Ticagrelor versus clopidogrel in patients with STEMI treated with thrombolysis: the MIRTOS trial.

AIMS: We aimed to demonstrate whether coronary microvascular function is improved after ticagrelor administration compared to clopidogrel administration in STEMI subjects undergoing thrombolysis. METHODS AND RESULTS: MIRTOS is a multicentre study of ticagrelor versus clopidogrel in STEMI subjects treated with fibrinolysis. We enrolled 335 patients <75 years old with STEMI eligible for thrombolysis, of whom 167 were randomised to receive clopidogrel and 168 to receive ticagrelor together with thrombolysis. Primary outcome was the difference in post-PCI corrected TIMI frame count (CTFC). All clinical events were recorded in a three-month follow-up period. From the 335 patients who were randomised, 259 underwent PCI (129 clopidogrel and 130 ticagrelor) and 154 angiographies were analysable for the study primary endpoint. No significant difference was found between the clopidogrel (n=85) and ticagrelor (n=69) groups for CTFC (24.33±17.35 vs 28.33±17.59, p=0.10). No significant differences were observed in MACE and major bleeding events between randomisation groups (OR 2.0, 95% CI: 0.18-22.2, p=0.99). CONCLUSIONS: Thrombolysis with ticagrelor in patients <75 years old was not able to demonstrate superiority compared to clopidogrel in terms of microvascular injury, while there was no difference between the two groups in MACE and major bleeding events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02429271. EudraCT Number 2014-004082-25.

Prognostic value of cardiovascular magnetic resonance T1 mapping techniques in non-ischemic dilated cardiomyopathy: A systematic review and meta-analysis.

BACKGROUND: Cardiovascular magnetic resonance T1 mapping is a non-invasive tool for quantifying tissue alterations in the myocardium. Its prognostic value in non-ischemic dilated cardiomyopathy (DCM) remains unclear. The purpose of this study was to synthetize available data and explore the prognostic value of T1 mapping in DCM. METHODS: We searched Pubmed, Embase, Cochrane Library and Scopus for cohort studies up to 28 March 2020 that reported prognostic data for cardiovascular magnetic resonance T1 mapping in patients with DCM. Hazard ratios (HRs) were pooled using random-effects meta-analysis. Values were expressed as standard deviation (SD) of normal controls. Heterogeneity was assessed with the I2 statistic. RESULTS: Eight studies were included in the meta-analysis, with a total of 1242 patients. Extracellular volume fraction (ECV) had high prognostic value for a composite outcome of mortality and morbidity with HR 1.38 (95% confidence interval, 1.18-1.61). Native T1 was also shown to have high prognostic value for a composite outcome of mortality and morbidity with HR 1.20 (95% confidence interval, 1.14-1.27). Heterogeneity was moderate for the ECV analysis (I2 = 64%). CONCLUSIONS: ECV and native T1 could potentially be used to improve risk stratification in DCM. Future studies should investigate the prognostic value of T1 mapping by separating mortality and morbidity as primary outcomes and evaluate its incremental value in addition to standard risk stratification criteria.

Data on diagnostic performance of stress perfusion cardiac magnetic resonance for coronary artery disease detection at the vessel level.

