Results of currently available randomized trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The 2018 ESC/EACTS guidelines on myocardial revascularization do not recommend PCI in patients with diabetes and SYNTAX score ≥23. We aimed to compare the all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics. The study group comprised consecutive diabetics with angiographically proven three-vessel CAD (≥50% diameter stenosis) and/or unprotected left main CAD (≥50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG between 2008 and 2010. All-cause mortality was ascertained by telephone contacts and/or from Mortality Registries. Using the hospital data system, 5145 patients were screened and 4803 elected not to follow the inclusion criteria. Out of 342 included patients, 177 patients underwent PCI and 165 patients were referred for CABG. Patients with whom CABG was performed were significantly older (64.69±8.8 vs. 62.6±9.4, p=0.03), more often on insulin treatment (91/165=55.2% vs. 26/177=14.7%, p<0.01), had more complex anatomical characteristics i.e. higher SYNTAX scores (32.5 IQR (15) vs. 18.0 IQR (15), p<0.01) and with left main stenosis (70/165=42.4% vs. 7/177=4.0%, p<0.01), compared to patients treated with PCI. The cumulative incidence rates of all-cause death were significantly different between PCI and CABG at 4 years (16/177=9.0% vs. 26/165=15.7%, respectively, log-rank p=0.03). There was a higher incidence of all-cause mortality in PCI patients with intermediate (23–32) and high (≥33) SYNTAX scores compared with those with low (0–22) SYNTAX scores (6/32=18.8% vs. 6/124=4.8%, log-rank p=0.01; 4/21=19.1% vs. 6/124=4.8%, log-rank p=0.02, respectively). On the contrary, patients who underwent CABG displayed similar morality rates irrespective of the SYNTAX scores (SYNTAX 0–22: 5/34=14.7%; SYNTAX 23–32: 9/54=16.7%; SYNTAX ≥33: 12/77=15.6%; log-rank p=0.9). Finally, when compared with CABG, more deaths were observed following PCI with intermediate and high SYNTAX scores (intermediate SYNTAX (23–32) PCI: 6/32=18.8% vs. CABG: 26/165=15.8%, log-rank p=0.94; high SYNTAX (≥33) PCI: 4/21=19.1% vs. CABG 26/165=15.8%, log-rank p=0.87). During a 4-year follow-up, CABG in comparison with PCI was associated with a higher rate of all-cause death, which can be accounted for by older age and comorbidities. In diabetics, our analysis is suggestive that PCI probably should be avoided in patients with SYNTAX ≥23, which is in concordance with the most recent guidelines. Individualized risk assessment as well as quantification of CAD by SYNTAX score remains essential in choosing appropriate revascularization method in patients with diabetes and complex CAD. None

Pulmonary embolism (PE) can lead to multi-organ damage including an acute renal dysfunction which is associated with adverse events and high long-term mortality rate. The aim of our study was to investigate the predictive role of renal dysfunction on intrahospital mortality risk in patients hospitalized due to PE. The study was performed in intensive care units of six university hospitals. The prospective cohort study comprised 665 consecutive patients with acute PE which was confirmed using MDCT. All patients underwent echocardiography examination on admission and blood samples were collected for troponin I (TnI), B-type natriuretic peptide (BNP) and routine laboratory analyses. Based on estimated glomerular filtration rate (GFR), patients were divided into three groups: first with the GFR <30ml/min, second with GFR 30–60 ml/min, and third with GFR >60 ml/min. During hospitalization in the first group the overall incidence of death was recorded in 28 (45.9%), in the second in 42 (18.9%), and in the third in 30 (7.9%) patients (p<0.0001). Pulmonary embolism as a cause of death was recorded in the first group in 18 (29.5%) patients, in the second in 25 (11.3%) and in the third in 17 (4.5%) patients (p<0.0001). Fatal bleeding was recorded in the first group in 1 (1.6%), in the second in 1 (0.5%) and in the third group in 3 (0.8%) patients (p<0.05). There were no significant differences regarding major bleeding frequency among the groups. Multivariate analysis showed that age, comorbidities, hemodynamic status, TnI, and GFR were strongly associated with an overall mortality rate and with death due to PE, while the use of anticoagulation therapy influenced the fatal bleeding rate. After controlling for age, we found that GFR on admission had a significant effect on in-hospital survival. Compared with patients in the third group, those from the second group had more than 2 fold increased mortality risk [OR 2.17 (CI 1.301–3.625), p=0.001], and patients in the first group had 6 fold higher risk of mortality [OR 6.006 (CI 3.487–6.006)]. In the ROC analysis GFR showed significant predictive value for intra-hospital mortality risk in PE patients [AUC= 0.725, 95% CI (0.68–0.78), p<0.001]. The highest sensitivity (64%) and specificity (70%) had GFR “cutoff” value of 59.12/min. Renal dysfunction, on admission, in patients with acute PE is strongly associated with high intrahospital mortality risk and fatal bleeding. The estimation of GFR in these patients is important not only for prediction of the outcome but also for the prevention of bleeding complications, regarding the optimal dosage of anticoagulants. Even though it seems that GFR calculation is not still the clinical routine in PE.

