The Mystery of Diabetic Cardiomyopathy: From Early Concepts and Underlying Mechanisms to Novel Therapeutic Possibilities.

Diabetic patients are predisposed to diabetic cardiomyopathy, a specific form of cardiomyopathy which is characterized by the development of myocardial fibrosis, cardiomyocyte hypertrophy, and apoptosis that develops independently of concomitant macrovascular and microvascular diabetic complications. Its pathophysiology is multifactorial and poorly understood and no specific therapeutic guideline has yet been established. Diabetic cardiomyopathy is a challenging diagnosis, made after excluding other potential entities, treated with different pharmacotherapeutic agents targeting various pathophysiological pathways that need yet to be unraveled. It has great clinical importance as diabetes is a disease with pandemic proportions. This review focuses on the potential mechanisms contributing to this entity, diagnostic options, as well as on potential therapeutic interventions taking in consideration their clinical feasibility and limitations in everyday practice. Besides conventional therapies, we discuss novel therapeutic possibilities that have not yet been translated into clinical practice.

Nutrition in primary and secondary prevention of cardiovascular risk in the continental and Mediterranean regions of Croatia.

BACKGROUND: The aim of this observational study was to evaluate the effect of Mediterranean and continental nutrition on cardiovascular risk in patients with acute and chronic coronary heart disease in Croatia. METHODS: The study included 1284 patients who were hospitalized in a 28-month period due to acute or chronic ischaemic heart disease in hospitals across Croatia. An individual questionnaire was prepared which enabled recording of various cardiovascular risk factors. RESULTS: Patients with chronic coronary artery disease have a better index of healthy diet than patients with acute coronary disease. Women have a better index of diet than men in both Croatian regions. When the prevalence of risk factors (impaired glucose tolerance, diabetes mellitus types I and II, hypercholesterolaemia, hypertriglyceridaemia and hypertension) in patients with Mediterranean and continental nutrition is compared, a trend is seen for patients who have risk factors to consume healthier food. CONCLUSION: The Mediterranean diet is associated with reduced risk of developing cardiovascular disease. This effect is more evident in patients with known cardiovascular disease.

The 'peptide for life' initiative in the emergency department study.

AIMS: Natriuretic peptide (NP) uptake varies in Emergency Departments (EDs) across Europe. The 'Peptide for Life' (P4L) initiative, led by Heart Failure Association, aims to enhance NP utilization for early diagnosis of heart failure (HF). We tested the hypothesis that implementing an educational campaign in Western Balkan countries would significantly increase NP adoption rates in the ED. METHODS AND RESULTS: This registry examined NP adoption before and after implementing the P4L-ED study across 10 centres in five countries: Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia, and Serbia. A train-the-trainer programme was implemented to enhance awareness of NP testing in the ED, and centres without access received point-of-care instruments. Differences in NP testing between the pre-P4L-ED and post-P4L-ED phases were evaluated. A total of 2519 patients were enrolled in the study: 1224 (48.6%) in the pre-P4L-ED phase and 1295 (51.4%) in the post-P4L-ED phase. NP testing was performed in the ED on 684 patients (55.9%) during the pre-P4L-ED phase and on 1039 patients (80.3%) during the post-P4L-ED phase, indicating a significant absolute difference of 24.4% (95% CI: 20.8% to 27.9%, P < 0.001). The use of both NPs and echocardiography significantly increased from 37.7% in the pre-P4L-ED phase to 61.3% in the post-P4L-ED phase. There was an increased prescription of diuretics and SGLT2 inhibitors during the post-P4L-ED phase. CONCLUSIONS: By increasing awareness and providing resources, the utilization of NPs increased in the ED, leading to improved diagnostic accuracy and enhanced patient care.

The H1N1 influenza pneumonia as early complication after heart transplantation--experience from the Dubrava University Hospital, Zagreb, Croatia.

In April 2009, a novel influenza A (H1N1) virus was initially detected, and only after two months World Health Organization declared pandemic, while virus became globally present. We report here a confirmed case of patient suffering from H1N1 influenza pneumonia in an early period after heart transplantation. Complications of influenza A and B include viral pneumonia, secondary bacterial pneumonia and possibly acute allograft rejection in the setting of weaning of immunosuppression. In our case H1N1 influenza pneumonia was treated according to the published guidelines and had a mild course of disease, but nevertheless emphasis should be put on the prevention of disease applying known general infection control procedures and vaccination while disease course cannot be predicted.

Predictors of short-term neurocognitive outcome following coronary revascularisation (CABG) depending on the use of cardiopulmonary bypass.

