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Background Although Brain Natriuretic Peptide (BNP) provides strong prognostic information of an unfavorable outcome in patients with acute heart failure (AHF), there is little information of its relevance as a biomarker for outcomes in COVID-19 and its complications Purpose To evaluate the association of increased BNP levels with complications and in-hospital mortality in a cohort of hospitalized COVID-19 patients. Methods The study included COVID-19 patients with data on BNP levels included in the ISACS COVID-19 registry. The population was categorized according to the presence of peak BNP levels ≥100 pg/mL during hospitalization. Primary outcomes included in-hospital mortality, AHF or acute respiratory failure (ARF, defined as PiO2/FiO2 Results Of the 1152 patients included in the study, 615 (53.4%) had elevated BNP levels. These subjects were older (69.9±13.8 vs 59.1±16.8, p-value Conclusions In COVID-19, blood BNP level not only appears to be predictor of in-hospital mortality and AHF but was also independently associated with an increased risk of ARF. This finding supports the routine use of BNP in all patients admitted to hospital for COVID-19, regardless of a prior history of CVD. Funding Acknowledgement Type of funding sources: None.

Background Patients with cancer represent a uniquely vulnerable population not only with higher susceptibility to COVID-19 but also at increased risk for death. However, detailed information on causes of death and the contribution of pre-existing health conditions to death yet is missing. Purpose This study focuses on the implications of COVID-19 in the cardiovascular health of patients with cancer by assessing the relation between cancer and de novo acute heart failure (AHF) with in-hospital mortality. Methods The initial population consisted of 3968 patients included in the ISACS COVID-19 registry between March 2020 and February 2022. Of these, 546 patients with chronic HF were excluded, leaving a final population of 3422. Patients were divided in two groups according to the presence or absence of a cancer diagnosis at the time of hospitalization for COVID-19. Primary outcomes were incidence of in-hospital mortality or AHF during hospitalization. Association between cancer and outcomes was estimated using multivariable logistic regression analyses. Subsidiary analysis was conducted to evaluate differences between patients with prior vs active cancer. Results Of the 3422 patients included in the study, 468 patients had cancer (8.2% active, 5.5% past cancer). Cancer patients were older (68.9±13.4 vs 63.3±15.6, p-value Conclusions The incidence of AHF in cancer patients with COVID-19 is high. Patients with active cancer are also at high risk for mortality. This has implications for cardiac monitoring and chemotherapy administration during COVID-19. Funding Acknowledgement Type of funding sources: None.

Background It has been recently suggested that more than 15% of patients with ST-segment–elevation myocardial infarction (STEMI) lack any of the standard modifiable risk factors (cigarette smoking, diabetes, hyperlipidemia, and hypertension -SMuRFs). This claim implies that other factors play a significant role in development of STEMI and has led to considerable interest in genetic causes of coronary heart disease including family history (FHx) Purpose To investigate whether FHx may be a significant driver for STEMI in patients without SMuRFs. Methods We analyzed 11,840 patients with ACSs, without evidence of prior cardiovascular disease (CVD) enrolled in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry between January 2010 to January 2021. Main outcome measures were the adjusted rates of STEMI and 30-day mortality from STEMI using multivariable logistic regression models. Patients presenting with non-ST elevation acute coronary syndromes served as controls. Results Among patients with STEMI, at least 1 of the 4 conventional risk factors was present in 88.1% of women and 86.7% of men. Overall, 3,194 patients (27.0%) self-reported a FHx of CV disease, defined as a first-degree relative with premature CV events (men, age Conclusions In direct contrast with recent findings, almost 90% of patients with STEMI have SMuRFs. Self-reported FHx is not a significant risk factor for development of STEMI and related high rate of CV mortality in patients without SMuRFs. Although research on genetic causes of heart disease is important, public health policies, and research efforts should place significant emphasis on the 4 SMuRFs and the lifestyle behaviors causing them to reduce the epidemic of STEMI. Funding Acknowledgement Type of funding sources: None.

