OBJECTIVE Our objective was the comparison of combined utility of two-dimensional (2D) transthoracic echocardiography (TTE) and three-dimensional (3D) TTE versus 2D and 3D transesophageal echocardiography (TEE) in evaluation of anatomy of the left atrium appendage (LAA) and for clot formation in LAA. BACKGROUND 2DTEE as semi-invasive method has been for a long time used to visualize the LAA. Improved echocardiography technology has increasingly improved visualization of LAA by 2DTTE and 3DTTE in many patients and decreased the need for TEE performance. METHODS We compared combined 2DTTE and 3DTTE with 2DTEE and 3DTEE in evaluating the LAA for anatomical features and thrombus. Eighty-six patients underwent 2DTTE, 3DTTE, 2DTEE and 3DTEE. RESULTS LAA could be visualized in all patients. 31 % of patients had one lobe, 43% had 2 lobes and 26% had > 2 lobes. Of 86 patients studied, 79 had no thrombus and 7 had thrombus in the LAA by all modalities. Six patients, 3 with atrial fibrillation (AF), and 4 in sinus rhythm (SR) had a suspected thrombus by 2DTEE. Only in one patient 3DTEE cropping has been needed to clearly show thrombus which was suspected in short axis view on 2DTEE as rounded echo dense mass. CONCLUSIONS Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LAA anatomy and pathology in terms of thrombus. Only in inappropriate (obese) patients 2TTE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.

Brain natriuretic peptide (BNP) is released from ventricular myocites due to their stretching and volume overload. In heart failure there is BNP release. Aim of this study was to observe BNP release in acute myocardial infarction (AMI). We measured BNP in 75 patients with AMI. Control group (n=61) was similar by age and gender to AMI group. We found statistically significant elevation of BNP compared to controls (462.875 pg/ml vs 35.356 pg/ml, p< 0.001). Patients with severe systolic dysfunction had the highest BNP levels, while patients with the preserved systolic function had the lowest BNP levels (Group with EF< 30% BNP= 1129.036 pg/ml vs Group with EF31-40 % BNP= 690.177 pg/ml vs Group with EF 41-50% BNP= 274.396 pg/ml vs Group with EF> 51% BNP= 189.566 pg/ml, p< 0.001). We found statistically significant light positive correlation between BNP and left ventricle end-diastolic diameter (LVDd) (r= 0.246, p<0.05). and real positive correlation between BNP and peak troponin levels (r= 0.441, p < 0.05). BNP levels were higher in anteroseptal allocation of AMI compared to inferior allocation (835.80 pg/ml vs 243.03 pg/ml, p< 0.001) and in patients who were treated with heparin compared to fibrinolitic therapy (507.885 pg/ml vs 354.73 pg/ml, p< 0.05). BNP is elevated in AMI and is a quantitative biochemical marker related to the extent of infarction and the left ventricle systolic dysfunction. Besides echocardiographic calculation, elevation of BNP could be used for quick and easy determination of the left ventricle systolic dysfunction.

This study evaluated brain natriuretic peptide (BNP) release in acute myocardial infarction (AMI), absolute values as well as pattern of its release. There are two different patterns of BNP release in AMI; monophasic pattern--concentration in the first measurement is higher than in the second one, and biphasic pattern--concentration in the first measurement is lower than in the second one. We observed significance of biphasic and monophasic pattern of BNP release related to diagnostic and prognostic value. We included in this prospective observational study total of 75 AMI patients, 52 males and 23 females, average age of 62.3 +/- 10.9 years with range of 42 to 79 years. BNP was measured and pattern of its release was evaluated. In AMI group BNP levels were significantly higher than in controls (462.88 pg/mL vs. 35.36 pg/mL, p < 0.001). We found statistically significant real negative correlation (p < 0.05) between BNP concentration and left ventricle ejection fraction (LVEF) with high correlation coefficient (r = -0.684). BNP concentrations were significantly higher among patients in Killip class II and III compared to Killip class I; Killip class I BNP = 226.18 pg/mL vs. Killip class II 622.51 pg/mL vs. Killip class III 1530.28 pg/mL, p < 0.001. BNP concentrations were significantly higher in patients with; (i) myocardial infarction vs. controls; (BNP 835.80 pg/mL vs. 243.03 pg/mL); (ii) in pts with positive major adverse cardiac events (MACE) vs. negative MACE (BNP 779.08 pg/mL vs. 242.28 pg/mL, p < 0.001); (iii) in pts with positive compared to negative left ventricle (LV) remodelling (BNP 840.77 pg/mL vs. 341.41 pg/mL, p < 0.001). Group with biphasic pattern of BNP release had significantly higher BNP concentration compared to monophasic pattern group. In biphasic pattern group we found significant presence of lower LVEF, Killip class II and III, LV remodelling and MACE. We found that BNP is strong marker of adverse cardiac events in patients presenting with a myocardial infarction. In our AMI group we found significant elevation of BNP and it is suspected that second peak secretion is not only due to systolic dysfunction and subsequent remodeling of LV but also due to impact of ischaemia. Patients with biphasic pattern probably have worse prognosis due to severe coronary heart disease. Besides its diagnostic role as a simple blood marker of systolic function, BNP is also important prognostic marker who helps making clinical decision about early invasive vs. conservative management.

