Mirjana Krotin

Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS‐ELD trial

Various beta‐blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta‐blockers in elderly patients with heart failure.

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.

Markers of oxidative damage in chronic heart failure: role in disease progression

Abstract Background: We aimed to study the relationship between markers of oxidative lipid or protein damage and ventricular remodeling and the validity of 8-epi-prostaglandin F2α (8-epi-PGF2α) as an indicator of disease severity in patients with ischemic chronic heart failure (CHF). Patients and methods: We enrolled four groups of 12 patients with varying CHF according to the New York Heart Association (NYHA) classification and 25 controls. Urinary 8-epi-PGF2α and plasma malondialdehyde and protein thiol (P-SH) groups were correlated with echocardiographic indices of remodeling. The reliability of isoprostanes was analyzed by a receiver operating characteristics (ROC) curve. Results: NYHA class III and IV patients exhibited elevated 8-epi-PGF2α levels, increased malondialdehyde concentrations and decreased P-SH groups when compared to controls and NYHA I and II patients. 8-Epi-PGF2α and P-SH groups correlated significantly with indices of remodeling. The ROC curve drawn for 8-epi-PGF2α allowed us to differentiate NYHA class III and IV patients from NYHA class I and II patients with a sensitivity of 95.8% and specificity of 95.8% (cut off 0.84 ng/mg creatinine; area under curve 0.99; P < 0.001). Conclusions: Markers of oxidative damage are unlikely to play a significant role in early stages of CHF. However, they might become important in the course of CHF when their concentrations reach critical levels. Urinary 8-epi-PGF2α is a reliable indicator of symptomatic CHF.

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.

[Prognostic value of dobutamine stress echocardiography in patients with terminal renal insufficiency undergoing hemodialysis--a 5-year follow up].

INTRODUCTION Patients with end-stage renal failure have high morbidity and mortality rates due to cardiovascular complications. Screening for coronary heart disease in these patients is of utmost importance. The aim of this study was to investigate the prognostic value of the dobutamine test in patients on hemodyalisis during a 5-year follow-up period. MATERIAL AND METHODS During the pretransplantation period, 24 patients on chronic hemodialysis underwent echocardiography and dobutamine echocardiography. The average age of patients was 51.50 +/- 7.35 years. The mean duration of dialysis was 74 +/- 40 months. RESULTS The dobutamine stress test was positive in 50% of patients, and undefined in 12.5%. The wall motion score index before the test was 1, and after the test it was 1.54 +/- 0.27. There were no serious complications. Left ventricular mass, diastolic and systolic dimension and posterior wall were significantly higher in patients with positive dobutamine stress results and they were associated with late cardiac morbidity and mortality. Five-year survival in patients with positive dobutamine stress results was 33.3% and 52.3% in patients with negative dobutamine results. Causes of mortality were as follows: cardiac 45.4%, cerebrovascular 18.1%, other causes 36.4%. Cardiogical complications were not the cause of death in any of the patients with negative dobutamine results. In dobutamine positive group 62.5% died from cardiological complications. During the 5-year period, cardiac death and manifest coronary disease occurred in 75% of patients with positive dobutamine stress results and only in one patient with negative dobutamine results. Sensitivity was 75%, specificity 89% and positive predictive value 90%. CONCLUSION Dobutamine stress echocardiography has a good predictive value for future cardiac events in hemnodyalisis patients, and in screening for coronary disease.

[Early risk predictors of sudden cardiac death after myocardial infarction: results of follow up of 881 patients].

INTRODUCTION It has been shown that depolarization disorders, autonomic dysfunction, and systolic dysfunction of the left ventricle are associated with sudden cardiac death after myocardial infarction. OBJECTIVE The objective of study was to examine the prognostic value of the most important predictors in the first week after myocardial infarction. METHOD Study included 881 patients who were followed up from 1 to 60 months. During the first week after myocardial infarction, following examination were performed: ECG with standard leads and X, Y, Z orthogonal leads, vectorcardiogram, QT interval, late potentials, short-time spectral analysis of RR variability, nonlinear (Poincaré plot) analysis and echocardiogram. RESULTS In univariate analysis, the following parameters measured on the first day were important predictors of sudden cardiac death: lower LF/HF ratio (<1.5) (p = 0.000), T wave inversion in X lead (p = 0.000), high P wave in D2 lead (p=0.030), and diminished systolic function (p = 0.000). In multivariate analysis, the following parameters were significant risk predictors: T wave inversion in X lead, lower LF/HF ratio, positive late potentials and the left ventricle systolic dysfunction. CONCLUSION The parameters of the left ventricle systolic disfunction with sympathicovagal imbalance and electric instability are the key risk predictors in the first few days after myocardial infarction.

