Arteriovenous fistula after femoral artery puncture leading to pulmonary edema: the role of ultrasonography.

Local complications of arterial puncture include hematoma, pseudoaneurysm and formation of arteriovenous fistula (AVF). The latter could cause ischemia of the particular extremity or can be hemodynamically significant especially in patients suffering from congestive heart failure. We report a case of femoro-femoral AVF after thin needle arterial puncture for blood drawing. The development of this iatrogenic AVF led to pulmonary edema. The patient stabilized completely after surgical closure of the AVF. The AVF was diagnosed by duplex Doppler ultrasonography and this method was also used for estimation of blood flow through the AVF. We discuss the role of ultrasound AVF diagnostics and the method of flow calculation.

Effect of short-term maximal exercise on BNP plasma levels in healthy individuals.

Many studies documented the relationship between elevated plasma concentrations of natriuretic peptides and cardiovascular diseases, especially heart failure. However, it is still uncertain whether physical exercise leads to a significant release of natriuretic peptide in healthy subjects. The aim of this study was to determine the effect of maximal physical activity on plasma BNP concentrations in healthy individuals within 3 hours after the short-term exercise. BNP plasma concentrations were measured in 15 healthy volunteers before, immediately after as well as 1 hour and 3 hours after bicycle spiroergometry. Maximal workload and exercise capacity were assessed in watts, watt-seconds, metabolic equivalents and VO(2max). Mean BNP plasma levels before, immediately after, 1 hour and 3 hours post-exercise were 19.4+/-2.5; 30.6+/-4.7; 17.9+/-2.5 and 18.7+/-3.1 pg/ml, respectively. The increase of BNP concentrations immediately after exercise was statistically significant (p=0.0017) compared to baseline values. We did not find any correlation between the post-exercise increase of BNP levels and age, body mass index, maximal workload or exercise capacity. In conclusion, short-term maximal physical exercise in healthy individuals led to a fast and transient rise of plasma BNP concentrations, which remained well within normal range and far below the cut-off value for heart failure (100 pg/ml).

[Hypertensive crisis--the present view]. / Hypertenzní krise--soucasný pohled.

Hypertensive crisis is an acute, life-threatening condition associated with a substantial sudden increase in blood pressure. If the increase is accompanied by a damage of brain, cardiovascular system, eye ground or kidneys, it is referred to as an emergent hypertensive situation. In case of complaints comprising chest pain, shortness of breath, headache, epistaxis, weakness, faintness or seizure alone without organ damage, it is referred to as an urgent hypertensive situation. Treatment of emergent situations is parenteral and is conducted under a permanent monitoring in an intensive care unit. Nitrates, urapidil, diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, beta blockers and clonidin are used with respect to organ damage and accompanying diseases. Rate of blood pressure reduction and target values depend on a type of organ damages. An escalation of per oral medication is used in the treatment of urgent situations. Parenteral medication is indicated only in case of failure of this approach.

[Will the therapy of chronic heart failure be guided by plasma levels of natriuretic peptides?]. / Budeme lécit srdecní selhání podle plazmatické koncentrace natriuretických peptidu?

Natriuretic peptides, especially BNP and NT-proBNP became useful tool for both, the diagnostics and the estimation of prognosis in chronic heart failure. As the plasma levels of natriuretic peptides copy changes in clinical status, an attractive hypothesis was formed saying that BNP/NT-proBNP guided therapy could have better clinical outcomes than therapy guided by patients' clinical status (symptoms). In past few years this hypothesis was tested in several randomized controlled clinical trials (STARS-BNP, TIME-CHF, PRIMA). However, results of these trials are very controversial. There are preliminary results of clinical trial OPTIMA referred in this paper, too. This one-centre study was performed at the authors' institution. Altogether 52 patients with chronic heart failure were randomized to one of the above mentioned treatment strategies. The rate of cardiovascular events was lower in the patients in whom the treatment was guided by BNP values compared to the patients in whom the treatment was guided by their clinical status. However, the difference was not statistically significant.

