[Early diagnosis and reasons for not administering thrombolytic therapy in acute myocardial infarct]. / Vcasná diagnóza a príciny nerealizácie trombolytickej liecby u chorých s akútnym infarktom myokardu.

In Slovakia we are lacking data on early (before examination of serum markers of myocardial necrosis) pertaining to thrombolytic treatment (TLL) which is inevitable in case of acute myocardial infarction (AIM) as well as data on the reasons why TLL is not implemented. This why the authors analyze the results of completed comprehensive project Audit concerned with diagnostic and therapeutic procedures in patients with acute coronary syndromes during the pre-hospital and hospital stage (AUDIT). The investigation was a perspective multi-centre study. Data were collected from 3123 patients with AIM in 66 departments (in 64 health institutions) during Sept. 16 1997 till Sept. 15 1998. The group included patients admitted within 96 hours after the development of complaints with the diagnosis or suspicion of AIM and discharged with the diagnosis of a first/repeated AIM. Early diagnosis of AIM was made in 1736 (55.6%) patients. In the AUDIT study TLL was assessed in 1074 (34.6%) patients. A marked difference between the number of candidates for TLL and the number of patients with TLL where TLL was implemented requires that in analyses of TLL in patients with AIM attention should be paid also to reasons why it was not implemented. The most frequent cause why TLL was nor implemented was late admission of the patient to hospital (in patients who attended hospital < 6 hours, TLL was not implemented in 48.5%, after admission between 6 and 12 hours in 70% and in patients admitted > 12 hours in as many as 90.8% patients), equivocal indication of TLL (in 29.9% patients) and contraindications (in 16.1% patients). The presented results are priority data on the early diagnosis of AIM and reasons why TLL was not implemented. It is part of data essential needed for elaboration of a (national) programme of better care (management) of patients with AIM taking into account also economic factors.

Thrombolytic therapy for patients with acute myocardial infarction. Causes increasing the probability of not receiving thrombolytic therapy.

Intravenous thrombolysis is the most accessible and the most common form of reperfusion therapy. The aim of this study was to identify demographic, clinical and electrocardiographic factors, which based on published data and in patients included in the project Audit of diagnostic and therapeutic procedures in patients with acute myocardial infarction (AUDIT), increased the probability of not receiving thrombolytic therapy. In order to maximize the impact of thrombolytic therapy to reduce the case fatality rate associated with an acute myocardial infarction, we review, which a number of studies provide evidence on the usage of thrombolytic therapy in elder, women, patients with diabetes mellitus, bundle-branch block and after stroke. (Fig. 10, Ref. 52.).

[Effect of demographic, anamnestic and clinical factors on hospital mortality in patients with myocardial infarct]. / Ovplyvnenie nemocnicnej smrtnosti chorých s akútnym infarktom myokardu demografickými, anamnestickými a klinickými faktormi.

The objective of the work was to analyze local priority data on the possible effect of demographic, anamnestic and clinical factors in a non-selected population of 3123 patients with acute myocardial infarction (AIM) on the hospital mortality (HM). 12.6% patients with AIM died in hospital. The mean age of those who died was 71.92 years. There were more than 4 times more patients above 64 years than 64-year-old ones or younger ones who died. The mortality rate of 64-year-old patients and younger ones (5.2% is significantly lower than in patients above 64 years (19%). The mortality rate of patients above 74 years was 27.1%. Important correlations of the HM were moreover found--in women, patients living permanently in rural areas, in widowed subjects, in patients with elementary education, old age, pensioners and non-smokers. The HM was lower (< 10%) in patients with a history of complex ventricular arrhythmias, impaired lipid metabolism and those who had no other serious disease in the case-history. A higher HM (> 15%) was recorded in patients with a history of a cerebrovascular attack, with data on heart failure and in diabetic patients. The majority of patients (39.4% of all who died) died within 24 hours after admission. During the first three days 57% patients died. Analysis of the characteristic of AIM and HM revealed some clinically important data on the HM less than 30% (patients with complicated AIM, with elevated ST segments, with a left ventricular ejection fraction of less than 40% and with and concurrent heart failure). An adverse course of the disease with a high HM (> 30%) was found in patients with complications of AIM. It was highest, more than 60%, in patients after implemented cardiopulmonary resuscitation, in patients with a combination of three markers of imminent shock and patients in shock. The local priority findings on the HM assembled in Slovakia in a non-selected population of patients with AIM confirm that the high HM still persists in patients of advanced age and in women. It is adversely influenced also by some demographic data, educational level, some anamnestic and clinical factors. The HM of patients with AIM may be adversely influenced also by side-effects of protracted economic transformation which is under way. Data assembled in Slovakia are comparable with similar results assembled in other countries.

