History Of Arterial Hypertension Research Articles

AUTOIMMUNE MYOCARDITIS IN MELANOMA IMMUNOTHERAPY–COMPLEX CLINICA PRESENTATION AND ADVERSE THERAPEUTIC RESPONSE

Abstract A 68–year–old Caucasian female presented to the ED with cardiac chest pain and dyspnea. The patient had a history of arterial hypertension and was equipped with a biventricular pacemaker due to atrial fibrillation with low ventricular response. She had recently been diagnosed with metastatic melanoma and initiated treatment with nivolumab and ipilimumab two weeks prior. Troponin levels were elevated (700 ng/ml), and no ST–segment elevation was observed on the electrocardiogram (ECG). In suspicion of NSTEMI–ACS, coronary angiography was performed, revealing an intact epicardial coronary circulation without stenotic lesions. The echocardiogram showed borderline left ventricular systolic function (EF 50%), and the right ventricle exhibited initial signs of reduced systolic function (TAPSE, 15 mm; S RV, 9.5 m/s). The following day, there was a deterioration in hemodynamics and respiratory exchange, with evidence of apical and mid–distal interventricular septum hypokinesia of the left ventricle (EF 40%) and dilated right ventricle (BD 4.8 cm; MD 4 cm) with severely reduced systolic function (TAPSE 10 mm, S RV 7 m/s, FAC, 20%), and severe tricuspid regurgitation. Urgent computed tomography pulmonary angiography (CTPA) excluded pulmonary embolism. Additionally, there was a new troponin increase (5000 ng/ml) and elevated hepatic biomarkers. The clinical picture raised suspicion of myocarditis related to immune checkpoint inhibitor therapy. Corticosteroid therapy was initiated with a daily administration of methylprednisolone 1000 mg. Diagnostic confirmation was sought through autoimmune panel and viral marker assessments, which yielded negative results. Endomyocardial biopsy (EMB) revealed CD4 and CD8–positive lymphocytic infiltration and myocardial necrosis. Despite initial clinical improvement, an arrhythmic storm developed. Despite treatment with a defibrillator, intravenous antiarrhythmic therapy (beta–blocker, amiodarone, and lidocaine), and sedation, the patient unfortunately succumbed. Immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of many solid tumors. However, the dysregulation of immune mechanisms can rarely (2%) lead to autoimmune events involving multiple organs. Myocarditis, despite optimal treatment, is characterized by a mortality rate exceeding 50%, representing a significant challenge in the Intensive Care Unit.

РАСПРЕДЕЛЕНИЕ ГЕНОТИПОВ ГЕНА SLC2A9, УРОВЕНЬ МОЧЕВОЙ КИСЛОТЫ И МЕТАБОЛИТЫ ПУРИНОВОГО ОБМЕНА У ПАЦИЕНТОВ С АРТЕРИАЛЬНОЙ ГИПЕРТЕНЗИЕЙ И ФИБРИЛЛЯЦИЕЙ ПРЕДСЕРДИЙ

The aim is to investigate the frequency of genotypes and alleles of the SLC2A9 gene rs734553 polymorphism, the level of serum uric acid (sUA) and metabolites of purine metabolism in patients with arterial hypertension (AH) and atrial fibrillation (AF), as well as in healthy individuals. Material and methods. The study included 154 patients: 50 were healthy individuals (group 0), of which 22 (44%) were men and 28 (56%) were women aged 50 [45;53] years and 104 were patients with AH and AF (main group), of which 94 (90.4%) were men and 10 (9.6%) were women aged 55 [45; 61] years. The main group was divided into subgroups: subgroup I – patients with AF without a history of AH and other rhythm disorders (n=13); subgroup II – patients with AH in combination with AF (n=68); subgroup III – patients with AH without a history of AF or other rhythm disturbances (n=23). Hyperuricemia was detected in 34 (22.1%) patients, normal uric acid levels were revealed in 120 (77.9%) patients. All patients were studied using clinical, laboratory, instrumental and molecular genetic research methods. The level of sUA was determined by the enzymatic colorimetric method. Serum xanthine oxidase was measured using a method based on a solid phase sandwich-type enzyme-linked immunosorbent assay. Metabolites of purine metabolism in blood plasma were measured using the method of high-performance liquid chromatography. The SLC2A9 gene rs734553 polymorphism was determined using the polymerase chain reaction with real-time detection of results. Results. The patients with AH and AF, as compared to healthy individuals, had more severe disturbances of purine metabolism, characterized by higher concentration of sUA (330 [283; 412] µmol/l and 197 [161; 229] µmol/l (p<0.001), respectively). Also, in contrast to the group of healthy individuals, the group of patients with AH and AF demonstrated an increase in the level of adenosine (p=0.001), and a decrease in the levels of hypoxanthine and xanthine (p<0.001). There were no statistically significant differences in xanthine oxidase activity level (p>0.05), however, in 54% of patients in the main group it was higher than normal values. The dominant allele A and the dominant genotype A/A of the SLC2A9 gene rs734553 polymorphism (75%, p=0.005; 64%, p=0.001, respectively) occurred significantly more often in healthy individuals, while the recessive allele C and the heterozygous genotype A/C were found significantly more often in the group of patients with AH and AF (41.3%, p=0.005; 48.1%, p=0.003, respectively). The C/C genotype (41.7%, p=0.001) was significantly more common in patients with AH in combination with AF and hyperuricemia, compared to patients with AH combined with AF without hyperuricemia as well as healthy individuals (6.8%; 14%, p=0.001, respectively). Patients with AH in combination with AF and the C/C genotype were characterized by a significantly higher level of sUA (p=0.003) compared to patients with the A/A genotype. Conclusions. A statistically significant predominance of the recessive allele C of the SLC2A9 gene rs734553 polymorphism was established in patients with AH and AF compared with healthy individuals (p=0.005). In patients with AH in combination with AF and hyperuricemia, the C/C genotype was significantly more common (41.7%, p=0.001). Patients with AH in combination with AF and the C/C genotype were characterized by a significantly higher level of sUA (p=0.003) compared to patients with the A/A genotype.

