Tomislav Kostic

Manifestations of Lyme carditis

The first data of Lyme carditis, a relatively rare manifestation of Lyme disease, were published in eighties of the last century. Clinical manifestations include syncope, light-headedness, fainting, shortness of breath, palpitations, and/or chest pain. Atrioventricular (AV) electrical block of varying severity presents the most common conduction disorder in Lyme carditis. Although is usually mild, AV block can fluctuates rapidly and progress from a prolonged P-R interval to a His-Purkinje block within minutes to hours and days. Rarely, Lyme disease may be the cause of endocarditis, while some studies and reports, based on serological and/or molecular investigations, have suggested possible influence of Borrelia burgdorferi on degenerative cardiac valvular disease. Myocarditis, pericarditis, pancarditis, dilated cardiomyopathy, and heart failure have also been described as possible manifestations of Lyme carditis. The clinical course of Lyme carditis is generally mild, short term, and in most cases, completely reversible after adequate antibiotic treatment.

The influence of stress hyperglycaemia on the prognosis of patients with acute myocardial infarction and temporary electrical cardiac pacing

INTRODUCTION Elevated glucose levels on admission in many emergency conditions, including acute myocardial infarction (AMI), have been identified as a predictor of hospital mortality. OBJECTIVE Since there are no data in the literature related to stress hyperglycaemia (SH) in patients with both AIM and temporary electrical cardiac pacing, we aimed to investigate the influence of stress hyperglycaemia on the prognosis of patients with AMI and temporary electrical cardiac pacing. METHODS The prospective study included 79 patients with diagnosed AMI with ST-segment elevation (STEMI), admitted to the Coronary Care Unit of the Clinic for Cardiovascular Diseases, Clinical Centre Nis, from 2004 to 2007, who were indicated for temporary electrical cardiac pacing. The blood was sampled on admission for lab analysis, glucose levels were determined (as well as markers of myocardial necrosis troponin I, CK-MB). Echocardiographic study was performed and ejection fraction was evaluated by using area length method. RESULTS The ROC analysis indicated that the best glycaemic level on admission, which could be used as a predictor of mortality, was 10.00 mmol/l, and the area under the curve was 0.82. In the group without SH, hospital mortality was 3-fold lower 11/48 (22.91%) compared to the group with SH 19/31 (61.29%), p < 0.0001. Patients with SH were more likely to have higher troponin levels, Killip >1, lower ejection fraction and heart rate, as well as systolic blood pressure. CONCLUSION The best cut-off value for SH in patients with AMI (STEMI) and temporary electrical cardiac pacing is 10 mmol/l (determined by ROC curve) and may be used in risk stratification; patients with glucose levels <10 mmol/l on admission are at 3-fold lower risk compared to those with glucose levels >10 mml/l. Our results suggest that SH is a more reliable marker of poor outcome in AMI patients with temporary pace maker, without previously diagnosed DM.

Preoperative Midregional Pro-Adrenomedullin and High-Sensitivity Troponin T Predict Perioperative Cardiovascular Events in Noncardiac Surgery

Objective: We evaluated the utility of preoperative midregional (MR) pro-adrenomedullin (proADM) and cardiac troponin T (TnT) for improved detection of patients at high risk for perioperative cardiac events and mortality after major noncardiac surgery. Subjects and Methods: This prospective, single-center, observational study enrolled 79 patients undergoing major noncardiac surgery. After initial clinical assessment (clinical history, physical examination, echocardiogram, blood tests, and chest X-ray), MR-proADM and high-sensitivity TnT (hsTnT) were measured within 48 h prior to surgery by immunoluminometric and electrochemiluminescence immunoassay. Patients were followed by the consulting physician until discharge or up to 14 days in the hospital after surgery. Perioperative cardiac events included myocardial infarction and development or aggravation of congestive heart failure. Data were compared between patients who developed target events and event-free patients. Results: Within 14 days of monitoring, 14 patients (17.72%) developed target events: 9 (11.39%) died and 5 (6.33%) developed cardiovascular events. The average age of the patients was 71.29 ± 6.62 years (range: 55–87). Sex, age, and hsTnT did not significantly differ between groups. MR- proADM concentration was higher in deceased patients (p = 0.01). The upper quartile of MR-proADM was associated with a fatal outcome (66.7 vs. 20.0%, p < 0.01) and with cardiovascular events (64.3 vs. 16.9%, p < 0.01). MR-proADM above the cutoff value (≥0.85) was associated with a fatal outcome (88.9 vs. 20.0%, p < 0.01) and cardiovascular events (71.4 vs. 28.6%, p < 0.01); this association was not observed for hsTnT. Conclusion: Preoperative measurement of MR-proADM provides useful information for perioperative cardiac events in high-risk patients scheduled for noncardiac surgery.

