Impact of hypertension on postreperfusion left ventricular recovery in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease.

OBJECTIVE: The aim of this study was to investigate the impact of admission systolic blood pressure (ASBP) and left ventricular (LV) mass on the postreperfusion LV recovery in patients with ST-segment elevation myocardial infarction (STEMI) and concomitant coronary multivessel disease (MVD). MATERIALS AND METHODS: A retrospective analysis of 12-month postreperfusion LV recovery was performed in 104 patients after primary percutaneous coronary intervention (PPCI). Patients with elevated ASBP (>140mmHg) were assigned to the first group (n=58); with normal ASBP (<140mmHg), to the second group (n=46); with increased myocardial mass index (MMI) (>100g/m(2)), to the third group (n=70); and with normal MMI (<100g/m(2)), to the fourth group (n=34). Severity of MVD was evaluated by the Syntax score. The LV recovery was assessed by evolution of quantitative characteristics of electrocardiography (QRS score, ST score, ECG STEMI stage) and echocardiography (LV ejection fraction, volume and mass indices) registered before and after PPCI, at discharge, and after 1, 6, and 12 months. RESULTS: There were no significant differences in the baseline QRS and ST scores, ECG STEMI stage, LVEF, MMI, and Syntax score comparing all the patients' groups. The serial ECG criteria showed only a very small impact of ASBP on postreperfusion LV recovery. Only ECG STEMI stage progression was slower in the patients with elevated ASBP. In patients with different MMI, the QRS and ST scores were higher and ECG STEMI stage was lower in patients with increased MMI. LVEF after 1 year was significantly lower in the third group as compared to the fourth group (42.58%±8.25% vs. 46.8%±7.13%, P=0.018). CONCLUSION: Postreperfusion LV recovery was more related not to ASBP but to the increased LV mass assessed by echocardiography in patients with STEMI and MVD.

Prognostic value of myocardial perfusion abnormalities for long-term prognosis in patients after coronary artery bypass grafting.

AIMS: The objective was to evaluate the prognostic value of exercise myocardial perfusion scintigraphy (MPS) in patients who underwent coronary artery bypass grafting (CABG). SUBJECTS AND METHODS: A retrospective, one-center study of 361 patients with multivessel coronary artery disease was carried out. All the patients underwent MPS after CABG due to worsened health status. MPS was performed at 4.5 years standard deviation (SD: 0.2), based on symptoms. MPS was carried out using Tc-99m methoxy isobutyl isonitrile and following a 1-day protocol (stress-rest). The end points were analyzed at 6.5 years (SD: 3.3) after MPS, on the average. STATISTICAL ANALYSIS USED: SPSS software for Windows, version 13.0. The t-test or the χ(2)-test was used. Survival times were calculated. A multivariate Cox proportional hazards model was developed. RESULTS: During the follow-up, death occurred in 54 patients, and 37 patients experienced major adverse cardiovascular events (MACE). In the multivariate analysis, advanced age hazard ratio (HR: 1.45; 95% confidence interval [CI]: 1.4-2.02; P = 0.027), previous myocardial infarction (HR: 3.17; 95% CI: 1.22-8.2; P = 0.018), left ventricular ejection fraction of <40% (HR: 2.16; 95% CI: 1.2-3.89; P = 0.01), and the summed stress score (SSS) of ≥4 (HR: 1.87; 95% CI: 1.02-3.41; P = 0.04) were independent predictors of all-cause death. The summed difference score (SDS) was the only independent predictor of MACE (HR: 1.26; 95% CI: 1.06-1.48; P = 0.034). CONCLUSIONS: The parameters of MPS were found to have prognostic value in the long-term period after CABG. Advanced age, previous myocardial infarction, decreased left ventricular ejection fraction, and the abnormal SSS were associated with an increased risk of all-cause death. The SDS was found to be the only significant risk factor for MACE.

Identification of predictors of inhospital postreperfusion mode of death in patients with acute ST-elevation myocardial infarction.

