Obesity Paradox in the Intrahospital and Follow-Up Phases of the Acute Coronary Syndrome: A Meta-Analysis and Systematic Review.

BACKGROUND: Obesity is an important risk factor for the development of dyslipidemia, diabetes mellitus, hypertension, coronary artery disease, ventricular dysfunction, congestive heart failure (HF), stroke, and cardiac arrhythmias. OBJECTIVES: This meta-analysis brings comprehensive evaluation about still controversial association between the body mass index (BMI) and the outcomes of acute coronary syndrome. METHOD: PubMed/ScienceDirect databases were systematically searched for studies with baseline parameters, primary (HF, cardiogenic shock, cardiac arrest, reinfarction, stroke, death, total in-hospital complications) and secondary outcomes (reinfarction, stroke, death, total major adverse cardiovascular events [MACE]) in relation to BMI strictly classified into four groups (underweight [<18.5 kg/m2], normal weight [18.5-24.9 kg/m2], overweight [25.0-29.9 kg/m2], and obese [≥30.0 kg/m2], grouped into mildly obese [30.0-34.9 kg/m2] and severely obese [≥35.0 kg/m2]). RESULTS: We included 24 studies, with 585,919 participants (55.5% males), aged 66.8 years. Underweight was negatively associated with hypertension, hyperlipidemia and diabetes, and positively with primary outcomes {HF (odds ratio [OR] = 1.37, confidence interval [CI] [1.15-1.63]), cardiogenic shock (OR = 1.43, CI [1.04-1.98]), stroke (OR = 1.21, CI [1.05-1.40]), overall death (OR = 1.64, CI [1.20-2.26]), total in-hospital complications (OR = 1.39, CI [1.24-1.56])} and secondary outcomes during 34-month follow-up {cardiovascular/overall death (OR = 3.78, CI [1.69-8.49]/OR = 2.82, CI [2.29-3.49]), respectively, total MACE (OR = 2.77, CI [2.30-3.34])} (for all p < 0.05). Obesity had positive association with hypertension, hyperlipidemia, diabetes and smoking, and negative with primary outcomes {reinfarction (OR = 0.83, CI [0.76-0.91]), stroke (OR = 0.67, CI [0.54-0.85]), overall death (OR = 0.55, CI [0.49-0.63]), total in-hospital complications (OR = 0.81, CI [0.70-0.93])} and secondary outcomes {cardiovascular/overall death (OR = 0.77, CI [0.66-0.88]/OR = 0.62, CI [0.53-0.72]), respectively, total MACE (OR = 0.63, CI [0.60-0.77])} (for all p < 0.05). This negative association with several primary outcomes (cardiogenic shock, overall death, total in-hospital complications) and secondary outcomes (cardiovascular/overall death, total MACE) was more pronounced in mild obesity (p < 0.05). These results give an "obesity paradox" with a bimodal pattern (slightly U-shaped). CONCLUSIONS: Obesity is positively associated with traditional cardiovascular risk factors and negatively with primary and secondary outcomes, which confirms the persistence of overall "obesity paradox."

CHANGES IN PHYSICAL ACTIVITY LEVELS IN PATIENTS WITH ACUTE CORONARY SYNDROME BETWEEN THE FIRST AND THIRD DECADES OF THE 21st CENTURY.

Sedentary lifestyle and obesity increase the risk of coronary disease (CAD). The aims of this prospective study were to estimate the trends in physical activity (PA) level, accuracy of the Baecke's/LRC-PA questionnaires, and trends in obesity parameters (body mass index-BMI/waist-to-hip ratio-WHR) in patients with acute coronary syndrome (ACS) in the last two decades. We grouped 209 patients with ACS (UAP-unstable angina, STEMI-ST-elevation myocardial infarction, NSTEMI-non STEMI) by year of admission (Group 2002-05/Group 2017) and compared them by the levels of PA (Baecke's/LRC-PA questionnaires) and obesity parameters (BMI, WHR). Group 2017 had higher WHR (1.02 vs. 0.97) and leisure PA index (LI) (3.00 vs. 2.50), as well as less high and very low activity patients (P<0.05). Patients with UAP/STEMI had higher WHR in 2017 (1.02 vs. 0.96, 1.02 vs. 0.99, respectively) (P<0.05) and had lower LI in 2002-05 (2.50 vs. 3.25, 2.75 vs. 3.50, respectively) (P<0.05). In conclusion, leisure PA and WHR was increased in the study period both in patients with ACS and in the general population. We emphasize the usage of more precise methods for evaluation of PA and obesity (Baecke's/Four-point LRC-PA questionnaires, WHR), and that only increased PA with dietary changes leads to reduction of central obesity and risk of ACS.

