Polymorphism of angiotensin converting enzyme in hemodialysis patients--association with cardiovascular morbidity.

INTRODUCTION: Cardiovascular morbidity and mortality are the major concern in dialysis patients and many risk factors are thought to be involved in its pathogenesis. Apart from traditional and non-traditional risk factors, the genetic susceptibility may be of importance, including renin-angiotensin system gene polymorphism. The aim of this study was to analyse renin-angiotensin system polymorphism in our group of hemodialysis patients and to correlate the findings with cardiovascular morbidity. MATERIAL AND METHODS: The study included 196 patients on regular hemodialysis on polysulphone membrane three times per week for more than six months. Genetic analysis was performed by using polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: Out of 196 patients, 55% had I/D genotype, 35% had D/D and 10% had I/I, including angiotensin-converting enzyme polymorphism. It was shown that the patients with D allele genotype developed a significantly higher incidence of left ventricular hypertrophy and peripheral vascular disease. The angiotensin-converting enzyme polymorphism showed a significant association with the incidence of cerebrovascular accident and hyperlipoproteinemia in our group of hemodialysis patients. CONCLUSION: The angiotensin-converting enzyme gene polymorphism is associated with the development of cerebrovascular accidents and hyperlipoproteinemia. Allele D of this gene increases the risk for the development of left ventricular hypertrophy and peripheral vascular disease significantly in hemodialysis patients. A longer follow-up is needed to make the definitive conclusion about the influence of angiotensin-converting enzyme polymorphism on cardiovascular morbidity and its importance in everyday clinical practice.

Association of adiponectin with peripheral muscle status in elderly patients with heart failure.

BACKGROUND: Reduced peripheral muscle mass was demonstrated in patients with chronic heart failure (HF). Adipokines may have potent metabolic effects on skeletal muscle. The associations between adipokines, peripheral muscle mass, and muscle function have been poorly investigated in patients with HF. METHODS: We measured markers of fat and bone metabolism (adiponectin, leptin, 25-hydroxy vitamin D, parathyroid hormone, osteoprotegerin, RANKL), N-terminal pro B-type natriuretic peptide (NT-pro-BNP) in 73 non-cachectic, non-diabetic, male patients with chronic HF (age: 68 ± 7 years, New York Heart Association class II/III: 76/26%, left ventricular ejection fraction 29 ± 8%) and 20 healthy controls of similar age. Lean mass as a measure of skeletal muscle mass was measured by dual energy X-ray absorptiometry (DEXA), while muscle strength was assessed by hand grip strength measured by Jamar dynamometer. RESULTS: Serum levels of adiponectin, parathyroid hormone, osteoprotegerin, RANKL, and NT-pro-BNP were elevated in patients with chronic HF compared to healthy controls (all p<0.0001), while no difference in serum levels of leptin, testosterone or SHBG was noted. Levels of 25-hydroxy vitamin D were reduced (p=0.002) in HF group. Peripheral lean mass and hand grip strength were reduced in patients with HF compared to healthy subjects (p=0.006 and p<0.0001, respectively). Using backward selection multivariable regression, serum levels of increased adiponectin remained significantly associated with reduced arm lean mass and muscle strength. CONCLUSIONS: Our findings may indicate a cross-sectional metabolic association of increased serum adiponectin with reduced peripheral muscle mass and muscle strength in non-cachectic, non-diabetic, elderly HF patients.

Effect of beta blockade on natriuretic peptides and copeptin in elderly patients with heart failure and preserved or reduced ejection fraction: results from the CIBIS-ELD trial.

BACKGROUND: We sought to investigate the effect of beta-blocker (BB) up-titration on serum levels of NT-proBNP and copeptin in patients with heart failure (HF) with reduced (HFREF) or preserved ejection fraction (HFPEF). METHODS: Serial measurements of NT-proBNP and copeptin were obtained after initiation of BB up-titration in 219 elderly patients with HFREF or HFPEF. RESULTS: After initial increasing trend of NT-proBNP at 6 weeks in HFREF patients, there was a subsequent decrease at 12 weeks of BB treatment up-titration (p=0.003), while no difference was found compared to baseline levels. In contrast to NT-proBNP, there was a continuous decreasing trend of copeptin in HFREF patients (at 12 weeks: p=0.026). In HFPEF patients, NT-proBNP significantly decreased (p=0.043) compared to copeptin after 12 weeks of BB up-titration. CONCLUSIONS: After 12 weeks of BB optimization copeptin might reflect successful up-titration faster than NT-proBNP in HFREF, while the opposite was found in patients with HFPEF.

