A prospective study about impact of renal dysfunction and morbidity and mortality on cardiovascular events after ischemic stroke

Background: The aim of our prospective study was to define the impact of renal dysfunction on future cardiovascular events and total mortality in 390 patients suffering from ischemic stroke. Methods: A quantitative measurement of neurologic deficit according to National Institutes of Health Stroke Scale (NIHSS) score was performed. Blood parameters were measured. Diabetes, hypertension and smoking habits were defined. Estimated glomerular filtration rate was calculated. Results: 153 (39.2%) patients had renal dysfunction. In the follow-up period in 36 (9.2%) patients acute coronary syndrome, in 102 (26.2%) recurrent ischemic stroke and in 44 (11.3%) peripheral arterial disease were documented. 191 (49%) patient died, 118 (30.3%) of whom died of cardiovascular events. Patients who died were older, had higher prevalence of renal dysfunction and NIHSS score. The Kaplan-Meier survival analysis showed that total mortality (p < 0.003) and cardiovascular mortality (p < 0.01) were higher in patients with renal dysfunction. According to Cox’s regression analysis, renal dysfunction was the predictor of cardiovascular events, cardiovascular and total mortality. Conclusions: Patients with ischemic stroke and renal dysfunction are at higher risk for long term cardiovascular and total mortality. The patients with ischemic stroke and renal dysfunction are also at higher risk of new cardiovascular morbidity. Renal dysfunction should be added to the other known prognostic factors in patients with ischemic stroke. Our results also emphasize the importance of identification and management of renal dysfunction in stroke patients.

Influence of renal function at stent implantation on the outcome after stent thrombosis

