Editorial

Редакционен коментар Editoria

A case of acute infective endocarditis and septic shock

Инфекциозният ендокардит (ИЕ) бележи нарастваща заболяемост и непроменяща се смъртност въпреки напредъка в диагностиката и лечението му. При около 20% от случаите ИЕ протича остро, с признаци на сепсис и септичен шок, който влошава драматично прогнозата и е независим предиктор за вътреболнична смърт. Навременното диагностициране и спешната хирургична интервенция могат да подобрят преживяемостта при тези пациенти. Представяме случай на 47-годишен мъж, без анамнеза за минали или съпътстващи заболявания, постъпил по спешност в Интензивно кардиологично отделение, по време на COVID-19 пандемията, с изразен фебрилно-интоксикационен синдром, задух, прекордиален дискомфорт и болка, кашлица, хемоптое. От лабораторните изследвания има данни за изразена възпалителна констелация, също така увеличени тропонин I и D-димери. Този случай показва трудностите в диагностиката на острия ИЕ, спецификите в клиничния ход на болестта, както и значението на спешната хирургична интервенция за подобряване на преживяемостта. Infective endocarditis (IE) marks an increasing morbidity and unchanged mortality despite advances in its diagnosis and treatment. In about 20% of IE cases are acute, with signs of sepsis and septic shock. Septic shock dramatically worsens prognosis and is an independent predictor of in – hospital death. Timely diagnosis and urgent surgical intervention can improve survival in these patients. We present a case of a 47-year-old man, with no history of past or concomitant diseases, who was admitted as an emergency to the Cardiology Intensive Care Unit, during the COVID-19 pandemic, with pronounced febrile-intoxication syndrome, shortness of breath, precordial discomfort and pain, cough, haemoptysis. From laboratory studies with a pronounced infl ammatory constellation, troponin I and D-dimers are also increased. This case shows the diffi culties in the diagnosis of acute IE, the specifi cs in the clinical course of the disease, as well as the importance of urgent surgical intervention to improve survival

Hypertension in pregnancy as an early sex-specific risk factor for cardiovascular diseases: evidence and awareness

Despite being a physiological condition, human pregnancy is known to cause numerous complications that can endanger the life of the mother and the fetus alike. While the majority of complications are mostly limited within the peripartum period, more and more information is available about persistently higher short- and long-term cardiovascular risk after a pregnancy complicated by a hypertensive disorder. There is evidence that women after gestational hypertension or preeclampsia are more likely to develop arterial hypertension, coronary atherosclerosis, myocardial infarction, stroke, peripheral artery disease, and even diabetes mellitus and venous thromboembolism years after the target pregnancy. This has urged some authors to view hypertensive disorders of pregnancy as a “stress test” for the maternal organism that unmasks latent endothelial dysfunction. An explanation is sought in the presence of common risk factors and underlying pathological pathways with cardiovascular diseases, although a certain etiological mechanism for the development of hypertensive disorders in pregnancy has not been established yet. More attention is needed towards the follow-up of women after a hypertensive pregnancy as it could be an opportunity for early prevention of cardiovascular diseases

High-sensitivity CRP levels in women with gestational hypertension, preeclampsia and in normotensive pregnant women and its correlations

Introduction: Gestational hypertension is a less investigated hypertensive disorder of pregnancy than preeclampsia, but evidence exists of an unfavourable cardiovascular profile for women after such a pregnancy.Aim: To determine serum high-sensitivity C-reactive protein (hs-CRP) levels in women with preeclampsia, gestational hypertension, and in normotensive pregnancy in order to assess the cardiovascular implications and to examine its correlations with some characteristics of women.Materials and methods: Thirty-six women with gestational hypertension, thirty-seven with preeclampsia, and fifty maternal and gestational age-matched controls were included in a single-center prospective clinical-epidemiological study. Serum hs-CRP levels were determined using ELISA method.Results: Significantly higher hs-CRP levels were found in the gestational hypertension group than in the controls (p=0.043), but not in the preeclampsia group (p=0.445). The levels between the two pathological groups did not differ significantly (p=0.247). Odds ratio for hs-CRP levels higher than the provided cut-off was 3.31 (95% CI 1.32–8.29) for the presence of gestational hypertension. In the normotensive pregnant women, the hs-CRP levels had a positive correlation with BSA, pre-pregnancy and current BMI, but such correlations were absent in the hypertensive groups. There were no correlations with the maternal or gestational age, current weight gain in any of the groups or with the highest detected blood pressure in the pathological groups. These levels did not differ according to gravidity, smoking status and smoking during pregnancy.Conclusions: Elevation of hs-CRP was more pronounced in women with gestational hypertension than in women with preeclampsia, which could indicate a different pathophysiological mechanism and a higher cardiovascular risk for those women

