Biomarkers and their combination in a prediction of decompensation after an index hospitalization for acute heart failure.

Introduction: Heart failure (HF) still remains as one of the most common causes of hospital admission with a high mortality rate. Aim: To investigate the possible prognostic role of brain natriuretic peptide (BNP), high-sensitivity (hs) cardiac troponin (cTn) I, cystatin C, and cancer antigen 125 (CA125) in the prediction of decompensation after an index hospitalization and to investigate their possible additive prognostic value. Patients and Methods: Two hundred twenty-two patients hospitalized with acute HF were monitored and followed for 18 months. Results: BNP at discharge has the highest sensitivity and specificity in the prediction of decompensation. For a cutoff value of 423.3 pg/ml, sensitivity was 64.3% and specificity was 64.5%, with a positive predictive value of 71.6% and an area under the curve (AUC) of 0.69 (P < 0.001). The hazard risk (HR) for decompensation when the discharge BNP was above the cutoff value was 2.18. Cystatin C, at a cutoff value of 1.46 mg/L, had a sensitivity of 57% and specificity of 57.8%, with a positive predictive value of 65.8% and an AUC of 0.59 (P = 0.028). CA125, in the prediction of decompensation in patients with acute heart failure (AHF) and at a cutoff value of 80.5 IU/L, had a sensitivity of 60.5% and specificity of 53.3%, with a positive predictive value of 64.5% and an AUC of 0.59 (P = 0.022). The time till onset of decompensation was significantly shorter in patients with four versus three elevated biomarkers (P = 0.047), with five versus three elevated biomarkers (P = 0.026), and in patients with four versus two elevated biomarkers (P = 0.026). The HR for decompensation in patients with five positive biomarkers was 3.7 (P = 0.001) and in patients with four positive biomarkers was 2.5 (P = 0.014), compared to patients who had fewer positive biomarkers. Conclusion: BNP, cystatin C, and CA125 are predictors of decompensation, and their combined usage leads to better prediction of new decompensation.

Triglyceride level as a potential marker of residual cardiovascular risk and its relation to HeartScore.

BACKGROUND: Atherosclerotic cardiovascular diseases (ASCVD) are still the leading cause of morbidity and mortality in Bosnia and Herzegovina. Elevated LDL-cholesterol is established as a strong marker of cardiovascular risk. Some researchers believe that measuring triglyceride levels gives a good assessment of the residual risk for ASCVD besides the measurement of LDL-cholesterol. OBJECTIVE: The aim of this study was to evaluate the overall prevalence of major risk factors for ASCVD, lipid profile and 10-year fatal cardiovascular risk using the HeartSCORE scoring system. Further, we want to evaluate the prevalence and relationship between elevated triglyceride levels and high 10-year fatal cardiovascular risk calculated as a HeartSCORE. METHODS: This is a cross-sectional study conducted on 832 volunteers aged between 40 and 65 years without a diagnosis of diabetes and without known preexisting cardiovascular disease, as a part of the preventive program conducted at the Family Medicine office. Data were collected for ASCVD risk factors and lipid panel (total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides). 10-year fatal cardiovascular risk was calculated using the HeartSCORE scoring system for countries with high CV risk. RESULTS: Among 832 participants included, 565 (67.9%) were female, and 267 (32.1%) were male. We found high prevalence of hypertension (27.7%), obesity (32.2%), and smoking (36.2%). All lipid parameters, except HDL-C, were not optimal. Only 17.4% of participants had normal estimated HeartSCORE risk, while more than one-third (33.9%) had high or very high estimated HeartSCORE risk. Although we found a higher percentage of participants with elevated triglycerides in groups with higher HeartSCORE, there was a very weak positive correlation between values of triglycerides and the 10-year risk of a fatal cardiovascular event (r= 0.249, p= 0.000). CONCLUSION: The high prevalence of major known risk factors and high estimated HeartSCORE risk indicate a high overall risk for ASCVD in the sample. The proportion of participants with elevated triglycerides was increased in patients with high HeartSCORE risk what implicates importance of triglyceride measurement.

