Analysis of the aplication the reperfusion therapy in according to estimated level of risk patients with ST elevation myocardial infarction in Serbia

Iako je primena reperfuzione terapije (RT) u Srbiji počela pre 30 godina, do 2006 godine se u infarktu miokarda sa ST elevacijom (STEMI) primenjivala samo fibrinolitička terapija (FT) od kada se uvodi i primarna perkutana koronarna intervencija (p-PCI). Od 2002 godine, kada je zabeležena primena RT u 25% bolesnika sa STEMI, beleži se smanjenje intrahospitalnog mortaliteta ali je još uvek procenat bolesnika koji ne dobiju RT visok. Dobro je poznato da prognoza STEMI bolesnika zavisi od vremena koje prodje od početka simptoma do primene RT, ali i od niza komorbiditeta, faktora rizika, prethodne koronarne bolesti, godina starosti, pola, veličine i lokalizacije infarkta. Do sada nema dovoljno podataka o mortalitetu i tipu primenjene reperfuzione terapije kod bolesnika sa STEMI u Srbiji, zemlji u tranziciji. Poznato je da je odluka o primeni reperfuzione terapije i tip terapije uslovljena blizinom sale za kateterizaciju i mogućnosti da se što pre primeni p-PCI u toku 24h/7 dana u nedelji, ali i od ostalih navedenih faktora koji se odnose na bolesnika. Cilj rada je da se analiziraju mogućnosti i karakteristike koje bi imale uticaj na procenu rizika akutnog oboljenja, koji bi bio u skladu sa primenom odredjene vrste terapije. Ciljevi ovog istraživanja su da se u Srbiji, kod bolesnika sa STEMI: 1. utvrdi povezanost procenjenog stepena rizika i vremena proteklog od početka simptoma na odluku o primeni i tipu RT i 2. efekat primenjene RT na hospitalni tok i ishod u zavisnosti od napred navedenih faktora. Materijal i metode: Istraživanje je studija preseka sprovedena od 01.01.2007.-31.12.2009. godine, bazirana na podacima iz Hospitalnog registra za akutni koronarni sindrom u Srbiji (HORAKS). Kriterijum za uključivanje u studiju su konsekutivni bolesnici kod kojih su ispunjeni uslovi za postavljanje dijagnoze STEMI prema Evropskim preporukama. Tokom 3 posmatrane godine, na terirotiji Srbije je lečeno 22424 bolesnika sa STEMI. Bolesnici su prema načinu lečenja podeljeni u tri terapijske grupe: grupa lečena p-PCI (p-PCI grupa), grupa lečena FT (FT grupa) i grupa koja nije lečena RT (ne-RT grupa). Rezultati: U analizu je uključeno 15354 konsekutivnih pacijenata, srednjih godina starosti 63.58±11.97 godina, med 64 (55-73), odnos muškaraca/žena je bio 65/35%. U p-PCI grupi je bilo N=3370 bolesnika (21.9%), u FT grupi N=5132 bolesnika (33.4%), a u ne-RT grupi N=6852 (44.6%). Reperfuziona terapija se kod bolesnika sa visokim rizikom manje primenjuje, p-PCI i FT konsekutivno: stariji ≥65 godina 16.2% i 27.6%; srčana insuficijencija (SI) 14% i 31.1%; dijabetes 17.6% i 29.4%; cerebrovaskularna bolest (CVI) 17.9% i 23.9%; prethodni infarkt miokarda 16.2% i 27.1%; anemija 11.8% i 26.4%; bubrežna slabost 12.4% i 28.4%; predhodna perferna vaskularna bolest 12.% i 25.7%...Although, the treatment using reperfusion therapy (RT) in patients with ST elevation myocardial infarction (STEMI) started 30 years ago in Serbia, the use of fibrinolysis therapy (FT) has been only possible until 2006 years. The implementation primary percutaneous coronary intervention (p-PCI) was started to be applied during 2006 year. Since 2002, when it was recorded that RT was applied in 25%, the application is growing, especially in recent years. It is associated with reduction of in-hospital mortality. However, the percentage of patients with STEMI who do not receive RT is still high. It is well known that prognosis of ST-segment elevation myocardial infarction (STEMI) patients (pts) is time-dependent, but it depends on comorbidities, risk factors, previous coronary diseases, age, gender, the size and localization of the myocardial infarction. Until now, there are not enough data about mortality and the type of applied RT in STEMI patients in Serbia as a transition country. It is known that decision about application and type of RT is conditioned by distance to the catheterization laboratory and possibility of the emergency application p-PCI within 24 hours/7 days in a week, but it also depends on other factors which are related to the patients. The aim of the present work is to analyze abilities and characteristics, which could have an influence on risk evaluation acute disease and in accordance to that application and type of therapy. Moreover, during the study, it was great importance to: 1. determine which factors have the influence on fewer application of RT in STEMI patients, in Serbia, a country in transition, and to establish if application of RT and type of RT depend on the risk level of patients and the time of symptoms onset and 2. analyze the effects of RT on in-hospital outcome depending on the previously mentioned factors. Materials and Methods: The research is across sectional study, with used data from the Hospital registry for acute coronary syndrome in Serbia (HORAKS) from 01.01.2007-31.01.2009 year. Criteria for inclusion in the study are consecutive patients in whom the diagnosis of STEMI was in accordance to European guidelines. During the three analyzed years, 22424 patients were treated with STEMI in Serbia. Patients are divided according to the method of treatment in three groups: 1. patients treated with p-PCI (p-PCI group), 2. patients treated with FT (FT group) and 3. patients not treated with RT (non-RT group). Results: The analysis includes 15354 patients, average age of 63.58±11.97 years, med 64 (55-73), male/female ratio was 65/35%. The p-PCI group includes N=3370 patients (21.9%), the FT group of N=5132 patients (33.4%), and the non-RT group of N=6852 (44.6%) patients. In patients with high risk, RT is less applied, p-PCI and FT consecutively: elderly ≥65 yr. 16.2% and 27.6%; heart failure (HF) 14% and 31.1%; diabetes 17.6% and 29.4%; stroke 17.9% and 23.9%; previous myocardial infarction 16.2% and 27.1%; anemia 11.8% and 26.4%; renal failure 12.4% and 28.4%; previous vascular disease 12.% and 25.7%..

