Renal dysfunction and heart failure – epidemiology and clinical significance

The prevalence of heart failure (HF) and chronic kidney disease (CKD) tends to increase in the general population as a consequence of the increasing age and improvement of the management and the outcome of acute cardiac and renal syndromes. Both conditions co-exist very often in one and the same patient which is probably due to “sharing” common risk factors like arterial hypertension, diabetes mellitus and atherosclerotic disease. It is considered that cardiac dysfunction may lead to renal failure and vice versa. The prevalence of CKD among patients with HF is around 30-40%.  In recent years, we speak about cardiorenal syndrome (CRS) which is a pathophysiological condition of the heart and kidneys where the acute or chronic dysfunction of one of these organs leads to acute or chronic dysfunction of the other. For a more precise chronological and pathophysiological definition CRS is classified in 5 types. New biomarkers for renal impairment such as NGAL, KIM-1, NAG, Cystatin С are already in clinical practice. More vigilance and more frequent laboratory monitoring of serum creatinine and electrolytes is required in patients with HF and CKD who are treated with ACE inhibitors/angiotensin-receptor blocking agents and aldosterone antagonists

El Sistema Financiero Digital: los nuevos agentes

84 p.Durante las últimas décadas, las nuevas tecnologías han irrumpido prácticamente en todos los sectores de la actividad económica y uno de los más favorecidos ha sido el sector financiero. La innovación es constante y la transformación en este sector no ha hecho más que comenzar. Sin duda, estos cambios presentarán muchos beneficios, pero, a la vez, muchos retos. El objetivo de este trabajo será analizarlos y crear una imagen global del sistema que está por venir. Para ello, nos centramos en analizar cómo están afrontando las entidades clásicas el cambio. Además, investigamos sobre el origen y la posición de los nuevos agentes del sector. Finalmente damos paso a explicar los beneficios y retos de las nuevas tecnologías. Con todo ello, extraemos las principales conclusiones del análisis y tratamos de proporcionar un concepto holístico de todos los cambios.During the last few decades, new technologies have broken into almost all sectors of economic activity and one of the most benefited has been the financial sector. The innovation is constant and the transformation of the industry has only just begun. Undoubtedly, these changes will have many benefits, but, at the same time, will bring on many challenges. The purpose of this document will be to analyze these benefits and challenges and create a global image of the system that is to come. For this matter, we focus on analyzing how the classic organizations are facing the change. In addition, we investigate the origin and competitive position of new agents in the sector. Finally we give way to explain the benefits and challenges of new technologies. After the whole analysis, we extract the main conclusions of the investigation and try to provide a holistic concept the new digital financial system

Transit-time flowmetric evaluation of coronary artery bypass graft flow after off- and on-pump myocardial revascularization

Introduction: Incorrect performance of anastomoses to the target coronary arteries often causes coronary artery disease and patient`s death following myocardial revascularization. Coronary graft patency evaluation is obligatory for prevention of peri- and postoperative myocardial ischemia.Aim: The objective of the present study was to comparatively assess the values of mean coronary flow and pulsatility index in arterial and venous grafts in patients after on-pump- and off-pump myocardial revascularization.Materials and Methods: During the period between January 1, 2014 and December 31, 2017, 143 coronary artery disease patients, 111 males at a mean age of 63.29±9.78 years and 32 females at a mean age of 66.43±9.58 years were operated on in the Department of Cardiac Surgery, St. Marina University Hospital of Varna. Myocardial revascularization was performed by using 92 arterial and 65 venous coronary grafts in the on-pump group (ONCAB) and 137 arterial and 45 venous grafts in the off-pump group (OPCAB). Coronary graft blood flow was assessed by means of coronary angiography and transit-time flowmetry (TTFM).Results: There were different values of the mean coronary flow and pulsatility index (PI) in arterial and venous conduits, both intervention types, as well as in males and females. The difference between male and female patients in terms of the mean values of venous grafts is statistically reliable (χ2=11.410; р≤0.022 and r=-0.310; p=0.001). The PI values in arterial grafts differed statistically significantly between both intervention types (p=0.003). Much more revisions of arterial and venous conduits on the occasion of insufficient patency were performed in the ONCAP than in the OPCAB group.Conclusion: Based on our results and literature data available, we could recommend the wide application of the method of TTFM for exact recognition of the circulatory disorders in the coronary graft following CAGB in Bulgaria