Coronary artery bypass surgery in patients with low EuroSCORE preoperative risk

Patients with EuroSCORE <2 are usually considered to have a low surgical risk and the lowest mortality. In our study preoperative factors in a group of 250 consecutive low-risk patients (EuroSCORE<2), who underwent first isolated coronary artery by-pass surgery during 1999 and 2000., were analyzed. Cumulative follow-up period was 1178.48 patient-years and the primary clinical outcome was all-cause mortality. Patients’ average age was 59.2±7.5 yr. The following preoperative risk factors of increased 5-year mortality were identified: older age (P<0.001), smoking, prior non-recent myocardial infarction and reinfarction, anteroseptal localization of myocardial infarction (P<0.001), poor ejection fraction<=35% (P<0.001), dilatative cardiomyopathy (P<0.001), wall motion systolic index 〉2 (P<0.001), left atrial dilatation (P<0.001), mitral regurgitation more than 2+ (P<0.001), presence of left main disease, triple vessel coronary artery disease (P<0.001), absence of collaterals (P<0.001) and presence of more than 3 distal anastomoses. Through the present study it has been shown that it is possible to identify a subgroup of patients with low operative mortality and excellent 5-year survival after surgical treatment for coronary artery bypass surgery using preoperative clinical, echocardiographic, coronarographic and intraoperative data, even in difficult conditions of the civil war in the region.

Double-trouble: An unusual case of two simultaneous arterial thromboses in thrombophilia

Multiple arterial and venous thromboses are usually related to thrombophilia or antiphospholipid syndrome. Recurrent pulmonary embolism strongly indicates the presence of genetic or acquired thrombophilic factors. Simultaneous double arterial in situ thromboses are unusual, even in thrombophilic conditions. Simultaneous occurrence of pulmonary embolism and cerebrovascular ischaemic insult are highly indicative of existence of patent foramen ovale. We present herein a patient with the double simultaneous arterial thromboses as the manifestation of thrombophilia (heterozygous for methylenetetrahydrofolate-reductase (MTHFR) C677T gene mutation). There was no patent foramen ovale suspected upon the patient’s admittance to hospital. To the best of our knowledge there have been no similar cases presented to date.

Large saphenous venous graft aneurysm mimicking atypical mediastinal mass

BACKGROUND Saphenous venous graft (SVG) aneurysm is a very rare but potentially fatal complication of the coronary artery bypass surgery. CASE REPORT We reported a case of 72-year-old man admitted to hospital because of atypical chest pain related to body motions in horizontal position, especially to the left side. Pain was followed by dispnea, palpitations, fatigue, cough, yellow sputum expectorations, as well as elevated temperature. He had had coronary artery bypass grafting (CABG) surgery with saphenous vein grafts (SVGs) to the left anterior descending artery (LAD) and right coronary artery (RCA) 27 years earlier. Chest X-ray revealed a poor-defined shadow in the region of the right atrium. A transthoracic echocardiogram revealed an atypical tumorous mediastinal mass near the right atrium and right ventricle that seemed partially calcified on transesophaeal echocardiography (TEE). CT scan confirmed an atypical mediastinal mass in contact with the right ventricle that might be a right ventricle aneurysm, pericardial cyst or SVG aneurysm. Coronary angiography was performed subsequently and it revealed a big saphenous venous graft aneurysm originating from the previous venous graft to the RCA. The aneurysm was resected and a new bypass graft was placed. Histopathology confirmed a true aneurysm of the venous graft. CONCLUSION Although SVG aneurysm is a very rare complication of CABG surgery, patients presenting with atypical hilar or mediastinal mass following CABG should always be evaluated firstly for existence of this cardiosurgical complication.

[Cervical lymphodenopathy--a single presentation of sarcoidosis?].

BACKGROUND Sarcoidosis is a chronic inflammatory disease, commonly found in lungs and hilar lymph nodes, but multiple organs could be involved. The diagnosis is based on specific pathohistology which should be always combined with clinical, radiological and laboratory findings. CASE REPORT A patient initially presented with pneumonia, and treated with antibiotics, but with the general symptoms that persisted despite radiological resolution of lung infiltration was reported. The further diagnostic procedures revealed the presence of sarcoid granulomas in cervical lymph nodes. The peripheral lymph nodes are often affected in the early course of the disease, but it is difficult to distinguish if the illness is a sarcoid reaction to lung infection or a acute onset of sarcoidosis. CONCLUSION The detection of sarcoid granulomas in cervical lymph nodes should be precisely analyzed for the presence of sarcoidal changes in other tissues, primarily in the lungs tissue. Early diagnosis of lung sarcoidosis is significant, especially in the light of the fact that the latest studies point out that the prednisone therapy, started immediately after the diagnosis has been made, renders positive effects also in asympthomatic patients in II and III phase of the disease.