Transcutaneous canine breast cancer detection in Tunisia: a pilot study

BackgroundBreast cancer in Tunisia is often diagnosed at a late stage with long delay in time to consultation and to diagnosis.The aim of this study is to estimate the sensitivity and specificity of the transcutaneous breast cancer detection by canine olfactionin Tunisian women and to identify the potential confounding factors.MethodsThis is a diagnostic case control study that took place from October 2021 to November 2022 in the Department of Medical Oncology at the University Hospital Farhat Hached of Sousse and in the security and training dog center located in Sousse (K9 Dog Center Security & Training). A two-year-old male Belgian Malinois was trained to detect breast cancer on skin secretion samples in compresses that had been worn overnight by women on their breast and then a double-blind testing was performed. There was no contact between women and the dog. From the mentioned responses of the dog, four parameters were calculated: sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV).ResultsTwo hundred women were included in this trial: 100 breast cancer (BC) patients recruited from Farhat Hached University Hospital of Sousse and 100 healthy volunteers (HV).The calculated sensitivity was 84% (95% CI 78–89%) and the calculated specificity was 81% (95% CI 75–86%). The calculated predictive values were: PPV = 83,51% (95% CI 78,37–88,65%) and NPV = 81,55% (95% CI 76.17–86.93%). In the multivariate study, only four confounding factors of test’s sensitivity were retained: age (OR = 1.210 [95% CI = 1.085–1.349]; p = 0.001), history of diabetes(OR = 0.017 [95% CI = 0.001–0.228]; p = 0.002), sampling at hospital (OR = 0.010 [95% CI = 0.003–0.464]; p = 0.010) and testing during chemotherapy courses (OR = 0.034 [95% CI = 0.003–0.404]; p = 0.007).For test’s specificity, we retained the three following confounding factors: age (OR = 1,104 [95% CI = 1.021–1.195]; p = 0.014), history of benign mastopathy (OR = 0.243 [95% CI = 0.074–0.805]; p = 0.021)and history of arterial hypertension (OR = 0.194 [95% CI = 0.053–0.707]; p = 0.013).ConclusionThis is a pilot study that opens new avenues in developing a reliable cancer diagnostic tool that integrates the dog's olfactory ability to detect breast cancer using a transcutaneous sampling method. It could be a pre-test to select patients who are eligible to a screening mammogram, especially in low-income countries where there is no national mammography screening program.Pactr.org identifierPACTR202201864472288, registration date 11/01/2022.

Peculiarities of ambulatory blood pressure monitoring in patients who have suffered from COVID-19

Violations of blood pressure control in patients who have had COVID-19 can be due to many pathophysiological factors. Further study of the features of blood pressure (BP) fluctuations in this category of patients will allow to diagnose arterial hypertension (AH) on time, to identify the uncontrolled course of AH and to select the optimal tactics of patients’ management. It was suggested to determine the characteristics of BP fluctuations in patients who have suffered from COVID-19 more than 12 weeks ago, based on the results of ambulatory (daily) blood pressure monitoring. 98 patients (51 men – 52.0%, 47 women – 47.9%) who have had COVID-19 infection more than 12 weeks ago were examined. Patients were divided into 2 groups – with and without a history of AH. The groups of examinees were homogeneous in age and gender. Ambulatory blood pressure monitoring (AM BP) was carried out on the CardioTens apparatus (Meditech, Hungary) according to the standard method. According to the data of AM BP in patients with AH in the anamnesis, who have suffered from COVID-19 more than 12 weeks ago, significantly higher average indicators of daily systolic blood pressure were recorded, and significant violations of the indicators of variability of systolic blood pressure during the day and night periods, pressure load during the day period, as well as a significantly higher degree and the rate of the morning rise in systolic blood pressure. In patients without a history of AH who have suffered from COVID-19 more than 12 weeks ago, in 21.4% cases there was newly diagnosed AH, in 33.3% of cases, increased variability of systolic blood pressure was observed, mainly during the day, in 21.4% of cases, the degree and speed of the morning rise of systolic blood pressure were increased, which indicated the presence of hypertensive reactions to household loads. In patients with a history of AH, in 55.3% of cases there was observed an increase in average blood pressure values per day, during the day and night periods, which was considered as ineffective blood pressure control and required an increase in the doses of previously prescribed antihypertensive drugs or the use of additional antihypertensive drugs in the treatment regimen. In patients with AH in the anamnesis, who have suffered from COVID-19 more than 12 weeks ago, reliable violations of many indicators of AM BP, deterioration of blood pressure control were recorded. In the patients, who did not have AH and who have suffered from COVID-19 more than 12 weeks ago, the presence of a hypertensive reaction to household loads and newly diagnosed AH were odserved.

