Terminalna faza zatajenja srca – transplantacija ili LVAD

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood. According to the data from the International Society for Heart and Lung Transplantation registry, the half-life of patient survival after heart transplantation has progressively improved from 8.9 years in 1982 to a projected half-life of approximately 11 years from 2002 to 2006. The peak VO2 (VO2max) is the most objective assessment of functional capacity in patients with heart failure, and may be the best predictor of when to list a patient for cardiac transplantation. Mechanical cardiac support devices may be implanted in patients, in whose cases all other pharmacological therapies (oral medications and intravenous inotropes) for severe heart failure, as well as non-pharmacological support with intraaortic balloon pump counterpulsation, have failed. Left ventricular assist device provide support of the left ventricular function, causing reverse ventricular remodeling and permanent improvement of left ventricular function. End stage heart failure is not an end of life, since heart transplantation, better medications and devices, including ventricular assist devices implantations, offer patients a better quality and an appreciable extension of life.Zatajenje srca kompleksni je klinički sindrom, a može se razviti kao posljedica bilo kojeg strukturalnog ili funkcionalnog poremećaja koji utječe na punjenje klijetki i ispumpavanje krvi. Prema podacima ISHLT registra, poluvrijeme preživljavanja nakon srčane transplantacije produžilo se s 8,9 godina u 1982. na oko 11 godina u razdoblju između 2002. i 2006. Vršni VO2 (VO2max) najobjektivniji je parametar u procjeni težine zatajenja srca i mogao bi biti najbolji prediktor stavljanja bolesnika na transplantacijsku listu. Mehanička srčana potpora indicirana je u bolesnika u kojih se farmakološkom terapijom (oralnom i parenteralnom) te nefarmakološkom s intraaortnom balon pumpom ne ostvari adekvatno poboljšanje kliničkog statusa bolesnika. LVAD potpora je lijevom srcu, a može dovesti do remodeliranja i trajnog poboljšanja funkcije lijeve klijetke. Terminalna faza zatajenja srca nije i kraj života jer transplantacija, noviji farmakološki pripravci i mehanička potpora, uključujući i VAD, bolesnicima omogućuju bolju kvalitetu i produžetak života

Chronic heart failure – therapeutic approaches

Zatajivanje srca (ZS) jest poremećaj srčane strukture ili funkcije zbog kojeg srce ne može osigurati adekvatnu količinu kisika tkivima. Očituje se simptomima i znakovima oštećenja gotovo svih ciljnih organa. Najčešće je u podlozi oštećenje sistoličke funkcije lijeve klijetke, ali i oštećenje dijastoličke funkcije, valvularne bolesti, bolesti perikarda, endokarda te poremećaji srčanog ritma. Dijagnoza ZS-a postavlja se neinvazivnim i invazivnim tehnikama. Svrha terapije bolesnika sa ZS-om jest redukcija simptoma i znakova bolesti, smanjenje broja rehospitalizacija, poboljšanje kvalitete i produživanje života. U tu svrhu najvažniju ulogu imaju tri skupine neurohumoralnih antagonista: ACE inhibitori (ili blokatori angiotenzinskih receptora), beta-blokatori te antagonisti mineralokortikoidnih receptora. Kod refraktornog ZS-a u terminalnoj se fazi može liječiti transplantacijom srca te potpornim crpkama koje mogu biti jednoventrikularne i dvoventrikularne, privremene ili trajne.Heart failure (HF) is a disorder in the structure or function of the heart that prevents it from maintaining adequate oxygen supply to other tissue. It manifests with symptoms and signs of damage to almost all target organs. The most common cause is damage of the systolic function of the left ventricle, but causes include disrupted diastolic function, valvular diseases, pericardial and endocardial diseases, and heart rhythm disorders. The diagnosis of HF can be established using both invasive and non-invasive techniques. The goal of HF treatment is to reduce the symptoms and signs of the disease, reduce rehospitalization, and improve the quality and length of the patient’s life. Three neurohormonal antagonists play a key role in the treatment: angiotensin-converting enzyme inhibitors (or angiotensin receptor blockers), beta-blockers, and mineralocorticoid receptor antagonists. Refractory HF in the terminal phase can be treated with heart transplants and cardiac support pumps, which can be uni- or biventricular and either temporary or permanent

Psihosocijalne karakteristike kao čimbenici rizika u hospitaliziranih koronarnih bolesnika u Hrvatskoj

