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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.

Tjelesna neaktivnost i sjedilački (sedentarni) način života smatraju se nezavisnim kardiovaskularnim čimbenicima rizika. Brojne su studije dokazale obrnutu povezanost stupnja tjelesne aktivnosti i pojavnosti kardiovaskularnih bolesti. Tjelesna neaktivnost navješćivač (prediktor) je kardiovaskularnih bolesti i u zdravih osoba, ali i osoba s već postojećom bolesti. Različiti su mehanizmi uključeni u kardiovaskularni zaštitni učinak tjelesne aktivnosti, a temelje se na poboljšanju endotelne funkcije, smanjenju simpatičke neuralne aktivnosti i rigidnosti stijenka krvnih žila. Potrebni su veliki napori pri promjeni usađenih nezdravih navika na individualnoj razini, razini zajednice i političkoj razini da bi se postiglo uvođenje tjelesne aktivnosti kao stila življenja. Zaključno, s javnozdravstvenoga gledišta, nijedan lijek nije toliko moćan kao tjelesna aktivnost u bilo kojoj životnoj dobi., Physical inactivity combined with sedentary lifestyle is considered one of the independent risk factors for cardiovascular diseases. Numerous studies have demonstrated the inverse correlation between the level of physical activity and the incidence of cardiovascular diseases. Physical activity is not just a predictor of cardiovascular disease in healthy individuals, but also in individuals with previously known disease. The cardiovascular protective effect of physical activity involves various mechanisms that are based on the improvement of endothelial function, decrease in sympathetic neural activity and reduction of arterial stiffness. Enormous efforts are needed to promote the change of the ingrained unhealthy habits at personal, community and political level in order to establish physical activity as lifestyle. Finally, from the perspective of public health, no drug is as powerful as physical activity, at any age.

ntroduction: Coronary artery disease (CAD) is common among elderly patients and may have certain characteristics that are different from those in younger age.1-3 The aim of this study is to determine the presented risk factors, clinical presentation and angiographic findings in elderly patients. Patients and Methods: This retrospective observational study included all patients referred for coro-nary angiography at our department in eight-month period. The cutoff of 75 years was used to deter-mine characteristics and outcomes of patients older than 75 years (OP) vs. younger than 75 (YP). Results: Among the 942 patients referred for coronary angiography, 178 (18.9%) were OP. 46 patients (25.8%) of OP had acute coronary syndrome (ACS) and 22.6% of YP. Female/male ratio was 46.7% in OP and 31% in YP. OP had the higher prevalence of previous myocardial infarction (32% vs. 24.4%) and similar rate of previous PCI (25.8% vs. 26.7%). Cerebrovascular disease was present in 10.1 vs. 6.6% and peripheral artery disease in 10.1 vs. 7.6%. Previous cardiovascular risk factors were present in OP: smoking 6.7% vs. 25.7% ; hypertension 88.7% vs. 82.4% ; diabetes 30.8% vs. 26.7% ; hyperlipidemia 67.4% vs. 69.7%. Beta blockers were used in 64.4%, ACE inhibitors in 57.8% and statins in 45.5% of OP, while 55.9%, 51.1% and 45.8% in YP. Mean hospitalization stay was 5.97 days in OP and 5.56 in YP (both me-dian 4 days). Culprit coronary artery was in OP RCA in 39.5%, LAD in 38.4% and ACx in 22.1%, while in YP RCA in 35.7%, LAD in 42.6% and ACx in 21.6%. In OP, type A lesion was present in 10.5%, type B in 57%, type C in 15.1% and coronary occlusion in 17.4% ; while in YP 21.2%, 51.3%, 11.7% and 15.8%. OP had more coronary segments involved (2.86 vs. 2.57). A median value of percent of luminal stenosis was 99% in OP and 90% in YP (mean values - 90.8% and 85.9%). The mean number of stents implanted was higher in OP (0.73 vs. 0.67). GpIIb/IIIa inhibitor was used more in YP (3.9% vs. 5.3%). Discussion and Conclusion: Patients older than 75 show specific group characteristics. This group presented more with ACS, higher female/male ratio, prevalence rates of arterial hypertension, diabe-tes, previous myocardial infarction, cerebrovascular and peripheral artery disease, and drug intake. More diffused CAD was also observed with more severe types of coronary lesions and higher luminal stenosis

Background: Mitral regurgitation (MR) is often complicated with atrial fibrillation (AF), with estimated rate of 5% per year. Patients with both MR and AF have higher risk of cardiac events1. The aim of our study was to investigate how many of patients with MR have AF, and is there any correlation with the severity of MR and AF occurrence.Patients and Methods: Retrospective study was conducted to investigate frequency of AF in patients with MR. A total number of 686 patients were included, 45% were female. The prevalence of arterial hy-pertension, diabetes mellitus, hyperlipidemia were similar between men and women. When compared to women, men smoke more frequently. On the other hand, women had higher serum uric acid levels. Results: Atrial fibrillation was found in 44% of patients with MR. Almost half of women (49.5%) and 39.5% of men with MR had AF. Paroxysmal AF was present in 38.7%, and permanent in 27.4% of patients with MR. 45% of patients had mild, 36.4% had moderate, and 18.6% had severe MR. 25.5% of men and 18.3% of women had concomitant AF and severe MR. Mitral regurgitation was associated with AF and coronary artery disease in 16.2% of cases, with 53% having mild MR. Conclusion: Atrial fibrillation can often be found in patients with mitral regurgitation. Mild MR was more often associated with AF occurrence, as well as in patients with both AF and CAD

