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Clinical picture of coronary artery disease is different in men and women. Later incidence of coronary disease in women than in men, presence of less typical symptoms, lower specificity of non invasive diagnostic tests as well as higher mortality during percutaneous or surgical revascularization are underlined. Aim of the study was to examine clinical variables, diagnostic and treatment methods in women with coronary disease on the basis of retrospective analysis of patients hospitalized in the Department of Coronary Artery Disease of the Jagiellonian University Medical School in Cracow between 1991 and 1999. 929 patients aged 31-95 years mean 56.95 +/- 10.02 years were enrolled in the study. Clinical usefulness in women with coronary disease of diagnostic tests: electrocardiographic exercise test, exercise thalium-201 scintigraphy and stress echo-cardiography with dobutamine were analyzed. The highest sensitivity was found in exercise scintigraphy (92.9%) compared to ECG exercise test (80.6%) and stress echocardiography with dobutamine (76.9%). The highest specificity characterized stress echocardiography with dobutamine (76.9%) versus exercise scintigraphy (34.7%) and ECG exercise test (25.9%). Between 1991 and 1999 women with coronary artery disease consisted 19.4% of all patients hospitalized in the Department of Coronary Artery Disease in Cracow. Among patients investigated with coronary angiography there were 18.2% of women. Among percutaneously revascularized patients women constituted 17.8%. In the analyzed period 3.5-fold increase of the number of women with CAD hospitalized in the Department of Coronary Artery Disease in Cracow, 7.5-fold increase of the number of women investigated with coronary angiography and 10.5-fold increase of the number of percutaneously or surgically revascularized women was observed. On the basis of performed diagnostic tests 650 women (69.9%) were treated pharmacologically. In 157 patients (16.9%) percutaneous coronary angioplasty was performed, in 118 patients (12.7%) coronary artery bypass surgery was done. In 4 women (4.3%) heart transplantation was performed.

Stress echocardiography (stress echo) is a method in which various stimuli are used to elicit myocardial contractility or provoke cardiac ischemia with simultaneous echocardiographic image acquisition of left ventricular function and valvular flow, if needed. The technique is a well-recognized, safe and widely available stress test used for the diagnosis and assessment of prognosis in coronary heart disease, but may also prove valuable in valvular heart disease. The stressors used include physical exercise, pharmacological agents (dobutamine, vasodilators) and pacing stress, most often with the use of a permanent pacemaker. Two operators should perform the test: a physician experienced in stress echocardiography (at least 100 tests completed under supervision of an expert) and a trained nurse or another doctor. The laboratory should feature a defibrillator and a resuscitation kit with a set of pharmaceuticals, an intubation kit and an AMBU bag. Pacing stress echo requires an external programmer for the implanted permanent pacemaker. Exercise should be the preferred stressor for the diagnosis of ischemic heart disease with alternative of high-dose dobutamine test in cases of contraindications to physical stress. Pacing stress echo is recommended for patients with pacemakers, and dipyridamole test for the assessment of coronary flow reserve. Chest pain in patients with intermediate probability of coronary artery disease, inability to perform physical exercise and non-diagnostic resting or exercise electrocardiography are indications for stress echo. The test is also used in symptomatic patients after revascularization or patients qualified for revascularization for functional assessment of coronary artery stenosis. Low-dose dobutamine test is usually performed in patients after myocardial infarction or with moderate-to-severe left ventricular dysfunction to assess myocardial viability before potential revascularization. [ABSTRACT FROM AUTHOR]

Stress echocardiography (stress echo), with use of both old and new ultrasonographic cardiac function imaging techniques, has nowadays become a widely available, safe and inexpensive diagnostic method. Cardiac stress, such as exercise or an inotropic agent, allows for dynamic assessment of a wide range of functional parameters describing ventricles, heart valves and pulmonary circulation. In addition to diagnosis of ischemic heart disease, stress echocardiography is also used in patients with acquired and congenital valvular defects, hypertrophic cardiomyopathy, dilated cardiomyopathy as well as diastolic and systolic heart failure. Physical exercise is the recommended stressor in patients with aortic and especially mitral valvular disease. Nevertheless, dobutamine stress echo is useful for the assessment of contractile and flow reserve in aortic stenosis with reduced left ventricular ejection fraction. Stress echo should always be performed by an appropriately trained cardiologist assisted by a nurse or another doctor, in the settings of an adequately equipped echocardiographic laboratory and with compliance to safety requirements. Moreover, continuous education of cardiologists performing stress echo is needed. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was to compare 12-month mortality rate of patients with and without complete coronary revascularization before transcatheter aortic valve implantation (TAVI).Background: There are limited data on the impact of coronary artery disease burden in patients with severe aortic stenosis undergoing TAVI.Methods: One hundred and one consecutive patients undergoing TAVI were enrolled. Of them 16 (15.8%) had an incomplete coronary revascularization. The primary endpoint was 12-month all-cause mortality.Results: Twelve-month all-cause mortality was higher in patients with incomplete coronary revascularization than in patients with complete coronary revascularization or without significant lesions (75.0% vs 7.1%; P < 0.001). Importantly, incomplete coronary revascularization was an independent predictor of higher mortality rate after 12 months (hazard ratio (HR) for incomplete coronary revascularization 10.86, 95% CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95% confidence interval (CI) 1.39-11.07; P < 0.001; HR for blood transfusion 2.84 95% CI (1.06-7.63); P = 0.039). In 9 of 16 (56.3%) patients, incomplete revascularization was related to the presence of chronic total occlusions (CTO). Patients with CTO had an increased mortality rate after 12 months (55.6% vs 14.1%; P = 0.008) as compared to patients without the CTO.Conclusions: Incomplete coronary revascularization and a history of stroke or TIA may be independent predictors of all-cause mortality in patients undergoing TAVI. However, further studies are recommended to confirm the results, especially in terms of the impact of CTO presence on long-term mortality after TAVI. [ABSTRACT FROM AUTHOR]

