Exercise and cardiac rehabilitation in hypertensive patients with heart failure with preserved ejection fraction: A position statement on behalf of the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology.

Arterial hypertension is a major cause of cardiovascular morbidity and mortality and the most common cause of comorbidity in heart failure (HF) with preserved ejection fraction (HFpEF). As an adjunct to medication, healthy lifestyle modifications with emphasis on regular exercise are strongly recommended by both the hypertension and the HF guidelines of the European Society of Cardiology. Several long-term studies have shown that exercise is associated with a reduction in all-cause mortality, a favorable cardiac and metabolic risk profile, mental health, and other non-cardiovascular benefits, as well as an improvement in overall quality of life. However, the instructions for the prescriptive or recommended exercise in hypertensive patients and, more specifically, in those with HFpEF are not well defined. Moreover, the evidence is based on observational or small randomized studies, while well-designed clinical trials are lacking. Despite the proven benefit and the guidelines' recommendations, exercise programs and cardiac rehabilitation in patients with hypertensive heart disease and HFpEF are grossly underutilized. This position statement provides a general framework for exercise and exercise-based rehabilitation in patients with hypertension and HFpEF, guides clinicians' rehabilitation strategies, and facilitates clinical practice. It has been endorsed by the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology and is focused on the Health Care System in Greece.

Therapeutic inertia in rhythm control strategies in hospitalized patients with fibrillation: Insights from Hellenic Cardiorenal Morbidity Snapshot (HECMOS) study.

BACKGROUND: Current guidelines recommend a rhythm control strategy in patients with symptomatic atrial fibrillation (AF) while catheter ablation has been shown to be a safer and more efficacious approach than antiarrhythmic medications. METHODS: HECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. In this sub-study, we included 276 cases who had a history of AF, particularly on the rhythm strategy, and catheter ablation procedures had been performed before the index admission. RESULTS: Among 276 AF patients (mean age: 76.4 ±â€¯11.5 years, 58 % male), 60.9 % (N = 168) had persistent AF and 39.1 % (N = 108) had paroxysmal AF. Heart failure was the main cause of admission in 54.3 % (N = 145) of the patients, while 14.1 % (N = 39) were admitted due to paroxysmal AF, 7.3 % (N = 20) due to bradyarrhythmic reasons, and 6.5 % (N = 18) suffered from acute coronary syndrome. Most importantly, heart failure with reduced ejection fraction was present in 76 (27 %) patients. Only 10 patients out of the total (3 %, mean age 59.7 years) had undergone AF ablation while electrical cardioversion had been attempted in 37 (13.4 %) patients. Interestingly, in this AF population with heart failure, 3.6 % (N = 10) had a defibrillator implanted (4 single-chamber), and only 1.5 % (N = 4) had a cardiac resynchronization therapy defibrillator (CRT-D). CONCLUSION: High prevalence of persistent AF was detected in hospitalized patients, with heart failure being the leading cause of admission and main co-morbidity. Rhythm control strategies are notably underused, along with CRT-D implantation in patients with AF and heart failure.

Modern mapping and ablation of idiopathic outflow tract ventricular arrhythmias.

Outflow tract (OT) premature ventricular complexes (PVCs) are being recognized as a common and often troubling, clinical electrocardiographic finding. The OT areas consist of the Right Ventricular Outflow Tract (RVOT), the Left Ventricular Outflow Tract (LVOT), the Aortomitral Continuity (AMC), the aortic cusps and the Left Ventricular (LV) summit. By definition, all OT PVCs will exhibit an inferior QRS axis, defined as positive net forces in leads II, III and aVF. Activation mapping using the contemporary 3D mapping systems followed by pace mapping is the cornerstone strategy of every ablation procedure in these patients. In this mini review we discuss in brief all the modern mapping and ablation modalities for successful elimination of OT PVCs, along with the potential advantages and disadvantages of each ablation technique.

Myocardial infarction with non obstructive coronary arteries complicated with ventricular septal rupture: A case report and literature review.

Ventricular septal rupture represents one of the most serious complications after an acute coronary syndrome. Nowadays this condition is rare due to early revascularization, but is still associated with high mortality rate. In this case report, we present an unusual case of a woman suffering an acute myocardial infarction with normal coronary arteries complicated with a ventricular septal rupture, which required surgical correction.

Loading with Oral P2Y12 Receptor Inhibitors: To Crush or Not to Crush?

