32-year-old Traumatic Arteriovenous Fistula Presenting With Leg Ulcer and High-output Heart Failure.

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

The Significance of Thallium-201-Chloride SPECT Myocardial Perfusion Imaging in the Management of Patients With Stable Chronic Coronary Artery Disease.

BACKGROUND: Patients with stable coronary artery disease (CAD) can be evaluated for myocardial viability by examining reverse redistribution of Thallium-201 (201TI) through cardiac scintigraphy. There is limited knowledge about association of a reverse redistribution with favorable cardiac outcomes. In this study, we hypothesized that higher left ventricular ejection fraction (LVEF), lower myocardial necrosis, fewer ischemic events, and less angina will be associated with reverse redistribution of 201TI imaging. METHODS: Adult patients with stable CAD included in this study underwent exercise-redistribution Thallium single-photon emission computed tomography (SPECT) and were followed for one year. LVEF and regional wall motion abnormalities were evaluated with echocardiography, exercise duration by bicycle testing, and myocardial ischemia and viability by Thallium SPECT. RESULTS: We studied 159 patients (87 men, 72 women, median age 60 years, range: 38-84) with well-developed collaterals. Those with reverse redistribution on SPECT (n = 61, 38.3%) had significantly better exercise tolerance (⩾85%; P < .001). Subjects with reverse redistribution had better LVEF (P < .001), wall motion parameters (P < .001), a lower degree of myocardial necrosis (P < .05), less angina during follow-up (P = .02), and fewer ischemic events whether treated with OMT or PCI (P < .001). CONCLUSIONS: Reverse redistribution of 201Tl on scintigraphic images is a predictor of myocardial viability. Evidence from our study suggests that optimally treated chronic CAD patients with reverse redistribution may have lower likelihood of future adverse cardiovascular events and better prognosis.

Current uses of ISACS-TC registry in Mostar.

Cardiovascular disease (CVD) contributes greatly to inequalities in health in Europe. The acute myocardial infarction (MI) in hospital death rate in Bosnia and Herzegovina is three fold higher than in European Union countries before the enlargement in 2004. There is also a striking difference in mortality between Bosnia and Herzegovina and Central and East European countries that joined the EU in 2004. Rapid development of high technology treatment procedures, which followed the economic recovery of the European Union countries, still have only limited influence on the overall control of MI death rate. Large potential to control MI death rate lies in developing PCI capable network with target to rapid reperfusion therapy in MI patients. The hypothesis that social factors may contribute to explain high MI death rate is attractive, but still is an assumption. However, if confirmed, transforming such knowledge into a practical health policy would be a great challenge. A resource-saving balanced assessment approach to health technology development is warrant in Bosnia and Herzegovina. An international help is needed.

European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions.

AIMS: The European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT-R) was set up with the aim of describing the clinical epidemiology and the 1-year outcomes of patients with heart failure (HF) with the added intention of comparing differences between participating countries. METHODS AND RESULTS: The ESC-HF-LT-R is a prospective, observational registry contributed to by 211 cardiology centres in 21 European and/or Mediterranean countries, all being member countries of the ESC. Between May 2011 and April 2013 it collected data on 12 440 patients, 40.5% of them hospitalized with acute HF (AHF) and 59.5% outpatients with chronic HF (CHF). The all-cause 1-year mortality rate was 23.6% for AHF and 6.4% for CHF. The combined endpoint of mortality or HF hospitalization within 1 year had a rate of 36% for AHF and 14.5% for CHF. All-cause mortality rates in the different regions ranged from 21.6% to 36.5% in patients with AHF, and from 6.9% to 15.6% in those with CHF. These differences in mortality between regions are thought reflect differences in the characteristics and/or management of these patients. CONCLUSION: The ESC-HF-LT-R shows that 1-year all-cause mortality of patients with AHF is still high while the mortality of CHF is lower. This registry provides the opportunity to evaluate the management and outcomes of patients with HF and identify areas for improvement.

Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry.

