Significance of Beta-Blocker in Patients with Hypertensive Left Ventricular Hypertrophy and Myocardial Ischemia.

BACKGROUND: Arterial Hypertension (HTN) is a key risk factor for left ventricular hypertrophy (LVH) and a cause of ischemic heart disease (IHD). The association between myocardial ischemia and HTN LVH is strong because myocardial ischemia can occur in HTN LVH even in the absence of significant stenoses of epicardial coronary arteries. OBJECTIVE: To analyze pathophysiological characteristics/co-morbidities precipitating myocardial ischemia in patients with HTN LVH and provide a rationale for recommending beta-blockers (BBs) to prevent/treat ischemia in LVH. METHODS: We searched PubMed, SCOPUS, PubMed, Elsevier, Springer Verlag, and Google Scholar for review articles and guidelines on hypertension from 01/01/2000 until 01/05/2022. The search was limited to publications written in English. RESULTS: HTN LVH worsens ischemia in coronary artery disease (CAD) patients. Even without obstructive CAD, several pathophysiological mechanisms in HTN LVH can lead to myocardial ischemia. In the same guidelines that recommend BBs for patients with HTN and CAD, we could not find a single recommendation for BBs in patients with HTN LVH but without proven CAD. There are several reasons for the proposal of using some BBs to control ischemia in patients with HTN and LVH (even in the absence of obstructive CAD). CONCLUSION: Some BBs ought to be considered to prevent/treat ischemia in patients with HTN LVH (even in the absence of obstructive CAD). Furthermore, LVH and ischemic events are important causes of ventricular tachycardia, ventricular fibrillation, and sudden cardiac death; these events are another reason for recommending certain BBs for HTN LVH.

The Association between Galectin-3 and hs-CRP and the Clinical Outcome after Non-ST-Elevation Myocardial Infarction with Preexisting Atrial Fibrillation.

Increased galectin-3 plasma concentration has been linked to an unfavorable outcome in patients with heart failure or atrial fibrillation (AF). There are no published data about the prognostic utility of galectin-3 and high-sensitivity C-reactive protein (hs-CRP) for long-term clinical outcome in the Non-ST elevation acute myocardial infarction (NSTEMI) patients with preexisting AF. Thirty-two patients with the first acute NSTEMI and preexisting AF and 22 patients without preexisting AF, were prospectively followed for fifteen months. Patients with AF had significantly higher galectin-3 plasma levels (p < 0.05) and hs-CRP concentration (p < 0.01), compared with patients without AF. Galectin-3 plasma concentration was not a significant covariate of the composite outcomes (p = 0.913). Patients with high hs-CRP (above 4.55 mg/L) showed 2.5 times increased risk (p < 0.05) of the composite outcome occurrence (p < 0.05). Besides, three-vessel coronary artery disease, creatinine serum level, and creatinine clearance were significant covariates (p < 0.05; p < 0.05; p < 0.01) of the composite outcome, respectively. Creatinine clearance, solely, has been shown to be an independent predictor of unfavorable prognosis after a 15-month follow-up. Galectin-3 and hs-CRP plasma levels were elevated in NSTEMI patients with AF, but with differential predictive value for an unfavorable clinical outcome. Only hs-CRP was associated with increased risk of composite outcome occurrence.

Translation and Validation of the Serbian Version of the Skindex-29 Instrument for Measuring Impact of Skin Disease on Quality of Life.

The Skindex-29 instrument, which is intended for measuring the influence of skin diseases on quality of life, was developed and validated in several languages. However, a Serbian translation of the instrument is not available. The aim of this study was to translate the Skindex-29 from English to Serbian, to make necessary cultural adaptations, and to test its psychometric properties in a sample of outpatients with various skin diseases. The Skindex-29 was translated and adapted according to internationally accepted guidelines and then tested on a sample of Serbian outpatients with various skin diseases. Internal consistency was checked through calculation of Cronbach's alpha and Interclass Correlation Coefficient for the instrument's domains. The criterion validity of the translation was tested by correlating scores of domains with scores on the Serbian version of Dermatological Life Quality Index (DLQI).Validity of the construct was tested through comparison of the domains scores in groups of patients with different skin diseases. Fifty-three patients (18.6%) suffered from acne vulgaris, 48 (16.8%) from verrucae vulgares, 40 (14.0%) from psoriasis, 34 (11.9%) from an undetermined type of mild dermatitis, 20 (7.0%) from venous ulcers, 19 (6.7%) from eczema, and 71 (24.9%) from other skin diseases. The Serbian translation of Skindex-29 showed good internal consistency: Cronbach's alpha for Emotional, Symptoms, and Functioning domains was 0.885, 0.752, and 0.901, respectively. Validity of the instrument in all aspects (criterion, content, and construct validity) was satisfactory, yet the Symptoms domain could not discriminate well between more and less severe skin diseases. The Serbian translation of Skindex-29 appears to be a reliable and valid specific instrument for measuring the adverse influence of skin diseases on quality of life.

