Regulation of nitric oxide production in hypothyroidism.

Hypothyroidism is a common endocrine disorder that predominantly occurs in females. It is associated with an increased risk of cardiovascular diseases (CVD), but the molecular mechanism is not known. Disturbance in lipid metabolism, the regulation of oxidative stress, and inflammation characterize the progression of subclinical hypothyroidism. The initiation and progression of endothelial dysfunction also exhibit these changes, which is the initial step in developing CVD. Animal and human studies highlight the critical role of nitric oxide (NO) as a reliable biomarker for cardiovascular risk in subclinical and clinical hypothyroidism. In this review, we summarize the recent literature findings associated with NO production by the thyroid hormones in both physiological and pathophysiological conditions. We also discuss the levothyroxine treatment effect on serum NO levels in hypothyroid patients.

The prevalence of polyvascular disease in patients with carotid artery disease and peripheral artery disease.

BACKGROUND: Cardiovascular disease remains the major cause of mortality in the Western World. AIMS: We aimed to assess the prevalence of polyvascular disease in patients with carotid artery disease and peripheral artery disease (PAD), and to determine the risk profile of patients with polyvascular disease. METHODS: The study included 1045 consecutive patients presenting to our department with carotid disease or PAD. Demographic characteristics, anthropometric parameters, and data on cardiovascular risk factors were collected in all patients. On the basis of medical history, patients were classified into those who had only symptomatic carotid disease or symptomatic PAD and those who had symptomatic polyvascular disease. RESULTS: Carotid disease alone was reported in 366 participants (35%), PAD alone, in 199 (19%), and polyvascular disease, in 480 (46%). Compared with carotid disease, PAD was more often a component of polyvascular disease (P = 0.002) and was combined with a higher number of other atherosclerotic diseases (P = 0.02). Compared with patients with symptomatic atherosclerotic disease in only 1 territory, patients with various types of polyvascular disease more often had hypertension (P from 0.03 to <0.001), dyslipidemia (P <0.001), high­sensitivity C­reactive protein levels of 3 mg/l or higher (P = 0.005), and more often were current smokers (P <0.001) or former smokers (P from 0.03 to 0.001). CONCLUSIONS: We showed a high prevalence of symptomatic polyvascular disease in patients with carotid disease or PAD. The risk profile was worse in patients with polyvascular disease than in those with a disease in a single vascular territory.

Awareness and knowledge of cardiovascular disease risk factors among medical students.

BACKGROUND: The aim of this study was to assess the knowledge and attitude of medical students in relation to cardiovascular disease (CVD) risk factors as well as to assess the impact of medical education on their knowledge and recognition of the importance of implementation of preventive measures. METHODS: This cross-sectional study included 514 students in the second year of studying at the Faculty of Medicine in Belgrade, Serbia (younger students response rate 79.57%) and 511 students in the last year of education (older students response rate 90.21%). For data collection, an anonymous self-administered questionnaire was used, which included two types of questions about CVD risk factors and questions about the student's attitude. RESULTS: Older students knew significantly more about CVD risk factors than students who were at the beginning of their medical studies; however, more than half of the older students did not know the correct answers about CVD risk factors. The only exceptions were questions about "bad" and "good" cholesterol, metabolic syndrome (MSy) and lipid lowering therapy in high risk subjects. Physical inactivity, obesity, type 2 diabetes, smoking and hypertension were not ranked highly enough as important CVD risk factors. Compared groups of students did not significantly differ in attitude scores. The majority of them recognized CVD as the leading cause of death, had normal weight and knew their own blood pressure. CONCLUSION: Knowledge of medical students from Belgrade about CVD risk factors should be improved.

Quality of life in chronic venous disease patients measured by short Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) in Serbia.

