Role of echocardiography in diagnosis of pulmonary hypertension.

Pulmonary hypertension (PH) is a progressive process that leads to right ventricular (RV) overload, hypertrophy, dilatation and RV failure. In cases with chronic heart failure, this condition is associated with more severe symptoms and worse outcomes. Transthoracic echocardiography can give several parameters which correlate with right heart haemodynamics, and should be performed in a case of suspected PH. Several parameters are important for estimation of the RV function, which can be reason for poor outcome: right atrial and ventricular dimensions and volumes, functional area changes, tricuspid annular plane systolic excursion (TAPSE), myocardial performance index, inferior vena cava size and collapsibility, S velocity estimated by Tissue Doppler Imaging, and additional information obtained from the advance echocardiograpic techniques, like strain, strain rate, three-dimensional echo- cardiography. Estimation of PH based on Doppler echocardiography measurements is not suitable for screening of mild, asymptomatic PH. Echocardiography can be recommended as a screening tool for specific diseases, follow up PH, and assessment when right heart catheterization is indicated

Role of echocardiography in diagnosis of pulmonary hypertension.

Pulmonary hypertension (PH) is a progressive process that leads to right ventricular (RV) overload, hypertrophy, dilatation and RV failure. In cases with chronic heart failure, this condition is associated with more severe symptoms and worse outcomes. Transthoracic echocardiography can give several parameters which correlate with right heart haemodynamics, and should be performed in a case of suspected PH. Several parameters are important for estimation of the RV function, which can be reason for poor outcome: right atrial and ventricular dimensions and volumes, functional area changes, tricuspid annular plane systolic excursion (TAPSE), myocardial performance index, inferior vena cava size and collapsibility, S velocity estimated by Tissue Doppler Imaging, and additional information obtained from the advance echocardiograpic techniques, like strain, strain rate, three-dimensional echo- cardiography. Estimation of PH based on Doppler echocardiography measurements is not suitable for screening of mild, asymptomatic PH. Echocardiography can be recommended as a screening tool for specific diseases, follow up PH, and assessment when right heart catheterization is indicated

Venous Thromboembolism – Current Diagnostic and Treatment Modalities

BACKGROUND: Pulmonary embolism and deep venous thrombosis, known as venous thromboembolism (VTE), are associated with a high proportion of morbidity and mortality.AIM: Aim of this review is to emphasise current diagnostic and therapeutic modalities for VTE.RESULTS: No differences have been noticed in European and American guidelines in diagnostic approach of this disorder. Today there is enough clinical information for the use of heparin (either, unfractionated or low molecular) and vitamin K antagonists in the treatment of acute and chronic phases of VTE. Novel oral anticoagulants seem to have some advantages in the treatment of this disorder. Rivaroxaban has been approved widespread, for use as a single-drug approach of VTE.CONCLUSION: Both guidelines are almost similar and good basis for evidence-based treatment of this disorder

Prevalence of risk factors and asymptomatic carotid atherosclerosis in diabetic patients screened for silent myocardial ischemia by SPECT myocardial imaging