Namen raziskave Namen raziskave je bil opredeliti, ali kronična ledvična bolezen (KLB) po vgraditvi žilne opornice vpliva na dolgoročen izzid zdravljenja po kasnejši trombozi v žilni opornici (TŽO). Teoretična podlaga za raziskavo Bolniki s KLB imajo slabše rezultate zdravljenja po perkutani koronarni intervenci. Med samo perkutano koronarno intervenco lahko s kontrastom dodatno poslabšamo KLB. Ni nobenih podatkov, ali KLB po implantaciji žilne opornice vpliva na slabši izzid zdravljenja po kasnejši TŽO. Če bi bilo to res, bi lahko že ob implantaciji žilne opornice opredelili skupino bolnikov z večjim tveganjem za slabši izhod ob TŽO, ki bi jih lahko bolje spremljali in pazljiveje zdravili. Metode dela Pregledali smo podatke 4824 zaporednih bolnikov, ki so v našem centru imeli opravljeno perkutano koronarno intervenco od Marca 2004 do Aprila 2010. Izluščili smo 100 bolnikov, ki so utrpeli TŽO in jih spremljali do 31.12.2012. Povprečno smo jih spremljali 48,03±29,32 meseca (najmanj 30 in največ 98 mesecev). Opazovali smo samo bolnike z definitivno TŽO, opredeljeno po ARC (Academic Research Consortium) kriterijih. Spremljali smo podatke o smrti, miokardnih infarktih, ponovnih perkutanih ali kirurških revaskularizacijah. Podatke smo dobili iz bolnišničnega sistema, pregledi ali po telefonu. Primerjali smo skupino z in brez KLB po.implantaciji žilne opornice (KLBpoIŽO). KLB smo opredelili kot hitrost glomerulne filtracije < 60 ml/min/1,73 m2. Rezultati Bolniki s KLBpoIŽO so v opazovanem obdobju pomembno bolj umirali po TŽO, kot bolniki brez KLBpoIŽO (64,5% proti 17,4%p <0,0001)(hi-kvadrat test). Sestavljeni končni koronarni dogodki (smrt, miokardni infarkt, ponovna revaskulariozacija) so bili prav tako pomembno pogostejši v skupini s KLBpoIŽO (83,9% proti 58,8%p <0,021) (hi-kvadrat test). Pogostnost ponovnih miokardnih infarktov po TŽO je bila podobna v skupini z in brez KLBpoIŽO (32,3% proti 31,9%), pa tudi perkutanih in kirurških revaskularizacij je bilo podobno (41,9% proti 46,4%). Smrt po TŽO sta napovedovali KLBpoIŽO (prilagojeno razmerje ogroženosti = adjusted HR 5,3095% interval zaupanja = CI 2,30 do 1,22p < 0,0001) in starost več kot 75 let (adjusted HR 2,99: 95 % CI 1,27 do 7,05p = 0,012). Sestavljen končni koronarni dogodek po TŽO sta napovedovala KLBpoIŽO (adjusted HR 1,77: 95% CI 1,01 do 3,19p = 0,049) in sladkorna bolezen (adjusted HR 1,78: 95% CI 1,02 do 3,01p = 0,041). Zaključek Bolniki s KLBpoIŽO, starejši od 75 let umirajo pogosteje po TŽO. Bolniki s KLBpoIŽO, ki imajo ob tem še sladkorno bolezen, pa utrpjio po TŽO bistveno več sestavljenh končnih koronarnih dogodkov. Z določitvijo KLBpoIŽO lahko že ob implantaciji žilne opornice opredelimo skupino bolnikov, ki bo ob TŽO imela pomembno večje tveganje za slab izhod. Na te bolnike moramo biti pozorni že ob implantaciji žilne opornice. TŽO lahko poskusimo preprečiti pri njih s podaljšanim dvojnim protitrombocitnim zdravljenjem, z novimi zdravili ali kombinacijo obojega. Individualno prilagojeno dvojno protitrombocitno zdravljenje glede na bolnikovo KLB in tveganje za krvavitev bi lahko bila najvarneje. Trenutno ni nobenih podatkov o varnosti takšnih pristopov. Do takrat moramo te bolnike po implantaciji žilne opornice skrbno spremljati, jim razložiti nevarnosti TŽO in krvavitev, da bodo čimbolj upoštevali navodila zdravljenja.Objectives The aim of the study was to examine the possible influence of renal dysfunction after stent implantation on long term outcomes after stent thrombosis (ST). Bacminround Renal dysfunction is associated with an increased risk of worse outcome after percutaneous coronary intervention (PCI). Furhermore contrast used during PCI worsens renal dysfunction. There are no data if renal dysfunction immediately after stent implantation influences worse prognosis after ST. If so patients with a higher risk for worse outcome after ST can be identified already at the time of stent implantation. Methods Data from 4824 consecutive patients treated with PCI in our centre was recorded from March 2004 through April 2010. From these 100 patients with ST were identified and prospectively followed until December 2012 for 48.03±29.32 months. Only patients with definite ST were included in the study. The Academic Research Consortium definition of ST was used. Data on death, myocardial infarction and repeated percutaneous or operative revascularization after ST were ascertained from the hospital database, by phone or with clinical examinations. The outcomes after definite ST were compared in patients with and without renal dysfunction after stent implantation (RDafterSI). Renal dysfunction was defined as estimated glomerular filtration rate <60 ml/min/1.73m2. Results Patients with RDafterSI had a higher mortality rate after ST than patients without RDafterSI (64.5% vs. 17.4%p <0.0001)(chi-square test) during observation period. Major adverse cardiac events (MACE - death, myocardila infarction, repeated revascularization) rate after ST was significant different considering patients with or without RDafterSI (83.9% vs. 58.8%p <0.021)(chi-square test). The prevalence of myocardial infarction was similar in both groups (32.3% vs. 31.9%) as was the revascularization rate (41.9% vs. 46.4%). Death was independently predicted by RDafterSI (adjusted HR 5.3095 CI 2.30 to 12.22p 75 years (adjusted HR 2.99: 95 % CI 1.27 to 7.05p = 0.012). MACE was predicted by RDafterSI (adjusted HR 1.77: 95% CI 1.01 to 3.19p = 0.049) and diabetes (adjusted HR 1.78: 95% CI 1.02 to 3.01p = 0.041). Conclusions Patients with RDafterSI who are older than 75 years at stent implantation had significantly higher long term mortality after ST. RDafterSI and diabetes influenced MACE rate as well. RDafterSI and age >75 point out the group of patients with a high risk for death and MACE after ST already at the time of stent implantation. They should be payed special attention after stent implantation. Prolonged dual antiplatelet therapy or newer antiplatelet drugs might be considered for these patients. Patient’s tailored antiplatelet therapy according to renal function and bleeding risk may be the safest therapy. However, there are no data of these alternative approaches jet. Until then strict follow up should be advocated so patients will stick to the therapy vigorously

Perkutana balonska aortna valvuloplastika kot možnost paliativnega zdravljenja za inoperabilne bolnike?