Patients are hospitalized for coronary illness on average at 63 years of age, men at 61 and women seven years later at 68, regardless of whether they have acute or chronic coronary illness and regardless which region they live in (p<0.001). The relative risk for hospitalization for acute coronary illness is twice as high in Mediterranean Croatia as it is in continental Croatia (RR 1.98, 95% CI1.58-2.48, p<0.001). The waist-to-hip ratio patients hospitalized with coronary illness in Croatia is around 1 in male patients, and 0.93 in female patients. In continental Croatia the average waist-to-hip ratio for women is 0.95, and in Mediterranean Croatia 0.91. There was no significant difference in body mass index (BMI) between men in continental Croatia (28.27 kg/m2) and men in Mediterranean Croatia (27.93 kg/m2), as there was not in regard to acute or chronic coronary illness. Patients hospitalized for coronary illness have a higher BMI in the continental part of Croatia, ITM 29.17 kg/m2: 27.03 kg/m2 (p<0.0001). Dried meat products increase the relative risk of hospitalization for acute coronary illness by two times, skimmed milk by 1.24 times (46%), whole milk by 1.45 times (45%) and olive oil by 68%. Fruit reduces the relative risk of hospitalization for acute coronary illness by 44% (OR 0.56, 95% CI 0.33-0.95, p=0.0321), and the taking of statins reduces it by 54% (OR=0.46, 95%CI 0.35-0.60, p<0.001). There is no significant difference in dietary habits (healthy: continental diet) between the Mediterranean and continental parts of Croatia, nor is there in diet quality between men and women, although women tend towards a healthier diet. There is no difference in men's and women's income based on region or acute or chronic coronary illness. Female subjects surveyed in the continental part of Croatia had the lowest income, with 19.25% of them having a monthly income lower than 2,000 kn. There is no statistically significant difference in BMI in men and women related to level of education, although there is a tendency towards lower BMI as level of education increases (28.04:27.96:27.80 in men, and 28.76:28.07:28.21 in women). Men and women with a higher level of education have a healthier diet and lower cholesterol (men 5.4:5.4:5.0 and women 5.4:5.5:4.9 mmol/l). Smoking and alcohol consumption in both men and women are inversely related to level of education. Men and women with a higher level of education pay more attention to physical activities. In all categories, women are less physically active than men. Male patients with coronary illness are more educated than the general population in Croatia (23.40%:32.2% have elementary education; 55,77%:55% have secondary education; and 20.83%:12.8% have higher education). The case is similar in patients with coronary illness (48.3%:46.72%; 40.5%:43.17%; 11.2%:10.11%). 58.21% of male patients with coronary illness are blue collar workers, while 41.79% of them are white collar workers. Blue collar worker have a 22% lower relative risk of hospitalization for acute coronary illness in relation to white collar workers (RR=0,78,95%, CI 0,61-0,99, p=0,0382). 12.19% of patients have work-related stress as a potential risk factor in coronary illness. 15% of male patients in continental Croatia have work-related stress related to failure or loss of work, while this relates 8.7% of male patients in Mediterranean Croatia. 18% of patients hospitalized for acute coronary illness in continental Croatia suffer from work-related stress, while this number in Mediterranean Croatia is 9%. 7.73% of patients suffer from work-related stress, and there is no significant difference in relation to acute or chronic illness by region. Hospitalized patients with coronary illness are mainly satisfied with the surroundings in which they live with over 95% of them listing it as comfortable, so that this cannot be separated as a potential risk factor for coronary illness in neither men nor women. According to the SF-36 results, subjects surveyed with coronary illness feel worse compared to the general population in all parameters in which they rate their physical and mental status compared to the general population (p<0.05). The health of 70.3% of subjects surveyed worsened within the last year, while only 1.6% of sufferers felt much better. Physical and mental condition is better in men in all tested variables of survey SE-35 in comparison to women. The lowest difference is in the rating of one's own mental condition (3.22). There was a small difference in variables which demanded a positive answer in order to provide a good result (strength, vitality 6.3; consideration of general health 5.99 and mental condition 3.22). Conclusion: Considering environment, there is no significant difference between the sexes with regard to acute and chronic coronary illness in either region. Family- and work-related stress as a potential risk factor is more present in men in the continental region compared to the Mediterranean region. The socioeconomic pattern follows the characteristics of the general population in Croatia. Coronary disease sufferers, both men and women, are more educated than the general population. Coronary disease sufferers feel worse than the general population according to all parameters of survey SF-36. The smallest difference is in mental condition. Men feel better than women by all parameters. The healthy Mediterranean diet loses its historical difference according to region