was increased by 44% in the atorvastatin plus diet group compared with the placebo plus diet group. Treatment with atorvastatin led to a significant reduction in levels of PAI-1 and hs-CRP; however, the elevation of vWF level was observed. In the placebo plus diet group, we observed a significant reduction in levels of hs-CRP but not of vWF and PAI-1.

CONCLUSIONS

Atorvastatin improves endothelial function and reduces some proinflammatory and prothrombotic markers of atherosclerosis in T1DM patients without CHD and AH. The surprising effect of atorvastatin on serum vWF levels in T1DM requires further study.

Transient ST-segment elevation in lead aVR associated with tako-tsubo cardiomyopathy

ST-segment elevation in lead aVR in patients with angina at rest can be related to transmural ischemia of the basal part of the interventricular septum, frequently due to left main or multivessel coronary disease. However, this electrocardiographic (ECG) sign may also occur in other clinical conditions manifesting by acute chest pain. We present a case of a 76-year-old Caucasian woman with transient ST-segment elevation in lead aVR associated with tako-tsubo cardiomyopathy. Our report seems to confirm the hypothesis about the role of reversible myocardial ischemia involving the basal part of the interventricular septum in the pathogenesis of tako-tsubo cardiomyopathy. In conclusion, ST-segment elevation in lead aVR in patients with a clinical presentation of acute coronary syndrome may be not related to coronary artery disease. Tako-tsubo cardiomyopathy should be considered among the causes of ST-segment elevation in lead aVR in patients with angina at rest. Further studies are needed to evaluate the occurrence and importance of this ECG sign in patients with tako-tsubo cardiomyopathy.

Diabetes-specific cardiomyopathy in type 1 diabetes mellitus: no evidence for its occurrence in the era of intensive insulin therapy

Aims The incidence of diabetic cardiomyopathy, independent of arterial hypertension (AH) and coronary heart disease (CHD), remains controversial. The present study aimed to determine the influence of type 1 diabetes mellitus (T1DM) of long duration (>10 years) on myocardial function estimated by echocardiography (ECHO) and serum level of N-terminal pro-B type natriuretic peptide (NT-proBNP) in patients without CHD and AH. We also retrospectively investigated the relationship between the structural changes in the hearts of other deceased T1DM patients, and had their myocardial function echocardiographically assessed before death. Methods and results In 185 patients (96 males) with T1DM (mean duration 22.8 years) and 105 non-diabetic control subjects (57 males), detailed ECHO parameters and NT-proBNP were assessed. No significant differences were found between the respective groups. Histological studies of 17 hearts of deceased T1DM patients were carried out and retrospectively compared with their ECHO performed before death. Histological changes were identified, although without the signs of myocardial dysfunction on ECHO prior to death. Conclusion Even the application of echocardiographic, biochemical and morphologic techniques hardly gives sufficient grounds to believe that type 1 diabetes alone may actually precipitate myocardial dysfunction, despite long-term course of the disease and typical histological changes in the myocardium.

Patency of infarct related artery after pharmacological reperfusion during transfer to primary percutaneous coronary intervention influences left ventricular function and one-year clinical outcome

BACKGROUND

Time-to-treatment is an important determinant of mortality in primary angioplasty for ST-segment elevation myocardial infarction (STEMI). Thus, the benefits in outcome observed with transferring for primary angioplasty in comparison with on-site thrombolysis may be reduced or even lost when long-distance transportation is required. Even though pharmacological reperfusion might overcome this limitation, no data have been reported so far on the prognostic role of early pharmacological recanalization in STEMI patients undergoing long-distance transportation for primary angioplasty.

METHODS

We enrolled 225 consecutive STEMI patients without shock, eligible for thrombolysis, with at least 90-minute transport time to our primary PCI center. During transport, patients received i.v. heparin 40 U/kg, alteplase 15 mg+35 mg infusion and abciximab 0.25 mg/kg+0.125 microg/kg/min infusion for 12 h.

RESULTS

Patients were divided into two groups according baseline angiography, which showed early pharmacological reperfusion (preprocedural TIMI flow 2+3) in 193 patients (85.8%) and no reperfusion (preprocedural TIMI flow 0+1) in 32 patients (14.2%). Despite no difference in postprocedural TIMI flow, early reperfusion was associated with better postprocedural myocardial perfusion (TMPG 3: 54.9% vs. 18.7%, p<0.0001), better improvement in left ventricular ejection fraction (LVEF) (from 55.6+/-8.6% to 58.8+/-10.4% p<0.001 with early reperfusion vs. 52.9+/-13.4% to 50.4+/-15.8% with no early reperfusion, p=NS) and 1-year outcome (p=0.002 log rank). In multivariate analysis, preprocedural TIMI flow 0+1 independently predicted death and reinfarction at 1 year, and lack of LVEF improvement at 6 months.

