Pharmacoinvasive strategy and its role in the management of patients with acute ST-segment elevation myocardial infarction

Učinkovita, rana i brza reperfuzijska terapija je najvažniji cilj u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta (STEMI). Pravovremeno učinjena primarna perkutana koronarna intervencija (pPCI) je nesumnjivo strategija izbora u liječenju STEMI i u posljednjih desetak godina pPCI kao način revaskularizacijske strategije je zamijenila fibrinolitičku terapiju. Mnoga klinička istraživanja su pokazala da bolesnike liječene fibrinolizom treba rutinski premjestiti u invazivni kardiološki centar radi elektivne perkutane koronarne intervencije (PCI) unutar 24 sata te da ovakva rana invazivna strategija dovodi do stabilizacije ciljne lezije i manje pojavnosti rekurentne ishemije. Najnovije Smjernice Europskog kardiološkog društva za zbrinjavanje bolesnika sa STEMI farmakoinvazivnoj strategiji daju klasu I indikacija. U ovom preglednom članku su prikazana najvažnija klinička istraživanja o farmakoinvazivnoj strategiji i mjesto ovog načina liječenja STEMI. Ovakav način reperfuzije dovodi do značajnog smanjenja reinfarkta i rekurentne ishemije bez povišenog rizika od krvarenja te bi implementiranje ove strategije u regionalne protokole zbrinjavanja bolesnika sa STEMI povećalo broj bolesnika kojima je pružena pravilna i pravodobna primjena reperfuzijske terapije.Effective, early and rapid reperfusion therapy is the most important goal in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI). Timely performed primary percutaneous coronary intervention (pPCI) is undoubtedly the strategy of choice in the treatment of STEMI and in the last decade pPCI has replaced fibrinolytic therapy as a way revascularization strategy. Many clinical studies have shown that patients treated with fibrinolysis should be routinely moved to the invasive cardiology center for elective percutaneous coronary intervention (PCI) within 24 hours and that this early invasive strategy leads to a stabilization of the target lesion and lowers the incidence of recurrent ischemia. The latest European Society of Cardiology Guidelines for the management of patients with STEMI award the Class I indication to the pharmacoinvasive strategy. This review article presents the most important clinical research on pharmacoinvasive strategy and importance of this method of treatment of STEMI. This method of reperfusion leads to a significant reduction in reinfarction and recurrent ischemia without increased risk of bleeding and implementing this strategy in regional protocols for the management of patients with STEMI would increase the number of patients who are to receive proper and timely reperfusion therapy

Application of pharmacoinvasive strategy in primary percutaneous coronary intervention network in Western Slavonia

Hrvatska mreža primarne perkutane intervencije međunarodno je prepoznati sustav dobre organizacije urgentnog liječenja kardioloških bolesnika. U svakodnevnoj kliničkoj praksi svjedoci smo da je vrijeme potrebno za organiziranje primarne perkutane koronarne intervencije (pPCI), koja predstavlja najbolji način reperfuzijske terapije u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta, često predugo i povezano s neprihvatljivo dugim kašnjenjima. Farmakoinvazivna strategija obuhvaća selektivnu primjenu fibrinolitičke terapije nakon koje slijedi neodložan transport bolesnika u centar s mogućnošću perkutane koronarne intervencije i organiziranje invazivne obrade unutar 3-24 sata. Obzirom na organizacijske teškoće koje uzrokuju nemogućnost pravovremene pPCI, primjenom farmakoinvazivnog pristupa povećao bi se broj bolesnika kojima bi bila omogućena pravilna i pravodobna reperfuzijska terapija. Donosimo praktične preporuke za implementaciju farmakoinvazivne strategije u svakodnevnu kliničku praksu te protokol lokalne organizacije mreže pPCI u Općoj bolnici „Dr. Josip Benčević“ u Slavonskom Brodu, Hrvatska.Croatian Primary Percutaneous Intervention Network is an internationally recognized system of good organization of urgent treatment of cardiac patients. In everyday clinical practice, we have witnessed that the time required for the organization of primary percutaneous coronary intervention (pPCI), which represents the best way of reperfusion therapy in the treatment of patients with acute ST-segment elevation myocardial infarction is often too long and associated with unacceptably long de- lays. Pharmacoinvasive strategy encompasses a selective use of fibrinolytic therapy to be followed by prompt transportation of patients to a center capable of undertaking percutanous coronary intervention and organizing invasive treatment within 3-24 hours. Considering the organizational difficulties caused by the incapability of undertaking prompt pPCI, the application of pharmacoinvasive approach would increase the number of patients that would be provided proper and timely reperfusion therapy. Here are some practical recommendations for implementation of the pharmacoinvasive strategy in everyday clinical practice and protocol of the local organization of the pPCI network in the General Hospital “Dr. Josip Benčević “ in Slavonski Brod, Croatia