Relationship of reduced cerebral blood flow and heart failure severity in elderly males.

INTRODUCTION: Brain detrimental effects are under-recognised complication of chronic heart failure (CHF). One of the major causes may be cerebral hypoperfusion. This study was designed to investigate the relationship between cerebral blood flow (CBF) and severity of CHF as well as to evaluate its determinants among different parameters of cardiac dysfunction. METHODS: Seventy-one CHF males with NYHA class II and III and 20 control subjects age ≥ 55 years were recruited. CBF was evaluated by colour duplex sonography of extracranial arteries. Echocardiography, 6-min walk test, quality of life and endothelial function were also assessed. Serum NT-pro-BNP and adipokines levels (adiponectin and leptin) were measured. RESULTS: CBF was significantly reduced in elderly patients with CHF compared to healthy controls (677 +/- 170 vs 783 +/- 128 ml/min, p=0.011). Reduced CBF was associated with reduced left ventricular ejection fraction (LVEF) (r=0.271, p=0.022), lower 6-min walk distance (r=0.339, p=0.004), deteriorated quality of life (r= -0.327, p=0.005), increased serum adiponectin (r= -0.359, p=0.002), and NT-pro-BNP levels (r= -0.375, p=0.001). In multivariate regression analysis, LVEF and adiponectin were independently associated with reduced CBF in CHF patients (R(2)=0.289). CONCLUSION: CBF was reduced in elderly males with mild-to-moderate CHF, and was associated with factors that represent the severity of CHF including high serum adiponectin and NT-pro-BNP levels, decreased LVEF, impaired physical performance, and deteriorated quality of life.

Relationship between RANKL and neuroendocrine activation in elderly males with heart failure.

The main cytokines regulating bone remodeling are the receptor activator of nuclear factor-κB ligand (RANKL) and its decoy receptor, osteoprotegerin (OPG). Recent data have linked RANKL and OPG to cardiovascular disease as well. NT-pro-BNP and adiponectin are well-established biomarkers of heart failure reflecting neuroendocrine activation in this multi-complex disorder. The objective of this article was to investigate whether RANKL is associated with neuroendocrine activation in 75 elderly males with mild to moderate congestive heart failure (CHF) and left ventricular ejection fraction <40%. The control group consisted of 20 healthy male volunteers with matching age and body mass index (BMI). Serum RANKL (sRANKL), OPG, NT-pro-BNP, adiponectin, leptin, clinical, and echocardiography parameters were evaluated. In comparison to the control group, the CHF patients showed significantly increased sRANKL levels [126.8 (122.6) vs. 47.8 (44.4) pg/ml, P < 0.0001]. There was a significant relative risk of systolic CHF in elderly males associated with increased sRANKL above the calculated cut-off of 83 pg/ml [OR = 10.286 (95%CI 3.079-34.356), P < 0.0001; RR = 3.600 (95%CI = 1.482-8.747)]. In the CHF patients, the log-transformed values of sRANKL levels correlated positively with the log-transformed values of the serum NT-pro-BNP and adiponectin levels (P = 0.004, r = 0.326 and P = 0.037, r = 0. 241, respectively), while inversely correlated with the BMI and creatinine clearance (P = 0.015, r = -0.281 and P = 0.042, r = -0.236, respectively). In multivariate regression model, sRANKL was a significant determinant of NT-pro-BNP independent of age, BMI and creatinine clearance (P = 0.002, R (2) = 0.546). In conclusion, our study suggests that in elderly males with systolic heart failure sRANKL was significantly associated with parameters of neuroendocrine activation such as NT-pro-BNP and adiponectin. Further studies are needed to elucidate the potential role of sRANKL in the complex pathogenesis of heart failure.

Relationship between high circulating adiponectin with bone mineral density and bone metabolism in elderly males with chronic heart failure.

