Evaluation of the usability of the digital platform navigator KardioUp for the journey of patients with chronic heart failure.

INTRODUCTION: Digital health interventions constitute a promising supplementary approach for further improvement of the quality and experience of cardiovascular care in patients with heart failure (HF). However, concerns about privacy, security, and quality may arise additionally to lack of personal motivation and accessibility to digital resources. Therefore, the proposed system aims to implement innovative technological trends in HF monitoring by recording clinical, biological, and biometric parameters. METHODS: The availability and feasibility of the digital platform KardioUp was evaluated in a group of 25 patients with HF (mean age: 60 years) and 15 medical doctors (mean age 40 years) in two University Cardiology Clinics of the country. Connectivity of platform with the application and Android devices, use of alerts in clinical measurements, educational material provided, and total satisfaction by both patients and physicians were also evaluated. Patients with health barriers to understand the use of digital platforms or low eHealth ≤8 (digital unawareness) were excluded. RESULTS: All patients answered that the upload of measurements of blood pressure, blood glucose, and weight into the application were feasible. Patients mean eHealth score was 32,7. Additionally, the graphics of the application were friendly and educational material was also easily approached. Patients felt that this application can enable real patient-empowerment and self-management support. CONCLUSIONS: KardioUp was evaluated as a non-pharmacological intervention that could promote autonomous living of patients. Thus, possible alterations in daily activities and other parameters will be continuously evaluated providing metrics' monitoring on patients' performance, adherence to their treatment plan, avoidance of rehospitalizations, and overall health metrics.

Percutaneous coronary intervention for distal coronary graft anastomosis le-sions: a case series.

BACKGROUND: Management of coronary artery graft failure, especially at the site of a recent distal anastomosis, is a challenging clinical situation, and literature data are scarce. CASE SERIES: We present a case series of patients with coronary artery bypass graft failure up to six months after surgical revascularization, who were treated with percutaneous coronary intervention at the site of distal graft anastomosis through the graft or the native vessel. CONCLUSIONS: Percutaneous coronary intervention at distal graft anastomotic lesions is challenging, it can be performed from either the graft or the native vessel, and the angiographic result may not always be optimal. HIPPOKRATIA 2019, 23(2): 87-91.

Impact of Post-Exodontia Bleeding in Cardiovascular Patients: A New Classification Proposal.

BACKGROUND: Exodontia (dental extraction), being the most frequent minor surgical procedure in the general population, inevitably involves a large number of patients on antithrombotic medication. Current experience shows that there is a degree of confusion in managing these patients. DESCRIPTION: Post-exodontia bleeding, a natural consequence of every dental extraction with no or minor clinical significance in the vast majority of cases, often appears to be of major concern to both patients and healthcare practitioners (dentists or physicians), either because of the alarming nature of oral bleeding itself or because of the distorted perception about its importance. These concerns are enhanced by the lack of a universal standardized definition of post-exodontia bleeding and by the fact that all currently available post-exodontia bleeding definitions bear intrinsic limitations and tend to overestimate its clinical significance. CONCLUSION: In order to overcome the aforementioned issues, this article presents an overview of post-extraction bleeding and proposes a classification, based on the well-recognized Bleeding Academic Research Consortium (BARC) bleeding definition, aiming at reducing heterogeneity in this field.

Blood pressure response to catheter-based renal sympathetic denervation in severe resistant hypertension: data from the Greek Renal Denervation Registry.

