Polypill Strategy in Secondary Cardiovascular Prevention.

BACKGROUND: A polypill that includes key medications associated with improved outcomes (aspirin, angiotensin-converting-enzyme [ACE] inhibitor, and statin) has been proposed as a simple approach to the secondary prevention of cardiovascular death and complications after myocardial infarction. METHODS: In this phase 3, randomized, controlled clinical trial, we assigned patients with myocardial infarction within the previous 6 months to a polypill-based strategy or usual care. The polypill treatment consisted of aspirin (100 mg), ramipril (2.5, 5, or 10 mg), and atorvastatin (20 or 40 mg). The primary composite outcome was cardiovascular death, nonfatal type 1 myocardial infarction, nonfatal ischemic stroke, or urgent revascularization. The key secondary end point was a composite of cardiovascular death, nonfatal type 1 myocardial infarction, or nonfatal ischemic stroke. RESULTS: A total of 2499 patients underwent randomization and were followed for a median of 36 months. A primary-outcome event occurred in 118 of 1237 patients (9.5%) in the polypill group and in 156 of 1229 (12.7%) in the usual-care group (hazard ratio, 0.76; 95% confidence interval [CI], 0.60 to 0.96; P = 0.02). A key secondary-outcome event occurred in 101 patients (8.2%) in the polypill group and in 144 (11.7%) in the usual-care group (hazard ratio, 0.70; 95% CI, 0.54 to 0.90; P = 0.005). The results were consistent across prespecified subgroups. Medication adherence as reported by the patients was higher in the polypill group than in the usual-care group. Adverse events were similar between groups. CONCLUSIONS: Treatment with a polypill containing aspirin, ramipril, and atorvastatin within 6 months after myocardial infarction resulted in a significantly lower risk of major adverse cardiovascular events than usual care. (Funded by the European Union Horizon 2020; SECURE ClinicalTrials.gov number, NCT02596126; EudraCT number, 2015-002868-17.).

[The role of therapeutic hypothermia in post-resuscitation care - review of the literature and personal experience]. / A terápiás hypothermia szerepe a postresuscitatiós ellátásban - irodalmi áttekintés és saját tapasztalatok.

In the last fifteen years mild therapeutic hypothermia became an accepted and widespread therapeutic method in the treatment of successfully resuscitated patients due to sudden cardiac death. Based on the available evidence therapeutic hypothermia is part of the resuscitation guidelines, however, many aspects of its therapeutic use are based on empirical facts. In particular, the subjects of intense debate are the ideal target temperature and the benefit of hypothermia in patients found with non-shockable rhythm. Hypothermia affects almost all organ systems and, therefore, early detection and treatment of side effects are essential. The aim of the authors is to summarize the clinical role and pathophysiologic effects of therapeutic hypothermia in the treatment of resuscitated patients based on current evidence and their practical experience.

Long-term clinical follow-up after drug-eluting stent implantation for bare metal in-stent restenosis.

OBJECTIVES: We aimed to evaluate the long-term safety and efficacy of drug-eluting stent (DES) implantation in the treatment of diffuse bare metal stent (BMS) restenosis as compared to the treatment of de novo coronary lesions in high restenosis risk patient population. BACKGROUND: To date limited long-term data are available about the treatment of BMS restenosis with DES. METHODS: Five hundred and fourteen consecutive patients who underwent DES implantation between January 2003 and October 2006 at our institute were studied: 201 patients received DES for treatment of BMS restenosis and 313 patients received DES for high restenosis risk de novo lesions. Outcomes were calculated using propensity score adjustment. Mean follow-up length was 45.6 ± 21.5 months. RESULTS: The rates of acute coronary syndrome, three-vessel disease, and diabetes were high in both restenosis and de novo groups: 44.8% versus 46.3%, 20.9% versus 28.7%, and 34.3% versus 38.9%, respectively. The incidence of ischemia-driven target lesion revascularization (TLR) yielded similar results in the restenosis group and de novo group at 4 years (10.4% vs 12.4%, P = 0.490). All-cause mortality was lower in the restenosis group at 4 years (7.4% vs 14.7%, P = 0.032); however, the incidence of definite and probable stent thrombosis did not differ (1.9% vs 1.6%, P = 0.708) between the 2 groups. CONCLUSIONS: DESs are safe in the treatment of diffuse BMS restenosis and the rate of additional TLR is acceptable as compared to the use of DES in de novo lesions.

