LDL-C: The Only Causal Risk Factor for ASCVD. Why Is It Still Overlooked and Underestimated?

PURPOSE OF REVIEW: Low-density lipoprotein cholesterol (LDL-C) is the most important causal risk factor for atherosclerotic cardiovascular disease (ASCVD). This article reviews why LDL-C remains overlooked and underestimated despite numerous studies that have proved its role. RECENT FINDINGS: Recently published EAS/ESC Guidelines for dyslipidemia and EAS Guidelines for prevention set new targets for LDL-C levels in primary and secondary prevention of ASCVD. These guidelines are based on data from large studies and meta-analyzes that have shown that lower LDL-C also means lower cardiovascular event rates. Real-life experience published in registries worldwide has shown us that the guidelines have not been translated to everyday clinical practice, meaning that a significant number of patients are undertreated and have LDL-C levels well above target. Potential reasons for the abovementioned are poor adherence and education of the patient and physician and health care system related factors. Implementation of the latest version of guidelines will require continuous patient and physicians education, as well as a shared decision-making process between physician and patient.

From Heart Murmur to Echocardiography - Congenital Heart Defects Diagnostics Using Machine-Learning Algorithms.

The most common clinical sign in pediatric cardiology is heart murmur, which can often be uncharacteristic. The aim of this research was to present the results of development of a classifier based on machine learning algorithms whose purpose is to classify organic murmur that occur in congenital heart defect (CHD). The study is based on the data collected at Pediatric Clinic, Clinical Center University of Sarajevo during three-year period. Totally, 116 children aged from 1 to 15 years were enrolled in the study. Input parameters for classification are parameters obtained during basic physical examination and assessment of patient. First, analysis of relevance of the feature for classification was done using InfoGain, GainRatio, Relief and Correlation method. In the second step, classifiers based on Naive Bayes, Logistic Regression, Decision Tree, Random Forest and Support Vector Machine were developed and compared by performance. The results of this research suggest that high accuracy (>90%) classifier for detection of CHD based on 16 parameters can be developed. Such classifier with appropriate user interface would be valuable diagnostic aid to doctors and pediatricians at primary healthcare level for diagnostic of heart murmurs.

Breaking habits: safety and efficacy of elective electrocardioversion of atrial fibrillation and atrial flutter in the setting of day hospital.

Aim To examine safety and efficiency of electrocardioversion (EC) in elective treatment of atrial fibrillation and atrial flutter in the setting of Day Hospital by determining success rate, frequency of adverse events and possible cost benefit compared to admitting a patient into hospital. Methods This prospective observational cohort study was performed in Day Hospital and in Intensive Care Department of Internal Medicine Clinic, University Clinical Centre Tuzla from January 2019 to December 2022 and included 98 patients with a persistent form of atrial fibrillation (AF) or atrial flutter. The patients who were divided in two groups, 56 hospitalized and 42 patients accessed in Day Hospital. In all patients, medical history, physical examination, electrocardiogram (ECG) and transthoracic echocardiogram (TTE) evaluation was performed in addition to laboratory findings. Electrocardioversion was performed with a monophasic General Electric defibrillator in anterolateral electrode position with up to three repetitive shocks. Results In hospital setting group overall succes rate of electrocardioversion was 85%, with average 2.1 EC attemps, there was with one fatal outcome due to stroke, one case of ventricular fibrillation (VF) due to human error, and 6 minor adverse events; with average cost of was 1408.70 KM (720.23 €) per patient. In Day Hospital setting succes rate was 88%, with average 2 EC attempts, no major adverse events, 8 minor adverse events; and average cost was of 127.23 KM (65.05 €) per patient. Conclusion Performing elective electrocardioversion in Day Hospital setting is as safe as admitting patients into hospital but substantially more cost effective.

[Acute coronary syndrome after hornet bite, type II Kounis syndrome - a case report]. / Akutni koronarni sindrom poslije uboda strsljena, Kounisov sindrom tipa II - prikaz bolesnika.

Kounis syndrome is an accidental occurrence of acute coronary syndrome associated with anaphylaxis, where acute inflammatory mediators cause the spasm of coronary arteries with the erosion and rupture of atheromatous plaque. We present a 53-year-old male who during the treatment of anaphylaxis after a hornet bite developed acute anteroseptal myocardial infarction. The diagnosis of type II Kounis syndrome was proven by electrocardiographic abnormalities and biochemical markers with clinical manifestation of acute coronary syndrome, and was associated with anaphylaxis which demanded prehospital treatment of the patient after the hornet bite. Anaphylaxis after a hornet bite requires consideration of acute coronary syndrome if patients have chest pain and hemodynamic impairment, as these conditions occur infrequently but demand additional diagnostics and adequate treatment.

The benefits of GLP1 receptors in cardiovascular diseases.