Introduction: Hyperhomocysteinemia (Hhcy) is a rare condition, observed in 5% of the general population, more commonly in men. It is mostly caused by a mutation in the MTHFR gene responsible for encoding methylenetet-rahydrofolate reductase. Other possible causes include mutations in methionine synthase gene, vitamin B6, B12 or folate deficiency. It may be associated with cardiovascu-lar diseases, renal failure, diabetes mellitus, muscle atro-phy, and persistent hypercoagulable state, which can lead to acute coronary syndrome (ACS), acute cerebrovascular events (ACE) and deep venous thrombosis (DVT)1, 2. Case report: We present a case of a young man, 35- years-old, who suffered multiple strokes and transient ischemic attacks, causing right sided hemiparesis and dysphasia. Extensive neurological evaluation showed numerous ischemic lesions. He had dilatated cardiomyopathy (5.8 cm) with mildly decreased left ventricular ejection frac-tion (50%), frequent episodes of nodal rhythm, bradycardia (3.8 seconds. A permanent VVI pacemaker was implanted. Due to mus- cular hypotrophy, muscle biopsy was performed, which excluded any known dystrophy. In June 2016 patient was hospitalized with typical stenocardia with normal electrocardiographic (ECG) finding and troponin levels. Coronary angiography has been performed, and coronary artery disease (CAD) has been excluded. In March 2017, due to physical activity patient has had typical steno-cardia again. We have found high troponin levels and ST depression in inferoposterior leads on the ECG. Coronary angiography again showed no signs of CAD. Extensive diagnostics were performed in order to see whether the patient suffers from a hereditary hypercoagulable state. Mentioned analysis has showed that patient is homozy-gous for MTHFR gene and heterozygous 4G/5G PAI-1 gene. Permanent oral anticoagulant therapy as well as vitamin B12 and folate were introduced. Conclusion: Hyperhomocysteinemia is a rare condition which can be associated with muscle hypotrophy, as well as hypercoagulable state by which it can lead to ACS and ACE. Therefore, Hhcy should be taken into account in es- pecially in healthy young adults especially because by us-ing therapy, its consequences could be prevented.

Mitral regurgitation (MR) represents the second most common valvular heart disease (VHD), with incidence of 24%. 10, 4 % of patients have two and 0.8% three or more concurrent valvular heart disease. MR can be isolated or associated with other valvular heart disease, most commonly with tricuspid regurgitation. In this article we represent data from our centre.

In the last 30 years women have a worse outcome after acute coronary syndrome (ACS) than men, but unfortunately women are not well represented in the studies.Women with ACS are “older and sicker” and are on average about 10 years older than men for the 1st ACS. Younger women with ACS (

ntroduction: Angiotensin receptor-neprilysin inhibitors have been introduced in the last few years as a new class of drugs for the treatment of heart failure (HF) patients. Its benefits have been proven in randomized control tri-als in HF patients, mostly with reduced ejection fraction. Recent studies reveal new indications and information about benefit in patients after myocardial infarction by re- ducing myocardial fibrosis and remodeling. Treatment of HF in patients after heart transplantation is challenging with limitations in therapeutic possibilities.1, 2 We present a case report of a heart transplant patient with significant clinical and echocardiographic improvement after sacu-bitril/valsartan introduction. Case report: 56-year-old patient, with a history of heart transplantation in 2014 due to ischemic cardiomyopathy, was hospitalized for HF. Dyspnea and reduced exercise tolerance had been worsening 2 months prior to hospi-tal admission. Echocardiography showed moderately reduced left ventricular systolic function (EF 32%), dif-fuse hypocontractility (GLPSavg -4%) and pulmonary artery hypertension (RSVP 65 mmHg), which did not dif-fer much from earlier examinations. In order to improve cardiac function, sacubitril/valsartan was added into treatment. 3 months later the patient was feeling much better with significantly improved physical activity toler-ance. Echocardiography exam showed improvement of left ventricular systolic function (EF 41%) and longitudinal myocardial deformation (GLPSavg -7.5%) with reduction of pulmonary artery hypertension (RSVP 50 mmHg). Conclusion: To our knowledge and available literature, sa- cubitril/valsartan has not been used in treatment of HF patients after heart transplantation. Significant clinical and echocardiographic improvement in short period of time after introduction of sacubitril/valsartan presents curiosity. Undoubtedly, such information requires further investigation