CONCLUSIONS

Early pharmacological reperfusion in STEMI patients undergoing long-distance transportation for primary angioplasty is associated with better postprocedural myocardial perfusion, better LVEF recovery at 6 months and improved 1-year clinical outcome.

Time-to-reperfusion therapy influences outcome of patients with myocardial infarction subjected to facilitated PCI

AIM

The purpose of this study was to evaluate the impact of time-to-reperfusion on outcome after facilitated percutaneous coronary intervention (PCI) i.e. PCI following early pharmacological reperfusion therapy in ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

The study population consisted of 262 consecutive patients with STEMI, aged <75 years, without cardiogenic shock, presenting <12 hours of chest pain onset, transferred from community hospitals to a catheterization laboratory with time delay >90 min after pharmacological reperfusion therapy (alteplase i.v. bolus 15 mg followed by an infusion - 35 mg/60 min; abciximab i.v. bolus 0.25 mg/kg followed by a 12-hour infusion - 0.125 microg/kg/min; unfractionated heparin i.v. bolus 40 U/kg [maximum 3000 U]). One hundred seventeen patients (44.7%) received pharmacological reperfusion therapy <3 h after chest pain onset, 101 (38.5%) at 3-6 h and 44 patients (16.8%) >6 h. Patent infarct-related artery rates at initial angiography were similar among the study groups. PCI significantly improved epicardial flow in all three groups. Mortality at 12 months was significantly related to time-to-pharmacological reperfusion (3.4% [<3 h], 4.0% [3-6 h], 13.6% [>6 h], p = 0.027). At 6 months left ventricular ejection fraction was significantly improved in the two groups of patients with time-to-pharmacological reperfusion <6 hours and the time-to-pharmacological reperfusion was the independent predictor of lack of left ventricular ejection fraction recovery.

CONCLUSION

Our study shows that among STEMI patients undergoing facilitated PCI, time-to-pharmacological reperfusion significantly affects left ventricular function recovery and long-term mortality.

Comparison of echocardiography and plasma B-type natriuretic peptide for monitoring the response to treatment in acute heart failure

AIMS

Comparison of the value of echocardiography and B-type natriuretic peptide (BNP) in monitoring response to treatment in patients admitted for acute heart failure (HF).

METHODS AND RESULTS

Ninety-five consecutive patients admitted with acute HF underwent bedside Doppler echocardiography and BNP measurements on admission, after 24 h of intravenous treatment, and at day 7. We then studied the association between the clinical status, the Doppler echocardiographic findings, the BNP measurements and subsequent 60-day adverse outcome (death, resuscitated cardiac arrest, urgent heart transplantation, readmission). On admission and during hospitalisation, relationships were found between plasma BNP and Doppler echocardiographic findings, and between their changes. During a 60 day follow-up, 37 events occurred. Multivariable analysis taking into account clinical factors, Doppler echocardiography and BNP showed that the two best models to predict outcome were (1) early evaluation at day 2 (previous CHF treatment, dobutamine use, relative BNP change during first 24 h) and (2) late evaluation at day 7 (previous CHF treatment, dobutamine use, BNP at day 7). Patients with a decrease in plasma BNP >10% at day 2, or with plasma BNP <300 pg/ml at day 7 had a better outcome than the others (19% versus 65% and 16% versus 72% events, respectively, p<0.0001).

CONCLUSIONS

Serial BNP measurements during the treatment of acute HF provide incremental prognostic information over clinical presentation and repetitive echocardiographic examination.

Relationship between hyperinsulinemia and angiographically defined coronary atherosclerosis in non-diabetic men

BACKGROUND

Our aim was to estimate the relationship between hyperinsulinemia and angiographically validated coronary atherosclerosis.

METHODS

102 consecutive non-diabetic male subjects (age 48.9 +/- 9.6 years) with a body mass index 25.9 +/- 2.8 kg/m(2) referred to coronary angiography in our centre were studied. A 75-g oral glucose tolerance test (OGTT) was performed and the areas under the curve (AUC) of serum insulin and glucose were calculated.

RESULTS

Discriminant analysis with stepwise forward variable selection revealed that in younger patients (<50 years), the following parameters affected positively the number of significant coronary lumen reductions: age (F=8.5, p=0.005), lnAUCinsulin (F=5.8, p=0.02), low HDL cholesterol (F=4.4, p=0.04), the smoking habit (F=4.1, p=0.05). In those >=50 years of age, exclusively age (F=5.8, p=0.02) and hyperuricemia (F=3.8, p=0.06) entered the final model.

