Marina Deljanin Ilic

Detrimental effects of a bout of physical exercise on circulating endogenous inhibitors of endothelial function in patients with coronary artery disease.

Background A bout of intense physical activity has been shown to transiently impair endothelial function; however, the underlying mechanisms are unclear. Aim The purpose of the review was to assess the impact of a bout of physical exercise induced by exercise stress echocardiography, on blood concentration of the endogenous inhibitors of nitric oxide synthase, asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA), in patients with atherosclerosis. Methods Overall, 83 study participants were enrolled, 25 coronary artery disease (CAD) patients, 20 age and sex-matched asymptomatic study participants with at least one risk factor for CAD, and 38 healthy controls. Results Patients with CAD developed symptoms and/or left ventricular wall motion abnormalities during exercise; no changes were seen in study participants with risk factors, or in healthy controls. At baseline, in CAD patients and in study participants with risk factors, both ADMA and SDMA were higher than healthy controls (P < 0.001). However, a further large increase occurred during exercise stress echocardiography in both groups, regardless of development of symptoms (P < 0.001). Conclusion Basal concentrations of ADMA and SDMA are high in CAD patients and in study participants with risk factors, consistent with impaired nitric oxide synthase activity in atherosclerosis. Large increase of these endogenous inhibitors of nitric oxide during intense exercise provide support to the hypothesis that in patients with atherosclerosis endothelial function may further deteriorate as a consequence of a bout of physical activity.

Crosstalk of Various Biomarkers That Might Provide Prompt Identification of Acute or Chronic Cardiorenal Syndromes

Introduction: Pathophysiological interaction between the heart and kidneys represents the basis for clinical entities called cardiorenal syndromes. The purpose of the study was to assess the relations between acute and chronic cardiorenal syndromes and biomarkers [advanced oxidation protein products, brain natriuretic peptide, malondialdehyde, xanthine oxidoreductase (XOD), xanthine oxidase, xanthine dehydrogenase, interleukin 8, cystatin C, plasminogen activator inhibitor-1, high-sensitive troponin T, C-reactive protein and glomerular filtration rate, measured by the Modification of Diet in Renal Disease (MDRD) formula], to hypothesize biomarkers that might provide a prompt identification of acute or chronic cardiorenal syndromes, and to distinguish acute versus chronic types of these syndromes. Methods: A total of 114 participants were enrolled in this study, i.e. 79 patients divided into subgroups of acute and chronic cardiorenal syndromes and 35 volunteers. Results: Nonadjusted odds ratio (OR) showed that there was a significant risk for acute cardiorenal syndrome with increased XOD activity (p = 0.037), elevated cystatin C concentration (p = 0.038) and MDRD (p = 0.028). Multivariable adjusted OR, on the other hand, revealed that only glomerular filtration rate measured by the MDRD formula had a significance for acute cardiorenal syndrome (p = 0.046). Nonadjusted OR showed a significant risk for chronic cardiorenal syndrome only in elderly (p = 0.002). Multivariable adjusted OR exhibited that age was the only risk factor for chronic cardiorenal syndrome (p = 0.012). Conclusion: Cystatin C, glomerular filtration rate measured by the MDRD equation and XOD were independent risk factors for acute cardiorenal syndrome, while age remained an independent risk factor for chronic cardiorenal syndrome. When comparing ORs of evaluated parameters, the highest significance for acute cardiorenal syndrome was plasma concentration of cystatin C.

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).

The Association Between Obesity and Visit-to-visit Variability in Systolic Blood Pressure: A Prospective Study

Abstract With the prevalence of obesity and all accompanying health risks, both prevention and health education, as well as identifying predictors for the development of obesity-related diseases are primary. Th e pathophysiological relationship between obesity and visit-to-visit variability in systolic blood pressure (SBPV) has not been completely resolved. To investigate the association between obesity and SBPV in hypertensive patients. Th e prospective study comprised three visits was performed at the hypertension outpatient clinic during the follow up period of 22-months between March 2014 and January 2016. Th is study included 300 randomly selected hypertensive patients (average 67.76±9.84 years), who were divided in groups of obese/non-obese examinees. SBPV was defined as the standard deviation (SD) from three values of SBP. Th e values of SBP and SBP-SD were significantly higher in the group of obese hypertensive patients than in the group of non-obese patients (126.67±8.22 vs 120.45±7.79 mmHg, 11.00±5.64 vs 7.34±3.96; p<0.01). Th e highest SBPV was recorded in the 4th quartile in obese patients (43.13±7.50 mmHg). Th ere was statistically stronger correlation between SBPV and BMI/Waist cirumferences (WC) (ρο=0.425/ ρο=0.356, p<0.01). During 22-months follow up there was a significant decrease of SBPV for 8.2 mmHg, BP for 31/8 mmHg, BMI for 3.8 kg/m2, WC for 10 cm and body weight for 8.24 kg. During 22-months follow-up, reduction of body weight was associated with reduction of blood pressure variability in hypertensive patients. Persistently decrease both body weight and long term visit-to-visit variability may explain lower cardiovascular risk in obese-related disease.

