Feasibility of Coronary Access in Patients With Acute Coronary Syndrome and Previous TAVR.

OBJECTIVES: The aim of this study was to characterize the feasibility of coronary angiography (CA) and percutaneous coronary intervention (PCI) in acute settings among patients who have undergone transcatheter aortic valve replacement (TAVR). BACKGROUND: Impaired coronary access after TAVR may be challenging and particularly in acute settings could have deleterious consequences. METHODS: In this international registry, data from patients with prior TAVR requiring urgent or emergent CA were retrospectively collected. A total of 449 patients from 25 sites with acute coronary syndromes (89.1%) and other acute cardiovascular situations (10.9%) were included. RESULTS: Success rates were high for CA of the right coronary artery (98.3%) and left coronary artery (99.3%) and were higher among patients with short stent-frame prostheses (SFPs) than in those with long SFPs for CA of the right coronary artery (99.6% vs 95.9%; P = 0.005) but not for CA of the left coronary artery (99.7% vs 98.7%; P = 0.24). PCI of native coronary arteries was successful in 91.4% of cases and independent of valve type (short SFP 90.4% vs long SFP 93.4%; P = 0.44). Guide engagement failed in 6 patients, of whom 3 underwent emergent coronary artery bypass grafting and another 3 died in the hospital. Among patients requiring revascularization of native vessels, independent predictors of 30-day all-cause mortality were prior diabetes, cardiogenic shock, and failed PCI but not valve type or success of coronary engagement. CONCLUSIONS: CA or PCI after TAVR in acute settings is usually successful, but selective coronary engagement may be more challenging in the presence of long SFPs. Among patients requiring PCI, prior diabetes, cardiogenic shock, and failed PCI were predictors of early mortality.

Stress kardiomyopathy triggered by unusual situation.

Stress - “takotsubo” cardiomyopathy - is a reversible mimicking acute myocardial infarction. The trigger is extreme mental or physical stress. The main diagnostic examination is ventriculography with typical left ventricle apical ballooning wall motion abnormality. We present a case report of 63 years old woman, hospitalized at the Department of IV. internal Clinic Medical Faculty and University Hospital Bratislava due to angina. The main trigger was atypical stress situation - urgent need to urinate. On admission, the patients condition was dominated by the hypertension emergency, tachycardia and psychic tension. The ECG on admission revealed the sinus tachycardia and only marked ST elevation in leads I, II, V3-V6. The negative T wave in the leads I, II, V1-V6 was documented on latter ECG. Following the dynamics of troponin levels we assumed the non-STEMI, but due to psychic stress we also considered stress cardiomyopathy. Our patient underwent the coronary angiography and only marginal changes were present. The catecholamine cardiomyopathy with left ventricular apical wall motion abnormality, mild reduction of ejection fraction (48-50 %) and 1st degree of diastolic dysfunction was proved by ventriculography and echocardiography. After the 2 months follow-up, echocardiography confirmed the physiologic finding. This case report points out to the atypical urgent situation that provoked the stress cardiomyopathy.

Changes in levels of oxidative stress markers and some neuronal enzyme activities in cerebrospinal fluid of multiple sclerosis patients.

OBJECTIVES: The aim of the present study was to assess cerebrospinal fluid (CSF) levels of malondialdehyde (MDA), F2 isoprostanes (8-iso-PGF2α) and total antioxidant status (TAS) in relapsing-remitting (RR) and secondary progressive (SP) course of MS and neurological controls. These parameters were correlated with brain tissue damage parameters - neuron-specific enolase and 3´,5´-cAMP-phosphodiesterase (PDE) in CSF. METHODS: CSF samples were obtained from MS patients divided into two groups according to the disease severity (EDSS) - RR and SP course of MS. Control group composed of neurological diagnoses without demyelination and neurodegeneration. 8-iso-PGF2α and NSE levels in the CSF samples were determined using specific immunochemistry assays. MDA levels in the CSF were measured by HPLC method after reaction with thiobarbituric acid in acidic conditions. TAS and total PDE activity of CSF was determined spectrophotometrically. RESULTS: There were significant differences in CSF MDA levels between MS group and controls and also between RR and SP disease course. By contrast, CSF levels of 8-iso-PGF2α in MS group and both forms of MS were comparable to control values. In addition, the results show increased CSF levels of PDE in MS group and no changes of NSE in CSF between MS and control group. CONCLUSION: These findings point to a possibility of using the parameters of different specificity to lipid peroxidation for monitoring different stages (acute/progressive) of MS. This study support the idea, that combination of CSF markers is important for monitoring overall brain tissue pathology in MS.

