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.

The Role of Dyslipidemia in Atherogenesis in Peritoneal Dialysis Patients.

Background: To evaluate atherosclerotic changes in carotid arteries (CCA) in uremic patients before and after 18 months of continuous ambulatory peritoneal dialysis (CAPD) treatment, and to evaluate the impact of dyslipidemia and CAPD treatment on vascular remodeling. Materials and Methods: We conducted a longitudinal, prospective study during 2020 and 2021 at the Clinic for Nephrology, Clinical Center University of Sarajevo. Patients with end-stage renal disease were included and were followed during 18 months of CAPD treatment. All patients were treated using commercially prepared biocompatible balanced dialysis solutions. Carotid intima-media thickness (IMT) and atherosclerotic plaques on the common carotid artery (CCA) were measured by echotomography. Results: A total of 50 patients were included and were followed during 18 months of CAPD treatment. Lipid values in the serum of patients with CAPD were significantly lower after 18 months of CAPD treatment compared to the values before treatment, while the value of high-density lipoprotein (HDL) was significantly increased after 18 months of CAPD treatment. The values of IMT and the diameter of the CCA compared to the basal values were significantly lower (P < 0.001). Conclusion: We demonstrated significantly lower lipid values and higher HDL levels following CAPD treatment. Correct selection of the targeted pharmacological intervention can substantially impact the regression of vascular changes in patients on peritoneal dialysis.

Lipid status and carotid intima-media thickness in patients with end-stage renal disease.

Aim To assess morphological characteristics of carotid blood vessels in uremic patients before to the initiation of the dialysis treatment, and corelate data with various dialysis therapy modules. Methods The study included 30 patients with end-stage renal disease (ERDS) prior to commencing dialysis, 30 patients treated with haemodialysis and 30 patients treated with continuous ambulatory peritoneal dialysis. The control group consisted of 15 subjects with normal kidney function (eGFR>60ml/min). Carotid intima-media thickness (CIMT), as well as lipid status values (cholesterol, triglycerides, low-density lipoprotein (LDL), high-density lipoprotein (HDL), apolipoprotein A, apolipoprotein B) were evaluated. Results The significant difference in CIMT was detected between the control and haemodialysis groups (p<0.001), and between the control and the peritoneal dialysis group (p=0.004). In patients in the predialysis group, CIMT was influenced by cholesterol (p=0.013), HDL (p=0.044), LDL (p=0.001) and ApoB (p=0.042) values. A significant difference in CIMT was proved between the haemodialysis and predialysis group of patients (p<0.001). The only variable from the patient's lipometabolic profile significantly associated with the change in IMT in uremic patients was HDL. A significant difference was found in the average value for systolic blood pressure (p<0.001) and diastolic blood pressure (p=0.018) in patients before starting the dialysis treatment compared to patients treated with other dialysis methods. Conclusion Patients on haemodialysis treatment had a significantly greater CIMT, which is in relation with a higher cardiovascular risk.

The Effectiveness of Eplerenone vs Spironolactone on Left Ventricular Systolic Function, Hospitalization and Cardiovascular Death in Patients With Chronic Heart Failure-HFrEF.