[The electrocardiogram and thrombolytic therapy in patients with acute myocardial infarct]. / Elektrokardiogram a trombolytická liecba u chorých s akútnym infarktom myokardu.

The objective of the submitted work is to analyze in patients with acute myocardial infarction (AIM) local priority data on ECG markers after admission to hospital, data on some associations of ECG and thrombolytic treatment and to assess in patients with the first AMI data on hospital mortality in connection with some ECG markers. The project was implemented as a prospective multicentre study. An independent audit and collection of data was done in 3123 patients with AIM in 66 departments between Sept. 16 1997 and Sept. 15 1998. The group included patients admitted within 96 hours after development of complaints with the diagnosis or suspicion of AMI who were discharged with the diagnosis of a first/repeated AMI. Elevation of ST segments was recorded in 67.1%, a Q wave in 42.2% and left bundle branch block in 3.7% of the patients. Early diagnosis of AMI based on ECG and data on prolonged stenocardia was made in 55.6% patients. This is the maximal proportion of patients where thrombolytic treatment can be contemplated. Thrombolytic treatment was not administered to 54.9% patients with elevations of the ST segments and in as many as 81.2% patients with left bundle branch block. The hospital mortality in patients with a first AMI is significantly greater in patients with elevations of the ST segment, Q infarction, anterior wall infarction, combined infarction, right ventricular infarction and in patients with bundle branch and fascicular block. It was confirmed that in Slovakia in clinical practice thrombolytic treatment is not always administered consistent with criteria adopted from randomized studies. The result is underutilization or overutilization of thrombolytic treatment to patients with AIM in clinical practice. Underutilization of thrombolytic treatment is generally known. It was demonstrated that attention must be devoted also to overutilization of thrombolytic treatment. All patients where significantly higher hospital mortality was recorded must receive special care already on admission to hospital.

[Hospitalization of discharged patients with acute myocardial infarction in the thrombolytic era]. / Hospitalizácia prepustených chorých s akútnym infarktom myokardu v trombolytickej ére.

The objective of the work is to assess in discharged patients with AIM data on the period of hospitalization in the intensive care unit and the total period of hospitalization and how these were influenced by stratification into patients with complicated and uncomplicated AIM and patients with a low, medium and high risk. Data on hospitalization were analyzed in 2,527 discharged patients with AIM. The median of hospitalization at intensive care units was 5 days and the mean period of hospitalization 6.35 days. The significantly longer hospitalization (p < 0.001) in patients with complicated AIM (median 6 days) as compared with patients with uncomplicated AIM (median 5 days) impliesonly a one-day longer hospitalization in patients with complicated AIM. The median of total hospitalization was 17 days and the mean period of hospitalization 17.95 days. In the majority of patients the period of hospitalization was 15 - 21 days. More than 20% are hospitalized for more than 21 days. A significant difference of the total period of hospitalization in high risk patients and patients with a medium and low risk expressed in medians is only 2 days. The majority of patients in all three sub-groups of patients with AIM is dicharged between the 15th to 21st day of hospitalization. In the period of hospitalization at intensive care units and total hospitalizatiob of different sub-groups there is no substantial difference in their health status, incl. the danger of sudden cardiac death. By reducing the total period of hospitalization in discharged patients without complications it would be possible to save a considerable percentage of costs of hospitalization. The period of hospitalization must be fixed individually in every patient. In early dicharges it is important to consider also the psychosocial impact of discharge on the patient and his relatives.

[The prehospital phase in patients with acute myocardial infarct in Slovakia. A challenge]. / Predhospitalizacná fáza u chorých s akútnym infarktom myokardu na Slovensku. Výzva na akciu.

