Achievement of ESC/EAS LDL-C treatment goals after an acute coronary syndrome with statin and alirocumab

AIMS

European guidelines set low-density lipoprotein cholesterol (LDL-C) treatment goals <1.4 mmol/L after acute coronary syndrome (ACS), and <1.0 mmol/L for patients with recurrent cardiovascular events ≤2 years. Many ACS patients do not achieve these goals on statin alone. We examined actual goal achievement with alirocumab and projected achievement with ezetimibe, either added to optimized statin therapy.

METHODS AND RESULTS

The ODYSSEY OUTCOMES trial (NCT01663402) compared alirocumab with placebo in 18,924 patients with recent ACS and hyperlipidaemia despite high-intensity or maximum-tolerated statin therapy. This subanalysis comprised 17,589 patients with LDL-C ≥1.4 mmol/L at baseline who did not receive ezetimibe treatment. High-intensity statin treatment was used in 88.8%. Median (interquartile range) baseline LDL-C was 2.3 (1.9-2.7) mmol/L. With alirocumab, 94.6% of patients achieved LDL-C <1.4 mmol/L at ≥1 post-baseline measurement vs. 17.3% with placebo. Among 2236 patients with a previous cardiovascular event within 2 years (before the qualifying ACS), 85.2% vs. 3.5%, respectively, achieved LDL-C <1.0 mmol/L. Among patients not treated with ezetimibe, we projected that its use would have achieved LDL-C <1.4 and <1.0 mmol/L in 10.6% and 0%, respectively at baseline (assuming 18 ± 3% reduction of LDL-C).

CONCLUSION

Among patients with recent ACS and LDL-C ≥1.4 mmol/L despite optimized statin therapy, addition of alirocumab allowed 94.6% to achieve the 2019 European guideline LDL-C goal <1.4 mmol/L, and 85.2% of those with recurrent cardiovascular events to achieve <1.0 mmol/L. In contrast, addition of ezetimibe to optimized statin therapy was projected to achieve LDL-C <1.4 mmol/L in only 10.6% of patients at baseline.

Primary prevention efforts are poorly developed in people at high cardiovascular risk: A report from the European Society of Cardiology EURObservational Research Programme EUROASPIRE V survey in 16 European countries

BACKGROUND

European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V in primary care was carried out by the European Society of Cardiology EURObservational Research Programme in 2016-2018. The main objective was to determine whether the 2016 Joint European Societies' guidelines on cardiovascular disease prevention in people at high cardiovascular risk have been implemented in clinical practice.

METHODS

The method used was a cross-stional survey in 78 centres from 16 European countries. Patients without a history of atherosclerotic cardiovascular disease either started on blood pressure and/or lipid and/or glucose lowering treatments were identified and interviewed ≥ 6 months after the start of medication.

RESULTS

A total of 3562 medical records were reviewed and 2759 patients (57.6% women; mean age 59.0 ± 11.6 years) interviewed (interview rate 70.0%). The risk factor control was poor with 18.1% of patients being smokers, 43.5% obese (body mass index ≥30 kg/m2) and 63.8% centrally obese (waist circumference ≥88 cm for women, ≥102 cm for men). Of patients on blood pressure lowering medication 47.0% reached the target of <140/90 mm Hg (<140/85 mm Hg in people with diabetes). Among treated dyslipidaemic patients only 46.9% attained low density lipoprotein-cholesterol target of <2.6 mmol/l. Among people treated for type 2 diabetes mellitus, 65.2% achieved the HbA1c target of <7.0%.

CONCLUSION

The primary care arm of the EUROASPIRE V survey revealed that large proportions of people at high cardiovascular disease risk have unhealthy lifestyles and inadequate control of blood pressure, lipids and diabetes. Thus, the potential to reduce the risk of future cardiovascular disease throughout Europe by improved preventive cardiology programmes is substantial.

EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond

These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.

Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: Results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry

Aims

The aim of this study was to determine whether the Joint European Societies guidelines on secondary cardiovascular prevention are followed in everyday practice.

Design

A cross-sectional ESC-EORP survey (EUROASPIRE V) at 131 centres in 81 regions in 27 countries.

