Branko Gligic

Severe propranolol and ethanol overdose with wide complex tachycardia treated with intravenous lipid emulsion: A case report

Background. Propranolol is a highly lipid-soluble beta-blocker. We describe a case of severe propranolol overdose, with atypical dysrhythmia – wide complex tachycardia – which was successfully treated with lipid emulsion. Case report. A 31-year-old woman ingested approximately 3.6 g of propranolol along with ethanol. Clinical manifestations of poisoning included coma, seizures, respiratory failure, hypoglycaemia, circulatory shock, and dysrhythmias. An ECG revealed nonspecific intraventricular conduction delay, followed by wide complex supraventricular tachycardia. Toxicological analysis of blood showed ethanol 2.42 g/L and propranolol 4.21 mg/L. The patient responded poorly to conventional therapy, so intravenous lipid emulsion was used. Apart from IV dopamine, the only treatment after the onset of wide complex tachycardia was 20% Intralipid. Transient improvement was noticed after the initial dose of 500 mL; during the infusion of further Intralipid, blood pressure returned to normal and sinus rhythm was re-established. Conclusion. We believe that lipid emulsion had a beneficial effect in the treatment of propranolol toxicity.

Autologous bone marrow-derived progenitor cell transplantation for myocardial regeneration after acute infarction.

BACKGROUND Experimental and first clinical studies suggest that the transplantation of bone marrow derived, or circulating blood progenitor cells, may beneficially affect postinfarction remodelling processes after acute myocardial infarction. AIM This pilot trial reports investigation of safety and feasibility of autologous bone marrow-derived progenitor cell therapy for faster regeneration of the myocardium after infarction. METHODS AND RESULTS Four male patients (age range 47-68 years) with the first extensive anterior, ST elevation, acute myocardial infarction (AMI), were treated by primary angioplasty. Bone marrow mononuclear cells were administered by intracoronary infusion 3-5 days after the infarction. Bone marrow was harvested by multiple aspirations from posterior cristae iliacae under general anesthesia, and under aseptic conditions. After that, cells were filtered through stainless steel mesh, centrifuged and resuspended in serum-free culture medium, and 3 hours later infused through the catheter into the infarct-related artery in 8 equal boluses of 20 ml. Myocardial viability in the infarcted area was confirmed by dobutamine stress echocardiography testing and single-photon emission computed tomography (SPECT) 10-14 days after infarction. One patient had early stent thrombosis immediately before cell transplantation, and was treated successfully with second angioplasty. Single average ECG revealed one positive finding at discharge, and 24-hour Holter ECG showed only isolated ventricular ectopic beats during the follow-up period. Early findings in two patients showed significant improvement of left ventricular systolic function 3 months after the infarction. There were no major cardiac events after the transplantation during further follow-up period (30-120 days after infarction). Control SPECT for the detection of ischemia showed significant improvement in myocardial perfusion in two patients 4 months after the infarction. Echocardiographic assessment in these two patients also showed significant improvement of systolic function three months after the infarction. CONCLUSION Preliminary results of the study showed that the transplantation of bone marrow-derived progenitor cells into the infarcted area was safe, and feasible, and might improve myocardial function. Further follow-up will show if this treatment is effective in preventing negative remodeling of the left ventricle and reveal potential late adverse events (arrhythmogenicity and propensity for restenosis).

Elevations in soluble CD40 ligand in patients with high platelet aggregability undergoing percutaneous coronary intervention.

High aggregatory responses despite antiplatelet treatment is associated with an increased risk of thrombotic complications following percutaneous coronary intervention (PCI). In the present study, we investigated the relationship between platelet aggregatory responses to ADP and the release of CD40L (sCD40L): an immunomodulatory compound involved in atherothrombosis – in patients undergoing PCI. ADP-induced platelet aggregation, sCD40L and soluble P-selectin (sP-selectin) were determined before and 24 h after PCI, in samples from 52 patients receiving aspirin and thienopyridines. Platelet aggregation to ADP above the median was defined as ‘high aggregation’, and aggregation below the median as ‘low aggregation’. Data below are medians and interquartile ranges. Patients with ‘high platelet aggregability’ had a significantly higher increase in both sCD40L (Δ-values: 0.78 (−0.19–3.18) vs. −0.65 (−2.10–0.00) ng/ml, P = 0.002) and sP-selectin (Δ-values: 8.0 (−2.00–16.00) vs. 4.50 (−13.00–0.50) ng/ml, P = 0.001) compared with patients with ‘low platelet aggregability’. In a multivariate linear regression analysis adjusted for clinical characteristics and type of preintervention therapy, the only independent predictors of sCD40L and sP-selectin were platelet aggregation to ADP before PCI (P < 0.001) and the combination of platelet aggregation to ADP before PCI and urgency of PCI (P < 0.001). Circulating CD40L is more markedly increased after PCI in patients with high ADP-induced platelet aggregation.

