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Kardio LIST
»asopis Hrvatskog kardioloπkog druπtva Journal of the Croatian Cardiac Society
Godina — Volume 7 • Broj — Number 3-4 • Oæujak - Travanj — March - April 2012
Sadræaj / Table of contents
Bolesti srËanih zalistaka u Hrvatskoj u
2011. godini
Valvular heart diseases in Croatia in
2011
stranica / page 59-65
Almanah 2011. godine: valvularne
bolesti srca
»asopisi nacionalnih druπtava
predstavljaju odabrana istraæivanja
koja predstavljaju napredak u kliniËkoj
kardiologiji
Almanac 2011: valvular heart disease.
The national society journals present
selected research that has driven
recent advances in clinical cardiology.
stranica / page 66-85
Simpozij e-CARDIOLOGY 2012
Symposium e-CARDIOLOGY 2012
stranica / page 92
www.kardio.hr/kardio-list.html
Nakladnik i izdavaË / Editing and publishing company:
Hrvatsko kardioloπko druπtvo / Croatian Cardiac Society
Adresa / Address:
KiπpatiÊeva 12, HR-10000 Zagreb, Croatia
Telefon /Phone: +385-1-2388-888
E-mail: [email protected]
URL: http://www.kardio.hr/kardio-list.html
Za nakladnika / For Publisher:
Davor MiliËiÊ (HR)
Simpozij e-CARDIOLOGY 2012 —
oralne prezentacije
Glavni urednik / Editor-in-Chief:
Mario Ivanuπa (HR)
Symposium e-CARDIOLOGY 2012 —
oral presentations
UredniËki odbor / Editorial Board:
Zdravko BabiÊ, Æeljko BariËeviÊ, Antun Car, Maja »ikeπ,
Viktor »uliÊ, Duπka Glavaπ, Irena Ivanac VraneπiÊ, Mario
Ivanuπa, Goran KrstaËiÊ, Jana Ljubas, Æeljko Madæar, Goran
MiliËeviÊ, Viktor PerπiÊ, –eiti PrvuloviÊ, Robert Steiner,
Vedran VelagiÊ i Hrvoje VraæiÊ
stranica / page 93-118
Simpozij e-CARDIOLOGY 2012 —
posteri
Symposium e-CARDIOLOGY 2012 —
posters
stranica / page 119-133
Savjet / Advisory Board:
Mijo Bergovec (HR) , Bojan JelakoviÊ (HR) , Æarko MavriÊ
(HR) , Davor MiliËiÊ (HR) , Jure Mirat (HR) , Vjeran NikoliÊHeitzler (HR) , Dubravko PetraË (HR) , Stojan PoliÊ (HR) ,
Æeljko Reiner (HR) i Luka ZaputoviÊ (HR)
TehniËki urednik / Technical Editor:
Stjepan Horvat (HR)
Protokol za lijeËenje akutnog infarkta
miokarda s elevacijom ST-segmenta u
Meimurskoj æupaniji
Terapija atorvastatinom i nove
europske smjernice za lijeËenje
dislipidemije
Protocol for the treatment of acute
ST-segment elevation myocardial
infarction in the County of Meimurje
Priprema i tisak / Editing prepared by:
»VOR d.o.o., Matice hrvatske 24
HR-43000 Bjelovar, Croatia
Phone: +385-43-244-050, www.cvor.hr
Atorvastatin treatment meets new
European recommendations for the
treatment of dyslipidemias
Prijevod / Translated by:
Studium d.o.o. Phone: +385-1-3475-720
www.studium-jezici.hr or www.sudski-tumaci.com
stranica / page 86-91
stranica / page 136-139
Naklada / Print run: 1.100 copies
Informacije o pretplati / Subscription info:
Tiskano izdanje je besplatno za lijeËnike, a mreæno izdanje
je u cijelosti dostupno svima. / Physicians can receive the
print editions of Kardio list free of charge. Kardio list is
open access journal with free and unrestricted access for
all online readers.
»lanci su kategorizirani prema “Uputama za uredniπtva
Ëasopisa” koji su dostupni na portalu HrËak / The articles
are categorized according to “Instructions for journal
editorial boards” available at the HrËak web site:
http://hrcak.srce.hr/admin/upute.doc
Copyright:
Hrvatsko kardioloπko druπtvo / Croatian Cardiac Society.
This publication was printed with an unrestricted educational
grant from: Krka-Farma d. o. o. , Zagreb, Croatia
Hrvatsko kardioloπko druπtvo
Croatian Cardiac Society
Adresa / Address: Hrvatsko kardioloπko druπtvo
HR-10000 Zagreb, KiπpatiÊeva 12, Croatia
www.kardio.hr • E-mail: [email protected]
Æiro-raËun: 2360000-1101412726
OIB: 18767182406
Kardio LIST
Predsjednik / President:
Dopredsjednik / Vice-President:
Tajnik / Secretary:
RizniËar / Treasurer:
Davor MiliËiÊ
Mijo Bergovec
Darko PoËaniÊ
Eduard MargetiÊ
Upravni odbor / Management Board: Diana DeliÊ-BrkljaËiÊ,
Mladen JukiÊ, Viktor PerπiÊ, Robert Steiner, Maja Strozzi,
Josip Vincelj, Luka ZaputoviÊ i predsjednici podruænica
HKD.
2012;7(3-4):58.
Uvodnik / Editorial
Simpozij e-CARDIOLOGY 2012
CROATIAN
CARDIAC
SOCIETY
Symposium e-CARDIOLOGY 2012
Goran KrstaËiÊ*, Enno van der Velde
Direktori Simpozija e-CARDIOLOGY 2012
Symposium Directors e-CARDIOLOGY 2012
znimna nam je Ëast ugostiti vas na Simpoziju e-CARDIOLOGY 2012, prvom znanstvenom i struËnom simpoziju u organizaciji Radne skupine e-Cardiology Europskog kardioloπkog druπtva (ESC) i Hrvatskog kardioloπkog
druπtva (HKD).
Simpozij e-CARDIOLOGY 2012 se organizira kao interaktivni, edukacijski simpozij visoke razine kvalitete koji Êe
obuhvatiti najzanimljivija podruËja uporabe informacijske
tehnologije (IT) kao πiroko rasprostranjene moguÊnosti primjene u razliËitim podruËjima kardiologije. To podrazumijeva primjenu IT u istraæivanju, ali i svakodnevnoj kliniËkoj
praksi unutar ili izvan bolniËkog okruæja.
PodruËje rada i istraæivanja e-Kardiologije je promocija specijaliziranih raËunalnih postupaka u kardiovaskularnom slikovnom prikazu, raËunalnom otkrivanju znanja, umjetnoj inteligenciji, strojnom uËenju, modeliranju i analizi bio-signala,
bazi podataka, intra- i interbolniËkoj komunikaciji i razvoju
prediktivnih modela. Ove aktivnosti omoguÊavaju logistiËku
potporu znanstvenicima i lijeËnicima u kliniËkoj praksi iz razliËitih podruËja u suradnji na novim temama i primjenama u
kardiologiji.
StruËni sadræaj Simpozija e-CARDIOLOGY 2012 donosi
pregled najvaænijih suvremenih tema iz telemedicine, elektrokardiologije, intervencijske kardiologije, elektrofiziologije,
kardiovaskularnog slikovnog prikaza i raËunarstva u kardiologiji. Simpozij je namijenjen kardiolozima, specijalizantima
kardiologije, internistima, anesteziolozima, medicinskim informatiËarima, medicinskim fiziËarima i svim drugim lijeËnicima koji u svakodnevnom struËnom i znanstvenom radu
koriste IT. Ovaj Simpozij takoer predstavlja i iznimnu prigodu za okupljanje Ëlanova HKD na otvorenoj skupπtini Radne
skupine e-Cardiology ESC.
Ponosni smo πto se Simpozij i sastanak Ëlanova Nukleusa
Radne skupine ESC odræava po prvi put u Hrvatskoj i veselimo se Vaπem dolasku u Osijek.
I
e are greatly honored to welcome you to Symposium e-CARDIOLOGY 2012, the first scientific
and expert symposium co-organized by the European Society of Cardiology Working Group on e-Cardiology
of the (ESC) and the Croatian Cardiac Society (CCS).
Symposium e-CARDIOLOGY 2012 is organized as a high
quality interactive and educational symposium that will cover
the most interesting areas of using information technology
(IT) applied in various areas of cardiology. It includes the
application of IT in research, and also in daily clinical practice inside or outside the hospital environment.
The field of work and research of e-Cardiology is the promotion of specialized computer procedures in cardiovascular
imaging, computer-aided discovery of knowledge, artificial
intelligence, machine learning, modeling and analysis of biosignals, database, intrahospital and interhospital communication and development of predictive models. These activities provide logistical support to scientists and clinicians
from different fields to cooperate on new topics and applications in cardiology.
The professional contents of e-CARDIOLOGY 2012 gives
an overview of the most significant contemporary issues in
telemedicine, electrocardiology, interventional cardiology,
electrophysiology, cardiovascular imaging and computing in
cardiology. The Symposium is intended for cardiologists,
cardiology specialists, internists, anesthesiologists, medical
IT experts, medical physicists and all other physicians who
use IT in their daily professional and scientific work. This
Symposium is also an exceptional opportunity for getting
CCS members together at the open general meeting of the
ESC Working Group on e-Cardiology.
We are proud of the fact that the Symposium and the meeting of the members of the ESC Working Group Nucleus will
for the first time take place in Croatia and we look forward to
seeing you in Osijek.
W
Received: 12th February 2012
*Address for correspondence: Poliklinika za prevenciju kardiovaskularnih bolesti i
rehabilitaciju, DraπkoviÊeva 13, HR-10000 Zagreb, Croatia.
Phone: +385-1-4612290
E-mail: [email protected]
Kardio LIST
2012;7(3-4):92.
Proπireni saæetak / Extended abstract
Varijabilnost srËanog ritma zasnovana na teoriji
kaosa i nelinearnoj dinamici
Heart rate variability based on chaos theory and
non-linear dynamics
Goran KrstaËiÊ*
Poliklinika za prevenciju kardiovaskularnih bolesti i rehabilitaciju, Zagreb, Hrvatska
Institute for Cardiovascular Diseases Prevention and Rehabilitation, Zagreb, Croatia
ve je viπe dokaza da srce u normalnim fizioloπkim uvjetima nije periodiËni oscilator, kardiovaskularne funkcije nisu stacionarne, a tradicionalni pokazatelji varijabilnosti srËanog ritma (VSR) nisu uvijek u moguÊnosti otkriti suptilne ali vaæne promjene u radu srca.1,2 Nekoliko novih
metoda objektivizacije srËanog ritma, zasnovane na nelinearnoj dinamici i teoriji kaosa, razvijene su glede kvantificiranja dinamike fluktuacije srËanog ritma.3,4
VSR odraæava modulaciju autonomnog i drugih fizioloπkih
sustava i njegovo odreivanje iz EKG zapisa za vrijeme snimanja elektrokardiografije, testa optereÊenja ili 24-satnog
dinamiËkog elektrokardiograma predstavlja korisnu metodu
za kIiniËke i znanstvene svrhe.5,6
Tradicionalne linearne statistiËke metode (u vremenskoj i
frekvencijskoj domeni) omoguÊavaju ograniËene informacije o promjeni VSR, poglavito jer su i nelinearni mehanizmi
takoer ukljuËeni u nastanak dinamike srËanog ritma.7,8
Kaos oznaËava vrstu vremenskog ponaπanja u kojem razlika izmeu dva stanja u poËetku raste eksponencijalno s
vremenom. KaotiËni sustav je izrazito osjetljiv na poËetno
stanje i nepredvidljiv u dugoj vremenskoj skali, gdje je poËetno stanje rijetko poznato s apsolutnom preciznoπÊu. Sustavi koje nalazimo u prirodi pokazuju karakteristike nelinearnog i kaotiËnog ponaπanja. Kaos se moæe pojaviti u dinamiËkom sustavu koji je modeliran deterministiËkim nelinearnim jednadæbama. Takav dinamiËki sustav moæe evoluirati
u statiËko stanje, oscilatorno stanje, nestabilno stanje te
kaos, koji predstavlja nepravilne oscilacije sliËne stohastiËnom ili sluËajnom ponaπanju. Svi sustavi mogu se prikazati
kao linearni, blizu stanja ravnoteæe. Meutim, ako kontinuirani “dotok” energije bude dostatan da se sustav dovoljno
pobudi, on postaje nelinearan pa Ëak i kaotiËan.9
Kaos se moæe lakπe razumjeti kada se usporeuje s druga
dva oblika ponaπanja; sluËajnim, nekontroliranim sustavom
i sustavom periodiËnosti. SluËajno ponaπanje nikada se ne
ponavlja u istom obliku i ono je nepredvidivo i neorganizirano. TipiËan primjer je elektrokardiografski zabiljeæen normalan sinusni ritam. Ako znamo amplitudu, frekvenciju i fazu
sinusnog vala, u svakom trenutku moæemo predvidjeti pojavnost i amplitudu sinusnog vala. Kaos se razlikuje od ponaπanja periodiËnosti i sluËajnosti, no istovremeno sadræi i
karakteristike oba sustava. Iako kaotiËno ponaπanje izgleda
neorganizirano, sluËajno ponaπanje, ono je zapravo deterministiËko, periodiËno ponaπanje. Najvaæniji kriteriji kaotiËnog ponaπanja su sljedeÊi:
S
2012;7(3-4):93.
here is increasing evidence to suggest that the heart is
not a periodic oscillator under normal physiologic conditions, and the commonly employed moment statistics
of heart rate variability (HRV) may not be able to detect subtle, but important changes in heart rate time series.1,2 Therefore several new analysis method of heart rate behaviour,
motivated by nonlinear dynamics and chaos theory, have
been developed to quantify the dynamics of heart rate fluctuations.3,4
HRV reflects the modulation of cardiac function by autonomic and other physiological systems, and its measurements from ECG recordings during the resting ECG or the
exercise ECG testing or 24-hours ECG may be the useful
methods for both clinical and scientific purposes.5,6
Traditional linear statistical measures (time and frequency
domain) provide limited information about HRV, mostly
because non-linear mechanisms seem to be also involved in
the genesis of HR dynamics.7,8
Chaos, in the technical sense, is used to denote a type of
time evolution in which the difference between two states
that are initially closely similar grows exponentially over
time. All systems have been shown to be linear, close to any
static equilibrium, unless or until there is a continuous injection of energy to excite the system enough to make non-linearity appreciable and chaos possible. Chaos also requires
a dissipative mechanism to prevent the system from blowing
apart.9
Chaos is more easily understood through a comparison
with randomness and periodicity. Random behaviour never
repeats itself and is inherently unpredictable and disorganised. Unlike random behaviour, periodic behaviour is highly
predictable, because it always repeats itself over some finite
time interval. A sine wave is a typical example. If we know
the amplitude, frequency and phase of a sine wave at any
instant, we can predict the wave perfectly at any other point
in time. Chaos is distinct from periodicity and randomness,
but has characteristics of both. It looks disorganised, but is
actually organised. The most important criteria for chaotic
behaviour are summarised as follows:
1. Chaos is deterministic and aperiodic and it never repeats
itself exactly. There are no identifiable cycles that recur at
regular intervals.
2. Most chaotic systems have sensitive dependence on the
initial conditions. In other words, very small differences in
T
Oralna prezentacija / Oral presentation
Kardio LIST
1. Kaos moæe biti deterministiËki i neperiodiËan. Za razliku
od Newtonovih zakona fizike kaotiËno ponaπanje se nikada
toËno ne ponavlja. Nema vidljivih ciklusa koji kruæe u regularnim vremenskim intervalima;
2. KaotiËni sustavi vrlo su ovisni o poËetnim stanjima. To
znaËi da vrlo male promjene u poËetnom stanju mogu rezultirati velikim razlikama u kasnijem vremenskom periodu.
3. KaotiËno ponaπanje je ograniËeno. Kako sustav postaje
kontroliran, ponaπanje biva ograniËeno i predvidivost raste;
4. KaotiËno ponaπanje ima krajnji oblik. KaotiËno ponaπanje
u cjelini ima definitivnu formu dok dijelovi obrazaca imaju
sliËni oblik.9
Nove studije na veÊem broju ispitanika mogu pomoÊi za ispitivanje kliniËkih promjene kod fraktalnih mjerenja VSR kao
riziËnih Ëimbenika. U konaËnici, dinamiËka analiza moæe dopuniti analizu otkrivanja kardiovaskularnih bolesti, kao i
eventualnu korist od lijekova koji utjeËu na promjenu VSR.
KljuËne rijeËi: varijabilnost srËanog ritma, nelinearna dinamika, teorija kaosa.
the initial conditions will later result in large differences in
behaviour.
3. Chaotic behaviour is constrained. Although a system
appears random, the behaviour is bounded, and does not
wander off to infinity.
4. Chaotic behaviour has a definite form. The behaviour is
constrained, and there is a particular pattern to the behaviour.9
We continuously need the further studies in larger population to further more define the clinical utility of new fractal
measurements of HRV for risk stratification. We could make
a conclusion that dynamic analysis of HRV could enhance
detection of cardiovascular disease as well as the benefit of
using some cardiovascular drugs in relation to changes of
HRV.
Keywords: heart rate variability, nonlinear dynamics, chaos
theory.
*Corresponding author — E-mail:
[email protected]
Literature
1. Vesa J. Longitudinal changes and prognostic significance of cardiovascular autonomic regulation assessed by heart rate variability and analysis of non-linear heart rate dynamics (dissertation). University of Oulu, Finland, 2003.
2. Huikuri HV. Heart rate variability in coronary artery disease. J Intern Med. 1995;237:349-57.
3. Tulppo MP, Makikallio TH, Seppanen T, Laukkanen RT, Huikuri HV. Vagal modulation of heart rate during exercise: effects of age and physical fitness. Am J
Physiology.1998;74:424-9.
4. Goldberger AL. Non-linear dynamics for clinicians: chaos theory, fractals, and complexity at the bedside. Lancet 1996;347:1312-4.
5. Huikuri HV, Makikallio TH, Perkiomaki J. Measurement of heart rate variability by methods based on nonlinear dynamics. J Electrocardiol. 2003;36 Suppl:95-9.
6. KrstaËiÊ G. Ispitivanje nelinearne dinamike kratkih vremenskih serija kod bolesnika sa stabilnom anginom pektoris (disertacija). Zagreb: Medicinski fakultet; 2002.
7. Krstacic G, Krstacic A, Smalcelj A, Milicic D, Jembrek-Gostovic M. The “Chaos Theory” and non-linear dynamics in heart rate variability analysis: does it work in short time series
in patients with coronary heart disease? Ann Noninvasive Electrocardiol. 2007;12(2):130-6.
8. Martinis M, KnezeviÊ A, KrstaciÊ G, VargoviÊ E. Changes in the Hurst exponent of heartbeat intervals during physical activity. Phys Rev E Stat Nonlin Soft Matter Phys. 2004;70(1
Pt 1):012903.
9. Glass L. Chaos and heart rate variability. J Cardiovasc Electrophysiol. 1999;10(10):1358-60.
Kardio LIST
2012;7(3-4):94.
Proπireni saæetak / Extended abstract
PodruËje primjene telekardiolgije
Applications in telecardiology
Enno van der Velde*
Leiden University Medical Center, Leiden, Nizozemska
Leiden University Medical Center, Leiden, The Netherlands
elemedicina predstavlja primjenu napredne telekomunikacijske tehnologije za dijagnostiku, nadzor i u terapijske svrhe, a moæe se koristiti u gotovo svakoj subspecijalizaciji. Telekardiologija je jedna od najrazvijenijih medicinskih disciplina koju pokriva telemedicina. Telekardiologija
je krajnje nastojanje da se tehnologija ujedini s kardiologijom, kako bi pacijenti dobili odgovarajuÊe i toËne savjete i
medicinsku skrb bez prekidanja njihove dnevne rutine, a da
se u isto vrijeme sve potrebne informacije, πto je prije moguÊe, uËine dostupnima kardiolozima konzultantima. Na taj se
naËin smanjuje teret kliniËkih posjeta i nepotrebnih hospitalizacija u optereÊenom zdravstvenom sustavu1,2. Uz pruæanje
skrbi za pacijente s bolesti srca, telekardiologija ima kljuËnu
ulogu u educiranju tih pacijenata o prirodi njihovog stanja,
poboljπavajuÊi njihovu suradljivost pri farmakoloπkoj terapiji
te usmjeravajuÊi pacijente zdravim æivotnim navikama. Dobrobit telekardiologije u ruralnim zajednicama naroËito je
vaæna zbog njezine sposobnosti da prevlada zapreke koje
nastaju zbog velikih udaljenosti kako bi se dobio pristup
medicinskoj usluzi. Tako je pomoÊu savjetovanja sa struËnjacima moguÊe izbjeÊi opasan i Ëak nepotreban prijevoz
kritiËno bolesnih pacijenata u svrhu dijagnoze. Naposljetku,
pacijenti mogu dobiti drugo miπljenje i lijeËnici se mogu konzultirati s ekspertima, πto sve predstavlja moguÊnosti za
koje je dokazano da imaju koristan uËinak i na preæivljenje i
oporavak pacijenata. Ukratko Êemo opisati neke od najvaænijih podruËja primjena telekardiologije.
T
elemedicine is the application of advanced telecommunication technology for diagnostic, monitoring and therapeutic purposes that can be used in almost every
medical subspecialty. Telecardiology is one of the most
highly developed of the medical disciplines covered by Telemedicine. Telecardiology is the ultimate effort to merge
technology with cardiology in order to provide the patient
with proper and accurate medical advice and medical care
without interrupting his or her daily routine, while making the
necessary information available for the consulting cardiologist as quickly and reliably as possible, thus alleviating the
burden of clinical visits and unnecessary hospitalizations on
the exhausted health systems1,2. In addition to the provision
of care to patients with heart disease, it has a vital role in
educating these patients on the nature of their conditions,
improving their compliance to medical therapy, and guiding
them in practicing healthy life habits. The benefit of Telecardiology in rural communities is especially important because of its capability of overcoming the obstacle of the
large distances that would have to be covered in order to
access medical assistance. As such, hazardous and even
unnecessary transportation of critically ill patients for the
purpose of diagnosis can be avoided by remote expert
counselling. Finally, patients can receive second opinions
and physicians can consult experts, capabilities that have
proven to have a beneficial effect on both patient survival
and recovery. We will briefly describe some of the most
important applications of telecardiology.
Telekardiologija u lijeËenu zatajivanja srca
Telecardiology in the treatment of heart failure
Kongestivno zatajivanje srca (HF) predstavlja kliniËki sindrom Ëija se uËestalost u zapadnim industrijaliziranim zemljama poveÊava, uz visoku stopu smrtnosti od 5% do 50%3.
UËinkovita primjena telemedicine u lijeËenju pacijenata s HF
znaËajno se proπirila diljem svijeta. Mnoge studije dokazale
su znaËajno smanjenje broja i duljine trajanja hospitalizacija
te poboljπanje preæivljavanja kod pacijenata s HF koji su lijeËeni primjenom telemedicinskih konzultacija4. Nedavno
objavljena meta-analiza koja je ukljuËila 96 studija (s ukupno 6.258 pacijenata), Klersy i sur5, izvijestila je da je daljinski nadzor pacijenata, u usporedbi s uobiËajenom skrbi, u
mnogim sluËajevima uvelike smanjio rizik od smrti i duljine
trajanja hospitalizacije, ukljuËujuÊi i HF.
