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Aim      A 12-month evaluation of the potentialities of the angiotensin II receptor inhibitor olmesartan (Olme) and the angiotensin receptor and neprilysin inhibitor (ARNI) sacubitril/valsartan in patients with arterial hypertension (AH) and dyslipidemia in the dynamics of the following indicators of chronic heart failure (CHF): N-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), LV global longitudinal strain (LV GLS) in diffuse myocardial fibrosis (MF) previously diagnosed by magnetic resonance imaging (MRI).Material and methods  Olmesartan medoxomil (n=56) and sacubitril/valsartan (n=63) were used for 12 months in patients with hypertension, dyslipidemia and NYHA functional class II-III CHF with mid-range LVEF (CHFmrEF). MF was diagnosed by the following MRI criteria: late gadolinium enhancement and an increased proportion of extracellular matrix (33% or more). The frequency of persisting late gadolinium enhancement and the increased proportion of extracellular matrix (33% or more) was evaluated at 12 months; changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), NT-proBNP, and LV GLS were evaluated after 3, 6, and 12 months of follow-up.Results Baseline parameters did not differ between groups. The late gadolinium enhancement and increased proportion of extracellular matrix were present at baseline in all patients of both groups (100%; p=1.0). Already at 3 months, statistically significant decreases in SBP and DBP were observed in both groups. In addition, the LV GLS monitoring showed LV GLS significantly increased in both groups after 3 months and continued changing after 6 and 12 months. The NT-proBNP concentration significantly decreased in both groups already after 3 months and continued to decrease after 6 and 12 months. At 6 and 12 months, sacubitril/valsartan was superior to olmesartan in reducing SBP and NT-proBNP and in restoring LV GLS. At 12 months, the incidence of persisting, abnormal late gadolinium enhancement and increased proportion of extracellular matrix was significantly less in the ARNI group.Conclusion      Olmesartan was demonstrated effective in the multi-modality therapy of CHFmrEF and MF in patients with AH and dyslipidemia. ARNI was superior to olmesartan in this regard, but further research of this issue is required.

Resistance to acetylsalicylic acid (ASA) in patients with coronary artery disease is a poor predictor for the development of atherothrombotic complications. In 277 patients with coronary artery disease suffered uncomplicated coronary angioplasty with stent implantation, we was estimated arachidon-induced platelet aggregation during treatment with acetylsalicylic acid by bedside VerifyNow Assay test at 28-90 days after the intervention. It was found that 18.9% of the 144 patients receiving a combination of ASA 75 mg with 15.2 mg of magnesium hydroxide had true (laboratory) resistance to ASA. At the same time on the original enteric coated ASA 100 mg, we can found only 0.8% resistance to ASA among 129 patients. We made switch from combination of ASA 75 mg with 15.2 mg of magnesium hydroxide to original enteric coated ASA 100 mg and repeat VerifyNow Assay test at 2-4 days and found lost of resistance in 92% of 28 patients. Thus, resistance to the ASA is not constant, it depends on the form and the applied dose of ASA, and eliminating more than 92% when ASA changes from ineffective to effective form.

Aim of the study was assessment of prognostic value of exercise myocardial perfusion scintigraphy in patients with stable and unstable angina in whom revascularization by percutaneous coronary intervention (PCI) was incomplete and at least one chronic total coronary artery occlusion (CTO) remained after PCI. Between March 2002 and December 2007 569 consecutive patients with multivessel lesions were subjected to SPECT imaging of myocardial perfusion after incomplete revascularization of the myocardium by PCI. At least 1 residual CTO was found in 129 patients (79% men, mean age 64+/-8 years). Primary outcomes were defined as cardiac death or myocardial infarction. Secondary outcomes were registered in 10 (7.9%) and 15 (11.9%) patients, respectively, with moderate and large transitory disturbances of perfusion. Logarithimic range criterion was statistically significant in patients distributed to groups by total estimation of rest in relation to cardiac complications. Univariate and multivariate Cox proportional hazards regression analysis gave additional important information for prediction of severe and nonsignificant cardiac complications when scintigraphic data were added to angiographic and clinical data, left ventricular ejection fraction, and results of treadmill test. Early monitoring with the use of myocardial scintigraphy by SPECT method is associated with increasing prognostic value relative to severe cardiac complications in patients subjected to incomplete revascularization by PCI, and having at least one residual chronic total occlusion.

