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P0826 HEART FAILURE AND NONVALVULAR ATRIAL FIBRILLATION: AN UNEQUIVOCAL RELATIONSHIP
S268
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
P0824 THE CORRELATION OF RESISTANCE INDEX OF SUPERIOR MESENTERIC ARTERY AND ENDOTHELIAL CHANGES IN HEART FAILURE
Ilinca Savulescu-Fiedler 1 , Roxana-Nicoleta Siliste 1 , Mihaela Gherghiceanu 1 , Ion Bruckner 1 . 1 Coltea Clinical Hospital; 2 Reasearch Institute "victor Babes" Introduction: A characteristic of the patients with heart failure (HF) is a decreased peripheral blood flow by rest as well as by exercise. This is caused, at least in part, by a reduced vasodilator response of the peripheral vessels endothelium. Objectives: The purpose of our study is to correlate the morphological and structural changes of the endothelium with the splanhnic blood flow, estimated by measuring the resistance index in superior mesenteric artery (RI SMA) using Doppler ultrasonography. Methods: 25 small vessels biopsies from patients that underwent abdominal surgery (15 patients with HF, 10 controls) were examined by optical and electronically microscopy. The endothelial changes were quantified by using Masuda scoring. Before intervention we measured in all patients the RI SMA and systolic peak velocity of SMA, as well as flow mediated dilation (FMD) of brachial artery. Results: we noticed very high RI SMA in patients with HF vs. controls (0.85±0,16 vs. 0.763±0,10, p<0.003), but without correlation of this index with the reactivity of the brachial artery to hyperaemia. A very low FMD (FMD 2,48±6,55 vs. 10,85±17, p<0.0001) was associated with changes of Doppler IntroductionObjectivesMaterials & MethodsResultsDiscussion & ConclusionKeywordsKeywordsflow wave pattern in SMA, namely, the lack of protodiastolic reverse. Only 9 biopsies from patients with HF have revealed important endothelial changes and a high activity score (Masuda 2-3) was correlated with low values of FMD and high peak systolic velocities in SMA. Conclusions: the correlation between FDM, endothelial structural changes and the flow wave pattern in SMA could indicate important hemodynamic disturbance and extensive endothelial dysfunction in heart failure. RI SMA, peak velocities in SMA and the Doppler flow pattern in SMA could be usefully in monitoring the peripheral circulatory status in patients with HF. Keywords: endothelial dysfunction; heart failure; superior mesenteric artery Doppler flow; Masuda scoring.
P0825 A CASE OF VARIANT ANGINA ASSOCIATED WITH THIRD DEGREE ATRIO-VENTRICULAR BLOCK
Roxana-Nicoleta Siliste 1 , Ilinca Savulescu-Fiedler 1 , Irina Calangea 1 , Calin Siliste 2 , Ion Bruckner 1 . 1 Coltea Clinical Hospital Bucharest; 2 Emergency Universitary Hospital Bucharest A 46 year old female with two years of increasingly frequent nocturnal angina pectoris and syncope was found on 24 hours ECG monitoring to develop marked ST segment elevation followed by atrioventricular 3rd degree block and Adam-Stokes syncope. Further evaluation included normal maximal exercise tolerance test, normal coronary arteriography and left ventricular angiography. She received a DDD-R pace-maker and nitrates with very good outcome. The association of nocturnal angina and sleep stages and the possibility of altering the coronary vasospasm by approaching the central neurophysiologic trigger rather than the peripheral coronary arteries is discussed. Keywords: variant angina; Adam-Stokes syncope; normal coronary arteries
P0826 HEART FAILURE AND NONVALVULAR ATRIAL FIBRILLATION: AN UNEQUIVOCAL RELATIONSHIP
Helder Dores, Ricardo Ferreira, Rosa Cardiga, Filipa Gândara, Filipa Marques, Inês Araújo, Ana Leitão, Cândida Fonseca, Fátima Ceia. Hospital São Francisco Xavier Introduction: Atrial Fibrillation (AF) is a common aetiology of Heart Failure (HF), increasing long term risk of stroke and all-cause morbidity and mortality. During the past 20 years the hospital admissions for AF has been increased 66%. The relation between AF and HF makes the management of these patients (pts) a clinical challenge with prognostic implications. Objectives: To analyse a nonvalvular AF population and determine early predictors of long term death, hospitalisation and haemorrhagic/ischemic stroke (CEP), as well as determinants of HF development.