Natriuretic peptides - physiology, pathophysiology and clinical use in heart failure.

The natriuretic peptides - atrial, brain and C-type - were discovered during the last twenty years. Their effects on cardiovascular, renal, cerebral and other tissues through guanylyl cyclase were uncovered. Over the past decade natriuretic peptides (NPs) became a very useful tool in the management of heart failure patients. Results of many clinical trials have shown that BNP and NT-proBNP are helpful for diagnosis of heart failure. They are also independent markers of prognosis not only in heart failure patients but also in patients with other cardiovascular diseases. Recently published data document the utility of NPs in guiding treatment of heart failure patients. In this article, we focus on basic biochemical and physiological characteristics of NPs as well as on their significance in management of heart failure patients. Some limitations and pitfalls of NPs levels interpretation in diagnosing heart failure are also discussed.

Impact of essential hypertension and primary aldosteronism on plasma brain natriuretic peptide concentration.

INTRODUCTION: Brain natriuretic peptide (BNP) has important role in the diagnosis and management of heart failure. Data on the impact of blood pressure (BP) on BNP are controversial. In primary aldosteronism (PA), BNP production can be affected by both hypertension and specific endocrine mechanisms. This study was aimed at investigating the impact of hypertension and hyperaldosteronism on plasma BNP levels. METHODS: Plasma BNP concentration, casual and 24-h BP and echocardiographic indices were assessed in 40 patients with moderate to severe essential hypertension (EH), 40 BP-matched patients with PA, and 40 age- and sex-matched healthy controls. RESULTS: BNP levels in PA and EH groups did not differ significantly and were higher compared with those in controls [median and interquartile range 26 (13-48) pg/ml, p = 0.01, and 23 (9-32) pg/ml, n.s., vs 14 (6-26) pg/ml in controls]. Remarkably elevated BNP was observed only in three PA and two EH patients, all having significant left ventricular (LV) hypertrophy. BNP levels in PA and EH groups correlated weakly with casual and 24-h BP, interventricular septal thickness and LV mass index (LVMI). Diastolic BP and LVMI were identified as the strongest independent determinants of BNP (p = 0.002 and p = 0.01, respectively). CONCLUSIONS: Both PA and EH patients had modest and mutually comparable elevation of BNP, which was independently determined by diastolic BP and LVMI. Both subtypes of PA (aldosterone-producing adenoma and bilateral adrenal hyperplasia) had similar effect on BNP production. Specific impact of hyperaldosteronism on BNP was not confirmed.

Regression of acromegalic left ventricular hypertrophy after lanreotide (a slow-release somatostatin analog).

A group of 13 acromegalic patients was treated with lanreotide for 18 months and followed-up echocardiographically; these patients showed significant correlations between the decrease of both growth hormone (GH) and insulin-like growth factor-1 and the decrease of left ventricular mass index. This documents a regression of left ventricular hypertrophy in acromegaly after lanreotide treatment, the degree of which is dependent on the magnitude of the decrease of GH and insulin-like growth factor-1 serum levels.

Autonomic modulation of ventricular rate in atrial fibrillation.

This study investigated the changes in R-R interval in 23 patients (11 men and 12 women; mean age 61 yr) with persistent atrial fibrillation in response to several provocative maneuvers including active postural change, Valsalva maneuver, handgrip, and rhythm-controlled respiration. Averaged R-R intervals were shortened immediately after postural change (from 797 +/- 35 ms supine to 677 +/- 27 ms standing; P < 0.01) and recovered to the 90% level within 100 s. During Valsalva strain and handgrip, mean R-R intervals were significantly shortened (from 737 +/- 37 ms sitting to 697 +/- 38 ms in Valsalva and from 773 +/- 68 ms sitting to 701 +/- 58 ms in handgrip; both P < 0.01). During rhythm-controlled respiration, only two cases (10.5%) showed power peaks in spectrograms of moving-window-averaged R-R intervals at the frequency corresponding to respiration rhythm. The ventricular response to atrial fibrillation is influenced by an increase in sympathetic tone and a decrease in parasympathetic tone but is not necessarily influenced by the increase in parasympathetic dominance. These results suggest that even in atrial fibrillation patients, the autonomic nervous system modulates the ventricular rate via the atrioventricular node and atrial tissue.