There are controversial data on relatively unfavorable effect of female gender on postoperative mortality of patients underwent to coronary artery bypass grafting (CABG). In order to assess risk factors and hospital outcomes after elective CABG we studied retrospectively data on patients who had undergone CABG in Sani Konuogly medical center (Gasiatep, Turkey) during the period from March 2002 to March 2010. For elimination of unfavorable effect of old age we included into analysis data from patients younger than 65 years. In accordance with study aim all patients (n=2692) were divided into two gender groups 1966 men (mean age 54,01 years) and 726 women (mean age 54.35 years). Diabetes (48.3 and 26.9%; p=0.0001), arterial hypertension (76.6 and 28.4%; p=0.00001), and obesity (50 42%; p=0.03) were more frequent among women while smoking (44.5 and 10.3%; p=0.0001), hyperlipidemia (37.6 and 21.5%; p=0.0002), and history of myocardial infarction (31.3 and 17.3%; p=0.06) were more often registered among men. Mortality was insignificantly higher in women (1.6 and 0.9%; p=0.06). Perioperative Q-wave myocardial infarction was more frequent among men than among women (1.5 and 0.4% respectively; p=0.04). It is necessary to conduct prospective well controlled study for exclusion of gender influences on perioperative outcomes in patients subjected to CABG .

Introduction: Effect on left ventricular (LV) contractility of percutaneous coronary interventions (PCI) with implantation of bare-metal stents in patients with chronic total occlusions (CTO) of coronary arteries (CA) has not been completely studied. Aim of this study was to assess effect of PCI with implantation of bare-metal stents ("L+", Relisys, U) on LV ejection fraction (EF) and to investigate clinical and angiographical factors capable to affect restoration of LVEF., Material and Methods: We included in this study 154 patients after successful implantation of bare-metal stents in CTO of main epicardial CA. For assessment of LV function we performed echocardiographical examination before and in 6 months after PCI., Results: Significant increase of LV EF (from 50.4 +/- 10.7 to 56.1+/-11.3%, p<0.0001), decreases of LV end diastolic (from 86.2+/-17.9 to 80,8+/-18,1 ml/m2, p<0.001) and end systolic (from 41.4+/-14.9 t 34.7+/-13.8 ml/m2 (p<0,001) volumes took place after implantation of stents. Multivariate analysis showed that initial LVEF <50%, duration of occlusion <2 months and absence of diabetes mellitus were independent predictors of improvement of LVEF., Conclusion: Implantation of bare-metal stents in patients with CTO CA affects positively LVEF during first 6 months after PCI especially in patients with lowered LVEF, in patients without diabetes mellitus, and duration of occlusion less or equal 2 months.

We implanted 59 paclitaxel eluting Apollo stents to 48 patients with ischemic heart disease (IHD) and long de novo coronary artery lesions in 2007 with 100% immediate success rate without inhospital major cardiac complications. One patient developed hematoma at femoral artery puncture site. There were no cases of restenosis among 18 patients subjected to control angiography after 6 months. One patient had acute myocardial infarction in area supplied by nontarget artery. Control angiography after 12 months was carried out in 81.3% of patients while 14.6% of patients who refused angiography were examined with stress tests. Restenosis of stented segments was found in 3 (5.3%) patients, diameter loss was 0.32+/-0.45 mm. All these patients were subjected to repeat PCI. During follow up myocardial infarctions were registered in 4.2% of patients, overall rate of serious cardiac complications was 11.6%. PCI with implantation of paclitaxel was safe and effective with acceptable rate of major cardiac complications. Our results evidence in favor of further use of these stents.

In a series of articles the authors consider clinical pharmacology and experience of clinical application of blockers of platelet P2Y12 receptors, most well known representatives of which ticlopidine and clopidogrel according to chemical structure belong to thienopyridine derivatives. In the fifth communication we consider data of two randomized studies in which efficacy and safety of clopidogrel in combination with acetylsalicylic acid (ASA) has been assessed in comparison with ASA in stable patients with atherothrombotic cardiovascular disease. It has been shown in both studies that in stable patients with atherothrombotic cardiovascular disease long-term therapy with combination of clopidogrel and ASA was no more effective than monotherapy with ASA or clopidogrel but was associated with high risk of hemorrhagic complications. Thus contrary to acute coronary syndromes and percutaneous interventions with stenting combinations of clopidogrel and ASA is not indicated to patients with stable course cardiovascular diseases.