Congestive heart failure (HF) is a clinical syndrome whose
occurrence is increasing in western industrialized countries,
with a high mortality rate, ranging from 5% to 50%3. Effective
use of telemedicine in the treatment of HF patients has been
expanding considerably worldwide. Many studies have demonstrated a substantial reduction in hospital admission
and in the length of hospitalization, and an increase in survival among HF patients who were managed by telemedicine4. In a recently published meta-analysis that summarized 96 studies (with a total of 6,258 patients), Klersy et al.5
reported that remote patient monitoring significantly reduced
the risk of death and the length of hospitalization for any
cause, including HF, compared with usual care.
Telekardiologija u dijagnosticiranju akutnog
infarkta miokarda s elevacijom ST-segmenta
Telecardiology in diagnosing acute
ST-segment elevation myocardial infarction
Poboljπanje uËinkovitosti lijeËenja kod infarkta miokarda s
elevacijom ST-segmenta i smanjenje vremena od dolaska u
Increasing the treatment efficacy in ST elevation myocardial
infarction and reducing the door-to-balloon time, are major
2012;7(3-4):95.
T
Oralna prezentacija / Oral presentation
Kardio LIST
prvu zdravstvenu ustanovu do postizanja reperfuzije (doorto-balloon), su glavni ciljevi suvremenog lijeËenja4. Vaænost
“door-to-ballon” vremena se ne moæe dovoljno naglasiti: to
je jedna od temeljnih mjera kvalitete koju prikuplja i o kojoj
izvijeπta ZajedniËka komisija za akreditaciju u zdravstvenoj
skrbi6. Bilo je mnogo pokuπaja implementacije telemedicinske tehnologije kako bi se smanjilo ovo kljuËno vremensko
razdoblje. Liem i sur. su izvijestili o rezultatima implementacije pristupa koji se temelji na smjernicama, kod kojeg se
EKG zapis pacijenta iz ambulante usmjerava u PCI centar7.
EKG postaje takoer automatski dostupan na smartphone
ureaju konzultativnog intervencijskog kardiologa.
Telekardiologija u dijagnozi i lijeËenju aritmija
Simptomi koji su pripisuju aritmijama, poput palpitacija i sinkopa, mogu se dokumentirati na EKG zapisu, no mnoge
EKG promjene su prolazne ili paroksizmalne te potraga za
potvrdnim dokazima aritmija moæe biti dugotrajna i problematiËna, a aritmije se ne moraju detektirati Ëak i kod dugoroËnog Holter EKG snimanja8. Detektiranje aritmija ima
kljuËne terapijske implikacije, kao πto su: pruæanje antiaritmijskog i antikoagulacijskog lijeËenja za visoko-riziËne pacijente s atrijskom fibrilacijom, trajnih elektrostimulatora srca
za pacijente koji imaju visok stupanj AV bloka, ablacije za
pacijente s povratnom supraventrikulskom tahikardijom i dr.
Uporaba telemedicine moæe osigurati pruæanje hitnog medicinskog lijeËenja za po æivot potencijalno opasne aritmije.
Retrospektivne studije su pokazale da se prije srËanog zastoja pojavljuju znaËajne promjene u varijabilnosti srËanog
ritma. Na temelju ovih studija, Singh i sur.9 su nedavno dizajnirali ruËni daljinski EKG monitor koji detektira QRS kompleks i raËuna kratkoroËnu pojavnost varijabilnosti srËanog
ritma u stvarnom vremenu. Autori vjeruju da ovaj ureaj moæe osigurati rano upozorenje za predstojeÊe kardijalne dogaaje.
Telekardiologija kod pacijenata s implatibilnim
elektroniËkim ureajima
Nedavno uvedena tehnologija omoguÊava daljinski nadzor i
kontinuirano ispitivanje implatibilnih elektroniËkih ureaja
kako bi se πtetni dogaaji detektirali ranije nego πto je to
moguÊe kod standardnog praÊenja te kako bi se smanjio
broj ambulantnih kontrolnih pregleda. Iskustva su do sad prikupljena kod pacijenata s implantabilnim kardioverter defibrilatorima te kod onih koji se lijeËe kardioloπkom resinkronizacijskom terapijom10. Prijenos iz implantiranog ureaja se
obavlja svakodnevno u unaprijed programirano vrijeme (veÊinom tijekom noÊi) ili odmah nakon detektiranja unaprijed
odabranih kljuËnih dogaaja o kojima se lijeËnik odmah obavjeπtava te moæe reagirati neposredno i bez kaπnjenja. Prijenosi se aktiviraju automatski i pacijenti ih ne moraju sami
potaknuti10. Podaci iz udaljene baze podataka za nadzor takoer se mogu poslati u elektroniËki zdravstveni karton bolnice temeljeno na meunarodnim standardima11.
Telekardiologija u dijagnozi i lijeËenju
hipertenzije
Iako je arterijska hipertenzija meu najËeπÊim razlozima
pregleda izvanbolniËkih pacijenata, nekoliko studija je pokazalo da svega 25% pacijenata s ovom bolesti ima adekvatnu kontrolu arterijskog tlaka, πto rezultira poveÊanim rizikom
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targets of contemporary patient management4. The importance of the door-to-balloon time cannot be overemphasized: it is one of the core quality measures collected and reported by the Joint Commission on Accreditation of Healthcare Organizations6. Many attempts have been made to
implement telemedicine technology in order to reduce this
crucial time period. Liem et al. have reported the results of
the implementation of a guideline-based approach, where
the patient’s ECG is transferred from the ambulance to the
PCI center7. The ECG is also automatically made available
on the smartphone of the PCI cardiologist on call.
Telecardiology in diagnosis and treatment of
arrhythmias
Symptoms secondary to arrhythmias, such as palpitations
and syncope, can be documented on ECG tracings, but many ECG changes are transient or paroxysmal, and the
search for corroboratory evidence of these arrhythmias can
be lengthy and problematic and missed even by long-term
Holter ECG recordings8. The detection of these arrhythmias
has crucial therapeutic implications, such as the provision of
anti-arrhythmic and anticoagulation treatment for high-risk
atrial fibrillation patients, permanent pacemakers for patients suffering from high-degree atrioventricular nodal
block, ablation for patients suffering from recurrent supraventricular tachycardia, and others. The use of telemedicine
can ensure urgent provision of medical treatment for potentially life-threatening arrhythmias. Retrospective studies have shown that significant changes in heart rate variability indices occur prior to cardiac arrest. Based on these studies,
Singh et al.9 recently designed a handheld remote ECG
monitor that detects the QRS complex and calculate shortterm heart rate variability indices in real time. The authors
believe that this device may provide early warnings of impending cardiac conditions.
Telecardiology in patients with implantable
electronic devices
A recently introduced technology allows remote monitoring
and continuous interrogation of implantable electronic devices in order to detect adverse events earlier than is possible with standard follow-up visits and to decrease the number of ambulatory follow-up visits. The experience thus far
has been in patients with implantable cardioverter defibrillators and in those undergoing cardiac resynchronization therapy10. Transmissions from the implanted device are made
every day at a specific programmable time (generally during
the night) or immediately upon detection of preselected critical events of which the physician is directly alerted and can
respond without delay. The transmissions are automatically
triggered and the patients play no role in initiating them10.
The data in the remote monitoring database can also be
sent to the Electronic Health Record System in the hospital
based on international standards11.
Telecardiology in the diagnosis and
management of hypertension
Although hypertension is among the most common reasons
for an outpatient medical visit, several studies have shown
that only 25% of the patients with hypertension have adequate blood pressure control, resulting in an elevated risk of
coronary artery disease, CHF, renal insufficiency, peripheral
2012;7(3-4):96.
od koronarne bolesti srca, kroniËnog zatajivanja srca, renalne insufijencije, periferne vaskularne bolesti i moædanog
udara12. KuÊni nadzor arterijskog tlaka je dobro utvrena
praksa za koju se pokazalo da poboljπava suradljivost pacijenata prema terapijskim reæimima uz ostvarivanje æeljenih
ciljnih vrijednosti13. Provedene su mnoge studije uËinkovitosti telemedicine u lijeËenju hipertenzije.
vascular disease, and stroke12. Home blood pressure monitoring is a well-established practice that has been shown to
improve patient adherence to treatment regimens and to
achieve target blood pressure levels13. Many studies have
been conducted on the effectiveness of telemedicine in the
treatment of hypertension.
Conclusion
ZakljuËak
Telekardiologija je podruËje koje brzo raste i u kojem tehnoloπki razvoj moæe podræati dijagnozu i kliniËko upravljanje
kod pacijenata s razliËitim kardioloπkim bolestima. OmoguÊavanjem prikupljanja kliniËkih podataka bez potrebe za
osobnim kontaktom, telemonitoring moæe skrb uËiniti pristupaËnijom pacijentima i ima potencijala za poboljπanje ishoda lijeËenja. Meutim, uspjeh pri uspostavi provedive telekardioloπke primjene je smanjen nemoguÊnoπÊu da se pribave uvjerljivi podaci o njezinom utjecaju na ishode zdravstvene skrbi te njezinoj isplativosti.
KljuËne rijeËi: telemedicina, telekardiologija, srËano zatajivanje, infarkt miokarda, aritmije, arterijska hipertenzija.
Telecardiology is a rapidly growing area where technological developments can support the diagnosis and clinical
management of patients with various cardiac diseases. By
allowing clinical data to be collected without the need for
face-to-face contact with patients, telemonitoring can make
care more accessible for patients and has the potential to
improve outcomes. However, success in establishing the
feasibility of Telecardiology applications is offset by a failure
to obtain convincing data on its effect on healthcare outcomes and on their cost-effectiveness.
Keywords: telemedicine, telecardiology, heart failure,
myocardial infarction, arrhythmias, hypertension.
*Corresponding author — E-mail: [email protected]
Literature
1. Atar S. Telecardiology - Close to the Heart, but Still out of Reach. IMAJ Isr Med Assoc J. 2011;13:496-7.
2. Birati E, Roth A. Telecardiology. Isr Med Assoc J. 2011;13:498-503.
3. Nieminen MS, Bohm M, Cowie MR. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the
European Society of Cardiology. Eur Heart J. 2005;26:384-416.
4. Woodend AK, Sherrard H, Fraser M, Stuewe L, Cheung T, Struthers C. Telehome monitoring in patients with cardiac disease who are at high risk of readmission. Heart Lung.
2008;37:36-45.
5. Klersy C, De Silvestri A, Gabutti G, Regoli F, Auricchio A. A meta-analysis of remote monitoring of heart failure patients. J Am Coll Cardiol. 2009;54:1683-94.
6. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355:2308-20.
7. Liem SS, van der Hoeven BL, Oemrawsingh PV et al. MISSION!: optimization of acute and chronic care for patients with acute myocardial infarction. Am Heart J.
2007;153(1):14.e1-14.e11.
8. Kaleschke G, Hoffmann B, Drewitz I, et al. Prospective, multicentre validation of a simple, patient-operated electrocardiographic system for the detection of arrhythmias and electrocardiographic changes. Europace. 2009;11:1362-8.
9. Singh SS, Hsiao HS. Development of a remote handheld cardiac arrhythmia monitor. Conf Proc IEEE Eng Med Biol Soc. 2006;1:3608-11.
10. Lazarus A. Remote, wireless, ambulatory monitoring of implantable pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy systems: analysis of a worldwide database. Pacing Clin Electrophysiol. 2007;30:S2-12.
11. Van der Velde ET, Foeken H, Witteman TA, van Erven L, Schalij MJ: Integration of data from remote monitoring systems and programmers into the hospital electronic health
record system based on international standards. Neth Heart J. 2012;20:66-70.
12. Green BB, Cook AJ, Ralston JD. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled
trial. JAMA. 2008;299:2857-67.
13. Bobrie G, Postel-Vinay N, Delonca J, Corvol P. Self-measurement and selftitration in hypertension. Am J Hypertens. 2007;20:1314-20.
2012;7(3-4):97.
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Proπireni saæetak / Extended abstract
Standardi zdravstvene informacijske tehnologije
(HIT) u telekardiologiji
Health Information Technology (HIT) Standards in
Telecardiology
Catherine E. Chronaki*
Foundation for Research and Technology - Hellas (FORTH), Heraklion, Kreta, GrËka
Foundation for Research and Technology - Hellas (FORTH), Heraklion, Crete, Greece
d vremena Einthovena, kardiologija je predstavljala
predvodnicu tehnoloπkih inovacija. Zdravstveni karton
kardioloπkog pacijenta moæe sadræati brojne vrste ispitivanja od razliËitih proizvoaËa: elektrokardiogrami, digitalni angiogrami, testovi optereÊenjem, laboratorijski testovi,
rendgen, MRI, ultrazvuk, itd. Spomenuto se dopunjava s
anamnezom, propisivanjem lijekova, kliniËkom slikom, dijagnostiËkim nalazima i dr. Standardi zdravstvene informacijske tehnologije (HIT) njeguju interoperabilnost, kako bi kliniËke informacije bile dostupne kao dio jedinstvenog ujedinjenog i aktivnog elektroniËkog zdravstvenog kartona, u
usuglaπenim otvorenim i od proizvoaËa nezavisnim formatima, a ne zaπtiÊenim zatvorenim sustavima.
Kako se pojavnost kardiovaskularnih bolesti poveÊava, integrirane telekardioloπke usluge namijenjene primarnoj zdravstvenoj zaπtiti, bolniËkoj skrbi i u domu pacijenta, postaju
kljuËni naËini ne samo uπtede, veÊ i poboljπanja pristupa i
kvalitete zdravstvene skrbi. Nadogradnjom HIT standarda,
telekardiologija dobiva moguÊnost selektivne integracije na
temelju kliniËkih smjernica, zdravstvenih podataka iz razliËitih izvora te nudi zdravstvenim struËnjacima uËinkovitost i
podrπku pri donoπenju odluka.
Ureaji za skrb o pacijentima i koordinacija skrbi za pacijente u sklopu inicijative Integriranja zdravstvene zaπtite rezultirali su s nekoliko profila integracije, koje je potrebno potvrditi i testirati na struËnim skupovima. Izgraeni su na prikladno ograniËenim HIT standardima kao πto su oni stvoreni od
strane HL7 i IEEE 11073. The Continua Health Alliance pruæa smjernice za dizajn i oznake kvalitete za interoperabilnost
struËnih zdravstvenih ureaja. Rani uspjesi utjecaja interoperabilnosti u telekardiologiji su prisutni. Cilj inovativnih projekata poput iCARDEA (inteligentna platforma za personalizirani nadzor pacijenata s implatibilnim kardijalnim elektroniËkim ureajima) je da integriraju podatke bolniËke dokumentacije, podatke o implantatima i osobne zdravstvene
kartone kako bi se poboljπalo donoπenje odluka.
Meutim, unatoË, uspjesima i zapaæenim dobrobitima, interoperabilnost je uvijek bila najslabija karika; komponenta koja
prva popuπta pod pritiskom proraËuna. Meutim, ako se ne
poduzmu uËinkovite investicije u interoperabilnost, jaz znanja izmeu opÊenito dostupnih i kliniËki korisnih/iskoristivih
podataka o pacijentima Êe se nastaviti proπirivati i biti izazov
za povjerenje sudionika u kvalitetu i istinsku vrijednost telekardioloπkih usluga.
ince the time of Einthoven, cardiology has been at the
forefront of technological innovation. The Health Record of a cardiology patient may include numerous types of investigations offered by potentially different manufacturers: electrocardiograms, digital angiograms, stress test,
lab tests, X-rays, MRI, U/S, etc. These are complemented
with medical history, prescriptions, clinical observations, diagnostic reports etc. Health Information Technology (HIT)
standards foster interoperability so that clinical information
can be available as parts of a single unified and active Electronic Health Record, in harmonized open vendor-independent formats rather than in dedicated closed systems.
As the prevalence of cardiovascular disease increases, integrated telecardiology services for primary, hospital, and home care, are critical means not only of saving costs, but also
of improving access and quality in healthcare. Building on
HIT standards, telecardiology gains the ability to selectively
integrate based on clinical guidelines, health information
from different sources, offering efficiency and decision support to health professionals.
The Patient Care Devices and Patient Care Coordination
domains of the Integrating the Healthcare Enterprise
Initiative have created, to be validated and tested in connectathons, several integration profiles build on appropriately
constrained HIT standards such as those created by HL7
and IEEE 11073. The Continua Health Alliance offers design
guidelines and quality labels for interoperability of personal
health devices. Early success stories on the impact of interoperability in telecardiology appear. Beyond that, innovative
projects like iCARDEA (an intelligent platform for personalized monitoring of patients with implantable cardiac electronic devices) aims to integrate data from hospital records,
implants, and personal health records for improved decision
making.
However, despite success stories and perceived benefits,
interoperability has always been the weakest link; the component that would go first under budget pressure. However,
unless effective investments in interoperability are made,
the gap of knowledge between the generally available and
the clinical useful/usable patient informationwill continue to
widen, challenging the stakeholders’ trust in the quality and
the true value of telecardiology services.
KljuËne rijeËi: telekardiologija, integracija, medicinski zapis.
*Corresponding author — E-mail: [email protected]
O
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S
Keywords: telecardiology, integration, health record.
Oralna prezentacija / Oral presentation
2012;7(3-4):98.
Proπireni saæetak / Extended abstract
Neinvazivna stratifikacija kardioloπkog rizika
Noninvasive cardiac risk stratification
Marek Malik*
St. Paul’s Cardiac Electrophysiology i St. George’s, University of London, London, Ujedinjeno Kraljevstvo
St. Paul’s Cardiac Electrophysiology and St. George’s, University of London, London, United Kingdom
ntiaritmijska profilaksa kod kardioloπkih pacijenata je
trenutno ograniËena na implantaciju kardioverter defibrilatora (ICD). Na temelju dostupnih prospektivnih podataka, odabir pacijenata za profilaktiËku implantaciju ICD
se trenutno temelji na dijagnozi reducirane ejekcijske frakcije lijeve klijetke (LV). Naæalost ovo nije niti osjetljiva niti specifiËna metoda. Niz kardioloπkih pacijenata trpi aritmijske
komplikacije uz oËuvanu funkciju LV, a samo manjina pacijenata s kompromitiranom ejekcijskom frakcijom LV naposljetku dobije aritmijske komplikacije. Stoga postoji stvarna
potreba za poboljπanjem strategija za identifikaciju pacijenata s poveÊanim rizikom od aritmije.
Kako bi osigurali πiroku primjenu novih strategija stratifikacije rizika te takoer smanjili povezane rizike kod pacijenata,
pozornost se prije svega daje neinvazivnom testiranju. Ono
se moæe karakterizirati prema standardnom konceptu podloænosti aritmiji tj. testovi koji primarno prikazuju abnormalni
supstrat miokarda, testovi koji dijagnosticiraju poveÊanu uËestalost okidaËa aritmija i istraæivanja abnormalnosti autonomnih i drugih modulatora kardioloπke regulacije koji, u normalnim okolnostima, predstavljaju prirodnu antiaritmijsku zaπtitu.
Dijagnoza abnormalnog supstrata miokarda veÊinom
ukljuËuje ispitivanja abnormalnih uzoraka aktivacije, koji se
pojavljuju ili bez pobude (kao πto je sluËaj kod elektrokardiografijom usrednjenih signala) ili na temelju specifiËnih pobuda (kao πto je procjena tzv. Wedensky modulacije). Karakterizacija aritmijskih okidaËa se primarno temelji na procjeni ektopijskih ritama i ektopijske dinamiËnosti kod dugoroËnih elektrokardiografskih snimaka. Abnormalnosti regulatornih modulatora veÊinom ukljuËuju testove autonomnog
kardijalnog statusa koji ne ukljuËuju samo mjerenje autonomnih modulacija kardijalne periodiËnosti, veÊ takoer i
kombinirane testove poput barorefleksne osjetljivosti. Uz
ova unidirekcionalna ispitivanja, postoje i druge strategije
procjene rizika koje koriste razliËite kombinacije ovih glavnih
aspekata rizika. One, primjerice ukljuËuju mikrovoltaæni alternans T-vala ili mjerenje heterogenosti repolarizacije i sinkronije za koje se Ëini da su kombinacija procjene supstrata
miokarda i aritmijskih modulatora.
Pojavljuje se koncenzus da uspjeπna stratifikacija rizika od
aritmije mora ukljuËivati stepeniËastu strategiju s ukljuËenih
viπe Ëimbenika rizika, jer je malo vjerojatno da bi jedan Ëimbenik rizika bio dostatno osjetljiv i specifiËan za optimalni
odabir pacijenata za profilaktiËke aritmijske intervencije.
Odista, nedavno su se pojavile multivarijatne studije koje
vode u ovom smjeru.
KljuËne rijeËi: stratifikacija rizika, aritmija, funkcija lijeve klijetke.
*Corresponding author — E-mail:
[email protected]
A
2012;7(3-4):99.
ntiarrhythmic prophylaxis in cardiac patients is presently restricted to the implantation of cardioverters defibrillators (ICD). Based on available prospective data,
the selection of patients for prophylactic ICD implantation is
currently based on the diagnosis of reduced left ventricular
(LV) ejection fraction. Unfortunately, this is neither sensitive
nor specific. A number of cardiac patients suffer from arrhythmic complications while having preserved LV performance and only a minority of patients with compromised LV
ejection fraction eventually suffer from arrhythmic complications. There is therefore a substantial unmet need to improve the strategies for the identification of patients at increased arrhythmic risk.
In order to ensure broad applicability of novel risk stratification strategies as well as to reduce the associated medical
risks to the patients, attention is primarily been given to noninvasive tests. These could be broadly characterized according to the standard concept of arrhythmia susceptibility that
is tests primarily depicting abnormal myocardial substrate,
tests diagnosing increased incidence of arrhythmic triggers,
and investigations of the abnormalities of autonomic and
other modulators of cardiac regulation which, under normal
circumstances, represent the natural anti-arrhythmia defence.
The diagnosis of abnormal myocardial substrate mainly
include investigations of abnormal activation patterns, either
occurring without any provocation (such as in the diagnosis
of signal average electrocardiography) or based on specific
provocations (such as the assessment of the so-called Wedensky modulation). Characterization of arrhythmic triggers
is predominantly based on the evaluation of ectopic rhythms
and ectopic dynamicity in long term electrocardiographic recordings. Abnormalities of the regulatory modulators include
mainly the tests of cardiac autonomic status which comprise
not only the measurement of the autonomic modulations of
cardiac periodicity but also combined tests such as the baroreflex sensitivity. In addition to these unidirectional investigations, there are other risk assessment strategies that
combine different combinations of these principal risk
facets. These include, for instance, microvolt T wave alternans or the measurement of repolarisation heterogeneity
and repolarisation synchrony which appear to be a combination of the assessment of myocardial substrate and arrhythmia modulators.
A consensus emerges that successful arrhythmia risk stratification will need to involve multifactorial stepwise strategies since it is unlikely that a single risk factor would be
found sufficiently sensitive and specific for the optimum
selection of patients for prophylactic anti-arrhythmic interventions. Indeed, multivariate studies have recently appeared pointing in this direction.
Keywords: risk stratification, arrhythmia, left ventricular
function.
