UNSUCCESSFUL PRIMARY PCI FOR POSTPARTAL DISSECTION OF ALL THREE MAJOR CORONARY ARTERIES

Coronary artery dissection is rare but very dangerous condition which can result in myocardial infarction. It mostly occurs in young postpartum women. The left anterior descending artery is affected in 75% of cases and in some extremely rare cases dissection may include all three coronary arteries. Treatment guides are still not consistent. While some authors recommend medical treatment other recommend surgical one. Case report. We present a 36-year-old female patient who was admitted to our hospital with intermittent chest pain and dyspnea that occurred two hours before admission. After premedication with Aspirin 300 mg per os, Clopidogrel 300 mg per os and Enoxaparin 30 mg iv, the pain disappeared. Chest pain was repeated after five days. Coronary angiography revealed spiral dissection in medial segment of LAD. After PCI attempt, dissection progressed and ended fatal. Pathological finding was intimal dissection of the coronary arteries with loss of some parts of internal elastic lamina. It is interesting that in the literature there is no consistent opinion about therapeutic approach to SDCA and we hope that this case report will contribute to elucidating the problem

Life-saving percutaneous coronary interventions on the unprotected left main coronary artery in patients with acute coronary syndrome in the catheterization laboratory without cardiosurgical back-up

Introduction. The optimal revascularization strategy for unprotected left main coronary disease (ULMCD) is the subject of ongoing debate and patients with ULMCD still represent a challenge for interventionalist, especially in the setting of an acute coronary syndome (ACS). Case report. We presented two cases of percutaneous treatment of ULMCD in the settings of ACS (ST Segment Myocardial Infarction and Non ST Segment Myocardial Infarction - STEMI and NSTEMI) in a catheterization laboratory without back-up of cardiosurgical department. Both patients were hemodynamically unstable with clinical signs of cardiogenic shock. Coronary angiography revealed left main thromobosis and using intra-aortic balloon pump as hemodynamic support primary angioplasty procedures were performed. Immediately after the procedures the patients hemodynamically improved and remained stable till discharge from hospital. Conclusion. Percutaneous coronary intervention (PCI) has become the most common strategy of revascularization in ACS patients with ULMCD and is generally preferred in patients with multiple comorbidities and/or in very unstable patients. In cases with no cardiosurgical departments PCI is an inevitable, bail-out, life saving procedure

Coronary flow and hemorrhagic complications after alteplase and streptokinase administration in patients with acute myocardial infarction

Background/Aim. Up-to-date treatment of acute myocardial infarction (AIM) has been based on as early as possible establishment of circulation in ischemic myocardium whether by the use of fibrinolythic therapy and/or urgent coronary intervention which significantly changes the destiny of patients with AMI, but also increases the risk of bleeding. The aim of this study was to compare coronary flow and bleeding complications in patients with acute myocardial infarction with ST-elevation (STEMI) after administration of alteplase or streptokinase. Methods. The study included 254 patients with STEMI. The group I (n = 174) received streptokinase, and the group II (n = 80) received alteplase. We followed frequency of complications such as bleeding and hypotension in the investigated groups of patients, based on the TIMI classification of bleeding, as well as the transience of infarction artery in accordance with TIMI flow. Results. The patients with myocardial infarction after administration of alteplase had statistically significantly higher coronary flow (TIMI- 3), 72.5% as compared to the patients who received streptokinase, 39.2%. Hypotension as complication of fibrynolythic therapy administration occurred in a significantly higher percentage in the group of patients who received streptokinase. There was no statistically significant difference in the appearance of major bleeding in the groups of patients who received streptokinasis and alteplase (6.9% and 7.5%, respectively). Also, there was no difference in the appearance of minor and minimal bleeding among the investigated groups of patients. Conclusion. It was shown that alteplase in a higher number of patients provided TIMI-3 coronary flow as compared to streptokinese. In comparison with streptokinase, a combination of alteplase, enoxaparin and double antiplatelet therapy enabled earlier achievement of coronary flow through previously blocked coronary artery that was more complete (higher frequency of TIMI-3 flow). There were no statistically significant difference in frequency of bleeding, first of all major bleeding, between the groups treated by alteplase and streptokinase

Echocardiographic estimation of acute haemodynamic response during optimization of multisite pace-maker using different pacing modalities and atrioventricular delays

