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Background: It has recently been shown that cardiac-specific troponin I concentrations in first morning urine samples can be measured with commercially available tests. Due to their accumulation in the first morning urine, scientific papers indicate a potential predictive value for cardiovascular diseases. Therefore, the aim of this study was to compare the concentration of cardiac troponin I in the first morning urine in patients with severe aortic stenosis and the healthy population. Patients and Methods: Blood and first morning urine samples were collected from 34 healthy individuals (17 female) at University Hospital Merkur and 25 patients with severe aortic stenosis (14 female) before surgical treatment at University Hospital Dubrava. Cardiac troponin I and T values were determined using high-sensitivity assays using commercially available Abbott and Roche tests. Results: Patients with severe aortic stenosis had significantly lower troponin I concentrations in the first morning urine samples (0.3 ng/L (0.1–0.6)) as compared to the healthy population (15.2 ng/L (8.4–19.9)) (p < 0.001). There was no statistically significant difference in troponin T concentrations between healthy individuals and patients with severe aortic stenosis. In parallel, both I and T plasma troponin concentrations were significantly higher in patients with severe aortic stenosis. Conclusions: In patients with severe aortic stenosis, cardiac troponin I values in the first morning urine are significantly lower than in healthy subjects. [ABSTRACT FROM AUTHOR]

Introduction: Safety studies of anticoagulant therapy have so far been conducted on many subjects in controlled conditions (i.e., clinically monitored) and demonstrated the noninferiority of new ones over old anticoagulant drugs. Data on the propositions for the presence of symptoms and signs of bleeding among various anticoagulants in the emergency department indicate that these data do not match the data published so far. Aim: The aim of the study was to investigate the differences in the frequency of bleeding and bleeding-related symptoms as a reason for emergency department attendance in patients on anticoagulant therapy. Methods: The study included patients from the emergency department of University Hospital for one year, who were on anticoagulant therapy and who met the inclusion criteria. Out of a total of 595 patients, 409 were on warfarin (68.74%), and the rest were taking direct oral anticoagulants (DOAC): dabigatran 71 (11.93%), rivaroxaban 66 (11.09%) and apixaban 49 (8.23%). Results: Out of 409 patients taking warfarin, 34.4% were adequately anticoagulated with the frequency of bleeding 13.7%, while in 57.2% of patients, PT INR was higher than the reference values with the frequency of bleeding 15.0%. A comparison between all DOAC groups and adequately anticoagulated warfarin patients in the frequency of bleeding and bleeding-related symptoms as a reason for emergency attendance yielded a difference that was marginally statistically significant (Pearson Chi-Square = 7.554, p = 0.052). Conclusion: Monitoring the frequency of bleeding and bleeding-related symptoms in patients on oral anticoagulant therapy as a reason for emergency department attendance may be a new safety and efficacy factor in real-life patient scenarios. [ABSTRACT FROM AUTHOR]

Liver cirrhosis is an increasing public health problem and a major cause of morbidity and mortality. Accordingly, cirrhotic cardiomyopathy, a frequently underdiagnosed condition, is becoming a growing health problem. In the last 20 years, cardioselective biomarkers have been investigated for their diagnostic and prognostic properties for numerous conditions. The aim of this article is to review the literature on the relationship between the most commonly used cardioselective biomarkers (cardiac troponins I and T, N-terminal pro-B-type natriuretic peptide, brain natriuretic peptide, and heart-type fatty-acid binding protein) and the presence, functional stage, and clinical outcomes of liver cirrhosis. Elevated plasma levels of these biomarkers have been reported in patients with liver cirrhosis, and there is mounting evidence on their predictive value for clinical outcomes in this disease. In addition, elevated plasma levels of these biomarkers have been reported in patients before, during, and after liver transplantation, but in fewer studies. Due to their predictive value for clinical outcomes, we advocate the use of these markers in patients with liver cirrhosis and cirrhotic cardiomyopathy, as well as in candidates for liver transplant. [ABSTRACT FROM AUTHOR]

The article presents a retrospective study to evaluate the mitochondrial unfolded protein response, mitophagy and other mitochondrial quality control mechanisms in heart disease and aged heart. It deals with mitochondrial quality control in heart diseases, especially myocardial infarction and heart failure.