The contributions of fasting and postprandial blood glucose increments to oxidative stress and inflammation in dyslipidemic type 2 diabetic patients with stable ischemic heart disease

BACKGROUND/OBJECTIVES Contributions of fasting and postprandial blood glucose increments on level of inflammation and oxidative stress biomarkers in patients with stable ischemic heart disease (IHD) and diabetes mellitus type 2 (T2DM) was evaluated. METHODOLOGY Ninety T2DM patients (60 with IHD and 30 without IHD) treated with metformin and/or sulphonylurea were enrolled in cross-sectional nested case-control clinical study. The areas under the six-point daily glucose curve above the fasting glucose concentrations (AUCpp) and over 5.5mmol/L (AUCbg) were calculated to determine postprandial (AUCpp) and fasting (AUCbg-AUCpp) glucose increments. Malondialdehyde (MDA), protein carbonyl group (PCO), fibrinogen, C-reactive protein (hsCRP), leukocyte count and adhesion molecules ICAM-1 and VCAM-1 were determined. RESULTS AUCbg-AUCpp 58.2 (95%CI 40.6-75.8) was higher in IHD group compared to non-IHD 36.9 (95%CI 23.5-50.2) mmol*h/L. They had significantly higher ICAM-1 (mean±SD) 72.70±30.6 vs. 60.22±22.6ng/mL and MDA 16.47±4.5 vs. 13.42±4.01μmol/g plasma proteins, but similar PCO, VCAM-1, fibrinogen, hsCRP concentration and leukocyte count. AUCpp positively correlated with MDA (r=0.45) and ICAM-1 (r=0.32) in the presence of IHD, and VCAM-1 (r=0.44) in the absence of IHD. AUCbg-AUCpp positively correlated with PCO (r=0.45) in the absence of IHD. The analysis revealed that AUCpp over turning point of 0mmol*h/L was associated with high MDA and ICAM-1 expression in diabetics with IHD. AUCbg-AUCpp over 30mmol*h/L leads to high oxidative protein modification in diabetics without IHD. CONCLUSION In T2DM patients with stable IHD, AUCpp at any point, significantly contributes to increasing of MDA and ICAM-1 expression. Fasting blood glucose increment showed significant correlation with carbonyl content in diabetics without IHD.

Erectile dysfunction as a predictor of two-year prognosis in acute myocardial infarction

BACKGROUND Erectile dysfunction (ED) is a predictor or marker of coronary artery disease in patients at high risk of cardiovascular diseases. The aim of this study was to investigate the prevalence of ED in patients with acute myocardial infarction (AMI) and after 2 years of follow-up, and to determine the association between ED and the concentrations of the markers of inflammation, endothelial dysfunction and oxidative stress which were measured on the third day after hospital admission. METHODS The study included 80 patients aged 62.25 ± 10.47 years. The primary endpoints of interest were re-hospitalization due to cardiovascular causes and death during the 2 year period after hospital-ization. The Sexual Health Inventory for Men (SHIM) was assessed at the point of hospital discharge and 24 months thereafter. RESULTS 40.1% of patients had some degree of ED. The percentage of patients without ED increased (13.2%), while the percentage of patients with severe ED significantly decreased (14.7%) after 2 years. Patients with ED had significantly higher B-type natriuretic peptide (BNP) levels and decreased levels of nitric-oxide. During the 2 years of follow-up, 9 patients died (6.5% without ED, 68.6% with ED) (c2 = 7.19, p = 0.015). During the same time period, 22 (27.5%) patients were re-hospitalized due to cardiovascular causes, of whom 59.1% had ED at hospital admission (p < 0.05). CONCLUSIONS Low levels of nitric-oxide were the best predictors of ED during AMI and after 2 years. ED predicted the worst outcomes of AMI: death and re-hospitalization. Lifestyle changes and nitric- -oxide donors could assist in the treatment of ED and in the improvement of long-term prognosis for AMI. (Cardiol J 2017; 24, 4: 393-402).

