Era tikagrelora

Coronary heart disease is still one of the leading causes of mortality in developed counties. In the last three decades, a significant step forward has been achieved in its treatment, primarily for acute coronary syndrome (ACS). These results are the consequence of the introduction of a treatment strategy based on percutaneous coronary interventions and dual antiplatelet therapy. The last decade was also marked by the introduction of more potent antiplatelet medications such as ticagrelor and prasugrel. We can now confidently say that dual combination of aspirin and ticagrelor is one of the fundamental combinations for the treatment of patients with ACS, whether they were treated with percutaneous coronary intervention or with conservative treatment. Over time, ticagrelor has expanded its scope of indications and can today be included in the treatment of patients with high ischemic risk even one year after an intervention or the initial acute coronary event. It is important to emphasize that although the risk of bleeding in all the studies was somewhat higher compared with clopidogrel, the bleeding did not cause a reduction in the clinical benefits of ticagrelor. While there are no large studies on the application of ticagrelor in patients with chronic coronary syndrome (CCS), guidelines recommend the introduction of ticagrelor to the treatment of patients with CCS and high risk of ischemic events. Over the last decade, ticagrelor has embedded itself deeply in clinical practice and become the basis of dual antiplatelet therapy in most patients with ACS as well as some patients with CCS.Koronarna bolest srca jedan je od vodećih uzroka smrtnosti u zemljama razvijenoga svijeta. U posljednja tri desetljeća učinjen je velik iskorak u njezinu liječenju, i to prije svega akutnoga koronarnog sindroma (AKS). Takvi su rezultati posljedica uvođenja strategije perkutane koronarne intervencije i dvojne antiagregacijske terapije. Posljednjih deset godina obilježilo je uvođenje potentnijih antiagregacijskih lijekova kao što su tikagrelor i prasugrel. Danas slobodno možemo reći da je dvojna kombinacija acetilsalicilatne kiseline i tikagrelora jedna od temeljnih kombinacija u liječenju bolesnika s AKS-om, bilo da su liječeni koronarnom intervencijom bilo konzervativno. Tikagrelor je s vremenom proširio lepezu indikacija tako se danas može uključiti u liječenje bolesnika s visokim ishemijskim rizikom i nakon godinu dana od izvedene intervencije ili inicijalnoga akutnoga koronarnog događaja. Bitno je istaknuti da u svim provedenim istraživanjima, iako je rizik od krvarenja bio nešto viši u usporedbi s klopidogrelom, krvarenja nisu uzrokovala smanjenje klinički pozitivnog učinka tikagrelora. Iako nema velikih istraživanja s primjenom tikagrelora u bolesnika s kroničnim koronarnim sindromom (KKS), smjernice daju preporuku da se tikagrelor može uvesti u terapiju bolesnika s KKS-om i visokim rizikom od ishemijskog događaja. Posljednjih je deset godina tikagrelor duboko ušao u kliničku praksu i postao temelj dvojne antiagregacijske terapije u većine bolesnika s AKS-om, kao i u dijela bolesnika s KKS-om

Influence of ATII Blockers and Calcium Channel Blockers on Renal Vascular Resistance in Patients with Essential Hypertension

Doppler can evaluate renal vascular resistance, and resistance index (RI) highly correlates with blood pressure and renal function in various pathological conditions. Purpose of the study was to measure and compare renal Doppler indices in patients with newly-diagnosed essential hypertension (EH) and in healthy subjects; to determine changes of Doppler indices in patients after six-months monotherapy with either the AT II blocker (valsartane) or calcium channel blocker (niphedipine); to determine which drug has better renoprotective effect. 65 healthy controls were examined, as well as 69 patients with the newly-diagnosed EH, without signs of the target organ damage. Duplex Doppler US of interlobar intrarenal arteries was performed, and RI, acceleration index (AI) and acceleration time (AT) measured. Antihypertensive monotherapy was performed with vaslartane in 34 patients and with niphedipine in 35 patients. Doppler was repeated after the six-months therapy. RI in patients with the 1. stage of EH is significantly higher compared to the controls (p<0.001), and significantly lower compared to the stage 2. of EH (p<0.001). The significant decrease of systolic (p<0.001) and dyastolic blood pressure (BP) (p<0.001) was noted after the therapy. RI in healthy examinees (RI=0.59±0.023) is significantly lower than in EH (RI=0.66±0.26) (p<0.001), while AI is significantly higher (p<0.001), and AT is significantly lower (p<0.001). In patients treated with valsartane and those treated with niphedipine, the RIs are significantly lower than before (p<0.001), while AIs were significantly higher, and ATs were significantly lower after the therapy after the therapy with both drugs. RIs in patients treated with valsartane (RI = 0.615 ± 0.036) are significantly lower than RIs of patients treated with niphedipine (RI=0.642±0.030) (p<0.01) after therapy. Regression analysis for the predictive values of RI, AT, AI in relation to the age-standardized values of systolic and diastolic BP of healthy examinees and patients with hypertension has demonstrated that RI is the strongest and statistically significant predictor in all groups of examinees. Six-months monotherapy of EH with valsartane or with niphedipine is equally efficient in the decrease of the blood pressure, but valsartane has more favourable effect on kidney. Resistance index measured in intrarenal arteries is the best parameter of Doppler spectrum in the evaluation of the effects of antihypertensive therapy on the kidney