Introduction: Acute coronary syndrome (ACS) mainly occurs in patients over 50 years of age, but younger patients can also be affected.1, 2Patients and Methods: This retrospective observational study was conducted in our cardiovascular department in an eight-month period. The cutoff of 50 years was used to determine clinical character- istics and outcomes of patients younger than 50 years (YP) comparing them with older than 50 years (OP). Results: Among the 219 patients with ACS, 26 (11.8%) were YP. Women were affected in 11.5% in YP and 32.1% in OP group. There were no female patients younger than 46 years. Compared to OP, YP had the lower prevalence of previous myocardial infarction (3.8% vs. 17.1%) and previous PCI (3.8% vs. 11.9%). Cerebrovascular disease was present in 5.7% and peripheral artery disease in 6.7% of OP, while in YP both were not observed. Previous cardiovascular risk factors were present in YP: smoking 65.4% vs. 29.4% in OP ; arterial hypertension 57.7% vs. 75.6% ; diabetes 26.9% vs. 23.8% ; hyperlipidemia 42.3% vs. 61.6%. Beta blockers were used in 19.2%, ACE inhibitors in 3.8% and statins in 11.5% of YP, while 27.9%, 33.6% and 24.8% in OP. Mean hospitalization stay was 5.26 days in YP (median 4 days) and 7.38 in OP (median 5 days). Culprit coronary artery was in YP RCA in 42.8%, LAD in 28.6% and ACx in 28.6%, while in OP RCA in 37.7%, LAD in 41.3% and ACx in 21.0%. In YP, type A lesion was present in 19%, type B in 42.8%, type C in 4.8% and coronary occlusion in 33.4% ; while in OP 21.4%, 32.4%, 13.1% and 33.1%. YP had fewer coronary segments involved (2.92 vs. 3.46). A median value of percent of luminal stenosis was 99% in both groups (mean value of 91% in YP and 94.7% in OP). The mean number of stents implanted was higher in YP (1.46 vs. 1.17). GpIIb/IIIa inhibitor was used in 30.7% of YP vs. 15% of OP. Discussion and Conclusion: Patients younger than 50 years present smaller percentage of ACS pa-tients. Our study showed no differences between the percentage of complete vessel occlusion in YP and OP. Among cardiovascular risk factors, greatest difference was seen in smoking. YP had less docu-mented arterial hypertension, hyperlipidemia, and rate of previous drug use. RCA and ACx were more frequent culprit in YP and LAD in OP. YP had less coronary segments affected but higher rates of im-planted stents and more need for antiplatelet GpIIb/IIIa therapy. (2) (PDF) Age differences in patients presenting with acute coronary syndrome – does age influence the severity of the disease and outcome?. Available from: https://www.researchgate.net/publication/323354 046_Age_differences_in_patients_presenting_with _acute_coronary_syndrome_- _does_age_influence_the_severity_of_the_disease _and_outcome [accessed Mar 05 2019].

Aim: exploring literature on water immersion, balneo-therapy aqua exercise and swimming in patients with left ventricular dysfunction (LVD) and/or stable chronic heart failure (CHF). Aqua exercise is recommended for low-risk cardiac patients, but it is not clear whether it is safe, or what optimal water temperature in patients with CHF is. With water immersion, the water rises pressure on the body surface and blood volume shifts to the central cir-culation, resulting in marked volume loading of the heart, but only if immersion is up to the neck, with enlargement of all 4 chambers, in 6 seconds up to 30% increase in heart size.1Results: Until now, based on exploratory studies of central hemodynamics and neurohumoral responses of aquatic therapies it is clear that: 1) In patients with LVD a posi-tive effect of therapeutic warm-water tub bathing is due to afterload reduction caused by peripheral vasodilata-tion with warm water ; 2) In coronary patients with LVD, at low-level water cycling, the heart is working more ef-ficiently than at low-level cycling outside of water ; 3) In patients with previous extensive myocardial infarction, immersion to the neck resulted in temporary pathologi-cal increases in mean pulmonary artery pressure (mPAP) and mean pulmonary capillary pressures (mPCP) ; 4) Dur-ing slow swimming the mPAP and/or PCP were higher than during supine cycling outside water at a 100W load ; 5) In CHF patients, neck-deep immersion resulted in a de-crease or no change in stroke volume ; 6) Even hemody-namically compromised, patients feel well during aquatic therapy: 7) Decompensated heart failure is an absolute contraindication for immersion or swimming ; 8) Patient with severe LVD or CHF who can sleep in a flat position can bath in the tube, immersed no deeper up the xiphoid ; 9) Therapeutic water exercise in a pool can be allowed, provided that the patient is in an upright position im-mersed no deeper than up to xiphoid. Conclusion: Based on these findings, whether swimming is truly safe, yet needs to be proven for patients with severe LVD.

Prekomjerna težina, a osobito pretilost, čimbenici su rizika od razvoja kardiovaskularnih bolesti te su povezani s povišenim kardiovaskularnim i ukupnim mortalitetom. Poznato je i da izrazito reducirana tjelesna težina ne djeluje zaštitno na kardiovaskularni sustav, stoga je održavanje „zdrave“ stabilne tjelesne težine glavni cilj u redukciji kardiovaskularnog rizika. Učinak u redukciji ukupnoga kardiovaskularnog rizika očituje se redukcijom ukupnoga kardiovaskularnog rizika per se, kao i redukcijom pojedinačnih čimbenika rizika povezanih s pretilošću (arterijske hipertenzije, hiperlipidemije i intolerancije glukoze)., Excessive weight and obesity are risk factors for the development of cardiovascular diseases. Both are associated with increased cardiovascular as well as total mortality. It is well known that a markedly reduced body weight does not protect the cardiovascular system, so maintaining a “healthy”, stable body weight is a primary goal of reducing cardiovascular risk. The reduction in overall cardiovascular risk is reflected in the reduction of total cardiovascular risk per se as well as in the reduction of other risk factors associated with obesity (arterial hypertension, hyperlipidaemia and glucose intolerance).

High-intensity statin therapy in patients with acute coronary syndrome: is it enough to achieve target values?