Better management of patients with acute myocardial infarction during the prehospital phase is at present a challenge not only for health workers but for society as a whole. The authors pay attention to knowledge of the complex problem of the prehospital phase in patients with acute myocardial infarction which is a prerequisite for finding possible solutions for a favourable effect on their management. The authors analyzed 3,040 patients who were admitted to hospital alive within 96 hours after the development of complaints with suspicion of a first or repeated acute myocardial infarction. They focused attention in particular on prehospital time delay. They found that within a satisfactory time interval (within 2 hours) 29.8% patients were delivered and within a yet acceptable interval of 4 hours 51.6% patients (with respect to effectiveness of thrombolytic treatment). Similarly undesirable are also data on the patient time delay. Within the optimal first hour after development of complaints following the decision of the patient (subjects present) to ask for or seek medical assistance was the decision of 34% patients, during the first two hours 47.5% and within 4 hours 61.2% patients with acute myocardial infarction. The ratio of time delay of the patient in the total prehospital delay is 45.5% even in patients who were admitted during the first hour after development of acute myocardial infarction. In patients who were admitted 4 hours after development of complaints it is 79.5%. The patient is admitted to hospital most quickly if he calls the medical emergency service and latest when he decides to see a doctor. Physicians and other health workers contributed only in 16.4-20.9% patients with acute myocardial infarction to their early decision to seek medical assistance. Patients with an early decision (within one hour) call most frequently the medical emergency service and are taken to hospital by this service. The time delay due to transport is shortest in these patients. The late hospital admission of patients with acute myocardial infarction in Slovakia calls for reduction of the time interval from the development of complaints to hospital admission (total prehospital delay), in particular the time taken by the patient to make up his mind (patient time delay). Early calling of the emergency medical service and transport of the maximum possible number of patients with acute myocardial infarction to hospital by the emergency medical service will greatly improve the management of patients with acute myocardial infarction. Comprehensive implementation of the survival chain (24), the most comprehensive implementation of recommendations of the European Society of Cardiology and the European Resuscitation Council for in the management of patients with acute heart attacks during the prehospital phase (21) and early effective treatment which begins already in the prehospital phase has a favourable impact on the condition of patients with acute myocardial infarction and on their prognosis. Along with early and effective treatment of patients with acute myocardial infarction in hospital and their stratification these are the most important approaches to the development and control of sudden cardiac death. Knowledge of the complex problem of the prehospital phase in patients with acute myocardial infarction is the prerequisite for the elaboration of high standard prehospital management of patients with acute myocardial infarction.

[Early diagnosis of acute myocardial infarct]. / Vcasná diagnostika akútneho infarktu myokardu.

Inappropriately long patient time delay (PTD) is the main cause for undesirable pre-hospitalization delay, so called global pre-hospital time delay (GTD). The fact that patients treated for cardiovascular diseases have long GTD is alarming. General awareness of basic symptomatology and of the importance of time factor for further course of the disease may substantially influence the duration of AIM pre-hospitalization phase. Pre-hospitalization care of patient is a very demanding task for the first-contact physician (most often general practitioner) mainly because of the symptomatology variability. If there is a suspicion for AIM it is recommended to treat the patient as life-threatened and to assure the transport to hospital as rapid and "comfortable" as possible. The organisational structure of emergency units in hospitals must accept the main presumption for future treatment success-vital importance of immediate management of possible AIM patient. In this connection most important task for the doctor is rapid diagnostics, because of the requirement for hospitalization at coronary unit or intensive care unit and the need for urgent treatment. Exceptional attention must be paid to AIM high risk patients. Unrecognition of AIM, mainly in the early period, when the diagnostic process may be difficult, can have catastrophic consequences: 1. sudden cardiac death due to ventricular fibrilation and 2. impossibility to administer fibrinolytic therapy in the period of its maximum treatment. At the present state of knowledge because of the consequences of undiagnosed AIM it is safer to presume cardiac origin of the symptoms, above all of pain until proving other reason. Therefore the idea of so called Chest Pain Evaluation Units seems to be very interesting.

[Minimizing the prehospital delay in patients with acute myocardial infarct]. / Moznosti skrátenia prednemocnicného oneskorenia u chorých s akútnym infarktom myokardu.

