Summary Post-myocardial infarction ventricular arrhythmia and sudden cardiac death risk remain important issues in these patients. In high-risk post-myocardial infarction (MI) patients prophylactic implantable cardioverter defibrillators (ICD) may significantly improve survival. Risk stratification studies of post-MI patients will allow ICD therapy to be applied in a more cost-effective manner. We present some key features of non-invasive and invasive methods of risk assessment relevant to the assessment of the arrhythmic risk after myocardial infarction.

Toader, D.; Belu, E.; Radu, R.; Popescu, M.; Musetescu, R.; Ionescu, D.-D. Author Information

Musetescu, R.; Toader, D.; Belu, E.; Musetescu, A. E.; Popescu, M.; Ionescu, D. D Author Information

Belu, E.1; Musetescu, R1; Bataiosu, C.1; Popescu, M.1; Cosulschi, M2; Florescu, N.1; Ionescu, D.-D.1 Author Information

Belu, E.; Musetescu, R.; Bataiosu, C.; Popescu, M.; Toader, D.; Mustafa, R.; Cosulschi, M.; Florescu, N.; Ionescu, D.-D. Author Information

Purpose: We investigated the relationship between P wave dispersion, as measured on the surface electrocardiogram, and left ventricular diastolic function, in a group of hypertensive patients. Methods: We included 86 patients (52 males, aged between 35–67 years). We excluded patients with previous acute myocardial infarction, thyroid dysfunction, valvular heart disease, cardiomyopathy, electrolyte imbalance, drug use that affects atrial conduction, or alcohol use. P wave dispersions were calculated by measuring minimum and maximum P wave duration values on the surface electrocardiogram. By standard transthoracic echocardiography we investigated the presence and degree of diastolic dysfunction, classified as: stage 1 - prolonged relaxation pattern, stage 2 - pseudonormalization pattern, and stage 3 - restrictive pattern. There were 47 patients with diastolic dysfunction and 39 without. The relationships between P wave dispersion and echocardiographic measurements of diastolic dysfunction were analyzed. Results: P wave dispersion was 62 ± 12 ms in patients with diastolic dysfunction and 49 ± 10 ms in those without (p < 0.01). The maximum P wave duration was 118 ± 9 ms in patients with diastolic dysfunction vs 107 ± 8 ms in the control group (p < 0.05). The minimum P wave duration was 64 ± 11 ms vs 63 ± 10 ms (not significant). When patients were grouped according to the stage of diastolic dysfunction, P wave dispersion was 52 ± 8 ms in stage 1, 58 ± 9 ms in stage 2, and 64 ± 13 ms in stage 3. As the severity of diastolic dysfunction increased, P wave dispersion increased, the difference was statistically significant (p < 0.05). Conclusion: P wave dispersion is increased in hypertensive patients with diastolic dysfunction, and this increase is related to the severity of diastolic dysfunction.

Background: An increased filling presure is revealed by a severe diastolic dysfunction, associated with a large acute myocardial infarction (AMI) and the risk of acute complications. Aim of the study was to find a correlation between the pattern of distolic mitral inflow and the complications during the first week after AMI in hypertensive patients. Methods: A number of 98 hypertensive patients (56 males and 43 females) aged 36 - 82 years, admitted with acute myocardial infarction with ST-segment elevation were evaluated in the first week of hospitalization by: clinical examination: angina, heart failure symptoms, 12 lead standard ECG, Holter: the presence of arrythmias, echocardiographic measurement of diastolic mitral inflow using Doppler method, the presence of complications: left ventricular aneurysm, left ventricular thrombus, rupture of interventricular septum, using transthoracic echocardiography. Patients were divided in 4 groups: 1. LVH+ and reperfusion 2. LVH+ without reperfusion 3. LVH- and reperfusion 4. LVH- without reperfusion. Results: 1. LVH was found in 67 patients (68,36%). 2. Failled reperfusion was present in 16,33% patients with LVH and 36,73% in patients with LVH which matched not criterias for thrombolitic therapy administration. 3. In hypertensive patients with LVH and without successful reperfusion pseudonormal pattern was found in 10,20% and restrictive pattern in 10,20% percentage. 4. Complications during the first week were more frequent in patients with pseudonormal pattern: angina: 55%, pericarditis: 20%, heart failure classes NYHA III and IV: 80%, aneurysm: 25%, thrombus: 5%, atrial fibrillation: 25% and restrictive pattern: angina: 57,14%, pericarditis: 50%, heart failure classes NYHA III and IV: 100%, aneurysm: 42,85%, thrombus: 35,71%, rupture of interventricular septum: 7,14%, atrial fibrillation: 71,42%. Conclusions 1. The most severe patterns of diastolic dysfunction such as pseudonormal and restrictive were present in hypertensive patients with LVH and without successful reperfusion. 2. In these patients complications during the first week of hospitalization were more frequent. 3. We can conclude that an increased filling pressure revealed by a severe diastolic disfunction were associated with short therm complications after AMI.

