Drugs for spontaneous coronary dissection: a few untrusted options.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome that is often overlooked, misdiagnosed, and maltreated. Medical treatment poses a significant challenge because of the lack of randomized studies to guide treatment. The initial clinical presentation should guide medical and interventional management. Fibrinolytic agents and anticoagulants should be avoided because they could favor hematoma propagation. In patients with SCAD, antiplatelet therapy should be prescribed especially dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel, whereas potent P2Y12 inhibitors, e.g., ticagrelor and prasugrel, should be avoided. If a stent was used, DAPT should be continued for 12 months. Aspirin only can be an option for patients without "high-risk" angiographic features-thrombus burden, critical stenosis, and decreased coronary flow. Beta-blocking (BB) agents should be used to prevent recurrence of SCAD. There is a general agreement that angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, mineralocorticoid antagonists, and loop diuretics should be used in patients with SCAD experiencing the symptoms of heart failure and a decrease in left ventricular ejection fraction below 50%. Although without firm evidence, statins can be used in SCAD due to their pleiotropic properties. The results of a randomized trial on the use of BB and statins are awaited. Aggregation of data from national registries might point out truly beneficial medications for patients with SCAD.

The imPAct of Trimetazidine on MicrOcirculation after Stenting for stable coronary artery disease (PATMOS study).

Background: Myocardial ischemia is caused by epicardial coronary artery stenosis or atherosclerotic disease affecting microcirculation. Trimetazidine (TMZ), promotes glucose oxidation which optimizes cellular energy processes in ischemic conditions. Small studies demonstrated protective effects of TMZ in terms of reducing myocardial injury after percutaneous coronary intervention (PCI), its effect on microcirculation using contemporary investigative methods has not been studied. The aim of the study was to examine effects of trimetazidine, given before elective PCI, on microcirculation using invasively measured index of microcirculatory resistance (IMR). Methods: This was prospective, single blinded, randomized study performed in a single university hospital. It included consecutive patients with an indication for PCI of a single, de novo, native coronary artery lesion. Patients were randomly assigned to receive either TMZ plus standard therapy (TMZ group) or just standard therapy. Coronary physiology indices fractional flow reserve (FFR), coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were measured before and after PCI using coronary pressure wire. Results: We randomized 71 patients with similar clinical characteristics and risk profile, previous medications and coronary angiograms. Patientshad similar values of Pd/Pa, FFR and CFR prior to PCI procedure. After PCI, FFR values were higher in TMZ group, while IMR values were lower in this group respectively (FFR TMZ + 0.89 ± 0.05 vs. TMZ - 0.85 ± 0.06, p = 0.007; CFR TMZ + 2.1 ± 0.8 vs. TMZ- 2.3 ± 1.3, p = 0.469; IMR TMZ + 18 ± 9 vs. TMZ- 24 ± 12, p = 0.028). In two-way repeated measures ANOVA PCI was associated with change in FFR values (TMZ p = 0.050; PCI p < 0.001; p for interaction 0.577) and TMZ with change in IMR values (TMZ p = 0.034, PCI p = 0.129, p for interaction 0.344). Conclusion: Adding trimetazidine on top of medical treatment prior to elective PCI reduces microvascular dysfunction by lowering postprocedural IMR values when compared to standard therapy alone.

Serial stenosis assessment-can we rely on invasive coronary physiology.

Atherosclerosis is a widespread disease affecting coronary arteries. Diffuse atherosclerotic disease affects the whole vessel, posing difficulties in determining lesion significance by angiography. Research has confirmed that revascularization guided by invasive coronary physiology indices improves patients' prognosis and quality of life. Serial lesions can be a diagnostic challenge because the measurement of functional stenosis significance using invasive physiology is influenced by a complex interplay of factors. The use of fractional flow reserve (FFR) pullback provides a trans-stenotic pressure gradient (ΔP) for each of the lesions. The strategy of treating the lesion with greater ΔP first and then reevaluating another lesion has been advocated. Similarly, non-hyperemic indices can be used to assess the contribution of each stenosis and predict the effect of lesion treatment on physiology indices. Pullback pressure gradient (PPG) integrates physiological variables of coronary pressure along the epicardial vessel and characteristics of discrete and diffuse coronary stenoses into a quantitative index that can be used to guide revascularization. We proposed an algorithm that integrates FFR pullbacks and calculates PPG to determine individual lesion importance and to guide intervention. Computer modeling of the coronaries and the use of non-invasive FFR measurement together with mathematical algorithms for fluid dynamics can make predictions of lesion significance in serial stenoses easier and provide practical solutions for treatment. All these strategies need to be validated before widespread clinical use.

