Takotsubo syndrome (TTS) still remains as an enigmatic phenomenon. In particular, long-term challenges (including clinical recurrence and persistent symptoms) and specific entities in the setting of TTS have been the evolving areas of interest. On the other hand, a significant gap still exists regarding the proper risk-stratification of this phenomenon in the short and long terms. The present paper, the second part (part-2) of the consensus report, aims to discuss less well-known aspects of TTS including specific entities, challenges after recovery and risk-stratification.

In the recent years, there has been a burgeoning interest in Takotsubo syndrome (TTS), which is renowned as a specific form of reversible myocardial dysfunction. Despite the extensive literature available on TTS, clinicians still face several practical challenges associated with the diagnosis and management of this phenomenon. This potentially results in the underdiagnosis and improper management of TTS in clinical practice. The present paper, the first part (part-1) of the consensus report, aims to cover diagnostic and therapeutic challenges associated with TTS along with certain recommendations to combat these challenges.

Vitamin D plays significant role in calcium metabolism and in bone and vascular calcifications. To investigate the association between vitamin D level, arterial hypertension, arterial stiffness and coronary calcifications detected by MSCT. Method: A 2 female case report comparative to each other investigated the correlation between vitamin D serum level, blood pressure, arterial stiffness and severity of the coronary calcification using MSCT diagnostic tool estimating the calcium score. The first case report showed that decreased level of vitamin D is correlated with increased blood pressure, increased arterial stiffness and with a severe coronary calcifications. The second case report showed normal blood pressure, normal vascular age and low calcium score in a no-defficient vitamin D female. Vitamin D has impact on blood pressure, arterial stiffness, coronary calcifications and coronary heart disease. The lower vitamin D, the higher arterial blood pressure, arterial stiffness and coronary calcium score.

Objective Real-life management of patients with hypertension and chronic kidney disease (CKD) among European Society of Hypertension Excellence Centres (ESH-ECs) is unclear : we aimed to investigate it. Methods A survey was conducted in 2023. The questionnaire contained 64 questions asking ESH-ECs representatives to estimate how patients with CKD are managed. Results Overall, 88 ESH-ECS representatives from 27 countries participated. According to the responders, renin-angiotensin system (RAS) blockers, calcium-channel blockers and thiazides were often added when these medications were lacking in CKD patients, but physicians were more prone to initiate RAS blockers (90% [interquartile range: 70-95%]) than MRA (20% [10-30%]), SGLT2i (30% [20-50%]) or (GLP1-RA (10% [5-15%]). Despite treatment optimisation, 30% of responders indicated that hypertension remained uncontrolled (30% (15-40%) vs 18% [10%-25%]) in CKD and CKD patients, respectively). Hyperkalemia was the most frequent barrier to initiate RAS blockers, and dosage reduction was considered in 45% of responders when kalaemia was 5.5-5.9 mmol/L. Conclusions RAS blockers are initiated in most ESH-ECS in CKD patients, but MRA and SGLT2i initiations are less frequent. Hyperkalemia was the main barrier for initiation or adequate dosing of RAS blockade, and RAS blockers' dosage reduction was the usual management.