Developing a Treatment Quality Monitoring Program for Patients with Acute Coronary Syndrome in Western Slavonia

Dobra organizacija mreže primarne perkutane koronarne intervencije (pPCI) ima najvažnije mjesto u pružanju optimalne zdravstvene skrbi bolesnika s akutnim koronarnim sindromom (AKS). Organizacija mreže pPCI dugotrajan je i logistički kompleksan posao. Prikupljanje, analiziranje i dijeljenje podataka o funkcioniranju mreže zbrinjavanja bolesnika s AKS-om ima za cilj poboljšanje funkcioniranja sustava. Monitoriranje svakodnevnog rada, prikupljanje, analiziranje i dijeljenje podataka ključni je element za kontinuirano poboljšanje rada. U ovome članku opisujemo napore u razvoju programa praćenja kvalitete liječenja bolesnika s AKS-om u zapadnoj Slavoniji, dijagnostičke, terapijske i destinacijske protokole te način i vrstu podataka koje ćemo monitorirati kao pokazatelje kvalitetete i sveobuhvatnosti skrbi za bolesnike s AKS-om.A well-organized network for primary percutaneous coronary intervention (pPCI) is of paramount importance in providing optimal healthcare for patients with acute coronary syndrome (ACS). Organizing a pPCI network is a lengthy and logistically complex task. The purpose of gathering, analyzing, and sharing data on the functioning of the network is to improve the system. Monitoring everyday work and gathering, analyzing, and sharing data are the key elements of continuous improvement. This article describes the efforts to develop a quality monitoring program for the treatment of patients with ACS in western Slavonia – a region in Croatia. We also explain the diagnostic, treatment, and destination protocols used and the types of data we will monitor as indicators of quality and comprehensiveness of care for patients with ACS

Application of pharmacoinvasive strategy in primary percutaneous coronary intervention network in Western Slavonia

Hrvatska mreža primarne perkutane intervencije međunarodno je prepoznati sustav dobre organizacije urgentnog liječenja kardioloških bolesnika. U svakodnevnoj kliničkoj praksi svjedoci smo da je vrijeme potrebno za organiziranje primarne perkutane koronarne intervencije (pPCI), koja predstavlja najbolji način reperfuzijske terapije u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta, često predugo i povezano s neprihvatljivo dugim kašnjenjima. Farmakoinvazivna strategija obuhvaća selektivnu primjenu fibrinolitičke terapije nakon koje slijedi neodložan transport bolesnika u centar s mogućnošću perkutane koronarne intervencije i organiziranje invazivne obrade unutar 3-24 sata. Obzirom na organizacijske teškoće koje uzrokuju nemogućnost pravovremene pPCI, primjenom farmakoinvazivnog pristupa povećao bi se broj bolesnika kojima bi bila omogućena pravilna i pravodobna reperfuzijska terapija. Donosimo praktične preporuke za implementaciju farmakoinvazivne strategije u svakodnevnu kliničku praksu te protokol lokalne organizacije mreže pPCI u Općoj bolnici „Dr. Josip Benčević“ u Slavonskom Brodu, Hrvatska.Croatian Primary Percutaneous Intervention Network is an internationally recognized system of good organization of urgent treatment of cardiac patients. In everyday clinical practice, we have witnessed that the time required for the organization of primary percutaneous coronary intervention (pPCI), which represents the best way of reperfusion therapy in the treatment of patients with acute ST-segment elevation myocardial infarction is often too long and associated with unacceptably long de- lays. Pharmacoinvasive strategy encompasses a selective use of fibrinolytic therapy to be followed by prompt transportation of patients to a center capable of undertaking percutanous coronary intervention and organizing invasive treatment within 3-24 hours. Considering the organizational difficulties caused by the incapability of undertaking prompt pPCI, the application of pharmacoinvasive approach would increase the number of patients that would be provided proper and timely reperfusion therapy. Here are some practical recommendations for implementation of the pharmacoinvasive strategy in everyday clinical practice and protocol of the local organization of the pPCI network in the General Hospital “Dr. Josip Benčević “ in Slavonski Brod, Croatia

Duke Treadmill Score in Prioritizing Patients for Coronary Angiography: Retrospective Study of a Croatian Regional Hospital