Influence of ATII Blockers and Calcium Channel Blockers on Renal Vascular Resistance in Patients with Essential Hypertension

Doppler can evaluate renal vascular resistance, and resistance index (RI) highly correlates with blood pressure and renal function in various pathological conditions. Purpose of the study was to measure and compare renal Doppler indices in patients with newly-diagnosed essential hypertension (EH) and in healthy subjects; to determine changes of Doppler indices in patients after six-months monotherapy with either the AT II blocker (valsartane) or calcium channel blocker (niphedipine); to determine which drug has better renoprotective effect. 65 healthy controls were examined, as well as 69 patients with the newly-diagnosed EH, without signs of the target organ damage. Duplex Doppler US of interlobar intrarenal arteries was performed, and RI, acceleration index (AI) and acceleration time (AT) measured. Antihypertensive monotherapy was performed with vaslartane in 34 patients and with niphedipine in 35 patients. Doppler was repeated after the six-months therapy. RI in patients with the 1. stage of EH is significantly higher compared to the controls (p<0.001), and significantly lower compared to the stage 2. of EH (p<0.001). The significant decrease of systolic (p<0.001) and dyastolic blood pressure (BP) (p<0.001) was noted after the therapy. RI in healthy examinees (RI=0.59±0.023) is significantly lower than in EH (RI=0.66±0.26) (p<0.001), while AI is significantly higher (p<0.001), and AT is significantly lower (p<0.001). In patients treated with valsartane and those treated with niphedipine, the RIs are significantly lower than before (p<0.001), while AIs were significantly higher, and ATs were significantly lower after the therapy after the therapy with both drugs. RIs in patients treated with valsartane (RI = 0.615 ± 0.036) are significantly lower than RIs of patients treated with niphedipine (RI=0.642±0.030) (p<0.01) after therapy. Regression analysis for the predictive values of RI, AT, AI in relation to the age-standardized values of systolic and diastolic BP of healthy examinees and patients with hypertension has demonstrated that RI is the strongest and statistically significant predictor in all groups of examinees. Six-months monotherapy of EH with valsartane or with niphedipine is equally efficient in the decrease of the blood pressure, but valsartane has more favourable effect on kidney. Resistance index measured in intrarenal arteries is the best parameter of Doppler spectrum in the evaluation of the effects of antihypertensive therapy on the kidney

Wellensov sindrom u bolesnice primljene u hitnu službu nakon prestanka bolova u prsištu uzrokovanih tjelesnom aktivnošću

Wellens’ syndrome, also known as the left anterior descending (LAD) coronary T wave syndrome, is a potentially under-recognized syndrome in emergency room, which can have potentially fatal consequences. It usually consists of typical electrocardiography (ECG) finding in precordial leads that represents significant stenosis of the proximal LAD. Although the syndrome is not included in indications for primary percutaneous coronary intervention (patients with typical ECG findings are usually pain free at the time of recording), every patient with suspicion of typical Wellens’ syndrome should be seen by interventional cardiologist and considered for emergency cardiac catheterization. A case is reported of a patient with no previous medical history of coronary disease and with only one risk factor for cardiovascular disease that presented to emergency room with typical Wellens’ syndrome.Wellensov sindrom, također poznat kao sindrom T vala lijeve prednje silazne koronarne arterije (LAD), je sindrom koji može promaknuti kao neprepoznat u hitnoj službi, a može imati kobne posljedice. Obično se sastoji od znakovitog elektrokardiografskog (EKG) nalaza u prekordijalnim elektrodama, koji predstavlja značajnu stenozu proksimalne LAD. Iako ovaj sindrom nije uključen u indikacije za primarnu perkutanu koronarnu intervenciju (bolesnici s tipičnim nalazom EKG obično nemaju bolove u vrijeme snimanja), svakog bolesnika sa sumnjom na Wellensov sindrom trebalo bi uputiti intervencijskom kardiologu i razmotriti potrebu hitne kateterizacije srca. Opisuje se bolesnica bez prethodne anamneze koronarne bolesti i sa samo jednim rizičnim čimbenikom za kardiovaskularnu bolest, koja je primljena u hitnu službu s tipičnim Wellensovim sindromom

