Darija Mahović

Characteristics of Heart Rate Variability in War Veterans with Post-Traumatic Stress Disorder after Myocardial Infarction

OBJECTIVE The goal of the study was to evaluate differences in heart rate variability (HRV) among post-myocardial infarction (MI) patients, depending on their participation in the Croatian war and on established diagnoses of post-traumatic stress disorder (PTSD). METHODS The study included 34 male war veterans with diagnosed PTSD who had suffered a first MI and 34 age-matched post-MI patients without PTSD. Cardiac autonomic balance was evaluated through HRV analysis. RESULTS There were no differences in the mean R-R interval or overall HRV between the analyzed groups. Post-MI patients with PTSD had lower values for the square root of the mean of squared successive differences in R-R intervals (p = 0.02), the percentage of R-R intervals that were > or =50 milliseconds different from the previous interval (p = 0.03), and the high-frequency component (p = 0.03) but had higher values for the low-frequency component (p = 0.01) and the low-frequency/high-frequency ratio (p = 0.02), compared with post-MI patients without PTSD. CONCLUSION Post-MI patients with PTSD have higher sympathetic and lower parasympathetic heart rate modulation activity, compared with patients with MI and no PTSD.

Association of refractory complex partial seizures with a polymorphism of ApoE genotype.

Apolipoprotein E (ApoE) is a constituent of many types of lipoproteins that play a role in metabolism of cholesterol and lipids in the body as well as in the brain. ApoE is synthesised in astrocytes and microglia and enter to neurons through LDL, LRP and VLDL receptors. Recently it was shown that ApoE is also produced in neurons. ApoE has a role in modulating learning and memory, structural plasticity, mobilization of cholesterol in repair, growth and maintenance of myelin and neuronal membranes during development and aging, and cell death after ischemic, convulsive, or other type of brain injury. The aim of this research was to investigate the possible association of ApoE gene polymorphism with the development of resistance to pharmacological therapy in patients with partial complex seizures with or without secondary generalization. In this prospective matched‐pair controlled study, 60 patients with cryptogenic epilepsy with complex partial seizures, with or without secondary generalization, who have been suffering for five or more years, were studied. The first group comprised 30 patients refractory to the current therapy, while the second group consisted of patients with well‐controlled seizures. The refractory and non‐refractory groups of patients differed significantly in their phenotypes. Phenotype E3/4 was six times more frequent in refractory group than among non‐refractory group. The lack of response was shown to be significantly associated with the presence of β allele. This study provided evidence that the presence of β4 allele is more often associated with a lack of response to current antiepileptic drugs as compared to β2 and β3 alleles.

Outcome of patients with normal and decreased heart rate variability after coronary artery bypass grafting surgery

BACKGROUND Previous studies have shown that after coronary artery bypass grafting (CABG), heart rate variability (HRV) becomes decreased, even more significantly than in patients after myocardial infarction (MI). According to some reports, unlike in patients after MI, decreased postoperative HRV does not increase mortality in CABG patients. The aim of this study was to compare differences in mortality rate in CABG patients with normal vs. decreased postoperative HRV. METHODS This study included 206 consecutive patients who underwent CABG. During stationary rehabilitation, 24-hours Holter ECG was performed on all the patients, and HRV was analyzed from its recordings. After leaving cardiac rehabilitation, all patients were contacted in writing to provide data on their health in the follow-up period. In the analysis of survival rate depending on HRV findings log-rank analysis and Kaplan-Meier method were used. RESULTS Seventy four CABG patients (36%) had SDNN <93ms while 132 patients (64%) had normal overall HRV (SDNN≥93ms). The average time of follow-up period was 3.0±1.8years. In the follow up period 16 (7.8%) adverse coronary events were recorded. Out of the 16 CABG patients, 13 patients had decreased HRV and 3 had normal HRV (p=0.001). CONCLUSIONS Contrary to previous reports, results of this study show that the CABG patients with postoperative decreased HRV have a higher mortality rate than patients with normal HRV.

Level of sFas/APO 1 in serum and cerebrospinal fluid in multiple sclerosis

The aim of the study was to measure sFas/APO 1 serum and cerebrospinal fluid (CSF) levels in patients with relapsing-remitting multiple sclerosis (MS) during relapses, as an index of inhibition of apoptosis of activated lymphocytes in eight patients with clinically definite multiple sclerosis, and 12 healthy controls. The level of serum and CSF sFas/APO 1 was determined by commercially available enzyme-linked immunosorbent assay (ELISA) kits. No significant differences were detected in the sFas/APO 1 serum level between patients and controls, but the levels in CSF was lower in the former. Our results suggest the possibility of Fas mediated apoptosis as a contributing factor in the pathogenesis of multiple sclerosis.

Changes in Heart Rate Variability after Coronary Artery Bypass Grafting and Clinical Importance of These Findings

Heart rate variability is a physiological feature indicating the influence of the autonomic nervous system on the heart rate. Association of the reduced heart rate variability due to myocardial infarction and the increased postinfarction mortality was first described more than thirty years ago. Many studies have unequivocally demonstrated that coronary artery bypass grafting surgery generally leads to significant reduction in heart rate variability, which is even more pronounced than after myocardial infarction. Pathophysiologically, however, the mechanisms of heart rate variability reduction associated with acute myocardial infarction and coronary artery bypass grafting are different. Generally, heart rate variability gradually recovers to the preoperative values within six months of the procedure. Unlike the reduced heart rate variability in patients having sustained myocardial infarction, a finding of reduced heart rate variability after coronary artery bypass surgery is not considered relevant in predicting mortality. Current knowledge about changes in heart rate variability in coronary patients and clinical relevance of such a finding in patients undergoing coronary artery bypass grafting are presented.

