Systemic or local thrombolysis in high-risk pulmonary embolism

Background and Aim: High-risk pulmonary embolism (PE) represents an important health problem in emergency cardiology, being associated with a high rate of mortality. The aim of this study is to assess the efficacy and safety of pulmonary intra-arterial thrombolysis with streptokinase compared to systemic thrombolysis. Methods and Results: In our study, 28 patients with acute high risk PE were treated by intra-arterial thrombolysis with clinical success rate of 96.4%, while in the group with systemic thrombolysis (24 patients) the rate of clinical success was significantly lower (70.8%). Also, pressure gradient between right ventricle (RV) and right atrial (RA) (PRV-RA) decreased significantly in patients treated by pulmonary intra-arterial thrombolysis instead of systemic thrombolysis. Mortality during the hospitalization was 0% in the group with local thrombolysis and 29.2% in the other group, with a significant statistical difference. Major bleeding complications appeared in 14.3% of the patients with local thrombolysis and in 20.8% of the ones treated by systemic thrombolysis, without statistical significance. Moreover, the proportion of minor bleeding was comparable in the two groups of patients. There was no intracranial bleeding. Disseminated intravascular coagulation occurred in 1 patient with systemic thrombolysis. Conclusions: The rate of clinical success and the regression of RV overload were significantly higher in patients treated by pulmonary intra-arterial thrombolysis. The results regarding the efficiency of the pulmonary intra-arterial thrombolysis in high-risk PE are encouraging, the mortality in these patients being significantly lower than the one for systemic administration of the thrombolytic agent.

Simultaneous tromboembolic events in a patient with heterozygous MTHFR mutation

Background: Hyperhomocysteinemia is a well recognised risk factor for arterial and venous thrombosis. The most common form results from methylenetetrahydrofolate reductase (MTHFR) gene mutations leading to decreased enzymatic activity.Case report: We present the case of a 34 year-old woman with a sudden onset of left hemiparesis and aphasia accompanied by retrosternal pain. She is diagnosed with acute posteroinferolateral myocardial infarction and stroke. Homocysteine level was determined and it was moderately elevated. The coronary angiogram revealed partially recanalised embolic occlusion of posterior left ventricular branch and posterior interventricular artery. A conservative treatment management is adopted. She remained haemodynamically stable, with complete resolution of neurological symptoms and evolution to subacute myocardial infarction.Conclusions: The particularity of our case is represented by symultaneous thromboembolic events causing myocardial infarction and ischemic stroke in a patient with a history of recurrent pregnancy loss, which was previously diagnosed with MTHFR gene mutation. Moderate hyperhomocysteinemia, also found in our patient, is recognised as an ethiopathogenic factor of thrombophilia. The right diagnosis and therapeutic approach could be the key to improved prognosis in this category of patients. MTHFR gene mutation causing hyperhomocysteinemia should be suspected in patients with thromboembolic events, especially when occuring repeatedly or at young age

VULNERABILITY INDEX ASSESSMENT OF THE EROSIVE ATHEROSCLEROTIC PLAQUE ON ENDARTERECTOMY SPECIMENS

Background Atherosclerosis is an arterial inflammatory process which causes associated tissue ischemia of different degrees. It is not yet calculated an index of plaque vulnerability as a histological marker of acute cardiac event risk at these patients. Aim of the study This retrospective study aimed to answer the question of whether the index of plaque vulnerability can appreciate the risk of atherothrombosis of the erosive plaques using histological measurements. Material and methods 30 patients were included in the study. American Heart Association (AHA) classification was used for appreciating the histological degree of ATS lesions on endarterectomy pieces. In all patients, intima-media thickness (IMT), erosion depth, and parietal thrombosis area were assessed. Results The proposed vulnerability index showed that about 50% of patients have a medium risk of plaque vulnerability and of associated acute coronary syndrome (ACS). Conclusions The index of plaque vulnerability may be used as a reference in ATS assessment by using intravascular ultrasound (IVUS) methods

