Metabolic syndrome and left ventricular function: is the number of criteria actually important?

BACKGROUND: Metabolic syndrome (MS) is a clustering of cardiovascular risk factors responsible for the development of target organ damage. The aim of this study was to determine the effect of the increasing number of MS risk factors on left ventricular function assessed by noninvasive methods. MATERIAL/METHODS: The study included 204 subjects with MS and 76 controls with no MS risk factors. MS was defined by the presence of 3 or more of ATP-NCEP III criteria. MS subjects were grouped according to the number of criteria they fulfilled: 3 criteria (n=91), 4 criteria (n=65) and 5 criteria (n=48). All subjects underwent laboratory blood tests, complete 2-dimensional, pulse and tissue Doppler echocardiography. Echocardiography was used to assess systolic (LVEF, sseptal), diastolic function, by pulse-wave Doppler (E/A ratio) and tissue Doppler imaging (E/e'average), and global left ventricular function (Tei index). Appropriate time intervals for the estimation of the Tei index were obtained by tissue Doppler. RESULTS: Transmitral E/A ratio decreased significantly and progressively from the 3 criteria to the 5 criteria group (0.82 ± 0.25 vs. 0.79 ± 0.24 vs. 0.67 ± 0.14, p<0.001). The transmitral E/E'average ratio was significantly and gradually increased from the 3 criteria to the 5 criteria group (7.76 ± 1.81 vs. 9.44 ± 2.35 vs. 10.82 ± 2.56, p<0.001). The left ventricle Tei index progressively increased from the 3 criteria to the 5 criteria group (0.43 ± 0.11 vs. 0.48 ± 0.10 vs. 0.54 ± 0.12, p<0.001). CONCLUSIONS: The increasing number of MS criteria is associated with cardiac diastolic dysfunction.

Right ventricular myxoma obstructing the outflow tract.

Cardiac myxomas are benign tumors of endocardial origin. Symptoms might mimic heart disease as well as infectious disease, immunodeficiency, and malignant processes. We present the case of a 59-year-old female patient with a large right ventricular myxoma that was connected to the basal interventricular septum. Movement in systole provoked the obstruction of the right ventricular outflow tract. She presented clinically with syncope, systolic murmur, and signs of right heart failure. The diagnosis of the right ventricular tumor was based on 2D echocardiography, magnetic resonance, and multislice computed tomography findings.Emergency surgical excision of the myxoma was necessary to prevent embolism and sudden death.

The long-term risk of stroke in patients with acute myocardial infarction complicated with new-onset atrial fibrillation.

BACKGROUND: The long-term risk of stroke after acute myocardial infarction (AMI) complicated with new-onset atrial fibrillation (AF) remains unclear. The aim of this study was to determine the long-term risk of AF and stroke in patients with AMI complicated with new-onset AF. METHODS: Patients with AMI complicated with new-onset AF (n = 260) and those without new-onset AF (n = 292) were followed for a mean of 7 years. All patients had sinus rhythm at hospital discharge. RESULTS: During the follow-up, AMI patients with new-onset AF had more frequent AF than those without new-onset AF (10.4% vs 2.7%, respectively; P < 0.0001). New-onset AF during AMI was a significant predictor of subsequent AF occurrence (the time elapsing between 2 consecutive R waves [RR] = 3.15, P = 0.004); but AF recurrence in follow-up (RR = 5.08, P = 0.001) and non-anticoagulation at discharge (RR = 0.29, P = 0.008) were independent predictors of stroke (Cox regression analysis). A period of 3.5 hours of AF within the first 48 hours of AMI was the high sensitivity cut-off level for the prediction of low long-term risk of stroke obtained by receiver operating characteristic analysis. Among patients who did not receive anticoagulants at discharge, the patients with short AF did not experience stroke and AF recurrence during follow-up, while those in the other group developed it (10.8%, P = 0.038 and 13.5%, P = 0.019, respectively). CONCLUSION: New-onset AF during AMI identifies the patients at long-term risk for stroke who may potentially benefit from anticoagulant therapy. Atrial fibrillation recurrence in follow-up was independently related to the development of stroke. However, for low-risk patients with AF (those with short AF occurring early in AMI) long-term anticoagulants might not be required.

The incidence of difficult intubation in 2000 patients undergoing thyroid surgery--a single center expirience.

