[Deficits in lipid lowering therapy and achieving target lipid concentrations in patients with high risk of a cardiovascular event]. / Rezervy v hypolipidemické terapii a dosazení cílových koncentrací lipidu u pacientu s vysokým rizikem kardiovaskulárních príhod.

Lipid concentrations were analysed in 529 consecutive patients, 190 females (34%) and 339 males (66%) with mean age 66 years, at high cardiovascular risk, undergoing elective coronary angiography between 1st January and 31st May 2010. LDL-cholesterol level < 2,5 mmol/l was identified only in 36% of patients in primary prevention, LDL-cholesterol level < 2,0 mmol/l was identified only in 28% of subjects in secondary prevention of cardiovascular events. The study proves inadequate control of dyslipidaemia in patients at high cardiovascular risk.

[Spontaneous dissection of the left main coronary artery. Case report]. / Spontánní disekce kmene levé vencité tepny. Kazuistika.

The case report of a 59 years old woman present with spontaneous dissection of the left main coronary artery including origins of its major branches is described here. The patient had emergency surgery and a triple ACEG was performed. The postoperative course was uneventful and a control angiogram proved both complete graft patency and absence of previous dissection. Six months following surgery the patient is doing well except for a minor effort dyspnea. The available literary experience with this rare and potentially fatal coronary condition is discussed in comments.

Local changes in the plasma endothelin level in the coronary artery immediately after percutaneous transluminal coronary angioplasty.

Endothelin plays an important role in cardiovascular pathology. As one of the most important endothelium-derived vasoconstrictor substances, endothelin together with endothelium-derived vasodilating factor control vascular tone and contribute to the vasoconstrictory response if the production of endothelium-derived vasodilating factor is impaired. The aim of the study was to assess the changes of the local endothelin level in coronary circulation immediately after percutaneous transluminal coronary angioplasty (PTCA). Plasma endothelin levels were measured in blood samples from the peripheral vein and ostium of the coronary artery before the angioplasty, and from the distal coronary artery just beyond the dilated segment and the peripheral vein immediately after the procedure. The plasma endothelin level was significantly higher in the ostium of the coronary artery already prior to PTCA as compared to the peripheral vein (10.9 +/- 3.4 vs. 7.2 +/- 2.1 pg/ml, p < 0.005). There was no change in the endothelin level in the coronary artery distal to the dilated segment immediately after the procedure as compared to the initial level, although this level was higher than the postangioplasty venous level (9.8 +/- 2.9 vs. 7.7 +/- 2.0 pg/ml, p < 0.005). Individual changes in coronary-artery plasma endothelin levels as a response to coronary angioplasty were disparate. An increase and a decrease in coronary artery plasma endothelin levels by more than 2 pg/ml after coronary angioplasty were observed in 3 and 6 subjects, respectively. In conclusion, increased plasma endothelin levels were found in blood samples drawn from the coronary artery as compared to the peripheral vein. There was no further change in the plasma endothelin level in the coronary artery distal to the dilated segment after angioplasty; however, the individual responses were disparate.

Changes in proximal and distal coronary artery diameter during atrial pacing-induced myocardial ischemia.

BACKGROUND: The present study was designed to evaluate the role of tachycardia-induced dynamic coronary artery diameter changes in the development of myocardial ischemia. METHODS: Coronary angiography at rest and during atrial pacing-induced myocardial ischemia was performed in 22 patients. The diameter of the proximal and the corresponding distal coronary artery segments at rest and during pacing was measured using quantitative coronary angiography. Plasma levels of noradrenaline, adrenaline, dopamine and endothelin were determined in a subset of 14 patients in blood drawn from aorta and coronary sinus at rest and during pacing. RESULTS: Luminal diameter in normal proximal and distal segments increased, respectively, from 2.93 +/- 0.34 and 1.40 +/- 0.04 mm at rest to 3.03 +/- 0.25 and 1.58 +/- 0.07 mm during atrial pacing. The diameter of the proximal coronary artery segments with significant concentric stenosis decreased from 1.28 +/- 0.4 mm at rest to 0.95 +/- 0.34 mm during pacing, whereas segments with either significant eccentric or non-significant stenosis did not change significantly. A correlation was found between the noradrenaline level in the coronary sinus and the distal coronary artery diameter. CONCLUSIONS: A decrease in diameter of coronary artery segments with concentric stenosis during tachycardia might contribute to the development of myocardial ischemia. Some of the dynamic coronary artery changes may be influenced by the plasma level of noradrenaline. No evidence was found to suggest that dynamic changes in the diameter of proximal segments are related to the changes in diameter of the corresponding distal segments.

Results of a national survey on anticoagulation for PTCA.

In order to assess the current practice patterns in the United States for anticoagulation during PTCA, a survey was sent to the ACC membership. A total of 377 surveys from physicians performing PTCA were tabulated; 5 (1.3%) respondents performed < 20 PTCAs/year, 128 (34.0%) performed 20-75 PTCAs/year, 141 (37.4%) performed 75-150 PTCAs/year, 98 (26.0%) performed > 150 PTCAs/year and 5 (1.3%) did not report their volume. Seventy-eight (20.7%) were at university hospitals 153 (40.6%) were at other teaching hospitals, 142 (37.7%) were at non-teaching hospitals and 4 (1.1%) did not report their institutional affiliation. A total of 76.8% of respondents routinely started with a 10,000 U bolus of heparin, while only 3.2% of respondents used only a weight-adjusted heparin bolus. Fifty-nine percent of respondents routinely used intra-procedure heparin infusions, usually 1000 U/hr. Anticoagulation monitoring was used by 92.6% of respondents during PTCA, almost always activated clotting times (ACTs). Of the 335 physicians who used ACTs to guide heparin therapy during PTCA, 59.1% used the Hemochron device, 16.7% used the HemoTec device, and 24.2% did not know which machine they used. Lower volume operators and operators at non-teaching hospitals were more likely not to know the type of ACT machine used. Post-procedure heparin infusions (usually titrated to an aPTT > 2 x control) were used by 70.3% of respondents. Lower volume operators were more likely to use post-procedure heparin infusions. Thus, heparin therapy for PTCA continues to be largely empiric, although the vast majority of cardiologists surveyed use ACT-guided heparin therapy for the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Endothelin concentrations in coronary sinus during atrial pacing-induced myocardial ischemia.

