Objective: There are no data about the prevalence of silent coronary artery disease in asymptomatic severe aortic stenosis patients with normal exercise testing. Importantly, unmasking significant coronary artery disease in patients with aortic stenosis could influence the choice/timing of treatment in these patients. Method: Exercise testing was performed on semi-supine ergobicycle. Cardiopulmonary analysis during exercise testing, echocardiography, and laboratory analysis at rest was done. Standard clinical/electrocardiography criteria were assessed for symptoms/signs of ischemia during/after exercise testing. In patients with normal exercise testing coronary angiography was performed using standard femoral/radial percutaneous approach. Coronary stenosis was considered significant if >70% of vessel diameter or 50%–70% with fractional flow reserve ≤0.8. Results: Total of 96 patients with normal exercise testing were included (67.6 years, 50.6% males). No patient had any complication or adverse event. The P _mean was 52.7 mmHg, mean indexed aortic valve area was 0.36 cm²/m² and left ventricular ejection fraction, 69.5%. 19/96 patients (19.8%) had significant coronary artery disease on coronary angiography. Multivariate logistic regression analysis revealed brain natriuretic peptide and blood glucose as independent predictors of silent coronary artery disease. Brain natriuretic peptide value of 118 pg/ml had sensitivity/specificity of 63%/73% for predicting coronary artery disease (area under the curve 0.727, P = 0.006). Conclusion: Our results are the first to show that in patients with severe aortic stenosis, normal left ventricular ejection fraction,, and normal exercise testing, significant coronary artery disease is present in as many as 1/5 patients. In such patients, further prospective studies are warranted to address the diagnostic value of brain natriuretic peptide in detecting silent coronary artery disease.

Caesarean section is a challenging intervention in patients treated with dual antiplatelet therapy. We present a case of a 32-year-old pregnant woman experiencing large acute myocardial infarction (MI) of the anterolateral wall, complicated by cardiogenic shock in the 38th week of pregnancy, and treated with drug-eluting stent implantation and dual antiplatelet therapy (DAPT) consisting of aspirin and ticagrelor. Less than 24 h after the MI delivery started, an urgent Caesarean section was indicated. As multiplate aggregometry testing showed a relatively insufficient level of ticagrelor platelet inhibition and a moderate level of aspirin platelet inhibition, a Caesarean section was performed without discontinuation of ticagrelor, which was decided due to the need for emergency surgery. Local hemostatic measures including administration of tranexamic acid were applied. The patient did not experience excessive bleeding. A healthy male baby was born. To the best of our knowledge, this is the first reported case of surgery in pregnant women treated with DAPT without ticagrelor discontinuation.

Although numerous studies have shown that early post-infarction angina was a predictor of poor prognosis in patients with acute myocardial infarction, not a single study has considered this issue in the elderly. The goal of this study, based on a five-year follow-up of elderly patients with acute myocardial infarction, was to determine whether early post-infarction angina in the elderly had any influence on mortality and the incidence of additional coronary events. The study population consisted of 51 patients, aged 60 years or more, with acute myocardial infarction. Early post-infarction angina occurred in 31 subjects (Group 1), while it did not in 20 subjects (Group 2). Patients were monitored for five years and the incidences of death and new coronary events were recorded. A survival analysis was carried out using the Kaplan-Meier method. The survival analysis showed no difference between the observed groups concerning the following probabilities: death (p=0.9459), cardiac death (p=0.8253), myocardial reinfarction (p=0.7405), new coronary events (p=0.1708), unstable angina (p=0.1788), myocardial revascularisation (p=0.0691), and heart failure (p=0.7047j. In contrast to the younger population, where numerous studies have confirmed the link between early post-infarction angina and poor long-term prognosis, such findings could not be replicated in this study of the elderly population.

Introduction. Ventricular septal rupture (VSR) in the acute myocardial infarction (AMI) is a rare but very serious complication, still associated with high mortality, despite significant improvements in pharmacological and surgical treatment. Therefore, hybrid approaches are introduced as new therapeutical options. Case Outline. We present an urgent hybrid approach, consisting of the initial percutaneous coronary intervention (PCI) of the infarct-related artery, followed by immediate surgical closure of the ventricular septal rupture, for treatment of high risk, hemodynamically unstable female patient with AMI caused by one-vessel disease and complicated by VSR and cardiogenic shock. Since the operative risk was also very high (EUROSCORE II 37%), this therapeutic decision was based on the assumption that preoperative PCI could promptly establish blood flow and thereby lessen the risks, duration and complexity of urgent cardiosurgical intervention, performed on the same day. This approach proved to be successful and the patient was discharged from the hospital on the fifteenth postoperative day in stable condition. Conclusion. In selected cases, with high operative risk and unstable hemodynamic state due to AMI complicated by VSR, urgent hybrid approach consisting of the initial PCI followed by surgical closure of VSR may represent an acceptable treatment option and contribute to the treatment of this complex group of patients.

The efficacy of percutaneous coronary intervention (PCI) is often compromised by the need for repeat revascularization, because of restenosis development. Numerous studies have tried to establish the predictive value of different biochemical markers of restenosis, with conflicting results. The aim of this study was to assess the prognostic significance of inflammatory and lipid markers, and major antioxidant enzyme activity for the development of in-stent restenosis (ISR) following PCI. Serum high sensitive C-reactive protein (hs-CRP), soluble intercellular cell adhesion molecule-1 (sICAM-1), transforming growth factor-beta (TGF-?), lipoprotein(a) and oxidized low-density lipoprotein (oxLDL) levels, as well as serum extracellular superoxide dismutase (EC-SOD) and catalase (CAT) activity were determined in 44 patients before stent implantation procedure, and after 6-month follow-up. Results after follow-up revealed that, in patients that developed angiografically confirmed ISR, the increase in serum hs-CRP levels was significanty higher, compared to those without stenosis. Stent implantation induced compensatory increase in serum antioxidant enzyme activities at follow-up, with significantly lower CAT activity in patients with ISR, possibly contributing to stenosis development. No significant changes in circulating levels of ICAM-1, TGF-?, oxLDL and Lp(a) were observed between the groups. In conclusion, serum hs-CRP level and CAT activity may be considered as useful biochemical markers for monitoring patients during follow-up after stent implantation.

Cesarean section is a challenge intervention in patients treated with dual antiplatelet therapy. We present case of 32 years old pregnant woman experiencing large acute myocardial infarction (MI) of anterolateral wall complicated by cardiogenic shock in the 38th week of pregnancy treated with drug-eluting stent implantation and dual antiplatelet therapy (DAPT) consisting of aspirin and ticagrelor. Less than 24 hours after MI delivery started, urgent Caesarean section was indicated. As multiplate aggregometry testing showed a relatively insufficient level of ticagrelor platelet inhibition and a moderate level of aspirin platelet inhibition, Caesarean section was performed without discontinuation of ticagrelor, which was decided due to the need for emergency surgery. Local hemostatic measures including administration of tranexamic acid were applied. The patient did not experience excessive bleeding. A healthy male baby was born. To the best of our knowledge, this is the first reported case of surgery in pregnant women treated with DAPT without ticagrelor discontinuation.