[Acute myocardial infarction in young patients--severe failures in the system of acute and secondary care]. / Akutní infarkt myokardu u mladých nemocných - závazné nedostatky v systému akutní a následné péce.

INTRODUCTION: The incidence of cardiovascular (CV) diseases and acute myocardial infarction (AMI) in Czech Republic is de-clining. In spite of this in a proportion of patients AMI occurs in young age. The aim of our project was to assess the character of risk factors, precipitating diseases and the quality of care in young AMI survivors. METHODS: We included 132 patients (97 men and 35 women) in whom AIM with ST elevations occurred before age of 45 years in men and age of 50 years in women. Several results were compared to a control group composed of 84 healthy volunteers of comparable age. We assessed the course of the disease, extent of coronary involvement, subsequent therapy and control of risk factors after 3 years from the index event. RESULTS: Smoking represented the main risk factor - 85% patents were active smokers at the time of AMI and 9% were former smokers, 64% patients had a positive family history of CV disease. We found a higher prevalence of dyslipidemia history in men. In spite of high rate of statin use, laboratory examination during follow-up revealed higher triglyceride values and low levels of HDL-cholesterol in both genders. All together 23% of patients had a history of provoking underlying disease or precipitating factors (inflammatory diseases, malignancies, combined thrombophilias, drug abuse). In total 95% of patients underwent coronary angiography during the acute phase of AMI, the median time from pain onset to intervention was 9 hours. Most patients had single vessel disease, 14% had even coronary angiogram without clinically significant stenosis. The subsequent care was satisfactory concerning the rate of drug prescriptions. However, target lipid values were not reached in 78% patients and blood pressure targets in 37%. CONCLUSIONS: In patients who suffered AMI in young age, risk factors are dominated by smoking and positive family history of CV diseases. One fifth of patients suffer from other underlying disease (inflammatory disease, malignancies, combined thrombophilia) or have another precipitating factor (febrile disease, drug abuse). The acute care seems unsatisfactory due to late arrival of most patients to catheterization laboratories (underestimation of the disease, incorrect initial diagnosis). Subsequent therapy is well composed but lacks in intensity.

[Pulmonary hypertension in Takayasu arteritis]. / Plicní hypertenze u Takayasuovy arteritidy.

Takayasu arteritis (TA) is a rare chronic vasculitis primarily involving the aorta and its main branches. The disease affects women much more frequently than men, the ratio being 8:1. The onset occurs in the teenage years, always before age of 40. Aortic regurgitation is rare. The pulmonary artery stenosis may also rarely occur. We report the case of a 49-year old female patient with Takayasu arteritis who presented with severe left pulmonary trunk stenosis resulting in pulmonary hypertension, severe aortic regurgitation due to the dilatation of the ascending aorta, mitral insufficiency, critical left renal artery stenosis, and probably with left main coronary artery stenosis. No severe stenosis or occlusion in the mid portion of mid subclavian artery lesion were present. Because the patient presented with serious congestive heart failure, she underwent mitral valvuloplasty and aortic valve replacement. However, the patient died in early postoperative period due to pulmonary hypertension which failed to respond to pharmacotherapy.

[Pulmonary endarterectomy--the surgical treatment of chronic thromboembolic pulmonary hypertension]. / Endarterektomie plicních tepen--chirurgická lécba chronické tromboembolické plicní hypertenze.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) in indicated cases can be successfully treated by the endarterectomy of pulmonary arteries (PEA). Symptomatically not treated CTEPH has highly unfavourable prognosis. Five years survival of patients with mean pulmonary pressure over 50 mmHg is only 10%. PEA was not available in the Czech Republic till 2004, when PEA program was initiated it the Cardiocenter of the General teaching hospital in Prague in collaboration with leading clinics in that field (Prof. Mayer, University of Mainz, BRD). METHODS AND RESULTS: Up-to-date surgical technique, which in various modifications has been used at majority of clinics, was elaborated by Jamieson and Daily at University of California in San Diego. It is based on reverse endarterectomy performed during complete circulatory arrest with brain protection by deep hypothermia. Till September 2005 twelve patients were operated with zero mortality. In one patient a suture of atrial septum defect was necessary to perform along. Average time of the circulatory arrest was 45 minutes; duration of the extracorporal circulation was 334 minutes. Average duration of the operation was 450 minutes. Duration of the mechanical ventilation was in average 45.5 hours. After one month already haemodynamic parameters (mPA, CI, PVR) significantly improved or normalized and the average length in the test of six minutes walking increased by 132 meters. CONCLUSION: PEA represents a treatment method for patients with CTEPH and surgically accessible pulmonary artery obstruction. Centralized care of those patients is a rational necessity enabling to get maximum experience with complicated diagnostics and treatment of those patients. Multidisciplinary collaboration is the essential condition for the success of the program.

