[One year persistence of free and fixed dose combinations of perindopril/amlodipine]. / A perindopril/amlodipin szabad és fix kombinációk egyéves terápiahusége.

INTRODUCTION: In management of hypertension patient adherence is one of the most important factors. In hypertension the cardiovascular risk reduction can be reached only by prolonged and effective pharmacotherapy. AIM: To evaluate the persistence of one-year treatment of free and fixed-dose combination of perindopril/amlodipine in hypertension. METHOD: Information from the National Health Insurance of Hungary prescriptions database on pharmacy claims between October 1, 2012 and September 30, 2013 was analysed. Authors identified patients who filled prescriptions for free and fixed-dose combination of perindopril/amlodipine, prescribed for the first time for hypertension. Patients have not received antihypertensive therapy with similar active substances during the one year before. Apparatus of survival analysis was used, where "survival" was the time to abandon the medication. As it was available to month precision, discrete time survival analysis was applied. RESULTS: 109,248 patients met the inclusion criteria. Combination antihypertensive therapy with perindopril/amlodipine was started with a free or a fixed-dose combination of these agents in 19,365 and 89,883 patients, respectively. One year persistence rate in patients taking perindopril/amlodipine as a free combination was 27.15%, whereas it was 46.89% in those on the fixed-dose combination. Mean duration of persistence was 177.6 days in patients on the perindopril/amlodipine free, whereas 245.7 days on fixed-dose combination. Actual rate of discontinuation was approximately twice higher with the treatment of free, compared with the use of the fixed-dose combination (hazard ratio =1.94 [95% CI: 1.91-1.98], p<0.001). Orv Hetil. 2017; 158(36): 1421-1425.

A Simple Numerical Body Surface Mapping Parameter Signifies Successful Percutaneous Coronary Artery Intervention.

BACKGROUND: In coronary artery disease (CAD), body surface potential mapping (BSPM) may reveal minor electrical potential changes appearing in the depolarization phase even if pathological changes are absent on the conventional 12-lead ECG. We hypothesized that a simple BSPM parameter, Max/Min signifies successful percutaneous coronary intervention (PCI). METHODS: Ninety-two adult Caucasian patients with stable CAD and positive exercise test underwent coronary angiography. Seventy patients (age, 59 ± 8; 46 males) were revascularized by PCI (left anterior descending [LAD] in 38, right [RCA] in 17 and left circumflex [LCX] coronary artery in 15). Control groups contained 22 patients (age, 60 ± 8; 14 males) without intervention and 35 healthy subjects (age, 58 ± 2; 15 males). Left ventricular ejection fraction (LVEF, transthoracic echocardiography) and Max/Min BSPM parameter (63-lead Montreal system) were evaluated before and 4-40 days following coronary angiography. Max/Min was defined by the ratio of the highest maximum to the deepest minimum potential of all leads recorded by BSPM. RESULTS: Before PCI, Max/Min value of patients with LAD lesion (0.83 [0.74; 0.93]) was significantly lower while that with RCA lesion (1.63 [1.35; 1.99]) was significantly higher than that of healthy group (1.01 [0.970; 1.13]) (P < 0.05) and LVEF was significantly lower in LAD lesion (46.50% [43.00; 51.00]) than in the healthy group (55.00% [50.00; 58.75]) (P < 0.01). Max/Min value significantly increased from 0.83 [0.74; 0.93] to 0.92 [0.82; 0.99] (P < 0.01) following LAD PCI while significantly decreased from 1.63 [1.35; 1.98] to 1.35 [1.21; 1.43] (P < 0.01) post-RCA PCI. It did not vary significantly, however, either following LCX PCI or without intervention. LVEF significantly increased (from 46.50% [43.00; 51.00] to 49.00% [46.00; 51.00]) only after LAD PCI. CONCLUSION: Max/Min parameter is suitable to follow patients after LAD and RCA PCI.

[Instrumental therapy of drug-resistant hypertension]. / A rezisztens hypertonia eszközös kezelése.