Role of astrocytes in pathogenesis of multiple sclerosis and their participation in regulation of cerebral circulation.

There is about 30% higher risk of the myocardial infarction in patients diagnosed with multiple sclerosis (MS) than in people without MS. Increased risk of cardiovascular disease development positively correlates with levels of serum markers of an endothelial dysfunction, and may give rise to a global cerebral hypoperfusion. It appears that these complications precede progressive loss of axons, which mechanisms are complex and should be linked to a loss of ß2 adrenergic receptors on astrocytes of demyelinating lesions. Consequence of this deficiency, the cause of which is not known yet, is a decline in energy metabolism of axons. Moreover, the loss of these receptors is linked to a reduced redistribution of potassium ions by astrocytes, glutamate excitotoxicity and increase of calcium ion concentration in the axon with subsequent activation of necrotic processes. In addition to immunological aspects we should take into account also parameters of the functional state of endothelium when appropriate targeted therapy for patient is considered.

No difference in intra-arterial and intramuscular delivery of autologous bone marrow cells in patients with advanced critical limb ischemia.

Stem cell therapy has been proposed to be an alternative therapy in patients with critical limb ischemia (CLI), not eligible for endovascular or surgical revascularization. We compared the therapeutic effects of intramuscular (IM) and intra-arterial (IA) delivery of bone marrow cells (BMCs) and investigated the factors associated with therapeutic benefits. Forty-one patients (mean age, 66 ± 10 years; 35 males) with advanced CLI (Rutherford category, 5 and 6) not eligible for revascularization were randomized to treatment with 40 ml BMCs using local IM (n = 21) or selective IA infusion (n = 20). Primary endpoints were limb salvage and wound healing. Secondary endpoints were changes in transcutaneous oxygen pressure (tcpO(2)), quality-of-life questionnaire (EQ5D), ankle-brachial index (ABI), and pain scale (0-10). Patients with limb salvage and wound healing were considered to be responders to BMC therapy. At 6-month follow-up, overall limb salvage was 73% (27/37) and 10 subjects underwent major amputation. Four patients died unrelated to stem cell therapy. There was significant improvement in tcpO(2) (15 ± 10 to 29 ± 13 mmHg, p < 0.001), pain scale (4.4 ± 2.6 to 0.9 ± 1.4, p < 0.001), and EQ5D (51 ± 15 to 70 ± 13, p < 0.001) and a significant decrease in the Rutherford category of CLI (5.0 ± 0.2 to 4.3 ± 1.6, p < 0.01). There were no differences among functional parameters in patients undergoing IM versus IA delivery. Responders (n = 27) were characterized by higher CD34(+) cell counts in the bone marrow concentrate (CD34(+) 29 ± 15×10(6) vs. 17 ± 12×10(6), p < 0.05) despite a similar number of total nucleated cells (4.3 ± 1.4×10(9) vs. 4.1 ± 1.2×10(9), p = 0.66) and by a lower level of C-reactive protein (18 ± 28 vs. 100 ± 96 mg/L, p < 0.05) as well as serum leukocytes (8.3 ± 2.1×10(9)/L vs. 12.3 ± 4.5×10(9)/L, p < 0.05) as compared with nonresponders (10 patients). Both IM and IA delivery of autologous stem cells are effective therapeutic strategies in patients with CLI. A higher concentration of CD34(+) cells and a lower degree of inflammation are associated with better clinical therapeutic responses.

Implementation of ESC-STEMI guidelines into clinical practice: an analysis of the Slovak Registry of Acute Coronary Syndromes (SLOVAKS).