BACKGROUND/AIM: The incidence of difficult intubation (DI) is 1-10%, and DI leading to inability to intubate occurs in 0.04% of the population. The aim of this study was to evaluate the incidence of DI in thyroid surgery and to assess possible correlation of difficult tracheal intubation with sex and primary diagnosis. METHODS: We studied 2000 consecutive patients (1705 females) scheduled for thyroid surgery who were assessed for DI prior to general anesthesia, with respect to primary disease diagnosis and sex. Patients were divided into four groups: patients with nodal goiter (group A), polynodal goiter (group B), hyperthyroidism (group C) and thyroid carcinoma (group D). Difficult intubation was predicted using the scoring system which included 13 parameters ranged from 0 to 2. Additive score > 5 was accepted as a predictor of DI. True DI was defined as impossible visualization of glottis with direct laryngoscopy (grade III and IV). RESULTS: Difficult intubation was observed in 110/2000 patients (5.5%). The incidence of DI was higher in males (26/295, 8.8%) than females (84/1705, 4.9%) (p < 0.01). The incidence of DI was highest in the group B (6.2%). Extremely DI occurred in 15/2000 patients (0.75%), the most of them in the group C (1.1%). Sensitivity of used scoring system was 91.8% and specificity 86.5%. CONCLUSIONS: The incidence of DI was higest in patients with polynodal goiter but extremly DI was present mostly in patients with hyperthiroidism. Men seem to be at higher risk for DI than women. Scoring system used in this study for prediction of DI may be useful in this patient population.

Acute myocardial infarction following a hornet sting.

BACKGROUND: The occurrence of an acute myocardial infarction following a hornet sting has been very rarely reported in the previous literature. Pathogenetic mechanisms include direct action of the venom components on the coronary endothelium and allergic reaction with mediators released from mast cells. The anaphylactic reaction and venom components can produce acute coronary artery thrombosis. CASE REPORT: We reported a 45-year-old man with acute myocardial infarction after a hornet sting in the presence of anaphylaxis. We also discussed clinical implications and pathophysiological mechanisms of acute myocardial infarction caused by hymenoptera sting. CONCLUSION: A case report of this unusual acute myocardial infarction highlights the potential acute myocardial ischemia associated with hymenoptera sting which requests early diagnosis, thorough cardiovascular evaluation and appropriate treatment.

[Nonoclusive thrombosis of mechanical mitral valve prosthesis caused by inadequate treatment of anticoagulant therapy resistance].

UNLABELLED: BACKGROUND; Oral anticoagulants have been used in the prevention of thromboembolic complications for over six decades. A rare, but possible problem in the application of these medications could be resistance to them. CASE REPORT: We presented a patient with nonocclusive thrombosis of the mechanical mitral prosthesis due to inadequately treated resistance to peroral anticoagulant therapy. Resistance to oral anticoagulant medications was proven by an increased dosage of warfarin up to 20 mg and, after that, acenokumarol to 15 mg over ten days which did not lead to an increase in the international normalised ratio (INR) value over 1.2. On the basis of information that she did not take food rich in vitamin K or medications which could reduce effects of oral anticoagulants, and that she did not have additional illnesses and conditions that could cause an inadequate response to anticoagulant therapy, it was circumstantially concluded that this was a hereditary form of resistance. Because of the existing mechanical prosthetics on the mitral position, low molecular heparin has been introduced into the therapy. The patient reduced it on her own initiative, leading to nonocclusive valvular thrombosis. CONCLUSION: When associated complications like absolute arrhithmia does not exist, the finding of resistance to oral anticoagulant agents is an indication for the replacement of a mechanical prosthetic with a biological one which has been done in this patients.

Metabolic syndrome and central retinal artery occlusion.

BACKGROUND: The accumulation of risk factors for central retinal artery occlusion can be seen in a single person and might be explained by the metabolic syndrome. CASE REPORT: We presented the case of a 52-year-old man with no light perception in his right eye. The visual loss was monocular and painless, fundoscopy showed central retinal artery occlusion and the laboratory investigation showed the raised erythrocyte sedimentation rate of 105 mm/h and the raised C-reactive protein of 22 mg/l. Specific laboratory investigations and fluorescein angiography excluded the presence of vasculitis, collagen vascular diseases, hypercoagulable state and antiphospholipid syndrome. CONCLUSION: The patient met all the five of the National Cholesterol Education Program (NCEP) criteria for the metabolic syndrome: hypertension, abnormal lipid profile, abnormal glucose metabolism, obesity and hyperuricemia. Measurement of C-reactive protein is useful for the assessment of therapeutic systemic effect on any abnormality in the metabolic syndrome. Individual therapy for all risk factors in the metabolic syndrome is necessary to prevent complications such as cardiovascular, retinal vascular diseases and stroke.

[Plasma and red blood cell superoxide dismutase activity in patients with different stages of essential hypertension]. / Aktivnost superoksid dizmutaze u plazmi i eritrocitima bolesnika sa razlicitim stadijumima esencijalne hipertenzije.