Characteristics of infective endocarditis according to the mode of acquisition – a single-center, retrospective analysis

Според начина на придобиване инфекциозният ендокардит (ИЕ) се класифицира като обществено придобит – CAIE (Community acquired IE), свързан със здравни грижи – HAIE (Health care–associated infective endocarditis) и ИЕ, резултат на интравенозна наркомания – IDUIE (intravenous drug use–related IE). На този етап липсват данни за България за тези три групи пациенти. Цел: Поставихме си за цел да изследваме ИЕ според начина на придобиване и да направим клинико-инструментална характеристика на групите. Материал и методи: Проучването е едноцентрово, ретроспективно и включва 270 пациенти, лекувани в УМБАЛ “Св. Георги“ – Пловдив, за периода 01.2005-12.2021 г. Резултати: Пациенти със CAIE са 64.8% (175), с HAIE 26,7% (72) и с IDUIE 8,5% (23). Пациентите с IDUIE са по-млади спрямо останалите две групи – 33 (8) г. (р = 0.000), с ниска коморбидност (CCI – 1, IQR 1; p = 0.000), с най-често десностранно засягане (p < 0.001), с често усложнение септичен шок – 21.7% (р = 0.017) и с най-чест причинител Staphylococcus aureus (р < 0.01). Пациентите с HAIE са най-възрастни (69; 18 г.), с най-голяма коморбидност (CCI 4, IQR 3), без сигнификантна разлика със CAIE (66; 20 г. и CCI 3 IQR 3). Големият дял входна врата при тях са манипулации/процедури (62.5%) и хемодиализа (18.1%), с най-чест причинител Enterococci (19.5%, р = 0.001). CAIE се причинява най-често от Staphylococci (29.6%) и Streptococci (12%). Вътреболничната смъртност и ранната хирургична интервенция са без сигнификантна разлика в трите групи. Заключение: Познаването на трите групи ИЕ според начина на придобиване – CAIE, HAIE и IDUIE, и техните характеристики, е важно за избора на начално емпирично антибиотично лечение и подобряване на превенцията. According to the mode of acquisition, infective endocarditis (IE) is classifi ed as community-acquired (CAIE), healthcareassociated (HAIE), and injection drug use–related IE (IDUIE). At this stage, there are no data for Bulgaria for these three groups of patients. Objective: We set ourselves the goal of investigating IE according to the mode of acquisition and to make a clinical-instrumental characterization of the groups. Material and methods: The study is single-center, retrospective and includes 270 patients treated at the UMHAT “Sveti Georgi” – Plovdiv for the period 01.2005-12. 2021. Results: Patients with CAIE were 64.8% (175), with HAIE 26.7% (72) and with IDUIE 8.5% (23). Patients with IDUIE are younger compared to the other two groups (33; 8 years) (p = 0.000), with low comorbidity (CCI – 1, IQR – 1; p = 0.000), with most frequent right-sided involvement (p < 0.001) and with the most common causative agent being Staphylococcus aureus (p < 0.01). Patients with HAIE were the oldest (69; 18 years;), with the most comorbidity (CCI – 4; IQR – 3), with no signifi cant difference with CAIE (66; 20 years; and CCI – 3; IQR – 3). The large proportion of portal of entry for them were manipulations/ procedures (62.5%) and hemodialysis (18.1%), with Enterococci being the most common causative agent (19.5%, p = 0.001). In-hospital mortality and early surgical intervention were without signifi cant difference in the three groups. Conclusion: Knowledge of the three groups of IE according to the mode of acquisition – CAIE, HAIE and IDUIE and their characteristics is important for the choice of initial empiric antibiotic treatment and for improvement of prevention