Coronary flow and hemorrhagic complications after alteplase and streptokinase administration in patients with acute myocardial infarction

BACKGROUND/AIM Up-to-date treatment of acute myocardial infarction (AIM) has been based on as early as possible establishment of circulation in ischemic myocardium whether by the use of fibrinolythic therapy and/or urgent coronary intervention which significantly changes the destiny of patients with AMI, but also increases the risk of bleeding. The aim of this study was to compare coronary flow and bleeding complications in patients with acute myocardial infarction with ST-elevation (STEMI) after administration of alteplase or streptokinase. METHODS The study included 254 patients with STEMI. The group I (n = 174) received streptokinase, and the group II (n = 80) received alteplase. We followed frequency of complications such as bleeding and hypotension in the investigated groups of patients, based on the TIMI classification of bleeding, as well as the transience of infarction artery in accordance with TIMI flow. RESULTS The patients with myocardial infarction after administration of alteplase had statistically significantly higher coronary flow (TIMI-3), 72.5% as compared to the patients who received streptokinase, 39.2%. Hypotension as complication of fibrynolythic therapy administration occurred in a significantly higher percentage in the group of patients who received streptokinase. There was no statistically significant difference in the appearance of major bleeding in the groups of patients who received streptokinasis and alteplase (6.9% and 7.5%, respectively). Also, there was no difference in the appearance of minor and minimal bleeding among the investigated groups of patients. CONCLUSION It was shown that alteplase in a higher number of patients provided TIMI-3 coronary flow as compared to streptokinese. In comparison with streptokinase, a combination of alteplase, enoxaparin and double antiplatelet therapy enabled earlier achievement of coronary flow through previously blocked coronary artery that was more complete (higher frequency of TIMI-3 flow). There were no statistically significant difference in frequency of bleeding, first of all major bleeding, between the groups treated by alteplase and streptokinase.

A Risk Stratification Model for Cardiovascular Complications during the 3-Month Period after Major Elective Vascular Surgery

Introduction The Revised Cardiac Risk Index (RCRI) is an extensively used simple risk stratification tool advocated by the European Society of Cardiology and European Society of Anesthesiology (ESC/ESA). Purpose The aim of this study was to find the best model for predicting 3-month cardiovascular complications in elective major vascular surgical patients using preoperative clinical assessment, calculation of the RCRI and Vascular Physiological and Operative Severity Score for the enumeration of mortality and morbidity (V-POSSUM) scores, and the preoperative levels of N-terminal brain natriuretic peptide (NT pro-BNP), high-sensitivity troponin I (hs TnI), and high-sensitivity C-reactive protein (hs CRP). Materials and Methods We included 122 participants in a prospective, single-center, observational study. The levels of NT pro-BNP, hs CRP, and hs TnI were measured 48 hours prior to surgery. During the perioperative period and 90 days after surgery the following adverse cardiac events were recorded: myocardial infarction, arrhythmias, pulmonary edema, acute decompensated heart failure, and cardiac arrest. Results During the first 3 months after surgery 29 participants (23.8%) had 50 cardiac complications. There was a statistically significant difference in the RCRI score between participants with and without cardiac complications. ROC analysis showed that a combination of RCRI with hs TnI has good discriminatory power (AUC 0.909, p<0,001). By adding NT pro-BNP concentrations to the RCRI+hs TnI+V-POSSSUM combination we obtained the model with the best predictive power for 3-month cardiac complications (AUC 0.963, p<0,001). Conclusion We need to improve preoperative risk assessment in participants scheduled for major vascular surgery by combining their clinical scores with biomarkers. Therefore, it is possible to identify patients at risk of cardiovascular complications who need adequate preoperative diagnosis and treatment.