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting.We analyzed 114 patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time – (5 ST deviation in mm) – (4 exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting

Duke Treadmill Score in Prioritizing Patients for Coronary Angiography: Retrospective Study of a Croatian Regional Hospital

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting.We analyzed 114 patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time – (5 ST deviation in mm) – (4 exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting

Percutaneous Coronary Interventions with Drug-eluting Balloons: Croatian Experience

Uvod: Lijekom obloženi baloni (DEB) predstavljaju novu tehnološku platformu u području perkutane koronarne intervencije. Jedina prihvaćena indikacija za njihovu uporabu je liječenje in-stent stenoze, a za sve ostale indikacije nema jasnog konsenzusa. Cilj: Evaluirati upotrebu DEB-a u rutinskoj kliničkoj praksi u Republici Hrvatskoj. Metode: Restrospektivni nerandomizirani multicentrični registar svih liječenih bolesnika u sedam hrvatskih centara između veljače 2011. i siječnja 2014. godine. Podatci su sakupljeni uvidom u dostupnu medicinsku dokumentaciju. Nije bilo kliničkih niti angiografskih isključnih kriterija, niti pisanog zajedničkog protokola za indikacije niti praćenje bolesnika. Praćena su velika nepovoljna događanja (MACE) definirana kao kombinacija srčane smrti, infarkta miokarda na tretiranoj krvnoj žili (MI) ili klinički indicirane reintervencije na tretiranoj krvnoj žili TLR za sve bolesnike tijekom iste hospitalizacije, nakon 6 mjeseci kliničkog praćenja te dostupni angiografski podatci. Rezultati: Kod 248 bolesnika tretirane su 284 lezije. Najčešća indikacija bila je in-stent restenoza u 31,4% bolesnika, u 21,4% bolesnika DEB je implantiran u žilama manjim od 2,75 mm, a ostale indikacije su bile: lezije veće od 2,8 mm, bifurkacije, ostijalne lezije, kronične totalne okluzije (redom: 11,3%; 11,3%; 7,3%; 1,6% ). U 39 bolesnika (15,6%) nakon prethodne implantacije običnih metalnih stentova (BMS) rađena je postdilatacija DEB-om. MACE su se tijekom hospitalizacije javili u 1,6% bolesnika: 1 smrt (0,4%), 3 akutne tromboze (1,2%), 1 MI (0,4%). Nakon 6 mjeseci praćenja dostupni su podatci za 83 bolesnika (33%). U 6% bolesnika je rađena TLR, a nije bilo registriranih smrti niti akutnih infarkta miokarda. Angiografska kontrola nakon 6 mjeseci učinjena je u 55 bolesnika (22%). U 69% bolesnika nalaz je opisivan kao potpuno uredan, nesignifikantna stenoza opisana je u 20% bolesnika, a u 11% bolesnika je opisana stenoza u rasponu od >50% do potpune okluzije. Zaključak: Naše kliničko iskustvo u svakodnevoj kliničkoj praksi pokazuje da se DEB u Hrvatskoj koristi u najvećem slučaju u prihvaćenim indikacijama in-stent restenoze, ali i u velikom postotku i za indikacije za koje ne postoji jasni konsenzus u literaturi. Akutni angiografski rezultati i rani klinički ishodi su odlični, a uporaba DEB-a je izrazito sigurna.Introduction: Drug-eluting balloons (DEB) represent a new technological platform in the area of percutaneous coronary interventions. The only accepted indication for their use is the treatment of in-stent stenosis, with no clear consensus for all other indications. Aim: To evaluate the use of DEB in routine clinical practice in Croatia. Methods: Retrospective nonrandomized multicentric register of all treated patients in seven Croatian centers in the time frame from February 2011 to January 2014. The data were collected from available medical documents. There were no clinical or angiographic exclusion criteria, nor was there any written common protocol for indications or for for the clinical follow up of patients. Major adverse cardiac events (MACE) were monitored. MACE were defined as the combination of cardiac death, development of myocardial infarction (MI) on treated vessel, and/or target lesion revascularization (TLR) for all patients during the same hospitalization, following a 6-month clinical observation and through available angiographic data. Results: 248 patients were treated for 284 lesions. The most common indication was the in-stent restenosis present in 31.4% of the patients, for 21.4% of the patients DEB was implanted in vessels smaller than 2.75 mm, and other indications were: lesions larger than 2.8 mm, bifurcations, ostial lesion, chronic total occlusions (11.3%; 11.3%; 7.3%; 1.6% respectively). On 39 patients (15.6%) following the previous implantation of bare metal stents (BMS), postdilatation with DEB was conducted. MACE during hospitalization appeared in 1.6% of the patients: 1 death (0.4%), 3 acute thromboses (1.3%), 1 MI (0.4%). Following the 6 month long observation, data is available for 83 patients (33%). TLR was performed on 6% of the patients, and there were no registered deaths or acute myocardial infarctions. Angiographic follow-up was performed on 55 patients (22%) after 6 months. In 69% of the patients the findings were described as completely clean, insignificant stenosis was described for 20% of the patients, and for 11% of the patients a stenosis to the amount of >50% of full occlusion was described. Conclusion: Our clinical experience in everyday clinical practice shows that in Croatia DEB is mostly used in cases of accepted indications of in-stent re-stenosis, but also to a great percentage for indications for which no clear consensus exists in literature. Acute angiographic results and early clinical results are excellent, and the use of DEB is highly safe