Stress perfusion cardiac magnetic resonance (CMR) has been proposed as an important gatekeeper for invasive coronary angiography (ICA) and percutaneous coronary interventions (PCI) in patients evaluated for possible coronary artery disease (CAD) (Fihn et al., 2012; Montalescot et al., 2013) [1], [2]. Several meta-analyses have evaluated the accuracy of stress perfusion CMR to diagnose CAD at the vessel level (Danad et al., 2017; Dai et al., 2016; Jiang et al., 2016; Takx et al., 2015; Li et al., 2015; Desai and Jha, 2013; Jaarsma et al. 2012; Hamon et al., 2010; Nandalur et al. 2007) [3], [4], [5], [6], [7], [8], [9], [10], [11]. However, they included in the same analysis studies with different definitions of significant CAD (i.e. fractional flow reserve [FFR] < 0.75 and < 0.80 or coronary stenosis ≥ 50% and ≥ 70%), magnetic field strength (1.5 or 3 Tesla [T]), and study protocol (integration or not of late gadolinium enhancement [LGE] into stress perfusion protocol). Data of 34 studies (6091 arteries) have been pooled with the aim of analyzing the accuracy of stress perfusion CMR for the diagnosis of ischemic heart disease at the vessel level according to different definitions of significant CAD, magnetic field strength and study protocol (Arnold et al., 2010; Bettencourt et al., 2013; Cheng et al., 2007; Chiribiri et al., 2013; Cury et al., 2006; De Mello et al., 2012; Donati et al., 2010; Ebersberger et al., 2013; Gebker et al., 2008; Greulich et al., 2015; Hussain et al., 2016; Ishida et al., 2005, 2003; Kamiya et al., 2014; Kitagawa et al., 2008; Klein et al., 2008; Klem et al., 2006; Klumpp et al., 2010; Krittayaphong et al., 2009; Lockie et al., 2011; Ma et al., 2012; Merkle et al., 2007; Meyer et al., 2008; Mor-Avi et al., 2008; Pan et al., 2015; Papanastasiou et al., 2016; Pons Lladó et al., 2004; Sakuma et al., 2005; Salerno et al., 2014; Scheffel et al., 2010; van Werkhoven et al., 2010; Walcher et al., 2013; Watkins et al., 2009; Yun et al., 2015) [12-45]. This article describes data related article titled "Diagnostic Performance of Stress Perfusion Cardiac Magnetic Resonance for the Detection of Coronary Artery Disease" (Kiaos et al., submitted for publication) [46].

Diagnostic Accuracy of Cardiovascular Magnetic Resonance in Acute Myocarditis: A Systematic Review and Meta-Analysis.

OBJECTIVES: The purpose of this systematic review was to explore the diagnostic accuracy of various cardiovascular magnetic resonance (CMR) index tests for the diagnosis of acute myocarditis in adult patients. BACKGROUND: Acute myocarditis remains one of the most challenging diagnoses in cardiology. CMR has emerged as the diagnostic tool of choice to detect acute myocardial injury and necrosis in patients with suspected myocarditis. METHODS: We considered all diagnostic cohort and case-control studies. We searched MEDLINE, EMBASE, Cochrane Library, SCOPUS, and Web of Science up to April 21, 2017. We used the Quality Assessment of Diagnostic Accuracy Studies-2 tool to assess the quality of included studies. PROSPERO registration number CRD42017055778 was used. RESULTS: Twenty-two studies were included in the systematic review. Because significant heterogeneity exists among the studies, we only present hierarchical receiver operator curves. The areas under the curve (AUC) for each index test were for T1 mapping 0.95 (95% confidence interval [CI]: 0.93 to 0.97), for T2 mapping 0.88 (95% CI: 0.85 to 0.91), for extracellular volume fraction (ECV) 0.81 (95% CI: 0.78 to 0.85), for increased T2 ratio/signal 0.80 (95% CI: 0.76 to 0.83), for late gadolinium enhancement (LGE) 0.87 (95% CI: 0.84 to 0.90), for early gadolinium enhancement (EGE) 0.78 (95% CI: 0.74 to 0.81), and for the Lake Louise criteria (LLC) 0.81 (95% CI: 0.77 to 0.84). Native T1 mapping had superior diagnostic accuracy across all index tests. The AUC of T2 mapping was greater than the AUC of increased T2 ratio/signal and EGE, whereas ECV showed no superiority compared with other index tests. LGE had better diagnostic accuracy compared with the classic CMR index tests, similar accuracy with T2 mapping and ECV, and only T1 mapping surpassed it. CONCLUSIONS: Novel CMR mapping techniques provide high diagnostic accuracies for the diagnosis of acute myocarditis and constitute promising successors of the classic elements of the LLC for routine diagnostic protocols.