BACKGROUND: The aim of the study was to investigate the associations of adiponectin and leptin to bone mass and bone specific surrogates in elderly males with chronic heart failure (CHF). METHODS AND RESULTS: Seventy-three males (mean age 68 +/- 7 years) with stable mild to moderate CHF and 20 healthy individuals age- and body mass index-matching underwent dual energy x-ray absorptiometry measurements (bone mineral density (BMD) at hip and lumbar spine, total bone mineral content, and body composition); echocardiography; 6-minute walk test; grip strength; and biochemical assessment including adiponectin, leptin, bone specific surrogates (osteocalcin, beta-CrossLaps, osteoprotegerin [OPG], receptor activator of nuclear factor kappaB ligand [RANKL]), parathyroid hormone, 25-hydroxy vitamin D, testosterone, sex hormone-binding globulin, and NT-pro-BNP. Serum adiponectin, osteocalcin, beta-CrossLaps, OPG, RANKL, and parathyroid hormone were significantly increased in CHF patients, whereas 25-hydroxy vitamin D was significantly lower compared to healthy controls. The significant positive association was found between adiponectin level with osteocalcin, beta-CrossLaps, OPG, and RANKL among CHF patients. In multivariate regression analysis, adiponectin was a significant determinant of total hip BMD, although the variance was small (r(2) = 0.239), whereas leptin was determinant for total bone mineral content (r(2) = 0.469) in patients with CHF. CONCLUSIONS: Serum adiponectin is an independent predictor of BMD in elderly males with mild to moderate CHF, and showed a positive correlation to bone specific surrogates. Adiponectin, as cardioprotective hormone, seems to be able to exert a negative effect on bone mass in chronic heart failure. Further research is needed to confirm the potential for adipokines in the crosstalk between bone and energy metabolism in CHF patients.

Quality of life in patients related to gender differences before and after coronary artery bypass surgery.

OBJECTIVES: The different aspects of quality of life (QOL) in patients of different sex structure have been examined as well as the presumption that sex structure could be a predictor of QOL changes after coronary artery bypass grafting (CABG). METHODS: The study included 243 consecutive patients who underwent an elective CABG. The QOL analysis was performed by using structured interviews with the Nottingham Health Profile (NHP) questionnaire part 1. RESULTS: Compared to men, women had worse preoperative QOL (in all sections except the section of sleep) and worse postoperative QOL (in all sections). Six months after CABG the QOL statistically improved in men and in women. Multivariate analysis showed that being female was an independent predictor of QOL worsening in section of pain [P=0.001, odds ratio (OR)=3.93, 95% confidence interval (CI) 1.74-8.88]. CONCLUSIONS: Compared to men, women have worse preoperative and postoperative QOL. Female sex was an independent predictor of QOL worsening six months after CABG.

Screening of vascular calcifications in patients with end-stage renal diseases.

Vascular calcifications (VC) are a major contributor to the massively increased mortality in hemodialysis (HD) patients. The present study aimed to detect arterial media and intima calcifications in HD patients and to evaluate potential risk factors. 214 patients aged 59.0 +/- 11.0 years on HD for 6.39 +/- 4.59 years were studied. VC were scored based on to plain radiographs. Potential risk factors were assessed. Out of the 214 patients studied, only 14% did not display any detectable VC. Using plain radiographs calcifications could be detected in 136 (63.6%) patients. Calcified plaques on carotid arteries were detected in 168 (78.4%) patients. There was the highest frequency of patients with the most pronounced calcifications. Calcifications of heart valves were detected in 89 (44.1%) patients. Univariante analysis indicate that risk to develop VC is present in older patients, patients with longer dialysis vintage, thicker intima media, higher lumen diameter and mitral valve calcifications. Multivariate multinomial logistic regression analysis revealed these factors as independent predictors of VC in dialysis patients. Our data confirm a high prevalence of VC in HD patients, their association with older ages, longer dialysis vintage, and presence of valvular calcifications and early markers of atherosclerosis.

[Application of enoxaparin simultaneously with fibrinolysis in patients with acute myocardial infarction with ST-elevation].

