LEFT-SIDED INFERIOR VENA CAVA ASSOCIATED WITH PROXIMAL DEEP VENOUS THROMBOSIS OF THE LEFT LOWER EXTREMITY.

Left-sided inferior vena cava (IVC) is a rare congenital venous anomaly that is most frequently detected incidentally during abdominal computer tomography scanning. However, as in the case presented, the first clinical manifestation of this anomaly may be deep venous thrombosis (DVT) of lower extremities. Therefore, left-sided IVC should be kept in mind in case of inferior DVT, especially in young patients with no predisposing thrombotic risk factors.

Three-Dimensional Transesophageal Echocardiography in the Diagnosis and Treatment of Mitral Prosthetic Valve Endocarditis-A Narrative Review.

Despite advances in diagnosis, imaging methods, and medical and surgical interventions, prosthetic valve endocarditis (PVE) remains an extremely serious and potentially fatal complication of heart valve surgery. Characteristic changes of PVE are more difficult to detect by transthoracic echocardiography (TTE) than those involving the native valve. We reviewed advances in transesophageal echocardiography (TEE) in the diagnosis of PVE. Three-dimensional (3D) TEE is becoming an increasingly available imaging method combined with two-dimensional TEE. It contributes to faster and more accurate diagnosis of PVE, assessment of PVE-related complications, monitoring effectiveness of antibiotic treatment, and determining optimal time for surgery, sometimes even before or without previous TTE. In this article, we present advances in the treatment of patients with mitral PVE due to 3D TEE application.

Deep breathing: A simple test for white coat effect detection in primary care.

AIM: White coat hypertension (WCH) is hard to differentiate from sustained hypertension without the use of 24-h ambulatory blood pressure monitoring (ABPM). This invaluable procedure is nevertheless cumbersome and expensive. A simple test of deep breathing over 30 s (DBT) was proposed as a method to unveil WCH. METHODS: Two hundred and fourteen outpatients referred for the evaluation of uncontrolled hypertension (blood pressure, BP > 140/90 mmHg despite therapy) were enrolled in a controlled clinical trial. The examinees were randomly divided in two groups: control (n = 108; sequential standard BP measurement only) and intervention (n = 106; the same+DBT), using ABPM as the reference standard. RESULTS: The relative decrease in BP was significantly larger in the intervention group than in the control group, by 15/4 mmHg (p = 0.005). The best detection of WCH was obtained at ≥ 15% systolic BP reduction following DBT, with a positive predictive value of 94.0% (95% CI 72.0-100.0). BP reduction of ≤ 8% may rule WCH out with a negative predictive value of 78.4% (95% CI 64.0 - 85.9). CONCLUSION: DBT is a reliable, inexpensive and fast test for the detection of WCH in primary care.

[LEFT VENTRICULAR NON-COMPACTION]. / NEKOMPAKTNA LIJEVA KLIJETKA.

Left ventricular non-compaction (LVNC) is a rare cardiomyopathy, which is today, due to modern ultrasound technology more frequently detected in clinical practice. It is caused by the failure of normal embryonic development of the myocardium from loosely arranged muscle fibers to the mature compacted form of myocardium. Morphologic presentation consists of unique two-layered structure, a thick noncompacted endocardial and a thin compact epicardial layer, in infero-lateral and apical segments. The endocardial layer contains loosely arranged muscle fibers, prominent trabeculations and deep perfused intertrabecular recesses. It could be diagnosed both as an infantile or adult type, appearing sporadically or among families where it is transferred x-linked or autosomal dominant. The recognition of the disease is mandatory because of its high mortality and morbidity due to the progressive heart failure, thromboembolic events and lethal arrhythmias. Echocardiography is the procedure of choice to confirm the diagnosis and in the follow-up of patients with LVNC. A literature review about LVNC pathogenesis, diagnostis, and treatment was discussed.

Relationship between interleukin-6 and cardiac involvement in systemic sclerosis.

