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Background and Aim: Despite significant progress on the diagnosis work-up of patients with suspented acute pulmonary embolism (APE), several therapeutic and prognostic issues have not yet been well established., Methods: We analysed the clinical course of 353 consecutive patients (141 males, 212 females, mean age 64.7 ± 18.12 years) with APE confirmed by contrast-enhanced multidetector computed tomography who were diagnosed and treated in a reference hospital between 2007 and 2009., Results: Among patients with APE, groups with high (HR), intermediate (IR) and low (LR) risk of early mortality were defined according to the recent European Society of Cardiology guidelines. High, intermediate and low risk groups included 23 patients (10 M, 13 F, age 70.13 ± 16.95 years), 146 patients (61 M, 85 F, age 65.77 ± 17.74 years), and 184 patients (70 M, 114 F, age 63.17 ± 18.45 years), respectively. Majority of patients (91.8%) were anticoagulated only with unfractionated or low-molecular-weight heparin, and thrombolysis was used in 24 patients, including 39.1% of HR patients, 8.9% of IR patients, and 1% of LR patients. In-hospital mortality rate was 7% overall (including 5.4% APE-related), 65.2% in HR (43.5% APE-related), 6.2% in IR (4.1% APE-related) and 2.2% in LR (1.63% APE-related). However, 4 of 9 high risk patients treated with thrombolysis died (mortality rate 44.4%), while mortality among HR patients not treated with thrombolysis reached 73.3%. Potential contraindications were taken into account before the decision to initiate thrombolysis. End-stage neoplasm or recent major surgery were considered contraindications for thrombolysis. Strong prognostic factors of overall in-hospital mortality included age (odd ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12), heart rate (OR 1.04, 95% CI 1.02-1.06), and plasma creatinine level (OR 3.65, 95% CI 1.62-8.27), the latter also being a significant prognostic factor of mortality in low risk group (OR 3.9, 95% CI 1.6-9.8). NT-proBNP and troponin I plasma levels were also significant prognostic factors of in-hospital mortality (NT-proBNP: OR 5.91, 95% CI 2.38-14.65, p < 0.05; troponin I (cut-off value ≥ 0.1 μg/L): OR 2.77, 95% CI 0.97-7.93, p = 0.056). In the overall study population and also in non-high risk group, significant predictors of a combined endpoint (death, shock, intubation, catecholamines, and thrombolysis) were: age, heart rate, creatinine, troponin I, NT-proBNP, and tricuspid pressure gradient., Conclusions: Despite adequate treatment there is a possibility of haemodynamic collapse and the need for thrombolysis in approximately 9% of intermediate risk APE patients. Not only age and compromised haemodynamic status but also plasma creatinine, NT-proBNP, and troponin I levels are prognostic factors of early in-hospital mortality in patients with APE. Due to high mortality rate among non-thrombolysed high risk patients, their therapy should be more aggressive and contraindications for thrombolysis should be less restrictive.

Background: In systemic sclerosis (SSc), changes in the lungs and pulmonary hypertension (PH) are complications most adversely affecting the prognosis. Given the availability of specific treatment, early diagnosis of PH is very important. Exercise echocardiography, by increasing the patient's cardiac output, makes it possible to identify patients with elevated pulmonary artery pressure (PAP) during exercise. The diagnostic role of exercise echocardiography is still unclear, mainly because of the lack of prospective studies., Aim: To identify SSc patients with abnormally elevated PAP at rest or with a significant increase PAP during exercise, subsequently verified by right heart catheterisation (RHC)., Methods: A total of 71 consecutive patients (67 females and 4 males, mean age 56.9 ± 17.1 years) with SSc diagnosed according to the American College of Rheumatology criteria were enrolled in this prospective study. The patients underwent transthoracic echocardiography (Philips iE33) with the measurement of tricuspid regurgitation peak gradient (TRPG) and an exercise test involving the standard treadmill exercise according to the Bruce protocol with the evaluation of TRPG at 1 min following the completion of exercise. The PH was suspected when TRPG at rest was 〉 31 mm Hg (V(max) 〉 2.8 m/s) or increased by at least 20 mm Hg from baseline following exercise. Patients with suspected PH were referred for resting and exercise RHC., Results: The exercise testing was performed in 67 patients revealing normal left ventricular (LV) systolic function in all of them. The mean LV ejection fraction was 66.1% ± 3.9%. The TRPG at rest could be recorded in 65 (97%) patients with the mean value of 26.9 ± ± 7.6 mm Hg (range 17-57 mm Hg). A resting TRPG of 〉 31 mm Hg, suggestive of possible PH, was demonstrated in 14 (21%) patients. During exercise test 56 (84%) patients achieved the maximum heart rate. A Doppler spectrum enabling the measurement of TRPG following the exercise was obtained in 66 (98.5%) patients. The gradient following the exercise could not be measured in one patient with a resting TRPG of 30 mm Hg. The mean post-exercise TRPG was 40.3 ± 4.1 mm Hg (range 17-70) and the mean post-exercise increase in TRPG was 12.9 ± 8.5 mm Hg (range 2-38). A TRPG increase of 〉 20 mm Hg was found in 11 (16%) patients (including 4 patients with resting values exceeding 31 mm Hg and 7 patients with normal resting values). Twenty-one (31%) patients with echocardiographic suspicion of PH (TRPG 〉 31 mm Hg at rest and/or a post-exercise increase in TRPG of more than 20 mm Hg) were referred for RHC with 16 patients actually undergoing the procedure. Four out of these 16 patients were qualified because of the "positive" exercise echocardiography in the presence of normal TRPG values. During catheterisation arterial PH was found in 2 patients, and an excessive precapillary PAP elevation in 2 further patients. Resting venous PH was found in 1 patient and an excessive postcapillary PAP elevation at rest was demonstrated in 11 patients., Conclusions: Exercise echocardiography is a safe and useful screening tool for PH diagnosis in patients with SSc. It enables to identify patients with normal systolic PAP at rest but a significant increase during exercise. The final confirmation of PH and differentiation between precapillary arterial and postcapillary venous PH requires RHC.