Changes of QT intervals associated with postural change in patients with chronic atrial fibrillation.

Although different computerized systems have been developed to localize specific patterns in electrocardiographic (ECG) signals, it is still difficult to detect T waves and measure QT intervals during atrial fibrillation. This article demonstrates the use of an auto-correlation (ECG) based system that was used to investigate the dynamicity of QT intervals related to active postural change in patients with chronic atrial fibrillation. Twenty patients (9 male, mean age 63 years) with chronic atrial fibrillation (8 idiopathic, 12 organic heart disease) were examined. Seventeen of these patients were on digoxin, but patients with other conditions potentially affecting the autonomic nervous system were not included. A 3-channel ECG was recorded digitally during active postural change from supine to standing. Data were first analyzed by the Burdick Altair system and subsequently processed using an in-house software package evaluating auto-correlations of ECG signals. An ECG channel with suitable repolarization patterns was found in 15 patients. The mean QT interval of 409.8 +/- 11.1 ms (mean +/- SE) recorded during supine position shortened to 401.9 +/- 9.89 ms during the first minute of active standing (P < 0.05) and to 394.8 +/- 10.0 ms during the second minute of active standing (P < 0.005). It did not further change during the subsequent minutes of active standing. The study shows that automatic detection of QT intervals during atrial fibrillation is possible. Although the effect of position change of the heart cannot be completely excluded, the study suggests that QT interval is changed directly by autonomic nervous mechanisms rather than indirectly via the mean heart rate.

Heart disease in acromegaly.

Evidence has accumulated regarding acromegalic heart muscle disease which existence now appears to be unequivocal. We took an advantage of a large group of acromegalic patients being followed-up at our institution for a long time and have studied pattern, nature and reversibility of acromegalic heart disease. Its major manifestation is cardiac hypertrophy expressed especially as left ventricular hypertrophy. The cardiac hypertrophy is slowly reversible after normalization of plasma growth hormone levels due to successful treatment. This we have first suggested on the basis of a retrospective analysis of clinical and echocardiographic data in 78 patients with acromegaly and subsequently confirmed by a 10-year prospective follow-up of the original patient cohort. We have also showed that effective treatment of acromegaly with a new slow release somatostatine analogue lanreotide leads to regression of cardiac hypertrophy.

Long-term echocardiographic follow-up of acromegalic heart disease.

Heart muscle disease in acromegaly manifests usually as cardiac hypertrophy. Based on a retrospective analysis, it was suggested that cardiac hypertrophy is slowly reversible after normalization of plasma growth hormone levels. The reversibility of acromegalic heart muscle disease during and after treatment of acromegaly was studied prospectively. A cohort of 78 patients was examined echocardiographically in 1981, and 38 survivors of this group were reexamined 10 years later. Patients were classified according to original hormonal activity in 1981, and change in hormonal activity during follow-up into the following 4 groups: group I--hormonally inactive for entire follow-up (n = 10); group II--hormonally active for entire follow-up (n = 11); group III--initially hormonally inactive with later resurgence (n = 6); and group IV--initially hormonally active with later normalization of growth hormone levels (n = 11). No significant echocardiographic changes occurred during follow-up in group I. Left ventricular posterior wall and septal diastolic thickness, and left ventricular mass increased significantly (all p < 0.05) in group II. Left ventricular posterior wall thickness, mass and diastolic volume increased significantly (p < 0.05, < 0.01 and < 0.001, respectively) in group III. On the contrary, there were significant decreases in left ventricular mass, and both diastolic and systolic left ventricular volumes (p < 0.01, < 0.05 and < 0.05, respectively) in group IV. It is concluded that both hypertrophy and dilatation of the left ventricle in acromegaly are slowly reversible after successful treatment. On the contrary, continuing or relapsed hyperproduction of growth hormone causes further deterioration of acromegalic heart disease.