Heart rate recovery time in metabolically healthy and metabolically unhealthy obese children

ABSTRACT Background: Autonomic dysfunction is an emerging non-traditional cardiovascular risk factor that correlates with obesity, components of metabolic syndrome, as well as cardiorespiratory fitness. As a simple and validated index of autonomic balance, heart rate recovery (HRR) has been reported as a useful biomarker for predicting cardiovascular morbidity and mortality. Objectives: The aim of this study was to compare HRR in metabolically healthy vs. metabolically unhealthy obese children. Methods: A total of 56 obese children of whom 31 had metabolic syndrome were examined. All the participants underwent the multistage submaximal cycle ergometer test and HRR was determined one minute after the test. Results: The HRR was significantly lower (18.9 ± 3.7) in a group of metabolically unhealthy obese children compared to metabolically healthy obese children (24 ± 4.1) p < 0.001. Logistic regression analysis showed that reduction in HRR was also influenced by higher BMI. Conclusion: Our findings implicate the presence of the autonomic dysfunction as reflected by impaired heart rate recovery (HRR) in obese children with metabolic syndrome.

The influence of type 2 diabetes mellitus on the frequency and complexity of ventricular arrhythmias and heart rate variability in patients after myocardial infarction

Background/Aim After myocardial infarction arrhythmic cardiac deaths are significantly more frequent compared to non-arrhythmic ones. The aim of the study was to investigate the influence of type 2 diabetes mellitus (T2DM) on the frequency and complexity of ventricular arrhythmias after myocardial infarction. Methods The study included 293 patients, mean age 59.5 ± 9.21 years, who were at least six months after acute myocardial infarction with the sinus rhythm, without atrioventricular blocks and branch blocks. In the clinical group 95 (32.42%) patients were with T2DM, while 198 (67.57%) patients were without diabetes. All of the patients were subjected to the following procedures: standard ECG according to which the corrected QT dispersion (QTdc) was calculated, exercise stress test, and 24-hour holter monitoring according to which, the four parameters of time domain of heart rate variability (HRV) were analyzed: standard deviation of all normal RR intervals during 24 hours (SDNN), standard deviation of the averages of normal RR intervals in all five-minute segments during 24 hours (SDANN), the square root of the mean of the sum of the squares of differences between adjacent normal (RMS-SD), and percentage of consequtive RR intervals which differed for more than 50 ms during 24 hours (NN > 50 ms). Results In patients after myocardial infarction, patients with T2DM had significantly higher percentage of frequent and complex ventricular arrhythmias compared to the patients without diabetes (p < 0.001). The patients with T2DM had significantly higher percentage of residual ischemia (p < 0.001), and arterial hypertension (p < 0.001), compared to patients without diabetes. The patients with T2DM had significantly lower values of HRV parameters: SDNN (p < 0.001); SDANN (p < 0.001); RMS-SD (p < 0.001), and NN > 50 ms (p < 0.001), and significantly higher values of QTdc (p < 0.001) compared to the patients without diabetes. Conclusion The study showed that type 2 diabetes mellitus has significant influence on ventricular arrhythmias, HRV parameters and QT dispersion in patients after myocardial infarction.

Implantable Loop Recorder – A Good Opportunity to Diagnose Unexplained Syncope

Summary Implantable loop recorder (ILR) is a method in cardiology, which is used for the diagnosis of unexplained syncope in patients who were not treated successfully using standard methods. Implantable loop recorder is a diagnostic device that is surgically implanted under the skin of the chest area. This device does not have the endovenous implantation of electrodes; instead, electrodes are attached to the machine housing. The device records the heart rhythm continuously, up to 14 months, and stores data outside the activator whenever symptoms appear, or by the automatic activation of the predefined program for bradycardia, asystole, and tachycardia. The aim of this paper was to describe the method for the detection of cardiac syncope with the use of implantable loop recorder.