Background: Before acute myocardial infarction (AMI), hypertensive patients has high filling pressure in left ventricle which is supplementary rised during the infarction by the areas of necrosis and ischemia. Aims of the study: was to evaluate echocardiographic parameters of diastolic dysfunction in hypertensive patients during the first week after AMI. Methods: A number of 98 hypertensive patients (56 males and 43 females), admitted with acute myocardial infarction with ST-segment elevation were evaluated in the first week by: clinical examination, 12 lead standard ECG, echocardiographic measurements of: left atrium volume index (LAVi) and left ventricle mass index (LVMi) using transthoracic echocardiography, pulmonary artery systolic pressure (PAPs) using Doppler echocardiography for tricuspid inflow, E/E’, E/vp and ar-A, using Doppler echocardiography for mitral inflow (E wave velocity, A wave duration), tissue Doppler echocardiography at lateral and medial corner of mitral annulus (E’ wave velocity), colour Mmode (flow propagation velocity vp) and pulmonary venous flow (ar wave duration): cut off levels: LAVi>32 ml/m2, LVMi>131 g/m2 in males and>125 g/m2 in females (left ventricular hypertrophy, LVH), PAPs>35mmHg, E/E’>14, E/vp>1,5, ar-A>25ms. Patients were divided in 4 groups: 1. LVH+ and reperfusion 2. LVH+ without reperfusion 3. LVH- and reperfusion 4. LVH- without reperfusion. Results: 1. LVH was find in 67 patients (68,36%). 2. Mean values of parameters of filling pressure in hypertensive patients with LVH and without reperfusion were: VASi: 35,04, p = 0,00007, PAPs: 45,57, p = 0,00122, E/E’: 14,81, p = 0,03992, E/vp: 1,99, p = 0,00197, ar-A: 28,79, p = 0,00726. 3. Percentages of patients with LVH and without reperfusion which presented filling pressure parameters values higer than cut off level were: VASi: 26,53%, PAPs: 26,53%, E/E’: 15,31%, E/vp:22,45%, ar-A: 16,33%. Conclusions: 1. In hypertensive patients without or failed thrombolitic therapy all echocardiographic parameters of filling pressure mean values were higher than cut off levels and than in hypertensive patients without LVH and with successful medical reperfusion. 2. The highest mean values were find in hypertensive patients with LVH and without reperfusion, which theoretical had the highest values of left ventricle filling pressure.

Purpose: A maximum P wave duration (Pmax) of > 110 msec and a P wave dispersion (PWD) > 40 msec are accepted indicators of a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse, respectively. The left atrial (LA) volume is considered to be a marker of atrial remodeling. We aimed to investigate the relationship between LA volume and Pmax or PWD in patients with hypertension. Methods: We included 52 hypertensive patients in sinus rhythm. We recorded for each patient a 12-lead electrocardiogram with a paper speed of 50 mm/s and an amplification of 20 mm/mV. P wave dispersion (PWD) was defined as the difference between the duration of the widest (Pmax) and the narrowest (Pmin) P wave, measured on all leads of the 12-lead electrocardiogram. Measurements were made by a single investigator, in a blinded fashion, using a computerized program; the onset and offset points of the P wave were marked manually. The study population was classified into four groups, according to the Pmax (>/= 110 ms or < 110 ms), and the PWD (>/= 40 ms or < 40 ms). The left atrial volume (LAV) was measured by transthoracic echocardiography. Results: There were significant differences in the ejection fraction, diastolic function, and LAV between patients with a Pmax >/= 110 ms or a PWD >/= 40 ms and those with a Pmax < 110 ms or a PWD < 40 ms. The LAV was independently associated with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse. The LAV can be used to identify patients with a disturbance in the propagation of the sinus impulse, which are at risk for atrial fibrillation. Conclusion: The maximum duration of the P wave and the P wave dispersion on standard 12-lead electrocardiograms are associated with the LA volume in hypertensive patients.