BACKGROUND: The aim of the study was to evaluate whether there is any association between myocardial ischemia, common risk factors and carotid artery ultrasound parameters in asymptomatic type 2 diabetic (DMT2) patients. MATERIAL AND METHODS: 60 asymptomatic DMT2 patients (pts) without known coronary artery disease (CAD) underwent one day rest Dypiridamole stress Tc-99m sestamibi single photon emission computed tomography myocardial perfusion scintigraphy (MPS). We used 17 segment models for perfusion analysis with the assessment of perfusion scores. Patients were studied for age, sex, hypertension, hyperlipidemia, hs-CRP, smoking, obesity and family history of cardiac disease. Color Ultrasound examination of carotid arteries was performed in all patients. RESULTS: 51 patients (pts) had hypertension, 48 pts had hyperlipidemia, 15 were smokers, 6 pts had BMI > 30 kg/m2 and 26 patients had positive family history for CAD. 18 (31%) patients had myocardial ischemia. Mild ischemia was found in 6 pts, moderate in 7 patients and severe ischemia in 5 patients. Carotid IMT was increased in 34 pts and 15 pts had carotid plaques. Mean c-IMT value in patients with normal MPS results was 0.7 ± 0.1; in moderate ischemia 0.9 ± 0.1 and in pts severe ischemia 1.0 ± 0.2. Multivariate analysis showed obesity, low HDL and increased diastolic blood pressure predictors of increased c-IMT. Increased pulse pressure (PP), age and non-HDL cholesterol were predictors for presence of carotid plaques. Multivariable analysis for prediction of stress induced ischemia showed OR 2.9 (95% CI 2.1−5.1) for male gender, OR 3.1 for systolic blood pressure (95% CI 1.9–3.8) and OR 2.8 for LDL cholesterol (95% CI 1.7−3.6). CONCLUSIONS: Our study has shown high prevalence of traditional risk factors and silent myocardial ischemia in type 2 diabetic patients, with the importance of SPECT imaging in selected diabetes type 2 patients. The study highlights the importance of screening for carotid atherosclerosis, which may be useful to identify diabetic patients at higher risk for coronary artery disease..

Предиктори за појава на атријална фибрилација по аорто-коронарна бајпас операција

Atrial fibrillation (AF) is the most common type of arrhythmia following open heart surgery and it contributes to prolonged hospital stay, increased prevalence of thromboembolic complications and overall increased postoperative morbidity and mortality. The aim of this prospective observational follow-up study was to determine the incidence of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass surgery, to identify predisposing  risk factors for its occurrence in the immediate preoperative period and to assess its effect on the postoperative outcome in patients at the University Clinic for Cardiac Surgery in Skopje, North Macedonia. Material and methods: The study included patients at the University Clinic for Cardiac Surgery in Skopje, North Macedonia undergoing coronary artery bypass surgery. The experimental group included patients developing POAF, whereas the control group those who did not develop the primary outcome. All patients were followed up for a period of 30 days postoperatively. Results: POAF was registered in 38% of the patient population and more frequently in the elderly. Patients developing POAF had significantly higher left atrial volume index, as well as higher CHADS2-VASC2, HATCH and Euroscore I values. Average time to POAF occurrence was 48-72 hours postoperatively. There were death outcomes, thromboembolic events, longer hospital stay, need for antiarrhythmic and oral anticoagulant therapy in the POAF group. Conclusion: POAF significantly increases postoperative morbidity and mortality in patients undergoing coronary artery bypass surgery. Age, higher CHADS2-VASC2, HATCH and Euroscore I values and left atrial volume were found to be significant predictors of POAF after coronary artery bypass surgery.Атријалната фибрилација (АФ) претставува најчестиот тип на аритмија по хирургија на отворено срце и истата придонесува за пролонгиран болнички престој, зголемена инциденција на тромбемболиски компликации и општо зголемен постоперативен морбидитет и морталитет. Целта на оваа проспективна, опсервациска студија на следење беше да се утврди инциденцијата на постоперативната атријална фибрилација (ПОАФ) кај пациентите кои подлегнуваат на аорто-коронарна бајпас операција, да се откријат предиспонирачките ризик-фактори за појава на атријална фибрилација во непосредниот предоперативен период, како и да се евалуира нејзиниот ефект врз постоперативниот исход на кардиохируршките пациенти на ЈЗУ Универзитетска клиника за кардиохирургијавоРепублика Северна Македонија. Материјал и методи: Во оваа проспективна отворена студија на следење беа вклучени пациенти хоспитализирани на ЈЗУ Универзитетска клиника за кардиохирургија- Скопје за изведување на аорто-коронарна бајпас операција. Во испитуваната група беа вклучени оние пациенти,  кои во постоперативниот период развија ПОАФ, додека во контролната група беа вклучени пациентите кои не развија ПОАФ. Постоперативно пациентите беа следени во период од 30 дена од кардиохируршката интервенција. Резултати: ПОАФ беше регистрирана кај 38% од испитаниците и тоа почесто кај повозрасната група испитаници. Пациентите со ПОАФ имаа значително повисока вредност на индексираниот волумен на левата преткомора, како и значително повисока вредност на CHADS2-VASC2, HATCH и Euroscore скоровите,во однос на групата без ПОАФ. Просечното време на појава на ПОАФ беше 48-72 часа од хируршката интервенција. Во групата пациенти со ПОАФ без забележани смртни случаи, како и тромбоемболиски компликации, од типот на исхемичен мозочен удар и овие пациенти имаа подолг болнички престој и потреба од антиаритмична терапија и орална антикоагулантна терапија (ОАК). Заклучок: ПОАФ значително го влошува морбидитетот и морталитетот кај кардиохируршките пациенти. Возраста, високата вредност на CHADS2-VASC2, HATCH и Euroscore, како и волуменот на левата преткомора претставуваат предиктивни фактори за атријална фибрилација во постоперативниот период по аорто-коронарна бајпас операција

