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In the submitted review the authors discuss rational criteria for the diagnosis of myocardial infarction, indications for thrombolysis, coronarography and possibly PTCA, the method of indirect (non-invasive) assessment of an occluded coronary artery and the most frequent mistakes in the diagnosis of infarction. Essential examinations in the acute stage of myocardial infarction are: case-history, ECG, CK-MB (possibly echocardiography). For indication of thrombolysis of acute PTCA case-history and ECG (or echocardiography) are sufficient. Indications of early coronarography before discharge from hospital: postinfarction angina pectoris, malignant arrhythmia (except on the first day), haemodynamic instability, evidence of myocardial ischaemia (restricted symptoms) during a maximal load before discharge.

The authors used programmed ventricular stimulation in 38 patients who had during Holter monitoring severe ventricular arrhythmias (greater than or equal to Lown 4a). The group comprised patients with IHD (22x), hypertrophic (11x) and dilatating cardiomyopathy (2x). Three patients had no organic heart disease. Nine patients were treated at the time of examination with antiarrhythmic drugs. In a total of 16 patients it proved possible to provoke ventricular tachycardia (VT)--four times permanent ventricular tachycardia, 12x transient ventricular tachycardia (NSVT). In the group of treated patients SVT was provoked twice and NSVT also twice, always in patients who took amiodarone. Using programmed ventricular stimulation the following antiarrhythmic drugs were tested: mexiletine, cordarone, ajmaline. The capacity of all tested antiarrhythmics in the prevention of VT was comparable. A total of two patients died during the investigation, in both cases a sudden death. One suffered from hypertrophic cardiomyopathy, one from IHD. In both on Holter monitoring NSVT episodes were revealed. Programmed stimulation provoked in both SVT, both were treated at the time of death with tested antiarrhythmics. The authors conclude that programmed ventricular stimulation is a suitable method for rationalization of antiarrhythmic treatment, the clinical results, however, do not correspond to laboratory results. They recommend therefore to use also Holter monitoring of patients at risk.

Unstable angina pectoris is a clinical syndrome characterized as a rule as rapid deterioration of angina or newly developed angina pectoris. The authors examined 30 patients with unstable angina pectoris who were admitted to hospital within 24 hours after the attack. Coronarography was performed on average after 14.6 hours. In all patients significant coronary stenoses were found. Streptokinase was administered into the coronary artery exhibiting the maximum narrowing in a total dose of 500,000 u. at a rate of 10,000 u/min. After streptokinase administration improvement of the coronarographic finding was recorded in 53% of the group, subjective improvement in 77%. Newly developed angina pectoris exhibited coronarographic improvement in 100%. Deteriorated angina improved coronarographically in 36%, subjective improvement was recorded in 68%. The authors found a significant difference (p less than 0.01) between the group of new anginas and deteriorated anginas following treatment, the coronarographic improvement being in favour of the group of fresh anginas (100% vs. 36%). The authors did not detect a significant difference between the groups when evaluating subjective improvement. In the group of deteriorated anginas more frequently subjective improvement was observed (68%) without detectable coronarographic improvement (36%). The authors verified on their own material that in more than 50% of the patients with sudden deterioration or the development of angina pectoris classified as unstable angina pectoris thrombotic narrowing can be found or even occlusion of the coronary arteries. The authors recommend therefore intravenous streptokinase administration in newly developed angina pectoris. In deterioration of angina pectoris they recommend heparin or possibly streptokinase as the drug of choice.