A
Oralna prezentacija / Oral presentation
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Proπireni saæetak / Extended abstract
Elektrokardiografske varijable za predvianje vodeÊe
lezije kod pacijenata s akutnim infarktom miokarda
Electrocardiographic criteria for predicting the culprit
artery in patients with acute myocardial infarction
Niek van der Putten*
Erasmus Medical Centre Rotterdam, Rotterdam, Nizozemska
Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
nvazivno lijeËenje pacijenata sa simptomima akutne ishemije miokarda pomoÊu perkutane koronarne intervencije
(PCI) prihvaÊeno je naπiroko. Elektrokardiogram (EKG)
snimljen od lijeËnika obiteljske medicine ili hitne medicinske
pomoÊi smatra se najvaænijim testom za dijagnosticiranje
akutnog infarkta miokarda (AIM).
Na temelju EKG zapisa i anamneze odluËuje se koje je lijeËenje najprikladnije kod pojedinog pacijenta. Sukladno trenutnim smjernicama pacijenti s infarktom miokarda s elevacijom ST-segmenta (STEMI) i pacijenti s infarktom miokarda
bez elevacije ST-segmenta (NSTEMI) stratificiraju se razliËito. Pacijenti sa STEMI bi trebali biti upuÊeni u primarni PCI
centar,a oni sa NSTEMI bi trebali biti upuÊeni u lokalnu bolnicu na dodatnu dijagnostiku i lijeËenje.
U ovoj prezentaciji se usporeuje niz EKG kriterija za predvianje vodeÊe lezije u pacijenata sa STEMI. Takoer procjenjujemo uËinkovitost ovih kriterija kod pacijenata koji nisu
imali kriterije za STEMI, iako imaju AIM. Sposobnost identifikacije vodeÊe lezije i mjesta okluzije unutar arterije moæe
imati viπestruke potencijalne koristi. Prije svega bi trebala
dati identifikaciju podruËja koje je pod rizikom od ishemije i
posljediËno njezinu teæinu. Ova informacija bi mogla biti
ukljuËena u trenutne metode poËetne stratifikacije rizika u
centrima intervencijske kardilogije. Nadalje, mogla bi biti korisna u sluËajevima u kojima se razmatra reperfuzijska terapija, tj. u bolnicama koje su znaËajno udaljene od intervencijskog centra1.
Mnogi se algoritmi, temeljeni na EKG zapisu, koriste za
predvianje s infarktom povezane arterije. Usporedili smo
kriterije iz Ëlanaka Fiol i sur2 te Tierala i sur3. Populacija studije se sastojala od pacijenata koji su podvrgnuti PCI za
lijeËenje AIM na jednom od Ëetiri sveuËiliπna PCI centra.
Baza podataka je sadræala 659 dobro dokumentiranih PCI
postupaka na pacijentima koji su bolovali od jednoæilne bolesti s TIMI protokom (tromboza kod infarkta miokarda) vrijednosti nula. Samo 65 % EKG zapisa zadovoljilo je kriterije za
STEMI. Ovaj rezultat ne iznenauje ako se u obzir uzme
Ëlanak Wang i sur4 koji pokazuje da je u skupini od 1957
NSTEMI pacijenata, 528 (27%) imalo u potpunosti okludiranu vodeÊu leziju.
Kriterij koji predlaæe Tierala ima najbolju uËinkovitost za detektiranje vodeÊe lezije u sluËajevima STEMI, iako su za
I
Kardio LIST
nvasive treatment through percutaneous coronary intervention (PCI) of patients experiencing symptoms of acute
myocardial ischemia has become widely accepted. The
ECG recorded by the alarmed general practitioner or ambulance nurse is considered the most important test for diagnosing acute myocardial infarction (AMI).
On basis of the ECG and presenting history of the patient is
decided which treatment is most adequate. According to the
current guidelines patients with ST-segment elevation myocardial infarction (STEMI) and patients with non-ST-elevation myocardial infarction (NSTEMI) are differently stratified.
The STEMI patient should be transported to a primary PCI
centre. The NSTEMI patient should be referred to a local
hospital for further diagnosis and alternative treatment.
In this presentation a variety of ECG criteria for predicting
the culprit artery in cases with STEMI are compared. We
also assess the performance of these criteria for patients
who did not meet the STEMI criteria although having an
AMI. The ability to identify the culprit artery and the site of
the occlusion within the artery may have multiple potential
benefits. Firstly it would provide an indication of the area at
risk of ischaemia and consequently its severity. This information could be incorporated into current methods of initial
risk stratification in PCI centres. Furthermore it may be useful in situations where reperfusion therapy is contemplated,
i.e. in settings far from a PCI centre1.
Many algorithms have been proposed to predict the possibly
infarct related arteries based on measurements in the ECG.
We have compared the criteria of Fiol et al2 and of Tierala et
al3. The study population consisted of patients who underwent a PCI for treatment of AMI in one of four university PCI
centres. The database contained 659 well documented PCI
procedures of patients suffering from a single-vessel disease with TIMI (Thrombolysis In Myocardial Infarction) flow
grade zero. Only 65 % of the ECG’s fulfilled STEMI criteria.
This result is not so surprising given the paper of Wang et
al4 demonstrating that, in a group of 1957 NSTEMI patients,
528 (27%) had a completely occluded culprit artery.
The criteria proposed by Tierala have the highest performance for detecting the culprit artery in STEMI cases, although for some arteries specificity and sensitivity values
were low. E.g.: For LCx, the algorithms of Fiol and Tierala
I
Oralna prezentacija / Oral presentation
2012;7(3-4):100.
neke arterije vrijednosti specifiËnosti i osjetljivosti bile niske.
Npr. za LCx, algoritmi prema Fioli i Tieralu su pokazali izvrsnu specifiËnost, no osjetljivost je bila niska. UËinkovitost je
znaËajno niæa kod pacijenata koji nemaju ispunjene kriterije
za STEMI. Kriteriji koji bi bolje predvidjeli vodeÊe lezije u
cijeloj skupini pacijenata s AIM predmet su trenutnih istraæivanja. Ustanovili smo korisni uËinak ukljuËivanja QRS-kompleksa i T-vala na osjetljivost i specifiËnost5.
show excellent specificities, but sensitivities are low. Performances are significantly lower in patients who do not
meet the STEMI criteria. Improved criteria that better predict
the culprit artery in the whole group of AMI patients are currently under investigation. We found a beneficial effect of inclusion of QRS and T-wave features on sensitivity and specificity5.
KljuËne rijeËi: akutni infarkt miokarda, EKG, stratifikacija
rizika.
Keywords: acute myocardial infarction, ECG, risk stratification.
*Corresponding author — E-mail:
[email protected]
Literature
1. Waduud MA, Clark EN, Payne A, Berry C, Sejersten M, Clemmensen P, et al. Location of the culprit artery in acute myocardial infarction using the ECG. Computing in Cardiology
2011;38:417-20.
2. Fiol M, Cygankiewicz I, Carrillo A, Bayés-Genis A, Santoyo O, Gómez A, et al. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction. Am J Cardiol. 2004;94:709-14.
3. Tierala I, Nikus KC, Sclarovsky S, Syvänne M, Eskola M; HAAMU Study Group. Predicting the culprit artery in acute ST-elevation myocardial infarction and introducing a new
algorithm to predict infarct-related artery in inferior ST-elevation myocardial infarction: correlation with coronary anatomy in the HAAMU Trial. J Electrocardiol. 2009;42:120-7.
4. Wang TY, Zhang M, Fu Y, Armstrong PW, Newby LK, Gibson CM, et al. Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non-STelevation acute coronary syndromes undergoing diagnostic angiography. Am Heart J. 2009;157:716-23.
5. Maan AC, Dijk WA, van der Putten NHJJ, Man S, Rahmatullah C, van Zwet E, et al. A vector cardiographic based method to determine the culprit artery in acute coronary syndrome. Computing in Cardiology 2011;38:409-12.
2012;7(3-4):101.
Kardio LIST
Proπireni saæetak / Extended abstract
Kardiorespiratorna dinamika
Cardio-Respiratory Dynamics
Georg Schmidt*
Technische Universität München, München, NjemaËka
Technische Universität München, München, Germany
rocjena rizika nakon infarkta miokarda ostala je nezahvalna. Refleksne respiratorne reakcije na srËane sindrome imaju prognostiËku vrijednost, ali su teπke za
rutinsko mjerenje. U suvremeno lijeËenih skupini akutnih pacijenata s akutnim infarktom miokarda (IM), testirali smo donosi li frekvencija disanja dodatnu dobrobit rezultatima
GRACE ljestvice i ejekcijskoj frakciji lijeve klijetke (LVEF).
P
R
Metode
Design
Prospektivna kohortna studija provedena je u dva tercijarna
centra. Pacijenti su u ispitivanje bili ukljuËeni odmah nakon
IM ako su bili u sinusnom ritmu, imali £80 godina te ako su
pristali sudjelovati. UkljuËenje u studiju poËelo je u svibnju
2000. god., a zavrπilo u oæujku 2005 god. Zadnja kontrola
provedena je u srpnju 2010. god. Svi su pacijenti bili podvrgnuti desetominutnom snimanju disanja u opuπtenom stanju nakon infarkta miokarda (prosjeËno 7. dana) uz standardne kliniËke procjene, ukljuËujuÊi vrijednost prema GRACE ljestvici temeljem devet varijabli. Glavni ishod bila je
ukupna smrtnost pacijenata.
This was a prospective cohort study performed in two tertiary care centers. Patients were included immediately after
MI if they were in sinus rhythm, £80 years and consented to
participate. Enrollment started May 2000 and ended March
2005. Last follow-up was performed July 2010. All patients
underwent 10-minute resting recordings of respiratory after
MI (median on day 7) alongside standard clinical assessment including the 9-element GRACE score. Main outcome
measure was total mortality.
Rezultati
During a follow up of 5 years, 72 patients died. Respiratory
rate was a significant predictor of death in univariate analysis (hazard ratio 1.19 per 1/min, 95%-confidence interval
1.12-1.27) as was the GRACE score (1.04 [1.03-1.05] per
point), LVEF (0.96 [0.94-0.97] per 1%) and diabetes (2.78
[1.73-4.47]), all p<0.0001. On multivariate analysis, GRACE
score (p<0.0001), respiratory rate (p<0.0001), LVEF
(p=0.013) and diabetes (p=0.016) were independent prognostic markers.
Tijekom petogodiπnjeg praÊenja, 72 pacijenata je preminulo.
Frekvencija disanja bila je znaËajan prediktor smrti u univarijatnoj analizi (hazard ratio 1,19 za 1/min, 95%-pouzdanost
intervala 1,12-1,27), kao πto je bio i GRACE rezultat (1,04
[1,03-1,05] po bodu), LVEF (0,96 [0,94-0,97] za 1%) i dijabetes (2,78 [1,73-4,47]), sve p<0,0001. Multivarijatna analiza je utvrdila da su rezultat GRACE ljestvice (p<0,0001),
frekvencija disanja (p<0,0001), LVEF (p=0,013) i dijabetes
(p=0,016) neovisni prognostiËki biljezi.
isk stratification after myocardial infarction (MI)
remains imperfect. Reflex respiratory responses to
cardiac syndromes are prognostic but difficult to measure routinely. In a contemporarily-treated cohort of acute MI
patients, we tested whether respiratory rate is a useful adjunct to global standard risk assessment (GRACE score)
and left ventricular ejection fraction (LVEF).
Results
Conclusions
ZakljuËak
Pored rezultata GRACE ljestvice koja se temelji na devet
varijabli, frekvencija disanja i LVEF donose snaænu prognostiËku informaciju. Za globalnu procjenu rizika nakon IM potrebno je uzeti u obzir frekvenciju disanja kao jednostavnu,
dostupnu i jeftinu varijablu.
KljuËne rijeËi: stratifikacija rizika, frekvencija disanja, ejekcijska frakcija lijeve klijetke.
Kardio LIST
Respiratory rate provides powerful prognostic information
alongside 9-element GRACE score and LVEF. Simple, instant, and inexpensive, respiratory rate should be considered for global assessment of risk after MI.
Keywords: risk stratification, respiratory rate, left ventricular
ejection fraction.
*Corresponding author — E-mail: [email protected]
Oralna prezentacija / Oral presentation
2012;7(3-4):102.
Proπireni saæetak / Extended abstract
Intervencijska kardiologija - dosezi
Interventional cardiology - State of the art
Robert Steiner*
KliniËki bolniËki centar Osijek, Osijek, Hrvatska
University Hospital Centre Osijek, Osijek, Croatia
d doba Andreasa Gruentziga i prve perkutane koronarne intervencije (PTCA, PCI) 1977. god. uz uspjehe prisutne su i komplikacije (akutna, subakutna, kasna i vrlo kasna tromboza/okluzija stenta). Postavljanjem
metalnih stentova (BMS), kasnije stentova obloæenih lijekom
(DES), uvoenjem dvojne antitrombotske terapije (DAPT)
komplikacije su sve rjee, no i dalje prisutne, ali su se pojavili novi problemi (krvarenje, trajanje DAPT, rezistencija).
Pojavila se nova generacija stentova sa ili bez biodegradibilnih polimera, obloæenih novim lijekovima ili potpuno biodegradibilnih stentova koji se ispituju u kliniËkim studijama.
Sve je to dovelo do sve πirje primjene PCI i kod riziËnijih
skupina bolesnika te sve boljih rezultata kod stenoza glavnog stabla, bifurkacijskih stenoza, kroniËnih totalnih okluzija
(CTO), viπeæilne koronarne bolesti srca (KBS) i stenoza premosnica1. Postavljanje BMS nije stvar proπlosti. Kod bifurkacijskih stenoza BMS se preporuËuju kod postavljanja jednog
stenta, a DES kod postavljanja dva, no tada je veÊi rizik
periproceduralnog infarkta. DES je kvalitetnije rjeπenje za
CTO. Pojavnost kasnih i vrlo kasnih tromboza stenta ËeπÊa
je kod kroniËnih bubreænih bolesnika, CTO, starijih od 65
godina i ponovljene PCI. Druga generacija stentova nije se
pokazala boljom od SES, mada su izvrsni rezultati Serruys i
sur s drugom generacijom bioresorbilnih EES2. Najuæa indikacija za DES su inzulin ovisni dijabetiËari, manje koronarne arterije 3 mm i duæe stenoze 30 mm uz dobro postavljanje stenta.
Stent ili premosnica na SYNTAX studija daje prednost ugradnji premosnice (CABG) spram PCI sa DES kod veÊeg rezultata na Syntax ljestvici3. Elektivna PCI neprotektiranog
glavnog stabla lijeve koronarne arterije je prema istoj studiji
uspjeπna, ali je povezana s ËeπÊom revaskularizacijom nakon postavljanja DES, a nakon CABG je ËeπÊi moædani
udar. Kod bolesnika s viπeæilnom KBS ista studija daje prednost CABG naspram PCI, no ostala su otvorena pitanja (Taxus stent, trajanje dvojnog antitrombocitnog lijeËenja)4.
CARDIO i ARTS II studije su dale podjednake rezultate
PCI:CABG uz primjenu SES.
Rezultati FAME studije su pokazali da se nakon primjene
fractional flow reserve smanjuje broj postavljenih stentova i
komplikacija5. Colombova studija o uporabi IVUS prije
postavljanja stenta nije pokazala manju uËestalost komplikacija.
Rutinsko postavljanje intraaortalne pumpe (IABP) kod visoko riziËnih bolesnika nije preporuËljivo prema BCIS studiji6,
iako joπ nema preciznije definicije optimalnog vremena postavljanja IABP u kardiogenom πoku, a bolji su rezultati kod
postavljanja IABP prije intervencije.
O
2012;7(3-4):103.
rom the time of Andreas Gruentzig and the first percutaneous coronary intervention (PTCA, PCI) in 1977 there were successes but also complications (acute, subacute, late and very late thrombosis/occlusion of the stent).
By placing bare metal stents (BMS), drug-eluting stents
(DES) later, the introduction of dual antiplatelet therapy
(DAPT) complications are less frequent but still present, but
there appeared new problems (bleeding, duration of DAPT,
resistance on DAPT). A new generation of stents with or without biodegradibil polymer-coated, new eluting-drugs or
completely bioresorbable stents that are being tested in clinical studies. All this led to the widespread application of
PCI on the high-risk group of patients, and better results for
left main stenosis, bifurcation stenosis, chronic total occlusion (CTO), multi-vessel coronary artery disease (CAD) and
coronary artery bypass graft (CABG) stenosis1. BMS is not
the past. At bifurcation stenosis BMS are recommended
when one stent is going to be placed, DES for setting up two
stents, but then there is a higher risk of periprocedural myocardial infarction. DES is a better solution for CTO. Prevalence of late and very late stent thrombosis is more common in chronic renal patients, CTO, aged 65 years or more
and repeated PCI. The second-generation stents did not
proved to be better than SES, although there are excellent
results from Serruys et al with the second generation bioresorbable EES2. The narrowest indications for DES were insulin dependent diabetics, smaller coronary arteries 3 mm,
and stenosis 30 mm long with a well-stenting.
Stent or bypass? SYNTAX study preferred CABG vs. PCI
with DES when SYNTAX score3 is high. Unprotected elective PCI of a left main coronary artery stenosis in the SYNTAX study is successful, but is associated with more frequent revascularization after placing DES, and stroke was
more common after CABG. In patients with CAD the same
study in patients with multivessel disease studies favors
CABG toward PCI, but there remained an some questions
(Taxus stent, the duration of DAPT)4. CARDIO and ARTS II
studies have yielded similar results PCI:CABG with the use
of SES.
FAME study results showed that fractional flow reserve
reduces the number of stents and complications5. Colombo`s study with the use of IVUS and before placing stent did
not show a lower incidence of complications.
Routine setting intra-aortic ballon pump (IABP) in high-risk
patients is not recommended by BCIS Study6, whereas
there is no precise definition of the optimal time for placing
IABP in cardiogenic shock, and better results are when
IABP is placed before the intervention.
F
Oralna prezentacija / Oral presentation
Kardio LIST
NajuËinkovitija prevencija kontrastne nefropatije je infuzija
fizioloπke otopine prije intervencije, a najugroæeniji su bolesnici s niskom sistoliËkom funkcijom lijeve klijetke i uporabom veÊe koliËine kontrasta7.
U akutnom infarktu miokarda izuzetno je vaæno πto kraÊe vrijeme do intervencije, a manje od 90min od prvog pregleda i
postavljanja dijagnoze do intervencije (door-to-ballon). Dodatno prekondicioniranje miokarda smanjuje infarcirano
podruËje8.
Postavljanje stenta, naroËito DES, optimalnije je rjeπenje od
PTCA kod bolesnika s perifernom vaskularnom bolesti, naroËito kod distalnijih stenoza. Endarterektomija ili stent u
revaskularizaciji karotidnih arterija ostaje dilema, kao i kod
aneurizme abdominalne aorte. Kateterska renalna simpatiËka denervacija je dala dobre rezultate u lijeËenju rezistentne
arterijske hipertenzije, Ëime se postiglo smanjenje sistoliËkog tlaka za viπe od 10 mmHg u 84% bolesnika bez komplikacija. BuduÊe studije bi trebale pokazati uËinkovitost metode kod bolesnika s umjerenim stupnjem arterijske hipertenzije9.
Transkatetersko postavljanje aortalnog zaliska je uspjeπno,
a dovodi i do poboljπanja sistoliËke funkcije srca kod inoperabilnih, ali i visokoriziËnih bolesnika10. Postavljanje MitraClip kod znaËajne mitralne regurgitacije u inoperabilnih bolesnika je dugoroËno podjednako s operativnom korekcijom,
ali su kratkoroËni rezultati bolji11.
Nakon transradijalnog pristupa tijekom PCI manje je vaskularnih komplikacija te se sve ËeπÊe primjenjuje i u akutnom
infarktu miokarda.
KljuËne rijeËi: perkutana koronarna intervencija, aortokoronarno premoπtenje, stentovi obloæeni lijekovima.
The most effective prevention of contrast nephropathy is the
infusion of saline before the intervention, and the most vulnerable patients are those with low left ventricular systolic
function and use of larger amounts of contrast7.
In acute myocardial infarction it is extremely important to
have a shorter time until intervention and less than 90 minutes from the initial examination and diagnosis to intervention (door-to-balloon). In addition, preconditioning decreases myocardial infarction size8.
Stenting in particular DES is optimal solution for PCI in
patients with peripheral vascular disease, especially in the
distal artery stenosis. Endarterectomy or stent in the carotid
artery revascularization remains a dilemma as with abdominal aortic aneurysms.
Catheter renal sympathetic denervation has good results in
treating resistant hypertension, which can achieve reduction
in systolic blood pressure more than 10 mmHg in 84% of
patients without complications. Future studies should demonstrate the effectiveness of the method in patients with
moderate hypertension9.
Transcatheter aortic valve implantation is successful and
leads to an improvement in systolic function in inoperable,
as well as high-risk patients10. Implantation of MitraClip in a
significant mitral regurgitation in inoperable patients has
same long-term results as surgery, but the short-term results
are better11.
After PCI with transradial access there are less vascular
complications and therefore is increasingly used even in
acute myocardial infarction.
Keywords: percutaneous coronary intervention, CABG,
drug-eluting stent.
*Corresponding author — E-mail:
[email protected]
Literatura
1. Garg S, Serruys PW. Coronary stents. J Am Coll Cardiol. 2010; 56:43-78.
2. Serruys PW, Onuma Y, Ormiston JA, et al. Evaluation of the second generation of a bioresorbable everolimus drug-eluting vascular scafold for treatement of de novo coronary
artery stenosis. Six month cinical and imaging outcomes. Circulation. 2010;122:2301-12.
3. Banning AP, Westaby S,Morice MC, et al. Diabetic and non diabetic patients with left main and/or 3-vessel coronary artery disease. Comparison of outcomes with cardiac surgery and paclitaxel-eluting stents. J Am Coll Cardiol. 2010;55:1067-75.
4. Morice MC, Serruys PW, Kappetein AP, et al. Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using PaclitaxelEluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial.
Circulation. 2010;121:2645-53.
5. Tonino PAL, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenosis in the FAME study. J Am Coll Cardiol. 2010;55:2816-21.
6. Perera D, Stables R, Thomas M, et al. Elactive intra-aortic balloon counterpulsation during high-risk percutaneous coronary intervention: a randomized controlled trial. JAMA.
2010;304:867-74.
7. Seeliger E, Sendeski M, Rihal CS, Persson P. Contrast-induced kidney injury: mechanisms, risk factors, and prevention. Eur Heart J. 2012; doi: 10.1093/eurheartj/ ehr494 First
published online:January 19, 2012.
8. Botker HE, Kharbanda R, Schmidt M, et al. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in
patients with acute myocardial infarction: a randomised trial. Lancet. 2010;375:727-34.
9. Krum H, Schlaich M, Sobotka P, et al. Novel procedure- and device-based strategies in the management of systemic hypertension. Eur Heart J. 2011;32(5):537-44.
10. Webb J, Cribier A. Percutaneous transarterial aortic valve implantation: what do we know? Eur Heart J 2011;32(2):140-7.
11. Van den Branden BJ, Swaans MJ, Post MC, et al. Percutaneous edge-to-edge mitral valve repair in high-surgical-risk patients. JACC Cardiovasc Interv. 2012;5(1):105-11.
Kardio LIST
2012;7(3-4):104.