Rare Complication of Inferior Vena Cava Filter Implantation

Inferior vena cava filters are a valid option in treating patients with deep vein thrombosis of the lower limbs with contraindication or failure of anticoagulation or in cases of recurrent pulmonary embolism under adequate levels of anticoagulation. It should be recognized that, like any procedure, the implantation of these devices is not without complications, and migration is a rare but potentially severe late complication. The authors present the case of migration of a vena cava filter into the right ventricle in a 54-year-old female patient with a history of arterial hypertension and previous hospitalization for bilateral infrapatellar DVT.

Red cell distribution width (RDW) to serum albumin ratio (RAR) in chronic heart failure

Abstract Background The RDW to albumin ratio (RAR) is a novel and simple biomarker of inflammation. The value of RAR in predicting acute HF prognosis has been suggested. However, its application in chronic HF was never investigated. Purpose To study the association of RAR with all-cause mortality in chronic HF. Methods We conducted a retrospective cohort study in patients followed in a HF clinic of a tertiary care academic hospital between January 2012 and December 2020. Consecutive adult patients with left ventricular systolic dysfunction (ejection fraction <50%) referred to the clinic were included. Patients with no measurement of RDW and no measurement of serum albumin were excluded from the analysis. The RAR was calculated as RDW (in %) / albumin (in g/dL). Patients were followed up to December 2022 and the endpoint under analysis was all-cause mortality. The association of RAR with mortality was assessed using a Cox-regression analysis. RAR was analysed as a continuous variable and as a categorical variable (cut-off 1st tertile). Multivariable models were built with adjustments to age, sex, arterial hypertension (AHT) history, diabetes mellitus (DM), atrial fibrillation (AF), ischaemic HF, severe left ventricular systolic dysfunction (LVSD), New York Heart Association class, systolic blood pressure (SBP), estimated glomerular filtration rate, haemoglobin, BNP, beta blocker (BB) use, angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi) or angiotensin receptor neprilysin inhibithors (ARB) use and mineralocorticoid receptor antagonist (MRA) use. Results We studied 754 patients, 63.3% male, mean age 71 (13) years, 64.1% had AHT history, 38.5% had DM, 33.3% had AF, HF was ischaemic in 44.4%, and 49.3% has severe LVSD. A total of 92.3% of the patients were on BB, 82.8% on ACEi or ARB or ARNi, and 29.7% on MRA. RAR presented a skewed right tailed distribution with a median value of 3.56, percentile 33.3 = 3.31 and percentile 66.7 = 3.85. During a median follow-up of 43 months 370 (49.1%) patients died. Mortality increased with increasing RAR: 33.2% in patients with ratio<3.31, 50.6% in patients with ratio 3.31 to <3.85 and 63.1% in patients with ratio≥3.85, p<0.001. The multivariate adjusted HR of all-cause death was 1.27 (95% CI: 1.12-1.43) per each unit increase in the RDW: albumin ratio. If RAR was analysed as a categorical variable, patients with RAR≥3.31 (1st tertile) presented an increased mortality risk of 1.48 (1.12-1.96); the increase in risk was independent of age, sex, comorbidities, LVSD, symptoms, SBP, haemoglobin, renal function, BNP and disease-modifying therapy. Conclusions The RAR is a strong and independent mortality predictor in chronic HF. Patients with a RAR ≥3.31 have a 48% increase in all cause-death in the long term; the increase in risk is of 27% per each unit rise in the ratio. Our results reinforce the importance of inflammation in chronic HF pathophysiology and progression.

Cardiac function in patients with Paget disease of bone: standard and advanced echocardiographic study

Abstract Background/Introduction Paget’s disease of bone (PDB) is a common metabolic bone disorder and cardiovascular diseases are considered a possible PDB metabolic complication. Heart complications have only been described anecdotally as high-output heart failure due to high blood flow when skeletal involvement is extensive. Purpose Scientific studies that compare the structural and functional characteristics of the heart in this population are few and dated. The aims of this study were to evaluate echocardiographic parameters in PDB patients. Methods 60 PDB patients and 115 control subjects, matched by age, weight, height and history of arterial hypertension were enrolled. All subjects underwent to standard and advanced echocardiography examination. Results PBD patients showed a lower values of left ventricular ejection fraction (LVEF) (60,86 ± 4,51 vs 62,79 ± 4,30%, p 0,007), global longitudinal strain (GLS) (21,42 ± 2,20 vs 22,35 ± 2,21%, p 0,021) and myocardial work efficiency (MWE) (94,1 ± 2,0 vs 95,4 ± 2,9%, p 0,021), and higher values of interventricular septum thickness (IVSd) (9,9 ± 1,4 vs 9,1 ± 1,4 mm; p 0,003), and relative wall thickness (RWT) (0,38 ± 0,07 vs 0,35 ± 0,07, p 0,031) compared to controls, while there were no significant difference between the other parameters analyzed (Table 1). Calcification and/or sclerosis of aortic valve was detected in 26 PDB patients (43,3%) compared to 27 subjects (23,5%) in control group (Fisher’s exact test p-value = 0,006). Calcification and/or sclerosis of mitral annulus was detected in 14 PDB patients (23,3%) compared to 12 controls (11,6%) (Fisher’s exact test p-value = 0,022) (Table 2). Conclusion The study results support the hypothesis that PDB is a systemic condition, influencing cardiac function and structure, associated with increased cardiovascular risk. Our data showed that myocardial function in PDB patients is impaired. The lower resting values of LVEF, GLS and MWE represent an early subclinical myocardial damage.Table 1Table 2