Can intracoronary thrombolytic therapy (ITT) reduce the infarct size and improve regional and global left ventricular function and if so how long after recanalization does this improvement develop? 42 patients were treated with ITT, of whom 25 showed successful recanalization (group A) and 17 had persistent occlusion or reocclusion (group B). Both groups were examined five times during the first month after infarction with two-dimensional echocardiography. The 'asynergy index' improved in group A by 45% of initial pretreatment values, compared with no significant change in group B (P less than 0.005). The 'asynergy extent' improved in group A by 35%, while in group B again no change was observed (P less than 0.01). This improvement occurred slowly, significant differences being achieved by the 10th day. Entire normalization of left ventricular wall motion was observed in 5 patients (20%) from group A and in no patient from group B. We conclude that successful recanalization of the occluded coronary artery by ITT improves left ventricular wall motion in 80% of patients, with entire normalization of local function in 20% of cases. The improvement occurs slowly during the first 10 days.

Two-dimensional echocardiography was performed in 75 patients with extensive myocardial infarctions to prove why cardiogenic shock develops only in a minority of such patients. 23 patients with clinical signs of shock formed group A, and 52 patients without signs of shock group B. The extent of akinesis and/or dyskinesis was the same in both groups. The "Asynergy Index"--involving also hypokinesis--was more favourable in group B (126 +/- 28, compared with 158 +/- 23 in group A, p less than 0.05). The ejection fraction was significantly higher in group B (33 +/- 12%, compared with 17 +/- 6% in group A, p less than 0.01). The cause of these differences was severe diffuse hypokinesis of the remote myocardium, which was present in all 23 patients with cardiogenic shock and only in 2 patients without shock (p less than 0.001). All 23 patients with shock had multi-vessel disease, which was present only in 19% of patients without shock (p less than 0.01). The study shows that in addition to two known conditions necessary for the development of cardiogenic shock (multi-vessel disease and infarct size at least 40% of the left ventricle), there exists a third condition of equal importance: severe diffuse hypokinesis of the remote myocardium.

In a group comprising a total of 217 patients with a recent myocardial infarction, who were treated with streptokinase the authors provided evidence that early recanalization of the coronary occlusion occurred after superselective intracoronary administration in 81 and 83% of the patients. After intravenous streptokinase administration they recorded early recanalization in 62%. They found a significant diminution of the infarction focus and improved left ventricular function, as compared with patients treated in the "classical" way by antiarrhythmic drugs, beta-blockers and vasodilatating drugs. The follow up of some other indicators is also in favour of significant improvement after thrombolytic treatment--thrombi in the left ventricle, cardiac decompensation, development of an aneurysm, myocardial rupture. Conversely an argument against thrombolytic treatment are more frequent haemorrhagic complications--16%. However, in these complications no deaths were recorded nor the need of an operation or discontinuation of maintenance anticoagulant treatment. In reperfused patients no hospitalization mortality was recorded. Reocclusions occurred most frequently during the first four weeks after treatment and only after intracoronary administration--10%. According to the authors this is due to residual stenoses more serious ones, 75% of the lumen--the higher incidence of reocclusions in significant stenoses is statistically evident. The only prevention of reocclusions is immediate follow up of PTCA after intracoronary thrombolysis. The intravenous administration of streptokinase in myocardial infarctions is according to the authors a safe method and they recommend its use in all coronary units in the CSSR.

The authors report on 18 patients with fresh transmural myocardial infarction (MI) and 5 patients with an abrupt change of stable into unstable angina pectoris (AP), in whom superselective intracoronary thrombolysis (SIT) was performed. All patients with unstable AP showed an improvement of subjective complaints and increased tolerance of exercise, even though a demonstrable angiographic effect of SIT was found only in 1 patient. Coronary occlusion disappeared in 13 patients with MI (72%). A significant improvement of local kinetic disturbances and of the global left ventricular function occurred in 50%, in-hospital death occurred only in the group in which recanalization did not succeed. Emphasis is placed on the necessity of checking the effect of SIT not only by documenting correction, of the coronary occlusion but also by evaluating the size of MI and the extent of disturbances of local and total left ventricular kinetics. The most accurate and practical method for this purpose is two-dimensional echocardiography. The authors developed their own echocardiographic indicators of the infarction focus--asynergy extent and asynergy index.