It is well known that hypertension is an independent cardiovascular risk factor. Treatment of hypertension frequently includes administration of three or more drugs. Resistant hypertension is defined when blood pressure remains above target value despite full doses (the patient's maximum tolerated dose) of antihypertensive medication consisting of at least three different classes of drugs including a diuretic. Pharmacological treatment of hypertension is often unsuccessful despite the increasing number of drug combinations. Uncontrolled hypertension, however, increases the cardiovascular risk. Instrumental treatment of resistant hypertension is currently testing two major fields. One is the stimulation of baroreceptors in the carotid sinus and the other is radiofrequency ablation of sympathetic nerve fibers around renal arteries to reduce blood pressure in drug resistant hypertension.

[One-year persistence of renin-angiotensin-aldosterone system inhibitors fixed drug combinations in hypertensive patients]. / Renin-angiotenzin-aldoszteron-rendszer-gátlók fix gyógyszer-kombinációinak egyéves perzisztenciája hypertoniás betegekben.

INTRODUCTION: Various fixed combinations of antihypertensive agents are highlighted in European and Hungarian hypertension guidelines. A renin-angiotensin-aldosterone system antagonist (RAAS inhibitor) in combination with calcium channel blockers (CCBs) or diuretics are recommended as the first step in antihypertensive therapy. OBJECTIVES: The aim of the authors was to compare the one-year persistence of RAAS inhibitor fixed-dose combinations (FDCs) in hypertension. METHOD: The authors have analyzed the prescription database of the National Health Insurance Fund and selected patients who first filled prescriptions for any RAAS inhibitor FDC between October 1, 2012, and September 30, 2013, and who did not redeem prescriptions for similar preparations in the year preceding the selection period. Apparatus of survival analysis was used, where "survival" was the time to abandon the medication. RESULTS: A total of 443 149 patients met the selection criteria. The one-year persistence of angiotensin-converting enzyme inhibitor (ACE inhibitor)/CCB FDCs was 44.59%, while that of angiotensin II receptor inhibitor (ARB)/thiazide diuretic (HCT) FDCs was 42.52%. This was followed by ACE inhibitor/indapamide FDCs at 37.27%, ARB/CCB FDCs at 29.04%, and ACE inhibitors/HCT FDCs at 27.47%. Compared to ACE inhibitor/indapamide FDCs (reference), the risk of discontinuing ACE inhibitor/CCBs was 31 percentage points lower (HR = 0.69, 95% CI 0.6855-0.6996, p<0.0001), and the risk of discontinuing ARB/HCT FDCs was 18 percentage points lower (HR = 0.82, 95% CI 0.8096-0.8267, p<0.0001). However, the risk of discontinuing ACE inhibitor/HCT FDCs was 17 percentage points higher (HR = 1.17, 95% CI 1.1562-1.1825, p<0.0001), and the risk of discontinuing ARB/CCB FDCs was 20 percentage points higher (HR = 1.20, 95% CI 1.17316-1.2239, p<0.0001). The average medication adherence time limited to 360 days was 239.9 days for ACE inhibitor/CCB FDCs, 214.8 days for ARB/HCT FDCs, 193.8 days for ACE inhibitor/indapamide FDCs, 178.8 days for ARB/CCB FDCs, and 177.6 days for ACE inhibitor/HCT FDCs. CONCLUSIONS: The authors have demonstrated that the one-year persistence of RAAS inhibitor FDCs varies significantly in hypertensive patients. ACE inhibitor/CCB FDCs were found to be the most advantageous. Orv Hetil. 2023; 164(34): 1337-1341.

[Analysis of sudden cardiac death in competitive athletes, possibilities for reducing cases]. / Versenysportolók hirtelen szívhalálának elemzése, az esetszámok csökkentésének lehetoségei.