Predictors of Early Deterioration of Renal Function in Patients Older Than 70 Years Undergoing Valvular Surgery.

BACKGROUND: Cardiac surgery-associated acute kidney injury (CSA-AKI) is the most common clinically important complication in adult patients undergoing open-heart surgery, with an incidence between 8.9% and 39%. Studies have shown that even a slight increase in serum creatinine levels after cardiac surgery significantly affects the mortality and morbidity of these patients. AIM: This study sought to determine the predictors and incidence of acute kidney injury (AKI) in patients older than 70 years undergoing elective valvular surgery. METHODS: Prospective study included 156 patients scheduled for elective cardiac surgery requiring cardiopulmonary bypass (CPB) at Dedinje Cardiovascular Institute between January and September 2019. Isolated valvular surgery was performed in 87 patients, while the remaining 69 patients underwent combined coronary and valvular surgery. The development and stage of CSA-AKI were diagnosed, according to Kidney Disease Improving Global Outcome (KDIGO) criteria. Predictors and incidence of CSA-AKI development were assessed using univariate binary logistic regression analysis. RESULTS: The incidence of CSA-AKI was 17.3%. CSA-AKI stage 1 was diagnosed in 25 patients  (16.02%). CSA-AKI stage 2 was noted in one patient (0.64%), as well as stage 3 (0.64%). In six patients (3.85%), renal replacement therapy (RRT) was required. Using univariate binary logistic analysis, the following parameters were identified as predictors for CSA-AKI development: duration of cardiopulmonary bypass (OR 1.01; CI 95% (1.01-1.02); P = .002), duration of aortic clamping (OR 1.02; CI 95% (1.01-1.03); P = .002), lactate levels during the intensive care unit (ICU) stay (OR 1.33; CI 95% (1.04-1.70); P = .026), duration of mechanical ventilation (MV) (OR 1.03; CI 95% (1.1-1.07); P = .014), the use of inotropic drugs (adrenaline, dobutamine) (OR 0.38: CI 95% (0.16-0.9); P = .026; and OR 0.23; CI 95% (0.1-0.56); P = .0019, respectively), and the use of diuretics (OR 0.24; CI95% (0.06-095); P = .041). Using Mann-Whitney U test for independent samples show that the group of patients who developed CSA-AKI had significantly longer duration of hospitalization (Z = -2.751); P = .006), prolonged ICU stay (Z = -4.160; P < .001), and need for prolonged mechanical ventilation (Z = -4.411; P < .001). CONCLUSION: Independent predictors for AKI development after valvular surgery in patients older than 70 years are prolonged mechanical ventilation and increased lactate values, while the use of diuretics after surgery reduces the incidence of AKI. Also, the development of CSA-AKI is associated with prolonged ICU stay and a longer duration of hospitalization.

Implementation of Best Practice Guidelines as an Effort in Reducing Hospital Readmission following Coronary Artery Bypass Surgery.

OBJECTIVES: The present study aimed to identify significant causes of readmission within 30 days following coronary artery bypass graft (CABG) surgery and compare readmission incidence related to surgical site infections (SSIs) before and after implementing international recommendations for antibiotic prophylaxis. METHODS: We analyzed 2,225 CABG patients who received either guideline-directed antibiotic prophylaxis (GDAP = 568) or institutional antibiotic prophylaxis (non-GDAP = 1,657) between January 2017 and December 2019. The primary outcome was a composite of sternal wound infection (SWI) or harvest SWI. Secondary outcomes consisted of the individual components of composite end point, the incidence of in-hospital SSIs, and prolonged postoperative length of hospital stay (LOS) (>7 days). Propensity matching was used to select pairs for final comparison. RESULTS: Before implementing GDAP, the most frequent reason for readmission were SSIs, causing 58.2% of all readmissions within 30 days. Of 429 matched pairs, 48 patients in the GDAP group and 67 patients in the non-GDAP group were readmitted to a hospital within 30 days for any cause (11.2 vs. 15.6%, p = 0.048). We found a decreased readmission incidence for reasons related to SSIs, although these differences did not reach statistical significance (7.4 vs. 10.0%, p = 0.069). Adherence to GDAP was associated with reduced in-hospital risks of SSIs and prolonged postoperative LOS (19.6 vs. 26.6%, p = 0.015). CONCLUSIONS: In this contemporary clinical practice study, the adherence to GDAP was an insufficient measure to decrease rehospitalization due to SSIs. The present findings warrant further investigation on factors that may contribute to SSIs development after hospital discharge.