Objective: Atrial fibrillation (AF) is associated with increased cardiovascular risk and the incidence of AF is higher in hypertensive patients. Different data suggest that dual chamber pacing may decrease the incidence of AF compared with VVI pacing. Methods: We have evaluated 78 hypertensive patients implanted in our centre in 2007: 24 with DDD pacing and 54 patients with VVI pacing. Patients with a previous history of atrial fibrillation were excluded from our analisys. The pacing indications were: sinus node disease (SND, 14%), atrioventricular (AV) block (55%), bradycardia-tachycardia syndrome (BTS, 11%) and AV block + sinus node disease (20%). The follow up period lasted for 2 years. Results: The mean age of the study group was 67 ± 8 years. The incidence of AF was: 14% after 1 year and 35% after 2 years of follow up. In patients with AF, New York Heart Association functional class of heart failure was higher than in patients without AF (p < 0.05). No significant differences have been observed between patients with complete AV block and those with SND regarding the incidence of atrial fibrillation (p>0.05). Conclusions: The incidence of atrial fibrillation was significantly lower in hypertensive patients treated with dual chamber devices than in pacients with ventricular pacemakers.

Objective: Metabolic syndrome consists of several interrelated risk factors that have been shown to increase the risk of heart disease and also the risk of atrial fibrillation. Method: We have included in the study group patients admitted in Cardiology Center in 2006 and we have divided them in 2 subgroups: individuals with hypertension and metabolic syndrome according to NCEP criteria and the second subgroup of hypertensives without metabolic syndrome. The follow-up period lasted for 3 years. We performed multivariate logistic regression analyses in order to assess the relationships between hypertension, metabolic syndrome, atrial fibrillation, dyslipidemia and diabetes mellitus. Results: We have evaluated 542 patients with metabolic syndrome and hypertension mean age of 55,12 years. There were 48,72% men and 51,28% women. The profile of our MS patients was depicted by older age, higher systolic pressure, higher body mass indexes and higher incidence of atrial fibrillation. The procent of patients with diabetes mellitus was 34,19%, but 27,35% from them had impaired fasting glucose. This population had more left ventricular hypertrophy, renal and cardiac diseases were more prevalent (p < 0.01), and they received more antihypertensive drugs (p < 0.05). Conclusions: The study shows the poor adherence to treatment of hypertensive patients with metabolic syndrome. The hypertensive patients with atrial fibrillation are achieving the target values for blood pressure in a very small percent (p < 0.05). The number of important cardiovascular events is increased in the case of these young patients with a very high risk profile.

Objective: Metabolic syndrome consists of several interrelated risk factors that have been shown to increase the risk of heart disease and also the risk of atrial fibrillation. Method: We have included in the study group patients admitted in Cardiology Center in 2006 and we have divided them in 2 subgroups: individuals with hypertension and metabolic syndrome according to NCEP criteria and the second subgroup of hypertensives without metabolic syndrome. The follow-up period lasted for 3 years. We performed multivariate logistic regression analyses in order to assess the relationships between hypertension, metabolic syndrome, atrial fibrillation, dyslipidemia and diabetes mellitus. Results: We have evaluated 542 patients with metabolic syndrome and hypertension mean age of 55,12 years. There were 48,72% men and 51,28% women. The profile of our MS patients was depicted by older age, higher systolic pressure, higher body mass indexes and higher incidence of atrial fibrillation. The procent of patients with diabetes mellitus was 34,19%, but 27,35% from them had impaired fasting glucose. This population had more left ventricular hypertrophy, renal and cardiac diseases were more prevalent (p < 0.01), and they received more antihypertensive drugs (p < 0.05). Conclusions: The study shows the poor adherence to treatment of hypertensive patients with metabolic syndrome. The hypertensive patients with atrial fibrillation are achieving the target values for blood pressure in a very small percent (p < 0.05). The number of important cardiovascular events is increased in the case of these young patients with a very high risk profile.