Glucagon like peptide-1 (GLP-1) receptor agonists are well established drugs for the treatment of type 2 diabetes (T2D). In addition to glycemic control, GLP-1 receptor agonists have beneficial other effects. They act by binding to GLP-1 receptors, which are widely distributed in the body, including cardiomyocytes and blood vessels. The aim of this article is to provide a comprehensive review of GLP-1 receptor agonists impact on cardiovascular outcomes and risk reduction. In the last decade, several cardiovascular outcomes trials (CVOT) have been conducted in order to explore cardiovascular benefit of GLP-1 receptor agonists. CVOTs primarily proved cardiovascular safety and tolerability of different GLP-1 receptor agonists, but also showed cardiovascular benefit of specific drugs. CVOTs have shown that GLP-1 receptor agonists reduce MACE in patients with T2D compared to placebo. In addition, they have positive impact on several cardiovascular risk factors such as obesity by promoting weight loss, blood pressure and blood lipid levels. Also, they stimulate the endothelium to produce nitric oxide, reduce oxidative stress, and have antiatherogenic and antiinflammatory effects. Studies have shown their positive impact on kidney outcomes in patients with T2D compared to placebo. The results of previous trials are encouraging in terms of multiple positive effects of GLP-1 receptor agonists. However, further research is needed to understand their full potential and all details of their mechanism of action, which will enable to expand the therapeutic indications and to determine their optimal use in clinical practice.

Risk Factors in Patients with Non-ST Segment Elevation Myocardial Infarction.

INTRODUCTION: The most common cause of myocardial ischemia is atherosclerotic epicardial coronary artery disease, present in 90% of patients. Risk factors positively correlate with the onset, development and subsequent complications of atherosclerotic disease. AIM: Determine the percentage frequency of classic risk factors for coronary disease in patients with non-ST segment elevation myocardial infarction (NSTEMI), with regard to gender. METHODS: A retrospective study was conducted on 600 respondents, treated for NSTEMI at the Clinic for Internal Medicine of the University Clinical Center (UKC) Tuzla, in the period from June 2016 to December 2019. RESULTS: Overall, smoking was the leading risk factor (65%), followed by hypertension (58%), hyperlipoproteinemia (39%), overweight (33%), positive family burden (30%) and diabetes mellitus (19%). In male patients, the leading risk factor was smoking, rating at 74%, while in female patients - it was hypertension at 67%. In younger groups of patients leading risk factors were smoking and a positive family burden. CONCLUSION: With adequate prevention and treatment measures, a significant reduction in the prevalence of the cardiovascular disease can be achieved, since the risk factors for its development have long been known. Quitting smoking is one of the most effective secondary prevention measure since it reduces the reinfarction risk rate by 50%. Knowledge of coronary risks, as well as success in reducing them, can greatly contribute to patients' overall sense of contentment and significantly raise their self-confidence.

Amino-terminal pro-brain natriuretic peptid in prediction of left ventricular ejection fraction.

We aimed to evaluate levels of amino-terminal pro-brain natriuretic peptid (NT-proBNP) in prediction of left ventricular ejection fraction (LVEF) in heart failure patients. Prospective study on 60 consecutive patients with symptoms and signs of heart failure was performed. Blood samples for NT-proBNP analysis was taken from all test subjects and echocardiography was also done in all of them. According to LVEF value, patients were divided into four groups; those with or=50%. NT-proBNP values correlated with LVEF value. Regression analysis was used to evaluate how well NT-proBNP values predict LVEF. We used Receiver Operating Characteristic Curve calculation to evaluate diagnostic performance of NT-proBNP in estimation of LVEF. Average value of NT-proBNP in test group was 3191.69+/-642.89 pg/ml (p<0.001). Average value of NT-proBNP decreased with higher LVEF categories with significant (p<0.001) and high negative correlation (r= -0,75). Stepwise multivariate linear regression analysis showed that logarithmic value of NT-proBNP was excellent predictor of LVEF value (p<0.05). Model equation based on regression analysis was LVEF=88.645-15.311 x log (NT-proBNP). Predictive model for LVEF yielded from regression analysis had sensitivities of 98% and 81%, specificities of 20% and 90%, positive predictive values of 86% and 78% and negative predictive values of 67% and 92% for predicting patients with LVEF<50% and LVEF<40%, respectively. There was negative linear correlation between NT-proBNP and LVEF. NT-proBNP was excellent predictor of LVEF value (p<0.05).

The Patterns of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Use in Patients with Atrial Fibrillation in Seven Balkan Countries: a Report from the BALKAN-AF Survey.