Methods

Patients (<80 years old) with verified coronary artery events or interventions were interviewed and examined ≥6 months later.

Results

A total of 8261 patients (females 26%) were interviewed. Nineteen per cent smoked and 55% of them were persistent smokers, 38% were obese (body mass index ≥30 kg/m2), 59% were centrally obese (waist circumference: men ≥102 cm; women ≥88 cm) while 66% were physically active <30 min 5 times/week. Forty-two per cent had a blood pressure ≥140/90 mmHg (≥140/85 if diabetic), 71% had low-density lipoprotein cholesterol ≥1.8 mmol/L (≥70 mg/dL) and 29% reported having diabetes. Cardioprotective medication was: anti-platelets 93%, beta-blockers 81%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75% and statins 80%.

Conclusion

A large majority of coronary patients have unhealthy lifestyles in terms of smoking, diet and sedentary behaviour, which adversely impacts major cardiovascular risk factors. A majority did not achieve their blood pressure, low-density lipoprotein cholesterol and glucose targets. Cardiovascular prevention requires modern preventive cardiology programmes delivered by interdisciplinary teams of healthcare professionals addressing all aspects of lifestyle and risk factor management, in order to reduce the risk of recurrent cardiovascular events.

The Cumulative Incidence of Stroke, Myocardial infarction, Heart Failure and Sudden Cardiac Death in Patients with Atrial Fibrillation

Introduction:

Atrial fibrillation represents the most common cardiac arrhythmia in clinical practice. By year 2030, 14–17 million AF patients are anticipated in the European Union. Atrial fibrillation remains one of the major causes of stroke, heart failure, sudden death all over the world.

Research Objectives:

The objective of our study is to determine the cardiac and cerebrovascular events (myocardial infarction, heart failure, stroke, sudden cardiac death) and their cumulative incidence during 11 years follow up period.

Patients and methods:

This study includes 2352 ambulant and hospitalized patients with atrial fibrillation (AF) who were enrolled during the follow up period. All patients underwent clinical evaluation in order to determine cardiac and cerebrovascular events (myocardial infarction, heart failure, stroke, sudden cardiac death) and their cumulative incidence.

Results:

The results of cumulative incidence for sudden cardiac death was 1.71%, for stroke 2.56%, for myocardial infarction 1.20% and for heart failure was 5.73%. In our study the age-adjusted incidence and prevalence of AF are slightly lower in women. The study shows that the risk of death is higher in females than in males with AF.

Conclusion:

Despite good progress in the management of patients with atrial fibrillation (AF), this arrhythmia remains one of the major causes of stroke, heart failure, sudden death. Effective treatment of patients with atrial fibrillation includes not only rate control, rhythm control, and prevention of stroke, but also management of cardiovascular risk factors and concomitant diseases.

Delayed Care and Mortality Among Women and Men With Myocardial Infarction

Background

Women with ST‐segment–elevation myocardial infarction (STEMI) have higher mortality rates than men. We investigated whether sex‐related differences in timely access to care among STEMI patients may be a factor associated with excess risk of early mortality in women.

Methods and Results

We identified 6022 STEMI patients who had information on time of symptom onset to time of hospital presentation at 41 hospitals participating in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776) from October 2010 through April 2016. Patients were stratified into time‐delay cohorts. We estimated the 30‐day risk of all‐cause mortality in each cohort. Despite similar delays in seeking care, the overall time from symptom onset to hospital presentation was longer for women than men (median: 270 minutes [range: 130–776] versus 240 minutes [range: 120–600]). After adjustment for baseline variables, female sex was independently associated with greater risk of 30‐day mortality (odds ratio: 1.58; 95% confidence interval, 1.27–1.97). Sex differences in mortality following STEMI were no longer observed for patients having delays from symptom onset to hospital presentation of ≤1 hour (odds ratio: 0.77; 95% confidence interval, 0.29–2.02).

Conclusions

Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01218776.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors´ Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors´ Network of the European Society of Cardiology.