Objectives: Diabetes mellitus is a group of metabolic disorders associated with high risk for cardiovascular disease. Although troponins are primarily clinically used for the diagnosis of acute coronary syndrome, they are also used in risk assessment in patients with acute coronary syndrome as well as in a number of other conditions. The aim of this review was to investigate the relationship between hemoglobin A1c and serum troponin in patients with diabetes and cardiovascular events. Methods: Hemoglobin A1c has been chosen as the best clinical indicator of glucose control and risk of micro and macrovascular complications. We investigated cardiac troponins as a group of markers of muscle injury which includes troponin T, troponin I and troponin C. Troponin T and I are specific for myocardial injury, compared to C which is specific for skeletal muscle. Results: In this review, we showed that there was a causal relation between hemoglobin A1c levels and serum troponin concentrations. Hemoglobin A1c has shown to be a positive predictive factor of incidence, mortality and morbidity of conditions such as acute coronary syndrome, arrhythmias, stroke, pulmonary embolism and other conditions that causes troponin elevation by its release in circulation. Conclusions: Chronic hyperglycemia decreases glomerular filtration and consequently decreases troponin elimination and also by affecting the heart microcirculation it leads to microvascular damage and consequently to ischemia which contribute to troponin concentration elevation. Furthermore, correlation between hemoglobin A1c and troponin concentration manifests in their prognostic value for mortality. [ABSTRACT FROM AUTHOR]

Established surgical treatment of aortic stenosis, especially nowadays using a minimally invasive approach through ministernotomy, is still the gold standard in the treatment of the calcifying degenerative disease of aortic stenosis. Considering of the choice of artificial aortic valves, regarding the size and type of prosthesis, available today, it is crucial to monitoring their impact on hemodynamics, to avoid the prosthesis patient mismatch (PPT). Prosthesis patient mismatch occurs when the effective orifice area (EOA) of the inserted prosthetic valve is too small in relation to body size. It is necessary the calculate the patient’s body surface area (BSA) from weight and height and determined of the minimal valve EOA required to ensure an indexed EOA >0.85 cm²/m², select the type and size of prosthesis that has reference values for EOA greater or equal to the minimal EOA value.1,2 Aim: To present hemodynamic impact of different aortic valve prosthesis in a cohort of patients treated with surgical aortic valve repair in our institution, to avoid prothesis-patient mismatch, which may have a significant impact on the long-term results of valve surgery. Study included 115 patients (75 male, 40 female) who underwent isolated aortic valve replacement surgery in our center in the period of January 2022 until January 2023. Patient’s ages ranged from 32 to 81 (M=67.7), average BSA 1.96 m². Average EuroScore logistic was 6.15%. Biological prosthesis was implanted at 108 patients, while a mechanical prosthesis was used in 7 patients. Biological prosthesis that are used are Carpentier-Edwards Magna Ease, Edwards Inspiris Resilia, Medtronic Avalus, in range of 19-29 mm, and mechanical prosthesis St Jude Mechanical, CarboMedics Mechanical TopHat, On-X valves in range of 21-27 mm. The average velocity V max was 2.57 m/s±0.39, and average PPG was 26.92 mmHg±8.34. 17 patients (15.6%) who underwent surgical replacement had postprocedural velocity over the valve >3m/s. [ABSTRACT FROM AUTHOR]

