Sekundarna prevencija kardiovaskularnih bolesti

SAŽETAK Kardiovaskularne bolesti najvažniji su uzrok pobola i smrtnosti. Metabolički sindrom je vrlo koristan koncept koji pomaže u identificiranju visokorizičnih bolesnika. Ispravna sekundarna prevencija, u skladu sa smjernicama temeljenim na dokazima, značajno smanjuje učestalost nefatalnih i fatalnih kardiovaskularnih događaja te poboljšava kvalitetu i duljinu života. Takva prevencija uključuje više nefarmakoloških mjera, odgovarajuće farmakološko liječenje i moguću revaskularizaciju miokarda. Sekundarna prevencija koronarne bolesti srca može se sažeto izraziti akronimom BASIKOR (Beta-blokator, Acetilsalicilna kiselina, Statin, Inhibitor ACE, Kontrola čimbenika rizika, Omega-3 masne kliseline, Revaskularizacija

Akutni koronarni sindrom u bolesnika na terapiji inhibitorom tirozin kinaze – prikaz slučaja

SUMMARY The use of tyrosine kinase inhibitors is becoming increasingly common in oncological therapy due to their anti-tumor and anti-angiogenic effects. One of the more significant representatives of this group of medications is sunitinib, an oral multi-target inhibitor used in certain forms of gastrointestinal stromal tumors, metastatic renal cell carcinoma, and advanced neuroendocrine pancreatic cancer. In addition to the positive effects of this group of medications, some unwanted effects have also been observed. Depending on the authors, 10% to 30% of patients experienced some form of cardiovascular (CV) event during the application of tyrosine kinase inhibitors. Herein we present the case of a 73-year-old patient who initially received surgery for metastatic cancer in the right kidney, followed by treatment with sunitinib. Approximately eight months after starting this treatment, the patient presented to the Integrated Emergency Hospital Admission department due to chest pains. An electrocardiogram was performed, and suspicion of acute coronary syndrome with ST-segment elevation in the inferior, posterior, and lateral leads was established. Emergency coronarography showed occlusion of the proximal part of the right coronary artery, and treatment continued with primary percutaneous coronary intervention. Given that no significant CV comorbidities had been previously recorded in the patient, a potential link to the application of tyrosine kinase inhibitors was suspected. Examination of other international publications on similar topics indicates a significant incidence of a wide spectrum of CV events associated with these medications. Some studies found that the application of this group of medications leads to increased arterial pressure, arterial stiffness, and reduced elasticity. A case report by Italian authors described a patient who underwent a cardiosurgical bypass procedure after 2 years of sorafenib use, despite having no significant CV comorbidities. These publications and the present case report lead to the conclusion that higher-quality CV monitoring is needed in oncological patients using tyrosine kinase inhibitors with the goal of preventing unwanted events and outcomes.Inhibitori tirozin kinaze sve se češće primjenjuju kao dio onkološke terapije zahvaljujući svojemu protutumorskom učinku i učinku protiv angiogeneze. Jedan od značajnijih predstavnika navedene skupine lijekova jest sunitinib, oralni višeciljni inhibitor koji se uporabljuje kod određenih oblika gastrointestinalnih stromalnih tumora, metastatskog karcinoma bubrežnih stanica i proširenoga neuroendokrinog tumora gušterače. Osim pozitivnih učinaka navedene skupine lijekova, zabilježeni su i oni neželjeni. Ovisno o autorima, 10 do 30 % bolesnika doživjelo je neki oblik kardiovaskularnog (KV) događaja u vrijeme primjene inhibitora tirozin kinaze. Ovim radom prikazuje se slučaj 73-godišnjeg bolesnika koji je zbog metastatskog tumora desnog bubrega prvotno operiran, a potom liječen sunitinibom. Otprilike osam mjeseci od početka navedene terapije bolesnik dolazi u Objedinjeni hitni bolnički prijam zbog boli u prsima. Izvedenim elektrokardiogramom postavljena je sumnja na akutni koronarni sindrom uz elevaciju ST-segmenta u inferiornim, posteriornim i lateralnim odvodima. Hitnom koronarografijom prikazala se okluzija proksimalnog dijela desne koronarne arterije te se nastavilo s primarnom perkutanom koronarnom intervencijom. S obzirom na to da u bolesnika nisu ranije zabilježeni značajniji KV komorbiditeti, postavljena je sumnja na potencijalnu povezanost s primjenom inhibitora tirozin kinaze. Promatrani radovi stranih autora slične tematike pokazali su znatnu učestalost širokoga spektra KV događaja. Pojedina su istraživanja pokazala da primjena te skupine lijekova dovodi do porasta arterijskoga tlaka, krutosti arterija i smanjenja elastičnosti. Naveden je i prikaz slučaja talijanskih autora koji opisuju da je bolesnik nakon 2 godine primjene sorafeniba podvrgnut kardiokirurškom zahvatu ugradnje premosnica, iako nije imao značajnijih KV komorbiditeta. Kao zaključak promatranih radova i ovog prikaza bolesnika, nameće se potreba za kvalitetnijim KV praćenjem onkoloških bolesnika na terapiji inhibitorima tirozin kinaze u svrhu prevencije neželjenih događaja i ishoda

Is Mitral Valve Repair Safe Procedure in Elderly Patients?

