Patient with Dyspnea

Dispneja ili zaduha subjektivni je osjećaj nedostatka zraka u čijem nastanku sudjeluje više čimbenika. Aktivacija receptora gornjih i donjih dišnih putova, parenhima pluća i torakalne stijenke snažno podražuje centar za disanje u središnjemu živčanom sustavu koji putem kompleksnih neuromuskularnih mehanizama pridonosi stvaranju osjećaja zaduhe. Dispneja je jedan od najčešćih simptoma bolesti čija etiologija i diferencijalna dijagnoza obuhvaćaju brojna klinička stanja od blagih, kratkotrajnih bolesti pa sve do akutnih, hitnih stanja opasnih za život. Klinička procjena bolesnika s dispnejom najčešće se temelji na dobro uzetoj anamnezi i statusu bolesnika koje je potrebno nadopuniti uobičajenim laboratorijskim i slikovnim nalazima. U svakodnevnom radu, posebno u jedinicama hitne medicinske pomoći i ordinacijama liječnika obiteljske medicine, razlučivanje respiratorne od srčane dispneje najčešće je klinički problem koji definira i usmjerava daljnju strategiju liječenja dispnoičnih bolesnika.Dyspnea is a subjective feeling of a shortness of breath, which is a result of several factors. The activation of upper and lower airways receptors, lung parenchyma and the thoracic wall strongly stimulate the breathing centre in the central nervous system, which creates the feeling of the shortness of breath through complex neuromuscular mechanisms. Dyspnea is one of the most frequent symptoms of the disease whose etiology and differential diagnosis encompass many clinical conditions, ranging from mild and short illness to acute, life-threatening emergency conditions. The clinical assessment of the patient with dyspnea is usually based on thorough case history and patient’s status, which should be supplemented with usual lab results and images. In practice, particularly in ER units and GP’s offices, the differentiation from heart dyspnea usually poses a clinical problem which defines and directs the strategy of treating patients with dyspnea

Antiaggregation therapy and dental procedures in primary healthcare

Široka uporaba intravaskularnih koronarnih stentova višestruko je povećala broj bolesnika na antiagregacijskoj terapiji acetilsalicilnom kiselinom i klopidogrelom. Uzimajući u obzir povišen rizik krvarenja kod ovih bolesnika raste i (ponekad pretjerana) zabrinutost prilikom planiranja manjih kirurških, pa tako i stomatoloških zahvata. Ista je rezultirala povremenim preuranjenim isključivanjem spomenute terapije što može, mada rijetko, imati i katastrofalne tromboembolijske komplikacije. Cilj ovog članka je iznijeti aktualne preporuke za postupak s bolesnicima na antiagregacijskoj terapiji kod kojih se planiraju stomatološki zahvati u sustavu primarne zdravstvene zaštite.Extensive use of intravascular coronary stents has multiply increased a number of patients receiving antiaggregation therapy with aspirin and clopidogrel. Taking into account an increased risk of bleeding, there is an increasing (sometimes excessive) concern of minor surgical and dental procedures in these patients. This has resulted in occasional premature exclusion of the above therapy, which can, albeit rarely, lead to catastrophic thromboembolic complications. The aim of this article is to present the current recommendations for the management of patients receiving antiaggregation therapy where dental procedures in primary healthcare system are planned

