Introduction: Components of the metabolic syndrome (MetSy) have gone through myriad of changes ever since the initial cluster was defined. The Seven Countries Study taught us the basics of classical risk factors for atherosclerotic artery disease and their influence on both cardiovascular and cerebrovascular morbidity and mortality. Material and Methods: In a 3-continent, 7-country (USA, Japan, Greece, the Netherlands, Finland, Italy, and former Yugoslavia then, now Croatia and Serbia) sample of 12,763 participants -- all healthy men over 40 at entry -- systematic, quinquennial checkups were conducted over 4 decades and MetSy was defined using the IDF definition. ResultS: A total of 9,09% of participants were identified to have MetSy, while the detailed description of risk factors' combination is shown in Table 1 and Figure 1, below. Conclusion: The leading combination was hypertension (HTA), diabetes (DM) and dyslipidemia (HLP), while hypertension was the hallmark risk factor irrelevant of presence or absence of MetSy. The results of this study call for a contemporary comprehensive research involving both sexes that could elucidate better real life risk factors' relationships in aforementioned countries.

Coronary collateral circulation exerts protective effects on myocardial ischemia due to coronary artery disease (CAD) and can be promoted by exercise (E) with heparin (H) co-administration. Whether this arteriogenetic effects is accompanied by functional improvement of left ventricle (LV) during stress remains unknown. To establish the stress-induced functional effects on LV regional and global function of 2-week cycle of H+E in patients with “no-option” CAD. In a prospective, single-center, double-blind, randomized, parallel-group study we recruited 32 “no-option” patients (27 males; mean age of 61±8 years), with stable angina and CTO, refractory to OMT, not suitable for revascularization and with E-induced ischemia. All underwent 2-week cycle of E (2 E test per day, 5 days a week) and were pre-treated with i.v. 0.9% saline or unfractionated H (100 IU/kg up to maximum of 5.000IU, 10 min prior to E). Canadian Class Score (CCS) and 12-lead E-ECG for time-to-1 mm ST-segment depression were assessed at entry and after treatment. LV function was evaluated during treadmill exercise with conventional and advanced imaging indices: Wall Motion Score Index (WMSI); Ejection Fraction (EF); Force (systolic blood pressure/end-systolic volume); Global Longitudinal Strain (GLS). Post-treatment exercise-time and CCS improved in both groups. In H+E patients exercise-time improved from 369.8±107.8 sec to 475.3±114.6 sec (p=0.001) while in E patients improved from 384±152.7 sec to 464.8±134.1 sec (p=0.019). CCS score changed in H+E from 2.6±0.7 to 1.9±0.7 (p=0.000), and in E group from 2.4±0.7 to 2.1±0.9 (p=0.046). At peak exercise, H+E was different from E group for EF and GLS (see Table). Effects of H+E on SE parameters H+E p P+E p *H+E vs P+E STRESS Time 0 vs Time 1 Time 0 vs Time 1 Time 0 Time 1 WMSI 1.377 vs 1.279 0.005 1.404 vs 1.376 0.290 0.626 0.255 EF (%) 60.9 vs 64.8 0.016 61.2 vs 57.8 0.284 0.943 0.016 Force (mmHg/mL) 6.36 vs 6.5 0.158 5.82 vs 4.68 0.209 0.760 0.098 GLS (%) −16.96 vs −18.50 0.001 −15.79 vs −15.60 0.380 0.325 0.027 SE = stress echocardiography; H+E = heparin+exercise; P+E = placebo+exercise; Time 0 = before randomization; Time 1 = after 2-week therapy cycle. *p values. A 2-week, H+E cycle is associated with improvement in regional and global LV function during exercise, concordantly shown by conventional (WMSI, EF) and advanced (GLS) echocardiographic indices of LV function. This integrates and supplements the classical objective index based on ST-segment depression, unable to localize and quantify the functional consequences of therapy on myocardial ischemia.

Heart failure is a major cause of morbidity, mortality and re-hospitalizations and is highly prevalent in myocardial infarction survivors. Cardiac rehabilitation based on exercise training and heart failure self-care counseling have each been shown to improve clinical status and clinical outcomes. We designed our study with aim to evaluate the usefulness of exercise based in house cardiac rehabilitation/ secondary prevention program in patients with heart failure with mid-range ejection fraction (HFmrEF) after myocardial infarction. Out of 2753 patients who were admitted to our three weeks in- hospital secondary prevention program – exercised based cardiac rehabilitation, we analyze a total of 219 patients who were admitted early after coronary revascularization (percutaneus coronary interventions or coronary bypass surgery) with HFmrEF. The majority of patients were males (68%). Risk factors and co morbidities were noted. Patients were selected for exercise training after six minute walking test or exercise stress test (cardiopulmonary dominantly to evaluate unexpected exertional dyspnea). After 3 weeks in house cardiac rehabilitation the patients were re-tested. The major comorbidities in our patient population were as follows: hypertension, diabetes and dyslipidemia. Six minutes walking test was performed and the total distance walked ranged from 120 to 480 meters and the beginning of the program. Patient had 7 -days a week training program. After the 3 weeks in hospital exercise rehabilitation the improvement in the test was ∼32%. Cardiopulmonary test showed also improvement of functional capacity.We noted several rhythm disturbance complications by telemetry (VES, SVES). None had acutisation of heart failure (with peripheral edema and congestion). All patients fulfilled cardiac rehabilitation program. Supervised multidisciplinary cardiac rehabilitation program, including an individualized exercise component is effective and can improve functional status and exercise tolerance in patient with HFmrEF after myocardial infarction.

