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It has been shown that hyperglycaemia is associated with increased in-hospital and long-term mortality in patients with myocardial infarction (MI). There are only a few reports on the relationship between glycaemia in the acute phase of MI complicated by cardiogenic shock (CS) and prognosis.To assess the relationship between blood glucose level on admission and in-hospital as well as long-term mortality in patients with acute ST-segment elevation MI (STEMI) complicated by CS treated with percutaneous coronary intervention (PCI).Consecutive patients with STEMI complicated by CS treated with PCI were included. For the purpose of this analysis, the patients were divided into two groups: the first group included patients with glycaemia on admission7.8 mmol/L, and the other group patients with glycaemiaor = 7.8 mmol/L (hyperglycaemia group). Selected parameters from the in-hospital and long-term follow-up were compared between the two groups. Due to a possible linear relationship between blood glucose and mortality in multivariate analysis, glucose level on admission was treated as a continuous variable. The primary outcomes included in-hospital, 1-year and 5-year mortality.Out of 3166 consecutive patients with STEMI, 258 had CS and available data on glycaemia. In patients with hyperglycaemia on admission, we observed higher in-hospital (41.5% vs 28%, p = 0.041), 1-year (51.4% vs 34.7%, p = 0.015) and 5-year (65.8% vs 43.3%, p = 0.034) mortality in comparison to the patients with blood glucose7.8 mmol/L. The multivariate analysis revealed that blood glucose level on admission (per each glycaemia increment by 1 mmol/L) was an independent prognostic factor of in-hospital (OR 1.08, 95% CI 1.02-1.14, p = 0.0044), 1-year (HR 1.04, 95% CI 1.01-1.06, p = 0.005) and 5-year mortality (HR 1.03, 95% CI 1.01-1.05, p = 0.045). Of note, the diagnosis of diabetes mellitus had no influence on in-hospital and long-term mortality.Elevated blood glucose level on admission, regardless of the diagnosis of diabetes mellitus, results in increased in-hospital and long-term mortality in patients with STEMI complicated by CS and treated with PCI.

Cardiogenic shock (CS) continues to be the most important factor affecting the mortality rate of patients with acute myocardial infarctions (AMIs). However, controversy regarding the optimal treatment of older patients with AMIs complicated by CS still exists. The aim of this study was to compare the results of invasive (coronary angiography during index hospitalization) and noninvasive treatment strategies in patients aged ≥ 75 years with AMIs complicated by CS, defined as systolic blood pressure90 mm Hg or need for hemodynamic support and end-organ hypoperfusion. A multicenter Polish registry that included data on patients with acute coronary syndromes was examined to identify patients with AMIs treated from October 2003 to May 2007. A total of 97,531 patients with AMIs were hospitalized, and 5.5% of those patients (n = 5,390) had CS on admission, including 1,976 patients aged ≥ 75 years (509 treated invasively and 1,467 treated noninvasively). In-hospital mortality was 55.4% in patients treated invasively and 69.9% in patients treated noninvasively (p0.0001). After 6 months, the mortality rate was 65.8% in the invasive group and 80.5% in the noninvasive group (p0.0001). Propensity score analysis, in which 499 patients of each group were analyzed after being matched for demographic and clinical data, confirmed the early and long-term benefits of the invasive strategy. In conclusion, applying the invasive strategy to patients with AMIs complicated by CS reduced in-hospital and 6-month mortality in patients aged ≥ 75 years.

Today's knowledge concerning the progression of coronary artery disease (CAD) is mainly derived from randomised clinical studies performed in patients with stable CAD. Data on atherosclerosis progression (AP) after myocardial infarction are limited. The aim of this study was to assess the AP in such a population of patients.A total of 186 patients were analyzed. After exclusion of patients not suitable for quantitative coronary angiography analysis, the final group was comprised of 154 patients. AP was recognized in 93 (60.4%) patients. A multivariate regression analysis revealed that the risk of AP in patients increases with lack of adequate microvascular perfusion, as assessed by the thrombolysis in myocardial infarction (TIMI) myocardial perfusion grade (TMPG) score (odds ratio [OR] 4.13; 95% confidence interval [CI] = 1.17-14.53), non-smoking status and lower baseline cholesterol value (OR = 2,74; 95% CI 1.19-6.31 and OR = 1.44; 95% CI = 1.04-1.98, respectively). Moreover, the risk of progression of a pre-existing coronary lesion was enhanced the most when the baseline minimal lumen diameter was greater (OR = 2.34; 95% CI = 1.83-3.00), and a lack of adequate microvascular perfusion (OR = 3.12; 95% CI = 1.67-5.85) was the strongest predictor of risk of developing new coronary lesions.Atherosclerosis progression concerns over 60% of patients 12 months after acute myocardial infarction. Poor myocardial perfusion, as assessed by TMPG score, may be a simple tool for the identification of patients at greater risk of atherosclerosis progression, especially the development of new lesions.

