Piotr Bienias

Patients with an acute pulmonary embolism (APE) are a heterogeneous group, and some of them may benefit from early discharge and an ambulatory care referral. We aimed to evaluate the use of N-terminal pro-brain natriuretic peptide (NT-proBNP) plasma level assessment in patients with low-risk APE based on clinical findings (0 points on the simplified Pulmonary Embolism Severity Index (sPESI)). Preliminary analysis of an ongoing prospective study including 1,151 normotensive patients with at least a segmental APE. In the final analysis, 348 patients with a 0-point sPESI were included. Blood samples were collected within the first 24 h of admission. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis in patients with clinical deterioration. Clinical endpoints occurred in 3 patients who had higher plasma NT-proBNP levels than study participants with a favorable clinical course (164 [64-650] pg/mL compared to 2,930 [2,285.5-13,965] pg/mL; p = 0.01). Receiver operating characteristic (ROC) analysis showed that the area under the curve (AUC) for NT-proBNP for the prediction of the CEs was 0.918 (95% confidence interval [95% CI]: 0.831-1.00; p = 0.013). We defined the cutoff value of NT-proBNP at ≥1,641 pg/mL. Among subjects with 0 points on the sPESI, those with concentrations of NT-proBNP exceeding 1,641 pg/mL might require closer attention; remaining patients could be considered candidates for outpatient treatment. However, these findings warrant further investigation in a large, prospective group of patients.

Introduction: Although in the non-vitamin K oral anticoagulants (NOAC) era majority of low-risk acute pulmonary embolism (APE) patients can be treated at home, identifying those at very low risk of clinical deterioration may be challenging. We aimed to propose the risk stratification algorithm in sPESI 0 point APE patients, allowing them to select candidates for safe outpatient treatment. Materials and methods: Post hoc analysis of a prospective study of 1151 normotensive patients with at least segmental APE. In the final analysis, we included 409 sPESI 0 point patients. Cardiac troponin assessment and echocardiographic examination were performed immediately after admission. Right ventricular dysfunction was defined as the right ventricle/left ventricle ratio (RV/LV) > 1.0. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis and/or immediate surgical embolectomy in patients with clinical deterioration. Results: CE occurred in four patients who had higher serum troponin levels than subjects with a favorable clinical course (troponin/ULN: 7.8 (6.4–9.4) vs. 0.2 (0–1.36) p = 0.000). Receiver operating characteristic (ROC) analysis showed that the area under the curve for troponin in the prediction of CE was 0.908 (95% CI 0.831–0.984; p < 0.001). We defined the cut-off value of troponin at >1.7 ULN with 100% PPV for CE. In univariate and multivariate analysis, elevated serum troponin level was associated with an increased risk of CE, whereas RV/LV > 1.0 was not. Conclusions: Solely clinical risk assessment in APE is insufficient, and patients with sPESI 0 points require further assessment based on myocardial damage biomarkers. Patients with troponin levels not exceeding 1.7 ULN constitute the group of “very low risk” with a good prognosis.

The association between heart rate variability (HRV) and mortality risk of acute pulmonary embolism (APE), as well as its association with right ventricular (RV) overload is not well established. We performed an observational study on consecutive patients with confirmed APE. In the first 48 h after admission, 24 h Holter monitoring with assessment of time-domain HRV, echocardiography and NT-proBNP (N-terminal pro-B-type natriuretic peptide) measurement were performed in all participants. We pre-examined 166 patients: 32 (20%) with low risk of early mortality, 65 (40%) with intermediate–low, 65 (40%) with intermediate–high, and 4 (0.02%) in the high risk category. The last group was excluded from further analysis due to sample size, and finally, 162 patients aged 56.3 ± 18.5 years were examined. We observed significant correlations between HRV parameters and echocardiographic signs of RV overload. SDNN (standard deviation of intervals of all normal beats) correlated with echocardiography-derived RVSP (right ventricular systolic pressure; r = −0.31, p = 0.001), TAPSE (tricuspid annulus plane systolic excursion; r = 0.21, p = 0.033), IVC (inferior vena cava diameter; r = −0.27, p = 0.002) and also with NT-proBNP concentration (r = −0.30, p = 0.004). HRV indices were also associated with APE risk stratification, especially in the low-risk category (r = 0.30, p = 0.004 for SDNN). Univariate and multivariate analyses confirmed that SDNN values were associated with signs of RV overload. In conclusion, we observed a significant association between time-domain HRV parameters and echocardiographic and biochemical signs of RV overload. Impaired HRV parameters were also associated with worse a clinical risk status of APE.

