A young soldier with syncope, shortness of breath and palpitations

Introduction. Coronary artery disease in people under 30 years is relatively uncommon, but once a disease occurs it brings a significant morbidity and psychological effects. Case report. We reported a 28-year-old patient presenting atypical symptoms after sincopa and non-specific changes on electrocardiogram at admission. After noninvasive and invasive cardiology diagnostic procedures were made, we concluded that he had a subtotal tubular stenosis in proximal segment of the left anterior descending coronary artery. Myocardial revascularization was successfully performed 24-hour after coronarography with the left internal mammary thoracic artery graft on the left anterior descending coronary artery and the patient had a prompt and satisfactory postoperative recovery. Conclusion. This case indicates the importance of a careful evaluation of young adults even if they do not experience typical anginal symptoms or do not have multiple risk factors for cardiovascular diseases

Aortic stenosis: From diagnosis to optimal treatment

Aortic stenosis is the most frequent valvular heart disease. Aortic sclerosis is the first characteristic lesion of the cusps, which is considered today as the process similar to atherosclerosis. Progression of the disease is an active process leading to forming of bone matrix and heavily calcified stiff cusps by inflammatory cells and osteopontin. It is a chronic, progressive disease which can remain asymptomatic for a long time even in the presence of severe aortic stenosis. Proper physical examination remains an essential diagnostic tool in aortic stenosis. Recognition of characteristic systolic murmur draws attention and guides further diagnosis in the right direction. Doppler echocardiography is an ideal tool to confirm diagnosis. It is well known that exercise tests help in stratification risk of asymptomatic aortic stenosis. Serial measurements of brain natriuretic peptide during a follow-up period may help to identify the optimal time for surgery. Heart catheterization is mostly restricted to preoperative evaluation of coronary arteries rather than to evaluation of the valve lesion itself. Currently, there is no ideal medical treatment for slowing down the disease progression. The first results about the effect of ACE inhibitors and statins in aortic sclerosis and stenosis are encouraging, but there is still not enough evidence. Onset symptoms based on current ACC/AHA/ESC recommendations are I class indication for aortic valve replacement. Aortic valve can be replaced with a biological or prosthetic valve. There is a possibility of percutaneous aortic valve implantation and transapical operation for patients that are contraindicated for standard cardiac surgery

Late ventricular potentials in risk assessment of the occurrence of complex ventricular arrhythmia in patients with myocardial infarction and heart failure

Aim. To determine the prognostic significance of late ventricular potentials on signal-averaged electrocardiogram and left ventricular ejection fraction for the occurrence of complex ventricular arrhythmia in patients treated with accelerated tissue-type plasminogen activator, using the rapid protocol, within six months of acute myocardial infarction. Methods. In this analytic observational prospective study patients were divided into four groups: patients with left ventricular ejection fraction bellow 40% and late ventricular potentials, patients with left ventricular ejection fraction bellow 40% and without late ventricular potentials, patients with left ventricular ejection fraction over 40% and late ventricular potentials, and patients with left ventricular ejection fraction over 40% and without late ventricular potentials. Complex ventricular arrhythmias (Lown grade IVa, IVb, and V) were recorded using standard electrocardiography and 24-hour Holter monitoring 21, 60, and 90 days after acute myocardial infarction, respectively. Serial recordings of signal-averaged electrocardiogram were obtained 30, 90, and 180 days after acute myocardial infarction. Left ventricular ejection fraction was determined by echocardiography between 15 and 21 days after acute myocardial infarction. Multivariant logistic regression analysis was used to evaluate the relation between late ventricular potentials and left ventricular ejection fraction with the occurrence of complex ventricular arrhythmias. Sensitivity, specificity, positive and negative predictive values of late ventricular potentials and left ventricular ejection fraction for the occurrence of complex ventricular arrhythmias were determined. Results. The prospective study included 80 patients (73% men), mean age 64 ± 3.5 years. Complex ventricular arrhythmias were recorded in 34 (42.5%) of patients, all 17 (50%) of which were from the first group (p<0.01). Complex ventricular arrhythmias were recorded in 25 (73.5%) patients with late ventricular potentials, and in 23 (67.6%) patients with left ventricular ejection fraction bellow 40%. Left ventricular ejection fraction bellow 40% and late ventricular potentials represented independent predictors for the occurrence of complex ventricular arrhythmias (RR=14.33, p<0.01). When combined with left ventricular ejection fraction bellow 40%, late ventricular potentials had sensitivity (0.50), specificity (0.93), and positive predictive accuracy (0.85) higher than late ventricular potentials alone (0.44, 0.67, and 0.37, respectively) for the occurrence of complex ventricular arrhythmias following acute myocardial infarction. Conclusion. In this study, late ventricular potentials in patients with left ventricular ejection fraction bellow 40% represented the independent predictor for the occurrence of complex ventricular arrhythmias in the first six months after the first myocardial infarction treated with accelerated tissue-type plasminogen activator, using the rapid protocol

