Uloga tilt testa u diferencijalnoj dijagnostici neobjašnjene sinkope

The aim of this retrospective study (February 2012 – September 2014) was to assess the role of head-up tilt-table test in patients with unexplained syncope. It was performed on 235 patients at Clinical Department of Cardiology, Sestre milosrdnice University Hospital Center. Patients were classified according to test indications: group A (convulsive syncope, n=30), group B (suspected vasovagal syncope, n=180), and group C (paroxysmal vertigo, n=25). The groups were analyzed and compared according to demographic data (age and gender), referral specialist (cardiologist, neurologist, and others), and test results (positive/negative) with specific response (cardioinhibitory, vasodepressor, or mixed). Groups A and B were referred most frequently by neurologists and cardiologists (p<0.05). The test was positive in 34 (14.5%) of all evaluated patients (5 in group A and 29 in group B), of which 13 (38.2%) had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response. In the cardioinhibitory subgroup, three patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal electroencephalography were on antiepileptics. During headup tilt-table testing, they had bradycardia (heart rate 30.0±5.0 beats/min) and prolonged asystole (13.7±11.0 seconds) with development of typical convulsions. These three subjects got a permanent pacemaker (atrial/ventricular stimulation, heart rate control) and anticonvulsive therapy was slowly withdrawn with no syncope recurrence during 24-month follow up. In conclusion, head-up tilt-table test has an important role in the evaluation of patients with unexplained syncope and in differential diagnosis of vasovagal syncope. The indication for pacemaker implantation, strictly following the European Society of Cardiology guidelines, proved to be effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.Cilj ovoga retrospektivnog istraživanja (veljača 2012. – rujan 2014. godine) bio je ispitati ulogu tilt testa u bolesnika s neobjašnjenom sinkopom. Provedeno je na 235 bolesnika u Zavodu za kardiologiju KBC-a “Sestre milosrdnice”. Bolesnici su klasificirani prema indikaciji za izvođenje testa: skupina A (konvulzivna sinkopa, n=30), skupina B (suspektna vazovagalna sinkopa, n=180) i skupina C (paroksizmalni vertigo, n=25). Skupine su analizirane i uspoređivane prema njihovim demografskim podacima (dob, spol), specijalistima koji su ih uputili na pretragu (kardiolozi, neurolozi, ostali) te rezultatima (pozitivan/negativan) i specifičnim odgovorima (kardionhibicija, vazodepresija ili mješoviti) tilt testa. Skupine A i B najčešće je na testiranje uputio neurolog i kardiolog (p<0,05). Test je bio pozitivan u 34 (14,5%) bolesnika (5 u skupini A i 29 u skupini B), od kojih je 13 (38,2%) imalo kardioinhibicijski, 11 (32,4%) mješoviti i 10 (29,4%) vazodepresivni odgovor. U kardioinhibicijskoj podskupini troje bolesnika (23,1%, 2 muškarca/1 žena, srednje dobi 28,5 godina) je imalo normalan nalaz elektroencefalografije i uzimali su antiepileptike. Tijekom izvođenja testa zabilježili smo bradikardiju (30,0±5,0 otkucaja/min) i produženu asistoliju (13,7±11,0 sekunda) uz pojavu tipičnih konvulzija. U sve troje bolesnika ugrađen je trajni elektrostimulator (atrijska/ventrikulska stimulacija, kontrola frekvencije) i ukinuta je antikonvulzivna terapija, nakon čega su tijekom 24 mjeseca praćenja bili bez recidiva sinkope. U zaključku, tilt test ima važnu ulogu u procjeni bolesnika s neobjašnjenom sinkopom i u diferencijalnoj dijagnostici vazovagalne sinkope. Indikacija za ugradnju elektrostimulatora, strogo slijedeći smjernice Europskoga kardiološkog društva, pokazala se učinkovitom u sprječavanju recidiva sinkopa u bolesnika s kardioinhbicijskom konvulzivnom sinkopom

