Antiphospholipid Syndrome - A Case Report of Pulmonary Thromboembolism, Followed with Acute Myocardial Infarction in Patient with Systemic Sclerosis

AIM: We are presenting an uncommon case of pulmonary embolism, followed with an acute myocardial infarction, in a patient with progressive systemic sclerosis. CASE PRESENTATION: A female 40 years of age was admitted with signs of pulmonary embolism, confirmed with CT scan, which also reviled a thrombus in the right ventricle. The patient had medical history of systemic sclerosis since the age of 16 years. She suffered an ischemic stroke 6 years ago, but she was not taking any anticoagulant or antithrombotic medications ever since. She received a treatment with thrombolytic therapy, and subsequent UFH, but, on the second day after receiving fibrinolysis, she felt chest pain accompanied with ECG changes consistent for ST-segment elevation myocardial infarction (STEMI). Urgent coronary angiography was undertaken, which reviled cloths causing total occlusion in 4 blood vessels, followed with thromboaspiration, but without successful reperfusion. Several hours later the patient developed rapid deterioration with letal ending. During the very short hospital course, blood sampling reviled presence of antiphospholipid antibodies. CONCLUSION: The acquired antiphospholipid syndrome is common condition in patients with systemic autoimmune diseases, but relatively rare in patients with systemic sclerosis. Never the less, we have to be aware of it when treating the patients with systemic sclerosis

Antiphospholipid Syndrome - A Case Report of Pulmonary Thromboembolism, Followed with Acute Myocardial Infarction in Patient with Systemic Sclerosis

AIM: We are presenting an uncommon case of pulmonary embolism, followed with an acute myocardial infarction, in a patient with progressive systemic sclerosis. CASE PRESENTATION: A female 40 years of age was admitted with signs of pulmonary embolism, confirmed with CT scan, which also reviled a thrombus in the right ventricle. The patient had medical history of systemic sclerosis since the age of 16 years. She suffered an ischemic stroke 6 years ago, but she was not taking any anticoagulant or antithrombotic medications ever since. She received a treatment with thrombolytic therapy, and subsequent UFH, but, on the second day after receiving fibrinolysis, she felt chest pain accompanied with ECG changes consistent for ST-segment elevation myocardial infarction (STEMI). Urgent coronary angiography was undertaken, which reviled cloths causing total occlusion in 4 blood vessels, followed with thromboaspiration, but without successful reperfusion. Several hours later the patient developed rapid deterioration with letal ending. During the very short hospital course, blood sampling reviled presence of antiphospholipid antibodies. CONCLUSION: The acquired antiphospholipid syndrome is common condition in patients with systemic autoimmune diseases, but relatively rare in patients with systemic sclerosis. Never the less, we have to be aware of it when treating the patients with systemic sclerosis

Thoracic Aortic Disease - Aortic Dissection

The term Thoracic Aortic Disease (TAD), covers a wide range of degenerative, structural, acquired, genetically based and traumatic diseases, conditions and presentations of the thoracic aorta. In 2010 several professional associations published joint Recommendations for diagnosis and treatment of TAD, and last year ESC published new Guidelines for diagnosis and treatment of Aortic Disease. Interesting enough is the fact that, 2010 Guidelines were the first recommendations accompanied by a campaign designed for the general population, with a purpose to increase awareness of the existence and importance of these conditions. It was explained by the fact that dissection of the thoracic aorta, the most distinguished acute clinical manifestation of TAD, is recognized as one of the twenty most common causes of death. This is a condition that is diagnosed mainly based on data obtained by a detailed history and clinical examination, for the existence of high-risk situations, high-risk features of the chest pain and high risk clinical findings. Unfortunately, yet, there isn’t sensitive and specific biomarker that could help in the diagnosis of this acute condition. The definitive confirmation of the disease is made by imaging of the aorta with one of the imaging modalities such as transoesophageal echocardiography (TOE), computed tomography (CT) or magnetic resonance (MRI). And in terms of rapid diagnosis, this condition is still characterized with high mortality. This paper is an attempt to give an overview of the situation with TAD in our country, through a retrospective analysis of the medical database at the University Clinic of Cardiology of all patients hospitalized during the year 2009 with a working diagnosis of AoD

Glicoregulation in diabetic and no diabetic patients and the impact on early clinical outcome in patients with acute coronary syndrome