Transplanted heart coronary artery disease (TxCAD) may occur in a significant proportion of patients following cardiac transplantation. Drug-eluting stents (DES) have been successfully used in patients with CAD, but their efficacy in TxCAD patients has not been well established.To compare long-term results of intracoronary implantation of DES and BMS in patients suffering from TxCAD.We performed a retrospective analysis of all intracoronary stent implantations for TxCAD with at least one control coronary angiography performed during follow-up. We identified 28 DES (all sirolimus-eluting stents, SES) and 28 BMS implantations in 23 patients. The mean follow-up time was 410+/-58 days after DES, and 572+/-434 days after BMS implantation (p=0.004). We compared the occurrence of in-stent restenosis (ISR) in DES and BMS, and survival of patients in the context of risk factors that were identified for each stent implantation separately.There were 2 (7%) ISR revealed in DES patients (mean time from PCI to restenosis 492+/-58 days) vs. 17 (61%) ISR in BMS patients (mean time from PCI to restenosis 475+/-345 days) (p0.001). There were 3 (18%) deaths in patients with DES, 4 (31%) in patients with BMS, and 1 (14%) in a patient with DES and BMS (NS). The risk factor profile was comparable, except for higher age at the time of transplantation (46+/-7 vs. 41+/-6 years, p=0.011) and stent implantation (54+/-7 vs. 49+/-6 years, p0.001) for DES.Favourable long-term results of DES compared with BMS implantation for TxCAD suggest the preferential use of DES in heart transplant recipients.

Prognoses in STEMI and NSTEMI beyond one year from onset remain unclear. We aimed to compare the treatments and the two-year outcomes in patients with myocardial infarction (MI) enrolled at the Polish Registry of Acute Coronary Syndromes (PL-ACS).A total of 13,441 patients with MI (8250 with STEMI, and 5191 with NSTEMI) underwent medical care between October 2003 and June 2005 in the Silesia region (4.8 million inhabitants). The events analyzed were death, MI, stroke and percutaneous (PCI) or surgical (CABG) revascularization.After two years, NSTEMI was associated with a higher incidence of death (hazard ratio (HR) of 1.09 (95% confidence interval (CI) 1.02-1.17, p0.0001)); a higher incidence of reinfarction, stroke, CABG and a lower rate of PCI. Adjustments for baseline characteristics and treatment strategy (invasive vs. non-invasive) reversed the HR for mortality and eliminated the difference in MI and stroke. The adjusted HR for mortality was 0.76 (95% CI, 0.71-0.83, p0.0001). STEMI and NSTEMI patients treated non-invasively were older and showed higher incidences of diabetes, obesity, pulmonary edema and cardiogenic shock than their invasively treated counterparts. Invasively treated patients received aspirin, beta-blockers, ACE inhibitors and statins more often during hospitalization and at discharge.The unadjusted long-term prognosis was worse in NSTEMI. After adjustment for the baseline characteristics and treatment strategy, the long-term prognosis was worse in STEMI. Patients with MI treated invasively showed more favorable clinical characteristics and received guideline-recommended therapy more often than patients who did not undergo invasive treatment.

Scarce data exist concerning the long-term effect of percutaneous transluminal renal angioplasty (PTRA) enhanced with intravascular gamma brachytherapy (IVBT) in patients with renovascular hypertension.Seventy one patients aged 52 +/- 8 years with refractory renovascular hypertension were randomized to Group I (PTRA + IVBT) or Group II (PTRA). For the IVBT procedure, the PARIS catheter and Microselectron HDR (Nucletron) system was employed. Both baseline and 9-month follow-up quantitative computerized angiography (QCA) and ambulatory blood pressure monitoring analysis was performed to assess luminal parameters of restenosis and the effect of treatment on blood pressure.Thirty three patients from Group I and 29 patients from Group II underwent successful procedure. During nine months of follow-up, three patients died; including two patients in Group I (cardiac causes) and one patient in Group II (stroke). The follow-up lumen diameter stenosis was 30.6 +/- 13.7% and 40.4 +/- 11% in Groups I and II, respectively (p = 0.004). Late lumen loss in quantitative computerized angiography was 1.2 +/- 0.7 mm and 1.7 +/- 0.7 mm in Groups I and II, respectively (p = 0.004).Intravascular gamma brachytherapy using self-centering source performed after balloon angioplasty is a safe and effective method of prevention of restenosis after PTRA in patients with renovascular hypertension.

OBJECTIVES Cardiogenic shock (CS) still remains one of the most important factors affecting the mortality rate of patients with ST segment elevation myocardial infarction (STEMI). However, the data with follow-up longer than 1 year are limited. The aim of this study was to evaluate the early and long-term treatment results of patients with STEMI, complicated or not by CS, who underwent percutaneus coronary interventions. METHODS A retrospective registry included data of all patients with STEMI admitted to our centre from January 1999 to December 2001. RESULTS One thousand three hundred and eighty-five patients with STEMI were hospitalized and 1237 of them were treated with immediate percutaneus coronary interventions. Among this subpopulation, 117 (9.5%) patients were with STEMI complicated with CS on admission (group I) and 1120 (90.5%) patients were with STEMI without complications from CS on admission (group II). The groups differed significantly with regard to baseline clinical characteristics, angiographic picture, and in-hospital course. A total of 38.5% of patients with myocardial infarction complicated by CS and 2.5% of patients without shock (P