BACKGROUND/INTRODUCTION: The efficacy of catheter-based renal sympathetic denervation (RDN) in terms of blood pressure (BP) reduction has been questioned, while "real-world" data from registries are needed. In this study, we report the complete set of 12-month data on office and ambulatory BP changes as well as the predictors for BP response to RDN from a national registry. METHODS: In 4 Greek hospital centers, 79 patients with severe drug-resistant hypertension (age 59 ± 10 years, 53 males, body mass index 33 ± 5 kg/m2; office BP and 24-h ambulatory BP were 176 ± 15/95 ± 13 and 155 ± 14/90 ± 12 mmHg, respectively, 4.4 ± 0.9 antihypertensive drugs) underwent RDN and were followed-up for 12 months in the Greek Renal Denervation Registry. Bilateral RDN was performed using percutaneous femoral approach and standardized techniques. RESULTS: Reduction in office systolic/diastolic BP at 6 and 12 months from baseline was -30/-12 and -29/-12 mmHg, while the reduction in 24-h ambulatory BP was -16/-9 and -15/-9 mmHg, respectively (p < 0.05 for all). Patients that were RDN responders (85%, n = 58), defined as an at least 10-mmHg decrease in office systolic BP at 12 months, compared to non-responders were younger (57 ± 9 vs 65 ± 8 years, p < 0.05), had higher baseline office systolic BP (176 ± 17 vs 160 ± 11 mmHg, p < 0.05) and 24-h systolic BP (159 ± 13 vs 149 ± 11 mmHg, p < 0.05). Stepwise logistic regression analysis revealed that age, obesity parameters, and baseline office BP were independent predictors of RDN response (p < 0.05 for both), but not the type of RDN catheter or the use of aldosterone antagonists. At 12 months, there were no significant changes in renal function and any new serious device or procedure-related adverse events. CONCLUSIONS: In our "real-world" multicenter national registry, the efficacy of renal denervation in reducing BP as well as safety is confirmed during a 12-month follow-up. Moreover, younger age, obesity, and higher levels of baseline systolic BP are independently related to better BP response to RDN.

Impact of stent implantation on endothelial shear stress.

BACKGROUND: Endothelial shear stress (ESS) may play a key role in the pathobiology of stent restenosis (SR). Nevertheless, limited data are available about ESS and its relation to SR. PATIENTS AND METHODS: We enrolled 14 patients who underwent successful percutaneous coronary intervention (PCI) in this study. Three-dimensional (3D) reconstruction of 14 coronary arteries before and after stent implantation was performed. Using computational fluid dynamics, mean ESS was calculated proximally, in tertiles within and distal to the stent, both before and after stent implantation. RESULTS: Stent implantation resulted in a significant ESS decrease in the entire atherosclerotic lesion (1.83 vs. 1.26 Pa, p = 0.02). Regarding the five territories in which the entire lesion was divided, ESS decrease was marginally significant in the area of the second in-stent tertile, and in the area 5 mm distal to the stent, whereas ESS decrease was not significant in the area 5 mm proximal to the stent, and in the area of the first and third in-stent tertile. At 12 months, two patients had SR, but restenosis was not related to ESS decrease. CONCLUSION: ESS decreases after stent implantation but not uniformly, with the major reduction being in the middle tertile of the stent, and distal to the stent. In-stent ESS decrease may create local hemodynamic conditions leading to in-stent and in-segment restenosis.

Ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure.

BACKGROUND: Switching to femoral after a failed radial approach carries an increased risk of bleeding complications since the femoral artery puncture is performed in patients already anticoagulated. Moreover, dedicated radial operators find it more and more difficult to use the femoral approach, and ulnar artery cannulation provides them with the opportunity to further reduce its use. Our objective was to evaluate the feasibility and safety of ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure. METHODS: We performed a retrospective analysis of all cardiac catheterizations, from January 2015 until June 2016, with initial radial approach and conversion to ipsilateral ulnar approach. Patients with sheath insertion both in radial and ipsilateral ulnar arteries were further evaluated. RESULTS: Four thousand one hundred and two procedures were performed during the study period, and 3,876 (94.5 %) of them were performed initially through a radial approach. Radial and ipsilateral ulnar catheterization was accomplished in nine patients, resulting in successful catheterization and procedure completion, without any serious complications recorded. CONCLUSIONS: Ipsilateral radial and ulnar artery catheterization proved to be feasible and safe, without any serious complications. Hippokratia 2016, 20(3): 249-251.

Aortic balloon valvuloplasty before transcatheter valve replacement in high-risk patients with aortic stenosis. Cardiac catheterization and echocardiographic hemodynamic study.