THE ROLE OF ANTHROPOMETRIC PARAMETERS AND PHYSICAL ACTIVITY LEVEL IN PATIENTS WITH ACUTE CORONARY SYNDROME ADMITTED TO THE INTENSIVE CARDIAC CARE UNIT.

Anthropometric parameters have a role in diagnosing obesity, which increases the risk of acute coronary syndrome (ACS). The aim of the study was to assess the impact of obesity and physical activity level on the severity and long-term prognosis of ACS. A total of 116 patients with ACS were analyzed according to baseline (demography, medical history, anthropometry), severity (clinical presentation, in-hospital complications, laboratory, echocardiography, coronary angiography) and prognostic parameters (major adverse cardiovascular events during a six-year period). The levels of obesity and physical activity (Baecke/Lipid Research Clinics physical activity questionnaires) were compared with a sample of the Croatian general population. Study results showed the subjects with a higher number of narrowed coronary arteries (CAs) to have higher body mass index (BMI) and waist circumference (WC); those with stenosed left anterior descending artery and anterior myocardial infarction (MI) had higher BMI; waist-to-hip ratio (WHR) positively correlated with creatine kinase and negatively with left ventricle ejection fraction (p<0.05). Inactive patients more often had multi-vessel coronary disease and anterior MI; patients with a higher leisure physical activity index had a lower number of affected CAs, lower rate of stent implantations and lower stent length, while those with a higher work physical activity index had a lower rate of anterior MI (p<0.05). During the follow-up, inactive patients had more strokes and deaths (p<0.05). Our patients had higher body weight, WC and WHR, as well as lower leisure time and total physical activity indices than the general population (p<0.05). In conclusion, ACS is less severe and has better long-term prognosis in less obese patients with a higher level of physical activity. Patients with ACS are more obese and have lower total, as well as leisure time physical activity indices than the general population.

The Role of Ambulatory Cardiac Rehabilitation in Improvement of Quality of Life, Anxiety and Depression.

BACKGROUND: Psychological reactions may adversely affect recovery after major cardiac events. This study investigates the role and frequently negligible importance of ambulatory cardiac rehabilitation (ACR) in improvement of quality of life (QoL), anxiety and depression at patients with various cardiac pathology. SUBJECTS AND METHODS: This prospective study included subjects treated for acute coronary syndrome (ACS), those with performed elective revascularization, and OTHERS (after valve replacement, implanted pacemaker or other device, with stable heart failure and coronary artery disease). Their anxiety (State Trait Anxiety Inventory (STAI) questionnaire), depression (Beck Depression Inventory (BDI-II) questionnaire) and QoL data (Short Form Health Survey-36 (SF-36) questionnaire, for physical and mental QoL components) were collected initially and after 3-month of ACR. RESULTS: ACR underwent 170 patients, aged 59 (53-66 years), predominately males (74.7%). At both genders, median duration of ACR was 12 weeks, with reduction of anxiety and depression scores and improvement in almost all components of QoL (P<0.05), except in mental health and bodily pain in males and females, respectively. After ACS (63.5%), ACR lasted 12 weeks, with reduction of anxiety and depression scores and improvement in all components of QoL (P<0.05). After elective revascularization (14.1%), ACR lasted 12 weeks, with reduction of anxiety score and improvement in almost all components of QoL (P<0.05), except mental health. At OTHERS (22.4%), ACR lasted 4 weeks, with improvement in almost all components of QoL (P<0.05), except mental health; ACR duration negatively correlated with anxiety and depressive scores (P<0.05). CONCLUSION: ACR during 3-month results with improvement of anxiety, depression and QoL at patients with various cardiac pathology.

Sexual Activity in Patients with Cardiac Diseases.

In this article, we outline the latest guidelines published by the American Heart Association on sexual activity in patients with coronary artery disease, heart failure, structural heart diseases, arrhythmias, implanted pacemakers or cardioverter defibrillators, as well as on treatment options of sexual dysfunction. Sexual activities are similar to mild/moderate physical activity during a short period. Most patients are recommended to involve in sexual activity after prior comprehensive evaluation of physical condition. Those with stable cardiac symptoms and good functional capacity are at a low risk of adverse cardiovascular events, and others require treatment or stabilization before involving in sexual activity. Stress testing is useful in evaluating safety of sexual activity in patients with questionable or undetermined risk. Treatment of sexual dysfunction includes counseling of patients and their sexual partners, and drug treatment with phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) which have been demonstrated to be safe and effective, in men, and with serotonin reuptake inhibitors (flibanserin) and local vaginal estrogen administration in women. In conclusion, in routine clinical practice, patients should be approached individually and multidisciplinarily in order to detect and eliminate the factors that interfere with normal sexual activities and disturb the quality of life.