Neutrophil gelatinase-associated lipocalin is a predictor of complications in the early phase of ST-elevation myocardial infarction.

Aim To evaluate a correlation of serum level of neutrophil gelatinase-associated lipocalin (NGAL) to the risk of the occurrence of complications in patients with the early phase of ST-segment elevation myocardical infarction (STEMI) treated with fibrinolytic therapy prior to percutaneous coronary intervention (PCI). Methods A total of 54 patients with the diagnosis of STEMI treated with fibrinolytic therapy (alteplase) prior to PCI were included. Patients were admitted to the Intensive Care Unit (ICU) of Clinic for Heart, Blood Vessel and Rheumatic Diseases in the period January to March 2018. All patients underwent coronary angiography and PCI within the maximum of 48 hours delay after fibrinolysis, according to the hemodynamic and electrical stability and PCI availability. Blood samples were taken immediately after admission prior to fibrinolytic administration. Patients were divided into two groups according to NGAL values (less or more than 134.05 ng/mL). Results Higher values of NGAL have effect on a higher mean systolic and diastolic pressure (p=0.001 and p=0.003, respectively). Patients with higher NGAL values also have higher values of brain natriuretic peptide (p=0.0001) and highly sensitive troponin I (p=0.002). In that group relative risk (RR) for lethal outcome was 6.4 times significantly higher (p=0.002), for the development of heart failure 2.88 times (p=0.0002), for post-myocardial infarction angina pectoris 2.24 times (p=0.0158), and for ventricular rhythm disturbances (ventricular tachycardia, ventricular fibrillation) 1.96 times higher (p=0.0108). Conclusion Increased NGAL value is related to an unfavourable outcome of patients in the early phase of STEMI treated with fibrinolytic therapy prior to PCI.

Efficacy and Safety of Perindopril in Patients with Essential Hypertension.

INTRODUCTION: Perindopril is a tissue-specific ACE inhibitor with 24 hours long blood pressure-lowering effect, which protects blood vessels and decreases the variability of blood pressure. AIM: The aim of our study was to investigate the effectiveness and safety of perindopril in newly diagnosed or previously treated but uncontrolled adult hypertensive patients. METHODS: This prospective cohort study included primary care patients with essential hypertension. Primary study outcomes were decreasing arterial blood pressure to normal levels (<140/90 mmHg), reducing systolic arterial blood pressure for 10 mmHg or more and reducing diastolic arterial blood pressure for 5 mmHg or more. Safety was evaluated by type and frequency of adverse events. RESULTS: In the great majority of the study patients (more than 96%) perindopril was effective as monotherapy, achieving a significant reduction in both systolic and diastolic blood pressure, and in three-quarters of the study patients it normalized both systolic and diastolic blood pressure. The effectiveness of perindopril was shown in both patients with previously and newly diagnosed hypertension, adverse events were mild and rare, even hyperkalemia was encountered less often than before the onset of the therapy with perindopril. CONCLUSIONS: Our study confirmed excellent effectiveness of perindopril in the treatment of essential hypertension and its remarkable safety. When used as monotherapy of hypertension, perindopril's doses should be carefully titrated until the achievement of full effect, which in some patients should be awaited for at least 6 months from onset of the therapy.

Beta-blocker Use in Moderate and Severe Chronic Obstructive Pulmonary Disease.