Aim of the study: The aim of our study was to analyse the impact of glicoregulation before and during the hospital treatment in patients with acute coronary syndrome on early in-hospital clinical outcome (CE). Methods: We included in the analyse ACS patients (STEMI, NSTEMI, APNS) treated with PCI, in whom we analysed: demographics, risk profile, basic biochemical variables (Hgb, BUN, creatinine, Na, K), lipid profile (Tg, HDL, LDL Hol, lpa), HgbA1C, admitting glucose level and levels of glucose during the hospitalisation, and TIMI flow before and after PCI procedure. We divided patients in diabetics and non-diabetics. Than based on the level of HgbA1C measured at admition we subdivided diabetics in good (6.5%) DM, and patients without previously known diabetes in three groups: no diabetics (6.5) HgbA1C. Based on glycaemic levels we divided pts. in groups: good regulation (5-10mmol/L), bed regulation: >10mmol/L epizodes, and <5mmolL aeizodes. We analized influence of glikoregulation on biochemical variables and lipide profile, PCI results (TIMI flow), and cardiac events (heart failure, shock, dysrhythmias, GIT bleeding, CVI and cardiac death). Statistical analyse: descriptive and comparative statistics with t-test, Chi square test, uni and multivariate analyse. Significance determined at 0.05. Results: 80 pts. Were included in the analyse (33.8% females and 66.2% males), at mean age of 60.2±10.8y. Risk profile: 51% had HTA, 6.3% HLP, 36.3% positive family history, 33.8% were diabetics, 61.4% smokers, 5% previous CAD. Mean Hgb 14.6±1.4mg/dl, BUN 5.9±3.2, creatinine 80.5±30.6 micromol/L, Na 137.5±3.4, K 4.2±0.5. No differences in biochemical and lipide profile was found between groups. Among 53 no diabetic patients prior to ACS, we identified 4 (5%) patients with diabetes (>6,5), and 18 (22.5%) with pre-diabetes (5.6-6.5%). Mean TIMI flow was 0.45±0.79 before, and 2.96±0.19 after PCI, r -.221, p 0.000. The single independent predictor in multivariate analyse (included HgbA1C, admitting glycaemic level, glucoregulation and diabetic group) on TIMI flow was admitting glycaemia (beta -.327, p 0.003). 12/80 pts. had CE, and again we included same variables and identified two independent predictors of CE: admitting glycaemic level (beta .386, p 0.007) and HgbA1C (beta .254, p 0.070). Conclusion: Acute coronary syndrome identified patients with previously no diagnosed diabetes. Stress glycaemia (admition glycaemic level) was found to be significant predictor of PCI results, and together with HgbA1C level of CE in ACS patients treated with PCI

Anemia, renal impairment and in-hospital mortality, in acute worsening chronic heart failure patients

Aim of the study: To analyze the impact of anemia and renal impairment on in-hospital mortality(IHD), in patients with acute worsening chronic heart failure. Methods: 232 randomly selected patients with symptoms of HF were retrospectively analyzed. Analyzed variables: gender, age, risk factors and co-morbidities: HTA, HLP, DM, COPD, CAD, PVD, CVD, anemia(defined as Hgb ≤10mg/dl), renal failure. Measured variables: systolic and diastolic BP, Hgb, sodium, BUN, creatinine, length of hospital stay and IHD. Comparative analysis was performed between patients with in-hospital mortality(IHD) and survivors, as a function of anemia and renal impairment. Statistical analysis: descriptive and comparative analysis, t-test, Chi square, univariate (binary logistic and linear regression and multivariate linear regression(stepwise backward). Results: Mean age 69.6±11.4, 102(44%)females and 130(56%) males, with females being significantly older 72.6±12.5 vs. 67.7±10.2(p=0.002), with significantly higher SBP, DBP and sodium level (p=0.003; 0.002 and 0.028 respectively), and males having HTA more often OR 1.3; p=0.017. Mean hospital stay was 6.8±5.8 days, with significant difference between IHD and non IHD group(7.9±4.5 vs. 3.8±7.9; p=0.000), with the highest mortality during the first (37.3%) and second hospital day (44.1%). 44 pts.(19%) had anemia, 31(13.4%) had known Chronic Renal Failure(CRF), and 59(25.4%) had IHD. Anemia was significantly associated with IHD (Chi square 6,36, sig 0.012, Exp B 2.48, sig 0.010), meaning pts. with anemia had 2,5 times greater risk for IHD. CRF per se, was not associated with IHD. Univariate linear regression identified creatinine(R square .032, beta .180, sig 0.006), and BUN(R square .034, beta .184, sig 0.005), as predictors of IHD. Multivariate stepwise regression model(anemia, HRF, Hgb, BUN, creatinine, sodium) at step 3(mean square .799, sig 0.002), identified two independent predictors Hgb(beta -.148, sig 0.028), and BUN(beta .163, sig 0.055). Multivariate model that included other known predictors of IHD(EF%, SBP, DBP, HRF, CAD, anemia, Hgb, BUN, creatinine, sodium) at step 8(mean square 1.537, sig 0.000), identified four independent predictors: EF%(beta -.204, sig 0.002), SBP(beta -.130, sig 0.052) as markers of systolic dysfunction and again anemia(Exp B 2.2.06, sig 0.041), and BUN(beta .200, sig 0.002). Conclusion: Anemia and renal impairment are well known comorbidities associated with HF that have great impact on course of HF. We confirmed that anemia and BUN, are significantly independent predictors of in hospital mortality in acute worsening CHF