BACKGROUND: This was a psychometric validation of the short Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) as quality of life (QOL) instrument for chronic venous disease (CVD) patients. METHODS: Patients aged >18 years who had CVD in CEAP C stages C0s to C6 were included in the study. Diagnosis was made by general practitioners according to CVD symptoms and visual examination of the lower extremities. QOL was assessed with the self-administrated CIVIQ-14. The reliability, construct, and convergent validity of the CIVIQ-14 was estimated as well as QOL of CVD patients according to CEAP C stages. RESULTS: The study comprised 2260 subjects who fully completed the CIVIQ-14. CIVIQ-14 had a high level of reliability, construct, and convergent validity, but the structure of its three dimensions (pain [P], physical [PHY], and psychological [PSY]) was suboptimal. After adjustment for age, body mass index, and number of CVD symptoms, CIVIQ -14 global, P, PHY, and PSY scores showed significant progressive reduction of QOL from CEAP class C0s to C6. These differences were present in both sexes. The progressive impairment of the QOL involved primarily the pain and the physical items. For all CEAP C classes, the P and PHY scores were lower than the PSY scores. Global scores for men and women were: 76.7 and 73.9 for C0s; 75.5 and 70.6 for C1; 67.8 and 64.5 for C2; 68.3 and 61.6 for C3; 60.7 and 54.6 for C4; 49.5 and 50.2 for C5; and 41.3 and 46.7 for C6. CONCLUSIONS: CVD in the lower extremities has a substantial effect on both physical and psychologic aspects of QOL, the physical aspects of QOL (P and PHY items) being more important. CIVIQ-14 is valuable in assessing QOL in CVD patients. Further investigations are necessary to confirm the stability of its two dimensions.

Technical strategy in a patient with symptomatic thoracic aneurysm near the origin of the left subclavian artery and left internal thoracic artery coronary graft.

Thoracic endovascular aortic repair (TEVAR) is a safe and reliable technique utilized in the treatment for aortic aneurysms. However, in up to 40% of patients, devices are typically placed over the left subclavian artery (LSA) origin. In this report, we present a case of a successful TEVAR procedure following the transposition of the LSA with protective carotico-axillary/carotid bypass in a patient with a patent left internal thoracic artery (LITA)-left anterior descending (LAD) coronary artery bypass graft and right internal carotid artery (ICA) occlusion.

Prevalence of the metabolic syndrome in patients with carotid disease according to NHLBI/AHA and IDF criteria: a cross-sectional study.

BACKGROUND: Metabolic syndrome (MetS) has been related to type 2 diabetes and cardiovascular diseases. Different criteria for diagnosis of MetS have been recommended, but there is no agreement about which criteria are best to use. The aim of the present study was to investigate agreement between the National Heart, Lung, and Blood Institute, American Heart Association (NHLBI/AHA) and the International Diabetes Federation (IDF) definitions of MetS in patients with symptomatic carotid disease and to compare the frequency of cardiovascular risk factor in patients with MetS diagnosed by these two sets of criteria. METHODS: The study was a cross-sectional one involving 644 consecutive patients with verified carotid disease who referred to the Vascular Surgery Clinic Dedinje in Belgrade during the period April 2006 - November 2007. Anthropometric parameters blood pressure, fasting plasma glucose and lipoproteins were measured using standard procedures. RESULTS: MetS was present in 67.9% of participants, according to IDF criteria, and in 64.9% of participants, according to the NHLBI/AHA criteria. A total of 119 patients were categorized differently by the two definitions. Out of all participants 10.7% had MetS by IDF criteria only and 7.8% of patients had MetS by NHLBI/AHA criteria only. The overall agreement of IDF and NHLBI/AHA criteria was 81.5% (Kappa 0.59, p < 0.001). In comparison with patients who met only IDF criteria, patients who met only NHLBI/AHA criteria had significantly more frequently cardiovascular risk factors with the exception of obesity which was significantly more frequent in patients with MetS diagnosed by IDF criteria. CONCLUSION: The MetS prevalence in patients with symptomatic carotid disease was high regardless of criteria used for its diagnosis. Since some patients with known cardiovascular risk factors were lost by the use of IDF criteria it seems that NHLBI/AHA definition is more suitable for diagnosis of MetS. Large follow-up studies are needed to test prognostic value of these definitions.