Predictive factors of return to activity in elderly patients operated on for a fracture of the lower limb: a study of 113 patients

Background: The aim of this study was to determine the factors predictive of resumption of activity in elderly subjects operated on for a fracture of the lower limb. Methods: This was a cross-sectional study with retrospective data collection in subjects aged 56 and over who had undergone lower-limb surgery with a minimum follow-up period of six months. Patients' walking autonomy was assessed using the Parker score. The modular integrated household survey on living conditions was used to assess patients' socio-economic status. Bivariate analysis was performed using the chi-square test and the calculation of measures of association. Results: The series included 113 patients with a mean age of 70±9.54 years and a sex ratio of 1.09. Fractures of the upper end of the femur predominated in 67.6% of cases. The most common surgical procedure was intermediate hip replacement in 30 patients (26.5%). Rehabilitation sessions were performed in 95 patients (84.1%). The postoperative Parker score at the last follow-up was 9/9 in 41 patients (36.3%). Resumption of educational and productive activities and interpersonal responsibilities was achieved in 90 patients (79%). Significant associations (p<0.05) were found between resumption of activities and age, sex, marital status, history of arterial hypertension, psychiatric history, preoperative Parker score, postoperative Parker score and return to a private residence. Conclusions: Older age, female gender, absence of a partner, high blood pressure, non-personal residence and poor Parker score are factors with a poor prognosis for return to activity.

AUSTRIAN SYNDROME: A RARE CASE REPORT.

Austrian syndrome is a rare and fatal triad of pneumonia, meningitis and endocarditis caused by Streptococcus pneumoniae, with a mortality rate of 60%. We report a case of Austrian syndrome in a 59-year-old patient, with a history of arterial hypertension on angiotensin 2 receptor antagonist therapy for five years, chronic smoking at 20 packs per year and occasional enolism for fifteen years, presenting with prolonged fever associated with loss of consciousness with no respiratory or cardiac signs, in whom purulent bacterial meningitis with positive Gram stain, infective endocarditis with mitral and aortic localization and interstitial pneumopathy have been demonstrated with negative blood cultures. Although the mortality rate is very high, early management of Austrian syndrome can improve the patient's quality of life.

Segmental Arterial Mediolysis and its Mimickers: A Case Report and Review of the Literature.

Segmental arterial mediolysis (SAM) is a rare and underdiagnosed vasculopathy.SAM is a challenging diagnosis and should not be confused with vasculitis.SAM has a good prognosis with spontaneous resolution in most cases.

In-hospital outcomes after acute myocardial infarction with obstructive coronary artery disease in critically ill patients hospitalized for non-cardiac disease

BackgroundAcute myocardial infarction (AMI) is one of the major cardiac complications in patients hospitalized in the intensive care unit (ICU) for non-cardiac disease. A better knowledge of ischemic and bleeding risks in these patients is needed to identify those most likely to benefit from specific cardiac management. We therefore assessed the incidence and predictors of a composite outcome of severe ischemic event (AMI recurrence, ischemic stroke), major bleeding, or all-cause death in this setting.MethodsIn this multicenter retrospective study, all consecutive adult patients admitted for non-cardiac disease to four French university hospital ICUs between January 2012 and December 2018 who had an AMI with obstructive coronary artery disease (OCAD) during the ICU stay were considered for inclusion. AMI with OCAD was defined as an elevated cardiac troponin value associated with at least one sign (clinical, electrocardiographic, or echocardiographic) suggestive of myocardial ischemia and presence of OCAD on coronary angiography. The primary endpoint was in-hospital occurrence of the composite outcome.ResultsNinety-six patients [median age 69 years, 22 women (23%), 59 with sepsis (61%), 35 with ST elevation (37%), median sequential organ failure assessment (SOFA) of 8 on the day of AMI] were included. The median peak cardiac troponin value was 131 (IQR 44–303) times the upper reference limit. Dual antiplatelet, therapeutic anticoagulation, and early mechanical reperfusion therapies were administered in 61 (64%), 68 (71%), and 47 (49%) patients, respectively. The composite outcome occurred in 48 (50%) patients. Severe ischemic events occurred in 17 (18%) patients and major bleeding in 26 (27%) patients; 26 patients (27%) died in the hospital. AMI management was not significantly different in patients with and without the composite outcome. A history of arterial hypertension (HR 2.05, 95% CI 1.01–4.16) and high SOFA score at the time of AMI (HR 1.07, 95% CI 1.00–1.15) were independent risk factors for the composite outcome.ConclusionsPatients who have an AMI with OCAD during an ICU stay for non-cardiac disease are at risk of a composite outcome of severe ischemia, major bleeding, and death. A history of arterial hypertension and high SOFA scores were independent hazards for poor prognosis.Graphical