Patients with severe symptomatic aortic stenosis, who from November 2008 to March 2009 were treated with Edwards-Sapien transcatheter aortic valve implantation (TAVI) within the POL-TAVI First Polish Registry, were included in the analysis. Nineteen patients aged 78+/-4.8 years with high operation risk and Logistic EuroSCORE 25+/-7.6% were reported (74% were females). In 15 (79%) patients the valve was implanted transapically (TA), in the other four (21%)--via the femoral arterial access (TF). The valve was successfully implanted in 16 (84%) patients, in one patient aortic valvuloplasty alone was performed. During in-hospital period two patients died (one during periprocedural period and another one--two months after the implantation). During the mean follow-up of 5+/-1.5 months (except for one patient who is still in hospital) all patients are in NYHA class I or II. Results of the initial series of 19 TAVI patients in Poland are satisfactory, and the trial will be continued with careful medical and economical analysis.

Renal ischaemia resulting from stenosis of the renal artery may result in two important sequelae: systemic arterial hypertension, and renal atrophy and nephron loss, resulting in an increased risk of progression to end-stage renal disease. Renal artery stenosis (RAS) may lead to both renovascular hypertension and ischaemic nephropathy - a potentially curable cause of renal failure.To assess the efficacy of g-intraluminal brachytherapy (ILBT) in prevention of restenosis after percutaneous transluminal renal artery angioplasty (PTRA) and the effects of this method of revascularisation on renal function.71 patients aged 52+/-8 years with refractory renovascular hypertension were randomised to group I (PTRA + ILBT) or group II (PTRA). Both baseline and 9-month follow-up angiography, intra-vascular ultrasound and non-invasive examination were performed to assess the efficacy of PTRA on renal function.The overall PTRA success rate was 87%: 33 patients from group I and 29 from group II underwent a successful procedure. A decrease of serum creatinine level was observed regardless of the treatment modality, directly after angioplasty: 20 micromol/l (17.5%) in group I and 26 micromol/l (22%) in group II (NS). Also in long-term follow-up this effect was sustained: 18 micromol/l (15.8%) in group I and 10 micromol/l (8.5%) in group II (NS). In the follow-up period a non-significant increase of serum creatinine level was observed in group I (from 94+/-19 to 96+/-25 micromol/l, NS). In group II the increase of serum creatinine level was significantly higher (from 92+/-39 micromol/l to 108+/-60 micromol/l, p=0.001).PTRA improves renal function in patients with ischaemic nephropathy. In long-term observation the positive effect of PTRA on renal function is especially visible in patients with ILBT after PTRA.

Diabetes mellitus (DM) is a significant factor regarding poor outcome in patients with myocardial infarction. Recently a new prognostic factor is under consideration - a baseline glucose level on admission. We sought to assess the influence of blood glucose levels on admission on prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI).Consecutive patients treated with PCI for STEMI were analyzed. Presence or absence of DM was the first grouping criterion. The secondary criterion was the blood glucose level on admission [thresholdor= 7.8 mmol/L (140 mg/dL)]. Hyperglycemic and non-hyperglycemic subgroups were selected within both DM and non-DM groups according to the threshold. One-year mortality of diabetics was 16.0%. There was no significant difference in 1-year mortality between hyperglycemic and non-hyperglycemic patients with DM. One-year mortality in the non-DM group was 5.6%. Patients without DM but with hyperglycemia showed a higher 1-year mortality rate than non-hyperglycemic patients (8.51% vs. 3.68%, p = 0.001). Multivariate analysis revealed that in the non-DM group blood glucose level (per 1 mmol/L) on admission was a factor affecting 1-year mortality [HR = 1.09 (1.01-1.17)].Elevated blood glucose levels in STEMI affect the prognosis of patients without DM; however, it is not an independent death risk factor of patients with DM treated with PCI.

In the present report we describe a 70-year-old woman after antimitotic stent implantation who developed an allergy to clopidogrel. We monitored her platelet activity while on different drug regimes and at different time points during the allergic reaction. Tests showed incomplete platelet inhibition by acetylsalicylic acid and clopidogrel (dual antiplatelet drug resistance) during the acute allergic reaction with gradual improvement together with patient clinical status.

The progressive aging of society results in increased numbers of acute myocardial infarctions (MI) in the elderly. In the presence of huge progress in MI treatment, it seems to be reasonable to analyse clinical course and prognosis in the elderly with MI.To assess differences in clinical characteristics and treatment of MI between patients younger than 65 and the elderly.A total of 491 patients over 65 and 398 patients younger than 65 with acute MI between June 2005 and February 2006 were retrospectively analysed.In patients over 65 there was significantly higher prevalence of arterial hypertension and diabetes, as well as low left ventricular ejection fraction and advanced heart failure. The time from onset of symptoms to admission was longer in the older group. The rate of reperfusion therapy in the elderly was significantly lower, and the results of invasive treatment were poor. Antiplatelet treatment was less aggressive in this group. In-hospital and long-term mortality were significantly higher in patients over 65, but the lowest in subjects undergoing invasive strategy.Risk factors in baseline characteristics and lower rate of invasive therapeutic strategy result in worse prognosis in patients over 65 with acute MI. A significant reduction in mortality due to the invasive approach should encourage wide implementation of this approach in the elderly.