INTRODUCTION: Applied simultaneously with fibrinolytic therapy, low-molecular heparin enoxaparin is showing the potential of improving efficacy with rare adverse effects. Our objective was to investigate if enoxaparin with streptokinase (SK) in patients with acute myocardial infarction (AMI) had better effect than unfractioned heparin (UFH). MATERIAL AND METHODS: The patients with AMI with ST elevation where SK was applied, were divided into two groups: 1. In the study group (N=32, SK+E) both SK and enoxaparin were administered (E, 30 mg intravenously before SK, then after SK 80 mg subcutaneously every 12 hours for 3 days); 2. The patients of the control group were given continuous infusion of UFH 4 hours after SK (1000 i.j. per hour, 3 days). Two groups were similar regarding average age, previous coronary events and diabetes mellitus. RESULTS: The reperfusion, depending mostly on fibrinolytic therapy, was successful in both groups (71.9% vs. 65.8%). The recurrent ischemia was less frequent in the group where enoxaparin was used (18.8% vs. 40.6%, p=0.055), as well as heart failure (15.6% vs. 53.2%, p=0,095). There was no difference in adverse effects. CONCLUSIONS: Enoxaparin used simultaneously with streptokinase in patients with AMI with ST elevation was safe and effective. The recurrent ischemia, the parameter of "infarcted" coronary artery reoclusion, is less frequent in patients who had enoxaparin than unfractioned heparin with fibrinolytic therapy.

Clinical features of hemodialysis patients with intimal versus medial vascular calcifications.

BACKGROUND: Vascular calcifications (VCs) contribute to the massive mortality in hemodialysis (HD) patients. We aimed to identify prevalence and risk factors for arterial medial calcifications (AMCs) versus intimal calcifications (AICs) in a single-center HD population. METHODS: This cross-sectional study included 134 patients, mean age 56.9 +/- 9.7 years, on HD for 8.2 +/- 5.0 years. VCs were scored based on plain radiographs and ultrasonography of the common carotid arteries. RESULTS: Patients were categorized into groups I (13% without VC), II (10% with an AMC pattern), III (24% with an AIC pattern) and IV (53% with a mixed pattern). AIC and mixed patterns were associated with older age (p=0.006 and p=0.004, respectively), and mixed pattern with longer dialysis vintage (p=0.001). Pulse pressure was significantly higher in patients from group III than group IV, and intima-media thickness (IMT) was higher in both groups with AIC. By multivariate analysis, risk factors for any VC were high serum Ca, phosphate, CaxP product, low total protein, high body mass index (BMI), systolic and diastolic blood pressure, IMT and history of smoking. Elevated calcium and/or phosphate predicted an AMC pattern, and high calcium, BMI and IMT an AIC pattern. Finally, high IMT, systolic blood pressure, BMI and older age were predictors of a mixed pattern. CONCLUSION: We observed a very high prevalence of VC, mostly with a mixed AIC+AMC pattern. Apart from well-known risk factors, the data stress the importance of smoking, an under-recognized cause of AMC, and systolic blood pressure for AIC+AMC.

Risk factors for cardiovascular calcifications in non-diabetic Caucasian haemodialysis patients.

BACKGROUND/AIMS: Dialysis patients display an increased mortality which is associated with cardiovascular calcifications. Diabetes mellitus and ethnicity are known factors that affect the extent of cardiovascular calcifications. However, most studies have investigated mixed cohorts with diabetics and/or mixed ethnicity. METHODS: Cardiovascular calcifications were assessed in non-diabetic Caucasian haemodialysis patients by the semiquantitative Adragao calcification score (X-ray pelvis and hands) and a novel composite calcification score encompassing the Adragao score as well as calcifications detected by X-ray of the fistula arm, echocardiography of heart valves and carotid ultrasound. RESULTS: Using multivariate analysis, age, male gender, dialysis vintage, lower Kt/V, calcium-phosphate product, smoking and high-sensitivity CRP were independent risk factors for cardiovascular calcifications as assessed by the Adragao or the composite score. Pulse wave velocity was independently related to both calcification scores. Body mass index, cholesterol, triglycerides, iPTH and serum levels of fetuin-A and uncarboxylated matrix Gla protein were not associated with cardiovascular calcifications. CONCLUSIONS: In our cohort of non-diabetic Caucasian haemodialysis patients, age, male gender, dialysis vintage, smoking, calcium-phosphate product, high-sensitivity CRP and lower Kt/V were independent risk factors for cardiovascular calcifications. Whether lowering the calcium-phosphate product and increasing dialysis efficiency can reduce cardiovascular calcifications in dialysis patients remains to be determined.