Pulmonary Vein Isolation Outcome Degree Is a New Score for Efficacy of Atrial Fibrillation Catheter Ablation.

This study introduces the pulmonary vein isolation outcome degree (PVIOD) as a new semiquantitative measure for the efficacy of atrial fibrillation (AF) catheter ablation and reports the determination of predictors associated with PVIOD. The median follow-up periods of 117 patients after the first and last ablation were, respectively, 82 (IQR 15) and 72 (IQR 30) months. PVIOD 1 included 32.5% of patients, those with successful single pulmonary vein isolation (PVI); PVIOD 2 included 29.1% of subjects, those with success after multiple procedures; PVIOD 3 comprised 14.5% of patients, those with clinical success; and PVIOD 4 included 23.9% of cases, those with procedural and clinical failure. In the multivariate ordinal logistic regression analysis, PVIOD 1-4 were independently associated with longstanding persistent AF with paroxysmal AF as the referent category (odds ratio (OR), 3.5; 95% confidence interval (95% CI), 1.1-10.7 (p = 0.031)), left atrial (LA) diameter (OR, 1.2; 95% CI, 1.1-1.3 (p = 0.001)) and left ventricular ejection fraction (LVEF) (OR, 0.9; 95% CI, 0.86-1.0 (p = 0.038)). LA size > 41 mm, LVEF ≤ 50% and longstanding persistent AF are strong predictors of AF recurrence. PVIOD 1-4 offer the most exact long-term prognosis of PVI. The purpose of the present article is to expand the quantitative measure of procedural success in the medical and biological fields.

Early Selective C-Reactive Protein Apheresis in a Patient with Acute ST Segment Elevation Myocardial Reinfarction.

The patient was admitted for urgent coronary angiography following an acute anterior ST segment elevation myocardial reinfarction (STEMI) caused by acute stent thrombosis. A stent had been implanted 10 days prior to the reinfarction for an acute anterior STEMI. However, the patient had stopped taking ticagrelor post-discharge. Primary percutaneous coronary intervention of the left anterior descending artery was performed. Subsequently, due to a high C-reactive protein (CRP) level, 3 CRP apheresis sessions were performed, with the first session starting 12 h after the onset of symptoms. A significant drop in CRP was noted after each apheresis. The post-procedural course was uneventful.

Renal Dysfunction Following Elective Endovascular Aortic Aneurysm Repair.

Abdominal aortic aneurysm (AAA) is a degenerative disease of the aortic wall with potentially fatal complications. Open repair (OR) was considered the gold standard, until the emergence of endovascular aneurysm repair (EVAR), which is less invasive and equally (if not more) effective. As the popularity of endovascular procedures grows, related complications become more evident, with kidney damage being one of them. Although acute kidney injury (AKI) following EVAR is relatively common, its true incidence is still uncertain. Also, there is insufficient data concerning long-term renal outcomes after EVAR, especially with repeated contrast agent exposure. Despite the lack of firm evidence on the effectiveness of individual strategies, it is evident that prevention of AKI following EVAR requires a multifactorial approach. This review focuses on recent findings based on human studies regarding the current evidence of renal impairment after EVAR, its quantification and strategies for its prevention.

Combined GSTM1 and GSTT1 null genotypes are strong risk factors for atherogenesis in a Serbian population.

