STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial.

BACKGROUND: ST-segment-elevation myocardial infarction (STEMI) guidelines recommend pharmaco-invasive treatment if timely primary percutaneous coronary intervention (PCI) is unavailable. Full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. Whether pharmaco-invasive treatment with half-dose tenecteplase is effective and safe in older patients with STEMI is unknown. METHODS: STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) was an investigator-initiated, open-label, randomized, multicenter study. Patients ≥60 years of age with ≥2 mm ST-segment elevation in 2 contiguous leads, unable to undergo primary PCI within 1 hour, were randomly assigned (2:1) to half-dose tenecteplase followed by coronary angiography and PCI (if indicated) 6 to 24 hours after randomization, or to primary PCI. Efficacy end points of primary interest were ST resolution and the 30-day composite of death, shock, heart failure, or reinfarction. Safety assessments included stroke and nonintracranial bleeding. RESULTS: Patients were assigned to pharmaco-invasive treatment (n=401) or primary PCI (n=203). Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively. After last angiography, 85.2% of patients undergoing pharmaco-invasive treatment and 78.4% of patients undergoing primary PCI had ≥50% resolution of ST-segment elevation; their residual median sums of ST deviations were 4.5 versus 5.5 mm, respectively. Thrombolysis In Myocardial Infarction flow grade 3 at last angiography was ≈87% in both groups. The composite clinical end point occurred in 12.8% (51/400) of patients undergoing pharmaco-invasive treatment and 13.3% (27/203) of patients undergoing primary PCI (relative risk, 0.96 [95% CI, 0.62-1.48]). Six intracranial hemorrhages occurred in the pharmaco-invasive arm (1.5%): 3 were protocol violations (excess anticoagulation in 2 and uncontrolled hypertension in 1). No intracranial bleeding occurred in the primary PCI arm. The incidence of major nonintracranial bleeding was low in both groups (<1.5%). CONCLUSIONS: Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI. If timely PCI is unavailable, this pharmaco-invasive strategy is a reasonable alternative, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02777580.

Symptom management strategies: Rhythm vs rate control in patients with atrial fibrillation in the Balkan region: Data from the BALKAN-AF survey.

BACKGROUND: Symptom-focused management is one of the cornerstones of optimal atrial fibrillation (AF) therapy. OBJECTIVES: To evaluate the use of rhythm control and rate control strategy. Second, to identify predictors of the use of amiodarone in patients with rhythm control and of the use of rhythm control strategy in patients with paroxysmal AF in the Balkans. METHODS: Prospective enrolment of consecutive patients from seven Balkan countries to the BALKAN-AF survey was performed. RESULTS: Of 2712 enrolled patients, 2522 (93.0%) with complete data were included: 1622 (64.3%) patients were assigned to rate control strategy and 900 (35.7%) to rhythm control. Patients with rhythm control were younger, more often hospitalised for AF and with less comorbidities (all P < .05) than those with rate control. Symptom score [European Heart Rhythm Association (EHRA)] was not an independent predictor of a rhythm control strategy [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.90-1.10, P = .945]. The most commonly chosen antiarrhythmic agents were amiodarone (49.7%), followed by propafenone (24.3%). CONCLUSION: More than one-third of patients in the BALKAN-AF survey received a rhythm control strategy, and these patients tended to be younger with less comorbidities than those managed with rate control. EHRA symptom score is not significantly associated with rhythm control strategy. The most commonly used antiarrhythmic agents were amiodarone, followed by propafenone.

Stroke prevention in elderly patients with non-valvular atrial fibrillation in the BALKAN-AF survey.