In patients with an implanted aortic valve, the importance of obtaining the maximum values of velocity and flow over the valve is extremely important to obtain adequate data on hemodynamics. However, the variability between the obtained values of ultrasound measurements in the same patients and among different ultrasound specialists has been known for a long time. Also, differences in hemodynamics between different manufacturers of heart valves are known, with a note that the larger the valve, the more favorable the hemodynamic effect on the valve is. By measuring the average internal diameter (ID) of the biological aortic valve in comparison with the body surface area (BSA) and the body mass index (BMI), an adequate instrument can be obtained for the comparison of different cardiac surgical centers. ID could also be a parameter that would allow us to compare different manufacturers of prosthetic aortic valves.1,2 The aim is to show the results of one center over a year, the average ID of the aortic valve and its relationship with body surface area and body mass index. The study included patients from University Hospital Centre Osijek, who were treated for severe isolated aortic valve stenosis from January to December 2022, and who have had a biological aortic valve implanted. Patients who had dilatation of the ascending part of the aorta, who had an implanted mechanical aortic valve, and who had significant aortic regurgitation in addition to aortic stenosis were excluded from data analysis. For adequate assessment and comparison with other centers, the average UP is expressed in relation to body surface area and body mass index. Patient’s data and measured values are shown in Table 1. Data are shown as average ± standard deviation. The presence of a bicuspid aortic valve, the left ventricular ejection fraction, and the presence of postoperative aortic regurgitation were not examined in the presentation of the results. The above should be examined in more detail in future research. Due to the different sizes of biological aortic valves used in clinical practice, we believe that the average internal diameter of the valve (the part through which blood passes) indexed by body surface area or body mass index would be adequate data for comparing different types of aortic valves. Also, it could become one of the parameters for comparison with different cardiac surgery centers. [ABSTRACT FROM AUTHOR]

Introduction: Cardiac troponin I (cTnI) has been shown to have predictive value for cardiovascular incidents in the general population. With the newest 5th generation cTn tests it is possible to measure its concentration in most of population1,2. The aim of this study is to investigate the correlation between plasma levels of cTnI measured by Beckman Coulter high sensitivity test and presence of cardiac pathology (mostly coronary artery disease and heart failure). Patients and Methods: All 100 patients who underwent computed tomography coronary angiography in Dubrava University Hospital from 14th February until 28th June 2022 were included in study. 75 patients had no cardiac pathology (median age 58 y [IQR 48-85], 49% were male) and 25 patients had heart failure or known/new verified coronary artery disease (median age 63 y [IQR 57-72], 60% were male). cTnI was measured using chemiluminescent high sensitivity Beckman Coulter cTnI test. Results: For statistical analysis, we used the non-parametric Mann Whitney U test. The median value of cTnI concentration in the population of patients without verified cardiac pathology is 3.9 ng/L [IQR 2.9-5.15], while the median value of cTnI in patients with heart disease is 7.4 ng/L [IQR 4.2-11.5] P=0.2113. Conclusion: Although cTnI values are slightly higher in patients with cardiac pathology compared to the control group, the difference is not statistically significant. The above can be explained by the good control of cardiovascular risk factors, which is why the most of concentration of cTnI in heart disease group overlaps with the values in the control group. cTnI could be a good screening marker for patients with increased cardiovascular risk. [ABSTRACT FROM AUTHOR]

High sensitive troponin I (hsTnI) is one of the markers of cardiac damage. Its values increase two to three hours after a heart attack and remain elevated for days. Recent studies have shown that kidneys are the main organ of elimination of troponin from blood. Our previous studies have shown that troponin I is removed and concentrated in the first morning urine. Increased blood pressure is one of the most common comorbidities today. By measuring blood pressure, we can see the current value of the pressure, but we do not know what the values are during the rest of the day. The aim of our research was to determine if there is a difference in the concentration of troponin I in urine among patients suffering from hypertension and among healthy individuals. The study involved 20 participants divided into two groups. In the first group were healthy individuals, while in the second group were individuals with hypertension. The first morning urine was sampled and the hsTnI was measured using a highsensitivity test on the Immuno-enzymatic analyser Abbott Architect i1000SR. Within the normotensive group, the mean value of hsTnI in the first morning urine was 14.95 pg/mL, while in the group of participants with elevated blood pressure, the mean value of hsTnI in the first morning urine was 26.59 pg/mL. The difference between these two groups was statistically significant with p=0.0451 (p<0.05). By measuring hsTnI in urine and determining the difference between healthy and those with hypertension, a new diagnostic test for hypertension monitoring and detection would be obtained. [ABSTRACT FROM AUTHOR]

