Reperfusion therapies and in-hospital outcomes for ST-elevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology.

AIMS: The aim of this study was to determine the contemporary use of reperfusion therapy in the European Society of Cardiology (ESC) member and affiliated countries and adherence to ESC clinical practice guidelines in patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Prospective cohort (EURObservational Research Programme STEMI Registry) of hospitalized STEMI patients with symptom onset <24 h in 196 centres across 29 countries. A total of 11 462 patients were enrolled, for whom primary percutaneous coronary intervention (PCI) (total cohort frequency: 72.2%, country frequency range 0-100%), fibrinolysis (18.8%; 0-100%), and no reperfusion therapy (9.0%; 0-75%) were performed. Corresponding in-hospital mortality rates from any cause were 3.1%, 4.4%, and 14.1% and overall mortality was 4.4% (country range 2.5-5.9%). Achievement of quality indicators for reperfusion was reported for 92.7% (region range 84.8-97.5%) for the performance of reperfusion therapy of all patients with STEMI <12 h and 54.4% (region range 37.1-70.1%) for timely reperfusion. CONCLUSIONS: The use of reperfusion therapy for STEMI in the ESC member and affiliated countries was high. Primary PCI was the most frequently used treatment and associated total in-hospital mortality was below 5%. However, there was geographic variation in the use of primary PCI, which was associated with differences in in-hospital mortality.

Differences Among Body Mass Index (BMI) Groups in Patients Undergoing First Elective Percutaneous Coronary Intervention.

BACKGROUND AND PURPOSE: Body Mass Index (BMI) is known to be an independent risk factor for hypertension, type 2 diabetes mellitus, dyslipidemia and various cardiovascular diseases. Our aim was to investigate the differences among BMI groups in patients undergoing first elective PCI. METHODS: 781 consecutive patients who underwent their first-time elective PCI from September 2011 to December 2013 in the Department of Cardiology were enrolled in the study. The patients with BMI < 18.5 kg/m(2) or > 50 kg/m(2) and those who had previously undergone revascularization were excluded from the study. Patients were categorized according to their BMI groups. BMI 18.5 - 24.9 kg/m(2) normal group, 25 - 29.9 kg/m(2) overweight group and > 30 kg/m(2) obese group. We studied the demographic, angiographic, and interventional differences between BMI groups. RESULTS: Compared with normal weight individuals, those obese were younger (61.9 ±10.34 vs. 58.41 ± 8.01 p = 0.0006), had higher prevalence of diabetes mellitus (46.4% vs. 26.6% p = 0.0001), dyslipidemia (77.5% vs. 65.4% p=0.0134) and hypertension (1.3% vs. 81.3% p=0.0067). There was a greater use of calcium channel blockers (CCBs) and Angiotensin Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs) in obese individuals but it was not statistically significant. Obese individuals were associated with higher risk anatomy (3-Vessel CAD or LM) compared to normal individuals but not statistically significant (18.8% vs. 14.2% p=0.25). Obese patients were associated with a higher length of stents/person used (36.7 ± 22.02 vs. 31.7 ± 17.48 p=0.016) and also a larger diameter of stents/person used (3.14 ± 0.4 vs. 2.98 ± 0.33 p=0.0001) compared to normal individuals. CONCLUSIONS: Patients with a higher BMI are younger and have diabetes mellitus, hypertension and dyslipidemia more frequently. Patients with a higher BMI have a higher length and larger diameter of stents/person used, probably related to a more extensive coronary artery disease.

Role of Intracoronary Adrenaline in the Treatment of No-Reflow Phenomenon in Patients Undergoing Percutaneous Coronary Intervention.

