Luka Zaputović

Unmasking effect of propafenone on the concealed form of the Brugada phenomenon

A case report of a patient with frequent ventricular premature beats but with an otherwise normal ECG and no structural heart disease. Propafenone in therapeutical doses unmasked the ECG picture of the Brugada phenomenon

Prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and without right ventricular involvement

Data were obtained and analyzed in 243 patients with acute inferior myocardial infarction who were admitted to the coronary care unit during the years 1987 and 1988. One hundred and ninety-eight patients had no signs of right ventricular involvement (group I), whereas 45 patients had inferior myocardial infarction with right ventricular infarction (group II). Patients were divided into groups depending on the presence or absence of complete atrioventricular block during hospital stay (groups Ia and IIa without block and groups Ib and IIb with block). Selected clinical and laboratory variables were compared for each group. We found that patients with inferior myocardial infarction and complete atrioventricular block had significantly higher mortality rates only in the presence of right ventricular infarction: 41% mortality rate in group IIb versus 11% mortality rate in group Ib (p less than 0.05). Patients with right ventricular infarction but without complete atrioventricular block (group IIa) had a mortality rate similar to that found in patients with inferior myocardial infarction and no atrioventricular block (group Ia): 14% versus 11% (p = NS). In patients with inferior myocardial infarction without right ventricular involvement (group I), complete atrioventricular block did not influence survival: 14% mortality rate in group Ib versus 11% mortality rate in group Ia (p = NS). The excessively high mortality rate in patients who have inferior myocardial infarction with right ventricular involvement and complete atrioventricular block could be the consequence of greater infarct size, but the synergistic influence of right ventricular infarction and complete atrioventricular block could be the other factor that influences outcome.

C-reactive Protein Is a Strong Predictor of Mortality in Hemodialysis Patients

Background. To establish the baseline cutoff value of C-reactive protein (CRP) that would predict increased overall and cardiovascular mortality in patients with end-stage renal disease (ESRD). Methods. A cohort of 270 prevalent hemodialysis patients treated at Rijeka University Hospital was eligible for the study. Monthly CRP measurements were performed for three consecutive months. Only the patients with CRP values varying <20% were included (n=256). During the follow-up, 24 patients were transplanted and therefore excluded from the analysis. The CRP cutoff point of 6.2 mg/L was established by Receiver Operating Characteristic curve. The patients were divided into four groups according to their CRP values. Group 1 included 80 (34.5%) patients with CRP <3.0 mg/L, group 2 included 23 (9.9%) patients with CRP 3.0–6.1 mg/L, group 3 consisted of 18 (7.7%) patients with CRP 6.2–10.0 mg/L, and group 4 included 111 (47.9%) patients with CRP >10.0 mg/L. The survival was evaluated by Kaplan-Meier curve. Results. During the two-year follow-up, 59 patients died. The major cause of death was cardiovascular disease (64%). Significantly higher overall and cardiovascular mortality was observed in group 3 when compared with groups 1 and 2 (χ2=11.97; P < 0.001) and in group 4 when compared with groups 1 and 2 (χ2=14.40; P<0.001). Compared with survivors, non-survivors had a higher median CRP value (19.0 [1.5–99.7] mg/L vs. 2.3 [0.1–49.1] mg/L, respectively; P<0.001). Conclusion. Serum concentration of CRP above 6.2 mg/L is a strong predictor of overall and cardiovascular mortality in patients with ESRD.

Relationship between QT dispersion and the incidence of early ventricular arrhythmias in patients with acute myocardial infarction

There is controversy about the influence of QT dispersion on the incidence of early ventricular arrhythmias in patients with acute myocardial infarction (AMI). The QT and QTc dispersion (QTd, QTcd) between two groups of patients with AMI were compared: 39 patients with early sustained ventricular tachycardia or ventricular fibrillation (VT/VF) and 40 patients without such arrhythmias. QTd and QTcd were calculated from the admission and predischarge ECG, expressed as the difference between the maximum and minimum QT and QTc interval in 12 leads. The coefficient of variability was also calculated (VQT, VQTc). Groups did not differ significantly in age, incidence of previous infarction, Killip class, electrolyte status, infarct location, expected and final ECG infarct size, enzymatic infarct size, thrombolytic treatment and reperfusion rate, i.e., in variables that could influence the VT/VF occurrence. On admission, patients with VT/VF had significantly greater QTd (77+/-23 vs 53+/-27 ms, P<0.001) and QTcd (90+/-29 vs 62+/-28 ms, P<0.001); VQT and VQTc were also significantly higher. Although similar differences existed on predischarge ECG, they were smaller. The results indicate that QT dispersion varies during the illness, and that measurements of QT dispersion could be helpful in predicting serious ventricular arrhythmias.

