[Primary percutaneous coronary intervention (pPCI) in hospital without regional cardiac surgery support, data from Split region]. / Primarna perkutana koronarna intervencija (pPCI) bez kardiokirurske potpore u regiji; iskustvo iz Splita.

OBJECTIVES: The aim of our study was to investigate the feasibility of pPCI in hospital without cardiac surgery, and to compare our "real-world" results to current guidelines and historical controls. METHODS: Data of all STEMI patients treated by PCI were prospectively recorded. RESULTS: From January 2005 through October 2007, 366 consecutive patients with STEMI were enrolled. In-hospital mortality was 6.3%, as compared to 15% (87/543) in historical records of a three year period before pPCI program was developed. Pain to balloon time was 315 minutes, pain to first medical contact was 102 minutes, first medical contact to door was 94 minutes, door to cathlab time was 84 minutes, cathlab to balloon time was 45 minutes, and door to balloon time was 129 minutes. CONCLUSIONS: Our preliminary experience indicates that implementation of pPCI in a hospital without regional cardiac surgical back-up is feasible and offers significant mortality reduction in STEMI patients. Intrahospital time delays should be managed aggressively.

Gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).

There are conflicting reports in the literature regarding the role of sex on the in-hospital mortality of patients with acute myocardial infarction. The objective of this study is to determine whether there are gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We conducted a prospective study of all patients admitted to University Hospital Center Split, Croatia with STEMI from 2004 to 2008 who underwent PCI. From March 2004 throughout September 2008, 488 patients with STEMI underwent PCI (364 men, 74.6%; 124 women, 25.4%). Compared with men, women were significantly older (mean age, 67.3 vs. 60.3 years; p < 0.001). Men had a significantly higher proportion of circumflex artery occlusion (19.5% vs. 10.5%, p = 0.022). A higher proportion of men had a multivessel disease than women (56.8% vs. 41.9%; p = 0.004). In-hospital mortality was significantly higher among women (11.3% vs. 4.6%; p = 0.002) but after adjustment for the baseline difference in age, the female sex was not an independent predictor of in-hospital mortality (adjusted OR 1.15; 95% CI 0.82-1.84). In men, occlusions of left anterior descending artery showed higher mortality rate than occlusions of other coronary arteries (LM 0%, LAD 7.3%, Cx 2.8%, RCA 0.7%, p = 0.03). According to our results female gender is not an independent predictor of in-hospital mortality after percutaneous coronary intervention. In men, occlusions of left anterior descending arteries are associated with higher mortality rate comparing to occlusions of other coronary arteries.

Specific and gender differences between hospitalized and out of hospital mortality due to myocardial infarction.

In this paper, the authors evaluate gender related differences of myocardial infarction mortality before and after hospital admittance. Myocardial infarction mortality in the Clinical Hospital Split in the seven years period between 2000 and 2006, have been analyzed together with out of hospital sudden death patients with acute myocardial infarction established during autopsy. During the seven year period between 2000 and 2006, 3434 patients were treated for myocardial infarction in the Split Clinical Hospital, 2336 (68%) males and 1098 (32%) females with a 12% total mortality (427 patients). The annual number of hospitalized persons has been increasing during that period (474 in yr. 2000 us. 547 in yr. 2006), while mortality decreased from 15% in 2000 to 9.6% in 2006. Female patients had significantly higher hospital mortality than male patients, (228 or 21% vs. 202 or 9%, p<0.05). Women also had significantly higher total AMI mortality (23.7% vs. 15,7%, p <0.05). Anterior myocardial infarction with ST elevation in precordial leads had significantly higher mortality (19%) compared to patients with lateral (11%), inferior (10%) myocardial infarction with ST elevation and also NSTEMI (4%) mortality p<0.05. Female patients more frequently die in hospital, 84% (230) than out of hospital 16% (43). From the total number of AMI deaths (388) in male patients, 56% (217) were in hospital and 44% (171) out of hospital (p<0.001). Men had significantly higher prehospital mortality rate than women (81% vs. 19%, p<0.05). Men also more frequently died from ventricular fibrillation (22% vs. 10%, p<0.05), while women died more frequently of heart failure, cardiogenic shock, and myocardial rupture (33% vs. 15% p<0.05). Regarding the total number of deaths from myocardial infarction men had significantly higher prehospital mortality compared to women (178 or 7.3% vs. 43 or 3.7%, p<0.05). Anterior myocardial infarction had a significantly higher rate in patients dying pre-hospital (58%), in contrast to inferior (36%) and lateral myocardial infarction with ST elevation (6%) p<0.05. We have concluded that male patients die more frequently within the first few hours of AMI mostly due to malignant arrhythmias, while female patients died in sub acute stage due to heart failure while being hospitalized. Nevertheless total mortality of AMI remains significantly higher in women.

