Are we on the path to solve the enigma of resistant hypertension: renal sympathetic denervation.

Renal sympathetic denervation (RSD) opens new perspectives and possibilities not only in the treatment of resistant hypertension but also of other cardiometabolic diseases. In patients with hypertension, it has been demonstrated that activity of the sympathetic nervous system correlates with grade of hypertension. Decreasing sympathetic activity using RSD significantly reduces blood pressure in resistant hypertension. It is too early to say a definite opinion about appropriateness of this method in the treatment of resistant hypertension, because there are not great studies with huge number of the patients. After we get and evaluate these results through a longer span of time, only than we shall know what is the role of RSD in the treatment of resistant hypertension and other cardiometabolic conditions related to increased function of the sympathetic nervous system, such as heart failure, diabetes mellitus, obstructive sleep apnea, renal disease with microalbuminuria and macroalbuminuria.

The role of echocardiography in diagnosis and follow up of patients with takotsubo cardiomyopathy or acute ballooning syndrome.

BACKGROUND: The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy was first described in Japan approximately 20 years ago (Satoh and coworkers, 1991). It was later described elsewhere as well and is being increasingly recognized. Takotsubo Cardiomyopathy characterized by transient apical and midventricular LV dysfunction in the absence of significant coronary artery disease that is triggered by emotional or physical stress. Its name refers to a contraption used for catching octopuses and suggests the aspect assumed by the ventricle during the systole due to the typical regional wall motion abnormalities that occur after onset. Takotsubo cardiomiopathy occurring mainly in post-menopausal women, echocardiography in the Takotsubo cardiomyopathy reveals during its acute phase a ballooning resembling the octopus trap configuration--the apex and lateral ventricular segments are hypokinetic while the base is hyperkinetic--along with reduced ejection fraction. Ventricular function will usually recover within a few days/weeks. OBJECTIVE AND PURPOSE: The objective of this study is to determine the role of echocardiography in detecting and establishing the diagnosis of Takotsubo cardiomiopathy in patients with suspect acute coronary syndrome and during the follow up period. PATIENTS AND METHODS: The study covered 12 adult patients the majority are women (92%) who were subjected to echocardiography evaluation as part of the clinical cardiological examination due to suspect acute coronary syndrome or Takotsubo Stress Cardiomyopathy. The patients were examined on an ultrasound machine Philips iE 33 x Matrix, ATL HDI and GE Vived 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated clinical characteristics, LV systolic function, biomarkers, and prognosis in all patients. RESULTS: Among all the patients referred for Echocardiographic evaluation for left ventricle motion abnormalities with suspect acute coronary syndrome, the echo exam revealed 12 patients with acute apical ballooning which involving the left ventricular apex and med-ventricle. The triggering factors were physical stress in 4 patients (33%) and emotional stress in 8 patients (67%). The initial symptom was chest pain (n = 8, 67%) rather than dyspnea (n = 4, 33%). An initial electrocardiogram (EKG) presented ST-elevation (n = 10, 83%) and T-wave inversion (n = 2, 17%), other data are shown on Table 2. Among the all patients 8 of them (66%) had normal EF by the 1st follow up (47 +/- 51 days), and the rest 4 patients (34%) had normal EF by 68 +/- 96 days. CONCLUSION: Widespread uses of echocardiography has contributed to more frequent recognition of Takotsubo stress cardiomyopathy and highlight the central role of this noninvasive method from an echocardiographers' perspective.

The role of dobutamine stress echocardiography in detecting coronary artery disease compared with coronary angiography.

BACKGROUND: Ischemic heart disease (IHD) causes more deaths, disability and economic loss in developed and developing countries than any other disease. Our country belongs to the group of countries in transition, and it has seen a continuous growth in mortality and morbidity rates caused by cardiovascular diseases. An early, accurate and fast diagnosis of the myocardial ischemia is the main step toward reducing patient morbidity and mortality, and hospital costs. It also reduces prolonged diagnostic observation, defines the strategy of approach and etiological treatment in order to prevent serious complications. OBJECTIVES: The aim of this study is to examine the occurrence of segmental wall motion abnormalities during pharmacological stress and measurement of coronary flow reserve in order to establish the diagnostic value of Dobutamine stress echocardiography in detecting and assessing the degree of myocardial ischemia and coronary stenosis in patients with suspected coronary artery disease, and to justify its wider application as a non-invasive diagnostic method. METHODS: The research study covered 86 adult subjects of both genders, referred to dobutamine stress echocardiography test and assessment of coronary flow reserve as part of their cardiological evaluation. RESULTS: The study results obtained indicate a high degree of sensitivity (97%), specificity (83%) and accuracy (95%) of the dobutamine stress echocardiography as a non-invasive diagnostic method compared to invasive diagnostics i.e. coronary angiography. Measurement of coronary flow reserve represents a strong diagnostic and prognostic tool in evaluation patients with suspected CAD. CONCLUSIONS: The Dobutamine stress echocardiography (DES) has come a long way as a diagnostic tool, from detecting myocardial ischemia, viability, and prognostics to problems underlying the coronary artery diseases. The safety and cost-effectiveness of the Dobutamine stress echocardiography as a diagnostic procedure has been proved. In modern cardiology, the DSE occupies a significant place in the evaluation of patients with known or suspected coronary artery disease, which has contributed to its accessibility and availability in a great number of centers.