Influence of the Subclinical Hypothyroidism on the Left Ventricular Systolic and Diastolic Function (pilot study)

Introduction: The clinically manifested hypothyroidism is associated with systolic and diastolic dysfunction. Studies investigating the left ventricular function in subclinical hypothyroidism (ScH) have shown controversial results. The aim of the study was to assess whether ScH is associated with the left ventricular systolic and diastolic dysfunction. Material and methods: Seventeen consecutive patients with newly diagnosed ScH and 20 healthy euthyroid patients as controls were analyzed. The two groups were appropriate by: age, sex, and body mass index. Laboratory analyses were performed in all patients - determination of TSH, free thyroxin (FT4), free triijodothyronine (FT3), antibodies directed to thyroid peroxidase (TPOAb) and antitiroglobulin antibodies (TgAb), and the assessment of left ventricular systolic and diastolic function by M-mode, two-dimensional echocardiography, pulse, continuous and color-Doppler, advanced echocardiographic modalities Tissue Doppler (TDI) and two-dimensional speckle tracking. Results: ScH patients had statistically significant lower ejection fraction, smaller ratio s/d (where s is the systolic velocity and d is the diastolic velocity through the pulmonary veins) and lower negative longitudinal global strain compared with the control group (62.1 ± 2.1 vs. 58.7 ± 6.2%, p<0.05, 1.27 ± 0.12 vs. 1.06 ± 0.20, p<0.001, -0.21 ± 0.01 versus -0.19 ± 0.01%, p<0.05, respectively). There was a statistically significant negative correlation of TSH with s/d and S/ TDI (r = 0.43 and r = 0.26, p<0.05, respectively). There was a statistically significant negative correlation of free thyroxine with myocardial performance index (r = -0.17, p<0.05), and a positive correlatin with s/d (r =0.48, p<0.05). Conclusion: ScH was associated with a statistically significant reduction in global systolic and global longitudinal systolic function of the left ventricle

The effect of levothyroxine treatment on left ventricular function in subclinical hypothyroidism

