Endocarditis is a rare and serious complication of brucellosis and is the main cause of death in this pathology. Diagnosis requires a high level of attention, and is based on the association of epidemiological, clinical and serological elements. Echocardiography plays a crucial role in early diagnosis, as well as in identifying a predisposition to heart disease and local complications typical of this pathology. This case study follows a case of Brucella endocarditis involving the aortic valve, in a 39-year-old male, diagnosed in October 2010. Despite being given complete pharmaceutical treatment, in this instance emergency heart surgery was necessary, due to an inability to control the infection and subsequent changes in the patient’s condition, which were leading to congestive heart failure. Aggressive treatment, with surgery performed during a period of active infection, produced good results in the eradication of infection, and in preventing fatal complications. The patient is now fully recovered, and was given triple therapy for brucellosis according to existing recommendations.

Methods and results Out of a total 33 patients with moderate severe to severe asymptomatic aortic stenosis (mean aortic area EOA 0.9±0.34 cm2) we followed up 31 patients (two were excluded) during the 12 months’ period by clinical, transthoracic echocardiogram and treadmill stress testing. 18 (58%) patients discontinued the test due to limiting symptoms, and had severe aortic stenosis (EOA ≤0.8 cm2).

We investigated the insulin-like growth factor 1 (IGF-1)/growth hormone (GH) axis in patients with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). This was a prospective study that was carried out in 2010. The study included an analysis of levels of GH, insulin, IGF-1, and its binding protein (IGFBP-3) in 43 patients with STEMI, 30 patients with NSTEMI, and 30 healthy individuals (control group). Blood samples for all analyses were taken within 24 h of admission. We found lower IGF-1 and IGFBP-3 levels and higher GH, C-reactive protein, glucose, and glycol glycosylated hemoglobin (HbA1c) levels in both STEMI and NSTEMI patients compared with controls. Insulin levels and the insulin resistance index did not differ between NSTEMI patients and controls. A significant difference in GH values was observed between the STEMI and NSTEMI groups (P<0.05). The increased GH levels in the STEMI compared with the NSTEMI group are consistent with a stronger inflammatory response in patients with STEMI.

Cardiologia CROATICA Background: Modern approach to evaluation of left ventricular diastolic function should be based on determining the value of left ventricular filling pressures, which are the actual parameters of the symptoms and/or signs and prognosis in acute myocardial infarction. Aim: Compare parameters of left ventricular filling pressure in patients with acute myocardial infarction (AMI) with anteroseptal and inferior localization. Methods: Prospective study of 60 patients (37 men, mean age 59 ±10 years) with acute myocardial infarction were divided into two groups. The first group consists of patients with myocardial infarction, anteroseptal localization (27 patients) and the second group consists of patients with myocardial infarction inferior localization (33 patients). Accompanied by the ratio of early diastolic filling velocity of mitral flow velocity and early mitral annular filling (E/E’), the difference between the duration of flow reversal in the pulmonary veins and duration of the mitral A wave flow (PVA-MVAdur), and the relative velocity of early diastolic filling mitral flow and color M mode display of early mitral flow (E/Vp) of the left ventricle as determined by continuous (mitral flow) and pulsed color Doppler echocardiographic technique (flow in the pulmonary veins and the mitral ring velocities). Results: The value of E/E’ ≥13 was found in 14 patients (8 patients in the first group, and 6 patients in the second group), while the value of 8 <E/E’ <13 in 25 patients. The value of E/E ‘<8 was found in 21 patients. The average value of Avg=E/E’ for the first group of patients was Avg=10.87 and the second group of subjects was Avg=9.39 was found to be a statistically significant difference (p <0.05) between the two groups, using the Student’s t-test. Using Pearson’s correlation coefficient we found that there was a significant correlation between E/E’ and E/Vp in all patients (P = 0.66), whereas there was no difference in the correlation of these two proposed relationships between groups (P = 0.70 and P = 0.67). When comparing the ratio E/E’ and PVA-MVAdur and E/Vp and PVA-MVAdur, Pearson correlation coefficient at a given group of 60 subjects showed no statistically significant correlation of this data. For PVA-MVAdur Pearson correlation coefficient has medium correlation compared to infarcted zone with inferior localization for the patients with E/E’ ≥13. Conclusions: Comparison of parameters of yhe left ventricular filling pressures, it is proved that the left ventricular filling pressures in acute myocardial infarction is increased. There is a high correlation between the filling pressures and infarcted zone in the AMI anteroseptal localization in relation to the inferior localization of E/E’ and E/Vp.