Diagnostic performance of stress perfusion cardiac magnetic resonance for the detection of coronary artery disease: A systematic review and meta-analysis.

INTRODUCTION: The purpose of this study was to investigate the accuracy of qualitative stress perfusion cardiac magnetic resonance (CMR) to diagnose ischemia-causing lesions according to different definitions of significant coronary artery disease (CAD), and magnetic field strength. METHODS: We searched PubMed, Web of Science, and the Cochrane Library for studies evaluating diagnostic performance of qualitative stress perfusion CMR for diagnosis of CAD versus coronary angiography or fractional flow reserve (FFR) from inception to 10 September 2017. We used hierarchical models to synthesize the available data. RESULTS: Sixty-seven studies (7113 patients) met the inclusion criteria. The patient-based analysis of studies using FFR as the reference standard demonstrated a mean sensitivity of 0.90 (95% confidence interval [CI], 0.85-0.93) and a mean specificity of 0.85 (95% CI, 0.80-0.89). The patient-based analyses for detecting coronary stenosis ≥50% and coronary stenosis ≥70% at 1.5T and for detecting coronary stenosis ≥50% and coronary stenosis ≥70%, at 3T, demonstrated a mean sensitivity of 0.82 (95% CI, 0.79-0.84), 0.86 (95% CI, 0.83-0.89), 0.90 (95% CI, 0.82-0.95), and 0.91 (95% CI, 0.79-0.96), respectively; with a mean specificity of 0.75 (95% CI, 0.71-0.80), 0.77 (95% CI, 0.71-0.81), 0.79 (95% CI, 0.69-0.86), and 0.74 (95% CI, 0.59-0.85). CONCLUSION: Qualitative stress perfusion CMR has high accuracy for the diagnosis of CAD, irrespective of the reference standard and the magnet strength. Studies using FFR as the reference standard had higher diagnostic accuracy on a patient level compared to studies using coronary angiography, with a notable difference in specificity.

Iatrogenic Lutembacher Syndrome after Percutaneous Mitral Commissurotomy.

Atrial septal defects (ASDs) are common immediately after percutaneous mitral commissurotomy (PMC). They are usually small, hemodynamically insignificant, and tend to decrease or disappear within 6 to 12 months. Herein, a case is described of persistent ASD in a patient with mitral valve stenosis who had undergone successful PMC three years previously. The patient had signs and symptoms of right heart failure and severe tricuspid regurgitation (TR) with borderline right ventricular systolic function on echocardiography, in addition to the ASD. Cardiac magnetic resonance (CMR) imaging played a significant role in decision-making by clarifying the anatomy of the ASD and severity of the shunt, measuring right ventricular systolic function, and providing absolute quantification for TR. The right ventricular systolic function was normal on CMR, rendering the patient suitable for surgical treatment. Persistent iatrogenic ASDs have become an increasingly common finding after invasive procedures requiring trans-septal puncture and the manipulation of catheters. Multimodality imaging can provide significant aid in the management of patients with valvular heart disease complicated by iatrogenic shunts.

The use of statins alone, or in combination with pioglitazone and other drugs, for the treatment of non-alcoholic fatty liver disease/non-alcoholic steatohepatitis and related cardiovascular risk. An Expert Panel Statement.