[Renoprotective effect of calcium channel blockers].

The advancing chronic renal failure is at most the consequence of secondary haemodynamic and metabolic factors as intraglomerular hypertension and glomerular hypertrophy. Although tight blood pressure control is the major preventive mechanism for progressive renal failure, ACE inhibitors and angiotensin receptor blockers have some other renoprotective mechanisms beyond the blood pressure control. That is why these two groups of antihypertensive drugs traditionally have advantages in treating renal patients especially those with proteinuria over 400-1000 mg/day. Even if earlier experimental studies have shown renoprotective effect of calcium channel blockers, later clinical studies did not prove that calcium channel blockers have any advantages in renal protection over ACE inhibitors given as monotherapy or in combination with ACE inhibitors. It was explained by action of calcium channel blockers on afferent but not on efferent glomerular arterioles; a well known mechanism that leads to intraglomerular hypertension. New generations of dihydropiridine calcium channel blockers can dilate even efferent arterioles not causing unfavorable haemodynamic disturbances. This finding was confirmed in clinical studies which showed that renoprotection established by calcium channel blockers was not inferior to that of ACE inhibitors and that calcium channel blockers and ACE inhibitors have additive effect on renoprotection. Newer generation of dihydropiridine calcium channel blockers seem to offer more therapeutic possibilities in renoprotection by their dual action on afferent and efferent glomerular arterioles and, possibly by other effects beyond the blood pressure control.

Predictors of worsening of patients' quality of life six months after coronary artery bypass surgery.

BACKGROUND: The possibility to predict the change in (the) quality of life after coronary artery bypass surgery (CABG) being unclear, the aim was to evaluate the change of quality of life and predictors of worsening of quality of life in patients six months after CABG. METHODS: We studied 208 consecutive patients, who underwent elective CABG. The Nottingham Health Profile Questionnaire part 1 was used as the model for quality of life determination. The questionnaire contains 38 subjective statements divided into six sections: physical mobility, social isolation, emotional reaction, energy, pain, and sleep. We distributed the questionnaire to all patients before CABG and six months after CABG. One hundred ninety-two patients filled in the postoperative questionnaire. RESULTS: The comparison between mean preoperative and postoperative scores showed an improvement in all sections of quality of life (p < 0.001). New York Heart Association functional class was significantly improved after CABG (2.23 +/- 0.65 vs. 1.58 +/- 0.59, p<0.001). Independent predictors of patients worsened by CABG were as follows: female gender in the pain section (p = 0.002; OR = 4.27; CI 1.74-10.47), diabetes mellitus in the physical mobility section (p = 0.003; OR = 8.09; CI 2.04-32.09), low ejection fraction in the physical mobility (p = 0.047; OR = 0.73; CI 0.56-0.95) and emotional reaction (p = 0.03; OR = 0.86; CI 0.60-0.93) sections, and postoperative complications in the social isolation (p = 0.002; OR = 4.63; CI 1.79-11.99), sleep (p = 0.03; OR = 2.71; CI 1.12-6.51), and pain (p = 0.005; OR = 3.39; CI 1.45-7.97) sections. CONCLUSION: The predictive factors for quality of life worsening six months after CABG are female gender, diabetes mellitus, low ejection fraction, and the presence of postoperative complications.

[Hospital mortality trend analysis of patients with ST elevation myocardial infarction in the Belgrade area coronary care units].