The role of weather conditions and normal level of air pollution in appearance of stroke in the region of Southeast Europe.

We investigated correlation between the normal level of air pollution, weather conditions and stroke occurrence in the region of Southeast Europe with a humid continental climate. This retrospective study included 1963 patients, 1712 (87.2%) with ischemic (IS) and 251 (12.8%) with hemorrhagic stroke (HS) admitted to emergency department. The number of patients, values of weather condition (meteorological parameters) [air temperature (°C), atmospheric pressure (kPa), relative humidity (%)] and concentrations of air pollutants [particulate matter (PM10), nitrogen dioxide (NO2), ozone (O3)], were recorded and evaluated for each season (spring, summer, autumn, winter) during 2 years (July 2008-June 2010). The highest rate of IS was observed during spring (28.9%) (p = 0.0002) and HS in winter (33.9%) (p = 0.0006). We have found negative Spearman's correlations (after Bonferroni adjustment for the multiple correlations) of the number of males with values of relative humidity (%) (day 0, rho = - 0.15), the total number of strokes (day 2, rho = - 0.12), females (day 2, rho = - 0.12) and IS (day 2, rho = - 0.13) with concentrations of PM10 (µg/m3), as well as negative correlations of the number of females (day 2, rho = - 0.12) and IS (day 2, rho = - 0.12) with concentrations of NO2 (µg/m3) (for all p < 0.002). In winter, the number of HS (day 0, rho = 0.25, p = 0.001) positively correlated with concentrations of O3 (µg/m3). The appearance of stroke has seasonal variations, with the highest rates during spring and winter. Positive correlation between the number of HS and values of O3 requires an additional reduction of the legally permitted pollutants concentrations.

Correlation Between Concentration of Air Pollutants and Occurrence of Cardiac Arrhythmias in a Region with Humid Continental Climate

In this study, we investigated the correlation of air temperature, pressure and concentration of air pollutants with the rate of admissions for cardiac arrhythmias at two clinical centers in the area with a humid continental climate. This retrospective study included 3749 patients with arrhythmias admitted to emergency department (ED). They were classified into four groups: supraventricular tachycardia (SVT), ventricular tachycardia (VT), atrial fibrillation/undulation (Afib/Aund), and palpitations (with no ECG changes, or with sinus tachycardia and extrasystoles). The number of patients, values of meteorological parameters (average daily values of air temperature, pressure and relative humidity) and concentrations of air pollutants (particles of dimensions ~10 micrometers or less (PM(10)), ozone (O(3)) and nitrogen dioxide (NO(2))) were collected during a two-year period ( July 2008-June 2010). There were 1650 (44.0%), 1525 (40.7%), 451 (12.0%) and 123 (3.3%) patients with palpitations, Afib/Aund, SVT and VT, respectively. Spearman's correlation yielded positive correlation between the occurrence of arrhythmias and air humidity on the day (r=0.07), and 1 (r=0.08), 2 (r=0.09) and 3 days before (r=0.09), and NO(2) particles on the day (r=0.08) of ED admission; palpitations and air humidity on the day (r=0.11), and 1 (r=0.09), 2 (r=0.07) and 3 days before (r=0.10), and PM(10) (r=0.11) and NO(2) (r=0.08) particles on the day of ED admission; and Afi b/Aund and air humidity 2 days before (r=0.08) ED admission (p<0.05 all). In conclusion, there was a very weak positive correlation of the occurrence of cardiac arrhythmias with air humidity and concentration of air pollutants in the region with a humid continental climate.

The importance of two metabolic syndrome diagnostic criteria and body fat distribution in predicting clinical severity and prognosis of acute myocardial infarction.