OBJECTIVES. The aim of this study was to identify the predictors of the postreperfusion mode of death using the distinctions in clinical characteristics of patients who died and survived after reperfusion therapy, treated due to ST-elevation myocardial infarction (STEMI). MATERIAL AND METHODS. This consecutive study has involved 36 patients: 18 patients who died from progressive heart failure (PHF) (group 1, n=13) or from cardiac rupture (CR) (group 2, n=5) after primary coronary intervention. The control group consisted of 18 randomly selected patients who survived in-hospital period (group 3). The initial and postreperfusion heart rate (HR), systolic and diastolic arterial pressures (SAP and DAP), maximal ST elevation (max ST upward arrow) and depression (max ST downward arrow), ST score, TIMI flow grade, coronary score (CS), and their perireperfusion changes were assessed for each patient. The complex prognostic predictors--TIMI Risk Score and TIMI Risk Index--were also assessed. The data analysis was performed by standard statistical and machine learning approach methods. RESULTS. The comparison of three patients' groups according to simple ECG or circulatory characteristics showed that more significant differences were seen in postreperfusion characteristics or their perireperfusion changes. Herewith, the major part of significantly different characteristics (baseline SAP, DAP, and HR, postreperfusion SAP, DAP, ST score, and TIMI flow grade, resolution of ST score) was observed comparing both the groups of dead patients with survivors (control group). The differences in the complex predictors (TIMI Risk Score and TIMI Risk Index) were similar. However, the smallest number of significantly different characteristics was seen comparing both the groups of dead patients. The baseline DAP (P=0.045), postreperfusion SAP (P=0.04) and DAP (P=0.03), and ST score (P=0.0025) were higher in the patients who died from CR. The postreperfusion ST score and SAP were also identified as necessary components in the assessment of informative prognostic sets according to feature selection methods used in data mining field. CONCLUSION. The postreperfusion ST score, SAP, and DAP could be useful for the prediction of in-hospital postreperfusion mode of death in patients with STEMI; evidently more clinical predictors could be useful for the prediction of general occurrence of postreperfusion deaths.

[Data of coronary angiography and normal stress myocardial perfusion scintigraphy]. / Normali kruvio miokardo perfuzija ir vainikiniu arteriju bukle.

OBJECTIVE: To determine informativity of clinical variables in predicting significant coronary artery disease in patients with chest pain and normal stress myocardial perfusion scintigraphy. MATERIAL AND METHODS: This study was a retrospective analysis of data of coronary angiography performed in 84 patients with chest pain and normal stress myocardial perfusion scintigraphy during 2000-2007. Single-photon emission computed tomography was performed following a one-day protocol (stress-rest). A 5-point (0-4) scoring system in a 20-segment model was used for interpretation of results. Myocardial perfusion was considered normal if the sum of stress scores was 0 to 3. RESULTS: High pretest probability and informative exercise-terminating criteria were documented in 25% and 45.2% of patients, respectively. Significant coronary artery disease (stenosis ≥ 75%) was determined in 26 (31%) patients with normal myocardial perfusion scintigraphy: 15 (17.9%) patients had coronary artery disease of a single vessel, 5 (6%) of two vessels, and 6 (7.1%) of three vessels. Univariate logistic regression analysis showed that patients with typical angina and high pretest probability were more likely to have significant stenosis of one to three arteries (odds ratios, 3.8; P=0.008 and 3.43; P=0.023, respectively). Three-vessel disease was more often documented in patients with typical angina (odds ratio, 11.2; P=0.009), high pretest probability (odds ratio, 7.93; P=0.018), and signs of ischemia during exercise test (odds ratio, 6.4; P=0.037). CONCLUSION: Patients with typical angina, high pretest probability, and signs of ischemia during exercise test have an increased probability of having significant coronary artery disease despite normal stress myocardial perfusion scintigraphy; therefore, this group of patients should undergo coronary angiography.

The value of 99mTc-MIBI myocardial perfusion imaging in differentiation of heart failure conditioned by global left ventricular systolic impairment.