COVID-19 and Coronary Heart Disease – Strategies in Interventional Cardiology

Kardiovaskularne bolesti (KVB), uključujući i koronarnu bolest srca (KBS), i dalje su vodeći uzrok smrti u Republici Hrvatskoj. Uz pravovremeno dijagnosticiranje bolesti, suvremene lijekove i organizirane sustave liječenja poput mreže primarne perkutane koronarne intervencije za bolesnike s akutnim infarktom miokarda (AIM), smrtnost od KVB-a je u padu. U ovom preglednom članku korištena je baza podataka PubMed i najnovija literatura o povezanosti novoga koronavirusa SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) i KVB-a. Navedeni virus, uzročnik koronavirusne bolesti 2019 (engl. coronavirus disease 2019 – COVID-19) postavio je nove izazove u liječenju KBS-a iz više razloga. COVID-19 je bolest koja najviše zahvaća starije ljude s komorbiditetima kao što su arterijska hipertenzija, dijabetes, debljina i KVB. Primarno zahvaća respiratorni sustav, ali može uzrokovati i kardiovaskularne komplikacije poput lezije/infarkta miokarda, miokarditisa, šoka, aritmija i smrti. Dijagnostika i liječenje bolesnika s AIM-om tijekom epidemije može biti otežana zbog protuepidemijskih mjera koje se provode s ciljem zaustavljanja transmisije na bolesnike i medicinsko osoblje. U preporukama Europskoga kardiološkog društva naglašava se pridržavanje dosadašnjih smjernica za liječenje AIM-a s ciljem što ranije i uspješne reperfuzije, ali uz obavezno korištenje osobne zaštite opreme i maske za bolesnika. Na morbiditet i mortalitet koronarnih bolesnika može utjecati strah od bolnica dovodeći do produženja vremena od početka simptoma do prvoga medicinskoga kontakta. Za vrijeme epidemije važno je educirati bolesnike i omogućiti im izravni kontakt i komunikaciju s liječnikom/kardiologom s ciljem korekcije terapije, poticanja na zdrav način života te prepoznavanja alarmirajućih simptoma.Cardiovascular diseases (CVDs), including coronary heart disease (CHD), are still the leading causes of death in the Republic of Croatia. With timely diagnosis, modern medication, and organized systems such as a network of primary percutaneous coronary intervention (PPCI) for patients with acute myocardial infarction (AMI), mortality from CVD is declining. The PubMed database and latest studies on the correlation of the new coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) and CVD were used in this review article. This virus, the cause of coronavirus disease 2019 (COVID-19), posed a new challenge in the treatment of CHD for several reasons. COVID-19 is a disease that mainly affects the elderly with comorbidities such as arterial hypertension, diabetes, obesity, and CVD. The respiratory system is primarily affected, but cardiovascular complications may develop, such as myocardial lesions/infarction, myocarditis, shock, arrhythmias and death. Diagnosis and treatment of patients with AIM during the epidemic may be delayed due to anti-epidemic measures to stop transmission to patients and medical staff. The recommendations of the European Society of Cardiology emphasize adherence to current guidelines for the treatment of AIM, including PPCI as an optimal reperfusion strategy as early as possible, but with obligatory use of personal protection equipment and masks for patients. The morbidity and mortality of coronary patients may be most affected by the patient’s fear of hospitals, leading to a prolongation of the time from the onset of symptoms to the first medical contact. During an epidemic, it is important to educate patients, enable them direct contact and communication with a primary physician/cardiologist to prescribe amendments to their therapy, encourage a healthy lifestyle, and identify alarming symptoms as early as possible

Uromodulin - poveznica između natriurije i dnevnog ritma arterijskog tlaka kod predhipertoničara

Although changes in dietary sodium intake alter blood pressure (BP) in salt-sensitive individuals, pathophysiological mechanisms are still unknown. It has been reported that uromodulin is involved in sodium tubular transport, and genome-wide association studies pointed to UMOD gene as one of the most important gene candidates for arterial hypertension. Our aim was to analyze urinary uromodulin, salt intake and BP in 326 young middle-aged subjects (mean age 36±8 years, 49.4% male). In a subgroup of 175 individuals, ambulatory blood pressure monitoring and echocardiogram were performed. Uromodulin was determined by ELISA. According to the JNC-7 criteria, subjects were classified as optimal BP (n=103, men 72%), prehypertension (PHT) (n=143, men 43%) and hypertension (HT) (n= 80, men 38%). There were no differences in age, salt intake, estimated glomerular filtration rate, sodium excretion and uromodulin among BP groups. However, in PHT subjects, uromodulin was positively associated with fractional sodium excretion and negatively with 24-h sodium excretion and diastolic BP dip. These findings point to the effect of uromodulin on sodium reabsorption along the nephron and consequently circadian BP alteration in prehypertensives.Promjene u dnevnom unosu kuhinjske soli u osoba osjetljivih na sol utječu na arterijski tlak (AT), ali točan patofiziološki mehanizam još nije u potpunosti razjašnjen. Cilj ove studije je bio istražiti izlučivanje uromodulina (UM) i natrija mokraćom i povezanost s AT u mlađih odraslih osoba. U 326 ispitanika (medijan dobi 36, IQR 18-48, 64,6% muškarci) analizirani su uzorci krvi i mokraće uzeti natašte i izmjeren je AT u ordinaciji, a kod 175 ispitanika učinjeno je kontinuirano mjerenje arterijskoga tlaka. UM je određen metodom ELISA. Prema klasifikaciji JNC-7 optimalni AT, predhipertenzija (PHT) i hipertenzija (HT) su dijagnosticirani u 103 (72% m), 143 (43% m) i 80 (38% m) ispitanika. Nije bilo razlike u dobi, unosu kuhinjske soli, procijenjenoj stopi glomerularne filtracije niti u izlučivanju natrija i UM mokraćom između kategorija AT. Uočena je pozitivna povezanost UM s frakcijskom ekskrecijom natrija, a negativna s 24-satnom natriurijom i noćnim sniženjem dijastoličkoga AT u PHT. Ovi rezultati upućuju na povezanost UM s tubularnom reapsorpcijom natrija i promjenama dnevnoga ritma AT u predhipertoničara

Transkatetersko zatvaranje otvorenog foramena ovale i radiofrekventna ablacija atrijske tahikardije iz desnog atrija

Patent foramen ovale (PFO ) can be found in approximately 25% of adult population. Transcatheter closure of PFO is a potential option in selected patients with PFO . We report a case of a female patient that underwent mapping and catheter ablation of atrial tachycardia and PFO closure in the same procedure.Otvoreni foramen ovale (PFO ) može se naći u gotovo 25% populacije. Katetersko zatvaranje PFO je terapijska opcija u određenog broja bolesnika. Prikazujemo slučaj bolesnice kojoj je u istom aktu učinjeno mapiranje i ablacija atrijske tahikardije te zatvaranje PFO -