The contributions of fasting and postprandial blood glucose increments to oxidative stress and inflammation in dyslipidemic type 2 diabetic patients with stable ischemic heart disease.

BACKGROUND/OBJECTIVES: Contributions of fasting and postprandial blood glucose increments on level of inflammation and oxidative stress biomarkers in patients with stable ischemic heart disease (IHD) and diabetes mellitus type 2 (T2DM) was evaluated. METHODOLOGY: Ninety T2DM patients (60 with IHD and 30 without IHD) treated with metformin and/or sulphonylurea were enrolled in cross-sectional nested case-control clinical study. The areas under the six-point daily glucose curve above the fasting glucose concentrations (AUCpp) and over 5.5mmol/L (AUCbg) were calculated to determine postprandial (AUCpp) and fasting (AUCbg-AUCpp) glucose increments. Malondialdehyde (MDA), protein carbonyl group (PCO), fibrinogen, C-reactive protein (hsCRP), leukocyte count and adhesion molecules ICAM-1 and VCAM-1 were determined. RESULTS: AUCbg-AUCpp 58.2 (95%CI 40.6-75.8) was higher in IHD group compared to non-IHD 36.9 (95%CI 23.5-50.2) mmol*h/L. They had significantly higher ICAM-1 (mean±SD) 72.70±30.6 vs. 60.22±22.6ng/mL and MDA 16.47±4.5 vs. 13.42±4.01µmol/g plasma proteins, but similar PCO, VCAM-1, fibrinogen, hsCRP concentration and leukocyte count. AUCpp positively correlated with MDA (r=0.45) and ICAM-1 (r=0.32) in the presence of IHD, and VCAM-1 (r=0.44) in the absence of IHD. AUCbg-AUCpp positively correlated with PCO (r=0.45) in the absence of IHD. The analysis revealed that AUCpp over turning point of 0mmol*h/L was associated with high MDA and ICAM-1 expression in diabetics with IHD. AUCbg-AUCpp over 30mmol*h/L leads to high oxidative protein modification in diabetics without IHD. CONCLUSION: In T2DM patients with stable IHD, AUCpp at any point, significantly contributes to increasing of MDA and ICAM-1 expression. Fasting blood glucose increment showed significant correlation with carbonyl content in diabetics without IHD.

Amlodipine as an antiischemic drug is superior to long acting nitrates.

European Society of Cardiology Guidelines cite results of meta-analysis that the use of calcium channel blockers results in fewer angina episodes per week vs. long-acting nitrates. Moreover, we listed 12 reasons more to prefer amlodipine over long-acting nitrates, especially in stable angina pectoris patients with arterial hypertension. It may be the way to decrease polypharmacy without loosing efficacy. Some important advantages of amlodipine versus long-acting nitrate(s) are: amlodipine also treats hypertension, it helps reducing hypertensive target organ damages (e.g. left ventricular hypertrophy) and prevents morning blood pressure surge. Moreover, amlodipine can be given once daily (which improves adherence), it produces neither tolerance nor rebound, it has less side effects.

[Postmarketing study of efficacy and safety of losartan during the treatment of patients with mild and moderate hypertension: LOTAR (corrected) study].