DIAGNOSTIC AND PROGNOSTIC VALUE OF Β2-MICROGLOBULIN IN THE DEVELOPMENT OF CARDIORENAL SYNDROME IN PATIENTS WITH TYPE 2 DIABETES MELLITUS AND ARTERIAL HYPERTENSION

Arterial hypertension is the largest pandemic in the history of mankind, which defines the structure of cardiovascular morbidity and mortality. Currently, the correlation between hypertension and various pathological conditions and diseases has been proven, which largely determines its progression and contributes to the development of cardiovascular and renal complications. These diseases include type 2 diabetes mellitus, which is spreading globally as a pandemic. The history of arterial hypertension in combination with type 2 diabetes mellitus is often accompanied by the development of cardiorenal syndrome, so it is crucial to diagnose renal dysfunction and prevent cardiovascular complications in such patients. One of these biomarkers is β2-microglobulin (β2-M), which depends on the glomerular filtration rate and tubular reabsorption.
 Materials and methods. 90 patients with AH (men/women – 48/42) and 20 control subjects were examined. During a thorough examination and follow-up of patients, they were classified into 3 groups: patients with AH – group 1 – 31 people; group 2 – AH in combination with T2DM – 31 people; group 3 – patients with AH, T2DM, and obesity – 28 people. Body weight and height were measured in all patients, and BMI = body weight/height2 (m2) was calculated. The β2-microglobulin levels in the patients' serum, cardiotrophin-1, catestatin, leptin, cystatin C, neutrophil gelatinase-associated lipocalin, and N-terminal pro-brain natriuretic peptide, 25-OH total vitamin D, serum insulin levels, glycosylated hemoglobin, lipid metabolism, and systolic and diastolic blood pressure were measured. Statistical data analysis was performed using Statistica, 12 (Stat Soft Inc, USA) and Microsoft Office Excel 2013. The data are presented as mean (M) and standard deviation (δ). Differences between groups of mean values were evaluated using the Student's t-test.
 Results and conclusions. The level of β2-M in the observed groups of patients differed significantly from that of healthy individuals. An increase in β2-M concentration allowed us to confirm the presence of tubular renal dysfunction, which was not diagnosed by conventional methods. All examined patients were divided into 2 groups depending on the β2-M level. Our data prove the role of β2-microglobulin as an independent biomarker of renal dysfunction, as well as the development of early cardiovascular complications. The data obtained from the mathematical models between creatinine and β2-microglobulin, urea and β2-microglobulin levels show a highly significant correlation between β2-microglobulin and renal function and demonstrate that β2-microglobulin is an independent factor in the prediction of renal dysfunction in patients with hypertension and concomitant type 2 diabetes mellitus. β2-microglobulin is a biomarker that should be used in the diagnosis and prognosis of early manifestations of cardiorenal syndrome.

Retrospective analysis of cases of transient global amnesia admitted to the hospital

Introduction. Transient global amnesia (TGA) is a clinical syndrome, the main clinical manifestation of which is sudden development of anterograde and retrograde amnesia, lasting not more than 24 hours, without other general cerebral or focal neurological symptoms.The aim of the work was to reveal the peculiarities of clinical manifestations and data of additional methods of examination of patients with TGA syndrome referred to the primary vascular department with suspected acute cerebral circulation disorder (ACCD).Materials and methods. The study included 16 patients with transient global amnesia diagnosed according to the diagnostic criteria of Hodges and Warlow (1990). All patients underwent a detailed neurological and general medical examination. Electrocardiography, multispiral computer tomography of the head, echocardiography, ultrasound duplex scanning of the main arteries of the head and neck, laboratory examination (lipid spectrum) were performed. The Brief Mental Status Rating Scale was used to assess cognitive impairment.Results. The majority of patients had elevated blood pressure (BP). The leading trigger factor of transient global amnesia was stress. The duration of amnesia ranged from 1.5 to 5 hours. There was a significant impairment of short-term memory. On the first and second days of hospitalization, 50% of patients had normal cognitive functions on a brief mental status assessment scale, but by the 5th−7th day only 12.5 % of patients had abnormalities. Ultrasound markers of atherosclerosis in the form of intima-media complex thickening and dyslipidemia were found in 6 patients. Signs of left ventricular hypertrophy were found in the majority of patients. Discussion TGA is a relatively rare condition and an understudied syndrome. Due to its suddenness of clinical manifestation, TGA requires differential diagnostics with acute cerebral circulatory disorders, epilepsy, acute hypertensive encephalopathy and psychogenic amnesia.Conclusion. The clinical features of TGA identified in the patients were a history of arterial hypertension, elevated BP during an episode of TGA. The leading provoking factor was stress. TGA episode occurred predominantly in the first half of the day. The majority of patients had complaints of headache on admission. Cognitive disorders detected in patients on the first and second days of the disease quickly regressed to normal. Left ventricular hypertrophy was detected in most patients.