Background: Amyloidosis is a heterogeneous group of diseases characterized by the accumulation of protein deposits. Some of them affect the heart, and the most common are the immunoglobulin light chains and transthyretin. 1-3 Case report: A patient at the age of 60 is admitted to emergency care due to chest pain. She has been taking medicines for dyslipidemia. Chest X ray in ER (emergency room) described a heart enlargement. As a result of the echocardiography, a preserved left ventricular fraction was observed and thickened wall of both ventricles. Coronarography excluded atherosclerotic changes in epicardial vessels. Further treatment of the patient verified an elevated NT-proBNP of 4055.4 pg/ml and a 24-hour proteinuria of 1.52 g. Electrophoresis of proteins and immunofixation indicates elevated lambda light chains. Bone marrow puncture is performed and multiplying plasma cells (15%) were observed. Due to kidney involvement, the kidney biopsy was performed with a positive pathohistological finding of amyloidosis with lambda light chains. The second patient at the age of 57 is admitted to emergency care due to signs of heart failure. He has a history of Hashimoto's disease. Chest X ray in ER has described myopathic heart. 12-lead ECG is characterized by nonspecific conduction disorders. As a result of the echocardiography, slightly lowered left ventricular fraction was observed and thickened walls of both ventricles. Further tests verified an increased NT-proBNP > 8000 pg/ml. Electrophoresis of proteins and immunofixation indicates elevated kappa light chains. Bone marrow puncture is performed and multiplied plasma cells (9%) were observed. Due to skin lesions of the face, the biopsy was performed with a positive pathohistological finding of amyloidosis with kappa light chains. Conclusion: The timely recognition of cardiac amyloidosis is of extreme importance for the treatment and prognosis of the disease. The timely detection of illness provides patients with adequate treatment and significant life extensions. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is characterized by gradual progressive loss of all kidney functions over a period of time. One-fifth of men and one-quarter of women over the age of 65 suffer from CKD. Given the growing incidence of diabetes and hypertension, which are the main causes of this disease, CKD is becoming one of the major global public health issues. Cardiovascular diseases are the leading cause of death in people with CKD, primarily heart-related conditions such as ischemic heart disease and heart failure. High-sensitivity troponins (hs-cTnT, hs-cTnI) are crucial biomarkers used in the detection of cardiac pathology. They are mostly used in the detection of acute coronary syndrome, but elevated values can be also observed in several other conditions. Studies have shown that serum troponin levels are elevated in more than two-thirds of patients with CKD on dialysis, even in those without any cardiovascular pathology. The aim of this review was to examine the literature and to determine the reason for troponin increase in patients with CKD, and to establish whether there is a connection between their increase and the mortality rate. A literature search revealed that patients with end-stage renal disease (ESRD) are at especially high risk of cardiovascular morbidity and mortality. Studies have also found a strong association of high-sensitivity troponins with cardiovascular and all-cause mortality in those patients. On the other hand, even though the function of troponins is very well-known, little is known about their production and excretion from the body. The theory that troponins are excreted by the kidneys is becoming widely accepted in scientific circles. New studies, some of which are Croatian, have demonstrated the presence of troponins in urine, but further research is needed to determine whether it is possible to use troponins in urine as potential biomarkers for cardiovascular and kidney disease. [ABSTRACT FROM AUTHOR]