ST-segment elevation myocardial infarction (STEMI) diagnosis is essentially based on three elements: (1) typical chest pain that also represents the clinical counterpart of acute myocardial ischemia onset due to acute coronary occlusion and might be taken as time zero on which all successive delays should be calculated, (2) electrocardiogram (ECG) changes of the ST-T segment that are persistent (> 20 min) and evolve in time whereas they might soon present with a new pathological (> 40 ms duration) Q wave, and (3) critical abnormalities of high sensitivity cardiac troponin of either T or I types that should be higher than certain levels (> 5–14 pg/mL), which represent the respective and recommended upper reference limit. Although it should be important to have these limits measured in relation to the local population, and both gender and age ranges should be considered along with the specific essay used, short-term repetition of cardiac troponin assays may rule out the probability of acute coronary syndromes or confirm the presence of STEMI.

Substantial advances in the management of ST-segment elevation myocardial infarction (STEMI) have occurred in the last decade. A disturbing note, however, is the recognition that the rate of cardiovascular mortality after discharge is still unacceptably high. With many therapeutic options available, the clinician is challenged to identify the safest and most effective treatment for long-term survival of each individual patient. Steps in this process may include simple prognostic markers that reflect pathophysiologic mechanisms to be identified. Empiric testing and further confirmation of new or old score markers remain essential.

In ST-elevation myocardial infarction patients, every single minute is essential for the prognosis. Reperfusion therapy is the primary goal. Dissolution or removal of the intracoronary thrombus provides the best chance for mortality reduction. It can be achieved by pharmacological (fibrinolysis) or mechanical-catheter-based (primary percutaneous coronary intervention) approaches within 12 h. Optimal adjunctive medical therapy includes aspirin, nitrates, P2Y12 inhibitors, anticoagulants, beta-blockers, angiotensin converting enzyme inhibitors, and statins. Secondary prevention strategies are necessary to prevent hospital readmissions, new cardiovascular events, and premature death.

During the past 10 years, the health of people in Eastern Europe and the former Soviet Union has undergone changes very different from the health patterns seen in their Western counterparts. Mortality from cardiovascular disease has been decreasing continuously in the USA and many Western European countries, but it has increased or remained unchanged in many of the states of Eastern Europe. Analysis of this phenomenon has been hindered by insufficient information. The International Registry of Acute Coronary Syndromes registry study in Transitional Countries (ISACS-TC) is both a retrospective - over a 1-year period - and prospective study which was designed in order to obtain data of patients with acute coronary syndromes (ACSs) in countries with economy in transition in Central and Eastern Europe, and herewith control and optimize internationally guideline recommended therapies in these countries. Adhesion to the project was given by 112 Collaborating Centres in 17 countries with economy in transition (Albania, Bosnia and Herzegovina, Belarius, Bulgaria, Croatia, Hungary, Kosovo, Latvia, Lithuania, Macedonia, Moldova, Montenegro, Romania, Russian Federation, Serbia, Slovakia, Slovenia, and Ukraine). A total of 47 cluster sites in 11 countries in Central and Eastern Europe are currently collaborating in ISACS-TC. The registry encourages optimal individualization of evidence-based therapies and the international patient body ensures good representation of multiple practice patterns. It may help to make an additional improvement in clinical outcomes of countries with economy in transition.

The aim of this study is to describe the ultrastructural changes in anoxic rat hearts perfused with Langendorff technique and the effects of reoxygenation on myocardial cells. After 1 h of aerobic perfusion, the hearts were subjected to 30 min of anoxia and then to 5 and 30 min of reoxygenation. The following findings were observed: after 30 min of anoxia, loss of mitochondrial matrix and dilatation of the intracristal spaces. After 5 min of reoxygenation: diffuse mitochondrial swelling, sarcomeres disarranged and out of register, several contraction bands. After 30 min: no evidence of cytoplasmic or mitochondrial swelling. The maximum enzyme release was observed when a wide myofibrillar contraction occurred. These results may suggest that the oxygen availability consequent to myocardium anoxia lead to further cell damage.