Oral P2Y12 receptor inhibitors represent a mainstay treatment in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention. In the setting of ST-elevation myocardial infarction, when early platelet inhibition is highly desirable, the onset of action of oral P2Y12 receptor inhibitors is, however, delayed, likely due to delayed drug absorption. Crushing the tablets, which are to be used for patient loading with an oral P2Y12 receptor inhibitor, has been shown to provide earlier platelet inhibition than standard, integral tablets administration. Chewed ticagrelor tablets may also result in a similar effect. Such findings should be interpreted with caution, mainly due to the small number of patients enrolled and the nature (pharmacodynamic/pharmacokinetic) of the respective studies. Furthermore, in patients with out-of-hospital cardiac arrest, who remain comatose, crushing tablets is commonly applied in clinical practice for platelet P2Y12 receptor inhibition. In this review, we focus on current evidence regarding the role of crushed P2Y12 receptor inhibitor pills, analyzing clinical scenarios where most of the promise exists along with future expectations from this type of formulation. Large randomized studies are needed to draw firm conclusions regarding the clinical benefit of 'crushing' over the usual 'not-crushing' practice.

Multicenter Randomized Evaluation of High Versus Standard Heparin Dose on Incident Radial Arterial Occlusion After Transradial Coronary Angiography: The SPIRIT OF ARTEMIS Study.

OBJECTIVES: The aim of this study was to test the hypothesis that more intensive over standard anticoagulation administered during coronary angiography would significantly reduce rates of radial artery occlusion (RAO). BACKGROUND: RAO, although silent, remains a frequent and therefore worrisome complication following transradial coronary angiography. Anticoagulation is effective in reducing RAO, but the optimal heparin dose remains ill defined. METHODS: In this multicenter, randomized superiority trial, a high dose (100 IU/kg body weight administered in divided doses) and a standard dose (50 IU/kg body weight) of heparin during 5- or 6-F coronary angiography were compared. A total of 3,102 patients were randomized, of whom 1,836 patients not proceeding to percutaneous coronary intervention and without need for arterial access crossover entered the trial. Post-catheterization hemostasis did not follow a rigid protocol. RESULTS: A total of 102 early RAOs were found on ultrasonography (incidence 5.6%). In the high-dose heparin group, the rate of RAO was significantly lower compared with the standard-dose heparin group (27 [3.0%] vs. 75 [8.1%]; odds ratio: 0.35; 95% confidence interval: 0.22 to 0.55; p < 0.001), without compromising safety. The time to achieve hemostasis was similar between groups. To avoid 1 RAO, the number of patients needed to treat in the high-dose heparin group was approximately 20. These results were corroborated by our integrated database, showing an 80% reduction of forearm artery occlusions in high versus low heparin dose patients and our updated meta-analysis of randomized controlled trials demonstrating significant benefit of higher over lower anticoagulation intensity. CONCLUSIONS: High compared with standard heparin dose significantly reduced the rate of RAO in patients undergoing coronary angiography. High-intensity anticoagulation should be considered in transradial diagnostic procedures. (High [100IU/Kg] Versus Standard [50IU/Kg] Heparin Dose for Prevention of Forearm Artery Occlusion; NCT02570243).

Acute right ventricular myocardial infarction.

INTRODUCTION: Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.

Prevention of Radial Artery Occlusions Following Coronary Procedures: Forward and Backward Steps in Improving Radial Artery Patency Rates.

Radial artery (RA) occlusion (RAO) remains the Achilles heel of transradial coronary procedures. Although of silent nature, RAO is relatively frequent, results in graft shortage for future coronary artery bypass surgery, and may occur even after short-lasting, 5F coronary angiography (CAG). The most frequent predictors of RAO are RA size, body size, female gender, and periprocedural anticoagulation intensity. Methods to detect RAO are variable, of which the Barbeau test and ultrasonography have similar diagnostic accuracy. Data indicate that late RAO recanalization may occur. Meticulous handling of RA and the use of appropriate hemostatic devices and techniques along with sufficient heparin dose appear important measures to reduce RAO rates. Recent contradictory studies indicate that the decreasing incidence of RAO overtime is not as uniform as previously thought. In 2 meta-analyses, the benefit of higher over lower anticoagulation intensity became evident. As "it may all be appropriate anticoagulation" for a simplified approach against RAO, the results of an ongoing trial comparing 100 with 50 IU/kg body weight in transradial CAG are eagerly awaited.

Radial artery as a graft for coronary artery bypass surgery in the era of transradial catheterization.