Background/Aim. Cardiac resynchronization therapy (CRT) improves ventricular dyssynchrony and is associated with an improvement in symptoms, quality of life and prognosis in patients with severe heart failure and intraventricular conduction delay. Different pacing modalities produce variable activation patterns and may be a cause of different haemodynamic changes. The aim of our study was to investigate acute haemodynamic changes with different CRT configurations during optimization procedure. Methods. This study included 30 patients with severe left ventricular systolic dysfunction and left bundle branch block with wide QRS (EF 24.33 ± 3.7%, QRS 159 ± 17.3 ms, New York Heart Association III/IV 25/5) with implanted CRT device. The whole group of patients had severe mitral regurgitation in order to measure dP/dt. After implantation and before discharge all the patients underwent optimization procedure guided by Doppler echocardiography. Left and right ventricular pre-ejection intervals (LVPEI and RVPEI), interventricular mechanical delay (IVD) and the maximal rate of ventricular pressure rise during early systole (max dP/dt) were measured during left and biventricular pacing with three different atrioventricular (AV) delays. Results. After CRT device optimization, optimal AV delay and CRT mode were defined. Left ventricular pre-ejection intervals changed from 170.5 ± 24.6 to 145.9 ± 9.5 (p < 0.001), RVPEI from 102.4 ± 15.9 to 119.8 ± 10.9 (p < 0.001), IVD from 68.1 ± 18.3 to 26.5 ± 8.2 (p < 0.001) and dP/dt from 524.2 ± 67 to 678.2 ± 88.5 (p < 0.01). Conclusion. In patients receiving CRT echocardiographic assessment of the acute haemodynamic response to CRT is a useful tool in optimization procedure. The variability of Doppler parameters with different CRT modalities emphasizes the necessity of individualized approach in optimization procedure

POPULATION PHARMACOKINETICS OF 2-OXO-CLOPIDOGREL IN PATIENTS WITH ACUTE CORONARY SYNDROME

The aim of the study was to develop a population pharmacokinetic (PK) model for clearance of 2-oxo-clopidogrel in patients with acute coronary syndrome (ACS). Population pharmacokinetic analysis was performed by using 72 plasma concentrations from the same number of patients (mean age of 60.82±10.76 years; total body weight (TBW) of 73.63±9.67 kg) with ACS using non-linear mixed-effect modeling (NONMEM). Validation of the final PPK model was carried out through the bootstrap analysis with 200 runs and it was used to estimate the predictive performance of the pharmacokinetic model. The typical mean value for 2-oxo-clopidogrel clearance (CL), estimated by the base model (without covariates), in our population was 39.2 l h−1.The value of aspartate transaminase and co-medication with digoxin were determinants of a derived population model. The final regression model for the clearance of 2-oxo-clopidogrel was the following: CL (lh-1) = 1.7 + 1.31*AST + 115*DIGOXIN. The derived PK model describes the clearance of 2-oxo-clopidogrel in patients with ACS, showing that the value of aspartate transaminase and co-medication with digoxin are the most important covariate. This finding will provide the basis for future PK studies

Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS-ELD trial

AIMS: Various beta-blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta-blockers in elderly patients with heart failure. METHODS AND RESULTS: We performed a double-blind superiority trial of bisoprolol vs. carvedilol in 883 elderly heart failure patients with reduced or preserved left ventricular ejection fraction in 41 European centres. The primary endpoint was tolerability, defined as reaching and maintaining guideline-recommended target doses after 12 weeks treatment. Adverse events and clinical parameters of patient status were secondary endpoints. None of the beta-blockers was superior with regards to tolerability: 24% [95% confidence interval (CI) 20-28] of patients in the bisoprolol arm and 25% (95% CI 21-29) of patients in the carvedilol arm achieved the primary endpoint (P= 0.64). The use of bisoprolol resulted in greater reduction of heart rate (adjusted mean difference 2.1 b.p.m., 95% CI 0.5-3.6, P= 0.008) and more, dose-limiting, bradycardic adverse events (16 vs. 11%; P= 0.02). The use of carvedilol led to a reduction of forced expiratory volume (adjusted mean difference 50 mL, 95% CI 4-95, P= 0.03) and more, non-dose-limiting, pulmonary adverse events (10 vs. 4%; P < 0.001). CONCLUSION: Overall tolerability to target doses was comparable. The pattern of intolerance, however, was different: bradycardia occurred more often in the bisoprolol group, whereas pulmonary adverse events occurred more often in the carvedilol group. This study is registered with controlled-trials.com, number ISRCTN34827306