Advantages of renin-angiotensin system blockade in the treatment of cardiovascular diseases.

The renin angiotensin system (RAS) plays a key role in the regulation of cardiovascular function, with angiotensin II being involved in hemodynamic and non-hemodynamic mechanism in the pathophysiology of cardiovascular disease. A number of studies demonstrated that pharamacological modulation of the RAS, either with angiotensin converting (ACE) inhibitor or an angiotensin II receptor blocker (ARB), provides cardiovascular and renal protection. Blockade of the RAS, either with ACE inhibitors or ARBs, decreases cardiovascular morbidity and mortality in high risk patients. ACE inhibitors as well as ARBs are drugs of choice in congestive heart failure, as well as in diabetic nephropathy. Especially, the combined RAS blockade with ACE inhibitors and ARBs was more effective than monotherapy in diabetic or non-diabetic nephropathy with proteinuria. However, this combined RAS blockade was not equally dominant in treatment of hypertension and was not recommended for widespread antihypertensive use.

Clinical, echocardiographic and echophonocardiographic characteristics of the atrial myxomas in 22 years period.

INTRODUCTION: Atrial myxomas are the most frequent benign tumors of the heart. Left atrial myxomas are about 3-4 times more frequent then right. Clinical findings reveal atrioventricular obstruction symptoms and signs, symptoms and signs of peripheral arteries or pulmonary artery embolisation and/or nonspecific symptoms. AIM: Review of atrial myxomas diagnosed at the Clinic of Cardiology in 20 years period and analysis of clinical characteristics, transthoracic echocardiographic (TTE), transesophageal echocardiographic (TEE), and M-mod echophonographic findings. METHODS: TTE is performed in all, but TEE in 16 patients. Simultaneous M-mod echophonocardiographic examination were performed in 11 patients, when optional equipment was applicable. RESULTS: We found 24 atrial myxomas: 19 (79.2%) in left and 5 (20.810%) in right atrium. 21(87.5%) patients had some of the symptoms, but 3 (12.5%) were asymptomatic. TTE was performed in all patients, but we found 1 (2.4%) false negative result. TEE was performed in 14 (58.3%) patients. Echophonocardiographic recordings showed early diastolic tumor "plop" in 10 patients and unusual late diastolic tumor "plop" in one right atrial myxoma, which has not yet been described. CONCLUSIONS: TTE is a reliable method in diagnosis of atrial myxomas, but not in all cases, while TEE has been found as always reliable. Echophonocardiographic recording is useful for confirmation and understanding of auscultatory finding when applicable.

Is aliskiren superior to inhibitors of angiotensin-converting enzyme and angiotensin receptor blockers in renin-angiotensin system blockade?

The renin-angiotensin system (RAS) plays a crucial role in development of hypertension, heart failure, as well as in the whole process of nephropathy, particularly of diabetic nephropathy, with or without proteinuria. Blockade of RAS plays the key role in the management of hypertension and other cardiovascular diseases. Angiotensin-converting enzyme (ACE) inhibitors do not provide the full blockade of angiotensin II because it is produced through alternative pathways. Angiotensin receptor blockers (ARBs) also block the negative feedback of angiotensin II upon renin like ACE inhibitors, leading to a several fold increase in angiotensin II levels. Aliskiren is an orally-active, nonpeptidic, direct inhibitor of renin which simultaneously reduces angiotensin I, angiotensin II and plasma renin activity (PRA). This is the main point of action of aliskiren, making it completely different from ACE inhibitors and ARBs. Aliskiren introduces a new concept into the management of hypertension. However, the question concerning its real role in the management of heart failure and its place in the existing therapeutic schemes with ACE inhibitors, ARBs, beta blockers and antagonists of aldosterone receptor, will be answered by numerous ongoing studies and clinical trials. Aliskiren shows renoprotective and antiproteinuric effects similar to those of ACE inhibitors and ARBs. The available results demonstrate that aliskiren provides a new approach to the antagonism of the RAS, offering possibilities of a more efficacious and effective treatment of hypertension, heart failure and proteinuria in diabetic patient.