Background: Heart failure remains one of the most prevalent clinical syndromes associated with significant morbidity and mortality. According to current guidelines, the prescription of a MRA is recommended to reduce the risk of HF hospitalization and death in all patients with symptomatic heart failure and no contraindications for this therapy. Objective: The aim of our study was to determine the efficacy of eplerenone vs. spironolactone on left ventricular systolic function by measuring left ventricle ejection fraction (LVEF) in patients with chronic heart failure, especially their effect on preventing hospitalization, reducing mortality, and improving clinical status among patients with chronic HF. Methods: From June 2021 to June 2022, the study was a randomized, prospective clinical trial single blind study. A total of 142 patients of chronic heart failure with reduced ejection fraction were selected by random sampling. Each patient was randomly allocated into either of the two groups and was continued receiving treatment with either spironolactone (Spiron-HF group) or eplerenone (Epler-HF group). Patients in Epler-HF group were compared with an arm of the same size and matched by age and gender patients in Spiron-HF group for management of chronic HFrEF. Each patient was evaluated clinically, biochemically, and echocardiographically at the beginning of treatment (baseline) after 6 months and at the end of 12th month. Echocardiography was performed to find out change in left ventricular systolic function. Results: After 12 months of treatment, significant improvement of left ventricular ejection fraction was observed in eplerenone treated arm (37.9 ± 3.8 ± 4.6 in Spiron-HF group versus 40.1 ± 5.7 in Epler-HF group; P < 0.05). A significant reduction in left ventricular end-systolic volume (6.3 ± 2.5ml in Spiron-HF versus 17.8± 4.4ml in Epler-HF group; P < 0.05) and left ventricular systolic diameter volume (2.7 ± 0.5ml in Spiron-HF versus 6.7 ± 0.2ml in Epler-HF group; P < 0.05), occurred after 12 months of treatment. Left ventricular global longitudinal strain (LV GLS) was significantly improved in Epler-HF group compared with Spiron-HF group (0.6 ± 0.4 versus 3.4 ± 0.9; P < 0.05). There were no significant differences observed in reduction of left ventricular end-diastolic volume (2.2 ± 0.5 ml versus 4.7 ± 1.1ml; P =0.103) and left ventricular diastolic diameter (1.2 ± 0.6 versus 1.7 ± 0.3; P=0.082) in both arms. The effects of both MRA agents spironolactone and eplerenone on the primary composite outcome, each of the individual mortality and hospital admission outcomes are shown in Figure 1 and 2. Patients of the Epler-HF group showed statistically significant lower cardiovascular mortality (HR 0.53; 95% CI 0.34-0.82; p= 0.007) and all-cause mortality (HR 0.64; 95% CI 0.44-0.93; p= 0.022) than patients of the Spiron-HF group. The statistical analysis did not show a statistically significant difference between Epler -HF and Spiron-HF study groups regarding the risk of the primary composite outcome; cardiovascular death or hospitalization due to HF (Hazard Ratio (HR) eplerenone vs. spironolactone = 0.95; 95% Confidence Interval (CI) 0.73- 1.27; p= 0.675). Conclusion: Our study has demonstrated favorable effects of eplerenone on cardiac remodeling parameters and reduction of cardiovascular mortality and all-cause mortality compared with spironolactone in the treatment of HFrEF. The ability of eplerenone to effectively block the mineralocorticoid receptor while minimizing side effects and a significant reduction in the risk of hospitalization and cardiovascular death confirms its key role in the treatment of patients with chronic HFrEF.

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.

Relation between thyroid hormonal status, neutrophillymphocyte ratio and left ventricular systolic function in patients with acute coronary syndrome.

Aim To examine a relation of thyroid function, neutrophil-lymphocyte ratio (NLR) with left ventricular function measured through the left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction treated with percutaneous coronary intervention (PCI). Methods This prospective research involved 160 consecutive patients with acute myocardial infarction. Patients were divided into those with normal thyroid hormone status (n=80) and those with hypothyroidism (newly diagnosed) (n=80). Inflammatory parameters and parameters of hormonal status were taken for analysis: thyroid-stimulating hormone (TSH), thyroxine (T4), triiodothyronine (T3), free thyroxine (FT4), and free triiodothyronine (FT3). All patients underwent transthoracic echocardiographic examination (TTE) five days upon admission, and left ventricular ejection fraction (LVEF) was analysed. Results Significant difference between the two groups was verified in values of T3, T4, erythrocytes, haemoglobin, haematocrit, neutrophil, lymphocytes, NLR, C-reactive protein (CRP) and sedimentation rate. Patients with euthyroidism had a higher frequency of coronary single-vessel disease (p=0.035) and a significantly lower frequency of triple vessel disease (p=0.046), as well as a higher median value of LVEF (p=0.003). There was a significant correlation between LVEF with haemoglobin values (p=0.002), NLR (p=0.001), and CRP (p=001). Conclusion The altered status of the thyroid gland in acute myocardial infarction is associated with the severity of the coronary blood vessel lesion, LVEF and correlates with inflammatory response.

Pericardial Effusion in Postcoronavirus Disease Patients with Preserved Ejection Fraction of the Left Ventricle and Normal Values of N-Terminal-Pro B-Type Natriuretic Peptide-Link with C-Reactive Protein and D-Dimer.

