Risk for post-thrombotic syndrome after lower-limb deep vein thrombosis: location of the thrombus or residual thrombi? / Risk razvitiia posttromboflebiticheskogo sindroma posle tromboza glubokikh ven nizhnikh konechnostei: lokalizatsiia tromba ili rezidual'nyi tromboz?

BACKGROUND: Many works aimed to determine factors that influence the onset of postthrombotic syndrome after an acute episode of deep venous thrombosis. We aimed to compare the prognostic value of the most proximal extent of thrombus (proximal and distal DVT) versus the residual thrombosis as identified by venous ultrasonography performed during follow-up. METHOD: We conducted a retrospective study of prospectively collected 1183 consecutive cohort patients in the RIETE registry after a first episode of deep venous thrombosis and assessed for postthrombotic syndrome after 12 months. RESULTS: Multivariate analysis revealed that: residual thrombosis (OR 1.40; 95% CI 0,88-2,21), the presence of cancer (OR 1.38; 95% CI: 0,64-2,97), immobility (OR 1.31; 95% CI 0,70-2,43) and estrogen-containing drugs use (OR 2.08, 95% CI 0,63-6,83), all had a predictive value for the occurrence of PTS. CONCLUSION: Our study results revealed that ultrasound finding of residual thrombosis is more predictive than proximal location of thrombus for postthrombotic syndrome after episode of deep venous thrombosis. Real life data from a large group of patients from the RIETE registry substantiates that.

Carotid artery disease in patients with type 2 diabetes.

The aim of this study is to determine the risk factors for carotid artery disease (CARD) in patients with type 2 diabetes. 340 pts with T2DM and coronary artery disease were enrolled in cross sectional study. Evaluation for CARD was done by ultrasound. Multivariant logistic regresion analysis defined as independent predictors for CARD: age of occurrence of bilateral plaques, PAD about the presence of bilateral plaques and carotid stenosis, non HDL cholesterol about the presence of carotid stenosis and stenosis of the internal carotid artery. These results can contribute in the refresment of the criteria for screening programes for CARD in the population with T2DM.

Peripheral arterial disease and diabetes.

There are two points of view for the interplay of peripheral arterial disease (PAD) with diabetes: the higher prevalence of PAD that is presented in diabetes than in the general population, and secondly that peripheral atherosclerosis is a marker of polyvascular disease in these pts. The main aim of this review is to describe risk factors, diagnostic approaches and treatment modalities of this condition.

Carotid IMT in type 2 diabetic patients: a survey on factors of influence.

The study was aimed to determine factors of carotid intimamedia thickness (CIMT) in a population of patients with type 2 diabetes (T2D). A survey was conducted on 370 patients (mean age 60.3±8.3 years and diabetes duration 8.6±6.2 years) with T2D and coronary artery disease. Multivariate linear regression analysis was built to define the factors of CIMT, when age, systolic and diastolic blood pressure, weight, body mass index, waist circumference, glycaemia, urea, creatinin, triglycerides, total cholesterol, LDL-, HDL-, and non-HDL-cholesterol were put in a model. Mean CIMT of 0.8992±0.1529 mm, and its maximal value of 0.9905±1.946 mm was detected in this study population. Regression analysis demonstrated that mean and maximal CIMT were independently influenced by age, blood creatinin, diastolic pressure and non-HDL cholesterol, as well. The results have clinical value in defining target groups in patients with T2D and arterial hypertension, higher non-HDL cholesterol and blood creatinin, and those-that are older have a greater probability of detection of increased CIMT.

Risk factors for development of peripheral and carotid artery disease among type 2 diabetic patients.