The purpose of our study was to investigate the association between perioperative cerebral microembolization, expressed as high-intensity transient signals (HITS) and postoperative dynamics of the neuromarker S100P in patients operated using cardiopulmonary bypass, and to assess their impact upon the neurocognitive function in the early postoperative stage. The study involved 62 consecutive male patients aged 60 or above, alls scheduled for elective aortocoronary bypass. The patients were recruited from two groups with respect to the use of CPB: on-pump group (CPB+, N = 30) and off-pump group (CPB-, N = 32). In all patients we performed intraoperative monitoring of cerebral haemodynamics using transcranial Doppler, with the goal of quantifying perioperative cerebral microembolization. The serum levels of the neuromarker S100l were measured immediately after surgery, and then 12, 24 and 48 hours after the surgery. Neurocognitive status was assessed before and after the surgery and in three cognitive domains. Results of the study have shown that with respect to the short-term postoperative neurocognitive outcome there is no significant difference between the on-pump and off-pump surgical technique of coronary revascularization'. Perioperative cerebral microembolization was significantly more pronounced in the on-pump group yet it did not affect early postoperative neurocognitive function, while the increase in the neuromarker S100beta serum level 48 hours after surgery may have prognostic value as a predictor of postoperative neurocognitive dysfunction.

The prevalence of overweight and obesity among Croatian hospitalized coronary heart disease patients.

The aim of this article was to investigate the prevalence of overweight and obesity using selected anthropometric variables in a sample of hospitalized coronary heart disease (CHD) patients in Croatia (N = 1,298). Prevalence of overweight and obesity in surveyed patient population was high: 48.2% of participants were overweight and 28.6% were obese according to their body mass index; measured through waist-to-hip ratio 54.5% of participants were centrally obese. These data on prevalences of overweight, obesity and central obesity show that although there are some reassuring trends, there is still considerable amount of work to be done if the prevalence of this cardiovascular risk factor is to be reduced further among Croatian CHD patients. While the prevalence of obesity seems to be on the decline, the prevalence of overweight is rising, which may be just an early warning sign of an incoming wave of obesity epidemic in future years.

The prevalence of hypertension among Croatian hospitalized coronary heart disease patients.

The aim of this article was to investigate the prevalence of hypertension with selected anthropometric variables in a sample of hospitalized coronary heart disease (CHD) patients in Croatia. This study investigated patients hospitalized in the period of October 1st 2007 until January 7th 2010 because of acute or chronic CHD in various hospitals in Croatia (N = 1,298). Prevalence of hypertension in surveyed patient population was high: 70.1% of participants had raised blood pressure (BP) or previously diagnosed hypertension. Men had statistically significantly higher mean diastolic BP values than women (78.91 +/- 8.97 vs. 77.12 +/- 10.61 mmHg, p = 0.011). Prevalence of hypertension was statistically significantly more frequent in women (80.6% vs. 65.8%, p < 0.001). Hypertension still represents an important problem among hospitalized Croatian CHD patients. Its prevalence, unfortunately, continues to increase in this population, suggesting that there is still great potential for improvement of preventive cardiology standards and measures that have already been undertaken.

The prevalence of diabetes mellitus and abnormal lipid status among Croatian hospitalized coronary heart disease patients.

The aim of this article was to investigate the prevalence of diabetes mellitus and abnormal lipid status with selected anthropometric variables in a sample of hospitalized coronary heart disease (CHD) patients in Croatia (N = 1,298). Prevalence of diabetes mellitus was 31.6% (statistically significantly more frequent in women, 35.7% vs. 30.0%), while prevalences of increased total cholesterol were 72.0%, decreased HDL-cholesterol 42.6% (statistically significantly more frequent in women, 50.2% vs. 39.6%), increased LDL-cholesterol 72.3% and increased triglycerides 51.5%. Reported data on prevalences of diabetes mellitus can be somewhat reassuring (a decrease in its prevalence compared to data from 2006, but they still signal a situation which is a lot worse than in 2002 and 2003); the trend of rising prevalences of dyslipidaemic cardiovascular risk factors must be a cause for an alarm, furthermore as today's preventive and treatment measures in cardiology, both primary and secondary, are strongly focused on dyslipidaemias.

The prevalence of smoking among Croatian hospitalized coronary heart disease patients.

The aim of this paper was to investigate the prevalence of smoking using selected anthropometric variables in a sample of hospitalized coronary heart disease (CHD) patients in Croatia (N = 1,298). A total of 444 subjects (34.6%) were non-smokers, 548 (42.6%) were smokers and 293 (22.8%) were ex-smokers. Men, on average, smoked more cigarettes per day than women (22.62 vs. 19.84 cigarettes, p < 0.001) and they also had bigger index "pack-years" than women (36.96 vs. 33.91, p = 0.024). Men were more often smokers and ex-smokers than women (47.4% vs. 30.8% for smokers and 25.0% vs. 22.8% for ex-smokers, p < 0.001). In this study a high prevalence of smoking was found among CHD patients in Croatia. Unless it is decreased, it can be expected that CHD patients in Croatia will continue to experience adverse effects more often than other CHD patients in the rest of Europe.

