Evaluation of importance of door-to-balloon time and total ischemic time in acute myocardial infarction with ST-elevation treated with primary percutaneous coronary intervention.

The aim of the study was to evaluate the influence of door-to-balloon time and symptom onset-to-balloon time on the prognosis of patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in the Croatian Primary PCI Network. A total of 1190 acute STEMI patients treated with primary PCI were prospectively investigated in eight centers across Croatia (677 non-transferred, 513 transferred). All patients were divided according to door-to-balloon time in three subgroups (< 90, 90-180, and > 180 minutes) and according to symptom onset-to-balloon time in three subgroups (<180, 180-360, and > 360 minutes). The postprocedural Thrombolysis in Myocardial Infarction flow, in-hospital mortality, and major adverse cardiovascular events (mortality, pectoral angina, restenosis, reinfarction, coronary artery by-pass graft and cerebrovascular accident rate) in six-month follow-up were compared between the subgroups. The Croatian Primary PCI Network ensures results of treatment of acute STEMI comparable with randomized studies and registries abroad. None of the result differences among the door-to-balloon time subgroups was statistically significant. Considering the symptom onset-to-balloon time subgroups, a statistically significant difference at multivariate level was highest for in-hospital mortality in the subgroup of patients with longest onset-to-balloon time (4.5 vs. 2.6 vs. 5.7%; p = 0.04). Door-to-balloon time is one of the metrics of organization quality of primary PCI network and targets for quality improvement, but without an impact on early and six-month follow-up results of treatment for acute STEMI. Symptom onset-to-balloon time is more accurate for this purpose; unfortunately, reduction of the symptom onset-to-balloon time is more complex than reduction of the former.

Metabolic syndrome and outcome in patients with acute myocardial infarction.

The impact of the metabolic syndrome/insulin resistance syndrome (MS/IRS) on the severity and prognosis of acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) was assessed using the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) definition from 2003. A total of 385 patients having suffered acute STEMI and treated with primary PCI over a two-year period were divided into two groups (with and without MS/IRS) and compared according to the parameters of severity (clinical, laboratory, echocardiography, coronary angiography parameters and complications) and prognosis using major adverse cardiovascular events (MACE) during the six-month follow-up of acute STEMI. In comparison with control group, the MS/IRS group of patients had worse or similar results of almost all study parameters of severity (hospital days 6.5 versus 6.5, cardiogenic shock 2.9% versus 2.6%, cardiac arrest 6.8% versus 5.2%, reinfarction 0.5 versus 1.6%) and prognosis (total MACE 30.7 versus 30.7%), however, none of the differences reached statistical significance. It is concluded that the unexpected lack of such differences in MS/IRS could be due to the absence ofwaist-to-hip ratio in the definition and other open questions in metabolic syndrome in general.

Therapeutic approach in acute coronary syndrome focusing on oral therapy.

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.

[Cardiogenic shock in acute coronary syndrome--therapeutic approach]. / Kardiogeni sok u akutnom koronarnom sindromu--terapijski pristup.

AIM: Cardiogenic shock is the most serious complication of acute coronary syndromes and cause of death in 4.2-7.2% of patients with acute ST-elevation myocardial infarction (STEMI), in 2.1% of patients with acute non-ST-elevation myocardial infarction and in 2.9% of patients with unstable angina pectoris. The cardiogenic shock mortality rate of 80% in patients treated conservatively has been decreased with the introduction of primary percutaneous coronary intervention (PCI) in the treatment of STEMI. The incidence and mortality rate were assessed in patients with cardiogenic shock treated with primary PCI at Department of Cardiovascular Diseases, Sestre Milosrdnice University Hospital. PATIENTS AND METHODS: Since 2000, the emergency interventional cardiologic service has been available for 24 h at the Department. During this period, 701 patients were hospitalized with the diagnosis of STEMI, 312 of them meeting the recommended criteria, were treated with primary PCI. RESULTS: According to study results, the incidence of cardiogenic shock in STEMI patients was 8.3%. Treatment with primary PCI decreased cardiogenic shock mortality rate to 35%. CONCLUSION: Primary PCI is definitely therapy of choice in the treatment of this serious complication of acute STEMI.