Blood pressure cut-offs to diagnose impending hypertensive emergency depend on previous hypertension-mediated organ damage and comorbid conditions.

Background Hypertensive emergencies (HTN-E) are important due to a high risk of mortality. However, a sudden increase in blood pressure (BP) can damage target organs before the BP reaches cut-offs to diagnose HTN-E. We (i) analyse HTN guidelines for recommendations of treatment individualization, such as adjusting BP cut-offs for hypertensive urgency or impending HTN-E according to patient's susceptibility to complications (because of previous hypertension-mediated organ damage [HMOD], cardiovascular events and comorbid conditions), and (ii) provide a rationale for the inclusion of patient's susceptibility in protocols for treatment of acute HTN-E. Methods We searched PubMed, SCOPUS, Science Direct, Springer, Oxford Press, Wiley, SAGE and Google Scholar for the following terms: arterial hypertension, impending, emergency, target organ damage, hypertension-mediated organ damage, and comorbidity. Results The available guidelines do not recommend that when we estimate the probability of HTN-E in a patient with very high BP, we take into account not only the 'aggressive factor' (i.e. history of HTN, absolute BP values and rate of its increase), but also the 'vulnerability of the patient' due to previous major adverse cardio-vascular events, HMOD and comorbid conditions. Conclusion The risk does not depend only on the aggressiveness of the health threat but also on the strength of the host's defence. It is, therefore, surprising that one side of the natural interaction (i.e. susceptibility of a patient) is overlooked in almost all available guidelines on HTN.

The Association between Galectin-3 and hs-CRP and the Clinical Outcome after Non-ST-Elevation Myocardial Infarction with Preexisting Atrial Fibrillation.

Increased galectin-3 plasma concentration has been linked to an unfavorable outcome in patients with heart failure or atrial fibrillation (AF). There are no published data about the prognostic utility of galectin-3 and high-sensitivity C-reactive protein (hs-CRP) for long-term clinical outcome in the Non-ST elevation acute myocardial infarction (NSTEMI) patients with preexisting AF. Thirty-two patients with the first acute NSTEMI and preexisting AF and 22 patients without preexisting AF, were prospectively followed for fifteen months. Patients with AF had significantly higher galectin-3 plasma levels (p < 0.05) and hs-CRP concentration (p < 0.01), compared with patients without AF. Galectin-3 plasma concentration was not a significant covariate of the composite outcomes (p = 0.913). Patients with high hs-CRP (above 4.55 mg/L) showed 2.5 times increased risk (p < 0.05) of the composite outcome occurrence (p < 0.05). Besides, three-vessel coronary artery disease, creatinine serum level, and creatinine clearance were significant covariates (p < 0.05; p < 0.05; p < 0.01) of the composite outcome, respectively. Creatinine clearance, solely, has been shown to be an independent predictor of unfavorable prognosis after a 15-month follow-up. Galectin-3 and hs-CRP plasma levels were elevated in NSTEMI patients with AF, but with differential predictive value for an unfavorable clinical outcome. Only hs-CRP was associated with increased risk of composite outcome occurrence.

Life-saving percutaneous coronary interventions on the unprotected left main coronary artery in patients with acute coronary syndrome in the catheterization laboratory without cardiosurgical back-up.

INTRODUCTION: The optimal revascularization strategy for unprotected left main coronary disease (ULMCD) is the subject of ongoing debate and patients with ULMCD still represent a challenge for interventionalist, especially in the setting of an acute coronary syndome (ACS). CASE REPORT: We presented two cases of percutaneous treatment of ULMCD in the settings of ACS (ST Segment Myocardial Infarction and Non ST Segment Myocardial Infarction--STEMI and NSTEMI) in a catheterization laboratory without back-up of cardiosurgical department. Both patients were hemodynamically unstable with clinical signs of cardiogenic shock. Coronary angiography revealed left main thromobosis and using intra-aortic balloon pump as hemodynamic support primary angioplasty procedures were performed. Immediately after the procedures the patients hemodynamically improved and remained stable till discharge from hospital. CONCLUSION: Percutaneous coronary intervention (PCI) has become the most common strategy of revascularization in ACS patients with ULMCD and is generally preferred in patients with multiple comorbidities and/or in very unstable patients. In cases with no cardiosurgical departments PCI is an inevitable, bail-out, life saving procedure.