Postperikardiotomijski sindrom - učestalost, dijagnostički kriteriji i liječenje: iskustva suradnje dvaju centara

Postpericardiotomy syndrome (PPS) is worsening or new formation of pericardial and/or pleural effusion mostly 1 to 6 weeks after cardiac surgery, as a result of autoimmune inflammatory reaction within pleural and pericardial space. Its incidence varies among different studies and registries (2% to 30%), as well as according to the type of cardiac surgery performed. We conducted this retrospective analysis of PPS incidence and diagnostic and treatment strategies in patients referred for cardiac surgery for revascularization, valvular and/or aortic surgery. We retrospectively analyzed 461 patients referred for an urgent or elective cardiac surgery procedure between 2009 and 2015. PPS diagnosis was established using well defined clinical criteria. Demographic and clinical characteristics were used in regression subanalysis among patients having undergone surgery of aortic valve and/or ascending aorta. Within 6 weeks after cardiac surgery, 47 (10.2%) patients had PPS. The median time from the procedure to PPS diagnosis was 14 days. The incidence of PPS was 26% after aortic valve and/or aorta surgery, and 7.9% and 8.3% after coronary bypass and mitral valve surgery, respectively. Among patients subjected to aortic valve and/or aortic surgery, regression analysis showed significant association of fever, C-reactive protein (CRP) elevation between 5 and 100 mg/L, urgent procedure and postoperative antibiotic use with PPS diagnosis, whereas younger age showed nearsignificant association. All patients had complete resolution of PPS, mostly after corticosteroid therapy, with only 2 cases of recurrent PPS that successfully resolved after colchicine therapy. Pleural drainage was indicated in 15 (32%) patients, whereas only one patient required pericardial drainage. In conclusion, PPS incidence in our retrospective analysis was similar to previous reports. Patients having undergone aortic valve and/or aortic surgery were most likely to develop PPS. The most relevant clinical criteria for diagnosis in these patients were fever, CRP elevation between 5 and 100 mg/L, and pericardial and/or pleural effusion formation or worsening 2 weeks after cardiac surgery.Postperikardiotomijski sindrom (PPS) je pogoršanje ili novo stvaranje perikardijalnog i/ili pleuralnog izljeva uglavnom 1 do 6 tjedana nakon kardiokirurške operacije, i to kao rezultat autoimune upalne reakcije unutar pleuralnog i perikardijalnog prostora. Njegova učestalost varira među različitim studijama i registrima (između 2% i 30%), kao i prema vrsti kirurškog zahvata koji je proveden. Proveli smo retrospektivnu analizu učestalosti PPS-a i dijagnostičkih i terapijskih strategija u bolesnika upućenih na kardiokirurgiju radi revaskularizacije, valvularne i/ili kirurgije torakalne aorte. Retrospektivno smo analizirali 461 bolesnika upućenog na hitan ili elektivni kardiokirurški zahvat između 2009. i 2015. godine. Dijagnoza PPS-a utvrđena je pomoću dobro definiranih kliničkih kriterija. Demografske i kliničke karakteristike korištene su u regresijskoj subanalizi kod bolesnika koji su bili podvrgnuti operaciji aortnog zaliska i/ili uzlazne aorte. U roku od 6 tjedana nakon zahvata 47 (10,2%) bolesnika razvilo je PPS. Srednje vrijeme od postupka do dijagnoze PPS bilo je 14 dana. Učestalost PPS-a bila je 26% nakon operacije aortnog zaliska i/ili torakalne aorte te 7,9% i 8,3% nakon izoliranog koronarnog premoštenja odnosno operacije mitralnog zaliska. Među bolesnicima koji su bili podvrgnuti kirurškom zahvatu aortnog zaliska i/ili torakalne aorte regresijska analiza pokazala je značajnu povezanost povišene temperature, povišenja C-reaktivnog proteina (CRP) između 5 i 100 mg/L, veće hitnosti zahvata i poslijeoperacijske uporabe antibiotika s PPS-om, dok je za mlađu dob ta povezanost bila blizu razine značajnosti. Kod gotovo svih bolesnika došlo je do povlačenja PPS-a i to uglavnom nakon terapije kortikosteroidima, pri čemu su samo 2 slučaja rekurentnog PPS-a uspješno liječena kolhicinom. Pleuralna drenaža bila je indicirana u 15 (32%) bolesnika, dok je samo jedan bolesnik zahtijevao perikardijalnu drenažu. Zaključno, učestalost PPS-a u našoj retrospektivnoj analizi bila je slična prethodnim izvješćima. Bolesnici koji su bili podvrgnuti operacijama aortnog zaliska i/ili aorte imali su najveću učestalost PPS-a. Najrelevantniji klinički kriteriji za postavljanje dijagnoze u tih bolesnika su povišena temperatura, povišenje CRP-a između 5 i 100 mg/L te nastanak perikardijalnog i/ili pleuralnog izljeva ili njihovo pogoršanje 2 tjedna nakon kirurškog zahvata na srcu

