Terapijski pristup kod akutnog koronarnog sindroma usredotočen na oralnu terapiju

In the light of some new information based on clinical evidence, current therapeutic approach to patients with acute coronary syndrome especially focusing on oral therapy is being considered. The initial stage of treatment does not differ greatly among patients with unstable angina pectoris (UA), non-ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI). It is necessary to simultaneously resolve a series of problems within the first twenty minutes upon admission, i.e. risk assessment, selection of treatment strategy (conservative, invasive), relief of ischemic pain, determination of hemodynamic status and elimination of any undesired complications (hypertension, tachycardia, heart failure), and administration of antithrombotic therapy. Patients suffering from STEMI require reperfusion treatment, and the method of choice is primary percutaneous coronary intervention (PCI) where available. Fibrinolytic reperfusion therapy is limited exclusively to STEMI within the first three hours from the onset of pain. Unlike this, in patients suffering from UA/NSTEMI it is necessary to make risk assessment in the early stage of disease, and thus select the patients that will certainly benefit from invasive treatment through PCI. For pain relief, the patient should be immediately administered nitroglycerin along with oxygen. Beta-blockers that are reasonably used in the initial stage of treatment during the first 24 hours, if not contraindicated, are still underused. Clopidogrel becomes an obligatory drug not only in patients having undergone PCI, but also in those treated conservatively following fibrinolysis.U svjetlu nekih novih podataka zasnovanih na kliničkim dokazima razmatra se terapijski pristup bolesnicima s akutnim koronarnim sindromom koji se osobito oslanja na oralnu terapiju. U početnoj fazi liječenja nema većih razlika u pristupu bolesnicima s nestabilnom pektoralnom anginom, infarktom miokarda bez povišenja ST segmenta (NSTEMI) ili infarktom miokarda s povišenjem ST segmenta (STEMI). Istodobno treba razriješiti niz problema unutar prvih dvadesetak minuta od prijma bolesnika: procjenu rizika, odabir strategije liječenja (konzervativno, invazivno), ublažavanje ishemijske boli, određivanje hemodinamskog statusa i uklanjanje neželjenih komplikacija (hipertenzija, tahikardija, srčano zatajenje), te davanje antitrombotske terapije. Bolesnici koji imaju STEMI zahtijevaju liječenje reperfuzijom, a metoda izbora je primarna perkutana koronarna intervencija (PCI) tamo gdje je dostupna. Fibrinolitička reperfuzijska terapija je ograničena isključivo na STEMI unutar prva tri sata od nastupa boli. Za razliku od toga, kod bolesnika s nestabilnom pektoralnom anginom/NSTEMI treba procijeniti rizik u ranom stadiju bolesti te tako odabrati one bolesnike kod kojih će invazivno liječenje pomoću PCI zasigurno biti korisno. Uz kisik bolesniku treba smjesta dati nitroglicerin radi ublažavanja boli. Primjena beta blokatora je razumna u početnoj fazi liječenja tijekom prva 24 sata, ako nisu kontraindicirani, no oni se još uvijek nedostatno primjenjuju. Klopidogrel postaje obvezatan lijek ne samo u bolesnika podvrgnutih PCI, nego isto tako u bolesnika koji se liječe konzervativno nakon fibrinolize

Novo nalazište vrste Corydalis acaulis (Wulfen) Pers. (Fumariaceae) u Hrvatskoj

In this short communication a new locality for the endemic Illyric-Adriatic floral species Corydalis acaulis (Wulfen) Pers. on the island of Vela Kluda is reported. A previously known locality (Visiani 1852) of the species in Šibenik is confirmed.U ovom kratkom priopćenju govori se o novom nalazištu endemične ilirsko-jadranske vrste Corydalis acaulis (Wulfen) Pers. na otoku Vela Kluda. Potvrđuje se otprije poznato nalazište vrste (Visiani 1852) u Šibeniku

