Hrvoje Pintarić

Impact of admission anemia, C-reactive protein and mean platelet volume on short term mortality in patients with acute ST-elevation myocardial infarction treated with primary angioplasty.

OBJECTIVES To investigate admission anemia, C-reactive protein (CRP) and mean platelet volume (MPV) together as prognostic markers in ST-elevation myocardial infarction (STEMI). DESIGN AND METHODS Baseline hemoglobin, CRP and MPV were determined in 543 patients with acute STEMI to whom primary angioplasty was performed and evaluated for short term mortality (30 days). RESULTS After multivariate analysis anemia (odds ratio 2.69, 95% confidence interval 1.24-5.86) and CRP (odds ratio 3.40, 95% confidence interval 1.13-10.22) remained significant independent predictors of short-term mortality. Addition of anemia and CRP to PAMI risk score improved prediction of short-term outcome; area under ROC curve rose from 0.76 to 0.87 (p<0.001). CONCLUSION Better ability to determine 30-day mortality was obtained when anemia and CRP were incorporated into the PAMI risk score.

Successful primary percutaneous coronary intervention in the first trimester of pregnancy

A 28‐year‐old patient, medical nurse, in 10th week of her second pregnancy suffered ventricular fibrillation just after entering the waiting room of the emergency department. After she was successfully defibrillated, electrocardiography revealed a large acute anteroseptolateral ST elevation myocardial infarction. Urgent coronarography was done (premedication with 300 mg of aspirin and 600 mg of clopidogrel) with 90 min door‐to‐balloon time. Proximal left anterior descending occlusion was found, primary percutaneous coronary intervention was done using Amazonia CroCo 3.0/12 bare‐metal stent, and Thrombolysis in Myocardial Infarction III flow was achieved. During the procedure, the patient was wrapped in lead apron. Because of postresuscitational agitation, procedure was done in intravenous anesthesia. The revealed risk factors were smoking and hypercholesterolemia. PAI‐1 gene 4G/4G genotype and Apo E gene E2/E4 genotype were also found. Estimated X‐ray dosage that fetus received during the procedure was 0.45 mSv, which is less than the upper safe limit in pregnancy. All drugs given to our patient (clopidogrel, aspirin, ivabradine, bisoprolol, anesthetics, low‐molecular‐weight heparin, and unfractionated heparin) have B or C Food and Drug Administration Pregnancy Category. Fetal ultrasonography showed normal fetal growth, and, after consultation with our team, the patient decided to maintain the pregnancy. Before discharge echocardiography showed left ventricle of normal size with anteroseptolateral hypokinesia, small apical aneurysm, left ventricular ejection fraction of 40–45%, and diastolic dysfunction grade II, without pulmonary hypertension. At the 36th week of pregnancy, the patient was hospitalized and closely monitored; clopidogrel and aspirin were discontinued, and low‐molecular‐weight heparin was administered. She gave birth to a normal boy by vaginal delivery with epidural anesthesia and without any complication.

Coronary artery stent fracture with aneurysm formation and in-stent restenosis

Coronary stent fracture is a relatively rare but potentially serious complication of coronary artery stenting. It has been recognised as a cause of in-stent restenosis as well as acute stent thrombosis. Most fractures occur in stents after aggressive post-dilatation, stents implanted in tortuous and calcified lesions, and after cardiac trauma [M.S. Lee, D. Jurewitz, J. Aragon, J. Forrester, R.R. Makkar, S. Kar Stent fracture associated with drug-eluting stents: clinical characteristics and implications. Catheter Cardiovasc Interv. Feb 15 2007;69(3):387-394.,Makaryus AN, Lefkowitz L, Lee AD, Coronary artery stent fracture. Int J Cardiovasc Imaging. Jun 2007;23(3):305-309. Electronic publication 2006 Sep 28.,E.S. Brilakis, C. Maniu, M. Wahl, G. Barsness (2004) Unstable angina due to stent fracture J Invasive Cardiol 16(9):545.,G. Sianos, S. HOfma, J.M. Ligthart et al. Stent fracture and restenosis in the drug eluting stent era. Catheter cardiovasc Interv 2004; 61(1):111-116.]. We report on a case of delayed stent fracture that gradually lead to in-stent restenosis (distal part), significant fragment displacement with the formation of a coronary artery aneurysm that was unsuitable for percutaneous intervention.

C-reactive protein, not cardiac troponin T, improves risk prediction in hypertensives with type A aortic dissection

Abstract Background: The aim of the study was to evaluate prognostic role of inflammatory biomarkers, cardiac troponin T (cTnT) and D-dimer in type A acute aortic dissection (AAD) and to examine whether they might help in risk stratification beyond values of International Registry of Acute Aortic Dissection (IRAD) score. Methods: Baseline biomarkers were determined in 54 consecutive predominantly hypertensive patients with type A AAD and evaluated for in-hospital mortality. Results: After multivariable adjustment, the independent predictors of outcome were age (OR = 1.09; 95% CI 1.02–1.18), treatment strategy (OR = 0.11; 95% CI 0.02–0.06) and C-reactive protein (CRP) either as binary (OR = 7.06; 95% CI 1.34–37.36) or continuous variable (OR = 1.10; 95% CI 1.01–1.21). cTnT did not independently influence mortality. Receiver- operating characteristic (ROC) curve analysis showed significant link between CRP and outcome (area under the ROC curve, AUC = 0.79; p < 0.01). Values of CRP > 9.8 mg/l had 83% sensitivity and 80% specificity for predicting in-hospital mortality. Addition of CRP to IRAD score improved prediction of short-term outcome, AUC increased from 0.74 to 0.89 (p = 0.004). Conclusion: Admission CRP has independent prognostic value in type A AAD and the addition of CRP to IRAD score improved discriminative capacity of in-hospital mortality irrespective of symptom duration and treatment strategy.