OBJECTIVES: To explore the relationship between IL-6 levels and echocardiographic abnormalities, and N-terminal probrain natriuretic peptide (NT-proBNP) levels in SSc patients and to correlate tested parameters with European Scleroderma Activity (EUSTAR) score. METHODS: This case-control study included 31 SSc patients with preserved left ventricular ejection fraction (LVEF) and 32 matched healthy controls. Serum IL-6 and NT-proBNP levels were measured and subjects were evaluated by conventional and pulsed-wave tissue Doppler echocardiography. RESULTS: The level of IL-6 was significantly increased in patients with SSc (3.2 vs 2.2 pg/ml, P < 0.001). SSc patients had significantly lower values of LV systolic (7.7 vs 9.25 cm/s, P < 0.001) and early diastolic (8.7 vs 10.3 cm/s, P = 0.014) myocardial velocities and higher E/e' (9.04 vs 7.37, P = 0.001) ratio, although there was no between-group difference according to LVEF (68% vs 65%, P = 0.248). On evaluating the right ventricle there was no significant between-group difference in systolic tricuspid annular velocity (13 vs 13.9 cm/s, P = 0.105), but the peak early diastolic velocity was significantly lower (11.7 vs 13.6, P = 0.044) and E/e' was significantly higher (4.3 vs 3.38, P = 0.008) in SSc patients. IL-6 level showed correlation with LV mean e' (r = -0.57, P = 0.001), E/e' (r = 0.55, P = 0.001) and NT-proBNP (r = 0.52, P = 0.003). EUSTAR score correlated with LV E/e' (r = 0.48, P = 0.006), mean e' (r = -0.67, P < 0.001), mean s' (r = -0.51, P = 0.004), NT-proBNP (r = 0.60, P < 0.001) and IL-6 (r = 0.79, P < 0.001). CONCLUSION: IL-6 level is increased in patients with SSc and significantly correlates with LV diastolic dysfunction, NT-proBNP and EUSTAR score. These results support the role of IL-6 in the development of cardiac disease in SSc patients.

[Thromboembolic and bleeding risk assessment in patients with non-rheumatic atrial fibrillation using CHA2DS2-VASc and HAS-BLED scoring systems]. / Procjena tromboembolijskog rizika i rizika od krvarenja u bolesnika s nereumatskom atrijskom fibrilacijom primjenom bodovnih sustava CHA2DS2-VASC i HASBLED.

It is estimated that approximately 1-2% of the world population are affected with non-rheumatic atrial fibrillation (nAF). The most frequent complications of this arrhythmia are thromboembolic events, primarly ischemic stroke. In comparison with patients in sinus rhythm, stroke affected nAF patients have more severe clinical course and significantly higher mortality rate, and the survivors have significantly lower recovery rate and more serious permanent mental and physical impairments. The administration of anticoagulants to patients with nAF significantly reduces the incidence of stroke, while those who were stroke affected during the anticoagulant therapy show better treatment outcomes. Therefore, professional associations guidelines recommend the anticoagulant treatment for the majority of patients with nAF. The fear of bleeding caused by anticoagulants results in their frequently unjustified omission from the therapy in patients with high thromboembolic risk. This paper presents CHA2DS2-VASc- and HAS-BLED systems recommended for thromboembolic and bleeding risk assessment when deciding on thromboprophylactic therapy in patients with nAF.

[Anticoagulant therapy in patients with permanent atrial fibrillation - evidence based medicine and clinical practice]. / Antikoagulantno lijecenje u bolesnika s trajnom fibrilacijom atrija - medicina utemeljena na dokazima i klinicka praksa.

Objective of study was to assess the concordance of the tromboprophylactic treatment in patients with permanent atrial fibrillation (pAF) with guidelines of the European Society of Cardiology. Prospective cross-sectional study consecutivelly included 674 patients (400 S59%C male) discharged from cardiology department with the diagnosis pAF. The thromboembolic risk (TE) has been established according to CHA2DS2-VASc score, whereas the bleeding risk has been assessed according to HAS-BLED score. 578 (86%) belonged to the group of high, 57 (8%) to the group of moderate, and 39 (6%) patients to the group of low TE risk. 601 (89%) patients received thromboprophylaxis: 310 (46%) warfarin, 258 (38%) acetylsalicylic acid, and 33 (5%) patients clopidogrel. Warfarin has been prescribed to 47% of patients with high, 49% of patients with moderate and to 26% of patients with low TE risk (P=0.03). Acetylsalicylic acid (ASA) has equally been prescribed to patients of all TE risk groups: low, moderate and high (39% vs. 39% vs.38%/o; P=0.998). ASA (P<0.001) and warfarin (P=0.007) have been used more frequently in the group of patients with high bleeding risk, in which the same incidence of warfarin and ASA administration has been registered (53% vs. 47%; P=0.416). Age > or =75 has been an independent predictor of non-administration (OR 1.7; 95% CI 1.2-2.4; P=0.003), whereas the history of stroke was for warfarin administration (OR 0.47; 95% CI 0.29-0.76; P-0.002). In prescribing thromboprophylaxis to patients with pAF, cardiologists do not observe the recommended clinical guidelines. Despite nonexistence of contraindications, a significant number of patients with high TE risk has not been administered warfarin. At the same time, warfarin has been administered to the patients with low TE risk, exposing them unnecessarily to the undesired effect of anticoagulant treatment.