Značenje registara akutne skrbi kardioloških bolesnika na nacionalnoj razini

Improving organization and patient care quality in intensive care units is increasingly important as intensive care unit diagnostic and therapeutic procedures account for a growing proportion of hospital services. We identified the lack of comprehensive national and international registries available in the contemporary literature. This paper aims to describe and analyze cardiac intensive care unit (CICU) network at the national level in Croatia and its comparison with more developed countries. Thirty-four representatives from all Croatian acute hospitals (response rate of 100%) filled in a web based questionnaire on CICU organization and competence during September and October 2016. Organization and available technical procedures for health care in general, and especially in very expensive CICU treatment, highly depends on gross domestic product (GDP) per capita. That is why one could expect that Croatia, with the second lowest GDP among European Union countries and 4.7 CICU per million inhabitants will have worse results in this field in comparison with most of these countries. Results such as one nurse responsible for a mean of 2.7 CICU patients, 52% of cardiologists among physicians during working hours but 37% during night shifts, 24/7 transesophageal echocardiography in only 26.5% of CICUs, one-third without therapeutic hypothermia, and 23.5% without extracorporeal membrane oxygenation treatment are some of these results, revealing much room for improvement. This representative, nationwide sample of Croatian CICUs also demonstrated considerable variation of key elements of structures with respect to hospital size, academic status and financial issues, as well as a trend towards current guidelines. This kind of investigation is very important for proposing standards, reimbursement master plan, or quality assessment of the national health system.Unaprjeđenje organizacije i kvalitete skrbi o bolesnicima u jedinicama intenzivne skrbi postaje sve važnije zbog rastućeg opsega dostupnih metoda liječenja i skrbi. Suvremena literatura ukazuje na nedostatak odgovarajućih nacionalnih i internacionalnih registara. Cilj ovog istraživanja bio je analiza organizacije jedinica intenzivne kardijalne skrbi (JIKS) u Hrvatskoj i usporedba s ekonomski razvijenijim zemljama. Liječnici iz 34 hrvatske akutne bolnice (100%-tni odgovor) ispunili su e-poštom poslan upitnik o organizaciji skrbi i metodama liječenja akutnih kardioloških bolesnika. Odgovori su prikupljeni i analizirani tijekom rujna i listopada 2016. godine. Hrvatska ima oko 5 JIKS na milijun stanovnika (raspon od 1 do 9, većinom 5-6 kreveta). Jedna medicinska sestra skrbi za prosječno 2,7 bolesnika (u jutarnjim satima za 2,3 bolesnika, u poslijepodnevnim satima 2,3 bolesnika, noću 3,3 bolesnika) uz varijabilnost ovisno o veličini bolnice (u manjim bolnicama prosječno za 2,9 bolesnika, u sveučilišnim bolnicama za 2,1 bolesnika, p<0,001). Gotovo dvije trećine JIKS sadrži manje od 4 kreveta na jednog liječnika, dok kardiolozi čine 52% liječnika tijekom radnog dana, ali samo 37% liječnika tijekom dežurstva. Utvrdili smo značajnu varijabilnost u dostupnosti ultrazvuka srca tijekom radnog dana u odnosu na dežurstvo (76,5% JIKS ima 24-satnu dostupnost transtorakalne ehokardiografije, ali samo 26,5% za transezofagusnu ehokardiografiju). Trećina ispitivanih centara nije uvela terapijsku hipotermiju, a 23,5% centara ne radi izvantjelesnu membransku oksigenaciju niti premješta bolesnike u odgovarajuće ustanove. Organizacija i dostupne metode liječenja u JIKS ovise i o bruto društvenom proizvodu. Ovo istraživanje, prvo takve vrste u Republici Hrvatskoj, ukazuje na značajnu varijabilnost ključnih dijelova zdravstvene skrbi akutnih kardioloških bolesnika ovisno o veličini bolnice, ali i ukupni trend prema postojećim smjernicama. Ukazujući na prostor za napredak, ono može poslužiti kao polazna točka u postizanju željenog standarda, planiranju financija te procjeni i praćenju kvalitete nacionalnog zdravstvenog sustava

Inhibitor aktivatora plazminogena 1 u procjeni dugoročnoga ishoda bolesnika s akutnim infarktom srca s elevacijom ST spojnice liječenih primarnom perkutanom koronarnom intervencijom [Prognostic value of plasminogen activator inhibitor 1 on long term outcome in patients with acute myocardial infarcton with ST elevation treated with primary percutaneous coronary intervention]

