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

Pseudoopstrukcija debelog crijeva i teška hipokalemija u anurične dijabetične bolesnice liječene hemodijalizom: Prikaz bolesnice i literature

Hypokalemia is a rare condition in the end-stage renal disease patients on hemodialysis, and especially in those with no residual diuresis. If hypokalemia occurs, it is usually transient and mostly associated with gastrointestinal loss of potassium (massive diarrheal stools), or appears immediately after hemodialysis with the use of dialysis solutions with potassium concentrations lower than 2 mmol/L. The aim of this report is to present a case of a female diabetic patient on hemodialysis with permanent severe hypokalemia associated with chronic colonic pseudo-obstruction and secretory diarrhea, and to point to the possible rare causes of permanent hypokalemia in anuric patients with end-stage renal disease as well as to the causal relations of persistent hypokalemia with changes in different organ systems.Hipokalemija je vrlo rijetka u bolesnika s kroničnim bubrežnim zatajenjem koji se liječe hemodijalizom, a pogotovo u onih koji nemaju ostatnu diurezu. Ako se hipokalemija pojavi, obično je prolazna i najčešće povezana s gubitkom kalija putem probavnog sustava (obilne proljevaste stolice) ili se javlja neposredno nakon hemodijalize uz primjenu otopine za dijalizu u kojoj je koncentracija kalija manja od 2 mmol/L. Cilj ovoga rada je prikazati slučaj dijabetične bolesnice liječene hemodijalizom s trajno prisutnom teškom hipokalemijom praćenom pseudoopstruk¬cijom debelog crijeva i sekretornom dijarejom, te ukazati na moguće rijetke uzroke trajne hipokalemije u anuričnih bolesnika s kroničnim bubrežnim zatajenjem i na uzročno-posljedične veze dugotrajne hipokalemije s promjenama na različitim organskim sustavima

Elektrofiziološki utjecaj, učinkovitost i sigurnost intravenskog propafenona u okončanju atrioventrikulske nodalne tahikardije ponovnog ulaza i atrioventrikulske tahikardije ponovnog ulaza: Prospektivna nerandomizirana intervencijska studija

The aim of this prospective, non-randomized interventional study was to assess electrophysiological effects, efficacy and safety of intravenous propafenone in termination of atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic atrioventricular reentrant tachycardia (AVRT). This single-center study was carried out at Department of Cardiology, Sestre milosrdnice University Hospital in Zagreb, Croatia, between January 1, 2005 and December 31, 2006. Eligibility requirements were fulfilled by a total of 70 patients with AVNRT (n=37) and AVRT (n=33). The intervention consisted of the electrophysiological study aimed at inducing tachycardia, followed by intravenous administration of 2 mg/kg propafenone in both groups. The main outcome measures were safety and efficacy of 2 mg/kg intravenous propafenone in tachycardia termination and re-induction. Out of 37 patients with AVNRT, propafenone managed to terminate it in 28 (75.7%) patients, while tachycardia was not inducible in 25 (67.56%) patients. Out of 33patients with AVRT, propafenone managed to terminate AVRT in 29 (87.9%) patients, while tachycardia was not inducible in 22 (66.66%) patients. The overall propafenone efficacy in tachycardia termination was 81.42%. No propafenone-related adverse effects were recorded during the study period. Propafenone was found to be a safe and effective anti-arrhythmic drug and can be justifiably administered for AVNRT and AVRT termination. It could be considered as an alternative to adenosine and verapamil.Cilj ove prospektivne nerandomizirane intervencijske studije bio je procijeniti elektrofiziološki utjecaj, učinkovitost i sigurnost intravenskog propafenona u okončanju atrioventrikulske nodalne tahikardije ponovnog ulaza (AVNRT) i ortodromne atrioventrikulske tahikardije ponovnog ulaza (AVRT). Ispitivanje je provedeno u jednom centru, tj. u Kliničkoj bolnici “Sestre milosrdnice” u Zagrebu, od 1. siječnja 2005. do 31. prosinca 2006. godine. Uvjete za uključenje u studiju ispunjavalo je 70 bolesnika s AVNRT (n=37) i AVRT (n=33). Intervencija se sastojala od elektrofiziološkog ispitivanja radi izazivanja tahikardije, nakon čega je slijedila intravenska primjena 2 mg/kg propafenona u objema skupinama. Glavne mjere ishoda bile su sigurnost i učinkovitost 2 mg/kg intravenskog propafenona u okončanju i ponovnom izazivanju tahikardije. Od 37 bolesnika s AVNRT propafenon ju je uspješno okončao u 28 (75,7%) bolesnika, dok tahikardiju nije bilo moguće izazvati u 25 (67,56%) bolesnika. Od 33 bolesnika s AVRT propafenon ju je uspješno okončao u 29 (87,9%) bolesnika, dok se tahikardiju nije moglo izazvati u 22 (66,66%) bolesnika. Sveukupna učinkovitost propafenona u okončanju tahikardije bila je 81,42%. Za vrijeme studije nisu zabilježeni nikakvi štetni učinci povezani s propafenonom. Zaključuje se kako je propafenon siguran i učinkovit antiaritmik koji se može opravdano davati radi okončanja AVNRT i AVRT, te se može smatrati alternativom za adenozin i verapamil

