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Background: Frailty syndrome (FS) is a syndrome characterized by a reduction in the body’s physiological reserves as a result of the accumulation of reduced efficiency of many organs and systems. Experts of the Heart Failure Association of the European Society of Cardiology (ECS) emphasize the need to assess frailty in all patients with heart failure (HF). There is no specific scale dedicated to this group of patients. The aim of the study was to assess the occurrence of the frailty syndrome in heart failure using the multidimensional Edmonton Frailty Scale (EFS). Methods: The study included 106 patients diagnosed with heart failure with reduced left ventricular ejection fraction (LVEF < 40%). The average age was 62.6 ± 9.7 years. Most of the patients (84%) studied were men. In 70 people (66%), the cause of heart failure was coronary artery disease. The study group included patients admitted to hospital on a scheduled basis and with exacerbation of heart failure. Frailty was measured using the EFS before discharge from the hospital. Demographic, sociodemographic and clinical data were obtained. A 12-month follow-up period was included in the project. The number of readmissions after 6 and 12 months was assessed. Results: A correlation was observed between the New York Heart Association (NYHA) functional class and the occurrence of frailty—this applies to the assessment at the beginning and at the end of hospitalization. When analyzing the age of the patients in relation to frailty, a statistically significant difference was obtained. The youngest group in terms of age were non-frail patients. Hospitalization of people prone to development of the frailty syndrome and diagnosed with the FS was significantly more often associated with the occurrence of complications during hospital stays. Rehospitalizations for exacerbation of heart failure were much more frequent in patients with frailty. Conclusions: Assessment and monitoring of the state of increased sensitivity to the development of frailty or FS in patients with heart failure should influence the differentiation of clinical management. The Edmonton Questionnaire may be a helpful tool for the assessment of frailty in hospitalized patients with HF.

Background Advanced heart failure (AdvHF) is associated with high morbidity and mortality. Patients with this clinical condition are potential candidates for heart transplantation or mechanical circulatory support. Initially, however, they are usually supported with inotropic drugs. Recent studies have suggested that levosimendan, independently of hemodynamic improvements, may lead to outcome benefits. Objectives To present clinical experiences concerning the indications, effectiveness, tolerance, and safety of levosimendan in the real-life therapy of patients with decompensated AdvHF in 3 cardiac centers in Poland. Material and methods This is a prospective, observational, three-center study. Forty-nine patients with AdvHF admitted with decompensation were included (88% men, mean age 58 years, 65% ischemic etiology, left ventricular ejection fraction (LVEF) in median 20%) and followed up for an early (3 months) and prolonged period (1 year) after infusion of levosimendan. Patients were analyzed in relation to death. Results Levosimendan therapy was associated with reduced HF symptoms and signs, New York Heart Association (NYHA) class and level of B-type natriuretic peptide (BNP) at discharge. Five patients died during hospitalization, a further 10 during the three-month follow-up and 3 died during the next nine-month follow-up. During the three-month follow-up, 22 patients were re-hospitalized due to HF and in the next nine-month follow-up 8 were re-hospitalized. A multivariate analysis indicated the QRS duration at discharge (hazard ratio (HR) = 1.02; 95% confidence interval (95% CI) = 1.003-1.03; p = 0.018), high-sensitivity C-reactive protein (hsCRP) (HR = 1.01; 95% CI = 1.004-1.02; p = 0.002), and simultaneous dobutamine infusion (HR = 6.54; 95% CI = 1.4-30.5; p = 0.017) were independent risk factors for death in the one-year follow-up. There were no side effects leading to the interruption of the levosimendan infusion. Conclusions The use of levosimendan was safe and associated with clinical improvement and reduction in BNP level in AdvHF patients hospitalized due to HF decompensation, although the mortality and re-hospitalization rate during the one-year follow-up remains high.

Background: Trimetazidine (TMZ) modulates cardiac metabolism, but its use in heart failure remains controversial. The aim of the study was to evaluate the effects of TMZ on exercise capacity, left ventricular ejection fraction (LVEF), mortality, and quality of life in stable patients with heart failure with reduced left ventricular ejection fraction (HFrEF). Methods: Forty-five patients with stable advanced HFrEF treated with optimal medical therapy were randomized in a prospective, single-center, open-label, cross-over study of trimetazidine (35 mg b.i.d.) on top of standard medical therapy or standard pharmacotherapy for two periods of 30 days and one period of 6 months. Initially and at the end of each period all patients underwent the following: exercise testing, six-minute walk test (6MWT), two-dimensional-echocardiography, and quality of life assessment. Results: The mean age of patients was 58.2 ± 10.6 years. Etiology of HFrEF was ischemic in 66.6% of patients. After 6 months no significant changes were observed in either group with regards to peak VO 2 uptake, 6MWT, LVEF, or quality of life. TMZ had no effect on mortality or cardiovascular events. Conclusions: The additional use of TMZ on top of standard medical therapy in stable advanced HFrEF patients was not associated with significant changes in mortality, exercise capacity, LVEF, or quality of life.