INTRODUCTION: Mortality in ST elevation myocardial infarction (STEMI) ranges from 4-24% and is dependent on the variety of patients' clinical characteristics (CC) that are present prior to and within the first hours of the onset of MI, affecting reliability of the diagnosis. The higher mortality rate of patients with STEMI should be associated with a higher rate of applied reperfusion therapy according to guidelines and randomized study results, which is in opposition to everyday hospital practice. OBJECTIVE: The aim of this study was to analyze the mortality of STEMI patients in relationship to their clinical characteristics at presentation, their age, sex, risk factors, prior coronary disease, and time interval from symptom onset to hospital presentation, complications and administered therapy. METHOD: The analysis involved patients treated in five coronary care units, four Belgrade Hospital Centres and the Belgrade Emergency Centre of the Clinical Centre of Serbia. Evaluated data was obtained from the Serbian National Registry for Acute Coronary Syndrome (REAKSS) and databases of local coronary care units (CCU). RESULTS: During 2005 and 2006, a total of 2739 patients with STEMI, of average age 63.3 +/- 11.7, with 64.9% males aged 61.3 +/- 11.7 and 35.1% females aged 67.0 +/- 10.7 (p < 0.01) who underwent treatment. Most of the patients (80.5%) were distributed within the elderly groups of 60, 70 and 80 years of age, with the highest percent of mortality rate (45.9%) noted at age 80 years. Anterior localization of myocardial infarction was observed in 40.2% of patients, with lethal outcome in 21.4% patients, while 59.8% of patients suffered inferiorly localized MI with much lower mortality rate (12.2%, p < 0.01). In 2005, STEMI was registered in 48.7%, while in 2006 in 44.7% of patients. Prior angina pectoris was present in 19.9% of patients, more frequently among women (p < 0.05), prior MI in 14.5% of patients, more often among males (p < 0.05), while aortocoronary revascularization was found in 3.9% of patients. Hospital mortality rate due to STEMI was higher in the group of patients with a history of prior MI (19.1% vs. 15.7%; p > 0.05). Regarding risk factors, hypertension was present in 61.8% of patients, more often among women (69.1% vs.57.9%) (p < 0.01), carrying a higher mortality rate of 18.9% vs. 9.9% among males (p < 0.01). Hyperlipidemia was found in 31.9% of patients; more frequently among women 34.8% vs. 30.4% males (p < 0.05), as well as diabetes mellitus observed in 25.1% of patients; 22.4% males and 30.1% females (p < 0.01). 39.6% of patients were smokers; 46.9% males and 28.0% females (p < 0.01). Heart failure had 33.4% of patients; mortality rate was registered in 28.2% of patients, and was significantly higher than in the non heart failure group (7.9%, p < 0.01). Heart rhythm disorders were registered in 21.3% of patients, more frequently involving posterior MI 55.3% vs 44.7% of anterior MI (p > 0.05), and was significantly higher among females 23.5% vs. 20.1% in males (p < 0.05). In 2005 in Belgrade hospitals, reperfusion therapy (RT) was performed in 34.6% of patients, mostly as thrombolytic therapy (TT) (in 99.0% of patients), and as percutaneous coronary intervention (PCI) in 1.0% of patients. STEMI mortality rate was 12.8%. In 2006, in the CCU of the In the Emergency Center RT was applied in 48.0% of patients, TT in 13.8% and PCI in 34.2%, while classical therapy without RT was applied in 52.0% of patients. CONCLUSION: Clinical characteristics significantly influence mortality in STEMI; a significantly higher mortality is among women, patients in their 80's and 90's, anterior MI localization and prior coronary disease. RT significantly lowers mortality in STEMI compared to the use of classical therapeutic approach and therefore STEMI patients with a higher mortality determined by their prehospital charactheristics, i.e. higher risk, are those who have higher benefit of RT, which should be taken into consideration when making decision about the therapy of choice.

Vascular access calcification predicts mortality in hemodialysis patients.

Vascular calcification is a recognized risk factor for cardiovascular mortality in patients with end-stage renal disease. The aim of this study was to identify risk factors for vascular access calcification and to determine if patients with this disorder are at increased risk of death. Vascular access calcification was found in 49 of 212 hemodialysis patients as measured by plain X-ray (arteriovenous fistula or synthetic graft) in two dimensions. Male gender, diabetes mellitus, and length of time on dialysis were independent predictors for access calcification determined by logistic regression multivariate analysis. Serum parameters were not independently related to access calcification. Kaplan-Meier analysis showed an increased mortality risk, and Cox regression analysis confirmed that vascular access calcification was an independent mortality predictor. Our study suggests that detection of vascular access calcification is a cost-effective method to identify patients at increased mortality risk.