INTRODUCTION: Sudden cardiac death in athletes is rare (0.5 to 1 per 100 000 athlete years), but sudden cardiac death in known athletes causes general shock. OBJECTIVE: Our research aim was to collect and study as many sudden cardiac death cases as possible, judge the role of stress and look for ways to reduce fatal tragedies. METHOD: From registers and newspaper articles found on the Internet, we collected 360 (including 14 women) athletes' sudden cardiac death cases where the sport, age and place of death (during training/competition/after) could be determined. From these, a single database has been prepared in order of the year of death. The cases were grouped and analyzed by sports. Based on our results and literature data, we made recommendations to reduce fatalities. RESULTS AND CONCLUSION: There were more sudden cardiac deaths in competitions than in trainings (239 vs. 99), but tragedies also happened during warm-ups and chess without physical exertion, furthermore, there was no sudden cardiac death in the stakeless training of marathon/half marathon/triathlon athletes; all these prove the role of stress, so we recommend a psychological conversation before a high-stakes race. There were also a lot of sudden cardiac deaths (79/360) during team sports trainings, so we recommend reanimation readiness there as well. After training/competition, sudden cardiac death happened mainly in sports requiring high static effort, where post-competition monitoring is also recommended. Those who died in training were younger than those who died during the race (p<0.01), so young people should be monitored more closely for medical and (under)fitness. Marathon runners and triathletes were older than team athletes (p<0.005) and only died in competition, so for them a basic examination and an ECG within 1 month before competition are recommended. Conclusions drawn from literature data: sports medicine examination should be standardized and documented in an accessible way; since resuscitation started earlier and professionally is more effective, all competitors should receive reanimation training. Orv Hetil. 2023; 164(29): 1155-1163.

[The pharmacological treatment of obesity: past, present and future]. / Az elhízás gyógyszeres kezelése: múlt, jelen, jövo

Currently, obesity presents one of the biggest health problems. Management strategies for weight reduction in obese individuals include changes in life style such as exercise and diet, behavioral therapy, and pharmacological treatment, and in certain cases surgical intervention. Diet and exercise are best for both prevention and treatment, but both require much discipline and are difficult to maintain. Drug treatment of obesity offer a possible adjunct, but it may only have modest results, limited by side effects; furthermore, the weight lowering effects last only as long as the drug is being taken and, unfortunately, as soon as the administration is stopped, the weight is regained. These strategies should be used in a combination for higher efficacy. Drugs used to induce weight loss have various effects: they increase satiety, reduce the absorption of nutrients or make metabolism faster; but their effect is usually moderate. In the past, several drugs were used in the pharmacological therapy of weight reduction including thyroid hormone, dinitrophenol, amphetamines and their analogues, e.g. fenfluramine, At present, only orlistat is available in the long term treatment (≥ 24 weeks) of obesity as sibutramine and rimonabant were withdrawn form the market. Several new anti-obesity drugs are being tested at present, and liraglutide, a GLP-1 analogue (incretin mimetic), is the most promising one.

[Rivaroxaban in prevention of stroke in patients with atrial fibrillation]. / A rivaroxaban a stroke megelozésében pitvarfibrilláló betegekben.

Atrial fibrillation (AF) is well established risk factor for cardioembolic stroke. With thromboprophylatic treatment we can reduce the risk of stroke in patients with AF. Oral vitamin K antagonists (VKA) such as warfarin and acenocoumarol are effective for stroke prevention in patients with atrial fibrillation. VKAs are associated with several limitations including very narrow therapeutic range, several factors (diet, drugs, alcohol consumption) affecting the effect of VKA and excessive bleeding may occur if INR value not controlled successfully. New oral anticoagulant direct Xa factor inhibitor rivaroxaban has a good therapeutic efficacy in prevention (primary and secondary) of stroke in AF patients. Its advantages are including no need for monitoring, fixed oral dose, not affected by meal, age and body weight, all of them can improve patient adherence. In ROCKET AF trial in patients with AF, rivaroxaban was noninferior to warfarin for the prevention of stroke or systemic embolism. There was no significant between-group difference in the risk of major bleeding, although intracranial and fatal bleeding occurred less frequently in the rivaroxaban group.

Supplementary Therapeutic Possibilities to Alleviate Myocardial Damage Due to Microvascular Dysfunction in Coronavirus Disease 2019 (COVID-19).