The current profile of the patient with atrial fibrillation

Abstract: Atrial fibrillation (AF) is the most common supraventricular arrhythmia, characterized by an irregular and extremely rapid atrial electrical activation that causes loss of atrial mechanical function and important hemodynamic consequences. AF classification is important in both the therapeutic approach and the prognosis. Several classifications based on the ECG patch, epicardial or endocavitary records have been performed over time, but no classification can take into account all the characteristics of AF and especially associated diseases, which may be both the cause and consequence of arrhythmia. Aim: The aim of the study is to establish the current profile of the patient with atrial fibrillation in the new era of oral anticoagulant therapy and sinus rhythm restoration. Material and methods: The trial was conducted on patients with atrial fibrillation hospitalized between 01.10.2014-31.03.2015 at Institute of Cardiovascular Diseases ”Prof. Dr. G. Georgescu”, Iasi. Patients included in the study were analyzed according to age and sex, criteria for the clinical and paraclinic definition for atrial fibrillation. Results: Atrial fibrillation is an extremely common cardiovascular pathology and is present in about one-third of patients admitted to our clinic. Cardiovascular diseases such as hypertension, ischemic coronary artery disease, and valvulopathy are common in patients with AF. Patients with AF are usually elderly patients with many associated diseases in whom sinus rhythm restoration treatment and anticoagulant therapy are difficult to establish. AF is one of the most common arrhythmias that complicates the evolution of acute myocardial infarction, association between dual antiplatelet therapy and anticoagulation treatment, increasing the risk of bleeding complications. Conclusions: Atrial fibrillation is an extremely common cardiovascular pathology and is present in about one-third of patients admitted to our hospital. The data obtained revealed that this arrhythmia occurs in a small number of cases as the only pathology of the patient, usually associated with numerous comorbidities. Cardiovascular diseases such as hypertension, ischemic coronary artery disease, valvulopathy are common in our practice. Patient with AF is a patient who requires long-term anticoagulant therapy and in whom sinus rhythm recovery therapy is dependent on the precocity of presentation to the physician, as well as on the therapeutic resources of current medicine

The Patterns of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Use in Patients with Atrial Fibrillation in Seven Balkan Countries: a Report from the BALKAN-AF Survey

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Zofenopril and Ramipril in Combination with Acetyl Salicylic Acid in Postmyocardial Infarction Patients with Left Ventricular Systolic Dysfunction: A Retrospective Analysis of the SMILE-4 Randomized, Double-Blind Study in Diabetic Patients

OBJECTIVE: In the SMILE-4 study, zofenopril + acetyl salicylic acid (ASA) was more effective than ramipril + ASA on 1-year prevention of major cardiovascular events (MACE) in patients with acute myocardial infarction complicated by left ventricular dysfunction. In this retrospective analysis, we evaluated drug efficacy in subgroups of patients, according to a history of diabetes mellitus. METHODS: The primary study endpoint was 1-year combined occurrence of death or hospitalization for cardiovascular causes. Diabetes was defined according to medical history (previous known diagnosis). RESULTS: A total of 562 of 693 (81.0%) patients were classified as nondiabetics and 131 (18.9%) as diabetics. The adjusted rate of MACE was lower under zofenopril than under ramipril in both nondiabetics [27.9% vs. 34.9% ramipril; odds ratio, OR and 95% confidence interval: 0.55 (0.35, 0.86)] and diabetics [30.9% vs. 41.3%; 0.56 (0.18, 1.73)], although the difference was statistically significant only for the nondiabetic group (P = 0.013). Zofenopril was superior to ramipril as regards to the primary study endpoint in the subgroup of 157 patients with uncontrolled blood glucose (≥126 mg/dL), regardless of a previous diagnosis of diabetes [0.31 (0.10, 0.90), P = 0.030]. Zofenopril significantly reduced the risk of hospitalization for cardiovascular causes in both nondiabetics [0.64 (0.43, 0.96), P = 0.030] and diabetics [0.38 (0.15, 0.95), P = 0.038], whereas it was not better than ramipril in terms of prevention of cardiovascular deaths. CONCLUSIONS: This retrospective analysis of the SMILE-4 study confirmed the good efficacy of zofenopril plus ASA in the prevention of long-term MACE also in the subgroup of patients with diabetes mellitus