BACKGROUND: Atrial fibrillation (AF) is common amongst the elderly, but this group tends to be suboptimally treated. Limited data are available on the stroke prevention strategies in the elderly, especially in the Balkan region. AIM: We investigated the use of oral anticoagulant therapy (OAC) amongst elderly AF patients in clinical practice in the Balkan region. METHOD: A 12-week prospective snapshot survey (2014-2015) of consecutive non-valvular AF patients was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania and Serbia. Data were collected via an electronic case report form. RESULTS: Of 2671 patients, 418 (15.6%) were ≥80 years old. Overall, OAC was used in 1965 patients (73.6%). Compared with younger patients, the elderly (age ≥ 80) had a higher mean CHA2 DS2 -VASc score (3.22 ± 1.71 vs 4.89 ± 1.35, P < .001) and more often a HAS-BLED score of ≥3 (n = 198 [47.0%] vs n = 625 [27.3%], P < .001), but were less likely to receive OAC (n = 269 [64.4%] vs n = 1696 [75.3%], odds ratio [OR] 0.91; 95%CI 0.86-0.97, P = .003). There was no significant association between OAC use and mean CHA2 DS2 -VASc (OR 0.86; 95%CI 0.75-1.00, P = .053) or HAS-BLED score (OR 1.21; 95%CI 0.81-1.81, P = .349) in the elderly. CONCLUSION: In the BALKAN-AF Survey, elderly AF patients were less likely to receive the guideline-adherent treatment despite their less favourable risk profile. Since OAC nonuse among the elderly was not associated with increased HAS-BLED score, factors other than patients' risk profile could influence the implementation of guideline-adherent treatment for thromboprophylaxis in the elderly AF patients.

Adherence to the 4S-AF Scheme in the Balkan region: Insights from the BALKAN-AF survey.

BACKGROUND: The 4S-AF scheme includes stroke risk, symptoms, severity of burden, and substrate severity domain. AIM: We aimed to assess the adherence to the 4S-AF scheme in patients classified according to stroke risk in post hoc analysis of the BALKAN-AF dataset. METHODS: A 14-week prospective enrolment of consecutive patients with electrocardiographically documented atrial fibrillation (AF) was performed in seven Balkan countries from 2014 to 2015. RESULTS: Low stroke risk (CHA2DS2-VASc score, 0 in males or 1 in females) was present in 162 (6.0%) patients. 2 099 (77.4%) patients had CHA2DS2-VASc score ≥3 in females or ≥2 in males (high stroke risk), and 613 (22.6%) had CHA2DS2-VASc score <3 in females or <2 in males. Seventy-five (46.3%) patients with low stroke risk and 1555 (74.1%) patients with high stroke risk were prescribed oral anticoagulants (OAC). Two thousand six hundred and seventy-seven (98.6%) had data on European Heart Rhythm Association (EHRA) class. Among 2099 patients with high stroke risk, 703 (33.4%) had EHRA class ≥3. Two hundred and seven (29.4%) patients with EHRA class ≥3 and high stroke risk were offered rhythm control; 620 (55.2%) of individuals with first-diagnosed or paroxysmal AF with high stroke risk were offered rhythm control. Two or more comorbidities occurred in 1927 (91.8%) patients with high stroke risk. CONCLUSIONS: OAC overuse was observed in patients with low stroke risk, whilst OAC underuse was evident in those with high risk of stroke. The percentage of highly symptomatic patients with high risk of stroke who were offered a rhythm control strategy was low.

Quality indicators in the management of atrial fibrillation: the BALKAN-AF survey.

BACKGROUND: The implementation of quality indicators in the atrial fibrillation (AF) care should be considered to improve quality of management and patient outcome. METHODS: In the post-hoc analysis of the BALKAN-AF dataset, we assessed concordance with quality indicators for AF management. Available domains for AF management [patient assessment (baseline), anticoagulation, rate control strategy, rhythm control strategy and risk factor management] were identified and assessed at baseline visit. RESULTS: Among 132 patients with a CHA2DS2-VASc score of 0 (men) or 1 (women), 75 (56.8%) were prescribed oral anticoagulation (OAC). Of 2539 patients with a CHA2DS2-VASc score ≥ 1 for men and ≥ 2 for women, 1890 (74.4%) were prescribed OAC. Among 1088 patients with permanent AF, 110 (10.1%) individuals were prescribed antiarrhythmic drugs (AADs). Of 1616 patients with structural heart disease, 37 (2.2%) were prescribed class IC AADs. Of 1624 patients with paroxysmal or persistent AF, 59 (3.6%) were offered catheter ablation. Among 2712 AF patients, 2121 (78.2%) had hypertension, 671 (24.7%) were obese, 53 (2.0%) had obstructive sleep apnoea, 110 (4.0%) had alcohol abuse and 340 (12.5%) were smokers. CONCLUSIONS: In the BALKAN-AF cohort, the use of OAC for stroke prevention was poorly associated with patients stroke risk. The use of AADs in patients with permanent AF was low. The prescription of class IC AADs to patients with structural heart disease was infrequent. A large proportion of AF patients had their modifiable risk factors identified.