Predictors of in-hospital mortality in patients with acute or acute worsening chronic heart failure

Aim of the study: to identify predictors of in-hospital mortality in acute HF patients. Patients and methods: 355 randomly selected patients admitted to ICCU with symptoms of HF were analyzed for: risk factors and co-morbidities (COPD, CAD, PVD, anemia, renal failure), heart rate, systolic and diastolic BP, Hgb, sodium, BUN, creatinine, ejection fraction (based on which patients were divided in PEF-HF and REF-HF); length of stay and GWTG-HF score (Get with the Guidelines-HF risk score), calculated from the seven clinical variables in that score. Comparative analyze was performed between patients with in-hospital mortality (IHM) and survivors. Statistical analyze: univariate and multivariate binary and linear logistic regression, ROC Curve for testing of discriminate function of GWTG-HF score. Results: 355 patients at mean age 70.1±10.9, 150 (42%) females and 205 (58%) males were included. Females were older 72.9±11.4 vs. 67.9±10.0 (p=0.000), had higher DBP (p 0.007) and EF (%): 43.6±11.6 vs 41.1±9.5 (p 0.029), and sodium level (p 0.018), more often had HTA (OR 1.4; p=0.001), while males had PAD (OR 1.7; p 0.020), and prior MI (OR 2.2; p 0.001). No significant differences in death rate, length of hospital stay and GWTG-HF score was observed. 82 (23.1%) events were registered (IHD group). The highest mortality rate was observed during the first 48 hours (40.4%). Mean hospital stay was 6.3±5.3 days, with no differences between the groups (5.6±3.9 vs. 6.7±5.9; p=0.056). We identified several univariate predictors: prior MI (beta -.490; p 0.041), PVD (beta -1.01; p 0.007); anemia (OR 1,89; p 0.044); REF-HF (OR 2.43; CI 1.7-3.6; p 0,000); EF (beta -.258; p=0.000); SBP (beta -.299; p=0.000), DBP (beta .315; p=0.000); Hgb (beta -.142; p=0.007), sodium (beta -.107; p 0.045); creatinine (beta .184; p=0.000), BUN (beta .199; p=0.000), and GWTG-HF score (beta .279; p 0.000). Multivariate logistic regression identified SBP (beta -.014; p 0.020) and anemia (ExpB 3.668; p 0.019); as positive, while prior MI (ExpB -2.753; p 0.050); PVD (ExpB -1.348; p 0.005) and DBP (beta .034; p 0.003) as negative predictors for in-hospital death. Mean GWTG-HF score was 38.9 ±10.1 (37.3 ±9.3; 44.0 ±11.0; p 0.000, non-IHD vs IHD pts). It had excellent discriminate function (ROC Curve: Area under the Curve .694, p< 0.000 (CI .627-.778), in predicting IHD. Conclusion: Low sodium, high BUN and creatinine are predictors of IHD, but only anemia, reduced EF and low systolic BP were identified as independent predictors of IHD. GWTG-HF score is a powerful tool for prediction of IHD in acute or acute worsening CHF patients

Acute heart failure in the context of acute coronary syndrome (a case report)

RVMI is associated with acute STEMI myocardial infarction of the inferior wall of the left ventricle, and occurs in 30 to 50 percent of such cases

Early rehospitalizations in patients treated for acute coronary syndrome - can we identify predictors?