Prognostic significance of microalbuminuria in patients with acute myocardial infarction.

BACKGROUND: Microalbuminuria has been reported to occur in patients with acute myocardial infarction (AMI) and associated with worse outcome. In our prospective analysis we included patients with AMI with the primary aim to examine whether urinary albumin excretion is increased in those patients and whether it is associated with worse in-hospital prognosis (major complications). The secondary objective was to examine the predictive power of microalbuminuria for 6-month mortality and re-hospitalization for cardiovascular disease. METHODS: One hundred thirty patients admitted to the Coronary Care Unit were studied prospectively. The diagnosis of myocardial infarction was based on the latest criteria of the European Cardiac Society. Microalbuminuria was defined as a urinary albumin creatinine ratio (UACR) and was measured on the third day after admission in the first morning urine sample. RESULTS: One hundred thirty patients were enrolled in this study--82 (63.03%) men and 48 (36.92%) women, age 62.48 +/- 12 years. A high proportion of study patients (27.7%) had microalbuminuria and 8.5% had overt albuminuria (UACR over 25 mg/mmol in men and over 35 mg/mmol in women) at the time of urine examination. During the hospital stay (average 7.6 +/- 3.0 days) 4 patients (3.1%) died from cardiovascular complications and all had microalbuminuria. In our study a high percentage of patients with in-hospital nonfatal complications had microalbuminuria but it did not have positive predictive association with the occurrence. During a 6-month follow-up period, 8 patients died from cardiovascular cause. In-hospital and total mortality (in-hospital and the during six-month follow-up) were significantly frequent in patients with microalbuminuria (p < 0.05). During a six-month follow-up period, 24 patients (18.5%) were re-hospitalized for cardiovascular disease and, among them, 54.2% had microalbuminuria. In univariant regression analysis microalbuminuria increased the risk for re-hospitalization, but multiple analysis didn't show the significance. CONCLUSIONS: We found that UACR measured during the first week after AMI is independently associated with increased long-term risk for in-hospital and six-month mortality. On the basis of these results, we suggest that this measurement should be included in the routine clinical work up of patients with AMI.

[Echocardiographic estimation of acute haemodynamic response during optimization of multisite pace-maker using different pacing modalities and atrioventricular delays].

BACKGROUND/AIM: Cardiac resynchronization therapy (CRT) improves ventricular dyssynchrony and is associated with an improvement in symptoms, quality of life and prognosis in patients with severe heart failure and intraventricular conduction delay. Different pacing modalities produce variable activation patterns and may be a cause of different haemodynamic changes. The aim of our study was to investigate acute haemodynamic changes with different CRT configurations during optimization procedure. METHODS: This study included 30 patients with severe left ventricular systolic dysfunction and left bundle branch block with wide QRS (EF 24.33 +/- 3.7%, QRS 159 +/- 17.3 ms, New York Heart Association III/IV 25/5) with implanted CRT device. The whole group of patients had severe mitral regurgitation in order to measure dP/dt. After implantation and before discharge all the patients underwent optimization procedure guided by Doppler echocardiography. Left and right ventricular pre-ejection intervals (LVPEI and RVPEI), interventricular mechanical delay (IVD) and the maximal rate of ventricular pressure rise during early systole (max dP/dt) were measured during left and biventricular pacing with three different atrioventricular (AV) delays. RESULTS: After CRT device optimization, optimal AV delay and CRT mode were defined. Left ventricular pre-ejection intervals changed from 170.5 +/- 24.6 to 145.9 +/- 9.5 (p < 0.001), RVPEI from 102.4 +/- 15.9 to 119.8 +/- 10.9 (p < 0.001), IVD from 68.1 +/- 18.3 to 26.5 +/- 8.2 (p < 0.001) and dP/dt from 524.2 +/- 67 to 678.2 +/- 88.5 (p < 0.01). CONCLUSION: In patients receiving CRT echocardiographic assessment of the acute haemodynamic response to CRT is a useful tool in optimization procedure. The variability of Doppler parameters with different CRT modalities emphasizes the necessity of individualized approach in optimization procedure.

