Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation

Cilj istraživanja: Koronarna bolest je vodeći uzrok smrtnosti bolesnika s kroničnom bubrežnom bolesti (CKD). Bolesnici s CKD, podvrgnuti perkutanoj koronarnoj intervenciji (PCI), imaju veći rizik razvoja kardiovaskularnih komplikacija u odnosu na bolesnike s očuvanom bubrežnom funkcijom. Cilj ovog istraživanja je odrediti incidenciju i intenzitet periproceduralne ozljede miokarda (PMI) nakon elektivne PCI u ovisnosti o CKD. Nacrt studije Ova prospektivna studija je uključila 344 bolesnika sa stabilnom koronarnom bolesti koji su podvrgnuti elektivnoj PCI u Kliničkoj bolnici Merkur u Zagrebu, u vremenskom periodu od ožujka 2012. do lipnja 2015. godine. Ispitanici i metode Svi ispitanici su imali stabilnu koronarnu bolest. Isključujući kriteriji su bili: dob ispod 18 godina, akutno zatajenje bubrežne funkcije, akutni koronarni sindrom, okluzija postraničnog ogranka, kronična totalna okluzija, višežilno stentiranje i kontraindikacija za primjenu dvojne antiagregacijske terapije. Ispitanici su podijeljeni u dvije skupine: kontrolna skupina s očuvanom bubrežnom funkcijom i ispitivana skupina s CKD koja je dalje podijeljena u četiri podskupine ovisno o stadiju bubrežne bolesti. Serumska koncentracija troponina I (cTnI), C reaktivnog proteina i kreatinina je određena bazalno te 8 i 16 sati nakon PCI. Periproceduralni porast cTnI iznad gornje referentne serumske vrijednosti definira PMI, a razlika postproceduralne i bazalne vrijednosti cTnI definira intenzitet ozljede. Rezultati Nije bilo statistički značajne razlike u incidenciji PMI 8 i 16 sati nakon PCI između kontrolne i ispitivane skupine bolesnika. Isto tako nije bilo statistički značajne razlike u incidenciji PMI, 8 i 16 sati nakon PCI između kontrolne skupine i pojedinih podskupina bolesnika s CKD. Nismo uočili statistički značajnu razliku u intenzitetu PMI 8 i 16 sati nakon PCI između kontrolne i ispitivane skupine niti smo uočili statistički značajnu razliku u intenzitetu ozljede između kontrolne skupine i pojedinih podskupina bolesnika s CKD. Multivarijantna analiza je pokazala da su angina pectoris CCS stadij IV, ugradnja BMS-a i ACEI-i u terapiji neovisni prediktori razvoja PMI, dok je arterijska hipertenzija ostala neovisan protektivni čimbenika razvoja PMI. Zaključak: Niti jedan stupanj CKD nije bio povezan s većom incidencijom odnosno s većim intezitetom ozljede miokarda tijekom elektivne PCI. Svakako su neophodne prospektivne i randomizirane kliničke studije koje će istražiti sigurnost i učinkovitost perkutane revaskularizacije miokarda u ovoj populaciji bolesnika kao i optimalni izbor stenta i optimalni izbor preproceduralne terapije koja ima za svrhu prevenciju periproceduralne ozljede miokarda.Objectives Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo coronary revascularization may have more ischemic events than patients without CKD. The aim of this study was to determine the incidence and intensity of periprocedural myocardial injury (PMI) after elective stent implantation among patients with and without CKD. Study Design In a single center prospective cohort study, we enrolled 344 consecutive patients who underwent an elective PCI at Merkur University Hospital, Zagreb, Croatia, in a period of 39 months between March 2012 and June 2015. Patients and Methods All patients had stable angina pectoris, or documented inducible myocardial ischemia. Criteria for inclusion were successful PCI procedure and an optimal final result. The exclusion criteria were: age less than 18, acute coronary syndrome, acute kidney injury, multivessel stenting in a single procedure, major (>1,5 mm) side branch occlusion, chronic total occlusion and contraindication to the use dual antiplatelet therapy. Patients were divided into two groups: control group with estimated glomerular filtration rate (eGFR) > 90 ml/min/1,73m² and the CKD group with eGFR 90 ml/min/1.73m2) and the CKD group (< 90 ml/min/1.73m2) both 8 and 16 hours after PCI. When the CKD patients were further subdivided according to their CKD stage, there was again no difference in the intensity or incidence of PMI compared to the control group. Further analyses of our data showed angina pectoris CCS IV, bare metal stent (BMS) implantation and treatment with angiotensin-converting enzyme inhibitors (ACEI) as independent predictors of PMI. Furthermore presence of hypertension was inversely related to the occurrence of PMI. Conclusion: We found no association between PMI occurrence and the presence of CKD. Furthermore, CKD burden (i.e. stratification of patients according to the CKD stage) was also not associated with higher PMI incidence or PMI intensity. Further analyses showed other factors that could potentially influence the occurrence of PMI