INTRODUCTION: Losartan, the angiotensin type 1 receptor blocker (ARB) exercises its main antihypertensive effect by vasodilatation of peripheral arteries. OBJECTIVE: The aim of this study was to evaluate the antihypertensive effect and safety of losartan in patients with mild and moderate arterial hypertension (AH). METHODS: This was an open post-marketing study with losartan as monotherapy in previously treated or untreated patients with AH. Primary efficacy parameter was the percentage of patients that achieved target blood pressure after 8-week treatment with a single daily dose of losartan of 50-100 mg. Safety parameters were assessed according to the percentage of adverse events and metabolic effects of therapy. RESULTS: The study included 550 patients with AH (59% female and 41% male), mean age 56.8 +/-11.4 years, BMI = 27 +/- 4 kg/m2. Losartan was applied in 31% of untreated and 69% of previously treatment-resistant patients After 8 weeks target blood pressure was achieved in 67.8% (SBP) and in 81.1% (DBP) of patients, respectively. The mean decrease was 21.8% for SBP and 21.1% for DBP (p < 0.001). Out of all, 65% of patients achieved both target SBP and DBP values. Hydrochlorothiazide was added to the therapy in 11.6% of patients. There were no significant differences in drug efficacy between the entire group and subgroups of patients with diabetes mellitus and impaired renal function (p = ns). Adverse events were rare and metabolic effect was favorable. CONCLUSION: Monotherapy with losartan in a dosage of 50-100 mg applied during 8 weeks resulted in achieving target values of blood pressure in 65% of patient with mild and moderate hypertension, also including the patients with diabetes mellitus and impaired renal function. Losartan is a safe and metabolically neutral medication.

Diagnostical significance of dimethylarginine in the development of hepatorenal syndrome in patients with alcoholic liver cirrhosis.

BACKGROUND/AIM: Chronic consumption of alcohol during a longer period of time leads to the development of cirrhosis with the reduction in metabolic liver function and disorders in arginine metabolism. Hepatorenal syndrome (HRS) is the most severe complication of alcoholic liver cirrhosis. The aim of the study was to analyze disorders in arginine metabolism by monitoring concentrations of asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) in patients with liver cirrhosis and HRS. METHODS: The study included three groups of subjects: a group of patients with cirrhosis and HRS (24 patients), a group of patients with cirrhosis without HRS (18 patients) and a control group composed of 42 healthy voluntary blood donors. Concentrations of ADMA, SDMA and L-arginine in plasma were measured in all groups using the high pressure liquid chromatography (HPLC) method. RESULTS: The concentration of SDMA was significantly higher in the patients with HRS compared to the patients without HRS and it was also higher than the values obtained from the healthy participants 1.76 +/- 0.3 micromol/L; 1.01 +/- 0.32 and 0.520 +/- 0.18 micromol/L, respectively; p < 0.01). The concentrations of ADMA were higher in the cirrhotic patients with HRS than in those without this serious complication of cirrhosis. The concentration of ADMA in all the examined cirrhotic patients was higher than those obtained from healthy volunteers (1.35 +/- 0.27 micromol/L, 1.05 +/- 0.35 micromol/L and 0.76 +/- 0.21 micromol/L, respectively). In the patients with terminal alcoholic liver cirrhosis, the concentrations of ADMA and SDMA correlated with the progress of cirrhosis as well as with the development of cirrhosis complications. In the patients with HRS there was a positive correlation between creatinine and SDMA in plasma (r2 0.0756,p < 0.001) which was not found between creatinine and ADMA. CONCLUSION: The obtained results demonstrate that the increase in SDMA concentration is proportionate to the progression of chronic damage of the liver and kidneys. Increased ADMA concentration can be a causative agent of renal insufficiency in patients with cirrhosis.

[Vasospastic angina pectoris complicated by acute myocardial infarction and complete atrioventricular block].

BACKGROUND: A prolonged coronary artery spasm with interruption of coronary blood flow can lead to myocardial necrosis and increase of cardiospecific enzymes and can be complicated with cardiac rhythm disturbances, syncopc, or even sudden cardiac death. CASE REPORT: A 55-year old male felt a severe retrosternal pain when exposing himself to cold weather. The pain lasted for 20 minutes and was followed by the loss of conscience. Electrocardiogram (ECG) showed a complete antrioventricular (AV) block with nodal rhythm and marked elevation of ST segment in inferior leads. Electrocardiogram was soon normalized, but serum activities of cardiospecific enzymes were increased. Coronarography showed normal findings for the left coronary artery and a narrowing at the middle part of the right coronary artery, which disappeared after intracoronary application of nitroglycerine. The following therapy was prescribed: Diltiazem, Amlodipin, Isosorbid mononitrate, Molisdomin, Atrovastatin, Aspirin and Nitroglycerine spray. After 7 months medicaments were abandoned and the patient experienced again reccurent chest pain episodes at rest. Transitory ST segment elevation was recorded in inferior leads of ECG, but without increase of cardiospecific enzymes serum activities. After restoration of the medicament therapy anginal episodes ceased. CONCLUSION: Coronary dilators in maximal doses can prevent attacks of vasospastic angina.

