Therapeutic hypothermia and neurological outcome after cardiac arrest.

INTRODUCTION/AIM: The most important clinically relevant cause of global cerebral ischemia is cardiac arrest. Clinical studies showed a marked neuroprotective effect of mild hypothermia in resuscitation. The aim of this study was to evaluate the impact of mild hypothermia on neurological outcome and survival of the patients in coma, after cardiac arrest and return of spontaneous circulation. METHODS: The prospective study was conducted on consecutive comatose patients admitted to our clinic after cardiac arrest and return of spontaneous circulation, between February 2005 and May 2009. The patients were divided into two groups: the patients treated with mild hypothermia and the patients treated conservatively. The intravascular in combination with external method of cooling or only external cooling was used during the first 24 hours, after which spontaneous rewarming started. The endpoints were survival rate and neurological outcome. The neurological outcome was observed with Cerebral Performance Category Scale (CPC). Follow-up was 30 days. RESULTS: The study was conducted on 82 patients: 45 patients (age 57.93 +/- 14.08 years, 77.8% male) were treated with hypothermia, and 37 patients (age 62.00 +/- 9.60 years, 67.6% male) were treated conservatively. In the group treated with therapeutic hypothermia protocol, 21 (46.7%) patients had full neurological restitution (CPC 1), 3 (6.7%) patients had good neurologic outcome (CPC 2), 1 (2.2%) patient remained in coma and 20 (44.4%) patients finally died (CPC 5). In the normothermic group 7 (18.9%) patients had full neurological restitution (CPC 1), and 30 (81.1%) patients remained in coma and finally died (CPC 5). Between the two therapeutic groups there was statistically significant difference in frequencies of different neurologic outcome (p = 0.006), specially between the patients with CPC 1 and CPC 5 outcome (p = 0.003). In the group treated with mild hypothermia 23 (51.1%) patients survived, and in the normothermic group 30 (81.1%) patients died, while in the group of survived patients 23 (76.7%) were treated with mild hypothermia (p = 0.003). CONCLUSION: Mild therapeutic hypothermia applied after cardiac arrest improved neurological outcome and reduced mortality in the studied group of comatose survivors.

Effects of tirofiban and percutaneous coronary intervention in an old patient with acute myocardial infarction and cardiogenic shock.

A 75 year old man presented in our institutition with acute inferoposterior and right ventricular ST-segment elevation myocardial infarction and cardiogenic shock, 40 minutes after the pain onset. He was pretreated with 300 mg of aspirin, 600 mg of clopidogrel, and was taken to the catheterization laboratory. Door to needle time was 35 minutes. Primary percutaneous coronary intervention with bare-metal stent implantation first in infarct related right coronary artery, with subsequent high-bolus dose (25 microg/kg) tirofiban, and then in suboccluded RCx were done. The procedures were done during the cardio-pulmo-cerebral reanimation because of relapsing ventricular fibrillation, with final TIMI 3 coronary flow established. Subsequently, intraaortic balloon pump was inserted Echocardiography taken on the second day showed globaly hypokinetic left ventricle, with 10% ejection fraction and competent valves. During the next three weeks of hospital follow-up, there were no major adverse cardiac events, a transient azotemia and fall in hemoglobin concentration without major bleeding, and no episodes of severe thrombocytopenia were recorded. After six months, the patient was without chest pains, 2/3 class according to the New York Heart Association, without major adverse events, and echocardiographic left ventricular ejection fraction increment for 30%.

[The relationship between C-reactive protein and subclinical carotid arteriosclerosis in military pilots].

BACKGROUND/AIM: Inflammation plays a key role in the physiopathology of arteriosclerosis. C-reactive protein (CRP) and common carotid artery intima-media thickness are independent predictors of cardiovascular events and diabetes mellitus in apparently healthy men, but relationship between them is not fully elucidated. The aim of the study was to assess the cross-sectional relationship between CRP and cardiovascular risk factors with common carotid artery intima-media thickness in military pilots as representatives of healthy men. METHODS: We studied 161 military pilots (age 38 +/- 6 years) free of cardiovascular disease and diabetes mellitus. Traditional and metabolic risk factors were determined. Plasma CRP was measured by immunonephelometry. The common carotid artery intima-media thickness was measured by ultrasonography in the posterior wall of both common carotid arteries. RESULTS: A total of 66.5% subjects had common carotid artery intima-media thickness > 0.9 mm (p < 0.01). The mean CRP plasma concentration was significantly higher in the subjects with common carotid artery intima-media thickness > 0.9 mm than in those with common carotid artery intima-media thickness < or = 0.9 mm. In a simple regression analysis age adjusted CRP was associated with common carotid artery intima-media thickness (beta = 0.285, p < 0.01), and only high density lipoprotein cholesterol was not associated with common carotid artery intima-media thickness. The association between CRP and common carotid artery intima-media thickness remained highly significant after controlling for body mass index, blood pressure, total cholesterol, low density lipoprotein cholesterol, triglycerides, glycosylated hemoglobin and smoking (p < 0.01). Controlling for glucose, triglycerides to high density lipoprotein cholesterol ratio, and total cholesterol to high density lipoprotein cholesterol ratio resulted in some reduction in the strength of the association, but including waist circumference in the regression made the relationship no longer significant (p = 0.119). Body mass index (beta = 0.352; p < 0.01), total cholesterol to high density lipoprotein cholesterol ratio (beta = 0.334; p < 0.01) and age (beta = 0.190; p = 0.036) were the independent predictors of common carotid artery intima-media thickness. CONCLUSIONS: In the studied group of healthy men CRP per se is not an independent predictor of early arteriosclerosis, and may mediate the effect of certain traditional risk factors, especially visceral obesity, on promoting aterogenesis.