Myocardial damage with a consequent rise in cardio-specific troponin level is a frequent phenomenon in severe cases of coronavirus disease 2019 (COVID-19). Its causes are capillary endothelial cell dysfunction, associated carditis, low oxygenization, and increased sympathetic tone, which all worsen myocardial stiffness and microvascular dysfunction (MD). They lead to severe myocardial dysfunction, arrhythmia, acute congestive heart failure, and a significant rise in death cases. During COVID-19, no specific cardiological treatment is started. As adjuvant therapy, anxiolytics in COVID-19 are widely used, but not in all anxious patients who had been infected with coronavirus. Anxiolytics can be useful to moderate MD and immunosuppressive effect of anxiety. The favorable effects of trimetazidine (TMZ) and Coenzyme Q10 (CoQ10) in the treatment of myocardial ischemia and heart failure had previously been proven, and also their anti-inflammatory effects had been suspected; however, they have not yet been used in COVID-19 cases. TMZ promotes glucose-mediated ATP production, which requires less oxygen, which explains its advantageous cardiac effects. Since it lowers serum and myocardial tissue proinflammatory cytokine levels and inhibits myocardial macrophage infiltration, it was suspected that TMZ might represent a novel therapeutic agent to prevent and treat sepsis-induced myocardial dysfunction. CoQ10 plays an important role in cellular ATP production; however, its concentration is decreased in cardiovascular diseases and in influenza patients. Due to its anti-inflammatory effect, CoQ10 has been suspected to have a key therapeutic target in influenza infection. We suggest considering these medicines to alleviate myocardial damage and inflammation in COVID-19.

Diagnostic value of body surface potential mapping in assessment of the coronary artery lesion after angina pectoris and without repolarization changes on the electrocardiogram.

BACKGROUND: The body surface potential mapping (BSPM) method is sensitive in detecting minor electrical potential abnormalities, but its diagnostic value is unclear in detection and localization of significant coronary artery lesion (CAL) in patients after angina pectoris and without ischemic electrocardiogram abnormalities at the time of the BSPM record. METHODS AND RESULTS: Characteristic features and quantitative parameters of the isopotential maps during the depolarization were evaluated and compared with the result of coronary angiography in 228 patients (164 males; age, 61.6 +/- 9.5 years). Twenty-three of them had their first angina, but the others had a history of earlier angina, unstable angina, non-ST-elevation infarction. Fifty-nine healthy subjects (32 males; age, 53.3 +/- 12.2 years) served as control. The diagnostic power was high in detection of CAL among patients with previous ischemic events, but it was low in first angina. The accuracy of the CAL localization by multiple regression was different: at 90% specificity level, the sensitivity was near 80% for right/posterior descending CAL and slightly more than 60% for left anterior descending CAL but only 19% for first marginal/first diagonal CAL. CONCLUSIONS: The BSPM changes during the depolarization could well indicate CAL only after previous ischemic events. Sensitivity and specificity of the CAL localization depended on the extension and location of the underlying myocardium damage.

Real-world adherence to oral anticoagulants in atrial fibrillation / [Orális antikoagulánssal kezelt pitvarfibrilláló betegek terápiahusége a mindennapokban]

Introduction: In the treatment of non-valvular atrial fibrillation (AF) with oral anticoagulant (OAC), the patients' adherence to therapy is a very important factor in stroke prevention. Aim: To investigate the one-year persistence of different OAC therapies (vitamin K antagonist [VKA] and new oral anticoagulants [NOAC]) in patients with AF. Method: The authors investigated the persistence of oral anticoagulant (OAC = VKA/NOAC) in atrial fibrillation using the National Health Insurance Fund of Hungary prescriptions database on pharmacy claims between June 1, 2016 and December 31, 2016. Results: 122 870 patients met the inclusion criteria. 18 650 patients started OACs therapy newly (therapy-naïve group), while 104 220 were already on one of the OACs. Among new patients, the one-year persistence of NOACs was 65.7% and that of VKA was 39.0% (p<0.001). The one-year persistence rate was 72.6% for NOAC and 53.9% for VKA (p<0.001) in patients already on OACs. In the therapy-naïve group, the one-year persistence to rivaroxaban was 65.7%. To apixaban it was 62.6%, and to dabigatran it was 59.2% (logrank p<0.001 in all comparisons except rivaroxaban vs. apixaban: p = 0.017, and dabigatran vs. apixaban: p<0.01). The one-year persistence rate of patients treated with NOACs was 73.4% to rivaroxaban, 68.0% to apixaban, and 68.4% to dabigatran (logrank p<0.001 in all comparisons except apixaban vs. dabigatran, NS). Conclusions: The one-year persistence of NOACs was significantly higher in AF compared to VKA therapy (in therapy-naïve and in already treated patients, too). Among the NOACs, rivaroxaban has the best one-year persistence in all patient populations. Orv Hetil. 2020; 161(20): 839-845.