Oxidative stress (OS) plays an important role in atherogenesis and since glutathione S-transferases (GSTs) provide protection against OS, we have tested the hypothesis that deletion polymorphisms in two GSTs (GSTM1 and GSTT1) may affect the risk of developing atherosclerosis. A total of 382 individuals (200 patients with atherosclerosis and 182 healthy controls) were included in this association study. Genomic DNA was isolated from peripheral blood cells or from buccal epithelial cells and genotyping was performed using multiplex-PCR or real-time PCR methods. GSTM1 null genotype was significantly more frequent in atherosclerotic patients than in controls (52.0% vs 34.1%) and individuals with the GSTM1 null genotype had an approximately 2-fold increase in atherosclerosis risk (OR: 2.1, 95%CI=1.39-3.17, P=0.0004). GSTT1 null genotype alone did not show a statistically significant effect on atherosclerosis risk modulation, but the association approached significance (OR: 1.57, 95%CI=0.94-2.64, P=0.08). The combined analysis showed that the presence of both genes had a protective effect against atherosclerosis (OR=0.55, 95%CI=0.37-0.83, P=0.005) while double null genotypes led to a robust atherosclerosis risk increase (OR: 8.14, 95%CI= 2.41-27.51, P < 0.0001). This study demonstrated that the GSTM1 null and combined GSTM1/GSTT1 null genotypes are susceptibility factors for development of atherosclerosis in a Serbian population.

Combined GSTM1 and GSTT1 null genotypes are strong risk factors for atherogenesis in a Serbian population

Abstract Oxidative stress (OS) plays an important role in atherogenesis and since glutathione S-transferases (GSTs) provide protection against OS, we have tested the hypothesis that deletion polymorphisms in two GSTs (GSTM1 and GSTT1) may affect the risk of developing atherosclerosis. A total of 382 individuals (200 patients with atherosclerosis and 182 healthy controls) were included in this association study. Genomic DNA was isolated from peripheral blood cells or from buccal epithelial cells and genotyping was performed using multiplex-PCR or real-time PCR methods. GSTM1 null genotype was significantly more frequent in atherosclerotic patients than in controls (52.0% vs 34.1%) and individuals with the GSTM1 null genotype had an approximately 2-fold increase in atherosclerosis risk (OR: 2.1, 95%CI=1.39-3.17, P=0.0004). GSTT1 null genotype alone did not show a statistically significant effect on atherosclerosis risk modulation, but the association approached significance (OR: 1.57, 95%CI=0.94-2.64, P=0.08). The combined analysis showed that the presence of both genes had a protective effect against atherosclerosis (OR=0.55, 95%CI=0.37-0.83, P=0.005) while double null genotypes led to a robust atherosclerosis risk increase (OR: 8.14, 95%CI= 2.41-27.51, P < 0.0001). This study demonstrated that the GSTM1 null and combined GSTM1/GSTT1 null genotypes are susceptibility factors for development of atherosclerosis in a Serbian population.

Effect of short-term exercise training in patients following acute myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: Exercise-based rehabilitation is an important part of treatment patients following acute myocardial infarction (MI). However, data are scarce on the efffects of short-term exercise programs in patients with acute MI treated with primary percutaneous coronary intervention (PPCI). AIM: To evaluate the effect of short-term exercise training on cardiopulmonary exercise testing (CPET) parameters in patients suffering acute MI treated with PPCI. STUDY DESIGN: Observational longitudinal study. SETTING: Inpatient cardiac rehabilitation. POPULATION: Sixty consecutive patients with MI treated with PPCI referred for rehabilitation. METHODS: We studied 60 consecutive patients with MI treated with PPCI reffered for rehabilitation to our institution. The study population consisted of 54 men and 6 women (age 52.0±8.4 years, left ventricular ejection fraction 54.1±8.1%), who participated in a 3-week clinical cardiac rehabilitation program. The program consisted of cycling for 7 times/week, and daily walking for 45 minutes at an intensity of 70-80% of the individual maximal heart rate. All patients performed symptom-limited CPET on a bicycle ergometer with a ramp protocol of 10 w/min. The CPET was also performed after cardiac rehabilitation programs. RESULTS: After 3 weeks of exercise-based cardiac rehabilitation program improved exercise tolerance as compared to baseline (peak workload 119.28±20.45 vs. 104.35±22.01 watts, respectively, P<0.001), as well as peak respiratory exchage ratio (1.10±0.14 vs. 1.04±0.01, respectively, P<0.001). Peak heart rate at rest, peak and after 1 minute of rest were also improved. Most importantly, peak VO2 (19.27±4.16 vs. 17.27±3.34 ml/kg/min, respectively, P<0.001), peak VCO2 (1.83±0.38 vs. 1.58±0.30, respectively, P<0.001), peak ventilatory exchange (53.73±12.47 vs. 45.50±11.32 L/min, respectively, P<0.001) and peak breathing reserve (55.20±12.36 vs. 60.18±14.19%, respectively, P<0.001) were also improved. No major adverse cardiac events were noted during the rehabilitation program. CONCLUSIONS: Our data indicate that short-term exercise training in patients with acute MI treated with PPCI is safe and improves functional capacity, as well as test duration, work load and heart rate response. CLINICAL REHABILITATION IMPACT: It appears that three week cardiac rehabilitation is an effective approach to improve exercise capacity in patients with acute MI treated with PPCI.