The effects of weight loss following bariatric surgery on autonomic balance, arrhythmias and insulin resistance are still of interest. We prospectively investigated 50 patients with BMI > 40 kg/m², aged 36.5 (18–56) years who underwent laparoscopic sleeve gastrectomy. Among other examinations, all subjects had 24-h Holter monitoring with heart rate variability (HRV) and heart rate turbulence (HRT) evaluation. After a median of 15 months, BMI decreased from 43.9 to 29.7 kg/m², the incidence of hypertension decreased from 54 to 32% (p = 0.04) and any carbohydrate disorders decreased from 24 to 6% (p = 0.02). Fasting insulin concentration and insulin resistance index improved significantly (p < 0.001). Improvements in HRV parameters related to the sympathetic autonomic division were also observed (p < 0.001), while HRT evaluation was not conclusive. The enhancement of autonomic tone indices was correlated with reduction of BMI (SDNN-I r = 0.281 p = 0.04; SDNN r = 0.267 p = 0.05), but not with reduction of waist circumference, and it was also associated with decrease of mean heart rate (OR 0.02, 95%CI 0.0–0.1, p < 0.001). The incidence of arrhythmias was low and similar before and after follow-up. In conclusion, improvement of homeostasis of carbohydrate metabolism and autonomic function is observed in relatively young patients after weight loss due to laparoscopic sleeve gastrectomy.

Summary: There is no sufficient data on arrhythmias occurrence in obesity class III. The influence of hyperinsulinemia and insulin resistance on arrhythmias and cardiac autonomic tone is also of ongoing interest in these subjects. We prospectively studied 81 selected patients with body mass index >40 kg/m², aged 34 (18‐65) years. Among other examinations all subjects underwent electrocardiography and Holter monitoring with heart rate variability (HRV) and turbulence (HRT) evaluation. Controls consisted of 45 healthy, sex‐ and aged‐matched lean volunteers. In patients median BMI was 44.5 kg/m² (40.1‐58.1), benign arterial hypertension was present in 43.2% and dysglycemia in 27.2% of cases. In the group with obesity longer PR interval (P < .001) and corrected QT interval (P < .001) were observed, while in Holter monitoring no significant differences in supraventricular or ventricular arrhythmias and also bradyarrhythmias prevalence were observed in comparison to controls. In individuals with obesity HRV indices associated with sympathetic tone were significantly impaired and also abnormal HRT values (21.9 vs 0%, P = .04) were more frequently observed. There were no significant correlations between anthropometric obesity parameters and fasting insulin concentration, insulin resistance index and also HRV/HRT parameters in studied individuals. Univariate regression analysis revealed that only age influenced abnormal HRT occurrence (OR 1.69, 95%CI 1.08‐2.98, P = .04). In conclusions, patients with obesity class III at a relatively young age who reported they felt healthy, do not present increased prevalence of arrhythmias, including life‐threatening ones. Cardiac autonomic dysfunction is observed in these patients, however it has not been shown to be associated with anthropometric measurements.

There are no data on the influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in 24-hour Holter monitoring in systemic lupus erythematosus (SLE). Consecutive 92 SLE and 51 healthy subjects were studied. The standard 12-lead electrocardiography (ECG), Holter monitoring with heart rate turbulence (HRT) and QT, Tp-e and Tp-e/QT ratio assessment (including corrected values) were performed. Subjects with conditions causing repolarization abnormalities or insufficient number of beats suitable for QT evaluation were excluded (17 SLE and 8 controls). Finally, 75 SLE and 43 sex- and age-matched controls were included to the study. In SLE patients, the median disease severity score (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI)) was 3.0. The mean values of QTc, cTp-e and cTp-e/QTc were significantly higher in SLE patients than in controls. QTc ≥ 460 ms was observed in 18.7% of patients using standard ECG and in 58.7% using Holter monitoring. With Holter monitoring, patients with SLICC/ACR-DI >3.0 presented longer QTc than those with SLICC/ACR-DI ≤3.0 (418±15 vs. 409 ± 16, p = 0.04), while cTp-e and cTp-e/QTc values were similar. Patients with abnormal HRT presented longer cTp-e and higher cTp-e/QTc than those with normal HRT (92 ± 52 vs. 71 ± 16 ms, p = 0.04; 0.244 ± 0.126 vs. 0.187 ± 0.035, p = 0.03), while QTc values were similar. No differences in QT and Tp-e parameters were observed according to disease duration. In SLE patients, Holter monitoring revealed QTc prolongation more frequently than standard ECG. Longer QTc values were observed in patients with more advanced disease, while increased cTp-e and cTp-e/QTc were related to cardiac autonomic dysfunction expressed by abnormal HRT.