Aim of investigation was to study complications during 3 years follow up of patients after implantation of standard metal stents (SMS) in unprotected left main coronary artery (LMCA). Patients with high risk of surgery (n=124) with stenting of unprotected LMCA performed between August 2002 and November 2004 were included in this investigation. Study end points were death, myocardial infarction, repeat vessel revascularization. Success of intervention was achieved in 96.7% of cases. Mean duration of follow up was 38.1 +/- 1.8 months. Death due to cardiac causes was registered in 6.5% of cases, 3 of these deaths were sudden. Noncardiac mortality was 3.2% (4 patients died). Peripheral complications were noted in 1 case: in one patient pseudoaneurism of femoral artery developed and was successfully resolved by compression under ultrasound control. Restenosis in stented segment during follow up was noted in 25 patients (20.2%). Repeat percutaneous coronary intervention (PCI) was carried out in 18 patients. In other cases patients were referred to coronary bypass surgery. Total survival of patients in the investigation was 95.2, 91.9, 90.3% in 1, 2, an 3 years, respectively. Despite high success of PCI of unprotected LMCA with the use of SMS and relatively low percent of restenosis it is necessary to use this method carefully in the treatment of patients with lesions in unprotected LMCA. We consider PCI in unprotected LMCA justified only in patients with high risk of surgical intervention who are not suitable candidates for coronary bypass surgery.

Introduction: Little is known of the clinical significance of myocardial bridges, which may be recognised as the narrowing of the systolic coronary artery as seen in an angiography. In this study, our goal was to review the literature information about the anatomic aspects, the clinical manifestations and implications, and the angiographic characteristics., Materials and Methods: The angiographic data of 7200 adult patients undergoing coronary angiography were retrospectively analysed for the diagnosis of myocardial bridge. The main angiographic evidence of a myocardial bridge that we required was the narrowing of a systolic coronary artery resulting in at least 50% reduction of lumen diameter in comparison with the diastolic phase. All coronary angiograms were reviewed independently by at least 2 of the authors and the case was included only if there was a consensus that the myocardial bridge resulted in 50% narrowing or more., Results: Myocardial bridge was present in 29 (0.4%) of the 7200 coronary angiographies. The location of the myocardial bridge was in the left anterior descending coronary artery in 28 cases (96.5%), and the left circumflex coronary artery in 1 case (3.4%). Myocardial bridge was most common in the middle segment of the left anterior descending coronary artery (78.5 %). Each of these patients with myocardial bridge was referred for angiography because of symptom of chest pain alone or symptom of chest pain, palpitations and dyspnoea. Of the 29 patients with myocardial bridge, 2 patients without any symptom, demonstrated ischaemia as assessed by Tc- 99m MIBI myocardial perfusion scintigraphy., Conclusion: Chest pain was the common reason for angiography in patients with myocardial bridge. The incidence of myocardial bridge may vary according to population. Myocardial bridge is more frequently found in the middle segment of the left anterior descending coronary artery.

The purpose of this investigation was to assess the effects of acute hypoxia on left (LV) and right ventricular (RV) contractility in clinically stable chronic obstructive pulmonary disease (COPD) patients. Eleven male patients (mean age 52.4 +/- 12.6 years) who were diagnosed to have COPD were included into the study. All of the patients underwent left and right heart catheterization. RV contractility was measured according to the method of Ferlinz and LV contractility according to the method of Kennedy and colleagues using indirect digital substraction angiography. Mean pulmonary artery pressures (Mean PPA) and oxygen saturation of the pulmonary artery (SaO2) were measured before and at each stage of graded hypoxic exposure 14%, 12%, and 10% of O2. Right atrial pressures (PRA,syst, PRA,diast, PRA,mean), RV pressures (PRV,syst, PRV,diast, PRV,mean, PRV,end-diast), RV and LV end-diastolic volume index (EDVI), end-systolic volume index (ESVI), stroke volume index (SVI), cardiac index (CI), ejection fraction (EF), and heart rate (HR) were calculated before and after breathing a hypoxic mixture of 10% of O2 for 30 minutes. Acute hypoxia induced significant elevation of mean PPA, PRA,syst, PRA,diast, PRA,mean, PRV,syst, PRV,mean, PRV,end-diast, RV EDVI, RV ESVI, LV EDVI, LV ESVI, confidence interval, and HR (p < 0.05). Whereas SaO2 decreased significantly after acute hypoxia (p < 0.05). These findings suggest that the systolic performance of the right and left ventricles were well-maintained during acute hypoxia in patients with COPD.