OBJECTIVE: The global left ventricular systolic impairment with left ventricular dilatation can manifest due to idiopathic dilated cardiomyopathy or ischemic heart disease and can present a similar clinical picture of severe heart failure. The aim of our investigation was to assess a differential diagnostic value of resting (99m)Tc-MIBI myocardial perfusion defects in evaluation of the etiology of heart failure. MATERIAL AND METHODS: The data of 2D echocardiography, coronary angiography, and myocardial gated single photon emission computed tomography with (99m)Tc-MIBI investigation were evaluated in 43 patients with global left ventricular systolic impairment, characterized by left ventricular end-diastolic diameter of > or =65 mm and ejection fraction of < or =40%. The idiopathic dilative cardiomyopathy was diagnosed in 26 patients (Group 1) and ischemic heart failure in 17 patients (Group 2). The area and the degree (severity) of myocardial perfusion defects (AMPD and DMPD) at rest in regions supplied by three coronary arteries were evaluated in all the patients. RESULTS: The area of perfusion defects in the left anterior descending (LAD) and right coronary artery (RCA) regions in dilative cardiomyopathy patients was smaller than in ischemic heart failure patients (1.43+/-0.9 vs 2.53+/-0.53, P=0.001, and 2.19+/-0.6 vs 2.82+/-0.56, P=0.02). The degree of perfusion defects was also less severe in the same circulation regions (1.39+/-0.93 vs 2.59+/-0.6, P=0.01, and 1.6+/-0.46 vs 2.71+/-0.15, P=0.001). We have designed a logistic regression model expressed by formula x=2.52AMPD(rca)+2.47AMPD(lad)+2.21DMPD(rca). Idiopathic dilative cardiomyopathy was predicted when x was < or =16 and ischemic heart failure when x was >16. The sensitivity in predicting idiopathic dilative cardiomyopathy was 94.44%, and the specificity was 88.24%. CONCLUSION: The difference in the area and degree of (99m)Tc-MIBI myocardial perfusion defects at rest in patients with heart failure caused by idiopathic dilative cardiomyopathy or ischemic heart failure is measurable and has a predictive value for differentiation of the etiology of global left ventricular systolic impairment.

Changes of electrocardiographic and echocardiographic data after early and late mechanical recanalization of infarct-related artery with and without stent implantation.

OBJECTIVE: To show differences in the changes of electrocardiographic and echocardiographic data after early and late mechanical recanalization of infarct related artery with and without stent implantation and to assess the value of QRS score in the follow-up period. MATERIAL AND METHODS: A total of 248 consecutive patients were divided into these groups: early angioplasty (24 hours) angioplasty without stents (n=114) or with stents (n=14). The changes in QRS score and echocardiographic left ventricular ejection fraction during the hospital and 3-month follow-up periods were compared between the groups. RESULTS: QRS score did not increase in a hospital in early or late angioplasty with stents groups, while in the groups without stents especially of early angioplasty increased (2.6+/-2.5 vs. 3.6+/-2.4, P=0.001). Left ventricular ejection fraction increased after 3 months only in early angioplasty groups especially with stents (30.0+/-3.5 vs. 38.4+/-5.2, P=0.008), but there were no significant differences between the QRS score at discharge and after 3 months (5.4+/-4.3 vs. 5.0+/-1.9). CONCLUSIONS: Myocardial injury did not increase in a hospital in the cases of early or late angioplasty with stents, while in the cases without stents increased. Left ventricular ejection fraction increased after 3 months only in the cases of early angioplasty especially with the stent implantation, but the QRS score showed no differences, so the QRS score may be not predictive of improvement in ejection fraction at follow-up.

Prediction of improvement in left ventricular function during a 1-year follow-up after acute myocardial infarction by the degree of acute resolution of electrocardiographic changes.

BACKGROUND AND PURPOSE: Reperfusion therapy results in better left ventricle (LV) function in cases of successful myocardial reperfusion; however, insufficient reperfusion or reocclusion of the infarct-related artery is associated with LV dysfunction. This study was proposed to determine whether the rate of ECG stage dynamics, after mechanical, thrombolytic, or spontaneous recanalization, is a predictor of improvement in LV function. METHODS: Twenty-seven consecutive patients, observed for 1 year, were divided into group A (11, change rate of > or =2 ECG stages per 2 days), group B (13, no rapid change), and cases with reocclusion (3). RESULTS: Clinical and radiographic signs of heart failure tended to decrease in group A but tended to increase in other cases. Echocardiographic dyssynergic score decreased, and LV ejection fraction increased only in group A: 4.3 +/- 1.2 vs 2.7 +/- 1.5, P = .04, and 42.0 +/- 4.8 vs 46.0 +/- 8.3, P = .049, respectively; in group B, the values were 3.4 +/- 2.4 vs 3.4 +/- 2.2 and 44.0 +/- 6.9 vs 43.8 +/- 9.3, respectively. CONCLUSIONS: Rapid ECG stage changes predict follow-up improvement in LV function.

