Nebojsa Tasic

Head-to-head comparison of indices of left ventricular contractile reserve assessed by high-dose dobutamine stress echocardiography in idiopathic dilated cardiomyopathy: five-year follow up

Objective: To compare head to head the indices of left ventricular contractile reserve assessed by high-dose dobutamine in the five-year prognosis of patients with idiopathic dilated cardiomyopathy. Design and setting: Prospective study in a tertiary care centre. Patients: 63 consecutive patients with idiopathic dilated cardiomyopathy. Interventions: High-dose dobutamine stress echocardiography was performed in progressive stages lasting 5 min each. Wall motion score index, ejection fraction, cardiac power output and end systolic pressure to volume ratio were evaluated as indices of left ventricular contractility. Main outcome measure: Five-year cardiac mortality. Results: During the follow up of 59 patients, 27 (45.8%) died of cardiac causes. According to Kaplan–Meier and receiver operating characteristic analyses all indices of contractile reserve differentiated patients with respect to cardiac death. Wall motion score index achieved the best separation (log rank 21.75, p < 0.0001, area under the curve 0.84), followed by change in ejection fraction (log rank 11.25, p  =  0.0008, area under the curve 0.79), end systolic pressure to volume ratio (log rank 14.32, p  =  0.0002, area under the curve 0.75) and cardiac power output (log rank 9.84, p  =  0.0017, area under the curve 0.71). Cox’s regression model identified wall motion score index as the only independent predictor of cardiac death. Conclusions: These data show that all examined indices of left ventricular contractile reserve are predictive of five-year prognosis, but change in wall motion score index may have the greatest prognostic potential.

Comparison of Valve Annuloplasty and Replacement for Ischemic Mitral Valve Incompetence

OBJECTIVE Mitral incompetence is a chronic sequela of myocardial infarction. It is caused by apical displacement and tethering of the mitral valve leaflets after myocardial infarction, resulting in incomplete coaptation. The consensus is for mitral valve surgery in the presence of significant ischemic mitral regurgitation (IMR). Previously, the only option was mitral valve replacement (MVR) with a mechanical or tissue valve. The suboptimal results obtained prompted the development of several methods of mitral valve repair. Today, the most commonly used repair is undersized annuloplasty. METHODS We conducted a retrospective nonrandomized study of all patients who underwent operation for coronary artery disease and IMR between 2000 and 2006. The surgeon chose the surgical method used for the mitral valve procedure. The most commonly used procedures were restrictive mitral valve annuloplasty (MVP) and MVR with a mechanical prosthesis. We collected all pertinent preoperative, intraoperative, and early-postoperative data. We followed up with phone interviews of the patients and their relatives and with complete clinical and echocardiography examinations. RESULTS We carried out operations on 138 patients during the study period (MVR, 52 patients; MVP, 86 patients). The 2 groups had comparable demographic data and risk factors. The 2 groups were significantly different with respect to mean (+/-SD) New York Heart Association (NYHA) class (MVP, 2.72 +/- 0.62; MVR, 2.48 +/- 0.70; P < .01) and ejection fraction (MVP, 29.01% +/- 11.00%; MVR, 35.87% +/- 11.00%; P </= .01). The 30-day mortality rates for the MVR and MVP groups were significantly different (9.61% and 5.81%, respectively; P < .01). Our follow-up included 83% of the patients and continued for up to 84 months. The 2 groups showed no significant difference in mortality by the end of follow-up; however, the MVR patients had a better ejection fraction (37.79% versus 29.86%) and NYHA functional class (1.88 +/- 0.498 versus 2.36 +/- 0.564; P < .01). CONCLUSION Correcting chronic IMR with either repair or replacement produces a good mid-term survival rate (approximately 75%) for survivors in NYHA classes I and II. In our study, mortality rates for the MVP and MVR groups were similar, even though the repair group had a lower mean ejection fraction and a higher NYHA class before and after the operation. We therefore conclude that repair is superior to replacement in treating ischemic mitral insufficiency. A prospective randomized study is needed to better compare these 2 approaches.