The no-reflow phenomenon is defined as the failure to restore coronary flow demonstrated by the reduced or missing flow in angiography despite the patent artery. There are pharmacological strategies proposed and studied to manage the no-reflow phenomenon. The medication groups used are purine nucleoside (adenosine), calcium channel blockers (verapamil, nicardipine), beta 2 receptor agonists (adrenaline, nitroprusside), fibrinolytic agents (streptokinase, tissue plasminogen activators), glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban). We present a case of a woman hospitalized in non-ST elevation myocardial infarction (NSTEMI) conditions. The patient underwent coronary angiography, in which a single vessel coronary artery disease (CAD); left anterior descending (LAD) stenosis of 90% was found. In this condition, the patient underwent percutaneous coronary intervention (PCI) of LAD. The no-reflow phenomenon occurred with thrombolysis in myocardial infarction (TIMI) flow grade of 0 during the procedure. As a consequence, the patient presented chest pain and important hypotension (BP of 70/45). Because of the hypotensive state of the patient, we decided to administer intracoronary (IC) adrenaline directly. In our case, we used adrenaline as a first-line treatment for the no-flow phenomenon due to the hypotensive state during the PCI procedure. Generally, we initially use IC nitrate or IC adenosine to resolve the phenomenon, and when the no-reflow persists we use IC adrenaline because of its side effects mentioned above. Anyway, we believe that in specific cases of hypotension and bradycardia, the use of adrenaline as the first line of therapy should be considered.

Percutaneous Coronary Intervention in a Patient Presenting With Inferior Myocardial Infarction and an Anomalous Left Main Artery Originating From the Right Coronary Sinus.

We present a case of a patient with inferior myocardial infarction (MI) and anomalous left main artery originating from the right coronary sinus. The left main artery and right coronary artery originated from the right coronary sinus but with separate ostia. The patient underwent revascularization of the right coronary artery with balloon angioplasty and a drug-eluting stent. Despite being rare, these anomalies can be life-threatening depending on the course of the artery, and when atherosclerotic disease is present, a revascularization strategy can be challenging. Knowing the existence of the left main artery anomaly is important to choose the right guide catheter to achieve successful cannulation and decrease the risk of complications, radiation exposure, and contrast usage.

Contrast-Induced Nephropathy in Interventional Cardiology: Incidence, Risk Factors, and Identification of High-Risk Patients.

AIM: This study aimed to study contrast-induced nephropathy (CIN) or more recent nomenclature contrast-associated acute kidney injury (CI-AKI) in patients undergoing percutaneous coronary procedures, evaluating CIN incidence, risk factors (RFs), and high-risk patients with CIN.  Methods: This is a prospective, observational, unicentric trial of patients who underwent coronary angiography and/or percutaneous coronary intervention (PCI) in the University Hospital Center (UHC) "Mother Teresa" in Tirana, Albania, during 2016-2018. CIN was defined as an increase of 25% and/or by 0.5 mg/dL of serum creatinine (SCr) and high-risk patients with CIN as an increase by 50% and/or by 2 mg/dL and/or need for dialysis compared to the basal pre-procedural values. We evaluated RFs for CIN: preexisting renal lesion (PRL), heart failure (HF), age, diabetes mellitus (DM), anemia, and contrast quantity.  Results: The incidence of CIN resulted in 14.4%. HF, PRL, and age ≥65 years resulted in independent RFs for CIN, whereas anemia, DM, and contrast quantity >100 mL did not. PRL proved to be the most important RF for CIN, whereas HF was the only independent RF for high-risk CIN patients. CONCLUSIONS: The incidence of CIN coincides with the results in the literature. PRL, HF, and age ≥65 years resulted in independent RFs for CIN; more and larger trials are needed to evaluate DM, anemia, and contrast quantity related to their impact on CIN. High-risk patients with CIN represent the most problematic patients of this pathology.

Care of patients with ST-elevation myocardial infarction: an international analysis of quality indicators in the acute coronary syndrome STEMI Registry of the EURObservational Research Programme and ACVC and EAPCI Associations of the European Society of Cardiology in 11 462 patients.

AIMS: To use quality indicators to study the management of ST-segment elevation myocardial infarction (STEMI) in different regions. METHODS AND RESULTS: Prospective cohort study of STEMI within 24 h of symptom onset (11 462 patients, 196 centres, 26 European Society of Cardiology members, and 3 affiliated countries). The median delay between arrival at a percutaneous cardiovascular intervention (PCI) centre and primary PCI was 40 min (interquartile range 20-74) with 65.8% receiving PCI within guideline recommendation of 60 min. A third of patients (33.2%) required transfer from their initial hospital to one that could perform emergency PCI for whom only 27.2% were treated within the quality indicator recommendation of 120 min. Radial access was used in 56.6% of all primary PCI, but with large geographic variation, from 76.4 to 9.1%. Statins were prescribed at discharge to 98.7% of patients, with little geographic variation. Of patients with a history of heart failure or a documented left ventricular ejection fraction ≤40%, 84.0% were discharged on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and 88.7% were discharged on beta-blockers. CONCLUSION: Care for STEMI shows wide geographic variation in the receipt of timely primary PCI, and is in contrast with the more uniform delivery of guideline-recommended pharmacotherapies at time of hospital discharge.

