ANTIPLATELET THERAPY AFTER CORONARY ARTERY BYPASS GRAFT SURGERY - UNEVENNESS OF DAILY CLINICAL PRACTICE.

Antiplatelet therapy is an integral part of optimal medicamentous therapy in patients with coronary artery disease. The strategy of antiplatelet/anticoagulant therapy is adjusted (combination of drugs, dosing and duration of therapy) depending on the stage of the disease (acute coronary syndrome with percutaneous coronary intervention, chronic coronary syndrome, or coronary surgical revascularization) and comorbidity of each patient (e.g., atrial fibrillation, left ventricular thrombus, etc.). Guidelines and clinical practice in particular are not uniform and specific regarding dual antiplatelet therapy in patients undergoing coronary artery bypass grafting, especially in the setting of chronic coronary syndrome.

TORSADES DE POINTES IN ELDERLY PATIENT WITH PAROXYSMAL ATRIAL FIBRILLATION TREATED BY SHORT-TERM PARENTERAL AMIODARONE THERAPY.

One of the drugs that are widely used in the treatment of atrial fibrillation is amiodarone. Despite considerable prolongation of the corrected QT interval and a substantial degree of bradycardia, amiodarone exhibits a remarkably low frequency of pro-arrhythmic events and <1.0% incidence of torsades de pointes, mostly after long-term usage. We present a case of an 80-year-old female with paroxysmal atrial fibrillation accompanied by acute heart failure treated by short-term parenteral amiodarone therapy and development of torsades de pointes.

Changes in Heart Rate Variability after Coronary Artery Bypass Grafting and Clinical Importance of These Findings.

Heart rate variability is a physiological feature indicating the influence of the autonomic nervous system on the heart rate. Association of the reduced heart rate variability due to myocardial infarction and the increased postinfarction mortality was first described more than thirty years ago. Many studies have unequivocally demonstrated that coronary artery bypass grafting surgery generally leads to significant reduction in heart rate variability, which is even more pronounced than after myocardial infarction. Pathophysiologically, however, the mechanisms of heart rate variability reduction associated with acute myocardial infarction and coronary artery bypass grafting are different. Generally, heart rate variability gradually recovers to the preoperative values within six months of the procedure. Unlike the reduced heart rate variability in patients having sustained myocardial infarction, a finding of reduced heart rate variability after coronary artery bypass surgery is not considered relevant in predicting mortality. Current knowledge about changes in heart rate variability in coronary patients and clinical relevance of such a finding in patients undergoing coronary artery bypass grafting are presented.

Influence of in-hospital cardiac rehabilitation on psychological status after myocardial infarction in patients with D-type personality.

The aim of this study was to determine the number of D-type personality patients in the group with a history of myocardial infarction (MI) and the influence of comprehensive in-hospital cardiac rehabilitation (iCR) on their psychological status (PS). The study included 316 consecutive patients aged 18 to 65 with MI in the last six months admitted into the programme of iCR. Surgical revascularized patients, clinically unstable patients and patients with sever chronic diseases and disorders were excluded. At the beginning and in the end of iCR diagnostic exam, hematological/biochemical blood analysis, ergometric testing was conducted. At the beginning and four weeks after the finish of the iCR estimation of PS was conducted. Distress scale 14 (DS14) questioner was used for that purpose. In the period of three weeks, patients were included in the programme of comprehensive iCR. Out of 316 patients in the study group 83.2% were male, while 16.8% were female. Average age of the patient was 51.3 +/- 7.2. When being admitted to iCR 42.7% patients had characteristics of D-type personality. Those patients had substantially lower level of body mass and body mass index. In the same time there were no differences among groups in risk factors, values of clinical, laboratory and diagnostic parameters. During iCR study group had more complications in comparison to the control group. At the end of iCR substantial rise of functional capacity of patients, improvement of lipid profile and lowering of glycaemia was recorded. Also at the end of iCR antiarrhythmics and psychopharmaceutical medicaments were more often prescribed to the patients in the study group. Four weeks after the iCR share of D-type personality patients was 41% and 71% of study group patients kept their D-type structure.