Survival of Myocardial Infarction Patients with Diabetes Mellitus at the Invasive Era (Results from the Városmajor Myocardial Infarction Registry).

Due to the lifelong nature of diabetes mellitus (DM), it has been demonstrated to have significant effects on patients' morbidity and mortality. The present study aimed to assess the effects of DM on the clinical outcome and survival in patients who underwent percutaneous coronary intervention (PCI) due to myocardial infarction (MI) and to examine the relationship of DM to the type of the MI and to left ventricular (LV) and renal functions. A total of 12,270 patients with ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI) were revascularized at our Institution between 2005 and 2013. In this pool of patients, 4388 subjects had DM, while 7018 cases had no DM. In both STEMI and NSTEMI, the 30-day and 1-year survival were worse in diabetic patients as compared to non-diabetic cases. In the patients with DM, NSTEMI showed worse prognosis within 1-year than STEMI similarly to non-diabetic subjects. Regarding survival, the presence of DM seemed to be more important than the type of MI. Regardless of the presence of DM, reduced LV function was a maleficent prognostic sign and DM significantly reduced the prognosis both in case of reduced and normal LV function. Survival is primarily affected by LV function, rather than DM. Worse renal function is associated with worse 30-day and 1-year survival in both cases with and without DM. Considering different renal functions, the presence of DM worsens both short- and long-term survival. Survival is primarily affected by renal function, rather than DM. The results from a high-volume PCI center confirm significant the negative prognostic impact of DM on survival in MI patients. DM is a more important prognostic factor than the type of the MI. However, survival is primarily affected by LV and renal functions, rather than DM. These results could highlight our attention on the importance of recent DM treatment with new drugs including SGLT-2 inhibitors and GLP-1 antagonists with beneficial effects on survival.

[Myocardial bridge: morphological factors which influence symptoms]. / Myocardialis izomhíd: a tüneteket befolyásoló morfológiai faktorok vizsgálata.

INTRODUCTION: Myocardial bridge is a frequently detected congenital coronary anomaly which is kept benign. It is unique because it can cause a dynamic compression during systole. OBJECTIVE: In this article, we focus on the detection and evaluation of morphological parameters that can determine the symptomatic bridges. METHOD: We summarize the invasive and noninvasive modalities regarding this topic. We also present our retrospective research when we studied the morphological features of the left anterior descendent bridges with coronarography which led to angina pectoris. We compared the prognosis of patients where only myocardial bridge was found to those where atherosclerosis also had been presented. RESULTS: Intravascular ultrasound can be adapted for the visualization of myocardial bridge and for measuring the severity of compression. Intracoronary Doppler- and fractional flow reserve allow the appreciation of functional significance. Stress echocardiography is the most used non-invasive imaging modality in this field. According to our results, the group where only myocardial bridge was presented has more severe morphological features. The shortening of the tunneled segment was more expressed. The mortality during long term (appr. 10 years) follow-up was low. Meanwhile, our results have demonstrated that none of the morphological parameters influence mortality. CONCLUSION: There is an essential discrepancy between the phenomenon's high prevalence, the good prognosis, and the numerous case reports where the authors report about severe complications. Today we possess those invasive and non-invasive techniques which can help us to design prospective trials clarify the morphological features' functional significance. Orv Hetil. 2023; 164(14): 563-570.

Ventricular septal rupture caused by myocardial bridge, solved by interventional closure device.

Myocardial bridging is a common coronary anomaly, which is generally described as a benign phenomenon. However, a growing number of studies consider this anomaly a relevant pathophysiological phenomenon with serious pathological consequences. Here we report on the case of an 88-year-old woman suffering from myocardial infarction and ventricular septal rupture, lacking any recognizable coronary disease except for a myocardial bridge causing the systolic compression of the left anterior descending coronary artery. A wide range of diagnostic procedures, including coronarography, echocardiography, and magnetic resonance imaging were used. The septal rupture was finally closed by using a percutaneous closure device. This event indicates that myocardial bridges - at least in some cases - may have notable clinical relevance.

Impact of Clinical and Morphological Factors on Long-Term Mortality in Patients with Myocardial Bridge.