Exercise training after coronary angioplasty improves cardiorespiratory function.

AIM: The aim of this prospective randomized study was to evaluate the impact of long-term aerobic exercise training on respiratory function, left ventricular systolic function and remodeling in patients with coronary heart disease and ischemic heart failure after successful angioplasty. DESIGN: Patients (n=185) have undergone Doppler echocardiography and ergospirometry. Ninety-five patients practiced 6 month-term aerobic exercise training, less by 10% to their anaerobic threshold. Ninety patients were studied as controls. They were given only drug treatment without training. Measurements were repeated after 6 and 12 months. RESULTS: Training group patients after 6 months showed significant (p<0.05) improvement in exercise capacity, oxygen consumption and ventilating equivalents. The Doppler echocardiographic findings revealed significant (p<0.05) improvement in ejection fraction, left ventricular and atria morphometric data. Improved ergospirometric and echocardiographic data were established after 12 months, too. CONCLUSIONS: Long-term aerobic exercise training is an effective and workable measure improving respiratory efficiency, left ventricular systolic function, attenuating negative remodeling and stopping further progression in patients with coronary heart disease and chronic heart failure after successful angioplasty.

[Stents in interventional cardiology]. / Kraujagysliu pletikliai intervencineje kardiologijoje.

Since the first percutaneous transluminal coronary angioplasty performed by A. Gruentzig in 1977, percutaneous coronary interventions have become the most important treatment modality for coronary heart disease. Coronary angioplasty carried a significant risk of coronary flow-limiting dissections and restenosis during the first six months following the procedure. Two main studies comparing percutaneous transluminal coronary angioplasty and coronary stenting (STRESS and BENESTENT) performed in 1994 showed a significant reduction in restenosis rate using stents. Thus, until now stents are the most widely used devices for coronary intervention despite two problems: subacute stent thrombosis (1-2%) and still high restenosis rate (5-40%). Subacute stent thrombosis occurs within the first month after stent placement and can be prevented using the double antiplatelet regimen with aspirin and clopidogrel. Some risk of subacute thrombosis remains beyond the first month when drug-eluting stents are used. This requires prolonged antiplatelet therapy. Drug-eluting stents are the most significant innovation in interventional cardiology. They can reduce the incidence of restenosis in native stable coronary arteries to 3-5%. However, the long-term studies comparing bare-metal stents and drug-eluting stents did not show any significant differences in the rate of major adverse cardiac events (death, myocardial infarction), especially in patients with diabetes after the treatment of bifurcational lesions. According to proposed recommendations, drug-eluting stents should be used in small vessels, restenotic lesions, and in saphenous vein grafts. Despite some disadvantages, the results of coronary stenting using drug-eluting stents continue to improve.

Percutaneous coronary interventions in Europe 1992-2003.

AIMS: The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe. We report the data of the year 2003 and give an overview of the development of coronary interventions since 1992, when the first data collection was performed. METHODS AND RESULTS: Questionnaires were distributed yearly to delegates of all national societies of cardiology represented in the European Society of Cardiology to collect the case numbers of all local institutions and operators. The overall numbers of coronary angiographies increased from 1992 to 2003 from 684,000 to 1,993,000 (from 1,250 to 3,500 per million inhabitants). The respective numbers for percutaneous coronary interventions (PCI-coronary angioplasty) and coronary stenting procedures increased from 184,000 to 733,000 (from 335 to 1,300) and from 3,000 to 610,000 (from 5 to 1,100), respectively. Germany has been the most active country for the past years with 653,000 angiographies (7,800), 222,000 angioplasties (2,500), and 180,000 stenting procedures (2,200) in 2003. The indication has shifted towards acute coronary syndromes, as demonstrated by raising rates of interventions for acute myocardial infarction over the last decade. The procedures are more readily performed and safer, as shown by increasing rate of "ad hoc" PCI and decreasing need for emergency coronary artery bypass surgery (CABG). In 2003, use of drug-eluting stents had further increased. However, an enormous variability is reported with the highest rate in Portugal (55%). CONCLUSION: Interventional cardiology in Europe is still expanding, mainly but not exclusively due to rapid growth in the eastern European countries. A number of new coronary revascularization procedures introduced over the years have all but disappeared. Only stenting has experienced an exponential growth. The same can be forecast for drug-eluting stenting.