Introduction: Lyme disease is a multisystem disease caused by infection with Borelia burgdoferi and spread by a tick bite. Even though it most commonly affects the skin, joints and nervous system, it can rarely cause Lyme carditis.1 In Europe, cardiac involvement as a complica-tion of Lyme disease occurs in up to 4%, with 3-fold higher male predominance. The most common clinical feature of Lyme carditis is atrioventricular (AV) conduction block of varying severity but may also include decreased car-diac contractility due to myopericarditis. These cardiac features typically occur one to two months after the onset of infection. We present a case report of a patient with car-diogenic shock and later confirmed Lyme disease. Case report: 71-year-old patient, with two-month long history of progressive exertional dyspnea, was hospital-ized in coronary intensive care unit due to cardiogenic shock with severely impaired left ventricular function (EF 15% ; in 2016 EF was 56%) and developed signs of type 1 cardiorenal syndrome. The patient had no chest pain, no electrocardiographic signs of ischemia nor elevation of cardiac biomarkers. The patient initially required inotro-pic support that with other standard treatment for acute heart failure gradually led to clinical and echocardio-graphic improvement (EF 31%). The patient then under-went coronary angiography that showed diseased left an-terior descending coronary artery that was treated with two stents. Since acute myocardial infarction was not the cause of acute heart failure, other possible causes were in-vestigated, primarily myocarditis. More detailed clinical history revealed tick bite about two months prior to hos-pital admission, which rose suspicion of Lyme carditis, even though the patient had no registered AV conduction disturbances. An enzyme-linked immunosorbent as-say and Western blot both came seropositive for Borelia burgdoferi antibodies, confirming the diagnosis. Conclusion: Lyme carditis is a rare manifestation of boreliosis with possible lethal complications. Therefore, detailed clinical history and physical examination are crucial for making correct diagnosis and giving the right treatment.

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. Electronic supplementary material The online version of this article (10.1186/s12872-017-0678-z) contains supplementary material, which is available to authorized users.

WHAT IS KNOWN AND OBJECTIVE: Ulipristal acetate a progesterone receptor modulator pharmacologically inhibits endometrial proliferation and thereby prevents pregnancy. It is primarily used as emergency contraception but also for the treatment of fibroids in women of reproductive age. There have been no published cases of pregnancy while on therapy with ulipristal acetate. CASE DESCRIPTION: In this article we present a case report of spontaneous pregnancy during ulipristal acetate therapy. WHAT IS NEW AND CONCLUSION: To our knowledge this is the first patient with spontaneous conception while on ulipristal acetate treatment. There were no drug-related complications and the pregnancy resulted in the delivery of a healthy baby. (c) 2017 John Wiley & Sons Ltd.

ntroduction: Acquired QT prolongation can be caused by drug therapy and electrolyte abnormalities but can also occur as a result of raised intracranial pressure (ICP). QT prolongation is associated with torsades de pointes (TdP), a life-threatening form of polymorphic ventricular tachy-cardia. Case report: 36-year-old man with a known opioid addic-tion and receiving methadone maintenance therapy (100 mg/day), came to emergency room after an epileptic sei-zure. On the admission day he took additional unknown dose of methadone. An expansive intracranial process with cerebral edema was found on CT scan. The ECG showed sinus bradycardia and prolonged QT interval, he had recurrent episodes of TdP, some requiring defibril- lation (Figure 1 and Figure 2). Intravenous magnesium was immediately applied. Serum potassium and calcium were mildly decreased and therefore adequately correct-ed. Antiedematous therapy with glucocorticoids was also initiated. Methadone could not be discontinued because of abstinence syndrome, but the dose was reduced. Acute coronary syndrome was excluded, and no structural heart disease was found.

This is a case report of drug-eluting balloon as a new treatment option for cardiac allograft vasculopathy.

We report a first case of refractory several- hour sinus bradycardia, a rare but already described side effect of intramuscular administration of carboprost tromethamine to induce abortion for medical indication in a patient without cardiovascular and other diseases. After administration of atropine sulfate 3x0.5 mg intravenously without effect, the patient's sinus rhythm spontaneously normalized as carboprost was eliminated from the body (it has a 3-hour half-life). It is reasonable to believe that the specific prostaglandin underlay the etiology of bradycardia.

Aortalna stenoza (AS) suženje je ušća aorte koje može biti prirođeno ili stečeno, a incidencija raste s dobi. Bikuspidalna aortalna valvula često je udružena s drugim srčanim i aortalnim greškama. Bolesnici mogu biti klinički asimptomatski ili simptomatski (uglavnom u uznapredovaloj fazi). U procjeni težine aortalne stenoze osim ultrazvuka srca izvode se ergometrija, MSCT i MR srca. Vrlo je važno dobro procijeniti stupanj aortalne stenoze, osobito kod niskoga transvalvularnoga gradijenta. Zamjena aortalne valvule može biti kirurška (biološki ili mehanički zalistak) ili manje invazivna, transkateterska (TAVI)., Aortic stenosis (AS) is a narrowing of the aortic valves. AS can be congenital or acquired, and the incidence increases with age. Bicuspid aortic valve is often associated with other cardiac and aortic anomalies. Clinically, patients can be asymptomatic or symptomatic (mainly in advanced stage). Echocardiography, exercise test, MSCT and MR are non-invasive methods of choice. Assessment of stenosis severity is very important, especially in low transvalvular gradient. Surgical valve replacement is performed with biological or mechanical valves; another, less invasive method is transcatheter aortic replacement (TAVI).

