SummaryBackgroundRemote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months.MethodsWe did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed.FindingsBetween Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91–1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed.InterpretationRemote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI.FundingBritish Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden.

BackgroundNicorandil, as a selective potassium channel opener, has dual action including coronary and peripheral vasodilatation and cardioprotective effect through ischemic preconditioning. Considering those characteristics, nicorandil was suggested to reduce the degree of microvascular dysfunction.MethodsThirty-two patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI) were included in the study. Index of microvascular resistance (IMR) was measured in all patients immediatelly after pPCI before the after administration of Nicorandil. ST segment resolution was monitored before intervention and 60 min after terminating the procedure. Echocardiographic evaluation of myocardial function and transthoracic Doppler derived Coronary flow reserve (CFR) of infarct related artery (IRA) was performed during hospitalization and 3 months later.ResultsIMR was significantly lower after administration of Nicorandil (9.9 ± 3.7 vs. 14.1 ± 5.1, p < 0.001). There was significant difference in ST segment elevation before and after primary PCI with administration of Nicorandil (6.9 ± 3.7 mm vs. 1.6 ± 1.6 mm, p < 0.001). Transthoracic Doppler CFR measurement improved after 3 months (2.69 ± 0.38 vs. 2.92 ± 0.54, p = 0.021), as well as WMSI (1.14 ± 0.17 vs. 1.07 ± 0.09, p = 0.004).ConclusionIntracoronary Nicorandil administration after primary PCI significantly decreases IMR, resulting in improved CFR and ventricular function in patients with STEMI undergoing primary PCI.

SummaryBackgroundSince serial analyses of NT-proBNP in patients with acute coronary syndromes have shown that levels measured during a chronic, later phase are a better predictor of prognosis and indicator of left ventricular function than the levels measured during an acute phase, we sought to assess the association of NT-proBNP, measured 6 months after acute myocardial infarction (AMI), with traditional risk factors, characteristics of in-hospital and early postinfarction course, as well as its prognostic value and optimal cut-points in the ensuing 1-year follow-up.MethodsFasting venous blood samples were drawn from 100 ambulatory patients and NT-proBNP concentrations in lithium-heparin plasma were determined using a one-step enzyme immunoassay based on the »sandwich« principle on a Dimension RxL clinical chemistry system (DADE Behring-Siemens). Patients were followed-up for the next 1 year, for the occurrence of new cardiac events.ResultsMedian (IQR) level of NT-proBNP was 521 (335–1095) pg/mL. Highest values were mostly associated with cardiac events during the first 6 months after AMI. Negative association with reperfusion therapy for index infarction confirmed its long-term beneficial effect. In the next one-year follow-up of stable patients, multivariate Cox regression analysis revealed the independent prognostic value of NT-proBNP for new-onset heart failure prediction (p=0.014), as well as for new coronary events prediction (p=0.035). Calculation of the AUCs revealed the optimal NT-proBNP cut-points of 800 pg/mL and 516 pg/mL, respectively.ConclusionsNT-proBNP values 6 months after AMI are mainly associated with the characteristics of early infarction and postinfarction course and can predict new cardiac events in the next one-year follow-up.

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.

Uvod Srčani zastoj u vanbolničkim uslovima je glavni uzrok neočekivane smrti u razvijenim zemljama, sa stopom preživljavanja od 5 % do 35%.1 Iako je za preživljavanje ovih bolesnika od najvećeg značaja pravovremeno preduzeta kardiopulmonalna resuscitacija, terapijske procedure primenjene nakon uspostavljana srčanog rada i spontane cirkulacije, kao što je terapijska hipotermija, mogu značajno da smanje mortalitet i poboljšaju funkcionalni neurološki ishod.2 Sigurnost i efikasnost terapijske hipotermije ispitane su u brojnim kliničkim studijama koje su pokazale veoma dobre rezultate, zbog čega se ova procedura sve više uvodi kao nova terapijska mera u cilju smanjenja posledica hipoksične povrede mozga nakon srčanog zastoja.3 Najče-šći uzrok srčanog zastoja u vanbolničkim uslovima je koronarna bolest, a najvažniji prediktori preživljavanja ovih bolesnika su oštećenje mozga i kardiovaskularni status. Prikaz slučajaBolesnik star 52 godine primljen je u Koronarnu jedinicu (KJ) KCS u postreanimacionoj komi nakon srčanog zastoja u vanbolničkim uslovima, a u okviru akutnog infarkta miokarda (AIM) inferoposterolateralne lokalizacije. Tokom prethodne noći iz sna ga je probudio jak bol u grudima, zbog čega se obratio službi Hitne pomoći koja je postavila dijagnozu, ordinirala dvojnu antitrombocitnu terapiju i transportovala bolesnika u salu za kateterizaciju srca KCS. Tokom transporta kod bolesnika dolazi do srča-nog zastoja, monitorski se registruje asistolija, te su započete mere kardiopulmonalne resuscitacije koje su nastavljene u ambulanti reanimacije Urgentnog centra. Registrovana je ventrikularna fibrilacija, bolesnik je defibrilisan i nakon 15 minuta od srčanog zastoja uspostavljena je srčana radnja i spontana cirkulacija. U stanju postreanimacione kome bolesnik je primljen u KJ, intubiran, veštački ventiliran, acijanotičan i afebrilan. U objektivnom nalazu nad plućima se registruje normalan disajni šum, na srcu pravilan ritam, vrednost krvnog pritiska iznosila je 100/50 mmHg, a srčane frekvence 130/min. Fizikalni nalaz abdomena i na ekstremitetima je bio bez osobenosti. EKG pri prijemu je pokazao ST elevaciju u inferolateralnim odvodima uz ST depresiju u odvodima V1-V4. Bolesnik je odmah preveden u salu za kateterizaciju radi primarne perkutane koronarne intervencije (pPCI). Na koronaroTerapijska hipotermija i primarna perkutana koronarna intervencija kod bolesnika u postreanimacionoj komi nakon srčanog zastoja u akutnom infarktu miokarda Medicinski fakultet Univerziteta u Kragujevcu, Kragujevac, Srbija Najčešći uzrok srčanog zastoja u vanbolničkim uslovima je koronarna bolest, a najvažniji prediktori preživljavanja su oštećenje mozga i kardiovaskularni status. Prikazan je slučaj bolesnika starog 52 godine, primljenog u Koronarnu jedinicu (KJ) u postreanimacionoj komi nakon srčanog zastoja u vanbolničkim uslovima, a u okviru akutnog infarkta miokarda (AIM). Nakon uspostavljanja spontane cirkulacije bolesnik je, uz odgovarajuću medikamentnu pripremu, upućen u salu za kateterizaciju srca KCS, gde je urađena aspiracija...