Proπireni saæetak / Extended abstract
Novi multimodalni pristup procjeni rizika od
iznenadne smrti
A new multimodal approach to evaluate the risk of
sudden death
Philippe Chevalier*
Hospices Civils de Lyon, Lyon, Francuska
Hospices Civils de Lyon, Lyon, France
nfarkt miokarda (IM) uzrokuje simpatiËku ventrikulsku
denervaciju praÊenu reinervacijom simpatikusa. Iako su
opseg i karakteristike takve reinervacije i dalje neizvjesne,
jasno je da infarkt rezultira heterogenom distribucijom simpatiËke inervacije i tako diferencijalnom simpatiËkom aktivnoπÊu. Ova heterogenost bi mogla imati ulogu modifikatora
nastanka kruænog mehanizma koji stvara uvjete za nastanak po æivot opasnih ventrikulskih aritmija. Isto aritmogeno
okruæenje je vjerojatno u uroenom long QT sindromu. Zanimljivo je da pacijentima s ovim sindromom i onima s IM
pomaæu beta-blokatori. Kod pacijenata s IM, poveÊanje muskarinskih receptora (odnosno poveÊana endogena betablokada uslijed vagusne stimulacije) moæe djelovati kao mehanizam za smanjenje aritmogenosti heterogenih simpatiËkih aktivnosti. Trenutno, samo snimanja PET ureajem
mogu kvantificirati muskarinske receptore u ventrikulu.
Naπa studija, koristeÊi pojednostavljen 2-injekcijski protokol,
ukazuje na izvedivost ovog pristupa u kliniËkom okruæenju.
Osjetljivost barofleksa i varijabilnost srËanog ritma uveliko
su povezani s vagusnom kontrolom srca i utvrene su kao
korisne odrednice rizika nakon IM. Meutim, ovi markeri su
primarno indikatori parasimpatiËke inervacije u sinusnom
Ëvoru, a ne ventrikulskih miocita. Ova Ëinjenica moæe objasniti zaπto trenutno dostupne tehnike ne uspijevaju efikasno
stratificirati pacijente s preboljelim infarktom za nastanak
ventrikulskih aritmiËkih zbivanja. Zapravo, u veÊini studija
gdje je koriπteno neinvazivno testiranje, ne radi se razlika
izmeu smrtnosti od ostalih uzroka i smrtnosti od iznenadne
smrti. Ukazali smo da je QT dinamiËnost poseban marker
miokardijalne elektriËne nestabilnosti. Dodatne studije koje
integriraju razliËite alate, genotipizaciju, snimke presjeka i
neuroloπko oslikavanje te Holter analizu, potrebne su za
bolju identifikaciju pacijenata koji bi mogli imati znatne koristi od automatskog defibrilatora.
yocardial infaction (MI) leads to ventricular sympathetic denervation followed by sympathetic reinnervation. Although the extent and characteristics of
such reinnervation remain uncertain, it is clear that infarction
results in the heterogeneous distribution of sympathetic
innervation and thus in differential sympathetic activity. This
heterogeneity could play a modifier role as a substrate of
reentry that favors life-threatening ventricular arrhythmias.
The same arrhythmogenic setting has been suggested in
congenital long QT syndrome. Interestingly, patients with
this syndrome and those with MI both benefit from betablockers. In patients with MI, the upregulation of muscarinic
receptors (ie, increased endogenous beta-blocking due to
vagal stimulation) could act as the mechanism attenuating
the arrhythmogenicity of heterogeneous sympathetic activity. At present, only PET cardiac imaging can quantify muscarinic receptors in the ventricle. Our study using a simplified 2-injection protocol demonstrated the feasibility of this
approach in the clinical setting. Baroreflex sensitivity and
heart rate variability are grossly associated with vagal control of the heart, and they have been found to be useful risk
stratifiers after MI. However, these markers are primarily
indicators of parasympathetic innervation of the sinus node,
not the ventricular myocyte. This fact may explain why currently available techniques fail to effectively stratify infarcted
patients for the risk of ventricular arrhythmic events.
Actually, in most studies using noninvasive testing, no differentiation is made between the mortality from all causes and
mortality from sudden death. We have demonstrrated that
QT dynamicity was a specific marker of the myocardial electrical instability. Additional studies integrating various tools,
genotyping, cross-sectionnal and neuro imaging and Holter
analysis, are needed for better identification of patients who
will benefit most from automatic defibrillator.
KljuËne rijeËi: infarkt miokarda, aritmije, stratifikacija rizika.
Keywords: myocardial infarction, arrhythmias, risk stratification.
I
M
*Corresponding author — E-mail:
[email protected]
2012;7(3-4):105.
Oralna prezentacija / Oral presentation
Kardio LIST
Proπireni saæetak / Extended abstract
Kateterska ablacija atrijske fibrilacije:
od dijagnostiËkog slikovnog prikaza,
preko 3D navigacije do nadzora u praÊenju
Catheter ablation of atrial fibrillation:
from preprocedural imaging, through 3D navigation
to follow-up monitoring
Robert Bernat*
Magdalena - Klinika za kardiovaskularne bolesti, Krapinske Toplice, Hrvatska
Magdalena - Clinic for cardiovascular diseases, Krapinske Toplice, Croatia
trijska fibrilacija (AF) najËeπÊa je aritmija u kliniËkoj
praksi. Prevalencija se znaËajno poveÊava s dobi, a u
ukupnoj populaciji kreÊe se izmeu 1-2%. Kateterska
ablacija AF odnosi se na ablacijske postupke uglavnom u
lijevom atriju (LA) s ciljem kontrole ritma. Najbolji rezultati
(kontrola ritma tijekom najmanje godine dana i do 90%) mogu se oËekivati kod mlaih bolesnika (<65 godina), bez uznapredovale strukturne bolesti srca (ukljuËujuÊi arterijsku
hipertenziju), ne bitno dilatiranim LA, kraÊom anamnezom
recidivirajuÊe paroksizmalne znaËajno simptomatiËne AF.
Kod dobrih kandidata postupak se odnosi u prvom redu na
izolaciju uπÊa pluÊnih vena, Ëime se djeluje na dominirajuÊi
patofizioloπki mehanizam okidaËa koji su ovdje anatomski
locirani. Kod bolesnika s duljom anamnezom, permanentnom ili perzistentnom AF, velikim LA, uznapredovanom
strukturnom boleπÊu srca i starije æivotne dobi patofizioloπki
dominantnu ulogu igra promjena supstrata (bolest LA), pa
su rezultati oËekivano loπiji (uspjeπna kontrola ritma u 5060% sluËajeva). Postupak se ovdje mora proπiriti na Ëitav LA
(dijelom imitirajuÊi klasiËni kirurπki postupak tzv. maze operacije, tj. stvaranja odjeljaka u LA).
Moderna kardiologija neizostavno koristi kompjutorsku
tehnologiju u svim segmentima dijagnostike i terapije. Iz
uvoda je razvidno da nam pomoÊ kompjutorizirane tehnologije procesu planiranja, izvedbe i praÊenja nakon kateterske
ablacije AF treba na viπe razina. Osim u dijagnostici paroksizmalne AF (24-satni Holter, transtelefonski elektrokardiogram), u planiranju zahvata moæe pomoÊi kompjutorizirana
tomografija i/ili nuklearna magnetska rezonancija. Obje pretrage u prvom redu sluæe za konstruiranje trodimenzionalne
slike samog LA i pluÊnih vena. Ove su strukture glavni cilj
ablativnog postupka i istovremeno su podloæne vrlo znaËajnim anatomskim varijacijama te je stoga precizan prikaz od
velike pomoÊi u planiranju postupka.
Sam se zahvat danas tipiËno izvodi uz pomoÊ kompjutoriziranog sustava za tzv. 3D navigaciju. Radi se o vrlo sofisticiranoj tehnologiji koja se temelji na moguÊnosti da raËunalo
prepoznaje vrh ablacijskog katetera (ali i ostalih katetera u
srcu) u elektromagnetskom polju koje generira dio ureaja
koji se postavlja ispod grudnog koπa pacijenta. Potom se
A
Kardio LIST
trial fibrillation (AF) is the most common arrhythmia in
clinical practice. The prevalence significantly increases with age, amounting to up to 1-2% in general population. Catheter ablation of AF implies ablative procedures
mostly confined to the left atrium (LA) with the goal of rhythm
control. The best results (rhythm control up to 90% after at
least one year) can be expected in younger patients (<65
years), with no advanced structural heart disease (including
hypertension), no significant LA dilatation, shorter history of
repeating paroxysmal symptomatic AF. In good candidates,
the procedure typically involves pulmonary vein ostia isolation, acting on the dominant pathophysiologic trigger mechanism, which is usually located in this area. In patients
with longer disease history, persistent or permanent AF, large LA, advanced structural heart disease and older age, the
dominant pathophysiological role is assigned to the substrate change (LA disease), so the results are less impressive (successful rhythm control in 50-60% of cases). Here,
the procedure may be extended to the whole LA (partially
imitating the classic surgical procedure of the so-called
maze operation, i.e. compartmentalization of the LA).
Modern cardiology inevitably uses computerized technology
in all segments of diagnostics and therapy. As stated in the
introduction, it is clear that we need help of this technology
during the process of planning, performing and follow-up
after AF catheter ablation. Besides in diagnostics of paroxysmal AF (24-hour ECG Holter, transtelephonic ECG),
computerized tomography and/or nuclear magnetic imaging
also may help. Both procedures are used for obtaining a
three-dimensional image of the LA itself and the adjacent
pulmonary veins. It is these structures that are the main target of the ablation procedure, as they are at the same time
subject to large anatomical variations, thus making a precise
imaging a major help in planning of the procedure.
Today, the procedure is typically performed using a computerized 3D-navigation system. This is a highly sophisticated
technology which is based on the ability of the computer to
recognize the distal part of the ablation catheter (but also
other catheters in the area) within an electromagnetic field
generated by a part of the device which is placed under the
A
Oralna prezentacija / Oral presentation
2012;7(3-4):106.
pokretima katetera “slika” 3D rekonstrukcija atrija (koja se u
idealnom sluËaju s vrlo velikom toËnoπÊu poklapa s nalazima CT ili NMR snimke). Nakon rekonstrukcije LA i poËetnih
segmenata pluÊnih vena, pristupa se terapijskom dijelu zahvata, pri Ëemu se radiofrekventnom (RF) energijom stvaraju
toËkaste lezije u podruËju LA neposredno ispred uπÊa pluÊnih vena. Spajanje toËkastih lezija u konaËnici stvara “linije”
koje imaju za cilj elektriËki izolirati pluÊne vene od ostatka
LA, Ëime se postiæe terapijski cilj, tj. suzbijaju napadaji AF.
Pri tome raËunalo nadgleda i samu terapiju u smislu optimalnog djelovanja RF energije u miokardu i okolnog tkiva,
koristeÊi pri tome joπ jedan trik — hlaenje vrha katetera
fizioloπkom otopinom.
PraÊenje nakon kateterske ablacije AF nije uvijek jednostavno. Naime, kliniËka slika Ëesto moæe biti nedostatna, tj.
bolesnik sam ne mora nuæno osjetiti svaki eventualni ponovni napadaj fibrilacije. BuduÊi da eventualna daljnja nazoËnost povremenih fibrilacija moæe biti znaËajna zbog kliniËke odluke o potrebi za antikoagulantnom terapijom u kasnijem tijeku, od velike je vaænosti pouzdano biljeæenje elektrokardiograma. Ponekad ovdje nije dovoljan kontrolni 24satni Holter, buduÊi da moæe propustiti aritmiju, ukoliko se
ona javlja rjee. Stoga se u nekim sluËajevima upotrebljavaju i kontinuirani snimaËi otkucaja, periodiËko transtelefonsko
praÊenje te (ukoliko bolesnik veÊ od ranije zbog drugog
razloga ima elektrostimulator) moderni dijagnostiËki algoritmi i moguÊnosti u samom elektrostimulatoru.
patient’s thorax. Moving the catheter then generated a 3D
image of the atrium (which, in an ideal case, almost exactly
corresponds with the CT or NMR findings). After LA and proximal PV segments reconstruction, we continue with the
therapeutic part of the procedure, whereby punctual lesions
are created by means of radiofrequency energy in the LA
area just before the PV ostia. Connecting the dots finally
creates lines, which then electrically isolate the veins from
the rest of the LA, thereby achieving the therapeutic goal,
i.e. suppressing the AF attacks. During this process, the
computer controls the therapy itself, as it optimizes the
action of the RF energy, using another trick — cooling the
tip of the catheter with saline.
Follow up after AF catheter ablation is not always simple.
The clinical picture may often not be enough, as the patient
does not necessarily perceive every repeated AF attack.
Since the possibility of further AF episodes after the ablation
may well be of significance, because of the possible need
for anticoagulation therapy in later course, confident ECG
information might be of essential importance. Sometimes, a
simple 24-hour ECG recording may not be enough, since it
may miss the arrhythmia if it occurs on a less frequent basis.
Therefore, sometimes additional tools such as continuous
loop recorders, periodical transtelephonic monitoring and (if
the patient for some other reason already has a pacemaker)
modern diagnostic algorhythms and possibilities of the
pacemaker are used.
Keywords: atrial fibrillation, catheter ablation, ECG.
KljuËne rijeËi: atrijska fibrilacija, kateterska ablacija, elektrokardiogram.
2012;7(3-4):107.
*Corresponding author — E-mail:
[email protected]
Kardio LIST
Proπireni saæetak / Extended abstract
Intrakoronarno snimanje
Intracoronary imaging
Nico Bruining*
Erasmus MC/Thoraxcenter, Rotterdam, Nizozemska
Erasmus MC/Thoraxcenter, Rotterdam, The Netherlands
anas je u laboratoriju za kateterizaciju dostupan cijeli
niz modaliteta oslikavanja. Uz standardnu koronarnu
angiografiju, modaliteti intrakoronarnog snimanja, kao
πto su intravaskularni ultrazvuk (IVUS)1 i optiËka koherentna
tomografija (OCT)2 se Ëesto koriste kako bi se procijenile
nove opcije terapijskog lijeËenja te za voenje intervencijskih postupaka. Trenutno je IVUS joπ uvijek referentna metoda za prouËavanje in-vivo intervencijskih strategija3. Novi
dizajni stentova mogu se procijeniti vizualizacijom apozicije
æiËice stenta, NIH rastom, remodeliranjem plaka4 te takoer
i promjenama komponente tkiva plaka tijekom vremena5.
Meutim, od nedavno postoji sve viπe interesa da se novi
modaliteti snimanja kao πto su OCT i neinvazivna viπeslojna
kompjuterizirana tomografija — koronarna angiografija
(MSCT-CA) koriste kao dodatni alati za snimanje uz IVUS.
OCT kao prednost ima superiornu rezoluciju snimanja u usporedbi s IVUS, a dostupne neinvazivne metode snimanja
kao πto je MSCT bi kod longitudinalnih studija mogle biti preferirane od strane pacijenata te bi takoer mogle poboljπati
istraæivaËko znanje obzirom da ne pokazuju protoËnost
stentiranog podruËja, veÊ takoer i plak i njegov sastav.
»esto se smatra da su ovi modaliteti konkurentni, meutim,
viπe su komplementarni nego πto su konkurentni. Usporedba ovih modaliteta meusobno je izazovan je zadatak zbog
Ëinjenice da imaju veoma razliËita fizikalna svojstva6. Stoga
je kombiniranje ovih modaliteta snimanja vrlo dovitljiva opcija za koriπtenje tijekom prvih ispitivanja na ljudima te takoer
moguÊe tijekom prve faze multicentriËnih studija koje procjenjuju uËinkovitost novih terapijskih strategija.
Kod studija koronarnih stentova, velika prednost OCT predstavlja izvrsna vizualizacija æiËice stenta i njezine apozicije u
trenutku implantacije te vizualizacija endotelijalizacije æiËice
strenta tijekom praÊenja. U novoj generaciji bioabsorbilnih
stentova naËinjenih od poli-l-laktiËne kiseline (PLLA) moæe
se kvantificirati Ëak i πirina i debljina æiËice stenta7. »ini se da
su trenutni nedostaci kao πto su zatvaranje æile i niska dubina penetracije rijeπeni u nadolazeÊim generacijama OCT
dizajniranih katetera koji se nazivaju OFDI.
MSCT-CA brzo postaje sve popularnija metoda koja se
koristi kao dodatni alat za dijagnostiËko snimanje. Naravno,
njezina neinvazivna priroda bi ju mogla uËiniti izvrsnim
alatom za primjenu u longitudinalnim studijama. Dostupan je
kvantifikacijski softver te se dimenzije lumena i krvne æile
mogu kvantificirati. Meutim, njegova rezolucija slike u
usporedbi s IVUS je mnogo niæa (120 m prostorno i 80 m
ploπno za IVUS nasuprot 400 m prostorno i ploπno za
MSCT od 64 sloja). Nadalje, i kalcificirane i metalne strukture uzrokuju “blooming” uËinak (bljeπtavost) na CT slikama,
πto moæe ograniËiti toËnost kvantifikacije. Novije generacije
D
Kardio LIST
oday a large array of imaging modalities is available in
the catheterization laboratory. Besides standard coronary angiography, intracoronary imaging modalities,
such as intravascular ultrasound (IVUS)1 and optical coherence tomography (OCT)2 are often used to evaluate new
therapeutic treatment options and to guide interventional
procedures. Currently, IVUS is still the reference method to
study in-vivo new interventional strategies3. New stent designs can be evaluated by visualizing stent strut apposition,
NIH growth, plaque remodeling4 and possibly also plaque
tissue component changes over time5. However, recently,
new imaging modalities such as OCT and the non-invasive
multi-slice computed tomography coronary angiography
(MSCT-CA) are gaining rapidly large interest to be used as
additional imaging tools besides IVUS. OCT has as advantage a superior image resolution over IVUS and of course
the availability of a non-invasive imaging method as MSCT
for longitudinal studies could be preferred by the patients
and also it could improve research knowledge since it not
only shows the patency of the stented area but also the plaque and its composition.
Often it is thought that these modalities are competitors,
however, they are more complementary as they are competitive. A 1-to-1 comparison of these modalities is a challenging task due to the fact that they have very different physical
properties6. Therefore, combining these imaging modalities
is a very resourceful option to be used during first-in-man
studies, and possibly also during the first phase of multi-center trials, evaluating the effectiveness of new therapeutic
strategies.
In coronary stent studies, the big advantage of OCT is the
excellent visualization of the stent struts and its apposition at
the time of implantation and to visualize the endotheliazation
of the struts at follow-up. In the new generation of bio-absorbable stents made of poly-l-lactic-acid (PLLA) even the
width and thickness of the struts can be quantified7. The current disadvantages such as closure of the vessel and low
penetration depth, seems to be solved in the upcoming generation of OCT catheter designs called OFDI.
MSCT-CA is becoming rapidly popular to be used as an
additional diagnostic imaging tool. Of course, its non-invasive nature could make it an excellent tool to be applied in
longitudinal studies. Quantification software is available and
lumen- and vessel-dimensions can be quantified. However,
its image resolution as compared to IVUS is much lower
(120 m spatial and 80 m in-plane for IVUS vs. 400 m
spatial and in-plane for 64-slice MSCT). Furthermore, both
calcium and metallic structures are causing a blooming
effect on CT images, which could hamper accurate quantifi-
T
Oralna prezentacija / Oral presentation
2012;7(3-4):108.
skenera bi potencijalno mogle rijeπiti ove ograniËavajuÊe
Ëimbenike. Meutim, Ëini se da se u sluËaju novog PLLA
bioabsorbilnog stenta MSCT moæe koristiti za kvantifikaciju
lumena i krvnih æila8. MoguÊe je da bi se MSCT takoer
mogao koristiti za detektiranje i kvantifikaciju promjena u
sastavu plaka9; meutim, potrebna su daljnja istraæivanja.
Kako bi iz ova 3 modaliteta snimanja dobili optimalne podatke, kljuËni Ëimbenik je pronalaæenje toËnog podruËja interesa za svaki pojedini modalitet. Danas se ovo i dalje mora
razvijati interno, meutim, pod uvjetom da imamo moguÊnost usporedbe IVUS, OCT i MSCT snimaka postavljenih
jedna pored druge i sinkronizirano na jednom raËunalnom
ekranu9. Ovo je najoptimalnija situacija za ispitivanje
mehaniËkih i bioloπkih uËinaka novih dizajna stentova kako
bi se rijeπili problemi koji se pojavljuju kod koronarne bolesti
srca10.
KljuËne rijeËi: koronarna angiografija, intravaskularni ultrazvuk, koronarna angiografija viπeslojnom kompjutoriziranom
tomografijom.
cation. Newer generation scanners could potentially solve
these limiting factors. However, in case of the new PLLA
bio-absorbable stent, it seems that MSCT can be used for
lumen and vessel quantification8. Possibly, MSCT could also
be used to detect and quantify plaque compositional changes9; however, further research is still required.
To derive the optimal information out of these 3 imaging
modalities, the key-factor is to find the exact region of interest for every individual modality. Today, this must be still
developed in-house, however, providing the ability to compare IVUS, OCT and MSCT onto one single computer
screen on top of each other and synchronized9. This is the
most optimal situation to study the mechanical and biological effects of new stent designs to resolve problems occurred in coronary artery disease10.
Keywords: coronary angiography, intravascular ultrasound, multi-slice computed tomography coronary angiography.
*Corresponding author — E-mail:
[email protected]
Literature
1. Mintz GS, Garcia-Garcia HM, Nicholls SJ, Weissman NJ, Bruining N, Crowe T, et al. Clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound regression/progression studies. EuroIntervention. 2011;6:1123-30.
2. Regar E, Ligthart J, Bruining N, van Soest G. The diagnostic value of intracoronary optical coherence tomography. Herz. 2011;36:417-29.
3. Aoki J, Abizaid AC, Serruys PW, Ong AT, Boersma E, Sousa JE, et al. Evaluation of four-year coronary artery response after sirolimus-eluting stent implantation using serial
quantitative intravascular ultrasound and computer-assisted grayscale value analysis for plaque composition in event-free patients. J Am Coll Cardiol. 2005;46:1670-6.
4. Rodriguez-Granillo GA, de Winter S, Bruining N, Ligthart JM, Garcia-Garcia HM, Valgimigli M, et al. Effect of perindopril on coronary remodelling: Insights from a multicentre, randomized study. Eur Heart J. 2007;28:2326-31.
5. Bruining N, Verheye S, Knaapen M, Somers P, Roelandt JR, Regar E, et al. Three-dimensional and quantitative analysis of atherosclerotic plaque composition by automated differential echogenicity. Catheter Cardiovasc Interv. 2007;70:968-78.
6. Bruining N, Tanimoto S, Otsuka M, Weustink A, Ligthart J, de Winter S, et al. Quantitative multi-modality imaging analysis of a bioabsorbable poly-l-lactic acid stent design in the
acute phase: A comparison between 2- and 3d-qca, qcu and qmsct-ca. EuroIntervention. 2008;4:285-91.
7. Serruys PW, Ormiston JA, Onuma Y, Regar E, Gonzalo N, Garcia-Garcia HM, et al. A bioabsorbable everolimus-eluting coronary stent system (absorb): 2-year outcomes and
results from multiple imaging methods. Lancet. 2009;373:897-910.
8. Bruining N, Roelandt JR, Palumbo A, La Grutta L, Cademartiri F, de Feijter PJ, et al. Reproducible coronary plaque quantification by multislice computed tomography. Catheter
Cardiovasc Interv. 2007;69:857-65.