Mortality and causes of death among Croatian male Olympic medalists

Aim To compare the overall and disease-specific mortality of Croatian male athletes who won one or more Olympic medals representing Yugoslavia from 1948 to 1988 or Croatia from 1992 to 2016, and the general Croatian male population standardized by age and time period. Methods All 233 Croatian male Olympic medalists were included in the study. Information on life duration and cause of death for the Olympic medalists who died before January 1, 2017, was acquired from their families and acquaintances. We asked the families and acquaintances to present medical documentation for the deceased. Data about the overall and disease-specific mortality of the Croatian male population standardized by age and time period were obtained from the Croatian Bureau of Statistics (CBS). Overall and disease-specific standard mortality ratios (SMR) with 95% confidence intervals (CI) were calculated to compare the mortality rates of athletes and general population. Results Among 233 Olympic medalists, 57 died before the study endpoint. The main causes of death were cardiovascular diseases (33.3%), neoplasms (26.3%), and external causes (17.6%). The overall mortality of the Olympic medalists was significantly lower than that of general population (SMR 0.73, 95% CI 0.56-0.94, P = 0.013). Regarding specific causes of death, athletes’ mortality from cardiovascular diseases was significantly reduced (SMR 0.61, 95% CI 0.38- 0.93, P = 0.021). Conclusions Croatian male Olympic medalists benefit from lower overall and cardiovascular mortality rates in comparison to the general Croatian male populatio

Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation: a single center prospective cohort study

Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo percutaneous coronary intervention (PCI) may have more ischemic events than patients without CKD. The aim of our study was to determine the incidence of periprocedural myocardial injury (PMI) after elective stent implantation in patients with CKD using the Third Joint ESC/ACCF/AHA/WHF PMI definition.In a single center prospective cohort study, we enrolled 344 consecutive patients who underwent elective PCI in a period of 39 months. Serum troponin I (cTnI) concentrations were measured at baseline and at 8 and 16 hours after PCI. Periprocedural increase of cTnI, according to the most recent PMI definition, was used to define both the presence and intensity of PMI. Patients were further stratified according to the estimated glomerular filtration rate (eGFR) using 4 variable Modification of Diet in Renal Disease (MDRD) equation: control group with eGFR >90 mL/min/1.73 m and the CKD group with eGFR 90 mL/min/1.73 m) and the CKD group (<90 mL/min/1.73 m) both 8 and 16 hours after PCI. When the CKD patients were further subdivided according to their CKD stage, there was again no difference in the intensity or incidence of PMI compared to the control group. Further analyses of our data showed angina pectoris CCS IV, bare metal stent (BMS) implantation, and treatment with angiotensin-converting enzyme inhibitors (ACEI) as independent predictors of PMI. Furthermore, the presence of hypertension was inversely related to the occurrence of PMI.Applying the new guidelines for PMI and using the eGFR equation most suitable for our patients, we found no association between PMI and CKD. Further analyses showed other factors that could potentially influence the occurrence of PMI

Nedostatna primjena antagonista vitamina K u bolesnika s atrijskom fibrilacijom - prikaz rezultata iz kliničke prakse u Kliničkoj bolnici "Merkur", Zagreb

