Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP).

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Much of these diseases burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that with respect to low density lipoprotein cholesterol (LDL-C), "lower is better for longer", and the recent data have strongly emphasized the need of also "the earlier the better". In addition to statins, which have been available for several decades, the availability of ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) are additional very effective approach to LLT, especially for those at very high and extremely high cardiovascular risk. LLT is initiated as a response to an individual's calculated risk of future ASCVD and is intensified over time in order to meet treatment goals. However, in real-life clinical practice goals are not met in a substantial proportion of patients. This Position Paper complements existing guidelines on the management of lipids in patients following ACS. Bearing in mind the very high risk of further events in ACS, we propose practical solutions focusing on immediate combination therapy in strict clinical scenarios, to improve access and adherence to LLT in these patients. We also define an 'Extremely High Risk' group of individuals following ACS, completing the attempt made in the recent European guidelines, and suggest mechanisms to urgently address lipid-medicated cardiovascular risk in these patients.

Nutrition in primary and secondary prevention of cardiovascular risk in the continental and Mediterranean regions of Croatia.

BACKGROUND: The aim of this observational study was to evaluate the effect of Mediterranean and continental nutrition on cardiovascular risk in patients with acute and chronic coronary heart disease in Croatia. METHODS: The study included 1284 patients who were hospitalized in a 28-month period due to acute or chronic ischaemic heart disease in hospitals across Croatia. An individual questionnaire was prepared which enabled recording of various cardiovascular risk factors. RESULTS: Patients with chronic coronary artery disease have a better index of healthy diet than patients with acute coronary disease. Women have a better index of diet than men in both Croatian regions. When the prevalence of risk factors (impaired glucose tolerance, diabetes mellitus types I and II, hypercholesterolaemia, hypertriglyceridaemia and hypertension) in patients with Mediterranean and continental nutrition is compared, a trend is seen for patients who have risk factors to consume healthier food. CONCLUSION: The Mediterranean diet is associated with reduced risk of developing cardiovascular disease. This effect is more evident in patients with known cardiovascular disease.

Drug-eluting balloons in patients with non-ST elevation acute coronary syndrome.

BACKGROUND: We compared efficacy of bare-metal stent (BMS) and drug-eluting balloon (DEB) combination vs BMS alone, in patients with non-ST elevation acute coronary syndrome treated with percutaneous coronary intervention (PCI). METHODS: Patients with non-ST elevation myocardial infarction (NSTEMI) or unstable angina (UA) were randomized to BMS only or BMS+DEB group. Angiographic follow-up was performed after 6 months. The primary endpoints were binary in-stent restenosis (ISR) and late lumen loss (LLL) and the secondary endpoints were target lesion revascularization (TLR), stent thrombosis (ST), and new acute coronary syndrome (ACS). RESULTS: A total of 85 patients were enrolled, 44 (BMS) and 41 (BMS+DEB). The median age was 67 (36-84) years and 68 (80%) were male. Fifty-two patients (61.2%) had NSTEMI and 33 patients (38.8%) UA. There was no difference in patient demographics, risk factors, and clinical characteristics, except for more smokers in the BMS+DEB group 18/41 (43.9%) vs 9/44 (20.5%). At follow-up, no significant difference in binary ISR was found; p=0.593, but LLL was significantly lower in the BMS+DEB group 0.68 (0.00-2.15) mm vs 0.22 (0.00-2.35) mm; p=0.002. The difference in major adverse cardiac events (MACE) rate combining TLR, ST, and ACS, between the groups was also non-significant, 29.5% (BMS) vs 24.4% (BMS+DEB); p=0.835. One patient had a subacute ST (BMS+DEB) due to clopidogrel resistance. CONCLUSION: Patients treated with BMS+DEB combination for non-ST elevation acute coronary syndrome had significantly less LLL in comparison to patients treated with BMS alone but without an impact on patient clinical outcomes.

An update on the management of young-onset Parkinson's disease.

In the text that follows, we review the main clinical features, genetic characteristics, and treatment options for Parkinson's disease (PD), considering the age at onset. The clinical variability between patients with PD points at the existence of subtypes of the disease. Identification of subtypes is important, since a focus on homogenous group may lead to tailored treatment strategies. One of the factors that determine variability of clinical features of PD is age of onset. Young-onset Parkinson's disease (YOPD) is defined as parkinsonism starting between the ages of 21 and 40. YOPD has a slower disease progression and a greater incidence and earlier appearance of levodopa-induced motor complications; namely, motor fluctuations and dyskinesias. Moreover, YOPD patients face a lifetime of a progressive disease with gradual worsening of quality of life and their expectations are different from those of their older counterparts. Knowing this, treatment plans and management of symptoms must be paid careful attention to in order to maintain an acceptable quality of life in YOPD patients.

Echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

We found increased systolic coronary flow in transthoracic pulsed wave (PW) Doppler in a 42-year-old patient with anomalous origin of left main coronary artery from the pulmonary artery. This is a characteristic echocardiographic finding in this anomaly in the presence of collateral circulation and coronary L-R shunt. In comparison with so far used echocardiographic criteria this parameter when present allows quick recognition of anomalous origin of left coronary artery from the pulmonary artery, and its differentiation from other potentially lethal coronary anomalies.

[Overall and therapy specific mortality of patients hospitalized for acute myocardial infarction in Zagreb University Hospital Centre]. / Razlike u mortalitetu bolesnika hospitaliziranih zbog akutnog infarkta miokarda u KBC-u Zagreb ovisno o nacinu lijecenja.

In Coronary Care Unit and Intensive Care Unit, Zagreb University Hospital Centre, 403 patients were hospitalized for acute myocardial infarction (AMI) in the year 2005. Majority (288) patients presented with ST-segment elevation myocardial infarction (STEMI) and 115 patients with acute myocardial infarction without ST-segment elevation (NSTEMI). In-hospital mortality of STEMI patients was 13.9% vs. 9.6% of NSTEMI group of patients. In STEMI group 202 patients underwent urgent percutaneous coronary intervention (PCI), and 86 patients in STEMI group received conservative therapy. In-hospital mortality of patients treated with primary PCI was 5.9% vs. 29.1% in the group treated conservatively. The main reason for conservative therapy was late presentation to the hospital (> 12 hours from the beginning of symptoms). Only 11 high-risk patients in NSTEMI group underwent primary PCI and 99 NSTEMI patients received conservative therapy (in-hospital mortality 10.1%). We performed totally 218 urgent PCI interventions in both groups with low in-hospital mortality of 6.1% in comparison with high mortality in conservatively treated groups of patients. The mortality in PCI group was strongly connected with unsuccessful intervention and late reperfusion. Total ischemic time (6 hours and 5 minutes), and time from hospital presentation to reperfusion -"door to balloon time" (1 hour and 25 minutes) are longer that in similar patients series, and need to be improved. Transportation time (1 hour and 40 minutes) is acceptable. In conclusion, high percentage (70.1%) of STEMI and NSTEMI patients underwent primary PCI in our institution with low perioperative mortality. This group of patients had superior in-hospital mortality when compared with conservatively treated group of patients. There is still unacceptably high percentage of patients with AMI, who came into the hospital too late for any reperfusion therapy.

[Acute results and 6 month follow up in patients with direct stenting during primary angioplasty in acute myocardial infarction with ST elevation in KBC Zagreb]. / Primarni uspjeh i 6-mjesecni ishod bolesnika s akutnim infarktom miokarda sa ST-elevacijom u KBC-u Zagreb kod kojih je primijenjena metoda direktnog stentinga.

We perform primary angioplasty in all acute myocardial infarction patients with ST elevation in the first 6 hours, with good results. In 30 selected patients (36.2% of all primary angioplasty patients in this period) we used the method od direct stenting with 100% primary success. In all patients we achieved TIMI 2-3 flow, and complete or partial ST elevation resolution. The early mortality rate was 3.3%, and no other complications arose. Direct stenting in primary coronary angioplasty is a safe and effective procedure, with high primary result in selected cases, and low complication rate during procedure and incidence of MACE (Mayor Adverse Cardiac Events) during hospital stay and after 6 month follow up. The results are comparable with standard interventional procedure in acute myocardial infarction, with the advantage of shorter procedure, lower radiation exposure and less material use.

Giant, dissecting, high-pressure pulmonary artery aneurysm: case report of a 1-year natural course.

We report the rare subchronic clinical course of a giant, dissecting pulmonary artery aneurysm in an oligosymptomatic middle-aged woman who had idiopathic pulmonary hypertension. Diagnosis was simple with the use of echocardiography and multislice computed tomography. Conversely, deciding on the treatment was difficult, because prominent surgeons declined to perform surgical repair of the aneurysm and recommended heart-lung transplantation. Therefore, we were forced to treat our patient medically. She survived for 1 year, including 8 months of treatment with sildenafil, and then died suddenly while awaiting transplantation. Our patient, who had a dissecting, high-pressure pulmonary artery aneurysm, had an unexpectedly stable and uneventful clinical course for 1 year, which, under more favorable circumstances, might have provided enough time for heart-lung transplantation to be performed.