INTRODUCTION: The most appropriate choice of pharmacological treatment of heart rhythm disorders occurring in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular comorbidity is often a topic of debate between pulmonologists and cardiologists in clinical practice, although numerous studies and clinical trials have demonstrated evidence to support the use of selective beta-blockers (BBs) in these patients. AIM: To examine the difference in the number of exacerbations in patients treated with a combination of verapamil and digoxin or BB alone in patients with different COPD stages. PATIENTS AND METHODS: The study included 68 patients (n = 68) diagnosed with COPD who were followed-up during a 12-month period, and the number of exacerbations were analyzed. The patients were divided into two groups according to the stage of COPD: GOLD II (moderate), and GOLD III (severe), and in each group a subdivision was established in relation to the use of either a combination of verapamil and digoxin or the use of BBs alone in pharmacological treatment. The inclusion criteria for patients were defined as following: a) established diagnosis of COPD according to present or deteriorated relevant clinical symptoms and signs, b) the ejection fraction (EF) of a left ventricle (LV) >35%, and c) spirometric cut-points classified as GOLD II (FEV1 / FVC <0.7, FEV1 predicted 50-80%), or GOLD III (FEV1/FVC <0.7, FEV1 predicted 30-50%) stage of the COPD. The exclusion criteria were EF of LV <35% and a lethal outcome during a follow-up period (2 patients were encountered). Exacerbation was defined as functional deterioration of the COPD symptoms verified by spirometric functional testing, frequency of hospitalizations according to GOLD stage assignment or verified clinical symptoms deterioration. RESULTS: Regardless the pharmacological treatment, there is a statistically significant increase in the number of COPD exacerbations, in a 12-month period follow-up, in the GOLD III group (severe) compared to the GOLD II group (moderate). In the group of patients taking verapamil and digoxin, a two-tailed t-test was used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.01, and 2. In the group of patients taking BBs, a two-tailed t-test was also used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.003). Within the COPD GOLD II stage group, there appears to be no statistically significant difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 24) and the patients taking BBs alone (n = 15), although, in patients taking BBs alone, there appears to be a trend towards a decrease in the exacerbations compared to the number of exacerbations in patients taking verapamil and digoxin (p = 0.007). Within the COPD GOLD III stage group, there is no difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 20), and the patients taking BBs alone (n = 9), as analyzed by a two-tailed t-test, p = 0.577. CONCLUSION: Use of selective BBs in the treatment of cardiovascular comorbidity in patients with COPD represents a far better choice of pharmacological approach in the treatment of patients diagnosed with COPD GOLD II (moderate) stage.

Therapeutic hypothermia as a treatment option after out-ofhospital cardiac arrest: our experience.

Aim To examine the effects of therapeutic hypothermia on the outcome of patients with the diagnosis of out-of-hospital cardiac arrest (OHCA). Methods The study included 76 patients who were hospitalised at the Medical Intensive Care Unit (MICU) of the Clinical Centre University of Sarajevo, with the diagnosis of out-of-hospital cardiac arrest, following the return of spontaneous circulation. Therapeutic hypothermia was performed with an average temperature of 33oC (32.3 - 34.1o C) on the patients who had coma, according to the Glasgow Coma Scale (GCS). Results Multiple organ dysfunction syndrome (MODS) significantly affected survival (p=0.0001), as its presence reduced patients' survival by 96%. In addition, ventricular fibrillation (VF) as the presenting rhythm, also significantly affected survival (p=0.019). A degree of patient's coma, as measured by the GCS, significantly affected survival (p=0.011). For each increasing point on the GCS, the chance for survival increased twice. Moreover, other physiological factors such as the pH and the lactate serum levels significantly affected patients' survival (p=0.012 and p=0.01, respectively). Conclusion In patients with the diagnosis of OHCA who underwent to the treatment with therapeutic hypothermia, verified VF as a presenting rhythm was a positive predictive factor for their outcome. Therefore, therapeutic hypothermia represents an option of therapeutic modality for this type of patients.

Optimal Choice of Pharmacological Therapy - Prevention of Stroke and Assessment of Bleeding Risk in Patients with Atrial Fibrillation.