Heart Rate Variability after Off-Pump versus On-Pump Coronary Artery Bypass Graft Surgery.

Background. It is known that after coronary artery bypass graft surgery (CABG) heart rate variability (HRV) becomes significantly decreased with a gradual recovery in a few months after surgery. However, literature data about the impact of the off-pump CABG on postoperative HRV are not complete. Therefore, the aim of this study was to analyze postoperative value of HRV in CABG patients operated on with off-pump versus on-pump coronary surgery. Methods. This study included 206 consecutive patients who underwent CABG. Sixty six patients (32%) were operated on off-pump while 140 patients (68%) were operated on using the machine for extracorporal circulation. HRV was analyzed from 24-hours Holter electrocardiogram recordings. Results. No significant differences in postoperative values of HRV variables were found between off-pump versus on-pump CABG patients (Mean RR interval 885 +/- 106 versus 879 +/- 125 ms, standard deviation of all normal R-R intervals 107 +/- 30 versus 105 +/- 34 ms, NS, total power 2298 +/- 2472 versus 2156 +/- 1913 ms(2), NS). Conclusions. The results of the study showed that there are no differences in HRV few months after surgery between patients operated on with off-pump versus on-pump CABG.

[Incidence of major adverse cardiovascular events after cardiac surgery procedures]. / Pojavnost velikih nezeljenih srcanozilnih dogadaja nakon kardiokirurskih zahvata.

The aim of the study was to analyze the incidence of major adverse cardiovascular events after different cardiac surgery procedures. This study included 307 patients who underwent some of cardiac surgery procedures within a period of 6 months of arriving at stationary cardiac rehabilitation. There were 101 patients (33%) who had valve surgery and 206 patients (67%) who underwent coronary artery bypass grafting (CABG). Primary end-point was death caused by fatal myocardial infarction (MI) or sudden death, and secondary end-points were non-fatal MI or unstable angina pectoris, stroke, new cardiac surgery or percutaneous coronary intervention, heart failure or significant arrhythmia and non-cardiac death. The mean duration of follow-up period after leaving stationary cardiac rehabilitation was 35 +/- 21 months. During the follow up period, there was total of 61 primary and secondary end-points. In CABG group, there were 48 major adverse cardiovascular events compared to 13 in the group of patients with prosthetic valve (p=0.03). There was total of 19 fatal MI or sudden death (6%). The fatal outcome rates of cardiovascular origin were significantly higher in the group of patients after CABG than in the patients with prosthetic valve (16 vs. 3 death, NS). The results of this study suggest that the complications after cardiac surgery procedures occurs more often in CABG patients. However, mortality rate after cardiac surgery in the analyzed groups of patients is relatively low.

[Tako-Tsubo cardiomyopathy; reversible left ventricular dysfunction mimicking acute myocardial infarction with ST-elevation]. / Tako-Tsubo kardiomiopatija; reverzibilna disfunkcija lijeve klijetke koja oponasa akutni infarkt miokarda sa ST-elevacijom.

Tako-Tsubo cardiomyopathy is still en entity of unknown etiology and pathophysiology which clinically manifests with sudden, severe chest pain and/or dyspnea. It is generally triggered by emotional or physical stress and most cases are reported in postmenopausal women. Electrocardiographic changes are similar to acute myocardial infarction with ST-elevation, laboratory markers of myocardial lesion are usually mild to moderately high, and coronary angiography shows no significant pathomorphological changes of epicardial coronary arteries. Ventriculography and echocardiography show reversible akinesis and ballooning of the left ventricular apex with reduced ejection fraction which is usually normalized within 2-4 weeks. Generally, Tako-Tsubo cardiomyopathy has a good prognosis, in-hospital mortality rate is about 1%. In this article, we present a review about todays knowledge on Tako-Tsubo cardiomyopathy.

Stress cardiomyopathy with ST-segment elevation of the anterolateral location complicated by a secondary massive intracranial bleeding.

