Pacemaker reprogramming rarely needed after device replacement.

BACKGROUND: Most outpatient follow-ups after pacemaker implantation do not involve changes in the device settings. Moreover, the need for pacemaker reprogramming declines with time after implantation. Currently, data on the need for changes in pacemaker set-up after replacement owing to battery depletion are lacking. The aim of this study was to determine the rates of pacemaker reprogramming in this patient group. METHODS: A retrospective analysis was performed using the files of 217 patients who had undergone pacemaker replacement between 2002 and 2005. The data of 1,407 outpatient follow-up visits between 2002 and 2015 were analyzed. Scheduled and unscheduled visits were marked as visits with "action" or visits "without action", depending on whether pacemaker programming was or was not performed, respectively. RESULTS: Pacemaker programming was performed in only 53 (4%) of the 1,234 scheduled visits and in 44 (25%) of 173 unscheduled visits. Thus, only 97 (7%) of 1,407 visits involved changes in device settings. Of these visits, 446 occurred in the first year after device replacement. The rate of unscheduled visits in the first year was higher (17%) than during the overall period (12%), but the rate of visits involving action was the same: 6% (26 of 446, first year) compared with 7% (97 of 1,407). CONCLUSION: The vast majority of outpatient visits after pacemaker replacement do not involve subsequent device reprogramming during follow-up. This suggests the potential benefit of remote follow-up for these patients.

Rivaroxaban with or without aspirin in stable cardiovascular disease

BACKGROUND: We evaluated whether rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary cardiovascular prevention. METHODS: In this double-blind trial, we randomly assigned 27,395 participants with stable atherosclerotic vascular disease to receive rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg once daily). The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction. The study was stopped for superiority of the rivaroxaban-plus-aspirin group after a mean follow-up of 23 months. RESULTS: The primary outcome occurred in fewer patients in the rivaroxaban-plus-aspirin group than in the aspirin-alone group (379 patients [4.1%] vs. 496 patients [5.4%]; hazard ratio, 0.76; 95% confidence interval [CI], 0.66 to 0.86; P<0.001; z=-4.126), but major bleeding events occurred in more patients in the rivaroxaban-plus-aspirin group (288 patients [3.1%] vs. 170 patients [1.9%]; hazard ratio, 1.70; 95% CI, 1.40 to 2.05; P<0.001). There was no significant difference in intracranial or fatal bleeding between these two groups. There were 313 deaths (3.4%) in the rivaroxaban-plus-aspirin group as compared with 378 (4.1%) in the aspirin-alone group (hazard ratio, 0.82; 95% CI, 0.71 to 0.96; P=0.01; threshold P value for significance, 0.0025). The primary outcome did not occur in significantly fewer patients in the rivaroxaban-alone group than in the aspirin-alone group, but major bleeding events occurred in more patients in the rivaroxaban-alone group...

Periprocedural antithrombotic therapy during various types of percutaneous cardiovascular interventions.

Percutaneous catheter-based interventions became a critically important part of treatment in modern cardiology, improving quality of life as well as saving many life. Due to the introduction of foreign materials to the circulation (either temporarily or permanently) and due to a certain damage to the endothelium or endocardium, the risk of thrombotic complications is substantial and thus some degree of antithrombotic therapy is needed during all these procedures. The intensity (dosage, combination, and duration) of periprocedureal antithrombotic treatment largely varies based on the type of procedure, clinical setting, and comorbidities. This manuscript summarizes the current therapeutic approach to prevent clotting (and bleeding) during a large spectrum of interventions: acute and elective coronary interventions, acute stroke interventions and elective carotid stenting, electrophysiology procedures, interventions for structural heart disease, and peripheral arterial interventions.

Risk comparison of bleeding and ischemic perioperative complications after acute and elective orthopedic surgery in patients with cardiovascular disease.

