Diet and Cardiovascular Health

Prehrana na različite načine može utjecati na razvoj kardiovaskularnih bolesti. Nepravilni odabir namirnica, prevelik unos soli, ugljikohidrata, kolesterola i masti te prevelika količina hrane, odnosno kalorijski unos pridonose razvoju i pogoršanju bolesti. Incidencija pretilosti u svijetu je u porastu, a novija saznanja pokazuju da je uz smanjenje broja kalorija u borbi protiv pretilosti potrebno unositi hranu sa smanjenim potencijalom za njezin razvoj. Kardiovaskularni bolesnici imaju loše prehrambene navike te je za njih razvijen niz dijeta. Najdjelotvornijom se pokazala mediteranska prehrana s dodatkom ekstradjevičanskoga maslinova ulja i orašastih plodova koja se pokazala učinkovitom u smanjenju kardiovaskularne smrtnosti i kardijalnih događaja u primarnoj, kao i u sekundarnoj prevenciji. Osim nje učinkovita je DASH-dijeta koja ne samo da pomaže u regulaciji krvnog tlaka i smanjenju tjelesne težine nego i u sniženju razine ukupnog kolesterola u serumu. Daljnji povoljni učinak na regulaciju krvnog tlaka postiže se smanjenjem unosa soli na 6 g/dan ili manje. U kontroliranim studijama dokazano je da unos određene vrste hrane utječe na kardiovaskularno zdravlje. Konzumacija voća i povrća, ekstradjevičanskoga maslinova ulja, orašastih plodova i mahunarki, umjerena konzumacija ribe i morskih plodova, čaja te male količine alkohola pokazale su se korisnima u redukciji kardiovaskularnog rizika. Redovita, umjerena i pravilna prehrana jedan je od najvažnijih čimbenika na koji možemo utjecati kako bismo znatno smanjili rizik od nastanka bolesti srca i krvnih žila.Our diet can affect the development of cardiovascular diseases in various ways. A wrong selection of foods, excessive intake of salt, carbohydrates, cholesterol and fat, as well as an excessive amount of food, i.e. of caloric intake can contribute to the development and worsening of the disease. Obesity is one of the major public health problems with increasing incidence worldwide. Recent findings indicate that in addition to the reduction in the number of calories, the selection of food with reduced potential for the development of obesity is crucial for weight control. Cardiovascular patients have poor eating habits and a series of diets has been developed for them, with different benefits. The most potent is the Mediterranean diet, supplemented with extra virgin olive oil and nuts, acting favourably on cardiovascular mortality and development of cardiac events both in primary and secondary prevention. The DASH diet used in the regulation of blood pressure and body weight has proved to be helpful in reducing the levels of total serum cholesterol. Further regulation of blood pressure can be achieved by reducing salt intake to 6 g or less per day. Guided exclusively on evidence and controlled studies based medicine, the impact of certain foods on cardiovascular health has been established. The benefit in reducing cardiovascular risk was found in the consumption of fruits and vegetables, extra virgin olive oil, nuts and legumes, moderate consumption of fish and seafood, tea, and small amounts of alcohol. We can actively work to reduce the risk of cardiovascular disease by controlling one of the most important factors and this is a regular, moderate and appropriate diet

How to Monitor Your Physical Activity?

Redovita tjelesna aktivnost u svakoj dobi povezana je sa sniženjem rizika od gotovo svih bolesti. Međutim, usprkos sve većoj svjesnosti o potrebi tjelesne aktivnosti, incidencija pretilosti, kao i kardiovaskularnih bolesti u porastu je. Uzrok tomu jest nedostatak adherencije i redovitog praćenja tjelesne aktivnosti. Upravo u tome veliku nam pomoć posljednjih godina pruža razvoj mobilne tehnologije za praćenje tjelesne aktivnosti. Njezina prednost utvrđena je u brojnim kontroliranim studijama, kao i u svakodnevnom životu. Bez obzira na to o kojem se uređaju, programu ili mobilnoj aplikaciji za praćenje aktivnosti radi, najbitnija je njihova redovita uporaba. Sustavnim praćenjem svakodnevne aktivnosti, kao i trendova tjednih i mjesečnih aktivnosti postiže se bolja kontrola razlike između učinjene i planirane aktivnosti. Time se zdravstvenim radnicima omogućava individualni pristup u određivanju potrebne aktivnosti ovisno o dobi, kondiciji i eventualnim kroničnim bolestima.Regular physical activity at any age is connected with a reduced risk of almost all diseases. However, despite the increased awareness of the need for physical activity, the incidence of obesity and cardiovascular diseases is on the rise. The cause for this is the lack of adherence and regular tracking of physical activity. The development of mobile technology for tracking physical activity has been of great help in the last couple of years. The benefits of using such technology have been confirmed in numerous controlled studies, as well as in everyday life. No matter what device, programme or mobile application is used to track physical activity, regular usage is essential. Systematic tracking of daily, as well as weekly and monthly activity trends enables better control of variation between the planned and performed activity. As a result, healthcare professionals are provided with an individual approach to the determination of necessary activity, depending on age, physical condition and possible chronic diseases

