Cardiologia Croatica. 2019;14(1-2)

Iva Žegura, Denis Bratko, Nataša Jokić-Begić, Mario Ivanuša, Anita Lauri Korajlija

According to the five personality traits (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness), in accordance with the model by Costa and McCrae and the combinations of facets within them, there is a differentiation of people who are more prone to experiencing positive emotions, are more optimistic, and have developed positive habits related to health, all of which contributes to their life satisfaction and the subjective feeling of wellbeing, and those individuals who are more prone to experiencing negative emotions, are pessimistic, possess negative habits related to health, and are less satisfied with life and report a reduced feeling of subjective wellbeing. The goal of the study was to investigate the relationship of protective and risk personality factors within the model by Costa and McCrae, psychosocial variables (the state of general wellbeing, behaviors related to healthy living, the level of the perception of the risk of developing disease), and the measurement of the state of the cardiovascular system in healthy individuals, patients with stable angina pectoris, and individuals with risk factors for coronary heart disease (CHD). The study participants (N=248) were individuals who were being tested in the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. The participants were divided into three groups: a control group of healthy people, a control group of participants suffering from stable angina pectoris, and the study group of participants with risk factor for CHD. Contrary to expectations, it was shown that the three groups of participants did not differ according to personality traits. There is need for further research on the influence of protective and risk personality factors for the development of CHD, methodological improvements with the application of more sensitive personality measurements, and especially the relationship of positive and negative affect..

Bojan Jelaković, Ines Drenjančević, Mario Laganović, Ivan Pećin, Ana Jelaković, Maja Baretić, Živka Dika, Mario Ivanuša, Vesna Herceg-Čavrak, Josipa Josipović, Verica Kralj, Ninoslav Leko, Robert Likić, Martina Lovrić Benčić, Lidija Orlić, Draško Pavlović, Darko Počanić, Ingrid Prkačin, Ranko Stevanović, Hrvoje Tiljak, Tajana Željković Vrkić

The Governing Board of the Croatian Society of Hypertension held an e-meeting on December 12, 2018, where the observed increase in risk of non-melanoma skin cancer associated with hydrochlorothiazide treatment was discussed, and the following statement was prepared. On October 1, 2018, the European Medicines Agency (EMA) published a warning on the increased risk of non-melanoma skin cancer associated with higher cumulative hydrochlorothiazide doses (1). Their recommendation was to inform the patients of the risk and that patients receiving this treatment should undergo regular skin examinations. Other recommended preventive measures include avoiding exposure to sunlight, ultraviolet (UV) radiation, and the use of appropriate protection. Continued hydrochlorothiazide treatment should be reconsidered in patients who were previously treated for non-melanoma skin cancer. The Agency for Medical Products and Medical Devices of Croatia (HALMED; Hrvatska agencija za lijekove i medicinske proizvode) has published a statement on November 22, 2018 in which they warn of the slightly increased risk of non-melanoma skin cancer due to exposure to high cumulative doses of hydrochlorothiazide, with the conclusion that the benefits of hydrochlorothiazide application outweigh the potential risks (2). HALMED’s recommendation is for patients to continue with the application of the prescribed treatment and that self-induced treatment termination can cause serious harm to patients. The advice is for patients to regularly check their skin for possible manifestations of any new lesions or changes in existing ones. It is also recommended that patients limit exposure to sunlight and UV radiation. HALMED provided a list of medications containing hydrochlorothiazide that are on the market in the Republic of Croatia (2), as shown in **Table 1**. ### TABLE 1: List of medications containing hydrochlorothiazide that are on the market in the Republic of Croatia ( 2 ). | Amicor H | Enap-H | Laaven-HL | Monopril plus | Prinzide | Valnorm H | | --- | --- | --- | --- | --- | --- | | Ampril HD | Enap-HL | Lizinopril H Farmal | Nebilet plus | Ramicomp Genericon | Valsacombi | | Ampril HL | Exforge HCT | Lodoz | Olmesartan/hidroklorotiazid Genericon | Ramipril H Farmal | Vitozid | | Blocar Plus | Fortzaar | Lorista H | Optimon Plus | Ramzid | Zofecard Plus | | Cilazil Plus | Hyzaar | Lorista HD | Osan Plus | Skopryl plus | | | CoAprovel | Iruzid | Losartic Plus | Piramil H | Tolucombi | | | Co-Cazaprol | Kandapres Plus | Lotan H | Piramil HL | Tritazide | | | Co-Diovan | Laaven-HD | MicardisPlus | Prilen Plus | Val plus | | This warning is a result of the publication of the results obtained from data analysis performed on a Danish registry (3, 4). However, there had been earlier papers reporting the possible association between thiazide diuretics and risk of skin and lip carcinoma (5-7). What caused special attention in the Danish results was confirmation of the importance of cumulative doses, i.e. that the risk is greater for higher cumulative doses. A cause for concern and caution is also the fact that with a dose of 12.5 mg daily, which is the most commonly applied dose in our region, the cumulative dose after five years of treatment is equal to 22.812 mg, with an OR for risk of lip carcinoma of 3.9 (3.0-4.9) and the risk of skin cancer after ten years at OR 1.29 (1.23-1.35) for basal-cell carcinoma and OR 3.98 (3.68-4.31) for squamous cell carcinoma (3, 4). Similar data, but with a lower level of significance, were also obtained in the Kaiser Permanente Northern California US cohort (8). Although these studies have certain strengths, they have limitations as well. The fact that increased risk of these carcinomas with cumulative doses of hydrochlorothiazide has been observed cannot and must not be ignored. However, we must also be aware of the fact that the benefits of the application of thiazide diuretics is several times greater than the risk of carcinoma, which is especially evident in elderly persons, patients with heart failure, and those with a shorter life expectancy (9). It is also important to note that these carcinomas can be diagnosed early and in a timely manner if the patients are properly informed on how to monitor changes on the skin and lips.

