Coronary Disease in Croatia – Current Situation and Future Challenges.

Kardiovaskularne su bolesti, usprkos pozitivnim trendovima i napretku u liječenju, i dalje najčešći uzrok smrti u Republici Hrvatskoj, od čega najveći dio otpada na koronarnu bolest srca. S jedne strane, Hrvatska ima svako pravo pohvaliti se činjenicom da je koronarnom bolesniku dostupna suvremena i kvalitetna skrb, na razini razvijenih zemalja i bogatijih zdravstvenih sustava, no, s druge strane, to se ne odnosi na prosječnu razinu skrbi te postoji jasna neravnomjernost u njenoj dostupnosti i kvaliteti na razini pojedinih hrvatskih regija, uvjetovana geografskim, financijskim i kadrovskim ograničenjima.Cardiovascular diseases are, despite positive trends and recent treatment advances, still the most common cause of death in the Republic of Croatia, mostly due to coronary artery disease. Croatia has every right to pride itself on the fact that patients with coronary disease are provided with modern, up to date and high-quality care comparable to more developed countries and wealthier healthcare systems. At the same time, the cardiovascular care in certain regions of Croatia is not at this level due to geographical, financial, and personnel limitations

Pectus excavatum – cosmetic problem or something more?

Introduction: Pectus excavatum, a deformity of the sternum and ribs caused by an unbalanced costochondral hypertrophy, is a congenital abnormality with a prevalence of 1/1000 and it is commonly considered to be an incidental finding without clinical significance. In more advanced cases there may be a considerable compression and relocation of thoracic organs which can lead to serious cardiac or respiratory symptoms.1-3 Case report: 19-year-old male patient was admitted for two-month history of palpitations, shortness of breath and continuous chest pain. Physical exam showed significant pectus excavatum and thoracic lordosis with otherwise normal findings. Resting 12-lead ECG and laboratory tests were normal, including cardiac troponin T levels. 24-hour ECG revealed premature ventricular beats with a paroxysm of non-sustained ventricular tachycardia. Echocardiography (Figure 1) showed normal biventricular size and function and raised suspicion of a large tumor mass compressing the left atrium (LA). No obvious signs of flow obstruction in LA using color and spectral Doppler were noticed. Mitral valve showed billowing of the anterior leaflet with otherwise normal valve function. The next diagnostic step was thoracic CT scan (Figure 2) which revealed extremely thin sagittal thoracic diameter with vertebrae compressing posterior wall of the LA and no signs of a tumor mass. Exercise stress test showed normal functional capacity with no signs of ischemia or arrhythmias in ECG. Patient was started on minimal dose of bisoprolol and follow up 24-hour ECG showed no ventricular arrhythmias. Since CT scan is the gold standard for determining the severity of the pectus excavatum defect, pectus severity index (PSI) was calculated and in our patient the value was 4.8. A normal chest has an average PSI of 2.5 and patients with a PSI of >3.25 are considered candidates for surgery. Patient was scheduled for additional respiratory function tests and will be referred to thoracic surgeon. Conclusion: Severe cases of pectus excavatum can have significant impact on cardiorespiratory function and in those patients, surgery should be considered. On echocardiography, LA compression by vertebrae can even mimic a tumor mass but thoracic CT scan is a gold standard for diagnostic and severity assessment of this condition

Long-term angiographic and clinical outcomes after coronary intervention using drug-coated balloons in acute coronary syndrome

Aim: Aim of the study was to compare angiographic and clinical outcomes after percutaneous coronary interventions (PCI) using drug coated balloons (DCB) between patients treated for “de novo” lesions and in-stent restenosis (ISR) in acute coronary syndrome (ACS). Patients and Methods: Study included 128 ASC patients treated with DCB between 2012 and 2019. All coronary angiographies were reviewed to determine indication, lesion complexity, vessel size and procedural success. Baseline and follow up clinical data were extracted from hospital digital database. Results: Mean patient age was 63.8 years, with the majority being men (75.8%, N=97). In total, 24 (18.8%) patients were treated for ISR. Comparison of clinical, angiographic and procedural characteristics between groups is presented in Table 1. Patients in the non-ISR group had more often multivessel disease (56.7 vs 25.0%, p=0.005), bifurcation PCI (45.0 vs 20.8%, p=0.042) and more DCB used in the index event (1.1±0.3 vs 1.0±0, p=0.004). Furthermore, they had more concomitant PCI with stent implantation in other lesions (75.9 vs 33.3%, p<0.001) with consequent higher number of stents implanted per person (1.2 vs 0.5, p=0.002). Both mean DCB diameter and length were larger in the ISR group (2.85±0.59 mm vs 2.48±0.49 mm, p=0.007 and 23.38±3.23 vs 21.24±5.24 mm, p=0.012, respectively). In the non-ISR group 8 (7.7%) patients had “bail out” stent implantation, while none was done in ISR group. Mean angiographic and clinical follow up was not significantly different between groups (Table 2). Altogether 75 (58.6%) patients underwent repeated coronary angiography, more often in the non-ISR group (64.4% vs 33.3%, p=0.005) but most of those were elective (73.1%). There was no significant difference in the composite endpoint consisted of death, unplanned rehospitalisation, target vessel revascularization and target lesion failure (ISR vs non-ISR; 29.2% vs 26.9%, p=0.82), nor in any of its components (Table 2). Conclusions: DCB in treatment of native coronary arteries provides similar angiographic and clinical outcomes compared to DCB for ISR in patients presenting with ACS in real-world settings.1 Furthermore, the prevalence of target lesion failure after DCB treatment was smaller in native coronary arteries compared to ISR