Acute ischemia manifestation in a patient with coronary slow flow phenomenon.

A patient with anginal chest pain and electrocardiographic changes suggesting ischemia was referred to our hospital. Coronary angiography revealed no significant stenosis or ectasia but only slow flow in all 3 coronary arteries. After infusion of unfractionated heparin for 24 hours, negative T waves became less deep, and repeated coronary angiography showed significant improvement of the coronary flow. The coronary slow flow phenomenon, together with the associated ischemic electrocardiographic changes, should be considered as a separate entity in the differential diagnosis of acute coronary syndromes. Additional clinical research is required to better understand the syndromes of chest pain with normal coronary arteries.

Gender Differences in Admissions and In-Hospital Outcomes of Patients With Acute Coronary Syndromes During the Coronavirus Disease 2019 Pandemic.

Background The incidence of acute coronary syndromes (ACS) decreased during the coronavirus disease 2019 (COVID-19) pandemic. Few studies have investigated gender differences in ACS admissions and outcomes during pandemics and have presented divergent results. This study aimed to investigate the effect of the COVID-19 pandemic on male and female hospitalizations and in-hospital outcomes in patients presenting with ACS. Methodology We designed a retrograde, single-center trial gathering data for ACS hospitalizations during the lockdown (March 9, 2020, to April 30, 2020) compared with the same timeframe of 2019. ACS hospitalizations were subgrouped as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA). We calculated the incidence rate ratio (IRR) to compare all-ACS and subgroups for male and female hospitalizations and the risk ratio (RR) to compare overall male/female mortality. Results This study included 321 ACS patients (238 males, 83 females) during the COVID-19 lockdown and 550 patients (400 males, 150 females) during 2019. The IRRs of all-ACS/males/females were significantly lower during the COVID-19 period at 0.58 (95% confidence interval (CI) = 0.44-0.76), 0.59 (95% CI = 0.43-0.75), and 0.55 (95% CI = 0.37-0.74), respectively. The IRR for STEMI was significantly lower among females (0.59 (95% CI = 0.39-0.89)), but not among males (0.76 (95% CI = 0.55-1.08)) The IRR for NSTEMI was not significantly lower, meanwhile it was significantly lower for UA among both males and females. The overall ACS mortality increased during the COVID-19 period (7.4% vs. 3.4%; RR = 2.16 (95% CI = 1.20-3.89)). Important increase was found in males (7.45% vs. 2.5%; RR = 3.02 (95% CI = 1.42-6.44)), but not in females (7.2% vs. 6%; RR = 1.20 (95% CI = 0.44-3.27). Conclusions The admissions of ACS reduced similarly in males and females during the COVID-19 pandemic. The admissions of STEMI reduced predominantly in females. We identified a substantial increase in the overall ACS mortality, but predominantly in males, reducing the differences between males and females. Further studies are necessary to better understand the increase in male mortality during the pandemic.

Hospitalizations and in-hospital outcomes in patients with ST-elevation myocardial infarction during the coronavirus disease 2019 pandemic: The Albanian experience.

