What do we really know about contrast-induced nephropathy?

The increase in the number of diagnostic and therapeutic procedures by using contrast agents increases the possibility of developing of contrast-induced nephropathy (CIN). It has been noticed that CIN develops almost exclusively in invasive cardiovascular tests and procedures, while it develops very rarely during the CT-angiography. The risk factors for the development of CIN have been mentioned, recommendations for monitoring of renal function have been put forward and potential perioperative prevention methods have been mentioned. With most commonly used iodine ions as radiocontrast agents and the use of gadolinium, we can cause nephrogenic systemic sclerosis in patients with chronic renal failure, which sclerosis cannot be prevented or appropriately treated, and in addition to magnetic resonance imaging test with the use of contrast agents we should carefully evaluate the risks in relation to potential benefit of the test in nephrologic patients

Case report of dobutamine stress echocardiography selecting treatment strategy after acute pulmonary edema in a patient with acute coronary syndrome and severly depressed left ventricular function

Introduction: Assessment of myocardial viability can be done with a variety of imaging techniques, including nuclear, magnetic resonance and echocardiographic methods. Stress echocardiography offers higher specificity for postoperative ejection fraction improvement than perfusion techniques due to the requirement of viable myocardium with preserved contractile reserve.1,2 Low dose dobutamine is the preferred method for viability assessment. Myocardial revascularization without detected viability may be considered according to guidelines but portends worse prognosis3 and in this case, if feasible, left ventricular assist devices and heart transplantation may be considered. Dipyridamole in very low doses can be used for viability detection and may be considered due to a better safety profile than dobutamine in patients with uncontrolled hypertension or tachyarrythmias4. Case report: 64-years-old male patient, formerly treated for hypertension, type 2 diabetes mellitus and peripheral vascular disease (conservative therapy) was admitted to coronary care unit due to chest pain with modest troponin elevation. Coronary angiography was urgently performed and revealed highly significant stenoses in proximal parts of all coronary vessels with high syntax score (Figure 1, Figure 2). Immediate referral to the cardiac surgeon was suggested by an interventional cardiologist but upon completion of diagnostic procedure pulmonary edema was induced due to contrast infusion and hypertensive reaction (RR 180/100). Despite urgent treatment with parenteral nitrate, loop diuretics, morphine and non-invasive ventilation significant lactacidosis with pH 7.1 and acute respiratory failure ensued (SO2 72%). Bedside echocardiography showed left ventricular ejection fraction (LVEF) 30% with hypo/akinesia in all vascular territories. Patient was sedated, intubated and mechanically ventilated for a few hours. When he was clinically stabilized heart team opted for viability assessment in order to plan treatment (in case of no viability detected left ventricular assist device as a bridge to heart transplantation would be an option). Serial troponins showed only modest elevation above reference values. We opted for a low dose dobutamine protocol (up to 10 mcg/kg/min) when the patient was normotensive and clinically stable and verified LVEF increase to 54% (by Simpson method measuring 2- and 4-chamber with auto LVEF by speckle tracking) (Figure 3). The patient was transferred to cardiac surgery and had received LIMA to LAD and RIMA to PD which was a part of the right dominant coronary artery. Subsequently we documented good functional recovery (stress ECG test 4 months later was stopped after 6 minutes of Bruce protocol due to peripheral claudication with no chest pain or dyspnea and without significant ECG changes). Echocardiography 10 months after revascularization showed LVEF of 55% with normokynesia in all segments of myocardium. MSCT angiography verified bilateral femoral artery occlusion. With walking distance of 500 meters he has not been scheduled for operative/interventional treatment at this point in time and has completed hospital cardiac rehabilitation programme. Conclusion: Different imaging modalities can be used for viability detection in severely depressed left ventricular function. Pharmacological stress imaging has higher specificity for improvement of ejection fraction after revascularization than perfusion-based tests and may be done if the risk is perceived acceptable as it was in our patient after clinical stabilization

