D. Simonovic

Exercise elicits dynamic changes in extravascular lung water and haemodynamic congestion in heart failure patients with preserved ejection fraction: Exercise elicits dynamic changes in extravascular lung water and haemodynamic congestion in heart failure patients with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) represents about 50% of HF cases, and is a leading cause of morbidity and mortality.1 Typically, HFpEF patients are asymptomatic at rest but develop dyspnoea and pulmonary congestion with exercise or increased blood pressure, partly driven by impairment of diastolic function. In acute HF, a cascade of events starts with increased left ventricular (LV) filling pressures (‘haemodynamic congestion’) causing interstitial and alveolar oedema (‘pulmonary congestion’), before the appearance of signs and symptoms of congestion.2 In HFpEF, dynamic changes in diastolic function can be assessed by exercise test3; with exercise, diastolic stiffness induces acute elevation in invasively-measured wedge pressure.4 It is assumed that pulmonary congestion contributes to exercise intolerance; yet, there is no direct evidence of it. Lung ultrasonography (LUS), being capable of non-invasively scanning the pulmonary interstitium, might be well-suited to investigate this issue.5 Using standard cardiac transducers on chest echography, typical signals (‘B-lines’) can be visualized, which are strongly associated with echocardiographic and bio-humoral indices of congestion.6 Recently, LUS has been shown to reproducibly detect the rapid increase in pulmonary congestion typically seen when HF patients with reduced ejection fraction (HFrEF) exercise, through development or increase of B-lines.5,7,8 Additionally, stress B-line count correlates with natriuretic peptide concentration and estimated pulmonary pressures.8 Given the pathophysiological and clinical relevance of exercise response in HFpEF, it would be important to investigate pulmonary congestion also in this setting, as afforded by B-line assessment. However, this issue has remained largely unexplored. By LUS, we investigated changes in pulmonary congestion in response to exercise stress echocardiography (ESE) in HFpEF patients. B-lines were measured along with echocardiography and laboratory indices of congestion; findings were compared to those obtained in controls without HF.

Viral Myocarditis-Diagnostic and Therapeutic Challenge for Physicians

Viral Myocarditis-Diagnostic and Therapeutic Challenge for Physicians Myocarditis is defined as inflammation of the heart muscle according to clinical, immunohistological and pathological criteria. Myocarditis can manifest a wide spectrum of symptoms ranging from mild dyspnea or chest pain, and sometimes without a specific therapy it can lead to cardiogenic shock and death, too. According to the evidence, the incidence of myocarditis is 8-10 cases per 100.000 humans, and the prevalence of non-selected autopsies is 1-5 per 100 cases. The most common possible triggers for myocarditis are: coxsackie virus B3, parvovirus B19, adenovirus, and human herpesvirus 6. Viral myocarditis appears in three stages: acute viral infection, inflammatory cell infiltration, and myocardial remodeling. The initial patient evaluation includes a detailed history and a careful physical examination which should include an electrocardiogram, chest X-ray, blood studies, non-invasive imaging techniques. The diagnosis of myocarditis can only be obtained by investigations of endomyocardial biopsy, including: histology, immunohistology and molecular biology or virology. Therapy can be divided into supportive and specific therapy (immunosuppressive therapy, interferon, immunoglobulin, immune-adsorptive therapy, immune-modulation, vaccination). Virusni miokarditis - dijagnostički i terapijski izazov za lekare Miokarditis se definiše kao zapaljenje srčanog mišića prema kliničkim, imunohistohemijskim i patološkim kriterijumima. Miokarditis se može manifestovati širokim spektrom simptoma od blage dispneje do bola u grudima, a ponekad bez specifične terapije može dovesti do kardiogenog šoka i smrti. Prema podacima, učestalost miokarditisa je 8-10 slučajeva na 100000, a prevalenca na neselektovanim obdukcijama je 1-5 na 100 slučajeva. Najčešći mogući izazivači miokarditisa: koksaki virus B3, parvovirus B19, adenovirusi i humani herpesvirus 6. Patogeneza virusnog miokarditisa prolazi kroz tri faze: akutne virusne infekcije, infiltracije zapaljenskim ćelijama i remodelovanja miokarda. Početna evaluacija bolesnika obuhvata detaljnu istoriju bolesti i pažljiv fizički pregled; u daljem toku treba uraditi elektrokardiogram, rentgen srca i pluća, analize krvi, neinvazivne metode snimanja srca. Dijagnoza miokarditisa može se postaviti samo endomiokardnom biopsijom, uključujući: histologiju, immunohistologiju i molekularnu biologiju ili virusologiju. Terapija se može podeliti na suporativnu i specifičnu terapiju (imunosupresivna terapija, interferon, imunoglobulini, imuno adsorptivna terapija, imuno-modulacija, vakcinacija).