INTRODUCTION: The interrelation between metabolic syndrome (MetS) (the revised National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) and International Diabetes Federation (IDF)) and obesity indices in predicting clinical severity and prognosis of acute ST-elevation myocardial infarction (STEMI) is insufficiently known. MATERIAL AND METHODS: This prospective study included 250 acute STEMI patients treated with primary percutaneous coronary intervention. The patients with/without MetS were analyzed by baseline (medical history, demography and obesity indices: overall - body mass index (BMI) vs.central - body adiposity index (BAI), conicity index (Cindex), visceral adiposity index (VAI), waist circumference (WC), waist-to-hip (WHR) and waist-to-height ratio (WHtR)), severity (clinical presentation, laboratory, echocardiography, coronary angiography and in-hospital complications) and prognostic parameters (major adverse cardiovascular events and sick leave duration during 12-month follow-up). RESULTS: There were 136 (54.4%) and 147 (58.8%) patients with MetS (NCEP-ATP III) and MetS (IDF), respectively. MetS (NCEP-ATP III) increased the risk of > 1 significantly stenosed coronary artery (CA), very high BAI increased the risk of dyspnea, Cindex > 1.25/1.18 increased the risk of total in-hospital complications, increased VAI increased the risk of coronary segment 3 significant stenosis, WHR ≥ 0.90/0.85 increased the risk of proximal/middle coronary segments (especially of segment 1) significant stenosis, WHtR ≥ 63/58 increased the risk of heart failure, and the number of significantly stenosed CAs increased the risk of total MACE (p < 0.05). CONCLUSIONS: MetS (NCEP-ATP III) and several central obesity indices are superior to BMI in predicting acute STEMI severity (clinical presentation, in-hospital complications, severity of coronary disease), while WC and MetS (IDF) have no influence on it. They all have no influence on prognosis.

Correlation Between Occurrence and Deterioration of Respiratory Diseases and Air Pollution Within the Legally Permissible Limits.

The aim of the study was to investigate the unknown effect of air pollutants on the occurrence or deterioration of respiratory diseases in the area with a humid continental climate. This retrospective study included 5868 patients with respiratory symptomatology (upper respiratory tract infection (URTI), pneumonia, acute bronchitis, chronic obstructive pulmonary disease (COPD), and asthma) admitted to emergency department (ED). The number of patients, values of meteorological parameters (mean daily values of air temperature pressure and relative humidity) and concentrations of air pollution particles (≤10 µm (PM10), ozone (O3) and nitrogen dioxide (NO2)) were collected during a two-year ( July 2008 - June 2010) period. There were 1839 (31.3%), 1712 (29.2%), 1313 (22.4%), 614 (10.5%) and 390 (6.6%) patients with pneumonia, COPD, URTI, acute bronchitis and asthma, respectively. The mean daily concentrations of NO2 (25.9 (1.7-89.7) µg/m3), O3 (47.1 (4.7-135.4) µg/m3) and PM10 particles (25.7 (4.6-146.6) µg/m3) were below the legally defined thresholds. Among other results, the occurrence of respiratory diseases showed positive Spearman's correlation with the values of air humidity (days 0-3, r=0.15 to 0.19), PM10(days 0-3, r=0.10 to 0.13) and NO2 concentrations (day 0, r=0.11), and negative correlation with the values of air temperature (days 0-3, r=-0.36 to -0.34), pressure (day 0, r=-0.10) and O3 concentrations (days 0-3, r=-0.21 to -0.22) (p<0.05 all). In conclusion, the occurrence of respiratory diseases showed correlation with weather conditions and air pollutants despite the legally permitted values in the region with a humid continental climate.

The Role of Anthropometry in Acute St-Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention.

The aim of this study was to investigate the controversial influence of anthropometry on clinical severity and prognosis of acute ST-elevation myocardial infarction (STEMI). We prospectively analyzed 250 patients with acute STEMI treated with primary percutaneous coronary intervention (September 2011 ­ September 2012). They were grouped according to the following anthropometric parameters: body mass index (BMI) (<25.0, 25.0-29.9, ≥30.0 kg/m²), waist circumference (WC) (<102/88, ≥102/88 cm), waist-to-hip ratio (WHR) (<0.90/0.85, ≥0.90/0.85) and waist-to-height ratio (WHtR) (<53/49, 53/49-62/57, ≥63/58). The groups were analyzed by baseline, as well as severity (clinical, laboratory, echocardiography, coronary angiography, in-hospital complications) and prognostic parameters (major adverse cardiovascular events and sick leave duration during 12-month follow up). Patients with BMI <25.0 kg/m2 had the highest rates of dyspnea and those with BMI ≥30.0 kg/m² had the longest hospitalization and widest stents; patients with WHR ≥0.90/0.85 had higher rates of significantly stenosed proximal/middle coronary segments, while those with WHtR ≥63/58 had the highest rates of heart failure and total in-hospital complications (p<0.05). BMI <25.0 kg/m2 increased (odds ratio (OR) 2.00, confidence interval (CI) [1.09-3.68], p=0.026) and BMI 25.0-29.9 kg/m2 reduced (OR 0.52, CI [0.30-0.91], p=0.022) the risk of dyspnea; WHR≥0.90/0.85 increased the risk of significant proximal/middle coronary segment stenosis (OR 3.34, CI [1.13-9.86], p=0.029) and WHtR ≥63/58 the risk of heart failure (OR 2.05, CI [1.13-3.71], p=0.017) and total in-hospital complications (OR 1.94, CI [1.13-3.33], p=0.017) (p<0.05). In conclusion, WHR and WHtR are better anthropometric parameters than BMI in predicting acute STEMI severity, while WC has no influence on it. Anthropometry has no influence on prognosis.

