Mislav Vrsalovic

Impact of admission anemia, C-reactive protein and mean platelet volume on short term mortality in patients with acute ST-elevation myocardial infarction treated with primary angioplasty.

OBJECTIVES To investigate admission anemia, C-reactive protein (CRP) and mean platelet volume (MPV) together as prognostic markers in ST-elevation myocardial infarction (STEMI). DESIGN AND METHODS Baseline hemoglobin, CRP and MPV were determined in 543 patients with acute STEMI to whom primary angioplasty was performed and evaluated for short term mortality (30 days). RESULTS After multivariate analysis anemia (odds ratio 2.69, 95% confidence interval 1.24-5.86) and CRP (odds ratio 3.40, 95% confidence interval 1.13-10.22) remained significant independent predictors of short-term mortality. Addition of anemia and CRP to PAMI risk score improved prediction of short-term outcome; area under ROC curve rose from 0.76 to 0.87 (p<0.001). CONCLUSION Better ability to determine 30-day mortality was obtained when anemia and CRP were incorporated into the PAMI risk score.

Modulating role of alcohol and acetaldehyde on neutrophil and monocyte functions in vitro

Moderate alcohol intake lowers coronary heart disease risk. Because polymorphonuclear neutrophils (PMN) and monocytes (Mo) play a role in atherosclerotic plaque destabilization we investigated in vitro effects of clinically relevant concentrations of ethanol (0.05, 0.125, 0.25, and 0.5%) and its metabolite acetaldehyde (0.0625, 0.125, and 0.5 mM) on human PMN and Mo phagocytic functions. PMN and Mo from healthy volunteers were separated and purified according standard methods and the following parameters were determined: phagocytic activity (percent of phagocytes with at least one ingested particle), ingestion index (number of ingested particles per 100 phagocytic cells), and intracellular killing (percent of dead ingested particles per 100 phagocytes) using acridine orange method and living yeast cells as targets. Reactive oxygen species (ROS) formation of ethanol-treated PMN and Mo was evaluated using 2,7-dichlorofluorescin method and results were expressed as percent of fluorescence-positive cells. Ethanol and acetaldehyde significantly reduced PMN phagocytic functions, with the exception of phagocytic activity, starting at 0.125% for ethanol and 0.0625 mM for acetaldehyde. Mo ingestion and microbicidity were decreased at ethanol concentrations of 0.5% without effect on Mo phagocytic activity. Acetaldehyde impaired Mo ingestion ability starting at 0.0625 mM and phagocytic activity at 0.5 mM while was without effect on Mo microbicidity. ROS production was significantly increased at ethanol concentrations 0.25 and 0.5% in PMN and at 0.5% in Mo. These results might partly explain the benefitial role of moderate use of alcohol on cardiovascular disease.

C-reactive protein, renal function, and cardiovascular outcome in patients with symptomatic peripheral artery disease and preserved left ventricular systolic function.

Aim To investigate the prognostic role of C-reactive protein (CRP) and renal function for the occurrence of major adverse cardiovascular events (MACE) in patients with symptomatic peripheral artery disease (PAD) and preserved left ventricular ejection fraction (LVEF). Methods The occurrence of MACE, defined as composite endpoint of acute myocardial infarction, urgent coronary revascularization, stroke, and death was assessed in 319 consecutive PAD patients admitted to the University Hospital between January 2010 and January 2014 (66.5% men, mean [±standard deviation] age 70 ± 10 years, mean ankle brachial index 0.58 ± 0.14) with normal LVEF (>50%). Multivariate Cox regression analysis adjusted for age, sex, traditional cardiovascular risk factors, anemia, polyvascular disease, critical limb ischemia (CLI), statin treatment, CRP (>5 mg/L), and impaired renal function (estimated glomerular filtration rate <60 mL/min) was applied to assess the independent predictors of MACE. Results During median follow-up period of 24 months (interquartile range, 16-34 months), 77 patients (24%) experienced MACE. Compared to patients without MACE, these patients were older, more likely to have CLI, polyvascular disease, anemia, elevated CRP, and impaired renal function. In multivariate regression analysis, age (HR 1.04, 95% CI 1.01-1.07), polyvascular disease (HR 1.95, 95% CI 1.23-3.09), elevated CRP (HR 1.89, 95% CI 1.18-3.02), and impaired renal function (HR 1.68, 95% C 1.01-2.78) remained independent predictors of MACE. Patients with both impaired renal function and high CRP values on admission were 3.59 times more likely to experience MACE than patients with normal CRP and preserved renal function. Conclusion Elevated admission CRP and renal impairment are independent predictors of MACE in symptomatic PAD patients with preserved LVEF.

