Contemporary Concepts of Atrial Fibrillation

Ovaj pregledni članak sažima suvremene spoznaje o atrijskoj fibrilaciji za liječnike obiteljske medicine. Okvirno su prikazani podaci o epidemiološkom i kliničkom značenju atrijske fibrilacije, po učestalosti druge aritmije u praksi. Ukratko su objašnjene njezine elektrofiziološke raznolikosti i klinička klasifikacija. Raspravlja se o terapijskim mogućnostima, počinjući s dvojbom između konverzije u sinusni ritam i puke regulacije frekvencije ventrikula, uključujući preporuke za prevenciju tromboembolije i zavrπavajući s nefarmakološkim liječenjem. Temelj svih preporuka su ESC/ /AHA/ACC smjernice.This review article summarises concisely the present knowledge on atrial fibrillation for general practitioners. The data on epidemiological and clinical significance of this second most common arrhythmia in clinical practice are outlined. Its variegated electrophysiological properties and clinical classifications are explained briefly. Therapeutic options are discussed, beginning with the riddle ”rhythm control strategy vs. rate control strategy,” including the recommendations for the prevention of thromboembolism and ending with non-pharmacological treatment. The bases of all recommendations are the ESC/AHA/ACC guidelines

Estrogen receptor 1 gene (TA)n polymorphism is associated with lone atrial fibrillation in men

Aim To determine the association between the number of thymine-adenine (TA)n dinucleotide repeats in the promoter region of the gene coding for the estrogen receptor alpha (ESR1) and the prevalence of lone atrial fibrillation (AF) in men. Methods We conducted a case-control study involving 89 men with lone AF and 166 healthy male controls. The ESR1 genotype was established by polymerase chain reaction and capillary electrophoresis. To assess the association of ESR1 genotype with AF, logistic regression models were built with AF as outcome. Results Men with lone AF had significantly greater number of (TA)n repeats of single alleles than controls (mean ± standard deviation, 19.2 ± 4.2 vs 18 ± 4.3, P = 0.010). After adjustment for other factors, a unit-increase in (TA)n repeat number was associated with a significantly greater likelihood of AF (odds ratio 1.069; 95% confidence interval 1.024-1.116, P = 0.002). Conclusions Our results indicate that a greater number of (TA)n repeats in the promoter region of ESR1 is associated with a significantly increased likelihood of lone atrial fibrillation in men

Influence of In-Hospital Cardiac Rehabilitation on Psychological Status after Myocardial Infarction in Patients with D-type Personality

The aim of this study was to determine the number of D-type personality patients in the group with a history of myocardial infarction (MI) and the influence of comprehensive in-hospital cardiac rehabilitation (iCR) on their psychological status (PS). The study included 316 consecutive patients aged 18 to 65 with MI in the last six months admitted into the programme of iCR. Surgical revascularized patients, clinically unstable patients and patients with sever chronic diseases and disorders were excluded. At the beginning and in the end of iCR diagnostic exam, hematological/biochemical blood analysis, ergometric testing was conducted. At the beginning and four weeks after the finish of the iCR estimation of PS was conducted. Distress scale 14 (DS14) questioner was used for that purpose. In the period of three weeks, patients were included in the programme of comprehensive iCR. Out of 316 patients in the study group 83.2% were male, while 16.8% were female. Average age of the patient was 51.3±7.2. When being admitted to iCR 42.7% patients had characteristics of D-type personality. Those patients had substantially lower level of body mass and body mas index. In the same time there were no differences among groups in risk factors, values of clinical, laboratory and diagnostic parameters. During iCR study group had more complications in comparison to the control group. At the end of iCR substantial rise of functional capacity of patients, improvement of lipid profile and lowering of glycaemia was recorded. Also at the end of iCR antiarrhythmics and psychopharmaceutical medicaments were more often prescribed to the patients in the study group. Four weeks after the iCR share of D – type personality patients was 41% and 71% of study group patients kept their D-type structure

Heart Failure in Adults with Congenital Heart Disease: An Emerging Challenge.

