Marija Zdravkovic

Echocardiographic study of early left ventricular remodeling in highly trained preadolescent footballers.

Almost all the studies of athletes heart have been carried out on adult and older adolescent players; hence the limited data on the cardiac response to exercise in the beginning of the active sports career in the youngest athletes. The study was designed to examine the physiological limits of left ventricle (LV) cavity size and wall thickness in elite footballers at the preadolescent age, it the beginning of the active sports career. Ninety-four highly trained male footballers (mean aged 12.85±0.84) competing in the Serbian Football League and 47 age-matched healthy male controls, aged 12-14, were enrolled in the study. All the echocardiographic findings were adjusted to BSA(-0.5), while left ventricle mass (LVM) was additionally adjusted to BSA(-1.5). Reference ranges were defined as values of 5-95th centile according to the mean values in both groups. The proportions of the footballers with LV dimensions outside expected ranges were additionally noted. The data indicate significant increases in absolute values of LV dimensions, aortic root size and left atrium (p<0.001) in preadolescent professional footballers compared with the values expected for age-matched controls, whereas there are no differences in absolute values of ventricular septal and posterior wall thickness, LV wall thickness and LVM (p>0.05). Upon body-size adjustments, significant increases were observed in all echocardiographic parameters (p<0.001). Our data indicate an early cardiac remodeling, already apparent in pre-adolescence, even after a short period of training.

Delayed Care and Mortality Among Women and Men With Myocardial Infarction

Background Women with ST‐segment–elevation myocardial infarction (STEMI) have higher mortality rates than men. We investigated whether sex‐related differences in timely access to care among STEMI patients may be a factor associated with excess risk of early mortality in women. Methods and Results We identified 6022 STEMI patients who had information on time of symptom onset to time of hospital presentation at 41 hospitals participating in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776) from October 2010 through April 2016. Patients were stratified into time‐delay cohorts. We estimated the 30‐day risk of all‐cause mortality in each cohort. Despite similar delays in seeking care, the overall time from symptom onset to hospital presentation was longer for women than men (median: 270 minutes [range: 130–776] versus 240 minutes [range: 120–600]). After adjustment for baseline variables, female sex was independently associated with greater risk of 30‐day mortality (odds ratio: 1.58; 95% confidence interval, 1.27–1.97). Sex differences in mortality following STEMI were no longer observed for patients having delays from symptom onset to hospital presentation of ≤1 hour (odds ratio: 0.77; 95% confidence interval, 0.29–2.02). Conclusions Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01218776.

The Cardiomyopathy Registry of the EURObservational Research Programme of the European Society of Cardiology: baseline data and contemporary management of adult patients with cardiomyopathies

Aims The Cardiomyopathy Registry of the EURObservational Research Programme is a prospective, observational, and multinational registry of consecutive patients with four cardiomyopathy subtypes: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and restrictive cardiomyopathy (RCM). We report the baseline characteristics and management of adults enrolled in the registry. Methods and results A total of 3208 patients were enrolled by 69 centres in 18 countries [HCM (n = 1739); DCM (n = 1260); ARVC (n = 143); and RCM (n = 66)]. Differences between cardiomyopathy subtypes (P < 0.001) were observed for age at diagnosis, history of familial disease, history of sustained ventricular arrhythmia, use of magnetic resonance imaging or genetic testing, and implantation of defibrillators. When compared with probands, relatives had a lower age at diagnosis (P < 0.001), but a similar rate of symptoms and defibrillators. When compared with the Long-Term phase, patients of the Pilot phase (enrolled in more expert centres) had a more frequent rate of familial disease (P < 0.001), were more frequently diagnosed with a rare underlying disease (P < 0.001), and more frequently implanted with a defibrillator (P = 0.023). Comparing four geographical areas, patients from Southern Europe had a familial disease more frequently (P < 0.001), were more frequently diagnosed in the context of a family screening (P < 0.001), and more frequently diagnosed with a rare underlying disease (P < 0.001). Conclusion By providing contemporary observational data on characteristics and management of patients with cardiomyopathies, the registry provides a platform for the evaluation of guideline implementation. Potential gaps with existing recommendations are discussed as well as some suggestions for improvement of health care provision in Europe.