Data sharing: A new editorial initiative of the International Committee of Medical Journal Editors. Implications for the editors' network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors' Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship - emphasizing the importance of responsibility and accountability - have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors' Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors' Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship - emphasizing the importance of responsibility and accountability -, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors´ Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship - emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors´ Network of the European Society of Cardiology. Resumo O Comitê Internacional de Editores de Revistas Médicas (ICMJE) fornece recomendações para aprimorar o padrão editorial e a qualidade científica das revistas biomédicas. Tais recomendações variam desde requisitos técnicos de uniformização até assuntos editoriais mais complexos e elusivos, como os aspectos éticos do processo científico. Recentemente, foram propostos registro de ensaios clínicos, divulgação de conflitos de interesse e novos critérios de autoria, enfatizando a importância da responsabilidade e da responsabilização. No último ano, lançou-se uma nova iniciativa editorial para fomentar o compartilhamento dos dados de ensaios clínicos. Esta revisão discute essa nova iniciativa visando a aumentar a conscientização de leitores, investigadores, autores e editores filiados à Rede de Editores da Sociedade Europeia de Cardiologia.

The Impact of Risk Factors and Comorbidities on The Incidence of Atrial Fibrillation

Introduction

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia in clinical practice and its prevalence increases with age. Patients who develop AF also have cardiovascular risk factors, structural heart disease, and comorbidities, all of which can increase mortality. AF causes a significant economic burden with the increasing trend in AF prevalence and hospitalizations.

Research Objectives

The objective of our study is to evaluate the impact of the most common known risk factors on the incidence of atrial fibrillation as an important precursor of cardiac and cerebrovascular morbidity and mortality among our patients in Bosnia and Herzegovina during median follow up period (September 2006 - September 2016). The other objective is to estimate the CHA2DS2-VASc score among our patients based on clinical parameters.

Patients and methods

This study includes 2352 ambulant and hospitalized patients with atrial fibrillation. All patients underwent clinical evaluation which includes thorough assessment for potential risk factors and concomitant conditions in order to determine which of them represent the most common among examinees with atrial fibrillation.

Results

The results show that male gender has slightly more incidence of AF. Obesity and overweight with BMI ≥ 27, cigarettes smoking and sedentary life style are almost present in patients with AF. Arterial hypertension, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal dysfunction, structural and valvular heart disease and peripheral vascular disease are the most common comorbidities among our patients. The mean CHA2DS2-VASc score was 3.2±1.4 and the mean HAS-BLED score was 2.1±1.2.

Conclusion

Atrial fibrillation is the most common sustained cardiac rhythm disorder. The study shows that obesity, alcohol consumption, smoking cigarettes and dyslipidemia can be considered as triggers and predisposing factors for appearance of AF. Arterial hypertension, coronary artery disease, chronic obstructive pulmonary disease, diabetes mellitus, Peripheral vascular disease and chronic kidney disease are playing important role in developing of AF.

Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions

Background European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV in primary care was a cross-sectional survey carried out by the European Society of Cardiology, EURObservational Research Programme in 2014-2015 in 71 centres from 14 European countries. The main objective was to determine whether the 2012 Joint European Societies' guidelines on cardiovascular disease (CVD) prevention in people at high CVD risk have been followed in clinical practice. Methods Patients without a history of atherosclerotic disease started on either blood pressure and/or lipid and/or glucose-lowering treatments were identified and interviewed at least six months after the start of medication. Results Medical notes of 6700 patients were reviewed, and 4579 patients (58.7% women; mean age 58.8 (standard deviation (SD) 11.3) years) interviewed (interview rate 68.3%). Overall, 16.6% were smokers, 39.9% were overweight (body mass index (BMI)≥25 and <30 kg/m²), 43.5% obese (BMI ≥30 kg/m²) and 63.9% centrally obese (waist circumference of ≥88 cm for women, ≥102 cm for men). The medical risk factor control was very poor, with less than half (42.8%) of the patients on blood pressure lowering medication reaching the target of <140/90 mm Hg (<140/80 mm Hg in people with self-reported diabetes). Among treated dyslipidaemic patients only 32.7% attained the low-density lipoprotein (LDL)-cholesterol target of <2.5 mmol/l. Among people treated for type 2 diabetes mellitus, 58.5% achieved the glycated haemoglobin (HbA1c) target of <7.0%. Conclusion The EUROASPIRE IV survey shows that large proportions of patients at high CVD risk have unhealthy lifestyle habits and uncontrolled blood pressure, lipids and diabetes. The present data make it clear that more efforts must be taken to improve cardiovascular prevention in people at high CVD risk.