Relationship of Genetic Markers for Atherosclerosis and Long-Term Outcome after Percutaneous Coronary Intervention with Stenting

The aim of the study was to describe the relationship of clinical outcome after percutaneous coronary intervention (PCI) with stenting and genetic polymorphisms (GP) which are known to relate to the incidence of in-stent restenosis and late thrombotic complications. The study included 190 patients with standardized clinical follow-up over 5 years, which were initially treated with PCI. We investigated clinical data, angiographic characteristics, 10 polymorphisms involved in neointimal hyperplasia and late thrombosis at 6 different levels and their relationship with the major adverse cardiac events (MACE). The long term clinical outcome was defined by MACE: death, target vessel revascularization (PCI or coronary bypass grafting, CABG) and myocardial infarction. Angiotensin receptor type I (AGTR A1166C) and angiotensinogen (AGT MET235THR) GPs correlated with repeat revascularization and total MACE. Carriers of G allele for NOS3 A922G GP were shown to have a significantly lower repeat revascularization rate in comparison with the AA genotype, as did the T allele carriers in the NOS3 C690T GP analysis when compared to the CC genotype. The Asp genome carriers with the NOS3 GLU298ASP GP were also shown to have significantly less re-PCI in contrast to the Glu/Glu genotype. The study could document the protective influence of the 4G/5G GP for plasminogen inhibitor activator-1, which carried the lowest rate of re-PCI and total MACE during the follow-up. GPs for b-1 G-protein subunit GNB3 C825T, fibrinogen FGB G455A and E-selectins Ser128Arg and Leu554Phe did not show statistical correlation with the clinical outcome. The results illustrate the potential use of genetic markers in defining patients with possibly worse clinical outcome after PCI, who may profit from more aggressive prevention of restenosis and late thrombotic complications

Angiographic Control and Percutaneous Treatment of Myocardial Ischemia Immediately after CABG

Perioperative myocardial ischemia is rare but serious complication of CABG. Graft dysfunction, coronary artery thrombosis and incomplete revascularization are main causes. Pharmacological treatment, intra aortic counter pulsation and immediate additional grafting have limited results. Treatment strategy based on coronary angiography findings could lessen the burden of high mortality rate in these patients. The purpose of this study was to analyze the causes of perioperative ischemia and angiography based treatment strategy including percutaneous intervention. We enrolled all 55 consecutive patients that went early coronary angiography for perioperative myocardial ischemia in a prospective longitudinal study. Incorrect graft anastomosis, graft spasm, displacement and dissection were found in 49%, 7%, 5% and 4% of patients, respectively. Acute coronary artery thrombotic occlusion was found in 5% of patients and ischemia due to incomplete revascularization in 6% of patients. In 22% of patients no cause of myocardial ischemia could be detected. There were no complications of coronary angiography. Based on coronary angiography findings percutaneous intervention was performed in 30 patients, additional grafting in 8 patients and no action was taken in 17 patients. Percutaneous intervention with stenting was performed on coronary arteries (78%) and graft anastomosis (22%) with primary success 97%. One anastomosis rupture with treatable tamponade and one lethal stent thrombosis were complications of percutaneous treatment. Overall in hospital mortality was 30%. We concluded that graft dysfunction is usual cause of myocardial ischemia due to incorrect anastomosis and that percutaneous intervention on bypass graft or coronary artery can lessen high mortality rate in these patients