Non-alcoholic fatty liver disease (NAFLD), the most common liver disease, is characterized by accumulation of fat (>5% of the liver tissue), in the absence of alcohol abuse or other chronic liver diseases. It is closely related to the epidemic of obesity, metabolic syndrome or type 2 diabetes mellitus (T2DM). NAFLD can cause liver inflammation and progress to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis or hepatocellular cancer (HCC). Nevertheless, cardiovascular disease (CVD) is the most common cause of death in NAFLD/NASH patients. Current guidelines suggest the use of pioglitazone both in patients with T2DM and in those without. The use of statins, though considered safe by the guidelines, have very limited use; only 10% in high CVD risk patients are on statins by tertiary centers in the US. There are data from several animal studies, 5 post hoc analyses of prospective long-term survival studies, and 5 rather small biopsy proven NASH studies, one at baseline and on at the end of the study. All these studies provide data for biochemical and histological improvement of NAFLD/NASH with statins and in the clinical studies large reductions in CVD events in comparison with those also on statins and normal liver. Ezetimibe was also reported to improve NAFLD. Drugs currently in clinical trials seem to have potential for slowing down the evolution of NAFLD and for reducing liver- and CVD-related morbidity and mortality, but it will take time before they are ready to be used in everyday clinical practice. The suggestion of this Expert Panel is that, pending forthcoming randomized clinical trials, physicians should consider using a PPARgamma agonist, such as pioglitazone, or, statin use in those with NAFLD/NASH at high CVD or HCC risk, alone and/or preferably in combination with each other or with ezetimibe, for the primary or secondary prevention of CVD, and the avoidance of cirrhosis, liver transplantation or HCC, bearing in mind that CVD is the main cause of death in NAFLD/NASH patients.

Acute Invasive Hemodynamic Effects of Transcatheter Aortic Valve Replacement.

BACKGROUND: Aortic stenosis imposes a chronic pressure overload on the left ventricle, with attendant adaptations in hemodynamics, muscle mass and performance. The hemodynamic changes that occur during the initial 24 h following abrupt removal of the impediment to left ventricular outflow have not been previously examined. METHODS: A total of 52 patients with right heart catheterization was evaluated before, within 6 h and at 24 h after successful transcatheter aortic valve replacement (TAVR). Echocardiographic data were examined before and within 30 days of the procedure. RESULTS: TAVR was successful in all 52 patients, and at 24 h after the procedure resulted in: (i) an increase in cardiac index (CI) (from 2.0 ± 0.6 to 3.1 ± 0.7 l/min/ m2, p <0.001) and stroke volume (SV) (from 62.3 ± 18.7 to 76.6 ± 21.3 ml, p <0.001); (ii) reductions in systemic vascular resistance (from 1555 ± 458 to 1021 ± 280 dyne·s/cm5, p <0.001) and pulmonary vascular resistance (from 174 ± 150 to 112 ± 76 dyne·s/cm5, p = 0.001); (iii) reductions in pulmonary capillary wedge pressure (from 24.2 ± 6.7 to 19.7 ± 7.3 mmHg, p <0.001), mean pulmonary artery pressure (from 32.2 ± 9.9 to 27.5 ± 8.8 mmHg, p = 0.002) and in central venous pressure (from 13.5 ± 4.8 to 9.4 ± 3.9 mmHg, p <0.001); and (iv) an increase in systolic arterial pressure (from 127 ± 25 to 135 ± 14 mmHg, p = 0.04), along with a decrease in diastolic arterial pressure (from 58 ± 11 to 53 ± 9 mmHg, p = 0.009). CONCLUSIONS: Successful TAVR results in immediate and sizeable improvements in SV and CI, reductions in left and right ventricular filling pressures, and marked reductions in systemic and pulmonary vascular resistances.

Evaluation of a Decision Support System for Obstructive Sleep Apnea with Nonlinear Analysis of Respiratory Signals.

