Objective: The current picture of cardiology is the result of great therapeutic advances and large clinical trials. Perhaps the most spectacular impact seen in recent decades has been among patients with coronary artery disease, whose life expectancy and quality of life have been profoundly altered by the introduction of percutaneous myocardial revascularization into practice. Design and method: The study was carried out in the Carol Davila Central Military Emergency University Hospital in Bucharest, on a group of patients with acute coronary syndrome with ST segment elevation, treated interventionally in our center through the RO-STEMI program. In the period 2015-2018, 1316 STEMI procedures were performed, of which 107 presented stent restenosis of various degrees, visually quantified by the angiographer. The presented study is observational, analytical, retrospective. This study can be considered a real world one, because the phenomenon of stent restenosis was studied and objectively correlated with clinical practice, reflecting the experience of our center. Results: HT represented an indicator present in the current study in a significant proportion - 80% of the patients in the study, being more frequent in men. A higher prevalence of arterial hypertension was observed in smoking patients. It has been noted that the presence of HT in overweight or HT associated with dyslipidemia increases the risk of AMI or other acute events (stroke). In the hypertensive patients studied, the percentage of major events was 20% higher, but without a statistically significant influence. The main risk factor incriminated in the determination and occurrence of the process of intraluminal proliferation resulting in intrastent restenosis was diabetes mellitus. In patients with DM, the percentage of events was 20% higher than in patients without DM. Diabetes, dyslipidemia, stent characteristics were independent risk factors for in-stent restenosis (p <0.05). Conclusions: In conclusion, for patients with risk factors indicating PCI, identification and personalized patient management are warranted to prevent in-stent restenosis. Long-term follow-up of patients with STEMI is essential both for their prognosis and for the individualization of this population through studies.

Background and aim. Coronary artery disease (CAD) is one of the most important causes of death worldwide. ST-elevation myocardial infarction (STEMI) is an acute form of presentation in patients with CAD. Percutaneous coronary intervention (PCI) is the treatment of choice in STEMI patients. Generally, a stent is placed after the culprit lesion is dilated in order to ensure the patency of the coronary artery. In-stent restenosis (ISR) is a possible chronic complication in this setting. The following study is one of the few of its kind, since it investigates ISR in a cohort of Romanian patients who underwent PCI in the setting of STEMI. Our current descriptive study aims at highlighting the characteristics of these patients and identifying potential risk factors in this specific population, which could be validated by a further larger study. Methods. We studied 68 patients from “Dr. Carol Davila” Central Military Emergency University Hospital in Bucharest, Romania, who presented with STEMI in 2016. The mean time for angiographic reevaluation was 111 days. Results. 94% (64) of the patients underwent primary PCI, while in 6% (4) of the cases thrombolysis was initially attempted before PCI. The most prevalent risk factors that we identified were: arterial hypertension (61%), dyslipidemia (60%) and smoking or history of smoking (47%). The anterior myocardial infarction was the most prevalent (49%). Only 6% of the patients had a documented history of CAD, while on the other hand chronic occlusions were observed in most patients (85%). Of note is that only 11% of the patients reported recurrent angina before the angiographic reevaluation. Conclusion. Common cardiovascular risk factors are also involved in ISR. Their poor management in the case of Romanian patients with STEMI increases the risk of ISR. The lack of symptoms in patients with ISR constitutes a warning sign for clinicians and shows that ISR is a complication which can be easily omitted. Therefore, its incidence is probably underestimated.

