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An 82-year-old man presented with a two-week history of increasing shortness of breath and exercise intolerance. His medical history included chronic obstructive pulmonary disease, hypertension and chronic kidney disease. He [...]

A 53-year-old man with a history of alcohol abuse was brought in by ambulance. He had been found on a park bench, after lying there for about eight hours. The [...]

We commend Fralick and colleagues for their article on drug interactions with rivaroxaban. (1) All novel oral anticoagulants (NOACs) were introduced as at least noninferior (in some cases superior) to [...]

Background The proportion of patients discharged after myocardial infarction with left ventricular systolic dysfunction remains high and the prognosis is unfavourable. The aim of this study was to analyse the temporal trends in the treatment and outcomes of a nationwide cohort of patients.Methods and results Data from the Polish Registry of Acute Coronary Syndromes and Acute Myocardial Infarction in Poland Registry were combined to achieve complete information on inhospital course, treatment and outcomes. An all-comer population of patients discharged with left ventricular ejection fraction of 40% or less formed the sample population (n= 28,080). The patients were analysed for the incidence of significant temporal trends and their possible consequences. The implementation of guideline-based treatment at discharge was high. In the post-discharge course a trend towards a higher frequency of percutaneous coronary intervention and a lower prevalence of planned coronary artery bypass grafting procedures was observed. The number of implantable cardioverter defibrillator/cardiac resynchronisation therapy defibrillator implantations was increasing. Cardiac rehabilitation was performed in 19–23% cases. The post-discharge outpatient care was based on general practitioner visits, with only 47.9–48.1% of patients attending an ambulatory cardiology specialist visit. In 12 months of observation the frequency of heart failure rehospitalisations was 17.5–19.1%, while the prevalence of rehospitalisations due to myocardial infarction decreased (8.3% in 2009 to 6.7% in 2013, P< 0.001). A trend towards lower all-cause mortality was observed. Assessment of composite outcomes (death, myocardial infarction, stroke or heart failure rehospitalisation) adjusted for sex and age at 12 months revealed a significant decreasing trend.Conclusion The overall prognosis in this population is improving slowly. This may be due to the increasing prevalence of guideline-based forms of secondary prevention. Efforts aimed at maintaining these trends are essential, as overall compliance with these guideline remains suboptimal.

AbstractThe investigation of death in young (<35 years), previously fit individuals, calls for a detailed autopsy with emphasis placed upon the examination of the heart. In most instances, the cause of cardiac death can be identified during autopsy. However, a large percentage of sudden deaths remain unexplained even after comprehensive medicolegal investigation, including autopsy, and are labelled as autopsy-negative sudden unexplained cardiac death (SUD). Still, when you look to the law, an autopsy, a much needed truth-finding-instrument, usually is not mandatory and is left up to the discretion of various medical or legal authorities, which when making a decision, balance various, often conflicting interests of the state and society on the one hand and of the deceased and his family on the other. Cardiac molecular autopsy calls for a close cooperation between medical examiner, pathologist, family physician, cardiologist, geneticist, and the relatives. Multidisciplinary approach and the identification of genetic cause of SUD enable proper genetic counselling for surviving relatives as well as for implementing specific preventive/therapeutic strategies, e.g. implantable cardioverter-defibrillator (ICD) implantation.

Se intentó el cierre percutáneo de la comunicación interventricular postinfarto (CIVPI) en 19 pacientes: 2 con recanalización tras el cierre quirúrgico y 17 con CIVPI primaria. En estos últimos, el procedimiento se realizó en 3 pacientes con CIVPI aguda dentro de las primeras 3 semanas postinfarto, en 13 con CIVPI subaguda 3,5-12 semanas postinfarto y en uno con CIVPI crónica. Se llevaron a cabo 22 intervenciones mediante la utilización de 17 oclusores Amplatzer auriculares, 2 ventriculares postinfarto y 2 ventriculares musculares. El procedimiento fue satisfactorio en 14 pacientes: 11 con CIVPI subaguda, uno con CIVPI crónica y 2 posquirúrgicos. El cierre percutáneo de CIVPI con el Amplatzer Atrial Occlusor es probablemente el tratamiento de elección en pacientes con más de 3,5 semanas después del infarto de miocardio y en casos con recanalización tras el cierre quirúrgico.

BackgroundPrevious randomized trials have shown beneficial effects of coronary stenting on restenosis and event–free survival rates. However, it has not yet been fully established if routine high–pressure stenting with an antiplatelet regimen can show similar results. MethodsWe compared the 6-month angiographic restenosis rate and 2-year event-free survival rate in 400 patients randomly assigned to stent or angioplasty. Aspirin and ticlopidine were prescribed in both groups. ResultsThe procedural success rate did not significantly differ between the stent and angioplasty groups (97.92% vs 97.45%, P= not significant). No stent thrombosis was found. The 6-month restenosis rate was lower in the stent group (18.18% vs 24.87%, P=.055). At 2 years target lesion revascularization rate was 17.19% in the stent group and 25.51% in the angioplasty group (P=.02, 33% reduction). No significant differences with regard to death and myocardial infarction were observed. Event–free survival rate at 6, 12, and 24 months was 86.77% vs 78.84%, 84.13% vs 76.70%, and 83.07% vs 73.54% for stent and angioplasty groups, respectively (P=.0172). ConclusionsThe 6-month angiographic and 2-year clinical outcomes were better in patients who received stent than in those after balloon angioplasty. The difference in 2-year event–free survival rate was explained by a reduction in target lesion revascularization rate in the stent group. (Am Heart J 2000;140:264-71.)