Metabolic syndrome: influence on clinical severity and prognosis in patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

OBJECTIVE: The aim of this study was to investigate the metabolic syndrome (MS) influence on clinical severity and prognosis in patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHODS: We prospectively analysed 250 patients with acute STEMI treated with primary PCI, between September 2011-2012. MS was diagnosed by the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) criteria. Patients were divided into two groups (with/without MS) and compared by their baseline data (medical history, demographic and anthropometric data) and parameters of severity (clinical, laboratory, echocardiography, coronary angiography and in-hospital complications data) and prognosis (major adverse cardiovascular events and sick leave duration (SLD) during 12 months offollow-up). Results Our study included 136 (54.4%) and 114 (45.6%) patients with and without MS, respectively. MS patients had longer hospitalization (9.0 vs 8.0 days), higher rates of total in-hospital complications (25.0% vs 14.9%), higher number of significantly stenosed coronary arteries (CAs) (2 vs 1), higher stent diameters (3.5 vs 3.0 mm), higher rate of significantly stenosed proximal and middle CAs segments (94.1% vs 86.7%), and longer SLD (16 vs 10 weeks) (P < 0.05). MS was independently associated with higher risk of total in-hospital complications (odds ratio (OR) 1.90, confidence interval (CI) [1.06-3.64], P = 0.047) and with higher risk of > or =2 significant stenosed CAs (OR 1.72, Cl [1.04-2.84], P= 0.034). CONCLUSION: MS in acute STEMI is an important predictor of total in-hospital complications and severity of CAs disease, but not for other parameters of severity and prognosis. MS patients have longer SLD.

THE ROLE OF TILT-TABLE TEST IN DIFFERENTIAL DIAGNOSIS OF UNEXPLAINED SYNCOPE.

The aim of this retrospective study (February 2012-September 2014) was to assess the role of head-up tilt-table test in patients with unexplained syncope. It was performed on 235 patients at Clinical Department of Cardiology, Sestre milosrdnice University Hospital Center. Patients were classified according to test indications: group A (convulsive syncope, n = 30), group B (suspected vasovagal syncope, n = 180), and group C (paroxysmal vertigo, n = 25). The groups were analyzed and compared according to demographic data (age and gender), referral specialist (cardiologist, neurologist, and others), and test results (positive/negative) with specific response (cardioinhibitory, vasodepressor, or mixed). Groups A and B were referred most frequently by neurologists and cardiologists (p < 0.05). The test was positive in 34 (14.5%) of all evaluated patients (5 in group A and 29 in group B), of which 13 (38.2%) had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response. In the cardioinhibitory subgroup, three patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal electroencephalography were on antiepileptics. During head-up tilt-table testing, they had bradycardia (heart rate 30.0 ± 5.0 beats/min) and prolonged asystole (13.7 ± 11.0 seconds) with development of typical convulsions. These three subjects got a permanent pacemaker (atrial/ventricular stimulation, heart rate control) and anticonvulsive therapy was slowly withdrawn with no syncope recurrence during 24-month follow up. In conclusion, head-up tilt-table test has an important role in the evaluation of patients with unexplained syncope and in differential diagnosis of vasovagal syncope. The indication for pacemaker implantation, strictly following the European Society of Cardiology guidelines, proved to be effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.

[Breast cancer metastases to the stomach and colon: two case reports]. / Metastaze karcinoma dojke u zeludac i debelo crijevo: prikaz dviju bolesnica.

Summary. Breast cancer has a high potential for metastasis, usually to the lungs, bones, liver and lymph nodes. Metastases in the holow organs of the digestive system are rare and mainly affectes the stomach and colon. They are characterized by very different clinical and radiological manifestations. We have warned that the initial unrecognized breast cancer can appear as a primary tumor of the stomach and colon, and onlya histopathological analysis reveales that it is a metastatic breast cancer. Metastases to the stomach or intestine involve deep layer of the mucosa and pathohistological findings of standard biopsy sample can be falsely negative, despite positive imaging technique (abdominal ultrasound and MSCT, endoscopic ultrasound) that indicate the tumor process. That's,why we emphasize the importance of endoscopic mucosal resection in the detection of malignant process of deeper layers of the gastric mucosa and deep intestinal mucosal biopsies with postoperative analysis of its walls.