[One-year persistence of patients already treated with oral anticoagulants for atrial fibrillation]. / Orális antikoagulánssal már kezelt pitvarfibrilláló betegek egyéves terápiahusége.

INTRODUCTION: In the treatment of non-valvular atrial fibrillation (AF) with oral anticoagulants (OAC), medical adherence is a relevant factor for stroke prevention. AIM: To evaluate the one-year persistence of vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC) in patients suffering from AF and already treated with OACs. METHOD: Information from the National Health Insurance Fund of Hungary prescriptions database on pharmacy claims between June 1, 2015 and December 31, 2015 was analysed. Authors identified patients who filled prescriptions for OACs (VKAs or DOACs) prescribed for AF who have already received OACs therapy during one year before. Apparatus of survival analysis was used, where 'survival' was the time to abandon the medication. RESULTS: 196 016 patients met the inclusion criteria. 181 810 patients received VKA and 14 206 patients were treated with DOACs. The one-year persistence rate in patients taking VKA was 52.9% whereas it was 66.8% in those on the DOACs. The persistence rates after 360 days were 67.5% for rivaroxaban, 63.6% for apixaban and 63.4% for dabigatran. The mean duration of persistence was 311 days for rivaroxaban, 308 days for apixaban and 284 days for dabigatran. The actual rate of discontinuation was 14% (HR = 1.14 [95% CI 1.05-1.24]), p = 0.0015) for apixaban, 15% (HR = 1.15 [95% CI 1.08-1.23], p = 0.003) for dabigatran and 62% (HR = 1.62 [95% CI 1.56-1.69], p<0.0001) for VKA compared to rivaroxaban (reference). CONCLUSIONS: The authors have confirmed that the one-year persistence of DOAKs was significantly higher compared to KVA therapy in AF. The one-year persistence of rivaroxaban was more favoured than apixaban and dabigatran. Orv Hetil. 2019; 160(13): 509-515.

[One-year persistence of fixed-dose combinations of angiotensin-converting enzyme inhibitor and calcium channel blocker in hypertensive patients]. / Az angiotenzinkonvertálóenzim-gátló/kalciumcsatorna-blokkoló fix gyógyszer-kombinációk egyéves perzisztenciája hypertoniában.

INTRODUCTION: The most recent European guidelines for the treatment of hypertension suggest the use of renin-angiotensin-aldosterone system antagonists (RAAS inhibitors) and calcium channel blockers (CCBs) or diuretics fixed-dose combinations (FDCs) as the first therapeutic option. In antihypertensive therapy, the patient's adherence is one of the most important factors in reducing unwanted cardiovascular events. AIM: Our aim was to assess the one-year persistence of angiotensin-converting enzyme inhibitor (ACEI) and CCB FDCs in hypertensive patients. METHOD: Authors have analysed the prescription database of the National Health Insurance Fund in Hungary on pharmacy claims between October 1, 2012 and September 30, 2013. Those patients were identified who filled prescriptions for FDCs of ACEI and CCBs prescribed for the first time for hypertensive patients and who had not received similar drugs during the year before. Apparatus of survival analysis was used, where 'survival' was the time to abandon the medication. RESULTS: 124 388 patients met the inclusion criteria. One-year persistence rate and hazard ratio (HR) of discontinuation in patients with ramipril/amlodipine FDC was 54% (HR = 1.00, reference), perindopril/amlodipine 47% (HR = 1.30, p<0.0001), lisinopril/amlodipine 36% (HR = 1.79, p<0.0001), ramipril/felodipine 26% (HR = 2.28, p<0.0001) and trandolapril/verapamil 12% (HR = 4.13, p<0.0001). The average survival time of drug limited to 360 days was 270.2 days for ramipril/amlodipine FDC, 242.7 days for perindopril/amlodipine FDC, 211.2 days for lisinopril/amlodipine FDC, 186.3 days for ramipril/felodipine FDC and 125.7 days for trandolapril/verapamil FDC. CONCLUSIONS: The authors demonstrated that the one-year persistence of ACEI/CCB FDCs was significantly different in hypertensive patients. Ramipril/amlodipine FDC was more advantageous for patient adherence. Orv Hetil. 2019; 160(9): 343-348.