Wellensov sindrom u bolesnice primljene u hitnu službu nakon prestanka bolova u prsištu uzrokovanih tjelesnom aktivnošću

Wellens’ syndrome, also known as the left anterior descending (LAD) coronary T wave syndrome, is a potentially under-recognized syndrome in emergency room, which can have potentially fatal consequences. It usually consists of typical electrocardiography (ECG) finding in precordial leads that represents significant stenosis of the proximal LAD. Although the syndrome is not included in indications for primary percutaneous coronary intervention (patients with typical ECG findings are usually pain free at the time of recording), every patient with suspicion of typical Wellens’ syndrome should be seen by interventional cardiologist and considered for emergency cardiac catheterization. A case is reported of a patient with no previous medical history of coronary disease and with only one risk factor for cardiovascular disease that presented to emergency room with typical Wellens’ syndrome.Wellensov sindrom, također poznat kao sindrom T vala lijeve prednje silazne koronarne arterije (LAD), je sindrom koji može promaknuti kao neprepoznat u hitnoj službi, a može imati kobne posljedice. Obično se sastoji od znakovitog elektrokardiografskog (EKG) nalaza u prekordijalnim elektrodama, koji predstavlja značajnu stenozu proksimalne LAD. Iako ovaj sindrom nije uključen u indikacije za primarnu perkutanu koronarnu intervenciju (bolesnici s tipičnim nalazom EKG obično nemaju bolove u vrijeme snimanja), svakog bolesnika sa sumnjom na Wellensov sindrom trebalo bi uputiti intervencijskom kardiologu i razmotriti potrebu hitne kateterizacije srca. Opisuje se bolesnica bez prethodne anamneze koronarne bolesti i sa samo jednim rizičnim čimbenikom za kardiovaskularnu bolest, koja je primljena u hitnu službu s tipičnim Wellensovim sindromom

Echocardiographic Assessment of Revascularization Completeness Impact on Diastolic Dysfunction in Ischemic Heart Disease

Diastolic dysfunction indicates a functional abnormality of diastolic relaxation, filling, or distensibility of the left ventricle (LV), regardless of whether the LVEF is normal or abnormal. Diastolic dysfunction is practically always pro- gressive and connected with higher morbidity and mortality rates, and, if not treated may lead to a diastolic heart fail- ure. The golden standard for evaluation of diastolic function is echocardiography. One of the most important causes of diastolic dysfunction is ischemic heart disease. The revascularization of chronic myocardial ischemia can be partial (in- complete) or complete. Previous data have shown that the completeness of revascularization could have influence on clin- ical outcomes. The aim of this study was to asses, by means of echocardiography, the impact of completeness of revascula- rization on diastolic dysfunction in ischemic heart disease. This study included 65 consecutive patients with previously recognized diastolic dysfunction that met criteria for PCI revascularization. Two groups of patients were identified; one with complete revascularization achieved and another one with incomplete one. There were no statistical differences be- tween two groups considering gender, age, arterial hypertension, hyperlipoproteinaemia, previous CABG and left ventricle systolic function. In the incomplete revascularization group, the proportion of patients that had diabetes mellitus, previ- ous myocardial infarction and previous PCI procedure were statistically higher (p<0.05). The diastolic function recovery was statistically significant in both groups (p<0.001), and there was no statistically significant difference in recovery be- tween the two groups. Lack of recovery was registered in 18.2% patients with incomplete revascularization achieved, and 15.6% in the complete group, which was not significant, but shows a trend. The causes of somewhat worse recovery in the incomplete revascularization group could be attributed to the higher proportion of diabetics, to the somewhat older popu- lation and ultimately to the incomplete revascularization. The E/A ratio on diastolic transmitral flow as well as the E/E lat ratio on tissue doppler were found as the best echocardiographic parameters in diastolic function evaluation. In fol- low up recovery after complete or incomplete revascularization the tissue doppler (E/E lat) was recognized as the best parameter. In conclusion, we found that echocardiographic assessment of diastolic function recovery was a safe method, and our results showed that even in incomplete revascularization group of patients the recovery of diastolic function could be as good as in the complete one, if the indication for revascularization was correct