[Stress echocardiography in the selection of patients for coronarography]. / Prínos zátezové echokardiografie pri výberu nemocných ke koronarografii.

Exercise echocardiography has in recent years become the best non-invasive method for detection of IHD. The authors made an investigation with the objective to test the feasibility of exercise echocardiography, under our technically imperfect but generally available conditions, for the selection of patients for coronarography. In 44 consecutive patients (30 men, 14 women, mean age 50 years) the authors used before planned coronarography exercise echocardiography and 24-hour monitoring of ECG according to Holter with evaluation of ST segments. The results of all three non-invasive methods were compared with the coronarographic findings. The criterium of positivity of coronarographies was 75% stenosis. Such a stenosis is an unequivocal indication for cardiosurgery or percutaneous angioplasty. On comparison of results of non-invasive examination methods with coronarographic findings the best indicators as regards reliability were obtained with exercise echocardiography. Its sensitivity was 71%, specificity 69%, positive predictive value 77% and negative predictive value 61%. The sensitivity of exercise echocardiography increased, depending on the number of affected arteries (50, 71 and 100%). On isolated evaluation of findings in individual main coronary arteries the sensitivity was highest in the area supplied from the ramus interventricularis anterior (67%), the specificity was 77%. For the ramus circumflexus the sensitivity was 50% and the specificity 96%. For the right coronary artery the sensitivity was 25% and the specificity 96%. The sensitivity of exercise ECG (44%) was even lower than Holter sensitivity (57%). The specificity, on the other hand, was lower in Holter (47%) than in exercise ECG (61%). Electrocardiographic methods were not, contrary to echocardiography, usable for evaluation fo the extent of damage.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of creatine phosphate (Neoton) in acute myocardial infarct (a prospective multicenter pilot study]. / Ucinek kreatinfosfátu (Neoton) u akutního srdecního infarktu (pilotní multicentrická prospektivní studie).

The authors investigated in a group of 106 patients with a first myocardial infarction treated by thrombolysis the effect of i.v. administration of creatine phosphate (a new drug with cardioprotective action--Neoton Alfa Schiapparelli Wassermann Co). In the course of treatment electrocardiographic changes were recorded and the presence of arrhythmias examined by the Holter technique. The Neoton group displayed a statistically insignificant but nevertheless obvious trend of electrocardiographically less serious forms of infarction and a lower incidence of infarctions, as compared with the control group.

Heart in adrenal diseases.

The paper reviews the hitherto rather scarce literature concerned with cardiac changes in phaeochromocytoma, primary hyperaldosteronism and Cushing syndrome, and presents the authors' own echocardiographic findings in these diseases. In phaeochromocytoma they found a slight thickening of the interventricular septum which, however, did not fulfil the criteria of asymmetric left ventricular hypertrophy. Also other parameters showed higher values attesting to an increased left ventricular mass, however, without exceeding normal limits. Focal disturbances of left ventricular kinetics and the decrease in LV systolic function were non significant. The picture of obstructive hypertrophic cardiomyopathy, frequently mentioned in the literature, was observed only once, giving grounds to the suspicion that it is only a nonspecific manifestation of the hypercontractile state of the myocardium. In primary hyperaldosteronism only slight posterior LV wall thickening and an increase in the LV mass index were found, compared to control group. No significant changes were found in Cushing syndrome besides a tendency to concentric LV hypertrophy. Echocardiographic changes observed in all three affections disappeared after successful surgical or drug treatment.