INTRODUCTION: The study objective was to ascertain the incidence of bleeding and ischemic complications related to acute and planned orthopedic surgery in patients with known cardiovascular diseases. MATERIALS AND METHODS: The study conducted between 2010 and 2013 enrolled 477 patients (289 women, 188 men) with a diagnosed cardiovascular disease or a history of thromboembolic event. Aside from gender, age, height and weight, the study observed other anamnestic data and perioperative laboratory test results that may impact on a bleeding or ischemic event. RESULTS: Two hundred seventy-two (57 %) patients had acute surgery, and 205 (43 %) patients had elective surgery. Complications arose in 55 (11.6 %) patients, 32 (6.9 %) had bleeding complications, 19 (4.0 %) ischemic complications, and both complications were experienced by 4 (0.8 %) patients. Bleeding developed in 14 (5.1 %) patients who had acute surgery, and in 22 (10.7 %) who had elective surgery. Twenty-two (8.1 %) patients having acute surgery and one (0.1 %) undergoing elective surgery suffered from ischemic complications. The incidence of bleeding complications was significantly higher in elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, and use of warfarin), the difference was even higher (p = 0.015, OR 2.44), whereas the occurrence of ischemic complications was significantly higher in acute surgery (p = 0.005, OR 18.0), and when adjusted (age), the difference remained significant (p = 0.044, OR 8.3). CONCLUSIONS: The study noted a significantly higher incidence of bleeding complications in elective orthopedic surgery when compared with acute surgery. Conversely, the incidence of ischemic complications was significantly higher in patients having acute orthopedic surgery when compared with those operated on electively.

THA and TKA in patients with cardiovascular disease: What makes the risk of perioperative bleeding?

Backround: The purpose of the study was to ascertain the incidence of bleeding and ischaemic complications in patients with cardiac disease after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: In total, 477 patients (289 women, 188 men) with known history of cardiac disease or thromboembolic disease treated with surgery in 2010-2013, were enrolled in the study. Perioperative prevention of thromboembolic disease using low-molecular-weight heparins was applied in all the patients. The data that could have an impact on the development of monitored perioperative complications, were observed. RESULTS: Complications occurred in 55 (11.6 %) patients: bleeding complications in 32, ischaemic in 19, and both in four patients. Complications were found in 13 (12.0 %) patients after THA and in 6 (9.5 %) patients after TKA. Bleeding complications were observed in 17 patients after THA and TKA, ischaemic in one, and both simultaneously in one patient.Bleeding complications occurred insignificantly more frequently after THA and TKA (p = 0.094); however, this difference was statistically significant after adjustment for risk factors (p = 0.003). On the contrary, ischaemic complications were significantly more frequent after other skeletal surgeries (p = 0.014). Nevertheless, this difference was not statistically significant after the adjustment (p = 0.880). The comparison of the risk of complications in patients after THA with that in patients after TKA showed no significant difference (p = 0.580). CONCLUSION: The study showed a significantly higher incidence of bleeding complications in patients after THA and TKA compared to other surgeries of the musculoskeletal system in patients with a history of cardiac disease. Bleeding complications cannot be detected in advance (Tab. 1, Ref. 16).

Randomized Trial of Primary PCI with or without RoutineManual Thrombectomy

During primary percutaneous coronary intervention (PCI), manual thrombectomymay reduce distal embolization and thus improve microvascular perfusion. Smalltrials have suggested that thrombectomy improves surrogate and clinical outcomes,but a larger trial has reported conflicting results.MethodsWe randomly assigned 10,732 patients with ST-segment elevation myocardial infarction(STEMI) undergoing primary PCI to a strategy of routine upfront manualthrombectomy versus PCI alone. The primary outcome was a composite of deathfrom cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, orNew York Heart Association (NYHA) class IV heart failure within 180 days. The keysafety outcome was stroke within 30 days.ResultsThe primary outcome occurred in 347 of 5033 patients (6.9%) in the thrombectomygroup versus 351 of 5030 patients (7.0%) in the PCI-alone group (hazard ratio in thethrombectomy group, 0.99; 95% confidence interval [CI], 0.85 to 1.15; P = 0.86). Therates of cardiovascular death (3.1% with thrombectomy vs. 3.5% with PCI alone;hazard ratio, 0.90; 95% CI, 0.73 to 1.12; P = 0.34) and the primary outcome plusstent thrombosis or target-vessel revascularization (9.9% vs. 9.8%; hazard ratio,1.00; 95% CI, 0.89 to 1.14; P = 0.95) were also similar. Stroke within 30 days occurredin 33 patients (0.7%) in the thrombectomy group versus 16 patients (0.3%)in the PCI-alone group (hazard ratio, 2.06; 95% CI, 1.13 to 3.75; P = 0.02).ConclusionsIn patients with STEMI who were undergoing primary PCI, routine manual thrombectomy,as compared with PCI alone, did not reduce the risk of cardiovasculardeath, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heartfailure within 180 days but was associated with an increased rate of stroke within30 days. (Funded by Medtronic and the Canadian Institutes of Health Research;TOTAL ClinicalTrials.gov number, NCT01149044.

Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry.

BACKGROUND: Interruption of antithrombotic treatment before surgery may prevent bleeding, but at the price of increasing cardiovascular complications. This prospective study analysed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease (CVD). METHODS: All 1200 consecutive patients (age 74.2 ± 10.2 years) undergoing major non-cardiac surgery (37.4 % acute, 61.4 % elective) during a period of 2.5 years while having at least one CVD were enrolled. Details on medication, bleeding, cardiovascular complications and cause of death were registered. RESULTS: In-hospital mortality was 3.9 % (versus 0.9 % mortality among 17,740 patients without CVD). Cardiovascular complications occurred in 91 (7.6 %) patients (with 37.4 % case fatality). Perioperative bleeding occurred in 160 (13.3 %) patients and was fatal in 2 (1.2 % case fatality). Multivariate analysis revealed age, preoperative anaemia, history of chronic heart failure, acute surgery and general anaesthesia predictive of cardiovascular complications. For bleeding complications multivariate analysis found warfarin use in the last 3 days, history of hypertension and general anaesthesia as independent predictive factors. Aspirin interruption before surgery was not predictive for either cardiovascular or for bleeding complications. CONCLUSIONS: Perioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns.

Importance of thorough investigation of resistant hypertension before renal denervation: should compliance to treatment be evaluated systematically?

Catheter-based renal denervation (RD) has been introduced recently as a potentially effective invasive treatment of refractory hypertension. The proportion of patients with severe hypertension suitable for RD is not clear. The aim of this study was to identify what percentage of patients has truly resistant essential hypertension and are thus potentially eligible for RD. We investigated 205 consecutive patients referred to a university hypertension center for severe hypertension within 12 months. Ambulatory 24-h blood pressure (BP) monitoring (24 h ABPM), secondary hypertension screening and compliance to treatment testing (by use of plasma drug level measurements) were performed in all patients. Fifty-seven patients (27.8%) did not have truly resistant hypertension (RH) based on clinical BP. Among the remaining 122 patients (59.5%) with RH confirmed by 24 h ABPM, 50 patients (24.4% of the original cohort) had a secondary cause of hypertension and in 27 (13.2%) non-compliance to treatment was confirmed. Thus, only 45 patients (22%) had truly resistant essential hypertension and were considered for RD. Only one-third (n=15, 7.3% of the original cohort) was, however, finally referred for RD (14 were excluded due to contraindications for RD and 16 refused the invasive treatment). In conclusion, thorough examination of severe hypertension including 24 h ABPM, secondary hypertension exclusion and drug compliance testing before considering RD reveals that majority of these patients are not suitable for RD. Specifically, compliance to treatment testing should be mandatory in order to identify eligible candidates for RD.

Blood pressure changes after renal denervation at 10 European expert centers.

We did a subject-level meta-analysis of the changes (Δ) in blood pressure (BP) observed 3 and 6 months after renal denervation (RDN) at 10 European centers. Recruited patients (n=109; 46.8% women; mean age 58.2 years) had essential hypertension confirmed by ambulatory BP. From baseline to 6 months, treatment score declined slightly from 4.7 to 4.4 drugs per day. Systolic/diastolic BP fell by 17.6/7.1 mm Hg for office BP, and by 5.9/3.5, 6.2/3.4, and 4.4/2.5 mm Hg for 24-h, daytime and nighttime BP (P0.03 for all). In 47 patients with 3- and 6-month ambulatory measurements, systolic BP did not change between these two time points (P0.08). Normalization was a systolic BP of <140 mm Hg on office measurement or <130 mm Hg on 24-h monitoring and improvement was a fall of 10 mm Hg, irrespective of measurement technique. For office BP, at 6 months, normalization, improvement or no decrease occurred in 22.9, 59.6 and 22.9% of patients, respectively; for 24-h BP, these proportions were 14.7, 31.2 and 34.9%, respectively. Higher baseline BP predicted greater BP fall at follow-up; higher baseline serum creatinine was associated with lower probability of improvement of 24-h BP (odds ratio for 20-µmol l(-1) increase, 0.60; P=0.05) and higher probability of experiencing no BP decrease (OR, 1.66; P=0.01). In conclusion, BP responses to RDN include regression-to-the-mean and remain to be consolidated in randomized trials based on ambulatory BP monitoring. For now, RDN should remain the last resort in patients in whom all other ways to control BP failed, and it must be cautiously used in patients with renal impairment.