Invasive versus conservative strategy in acute coronary syndromes: The paradox in women's outcomes

BACKGROUND

We explored benefits and risks of an early invasive compared with a conservative strategy in women versus men after non-ST elevation acute coronary syndromes (NSTE-ACS) using the ISACS-TC database.

METHODS

From October 2010 to May 2014, 4145 patients were diagnosed as having a NSTE-ACS. We excluded 258 patients managed with coronary bypass surgery. Of the remaining 3887 patients, 1737 underwent PCI (26% women). The primary endpoint was the composite of 30-day mortality and severe left ventricular dysfunction defined as an ejection fraction <40% at discharge.

RESULTS

Women were older and more likely to exhibit more risk factors and Killip Class ≥2 at admission as compared with men. In patients who underwent PCI, peri-procedural myocardial injury was not different among sexes (3.1% vs. 3.2%). Women undergoing PCI experienced higher rates of the composite endpoint (8.9% vs. 4.9%, p=0.002) and 30-day mortality (4.4% vs. 2.0%, p=0.008) compared with men, whereas those who managed with only routine medical therapy (RMT) did not show any sex difference in outcomes. In multivariable analysis, female sex was associated with favorable outcomes (adjusted HR for the composite endpoint: 0.72, 95% CI: 0.58-0.91) in patients managed with RMT, but not in those undergoing PCI (adjusted HR: 0.96, 95% CI: 0.61-1.52).

CONCLUSIONS

We observed a more favorable outcome in women than men when patients were managed with RMT. Women and men undergoing PCI have similar outcomes. These data suggest caution in extrapolating the results from men to women in an overall population of patients in the context of different therapeutic strategies.

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology

Background

In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines.

Methods

A total of 6187 patients (18–80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012–2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys.

Results

A total of 2846 (46 %) patients had no diabetes, 1158 (19 %) newly diagnosed diabetes and 2183 (35 %) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60 %, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54 % and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28 %. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0 % (53 mmol/mol) in 95 and 53 % and 11 % of those with previously known diabetes had an HbA1c >9.0 % (>75 mmol/mol). Of the patients with diabetes 69 % reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27 % of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets.

Conclusions

Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.

Comparison of two and three dimensional transthoracic versus transesophageal echocardiography in evaluation of anatomy and pathology of left atrial apendage

OBJECTIVE

Our objective was the comparison of combined utility of two-dimensional (2D) transthoracic echocardiography (TTE) and three-dimensional (3D) TTE versus 2D and 3D transesophageal echocardiography (TEE) in evaluation of anatomy of the left atrium appendage (LAA) and for clot formation in LAA.

BACKGROUND

2DTEE as semi-invasive method has been for a long time used to visualize the LAA. Improved echocardiography technology has increasingly improved visualization of LAA by 2DTTE and 3DTTE in many patients and decreased the need for TEE performance.

METHODS

We compared combined 2DTTE and 3DTTE with 2DTEE and 3DTEE in evaluating the LAA for anatomical features and thrombus. Eighty-six patients underwent 2DTTE, 3DTTE, 2DTEE and 3DTEE.

RESULTS

LAA could be visualized in all patients. 31 % of patients had one lobe, 43% had 2 lobes and 26% had > 2 lobes. Of 86 patients studied, 79 had no thrombus and 7 had thrombus in the LAA by all modalities. Six patients, 3 with atrial fibrillation (AF), and 4 in sinus rhythm (SR) had a suspected thrombus by 2DTEE. Only in one patient 3DTEE cropping has been needed to clearly show thrombus which was suspected in short axis view on 2DTEE as rounded echo dense mass.

CONCLUSIONS

Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LAA anatomy and pathology in terms of thrombus. Only in inappropriate (obese) patients 2TTE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.