[Recovery after long-term pulsatile mechanical circulatory support in patient with chronic heart failure: a case report]. / Oporavak nakon dugotrajne mehanicke cirkulatorne potpore u bolesnika s kronicnim zatajivanjem srca: prikaz bolesnika.

Use of mechanical circulatory support (MCS) is a part of today's standard therapy in the treatment of end-stage heart failure. In this paper we describe characteristics of Thoratec pVAD device for MCS, implantation techniques, as well as the most important advantages and complications of application of the device. We present a 41-year-old patient with dilatated cardiomyopathy, who was the first recipient ofparacorporeal left ventricular assist device (LVAD) in the Republic of Croatia due to end-stage heart failure. After heart function recovery the patient was successfully weaned from MCS after 130 days of support.

Multiple Coronary Fistulas as a Rare Cause of Stable Angina Pectoris.

Congenital coronary artery-left ventricular multiple microfistulas (CA-LVMMFs) are rare anomalies in adults. They are more often found in female patients, and they usually originate from the distal segments of the coronary arteries, but they can originate from a proximal segments of a coronary arteries, and these patients are likely to be identified and treated in the pediatric age group. They are mostly asymptomatic. When symptoms and complications occur, they include angina, myocardial infarction, atrial heart failure, arrhythmias, and endocarditis. The management of CA-LVMMFs is controversial, but it is generally agreed that conservative medical management is the primary treatment of choice. Our case describes a rare form of CA-LVMMFs draining into the left ventricle in a female patient presenting with fatigue, atypical anginal symptoms, atrial fibrillation, and premature ventricular complexes, without concomitant obstructive coronary artery disease.

Sudden Cardiac Death-A New Insight Into Potentially Fatal Genetic Markers.

Sudden cardiac death (SCD) is an unexpected and dramatic event. It draws special attention especially in young, seemingly healthy athletes. Our scientific paper is based on the death of a young, 23-year-old professional footballer, who died on the football field after a two-year history of cardiac symptoms. In this study we analyzed clinical, ECG and laboratory data, as well as results of genetic testing analysis in family members. To elucidate potential genetic etiology of SCD in this family, our analysis included 294 genes related to various cardiac conditions.

COVID-19: The Impact on Cardiovascular System.

SARS-CoV-2 has been circulating in population worldwide for the past year and a half, and thus a vast amount of scientific literature has been produced in order to study the biology of the virus and the pathophysiology of COVID-19, as well as to determine the best way to prevent infection, treat the patients and eliminate the virus. SARS-CoV-2 binding to the ACE2 receptor is the key initiator of COVID-19. The ability of SARS-CoV-2 to infect various types of cells requires special attention to be given to the cardiovascular system, as it is commonly affected. Thorough diagnostics and patient monitoring are beneficial in reducing the risk of cardiovascular morbidity and to ensure the most favorable outcomes for the infected patients, even after they are cured of the acute disease. The multidisciplinary nature of the fight against the COVID-19 pandemic requires careful consideration from the attending clinicians, in order to provide fast and reliable treatment to their patients in accordance with evidence-based medicine principles. In this narrative review, we reviewed the available literature on cardiovascular implications of COVID-19; both the acute and the chronic.

[Acute coronary syndrome: monitoring and invasive treatment]. / Akutni koronarni sindrom: monitoriranje i invazivno lijecenje.

Acute coronary syndromes whose clinical spectrum consists of unstable angina pectoris, non-ST-elevation myocardial infarction and ST-elevation myocardial infarction carry the greatest risk of death and severe complications to patients with coronary artery disease. Patients with acute coronary syndromes may be submitted to conservative or invasive management, with differences in the timing of invasive management in patients selected for that strategy. Early diagnosis, good monitoring and appropriate global assessment of every patient improve the selection of patients for adequate modality of treatment that will prevent death, complications and other serious events.

Clinical Paradox: Anterior Wall Myocardial Infarction with Predominant Inferior ST Elevation and No Variation in Coronary Anatomy in a PAI-1 Homozygote.

Changes of the ST segment are commonly used as predictors of the culprit vessel during an acute myocardial infarction. In case of combined ST elevation in both inferior and anterior leads, these changes can be due to a distal occlusion of a "wrapped" left anterior descending artery (LAD) or a two-vessel disease. Our case of anterior wall myocardial infarction with inferior ST elevation and anterior ST depression shows that electrocardiographic changes during acute myocardial infarction cannot always be explained by logical sequelae of the injury current, vessel anatomy, and their irrigation territory.

Drug coated balloons and their role in bifurcation coronary angioplasty: appraisal of the current evidence and future directions.