Results of currently available randomized trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The 2018 ESC/EACTS guidelines on myocardial revascularization do not recommend PCI in patients with diabetes and SYNTAX score ≥23. We aimed to compare the all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics. The study group comprised consecutive diabetics with angiographically proven three-vessel CAD (≥50% diameter stenosis) and/or unprotected left main CAD (≥50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG between 2008 and 2010. All-cause mortality was ascertained by telephone contacts and/or from Mortality Registries. Using the hospital data system, 5145 patients were screened and 4803 elected not to follow the inclusion criteria. Out of 342 included patients, 177 patients underwent PCI and 165 patients were referred for CABG. Patients with whom CABG was performed were significantly older (64.69±8.8 vs. 62.6±9.4, p=0.03), more often on insulin treatment (91/165=55.2% vs. 26/177=14.7%, p<0.01), had more complex anatomical characteristics i.e. higher SYNTAX scores (32.5 IQR (15) vs. 18.0 IQR (15), p<0.01) and with left main stenosis (70/165=42.4% vs. 7/177=4.0%, p<0.01), compared to patients treated with PCI. The cumulative incidence rates of all-cause death were significantly different between PCI and CABG at 4 years (16/177=9.0% vs. 26/165=15.7%, respectively, log-rank p=0.03). There was a higher incidence of all-cause mortality in PCI patients with intermediate (23–32) and high (≥33) SYNTAX scores compared with those with low (0–22) SYNTAX scores (6/32=18.8% vs. 6/124=4.8%, log-rank p=0.01; 4/21=19.1% vs. 6/124=4.8%, log-rank p=0.02, respectively). On the contrary, patients who underwent CABG displayed similar morality rates irrespective of the SYNTAX scores (SYNTAX 0–22: 5/34=14.7%; SYNTAX 23–32: 9/54=16.7%; SYNTAX ≥33: 12/77=15.6%; log-rank p=0.9). Finally, when compared with CABG, more deaths were observed following PCI with intermediate and high SYNTAX scores (intermediate SYNTAX (23–32) PCI: 6/32=18.8% vs. CABG: 26/165=15.8%, log-rank p=0.94; high SYNTAX (≥33) PCI: 4/21=19.1% vs. CABG 26/165=15.8%, log-rank p=0.87). During a 4-year follow-up, CABG in comparison with PCI was associated with a higher rate of all-cause death, which can be accounted for by older age and comorbidities. In diabetics, our analysis is suggestive that PCI probably should be avoided in patients with SYNTAX ≥23, which is in concordance with the most recent guidelines. Individualized risk assessment as well as quantification of CAD by SYNTAX score remains essential in choosing appropriate revascularization method in patients with diabetes and complex CAD. None

AIMS The long-term outcomes of biolimus-eluting stents (BESs) with biodegradable polymer as compared with bare-metal stent (BMS) in patients with ST-segment elevation myocardial infarction (STEMI) remain unknown. METHODS AND RESULTS We performed a 5-year clinical follow-up of 1157 patients (BES: N = 575 and BMS: N = 582) included in the randomized COMFORTABLE AMI trial. Serial intracoronary imaging of stented segments using both intravascular ultrasound (IVUS) and optical coherence tomography performed at baseline and 13 months follow-up were analysed in 103 patients. At 5 years, BES reduced the risk of major adverse cardiac events [MACE; hazard ratio (HR) 0.56, 95% confidence interval (CI): 0.39-0.79, P = 0.001], driven by lower risks for target vessel-related reinfarction (HR 0.44, 95% CI: 0.22-0.87, P = 0.02) and ischaemia-driven target lesion revascularization (HR 0.41, 95% CI: 0.25-0.66, P < 0.001). Definite stent thrombosis (ST) was recorded in 2.2% and 3.9% (HR 0.57, 95% CI: 0.28-1.16, P = 0.12) with no differences in rates of very late definite ST (1.3% vs. 1.6%, P = 0.77). Optical coherence tomography showed no difference in the frequency of malapposed stent struts at follow-up (BES 0.08% vs. BMS 0.02%, P = 0.10). Uncovered stent struts were rarely observed but more frequent in BES (2.1% vs. 0.15%, P < 0.001). In the IVUS analysis, there was no positive remodelling in either group (external elastic membrane area change BES: -0.63 mm2, 95% CI: -1.44 to 0.39 vs. BMS -1.11 mm2, 95% CI: -2.27 to 0.04, P = 0.07). CONCLUSION Compared with BMS, the implantation of biodegradable polymer-coated BES resulted in a lower 5-year rate of MACE in patients with STEMI undergoing primary percutaneous coronary intervention. At 13 months, vascular healing in treated culprit lesions was almost complete irrespective of stent type. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique identifier: NCT00962416.

