DOI: 10.3897/folmed.67.e152244

Authors: Rozen K. Grigorov, Stefan Yambolov, Daniel Tsvetkov, Ivaylo Borisov, Svetoslav Georgiev

Abstract: Introduction: The time for contrast to pass through the myocardium (TCPM) is a novel fluoroscopic method proposed for the assessment of coronary microcirculation in patients with non-significant epicardial coronary artery disease. Aim: This study aims to determine the mean TCPM in patients with angina and non-obstructive coronary arteries (ANOCA) and to analyze its relationship with hemodynamic parameters, myocardial mass, and traditional cardiovascular risk factors. Materials and methods: Sixty-two patients with typical angina referred for invasive coronary angiography were enrolled in this prospective observational study. The mean TCPM was measured in all patients. A linear regression analysis was performed to identify independent predictors of TCPM. Results: The mean TCPM was 4.99±1.01 seconds, with values ranging from 3.1 to 7.7 seconds. Regression analysis identified hypertension (p=0.019) as a positive predictor, while female sex (p=0.040) and mean arterial pressure (p=0.009) showed negative associations with TCPM. Traditional cardiovascular risk factors, including dyslipidemia, diabetes, smoking, and age, were not significantly associated with TCPM. Conclusion: A positive association was observed between TCPM and hypertension, while mean arterial pressure and female sex showed an inverse relationship with this parameter. TCPM is a technically simple and reproducible method that could have potential applications in the diagnosis of patients with angina and non-obstructive coronary arteries.

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DOI: 10.3897/folmed.67.e141763

Authors: Tomasz Furgoł, Karolina Karska, Michał Miciak, Joanna Jureczko, Konrad Gigoń, Marcin Jezierzański, Paweł Jureczko

Abstract: Coronary artery disease and atherosclerosis are a very significant and widespread problem in modern medicine. The development of current diagnostics and treatment of atherosclerotic lesions is moving towards minimally invasive methods. The purpose of this article is to present selected novel methods of treating coronary atherosclerosis, comparing their effectiveness, indications, contraindications, and possible complications. A literature review of selected treatment methods for calcified atherosclerotic lesions was conducted in the online databases of PubMed, PubMed Central, Google Scholar, and NCBI. It includes original and review papers. The main language of the articles was English. The search used keywords such as “coronary artery disease,” “calcified atherosclerotic lesions,” “rotational atherectomy,” “intravascular lithotripsy,” and “RotaTripsy,” as well as related phrases. After analyzing the abstracts, the papers that most closely matched the stated topic were selected. Atherosclerosis is the leading cause of coronary heart disease incidence. Several risk factors, both non-modifiable and modifiable, predispose to its occurrence. Heavily calcified atherosclerotic plaques are associated with a higher risk of coronary artery disease consequences. Currently, methods such as CT coronary angiography and optical coherence tomography are used for diagnosis. Endovascular therapies are now recommended for the treatment of atherosclerosis with heavily calcified plaques. Rotational atherectomy, intravascular lithotripsy and RotaTripsy are promising methods for treating high-grade atherosclerosis with calcified deposits. However, especially in the case of RotaTripsy, further clinical studies are required to better evaluate the efficacy of this novel method.

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DOI: 10.3897/folmed.66.e121658

Authors: Dzhem Farandzha, Iva Gasharova-Petrova, Dobri Hazarbasanov

Abstract: One of the most feared complications of percutaneous coronary interventions is coronary artery dissection. Rarely, such dissections can propagate into the ascending aorta, which may then require surgical intervention. We present the case of a 50-year-old patient with new-onset angina and two-vessel coronary artery disease who underwent percutaneous coronary intervention on the right coronary artery, complicated by an iatrogenic coronary dissection extending into the ascending aorta. A decision was taken to perform emergent cardiac surgery due to ongoing chest pain and the extent of the dissection. Computed tomography after surgery revealed no signs of aortic dissection with normal dimensions in all aortic segments. The patient was discharged home in a stable condition.