Left atrial size in patients with arterial hypertension

INTRODUCTION Left atrial size is increased in patients with arterial hypertension. Left atrial enlargement represents a risk factor of atrial fibrillation and stroke. Left atrial size depends on the effect of many other etiological factors, predominantly by body mass and the left ventricular mass. OBJECTIVE The objective of the study was to investigate the frequency of the left atrial enlargement in patients with arterial hypertension, in obese patients with arterial hypertension and in patients with arterial hypertension and left ventricular hypertrophy. In addition, the aim was to investigate the influence of diastolic function parameters on the left atrial dimension. METHOD The study included 93 patients with arterial hypertension (mean age of 46.9 ± 9.7 years, 50.5% of males) and 33 healthy subjects (mean age 45.6 ±10.6 yrs., 40% of males) who consisted the control group. There was no statistical difference of the age and sex between patients and healthy persons. All patients were examined by the echocardiographic ultrasound device HP Sonos 2500 by three echosonographers. RESULTS The patients with arterial hypertension compared to the control group had significantly higher: body mass index (27.8 ± 4.1 versus 24.3 ± 3.0) (p&lt;0.001), the left ventricular mass (249.7 ± 79.1 versus 174.6 ± 47.7) (p&lt;0,001), the left ventricular mass index (122.2 ± 34.3 versus 96.7 + 20.9)(p&lt;0.001) and the left atrium (3.8 ± 0.7 versus 3.3 ± 0.5) (p&lt;0.001). The frequency of the left atrial enlargement in patients with arterial hypertension was 44.1%. The frequency of the left atrial enlargement In patients with arterial hypertension and the left ventricular hypertrophy was 53.3%, and in obese patients with arterial hypertension was 58.3%. Left ventricular diastolic function parameters in patients with arterial hypertension in relation to control exhibited statistically significant differences: isovolumetric relaxation time (IVRT) was longer (193.2 ± 37.8 versus 175,8 ± 23,6) (p&lt;0.001), deceleration time (DT) was longer (193.2 ±37,8 versus 175.8 ±23.6) (p&lt;0.01) and peak early diastolic filling wave velocity /peak atrial diastolic filling wave velocity ratio (E/A ratio) was lower (1.0 ± 0.3 versus 1.2 ± 0.3) (p&lt;0.01). The quotient of linear correlation of the left ventricular diastolic function parameters in patients with arterial hypertension with left atrial volume did not show any significant correlation. CONCLUSION The left atrial size was statistically bigger in patients with arterial hypertension in relation to healthy subjects. The biggest left atrial enlargement was in hypertensive patients with the left ventricular hypertrophy and obese hypertensive patients. Left ventricular diastolic function parameters in patients with arterial hypertension had no statistically significant influence on the left atrial size

THE FREQUENCY OF LEFT VENTRICULAR HYPERTROPHY IN PATIENTS WITH ARTERIAL HYPERTENSION AND OBESE PATIENTS WITH ARTERIAL HYPERTENSION

The aim of this research was to investigate the potential relationship between the longterm exposure to air pollution, as a risk factor, and the development of allergic reactions in the population. The observed sample consisted of Nis citizens of different age groups who lived in areas with high concentrations of air pollutants (investigated group) such as the Square of the October Revolution and Sindjelic’s Square (investigated group), as well as the citizens of Niska Banja (control group) which is the zone with the lowest concentration of air pollution. The investigation was carried out in the Public Health Institute in the period between 1996 and 2000. A significance test was performed using a Mantel-Haenszel chi square test. This test was used to check for a statistically significant difference between the incidence of the obstructive lung disease between the investigated group and the control group across all age groups. The cross-risk and relative risk were determined. The highest value of the chi square test was determined in the age group 26-50 (RR=3.50), in the group up to 25, RR=2.25, and in the group above 51, RR=1.89. The obtained results prove that the incidence of the obstructive lung disease is significantly higher in the exposed population than in the non-exposed

Late thrombosis of coronary bare-metal stent: Case report

Stent thrombosis remains the primary cause of death after percutaneous coronary interventions (PCI). Despite modern concepts of PCI, stent thrombosis occurs in 0.5% -2% of elective procedures and even 6% of patients with the acute coronary syndrome (ACS). Stent thrombosis most often develops within the first 48 hours after the PCI, and rarely after a week of stent implantation. Angiographically documented late (&gt;6 months) thrombosis of coronary bare-metal stent (BMS) is rare, because the stent endothelialization is considered to be completed after four weeks of the intervention. Our patient is a 41 year old male and he had BMS thrombosis 345 days after the implantation, which was clinically manifested as an acute myocardial infarction in the inferoposterolateral localization. Stent Clinical Centre of Serbia, Belgrade thrombosis occurred despite a long term dual antiplatelet therapy and control of known risk factors. Thrombolytic therapy (Streptokinase in a dose of 1 500 000 IU) was not successful in reopening the occluded vessel, so the flow through the coronary artery was achieved by rescue balloon angioplasty, followed by implantation of drug eluting stent in order to prevent restenosis