OBJECTIVE: Global studies report a significant decline in ST-elevation myocardial infarction (STEMI) related hospitalization rates during the coronavirus disease 2019 (COVID-19) pandemic outbreak. However, there have been several divergent reports on hospital outcomes. In this study, we aim to investigate the impact of the COVID 19 outbreak on hospitalizations because of STEMI and in-hospital outcomes in Albania. METHODS: This was a retrograde study, collecting data for hospitalizations because of STEMI from March 9, (first COVID 19 case in our country) to April 30, 2020, (period of total lockdown) compared with the same period in 2019 at our center. The incidence rate ratio (IRR) was used to compare admissions because of STEMI and procedures and the risk ratio (RR) to compare mortality and other complication rates. RESULTS: Admissions for STEMI declined during the COVID-19 period from a total of 217 in 2019 to 156 in 2020 (-28.1%) representing IRR 0.719 (p=0.033). PCIs also reduced from 168 procedures in 2019 to 113 in 2020 (-33%), representing an IRR of 0.67, p=0.021. The time from symptom onset to arrival at our intensive care unit was significantly higher in 2020 compared to 2019 (925.6±1097 vs. 438.7±385 minutes, p<0.001). The STEMI death rate during the pandemic compared to the control period was significantly increased to 14.1% vs. 7.8% (RR=1.91 p=0.037, but with no significant increase in primary PCI-STEMI death rate (8.9% vs. 4.8% RR=1.85 p=0.217). Cardiogenic shock also increased during the pandemic to 21.2% from 12.4% in 2019 (RR=1.70 p=0.025). CONCLUSION: Hospitalizations and revascularization procedures for STEMI significantly reduced during the COVID-19 pandemic. We identified a substantial increase in the STEMI mortality rate and cardiogenic shock during the pandemic outbreak. Delayed timely reperfusion intervention might be responsible for the increased risk for complications.

Ongoing COVID-19 Pandemic Effects on Admissions and In-Hospital Outcomes in Patients With ST-Elevation Myocardial Infarction (STEMI): An Albanian Observational Study.

Background Multiple studies conducted worldwide and in Albania documented an important reduction of acute ST-elevation myocardial infarction (STEMI) admissions during the Coronavirus Disease 19 (COVID-19) pandemic. There are few studies regarding STEMI admissions and outcomes during the ongoing pandemic after the initial lockdown. We aimed to study STEMI admissions and in-hospital outcomes after the COVID-19 lockdown period. Methods A retrospective single-center study was conducted, collecting data for all consecutive STEMI admissions from March 9th, (the first COVID-19 case) until April 30th, the corresponding period of 2020 total lockdown, for years 2019 and 2021. The control period was considered the year 2019 [pre-pandemic (PP)] and the study period was in 2021 [ongoing pandemic (OP)]. The incidence rate ratio (IRR) 95% confidence interval (CI) was used to compare all-STEMI admissions, invasive procedures, and risk ratio (RR) 95% CI to compare the mortality and complications rate between the study and control period. Results The study included 217 STEMI patients admitted in 2019, and 234 patients during the 2021 period. The overall-STEMI admissions IRR is in a similar range during the 2021 OP compared to the 2019 PP period IRR=1.07 (95%CI 0.90-1.28). Similar invasive procedures were observed during OP compared to PP period, respectively for coronary-angiography IRR= 1.07; (0.87-1.31), for all-PCI [1.12 (0.92-1.35)], and primary percutaneous coronary interventions (PCI) [1.09 (0.89-1.34)]. The STEMI death rate during OP compared to PP period was similar (7.3 vs. 7.4%), RR=1.01 (0.53-1.96), and a non-significant lower primary-PCI-death rate (4.0 vs 4.8%), RR= 0.83 (0.30-2.3)]. Conclusions After the initial reduction of admissions and invasive procedures in STEMI patients during the 2020 lockdown period and the increase of all-STEMI mortality, the number of hospitalizations, invasive procedures, and mortality returned to a similar range during OP compared to the PP period despite a highly incident ongoing COVID-19 pandemic.

The potential effect of cardiac function on pulmonary hypertension, other risk factors, and its impact on survival in dialysis patients.