Aim: The aim of this study was to link the values of D-dimer and C-reactive protein (CRP), with the occurrence of pericardial effusion in patients who had coronavirus disease 2019 (COVID-19) and have preserved systolic function of the left ventricle (LV). Methods: This was a prospective study and included 146 patients who underwent echocardiographic examination 30 days after the acute phase of COVID-19. Patients who were placed on mechanical ventilation, patients who had pulmonary thromboembolism or acute coronary syndrome during the acute period of the disease, patients who had an ejection fraction of the LV <50%, patients who were diagnosed with pericarditis during acute illness or clinical signs of heart failure (or had elevated N-terminal-pro hormone B-type natriuretic peptide value), with verified renal or hepatic dysfunction were excluded from the study, including patients with diabetes mellitus Type 1, patients with cancer, connective tissue disease, or pregnant women. The existence of cardiovascular risk factors (hypertension, diabetes mellitus Type 2, and hyperlipidemia), the presence of previous ischemic heart disease, maximum values of D-dimer, and CRP (during the first 15 days of the disease) was taken into the analysis. Results: Effusion was verified around the right atrium (RA) in 104 patients (3.85 ± 1.75 mm), in 135 patients next to the free wall of the right ventricle (RV) (5.24 ± 2.29 mm), in front of the apex of the LV in 27 patients (2.44 ± 0.97 mm), next to the lateral wall of LV in 35 patients (4.43 ± 3.21 mm), and behind the posterior wall of LV in 30 patients (2.83 ± 1.62 mm). Mean CRP values during the acute phase of the disease were 43.0 mg/L (8.6-76.2 mg/L), whereas D-dimer mean value was 880.00 µg/L (467.00 -2000.00 µg/L). CRP values correlated with effusion next to the free wall of RV (rho = 0.202; P = 0.018). The D dimer correlated with effusion around RA (rho = 0.308; P = 0.0001). Conclusion: The clinical picture of the post-COVID patients could be explained by the appearance of pericardial effusion. D-dimer value correlates with the occurrence of effusion around RA, whereas CRP value correlates with effusion next to the free wall of RV.

Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP).

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Much of these diseases burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that with respect to low density lipoprotein cholesterol (LDL-C), "lower is better for longer", and the recent data have strongly emphasized the need of also "the earlier the better". In addition to statins, which have been available for several decades, the availability of ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) are additional very effective approach to LLT, especially for those at very high and extremely high cardiovascular risk. LLT is initiated as a response to an individual's calculated risk of future ASCVD and is intensified over time in order to meet treatment goals. However, in real-life clinical practice goals are not met in a substantial proportion of patients. This Position Paper complements existing guidelines on the management of lipids in patients following ACS. Bearing in mind the very high risk of further events in ACS, we propose practical solutions focusing on immediate combination therapy in strict clinical scenarios, to improve access and adherence to LLT in these patients. We also define an 'Extremely High Risk' group of individuals following ACS, completing the attempt made in the recent European guidelines, and suggest mechanisms to urgently address lipid-medicated cardiovascular risk in these patients.

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.

The serum triglyceride to high-density lipoprotein (HDL) ratio in patients with acute coronary syndrome with and without renal dysfunction.

Aim To assess triglyceride - to high-density lipoprotein cholesterol (TG/HDL)-C ratio in patients with acute coronary syndrome (ACS) and to verify its association with renal dysfunction. Methods A cross sectional study included 85 ACS patients divided in two groups with (ACS - RD) and without (ACS-nRD) presence of renal dysfunction, and 35 healthy subjects. Blood pressure, blood glucose, C-reactive protein, urea, creatinine, eGFR and serum lipids levels (total cholesterol, triglycerides, LDL-C, HDL-C) was measured in all participants. Based on the values of the measured lipid fractions TG/HDLc ratio was calculated. Results Patients in ACS group had significantly lower HDL-C level (p<0.0005) but significantly higher TG level (p=0.046) and TG/HDL-C ratio (p<0.0005) than controls. There was a significant increase (p<0.0005) in TG/HDL-C ratio in ACS-RD group compared to ACS-nRD group. The ACS-RD group had significantly higher level of TG (p=0.001), serum urea (p=0.02) and creatinine (p<0.0005) compared to the ACS-nRD group. With a cut-off level of 1.135 TG/HDL-C ratio had a sensitivity of 77.6% and a specificity of 62.9% in distinguishing between ACS patients and healthy subjects. With cut-off value of 1.905 TG/HDL-C ratio had a sensitivity of 75.9% and a specificity of 78.6% in distinguishing between ACS patients with and without renal dysfunction. Conclusion This study confirms the reliability of the TG/HDLC ratio as a simple, low cost and useful marker in distinguishing between patients with ACS and healthy subjects and ACS patients with and without renal dysfunction.