BACKGROUND: Balloon aortic valvuloplasty (BAV) has been revived as a bridge to transcatheter aortic valve replacement (TAVR). The aim of the current prospective study was to define a safe time period from BAV to TAVR and to determine hemodynamic variables that predict event-free survival after BAV. PATIENTS AND METHODS: The present prospective study included 68 consecutive patients with severe aortic stenosis who were treated initially with BAV from 2009 to 2012. Echocardiographic and invasive hemodynamic assessments were performed before BAV. The patients were followed up at regular intervals and events were defined as cardiac hospitalization or death. RESULTS: Invasive hemodynamic evaluation yielded more favorable results than echocardiographic assessment: aortic stenosis was less severe, cardiac output was higher, and pulmonary capillary wedge pressure (PCWP) was lower. Post-BAV event-free survival was 80.4 % at 30 days, 64.5 % at 6 months, 37 % at 1 year, 22.3 % at 2 years, and 9.3 % at 3 years. After excluding pre-discharge deaths (n = 7), the 30-day event-free survival rate was 90 %. Predictors of events after BAV were atrial fibrillation, cardiogenic shock, elevated euroSCORE (European System for Cardiac Operative Risk Evaluation), elevated PCWP, and elevated pulmonary artery systolic pressure. Invasively measured PCWP was the only independent predictor of events (hazard ratio, 1.07; 95 % confidence interval, 1.03-1.11; p = 0.001). CONCLUSION: A 30-day post-BAV period may be considered a bridge to TAVR. Furthermore, invasive assessment of PCWP before BAV is an independent hemodynamic predictor of events after BAV.

The pathophysiological basis of renal nerve ablation for the treatment of hypertension.

Renal sympathetic innervation plays an important role in blood pressure regulation. Gradual activation of renal sympathetic efferent nerves enhances renin release, promotes sodium and water re-absorption, and reduces renal blood flow and glomerular filtration rate. On the other hand, activation of renal afferent sympathetic nerves induced by renal injury results in central sympathetic activation. This reciprocal relationship between the kidneys and the brain is involved in the pathogenesis of hypertension and other disease conditions characterized by sympathetic overactivity. Renal sympathetic nerve ablation has been recently introduced for the treatment of resistant hypertension. This review aims to provide the pathophysiological basis of renal nerve ablation for the attenuation of sympathetic overactivity.

Pheochromocytoma crisis presenting with cardiogenic shock.

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands whose typical presentation includes the triad of headache, palpitations, and diaphoresis. Pheochromocytoma crisis is an urgent medical condition whose diagnosis and management constitute a challenge for physicians. We present the case of a 55-year-old man who developed cardiogenic shock in the setting of a pheochromocytoma crisis. After stabilizing blood pressure with combined administration of α- and ß-blockers, the tumor was surgically removed. Our diagnostic and therapeutic challenges are discussed.

Left anterior descending artery perforation treated with graft stenting combining dual catheter and side branch graft stenting techniques.

Reported is a technique that was used to treat a distal left anterior descending (LAD) perforation in a patient undergoing percutaneous coronary intervention (PCI) for distal LAD total occlusion. The perforation was successfully treated by re-occluding the LAD with implantation of a polytetrafluoroethylene (PTFE)-covered stent in a diagonal branch extending to the LAD (side branch graft stenting technique) delivered using the dual catheter technique. This approach is proposed as an alternative bail-out technique that can be used in cases where other treatment options for coronary perforation are either unavailable or potentially not successful, especially during PCI for total occlusions, where the disadvantage of main vessel occlusion is already present.

Clinical applications of intravascular ultrasound (IVUS): experience from an academic high volume centre of Northern Greece.