Sport i slobodno vrijeme u bolesnika s kardiomiopatijom

Cardiomyopathy (hypertrophic, dilated, left ventricular non-compaction and arrhythmogenic cardio- myopathy) is primarily a genetic disease associated with an increased risk of potentially fatal cardiac arrhythmias and sudden death/cardiac arrest during exercise. The diagnosis of cardiomyopathy is based on complete cardiac evaluation with detailed personal and family history, 12-lead ECG, echocardiogram, cardiac magnetic resonance imaging (CMRI), stress-test- ing, genetic testing and counseling. The differentiation between the physiological adaptation to exercise and cardiomyopathy is of the mutual importance. In this review, we outline the latest recommendations published by the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC) on sport and leisure-time physical activity in patients with cardiomyopathy. It offers recommendations for practicing cardiologists and sport physi- cians managing athletes with cardiomyopathies and provides advice for safe participation in competitive sport at professional and amateur level, as well as in a leisure-time physical activity.Kardiomiopatija (hipertrofijska, dilatacijska, hipertrabekulirana lijeva klijetka, aritmogena kardio- miopatija) je primarno genetska bolest povezana s povećanim rizikom potencijalno fatalnih kardijal- nih aritmija i iznenadnom smrću/kardijalnim arestom tijekom vježbanja. Dijagnoza kardiomiopatije bazirana je na kompletnoj kardiološkoj obradi s detaljnom osobnom i obiteljskom anamnezom, učinjenim elektrokardiogramom, ultrazvukom srca, magnetskom re- zonancijom srca, stres testiranjem, genetskim testiranjem i savjetovanjem. Razlikovanje fiziološke prilagodbe srca na vježbanje od kardiomiopatije je od neobične važnosti. U ovom pregledu donosimo najnovije preporuke Sekcije za sportsku kardiologiju pri Europskom drušvu za preventivnu kardiologiju (engl. EAPC) o sportskoj i rekreativnoj fizičkoj aktivnosti u bolesnika s kardiomiopatijom. Ona sadrži preporuke za kardiologe i sportske liječnike koji se bave sportašima s kardiomiopatijama i donosi savjete o sigurnom participiranju u kompetitivnom sportu na profesionalnoj i amaterskoj razini, kao i kod rekreativne fizičke aktivnosti

Sport activity at patients with myocarditis and pericarditis

Mycarditis and pericarditis may be related with sudden cardiac death/cardiac arrest (SCD/CA) in athletes, not exclusively in those with reduced left ventricular systolic function, but also in subjects with normal cardiac function related to arrhythmias generated in the area of myocardial necrosis and scar. The diagnosis is based on a complete cardiac evaluation (12-lead ECG, echocardiography, cardiac magnetic resonance imaging, and endomyocardial biopsy). In this review, we outline the latest recommendations published by the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC) on sport activity with these patients. It offers recommendations for practicing cardiologists and sport physicians for safe participation in competitive sport at professional and amateur level. Participation in competitive sport should be considered on an individual basis, after the evaluation of the disease characteristics and risk determinants, and complete resolution of the inflammatory process

Utjecaj meteoroloških parametara i onečišćenja zraka na preglede u Hitnoj službi zbog kardiovaskularnih bolesti u gradu Zagrebu, Hrvatska

The aim of this study was to investigate whether nitrogen dioxide (NO2), ozone (O3), and certain meteorological conditions had an impact on cardiovascular disease (CVD)-related emergency department (ED) visits in the metropolitan area of Zagreb. This retrospective, ecological study included 20,228 patients with a cardiovascular disease as their primary diagnosis who were examined in the EDs of two Croatian University Hospitals, Sisters of Charity and Holy Spirit, in the study period July 2008-June 2010. The median of daily CVD-related ED visits during the study period was 28 and was the highest during winter. A significant negative correlation was found between CVD-related emergency visits and air temperature measured no more than three days prior to the visit, and the highest negative correlation coefficient was measured two days earlier (R=–0.266, p≤0.001). The number of CVD-related emergency visits significantly correlated with the average NO2 concentration on the same day (R=0.191, p<0.001). The results of multiple stepwise regression analysis showed that the number of CVD-related emergency visits depended on air temperature, and NO2 and O3 concentrations. The higher the air temperatures, the lower the number of daily CVD-related emergency visits (p<0.001). An increase in NO2 concentrations (p=0.005) and a decrease in O3 concentrations of two days earlier (p=0.006) led to an increase in CVD-related ED visits. In conclusion, the decrease in O3 concentrations and the increase in NO2, even if below the legally binding thresholds, could be associated with an increase in CVD-related emergency visits and a similar effect was observed with lower temperature measured no more than three days prior to the visit.Cilj istraživanja bio je ispitati imaju li dušikov dioksid (NO2), ozon (O3) i određene meteorološke prilike utjecaja na broj pregleda u Hitnoj službi (HS) zbog kardiovaskularnih bolesti (KVB) u gradu Zagrebu. U ovu retrospektivnu, ekološku studiju bilo je uključeno 20.228 bolesnika s primarnom dijagnozom jedne od kardiovaskularnih bolesti, pregledanih u HS-u dviju kliničkih bolnica: Sestre milosrdnice i „Sveti Duh“, u promatranom razdoblju od srpnja 2008. do lipnja 2010. Medijan dnevnih pregleda u HS-u zbog KVB-a tijekom promatranog razdoblja bio je 28, a najviše tijekom zime. Značajna negativna korelacija utvrđena je između broja pregleda u HS-u zbog KVB-a i temperature zraka do tri dana ranije, s najvećim negativnim koeficijentom korelacije dva dana ranije (R=-0,266, p=0,000). Broj pregleda u HS-u zbog KVB-a značajno korelira s prosječnim koncentracijama NO2 na isti dan (R=0,191, p=0,000). Rezultati stupnjevite regresijske analize pokazali su da broj pregleda u HS-u zbog KVB-a ovisi o temperaturi zraka i koncentraciji NO2 i O3. Što je viša temperatura zraka, to je manji broj pregleda u HS-u zbog KVB-a (p=0,000), a slično vrijedi i za koncentraciju ozona (p=0,006). Povećanje koncentracije NO2 povezano je s povećanjem broja pregleda u HS-u zbog KVB-a (p=0,005). Zaključno se može ustvrditi da povećanje koncentracije NO2 može biti povezano s povećanjem broja pregleda u HS-u zbog KVB-a, čak ako su navedene koncentracije unutar pravnoobvezujućih razina, sa sličnim utjecajem niže temperature zraka do tri dana ranije