Materials & methods: Retrospective study of pts consecutively discharged with AF diagnosis, DRG: ICD-9-CM (427.31/32) during one year, mean follow-up of 378±241 days. The following factors were included in a Cox regression analysis to determine independent predictors of composite endpoint (CEP): gender, age≥80 years (y), hypertension (HTA), coronary artery disease (CAD), diabetes (DM), tabagism (T), HF, pulmonary disease (PUD), peptic disease (PED), hemorrhagic events (HE), renal failure (RF), NT-proBNP, systolic dysfunction (SD), oral anticoagulation (OAC), isolated antiagregation therapy (AT) and prior stroke/transient ischemic attack (PS). Results: 161 pts, 94 (58.4%) females, m= 77.7±9.8 y, 47.2% ≥80 y. Risk factors: HTA 65.8%, DM 24.2%, T 16.8%, CAD 20.6%, HF 60.9%, RF 31.3%, PUD 32.9%, PED 2.5%, HE 5.6%, SD 22.5%, NTproBNP median 3306 pg/ml, OAC 53.5%, AT 26.9% and PS 12.5%. The only long term independent predictors of CEP were: HF (p=0.049, HR: 2.3, CI 95% [1.0-5.2]), RF (p=0.015, HR: 2.3, CI 95% [1.2-4.3]) and OAC (p=0.015, HR: 0.5, CI 95% [0.2-0.9]) (Table). Determinants of HF were NTproBNP≥3306 pg/ml (p=0.009 and SD (p=0.03).
Heart failure Renal failure Oral anticoagulation
P
HR
CI 95%
0.049 0.015 0.015
2.3 2.3 0.5
[1.0-5.2] [1.2-4.3] [0.2-0.9]
Discussion & conclusion: In this population of pts discharged with nonvalvular AF, HF and RF were the only long term independent predictors of CEP. OAC was the unique protector factor of CEP justifying the formal recommendation in these high risk pts. Keywords: Atrial fibrillation, heart failure, renal failure, oral Anticoagulation
P0827 PULMONARY HYPERTENSION IN A PATIENT WITH ESSENTIAL THROMBOCYTHEMIA
Alexandra Vaz 1 , Andreia Correia 1 , Borges Martins 1 , Pedro Henriques 1 , Antonio Marinho 2 , Paula Cruz 1 . 1 Hospital S. Teotónio Viseu; 2 Hospitais Universidade De Coimbra Introduction: Essential thrombocythemia (ET) is a nonreactive chronic myeloproliferative disorder (CMPD) characterized by a sustained platelet count. The clinical picture is dominated by a predisposition to vascular occlusive events (involving the cerebrovascular, coronary and peripheral circulation) and hemorrhages. Some studies have suggested an association between pulmonary hypertension (PH) and CMDP but the exact incidence of PH in ET is unknown. The main etiology of PH in this context might be the pulmonary capillary obstruction by megakaryocytes with stasis and secondary microthrombosis. Case report: A 56-year-old woman was admitted to our hospital with a history of progressive exertional dyspnea (NYHA grade III) over the last 8 months. She had a history of hypertension of unknown duration. Physical examination revealed a blood pressure of 140/100 mmHg with a regular pulse of 100 bpm and a respiratory rate of 24 cpm. A grade 3/6 systolic murmur (at the left sternal border in the 2° intercostal space) was heard and there was edema of the lower extremities, without signs of venous thrombosis. The following laboratory parameters were of note: platelet count 1054×109 /L; haemoglobin 14.5 g/dL; hematocrit 45%; white blood cells count 8.90×109 /L; CRP 0,48 mg/dL; LDH 1161 UI/L; D-dimer 232 ng/mL; BNP 395 pg/mL. Arterial blood gas analysis showed PaO2 41 mmHg, PaCO2 40 mmHg and HCO3- 24 meq/L. Bone marrow examination showed hypermegakaryocytosis with normocellularity; cytogenetis studies ruled out the possibility of another CMPD. We also excluded causes of reactive thrombocytosis (serum iron studies, tumoral markers, coagulation tests) and the diagnosis of ET was made according to the criteria of PVSG (Polycythemia Vera Study Group). Chest X-ray revealed cardiomegaly with enlargement of both main pulmonary arteries. Transthoracic echocardiography demonstrated marked enlargement of the right ventricle with septal flattening and the Doppler study showed severe regurgitation of the tricuspid valve with a estimated pressure gradient of 107 mmHg. We performed a chest Angio-TAC that revealed dilated central pulmonary arteries, bronchial artery collateral flow and mosaic attenuation of the pulmonary parenchyma. Pulmonary angiography showed small fillings defects in segmental branches of the pulmonary arteries. Treatment with diuretics, warfarin and hydroxyureia was started and at the moment the patient awaits right heart catheterization. Conclusion: In this case we found that the main predisposing factor for pulmonary thrombosis was ET. Although PH associate with ET is uncommon, it should be always considered as a possible cause of dyspnea in these patients.