Aim: Assessment of safety, diagnostic, and prognostic value of a stress echocardiography protocol based on rapid pacing in patients with implanted permanent pacemakers according to the pacing mode (AAI/DDD or VVI) and concomitant antiischemic therapy. Material and methods: 149 rapid pacing stress echo tests were performed in 100 patients (33 females, 67 males, aged 47–79, mean 65 ± 8 years), utilizing previously implanted permanent pacemakers. Left ventricular segmental contractility was assessed at rest, during pacing at the rate of 100/minutes and then at 85% of maximal age-predicted heart rate. Each pacing stage lasted for 3 minutes. The test was performed using only VVI pacing mode in 27 patients in whom atrial pacing was not possible. In the remaining 73 patients AAI/DDD pacing mode was initially used in all 73 patients and followed by VVI pacing in 49 patients. Angiographic coronary stenosis of at least 50% was considered significant. Results: No severe adverse effects were observed. Mean duration of the test was 7 ± 2 minutes for VVI pacing and 10 ± 2 minutes for both AAI/DDD and VVI pacing. Among 149 tests performed, AAI/DDD mode was used in 73 (49%), while in VVI mode was used in 76 (51%) tests. Significant increase in heart rate comparing to baseline was achieved{[ 68/minutes vs. 129/minutes (P < 00001)]}, also in patients treated with beta-blockers{[ 69/minutes vs. 129/minutes (P < 00001)]}, whereas, blood pressure remained unchanged between rest and rapid pacing stage. Wall motion score index increased significantly (from 1.32 vs. 1.49 in AAI/DDD to 1.36 vs. 1.65 in VVI mode). Among all 149 tests, 89 (60%) were considered positive, 57 (38%) negative, and 3 (2%) — nondiagnostic. Sensitivity, specificity, accuracy, positive, and negative predictive values for significant coronary stenosis were respectively: 91%, 75%, 83%, 81%, and 88%. For AAI/DDD mode the above values were: 91%, 81%, 86%, 82%, 91%, while for VVI mode they were: 91%, 68%, 80%, 80%, 84% (ns). In patients treated with beta-blockers test accuracy was – 79%., with ACE inhibitors – 84%, and with nitrates – 93%. During 1-year follow-up 5 (5%) cardiac deaths and 9 (9,1%) myocardial infarctions occurred. The risk of myocardial infarction or cardiac death was significantly higher in patients with positive comparing to negative result of RAPSE test. Complications hazard ratio associated with positive result of RAPSE was 13.5 (95% confidence interval, 1.7–106.0, P + 0.0133) for AAI/DDD mode and 7.9 (95% confidence interval, 1.0–60.9, P + 0.00472) for VVI mode. Conclusions: Rapid pacing stress echo test using permanent pacemaker is a rapid and safe diagnostic technique. The accuracy is good for both pacing modes, including tests performed in patients treated with beta-blockers. The test can be utilized as atechnique of choice in noninvasive diagnostics of coronary disease and prognostic assessment in patientswith permanent pacemakers. [ABSTRACT FROM AUTHOR]

We report a rare case of primary antiphospholipid syndrome (APS) in a 43-year-old man presenting as recurrent acute coronary stent thrombosis and complicated by three myocardial infarctions. As illustrated in this report, in APS patients recurrent life-threatening arterial thrombotic events may occur in spite of recommended anticoagulant therapy. We conclude that the APS should be considered as a potential cause of acute coronary syndrome, particularly in young individuals with a history of recurrent thrombotic events and/or with abnormal coagulation test results. Further studies are needed to determine the best therapeutic strategy for APS patients with acute coronary syndrome. [ABSTRACT FROM AUTHOR]