High-sensitivity CRP levels in women with gestational hypertension, preeclampsia and in normotensive pregnant women and its correlations

Introduction: Gestational hypertension is a less investigated hypertensive disorder of pregnancy than preeclampsia, but evidence exists of an unfavourable cardiovascular profile for women after such a pregnancy.Aim: To determine serum high-sensitivity C-reactive protein (hs-CRP) levels in women with preeclampsia, gestational hypertension, and in normotensive pregnancy in order to assess the cardiovascular implications and to examine its correlations with some characteristics of women.Materials and methods: Thirty-six women with gestational hypertension, thirty-seven with preeclampsia, and fifty maternal and gestational age-matched controls were included in a single-center prospective clinical-epidemiological study. Serum hs-CRP levels were determined using ELISA method.Results: Significantly higher hs-CRP levels were found in the gestational hypertension group than in the controls (p=0.043), but not in the preeclampsia group (p=0.445). The levels between the two pathological groups did not differ significantly (p=0.247). Odds ratio for hs-CRP levels higher than the provided cut-off was 3.31 (95% CI 1.32–8.29) for the presence of gestational hypertension. In the normotensive pregnant women, the hs-CRP levels had a positive correlation with BSA, pre-pregnancy and current BMI, but such correlations were absent in the hypertensive groups. There were no correlations with the maternal or gestational age, current weight gain in any of the groups or with the highest detected blood pressure in the pathological groups. These levels did not differ according to gravidity, smoking status and smoking during pregnancy.Conclusions: Elevation of hs-CRP was more pronounced in women with gestational hypertension than in women with preeclampsia, which could indicate a different pathophysiological mechanism and a higher cardiovascular risk for those women

Acute neurological symptoms as a debut of infective endocarditis

Инфекциозният ендокардит (ИЕ) е възпалително заболяване на ендокарда на сърцето, засягащо сърдечните клапи (нативни или протезни), а в последните няколко десетилетия и налични вътресърдечни постоянни устройства или катетри. Въпреки технологичния прогрес и натрупания опит, тази болест не спира да бъде огромно предизвикателство за лекарите по отношение на диагностика, лечение и подобряване на преживяемостта. Клиничната картина е нетипична и разнородна, с различни клинични „маски“ на други заболявания – инфекциозни, онкологични, хематологични, ревматологични, неврологични и др. Емболичните усложнения често са първа изява на болестта, като най-често са мозъчни. Представяме клиничен случай на 29 г. жена, с остра неврологична симптоматика като първа проява на ИЕ. Този случай отразява нетипичната клинична презентация на заболяването, значението на новите образни модалности в прецизната диагностика на неврологичнте усложнения, както и решението за времето на оперативната интервенция, когато е покзана. Остава отворен въпросът за профилактиката на ИЕ при умеренорисковите пациенти, каквито са тези с митрален клапен пролапс и бикуспидна аортна клапа. Infective endocarditis (IE) is an infl ammatory disease of the endocardium of the heart affecting heart valves (native or prosthetic) and, in the last few decades, also available intracardiac permanent devices or catheters. Despite technological progress and accumulated experience, this disease continues to be a huge challenge for doctors in terms of diagnosis, treatment and improvement of survival. The clinical picture is atypical and heterogeneous, with different clinical "masks" of other diseases – infectious, oncological, hematological, rheumatological, neurological, etc. Embolic complications are often the fi rst manifestation of the disease and are most often cerebral. We present a clinical case of a 29-year-old woman with acute neurological symptoms as a fi rst manifestation of IE. This case refl ects the atypical clinical presentation of the disease, the importance of new imaging modalities for the precise diagnosis of neurological complications, and the decision on the timing of operative intervention when indicated. The question of IE prophylaxis in moderate-risk patients, such as those with mitral valve prolapse and bicuspid aortic valve, remains open