[The diagnostic value of non-invasive tests for determining idiopathic dilated, ischemic and hypertensive cardiomyopathies]. / Neinvaziniu tyrimu svarba atskiriant idiopatine dilatacine, isemine ir hipertenzine kardiomiopatijas.

UNLABELLED: The objectives of this study were to detect regional myocardial perfusion defects performing 99mTc-MIBI myocardial perfusion imaging and to compare the results with echocardiography for differential diagnostics of the idiopathic dilated, ischemic and hypertensive cardiomyopathies until coronary angiography will be performed. MATERIAL AND METHODS: In total 90 patients with cardiomegaly have been evaluated: 30 patients with idiopathic dilated cardiomyopathy (group I), 30 with ischemic cardiomyopathy (group II) and 30 with hypertensive cardiomyopathy (group III). All patients underwent 2D echocardiography examination and 99mTc-MIBI myocardial perfusion imaging before coronary angiography was done. RESULTS: Informative complex findings (age, thickness of the interventricular septum, thickness of the left ventricle posterior wall, the wall motion score index in the region of the right coronary artery and the left anterior descending branch and the degree of distress of myocardial perfusion in the area of right coronary artery circulation) selected by variable logic model enabled to differentiate patients with idiopathic dilated, ischemic and hypertensive cardiomyopathies with an accuracy of 92.0%, 86.2% and 79.2%, respectively. CONCLUSION: Informative echocardiographic indices (thickness of the interventricular septum and left ventricle posterior wall, the mass of the myocardium, the wall motion score index in the region of the right coronary artery and left anterior descending branch, ejection fraction) selected by discriminative analysis enabled to differentiate patients with idiopathic dilated, ischemic and hypertensive cardiomyopathies with an accuracy of 62.1%, 75.2% and 80.0%, respectively.

[JT interval changes in acute myocardial infarction following coronary angioplasty]. / Ligoniu, serganciu uminiu miokardo infarktu, JT intervalo kitimai mechanines vainikiniu arteriju rekanalizacijos metu.

OBJECTIVE: The aim of the study was to determine the influence of early reperfusion on the behavior of JT interval in patients with acute myocardial infarction undergoing percutaneous transluminal coronary angioplasty. MATERIAL AND METHODS: Coronary angiography and percutaneous transluminal coronary angioplasty were done for 14 acute myocardial infarction patients. Measurements were performed from 12-lead surface electrocardiogram with "Kaunas-Load" equipment before percutaneous transluminal coronary angioplasty, 5 minutes and 24 hours after it. RESULTS: Immediately after percutaneous transluminal coronary angioplasty there were shortenings of JT and JT dispersion (JTd) and after 24 hours in all the patients prolongation of JT and JTd intervals was observed. CONCLUSIONS: Changes of the repolarization during percutaneous transluminal coronary angioplasty could be related with ischemic myocardial lesion. Early reperfusion has positive impact on the ventricular repolarization.

[Interventional cardiology in Lithuania: current status and perspectives]. / Intervencine kardiologija Lietuvoje. Dabartine situacija ir perspektyvos.