9. Bruining N, Roelandt JR, Verheye S, Knaapen M, Onuma Y, Regar E, et al. Compositional volumetry of non-calcified coronary plaques by multislice computed tomography: An
ex vivo feasibility study. EuroIntervention. 2009;5:558-64.
10. Brugaletta S, Gomez-Lara J, Serruys PW, Farooq V, van Geuns RJ, Thuesen L, et al. Serial in vivo intravascular ultrasound-based echogenicity changes of everolimus-eluting
bioresorbable vascular scaffold during the first 12 months after implantation insights from the absorb b trial. JACC Cardiovasc Interv. 2011;4:1281-9.
2012;7(3-4):109.
Kardio LIST
Proπireni saæetak / Extended abstract
Automatska kvantifikacija zapisa Doppler
ehokardiografije — donosi li dodatne podatke o
ventrikulskoj funkciji?
Automated quantification of Doppler traces — can it
provide additional data on ventricular function?
Davor MiliËiÊ*1, Maja »ikeπ1, Hrvoje KaliniÊ2, Sven LonËariÊ2
1
KliniËki bolniËki centar Zagreb, Zagreb, Hrvatska
2
Fakultet elektrotehnike i raËunalstva, Zagreb, Croatia
1
University Hospital Centre Zagreb, Zagreb, Croatia
2
Faculty of Electrical Engineering and Computing, Zagreb, Croatia
svakodnevnoj kliniËkoj praksi, detaljna analiza zapisa
Doppler ehokardiografije Ëesto je ograniËena optereÊenjem radnim procesom u ehokardiografskom laboratoriju. Trenutno se osnovna Doppler ehokardiografska
mjerenja na izlaznog dijela aorte rutinski dobivaju manualnim praÊenjem i predstavljaju primarni izvor podataka o valvularnom protoku. Manualno praÊenje zapisa Ëesto je nepraktiËno, troπi puno vremena te ovisi o struËnosti kardiologa. Automatsko prepoznavanje zapisa trebalo bi smanjiti vrijeme potrebno za analizu podataka i pritom ne bi trebalo poveÊati greπku mjerenja.
Razvili smo metodu segmentacije slike koja se temelji na
ekstrahiranju Doppler ehokardiografskih zapisa iz ultrazvuËne slike. Slika se poËetno konvertira i predprocesuira kako
bi se dobile samo brzine prema naprijed dok se brzinski
spektar detektira automatski pomoÊu odreivanja praga. Zatim se poËetak i kraj aortnog protoka oznaËavaju manualno
te se izolira profil protoka iz izlaznog dijela. Kako bi ujednaËili zapis Dopplera, primjenjuje se ograniËenje πto zapis u dijelovima Ëini polinomnim. Takva automatska analiza se primjenjuje na kontinuirane aortne zapise valne brzine kod pacijenata koronarnom bolesti srca (KBS) i onih s aortnom stenozom (AS). Iz modeliranih signala analizira se nekoliko varijabli koje opisuju njihov oblik, a meu njima je i asimetrija
profila brzine. Faktor asimetrije je definiran kao normalizirana razlika povrπine ispod krivulje lijeve i desne polovice
spektra te niæa vrijednost faktora asimetrije odgovara simetriËnijem, kasnijem vrπnom toku. Kod KBS utvrdili smo da
smanjena ukupna kontraktilnost lijeve klijetke (LV) rezultira
simetriËnijim brzinskim profilom izlaznog toka, dok kod AS
simetriËni profil ne ukazuje samo na teæi stupanj AS, veÊ se
Ëini da je povezan i sa smanjenom funkcijom LV te predvia
oporavak nakon zamjene aortnog zaliska.
Studije koje se temelje na metodi segmentacije slike su
pokazale da dodatni podaci dobiveni automatskom analizom zapisa daju relevantne kliniËke podatke o funkciji LV,
pomaæuÊi kod dijagnosticiranja i strategija buduÊeg lijeËenja
pacijenata.
U
KljuËne rijeËi: Doppler ehokardiografija, funkcija lijeve klijetke, aortna valvula, koronarna bolest srca.
Kardio LIST
n everyday clinical practice, a detailed analysis of Doppler
echocardiography traces is often limited by a high frequency workflow in the echocardiographic laboratory.
Currently, basic measurements of aortic outflow Doppler
traces are routinely obtained by manual tracking of Doppler
traces, predominantly providing data on valvular flows. Manual tracking of the traces is often cumbersome, time-consuming and dependent on the expertise of the cardiologist.
However, automatic trace delineation should reduce the
required time needed for data analysis, while not increasing
the measurement error.
We have developed an image segmentation method based
on the extraction of Doppler traces from the ultrasound
image. Initially, the image is converted and pre-processed to
obtain only the forward velocities while the velocity envelope
is detected automatically using thresholding. Next, the onset
and the end of the aortic flow were indicated manually, thus
isolating the outflow profile. In order to smooth the Doppler
trace, the constraint was implemented forcing the trace to be
piecewise polynomial. Such automated analysis was applied to aortic continuous wave velocity traces in patients
with coronary artery disease and patients with aortic stenosis (AS). From the modelled signals, several parameters describing their shape were extracted among which the asymmetry of the velocity profile. The asymmetry factor was defined as the normalized difference of area under the curve of
left and right half of the spectrum so that a lower asymmetry
factor corresponded to more symmetrical, later peaking
flow. In coronary artery disease, we have demonstrated that
decreased overall LV contractility results in a more symmetrical outflow velocity profile while in AS a symmetrical profile
suggests not only higher grade AS, but appears to be related to reduced LV function and predicts recovery after aortic
valve replacement.
Studies based on such an image segmentation method demonstrated that additional data obtained by automatic trace
analysis would provide relevant clinical data on LV function,
aiding in diagnostics and further patient management strategies.
I
Keywords: Doppler echocardiography, left ventricle function, aortic valve, coronary heart disease.
*Corresponding author — E-mail: [email protected]
Oralna prezentacija / Oral presentation
2012;7(3-4):110.
Proπireni saæetak / Extended abstract
Slikovne metode deformacije miokarda
(strain/strain-rate)
Deformation Imaging (Strain and Strain-rate
Imaging)
Jadranka ©eparoviÊ-HanæevaËki*
KliniËki bolniËki centar Zagreb, Zagreb, Hrvatska
University Hospital Centre Zagreb, Zagreb, Croatia
kliniËkoj kardiologiji postoji sve je veÊa potreba za
neinvazivnim mjerenjima poËetnih promjena regionalne kontraktilnosti miokarda. Jednostavan naËin odreivanja regionalne funkcije je promatranje zadebljanja /stanjenja miokarda tijekom srËanog ciklusa. Posljednjih desetljeÊa razvijene su ehokardiografske metode za precizna
mjerenja regionalne deformacije miokarda, kojima se odreuje ukupna deformacija zadanog segmenta i brzine njegove deformacije, tzv. Strain i strain/rate. Za toËnost interpretacije i kliniËke primjene ovih metoda vaæno je razumjeti
πto se mjeri i na koji naËin. Doppler miokarda (ili prvotno
nazivan tkivni Doppler) prva je kvantitativna metoda za mjerenje funkcije miokarda. Ova metoda koristi izmjerene brzine miokarda odreenog segmenta za izraËunavanje regionalne deformacije (strain) i brzine deformacije (strain rate) u
longitudinalnom i radijalnom smjeru (za samo neke segmente). Metoda ima visoku vremesku rezoluciju Ëime se mogu
obuhvatiti i vrlo kratke i brze promjene deformacije miokarda tijekom srËanog ciklusa. Negativna strana ove metode je
ovisnost o kutu skeniranja i zahtjevnost u interpretaciji vrijednosti specifiËnih za segmente. Druga metoda je novijeg
datuma tzv. Speckle-tracking ili praÊenje referentne toËke u
miokardu, zasniva se na standardnom dvodimenzionalnom
(ili trodimenzionalnom) prikazu (B-mode). Metoda omoguÊuje mjerenje longitudinalne i radijalne deformacije miokarda
svih segmenata. Loπa strana ove metode je vrlo niska temporalna rezolucija i ovisnost o kvaliteti dvodimenzinalnog
prikaza, πto znatno umanjuje preciznost odreivanja regionalnih promjena. Svaka od ovih metoda ima svoja ograniËenja ovisna o tehnologiji koju koristi i o primjerenom naËinu
snimanja i procesuiranja podataka. Valjana implementacija
deformaciji miokarda u kliniËkom radu ovisna je o dobrom
poznavanju nalaza promjene funkcije miokarda specifiËnog
za odreenu bolest i razumijevanju metoda oslikavanja deformacije kojima bi se te rane promjene mogle uoËiti.
U
KljuËne rijeËi: ehokardiografija, regionalna funkcija miokarda, Doppler.
2012;7(3-4):111.
he non-invasive quantification of regional myocardial
function is an important goal in clinical cardiology.
Myocardial thickening/thinning indices is one method
of attempting to define regional myocardial function. An
ultrasonic method of quantifying regional deformation has
been introduced last decades based on the principles of
‘strain’ and ‘strain rate’ imaging. These imaging modes introduce concepts derived from mechanical engineering. In
order to maximally exploit these techniques, an understanding of what they measure is indispensable. Doppler Myocardial Imaging (also called Tissue Doppler Imaging or Myocardial Velocity Imaging) is a quantitative approach to the
assessment of regional myocardial function. Based on local
velocity estimation, the technique allows the measurement
of regional strain and strain rate parameters with high temporal resolution with respect to angle-dependence. Another
relatively new ultrasound technique is Speckle-tracking
echocardiography (STE) that can be used in conjunction
with two-dimensional or three-dimensional echocardiography for resolving the multidirectional components of left ventricular (LV) deformation. The tracking system is based on
grayscale B-mode images and is obtained by automatic
measurement of the distance between 2 pixels of an LV segment during the cardiac cycle, independent of the angle of
insonation. However, the accuracy of speckle tracking is
dependent on 2D image quality and low frame rates. This
topic will define each of these modalities in terms of physical principles and limitations, and will give an introduction to
the principles of data acquisition and processing required to
implement ultrasonic strain and strain rate imaging in clinical
work.
T
Keywords: echocardiography, regional myocardial function,
Doppler.
*Corresponding author — E-mail: [email protected]
Oralna prezentacija / Oral presentation
Kardio LIST
Proπireni saæetak / Extended abstract
Obrada i modeliranje 3D slike iz ehokardiograma
3D echocardiographic image processing and
modelling
Enrico G. Caiani*
Politecnico di Milano, Milano, Italija
Politecnico di Milano, Milan, Italy
D ehokardiografija je relativno mlada naËin ultrazvuËnog snimanja koji je razvijen poËetkom 80-ih godina
kada je prvi puta zabiljeæena off-line trodimenzionalna
rekonstrukcija slika iz serije 2D skeniranja viπe ravnina.1 U
posljednjih deset godina, na ovom podruËju, postignut je impresivan napredak razvojem tehnologije matriËne sonde punog polja s oko 3.000 piezoelektriËnih elemenata, koja se
temelji na naprednoj digitalnoj obradi i poboljπanim algoritmima formiranja slike sposobnim da pruæe veÊu prostornu i
vremensku rezoluciju kod ultrazvuËnog skeniranja u realnom vremenu. Najnovija dostignuÊa ukljuËuju trenutnu dostupnost punog matriËnog niza u vrhu transezofagusne sonde2 te najnoviju moguÊnost momentalnog snimanja punog
opsega kako bi se obuhvatila cijela πupljina lijeve klijetke
tijekom jednog otkucaja3.
Usporedo s tim tehnoloπkim poboljπanjima, na prikupljene
3D grupe podataka primjenjuje se nekoliko tehnika obrade
slike da bi se iskoristile njihove kliniËke informacije. Kao rezultat toga, u danaπnje vrijeme je moguÊe izraËunati dimenzije lijevog ventrikula, ejekcijske frakcije4 i mase5 neposredno u 3D tehnici, bez potrebe za primjenom matematiËkih formula na kombinirane 2D apikalne prikaze te tako dobiti preciznije i pouzdanije informacije o kardioloπkom statusu bolesnika. Takoer, ovaj pristup je proπiren na kvantifikaciju desnog ventrikula6, kao i na lijevi atrij.
Dostupnost transezofagusnog snimanja je proπirila kliniËku
primjenu 3D ehokardiografije na praÊenje kirurπkih zahvata
u realnom vremenu. U tom kontekstu moguÊe je dobiti izvanredne snimke mitralnog i aortnog valvularnog aparata
koje su sliËne kirurπkom prikazu. Ovakve snimke je takoer
moguÊe obraditi da bi dobili geometrijske informacije o mitralnom valvularnom (MV) aparatu7, da bi pratili njegove dinamiËke deformacije8, ili kombinirali skupljene kvantitativne
podatke da bi dobili stvarni model metode konaËnih elemenata specifiËan za pacijenta u cilju planiranja kirurπkog zahvata. U stvari, prethodna ograniËenja vezana uz pristup modeliranja, ukljuËujuÊi pojednostavljenju geometriju listiÊa,
planarnih i akinetiËkih anulusa i papilarnih miπiÊa sada se
mogu prevladati analizom 3D ehokardiografskih podataka i
izvlaËenjem iz njih informacija potrebnih za prilagodbu generiËkog modela morfologiji pacijenta9.
Kada se koristi za stimulaciju sistoliËke funkcije MV s organskim prolapsom, predloæena strategija modeliranja pokazuje sposobnost imitiranja s dobrom aproksimacijom stvarnog
zatvaranja zaliska, shvatanjem glavnih znaËajki patologije i
3
Kardio LIST
D echocardiography is a relatively young imaging submodality of ultrasound imaging that was developed in
the early 1980s, when off-line three-dimensional reconstruction from serial multiplane 2D acquisitions was reported for the first time1. In the last ten years, impressive progresses have been reached in this field by the development
of a full matrix array probe technology of about 3,000 piezoelectric elements, based on advanced digital processing
and improved image formation algorithms, capable of providing higher spatial and temporal resolution for real-time
volumetric acquisition. Further and latest advances include
the current availability of a full matrix array into the tip of the
transesophageal probe2, and the recent availability of instantaneous full volume imaging to include the entire left
ventricular cavity in a single beat3.
In parallel with these technological improvements, several
image processing techniques have been applied to the acquired 3D datasets in order to exploit their clinical information. As a result, it is possible nowadays to compute the left
ventricular dimensions, ejection fraction4 and mass5 directly
in 3D, without the need of applying mathematical formulas
to combined 2D apical views, thus obtaining more precise
and reliable information on the patient cardiac status. Also,
this approach has been extended to the quantification of the
right ventricle6, as well as of the left atrium.
The availability of transesophageal images has extended
the clinical applicability of 3D echocardiography to the realtime monitoring of surgical intervention. In this context, it is
possible to obtain astonishing images of the mitral and aortic valvular complex, similar to the surgeon’s view. These
images can also be processed in order to provide geometrical information of the mitral valvular (MV) apparatus7, to
track its dynamic deformation8, or to combine these quantitative data together to obtain a realistic patient-specific finite
element model for surgical planning purpose. In fact, previous limitations relevant to the modelling approach, including
simplified leaflet geometry, planar and akinetic annulus and
papillary muscles, can now be overcome by analyzing the
3D echocardiographic data and extracting from it the information needed to adapt a generic model to the patient’s
morphology9.
When used to simulate the systolic function of MVs with
organic prolapse, the proposed modelling strategy proved
capable of mimicking with good approximation the real valve
closure, capturing the main features of the pathology, and
3
Oralna prezentacija / Oral presentation
2012;7(3-4):112.
omoguÊavanjem razlikovanja izmeu fizioloπkih i patoloπkih
uzoraka biomehaniËkih varijabli nad podstrukturama MV.
Ovaj pristup moæe omoguÊiti predvianje hipotetskih postoperativnih scenarija, kao pomoÊni alat za planiranje operativnih zahvata.
allowing discriminating between physiological and pathological patterns of biomechanical variables over the MV substructures. This approach could allow the prediction of hypothetical post-operative scenarios, as a support tool for the
surgical planning.
KljuËne rijeËi: ehokardiografija, obrada snimaka, modeliranje metodom konaËnih elemenata.
Keywords: echocardiography, image processing, finite element modelling.
*Corresponding author — E-mail: [email protected]
Literature
1. Matsumoto M, Inoue M, Tamura S, et al. Three-dimensional echocardiography for spatial visualization and volume calculation of cardiac structures. J Clin Ultrasound. 1981;9:15765.
2. Sugeng L, Shernan SK, Salgo IS, et al. Live three-dimensional transesophageal echocardiography: initial experience using the fully-sampled matrix array probe. J Am Coll Cardiol.
2008;52:446-9.
3. GonÁalves A, Zamorano JL. Valve anatomy and function with transthoracic three-dimensional echocardiography: advantages and limitations of instantaneous full-volume color
Doppler imaging. Ther Adv Cardiovasc Dis. 2010;4:385-94.
4. Caiani EG, Corsi C, Zamorano J, et al. Improved semiautomated quantification of left ventricular volumes and ejection fraction using 3-dimensional echocardiography with a full
matrix-array transducer: comparison with magnetic resonance imaging. J Am Soc Echocardiogr. 2005;18:779-88.
5. Mor-Avi V, Sugeng L, Weinert L, et al. Fast measurement of left ventricular mass using real-time three-dimensional echocardiography: comparison with magnetic resonance imaging. Circulation. 2004;110:1814-8.
6. Tamborini G, Muratori M, Brusoni D, et al. Is right ventricular systolic function reduced after cardiac surgery? A two and three-dimensional echocardiographic study. Eur J
Echocardiogr. 2009;10:630-4.
7. Maffessanti F, Marsan NA, Tamborini G, et al. Quantitative analysis of mitral valve apparatus in mitral valve prolapse before and after annuloplasty: a three-dimensional intraoperative transesophageal study. J Am Soc Echocardiogr. 2011;24:405-13.
8. Caiani EG, Fusini L, Veronesi F, et al. Quantification of mitral annulus dynamic morphology in patients with mitral valve prolapse undergoing repair and annuloplasty during a 6months follow-up. Eur J Echocardiogr. 2011;12:375-83.
9. Votta E, Caiani E, Veronesi F, et al. Mitral valve finite-element modelling from ultrasound data: a pilot study for a new approach to understand mitral function and clinical scenarios. Philos Transact A Math Phys Eng Sci. 2008;366:3411-34.
2012;7(3-4):113.
Kardio LIST
Proπireni saæetak / Extended abstract
Otkrivanje znanja i prediktivni modeli u kardiologiji
Knowledge discovery and predictive models in cardiology
Guy Carrault
Campus de Beaulieu, Université de Rennes I, Rennes, Francuska
Campus de Beaulieu, Université de Rennes I, Rennes, France
vim priopÊenjem æelimo ukazati kako razmatranje vremenske dinamike srËanih funkcija poboljπava interpretaciju kardioloπke multivariatne vremenske serije.
Opisat Êe se dva razliËita pristupa koja Êe se predstaviti na
dva razliËita primjera.
Prva metodologija kombinira prostorno-vremensko neizrazito (fuzzy) kodiranje i multikorespodencijsku analiza (MCA).
MCA se primjenjuje da bi se: 1) smanjio broj dimenzija podataka i osigurali novi sintetski indeksi temeljeni na “faktorskim osima” dobivenim od MCA; 2) tumaËile dobivene faktorske osi u fizioloπkim uvjetima i 3) analizirala promjena
stanja bolesnika projekcijom prikupljenih podataka u ravninu
nazvanu “faktorska ravnina” formiranu od prve dvije faktorske osi. Kao ilustracija, podaci dobiveni implatibilnim ureajima s dva senzora (senzor transtorakalnog otpora i akcelerometar) analizirani su da bi se otkrila njihova potencijalna
primjena za praÊenje pacijenata lijeËenih kardijalnom resinkronizacijskom terapijom (CRT). Da bi se klasificirali razliËiti uzorci nastanka, nakon smanjenja broja dimenzija podataka dobivenih od MCA, uvedena je mjera sliËnosti za grupiranje promatranih podataka dobivenih od 41 pacijenta s
CRT. Istraæivanje cijele baze podataka omoguÊilo je otkriÊe
da su dobiveni klasteri u usporedbi s napomenama iz zdravstvenog kartona pojedinog bolesnika te je zauzelo dva podruËja u faktorskoj ravnini, jedno vezano uz pogorπanje
zdravlja pacijenta i drugo vezano uz stabilno kliniËko stanje.
U drugoj metodologiji dinamiku pojedinih vremenskih serija
odlikuje niz skrivenih polu-Markovljevih modela (HSMM). U
tom sluËaju metoda dijagnostike koristi ne samo trenutne
vrijednosti nego je takoer predloæena i uporaba unutarnje
dinamike vremenske serije. Predloæen je skriveni polu-Markovljev model da bi se otkrila vremenska evolucija promatranih serija te su ispitane razliËite predprocesne metode
ovih serija. Temeljem usporedbi vjerojatnosti stvoren je detektor koji za opservirano promatranje generira referentni ili
patoloπki HSMM. Za ilustraciju analizirane su unutarnje dinamike RR serije od 18 nedonoπËadi iz neonatalnih jedinica
intenzivnog lijeËenja (NICU) da bi se otkrili prediktivni uzorci bradikardije. NeobiËna i ponavljajuÊa bradikardija kod nedonoπËadi Ëesto otkriva vaæne bolesti kao sto je to kasnonastala sepsa. Obzirom na visok morbiditet i mortalitet povezan s infekcijom, neophodno je brza detekcija. Pristup je
bio kvantitativno ocijenjen. Usporedbom dva konvencionalna detektora koriπtena u NICU, ovaj pokazuje poboljπanje
od oko 13% u osjetljivosti i 7% u specifiËnosti te takoer
reducira kaπnjenje dijagnostike od oko tri sekunde u usporedbi s konvencionalnim detektorima.
KljuËne rijeËi: prediktivni modeli, otkrivanje znanja, kardiologija.
O
n this communication, we would like to show how the consideration of the temporal dynamics of cardiac features
improve interpretation of cardiac multivariate time series.
Two different approaches will be described and demonstration will be illustrated over two examples.
The first methodology combines spatiotemporal fuzzy coding and multiple correspondence analysis (MCA). MCA is
applied in order to: 1) reduce the dimensionality of the data
and provide new synthetic indexes based on the “factorial
axes” obtained from MCA; 2) interpret these factorial axes in
physiological terms; and 3) analyze the evolution of the patient’s status by projecting the acquired data into the plane
formed by the first two factorial axes named “factorial plane.” As an illustration, data obtained from an implantable device with two sensors (a transthoracic impedance sensor
and an accelerometer) are analyzed in order to discover
their potential application for the follow-up of patients treated with a cardiac resynchronization therapy (CRT). In order
to classify the different evolution patterns, after reducing the
dimensionality of the data by MCA, a similarity measure is
introduced to cluster the observed data set from 41 CRT
patients. Exploration of all the data base allows to discover
that the obtained clusters, compared with the annotations
on each patient’s medical record, occupy two areas on the
factorial plane, one being correlated with a health degradation of patients and the other with a stable clinical state.