It has been shown that diabetes mellitus (DM) is an independent prognostic factor in patients with myocardial infarction (MI). In addition to that fact the prognostic significance of blood glucose (BG) abnormalities in the acute phase of MI has also been suggested. Recently, a new prognostic factor has been evaluated - the glucose level at hospital discharge.To assess whether the glucose level at hospital discharge is associated with one-year mortality in patients with DM treated with percutaneous coronary intervention (PCI) for ST-segment elevation MI (STEMI), taking into account hypoglycaemic treatment.Consecutive patients with STEMI and DM treated with PCI, who survived hospitalisation, were included in the analysis. Patients were assumed to have DM if previous diagnosis of DM or newly diagnosed DM during hospital stay was noted. Criteria of newly diagnosed DM were as follows: fasting BGor=7 mmol/l at least twice after acute phase of STEMI, BGor=11.1 mmol/l in a 2-hour glucose tolerance test performed before discharge. Fasting plasma glucose at hospital discharge was used for analysis.Out of 2762 consecutive patients with STEMI, 565 had DM. In-hospital mortality in this group was 9.4% (53 patients), so the final DM group consisted of 512 patients. After discharge 59 (11.5%) patients died during one-year follow-up. The glucose level at discharge was not an independent prognostic factor of one-year mortality in the whole analysed group, however insulin treatment at discharge was (HR 2.61, 95% CI 1.29-5.29; p=0.008). Afterwards, we undertook multivariate analysis separately in the group treated with insulin (253 patients) and in the group treated with oral drugs or diet only (259 patients). This analysis showed that in the group treated with insulin the glucose level at discharge was not an independent prognostic factor of one-year mortality (HR 1.07, 95% CI 0.95-1.22; p=0.27), whereas in patients treated with hypoglycaemic agents or diet it was significantly associated with a one-year mortality (HR 1.30, 95% CI 1.01-1.68; p=0.049).1. Patients with STEMI and DM treated with insulin at hospital discharge have higher risk of death, probably because of more advanced DM and more severe complications, than patients treated with oral drugs or diet. 2. Elevated glucose level at hospital discharge predict one-year mortality only in patients with MI and DM treated with oral drugs or diet.

In recent years significant progress has been made in invasive treatment of patients with acute myocardial infarction (AMI). Primary coronary stenting is currently a routine strategy which replaced primary balloon angioplasty with bailout stenting preferred in the past. Studies comparing these two strategies of stenting in AMI are scarce.To compare the immediate and long-term outcomes after primary angioplasty strategy and bailout stenting versus primary stent placement strategy in patients with AMI.We analysed data from a single-centre registry of consecutive patients with ST segment elevation myocardial infarction admitted between January 1998 and October 2003. In our centre in years 1998-2000 stenting was used only after failed or suboptimal balloon angioplasty. Starting from year 2001 we used routine primary stenting strategy. We compared these two angioplasty strategies applied in different time intervals with regard to in-hospital outcome and long-term mortality. Patients with cardiogenic shock at admission were excluded.Out of a total of 1602 patients treated invasively for AMI (cardiogenic shock excluded) 479 underwent primary balloon angioplasty strategy with bailout stenting - group 1 (years 1998-2000) and 1123 were treated with primary stenting strategy - group 2 (years 2001-2003). In group 1 bailout stenting occurred in 34.4% of patients whereas in group 2 stents were implanted in 83% of patients. Patients in the balloon angioplasty group were younger, had shorter time from the onset of symptom to hospital arrival and more frequently underwent rescue coronary intervention after failed thrombolysis. In-hospital mortality was 2.9 vs. 2.4% in groups 1 and 2, respectively (p=NS). Twenty-four month mortality rate was 9.8% in group 1 and 10.06% in group 2 (p=NS).1. Effectiveness of coronary angioplasty is high and comparable in both groups. 2. In-hospital and long-term mortality and procedure-related complication rate are all low and comparable with both stenting strategies. 3. Independent factors increasing long-term mortality include: culprit vessel reocclusion, multivessel coronary disease, older age and hypertension. 4. Patients with complete patency of culprit vessel restored and with higher left ventricular ejection fraction presented lower 2-year mortality rate. 5. Bailout stenting did not increase 2-year mortality.