We present first case report on itraconazole, a drug very commonly used for onychomycosis, used along with simvastatin that caused metrorrhagia. The suggested probable mechanism is the inhibition of steroidogenesis, especially estrogens that resulted in low- estrogen breakthrough bleeding. This article emphasizes the importance of drug interaction check prior the initiation of onychomycosis treatment.

Background: So far, no percutaneous nor cardiac surgical intervention did not present with significant and apparent long-term graft patency preventing and treating coronary artery bypass graft (CABG) restenosis at the site of the anastomosis1. A process of restenosis, mainly driven by intimal hyperpla- sia, with abnormal migration and proliferation of smooth muscle cells, has many characteristics of inflammation like process. Proliferating tissue reaction after aortic valve replacement (AVR) at the site of coronary ostia may be due to traumatic consequence, debris embolization or edematous reaction2, 3. Young patients are in undesirable position.Case report: 34-year-old man was admitted in 2007 in a local hospital due to bicuspid aortic valve en-docarditis due to Streptococcus sp “D”, proceeding with biological AVR. One month after the surgery, due to recurrent endocarditis presenting with paravalvular leak and severe aortic regurgitation, reop-eration was performed with the implantation of the mechanical valve. Two years later symptomatic severe paravalvular aortic regurgitation and severe mitral regurgitation due to the prolapse of the an- terior cusp led to invasive diagnostic approach. Coronary angiography revealed subtotal restenosis of the left main coronary artery ostium. In September 2009, simultaneous third time redo was performed with replacement of the aortic root with the homograft, mitral valve repair with a pericardial patch of a perforation of the A2 segment, medial commissuroplasty with the insertion of Cosgrove ring, CABG with saphenous vein graft (SVG) to obtuse marginal (OM) and SVG to left anterior descending artery (LAD). Two years later, occluded anastomosis of a SVG to LAD and significant restenosis of a SVG to OM (both at the site of anastomosis), led to re-CABG of LAD with left internal mammary artery (LIMA) and repositioning of a SVG to OM. In 2017, coronary angiography showed significant restenosis of the LIMA-LAD graft anastomosis and SVG-OM graft.Discussion: Young patients present with intensive immunological reaction leading to CABG anasto-mosis or valvular junction stenosis. This patient demonstrates not only challenges in treating en-docarditis, redo interventions and complications of valvular disease per se but also impediments in coronary artery supply.

Introduction: Mitral regurgitation (MR) represents the second most common valvular heart disease1. It is classified as primary (organic) and secondary (functional) MR, with secondary being more fre-quent2. Degenerative valvular disease, rheumatic fever, infective endocarditis and mitral valve pro-lapse are most common causes of primary MR2. On the other hand, secondary MR is usually result of ischemic heart disease or dilatative cardiomyopathy2. The aim of our study was to investigate the incidence of primary MR according to gender. Patients and Methods: Retrospective study was conducted to assess the relation between MR with other VHD. A total of 686 patients, with male predominance of 55%, were included in the study. Results: Among all patients with MR 519 (75.6%) had primary MR. Degenerative valvular heart disease was the main cause of primary MR, counting for 474 patients (91.3%). Other causes of primary MR in-cluded mitral valve prolapse, rheumatic valvular heart disease, and other causes, with frequency of 19 (3.6%), 5 (1%), 21 (4.1%), respectively. According to gender distribution, 290 (55.9%) males and 229 (44.1%) females had primary MR. Degenerative mitral valve disease was the main cause of primary MR in both men and women (90.3 and 92.5%), while the least frequent was infective endocarditis among men and rheumatic heart disease among women. Conclusion: Degenerative MR was most common cause of primary MR. Regardless of gender groups, with women slightly more affected

Background: Mitral regurgitation (MR) represents the second most common valvular heart disease (VHD)1. It is classified as primary (organic) and secondary (functional) MR, with secondary being more frequent2. Secondary MR is usually result of dilatative cardiomyopathy, ischemic heart disease, post- myocarditis and similar2. Its prevalence is approximately 1.6% to 19.4%, and is associated with worse prognosis than primary3. The aim of our study was to investigate the incidence of secondary MR ac-cording to gender.Patients and Methods: Retrospective study was conducted to assess the relation between MR with other VHD. A total of 686 patients, with male predominance of 55%, were included in the study. Results: Among all patients with MR 167 (24.3%) had secondary MR. The main cause was left ven- tricular enlargement with mitral annular dilatation, counting for 96 (57.5% of secondary MR patients and 14.0% of all MR patients). Other causes of secondary MR included ischemic and postmyocarditis causes, with frequency of 64 (38.3% of secondary MR patients and 9.3% of all MR patients) and 7 (4% of secondary MR patients and 1% of all MR patients), respectively. According to gender distribution, 99 (59.3%) males and 68 (40.7%) females had secondary MR. Dilatative cardiomyopathy was the main cause of secondary MR in both men and women (60.6% and 52.9%). Ischemic MR was present in 36 (36.4%) men, 28 (41%) women, while postmyocarditis MR was observed in 3 (3%) of men and 4(5.8%).Conclusion: Secondary MR presents high proportion of all MR causes. Dilatative cardiomyopathy was most common cause of secondary MR, regardless of gender groups, with men more affected. Ischemic cause was slightly more common in women than men.