BACKGROUND: The aim of the study was to highlight the importance of adequate anticoagulant therapy and the correlation of higher risk of stroke. METHODS: This study analyzed data obtained from 103 patients with diagnosis of atrial fibrillation (AF) (39 of them had a stroke). Patients were divided into groups according to the CHADS2, CHA2DS2-VASc, and HASBLED scores. RESULTS: An analysis showed that anticoagulant drugs were more often prescribed to subjects <75 years of age (P = 0.001). Patients with a higher CHADS2 score had a higher CHA2DS2-VASc score and vice versa (rho = 0.513; P = 0.0001). According to the CHA2DS2-VASc, 91.3% of the patients examined were prescribed an anticoagulant medication as a therapy at discharge from the hospital. The result was statistically significant compared to the practice where an anticoagulant was prescribed to 55.9% of high-risk subjects as estimated by the CHA2DS2-VASc score (P < 0.05). Our results also show that rivaroxaban is more commonly prescribed as a discharge therapy than warfarin (χ2 = 12.401; P = 0.0001). Furthermore, a significantly higher number of patients who were being prescribed aspirin (38.5%) had a stroke compared to 12.8% of patients who were being prescribed warfarin (χ2 = 12.259; P = 0.0001). CONCLUSIONS: Novel oral anticoagulants (NOACs) seem to be a better choice as a pharmacological therapy in the treatment of AF, due to a lack of adequate monitoring of patients' international normalized ratio (INR) values. CHA2DS2-VASc and HASBLED scores must be used as a part of routine clinical diagnostics when dealing with patients with AF.

Effect of myocardial infarction on the occurrence of erectile dysfunction.

Aim To investigate etiological link between acute myocardial infarction (AMI) and the accompanying impotence/erectile dysfunction (ED). Methods Study included 99 male patients (48 who had AMI - patient group, and 51 healthy examinees without previous cardiovascular disease - control group). All patients completed a standardized questionnaire, the International Index of Erectile Function (IIEF-5). Results Older patients had significantly lower IIEF-5 score (negative correlation) (p<0.05), but higher ED degree (significant positive correlation) (rho=0.522; p=0.0001). In the patient group, 37 (77.1%) patients had ED, while in the control group it was found in 26 (51%) examinees (p<0.05). A clear correlation was found between incidence of ED and diabetes, dyslipidaemia, hypertension and positive family history (they were more common in patients with ED, with no statistically significant difference). There was no statistically significant difference between patients with ED and patients without ED according to the beta-blocker usage (p=0.824): ED was reported in 11 (68%) patients in the group who used carvedilol, 14 (82.3%) in the group who used metoprolol, and nine (81.8%) who used nebivolol. Conclusion Myocardial infarction as well as age are directly related to the occurrence of ED. Cardiovascular risk factors are in direct correlation for the occurrence of erectile dysfunction after myocardial infarction.

Predictors of Hospitalization for Heart Failure Decompensation in 18-months Follow-up After Index Hospitalization for Acute Heart Failure.

INTRODUCTION: Heart failure (HF) has very high rate of repeat hospitalizations due to HF decompensation (HHFD), sometimes very shortly after discharge for acute HF. AIM: The aim of this paper is to investigate rate of HHFD and to identify their possible predictors. PATIENTS AND METHODS: Total amount of 222 patients hospitalized at Clinic for heart and vessel disease and rheumatism in acute HF were followed for next 18 months for occurrence of HHFD. During hospitalization were collected demographic data, risk factors, routine laboratory tests and admission BNP (brain natriuretic peptide), discharge BNP, percentage change of BNP during hospitalization, high sensitive troponin I, CA125 (cancer antigen125) and cystatin C. RESULTS: In next 18 months 129 patients (58.11%) reached end-point HHFD- mean time of its occurrence was 2.2 (95% CI=1.67-2.7) months. Patients with HHFD had more often arterial hypertension (HTA) (p=0.006), had higher BMI (p=0.035) and had higher values of bilirubin, admission BNP (p=0.031), discharge BNP (p <0.001), CA125 (p=0.023) and cystatin C (p=0.028). There was no difference in troponin values (p=0.095), while % reduction of BNP during hospitalization was lower (p<0.001) in group with HHFD. In univariate Cox hazard analysis HTA was positively and BMI negatively correlated with HHFD, while in multivariate Cox hazard analysis independent predictors were HTA (HR 1.6; 95% CI=1.1-2.2; p=0.018) and BMI<25 (HR 1.6; 95% CI=1.1-2.3; p=0.007). In univariate Cox hazard analysis admission BNP, discharge BNP, rise of BNP during hospitalization, CA125 and bilirubin were positively correlated, while sodium was negatively correlated with HHFD. In multivariate Cox hazard analysis there was only one independent predictor of HHFD - discharge BNP (HR 6.05; 95% CI=1.89-19.4; p=0.002). Conclusion: Arterial hypertension, BMI>25 and discharge BNP are independent predictors of HHFD. This could help us to identify high-risk patients for readmission who should be monitored more frequently and treated with sophisticated drug and device therapy.