PREVALENCE OF ARTERIAL HYPERTENSION IN PATIENTS WITH ATRIAL FIBRILLATION: ONE CENTER EXPERIENCE

Objective: To determine the prevalence of hypertension in patients suffering from atrial fibrillation (AF), to assess echocardiographic parameters in patients with AF with or without hypertension, and to assess the current status of the use of anticoagulation for the treatment of AF. Design and method: The study included 167 patients with AF: 116 men (69.46%) and 51 women (30.54%) who were hospitalized at our University Hospital between 2014. and 2016 year. Out of 167 patients with AF, 133 (79.6%) had hypertension (group AFHT), while 34 (20.4%) had not (group AF). In all pts echocardiography study was performed and size of left atrium (LA), ejection fraction (LVEF) and systolic pulmonary artery pressure (sPAP) were determined. Results: The most common type of atrial fibrillation AFHT group was paroxysmal (37.5%), while in the AF group was permanent (40.2%). Size of LA was higher in AFHT group than in AF group (48.3 ± 6.84 vs 47.4 ± 10.82 mm, ns), as well as LVEF 49.5%vs 48.8% (ns). Patients with new diagnosed AF and hypertension had statistically higher values of LVEF than patients with first diagnosed AF without hypertension (53.0 ± 14.6 vs 39.2 ± 10.5; P < 0,042). Value of sPAP was higher (ns) in the subgroup of pts with first diagnosed and pts with persistent AF in AFHT than in AF group. At the admission, only 98 (58.7%) pts had used oral anticoagulant therapy, while 127 (76.1%) pts was on OAT at discharge. Conclusions: Our study showed high prevalence of arterial hypertension in patients with atrial fibrillation. In pts with AF, size of LA, LVEF and sPAP are higher in pts with than without hypertension. In spite of high prevalence of AF, use of OAT is still low.

IMPACT OF SHORT-TERM EXERCISE TRAINING ON ARTERIAL BLOOD PRESSURE AND QT DISPERSION IN DIABETIC PATIENTS AFTER MYOCARDIAL INFARCTION

Objective: The aim of this study was to establish the influence of short-term exercise training on arterial blood pressure and QT dispersion in diabetic patients after myocardial infarction. Design and method: The study involved 139 diabetic patients after myocardial infarction (average age 55.7 years), in the sinus rhythm without AV blocks or branch blocks. Patients were randomly divided into the physical training group (TG: 115 patients) and non-training group (NTG: 24 patients). Patients were of similar age, site of infarction and baseline stress test duration. In all subjects standard ECG and exercise test on treadmill were performed and after that TG patients were included in a training program for three weeks. TG patients were instructed to follow a training program using the bicycle ergometer (10 min, 2 times a day), gymnastic exercises, and walking. The patients continued to take the same medicaments in same doses. From standard ECG corrected QT dispersion (QTdc) was calculated. Results: After program of physical training in TG of patients, significant reduction of QTdc was found, from 81.9 ± 24.8 to 73.5 ± 23.7 ms; p < 0.01. Also, in TG of patients, after program of physical training, we have found significant reduction of systolic blood pressure from 137.6 ± 12.9 to 128.4 ± 12.1 mmHg; p < 0.001; of diastolic blood pressure from 87.1 ± 7.9 to 82.9 ± 9.1 mmHg; p < 0.001 and of double product from 12834.6 ± 1975.2 to 11392.1 ± 1684.3 beat/min x mmHg; p < 0.001. In TG of patients, after program of physical training, significant reduction of glycemia was found, from 7.9 ± 2.9 to 6.9 ± 1.9 mmol/L; p < 0.005. In contrast, NTG of patients showed no significant changes. Conclusions: Short-term exercise training has favourable effects on arterial blood pressure and QT dispersion in diabetic patients after myocardial infarction. Physical training led to the significant decrease of myocardial oxygen uptake at rest and probably decreased the possibility of arrhythmia events in diabetic patients after myocardial infarction.