Introduction: epidemiological data suggests worldwide burden of clinical manifestations of atherosclerosis, (i.e. coronary heart disease, cerebrovascular disease and peripheral vascular diseases). Combined coronary and carotid disease is the most presented type of the polyvascular atherosclerotic disease. The goal is to evaluate the influence and correlation of multiple risk factors in combined coronary and carotid atherosclerotic disease and to compare them to isolated coronary atherosclerotic disease. Material and methods: we included total of 124 consecutive patients with established coronary and carotid atherosclerotic disease. Patients were divided in two groups; group with isolated coronary atherosclerotic disease (ICAD) (n=60) with clinicaly established atherosclerosis on coronary vascular bed. Group with combined carotid and coronary atherosclerotic disease (CCAD) (n=64), had clinicaly established combined atherosclerosis of two vascular beds, coronary and carotid. We performed clinical assessment, laboratory tests, and specific cardiac investigations, (i.e. invasive and non-invasive diagnostic procedures). Results: in ICAD group we found high significance in multiple risk factors; total cholesterol 92,6%, obesity 80%, and elevated fibrinogen 77,5%. In CCAD group we found high significance of multiple risk factors; total cholesterol (82,5%), elevated fibrinogen (82,5%) and tobacco smoking of 77,5%. In CCAD group in males most assessed risk factor was smoking 88,4%, and in females total cholesterol 92,8%. Comparing ICAD and CCAD group we found significantly more diabetes mellitus type 2 in CCAD group. Conclusion: in both groups of patients we found markedly increase risk factors especially arterial hypertension, smoking and total cholesterol level. Multiple regression analysis showed significant correlation of patients age as a predictor of arterial hypertension. In other risk factors; total cholesterol, obesity, diabetes mellitus and fibrinogen, we found no statistical significance related to patients’ age.

Introduction: Coronary heart disease and its etiology are complex socio-medical and clinical problem in this century. World Health Organization defined coronary artery disease as acute and chronic heart ailments due to disruption of flow and myocardial blood supply. Diseases of the cardiovascular system in spite of preventable risk factors are responsible for approximately 50% of all deaths in the developed world, and this ratio is higher in developing countries. Risk factors: Coronary heart disease risk factors can be divided in those which are not preventable such as: personal and family history of cardiovascular diseases, age and gender and preventable risk factors including: high blood pressure, elevated blood cholesterol, smoking, reduced physical activity, elevated blood sugar, increased body weight, alcohol use, psychosocial factors and nutrition. There are also newly emerging risk factors which includes increased homocysteine, thrombogenic and inflammatory factors. Prevention of coronary heart disease risk factors: The concept of risk assessment factors, their reduction, initially begun in the Framingham Heart Study and refined in other models. Primary prevention relates to changing lifestyle and influencing preventable risk factors. Numerous studies and meta-analysis showed that lifestyle modification, risk reduction factors, particularly by changing diet, stopping smoking, increasing physical activity, blood pressure control can be effective in the prevention and reduction of coronary heart disease. Primary health care physicians i.e. family physicians need to take an active role in assessment of risk factors for coronary heart disease. Conclusion: The data in this paper, based on the findings from other studies, suggest the importance of using a modified algorithm in order to estimates the overall risk of coronary disease in high-risk groups among the patients in the primary health care settings.

We present a case of catheter induced pseudoaneurysm of femoral artery and postprocedural course. This type of complications occurs in 2% to 8% patients after interventional procedures via trans femoral access and and has overall trend of increase due to significant number of this procedures in diagnostic and interventional cardiology. A 74-year-old female was admitted to Vascular department complaining of severe pain in her left groin. On physical examination, there was a femoral mass palpable but non-pulsatile in her left groin. Color Doppler documented the presence of femoral pseudoaneurysm as well as "to-and-fro" flow pattern on the pseudoaneurysm neck. CT arteriogram showed pseudoaneurysm with mostly thrombosed cavity, diameter of 85 x 27 mm. We concluded for further surgical repair.

Reperfusion therapy is the most useful part of the treatment for patients suffering from an acute coronary syndrome. Start time of reperfusion therapy is an important factor which influenced positively on the number of days of hospitalization, and readmission, the risk of reinfarction, as well as both, short and long-term mortality. Today, several models of reperfusion therapy are available: thrombolytic treatment (pre-hospital or in-hospital setting), primary percutaneous coronary intervention (primary PCI or pPCI) or a combination of both. pPCI is preferred, as soon as possible, in centers with experienced teams, especially for patients in shock, or those with contraindicated fibrinolytic therapies. We will compared, very shortly, the daily practices in 4 countries (Czech Republic, Austria, Croatia, Serbia ), where (well) developed primary PCI hospital networks works efficiently for a years, with the current situation in Bosnia and Herzegovina. Our goal is to describe the easiest and quickest way of establishing the primary PCI network in Bosnia and Herzegovina. By combining the efforts of both Entities of Bosnia and Herzegovina will be possible in the forthcoming period, that B&H becomes a participant in the Stent for life initiative.