Tireotoksična periodična paraliza: prikaz slučaja

A case of thyrotoxic periodic paralysis in a 24-year-old male with hyperthyroidism is presented. Clinical manifestations included progressive symmetrical weakness that led to flaccid paralysis due to hypokalemia with concurrent thyrotoxicosis. Intravenous administration of potassium chloride resulted in complete regression of the symptoms of muscle weakness and paralysis. Hypokalemic periodic paralysis is an uncommon complication of thyrotoxicosis, which primarily occurs in Orientals, with a high male predominance, and has rarely been described in Caucasians.U radu je prikazan 24-godišnji muškarac s napadajem periodične paralize u hipertireozi. Prikazan je bolesnik s progresivnom simetričnom slabošću koja je dovela do mlohave paralize uslijed hipokalijemije tijekom tireotoksikoze. Nakon parenteralnog dodatka kalija (intravenskom primjenom kalijevog klorida) došlo je do potpunog povlačenja simptoma mišićne slabosti i paralize. Hipokalijemična periodična paraliza rijetka je komplikacija tireotoksikoze opisana u stanovnika Dalekog Istoka, i to prvenstveno u mlađih muškaraca, a iznimno se rijetko javlja u bijelaca

Evaluation of D-dimer test in patients on chronic hemodialysis.

Determining the value of D-Dimer is a routine test in case of suspecting thromboembolic event. In patients on chronic dialysis, baseline concentrations for biomarkers have changed in widespread clinical use, which prompted us to measure the concentration of D-dimer, due to disorders of hemostasis in chronic kidney failure. From the evaluation of the findings of D-dimer in 67 patients and the available literature we can conclude that the value of the test in the diagnosis of thromboembolic events has significantly decreased

A Case of Transient Constrictive Pericarditis in a 42 year old Patient

We report a case of 42 year old patient with acute idiopathic pericarditis in whom we describe transient cardiac constriction, consisting of the temporary development of features of constrictive pericarditis with subsequent return to normality after medical therapy alone. After a mean of 6 months, there have been no recurrences of constrictive physiology or clinical symptoms. The results of our study suggest that patients who have constrictive features early in the course of their illness and are hemodynamically stable should be considered for a trial of conservative therapy before pericardiectomy is pursued

Protocol for the treatment of acute ST-segment elevation myocardial infarction in the County of Međimurje.

Međimurska  županija  jedna  je  od  prvih županija u Republici Hrvatskoj koja se uključila u  projekt  liječenja  akutnog infarkta miokarda s elevacijom ST-segmenta (STEMI) putem Hrvatske mreže  primarne perkutane koronarne intervencije. U  tu svrhu, nakon američkih i europskih smjernica,  još 2006. god. uredili smo vlastiti Protokol za  liječenje  STEMI i  u  tiskanom  ga  obliku podjelili  svim  članovima Hrvatskog  liječničkog  zbora  u  županiji. Godine 2012. preuredili smo protokol, sukladno novostima iz  Smjernicama Europskog kardiološkog društva za STEMI i revaskularizaciju miokarda. Svrha ovog članka je precizirati i standardizirati prehospitalni postupak i time osigurati siguran i brz transport pacijenta do intervencijskog centra.The County of Međimurje is one of the first counties in the Republic of Croatia which is involved in the project of treatment of acute ST-segment elevation myocardial infarction (STEMI) through the Croatian Primary Percutaneous Coronary Intervention Network. For this purpose, following the adoption of American and European guidelines, we adapted our own Protocol for the treatment of STEMI in 2006 and distributed it in printed form to all members of the Croatian Medical Association in the County. In 2012, we have rearranged the protocol according to the novelties from the European Society of Cardiology Guidelines for STEMI and myocardial revascularization. The purpose of this article is to specify and standardize pre-hospital process, thereby ensuring a safe and quick transport of patients to the intervention center

Comparison of the Hospital Arrival Time and Differences in Pain Quality Between Diabetic and Non-Diabetic STEMI Patients

The aim of our study was to determine whether diabetic ST segment elevation myocardial infarction (STEMI) patients arrive in the emergency room (ER) later than non-diabetics, compare the differences in pain quality and quantity between those groups, and measure differences in the outcome after an index hospitalization. A total of 266 patients with first presentation of STEMI were included in our study during a period of two years, 62 with diabetes and 204 without diabetes type 2. Pain intensity and quality at admission were measured using a McGill short form questionnaire. Diabetic patients did not arrive significantly later than non-diabetic (χ²; p = 0.105). Most diabetic patients described their pain as "slight" or "none" (χ²; p < 0.01), while most non-diabetic patients graded their pain as "moderate" or "severe" (χ²; p < 0.01). The quality of pain tended to be more distinct in non-diabetic patients, while diabetic patients reported mainly shortness of breath (χ²; p < 0.01). Diabetic patients were more likely to suffer a multi-vessel disease (χ²; p < 0.01), especially in the late arrival group. Therefore, cautious evaluation of diabetic patients and adequate education of target population could improve overall survival while well-organized care like a primary PCI Network program could significantly reduce CV mortalit