Data on the efficacy of coronary angioplasty in patients with ST-segment elevation myocardial infarction (STEMI) treated during off-shift hours are limited, but some publications suggest a worse outcome in this group of patients.To compare the results of percutaneous coronary interventions (PCI) in STEMI patients admitted to hospital during the daytime and off-shift hours and to identify factors which influence prognosis.From January 1998 to October 2003, 1992 patients with STEMI were hospitalised and 1778 of them were treated with immediate PCI, including 482 admitted in the daytime (weekdays 8 a.m. - 3 p.m.; group I) and 1296 during off-shift hours (weekdays 3 p.m. - 8 a.m., weekends and holidays; group II). The clinical characteristics of both groups were similar, except for less frequent hypercholesterolaemia in the daytime group (52.1 vs. 59.7%; p=0.0041).There was no significant difference between the groups regarding time from admission to angiography (30 vs. 25 minutes), rates of reocclusion (5.2 vs. 4.9%), stroke (1.4 vs. 1.6%), haemorrhagic complications (8.1 vs. 6.9%), in-hospital mortality (6.8 vs. 6.2%) and long-term (24 months) mortality (13.7 vs. 13.6%) (p0.05 for all parameters). The rate of stent implantation was significantly higher in the daytime group (71.2 vs. 66.2%; p=0.047).The proper organisation of duties of the division of cardiology and the cardiac catheterisation laboratory, with focus on providing onsite staffing of the cardiac catheterisation laboratory around the clock, enables similar results of PCI in patients with ST-segment elevation myocardial infarction treated during off-shift hours as compared with patients treated during the daytime.

Diabetes mellitus in patients with myocardial infarction affects in-hospital and late mortality. It has been shown that the glucose level on admission can also affect prognosis. This conclusion was based on an analysis performed on a heterogeneous group of patients, treated not only with percutaneous coronary intervention (PCI) but also with fibrinolysis. Moreover, the threshold values hyperglycaemia for the diagnosis of were also variable.To assess whether glucose level on admission affects in-hospital and one-year prognosis in patients with ST-segment elevation myocardial infarction (STEMI) treated with PCI.Consecutive patients with STEMI treated with PCI were included in the analysis. Patients with STEMI complicated by cardiogenic shock were also included. Three groups according to the glucose level on admission were analysed: group I -7.8 mmol/l (140 mg/dl), group II - 7.8-11.1 mmol/l (140-200 mg/dl), and group III -or = 11.1 mmol/l (200 mg/dl).The incidence of diabetes mellitus in the total group (1027 patients) was 26.1%, and of cardiogenic shock - 9.2%. Group I consisted of 472 patients, group II - 307 patients, and group III - 248 patients. Compared with normoglycaemic patients, those with elevated glucose level were older, more often female, had more often hypertension, diabetes mellitus, cardiogenic shock, were more often treated with fibrinolysis before PCI but were less often smokers. Multivessel disease and initial patency of the infarct-related artery (TIMI 0-1) were more often observed in patients with higher glucose level. A trend towards a higher incidence of reocclusion was also more often present in patients with increased glucose level. Moreover, mean creatine kinase concentration was the highest and the left ventricular ejection fraction was the lowest in group III. During the in-hospital stay, the complication rate was as follows: stroke (1.1% vs. 1.3% vs. 4.4%), and mortality (2.8 vs. 4.9 vs. 13.3%) in groups I, II, and III, respectively. The same tendency was observed during the one-year follow-up period: stroke (1.3 vs. 2.9 vs. 6.9%), mortality (6.4 vs. 9.1 vs. 22.6%). The 1 mmol/l (18 mg/dl) increase of the baseline glucose level among various risk factors was an independent prognostic factor of higher -year mortality (HR=1.06; 95% CI 1.02-1.09). Diabetes mellitus did not affect prognosis among patients included in the analysis.Elevated glucose level on admission is associated with adverse prognosis in patients with STEMI treated with PCI.

Background/Aim: Scarce data exist concerning the long-term effect of renal balloon angioplasty (PTRA) enhanced by intravascular γ-brachytherapy (IVBT) in patients with renovascular hypertension. The aim of this randomized study was to evaluate long-term outcome after PTRA with IVBT in patients with renal artery stenosis. Patients and Methods: 71 patients with renovascular hypertension were randomized into group I (PTRA + IVBT) or group II (PTRA). 9 patients who required stent implantation were excluded. Both baseline and 9-month follow-up quantitative computerized angiography and intravascular ultrasound (IVUS) analysis were performed to assess restenosis. During the 9-month follow-up, 3 patients died – 2 from group I and 1 from group II. Results: The restenosis rate was 16.1% in group I and 32.1% in group II. The 9-month lumen loss in angiography was 1.2 ± 0.7 and 1.7 ± 0.7 mm (p = 0.004) and the area loss (IVUS) was 6.5 ± 4.8 and 10.1 ± 5.6 mm2 in groups I and II, respectively (p = 0.01). eGFR increased both in group I (from 75 ± 22 to 84 ± 31 ml/min/1.73 m2; p < 0.001) and in group II (from 74 ± 23 to 77 ± 23 ml/min/1.73 m2; p = 0.04). Only the diastolic blood pressure in group I decreased significantly (65 ± 17 and 77 ± 18 mm Hg; p = 0.048). The rate of blood pressure normalization was low in both groups (6.1 and 6.9%). Conclusions: IVBT after PTRA with a self-centering source is a safe and effective method for prevention of restenosis in patients with renovascular hypertension.