Clinical characteristics and factors associated with death from acute decompensated heart failure

Aim. To assess the diagnostic significance of clinical indicators and left ventricle ejection fraction (LV EF) for predicting the probability of death from acute decompensated heart failure (ADHF) in patients with chronic heart failure with a reduced LV EF (HFrEF) within one year after implantation of cardioverter defibrillator (ICD).Methods. The study included 384 patients with heart failure NYHA 3-4 functional class with LV EF ≤ 35%, undergoing ICD implantation for the purpose of primary prevention of sudden cardiac death. After ICD implantation the patients included in the study were prospectively observed during one year (visits to the clinic after 3, 6, 12 months). The primary end point - a case of ADHF was registered.Results. In a one-year observation, the primary endpoint was recorded in 38 patients (10 per cent). Single factor logistic regression analysis showed 5 factors with the greatest predictive potential (p<0.1), related to the occurrence of the investigated endpoint. These included: history of arterial hypertension (AH) and obesity, LV EF based on the biplane Simpson’s method, LV EF ≤ 28% and systolic blood pressure. Based on the results of the multi-factor regression analysis, a predictive model was developed, which included three factors with the highest levels of statistical significance: the presence of AH, obesity and LV EF ≤ 28%. The diagnostic efficiency of the model was 69.5% (sensitivity 78.9%; specificity 68.5%).Conclusion. The results of the research indicate that the main predictor of one-year mortality due to ADHF in the studied cohort of HFrEF patients with NYHA class 3-4 is LV EF ≤ 28%. The presence in the history of AH and obesity was associated with the best prognosis for life.

#3041 DNAJB9 POSITIVE PRIMARY FIBRILLARY GLOMERULONEPHRITIS: TREATMENT WITH CORTICOSTEROID PULSES EXPERIENCE

Abstract Background and Aims Fibrillary glomerulonephritis (FGN) is a rare histological pattern. Electron microscopy is needed for diagnostic confirmation where predominantly mesangial fibrils are observed. To support the diagnosis; DNAJB9 is a biomarker that is 100% sensitive and 100% specific for FGN. To date, there is no defined therapeutic approach. Various immunosuppressants have been implemented to treat FGN showing poor renal response and approximately 50% progression to chronic kidney disease. Method Ambispective observational study. A protocol based on a bibliographic review was developed. The protocol included an induction therapy with methylprednisolone pulses (MTP), 500 mg a day for three days. Followed by oral prednisone at a dose of one mg/kg with an individual titration period considering the clinical evolution. Demographic, clinical, and pathological variables were extracted from the electronic health record. Results Case 1. Seventy-eight-year-old female. History of arterial hypertension (HT) treated with an angiotensin-converting enzyme inhibitor (ACEi). She debuted with a nephrotic syndrome characterized by proteinuria of 15 grams/day, hypoalbuminemia, and altered kidney function with creatinine (Cr) of 2.7 mg/dL. Secondary causes were rule out. The kidney biopsy showed mesangial expansion with mesangial deposition of IgG and C3 on the immunofluorescence. Congo red was negative. Positivity for DNAJB9 was observed. The electron microscopy (EM) showed 20-nanometer fibrils in the mesangium. The patient was initiated on the treatment protocol with a subsequent reduction of prednisone over a period of 24 weeks. Complete remission, defined as proteinuria <0.5g/day and reduction > 50% of Cr was achieved after 20 weeks of treatment. Case 2. Forty-seven-year-old female with a history of hypertension treated with ACEi. The patient presented with proteinuria 3.5g/d with a normal kidney function. Secondary causes were rule out. The kidney biopsy showed mesangial thickening with IgG, C3, C1q, Kappa, and lambda positivity on immunofluorescence. Congo red was negative. DNAJB9 was positive. An electron microscopy study showed randomly arranged mesangial fibrils. The treatment protocol was started. Prednisone was titrated over a period of 20 weeks. Partial remission was observed, defined by >50% reduction of proteinuria. Kidney function remained preserved. Conclusion Induction treatment based on steroid pulses followed by prednisone titration in patients with FGN with predominantly mesangial compromise was associated with a substantial reduction of proteinuria and stabilization of kidney function.

ОЦЕНКА ЗНАЧИМОСТИ ВЗАИМОСВЯЗИ МЕЖДУ ПОКАЗАТЕЛЯМИ РЕМОДЕЛИРОВАНИЯ СОСУДОВ, ВОСПАЛИТЕЛЬНОГО ОТВЕТА И ПОЛИМОРФИЗМА ГЕНОВ ДИСФУНКЦИИ ЭНДОТЕЛИЯ У ПАЦИЕНТОВ МУЖСКОГО ПОЛА С ИНФАРКТОМ МИОКАРДА В ЗАВИСИМОСТИ ОТ НАЛИЧИЯ ИЛИ ОТСУТСТВИЯ ГИПЕРТОНИЧЕСКОГО АНАМНЕЗА