RATIONAL USE OF ANTIMICROBIAL DRUGS IN CLINICAL PRACTICE BY IMPLEMENTING ANTIMICROBIAL STEWARDSHIP PROGRAMS

Prema dosadašnjim istraživanjima neracionalna primjena antimikrobne terapije značajan je problem u bolničkim i vanbolničkim ustanovama. Studije su pokazale da se približno 50 % antimikrobnih lijekova koristi nepotrebno i suboptimalno s obzirom na indikaciju, vrstu antimikrobnog lijeka, te duljinu primjene. Dosadašnja istraživanja su pokazala uzlazni trend prevalencije Clostridium diffi cile pseudomembranoznog kolitisa, bakterijskih patogena rezistentnih na fl uorokinolone i vankomicin rezistentnih enterokoka. Porast multirezistencije gram negativnih bakterija i na karbapeneme opasnost je za sigurnost bolesnika te ostavlja ograničene terapijske mogućnosti zadnje linije obrane poput primjene toksičnog polimiksinskog ntibiotika kolistina. U skladu s time mogućnosti optimalnog infektivnog liječenja već sada postaju ograničavajuće. Prema dosadašnjim radovima uvođenje bolničkog programa praćenja i rukovođenja antimikrobnom terapijom pokazalo se dobrim sredstvom optimalizacije antimikrobne terapije u 81 % studija. Primjena ovoga programa dovela je do značajnog poboljšanja mikrobiološkog ishoda, smanjenja stope antimikrobne rezistencije i nuspojava te kliničkog ishoda poput smanjenja stope mortaliteta i duljine boravka u bolnici. Stoga su Centres for Disease Control and Prevention, Atlanta, USA (CDC) i European Centre for Disease Prevention and Control (ECDC) suglasne da bi zdravstvene ustanove trebale implementirati multidisciplinarni Bolnički program praćenja i rukovođenja antimikrobnom terapijom (engl. Antimicrobic Stewardship Programs - ASP) u svakodnevnu kliničku praksu. Primjena navedenog programa započeta je 1. 12. 2016. g. u Klinici za kardiovaskularne bolesti Magdalena u sklopu Internacionalne kanadske akreditacije (Accreditation Canada International).According to studies, about 50% of antimicrobial drugs are prescribed unnecessarily and inappropriately in hospitals and other healthcare institutions. Besides the high prevalence of Clostridium diffi cile infection, of particular concern is the increase in bacterial pathogen resistance to fl uoroquinolones and vancomycin-resistant enterococci. Additionally, infections due to bacterial pathogens completely resistant to carbapenems are currently emerging in Europe. In this case, therapeutic options are limited to the use of the polymyxin antibiotic colistin, which is old and has many adverse and toxic events. Growing evidence demonstrates that hospital programs dedicated to improving the use of antimicrobial therapy, referred to as Antimicrobial Stewardship Programs (ASP), can optimize treatment of infections, reduce adverse events of antimicrobial therapy, improve patient safety and quality of care, and at the same time signifi cantly reduce hospital costs, mortality rate and length of hospital stay. Therefore, the US Centers for Disease Control and Prevention and European Centre for Disease Prevention and Control recommend that every acute care hospital implement the multidisciplinary ASP in daily clinical practice

ASSOCIATIONS OF IMMUNOGLOBULIN G N-GLYCOME WITH LEFT ATRIAL FIBROSIS AND ATRIAL FIBRILLATION RECURRENCE AFTER PULMONARY VEIN ISOLATION

