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  • Author: Marijan Bosevski x
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There are two points of view on the interplay between carotid artery disease and diabetes mellitus: Diabetes mellitus has been recognized as one of the main determinants for the presence and progression of asymptomatic and symptomatic carotid artery disease; and carotid intima-media thickness has been defined as a useful tool for risk stratification of this population.

Hyperglycaemia, duration of diabetes, arterial hypertension, cholesterol and inflammatory markers have previously been determined as independent factors for carotid atherosclerosis in diabetes, and aging as its predictor in this population by our own results. This paper focuses on the particularities of risk factors in diabetic patients (especially in type 2) and evidence-based guidelines for the management and risk reduction of these patients with stroke and/or carotid artery disease.

At present, carotid ultrasound is recommended in diabetic patients with cerebrovascular symptoms. Since the prevalence of diabetes increases constantly, we attempt to address refreshment of criteria for screening of carotid artery disease in the diabetic population. It could be recommended for diabetic patients with at least one more risk factors and for diabetic patients above 60 years of age.


There are two points of interplay of chronic kidney (CKD) and peripheral arterial disease (PAD): CKD has been recognized as one of the main factors for presence of PAD, and PAD has been defined as a useful tool for risk stratification of CKD population.

Peripheral arterial disease in patients with CKD is a frequent finding, even in those without symptoms.

This review tends to describe determinants for occurrence of arterial disease in chronic kidney disease patients and necessity for its screening.


Introduction: Homocystein (Hcy) is an amino acid and elevated plasma cause endothelial damage, followed with inflammation in the blood vessels and its progression in atherosclerosis. We aimed to evaluate the correlation between cardiovascular disease and serum homocysteine levels..

Methods: We performed a case control analysis of 212 patients, either for cardiovascular risk stratification or for invasive diagnostics and treatment of cardiovascular ischemic disease (CAD). Patients were divided into 4 groups: Group 1. Patients with low risk for CAD, with no symptoms of CAD and total of 10 years risk <10%. Group 2. High-risk patients with no symptoms of CAD, but 10 years total CAD risk of >20%. Group 3. Patients with symptomatic CAD, where angiography was performed and >50% occlusion of at least one coronary vessel was found. Group 4. Patients with carotid artery disease and documented CAD.

Results: Group 1 consists of 56 subjects, of whom 33 (60%) males and 22 (40%) females. Their mean age was 52.18±8.07 years and their average CAD risk was 5.

Group 2 included 60 patients, with average CAD risk of 23.73. There was a statistically significant difference between plasma homocysteine levels between the control and high CAD risk group, as well as between those with CAD and both CAD and CARD (p=0.001). In the high-risk subjects group, the level of homocysteine correlates albeit weak with the total CAD risk (p=0.04). Homocysteine levels correlate with the WBC count (p=0.02). In the subgroup of smokers with high CAD risk, homocysteine correlates with age, total CAD risk, total cholesterol, BUN (define BUN) and creatinine.

Group 3 consisted of 49 subjects with manifested and angiographically proven CAD, out of whom 80% were males and 20% females, mean age 56.06±9.7 years, with average 2 coronary vessels affected. There were significantly higher homocysteine plasma levels between the control group and the group with manifested CAD (p=0.008).There is no significant difference of homocysteine plasma levels between the high risk group and the group with manifested coronary artery disease (15.03□mol/l vs. 16.38□mol/l). In this group, plasma levels of homocysteine correlate only with the highest level of vessel stenosis (>95%) with (p=0.04).

The study population in group 4 showed a mean of IMT 0.9 +..09 mm and mean Hcy plasma levels of 21 + 11 µmol/L. From the evaluated patients with CAD, 82.9% of patients had elevated level of Hcy. From those, one showed elevated Hcy, 79.4 % had hypertension, 58.9 % had hyperlipidemia, 28.2% had diabetes mellitus as additional risk factors for atherosclerosis. 76.9 % of the patients had increased intima-media thickness; in 58.9 % plaques were detected, while 23 % of the patients had significant stenosis: 10.2 % with intermediate–grade stenosis (50-69%) and 12.8 % with high-grade stenosis (70-99 %). 17.1 % of the patients had normal level of Hcy, and in those ones 62.5 % only had increased IMT. We found linear correlation between IMT and HCy levels (r 0.7, p 0.05).