CONCLUSION

Our results indicate that in non-diabetic male subjects the association of hyperinsulinemia with the severity of coronary atherosclerosis is only seen in younger patients.

[Evaluation of magnesium cation levels in serum of patients with mitral valve prolapse syndrome]

Magnesium deficiency has been suggested to be related to the mitral valve prolapse syndrome (MVPS). The aim of the present study was to analyse the concentration of magnesium in blood plasma of patients (pts) with MVPS. In the group of 80 subjects, including 50 pts with MVPS and 30 healthy people matched for age and gender, who comprised the control group (CG), concentration of magnesium in blood plasma was estimated. Magnesium levels were measured by atomic absorption spectrophotometry. Mean concentration of magnesium cation in plasma in pts with MVPS was 0.74 +/- 0.12 mmol/l (range 0.47-1.02 mmol/l). It was only 1.02% lower than in the CG (x = 0.76 +/- 0.07 mmol/l; range 0.67-0.97 mmol/l). However evaluation of the magnesium concentration in blood plasma did not prove magnesium deficiency in the mitral valve prolapse syndrome. Moreover the study revealed that histograms of magnesium concentration values in both investigated groups were divergent.

[Variability of heart auscultation in patients with mitral valve prolapse]

The aim of the study was to analyze the auscultatory findings and its variability in 84 patients (pts) with mitral valve prolapse syndrome (MVPS) who were examined in the different body positions. All the pts underwent the echocardiographical examination and in 32 subjects (38%) prolapse of the anterior mitral leaflet was found, in 40 pts (48%) prolapse of the posterior mitral leaflet and in 12 (14%) pts prolapse of the both mitral leaflets. The auscultation of the heart was done in the supine position, in the lying position on the left side and in the upright position of the patient's body. Characteristic for the mitral valve prolapse (MVP) auscultatory findings (midsystolic murmur, late-systolic murmur and/or mid-systolic "non ejection" click) were demonstrated by 43 pts (51%) in the supine position. During the auscultation in the lying position of the pts on the left side, the auscultatory findings were found in 57 pts (68%) while in the upright position in 64 pts with MVPS (76%). The study showed that the auscultatory findings in pts with MVPS were demonstrated more frequently in the lying position of the body on the left side or in the upright position compared with the supine position. Moreover we found that 20 pts with MVPS (24%) did not demonstrate the characteristic auscultatory findings of MVP.

[The clinical course of end stage heart disease in 152 patients qualified for heart transplantation in a four year observation]

The aim of the study was to analyse the clinical course of pts with end stage disease (ESD) in the period of four years. The study population consisted of 152 pts (132 males, 20 females) at the age of 17-66 years (mean = 48.8 year SD = 9.1) primarily qualified to the heart transplantation (HTX). We analysed the ethiology of cardiac failure, the NYHA class of circulation insufficiency, frequency of occurrence of cardiac arrhythmias and conduction system disturbances in 24-hour ecg monitoring, and the pharmacotherapy efficacy. An ischemic ethiology of cardiac failure we found in 102 pts, cardiomyopathy (idiopathic, hypertrophic or postinfectious) in 46 and unoperable valvular disease--in 4. Ten pts were in II NYHA class, 112 in III, and 30 in IV. Left ventricular ejection fraction (echo assessed) ranged from 11% to 40%(mean = 24.9%), LVEDd = 46-111 mm (mean = 80.9 mm), LVESd = 34-83.5 mm(mean = 63 mm). We found IVa class by Lown ventricular arrhythmias (in Holter monitoring) in 38 pts and IVb in 78. Fifty six pts were treated with amiodarone, 10--with beta-blockers and 11 with sotalol. 19 pts were treated by permanent cardiac pacing during the waiting period, 2 ones--by PTCA, 2--by CABG, three ones--by dynamic cardiomyoplasty, and one--by partial aneurysmectomy. One pt was treated by CABG and automatic cardioverter-defibrilator implantation. In 5 cases HTX was delayed because of the positive effect of pharmacotherapy. In assessed period HTX were performed in 64 cases, 31 pts died and 43 are still waiting for the procedure.

CONCLUSIONS

During the 4-year period HTX were performed in 42% of waiting pts. Mortality in this group was 38.2%. In 9 pts (5.9%) the alternative methods of surgical treatment were applicable. In 5 pts (3.9) the decision about HTX was delayed because of the positive change of the clinical status. This fact confirms the necessity of the waiting list verification.