INTRODUCTION: Pulmonary hypertension (PH) is a recently recognized as a complication of chronic kidney disease and end-stage renal disease. The pathogenesis of pulmonary hypertension in this group of patients is not fully understood, probably due to the interaction of multiple aspects of the altered cardiovascular physiology and also hormonal and metabolic disorders. The present study aimed to determine the prevalence of PH, correlation with cardiac function and other risk factors and its impact of survival in chronic hemodialysis and peritoneal dialysis patients. METHODS: We studied 125 stable hemodialysis and peritoneal patients (females 40%, mean age 52.42 ± 11.88 years) on renal replacement therapy (RRT) for more than 3 months with a follow up 2 years. Demographic information, clinical characteristics, blood test, and thoroughly echocardiographic evaluation at the optimal dry weight were collected. After conventional echocardiographic examination, tissue Doppler echocardiographic (TDE) examination was performed to evaluate global and regional myocardial systolic as well as diastolic function, and pulmonary hypertension. PH was defined as systolic pulmonary artery pressure (sPAP) ≥ 35 mmHg. To rule out secondary PH, patients with pulmonary disease, collagen vascular disease, and volume overload at the time of echocardiography were excluded. Variables were compared between two groups-subjects with PH and non-PH. Logistic regression analysis was used to evaluate the risk factor for PH and its impact on survival. RESULTS: According to the echocardiographic findings, PH was found in 28% (35 patients) of all patients. Mean PH was 33.46 ± 5.38 mmHg. The higher level of higher parathormone (PTH), C-reactive protein (CRP) and E/E' average, lower left ventricular ejection fraction (EF), peak systolic velocity at the lateral mitral annulus (MASa) and the peak systolic velocity at the lateral tricuspid annulus (TASa) were found predictor of PH. The cardiovascular mortality rate was 15.5%. Patients evaluated with PH have a significantly lower cardiovascular survival rate [Long Rank (Mantel-Cox) p = 0.0001]. In ROC analysis for CV mortality, the area under the curve (AUC) for PH and CRP was found 0.8; for LVM-I, E/E' and PP, AUC = 0.76; 0.75; 0.72 respectively while the inverse relationship was found with MASa and TASa with AUC = 0.66 and 0.95 respectively. CONCLUSION: Our study shows that PH is frequent in dialysis patients. It is influenced by inflammation, CKD-MBD biomarkers associated with diastolic and also systolic left and right ventricle dysfunction. Pulmonary hypertension, inflammation, vascular stiffness, and left ventricular hypertrophy are interrelated and all contribute to cardiovascular morbidity and mortality among dialysis patients. Easy to implement, cardiac imaging at the bedside and in outpatient clinics offers a positive perspective in early diagnosis of cardiac abnormalities and immediate approach to this condition, so is highly recommended in the dialysis population.

Religious affiliation and acute coronary syndrome: a population-based case-control study in Tirana, Albania.

BACKGROUND: Our aim was to assess the association of religious affiliation (Muslim versus Christian) with acute coronary syndrome (ACS) in Albania, a predominantly Muslim country in Southeast Europe. METHODS: A population-based case-control study was conducted in Tirana, the Albanian capital, in 2003-2006. Of non-fatal consecutive ACS patients, 467 were recruited (370 men aged 59.1 +/- 8.7 years and 97 women 63.3 +/- 7.1 years, 88% response). The coronary heart disease-free control group comprised 469 men (53.1 +/- 10.4 years) and 268 women (54.0 +/- 10.9 years) (69% response), 452 and 237 of whom were fully examined. Information collected included sociodemographic, psychosocial and behavioural characteristics by structured interview and anthropometric measurements. Furthermore, data on religious affiliation was available for all but 20 of the non-respondents. Multivariable-adjusted logistic regression was used to assess the association of religious affiliation (Muslim versus Christian) with ACS. RESULTS: Of ACS patients, 77.1% were Muslims compared with 65.8% of the entire control group. Muslims in both sexes were at higher risk of ACS than Christians (age- and sex-adjusted OR = 1.8, 95% CI = 1.4-2.3, P < 0.01). The association persisted (OR = 1.6, 95%CI = 1.1-2.3, P = 0.02) upon further adjustment for marital status, family size, education, income, employment status, social position, emigration of close relatives, financial loss and coronary risk factors. CONCLUSIONS: In this transitional country, we found a higher risk of ACS in Muslims than Christians, independent of the socioeconomic circumstances and conventional coronary risk factors assessed. This finding requires replication and the determinants of the excess risk sought.

The health effects of emigration on those who remain at home.