Routine pretreatment with abciximab versus standard periprocedural therapy in mechanically ventilated cardiogenic shock patients undergoing primary percutaneous coronary intervention: Subanalysis of the PRAGUE-7 study.

BACKGROUND: The clinical outcome of patients with myocardial infarction (MI) complicated by cardiogenic shock (CS) who require mechanical ventilation (MV) is poor. OBJECTIVE: To analyze the impact of abciximab pretreatment in this high-risk population of MI patients. METHODS: The present study was a retrospective subanalysis of the multicentre randomized Routine Upfront Abciximab Versus Standard Peri-Procedural Therapy in Patients Undergoing Percutaneous Coronary Intervention for Cardiogenic Shock (PRAGUE-7) study, which included 80 MI patients in CS undergoing primary percutaneous coronary intervention (PCI). Patients were randomly assigned into group A (routine pretreatment with an abciximab bolus followed by a 1 h abciximab infusion) and group B (standard therapy). The subanalysis included 37 patients requiring MV. Seventeen patients were in group A and 20 were in group B. The primary end point (death/stroke/reinfarction/new severe renal failure) at 30 days, procedural success (thrombosis in myocardial infarction [TIMI] flow) and frequency of bleeding were assessed. The χ(2) and Student's t tests were used for statistical analysis; P<0.05 was considered to be statistically significant. RESULTS: The primary end point occurred in nine (53%) patients in group A and 12 (60%) patients in group B (P=0.66). TIMI flow after primary PCI was higher in group A (2.75 versus 2.31; P<0.05). Major bleeding occurred in 12% of patients in group A versus 10% of patients in group B (P=0.86). Minor or minimal bleeding was more common in group A (29%) compared with group B (5%; P<0.05). CONCLUSION: The results of the present study suggest that routine pretreatment with abciximab before primary PCI in mechanically ventilated patients with MI complicated by cardiogenic shock was associated with better angiographic results but also with a higher incidence of bleeding.

Practical use of dabigatran etexilate for stroke prevention in atrial fibrillation.

Atrial fibrillation (AF) is associated with an increased risk of thromboembolism, and is the most prevalent factor for cardioembolic stroke. Vitamin K antagonists (VKAs) have been the standard of care for stroke prevention in patients with AF since the early 1990s. They are very effective for the prevention of cardioembolic stroke, but are limited by factors such as drug-drug interactions, food interactions, slow onset and offset of action, haemorrhage and need for routine anticoagulation monitoring to maintain a therapeutic international normalised ratio (INR). Multiple new oral anticoagulants have been developed as potential replacements for VKAs for stroke prevention in AF. Most are small synthetic molecules that target thrombin (e.g. dabigatran etexilate) or factor Xa (e.g. rivaroxaban, apixaban, edoxaban, betrixaban, YM150). These drugs have predictable pharmacokinetics that allow fixed dosing without routine laboratory monitoring. Dabigatran etexilate, the first of these new oral anticoagulants to be approved by the United States Food and Drug Administration and the European Medicines Agency for stroke prevention in patients with non-valvular AF, represents an effective and safe alternative to VKAs. Under the auspices of the Regional Anticoagulation Working Group, a multidisciplinary group of experts in thrombosis and haemostasis from Central and Eastern Europe, an expert panel with expertise in AF convened to discuss practical, clinically important issues related to the long-term use of dabigatran for stroke prevention in non-valvular AF. The practical information reviewed in this article will help clinicians make appropriate use of this new therapeutic option in daily clinical practice.

Why we are not able to find the coronary heart disease gene - apoE as an example.