INTRODUCTION: Obstructive Sleep Apnea (OSA) is a common sleep disorder requiring the time/money consuming polysomnography for diagnosis. Alternative methods for initial evaluation are sought. Our aim was the prediction of Apnea-Hypopnea Index (AHI) in patients potentially suffering from OSA based on nonlinear analysis of respiratory biosignals during sleep, a method that is related to the pathophysiology of the disorder. MATERIALS AND METHODS: Patients referred to a Sleep Unit (135) underwent full polysomnography. Three nonlinear indices (Largest Lyapunov Exponent, Detrended Fluctuation Analysis and Approximate Entropy) extracted from two biosignals (airflow from a nasal cannula, thoracic movement) and one linear derived from Oxygen saturation provided input to a data mining application with contemporary classification algorithms for the creation of predictive models for AHI. RESULTS: A linear regression model presented a correlation coefficient of 0.77 in predicting AHI. With a cutoff value of AHI = 8, the sensitivity and specificity were 93% and 71.4% in discrimination between patients and normal subjects. The decision tree for the discrimination between patients and normal had sensitivity and specificity of 91% and 60%, respectively. Certain obtained nonlinear values correlated significantly with commonly accepted physiological parameters of people suffering from OSA. DISCUSSION: We developed a predictive model for the presence/severity of OSA using a simple linear equation and additional decision trees with nonlinear features extracted from 3 respiratory recordings. The accuracy of the methodology is high and the findings provide insight to the underlying pathophysiology of the syndrome. CONCLUSIONS: Reliable predictions of OSA are possible using linear and nonlinear indices from only 3 respiratory signals during sleep. The proposed models could lead to a better study of the pathophysiology of OSA and facilitate initial evaluation/follow up of suspected patients OSA utilizing a practical low cost methodology. TRIAL REGISTRATION: ClinicalTrials.gov NCT01161381.

In-hospital management of acute heart failure: Practical recommendations and future perspectives.

Acute heart failure (AHF) represents the first reason for hospitalization in the elderly and despite therapeutic advances, remains a syndrome with significant morbidity and dismal prognosis. Hospitalization for AHF, on the other hand, is the single most important contributor to the huge financial burden related to HF. As a result, there is a significant unmet need for more effective in-hospital management of patients with AHF in order to improve outcomes, reduce readmission rate and alleviate the socioeconomic burden of the syndrome. The in-hospital management of AHF patients may schematically be divided into three phases, an early phase of intensive management of congestion and/or hypoperfusion, an intermediate phase of transition to oral life-saving medications and a late phase of discharge and transition to outpatient management. In the present paper, we attempt to provide a concise and practical roadmap for each of the above phases, focusing mainly on defining clinical and laboratory criteria for the evaluation of patients and on describing therapeutic algorithms that summarize the available evidence and guidelines. In addition, we highlight some key open issues that need to be addressed by future research.

Percutaneous extraction of transvenous permanent pacemaker/defibrillator leads.

BACKGROUND: Widespread use of cardiovascular implantable electronic devices has inevitably increased the need for lead revision/replacement. We report our experience in percutaneous extraction of transvenous permanent pacemaker/defibrillator leads. METHODS: Thirty-six patients admitted to our centre from September 2005 through October 2012 for percutaneous lead extraction were included. Lead removal was attempted using Spectranetics traction-type system (Spectranetics Corp., Colorado, CO, USA) and VascoExtor countertraction-type system (Vascomed GmbH, Weil am Rhein, Germany). RESULTS: Lead extraction was attempted in 59 leads from 36 patients (27 men), mean ± SD age 61 ± 5 years, with permanent pacemaker (n = 25), defibrillator (n = 8), or cardiac resynchronisation therapy (n = 3) with a mean ± SD implant duration of 50 ± 23 months. The indications for lead removal included pocket infection (n = 23), endocarditis (n = 2), and ventricular (n = 10) and atrial lead dysfunction (n = 1). Traction device was used for 33 leads and countertraction device for 26 leads. Mean ± SD fluoroscopy time was 4 ± 2 minutes/lead for leads implanted <48 months (n = 38) and 7 ± 3 minutes/lead for leads implanted >48 months (n = 21), P = 0.03. Complete procedural success rate was 91.7% and clinical procedural success rate was 100%, while lead procedural success rate was 95%. CONCLUSIONS: In conclusion, percutaneous extraction of transvenous permanent pacemaker/defibrillator leads using dedicated removal tools is both feasible and safe.

Novel non-invasive P wave analysis for the prediction of paroxysmal atrial fibrillation recurrences in patients without structural heart disease: a prospective pilot study.