Background: Right ventricular dysfunction (RVD) is a well-known predictor of early death in patients with acute pulmonary embolism and thus early identification of RVD is critical in the risk stratification or management of acute pulmonary embolism (PE). Aim of this study was to investigate a useful role of cardiac biomarker NTproBNP for predicting echocardiographic right ventricular dysfunction in patients with acute pulmonary embolism. Methods: A retrospective analysis was performed in 195 consecutive adult patients with pulmonary embolism from the Serbian University Pulmonary Embolism Registry (SUPER 2015-2019) created by six university clinics: Military Medical Academy (Belgrade), Institute of Pulmonary Diseases (Sremska Kamenica), Clinical Center (Nis), University Clinic Zvezdara, Clinical Center (Kragujevac) and University Clinical Centre of Republic of Srpska (Banja Luka). All patients were divided into RVD group and non-RVD group according to whether there was increase in systolic pressure in right ventricle (>40mmHg) on echocardiography. Odds ratios (OR) and 95% confidence intervals (CI) assessing the risk factors for RVD were assessed by multivariate logistic regression. The ability of the NT proBNP in predicting the RVD was described by the Receiving Operating Curves analysis. Results: The mean age is a strong predictor of echocardiographic RVD in patients with PE. The simple measurements of this cardiac biomarker could be helpful in clinical decision-making or risk stratification in patients with PE.

Tamara Kovačević-Preradović1,2, Bojan Stanetić1,2, Ljiljana Kos1,2, Vlastimir Vlatković2,3 1Department of Cardiology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina, 2Medical School, University of Banja Luka, Banja Luka, Bosnia and Herzegovina, 3Department of Nephrology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina; Case presentation

Uvod. Poremecaji funkcije desnog srca su prediktori lose prognoze kod pacijenata na programu hronicne hemodijalize (HD). U ovoj studiji ispitivana je validnost ehokardiografije u procjeni sistolne i dijastolne funkcije desne komore kod pacijenata na HD. Metode. Istraživanjem je obuhvaceno 30 pacijenata (55±11 godina) na hronicnoj HD kojima su rađene standardna 2D ehokardiografija i tkivni Doppler, prije i nakon HD. Rezultati. Ispitivanje sistolne funkcije desne komore prije i poslije HD je pokazalo da su frakciona promjena povrsine – FAC (36%±11 vs. 34%±11, p=0,464) i amplituda sistolne pokretljivosti anulusa trikuspidne valuvle –TAPSE (25,2mm±4,8 vs. 24,2mm±5, p=0,207) bile u granicama normalnih vrijednosti, nezavisno od smanjenja ukupnog volumena krvi nakon HD, dok je frakciono skracenje – Fs (43,8%±11,6 vs. 39,3%±13,2, p=0,014) bilo znacajno manje nakon HD, sto pokazuje zavisnost ovog parametra od smanjenja cirkulatornog volumena. Tei indeks desne komore pokazao je normalne vrijednosti, nezavisno od smanjenja punjenja desne komore nakon HD (0,59±0,44 vs. 0,69±0,27, p=0,18). Evaluacija dijastolne funkcije desne komore preko brzina transtrikuspidnog protoka (E talas, E/A) pokazala je znacajno smanjenje brzina nakon smanjenja volumena poslije HD, dok je odnos brzina E/E’ (6,02±3,19 vs. 5,66±1,83, p=0,599) ostao u granicama normalnih vrijednosti i nakon HD. Zakljucak. Ehokardiografska procjena sistolne funkcije desne komore pomocu FAC i TAPSE, kao i procjena globalne funkcije miokarda pomocu Tei indeksa, su pouzdane metode kod pacijenata na HD, posto se njihove vrijednosti nisu mijenjale u uslovima smanjenja cirkulatornog volumena nakon HD. Kao pouzdan parametar za procjenu dijastolne funkcije kod pacijenata na HD se može koristiti odnos brzina E/E’, koji se u ovom istraživanju nije znacajno mijenjao usljed smanjenja volumena krvi nakon HD.