Introduction. Endothelial dysfunction, arterial hypertension and surrogate events of myocardial infarction are interrelated phenomena, while the genetic predisposition in these patients is an independent risk factor for the development of cardiovascular pathology. Aim. The aim of the study was to evaluate the significance of the interaction of associations of polymorphic loci of adhesion molecule genes (immunoglobulin VCAM1), MCP-1 chemokine, vascular endothelial growth factor (VEGFA), nitric oxide control enzyme (DDAH1), markers of the inflammatory response, vascular remodeling and endothelial dysfunction in patients with male myocardial infarction, depending on the presence or absence of arterial hypertension in history in the development of myocardial infarction. Material and methods. 667 male patients and 621 practically healthy individuals in the comparison group were examined. Patients underwent determination of general clinical parameters, serum concentrations of monocyte-chemoattractant protein-1 (MCP-1), vascular endothelial growth factor (VEGFA), cytokines (IL-1,6; TNF-α), molecular genetic study, measurement of media intima thickness of the common carotid artery. Selected in the group of patients with myocardial infarction, individuals with or without a history of arterial hypertension. Results and discussion. As a result of a comparative analysis of groups of patients with and without a history of arterial hypertension with a group of healthy individuals, significant differences in the frequencies of genotypes and alleles for the following polymorphic gene loci were revealed: MCP-1, VEGFA, DDAH1, VCAM1. The serum concentration of cytokines (IL-1,6; TNF-α) in patients, regardless of the presence or absence of a history of hypertension, significantly exceeded the level in the comparison group. The VEGFA index in patients with myocardial infarction with arterial hypertension was significantly increased compared to the serum level in patients with myocardial infarction without arterial hypertension. Conclusion. A higher significance of the interaction between indicators of vascular remodeling, inflammation, endothelial dysfunction gene polymorphism in the development of myocardial infarction in patients with a history of hypertension, in contrast to non-hypertensive patients with myocardial infarction, was revealed, which indicates a powerful contribution of arterial hypertension to the etiology and implementation of myocardial infarction.

EFFECTS OF SARS-COV-2 INFECTION ON THE CARDIORESPIRATORY PERFORMANCE BY HYPERTENSION STATUS

Objective: Few data have been published regarding the holistic approach of patients with history of arterial hypertension after Sars-Cov-2 infection. The purpose of our study was to examine the impact of Covid-19 in the cardiopulmonary status of hypertensive patients 3 months after the first day of infection. Design and method: All participants who recovered Covid-19 infection underwent cardiorespiratory exercise test using either Bruce or modified Bruce protocol and transthoracic echocardiogram where all parameters were evaluated. The population was separated into two groups based on history of hypertension. Group I included 62hypertensives and Group II included 134normotensive subjects. Results: A total of 198 patients (51±15 years, 44.4% males, 6.6% history of coronary heart disease) were assessed. Hypertensives had higher BMI (30.47±4.68 vs. 26.20 ±5.36 kg/m2, p<0.001) and BSA (2.03±0.24 vs. 1.91±0.45, p<0.001). They were hospitalized in higher percentage comparing to normotensives(54.8% vs. 35.8%, p<0.01). Out of echocardiographic parameters, diastolic dysfunction parameters including left atrial diameter(40 ±6 vs. 35±5mm, p<0.001) and E/A ratio (0.95±0.34 vs. 1.22±0.43, p<0.001) differed significantly between two groups. LVEF(%) was also significantly impaired (56±10% vs. 58±9%, p:0.04) in hypertensives. This finding was depicted in lower oxygen consumption (VO2 (ml/kg/min)) both maximum (22±4 vs.28±7, p<0.001) and during the 1st minute of recovery (19±18 vs.21±23, p<0.006), metabolic equivalents (METS) at peak, 10±13 vs. 10±3, p<0.001) and HR1st minute recovery (124±23 vs. 138±21 bpm, p< 0.001) comparing to normotensives. Systolic blood pressure(mmHg) at rest (132±13 vs. 125±16, p: 0.002), maximum (189±28 vs. 177±26, p: 0.01) and during the 1st minute of recovery (179±29 vs. 162±25, p: 0.001) was higher while the exercise duration was significantly lower (8±3 vs. 9±3 min, p<0.001) in patients with hypertension. Finally, hypertensive subjects reported higher scores in Borg scale for dyspnea (7±2 vs. 6±2, p:0.02) comparing to normotensives. Conclusions: Current study highlighted the negative impact of Sars-Cov-2 infection in the ability of patients with hypertension to exercise. Therefore, the need for a more comprehensive approach for rehabilitation including the modification of risk factors like hypertension and obesity in post-covid patients is mandatory

Prevalence, Risk Factors, and Economical Cost of Work-Related Injuries Among Olive Workers in the Achaia Region, Greece.

Background Olive gathering involves tree climbing, carrying heavy loads, navigating rough terrain, and using sharp tools. However, little is known about occupational injuries among olive workers. The aim of this study is to evaluate the prevalence and risk factors of occupational injuries among olive workers in a rural Greek area and to assess the financial burden on the health system and insurance funds. Methods A questionnaire was administered to 166 olive workers in the Aigialeia municipality in the Achaia region, Greece. The questionnaire contained detailed information on demographic characteristics, medical history, working environment, protective measures, gathering tools, and type and site of injuries. Moreover, data were recorded about the duration of hospitalization, medical examinations and treatment received, sick leaves, complications, and rate of re-injury. Direct economic costs were calculated for hospitalized and non-hospitalized patients. The associations between olive workers' characteristics, risk factors, and occupational injury within the last year were examined using log-binomial regression models. Results In total, 85 injuries were recorded in 50 workers. The prevalence of one or more injuries in the last year was 30.1%. Factors associated with a higher rate of injury were male gender, age > 50 years, working experience > 24 years, history of arterial hypertension and diabetes mellitus, climbing habits, and non-use of protective gloves. The average cost of agricultural injuries was more than 1400 € per injury. The cost seems to be associated with the severity of the injury, as injuries requiring hospitalization were associated with increased costs, higher cost of medication, as well as more days of sick leave. Losses due to sick leave cause the greatest financial costs. Conclusions Farm-related injuries are quite usual among olive workers in Greece. Injury risk is influenced by gender, age, working experience, medical history, climbing habits, and use of protective gloves. Days off work have the greatest financial cost. These findings can be useful as a starting point to train olive workers to reduce the incidence of farm-related injuries in Greece. Knowledge of risk factors for farm-related injuries and diseases could help the development of proper interventions to minimize the problem.