Despite the known importance of early intervention, delays between symptoms onset and manifestation of acute myocardial infarction (AMI) in the hospital are common. Most of the prehospital delay consists of the interval between the onset of symptoms and the decision to seek medical help. The aim of this paper is to review the factors associated with the long duration of patient delay (patient time delay). The media campaigns designed to reduce the delay between the onset of AMI have so far not been proved to be worthwhile and it is not certain that further campaigns will be more successful. Physicians and other health care professionals play an important role in reducing the delay to treatment in patients with evolving AMI. Patients with some cardiovascular disease are at high risk for AMI. High-risk patients have to be educated about the symptoms they may develop during a coronary occlusion, what steps to take if symptoms occur, and the importance of contacting emergency medical services immediately. These instruction need to be reviewed frequently and reinforced with appropriate printed material. The situational and psychological variables are important determinants of the length of decision delays in response to symptoms of AMI. No single intervention, no matter how carefully designed and implemented, will alter the patient's propensity to delay. However, consistent, regularly delivered information may be helpful. Family members should participate in all instructions because they play an important role in increasing or decreasing the delay to treatment in patients with AMI.

[Pharmacotherapeutic profile of patients with acute myocardial infarct in the early hospitalization period]. / Farmakoterapeutický profil chorých s akútnym infarktom myokardu vo vcasnom období hospitalizácie.

BACKGROUND: The early treatment efficacy of patients with acute myocardial infarction (AMI) with thrombolysis, antiplatelet drugs, betablockers and ACE inhibitors has been well documented in randomized mega trials. However, little is known about the fact to what extend the results of these mega trials have influenced the treatment practices. Moreover, in the view of a complete lack of data on management of patients with AMI in Slovak Republic a project of the Ministry of Health "Audit of diagnostic and therapeutic management in patients with acute coronary syndromes" (AUDIT) has been conducted. OBJECTIVES: To obtain preliminary information on the present state of pharmacotherapy of patients with AMI in Slovak Republic during the early hospitalization phase (EHP) from the Pilot Study (PS) of the project AUDIT. METHODS: Pharmacotherapy of AMI during EHP was analysed in 336 patients (232 males and 104 females, mean age 65 12 years, age range 30-93 years). Patients admitted with diagnosis of the first or repeated AMI or with suspect AMI were included. PS was done in prospective multicentric study between November 1, 1996 and December 31, 1996. 23 hospitals from various parts of Slovakia participated in this study. Data were compiled by means of questionaires and were processed by ACCES 97 and EXCEL 97. RESULTS: Antiplatelet therapy with acetylosalicylic acid (almost exclusively Anopyrin) received as much as 87.8% of patients with AMI during EHP. Thrombolytic therapy (TLT), almost exclusively with streptokinase, was performed in 105, i.e. in 31.8% of patients with AMI. TLT was performed in a statistically significantly smaller proportion of patients older than 65 years compared to patients 65 years of age and younger (20.9% vs 41.2%, p < or = 0.01). Females were treated with TLT statistically significantly less frequently than males (24.5% vs 35.1%, p < or = 0.05). The major cause for not performing the TLT was late arrival to hospital (in 32.1% patients). Betablockers were administered to a total of 42.9% of patients during EHP. Betablockers received only 3.6% of patients intravenously (!) and only 39.3% of patients orally. Treatment with oral betablockers was performed in a statistically significantly smaller proportion of patients older than 65 years compared to patients 65 years of age and younger (27.4% vs 49.7%, p < or = 0.01). Up to 49.1% of patients in EHP were treated with ACE inhibitors, however, left ventricular ejection fraction < 40% warranting feasibility of this treatment was achieved only in 26.7% of patients. Nitrates were administered to 62% of patients in EHP, of this number intravenously to 37.4% of patients. Calcium channel blockers were given only to 7.3% of patients. Treatment with heparin was performed in 90.9% of patients. 14.3% of patients received during EHP antiarrhythmics of class I and 2.7% of patients of class III. MgSO4 was used in 26.4% of patients in EHP. CONCLUSIONS: The reported PS of AUDIT Project gives for the first time information on the state of the pharmacotherapy of patients with AMI in Slovak Republic. Some results are relatively encouraging, however, others can not be a reason for satisfaction. The fact, that in Slovakia, adequate number of patients with AMI receive acetylosalicylic acid (Anopyrin) and that Slovakia belongs to countries with the smallest proportion of patients with AMI treated with calcium channel blockers and antiarrhythmics during EHP is encouraging. On the other hand, the use of TLT and betablockers is dissatisfactory. Requirement to increase the proportion of thrombolysed patients with AMI and the necessity for substantially more frequent use of betablockers, especially intravenous, in EHP in these patients result from these findings. In Slovakia, inadequately large proportion of patients with AMI is treated with ACE inhibitors, heparin, and partially also nitrates administered per os during EHP. (ABSTRACT TRUNCATED)

[Epidemiology and prevention of cardiovascular diseases after 1989]. / Poznámky k epidemiológii a prevencii kardiovaskulárnych chorôb po roku 1989.