Echocardiography in the detection of lead-related infective endocarditis.

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Cardiac myxoma: benign, but deadly disease.

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The Influence of Accelerated Carbonation on Physical and Mechanical Properties of Hemp-Fibre-Reinforced Alkali-Activated Fly Ash and Fly Ash/Slag Mortars.

The physical and mechanical properties of hemp-fibre-reinforced alkali-activated (AA) mortars under accelerated carbonation were evaluated. Two matrices of different physical and chemical properties, i.e., a low Ca-containing and less dense one with fly ash (FA) and a high Ca-containing and denser one with FA and granulated blast furnace slag (GBFS), were reinforced with fibres (10 mm, 0.5 vol% and 1.0 vol%). Under accelerated carbonation, due to the pore refinement resulting from alkali and alkaline earth salt precipitation, AA hemp fibre mortars markedly (20%) decreased their water absorption. FA-based hemp mortars increased significantly their compressive and flexural strength (40% and 34%, respectively), whereas in the denser FA/GBFS matrix (due to the hindered CO2 penetration, i.e., lower chemical reaction between CO2 and pore solution and gel products), only a slight variation (±10%) occurred. Under accelerated carbonation, embrittlement of the fibre/matrix interface and of the whole composite occurred, accompanied by increased stiffness, decreased deformation capacity and loss of the energy absorption capacity under flexure. FA-based matrices exhibited more pronounced embrittlement than the denser FA/GBFS matrices. A combination of FA/GBFS-based mortar reinforced with 0.5 vol% fibre dosage ensured an optimal fibre/matrix interface and stress transfer, mitigating the embrittlement of the material under accelerated carbonation.

Echocardiographic appearance of a hydatid cyst of the papillary muscle and chordae tendineae.

A 24-year-old woman with a history of hydatid disease of the lung and brain, which was treated surgically and medically with albendazole, was admitted because of syncope. Echocardiography demonstrated a mass in the anterolateral papillary muscle and chordae tendineae. Despite negative serologic tests for Echinococcus granulosus, cytology and histology of the surgically removed mass confirmed hydatid disease. The patient was discharged and treated further with albendazole and praziquantel.

Three-dimensional echocardiography in rapid differentiation of the left ventricular mass - a case of left ventricular myxoma.

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Predictive impact of coronary risk factors in southern Croatia: a case control study.

The aim of study was to compare the impact of coronary risk factors on the incidence of acute myocardial infarction (MI) between Croatia, Central and Eastern Europe, and the rest of the world. As a part of the large international INTERHEART case-control study of acute MI in 52 countries (15,152 cases and 14,820 controls) we have investigated the relationship between several known risk factors (smoking, history of hypertension or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood apolipoproteins, and psychosocial factors) and MI among patients without previously known coronary heart disease in Southern Croatia. The main identified MI risk factors in Southern Croatia were heavy smoking (>20 cig/day; OR 3.86; 95% CI 2.31-6.46), diabetes mellitus (OR 2.83; 95% CI 1.58-5.23), abnormal ratio of B-100 and A-1 apolipoproteins (OR 2.23; 95% CI 1.28-3.89), elevated waist to hip ratio (OR 1.96; 95% CI 1.21-3.18), and arterial hypertension (OR 1.68; 95% CI 1.15-2.45). Protective was moderate alcohol consumption (OR 0.63; 95% CI 0.40-0.99). The prevalence of major MI risk factors in Croatia is similar to that in the surrounding countries and in the world, accounting for over 90% of the population attributable risk. However, physical activity, dietary and psychosocial factors are seemingly less important in this country, while moderate alcohol consumption is more protective than regionally or globally.

Isolated left ventricular non-compaction cardiomyopathy associated with ventricular preexcitation: a case report.

Isolated left ventricular non-compaction (ILVNC) is one of the most misclassified cardiomyopathies. It is caused by failure of normal embryonic development of the myocardium from loosely arranged muscle fibers to the mature compacted form of myocardium, but it seems that etiology is not exclusively congenital. Diagnosis of ILVNC is mostly missed because of lack of awareness and knowledge. The recognition of the disease is mandatory, because of its high mortality and morbidity due to the progressive heart failure, thromboembolic events and lethal arrhythmias. We report of a family in which two adult members were found to have ILVNC. A literature review about ILVNC pathogenesis, diagnosing, and treatment was discussed.

Comparison between continuous ambulatory arterial blood pressure monitoring and standard blood pressure measurements among patients of younger and older age group.