This study analysed the implementation of official European Society of Cardiology (ESC) guidelines for the management of ST elevated myocardial infarction (STEMI) patients. Initiatives were aimed at the education of both healthcare professionals and inhabitants. Changes in clinical practice and clinical outputs were analysed using data acquired from the SLOVak registry of Acute Coronary Syndromes (SLOVAKS). From 2007 to 2008 positive changes were noticed at every level of the 'life chain'. The proportion of patients treated by primary percutaneous coronary intervention (PCI) and by early reperfusion rose significantly. Total ischaemic time was shortened by 12 min in patients treated by thrombolysis and by 26 min in patients treated by PCI. In-hospital lethality for STEMI decreased significantly. The weakest point in the management of STEMI patients in Slovakia was the still-significant time loss incurred by patients themselves. Targeted initiatives aimed at implementing official ESC guidelines can significantly improve clinical outcomes in a relatively short period of time.

Clinical and hemodynamic predictors of natriuretic peptide elevation among aortic valve disease patients.

We investigated the relative contribution of hemodynamic and clinical factors to serum natriuretic peptide elevation in seventy-one patients with either aortic stenosis or aortic regurgitation. We found that pulmonary hypertension, heart failure and renal failure are the most powerful independent predictors of natriuretic peptide elevation in patients with aortic valve disease, irrespective of the type or severity of valvular lesion itself.

Plaque characteristics of nonobstructive coronary lesions in diabetic patients: an intravascular ultrasound virtual histology analysis.

BACKGROUND: Patients with diabetes mellitus are known to be at increased risk for acute cardiovascular events. We used intravascular ultrasound virtual histology (IVUS-VH) to examine whether nonobstructive coronary artery lesions of diabetic patients have distinct plaque composition and morphology compared with nondiabetic patients. METHODS: A total of 41 patients (13 diabetic and 28 nondiabetic) with proximally located angiographically nonobstructive coronary lesions were prospectively enrolled. In addition to plaque geometry, IVUS-VH lesion evaluation of the fibrous, fibro-fatty, necrotic core and calcified plaque components was performed. An IVUS-derived thin-cap fibroatheroma (IDTCFA) was defined as a lesion with a confluent necrotic core of at least 10% lumen cross-sectional area without evident overlying fibrous tissue and a plaque atheroma volume of at least 40% in at least three consecutive frames. RESULTS: Coronary artery lesions of diabetic and nondiabetic patients had similar plaque geometry. Lesions of diabetic patients were more likely to be positively remodeled than those of nondiabetic patients (67 vs. 27%, respectively, P = 0.02). Plaques of diabetic patients had significantly higher necrotic core percentages (23.3 +/- 6.1 vs. 17.1 +/- 8.7%, P = 0.03) and lower fibro-fatty tissue percentages (8 +/- 5 vs. 14.2 +/- 7.5%, P = 0.01) than those of nondiabetic patients. In addition, IDTCFAs were significantly more prevalent at the minimal lumen area site of diabetic patients compared to nondiabetic patients (92 vs. 54%, respectively, P = 0.02). After adjustment for various confounders, diabetes mellitus remained as the only independent clinical predictor of IDTCFAs at the minimal lumen area site [odds ratio (OR) 9.43, 95% confidence interval (CI) 1.06-84.04, P = 0.04]. CONCLUSION: Nonobstructive coronary artery lesions of diabetic patients have distinct compositional and morphological features, suggesting that these differences may explain the increased likelihood of coronary events in diabetic patients.

The recurrence of iatrogenic femoral artery pseudoaneurysm after occlusion by ultrasound guided percutaneous thrombin injection.