BACKGROUND: The health effects of emigration on relatives staying behind has received little attention in the recent literature. Our aim was to assess the association of spouse and offspring emigration with acute coronary syndrome (ACS) in Albania, a country which is undergoing a particularly rapid socio-economic transition accompanied by intensive emigration. METHODS: A population-based case-control study, conducted in Tirana, Albania, in 2003-06, included 467 non-fatal consecutive ACS patients (370 men, 97 women; 88% response) and 737 population-representative controls (469 men, 268 women; 69% response) aged 35-74 years. Information on emigration of family members and financial support, socio-demographic characteristics and conventional coronary risk factors was obtained by a structured questionnaire and examination. Associations of emigrational variables with ACS were assessed by logistic regression. RESULTS: Forty five percent of female and 25% of male patients, and 17 and 15% of controls, respectively, reported emigration of a close family member. These were younger and of lower education, income and social status than controls without emigrants. Forty nine percent of patient emigrants vs 76% of control emigrants remitted funds. Excess risk of ACS was confined to individuals whose emigrant relatives did not remit monies home [multivariable-adjusted odds ratio (OR) = 10.8, 95% confidence interval (CI) = 2.6-44.8 in women, and OR = 2.0, 95% CI = 0.9-4.3 in men; P for sex-interaction = 0.03] and was attributable largely to spouse emigration. CONCLUSIONS: Our findings, which require confirmation, suggest that emigration of close family, but especially of spouses, coupled with non-remittance of financial support is associated with marked health effects in the spouse or parent left behind, and that women are more vulnerable than men.

Conventional risk factors and acute coronary syndrome during a period of socioeconomic transition: population-based case-control study in Tirana, Albania.

AIM: To assess the association between conventional risk factors and acute coronary syndrome in Albania, a transitional country in Southeast Europe. METHODS: A population-based case-control study was conducted in Tirana in 2003-2006. A total of 467 consecutive patients with nonfatal acute coronary syndrome were recruited. There were 370 men with mean+/-standard deviation (SD) age of 59.1+/-8.7 years and 97 women with mean+/-SD age of 63.3+/-7.1 years. The control group comprised a population-representative sample of Tirana residents. In the control group, there were 469 men with mean+/-SD age of 53.1+/-10.4 years and 268 women aged 54.0+/-10.9 years. A structured questionnaire on demographic, socioeconomic, psychosocial factors, and health behaviors was administered. Physical measurements included anthropometrics and blood pressure. Venous blood and adipose tissue aspirations from the gluteal region were frozen-stored for future analysis. Multivariable-adjusted logistic regression was used to assess the independent associations of conventional risk factors with acute coronary syndrome. RESULTS: Upon adjustment for covariates, family history of coronary heart disease was found to be a strong predictor of acute coronary syndrome in both men (odds ratio [OR], 3.70; 95% confidence interval [CI], 2.58-5.30) and women (OR, 4.53; 2.40-8.57). Waist-to-hip ratio in men (OR, 4.03; 2.83-5.73) and obesity in women (OR, 3.31; 1.54-7.14) were strongly associated with acute coronary syndrome. In men, but not in women, there was a significant association with hypertension and current smoking (P=0.011 and P<0.001, respectively). Diabetes was not significantly independently associated in either sex. CONCLUSION: Classical risk factors predicted coronary heart disease in Albania, similarly as in the rest of the world, although associations with family history and anthropometric indices were stronger. These findings are resulting largely from the heterogeneous adoption of lifestyles conducive to increased coronary risk in transitional countries, and they point to the urgent need for targeted public health interventions.

The Patterns of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Use in Patients with Atrial Fibrillation in Seven Balkan Countries: a Report from the BALKAN-AF Survey.

INTRODUCTION: Data on management of atrial fibrillation (AF) in the Balkan Region are scarce. To capture the patterns in AF management in contemporary clinical practice in the Balkan countries a prospective survey was conducted between December 2014 and February 2015, and we report results pertinent to the use of non-vitamin K antagonist oral anticoagulants (NOACs). METHODS: A 14-week prospective, multicenter survey of consecutive AF patients seen by cardiologists or internal medicine specialists was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania, and Serbia (a total of about 50 million inhabitants). RESULTS: Of 2712 enrolled patients, 2663 (98.2%) had complete data relevant to oral anticoagulant (OAC) use (mean age 69.1 ± 10.9 years, female 44.6%). Overall, OAC was used in 1960 patients (73.6%) of whom 338 (17.2%) received NOACs. Malignancy [odds ratio (OR), 95% confidence interval (CI) 2.06, 1.20-3.56], rhythm control (OR 1.64, 1.25-2.16), and treatment by cardiologists were independent predictors of NOAC use (OR 2.32, 1.51-3.54) [all p < 0.01)], whilst heart failure and valvular disease were negatively associated with NOAC use (both p < 0.01). Individual stroke and bleeding risk were not significantly associated with NOAC use on multivariate analysis. CONCLUSIONS: NOACs are increasingly used in AF patients in the Balkan Region, but NOAC use is predominantly guided by factors other than evidence-based decision-making (e.g., drug availability on the market or reimbursement policy). Efforts are needed to establish an evidence-based approach to OAC selection and to facilitate the optimal use of OAC, thus improving the outcomes in AF patients in this large region.