(Full text is available at http://www.manu.edu.mk/prilozi). The study was aimed to define the risk factors for development of peripheral arterial (PAD) and carotid artery disease (CARD) among type 2 diabetic patients (T2D). The study population consisted of 30 patients diagnosed with type 2 diabetes and absent vascular disease. the mean age of the study population was 53.3 +/- 7.3 years. 60% of patients were women and 40% of them men. Patients were followed up for three years for development of peripheral and carotid artery disease. Peripheral arterial disease (PAD) was defined by ankle-brachial index < 0.9 or > 1.3. Carotid arterial disease was defined if carotid plaque or stenosis (> 50%) presented. We built a multivariable logistic regression analysis to define the factors of development of vascular disease and a multiple linear regression analysis to identify the factors associated independently with numerous values of carotid IMT and ABI. Development of PAD and CARD were registered in 43.8% of patients. Progression of carotid IMT was found in 62.5 % of pts. Progression of PAD was predicted by HDL - cholesterol and urea, systolic blood pressure and diabetes duration. Progression of carotid IMT was determinate with: BMI, weight, diastolic blood pressure and age. Our study defined risk factors that independently influence the development of PAD and CARD in pts with T2D. This data has clinical usefulness in the improvement of prevention and in optimizing the treatment of type 2 diabetic patients. Key words: peripheral arterial disease, ankle-brachial index, carotid plaque, carotid stenosis, IMT, type 2 diabetes.

Dyslipidaemia and hypertension in patients with subclinical hypothyroidism.

OBJECTIVE: The aim of this study was to assess whether subclinical hypothyroidism (SCH) is associated with dyslipidaemia and arterial hypertension. METHODS: At the Department of Endocrinology, Diabetes and Metabolic Disorders, Skopje, R. Macedonia, we examined 24 consecutive patients with SCH and 13 healthy controls in a period of 6 months. SCH was defined as an elevated thyrotropin (TSH) (> 4.2 mU/l) and normal free thyroxine (fT4) level (10.3-24.45 pmol/l). None of the patients had been previously treated with thyroxine. In all participants we determined blood pressure, body mass index (BMI), TSH, fT4, antibodies to thyroid peroxidise (TPOabs), total lipids (TL), total cholesterol (TH), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides. RESULTS: Mean diastolic blood pressure increased in SCH patients vis-a-vis controls (85 vs. 74 mmHg; p < 0.05). Mean values of TL, TH, HDL-C, LDL-C, triglycerides, TC/HDL-C, and LDL-C/HDL-C were no different in patients with SCH compared with controls. Individual analysis revealed that the percentages of patients with SCH having arterial hypertension (29%), hypertriglyceridaemia (34.78%), elevated LDL-C (41.66%), elevated TC/HDL-C (21.7%), and LDL-C/HDL-C (21.74%) ratios were higher than the percentages in controls. No significant correlation between TSH and biochemical parameters was detected. CONCLUSION: Our study revealed that SCH patients have a greater prevalence of dyslipidaemia and arterial hypertension, and, as well, a greater value of mean diastolic pressure vs. control patients.

Is assessment of peripheral endothelial dysfunction useful tool for risk stratification of type 2 diabetic patients with manifested coronary artery disease?

Endothelial dysfunction, per se, in coronary arteries can stratify a risk in coronary artery disease patients. Selected studies evaluating endotheliopathy as predictor of events in patients with type 2 diabetes, but without coronary artery disease. We hypothesized that peripheral endothelial dysfunction could predict prognosis of type 2 diabetic patients who presented coronary artery disease. Our data presented endothelial dysfunction as prognostic marker of cardiovascular events in type 2 diabetic patients with manifested coronary artery disease, according univariate regression model.

Premature atherosclerosis in patients with growth hormone deficiency and diabetes mellitus.

In this article cases of two sisters with premature atherosclerosis have been described. The first one aged 31 with diagnosis of growth hormone deficiency (GHD) and diabetes mellitus presented with calf intermittent claudication as a result of tibial arteries occlusions. The second one aged 34 with impaired fasting glycemia and without any sign of GHD presented with sudden calf pain as a result of tibial posterior arterial acute occlusion. These cases support the hypothesis that in GH deficiency patients is a higher incidence of diabetes mellitus and early atherosclerosis and they are more vulnerable to vascular thrombotic events (Tab. 1, Ref. 5).