AIMS: To evaluate efficacy of percutaneous ultrasound-guided thrombin injection (UGTI) of iatrogenic femoral artery pseudoaneurysm (PSA) and to identify the risk factors associated with PSA recurrence. METHODS AND RESULTS: We treated 140 patients aged 76 years (range 49-83) presented with femoral artery PSA after cardiac catheterisation by percutaneous UGTI (500 IU/ml solution of activated human thrombin). Factors associated with the recurrence of PSA were analysed. One hundred nineteen patients were successfully treated by one injection of thrombin (immediate success rate 85%). In 19 patients (13.6%), short local compression following injection was needed for complete occlusion (overall success rate 98.6%, 138/140). In one case, progression of PSA required conversion to surgery (0.7%). In one patient with pre-existing stenosis of superficial femoral artery, acute limb ischaemia developed after UGTI (0.7%). The recurrence of PSA in 30-days follow-up (10 patients, 7%) was associated with obesity (BMI>30, OR=1.39, 95% CI 1.09-1.78, p<0.05), and with extensive combination of anti-aggregation and anti-coagulation therapy (OR=2.11, 95% CI 1.23-3.62, p<0.0001) as revealed by both univariate and multivariate analysis. CONCLUSIONS: The UGTI is a safe and effective treatment of iatrogenic femoral artery PSA. Recurrence is low and associated with obesity and extensive use of combined anti-aggregation and anti-coagulation therapy.

Simvastatin and ezetimibe in addition to nonpharmacological risk factor modification for achieving new low-density lipoprotein cholesterol targets.

BACKGROUND: Though guidelines emphasize low-density lipoprotein cholesterol (LDL-C) lowering as an essential strategy for cardiovascular risk reduction, achieving target levels may be difficult. PATIENTS AND METHODS: The authors conducted a prospective, controlled, open-label trial examining the effectiveness and safety of high-dose fluvastatin or a standard dosage of simvastatin plus ezetimibe, both with an intensive guideline-oriented cardiac rehabilitation program, in achieving the new ATP III LDL-C targets in patients with proven coronary artery disease. 305 consecutive patients were enrolled in the study. Patients were divided into two groups: the simvastatin (40 mg/d) plus ezetimibe (10 mg/d) and the fluvastatin-only group (80 mg/d). Patients in both study groups received the treatment for 21 days in addition to nonpharmacological measures, including advanced physical, dietary, psychosocial, and educational activities. RESULTS: After 21 days of treatment, a significant reduction in LDL-C was found in both study groups as compared to the initial values, however, the reduction in LDL-C was significantly stronger in the simvastatin plus ezetimibe group: simvastatin plus ezetimibe treatment decreased LDL-C to a mean level of 57.7 +/- 1.7 mg/ml, while fluvastatin achieved a reduction to 84.1 +/- 2.4 mg/ml (p < 0.001). In the simvastatin plus ezetimibe group, 95% of the patients reached the target level of LDL-C < 100 mg/dl. This percentage was significantly higher than in patients treated with fluvastatin alone (75%; p < 0.001). The greater effectiveness of simvastatin plus ezetimibe was more impressive when considering the optional goal of LDL-C < 70 mg/dl (75% vs. 32%, respectively; p < 0.001). There was no difference in occurrence of adverse events between both groups. CONCLUSION: Simvastatin 40 mg/d plus ezetimibe 10 mg/d, on the background of a guideline-oriented standardized intensive cardiac rehabilitation program, can reach 95% effectiveness in achieving challenging goals (LDL < 100 mg/dl) using lipid-lowering medication in patients at high cardiovascular risk.

Diazepam versus fentanyl for premedication during percutaneous coronary intervention: results from the Myocardial Protection by Fentanyl during Coronary Intervention (PROFIT) Trial.

BACKGROUND: Sedation is a cornerstone in the premedication for percutaneous coronary intervention (PCI). Benzodiazepines and opioids are frequently used. Previous results suggest that opioids mimic the adaptation to ischemia during repeated balloon inflations and may provide direct myocardial protection in addition to their sedative effect. However, no comparative data exist. METHODS: We conducted a prospective, randomized, controlled, single-blind trial comparing diazepam and fentanyl in 276 patients undergoing elective PCI. Patients were randomized to either diazepam 5 mg sublingually or fentanyl 0.05 mg or 0.1 mg intravenously at least 5 minutes prior to the first balloon inflation. The primary end-point was the postprocedural elevation of myocardial markers of necrosis defined as an elevation of cardiac troponin T > or = 0.01 ng/ml. RESULTS: The three groups had similar baseline clinical, angiographic, and procedural characteristics, with no significant differences in lesion morphology, procedural complexity, or adjunctive medical treatment. No significant variation in the hemodynamic response to the study drugs was observed in the three groups. The rate of postprocedural troponin T elevation was 28% in the diazepam group, 20% in the fentanyl 0.05 mg group, and 30% in the fentanyl 0.1 mg group (P = 0.26). Rates of postprocedural myocardial infarction were 3%, 2%, and 2%, respectively (P = 0.84), with one case of in-hospital death in the diazepam group and no urgent TVR in the whole study population. CONCLUSION: Although providing a well-tolerated alternative to diazepam for sedation during PCI, fentanyl did not provide additional cardioprotection assessed through the postinterventional elevation of cardiac troponin T during elective coronary intervention.