During the past 30 years the geographical distribution of cardiovascular diseases in Europe has substantially changed. The highest rates that were reported in the mid sixties in Finland occurred in 1990/91 occurred in central and eastern Europe. The reasons for such different development of cardiovascular mortality have not been explained yet. The epidemy of cardiovascular diseases in post-socialist countries may be only partially associated with high prevalence of the three classical risk factors (hypercholesterolemia, smoking, hypertension). Presumably other, yet unrecognized risk factors have potentiated the classical ones (psychosocial stress, specific nutritional deficiencies). A decrease in mortality from cardiovascular diseases can be attributed to improvements in care of patients with cardiovascular diseases, mainly with coronary heart disease including AMI, with favourable effects on survival and to a decline in risk factors prevalence or to a combination of both. Similar detailed information for Slovakia is lacking. Therefore it is difficult to predict the future incidence of cardiovascular diseases and AMI in Slovakia. The authors in the review article focused on some epidemiological and preventive aspects of cardiovascular diseases and their implementation at present. In order to achieve a reversal of the unfavourable trend of cardiovascular mortality it is insufficient only to answer the basic questions, as e.g., what was the reason for such differing trends in disease rates and mortality from cardiovascular diseases in our country (and in post-socialist countries of central and eastern Europe) and e.g. in Finland or in the U.S.A., where cardiovascular mortality decreased almost by half. For the appropriate formulation of prevention measures with a focus on cardiovascular diseases, detailed analysis of the current specific situation in our country is also necessary.

[Relation between insulin resistance and small, dense lipoproteins with low density and the development of atherosclerosis in type 2 diabetes mellitus]. / Vztah inzulínovej rezistencie a malých denzných lipoproteínov s nízkou hustotou k rozvoju aterosklerózy pri diabetes mellitus 2. typu.

Diabetes mellitus type 2 (DM type 2) is a common disease that is associated with high mortality and morbidity due to macrovascular and microvascular complications. CHD mortality and morbidity is 2-3 times higher in diabetic than in non-diabetic patients. There are many potentially atherogenic factors in diabetes these may underlie this problems. Except major risk factors (high serum cholesterol concentration, hypertension, cigarette smoking), insulin resistance is common in DM type 2 patients. The dyslipidemic component of insulin resistance is "atherogenic lipoprotein phenotype", its components include small LDL particles (pattern B) with higher atherogenic risk. Several recent studies have demonstrated the preponderance of small, dense LDL in patients with DM type 2 and IR. The question of whether small, dense LDL can be explained by triglyceride levels alone or whether it is directly related to DM type 2 and insulin resistance is still the subject of debate. If serum triglycerides exceed 1.3 mmol/l, small, dense LDL increases. The practical implication is that serum triglyceride levels should be maintained as low as possible to prevent the deleterious effects of triglycerides on LDL subclass distribution and size. There are several potential mechanisms to explain the increased atherogenicity of dense LDL (small dense LDL is more susceptible to lipid peroxidation and oxidation leading to its increased uptake by macrophages and subsequent removal by scavenger pathway, also has a lower binding affinity to LDL receptors). Theoretical grounds postulate that the treating of diabetic dyslipoproteinemias would reduce atherosclerosis disease. However, to date, there have been no intervention studies specifically designed to test this postulate in the diabetic population. Such studies the Diabetes Atherosclerosis Intervention Study (DAIS), Fenofibrate Intervention and Event Lowering in Diabetes (FIELD), Collaborative Atorvastatin in Diabetes Study and Lipid in Diabetes Study are currently in progress. (Tab. 4, Fig. 2, Ref. 81.)

[Reperfusion arrhythmias]. / Reperfúzne arytmie.