In the second methodology, the dynamics of individual time
series are characterized by a set of Hidden Semi-Markovian
Models (HSMM). In this case, a detection method that exploits not only the instantaneous values, but also the intrinsic dynamics of the temporal series, is proposed. The hidden semi-Markov model is proposed to discover the temporal evolution of observed series and different pre-processing
methods of these series are investigated. The detector is based on the comparison of the likelihood that a given observation being generated by a reference HSMM or a pathologic HSMM. As an illustration, the intrinsic dynamics of the
RR series of 18 preterm new-borns acquired in neonatal intensive care units (NICU) are analysed in order to discover
predictive patterns of the bradycardia. Unusual and recurrent bradycardias in preterm babies often revealed important disorders such as late-onset sepsis. In view of the high
morbidity and mortality associated with infection, rapid detection is requested. The approach was quantitatively evaluated. Compared to two conventional detectors used in NICU,
our detector shows an improvement of around 13% in sensitivity and 7% in specificity and also reduces the detection
delay of approximately 3 seconds with respect to conventional detectors.
Keywords: predictive models, knowledge discovery, cardioogy.
*Corresponding author — E-mail: [email protected]
I
Literature
1. Guéguin M, Roux E, Hernández AI, Porée F, Mabo P, Graindorge L, Carrault G. Exploring time series retrieved from cardiac implantable devices for optimizing patient follow-up,
IEEE Trans Biomed Eng. 2008;55(10):2343-52.
2. Altuve M, Carrault G, Beuchee A, Pladys P, Hernández AI. On-line apnea-bradycardia detection using hidden semi-Markov models. Conf Proc IEEE Eng Med Biol Soc.
2011;2011:4374-7.
3. Beuchée A, Carrault G, Bansard JY, Boutaric E, Bétrémieux P, Pladys P. Uncorrelated randomness of the heart rate is associated with sepsis in sick premature infants,
Neonatology. 2009;96(2):109-14.
Kardio LIST
Oralna prezentacija / Oral presentation
2012;7(3-4):114.
Proπireni saæetak / Extended abstract
Konceptualizacija medicinskog znanja u podruËju
zatajivanja srca: HEARTFAID projekt
Conceptualization of medical knowledge for heart
failure management: HEARTFAID project
Dragan Gamberger*
Institut Ruer BoπkoviÊ, Zagreb, Hrvatska
Ruer BoπkoviÊ Institute Zagreb, Croatia
onceptualizacija medicinskog znanja obuhvaÊa sakupljanje i sistematizaciju relevantnog medicinskog znanja. Znanje treba biti prikazano tako da ga raËunala
mogu korististiti, a ljudi jednostavno nadopunjavati. Viπe je
razloga zaπto je potrebna konceptualizacija medicinskog
znanja. MoguÊe primjene su: integracija podataka o bolesniku iz raznih izvora (semantiËka integracija), sustavi za intelignetno nadziranje i rano upozoravanje (pomoÊ u odluËivanju), integracija medicinskog znanja raznih specijalizacija,
sveprisutna dostupnost najbolje medicinske prakse, inteligentna analiza podataka za potrebe medicine utemeljene
na dokazima.
Ontologije su danas prihvaÊene kao najprikladnija forma formalizacije prikaza znanja. Na osnovnoj razini one su rijeËnik
relevantnih koncepata koji su organizirani u hijerarhijsku
strukturu klasa koja se naziva taksonomija. Bitna karakteristika ontologija je postojanje svojstava koja povezuju koncepte i koja predstavljaju relacije kao “indicirano_sa” i “moæe_se_lijeËiti_sa”. Osnovne klase razvijene ontologije o zatajivanju srca (HF), koja je dostupna na http://lis.irb.hr/heartfaid/ontology/ su “HF_concept”, “Patient_characteristics”,
“Testing”, and “Treatment”. Ove osnovne klase sadræe
ukupno oko 200 podklasa i 2.000 instanci koje predstavljaju
relevantne medicinske koncepte i oko 100 svojstava koje
povezuju te koncepte. Gdjegod je to bilo moguÊe koncepti i
relacije su koriπtenjem CUI (Concept Unique Identifiers) povezani s odgovarajuÊim pojmovima u UMLS (Unified Medical Language System, http://www.nlm.nih.gov/research/umls/) velikom, javno dostupnom medicinskom taksonomijom.
Ontologija HF predstavlja deskriptivno znanje o domeni HF.
Ali znanje treba omoguÊiti i akcije, tipiËno u formi savjeta bolesnicima i medicinskom osoblju. Znanje u formi nuænih i
dovoljnih uvjeta da se neke akcije mogu poduzeti se naziva
proceduralno znanje. Primjer takovog znanja je pravilo: Dijagnoza sistoliËkog HF — AKO bolesnik ima znakove ili
simptome HF I patoloπki EKG nalaz (blok lijeve grane I Q val
u prednjim odvodima) I bolesnik ima ishemijsku bolest srca
I patoloπki rendgenski nalaz srca i pluÊa (kardiotorakalni
omjer >0.5) I poveÊanu vrijednost natriuretskog peptida
(BNP >100 pg/ml). Proceduralno znanje o HF podijeljeno je
u 10 funkcionalnih cjelina kao πto su dijagnoza, procjena
K
2012;7(3-4):115.
onceptualization of medical knowledge means collection of relevant medical knowledge and its systematization. The knowledge must be presented in the form
that may be used by machines and easily updated by humans. Motivations for doing conceptualization of medical
knowledge are manifold and they include: integration of
patient data from various sources (semantic integration), intelligent monitoring and early warning systems (decision
support), integration of medical knowledge of different specializations, ubiquitous availability of best medical practice,
intelligent data analysis for evidence based medicine.
Ontologies are today accepted as the most appropriate form
for knowledge formalization. At the basic level they present
a dictionary of relevant concepts that are ordered in a hierarchical structure called taxonomy. The distinguishing characteristics of ontologies are properties connecting the concepts and representing relations like “indicated_by” and
“may_be_treated_by”. Basic classes of the developed heart
failure ontology (HF, available at http://lis.irb.hr/heartfaid/ontology/) are “HF_concept”, “Patient_characteristics”, “Testing”, and “Treatment”. These basic classes include in total
200 subclasses and 2,000 instances representing relevant
medical concepts and about 100 properties connecting these concepts. Whenever possible the used concepts are with
CUI numbers (Concept Unique Identifiers) connected with
UMLS (Unified Medical Language System, http://www.nlm.
nih.gov/research/umls/) a large, publicly available medical
taxonomy.
The HF ontology represents descriptive knowledge about
the heart failure domain. Knowledge should enable also to
perform some actions, typically in the form of suggestions
for patients and medical personnel. The knowledge representing sufficient and necessary conditions that some
actions can be done is the so called procedural knowledge.
An example of procedural knowledge is the rule: Diagnosis
of systolic HF IF patient has either HF signs or HF symptoms AND abnormal ECG (left bundle branch block AND
anterior Q waves) AND patient has (ischemic heart disease)
AND Chest X-ray abnormal (cardiothoracic ratio >0.5) AND
natriuretic peptides abnormal (BNP >100 pg/ml). HF procedural knowledge has been divided into 10 functional subtasks like diagnosis of HF, severity assessment of HF, and
C
Oralna prezentacija / Oral presentation
Kardio LIST
teæine, lijekovi i kontraindikacije. Namjera je bila omoguÊiti
jednostavniju ljudsku kontrolu kompletnosti i konzistentnosti uvjeta. KonaËno, u izlaganju Êe se pokazati kako se u
ontoloπkoj formi mogu integrirati deskriptivno i proceduralno
znanje i kako se takav formalizam moæe iskoristiti u primjenama pomoÊi u odluËivanju.
contraindications for HF medications. The intention has
been to enable easier human control of the completeness
and consistency conditions. Finally, in the presentation it will
be demonstrated how descriptive and procedural knowledge can be integrated into an ontological representation
and how such formalism may be used for decision support
tasks.
KljuËne rijeËi: prikaz znanja, ontologije, pomoÊ u odluËivanju.
Keywords: knowledge representation, ontologies, decision
support.
*Corresponding author — E-mail: [email protected]
Literature
1. Ceusters W, Smith B. Ontology and medical terminology: why descriptions logics are not enough. Proceedings of the conference Towards an Electronic Patient Record (TEPR
2003), San Antonio, 10-14 May 2003.
2. de Clercq PA, Hasman A, Blom JA, Korsten, HHM. Design and implementation of a framework to support the development of clinical guidelines. Int J Med Info. 2001;64:285318.
3. Noy NF Rubin DL, Musen MA. Making biomedical ontologies and ontology repositories work. IEEE Intelligent Systems. 2004;19(6):78-81.
4. Peleg M, Tu SW. Decision Support, Knowledge Representation and Management in Medicine. Haux & C. Kulikowski (Eds.). Schattauer; 2006.
5. Peleg M, Gutnik LA, Snow V, Patel VL. Interpreting procedures from descriptive guidelines. J Biomed Info. 2006;39(2):184-95.
6. Star JR. On the Relationship Between Knowing and Doing in Procedural Learning. In B. Fishman & S. O’Connor-Divelbiss (Eds.), Proceedings of the Fourth International
Conference of the Learning Sciences. Mahwah, NJ: Erlbaum; 2000, pp. 80-86.
Kardio LIST
2012;7(3-4):116.
Proπireni saæetak / Extended abstract
RaËunalni pristup ispitivanju kardiorespiratorne
sinkronizacije
Computational approach for the study of
cardiorespiratory synchronization
Alberto Macerata*
Department of Physiological Sciences, Pisa, Italija
Department of Physiological Sciences, Pisa, Italy
itmiËko ponaπanje je vrlo uobiËajeno kod mnogih bioloπkih funkcija naπeg tijela, kao πto je srËana frekvencija, tijekom dnevnog ciklusa hodanja i spavanja, pri
otpuπtanju hormona itd. Ovi ritmovi pod kontrolom razliËitih
sustava fiziologiËke interakcije mogu meudjelovati jedni s
drugima, kao i s vanjskim okruæenjem. Od bioloπkih ritmova,
srËani ritam i respiracija su od posebnog interesa. Dobro je
poznato da je frekvencija srca (HR) pod utjecajem respiratorne funkcije, a respiratorna sinusna aritmija (RSA) je izravan uËinak respiracije na trend HR. Kod RSA HR slijedi isti
trend respiratornog signala, poveÊavajuÊi se tijekom inspirija i smanjujuÊi se tijekom ekspirija. Sa stajaliπta frekvencije,
ovo znaËi da moæemo pronaÊi istu frekvenciju i u HR i vremenskim serijama respiracije. Ova interakcije nije uvijek prisutna zato πto je to funkcija razliËitih fizioloπkih stanja, od
kojih je najvaænije simpatetiËka-parasimpatetiËka ravnoteæa
autonomnog æivËanog sustava (ANS). Interesantno je da se
izmeu HR i respiracije moæe pojaviti poseban fenomen koji
se naziva fazna sinkronizacija.
Kardiorespiratorna fazna sinkronizacija (CRS) se pojavljuje
kada je kod uzastopnih n respiratornih ciklusa uvijek prisutan jednak broj otkucaja u EKG zapisu, a fazna razlika izmeu kaπnjenja izmeu poËetka respiracije i prethodnog ciklusa u EKG je konstantna. U ovom sluËaju moæemo reÊi da
postoji sinkronizacija s omjerom frekvencije. U biti, klasiËna
definicija “sinkronizacije” se odnosi na periodiËke, samoodræive oscilatore. Kod nestacionarnih, nelinearnih oscilatora kao πto su oni koji su prisutni u bioloπkim sustavima, definicija se mora pravilno podesiti i pojednostaviti. Dostupne
su mnoge metode za identifikaciju prisutnosti sinkronizacije
i izraËuna omjera frekvencije. Najpopularniji je Sinkrogram
koji se temelji na izraËunu stroboskopskog prikaza respiratornog signala koji se dobija u vremenskim markerima koji
odgovaraju svakom ciklusu u EKG zapisu. Dobija se grafiËka reprezentacija koja moæe pokazati prisutnost razdoblja
sinkronizacije, njihovo vremensko trajanje i omjer frekvencije.
©to se tiËe HR i respiracijskih signala, sinkronizacija nije
uobiËajeno stanje u svakodnevnom æivotu. Ustanovljeno je
da je prisutnija pri mirovanju, nego kod vjeæbanja ili umnih
aktivnosti. A tijekom mirovanja je naglaπenija kod sportaπa
nego kod ne-sportaπa. Ova ovisnost CRS o razliËitim uvjetima u okolini i zdravstvenom stanju ukazuje da fenomen
R
2012;7(3-4):117.
hythmic behaviors are quite common in many biological functions of our body, like in the heart beating, during the daily cycle of waking and sleeping, in the release of hormones and so on. These rhythms can interact
each others, as well as with the outside environment under
the control of different physiological feedback systems.
Among biological rhythms, the heart rate and respiration are
of special interest. It is well known that Heart Rate (HR) is
influenced by the respiratory function, and the Respiratory
Sinus Arrhythmia (RSA) is the direct effect of respiration on
the HR trend. In the RSA the HR follows the same trend of
the respiratory signal, increasing during inspiration and decreasing at expiration. From frequency point of view, this
means that we find the same frequency both in the HR and
in the respiration time series. This interaction is not always
present because it is function of different physiological conditions, the most relevant one being the sympatheticparasympathetic balance of the Autonomic Nervous System
(ANS). What is interesting is that, between HR and respiration, a special phenomenon, named Phase Synchronization,
can happen.
The Cardiorespiratory Phase Synchronization (CRS) occurs
when in consecutive n respiratory cycles are always present
the same number of ECG beats, and the phase difference
between the delay between the onset of the respiration and
the preceding ECG cycle is constant. In this case we can
say that exists a synchronization with a frequency ratio. Actually the classical definition of ‘synchronization’ refers to periodic, self-sustained oscillators. With not stationary, non linear oscillators like those present in biological systems, the
definition has to be properly adjusted and generalized. Many
methods are available for identifying the presence of synchronization and computing the frequency ratio. The most
popular one is the Synchrogram which is based on computing a stroboscopic view of the respiratory signal as obtained
at the time markers corresponding to every ECG cycles. The
output is a graphic representation able to show the presence
of synchronization periods, their time length and frequency
ratio.
For what concerns the HR and respiration signals, the synchronization is not a common condition in daily life. It was
found that it is more present at rest than during exercise or
mental tasks. And, at rest, it is more pronounced in athletes
R
Oralna prezentacija / Oral presentation
Kardio LIST
sinkronizacije sadræi korisne informacije koje mogu poboljπati naπe znanje o kardiorespiratornoj interakciji i povezanim
neuralnim i kardiovaskularnim sustavima. U literaturi postoje primjeri koji naglaπavaju vaænost obrazaca disanja kod
promoviranja sinkronizacije. Ovo je posebice toËno kada
okruæenje pogoduje “sinkronom” disanju, kao πto je tijekom
izgovaranja krunice ili mantra ili recitiranja poezije.
KljuËne rijeËi: fazna sinkronizacija, varijabilnost srËanog
ritma, fizioloπki ritam.
than in non-athletes. This dependence of CRS on different
environmental conditions and health status suggests that
the phenomenon of synchronization contains useful information that can improve our knowledge on the cardiorespiratory interaction and on related neural and cardiovascular
systems. In literature, there are examples that highlight the
importance of the breathing pattern in promoting synchronization. In particular, this is true when the environment favors breathing ‘synchronous’, as during the rosary or mantras reciting or poetry recitation.
Keywords: phase synchronization, heart rate variability,
physiological rhythms.
*Corresponding author — E-mail: [email protected]
Literature
1. Berntson GG, Cacioppo JT, Quigley KS. Respiratory sinus arrhythmia: autonomic origins, physiological mechanisms, and psychophysiological implications. Psychophysiology.
1993;30:183-96.
2. BraËiË LortiË M, Stefanovska A. Synchronization and modulation in the human cardiorespiratory system. Physica A: Statistical Mechanics and its Applications. 2000;283:451-463.
3. Bernadi L, Sleight P, Bandinelli G, Cencetti S, Fattorini L, Wdowczyc-Szulc J. Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: comparative study.
BMJ. 2001;323:1446-9.
4. Glass L. Synchronization and rhythmic processes in physiology. Nature. 2001;410:277-84.
5. Toledo E, Akselrod S, Pinhas I, Aravot D. Does synchronization reflect a true interaction in the cardiovascular system? Med Eng Phys. 2002;24(1):45-52.
6. Cysarz D, von Bonin D, Lackner H, Heusser P, Moser M, Bettermann H. Oscillations of heart rate and respiration synchronize during poetry recitation. Am J Physiol Heart Circ
Physiol. 2004;287:H579-87.
7. Yasuma F, Hayano J. Respiratory sinus arrhythmia: Why does the heartbeat synchronize with respiratory rhythm? Chest. 2004;125:683-90.
8. Cysarz D, Bussing A. Cardiorespiratory synchronization during Zen meditation. Eur J Appl Physiol. 2005;95:88-95.
9. Kenwright DA, Bahraminasab A, Stefanovska A, McClintock PVE. The effect of low-frequency oscillations on cardio-respiratory synchronization. Eur Phys J B 2008;65:425-33.
10. Zhang J, Yu X, Xie D. Effects of mental tasks on the cardiorespiratory synchronization. Respir Physiol Neurobiol. 2010;170:91-5.
Kardio LIST
2012;7(3-4):118.
Saæetak sa skupa / Meeting abstract
Uporaba naprednog i personaliziranog IT sustava
za prikupljanje i analizu podataka kod pacijenata s
implantiranim ureajima za defibrilaciju
The use of an advanced and personalized IT
system for data collection and analysis in patients
with implanted defibrillating devices
Przemyslaw Guzik*1, Sebastian Zurek2, Jaroslaw Piskorski1,2, Tomasz Krauze1,
Dagmara Przymuszala1, Mateusz Bryl1, Jerzy Ellert1, Krzysztof Klimas1
1
Poznan University of Medical Sciences, Poznan, Poljska
Institute of Physics, University of Zielona Gora, Zielona Gora, Poljska
1
Poznan University of Medical Sciences, Poznan, Poland
2
Institute of Physics, University of Zielona Gora, Zielona Gora, Poland
2
oderno kardiovaskularno istraæivanje stvara velike
koliËine podataka koji su vrlo Ëesto smjeπteni u male
baze podataka te tako odvojeno analizirani bez cjelokupne sinteze i zakljuËka. Da bi izbjegli takvu opasnost, dizajniran je i izgraen poseban sustav posveÊen projektu
“Predvianja negativnih kliniËkih ishoda kod pacijenata s implantiranim ureajima za defibrilaciju” (istraæivanje potpomognuto Poljskom zakladom za znanost). Ovaj sustav temelji se
na OpenGranary tehnologiji (www.opengranary.com) i
omoguÊava registraciju pacijenata, planiranje njihovih dolazaka i praÊenje posjeta, unos svih vrsta podataka iz kliniËke evaluacije, rezultata laboratorijskih ispitivanja, slika
(npr. iz ehokardiograma) te kardiovaskularnih signala (npr.
kontinuirani EKG, krivulja tlaka, signala srËane impedancije)
ili oËitanja iz telemetrijskog praÊenja implantiranih ureaja
za defibrilaciju. Za sve vrste podataka postoje posebne granice za kontrolu kvalitete podataka, informiranje o neuobiËajenim ili moguÊim greπkama. OpenGranary sustav ukljuËuje
nekoliko statistiËkih rjeπenja uz moguÊnost definiranja razliËitih filtara, usporedbi i on-line praÊenja, npr. usporeivanje rezultata prema spolu, pojedinaca s/bez ishemijske bolesti srca ili drugih grupa prema unaprijed definiranom izboru.
Rezultati su prikazani u obliku brojki i slika. Od kraja listopada 2010. ukljuËili smo 370 pacijenata od kojih je svaki imao
oko 1.000 razliËitih varijabli. Primjenom ovog sustava znatno je poboljπana kvaliteta studije, a njena je kontrola znatno
olakπana. Analiza podataka je bræa i djelomiËno automatizirana, a svi podaci su sakupljeni na jednom mjestu. Baza
podataka se svakodnevno pohranjuje, a podaci se lagano i
momentalno isporuËuju u razliËite oblike (txt, csv). Pridodana je i dodatna funkcionalnost izmjene podataka s mobilnim
ureajima, poput PDA ili smartphone ureaja. Trenutno iskustvo pokazuje da izgradnja takvog specijaliziranog sustava nije samo korisna nego i neophodna za realizaciju buduÊih kliniËkih studija baziranih na stotinama razliËitih varijabli
i pacijenata.
KljuËne rijeËi: analiza velike skupine podataka, databaze,
ureaji za defibrilaciju.
M
2012;7(3-4):119.
odern cardiovascular research produces a great deal
of data which quite often are scattered in smaller databases, and separately analyzed without an overall
synthesis or conclusion. To avoid such risk we have designed and created a dedicated system for project “Predicting
adverse clinical outcomes in patients with implanted defibrillating devices” (research grant from Foundation for Polish
Science). This system, based on the OpenGranary technology (www.opengranary.com), and it allows to register patients, plan their entry and follow-up visits, enter all type of
data from clinical evaluation, results of laboratory tests, images (e.g. from echocardiography), and cardiovascular signals (e.g. continuous ECG, pressure waveforms, cardiac
impedance signals) or readings from telemetric interrogation
of the implanted defibrillating devices. For all types of data
there are individual ranges to control the quality of data,
inform about outliers or possible errors. The OpenGranary
system incorporates several statistical solutions allowing to
define different filters, comparisons and on-line monitoring,
e.g. comparing male and female patients, ischemic and nonischemic individuals or any groups according to predefined
cut-offs. The results are shown both as values and as figures. Since the end of October of 2010 we have enrolled
370 patients each of whom has nearly 1,000 different variables. With this system the study quality has significantly
improved and its control is much easier, data mining faster
and partially automated, all data are gathered in one place
and the database is daily backed up, data export to different
formats (txt, cvs) is easy and immediate. Additional functionality for data exchange with mobile devices like PDAs or
smartphones is now being added. Our current experience
shows that building a dedicated system is not only helpful
but necessary for the realization of prospective clinical studies based on hundreds of variables and patients.
Keywords: big data analysis, databases, defibrillating
devices.
*Corresponding author — E-mail: [email protected]
M
Poster / Poster
Kardio LIST
Saæetak sa skupa / Meeting abstract
Pregled programa otvorenog koda za raËunalom
potpomognuto dijagnosticiranje u kardiologiji
Overview of open source software for computer
aided detection in cardiology
Nihad MeπanoviÊ*, Elnur SmajiÊ
Javna zdravstvena ustanova Univerzitetski kliniËki centar Tuzla, Tuzla, Bosna i Hercegovina
University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
apredak u tehnologiji oslikavanja i raËunalne znanosti znaËajno su poboljπali moguÊnosti analize medicinskih slika i tako doprinijeli ranoj dijagnostici bolesti.
TipiËna arhitektura sustava za raËunalom potpomognuto dijagnosticiranje (CAD) obuhvaÊa pripremnu obradbu, definiranje podruËja od interesa, ekstrakciju i odabir znaËajki,
segmentaciju i klasifikaciju. ZahvaljujuÊi razvoju novih ureaja za oslikavanje koji stvaraju sve veÊi broj snimaka, neophodne su napredne tehnologije za obradu tako velike
koliËine podataka. Zbog navedenog potrebna je potpora raËunalom da bi se iz serije dinamiËkih 3-D modela snimaka
izdvojila odreena anatomska regija pacijenta. BuduÊi da
dijagnostiËar mora biti spreman brzo donijeti logiËne odluke
na temelju predloæenih modela, potreban je visok stupanj
toËnosti predloæenih rjeπenja u πto kraÊem vremenskom
razdoblju. U ovom Ëlanku demonstrirani su principi dizajna i
razvoja CAD sustava u smislu pregleda programa otvorenog koda za segmentaciju srca. ZakljuËak je da se raËunalna analiza oslikavanja srca u kombinaciji s umjetnom
inteligencijom moæe koristiti u kliniËkoj praksi i i da ista moæe
doprinijeti uËinkovitijoj dijagnozi.