[PP.25.13] IMPACT OF EXERCISE TRAINING ON BIOMARKERS ON ENDOTHELIAL FUNCTION IN HYPERTENSIVE PATIENTS WITH METABOLIC SYNDROME

Objective: To evaluate the effects of exercise training on circulating blood markers of endothelial function: nitric oxide (NOx), Advanced Oxidation Protein Products (AOPP) and Xanthine Oxidase (XO) in hypertensive patients (pts) with metabolic syndrome. Design and method: 80 male hypertensive pts after myocardial infarction were studied. At baseline and after 3 weeks in all pts values of NOx, AOPP and XO were determined and exercise test was performed. After the initial study, pts were randomized to group with metabolic syndrome (MetS group, n = 40) and group without metabolic syndrome (no- MetS group, n = 40). All pts underwent a supervised 3 weeks aerobic exercise training at residential center. Results: Baseline value of NOx was lower (P = 0.018), and values of AOPP and XO were higher (ns for both) in MetS than in no- MetS group. After 3 weeks values of NOx increased in both groups: in MetS group from 39.09 ± 14.34 to 44.13 ± 13. 57 &mgr;mol/l (P = 0.025) and in no- MetS group from 47.11 ± 15.32 to 51.81 ± 16.48 &mgr;mol/l (P = 0.018), with mean difference higher in MetS than in no- MetS group 5.03 ± 13.71 vs 4.71 ± 12.01, ns. Compared to the baseline, value of XO at the end of the study was significantly lower in both groups (P < 0.0005, both) with mean difference higher in MetS than in no- MetS group (103.67 ± 27.57 vs 99.36 ± 28.11, ns) and with lower second value in MetS than in no- MetS group (P = 0.46).Value of AOPP significantly decreased in both groups (MetS group, P < 0.009; no- MetS group P = 0.002). After 3 weeks level (METs) and duration of exercise test significantly increased in both groups (P < 0.0005) with slightly higher mean increase of duration in MetS than in no- MetS group (ns). Conclusions: Regular residential exercise training induced improvement in endothelial function in hypertensive pts expressed through significant increase of NOx and decrease of XO and AOPP. Higher increase in NOx and reduction in XO in MetS than in no- MetS pts suggests that exercise training induces more pronounced benefit in pts with than in pts without metabolic syndrome.

Case Report of the Patient with Acute Myocardial Infarction: “From Flatline to Stent Implantation”

Summary Asystole is a rare primary manifestation in the development of sudden cardiac death (SCD), and survival during cardiac arrest as the consequence of asystole is extremely low. The aim of our paper is to illustrate successful cardiopulmonary resuscitation (CPR) in patients with acute myocardial infarction (AMI) and rare and severe form of cardiac arrest - asystole. A very short time between cardiac arrest in acute myocardial infarction, which was manifested by asystole, and the adequate CPR measures that have been taken are of great importance for the survival of our patient. After successful reanimation, the diagnosis of anterior wall AMI with ST segment elevation was established. The right therapeutic strategy is certainly the early primary percutaneous coronary intervention (PPCI). In less than two hours, after recording the “flatline” and successful reanimation, the patient was in the catheterization laboratory, where a successful PPCI of LAD was performed, after emergency coronary angiography. In the further treatment course of the patient, the majority of risk factors were corrected, except for smoking, which may be the reason for newly discovered lung tumor disease. Early recognition and properly applied treatment of CPR can produce higher rates of survival.