Potential of bare uncoated metal stents in prevention of restenosis in coronary arteries with diameter of 2.2-3.0 mm in comparison with balloon angioplasty (BA) was studied in 426 patients with ischemic heart disease (mean age 58+/-11 years, 16% women, 8% with diabetes, total cholesterol 211+/-44 mg/dl, all received aspirin and clopidogrel). BA was carried out in 214 patients (mean artery diameter 2.45+/-0.25 mm) and coronary stenting (CS) - in 212 patients (mean artery diameter 2.43+/-0.27 mm). Immediate success rate was 85.5 and 96.2% in BA and CS groups, respectively (p<0.001). When complementary methods of revascularization were taken into account success rate of the whole intervention was 100% in both groups. Inhospital cardiovascular complications developed in 3.7 and 2.8% of patients in BA and CS groups, respectively (p=ns). During 6 months of follow-up rates of target vessel restenosis and repeat percutaneous interventions were 24.3 and 15.6% (p=0.034) while total rate of complications related to target vessel was 36.9 and 26.9% in BA and CS groups, respectively (p=0.035). Thus CS compared with BA in patients with low risk of restenosis development in small coronary arteria provides better immediate, inhospital and remote results.

Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions. Aim of this study--to assess inhospital and long term outcomes in patients in whom perforation occurred during coronary intervention and elucidation of predictors of coronary artery perforation. Between May 1997 and October 2002 perforations were formed in the course of percutaneous interventions in 127 patients what amounted 1.08% of 11,793 patients, subjected to coronary interventions, and 0.77% of 16,494 treated coronary segments. Causes of perforations were complex stenoses, chronic occlusions, calcified lesions, small predicted and minimal vessel lumen, high percent stenosis, use of excimer laser or thromboextrator. Rates of arterial perforations and subsequent adverse events including cardiac tamponade and urgent coronary artery bypass surgery as well as mortality had been declining throughout observation period.

Left main coronary artery dissection occurs very rarely during selective coronary angiography, but it generally progresses to complete coronary occlusion. The traditional treatment of occlusive dissection of the unprotected left main coronary artery has been surgical. Percutaneous treatment has been sporadic and controversial. We report a case of iatrogenic occlusive dissection of the unprotected left main coronary artery during diagnostic coronary angiography, followed by successful stenting of the lesion.

Unlabelled: The authors assessed the in-hospital and long-term (up to 6 months) results of coronary stenting conducted just after diagnostic coronarography during a common procedure in patients with stable angina pectoris on effort. The 2001-2002 study included 2277 patients. The clinical indications for catheterization were Functional Classes II-IV stable angina on effort in 83 % of patients and silent ischemia in 17%. The study excluded patients with previous coronarography, acute coronary syndrome on admission, renal failure, left ventricular ejection fraction <30%, and left trunk stenosis. All the patients received aspirin and clopidogrel before catheterization., Results: 57% of patients had multivessel disease; full revascularization was performed in 59% of the patients with multivessel disease. The coronary intervention was successful in 100% of cases. Significant in-hospital events (myocardial infarction without Q wave) were in 1.2% of cases. The mean length of hospital stay was 2.9 +/- 2.4 days. The rate of stent thrombosis for as long as 30 days was 0.2%. Recurrent angina and/or positive exercise tests were in 12% during 6 months., Conclusion: immediate stening is effective and safe in most patients with stable angina during diagnostic catheterization. It does not increase immediate and late complications.