[Late stent thrombosis].

INTRODUCTION: Late stent thrombosis is a serious complication after stent implantation and it can lead to the development of acute myocardial infarction or death. A CASE REPORT: A 43-year-old patient was admitted to our clinic to coronary care unit. He was diagnosed with acute ST elevation myocardial reinfarction of inferoposterior localization and with right ventricular myocardial infarction. Eighteen months ago, he had acute myocardial infarction of the same localization, and at the same time, PCI (Percutaneous Coronary Intervention) was performed in acute phase, and two bare metal stents were implanted. Now, the patient had chest discomfort two hours before admittance, and PCI was performed once again in acute phase. The diagnostic coronarography resulted in occlusion of the right coronary artery, on the spot of the previously implanted stents. After the passage of guidewire, the artery was recanalized, and defects of artery opacification, which might have been thrombs, were noticed. The thrombs were seen on the spots of earlier implanted stents and in the posterior inteventricular and posterolateral branches of the right coronary artery. PTCA was performed and the patient received the GP IIb/IIIa antagonist therapy after which the control coronarography showed minimal defects of artery opacification, with good anterograde flow. After complete treatment the patient was in good condition. CONCLUSION: Late stent thrombosis, although not very often, is a very serious complication and can lead to death or acute myocardial infarction. To prevent it, it is necessary that the patient receives dual antiplatelet therapy, and that PCI procedure is performed technically correctly (suitable stent dimensions and proper stent expansion).

[The significance of coronary collateral circulation in the preservation of myocardial function].

INTRODUCTION: After occlusion or subocclusion of the blood vessels, myocardial perfusion is maintained through the collateral vessels. There are two mechanisms of vessel formation: arteriogenesis and angiogenesis. The term arteriogenesis describes the growth of the existing collaterals into mature arteries. On the other hand, angiogenesis, is a process of developing new blood vessels from the preexisting ones. Collateral blood vessels have many functional roles. If they are adequately developed, they can protect the myocardium from ischemic injury. Even when a total occlusion develops, regional left ventricular motility is better in segments with developed collateral circulation. In patients with well-developed collaterals, who experience coronary artery occlusion, often there is no evidence of myocardial infarction in the area of the occluded artery. Well-developed collaterals reduce the risk of unstable cardiac events. CASE REPORT: A case of right coronary artery occlusion with good collateral circulation and preserved myocardial left ventricular motility is presented. After coronary stent implantation, the patient was asymptomatic, and the maximal stress test for myocardial ischemia was negative. CONCLUSION: Despite coronary vessel occlusion, collateral blood flow maintains the pump function of the left ventricle.

[Our experiences with therapeutic hypothermia].

INTRODUCTION: The single most important clinically relevant cause of global cerebral ischemia is cardiac arrest. The estimated rate of sudden cardiac arrest is between 40 and 130 cases per 100.000 people per year. Almost 80% of patients initially resuscitated from cardiac arrest remain comatose for more than one hour. One year after cardiac arrest only 10-30% of these patients survive with good neurological outcome. The ability to survive anoxic no-flow states is dramatically increased with protective and preservative hypothermia. The results of clinical studies show a marked neuroprotective effect of mild hypothermia in resuscitation. MATERIAL AND METHODS: In our clinic, 12 patients were treated with therapeutic hypothermia. A combination of intravascular and external method of cooling was used according to the ILCOR (International Liaison Committee on Resuscitation) guidelines. The target temperature was 33 degrees C, while the duration of cooling was 24 hours. After that, passive rewarming was allowed. All patients also received other necessary therapy. RESULTS: Six patients (50%) had a complete neurological recovery. Two patients (16.6%) had partial neurological recovery. Four patients (33.3%) remained comatose. Five patients (41.66%) survived, while 7 (58.33%) patients died. The main cause of cardiac arrest was acute myocardial infarction (91.6%). One patient had acute myocarditis. CONCLUSION: Mild resuscitative hypothermia after cardiac arrest improves neurological outcome and reduces mortality in comatose survivors.