To investigate the possible role of endothelin in coronary vasoconstriction contributing to the development of myocardial ischemia, plasma endothelin concentrations at rest and during atrial pacing-induced myocardial ischemia have been measured in blood samples drawn from the aorta and coronary sinus in 12 patients with significant narrowing of the left anterior descending coronary artery. The plasma endothelin concentrations at rest were similar in the aorta (AO/R) and coronary sinus (CS/R) (4.8 +/- 2.4 and 4.5 +/- 1.7 pg/ml, respectively), the difference between coronary sinus and aorta plasma endothelin concentration (CS/R-AO/R) being -0.3 +/- 1.7 pg/ml. During atrial pacing-induced myocardial ischemia aortic plasma endothelin concentration (AO/P) did not change (4.6 +/- 2.6 pg/ml) and only an insignificant increase in the plasma endothelin concentration in the coronary sinus (CS/P) was observed (5.3 +/- 2.8 pg/ml). The difference between coronary sinus and aortic endothelin plasma concentration (CS/P-AO/P) was 0.6 +/- 2.5 pg/ml. Finally, the difference in endothelin concentrations between coronary sinus and aorta rose only insignificantly during pacing as compared to the resting values ([CS/P-AO/P]-[CS/R-AP/R] being 0.9 +/- 3.2 pg/ml). Thus, atrial pacing-induced myocardial ischemia in patients with significant left anterior descending coronary artery stenosis was not accompanied by significant changes in coronary sinus plasma endothelin concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical picture of various types of inferior myocardial infarcts. Clinico-electrocardiographic study]. / Klinický obraz u ruzných typu spodních infarktu myokardu. Klinicko-elektrokardiografická studie.

In the submitted study the authors evaluate the relationship of the clinical course in patients with inferior myocardial infarction (AIM) in relation to the electrocardiographic (ECG) finding in standard and dextro-lateral leads. In a group of 96 patients (mean age 65 +/- 10 years, 66 men and 30 women) according to the ECG 38 had an isolated inferior AIM (group 1), 28 had signs of extension of the inferior AIM to the posterior wall of the left ventricle (group 2) and 30 patients in group 3 had an extension of the inferior AIM to the right ventricle, i.e. an infarction of the right ventricle. All three groups differed significantly as regards the extent of the AIM according to creatine kinase values (7.1 +/- 4.4 and 18.2 +/- 7.2 resp. and 24.8 +/- 11.6 resp.), as regards mortality (0 and 14% and 37% resp.). In group 2, contrary to the other groups, the significantly most frequent complication was pulmonary oedema (36%) and ventricular tachycardia (30%) and in group 3 the significantly most frequent complication was cardiogenic shock (30%) and advanced atrioventricular block (50%). The cause of death in these patients with infarctions of the right ventricle was cardiogenic shock (n = 6), cardiac rupture (n = 3) and electromechanical dissociation (n = 2). A total of 29 (30%) patients with inferior AIM were treated by temporary pacing: in group 1 21%, in group 2 14% and in group 3 57%. The prognosis of these patients was favourable in groups 1 and 2 (1 of 12 patients died) while in group 3 with infarctions of the right ventricle 9 of 17 patients died (p < or = 0.001). The authors found moreover that patients with precordial depression of the ST segment and inferior AIM have, as compared with patients without this depression, significantly higher creatine kinase values (12.5 +/- 5.5 vs. 5.2 +/- 1.3 mu kat; p < or = 0.001) and a higher general incidence of complications. Patients with inferior AIM are thus a non-homogeneous group from which we can differentiate, based on standard ECG examination and by recording right-sided thoracic leads, patients with an increased risk and start specific treatment in time.

[Occurrence and prognosis of silent ischemia]. / Výskyt a prognóza nemé ischémie.

The authors assessed in a group of 486 asymptomatic middle-aged men (50-60 years) the prevalence of silent myocardial ischaemia. For screening they used the exercise test on a bicycle ergometer and in men with a positive test the presence of silent ischaemia was confirmed by perfusion scintigraphy with thallium-201 or by. The prevalence of silent ischaemia was compared with the incidence of angina angiography, myocardial infarction and sudden deaths in a similar group of 1419 men followed up for 10 years in the same department. In patients with a confirmed diagnosis of silent ischaemia the prognosis was monitored, as well as possible clinical manifestations of IHD, in the course of 4-7 years of the investigation. The presence of silent ischaemia was confirmed in 32 men, i.e. 6.6%. As compared with other forms of IHD, silent ischaemia was detected almost equally frequently as myocardial infarction and as compared with angina pectoris it was observed twice as frequently. In the course of the investigation period two patients were subjected to a revascularization (CABC or PTCA). In the remaining group of 30 patients who underwent conservative treatment two patients died (sudden deaths), seven developed angina and five myocardial infarctions (incl. one clinically silent).