In Poland, together with the transformation of the political system, significant positive changes have been made to the national health care system. This provided a possibility for hospitals to apply current standards of care to patients with acute coronary syndromes (ACS).To assess contemporary data on epidemiology, management and outcomes of patients with ACS in Poland, and to evaluate adherence to the guidelines' recommended treatment.We performed an observational study of 100,193 patients hospitalised due to unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), or ST-segment elevation myocardial infarction (STEMI), prospectively enrolled in 417 hospitals from October 2003 to March 2006 in the ongoing Polish Registry of Acute Coronary Syndromes (PL-ACS). The registry is carried out in cooperation with the Ministry of Health and the National Health Fund.The initial diagnoses were unstable angina in 42.2%, NSTEMI in 26.6%, and STEMI in 31.2% of patients. About one-third of patients were treated outside of cardiology departments (mainly in the internal medicine wards). In patients without ST elevation, invasive strategy (early coronary angiography) was used with almost equal frequency in unstable angina (29.4%) and NSTEMI (31.7%). However, in-hospital mortality was low in unstable angina (0.8%), being much higher in NSTEMI patients (6.6%), (p0.001). In STEMI reperfusion therapy was administered in 63.3% of patients (thrombolysis 7.8%, primary PCI 54.1%, and PCI after thrombolysis 1.4%). In-hospital mortality in STEMI was 9.3%. Median times from the onset of symptoms to invasive treatment were: 37 hours in unstable angina, 23 hours in NSTEMI, and 5 hours in STEMI. The guidelines' recommended pharmacotherapy was used in a high percentage of patients except for thienopyridines and GP IIb/IIIa inhibitors.The Polish Registry of Acute Coronary Syndromes shows several discrepancies between guidelines' recommended treatment and their utilisation in everyday practice. Particularly, the under-utilisation of invasive treatment in patients with NSTEMI is alarming. Efforts should be made to increase the usage of invasive treatment in NSTEMI patients and to shorten the delay from the symptom onset to intervention.

It has been shown that successful reperfusion improves in-hospital and long-term outcome of patients with acute myocardial infarction (AMI). Nevertheless, some patients are still at high risk due to AMI despite achievement of reperfusion. Impaired renal function (IRF) is one of the recently recognised risk factors in this population. However, the prognostic value of different types of IRF in patients with AMI treated with percutaneous coronary intervention (PCI) has not been well characterised.To evaluate the prognostic value of different types of IRF in AMI patients treated with PCI.The single centre AMI registry encompassed 1486 consecutive AMI patients treated with PCI, who were followed for a mean of 29.7 months. Subjects with at least 1 measurement of serum creatinine133 micromol/l (1.5 mg/dl) during hospitalisation were selected (n=194; 13.1%) and incorporated into the IRF group. The control group consisted of 1292 (86.9%) subjects with normal renal function. The IRF patients were divided into subgroups: contrast-induced nephropathy--CIN (n=90; 6.1%); and chronic kidney disease--CKD (n=66; 4.4%). Thirty-eight patients from the IRF group (2.6%) had normal value of serum creatinine on admission and did not match criteria of CIN. Patients with creatinine value133 micromol/l on admission were incorporated into the CKD group. CIN was defined as a serum creatinine level134 micromol/l on admission and a 25% increase of that parameter, with a value133 micromol/l within 48 hours after PCI. Among CIN patients 2 subgroups were identified with respect to coexisting diabetes mellitus: CIN-DM and CIN-nDM (both n=45; 3.05%).Remote mortality rate was significantly higher in the IRF group (38.7%) and in particular subgroups--CKD (51.5%), CIN-DM (46.7%), CIN-nDM (28.9%)--than in controls (10.3%, p0.001 for all study groups vs. controls). Multivariate analysis identified IRF as an independent predictor of any-cause death in the whole population [hazard ratio (HR) 2.23; 95% CI 1.99-2.47, p0.001]. All defined types of IRF had a significant and independent influence on remote survival in the study population (CIN-DM - HR 3.52; 95% CI 3.23-3.81; CIN-nDM--HR 2.60; 95% CI 2.29-2.91; CKD--HR 1.98; 95% CI 1.68-2.28).Impaired renal function and all defined types of renal impairment have been shown to worsen the long-term prognosis of AMI patients treated with PCI. The most important risk factor of mortality is CIN in diabetic patients, which is associated with an over 3.5-fold increase of death hazard in this study population.