Introduction:Obesity is a component of metabolic health assessment and metabolic syndrome (MetS) diagnosis. In recent years, concept of "metabolically healthy obese" (MHO) emerged to describe obese patients, not meeting the MetS diagnostic criteria in contrast to metabolically unhealthy obese (MUO) subjects. The aim of this study was to investigate the differences between metabolome of MHO, MUO and healthy slim (HS) subjects enrolled to MAGNETIC (Metabolic and Genetic Profiling of Young Adults with and without a Family History of Premature Coronary Heart Disease) study.Methods:This analysis comprised on 94 men (MUO n=24, MHO n=24, HS n=46) aged 18-35 years without any chronic disease requiring pharmacotherapy. Patients on dietary supplements, or being on any special diet were excluded from analysis. We performed metabolic profiling of serum spectra with the use of 1HNMR spectroscopy (Varian 600MHz). Obtained spectra were binned using intelligent adaptive binning algorithm. Principal component analysis and partial least square analysis discriminant analysis were carried out on binned spectra to identify metabolites that differed between groups. Variable in projection score (VIP score) >2.0 was considered significant.Results:The metabolic signature of MUO was mainly associated with obesity and insulin resistance. Branched chain amino acids concentration and their metabolites as well as kynurenine pathway metabolite concentrations were higher in MUO group. Metabolome of MHO showed features between the MUO and HS signature, but in general reflecting higher level of metabolites associated with obesity as compared with HS.Conclusions:The results of the present study revealed that metabolic signature of the MHO subjects is closely related to the same metabolic pathways, as in the MUO group, what undermines the concept of metabolically healthy obesity.

Introduction:Despite a large number of meta-analyses confirming the lipid-lowering effect of several nutraceuticals little is known about their comparative efficacy. The aim of this meta-analysis was to investigate whether the use of specific nutraceuticals is more effective in improving plasma lipids than others.Methods:The eligibility criteria for included studies were defined as follows: a) participants aged?18 years, b) intervention with artichoke, berberine, bergamot, garlic, green tea, red yeast rice (RYR), silymarin, spirulina or soybean, c) placebo/no-intervention or other nutraceuticals as comparator, d) RCT (parallel or cross-over) and e) no co-administration of lipid-lowering agents. For each outcome of interest, a pairwise and frequentist network meta-analyses were conducted. A relative ranking of treatment effectiveness was obtained by calculating P-scores, which indicate the probability of being the best one.Results:A total of 146 trials, randomizing 17,240 participants to receive a nutraceutical (n=8784) or placebo/no-intervention (n=8456) were included. For reducing low-density lipoprotein cholesterol (LDL-C), RYR was identified as the most effective approach (P-score=96%), followed by berberine (92%) and spirulina (67%) in comparison to placebo/no-intervention. For increasing HDL-C, RYR was identified as the most effective approach (94%), followed by berberine (85%) and soybean (63%) in comparison to placebo/no-intervention. While evaluating total cholesterol reducing, red yeast rice was identified as the most effective approach (99%), followed by berberine (87%) and artichoke (74%) in comparison to placebo/no-intervention. Finally, for reducing triglycerides, RYR was identified as the most effective approach (96%), followed by berberine (92%) and spirulina (67%) in comparison to placebo/no-intervention.Conclusions:RYR is the most effective nutraceutical to improve lipid profile.

The aim of this study was to assess the influence of pre-hospital treatment with intravenous heparin on the early patency rate olthe infarct related artery in acute myocardial infarction. The inclusion criteria were: beginning of chest pain in the 6hours preceding admission, ST segment elevation ≥1mm in at least two leads of the standard ECG and no contraindications to antithrombotic treatment. One hundred and twenty four patients with these criteria were divided into 2 groups. Forty five patients (group I) were treated with 5,000 units of heparin i.v. before admission tD hospital. Seventy nine patients (group II) did not receive heparin before hospitalisation. All patients in both groups were put on Aspirin 150mg p.o., nitro-glycerine and analgesics before admission. The mean period from the beginning of the chest pain was 2.7±1.5 hour in group I and 2.8±1.4 hour in group II (p=NS). Both groups did not differ in relation to age, sex, risk factors and previous incidence of myocardial infarction. In the emergency room all patients were put on heparin and nitro-glycerine infusions i.v. and were transferred immediately to the catheterisation laboratory for coronary angiography. The flow through the infarct related artery was assessed according to the TIMI classification. Patent infarct related arteries (i.e. TIMI flow grade 1, 2 or 3) were observed in 19 patients (42.2%) in group I and in 18 (22.8%) in group II (p=0.038). Successful reperfusion (defined as TIMI grade 2 or 3) was present in 11 patients (24.4%) in group I and in 7 (8.8%) in group II (p=0.035).