Endothelial dysfunction correlates with plasma fibrinogen and HDL cholesterol in type 2 diabetic patients with coronary artery disease.

OBJECTIVE: Assessment of endothelial dysfunction (ED) in type 2 diabetic patients with coronary artery disease (CAD) and estimation of correlation of ED with metabolic parameters: low HDL, hypertriglyceridemia, obesity, systolic blood pressure and with inflammatory-hemostatic parameters: CRP and fibrinogen. PATIENTS AND METHODS: 42 patients (age 60.0 +/- 8.5 years) with diagnosed type 2 diabetes and CAD were randomly included in a cross sectional study. B-mode ultrasound system with a linear transducer 7.5 MHz was used for evaluation of flow mediated vasodilation in brachial artery (FMV). FMV was presented as the percentage increase in brachial artery diameter, within 30 s after limb ischemia, previously provoked by cuff inflation. Percentage value up to 10% was defined as ED. RESULTS: Bivariate linear correlation model presented significant correlation between plasma fibrinogen and FMV percentage, with r -0.47, p < 0.01. Presence of ED correlates linearly with plasma level of HDL < 1.03 mmol/L (r -0.35, p < 0.03). Multivariate analysis using Backward Wald model presented fibrinogen (OR 3.14, 95% CI 0.87-11.28) and low HDL (OR 5.16, 95% CI 0.53-60.39) as factors correlated with the presence of endothelial dysfunction. CONCLUSION: These results presented plasma fibrinogen level and low HDL < 1.03 mmol/L as factors, independently correlated to the presence of endothelial dysfunction in type 2 diabetic patients with coronary artery disease (Tab. 8, Fig. 1, Ref. 25). Full Text (Free, PDF) www.bmj.sk.

Arterial hypertension in patients with coronary artery disease treated with surgical myocardial revascularization.

OBJECTIVES: To evaluate the incidence and prognostic power of arterial hypertension in patients with coronary artery disease treated with surgical myocardial revascularisation, before and after the operation. BACKGROUND: Arterial hypertension is one of the leading modifiable risk factors in CAD patients who underwent CABG surgery with the major impact on clinical outcome in these patients. METHODS: 749 patients with mean age of 55 +/- 8 years, (639 male/119 female) were analyzed for their preoperative: demographic, clinical, left ventricular morphologic and functional and angiographic, perioperative: type of operation, type and number of applied conduits, in-hospital morbidity and mortality, and post-operative: demographic, clinical, left ventricular morphologic and functional and angiographic characteristics. Mean postoperative follow-up period was 5.97 +/- 4.27 years. RESULTS: Hypertension was found in 52.7% of patients before the operation, and it was the most frequent risk factor, without any differences between different age groups, but significantly more often in females (p = 0.0001), diabetics (p = 0.0001), and patients with preserved LV function (p = 0.011). Although significantly correlated with in-hospital morbidity (r = 0.085 and p = 0.023), HTA was not identified as independent predictor. The most predictable was the occurrence of early neurological complications. HTA was also found to be a predictor of long life prognosis in CABG patients, but not as independent prognostic factor. Significant reduction in incidence was found in post-CABG patients (30.1%), which is most likely a result of applied pharmacologic treatment. ACE-inhibitors, Ca-antagonists and B-blockers were applied in 39.44%, 30.1% and 33.6% of patients respectively, with significant positive correlations found for all of them as follows: r = 0.221, p = 0.0001, r = 0.316, p = 000.1 and r = 0.093, p = 0.031. CONCLUSION: Hypertension is the most powerful risk factor in CAD patients who undergo CABG surgery in our country, and a powerful prognostic factor of early and late clinical outcome. There is a trend toward decreasing the incidence of HTA in post-CABG patients, as a result of improved pharmacologic treatment after the operation (Tab. 5, Fig. 1, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

Relationship between myocardial viability and improvement in left ventricular function and heart failure symptoms after coronary artery bypass surgery.