Although myocardial bridging (MB) has been intensively investigated using different methods, the effect of bridge morphology on long-term outcome is still doubtful. We aimed at describing the anatomical differences in coronary angiography between symptomatic and non-symptomatic LAD myocardial bridges and to investigate the influence of clinical and morphological factors on long-term mortality. In our retrospective, long-term, single center study we found relevant MB on the left anterior descendent (LAD) coronary artery in 146 cases during a two-year period, when 11,385 patients underwent coronary angiography due to angina pectoris. Patients were divided into two groups: those with myocardial bridge only (LAD-MBneg, n = 78) and those with associated obstructive coronary artery disease (LAD-MBpos, n = 68). Clinical factors, morphology of bridge by quantitative coronary analysis and ten-year long mortality data were collected. The LAD-MBneg group was associated with younger age and decreased incidence of diabetes mellitus, as well as with increased minimal diameter to reference diameter ratio (LAD-MBneg 54.5 (13.1)% vs. LAD-MBpos 46.5 (16.4)%, p = 0.016), while there was a tendency towards longer lesions and higher vessel diameter values compared to the LAD-MBpos group. The LAD-MBpos group was associated with increased mortality compared to the LAD-MBneg group. The analysis of our data showed that morphological parameters of LAD bridge did not influence long-term mortality, either in the overall population or in the LAD-MBneg patients. Morphological parameters of LAD bridge did not influence long-term mortality outcomes; therefore, it suggests that anatomical differences might not predict long-term outcomes and should not influence therapy.

The effect of COVID-19 pandemic on myocardial infarction care and on its prognosis - Experience at a high volume Hungarian cardiovascular center.

Introduction: The COVID-19 pandemic has impacted many aspects of acute myocardial infarction. Based on literature data, the prognosis of COVID+, STEMI patients is significantly worse than that of COVID- STEMI patients. On the other hand, physicians report fewer acute coronary syndrome (ACS) patients presenting to hospitals in countries severely affected by the pandemic. It is concerning that patients with life-threatening illness can suffer more complications or die due to their myocardial infarction. We aimed to investigate the changes in myocardial infarction care in the country's biggest PCI-center and to compare total 30-day mortality in COVID+ and COVID-patients with acute myocardial infarction treated at the Semmelweis University Heart and Vascular Center, and to investigate risk factors and complications in these two groups. Methods: Between 8 October 2020 and 30 April 2021, 43 COVID+, in 2018-2019, 397 COVID-patients with acute myocardial infarction were admitted. Total admission rates pre- and during the pandemic were compared. Results: Within 30 days, 8 of 43 patients in the COVID+ group (18.60%), and 40 of the 397 patients in the control group (10.07%) died (P = 0.01). Regarding the comorbidities, more than half of COVID+ patients had a significantly reduced ejection fraction (EF≤ 40%), and the prevalence of heart failure was significantly higher in this group (51.16% vs. 27.84%, P = 0.0329). There was no significant difference between the two patient groups in the incidence of STEMI and NSTEMI. Although there was no significant difference, VF (11.63% vs. 6.82%), resuscitation (23.26% vs. 10.08%), and ECMO implantation (2.38% vs. 1.26%) were more common in the COVID+ group. The mean age was 68.8 years in the COVID+ group and 67.6 years in the control group. The max. Troponin also did not differ significantly between the two groups (1,620 vs. 1,470 ng/L). There was a significant decline in admission rates in the first as well as in the second wave of the pandemic. Conclusions: The 30-day total mortality of COVID+ patients was significantly higher, and a more severe proceeding of acute myocardial infarction and a higher incidence of complications can be observed. As the secondary negative effect of the pandemic serious decline in admission rates can be detected.

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization.

Background: Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures. Methods: From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time). Results: A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm2 vs. 1,300 mGy×cm2, p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35). Conclusion: Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

Primary coronary intervention in ST-elevation myocardial infarction / Primer coronariaintervenció ST-elevációs infarktusban.

