Biljana Parapid

In-hospital outcomes and long-term mortality according to sex and management strategy in acute myocardial infarction. Insights from the French ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 Registry

BACKGROUND The early mortality of acute myocardial infarction (AMI) has dramatically decreased in the recent past. Whether the previously reported sex disparities in use of invasive strategies (IS) persist and translate into differences in outcomes deserves to be examined. METHODS We used the data from a nationwide French prospective multicentre registry from 3,670 AMI patients (1155 women (31.5%), 2515 men (68.5%)) recruited in 223 centres in 2005 and followed-up for 5 years. We examined in-hospital outcomes and 5-year mortality in patients categorized according to sex and use of IS (i.e. coronary angiography during the hospitalisation with a view to revascularisation). RESULTS IS was less frequently used in women than in men (adjusted OR=0.66; 95% CI: 0.52-0.85), regardless of the type of AMI, age group or risk category, while use of recommended medications was similar at 48 hours and discharge. In-hospital mortality did not differ according to sex, whatever the age group and use of an IS. At 5 years, overall and post-discharge mortality were similar in men and women. However, IS was associated with lower 5-year mortality in women (HR=0.66; 95% CI: 0.51-0.86) as in men (HR=0.48; 95% CI: 0.38-0.60) and there was no sex-strategy interaction. CONCLUSIONS Invasive strategy remains less frequently used in women than in men, yet is associated with improved five-year survival irrespective of sex. Whether reducing the sex gap in its use would translate into a higher survival in women remains an open question. CLINICAL TRIAL REGISTRATION NCT 00673036.

Epidemiology of typical coronary heart disease versus heart disease of uncertain etiology (atypical) fatalities and their relationships with classic coronary risk factors

OBJECTIVES The relationships were explored of some cardiovascular risk factors to typical (TYP) and atypical (ATYP) fatal coronary events (CHD). MATERIAL AND METHODS Thirteen cohorts of 40-59 year-old men of the Seven Countries Study were followed-up for 40 years (N = 9704 heart disease free subjects). Fatal TYP-CHD were classified when manifested as myocardial infarction, other acute coronary syndromes, angina pectoris and sudden death; and as ATYP-CHD when manifested only as heart failure or arrhythmia in the absence of other clear etiologies. Death rates were computed for single countries separately for TYP and ATYP and for different lengths of follow-up. Cox models included: age, smoking habits, systolic blood pressure (SBP), serum cholesterol (CHOL), forced expiratory volume in ¾ sec (FEV) and diabetes. RESULTS TYP-CHD was more common in North American and Northern European countries, while ATYP-CHD were more common in Southern and Eastern Europe. Age at death was 5 years greater for ATYP-CHD than for TYP-CHD. Cox models in the pool of 13 cohorts showed that coefficient for age was significantly larger for ATYP-CHD (hazard ratio, HR: 2.36; confidence intervals CI: 2.18 - 2.26) versus TYP-CHD (HR 1.50, CI 1.43-1.58) while coefficients for CHOL was larger and significant for TYP-CHD (HR 1.29, CI 1.22-1.35) but not for ATYP-CHD (HR 0.93, CI 0.85-1.03). SBP, smoking habits, FEV and diabetes all predicted both conditions almost equally. CONCLUSION The different relationships of CHOL and age with the two types of fatal CHD suggest that the two groups of manifestations may belong to different diseases.

Influence of the metabolic control on latency values of visual evoked potentials (VEP) in patients with diabetes mellitus type 1

The aim of our study was to investigate the relationship between the metabolic control parameters of diabetes mellitus (glycemia and HbA1c) and visual evoked potentials (VEP) latency values. The study included 61 patients with diabetes mellitus type 1 that were hospitalized at the Clinic for Endocrinology, Diabetes and Metabolic Diseases due to the poor metabolic control. All patients were divided into 3 groups. Group 1 consisted of patients on conventional insulin therapy (CT); Group 2 included patients on CT at the moment of hospitalization, with a change towards intensified insulin therapy (IIT); and Group 3 consisted of patients on IIT. Patients with diabetic retinopathy (DR) were excluded from the study. Metabolic control (glycemia and HbA1c) and VEP parameters were compared at the beginning of the study and six months later. After six months of strict glycoregulation, significant improvement in VEP parameters was followed by significant improvement of evaluated parameters of metabolic control. We found statistically significant reduction in frequency of pathological VEP findings, prolonged P100 latency and low amplitude potentials in Group 2, while in Groups 1 and 3 we found that these parameters did not significantly changed but the frequencies were lower. The VEP testing is a noninvasive diagnostic procedure which may help in early diagnosis of DR, prognosis during the metabolic control and treatment. If changes in the retina could be detected before DR is noticed using this noninvasive diagnostic procedure and include patients in a strict glycoregulation, we could be in the position to prevent serious complications that may cause blindness.