Troponin and CRP as Indicators of Possible Ventricular Arrhythmias in Myocardial Infarction of the Anterior and Inferior Walls of the Heart.

INTRODUCTION: Heart rhythm disorders are quite common in the clinical course of acute myocardial infarction and have a significant influence on the prognosis of the disease. AIM: To investigate the type and frequency of ventricular arrhythmias in patients with acute myocardial infarction (AMI) by sex and age, according to localization of myocardial infarction, and correlated with troponin and C reactive protein (CRP). MATERIAL AND METHODS: A prospective, analytical, comparative clinical study was performed. A total of 100 patients was included who were hospitalized at the Clinic for Heart Disease and Rheumatism at the Clinical Center University of Sarajevo for a period of 6 months, of both sexes, aged from 20 to 90 years. The occurrence of ventricular arrhythmias, CRP and troponin, were observed in relation to the localization (anterior and inferior myocardial wall). RESULTS: It was found that men are more represented in comparison to women and that the largest number of males were in the age group of 51-60 years of life and women in the age group of 71-80 years. It has been established that there is no significant difference between ventricular arrhythmia according to localization of AMI. By determining the mean CRP and troponin levels, a positive correlation was found between CRP and troponin values and recorded ventricular arrhythmias. CONCLUSION: There is a positive correlation between the troponin and CRP values and ventricular arrhythmias, not related to the localization of AMI, which is important in prevention and planning the treatment of complications of potentially malignant ventricular arrhythmias and fatal outcome at AMI.

Tetralogy of Fallot - Clinical Course and Treatment as a Mirror of Contemporary Cardiology/Cardiac Surgery Development in Correction of Congenital Heart Disease in the Adults.

AIM: The aim of this paper was to present a 65 year old female patient with chronic heart disease, surgically treated for congenital heart defect type Tetralogy of Fallot. CASE REPORT: In the sixth year of life the patient underwent palliative Potts anastomosis surgery which created an anastomosis between the left pulmonary artery and the descending aorta. Total correction was made in 34 years of life, six months after catheterization, which indicated malignant pulmonary hypertension. She is regularly followed up by the cardiologists and receives daily therapy. The present state of the patient is satisfactory with cardiomegaly, light left ventricular dysfunction, moderate mitral and tricuspid regurgitation, pulmonary arterial hypertension, and aneurysmatic dilatation of left pulmonary artery as well as atrial fibrillation. CONCLUSION: The intense development of cardiology and cardiac surgery in the USA in children and adults over the last fifty years has led to the extension and improvement of the quality of life.

Potential Anti-Inflammatory Treatment of Ischemic Heart Disease.