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
P0824 THE CORRELATION OF RESISTANCE INDEX OF SUPERIOR MESENTERIC ARTERY AND ENDOTHELIAL CHANGES IN HEART FAILURE
Ilinca Savulescu-Fiedler 1 , Roxana-Nicoleta Siliste 1 , Mihaela Gherghiceanu 1 , Ion Bruckner 1 . 1 Coltea Clinical Hospital; 2 Reasearch Institute "victor Babes" Introduction: A characteristic of the patients with heart failure (HF) is a decreased peripheral blood flow by rest as well as by exercise. This is caused, at least in part, by a reduced vasodilator response of the peripheral vessels endothelium. Objectives: The purpose of our study is to correlate the morphological and structural changes of the endothelium with the splanhnic blood flow, estimated by measuring the resistance index in superior mesenteric artery (RI SMA) using Doppler ultrasonography. Methods: 25 small vessels biopsies from patients that underwent abdominal surgery (15 patients with HF, 10 controls) were examined by optical and electronically microscopy. The endothelial changes were quantified by using Masuda scoring. Before intervention we measured in all patients the RI SMA and systolic peak velocity of SMA, as well as flow mediated dilation (FMD) of brachial artery. Results: we noticed very high RI SMA in patients with HF vs. controls (0.85±0,16 vs. 0.763±0,10, p<0.003), but without correlation of this index with the reactivity of the brachial artery to hyperaemia. A very low FMD (FMD 2,48±6,55 vs. 10,85±17, p<0.0001) was associated with changes of Doppler IntroductionObjectivesMaterials & MethodsResultsDiscussion & ConclusionKeywordsKeywordsflow wave pattern in SMA, namely, the lack of protodiastolic reverse. Only 9 biopsies from patients with HF have revealed important endothelial changes and a high activity score (Masuda 2-3) was correlated with low values of FMD and high peak systolic velocities in SMA. Conclusions: the correlation between FDM, endothelial structural changes and the flow wave pattern in SMA could indicate important hemodynamic disturbance and extensive endothelial dysfunction in heart failure. RI SMA, peak velocities in SMA and the Doppler flow pattern in SMA could be usefully in monitoring the peripheral circulatory status in patients with HF. Keywords: endothelial dysfunction; heart failure; superior mesenteric artery Doppler flow; Masuda scoring.
P0825 A CASE OF VARIANT ANGINA ASSOCIATED WITH THIRD DEGREE ATRIO-VENTRICULAR BLOCK
Roxana-Nicoleta Siliste 1 , Ilinca Savulescu-Fiedler 1 , Irina Calangea 1 , Calin Siliste 2 , Ion Bruckner 1 . 1 Coltea Clinical Hospital Bucharest; 2 Emergency Universitary Hospital Bucharest A 46 year old female with two years of increasingly frequent nocturnal angina pectoris and syncope was found on 24 hours ECG monitoring to develop marked ST segment elevation followed by atrioventricular 3rd degree block and Adam-Stokes syncope. Further evaluation included normal maximal exercise tolerance test, normal coronary arteriography and left ventricular angiography. She received a DDD-R pace-maker and nitrates with very good outcome. The association of nocturnal angina and sleep stages and the possibility of altering the coronary vasospasm by approaching the central neurophysiologic trigger rather than the peripheral coronary arteries is discussed. Keywords: variant angina; Adam-Stokes syncope; normal coronary arteries
P0826 HEART FAILURE AND NONVALVULAR ATRIAL FIBRILLATION: AN UNEQUIVOCAL RELATIONSHIP
Helder Dores, Ricardo Ferreira, Rosa Cardiga, Filipa Gândara, Filipa Marques, Inês Araújo, Ana Leitão, Cândida Fonseca, Fátima Ceia. Hospital São Francisco Xavier Introduction: Atrial Fibrillation (AF) is a common aetiology of Heart Failure (HF), increasing long term risk of stroke and all-cause morbidity and mortality. During the past 20 years the hospital admissions for AF has been increased 66%. The relation between AF and HF makes the management of these patients (pts) a clinical challenge with prognostic implications. Objectives: To analyse a nonvalvular AF population and determine early predictors of long term death, hospitalisation and haemorrhagic/ischemic stroke (CEP), as well as determinants of HF development.