[Acute myocardial infarct as a result of external compression caused by an expanding pulmonary adenocarcinoma]. / Akutní infarkt myokardu jako dusledek zevní komprese prorustajícího adenokarcinomu plic.

The case report describes a rare cause of acute myocardial infarction. 68-years old man with the cancer triplicity (follicular and papillar carcinoma of the thyroid gland, Grawitz tumor, bronchogenic carcinoma with generalization) was admitted to the intensive care unit for the sudden onset of chest pain, positivity of cardioselective enzymes and signs of cardiogenic shock. Echocardiographic examination proved diaphragmatic akinesis with low left ventricular ejection fraction about 30%. The acute coronary angiogram revealed unimportant atherosclerotic narrowing of the left coronary artery and a long significant stenosis in the proximal portion of the right coronary artery untypical for atherosclerotic lesion suspicious of extramural compression. A pathological vascularization to the extramyocardial region was documented during right coronary angiogram. The patient was treated conservatively and finally transferred to the pulmonary disease department, where he died of progression of the cancer disease two months later. Postmortem examination found spreading of the bronchogenic adenocarcinoma to the pericardium along the course of the right coronary artery, but neither direct infiltration of the vessel wall by the tumor nor atherosclerotic disease of the proximal portion of the right coronary artery were proved. These findings together with the coronary angiogram demonstrate a rare cause of the myocardial infarction due to the extramural compression by the malignant tumor.

[Elective coronary angioplasty in the unprotected branch of the left coronary artery]. / Elektivní koronární angioplastika nechráneného kmene levé vencité tepny.

BACKGROUND: PTCA of the left main stem is an alternative therapy to coronary artery bypass grafting for left main stenosis. METHODS AND RESULTS: For the retrospective analysis, 32 consecutive patients referred for left main PTCA were selected. Patients were subdivided into 2 groups. Group I consisted of 17 patients with no concomitant disease and with good left ventricular function, where CABG was an alternative strategy. 15 patients of the group II were patients to whom bypass was contraindicated for cardiac or extracardiac reasons (malignancy, poor LV function, non graftable) and they were recommended for the palliative treatment of their angina symptoms. We observed 100% procedural success rate of the PTCA in both groups. There was no mortality at 6-month follow up among patients of the group I and 13% clinical restenosis rate at 6 months. In patients of the group II there was total 6-month mortality 26.6%, all due to causes unrelated to procedure or coronary ischaemia (progression of malignancy, intractable heart failure). CONCLUSIONS: PTCA to left main stem represents an alternative treatment to aortocoronary bypass in cases of favourable anatomy with high procedural success and no 6-month mortality in patients with good LV function. In patients in whom CABG is contraindicated, PTCA can be used as a balliative strategy in abating ischaemic symptoms. In this group, short-term prognosis relates to concomitant cardiac or extracardiac disease.

[Electrocardiographic changes in patients with acute pancreatitis. Case report and review of the literature]. / Elektrokardiografické zmeny u pacientu s akutní pankreatitidou. Kazuistika a prehled literatury.

Transient electrocardiographic changes in patients with acute pancreatitis are well known in the literature. Mostly these changes are in the form of T-wave inversion, ST-segment depression, and rarely ST-segment elevation without the presence of coronary artery disease. We report a patient, in whom electrocardiographic changes mimicked acute inferior myocardial infarction with subsequent evolution of Q-waves in the inferior leads and ischaemia in the anterior wall. To the authors' knowledge, this is the first report documenting the evolution of Q-waves on surface ECG in the absence of myocardial necrosis verified by postmortem examination in the patient, who died of cardiorespiratory failure and massive haemoperitoneum as a complication of ongoing acute necrotizing haemorrhagic pancreatitis. The authors also discuss diagnostic and therapeutic options in patients with acute pancreatitis and ECG pattern of acute myocardial infarction. Acute pancreatitis may mimic acute myocardial ischaemia (or infarction) or these two diseases may be present at the same time. In differential diagnosis, selective coronarography might be helpful and it allows also immediate revascularisation. Administration of thrombolytic therapy in such patients is not safe and might end up with fatal consequences.

[Echoccardiographic hyperventilation test in patients with negative coronarography]. / Echokardiografický hyperventilacní test u pacientu s negativní koronarografií.

Opportunities to examine patients with spastic angina pectoris are at present, due to the inaccessibility of ergonovine, very limited. The authors demonstrate on a small group of patients the application of echocardiographic hyperventilation test for assessment of the diagnosis of spastic angina pectoris.