The apoprotein E gene ranks among the most discussed candidate genes for cardiovascular disease. We studied whether the association between apoprotein E gene polymorphism and manifestation of acute coronary syndrome is modulated by the presence/absence of traditional cardiovascular risk factors. The population under study were 1066 patients (men under 65 years) admitted between 2006- 2009 to five coronary care units in Prague (GENetic DEtermination of Myocardial Infarction in Prague) and the control population (1066 age-matched men selected from the Czech population sample). The frequency of disadvantage genotype E4+ was significantly higher (P < 0.01) in acute coronary syndrome patients (22.38 %) than in controls (16.76 %). When the acute coronary syndrome group was step by step limited to non-smokers, non-diabetics and normotensive individuals, the odds ratio displayed a gradual increase from 1.35 (for the entire group) through 1.48 (non-smokers), 1.53 (non-smokers+non-diabetics) to 1.71 (non-smokers+non-diabetics+normotensives). The effect of the apoprotein E gene on the individual risk of acute coronary syndrome is nonhomogenous within the patient groups. This association of apoprotein E gene with acute coronary syndrome is strongly modified by the presence/absence of traditional cardiovascular factors of atherosclerosis in a high-risk Czech population.

The impact of gender on outcomes of patients with ST elevation myocardial infarction transported for percutaneous coronary intervention: analysis of the PRAGUE-1 and 2 studies.

BACKGROUND: Data comparing survival outcomes for women versus men transported for pPCI were absent. OBJECTIVES: To assess the impact of gender on 30-day mortality of patients with STEMI transported for pPCI. METHODS: The data from the PRAGUE-1 and PRAGUE-2 trials were analysed. Studies compared thrombolysis in the community hospital and pPCI after transportation to cardiocentre. A group of 520 patients treated with thrombolysis, and 530 transported for pPCI, were analysed. RESULTS: Women were older, with a higher risk profile. They had longer ischaemia time. Mortality of patients treated with TL was significantly higher in women than in men (15% vs 9%, p = 0.043). There was no significant gender difference in mortality in the PCI group (8.2% of women vs 6.2% of men, p = 0.409). Mortality of women treated with on-site TL was nearly twice as high as mortality of women transported for pPCI (p = 0.043). After adjustment in a multivariate model the odds ratio for mortality in women was 0.74 (95% CI 0.26 to 2.05; p = 0.556). CONCLUSION: Long-distance transportation of women with STEMI from a community hospital to a tertiary PCI centre is a significantly more effective treatment strategy than on-site TL. Gender did not determine survival in patients transported for pPCI.

One-day kinetics of myocardial engraftment after intracoronary injection of bone marrow mononuclear cells in patients with acute and chronic myocardial infarction.

OBJECTIVE: To investigate the kinetics of myocardial engraftment of bone marrow-derived mononuclear cells (BMNCs) after intracoronary injection using 99mTc-d,l-hexamethylpropylene amine oxime (99mTc-HMPAO) nuclear imaging in patients with acute and chronic anterior myocardial infarction. DESIGN: Nuclear imaging-derived tracking of BMNCs at 2 and 20 h after injection in the left anterior descending (LAD) coronary artery. SETTING: Academical cardiocentre. PATIENTS: Five patients with acute (mean (SD) age 58 (11) years; ejection fraction range 33-45%) and five patients with chronic (mean (SD) age 50 (6) years; ejection fraction range 28-34%) anterior myocardial infarction. INTERVENTIONS: A total of 24.2 x 10(8)-57.0 x 10(8) BMNCs (20% labelled with 700-1000 MBq 99mTc-HMPAO) were injected in the LAD coronary artery. RESULTS: At 2 h after BMNC injection, myocardial activity was observed in all patients with acute (range 1.31-5.10%) and in all but one patient with chronic infarction (range 1.10-3.0%). At 20 h, myocardial engraftment was noted only in three patients with acute myocardial infarction, whereas no myocardial activity was noted in any patient with chronic infarction. CONCLUSIONS: Engraftment of BMNCs shows dynamic changes within the first 20 h after intracoronary injection. Persistent myocardial engraftment was noted only in a subset of patients with acute myocardial infarction.

Prevalence of normal coronary angiography in the acute phase of suspected ST-elevation myocardial infarction: experience from the PRAGUE studies.