Atrial fibrillation is the most common cardiac arrhythmia. It increases the risk of death and thromboembolic events. Vitamin K antagonists reduce these risks. Disadvantages of vitamin K antagonist therapy are narrow therapeutic range and interactions with drugs and food. In a single center prospective study, we enrolled 249 patients with atrial fibrillation over a 12-month period. The aim of our study was to evaluate vitamin K antagonist use regarding the indication and adequate dose. Data on 249 consecutive patients with atrial fibrillation were collected before general availability of novel oral anticoagulants. Out of 249 patients, 160 (64.2%) had indication for oral anticoagulant therapy. Only 81 (50.6%) patients had vitamin K antagonist in therapy, 12 (14.8%) of them in adequate dose. We also analyzed 129 patients aged over 75, of which 109 (84.4%) had absolute indication for oral anticoagulant therapy. Only 34 (31.2%) patients aged over 75 had been receiving vitamin K antagonist therapy and 6 (17.6%) had the International Normalized Ratio values within the proposed therapeutic interval. We found a significantly higher rate of anticoagulant therapy introduction in patients under 75 years (p=0.03), but there were no significant differences in the adequacy of anticoagulant therapy (p=0.89) between these two populations. Our results showed clear inadequacies of vitamin K antagonist treatment with a growing need for a wider use of novel oral anticoagulants.Atrijska fibrilacija je najučestalija aritmija koja povećava rizik smrti i tromboembolijskih incidenata. Antagonisti vitamina K smanjuju taj rizik. Problem terapije s antagonistima vitamina K je uska terapijska širina i brojne interakcije s lijekovima i hranom. Cilj ovoga istraživanja bio je utvrditi dostatnost primjene antagonista vitamina K s obzirom na indikaciju i dozu. Prikupljeni su podaci 249 bolesnika s atrijskom fibrilacijom hospitaliziranih u Kliničkoj bolnici “Merkur” u razdoblju od 12 mjeseci i to prije šire dostupnosti novijih oralnih antiokoagulansa. Od svih bolesnika, 160 (64,2%) ih je imalo indikaciju za primjenu oralne antikoagulantne terapije, a tek je njih 81 (50,6%) imalo antagonist vitamina K u terapiji. Samo 12 (14,8%) bolesnika je uzimalo antagonist vitamina K u dostatnoj dozi, a 129 (51,8%) ih je bilo iznad 75 godina starosti. Njih 109 (84,4%) je imalo indikaciju za oralnu antikoagulantnu terapiju, a samo 34 (31,2%) ih je uzimalo antagonist vitamina K, od kojih je 6 (17,6%) imalo INR u terapijskim vrijednostima. Statistička analiza podataka pokazala je da su bolesnici mlađi od 75 godina češće uzimali indiciranu oralnu antikoagulantnu terapiju u odnosu na bolesnike starije od 75 godina (p=0,03), dok nije bilo statistički značajne razlike u dostatnoj primjeni antikoagulantne terapije između ovih dviju populacija (p=0,89). Naši rezultati jasno pokazuju nedostatnosti primjene antagonista vitamina K kao i potrebu bržeg prijelaza prema terapiji novijim oralnim antikoagulansima

Approach to a patient with conduction disturbance caused by Lyme borreliosis

U muškarca s kliničkom slikom Lyme borelioze i atrioventrikulskim blokovima svih stupnjeva indicirano je elektrofiziološko ispitivanje, a po nalazu i ugradnja dvokomornog elektrostimulatora srca. Smatramo da je elektrofiziološko ispitivanje indicirano kod te grupe bolesnika radi donošenja odluke o potrebi ugradnje privremenog ili trajnog elektrostimulatora srca.In a man presented with Lyme disease and atrioventricular blocks of all grades, electrophysiology study is indicated followed by the implantation of the two chamber permanent pacemaker upon obtaining the findings. We consider electrophysiology study indicated in that group of patients for the purpose of making a decision – to implant a temporary or a permanent pacemaker