Ortostatska intolerancija: sindrom posturalne ortostatske tahikardije s vazovagalnom sinkopom

A 28-year-old female with a history of situational syncope and a new-onset right sided hemiparesis is described. Tilt-up table test revealed the postural orthostatic tachycardia syndrome followed by vasovagal syncope. Neurological and internal medicine tests showed no particular disorders. The patient underwent autonomic physical training and the tilt-up test performed three months later showed improvement of the autonomic system in terms of lower heart beat rate of the postural orthostatic tachycardia syndrome and longer duration of the test. This case report describes longstanding idiopathic dysautonomia that can be improved by nonpharmacological treatment, while reminding that this medical condition may also be the cause of syncope.Prikazuje se 28-godišnja bolesnica s anamnezom višegodišnje situacijske sinkope i novonastalom desnostranom hemiparezom. Učinjen tilt-up table testom utvrđen je sindrom posturalne ortostatske tahikardije (engl. POTS , postural orthostatic tachycardia syndrome), nakon kojeg je uslijedila vazovagalna sinkopa. Neurološkom i internističkom obradom nije utvrđen eventualan drugi uzrok sinkope. Tijekom slijedeća tri mjeseca bolesnica je u kućnim uvjetima provodila ortostatske vježbe autonomnog sustava, nakon čega je učinjen kontrolni tilt-up table test kojim je objektivizirano poboljšanje statusa autonomnog sustava u smislu nižih vrijednosti frekvencije tahikardije POTS -a i duljeg trajanja testa, odnosno održavanja ortostaze. Ovaj slučaj govori o višegodišnjoj idiopatskoj disautonomiji na koju je moguće utjecati nefarmakološkim metodama te je ujedno i podsjetnik na jedan od mogućih uzroka sinkope

Percutaneous Coronary Intervention Registry in University Hospital Centre Sestre milosrdnice