BACKGROUND: Acute ST-elevation myocardial infarction in patients with normal coronary arteries has previously been described, but coronary angiography in these patients was performed after the acute phase of the infarction. It is possible that these patients did not have normal angiograms during the acute phase (transient coronary thrombosis or spasm were usually suspected to be the cause). Information on the prevalence of truly normal coronary angiograms during the acute phase of a suspected ST-elevation myocardial infarction is lacking. PATIENTS AND METHODS: The Primary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis-1 (PRAGUE-1) and PRAGUE-2 studies enrolled 1150 patients with ST-elevation acute myocardial infarction, in whom 625 coronary angiograms were performed within 2 h of the initial electrocardiogram. A simultaneous registry included an additional 379 coronary angiograms performed during the ST-elevation phase of a suspected myocardial infarction. Thus, a total of 1004 angiograms were retrospectively analyzed. A normal coronary angiogram was defined as one with the absence of any visible angiographic signs of atherosclerosis, thrombosis or spontaneous spasm. RESULTS: Normal coronary angiograms were obtained for 26 patients (2.6%). Among these, the diagnosis at discharge was a small myocardial infarction in seven patients (0.7%), acute (peri)myocarditis in five patients, dilated cardiomyopathy in four patients, hypertension with left ventricular hypertrophy in three patients, pulmonary embolism in two patients and misinterpretation of the electrocardiogram (ie, no cardiac disease) in five patients. Seven patients with small infarctions underwent angiography within 30 min to 90 min of complete relief of the signs of acute ischemia, and thus, angiograms during pain were not taken. None of the 898 patients catheterized during ongoing symptoms of ischemia had a normal coronary angiogram. Spontaneous coronary spasm as the only cause (without underlying coronary atherosclerosis) for the evolving infarction was not seen among these 898 patients. Thus, the causes of the seven small infarcts in patients with normal angiograms remain uncertain. CONCLUSIONS: The observed prevalence of normal coronary angiography in patients presenting with acute chest pain and ST elevations was 2.6%. Most of these cases were misdiagnoses, not infarctions. A normal angiogram during a biochemically confirmed infarction is extremely rare (0.7%) and was not seen during the ongoing symptoms of ischemia.

Prospective use of EuroSCORE for the short-term risk evaluation of consecutive cardiac surgery candidates: are there any differences in prediction of perioperative risk versus risk of nonsurgical treatments?

BACKGROUND: In the era of modern medicine, the relevance of perioperative risk stratification with respect to the practice of cardiac surgeons and cardiologists worldwide has increased. AIM: This study aims at estimating the validity of a preoperative risk stratification model EuroSCORE in predicting short-term mortality in Czech adult cardiac population. METHODS: All consecutive patients (n = 460) presented to cardiac surgeons as surgery candidates during a six-month period were enrolled in this study. The Additive and logistic EuroSCORE were used for the risk assessment. The operative mortality, as well as the mortality within 30 days from discharge were recorded. The observed and predicted mortality derived from the EuroSCORE were compared. RESULTS: Fifty-seven percent of the patients underwent cardiac surgery, while 43% was refused for surgery by the cardiac surgeon. There was no significant difference between the observed and predicted mortality in both subgroups. EuroSCORE showed good discriminatory ability in predicting short-term mortality (C statistic 0.755 vs. 0.762 for the surgery subgroup and 0.695 vs. 0.716 for the refused subgroup). CONCLUSIONS: The EuroSCORE has a good discriminatory ability in predicting early mortality after cardiac surgery as well as in patients rejected for cardiac surgery. Both EuroSCORE risk prediction model forms are a suitable mortality predictor in Czech cardiac patients.

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization.

AIMS: The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD). METHODS AND RESULTS: Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%). CONCLUSION: The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.

[Huge sinus of Valsalva aneurysm in patient with cystic medial necrosis of the aorta]. / Obrovské aneuryzma Valsalvova sinu u pacientky s cystickou medionekrózou aorty.

In this case we present a patient with unruptured non-coronary sinus of Valsalva aneurysm associated with diverse clinical findings, caused by acquired degenerative changes of the aortic wall. A previously healthy 36-year-old female was admitted to the neurological clinic of our hospital having suffered from an episode of unconsciousness prior to admission, with accompanying seizures. For the preceding two months she had also been suffering from dyspnoea and palpitation. Neurological examination, computed tomography of the head and electroencephalography were with normal findings. Thereafter, due to paroxysm of supraventricular tachycardia she was referred to cardiology clinic. On routine physical examination a diastolic murmur was detected and the patient was referred for transthoracic echocardiography. This examination revealed a large, unruptured noncoronary sinus of Valsalva aneurysm, which was thereafter confirmed by transoesophageal echocardiography a angiography. The patient was indicated for surgical correction with aortic valve and aortic root replacement by Bentall procedure. Histological examination of the part of resected aneurysm found cystic medial degeneration of the aortic wall, also called cystic medial necrosis.