KljuËne rijeËi: raËunalom potpomognuto dijagnosticiranje,
segmentacija u kardiologiji, analiza medicinskih slika.
N
Kardio LIST
dvances in imaging technology and computer science
have greatly enhanced interpretation of medical images, and contributed to early diagnosis. The typical architecture of a Computer Aided Detection (CAD) system includes image pre-processing, definition of region(s) of interest, features extraction and selection, segmentation and
classification. Due to the development of new imaging devices, which produce a large number of images, advanced
techniques for the evaluation of large amounts of data are
required. Therefore, computer-supported extraction of dynamic 3-D models of patient anatomy from temporal series is
highly desirable. Since the diagnostician must be able to
quickly make rational decisions based on the proposed models, a high degree of accuracy is required within a minimum
amount of time. In this paper, the principles of CAD systems
design and development are demonstrated by means of
open source software overview for cardiac image segmentation. It is concluded that computerized analysis of cardiac
images in combination with artificial intelligence can be used
in clinical practice and may contribute to more efficient diagnosis.
Keywords: computer aided detection, segmentation in cardiology, medical image analysis.
*Corresponding author — E-mail: [email protected]
A
Poster / Poster
2012;7(3-4):120.
Saæetak sa skupa / Meeting abstract
Kardiometrija
Cardiometry
Mikhail Rudenko*, Olga Voronova, Vladimir Zernov
Russian New University, Taganrog, Ruska Federacija
Russian New University, Taganrog, Russian Federation
Uvod
Introduction
Za razliku od kardiografije koja utvruje korelaciju izmeu
specifiËnih oblika kardioloπkih signala i kliniËke lokalizacije
patoloπkih promjena, kardiometrija pruæa kvantitativnu procjenu hemodinamskih varijabli i kvalitativnu procjenu funkcije temeljenu na kvalitativnoj analizi osobnosti EKG i reograma. Poznate su izravne i neizravne mjerne tehnologije. Ne
izravno mjerenje uvijek zahtijeva referentni objekt. Otkrivanjem hemodinamskih pravilnosti u kardiovaskularnom sustavu, autori su stvorili mjeriteljsku referencu u kardiologiji
kao inovativni matematiËki model. Otkrili su da je ona je bazirana na novom obliku poviπenih protoka tekuÊine u biosustavima. Dobiveni rezultati u praksi u vezi vrednovanja ove
inovativne teorije hemodinamike stvorili su temelj razvoja
kardiometrije, novog podruËja u istraæivanju i praksi.
Contrary to cardiography, that establishes correlations between specific cardiac signal shapes and clinical localization
of pathology, cardiometry delivers quantitative evaluation of
hemodynamic parameters and qualitative assessment of
functions, based on qualitative analysis of ECG and RHEOgram peculiarities. Known are direct and indirect measuring
technologies. Indirect measuring requires always a reference object. By discovering hemodynamics regularities in
cardiovascular system, the authors created the metrological
reference in cardiology as innovative mathematical model. It
is based on a new mode of elevated liquid flow in bio systems, discovered by them. The results obtained in practice
in validation of this innovative hemodynamics theory create
the foundation for development of a new field in research
and practice: cardiometry.
Ciljevi
Objectives
Evaluacija u praksi teoretskih potencijala precizne indirektne
mjerne tehnologije dostave hemodinamskih varijabli.
Metode
Za proizvodnju mjernih signala informativnih za sve faze
srËanog ciklusa koriπten je novi originalni kanal zvan EKG iz
uzlazne aorte. OmoguÊava ispitivanje svih 10 faza po srËanom ciklusu πto nije bilo moguÊe konvencionalnim metodama ispitivanja srca. Mjerenjem faza kao linearnih vrijednosti i njihovim koriπtenjem u hemodinamskim jednadæbama
od strane G. Poyedintseva i O. Voronove dobivene su odgovarajuÊe volumetrijske varijable. Na taj naËin moguÊe je
izraËunati 7 faza volumena krvi. SljedeÊi korak predstavlja
evaluacija funkcije kontrakcije miokarda u svakoj fazi.
Evaluation in practice of theoretical potentialities of precise
indirect measuring technology delivering hemodynamic
parameters.
Methods
To produce measuring signals informative for all heart cycle
phases, used is a new original lead called an ECG from ascending aorta. It delivers all 10 phases per heart cycle that
is not possible by conventional recording methods. By measuring phases as linear values and using them in hemodynamics equations by G. Poyedintsev and O. Voronova, the
respective volumetric parameters are obtained. In such a
manner, 7 phase-related volumes of blood are calculated.
Next step is to evaluate the contraction function the cardiac
muscles in every phase.
Rezultati
Istraæivanja s mjerenjima faze volumena krvi omoguÊavaju
nam razumijevanje mehanizama odræavanja hemodinamike.
To nam omoguÊava klasificirati podruËja promjene rada srca
od normalnog do ekstremnih patoloπkih procesa.
ZakljuËak
Results
Researches with phase blood volume measuring allows for
us to understand hemodynamics maintenance mechanisms.
It enables us to classify the ranges of heart performance
changes from norm to extreme pathology.
Conclusion
Primjena analize faze srËanog ciklusa i uzroËno-posljediËne
veze omoguÊuje nam da otkrijemo primarni uzrok bilo koje
bolesti srca.
An application of the heart cycle phase analysis and causeeffect relationship makes possible to reveal the primary
cause of any cardiac disease.
KljuËne rijeËi: kardiovaskularni sustav, srce, hemodinamika.
Keywords: cardiovascular system, heart, hemodynamics.
*Corresponding author — E-mail:
[email protected]
2012;7(3-4):121.
Poster / Poster
Kardio LIST
Saæetak sa skupa / Meeting abstract
Ispitivanje varijabilnosti srËanog ritma zasnovano
na analizi nelinearne dinamike kod bolesnika sa
stres-induciranom kardiomiopatijom
Heart rate variability based on nonlinear dynamic
analysis in patients with stress-induced
cardiomyopathy
Goran KrstaËiÊ*1, Gianfranco Parati2, Dragan Gamberger3, Paulo Castiglioni4,
Antonija KrstaËiÊ5, Robert Steiner6, Mario Ivanuπa1
1
Poliklinika za prevenciju kardiovaskularnih bolesti i rehabilitaciju, Zagreb, Hrvatska
2
Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italija
3
Institut Ruer BoπkoviÊ, Zagreb, Hrvatska
4
Centro di Bioingegneria, Fondazione Don Gnocchi, Milano, Italija
5
KliniËki bolniËki centar Sestre milosrdnice, Klinika za traumatologiju, Zagreb, Hrvatska
6
KliniËki bolniËki centar Osijek, Osijek, Hrvatska
1
Institute for Cardiovascular Diseases Prevention and Rehabilitation, Zagreb, Croatia
Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy
3
Ruer BoπkoviÊ Institute, Zagreb, Croatia
4
Centro di Bioingegneria, Fondazione Don Gnocchi, Milan, Italy
5
University Hospital Center Sestre milosrdnice, Clinic of Traumatology, Zagreb, Croatia
6
University Hospital Centre Osijek, Osijek, Croatia
2
Uvod
Background
Tehnike dinamiËke analize mogu kvantificirati poremeÊaj
varijabilnosti srËanog ritma (VSR) zasnovano na nelinearnoj
analizi.
Dynamic analysis techniques may quantify abnormalities in
heart rate variability (HRV) based on non-linear analysis.
Aim
Cilj
Istraæivanje kliniËke i prognostiËke znaËajnosti dinamiËkih
promjena VSR kod bolesnika sa stres-induciranom kardiomiopatijom (Takotsubo sindrom /TS/).
Aim of this study was to investigate the clinical and prognostic significance of dynamic HRV changes in patients with
stress-induced cardiomyopathy (Takotsubo Syndrome
/TS/).
Metode
Methods
Bolesnici sa TS su ukljuËeni u studiju nakon kompletne neinvazivne i invazivne dijagnostiËke kardiovaskularne obrade
usporedivo po spolu i dobi sa kontrolnom skupinom zdravih
ispitanika. Vremenska serija R-R intervala (RRI) je izolirana
iz 24-satnog EKG snimanja nakon digitalnog uzorkovanja.
Hurstov eksponent je odreivan metodom “reskalirane” analize. Za odreivanje svojstva dugo doseæne korelacije VSR,
uporabljena je metoda pomaknute fluktuacijske analize.
Aproksimativna entropija je primijenjena za odreivanje re-
Subjects with TS were included in this study after complete
non-invasive and invasive cardiovascular diagnostic evaluation compared to an age and gender matched control group
of healthy subjects. Series of R-R interval (RRI) values were
obtained from 24-hour ECG recordings after digital sampling. The “range rescaled analysis” method determined the
Hurst exponent of RRI values. To quantify fractal long-range
correlation properties of HRV, the detrended fluctuation
analysis technique was used. Approximate entropy was
Poster / Poster
Kardio LIST
2012;7(3-4):122.
gularnosti i kompleksnosti, kao i predvidljivosti fluktuacija u
vremenskoj seriji.
applied to quantify the regularity and complexity, as well as
unpredictability of fluctuations in time series.
Rezultati
Results
Kratko-doseæni i dugo-doseæni fraktalni skalarni eksponenti
(1 i 2) su bili znaËajno poviπeni kod bolesnika sa TS u
akutnoj fazi nego u kontrolnoj skupini, dok su aproksimativna entropija i Hurstov eksponent bili sniæeni, no sve se normaliziralo kroz nekoliko tjedana.
Short-term and long-term fractal scaling exponent (1 and
2) were significantly higher in patients with TS in acute
phases than in controls as well as lower approximate entropy and Hurst exponent, but those variables has been normalized in a few weeks.
ZakljuËci
Conclusion
Analiza zasnovana na kompleksnosti odraæava poremeÊene
neuroanatomske interreakcije koji mogu doprinijeti razvoju
stres kardiomiopatije. DinamiËka nelinearna analiza VSR
omoguÊava procjenu fraktalnosti vremenske serije kod TS
bolesnika koji su veÊ izgubili normalne fraktalne karakteristike i nelinearne obrasce VSR i moæe posluæiti za nadopunu
tradicionalnih elektrokardiografskih ispitivanja i kliniËkoj prosudbi.
Complexity based analysis may reflect altered neuroanatomic interactions that may predispose to severe stress cardiomyopathy. Dynamic non-linear HRV analysis allows assessing fractal time series in TS patients who already lost
normal fractal characteristics and nonlinear patterns in HRV,
and may thus complement traditional ECG and clinically
analysis.
KljuËne rijeËi: varijabilnost srËanog ritma, nelinearna dinamika, teorija kaosa, stres-inducirana kardiomiopatija, Takotsubo sindrom.
Keywords: heart rate variability, nonlinear dynamics, chaos
theory, stress-induced cardiomyopathy, Takotsubo syndrome.
*Corresponding author — E-mail:
[email protected]
2012;7(3-4):123.
Kardio LIST
Saæetak sa skupa / Meeting abstract
Varijabilnost srËanog ritma i prediktivni modeli
autonomne disfunkcije nakon ozljede vratne
kraljeπnice
Heart rate variability and predictive models of
autonomic dysfunction after spinal cord injury
Antonija KrstaËiÊ*1, Goran KrstaËiÊ2, Dragan Gamberger3
1
KliniËki bolniËki centar Sestre milosrdnice, Klinika za traumatologiju, Zagreb, Croatia
2
Poliklinika za prevenciju kardiovaskularnih bolesti i rehabilitaciju, Zagreb, Croatia
3
Institut Ruer BoπkoviÊ, Zagreb, Croatia
1
University Hospital Centre Sestre milosrdnice, Clinic for Traumatology, Zagreb, Croatia
Institute for Cardiovascular Diseases and Rehabilitation, Zagreb, Croatia
3
Ruer BoπkoviÊ Institute, Zagreb, Croatia
2
zljedom vratne kraljeπnice moæe doÊi do gubitka simpatiËki posredovanih kardiovaskularnih refleksa zbog
prekida supraspinalne kontrole spinalnih simpatiËkih
motoneurona.
Cilj rada je analiza simpatovagalnog balansa nakon akutne
ozljede vratne kraljeπnice prikazom rezultata standardne
statistiËke analize i prediktivnim modelima autonomne funkcije i disfunkcije.
Istraæivanje je provedeno na 40 ispitanika sa akutnom ozljedom vratne kraljeπnice i kraljeæniËne moædine i 40 zdravih
ispitanika kontrolne skupine.
Provedeno istraæivanje potvruje ispitivanje varijabilnosti
srËanog ritma (VSR) linearnim metodama kao objektivni pokazatelj normalne i poremeÊene funkcije autonomnog æivËanog sustava.
Ispitivanje parametara VSR ukazuje na sniæeni simpatovagalni balans nakon akutne ozljede.
Prediktivni modeli inducirani metodom strojnog uËenja i metode vizualnog prikaza pokazuju sniæenu, ali nazoËnu funkciju n. simpatikusa predmnijevajuÊi da su aferentne i eferentne sveze simpatiËkog autonomnog sustava u izoliranom
segmentu ostale funkcijski neoπteÊene iako bez kontrole
viπih centara. (LF/HF <1,23 ms2)
U konaËnici, akutna ozljeda vratne kraljeπnice dovodi do poremeÊaja modulatorne aktivnosti n. simpatikusa na kardiovaskularni sustav. Prediktivni modeli mogu pomoÊi u evaluaciji i objektivizaciji povezanosti srediπnjeg æivËanog sustava i spinalnih simpatiËkih motoneurona s autonomnom kardiovaskularnom kontrolom.
O
KljuËne rijeËi: ozljeda kraljeπnice, varijabilnost srËanog ritma, simpatovagalni balans, prediktivni modeli.
Kardio LIST
pinal cord injury may cause loss of cardiovascular reflexes mediated by sympathetic drive due to interruption supraspinal control of spinal sympathetic motoneurons.
The purpose of this study is analysis sympathovagal balance after acute spinal cord injury presented by standard statistical analysis and by predictive models of autonomic function and dysfunction.
We analysed a sample of 40 patients after acute spinal cord
injury and 40 healthy persons of the controls.
This study establish analysing of heart rate variability (HRV)
by linear methods as objective measures of normal and
abnormal function of autonomic nervous system.
The analysis parameters of HRV indicates decreased sympathovagal balance after acute spinal cord injury.
Predictive models induced by inductive machine learning by
logic minimization and visual methods presented decreased, but still present sympathetic activity and suggest that
descending and ascending fibres of sympathetic nervous
system in an isolated segment are undamaged although
without supraspinal control. (LF/HF <1.23 ms2)
Finally, acute spinal cord injury leads to disturbances of modulatory sympathetic activity on cardiovascular system. Predictive models could help in evaluation and objectification of
the connections between central nervous system and spinal
sympathetic motoneurons on one side and autonomic cardiovascular control on the other side.
S
Keywords: spinal cor injury, heart rate variability, sympathovagal balance, predictive models.
*Corresponding author — E-mail:
antonija.krstacic@ zg.t-com.hr
Poster / Poster
2012;7(3-4):124.
Saæetak sa skupa / Meeting abstract
Utjecaj srËane frekvencije na reproducilnost
varijabilnosti srËanog ritma
Heart rate influences reproducibility of heart rate
variability
Jerzy Sacha*1, Jacek Sobon2, Krzysztof Sacha3
1
Regional Medical Center, Opole, Poljska
2
Faculty of Physical Education and Physiotherapy, Opole University of Technology, Opole, Poljska
3
Uniwersytet Jagiellonski, Krakow, Poljska
1
Regional Medical Center, Opole, Poland
2
Faculty of Physical Education and Physiotherapy, Opole University of Technology, Opole, Poland
3
Uniwersytet Jagiellonski, Krakow, Poland
arijabilnost srËanog ritma (HRV) izraËunata iz RR-intervala u inverznom je odnosu sa srednjom vrijednosti
frekvencije srca (HR). Meutim, matematiËkim modifikacijama moæe se pojaËati, oslabiti ili Ëak promijeniti smjer
ove povezanosti. Cilj ove studije je bio istraæiti utjeËu li takve
izmjene na poboljπanje reproducibilnosti HRV.
Analiza je izvrπena na seriji od 948 RR-intervala (svaki se
sastojao od 512 intervala) od 24 zdrava dobrovoljca (14 muπkaraca; srednja dob SD 31,1±10,3 godina) u sjedeÊem
poloæaju dva puta dnevno u isto vrijeme ujutro (do 10 sati) i
V
eart rate variability (HRV) calculated from RR-intervals is inversely dependent on average heart rate
(HR). However, by mathematical modifications one
may strengthen, weaken or even inverse this dependence.
The aim of the study was to explore if such modifications
improve reproducibility of HRV.
The analysis was performed on 948 RR-interval series
(each consisted of 512 intervals) taken from 24 healthy volunteers (14 men; mean age SD 31.1±10.3 years) in a sitting
position twice daily at the same time in the morning (before
H
Figure 1. Relationship between average values of coefficients of variation for spectral HRV indices and their correlation coefficients with HR are shown. The indices presenting the lowest dependence on HR (i.e. correlation coefficients close to zero)
exhibit the best reproducibility (i.e. the lowest coefficients of variation). To facilitate visualization, points of the respective HRV
indices are connected with lines - the circles correspond to standard HRV indices. Coefficients of variation for respective HRV
indices significantly differ, p<0.00001 (Friedman ANOVA test).
2012;7(3-4):125.
Poster / Poster
Kardio LIST
uveËer (nakon 18 sati) tijekom 30 dana (39,5±2,3 snimaka/osoba). Procijenjeni su sljedeÊi HRV spektralni indeksi,
tj. vrlo niske frekvencije (VLF), niske frekvencije (LF), visoke
frekvencije (HF) i ukupna snaga (TP). Koriπtenjem matematiËkih izmjena, izraËunato je 17 klasa indeksa s razliËitim
povezanostima s HR. Njihovi prosjeËni koeficijenti korelacije
s HR (pojedinaËno za svaku klasu) su iznosili: 0.66, 0.58,
0.48, 0.36, 0.22, 0.06, -0.1, -0.25, -0.39*, -0.5, -0.59, -0.66,
-0.72, -0.76, -0.8, -0.83, -0.85 (prosjeËni koeficijent korelacije za klasu sa standardnim HRV indeksima oznaËen je s
*). Za usporedbu promjenjivosti, izraËunati su koeficijenti
varijacije (CV) za svaku HRV kod svakog pacijenta.
Slika prikazuje prosjeËan CV u odnosu na prosjeËne koeficijente korelacije za odreeni indeks. HRV indeksi koji predstavljaju najniæu ovisnost o HR (tj. koeficijente korelacije
blizu nule) pokazuju najbolju obnovljivost (tj. najmanji CV).
ZakljuËno, HR utjeËe na obnovljivost HRV i iskljuËivanje utjecaja HR na HRV poboljπava obnovljivost spektralnih HRV
indeksa.
KljuËne rijeËi: varijabilnost srËanog ritma, frekvencija srca,
RR-interval.
10 a.m.) and evening (after 6 p.m.) over 30 days (39.5±2.3
recordings/person). The following HRV spectral indices were estimated, i.e. very low frequency (VLF), low frequency
(LF), high frequency (HF) and total power (TP). Using mathematical modifications, 17 classes of these indices with
different association with HR were calculated — their average correlation coefficients with HR (for each class respectively) were: 0.66, 0.58, 0.48, 0.36, 0.22, 0.06, -0.1, -0.25, 0.39*, -0.5, -0.59, -0.66, -0.72, -0.76, -0.8, -0.83, -0.85 (the
average correlation coefficient for the class with standard
HRV indices is marked with *). To compare the reproducibility, coefficients of variation (CV) were calculated for each
HRV index for each patient.
Figure shows average CV plotted against average correlation coefficients for a given index. The HRV indices presenting the lowest dependence on HR (i.e. the correlation coefficients close to zero) exhibit the best reproducibility (i.e. the
lowest CV).
To conclude, HR influences HRV reproducibility and the
exclusion of HR impact on HRV improves the reproducibility of spectral HRV indices.
Keywords: heart rate variability, heart rate, RR-interval.
*Corresponding author — E-mail: [email protected]
Kardio LIST
2012;7(3-4):126.
Saæetak sa skupa / Meeting abstract
IzluËivanje nelinearnih znaËajki iz biomedicinskih
vremenskih nizova koriπtenjem radnog okvira
HRVFrame
Extraction of nonlinear features from biomedical
time-series using HRVFrame framework
Alan JoviÊ*1, Nikola BogunoviÊ1, Goran KrstaËiÊ2
1
Fakultet elektrotehnike i raËunarstva, Zagreb, Hrvatska
2
Poliklinika za prevenciju kardiovaskularne bolesti i rehabilitaciju, Zagreb, Hrvatska
1
Faculty of Electrical Engineering and Computing, Zagreb, Croatia
2
Institute for Cardiovascular Diseases Prevention and Rehabilitation, Zagreb, Croatia
iomedicinski vremenski nizovi (BVN) kao πto su srËani
ritam, elektrokardiogram, elektroencefalogram, itd.,
obiËno zahtjevaju detaljnu analizu kako bi se ustanovila prisutnost poremeÊaja. Normalan obrazac odreenog
BVN Ëesto ima vrlo sloæeno ponaπanje i sadræi nestacionarnosti koje su rezultat bioloπkih procesa koji se dogaaju
u pozadini. Modeliranje normalnih obrazaca kao i obrazaca
poremeÊaja je problematiËno buduÊi da je prostor znaËajki
beskonaËan — bilo koja karakteristika vremenskog niza moæe se smatrati znaËajkom. UobiËajeni pristup za odreivanje
koja znaËajka vremenskog niza se treba analizirati je putem
informirane odluke koju donosi medicinski struËnjak. Ova
odluka je poneπto proizvoljna buduÊi da u nekim sluËajevima ne postoje jasne smjernice koja bi znaËajka trebala biti
najbolja za modeliranje pojedinog obrasca BVN. Nelinearne
znaËajke BVN kao πto su: pribliæna entropija, entropija uzorka, spektralna entropija, korelacijska dimenzija, indeks prostorne popunjenosti, fraktalna dimenzija i mnoge druge su
nedavno razvijene s ciljem boljeg opisa normalnog obrasca
kao i za razlikovanje normalnog obrasca od obrasca poremeÊaja. Prema naπoj spoznaji, ne postoji slobodno dostupan alat za izluËivanje velikog broja nelinearnih znaËajki iz
BVN. Cilj ovog rada je promovirati HRVFrame, radni okvir
otvorenog koda pisan u Javi koji omoguÊuje korisnicima da
izluËe velik broj nelinearnih znaËajki (i odreen broj standardnih linearnih znaËajki) iz BVN. TrenutaËno, HRVFrame
je ograniËen na izluËivanje znaËajki iz srËanog ritma, ali su
nadogradnje za druge BVN u planu. HRVFrame omoguÊuje
proces nadziranog uËenja i olakπava izgradnju toËnog modela tako πto izluËuje vektore znaËajki u datoteke koje se
zatim mogu analizirati pomoÊu uobiËajenih alata za dubinsku analizu podataka.