Logistic equation is proposed as a new mathematical model describing the course of the ascending branch of the serum creatine kinase curve: E(t) = K divided by 1 + ea-bt where: E(t) = CK concentration at time t (mU/ml); t = time in hours from the onset of enzyme release; e = natural logarithm base; K = horizontal asymptote of the curve (maximal enzyme activity); a, b = typical variable prameters of the curve. Prediction is based on the identification of the infection point of the ascending branch of the serum CK curve. The enzyme activity corresponding to this point is half of the maximal one. In 14 patients with acute myocardial infarction infarct size (CK-g-Eq) was calculated by the method of Shell et al. In these patients the average differences between observed and predicted parameters were respectively (X +/- SD): -0.64 +/- 2.13 h for the maximal activity time; 16.57 +/- 53.15 mU/ml for the maximal activity and 0.02 +/- 2.44 CK-g-Eq for the infarct size. In detail it can be observed that the average of the per cent differences between observed and predicted infarct size was 1.10 +/- 5.31% and the maximal per cent difference only +10.40%.

Isoenzymes of alkaline phosphatase (ALP) and total gamma-glutamyltransferase (gamma GT) have been studied in patients with increased total ALP. Fractionation of alkaline phosphatase yielded clinical information which could not be obtained by determination ALP and gamma GT alone. 1. There was a high degree of correlation between isoALP 1 (biliary band) and total gamma GT. 2. The ALP2 fraction increases after cytolysis in acute and chronic hepatitis. 3. A new ALP4 fraction appears, probably due to fibroblastic activity, in some histological types of cirrhosis.

85 patients with acute myocardial infarction (AMI) have been studied retrospectively. 25 of them died within the 40th day after admission. Serum CK release during AMI can be described by the logistic equation: (formula: see text). We have evaluated for each patient both the final infarct size (calculated at the time of maximal enzyme activity: Tmax) and the initial one (calculated at the inflection time of the curve: Tflex). The total enzyme release in 1 ml of blood has been considered as an indirect index of infarct size. Our results show a good correlation between the initial and the final infarct size. We have considered as limits between survivors and non-survivors the following values: 2.2 IU/ml and 0.6 IU/ml for total CK release at Tmax and at Tflex respectively. The percentage of mortality in those groups is very similar (69% and 75%). However only 38% of non-survivors shows higher values than both 2.2 IU/ml and 0.6 IU/ml. The calculation of infarct size at Tflex allows an early identification of the high risk patients.

In the present study we used a model of underperfusion or anoxia followed by reperfusion to assess the role of glycolysis by substituting pyruvate or mannitol for glucose as substrate. Hearts were removed from male Sprague-Dawley rats (250-400 g) and perfused by the technique of Langendorff. The perfusate was Krebs-Henseleit bicarbonate buffer gassed with 95% O2, 5% CO2 or with 95% N2, 5% CO2 mixture and containing substrates as can be seen in the figures. The mild ischemia was obtained by reducing the perfusion pressure by 70%, from 60-70 cm H2O to 10-20 cm H2O. The coronary flow was rapidly reduced to 0.8 +/- 0.03 ml/min within the first 5 minutes. After mild ischemia anaerobic glycolysis was accelerated because lactate production in ischemic hearts perfused with glucose (36.2 +/- 15.3 microM/g/min-1) was higher than in the ischemic hearts perfused with mannitol (6.8 +/- 1.9 microM/g/min-1). During mild ischemia or anoxia there was little difference in the rate of release of creatin-kinase for all the substrates tested, but major differences become apparent on reperfusion. In that period the highest values of CK release were found in mannitol perfused hearts, the lowest in glucose perfused hearts. These results suggest that the rate of glycolytic flux during mild ischemia or anoxia may prevent enzyme release. The beneficial effect of glucose has been observed also during reperfusion. In fact enzyme release was higher in hearts reperfused with glucose than with pyruvate. When pyruvate is the only exogenous substrate available for isolated oxigenated hearts, tissue levels of citric acid cycle intermediates are high and oxidation of these substrates can account for 100% of the oxygen consumption. Therefore we suppose that oxidation of noncarbohydrate substrates such as pyruvate in reperfusion is complicated by the high mitochondrial damage. As a consequence anaerobic glycolytic pathway may play a special role in the maintenance of the membrane integrity also in the early phases of reperfusion.