Drugs for spontaneous coronary dissection: a few untrusted options

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome that is often overlooked, misdiagnosed, and maltreated. Medical treatment poses a significant challenge because of the lack of randomized studies to guide treatment. The initial clinical presentation should guide medical and interventional management. Fibrinolytic agents and anticoagulants should be avoided because they could favor hematoma propagation. In patients with SCAD, antiplatelet therapy should be prescribed especially dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel, whereas potent P2Y12 inhibitors, e.g., ticagrelor and prasugrel, should be avoided. If a stent was used, DAPT should be continued for 12 months. Aspirin only can be an option for patients without “high-risk” angiographic features—thrombus burden, critical stenosis, and decreased coronary flow. Beta-blocking (BB) agents should be used to prevent recurrence of SCAD. There is a general agreement that angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, mineralocorticoid antagonists, and loop diuretics should be used in patients with SCAD experiencing the symptoms of heart failure and a decrease in left ventricular ejection fraction below 50%. Although without firm evidence, statins can be used in SCAD due to their pleiotropic properties. The results of a randomized trial on the use of BB and statins are awaited. Aggregation of data from national registries might point out truly beneficial medications for patients with SCAD

Sex and age differences and outcomes in acute coronary syndromes

Background: There is conflicting information about sex differences in presentation, treatment, and outcome after acute coronary syndromes (ACS) in the era of reperfusion therapy and percutaneous coronary intervention. The aim of this study was to examine presentation, acute therapy, and outcomes of men and women with ACS with special emphasis on their relationship with younger age ( lt = 65 years). Methods: From January 2010 to June 2015, we enrolled 5140 patients from 3 primary PCI capable hospitals. Patients were registered according to the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC) registry protocol (ClinicalTrials.gov: NCT01218776). The primary outcome was the incidence of in-hospital mortality. Results: The study population was constituted by 2876 patients younger than 65 years and 2294 patients older. Women were older than men in both the young (56.2 +/- 6.6 vs. 54.1 +/- 7.4) and old (74.9 +/- 6.4 vs. 73.6 +/- 6.0) age groups. There were 3421 (66.2%) patients with ST elevation ACS (STE-ACS) and 1719 (33.8%) patients without ST elevation ACS (NSTE-ACS). In STE-ACS, the percentage of patients who failed to receive reperfusion was higher in women than in men either in the young (21.7% vs. 15.8%) than in the elderly (35.2% vs. 29.6%). There was a significant higher mortality in women in the younger age group (age-adjusted OR 1.52, 95% CI: 1.01-2.29), but there was no sex difference in the older group (age-adjusted OR 1.10, 95% CI: 0.87-1.41). Significantly sex differences in mortality were not seen in NSTE-ACS patients. Conclusions: In-hospital mortality from ACS is not different between older men and women. A higher short-term mortality can be seen only in women with STEMI and age of 65 or less

Analysis of the aplication the reperfusion therapy in according to estimated level of risk patients with ST elevation myocardial infarction in Serbia