BACKGROUND: Intravascular ultrasound (IVUS) has become a valuable tool adjunctive to coronary angiography due to its ability to directly image atheroma and the vessel wall. We aimed to evaluate the use of IVUS during diagnostic angiography and coronary interventions in a coronary intervention academic high volume center of northern Greece. PATIENTS AND METHODS: IVUS studies have been retrospectively retrieved from 2005 to 2008 from the archives of the catheterization laboratory of our department. IVUS was performed in 403 patients (294 male) of mean age 62±6 years. Indications for coronary angiography +/- intervention were acute coronary syndromes (49%), stable angina (46%) and previous coronary angioplasty evaluation (5%). RESULTS: Forty eight per cent of the IVUS studies were performed in left anterior descending artery (LAD), 25% in right coronary artery (RCA), 18% in left circumflex artery (LCx), and the rest (9%) in left main coronary artery (LMCA) or in coronary branches. Indications for performing an IVUS study were assessment of intermediate lesions (60%), evaluation of stent placement (36.5%), and determination of stent restenosis aetiology (3.5%). Among studies performed for assessment of intermediate lesions, 63% showed a non critical stenosis. IVUS after coronary stenting revealed a suboptimal stent placement in 77% of the cases, while in cases of stent restenosis, IVUS showed inadequate initial stent deployment in 43% of the patients. CONCLUSIONS: The use of IVUS in our department has contributed to the optimization of intervertional treatment of coronary lesions by means of evaluating borderline lesions, stenting placement and stent restenosis.

Accelerated in-stent restenosis after bare-metal stenting of a myocardial bridge and successful treatment with drug-eluting stenting.

Stenting of symptomatic myocardial bridges is a therapeutic option with documented good short-term outcome. However, limited data on the long term outcome of myocardial bridge stenting has shown a higher restenosis rate comparing to stenting of de novo atherosclerotic lesions. Drug-eluting stenting of de novo atherosclerotic lesions has reduced the rate of restenosis comparing to bare metal stenting, but there is no available data on drug-eluting myocardial bridge stenting. We present a case of accelerated in-stent restenosis after bare-metal myocardial bridge stenting, successfully treated with drug-eluting stenting.

In-hospital and long-term prognostic value of fibrinogen, CRP, and IL-6 levels in patients with acute myocardial infarction treated with thrombolysis.

Plasma fibrinogen, C-reactive protein (CRP), and interleukin-6 (IL-6) levels in patients with acute myocardial infarction (AMI) receiving thrombolysis have been related to prognosis. The aim of this study was to investigate the time course of plasma fibrinogen, CRP, and IL-6 levels during the in-hospital phase in patients with AMI receiving thrombolysis, and their relationship to in-hospital and prognosis after 12-months follow-up. In 40 patients presenting with AMI within 6 hours of symptom onset and treated with thrombolysis, plasma fibrinogen, CRP, and IL-6 levels were measured on admission and after 6, 12, 24, 48, and 72 hours; 7 days; and 6 months. Patients with other diseases that can alter fibrinogen, CRP, or IL-6 levels were excluded. Patients had a clinical follow-up at 6 and 12 months, and the following cardiac events were recorded: cardiac death, recurrent angina, recurrent AMI, and heart failure. Plasma fibrinogen concentrations decreased significantly (p <0.01 vs admission levels) at 12 hours (425 +/-94 vs 322 +/-132 mg/dL), started to increase at 24 hours, reached peak value at 72 hours (602 +/-209 mg/dL), remained elevated at 7 days, and were back to admission levels at 6 months (375 +/-79 mg/dL). CRP levels increased significantly at 12 hours (0.73 +/-0.43 vs 0.23 +/-0.11 mg/dL, p <0.01), reached peak value at 72 hours (7.66 +/-3.28 mg/dL), decreased significantly on day 7 (2.32 +/-1.17 mg/dL), and at 6 months were within normal limits (0.49 +/-0.29 mg/dL). IL-6 levels increased significantly at 6 hours (14.03 +/-8.13 vs 6.37 +/-3.88 pg/mL, p <0.05), reached peak value at 24 hours (59.49 +/-23.57 pg/mL), started to decrease at 48 hours, and at 6 months were within normal limits (2.25 +/-1.24 pg/mL). During the in-hospital phase 33 patients had an uneventful course and 7 patients had complications (3 post-AMI angina; 4 heart failure). During the 12-month follow-up period 28 patients had an uneventful course, and 12 patients had complications (1 cardiac death, 5 recurrent angina, 2 recurrent AMI, and 4 heart failure). Regarding the in-hospital prognosis, fibrinogen, CRP, and IL-6 levels were significantly higher (p <0.05) in patients with complications from 48 to 72 hours, from 12 hours until day 7, and from 6 hours until day 7, respectively. During the 12-month follow-up period fibrinogen, CRP, and IL-6 levels were significantly higher in patients with complications (at 48, 24, and 24 hours, respectively) only in the subgroup of patients who had complications within the first 6 months following AMI. Multivariate analysis showed that CRP at 48 hours was the most important factor related to in-hospital prognosis (p = 0.02), and ejection fraction followed by CRP at 24 hours (p = 0.02) to 6-month prognosis (p = 0.018). Fibrinogen, CRP, and IL-6 levels alter in patients with AMI receiving thrombolysis, and are related both to in-hospital and to 6-month follow-up prognosis.

