Aims Widespread availability of tertiary hospitals with catheterization facilities, although vigorously promoted, has yet to become a reality in many countries with economy in transition. We sought to evaluate the clinical profile and mortality of patients who were hospitalized with a diagnosis of ST-segment elevation myocardial infarction (STEMI) and either received reperfusion therapy or remained without reperfusion in Eastern Europe. Methods and results Data were obtained from the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC; NCT01218776) on STEMI patients admitted to 57 hospitals in Eastern European countries from January 2010 to February 2015. The primary endpoint was 30-day mortality. Of 7982 patients, 65 (0.8%) had a documented contraindication to reperfusion, 5973 (75.5%) received fibrinolysis ( n = 1032) or underwent primary percutaneous coronary intervention (p-PCI; n = 4941), and 1944 patients (24.6%) did not receive any reperfusion therapy. The overall unadjusted 30-day mortality rate was 7.9%. Thirty-day mortality rates were higher in non-reperfusion patients (16.0 vs. 5.0% in the p-PCI group and 7.4% in fibrinolysis group). The strongest factors associated with not attempting reperfusion therapy among these patients were female sex (OR 1.29 CI 1.07-1.56), age (OR 1.02; CI 1.01-1.03), prior MI (OR 1.79; CI 1.38-2.32), prior cerebrovascular events (OR 1.87; CI 1.30-2.68), chronic kidney disease (OR 1.76; CI 1.22-2.53), Killip class >1 (OR 1.31; CI 1.06-1.62), and time to admission >12 h (OR 15.9; CI 13.1-19.3). Conclusions A substantial number of patients are still not offered any reperfusion therapy in many Eastern European countries with economy in transition, and this was associated with increased 30-day mortality. Time from symptoms onset to admission >12 h was the highest ranking among factors related to lack of reperfusion therapy. Quality improvement efforts should focus on minimizing delay to hospital admission among STEMI patients.

Introduction: There is controversy whether there are sex differences in mortality following ACS. Hypothesis: Comparisons are confounded by the lower likelihood of obstructive CAD in women than men, and by the less frequent use of coronary angiography, revascularization and evidence-based therapies. All of these factors may affect prognosis. Methods: The International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC, NCT01218776), enrolled 6811 ACS patients (4908 men and 1903 women) who underwent coronary angiography during their hospitalization. We investigated sex differences in-hospital mortality among patients with confirmed obstructive CAD, defined as ≥50% stenosis in ≥1 epicardial coronary artery. Cox proportional hazards regression model was adjusted to covariates significantly different between groups in univariate analysis. The primary endpoint was in-hospital death; the secondary endpoint was the composite of in-hospital death, stent thrombosis, and stroke or major bleeding. Results: Among patients who underwent coronary angiography, the majority had obstructive CAD (6531/6811, 95.9%). Women (1786/1903, 93.9%) with obstructive CAD had a higher rate of death than men (6.4% vs. 3.2%, p Conclusions: Women with ACS and documented obstructive CAD have higher short term mortality despite adjustment for clinical factors, revascularization and evidence-based therapies as compared with men. These data suggest that knowledge of coronary anatomy and treatment variables are critical to the accurate assessment of differences in outcomes among ACS women and men.

Introduction: Previous works have shown that women hospitalized with STEMI have higher short-term mortality rates than men. However, it is unclear if these differences persist among patients undergoing contemporary primary PCI. Hypothesis: We sought to investigate whether the risk of in-hospital death after STEMI is higher in women than men and, if so, to assess the role of age, medications and primary PCI in this excess of risk. Methods: From January 2010 to May 2014, a total of 6690 patients have been hospitalized and received medical treatment for STEMI in 57 hospitals, referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776). Logistic regression model was adjusted to covariates significantly different between groups in univariate analysis. The endpoint was in-hospital mortality after STEMI. Results: There were 2070 women and 4620 men. Women were older than man, with a higher prevalence of risk factors and comorbidities. Fewer wo...