Thrombosed femoral artery pseudoaneurysm: complication of cardiac catheterization

We present a case of catheter induced pseudoaneurysm of femoral artery and postprocedural course. This type of complications occurs in 2% to 8% patients after interventional procedures via trans femoral access and and has overall trend of increase due to significant number of this procedures in diagnostic and interventional cardiology. A 74-year-old female was admitted to Vascular department complaining of severe pain in her left groin. On physical examination, there was a femoral mass palpable but non-pulsatile in her left groin. Color Doppler documented the presence of femoral pseudoaneurysm as well as "to-and-fro" flow pattern on the pseudoaneurysm neck. CT arteriogram showed pseudoaneurysm with mostly thrombosed cavity, diameter of 85 x 27 mm. We concluded for further surgical repair.

Trends in cardiovascular diseases in Bosnia and Herzegovina and perspectives with heartscore programme

Cardiovascular diseases are still the major cause of death, morbidity, mortality and loss of quality of life in European countries and worldwide. In Bosnia and Herzegovina we have burden of cardiovascular diseases with higher rate of morbidity and mortality than in the countries of EU zone or broader Europe. The cause of mortality is in close relation to multiple risk factors but also with specific conditions in our country; post war situation, transition and overall economic position. The main mission of European Society of Cardiology is to improve quality of life in the European population by reducing the impact of cardiovascular diseases. HeartScore web based program and PS Standalone program are introduce to assesses the overall risk of cardiovascular death for a period of 10 years, based on variables such as age, sex, smoking, systolic blood pressure and cholesterol levels in the blood, or total cholesterol/HDL ratio. Standalone PS HeartScore is practical to use, requires no permanent internet connection, the system offers its own database for each patient and the print version of the guidelines to reduce risk factors, based on evidence based medicine Program is tailored to patients, the system provides a graphical representation of the absolute risk of CVD, a version for our country is developed on the principle of high-risk populations and is available in the languages of the peoples of Bosnia and Herzegovina. Program is available for all types of medical practice which is equipped with computers, the laptop, and suitable for community nursing service as well.

Socio-medical Characteristics of Coronary Disease in Bosnia and Herzegovina and the World

INTRODUCTION

Coronary heart disease and its etiology are complex socio-medical and clinical problem in this century. World Health Organization defined coronary artery disease as acute and chronic heart ailments due to disruption of flow and myocardial blood supply. Diseases of the cardiovascular system in spite of preventable risk factors are responsible for approximately 50% of all deaths in the developed world, and this ratio is higher in developing countries.

RISK FACTORS

CORONARY HEART DISEASE RISK FACTORS CAN BE DIVIDED IN THOSE WHICH ARE NOT PREVENTABLE SUCH AS: personal and family history of cardiovascular diseases, age and gender and preventable risk factors including: high blood pressure, elevated blood cholesterol, smoking, reduced physical activity, elevated blood sugar, increased body weight, alcohol use, psychosocial factors and nutrition. There are also newly emerging risk factors which includes increased homocysteine, thrombogenic and inflammatory factors. Prevention of coronary heart disease risk factors: The concept of risk assessment factors, their reduction, initially begun in the Framingham Heart Study and refined in other models. Primary prevention relates to changing lifestyle and influencing preventable risk factors. Numerous studies and meta-analysis showed that lifestyle modification, risk reduction factors, particularly by changing diet, stopping smoking, increasing physical activity, blood pressure control can be effective in the prevention and reduction of coronary heart disease. Primary health care physicians i.e. family physicians need to take an active role in assessment of risk factors for coronary heart disease.

CONCLUSION

The data in this paper, based on the findings from other studies, suggest the importance of using a modified algorithm in order to estimates the overall risk of coronary disease in high-risk groups among the patients in the primary health care settings.

Primary percutaneous coronary interventions network in Bosnia and Herzegovina--Sarajevo's proposal

Reperfusion therapy is the most useful part of the treatment for patients suffering from an acute coronary syndrome. Start time of reperfusion therapy is an important factor which influenced positively on the number of days of hospitalization, and readmission, the risk of reinfarction, as well as both, short and long-term mortality. Today, several models of reperfusion therapy are available: thrombolytic treatment (pre-hospital or in-hospital setting), primary percutaneous coronary intervention (primary PCI or pPCI) or a combination of both. pPCI is preferred, as soon as possible, in centers with experienced teams, especially for patients in shock, or those with contraindicated fibrinolytic therapies. We will compared, very shortly, the daily practices in 4 countries (Czech Republic, Austria, Croatia, Serbia ), where (well) developed primary PCI hospital networks works efficiently for a years, with the current situation in Bosnia and Herzegovina. Our goal is to describe the easiest and quickest way of establishing the primary PCI network in Bosnia and Herzegovina. By combining the efforts of both Entities of Bosnia and Herzegovina will be possible in the forthcoming period, that B&H becomes a participant in the Stent for life initiative.