Effects of fixed combination of lisinopril plus hydrochlorothiazide on regression of left ventricular hypertrophy in patients with essential hypertension: an opened, multi-centre, prospective clinical trial.

The aim of this trial was to examine the effects of antihypertensive fixed combination of lisinopril plus hydrochlorothiazide (Lopril H, Bosnalijek dd, Bosnia and Herzegovina) on regression of left ventricular hypertrophy in patients with essential arterial hypertension. We included 297 patients in our trial, aged 54.65+/-9.6 years, with treated or untreated hypertension and with high risk of cardiac events, in an opened trial of therapy based on lisinopril plus hydrochlorothiazide. Patients from five European countries were followed up for a period of 12 weeks. Duration of treatment was 12 weeks. We adjusted daily doses of lisinopril plus hydrochlorothiazide after every clinical examination and recorded adverse effects of drugs. In the beginning and after 12 weeks of treatment, 277 patients (93.2%) underwent 2-dimensional echocardiography and there were 186 patients evaluated for efficacy of treatment on left ventricular hypertrophy (LVH). We recorded a regression of index mass LVH (168.56 vs 161.51 g/m2, P<0.0001), and regression was something more in women vs men. We recorded average reduction of left ventricular mass index for patients with LVH (N=186) by 7.05 g/m2 (4.18%) in all patients, by 6.73 g/m2 (3.93%) in men and 7.27 g/m2 (4,37%) in women. The proportion of patients who attained a regression of left ventricular mass tended to be greater in men (54.55% vs 53.21%). This research has proved regression of LVH in more than 53% patients after using fixed combination of lisinopril plus hydrochlorothiazide.

Fixed combination lisinopril plus hydro-chlorothiazide in the treatment of essential arterial hypertension: an opened, multi-centre, prospective clinical trial.

The aim of this trial was to examine the efficacy and safety of antihypertensive fixed combination lisinopril plus hydrochlorothiazide (Lopril H, Bosnalijek dd) in the treatment of essential arterial hypertension. In our trial we included 297 patients, aged 54.65+/-9.6 years, with treated or untreated hypertension and with high risk of cardiac events, in an opened trial of therapy based on lisinopril plus hydrochlorothiazide. Upon the examination by physicians, patients were divided into three groups in accordance with European Society of Cardiology guidelines for the management of arterial hypertension. Patients from five European countries were followed up for a period of 12 weeks. Duration of treatment was 12 weeks. We adjusted daily doses of lisinopril plus hydrochlorothiazide after every clinical examination and recorded adverse effects of drugs. After 12 weeks of treatment, 288 patients (96%) were evaluated for efficacy, tolerability and safety. In almost 81.5% patients with mild, moderate and severe hypertension, we recorded a reduction in blood pressure to approximately normal values SBP and DBP (140/90 mmHg). Drug-related side-effects occurred in 11 patients (3.66%). The most commonly reported adverse effects associated with lisinopril plus hydrochlorothiazide were cough (5) and dry mouth (5). This research has proved good efficacy of fixed combination lisinopril plus hydrochlorothiazide with more than 97% patients. Based on subjective estimation by patients: this drug improved quality of life in all cases.

[Arterial hypertension 2007: Guidelines for the management of arterial hypertension]. / Pristup lijecenju arterijske hipertenzije u svijetlu novih Evropskih smjernica za hipertenziju.