Background: An increased filling pressure in acute phase of myocardial infarction can be identified echocardiography. P-HiRes reveales late atrial potentials (LAP), associated with the risk of reentry arrythmias. Aim of the study was to find a correlation between echocardiographic parameters of increased filling pressure and the presence of LAP. Methods: A number of 98 hypertensive patients (56 males and 43 females), admitted with acute myocardial infarction (AMI) with ST-segment elevation were evaluated in the first week by: clinical examination, 12 lead standard ECG, echocardiographic measurements of: left atrium volume index (LAVi) and left ventricle mass index (LVMi), pulmonary artery systolic pressure (PAPs) (transthoracic and Doppler echocardiography), E/E’ (tissue Doppler echocardiography), E/vp (colour Mmode) and ar-A (pulmonary venous flow): cut off levels: LAVi>32 ml/m2, LVMi>131 g/m2 in males and >125 g/m2 in females (left ventricular hypertrophy, LVH), PAPs>35mmHg, E/E’>14, E/vp>1,5, ar-A>25ms. Criterias for he presence of LAP were evaluated using P-HiRes were: SAPWD>140ms, RMS(LP20)>3,5 μV, integral of p wave>800 μVs, nomber of beats 250, filters 25–40 MHz, noise level<0,1 μV (target). Results: 1. The higher incidence of LAP was found in patients with LVH without reperfusion: 25,51%. 2. Percentages of patients with LVH and without reperfusion which presented filling pressure parameters values higer than cut off levels were: VASi: 26,53%, PAPs: 26,53%, E/E’: 15,31%, E/vp:22,45%, ar-A: 16,33%. 3. Using chi squared (cs), odd ratio(or) and relative risk (rr) we found significant correlation between the presence of LAP and these parameters: VASi>32 ml/m2: cs = 36,64729, or= 19,28205, rr=4,96111, E/E’>14: cs=11,26657, or=5,677419, rr=1,866189, E/vp>1,5: cs=35,39615, or=0,rr=0, ar-A>25ms: cs=14,72762, or=6,08, rr=2,016. Conclusions: 1. The incidence of LAP was higher and echocardiographic parameters of filling pressure were higher than cut off levels in hypertensive patients with LVH without reperfusion. 2. Because of this good correlation between these parameters and the presence of LAP we can conclude that may be a link between increased filling pressure and damage of atrial myocardium which may lead to reentry arrythmias in hypertensive patients with AMI.

Purpose: The goal of this study was to assess the proportion of hypertensive patients who had 1 or more of the following major modifiable cardiovascular risk factors: dyslipidemia, metabolic syndrome, diabetes, current smoking and overweight. Material and Methods: A total of 650 individuals, aged between 20–80 years with a positive diagnosis of arterial hypertension were enrolled in our prospective epidemiological study in 2006. The follow up period lasted for 3 years. Data collection was conducted in local county hospital in the participant's residential area. During the study visit, we administered a standardized questionnaire which assessed: age, sex, education, cigarette smoking, myocardial infarction, congestive heart failure and the previous diagnosis and treatment of hypertension, high cholesterol, and diabetes. Descriptive statistics (SPSS 17) for categorical variables were used for the study cohort. Results: 328 women and 322 men were available for analysis. 50,37% of patients had been diagnosed with high blood pressure for more than 10 years, 21,84% had HT between 5 to 10 years and 19,53% had a positive diagnosis of HT between 2 to 5 years. The prevalence of the risk factors in study population was: 14,30%, 14,30%, and 13,53% of men and 13,38%, 14%, and 16,46% of women had 1, 2, and 3 of these risk factors, respectively. We also assessed the prevalence of individual metabolic syndrome (MS) components and number of fulfilled components. MS was present in 268 subjects (41,23%) according to the NCEP-ATP III definition. The prevalence of the metabolic syndrome was higher in women (21,23%) compared with men (20%). Conclusions: Arterial hypertension is a major cause of cardiovascular morbidity and mortality in our area. Overall, 72,31% of hypertensive patients have at least 1 cardiovascular risk factor from the 7 cardiovascular risk factors assessed in the current study. Effective population-based interventions such as smoking cessation, improved diet, and increased physical activity can safely and effectively lower the risk of cardiovascular morbidity’ and mortality.