Introduction: Women with the acute coronary syndrome (ACS) have higher short and long-term mor-tality rates than similarly aged men.1, 2 Patients and Methods: This retrospective observational study was conducted in the cardiovascular department in an eight-month period. Patients over 26 years of age with ACS were enrolled in this st udy. Results: Among the 219 included patients, 65 (29.6%) were female. Compared with men, women had higher prevalence of previous myocardial infarction (21.5% vs. 12.9%), while the previous percutane-ous coronary intervention (PCI) was performed in 6.1% of women and 12.9% of men. Cerebrovascular disease was present in 4.6% of women and 5.1% of men, while peripheral artery disease was present in 9.2% of women and 4.5% of men. Previous cardiovascular risk factors were present in women: smoking 29.2% vs. 35.7% ; arterial hypertension 78.4% vs. 71.4% ; diabetes 27.7% vs. 22.7% ; hyperlipidemia 66.6% vs. 56.5%. Beta blockers were used in 32.3%, ACE inhibitors in 41.5% and statins in 26.2% of women, while 24.6%, 25.3% and 22.1% in men. Hospitalization stay was similar for both sexes (6.96 days for women vs. 7.19 days for men). At the time of ACS, women were older than men (average age 68.03 vs. 61.24). Culprit coronary artery was in women RCA in 32.6%, LAD in 50% and ACx in 17.4%, while in men RCA in 34.7%, LAD in 42.7% and ACx in 22.6%. According to the type of the lesion in women, type A was present in 25.6%, type B in 30.2%, type C in 11.6% and coronary occlusion in 32.6% ; while in men 19.5%, 35%, 12.2% and 33.3%. Regarding the severity of coronary artery disease, measured as a number of diseased coro-nary segments, women had fewer segments involved (3.09 vs. 3.52). The number of stents implanted was less in women (1.01 vs. 1.28). GpIIb/IIIa inhibitor was used in 13.8% of women vs. 18.1% of men. Discussion and Conclusion: Women with ACS present seven years later than men. The higher rate of previous myocardial infarction and a lower rate of previous PCIs were observed in women. Regarding cardiovascular risk factors, women had higher rates of diabetes, arterial hypertension, and hyperlipid-emia, as well as higher rates of using optimal medical therapy. It seems that more complex coronary artery disease was present in men, mainly seen as a shift type A and B lesions, but also as more coro-nary segments involved, more stents implanted and more antiplatelet GpIIb/IIIa inhibitors used.

Peripartum cardiomyopathy (PPCM) is a rare form of dilated cardiomyopathy that occurs in previously healthy women in the last month of pregnancy and up to several months after delivery. The incidence of PPCM is low, but its morbidity and mortality rate are high, with a substantial risk of poor outcome of the pregnancy. Patients who have recovered from PPCM run a high risk of reoccurrence in subsequent pregnancies. In this case report we present a 32-year old female patient who developed acute heart failure (HF) associated with significantly reduced systolic function due to PPCM soon after a delivery of triplets. Treatment was immediately initiated in the intensive coronary unit with oxygen-therapy, loop diuretics, aldosterone blockers, beta blockers, angiotensin-converting enzyme (ACE) inhibitors and bromocriptine. During the follow up period, a year and a half after delivery, a complete recovery of systolic function was observed with no residual symptoms.

Peripartum cardiomyopathy (PPCM) is a rare form of dilated cardiomyopathy that occurs in previously healthy women in the last month of pregnancy and up to several months after delivery. The incidence of PPCM is low, but its morbidity and mortality rate are high, with a substantial risk of poor outcome of the pregnancy. Patients who have recovered from PPCM run a high risk of reoccurrence in subsequent pregnancies. In this case report we present a 32-year old female patient who developed acute heart failure (HF) associated with significantly reduced systolic function due to PPCM soon after a delivery of triplets. Treatment was immediately initiated in the intensive coronary unit with oxygen-therapy, loop diuretics, aldosterone blockers, beta blockers, angiotensin-converting enzyme (ACE) inhibitors and bromocriptine. During the follow up period, a year and a half after delivery, a complete recovery of systolic function was observed with no residual symptoms.

NTRODUCTION: Having reviewed the scientific lit-erature it is possible to describe the connection between the application of electrophysical therapy and atrial fibrillation, and according to the existing literature by stimulating the cervical ganglia and thus stimulation of the autonomic sympathetic system it could provoke ar-rhythmias.CASE pRESENTATION: 55-year-old male patient with known reconstruction of both shoulders and implanted total endoprosthesis in December 2012 was regularly treated with magnetic, cryo, laser and electrophysical therapy in the area of both shoulders. Conducted electro-physical therapy was applied as transcutaneous electri-cal nerve stimulation therapy. During 2013, the patient had three times episodes of paroxysmal atrial fibrilla-tion during treatment with electrophysical therapy, for which he was twice examined in the emergency unit with spontaneous conversion to sinus rhythm. Since the termination of electrophysical therapy in August 2013 he is in stable sinus rhythm. Conclusions: Further research is needed to power this hypothesis.