The role of exercise test in stratifying the risk of asymptomatic patients with moderate/severe aortic stenosis

OBJECTIVES

The role of exercise test in risk stratifying of asymptomatic patients with moderate and severe aortic stenosis (AS) in recent literature is still controversial. The aim of this study was to evaluate the role of exercise test in stratifying the risk of patients with moderate to severe aortic stenosis.

METHODS

At the Internal Medicine Clinic, Department of Cardiology in Tuzla, in the period from January 2008 until January 2010 was followed 33 patients with clinical and echocardiographic parameters of moderate to severe asymptomatic aortic stenosis (mean effective orifice area EOA 0.9 +/- 0.34 cm2). In statistical analysis we used descriptive statistics, t-test, chi-square test and Kaplan-Meier life table for predictive values, sensitivity and specificity. A significance level of 0.05 was used.

RESULTS

Two patients were excluded due to exclusion criteria, so 31 patient was followed up during 12 months period. Eighteen patients (58%) with EOA pounds sterling 0.8 cm2 had limiting symptoms during the test. During follow-up period, 11 patients developed serious spontaneous symptoms, and out of them 8 patients underwent surgical valve replacement, one patient died (sudden cardiac death), and 2 patients had serious complications (ischemic cerebral stroke). Twenty patients remained asymptomatic. The highest positive predictive accuracy had EOA pounds sterling 0.8 cm2 with limiting symptoms and it was 85%. The highest negative predictive accuracy had ST depression.

CONCLUSION

only limiting symptoms along with EOA pounds sterling 0.8 cm2 had positive predictive accuracy.

Cerebrovascular events: correlation with plaque type, velocity parameters and multiple risk factors

PURPOSE

Cerebrovascular events (CVE) are the third most common cause of death in Western countries and about 65-70% of CVE are due to atherosclerotic disease of carotid arteries. Color Doppler scanning is used to evaluate the presence, severity and type of atheromatous plaques as well as velocity parameters of carotid arteries. We performed this study to correlate data of morphological and velocity parameters with clinical variables in patients following CVE.

METHODS

We included total of 211 pts who had CVE, 118 females, 93 males, mean age 71.1 +/- SD 12.5 years. Out of total number of pts (n = 211) 93 pts had transient ischemic attacks (TIAs), 49 had recurrent TIAs (rTIAs), 44 had ischemic stroke (IS), and 25 had recurrent IS (rIS). As a control group we took 50 pts without CVE but with at least three multiple risk factor (MRF). Morphological parameters were; plaque composition and echogenecity. Velocity parameters were: peak-systolic velocity (PSV) and end-diastolic velocity (EDV). The following MRF were evaluated: age, gender, hypertension, tobacco smoking, hyperlipidemia (total cholesterol and LDL-cholesterol), obesity, and diabetes mellitus. Examination was performed on CCA/ICA segment.

RESULTS

We found significant presence of heterogeneous plaques in TIAs and rIS subgroup, p < 0.014, and borderline significance for the rTIAs and IS subgroups, p < 0.04. We found significant difference in PSV in TIAs and rTIAs subgroups vs. controls (PSV 103 cm/s vs. PSV in controls 87 cm/s, p < 0.01). Decreased EDV, below 20 cm/s, was found in all subgroups, p < 0.01, while EDV, below 16 cm/s, was found in IS and rIS subgroups. MRF score of CVE group was 4.34 vs. 3.65 in controls, p < 0.012, while MRF score in TIAs and rTIAs vs. IS and rIS subgroups was 4.34 vs. 4.51, NS, p = 0.14. We found a significant correlation (95% CI) of tobacco smoking, obesity and arterial hypertension with presence of heterogeneous plaques, p = 0.0069. Interestingly, hyperlipidemia showed no correlation with heterogeneous plaques, p = 0.027.