Gender differences in in-hospital mortality and mechanisms of death after the first acute myocardial infarction.

BACKGROUND: There are conflicting data about gender differences in short-term mortality after acute myocardial infarction (AMI) after adjusting for age and other prognostic factors. Therefore, we investigated the risk profile, clinical presentation, in-hospital mortality and mechanisms of death in women and men after the first AMI. METHODS: The data were obtained from a chart review of 3382 consecutive patients, 1184 (35%) women (69.7+/-10.9 years) and 2198 (65%) men (63.5+/-11.8 years) with a first AMI. The effect of gender and its interaction with age, risk factors and thrombolytic therapy on overall mortality and mechanisms of death were examined using logistic regression. RESULTS: Unadjusted in-hospital mortality was higher in women (OR 1.77, 95% CI 1.47-2.15). Adjustment that included both age only and age and other baseline differences (hypertension, diabetes mellitus, hypercholesterolemia, smoking, AMI type, AMI site, mean peak CK value, thrombolytic therapy) decreased the magnitude of the relative risk of women to men but did not eliminate it (OR 1.26, 95% CI 1.03-1.54 and OR 1.31 95% CI 1.03-1.66, respectively). Multivariate analysis revealed that female gender was an independent predictor of in-hospital mortality after the first AMI. Women were dying more often because of mechanical complications - refractory pulmonary edema and cardiogenic shock (P=0.02) or electromechanical dissociation (P=0.03), and men were dying mostly by arrhythmic death, primary ventricular tachycardia/fibrillation (P=0.002). Female gender was independently associated with mechanical death (OR 1.56, 95% CI 1.35-2.58; P=0.01) and anterior AMI was independently associated with arrhythmic death (OR 0.54, 95% CI 0.34-0.86; P=0.01). CONCLUSION: Our results demonstrate significant differences in mechanisms of in-hospital death after the first AMI in women and men, suggesting the possibility that higher in-hospital mortality in women exists primarily because of the postponing AMI death due to the gender-related differences in susceptibility to cardiac arrhythmias following acute coronary events.

Triggering of ventricular ectopic beats by emotional, physical, and meteorologic stress: role of age, sex, medications, and chronic risk factors.

AIM: To investigate the association of a single ventricular ectopic beat with physical, emotional, or meteorologic stress and the role of age, sex, antiarrhythmic and other medicament therapy and participant characteristics. METHODS: The study included 457 participants who were consecutively assigned to undergo continuous 24-hour Holter monitoring and who completed a structured questionnaire about their physical activity and mental stress. Multiple regression analysis of data on 11 meteorologic parameters, participants' baseline characteristics, and medications they used was performed for subgroups according to sex and age, with 65 years as age limit. RESULTS: Wind speed, low relative humidity, increasing relative humidity, and emotional stress were independent predictors of ventricular ectopic beat, whereas warm front passage showed a protective effect in all participant subgroups (P<0.05 in all cases). Physical activity was an independent predictor of ventricular ectopic beat in women (P=0.02) and cold front passage in men P=0.003). The circadian variation in frequency of ventricular ectopic beats persisted in all subgroups after adjustments for external triggers (P<0.001 in all cases). Among chronic risk factors, familial background and previous myocardial infarction were independent predictors of ventricular ectopic beat in men and younger (P<0.05 in all cases). Nitrates (P<0.03 in all cases) and angiotensin converting enzyme inhibitors (P<0.02 in all cases) exerted protective effect in younger participants as well as did beta-blockers in the elderly (P<0.003 in all cases). CONCLUSION: In addition to existence of an endogenous, external triggering-independent circadian pattern, physical, emotional, and meteorologic stress may act as triggers of ventricular ectopic beat in a manner that differs from triggering more complex arrhythmias. Familial background seems to have a significant impact on arrhythmogenesis in men.