Relationship between cardiovascular risk as predicted by established risk scores and coronary artery plaque composition as detected by virtual histology intravascular ultrasound analysis: the PREDICT pilot study.

AIMS: Identification of subclinical high-risk plaques is potentially important because they may have greater likelihood for rupture and thrombosis. The aim of this study was to assess the relationship between in vivo coronary artery plaque composition using intravascular ultrasound virtual histology (IVUS-VH) and cardiovascular risk as predicted by clinical risk scores in patients with non-obstructive stable coronary artery disease. METHODS AND RESULTS: Forty patients undergoing elective coronary angiography revealing <50% coronary artery stenoses were prospectively included. Of these, 38 (29 men; mean age 65+/-9 years) underwent a satisfactory IVUS-VH investigation of the affected vessel. For each patient, the 10-year risk of cardiovascular events was calculated using the Framingham and the SCORE-Deutschland risk prediction algorithms, and compared to the VH-derived plaque composition at the site of the minimal lumen area (MLA). For both algorithms, patients at low estimated risk of events showed more fibrous tissue percentages than patients at high risk (67.4+/-9.7% versus 53.2+/-10.4% for the SCORE algorithm, and 65.6+/-13.4% versus 51.5+/-9.4% for the Framingham algorithm, p=0.002 and p=0.004, respectively). Plaques of patients with higher risk showed a non-significantly higher necrotic core percentage. For the SCORE algorithm, dense calcium percentage was higher in patients with high risk compared to patients with low risk (13.9+/-10.4% versus 4.9+/-4.9%, p=0.008). The prevalence of IVUS-derived thin cap fibro-atheromas at the MLA site was higher in patients at high risk (80% of lesions in patients at high risk using the SCORE algorithm and 92% of lesions in patients at high risk using the Framingham algorithm), whereas patients at low risk had more stable plaque phenotypes (p=0.002 and 0.003 for the SCORE and Framingham algorithms, respectively). CONCLUSIONS: In vivo plaque composition and morphology assessed by IVUS-VH were related to the cardiovascular risk predicted by established risk prediction algorithms in patients with non-obstructive coronary artery disease, suggesting a link between the higher risk for future events and the VH-derived plaque morphology.

Hostility in coronary artery disease patients and health care workers in Slovakia.

PURPOSE: Increased levels of hostility are associated with the increased risk of coronary artery disease (CAD), and with poorer outcomes in CAD patients. The purpose of this paper is to estimate the level of hostility in CAD patients and in health care (HC) workers, as potential groups for intervention programmes. DESIGN/METHODOLOGY/APPROACH: A qualitative cross-sectional study was undertaken. Hostility questionnaires were distributed in a non-randomized fashion in a group of 236 CAD patients (187 men, 49 women), aged from 33 to 69 years (average 52 years) and 181 health care workers (52 men, 129 women), aged from 19 to 65 (average 31 years). The results of the survey were discussed in a focused group. FINDINGS: The results showed that the high level of hostility in both CAD patients and HC workers exceeded the risk value of 10 in 89 per cent of CAD patients and 95 per cent of HC workers. No difference was found in the hostility scores between CAD patients and HC workers. There was a tendency to higher scores of hostility or of its subcategories (cynicism, anger, aggression) in physicians and nurses of the invasive cardiology or the intensive care units. ORIGINALITY/VALUE: This paper is of value by showing how increased level of hostility was the issue in both patients and HC workers, with potential consequences of health risk for individuals, as well as deteriorated interpersonal relations and a conflict-generated corporate culture for organizations. Differently tailored programmes for hostility management for particular target groups may help to prevent negative developments.