Objective: Treatment of subclinical hypothyroidism (ScH), especially the mild form of ScH, is controversial because thyroid hormones influence cardiac function. We investigate left ventricular systolic and diastolic function in ScH and evaluate the effect of 5-month levothyroxine treatment. Subjects and methods: Fifty-four patients with newly diagnosed mild ScH (4.2 < TSH < 10.0 mU/L) and 30 euthyroid subjects matched by age were analysed. Laboratory analyses and an echocardiography study were done at the first visit and after 5 months in euthyroid stage in patients with ScH. Results: Compared to healthy controls, patients with ScH had a lower E/A ratio (1.03 ± 0.29 vs. 1.26 ± 0.36, p < 0.01), higher E/e’ sep. ratio (7.62 ± 2.29 vs. 6.04 ± 1.64, p < 0.01), higher myocardial performance index (MPI) (0.47 ± 0.08 vs. 0.43 ± 0.07, p < 0.05), lower global longitudinal strain (GLS) (-19.5 ± 2.3 vs. -20.9 ± 1.7%, p < 0.05), and lower S wave derived by tissue Doppler imaging (0.077 ± 0.013 vs. 0.092 ± 0.011 m/s, p < 0.01). Levothyroxine treatment in patients with ScH contributed to higher EF (62.9 ± 3.9 vs. 61.6 ± 4.4%, p < 0.05), lower E/e’ sep. ratio (6.60 ± 2.06 vs. 7.62 ± 2.29, p < 0.01), lower MPI (0.43 ± 0.07 vs. 0.47 ± 0.08%, p < 0.01), and improved GLS (-20.07 ± 2.7 vs. -19.55 ± 2.3%, p < 0.05) compared to values in ScH patients at baseline. Furthermore, in all study populations (ScH patients before and after levothyroxine therapy and controls), TSH levels significantly negatively correlated with EF (r = -0.15, p < 0.05), E/A (r = -0.14, p < 0.05), GLS (r = ‑0.26, p < 0.001), and S/TDI (r = -0.22, p < 0.01) and positively correlated with E/e’ sep. (r = 0.14, p < 0.05). Conclusion: Patients with subclinical hypothyroidism versus healthy individuals had subtle changes in certain parameters that indicate involvement of systolic and diastolic function of the left ventricle. Although the values of the parameters were in normal range, they were significantly different compared to ScH and the control group at baseline, as well as to the ScH groups before and after treatment. The results of our study suggest that patients with ScH must be followed up during treatment to assess improvement of the disease. Some of the echocardiography obtained parameters were reversible after levothyroxine therapy

European Society of Cardiology: Cardiovascular Disease Statistics 2019

Aims The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. Methods and results In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5–23.1%] vs. 15.7% (IQR 14.5–21.1%)}, diabetes [7.7% (IQR 7.1–10.1%) vs. 5.6% (IQR 4.8–7.0%)], and among males smoking [43.8% (IQR 37.4–48.0%) vs. 26.0% (IQR 20.9–31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0–10.8) vs. 16.7% (IQR 13.9–19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655–8115)] compared with high-income [2235 (IQR 1896–3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. Conclusion A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest

Assessment of left ventricular systolic and diastolic function in subclinical hypothyroidism

Objective: Studies investigating systolic and diastolic left ventricle function in subclinical hypothyroidism (ScH) have shown controversial results. As myocardium is a target organ of thyroid hormone action, the aim of the study was to assess the left ventricular systolic and diastolic function in ScH. Methods: Fifty-four patients with newly diagnosed ScH and 30 euthyroid controls, patients of the University Clinic of the Endocrinology, Diabetes, and Metabolic Disorders Clinic were enrolled. Transthoracic echocardiography, using M-mode, two-dimensional (2D), pulsed, continuous and color-Doppler, and advanced echocardiographic modalities Tissue Doppler and two-dimensional speckle tracking was performed in all subjects. Results: Although normal echocardiographic values of all measured parameters, SCH patients were significantly different from their matched controls: the ratio between E/A was statistically significantly lower (1,26±0,36 vs. 1,03±0,29, p<0,01), the ratio between Е/е’ sep. was statistically significantly higher (6,04±1,64 vs. 7,62±2,29, p<0,01), MPI was statistically significantly higher (0,43±0,07 vs. 0,47±0,08, p<0,05), GLS had statistically significantly lower negative value (-20,9±1,7 vs. -19,55±2,3%, p<0,001), and S/TDI was statistically significantly lower (0,092±0,011 vs. 0,077±0,013, p<0,01). TSH negatively correlated with EF (r=-0,15, p<0,05), E/A(r=-0,14, p<0,05), GLS (r=-0,26, p<0,001), S/TDI (r=-0,22, p<0,01), and positively correlated with E/e 'sep. (r=0,14, p<0,05). Conclusion: Subclinical hypothyroidism contributes to changes in certain parameters involved in the assessment of global and longitudinal systolic and diastolic left ventricular function compared to healthy individual