Impact of multimorbidity and polypharmacy on the management of patients with atrial fibrillation: insights from the BALKAN-AF survey.

OBJECTIVE: We investigated the impact of multimorbidity and polypharmacy on the management of atrial fibrillation (AF) patients in clinical practice and assessed factors associated with polypharmacy and oral anticoagulation (OAC) use in AF patients with multimorbidity and polypharmacy. METHODS: A 14-week prospective study of consecutive non-valvular AF patients was performed in seven Balkan countries. RESULTS: Of 2712 consecutive patients, 2263 patients (83.4%) had multimorbidity (AF + ≥2 concomitant diseases) and 1505 patients (55.5%) had polypharmacy. 1416 (52.2%) patients had both multimorbidity and polypharmacy. Overall, 1164 (82.2%) patients received OAC, 200 (14.1%) patients received antiplatelet drugs alone and 52 (3.7%) patients had no antithrombotic therapy (AT). Non-emergency centre and paroxysmal AF were significantly associated with OAC non-use in patients with multimorbidity, whilst age ≥80 years and non-emergency centre were identified to be independent predictors of OAC non-use in patients with polypharmacy. CONCLUSIONS: Multimorbidity and polypharmacy were common among AF patients in our study. AT was suboptimal and approximately 18% of multimorbid patients with polypharmacy were not anticoagulated. Pattern of AF and non-emergency centre were associated with OAC non-use in AF patients with multimorbidity, whilst non-emergency centre and age ≥80 years were associated with OAC non-use in AF patients with polypharmacy. Key Message Multimorbidity and polypharmacy are common among patients with AF. Antithrombotic therapy was suboptimal in AF patients with multimorbidity and polypharmacy. Approximately, 18% of multimorbid patients with polypharmacy were not anticoagulated.

Treatment implications of renal disease in patients with atrial fibrillation: The BALKAN-AF survey.

BACKGROUND: Atrial fibrillation (AF) often co-exists with renal function (RF) impairment. We investigated the characteristics and management of AF patients across creatinine clearance strata and potential changes in the use of nonvitamin K oral anticoagulants (NOAC) according to different equations for estimation of RF. METHODS: In this post hoc analysis of the BALKAN-AF survey, patients were classified according to RF (Cockcroft-Gault formula) as: preserved/mildly depressed RF (P-RF) ≥50 mL/min, moderately depressed RF (MD-RF) 30-49 mL/min, and severely depressed RF (SD-RF) <30 mL/min. RESULTS: Of 2712 enrolled patients, 2062 (76.0%) had data on RF. Patients with SD-RF and MD-RF were older, had higher mean value of European Heart Rhythm Association score, stroke and bleeding risk scores, and more comorbidities than patients with P-RF (all P < .05). They received oral anticoagulants (OAC), AF catheter ablation, and electrical cardioversion less often than those with P-RF (all P < .05). Rate control, no OAC, single-antiplatelet therapy (SAPT) alone, and loop diuretics were more prevalent in patients with SD-RF and MD-RF than in subjects with P-RF (all P < .005). An important change in NOAC therapy could appear in <1% of patients (Modification of Diet in Renal Disease formula) and in <1% of patients (Chronic Kidney Disease Epidemiology Collaboration group formula). CONCLUSIONS: Patients with SD-RF and MD-RF were older, more symptomatic, had higher stroke and bleeding risk and more comorbidities than those with P-RF. They were less likely to receive OAC and more likely to use rate control strategy, SAPT alone, and no OAC than subjects with P-RF.

Adherence to the ABC (Atrial fibrillation Better Care) pathway in the Balkan region: the BALKAN-AF survey.