Incidence and predictors of asymptomatic atrial fibrillation in patients older than 70 years with complete atrioventricular block and dual chamber pacemaker implantation

Aim To evaluate predictors of asymptomatic atrial fibrillation in patients older than 70 years with complete atrioventricular (AV) block, normal left ventricular systolic function, and implanted dual chamber (DDD) pacemaker. Methods Hundred and eighty six patients with complete AV block were admitted over one year to the Sisters of Mercy University Hospital. The study recruited patients older than 70 years, with no history of atrial fibrillation, heart failure, or reduced left ventricular systolic function. All the patients were implanted with the same pacemaker. Out of 103 patients who were eligible for the study, 81 (78%) were evaluated. Follow-up time ranged from 12 to 33 months (average±standard deviation 23 ± 5 months). Primary end-point was asymptomatic atrial fibrillation occurrence recorded by the pacemaker. Atrial fibrillation occurrence was defined as atrial high rate episodes (AHRE) lasting >5 minutes. Binary logistic regression was used to identify the predictors of development of asymptomatic atrial fibrillation. Results The 81 patients were stratified into two groups depending on the presence of AHRE lasting >5 minutes (group 1 had AHRE>5 minutes and group 2 AHRE<5 minutes). AHRE lasting >5 minutes were detected in 49 (60%) patients after 3 months and in 53 (65%) patients after 18 moths. After 3 months, only hypertension (odds ratio [OR], 17.63; P = 0.020) was identified as a predictor of asymptomatic atrial fibrillation. After 18 months, hypertension (OR, 14.0; P = 0.036), P wave duration >100 ms in 12 lead ECG (OR, 16.5; P = 0.001), and intracardial atrial electrogram signal amplitude >4 mV (OR, 4.27; P = 0.045) were identified as predictors of atrial fibrillation. Conclusion In our study population, hypertension was the most robust and constant predictor of asymptomatic atrial fibrillation after 3 months, while P wave duration >100 ms in 12-lead ECG and intracardial atrial signal amplitude were predictors after 18 months.

Metabolic syndrome: infl uence on clinical severity and prognosis in patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

Objective The aim of this study was to investigate the metabolic syndrome (MS) infl uence on clinical severity and prognosis in patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Methods We prospectively analysed 250 patients with acute STEMI treated with primary PCI, between September 2011-2012. MS was diagnosed by the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) criteria. Patients were divided into two groups (with/without MS) and compared by their baseline data (medical history, demographic and anthropometric data) and parameters of severity (clinical, laboratory, echocardiography, coronary angiography and in-hospital complications data) and prognosis (major adverse cardiovascular events and sick leave duration (SLD) during 12 months of follow-up). Results Our study included 136 (54.4%) and 114 (45.6%) patients with and without MS, respectively. MS patients had longer hospitalization (9.0 vs 8.0 days), higher rates of total in-hospital complications (25.0% vs14.9%), higher number of signifi cantly stenosed coronary arteries (CAs) (2 vs1), higher stent diameters (3.5 vs3.0 mm) ,higher rate of signifi cantly stenosed proximal and middle CAs segments (94.1% vs86.7%), and longer SLD (16 vs10 weeks) (P <0.05). MS was independently associated with higher risk of total in-hospital complications (odds ratio (OR) 1.90, confi dence interval (CI) [1.06-3.64], P= 0.047) and with higher risk of ? 2 signifi cant stenosed CAs (OR 1.72, CI [1.04-2.84], P= 0.034). Conclusion MS in acute STEMI is an important predictor of total in-hospital complications and severity of CAs disease, but not for other parameters of severity and prognosis. MS patients have longer SLD.