Background: Right ventricular dysfunction (RVD) is a well-known predictor of early death in patients with acute pulmonary embolism and thus early identification of RVD is critical in the risk stratification or management of acute pulmonary embolism (PE). Aim of this study was to investigate a useful role of cardiac biomarker NTproBNP for predicting echocardiographic right ventricular dysfunction in patients with acute pulmonary embolism. Methods: A retrospective analysis was performed in 195 consecutive adult patients with pulmonary embolism from the Serbian University Pulmonary Embolism Registry (SUPER 2015-2019) created by six university clinics: Military Medical Academy (Belgrade), Institute of Pulmonary Diseases (Sremska Kamenica), Clinical Center (Nis), University Clinic Zvezdara, Clinical Center (Kragujevac) and University Clinical Centre of Republic of Srpska (Banja Luka). All patients were divided into RVD group and non-RVD group according to whether there was increase in systolic pressure in right ventricle (>40mmHg) on echocardiography. Odds ratios (OR) and 95% confidence intervals (CI) assessing the risk factors for RVD were assessed by multivariate logistic regression. The ability of the NT proBNP in predicting the RVD was described by the Receiving Operating Curves analysis. Results: The mean age is a strong predictor of echocardiographic RVD in patients with PE. The simple measurements of this cardiac biomarker could be helpful in clinical decision-making or risk stratification in patients with PE.

Introduction: Postoperative Atrial Fibrillation (POAF) is associated with a higher rate of postoperative complications and mortality, as well as with longer hospitalization and increased treatment costs. We have designed and performed a randomized, trial of pharmacological prophylaxis in which the event of interest is POAF. Aim: The aim of this study is to reduce the risk of postoperative, complications associated with this arrhythmia. Methods: We included 240 stable patients with a coronary heart disease, who were referred to elective surgical revascularization of the myocardium. The patients were assigned into three groups of 80 patients each: group A (BB, beta blocker, comparator), group B (BB+ Amiodarone) and group C (BB + Rosuvastatin). The goal was to establish whether intervention by combination therapy was more useful than a comparator. Results: An event of interest (POAF) has occurred in 66 of the total 240 patients. Number of new POAF cases is the lowest in Group B, 14 (17.5%) compared to 25 (31.25%) new cases in the comparator group, and 27 new cases (33.75%) in group C. Absolute risk reduction was 13.75%, ≈14% less POAF in group B compared to comparator. Relative risk reduction was 56% (RR 0.56, p = 0.04). Number Needed to Treat was 7.27. In group C, 33.75% of patients developed POAF. Absolute risk was insignificantly higher in group C (2.5%, NS) compared to the comparator .The number needed to harm was high, 40. Conclusion: The results of our research show that prophylaxis of POAF with combined therapy BB + Amiodarone was the most efficient one.

Background/Aim. Decision-making by the Heart Team is an established way of making appropriate decisions regarding the management of patients with coronary artery dis-ease. In clinical practice, it is not infrequent to see changes in decisions made by different Heart Teams. However, clinical implications regarding changes in the Heart Team decisions are not clear. The aim of this study was to determine clinical implications of change in the Heart Team decision in patients in whom surgical myocardial revascularization was advised first but consequently changed to percutaneous coronary intervention (PCI). Methods. We retrospectively analyzed data for 1,501 patients admitted to a single tertiary care high-volume center for coronary artery bypass grafting (CABG). In all patients, decisions were made by the Heart Team prior to admission. Upon admission, decisions were reevaluated by another Heart Team. The decision regarding the mode of revascularization was changed in 73 (4.86%) of patients. Propensity matching was made with patients from the same population who underwent CABG. Patients in both groups were followed for major adverse cardiac events (MACE) and total mortality for 12 months. Results. PCI and CABG groups were balanced with respect to demo-graphic and clinical characteristics. All patients had two- and three vessel disease, with similar incidence of left main stenosis (26% in the PCI group and 30.10% in the CABG group). EuroSCORE II was similar between the groups (2.48 ? 2.38 vs. 2.36 ? 2.92). During the follow-up period, a total of 5 (6.80%) MACE in the PCI group and 12 (5.80%) MACE in the CABG group were observed (log rank 0.096, p = 0.757). A total of 6 (8.20%) patients died in the PCI group, and 15 (7.30%) patients died in the CABG group (log rank 0.067, p = 0.796). Conclusion. Our data indicate that patients in whom CABG was advised first but consequently changed to PCI have a prognosis similar to CABG patients over 12 months after the index procedure.

BackgroundThe effectiveness trial “Stress echo (SE) 2020” evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion.PurposeTo provide web-based upstream quality control and harmonization of B-lines reading criteria.Methods60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module (http://se2020.altervista.org). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics.ResultsAll 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01).ConclusionsWeb-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.