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.

Perforation of the Right Ventricle as a Complication of Pericardiocentesis: A Case report

Summary Pericardial effusion represents the accumulation of larger amounts of fluid in the pericardial cavity. If not timely diagnosed and adequately treated, it can lead to cardiac tamponade. The treatment of pericardial effusion includes primarily the use of drugs like aspirin, NSAIDs, corticosteroids, and/or colchicine followed by invasive procedures such as pericardiocentesis or pericardiectomy. Pericardiocentesis complications are extremely rare but very serious especially in the case of the rupture of the right ventricle or the coronary arteries. Patient S.V, born in 1938, from Svrljig, was examined because of suffocating and swollen shin. The medical reports showed that the patient previously had had a permanent pacemaker implanted and that he had undergone a triple coronary artery bridging. Medical reports also showed that two months before the examination he was hospitalized due to pericardial effusion at the reference institution. The ultrasonographic examination registered large circular effusion with the motion of the right ventricle and the patient underwent urgent pericardiocentesis. During pericardiocentesis, the rupture of the right ventricle occurred and the patient was sent to the cardiac surgery clinic where he had catheter extraction performed. The control ultrasound examination of the heart showed no pericardial effusion, and no signs of damage to the right ventricle.

Aortic Dissection - The Role of Echocardiography in Emergency Unit: Case Report

Summary Aortic dissection is a quite rare but serious condition, often associated with a very high mortality rate; it is manifested by sudden chest pain and acute hemodynamic compromise. In the presented review, a case of an ascending aortic dissection with the lethal outcome is been shown. A healthy man with no past history of illness suddenly felt acute excruciating chest pain which was radiating to the back. A quick diagnosis, ideally within one hour of manifestation, heart auscultation and echocardiography are the key to aortic dissection recovery.

Rehabilitation of a Female Patient after Corrective Surgery for Tetralogy of Fallot

Summary Herein we present a 25-year-old female patient with tetralogy of Fallot (TOF). This congenital heart defect is not very common, but it is the most common one among cyanotic heart defects. Treatment of the patients with TF is surgical, with palliative or curative (corrective) intent. Our patient underwent palliative surgery, definitive correction, and another surgery for pulmonary valve insufficiency. During cardiovascular rehabilitation, the patient was rhythmically stable, with excellent tolerance of physical exertion. Bearing in mind that this was a young female person who previously had had two spontaneous abortions, pregnancy was not absolutely contraindicated, although spontaneous abortion and pregnancy complications were more common in these patients. Sažetak Prikazana je bolesnica stara 25 godina sa tetralogijom Fallot. Ova urođena srčana mana nije tako česta, ali je najčešća među manama sa cijanozom. Lečenje bolesnica sa tetralogijom Fallot je hirurško i može biti palijativno i korektivno. Bolesnica koju smo prikazali imala je palijativnu operaciju, definitivnu korekciju i ponovnu operaciju zbog insuficijencije pulmonalne valvule. Tokom kardiovaskularne rehabilitacije bolesnica je bila ritmički stabilna uz odličnu toleranciju fizičkog napora. Imajući u vidu da se radi o mlađoj ženskoj osobi koja je tokom proteklih godina imala dva spontana abortusa, trudnoća nije apsolutno kontraindikovana, mada su spontani abortusi i komplikacije trudnoće češći kod ovih bolesnica.

Significance of Echocardiography in the Assessment of Left Ventricular Function in Patients Receiving Combined Adjuvant Treatment with Anthracyclines and Trastuzumab / Značaj ehokardiografije u proceni funkcije leve komore kod bolesnica na adjuvantnoj terapji (kombinovana terapija antraciklinima i trastuzumabom)

