Survival benefit of the late percutaneous coronary intervention in the patients after acute myocardial infarction who are or who are not treated with thrombolysis.

The impact of late percutaneous coronary intervention (PCI) in the patients after acute myocardial infarction (AMI) on long term mortality remains to be established. At currently, thrombolysis is accepted as standard therapy when PCI is not immediately available. However, PCI is often performed in stable patients with AMI who are/are not received thrombolysis . We performed the trial that enrolled myocardial infarction patients treated with thrombolysis, late PCI and medically to assess the potential benefits of delayed PCI. We follow up 164 consecutive patients after AMI one year. The patients are divided in two groups; first group-66 patients who received reperfusion (37 patients received only thrombolysis, 10 patients received thrombolysis and PCI 7-9 days after thrombolysis and 19 patients underwent only PCI after 7-9 days) and second group-98 patients medically treated. One year mortality was 3% in the reperfusion group (2/66) and 14,3% in the medical group (14/98) (p=0,016). There were not significant differences between groups about other end points-reinfarctus, coronary artery bypass surgery and PCI performed later after discharge. The major predictors of one year mortality were ages (p<0,001) and ejection fraction (p=0,003). Also, therapy with beta-blockers (p=0,002), statins (p=0,001) and ACE-inhibitors (p=0,024) was associated with better survival. Delayed PCI performed 7-9 days after AMI in the patients who underwent thrombolysis or those did not improves outcome at long-term follow-up.

Predictions and Outcomes of Atrial Fibrillation in the Patients with Acute Myocardial Infarction.

The large epidemiological studies demonstrated that atrial fibrillation is correlated with high mortality and adverse events in patients with acute myocardial infarction. The aim of this study was to determinate predictors of atrial fibrillation develop during the hospital period in patients with acute myocardial infarction as well as short- and long-term mortality depending on the atrial fibrillation presentation. The 600 patients with an acute myocardial infarction were included in the study and follow-up 84 months. Atrial fibrillation develops during the hospital period was registered in 48 patients (8%). After adjustment by logistic regression model the strongest predictor of atrial fibrillation develop during the hospital period was older age, particularly more than 70 years (odds ratio 2.37, CI 1.23-4.58, p=0.010), followed by increased of Body Mass Index (odds ratio 1.17, CI 1.04-1.33, p=0.012), enlarged diameter of left atrium (LA) (odds ratio 1,18, CI 1,03-1,33, p=0,015) presentation of mitral regurgitation (odds ratio 3.56, CI 1.25-10.32, p=0.018) and B-type natriuretic peptide (odds ratio 2.12, CI 1.24-3.33, p=0.048).Patients with atrial fibrillation develop during the hospital period had a higher mortality during the hospital course (10.4% vs. 5.6%) p=0.179. as well as follow-up period of 84 months than patients without it (64.6% vs. 39.1%) p=0.569, than patients without it, but without statistically significance. Patients with AF develop during the hospital period had higher mortality during the hospital course as well as follow up period of 84 months than patients without it, but without statistically significance.

Factors affecting the development of adverse drug reactions to ß-blockers in hospitalized cardiac patient population.

The aim of the present study was to undertake a study on the prevalence of cytochrome P450 2D6 (CYP2D6) poor metabolizer alleles (*3, *4, *5, and *6) on a Montenegrin population and its impact on developing adverse drug reactions (ADRs) of ß-blockers in a hospitalized cardiac patient population. A prospective study was conducted in the Cardiology Center of the Clinical Center of Montenegro and included 138 patients who had received any ß-blocker in their therapy. ADRs were collected using a specially designed questionnaire, based on the symptom list and any signs that could point to eventual ADRs. Data from patients' medical charts, laboratory tests, and other available parameters were observed and combined with the data from the questionnaire. ADRs to ß-blockers were observed in 15 (10.9%) patients. There was a statistically significant difference in the frequency of ADRs in relation to genetically determined enzymatic activity (P<0.001), with ADRs' occurrence significantly correlating with slower CYP2D6 metabolism. Our study showed that the adverse reactions to ß-blockers could be predicted by the length of hospitalization, CYP2D6 poor metabolizer phenotype, and the concomitant use of other CYP2D6-metabolizing drugs. Therefore, in hospitalized patients with polypharmacy CYP2D6 genotyping might be useful in detecting those at risk of ADRs.

Optimizing prevention and guideline-concordant care in Montenegro.

BACKGROUND: Guidelines recommend use of evidence-based medications in patients discharged after an acute coronary syndrome (ACS). Yet the current rates of adherence in many eastern European countries are unknown. OBJECTIVE: To determine whether 6month outpatient follow-up after ACS is associated with recommended rates of medication adherence in Montenegro. METHODS: A prospective analysis was conducted in 585 ACS patients confirmed to be alive after ACS at 6month follow-up. The study was undertaken between 2012 and 2015, from 9 International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC) hospitals in the Montenegro. The primary outcome was guideline-concordant care, defined as 100% compliance with 5 medications: aspirin, clopidogrel, beta-blockers, and statins in ACS patients, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB] for the subset of patients with left ventricular systolic dysfunction, as assessed by an ejection fraction less than 40% at discharge. In addition to the composite end point, the achievement of each single treatment measure was analyzed. Multivariate predictors of long-term medication adherence were also identified. RESULTS: Guideline-concordant care (GCC) at discharge increased from 2012 to 2015 (adjusted OR for increase 1.51; CI 0.88-2.52). GCC over 6months was adhered in 73% of patients. In patients who did not achieve GCC, adherence was persistently high with 92.3% for aspirin, 91.3% for statins and 72% for ACE-inhibitors or angiotensin-receptor blockers (ARBs). Adherence was lower for clopidogrel (57.7%) and beta-blockers (64.4%). After adjusting for demographic and clinical differences, in-hospital referral to PCI and ST segment elevation myocardial infarction (STEMI) were associated with greater medication adherence at 6month follow-up. CONCLUSIONS: In Montenegro, long-term adherence to evidence-based medication after ACS is high. Adherence to guideline-recommended therapies increased over time with participation to the ISACS-TC. The lower achievement of GCC in patients treated medically and in those with non-ST-segment elevation ACS needs particular attention.