Összefoglaló. Bevezetés: Heveny myocardialis infarctusban a szívizommentés sikere, a beteg életkilátása nagymértékben függ a panasz kezdete és az elzáródott koszorúér rekanalizálása között eltelt ischaemiás idotol. Jelenleg az ér nyitása optimális esetben minden betegnél koszorúér-intervencióval történik. Célkituzés: Annak vizsgálata, hogy öt év alatt mennyit változtak az ischaemiás ido összetevoi, és miben változott az elzáródott ér nyitásának módszere ST-elevációs myocardialis infarctus (STEMI) miatt végzett primer coronariaintervencióban. Módszer: 2014. 01. 01. és 2018. 12. 31. között 1663, STEMI miatt koszorúér-intervencióval kezelt betegnél (1173 férfi és 490 no) vizsgáltuk évenkénti bontásban a panasztól a koszorúér nyitásáig eltelt ido összetevoit és a 30 napos halálozást. Eredmények: Öt év alatt a panasztól az elso egészségügyi kontaktusig medián 2:53 vs. 2:10 óra (p = 0,0132), ettol az intervenciós centrumba történt felvételig medián 1:17 vs. 1:03 óra (p = 0,009), a felvételtol a ballon nyitásáig medián 0:31 vs. 0:29 óra (p = ns) telt el. A panasztól a ballon nyitásáig eltelt ido (medián 5:29 vs. 4:07 óra, p = 0,0001) rövidült, döntoen 2014 és 2015 között. A gyógyszerkibocsátó stent beültetése 15%-ról 96%-ra nott. A vizsgált években a légzés/keringés támogatás aránya 8,2-10,6-13,9-7,6-8,4, a 30 napos halálozásé 4,1-6,8-11,1-7,4-5,7% volt; a két érték korrelációt mutat (p = 0,827). Következtetés: Öt év alatt a panasztól az elso egészségügyi kontaktusig és a kórházi beszállításig eltelt ido rövidült, de az Európai Kardiológiai Társaság ajánlásához képest hosszú; a kórházi felvételtol a ballon nyitásáig eltelt ido megfelelo. A négy órán belüli reperfúzió a betegek közel felében valósult meg. Az intervenciós centrumba való gyorsabb bekerülés javíthatna az eredményen. Orv Hetil. 2021; 162(13): 497-503. INTRODUCTION: In acute myocardial infarction, the heart muscle salvage, the patient's life expectancy is highly dependent on the elapsed ischaemic time from the onset of complaint to target vessel recanalisation. Nowadays, target vessel recanalisation is performed with coronary intervention in all patients in optimal case. OBJECTIVE: To examine how the components of ischemic time and the opening procedure of the occluded coronary have changed over five years in primary intervention done in acute ST-elevation myocardial infarction (STEMI). METHOD: Authors studied data of 1663 (1173 male and 480 female) STEMI patients in annual breakdowns treated with coronary intervention between 01. 01. 2014 and 31. 12. 2018, time from complaint to coronary artery opening, details of intervention and 30 days mortality rate. RESULTS: During the five years, time intervals were as follows: from onset of complaint to first medical contact: median 2:53 vs. 2:10 hours (p = 0.0132), from this to admission in the interventional centre: median 1:17 vs. 1:03 hours (p = 0.009), from hospital admission to balloon opening: median 0:31 vs. 0:29 hours (p = ns). In total, the complaint to balloon opening time (median 5:29 vs. 4:07 hours, p = 0.0001) diminished, decisively from 2014 to 2015. Ratio of drug-eluting stent implantation increased from 15% to 96%. In the investigated years, the need of respiratory and/or circulatory device support ratio was 8.2-10.6-13.9-7.6-8.4, 30-day mortality rate between 4.1-6.8-11.1-7.4-5.7%; these two values showed a correlation (p = 0.827). CONCLUSION: The time from complaint to first medical contact and transfer to hospital against the significant decrease is still longer than the recommendation of the European Society of Cardiology. The time from hospital admission to balloon opening is adequate. Reperfusion within four hours was achieved in half of the patients in total. Faster hospitalization may improve results. Orv Hetil. 2021; 162(13): 497-503.

Prognosis and clinical characteristics of patients with early ventricular fibrillation in the 6-week guideline-offered time period: is it safe to wait 6 weeks with the assessment? (results from the VMAJOR-MI Registry).