Nonalcoholic fatty liver disease (NAFLD): A new risk factor for adverse cardiovascular events in dialysis patients

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in Western countries. Today it is believed that NAFLD is a hepatic manifestation of metabolic syndrome, and thus it is closely related to the cardiovascular morbidity and mortality. Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality in patients with end-stage-renal disease (ESRD). NAFLD and ESRD share some important cardiometabolic risk factors and possible common pathophyisiological mechanisms, and are linked to an increased risk of incident CVD events. We hypothesize that the coexistence of these two conditions could lead to much faster progress of the aterogenic process. Furthermore, patients with ESRD who suffer from NAFLD have a much higher risk for the development of adverse CVD events. Given the high prevalence of NAFLD, and its tight association with other manifestations of the metabolic syndrome and thus cardiovascular complications, it is important to recognize and aggressively treat this condition in ESRD patients. To evaluate this hypothesis, we propose the use of non-invasive methods such as transient elastography (TE) (Fibroscan-CAP) for the detection and quantification of liver steatosis and fibrosis, as well as an abdominal ultrasound for detecting liver steatosis. We focus on their correlation with carotid intima-media thickness (IMT) and plaque as surrogate measures of increased cardiovascular risk in HD patients in order to investigate the association of NAFLD and increase risk of adverse CVD events. This evaluation will prove useful in assessing the risk in HD patients with NAFLD for increase CVD mortality.

Assessment of Hemodialysis Adequacy by Ionic Dialysance: Comparison to Standard Method of Urea Removal

Background. The hemodialysis adequacy is one of the most important issues influencing the survival of patients on maintenance hemodialysis (HD). Assessment of measuring the delivered dialysis dose using clearance × time/volume (Kt/V) index requires multiple blood sampling. New methods for assessment of dialysis dose based on ionic dialysance (ID) have been suggested. Online conductivity monitoring (using sodium flux as a surrogate for urea) allows the repeated noninvasive measurement of Kt/V on each HD treatment. In this study we have compared this method with the standard method of estimating Kt/V. Methods. We studied 24 established HD patients over a 4 week time period. Patients were dialyzed using Fresenius 4008S dialysis monitors, equipped with modules to measure ID. Data were manually collected and analyzed using the appropriate statistical software. Urea removal (UR) was measured once a week by a two-pool calculation, estimating an eKt/V. Results. The Kt/V measured by ID highly correlated with the one derived from the measurement of the UR (r = 0.8959, p< 0.0001). The ID underestimated UR by the mean of 6%. The ID varied greatly within individual patients with a median of 1.29 ± 0.22. If the eKt/V ≥ 1.2 is considered adequate, 33% of the patients would have been inadequately dialyzed. The mean HD duration to achieve an adequate dialysis was 4 hours and 47 minutes with high interpatient variability. Conclusion. The ID seems to be an easily obtained measure of the delivered dialysis dose, correlating well with standard UR method. Substantial individual variations imply that repeated measures (ideally for all treatments) are necessary to obtain a real answer to the mean treatment dose being delivered to the patients.

Bone mineral densitometry in patients on hemodialysis: difference between genders and what to measure

Introduction: Chronic kidney disease (CKD) and osteoporosis are important health problems. There is an interrelationship between osteoporosis and CKD. Bone densitometry is the “gold” standard in the diagnosis of osteoporosis. Unfortunately, there are some problems with the interpretation of bone densitometry in CKD patients. The goal of this study was to determine bone mineral density (BMD) in CKD patients, to assess the difference between genders and different sites of bone densitometry correlation between BMD and laboratory parameters, and to assess the most optimal measuring site. Methods: We studied 134 hemodialysis (HD) patients (62 females, 72 males). The mean age was 56.4 ± 12.4 years and the mean duration of HD was 54.4 ± 60 months. BMD of the lumbar spine (posterior–anterior projection and lateral projection), hip (femoral neck, trochanter, intertrochanter, total femur, the Wards Triangle), and forearm (ultradistal (UD), middistal (MID), distal third portion, and total forearm) was measured using dual X-ray absorptiometry (DXA) (Hologic Delphi apparatus). Values were expressed as BMD, T-score, and Z-score. Results: Females had lower values of BMD in all measurement points. There were no significant differences in T- and Z-scores of forearm between males and females. Age was in a positive correlation with lumbar spine BMD in males and females. There was a negative correlation with neck and forearm BMD in both groups. Serum parathyroid hormone (PTH) was also in negative correlation with hip and forearm BMD in both groups. The best correlation of BMD in different sites was between forearm and neck. Conclusion: BMD data in CKD patients should be interpreted with caution and appendicular skeletal sites should be included in the evaluation.