The objective of the article is to evaluate current status of interventional cardiology in Lithuania, to compare these data with the results of interventional cardiology of other European countries and to discuss about perspectives of interventional cardiology in Lithuania. A detailed questionnaire of interventional cardiology of European Society of Cardiology was used for analysis of Lithuanian interventional cardiology data of 2000-2002. Lithuanian interventional cardiologists in 2000-2002 annually performed respectively 1535, 1666 and 2085 coronary angiographies, 500, 532 and 632 PTCA, 120, 133 and 193 stenting procedures per 1000000 inhabitants. According to morbidity of heart diseases in Lithuania and the rate of interventional procedures in Europe, in 2004 more than 9000 coronary angiographies should be performed, 3000 percutaneous transluminal coronary angioplast procedures, and 2000 coronary stent implantations in Lithuania. Achievement of such results would be possible, if the State Sickness Fund and the Ministry of Health would pay more attention to financial problems of interventional cardiology in Lithuania. In conclusion, it can be stated that there are good perspectives for Lithuanian cardiologists to achieve mean European level of interventional procedures in the nearest future.

[Results of percutaneous coronary angioplasty in patients with stable and unstable angina]. / Serganciuju stabiliaja ir nestabiliaja krutines angina perkutanines vainikiniu arteriju angioplastikos rezultatai.

Percutaneous coronary angioplasty is very well known percutaneous revascularization procedure. Results of the percutaneous coronary angioplasty vary according to the stage of ischemic heart disease. The aim of our study was to evaluate and to compare the results of percutaneous coronary angioplasty in patients with stable and unstable angina. We analyzed data from 1148 patients in both groups. The extent of atherosclerosis was significantly higher in unstable angina group, however there was no significant difference in procedural as well in in-hospital outcomes between two groups. Success rate was 86% in unstable angina group and 83.3% in stable angina group. Major adverse cardiac events occurred in 1.48% patients with no difference in both groups. Left ventricular ejection fraction and end-diastolic diameter improved more in unstable angina group.

[Percutaneous revascularization of myocardium: extent, application and treatment strategy of acute coronary syndromes]. / Perkutanine miokardo revaskulizacija ligoniams, sergantiems uminiais koronariniais sindromais. Gydymo apimtys ir strategija.

UNLABELLED: The comparative value of different factors of reperfusion technique and strategy in restoring of myocardial function is underestimated. The aim of this study is to assess the value of reperfusion strategy for restoring of myocardial function in follow-up period. MATERIAL AND METHODS: From 1999 to 2001, 4260 patients with acute coronary syndromes were analyzed. Coronarography was performed for 2990 patients and percutaneous coronary interventions - for 1257 patients. QRS score was calculated; electrocardiogram and echocardiograms were done for 248 patients with acute myocardial infarction after reperfusion therapy by percutaneous transluminal coronary angioplasty (PTCA) (228 patients) and by stenting (20 patients). Urgent PTCA was used for 114 patients, urgent stenting for 14 patients, delayed PTCA for 114 patients and delayed stenting for 6 patients. RESULTS: Coronarography was performed for 66% of all hospitalized patients; percutaneous coronary interventions - for 825 (45.6%) of patients with acute myocardial infarction and only for 11.7% of patients with unstable angina pectoris. In hospital period QRS score increased for all patients with the exception of patients with delayed stenting (p from 0.05 to 0.001). LVEF had tendency to increase in all groups of patients during 3 months. CONCLUSIONS: Coronarography can be performed for 65-70% of hospitalized patients with acute coronary syndromes and percutaneous coronary interventions for 45% of patients with acute myocardial infarction. Differences in reperfusion strategy do not have manifest value on restoring of left ventricle function.

[Statistical study of the wavelet-based lossy medical image compression technique]. / Statistinis tyrimas medicininiu vaizdu suspaudimui "bangeliu" transformacijos metodu ivertinti.

Medical digital images have informational redundancy. Both the amount of memory for image storage and their transmission time could be reduced if image compression techniques are applied. The techniques are divided into two groups: lossless (compression ratio does not exceed 3 times) and lossy ones. Compression ratio of lossy techniques depends on visibility of distortions. It is a variable parameter and it can exceed 20 times. A compression study was performed to evaluate the compression schemes, which were based on the wavelet transform. The goal was to develop a set of recommendations for an acceptable compression ratio for different medical image modalities: ultrasound cardiac images and X-ray angiographic images. The acceptable image quality after compression was evaluated by physicians. Statistical analysis of the evaluation results was used to form a set of recommendations.