Regulation of Inducible Nitric Oxide Synthase (iNOS) and its Potential Role in Insulin Resistance, Diabetes and Heart Failure.

Nitric oxide synthases (NOS) are the enzymes responsible for nitric oxide (NO) generation. NO is a reactive oxygen species as well as a reactive nitrogen species. It is a free radical which mediates several biological effects. It is clear that the generation and actions of NO under physiological and pathophysiological conditions are regulated and extend to almost every cell type and function within the circulation. In mammals 3 distinct isoforms of NOS have been identified: neuronal NOS (nNOS), inducible NOS (iNOS) and endothelial NOS (eNOS). The important isoform in the regulation of insulin resistance (IR) is iNOS. Understanding the molecular mechanisms regulating the iNOS pathway in normal and hyperglycemic conditions would help to explain some of vascular abnormalities observed in type 2 diabetes mellitus (T2DM). Previous studies have reported increased myocardial iNOS activity and expression in heart failure (HF). This review considers the recent animal studies which focus on the understanding of regulation of iNOS activity/expression and the role of iNOS agonists as potential therapeutic agents in treatment of IR, T2DM and HF.

Eversion carotid endarterectomy versus best medical treatment in symptomatic patients with near total internal carotid occlusion: a prospective nonrandomized trial.

BACKGROUND: We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion. METHODS: From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months. RESULTS: There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B. CONCLUSION: Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Temporal trends in eversion carotid endarterectomy for carotid atherosclerosis: single-center experience with 5,034 patients.

The aim of this article is to review our experience in surgical treatment of carotid atherosclerosis using eversion carotid endarterectomy (ECEA) in 5,034 patients, with particular attention to temporal changes in patients' characteristics, diagnostic approach, surgical technique, medical therapy, and outcome in the early (group A, 1991-1997) versus late (group B 1998-2004) period of ECEA. From January 1991 to December 2004, 5,034 primary ECEAs were performed for high-grade carotid stenosis. Patients treated for restenosis after previous carotid surgery were excluded from the analysis. Group A consisted of 1,714 patients who underwent surgery between 1991 and 1997, and group B consisted of 3,320 patients who underwent surgery between 1998 and 2004. Follow-up included routine clinical evaluation and noninvasive surveillance, with duplex scanning at 1 month after surgery, after 6 months, and annually afterward. Only 3% of patients in group A and 0.6% in group B were asymptomatic, with 23% and 47% of them having preoperative stroke, respectively. In group A, angiography was used for the final diagnosis in 78% of patients. In group B, duplex scanning was performed in 82% of patients and angiography in only 18% (p < .001). Clamping time was shorter in the latter group (12.4 +/- 3.1 vs 14.5 +/- 4.1 min, p < .01). Introperative shunting and regional anesthesia were rarely performed in both groups (1.4% vs. 0.4%, p < .01, and 2% vs 0.3%, p < .001). Total and neurologic morbidity was significantly higher in group A than in group B (6.41% +/- 0.47% vs 4.81% +/- 0.53%, p < .001, and 2.14% +/- 0.31% vs 1.23% +/- 0.29%, p < .001, respectively). Total mortality was also higher in group A than in group B (1.92% +/- 0.24% vs 1.36% +/- 0.50%, p < .05), but although there was a trend toward lower neurologic mortality, it did not reach statistical significance (1.04% +/- 0.5% vs 0.57% +/- 0.25%, p = .074). There was a lower rate of nonsignificant restenosis (< 50%) in group B (2% vs 5%, p < .01), but the incidence of restenosis > or = 50% was identical between the groups (5.5% for both). Our data show that ECEA is a reliable surgical technique for the treatment of atherosclerotic carotid disease. Temporal trends in our patients demonstrated a decline in periopertive mortality and morbidity, despite a higher incidence of preoperative stroke.