It has been suggested that superoxide dismutase (SOD) plays an important role in endothelial dysfunction in essential hypertension (EH), by competing with nitric oxide for superoxide, thus influencing nitric oxide bioavailability. To answer the question of whether endothelial dysfunction is consequence of altered SOD expression we determined SOD activity in patients with different stages of EH. In this study 45 EH patients and 25 normotensive subjects were included. EH patients were divided into the three groups according to the guidelines of European Society of Hypertension. SOD activity was determined spectrophotometrically in RBC and plasma of EH patients and controls. The results obtained have shown that all groups of EH patients exhibit lower SOD activity than control normotensive subjects. Significant correlation between SOD activity and both diastolic (p<0.05, r=-0.394) and systolic blood pressure (p<0.05, r=-0.356) was found. Lowering of SOD activity in patients with different stages of EH leads to inefficient detoxification of superoxide in EH. An excess of superoxide of both cellular and extracellular origin takes part in enhanced degradation of nitric oxide and altered vasodilation, and consequent endothelial dysfunction.

Time course of erythrocyte antioxidant activity in patients treated by thrombolysis for acute myocardial infarction.

The deleterious effects of free radicals in acute myocardial ischaemia/reperfusion are rather well known. However, the possibility that thrombolysis positively affects the recovery of blood antioxidant capacity in the later postinfarction period, and thus contributes to the better overall outcome of these patients, has not yet been investigated. We followed the time course of erythrocyte antioxidant activity in 45 patients with first acute myocardial infarction (AMI), who were treated with streptokinase. Success of thrombolysis was evaluated by noninvasive clinical signs of reperfusion using continuous vector cardiography. The patients were divided into two groups according to successful or unsuccessful, reperfusion, The control group consisted of 24 healthy subjects. Glutathione peroxidase (GPX) and superoxide dismutase (SOD) were determined immediately after admittance to the hospital (0 hours) and after subsequent thrombolytic therapy (1.5, 6, 12, and 24 hours after initiation of infusion of streptokinase), and 2, 4, and 8 days after AMI. Patients with AMI had decreased antioxidant enzyme activity at the time of admit- tance to the hospital, showing that the oxidative/antioxidative balance is disturbed early during the ischemic phase of AMI. In AMI patients without successful reperfusion, erythrocyte antioxidant enzyme activity remains low during the postinfarction period of 7 days. It can be concluded that prolonged ischemia reduces antioxidant enzyme activity. AMI patients with successful reperfusion have a significant rise in the activity of antioxidant enzymes within the first hours after thrombolysis, followed by a decrease until the third postinfarction day. During the subsequent postinfarction period, erythrocyte antioxidant activity gradually recovered and reached control levels. These beneficial effects of reperfusion on erythrocyte antioxidant status might contribute to the better overall prognosis of these patients.

[Cardiac echinococcosis]. / Ehinokokoza srca.

Cardiac hydatid disease is rare. We report on an uncommon hydatid cyst localized in the right ventricular wall, right atrial wall tricuspid valve, left atrium and pericard. A 33-year-old woman was treated for cough, fever and chest pain. Cardiac echocardiographic examination revealed a round tumour (5.8 x 4 cm) in the right ventricular free wall and two smaller cysts behind that tumour. There were cysts in right atrial wall and tricuspidal valve as well. Serologic tests for hydatidosis were positive. Computed tomography finding was consistent with diagnosis of hydatid cyst in lungs and right hylar part. Surgical treatment was rejected due to great risk of cardiac perforation. Medical treatment with albendazole was unsuccessful and the patient died due to systemic hydatid involvement of the lungs, liver and central nervous system.

[Tuberculous lymphadenitis of the cervical mediastinum]. / Tuberkulozni limfadenitis cervikomedijastinuma.

Tuberculous lymphadenitis is an uncommon form of extrapulmonary tuberculosis. We report on a case of isolated Cervicomediastinal tuberculous lymphadenitis without parenhimal involvement. A 49-year old woman was hospitalized with a four week history of night sweats and weight loss. Plain chest radiography disclosed mediastinal mass of the right side. Echocardiographic examination revealed a soft tissue mass below the ascending aorta and aortic arch causing moderate narrowing of the right ventricular outflow tract and the main pulmonary artery. Computed tomographic scanning showed soft tissue mass in the middle mediastinum surrounding the great vessels extending posteriorely with moderate compression of trachea. Histological examination of the cervical mass revealed caseating granuloma containing acid-alcohol fast bacillus. Antituberculous chemotherapy was started.