[The safety of enoxaparine use in elderly with acute myocardial infarction].

BACKGROUND/AIM: Enoxaparin (ENOX), the low-molecular-weight heparin, used in acute myocardial infarction (AMI) could lead to hemorrhage. The aim of this study was to determine wether bleeding was more often in AMI patients older than 65 or 75 years who receive ENOX or unfractionated heparin (UFH). METHODS: Among the patients with AMI hospitalized during three successive months receiving ENOX or UFH, three group of parameters were investigated: demographic, ischemic and bleeding TIMI criteria. RESULTS: Among 85 hospitalized patients with signs of AIM, there were 35 (41.2%) old 65 years or less, 32 (38.5) old 66-75 years and 18 (21.2%) older than 75 years. In AMI elderly patients, according to the received ENOX/UFH: ischemic complication (18.2 vs. 21.4%) were insignificantly lower and the number of lethal outcomes (18.2 vs. 17.8%) were insignificantly more often in ENOX group; represented only by one patient (age beyond 75 years), major and non-major bleeding events occurred only in UFH group. CONCLUSION: The ENOX usage in AMI in patients older than 65 years did not show any significant difference in efficacy and bleeding rate comparing to UFH.

[The cardio-renal anemia syndrome].

INTRODUCTION: The problem of anemia in congestive heart failure and chronic kidney disease was thought to be insignificant for a long period of time. Recent investigations pointed out that the problem of anemia should be defined in the context of the cardio-renal anemia syndrome. A positive feedback mechanism indicates that cardio-renal anemia syndrome is due to an interaction between congestive heart failure, chronic renal failure and anemia. The aim of the study was to present the possible pathophysiological mechanisms of this syndrome, epidemiological characteristics and therapeutic results of the former investigations. RESULTS: The results of the retrospective and prospective controlled trails have shown that management of anemia with subcutaneous administration of recombinant human erythropoietin together with intravenous iron infusion for at least 3-6 months lead to: relief of symptoms (improved NYHA functional class), increased left ventricular ejection fraction; reduced cardiovascular morbidity and mortality; reduced number of rehospitalizations; reduced requirements for usual therapeutic agents (especially diuretics); and improved renal function. CONCLUSION: In patients with heart and kidney disease anemia should be routinely identified and appropriately treated. Subcutaneous recombinant erythropoietin and intravenous iron may significantly improve overall survival and quality of life of these patients.

[Rare cardiomyopathy in haemodialysis patients: noncompaction of the ventricular myocardium].

INTRODUCTION: Isolated noncompaction of the ventricular myocardium is a rare, unclassified cardiomyopathy characterized by the presence of numerous prominent trabeculations and deep intratrabecular recesses which communicate with the left ventricular cavity. CASE REPORT: We describe a case of noncompaction of the ventricular myocardium in a 67 years old, asymptomatic patient on regular hemodialysis. The male patient, on haemodilaysis for three and a half yrs (mesangioproliferative glomerulonephritis was a cause of end-stage renal disease), with no previous signs or symptoms of congestive heart failure or ventricular tachycardia or systemic embolisation, had a routine echocardiography assessment. We found enlarged left (60 mm) and right ventricle (32 mm) with small ejection fraction (EF 48%), but the left ventricle wall was thickened (septum 13 mm and posterior wall 13 mm) with many small lacunes and chanells with blood flow in it. Spongious muscle made more than two thirds of the ventricle wall of both chambers. No thrombus was seen. Diastolic dysfunction was also present (EA). DISCUSSION: The most frequent symptoms in these patients are: heart failure, ventricular tachycardia, sudden cardiac death, cardioembolic events and syncopa. Because of that, all patients need oral anticoagulant therapy, and regular Holter ECG--to identify patients with ventricular tachycardia for whom implantabile cardioverter--defbrilator is indicated. CONCLUSION: Although non-compaction left ventricle is a very type of cardiomyopathy, it is important to be aware of its presence and criteria for diagnosis (left ventricle wall thickened with many trabeculations and deep intertrabecular recessess with blood flow in it), and the need for adequate therapy and follow-up.

[Correlation between the inferior vena cava collapsibility and asymptomatic pericardial effusion in hemodialysis patients].

