Prognostic Indicators for First and Repeated Hospitalizations in Heart Failure Patients with Reduced Left Ventricular Ejection Fraction

Heart failure with reduced ejection fraction (HFrEF) is a progressive clinical syndrome defined by changes in the myocardial structure, which lead to predominant systolic myocardial function impairment, with a left ventricle ejection of fraction ≤40%. The rehospitalization burden in HFrEF patients (pts) remains very high, with poor quality of life, increased mortality and large healthcare expenditures. In this research project, we investigated the risk factors for first and repeated hospitalization in pts with HFrEF. This retrospective study included 50 adult pts with a diagnosis of HFrEF and who were within the age range of 55 to 89 years old and of both sexes. Demographic and clinical data (HFrEF etiology, renal function parameters, complete blood count, markers of inflammation, electrocardiogram, troponin I, NTproBNP, echocardiographic parameters and comorbidities data) were collected from the pts’ medical histories. Statistical analysis was performed via Fischer’s exact test, the Shapiro-Wilk test and the Spearman correlation coefficient. This study included 70% male and 30% female HFrEF pts. Males were younger in both group of pts and had a higher incidence of rehospitalization. The most important HFrEF etiologic risk factors are arterial hypertension (82%), coronary heart disease (54%), atrial fibrillation (52%) and diabetes mellitus (40%). The most important noncardiac comorbidity related with the first HFrEF hospitalization is pneumonia (P=0.03), while progression of left ventricle systolic and diastolic dysfunction is related to rehospitalization risk (left ventricle end systolic diameter, P=0.003; diastolic dysfunction degree, P=0.04). The troponin level was associated with an increased risk of rehospitalization, but this was not statistically significant at this sample size (troponin I, p=0.10). Following the first and repeated hospitalizations of HFrEF pts, comorbidities, ageing and gender difference are crucial to HFrEF development, while echocardiographic parameters and biomarkers critically affect HFrEF rehospitalization risk

Dabigatran Use Associated with Hemopericardium and Hemothorax

Concurrent spontaneous hemopericardium and hemothorax due to anticoagulant use are extremely rare in clinical practice. Dabigatran is an oral direct thrombin inhibitor approved to prevent stroke or thromboembolic episodes in patients with nonvalvular atrial fibrillation. We report the case of a 73-year-old man who received dabigatran therapy (150 mg twice a day) for 3 months and developed massive spontaneous hemothorax and hemopericardium associated with fever. Emergency chest computed tomography scan established higher-density pericardial effusion (22HU) and left pleural effusion of heterogeneous density (5–15 HU) which could be hemorrhagic content while the heart ultrasound finding confirmed pericardial effusion 7–9 mm thick, without affecting hemodynamics. Almost 1100 mL of blood was drained by ultrasoundguided thoracentesis. After excluding other possible causes, diagnostic withdrawal was performed for dabigatran and no further pleural or pericardium effusion developed after dabigatran was discontinued. Therefore, practitioners could be aware of hemothorax as well as hemopericardium as a potential complication of dabigatran therapy

Erectile Dysfunction after Myocardial Infarction – Myth or a Real Problem?

Erectile dysfunction is a common problem whose relation to cardiovascular diseases has scientifically been proved, but it has not been studied sufficiently in patients recovering from myocardial infarction. The objective of this study was to establish the frequency of erectile dysfunction in patients recovering from myocardial infarction. We examined 89 patients (aged 30 to 75 years) included in the program of cardiac rehabilitation after myocardial infarction. The results were compared with 91 healthy examinees of the same age. Even 82% of the patients who recovered from myocardial infarction have problems with erectile dysfunction, compared to 42.9% of healthy examinees. The prevalence of erectile dysfunction increases with the age in both groups. In the group of patients recovering from myocardial infarction aged 30 do 39 years, the erectile dysfunction decreased after 6 months, while in other age subgroups and between controls, there were no significant changes in erectile dysfunction prevalence during the analysed time period.We concluded that erectile dysfunction is a significant problem in patients recovering from myocardial infarction. It should be recognized on time in order to provide a better life quality for the patient with a multidisciplinary approach

Abnormal Systolic Blood Pressure during Treadmill Test and Brachial Artery Flow – Mediated Vasodilatation Impairment

