P0847 A RARE CAUSE OF PERICARDIAL EFFUSION IN AN ADULT: A BRONCHOGENIC CYST

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Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283

Significant Pearson correlation coefficients are between: von Willebrand factor and uric acid (+0.97); between flux mediated vasodilatation and uric acid (-0.96); between 17β estradiol and von Willebrand factor (-0.83) and flux mediated vasodilatation (+0.93). Conclusions: 1. The von Willebrand factor correlates with the estradiol levels, suggesting that deprivation of this hormone leads to important changes of the normal endothelium. 2. We found that flux mediated vasodilatation is also correlated with the estrogen levels- adding a new proof for the link between hormone and endothelial function. 3. The uric acid level is correlated with age, circulating estradiol levels and endothelial dysfunction (flux mediated vasodilatation and von Willebrand factor levels) ... 4. In post menopausal women, the decrease of the estradiol levels is an important mechanism that promotes atherosclerosis. Keywords: 17β estradiol, endothelial function, atherosclerosis

P0844 EFFECT OF NEBIVOLOL ON ATRIAL FIBRILLATION RECURRENCE AND P-WAVE DISPERSION IN PATIENTS WITH PAROXYMAL ATRIAL FIBRILLATION

Adalet Gurlek, Aydan Ongun Ozdemir, Cagdas Ozdol, Cetin Erol. Ankara University School of Medicine Background: P-wave dispersion (PWD) has been shown to be a non-invasive electrocardiographic predictor for development of atrial fibrillation (AF). Aims: The aim of the study was to compare the effects of nebivolol and peridopril/losartan on atrial fibrillation recurrence, on PWD, and on left atrium (LA) size. Methods: A total of 75 patients in sinus rhythm but at least one episode of AF in the previous month were enrolled in the study. The patients had received treatment with either perindopril/losartan (n= 35) or nebivolol (n= 40) for one year. PWD, and echocardiograghic measurements were performed at baseline and after 3, 6 and 12 months of treatment. Results: Mean age was 65 years and 56% were males. The prevalence of various demographic, and etiologic factors were similar between the groups except that subjects treated with perindopril/losartan were significantly more likely to have coronary artery disease (p=0.001). During follow-up, a total of 33 (94.3%) patients treated with perindopril/losartan had a recurrence of AF as did 22 (48.9%) patients treated with nebivolol (p<0.0001). While PWD values were significantly reduced by nebivolol (41±11 ms to 22±5 ms, p<0,001), no significant change was observed with ramipril/losartan (42±6 ms to 35±2 msn, p>0.05). Nebivolol significantly decreased PWD at 3rd month, but no significant reduction on PWD was determined at 6th and 12th months (41±11 ms to 25±8 msn, p<0.001 at 3 month). Baseline and follow-up LA diameters were not significantly different between the groups. Conclusions: Nebivolol was more effective than perindopril/losartan in preventing new episodes of AF. This could be related to the greater PWD reduction observed with nebivolol. Keywords: Atrial fibrillation; P-wave dispersion; nebivolol; perindopril/losartan

P0845 HEYDE SYNDROME-AORTIC STENOSIS AND GASTROINTESTINAL BLEEDING

Alexandra Vaz, Andreia Correia, Borges Martins, Pedro Henriques. S Teotonio Hospital-Viseu Introduction: Iron deficiency anaemia and calcific aortic stenosis are common finding in elderly patients. Heyde ’s syndrome, the association of aortic stenosis (AS) and gastrointestinal bleeding from angiodysplasia is rare. Case report: A 73-year-old man was admitted to our hospital with complaint of shortness of breath at rest, orthopnea, paroxysmal nocturnal dyspnea, weakness and edema of lower extremities. One week before admission he had a episode of melaena. Physical examination revealed a blood pressure of 100/58 mmHg; an irregular pulse of 80 bpm and a respiratory rate of 22 cpm. There was mild skin pallor, a systolic murmur (grade III/VI) at the right second intercostal space and peripheral edema. We diagnosed iron deficiency anaemia: haemoglobin of 8 mg/dL, mean cell volume of 79 fL, serum iron of 7 μg/dL, ferritin of 39 ng/mL and total iron binding capacity of 398 μg/dL. Upper endoscopic examination revealed bleeding gastric angiodysplasia. Colonoscopy was normal. The bleeding areas were coagulated by argon beam diathermy and the patient received a blood transfusion. Transthoracic echocardiography confirmed severe AS with a transvalvular gradient of 83

