Mechanical valve thrombosis: Current management and differences between guidelines.

All foreign bodies inserted in the circulatory system are thrombogenic and require temporary or lifelong antithrombotic therapies to prevent thrombosis. The adequate level of anticoagulation during the first few months determines the long-term durability, particularly for mechanical prostheses, and also for biological valves. Suboptimal anticoagulation is the most frequent source of mechanical valve thrombosis (MVT). The patient's clinical presentation decides how mechanical prosthetic valve obstruction is managed. If the mechanical valve thrombosis is obstructive and the patient is in a critical condition with hemodynamic instability, an immediate surgical intervention should be performed.  The thrombolytic treatment is an option for left mechanical valve thrombosis in patients who have high surgical risk and no contraindications and also for right heart valve thrombosis. In non-obstructive thrombosis on the mechanical valve, patients can be asymptomatic, requiring optimization of the anticoagulant treatment. Both obstructive and non-obstructive thrombus formed on the mechanical prosthesis can result in embolic events. If the thrombus persists following anticoagulant treatment, the recommended options include thrombolytic treatment or redo surgery. Pannus can also cause obstruction of the prosthesis for which surgical treatment is the only option. While these clinical scenarios may initially appear to have straightforward solutions in terms of surgery, thrombolysis, or effective anticoagulation, real-world clinical experience often proves more complex. For instance, a patient with some usual comorbidities and non-obstructive mechanical valve thrombosis, experiencing symptoms solely by repeated systemic embolizations, might undergo all three therapeutic options due to the unpredictable nature of MVT. Therefore, treatment indications can intersect both on the time axis and depending on the patient's clinical status and the expertise of the center where he is hospitalized. Moreover, the European and American guidelines show subtle but important differences. The aim of this review was to compare these differences, comment on recent studies and evidence gaps, propose a more pragmatic algorithm combining all current recommendations, and highlight important research directions for this disease that has dominated the cardiovascular landscape for more than five decades, but for which there have been no significant recent changes in management.

Serum ghrelin level is associated with cardiovascular risk score.

UNLABELLED: Ghrelin, a newly discovered bioactive peptide, was originally reported to induce growth hormone release. Recent studies have shown beneficial hemodynamic effects of ghrelin in the cardiovascular system to support the wide distribution of its receptors in cardiovascular tissues. The aim of the study was to determine whether cardiovascular risk factors influence plasma ghrelin levels. METHODS: We evaluated in the Rehabilitation Hospital Cluj-Napoca, Cardiology-Department 88 consecutive subjects, 65 (73.86%) being women, with mean age 61.7 +/- 10.33 years. We assessed the presence of cardiovascular risk factors (obesity, arterial hypertension, diabetes mellitus, metabolic syndrome, smoking and lipid fractions). Plasma ghrelin levels were determined with a commercial ELISA kit (pg/ml). RESULTS: After the evaluation of cardiovascular risk factors, we found no statistically significant difference between ghrelin levels in the patients with vs those without cardiovascular risk factors (p>0.05). A negative correlation was found between ghrelin levels and age, r = -0.32 (p <0.05). Using the HeartScore Internet tool we calculated the cardiovascular risk for each patient according to the risk score system (SCORE) for high cardiovascular risk countries. Statistically, the risk of fatal cardiovascular events in the next 10 years was indirectly correlated with the ghrelin levels in each patient-correlation between ghrelin levels and SCORE system r = -0.25, p=0.015. In conclusion, low serum ghrelin concentrations are associated with an increased global cardiovascular risk, calculated based on the European SCORE scale. However, we could not demonstrate a direct relationship between any of the major risk factors and ghrelin.

Role of Duke treadmill score in the diagnosis of ischemic heart disease in women.

UNLABELLED: Ischemic heart disease is underdiagnosed in women due to atypical symptomatology as well as to the lower specificity of several paraclinical tests, such as exercise stress testing. The aim of the study was to ascertain whether the Duke treadmill score (DTS) could be an efficient parameter in the diagnosis of ischemic heart disease in women. MATERIAL AND METHOD: 105 patients were enrolled in the study, 45.71% women with average age ranged between 20 and 70 years, investigated in the Rehabilitation Hospital, Cardiology-Departament, Cluj-Napoca, Romania. All the patients were clinically assessed as concerns the presence of cardiovascular risk factors, and they underwent electrocardiographic, echocardiographic and treadmill stress tests. DST was calculated according to the formula: exercise time--5 x (ST deviation expressed in mm-4 x Angina Index). RESULTS: DTS was lower in women as compared to men: 2.54 +/- 5.36 vs. 6 +/- 4.69, p=0.0006. 54.28% of the patients were ranged with a low DTS risk category, whereas 45.71% belonged to a moderate and high risk category. DTS was significantly lower in women than in men with high blood pressure (2.03 +/- 4.8 vs. 5.8 +/- 4.28), hypercholesterolemia (1.14 +/- 4.51 vs. 6.24 +/- 4.13), diabetes mellitus (1.83 +/- 3.73 vs. 6.13 +/- 4.8), and obesity (2.42 +/- 5.35 vs. 5.81 +/- 4.64). By analyzing the presence of cardiovascular risk factors only in women, we noticed that only those with high blood pressure (2.03 +/- 4.89 vs. 8.13 +/- 7.85) and hypercholesterolemia (2.31 +/- 4.76 vs. 3.89 +/- 5.95) had a statistically significant low DTS (p<0.05). In conclusion, our research, which showed differences in DTS between women and men, raises concerns about the early diagnosis of ischemic heart disease in women.