Background and aim: Hormonal and immunological aspects of acute myocardial infarction (AMI) are in the past decade in focus of interest of researchers. We investigated concentrations of insulin like growth factor 1 (IGF-1), growth hormone (GH), insulin and markers of insulin resistance as like as inflammatory markers in order to find out their role and relationship in AMI. Material and methods: A prospective study was performed at University Clinical Center Tuzla from January to October 2010. Study group was consisted of 75 patients with AMI. There were 30 healthy controls. Blood samples were taken within first 24 hours of admission and analyzed for GH, IGF-1 and insulin at the Department of Nuclear Medicine. Glucose, glycolised hemoglobin HbA1c, C-reactive protein (CRP), fibrinogen etc. were analyzed by standard methods at Biochemistry unit. Results: Median of GH in the study group (0,96) was higher than in controls (0,26); p <0.001. Difference in median’s concentrations of IGF-1 between AMI and controls was also significant (123 vs. 132 respectively; p< 0,05) as like as IGF-1/GH ratio (p <0.001). Concentration of insulin was higher in study (9,5) than in control group (7,1), but without statistical significance. Despite this, we found out significant difference between concentrations of glucose, HOMA-IR and HbA1C among groups. Levels of CRP and fibrinogen were significantly higher in AMI. Simple linear correlation analysis showed positive correlation between GH and CRP (R 0,350255, p< 0,005). Conclusions: GH resistance in AMI (Low IGF-1/GH) is probably result of inflammatory/immunological response and therefore could be prognostic marker.

SAAEETAK: PoremeEaj dijastoliEke funkcije lijeve klijetke (LK) je jedan od prvih poremeEaja funkcije LK, koji se registriraju prije poremeEaja regionalnog kontraktiliteta, EKG promjena i bola u prsnom koπu, πto bitno mijenja prognozu pacijenata s akutnim koronarnim sindromom. PoremeEaj relaksacije LK Eesto se registrira u pacijenata s akutnim infarktom miokarda (AIM), a poremeEaj krutosti LK u pacijenata s AIM prednje stijenke. Najizraaeenija dijastoliEka abnormalnost uzrokovana ishemijom miokarda je produaeena i usporena relaksacija miokarda. Ehokardiografske tehnike omoguEavaju evaluaciju dijastoliEkog punjenja obje pretklijetke i klijetke.

BACKGROUND: Heart failure is a common disease that requires frequent and long hospitalizations, the active participation of health workers and family members in the care of such patients, and it leads to reduction of physical activity and lifestyle changes with the patient, which significantly affects the quality of life of patients with heart failure. OBJECTIVE: To determine the quality of life of patients with heart failure in relation to severity of the clinical features. RESPONDENTS AND METHODOLOGY: Analysis of life quality was performed for 120 patients suffering from heart failure, both genders, all age groups in relation to severity of the clinical features. Patients were divided into 4 groups according to NYHA classification of heart failure. The control group consisted of 10 subjects who do not suffer from heart failure. Assessment of quality of life was performed using the SF-36 questionnaire which consists of 8 segments classified in the dimension of physical and mental health. RESULTS: Study group consisted of 130 participants with heart failure had 66 (51%) of male, and other were females, divided into 4 NYHA groups, where every group had 30 subjects (23.1%), and one control group of 10 subjects (7.7%). The analysis of gender and age distribution within the groups found no statistically significant difference (X2=1.70; df=4; p=0.79), (ANOVA; F=0.74; p=0.57). The values of SF-36 score expressed as the median in the control and 4 NYHA groups were decreasing as the functional class progressed. The Spearman Correlation Coefficient showed that there is a strong negative correlation between the scores of SF 36 (total, segments and dimensions) and heart failure expressed through the NYHA classes. CONCLUSION: Quality of life in patients with heart failure was exacerbated and associated with severity of the clinical features.