Prognostic value of plasminogen activator inhibitor-1 (PAI-1) in patients with acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) was not studied extensively. Patients treated for STEMI with primary PCI within Sestre milosrdnice University Hospital Centre were included in the study. Beside routine treatment, two additional blood samples were taken for PAI-1 activity analyses: first one on admission, second one 24 hours after admission. PAI-1 activity was analysed using commercial test Berichrom PAI (Siemens, Marburg, Germany). A total of 87 patients aged 61,1±12,2 were included in the study, with 71,3% males. First sample PAI-1 activity correlated with anthropometric parameters, while percental increment in second sample negatively correlated with weight, body mass index and waist and hip circumference. Difference between two measurements higher than 3,7 U/mL was significantly more prevalent in females, patients with anterior myocardial infarction and affected left anterior descending artery, acute heart failure, worse final TIMI flow, slow flow, use of thrombaspiration, higher peak creatin-kinase level, and lower body weight. Long-term outcome data was available for 84 patients. Rise in PAI-1 activity related to worse short- and long-term survival, and higher occurrence of intermediate- and long-term composite endpoint

Re-initiating professional working activity after myocardial infarction in primary percutaneous coronary intervention networks era

Objectives: To investigate the aspects of return to work, socio-economic and quality of life aspects in 145 employed patients under 60 years of age treated with primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Material and Methods: During hospital treatment demographic and clinical data was collected. Data about major adverse cardiovascular events, rehabilitation, sick leave, discharge from job and retirement, salary, major life events and estimation of quality of life after myocardial infarction were obtained after follow-up (mean: 836±242 days). Results: Average sick leave was 126±125 days. Following myocardial infarction, 3.4% of patients were discharged from their jobs while 31.7% retired. Lower salary was reported in 17.9% patients, major life events in 9.7%, while 40.7% estimated quality of life as worse following the event. Longer hospitalization was reported in patients transferred from surrounding counties, those with inferior myocardial wall and right coronary artery affected. Age, hyperlipoproteinemia and lower education degree were connected to permanent working cessation. Significant salary decrease was observed in male patients. Employer type was related to sick leave duration. Impaired quality of life was observed in patients who underwent in-hospital rehabilitation and those from surrounding counties. Longer sick leave was observed in patients with lower income before and after myocardial infarction. These patients reported lower quality of life after myocardial infarction. Conclusions: Inadequate health policy and delayed cardiac rehabilitation after myocardial infarction may lead to prolonged hospitalization and sick leave as well as lower quality of life after the event, regardless of optimal treatment in acute phase of disease

Left main stenosis: how do we treat it?

Aim: To evaluate clinical, interventional and outcome data of patients treated for left main (LM) stenosis. Patients and Methods: Study was conducted in University Hospital Centre „Sestre milosrdnice“, Zagreb. We retrospectively analyzed all coronary angiographies from June 20, 2017 until February 12, 2020. Cases were identified by a nation-wide database (Stenos). Patients with percutaneous coronary intervention (PCI) involving LM were analyzed, regardless of Medina stenosis class. Results: Out of 5537 procedures (3255 interventions, 1775 non elective), 400 procedures involved LM stenosis. PCI was performed in 235 patients. In 25 cases LM interventions were protected (excluded from further analysis). Centre yearly LM volume was 79.7, average operator LM volume was 9.9/year. Male sex was predominant (72.4%), average age was 68.6±10.3. Total of 63.8% patients presented with acute coronary syndrome (elevation 16.7%, non-elevation 33.3%, unstable angina 13.8%). Ad-hoc PCI was performed in 70.0% of cases. Stenoses involved LM in 92.4%, ostial left anterior descending artery in 59.5%, ostial circumflex artery in 44.3% patients. Bifurcation was stented in 80.5%, while 2 or more stents were used in 20.5% of all cases. Dominant bifurcation technique was provisional stenting (74.6%), followed by T and protrusion (15.4%). Proximal optimization (POT) was performed in 96.4%, which was followed by kissing in 34.7%, or strut dilatation in 10.3%, and re-POT in 57.8% of eligible patients. Intravascular ultrasound (IVUS) was used in 16.7%, coronary flow physiology in 1.4% patients. Radial access was most commonly used (83.1%; 58.6% right-sided), followed by femoral (14.9%, rightsided in 84.6%). Shock was present in 7.3% on admission, while 9.6% of the patients were resuscitated. Mechanical circulatory support (MCS) was used in 1.4%. Two patients (0.9%) required emergent surgery. In-hospital mortality was 6.2%. Follow-up was available for 75.7% patients (294 [100-474] days). Major adverse cardiovascular event was observed in 7.0% patients. Conclusion: Patient preferences, operator and centre experience, and availability of cardiac surgery impacts the decision to interventional treat LM stenosis.1 Acute presentation, radial access, ad-hoc procedures, and simple stenting technics predominate. IVUS and MCS are still underutilized