AIMS: To evaluate how recommendations of European guidelines regarding pharmacological and non-pharmacological treatments for heart failure (HF) are adopted in clinical practice. METHODS AND RESULTS: The ESC-HF Long-Term Registry is a prospective, observational study conducted in 211 Cardiology Centres of 21 European and Mediterranean countries, members of the European Society of Cardiology (ESC). From May 2011 to April 2013, a total of 12,440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. Intravenous treatments for acute HF were heterogeneously administered, irrespective of guideline recommendations. In chronic HF, with reduced EF, renin-angiotensin system (RAS) blockers, beta-blockers, and mineralocorticoid antagonists (MRAs) were used in 92.2, 92.7, and 67.0% of patients, respectively. When reasons for non-adherence were considered, the real rate of undertreatment accounted for 3.2, 2.3, and 5.4% of the cases, respectively. About 30% of patients received the target dosage of these drugs, but a documented reason for not achieving the target dosage was reported in almost two-thirds of them. The more relevant reasons for non-implantation of a device, when clinically indicated, were related to doctor uncertainties on the indication, patient refusal, or logistical/cost issues. CONCLUSION: This pan-European registry shows that, while in patients with acute HF, a large heterogeneity of treatments exists, drug treatment of chronic HF can be considered largely adherent to recommendations of current guidelines, when the reasons for non-adherence are taken into account. Observations regarding the real possibility to adhere fully to current guidelines in daily clinical practice should be seriously considered when clinical practice guidelines have to be written.

Intrahospital sudden cardiac death (SCD) at internal medicine clinic of University Clinical Hospital Mostar.

AIM: Evaluation of general and specific sudden cardiac death (SCD) mortality and comorbidity which advances to SCD in patients of Internal Clinic of UCH Mostar in period from 2000 to 2009. METHODS: AND RESULTS: We analysed 2547 death of patients, part of general population of 26.471 hospitalised over this time period. Registered general mortality was 9.6%, specific SCD mortality was 5.85%, and hospitalised sudden death occurred in 1548 or 60.78% patients. Factors causing death of SCD patients in observed period were as follows: CHF was present in 368 or 23.8%, death after AIM was 344 or 22.2%, ICV was 212 or 13.7%, Shock cardiogenes was 200 or 12.9%, AHF with oedema pulmonum (145 or 9.4%), cardiac arrest was 121 or 7.8%, 89 patients experienced sudden death on the street and were transported to Clinic, electrical instability with malignant arrhythmias VF/ VT was found in 22 or 1.4%, dissection of aortae 16 or 1.03%, thrombosi a. mesentericae in 12 or 0.78%, and circumstances and end-presentation of death. Age structure was changing, with increase in numbers of younger patients. The results reflects general trend in SCD in grater Mostar region and whose inhabitants gravitate toward our Clinic. CONCLUSION: There is continuous increase in SCD in our patients and in the numbers and comorbidities, which explain existing burden. Although incidence of SCD increases with age, existed continuous trend of increase in SCD in the young people accelerates over time.

Analyzing recent trends in coronary heart disease (CHD) deaths among the elderly in the United States using data from official statistical sources.

Total mortality rates and coronary heart disease (CHD) mortality rates are declining in the USA. Accordingly, the oldest individuals (85+ years) comprise the fastest growing segment of the population. How do these declines in mortality apply to and re-apportion other age groups? We examined trends in CHD mortality for the USA population over 25 years of age, focusing on changes occurring among individuals 65-74 and 75-84 years of age.

Risk factors for cerebrovascular events: end-diastolic flow velocity.