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DOI: 10.3897/folmed.65.e109433

Authors: Irina Starodubtseva, Maria Meshkova, Anna Zuikova

Abstract: Stent restenosis is the most unfavorable complication of interventional treatment for coronary heart disease. We already know from various literature sources that the causes for stent restenosis in patients are both mechanical damage (partial opening, stent breakage, extended stented area, calcification, incomplete stent coverage of atherosclerotic plaque, weak radial stiffness of the stent metal frame, lack of stent drug coating), and the neointimal hyperplasia formation which is closely related to the de novo atherosclerosis development, being a predictor of the recurrent cardiovascular event. Considering this event, it is necessary to understand all the pathogenetic and pathophysiological processes of atherosclerosis. This review aims to comprehensively highlight the main issues of pathogenesis and the development of stent restenosis in the coronary artery after percutaneous transluminal coronary angioplasty. The review is based on relevant publications found by a selective search of PubMed, Google Scholar, Scopus, Web of Science, and eLibrary, including works published within the last 20 years. The influence of various factors of the pathogenetic process on the risk of stent restenosis has been demonstrated.

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DOI: 10.3897/folmed.65.e103031

Authors: Krasimir R. Dzhinsov

Abstract: The most common type of sustained arrhythmia is atrial fibrillation (AF). Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation, which has emerged as the primary therapeutic strategy for atrial fibrillation patients. Unfortunately, about one-third of patients experience recurrent atrial arrhythmias after the procedure. The leading cause of AF recurrence after PVI, especially during the first year, is reconnection of the pulmonary veins. There are different techniques and methods that could increase the efficacy of the procedure by making durable pulmonary vein isolation. A literature search was conducted using the terms atrial fibrillation, ablation, pulmonary vein isolation, and durable PVI in the PubMed, Scopus, and Web of Science databases. Durable pulmonary vein isolation could be achieved by avoiding gaps in the ablation line and PV reconnections using pharmacological testing, waiting time, various indexes based on data from the electroanatomical mapping system, and special ablation catheters. Furthermore, detecting the gaps in the ablation line in the end of the procedure using different pacing and mapping techniques and application of additional energy to close those gaps could increase the success rate of the procedure. Most commonly, AF recurrence after PVI is due to PV reconnections caused by gaps in the ablation line. To achieve safer and more effective PVI, the procedure has to be standardized and operator-independent with reproducible success rate and safety profile.

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DOI: 10.3897/folmed.65.e79996

Authors: Teodora Yaneva-Sirakova, Dobrin Vassilev, Kiril Karamfiloff, Julieta Hristova, Monika Shumkova, Latchezar Traykov

Abstract: Micro- and macrovascular consequences of atherosclerosis, arterial hypertension, dyslipidemia, and smoking can affect neurotransmission and markers for neuronal activity. The potential direction and specifics are under study. It is also known that optimal control of hypertension, diabetes, and dyslipidemia in midlife may positively affect cognitive functioning later in life. However, the role of hemodynamically significant carotid stenoses in neuronal activity markers and cognitive functioning is still being debated. With the increased use of interventional treatment for extracranial carotid disease, the question of whether it might affect neuronal activity indicators and whether we can stop or even reverse the path of cognitive deterioration in patients with hemodynamically severe carotid stenoses naturally emerges. The existing state of knowledge provides us with ambiguous answers. We sought the literature for possible markers of neuronal activity that can explain any potential difference in cognitive outcomes and guide us in the assessment of patients throughout carotid stenting. The combination of biochemical markers for neuronal activity with neuropsychological assessment and neuroimaging may be important from practical point of view and may provide the answer to the question for the consequences of carotid stenting for long-term cognitive prognosis.