Radial artery use as a bypass conduit is well established during the past decades, in terms of both patency and safety. On the other hand, transradial catheterization causes a series of structural and functional changes to the vessel itself. Impairment of nitric oxide-dependent vasodilation and notable decrease in radial artery diameter due to intima thickening and hyperplasia, especially during the first 3 months after its cannulation, constitute some of the most important alterations on the radial artery wall and its function after a transradial coronary catheterization procedure. Given the constantly increasing numbers of these transradial catheterization procedures, the authors of this article focus on the current knowledge regarding the potential use of the radial artery as a bypass conduit, after its catheterization, also considering several possible mechanisms on its subsequent structural and functional changes.

Cardiac Biomarkers Predict 1-Year Mortality in Elderly Patients Undergoing Hip Fracture Surgery.

This prospective study included 152 elderly patients (mean age, 80 years; range, 72-88 years) with a hip fracture treated surgically. Comorbidities were evaluated, and B-type natriuretic peptide was measured at baseline and at postoperative days 4 and 5 in addition to troponin I. Major cardiac events were recorded, and 1-year mortality was assessed. Comorbidity models with the important multivariate predictors of 1-year mortality were analyzed. Overall, 9 patients (6%) experienced major cardiac events postoperatively during their hospitalization. Three patients (2%) died postoperatively, at days 5, 7, and 10, from autopsy-confirmed myocardial infarction. Three patients (2%) experienced a nonfatal myocardial infarction, and 3 patients (2%) experienced acute heart failure. At 1-year follow-up, 37 patients (24%) had died. Age older than 80 years (P=.000), renal failure (P=.016), cardiovascular disease (P=.003), respiratory disease (P=.010), Parkinson disease (P=.024), and dementia (P=.000) were univariate predictors of 1-year mortality. However, in the multivariate model, only age older than 80 years (P=.000) and dementia (P=.024) were important predictors of 1-year mortality. In all comorbidity models, age older than 80 years and dementia were important predictors of 1-year mortality. Postoperative increase in B-type natriuretic peptide was the most important predictor of 1-year mortality. Receiver operating characteristic curve analysis showed a threshold of 90 ng/mL of preoperative B-type natriuretic peptide (area under the curve=0.773, 95% confidence interval, 0.691-0.855, P<.001) had 82% sensitivity and 62% specificity to predict 1-year mortality. Similarly, a threshold of 190 ng/mL of postoperative B-type natriuretic peptide (area under the curve=0.753, 95% confidence interval, 0.662-0.844, P<.001) had 70% sensitivity and 77% specificity to predict the study endpoint. [Orthopedics. 2017; 40(3):e417-e424.].

Neutrophil Gelatinase-Associated Lipocalin as an Early Marker of Contrast-Induced Nephropathy After Elective Invasive Cardiac Procedures.

BACKGROUND: Contrast-induced nephropathy (CIN) is an acute kidney injury (AKI) defined as serum creatinine (sCr) increase 48 to 72 hours after contrast administration. Because most subjects undergoing invasive cardiac procedures are discharged within 24 hours, sCr is unsuitable for CIN detection. HYPOTHESIS: In the present study we tested the hypothesis that neutrophil gelatinase-associated lipocalin (NGAL) is superior compared with sCr and other established nephropathy markers in early CIN diagnosis after elective invasive cardiac procedures. METHODS: Serum creatinine, urine creatinine, serum cystatin C, urine albumin, urine NGAL (uNGAL), and plasma NGAL were measured at 0, 6, 24, and 48 hours after contrast administration in 100 elective invasive cardiac procedures. Estimated glomerular filtration rate and albumin-to-creatinine ratio were calculated. Changes from baseline were considered statistically significant at P < 0.05 and clinically significant when > the biomarker's reference change value. Participants were divided into those with and without clinically significant uNGAL changes (uNGAL positive and negative for AKI, respectively). RESULTS: Thirty-three individuals were uNGAL positive for AKI. Serum cystatin C changes were statistically and clinically nonsignificant in both groups. Serum creatinine and plasma NGAL were statistically but not clinically elevated 48 hours postcatheterization in the AKI group. Except for contrast volume (higher in AKI group), groups were comparable at baseline (P not significant) regarding cardiovascular risk factors, coronary heart disease, coronary interventions performed, and renal biomarkers. Baseline uNGAL was significantly correlated to estimated glomerular filtration rate and albumin-to-creatinine ratio. CONCLUSIONS: Urine NGAL is potentially superior compared with conventional nephropathy markers in early CIN diagnosis after elective invasive cardiac procedures. Definition of clinically significant uNGAL changes with reference change value is probably a valuable supplement to statistically defined significant variations.