Predictors of type and site of first acute myocardial infarction in men and women.

BACKGROUND: The importance of pathophysiological mechanisms involved in onset of acute myocardial infarction (AMI) differs with age, gender, and risk profiles. Diversity in the triggering of cardiovascular events has been observed, particularly between men and women. Therefore, we investigated the relationship between age, gender, and risk factors and location of AMI and the presence of Q waves in ECG. PATIENTS AND METHODS: Data was obtained from a chart review of 2958 patients with first AMI: 770 (26%) patients with non-Q-wave AMI and 2188 (74%) patients with Q-wave AMI. Four clinical groups were formed by predetermined criteria (anterior Q-wave, anterior non-Q-wave, inferior Q-wave, inferior non-Q-wave). A logistic regression was performed to assess independent predictors of AMI type and site. RESULTS: Key findings were: 1) inferior non-Q-wave AMI was more frequent in young women (P<0.001); 2) inferior Q-wave AMI was more common in young men (P<0.001); 3) anterior non-Q-wave AMI was more common in older men (P<0.001). Multivariate analysis revealed that independent predictors of anterior non-Q-wave AMI were age over 65 (P=0.002), male gender (P=0.04) and hypercholesterolemia (P=0.0003), and that predictors of inferior Q-wave AMI were male gender (P<0.0001), smoking (P=0.04) and diabetes (P=0.049). In the gender-subgroup analyses, age <45 years (P=0.04), hypecholesterolemia (P=0.02) and smoking (P=0.01) were independent predictors of inferior Q-wave AMI whereas age >65 years (P<0.0001) and smoking (P=0.0003) were predictors of anterior non-Q-wave AMI in men. In women, age <45 years (P<0.0001) and smoking (P=0.02) were independent predictors of non-Q-wave AMI and hypercholesterolemia (P=0.02) was a predictor of inferior Q-wave AMI. CONCLUSION: The link between particular types and the site of AMI and age, gender and risk factors suggest that the importance of pathophysiological mechanisms for onset of AMI differs according to sex and age subgroup.

Meta-analysis of possible external triggers of acute myocardial infarction.

BACKGROUND: Although it is well known that the acute myocardial infarction can be triggered by events such as physical activity, emotional stress, sexual activity or eating, the observed frequencies of these events preceding the onset of myocardial infarction vary between published reports. METHODS: A meta-analysis of 17 seldom population-based studies that included data on frequency of external triggers or onsets during sleep was performed. In each analysis, the data were combined only from the studies reporting on a particular trigger. RESULTS: Of the 10519 patients, heavy physical activity was recorded before the onset of myocardial infarction in 6.1%, whereas mild-to-moderate physical activity was recorded in 28.6% of 7517 patients. Eating preceded the onset in 8.2% of 4785 patients, various kinds of emotional stress in 6.8% of 2565 (particularly anger in 2.1% of 2283), meteorologic stress in 3.7% of 3371, and sexual activity in 1.1% of 3406 patients. Out of 11778 patients, 20.7% had infarction onset during sleep. Triggers in general (OR = 1.45, 95%CI = 1.21-1.76; p < 0.0001), heavy physical activity (OR = 6.21, 95%CI = 3.77-10.23; p < 0.0001) and eating (OR = 1.70, 95%CI = 1.14-2.53; p = 0.0008) were more likely to precede the infarction onset in men while women were more likely to report emotional stress (OR = 0.66, 95%CI = 0.50-0.86; p = 0.002). CONCLUSIONS: The present meta-analysis defines the occurrence of possible external triggers before the onset of myocardial infarction in general population, but their actual contribution to the very onset is somewhat less frequent. Future investigation should identify other eventual triggers unrecognized as yet, asses the risk of triggering myocardial infarction among patients with defined levels of ischemic heart disease or plaque vulnerability, and further elucidate the pathophysiologic mechanisms of gender differences and beneficial effect of habitual physical activity.