Abstract The application of anthracycline and trastuzumab in adjuvant breast cancer treatment approach has significantly improved the survival of patients, but also carries the risk of cardiotoxicity that is manifested by reducing the ejection fraction of the heart. The aim of the study was to investigate the effect of cumulative anthracycline dose in combination therapy with trastuzumab on the left ventricular ejection fraction, and the influence of the time interval for starting the treatment with trastuzumab. The study included a group of 80 breast cancer patients (aged 28 to 75 years) who underwent the therapy with anthracyclines (IV-VI cycles) with the continuation of trastuzumab therapy for a period of one year. Ejection fraction at the end of completing the treatment period (VI anthracycline cycles and trastuzumab) was significantly lower in 68 (93%) patients compared to the value at the beginning of the study (68.2% ± 6.06 to 62.1 ± 6.1%; p <0.0001; difference 6.1%). In five patients (anthracyclines and trastuzumab IV cycles) a decrease of 7.1% EF; p = 0.0043 was registered compared to the baseline values. The reduction in the ejection fraction was highest in patients in whom the trastuzumab therapy was initiated one month after the last anthracycline therapy (7.33%), and lowest in the subgroup who started receiving the therapy after three months (5.31%). In patients on cytostatic therapy, echocardiography proves the reduction in the left ventricular ejection fraction, which is cumulative and dose-dependent, and it also proves that the shorter time interval between the last cycle of anthracycline and the initial trastuzumab treatment the more it is associated with a marked decrease in the left ventricular ejection fraction. Sažetak Primena antraciklina i trastuzumaba u adjuvantnom pristupu lečenja karcinoma dojke je značajno poboljšala preživljavanje ovih bolesnica, ali nosi rizik od kardiotoksičnosti koja se manifestuje smanjenjem ejekcione frakcije srca. Cilj studije bio je ispitivanje efekta kumulativne doze antraciklina u kombinovanoj terapiji sa trastuzumabom na ejekcionu frakciju leve komore, kao i uticaj vremenskog intervala započinjanja terapije trastuzumabom. Ispitivanje je obuhvatalo grupu od 80 bolesnica sa karcinomom dojke (starosti od 28 do 75 godina) kod kojih je primenjena terapija antraciklinima (IV-VI ciklusa) uz nastavak terapije trastuzumabom u trajanju od godinu dana. Ejekciona frakcija na kraju završenog terapijskog perioda (antraciklini VI ciklusa i trastuzumab) bila je značajno manja kod 68 (93%) bolesnica u odnosu na vrednost na početku studije (68,2% ± 6,06 prema 62,1 % ± 6,1; p<0,001; razlika 6,1%). Kod pet bolesnica (antraciklini IV ciklusa i trastuzumab) registrovano je smanjenje EF za 7,1%; p=0,0043 u odnosu na bazalne vrednosti. Smanjenje ejekcione frakcije bilo je najveće kod bolesnica kod kojih je započeta terapija trastuzumabom mesec dana od poslednje terapije antraciklina (7,33%), a najmanje u subgrupi, gde je terapija započeta nakon tri meseca (5,31%). Primena ehokardiografije kod bolesnica na citostatskoj terapiji dokazuje smanjenje ejekcione frakcije leve komore koje je kumulativno, dozno-zavisno, kao i da je kraći vremenski interval između poslednjeg ciklusa antraciklina i inicijalne terapije trastuzumabom povezan sa izraženim smanjenjem ejekcione frakcije leve komore.

Acute Myocardial Infarction with an Initially Non–Diagnostic Electrocardiogram – Clinical Intuition is Crucial for Decision Making

Summary Acute myocardial infarction (AMI) is a common cause of reduced cardiac capacity and functional status of a patient. Successful primary percutaneous coronary intervention (pPCI) in acute coronary syndrome and appropriate, complex cardiovascular rehabilitation play a major role in preserving left ventricular function and improvement of prognosis and quality of patient’s life. The aim of this paper was to present a clinical course in a patient with acute myocardial infarction who did not have a classic ECG presentation in the form of ST-segment elevation. We showed that in everyday clinical work it is essential to timely recognize the symptoms of acute myocardial infarction, make the proper diagnosis and perform right treatment strategy. The next step is cardiovascular rehabilitation program, which positive effects, in our patient, was achieved through the retrieval of functional capacity and correction of risk factors. Sažetak Akutni infarkt miokarda (AIM) je čest uzrok smanjenog kardijalnog kapaciteta i funkcionalnog stanja bolesnika. Uspešna primarna perkutana koronarna intervencija (pPCI) u akutnom koronarnom sindromu i adekvatna, kompleksna kardiovaskularna rehabilitacija imaju veliku ulogu u očuvanju funkcije leve komore i poboljšanju prognoze i kvaliteta života bolesnika. Cilj rada bio je prezentacija kliničkog toka kod bolesnika sa akutnim infarktom miokarda koji nije imao klasičnu EKG prezentaciju u formi elevacije ST segmenta. Pokazali smo da je u svakodnevnom kliničkom radu najbitnije pravovremeno prepoznavanje simptoma akutnog infarkta miokarda, što olakšava postavljanje prave dijagnoze i izbor prave terapijske strategije. Sledeći korak je program kardiovaskularne rehabilitacije, koja je svojim pozitivnim efektima kod našeg bolesnika ostvarila popravljanje funkcionalnog kapaciteta i korekciju faktora rizika.