INTRODUCTION: Coronary Bifurcation lesions are technically more challenging and Bifurcation percutaneous coronary intervention (PCI) remains a challenge with unpredictable and sub-optimal clinical and angiographic results. Drug-Coated Balloons (DCB) are emerging devices in the field of coronary intervention with promising results that may overcome some of drug eluting stents limitations and may have potential advantages in complex bifurcation PCI. AREAS COVERED: We have performed a re-appraisal about the issues with current bifurcation PCI techniques and the use of DCB in the treatment of Bifurcation lesions. Several studies performed utilizing DCB are described and critically appraised. Over the recent years, there have been tremendous developments in the DCB technology, lesion preparation, clinical experience, and clinical data during bifurcation PCI. The current review describes the advances in the DCB technology, pharmacokinetics, role of excipients, and optimization of the technique. Special emphasis in lesion preparation and potential pathway of using DCB in bifurcation PCI is proposed. EXPERT OPINION: Although different proof of concept and pilot studies have shown promising results in treatment of bifurcation lesions with DCB, larger randomized trials and/or international consensus papers are required to enable worldwide translation of this idea to clinical practice.

[Invasive approach to patients with acute coronary syndrome]. / Invazivni pristup bolesniku s akutnim koronarnim sindromom--perkutane koronarne intervencije.

Cardiovascular diseases are the leading cause of mortality in Croatia. In concordance with this epidemiologic situation, a new organization of emergency medicine and a network of invasive cardiac laboratories have been introduced throughout Croatia. Main goal of this structuring is to improve the care of patients with acute coronary syndrome (ACS). The aim of this paper is to open discussion on the optimal way of treatment in patients with ACS in our country today, in the era of interventional cardiology of the 21st century. The pathophysiology of ACS encompasses a complex atheroinflammatory and atherothrombotic process with dynamic and progressive mechanical obstruction of coronary arteries and subsequently oxygen supply-demand mismatch. Conversely, the best way to treat such patients is reperfusion therapy, a goal nowadays achieved by either antithrombotic medical therapy or percutaneous coronary intervention (PCI). The weight of evidence does support the use of primary PCI as a standard and supreme reperfusion therapy, especially in myocardial infarction with ST elevation. The logistic complexities such as triage, transportation, the development of capable interventional center working 24-hours, even in developed countries, may be a major problem to use such a practice in the whole community. In ACS with non ST elevation, problems are even broader and include the importance of using optimal revascularization procedure (even cardiac surgery), timing and concomitant medical therapy, with certain stratification of every individual. Finally, especially for our country, medical and economic resources should be used optimally in order to achieve an optimal system to treat patients with ACS.

Is there a place for angiotensin receptor-neprilysin inhibitors in the treatment of heart failure patients after heart transplantation?

We present a case report of a heart failure patient after heart transplantation due to end-stage ischemic cardiomyopathy with significant clinical and echocardiographic improvement 3 months after the introduction of sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor. This new class of drugs is proved to be beneficial in heart failure patients, especially with reduced ejection fraction (HFrEF), but they have not yet been used in heart failure patients after heart transplantation. We believe that the increase of left ventricular systolic function, improvement of global longitudinal strain, and reduction of pulmonary hypertension with consequent clinical recovery in our patient may have been caused by sacubitril/valsartan.

Hypersensitivity Eosinophilic Myocarditis in a Patient Receiving Multiple Drug Therapy: Challenges in Diagnosis and Defining the Aetiology.

Eosinophilic myocarditis (EM) is a rare and potentially fatal disease if left untreated. Because the disease can have a delayed presentation and can appear even after 2 years, its underlying causes often remain unknown. We report the case of a 63-year-old man with an atypical clinical presentation of hypersensitive EM and significant coronary artery disease, which was confirmed through coronary angiography. The patient was treated with hydrochlorothiazide (12.5 mg once daily for 2 years) and budesonide/formoterol (160/4.5 µg once daily for 2 years). Amoxicillin/clavulanic acid (1000/200 mg three times daily for 2 days) and azithromycin (500 mg once daily for 2 days) were used to treat pneumonia, while ibuprofen (600 mg three times daily for 2 days) was used to treat pericarditis. Extremely high levels of eosinophils led to clinical suspicion of non-acute coronary syndrome as the cause of chest pain and myocardial necrosis. In addition, early pulse doses of methylprednisolone (500 mg intravenously once daily) were administered. Complete clinical recovery and a fast decrease in eosinophils and troponin levels were observed after a few hours on the same day. No signs of recurrent myocarditis were noticed after 3 days of administering the same pulse doses of methylprednisolone, which was then replaced by oral methylprednisolone administered for the next 2 months (step-down regimen, starting from 64 mg/day). Despite causality assessment being difficult, prompt therapy must be given as soon as possible to prevent fatal outcomes. Delayed corticosteroid treatment, which is necessary regardless of the underlying cause, can result in heart failure and death.