INTRODUCTION: There are very few studies analysing blood flow velocity parameters of common carotid arteries (CCA), obtained with color Doppler examination as a predictor in cerebrovascular events (CVE). In everyday clinical practice there are number of patients (pts) without carotid stenosis or occlusion but with decreased blood flow velocities. AIM: We performed this study to compare data of velocity parameters with type of cerebrovascular events (CVE) and multiple risk factors in patients without stenotic or occlusive extracranial disease. METHODS: We included total of 127 consecutive patients who experienced various subtypes of cerebrovascular events, 68 females, 59 males, mean age 70.2 +/- SD 12.4 years, out of them 48 pts. had transients ischemic attacs (TIAs), 31 pts. had recurrent TIAs (recTIAs), 32 pts. developed ischemic stroke (IS), and 16 recurrent IS (recIS). All patients were without hemodynamically significant carotid stenosis or occlusion. As a control group we took 50 patients with comparable mean age and gender distribution, all without cerebrovascular events, but with at least 1 multiple risk factor. We included the following clinical variables: age, gender, hypertension, tobacco smoking, hyperlipidemia, obesity, diabetes mellitus. Velocity parameters were: peak-systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), resistive index (RI). Examination was performed on distal portion of CCA, and we took the mean of both CCA. RESULTS: Hemodynamic parameters in CVE pts were: PSV 83.5 cm/sec, EDV 19.5 cm/sec, PI 1.54, and RI 0.77, and in Controls values were: PSV 87.5 cm/sec, EDV 28.5 cm/sec, PI 1.42, RI 0.67, respectively. No sign. diff. in PSV and PI were found between CVE (n=127) and Controls (n=50), p = 0.2, while difference in EDV was significant, p < 0.01. We found significance for the following variables: age, tobacco smoking, hypertension, hyperlipidemia and obesity. The best single predictors for CVE were: age (70.1%, p < 0.01), tobacco smoking (63%, p < 0.01, hypertension (52.8%, p < 0.01) and obesity (51.2%, p < 0.01). and among hemodynamic parameters, end-diastolic velocity less than 18 cm/sec (p < 0.05). Decreased EDV (below 18 cm/sec) revealed a significant association with CVE. CONCLUSIONS: (a) we found significantly lower EDV in pts with IS and recIS, (b) EDV below 18 cm/sec was the best single predictor of IS, and recIS, (c) in our CVE pts--age, tobacco smoking, hypertension, obesity, were the best single predictors for CVE.

SCD in the world, Europe, Bosnia and Herzegovina and Mostar.

UNLABELLED: Sudden cardiac death (SCD) is "a natural death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of acute symptoms". Annual incidence is 0.36-1.28/1000 inhabitants. More than 1000 sudden deaths occur each day is in USA, and 100,000 people annually dead in the United Kingdom. Epidemiology differs greatly in 100-fold between young and old, and between developing and developed worlds. SCD is one of the leading causes of death and accounts for over 50% of the cardiac deaths. New data show that SCD is not nearly as sudden in most cases as the term may suggest. Warning symptoms that precede the sudden cardiac death are present for a surprisingly long time in many patients. Coronary artery disease (CAD) is the most common cause of death in the developed world. The major causes are inherited arrythmogenic right ventricular cardiomyopathy (ARVC), hypertrophic cardiomyopathy (HCM), anomalous coronary arteries and hereditary channelopathies (e.g., Long QT syndrome, LQTS). Prevalence is 3-4 fold higher in men, reflecting that of CAD. In adults, the incidence of CAD-related SCD varies with geography and age. The incidence of SCD increases with congestive heart failure (CHF), stroke, cancer and metabolic syndrome, particularly in the developed world. Coronary thrombi and plaque rupture or erosion are found in two thirds of SCD. In women over 50, rupture accounted for 80% of coronary thrombi. In Europe SCD accounts for 200,000 dead in 1 year. In FBiH rate of SCD fluctuates around 0.62/1000 inhabitants, in HNK it is 0.78/1000 and in Mostar 0.54/1000. A wide range of cardiac etiology and development of various management procedures in the primary and secondary preventive pharmacotherapy, device therapy, lifestyle changes and genetic profiling have had a major impact on the prediction and prevention of SCD. Improved resuscitation and defibrillation techniques together with advances in implantable pacemaker and defibrillator technology (AED) have all improved treatment outcome. Education of the Red Cross, Police, Army, Civic Protection members, public, patients and relatives to recognize and respond to symptoms of heart disease holds promise for reducing mortality attributed to sudden death. Developing a better understanding of the circumstances of sudden cardiac death and preventive measures and proper reactions to the impending events. Training in cardio-pulmonary resuscitation with public access defibrillation programs is necessary in fighting sudden death. Systematic screening of young athletes and implantation of implantable cardioverter defibrillators should prevent SCD. CONCLUSION: SCD remains one of the major public health problems in the world and is most commonly caused by CAD. Risk stratification is effective for groups, but difficult in case of individuals. There is a need for major improvements in prevention, risk protection, resuscitation and therapy.

Left bundle branch block (LBBB) in patients with heart failure (HF) in Mostar region of Bosnia and Herzegovina.