INTRODUCTION: Data on management of atrial fibrillation (AF) in the Balkan Region are scarce. To capture the patterns in AF management in contemporary clinical practice in the Balkan countries a prospective survey was conducted between December 2014 and February 2015, and we report results pertinent to the use of non-vitamin K antagonist oral anticoagulants (NOACs). METHODS: A 14-week prospective, multicenter survey of consecutive AF patients seen by cardiologists or internal medicine specialists was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania, and Serbia (a total of about 50 million inhabitants). RESULTS: Of 2712 enrolled patients, 2663 (98.2%) had complete data relevant to oral anticoagulant (OAC) use (mean age 69.1 ± 10.9 years, female 44.6%). Overall, OAC was used in 1960 patients (73.6%) of whom 338 (17.2%) received NOACs. Malignancy [odds ratio (OR), 95% confidence interval (CI) 2.06, 1.20-3.56], rhythm control (OR 1.64, 1.25-2.16), and treatment by cardiologists were independent predictors of NOAC use (OR 2.32, 1.51-3.54) [all p < 0.01)], whilst heart failure and valvular disease were negatively associated with NOAC use (both p < 0.01). Individual stroke and bleeding risk were not significantly associated with NOAC use on multivariate analysis. CONCLUSIONS: NOACs are increasingly used in AF patients in the Balkan Region, but NOAC use is predominantly guided by factors other than evidence-based decision-making (e.g., drug availability on the market or reimbursement policy). Efforts are needed to establish an evidence-based approach to OAC selection and to facilitate the optimal use of OAC, thus improving the outcomes in AF patients in this large region.

Mortality at the Clinic of Internal Medicine of University Clinical Center in Tuzla during 2008.

INTRODUCTION: Accurate information about the cause of death is given by expert teams based on pathological or forensic expertise. Reliable information can be obtained from doctors from clinical-hospital institutions if the deceased person was treated in such an institution and with previously diagnosed disease (hospital mortality). Analysis of hospital mortality provides a lot of data that can be used in planning the hospital beds capacities, the amount of drug procurement, purchasing equipment, organization and creation of highly specialized medical teams (medical team for resuscitation), the number of reanimation techniques, the number of pathologists who are required for autopsy procedures, etc. GOAL was to determine the total number of deaths, the most common causes of death and the 10 leading diagnoses of deceased patients at the Clinic for Internal Medicine of Clinical Center in Tuzla during 2008. MATERIAL AND METHODS: We used the material from the archive (medical records and reports on deceased patients, delivered by physicians working at the Clinic for Internal Medicine of Clinical Center in Tuzla). RESULTS: During 2008 at the Clinic for Internal Medicine 368 patients died. According to the analyzed data leading cause of death and leading diagnosis as cause of death at the Clinic for Internal Medicine in 2008 were as follows: cardiogenic shock in 73 (19.84%), cerebrovascular stroke in 46 (12.50%), coma due to stroke in 32 (8.70%), coma not classified as cerebral in 25 (6.79%) (metabolic 13 (3.53%) and hepatic 12 (3.26%), cardiomyopathy in 22 (5.98%), malignant neoplasm of the abdomen in 17 (4.62%), respiratory insufficiency in 17 (4.62%), acute myocardial infarction and myocardial infarction with rupture in 17 (4.62%), pulmonary edema in 16 (4.35%), and cardiorespiratory arrest in 13 (3.53%) deaths. CONCLUSION: During 2008 at the Clinic for Internal Medicine of Clinical Center in Tuzla died a total of 368 patients. The most common cause of death of patients at the Clinic for Internal Medicine of Clinical Center in Tuzla are cardiovascular disease (n = 175; 47.55% of deaths), in second place was cerebrovascular disease (n = 76; 20.65% of deaths) for a total of 251 (68.20%) of deaths from cardiovascular and cerebrovascular disease.

[Statins in dyslipidemia associated with acute myocardial infarct]. / Statini kod dislipidemije u akutnom infarktu miokarda.

Long time ago lipids increased in blood have been known as risk factor for atherosclerosis that causes coronary heart disease among which myocardial infarction is the most complicated. Aim were to present the lipids status structure in patients with acute myocardial infarction and on the basis of that to suggest corresponding statin in treatment. Our research involved 202 patients with acute myocardial infarction, patients were both gender and from 37 to 89 year. Out of total number of patients, 100 of them were with anterior myocardial infarction (group I) and 102 with inferior myocardial infarction (group II). Whole cholesterol, low density lipoproteins, high density lipoproteins and triglycerides were followed. Hi square test and variance analysis were used to prove statistically significant difference. In the sample of group I increased LDL was found in 92 patients and increased TGL in 46 patients while decreased HDL was found in 61 patients. In the sample of group II increased LDL was found in 64 patients, increased TGL in 44 patients, while decreased HDL was found in 51 patients. We analysed the next combinations in both groups: LDL > with HDL <; LDL > with TGL >; HDL < with TGL >; LDL >, TGL > with HDL <. Combination decreased HDL with increased TGL was found in group I in 5 patients, and in group II in 12 patients. Other combinations in both groups were similarly values. On the basis of the obtained results we found statistically significant difference between the two groups of patients. Patients in group I have more frequently increased values of LDL in comparison to patients in group II (p < 0.00005). In patients in group II who had decreased HDL and increased TGL statistically significant difference was found in comparison to the patients in group I (p < 0.02). On the basis of the obtained results and up to now studies on statins effects we suggest Atorvastatin for treatment the patients with anterior myocardial infarction, increased LDL with normal values of HDL and Simvastatin for treatment the patients with inferior myocardial infarction, decreased HDL.