Iako je primena reperfuzione terapije (RT) u Srbiji počela pre 30 godina, do 2006 godine se u infarktu miokarda sa ST elevacijom (STEMI) primenjivala samo fibrinolitička terapija (FT) od kada se uvodi i primarna perkutana koronarna intervencija (p-PCI). Od 2002 godine, kada je zabeležena primena RT u 25% bolesnika sa STEMI, beleži se smanjenje intrahospitalnog mortaliteta ali je još uvek procenat bolesnika koji ne dobiju RT visok. Dobro je poznato da prognoza STEMI bolesnika zavisi od vremena koje prodje od početka simptoma do primene RT, ali i od niza komorbiditeta, faktora rizika, prethodne koronarne bolesti, godina starosti, pola, veličine i lokalizacije infarkta. Do sada nema dovoljno podataka o mortalitetu i tipu primenjene reperfuzione terapije kod bolesnika sa STEMI u Srbiji, zemlji u tranziciji. Poznato je da je odluka o primeni reperfuzione terapije i tip terapije uslovljena blizinom sale za kateterizaciju i mogućnosti da se što pre primeni p-PCI u toku 24h/7 dana u nedelji, ali i od ostalih navedenih faktora koji se odnose na bolesnika. Cilj rada je da se analiziraju mogućnosti i karakteristike koje bi imale uticaj na procenu rizika akutnog oboljenja, koji bi bio u skladu sa primenom odredjene vrste terapije. Ciljevi ovog istraživanja su da se u Srbiji, kod bolesnika sa STEMI: 1. utvrdi povezanost procenjenog stepena rizika i vremena proteklog od početka simptoma na odluku o primeni i tipu RT i 2. efekat primenjene RT na hospitalni tok i ishod u zavisnosti od napred navedenih faktora. Materijal i metode: Istraživanje je studija preseka sprovedena od 01.01.2007.-31.12.2009. godine, bazirana na podacima iz Hospitalnog registra za akutni koronarni sindrom u Srbiji (HORAKS). Kriterijum za uključivanje u studiju su konsekutivni bolesnici kod kojih su ispunjeni uslovi za postavljanje dijagnoze STEMI prema Evropskim preporukama. Tokom 3 posmatrane godine, na terirotiji Srbije je lečeno 22424 bolesnika sa STEMI. Bolesnici su prema načinu lečenja podeljeni u tri terapijske grupe: grupa lečena p-PCI (p-PCI grupa), grupa lečena FT (FT grupa) i grupa koja nije lečena RT (ne-RT grupa). Rezultati: U analizu je uključeno 15354 konsekutivnih pacijenata, srednjih godina starosti 63.58±11.97 godina, med 64 (55-73), odnos muškaraca/žena je bio 65/35%. U p-PCI grupi je bilo N=3370 bolesnika (21.9%), u FT grupi N=5132 bolesnika (33.4%), a u ne-RT grupi N=6852 (44.6%). Reperfuziona terapija se kod bolesnika sa visokim rizikom manje primenjuje, p-PCI i FT konsekutivno: stariji ≥65 godina 16.2% i 27.6%; srčana insuficijencija (SI) 14% i 31.1%; dijabetes 17.6% i 29.4%; cerebrovaskularna bolest (CVI) 17.9% i 23.9%; prethodni infarkt miokarda 16.2% i 27.1%; anemija 11.8% i 26.4%; bubrežna slabost 12.4% i 28.4%; predhodna perferna vaskularna bolest 12.% i 25.7%...Although, the treatment using reperfusion therapy (RT) in patients with ST elevation myocardial infarction (STEMI) started 30 years ago in Serbia, the use of fibrinolysis therapy (FT) has been only possible until 2006 years. The implementation primary percutaneous coronary intervention (p-PCI) was started to be applied during 2006 year. Since 2002, when it was recorded that RT was applied in 25%, the application is growing, especially in recent years. It is associated with reduction of in-hospital mortality. However, the percentage of patients with STEMI who do not receive RT is still high. It is well known that prognosis of ST-segment elevation myocardial infarction (STEMI) patients (pts) is time-dependent, but it depends on comorbidities, risk factors, previous coronary diseases, age, gender, the size and localization of the myocardial infarction. Until now, there are not enough data about mortality and the type of applied RT in STEMI patients in Serbia as a transition country. It is known that decision about application and type of RT is conditioned by distance to the catheterization laboratory and possibility of the emergency application p-PCI within 24 hours/7 days in a week, but it also depends on other factors which are related to the patients. The aim of the present work is to analyze abilities and characteristics, which could have an influence on risk evaluation acute disease and in accordance to that application and type of therapy. Moreover, during the study, it was great importance to: 1. determine which factors have the influence on fewer application of RT in STEMI patients, in Serbia, a country in transition, and to establish if application of RT and type of RT depend on the risk level of patients and the time of symptoms onset and 2. analyze the effects of RT on in-hospital outcome depending on the previously mentioned factors. Materials and Methods: The research is across sectional study, with used data from the Hospital registry for acute coronary syndrome in Serbia (HORAKS) from 01.01.2007-31.01.2009 year. Criteria for inclusion in the study are consecutive patients in whom the diagnosis of STEMI was in accordance to European guidelines. During the three analyzed years, 22424 patients were treated with STEMI in Serbia. Patients are divided according to the method of treatment in three groups: 1. patients treated with p-PCI (p-PCI group), 2. patients treated with FT (FT group) and 3. patients not treated with RT (non-RT group). Results: The analysis includes 15354 patients, average age of 63.58±11.97 years, med 64 (55-73), male/female ratio was 65/35%. The p-PCI group includes N=3370 patients (21.9%), the FT group of N=5132 patients (33.4%), and the non-RT group of N=6852 (44.6%) patients. In patients with high risk, RT is less applied, p-PCI and FT consecutively: elderly ≥65 yr. 16.2% and 27.6%; heart failure (HF) 14% and 31.1%; diabetes 17.6% and 29.4%; stroke 17.9% and 23.9%; previous myocardial infarction 16.2% and 27.1%; anemia 11.8% and 26.4%; renal failure 12.4% and 28.4%; previous vascular disease 12.% and 25.7%..