[The use of low molecular weight heparins in patients with acute ST-elevated myocardial infarction].

UNLABELLED: INTRODUCTION According to the published guidelines for the management of acute coronary syndromes (ACS), treatment of acute ST-elevated myocardial infarction is based on rapid revascularization, either mechanical or pharmacological. Pharmacological revascularization consists of fibrinolytic therapy with antiplatelet and anticoagulant therapy. In regard to the anticoagulant therapy, low molecular weight heparins (LMWHs) are of special importance. LMWHs cause less complications (bleeding, thrombocytopenia, better bioviability) in comparison with unfractionated heparin (UFH). Some studies on use of LMWHs in ACS, show that LMWHs are equally efficient and safe as UFH, causing less complications (different types of hemorrhagic complications) (ESSENCE, TIMI 11B (enoxaparin), FRAXIS-fraxiparin), whereas some studies show better efficacy and safety of enoxaparin in therapy of acute ST-elevated myocardial infarction (ASSENT 3, ASSENT 3 PLUS, HART II, AMI-SK). INCLUSION CRITERIA: acute anterior myocardial infarction with ST-elevation, first myocardial infarction, no other structural heart defects, no signs of cardiogenic shock. Our study included 30 patients receiving fibrinolytic therapy with streptokinase, antiplatelet therapy and LMWH during 6 days, and 30 patients receiving UFH instead of LMWH. The follow-up period lasted for 6 months. RESULTS: Significantly more patients receiving unfractionated heparin presented with major adverse cardiac events (73.3%) in regard to patients in the study group (44.2% nadroparin, 39.8% enoxaparin) (p = 0.025). In the group receiving UFH, 6.7% patients had hemorrhagic complications, while none of patients receiving LMWHs. An equal number of patients died. CONCLUSION: Patients who were treated with LMWHs experienced less major adverse cardiac events and lower mortality. None suffered from hemorrhagic complications.

[Atypical presentation of right coronary artery occlusion].

INTRODUCTION: Inferior wall myocardial infarctions are usually benign and uncomplicated and rarely result in ventricular disturbances of the heart rhythm. An unusual presentation of an inferior acute myocardial infarction (AMI) with atypical symptoms, and ventricular tachycardia is described. CASE REPORT: A 44-year-old patient was admitted to the coronary care unit (CCU) due to atypical chest pain during exercise and ECG abnormalities in leads L2, L3 and aVF. On admission, ECG could mimic myocarditis, pericardial effusion, left anterior bundle branch block or early repolarization. Two-dimensional echocardiography revealed a hypertrophic myocardium without abnormal regional wall motion, good left ventricular function and ejection fraction of 65%. The presumptive prediction of a culprit artery based on the ECG recorded on admission was conclusive for inferior AMI. Fibrinolytic therapy was started 3 hours after the onset of chest pain. Resolution of ST segment elevation and relief of chest pain occurred within one hour of the infusion. On the fifth day after admission, the patient had a nonsustained ventricular tachycardia (VT) which was resolved with amiodarone. Angiography showed acute occlusion of the mid portion, right coronary artery (RCA) and collateral circulation in the distal portion. DISCUSSION AND CONCLUSION: Malignant ventricular arrhythmias can result from isolated inferior wall AMI, but literature reports on this phenomenon are rather rare. Collateral circulation can prevent myocardial ischemia and preserve myocardial function, but does not provide protection against exercise-induced myocardial ischemia.

[Telemedicine and cardiology]. / Telemedicina i kardiologija.

INTRODUCTION: Telecommunications and information technology provide clinical care at distance by means of telemedicine. Hospitals and other health care facilities use medical telemetry devices for monitoring patients' vital signs. These portable devices are used for measuring patient vital signs such as ECG, blood pressure, heart rate, respiration, capnography (CO2) and other important parameters and then transmit these information to a remote location using a nearby receiver. APPLICATION OF TELEMETRY: Eliminating the need for wired connection with the patient, monitors allow, otherwise bedridden patients to be mobile, which shortens the recovery time. Wireless technology is also useful in the emergency care units, because emergency physicians need not leave their patients while consulting a handheld wireless device. This equipment also enables a paramedic to communicate with emergency physicians for early assessment, well before patients' arrive in hospital. TELEMEDICINE: Certain types of medical telemetry devices may be used in home conditions. Telemetry can provide monitoring and home health care services at distance, using advanced telecommunications and information technology in patients with reasonably stable, but a severe, chronic, difficult condition and caring home environment. This information can enable health-care providers to effectively manage treatment without need for acute emergency treatment and hospitalization. CONCLUSION: Hospitals worldwide are under constant pressure to decrease healthcare cost and to improve treatment outcome. Telemedicine and home health care may be one of the solutions for the problem.