The aim of the study was to assess the relationship between systolic blood pressure during maximal treadmill test (SBPmtt) and flow-mediated vasodilation (FMD). Abnormal rise of SBPmtt is the phenomenon more frequent in hypertensive persons but it could be found in normotensive subjects too. 199 subjects referred to treadmill test were enrolled in the study. Four groups were formed: hypertensives with abnormal SBPmtt (group A), hypertensives with normal SBPmtt (group B), normotensives with abnormal SBPmtt (group C) and normotensives with normal SBPmtt (group D). Rise of SBPmtt above 200 mmHg was considered abnormal reaction. Simple linear regression analysis showed significant inverse relationship between SBPmtt and FMD (F=20.2036, p<0.001, R2=0.0956). Mean FMD index was worst in hypertensive subjects with abnormal SBPmtt (group A), followed by normotensives with abnormal SBPmtt (group C), hypertensives with normal SBPmtt (group B) and the best was in normotensives with normal SBPmtt (3.56±5.17, 4.19±5.14, 6.81±8.43 and 10.92±7.48%, respectively). In multivariate regression analysis FMD showed significant association with abnormal SBPmtt (p<0.001) along with brachial artery diameter (p<0.001), male gender (p<0.001), but not with hypertension (p=0.073), BMI (p=0.137) and total cholesterol (p=0.23) (coefficients: –0.26, –0.40, –0.27, –0.13, –0.11 and –0.07, respectively). There was a significant inverse relationship between SBPmtt and FMD. An impairment of FMD exists in normotensive subjects with abnormal SBPmtt. In hypertensives with abnormal SBPmtt an additional impairment of FMD exists when compared to hypertensives with normal SBPmtt. Abnormal SBPmtt should be taken into account in global cardiovascular risk assessment

Short- and long-term outcome of patients aged 65 and over after cardiac surgery

To analyze the short and long-term outcome of patients aged 65 years and over, after cardiac surgery. Over a 12-year period we analyzed 1750 patients with a mean age of 70.09 3.94 years. They were classified into three age groups: between 65 and 69 (n = 709), between 70 and 74 (n = 695) and 75 years and above (n = 346). Follow-up information was obtained by telephone conversation after a 6-month and 3-year period of discharge from the hospital. Included in the follow-up were 1235 patients and an interview was conducted with 501 (40.6%) patients or their next of kin. Even though the in-hospital morbidity was highest in the oldest age group, there were no significant differences between groups (p = 0.051). There was no significant difference between groups in the length of hospital stay. The greatest in-hospital mortality was noted in the oldest age group (p = 0.046) compared to patients in the age groups between 65 and 69 and between 70 and 74 years old (p = 0.023 and p = 0.036). In the follow-up study, there was a significantly smaller telephone feedback response in the oldest age group compared to the youngest group (p = 0.003). There were no differences between the groups with respect to mortality and cardiac death after the 6-month and 3-year periods of discharge from hospital. Our data showed that despite a poor short – and long-term outcome in patients aged 75 and over, all patients had an acceptable operative risk

Association of Cyp2c9 Gene Polymorphism with Bleeding as a Complication of Warfarin Therapy

The aim of this study was to determine the association of bleeding as a complication of warfarin therapy with polymorphism of CYP2C9 gene (alleles 1, 2 and 3). The CYP2C9 is the main enzyme for warfarin metabolism. Study included 181 patients receiving warfarin for at least one month. Allele 1 of CYP2C9 gene (in 94.5%) and genotype *1/*1 (57.5%) prevailed. Allele 3 was found in 12.7% patients. Bleeding side-effects occurred in 18 patients (10%). Patients with allele *1 needed significantly higher maintenance warfarin dose (p=0.011). Those with allele *3 had significantly lower maintenance warfarin dose (p=0.005) and higher prothrombin time (PT) at induction (p=0.034). Bleeding occurred significantly more often in those with lower maintenance warfarin dose (p=0.017). Patients with allele *3 had increased risk of bleeding, with marginal significance (p=0.05). Polymorphism of CYP2C9 could determine dose of warfarin therapy and thus it could be related to the risk of bleeding complications. Allele *3 carriers need lower warfarin dose. Therefore, initially reduced warfarin induction dose in allele *3 carriers could avoid more prolonged PT and decrease the risk of bleeding complication

Ozbiljna hepatotoksičnost udružena s pripravkom Herbalife® u prethodno zdrave žene