OBJECTIVE Real-life management of hypertensive patients with chronic kidney disease (CKD) is unclear. METHODS A survey was conducted in 2023 by the European Society of Hypertension (ESH) to assess management of CKD patients referred to ESH-Hypertension Excellence Centres (ESH-ECs) at first referral visit. The questionnaire contained 64 questions with which ESH-ECs representatives were asked to estimate preexisting CKD management quality. RESULTS Overall, 88 ESH-ECs from 27 countries participated (fully completed surveys: 66/88 [75.0%]). ESH-ECs reported that 28% (median, interquartile range: 15-50%) had preexisting CKD, with 10% of them (5-30%) previously referred to a nephrologist, while 30% (15-40%) had resistant hypertension. The reported rate of previous recent (<6 months) estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) testing were 80% (50-95%) and 30% (15-50%), respectively. The reported use of renin-angiotensin system blockers was 80% (70-90%). When a nephrologist was part of the ESH-EC teams the reported rates SGLT2 inhibitors (27.5% [20-40%] vs. 15% [10-25], P = 0.003), GLP1-RA (10% [10-20%] vs. 5% [5-10%], P = 0.003) and mineralocorticoid receptor antagonists (20% [10-30%] vs. 15% [10-20%], P = 0.05) use were greater as compared to ESH-ECs without nephrologist participation. The rate of reported resistant hypertension, recent eGFR and UACR results and management of CKD patients prior to referral varied widely across countries. CONCLUSIONS Our estimation indicates deficits regarding CKD screening, use of nephroprotective drugs and referral to nephrologists before referral to ESH-ECs but results varied widely across countries. This information can be used to build specific programs to improve care in hypertensives with CKD.

Objective: To investigate the arterial stiffness and risk factors in adolescence. Arterial stiffness often (AS) results from the degenerative process of the media layer of elastic arteries causing rigidity of the arteries. Arterial stiffness increases with age and it is associated with several risk factors as a disease predictor. But, arterial stiffness can be also increased in a healthy arteries as well. The increased sympathetic activity promotes vasoconstriction of resistant blood vessels i.e. arteries and arterioles that result in peripheral vasoconstriction. Adolescence age is the most important period of life for promoting future health. The certain dynamic risk factors in adolescence like, emotional dysregulation, psychological family stress, education pressure, lack of sleep, gambling, substance abuse, smartphone overuse and obesity can cause arterial stiffness. Design and method: The prospective open randomized study was designed. Adolescence age between 10 and 19 years have been investigated for increased arterial stiffness and risk factors. The inclusion criteria was healthy adolescence, while exclusion criteria was any disorder present. Arterial stiffness, non-invasive blood pressure and pulse wave datas have been measured using Agedio device. The risk factors were evaluated in every subject. The vascular age have been outlined as the final measure. Results: The preliminary results indicate the increase of Augmentation Index and Coefficient of Reflection. The average percentage of Augmentation Index was 40% and Coefficient of Reflection 65% (normal value 28% and 60% respectively). The main risk factors were educational pressure, lack of sleep and smartphone influence. The vascular age was on average, 3 years higher than biological age. Conclusions: Arterial stiffness in adolescence is increased mainly by peripheral vasoconstriction, manifested with Augmentation index and Coefficient of wave Reflection.

Aim To investigate the benefit of high-dose lipophilic statin therapy on cardiac remodelling, function and progression of heart failure (HF) in patients with ischemic heart disease. Methods A total of 80 patients with ischemic HF diagnosis were followed during 6 months, and they were divided in two groups. First group (n=40) was treated by high-dose lipophilic statin therapy (atorvastatin 40 mg) and conventional therapy for HF, while the second group (n=40) had no atorvastatin in the therapy. Results In the beginning of study, from all of the observed parameters, only the ratio of flow rates in early and late diastole (E/A ratio) differed between the test groups (p=0.007). After six months, a statistically significant increase in left ventricular end-diastolic diameter (LVIDD) in patients who had not been treated with atorvastatin was found. In the patients treated with atorvastatin, there was a significant reduction in basal right ventricle diameter in diastole and systole (p<0.001 and p<0.001, respectively), and in tricuspid annular plane systolic excursion (TAPSE) (p<0.001); there was a reduction in LVIDD (p<0.001), and an increase of ejection fraction of the left ventricle according to Teicholtz and Simpson (p<0.001 and p<0.001, respectively). Also, there was an increase of deceleration time of early diastolic velocity (DTE) (p<0.05) and a decrease of isovolumic relaxation time (IVRT) (p<0.001). Conclusion The reduction in the right and left ventricle diameters was noted after the six-month atorvastatin therapy. Atorvastatin in the therapy resulted in increased EFLV and better systolic function and should be a part of a therapeutic modality of HF.