Namen: V razvitih državah se zaradi staranja prebivalstva povečuje število starostnikov s hudo aortno stenozo. Tveganje za zaplete je pri kirurški zamenjavi aortne zaklopke, ki je standarden način zdravljenja, pri tej skupini bolnikov visoko. Za zdravljenje omenjene skupine starostnikov razvijajo perkutane načine zdravljenja, kot sta perkutana balonska aortna valvuloplastika in perkutana vstavitev aortne zaklopke. Prikaz primera: V prispevku je opisan primer 84-letne bolnice z levostransko hemiparezo po možganski kapi in generalizirano aterosklerozo. Sprejeta je bila zaradi pljučnega edema, zdravljenje z neinvazivno ventilacijo in inotropi pa ni bilo uspešno. Perkutana balonska aortna valvuloplastika je bila opravljena 6 ur po sprejemu. Takoj po posegu se je bolničino stanje izboljšalo. Po 25 dneh bolnišničnega zdravljenja smo jo odpustili v domsko varstvo. Zaključek: Perkutana balonska vulvoloplastika je dodatna možnost zdravljenja bolnikov z aortno stenozo in visokim tveganjem za zaplete ob kirurškem zdravljenju. Balonska dilatacija aortne zaklopke ima lahko vlogo paliativnega posega ali premostitvenega posega do kirurške ali perkutane zamenjave aortne zaklopke.Purpose: The number of elderly patients with severe aortic stenosis and comorbidities is increasing in the aging populations of "developed" countries. Unacceptably high perioperative mortality and morbidity makes the decision to undertake surgical aortic valve replacement in this group of patients difficult and unlikely. Development of less invasive procedures such as balloon aortic valvuloplasty and transcatheter aortic valve replacement is emerging as another treatment option. Case report: A 84-year-old female with previous left-sided hemiparesis after stroke and severe aortic stenosis presented with pulmonary edema to our institution. Non-invasive ventilation and inotropic support were unsuccessful. Balloon aortic valvuloplasty was done as emergency procedure and she improved immediately. She was discharged after 25 days of inhospital treatment. She died 8 weeks later of unrelated reasons (infected decubitus and sepsis). Conclusion: Balloon aortic valvuloplasty might be used as temporary and interim therapeutical options for patients with severe aortic stenosis and acute left ventricular failure who have unacceptably high risks when aortic valve replacement or emergency transcatheter aortic valve implantation is considered. Balloon aortic valvuloplasty may be used as a bridge to both procedure

Predictors of early cardiac changes in patients with type 1 diabetes mellitus: An echocardiography-based study

In patients with type 1 diabetes mellitus (T1DM) imaging studies have demonstrated an increased prevalence of left ventricular diastolic dysfunction and increased left ventricular mass (LVM) unrelated to arterial hypertension and ischemic heart disease. The aim of our study was to identify potential predictors of early subclinical changes in cardiac chamber size and function in such patients. Sixty-one middle-aged asymptomatic normotensive patients with T1DM were included in the study. Conventional and tissue Doppler echocardiography was performed and fasting serum levels of glucose, glycated hemoglobin (HbA1c), lipids, and creatinine were measured. We found moderate bivariate correlations of body mass index (BMI) with left atrial volume (r = 0.47, p < 0.01), LVM (r = 0.42, p < 0.01), left ventricular relative wall thickness (r = 0.32, p = 0.01), and all observed parameters of diastolic function of both ventricles. The five-year average value of HbA1c weakly correlated with the Doppler index of left ventricular filling pressure E/e´sept (r = 0.27, p = 0.04). We found no significant association of diabetes duration, five-year trend of HbA1c, serum lipids, and glomerular filtration rate with cardiac structure and function. After adjusting for other parameters, BMI remained significantly associated with left atrial volume, LVM as well as with the transmitral Doppler ratio E/A. In our study, BMI was the only observed parameter significantly associated with subclinical structural and functional cardiac changes in the asymptomatic middle-aged patients with T1DM