INTRODUCTION: Ischemic heart disease (IHD) is clinical manifestation of chronic inflammatory progressive pathological process of atherosclerosis in coronary arteries. IHD is the leading cause of morbidity and mortality in the world. The question is whether it is possible to improve and direct the therapeutic treatment of IHD patients in the treatment of the inflammatory process in the atherosclerotic leasions. MATERIAL AND METHODS: A prospective, comparative, analytica,clinically applicable, open-type study was performed. The study was conducted on 80 subjects with controlled biohumoral markers: troponin, CK, CK MB, BNP; markers of atherogenesis: LDL and homocystein; inflammatory markers: CRP, amyloid, cytokines IL-2, IL-6,TNF-alpha. The experimental group of 38 respondents had in addition to the conventional IHD treatment with: ampicillin (which included organosulfur compounds), cyancobalamin, vitamin B complex (B1, B2 and B6) and folacin. A control group of 42 respondents did not have this additional treatment. RESULTS: Major adverse cardic events (MACE) such as postinfarctic angina pectoris and repeated infarction, need for surgical interventions of myocardial revascularization, signs of cardiac insufficiency and death were observed during the one-year period. There was no correlation between the IL-2, IL-6 and TNF-alpha, as well as CK, CKMB and troponin and MACE in one-year follow-up. There was a strong positive correlation between MACE and CRP (p = 0,0002) and amyloid (p = 0,0005) as inflamatory markers; a strong positive correlation between MACE and homocysteine as an atherogenic marker (p = 0,0002, and amoderate positive correlation between MACE and BNP (p = 0.0403) as ischemic marker and marker of cardiac insufficiency. The echocardiographically monitored systolic function showed a moderate difference in the groups with average higher values in the experimantal group (p = 0.0282). CONCLUSION: The applied treatment exhibited a moderate positive effect on the systolic function of LV and significantly reduced the MACE in the work compared to the control group (p <0.0001), and demonstrated a potential anti-inflammatory effect.

Seasonal Incidence of Acute Coronary Syndrome and Its Features.

INTRODUCTION: Acute coronary syndrome (ACS) is one of the most common health problems in the world and the leading cause of death. GOAL: The goals of this study are to determine: ACS type, risk factors, incidence and the seasonal distribution of occurrence Spring/Summer, Autumn/Winter, ACS incidence by age and gender, and complications (post-infarction angina and heart failure) and fatal outcomes of ACS per season. MATERIAL AND METHODOLOGY: This study is designed as retrospective-prospective and analytical, which included 250 patients hospitalized in the Intensive Cardiac care unit of the Clinic for heart disease, blood vessels and rheumatism in the period from June 2013 to July 2014. It was assumed that there is the influence of the seasons on the incidence and characteristics of ACS. Material used were the medical records and data from the history of illness. RESULTS: The most common type of ACS was ST elevation myocardial infarction (STEMI), without statistical significant difference between seasons. Presence of risk factors is not significantly different between seasons, with the hypertension as the most common risk factor for ACS during both seasons. The highest incidence of ACS was recorded in December during the winter season, while the lowest incidence was recorded in March. The occurrence of ACS during the Spring/Summer, Autumn/Winter was different according to age, with more frequent occurrence of ACS in older patients during the winter months. ACS complications (postinfaction angina and cardiac insufficiency) were also statistically different between seasons (p=0.048). Fatal ACS is more often recorded during the season Autumn/Winter compared to Spring/Summer season (p=0.001). CONCLUSION: The results suggest seasonal meteorological impact on the incidence, complications and outcomes of ACS, so there is a necessity that patients adapt their lifestyle and health professionals to improve the ACS treatment.

Assesment of Rhythm Disorders in Classical and Nonclassical Mitral Valve Prolapse.

INTRODUCTION: Mitral Valve Prolapse (MVP) is the most common cardiac valve pathology of to day. Aim of article was to identify the types and frequency of potentially malignant arrhythmia and atrial brillation in patients with MVP, to determine the differences in these arrhythmias between classical and non-classical MVP, to evaluate the correlation of potentially malignant arrhythmia and atrial fibrillation with MVP with possible clinical complications of arrhythmogenic sudden cardiac death and potential risk of thromboembolic vascular incident. PATIENTS AND METHODS: Article has retrospective-prospective analytical character and present observational study on 239 patients (120 with MVP (66 with classical and 54 with non-classical MVP), who had a subjective feeling of palpitations and/or pain in the chest, and/or episode of syncope, and did not have ischemic heart disease or another valve pathology) and 119 healthy patients in the control group. All patients were analyzed by 24-hour ECG Holter. RESULTS: Signifficant difference in all analyzed arrhythmias between classical MVP and control group (p <0.001) between non-classical and control group in the presence of preexcitation signs (p = 0.047), and between classical and non-classical in presence of QT prolongation and AV block of II and III degree (p = 0.023), ventricular arrhythmias of the 3rd, 4th and 5th grade at scales according to Lown (p = 0.002) and atrial brillation in favor of classical MVP (p = 0.016). CONCLUSION: The potential risk of cardiac death and vascular incidence is signi cantly higher in classical MVP than in non-classical MVP, implying the need for routine ECG-Holter monitoring in their diagnosis for timely prevention of clinical arrhythmogenic complications.