BACKGROUND: The evaluation of myocardial viability is an important preoperative parameter, predictive of improvement in regional and global left ventricular (LV) function after coronary artery bypass surgery (CABG). However, whether the presence of viability is also associated with relief of heart failure symptoms after revascularization is not always certain. The aims of the study were to define the relationship between extent of viable myocardium and improvement in LV function after CABG and to determine whether preoperative viability testing can predict improvement in heart failure symptoms. METHODS: Eighty-five consecutive patients with ischemic cardiomyopathy (mean LVEF 35%) undergoing surgical revascularization were studied with a Tc-99m sestamibi one-day rest/nitrate enhanced myocardial perfusion SPECT imaging (MPI) to assess viability. Regional and global function were measured before and 16 -/+ 6 months after revascularization. We have used the Bull's eye quantitative analysis of MPI scans and 17 segment model of LV function and perfusion evaluation. Heart failure symptoms were graded according to the New York Heart Association (NYHA) criteria, before and 16 -/+ 6 months after revascularization. RESULTS: The number of viable segments per patient was directly related to the improvement in LVEF after revascularization (r 0.79, P < 0.01). Patients with > 4 viable segments representing 24% of the left ventricle yielded the sensitivity of 83% and specificity of 79% respectively for predicting improvement in LVEF. Furthermore, the presence of four or more viable segments predicted improvement in heart failure symptoms after revascularization, with positive and negative predictive values of 79% and 74%, respectively. CONCLUSION: The presence of substantial viability (four or more viable segments, 24% of the left ventricle) on myocardial perfusion gated SPECT imaging in patients with ischemic heart failure before CABG surgery has significant correlation with the improvement in LVEF and heart failure symptoms postoperatively.

Carotid ultrasound, blood lipids and waist determination can predict a future coronary revascularisation in the type 2 diabetic cohort.

The aim of the study was to identify incremental values of carotid ultrasound measurements (carotid plaques and stenosis) on the prediction of future coronary revascularization among type 2 diabetic patients. The second objective was to determine the predictive value of the assessment of blood lipids, BMI, abdominal obesity and the ankle-brachial index (ABI). Three hundred and thirty three (333) patients with type 2 diabetes and manifested coronary artery disease were randomly selected in a cohort prospective study. Univariate and multivariate logistic regression analyses were conducted to identify variables predictive of the need for future revascularization: percutaneus coronary interventions (PCI) or coronary bypass surgery (CABG) followed 24 months after the study starting point. The presence of arterial hypertension, hyperlipidemia, physical inactivity, intermittent claudication, the value of systolic pressure, BMI, waist and hip measurement, glycemia and blood lipid fraction (total cholesterol, HDL, LDL, non-HDL, triglycerides) were entered in a model. Ultrasound measurements: carotid IMT, presence of carotid plaques and stenosis, and ABI were also included in the analysis. Based on the univariate and multivariate findings, the presence of internal carotid artery (ICA) stenosis (OR 4,562, 95% CI 1,327-15,687), carotid plaque (OR 1,465, 95% CI 0,829-2,591), and increased waist measurement (OR 1,371, 95% CI 0,757-2,483) were found as significant independent predictors of future PCI. LDL and non HDL cholesterol were found to be factors independently associated with the need for future CABG by univariate analysis, which was not confirmed by multivariate analysis. In conclusion, the current study has provided an identification of predisposing factors for the future need of coronary revascularization among type 2 diabetic patients that permits risk stratification and may facilitate improved patient selection or optimization.

Prevalence of metabolic syndrome components in the type 2 diabetic population who presented coronary artery disease.