Adverse drug reactions in hospitalized cardiac patients: characteristics and risk factors.

BACKGROUND/AIM: Adverse drug reactions (ADRs) appear more frequently than actually reported and registered. The main goal of our work was to analyze risk factors, incidence and characteristics of ADRs in hospitalized cardiac patients. METHODS: This prospective study included 200 patients, hospitalized at Cardiology Center of the Clinical Centre of Montenegro. ADRs were collected using specially designed questionnaire, based on the list of symptoms and signs that could point out to potential ADRs. Data from medical charts of patients, lab tests and other available parameters were observed and combined with the data from questionnaire. Severity of ADRs were assessed as serious or nonserious according to the World Health Organization criteria. Causality was assessed using the Naranjo probability scale. RESULTS: A total of 34% of all the patients experienced at least one ADR. The most common ADRs occurred as nervous system disorders, less frequent were cardiovascular disorders, while the immune system disorders were the rarest. Sixteen percent of all ADRs were characterized as serious, most often caused by carvedilol and amiodarone. The majority of patients (97.3%) recovered without consequences. The multivariate analysis showed independent significant associations between ADRs and age, gender, comorbidities and polypragmasia. CONCLUSION: ADRs represent a significant issue in hospitalized cardiac patients population. The most significant predictors for ADRs in observed population were age, comorbidity, number of medications used during hospitalization and patients' gender. Preventive measures such as pharmacotherapy rationalization and continual education of health care professionals could reduce the frequency of ADRs appearance in patients with detected risk factors.

Prognostic value of heart rate variability in post-infarction patients.

BACKGROUND/AIM: Depressed heart rate variability (HRV) indicating autonomic disequilibrium and propensity to ventricular ectopy can be useful for risk stratification in patients following acute myocardial infarction (AIM). The aim of the study was to assess heart rate variability as a predictor of all-cause mortality in post-infarction patients. METHODS: We analyzed the 24-hour electrocardiographic (ECG) recordings of 100 patients (80 males) during hospitalization for AIM: The mean age of patients was 56.99 + 11.03 years. Time domain heart rate variability analysis was obtained from 8 to 13 days after index infarction by mean of a 24-hour ECG recording, and the calculated parameters were: standard deviation of all normal to normal RR intervals (SDNN), RRmax-RRmin (difference between the longest RR interval and the shortest RR interval), mean RR interval. We also analyzed ventricular premature complexes from the ECG data. The patients underwent clinical evaluation, laboratory tests and echocardiography. RESULTS: Within a one-year follow-up period 11 patients experienced death, 10 of them because of cardiac reason and one because of stroke. There were significantly lower values of SDNN (60.55 ± 12.84 ms vs 98.38 ± 28.21 ms), RRmax-RRmin (454.36 ± 111.00 ms vs 600.99 ± 168.72 ms) and mean RR interval (695.82 ± 65.87 ms vs 840.07 ± 93.97 ms) in deceased patients than in the survivors, respectively (p < 0.01). The deceased patients were of higher mean age, with lower left ventricular ejection fraction (0.46 ± 0.05 vs 0.56 ± 0.06 in survivors), and more frequent clinical signs of heart failure and ventricular ectopic activity (> 10VPCs/h; p < 0.01). Multivariate Cox analysis showed that SDNN was a significant, independent predictor of all-cause mortality in post-infarction patients. The other independent predictors were clinical signs of heart failure--Killip class II and III and ventricular ectopic activity. CONCLUSION: Depressed HRV is an independent predictor of mortality in post-infarction patients and may provide useful additional prognostic information in non-invasive risk stratification of these patients.

Successful treatment of cardiogenic shock by stenting of the left main coronary artery in acute myocardial infarction.

INTRODUCTION: Patients with non-ST elevation acute coronary syndromes (NSTE-ACS) are sometimes severely hemodynamicly compromised. Urgent coronary angiography should be performed in these patients in percutaneous coronary intervention (PCI) centers according to the ESC NSTE-ACS guidelines to determine suitabilty for percutaneous or surgical revascularization. CASE REPORT: We reported a 62-year-old male with chest pain admitted to the Coronary Care Unit. ST segment depression of 2 mm in leads I, L and V4-6 was revealed at electrocardiogram. After following 6 hours the patient had chest pain and signs of cardiogenic shock despite of the therapy. Chest xray showed pulmonary edema. Echocardiographic examination showed dyskinetic medium and apical segments of septum. The patient underwent coronary angiography immediately which revealed 75% stenosis of the left main coronary artery with thrombus. The use of a GPIIb/III inhibitor-tirofiban and stent implantation resulted in TIMI III flow. After that the patient had no chest pain and acute heart failure subsided in the following days Echocardiography done at the fourth day from PCI showed only hypokinesis medium and apical segment of septum. The patient was discharged at day 11 from admission in a stable condition. CONCLUSION: Stenting of left main coronary artery stenosis in patients with cardiogenic shock and non-ST segment elevation acute coronary syndromes may be a life saving procedure.