B
KljuËne rijeËi: nelinearna dinamika, srËane aritmije, izluËivanje znaËajki, dubinska analiza podataka.
2012;7(3-4):127.
iomedical time-series (BTS) such as cardiac rhythm,
electrocardiogram, electroencephalogram, etc., usually require in-depth analysis in order to determine the
presence of disorder. Normal pattern of a particular BTS
often possesses highly complex behavior and contains nonstationarities as a result of background biological processes.
Modelling of normal patterns as well as disorders is troublesome because of the indefinite feature space — as any
characteristic of the time-series might be considered a feature. A usual approach to determining which feature of the
time-series should be analyzed is through an informed decision by a medical professional. This decision is somewhat
arbitrary because in some cases there are no clear guidelines to which feature should be considered best for modelling of a particular BTS pattern. Nonlinear features of BTS
have been recently developed such as: approximate entropy, sample entropy, spectral entropy, correlation dimension, spatial filling index, fractal dimension, and many others, which aim to better describe both the normal pattern as
well as to distinguish normal patterns from disorders. To our
knowledge, there is no freely available tool for extraction of
many nonlinear features from BTS. This work aims to promote HRVFrame, a Java based open-source framework that
allows users to extract a large number of nonlinear features
(and a number of standard linear features) from BTS.
Currently, HRVFrame is limited to feature extraction from
cardiac rhthym, but upgrades for other BTS are planned.
HRVFrame enables supervised learning and facilitates
accurate model construction by extracting feature vectors to
files that can be analyzed by standard data mining tools.
B
Keywords: nonlinear dynamics, cardiac arrhythmia, feature
extraction, data mining.
*Corresponding author — E-mail: [email protected]
Poster / Poster
Kardio LIST
Saæetak sa skupa / Meeting abstract
Tranzitorna ishemijska ataka uzrokovana
tromboembolizmom s ishodiπtem u aneurizmi
membranoznog ventrikularnog septuma
Transient ischemic attack due to thromboembolism
from membranous ventricular septum aneurysm
Damir FabijaniÊ*, Cristijan Bulat, TonÊi BatiniÊ, Vedran CareviÊ, Kreπimir »aljkuπiÊ
KliniËki bolniËki centar Split, Split, Hrvatska
University Hospital Centre Split, Split, Croatia
23-godiπnji muπkarac, bez ranije kardioloπke bolesti, upuÊen je na ehokardiografski pregled nakon ponovljene tranzitorne ishemijske atake (TIA). Ehokardiografski je zabiljeæena vreÊasta aneurizma membranoznog ventrikularnog
septuma (AMS), veliËine oko 15x9 mm, utisnuta u desnu klijetku. Obojanim dopplerom je zabiljeæen protok usmjeren iz
lijeve klijetke u AMS, kroz uzak ventrikularni septalni defekt
(VSD). Nije zabiljeæena opstrukcija izlaznog trakta desne klijetke, infekcija ili tromboza aneurizme. Magnetna rezonancija srca (MRS) je potvrdila ehokardiografski nalaz. Iako ehokardiografija i MRS nisu zabiljeæile tromb u AMS, ova je tvorba prihvaÊena kao najvjerojatniji izvor embolizama odgovornih za ponovljenu TIA. Izvrπena je resekcija AMS i zatvaranje VSD. Osamnaest mjeseci nakon kirurπkog zahvata
neuroloπki se ispadi nisu ponavljali.
AMS je posljedica djelomiËnog ili potpunog, spontanog, zatvaranja VSD. VeÊi membranozni VSD prisutan u dojenaËkoj
dobi, u djetinjstvu regredira u manji defekt uz istodobno nastajanje aneuarizme. U odraslih se AMS najËeπÊe nalazi
sluËajno tijekom ehokardiografije, koja je u veÊini sluËajeva
dostatna za definitivnu dijagnozu ove anomalije.
A
A 23-year-old man, without history of cardiac disease, was
referred to the echocardiography after transient ischemic
attack (TIA). Echocardiography showed a sack-like aneurysm of the membranous ventricular septum (AMS), approximately 15x9 mm in size, protruding into the right ventricle.
Color Doppler revealed blood flow directly from the left ventricular cavity into the AMS through narrow ventricular septal defect (VSD). There were no signs of right ventricular
outflow tract obstruction, infection or thrombosis. Cardiac
magnetic resonance (CMR) confirmed echocardiography
findings. Although echocardiography and CMR did not detect thrombus in AMS, it was accepted as a most likely cause of embolic events responsible for recurrent TIA. Complete resection of AMS and closure of VSD was done by a
pericardial patch. Eighteen months after surgical repair no
other neurological event has occurred.
AMS develops as a consequence of partial or complete
spontaneous closure of a VSD. A large membranous VSD
in infancy progresses to a smaller defect with aneurysm formation later in childhood. In adult patients, AMS is the most
frequently detected accidentally, during echocardiography
B
Figure 1. Transesophageal echocardiography demonstrated membranous ventricular septum aneurysm bulging toward the
right ventricle (A). Doppler echocardiography revealed blood flow directly from the left ventricular cavity into the aneurysm
through small ventricular septal defect (B).
LA — left atrium; LV — left ventricle; RV — right ventricle; A — aneurysm of the membranous ventricular septum, Ao — aorta.
Kardio LIST
Poster / Poster
2012;7(3-4):128.
Figure 2. Cardiac magnetic resonance (Cine MRI 3-chamber view) revealed small membranous ventricular septal defect (A)
and sack-like aneurysm protruding into the right ventricle without signs of outflow tract obstruction (B).
LV — left ventricle; RV — right ventricle; A — aneurysm of the membranous ventricular septum.
Kompjutorizirana tomografija ili MRS mogu pomoÊi u jasnijem prikazu veliËine i oblika AMS, njezinog odnosa s okolnim strukturama srca, otkrivanju tromboze ili upale.
KliniËko znaËenje AMS proizlazi iz moæebitnih, potencijalno
smrtonosnih, komplikacija (primjerice, rupture aneurizme,
tromboembolijskih incidenata, infekcijskog endokarditisa).
Stoga je potpuna resekcija AMS i zatvaranje VSD indicirano
i u asimptomatskih bolesnika, odmah po otkrivanju ove anomalije.
which is, in the most cases, the only method needed for definite diagnosis. Computed tomography or CMR can help
delineate the extent of the AMS, its relationships to surrounding cardiac structures, and AMS thrombosis or inflammation.
Clinical importance of AMS stems from potentially severe or
fatal complications (e.g. rupture, thromboembolism, infectious endocarditis). Therefore, complete AMS resection and
VSD patch closure, should be done forthwith after diagnosis,
even in asymptomatic patients.
KljuËne rijeËi: aneurizma, ventrikularni septum; tromboembolizam; tranzitorna ishemijska ataka.
Keywords: aneurysm, ventricular septum; thromboemolism; transient ischemic attack.
*Corresponding author — E-mail:
[email protected]
2012;7(3-4):129.
Kardio LIST
Saæetak sa skupa / Meeting abstract
Brugada sindrom i morfofunkcionalne abnormalnosti
desnog ventrikula na ultrazvuku u mladog muπkarca
s obiteljskom anamnezom nagle srËane smrti
Brugada syndrome and right ventricle morphofunctional
abnormalities on echocardiography in young male
with familly anamnesis of sudden cardiac death
Robert Steiner, Zorin MakaroviÊ, Sandra MakaroviÊ*
KliniËki bolniËki centar Osijek, Osijek, Hrvatska
University Hospital Centre Osijek, Osijek, Croatia
rugada sindrom (BrS) je primarno elektriËni poremeÊaj
srca, koji moæe uzrokovati naglu srËanu smrt ili po æivot opasne ventrikulske aritmije. Ova nasljedna bolest
prenosi se autosomno dominantno i genetski je odreena.
Iako je veliki broj gena analizirano, sindrom je sa sigurnoπÊu
povezan jedino s mutacijama na genu SCN5A, koji kodira podjedinicu natrijevih kanala. EKG promjene koje sugeriraju BrS, ukljuËuju repolarizacijske i depolarizacijske promjene uz odsutnost strukturalnih promjena srca ili lijekova koji
mogu uzrokovati elevaciju ST-segmenta u desnim prekordijalnim odvodima (V1-V3). Intravenska primjena odreenih lijekova mogu promijeniti izgled EKG zapisa. Ajmalin, flekainid, prokainamid te propafenon poveÊavaju elevaciju STsegmenta ili je otkrivaju ako se prvobitno ne vidi. Kardioverter defibrilator je jedina dokazano uËinkovita terapija BrS.
Iako je BrS primarno elektriËni poremeÊaj, neki autori smatraju da postoje morfoloπke i funkcijske abnormalnosti, uglavnom izgonskog trakta desnog ventrikula.
U ovom kratkom izvjeπÊu prikazat Êemo sluËaj mladog muπkarca, s predispozicijom i pozitivnom obiteljskom anamnezom nagle srËane smrti, s kompletnom uËinjenom dijagnostiËkom obradom, ukljuËujuÊi propafenonski test. Navedeni
test je bio pozitivan te otkrio BrS. Ehokardiografski pregled
pokazao je proπirenje apikalnog dijela desnog ventrikula,
sugerirajuÊi da je moguÊe da BrS nije samo elektriËni poremeÊaj, nego moæe imati i morfofunkcionalne promjene desnog ventrikula, πto je takoer objavljivano u literaturi. U konaËnici, bolesniku je implantiran kardioverter defibrilator.
Analizirali smo moguÊe poveznice izmeu BrS i morfoloπkih
abnormalnosti desnog ventrikula.
B
rugada Syndrome (BrS) is a primary electrical disease
of the heart that causes sudden cardiac death or lifethreatening ventricular arrhythmias. This disease is
hereditary autosomic dominant transmited and genetically
determined. Although a number of candidate genes were
analysed, the syndrome has been linked only to mutations
in SCN5A, the gene encoding for the -subunit of the sodium channel. ECG abnormalities indicating BrS, include repolarization and depolarization abnormalities in the absence
of identifiable structural cardiac abnormalities or other conditions or agents known to lead to ST-segment elevation in
the right precordial leads (V1-V3). Intravenous administration of certain drugs may modify the ECG pattern. Ajmaline,
flecainide, procainamide and propafenone exaggerate the
ST-segment elevation or unmask it when it is initially absent.
An implantable cardioverter-defibrillator (ICD) is the only
proven effective device treatment for the disease. Although
BrS is primary electrical disease, some authors have suggested the presence of morphological and functional abnormalities mainly located in the right ventricle (RV), notably in
the outflow tract (RVOT).
In this short report we will demonstrate a young male, with
predisposition and possitive familly anamnesis of suden cardiac death, with his completelly diagnostical procedure, propafenon test which was possitive, unmasking BrS. An echocardiography demonstrated dilated apical RV, suggesive
BrS is not only electrical disorder, but may include morphofunctional abnormalities, that are also reported in the literature. Finally he was implanted ICD. In addition, we reviewed
the possible connection between BrS and morphological
abnormalities in RV.
KljuËne rijeËi: Brugada sindrom, nagla srËana smrt, propafenonski test, morfoloπke abnormalnosti desnog ventrikula,
kardioverter defibrilator.
Keywords: Brugada syndrome, sudden cardiac death, propafenon test, right ventricular morphological abnormalities,
implantible cardioverter defibrilator (ICD).
B
*Corresponding author — E-mail:
[email protected]
Kardio LIST
Poster / Poster
2012;7(3-4):130.
Saæetak sa skupa / Meeting abstract
Koronarna CT angiografija i perfuzija miokarda u
jednom aktu — kliniËki primjeri
Coronary CT angiography and myocardial perfusion in a single act — clinical cases
Mladen JukiÊ1*, Ladislav PaviÊ1, Petar MedakoviÊ1, Bitunjac Ivan2
1
Poliklinika Sunce, Zagreb, Hrvatska
OpÊa bolnica “Dr. J. BenËeviÊ”, Slavonski Brod, Hrvatska
1
Sunce Polyclinic, Zagreb, Croatia
2
General Hospital “Dr. J. BenËeviÊ”, Slavonski Brod, Croatia
2
ompjutorizirana tomografija (CT) predstavlja neinvazivnu dijagnostiËku metodu koja se u kliniËkoj praksi
sve viπe koristi i kao metoda za probir koronarne bolesti srca (KBS), poglavito zahvaljujuÊi znaËajnom smanjenju
doze zraËenja u posljednih nekoliko godina.
U Poliklinici Sunce u Zagrebu CT-koronarografiju vrπimo sukladno preporukama Advanced Cardiovascular Imaging
Consortium za minimaliziranje doze zraËenja te koristimo
64-slojni CT-ureaj Dual Source posebno dizajniran za oslikavanje srca. Novija istraæivanja ukazuju da se na CT, osim
anatomije i morfologije, moæe pouzdano analizirati i funkcija
— perfuzija miokarda.
U ovom radu prikazujemo nekoliko kliniËkih sluËajeva gdje
usporeujemo morfoloπki nalaz aterosklerotskog plaka s
perfuzijom miokarda. Morfoloπko i perfuzijsko oslikavanje srca i krvnih æila izvodi se u jednom scanu bez dodatne doze
zraËenja i bez dodatnog kontrastnog sredstva. Na ovaj naËin
CT oslikavanje srca omoguÊava potpuno kliniËko, ne samo
dijagnostiËko veÊ i terapijsko, razrjeπavanje veÊine pacijenata sa suspektnom KBS.
K
KljuËne rijeËi: kompjutorizirana tomografija, koronarna bolest srca, neinvazivna kardioloπka dijagnostika.
omputed tomography (CT) is a noninvasive diagnostic
method which is also increasingly used in clinical
practice as a screening method for coronary artery
disease (CAD), mainly owing to a significant reduction of
radiation dose over the last few years.
In the Sunce Polyclinic in Zagreb, CT-coronarography is
performed in accordance with the recommendations of the
Advanced Cardiovascular Imaging Consortium for minimizing the radiation dose and we use the 64-layer CT DualSource device specifically designed for cardiac imaging.
The recent trials show that the CT, except for anatomy and
morphology, can reliably analyze the myocardial function perfusion.
In this article we present several clinical cases where we
compare the morphological findings of atherosclerotic
plaque with myocardial perfusion. Morphological and perfusion imaging of the heart and blood vessels is performed in
a single scan with no additional radiation dose and additional contrast agent. In this way, CT imaging of the heart allows
a total clinical, not only diagnostic, but also therapeutic management of the majority of patients with suspected CAD.
C
Keywords: computed tomography, coronary heart disease,
cardiac noninvasive diagnostics.
*Corresponding author — E-mail: [email protected]
2012;7(1-2):131.
Poster / Poster
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Saæetak sa skupa / Meeting abstract
Vrijednost serumskog osteoprotegerina kao
biomarkera u bolesnika s kalcificiranom aortnom
stenozom sa ili bez zatajivanja srca
Value of serum osteoprotegerin as a biomarker in
patients with calcific aortic valve stenosis with or
withouth heart failure
Sandra MakaroviÊ*, Zorin MakaroviÊ, Robert Steiner, Marija Maras
KliniËki bolniËki centar Osijek, Osijek, Hrvatska
University Hospital Centre Osijek, Osijek, Croatia
eza izmeu koπtanog metabolizma i vaskularnih kalcifikacija potaknula je potragu za zajedniËkim medijatorima koji povezuju koπtani i vaskularni sustav. Od
kada je prvobitno otkrivena njegova uloga kljuËnog regulatora koπtanog metabolizma, osteoprotegerin (OPG) je postao predmetom intenzivnog istraæivanja, osobito u svojoj
ulozi formiranja vaskularnih i valvularnih kalcifikacija. Istraæivanja in vitro te ona u animalnih modela pokazala su da
OPG inhibira vaskularne kalcifikacije. Paradoksalno, kliniËka istraæivanja pokazala su da serumska razina OPG raste
u koronarnoj bolesti srca i kalcificirajuÊoj stenozi aortne valvule. Da istraæimo navedeno, sljedeÊi parametri su analizirani u 51 bolesnika s teπkom kalcificiranom aortalnom stenozom te 39 prema dobi i spolu usklaenih kontrolnih ispitanika, bez obstruktivne koronarne bolesti, ishemijske cerebralne bolesti, bolesti perifernih arterija te s oËuvanom renalnom funkcijom: OPG, sistoliËka funkcija srca te razvoj
srËanog zatajivanja. Vrijednost OPG je bio poviπena kod bolesnika s aortnom stenozom. U zakljuËku, ovi podaci podupiru hipotezu o povezanosti teπke aortne stenoze s promijenjenim metabolizmom OPG. Nadalje, pokazali smo da je
serumski OPG znaËajno viπi u bolesnika sa zatajivanjem
srca zbog aortne stenoze u usporedbi s bolesnicima s aortnom stenozom bez zatajivanja srca. Ovi podaci ukazuju da
bi se OPG mogao koristiti kao marker zatajivanja srca u ovih
bolesnika, ukazujuÊi na njihovu loπiju prognozu.
V
KljuËne rijeËi: osteoprotegerin, stenoza aortne valvule, kalcifikacije, zatajivanje srca, biomarker.
ssociation between bone metabolism and vascular calcification has stimulated search for common mediators
linking bone and vascular system. Since its initially discovered, as a key regulator in bone metabolism, osteoprotegerin (OPG) has become an object of intensive research in its role in forming vascular and valvular calcification. Studies in vitro and those in animal models have shown
that osteoprotegerin inhibits vascular calcification. Paradoxically however, clinical studies have shown that serum OPG
levels increases in coronary artery disease and calcific aortic valve stenosis. To further investigate the role of OPG in
calcific aortic valve stenosis with and without heart failure,
the following parameters were analyzed in 51 patients with
severe aortic stenosis (AS) and in 39 age and gender-matched controls, without obstructive coronary artery disease,
ishemic cerebral disease, ishemic peripheral artery disease
and with preserved renal function: OPG, sistolic heart function and development of heart failure, amongst patients with
aortic stenosis. Value of OPG was elevated in patients with
aortic stenosis. Furthermore, we found serum OPG levels to
be significantly higher in patients with heart failure due to severe aortic stenosis, compared to its value in aortic stenosis
patients, without heart failure. These data support a hypothesis connecting (severe) aortic stenosis to altered OPG,
thus OPG can be used as a nowel biomarker in aortic stenosis and as marker of heart failure in these patients, showing
poorer prognostic function.
Keywords: osteoprotegerin, aortic valve stenosis, calcification, heart failure, biomarker.
*Corresponding author — E-mail:
[email protected]
A
Table 1. Serum levels of OPG in pair-matched patients and controls.
Patients with AS
Controls
N
Mean OPG value
Standard deviation
t Value
p Value
51
39
7.5243
4.7964
3.71412
1.22384
t=4.908
p=0.000
*p value is significant at the 0.05 level; AS - aortic stenosis; OPG - osteoprotegerin
Table 2. Serum levels of OPG in aortic stenosis patients with or without heart failure.
AS patients
n
Mean Rank
t Value
p Value
With HF
Without HF
22
29
37.86
17
?2=24.643*
(df=1, p=0.000)
*For analyses it is used nonparametrical Mann-Whitney test, for the sample is <than 30 patients; AS - aortic stenosis, HF - heart hailure
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Poster / Poster
2012;7(3-4):132.
Saæetak sa skupa / Meeting abstract
ZnaËajan uËinak lijeËenja teπke i maligne
esencijalne hipertenzije
Important effect of treatment of severe and
malignant essential hypertension
Isma Gaπanin*
Dom zdravlja Sjenica, Sjenica, Srbija
Sjenica Health Centre, Sjenica, Srbija
Uvod
Background
Joπ kao lijeËnik primarne zdravstvene zaπtite registrirala sam
da kod jednog broja oboljelih od esencijalne hipertenzije
(EH) primjena antihipertenziva nije rezultirala oËekivanim
terapijskim uËinkom. Cilj ovog rada je ukazati, na osnovu
znaËajnog uËinka lijeËenja oboljelih od teπke i maligne EH,
da vaæni etioloπki faktori ove bolesti mogu biti i emocionalna
napetost i hipervolemija koji djeluju pojedinaËno ili udruæeno.
As a primary care physician I recorded that the administration of antihypertensive drugs did not result in the expected
therapeutic effect in a certain number of patients suffering
from essential hypertension (EH). The aim of this paper is to
show, based on the significant effect of treatment of patients
with severe and malignant EH, that important etiological factors of this disease can be emotional stress and hypervolaemia with individual or joint effect.
Ispitanici i rezultati
Respondents and results:
Od 1998. do 2003. god. lijeËila sam 27 pacijenata (23 æene
i 4 muπkarca) te od 2004. do 2010. god. 28 æena i 14 muπkaraca koji su imali visok arterijski tlak (AT) od 3 do 20 godina. Javili su se na lijeËenje po preporuci zbog perzistiranja
visokih vrijednosti AT i pored primjene 2 do 4 antihipertenziva. U svim sluËajevima, najmanje godinu dana, dijastoliËki
AT se kretao od 100 do 130mmHg i sistoliËki od 170 do 240
mmHg. Adekvatnom kombinacijom anksiolitika, diuretika i
vazodilatatora, postignuta je normalna vrijednost AT kod
svih pacijenata za 7 do 30 dana, ovisno od postojanja hipertrofije tunike muskuloze.
From 1998 to 2003 I treated 27 patients (23 women and 4
men) and from 2004 to 2010 I treated 28 women and 14
men who had high blood pressure (BP) from 3 to 20 years.
They came for treatment upon recommendation because of
persistent high BP values despite the administration of 2 to
4 antihypertensive drugs. In all cases, diastolic BP ranged
from 100 to 130 mmHg and systolic ranged from 170 to 240
mmHg at least during a period of one year. Appropriate
combination of anxiolytics, diuretics and vasodilators resulted in normal BP values in all patients during a period from 7
to 30 days, depending on the existence of hypertrophy of
muscular tunic.
ZakljuËak
Teπka i maligna EH lijeËi se antihipertenzivima koji imaju vazodilatatorno djelovanje: ACE inhibitorima, antagonistima
kalcijskih kanala, beta-1 blokatorima i drugima te njihovom
kombinacijom. Anksiolitik je preporuËljiv u adekvatnoj dozi
ovisno od stupnja emocionalne napetosti kako bi se uklonilo suviπno psihiËko optereÊenje i oËuvala motorna aktivnost.
Diuretik se daje svakodnevno u niskim dozama koje su danas pridodate najveÊem broju ACE inhibitora. Pored terapije antihipertenzivima nuæna je i prevencija u ishrani. “Volumensko pravilo” predstavlja vaæan i zdrav naËin prevencije
pretilosti i EH.
KljuËne rijeËi: arterijska hipertenzija, arterijski tlak, antihipertenzivna terapija.
Conclusion
Severe and malignant EH is treated with antihypertensive
drugs that have a vasodilative effect: ACE inhibitors, calcium channel antagonists, beta-1 blockers, and other drugs
and their combination. Anxiolytic drug is recommended in
adequate dose, depending on a degree of emotional stress
in order to eliminate excessive psychological load and maintain motor activity. The diuretic is administered on a daily basis in low doses that today supplement the majority of the
ACE inhibitors. In addition to antihypertensive therapy, prevention in diet is essential. “Volume rule” is an important and
healthy way of preventing obesity and EH.
Keywords: hypertension, blood pressure, antihypertensive
drugs.
*Corresponding author — E-mail: [email protected]
2012;7(3-4):133.
Poster / Poster
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