Is circulating Gla-rich protein linked with coronary calcium and cardiovascular pathology in patients with atrial fibrillation or heart failure? A pilot study

Introduction: Nowadays Gla-rich protein (GRP) is recognized as a novel biomarker playing a pivotal role in the crosstalk between chronic inflammation and vascular calcification.Aim: The aim of this article is to study the link between circulating GRP, cardiovascular pathology, and the degree of arterial calcification evaluated by the coronary arterial calcium score (CACS) in a Bulgarian population sample. Materials and Methods: Adult participants (n = 81) of both genders were divided into: controls (n = 41)—subjects with estimated moderate-to-high risk without known cardiovascular diseases (CVDs) and a combined CVD group (n = 40)—patients with paroxysmal or persistent atrial fibrillation in sinus rhythm, and heart failure subjects with preserved ejection fraction. A structured interview was carried out for evaluation of the classical CVD risk factors. CACS was determined by multislice computed tomography. Routine laboratory parameters were extracted from medical records. Serum levels of total GRP, matrix Gla protein, and osteocalcin were estimated by commercial ELISA kits. Standard statistical methods (descriptive statistics, Student’s t-test and Spearman’s correlation) were applied. Statistical significance was considered at p<0.05. Results: Significantly lower GRP levels were established in patients with coronary calcium compared to those without calcium deposits. Clear tendency for decreased levels of GRP was observed in the combined CVD group vs controls. Circulating GRP significantly correlates with uncarboxylated matrix Gla protein. An association between serum GRP, CRP, and low-density lipoproteins (LDLs) was demonstrated. Conclusion: This study adds new information regarding the role of circulating GRP as a new player in calcification inhibition. Our findings illuminate the link between total circulating GRP, CVD pathology, and the degree of coronary calcification

Uncorrected Tetralogy Of Fallot In A 60-Year-Old Female: Ethiopathogenetic Mechanisms Of The Observed Survival

Тетралогията на Фало е най-често срещаната цианотична сърдечна малформация в детска възраст и е рядко срещана при възрастни. Честота и е от 0,26% до 0,8% на 1000 новородени. Мъжкият пол е засегнат по-често. Включва четири компонента: междукамерен септален дефект, обструкция в изходния тракт на дясна камера, яздеща аорта и деснокамерна хипертрофия. Без оперативна корекция на дефекта смъртността е много висока. През първата година умират 25% от нелекуваните деца. Само около 5% от лицата с неоперативно коригирана малформация преживяват възрастта от 40 години като развиват дясна сърдечна недостатъчност. Представяме случай на 60-годишна пациентка с некоригирана тетралогия на Фало. Обсъждат се етиопатогенетичните механизми за наблюдаваната продължителност на живота.Tetralogy of Fallot is the most common form of cyanotic congenital heart disease in childhood but rarely seen in adulthood. The incidence is 0.26% - 0.8% out of 1000 newborns. The male sex is affected more often. It includes four components: ventricular septal defect, obstruction to the right ventricular outflow tract, overriding aorta and right ventricular hypertrophy. After the diagnosis is clear, the treatment is 100% surgical - full correction during the first two years. About 25% of the untreated children die within the first year. Only 5% of the untreated patients reach the age of 40 years and they develop right-sided heart failure. We present the case of a 60-year-old female patient with an uncor-rected tetralogy of Fallot, with discussion of the ethiopathogenetic mechanisms of the observed survival

Extracorporeal ultrafiltration in refractory heart failure

Сърдечната недостатъчност (СН) е значим здравен и социален проблем и, въпреки напредъка на медицината, продължава да бъде водеща причина за хоспитализациите в развитите страни. Основна изява на декомпенсация е хиперволемията, която при рефрактерна СН трудно може да бъде повлияна с познатите досега средства. В настоящия обзор е разгледана подробно ултрафилтрацията (УФ) като надежден, безопасен и ефективен метод за лечение на застойна рефрактерна СН. Описани са методиката, известните клинични проучвания в тази област, както и основните индикации и контраиндикации за нейното приложение.Heart failure (HF) is a major health and social problem and despite the advances in medicine it still remains the main cause for hospitalizations in the developed world. The main sign of decompensation is hypervolemia, which in refractory HF is difficult to treat with the currently available medications. This review studies in detail ultrafiltration (UF) as a safe, effective and promising method for management of refractory congestive HF. The procedure, the prominent clinical studies in this field, as well as the main indications and contraindications are described