Introduction: Integrated care for elderly patients is not a standard in Central European Countries (CEC). Lack of coordination between healthcare service providers and social support, and diverse financing has led to low effectiveness of the whole care system for elderly. Short description of practice changes implemented: "Center of Geriatric Care" project assumes development of integrated model of care for elderly patients, managed by interdisciplinary geriatric team. The essential aims are: to develop an effective, coordinated and integrated management, based on the patient-centred triangle consisting of healthcare providers - social workers – family. to educate patients and caregivers extensively with the intension of lowering deterioration and exacerbations of the underlying chronic disease. Aim and theory of change: The aim of the study is to improve the management of elderly patients, to decrease the incidence of exacerbations (especially those requiring hospitalisation), to hamper the deterioration of general health condition, and finally to reduce the cost of care. Target population and stakeholders: In the pilot study, the model of care would be delivered to 90 multimorbid elderly, recruited from three different healthcare pathways (primary care, n=30; patients with chronic heart failure, n=30; patients with chronic obstructive pulmonary disease, n=30). In our model, existing healthcare services will be broadened by: 1- Periodic evaluation by geriatricians with use of comprehensive geriatric assessment tools. 2- Regular home visits of specially trained carers, which include monitoring of general condition, encouraging appropriate physical activity and supporting adherence to medical recommendations, alerting about significant symptoms. 3- Comprehensive rehabilitation based on regular physiotherapy. 4- Using selected, simple e-health interventions. Timeline: 24 months. Highlights (innovation, Impact and outcomes): The primary outcome of the project is to design and testing of a model of home-based integrated care, which is innovative in Poland and CEC. The expected results include improvement in functional and cognitive status and quality of life of patients, followed by decrease in general demand for medical services, especially in-hospital, and selected health economics indicators. The secondary outcome is to increase the knowledge and competencies of social workers, nurses, physiotherapists and family members on the management of elderly chronically ill patients, and to improve cooperation between these groups and medical staff. Comments on sustainability: After the pilot study, the implementation of the model, or further testing on larger population, would be a matter of discussion between team members and decision-makers on local and national level. Comments on transferability: The proposed model of care seems to be possible to implement in Polish healthcare system, as it enhances coordination between already existing institutions and local care-providing structures. Conclusions (comprising key findings): Current work on designing the model indicates, that crucial area for change is to coordinate already existing institutional structures. Discussions: Detailed conclusions would be drawn after the testing the model. Lessons learned: The work on designing the model has already resulted in the successful creation of an active network of specialists from different backgrounds and allowed sharing different scopes, how to use limited resources for the benefit of the elderly.

Background The etiology of tako-tsubo cardiomyopathy, defined as a transient left ventricular dysfunction in the absence of significant coronary artery stenosis, still remains unclear. This syndrome mainly occurs in postmenopausal women and is often associated with emotional stress or miscellaneous diagnostic and therapeutic procedures. Estimated prevalence of tako-tsubo cardiomyopathy is found in 1% to 2% of patients presenting with suspected acute coronary syndrome. So far there has been only one case report of tako-tsubo cardiomyopathy in a renal transplant recipient. Case report We describe the case of a 68-year-old woman with a history of coronary artery disease and coronary artery bypass grafting in whom unspecific transient chest pain and hypotension were observed on the first day after renal transplantation. After transplantation, the patient was anuric with pulmonary congestion and toxic tacrolimus concentrations were observed. Electrocardiogram showed sinus rhythm with left bundle branch block (LBBB) that has not been described before. Plasma cardiac necrosis markers troponin I and creatine kinase MB were mildly elevated. Echocardiography showed severe left ventricular function impairment with characteristic shape of left ventricle. Subsequent cardiac catheterization revealed the absence of angiographic evidence of acute plaque rupture within both coronary arteries and bypass grafts. During the next few days there was marked clinical improvement with resolution of LBBB and full recovery of all biochemical parameters. On discharge, full functional recovery of the left ventricle in echocardiography was observed. Postulated mechanisms of tako-tsubo cardiomyopathy include catecholamine excess, coronary artery spasm, and microvascular dysfunction. On the other hand calcineurin inhibitors are known factors causing coronary epicardial endothelial dysfunction and negatively affecting vasomotor function. Conclusions Tako-tsubo cardiomyopathy in patients after renal transplantation may be at least in part a manifestation of calcineurin inhibitor cardiotoxicity.

Elevated values of heart rate (HR) and insulin resistance (IR) reflect enhanced sympathetic nervous system activity and may be connected to the development of coronary artery disease (CAD) and diabetes.To evaluate the relationship between HR, blood pressure (BP), double product and IR in nondiabetic hypertensive patients with stable CAD.There were 73 patients included in the study. Ambulatory BP monitoring was recorded in all patients by a Spacelabs 90207 device. Homeostasis model assessment (HOMA-IR) was used to estimate IR. Double product was calculated by multiplying systolic BP and HR.In the study population (mean age 67.1 ± 8.4 years, 52% males) there was a positive correlation between HOMAIR and 24-h double product (r = 0.35, p0.01) and body mass index (BMI) (r = 0.45, p0.001). The receiver operating characteristic analysis of 24-h double product and BMI as predictive markers of IR did not reveal statistical differences between AUC (0.72 ± 0.09 vs. 0.72 ± 0.08, 24-h double product and BMI, respectively, p = NS). The best cut-off points in predicting IR were 8,978 mm Hg/min for 24-h double product and 33.02 kg/m2 for BMI. There were differences between the non obese (n = 44, mean age 67.9 ± 9.2 years) and obese (n = 29, mean age 65.8 ± 6.9 years) groups in: serum insulin level (7.3 ± 2.3 µU/mL vs. 12.0 ± 7.3 µU/mL, p0.01), HOMA-IR (1.8 ± 0.7 µU/mL × mmol/L vs. 3.0 ± 2.0 µU/mL × mmol/L, p0.01), and day systolic BP (128.0 ± 10.8 mm Hg vs. 134.1 ± 10.1 mm Hg, p0.02).24-h double product and BMI may be complementary parameters in the prediction of IR in hypertensive nondiabetics with CAD confirmed by percutaneous coronary interventions in history and/or at least one coronary artery stenosis ? 70% in elective coronary angiography.