BACKGROUND: The most common, potentially fatal complication following an acute myocardial infarction (AMI) is early ventricular fibrillation (EVF). According to the guidelines, the assessment of implanting an implantable cardioverter defibrillator (ICD) is sufficient 6 weeks after the event, in patients with reduced left ventricular ejection fraction (LVEF), regardless of VF. The present study aimed to evaluate the 6-week prognosis of patients surviving an EVF. We divided the patients in two group based on their general condition at the time they left the hospital. We investigated the clinical characteristics of patients discharged in good general health but still dying within 6 weeks. METHODS: The present study comprised 12,270 patients with AMI following their primary revascularization in the first 12 h of symptom onset. Five hundred and forty-seven of them suffered EVF due to the AMI. Clinical and 6-week mortality data were examined. RESULTS: Poor general condition correlates with multiple comorbidities, higher troponin levels, more severe complications after the event. Patients leaving in good condition thought to be low risk, from dying. But low LVEF, high blood sugar, high cardiac biomarker level, poor renal function elevates the risk of dying within 6 weeks. However, there is no difference in clinical characteristics between EVF- cases and EVF+ cases in good condition who dies within 6 weeks. CONCLUSIONS: According to our study we can select patients who are safe in the critical 6-week period and those who need closer follow-up despite leaving in good general condition.

Prognosis of the non-ST elevation myocardial infarction complicated with early ventricular fibrillation at higher age.

Early ventricular fibrillation (EVF) predicts mortality in ST-segment elevation myocardial infarction (STEMI) patients. Data are lacking about prognosis and management of non-ST-segment elevation myocardial infarction (NSTEMI) EMI with EVF, especially at higher age. In the daily clinical practice, there is no clear prognosis of patients surviving EVF. The present study aimed to investigate the risk factors and factors influencing the prognosis of NSTEMI patients surviving EVF, especially at higher age. Clinical data, including 30-day and 1-year mortality of 6179 NSTEMI patients, were examined; 2.44% (n=151) survived EVF and were further analyzed using chi-square test and uni- and multivariate analyses. Patients were divided into two age groups below and above the age of 70 years. Survival time was compared with Kaplan-Meier analysis. EVF was an independent risk factor for mortality in NSTEMI patients below (HR: 2.4) and above the age of 70 (HR: 2.1). Mortality rates between the two age groups of NSTEMI patients with EVF did not differ significantly: 30-day mortality was 24% vs 40% (p=0.2709) and 1-year mortality was 39% vs 55% (p=0.2085). Additional mortality after 30 days to 1 year was 15% vs 14.6% (p=0.9728). Clinical characteristics of patients with EVF differed significantly from those without in both age groups. EVF after revascularization-within 48 h-had 11.2 OR for 30-day mortality above the age of 70. EVF in NSTEMI was an independent risk factor for mortality in both age groups. Invasive management and revascularization of NSTEMI patients with EVF is highly recommended. Closer follow-up and selection of patients (independent of age) for ICD implantation in the critical first month is essential.

Coronary plaque burden of the left anterior descending artery in patients with or without myocardial bridge: A case-control study based on coronary CT-angiography.

BACKGROUND: The clinical significance of myocardial bridging (MB) on the left anterior descending artery (LAD) is debated. We aimed to assess the association between MB and LAD plaque volumes/compositions in a case-control set up. METHODS: In our retrospective analysis we investigated 50 cases with incidentally recognized LAD MB and 50 matched controls without LAD MB on coronary computed tomography angiography. We quantified plaque volumes proximal to the MB and beneath it in patients with MB and in the corresponding coronary segments in patients without MB. RESULTS: In total, we have included 100 patients (mean age 60.6 ± 10.8 years, males: 80%). Plaque volume was similar in the LAD segments proximal to the MB in cases vs. controls (150.0 mm3 [IQR: 90.7-194.5 mm3] vs. 132.8 mm3 [IQR: 94.2-184.3 mm3], respectively; p = 0.95) while the plaque volume was smaller beneath LAD MB vs. control segment (16.2 mm3 [IQR: 12.6-25.8 mm3] vs. 21.1 mm3 [IQR: 14.0-42.4 mm3], respectively; p = 0.002). No significant differences were found regarding different plaque components in segments proximal to the MB while fatty plaque and necrotic core volumes were smaller or negligible in coronary segment beneath MB than in controls (0.07 mm3 [IQR: 0.005-0.27 mm3] vs. 12.7 mm3 [IQR: 7.4-24.4 mm3] and 0.00 mm3 [IQR: 0.00-0.04 mm3] vs. 0.06 mm3 [IQR: 0.03-2.8 mm3], respectively (p < 0.001). CONCLUSION: Comparing patients with MB vs. matched controls without it, MB was not associated with increased plaque volumes in LAD segment proximal to MB and plaque quantity was smaller in the MB segment. Our data are supportive of benign nature of incidentally recognized LAD MB.

