Lege Artis Medicinae

[Perioperative management of patients with coronary stent in case of interventions other than cardiac surgery - Part I. - Perioperative treatment of patients with coronary stent]

ZIMA Endre, MEZŐFI Miklós, BECKER Dávid, SZABÓ György, MERKELY Béla, PÉNZES István

OCTOBER 20, 2011

Lege Artis Medicinae - 2011;21(10)

[Percutaneous coronary intervention (PCI) is meant to optimalise cardiac status, that is, short-term and long-term outcomes. It is known from large Western databases that stent implantation is performed in 77-85% of coronary interventions, which means hundreds of thousands of new patients with stent every year. The great majority of these patients has to take platelet aggregation inhibitors, namely acetylsalicylic acid and thienopyridin, most often clopidrogel. It presents a major therapeutic dilemma when these patients require noncardiac surgery. First, surgery should be performed with the least possible blood loss, which would be optimal if the platelet aggregation inhibitor therapy - that is indispensable for a certain period because of the stent - was suspended. Second, stent thrombosis has to be avoided, which can only be achieved if platelet aggregation inhibitor therapy is continued. The aim of our paper is to summarise the current guidelines and the risk estimation on the basis of our current knowledge in the perioperative management of patients with coronary stent. In the first part, we overview the platelet aggregation inhibitor agents, their mechanisms of effect, stent types and the minimal therapeutic period to be strictly observed, which depends on the type of stent.]



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[Societal burden of blindness in Hungary]

NÉMETH János, NAGYJÁNOSI László, NAGYISTÓK Szilvia, TOLNAYNÉ Csattos Márta, SZABÓNÉ Berta Irén, KINCSE Éva, SZULYÁK Eleonóra, BOÉR Ibolya, HUNDZSA Gyula, KALÓ Zoltán, BERTA András

[OBJECTIVES - Blindness represents a significant health and economic burden worldwide as well as in Hungary. The aim of this research was to estimate medical and nonmedical expenses related to blindness of elderly patients (>60 years) in Hungary so that the results can be used for further analyses. METHODS - The data required for determining the socioeconomic burden of disesase were derived from the published literature, statistical databases and estimations of relevant experts. We divided the social burden of elderly blindness into public and private medical and nonmedical costs. In addition to direct costs (social care and subvention, conduct recourse, medical costs) indirect costs and lost revenues (unemployment, support to activities of daily living) were also calculated. RESULTS - The social burden of elderly blind patients was estimated as 53.35 million USD in 2009, 0.03% of the Hungarian GDP (1 USD = 128.19 HUF in purchasing power parity exchange rate). Social care and subventions (20.04 million USD) and support to everyday activities (15.91 million USD) represented the largest proportion of expenses of the 6051 elderly blind people. The burden on the public sector was 55% of the total burden, which means that the population bears almost half of the burden. Social subventions represented two-third of the public burden. CONCLUSION - Blindness of the elderly means a significant economic burden, which is further exacerbated by the health loss - excess mortality, deterioration of quality of life - not evaluated in our study. Prevention and treatment of blindness in the elderly and social integration of blind people is an important task from a social as well as a health policy aspect.]

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[The Physician-Author Silas Weir Mitchell and the Phantom Phenomenon]


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Lege Artis Medicinae

[Pulmonary arterial hypertension in systemic autoimmune diseases]

VÉGH Judit, ZEHER Margit

[Pulmonary arterial hypertension is a rare disease, but it occurs more often in systemic autoimmune diseases, where it represents one of the most severe, life-threatening complications. Its development is due to an immunoregulatory disorder characteristic to systemic diseases, persistent inflammation and the subsequent endothelial dysfunction, the presence of pathogenic autoantibodies, smooth muscle cell dysfunction and complex angiogenetic disorder. As a consequence of endothelial cell dysfunction, the balance between regulatory factors of vasoconstriction and vasodilation is disrupted. Intimal hyperplasia, endothelial cell proliferation, media hypertrophy and local thrombus formation can be observed and one of the main pathomorphological characteristic features, plexiform lesion develops, leading to obliterative vasculopathy. A more severe form of the disease develops in systemic sclerosis, which is explained by the main pathophysiological elements of scleroderma, namely immunoregulatory disorder, vasculopathy and fibroblast dysfunction. It is not easy to monitor the disease in these cases, because the deterioration can be caused by many other factors as well. Therefore, beseides the usual examinations, biomarkers and screening methods have a significant role. Treatment is not simple either, since no wellapplicable algorithms are available. In many disorders (systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis), effective immunosuppressive therapy started in time is crucial, whereas in case of systemic sclerosis, the principles of therapy applied for the idiopathic form should be followed.]