WORK GOAL: to determine the influence of Left branch block Hissa (LBBB) on: (a) the degree of heart weakness according to NYHA classification; (b) structural remodelling based on echocardiographic, and (c) functional remodelling based on EFLV i FS (echo), comparing patients with heart failure (HF) and the left branch block Hissa (LBBB) on EKG with heart failure with heart failure (HF) without the left branch block Hissa (LBBB). METHODS AND WORK: We selected group of So hospital patients with heart weakness of NYHA class II-IV with and 50 without the left branch block Hissa on EKG (LBBB). RESULTS: There was a clinical and echocardiographic evaluation of all patients and we determined their correlation related to the sex, NYHA class, structural and functional remodelling of heart cavities, EFLV, FS and survival and the number of hospitalisation in the last three years. The results where shown in a form of a table SAS 9.13 was used for statistic analysis. DISCUSSION AND CONCLUSION: LBBB is an important component of electric heart remodeling in patients with heart failure and represent an important clinic data in evaluation of patients and therapeutic approach. Because all our variables were expressed as a frequencies, chi square and Fisher exact test were used to test for potential differences. It particularly stressed the correlation of LBBB with echocardiographic movability parameters of i.v. septum and left atrium dimension (p < 0.001) while septum fibrosis (p < 0.001), paradoxal septum movability (p = 0.193) and EFLV (p < 0.001) point to a close correlation with LBBB. Other analysed parameters showed no correlation with LBBB.

Erythropoietin in cardiorenal anemia syndrome.

Incidents of heart and renal failure (HF, RF) together, are increasing in our country and all over the world, so a great attention has been dedicated to this problem recently. These diseases together have shown bad results because of the process of accelerated arteriosclerosis, structural changes of myocardium, oxidative stress, inflammation, increased activities of sympathetic nervous system (SNS), increased activities of a renin-angiotensin-aldosterone system (RAAS) (1). These factors are crucial in the development of patho-physiological process and consequential development of anemia, that together with heart and renal failure through interaction, cause serious disorder that we call the cardio-renal anemia syndrome (2). We examined effects of erythropoietin (Epoetin beta) at 90 (60 men and 30 women) pre-dialysed and dialysed patients with HF signs during a period of three years in individual dozes of 2000-6000 units subcutaneous (sc) weekly. Using computer S PLUS and SAS multiple variant analysis we have got correlations by Pearson. Epoetin beta significantly develops anemia parameters: number of erythrocytes (r=0.51779; p<0.0001), hemoglobin (r=0.38811; p<0.0002), MCV (r=0.59876; p<0.0001) at patients with HF. Positive effects are seen at NYHA class (r=0.59906; p<0.0001), on quality of life before and after prescribing medicine. Parameters of renal functions are improving: more urea (r =0.45557; p<0.0001) than creatinine (r=0.26397; p<0.00119) and potassium values K(+)) are not changed significantly (r=0.02060; p<0.8471). Epoetin beta has been useful in treatment of pre-dialysed and dialysed patients with HF and anemia by improving functional ability of myocardium and quality of life.

Effects of nebivolol on artery hypertension--multicentre study Bosnia and Herzegovina.

Hypertension is a major risk factor for cardiovascular diseases; drugs that reduce blood pressure and simultaneously improve or reverse endothelian dysfunction, as nebivolol, may be advantageous in terms of cardiovascular protection. The objective of this study is to show the anti-hypertensive efficacy and safety of nebivolol (5 mg once a day) given to patients with arterial hypertension for 3 months. It should also provide information about drug's influence on laboratory tests--fasting blood glucose and serum cholesterol, triglyceride and creatinine concentrations. Six centers--Tuzla, Sarajevo, Mostar, Bihac, Zenica and Banja Luka participated in this prospective study with follow-up period of 3 months that included 3 visits. The study group consisted of 328 hypertensic patients. Results showed a significant decrease in both systolic and diastolic blood pressure and heart rate at the end of the study. Fasting blood glucose level and serum cholesterol, triglyceride and creatinine changed significantly during the study, with lower levels of all the tests. Nebivolol seems to be free from some of the problems that generally accompany not only the classical beta- blockers but sometimes also newer classes of antihypertensive drugs. With its high anti-hypertensive efficiency and safety, and presence of statically significant difference in laboratory tests and beneficial effects, absence of adverse interaction with glucose and lipid metabolism, patients treated with Nebivolol may show an optimal adherence to therapy.