Reperfusion arrhythmias originate as a consequence of the complex of cellular and humoral reactions accompanying the opening of coronary artery. As the primary cause of their generation are considered the chemically defined substances that are produced and accumulated in myocardium during reperfusion. The key role is ascribed to free oxygen radicals but of importance are also other substances such as calcium, thrombin, platelet activating factor, inositol triphosphate, angiotensin II and others. These chemical mediators of reperfusion arrhythmias operate as modulators of cellular electrophysiology causing the complex changes at the level of ion channels. It is supposed that in the genesis of reperfusion arrhythmias unlike ischemic arrhytmias operate nonreentrant mechanisms such as abnormal or enhanced automacy and triggered activity due to afterdepolarizations. As a typical reperfusion arrhythmia is considered an early (within 6 hours after start of thrombolysis), frequent (> 30 episodes/hour) and repetitive (occurring during > 3 consecutive hours) accelerated idioventricular rhythm (AIVR). AIVR with such characteristics has a high specificity and positive predictive accuracy but relative low sensitivity as a predictor of reperfusion. Thus, in occurrence of AIVR, recanalization of infarction-related coronary artery is very probable, but in absence of AIVR, reperfusion is still not excluded. The following arrhythmias are regarded also as markers of reperfusion: frequent premature ventricular complexes (> twofold increase in frequency within 90 minutes after the start of thrombolysis), a significant increase of episodes in nonsustained ventricular tachycardia, sinus bradycardia and probably also high-degree atrioventricular blocks. At present, there is no definite evidence, as to whether sustained ventricular tachycardia and especially ventricular fibrillation can be caused by reperfusion. Reperfusion arrhythmias are an important noninvasive marker of successful recanalization of infarction-related coronary artery. However, they are also a sign of reperfusion injury and a finding which may limit the favourable effect of reperfusion. In account of that, there is a very intensive search for pharmacologic interventions which could protect or attenuate the reperfusion injury and thereby also the genesis of reperfusion arrthythmias. Although promising results were obtained with many substances antagonizing the effects of mediators of reperfusion injury, there is no definite recommendation for their use under clinical conditions. However, the results from the latest clinical trials with ACE inhibitors are very promising. These trials render relative conclusive evidence, that ACE inhibitors could have a protective effect against reperfusion arrhythmias. (Ref. 89, Tab. 1.)

[Supraventricular arrhythmias and disorders of atrioventricular and intraventricular conduction in patients with acute myocardial infarct]. / Supraventrikulárne arytmie a poruchy atrioventrikulárneho a intraventrikulárneho vedenia u chorých s akútnym infarktom myokardu.

In addition to ventricular arrhythmias, various forms of supraventricular arrhythmias (SVA) and atrioventricular (AV) and intraventricular (IV) conduction disturbances occur also in acute myocardial infarction (AMI). In the setting of AMI, SVA may be caused by relevant atrial ischemia or infarction. SVA complicate the course especially that of inferior, posterior and lateral AMI. SVA occur frequently also in the right ventricular myocardial infarction and in pericarditis. SVA appearing in the late phase of AMI are caused particularly by hemodynamic factors especially those of both left and right ventricular dysfunctions. Atrial dilatation and the increase of intraatrial pressure are also important factors in the genesis of SVA. The autonomous nervous system, electrolyte disturbances, acidosis and global hypoxia may operate as modulating factors in the development of SVA. AV conduction disturbances are significantly more frequent in patients with inferior than with anterior AMI. In inferior AMI, they are frequently caused by reflex parasympathetic activation. In the genesis of AV conduction disturbances, a significant role may be played also by the following mechanisms: ischemia or necrosis of AV node or AV junction and the negative dromotropic effect of adenosine and potassium which are released to a great extent during myocardial ischemia and reperfusion. A high-degree AV block complicating the course of inferior AMI has a significantly better prognosis than that occurring in the setting of anterior AMI. In inferior AMI, AV block is frequently reversible, whereas in anterior AMI, it is persistent and irreversible. Early AV conduction disturbances, appearing within 24 hours of AMI have a better prognosis than those occurring in the late phase of AMI. Bundle branch blocks (BBB) complicating the course of AMI are caused by occlusion of bundle-related coronary artery or by serious ischemia in its bed. BBB is frequently a marker of a multivessel disease. New BBB appearing in AMI especially the right bundle branch block is considered as an predictor for the development of a complete AV block. Frequent and repetitive SVA as well as serious AV and IV conduction disturbances are frequently associated with a significantly worse clinical course of AMI and with increased mortality, with that of especially hospital mortality. However, this is usually not caused by SVA or AV and IV conduction disturbances per se. The major cause of death in these patients are heart failure, cardiogenic shock and malignant ventricular arrhythmias due to larger AMI, significant reduction of left ventricular function and advanced coronary heart disease. Complex SVA as well as serious AV and IV conduction disturbances are usually considered as markers, but not as independent predictors for both increased hospital mortality and in some cases also for that of posthospital mortality. Their occurrence in AMI may help to identify the patients at great risk who require a very intensive treatment including aggressive management of extensive coronary heart disease. (Ref. 62.)