mmHg. At the moment the patient awaits aortic valve replacement at another hospital. Discussion: The proposed underlying mechanism of this condition is the development of an acquired form of Von Willebrand’s disease (type IIa). High shear rates across the stenotic valve lead to increased consumption of large multimers, which are required to maintain hemostasis in high flow conditions such as occur in angiodysplastic arteriovenous malformations. Treatment options include cauterization of bleeding points but this is associated with a high recurrence rate. Aortic valve replacement appears to offer the best hope of long term resolution of the bleeding and should be considered in most cases, particulary in those in whom AS is symptomatic.

P0846 CARDIOVASCULAR DISEASE AND THE LIPID PARAMETERS IN OBESE PATIENTS

Esma Altuno˘glu, Ender Ülgen, Cüneyt Müderriso˘glu, Füsun Erdenen, Mustafa Boz. Istanbul Education and Research Hospital Introduction: Obesity is a health problem worldwide; and affects the total and cardiovascular morbidity, and mortality. The metabolic syndrome is a strong predictor for cardiovascular disease (CVD). Numerous studies suggest an association between the metabolic syndrome and cardiovascular events (myocardial infarction with or without ST elevation), stroke, and peripheral vascular diseases. Our aim in this study was to examine the relationship between the lipid parameters and the markers of obesity in obese patients. Materials & methods: We investigated the records of 160 obese patients retrospectively. Body mass index (BMI), waist circumference (WC), the duration of obesity, and the lipid parameters were compared in patients with history of coronary heart disease (myocardial infarction, by-pass, or stent), and obese subjects without established CVD. Statistical analysis was performed with SPSS for Windows 13.0; and we used Pearson correlation analysis for comparisons. Results: Of the 160 patients, 69 (9 men and 60 women) had history of coronary artery disease. The group without coronary heart disease included 91 subjects (6 men and 85 women). The mean age and the duration of obesity were considerably higher in the group with CVD than they were in the group without CVD (51.82±11.27, 22.55±13.69 and 39.93±13.07, 14.35±11.88 respectively). BMI (p=0.005), WC (p=0.008), and waist to hip ratio (WHR) (p=0.047) were significantly higher in patients with CVD. WC and WHR showed positive correlation with triglyceride (TG), total cholesterol (TC), and LDL-cholesterol (LDL-C) (r=0.184, r=0.213, r= 0.904). WC and WHR showed negative correlation with HDL-cholesterol (HDL-C) (r= 0.183) (r=0.244). TG and TC levels were significantly higher in the group with CVD. Meaningful difference in LDL-C values was not found. HDL-C levels were slightly higher in the patients without CVD than in the patients with CVD (48.14, 47.37). Table 1 BMI

WC

TG

TC

HDL-C

LDL-C

CVD+ 40.67±7.51 115.31±12.78 177.97±93.97 205.19±39.41 47.37±11.11 123.13±35.91 CVD37.68±5.62 109.54±13.47 141.57±83.01 196.01±39.28 48.14±10.45 120.49±31.32

Discussion & conclusion: Obesity, among well-known factors such as hyperlipidemia, hypertension and insulin resistance, is a risk factor for CVD. The physiopathological effects of obesity in CVD are not completely clear. Beyond creating other risks, adipose tissue may secrete pro-inflammatory and pro-thrombotic factors and contribute to the atherosclerotic process. Furthermore, alterations in the cardiac structure and function may lead to heart failure and arrhythmia. All these reasons increase morbidity and mortality in obese people. We showed the relationship between the lipid parameters and CVD in obese subjects. Strict follow-up of the obesity parameters, as well as the lipid values, of people with CVD is necessary. Keywords: obesity, cardiovascular disease