Effect of Elective Bentall Procedure on Left Ventricular Systolic Function and Functional Status: Long-Term Follow-Up in 90 patients.

Because there are so few data on the long-term effects on left ventricular systolic function and functional status in patients who electively undergo Bentall procedures, we established a retrospective study group of 90 consecutive patients. This group consisted of 71 male and 19 female patients (mean age, 54 ± 10 yr) who had undergone the Bentall procedure to correct aortic valve disease and aneurysm of the ascending aorta, from 1997 through 2003 in a single tertiary-care center. We monitored these patients for a mean period of 117 ± 41 months for death, left ventricular ejection fraction and volume indices, and functional capacity as determined by New York Heart Association (NYHA) class. There were no operative deaths. The survival rate was 73.3% during follow-up. There were 10 cardiac and 13 noncardiac deaths, and 1 death of unknown cause. Echocardiography was performed before the index procedure and again after 117 ± 41 months. In surviving patients, statistically significant improvement in left ventricular ejection fraction, in comparison with preoperative values (0.49 ± 0.11 vs 0.41 ± 0.11; P <0.0001), was noted at follow-up. Similarly, we observed statistically significant reductions in left ventricular end-systolic (39.24 ± 28.7 vs 48.77 ± 28.62 mL/m(2)) and end-diastolic volumes (54.63 ± 6.97 vs 59.17 ± 8.92 mL/m(2); both P <0.0001). Most patients (53/66 [80.3%]) progressed from a higher to a lower NYHA class during the follow-up period. The Bentall procedure significantly improved long-term left ventricular systolic function and functional status in surviving patients who underwent operation on a nonemergency basis.

Copper and zinc concentrations in atherosclerotic plaque and serum in relation to lipid metabolism in patients with carotid atherosclerosis.

BACKGROUND/AIM: Some oligoelements are now investigated as possibly having a role in atherosclerosis. The aim of this study was to compare the concentrations of copper and zinc in the serum and carotid plaque and parameters of lipid metabolism in patients with different morphology of carotid atherosclerotic plaque. METHODS: Carotid endarterectomy due to the significant atherosclerotic stenosis was performed in 91 patients (mean age 64 ± 7). The control group consisted of 27 patients (mean age 58 ± 9), without carotid atherosclerosis. Atheroscletoric plaques were divided into four morphological groups, according to ultrasonic and intraoperative characteristics. Copper and zinc concentrations in the plaque, carotid artery and serum were measured by atomic absorption spectrophotometry. RESULTS: Serum copper concentrations were statistically significantly higher in the patients with hemorrhagic in comparison to those with calcified plaque (1.2 ± 0.9 µmol/L vs 0.7 ± 0.2 µmol/L, respectively; p = 0.021). Zinc concentrations were statistically significantly lower in plaques of the patients with fibrolipid in comparison to those with calcified plaques (22.1 ± 16.3 g/g vs 38.4 ± 25.8 µg/g, respectively; p = 0.024). A negative significant correlation was found for zinc and triglycerides in the serum in all the patients (r = -0.52, p = 0.025). In the control group we also demonstrated a positive significant correlation for low-density lipoprotein cholesterol and copper in the serum (r = 0.54, p = 0.04). CONCLUSION: The data obtained in the current study are consistent with the hypothesis that high copper and lower zinc levels may contribute to atherosclerosis and its sequelae as factors in a multifactorial disease. Further studies are necessary in order to conclude whether high concentration of copper and zinc in the serum could be risk factors for atherosclesrosis.