Since the publication of "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" (JNC 7) in 2003 and "2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension" (ESH/ESC guidelines), no substantial improvement has been made in the control of hypertension. Maybe, publishing of new 2007 Guidelines for the Management of Arterial Hypertension will contribute to a more rational and purposeful management of hypertension. The question whether beta blockers will keep their place as the first-line therapy in the new guidelines has been opened. After 30 years of their use in clinical practice, beta blockers have again become the focus of great discussion and controversy. Namely, according to the National Institute for Health and Clinical Excellence (NICE), beta blockers, which were for more than 30 years the first-line therapy for the treatment of high blood pressure, and antihypertensive effects of which were well documented in large randomized placebo controlled studies, have lost the first-line therapy role. Yet the normalization of the blood pressure has been difficult in spite of using the nowadays available drugs. This makes the question of disposal of such drugs even more open and disputable. Taking this into account, the 2007 Guidelines for the Management of Arterial Hypertension have kept beta blockers as the first line therapy. Besides, the separate guidelines for treatment of arterial hypertension and hypercholesterolemia, have been replaced by the new guidelines for management of the integrated cardiovascular risk. According to the Guidelines, the cardiovascular risk score should be applied in the everyday practice. Since cardiovascular risk factors multiply and interact with each other, moderate reduction in several factors will be more beneficial than major reduction in one. Much more than the 2003 ESH/ESC guidelines do, the new 2007 Guidelines emphasize the combined drug therapy using smaller dosages for simultaneous treatment of several cardiovascular risk factors as a replacement for separate management of hypertension alone. Also, there is a new goal of < 130/80 mm Hg for people with established cardiovascular disease including coronary artery disease, diabetes, renal dysfunction, or proteinuria. However, the main benefits of antihypetensive therapy are due to lowering of blood pressure per se.

[Statins and cardiovascular diseases]. / Statini i kardiovaskularna oboljenja.

Statins are utilised in the primary and secondary prevention of coronary heart disease, due to their efficacy at lowering lipid levels. However, statins may also prevent atherosclerosis disease by non-lipid or pleiotropic effects, for example, improving endothelial function by promoting the production of NO. By increasing NO production, statins may interfere with atherosclerosis lesion developement, stabilise plaque, inhibit platlet aggregation, improve blood flow and protect against ischaemia. Therofore, the ability of statins to improve endothelial function through the release of NO may partialy account for their beneficial effects at reducing the incidence of cardiovascular events. Other pleiotropic effects of statins, i.e. immunomedulatory, antiinflammatory, antioxidant and antiendothelin effects, also contribute to the reduction of the incidence of major cardiovascular events. Statins have become the basic drugs in high risk cardiovascular patients with hypercholesterolemia. The ATP III update recommends an optional therapeutic target of LDL-C < 1,8 mmol/L in very high risk patients: those with acute coronary syndrome or those with CHD plus diabetes, the metabolic syndrome, multiple-risk factors, or a poorly controlled risk factor. Studies have demonstrated benefit from lipid lowering irrispective of initial LDL-C levels, including those with average levels at baseline.

[Use of beta blockers in chronic heart failure]. / Primjena beta blokatora kod hronicnog zatajivanja srca.

Once contraindicated, beta-blockers have become, along with ACE inhibitors, diuretics and agiotensin II receptor blockers, an established, evidence-based, recommended treatment concept in chronic heart failure. The increased activation of the adrenergic system and renin-angiotensin-aldosterone system in heart failure syndrome provides the rationale for the use of beta-blockers in patients with heart failure influencing upon the most important pathological changes in the condition. Long term treatment with beta blockers additive to an ACE inhibitor and diuretic results in normalization of left ventricular function and EF. The long term treatment of heart failure using beta blockers reduces morbidity and mortality from this condition.

[Similarity and difference between American (JNC 7) and European (2003 ESH/ESC) guidelines for management of hypertension]. / Slicnosti i razlike izmedu novih amerixkih i evropskih smjernica za lijecenje hipertenzije (JNC 7 i 2003 ESH/ESC).

The American guidelines for management of hypertension (JNC 7) and the European guidelines (2003 ESH/ESC) communicate some new moments and attitudes in the treatment of the condition. According to JNC 7, in patients belonging to the prehypertension category (systolic bp 120-139, diastolic bp 80-89), life style modifications are prescribed. The second and third degrees of hypertension have been merged (degree 2). The drugs of choice for majority of the patients, according to INC 7, are thiazide diuretics, alone or in combination with other drugs. The European guidelines have, more or less, preserved the old classification of hypertension. According to the European guidelines, the assessment of global cardiovascular risk is one of the more important factors in making the decision when to begin the therapy of hypertension. In line with the European guidelines, it is not so important which drug will be applied at the beginning of therapy because, in time, most of the patients will be receiving two or three drugs.

[Role of intraoperative transesophageal echocardiography in repair of mitral valve (our experience)]. / Uloga intraoperativne transezofagealne ehokardiografije kod reparacija mitralnih valvula (nasa iskustva).