The Andersen-Tawil syndrome (ATS) is an autosomal dominant or sporadic disorder characterised by periodic paralysis, cardiac arrhythmias and dysmorphic features. Mutations in KCNJ2, which encodes the inward rectifier K+ channel Kir2.1 can be found in approximately 70% of ATS cases. The genetic mechanism in the remaining 30% of patients is still unknown. We present ECG of a 19-year-old man with the Andersen-Tawil syndrome. The standard ECG revealed prominent U wave with the ATS TU pattern.

Background: Systemic sclerosis (SSc) is a connective tissue disease characterised by vascular changes and immunologically induced fibrosis of the skin and internal organs. Systemic sclerosis may be associated with both right (RV) and left ventricular (LV) diastolic dysfunction., Aim: To analyse RV and LV myocardial diastolic function in patients with SSc and its relation to exercise capacity., Methods: We prospectively studied 51 consecutive patients (47 females, 4 males, age 53.3+/-15.2 years) with SSc (mean disease duration 9+/-12.4 years) and a group of 31 age-matched healthy subjects (28 females, 3 males, age 52.68+/-12.1 years). In addition to conventional investigation, transthoracic echocardiography (TTE) for assessment of RV and LV myocardial diastolic function and 6-minute walking test (6MWT) were performed., Results: Abnormal LV filling, as expressed by an inverted mitral E/A ratio (Mit E/A <1), was detected in 28 (55%) SSc patients and in 8 (25%) controls (p <0.001). The mean value of Mit E/A in the SSc group was lower than in controls (1.0+/-0.3 vs. 1.2+/-0.3, p=0.04). There were no differences in pulmonary venous flow between SSc patients and controls. The mean value of Tei index for the LV was higher in SSc than in controls (0.44+/-0.08 vs. 0.38+/-0.05, p <0.001). Abnormal RV filling, as expressed by an inverted tricuspid E/A ratio (TR E/A <1), was detected in 16 (31%) SSc patients and in 5 (16%) controls (p <0.001). Patients with SSc were found to have an inverted Tr E/A ratio (Tr E/A <1), indicating abnormal RV filling. The mean value of Tr E/A in SSc was lower than in controls (1.0+/-0.2 vs. 1.2+/-0.3, p=0.04). The mean value of Tei index for the RV was higher in SSc patients than in controls (0.35+/-0.07 vs. 0.29+/-0.03, p <0.001). In multiple regression analysis Tr E/A ratio was independently correlated with Mit E/A ratio (r=0.65, p=0.01). The mean 6MWT distance was shorter in the SSc group than in controls (528+/-100.6 vs. 617.7+/-80 m, p <0.001) and the mean saturation of capillary blood after the 6-MWT was lower in SSc patients (92.7+/-4.9 vs. 97.2+/-1.2%, p <0.001). Mean desaturation after test and D sat was significantly more pronounced in the SSc group than in controls (3.4+/-3.1 vs. 0.7+/-0.9, p <0.001). The Tr E/A ratio and Mit E/A ratio correlated positively with 6MWT distance (r=0,49, p=0.01 and r=0.48, p=0.02)., Conclusions: Impaired RV and LV relaxation is observed in a significant percentage of SSc patients and is associated with decreased exercise capacity.

A 74-year old woman was admitted to the orthopaedic word due to femoral bone fracture. Six days later she was admitted to the intensive care unit because of the clinical signs of circulatory and respiratory failure. Because acute pulmonary embolism was suspected, transthoracic echocardiography was performed and showed typical signs of acute massive pulmonary embolism as well as a highly mobile, longitudinal, additional echo in the right atrium attached to the interatrial septum in the place of foramen ovale, prolapsing in the diastole into the right ventricle. The patient was immediately and successfully treated with thrombolysis. Treatment options in patients with acute pulmonary embolism and right atrial mobile thrombus are discussed.