Results of studies comparing direct stenting (DS) with conventional stenting (CS) after balloon predilatation in patients with acute myocardial infarction (MI) have been reported in the past, however they are conflicting. There are only few randomised studies that aim to answer whether DS improves epicardial and myocardial patency.To assess the effects of DS on epicardial and myocardial patency in patients with acute MI.Consecutive patients with acute MI were randomised either to DS or CS strategy. Clinical exclusion criteria were as follows: clinical and electrocardiographic features of reperfusion, pulmonary oedema, cardiogenic shock, contradictions to coronarography, allergy to aspirin, ticlopidine, clopidogrel, heparin and stainless steel. Angiographic exclusion criteria were as follows: lesion50% with correct patency in the infarct-related artery (IRA), lesion in the left main coronary artery, previously performed percutaneous coronary intervention in the target vessel, diameter of the IRA2 mm or4 mm. We assessed epicardial patency according to the TIMI (thrombolysis in myocardial infarction) scale and myocardial patency according to the TMPG (TIMI myocardial perfusion grade) scale. In addition, we analysed ST segment resolution in 12-lead electrocardiography (ECG). The ECG was performed before and 30 minutes after PCI.We analysed 300 consecutive patients with acute ST segment elevation MI. After exclusion of patients not suitable for the study design, the DS group comprised 110 patients and the CS group - 107 patients. Clinical and angiographic results were similar in both groups. Initial TIMI 0 (48.2% vs. 43.0%), initial TIMI 3 (31.8% vs. 28.0%), initial TMPG 0-1 (77.3% vs. 78.5%), final TIMI 3 (95.5% vs. 93.5%) and final TMPG 2-3 (68.2% vs. 60.8%) were similar in the DS and CS groups, respectively (p=NS). The incidence of no-reflow phenomenon was comparable in both groups (4.5% vs. 6.5%, NS). The inclusive rate of no-reflow phenomenon plus worsening patency in the IRA were 6.4% vs. 10.3% in the DS and CS groups respectively. The ST segment resolutionor = 50% was 58.1% in the DS group and 56.1% in the CS group (NS).Direct stenting does not significantly improve epicardial and myocardial patency in an unselected group of patients with acute ST segment elevation MI.

Acute coronary syndromes (ACS) without ST elevation (which include unstable angina [UA] and non ST elevation MI [NSTEMI]) are caused by dynamic changes in the atherosclerotic plaque and coronary blood flow. To determine characteristics, in-hospital outcome and management of patients with ACS without ST elevation. The total of 502 patients were enrolled. Inclusion criteria were: rest angina within the last 24 hours, ST-segment deviation (0,05 mV), T-wave inversion (0,1 mV) in at least two leads, positive serum cardiac markers. There were 63,3% of patients with Braunwald's IIIB UA and 6,8% with IIIC UA, 29,9% of patients were diagnosed with NSTEMI. All patients were diagnosed invasively with subsequent revascularization (PCI-73,1% or CABG-16,7%) if apprioppriate. 1,6% of patients underwent PCI and elective CABG and 16,7% of patients were treated conservatively. Overall mortality was 2,98%--PCI subgroup (N = 367) 1,36%, CABG subgroup (N = 84) 8,33% and conservative subgroup (N = 43) 6,07%. Non-fatal myocardial infarction (MI) complicated the hospital course in 0,99%, 0,27%, 3,57%, and 2,32% of patients respectively. 1,4%, 0,54%, 6% and 0% of patients respectively had fatal MI. Early invasive strategy in patients with ACS without ST elevation is efficacious method of treatment.

Restenosis following percutaneous coronary interventions (PCI) increases re-hospitalisation rate and may lead to new myocardial infarction (MI) or death. Besides medical aspects, it may also reduce cost-effectiveness of the procedure.To analyse the medical and economical outcome of patients treated with PCI during a one year period.Medical outcome, cost of PCI and total cost of treatment during one year after PCI were assessed in 188 consecutive patients who underwent PCI during the first three months of 2002. Patients with acute MI treated with PCI were not included in the analysis.The rate of major adverse cardiac events (MACE) which included death, new MI or repeated revascularisation, was 1.6% during hospital stay and 14.4% during one-year follow-up. Re-hospitalisation rate was 28.2%. The mean number of outpatient visits during one year was 9.8. The costs of initial hospitalisation and procedures performed during this hospital stay were 7,839 Polish zlotys (PLN) per patient whereas the costs during one-year follow-up were 3,490 PLN (re-hospitalisations and repeated procedures 3,091 PLN, outpatient visits 238 PLN, and pharmacotherapy costs 161 PLN). In the group of patients with MACE, the costs of treatment during one-year follow-up were 13,398 PLN whereas in patients without complications 1,349 PLN per patient.Patients who develop complications after PCI generate costs exceeding ten times that of patients with a favourable outcome. Thus, from the economical and medical point of view, there is a need to identify high-risk patients before the decision is made as to which type of treatment is used. Because the health service in Poland is under-funded, patients at risk should be treated with the most effective methods (antiproliferative stents or surgical revascularisation) as an initial treatment, which may decrease total costs during a long-term period.

Diagnosis of acute pulmonary embolism is difficult. The aim of the study was analysis of electrocardiographic (ECG) changes in patients with acute pulmonary embolism and analysis of correlations between electrocardiographic changes and pulmonary angiography and pulmonary artery pressure. ECG in 22 patients aged 47 +/- 13 years old (9 women and 13 men) with confirmed pulmonary embolism and without pre-existing cardiorespiratory diseases were analyzed. Most frequently tachycardia, negative T wave in III, aVF and precordial leads, dextrogyria and dextrogram in ECG were observed. In 20 patients 3 or more criteria were found. Index Milleri--an quantitative method of estimation of pulmonary embolism correlated with pulmonary artery pressure. Conclusion of this study is that ECG is one of the important diagnostic tests in patients with pulmonary embolism: it gives us information about changes in pulmonary arteries.