The importance of two metabolic syndrome diagnostic criteria and body fat distribution in predicting clinical severity and prognosis of acute myocardial infarction

Introduction The interrelation between metabolic syndrome (MetS) (the revised National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) and International Diabetes Federation (IDF)) and obesity indices in predicting clinical severity and prognosis of acute ST-elevation myocardial infarction (STEMI) is insufficiently known. Material and methods This prospective study included 250 acute STEMI patients treated with primary percutaneous coronary intervention. The patients with/without MetS were analyzed by baseline (medical history, demography and obesity indices: overall – body mass index (BMI) vs.central – body adiposity index (BAI), conicity index (Cindex), visceral adiposity index (VAI), waist circumference (WC), waist-to-hip (WHR) and waist-to-height ratio (WHtR)), severity (clinical presentation, laboratory, echocardiography, coronary angiography and in-hospital complications) and prognostic parameters (major adverse cardiovascular events and sick leave duration during 12-month follow-up). Results There were 136 (54.4%) and 147 (58.8%) patients with MetS (NCEP-ATP III) and MetS (IDF), respectively. MetS (NCEP-ATP III) increased the risk of > 1 significantly stenosed coronary artery (CA), very high BAI increased the risk of dyspnea, Cindex > 1.25/1.18 increased the risk of total in-hospital complications, increased VAI increased the risk of coronary segment 3 significant stenosis, WHR ≥ 0.90/0.85 increased the risk of proximal/middle coronary segments (especially of segment 1) significant stenosis, WHtR ≥ 63/58 increased the risk of heart failure, and the number of significantly stenosed CAs increased the risk of total MACE (p < 0.05). Conclusions MetS (NCEP-ATP III) and several central obesity indices are superior to BMI in predicting acute STEMI severity (clinical presentation, in-hospital complications, severity of coronary disease), while WC and MetS (IDF) have no influence on it. They all have no influence on prognosis.

Re-initiating professional working activity after myocardial infarction in primary percutaneous coronary intervention networks era

OBJECTIVES To investigate the aspects of return to work, socio-economic and quality of life aspects in 145 employed patients under 60 years of age treated with primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. MATERIAL AND METHODS During hospital treatment demographic and clinical data was collected. Data about major adverse cardiovascular events, rehabilitation, sick leave, discharge from job and retirement, salary, major life events and estimation of quality of life after myocardial infarction were obtained after follow-up (mean: 836±242 days). RESULTS Average sick leave was 126±125 days. Following myocardial infarction, 3.4% of patients were discharged from their jobs while 31.7% retired. Lower salary was reported in 17.9% patients, major life events in 9.7%, while 40.7% estimated quality of life as worse following the event. Longer hospitalization was reported in patients transferred from surrounding counties, those with inferior myocardial wall and right coronary artery affected. Age, hyperlipoproteinemia and lower education degree were connected to permanent working cessation. Significant salary decrease was observed in male patients. Employer type was related to sick leave duration. Impaired quality of life was observed in patients who underwent in-hospital rehabilitation and those from surrounding counties. Longer sick leave was observed in patients with lower income before and after myocardial infarction. These patients reported lower quality of life after myocardial infarction. CONCLUSIONS Inadequate health policy and delayed cardiac rehabilitation after myocardial infarction may lead to prolonged hospitalization and sick leave as well as lower quality of life after the event, regardless of optimal treatment in acute phase of disease.

Timing of troponin T measurements in triage of pulmonary embolism patients

Aim To determine the appropriate timing of cardiac troponin T (cTnT) measurement for the early triage of pulmonary embolism (PE) patients. Methods In this single-center prospective study, PE was confirmed in all patients using computed tomography. 104 consecutive patients were divided into three groups (high-risk, intermediate, and low-risk) based on their hemodynamic status and echocardiographic signs of right ventricular dysfunction. cTnT levels were measured on admission and then after 6, 24, 48, and 72 hours with threshold values greater than 0.1 ng/mL. Results Intermediate-risk PE patients had higher cTnT levels than low-risk patients already in the first measurement (P = 0.037). Elevated cTnT levels significantly correlated with disease severity after 6 hours (intermediate vs low risk patients, P = 0.016, all three groups, P = 0.009). Conclusion In hemodynamically stable patients, increased cTnT level on admission differentiated intermediate from low-risk patients and could be used as an important element for the appropriate triage of patients.

Electrophysiological predictors of propafenone efficacy in prevention of atrioventricular nodal re-entrant and atrioventricular re-entrant tachycardia

Aim To assess the efficacy of propafenone in prevention of atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic atrioventricular tachycardia (AVRT) based on the clinical results of arrhythmia recurrence and find the electrophysiological predictor of propafenone effectiveness. Methods This retrospective study included 44 participants in a 12-month period, who were divided in two groups: group A – in which propafenone caused complete ventriculo-atrial block and group B – in which propafenone did not cause complete ventriculo-atrial block. Results Group A had significantly lower incidence of tachycardia than group B (95% vs 70.8%, P = 0.038), and complete ventriculo-atrial block predicted the efficacy of propafenone oral therapy in the prevention of tachycardia (sensitivity 87.5%, specificity 52.8%, positive predictive value 95%, negative predictive value 29.2%). Patients with AVNRT in group B who did not experience the recurrences of tachycardia had significantly shorter echo zone before intravenous administration of propafenone than the patients who experienced episodes of sustained tachycardia (median 40 ms [range 15-60 ms] vs 79 ms [range 50-180 ms], P = 0.008). Conclusion In patients with non-inducible tachycardia, complete ventriculo-atrial block can be used as an electrophysiological predictor of the efficacy of propafenone oral therapy in the prevention of tachycardia. In patients with non-inducible AVNRT, but without complete ventriculo-atrial block, propafenone was more effective in patients with shorter echo zone of tachycardia.