Introduction: Patients with symptomatic chronic heart failure (sCHF) and implanted cardiac resynchronization device (CRTD) were included in this retrospective study in order to evaluate possible ...differences in mitral (MR) and tricuspid (TR) valvular regurgitation severity, NYHA class and left ventricle ejection fraction (LVEF) between male and female CRTD patients during follow up of 6 months after CRTD implantation.
Patients and Methods: We included 135 patients (89 men, 46 women) with sCHF due to any cause with implanted CRTD according to guidelines with optimal medical therapy regardless of atrial fibrillation
or in sinus rhythm. Clinical (NYHA class) and echocardiographic data (valve pathology, LVEF) were assessed before and 6 months after CRTD implantation. Using color and continuous wave Doppler, PISA, regurgitation volume and vena contracta measurements, mitral regurgitation (MR) and tricuspid regurgitation (TR) were stratified in 3 grades. Echocardiography was recorded always by the same echo-technician to avoid inter-observer variability.
Results: Mean age of patients was 60 (±10) years. The results showed improvement in LVEF from 25% up to 36% (p=0.006) in all patients regardless of sex and age, as well as worsening of TR (p<0.001) and
no difference in MR (p=0.195). In male patients (N=89), significant worsening in MR and TR was present (p<0.05) while there was no significant worsening in MR (p=0.42) nor TR (p=0.06) in female patients (N=46). In patients older than 60 years (N=82, female 27 (33%), male 55 (67%)), as well as younger than 60 years (N=53; female 19 (36%), male 34 (64%)) significant worsening of TR grade was observed (p<0.05), while the grade of MR remained the same (p=0.255 and p=0.534). An improvement in NYHA class was observed in 75 patients (71%), no change in 25 patients (24%) and worsening in 5 patients (5%). Overall improvement in NYHA class was statistically significant (p<0.001).
Conclusion: Six months after CRTD implantation the severity of MR and TR remained the same in female patients while significant worsening of MR and TR severity was found in male patients. TR worsening might be due to implanted electrodes. The age of patients had no impact on LVEF, TR and MR change. Despite improvement in clinical status and NYHA class, the echocardiography results did not meet our expectations.1-4 Due to limited number of patients the results were not divided according to the etiology of CHF.
Introduction: Age and gender may influence the incidence of aortic regurgitation (AR) and its severity.
Significant aortic regurgitation (sAR) is often treated surgically especially when symptomatic ...or when
systolic function declines.1 The aim of this study was to evaluate the outcomes in patients with sAR
according to treatment strategy, age and gender differences in our study population.
Patients and Methods: In this retrospective descriptive single-centre study an overall of 107 patients
(22 female, 85 male) with significant AR in the last 5 years were analyzed. Patients were treated according
to valid recommendations, surgically (SUR) or conservatively (CON), except for 5 patients who
refused surgery. Baseline and follow up (FU) data (AR severity, left ventricle ejection fraction (LVEF),
ascending aorta diameter (AA), treatment, comorbidities and major adverse cardiovascular events
(MACE) during FU), from documented medical history and digital imaging data were collected and
analysed. Additional sub-analysis was performed according to sex and age differences (above vs. below
the age of 50). For statistical analysis a Chi-Square test was used.
Results: In the overall study population, during an average FU of 3.8 years, 16 patients (15%) developed
MACE with no statistically significant difference between gender (p=0.846). Forty-six (43%) patients
were surgically treated (87% male, 13% female) and 61 (54%) conservatively. LVEF did not worsen in FU
period (54.1%, vs. 53.8%). In SUR, median age was 54 years, severe AR was present in 93%, incidence of
MACE was 21.7%, 80.4% patients were symptomatic and 14.5% had dilatation of AA more than 50 mm.
In CON, MACE was present in 9.8% during FU (p=0.87), median age was 64 years. Moderate AR (48% vs
6.5%) and AA from 40-49 mm (80 vs 35%) was present more frequently as well as arterial hypertension
(82 vs 70%) and chronic renal disease (23.2 vs 16.6%). The incidence of MACE was not found to be agerelated
(p=0.426).
Conclusion: In patients with sAR treated by either surgery or medication therapy only, during 3.8 years
of FU, LVEF remained unchanged, while incidence of MACE was not found to be related to treatment
strategy nor gender. In surgically treated patients, as expected, AR was more severe and AA was more
dilated, while neither age nor gender had an impact on the incidence of MACE.