Rastuća populacija mladih bolesnika s kompleksnim prirođenim srčanim greškama (PSG) koji su odrasli zahvaljujući zahtjevnim kardiokirurškim operacijama u ranome djetinjstvu pojavljuje se kao zbunjujući izazov za suvremenu kardiologiju. To se odnosi ponajprije na bolesnike s: 1. operativno korigiranom Fallotovom tetralogijom i posljedičnom teškom insuficijencijom pulmonalne valvule; 2. jednom klijetkom i Fontanovim krvotokom; 3. kompletnom transpozicijom velikih arterija palijativno operiranom skretanjem krvi na atrijskoj razini; 4. kongenitalno korigiranom transpozicijom velikih arterija; 5. Eisenmengerovim sindromom. Zatajivanje desne klijetke zajednički je nazivnik za sva ta stanja, dok je u onom pod 3. i 4., često i pod 2., dekompenzirana desna klijetka ujedno i sistemna. Jako izobličena anatomija u kompleksnim PSG uzrokuje hemodinamiku zatajivanja srca (ZS) jako različitu od „uobičajene“, ali vjerojatno sa sličnim sistemnim odgovorom. Vremenski tijek ZS-a uz PSG jako se razlikuje od uobičajenog. Pojavljuje se mnogo ranije, a jako je ovisan o kirurškim i perkutanim intervencijama. Kirurške operacije, često više palijativne nego korektivne, odgađaju ZS s nagovještajem skore smrti iz djetinjstva u ranu ili srednju odraslu dob, ali pravi je izazov kako ga odgoditi dalje nakon što se mogućnosti kirurških i perkutanih intervencija iscrpe. Zatajivanje srca uz PSG opire se standardnim konceptima farmakološkog liječenja. Učinkovitost antagonista reninsko-angiotenzinskoaldosteronskog sustava i beta-blokatora nije provjerena. Antiaritmički su lijekovi u jako izobličenim srcima uglavnom neučinkoviti, ali ablativne intervencije i elektrostimulacija koji popravljaju hemodinamiku mogu biti korisni. Napredni pulmonalni vazodilatatori preporodili su liječenje Eisenmegerova sindroma ranije smatranog neizlječivim. Raznolikost PSG-a priječi definiranje jedinstvenih koncepata liječenja. U individualiziranom kliničkom pristupu treba imati na umu specifična hemodinamska stanja, ali su očito potrebni i novi načini liječenja: farmakološki, intervencijski i kirurški.A growing population of young heart failure (HF) patients with complex congenital heart disease, who have survived into adulthood owing to sophisticated cardiac surgery in infancy, emerges as a challenging quandary of contemporary cardiology. This new population primarily includes patients with: 1) repaired tetralogy of Fallot with consequent severe pulmonary valve regurgitation, 2) univentricular heart and Fontan circulation, 3) complete transposition of great arteries palliated by atrial switch surgery, 4) congenitally corrected transposition of great arteries, and 5) Eisenmenger syndrome. Right ventricular failure is a common denominator of all those entities, while in items 3 and 4, and often also in 2, the failing right ventricle is the systemic one. The grossly distorted anatomy of complex congenital heart disease, even if palliated by an early and often staged surgery, results in peculiar HF hemodynamics grossly aberrant from norm, but probably with similar systemic response. Time course of HF in congenital heart disease is much different from “ordinary” HF. It occurs much earlier and is heavily dependent on surgical and percutaneous interventions. Surgery, often more palliative than corrective, defers HF portending death from infancy into early or middle adulthood, but the real challenge is how to delay it further when the surgical and percutaneous interventional possibilities are used up. Heart failure in congenital heart disease defies standard concepts of medical HF treatment. The efficacy of renin-angiotensin-aldosterone antagonists and beta blockers has not been proven yet. Antiarrhythmic drugs are quite ineffective in grossly distorted hearts, but ablative antiarrhythmic interventions and hemodynamics improvement by pacing may be useful. Advanced pulmonary vasodilators have revived the treatment of Eisenmenger syndrome, previously deemed incurable. The diversity of congenital disease precludes unifying treatment concepts. Specific hemodynamic conditions have to be kept in mind in an individualized clinical approach, but new ways of treatment are clearly needed, medical, interventional, and surgical ones

Influence of In-Hospital Cardiac Rehabilitation on Psychological Status after Myocardial Infarction in Patients with D-type Personality

The aim of this study was to determine the number of D-type personality patients in the group with a history of myocardial infarction (MI) and the influence of comprehensive in-hospital cardiac rehabilitation (iCR) on their psychological status (PS). The study included 316 consecutive patients aged 18 to 65 with MI in the last six months admitted into the programme of iCR. Surgical revascularized patients, clinically unstable patients and patients with sever chronic diseases and disorders were excluded. At the beginning and in the end of iCR diagnostic exam, hematological/biochemical blood analysis, ergometric testing was conducted. At the beginning and four weeks after the finish of the iCR estimation of PS was conducted. Distress scale 14 (DS14) questioner was used for that purpose. In the period of three weeks, patients were included in the programme of comprehensive iCR. Out of 316 patients in the study group 83.2% were male, while 16.8% were female. Average age of the patient was 51.3±7.2. When being admitted to iCR 42.7% patients had characteristics of D-type personality. Those patients had substantially lower level of body mass and body mas index. In the same time there were no differences among groups in risk factors, values of clinical, laboratory and diagnostic parameters. During iCR study group had more complications in comparison to the control group. At the end of iCR substantial rise of functional capacity of patients, improvement of lipid profile and lowering of glycaemia was recorded. Also at the end of iCR antiarrhythmics and psychopharmaceutical medicaments were more often prescribed to the patients in the study group. Four weeks after the iCR share of D – type personality patients was 41% and 71% of study group patients kept their D-type structure

Interactions of MinK and e-NOS Gene Polymorphisms Appear to Be Inconsistent Predictors of Atrial Fibrillation Propensity, but Long Alleles of ESR1 Promoter TA Repeat May Be a Promising Marker