THERAPEUTIC APPROACH IN PATIENTS WITH A FLOATING THROMBUS IN THE RIGHT HEART

BACKGROUND The occurrence of a floating thrombus in the right heart, although rare, is a life-threatening condition requiring a specific approach. In most cases, these thrombi are a result of embolization from deep venous thrombosis, and have lodged temporarily in the right heart. The management of this condition is variable, depending on whether or not there is a thrombus entrapped within a foramen ovale (FO). OBJECTIVES To present the management of 2 patients with a free-floating thrombus in the right heart, and a third patient with an entrapped thrombus in the FO. CASE REPORTS Two patients with a free-floating thrombus in the right atrium who were treated with thrombolytic therapy had an immediate excellent outcome. The patient with a thrombus entrapped within the FO was scheduled for surgical removal of the thrombus due to an unacceptable risk of systemic embolization if treated with thrombolytic and anticoagulant therapy. Unfortunately, he developed an ischemic stroke on the fifth day of presentation, just a few hours before the scheduled surgery, despite meticulous monitoring of continuous heparin infusion with activated partial thromboplastin time. CONCLUSION Thrombolytic therapy is recommended in patients with a free-floating thrombus in the right heart. However, in patients with a thrombus entrapped within an FO, delaying surgical removal of the thrombus may be deleterious due to unpredictable systemic embolization.

Apolipoprotein(a) gene polymorphisms (TTTTA)n and G/A-914 affect Lp(a) levels in ischemic heart disease patients from Serbia

SummaryOBJECTIVES: Lipoprotein(a) (Lp(a)) concentration is determined primarily by the apolipoprotein(a) (apo(a)) gene. The pentanucleotide (TTTTA)n repeat and G/A-914 polymorphisms are in the 5′ promoter region of the apo(a) gene. To elucidate whether these polymorphisms affect Lp(a) levels, a total of 211 Serbian adults were investigated. DESIGN: One hundred and eleven patients with ischemic heart disease and 100 healthy controls were genotyped and Lp(a) levels determined. RESULTS: Lp(a) concentrations differed according to the (TTTTA)n genotypes: among those having at least one allele 8, patients had significantly higher Lp(a) values than controls. A decreasing trend of Lp(a) values was associated with the –914A allele in controls but the opposite was true in patients. Patients with genotype TTTTA allele 8/AA-914 had significantly higher Lp(a) values than those without allele 8/AA (p < 0.05). The >8>8/GG genotype was not detected. Significant linkage disequilibrium between (TTTTA)n and G/A-914 polymorphism (p < 0.001) was found. In multivariate regression analysis, the G/A-914 polymorphism significantly (p < 0.05) affected Lp(a) levels in patients, after taking into account the (TTTTA)n polymorphism. CONCLUSION: These results indicate that (TTTTA)n and G/A-914 polymorphisms affect Lp(a) levels in ischemic heart disease as a consequence of the linkage disequlibrium.ZusammenfassungZIEL: Das Lipoprotein(a) (Lp(a)) wird hauptsächlich vom Apolipoprotein(a)-(Apo(a)-)-Gen bestimmt. Im 5′-Promotor-Gen des Apo(a)-Gens bestehen Pentanukleotid-(TTTTA)n-Wiederholungs- und G/A-914-Polymorphismen. Ziel dieser Studie war es, einen möglichen Einfluss dieser Polymorphismen auf die Lp(a)-Konzentrationen zu erfassen. DESIGN DER STUDIE: Bei 111 Patienten mit ischämischer Herzerkrankung und bei 100 Kontrollpersonen erfolgte eine entsprechende Genotypisierung und eine Bestimmung der Lp(a)-Spiegel. ERGEBNISSE: Die Lp(a)-Konzentrationen unterschieden sich entsprechend der (TTTTA)n-Genotypen: Von den Personen, die wenigstens ein Allel aufwiesen, hatten 8 Personen signifikant höhere Lp(a)-Spiegel als die Kontrolle. Ein abnehmender Trend für Lp(a)-Spiegel bestand in Abhängigkeit vom Vorkommen des –914A-Allels bei den Kontrollen – dieser Trend war aber bei den Patienten entgegengesetzt. Patienten mit dem TTTTA-Allel-8/AA-914-Genotyp hatten signifikant höhere Lp(a)-Spiegel als jene ohne dieses Allel (p < 0.05). Der >8>8/GG-Genotyp wurde nicht gefunden. Es bestand ein signifikantes (p < 0,001) Koppelungs-Ungleichgewicht zwischen dem (TTTTA)n- und dem G/A-914-Polymorphismus. Unter Berücksichtigung des (TTTTA)n-Polymorphismus beeinflusste der G/A-914-Polymorphismus die Lp(a)-Spiegel unserer Patienten (multivariate Regressionsanalyse) signifikant (p < 0,05). SCHLUSSFOLGERUNGEN: Unsere Ergebnisse zeigen, dass (TTTTA)n- und G/A-914-Polymorphismen die Lp(a)-Spiegel von Patienten mit ischämischer Herzerkrankung als Folge des beobachteten Koppelungs-Ungleichgewichtes beeinflussen.