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[Percutaneous coronary intervention in ischaemic heart disease]

VOITH László

[In ischaemic heart disease, if the medically treated patient’s anginal complaints and/or ischaemic symptoms are persistent, coronary angiography, and according to its results, coronary intervention (surgery or dilatation) may become necessary. The intervention is required in critical stenosis (>70% diameter) of the main vessels, the emergency depends on the clinical situation. Basic method of coronary angioplasty is the balloon dilatation, other tools (stent, rotablator, laser wire, atherectomy device, etc.) are also available. Periprocedural anticoagulant (heparin) and platelet aggregation inhibitor (aspirin, ticlopidine, GP IIb/III/a receptor blocker) treatment is required, the latter after the procedure as well. After stent implantation the lumen of the vessel is bigger and the incidence of major adverse cardiac events (acute myocardial infarction, repeated intervention, fatal outcome) is diminished. Decrease of serum lipid level improves the outcome of coronary angioplasty. It is applicable successfully for multiple lesions, occluded vessels, stable and unstable angina, in the early phase of myocardial infarction, in patients who underwent coronary surgery, and in old age too. Risk factors of the intervention are: tortuous vessel, significant calcification, stenosis in angle or ostium, luminal thrombus, urgent intervention, old age, female gender, congestive heart failure, unstable condition and acute myocardial infarction. When indicating the intervention, besides the probable results, it is necessary to consider the possibility of complications (myocardial infarction, malignant rhythm disorders, acute heart failure, bleeding, etc.). In left main stem stenosis, 3 vessel disease and in the case of 1 functioning coronary artery surgery would be preferable. With the present facilities the ratio of urgent surgical intervention as well as the mortality is below 1%.]

Lege Artis Medicinae

[Benefit of combined clopidogrel-aspirin platelet aggregation inhibition in acute coronary syndrome and after percutaneous coronary angioplasty]


[Platelet aggregation inhibition is equally important both in conservative and interventional cardiological treatment of acute coronary syndrome. Recently, results from three important trial were published. All three proved the efficacy of the combined aspirin + clopidogrel treatment. The basic results of the three clinical trials (CURE, PCI-CURE, CREDO) are summarized in the article. In the CURE trial the combined primary endpoint was reached in 11.4% of the patients in the control group and in 9.3% in the clopidogrel group. The relative risk reduction was 20%. The combined primary endpoint included CV mortality, MI and stroke. The treatment effect was mostly detectable in the prevention of MI and stroke. In the PCI-CURE trial 2658 patients of the CURE trial were analysed. All of them were treated by coronary angioplasty. In this group the primary endpoint (CV death, nonfatal MI, urgent revascularisation) was reached in 6.4% of the aspirin treated and in 4.5% of the aspirin + clopidogrel treated patients. The relative risk reduction was 30%. The CREDO trial investigated patients after coronary angioplasty. The indication of angioplasty was either acute or chronic. All patients received combined aspirin + clopidogrel but only for four weeks in the control group or for one year in the treatment group. The combined primary endpoint was decreased by 26.9%. In all the 3 trials the risk of bleeding was slightly but significantly increased by the combined aspirin + clopidogrel treatment. Clinical application: based on the results of the 3 trials it is concluded that combined aspirin + clopidogrel treatment is indicated in all patients with acute coronary syndrome, independently from the treatment strategy. The treatment should be continued for one year. This is also applicable for all patients treated with coronary angioplasty.]

Lege Artis Medicinae

[Perioperative management of patients with coronary stent undergoing noncardiac surgical procedures - Part II. - Algorythm of emergency and perioperative treatment decisions]

ZIMA Endre, MEZŐFI Miklós, BECKER Dávid, SZABÓ György, MERKELY Béla, PÉNZES István

[The aim of percutaneous coronary intervention (PCI) is to optimise coronary and cardial status, and thus improve short- and long-term outcomes. It is known from large Western databases that stent implantation is performed during 77-85% of coronary interventions, which means hundreds of thousands of patients with new stent every year. The majority of patients need to take dual platelet aggregation inhibitor, namely acetyilsalicylic acid and thienopyridin - most often clopidrogel - following stent implantation. It presents a major therapeutic dilemma when these patients need noncardiac surgery. First, the surgery should be performed with the least blood loss possible, which would be optimally achieved by suspension of the platelet aggregation inhibitor therapy that cannot be stopped during the critical period after stent implantation. Second, stent thrombosis should be avoided, which can only be achieved if platelet aggregation inhibitor therapy is continued. The aim of our paper is to summarise the current professional guidelines and the current risk estimation in the perioperative management of patients with coronary stent. In the second part of the article, we summarise the preoperative preparation of the patient, assessment of coronary status and cardial medication, and the optimal time and location of the surgery. We present the decision principles regarding the risks of perioperative bleeding and stent thrombosis, and the need to continue platelet aggregation inhibitor therapy.]

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[Recently the indications of percutaneous coronary intervention have changed both in the ST elevation and in the non-ST elevation, unstable angina group of acute coronary syndrome. Current indications in these groups are briefly reviewed and the outcomes and indications of primary interventions or those following successful or unsuccessful thrombolysis are discussed based on the most recent guidelines. Of the technical aspects, experience of the person performing the intervention, the issue of stent implantation or balloon expansion, and protection against embolism are mentioned.]