Epidemiologic characteristics of hypertension in the civilians of Kosovo after the war.

34th Greek regimen, which was part of the NATO forces, provided medical services to the civilians of Kosovo. We studied epidemiologic data in the population of Kosovo regarding hypertension in order to determine the prevalence and characteristics of hypertension. 830 patients (281 - 33.86% male, 62 +/- 26 yrs and 549 - 66.14% female, 49 +/- 28 yrs) were examined for different diseases. We identified 254 (30.6%) patients with hypertension (188 female and 66 male). According to the international criteria used for the classification of the severity of hypertension, more than half of the patients (51.2%) had severe hypertension, 31.5% modest and 17.3% mild. Statistically significant relation between the severity of hypertension and age or sex was not found out. Increased BMI as well as the presence of proteinuria and rheumatic diseases were significantly related to the severity of the hypertension while the coexistent heart disease, diabetes mellitus and chronic obstructive pulmonary disease (COPD) wasn't. The use of non-steroid anti-inflammatory agents (NSAIDs) was related to the severity of hypertension with a borderline significance. 31.4% of the patients were on treatment with NSAIDs and/or cortisone because of rheumatic disease or obstructive pulmonary disease. Overfunction of the sympathetic system was present in 62.99%. The mean heart rate was greater in women (84/min) than in men (72/min). 28.35% of the patients had secondary hypertension, including the patients on a drug that can elevate the blood pressure and patients with increased activity of the sympathetic nervous system. So, 8.6% of the patients had usual causes of secondary hypertension and 19.6% hypertension secondary related to the use of NSAIDs or cortisone, or due to the increased activity of the sympathetic nervous system. Antihypertensive treatment was started in 248 patients, i.e. in all of them except the ones already on treatment having their blood pressure well controlled. For antihypertensive treatment beta-blockers or central adrenergic inhibitors either as monotherapy or in combination with other agents were used most frequently combined with diuretics and Ca antagonists and ACE inhibitors. In conclusion the diagnosis and treatment of hypertension in the population of Kosovo during the post war period had certain particularities.

Comparison of the radial and femoral approaches in left main PCI: a retrospective study.

Transradial percutaneous coronary intervention (PCI) is a safe and effective method of percutaneous revascularization. However, there are no data on the efficacy of the transradial approach in left main (LM) PCI. We studied 80 patients (pts) who underwent LM PCI between February 1994 and January 2002, and compared the radial (27 pts) and femoral (53 pts) approaches. Patients were considered free of restenosis if they were free of angina and had a negative treadmill or nuclear imaging study 6 months post-PCI. Mean follow-up time was 27.4+/-23.0 months. Reason for PCI (stable angina, unstable angina, acute myocardial infarction) and lesion location (ostial, mid, distal) were similar in both groups (p>0.05), whereas mean ejection fraction was higher in the radial group (56.5+/-11.1% versus 49.2+/-14.7%, respectively; p<0.05). Sheath size (7 or 8 French; 44.4% radial versus 77.3% femoral) and amount of heparin used (9,192+/-3,645 IU versus 11,468+/-5,083 IU) were significantly larger in the femoral group (p<0.05), and the use of intra-aortic balloon pump was significantly more frequent (3.7% versus 22.6%). Mean fluoroscopy time (21.3+/-12.8 minutes versus 16.7+/-8.5 minutes), amount of contrast used (227+/-92 ml versus 225+/-85 ml), mean procedural time (67.0+/-27.6 minutes versus 73.4+/-32.7 minutes), procedure success (96.3% versus 98.1%), in-hospital major adverse cardiac events (MACE; 7.4% versus 5.6%) and 6-month MACE (14.8% versus 25.5%) were similar in the 2 groups (p>0.05). However, major vascular complications occurred only in the femoral group (5.7%). Radial LM PCI is as fast and successful as the femoral approach and results in fewer vascular complications.