In-Hospital and Long-Term Prognosis after Myocardial Infarction in Patients with Prior Coronary Artery Bypass Surgery; 19-Year Experience

To present a 19-year experience of the prognosis of patients with acute myocardial infarction (AMI) and prior coronary artery bypass surgery (CABS), 748 patients with AMI after prior CABS (postbypass group) and a control group of 1080 patients with AMI, but without prior CABS, were analyzed. All indexes of infarct size were lower in the postbypass group. There was more ventricular fibrillation in the postbypass group. In-hospital mortality was similar (p = 0.3675). In the follow-up period, postbypass patients had more heart failure, recurrent CABS, reinfarction, and unstable angina than did control patients. Cumulative survival was better in the control group than in the postbypass group (p = 0.0403). Multiple logistic regression model showed that previous angina (p = 0.0005), diabetes (p = 0.0058), and age (p = 0.0102) were independent predictor factors for survival. Use of digitalis and diuretics, together with previous angina, also influenced survival (p = 0.0092), as well as male gender, older patients, and diabetes together (p = 0.0420). Patients with AMI after prior CABS had smaller infarct, but more reinfarction, reoperation, heart failure, and angina. Previous angina, diabetes, and age, independently, as well as use of digitalis and diuretics together with angina, and male gender, older patients, and diabetes together, influenced a worse survival rate in these patients

Upotreba reperfuzione terapije u zemljama tranzicije bez potpuno primenljive farmakoinvazivne strategije

Background/Aim.The pharmacoinvasive (PI) therapy is a recommended strategy in patients (pts) with ST elevation myocardial infarction (STEMI) unable to undergo timely primary percutaneous coronary intervention (p-PCI). The aim of the study was to find out the cohorts of pts who are not treated by any reperfusion therapy (RT) as well to determine the outcome of the pts treated with RT in a transition country without fully applicable PI therapy. Methods. The study analyzed data from the Hospital National Registry for Acute Coronary Syndrome of Serbia (HORACS). Results. The significant predictors of the withdrawing of the application of any RT in the model [c 75.6%, SE 0.004, 95% CI 0.748-0.761)] were age (≥ 65 years), heart failure (Killip II-IV), diabetes mellitus, and the time to first medical contact (FMC) (> 360 min). In patients without RT, mortality was 15.7%, in pts treated with fibrinolytic therapy (FT) was 10.5%, and in pts treated with pPCI, it was 6.2% (p 360min). Kod bolesnika koji nisu bili lečeni RT, mortalitet je bio 15,7%, kod bolesnika lečenih fibrinolitičkom terapijom (FT) iznosio je 10,5%, a kod bolesnika lečenih p-PCI 6,2% ( p <0,000). U grupi bolesnika koji su do PMK stizali za 3 sata, mortalitet lečenih pomoću FT bio je veći od mortaliteta bolesnika lečenih p-PCI (FT 8,7% vs p-PCI 4,3%). Bolesnici lečeni pomoću FT bili su stariji, sa više komorbiditeta i sa učestalijim znacima srčane insuficijencije. Ipak, posle primenjenog propensity skora, sa ciljem da se izbegnu razlike između dve grupe bolesnika, mortalitet u FT grupi ostao je veći, alibez statistički značajne razlike u odnosu na bolesnike lečene p-PCI (FT 8,8%. vs p-PCI 6,4%). Zaključak. Primena RT, uz postignuti idealan balans potrošnje i koristi, teško je izvodljiva u zemljama u tranziciji. Mogućnosti za blagovremenu primenu p-PCI, kao i FIterapije, posebno su ograničene kod visoko rizičnih, starijih bolesnika, kod bolesnika sa znacima srčane insuficijencije, komorbiditetima i dijabetesom melitusom