P224 THE SHARK–FIN THAT EMERGES AND IMMERGES: A CASE REPORT OF TRANSIENT AND REPETITIVE TRIANGULAR QRS–ST–T

Abstract Introduction Shark fin sign, also known as triangular QRS–ST–T waveform (TW), is characterized by a giant R wave (amplitude ≥ 1 mV) resulting from the fusion of the QRS complex, the ST–segment and the T wave and showing triangular morphology. TW pattern is quite uncommon and reveals a life–threatening condition that needs aggressive management. Case presentation: A 45–year–old black man with history of arterial hypertension and without known comorbidities arrived at our emergency department (ED) with out–of–hospital cardiac arrest (OHCA). Return of spontaneous circulation occurred after 11 minutes and 2 direct current shocks. At arrival in the ED, he was hemodynamically stable, electrocardiogram showed atrial fibrillation without repolarization abnormalities, and echocardiogram revealed left ventricular hypertrophy and hypokinesia of the mid–basal inferior wall. Plasma level of electrolytes and high–sensitivity troponin were in range. Sedation in the ED was needed due to psychomotor agitation. He was transferred to the cardiac intensive care unit; no arrhythmias were noted. During the night, electrocardiogram monitoring revealed a progressive ST segment elevation in inferior leads up to a triangular QRS–ST–T giant waveform (“Shark fin sign”), confirmed at 12–lead electrocardiogram. After 3 minutes the electrocardiogram showed a progressive and complete resolution of ST–elevation. Akinesia of the inferior wall was confirmed at echocardiogram. The episode repeated 5 more times in the following 40 minutes, while waiting for the arrival of the Cath lab personnel. Coronary angiography revealed a sub–occlusive mid right coronary artery (RCA) stenosis. Percutaneous coronary intervention with the implantation of one drug eluting stent was performed. After the procedure the patient was hemodynamically stable, and the ECG did not show any other abnormality and no episodes of recurrent ST–elevation occurred. Conclusion The shark fin sign refers to the abrupt total deprivation of blood flow in large areas of myocardium that are seen during coronary thrombotic occlusion or vasospasm. In our case we assisted to transient but repetitive inferior triangular ST–elevation, probably the expression of RCA plaque coronary vasospasm that cause the ECG shark fin sign and OHCA. This sign correlates with high risk of cardiogenic shock, electrical instability, and cardiac arrest, thus requiring prompt and aggressive management.

P333 A RARE CAUSE OF SHOCK: AORTO–PULMONARY FISTULA AS AORTIC ANEURYSM COMPLICATION

Abstract Clinical case A 69–year–old man with right shoulder discomfort, malaise for one hour and hemodynamic instability was admitted to our Emergency Department (ED). The patient had a history of arterial hypertension, diabetes, renal failure on peritoneal dialysis and ischemic cardiomyopathy with preserved ejection fraction treated by angioplasty and stent implantation on right coronary. At first medical contact out of hospital the patient appeared confused with severe hypotension (BP 70/40 mmHg). ECG transmitted to our Cardiology Unit showed sinus tachycardia with repolarization abnormalities consistent with diffuse ischemia. The patient was centralized with clinical suspicion of acute coronary syndrome complicated by cardiogenic shock. In ED, BP was 65/35 mmHg. On physical examination extremities were cold and mottled, crackles in the lower lung zones and turgid jugulars were present. Pulses were weak but present. ECG was repeated and no evolutive signs were detected. Echocardiography finding were: not dilated left ventricle with global systolic function at the lower limits, moderate aortic insufficiency, right ventricle with dimensions at the upper limits and hypocontractile, moderate tricuspid regurgitation, inferior vena cava dilated with preserved inspiratory collapse. Aortic root was non dilatated but aortic arch was 55 mm with no images of dissection flap. At blood test lactates were 4,2 with metabolic acidosis, troponin was just above the upper limit, inflammation indices were negative and electrolytes were in range. Vasopressor support with norepinephrine was started. With the high suspicion of acute aortic disease, CT angiography was performed showing a voluminous aneurysm of the aortic arch of 70x56 mm rupturing into the left pulmonary artery (Figure 1,2). Concomitant bilateral iliac artery dissection was detected. Cardiac and Vascular Surgeons were promptly alerted to plan tan emergent surgical intervention whose complexity was increased by the difficult vascular cannulation for iliac dissection. However, the patient‘s hemodynamic rapidly deteriorated requiring intubation and, after subsequent episodes of cardiac arrest in pulseless electrical activity (PEA), his death was assessed.