Twenty-Four-Hour Urine α1 -Microglobulin as a Marker of Hypertension-Induced Renal Impairment and Its Response on Different Blood Pressure-Lowering Drugs.

The purpose of this study was to assess the role of urine α1 -microglobulin as a marker of hypertension-induced renal damage compared with estimated glomerular filtration rate, (eGFR), urine albumin, and urine albumin-to-creatinine ratio (ACR). Its response on different blood pressure (BP)-lowering drugs was also studied. Sixty never-treated hypertensive patients (65.0% men, 46.9 years, BP 141.4/94.0 mm Hg) were randomized to an irbesartan (an angiotensin receptor blocker [ARB]) or a diltiazem (a nondihydropyridine calcium channel blocker [CCB])-based regimen. Patients with diabetes or established cardiovascular, renal, or liver disease were excluded. Blood samples and 24-hour urine were analyzed at baseline and 6 months after pharmaceutical BP normalization. Serum creatinine was measured and eGFR was calculated. Urine albumin, creatinine, and α1 -microglobulin were measured and ACR was calculated. Minor changes (P=not significant [NS]) in eGFR were noted during follow-up in both groups (from 111.0 mL/min/1.73 m2 to 108.4 mL/min/1.73 m2 in the ARB group and from 111.3 mL/min/1.73 m2 to 114.0 mL/min/1.73 m2 in the CCB group). Twenty-four-hour urine indices were all significantly improved (P<.01) in the ARB group (albumin from 19.4 mg/L to 8.2 mg/L, ACR from 21.5 mg/g to 10.0 mg/g, α1 -microglobulin from 5.06 mg/L to 3.64 mg/L) but not (P=NS) in the CCB group (albumin from 15.6 mg/L to 13.9 mg/L, ACR from 17.6 mg/g to 17.1 mg/g, α1 -microglobulin from 4.94 mg/L to 4.79 mg/L). These differences between groups remained significant (P<.05) after adjusting for office heart rate and BP. α1 -Microglobulin was significantly correlated (P<.05) with albumin and ACR both at baseline (r=0.283 and 0.299, respectively) and at the end of follow-up (r=0.432 and 0.465, respectively) but not (P=NS) with eGFR. It was also significantly related (P<.05) to cardiovascular risk scores (Framingham and HeartScore) both at baseline (r=0.264 and 0.436, respectively) and at the end of follow-up (r=0.308 and 0.472, respectively). Urine α1 -microglobulin emerges as a potentially usable marker of hypertension-induced renal impairment. Its excretion rate and its response to treatment appears similar to that of albumin. Irbesartan but not diltiazem seems to be associated with reduced excretion of α1 -microglobulin in urine.

Effects of ranolazine on left ventricular diastolic and systolic function in patients with chronic coronary disease and stable angina.

INTRODUCTION: The present study examined the effect of ranolazine, which acts via the mechanism of selective inhibition of late INa+, on parameters of left ventricular systolic and diastolic function in patients suffering from angiographically confirmed chronic coronary artery disease, presenting with chronic stable angina. METHODS: We studied 40 patients (age 67 ± 9 years; 30 men, 10 women) with chronic coronary artery disease who reported angina symptoms on optimal medication and who were not suitable for invasive treatment. Patients were randomized to the ranolazine group (group A, 20 patients taking oral ranolazine 500 mg bid for 3 months) and the control group (group B, 20 patients who did not receive the drug). Left ventricular systolic and diastolic function was assessed echocardiographically at baseline and after the end of the three-month treatment period. Left ventricular ejection fraction by the modified Simpson's method, E and A left ventricular filling velocities, E/A ratio, deceleration time (DT) of E, isovolumic relaxation time (IVRT), E and A waves, and the E/E ratio were measured using 2-dimensional echocardiography, Doppler and tissue Doppler imaging (TDI). RESULTS: Group A patients demonstrated a clear improvement of their initial angina symptoms. There were no adverse effects from ranolazine requiring withdrawal from the study. There was no statistically significant change in left ventricular systolic function in either group. A statistically significant change was seen in indexes of diastolic function measured using both conventional Doppler and TDI in Group A patients compared with Group B patients after three months' ranolazine treatment period. The changes in left ventricular diastolic function indexes in Group A patients were as follows: E 0.58 ± 0.11 vs. 0.76 ± 0.12 m/s, p<0.001; A 0.71 ± 0.22 vs. 0.83 ± 0.19 m/s, p<0.001; E/A 0.81 ± 0.14 vs. 0.97 ± 0.17, p<0.005; 5.4 ± 0.7 vs. 6.8 ± 0.9 cm/s, p<0.005; 7.2 ± 0.8 vs. 8.3 ± 1.1 cm/s, p<0.005; E/ 10.7 ± 1.1 vs. 11.1 ± 0.8, p=ns; DT 251 ± 14 vs. 226 ± 17 ms, p<0.004; IVRT 95 ± 11 vs. 74 ± 9 ms, p<0.001. Systolic function did not change: EF 46.3 ± 3.4 vs. 46.7 ± 2.7%, p: ns. CONCLUSIONS: The use of ranolazine in patients suffering from chronic coronary artery disease has a favorable impact on diastolic function parameters. Accordingly, a clinical benefit could be observed due to an improvement in patients' symptoms.