The accuracy of myocardial perfusion SPECT imaging in the evaluation of coronary artery disease in women and men.

BACKGROUND: The purpose of this study is to compare sensitivity, specificity and accuracy of myocardial perfusion SPECT for the detection of coronary artery disease (CAD) in women and men. MATERIAL AND METHODS: 588 patients (455 males and 133 females, 273 after a previous myocardial infarction) underwent stress myocardial perfusion SPECT. The accuracy of myocardial perfusion SPECT was proved by coronary angiography (stenosis > 50% was considered as a CAD). RESULTS: The sensitivity of SPECT was slightly higher, but statistically not significant, in men than in women (94% versus 91%, p > 0.05). The specificity was higher in women than in men (93% versus 82%), but this difference was not statistically significant either (p > 0.05). The accuracy of SPECT was the same for both sexes (92%). In angiographically verified group of patients the selection bias was obvious--patients with CAD dominated (74%) and the fraction of patients with CAD in men's group (83%) was significantly higher than in women's group (50%), p < 0.05. CONCLUSIONS: No significant difference was revealed in the accuracy of myocardial perfusion SPECT in men and women. Our results are in accordance with the prevailing opinion in literature that discovered differences in sensitivity, specificity and diagnostic accuracy are usually not statistically significant or that they can be explained by the selection bias of patients in angiographically verified groups (significantly higher fraction of patients with CAD in men's group).

[Prognostic significance of stress tomographic scintigraphy of myocardial perfusion in diabetic patients]. / Prognostický význam zátezové tomografické scintigrafie myokardiální perfuze u diabetických pacientu.

OBJECTIVE: To assess the prognostic value of SPECT in patients with diabetes (DM) and without DM. METHOD: A total of 366 patients (104 women, 262 men) were examined by T1 +/- 201 or Tc-99m-MIBI SPECT of the myocardium. DM was recorded in 149 patients, 217 patients did not suffer from DM. The SPECT findings were classified as normal and abnormal perfusion (fixed or reversible perfusion defect). A serious cardiac event was defined as sudden cardiac death or non-fatal myocardial infarction. Also angina pectoris requiring revascularization was recorded. RESULTS: During the average investigation period of 24 +/- 7 months we recorded in 147 patients with a normal load perfusion only one non-fatal myocardial infarction and the risk of a serious cardiac event was low: 0.3% per annum in the whole group. A significantly higher incidence of a severe cardiac event, 5.9% per year, was recorded in 219 patients with an abnormal finding on SPECT (10 deaths and 16 non-fatal myocardial infarctions, P < 0.01). On comparison of the frequency of serious cardiac events in groups of patients with and without DM no significant difference was found as regards normal load perfusion of the heart muscle (1.1% vs. 0%, P = NS) even in patients with an abnormal SPECT finding (5.8% vs. 6.1, P = NS). CONCLUSION: SPECT myocardial perfusion makes it possible to stratify the risk in patients with DM similarly as proved previously in non-selected groups. Similarly as in patients without DM normal perfusion in diabetic patients predicts a benign prognosis.

[Myocardial perfusion tomography imaging in patients without prior myocardial infarction--comparison between 201Tl, 99mTc-tetrofosmin and dual-isotope protocol (rest 201Tl/stress 99mTc-tetrofosmin)]. / Tomografické zobrazení myokardiální perfuze u pacientu bez infarktu myokardu--srovnání 201Tl s 99mTc-tetrofosminem a dual-izotopovým protokolem (klid 201Tl/zátez 99mTc-tetrofosmin).

The authors compared retrospectively the diagnostic accuracy of three protocols--201Tl stress-redistribution, 2-day 99mTc-tetrofosmin and the dual-isotope protocol (rest 201Tl/stress99m Tc-tetrofosmin)--for the detection of ischaemic heart disease (IHD) in a total of 115 patients without previous myocardial infarction (IM). 201Tl protocol (group A) was used to examine 43 patients, incl. 15 women, mean age 51 years (38-69 years). The 2-day 99m Tc-tetrofosmin protocol was used to examine 39 patients incl. 12 women, mean age 49 years (30-71 years). The dual-isotope protocol was used in 33 patients, incl. 8 women, mean age 52 years (31-69 years). In all patients coronarography was performed, stenosis of the artery >50% was considered significant for IHD. The sensitivity of the dual-isotope protocol was 95% and 96% resp. and 92% in the 2-day tetrofosmin and 201Tl protocol, (p>0.05). The specificity of the dual-isotope protocol was 82% and 89% resp. and 88% in the 201Tl and 2-day tetrofosmin protocol, (p >0.05). The diagnostic accuracy was 91% in the dualisotope and 201Tl protocol and 92% in the 2-day protocol (p>0.05). No significant difference was revealed in the sensitivity, specificity and diagnostic accuracy for the detection of IHD between different protocols in patients without previous IM.