Materials & methods: Retrospective study of pts consecutively discharged with AF diagnosis, DRG: ICD-9-CM (427.31/32) during one year, mean follow-up of 378±241 days. The following factors were included in a Cox regression analysis to determine independent predictors of composite endpoint (CEP): gender, age≥80 years (y), hypertension (HTA), coronary artery disease (CAD), diabetes (DM), tabagism (T), HF, pulmonary disease (PUD), peptic disease (PED), hemorrhagic events (HE), renal failure (RF), NT-proBNP, systolic dysfunction (SD), oral anticoagulation (OAC), isolated antiagregation therapy (AT) and prior stroke/transient ischemic attack (PS). Results: 161 pts, 94 (58.4%) females, m= 77.7±9.8 y, 47.2% ≥80 y. Risk factors: HTA 65.8%, DM 24.2%, T 16.8%, CAD 20.6%, HF 60.9%, RF 31.3%, PUD 32.9%, PED 2.5%, HE 5.6%, SD 22.5%, NTproBNP median 3306 pg/ml, OAC 53.5%, AT 26.9% and PS 12.5%. The only long term independent predictors of CEP were: HF (p=0.049, HR: 2.3, CI 95% [1.0-5.2]), RF (p=0.015, HR: 2.3, CI 95% [1.2-4.3]) and OAC (p=0.015, HR: 0.5, CI 95% [0.2-0.9]) (Table). Determinants of HF were NTproBNP≥3306 pg/ml (p=0.009 and SD (p=0.03).
Heart failure Renal failure Oral anticoagulation
P
HR
CI 95%
0.049 0.015 0.015
2.3 2.3 0.5
[1.0-5.2] [1.2-4.3] [0.2-0.9]
Discussion & conclusion: In this population of pts discharged with nonvalvular AF, HF and RF were the only long term independent predictors of CEP. OAC was the unique protector factor of CEP justifying the formal recommendation in these high risk pts. Keywords: Atrial fibrillation, heart failure, renal failure, oral Anticoagulation
P0827 PULMONARY HYPERTENSION IN A PATIENT WITH ESSENTIAL THROMBOCYTHEMIA
Alexandra Vaz 1 , Andreia Correia 1 , Borges Martins 1 , Pedro Henriques 1 , Antonio Marinho 2 , Paula Cruz 1 . 1 Hospital S. Teotónio Viseu; 2 Hospitais Universidade De Coimbra Introduction: Essential thrombocythemia (ET) is a nonreactive chronic myeloproliferative disorder (CMPD) characterized by a sustained platelet count. The clinical picture is dominated by a predisposition to vascular occlusive events (involving the cerebrovascular, coronary and peripheral circulation) and hemorrhages. Some studies have suggested an association between pulmonary hypertension (PH) and CMDP but the exact incidence of PH in ET is unknown. The main etiology of PH in this context might be the pulmonary capillary obstruction by megakaryocytes with stasis and secondary microthrombosis. Case report: A 56-year-old woman was admitted to our hospital with a history of progressive exertional dyspnea (NYHA grade III) over the last 8 months. She had a history of hypertension of unknown duration. Physical examination revealed a blood pressure of 140/100 mmHg with a regular pulse of 100 bpm and a respiratory rate of 24 cpm. A grade 3/6 systolic murmur (at the left sternal border in the 2° intercostal space) was heard and there was edema of the lower extremities, without signs of venous thrombosis. The following laboratory parameters were of note: platelet count 1054×109 /L; haemoglobin 14.5 g/dL; hematocrit 45%; white blood cells count 8.90×109 /L; CRP 0,48 mg/dL; LDH 1161 UI/L; D-dimer 232 ng/mL; BNP 395 pg/mL. Arterial blood gas analysis showed PaO2 41 mmHg, PaCO2 40 mmHg and HCO3- 24 meq/L. Bone marrow examination showed hypermegakaryocytosis with normocellularity; cytogenetis studies ruled out the possibility of another CMPD. We also excluded causes of reactive thrombocytosis (serum iron studies, tumoral markers, coagulation tests) and the diagnosis of ET was made according to the criteria of PVSG (Polycythemia Vera Study Group). Chest X-ray revealed cardiomegaly with enlargement of both main pulmonary arteries. Transthoracic echocardiography demonstrated marked enlargement of the right ventricle with septal flattening and the Doppler study showed severe regurgitation of the tricuspid valve with a estimated pressure gradient of 107 mmHg. We performed a chest Angio-TAC that revealed dilated central pulmonary arteries, bronchial artery collateral flow and mosaic attenuation of the pulmonary parenchyma. Pulmonary angiography showed small fillings defects in segmental branches of the pulmonary arteries. Treatment with diuretics, warfarin and hydroxyureia was started and at the moment the patient awaits right heart catheterization. Conclusion: In this case we found that the main predisposing factor for pulmonary thrombosis was ET. Although PH associate with ET is uncommon, it should be always considered as a possible cause of dyspnea in these patients.