With this report we communicate the results of a method for the fractionation of the isoenzymes of gamma-GT in human serum based on a modified technique of Hetland et al., using cellulosa acetate. With this method we observed the appearance of a complex of four band representing: gamma-GT1 = prealbumin-albumin, gamma-GT3 = alpha 1-globulin, gamma-GT3 = alpha 2-globulin, gamma-GT4 = beta-globulin. It has been noted that the gamma-GT2 is the only fraction which constantly appears. This isoenzyme also corresponds to the form, fisiologically present in serum and is presumably preduced in the cells of the bileduct. In the results we observed the appearance of gamma-GT1 only in the course of processes involving certainly cholestasis. This fraction was once reported by other AA., but it has an unknown origin. It was not possible to correlate the appearance of the fractions gamma-GT3 and gamma-GT4 with any specific pathology alterations even though Hetland et al. have affirmed that the gamma-GT3 band derives from hepatic parenchyma.

We have studied 135 subjects of whom 100 were normal individuals; 10 with diagnosis of acute myocardial infarction (AMI); 10 with angina pectoris; 10 undergoing cardiac catheterism; 5 who underwent open heart surgery. To verify the radioimmunoassay usefulness of CPK cardiac isoenzyme (CK-RIA), of lactate dehydrogenase [LDH (H4)], of myoglobin (MG) in the diagnosis of ischemic disease, we have determined for serum samples: LDH (H4) by radioimmunoassay and HBDH by biochemical assay; CK by biochemical assay; CK-MB by biochemical and radioimmunological assay; MG by radioimmunoassay. The results indicate MG as a sensitive marker for the diagnosis of AMI. In fact serial serum determinations in patients with AMI showed myoglobin levels in 60% of the cases within 1 h after the onset of pain. The CK-RIA is the most sensitive test to evaluate infarct size and LDH (H4) conditioned by the amount of intracellular lactate is an useful test to evaluate myocardial anoxia.

28 patients with acute myocardial infarct (AMI), 10 of whom presenting left ventricular failure, have been studied. By serial determinations of alpha-hydroxybutyrate dehydrogenase (HBDH) and creatine kinase (CK), the releasing times (RT) and the total releases (TR) of the two enzymes have been calculated, according to the Shell's method modified by Norris. The RT of HBDH have resulted more prolonged in the decompensated patients (48.1 +/- 16.0 vs 37.3 +/- 9.1 h; t = 2.297; p less 0.05). Highly significant correlations have been demonstrated between the total releases of the two enzymes; r = 0.816, p less than 0.01 (with failure); r = 0.766, p less than 0.001 (without failure). For neither enzyme, instead, significant differences have been shown between the TR of the two patient groups. The following conclusions can be drawn. 1) infarct size probably is not the only factor able to induce heart failure during AMI; 2) infarct size can be equally calculated from both HBDH or CK values, though some considerations may make preferable the choice of CK; 3) the more prolonged release of HBDH during heart failure suggests the hypothesis that lactate accumulation is an important factor influencing the appearance of this compliance.

It has been experimentally established that, to cause myocardial necrosis, an ischemic injury must be of sufficient duration and severity [1]. However, even when ischemia is brief and necrosis does not occur, there is a lengthy delay in the return of injured myocardium to normal function and metabolism [2–5].