Noninvasive assessment of myocardial bridging by coronary flow velocity reserve with transthoracic Doppler echocardiography: vasodilator vs. inotropic stimulation

BACKGROUND To consider hemodynamic assessment of myocardial bridging (MB) adequate, it is believed that inotropic stimulation with dobutamine should be estimated because its dynamic nature depends on the degree of extravascular coronary compression. This study evaluated comparative assessment of hemodynamic relevance of MB using coronary flow velocity reserve (CFVR) measurements by transthoracic Doppler echocardiography (TTDE) with vasodilatative and inotropic challenges. METHODS This prospective study included forty-four patients with angiographic evidence of isolated MB of the left anterior descending coronary artery (LAD) and systolic compression of ≥50% diameter stenosis. All patients were evaluated by exercise stress-echocardiography (ExSE) test for signs of myocardial ischemia, and CFVR of the distal segment of LAD during iv.infusion of adenosine (ADO:140μg/kg/min) and iv.infusion of dobutamine (DOB:10-40μg/kg/min), separately. RESULTS Exercise-SE was positive for myocardial ischemia in 8/44 (18%) of patients. CFVR during ADO was significantly higher than CFVR during peak DOB (2.85±0.68 vs. 2.44±0.48, p=0.002). CFVR during peak DOB was significantly lower in SE-positive group in comparison to SE-negative group (2.01±0.16 vs. 2.54±0.47, p<0.001), but not for ADO (2.47±0.51 vs. 2.89±0.70, p=0.168), respectively. Multivariable logistic analysis showed that CFVR peak DOB was the most significant predictor of functional significant MB (OR 0.011, 95%CI: 0.001-0.507, p=0.021). Receiver-operating characteristic curves have shown that TTDE-CFVR obtained by high-dose of dobutamine infusion is better than those by adenosine regarding to functional status of MB (AUC 0.861, p=0.004; AUC 0.674, p=0.179, respectively). CONCLUSIONS Non-invasive CFVR measurement by TTDE during inotropic stimulation, in comparison to vasodilation, provides more reliable functional evaluation of MB.

Neurophysiological evaluation in newly diagnosed Diabetes Mellitus type 1

The aim of the study was to evaluate the effects of hyperglycemia on nerve conduction in patients with newly diagnosed diabetes mellitus type 1, and to investigate the significance of early electrophysiological diagnostics in these patients. The study included 85 newly disclosed patients with type 1 diabetes mellitus, in the first three months after the disease. Nerve conduction velocities (NCV) of further nerves were evaluated: median, peroneal, tibial and sural nerve as well as late responses (F-wave and H-reflex). Metabolic control parameters that were evaluated included: glycemia rate on the day of investigation and HbA1c. All patients had poor metabolic control parameters. We found NCV slowing predominantly in the tibial nerve (in 82.4% of patients). Prolonged F-wave latency was disclosed in 72.9% of patients, while H-reflex was evoked in 27.1% of patients only. The most sensitive parameter in the early neurophysiologic diagnostics was the measurement of F-wave latency. Our study underline the significance of early neurophysiological diagnosis, since hyperglycemia can play an acute role in NCV slowing, despite the absence of clinical symptoms, particularly in the first three months after the diagnosis has been confirmed.

040: Myocardial bridging: comparative analysis of coronary angiography and autopsy results

Background Myocardial bridge (MB) is congenital myocardial band overriding a portion of a coronary artery, mainly LAD. Incidence on coronary angiography (CA) appears lesser than on autopsy, which can be ethnics-related, while clinically all forms of coronary artery disease (CAD) are reported: from benign arrhytmias up to sudden death. Aim We sought to determine incidence of MBs in the Serbian population along with respective clinical features. Methods Retrospective analysis was carried out in the same population, during the same 1-year time-frame and comprised consecutive: (A) 721 autopsies, with LM studies of the tunneled vessel (TV) wall together with the morphometric analysis of the ventricular myocardium supplied by TV (experimental group) and the ventricular myocardium of the same heart but with a different blood supply (control group); (B) 4510 CA of symptomatic patients were re-assessed for presence of MBs. Results (A) MBs were described in 6 cases (0.8%): 5 male, all over 70yrs. Only single MB over LAD were found, while all showed: a) TV’ intensive atherosclerotic changes proximal to MB, only focal in the tunneled part; b) intensive interstitial fibroses of the TV-supplied myocardium. (B) MBs were found in 42pts (0.93%): 33 male, aged of 55+11yrs, with single MB over the mid-LAD. 29% were CAD-free, 43% had 1-vessel CAD, 2-v-CAD (24%) and 3-v-CAD (4%). MBs were most frequent in hearts with right coronary dominance (69%). Hypertension and smoking were equally present (69%), dyslipidemia (59%), family history of CAD (48%) and diabetes (21%). Pts presented with stable angina (40%), nonspecific symptoms (14%), unstable angina (7%) and supraventricular arrhythmia (5%), with a history of an anterior wall STEMI vs. NSTEMI in 26% vs. 7%. Conclusions This first overview of MBs-incidence in Serbia (0.8% on autopsy vs. 0.9% on CA) might underestimate its actual presence, which prompted us to continue prospectively.