[Latent tetany in patients with a negative coronarographic finding]. / Výskyt latentní tetanie u pacientu s negativním koronarografickým nálezem.

UNLABELLED: Chest pain, constriction of the throat and palpitations are symptoms common to tetany and ischaemic heart disease. The objective of the work was to assess the latent prevalence of tetany in patients with typical chest pain and a negative outcome of coronarographic examination. The group comprised 20 patients (5 men and 15 women), mean age 54 years (28-74) with a history of chest pain, who had selective coronarography with a negative or minimal (up to 30% stenosis) outcome. In this group EMG, the ischaemic and hyperventilation test for latent tetany was made. A metabolic cause of tetany was ruled out. The results of the EMG test were positive in 10 patients (50%, 8 women, 2 men). Patients with a positive finding were treated with magnesium lactate by the oral route. All patients reported after one month regression of complaints. CONCLUSION: With regard to the high rate of positive EMG tests in patients with a history of chest pain and a negative coronarographic finding the authors recommend to add this simple test to the algorithm of examinations of these patients and supplement treatment according to its results.

[Correlation of SPECT myocardial stress scintigraphy with coronary angiography]. / Korelace zátezové perfuzní scintigrafie myokardu SPECT s koronarografickými nálezy.

The sensitivity and specificity of a myocardial perfusion single-photon emission tomography (SPECT) for the detection of the coronary artery disease (CAD) was investigated. As a gold standard the coronary angiography was used--the stenosis of the artery by 50% and more was considered as significant for CAD. After performing SPECT studies patients were examined by coronary angiography according to the attending physician's judgement. In the retrospectively created group of 123 subjects (94 males and 29 females, mean age 53 years, range 30-69 years) 55 patients underwent myocardial infarction (MI). The stress was performed using a bicycle ergometer or, in case of patient's inability, an intravenous dipyridamole infusion. Before december 1995 201T1 was used in all patients, after this date only in patients with prior MI with regard to the advantage of this radionuclide for the detection of the ischemic but viable myocardium. Other patients were administered 99mTc-tetrofosmin. In our group of patients we found the high sensitivity of myocardial SPECT of 94.5% 86 (from 91), specificity of 84.4% (27 from 32) corresponding to usually values and the high diagnostic accuracy of 91.9% (113 from 123). Specificity can be impaired by marked attentuation of gamma-rays by overlying soft-tissue structures such as the breast or diaphragm. The artificial imaging of the inferior wall due to the infradiaphragmatic structures represents the most serious problem-there were four false positive findings in our group; further ones in our 99mTc-tetrofosmin studies were avoided by the routine use of the prone position recommended in the literature. The validity of SPECT myocardial perfusion findings should be verified by coronary angiography; however, one must be aware of some questionable points inherent in this comparison.

New alternatives for the treatment of fistulas in Crohn's disease.

The authors refer on the combination of the administration of artificial nutrition with enterohormone Somatostatin in a group of 16 patients with Crohn's disease (CD), complicated by the occurrence of fistulas. The sole administration of total parenteral or enteral nutrition led in each case to a significant reduction of secretion from the fistulas, and in two cases to their complete closing. Apart from this, the nutritional status of the patients improved. The administration of Somatostatin i.v. in the form of the preparation Stilamin led to a further reduction of secretion from the fistulae. Complete closing of the fistulae due to a combination of total parenteral nutrition (TPN) or total enteral nutrition (TEN) and Stilamin, was achieved in only 2 patients, but the combination use of tissue sealant Histoacryle with the treatment resulted in a closure of the fistulas in a further 2 patients. Altogether the application of this treatment resulted in closing 6 fistulas (37.5%). The authors consider that the above mentioned methods can open new prospectives, but this requires further experience.

Granulomatous vasculitis of Churg-Strauss type in a patient with diabetes insipidus.

The CHSS was first described as an allergic granulomatosis and angiitis. This syndrome is characterized by pulmonary and systemic vasculitis, extravascular granulomas and eosinophilia which occur in patients with bronchial asthma and allergy. The CHSS in limited form may be present in an isolated organ or tissue. Despite increased awareness by clinicians, recognition of the condition can be difficult. It should be mentioned that CHSS may be a life-threatening disorder, especially via cardiac failure. Hence, an early diagnosis and treatment of this syndrome is very important, including the application of corticoids that favorably affect the course of the disease.