Juraj Jug, Martina Lovrić Benčić

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare progressive autosomal dominant genetic disease characterized by structural abnormalities of the right ventricle of the heart and the appearance of the reentry type arrhythmias. Of the 140 different genetic mutations, the most significant are those related to proteins in the intercalated discs and myocardial desmosomes. Myocyte degeneration and death, which are caused by disrupted myocyte growth and differentiation, are most obvious in the triangle of dysplasia and result in very non-specific symptoms. Arrhythmias caused by ARVC are considered the main cause of death in persons below 40 years of age. Since there are numerous other diseases that resemble ARVC, the diagnosis of ARVC is established based on a combination of fulfilling the working group criteria and magnetic resonance imaging, heart biopsy, and echocardiography findings. Despite all the diagnostic criteria, more than 50% of real ARVC cases remain inadequately diagnosed. This is why detailed and frequent health checkups from an early age are recommended in asymptomatic athletes with family history positive for ARVC. The main goal of treatment is the prevention of sudden cardiac death. Sotalol and amiodarone are favored in medication therapy, with the goal of preventing the development of malignant arrhythmias. In patients with a very high risk of such arrhythmias the implantation of a cardioverter defibrillator is absolutely indicated as part of primary prevention. The successfulness of radiofrequency ablation is lower in this disease due to the frequent appearance of new arrhythmic foci caused by fatty fibrotic changes in the myocardium and is considered a palliative treatment method. Definitive treatment for this diseases can be achieved only through heart transplantation.

Edin Begić, Mensur Mandžuka, Elnur Smajić, Enisa Hodžić, Amer Iglica, Aida Mujaković, Faris Zvizdić, Amra Dobrača, Azra Durak-Nalbantić

Atrial fibrillation (AF) is the most common tachyarrhythmia that requires treatment and represents constant clinical problem for general practitioners and cardiologists. Several bleeding risk scores have been developed for estimating bleeding risk in patients with AF. These include: HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, age >65 years, drugs/alcohol concomitantly), ORBIT (older age, reduced hemoglobin/hematocrit/anemia, bleeding history, insufficient kidney function, treatment with anti-platelets), ABC (age, biomarkers, clinical history), ATRIA (anemia, severe renal disease, age ≥75 years, previous hemorrhage, and diagnosed hypertension), and HEMORR(2)HAGES (Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk, and Stroke). The use of oral anticoagulants is still the standard in stroke prevention in AF but should be balanced against the associated bleeding risk. The aim of this article was to describe the development of a clinical decision support system (CDSS) that will enable clinicians to perform a quick assessment of bleeding risk in patients with AF in order to optimize anticoagulation therapy in patients with AF. The software was developed in the form of a web application. The responsive design of the interface was key to optimal user interaction, providing seamless control of every step of the process regardless of the type of device used, whether a laptop or a smartphone. The backend of the application was developed in Python. More specifically, a web framework named Flask was utilized. It is considered to be a good choice for rapid prototyping and development and deployment of small- to medium-sized applications. The application separates the decision process into three steps. Displaying the first step prompts the user to select the type of score they want calculated. The following step includes entering anamnestic data, laboratory findings, symptoms, and comorbidities. The final screen displays the calculated score, which assists the user in determining the course of the treatment. This software represents a CDSS that enables faster and easier assessment of bleeding risk in patients with AF in order to achieve a better therapeutic modality. The responsive design and the web application format makes the software easily accessible on a wide range of devices.