The scope of our study was to assess the prevalence of metabolic syndrome (MSy) and its components in the type 2 diabetic population with symptomatic coronary artery disease in a sample of the Macedonian population. 327 pts with type 2 diabetes and manifested coronary artery disease were randomly included in a survey. MSy was defined according ATP III criteria. The data presented a prevalence of MSy in 86.2%, respectively. 98% of pts had at least one more MSy component than impaired glycaemia. Study groups with four and three MSy components were most frequent in the study population. The data presented gender differences in MSy prevalence: 93.4% in women vs. 82.8% in men (p 0.009), as women tend to have a much more increased waist, arterial hypertension and low HDL. The most prevalent metabolic syndrome component was arterial hypertension (78.3%). Low HDL was detected in 67.9%, hypertriglicerydaemia in 62.7%, and an increased waist in 49.8% of the study population.

Usefulness of D-Dimers and fibrinogen plasma determination in patients with polyvascular disease.

OBJECTIVES: The goal of our study was to evaluate the value of fibrinogen, D-Dimers and antithrombin III plasma levels to prognosticate mortality in patients suffering from both peripheral artery disease (PAD) and coronary artery disease (CAD). MATERIAL AND METHODS: 90 patients with coexistent PAD and CAD were inrolled in 36 months study and evaluated for the following parameters: age, sex, current smoking, ankle-brachial index, claudicating distance, ejection fraction, triglycerides, cholesterol, LDL, fibrinogen, D-Dimers, antithrombin III, creatinin, glycaemia, histories of myocardial infarction, stroke, diabetes and previous revascularization, as well as number of other concurrent diseases. We developed linear regression model for identification of variables, associated with cardiovascular events, and multivariate regression model to define the predictors of mortality. RESULTS: We registered 126 cardiovascular events during three years follow-up. Number of cardiovascular events correlate with fibrinogen (r=0,59, p<0,01) and with D-Dimers (r=0,48, p<0,01). Mortality of 8,89% was found for the period of three years in patients with coexistent PAD and CAD. The variables independently associated with mortality found by mutlivariate analysis were fibrinogen (r= 0,21, p<0,02, score 2,78), D-Dimers (r=0,94, p<0,01, score 17,24) and ankle-brachial index (r=0,40, p<0,03, score 4,84). CONCLUSION: The reported data demonstrated fibrinogen and D-Dimers as independent predictors of mortality in pts with polyvascular disease.

Risk factors for development of critical limb ischemia -- a survey of diabetic vs. nondiabetic population.

The aim of this study is to identify the risk factors for development of chronic critical limb ischemia (CLI) in diabetic and nondiabetic patients with peripheral arterial disease (PAD). 127 patients (pts) with PAD (63 with type 2 diabetes and 64 nondiabetic) were randomly included in a cross sectional study. Out of them 17 were with CLI. Population was investigated for age, height, weight, sex, duration of PAD and diabetes, arterial hypertension, hyperlipidemia, smoking, obesity, systolic blood pressure, value of ankle-brachial index, previous claudicating distance and peripheral intervention, amputation, medical treatment with prostanoids, insulin and antiplatelet drugs and histories of cerebrovascular disease, coronary artery disease and other concomitant diseases. After adjudging linear correlation between mentioned variables and presence of CLI, logistic regression model was built. There were no significant differences in demographic data between both populations. Hyperlipidemia was more frequent in nondiabetic population. Multiple regression model show ankle-brachial index < 0,5, measured in previous 1-3 years (OR 3.39 CI 95% 0.28-40.78), microvascular complication retinopathy (OR 12.98 CI 95% 1.76-95.58), heart failure (OR 1.91 CI 95% 0.29-2.72) and previous prostanoids treatment (OR 15.92 CI 95% 0.53-476.58) as predictors of development of CLI in diabetic population with PAD. After heart failure exclusion of model of nondiabetic pts, previous surgery (OR 3.14 CI 95% 0.61-16.09) and smoking (OR 0.35 CI 95% 0.78-1.62) were presented as prognostic factors for CLI's onset. Our results indicate differences between predictors of CLI's onset in diabetic and nondiabetic population with PAD. Presence of retinopathy, previous measured ankle-brachial index and prostanoids treatment are predictors of development of CLI in diabetic population. Previous surgery is independent predictor for CLI'onset in nondiabetics. Treating concomitant heart failure for both populations and modifying risk factor smoking in nondiabetic population, have an important clinical usefulness in risk assessment approach of peripheral arterial disease patients.