The dynamics of soluble Fas/APO 1 apoptotic biochemical marker in acute ischemic stroke patients.

PURPOSE Until recently, neuronal death in ischemic stroke infarction was ascribed exclusively to necrotic process. However, experimental animal models of cerebral ischemia suggest apoptosis to play a role in the pathogenesis of cerebral infarction. The aim of this study was to determine the level and monitor the dynamics of soluble Fas/APO 1 (sFas/APO 1) in serum and cerebrospinal fluid of acute ischemic stroke patients. MATERIAL AND METHODS This prospective study included 23 patients with first ever, computed tomography verified acute ischemic stroke and 20 control subjects with other functional neurologic disorders. Serum and cerebrospinal fluid sFas/APO 1 levels were determined on several occasions. Blood samples were obtained on day 1, 3 and 12, and lumbar puncture on day 3 and 12 of disease onset. Quantitative sandwich ELISA method was used on sFas/APO 1 determination. RESULTS On day 1 of disease onset, serum and cerebrospinal fluid sFas/APO 1 levels were significantly higher in stroke patients as compared to control subjects, and then gradually declined during the period of monitoring. CONCLUSION Study results confirmed the dynamic pattern of sFas/APO 1 in serum and cerebrospinal fluid of patients with acute ischemic stroke, suggesting the possible role of apoptosis in the pathogenesis of cerebral infarction.

Tako-Tsubo syndrome: A diagnostic challenge

We have read with interest the article of Atanassova et al. [1] published in your respected Journal about electrocardiographic (ECG) changes during the acute phase of subarachnoid hemorrhage; which encouraged us to replay with regard to this subject.Tako-Tsubo Syndrome (TTS), or stress cardiomyopathy, is an entity of unknown etiology and pathophysiology that manifests with sudden, severe chest pain and/or dyspnea. It is generally triggered by emotional or physical stress, and most instances are reported in postmenopausal women. ECG changes are similar to acute myocardial infarction with ST-elevation (STEMI); laboratory markers of myocardial lesion are usually mild to moderately high; and coronarography shows no significant pathomorphological changes in the coronary arteries. Ventriculography and echocardiography show reversible akinesis and ballooning of the left ventricle apex with reduced ejection fraction that normalizes within 2 to 4 weeks [2,3]. In this syndrome, the left ventricle of a patient takes the shape of an octopus trap [4]. The main trigger of the complex pathophysiological mechanism that instigates TTS is stress. High catecholamine plasma level as a result of stress-induced sympathetic hyperactivity affects the cardiomyocytes of the left ventricle by b adrenoreceptors, and a complex chain of intracellular second signals [5,6]. The main symptom of TTS is sudden, severe chest pain and/or dyspnea, but it can also manifest with cardiogenic shock, syncope, or malignant heart arrhythmia [3]. ECG changes are similar to acute myocardial infarction with ST-elevation, significant ST-segment elevation most often reported in precordial leads. ST-segment elevation usually persists for a few hours and then becomes isoelectric. After some time, ECG shows a deep negative T wave, usually in all precordial leads, that can persist for a few months from the initial symptoms (Figure 1) [6,7]. For diagnosis of “real” TTS, some criteria must be applied. According to the Mayo Clinic, they are as follows: ECG changes similar to STEMI; absence of obstructive coronary artery disease; transient akinesis or dyskinesis of the left ventricle walls; absence of any kind of head trauma; intracranial bleeding; pheochromocytoma; and any other existing cardiomyopathy [4]

RECURRENT TRANSITORY ISCHEMIC ATTACKS WITH SUBSEQUENT DEVELOPMENT OF THE ISCHEMIC STROKE AS INITIAL MANIFESTATION OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS IN DEPRESSED PATIENT

Eosinophilic granulomatosis with poliangiitis (EGPA; formerly known as Churg Strauss syndrome) is a systemic disorder characterised by asthma, peripheral eosinophilia, sinusitis and affection of different organic systems, e.g. peripheral nervous system, skin, kidney and gastrointestinal tract. EGPA is a rare entity that is characterised by widespread vasculitis which affects both small and medium sized blood vessels, but in most cases initial clinical manifestations are asthma and skin changes (Sinico & Bottero 2009). The pathogenetic mechanisms are not completely clear. Following criteria are widely used for the EGPA diagnosis: asthma, eosinophilia (more than 10% in complete blood count CBC), monoor polyneuropathy, pulmonary infiltrates (may be transient), paranasal sinusitis and extra-vascular eosinophils (biopsy of arteries, arterioles or venules may demonstrate presence of eosinophilic infiltrates in the extravascular area) (Groh et al. 2015). EGPA is a rare systemic disorder. The annual incidence varies according to the published literature, with estimated prevalence of 17.8/ 1.000.000 (Watts et al. 2005). The most common neurologic manifestation of EGPA are peripheral neuropathy, usually mononeuritis simplex which untreated, may progress to symmetric or asymmetric polyneuropathy. Central nervous system (CNS) involvement (cerebral infarction and haemorrhage) is rare (Wolf et al. 2010). Eosinophilic vasculitis affects central nervous system (CNS) in less than 10% of cases (Sinico & Bottero 2009). We present a case of a male patient with EGPA and depression that initially manifested with atypical and rare clinical presentation of recurrent transitory ischemic attacks (TIAs) with subsequent development of the ischemic stroke.