Correlation of mortality and location of arteriovenous fistula in hemodialysis patients.

PURPOSE: Since the type of vascular access is very important and a significant risk factor for mortality in patients on hemodialysis, the aim of our study was to determine the impact of AVF positioning on the mortality of our patients. METHODS: The survey was organized as a prospective, clinical and non-randomized study of 538 surgical interventions on 323 patients, which indicates that a large number of patients had more than one fistula. Among these patients, 120 subjects (81 (67.5%) men and 39 (32.5%) women) died during the study period. We analyzed the demographic structure, the site location and type of anastomosis for the arteriovenous fistula, artery and vein lumen and presence of instillation catheters, as well as measuring flow through the fistula and arterial blood pressure. Biochemical parameters thought to have a significant impact on survival were obtained from routine monthly analyses. RESULTS: In patients in whom infection was the cause of death, termino-terminal anastomosis was more frequently present (p=0.035). Variables that were statistically significant predictors of death were elderly individuals (Beta 0.033, p<0.001); patients whose diastolic blood pressure was low (Beta -0.028, p<0.001); and the position of the arteriovenous fistula (distal Beta -0.737, p=0.001; proximal Beta -0.581, p=0.008). Patients with a cubital fistula (p=0.001) had a significantly shorter Kaplan-Meier survival curve. CONCLUSIONS: End-to-end artery and vein connection was a significantly more common form of anastomosis in patients who died as a result of infection. Important parameters of mortality in our study were the position of the arteriovenous fistula, age, and the diastolic component of arterial blood pressure.

[The influence of stress hyperglycemia on the prognosis of patients with acute myocardial infarction and temporary electrical cardiac pacing].

INTRODUCTION: Elevated glucose levels on admission in many emergency conditions, including acute myocardial infarction (AMI), have been identified as a predictor of hospital mortality. OBJECTIVE: Since there are no data in the literature related to stress hyperglycaemia (SH) in patients with both AIM and temporary electrical cardiac pacing, we aimed to investigate the influence of stress hyperglycaemia on the prognosis of patients with AMI and temporary electrical cardiac pacing. METHODS: The prospective study included 79 patients with diagnosed AMI with ST-segment elevation (STEMI), admitted to the Coronary Care Unit of the Clinic for Cardiovascular Diseases, Clinical Centre Nis, from 2004 to 2007, who were indicated for temporary electrical cardiac pacing. The blood was sampled on admission for lab analysis, glucose levels were determined (as well as markers of myocardial necrosis troponin I, CK-MB). Echocardiographic study was performed and ejection fraction was evaluated by using area length method. RESULTS: The ROC analysis indicated that the best glycaemic level on admission, which could be used as a predictor of mortality, was 10.00 mmol/l, and the area under the curve was 0.82. In the group without SH, hospital mortality was 3-fold lower 11/48 (22.91%) compared to the group with SH 19/31 (61.29%), p < 0.0001. Patients with SH were more likely to have higher troponin levels, Killip >1, lower ejection fraction and heart rate, as well as systolic blood pressure. CONCLUSION: The best cut-off value for SH in patients with AMI (STEMI) and temporary electrical cardiac pacing is 10 mmol/l (determined by ROC curve) and may be used in risk stratification; patients with glucose levels <10 mmol/l on admission are at 3-fold lower risk compared to those with glucose levels >10 mml/l. Our results suggest that SH is a more reliable marker of poor outcome in AMI patients with temporary pace maker, without previously diagnosed DM.

[Acute myocardial infarction incidence and mortality rates in the population of the city of Nis in the period 1974-2000].