Novel cardiovascular risk markers in women with ischaemic heart disease.

The incidence of coronary heart disease in premenopausal women is lower than in men because of their hormonal protection. Angina pectoris occurs in women about 10 years later than in men. However, mortality from ischaemic heart disease remains higher in women than in men. Current studies are focusing on novel cardiovascular risk biomarkers because it seems that traditional cardiovascular risk factors and their assessment scores underestimate the risk in females. Increased plasma levels of these newly established biomarkers of risk have been found to worsen endothelial dysfunction and inflammation, both of which play a key role in the pathogenesis of microvascular angina, which is very common in women. These novel cardiovascular risk markers can be classified into three categories: inflammatory markers, markers of haemostasis, and other biomarkers.

The response of circulating leptin levels to exercise stress testing in subjects diagnosed with metabolic syndrome.

Aim. To assess the plasma leptin responses after exercise stress testing in patients with metabolic syndrome (MS). Material and Methods. We investigated 67 patients with MS, with mean age of 55 ± 7 years. They underwent exercise stress testing on cycloergometer. The lot was divided into three groups: group 1-10 patients with a true positive test, group 2-18 patients with a true negative test, and group 3-39 patients with a false negative test. Leptin levels were measured using the ELISA method. Results. Leptin levels decreased after effort in patients with MS (9.42 ± 11.08 ng/mL before and 8.18 ± 11.5 ng/mL after the exercise stress test, P = 0.0005, r = 0.874). In groups 1 (8.98 ± 9.09 at rest versus 5.98 ± 8.73 ng/mL after the exercise test, P = 0.002) and 3 (8.6 ± 10.53 at rest versus 6.91 ± 9.07 ng/mL, P = 0.0005), lower leptin levels were recorded immediately after exercise testing. Leptin levels were not significantly lower in group 2 before effort (9.49 ± 11.36 ng/ml) and after (9.46 ± 13.81 ng/mL). We found no correlation between leptinemia and exercise stress testing parameters, regardless of group. Conclusion. Our research showed that short-term exercise lowers leptin levels in coronary patients, without a relationship between its parameters and leptin values.

Novel Cardiovascular Risk Markers in Women with Ischaemic Heart Disease : Review Article

The incidence of coronary heart disease in premenopausal women is lower than in men because of their hormonal protection. Angina pectoris occurs in women about 10 years later than in men. However; mortality from ischaemic heart disease remains higher in women than in men. Current studies are focusing on novel cardiovascular risk biomarkers because it seems that traditional cardiovascular risk factors and their assessment scores underestimate the risk in females. Increased plasma levels of these newly established biomarkers of risk have been found to worsen endothelial dysfunction and inflammation; both of which play a key role in the pathogenesis of microvascular angina; which is very common in women. These novel cardiovascular risk markers can be classified into three categories: inflammatory markers; markers of haemostasis; and other biomarkers

Evolution of cardiovascular risk factors and ischemic heart disease in an elderly urban Romanian population over the course of 1 year.

BACKGROUND: Romania has some of the highest mortality figures in the world attributable to ischemic heart disease and stroke among both men and women. OBJECTIVES: To assess the changes in cardiovascular risk factors and ischemic heart disease in a group of subjects over 65 years of age during 1 year in an urban community of Romania. MATERIALS AND METHODS: We studied 515 subjects (264 women and 251 men) with a mean age of 73.41±6.44 years, followed up over the course of 1 year in order to determine the changes that occurred in cardiovascular risk factors and in the evolution of ischemic heart disease. At the beginning and after 1 year, we determined the following parameters: anthropometric measurements, blood pressure, smoking status, lipid profile (total cholesterol, triglycerides, high-density lipid cholesterol, low-density lipid cholesterol), fasting plasma glucose, and the presence of ischemic heart disease. RESULTS: There were no differences between the first and second assessments concerning the incidence of smoking (12.3% versus (vs) 12.5%), obesity (25% vs 26%), diabetes mellitus (19% vs 22.9%), or hypertension (88.2% vs 92.2%). Statistically significant differences were recorded regarding dyslipidemia (40.6% vs 30.3%, P<0.001). Cholesterol median values decreased (204 mg/dL vs 194 mg/dL, P=0.003), while median concentrations of plasma glucose increased (101 mg/dL vs 105 mg/dL, P<0.05). At the same time, we noted a higher incidence of ischemic heart disease (51.65% vs 63%). CONCLUSION: Our data show that in subjects over 65 years of age, cardiovascular disease occurs more often in women, but with certain features that should be taken into account. In addition, we point out the importance of reducing cardiovascular risk factors. However, we should not expect a major decrease or improvement in cardiovascular risk factors with such a short follow-up. Such results will be achieved only through long-term interventions.