Impact of diabetes on mortality in peripheral artery disease: a meta-analysis

There are accumulating studies showing the association between diabetes and all‐cause mortality in peripheral vascular disease. However, the results in these studies are conflicting regarding the impact of diabetes on outcome.

Atrial Fibrillation Predicts Cardiovascular Outcome in Hypertensive Patients With Symptomatic Peripheral Artery Disease and Preserved Ejection Fraction

To the Editor: Atrial fibrillation (AF) and peripheral artery disease (PAD) are prevalent in the aging population and share some common risk factors. The coexistence of both represents a population at very high risk for vascular complications. The prevalence of left ventricular systolic dysfunction is significantly greater in patients with PAD compared with the general population and is associated with worse outcome. Since this fact was not included in previous outcome studies, we investigated the prognostic impact of AF on major adverse cardiovascular events (MACEs; composite endpoint of acute myocardial infarction, urgent coronary revascularization, stroke, and death) in a cohort of consecutive mostly hypertensive patients with symptomatic PAD and preserved left ventricular ejection fraction (LVEF >50%). Between January 2010 and January 2014 we prospectively studied 319 patients (66% men, 87% hypertensive, mean age 70 10 years, ankle brachial index 0.59 0.14) with symptomatic PAD in Rutherford stages 3 (58%), 4 (24%), and 5 (18%). The diagnosis of PAD was established by clinical examination, ankle brachial index measurement, duplex sonography, and/ or computed tomography or magnetic resonance angiography and confirmed with peripheral angiography using the criteria of the European Society of Cardiology. The diagnosis of hypertension was in accordance with the European Society of Cardiology/ European Society of Hypertension 2013 guidelines. The diagnosis of AF was based on history and electrocardiographic evidence of arrhythmia. Baseline anemia was defined as hemoglobin level <13 g/dL for men and <12 g/dL for women. LVEF was assessed using transthoracic echocardiography (Simpson method). Cardiovascular disease (CVD), in addition to confirmed PAD, was defined as history of angina, myocardial infarction, coronary revascularization, history of stroke, transient ischemic attack, or carotid revascularization. Differences between the groups were analyzed with t test and Mann-Whitney test for continuous variables and with chi-square test for categorical variables. Cox proportional hazards regression analysis was performed to determine the independent predictors of MACE and results were expressed as hazard ratios and 95% confidence intervals (CIs). Covariate selection included known correlates of poor cardiovascular outcome and those that were found to be significant in the univariate analysis, namely age, sex, traditional cardiovascular risk factors, anemia, impaired renal function (estimated glomerular filtration rate [eGFR] <60 mL/min), AF, history of CVD, critical limb ischemia (CLI), and statin treatment. Statistical analysis was performed using MedCalc version 11.3.1.0 (Ostend, Belgium). The prevalence of AF was 17.9% among PAD patients and was associated with unfavorable outcome (Figure). When compared with patients without AF, these patients were older (76 vs 69 years; P<.001), with higher CHADS2 (congestive heart failure, hypertension, age 75 years, diabetes mellitus, stroke) scores (2.64 vs 1.99; P<.001) and more likely to have CLI (72% vs 35%; P<.001), impaired renal function (61% vs 40%; P=.006), and anemia (35% vs 18%; P=.007). No significant difference between groups was found with regards to antiplatelet therapy or use of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. All patients with AF were on warfarin therapy. In logistic regression analysis, age (odds ratio, 1.09; 95% CI, 1.05–1.14; P<.001), and CLI (odds ratio, 3.62; 95% CI, 1.88–6.96; P<.001) were independently associated with AF. During the median follow-up period of 24 months (interquartile range, 16–34 months), 77 patients (24%) had a MACE, with 20 myocardial infarctions, eight percutaneous coronary interventions/ coronary artery bypass graft procedures, 11 strokes, and 38 deaths. In the univariable analysis, AF, age, hypertension, CLI, anemia, history of cardiovascular disease, and decreased eGFR were significantly associated with MACEs. Multivariable Cox regression analysis revealed that only AF, renal impairment, and polyvascular disease independently predicted MACEs (Table).