[Coronary flow and hemorrhagic complications after alteplase and streptokinase administration in patients with acute myocardial infarction].

BACKGROUND/AIM: Up-to-date treatment of acute myocardial infarction (AIM) has been based on as early as possible establishment of circulation in ischemic myocardium whether by the use of fibrinolythic therapy and/or urgent coronary intervention which significantly changes the destiny of patients with AMI, but also increases the risk of bleeding. The aim of this study was to compare coronary flow and bleeding complications in patients with acute myocardial infarction with ST-elevation (STEMI) after administration of alteplase or streptokinase. METHODS: The study included 254 patients with STEMI. The group I (n = 174) received streptokinase, and the group II (n = 80) received alteplase. We followed frequency of complications such as bleeding and hypotension in the investigated groups of patients, based on the TIMI classification of bleeding, as well as the transience of infarction artery in accordance with TIMI flow. RESULTS: The patients with myocardial infarction after administration of alteplase had statistically significantly higher coronary flow (TIMI-3), 72.5% as compared to the patients who received streptokinase, 39.2%. Hypotension as complication of fibrynolythic therapy administration occurred in a significantly higher percentage in the group of patients who received streptokinase. There was no statistically significant difference in the appearance of major bleeding in the groups of patients who received streptokinasis and alteplase (6.9% and 7.5%, respectively). Also, there was no difference in the appearance of minor and minimal bleeding among the investigated groups of patients. CONCLUSION: It was shown that alteplase in a higher number of patients provided TIMI-3 coronary flow as compared to streptokinese. In comparison with streptokinase, a combination of alteplase, enoxaparin and double antiplatelet therapy enabled earlier achievement of coronary flow through previously blocked coronary artery that was more complete (higher frequency of TIMI-3 flow). There were no statistically significant difference in frequency of bleeding, first of all major bleeding, between the groups treated by alteplase and streptokinase.

[Influence of the double antiplatelet therapy on patency of the occluded artery after acute myocardial infarction with ST-segment elevation].

BACKGROUND/AIM: Most patients with acute myocardial infarction with ST-segment elevation (STEMI) are still treated with pharmacological reperfusion, which is not always successful. That is the reason for searching possibilities for a better success of reperfusion with adding new antiplatelet drugs. The aim of this study was to investigate weather addition of clopidogrel as a second antiplatelet drug, improves the patency of the infarct-related artery after STEMI. METHODS: We prospectively enrolled 65 patients, 29-72 years old, hospitalized due to the first STEMI within 6 hours after the on-set of a chest pain. They were treated with a fibrinolytic agent (streptokinase or tissue plasminogen activator--tPA), aspirin, and low molecular heparin (enoxaparin). A group of 50 patients, beside this therapy, received clopidogrel. Coronary angiography was performed between 5th and 10th day of hospitalization to assess for late patency of the infarct-related artery. Infarct-related artery was considered as patent if thrombolysis in myocardial infarction (TIMI) flow grade was 2 or 3, and as occluded if TIMI flow grade was 0 or 1. RESULTS: In the group of patients who received double antiplatelet therapy (aspirin and clopidogrel), infarct-related artery was occluded in 3 cases (6%); in the group of patients without clopidogrel, infarct-related artery was occluded in 4 patients (26.7%),p < 0.05. There were less frequency of postinfarction angina (6% vs 13.3%), and rarer necessity for rescue percutaneous coronary intervention (4% vs. 13.3%) in the first group, but without statistical significance. CONCLUSION: Adding of clopidogrel to the standard reperfusion pharmacotherapy, as a second antiplatelet drug, increases the number of patients with patent infarct-related artery and the success of reperfusion.