BACKGROUND The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy was first described in Japan approximately 20 years ago (Satoh and coworkers, 1991). It was later described elsewhere as well and is being increasingly recognized. Takotsubo Cardiomyopathy characterized by transient apical and midventricular LV dysfunction in the absence of significant coronary artery disease that is triggered by emotional or physical stress. Its name refers to a contraption used for catching octopuses and suggests the aspect assumed by the ventricle during the systole due to the typical regional wall motion abnormalities that occur after onset. Takotsubo cardiomiopathy occurring mainly in post-menopausal women, echocardiography in the Takotsubo cardiomyopathy reveals during its acute phase a ballooning resembling the octopus trap configuration--the apex and lateral ventricular segments are hypokinetic while the base is hyperkinetic--along with reduced ejection fraction. Ventricular function will usually recover within a few days/weeks. OBJECTIVE AND PURPOSE The objective of this study is to determine the role of echocardiography in detecting and establishing the diagnosis of Takotsubo cardiomiopathy in patients with suspect acute coronary syndrome and during the follow up period. PATIENTS AND METHODS The study covered 12 adult patients the majority are women (92%) who were subjected to echocardiography evaluation as part of the clinical cardiological examination due to suspect acute coronary syndrome or Takotsubo Stress Cardiomyopathy. The patients were examined on an ultrasound machine Philips iE 33 x Matrix, ATL HDI and GE Vived 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated clinical characteristics, LV systolic function, biomarkers, and prognosis in all patients. RESULTS Among all the patients referred for Echocardiographic evaluation for left ventricle motion abnormalities with suspect acute coronary syndrome, the echo exam revealed 12 patients with acute apical ballooning which involving the left ventricular apex and med-ventricle. The triggering factors were physical stress in 4 patients (33%) and emotional stress in 8 patients (67%). The initial symptom was chest pain (n = 8, 67%) rather than dyspnea (n = 4, 33%). An initial electrocardiogram (EKG) presented ST-elevation (n = 10, 83%) and T-wave inversion (n = 2, 17%), other data are shown on Table 2. Among the all patients 8 of them (66%) had normal EF by the 1st follow up (47 +/- 51 days), and the rest 4 patients (34%) had normal EF by 68 +/- 96 days. CONCLUSION Widespread uses of echocardiography has contributed to more frequent recognition of Takotsubo stress cardiomyopathy and highlight the central role of this noninvasive method from an echocardiographers' perspective.

Direct coronary stenting in reducing radiation and radiocontrast consumption Introduction. Coronary stenting is the primary means of coronary revascularization. There are two basic techniques of stent implantation: stenting with balloon predilatation of stenosis and stenting without predilatation (direct stenting). Limiting the time that a fluoroscope is activated and by appropriately managing the intensity of the applied radiation, the operator limits radiation in the environment, and this saves the exposure to the patient and all personnel in the room. Nephrotoxicity is one of the most important properties of radiocontrast. The smaller amount of radiocontrast used also provides multiple positive effects, primarily regarding the periprocedural risk for the patients with the reduced renal function. The goal of the study was to compare fluoroscopy time, the amount of radiocontrast, and expenses of material used in direct stenting and in stenting with predilatation. Patients and methods. In a prospective study, 70 patients with coronary disease were randomized to direct stenting, or stenting with predilatation. Results. Fluoroscopy time and radiocontrast use were significantly reduced in the directly stented patients in comparison to the patients stented with balloon-predilatation. The study showed a significant reduction of expenses when using a direct stenting method in comparison to stenting with predilatation. Conslusions. If the operator predicts that the procedure can be performed using direct stenting, he is encouraged to do so. Direct stenting is recommended for all percutaneous coronary interventions when appropriate conditions have been met. If direct stenting has been unsuccessful, the procedure can be converted to predilatation.