Myocardial damage size assessment in the zone of infarction for indicating rescue percutaneous coronary intervention

BACKGROUND The most important predictors of subsequent patients outcome after acute myocardial infarction (AIM) are infarct size, left ventricular ejection fraction, left ventricular volumes and presence and extent of residual myocardial ischemia. All of these variables can be directly determined through scintigraphic approaches. The presence and extent of myocardial ischemia are strong pre dictors for fatal and nonfatal cardiac events and improve risk statification beyound the information gleaned from clinical variables. CASE REPORT We presented a case of 66-years-old male with myocardial infarction of anteroseptal localization. Myocardial perfusion imaging (MPI) detected a large zone of residual ischemia (culprit lesion) within infarction zone. It has an important role in risk stratification after myocardial infarction, and indicates subsequent therapeutic decision making, in this case rescue percutaneous coronary intervention (PCI). After PCI we followed the therapy effect by MPI, and we found practically normal perfusion with minimal zone of defect perfusion in the apex. CONCLUSION Myocardial perfusion imaging has an important role in the initial evaluation and risk stratification of patients surviving myocardial infarction. It also plays a major role in guiding subsequent therapeutic decision making, and in monitoring the benefits of these therapeutic measures.

Relationship between QT dispersion and reperfusion in the acute myocardial infarction

BACKGROUND: QT dispersion (QTd) represents the parameter of the expanded heterogeneity of myocard of ventricles. The aim of this study was to examine the dynamics of changes of QTd during the first 5 days of the acute myocardial infarction (AMI) in dependence to noninvasively estimated success of thrombolytic therapy. METHODS: Thirty six patients with AMI were included in the study. All patients were treated with alteplaze according to rapid protocol. QTd (QTc max-QTc min) was measured immediately after the reception (0 min), after the thrombolytic therapy (90 min) and since the 2nd to the 5th day of the hospitalization. Reperfusion was estimated on the basis of electrocardiographic and biohumoral parameters. RESULTS: In the group of 36 patients, 22 male and 11 female, both parameters of the reperfusion were not compatible in 3 patients. The other 23 patients had the reperfusion, while 10 patients did not have it. At the reception there was no significant difference of QTd between the group with reperfusion (79 +/- 34 ms) and the group without reperfusion (65 +/- 19 ms). After receiving alteplase, the average QTd in the group with reperfusion was 67 +/- 31 ms, which was not shorter in relation to the group without reperfusion (70 +/- 23 ms). Since the 2nd day of AMI, significantly smaller QTd in pa-patients with reperfusion was not registered compared with the patients without the reperfusion (54 +/- 17 vs. 73 +/- 20 ms), whereas since the 3rd day the difference became significant (46 +/- 16 vs. 87 +/- 24 ms). On the 4th day it was 43 +/- 12 vs. 78 +/- 21 ms, and on the 5th day it was 38 +/- 11 vs. 62 +/- 23 ms. On the 1st day significant difference of QTd between the groups with and without reperfusion was not registered in the group of patients with anterior AMI (0 min: 97 +/- 47 vs. 72 +/- 16; 90 min: 68 +/- 47 vs. 72 +/- 20) whereas on the 2nd day it became statistically significant (51 +/- 15 vs. 74 +/- 20 on the 2nd day, 51 +/- 20 vs. 88 +/- 24 on the 3rd day, 46 +/- 10 vs. 81 +/- 19 on the 4th day and 40 +/- 8 vs. 69 +/- 22 ms on the 5th day. In the group of patients with inferolateral AMI, only on the 3rd day significant difference of QTd between the group with and the group without reperfusion was registered (43 +/- 14 vs. 69 +/- 29 ms), while in all other measuring it was not registered (0 min: 69 +/- 22 vs. 42 +/- 9; 90 min: 67 +/- 20 vs. 67 +/- 41; 55 +/- 19 vs. 60 +/- 25 on the 2nd day; 41 +/- 14 vs. 51 +/- 6 on the 4th day and 51 +/- 12 vs. 37 +/- 8 ms on the 5th day). CONCLUSION: Qt dispersion was of significantly shorter duration in patients with the successfully performed reperfusion in relation to the patients without the reperfusion. In patients with the anterior AMI, QTd was significantly different in patients with in relation to the patients without the reperfusion in distinction with the patients with inferolateral AMI.