B-type natriuretic peptide vs. cardiac risk scores for prediction of outcome following major orthopedic surgery.

AIMS: The clinical role of B-type natriuretic peptide (BNP) in preoperative evaluation is not clear. We designed a prospective study to investigate the predictive value of BNP in comparison with established clinical risk scores for the outcome of major orthopedic surgery. METHODS: Overall 242 elderly patients [80 (74-85) years] undergoing orthopedic surgery were included. Inhospital cardiovascular events and 1-year mortality were the main endpoints. RESULTS: In total 20 (8.3%) patients had major cardiovascular events (MACE) and 41 (21.1%) died in 1 year. Logistic regression analysis for prediction of cardiac events and 1-year mortality, respectively, revealed a significant prognostic value for the BNP (P < 0.001 and P = 0.041), Goldman (P = 0.013 and P = 0.003), Lee (P = 0.022 and P = 0.200), Detsky (P < 0.001 and P < 0.001), and functional capacity indices (P = 0.034 and P = 0.001). BNP cutoff 149 ng/ml improved discrimination of all scores to predict MACE, and BNP cutoff 89 ng/ml improved discrimination of all scores to predict 1-year mortality (Net Reclassification Improvement, P values < 0.05 in all cases). Age [hazard ratio (HR): 1.100, 95% confidence interval (CI): 1.039-1.166, P = 0.001] and BNP (HR: 1.002, 95% CI: 1.000-1.003, P = 0.041) were independent associates of 1-year mortality. CONCLUSION: Preoperative levels of BNP compare favorably with the Goldman, Lee, Detsky, and functional capacity indices for prognosis of orthopedic surgery. Implementation of natriuretic peptides in cardiac risk scores is promising.

Neurophil gelatinase-associated lipocalin as a new biomarker in laboratory medicine.

Neutrophil gelatinase-associated lipocalin (NGAL) is a 25 kDa protein of the lipocalin superfamily. This protein is expressed and secreted by immune cells, hepatocytes, and renal tubular cells in various pathologic states. NGAL has recently generated great interest as an early biomarker of renal injury. However, like many other endogenous biomarkers it is not produced by just one cell type and it exists in more than one molecular form. As recent research has shown different pathological conditions may involved in the production of this molecule. This review summarizes the current knowledge about the biology of NGAL and examines the role of this molecule of acute renal injury as well as in other pathologic conditions like neoplasia, anemia, pregnancy, cardiovascular disease chronic kidney disease and in cardiorenal syndrome. Commercial and research immunoassays are used to measure NGAL in both plasma and urine but these assays are not standardized. The existence of different molecular forms of NGAL and their expression at various disease states further complicates the interpretation of the results. Pre analytical issues and biological variation are also not fully elucidated.

Neutrophil gelatinase-associated lipocalin in acute kidney injury.

Acute kidney injury (AKI) is recognized as an independent risk factor for morbidity and mortality. Unfortunately, this syndrome was historically underdiagnosed due to inconsistent definition of AKI as well as insensitive and nonspecific diagnostic tools. Recent advances in defining AKI, understanding its pathophysiology, and improving its diagnostic accuracy have an impact in disease management and clinical outcome. Prompt recognition and treatment of AKI still remains the cornerstone of clinical management of this syndrome. This chapter focuses on the recent advances in diagnosis of AKI using novel serum and urine biomarkers. The role of neutrophil gelatinase-associated lipocalin (NGAL) in pathophysiology and diagnosis of AKI is presented. A detailed analysis of the biology of NGAL and presentation of laboratory methods of measurement is also provided. The role of NGAL as biomarker beyond the boundaries of nephrology is also presented.