[Case of a young woman successfully operated on for acute pulmonary embolism and right ventricular thrombus after urogenital infection]. / Akut tüdoembolia és jobb kamrai thrombus sikeresen operált esete fiatal nobeteg urogenitalis infekciója után.

The authors report a case of a 22-year-old women operated on for pulmonary embolism with success. The venous embolism developed in two phases one week apart. The first clinical sign was a dyspnea of abrupt onset limiting physical activity even after a mild exertion. However, relevant diagnostic tests were performed after one week when the patient fainted, her dyspnea worsened. The results of ECG, echocardiography and pulmonary perfusion scintigraphy indicated the presence of a thrombus residing in the right ventricle and the embolism of the right pulmonary artery. Chest CT and pneumo-angiography findings show the embolus completely blocking the main right branch of the pulmonary artery and partially blocking the left lower lobe artery. On the basis of their experiences published earlier the patient was brought to a stable cardio-respiratory state prior to surgery. Both the adherent right ventricular thrombus and the fresh embolus residing in the right branch of the pulmonary artery were removed under the protection of extracorporeal circulation. After the elapse of an event-free 6-month postoperative period the patient continued to remain symptomless, while being on a long-term anticoagulant regimen. The long-term anticoncipient medication and the urogenital infection 3 months prior to surgery may have been involved in the etiology of the pulmonary embolism. The authors propose the implementation of an antithrombotic prophylaxis in young women after gynecological infections.

Simple, quantitative body surface potential map parameters in the diagnosis of remote Q wave and non-Q wave myocardial infarction.

BACKGROUND: Body surface potential mapping has been shown to be a useful tool in the diagnosis and localization of remote non-Q wave and Q wave myocardial infarction, but human expertise is required to interpret the maps. OBJECTIVE: To identify quantitative body surface potential mapping parameters that could enable a computer-based diagnosis. METHODS: Body surface isopotential maps (63 unipolar leads) were recorded in 86 patients with remote Q wave and 71 patients with remote non-Q wave myocardial infarction. Twenty-four healthy adults served as control subjects. Myocardial infarctions were classified using standard electrocardiogram leads in the acute and chronic phases, and were validated by coronary angiography, ventriculography and thallium scintigraphy. RESULTS: Two simple quantitative parameters with high diagnostic power were identified: the time interval between the peak minimum and the peak maximum potentials (time-shift), and the ratio of these potentials (maximum to minimum ratio [max/min]). Both parameters showed significant differences between infarction patients and normal control subjects, and optimum cut-off values were determined using receiver operating characteristic curves (anterior infarction: time-shift of -4 ms or less, max/min of 0.6 or less; posterior infarction: time-shift of 8 ms or greater, max/min of 1.25 or greater). The sensitivities of the two parameters were 100% and 97%, and the specificities were 99% and 100%, respectively, in the anterior Q wave infarction group, compared with sensitivities of 88% and 100%, and specificities of 94% and 95%, respectively, in the posterior Q wave infarction group. In the anterior non-Q wave infarction group, sensitivity was 35% for both parameters, specificity was 100% for both parameters, and only infarctions associated with a low ejection fraction were detected, indicating that infarction size may influence the power of the tests. CONCLUSIONS: Time-shift and max/min are two new, simple, powerful parameters for infarction diagnosis and may also be suitable for automated, computer-based processing.

Non-ST elevation myocardial infarction: a new pathophysiological concept could solve the contradiction between accepted cause and clinical observations.