INTRODUCTION The aim of the current study was to investigate the outcomes of coronary reperfusion therapies and ST-segment elevation myocardial infarction (STEMI) in patients of Eastern countries with economies in transition. Federation, and Serbia. The overall population consisted of 23,486 consecutive patients admitted to hospitals from January 1(st) to December 31(st) 2009. Registry data and statistics from the Organization for Economic Cooperation and Development (OECD) countries for the same period were used for comparison (2009-2010). In-hospital mortality was between 4% and 5% in the Western countries. In comparison mortality data were significantly larger in Serbia (10.8%) and Bosnia and Herzegovina (11.2%), intermediate in Russian Federation (7.2%) and similar in Hungary (5.0%). The rates of primary percutaneous coronary intervention (primary PCI) were very low in Bosnia and Herzegovina (18.3%), low in Russian Federation (20.6%) and Serbia (22%), and high in Hungary (70%). Major risk factors for death appear to be lack of reperfusion therapy, longer time delay from symptoms onset to hospital presentation as well as the higher percentage of patients with clinical presentation in Killip class III/IV. CONCLUSION In-hospital STEMI case-fatality rates ranges widely in the former Eastern Bloc countries. Beyond the quality of care provided in hospitals, differences in time delay from symptoms onset to hospital admission may strongly influence STEMI patients' outcome.

We sought to investigate characteristics, treatment, and outcome of octogenarian patients during hospital stay for acute coronary syndrome (ACS) in a transitional country. This is a cohort study of 437 patients ≥ 80 years old, consecutively admitted with a diagnosis of ACS at 14 hospitals in 8 Eastern European countries reporting data to ISACS-TC registry. The primary endpoint was in-hospital mortality. The mean age of the study population was 83.5 years; 50.1% of the patients were women. Females, less frequently than males, had a history of myocardial infarction, smoking habit, and episodes of typical chest pain. But they were more often admitted with left ventricular dysfunction. The rate of reperfusion treatment (29.5%) was very low in patients with ST-elevation myocardial infarction (STEMI). Also, most of the overall study population had a non-invasive approach (women, 79% vs. men, 70.6%; P = 0.042). However, when the coronary anatomy was known, there were no differences in the rates of revascularization between genders. There was no difference in the rates of death between male (21%) and female (21.1%) patients. Univariate and multivariate analyses revealed that the independent predictors ( P < 0.05) of death in octogenarians were systolic blood pressure <100 mmHg (odds ratio [OR], 2.74), Killip class ≥ 2 (OR, 1.71), and STEMI as an index event (OR, 2.01). Evidence-based drugs (beta-blockers, statins, and ACE-inhibitors) had all independent significant protective effect on the hospital outcome. In conclusion, age is relevant in the prognosis of ACS, but its importance should be considered not secondary to other clinical factors.

There is little information about coronary reperfusion therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the former federal states of Yugoslavia. The objective of this study was to evaluate the clinical profile and mortality of patients who were hospitalized with a diagnosis of STEMI, but did not receive reperfusion therapy in Bosnia and Herzegovina and Serbia. This was an observational study using registry data from the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC; ClinicalTrials.gov, [NCT01218776][1]) on 633 STEMI patients admitted to 14 hospitals in Bosnia and Herzegovina (both Republic Srpska and Federation of Bosnia and Herzegovina) and Serbia from October 2012 to September 2013. Of these, 61 (9.6%) received fibrinolytic therapy (Group A), almost exclusively with streptokinase (79.3%), 402 (63.5%) underwent primary percutaneous coronary intervention (PCI; Group B), and 170 (26.9%) received no-reperfusion therapy (Group C). In Groups A, B, and C, mean age was 60.3, 60.5, and 69.1 years, respectively. Patients in Group C were more likely to present after 12 h from symptoms onset (61.3 vs. 13.6% in Group A, and 13.4% in Group B). After adjustment for risk factors and clinical presentation, female sex, age, diabetes, prior MI, and symptom onset-to-presentation time after 12 h were all independent variables associated with no-reperfusion therapy. There was a significantly reduced in-hospital mortality in patients who received reperfusion therapy with fibrinolysis or primary PCI (odds ratio: 0.27, 95% confidence interval: 0.09–0.76, P = 0.01). The majority of STEMI patients from Bosnia and Herzegovina and Serbia undergo reperfusion therapy with fibrinolysis or primary PCI. More than one-fourth of the patients do not received any reperfusion therapy. Reperfusion therapies are applied to relatively lower risk patients . More elderly and diabetics should be considered for such strategies. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01218776&atom=%2Fehjsupp%2F16%2Fsuppl_A%2FA67.atom