Gigantic Thrombus of the Left Atrium in Mitral Stenosis.

INTRODUCTION: Excess dilatation of the left atrium >65 mm is known in the literature as gigantic atrium. This dilation is most commonly encountered in the mitral insufficiency of rheumatic etiology, but also in severe prolapses of the mitral valve, permanent atrial fibrillation, and at the left right shunt with cardiac insufficiency. CASE REPORT: In this paper is presented a case study of echocardiographically verified giant thrombus in left atrium in a 50 years old female patient aged 50 hospitalized because of tiredness, choking, heartburn and urinary tract symptoms. The patient had rheumatic fever at age of 18 years. At age of 35, she was diagnosed with mitral stenosis. In permanent atrial fibrillation with anamnestic data on the previous cerebrovascular stroke (CVI) and the repeated transitional ischemic seizures. Echocardiographic examination confirmed severe mitral stenosis with moderate aortic insufficiency and gigantic left atrium (LA) with gigantic thrombus. Invasive diagnostics were indicated and performed, followed by an acute cardiac surgery including left atrial thrombectomy and implantation of the mechanical aortic and mitral valve. The surgical course was without complications. CONCLUSION: On eleven postoperative day, after mobilization, the patient experiences stroke with motor aphasia. She was clinically recovering from stroke consequences, and remains cardiollogically stable.

Streptokinase versus alteplase: comparison of echocardiographic parameters and post-coronarography treatment--our experience.

INTRODUCTION: Usage of fibrinolytic therapy leads to reperfusion of the occluded coronary arteries, rescue of ventricle myocardium and successful recovery of patient. GOAL: The objective of this study was to compare the reperfusion effect of streptokinase and alteplase in acute myocardial infarction (AMI) by analyzing echocardiographic parameters and post-coronarography treatment. PATIENTS AND METHODS: We observed 53 patients in AMI and divided them depending on applied therapy in streptokinase and alteplase group. Both groups were further divided into three subgroups depending on the time passed from chest pain occurrence to admission at Clinic. Observed echocardiographic parameters were: mitral regurgitation, left ventricular systolic and diastolic function and signs of ischemic cardiomyopathy. On coronary angiogram we analyzed severity of coronary artery disease as well as recommended treatment thereafter. RESULTS: There were no significant difference in post-coronarography treatment, incidence and severity of mitral regurgitation and ischemic cardiomyopathy in alteplase vs streptokinase group- only significantly less diastolic dysfunction was noted in alteplase group (p=0.037). We noticed only significant difference when we took into consideration time from chest pain to admission at clinic. In alteplase first subgroup were more patients treated only with medications (without need for revascularization) vs streptokinase first subgroup (62,5% vs 28.6%, p=0.047). In alteplase first subgroup was lower incidence of mitral regurgitation (p =0.045), developed cardiomyopathy (p =0.009) and more preserved left ventricular diastolic function (p =0.008) compared to first streptokinase subgroup. CONCLUSION: In our study we have found a significant difference between streptokinase and alteplase in echocardiographic parameters and post-coronarography treatment when we took into consideration time from occurrence of chest pain to admission at Clinic. The best outcomes had patients who were treated with alteplase within 1.5 hour from occurrence of chest pain.

Serum level of tumor marker carbohydrate antigen-CA125 in heart failure.