Diastolic dysfunction types in the prediction of viable myocardium functional recovery

Background/Aim. It is well known that patients with coronary artery disease and viable tissue as a guarantee of contractile recovery (CR), despite of decreasing ejection fraction (EF) and systolic dysfunction, could have benefit from surgical revascularization. Therefore, relationship between diastolic filling type and early postoperative recovery and complications need to be established. The aim of this study was to investigate the relation between different left ventricular (LV) diastolic filling types and CR in patients after surgical revascularization with differently preserved systolic function. Methods. We investigated 60 patients. All of them had CR estimated by stress echocardiography regardless the extent of recovery of the heart systolic function. Echocardiographic evidence of diastolic dysfunction was estimated by Doppler examination of transmitral diastolic flow. According to the derived different diastolic filling types the patients were divided into three groups: I − patients with disorder of LV relaxation, II − with pseudovascularisation, and III − with restrictive filling type, and according to the value of systolic function into two subgroups: 1) relatively recovered systolic function − EF > 40% and 2) pronounced LV dysfunction − EF < 40%. Echocardiographic evaluation was performed before and two week after surgical revascularization. In the preoperative period the medication therapy was optimized. We estimated CR by echocardiografic paremeters but also by detection of cardiovascular events. Results. After CABG the mean value of WMSI LV tended to decrease in any groups: in the group I (n = 12) from 1.64±0.22 to 1.34±0.22; in the group II (n = 22) from 1.85±0.16 to 1.53±0.42, and in the group III (n = 26) from 1.92±0.29 to 1.81±0.52. The lowest improvement of systolic function according to EF value expressed by the number of patients was found in the group of patients with restrictive LV filling type (12; 53.8%) as contrasting to the group with pseudonormalisation (15; 78.9%). In the group of patients with restrictive diastolic filling type also was recorded the highest number of lethal outcomes (6; 23.1%), as well as cardiovascular complications (10; 38.5%). Conclusions. Restrictive LV diastolic filling type was the marker of poor prognosis in the patients with clinical heart failure undergoing surgical revascularization. The patients with heart failure and preserved systolic function were associated with similar prognosis

Repeated episodes of focal cerebral ischemia in a patient with mitral valve prolapse and migraine headache

Migraine is episodic, paroxysmal disorder where the headache represents the central symptom and is followed with different combinations of neurological gastrointestinal and vegetative changes. Not until the diagnostic procedures were developed, ischemic lesions were verified even in the patients with ordinary migraine. This is a report of a patient with migraine headache followed twice by verified episodes of temporary ischemic attacks and verified focal ischemic lesion of cerebral parenchyma. The mitral valve prolapse was also detected. This all imposed the administration of combined prophylactic antimigrainous and anticoagulant therapy as an imperative because of the risk of the development of repeated ischemia of cerebral tissue. This association also confirmed an opinion that migraine is a wider disorder with the dominant dysfunction of limbic system

Role of natriuretic peptides in the assessment of aortic stenosis severity

Background/Aim. Symptom onset is a critical point in natural course of aortic stenosis and the most important indication for aortic valve replacement. The aim of the study was to evaluate the role of natriuretic peptides level in the assessment of symtomatic status of patients with severe aortic stenosis and the preserved left ventricular systolic function. Methods. In 67 patients with isolated severe aortic stenosis symptomatic status, transthoracic echocardiography, and BNP and NT-proBNP plasma level were assesed. Natriuretic peptides levels were also measured in 36 healthy controls. Results. BNP and NT-proBNP levels were significantly higher in the patients with aortic stenosis compared with the healthy controls. The symptomatic patients had a higher level of natriuretic peptides than the asymptomatic ones (BNP 118 [29-266] vs 79 [44-90] pg/mL, p < 0.001; NT-proBNP 258 [67-520], vs 79 [77- 112] pmol/L, p < 0.0001). Natriuretic peptides levels increased with the severity of NYHA class. NT-proBNP level higher than 122 pmol/L was a cutoff value for detection of symptoms in the patients with severe aortic stenosis. Conclusion. The levels of natriuretic peptides were significantly higher in the patients with symptomatic aortic stenosis, and increased with NYHA class. Measurement of natriuretic peptides levels could be important addition to clinical and echocardiographic assessment in determing optimal timing for valve replacement in aortic stenosis