Pharmacoinvasive strategy and its role in the management of patients with acute ST-segment elevation myocardial infarction

Učinkovita, rana i brza reperfuzijska terapija je najvažniji cilj u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta (STEMI). Pravovremeno učinjena primarna perkutana koronarna intervencija (pPCI) je nesumnjivo strategija izbora u liječenju STEMI i u posljednjih desetak godina pPCI kao način revaskularizacijske strategije je zamijenila fibrinolitičku terapiju. Mnoga klinička istraživanja su pokazala da bolesnike liječene fibrinolizom treba rutinski premjestiti u invazivni kardiološki centar radi elektivne perkutane koronarne intervencije (PCI) unutar 24 sata te da ovakva rana invazivna strategija dovodi do stabilizacije ciljne lezije i manje pojavnosti rekurentne ishemije. Najnovije Smjernice Europskog kardiološkog društva za zbrinjavanje bolesnika sa STEMI farmakoinvazivnoj strategiji daju klasu I indikacija. U ovom preglednom članku su prikazana najvažnija klinička istraživanja o farmakoinvazivnoj strategiji i mjesto ovog načina liječenja STEMI. Ovakav način reperfuzije dovodi do značajnog smanjenja reinfarkta i rekurentne ishemije bez povišenog rizika od krvarenja te bi implementiranje ove strategije u regionalne protokole zbrinjavanja bolesnika sa STEMI povećalo broj bolesnika kojima je pružena pravilna i pravodobna primjena reperfuzijske terapije.Effective, early and rapid reperfusion therapy is the most important goal in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI). Timely performed primary percutaneous coronary intervention (pPCI) is undoubtedly the strategy of choice in the treatment of STEMI and in the last decade pPCI has replaced fibrinolytic therapy as a way revascularization strategy. Many clinical studies have shown that patients treated with fibrinolysis should be routinely moved to the invasive cardiology center for elective percutaneous coronary intervention (PCI) within 24 hours and that this early invasive strategy leads to a stabilization of the target lesion and lowers the incidence of recurrent ischemia. The latest European Society of Cardiology Guidelines for the management of patients with STEMI award the Class I indication to the pharmacoinvasive strategy. This review article presents the most important clinical research on pharmacoinvasive strategy and importance of this method of treatment of STEMI. This method of reperfusion leads to a significant reduction in reinfarction and recurrent ischemia without increased risk of bleeding and implementing this strategy in regional protocols for the management of patients with STEMI would increase the number of patients who are to receive proper and timely reperfusion therapy

Acute in-situ coronary thrombosis during elective coronary angiography

This report presented a case of in situ intracoronarythrombosis of the proximal left anteriordescending artery (LAD), causing significanttransient myocardial ischemia during electivecoronary angiography in a patient with knowncoronary artery disease (chronic occlusion ofthe circumflex artery, significant stable left mainstenosis) and a severe vasovagal reaction duringfemoral artery puncture. He was treated successfullywith local fibrinolytic therapy, whereasentire diagnostic procedure was completed successfully.There were no cardiac wall motionabnormalities after the procedure, and the rest ofthe hospitalization was uneventful