Secondary mitral regurgitation – when surgery "may be considered"

Introduction: Secondary mitral regurgitation (MR) is a dynamic myocardial disease accompanying cardiomyopathy and coronary artery disease.1-4 Case report: We present a case of 63-year-old patient with long standing cardiomyopathy after breast cancer chemotherapy. Her left ventricle (LV) is slightly dilated with moderately impaired systolic function (estimated EF 30%) and severe diastolic disfunction. Significant MR (Figure 1, Figure 2) has been present for years but patient’s condition deteriorated rapidly with frequent admissions for heart failure despite optimal medical therapy. Upon last discharge echocardiography showed slight improvement in LV systolic function and persistent severe secondary MR. She has no significant coronary artery disease or indication for CRT. Discussion and Conclusion: Severe secondary MR is in most cases treated conservatively, especially in the absence of other surgical indication. According to guidelines mitral valve intervention (surgery or transcatheter procedure) may be considered in refractory cases after heart team discussion. Our patient was subsequently scheduled for mitral valve replacement

Elektromagnetsko polje na frekvenciji mobilnih telefona (900 MHz) izaziva stres i modifikacije DNA u gujavici Eisenia fetida

Eisenia fetida earthworms were exposed to electromagnetic field (EMF) at a mobile phone frequency (900 MHz) and at field levels ranging from 10 to 120 V m-1 for a period of two hours (corresponding to specific absorption rates ranging from 0.13 to 9.33 mW kg-1). Potential effects of longer exposure (four hours), field modulation, and a recovery period of 24 h after two hours of exposure were addressed at the field level of 23 V m-1. All exposure treatments induced significant DNA modifications as assessed by a quantitative random amplified polymorphic DNA-PCR. Even after 24 h of recovery following a two hour-exposure, the number of probe hybridisation sites displayed a significant two-fold decrease as compared to untreated control earthworms, implying a loss of hybridisation sites and a persistent genotoxic effect of EMF. Expression of genes involved in the response to general stress (HSP70 encoding the 70 kDa heat shock protein, and MEKK1 involved in signal transduction), oxidative stress (CAT, encoding catalase), and chemical and immune defence (LYS, encoding lysenin, and MYD, encoding a myeloid differentiation factor) were up-regulated after exposure to 10 and modulated 23 V m-1 field levels. Western blots showing an increased quantity of HSP70 and MTCO1 proteins confirmed this stress response. HSP70 and LYS genes were up-regulated after 24 h of recovery following a two hour-exposure, meaning that the effect of EMF exposure lasted for hours.U ovom istraživanju gujavice vrste Eisenia fetida bile su izložene elektromagnetskom polju (EMP) na frekvenciji mobilnih telefona (900 MHz) te poljima jačine 10 do 120 V m-1 u dvosatnom razdoblju (što odgovara specifičnim ratama apsorpcije od 0,13 do 9,33 mW kg-1). Utjecaj dužeg izlaganja (4 sata), modulacije polja te vrijeme oporavka od 24 sata nakon dva sata izlaganja proučavan je pri jačini polja od 23 V m-1. Metoda kvantitativne nasumično umnožene polimorfne DNA (engl. quantitative random amplified polymorphic DNA – qRAPD) otkrila je značajne modifikacije DNA na svim proučavanim tretmanima. Čak i nakon 24-satnog oporavka broj hibridizacijskih mjesta bio je dvostruko manji u odnosu na broj zabilježen u kontrolnim gujavicama, što upozorava na gubitak hibridizacijskih mjesta i na dugoročan utjecaj EMP-a. Ekspresija gena uključenih u odgovor na stres (HSP70: kodira za 70kDa heat shock protein i MEKK1: uključen u provođenje signala), oksidacijski stres (CAT: kodira za katalazu) te kemijsku i imunosnu obranu (LYS: kodira za lysenin i MYD: kodira za faktor mijeloidne diferencijacije) bila je povišena nakon izlaganja polju jačine 10 V m-1 te moduliranome polju jačine 23 V m-1. Western blot analiza potvrdila je odgovor na stres detekcijom povišene količine HSP70 i MTCO1 proteina. HSP70 i LYS geni imali su povišenu ekspresiju i nakon razdoblja oporavka, što upućuje na dugotrajan utjecaj EMP-a