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DOI: 10.3897/folmed.64.e68349

Authors: Eka Prasetya Budi Mulia, Kartika Afrida Fauzia, Rerdin Julario

Abstract: Introduction: Patients with chronic renal disease (CKD) are at a significantly elevated risk for ventricular arrhythmia. Several electrocardiographic (ECG) methods can be used to assess the ventricular arrhythmia risk on the standard 12-lead ECG. Aim: This study aimed to evaluate the ECG parameters of ventricular repolarization abnormalities, such as QT, QTc, Tp-e, and Tp-e/QT ratio, Tp-e/QTc ratio, and their predictors in hemodialytic end-stage renal disease (ESRD) patients. Materials and methods: Fifty-three patients with hemodialytic ESRD and 32 pre-dialytic CKD patients were enrolled in the study. ECG parameters were measured manually using calipers. The independent samples t-test was used for comparative analysis. The multivariate linear regression analysis was used to distinguish the independent predictors of each ECG parameters and variables correlating significantly in bivariate analysis. Results: Mean ages of hemodialytics and pre-dialytics were 47±11 and 51±7 years, respectively. Ventricular repolarization abnormalities in the hemodialytic compared to the pre-dialytic group were found to be significantly different [QTc (448±34 vs. 428±31 ms, p=0.007), Tp-e (81±20 vs. 71±19 ms, p=0.025), Tp-e/QT (0.23±0.06 vs. 0.20±0.05, p=0.043)]. QTc interval was positively correlated with sodium (p=0.001) and age (p=0.007). Tp-e/QT ratio was the ECG parameter correlated to most of variables including eGFR (p=0.003), creatinine (p=0.040), potassium (p=0.009), chloride (p=0.048), and glucose (p=0.041). Conclusions: Ventricular repolarization was found to be increased in patients with hemodialytic ESRD. Hence, observation ECG parameters of ventricular repolarization should be performed in the hemodialytic patients for early detection of ventricular arrhythmia.

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DOI: 10.3897/folmed.64.e65824

Authors: Maya Risteska, Ludmila Vladimirova-Kitova, Vladimir Andonov

Abstract: Introduction: Based on many previous studies, liver cirrhosis is traditionally associated with cardiac dysfunction. The main clinical features of cirrhotic cardiomyopathy include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities, and chronotropic incompetence. Previous studies have found that the levels of brain natriuretic peptide (BNP) and its precursor the N-terminal pro B-type natriuretic peptide (NT-proBNP) are elevated in cirrhosis with systolic as well as diastolic dysfunction. Aim: The aim of this study was to establish the association between early changes in cardiac function in patients with liver cirrhosis and NT- proBNP plasma levels. Materials and methods: Forty-two consecutive hospitalized patients with viral-related cirrhosis were studied. We also evaluated a control group of 20 age and sex-matched patients with arterial hypertension. All underwent abdominal ultrasound, upper GI endoscopy, ECG, and echocardiography, and their plasma levels of NT-proBNP were determined. Results: We observed higher NT-proBNP plasma levels in cirrhotic patients than in controls. We also found that atrial volumes, ejection fraction and partially left ventricular mass and PAPs (systolic pulmonary arterial pressure) were significantly altered in comparison with the hypertensive controls. Supporting previous studies, we also found that the mean QTc interval was prolonged in 65% of women and 96% of men. Conclusions: In conclusion, the present study shows that plasma NT-proBNP levels, LAD (left atrium diameter), the E/A ratio, EDT (end diastolic time) and E/e’ ratio may be reliable indicators of the extent of cardiac abnormalities in cirrhotic patients.

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DOI: 10.3897/folmed.64.e64741

Authors: Dolina G. Gencheva, Fedya P. Nikolov, Ekaterina H. Uchikova, Krasimira A. Hristova, Rosen D. Mihaylov, Blagovesta G. Pencheva

Abstract: Despite being a physiological condition, human pregnancy is known to cause numerous complications that can endanger the life of the mother and the fetus alike. While the majority of complications are mostly limited within the peripartum period, more and more information is available about persistently higher short- and long-term cardiovascular risk after a pregnancy complicated by a hypertensive disorder. There is evidence that women after gestational hypertension or preeclampsia are more likely to develop arterial hypertension, coronary atherosclerosis, myocardial infarction, stroke, peripheral artery disease, and even diabetes mellitus and venous thromboembolism years after the target pregnancy. This has urged some authors to view hypertensive disorders of pregnancy as a “stress test” for the maternal organism that unmasks latent endothelial dysfunction. An explanation is sought in the presence of common risk factors and underlying pathological pathways with cardiovascular diseases, although a certain etiological mechanism for the development of hypertensive disorders in pregnancy has not been established yet. More attention is needed towards the follow-up of women after a hypertensive pregnancy as it could be an opportunity for early prevention of cardiovascular diseases.