In Turkey as well as in the whole world, cardiac catheterization is an invasive intervention that is being increasingly used both for diagnosis and treatment. With technological and pharmacologic development and experience, the indications for this intervention are ever increasing. This invasive intervention brings, of course, some complications with it. These may range from local ones to death. In this study the authors analyzed the local cardiac complications and those related to other systems that they encountered in 10,445 catheterizations conducted for diagnosis and treatment in their clinic over a 26-month period. They found the rate of all complications to be 3.54% (2.05% diagnostic, 9.1% therapeutic). Of these complications, 1.89% (0.80% diagnostic, 6.02% therapeutic) were cardiac, 1.27% (0.97% diagnostic, 2.4% therapeutic) local. They found that the ratios of death were 0.09% for diagnostic interventions, 1.13% for therapeutic interventions, and 0.31% altogether. In the diagnostic group 0.02% required urgent coronary bypass surgery, and 0.41% needed urgent coronary bypass surgery in the therapeutic group. In conclusion, despite the noticeable changes in patient profile and application, the ratios for cardiac catheterization have changed little over the years.

The stent was placed in 528 coronary artery segments (39% complicated lesions) in 448 patients with coronary artery disease and no previous invasive interventions. Immediate angiographic success was 99.8% with no case of acute thrombosis. Six months survival without restenosis, angina, and reintervention was 83%. Repeat angiography was carried out in 432 patients with 502 stented stenoses. Index of vessel diameter loss and level of restenosis were 0.32+/-0.26, and 15,6%, respectively. Fifty four patients with in-stent restenosis were subjected to successful repeat revascularization. Eighteen months survival without myocardial infarction and reintervention was 70%. The study demonstrated favorable effect of TAIS on 18 month rate of thrombosis and restenosis in patients with native atherosclerotic lesions.

Bicycle exercise tests were carried out in 2 weeks -- 9 months after successful stent implantation in 1463 patients. Result of exercise test was positive in 472 and negative -- in 991 patients. At control angiography which was performed within 1 week after exercise test binary in-stent restenosis >50% was found in 326 of 1463 patients. Sensitivity, specificity, predictive value of positive and negative results of exercise test for the presence of restenosis were 85, 83, 59 and 5%, respectively.

Aim: To evaluate two-year results of using a metallic stent EPHESOS in patients with native atherosclerotic lesion of coronary arteries (without prior interventions)., Material and Methods: The stent was implanted to 731 patients. 53% had manifestations of unstable angina. 42% of the lesions were complicated. The length of the stenosis was 15.5 +/- 6.8 mm, 44% stenoses were long., Results: The success of stenting was 99.6%. Cases of acute and subacute thrombosis were absent. Non-Q wave myocardial infarction in primary hospitalization developed in 4 patients. For 6 months, cardiovascular complications (death, angina, restenosis, repeated revascularization) occurred in 21%. Angiographic control follow-up of 6 months maximum covered 329 (45%) patients. Hemodynamically significant restenosis was detected in 18% patients. Cardiovascular complications for 24 months occurred in 39%., Conclusion: The EPHESOS stent has demonstrated a stable long-term effect on prevention of thrombosis and restenosis in the majority of patients with a relatively high risk of intervention.

The authors present a review of research works completed or conducted in 2003 which according to their opinion contributed most to the rapidly progressing field of invasive/interventional cardiology. The year passed was characterized by wide introduction into clinical practice of stents coated with antirestenotic agents, substantial advances in pharmacological support and improvements of safety of coronary interventions, active studies of contrast induced nephropathy and assessment of novel devices for myocardial protection against distal embolism during interventions both on coronary arteries and vein grafts. Recent results of comparisons of mechanical and pharmacological myocardial reperfusion in acute ST-elevation myocardial infarction can be considered revolutionary for clinical cardiology. Part I of the review deals with invasive treatment of acute coronary syndrome and pharmacological support of coronary interventions.