Fibrinogen kao faktor rizika za ishemijsku bolest srca

Mesto fibrinogena u razvoju ateroskleroze i arterijske tromboze je verovatno znacajno jer on ucestvuje i u procesu nastanka i rasta plaka modulise hemoreoloske osobine krvi, a cini i osnovu koaguluma tokom procesa tromboze. Koncentracija fibrinogena u krvi je dobar nezavisan prognosticki parametar za razvoj akutnog infarkta miokarda, kako kod zdravih odraslih osoba, tako i kod koronarnih bolesnika. Nivo fibrinogena u krvi je delimicno genetski determinisan, ali i brojni faktori spoljasnje sredine uticu na njegov nivo. Vrlo je bitan odnos između fibrinogena i nekih drugih važnih faktora rizika. Fibrinogen i holesterol imaju izgleda sinergisticki ucinak na razvoj akutnog koronarnog sindroma. Moguce je da je fibrinogen jedna od najznacajnijih spona između pusenja i koronarne bolesti. Veoma je mali broj lekova koji se mogu dugorocno primenjivati i smanjiti nivo fibrinogena u krvi, tako da za sada ne postoje klinicke studije o vrednosti ovakve terapije u lecenju i prevenciji akutnih koronarnih sindroma. Shodno tome sve dok se ne dokaže da se smanjenjem nivoa fibrinogena u krvi smanjuje rizik za ispoljavanje koronarne bolesti, njegova uloga kao faktora rizika ostaje nedovoljno definisana.

Dynamics of electrocardiographic changes, brain-natriuretic peptide and cortisol levels in a patient with stress (takotsubo) cardiomyopathy--a case report.

INTRODUCTION Takotsubo cardiomyopathy is a transient acute heart failure syndrome caused by stress that provokes left ventricular mid-apical akinesis and mimics acute coronary syndrome. CASE REPORT A 66-year-old woman had chest pain and dispnoea a few hours before hospitalization. A sudden emotional stressful event preceded the symptoms. Electrocardiographic abnormalities--precordial ST elevation and modest increase of cardiac troponin mimiced acute myocardial infarction. However, echocardiographic examination showed apical ballooning with markedly diminished left ventricle ejection fraction and the obstruction in the outflow tract of the left ventricle. Coronary angiography at admission showed no coronary stenosis and slower blood flow through the left anterior descending artery. According to anamnesis, echocardiography and coronarography finding we established the diagnosis of stress cardiomyopathy--takotsubo cardiomyopathy. We described in details the slow but dynamic electrocardiographic changes, levels of brain natriuretic peptide, cortisol and echocardiography evolution of disease during a 4-month follow-up till the full recovery. CONCLUSION Stress (takotsubo) cardiomyopathy--became an important differential diagnosis of acute anterior myocardial infarction and it should be reconsidered every time when emotionally stressed patients with transient-apical akinesis or dyskinesis of the LV are present.

Myocardial Perfusion Imaging in Diagnosis of Culprit Lesion in Patients Undergoing Elective Percutaneous Coronary Intervention

Myocardial perfusion imaging (MPI) was developed in the 1970s and has been used increasingly in clinical cardiology since the 1980s (Underwood et al., 2004). Technical developments that have fuelled this recent increases are single-photon emission computed tomography (SPECT) imaging, pharmacological stress and ECG-gated SPECT imaging. MPI comprises the only widely available method of assessing myocardial perfusion directly and many previously published reports support its evidence in the diagnosis of myocardial ischemia and necrosis. Moreover, the prognostic value of this method for patients’ risk stratification has already been extensively reported, with an incremental prognostic value after clinical assessment, exercise electrocardiography and even above coronary angiography. Thus, MPI is an established imaging technique that is already an integral part of the management of coronary artery disease (CAD) (diagnosis, prognostication, selection for revascularization and assessment of acute coronary syndromes) and is included in a number of professional guidelines. (1, 2) In the past two decades, a great body of literature has established the use of nuclear imaging for risk stratification in patients with known or suspected CAD. Risk stratification is of crucial importance for the practice of contemporary medicine. Extending the paradigm of noninvasive cardiac testing beyond the detection of disease is especially important, may risk assessment permits patients who are identified as being at a high risk for subsequent cardiac events should receive aggressive management, possibly including cardiac catheterization for potential revascularization procedures that may improve their outcome. Conversely, the management focus in patients with low future event rate should be shifted toward risk factor modification and aggressive medical therapy, reserving invasive procedures for