Jugular vein aneurysm.

Jugular vein aneurysm is a rare morphologic entity. This report describes a case of an asymptomatic internal jugular vein aneurysm that presented as an enlarging mass in the neck. Diagnosis was established with duplex ultrasonography and venography. No thrombus was diagnosed in the aneurysm, but since the patient was uncomfortable with having a tumor in his neck, surgery was performed with resection of the aneurysm and lateral venorrhaphy of the jugular vein.

Impact of concomitant aortic regurgitation on long-term outcome after surgical aortic valve replacement in patients with severe aortic stenosis

BackgroundPrognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality.MethodsStudy group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR.ResultsPatients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality.ConclusionOur data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.

Feasibility of semi-quantitative assessment of left ventricular contractile reserve in dilated cardiomyopathy

We and others have shown previously that left ventricular (LV) contractile reserve assessed quantitatively by high‐dose dobutamine stress‐echocardiography (DSE) has prognostic implications in patients with dilated cardiomyopathy.

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.

Correlation of Salt Sensitivity, Plasma Renin Activity and Aldosterone in Hypertensive Patients

Abstract Plasma-renin values vary in normotensive and hypertensive populations. Some studies consider renin to be a key factor in the aetiology of hypertension, but other studies note that renin is an important factor in cardiovascular homeostasis and functions more as a growth factor than as a pressor hormone. The aim of this study was to assess the PRA and aldosterone values under different salt intake regimes in patients with essential hypertension. The study group consisted of 50 untreated patients (27 women and 23 men; average age 42±9,2 yrs.; average BMI 27,91±4,6 kg/m2) with essential hypertension. All patients were put on a high-sodium diet (200 mmol NaCl per day) for one week after a week on a low-sodium diet (20 mmol NaCl per day). Sodium sensitivity (SS) was defined as a 10-mmHg increase in the mean blood pressure at the end of the high- vs. the low-sodium diet. The SS group consisted of 26 patients, and the sodiuminsensitive group consisted of 24 patients. The PRA and aldosterone levels were determined in 12 patients. PRA values in the SS group during rest were significantly lower compared with the salt-resistant group during all regimes of salt intake (F=10,56, p=0,0012). Salt loading in SS patients causes a significant decrease in PRA (in rest and effort) values in comparison to values during a low salt intake regime (rest: t=4,49, p<0,001; effort: t=3,45, p<0,01). The PRA values in the salt-resistant group did not vary significantly under the different salt intake regimes. The aldosterone values followed the pattern of the PRA values. It is necessary to distinguish investigations on salt intake effects based on incidence and value of blood pressure and investigations on salt restriction’s effects on of blood pressure levels (i.e., non-pharmacological hypertension therapy).

Orthostatic Hypotension and Therapy with an Ace Inhibitor in Hypertensive Patients

Abstract Orthostatic hypotension (OH) is defined as a drop in the systolic blood pressure greater than 20 mmHg and that of the diastolic blood pressure greater than 10 mmHg within 3 minutes from the change of the body’s position from lying or sitting down to standing up. The objective of this study is to analyse the incidence and severity of orthostatic hypertension when taking one of the generic representatives of the ACE inhibitor group (trandolapril) as a monotherapy in patients with essential hypertension. Th e study involved 314 patients (medium age of 54±4 years; 52.5% men) with poorly regulated hypertension for whom trandolapril was introduced as monotherapy. Th e incidence rates of patients with and without orthostatic hypotension between the first and second examination were not statistically significantly different. At the second control examination, 7 patients (2,3%) still had orthostatic hypotension, as was the case at the first examination. Between the third and fourth controls, a statistically significant decrease in the number of patients with orthostatic hypotension was recorded. No statistically significant difference in the incidence of orthostatic hypotension between patients with normal body mass and those who were overweight was observed. Our study has shown that certain ACE inhibitors, such as Trandolapril, do not have a pronounced adverse effect with regard to orthostatic hypotension and that in long-term application, they can have a positive role in the prevention of hypotensive episodes and improving patient compliance.