Coronary artery disease (CAD) is one of the most common causes of death. Various technological advancements in interventional cardiology have significantly improved the treatment of CAD and significantly reduced the mortality of cardiovascular diseases. One recent development, the drug eluting balloon (DEB), decreases the incidence of resteno-sis and acute coronary events. DEB uses Paccocath tech-nology in which the intima of the blood vessel is filled with carrier applied drug, paclitaxel, which penetrates into the lesion, preventing proliferation of vascular media and stabilizing atherosclerotic plaque. By applying that procedure the risk of restenosis is significantly reduced and most importantly the new acute coronary event. While the most common indication for DEB is stent restenosis, studies have also shown good results with bifurcation lesions, lesions in small vessels, certain lesions in native coronary arteries, and inpatients who require a month of dual antiaggregation thera- py prior to noncardiac surgery. In our experience with twenty patients, the indication for DEB was restenosis in sixteen patients, lesion at a bifurcation in three patients, and a new lesion in one patient. Clinical observation was not an indication for recoronarography in any of our patients. Our early success with DEB reaffirms the method for treating CAD, with an emphasis on shortening the length of dual antiaggregation therapy.

Background Diabetes mellitus (DM) type II is an important risk factor for coronary heart disease (CAD), regardless of age and other comorbidities. In this study we investigate the distribution of CAD in patients with acute coronary syndrome (ACS) and diabetes who underwent primary percutaneous coronary intervention (pPCI). Go to: Methods The study included 125 patients who were admitted to Department of Cardiovascular Diseases, University Hospital “Sveti Duh” for ACS in 2012 and treated with PCI. Analysis of coronarograms was conducted to determine the prevalence and distribution of CAD in patients with DM. Go to: Results Leading diagnosis at admission in ACS patients with DM and without DM was STEMI (53%, 55% respectfully). According to the ACC/AHA classification of coronary lesions patients with DM had 56% of type B lesion, 41% of type C lesion and 3% of type A lesion. In our study, the largest number of significant stenosis was observed in the proximal and middle segment of LAD: 74% of patients with DM and 60% in patients without DM. In patients with DM single-vessel CAD was observed in 26%, two-vessel in 41% and three-vessel in 32%, whereas in patients without DM, 52% single-vessel CAD, 30% two- vessel and 18 % three-vessel CAD. Go to: Conclusion Most of the studies showed that patients with DM are more likely to have diffuse distribution of CAD. Results of studies about the association of DM with the location of the lesion in CAD is also contradictory, in some studies was observed a higher incidence of proximal, and in other distal lesions. In our study, mostly affected was LAD, usually its proximal and middle segment. Also, RCA and ACx were more affected in the proximal and middle segment. The study found a higher prevalence of type C lesions and a higher prevalence of three-vessel CAD in patients with DM which confirms previous findings that patients with DM usually have diffuse CAD.

Background: Statins, in addition to lowering blood lipid levels, also protect the cardiovascular system by improving endothelial dysfunction and producing an antiinflammatory and antithrombotic effect that stabilizes plaques. The aim of this study was to investigate the effect of statin therapy(StTh) on the characteristicsof coronary artery disease(CAD) in acute coronary syndrome (ACS). Methods: The study included 125 patients who were admitted to Department of Cardiovascular Diseases of University Hospital Sveti Duh for ACS in 2012. An analysis was made of the impact of prior treatment with statins on the leading diagnosis, distribution of the CAD and type of lesion. Results: 31 patients (24.8%) were treated with StTh prior to admission. Leading diagnoses for patients previously on StTh were STEMI (39%) and unstable angina (39%), while in the group of patients without StTh the leading diagnosis was STEMI (60%). In patients who were treated with StTh the proximal and middle segment of LAD were the most common locations of stenosis. The frequency of single-vessel, two-vessel and three-vessel CAD was equal amongst both groups, while single-vessel CAD was more frequent in patients without prior StTh. According to ACC/AHA classification, type C lesion was discovered in 41% of patients without StTh and in 26% of patients with StTh. Conclusion: According to the results of studies, 10-20% of patientsexperiencing an ACS were being treated with statins priorto the event. In our study, 24.8% of patients had been onStTh. The number of vessels with lesions was seen withequal frequency amongst patients with and without StTh.This apparent lack of benefit can most likely be explainedby the increased number of risk factors amongst patientson StTh. Another advantageous finding seen in patientspreviously treated with statins was a significantly lowerproportion of total occlusions, especially STEMI

Introduction: Acute embolism from artifcial aortic valve to the coronary arteries resulting in acute myocardial infarction is an uncommon occurrence. There are cases reported in acute setting after mechanical aortic valve replacement, although embolization in properly anticoagulated patients, years after aortic valve replacement is rare.1, 2 Case report: We report the case of a 64-year-old man who underwent an aortic valve replacement six years earlier and presented to the emergency department with myocardial infarction without ST elevation. He was adequately anticoagulated with warfarin. Transthoracic echocardiography showed normal motion of bileafet artifcial aortic valve, without visualized thrombi or detected abnormally pressure gradient. 12-lead ECG showed ST depression in inferior and lateral leads, while urgent coronary angiography revealed subtotal atherothrombotic lesion of right coronary artery, but without signifcant coronary artery disease of left coronary artery. Percutaneous coronary intervention of right coronary artery was performed with implantation of one stent. Repeated ECG showed isoelectric level of ST segment. After four days of hospitalization sudden onset of prodromal chest pain occurred. ECG showed deep ST depression in anterolateral precordial leads. Coronary angiography was proposed to the patient, but the patient denied the procedure. One day later, after refractory cardiac arrest, patient died. Autopsy revealed thrombotic occlusion of left anterior descending artery with recent myocardial necrosis of left ventricle anterior wall and few microemboli of the aortic mechanical valve. Discussion: Embolic myocardial infarction is underdiagnosed and it is important to diagnose the source of embolism and treat the cause. Despite the patient was adequately anticoagulated, it is considered that even adequate anticoagulation therapy does not eliminate the risk of thromboembolism. Also, favorable in this patient was bileafet type of valve, which is less thrombogenic. Review of related literature did not show similar cases occurring in relatively short period of time, resulting in recurrent myocardial infarction with emboli of both left and right coronary artery.