[Endogenous mechanisms for protection in myocardium]

New opinions about myocardial adaptation during ischaemia are described in presented article. Myocardial preservation mechanisms in response to ischaemia are divided into metabolic adaptation like preconditioning and hibernation and anatomic mechanisms of adaptation like development of collateral circulation. Adaptation in clinical conditions can be observed in few situations. 1) During repeated in short period of time exercise tests (warm up). Adaptation may express through increasing tolerated ischemic burden, lenghtening time of exercise, increasing of ischaemic threshold and double product during successive exercise tests (predominately second). This phenomenon called warm up is a clinical counterpart of myocardial preconditioning. 2) In study during coronary angioplasty demonstrated that decrease of ST-segment, intensity of thoracic pain and serum lactacidaemia was lower during the second balloon inflation than the first. 4) The example of myocardial adaptation is repeated atrial stimulation. Ischaemic myocardium should be treated like some kind of mosaic of necrosis, hibernation, stunning and normal viability.

Successful full-term pregnancy in a patient three and a half years after a heart transplant

The patient is a 28 year old woman who received a heart transplant in 1992 secondary to hypertrophic cardiomyopathy with unremarkable post-operative course. In the period immediately post transplantation the patient was on a four-drug immunosuppressive regimen which was subsequently changed to standard three-agent therapy. This therapy was continued until the patient became pregnant. In the first trimester only Cyclosporine (CsA) was used, and thereafter, the patient was continued on the previous three agent regimen. Toward the end of pregnancy a rise in systolic pressure was observed, but the child was delivered by spontaneous vaginal delivery without complications in the 38th week of pregnancy. The newborn weighed 3320 g and was in good health. A sharp fall in the newborn CsA blood levels was observed post delivery reaching zero level on the third day of life. At the present time, both mother and baby are in good health, 6 weeks after delivery.

Evaluation of plasma cyclic GMP assay as a screening test for detection of acute cardiac allograft rejection

Our aim was to assess the value of a single determination of plasma cyclic guanosine 3',5'-monophosphate (cGMP) in noninvasive screening for acute cardiac allograft rejection warranting augmentation of immunosuppression. Plasma cGMP levels were measured in 26 patients 1 to 13 months after heart transplantation on the same day the endomyocardial biopsies were performed. Acute moderate rejection (ISHLT 3A or 3B) was found in 10 out of 17 subjects (59%) with plasma cGMP >5 nmol/L, whereas there was mild or no rejection (ISHLT 0 to 1) in 8 from among 9 subjects (89%) with cGMP <5 nmol/L. Because cGMP levels <5 nmol/L appear to argue against the presence of acute rejection requiring therapy modification, our preliminary results suggest that a single plasma cGMP assay might be helpful in establishing indications for endomyocardial biopsy in heart transplant recipients.

[Qualification of patients for heart transplantation in light of current views and personal observations]

Development of new diagnostic and therapeutic techniques along with increasing experience brought a great progress in heart transplantation over last 30 years. Changes occurred not only in the management of posttransplant patients but also in the subject of recipient selection, management and quantification. As there is insufficient number of potential donors to make heart transplantation in all candidates the problem of proper selection is very important. We discussed current approach to the potential candidates for heart transplantation: methods of patient quantification, indications and contraindications to transplantation, recipient selection criteria. Management of the potential recipients, who are on the waiting list is also discussed. Better knowledge, careful recipient selection and management bring significant improvement in posttransplant prognosis.

[Clinical usefulness of cardiopulmonary exercise testing in patients with cardiac failure waiting heart transplantation]

Heart transplantation has recently become an accepted method of treating heart failure patients, also in Poland. Criteria of patient selection to heart transplantation and follow-up was based (and in some centers still is) on the assessment of the patients' clinical status according to NYHA classification and on the data on the extend of myocardial damage obtained from echocardiography or ventriculography at rest. However, examinations performed in the resting state do not provide complete information on the patient's clinical status, especially during increased oxygen demand. Recently cardiopulmonary exercise testing (CPX-to measure maximal oxygen consumption) has been increasing used to establish the prognosis in patients with severe heart failure and to define indications to heart transplantation. CPX combines exercise testing with monitoring the air flow and gas exchange. The measurement of oxygen uptake and anaerobic threshold during exercise is an objective, reproducible, safe and non-invasive method to assess cardiac reserve. There is evidence implying that in heart failure patients VO2max is a good short-term indicator of mortality and that its deterioration frequently precedes clinical decompensation. Thus, the parameter may be useful not only in defining the indications, but also in the monitoring the patient's clinical state and timing of heart transplantation.