GUNSHOT WOUND TO THE HEAD – COMMON ERRORS IN DIAGNOSING THE DIRECTION AND DISTANCE OF THE SHOT /A CASE REPORT/

Introduction: Firearm-related injuries are a leading cause of morbidity – as the use of firearms increases and they are relatively easy to obtain. The wounds, caused by them, have their specifics, determinate by the type of the weapon, the projectile and the effect of the additional factors of the shot. In the forensic practice, the correct interpretation of the wounds is extremely important for the reconstruction of the events that led to the accident – whether it is a case of homicide or suicide. Materials and methods: Forensic autopsy, performed according to the standard section technique. Case presentation: We present a case of a 70-year old man, who died in a hospital from a gunshot injury to the head. In the Department of Forensic Medicine and Deontology Sofia, after a careful examination of the body of the deceased and analysis of the medical records from the hospital where he was treated, some discrepancies were found. Discussion: Not all of the firearm-related injuries are fatal - in some cases the interval between the trauma and the death is prolonged and both the entrance and the exit wounds can be surgically treated, which can lead to difficulties in diagnosing the direction and the distance of the shot. Conclusion: The aim of this article is to emphasize the need for trauma specialists to be alerted for the possibility of misinterpretation of gunshot wounds and to realize the medicolegal implications

Association between blood glucose on admission and 2-hour glucose during oral glucose tolerance test in patients with acute coronary syndrome without known diabetes

Въведение: Хипергликемията по време на остър коронарен синдром (ОКС) при пациенти без известен диабет е честа и се счита, че е `стресова`. От друга страна тя може да е първата индикация за предходно неразпознато гликемично нарушение.Цел: Да се потърси връзка между кръвната глюкоза (КГ) при спешна хоспитализация поради ОКС и глюкозните показатели в хода на орален глюкозотолерантен тест (ОГТТ).Материали и методи: При 96 лица с проведена KAPCI и без анамнеза за гликемични нарушения се приложи стандартен ОГТТ между 3и-10и ден след дехоспитализацията. Глюкозният статус се класифицира според критериите на СЗО - 2006 г., за плазмена глюкоза на гладно (ПГГ) и плазмена глюкоза на 2ри час (2-ч-ПГ). Анализирана е КГ по време на спешен прием при 39 пациенти с ОКС.Резултати: Установихме нарушен глюкозен метаболизъм при 64.58%, a хипергликемия на 2ри час (≥7,8 ммол/л) - при 52.1% от изследваните след проведения ОГТТ. Средната КГ при спешно приемане на лицата с новооткрит тип 2 захарен диабет (нТ2ЗД) беше 9,55±1,93 ммол/л, която беше значимо по-висока спрямо тази на лицата с предиабет (7,22±2,01 ммол/л; p=0,006) и нормален глюкозен толеранс (6,31±2,08 ммол/л; p=0,0007). КГ при спешно приемане показа по-силна права връзка с 2-ч-ПГ (r=0,55; p=0,0003), отколкото с ПГГ и HbA1c. Чрез ROC анализ оценихме стойностите на КГ при спешен прием за откриване на диабет. Праговата стойност (сut off) >7,4 ммол/л показа най-добра комбинация от 91.7% чувствителност и 67.9% специфичност (area under the ROC=0,82; SE 0,06; 95% CI 0.698÷0.953; p=0,001).Заключение: КГ при спешен прием показа най-силна корелация с 2-ч-ПГ, определена в хода на ОГТТ. Намерихме, че стойността на 2-ч-ПГ (ОГТТ) е дори по-висока от КГ при спешна хоспитализация. За отхвърляне на гликемично нарушение при стойност на КГ при спешен прием > 7,4 ммол/л изглежда по-подходящо провеждането на ОГТТ.Introduction: Hyperglycemia during acute coronary syndrome (ACS) in patients without known diabetes is common and is considered `stress hyperglycemia`. On the other hand, it could be the first indication for previous unrecognized glycemic abnormality.Aim: To search for correlation between blood glucose (BG) at acute admission due to ACS and glycemic parameters during oral glucose tolerance test (OGTT). Materials and methods: A standard OGTT 3-10 days after hospital discharge was applied in 96 patients without history of glucose abnormalities who underwent coronary angiography (CA) percutaneous coronary intervention (PCI). Glucose tolerance was defined according to WHO-2006 criteria for fasting plasma glucose (FPG) and 2-hour-plasma glucose (2-h-PG). The BG at acute admission in 39 ACS patients was analyzed.Results: We found impaired glucose metabolism in 64.58% and 2-hour-hyperglycemia (≥7,8 mmol/L) in 52,1% of study participants after the OGTT. Mean BG at acute admission in subjects with newlydiagnosed type 2 diabetes mellitus (nT2DM) was 9,551,93 mmol/L. It was significantly higher co