Surgical Treatment of Anomalous Origin of Right Coronary Artery in a Patient with Mitral Stenosis.

BACKGROUND: An anomalous origin of the right coronary artery is rarely observed, with a reported incidence between 0.026% and 0.25%. This condition is often completely asymptomatic and is found incidentally during angiographic evaluation for other cardiac diseases. However some patients present with exertion angina or sudden death. Surgical treatment in patients with anomalous RCA is still controversial. Treatment can be conservative, angioplasty or surgery. CASE PRESENTATION: A 59-year-old man was admitted with severe mitral stenosis. He complained exertion and rest dyspnea, NYHA III class. He had sequels of embolic stroke, results of left atrial thrombus. Echocardiography showed calcified severe mitral stenosis with mitral orifice area of 1.1 square centimeters with PSPAP 60 mmHg and normal LV function. Routine coronary angiography before surgery showed aberrant origin of RCA from the left sinus of Valsalva with 90% stenosis at his origin. Multi-slice computed tomography proved the diagnosis of anomalous RCA arising from the left sinus of Valsalva and taking an inter-arterial course between the aorta and pulmonary artery. The patient underwent mitral valve replacement with mechanical St. Jude prosthesis No 29 and saphenous vein graft to RCA. We chose by-pass grafting techniques because after aortotomy, RCA was too close to LMCA, intramural course was too short and stenosis of RCA was outside of aortic wall. The patient's perioperative course was without complications and patient was discharged on the seventh postoperative day. CONCLUSION: Correction of anomalous of the origin of right coronary artery is mandatory in cases where patient has to be operated for other cardiac causes.

Inflammation, Left Ventricular Hypertrophy, and Mortality in End-stage Renal Disease.

INTRODUCTION: The aim of this study was to evaluate ventricular geometry, its relationship with the inflammatory markers, and mortality of patients with end-stage renal disease on peritoneal and hemodialysis treatment. MATERIALS AND METHODS: We enrolled adult patients on long-term dialysis (hemodialysis and peritoneal dialysis) for more than 3 months. Two-dimensional echocardiography was performed by an experienced cardiologist who was blinded to all clinical details of patients. Cardiovascular mortality was assessed during a 2-year follow-up period. RESULTS: There were 129 participants, of whom 86 (66%) were on hemodialysis. Left ventricular hypertrophy was present in 86.7%; concentric hypertrophy was found in 64 (49.1%) and eccentric hypertrophy in 48 patients (37.2%). Patients with left ventricular hypertrophy were further divided into tertiles according to their left ventricular mass index. Logistic regression found pulse pressure as an independent risk factor associated with left ventricular mass index (odds ratio [OR], 1.04; 95% confidence interval (CI), 1.01 to 1.19; P = .047). Cardiovascular mortality rate was 15.5%. Multivariable analysis showed that C-reactive protein (OR, 1.06; 95% CI, 1.01 to 1.10; P = .01), pulse pressure (OR, 1.01; 95% CI, 1.0 to 1.26; P = .046), and left ventricular mass index (OR, 1.03; 95% CI, 1.01 to 1.21; P = .03) were independent risk factors for cardiovascular mortality. CONCLUSIONS: Concentric hypertrophy is the most frequent left ventricular geometry model in patients with chronic kidney disease. Inflammation, pulse pressure, and  left ventricular hypertrophy are interrelated and all contribute to mortality and cardiovascular death risk among dialysis patients.