Relationship between QT dispersion and reperfusion in the acute myocardial infarction

Background. QT dispersion (QTd) represents the parameter of the expanded heterogeneity of myocard of ventricles. The aim of this study was to examine the dynamics of changes of QTd during the first 5 days of the acute myocardial infarction (AMI) in dependence to noninvasively estimated success of thrombolytic therapy. Methods. Thirty six patients with AMI were included in the study. All patients were treated with alteplaze according to rapid protocol. QTd (QTc max-QTc min) was measured immediately after the reception (0 min), after the thrombolytic therapy (90 min) and since the 2nd to the 5th day of the hospitalization. Reperfusion was estimated on the basis of electrocardiographic and biohumoral parameters. Results. In the group of 36 patients, 22 male and 11 female, both parameters of the reperfusion were not compatible in 3 patients. The other 23 patients had the reperfusion, while 10 patients did not have it. At the reception there was no significant difference of QTd between the group with reperfusion (79±34 ms) and the group without reperfusion (65±19 ms). After receiving alteplase, the average QTd in the group with reperfusion was 67±31 ms, which was not shorter in relation to the group without reperfusion (70±23 ms). Since the 2nd day of AMI, significantly smaller QTd in patients with reperfusion was not registered compared with the patients without the reperfusion (54±17 vs.73±20 ms), whereas since the 3rd day the difference became significant (46±16 vs. 87±24 ms). On the 4th day it was 43±12 vs. 78±21 ms, and on the 5th day it was 38±11 vs. 62±23 ms. On the 1st day significant difference of QTd between the groups with and without reperfusion was not registered in the group of patients with anterior AMI (0 min: 97±47 vs. 72±16; 90 min 68±47 vs. 72±20) whereas on the 2nd day it became statistically significant (51±15 vs. 74±20 on the 2nd day, 51±20 vs. 88±24 on the 3rd day, 46±10 vs. 81±19 on the 4th day and 40±8 vs. 69±22 ms on the 5th day. In the group of patients with inferolateral AMI, only on the 3rd day significant difference of QTd between the group with and the group without reperfusion was registered (43±14 vs. 69±29 ms), while in all other measuring it was not registered (0 min: 69±22 vs. 42±9; 90 min: 67±20 vs. 67±41; 55±19 vs. 60±25 on the 2nd day; 41±14 vs. 51±6 on the 4th day and 51±12 vs. 37±8 ms on the 5th day). Conclusion. Qt dispersion was of significantly shorter duration in patients with the successfully performed reperfusion in relation to the patients without the reperfusion. In patients with the anterior AMI, QTd was significantly different in patients with in relation to the patients without the reperfusion in distinction with the patients with inferolateral AMI

Does thrombolytic therapy harm or help in ST elevation myocardial infarction (STEMI) caused by the spontaneous coronary dissection?

Introduction. Spontaneous coronary artery dissection (SCAD) is a very rare disease with poor prognosis. It mainly affects young women free of risk factors for coronary artery disease (CAD) and women during the peripartum period. The prognosis for myocardial infarction caused by SCAD is poor, management is often difficult and guidelines still missing. Case report. We presented a woman with acute myocardial infarction of anterior wall of the left ventricle, caused by spontaneous dissection of medial segment of the left anterior descending coronary artery. We treated the patient with thrombolytic therapy and performed coronary angiography after that. Finally we decided to do nothing more. Two years later we performed coronary angiography again and founded the coronary artery normal. We also analyzed 19 cases publiched from 1996 to 2012 when coronary artery dissection had been treated with thrombolytic agent. Analysis revealed only one case of 19, with complication after treating SCAD with thrombolysis. Conclusion. Sometimes, regarding myocardial infarction in young women with no risk factors for CAD, especially in young women in peripartum, we should think about SCAD. The presented case, like eight others, demonstrates that good clinical outcomes can be achieved with thrombolysis. In spite of all this, we still need more data to verify that thrombolysis does not have to harm the therapy for SCAD. For the time being thrombolytic therapy could be an option