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.

In Bosnia and Herzegovina we have burden of cardiovascular diseases (CVD) with higher rate of morbidity and mortality than in the countries of EU zone or broader Europe and CVD are still the major cause of death, morbidity, mortality and loss of quality of life. Burden of CVD is in close relation to multiple risk factors but also with specific conditions in our country; post war situation, transition and overall economic position. The main mission of European Society of Cardiology is to improve quality of life in the European population by reducing the impact of cardiovascular diseases. HeartScore web based program is introduced to estimate the overall risk of cardiovascular death for a period of 10 years, based on 5 variables: age, sex, smoking, systolic blood pressure and cholesterol level or total cholesterol/ HDL ratio. This is of particular importance in predicting cardiovascular outcomes where misjudgments may have fatal consequences. Program is practical to use, takes account of the multifactorial nature of CVD, estimates risk of all atherosclerotic CVD, not just coronary heart disease, shows how risk increase with age, allows flexibility in management – if an ideal risk factor level cannot be achieved. The program offers its own database for each patient and also printing advices for reducing risk factors. HeartScore is tailored to patients, the system provides a graphical representation of the absolute risk of CVD. Version for our country is developed on the principle of high-risk populations and is available in the languages of the peoples of Bosnia and Herzegovina. Program is available for all types of medical practice which is equipped with computers, the laptops, and suitable for community nursing service as well.

Cardiovascular diseases are still the major cause of death, morbidity, mortality and loss of quality of life in European countries and worldwide. In Bosnia and Herzegovina we have burden of cardiovascular diseases with higher rate of morbidity and mortality than in the countries of EU zone or broader Europe. The cause of mortality is in close relation to multiple risk factors but also with specific conditions in our country; post war situation, transition and overall economic position. The main mission of European Society of Cardiology is to improve quality of life in the European population by reducing the impact of cardiovascular diseases. HeartScore web based program and PS Standalone program are introduce to assesses the overall risk of cardiovascular death for a period of 10 years, based on variables such as age, sex, smoking, systolic blood pressure and cholesterol levels in the blood, or total cholesterol/HDL ratio. Standalone PS HeartScore is practical to use, requires no permanent internet connection, the system offers its own database for each patient and the print version of the guidelines to reduce risk factors, based on evidence based medicine Program is tailored to patients, the system provides a graphical representation of the absolute risk of CVD, a version for our country is developed on the principle of high-risk populations and is available in the languages of the peoples of Bosnia and Herzegovina. Program is available for all types of medical practice which is equipped with computers, the laptop, and suitable for community nursing service as well.

PURPOSE Cerebrovascular events (CVE) are the third most common cause of death in Western countries and about 65-70% of CVE are due to atherosclerotic disease of carotid arteries. Color Doppler scanning is used to evaluate the presence, severity and type of atheromatous plaques as well as velocity parameters of carotid arteries. We performed this study to correlate data of morphological and velocity parameters with clinical variables in patients following CVE. METHODS We included total of 211 pts who had CVE, 118 females, 93 males, mean age 71.1 +/- SD 12.5 years. Out of total number of pts (n = 211) 93 pts had transient ischemic attacks (TIAs), 49 had recurrent TIAs (rTIAs), 44 had ischemic stroke (IS), and 25 had recurrent IS (rIS). As a control group we took 50 pts without CVE but with at least three multiple risk factor (MRF). Morphological parameters were; plaque composition and echogenecity. Velocity parameters were: peak-systolic velocity (PSV) and end-diastolic velocity (EDV). The following MRF were evaluated: age, gender, hypertension, tobacco smoking, hyperlipidemia (total cholesterol and LDL-cholesterol), obesity, and diabetes mellitus. Examination was performed on CCA/ICA segment. RESULTS We found significant presence of heterogeneous plaques in TIAs and rIS subgroup, p < 0.014, and borderline significance for the rTIAs and IS subgroups, p < 0.04. We found significant difference in PSV in TIAs and rTIAs subgroups vs. controls (PSV 103 cm/s vs. PSV in controls 87 cm/s, p < 0.01). Decreased EDV, below 20 cm/s, was found in all subgroups, p < 0.01, while EDV, below 16 cm/s, was found in IS and rIS subgroups. MRF score of CVE group was 4.34 vs. 3.65 in controls, p < 0.012, while MRF score in TIAs and rTIAs vs. IS and rIS subgroups was 4.34 vs. 4.51, NS, p = 0.14. We found a significant correlation (95% CI) of tobacco smoking, obesity and arterial hypertension with presence of heterogeneous plaques, p = 0.0069. Interestingly, hyperlipidemia showed no correlation with heterogeneous plaques, p = 0.027. CONCLUSIONS (i) in CVE group we found significant presence of heterogeneous plaques in TIAs and rIS subgroups, (ii) in the pts with TIAs and rTIAs events we found significant increase in PSV, (iii) EDV below 16 cm/sec was a significant single predictor of IS and rIS events, (iv) MRF score was significantly increase in the pts with CVE compared to controls, but between CVE subgroups there was no significant difference.