Background: Nonvalvular atrial fibrillation (AF) is the most common cause of systemic embolism. In rare cases, AF can cause coronary artery embolism which is a rare but important nonatherosclerotic cause of acute myocardial infarction.1 Case report: We report the case of 81-years-old man with permanent atrial fibrillation who presented to our hospital with ST segment elevation myocardial infarction. Coronary angiography verified the embolic occlusion of distal posterolateral branch, which is a branch of the right coronary artery, unsuitable for percutaneous coronary intervention, and no significant atherosclerotic coronary artery disease was found. Transthoracic echocardiography showed a slightly reduced left heart systolic function (EF 45-50%), higher grade diastolic dysfunction and reduced longitudinal strain in inferoposterior segments of left ventricle (-2 to -7). The patient was treated according to the current guidelines. Conclusion: Proper anticoagulant therapy in patients with atrial fibrillation is extremely important in order to prevent thrombus formation, and consequently, the embolism commonly occurring in these conditions. Echocardiographic measurement of the longitudinal strain could indicate a greater possibility of forming the thrombus in patients with impaired cardiac contractility. At present, measurement of the ventricular strain is recommended as a better method for estimating the systolic function from the measurement of the ejection fraction. Using this method, it is better to examine segmental mobility of individual parts of the ventricle and to better evaluate contractility. Also, the strain may point to the hipo(a)contractility of the ventricle. In this case, there is a possibility that in this negligible part of the ventricle, conditions for the thrombus formation were created. Is this the case in this patient we cannot safely claim. Research is needed to confirm this assumption. [ABSTRACT FROM AUTHOR]

Objective: Limited data exists about health-related risk behavior among myocardial infarction (MI) survivors. Healthy lifestyle through physical activity, balanced diet and stress management remains the key recommendation in secondary prevention of cardiovascular events. However, this is challenging process that requires many lifestyle changes supported by organized professional help in the community, to encourage participants in the attempt to improve their health. In this study the relationship between COVID-19 vaccination status and dietary habits, among patients after myocardial infarction, has been evaluated. Positive correlation between vaccine hesitancy and poor diet could be explained by the lack of trust in science, lower level of education and lower health literacy¹. Patients and Methods: From January 2017 to January 2020, data from 1441 patients hospitalized for acute coronary syndrome in Dubrava University Hospital were reviewed. The median age of participants was 64 years, among them there were 409 females, and 974 males. The participants were divided into groups according to their COVID-19 vaccination status and dietary habits, based on diet questionnaire survey. Results: Patients who were not vaccinated less frequently reported daily consumption of fruit, fish, salad, and vegetables, with predominant consumption of pasta, lard, dried meats, white bread and alcohol (p<0.001). Conclusion: In our research, COVID-19 vaccination status in patients after myocardial infarction was associated with better dietary habits. This might imply that vaccinated patients show higher level of health literacy. Future research is necessary to establish which healthcare interventions are required in order to manage and maintain the full potential of health lifestyle improvement in those patients. [ABSTRACT FROM AUTHOR]