P0847 A RARE CAUSE OF PERICARDIAL EFFUSION IN AN ADULT: A BRONCHOGENIC CYST

Navin Venkatraman. University Hospitals of Leicester Introduction: Bronchogenic cysts are rare developmental anomalies of the bronchopulmonary foregut. We present an extremely rare presentation with

Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 considerable mass effect and a large pericardial effusion of haemodynamic significance. Case history: A 23-year-old male presented to the emergency department with a week history of gradual onset pleuritic chest pain and worsening dyspnoea. He complained of a cough productive of yellow sputum and vomiting with streaks of blood. There was no significant past medical history, he smoked 10 cigarettes per day and drank alcohol occasionally. He had recently been on a 4-hour flight. Initial examination revealed a tachycardia and saturations of 95% on room air. The remainder of his observations were essentially normal and examination was unremarkable. His ECG showed a sinus tachycardia and a chest radiograph demonstrated cardiomegaly. Arterial blood gases revealed a compensated metabolic acidosis. He underwent computed tomography (CT) for a suspected pulmonary embolism. This was reported as a left atrial mass with associated large global pericardial effusion. The diagnoses that were considered at this stage included a hydatid cyst, teratoma and atrial myxoma. Subsequently, he was transferred to the coronary care unit and echocardiography (ECHO) showed a large (2-3cm) global pericardial effusion with associated right atrial and right ventricular diastolic collapse. A pericardial drain was inserted under ECHO guidance, which drained 900mls of fluid. Review of the CT scan revealed a large well-defined mass in the subcarinal region, causing significant mass effect on the left atrium, superior vena cava, right pulmonary artery and both bronchi (See Figure 1). It also confirmed the presence of a large pericardial effusion compressing the right atrium and ventricle. On the 4th day of his admission, he had a video-assisted cervical mediastinoscopy (VAMS) and the cyst was identified anterior to the carina, drained and marsupialised. A drain was left in-situ and suction applied at 5kPa; this was removed on day 6 prior to discharge. A CT scan done at 3 months showed a 60×53mm collection at the site of excision, which was thought to be a post-operative collection or a recurrence. It was deemed to be reasonable to not intervene unless the patient became symptomatic. He was seen at follow-up and was well. Later, histology was consistent with pericarditis with no malignant cells.

Figure 1. CT scan showing large bronchogenic cyst and associated pericardial effusion

Discussion: This rare case highlights that Occam’s razor is not always suitable in diagnostic challenges. Bronchogenic cysts are relatively rare and often present in adulthood. They are the commonest cystic lesion of the mediastinum. In our patient, the management was based around prompt drainage of pericardial effusion and subsequent imaging to elicit the diagnosis. VAMS has superseded open thoracotomy as the surgical intervention of choice in the management of these patients. Keywords: bronchogenic cyst, pericardial effusion

P0848 EFFICIENCY OF ALGORITHM-BASED ANALGESIA AND SEDATION GUIDELINES IN A CARDIOLOGICAL INTENSIVE CARE UNIT: A PILOT STUDY

Nadine Abanador-Kamper 1 , Lars Bansemir 1 , Judith Wolfertz 1 , Petra Thürmann 2 , Hartmut Gülker 1 . 1 Department of Cardiology, 2 Department of Pharmacology, Helios-klinikum Wuppertal, Witten, Herdecke Introduction: Analgesia and sedation are essential in therapy of critically ill patients especially during mechanical ventilation. However, continuous administration of sedatives and analgesia prolongs mechanical ventilationtime and increases the probability of secondary complications. These adverse effects can be reduced by clear definition of analgesia and sedation goals by means of protocols and algorithms. Recent studies have demonstrated effectiveness of sedation practises, however the influence of continuous quality-and process improvement of analgesia and sedation in ICU has not been sufficiently examined so far.