Stress cardiomyopathy or Tako-Tsubo Syndrome (TTS) clinically manifests with sudden chest pain and/or dyspnea, and is generally triggered by emotional or physical stress. Electrocardiographic (ECG) changes are similar to acute myocardial infarction with ST-elevation, but coronarography shows no significant pathomorphological changes of coronary arteries. Ventriculography and echocardiography show reversible akinesis and ballooning of the left ventricle apex with reduced ejection fraction. Like as it is with TTS, similar ECG changes are extensively reported in patients with intracerebral bleeding. We reported the case of a 52-year-old female patient who was clinically presented with stress cardiomyopathy with ST-segment elevation of the anterolateral location complicated by a secondary massive intracranial bleeding. Many cases of TTS or ECG changes in intracranial bleeding were described separately, but to our knowledge, this is the first report where both events developed in the same patient with the fatal outcome.

Unremitting embolus from cardiac myxoma at circumflex artery trifurcation.

Embolisation of coronary artery from cardiac myxoma is very rare and it is not clear what happens with embolic material inside coronary artery after myocardial infarction. The natural course of myxomatous embolus is important because it determines the mode of surgical intervention. Different options of the course of embolus have been speculated, from spontaneous resorption to growth at artery wall. We report a case of embolisation of the circumflex artery trifurcation from a villous left atrial myxoma. The course of the embolus was displayed by coronary angiography repeated 6 months after myocardial infarction. Unlike the previously published case report, we found the embolus to be unremitting.

Characteristics of heart rate variability in war veterans with post-traumatic stress disorder after myocardial infarction.

OBJECTIVE: The goal of the study was to evaluate differences in heart rate variability (HRV) among post-myocardial infarction (MI) patients, depending on their participation in the Croatian war and on established diagnoses of post-traumatic stress disorder (PTSD). METHODS: The study included 34 male war veterans with diagnosed PTSD who had suffered a first MI and 34 age-matched post-MI patients without PTSD. Cardiac autonomic balance was evaluated through HRV analysis. RESULTS: There were no differences in the mean R-R interval or overall HRV between the analyzed groups. Post-MI patients with PTSD had lower values for the square root of the mean of squared successive differences in R-R intervals (p = 0.02), the percentage of R-R intervals that were > or =50 milliseconds different from the previous interval (p = 0.03), and the high-frequency component (p = 0.03) but had higher values for the low-frequency component (p = 0.01) and the low-frequency/high-frequency ratio (p = 0.02), compared with post-MI patients without PTSD. CONCLUSION: Post-MI patients with PTSD have higher sympathetic and lower parasympathetic heart rate modulation activity, compared with patients with MI and no PTSD.

[Functional capacity in patients after myocardial infarction dependent on treatment strategy in acute phase of disease]. / Funkcionalni kapacitet bolesnika s preboljelim infarktom miokarda ovisno o nacinu lijecenja u akutnoj fazi bolesti.