PCI in CAV

AIm: Femoral vascular access site complications in-cluding: hematoma, retroperitoneal hemorrhage, pseudo-aneurysm, arteriovenous fistula (AVF), arterial occlusion, femoral neuropathy and infection. AVF occurs according to literature from 0.2 to 2.1%. The goal was to find out inci-dence of AVF and their long term consequences. pATIENTs AN d mET hOds: From January 2008 until November 2013 a total of 6017 coronary angiographies were performed. AVF had 48 patients, respectively 0.7 %. At time of research, 5 patients died and 7 patients did not want to be involved. To the remaining 36 patients, lower extremities venous Doppler and previous AVF site Dop-pler, as well as echocardiography were performed.ReSultS: From 36 patients with previously diagnosed AVF, 16 patients at the control ultrasound had no visible arteriovenous communication, 20 patients had still open AVF. In group with open fistula 5 patients had no com-plaints, 15 patients complained of discomfort in the re- spective leg. Echocardiography in the group of patients with AVF showed only in one patient dilation of right atrium and ventricle. In 3 patients with persistent AVF mild pulmonary hypertension was found, but none in group without AVF. The average pressure in right ven- tricle measured on tricuspidal regurgitation was signifi-cantly higher in a group with AVF, than without (RVSP 22 mmHg ; 16 mmHg, p

Cardiologia CROATICA Mechanical support of circulation with a left ventricular assist device (LVAD) is a rapidly evolving field. In this article we present three patient cases that involve implantation of a LVAD called HeartMate II (HM II), and describe different strategies for treating patients with the terminal stage of heart failure (HF) and the indications for placement of a LVAD. Patient 1 — N. S. 66 y, M. The patient has a history of arterial hypertension (AH), diabetes mellitus type II (DM II), and a myocardial infarction in September 2011. Clinical suspicion for HF was confirmed by echocardiography, which showed global left ventricular hypertrophy, an ejection fraction of 20%, mitral regurgitation, and normal right ventricular dimensions. Coronary arteriography showed triple vessel disease and scintigraphy showed scar tissue without viable myocardium. In October 2011, HM II was indicated as destination therapy. The only incident worth nothing was an infection at the exit site of the cannula that occurred one year later and was treated without complications. The patient continues to perform laborious tasks on his farm and refuses to quit. Patient 2 — ©. J. 65 y, F. The patient has a history of AH, DM II, and terminal HF with LVAD implantation in April 2010. In October 2011, the heart transplantation was required due to a resilient infection at the HM II stoma that led to sepsis. In June 2012, a syncopal event subsequent to asystole indicated the need for implantation of a permanent pacemaker. The patient currently feels well and tolerates physical activity. Patient 3 — V. H. †63 y, F. The patient has a history of DM II, STEMI treated with primary PCI, triple vessel CAD, double CABG, femoral and iliac artery disease, renal and hepatic dysfunction, and vascular changes in the brain. Echocardiography showed left ventricular dilation, contractibility of only the base of the left ventricle, and an EF of ~15%. In December 2011, HM II was indicated as destination therapy. Due to anti-heparin antibodies implantation was postponed until May 2012, when it was performed alongside CABG (RCA-SVG). Three months later, the patient sustained NSTEMI. In February 2013, the patient was hospitalized for left ventricular failure due to partial papillary muscle rupture and resultant mitral insufficiency. Blood cultures at the time were negative. In April 2013, the patient died of multiorgan failure. Autopsy reports found a destroyed mitral valve without evidence of endocarditis.

Cardiologia CROATICA Coronary artery disease (CAD) is one of the most common causes of death. Various technological advancements in interventional cardiology have significantly improved the treatment of CAD and significantly reduced the mortality of cardiovascular diseases. One recent development, the drug eluting balloon (DEB), decreases the incidence of restenosis and acute coronary events. DEB uses Paccocath technology in which the intima of the blood vessel is filled with carrier applied drug, paclitaxel, which penetrates into the lesion, preventing proliferation of vascular media and stabilizing atherosclerotic plaque. By applying that procedure the risk of restenosis is significantly reduced and most importantly the new acute coronary event. While the most common indication for DEB is stent restenosis, studies have also shown good results with bifurcation lesions, lesions in small vessels, certain lesions in native coronary arteries, and in patients who require a month of dual anti-aggregative therapy prior to noncardiac surgery. In our experience with twenty patients, the indication for DEB was restenosis in sixteen patients, lesion at a bifurcation in three patients, and a new lesion in one patient. Clinical observation was not an indication for recoronarography in any of our patients. Our early success with DEB reaffirms the method for treating CAD, with an emphasis on shortening the length of dual anti-aggregative therapy.

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.