The purpose of the study was to evaluate whether there is a difference between blood pressure measured in a physician's office and the average 24 hr continuous blood pressure monitored by hypertensive patients at home. If there is a difference between these two situations then is it possibly the result of a blood pressure response by the patient to the physician which is known as "white coat effect" or "white coat hypertension". We studied 80 hypertensive outpatients which were divided into two groups of 40 patients each--a younger patient group, with a mean age of 22.8 +/- 1.8 years, and an older patient group with a mean age of 50.3 +/- 5.7 years. They were selected because they had been diagnosed as essentially hypertension grade 1, according to 2007 ESH/ESC Guidelines, or the USA Joint National Committee Guidelines (JNC 7) (i.e., arterial blood pressure > 140/90 mm Hg and < 160/100 mmHg) and 35 were not having any antihypertensive treatment. All participants in the study went through a two-week "wash-out" period without medication. At the beginning of the study blood pressure was measured using the Riva-Rocci-Korotkoff method (mercury sphygmomanometer) after 5 minutes of rest and with the patient in the sitting position. The average of the two last measurements by sphygmomanometer was used in the analysis. The subsequent measurement was made by continuous ambulatory blood pressure monitoring (SpaceLabs 90207 device). Continuous ambulatory blood pressure monitoring revealed that 17 patients of the younger age group (42.5%) who were diagnosed hypertonic, according to mercury sphygmomanometeric measurement, were in fact normotonic. In the older age group only 7 (17.5%) of participants were normotonic during 24 hr blood pressure monitoring. The proportion of miss-diagnosed normotonic younger patients was directly related to elevated clinic blood pressure, which could be referred to as office hypertension or isolated clinic hypertension (white coat hypertension). This was statistically significant (chi2 = 5.95; p = 0.015). Hypertension diagnosed in younger patients based only on occasional doctor's office mesurements, using a mercury sphygmomanometer, could be miss-interpreted and treated as the start of arterial hypertension. This could sometimes have unwanted results due to the side effects of precipitate antihypertensive medication as well as the unnecessary cost of testing, cost of treatment, prevalence of white-coat hypertension at baseline, and the varying incidence of new hypertension after the initial screening. The results indicate a potential savings of 3-14% in the cost of care for hypertension, and a 10-23% reduction in treatment days when ambulatory blood pressure monitoring is incorporated into the diagnostic process. Therefore CABPM should be used as a legitimate method in the diagnosing of "white coat hypertension", particularly in young patients. The identification of white coat hypertensive"' patients should be followed by a search for metabolic risk or organ damage using the latest guidelines, and medication should start after an organ damage or cardiovascular risk assesement.

[Coronary heart disease risk factors in Croatia and worldwide: results of the Interheart study]. / Koronarni cimbenici rizika u hrvatskoj i u svijetu: rezultati Interheart studije.