Cardiotoxicity due to biological cancer therapy

Kardiotoksičnost je sve češća nuspojava onkološkog liječenja pa tako i novijih, bioloških ciljanih lijekova. Posebno razvijena monoklonska protutijela ili inhibitori tirozin-kinaze blokiraju bilo receptore HER-2 bilo VEGF bilo pak aktivnost Abl-kinaze. Međutim, time se ometaju i molekularni mehanzimi ključni za kardiovaskularno zdravlje. Anti-HER2 terapija najčešće uzrokuju reverzibilnu sistoličku disfunkciju lijevog ventrikula, a blokadom VEGF receptora razvija se arterijska hipertenzija i povećava sklonost tromboembolijskim incidentima. Ranim prepoznavanjem i liječenjem bolesnika u kojih se razvila kardiotoksičnost postiže se poboljšanje kliničkih ishoda i kvalitete života, a time je često moguće nastaviti specifično liječenja raka. Pri tome su ključni multidisciplinarni pristup kardiologa i onkologa te redovito kardiološko praćenje.Cardiotoxicity has been increasingly reported as a side effect of oncologic treatment, including novel targeted biological therapy. Specific monoclonal antibodies or tyrosine kinase inhibitors have been developed for blockade of HER2 receptors, VEGF receptors, or Abl kinase activity. However, these actions also interfere with molecular mechanisms that are crucial for cardiovascular health. Anti HER2 therapy generally induces reversible systolic left ventricular dysfunction, whereas VEGF receptor blockade leads to development of arterial hypertension and increased susceptibility to thromboembolic events. In patients developing cardiotoxicity, better clinical outcome and quality of life can be achieved by early recognition and treatment, thus also enabling continuation of anti-cancer therapy in many cases. A multidisciplinary approach including cardiologists and oncologists, along with regular cardiologic follow up, is crucial for successful patient management

The magnitude and clinical implications of the interobserver variability of echocardiographic left ventricular ejection fraction measurement

The ejection fraction (EF) is the most commonly used echocardiographic measure of the systolic left ventricular (LV) function. Echocardiography has however several limitations in measuring LV volumes and EF since the formulas for quantifications are based on geometrical assumptions, the EF parameters (end-systolic and end-diastolic volumes) are preload dependent and adequate projections are not always possible to obtain. Previous studies have also shown correlation between different echocardiographic techniques of obtaining EF and even correlation between echocardiography and other methods (MRI, SPECT, CT) but the data on interobserver and intraobserver variability remains scarce.1 In this study we examined the interobserver limits of agreement and the therapeutic implications of the uncertainty obtained by the result. We examined 22 sequential patients referred to our echocardiography laboratory for LV function assessment. All echocardiography studies were performed by two independent cardiologists blinded to the measurements of the other observer. 2D methods including the biplane Simpson method and “eyeballing” were conducted, while automatic and semiautomatic 2D and 3D methods were not allowed. Bland-Altman analysis was performed to determine the systematic bias and limits of agreement (LOA) of EF between different observers (Figure 1). Next the LOA were used to obtain new “confidence intervals” on a previously gathered set of echocardiograms of 171 heart failure patients. We recorded the number of patients that now had different treatment recommendations according to the current ESC guidelines on heart failure and device therapy i.e. the “new” EF was 40%. McNemar’s test was used to determine the statistical significance of the difference with a two-tailed P=0.05 taken as a threshold. The bias was calculated to be -2.3 with LOA (7.8 to -12.5) which is in agreement with similar studies. The number of patients that received “new” treatment recommendations was 99 for the lower LOA and 65 for upper LOA, P<0.001 for both groups. We therefore conclude that the interobserver variability of the EF measurement can lead to significantly different treatment strategies in patients with heart failure. Echocardiographic methods introducing less variability (like automatic 3D techniques) should be preferred in determining the EF