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DOI: 10.3897/folmed.63.e59216

Authors: Gabriela Kehayova, Snezha Zlateva, Petko Marinov

Abstract: Introduction: Lipid emulsions are increasingly used as an antidote to lipophilic drug intoxications. The dose recommended by the American Society of Regional Anesthesia is used primarily for the treatment of local anesthetic systemic toxicity. There is insufficient information about what the dose of lipid emulsions (LE) should be in other intoxications depending on their severity.Aim: To determine the LE dose in a shock or haemodynamic instability in patients with acute exogenous intoxications treated with LE.Materials and methods: Forty-nine patients with acute lipophilic drug intoxications were treated with LE in the Clinic of Toxicology at the Naval Hospital in Varna.Statistical analysis was performed using the statistical functions of Excel 2016 and the Statistica 7.0 software package.Results: The percentage of patients receiving a low dose of LE of 0.3 ml/kg (93.87%) was significantly higher than the percentage of patients treated with a medium (2.04%) and a high dose (4.08%) of LF. The high dose of LE of 1.5 ml/kg recommended by the American Society of Regional Anesthesia was administered to two patients (4.08%). In severe intoxications with exotoxic shock, the rate of LE administration varies from 20 ml/h to 40 ml/h.Conclusions: In severe intoxications with cardiotoxic syndrome and haemodynamic instability, LE should be used in the dose as suggested by the American Society of Regional Anesthesia. It is possible to use lower doses of LE in the range of 0.3–0.6 ml/kg in all moderate poisonings administered by continuous intravenous infusion for 12-24-48 hours. No side effects were observed at these doses.

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DOI: 10.3897/folmed.63.e60249

Authors: Asparuh G. Nikolov, Nikola K. Popovski, Alexander B. Blazhev, Svetla Blazheva

Abstract: Introduction: Collagen type I is a major structural component of human uterus. Recent studies have found that collagen type I turnover is altered in preeclampsia and imbalance occurs between collagen synthesis and degradation processes. This acts as a stimulus for abnormal changes in the concentrations of collagen type I derived products in circulating blood.Aim: Having in mind the pathological collagen type I turnover in preeclampisa, the aim of the present study was to determine the levels of N-terminal propeptide of collagen type I (PINP), C-terminal propeptide of collagen type I (PICP): both markers of collagen type I synthesis and levels of matrix metalloproteinase-1 (MMP-1): marker of collagen type I degradation in sera of women with early-onset preeclampsia.Materials and methods: Thirty-two patients with early-onset preeclampsia were examined. The mean age of the patients was 28.8±5.5 years; and the mean age of 22 age-matched healthy pregnant women was 28.5±6.0 years. The enzyme-linked immunosorbent assay (ELISA) was used for measuring serum levels of PINP, PICP and MMP-1.Results: There were no statistically significant differences between levels of PINP, PICP and MMP-1 in the sera of women with preeclampsia and healthy pregnancies: 16.991 (15.41÷21.143) vs. 17.189 (15.805÷20.747) µg/L (KW=0.02; p>0.05), 10.929 (8.7÷13.937) vs. 11.474 (7.369÷11.932) µg/L (KW=0.026; p>0.05), and 2.097 (1.384÷2.923) vs. 2.589 (1.41÷4.533) µg/L (KW=0.238; p>0.05), respectively. There were statistically significantly higher number of patients from the preeclampsia group than healthy pregnant women with BMI≥25 (23/32 vs. 4/22) and abnormal UAD (18/32 vs. 2/22) (p<0.05).Conclusions: Our results did not show significant differences between serum levels of PINP, PICP and MMP-1 (markers of collagen type I turnover) in women with early-onset preeclampsia and healthy pregnancy. Further studies with more specific methods and larger sample size are required to assess changes in the serum levels of PINP, PICP and MMP-1 in early-onset preeclampsia.