Aim: To assess frequency of unstable angina due to restenosis after percutaneous angioplasty of venous grafts and to elucidate risk factors of its development., Material and Methods: Percutaneous interventions were successfully performed in 100 out of 106 patients with venous graft stenoses. These patients were followed up for 17+/-11 (maximum 36) months., Results: Unstable angina due to venous graft restenosis developed in 24% of patients. Patients with unstable angina compared with those without were characterized by higher frequency of hyperlipidemia (83 vs. 51%, respectively, p=0.032), lower rate of stenting (46 and 72%, respectively, p=0.032), greater residual stenosis (15+/-13 and 9+/-8%, respectively, p=0.008). At multifactorial regression analysis the following factors were significant predictors of unstable angina: hyperlipidemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.64-8.39), and residual stenosis after intervention (OR 1.04, 95% CI 1.01-1.07, p=0.04). In a subgroup of patients with hyperlipidemia there was a tendency to greater rate of unstable angina among patients not taking statins compared with users of statin (50 and 29%, respectively, p=0.083)., Conclusion: Unstable angina developed in (1/4) of patients after balloon dilatation of venous grafts and hyperlipidemia was its most powerful predictor.

Aim: To elucidate factors related to acute vessel closure (AVC) after transluminal coronary intervention., Methods: From population of 10439 patients subjected to transluminal coronary intervention 2 groups were formed: with (n=885) and without (n=885) acute vessel closure (AVC). Twenty five clinical, angiographical and procedural characteristics of patients of these 2 groups were included into mono and multifactorial logistic regression analysis., Results and Conclusion: The following factors were univariate predictors of acute vessel closure: smoking [odds ratio (OR) 1.42], unstable angina (OR=2.130, acute myocardial infarction within previous 24 hours (OR 2.76), cardiogenic shock (OR 4.31), urgent procedure (OR 1.94), eccentric stenosis (OR 1.67), calcified lesion (OR 2.21), preexisting thrombosis (OR 3.79), lacerated complicated stenosis (OR 2.02), tortuous lesion (OR 1.35), low operator experience (OR 3.37), balloon angioplasty as sole procedure (OR 1.66), concomitant rheolytic thrombectomy (OR 1.95), urgent stenting (OR 1.45). Elective stenting significantly lowered risk of acute vessel thrombosis. Multifactorial step-up analysis selected the following independent predictors of AVC: smoking, acute myocardial infarction within previous 24 hours, cardiogenic shock, preexisting thrombosis, lacerated complicated stenosis, and concomitant rheolytic thrombus extraction. Thus only elective stenting significantly reduced risk of AVC.

Objective: Autonomic neuropathy and impairment of left ventricular functions (LVF) have been frequently encountered in chronic renal failure (CRF). The aim of the present study was to evaluate the relationship of cardiac autonomic modulation impairments, as assessed by means of heart rate variability (HRV), with clinical characteristics, and left ventricular function in the patients with CRF undergoing hemodialysis (HD)., Methods: Twenty control subjects (Group I) and 22 comparable by age and gender patients with CRF undergoing hemodialysis (Group II) were enrolled in the study. After routine clinical and biochemical evaluations, electrocardiography, and 2 Dimensional, M Mode echocardiography were performed in all participants. Frequency domain HRV analysis was studied by using Kardiosis System. The powers (P1 and P2) and the central frequencies (F1 and F2) of low and of high frequency spectral bands were recorded., Results: End systolic (ESV) and end diastolic volumes (EDV) were significantly higher in Group II (59.3 +/- 21.1mL vs. 34.0 +/- 14.3 mL and 131.5 +/- 37.3 mL vs. 96.9 +/- 18.9 mL, p < 0.01, p < 0.05, respectively) when compared to those of Group I. Ejection fraction (EF) and fractional shortening (FS) were significantly lower in Group II than in control subjects (52.3 +/- 2.4% vs. 63.7 +/- 10.1% and 0.29 +/- 0.01 vs. 0.34 +/- 0.07, p < 0.001, p < 0.05, respectively). P and P2 were decreased in Group II than in Group I (136.2 +/- 173.9 m s2 vs. 911.0 +/- 685.5 and 96.5 +/- 149.6 vs. 499.7 +/- 679.5, p < 0.001, p < 0.01, respectively). Significant correlations were found between high frequency spectral power and dialysis duration (DD), ESV, EDV, EF, FS (r = 0.52 p < 0.01, r = 0.68 p < 0.001, r = 0.65 p < 0.002, r = 0.66 p < 0.02, and r = 0.69 p < 0.01)., Conclusion: As a result, the dependence of cardiac autonomic neuropathy on the disease duration and degree of left ventricular function impairment was shown in the patients undergoing chronic hemodialysis.