Stroke prevention in atrial fibrillation and 'real world' adherence to guidelines in the Balkan Region: The BALKAN-AF Survey.

Data on the management of atrial fibrillation (AF) in the Balkan Region are limited. The Serbian AF Association (SAFA) prospectively investigated contemporary 'real-world' AF management in clinical practice in Albania, Bosnia&Herzegovina, Bulgaria, Croatia, Montenegro, Romania and Serbia through a 14-week (December 2014-February 2015) prospective, multicentre survey of consecutive AF patients. We report the results pertinent to stroke prevention strategies. Of 2712 enrolled patients, 2663 (98.2%) with complete data were included in this analysis (mean age 69.1 ± 10.9 years, female 44.6%). Overall, 1960 patients (73.6%) received oral anticoagulants (OAC) and 762 (28.6%) received antiplatelet drugs. Of patients given OAC, 17.2% received non-vitamin K antagonist oral anticoagulants (NOACs). CHA2DS2-VASc score was not significantly associated with OAC use. Of the 'truly low-risk' patients (CHA2DS2-VASc = 0 [males], or 1 [females]) 56.5% received OAC. Time in Therapeutic Range (TTR) was available in only 18.7% of patients (mean TTR: 49.5% ± 22.3%). Age ≥ 80 years, prior myocardial infarction and paroxysmal AF were independent predictors of OAC non-use. Our survey shows a relatively high overall use of OAC in AF patients, but with low quality of vitamin K antagonist therapy and insufficient adherence to AF guidelines. Additional efforts are needed to improve AF-related thromboprophylaxis in clinical practice in the Balkan Region.

The role of computed tomography in detecting splenic arteriovenous fistula and concomitant atrial myxoma.

PATIENT: Female, 45 FINAL DIAGNOSIS: Arterio-venous fistula of the splean Symptoms: Lef-side abdominal pain Medication: - Clinical Procedure: - Specialty: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Splenic arterial-venous fistula and atrial myxoma are not rare cases but the co-existence of both lesions in the same patient is unpublished so far. CASE REPORT: A 45- year-old woman presented with vague left flank pain. She was initially scanned by B-dimensional echography, which revealed multiple enlarged hypo-echoic lesions in the splenic hilum. To further characterize the lesion, we performed computed tomography angiography (CTA). CTA showed dilatation of the splenic artery, and aneurismal dilatation of the splenic vein, associated with early opacification of the portal system. CTA showed also an intrasplenic venous aneurism, which was presumed to be the site of fistulous communication. Celiac arteriography confirmed the CTA findings. A left atrial mass was detected by cardiac echography, which was evaluated better by CTA, and was consistent with atrial myxoma. The patient underwent open surgery in different stage with resection of the atrial mass and spleen. The postoperative period was uneventful. CONCLUSIONS: This is a unique case in the literature, showing the coexistence of a dual-pathology splenic arterial venous fistula and atrial myxoma.

Television viewing, leisure-time exercise and acute coronary syndrome in transitional Albania.

OBJECTIVE: To assess the association of leisure-time exercise and television (TV) viewing, a sedentary marker, with acute coronary syndrome (ACS) in Albania, a transitional country in Southeast Europe. METHODS: A population-based case-control study was conducted among Tirana residents in 2003-2006. Information on leisure-time exercise (transformed into kilocalories of energy expenditure) and daily hours of TV viewing was obtained by interviewer-administered questionnaire. 460 non-fatal ACS patients (368 men, 92 women) and 628 coronary heart disease-free controls (413 men, 215 women) were studied. RESULTS: Adjusted for socio-demographic characteristics, conventional coronary risk factors and leisure-time exercise, TV viewing was associated with ACS in women (OR=1.66, 95%CI=1.12-2.46 per hour/day viewing), but not in men (OR=0.93, 95%CI=0.81-1.07; P for sex-interaction=0.02). A low level of leisure-time exercise (adjusted also for TV viewing) was associated with ACS similarly in men and women (pooled sexes OR=2.03, 95%CI=1.29-3.22 for bottom vs top tertile of energy expenditure). CONCLUSIONS: Leisure-time inactivity is confirmed as an important risk factor for ACS also in Southeastern Europe. TV viewing may be an informative coronary risk marker in transitional societies, especially in women.