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DOI: 10.3897/folmed.63.e56489

Authors: Dolina G. Gencheva, Fedya P. Nikolov, Ekaterina H. Uchikova, Rosen D. Mihaylov, Blagovesta G. Pencheva, Katerina I. Ivanova

Abstract: Introduction: Gestational hypertension is a less investigated hypertensive disorder of pregnancy than preeclampsia, but evidence exists of an unfavourable cardiovascular profile for women after such a pregnancy.Aim: To determine serum high-sensitivity C-reactive protein (hs-CRP) levels in women with preeclampsia, gestational hypertension, and in normotensive pregnancy in order to assess the cardiovascular implications and to examine its correlations with some characteristics of women.Materials and methods: Thirty-six women with gestational hypertension, thirty-seven with preeclampsia, and fifty maternal and gestational age-matched controls were included in a single-center prospective clinical-epidemiological study. Serum hs-CRP levels were determined using ELISA method.Results: Significantly higher hs-CRP levels were found in the gestational hypertension group than in the controls (p=0.043), but not in the preeclampsia group (p=0.445). The levels between the two pathological groups did not differ significantly (p=0.247). Odds ratio for hs-CRP levels higher than the provided cut-off was 3.31 (95% CI 1.32–8.29) for the presence of gestational hypertension. In the normotensive pregnant women, the hs-CRP levels had a positive correlation with BSA, pre-pregnancy and current BMI, but such correlations were absent in the hypertensive groups. There were no correlations with the maternal or gestational age, current weight gain in any of the groups or with the highest detected blood pressure in the pathological groups. These levels did not differ according to gravidity, smoking status and smoking during pregnancy.Conclusions: Elevation of hs-CRP was more pronounced in women with gestational hypertension than in women with preeclampsia, which could indicate a different pathophysiological mechanism and a higher cardiovascular risk for those women.

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DOI: 10.3897/folmed.63.e55313

Authors: Antoniya Kisheva, Yoto Yotov, Trifon Chervenkov, Atanas Angelov, Yana Bocheva

Abstract: Introduction: Cardiac fibrosis is the hallmark of atrial remodeling in atrial fibrillation. Galectin-3 (Gal-3) is a biomarker of fibrosis. It is well studied in heart failure, but the data about its role in atrial fibrillation are sparse.Aim: The aim of the study was to evaluate the levels of Gal-3 in patients with atrial fibrillation after sinus rhythm restoration, to examine the association between this biomarker and other factors for developing atrial fibrillation and to assess its prognostic role.Materials and methods: We included 67 patients (35 male) at the mean age of 67.36±7.25 years, with Gal-3 test after sinus rhythm restoration, a subgroup of participants in placebo-controlled randomized clinical trial of treatment with spironolactone. They were followed up for atrial fibrillation recurrence and hospitalizations. The effect of demographic parameters and other factors on Gal-3 levels were evaluated before and one year after treatment.Results: Mean Gal-3 at baseline was 16.9±6.8 ng/ml. Higher levels of Gal-3 were associated with female gender (р=0.008), increasing age (р=0.005), renal dysfunction (p<0.0001) and gout (р=0.002). Higher thromboembolic risk as assessed by CHA2DS2-VASc score was significantly related to Gal-3. The levels of biomarker did not affect the number of atrial fibrillation recurrences (p=0.9) and hospitalizations. No correlation was found with treatment with spironolactone, antiarrhythmic and antihypertensive drugs.Conclusions: Higher Gal-3 in atrial fibrillation was associated with female sex, renal dysfunction, and history of gout. The levels of Gal-3 were not related to rhythm control. Treatment with spironolactone did not affect the biomarker of fibrosis Gal-3 in AF patients. Higher Gal-3 was related to high embolic risk.

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