CONCLUSIONS

(i) in CVE group we found significant presence of heterogeneous plaques in TIAs and rIS subgroups, (ii) in the pts with TIAs and rTIAs events we found significant increase in PSV, (iii) EDV below 16 cm/sec was a significant single predictor of IS and rIS events, (iv) MRF score was significantly increase in the pts with CVE compared to controls, but between CVE subgroups there was no significant difference.

Correlation of arterial hypertension and type 2 diabetes mellitus with type of polyvascular atherosclerotic disease

Atherosclerosis is a systemic disease of blood vessels which in most of the cases affects two or three vascular beds. The occurrence and development of atherosclerotic disease is accelerated by multiple risk factors among which the significant role has arterial hypertension and diabetes mellitus. AIM of this article is to evaluate presence of hypertension and diabetes mellitus type 2 in patients with polyvascular atherosclerotic disease and compare them to those who have isolated disease of one vascular bed.

MATERIAL AND METHODS

we enrolled total of 160 consecutive patients. Patients were divided into 4 groups, in relation to the type of their atherosclerotic disease. COR-group included patients with coronary atherosclerotic disease, CAR-IF group included patients with carotid and iliac-femoral atherosclerotic disease, COR-IF group consists of patients with coronary and iliac-femoral atherosclerotic disease, and COR-CAR-IF group consists of patients with atherosclerotic disease in three vascular beds: coronary, carotid and iliac-femoral. We followed clinical variables: age, gender, arterial hypertension, tobacco smoking, total cholesterol and diabetes mellitus with focus on arterial hypertension and diabetes mellitus.

RESULTS

we had significant percentage of patients with arterial hypertension in all four groups in relation to those with normal blood pressure. Hypertension in male subjects was significantly higher in those with polyvascular disease i.e. COR-CAR-IF, and COR-IF groups, compared to monovascular disease i.e. COR group, (p < 0.05). In females the prevalence of hypertension was significantly higher in COR-CAR-IF and COR-IF groups, (< 0.05). Males had higher systolic values in the COR-CAR-IF group compared to other groups, but only signif. differ. was between COR-CAR-IF group vs. CAR-IF group, (p < 0.05). In females we found signif. differ. in systolic values in COR-CAR-IF group compared to COR group, p < 0,05. In diastolic values we found no signif. differ. between groups. The significant percentage of diabetics was in COR-CAR-IF group (77.5%), and the difference to other groups was statistically significant, p < 0.05. We found significant percentage of diabetics in COR-CAR-IF group (77.5%), and the difference between the diabetics versus non-diabetics was statistically significant. The largest percentage of diabetics both men (76.1%) and women (84.2%) belonged to the patients with polyvascular disease i.e. COR-CAR-IF group respondents.

CONCLUSIONS

prevalence of arterial hypertension and type 2 diabetes mellitus was statistically higher in individuals with polyvascular atherosclerotic disease.

Clinical, echocardiographic and echophonocardiographic characteristics of the atrial myxomas in 22 years period

INTRODUCTION

Atrial myxomas are the most frequent benign tumors of the heart. Left atrial myxomas are about 3-4 times more frequent then right. Clinical findings reveal atrioventricular obstruction symptoms and signs, symptoms and signs of peripheral arteries or pulmonary artery embolisation and/or nonspecific symptoms.

AIM

Review of atrial myxomas diagnosed at the Clinic of Cardiology in 20 years period and analysis of clinical characteristics, transthoracic echocardiographic (TTE), transesophageal echocardiographic (TEE), and M-mod echophonographic findings.

METHODS

TTE is performed in all, but TEE in 16 patients. Simultaneous M-mod echophonocardiographic examination were performed in 11 patients, when optional equipment was applicable.

RESULTS

We found 24 atrial myxomas: 19 (79.2%) in left and 5 (20.810%) in right atrium. 21(87.5%) patients had some of the symptoms, but 3 (12.5%) were asymptomatic. TTE was performed in all patients, but we found 1 (2.4%) false negative result. TEE was performed in 14 (58.3%) patients. Echophonocardiographic recordings showed early diastolic tumor "plop" in 10 patients and unusual late diastolic tumor "plop" in one right atrial myxoma, which has not yet been described.