INTRODUCTION: The inferior vena cava collapsibility index is a sign of hypervolemia in hemodialysis patients. Asymptomatic pericardial effusion in these patients can be either a sign of hypervolemia or bad systolic function of the left ventricle, or both. The aim of this study was to assess the incidence of asymptomatic pericardial effusion and its correlation to collapsibility index in haemodialysis patients during 2-year follow-up. RESULTS: Of 115 consecutive hemodialysis patients, at the beginning of the study and on every 6 months we performed: clinical, ECG, echocardiography, laboratory assessment. There was 29 patients with asymptomatic pericardial effusion (25.21%) vs. 86 (74.79%) without asymptomatic pericardial effusion. There was no significant difference considering gender, age, vintage of HD between the groups. Colapsibillity index was statistically significantly lower among the patients with asymptomatic pericardial effusion: 0.39+/-0.09 vs. 0.69+/-0.21 in those without it; p<0.001. Asymptomatic pericardial effusion correlated inversely with colapsibillity index (r=-0.577; p<0.0001) and ejection fraction of left ventricle (r=-0.282; p<0.030) and positively with the dimension of left ventricle in diastole. The colapsibillity index had inverse correlation with asymptomatic pericardial effusion (r=-0.668; p<0.0001), end-diastolic dimension of the left ventricle (r=-0.464; p<0.0001), and only one positive correlation with Kt/V (r=0.294, p<0.002). During the follow-up, 16 pts (13.91%) died: 7 of them had a symptomatic pericardial effusion (43.75%). Factors with greatest relative risk for death were: persistent asymptomatic pericardial effusion (3.48); systolic dysfunction at the second examination (2.95): heart failure (2.88) at the third. CONCLUSION: Colapsibillity index and asymptomatic pericardial effusion are the closely correlated in inverse manner and both are the sign of hypervolemia. Asymptomatic pericardial effusion is also a sign of a bad systolic function and a very bad prognosis.

[Hyperkalemia in hypertensive patients undergoing regular hemodialysis during enalapril and fosinopril therapy].

INTRODUCTION: Hypertension is evident in 80%-85% of patients with chronic renal failure and antihypertensive therapy is needed in 25%-30% of patients. Apart from antihypertensive effect, ACEi's decrease the left ventricular hypertrophy and mortality in dialysis patients. Even so, their use is limited due to hyperkalemia. OBJECTIVE: The objective of the study was to compare the effect of fosinopril and enalapril on serum potassium level in hypertensive hemodialysis patients. METHOD: Prospective pilot study included 16 patients undergoing chronic hemodialysis, with mean age of 58.9 +/- 9.6 years and mean duration of hypertension 11.3 +/- 7.1 years. The effect of antihypertensive drugs of equivalent dose was followed during three periods (three months each): period 1 (therapy with enalapril), period 2 (therapy with fosinopril) and period 3 (therapy with enalapril). Dialysis conditions were constant and patients were without signs of catabolic state. Laboratory results were followed on monthly basis and mean values were compared by ANOVA-one way test. Difference between variables between periods was tested using Bonferoni method. RESULTS: There was significant difference between mean serum potassium levels throughout three therapeutic periods (5.88 +/- 0.38 vs. 4.9910.44 vs. 5.46 +/- 0.46mmol/l; p<0.001). Difference was evident even in the first month of fosinopril therapy. The effect can not be explained by dialysis adequacy since Kt/ V was similar throughout three treatment periods (1.18 +/- 0.24 vs. 1.25 +/- 0.21 vs. 1.25 +/- 0.14; p=ns). Systolic blood pressure was regulated even better with fosinopril than with enalapril (187.5 +/- 21.4 mmHg vs. 160.0 +/- 20.0 mmHg; p=0.01) and this effect was prolonged during period 3 (160.0 +/- 26.1mmHg). Hemoglobin values mainly depended on specific anemia therapy and not on particular ACEi drug. CONCLUSION: Fosinopril carries less risk of hyperkalemia in hypertensive hemodialysis patients than enalapril. Although definite conclusion may be drawn after well-designed studies, the results presented in this pilot study suggest that fosinopril may be recommended for hypertensive hemodialysis patients who are at risk to develop inter-dialytic hyperkalemia.