BIO-TRACE ANALYSIS OF A BITE MARK SCAR LEFT ON THE HAND OF A PERPETRATOR OF A CRIME – A FORENSIC CASE REPORT

Introduction: We present a case of a homicide of a woman that was manually strangulated after she was sexually abused. On the right hand of the suspect specific scars were observed that could be dated around a month before our examination. In addition we were given gypsum casts of the deceased’s upper and lower jaws, as well as all the autopsy findings. Materials and methods: Examination of the suspect, analysis of the autopsy findings and the gypsum casts from the upper and lower jaws of the deceased, photo-superimposition, analysis of the results. Results: In this case, the obtained results showed the stable characteristics after the static and dynamic impact on perceptive surface (the hand of the perpetrator). These characteristics of the scars perfectly matched the specific features of the gypsum casts from the upper and lower jaw of the deceased. The study was performed by photo-superimposition and bio-trace analysis. Conclusion: Such types of forensic analysis are extremely important and informative in investigating criminal offenses, especially in cases where there is no other objective evidence (material evidence, testimony, available DNA research material, etc.) to identify the perpetrator of the crime

Intensifying the treatment of familial hypercholesterolemia—the experience of a single center in Eastern Bulgaria

Introduction: Familial hypercholesterolemia (FH) is an established risk factor for the development of atherosclerotic cardiovascular diseases (CVD), which determines early morbidity and mortality. Intensive reduction of the high levels of low-density lipoprotein cholesterol (LDL-c) reduces the incidence of CVD.Aim: The aim of this article is to analyze changes in lipid levels after intensification of the treatment of patients with familial hypercholesterolemia.Participants and Methods: Lipid levels of 59 patients with familial hypercholestrolemia from Eastern Bulgaria were studied with the aim of optimizing the management at an FH treatment center at St. Marina University Hospital, Varna. The period covered was from October 2017 to July 2020. The diagnosis of FH was determined as probable or certain according to the Dutch Lipid Clinics Network (DLCN) with a score of ≥ 6 points. After evaluation of the inclusion criteria for initiating treatment with evolocumab, all patients were monitored every 6 months for their lipid status. Baseline demographic characteristics and changes in the levels of laboratory tests for total cholesterol, LDL-c, and HDL cholesterol (HDL-c) were analyzed. A t-test for grouped pairs was used to estimate the difference from the baseline.Results: Of all 59 who passed through the center, the majority were men (58%). The mean age was 57.66 ± 9.57 years, from 37 to 76 years. A total of 54% had ischemic heart disease, 30.5% had survived a myocardial infarction, and 12% had a previous stroke. The mean baseline of total cholesterol was 8.23 ± 3.65 mmol/L, that of LDL cholesterol was 5.31 ± 1.95 mmol/L, and that of HDL-c was 1.25 ± 0.4 mmol/L. After 6 months, LDL-c levels dropped down to an average of 2.46 ± 1.59 mmol/L (p <0.0001) and persisted for 2.5 years after onset. The same trend was observed for total cholesterol. Achieving different target levels of LDL-c was reached as early as the 6th month in 76% and 56% of the treated, respectively.Conclusion: The use of evolocumab in addition to statin therapy leads to a significant and lasting reduction in total and LDL cholesterol in patients with FH. A significant number of them achieve targeted levels of LDL-c, which reduces the risk of new cardiovascular events