Metabolični sindrom i ishod u bolesnika s akutnim infarktom miokarda

The impact of the metabolic syndrome/insulin resistance syndrome (MS/IR S) on the severity and prognosis of acute ST elevation myocardial infarction (STEMI ) treated with primary percutaneous coronary intervention (PCI) was assessed using the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) definition from 2003. A total of 385 patients having suffered acute STEMI and treated with primary PCI over a two-year period were divided into two groups (with and without MS/IR S) and compared according to the parameters of severity (clinical, laboratory, echocardiography, coronary angiography parameters and complications) and prognosis using major adverse cardiovascular events (MACE) during the six-month follow-up of acute STEMI . In comparison with control group, the MS/IR S group of patients had worse or similar results of almost all study parameters of severity (hospital days 6.5 vs. 6.5, cardiogenic shock 2.9% vs. 2.6%, cardiac arrest 6.8% vs. 5.2%, reinfarction 0.5 vs. 1.6%) and prognosis (total MACE 30.7 vs. 30.7%), however, none of the differences reached statistical significance. It is concluded that the unexpected lack of such differences in MS/IR S could be due to the absence of waist-to-hip ratio in the definition and other open questions in metabolic syndrome in general.Istraživao se utjecaj metaboličnog sindroma/sindroma inzulinske rezistencije (MS/SIR ) koristeći definiciju American Association of Clinical Endocrinologists i American College of Endocrinology (AACE/ACE) iz 2003. na težinu i prognozu akutnog infarkta miokarda s elevacijom ST spojnice (STEMI ) liječenog primarnom perkutanom intervencijom (pPCI). Ukupno 395 bolesnika koji su preboljeli akutni STEMI i bili liječeni pomoću pPCI u dvogodišnjem razdoblju podijeljeno je u dvije skupine (s MS/SIR i bez njih) i uspoređeno prema parametrima težine (klinički, laboratorijski, ehokardiografski, koronarografski, komplikacije) i prognoze koristeći velike neželjene kardiovaskularne događaje (MACE) tijekom šestomjesečnog praćenja akutnog STEMI . Skupina bolesnika s MS/SIR u usporedbi s kontrolnom skupinom imala je uglavnom lošije ili jednake rezultate težine (dani u bolnici 6,5:6,5, kardiogeni šok 2,9%:2,6%, srčani zastoj 6,8%:5,2%, reinfarkt 0,5%:1,6%) i prognoze (ukupno MACE 30,7%:30,7%), no niti jedna od razlika nije dosegla statističku značajnost. Zaključuje se kako bi izostanak takvih očekivanih razlika u MS/SIR mogao biti posljedica isključenja omjera struka i kukova iz ove definicije i ostalih otvorenih pitanja u metaboličnom sindromu uopće

Postavljanje elektrode u lijevu klijetku za stimulaciju tijekom ugradnje kardioverter defibrilatora kod bolesnice s aritmogenom displazijom desne klijetke

We present a case of a 64-year-old female patient scheduled for implantable cardioverter defibrillator (ICD) implantation due to arrhythmogenic right ventricular cardiomyopathy (ARVC). Dual coil, active fixation ICD lead was introduced through the axillary vein. More than 20 positions were changed in the right ventricle (RV) (outflow tract, high, mid and apical septum, inferobasal, apical and lateral wall). Maximum R wave amplitude was 2 mV with pacing threshold of 0.5 V. Since the sensing was inappropriate, we decided to place the pace/sense lead of the ICD in the coronary sinus. The lead was placed in the basal part of the lateral vein. The pacing threshold was 1.0 V/0.40 ms and R wave was 9 mV. The lead was connected to the ICD sense-pace port and high voltage coils were connected in the usual way. The RV sense-pace lead was capped off. The device sensed an R wave of 7.0 mV 48 hours later. The purpose of this report is to show a possible solution of sensing problems during an ICD implantation in a patient with ARVC.Prikazujemo slučaj bolesnice s aritmogenom displazijom desne klijetke (ARVC) previđene za ugradnju kardioverter defibrilatora (ICD). Defibrilatorska elektroda s aktivnom fiksacijom postavljena je desnim aksilarnim pristupom. Adekvatni parametri stimulacije nisu se mogli postići na više od 20 pozicija u desnoj klijetki (izlazni trakt, bazalni, srednji i apikalni septum, inferobazalno, apikalno i na slobodnom zidu). Maksimalna amplitura R vala bila je 2 mV i prag stimulacije 0,5V. S obzirom na to da parametri nisu bili adekvatni odlučili smo se za postavljanje dodatne elektrode u bazalni segment lateralne grane koronarnog sinusa za sensing i stimulaciju. Amplituda R vala bila je 9 mV, a prag stimulacije 1 V. Cilj ovog prikaza slučaja je opisati potencijalna rješenja problema sa sensingom i stimulacijom tijekom ugradnje ICD-a kod bolesnika s aritmogenom displazijom desne klijetke