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.

Significance of Nitric Oxyde Saliva Concentration of the Patients with Renal Failure on Hemodialysis.

INTRODUCTION: An increase in nitric oxide (NO) synthesis concentration could help alleviate some pathological changes directly related to uremia. AIM: To investigate the concentration of nitric oxide in saliva of patients with terminal stage of chronic renal failure on hemodialysis and to investigate the effect of hemodialysis on concentration of nitric oxide in saliva of the patients with terminal stage of chronic renal failure on hemodialysis. MATERIAL AND METHODS: The study had a prospective character and included 60 respondents of both sexes, at age between 20 and 60 years. The control group included 30 healthy volunteers of both sexes (15 men and 15 women) of the same age, who were based on subjective and objective health status without any manifestations of pathophysiological changes. The group of patients with terminal stage of chronic renal failure on hemodialysis involved 30 patients of both sexes (15 men and 15 women). Inclusion criteria: hemodialysis duration more than 6 months and age between 20 and 60 years. RESULTS: The amount of non-stimulated saliva collected during 15 minutes in patients with chronic renal failure was lower by 31.3% compared to the control group of healthy subjects (p<0.0001). Concentration of NO in saliva in patients with chronic renal failure was higher by 121% than in the control group (p<0.001). Concentration of NO in saliva in patients with chronic renal failure after hemodialysis was 121% lower than in the same subjects prior to hemodialysis (p<0.001). A statistically significant negative correlation (r=-0.381, p<0.05) was found between the hemodialysis duration in months and the level of NO in saliva of the patients with chronic renal failure prior to hemodialysis. There was no statistically significant correlation (r=-0.167, NS) between the hemodialysis duration in months and NO levels in saliva of the patients with chronic renal failure after hemodialysis treatment. CONCLUSION: Concentration of NO in saliva of the patients on hemodialysis was statistically significantly higher in relation to NO concentration in the saliva of healthy subjects and after hemodialysis was statistically significantly lower in relation to NO values prior to hemodialysis. Monitoring of changes in NO concentration dynamics in saliva of hemodialysis patients will probably be helpful in monitoring hemodialysis efficacy.

Impact of Different Types of Statins on Clinical Outcomes in Patients Hospitalized for Ischemic Heart Failure.

INTRODUCTION: The effect of statins on risk of heart failure (HF) hospitalization and lethal outcome remains dubious. AIM: To investigate whether statin therapy improves clinical outcomes in patients hospitalized for ischemic heart failure (HF), to compare the efficacy of lipophilic and hydrophilic statins and to investigate which statin subtype provides better survival and other outcome benefits. MATERIAL AND METHODS: Total amount of 155 patients in the study were admitted to the Clinic for Cardiology, Rheumatology and Vascular diseases in Clinical Center University of Sarajevo in the period from January 2014- December 2017. Inclusion criteria was HF caused by ischemic coronary artery disease upon admission. For each patient the following data were obtained: gender, age, comorbidities and medications on discharge. New York Heart Association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. The patients were followed for a period of two years. Outcome points were: rehospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. RESULTS: Overall, 58.9% of HF patients received statin therapy, with 33.9% patients receiving atorvastatin and 25.0% rosuvastatin therapy. The most frequent rehospitalization was in patients without statin therapy (66.7%), followed by patients on rosuvastatin (64.1%), and atorvastatin (13.2%), with statistically significant difference p = 0.001 between the groups. Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy, 12.8% in patients on rosuvastatin therapy and 3.8% in patients on atorvastatin therapy (p = 0.004). CONCLUSION: Lipophilic statin therapy is associated with substantially better long-term outcomes in patients with HF.

Serum Aldosterone as Predictor of Progression of Coronary Heart Disease in Patients Without Signs of Heart Failure After Acute Myocardial Infarction.