Coronary Computed Tomography Angiography (CCTA) is now the fastest and only growing application for computed tomography in the United States, with approximately 500,000 Americans undergoing CCTA each ...year 1. On the other hand, this has stimulated professional and public concern about appropriateness of its widespread use. AHA/ACC Appropriate Use Criteria (AUC) for CCTA from 2006 defined 37 clinical situations where this method was considered appropriate, whereas in 2010 this has extended to 93, demonstrating and obvious growth. However, although recommendations for CCTA still remain cautious, on the other hand, diagnostic Invasive Coronary Angiography (ICA) is now recommended only if the results of non-invasive testing suggest high likelihood of significant 3-vessel dissease, or left main afliction, and also if the patient is willing to accept the posibility of imediate revascularization 2. In general, therefore, the AHA/ACC guideline update was less prescriptive than the earlier NICE guideline, perhaps partly because it put less emphasis on the cost efficiency of its recommendations. Although the indications might vary among different institutions, ICA and CCTA are now being commonly, and widely, used by clinicians to assess anatomic disease burden in patients with coronary artery disease (CAD), while other noninvasive imaging techniques are primarily used to ascertain ischemic burden. Beside a recent analysis has de facto called into question the rationale for many of the revascularization procedures performed until recently, at least in patients with stable CAD 3. In the meta-analysis including more than 5,000 patients, PCI seemed to be no better than medical therapy alone, patients with documented ischemia on stress testing or fractional flow reserve (FFR). As a curiosity in this respect, when Geroge W. Bush was stented in August 2013 a fierce dispute arose whether this intervention was really necessary or if he would have fared better off with only medical therapy. Also possibly interesting, the primary diagnostic work-up used in his case was CCTA, not ICA. Luckily, we believe, this dispute was settled after the COURAGE-trial systematically showed that patients with stable angina fare as well with optimal medical therapy alone, as they do with angioplasty/stenting, or by-pass. In our own series of roughly 800 patients, we also tried to evaluate how CCTA influenced the management and treatment of patients with CAD, that CCTA can reliably replace diagnostic ICA in majority of stable patients, no regardless of the pre-test risk stratification 4. In this respect, we would like to present a case "To stent or not to stent" our own debate (Figure 1 and 2). Having in mind the most recent evidence-based data that suggests that revascularization (coronary stenting, as well as by-pass) should probably be reserved only for patients with non-stable CAD, while patients with stable CAD should be treated conservatively, we think that also diagnostic work-up for these patients should be kept as non-invasive as possible, as the majority of the patients can be adequately managed in this way alone. To conclude, based upon this data and our clinical experience, we believe that CCTA can provide reliable diagnostic and prognostic information for adequate clinical decisionmaking and treatment of the majority of patients with stable CAD. The still ongoing 8,000-patient ISCHEMIA and other trials, will hopefully yield some more insights in this respect.
Šećerna bolest sa svojim komplikacijama uzrokuje 9 % ukupne smrtnosti diljem svijeta. Periferna arterijska bolest, uz kardiovaskularne bolesti, najčešća je komplikacija šećerne bolesti, čija ...prevalencija raste s dobi i duljinom trajanja dijabetesa. Specifičnost periferne arterijske bolesti u dijabetičara jest difuzno zahvaćanje arterijskog sustava, poglavito potkoljeničnih arterija. Posljedično tomu, dijabetes je i dalje glavni uzrok malih i velikih amputacija ekstremiteta, što, uz smanjenje kvalitete života, znatno utječe i na preživljenje bolesnika. Budući da razvijena aterosklerotska bolest uključuje niz komplikacija iz stručne domene različitih užih specijalnosti, poput dijabetičkog stopala, u dijagnostici i liječenju nužno je organizirati multidisciplinarne timove. U tu svrhu u Općoj bolnici „Dr. Josip Benčević“ u Slavonskom Brodu organiziran je multidisciplinarni tim sa svrhom ranog prepoznavanja periferne arterijske bolesti te pravodobnog liječenja. Dosadašnje iskustvo iz svakodnevne kliničke prakse pokazuje da je za pravilno funkcioniranje tima nužno imati precizan dijagnostičko-terapijski algoritam kako bi se izbjegle duge liste čekanja za slikovnu obradu koja uključuje dupleks ultrazvuk i višeslojnu kompjutoriziranu tomografiju. Dijagnostički algoritam temeljio se na vrijednostima gležanjskog indeksa, a njegova vrijednost i klinička slika usmjeruju i određuju stupanj hitnosti i tip slikovne obrade. Integriranjem algoritma u on-line registar baze podataka dobili smo mogućnost lakšeg praćenja stope učestalosti, uspješnosti liječenja i ovisnosti o unesenim varijablama. Nadamo se da će takav način rada rezultirati ranijim otkrivanjem simptomatske bolesti, a time i znatnim smanjenjem amputacija donjih ekstremiteta te naposljetku i smrtnosti.
PDF