CONCLUSIONS

TTE is a reliable method in diagnosis of atrial myxomas, but not in all cases, while TEE has been found as always reliable. Echophonocardiographic recording is useful for confirmation and understanding of auscultatory finding when applicable.

Why historians of medicine called Ibn al-Nafis second Avicenna?

At the end of IX and beginning of the X century begins development and renaissance of the medicine called Arabic, and which main representatives were: Ali at-Taberi, Ahmed at-Taberi, Ar-Razi (Rhazes), Ali ibn al-Abbas al-Magusi (Haly), ibn al-Baitar, ibn al-Qasim al-Zahrawi (Abulcasis), ibn Sina (Avicenna), ibn al-Haitam (Alhazen), ibn Abi al-Ala Zuhr (Avenzor), ibn Rushd (Averroes) and ibn al-Nafis. Doctors Taberi, Magusi and Razi were born as Persians. Each of the listed great doctors of the Arab medicine in their own way made legacy to the medical science and profession, and left lasting impression in the history of medicine. Majority of them is well known in the West well and have their place in the text-books as donors of significant medical treasure, without which medicine would probably, especially the one at the Middle dark century, be pale and prosaic, insufficiently studied and misunderstood, etc. Abdullah ibn Sina (Avicenna) remained unsurpassed in the series of above listed. Close to him can only come Alauddin ibn al-Nafis, who will in mid-XII century rebut some of the theories made by Avicenna and all his predecessors, from which he collected material for his big al-Kanun fit-tibb (Cannon of medicine). Cannon will be commended for centuries and fulfilled with new knowledge. One of the numerous and perhaps the best comments-Excerpts is from Nafis-Mugaz al-Quanun, article published as a reprint in War Sarajevo under the siege during 1995 in Bosnian language, translated from Arabic by the professor Sacir Sikiric and chief physician Hamdija Karamehmedovic in 1961. Today, at least 740 years since professor from Cairo and director of the Hospital A-Mansuri in Cairo Alauddin ibn Nefis (1210-1288), in his paper about pulse described small (pulmonary) blood circulatory system and coronary circulation. At the most popular search engines very often we can find its name, especially in English language. Majority of quotes about al-Nafis are on Arabic or Turkish language, although Ibn Nafis discovery is of world wide importance. Author of this article is among rare ones who in some of the indexed magazines emphasized of that event, and on that debated also some authors from Great Britain and USA in the respectable magazine Annals of Internal medicine. Citations in majority mentioning other two "describers" or "discoverers" of pulmonary blood circulation, Miguel de Servet (1511-1553), physician and theologian, and William Harvey (1578-1657), which in his paper "An Anatomical Exercise on the Motion of the Hearth and Blood in Animals" published in 1628 described blood circulatory system. Ibn Nafis is due to its scientific work called "Second Avicenna". Some of his papers, during centuries were translated into Latin, and some published as a reprint in Arabic language. Significance of Nafis epochal discovery is the fact that it is solely based on deductive impressions, because his description of the small circulation is not occurred by in vitro observation on corps during section. It is known that he did not pay attention to the Galen theories about blood circulation. His prophecy sentence say: "If I don't know that my work will not last up to ten thousand years after me, I would not write them" Sapient sat. Searching the newest data about all three authors: Alauddin ibn Nafis (1210-1288), Michael Servetus (1511-1533) and William Harvey (1628) in the prestige Wikipedia I manage to link several most relevant facts, based on which we can in more details explain to whom from these three authors the glory and the right to call them self first describer of the pulmonary and cardiac circulation belongs. About Servetus and Harvey there is much more data than on ibn Nafis, about which on Google there are mainly references in Arabic and Turkish language, and my four references on Bosnian, with the abstracts in English. Probably the language barrier was one of the key reasons that we know so little about Nafis and so little is written, although respectable professor Fuat Sezgin from Frankfurt in 1997 published comprehensive monograph about this great physician, scientist and explorer, in which papers we can clearly recognize detailed description of the pulmonary and cardiac circulation. Also, I personally published separate monographs about this scientist, and which can be found on www. avicenapublisher.org.

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.

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.