Beta-Blockers (Carvedilol) in Children with Systemic Ventricle Systolic Dysfunction - Systematic Review and Meta-Analysis

BACKGROUND Numerous prospective randomized clinical trials demonstrated favorable effect of beta-blockers in adults with chronic heart failure. However, effectiveness of beta blockers in pediatric patients with systemic ventricle systolic dysfunction was not recognized sufficiently. Limited number of pediatric patients might be the course of unrecognized carvediolol treatment benefit. Currently, no meta-analysis has examined the impact of carvedilol and conventional therapy on the clinical outcome in children with chronic heart failure due to impaired systemic ventricle systolic function. MATERIALS AND METHODS We have systematically searched the Medline/PubMed and Cochrane Library for the controlled clinical trials that examine carvedilol and standard treatment efficacy in pediatric patients with systemic ventricle systolic dysfunction. Mean differences for continuous variables, odds ratios for dichotomous outcomes, heterogeneity between studies and publication bias were calculated using Cochrane Review Manager (Rev Man 5.2). RESULTS Total of 8 prospective/observational studies met established criteria. Odds ratio for chronic heart failure related mortality/heart transplantation secondary to carvedilol was 0.52 (95% CI: 0.28-0.97, I(2) = 0%). Our analysis showed that carvedilol could prevent 1 death/ heart transplantation by treating 14 pediatric patients with impaired systemic ventricle systolic function. CONCLUSION Meta-analysis demonstrated clinical outcome benefit of carvedilol in children with chronic heart failure.

Acute Coronary Syndrome: The Risk to Young Women

Background Although acute coronary syndrome (ACS) mainly occurs in patients >50 years, younger patients can be affected as well. We used an age cutoff of 45 years to investigate clinical characteristics and outcomes of “young” patients with ACS. Methods and Results Between October 2010 and April 2016, 14 931 patients with ACS were enrolled in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry. Of these patients, 1182 (8%) were aged ≤45 years (mean age, 40.3 years; 15.8% were women). The primary end point was 30‐day all‐cause mortality. Percentage diameter stenosis of ≤50% was defined as insignificant coronary disease. ST‐segment–elevation myocardial infarction was the most common clinical manifestation of ACS in the young cases (68% versus 59.6%). Young patients had a higher incidence of insignificant coronary artery disease (11.4% versus 10.1%) and lesser extent of significant disease (single vessel, 62.7% versus 46.6%). The incidence of 30‐day death was 1.3% versus 6.9% for the young and older patients, respectively. After correction for baseline and clinical differences, age ≤45 years was a predictor of survival in men (odds ratio, 0.24; 95% confidence interval, 0.10–0.58), but not in women (odds ratio, 1.35; 95% confidence interval, 0.50–3.62). This pattern of reversed risk among sexes held true after multivariable correction for in‐hospital medications and reperfusion therapy. Moreover, younger women had worse outcomes than men of a similar age (odds ratio, 6.03; 95% confidence interval, 2.07–17.53). Conclusion ACS at a young age is characterized by less severe coronary disease and high prevalence of ST‐segment–elevation myocardial infarction. Women have higher mortality than men. Young age is an independent predictor of lower 30‐day mortality in men, but not in women. Clinical Trial Registration URL: http://clinicaltrials.gov/. Unique identifier: NCT01218776.

Primary percutaneous coronary intervention in octogenarians

BACKGROUND Limited data are available on the outcome of primary percutaneous coronary intervention (PCI) in octogenarian patients, as the elderly are under-represented in randomized trials. This study aims to provide insights on clinical characteristics, management and outcome of the elderly and very elderly presenting with STEMI. METHODS 2225 STEMI patients ≥70years old (mean age 76.8±5.1years and 53.8% men) were admitted into the network of the ISACS-TC registry. Of these patients, 72.8% were ≥70 to 79years old (elderly) and 27.2% were ≥80years old (very-elderly). The primary end-point was 30-day mortality. RESULTS Thirty-day mortality rates were 13.4% in the elderly and 23.9% in the very-elderly. Primary PCI decreased the unadjusted risk of death both in the elderly (OR: 0.32, 95% CI: 0.24-0.43) and very-elderly patients (OR: 0.45, 95% CI 0.30-0.68), without significant difference between groups. In the very-elderly hypertension and Killip class ≥2 were the only independent factors associated with mortality; whereas in the elderly female gender, prior stroke, chronic kidney disease and Killip class ≥2 were all factors independently associated with mortality. Factors associated with the lack of use of reperfusion were female gender and atypical chest pain in the very-elderly and in the elderly; in the elderly, however, there were some more factors, namely: history of diabetes, current smoking, prior stroke, Killip class ≥2 and history chronic kidney disease. CONCLUSIONS Age is relevant in the prognosis of STEMI, but its importance should not be considered secondary to other major clinical factors. Primary PCI appears to have beneficial effects in the octogenarian STEMI patients.