OBJECTIVES: The pathogenetic mechanisms responsible for the initiation and recurrence of PAF are not fully elucidated and vary among individuals. We evaluated the ability of a novel non-invasive approach based on P wave wavelet analysis to predict symptomatic paroxysmal atrial fibrillation (PAF) recurrences in individuals without structural heart disease. METHODS: We studied 50 patients (24 males, mean age 54.9 ± 9.8 years) presented to our emergency department with a symptomatic episode of PAF. The patients were followed-up for 12.1 ± 0.1 months and classified into two groups according to the number of PAF episodes: Group A (<5 PAF, n = 33), Group B (≥ 5 PAF, n = 17). A third Group of 50 healthy individuals without history of PAF was used as control. Study groups underwent echocardiography and orthogonal ECG-based wavelet analyses of P waves at baseline and follow-up. Maximum and mean P wave energies were calculated in each subject at each orthogonal lead using the Morlet wavelet analysis. RESULTS: Larger P wave energies at X lead and relatively larger left atrium were independently associated with >5 PAF episodes vs. <5 PAF episodes. No difference in P wave duration was detected between Groups A and B (p > 0.1), whereas Group A and B patients had longer P waves at Z lead compared to Group C (86.4 ± 13 vs. 71.5 ± 15 msec, p < 0.001). CONCLUSIONS: P wave wavelet analysis can reliably predict the generation and recurrence of PAF within a year. P wave wavelet analysis could contribute to the early identification of patients at risk for increased number of PAF recurrences.

Screening of patients with Obstructive Sleep Apnea Syndrome using C4.5 algorithm based on non linear analysis of respiratory signals during sleep.

AIM: To classify patients with possible diagnosis of Obstructive Sleep Apnea Syndrome (OSAS) into groups according to the severity of the disease using a decision tree producing algorithm based on nonlinear analysis of 3 respiratory signals instead of the use of full polysomnography. PATIENTS-METHODS: Eighty-six consecutive patients referred to the Sleep Unit of a Pulmonology Department underwent full polysomnography and their tests were manually scored. Three nonlinear indices (Largest Lyapunov Exponent-LLE, Detrended Fluctuation Analysis-DFA and Approximate Entropy-APEN) were extracted from two respiratory signals (nasal cannula flow-F and thoracic belt-T). The oxygen saturation signal (SpO(2)) was also selected. The above measurements provided data to the C4.5 algorithm using a data mining application. RESULTS: Two decision trees were produced using linear and nonlinear data from 3 respiratory signals. The discrimination between normal subjects and sufferers from OSAS presented an accuracy of 84.9% and a recall of 90.3% using the variables age, sex, DFA from F and Time with SpO(2)<90% (T90). The classification of patients into severity groups had an accuracy of 74.2% and a recall of 81.1% using the variables APEN from F, DFA from F and T90. CONCLUSION: It is possible to have reliable predictions of the severity of OSAS using linear and nonlinear indices from only two respiratory signals during sleep instead of performing full polysomnography. The proposed algorithm could be used for screening patients suspected to suffer from OSAS.

Identification of high risk patients with hypertrophic cardiomyopathy in a northern Greek population.

BACKGROUND: The percentage of hypertrophic cardiomyopathy (HCM) patients who are in high risk for Sudden Death (SD) constitutes only a minority of all HCM population but the incidence of SD in this subset is high (at least 5% annually). The identification of this small but important proportion of high risk HCM patients has been the clue in the clinical evaluation of these patients. METHODS: Our study cohort consisted from 123 patients with HCM who are currently followed up in our Institution. Five clinical risk factors were assessed: a family history of premature SD, unexplained syncope, Non Sustained Ventricular Tachycardia (NSVT) on 24-h ECG monitoring, Abnormal Blood Pressure Response (ABPR) during upright exercise testing and Maximum left ventricular Wall Thickness (MWT) > or =30 mm. The purpose of our study was the identification of high risk HCM patients coming from Northern Greece. RESULTS: Fifteen patients (12.2%) of the whole cohort had MWT > or = 30 mm, 30 patients (24.4%) had an ABPR to exercise, 17 patients (13.8%) had episodes of NSVT in 24-h Holter monitoring, 17 patients (13.8%) suffered from syncope, and 8 patients (6.5%) had a positive family history of premature SD. Data analysis revealed that 74 patients (60.1%) had none risk factor. Twenty four patients (19.5%) had 1 risk factor, 17 patients (13.8%) had 2 risk factors, 4 patients (3.25%) had 3 risk factors, and 4 patients (3.25%) had 4 risk factors, while none patient had 5 risk factors. Twenty five patients (20.3%) had 2 or more risk factors. CONCLUSION: This study for the first time confirms that, although a 60% of patients with HCM coming from a regional Greek population are in low risk for SD, a substantial proportion (almost 20%) carries a high risk for SD justifying prophylactic therapy with amiodaron or ICD implantation.