UNLABELLED: Non-ST elevation myocardial infarction (NSTEMI) and ST elevation infarction have many differences in their appearance and prognosis. A comprehensive search made us form a new hypothesis that a further cause also existsin NSTEMI: an acute, critical increase in the already existing high microvascular resistance in addition to the subtotal coronary artery occlusion. Various findings and studies can be interpreted only by our hypothesis: hemodynamic findings, ECG changes, autopsy reports and clinical observations (different long-time prognosis and different result of acute revascularization therapy in NSTEMI, similarities of NSTEMI with other clinical symptoms where increased microvascular resistance can be supposed without coronary artery disease). OBJECTIVE: Despite similarities in the underlying pathologic mechanism non-ST elevation myocardial infarction(NSTEMI) and ST elevation infarction (STEMI) have many differences in their clinical presentation and prognosis. METHOD: A systematic review of the literature about NSTEMI and the blood supply of the myocardium made us form a hypothesis that a further cause also exists in addition to the accepted cause of NSTEMI (subtotal coronaryartery occlusion): an acute, critical increase in an already existing high intramyocardial microvascular resistance. EVIDENCE: Knowledge about microcirculation disturbances in ischemic heart disease and development of microcirculation damage can be fitted in our hypothesis. Various findings and studies can be interpreted only by our hypothesis: hemodynamic findings, ECG changes, autopsy reports and clinical observations about NSTEMI. The latest ones involve the different long-time prognosis and different result of acute revascularization therapy in STEMI and NSTEMI. Regarding the repolarization changes on the ECG NSTEMI shows similarities with other clinical symptoms where increased intramyocardial microvascular resistance can be supposed without coronary artery disease: false positive exercise stress test, supraventricular tachycardia, left ventricular strain and conduction disturbances. CONCLUSION: The acute treatment of NSTEMI should aim to improve the blood inflow to the stiff myocardiumand/or impaired microvascular system and decrease the high microvascular resistance.

Diagnostic value of the left atrial electrical potentials detected by body surface potential mapping in the prediction of coronary artery disease.

BACKGROUND: The electrocardiographic diagnosis of significant coronary artery stenosis (CAD) is often based on the investigation of the left ventricular repolarization changes during exercise ECG stress test (EST). Our aim was to prove that the electric activity of the left atrium can indicate the ischemic damage of the left ventricle, and furthermore, it is able to indicate CAD without exercise. METHODS AND RESULTS: Patients with chest complaints but without evidence of acute coronary syndrome were investigated by EST and body surface potential mapping (BSPM, 63 leads). CAD was proven in 45 cases (32 men, years 40-76) and excluded in 50 cases (35 men, years 38-72) with coronary angiography. Left atrial electric potentials (EP-LA) before and after 0.08 mg sublingual nitroglycerine administration differed significantly (p<0.001) in the two groups. According to Fischer linear discriminant analysis, this difference in % (EP-LA(d%)) was the best separating parameter: below limit of -14.17% (CAD prevalence was considered) this parameter predicted CAD with 93% sensitivity, 100% specificity, >10 positive and 0.05 negative likelihood ratio (weighted for prevalence). The EST predicted CAD with 71% sensitivity, 78% specificity, 2.43 positive and 0.28 negative likelihood ratios. CONCLUSION: The electrical activity changes of the left atrium seemed to be suitable to predict CAD as an EST-alternative resting method.

Diagnosis and discrimination of remote antero- and inferoseptal non-Q wave myocardial infarctions with body surface potential mapping.

BACKGROUND: Previous studies have shown that the diagnosis and localization of previous non-Q wave myocardial infarction (NQMI) is possible by body surface potential mapping (BSPM), but the criteria for the discrimination between anteroseptal and inferoseptal middle regions remain to be determined. METHODS: BSPM using 63 unipolar leads was recorded in 119 patients with previous NQMI (36 to 76 years of age, average 61 years; 85 men). Localization of anteroseptal or inferior middle NQMI occurred in 70 cases (44 to 76 years of age, average 61 years, 53 men) by determining early anterior minimum potential with only slight negativity. In these cases, isopotential maps obtained at additional time points were investigated to discriminate between anteroseptal and inferoseptal NQMI. The clinical localization was based on the concordance of two of the following tests: wall motion disturbances on echocardiography, coronary angiogram and repolarization changes in the acute-phase electrocardiogram. RESULTS: Two milliseconds before the appearance of the first anterior minimum, a more accentuated superior negativity indicated anteroseptal NQMI (32 of 70 cases), while a more pronounced inferior negativity indicated inferoseptal NQMI (38 of 70 cases). Fisher's exact test showed statistically significant associations between the above BSPM localizations and the clinical localizations (P<0.001). Occlusion or stenosis of the expected infarct-related coronary artery was detected in all patients either as a single lesion or together with other coronary artery lesions. CONCLUSIONS: The BSPM criteria proposed here are suitable to detect the most frequent NQMI localizations. The narrowing of the infarct-related coronary arteries, the left anterior descending or the posterior descending coronary artery, can be thus differentiated.