309: Successful treatment of mitral valve endocarditis during the human brucellosis relapse

Background Brucellosis is the most frequent zoonotic infectious disease in the world. The most common affected systems are the locomotor, gastrointestinal, genitourinary and hematologic. Endocarditis is the most common cardiovascular manifestation of brucellosis with high mortality rate. Despite treatment by means of several antibiotic regimens, the relapse is estimated to occur in 5-40%. Brucella is an intracellular pathogen which makes it inaccessible to antibiotics and relapse can occur after a variable period of clinical latency. Case report This is a case report of Brucella mitral valve endocarditis as a complication of severe relapse of Brucella infection, which was successfully treated by medical and surgical therapy. Conclusion Cardiac involvement in human brucellosis is rare, especially in relapse, but should not be overlooked, since it is a major mortality cause in brucellosis infection. The success of Brucella endocarditis treatment depends on timely and complete medical and epidemiological evaluation, which leads to adequate medicamentous and surgical treatment of the patient. This approach would reduce complications and mortality associated with Brucella endocarditis and would improve patients quality of life.

308: Asymptomatic carotid artery stenosis in patients with coronary artery disease: could it be predicted?

Background Asymptomatic carotid artery stenosis (CAS) combined with coronary artery disease (CAD) remains of special interest to cardiologists and cardiac surgeons given the fact that coronary artery bypass grafting (CABG) is one of the most frequent procedures and that CAS cause 30% of all post-CABG strokes. Aim Determining the frequency of asymptomatic CAS in CAD patients and to what degree the extent of CAD and presence of certain risk factors can be indicators of CAS in asymptomatic patients. Methods Retrospective evaluation of consecutive patients that underwent CABG during one year in our center whithout present symptoms or signs of CAS. The pre-operative Doppler ultrasonography was used to determine the presence and the degree of CAS. Patients were divided according to the presence of significant CAS. Impact of age, gender, body mass index, presence of hypertension, diabetes, smoking, cholesterol, triglycerides and three echo-cardiographic variables obtained from transthoracic echocardiography (the presence of aortic wall sclerosis, aortic valve sclerosis and mitral valve calcification) were assessed. Results Hemodinamically significant asymptomatic CAS was present in 18 patients (7.1%). The risk of presence of CAS was more significant in those older than 60 years (OR 2.58; 95% CI 0.98–6.77) and in patients with left main stenosis (OR 8.92; 95% CI 3.2–24.83). Conclusion The presence of asymptomatic CAS is strongly associated with the presence of left main stenosis and an age older than 60. Noninvasive screening for carotid disease should be done in these subgroups of patients reffered to CABG.

Evaluation of neurophysiological parameters and good metabolic control in patients with type 1 diabetes mellitus

INTRODUCTION Numerous authors have indicated the beneficial effect of glycoregulation on micro- and macro-angiopathic complications. OBJECTIVE The aim of the study was to examine whether intensive treatment with maintaining blood glucose concentrations close to normal range could improve electrophysiological parameters. METHODS The study involved 81 patients with type 1 diabetes mellitus type 1 randomly assigned to intensive insulin therapy. The patients were followed for a period of 3 months by metabolic and electrophysiological control. The metabolic control included daily measurement of concentration of blood glucose and HbA1c and lipid status, while the neurophysiological control included nerve conduction velocity (NCV) of median, peroneal, tibial and sural nerve and latency of F wave. RESULTS In the beginning of our study blood glucose was 9.10 +/- 3.69 mmol/l and HbA1c 8.12 +/- 1.20%. After 3 months of administered intensive insulin therapy, blood glucose was 7.88 +/- 2.79 mmol/l and HbA1c 6.63 +/- 1.33. After 3 months NCV improved in the tibial, median and sural nerve (p < 0.05) and latency of F wave. CONCLUSION We found a significant association between the metabolic control and NCV findings which suggests that good metabolic control influences the improvement of neurophysiological parameters in patients with type 1 diabetes mellitus.

Poster 112: The influence of a combination of infrared light with transcutaneous electric nerve stimulation in patients with cervical symptoms of ankylosing spondylitis.1

Abstract Objective: To study the advantages of a home treatment combination of infrared (IR) light with transcutaneous electric nerve stimulation (TENS) over the classic approach of nonsteriodal anti-inflammatory drugs (NSAIDs) in treating ankylosing spondylitis (AS). Design: Prospective randomized follow-up study. Setting: Academic medical center. Participants: Patients were randomized into 2 groups (20 each). All were men, ages 30 to 40 years old, with cervical symptoms of AS. Interventions: Range of motion of the cervical spine and presence of pain in the neck were evaluated in each group. Patients in both groups underwent kinesitherapy during 2 weeks. Also, group 1 took NSAIDs (7.5mg of meloxicam twice a day), while group 2 had TENS (30min) applied with IR lamp 300W (20min) over the cervical region every morning. Main Outcome Measures: Pain decrease and movement increase. Results: After 2 weeks, in group 1, 60% of the patients experienced a reduction in pain, while 25% experienced an increased amplitude of neck movements. In group 2, 40% experienced a reduction in pain and 75% had a significant increase in neck movements. Conclusions: Application of TENS with an IR lamp is useful and practical in home treatment of patients with cervical symptoms of AS. Also, we must not forget kinesitherapy and NSAIDs, which are a necessary part of treatment.