Background. Drug-drug interactions (DDIs) are one potential cause of adverse drug events. Very little has been done to study the relationship between potential DDIs in patients (p) with atrial fibrillation (AF) on direct oral anticoagulants (DOACs). Many anticoagulants are eliminated by the kidneys, so they can accumulate if their dose is not adapted to the kidney function. DDI is one particular type of drug error that can result in adverse drug events (ADEs) in exposed patients and was the aim of this study. Materials and Methods. A total of 50 patients with AF on DOACs (25 patients on dabigatran and 25 on rivaroxaban) with normal, mildly or moderately decreased (estimated GFR > 30 mlmin-11.73m2) renal function were included (age 69±7 years, 26M/24F, body mass index (BMI) 35.4±5.1 kg/m2, duration of hypertension 11±5 years, duration of AF 5±2 years, eGFR 58±23 mlmin-11.73m2 (was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula). Results. The 12-month administration of DOACs caused a nonsignificant decrease of eGFR (declined from 58±23 mlmin-11.73m2 to 56±17 mlmin-11.73m2 (p=0.01). All patients have the right dose of DOACs according to eGFR. Patients with AF and DOACs on more than 3 different drugs (20%) such as statins, verapamil and amiodarone were more prone to AE. Conclusion. DDIs are one of the most important problems in every day practice. Coadministration of statins with dabigatran worsens clinical outcomes and a similar interaction might be seen with verapamil and amiodarone. Patients need to be on the right drug/right dose given the kidney function they have, with special care on DDIs. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous coronary intervention (PCI) in chronic total occlusions (CTO) is almost the only growing area of coronary interventional cardiology, where the key to success is true indication and knowledge of all available techniques and materials. Recently, the hybrid approach to CTO interventions proved to be an optimal strategy with the best ratio of success and complications.1 Here, we present experience in University Hospital Dubrava with hybrid PCI approach to CTO. Patients and Methods: Procedures before and after the routine adoption of a hybrid approach to CTO interventions were analyzed. Hybrid approach to CTO is based on routine dual catheter contrast injection in each CTO lesion indicated for PCI, and only depending on the angiographic assessment of the proximal cap, collateral circulation visualization, and the appearance of the distal target by collateral circulation, one of the following strategies is selected: anterograde CTO wire escalation (AWE), anterograde dissection and re-entry with dedicated materials ("Crossboss and Stingray") (ADR), retrograde CTO wire escalation (RWE), or reverse CART (retrograde dissection and re-entry into true lumen). Results: After the process of hybrid approach adoption to CTO interventions during 2016, the number of redo procedures in our center decreased considerably, whereas the success rate increased. In the period after the full adoption of the hybrid approach between July 2017 and July 2018, 52 CTO interventions were indicated, of which 34 on the right coronary artery. Proportions of final PCI strategies were: AWE 46/52, ADR 2/52, RWE 2/52, and reverse CART 2/52. Total success rate was 84.6%. Repeated procedure was indicated in 4/52 patients. Periprocedural complications were rare: 1 coronary perforation needing cardiac surgery and 1 coronary perforation treated in Cath lab without need for cardiac surgery. No periprocedural mortality was recorded. Conclusion: The hybrid approach to CTO PCI proved to be a safe, efficient, and economical method, and should be adopted as a routine approach to CTO intervention. [ABSTRACT FROM AUTHOR]

Objectives: Aortic stenosis is accompanied by progressive left ventricular hypertrophy and fibrosis.1 This study sought to investigate the intensity of potential reversal changes in left ventricular (LV) mass and global longitudinal strain at 3 months follow up after aortic valve replacement surgery. Patients and Methods: A total of 47 patients (age 70.32 ± 7.59 years; 53,2% female) with severe, symptomatic AS were assessed pre-aortic valve replacement (AVR) by echocardiography. Bioprostheses were implanted in 41 patients (87.23 %), and the 6 remaining patients (12.77 %) received mechanical prostheses. Assessment was repeated at three months post-AVR. Results: At three months post-operatively the mean valve gradient had improved (52.05±13.38 mmHg to 13.05±4.36 mm Hg; p<0.001), and indexed LV mass had regressed by 10.85 % (180.91±43.96 g/m2 t o 1 69.18±38.15 g /m2; p<0.001). However, at three months post-AVR, these changes were not accompanied by reduction in LV end-diastolic volume index (57.74±16.78 ml/m2 to 61.45±17.34 ml/m2) and LV endsystolic volume index (25.42±11.09 ml/m2 to 27.05± 12.25ml/ m2; P=0.294). Also, left ventricular ejection fraction (LVEF) did not improve (P=0.66). Nevertheless, septal thickness (P<0.001), posterior (PWT) wall thickness (P=0.001), and relative (RWT) wall thickness (P=0.032) were significantly reduced at follow-up. In addition, average global longitudinal strain (GLS; -15.86±4.25 to -17.16±3.42; P=0.008) and strain measured in two chamber view (2ch; -15.13±5.19 to -16.66±3.87; P=0.013) were also significantly improved while the strain measured in PLAX (-16.83±4.92 to -17.92±4.12; P=0.128) and in four-chamber view (4ch; -15.48±4.64 to -19.06±16.72; P=0.128) showed statistically insignificant improvement at 3 months follow up. There was no statistically significant improvement in diastolic function of LV. Conclusions: Three months post-AVR patients showed significant improvement in LV systolic function measured by GLS but not LVEF as well as improvement in reverse remodeling depicted by regression in LV mass. We did not see improvement in LV diastolic function. [ABSTRACT FROM AUTHOR]