OBJECTIVES: In the past 30 years, an increased cardiovascular disease (CVD) mortality has been observed in both industrialized and transition countries. The latter countries, such as Croatia, are considered to be in the third stage of epidemiological transition, defined as having 35%-65% of total as CVD mortality, predominantly ischemic heart disease and cerebrovascular disease. The CVD epidemic in transition countries is due to increasing rates of hypertension, obesity, smoking and sedentary lifestyle. Among CVD diagnoses, the most important is coronary heart disease (CHD), which varies in incidence among different ethnic groups and countries. Worldwide, it is estimated that nine potentially modifiable risk factors contribute to more than 90% of myocardial infarctions. Approximately 80%-90% of patients with symptomatic CHD and more than 95% of patients who died from CHD had at least one of the four traditional risk factors (smoking, hypertension, hyperlipidemia, and diabetes). AIM: Little research has been done to quantify the relationship between the prevalence of CHD risk factors and acute myocardial infarction (AMI) in Croatia. In south Croatia, we expected that specific dietary patterns and lifestyle would have favorable effects on CHD risk. Therefore, we have conducted a case-control study to examine the relationship between several CHD risk factors (smoking, hypertension, hyperlipidemia, diabetes, obesity, alcohol, fruit and vegetable consumption, and physical activity) in AMI patients and persons without previously known CHD in south Croatia. METHODS: We took part in the INTERHEART study over 4 years (1999-2002). Cases were all eligible patients with first AMI admitted to the Coronary Care Unit, Split University Hospital. Within one month of admission at least one control was recruited and matched to every AMI case by age (+/-5 years) and sex. Exclusion criteria were the same for cases and controls. Structured questionnaires were administered and physical examinations were undertaken in the same manner in cases and controls. Relationship between the risk factors and AMI are presented by odds ratios, estimated by multivariate logistic regression. RESULTS: During the study period 263 cases and 264 controls were enrolled. The proportion of males (74.6%) was threefold that of females. The highest relative difference between the case and control risk factors was noted for current smoking (16.6%; p<0.001), diabetes (10.5%; p<0.001), hypertension (9.0%; p=0.038) and abdominal obesity (18.5%; p<0.001). Ever smoking accounted for 75% higher AMI risk than non-smoking (OR 1.74; p=0.006), while current smoking accounted for a 2.6 time higher risk in comparison to non-smoking (OR 2.58; p<0.001). Diabetes had a threefold risk (OR 2.83; p<0.001). Hypertension accounted for a 70% higher risk (OR 1.68; p=0.007). Abdominal obesity was associated with a significantly increased AMI risk (OR 1.96; p=0.007). The highest apolipoprotein B/apolipoprotein A-1 (ApoB/ApoA-1) tertile accounted for nearly 2.5-fold risk (OR 2.23; p=0.005). Physical activity and daily consumption of fruits and vegetables did not prove to be significant factors in Croatia. Regular consumption of alcohol decreased coronary risk by approximately one third (OR 0.63; p=0.044). CONCLUSIONS: The most important AMI risk factor in south Croatia is current smoking, followed by diabetes, abnormal ApoB/ApoA-1 ratio, abdominal obesity, and hypertension. A protective risk factor is alcohol consumption, while physical activity and fruit and vegetable consumption are less important. These results are similar to the global INTERHEART data showing that most of AMI risk could be predicted with nine simple, measurable risk factors worldwide. Protective measures for CHD, including increased daily consumption of fruits and vegetables, moderate physical activity and particularly smoking cessation should be implemented worldwide. In specific regions such as south Croatia, moderate alcohol consumption (mostly red wine) may be included among protective measures due to sociologic and cultural reasons.

[Doppler echocardiographic assessment of diastolic function of left ventricle]. / Doplerehokardiografska procjena dijastolicke funkcije lijeve klijetke.

Approximately half of the patients with overt congestive heart failure (CHF) have diastolic dysfunction without reduced ejection fraction (LVEF>50%). Diastolic dysfunction is an abnormality in left ventricular myocardial relaxation and/or compliance that alters the ease with which blood is accepted into the left ventricle during diastole. Elevated pressures in the left atrium are compensatory, ensuring adequate filling. All patients with systolic dysfunction have concomitant diastolic dysfunction. Indeed, in patients with CHF and reduced systolic function the level of diastolic dysfunction influences the severity of symptoms. It is now clear that hypertension, coronary artery disease and other diseases and conditions commonly produce diastolic dysfunction in the absence of significant systolic dysfunction. Accurate noninvasive Doppler-echocardiographic assessment of the presence and severity of diastolic impairment is crucial to the broad application and understanding of this common condition. This review discusses the clinical impact of classic and recent echocardiographic contributions to the field of diastology.

Impact of Percutaneous Coronary Intervention on Exercise-Induced Repolarization Changes in Patients With Stable Coronary Artery Disease.

Recent reports suggest T peak to T end (Tpe) interval and Tpe/QT ratio as valuable indicators of increased arrhythmogenic risk in patients with coronary artery disease (CAD). We aimed to examine the exercise-induced changes in these indexes in patients with stable CAD, before and after percutaneous coronary intervention (PCI). Forty patients were consecutively included in the interventional group (n = 20), with significant lesions (≥75% luminal narrowing) suitable for PCI and in the control group (n = 20), with no significant coronary artery lesions (<50% luminal narrowing). One day before and 30 days after the coronarography, all patients performed treadmill exercise stress testing, and the electrocardiographic (ECG) indexes of repolarization were assessed during baseline and at peak exercise intensity. In the control group, the QT interval, QTc (QT-corrected) interval, Tpe interval, and Tpe/QT ratio measured at peak exercise significantly decreased from baseline values (p = 0.001, p = 0.004, p <0.001, and p = 0.017, respectively). Conversely, in interventional patients before the PCI, an increase in the Tpe interval and the Tpe/QT ratio was observed at exercise (p = 0.009, and p <0.001, respectively), with only the QT interval exhibiting a significant decrease from baseline (p <0.001). Thirty days after the PCI, all the ECG arrhythmogenic indexes measured at peak exercise significantly decreased from baseline values, thus assuming the same trend as detected in controls. In conclusion, restoration of blood supply normalized exercise-induced repolarization changes, suggesting that revascularization of previously ischemic myocardium lowers the cardiac arrhythmogenic potential in patients with stable CAD.