Background: Smoking is one of the most significant modifiable exosomes risk factors for rheumatoid arthritis (RA) (1). Studies suggest that 25-30% of people with RA in Denmark smoke (2). This is almost twice as many as in the background population in Denmark. People with RA have a significant increased risk of severe comorbidity including cardiovascular disease. In addition, there are indications that smokers with RA have a poorer effect of the medical inflammatory treatment compared to non-smokers, and consequently more difficult to achieve remission of the disease activity (3). Tobacco addiction is complex and can be a challenge in smoking cessation. In addition to physiological dependence, habits and social and environmental factors may influence addiction. Tobacco smoking is associated with an addiction to nicotine and it is unexplored how this addiction appears in people with RA. Objectives: The aim of this study was to examine from the patient’s perspective how tobacco addiction appears in people with rheumatoid arthritis. Methods: We conducted a qualitative study based on a hermeneutics approach. People with RA who previously had participated in a randomized controlled study (4) about smoking cessation conducted at the Center for Rheumatology and Spine Diseases at Rigshospitalet, Denmark were recruited for semi-structured interviews. Results: In total, 12 people with RA (50% female) were included in the study. The median age was 62 years and median RA disease duration was 12 years. The degree of physical dependence measured by Fagerstroms Test for Nicotine dependence (FTND) was on average: 4.9 (score: 0-10, 0=nonphysical dependence). Three categories of how tobacco addiction appeared emerged during the analysis: 1) It develops into ingrown habits referring to the fact that smoking already in adolescence contributes to the development of specific physical, mental and social smoking behavior. Not all individuals considered themselves addicted to nicotine as they did not necessarily connect the nicotine to the ingrown habits. 2) The body craves for nicotine referring to nicotine proved calming, while a lacking or insufficient dose caused withdrawal symptoms. Furthermore, smoking became a habit where a craving for smoking occurred in certain situations. 3) Ambivalence – for and against referring to the physical dependence and smoking habits making a smoking cessation difficult. Dependency to nicotine and challenges to quit smoking led to a feeling of ambivalence and a lack of control. Conclusion: Tobacco addiction appeared as a physical dependence and a habit, which, during a smoking cessation, led to ambivalent feelings. Therefore, based on this study, there is still a need for health professionals to talk to patients about smoking. But also, a need to articulate the complexity of addiction in order to support for smoking cessations. Information should be strengthened in the clinical practice in relation to nicotine’s implication in tobacco addiction as well as the consequences of tobacco smoking for individuals with RA. References: [1]Scott DL, Wolfe F, Huizinga TW. Lancet. 2010 ### [2]Loppenthin K, Esbensen BA, Jennum P, Ostergaard M, Tolver A, Thomsen T, et al. Clin Rheumatol. 2015. ### [3]Roelsgaard IK, Ikdahl E, Rollefstad S, Wibetoe G, Esbensen BA, Kitas GD, et al. Rheumatology (Oxford). 2019. ### [4]Roelsgaard IK, Thomsen T, Ostergaard M, Christensen R, Hetland ML, Jacobsen S, et al. Trials. 2017;18(1):570.### Disclosure of Interests: None declared

Objectives To describe and explore differences in formal regulations around sick leave and work disability (WD) for patients with rheumatoid arthritis (RA), as well as perceptions by rheumatologists and patients on the system’s performance, across European countries. Methods We conducted three cross-sectional surveys in 50 European countries: one on work (re-)integration and social security (SS) system arrangements in case of sick leave and long-term WD due to RA (one rheumatologist per country), and two among approximately 15 rheumatologists and 15 patients per country on perceptions regarding SS arrangements on work participation. Differences in regulations and perceptions were compared across categories defined by gross domestic product (GDP), type of social welfare regime, European Union (EU) membership and country RA WD rates. Results Forty-four (88%) countries provided data on regulations, 33 (75%) on perceptions of rheumatologists (n=539) and 34 (77%) on perceptions of patients (n=719). While large variation was observed across all regulations across countries, no relationship was found between most of regulations or income compensation and GDP, type of SS system or rates of WD. Regarding perceptions, rheumatologists in high GDP and EU-member countries felt less confident in their role in the decision process towards WD (β=−0.5 (95% CI −0.9 to −0.2) and β=−0.5 (95% CI −1.0 to −0.1), respectively). The Scandinavian and Bismarckian system scored best on patients’ and rheumatologists’ perceptions of regulations and system performance. Conclusions There is large heterogeneity in rules and regulations of SS systems across Europe in relation to WD of patients with RA, and it cannot be explained by existing welfare regimes, EU membership or country’s wealth.