Triggering of ventricular tachycardia by meteorologic and emotional stress: protective effect of beta-blockers and anxiolytics in men and elderly.

A circadian pattern with a morning peak and the triggering role of emotional stress have been suggested for ventricular arrhythmias. After controlling for participant baseline characteristics and medication used, the authors studied the association of emotional upset, physical activity, and meteorologic parameters with occurrence of ventricular tachycardia (VT) in 457 Croatian participants aged 11-88 years consecutively assigned to undergo continuous 24-hour Holter monitoring. In 2001, multivariate analysis of possible VT precipitators was performed separately for men, women, those aged <65 years, and those aged >64 years. A U-shaped pattern of wind speed (either very weak or very strong), rising relative air moisture, falling atmospheric pressure, and emotional upset were independent predictors of VT episodes in all participant subgroups. Positive association of VT with higher atmospheric temperature or pressure was observed in women and elderly. After adjustment for external triggers, a circadian variation in VT episodes persisted in women (p = 0.01) and those aged <65 years (p < 0.0001) only. A protective effect of beta-blockers and anxiolytics was especially apparent for men and elderly, as well as an adverse effect of digitalis in women. Results suggest that meteorologic and emotional stress could be considered external triggers of VT, with age- and sex-dependent susceptibility.

Acute myocardial infarction: differing preinfarction and clinical features according to infarct site and gender.

While differences between anterior and inferior acute myocardial infarction have been observed, clinical features of lateral infarction are poorly investigated. However, the impact of gender on clinical course and prognosis after myocardial infarction is not fully understood. Electrocardiographically determined infarct site, demographic and clinical variables were prospectively recorded for 1623 consecutive patients admitted to Clinical Hospital Split between 1990 and 1994 due to a first Q-wave acute myocardial infarction. Anterior infarctions were correlated with a higher prevalence of diabetes (P=4 x 10(-6)) or pulmonary venous congestion (P=2 x 10(-12)); inferior infarctions were correlated with a lower prevalence of hypertension (P=0.001), hypercholesterolemia (P=0.02) or diabetes (P=10(-5)), and a higher prevalence of smoking (P=0.001); lateral infarctions were characterized by a smaller infarction size and lower prevalence of pulmonary congestion (P=0.002). Among men under the age of 50 with inferior infarction there were 90% smokers, which was significantly more than among their gender (P=0.005) or infarct site (P=2 x 10(-5)) counterparts. After adjustment for age and other confounding factors, the prevalence of inferior infarction was higher in men (P=0.002). Increased age (P=0.002), female gender (P=0.0006), anterior site (P=10(-5)), diabetes (P=0.0003), greater creatine kinase-MB fraction level (P=0.001) and pulmonary congestion (P=9 x 10(-6)) were independent predictors of an adverse hospital outcome. Each site of acute myocardial infarction has relatively specific preinfarction and clinical features. Our results suggest a greater importance of vasoconstriction in the pathophysiology of inferior infarction, especially in young male smokers, and greater importance of advanced atherosclerotic process in occurrence of anterior infarction.

Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors.