INTRODUCTION: In patients with acute myocardial infarction (AMI) early risk assessment of development of complications is of great importance. It is proven that aldosterone level has a major role in progression of cardiovascular pathology. AIM: Determination of influence of aldosterone plasma level in the progression of heart disease in patients without signs of heart failure after AMI. MATERIAL AND METHODS: Research included 207 patients, hospitalized in the acute phase of myocardial infarction, and who were divided into two groups: 127 patients with no clinical signs of heart failure and 60 patients with heart failure. RESULTS: The serum aldosterone concentration was 73.4% higher in the group of decompensated patients, 128 pg/mL (75.4-236 pg/mL) in decompensated and 73.7 pg/mL (42.7 -115.25 pg/mL) in compensated. In the group of compensated patients, changes in aldosterone levels showed a statistically significant effect on the incidence of post-infarction angina (p=0.0001) as well as reinfarction (p=0.009). There is a connection between changes in aldosterone plasma level and positive stress test (p=0.012). CONCLUSION: In patients with AMI, elevated serum aldosterone level can be prognostic factor of the progression of coronary heart disease, development of heart failure, as well of development of post-infarction angina, myocardial reinfarction and pathological finding on the stress test.

Prognostic indicators of adverse renal outcome and death in acute kidney injury hospital survivors.

INTRODUCTION: Data regarding prognostic factors of post-discharge mortality and adverse renal function outcome in acute kidney injury (AKI) hospital survivors are scarce and controversial. OBJECTIVES: We aimed to identify predictors of post-discharge mortality and adverse renal function outcome in AKI hospital survivors. PATIENTS AND METHODS: The study group consisted of 84 AKI hospital survivors admitted to the tertiary medical center during 2-year period. Baseline clinical parameters, with renal outcome 3 months after discharge and 6-month mortality were evaluated. According survival and renal function outcome, patients were divided into two groups. RESULTS: Patients who did not recover renal function were statistically significantly older (P < 0.007) with higher Charlson comorbidity index (CCI) score (P < 0.000) and more likely to have anuria and oliguria (P = 0.008) compared to those with recovery. Deceased AKI patients were statistically significantly older (P < 0.000), with higher CCI score (P < 0.000), greater prevalence of sepsis (P =0.004), higher levels of C-reactive protein (CRP) (P < 0.017) and ferritin (P < 0.051) and lower concentrations of albumin (P<0.01) compared to survivors. By multivariate analysis, independent predictors of adverse renal outcome were female gender (P =0.033), increasing CCI (P =0.000), presence of pre-existing chronic kidney disease (P =0.000) and diabetes mellitus (P =0.019) as well as acute decompensated heart failure (ADHF) (P =0.032), while protective factor for renal function outcome was higher urine output (P =0.009). Independent predictors of post-discharge mortality were female gender (P =0.04), higher CCI score (P =0.001) and sepsis (P =0.034). CONCLUSION: Female AKI hospital survivors with increasing burden of comorbidities, diagnosis of sepsis and ADHF seem to be at high-risk for poor post-discharge outcome.

Renal Function Outcome Prognosis in Septic and Non-septic Acute Kidney Injury Patients.

AIM: The objective of this study was to evaluate prognostic impact of clinical factors on outcome of renal function in septic and non-septic acute kidney injury (AKI) patients. METHODS: The prospective, observational, clinical study was performed at Nephrology Clinic and Clinic for Infectious Diseases, University Clinical Centre Sarajevo. One hundred patients with diagnosis of AKI were enrolled in the study, and divided into two groups: septic and non-septic AKI patients. Clinical parameters included causes and type of AKI, pre-existing comorbidities and different treatment modalities. Patients were followed up until discharge or death. Renal function outcome was defined by creatinine clearance values at discharge. RESULTS: Septic AKI patients had significantly longer hospital stay (p=0.03), significantly worse renal function outcome (p<0.001), and higher burden of comorbidities (70.6% vs. 60.6%), compared to non-septic patients. Septic AKI patients were almost three times less likely to receive renal replacement therapy (8.8% vs. 24.4%) and they had significant delay in initiation of dialysis (p=0.03). By multivariate analysis, sepsis (95% CI 0.128-0.967, p=0.043) and hypertension (95% CI 0.114-0.788, p=0.015) were independent predictors of adverse renal function outcome in AKI patients. Postrenal type of AKI was independent predictor of renal function recovery in non-septic AKI patients (95% CI 1.174-92.264, p=0.035), while Failure, as third class of AKI, was independent predictor of non-recovered renal function only in septic AKI patients (95% CI 0.026 to 0.868, p=0.034). CONCLUSION: Septic AKI patients are clinically distinct compared to non-septic AKI patients with different prognostic factors and poorer renal function outcome.

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.