Early cardiac magnetic resonance imaging in troponin-positive acute chest pain and non-obstructed coronary arteries.

OBJECTIVE: We assessed the diagnostic and prognostic implications of early cardiac magnetic resonance (CMR), CMR-based deformation imaging and conventional risk factors in patients with troponin-positive acute chest pain and non-obstructed coronary arteries. METHODS: In total, 255 patients presenting between 2009 and 2019 with troponin-positive acute chest pain and non-obstructed coronary arteries who underwent CMR in ≤7 days were followed for a clinical endpoint of all-cause mortality. Cine movies, T2-weighted and late gadolinium-enhanced images were evaluated to establish a diagnosis of the underlying heart disease. Further CMR analysis, including left ventricular strain, was carried out. RESULTS: CMR (performed at a mean of 2.7 days) provided the diagnosis in 86% of patients (54% myocarditis, 22% myocardial infarction (MI) and 10% Takotsubo syndrome and myocardial contusion (n=1)). The 4-year mortality for a diagnosis of MI, myocarditis, Takotsubo and normal CMR patients was 10.2%, 1.6%, 27.3% and 0%, respectively. We found a strong association between CMR diagnosis and mortality (log-rank: 24, p<0.0001). Takotsubo and MI as the diagnosis, age, hypertension, diabetes, female sex, ejection fraction, stroke volume index and most of the investigated strain parameters were univariate predictors of mortality; however, in the multivariate analysis, only hypertension and circumferential mechanical dispersion measured by strain analysis were independent predictors of mortality. CONCLUSIONS: CMR performed in the early phase establishes the proper diagnosis in patients with troponin-positive acute chest pain and non-obstructed coronary arteries and provides additional prognostic factors. This may indicate that CMR could play an additional role in risk stratification in this patient population.

Life after coronary stent thrombosis.

BACKGROUND: Coronary stent thrombosis is a catastrophic complication of percutaneous coronary intervention. There is a paucity of long-term data regarding the clinical outcome of patients who have suffered stent thrombosis. MATERIAL/METHODS: We sought to assess the long-term clinical outcome of patients who suffered de novo ST-segment elevation myocardial infarction as well as those who suffered ST-segment elevation myocardial infarction as a result of stent thrombosis. In both patient groups, major cardiac adverse events were studied during a 1-year follow-up period. RESULTS: A total of 1890 consecutive patients who presented with ST-segment elevation myocardial infarction during the period January 2003 to December 2005 were studied: 1843 (97.5%) suffered de novo ST-segment elevation myocardial infarction, and 47 (2.5%) suffered ST-segment elevation myocardial infarction as a consequence of stent thrombosis. The rate of cardiogenic shock was significantly higher in the stent thrombosis group than in the de novo thrombosis group (21.3% vs 4.8%, respectively) (P<0.001). Mortality rates at 30 days (6.4% vs 8.8%) and at 1 year (17.0% vs 14.9%) showed no significant difference between the 2 groups. The repeat revascularization rate was higher among patients with post-stent thrombosis (35.7% vs 9.1%) (P<0.001), as was the major cardiovascular event rate (57.1% vs 31.2%) (P<0.001). CONCLUSIONS: The long-term clinical outcome of patients who have suffered stent thrombosis is poor. Additional research is warranted to further improve therapeutic measures associated with stent thrombosis.

Significance of off-hours in centralized primary percutaneous coronary intervention network.