OBJECTIVE: To assess serum levels of tumor marker carbohydrate antigen 125 (CA125) in patients with heart failure (HF) and to investigate possible correlation with echocardiographic parameters and level of brain natriuretic peptide (BNP). PATIENTS AND METHODS: We included 76 patients with different cardiac symptoms hospitalized at Clinic for heart disease and rheumatism. Control group (n = 26) was consisted of patients without signs and symptoms of HF, normal left ventricle ejection fraction (LVEF) and normal BNP level. Patients with diagnosis of HF (n = 50) were subdivided into 2 group depending on signs and symptoms of fluid overload: compensated (compHF, n = 10) and decompensated group (decompHF, n = 40). Serum CA125 and BNP were measured on admission and all patient underwent ECG recording and trans thoracic echocardiographic examination. RESULTS: The median CA125 level in HF group was significantly higher compared to control group (71.05 [30.70-141.47]U/ml vs 10.75 [8.05- 14.32] U/ml, p < 0.0005). Higher CA125 levels were found in decompHF group compared to compHF group (94.90 [49.75-196.75]U/ml vs 11.90 [10.25-15.80]U/ml, p < 0.0005). In decompHF group 13 of patients had pleural and/or pericardial effusion- their CA125 levels were significantly higher compared to patients without serosal effusion (n = 27) (205.10 [106.50-383.90]U/ml vs. 71.50 [47.30-109.55] U/ml, p < 0.002). We found significant difference in CA125 levels between patients with atrial fibrillation and sinus rhythm (98.40 [48.20-242.70] U/ml vs. 47.30 [12.95-99.05] U/ml, p = 0.015). There was no significant difference in CA125 levels in group with enlarged left atrium compared to normal sized atrium (p = 0.282), as well as in group with moderate/severe mitral regurgitation compared to group with no/mild mitral regurgitation (p = 0.99). Finally, levels of serum CA125 positively correlated with serum level of BNP (r = 0.293, p = 0.039), but not with LVEF (p = 0.369) and left atrium diameter (p = 0.636). CONCLUSION: Serum CA125 is elevated in decompensated HF patients: more pronounced elevation was found in patients with pleural and/or pericard effusion compared to patients with no serosal effusion. CA125 level correlated with BNP, but not with left atrium diameter nor with LVEF. Tumor marker CA125 could be used as a marker of systemic congestion and volume overload in decompensated HF. We hypothesized that high CA125 level indicates that measured high BNP is actually wet BNP.

Brain natriuretic peptide release in acute myocardial infarction.

Brain natriuretic peptide (BNP) is released from ventricular myocites due to their stretching and volume overload. In heart failure there is BNP release. Aim of this study was to observe BNP release in acute myocardial infarction (AMI). We measured BNP in 75 patients with AMI. Control group (n=61) was similar by age and gender to AMI group. We found statistically significant elevation of BNP compared to controls (462.875 pg/ml vs 35.356 pg/ml, p< 0.001). Patients with severe systolic dysfunction had the highest BNP levels, while patients with the preserved systolic function had the lowest BNP levels (Group with EF< 30% BNP= 1129.036 pg/ml vs Group with EF31-40 % BNP= 690.177 pg/ml vs Group with EF 41-50% BNP= 274.396 pg/ml vs Group with EF> 51% BNP= 189.566 pg/ml, p< 0.001). We found statistically significant light positive correlation between BNP and left ventricle end-diastolic diameter (LVDd) (r= 0.246, p<0.05). and real positive correlation between BNP and peak troponin levels (r= 0.441, p < 0.05). BNP levels were higher in anteroseptal allocation of AMI compared to inferior allocation (835.80 pg/ml vs 243.03 pg/ml, p< 0.001) and in patients who were treated with heparin compared to fibrinolitic therapy (507.885 pg/ml vs 354.73 pg/ml, p< 0.05). BNP is elevated in AMI and is a quantitative biochemical marker related to the extent of infarction and the left ventricle systolic dysfunction. Besides echocardiographic calculation, elevation of BNP could be used for quick and easy determination of the left ventricle systolic dysfunction.

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.