Case control analysis showed significant higher level of Hcy in the group with CAD and carotid artery disease vs. CAD group (p 0.001).

Conclusion:High plasma homocysteine concentrations are associated with high risk for vascular disease and consequently CAD itself and carotid artery disease, as well, proving its likely role in the development of atherosclerosis on inflammatory and metabolic levels.


Case presentation

Hypertrophic cardiomyopathy (HCM) is the most common and very heterogeneous genetic cardiac disease with a different clinical presentation and prognosis. The overall prevalence of the disease is estimated between 0.05-0.2% of the population. Left ventricular outflow obstruction at rest is present in about 20% of patients. Most of the patients have a normal life expectancy, however high risk patients might develop heart failure, atrial fibrillation, ventricular arrhythmias and sudden cardiac death.

We present the case of 47-year-old Caucasian man who was hospitalized at our clinic with a history of chest pain and shortness of breath on physical activity in the last six months, which caused significant limitations of his life quality. Hypertrophic obstructive cardiomyopathy was diagnosed in 2011, when the patient was put on therapy with beta blocker. Transthoracic echocardiography revealed normal systolic function, presence of systolic anterior mitral valve motion (SAM) with moderate mitral regurgitation (MR). There was a significant concentric left ventricular hypertrophy predominantly located in the ventricular septum. The intraventricular gradient at rest was 77.8 mmHg. MRI of the heart confirmed significant LV hypertrophy with regions of fibrosis at the septum. The patient shortness of breath worsened progressively in the last month (NYHA III) despite optimized medical treatment with maximal beta blocker dose. Surgical approach with septal myectomy was performed with mitral valve repair. There were no operative complications, with excellent postoperative recovery and complete symptoms resolution. Control Doppler echocardiograms revealed LVOT rest gradient reduction to 34 mmHg. The good operative results were still present 9 months after the intervention.

Our case confirmed that septal myectomy with MV repair is an excellent treatment approach in young patient with obstructive hypertrophic cardiomyopathy and mitral valve involvement refractory to medical treatment.


These case reports aim to show that hyperfibrinogenemia is a risk factor for the progression and prognosis of peripheral arterial disease (PAD), in patients with and without diabetes mellitus type 2.

We present a patient with PAD who has type 2 diabetes mellitus, who has previously been repeatedly treated for lower limb ischemia with multiple vascular surgeries performed. A few weeks before admission the patient developed critical lower limb ischemia, which was treated with an iliaco-popliteal and femorofemoral bypass. The patient had elevated serum fibrinogen values. In the current admission, renewed left limb ischemia was diagnosed, and surgically evaluated with a recommendation for amputation of the left limb as a surgical recommendation. Our second patient had a stable intermittent claudication, dyslipidemia and hyperfibrinogenemia. He was successfully treated for those risk factors. Regular monitoring of the patient showed improved claudication distance and quality of life

Our case reports, supported by a literature review, demonstrate that hyperfibrinogenemia is a possible risk factor for progression and the prognosis of PAD.

Occurrence and Progression of Coronary Artery Disease in Patients with Type 2 Diabetes

Aim. The aims of reaserch project were to determine the predictive role of diabetes type 2 as independent factor and/or in correlation with others in occurrence, extent and prognosis of CAD, as well as to evaluate the feasibility, safety and the effect of an aggressive control of risk factors, multifactoral medicament therapy and application of revascularization procedures in individuals prone to or with already manifested diabetes.

Material and methods. The research covered prospectively 30 individuals with type 2 diabetes (age 53.3 ± 3.1, mean diabetes duration 7.5 years) with presence of insulin resistance syndrome's componentes and retrospectively/ prospectively 333 patients with manifested diabetes type 2 and CAD (age 60.4 ± 8.23, mean diabetes duration 8.5 years).

Results. History of myocardial infarction corelates with obesity and hypoHDLemia. Dyslipidemia with the presence of chest pain in objective clinician state, and symptom of angina grade CCS3 correlates with presence of microvascular complications, and CCS1 angina with use of insulin in diabetes treatment. Gensini score, angiographicly estimated, was in multivariate relation with dyslipidemia and systolic pressure. Among pts undergone coronary surgery as predictor of by pass graft stenosis was found physical inactivity, and among pts undergone percutaneus revascularization, carotid IMT for in stent restenosis.