Purpose: To analyze early rehospitalization rate (defined as 90 days after the acute event) in patients with ACS, and to identify predictors of risk for readmission. Methods:463 randomly selected patients with ACS,were retrospectively analyzed.Analyzed variables:type of ACS(STEMI/NSTEMI/APNS),location of MI,gender,age,risk factors:HTA,HLP,DM,COPD,CAD,PVD,CVD,EF,type of treatment(PCI vs. noninvasive),extensiveness of coronary disease,GRACE and TIMI risk score, type of morbidity,and reason for rehospitalization.Comparative analysis was performed between patients with early rehospitalisation and others.Statistical analysis:t-test,Chi square,univariate and multivariate linear regression. Results:463 patients were enrolled:68.9% males mean age 60.4±10.9, and 31.1% females mean age 64.94±12.0(p 0.000).MI type:STEMI 75.8%,NSTEMI 11.2%,APNS 13%; MI location:40.2% anterior,39,7% inferior,3% lateral and 3.7% multiple locations(p 0.000).Risk profile:15.3% HCAD,27% HF,62% HTA,28.1% DM,5.8% PVD,2.6% COPD.Mean BMI was 27±2.9,mean SBP 138.8±28.5mmHg,mean HR 84.3±24.2,mean EF (in 208 pts.) 50.2±10.4%, mean GRACE score(in 72 pts.) was 148.9±60.6,mean TIMI score(in 263 pts.) was 3.9±2.3. 87.5% were treated with PCI procedure, with mean disease’s CA 1.84(range 1-5), median 1(p 0.000). Hospital morbidity was present in 16% of pts.,6.9% minor, 3% major bleeding complications, 2.4% acute HF, 1.9% pericardial effusion, and 1.1% early stent thrombosis.Early rehospitalization rate was 6.3% (29/463):14 ischemic/trombotic events;9 acute heart failures, 3 malignant arrhythmias, and three fatal events. Univariate predictors of RH: HR(R square 0.014, p 0.014, beta .116, r -.217, p 0.002);EF(%) (R square 0.055, p 0.001, beta -.234, r -.231, p 0.001).HTA was significantly associated with reduced hospitalization risk (Chi square 4.28, p 0.039, exp B .405, p 0.054),diabetes(Chi square 10.04, p 0.002, exp B 3.45, p 0.001), PVD (expB 2.85, p 0.070),early in-hospital morbidity(expB 2.12, p 0.084),and NSTEMI pts. had OR 1.3, and APNS pts. OR 1.16 for rehospitalization(higher but not significantly in comparison to STEMI pts.). Multivariate model with variables that were found significantly associated with HR, identified two strong independent predictors of early rehospitalization(mean square.424, sig 0.000),EF(beta -.220, p 0.001),and diabetes(t 2.52, p 0.012) Conclusions:LV systolic dysfunction was again proven to be a strong predictor of clinical outcome in terms of early hospital readmission in ACS patients no matter how they were treated for ACS, and diabetes was the single strong independent predictor-risk factor for this event

Diabetes in acute coronary syndrome patients: do we see only the tip of the iceberg?

Aim of the study: To analyse the influence of glycoregulation in pts. with known or newly detected diabetes, on in-hospital morbidity/mortality in patients with acute coronary syndrome. Methods: randomly selected ACS patients were analysed for: stress glycaemia, HgbA1c, risk profile, lipid profile, SINTAX score, TIMI flow, LV function and in-hospital morbidity/mortality. We comparatively analysed pts. based on the level of HgbA1c (⩾ 6,5% vs 6.5%). Mean values of HgbA1c and stress glycaemia were as follows: NonD - 5.19±0.56 and 6.82±1.87; PD - 5.99±0.19 and 8.32±3.17; ND - 8.19±1.15 and 17.68.19±1.15; CD - 5.79±0.55 and 8.89±4.38; and UD - 9.36±1.33 and 16.23±6.24; (ANOVA p >0.000). No significant difference was found between NonD and CD pts., and between ND and UD (high in the last two), but there was significant difference in HgbA1c (p0.000, Kappa agreement (0.516; sig p>0.000). TG levels were increased only in UD, and ND groups: 1.93±1.06, and 2.36±1.22, (ANOVA p=0.026, Tukey test ND vs NonD p=0.050; and vs PD p=0.016), without significant difference in other lipid fractions. Mean SINTAX score was 15.45±8.2, without significant inter-gorup differences. TIMI flow before PCI significantly differed across the groups, the lowest being in ND - 0.14±0.36 and PD - 1.13±1.42 pts. (group value 1.37±1.42; ANOVA p=0.001; Tukey test: NonD vs ND 0.000; and 0.043 vs CD). Mean EF was 51.51±8.5, without significant inter-group difference. 29 in-hospital events in 22 (19%) patients were registered: 7.7% arrhythmias, 6.9% heart failure, 3.4% GIT bleedings, and 2.6% CVI. In-hospital mortality was 4.3%. In multivariate logistic regression analysis, ejection fraction, stress glycaemia, and HgbA1c were identified as independent predictors of in-hospital outcome. Conclusion: High prevalence of unknown diabetes in ACS patients exists, leading to worse CAD, even in comparison with pts with known, well controlled diabetes. Stress glycaemia, HgbA1c and ejection fraction are independent predictors of in-hospital morbidity/mortality