We have examined alkaline phosphatase in five commercial sera employing three analyzers. Alkaline phosphatase in three samples is underestimated or overestimated according to the analyzers used. Therefore we have studied the isoenzymatic fractions employing the fractionation of alkaline phosphatase on celluloseacetate. Alkaline phosphatase isoenzymes have physical and biochemical marks different from human sera. In human sera on the contrary have not noticed any difference according to the analyser used.

ACCF : American College of Cardiology Foundation ACS : acute coronary syndrome AHA : American Heart Association CAD : coronary artery disease CABG : coronary artery bypass grafting CKMB : creatine kinase MB isoform cTn : cardiac troponin CT : computed tomography CV : coefficient of variation ECG : electrocardiogram ESC : European Society of Cardiology FDG : fluorodeoxyglucose h : hour(s) HF : heart failure LBBB : left bundle branch block LV : left ventricle LVH : left ventricular hypertrophy MI : myocardial infarction mIBG : meta-iodo-benzylguanidine min : minute(s) MONICA : Multinational MONItoring of trends and determinants in CArdiovascular disease) MPS : myocardial perfusion scintigraphy MRI : magnetic resonance imaging mV : millivolt(s) ng/L : nanogram(s) per litre Non-Q MI : non-Q wave myocardial infarction NSTEMI : non-ST-elevation myocardial infarction PCI : percutaneous coronary intervention PET : positron emission tomography pg/mL : pictogram(s) per millilitre Q wave MI : Q wave myocardial infarction RBBB : right bundle branch block sec : second(s) SPECT : single photon emission computed tomography STEMI : ST elevation myocardial infarction ST–T : ST-segment –T wave URL : upper reference limit WHF : World Heart Federation WHO : World Health Organization Myocardial infarction (MI) can be recognised by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology. It is a major cause of death and disability worldwide. MI may be the first manifestation of coronary artery disease (CAD) or it may occur, repeatedly, in patients with established disease. Information on MI rates can provide useful information regarding the burden of CAD within and across populations, especially if standardized data are collected in a manner that …

Background: We describe the clinical characteristics, treatments and in-hospital case-fatality rates in an unselected population of patients admitted for acute myocardial infarction. Methods: From January 2000 to June 2007, we tracked consecutive patients who were admitted to 7 tertiary referral and 21 county hospitals in Romania for medical treatment of ST-segment elevation acute myocardial infarction. These patients were enrolled in the Romanian Registry for ST-segment Elevation Myocardial Infarction. For this prospective study, we collected data on demographic characteristics, cardiovascular risk factors, various aspects of treatment for myocardial infarction, and in-hospital death. Results: The 9186 patients in the study group had a mean age of 63.8 years. The median time from onset of symptoms to thrombolysis was 230 (interquartile range 120-510) minutes. Of the 9186 patients, 4986 (54.3%) had hypertension, 1974 (21.5%) had diabetes mellitus, 3545 (38.6%) had lipid disorders and 4653 (50.7%) were smokers. The in-hospital mortality rate was 12.7% (1170 deaths). The study group consisted of 2893 women and 6293 men. The women were older than the men and had higher rates of hypertension and diabetes mellitus but were less likely to be smokers. A smaller proportion of women than men presented within 2 hours after onset of symptoms (23.1% v. 34.4%, p < 0.001). Smaller proportions of women received thrombolytics (40.8% v. 53.5%, p < 0.001), anticoagulants (93.4% v. 95.2%; p = 0.001), antiplatelet agents (88.3% v. 91.2%, p < 0.001) and primary percutaneous coronary interventions (1.5% v. 2.2%, p = 0.030). The risk of in-hospital death was greater for women, even after adjustment for confounders (odds ratio 1.33, 95% confidence interval 1.13-1.56; p < 0.001). Interpretation: The rates of reperfusion therapy for patients with acute myocardial infarction were low, and in-hospital case-fatality rates were high in this study. Excess in-hospital mortality was more pronounced among women.