C-reactive protein, not cardiac troponin T, improves risk prediction in hypertensives with type A aortic dissection

Abstract Background: The aim of the study was to evaluate prognostic role of inflammatory biomarkers, cardiac troponin T (cTnT) and D-dimer in type A acute aortic dissection (AAD) and to examine whether they might help in risk stratification beyond values of International Registry of Acute Aortic Dissection (IRAD) score. Methods: Baseline biomarkers were determined in 54 consecutive predominantly hypertensive patients with type A AAD and evaluated for in-hospital mortality. Results: After multivariable adjustment, the independent predictors of outcome were age (OR = 1.09; 95% CI 1.02–1.18), treatment strategy (OR = 0.11; 95% CI 0.02–0.06) and C-reactive protein (CRP) either as binary (OR = 7.06; 95% CI 1.34–37.36) or continuous variable (OR = 1.10; 95% CI 1.01–1.21). cTnT did not independently influence mortality. Receiver- operating characteristic (ROC) curve analysis showed significant link between CRP and outcome (area under the ROC curve, AUC = 0.79; p < 0.01). Values of CRP > 9.8 mg/l had 83% sensitivity and 80% specificity for predicting in-hospital mortality. Addition of CRP to IRAD score improved prediction of short-term outcome, AUC increased from 0.74 to 0.89 (p = 0.004). Conclusion: Admission CRP has independent prognostic value in type A AAD and the addition of CRP to IRAD score improved discriminative capacity of in-hospital mortality irrespective of symptom duration and treatment strategy.

Prognostic effect of cardiac troponin elevation in acute aortic dissection: A meta-analysis.

BACKGROUND Acute aortic dissection (AAD) is a highly lethal medical emergency that requires immediate assessment and therapy. To date, no one biomarker plays a significant role in risk stratification of patients with AAD and whether cardiac troponin could be a prognostic marker of in-hospital mortality is still unknown. METHODS AND RESULTS To assess the prognostic role of cardiac troponin elevation during AAD, we performed an updated systematic review and meta-analysis. Four studies were included in the final analysis. Elevated cardiac troponin was present in 26.8% of patients with AAD and ranged between 23% and 33%. We showed that elevated troponin levels were significantly associated with increased risk of short-term mortality (OR 2.57; 95% CI 1.66-3.96). The analysis of pooled studies showed a low heterogeneity (I(2) 34.3%), and no publication bias was detected (Egger bias 3.34, p=0.18). CONCLUSIONS Cardiac troponin elevation at the time of admission for AAD is associated with an increased risk of in-hospital mortality.