Lately there has been an increased consumption of herbal preparations, distributed as nutritional supplements, often claimed to be ‘natural’ and harmless. However, as their use is not subjected to strict pre-marketing testing and regulations, their ingredients are not clearly defined and there is no quality control or proof of their effectiveness and safety. A growing body of references accentuate their harmful effects, in particular hepatotoxicity, which varies from minimal hepatogram changes to fulminant hepatitis requiring liver transplantation. This case report describes liver damage that was highly suspected to originate from Herbalife® products consumption. We excluded alcohol, viral, metabolic, autoimmune and neoplastic causes of liver lesions, as well as vascular liver disease, but we noticed a connection between the use of Herbalife® products and liver damage. The exact mechanism of liver damage in our patient was not determined. After removing the Herbalife® products, liver damage resolved and there was no need to perform liver biopsy. Taking into consideration the growing consumption of herbal products and their potential harmfulness, we consider that more strict regulations of their production process and sale are necessary, including exact identification of active substances with a list of ingredients, toxicologic testing and obligatory side effect report.U novije vrijeme bilježi se porast upotrebe biljnih pripravaka koji su važan sastojak komplementarnih i alternativnih pripravaka te su široko dostupni pod krinkom “prirodnosti” i neškodljvosti. No budući da njihova upotreba ne podliježe strogim predmarketinškim testiranjima i regulativama, često nemaju jasno i detaljno definiran sastav, osiguranu kontrolu kvalitete, kao niti dokaz o učinkovitosti i sigurnosti. Štoviše, sve je više literaturnih podataka koji svjedoče štetnim učincima biljnih pripravaka, a kao najčešća posljedica njihove upotrebe navodi se hepatotoksičnost s različitim stupnjevima jetrenog oštećenja, od minimalnih promjena hepatograma sve do fulminantnog hepatitisa koji zahtijeva transplantacijsko liječenje. Prikazuje se slučaj jetrenog oštećenja visoko povezanog s uporabom određenih proizvoda Herbalife®, nakon što su kao moguć uzrok jetrenog oštećenja isključeni alkohol, virusne bolesti, metabolička, vaskularna, autoimuna i neoplastična zbivanja. Točan mehanizam jetrenog oštećenja u prikazane bolesnice nismo otkrili, a budući da su se jetrena funkcija i morfologija u potpunosti oporavile nakon ukidanja sumnjivih pripravaka Herbalife® nije bilo potrebe za biopsiju jetre. Imajući u vidu sve učestaliju konzumaciju biljnih pripravaka s potencijalno štetnim djelovanjem, smatramo da je neophodno uvođenje kako stroge regulacije proizvodnih i prodajnih procesa, tako i točne i detaljne identifikacije aktivnih tvari na popisu sastojaka te toksikološka testiranja uz obvezu prijavljivanja nuspojava

Secondary Hypertension due to Isolated Interrupted Aortic Arch in a 60-Year-Old Person – One-Year Follow up

Interrupted aortic arch (IAA) is a congenital defect characterized by loss of luminal continuity between the ascending and descending aorta1. It is a rare malformation with an estimated incidence of perinatally diagnosed cases of 3 per million live births3. The condition is considered extremely rare in adults. However, its true prevalence in this population is unknown. We have found 30 case reports of IAA in adults in literature, 5 of whom were older than 50 years. Four of them had type A IAA. Arterial hypertension is a typical co-morbidity. In this report we describe a 60-year-old male patient who had a type A asymptomatic IAA. Although we initially suspected the aortic coarctation, further invasive procedures revealed complete interruption of the aortic arch just distal to the origin of the left subclavian artery. The patient underwent surgical repair, followed by full recovery and near-normalization of blood pressure

Erectile Dysfunction after Myocardial Infarction – Myth or a Real Problem?

Erectile dysfunction is a common problem whose relation to cardiovascular diseases has scientifically been proved, but it has not been studied sufficiently in patients recovering from myocardial infarction. The objective of this study was to establish the frequency of erectile dysfunction in patients recovering from myocardial infarction. We examined 89 patients (aged 30 to 75 years) included in the program of cardiac rehabilitation after myocardial infarction. The results were compared with 91 healthy examinees of the same age. Even 82% of the patients who recovered from myocardial infarction have problems with erectile dysfunction, compared to 42.9% of healthy examinees. The prevalence of erectile dysfunction increases with the age in both groups. In the group of patients recovering from myocardial infarction aged 30 do 39 years, the erectile dysfunction decreased after 6 months, while in other age subgroups and between controls, there were no significant changes in erectile dysfunction prevalence during the analysed time period.We concluded that erectile dysfunction is a significant problem in patients recovering from myocardial infarction. It should be recognized on time in order to provide a better life quality for the patient with a multidisciplinary approach