Harmful immune reactions during acute myocardial infarction

Acute coronary syndrome, including myocardial infarction, can occur as a result of ischaemia-reperfusion injury caused by acute occlusion of the coronary vessel/s following the rupture of an atherosclerotic plaque. Superimposed thrombosis at the lesion obstructs blood supply to the myocardium causing myocardial necrosis and ischaemic inflammation. Although not fully described, researchers believe that this process is initiated by a dysfunctional endothelium that activates the nearby leukocytes in the blood stream, thus attracting them to the arterial wall and initiating a cascade of complex mechanisms that lead to myocardial infarction. Interestingly, this process is two sided as the leaking soluble factors from a damaged and/or necrotic myocardium enter the systemic circulation, activating the innate and adaptive cell-mediated immune responses, which include increasing cytotoxic mediators. We hypothesize that this unwanted side effect of increase in proinflammatory mediators can lead to harmful systemic immune reactions directed towards various dysfunctional endothelia. Additionally, a strong inflammatory response, caused by myocardial damage, can impair ventricular function, on top of baseline necrosis. To evaluate this hypothesis, we propose to use in vivo tests to measure endothelial dysfunction, as well as ventricular dysfunction by ultrasound methods, and their correlation with immunological and/or biochemical parameters. These tests will be useful in assessing the risk and therapeutic outcome in patients with acute coronary syndrome.

Nonalcoholic Fatty Liver Disease (NAFLD) And Cardiovascular Risk In Renal Transplant Recipients

Background/Aims: Renal transplant recipients (RTRs) are at high risk for cardiovascular (CVD) mortality. Recently, nonalcoholic fatty liver disease (NAFLD) has been recognized as a new risk factor for adverse CVD events in the general population. We examined whether transient elastography (TE) defined NAFLD was associated with atherosclerosis in RTRs, as measured by ultrasound in the carotid arteries. Methods: Carotid atherosclerosis was assesses in 71 RTRs with a TE proven NAFLD. With the help of TE liver stiffness was used to assess liver fibrosis and Controlled Attenuation Parameter (CAP) was used to detect and quantify liver steatosis. NAFLD was defined by the presence of steatosis with CAP values ≥238 dB.m-1. Results: RTRs with NAFLD showed more carotid atherosclerosis than RTRs without NAFLD. RTRs-NAFLD patients had the mean intima-media measurements (ITM) of 1.1±0.1 mm and that was statistically significant higher than the mean ITM founded in RTRs without NAFLD (1.1±0.1 vs. 0.9±0.1 mm; p<0.0001). Furthermore, RTRs-NAFLD patients had statistically significant higher prevalence of plaques in comparison with RTRs without NAFLD (p=0.021). Conclusion: We showed for the first time that carotid atherosclerosis is advanced in RTRs with NAFLD. Detection of NAFLD by TE should alert to the existence of an increased cardiovascular risk in RTRs.

Non-Alcoholic Fatty Liver Disease Proven by Transient Elastography in Hemodialysis Patients: Is It a New Risk Factor for Adverse Cardiovascular Events?

Background/Aims: Cardiovascular diseases (CVD) are the leading cause of mortality in hemodialysis (HD) patients. Recently, non-alcoholic fatty liver disease (NAFLD) has been recognized as a new risk factor for adverse CVD events in the general population. Our aim was to analyze the incidence of NAFLD in HD patients by using transient elastography and to analyze whether the presence of NAFLD is associated with a higher CVD risk in HD patients. Methods: The subjects were 72 HD patients and 50 sex- and age-matched controls. Results: NAFLD was found in 52.8% of HD patients. HD patients with NAFLD showed more carotid atherosclerosis and more adverse CVD events than HD patients without NAFLD and control subjects. Conclusion: We showed for the first time that HD patients have a high prevalence of NAFLD. HD patients with NAFLD show an advanced carotid atherosclerosis. Detection of NAFLD by transient elastography should alert to the existence of an increased cardiovascular risk in HD patients.