The aim of this randomized, prospective, study was to evaluate postoperative hospital mortality and morbidity after mitral valve repair by comparing two surgical techniques for resolving mitral valve insufficiency in elderly patients. In comparison were: mitral valve repair vs. mitral valve replacement in patients older than 70 years. In period from January 1st 2006 until August 30th 2009. Eighty patients with mitral valve disease, isolated or associated with other co morbidities, were scheduled for mitral valve repair or mitral valve replacement in our institution. Patients were randomized in two groups, one scheduled for mitral valve repair and another one for mitral valve replacement using the envelope method with random numbers. Results show no difference in hospital mortality and morbidity postoperatively in both groups. In group undergoing valve replacement we had one significant complication of ventricle rupture in emphatically calcified posterior part of mitral valve annulus. In conclusion we found no distinction in postoperative hospital mortality and morbidity after using one of two surgical techniques

Clinical Effects of Metoprolol Across the Cardiovascular Continuum.

Beta-adrenergetic receptor antagonists cause positive effects across the whole cardiovascular continuum. Compared to non-selective beta-blockers, cardioselective beta-1 blockers have an advantage in patients in whom we wish to avoid beta-2 receptor blockade in the bronchi and peripheral blood vessels, in patients with bronchoobstructive and/or peripheral arterial disease. A negative impact on blood glucose homeostasis and erectile function is to be avoided by selective application. Metoprolol has been internationally known as widely applied and checked cardioselective betablocker for a long time. A series of clinical studies have clearly proved the therapeutic effect of metoprolol in the hypertension, acute and chronic types of coronary heart disease, postinfarction prophylaxis, heart arrhythmia and chronic heart failure syndrome. In all researches, metoprolol has showed good tolerance and safety. If taking proper doses and managing patients properly, the side-effects are rare and reversible. Today, metoprolol succinate is available in Croatia in the form with sustained absorption and gradual plasma clearance with a possibility of a one-day dosage which ensures stable concentration of the drug in the plasma and effects during a period of 24 hours. This is how a safer effect and better cooperation of a patient required for the success of the treatment is achieved

Successful right atrial thrombus lysis with alteplase in a nine month old infant

Objective. To present the case of an infant with a catheter related atrial thrombus resolved with local instillation of alteplase. Clinical presentation. Echocardiography (ECHO) was performed in an infant with sepsis to estimate cardiac contractility, and a large mobile thrombus (28 x 8 mm) was detected in the right atrium. A left subclavian, double lumen, central venous line (CVL, 4 French, 8 cm), inserted 10 weeks previously, was left in place. Standard treatment with enoxaparine was commenced twice daily for 10 days at a dose of 1 mg/kg. Repeat ECHO showed no changes in thrombus size or mobility. Therefore, alteplase was administered into the distal catheter (1 mg in normal saline) at a dose of 110% of its priming volume. The dwelling time was 2 hours. Since no changes in thrombus size were observed, the same dose was given into the proximal catheter. ECHO performed 24 hours later showed a significant reduction in thrombus size. The third dose of alteplase was administered into the proximal catheter. ECHO showed complete dissolution of the right atrial thrombus. No bleeding was observed during and following therapy, and there were no signs of hemodynamic instability. The CVL was safely removed the same day and no endoluminal thrombus was seen. Conclusion. Local instillation of alteplase in three doses was a safe and effective approach to the management of a large catheter-related intraatrial thrombus. Systemic thrombolytic therapy, associated with an increased risk of bleeding, and open heart surgery were avoided

Perkutana aspiracijska trombektomija u Paget-Schroetterovu sindromu – prikaz bolesnika

SUMMARY We report the case of a younger, physically active patient who presented at the emergency department with swelling, pain, and bluish discoloration of the left arm, with clinical examination identifying effort-induced deep vein thrombosis of the arm (Paget-Schroetter syndrome). After unsuccessful medication treatment with a therapy dose of low-molecular-weight heparin, the patient was treated with an endovascular procedure – percutaneous aspiration thrombectomy. The procedure was successful, with the establishment of peripheral flow through the subclavian, axillary, and cephalic vein despite some thrombotic masses remaining. Before discharge, the patient was placed on peroral anticoagulation treatment with rivaroxaban. Additional imaging was performed during treatment of the superior thoracic aperture, confirming the diagnosis. Expanded laboratory testing showed values within normal limits. Follow-up showed regression of the symptoms. Color Doppler ultrasound and clinical examination verified maintenance of peripheral flow through the affected veins, with residual small thrombi and the development of collaterals. The patient was subsequently considered for decompression therapy by removing the first rib as a permanent solution for the symptoms.SAŽETAK Prikazujemo slučaj mlađeg, fizički aktivnog bolesnika u kojeg su se pri hitnom prijemu manifestirali oteklina, bolnost i plavičasta diskoloracija lijeve ruke te mu je obradom ustanovljena naporom inducirana duboka venska tromboza ruke (Paget-Schroetterov sindrom). Nakon neuspješna medikamentnog liječenja terapijskom dozom niskomolekularnog heparina liječen je endovaskularnim zahvatom – perkutanom aspiracijskom trombektomijom. Postupak je protekao uredno uz uspostavu rubnog protoka kroz potključnu, pazušnu te cefaličnu venu usprkos ostatnim trombotskim masama. Prije otpusta uvedena je peroralna antikoagulantna terapija rivaroksabanom. U sklopu obrade sindroma gornje torakalne aperture provedena je dodatna slikovna obrada kojom je dijagnoza potvrđena. Nalazi proširene laboratorijske obrade bili su u granicama normale. Na kontrolnim pregledima praćena je regresija tegoba. Color Doppler ultrazvukom te klinički verificiran je i dalje održan rubni protok kroz zahvaćene vene uz rezidualne male trombe te razvoj kolaterala. U bolesnika se razmatra dekompresijsko liječenje resekcijom prvog rebra kao konačno rješenje uzroka tegoba