Vrijeme primjene trastuzumaba i rizik za razvoj srčane disfunkcije u bolesnica sa ranim HER2 pozitivnim karcinomom dojke

Breast cancer is the most common malignant tumor in females in the world. Age is signifi cant risk factor and incidence increases rapidly after age of 35. Approximately one fourth of patients with breast cancer have tumors that overexpress HER2 protein or amplify the HER2/neu gene.Trastuzumab is a recombinant humanized monoclonal antibody that binds to a specific extracellular growth factor, human epidermal growth factor type 2 HER 2-neu or ErbB2, tyrosine kinase receptor responsible for alterations in cellular metabolism and growth.Clinical studies have shown that trastuzumab given concurrently or following adjuvant chemotherapy improves disease-free survival (DFS) and overal survival (OS) in early-stage HER-2 positive breast cancer. HERA study (Herceptin in Adjuvant breast cancer) showed that one of fifty women treated with trastuzumab adjuvantly developes congestive heart failure during treatment.Mechanisms of trastuzumab induced cardiac dysfunction are not clear yet. Studies have shown that differences in timing of trastuzumab after chemotherapy an ddifferences in total dose of anthracyclines can explain differences in incidence of cardiac dysfunction. The aim of our study was to determine incidence of trastuzumab induced cardiac dysfunction in patients with HER2 positive early breast cancer and impact of time interval between administration of chemotherapy and trastuzumab on prevalence of cardiac dysfunction. Follow up included 140 patients with early HER2 positive breast cancer treated with trastuzumab adjuvantly. Seventeen patients developed symptomatic cardiac dysfunction (12.1%) of which 6 developed severe congestive heart failure NYHA III/IV(4.2%) and 11 moderate NYHA II/III (7.9%).Patients who started trastuzumab therapy 11 to 20 days after finishing chemotherapy had 11% incidence of symptomatic heart failure, same as those patients who started trastuzumab 26 to 35 days after chemotherapy. There were no cardiac events if treatment was started 35 days after chemotherapy. Highest incidence of congestive heart failure was registered when trastuzumab was applied 21 to 25 days after adjuvant chemotherapy (22%). Time interval between cessation of adjuvant chemotherapy and fi rst trastuzumab application has a signifi cant impact on prevalence of trastuzumab induced cardiac dysfunction.Karcinom je najčešći maligni tumor u žena u svijetu. Dob je značajan rizični faktor i incidencija se povećava iznad dobi od 35 godina. Otprilike četvrtina bolesnica oboljelih od raka dojke ima tumor koji prekomjerno izražava HER2. Trastuzumab je rekombinantno humanizirano monoklonalno protutijelo koje se veže na humani epidermalni faktor rasta tip 2 HER2-neu ili ErbB2, tirozin kinazni receptor odgovoran za promjene u metabolizmu i rastu stanice. Kliničke studije su pokazale da davanje trastuzumaba konkomitantno s ili nakon adjuvantne kemoterapije produžuje period bez povrata bolesti (DSF) i ukupno preživljenje (OS) u ranog HER2 pozitivnog karcinoma dojke. Studija HERA (Herceptin in Adjuvant Breast Cancer) je pokazala da jedna od pedeset žena liječenih trastuzumabom adjuvantno, razvija kongestivno zatajenje srca tijekom liječenja. Mehanizmi nastanka trastuzumabom inducirane kardiotoksičnosti još nisu potpuno razjašnjeni. Studije su pokazale da razlike u vremenu započimanja terapije trastuzumabom nakon završene adjuvantne kemoterapije i razlike u ukupnoj dozi antraciklina mogu objasniti razlike u incidenciji srčanog zatajenja. Cilj našeg istraživanja je bio odrediti incidenciju trastuzumabom inducirane kardiotoksičnosti u bolesnica s ranim HER2 pozitivnim karcinomom dojke te odrediti utjecaj vremenskog intervala od završetka kemoterapije do početka liječenja trastuzumabom na pojavnost srčanog zatajenja. Praćenje je uključilo 140 bolesnica s ranim HER2 pozitivnim karcinomom dojke koje su liječenje trastuzumabom adjuvantno. 17 bolesnica je razvilo simptomatsko srčano zatajenje (12.1%) od kojih 6 teškog stupnja NYHA III/IV(4.2%) a 11 umjerenog NYHA II/III (7.9%).Bolesnice koje su započele liječenje trastuzumabom 11 do 20 dana po završetku kemoterapije su imale incidenciju simptomatskog srčanog zatajenja 11%, kao i bolesnice koje su započele terapiju trastuzumabom 26 do 35 dana nakon kemoterapije. U bolesnica koje su liječenje započele 35 dana nakon kemoterapije nije zabilježeno kardijalnih događanja. Najviša incidencija kongestivnog zatajenja srca je zabilježena kada je terapija trastuzumabom započeta 21 do 25 dana nakon adjuvantne kemoterapije (22%). Vremenski interval između završetka adjuvantne kemoterapije i prve aplikacije trastuzumaba ima značajan utjecaj na pojavnost trastuzumabom induciranog srčanog zatajenja