Early Left Ventricular Systolic and Diastolic Dysfunction in Patients with Newly Diagnosed Obstructive Sleep Apnoea and Normal Left Ventricular Ejection Fraction

The aim of the study was to evaluate whether obstructive sleep apnea (OSA) contributes directly to left ventricular (LV) diastolic and regional systolic dysfunction in newly diagnosed OSA with normal left ventricle ejection fraction. Methods. 125 consecutive patients were prospectively enrolled in the study. Control group consisted of 78 asymptomatic age-matched healthy subjects who did not have any cardiovascular and respiratory diseases. All patients had undergone overnight polysomnography and standard transthoracic and tissue Doppler imaging echocardiogram. Results. The E/A ratio and the peak E wave at mitral flow were significantly lower and the peak A wave at mitral flow was significantly higher in OSA patients compared with control subjects. Left ventricle isovolumetric relaxation time (IVRT) and mitral valve flow propagation (MVFP) were significantly longer in OSA patients than in controls. Tissue Doppler derived S′ amplitude of lateral part at mitral valve (S′Lm) and E′ wave amplitudes both at the lateral (E′Lm) and septal parts of the mitral valve (E′Sm) were significantly lower in OSA patients compared to controls. Conclusion. Newly diagnosed OSA patients with normal global LV function have significantly impaired diastolic function and regional longitudinal systolic function. OSA is independently associated with these changes in LV function.

Subcutaneous adipose tissue measurements and better metabolic prediction

The aim of the study was to establish the importance of an additional measurement of subcutaneous adipose tissue thickness (SAT) on a predetermined position on the waistline, and its relation to waist measurements as an improvement of metabolic prediction in equally obese subjects. One hundred and forty two consecutive patients were enrolled in the study: stratified by weight as normal (body mass index — BMI 20–25 kg/m2), overweight (BMI 25–30 kg/m2) and obese (BMI >30 kg/m2); and by fasting glucose level as normoglycemic, impaired fasting glucose (IFG), or with type 2 diabetes mellitus (T2DM). SAT was measured in relaxed expiration, 3 cm left of the umbilicus, with ultrasound. Fasting blood samples for glucose, insulin and HbAlc were taken. Waist circumference was slightly higher in the IFG (112.8 cm) and normoglycemic groups (115.62 cm), compared to T2DM (108.15 cm). The T2DM group had a lower average SAT (2.7 cm) than both the IFG group (3.4 cm, p<0.01) and the normoglycemic group (4.2cm, p=0.001). The homeostatic model of assessment for insulin resistance (HOMA IR) was the lowest in normoglycemic and the highest in IFG group. Waistline radius to SAT ratio provides better insight into the deterioration of glucose metabolism than standard anthropometric markers of abdominal obesity in equally obese patients.

Evaluation of myocardial function in the presence of left ventricular hypertrophy in athletes and hypertensive patients

INTRODUCTION Myocardial hypertrophy of the left ventricle may be of physiological or pathological nature. Distinction of these two types of hypertrophy is sometimes not easy and represents a diagnostic challenge. The aim of the study was to assess global diastolic and regional systolic and diastolic myocardial function in the presence of left ventricular hypertrophy in athletes and hypertensive patients. MATERIAL AND METHODS In 18 male hypertensive patients and 14 male athletes global diastolic left ventricular function and regional systolic and diastolic myocardial function of septum and posterior wall were investigated by pulsed wave tissue Doppler imaging. RESULTS Ejection fraction and left ventricle mass index did not differ significantly between two groups. Hypertensive patients were found to have diastolic dysfunction while athletes had normal left ventricular diastolic function (the difference between the groups was P < 0.00001). Index of regional diastolic function of septum as well as of the posterior wall was significantly less in hypertensive patients than in athletes (P < 0.00001 for both). In spite of the normal global systolic function the regional systolic function of septum and posterior wall was significantly less in hypertensive patients than in athletes (P < 0.02 for both). CONCLUSION The present results show significantly less global and regional diastolic function of hypertrophied myocardium in hypertensive patients than in athletes. In the presence of preserved left ventricular systolic function, the quantification of myocardial velocity revealed significantly lower regional systolic function of septum and posterior wall in hypertensive patients than in athletes.

Follow-Up and Risk Assessment in Patients with Myocardial Infarction Using Artificial Neural Networks

Artificial neural networks (ANNs) are machine learning technique, inspired by the principles found in biological neurons. This technique has been used for prediction and classification problems in many areas of medical signal processing. The aim of this paper was to identify individuals with high risk of death after acute myocardial infarction using ANN. A training dataset for ANN was 1705 consecutive patients who underwent 24-hour ECG monitoring, short ECG analysis, noninvasive beat-to-beat heart-rate variability, and baroreflex sensitivity that were followed for 3 years. The proposed neural network classifier showed good performance for survival prediction: 88% accuracy, 81% sensitivity, 93% specificity, 0.85 -measure, and area under the curve value of 0.77. These findings support the theory that patients with high sympathetic activity (reduced baroreflex sensitivity) have an increased risk of mortality independent of other risk factors and that artificial neural networks can indicate the individuals with a higher risk.