Safety of same-day-discharge radial percutaneous coronary intervention: a retrospective study.

BACKGROUND: The safety and feasibility of same-day discharge percutaneous coronary intervention (PCI) is still controversial. METHODS: Patients (n = 943) had same-day discharge radial PCI between April 1998 and March 2001 in our hospital. Patients were contacted and asked whether they had entry site complications or a repeat angiogram and/or PCI within 24 hours and 1 month after the procedure. RESULTS: At the time the study was conducted, 811 patients responded, 38 patients had died, and 94 were alive but refused to participate or it was impossible to contact them; 27 patients (2.8%) visited their doctor and/or the hospital within 24 hours after discharge because of entry site complications, and 38 patients (4.0%) visited within 1 month. However, none of the patients had major access site complications or needed to be admitted to the hospital. Within 24 hours from discharge 17 patients (2%) reported chest pain, and only 1 (0.1%) required a repeat angiogram, which did not show target vessel occlusion. During the first month, 94 patients (11.5%) reported chest pain, 11 (1.3%) underwent a repeat angiogram, out of which 4 had subacute vessel closure; 2 of the 132 patients that we could not contact had subacute stent thrombosis within 1 month and died. CONCLUSIONS: None of the patients having same-day discharge radial PCI had major access site complications. Six patients (0.6%) had subacute vessel closure, but none had this during the first 24 hours after discharge. Same-day discharge radial PCI in certain low-risk patients is a safe and feasible strategy.

Parasuicidal poisoning treated in a Greek medical ward: epidemiology and clinical experience.

OBJECTIVE: To study the epidemiology of acute poisoning patients presenting to an acute medical service ward in a Greek hospital between January 1998 and December 2000. DESIGN: Prospective case series. RESULTS: A total of 273 patients with self-poisoning were included in the study. This represented 3.8% of the overall admissions to the unit. The mean age of patients was 33, the most frequent age group being that aged 20-30 years (36.2% of total) with a male-to-female ratio of 1:1.97. Sixty per cent of patients was admitted within 4 h. Those from urban areas comprised 76.2% and 23.8% from rural areas. The most frequently ingested agents were psychopharmaceuticals (37.4%) and analgesics/anti-rheumatics (32.6%). Pesticides (7.7% of total) were most frequently used by patients coming from rural areas (32.3% of patients from rural areas). Alcohol was included in the overdose in 8.4%. Of the patients, 16.2% had a previous history of overdose. In this case series, psychiatric assessment suggested that 52% of the patients had a formal psychotic diagnosis, 21% had personality disorder and 27% had taken an overdose in response to stress. The most frequently documented precipitating factors were family problems and disputes (37%). Unusually, the seasonal distribution in these patients suggested a peak in summer (37.5% of presentations) with lower numbers in spring (30.2%), autumn (17.7%) and winter (14.6%). Of the patients, 23.7% presented in July. A total of 73.5% of patients was conscious, 16.4% was somnolent, 4.5% was in precoma and 5.6% was in coma (GCS <8). Patients who received antidotal therapy comprised 17.9%. Evidence of hepatic dysfunction was observed in 8.9% of patients and renal dysfunction in 3.6%. Extracorporeal techniques for drug removal (hemodialysis and hemoperfusion) were used in 2.2% of patients. Intensive care therapy was required in 11.4% of patients. The mean overall hospitalization time was 3.3 days. The mortality rate was 2.9%. CONCLUSIONS: This study shows that the epidemiology of self-harm by overdose in Greece is significantly different in terms of the seasonal presentation from other parts of Europe. The agents ingested and other features are similar to northern Europe. Psychiatric diagnoses are more common in our group than in those reported from northern Europe.