Serum levels of gelatinase associated lipocalin as indicator of the inflammatory status in coronary artery disease.

Background. Atherosclerosis is a chronic inflammatory disease and the acute clinical manifestations represent acute on chronic inflammation. Neutrophil gelatinase-associated lipocalin (NGAL) is found in the granules of human neutrophils, with many diverse functions. The aim of this study was to evaluate the hypothesis that levels NGAL in blood may reflect the inflammatory process in various stages of coronary artery disease. Methods. We studied 140 patients, with SA 40, UA 35, NSTEMI 40, and STEMI 25, and 20 healthy controls. Serum NGAL was measured upon admission and before coronary angiography. Results. Significant differences were observed in median serum-NGAL(ng/mL) between patients with SA (79.23 (IQR, 37.50-100.32)), when compared with UA (108.00 (68.34-177.59)), NSTEMI (166.49 (109.24-247.20)), and STEMI (178.63 (111.18-305.92)) patients and controls (50.31 (44.30-69.78)) with significant incremental value from SA to STEMI. We observed a positive and significant correlation between serum-NGAL and hs-CRP (spearman coefficient rho = 0.685, P < 0.0001) as well as with neutrophil counts (r = 0.511, P < 0.0001). Conclusions. In patients with coronary artery disease serum levels of NGAL increase and reflect the degree of inflammatory process. In patients with acute coronary syndromes, serum levels of NGAL have high negative predictive value and reflecting the inflammatory status could show the severity of coronary clinical syndrome.

Brain natriuretic peptide: a marker of cardiac dysfunction with ventricular or dual-chamber pacing.

BACKGROUND/OBJECTIVES: The inability of trials to exhibit the superiority in survival of atrioventricular compared to ventricular pacing can be partially explained by the apical stimulation of the right ventricle, which adversely affects both short- and long-term ventricular performance. We evaluated the impact of pacing mode (DDDR vs. VVIR) on the brain natriuretic peptide (BNP) level in patients with sick-sinus syndrome (SSS). METHODS: Sixty-seven patients were treated with DDDR pacemaker implantation due to SSS. They were randomized during the first post-implant day either to DDDR or WIR pacing mode and were reevaluated after 30 days. Group A comprised 35 patients on DDDR pacing mode and group B 32 patients on WIR pacing mode. Peripheral blood samples were drawn for BNP measurement at the time of randomization and one month later. RESULTS: BNP levels increased significantly in both groups at 30 days (group A: 85.6 +/- 29.5 pg/ml to 107.2 +/- 34.6 pg/ml, group B: 82.7 +/- 27.6 pg/ml to 253.1 +/- 60.2 pg/ml). On day 30, BNP levels in group B were significantly higher than in group A (P < 0.0001). CONCLUSIONS: Pacing from the apex of the right ventricle provokes an increase in the BNP levels regardless of the pacing mode. BNP is probably a very early marker predicting the structural and/or functional heart changes after long-term pacing from the apex of the right ventricle.

Rapid desensitisation of patients with aspirin allergy who undergo coronary angioplasty.

INTRODUCTION: Although aspirin is the cornerstone of medication in patients with coronary artery disease, a minority of these patients have aspirin sensitivity. The aim of this study was to evaluate the efficacy and safety of an aspirin desensitisation protocol in patients scheduled for coronary angioplasty and stenting. METHODS: We used a challenge-desensitisation protocol in 11 patients (6 men, mean age 56 ± 9.6 years) who reported allergy to aspirin and were to undergo percutaneous coronary intervention with stent implantation. Eight had a history of cutaneous sensitivity, 1 had rhinitis, 1 reported urticaria and rhinitis, while another patient showed a respiratory response in the form of an asthma attack after taking aspirin in the past. Eight successive doses of aspirin were given (0.1, 0.3, 10, 30, 40, 81, 162, 325 mg) at intervals of 15-25 min over a total period of 2 h 15 min. RESULTS: All patients with aspirin sensitivity completed the desensitisation therapy successfully, without adverse effects, and subsequently underwent angioplasty and stenting. During follow up, the patients continued to take aspirin over 6-19 months without any problems. CONCLUSIONS: Rapid aspirin desensitisation is an effective and safe procedure for patients with aspirin allergy who are to undergo coronary angioplasty and stenting, allowing them to receive the optimum treatment.