The prevalence of hypertension among Croatian hospitalized coronary heart disease patients.

The aim of this article was to investigate the prevalence of hypertension with selected anthropometric variables in a sample of hospitalized coronary heart disease (CHD) patients in Croatia. This study investigated patients hospitalized in the period of October 1st 2007 until January 7th 2010 because of acute or chronic CHD in various hospitals in Croatia (N = 1,298). Prevalence of hypertension in surveyed patient population was high: 70.1% of participants had raised blood pressure (BP) or previously diagnosed hypertension. Men had statistically significantly higher mean diastolic BP values than women (78.91 +/- 8.97 vs. 77.12 +/- 10.61 mmHg, p = 0.011). Prevalence of hypertension was statistically significantly more frequent in women (80.6% vs. 65.8%, p < 0.001). Hypertension still represents an important problem among hospitalized Croatian CHD patients. Its prevalence, unfortunately, continues to increase in this population, suggesting that there is still great potential for improvement of preventive cardiology standards and measures that have already been undertaken.

[Features and pathophysiology of acute coronary syndrome]. / Oblici i patofiziologija akutnog koronarnog sindroma.

Coronary heart disease (CHD) is the leading cause of death in developed countries, and it also has fastest growing death rates in developing countries. Patients with acute coronary syndromes (ACS) are divided into two groups - those with and those without ST segment elevation. ACS without ST segment elevation also includes unstable angina pectoris (UA) any non-ST elevation myocardial infarction (NSTEMI). It is important to note that UA is defined as ischemic chest pain at rest without a rise in serum cardiac biomarkers, while the establishment of NSTEMI diagnosis requires a rise in serum cardiac biomarkers. ACS with ST segment elevation is STEMI, and it includes both ST segment elevation and a rise in serum cardiac biomarkers. Connection of UA, NSTEMI and STEMI is based on the fact that these are closely connected conditions with similar pathogenesis and clinical presentation, but they do differ by the level of severity. The main difference lies in the fact whether or not the ischemia is serious enough to cause myocardial damage of such an extent that will cause the release of a sufficient amount of serum cardiac biomarkers so that these can be discovered and measured in serum (for example, cardiac troponin). The key role in ACS is played by atherosclerosis, atherosclerotic plaque and plaque rupture, in combination with thrombosis as an event of paramount importance--thrombosis.

[The role of diagnostic work-up at university hospital emergency service and coronary care unit in the management of acute coronary syndrome patients]. / Znacenje dijagnostickih postupaka u hitnoj sluzbi i koronarnoj jedinici klinicke bolnice u zbrinjavanju bolesnika s akutnim koronarnim sindromom.

Acute coronary syndrome (ACS) represents a significant global socioeconomic problem. In the United States, 6-7 million patients present to emergency service annually for chest pain or symptoms of ACS, the diagnosis of ACS being confirmed in 20-25% of these patients.There are two groups of ACS patients, with chest pain as the main and common the presentation that basically has the same pathophysiologic substrate. The groups show differences in electrocardiogram (ECG) changes, or in the presence or absence of ST elevation that distinguishes acute coronary syndrome with ST elevation, or acute myocardial infarction with ST elevation from acute coronary syndrome without ST elevation (ACS-NSTE). Within these groups there are subgroups of patients with acute myocardial infarction without ST elevation (NSTEMI) and patients with unstable angina pectoris (UA). Subgroup distinction between UA and NSTEMI is based on the findings of elevated cardiac markers (troponin). Diagnostic procedures performed at emergency service and coronary unit include history and clinical status, ECG, laboratory testing for cardiac markers and other biochemical parameters, heart and lung x-ray, heart ultrasound, radionuclide methods, and assessment of the risk level (risk score). It should be noted that history data, ECG findings and testing for cardiac markers are of particular importance in setting the diagnosis of ACS. Other useful methods of risk assessment include TIMI degree of risk, which is in general use because of its simplicity, but is less predictive, and the Pursuit and Frisco degree of risk. Regardless of the method used, it is recommended to determine the degree of risk for every patient on admission and at discharge.

[Anti-ischemic therapy in patients with STEMI or NSTEMI treated at county and university hospitals]. / Antiishemijska terapija bolesnika sa STEMI ili NSTEMI u zupanijskoj i klinickoj bolnici.