Cardiologia CROATICA Aim of this article is to present the state-of-the-art antithrombotic therapy for the secondary prevention of cardioembolic stroke due to new ESC, ACC, and ACCP guidelines which are the key-opinion guidelines in atrial fibrillation (AF). The statements are based on CHADS2 scoring calculation as well as newly developed CHA2DS2-VASc. Statements: for the patients (pts) with a history of ischemic stroke (IS) or TIA and AF, including paroxysmal AF, guidelines recommend oral anticoagulation (Grade IA), aspirin (Grade IB), or aspirin and clopidogrel (Grade IB). In pts with a history of IS or TIA and AF, guidelines suggest dabigatran 150 mg bid over adjusted-dose VKA (INR 2.0-3.0) (Grade IIB). ESC guidelines recommend for pts with CHA2DS2VASc Score 2, VKA therapy (INR 2,0-3,0), or direct thrombin inhibitor dabigatran, or an oral direct Xa factor inhibitors — rivaroxaban or apixaban (Grade IA). In pts with a history of IS or TIA and AF, who are unsuitable for or choose not to take an oral anticoagulant, guidelines recommend dual therapy, aspirin and clopidogrel (Grade IB). Recommendation is that oral anticoagulation should generally be initiated within 1 to 2 weeks after stroke onset. Earlier anticoagulation can be considered for pts at low risk of bleeding complications i.e. patients with a small infarct burden and no evidence of hemorrhage on brain imaging. Delaying anticoagulation should be considered for pts at high risk of hemorrhagic complications — those with extensive infarct burden or evidence of significant hemorrhagic transformation on brain imaging. In patients with a history of noncardioembolic IS or TIA, guidelines recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended-release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) (Grade IA), VKA (Grade IB), the combination of clopidogrel plus aspirin (Grade IB), or triflusal (Grade IIB). Of the recommended antiplatelet regimens, guidelines suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade IIB) or cilostazol (Grade IIC). Conclusions: It is an ongoing trend that recommendations follow CHADS2 scoring calculation as well as CHA2DS2VASc Score. Standard of care is based on net clinical benefit i.e. balance between clinical/prevention benefit and safety profile. Still there is a question mark: what to suggest for patients who are unsuitable for oral anticoagulants, for reasons other than major bleeding risk.

2013;8(9):287. Cardiologia CROATICA Heart failure (HF) is one of the most rapidly increasing cardiovascular disorder with unacceptably high mortality and readmissions rate. One possible solution to this problem could be the accurate assessment of prognosis of every single patient and personalized i.e. tailored therapeutic strategy, follow-up and allocation of resources according to the needs of each patient and thus improvement of the overall survival. But in real clinical practice we don’t have clear recommendations how to adequately determine a prognosis. The situation has become more complex with recognition of HF with preserved ejection fraction; we don’t know if we need separate prognostic model apart from HF with reduced EF. One possible reason for inadequate estimation of prognosis could be a fact that conventional predictors do not reflect newly discovered ongoing mechanisms in HF: inflammation, oxidative stress, neurohormonal activation, myocyte stress, injury and apoptosis, excessive or inadequate proliferation of the extracellular matrix. Biomarkers released in the above mentioned processes could be potential new predictors of survival in HF. As it is used alone, single biomarker reflects only one ongoing process, but when used in combination they may become helpful in estimating prognosis and selecting an appropriate therapy. So the next logical step would be clustering biomarkers in multimarker panel in a way to optimise its use in assessing a prognosis. Multimarker approach could be a step toward tailored therapy for every patient based on the individual biomarker signal, i.e. biomarker patient’s fingerprint. We hypothesized that combination of the next 4 biomarkers reflecting different pathological pathways in HF would improve prediction of survival: 1. BNP (myocytes stress), 2. troponin (myocytes injury), 3. cystatin C (renal function, ventricular remodelling and excessive interstitial fibrosis) and 4. tumor marker CA 125 (congestion and inflammation). It would be an interesting topic of future studies to see if the applied therapy could change the patient’s biomarker fingerprint. Also there is an idea that the integration of different echocardiographic variables and biomarkers could have incremental, additive predictive value in estimating survival. Conclusion: The combination of novel biomarkers in HF and echocardiographic parameters beyond left ventricle could play an important role in the prognosis and treatment of patients and may have a potential to reduce readmission rates and mortality.