Abstract Aims Raised blood pressure (BP) is the biggest contributor to mortality and disease burden worldwide and fewer than half of those with hypertension are aware of it. May Measurement Month (MMM) is a global campaign set up in 2017, to raise awareness of high BP and as a pragmatic solution to a lack of formal screening worldwide. The 2018 campaign was expanded, aiming to include more participants and countries. Methods and results Eighty-nine countries participated in MMM 2018. Volunteers (≥18 years) were recruited through opportunistic sampling at a variety of screening sites. Each participant had three BP measurements and completed a questionnaire on demographic, lifestyle, and environmental factors. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or taking antihypertensive medication. In total, 74.9% of screenees provided three BP readings. Multiple imputation using chained equations was used to impute missing readings. 1 504 963 individuals (mean age 45.3 years; 52.4% female) were screened. After multiple imputation, 502 079 (33.4%) individuals had hypertension, of whom 59.5% were aware of their diagnosis and 55.3% were taking antihypertensive medication. Of those on medication, 60.0% were controlled and of all hypertensives, 33.2% were controlled. We detected 224 285 individuals with untreated hypertension and 111 214 individuals with inadequately treated (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) hypertension. Conclusion May Measurement Month expanded significantly compared with 2017, including more participants in more countries. The campaign identified over 335 000 adults with untreated or inadequately treated hypertension. In the absence of systematic screening programmes, MMM was effective at raising awareness at least among these individuals at risk.

Title of Days of AMNuBiH 2018” and “SWEP 2018” is “Ethical Dilemmas in Science Editing and Publishing”. Why? If one wants to create a scientific work, must have on his mind that creating a scientific work requires creativity and openness, honesty, trust, and obeying the ethical principles for writing a scientific paper. While working on a an biomedical research involving human subjects medical workers should have on mind that it is the duty of the physician to remain the protector of the life and health of that person on whom biomedical research is being carried out. The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects.

Introduction: The effect of statins on risk of heart failure (HF) hospitalization and lethal outcome remains dubious. Aim: To investigate whether statin therapy improves clinical outcomes in patients hospitalized for ischemic heart failure (HF), to compare the efficacy of lipophilic and hydrophilic statins and to investigate which statin subtype provides better survival and other outcome benefits. Material and Methods: Total amount of 155 patients in the study were admitted to the Clinic for Cardiology, Rheumatology and Vascular diseases in Clinical Center University of Sarajevo in the period from January 2014- December 2017. Inclusion criteria was HF caused by ischemic coronary artery disease upon admission. For each patient the following data were obtained: gender, age, comorbidities and medications on discharge. New York Heart Association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. The patients were followed for a period of two years. Outcome points were: rehospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. Results: Overall, 58.9% of HF patients received statin therapy, with 33.9% patients receiving atorvastatin and 25.0% rosuvastatin therapy. The most frequent rehospitalization was in patients without statin therapy (66.7%), followed by patients on rosuvastatin (64.1%), and atorvastatin (13.2%), with statistically significant difference p = 0.001 between the groups. Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy, 12.8% in patients on rosuvastatin therapy and 3.8% in patients on atorvastatin therapy (p = 0.004). Conclusion: Lipophilic statin therapy is associated with substantially better long-term outcomes in patients with HF.