The objective of prehospital care of patients with acute coronary syndrom (ACS) [acute ST segment elevation myocardial infarction (STEMI), acute non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA)], is prompt diagnosis of the acute myocardial infarction, patient's risk assessment, drug administration in order to reduce patient's pain and fear, and prevention or treatment of heart failure. In hospital treatment therapeutic procedures include reperfusion therapy, limitation of infarction zone, treatment of complications (heart failure, life-threatening arrhythmias), prevention of reinfarction, heart failure and eventually prevention of sudden cardiac death. Acute therapeutic procedures include revascularization, anti-ischemic and antithrombolytic treatment, possible surgical revascularization and treatment of complications (arrhythmias, heart failure). The patients with STEMI that present within 3-12 hours from the onset of chest pain should undergo primary percutaneous coronary intervention (PCI). In case of presentation within 3 hours from the occurrence of chest pain, the administration of thrombolytic therapy in this period is equally efficient as PCI. Regardless of reperfusion regimen, the anti-ischemics administered including nitrates (nitroglycerin); intravenous analgesics (morphine-sulfate); O2 2-4 L/min; beta-adrenergic blockers; calcium channel blockers; angiotensin converting enzyme inhibitors (ACE-I); magnesium and glucose-insulin-potassium have proved to be efficient as shown by study results and clinical experience. The mechanism of action of anti-ischemics includes reduction in myocardial oxygen consumption achieved by a decrease of heart frequency, reduction of systemic blood pressure and reduction in myocardial contractility by vasodilatation and consequent better myocardial oxygen supply. The outstanding results of major clinical studies are presented, and main guidelines for anti-ischemic therapy of ACS adopted by the international professional associations are set forth.

[Elective percutaneous coronary intervention after acute coronary syndrome]. / Elektivna perkutana koronarna intervencija (PCI) nakon akutnog koronarnog sindroma.

Elective percutaneous coronary intervention (PCI) after acute coronary syndrome (ACS), according to guidelines issued by the European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology (AHA/ACC), is a therapeutic method that is indicated in patients with ACS with ST segment elevation in case of persistent signs of myocardial ischemia and with significant stenosis of coronary artery verified by coronary angiography, suitable for PCI according to the guidelines. It is also indicated for non-culprit significant stenosis of other coronary arteries which have been seen during primary PCI for ST segment elevation myocardial infarction (STEMI). After non ST segment myocardial infarction (NSTEMI) or after non-ST elevation ACS, elective coronary artery angiography is indicated in low risk patients if they have positive signs of ischemia on noninvasive tests. Depending on the results of coronary angiography, elective PCI is indicated according to ESC or AHA/ACC guidelines. The method success is assessed at three levels, i.e. by angiography, clinically and periprocedurally. PCI enables earlier and more efficient resolution of symptoms, better effort tolerance and lower rate of residual ischemia on noninvasive tests.

Type 5 and 6 nasal septal deformities: Could we predict and prevent acute coronary syndrome attacks in the future?

Undisturbed nasal breathing is essential for normal breathing physiology as a whole. Nasal septal deformities (NSD) are well known as a factor which can remarkably and substantially affect the quality of nasal and pulmonary breathing. However, it is well known that type 5 and type 6 nasal septal deformities may cause only a moderate, unilateral nasal obstruction or none at all. The effects of nasal obstruction on the respiratory and cardiovascular systems have been well studied so far: right ventricle problems, ischemic heart diseases, sleep disorders, mucociliary clearance system disturbances, paranasal sinus pathology, have all been described as a result of impaired nasal breathing. The connection between the upper and lower respiratory systems has been recognized in allergic rhinitis and asthma as well, resulting in the united airways concept. Most recently, the ostensible connection between chronic rhinosinusitis (CRS) and acute myocardial infarction has been said to be proven. However, the results of this study might have not been well founded since there are no direct and clear proofs that CRS as a chronic inflammatory process has anything to do with the acute coronary syndrome (ACS). On the other hand, a large international study on the incidence of NSD in CRS patients, based on the Mladina classification, showed that NSD were present in a high incidence and that the most frequent deformities were types 5 (36.18%) and 7 (29.92%). The vast majority of those types 7 consisted of types 3 and (again) types 5 or types 6 (76.32%). The fact that in CRS patients a remarkably high incidence of type 5 septal deformity can be seen, gives rise to thinking that this factor perhaps plays a role in the onset of ACS. Acute coronary syndrome is one of the leading causes of death all over the world. Traditional risk factors such as family history, overweight body, smoking, stress, hypertension, hypercholesterolemia, diabetes mellitus, coronary artery calcium score, C-reactive protein, lipoprotein, homocysteine, lipoprotein-associated phospholipase A2, as well as high-density lipoprotein functionality perhaps cannot account for the entire risk for incident coronary events. Several other potential risk factors have been identified in an effort to improve risk assessment for ACS. This article reviews one of them: the possible influence of an unusual, so far unknown predisposing factor: type 5 or type 6 nasal septal deformities. They have been found as pure, isolated types or as a part of combined nasal septal deformity (type 7).

[Percutaneous coronary interventions (PTCA and stent) myocardial infarct with ST segment elevation]. / Perkutane koronarne intervencije (PTCA i STENT) pri infarktu miokarda s elevacijom ST spojnice.