Similarities and Differences in Epidemiology and Risk Factors of Cerebral and Myocardial Ischemic Disease

Abstract Ischemic heart disease and cerebral ischemia represent the leading causes of mortality worldwide. Both entities share risk factors, pathophisiology and etiologic aspects by means of a main common mechanism, atherosclerosis. The autors aimed to investigate differences and similarities in epidemiology and risk factors that could be found between both entities. In a retrospective sudy 403 patients were included and divided into two groups: group of 289 patients with history of myocardial infarction (AMI), and group of 114 patients with history of ischemic stroke (IS). All patients were evaluated for nonmodifiable risk faktors, which included age and sex, and modifiable, such as hypertension, dyslipidemia, diabetes, obesity, physical activity and smoking. Diff erences in some epidemiological aspects were also considered: occupation, marital status, alcohol consumption, exposure to stress. Patients with history of IS were significantly older then AMI patients (64.0 ± 9.9 vs 64.0 ± 9.9, p=0,028), with higher diastolic blood pressure (87,1 ± 10,2 vs 83,6 ± 10,4, p=0,003) and higher Sokolow-Lyon index in ECG, an also index of left ventricular hypertrophy (19,2 ± 9,1 vs 14,7 ± 6,5). Th ere were no significant differences between groups in the estimated body mass index and waist circumference. Differences between groups in stress exposure, occupation, alcohol consumption or physical activity were no significant. Patients in AMI group were more frequently male (199 (69%) vs 59 (52%), p=0,001), married (252 (87%) vs 88 (77%), p=0,037), smokers (162 (56%) vs 50 (44%), p=0,018) and with higher incidence od dyslipidemia (217 (75%) vs 73 (64%), p=0,019) compared with IS group. Incidence of arterial hypertension and diabetes was similar in both groups. Both entities share similar pathophysiological mechanisms and, consequently, main traditional risk factors. However, incidence of myocardial infarction increases with male sex, dyslipidemia, smoking and marital status, while incidense of ischemic stroke increases with age, higher diastolic blood pressure and also with ECG signs of left ventricular hypertrophy.

Efficacy and Tolerability of a Fixed Combination of Perindopril/Amlodipine/Indapamide in Patients with Essential Hypertension: Pilot Study / Efikasnost I Tolerabilnost Fiksne Kombinacije Perindopril/Amlodipin/Indapimida Kod Pacijenata Sa Esencijalnom Hipertenzijom: Pilot Studija

Abstract Hypertension is the major risk factor in Serbia and worldwide for the morbidity and mortality from cardiovascular and cerebrovascular diseases. A majority of patients need two or more antihypertensive drugs to adequately control blood pressure. Our study group consisted of 12 patients with uncontrolled essential hypertension, without comorbidities, divided in two groups and followed for 12 weeks. The first group was treated with a single-pill of fixed-combination Perindopril 5 mg/Indapamide 1.25 mg and an additional tablet of Amlodipine 5 mg. The second group received a single-pill fixed-combination of Perindopril 5 mg/Indapamide 1.25 mg/Amlodipine 5 mg. Our research showed significant decreases in systolic (p=0,05) and diastolic (p<0,05) blood pressure in both groups after 12 weeks of treatment. The study also showed a higher percentage of patients who achieved the targeted blood pressure (< 140/90 mmHg) on the single-pill triple combination drug (69.7%) in comparison with the other group (50%). No adverse effects were recorded in both groups. Our results revealed significant efficacy and tolerability of a single-pill triple-fixed combination Perindopril/Amlodipine/ Indapamide in patients with uncontrolled essential hypertension without comorbidities.