Predictors of in-hospital morbidity and mortality in patients with coronary artery disease treated with coronary artery bypass surgery.

AIM OF THE STUDY: The aim of our study was to identify markers that can predict early morbidity and mortality in patients with coronary artery disease who underwent coronary artery bypass surgery (CABG) for myocardial revascularization. MATERIAL AND METHODS: 749 patients (pts) were enrolled in the study at mean age 55 +/- 8 years, 639 male and 119 female. We analyzed pre-operative demographic, clinical, left ventricular morphologic and functional and angiographic variables, per-operative characteristics, and we registered occurrence of hospital complications including cardiac death during the first 30 days after the operation. RESULTS: Hospital complications were registered in 173 (23.1%) patients, including cardiac death registered in two (3%) patients during the first 30 days after the operation. The most common complications were: pericardial effusion (8.4%), supraventricular arrhythmias (6.3%) and pleural effusion (5.6%), followed by more serious complications like infections, acute renal failure and stroke. Advanced age (>or=65 years), coexisting morbidities and risk factors: cerebrovascular disease (CVD), peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), hypertension (HTA), previous myocardial infarction (MI), heart failure before the operation, extensive coronary artery disease (CAD) (angiographicly identified), low left ventricular ejection fraction (LVEF), and high WMSS index were identified as predictors of in-hospital morbidity. Advanced age, Mod Gensini score (as marker of angiographic severity of CAD) and WMSS index were found to be independent predictors of in-hospital morbidity, while advanced age, heart failure before CABG and in-hospital complications were found to be independent predictors of in-hospital mortality. CONCLUSION: In patients with coronary artery disease who underwent CABG surgery, preoperative variables and operative technique can predict occurrence of in-hospital morbidity, while early complications can strongly predict in-hospital mortality.

Prognostic importance of haemostatic parameters in polyarterial disease.

UNLABELLED: The goal of our study was to evaluate the value of fibrinogen, D-dimers and antithrombin III plasma levels in prognosticating mortality in patients suffering from both peripheral arterial disease (PAD) and coronary artery disease (CAD). PATIENTS AND METHODS: 90 patients with coexistent PAD and CAD were enrolled in a 36 months study, and evaluated for the following parameters: age, sex, current smoking, ankle-brachial index, claudicating distance, ejection fraction, triglycerides, cholesterol, LDL, fibrinogen, D-Dimers, antithrombin III, creatinine, glycaemia, histories of myocardial infarction, stroke, diabetes and previous revascularization, as well as a number of other concurrent diseases. We developed a linear regression model for identification of variables, associated with cardiovascular events, and a multivariate regression model to define the predictors of mortality. RESULTS: We registered 126 cardiovascular events during three years' follow-up. The number of cardiovascular events correlated with fibrinogen (r=0.59, p=0.01) and with D-dimers (r=0.48, p=0.01). A mortality of 8.89% was found for the period of three years in patients with coexistent PAD and CAD. The variables independently associated with mortality found by mutlivariate analysis were fibrinogen (r=0.21, p 0.02, score=2.78), DD (r=0.94, p=0.01, score=17.24) and ankle-brachial index (r=0.40, p=0.03, score=4.84). CONCLUSIONS: The reported data demonstrated fibrinogen and D-dimers as independent predictors of mortality in patients with polyarterial disease.