Conclusions. High prevalence of insulin resistance syndrome' components: arterial hypertension and dyslipidemia were found in type 2 diabetes patients, who did not presented CAD. Symptomatic CAD, occurred in 6.7% od these pts was only in relation with the hypoHDLemia.


Background: We wanted to evaluate the presense of myocardial ischaemia in asymptomatic patients with high cardiovascular risk, the influencing clinical and laboratory factors and the impact of ischaemia on final management decision.

Material and methods: We evaluated 60 asymptomatic patients with high CV risk, who underwent SPECT myo-cardial perfusion imaging (MPI) for detection of suspected CAD. We used the 17 segment model for quantitative and semiquantitative scan perfusion and function analysis using perfusion scores. All patients had full blood laboratory analyses including lipid values, presence of albuminuria, rest and stress ECG. Logistic regression analysis was used to assess the impact of clinical and laboratory parameters on myocardial ischaemia prevalence.

Results: Stress-inducible ischaemia was found in 19 pts (33%), fixed defects were found in 13% and mixed defects in 9% of cases. The average ischaemia amount was 10%. Mild ischaemia was found in 12 patients (64%) - summed stress score (SDS) < 4, moderate ischaemia in 5 patients (26%) - SDS 5-7 and severely abnormal scans in 2 patients (10%) - SDS > 7. Severe ischaemia was only related to the duration of diabetes. Six pts with severe ischaemia had ST depression > 2 mm on stress study, and a higher wall motion index and LVEF fall > 5% during stress study (p < 0.01). Stepwise logistic regression analysis for prediction of stress-induced ischaemia showed OR 2.4 (95% CI 1.7?3.6) for stress-induced ECG changes and OR 3.9 for presence of DM over 10y (95% CI 2.3?6.6). Seven patients with ischaemia > 10%, were referred for coronary angiography.

Conclusions: MPI is a valuable method for preclinical assessment of myocardial ischaemia in patients with high CV risk, which can improve prognosis and guide treatment decision.


Background: The aim was to evaluate the Nt-proBNP discriminatory role between symptomatic and asymptomatic patients with severe aortic stenosis.

Methods: 187 patients with severe valvular aortic stenosis, with normal EF > 50%, were included, 61 asymptomatic and 126 symptomatic. We used clinical, laboratory (Nt-proBNP) and echocardiographic parameters. Endpoints of monitoring (occurrence of event) were: the onset of symptoms in asymptomatic patients and death in both groups.

Results: The symptomatic group with severe AS had a significantly higher means of Nt-proBNP, in comparison with the asymptomatic group. Nt-proBNP was a significant predictor for the risk of event occurrence (HR 1.4). In the group of severe AS without CAD (n = 101), the subgroup with Nt-proBNP above the cut-off value, took significantly higher percentage of patients with chest pain, fatigue and syncope. In the group with Nt-proBNP above the cut-off value, we had a significantly higher percentage of patients with severe AS without CAD, compared to those with CAD (n = 142). Nt-proBNP was negatively correlated with AVA and LVEF, whether the positive correlation was expressed for: LVEDd, LVEDs, IVSd, AV_Vmax, AV_MaxGrad, LVM and LA. Patients with Nt-proBNP above the cut-off, had a significantly lower event free survival, compared to patients with Nt-proBNP below the cut-off (n = 187; n = 101).

Conclusion: The Nt-proBNP cut-off> 460 pg/ml was confirmed as a useful tool in the determination of event free survival in patients with severe AS. Nt-proBNP not only had relevance in the assessment of the severity of the disease, but also was a significant predictor for the risk of event occurrence.


Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a preventable cause of in-hospital death, and one of the most prevalent vascular diseases. There is a lack of knowledge with regards to contemporary presentation, management, and outcomes of patients with VTE. Many clinically important subgroups (including the elderly, those with recent bleeding, renal insufficiency, disseminated malignancy or pregnant patients) have been under-represented in randomized clinical trials. We still need information from real life data (as example RIETE). The paper presents case series with VTE in special conditions, including cancer associated thrombosis, malignant homeopathies, as well in high risk population.