UVOD: Fibroza lijevog atrija (LA) snažno je povezana s lošijom prognozom fibrilacije atrija (FA) i recidivom nakon izolacije plućnih vena (PVI). Postoje jaki dokazi o ključnoj ulozi upale u patogenezi fibroze LA-a. Proupalni oblici imunoglobulina G (IgG) i N-glikana u plazmi povezani su s hipertenzijom, aterosklerozom, kardiovaskularnom smrtnošću, hipertrofijom lijeve klijetke i aortnom stenozom. Ovo je prvo istraživanje IgG-a i N-glikana u plazmi kod bolesnika s AF-om. CILJEVI: Utvrditi postoji li veza između specifičnih svojstava glikozilacije IgG-a i N-glikana u plazmi, fibroze LA-a i recidiva AF-a nakon PVI-a. DIZAJN STUDIJE: Pacijenti s paroksizmalnom ili perzistentnom AF-om i indikacijom za PVI konsekutivno su uključeni u ovu prospektivnu nerandomiziranu studiju. PACIJENTI I METODE: Pacijenti sa strukturnom bolešću srca, akutnom ili kroničnom upalnom bolešću ili anamnezom karcinoma isključeni su iz studije. Nakon uzimanja uzoraka krvi za analizu N-glikana tekućom „ultra-performance“ kromatografijom, učinjena je PVI radiofrekventnom ablacijom pomoću Carto 3D sustava prema CLOSE protokolu. Neposredno prije ablacije izvršeno je elektro-anatomsko mapiranje napona lijevog atrija u sinusnom ritmu. Pacijenti su praćeni 6 mjeseci. Rekurencija AF-a otkrivena je prijavljivanjem simptoma, 24-satnim holter EKG-om ili transtelefonskim EKG-om. REZULTATI: Obuhvaćeno je 114 bolesnika (65 % muškaraca i 35 % žena) aritmetičke sredine vrijednosti dobi 61 godina uz standardnu devijaciju od 9 godina. 30 (27 %) bolesnika imalo je perzistentnu AF, a 83 (73 %) paroksizmalnu. Značajna fibroza LA-a (≥ 5 % površine) pronađena je u 62 bolesnika (54 %). U 34 bolesnika (30 %) verificirana je rekurencija i to transtelefonskim EKG-om u 31 bolesnika, a holter EKG-om u samo 12 bolesnika. Pacijenti s perzistentnom AF-om imali su stopu recidiva 46 %, a oni s paroksizmalnom 23 %. Recidiv AF-a zabilježen je kod 19 pacijenata (36 %) s fibrozom LA, a kod 14 bolesnika (23 %) bez fibroze LA. Nije bilo statistički značajne razlike u IgG N-glikanima između bolesnika s recidivom i bez recidiva AF-a nakon PVI-a. Plazma GP15 nominalno je snižen u bolesnika s recidivom AF-a, ali razlika nije statistički značajna. IgG GP8 povećan je u bolesnika s LA fibrozom (P < 0,01). IgG GP6, kao i G1 i B, također su se samo nominalno razlikovali, ali bez statistički značajne razlike. Također je zabilježeno samo nominalno povišenje GP4 i LB u plazmi te sniženje GP26 i GP32 u bolesnika s LA fibrozom, ali bez statističke značajnosti. ZAKLJUČAK: Ne postoji povezanost između specifične glikozilacije IgG-a i plazmatskih N-glikana i recidiva AF nakon PVI-a. IgG GP8 značajno je povišen u bolesnika s fibrozom LA-a. Preliminarni su rezultati prvi put pokazali da postoji povezanost između proupalne IgG glikozilacije i patološkog supstrata u bolesnika s AF-om, no potrebne su daljnje studije kako bi se potvrdila ova teorija.INTRODUCTION: Left atrial (LA) fibrosis is strongly associatedwitha worse prognosis foratrial fibrillation (AF) and recurrence after pulmonary vein isolation (PVI). There is also strong evidence ofthe pivotal role of inflammation in the pathogenesis of LA fibrosis. Proinflammatory forms of immunoglobulin G (IgG) and plasma N-glycans are associated with hypertension, atherosclerosis, cardiovascular mortality, left ventricular hypertrophy and aortic stenosis. This study is the first to investigate IgG and plasma N-glycansin AF patients.OBJECTIVES: To determine whether there is an association between specific glycosylation traits of IgG and plasma N-glycans, LA fibrosis and AF recurrence after PVI. STUDY DESIGN: Patients with paroxysmal or persistent AF undergoing PVI were consecutively included in this prospective non-randomized study. PATIENTS AND METHODS: Patients with structural heart disease, acute or chronic inflammatory disease or cancer history were excluded from the study. After blood sampling for IgG and plasma N-glycan ultraperformance liquid chromatography analysis, PVI was performed with radio-frequent ablation using the Carto 3D system,contact-force catheter, CLOSE protocol and ablation index. Immediately before ablation, electro-anatomical voltage mapping of the left atrium was performed in sinus rhythm. Patients were followed for 6 months. AF recurrence was detected by symptom reporting, 24-hour Holter ECG or trans-telephonic ECG. RESULTS: 114 patients (65 % male and 35 % female) were included, with a mean age of 61 and standard deviation 9 years. Persistent AF was found in 30 (27 %) patients and paroxysmal in 83 (73 %) patients.Significant LA fibrosis (≥ 5 % surface) was found in 62 patients (54 %). AF recurred in 34 patients (30 %) and was verified by trans-telephonic ECG in 31 patients and by Holter ECG in only 12 patients. Patients with persistent AF had a higher recurrence rate (46 %) in comparison to paroxysmal AF patients (23 %). 19 patients (36 %) with and 14 patients (23 %) without LA fibrosis had AF recurrence. There was no statistically significant difference in IgG N-glycans between patients with and without AF recurrence after PVI. Plasma GP15 was nominally decreased in patients with AF recurrence, but the difference did not remain statistically significant.IgG GP8 was increased in patients with LA fibrosis (P < 0.01). IgG GP6 as well as G1 and B were also only nominally different, but without a statistical difference. There was also onlya nominal increase in plasma GP4 and LB and a decrease in GP26 and GP32 in patients with LA fibrosis without any statistical significance. CONCLUSION: There is no association between the specific glycosylation of both IgG and plasma N-glycans and AF recurrence after PVI. IgG GP8 is significantly increased in patients with LA fibrosis. The preliminary results have shown for the first time that there is an association between pro-inflammatory IgG glycosylation and the pathological substrate in AF patients, but further studies are needed to confirm this theory

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase&nbsp;1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation&nbsp;disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age&nbsp; 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score&nbsp; 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc&nbsp;= 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N&nbsp;= 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in&nbsp;Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in&nbsp;Asia&nbsp;and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701