Aim: The prognostic value of circulating antibodies to oxidized low-density lipoprotein (anti-oxLDL) in patients with coronary heart disease is not completely clear. We aimed to investigate the association between levels of anti-oxLDL in three groups of patients with different grades of severity of coronary heart disease. Patients and methods: The study included 101 patients classified into three groups: one (N=35) with acute myocardial infarction (AMI), a group (N=35) with angiographicallly proven coronary artery disease (APCAD), and a group without angiographicallly proven coronary artery disease (N=31) designated as a control group. Levels of IgG anti-oxLDL antibodies were meausured by enzyme-linked immunosorbent assay. Results: Mean anti-oxLDL value was significantly higher in patients with AMI than in patients with APCAS (1342.1±581.5 mIU/ml vs. 553.0±183.3 mIU/ml, p<0.001), as well as compared with control group (1342.1±581.5 mIU/ml vs. 246.5±114.3, p<0.001). Similarly, significant difference in anti-oxLDL levels was found between the patients with APCAS and control group (p<0.001). Conclusions: The present study showed that elevated levels of anti-oxLDL are positively related with a severity of coronary artery disease. Hence, elevated levels of anti-oxLDL may identify patients with unstable coronary heart disease. Oxidized LDL in circulating plasma could serve as a marker of cardiovascular events.

OBJECTIVES The role of exercise test in risk stratifying of asymptomatic patients with moderate and severe aortic stenosis (AS) in recent literature is still controversial. The aim of this study was to evaluate the role of exercise test in stratifying the risk of patients with moderate to severe aortic stenosis. METHODS At the Internal Medicine Clinic, Department of Cardiology in Tuzla, in the period from January 2008 until January 2010 was followed 33 patients with clinical and echocardiographic parameters of moderate to severe asymptomatic aortic stenosis (mean effective orifice area EOA 0.9 +/- 0.34 cm2). In statistical analysis we used descriptive statistics, t-test, chi-square test and Kaplan-Meier life table for predictive values, sensitivity and specificity. A significance level of 0.05 was used. RESULTS Two patients were excluded due to exclusion criteria, so 31 patient was followed up during 12 months period. Eighteen patients (58%) with EOA pounds sterling 0.8 cm2 had limiting symptoms during the test. During follow-up period, 11 patients developed serious spontaneous symptoms, and out of them 8 patients underwent surgical valve replacement, one patient died (sudden cardiac death), and 2 patients had serious complications (ischemic cerebral stroke). Twenty patients remained asymptomatic. The highest positive predictive accuracy had EOA pounds sterling 0.8 cm2 with limiting symptoms and it was 85%. The highest negative predictive accuracy had ST depression. CONCLUSION only limiting symptoms along with EOA pounds sterling 0.8 cm2 had positive predictive accuracy.

INTRODUCTION Accurate information about the cause of death is given by expert teams based on pathological or forensic expertise. Reliable information can be obtained from doctors from clinical-hospital institutions if the deceased person was treated in such an institution and with previously diagnosed disease (hospital mortality). Analysis of hospital mortality provides a lot of data that can be used in planning the hospital beds capacities, the amount of drug procurement, purchasing equipment, organization and creation of highly specialized medical teams (medical team for resuscitation), the number of reanimation techniques, the number of pathologists who are required for autopsy procedures, etc. GOAL was to determine the total number of deaths, the most common causes of death and the 10 leading diagnoses of deceased patients at the Clinic for Internal Medicine of Clinical Center in Tuzla during 2008. MATERIAL AND METHODS We used the material from the archive (medical records and reports on deceased patients, delivered by physicians working at the Clinic for Internal Medicine of Clinical Center in Tuzla). RESULTS During 2008 at the Clinic for Internal Medicine 368 patients died. According to the analyzed data leading cause of death and leading diagnosis as cause of death at the Clinic for Internal Medicine in 2008 were as follows: cardiogenic shock in 73 (19.84%), cerebrovascular stroke in 46 (12.50%), coma due to stroke in 32 (8.70%), coma not classified as cerebral in 25 (6.79%) (metabolic 13 (3.53%) and hepatic 12 (3.26%), cardiomyopathy in 22 (5.98%), malignant neoplasm of the abdomen in 17 (4.62%), respiratory insufficiency in 17 (4.62%), acute myocardial infarction and myocardial infarction with rupture in 17 (4.62%), pulmonary edema in 16 (4.35%), and cardiorespiratory arrest in 13 (3.53%) deaths. CONCLUSION During 2008 at the Clinic for Internal Medicine of Clinical Center in Tuzla died a total of 368 patients. The most common cause of death of patients at the Clinic for Internal Medicine of Clinical Center in Tuzla are cardiovascular disease (n = 175; 47.55% of deaths), in second place was cerebrovascular disease (n = 76; 20.65% of deaths) for a total of 251 (68.20%) of deaths from cardiovascular and cerebrovascular disease.