INTRODUCTION: Intraoperative transesophageal echocardiography (TEE) is a useful tool during valvular, great vessels and CABG surgery. In several large studies TEE has been shown to have higer sensitivity than TTE for native valve (94-100% vs. 44-63%) and prosthetic valves (75% vs 25%) both have high specificity (91-98%). TEE has got its value, particularly when surgeon intends to repair diseased valves, which are favorable operations due to its better survival rate, better ventricular function and fewer tromboembolic events. Most commonly valve repairs performed in patients with mitral and tricuspid valve diseases although reparative procedures have been described for all valve positions. AIM: Our aim is to define how important is TEE during mitral valve repairing operations. PATIENTS AND METHODS: At our institution, during five years period (between may 1999. and may 2004.) 29 patients have been operated with mitral valve repairing and monitored by TEE intraoperatively. They all went through preoperative preparations at the Clinic for Heart diseases and rheumatism, as well as Cardiology dept. of Cardiac surgery clinic KCU Sarajevo. We were following ASE/SCE guidelines for intraoperative examination during four different intraoperative mitral valve surgery stages, using Siemens ultrasound machine Sonoline Versa Plus with TEE multiplane probe type MPT-4. RESULTS: For 20 pts. (71%) mitral valve repairing has been performed solely, in 9 (29%) pts. combined mitral and tricuspide valves repairing. In two cases (6,9%) after not satisfied repairing cardiac surgeon had to replaced native (previously repaired) mitral valve with mechanical prosthesis. 7 pts. (24%) got Carpantier rings and others 22 (76%) have been operated with pericardium patch. CONCLUSIONS: IOP TEE proved to be very useful in determination of the nature, severity and egzact anatomic location (scaloping) of the mitral and other valves disorders, in assessment of the urgency and feasibility of valves reparation and in plaining of the surgical procedures. In the case of poor surgical valve reparations, intraoperative TEE is the first method of choice in monitoring the process of valve reparation and in estimating the time for valve replacement.

[Modern approach to treatment in pulmonary thromboembolism]. / Suvremeni pristup terapiji plucnog tromboembolizma.

Pulmonary embolism (PE) and deep vein thrombosis (DVT), respectively venous thromboembolism (VIE), are relatively frequent diseases. Appropriate management of PE includes risk stratification, preventive and primary therapy. Appearance of the disease ranges from mild to severe, and rapid and accurate risk stratification is extremely important. So appropriate management can range from prevention of recurent PE with anticoagulant therapy alone in low risk patients, to clot disolution or embolectomy in high risk patients. Preventive therapy prevents recurent VTE including anticoagulant therapy with heparin (low molecular weight heparin-LWM or unfr actional UFH), direct thrombin inhibitors (DTI) or oral anticoagulants. Primary therapy includes thrombolitic therapy or embolectomy (catheter or surgical). Prevention DVT and VTE includes mechanical and pharmacological measures in internal medicine, in general, cancer and orthopedics surgery.

[Dysfunction of the left chamber after myocardial infarct]. / Disfunkcija lijeve komore poslije infarkta miokarda.

Dysfunction of the left chamber of the heart happens when the function is not sufficient to supply all organs with needed quantity of blood, oxygen and nourishing materials. Consequence is an exhaustion of the heart compensatory and peripheral mechanisms. The research is based on the results of the analysis of residual changes that remained since acute myocardium infarct got over (scar, contracture changes, conductivity) and analysis of the remained functional part of the left chamber myocardium. Electrocardiogram, echocardiography and exercise test were used. 60 patients were examined. 6 varieties of chronic myocardium infarcts were found: anteroseptal, inferior, anterolateral and anterior-broaden, high-lateral and posterior localisation. Wagner's method QRS-scoring system and scores for wall motion by the American of ehocardiography were found the damage size of the myocardium mass. Correlative coefficient is full (r = 1.0). In chi2-test there is no significant difference (Wagner, echocardiography) in dimensions of old infarct (p < 0.05). Dyastolic dysfunction was set by echocardiographic method for 75%, systolic 41.11% examinees, remodelling in 80%, extended isovolumetric relaxation time and time of deceleration in 100% cases, speed ratio E-wave and A-wave below 1.0 in 82.66% cases. Exercise test was made for 85% examinees. Dysfunction was registered in 84.37%, diastolic in 80.39%, systolic in 43.17% cases. On the base of coronarographie results (23.33% examinees) the sensitivity was set for: exercise test in systolic dysfunction is 42.86%, in dyastolic is 71.43% and echocardiography in systolic disfunction is 57.14%, in dyastolic 100%. According to echocardiographic analysis of parameters the greatest influence has reduction of ejection fraction with 36.67% in systolic and extension of the period of deceleration with 38.79% in diastolic dysfunction. There is a good complement of the tested methods (p < 0.05). There is possibility, with these methods to appraise dysfunction of the left chamber in old myocardium infarct with conclusion that echocardiography is more sensitive since gives more data and direct visualization of changes.