INTRODUCTION: The Atrial fibrillation Better Care (ABC) pathway provides a useful way of simplifying decision­making considerations in a holistic approach to atrial fibrillation management. OBJECTIVES: To evaluate adherence to the ABC pathway and to determine major gaps in adherence in patients in the BALKAN­AF survey. PATIENTS AND METHODS: In this ancillary analysis, patients from the BALKAN­AF survey were divided into the following groups: A (avoid stroke) + B (better symptom control) + C (cardiovascular and comorbidity risk management)-adherent and -nonadherent management. RESULTS: Among 2712 enrolled patients, 1013 (43.8%) patients with mean (SD) age of 68.8 (10.2) years and mean CHA2DS2­VASc score of 3.4 (1.8) had A+B+C-adherent management and 1299 (56.2%) had A+B+C-nonadherent management. Independent predictors of increased A+B+C-adherent management were: capital city (odds ratio [OR], 1.23; 95% CI, 1.03-1.46; P = 0.02), treatment by cardiologist (OR, 1.34; 95% CI, 1.08-1.66; P = 0.01), hypertension (OR, 2.2; 95% CI, 1.74-2.77; P <0.001), diabetes mellitus (OR, 1.28; 95% CI, 1.05-1.57; P = 0.01), and multimorbidity (the presence of 2 or more long­ term conditions) (OR, 1.85; 95% CI, 1.43-2.38; P <0.001). Independent predictors of decreased A+B+C-adherent management were: age 80 years or older (OR, 0.61; 95% CI, 0.48-0.76; P <0.001) and history of bleeding (OR, 0.5; 95% CI, 0.33-0.75; P = 0.001). CONCLUSIONS: Physicians' adherence to integrated AF management based on the ABC pathway was suboptimal. Addressing the identified clinical and system­related factors associated with A+B+C-nonadherent management using targeted approaches is needed to optimize treatment of patients with AF in the Balkan region.

Management of patients with newly-diagnosed atrial fibrillation: Insights from the BALKAN-AF survey.

BACKGROUND: BALKAN-AF evaluated patterns of atrial fibrillation (AF) management in real-world clinical practice in the Balkans. The objectives were: to assess the proportion of patients with first-diagnosed AF in the BALKAN-AF cohort and to compare the management of patients with newly-diagnosed AF and those with previously known AF in clinical practice. METHODS: Consecutive patients from 7 Balkan countries were enrolled prospectively to the snapshot BALKAN-AF survey. RESULTS: Of 2712 enrolled patients, 2677 (98.7%) with complete data were included. 631 (23.6%) patients had newly-diagnosed AF and 2046 (76.4%) patients had known AF. Patients with newly-diagnosed AF were more likely to be hospitalized for AF and to receive single antiplatelet therapy (SAPT) alone and less likely to receive OACs than those with known AF (all p < 0.001). The use of OAC was not significantly associated with the CHA2DS2-VASc (p = 0.624) or HAS-BLED score (p = 0.225) on univariate analysis. Treatment in capital city, hypertension, dilated cardiomyopathy, mitral valve disease, country of residence or rate control strategy were independent predictors of OAC use, whilst non-emergency centre, treatment by cardiologist, paroxysmal AF, palpitations, symptoms attributable to AF (as judged by physician), mean heart rate and AF as the main reason for hospitalization were independent predictors of rhythm control strategy use. CONCLUSIONS: In BALKAN-AF survey, patients with newly-diagnosed AF were more often hospitalized, less often received OAC and were more likely to receive SAPT alone. The use of OAC for stroke prevention has not been driven by the individual patient stroke risk.

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.

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.

Double orifice mitral valve--A case report.

INTRODUCTION: Double orifice mitrol valve (DOMV) is a very rare congenital heart defect. CASE REPORT: We reported 20-year-old male referred to our center due to evaluation of his cardiologic status. He was operated on shortly after birth for a tracheoesophageal fistula. Accidentally, echocardiography examination at the age of 4 years revealed double orifice mitral valve (DOMV) without the presence of mitral regurgitation, as well as mitral stenosis, with normal dimensions of all cardiac chambers. The patient was asymptomatic, even more he was a kick boxer. His physical finding was normal. Electrocardiography showed regular sinus rhythm, incomplete right bundle branch block. Transthoracic echocardiography (ITE) examination revealed the normal size of the left atrial, mitral leaflets were slightly more redundant. The left and right heart chambers, aorta, tricuspid valve and pulmonary artery valve were normal. During TTE examination on a short axis view two asymmetric mitral orifices were seen as a double mitral orifice through which we registered normal flow, without regurgitation and mitral stenosis. Transesophageal echocardiography (TEE) examination from the transgastric view at the level of mitral valve, showed 2 single asymmetric mitral orifices separated by fibrous tissue, mitral leaflet with a separate insertion of hordes for each orifice. CONCLUSION: The presented patient with DOMV is the only one recognized in our country. The case is interesting because during 16-year a follow-up period there were no functional changes despite the fact that he performed very demanded sport activities. This is very important because there is no information in the literature about that.

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.

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.

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.