INTRODUCTION: The aim of this study was to investigate the annual incidence of hospital morbidity and mortality rates of acute myocardial infarction (AMI) in the population of Nis who were treated at the Cardiology Clinic in Nis during the period 1974-2000. MATERIAL AND METHODS: A retrospective clinical-epidemiological study was carried out in the population of the city of Nis aged 30 years and over. The number of citizens of Nis, aged 30 years and over, was 71,500 in 1974, and 100,000 in 2000, while the male to female ratio was 48%:52%. RESULTS: During the period from 1974 to 2000, 4319 patients of both sexes with AMI received hospital treatment. The average annual incidence rate was 159.92 per 100,000 inhabitants aged 30 years and over. The average annual incidence of AMI showed a trend of progressive increase, and in 2000 it was 274.87 (2.7 times higher than in 1974--102.19). The average annual mortality for both sexes was 1.57% (9.82% for males and 15.89% for females). The female mortality rate was significantly higher (p < 0.001). CONCLUSION: Trends in annual incidence rate of AMI in the population of the city of Nis aged 30 years and over are characterized by progressive increase during the period from 1974 to 2000. The trend line: yt = 159.92 + 6.2432x shows that without primary prevention further increase in the incidence of AMI can be expected.

[Prognostic significance of sinus deceleration during dobutamine stress echocardiography test following acute myocardial infarction].

BACKGROUND/AIM: Chronotropic incompetence during exercise stress testing after acute myocardial infarction is an indicator of ischemia or impaired left ventricular function. On the other side, infusion of dobutamine leads to a typical dose-dependent increase in heart rate. The aim of this study was to evaluate of paradoxical sinus deceleration during dobutamine stress echocardiography (DSE), as the sign of ischemia and impaired left ventricular function, or the consequence of infarction localization, and the estimation of prognostic significance after acute myocardial infarction. METHODS: Our investigation comprised 81 patients hospitalized because of the acute myocardial infarction, and all of them had uncomplicated infarction. Fifty five patients were treated with thrombolytic therapy (67.9%); 53 patients (65.4%) had anterior myocardial infarction, and 28 patients (34.6%) had inferoposterior localization of myocardial infarction. After 10-12 days all of them underwent dobutamine stress echocardiography examination. During the next 3-6 months, the patients underwent coronary angiography. The average follow-up period was 36 +/- 22 months. RESULTS: A decrease in heart rate occurred at the dobutamine doses increasing from 15-40mcg/kg/min in 9 (11.1%) of the patients, in 1 patient with an anterior localization and in 8 patients with an inferoposterior localization. The decrease was sudden in 4 (44.4%), and gradual in 5 (55.6%) of the patients. In 3 patients (33.3%) junction rhythm was developed, and in 2 patients (22.2%) AV block II-III. Only in 2 of them, there was a worsening of regional function during a high dose dobutamine infusion, but 7 of them showed an improvement during a low dose. In 7 (77.8%) of the patients there was a simultaneous decrease in blood pressure. Coronary angiographic examination showed that in 4 (44.4%) of the patients there was a significant coronary artery disease and they underwent the revascularisation procedure. During the follow up period, there was not any significant arrhythmic disorder in that group of the patients or repeated hospitalization because of postinfarction angina, re-infarction, or heart failure. CONCLUSION: We could conclude that paradoxical sinus deceleration is not only an indicator of a significant coronary artery disease and "bad left ventricle". It also may occur as a consequence of vasodepressor reflex (Bezold-Jarisch), even after acute myocardial infarction, withont influencing a long-term prognosis.

Prevention of pocket related complications with fibrin sealant in patients undergoing pacemaker implantation who are receiving anticoagulant treatment.

AIM: The aim of our study was to establish the efficiency of fibrin sealant in the prevention of pocket related complications in patients undergoing pacemaker implantation who are receiving anticoagulant treatment. METHODS: The study was performed on 40 and 41 patients prospectively randomized into treatment and control groups who underwent pacemaker implantation procedure between January 2002 and July 2004 at the Pacemaker Center - Clinical Centre Nis, Serbia. Both groups of patients were receiving anticoagulant treatment with either heparin or warfarin. Surgical procedures between the groups differed only in the application of fibrin sealant prior to wound closure in the treatment group. RESULTS: In the treatment group, there were no pocket related complications while in the control group six patients (14.63%) had minor haematomas that required no treatment. Four patients (9.76%) had significant haematomas (two patients were treated conservatively while the other two needed reintervention). The INR in the treatment group was 2.76+/-0.85 and in the control group 2.65+/-0.79 (P=ns). In the follow-up period (2-27 months) no late complications were registered in either group. CONCLUSION: Fibrin sealant is an effective haemostatic agent. The results obtained in our study show that the administration of fibrin sealant in patients receiving anticoagulant treatment eliminates postoperative haematomas after pacemaker implantation.