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Objectives: The aim of this retrospective-prospective clinical study was to examine the effect of a protocol- and algorithm based analgesia and sedation guideline on mechanical ventilation time (MVT) and length of stay (LOS) in ICU. Methods: A protocol- and algorithm-based analgesia and sedation guideline including sedation and pain scale was introduced using a multifaceted implementation strategy. Medical staff underwent long term training. The study was conducted in a 11-bed cardiological ICU. The intervention was tested in a pre-intervention and post-intervention comparative group. Our algorithms were introduced based on the current S2-Guidelines of analgesia and sedation. The multidisciplinary implementation included continuous evaluation of depth of sedation by using the Richmond agitation-sedation scale (RASS). Analgesia was continuously monitored by using a standardized pain scale. The pre- and post-interventional data for the MVT and LOS were analysed by non-parametrical statistics, including standard t-tests and the Mann-Whitney u-test. Results: In the retrospective observation of the pre-interventional period included 146 patients with a mean ventilation time of 170 h (sd: 132.6 h). The LOS for the pre-interventional group was 185 h. The preliminary post-interventional results show a remarkable reduction of MVT and LOS. Conclusion: Analgesia and sedation play a key role in therapy of critically ill patients on ICU. The preliminary results of our multidisciplinary study show a considerable reduction of the MVT and LOS on ICU, by implementation of standardized protocols for the sedation and analgesia. Detailed analyses of the post-interventional group will be available at the time of the congress. Secondary effects like reduction of complications are also subject of further examination.

P0849 EVALUATION OF NURSING APPROACHES TOWARDS CPR

Ebru Çelik 1 , Birsen Yürügen 2 . 1 Haliç University Institute of Health Sciences, Department of Nursing Master Thesis; 2 Haliç University of High School of Health Science, Department of Midwifery Aim: Nurses are responsible to identify the indications of cardiac arrest and planning and applying urgently the neccessary treatment. This research has been planned for the recognition of the cardiac arrest by the nurses,to determine their approach to start and continue CPR, to evaluate their responsibilities, the collected datas to become a guide to in service training and urgent applications The research covers 250 nurses working in one private and one state hospital’s internal-surgical intensive care units, cardiology and emergency services and the sampling covers 140 nurses who accepted to attend to the research. Datas were collected in 2 questionnaires. First form consists of 21 questions about the nurses’ demographical qualities and their knowledge about CPR, The second form consists of 43 questions about nurses’ evaluation about their approach towards CPR and this was applied between the dates 26.12.07-26.03.08. Descriptive statistical methods, Oneway Anova, Tukey HDS, Student t, Mann Whitney U and Ki-Kare tests were used for the evaluation of the datas. Findings: It has been seen that 50,1% (n=71) of the nurses have replied wrong to the expression “CPR rate in adults = 30/2”. The correct replies in the nurses between the ages 18 to 25 compared to other age groups, correct replies of the nurses working less than 1 year compared to the nurses working 1 to 5 and 6 to 15 years, service nurses correct replies compared to responsible nurses have been considerably lower (p<0.05). The replies about CPR of the nurses working in private hospitals compared to the ones working in state hospitals, replies of the nurses who applied CPR compared to the ones who never did were statistically much higher (p<0.05). As a result, it is extremely recommended to be specialized on the profession, to increase the number of the graduated nurses, to organize post-gradual CPR courses,education nurses who elicit the nurses orientation to the unit etc.

P0850 THE EFFECT OF ATORVASTATIN AND ROSUVASTATIN IN CHOLESTEROL LEVELS IN PATIENTS HAVING ISCHEMIC HEART DISEASE, HYPERTENSION AND DIABETES MELLITUS

Theodora Loufa 1 , Michalis Mataliotakis 1 , Eleftherios Kagmakis 2 , Nikolaos Nikolaidis 1 , Konstadinos Fotiou 1 , Petros Kagmakis 1 . 1 A’ Department of Internal Medicine G.n Asklipieion Voulas; 2 General Hospital Weiden, Bayern, Germany We tried to compare the effect of two known statins of cholesterol levels in