Background: Diabetic (DM) patients are at increased risk of cardiovascular events after an acute coronary syndrome, yet it remains unknown whether they derive enhanced benefit from an invasive strategy. Objective: We investigated the relation between coronary revascularization by percutaneus coronary intervention (PCI) and in-hospital survival of DM patients admitted to hospitals with a diagnosis of Unstable angina/ Non-ST-elevation myocardial infarction (UA/NSTEMI). Methods: This was a prospective cohort study using data from the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACSTC, NCT01218776) registry on patients admitted to the coronary care units of 58 Eastern European hospitals from January 2010 to February 2015. A total of 4,996 first-day survivors who were admitted with a diagnosis of UA/NSTEMI were included. To avoid survival bias, a landmark time was set to 24 hours after hospital admission. Patients who died before the landmark time were excluded. Patients, who had undergone coronary artery bypass grafting, were also excluded leaving a final study population of 4,965 patients. Results: The study populations consisted of 4,965 NSTE-ACS patients. There were 1,381 patients (27.8%) with DM. Patients with DM were older and prevalently women, and had higher rates of hypercholesterolemia, hypertension, prior cardiovascular events and chronic kidney disease. They had more severe clinical presentation and higher rates of atypical chest pain. Patients with DM underwent less (p

AIMS: The purpose of this review was to compare quality of care and outcomes following acute coronary syndrome (ACS) in Central and Eastern European Transitional (CEET) countries. METHODS: This was a review of original ACS articles in CEET countries from PubMed, ISI Web of Science, Medline and Embase databases published in English from November 2003 to February 2014. RESULTS: Seventeen manuscripts fulfilled the search criteria. Of 19 CEET countries studied, there were no published ACS management or outcome data for four countries. In-hospital mortality for patients with acute myocardial infarction (AMI) ranged from 6.3% in the Czech Republic to 15.3% in Latvia. In-hospital mortality for ST-elevation myocardial infarction (STEMI) ranged from 3.0% in Poland to 20.7% in Romania. For STEMI, primary percutaneous coronary intervention (PCI) ranged from 1.0% to over 92.0%, fibrinolytic therapy from 0.0% to 49.6%, and no reperfusion therapy from 7.0% to 63.0%. CONCLUSION: Many CEET countries do not have published ACS care and outcomes data. Of those that do, there is evidence for substantial geographical variation in early mortality. Wide variation in emergency reperfusion strategies for STEMI suggests that acute cardiac care is likely to be modifiable and if addressed could reduce mortality from ACS in CEET countries. The collection of ACS care and outcomes data across Europe must be prioritised.

Background: The impact of a mechanical reperfusion strategy beyond a 24-hour cut-off is still unsettled. Optimal management for these patients remains uncertain. Purpose: We sought to investigate the effect of delayed primary percutaneus coronary intervention (p-PCI) – 24 to 48 hours after symptom onset-for patients with ST-segment elevation myocardial infarction (STEMI) not undergoing timely reperfusion therapy. Methods: We conducted a cohort study of 1822 STEMI first-day survivors who were admitted with a diagnosis of STEMI, but did not receive any mechanical or pharmacological reperfusion therapy within 24 hours from symptom onset. We used multivariable logistic regression combined to landmark analysis to evaluate the effect of delayed p-PCI on in-hospital mortality and incidence of severe left ventricular dysfunction (LVD; ejection fraction