Interactions of MinK and e-NOS Gene Polymorphisms Appear to Be Inconsistent Predictors of Atrial Fibrillation Propensity, but Long Alleles of ESR1 Promoter TA Repeat May Be a Promising Marker. We analyzed minK, e-NOS and ESR1 gene polymorphisms in 40 patients with atrial fibrillation (AF) without major structural heart disease compared to 35 healthy controls. A missense polymorphism in the minK gene with A/G substitution at nucleotide 112 causing serine (S) to glycine (G) change, 786 T/C polymorphism in the 5’ flanking region of e-NOS gene and TA polymorphism in the regulatory region of estrogen receptor ESR1 gene with long (ł19 TA repeats) and short alleles were examined. Only a slight increase in minK G allele frequency, but with marked excess in AG/TT combination of minK and e-NOS polymorphisms was found in the AF group. The interpretation remains tentative due to small groups precluding statistical significance of differences, possible lab flaws and inconsistencies with earlier data. However, ESR1 long allele homozygotes were strikingly more frequent in the AF than in control group, reaching statistical significance surprisingly in males (p<0.02). Functional activity of estrogen receptors may be more critical in males than in females with abundance of circulating estrogen. Contrasting the intricate complexity of genetic polymorphisms influencing cardiac rhythm with our modest research, we would limit the conclusion to the plea for further research of ESR1 role in AF

Interactions of MinK and e-NOS gene polymorphisms appear to be inconsistent predictors of atrial fibrillation propensity, but long alleles of ESR1 promoter TA repeat may be a promising marker [Interakcije polimorfizama MinK i e-NOS gena su dvojbeni predskazatelji fibrilacije atrija, ali dugi ESR1 aleli s TA ponavljanjem u promotorskom dijelu mogli bi biti obećavajući biljeg]

Interactions of MinK and e-NOS Gene Polymorphisms Appear to Be Inconsistent Predictors of Atrial Fibrillation Propensity, but Long Alleles of ESR1 Promoter TA Repeat May Be a Promising Marker. We analyzed minK, e-NOS and ESR1 gene polymorphisms in 40 patients with atrial fibrillation (AF) without major structural heart disease compared to 35 healthy controls. A missense polymorphism in the minK gene with A/G substitution at nucleotide 112 causing serine (S) to glycine (G) change, 786 T/C polymorphism in the 5' flanking region of e-NOS gene and TA polymorphism in the regulatory region of estrogen receptor ESR1 gene with long (> or = 19 TA repeats) and short alleles were examined. Only a slight increase in minK G allele frequency, but with marked excess in AG/TT combination of minK and e-NOS polymorphisms was found in the AF group. The interpretation remains tentative due to small groups precluding statistical significance of differences, possible lab flaws and inconsistencies with earlier data. However, ESR1 long allele homozygotes were strikingly more frequent in the AF than in control group, reaching statistical significance surprisingly in males (p < 0.02). Functional activity of estrogen receptors may be more critical in males than in females with abundance of circulating estrogen. Contrasting the intricate complexity of genetic polymorphisms influencing cardiac rhythm with our modest research, we would limit the conclusion to the plea for further research of ESR1 role in AF

Left ventricle to left atrium shunt via a paravalvular abscess

Intracardiac fistulas are rare complications of infective endocarditis that contribute to the complexity of surgical management, and impose an additional hemodynamic burden on the already challenged heart. We report on a case of successful surgical management of a paravalvular communication between the left ventricle and the left atrium via an abscess cavity

Access site complications following cardiac catheterization assessed by duplex ultrasonography

Access site complications are major source of morbidity following cardiac catheterization. Their incidence varies in the literature because of multiple definitions and methods of determining the presence of particular complication. The aim of this prospective study was to determine the incidence of access site complications following cardiac catheterization using arterial duplex ultrasonography. A total of 319 consecutive patients, who had cardiac catheterization underwent femoral artery duplex study 24 to 48 hours following manual hemostasis. Diagnostic angiogram had 232 (71.8%) while 87 (28.2%) had percutaneous coronary intervention (PCI). Femoral artery duplex ultrasound was normal in 247 (77.4%). Haematoma was found in 48 (15.1%), pseudoaneurysm in 17 (5.3%), AV fistula in 2 (0.6%) and dissection of the femoral artery in 5 (1.6%) patients. Baseline demografic characteristics were similar in group with normal duplex study and group with detected complication. Pseudoaneurysm and AV fistula were more commonly observed in patients following PCI than diagnostic angiogram (9.2% vs. 4.7%, p<0.001). Patients with documented complications more frequently had concomitant administration of antiplatelet and anticoagulant medication compared to the patients without complications (p=0.003). Hemodynamic disturbances (hypotension and bradycardia) during manual compression were more frequent in patients with complication (11% vs. 4.5%, p=0.047). Low threshold for use of duplex ultrasound should be exercised in patients following cardiac catheterization to establish the presence of access site complications. Special attention is needed in the setting of aggressive antiplatelet and anticoagulant therapy, interventional procedures and hemodynamic disturbances during manual hemostas