Cardiologia CROATICA Objectives: The aim of this article is to investigate the relationship between the degree of the common carotid artery (CCA) atherosclerosis and the degree of complexity of the coronary artery disease (CAD) expressed with SYNTAX score. It is known that the existence of the CCA disease indicates with high probability the existence of CAD, but few studies have examined the relationship between CCA ultrasound findings and complexity, not just the presence of CAD. Patients and Methods: We included a total of 106 consecutive patients referred to the BH Heart Center for elective coronary angiography. In order to measure and calculate the mean intima-media thickness (IMT) we performed three measurements in predefined segments of CAA for both carotid arteries, the values are converged, and divided by the number of measurements. Plaque score (PS) was measured on the basis of maximum thickness of plaque in four clearly defined segments of both CCA. The final value of PS score is obtained by adding the thickness of plaques found in all segments of CCA. The complexity of coronary artery lesions is evaluated by using the SYNTAX score. The middle and high SYNTAX scores are associated with an increased risk of cardiac death and major cardiac events. Results: Data collection and statistical analysis is in progress and preliminary results indicate that IMT values and PS score significantly correlate with SYNTAX score >18 (r=.0,64, p 27 (r=.0,79, p<0,01). It is expected that final results will show that there is a significant correlation between the degree of CCA atherosclerosis measured by two methods — IMT and PS, and the degree of complexity of coronary artery lesions. Conclusion: Preliminary results show that carotid ultrasound examination has sufficient sensitivity and specificity in the detection of patients with high risk of significant CAD and it is an argument for broader use of CCA ultrasound for the evaluation of patients who are considered for coronary angiography. Besides, we are going to improve algorithm of patients selection for coronary angiography, so, our limited material and human resources and efforts will be directed towards the treatment of patients i.e. net clinical benefit will be improved.

European Society of Cardiology (ESC) National Society Cardiovascular Journals (NSCJs) are high-quality biomedical journals focused on cardiovascular diseases. The Editors’ Network of the ESC devises editorial initiatives aimed at improving the scientific quality and diffusion of NSCJ. In this article we will discuss on the importance of the Internet, electronic editions and open access strategies on scientific publishing. Finally, we will propose a new editorial initiative based on a novel electronic tool on the ESC web-page that may further help to increase the dissemination of contents and visibility of NSCJs. © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L. All rights

OBJECTIVE To assess serum levels of tumor marker carbohydrate antigen 125 (CA125) in patients with heart failure (HF) and to investigate possible correlation with echocardiographic parameters and level of brain natriuretic peptide (BNP). PATIENTS AND METHODS We included 76 patients with different cardiac symptoms hospitalized at Clinic for heart disease and rheumatism. Control group (n = 26) was consisted of patients without signs and symptoms of HF, normal left ventricle ejection fraction (LVEF) and normal BNP level. Patients with diagnosis of HF (n = 50) were subdivided into 2 group depending on signs and symptoms of fluid overload: compensated (compHF, n = 10) and decompensated group (decompHF, n = 40). Serum CA125 and BNP were measured on admission and all patient underwent ECG recording and trans thoracic echocardiographic examination. RESULTS The median CA125 level in HF group was significantly higher compared to control group (71.05 [30.70-141.47]U/ml vs 10.75 [8.05- 14.32] U/ml, p < 0.0005). Higher CA125 levels were found in decompHF group compared to compHF group (94.90 [49.75-196.75]U/ml vs 11.90 [10.25-15.80]U/ml, p < 0.0005). In decompHF group 13 of patients had pleural and/or pericardial effusion- their CA125 levels were significantly higher compared to patients without serosal effusion (n = 27) (205.10 [106.50-383.90]U/ml vs. 71.50 [47.30-109.55] U/ml, p < 0.002). We found significant difference in CA125 levels between patients with atrial fibrillation and sinus rhythm (98.40 [48.20-242.70] U/ml vs. 47.30 [12.95-99.05] U/ml, p = 0.015). There was no significant difference in CA125 levels in group with enlarged left atrium compared to normal sized atrium (p = 0.282), as well as in group with moderate/severe mitral regurgitation compared to group with no/mild mitral regurgitation (p = 0.99). Finally, levels of serum CA125 positively correlated with serum level of BNP (r = 0.293, p = 0.039), but not with LVEF (p = 0.369) and left atrium diameter (p = 0.636). CONCLUSION Serum CA125 is elevated in decompensated HF patients: more pronounced elevation was found in patients with pleural and/or pericard effusion compared to patients with no serosal effusion. CA125 level correlated with BNP, but not with left atrium diameter nor with LVEF. Tumor marker CA125 could be used as a marker of systemic congestion and volume overload in decompensated HF. We hypothesized that high CA125 level indicates that measured high BNP is actually wet BNP.