BACKGROUND AND AIM: Recently published studies suggest that percutaneous coronary inetrvention (PCI) is superior to fibrinolysis in terms of early and late mortality in patients with acute myocardial infarction (MI) with ST-elevation. The aim of this study was to evaluate the influence of treatment strategy in the acute phase of MI on postinfarction functional capacity. PATIENTS AND METHODS: This prospective study included 128 consecutive patients with MI, with ST-elevation over 12 weeks from the disease onset. There were 92 (72%) male and 36 (28%) female patients, mean age 59 +/- 10 years. Inclusion criteria were age under 70, first MI with ST-elevation, and sinus rhythm. Exclusion criteria were previous MI, non ST-elevation MI, acute heart failure, atrial fibrillation, unstable angina pectoris, re-IM or necessity for coronarography and PCI during rehabilitation, and other acute disease. Patients were divided into three groups according to treatment modality: group 1, 38 (30%) patients treated with primary PCI; group 2, 46 (36%) patients treated with fibrinolysis; and group 3, 44 (34%) conservatively treated patients. There were no significant between-group differences according to age, sex, risk factors for coronary artery disease, infarct site, and frequency of complications in the acute phase of MI. The functional capacity of patients was evaluated by symptom-limited exercise test. Echocardiographic examinations were also done in each patient. Statistical analysis was performed by using the commercial software package, Microsoft SPSS for Windows, Version 8.0. Results were expressed as a mean standard deviation. Differences between the groups were tested by analysis of variance (ANOVA) and post hoc Tuckey test. The value of p < 0.05 was considered statistically significant. RESULTS: At the end of rehabilitation, the mean values of exercise capacity in groups 1, 2 and 3 were 6.1 +/- 1.3, 5.5 +/- 1.2, and 4.8 +/- 1.3 METs, respectively (group 1 vs. 2, p = 0.03; group 1 vs. 3, p < 0.001; group 2 vs. 3, p = 0.01). The mean values of ejection fraction in groups 1, 2 and 3 were 56 +/- 10, 53 +/- 9 and 47 +/- 11, respectively (group 1 vs. 2, p = 0.03; group 1 vs. 3, p < 0.001: group 2 vs. 3, p = 0.009). Four (3%) patients were excluded from the study because of complications during rehabilitation treatment. CONCLUSION: Postinfarction functional capacity in patients with MI depends on treatment strategy in the acute phase of disease. Patients who underwent PCI in the acute phase of MI had a higher functional capacity and better preserved systolic function of the left ventricle in comparison with patients who received fibrinolysis or those who were treated conservatively.

[Place and role of cardiac rehabilitation in modern cardiology]. / Mjesto i uloga kardioloske rehabilitacije u suvremenoj kardiologiji.

Atherosclerotic cardiovascular disease is the major cause of death in middle-aged and older adults in most developing countries in the world. Numerous strong evidences in professional and scientific literature showed that regular aerobic exercise training and cardiac rehabilitation programmes lead to significant reduction in the risk profile and mortality of cardiac patients. However, less than 1/3 of patients eligible for cardiac rehabilitation currently participate in formal rehabilitation programmes in most European countries. In this review, we present today's "evidence-based" knowledge about many positive effects of cardiac rehabilitation with purpose to promote its greater use in daily clinical work.

The effect of 3-weeks stationary cardiac rehabilitation on plasma lipids level in 444 patients with coronary heart disease.

The aim of this study was to investigate the effect of 3-weeks stationary cardiac rehabilitation on plasma lipids level in patients with CHD. The study included 444 consecutive patients (364 male and 80 female, mean age 58 +/- 9 year) with CHD who underwent 3-weeks stationary cardiac rehabilitation. Patients were divided into groups depending on their baseline levels of cholesterol and medication therapy: patients with normal (< 5 mmol/L, group I, 129 patients) and elevate plasma level of Total cholesterol (> 5 mmol/L, group II, 315 patients) and subgroups Ia and IIa (with statin in therapy), Ib and IIb (without statin in therapy). After 3-weeks cardiac rehabilitation, the levels of Total cholesterol 5.75 +/- 1.34 vs. 5.17 +/- 1.08 mmol/l; p < 0.001, triglycerides 2.04 +/- 1.33 vs. 1.81 +/- 1.06 mmol/L; p = 0.004, LDL-cholesterol 3.77 +/- 1.14 vs. 3.21 +/- 0.96 mmol/L; p < 0.001 were significantly lower while the level of HDL-cholesterol 0.94 +/- 0.28 vs. 0.99 +/- 0.27 mmol/L; p = 0.008 were significantly higher in comparison with the baseline values. Furthermore, we found significant changes in lipid profile at the end of rehabilitation in each group of patients compared with the baseline values. There were no significant differences in plasma lipids level between group of patients with or without statin in therapy at the end of rehabilitation. The results of this study suggest that moderate regular physical activity and diet alone or in combination with hypolipidemic drugs already after 3 weeks have a favourable effect on plasma lipids level and should be propagate in the prevention of CHD.