Nomogram s jednostavnim i rutinskim kliničkim i biokemijskim parametrima može biti prediktor patološkog remodeliranja ventrikula u bolesnika sa STEMI-jem

Heart failure is the leading cause of morbidity and mortality worldwide, with ischemic heart disease being one of the most important etiologic factors. Heart failure develops due to ventricular remodeling, which leads to increases in left ventricular end-systolic and end-diastolic volumes. In this prospective observational study, we included 101 patients with first episode of ST-segment elevation myocardial infarction in whom percutaneous coronary intervention was conducted within 12 h and Thrombolysis in Myocardial Infarction III flow was achieved. The aim was to determine which clinical and biochemical parameters can help predict pathologic ventricular remodeling 1 year after myocardial infarction. We created a nomogram based on routinely used blood tests and vital parameters which showed highest correlation with pathologic ventricular remodeling. The nomogram included NTproBNP value 12 h after reperfusion, aspartate transaminase value 12 h after reperfusion, systolic blood pressure value on admission, and culprit coronary artery. We performed ROC analysis which yielded great predictive value of the nomogram. The area under curve was 0.907 (95% CI 0.842-0.973). The nomogram value of -3.54 had 91.4% sensitivity and 74.0% specificity. We believe that this nomogram, once validated, could offer a widely available, low-cost option that would help identify patients at risk of developing pathologic left ventricular remodeling and achieve this at a very early stage of myocardial infarction (12 h after reperfusion has been achieved).Zatajivanje srca je vodeći uzrok pobola i smrtnosti u svijetu, a ishemijska bolest srca je njegov najvažniji etiološki čimbenik. Zatajivanje srca nastaje posljedično remodeliranju lijevog ventrikula, koje uzrokuje povećanje njegova volumena na kraju sistole i dijastole. U ovom prospektivnom opservacijskom istraživanju uključili smo 101 bolesnika koji su imali prvu epizodu STEMI i kojima je učinjena perkutana koronarna intervencija 12 sati od početka bolova uz postignuti protok TIMI III. Cilj istraživanja bio je utvrditi koji klinički i biokemijski parametri mogu pomoći u predviđanju nastupanja patološkog ventrikulskog remodeliranja godinu dana nakon preboljelog infarkta. Na temelju rezultata istraživanja stvoren je nomogram koji je uključivao vitalne parametre i rutinske biokemijske nalaze koji su pokazali najbolju korelaciju s pojavom patološkog ventrikulskog remodeliranja. Nomogram uključuje vrijednost NTproBNP-a 12 sati nakon postignute reperfuzije, vrijednost AST-a 12 sati nakon reperfuzije, vrijednost sistoličkog tlaka kod prijma te koronarnu arteriju okluzija koje je odgovorna za nastanak infarkta miokarda. Učinjena je ROC analiza koja je pokazala izvrsnu prediktivnu vrijednost nomograma. Površina ispod krivulje (AUC) je bila 0,907 (95% CI 0,842-0,973). Vrijednost nomograma od -3,54 imala je osjetljivost od 91,4% i specifičnost od 74,0%. Mišljenja smo da bi ovaj nomogram, jednom validiran, mogao ponuditi jeftinu i široko primjenjivu metodu za rano prepoznavanje bolesnika koji će razviti patološko ventrikulsko remodeliranje nakon preboljelog infarkta miokarda i to omogućiti već u vrlo ranoj fazi bolesti odnosno 12 sati nakon postignute reperfuzije