Audit of cardiovascular diseases.

Project Audit of diagnostic and therapeutic procedures in patients with acute coronary syndromes was approved by the Ministry of Health of the Slovak Republic on 13 May 1996. The essence of the project resides in a systematic and complex analysis of quality of provided medical care and the use of sources with the seeking for possibilities of improvement of the provided care aimed at prognosis and quality of life of patients with acute coronary syndrome (acute infarction, unstable angina pectoris, sudden cardiac death). The subsequent step will reside in the Project of Sudden Cardiac Death Prevention and the establishment of the myocardial infarction register.

Vztah inzulinovej rezistencie a malych denznych lipoproteinov s nizkou hustotou k rozvoju aterosklerozy pri diabetes mellitus 2. typu.

Diabetes mellitus type 2 (DM type 2) is a common disease that is associated with high mortality and morbidity due to macrovascular and microvascular complications. CHD mortality and morbidity is 2--3 times higher in diabetic than in non-diabetic patients/. There are many potentially atherogenic factors in diabetes these may underlie this problems. Except major risk factors (high serum cholesterol concentration, hypertension, cigarette smoking), insulin resistance is common in DM type 2 patients. The dyslipidemic component of insulin resistance is "atherogenic lipoprotein phenotype", its components include small LDL particles (pattern B) with higher atherogenic risk. Several recent studies have demonstrated the preponderance of small, dense LDL in patients with DM type 2 and IR. The question of whether small, dense LDL can be explained by triglyceride levels alone or whether it is directly related to DM type 2 and insulin resistance is still the subject of debate. If serum triglycerides exceed 1,3 mmol/l, small, dense LDL increases. The practical implication is that serum triglyceride levels should be maintained as low as possible to prevent the deleterious effects of triglycerides on LDL subclass distribution and size. There are several potential mechanisms to explain the increased atherogenicity of dense LDL (small dense LDL is more susceptible to lipid peroxidation and oxidation leading to its increased uptake by macrophages and subsequent removal by scavenger pathway, also has a lower binding affinity to LDL receptors). Theoretical grounds postulate that the treating of diabetic dyslipoproteinemias would reduce atherosclerosis disease. However, to date, there have been no intervention studies specifically designed to test this postulate in the diabetic population Such studies the Diabetes Atherosclerosis Intervention Study (DAIS), Fenofibrate Intervention and Event Lowering in Diabetes (FIELD), Collaborative Atorvastatin in Diabetes Study and lipid in Diabetes Study are currently in progress (Tab. 4, Fig. 2, Ref. 81.).

Reperfuzne arytmie.

Reperfusion arrhythmias originate as a consequence of the complex of cellular and humoral reactions accompanying the opening of coronary artery. As the primary cause of their generation are considered the chemically defined substances that are produced and accumulated in myocardium during reperfusion. The key role id ascribed to free oxygen radicals but of importance are also other substances such as calcium, thrombin, platelet activating factor, inositol triphosphate, angiotensin II and others. These chemical mediators of reperfusion arrhythmias operate as modulators of cellular electrophysiology causing the complex changes at the level of ion channels. It is supposed that in the genesis of reperfusion arrhythmias unlike ischemic arrhythmias operate nonreentrant mechanisms such as abnormal or enhanced automacy and triggered activity due to afterdepolarizations. As a typical reperfusion arrhythmia is considered an early (within 6 hours after start of thrombolysis), frequent (> 30 episodes/hour) and repetitive (occurring during > 3 consecutive hours) accelerated idioventricular rhythm (AIVR). AIVR with such characteristics has a high specificity and positive predictive accuracy but relative low sensitivity as a predictor of reperfusion. Thus, in occurrence of AIVR, recanalization of infarction-related coronary artery is very probable, but in absence of AIVR, reperfusion is still not excluded. The following arrhythmias are regarded also as markers of reperfusion: frequent premature ventricular complexes (> twofold increase in frequency within 90 minutes after the start of thrombolysis), a significant increase of episodes in nonsustained ventricular tachycardia, sinus bradycardia and probably also high degree atrioventricular blocks. At present, there is no definite evidence, as to whether sustained ventricular tachycardia and especially ventricular fibrillation can be caused by reperfusion. Reperfusion arrhythmias are an important noninvasive marker of successful recanalization of infarction-related coronary artery. However, they are also a sign of reperfusion injury and a finding which may limit the favourable effect of reperfusion. In account of that, there is a very intensive search for pharmacologic interventions which could protect or attenuate the reperfusion injury and thereby also the genesis of reperfusion arrhythmias. Although promising results were obtained with many substances antagonizing the effects of mediators of reperfusion injury, there is no definite recomendation for their use under clinical conditions. However, the results from the latest clinical trials with ACE inhibitors are very promising. These trials render relative conclusive evidence, that ACE inhibitors could have a protective effect against reperfusion arrhythmias. (Ref. 89, Tab. 1.)