Objective: This case underlines the importance of thoroughly investigating alternative causes for hypertension in patients with atypical presentations, regardless of their age and risk factors. Design and method: Clinical case. Results: We present the case of a 68 year old woman without known cardiovascular diseases who came to the ER complaining of headaches, palpitations and chest pain of two hours duration. Upon admission, her blood pressure was 300/150 mmHg - overlapping values in all limbs with no asymmetric pulse. Heart rate was 140 bpm, rhythmic and without heart murmurs, abdomen without murmurs or palpable masses. Her ECG showed diffuse ST segment depression and high sensitivity troponin level at 0 h was 258 ng/L. Cardiac echo showed no wall motion abnormalities and no hypertrophy of the left ventricle. Her BP was acutely controlled with ACEi and iv nitroglycerin. Two hours after admission her BP returned to normal and remained within normal range without medication. Her ECG showed normal sinus rhythm with no other pathological findings. Coronary angiography was performed the next day and showed no atherosclerotic lesions. At this stage, her diagnosis was type 2 MI caused by severely elevated BP. Blood and urine tests revealed high levels of serum catecholamines and urinary normetanephrines - over 4000 micrograms/24 h. Abdominal ultrasound found a mass near her right kidney. Abdominal CT confirmed the presence of a nodular 5 × 3 cm mass in the right adrenal gland, compatible with a pheochromocytoma. She was submitted to laparoscopic adrenalectomy with normalization of her BP after the surgery. During follow-up, the patient presented with persistently normal blood pressure and normal ECG aspect without any chronic medication. Conclusions: Pheochromocytoma is a rare neuroendocrine tumour originating in the adrenal gland medulla. Sustained or paroxysmal arterial hypertension is sometimes associated with the classic triad: episodic headaches, profuse sweating and tachycardia. A timely diagnosis and an effective therapeutic strategy are important, as this is a potentially fatal disease with a very good prognosis if discovered and treated early. It should be excluded in patients with high paroxysmal BP, especially if under 20 or over 50 years old.

Objective: The case highlights the importance of diagnosing secondary hypertension and adequate treatment in the setting of a patient with classical cardiovascular risk factors which would otherwise make primary hypertension the most likely diagnosis. Design and method: Clinical Case Results: A 57 year-old male with cardiovascular risk factors (smoking, dislypidemia), grade 2 essential hypertension (ESC/ESH) and G3a stage chronic kidney disease (CKD) presents to our clinic with fatigue and persistent high blood pressure values despite treatment with ACEi. Clinical exam was unremarkable except for a 10mmHg difference between the arm and foot systolic blood pressure. The 24-hour ambulatory blood pressure monitoring revealed a non-dipping profile, with a mean blood pressure value of 150/100mmHg. TTE was performed and the following were observed: bicuspid aortic valve with tight aortic stenosis (mean AV PG > 40mmHg, AVA = 1.12cm2) and LV systolic dysfunction (LVEF = 35%). TEE was also performed and confirmed the bicuspid aortic valve. Given the context of the patient, computed tomography angiography (CTA) was the investigation of choice in order to visualize the aorta. Postductal coarctation was detected with a hypoplastic thoracic aorta and multiple collateral vessels. The coronary angiogram was normal. The ACEi was stopped and the patient received a dihydropyridine calcium channel blocker in combination with an adolsterone receptor antagonist with a favourable course. Aortic valve replacement surgery with mechanical valve implantation was recommended. Considering the multiple collateral vessels and complex vascular morphology, surgical correction of the coarctation was considered no longer feasible Conclusions: CoA was the actual cause for the persistent high blood pressure values in an adult male with cardiovascular risk factors who was believed to have essential hypertension. In the setting of aortic stenosis with impaired LV systolic function, high blood pressure values are not typical. Taking into account the BAV, the clinical suspicion of CoA was high and prompted further investigations. The CKD is the result of the the underperfusion of the kidneys secondary to the CoA and the use of ACEi.

Mortality rates from acute myocardial infarctions have been declining in the past 4 decades since percutaneous coronary interventions (PCIs) became a valid therapeutical option. PCI is a non-surgical revascularization procedure in which blood flow in an occluded or narrowed epicardial coronary artery is re-established by inflating an angioplasty balloon in order to remove the blockage, followed by the insertion of a stent in order to maintain the patency of the artery. Since the late ‘70s when the first bare metal stents (BMS) became available, progress has been made in developing new types of stents in order to lower the incidence of two important and feared complications: and thrombosis restenosis.While thrombosis is manageable and preventable with antithrombotic therapy, restenosis is a more complex issue of which many clinicians may not be aware or underestimate. The review would like to summarize the current knowledge from the literature on stent restenosis and present to clinicians some tools for recognizing, or at least suspecting, restenosis in their patients.