INTRODUCTION: Primary percutaneous coronary interventions (PCI) in acute coronary syndrome include coronary angioplasty (PTCA) and placing stent in occluded coronary artery, representing distinct progress in treating patients with acute coronary syndrome. PATIENTS AND METHODS: Permanent PCI service is available at Dubrava University Hospital since May 1, 2001. During the 2-year period, 142 patients with acute myocardial infarction with significant electrocardiographic ST-elevation were treated by this method. RESULTS: Occlusion was found and PCI treatment most often performed on the leading descending artery (46.5%) and right coronary artery (45.5%). The mortality during and immediately after PTC was reduced to 4.2%. CONCLUSION: Our results of successful recanalization of occluded coronary artery are similar to those reported from most European cardiology centers.

[Inflammation markers in acute coronary syndrome]. / Upalni biljezi u akutnom koronarnom sindromu.

Inflammation is a component of atherosclerotic plaque, but it is also a possible pathogenetic factor of acute coronary event responsible for coronary instability. Inflammatory markers are considered as new risk factors for atherosclerosis. Among others (C-reactive protein (CRP) is the best known marker of inflammatory response which is most frequently found in patients with acute myocardial infarction preceded by a period of instability. High values of inflammatory markers indicate poor prognosis after acute myocardial infarction. Therapy may lower the inflammatory component and the risk of coronary disease. Specific response of inflammatory marker during diagnostic and percutaneous coronary interventions indicates more severe coronary disease.

Percutaneous coronary intervention of an anomalous right coronary artery originating from the left coronary artery.

Anomalous origin of the right coronary artery is a rare congenital anomaly that was first described in 1948 by White and Edwards. It is well established that an anomalous origin of the right coronary artery can lead to angina pectoris, myocardial infarction, or sudden death, in the absence of atherosclerosis. Thus from the literature data it has been also suggested that the abnormal origin and course of anomalous coronary arteries could make them more prone to atherosclerosis due to altered flow patterns. We report our experience involving one patient who had significant atherosclerotic disease and was successfully treated with percutaneous coronary intervention (PCI) and stent implantation in an anomalous right coronary artery arising from the left coronary artery.

Results of the Croatian Primary Percutaneous Coronary Intervention Network for patients with ST-segment elevation acute myocardial infarction.

The Republic of Croatia, with a gross domestic product per capita of US$11,554 in 2008, is an economically less-developed Western country. The goal of the present investigation was to prove that a well-organized primary percutaneous coronary intervention network in an economically less-developed country equalizes the prospects of all patients with acute ST-segment elevation myocardial infarction at a level comparable to that of more economically developed countries. We prospectively investigated 1,190 patients with acute ST-segment elevation myocardial infarction treated with primary PCI in 8 centers across Croatia (677 nontransferred and 513 transferred). The postprocedural Thrombolysis In Myocardial Infarction flow, in-hospital mortality, and incidence of major adverse cardiovascular events (ie, mortality, pectoral angina, restenosis, reinfarction, coronary artery bypass graft, and cerebrovascular accident rate) during 6 months of follow-up were compared between the nontransferred and transferred subgroups and in the subgroups of older patients, women, and those with cardiogenic shock. In all investigated patients, the average door-to-balloon time was 108 minutes, and the total ischemic time was 265 minutes. Postprocedural Thrombolysis In Myocardial Infarction 3 flow was established in 87.1% of the patients, and the in-hospital mortality rate was 4.4%. No statistically significant difference was found in the results of treatment between the transferred and nontransferred patients overall or in the subgroups of patients >75 years, women, and those with cardiogenic shock. In conclusion, the Croatian Primary Percutaneous Coronary Intervention Network has ensured treatment results of acute ST-segment elevation myocardial infarction comparable to those of randomized studies and registries of more economically developed countries.

A cold shock response triggering acute myocardial infarction.

Acute risk factors are activities and events that suddenly and transiently increase the risk of acute cardiac events, as reported recently in International Journal of Cardiology. It has already been reported that sudden submersion in cold water may provoke myocardial infarction in both subjects with atherosclerotic coronary disease and young people with angiographically normal coronary arteries. We report a case of an acute myocardial infarction triggered by sudden exposure to cold air temperature extreme in a young person with acutely occluded proximal part of the left anterior descending coronary artery and normal other coronary arteries who had extreme obesity and cigarette smoking as cardiovascular risk factors. Our report indicates that the sudden cold exposure and the resulting cold shock response may provoke acute myocardial infarction in young susceptible patients.

Brugada syndrome unmasked by accidental inhalation of gasoline vapors.

Loss-of-function mutations in the gene SCN5A can cause Brugada syndrome (BrS), which is an inherited form of idiopathic ventricular fibrillation. We report the case of a 46-year-old patient, with no previous medical history, who had ventricular fibrillation after accidental inhalation of gasoline vapors. His electrocardiogram (ECG) showed a typical type-1 BrS pattern that persisted after the acute event. Genetic investigations allowed the identification of a novel SCN5A mutation leading to a frame-shift and early termination of the channel protein. Biochemical and cellular electrophysiology experiments confirmed the loss-of-function of the mutant allele. The patient was implanted with a cardioverter/defibrillator.