Mitral and tricuspid valvuloplasty in a patient with myelodysplastic syndrome

Mijelodisplastični sindrom (MDS) klonska je bolest matične hematopoetske stanice, koja se očituje poremećenom proliferacijom, diferencijacijom i sazrijevanjem hematopoeze te displastičnim promjenama u koštanoj srži. U kliničkoj slici i laboratorijskim nalazima bolesnika s MDS-om dominira anemija, nešto rjeđe neutropenija ili trombocitopenija različitih stupnjeva težine. Kardiokirurški zahvat u bolesnika s MDS-om velik je izazov jer su neutropenija i trombocitopenija vodeći uzroci infekcija i krvarenja tijekom operacije. Malen je broj izvješća u literaturi koja opisuju kardiokirurški zahvat u bolesnika s MDS-om. Prikazujemo 66-godišnju bolesnicu s MDS-om kod koje je uspješno izvedena rekonstrukcija mitralnog i trikuspidalnoga srčanog zalistka. Bolesnica se javila u hitnu službu zbog otežanog disanja, opće slabosti i znakova srčanog popuštanja. Radiološkom obradom verificirani su obostrani pleuralni izljev, izraženije lijevo, i povećana sjena srca s naglašenim vaskularnim hilusima. Daljnjom obradom dokazane su mitralna i trikuspidalna insuficijencija teškog stupnja pa je bolesnica operirana, a pet godina nakon zahvata ima dobru kvalitetu života. Multidisciplinarnom suradnjom kardiologa, hematologa, anesteziologa i kardiokirurga u bolesnice je uspješno izveden kirurški zahvat rekonstrukcije mitralne i trikuspidalne valvule. Ovaj prikaz bolesnice upućuje na važnost multidisciplinarnog pristupa specifičnoj i ranjivoj grupi bolesnika s MDS-om i kardiovaskularnim komorbiditetima.Myelodysplastic syndrome (MDS) is a clonal disease of mutated hematopoietic stem cells characterized by abnormal hematopoietic differentiation and dysplastic bone marrow changes. MDS usually tends to present with anemia, less often with neutropenia and thrombocytopenia of varying degrees. Cardiac surgery in MDS patients is a major challenge because neutropenia and thrombocytopenia are the leading causes of infection and bleeding during the procedure. There are only a few reports of cardiovascular surgery in patients with MDS. We are presenting a 66-year-old MDS patient with a successful reconstruction of the mitral and tricuspid heart valve. The patient presented in the Emergency department with weakness and dyspnea. Radiological workup verified 3rd stage heart failure. Severe mitral and tricuspid insufficiency was verified, after which the patient underwent cardiac surgery, and five years after the procedure has good quality of life. Through the multidisciplinary collaboration of cardiologists, hematologists and cardiac surgeons an operative reconstruction of mitral and tricuspid valve was successfully performed. This case indicates the need for multidisciplinary care for the specific and vulnerable group of MDS patients with cardiovascular comorbidities

Pretransplant echocardiographic findings as predictors of late adverse outcomes following liver and kidney transplantation

Introduction: Transthoracic echocardiography (TTE) is recommended as the standard of care in evaluation of cardiovascular (CV) disease in liver (LT) and kidney (KT) transplant candidates.1,2 Guidelines for preoperative CV assessment are oriented at the immediate perioperative period and non-ischemic CV processes that would predict poor outcomes after LT and KT are defined less clearly. Aim: to establish whether ≥moderate mitral (MR), tricuspid regurgitation (TR) or ≥mild aortic stenosis (AS) on pretransplant TTE are associated with mortality, graft survival or major CV adverse events (MACE) in the late postoperative period (>30 days). Patients and Methods: Patients were stratified into cohorts based on the presence of ≥moderate MR, TR and ≥mild AS. Exclusion criteria was loss to follow up, incomplete TTE findings and death within 30 days of transplantation. MACE were defined as stroke, myocardial infarction (MI) or heart failure. Patient survival was defined as time from transplantation to death or last follow-up and graft survival as time from transplantation to last follow-up, death, graft dysfunction or re-transplantation. Outcomes of interest were compared between cohorts via logistic or Cox regression. Results: 306 LT (median age 59, IQR 53-64) and 196 KT patients were included (median age 52, IQR 40- 61). Median follow up was 36 months for LT (range 14.3 – 55.9), 40,5 months for KT (range 18-64.9). MACE occurred in 4.25% LT and 4.59% KT recipients. Upon univariate analysis AS was associated with MACE in KT recipients but crossed the significance level after adjusting for common confounders (age, sex, hypertension, diabetes, smoking). 11.76% LT and 9.69% KT recipients died. The most common cause of death was sepsis. MR was found to be associated with LT patient survival, but the association was lost after adjusting for age. In an age adjusted model MR was found to be associated with KT patient survival (HR 2.97, 95% CI 1.06-8.26, P=0.037). Graft survival was not associated with any potential predictors. Conclusion: Associating TTE findings with adverse outcomes after LT and KT might help distinguish patients who would benefit from closer management in the late postoperative period. Moderate or more severe MR was found to be associated with late mortality in KT recipients, however the significance of this is yet to be determined in larger sample studies

Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation

Cilj istraživanja: Koronarna bolest je vodeći uzrok smrtnosti bolesnika s kroničnom bubrežnom bolesti (CKD). Bolesnici s CKD, podvrgnuti perkutanoj koronarnoj intervenciji (PCI), imaju veći rizik razvoja kardiovaskularnih komplikacija u odnosu na bolesnike s očuvanom bubrežnom funkcijom. Cilj ovog istraživanja je odrediti incidenciju i intenzitet periproceduralne ozljede miokarda (PMI) nakon elektivne PCI u ovisnosti o CKD. Nacrt studije Ova prospektivna studija je uključila 344 bolesnika sa stabilnom koronarnom bolesti koji su podvrgnuti elektivnoj PCI u Kliničkoj bolnici Merkur u Zagrebu, u vremenskom periodu od ožujka 2012. do lipnja 2015. godine. Ispitanici i metode Svi ispitanici su imali stabilnu koronarnu bolest. Isključujući kriteriji su bili: dob ispod 18 godina, akutno zatajenje bubrežne funkcije, akutni koronarni sindrom, okluzija postraničnog ogranka, kronična totalna okluzija, višežilno stentiranje i kontraindikacija za primjenu dvojne antiagregacijske terapije. Ispitanici su podijeljeni u dvije skupine: kontrolna skupina s očuvanom bubrežnom funkcijom i ispitivana skupina s CKD koja je dalje podijeljena u četiri podskupine ovisno o stadiju bubrežne bolesti. Serumska koncentracija troponina I (cTnI), C reaktivnog proteina i kreatinina je određena bazalno te 8 i 16 sati nakon PCI. Periproceduralni porast cTnI iznad gornje referentne serumske vrijednosti definira PMI, a razlika postproceduralne i bazalne vrijednosti cTnI definira intenzitet ozljede. Rezultati Nije bilo statistički značajne razlike u incidenciji PMI 8 i 16 sati nakon PCI između kontrolne i ispitivane skupine bolesnika. Isto tako nije bilo statistički značajne razlike u incidenciji PMI, 8 i 16 sati nakon PCI između kontrolne skupine i pojedinih podskupina bolesnika s CKD. Nismo uočili statistički značajnu razliku u intenzitetu PMI 8 i 16 sati nakon PCI između kontrolne i ispitivane skupine niti smo uočili statistički značajnu razliku u intenzitetu ozljede između kontrolne skupine i pojedinih podskupina bolesnika s CKD. Multivarijantna analiza je pokazala da su angina pectoris CCS stadij IV, ugradnja BMS-a i ACEI-i u terapiji neovisni prediktori razvoja PMI, dok je arterijska hipertenzija ostala neovisan protektivni čimbenika razvoja PMI. Zaključak: Niti jedan stupanj CKD nije bio povezan s većom incidencijom odnosno s većim intezitetom ozljede miokarda tijekom elektivne PCI. Svakako su neophodne prospektivne i randomizirane kliničke studije koje će istražiti sigurnost i učinkovitost perkutane revaskularizacije miokarda u ovoj populaciji bolesnika kao i optimalni izbor stenta i optimalni izbor preproceduralne terapije koja ima za svrhu prevenciju periproceduralne ozljede miokarda.Objectives Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo coronary revascularization may have more ischemic events than patients without CKD. The aim of this study was to determine the incidence and intensity of periprocedural myocardial injury (PMI) after elective stent implantation among patients with and without CKD. Study Design In a single center prospective cohort study, we enrolled 344 consecutive patients who underwent an elective PCI at Merkur University Hospital, Zagreb, Croatia, in a period of 39 months between March 2012 and June 2015. Patients and Methods All patients had stable angina pectoris, or documented inducible myocardial ischemia. Criteria for inclusion were successful PCI procedure and an optimal final result. The exclusion criteria were: age less than 18, acute coronary syndrome, acute kidney injury, multivessel stenting in a single procedure, major (>1,5 mm) side branch occlusion, chronic total occlusion and contraindication to the use dual antiplatelet therapy. Patients were divided into two groups: control group with estimated glomerular filtration rate (eGFR) > 90 ml/min/1,73m² and the CKD group with eGFR 90 ml/min/1.73m2) and the CKD group (< 90 ml/min/1.73m2) both 8 and 16 hours after PCI. When the CKD patients were further subdivided according to their CKD stage, there was again no difference in the intensity or incidence of PMI compared to the control group. Further analyses of our data showed angina pectoris CCS IV, bare metal stent (BMS) implantation and treatment with angiotensin-converting enzyme inhibitors (ACEI) as independent predictors of PMI. Furthermore presence of hypertension was inversely related to the occurrence of PMI. Conclusion: We found no association between PMI occurrence and the presence of CKD. Furthermore, CKD burden (i.e. stratification of patients according to the CKD stage) was also not associated with higher PMI incidence or PMI intensity. Further analyses showed other factors that could potentially influence the occurrence of PMI