Šećerna bolest i kritična ishemija ekstremiteta: smrtonosni dvojac u bolesnika sa simptomatskom perifernom arterijskom bolešću

Inflammation plays an important role in the initiation and progression of peripheral artery disease (PAD). Patients with diabetes have an increased risk of developing PAD. Data regarding the prognostic implication of diabetes and inflammation on all-cause mortality in patients with symptomatic PAD and preserved left ventricular ejection fraction (LVEF >50%). The study was conducted at the Sestre milosrdnice University Hospital Center between January 2010 and January 2014 on 319 consecutive patients with symptomatic PAD and preserved LVEF (66.5% men, mean age 70±10 years, ankle brachial index 0.58±0.14). Thirty-eight (12%) patients died during median follow up period of 24 months (interquartile range, 16-34 months). On univariate analysis, C-reactive protein was significantly associated with all-cause mortality (HR 2.21, 95% CI 1.09-4.48). After multivariate regression analysis, age (HR 1.07, 95% CI 1.02-1.11), diabetes (HR 2.24, 95% CI 1.04-4.82), and critical limb ischemia (HR 2.22, 95% CI 1.03-4.80) remained the only independent predictors for all-cause mortality. Diabetes and critical limb ischemia are independently associated with an increased risk of mortality in symptomatic PAD patients with preserved LVEF.

Electrophysiological predictors of propafenone efficacy in prevention of atrioventricular nodal re-entrant and atrioventricular re-entrant tachycardia

Aim To assess the efficacy of propafenone in prevention of atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic atrioventricular tachycardia (AVRT) based on the clinical results of arrhythmia recurrence and find the electrophysiological predictor of propafenone effectiveness. Methods This retrospective study included 44 participants in a 12-month period, who were divided in two groups: group A – in which propafenone caused complete ventriculo-atrial block and group B – in which propafenone did not cause complete ventriculo-atrial block. Results Group A had significantly lower incidence of tachycardia than group B (95% vs 70.8%, P = 0.038), and complete ventriculo-atrial block predicted the efficacy of propafenone oral therapy in the prevention of tachycardia (sensitivity 87.5%, specificity 52.8%, positive predictive value 95%, negative predictive value 29.2%). Patients with AVNRT in group B who did not experience the recurrences of tachycardia had significantly shorter echo zone before intravenous administration of propafenone than the patients who experienced episodes of sustained tachycardia (median 40 ms [range 15-60 ms] vs 79 ms [range 50-180 ms], P = 0.008). Conclusion In patients with non-inducible tachycardia, complete ventriculo-atrial block can be used as an electrophysiological predictor of the efficacy of propafenone oral therapy in the prevention of tachycardia. In patients with non-inducible AVNRT, but without complete ventriculo-atrial block, propafenone was more effective in patients with shorter echo zone of tachycardia.

Helicobacter pylori infection and severity of coronary atherosclerosis in patients with chronic coronary artery disease

Aim Controversy exists concerning the relation between Helicobacter pylori (HP) infection and coronary artery disease (CAD). We aimed to examine the relationship between HP infection and severity of coronary atherosclerosis in patients with chronic CAD. Patients and methods A total of 150 patients (109 [73%] men; mean age 62.61±10.23 years) scheduled for coronary artery bypass grafting surgery were consecutively enrolled in the cross-sectional study. According to rapid urease test and/or gastric biopsy samples stained with hematoxylin and eosin and according to Giemsa, patients were classified as HP positive (n=87; 58%) or HP negative (n=63; 42%). Coronary angiograms were scored by quantitative assessment, using multiple angiographic scoring system: 1) vessel score (number of coronary arteries stenosed ≥50%), 2) Gensini score (assigning a severity score to each coronary stenosis according to the degree of luminal narrowing and its topographic importance) and 3) angiographic severity score (number of coronary artery segments stenosed ≥50%). Results In comparison to HP-negative patients, HP-positive patients were more frequently hypertensive (P=0.014), had higher values of systolic (P=0.043) and diastolic (P=0.005) blood pressure and total cholesterol (P=0.013) and had lower values of high-density lipoprotein-cholesterol (HDL-C; P=0.010). There were no significant differences between the groups in the severity of coronary atherosclerosis: vessel score (P=0.152), Gensini score (P=0.870) and angiographic severity score (P=0.734). Conclusion It is likely that HP infection is not a risk factor for the severity of coronary atherosclerosis in chronic CAD patients.