Although the introduction of primary percutaneous coronary interventions (PCI) improved the outcome of patients with acute myocardial infarction (MI), diabetes remains a significant factor which worsens prognosis.To compare the immediate and in-hospital results of PCI in patients with acute MI with or without diabetes.The outcome of 139 patients with diabetes and 528 patients without diabetes was compared. Thrombolytic therapy was administered prior to PCI to 43.2% of patients with diabetes and 42.4% of patients without diabetes.Patients with diabetes were older, more frequently of female gender and had higher incidence of hypertension as well as multi-vessel coronary artery disease. PCI was effective in 85.6% of diabetics and 90.2% of non-diabetic patients (NS). The reocclusion rate was significantly higher in diabetics than in non-diabetics (11.5% vs 5.5%, p=0.012) whereas the incidence of haemorrhagic complications was similar. Mortality rates were comparable in both groups (7.2% in diabetics vs 5.9% in non-diabetics, NS).1) Immediate efficacy of primary PCI for acute MI is similar in diabetics and non-diabetics, however, the in-hospital reocclusion rate is higher in the former group of patients. 2) In-hospital mortality is not affected by the presence of diabetes. 3) Thrombolytic and invasive treatment of diabetic patients with acute MI is not associated with an increased risk of bleeding.

The aim of the study was a comparison of coronary angioplasty as the method of myocardial infarction treatment in the two groups of patients: 1st--aged 40 years and younger, and 2nd--older than 40 years of age. The 1st group consisted of 50 patients in the mean age of 36.5 +/- 3.5 years, the 2nd group included 617 patients in the mean age of 58.3 +/- 10.1 years. There was no difference between the two groups in pain duration, infarct localization, thrombolysis, and cardiogenic shock. The younger compared with the older patients were significantly more often of male gender: 45 (90.0%) vs 456 (73.9%), (p = 0.01). The young patients were more often smokers: 41 (82.0%) vs 393 (64.0%), (p = 0.01). There was no significant difference in an incidence of other coronary risk factors. Coronary angiogram showed that there was no significant difference between the both groups in the infarct-related artery localization, TIMI flow before PTCA and number of stenosed arteries. The frequency successful PTCA (TIMI 3 flow, residual stenosis below 30%) was similar in both groups: 45 (90.0%) vs 549 (89.1%), (p = 0.3). There was no significant difference between two groups in the efficacy of treatment, incidence of reocclusion, complications, and mortality during hospitalization.

Cardiogenic shock develops in 5-15% of patients hospitalised with acute myocardial infarction. It is responsible for more than a half of all hospital deaths with survival rate of about 20%. Conventional medical therapy with use of adrenergic, vasoactive, inotropic and thrombolytic agents has failed to improve survival. Treatment strategy combine hemodynamic stabilisation with restoration of coronary blood flow. The aim of the study was evaluation of mechanical restoration of coronary blood flow in infarction related artery and to assess its influence on mortality in patients with myocardial infarction complicated by cardiogenic shock. We retrospectively analysed 58 subjects: 26 patients treated by primary angioplasty, 25 patients with PTCA angioplasty after streptokinase treatment and 7 ones treated conservatively. TIMI 3 flow in angioplasty treated patients was achieved in 70.6% with in hospital mortality rate 14%, however, when reperfusion was unsuccessful the mortality was high (80%). 12 months follow-up mortality rate was 41.8%.Successful reperfusion with coronary angioplasty of the infarct-related artery can significantly reduce mortality rate in patients with cardiogenic shock. Patients who survived in-hospital period have favourable one-year prognosis.

Background In patients with acute myocardial infarction (MI), the efficacy of thrombolysis is low. Angioplasty after failed thrombolysis (rescue percutaneous coronary angioplasty [PTCA]) has been associated with an increase in the incidence of inhospital complications. It has been proposed that these complications result from the procedure itself. Thus, the aim of this study was to compare the efficacy, inhospital complications, and mortality rate of patients with MI who are treated with primary PTCA and PTCA after initial thrombolysis (rescue or immediate rescue) in an experienced clinical center specializing in percutaneous coronary interventions. Methods and results The study group consisted of consecutive patients with MI treated with primary PTCA (n = 195) or PTCA after initial thrombolysis (n = 179). The study was performed in a referral center with a 24-hour catheter-laboratory service. The success rate of the procedure was 90.5% and 88.2% in the PTCA after initial thrombolysis group and primary PTCA group, respectively. The groups did not differ in the frequency of reocclusion, emergency surgical revascularization (coronary artery bypass grafting), or stroke. In patients without cardiogenic shock, the inhospital mortality rates were 3.2% and 0.6% in the rescue and immediate rescue group and primary PTCA group, respectively (not significant). In a subgroup of patients with cardiogenic shock, the mortality rate was 36.0% in the initial thrombolysis PTCA group and 30.8% in the primary PTCA group. However, after successful PTCA in this subgroup, the mortality rate dropped to 18% and 10%, respectively. Conclusions After initial thrombolysis, PTCA is safe, effective, and likely to restore grade 3 Thrombolysis In Myocardial Infarction flow in about 90% of patients. When available, immediate rescue PTCA should be performed in all patients, including patients with cardiogenic shock.