Purpose: We explored clinical characteristics and outcome associated with atypical chest pain (CP) in patients with diagnosis of ACS. Methods: Data of 8947 patients (32.4% women) from the International Survey of Acute Coronary Syndrome in Transitional Country (ISACS-TC) were reviewed in our comprehensive coordinating center. Only patients with admission and discharge diagnosis of ACS were considered. Results: There were 778 patients with atypical CP for the index event. These patients were significantly (p12 hrs to arrive to hospital; absence of typical CP doubled the probability (OR: 2.18; CI: 1.89–2.55) to late hospital presentation. Interestingly, patients without typical CP were significantly more likely to exhibit signs of heart faliure (42.8% vs. 22.1%), although they less frequently had STEMI as index even. In-hospital mortality rate was in the overall cohort 8.2% (STEMI: 9.1%, NSTEMI: 8.8%, UA: 2.1%). Yet, the mortality was significantly greater for patients with atypical CP (STEMI: 19.8%, NSTEMI: 19.3%) than for those with typical CP (STEMI: 6.7%, NSTEMI: 7.1%). It should be noted, however, that patients with atypical CP were less likely (p

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

No abstract available - Guidelines

Cardiovascular disease (CVD) is estimated to be the leading cause of death and disability-adjusted life years lost worldwide being coronary heart disease the most prevalent form of heart disease. The underlying cause of most CVD is atherosclerosis, a process mainly governed by lifestyle factors. Several epidemiological studies have enabled the recognition of the major risk factors for CVD development, ‘the so-called conventional risk factors’. Identification of such global risk factors have led, in turn, to the development of risk-prediction algorithms and cardiovascular risk models for men and women. Indeed, during the last years, there has been increasing credit of the importance of CVD in women accompanied by growing awareness of gender differences in natural history, preventive strategies, treatment, and prognosis of CVD. Classical risk factors, however, cannot fully explain the excess cardiovascular risk, and at least 25% of all future events occur in individuals with only one of the classical risk factors. This scenario has prompted the interest for discovering new risk factors. Time-trend analysis of surveys by the European Society of Cardiology (EUROASPIRE surveys) has reflected, however, that large proportions of European coronary patients are failing to achieve lifestyle, risk factor, and therapeutic targets for the prevention of CVD leaving room from improvement. Moreover, although overt CVD takes place during adulthood, lifestyle and dietary changes that have occurred over the last two decades support the need to instigate primary prevention measures during childhood as the best strategy to retard atherogenic processes.

It is essential that context-appropriate health research and health interventions take place in countries with economy in transition. The aims of this study were to describe the clinical characteristics, management, and in-hospital outcomes of acute coronary syndrome (ACS) patients with heart failure (HF) in Montenegro and Serbia. The data of this study are a framework of the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC; [NCT01218776][1]), a multi-national and multicentre registry of patients hospitalized with ACS in the European countries that emerged from the Socialist era. The present analysis focused on participants admitted to 15 hospitals in Montenegro and Serbia with a diagnosis of ACS during the period between October 2012 and August 2013. Among 1115 patients, 94 (8.4%) had an admission diagnosis of HF (Killip Class II or III). Heart failure patients were significantly older ( P < 0.001). Heart failure was more frequently associated with hypertension. When compared with patients presenting without HF (Killip Class I), those with HF had lower rates of reperfusion therapy either by percutaneous coronary intervention (47.9 vs. 60.7%, P = 0.015) or by fibrinolysis (2.1 vs. 11.8%, P = 0.004). In multivariate logistic regression analysis, older age, prior coronary artery bypass graft, and ST-segment elevation myocardial infarction were the relevant predictor of HF at admission. Heart failure on admission was associated with a marked increase in mortality rates during hospitalization (13.8 vs. 3.7%, P < 0.001). After adjustment for differences in clinical characteristics, HF was still associated with higher mortality (odds ratio 2.88, 95% confidence interval 1.22–6.79, P = 0.016). Heart failure is observed in nearly 9% of patients with ACS in Serbia and Montenegro and is also associated with a significant increase in in-hospital mortality. More aggressive treatment of these patients is warranted to improve prognosis. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01218776&atom=%2Fehjsupp%2F16%2Fsuppl_A%2FA61.atom