[Arrhythmia and left ventricle remodeling in acute myocardial infarct: recommendations for drug therapy]. / Aritmije i remodeliranje lijevog ventrikula u akutnom infarktu miokarda: preporuke za medikamentozni tretman.

Occurrences of arrhythmias during the acute myocardial infarction is explained with local ischaemia, but mechanism of later occurrences is unclear. Our study had for the aim to examine relationship between postinfarction left ventricle dilatation and appearance of arrhythhmias, and to show drug effects on remodelling. Patients who developed progressive left ventricle dilatation had higher mortality then patients without changes of left ventricle volume, and mortality is due of sudden cardiac death. Drugs who had preventive effects or reverse remodelling can help in prevention of malignant arrhythhmias and sudden cardiac death. It is showed that ACE inhibitors, beta-blockers and aldosterone antagonists had preventive effects on left ventricle remodelling. The combined therapy with ACE inhibitors, beta-blockers and aldosterone antagonists is showed as the most-effective in prevention of remodelling, appearaance of arrhythhmias and sudden cardiac death.

[Therapy of hypertension 2004--quo vadis?]. / Terapija hipertenzije 2004--quo vadis?

Management of hypertension, at the beginning of the new millennium, persists in being a difficult, demanding and responsible task. Beta blockers and diuretics reduce mortality, stroke and coronary disease in patients suffering from arterial hypertension. Newer antihypertensive drugs which block the renin angiotensin system, such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), may have additional benefits in high-risk individuals with normal blood pressure. The additional benefit has been confirmed in LIFE and ANBP2 studies. In HOPE study, application of the ACE inhibitors in high-risk patients with "normal" BP values resulted in reduction of major cardiovascular events. Problem of adherence to therapy also continues to be one of the most important problems in management of hypertension. The success of antihypertensive management is directly proportional to the adherence to therapy. The new European guidelines for the management of arterial hypertension and JNC 7 recommendations offer a rational and effective approach to management of hypertension. These two documents contain a series of new attitudes, and reminded of some old and opened some new questions.

[New aspects in the diagnosis of pulmonary embolism]. / Novi aspekti dijagnostike plucnog embolizma (PE).

Pulmonary embolism (PE) and deep venous thrombosis (DVT), venous thromboembolism (VTE) respectively, are relatively frequent diseases. Despite progress in early detection and treatment, the rates of mortality and recurrent PE, remain high. Clinical findings include oligosymptomatic conditions with unexplained chest discomfort or shortness of breath that cannot be recognized as PE, but also and massive embolism with hemodynamic colapse and sudden cardiac death (SCD). The time from the first symptoms, till PE diagnosis is the most important for prognosis. Diagnostic methods include non imaging methods as plasma d-dimer Elisa, electrocardiogram, and many imaging methods from roentgenography, echocardiography, lung scanning, spiral chest computed tomography, magnetic resonance imaging to pulmonary angiography as "the gold standard" for PE diagnosis. It is recommended integrated diagnostic approach and various algorithms according to medical equipment and staff skill of a hospital.

[Angiotensin II antagonists in the treatment of cardiac decompensation]. / Antagonisti angiotenzina II u lijecenju kardijalne dekompenzacije.

The blockade of the renin-angiotensin system in the heart failure using ACE inhibitors, based on numerous clinical studies, demonstrated significant decrease in morbidity and mortality in the patients. Discovery of angiotensin II receptor antagonists brought about a new possibility of blockade of the rennin-angiotensin system. The blockade of the renin-angiotensin system with angiotensin II receptor antagonists should have been more effective and comprehensive than that induced by ACE inhibitors. However, the first studies with angiotensin II receptor antagonists in heart failure did not confirm that the antagonists are superior in reducing mortality and hospitalization in patients with heart failure when compared with ACE inhibitors. For the time being, the ACE inhibitors remain the current therapy of choice in treating heart failure. Angiotensin II receptor antagonists are a reasonable alternative in patients who cannot be treated with ACE inhibitors because of adverse effects. Clinical studies currently under way with angiotensin II receptor antagonists may alter these conclusions.