Radial artery vs saphenous vein graft used as the second conduit for surgical myocardial revascularization: long-term clinical follow-up.

BACKGROUND: There is ongoing debate regarding the efficacy of the radial artery (RA) as an aortocoronary conduit, with few solid data regarding long-term clinical results. We sought to determine if the use of the RA as the second arterial conduit, beside left internal thoracic artery (LITA), would improve long-term clinical outcome after CABG as compared to saphenous vein graft (SVG). METHODS: Between March 2001 and November 2003, 200 patients underwent isolated CABG and were randomized in 1:1 fashion to receive either LITA and RA grafts or LITA and SVGs. The primary end point was composite of cardiovascular mortality, non-fatal myocardial infarction and need for repeat myocardial revascularization (either surgical or percutaneous). RESULTS: There was no significant difference in absolute survival, with 12 deaths in each group during the study period (log rank = 0.01, p = 0.979). There were 3 and 2 cardiac deaths in RA and SVG groups, respectively. There was no difference in long-term clinical outcome between the groups (log rank = 0.450, p = 0.509). Eleven patients in RA group had one or more non-fatal events; 7 patients suffered a myocardial infarction, 9 patients underwent percutaneous coronary angioplasty, and 1 patient required redo coronary surgery. Likewise, 13 patients in SVG group had non-fatal event; 7 patients had myocardial infarction, 13 patients had percutaneous coronary intervention and 3 patients required redo coronary surgery. Angiograms were performed in 23 patients in RA group (patency rate 92 %) and 24 in SVG group (patency rate 86 %) (p = 0.67). CONCLUSION: In this small randomised study our data indicate that there is no difference in the 8 year clinical outcomes in relatively young patients between those having a RA or a saphenous vein graft used as a second conduit, beside LITA, for surgical myocardial revascularisation.

Contractile reserve assessed by dobutamine test identifies super-responders to cardiac resynchronization therapy.

INTRODUCTION: In this study, we sought to determine whether myocardial contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) can identify patients who experience nearly complete normalization of left ventricular (LV) function after the implantation of a cardiac resynchronization therapy (CRT) pacemaker. MATERIAL AND METHODS: The study group consisted of 55 consecutive patients with non-ischemic dilated cardiomyopathy, LV ejection fraction (LVEF) < 35%, and prolonged QRS complex duration, who were scheduled for CRT pacemaker implantation. The DSE (20 µg/kg/min) was performed in all patients. The CR assessment was based on a change in the wall motion score index (ΔWMSI) and ΔLVEF during DSE. Super-response was defined as an increase in LVEF to > 50% and reduction in left ventricular end-systolic dimension to < 40 mm 12 months following the CRT implantation. RESULTS: A total of 7 patients (12.7%) were identified as super-responders to CRT. When compared to non-super-responders, these patients had significantly higher values of the dobutamine-induced change in ΔWMSI (1.031 ±0.120 vs. 0.49 ±0.371, p < 0.01), and ΔEF (17.9 ±2.2 vs. 8.8 ±6.2, p < 0.01). Receiver operating characteristic analysis showed that dobutamine-induced changes in ΔWMSI ≥ 0.7 and ≥ 14% for ΔEF are the best discriminators for a super-response. Patients with ΔWMSI ≥ 0.7 and ΔEF ≥ 14% are significantly less often hospitalized (p < 0.01) for worsening of heart failure during 28.5 ±3.0 months of the follow-up. CONCLUSIONS: Contractile reserve assessed by DSE can identify patients with dilated cardiomyopathy who are likely to experience near normalization of LV function following CRT.

Temporal changes in plasma brain natriuretic peptide levels during exercise stress-echocardiography in patients with dilated cardiomyopathy.