OBJECTIVES: The purpose of this study was to examine the symptomatology of onset of acute myocardial infarction (AMI) in patients according to sex, age, and existence of conventional risk factors. BACKGROUND: Some studies have suggested that sex and other patient characteristics may influence symptoms in AMI, but data were limited and conflicting. METHODS: This was a prospective, observational study of a large number of symptoms in 1996 patients admitted to Clinical Hospital Split between January 1990 and July 1995 as the result of a first AMI. For each patient, the structured data form covering experience of pain at 10 body locations and 11 other symptoms, baseline characteristics, risk factors, and peak cardiac enzyme levels was completed a median of 3 days after AMI. RESULTS: Any pain, and specifically chest pain, was more often reported by male patients, smokers, hypertensive patients, nondiabetic patients, and hypercholesterolemic patients. Women were more likely to report nonchest pain other than epigastric and right shoulder pain, as well as various nonpain symptoms. The independent predictors of atypical AMI presentation (ie, absence of pain) in both men and women were lower levels of creatine kinase-MB fraction (P <.0001 and P =.0003, respectively), diabetes mellitus (P =.0002 and P =.002, respectively), older age (P =.001 and P =.01, respectively), and absence of smoking in men (P =.005). The independent predictors of presence of nonpain symptoms in both men and women were higher levels of creatine kinase-MB fraction (P =.01 and P =.049, respectively) and diabetes mellitus (P =.048 and P =.005, respectively); in men, it was hypercholesterolemia (P =.01). CONCLUSIONS: Our results suggest that sex, age, smoking, hypertension, diabetes, and hypercholesterolemia may affect the symptoms in AMI. Women with diabetes represent a high-risk subgroup for painless onset followed by various other symptoms.

Health care relief to neighbors: Split University Hospital during the 1991-1995 war in Bosnia and Herzegovina.

AIM: To assess the workload of the Split University Hospital during the war and its role in providing help to the neighboring countries. METHODS: We reviewed all available records of patients admitted to the four (out of 15) departments: General Surgery, Traumatology, Dermatovenerology, and Pulmonology. The files of 37,821 patients (78% of total number) treated during 1990-1995 were analyzed. RESULTS: The workload of the hospital paralleled the political crisis in Bosnia and Herzegovina (BH) -- the number of patients from BH increased more than 10-fold between 1990 and 1993, including during the time of armed conflict between BH Croats and Bosniaks (1993-94). Among them, there were 84% of ethnic Croats and 16% of ethnic Bosniaks. The hospital spent US$6.2 million (18% of total costs) on the treatment of BH citizens. Approximately two thirds of BH citizens (62%) were treated at one of the surgical departments, and approximately one third of Bosniak patients were young males, admitted for treatment of war-related injuries. CONCLUSION: The Split University Hospital took a large burden of managing BH citizens, despite the armed conflict of Bosnian Croats and Bosniaks, indicating the high professionalism of the hospital staff and management. Such attitude can contribute to peace and post-war reconciliation in the region.

[Epidemiologic characteristics of patients with myocardial infarct in the region of Split during the period of war in the homeland]. / Epidemioloske osobitosti bolesnika s infarktom miokarda na splitskome podrucju tijekom domovinskog rata.

The aim of this study was to determine the pattern of myocardial infarction (MI) incidence regarding the age, gender, infarction site and the most important risk factors. Between 1989 and 1997 there were 3454 patients hospitalized in coronary care units of Clinical Hospital Split. In the three-year period preceding the war, from 1989-1991, 1024 patients were hospitalized because of MI. During the three years of full was activities, from 1992-1994, there were 1257 patients (significantly more, p < 0.05), and in the three-year period after the was, from 1995-1997, there were 1173 patients. In the war period there were 12% (151) patients under the 45 years of age (p < 0.05); of that number, 95% (143) were men (significantly more than in other two periods, p < 0.05), and 5% (8) were women. In the period preceding the was there were 6.5% (66) patients under the 45 years; 91% (60) men and 9% (6) women, whereas in the period after the war there were 7.5% (88), 92% (81) and 8% (7), respectively. The patients under 45 (305) more often had MI of inferior than anterior site (49 vs. 28%, p < 0.001), whereas there was no difference in patients over 45 (36 vs. 37%, p > 0.05). The patients over 45 had significantly higher hospital mortality (21 vs. 4%, p < 0.001), and were more likely to have hypertension (51 vs. 15%, p < 0.001) as well as hypercholesterolemia (54 vs. 14%, p < 0.001). Smokers were more prevalent among those under the 45 (75 vs. 51%, p < 0.001). The number of hospitalized patients with MI was the greatest during the war period. It included significant increase in incidence in men under 45 (12 vs. 7%, p < 0.05), with smoking as the most important risk factor, especially for infarctions of inferior site.