Unatoč činjenici da je koronarna bolest srca (KBS) prvi uzrok smrtnosti, u Hrvatskoj ne postoji sveobuhvatni registar osoba koje boluju od KBS, a registre za perkutanu koronarnu intervenciju (PCI) imaju samo pojedini laboratoriji za kateterizaciju srca, koji se značajno razlikuju i nisu međusobno kompatibilni. Laboratorij za invazivnu i intervencijsku kardiologiju Kliničkog bolničkog centra Sestre milosrdnice 1. siječnja 2011. godine je oformio vlastiti registar za PCI. Ovaj registar dostupan je u elektroničkom obliku, s visokim stupnjem zaštite pristupa. U registar se upisuje 45 različitih podataka koji su podijeljeni u pet skupina: opći podaci, čimbenici rizika, simptomi i znakovi akutne bolesti, zahvat i utrošeni materijal te dijagnostički i terapijski nalaz. Osnovne razlike ovog registra, u odnosu na postojeće, jest model prema kojem je upis podataka za svakog bolesnika podijeljen između medicinskog tehničara, inžinjera medicinske radiologije i intervencijskog kardiologa, izrazita jednostavnost, kratko vrijeme potrebno za upis te istovremeno ispisivanje nalaza kateterizacije. Tek nakon što su ispunjeni svi traženi podaci intervencijski kardiolog upisuje dijagnozu i nalaz te se podaci zaključavaju. Na taj smo način osigurali da se u bazu podataka upisuju sve varijable vezane uz svaku pojedinačnu učinjenu intervenciju, mogu ispisati u Excel ekstenziji te implementirati u bilo koji registar. Nakon prve godine uporabe zaključili smo da je Registar značajno olakšao svakodnevni rad te da predstavlja nadopunu novih tehnologija uvedenih u liječenje KBS. Formiranje ovog Registra samo je korak prema zajedničkom cilju, formiranju nacionalnog registara PCI te sudjelovanju Republike Hrvatske u europskom registru bolesnika s akutnim koronarnim sindromom.Despite the fact that coronary heart disease (CHD) is the first cause of mortality, in Croatia there is no comprehensive registry of patiens with CHD, while the registries for percutaneous coronary intervention (PCI) are maintained only by specific cardiac catheterization laboratories, which greatly differ from each other and are not mutually compatible. Laboratory of Invasive and Interventional Cardiology of the University Hospital Centre Sestre milosrdnice established its own PCI registry from 1st January 2011. This registry is available in electronic format, with a high access protection level. The registry includes 45 different data which are divided into 5 groups: general data, risk factors, symptoms and signs of acute disease, procedure and materials used, and diagnostic and therapeutic results. The main differences of this registry compared to the existing registries is a model according to which the entry of data for each patient are divided between the medical technician, medical radiology engineer and interventional cardiologist, its utmost simplicity, short time required for the registration and writing the findings of catheterization at the same time. Only after all the required data have been filled in, the interventional cardiologist will enter a diagnosis and findings and the data are locked. In this way we have ensured that all the variables relating to each individual intervention performed are entered in the database, they can be written in Excel extension and implemented in any registry. After the first year of use, we have reached a conclusion that the Registry has greatly facilitated the daily work and that is complements the new technologies introduced in the treatment of CHD. The establishment of this Registry is only a step towards a common goal, establishment of the national PCI registry and participation of the Republic of Croatia in the European registry of patients with acute coronary syndrome

Kronična opstruktivna plućna bolest i zatajenje srca: tako blizu, a tako daleko

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) both are global epidemics with substantial burden on morbidity and mortality. They present major challenges to healthcare providers and often coexsist. Multiple interactions exist between these conditions. COPD is often responsible for delayed diagnosis of HF and vice versa, since both conditions have similar symptoms such as dyspnea and poor exercise tolerance based on the skeletal myopathic response rather than the primary organ failure. Patients with COPD also have an increased risk of developing HF and higher hospitalization and death rates compared with HF patients without COPD. Echocardiography and pulmonary function tests along with natriuretic peptides should be performed and carefully interpreted. Diagnostic assessment of both conditions present in the same patient is often difficult, but therapeutic approach is also often non-adherent to current guidelines. For example, patients with coexisting COPD and HF receive beta-blockers at disappointingly low rates below 20%. Closer collaboration between cardiologists and pulmonologists is required for better identification and management of concurrent COPD and HF.Kronična opstruktivna plućna bolest (KOPB) i zatajenje srca među vodećim su uzrocima pobolijevanja i smrtnosti u svijetu. Unatoč brojnim poveznicama, kod bolesnika s kroničnom opstruktivnom plućnom bolešću zatajenje srca ostaje često neprepoznato, no vrijedi i obratno. Kod bolesnika s prethodno utvrđenom KOPB dijagnoza zatajenja srca se često postavlja prekasno, no vrijedi i obratno, ponajviše zbog vrlo sličnih simptoma i znakova bolesti poput zaduhe i intolerancije napora uslijed disfunkcije skeletne muskulature. Bolesnici s KOPB-om imaju viši rizik zatajenja srca, ali i češće hospitalizacije i smrtnost od bolesnika sa zatajenjem srca bez pridružene KOPB. Ehokardiografija, testovi plućne funkcije i određivanje natriuretskih peptida trebaju biti neizostavni dio dijagnostičkog postupka i reevaluacije bolesnika uz bližu suradnju subspecijalista kardiologa i pulmologa sa svrhom ne samo pouzdane dijagnoze, već i optimalnog pristupa liječenju bolesnika s često prisutnim komorbiditetima