AIM: To analyze the efficacy of a regionally organized primary percutaneous coronary intervention (PCI) network at the Heart Center, Semmelweis University Budapest, part of the "Budapest model," and the factors that influence it. METHODS: In order to investigate the differences between regular and off-hours patient care in a 24-hour myocardial infarction primary care system, we included 1890 consecutive, unselected patients with ST-segment elevation myocardial infarction and followed them until at least one year. The follow-up was complete for all participants. RESULTS: The difference between regular hours and off-hours mortality was not significant either after 30 days (8.6% vs 8.8%, respectively) or after 1 year (15.3% vs 14.7%, respectively). The rate of patients with re-infarction, frequency of re-intervention, and major adverse cardiac events, including death, re-infarction, re-intervention, and coronary artery bypass graft surgery, were similar in both patient groups. The time delay between the onset of chest pain and arrival to the clinic was 5.9+/-5.8 hours (mean+/- standard deviation) during regular hours and 5.2+/-4.6 hours during off-hours (P=0.235). Direct transport caused significant decrease in the 30-day and 1-year mortality independent of duty time (7.2% vs 9.9%, P=0.027; 12.6% vs 16.7%, P=0.028; respectively). CONCLUSION: Centralized primary PCI network of the "Budapest model" achieved the same level of patient care during both off-hours and regular hours.

[Secondary prevention of patients with ischaemic heart disease--the reduction of LDL cholesterol level and the regression of atherosclerosis]. / A koszorúérbetegség szekunder prevenciója--az LDL-koleszterin-szint csökkentése, az atherosclerosis regressziója.

The authors review the options of secondary medical prevention in patients with ischaemic heart disease, stressing the need and safety of using statins. The beneficial effect of statin therapy on cardiovascular morbidity and mortality and the clinical benefit of the greatest possible reduction in LDL cholesterol level are presented. The atherosclerotic plaque regression achieved by a high-intensity statin therapy in the ASTEROID trial is also briefly reviewed.

[Evaluation of fitness to drive--conclusions after a case report]. / A gépjármúvezetói alkalmasság megítéléséról--egy eset tanulsága kapcsán.

Health evaluation of candidates applying driving license is general practitioner's duty, in the case of driving private cars. In Hungary no generally accepted guideline available on the evaluation process, the necessary examinations etc. A patient with a III degree A-V block was treated by the authors after suffering a serious syncope, with brain contusion, however he was regarded fit to drive by his GP, after the serious accident. The patient after the brain trauma was treated in two different institutions, however no ECG record was found, when the authors asked it to find out the time of the A-V block. Finally the patients was treated with temporary and later on with permanent pace-maker. During the half year follow up the patient was symptom less. The authors summarize the possible mechanism of syncope, and the criteria the evaluation of patients with heart diseases. In conclusion the authors emphasize the need for a generally accepted Hungarian guideline in the evaluation process of candidates applying driving license.

Efficacy of drug-eluting balloon in patients with bare-metal or drug-eluting stent restenosis.

INTRODUCTION: In spite of improving results, the treatment of in-stent restenosis (ISR) of bare-metal stents (BMS), and particularly drug-eluting stents (DES), is a challenging clinical problem. There are promising but limited follow-up data concerning drug-eluting balloons in the treatment of BMS and DES restenosis. The goal of this real-world registry was to assess the long-term safety and efficacy of drug-eluting balloons in the treatment of BMS and DES restenosis. METHODS: In this prospective registry, 82 patients with BMS or DES restenosis treated with paclitaxel-eluting balloons were enrolled. The primary endpoint was ischemia-driven target lesion revascularization (TLR); a secondary endpoint was the rate of major adverse cardiac events (MACE) at 28 months. RESULTS: Thirty-five patients (42.7%) had DES ISR and 16 patients (19.5%) presented with an acute coronary syndrome. The success rate of drug-eluting balloon inflation was 97.6%. The median (interquartile range) duration of follow up was 28.0 (25.0-30.3) months. The rate of TLR was 24.5%, and was not significantly higher in the DES-ISR group than in the BMS-ISR group: 29.0% vs. 21.1%, respectively (p=0.687). There were two cases of definite stent thrombosis in the BMS-ISR group and one probable subacute stent thrombosis in the DES-ISR group. The overall MACE rate was 37.0% and did not differ between the DES-ISR and BMS-ISR group (40.8% vs. 34.7%, respectively; p=0.994). CONCLUSIONS: This real-world registry provided less favorable long-term results for drug-eluting balloons in the treatment of BMS restenosis and in DES restenosis, compared to the promising mid-term results of previous studies. The TLR rate was slightly but not significantly higher after DES restenosis compared to BMS restenosis treatment.