[Atherosclerosis in patients hospitalized at the Internal Medicine Clinic in Mostar in the past three years]. / Ateroskleroza u pacijenata hospitaliziranih na Internoj klinici u Mostaru u posljednje tri godine.

UNLABELLED: Atherosclerosis, polygenetic, multifactorial and chronic progressive disease of arteries leaves significant consequences on organs and their systems and cause frequent hospitalisations of patients. Aim found out frequency of atherosclerosis process and its consequences (acute myocardial infarction, cardiomyopathy, cerebrovascular insult, renal diseases and diseases of peripheral blood vessels) together with risc factors (artery hypertension, diabetes mellitus, hyperlipidemia, smoking, obesitas, stress an so on.) at patients of Internal Clinic in Mostar in the last three years (2001; 2002; 2003). RESULTS AND METHODS: During last three years we hospitalised 7278 patients which consequences and manifestations of arterosclerosis process had 4825 patients or 66.29% (male 2595 or 53.7% and female 2230 or 46.22%. Most frequent were CM (1496 or 31%) CAD (1036 or 21.47%) peripheral vessel diseases (169 or 3.5%) and the most significant CVI (104 or 2.15%) which were at our clinic as complication for other internal diseases.

[Sudden cardiac death (SCD) in Mostar in 2003]. / Naprasna smrt (SCD) u Mostaru u 2003.

UNLABELLED: Sudden Cardiac Death (SCD), although all the technical medical developments in diagnostics and therapy is one of the biggest health problems in BH and the world. Incidence rates of SCD ranging between 0.36 to 1.28 per 1000 inhabitants in the general population in Western countries and 1/1000/year in the world. AIM: Considering of the incidence SCD in Mostar in 2003 and causes here events. METHODS AND RESULTS: With the standard methods of statistics and data regarding of Federal statistical office, the hospitals protocols and Emergency medical services of Mostar, and results of studies in the preventive actions SCD in BH of Association of Cardiologist of Bosnia and Herzegovina and Public Health office of BH made correlation and considered that the incidence SCD in Mostar is 0.42% in the general population or 50.8% all the natural death. The biggest is at people aged after 60 in 82.74%, more in men to women (53.36%). In the 30 deaths of the infarct myocardiac in Clinical Hospital of Mostar in 2003, 16 is sudden death, with 53.33%. Hospital sudden death is most in the women 62.5%. CONCLUSION: High incidence of sudden death in Mostar in 4.2/1000/year is results the multifactorial risc factors of coronary artery disease and beggest stress in Mostar in the postwar period especially with administrative regulation of the city.

[Sensitivity, specificity and predictive value of the treadmill stress test in comparison with coronary angiography findings]. / Senzitivnost, specificnost i prediktivna vrijednost tredmil testa opterecenja srca u odnosu na koronarografski nalaz.

UNLABELLED: Precondition to prevention and control of morbidity and mortality of myocardial ischemia--coronary disease, is its good diagnostic. Goal of this study is to asses diagnostic significance of positive trademill stress test in diagnosis of coronary disease. MATERIAL AND METHODS: we analyzed 120 patients with markedly positive classic trademill stress test using Bruce protocol in the year 2003. In all cases, positive stress test was followed by selective angiography, using standard technique with multiple sections. Blood vessel narrowing of more than 50% was chosen as the criteria for positive angiographie finding. With the help of coronary angiography, it was found that 62 (51.7%) of patients has stenosis of less than 50% or normal angiographic finding. 58 (48.3%) of patients had stenosis of more than 50%. Of that number, 24 (41.4%) had one-vessel coronary disease, 12 (20.7%) two-vessel coronary disease, and 10 (34.5%) three-vessel coronary disease. 2 patients (3.4%) had stenosis of the trunk of left coronary artery. Results of this study show that the sensitivity of trademill stress-test is less than optimal, and should be supplemented by other non-invasive techniques (such as myocardial perfusion scintigraphy, radionuclide ventriculography and stress echocardiography) in diagnostics of coronary disease.