Supraventrikularne arytmie a pouchy atrioventrikularneho a intraventrikularneho vedenia u chorych s akutnym infarktom myokardu.

In addition to ventricular arrhythmias, various forms of supraventricular arrhythmias (SVA) and atrioventricular (AV) and intraventricular (IV) conduction disturbances occur also in acute myocardial infarction (AMI). In the setting of AMI, SVA may be caused by relevant atrial ischemia or infarction. SVA complicate the course especially that of inferior, posterior and lateral AMI, SVA occur frequently also in the right ventricular myocardial infarction and in pericarditis. SVA appearing in the late phase of AMI are caused particularly by hemodynamic factors especially those of both left and right ventricular dysfunctions. Atrial dilatation and the increase of intraatrial pressure are also important factors in the genesis of SVA. The autonomous nervous system, electrolyte disturbances, acidosis and global hypoxia may operate as modulating factors in the development of SVA. AV conduction disturbances are significantly more frequent in patients with inferior than with anterior AMI. In inferior AMI, they are frequently caused by reflex parasympathetic activation. In the genesis of AV conduction disturbances, a significant role may be played also by the following mechanisms: Ischemia or necrosis of AV node or AV junction and the negative dromotropic effect of adenosine and potassium which are released to a great extent during myocardial ischemia and reperfusion. A high-degree AV block complicating the course of inferior AMI has a significantly better prognosis than that occurring in the setting of anterior AMI. In inferior AMI, AV block is frequently reversible, whereas in anterior AMI, it is persistent and irreversible. Early AV conduction disturbances, appearing within 24 hours of AMI have a better prognosis than those occurring in the late phase of AMI. Bundle branch blocks (BBB) complicating the course of AMI are caused by occlusion of bundle-related coronary artery or by serious ischemia in its bed. BBB is frequently a marker of a multivessel disease. New BBB appearing in AMI especially the right bundle branch block is considered as an predictor for the development of a complete AV block. Frequent and repetitive SVA as well as serious AV and IV conduction disturbances are frequently associated with a significantly worse clinically course of AMI and with increased mortality, with that of especially hospital mortality. However, this is usually not caused by SVA or AV and IV conduction disturbances per se. The major cause of death in these patients are heart failure cardiogenic shock and malignant ventricular arrthythmias due to larger AMI, significant reduction of left ventricular function and advanced coronary heart disease. Complex SVA as well as serious AV and IV conduction disturbances are usually considered as markers, but not as independent predictors for both increased hospital mortality and in some cases also for that of posthospital mortality. Their occurrence in AMI may help to identify the patients at great risk who require a very intensive treatment including aggressive management of extensive coronary heart disease. (Ref. 62.).

Informacia o niektorych vysledkoch z Pilotnej studie projektu Ministerstva zdravotnictva SR. AUDIT diagnostickeho a terapeutickeho postupu u chorych s akutnymi koronarnymi syndromami

The basic analysis of the Pilot study fully confirms the possibilities of the realization of the project AUDIT ... in the planned form, the necessity to realize this project regarding the discovery of several negative facts in the management of patients with AMI, which can affect infavourable the course of the disease in patients with AMI and their prognosis or unjustifiably increase the economic impact. The most severe of them are investigated in this information and we present them in subsequent order of individual phases of the management of patients afflicted by AMI.