Auxiliary diagnostic potential of ventricle geometry and late gadolinium enhancement in left ventricular non-compaction; non-randomized case control study

Background There are still ambiguities existing in regard to left ventricular non-compaction (LVNC) diagnostic imaging. The aim of our study was to analyze diagnostic potential of late gadolinium enhancement (LGE) and ventricle geometry in patients with LVNC and controls. Methods Data on cardiac magnetic resonance imaging (CMR) studies for LVNC were reassessed from the hospital’s database (3.75 years; n=1975 exams). Matching sample of controls included cases with no structural heart disease, hypertrophic or dilative cardiomyopathy, arrhythmogenic right ventricular dysplasia or subacute myocarditis. Eccentricity of the left ventricle was measured at end diastole in the region with pronounced NC and maximal to minimal ratio (MaxMinEDDR) was calculated. Results Study included 255 patients referred for CMR, 100 (39.2%) with LVNC (prevalence in the studied period 5.01%) and 155 (60.8%) controls. Existing LGE had sensitivity of 52.5% (95%-CI:42.3–62.5), specificity of 80.4% (95%-CI:73.2–86.5) for LVNC, area under curve (AUC) 0.664 (95%-CI:0.603–0.722);p1.10 had sensitivity of 95.0% (95%-CI:88.7–98.4), specificity of 82.6% (95%-CI: 75.7–88.2) for LVNC, AUC 0.917 (95%-CI:0.876–0.948); p<0.001. LGE correlated with Max-Min-EDD-R (Rho=0.130; p=0.038) and there was significant difference in ROC analysis ΔAUC0.244 (95%-CI:0.175–0.314); p<0.001. LGE also correlated negatively with stroke volume and systolic function (both p<0.05, respectively). Conclusions LGE was found to be frequently expressed in patients with LVNC, but without sufficient power to be used as a discriminative diagnostic parameter. Both LGE and eccentricity of the left ventricle were found to be relatively solid diagnostic landmarks of complex infrastructural and functional changes within the failing heart. Keyword

Posttraumatic Stress Disorder after Acute Coronary Syndrome or Cardiac Surgery; Underestimated Reality

Osim somatskih posljedica akutnoga koronarnog sindroma u obliku različitoga stupnja intolerancije napora, radne nesposobnosti, simptoma kroničnog srčanog zatajivanja, angine pektoris, pojave različitih aritmija i sl., moguć je već u ranoj subakutnoj te u kroničnoj fazi u oboljelih osoba razvoj niza psihosomatskih i psihičkih poremećaja, koji, ako se ne prepoznaju navrijeme i aktivno ne liječe, mogu pridonijeti nepovoljnom ishodu i povećanoj smrtnosti takve skupine bolesnika. Osim povezanosti akutnoga koronarnog sindroma i kroničnog stresa, anksioznosti i depresije, on može biti „okidač“ za razvoj kasnijega posttraumatskoga stresnog poremećaja (PTSP) sa stopom prevalencije od prosječno 15-ak posto među oboljelim osobama. Više je istraživanja pokazalo da bolesnici sa simptomima PTSP-a povezanog s prethodnim akutnim koronarnim sindromom, napose oni neliječeni, imaju povećanu smrtnost i veću stopu reinfarkta miokarda. Budući da PTSP povezan s akutnim koronarnim sindromom ili kardiokirurškom operacijom zna biti zanemaren i podcijenjen, svrha je ovog rada podizanje svijesti o ovom problemu u svakodnevnoj kliničkoj praksi.In addition to the somatic consequences of acute coronary syndrome (ACS) that include different levels of intolerance to exertion, incapacity for work, symptoms of chronic heart failure, angina pectoris, the manifestation of various arrhythmias, etc., the development of a whole range of psychosomatic and mental disorders is also possible already in the early subacute and chronic phases of the disease, and if these mental disorders are not actively treated in a timely fashion they can contributed to unwanted outcomes and increased mortality in this group of patients. ACS is associated with chronic stress, anxiety, and depression and can be a trigger for later development of posttraumatic stress disorder (PTSD) with an average prevalence rate of 15% in patients with ACS. Several studies have shown that patients with symptoms of PTSD associated with ACS, especially if untreated, have increased mortality and higher rates of myocardial reinfarction. Since PTSD associated with ACS or cardiac surgery can be neglected or underestimated, the aim of this review was to raise awareness about this issue that is present in everyday clinical practice