The aim of this study was to evaluate temporal changes in brain natriuretic petide (BNP) levels during exercise stress-echocardiography in patients with dilated cardiomyopathy with respect to the left ventricular contractile reserve. We studied 55 consecutive patients with dilated cardiomyopathy (mean age, 55 ± 10 years, 49 (89.1%) male). All patients underwent exercise stress-echocardiography on a treadmill using the modified Bruce protocol. Contractile reserve was assessed by measuring changes in the wall motion score index (ΔWMSI) at rest and and at peak exercise. Levels of BNP were measured at rest, in the first minute, and after 20 minutes following termination of the stress test. Thirty-six patients had preserved left ventricular contractile reserve and 19 patients did not. Patients with preserved left ventricular contractile reserve showed a continuous rise in BNP levels from baseline to peak exercise and to 20 minutes following exertion (83.95 ± 108.51 versus 105.89 ± 116.00 versus 110.95 ± 119.70 ng/L, P < 0.001, respectively). On the other hand, patients without preserved left ventricular contractile reserve showed a decline in BNP levels at peak exercise as compared to baseline (335.49 ± 693.11 versus 320.08 ± 562.60 P = 0.031). ΔBNP was positively correlated with preserved contractile reserve (r = 0.46, P = 0.03) and lower NYHA class (r = -0.65, P = 0.001) in patients in whom baseline LVEF was lower than 20%. Multivariate analysis identified only WMSI at rest (beta -3.365, P = 0.008, 95 CI 0.03 to 0.411) as an independent predictor of left ventricular contractile reserve.The increase in BNP levels during exercise stress-echocardiography is associated with preserved left ventricular contractile reserve in patients with dilated cardiomyopathy.

Endovascular treatment of symptomatic high-grade vertebral artery stenosis.

BACKGROUND: The purpose of this study was to evaluate the initial and long-term results of endovascular treatment (EVT) in patients with symptomatic high-grade extracranial vertebral artery (VA) origin stenosis. METHODS: From February 2001 to March 2013, 73 consecutive patients (33 men with a mean age of 61.7 ± 8.8 years) underwent EVT for symptomatic high-grade VA stenosis. Preoperative evaluation included Duplex ultrasonography and arteriography. After successful treatment, all patients were followed up at 1, 3, 6, and 12 months after the procedure and every 6 months thereafter. RESULTS: Successful EVT of the VA stenosis was achieved in 68 patients (93.2%). All procedures were performed without use of cerebral protection. The early complication rate was 5.5%, which included one periprocedural transient ischemic attack, two hematomas at the puncture site, and one allergic reaction to the contrast agent. No in-hospital deaths occurred. During follow-up (mean, 44.3 ± 31.2 months; range, 2-144 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 87.3%, 87.3%, and 87.3%, respectively. Ultrasound Doppler controls during follow-up detected seven VA restenoses (10.3%). Univariate analysis failed to identify any variable predictive of long-term patency of successfully treated VA stenosis. CONCLUSIONS: EVT of symptomatic VA origin stenosis is a safe and effective procedure associated with low risk and good long-term results, even without use of cerebral protection devices.

Genetic polymorphisms of paraoxonase 1 and susceptibility to atherogenesis.

INTRODUCTION: Paraoxonase 1 (PON1) is a multifunctional enzyme associated with high-density lipoprotein particles (HDL). It is a cellular antioxidant that hydrolyses oxidized macromolecules, especially low-density lipoproteins (ox-LDL). Because increased oxidative stress is believed to play a crucial role in the initiation and propagation of atherosclerosis, coding (Q192R and L55M) and promoter (C(-107)T) region polymorphisms of pon1 gene, that are responsible for catalytic efficiency, activity and the level of the enzyme, have been of great interest as a potential markers of susceptibility for atherogenesis. OBJECTIVE: The aim of the study was to assess possible association between these pon1 gene variants and clinical manifestations of the atherosclerosis and oxidative stress. METHODS: A total of 60 angiographically documented patients with manifested atherosclerotic disease and 100 control individuals were analyzed. Genomic DNA was isolated from the peripheral blood cells and genotyping was performed using polymerase chain reaction followed by the restriction fragment length polymorphism (PCR-RFLP) analysis. RESULTS: No significant difference in allele and genotype frequencies of all three examined polymorphisms was found between the atherosclerotic patients and healthy controls. The obtained results could not support an association of pon1 gene variants with the oxidative stress and atherogenesis. CONCLUSION: These polymorphisms cannot be considered risk factors of atherosclerosis in Serbian population. A larger study is required in order to establish possible contribution of pon1 variants to atherosclerosis-related cardiovascular diseases.