Epidemiological characteristics, management and early outcome of acute myocardial infarction in Greece: the HELlenic Infarction Observation Study.

INTRODUCTION: Taking into consideration the need for an updated survey on acute myocardial infarction (AMI) in Greece, we conducted the HELIOS study (HELlenic Infarction Observation Study), aiming to recruit a cohort of AMI patients that would be representative of the total AMI population. METHODS: The HELIOS study is a countrywide registry of AMI, conducted during 2005-2006 by the Prevention Working Group of the Hellenic Cardiological Society. We enrolled 1840 AMI pts from 31 hospitals (mean age 68 +/- 13 years, 75% men, 1096 ST-elevation myocardial infarction [STEMI] patients), with a proportional representation of all types of hospitals and of all geographical areas. The study recruited 10% of the total number of AMI cases that occur per year on a countrywide basis, taking into consideration the seasonal variations of the population in each geographical area. RESULTS: Despite demographic changes, there is still a male predominance among AMI patients and an increasing prevalence of cardiometabolic risk factors, (obesity, diabetes, hypertension) compared to previous AMI studies in the Greek population. Almost 60% of STEMI patients received reperfusion therapy, but the median value of the pain-to-door time was 180 minutes. The rates of administration of evidence-based medications during hospitalisation or upon discharge and the short-term mortality rates were in accordance with those observed in other international AMI registries. CONCLUSIONS: The HELIOS study provided valuable insights into the epidemiology, clinical characteristics, management and outcome of patients with AMI in the Greek population. Although there are notable advances compared to previous reports, there is still considerable room for improvement and we should particularly focus on minimising the time delay between arrival at the emergency department and performance of reperfusion, by either pharmacological or catheter-based approaches.

Primary percutaneous coronary intervention in an acute myocardial infarction due to the occlusion of the left main coronary artery.

A 75-year-old woman with no prior medical history was admitted to the hospital because of retrosternal pain for six hours, presenting in a state of cardiogenic shock, specifically hypotension, dyspnoea and slight confusion. Her admission ECG showed ST-segment elevation in the anterolateral leads. Having been started on aspirin, clopidogrel, heparin and dopamine, the patient was immediately transferred to the catheterisation laboratory. The coronary angiogram showed total occlusion of the bifurcation of the left main (LM) coronary artery and some collateral flow from the right coronary artery (RCA), the latter itself presenting multiple critical stenoses. Percutaneous coronary intervention (PCI) was performed with deployment of stents at the LM bifurcation, which resulted in the relief of the obstruction, the restoration of the flow in the left coronary artery and the immediate clinical improvement of the patient. The patient left the hospital in good general condition after being treated for ten days and underwent a successful second PCI in the RCA two months later.

The Citizen Health System (CHS): a modular medical contact center providing quality telemedicine services.

In the context of the Citizen Health System (CHS) project, a modular Medical Contact Center (MCC) was developed, which can be used in the monitoring, treatment, and management of chronically ill patients at home, such as diabetic or congestive heart failure patients. The virtue of the CHS contact center is that, using any type of communication and telematics technology, it is able to provide timely and preventive prompting to the patients, thus, achieving better disease management. In this paper, we present the structure of the CHS system, describing the modules that enable its flexible and extensible architecture. It is shown, through specific examples, how quality of healthcare delivery can be increased by using such a system.