Cardiologia Croatica. 2019;14(9-10)

Ivo Planinc

Aldosterone and eplerenone are mineralocorticoid receptor antagonists with one of the main roles in the treatment of heart failure, as demonstrated by large randomized controlled trials. Effects on patient outcomes are the result of blocking the renin-angiotensin-aldosterone system, which improves cardiac remodeling. Besides heart failure, mineralocorticoid receptor antagonists are used in treatment of patients with resistant arterial hypertension. This review focuses on the pharmacokinetics, pharmacodynamics, clinical effects, and safety profile of eplerenone.

Vlasta Soukup Podravec, Ivana Petrović Juren, Sandra Prša, Andreja Čleković-Kovačić, Kristina Milevoj Križić, Renata Ivanac Janković

**Introduction**: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare cardiovascular disease that predisposes to ventricular arrhythmias potentially leading to sudden cardiac death (SCD). In 1994 and 2010, an International Task Force document proposed guidelines for the standardized diagnosis of ARVC based on electrocardiographic (ECG), arrhythmic, morphological, histopathologic, and clinical-genetic factors. (1-3) Our case report shows how important is to diagnose this disease, because the patients with ARVC should undergo lifelong clinical follow-up to periodically evaluate new onset or worsening of symptoms, progression of morphological and/or functional ventricular abnormalities, and ventricular arrhythmias in order to reassess the risk of SCD. **Case report**: 53-year-old man with history of arterial hypertension and hyperlipidemia was treated at cardiac dispensary because of bad control of blood pressure. He was asymptomatic and his family history for SCD was negative. ECG demonstrated normal sinus rhythm with complete right bundle branch block and transthoracic echocardiography (TTE) was recommended. The left ventricle had normal dimension with normal ejection fraction (EF), right ventricle was enlarged (PLAX 34mm) with bulging of apical segment RV and thickness of trabecular muscles (**Figure 1**). Cardiac MRI presented imaging criteria for ARVC with reduced EF RV 35%. More detailed analysis of ECG showed epsilon wave in lead V2 (**Figure 2**). The 72-hours Holter electrocardiogram monitoring did not show any cardiac arrhythmias, same as during the exercise test. The patient was referred to University Clinic to make additional cardiological examinations. The ventricular late potential test was positive. Programmed stimulation of the left ventricle was made - without causing arrhythmia. The diagnosis of ARVC was confirmed – one major criteria on TTE and on cardiac MRI with present epsilon wave on ECG. The risk stratification was made, the patient had low risk and the therapy with beta blocker was prescribed with limitation of physical activity and regular follow-up. Genetic testing is planned. FIGURE 1. Enlargement of the right ventricle with bulging of the apical segment. FIGURE 2. Epsilon wave visible in lead V2. **Conclusion**: ARVC without arrhythmias is rare and easily misdiagnosed. The presentation can be non-specific, as was in our case, making the diagnosis of this condition challenging.

Kristina Selthofer-Relatić, Željka Breškić Ćurić, Maja Čikeš, Boško Skorić, Ivo Planinc, Davor Miličić

**Background**: Left ventricular hypertrophy (LVH) is a common cardiac finding generally caused by an adaptation of the myocardium to increased pressure or volume load, or systemic conditions or genetic mutations (1). Amyloidosis still remains a mysterious disease, with extremely diverse palette of symptoms and poor prognosis, caused by extracellular deposits of autological proteins with a fibrillar ultrastructure and specific properties. According to anatomical and clinical criteria, it can be presented as systemic or localized type (2). **Case report**: 61-year-old male with history of dyspnea for two years, syncope relapse and mild hypertension was hospitalized. The main findings were lower voltage in ECG precordial leads, increased level of NT-proBNP, mild normocytic anemia, thrombocytopenia, accelerated erythrocyte sedimentation, elevated creatinine serum level and urine proteinuria. Transthoracic echocardiography showed LVH with restrictive diastolic pattern and typical strain finding for amyloidosis. Monoclonal gammopathy IgM type λ was approved by electrophoresis and immunoelectrophoresis. Abdominal CT scan showed appearance of paraaortic, retroperitoneal and mesenteric lymphadenopathy; lymphatic cells were found in the cytological punctate of the lymph node, while biopsy of fat tissue and rectal biopsy were negative. Heart MRI approved infiltrative heart disease, and heart biopsy deposits of amorphous material and Congo red staining was positive for amyloidosis. Waldenström macroglobulinemia with an unusual presenting of systemic amyloidosis and heart involvement was diagnosed. **Conclusion**: LVH is most common echocardiographic finding although the cause itself is not always easy to find. This case shows a rare example of systemic amyloidosis associated with Waldenstrom’s macroglobulinemia (3). Modern diagnostic techniques are available with increased chance of diagnosing the rare diseases, but still the most important fact is to be aware of these conditions. **Funding**: Congress participation was supported by the European Structural and Investment Funds, grant for the Croatian National Scientific Center of Excellence for Personalized Health Care, Josip Juraj Strossmayer University of Osijek, #KK.01.1.1.01.0010.

Maja V. Sipic, Snezana Lazic, Dragisa Rasic, Biljana Krdžić, Slavica Pajović

**Introduction**: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Some of the predisposing factors for SCAD are atherosclerosis, peripartum period, inflammatory and connective tissue disorders, heavy exercise, and certain drugs (oral contraceptives, cocaine, etc.). (1, 2) **Case report**: 38-year-old woman was admitted to hospital after being examined at a specialist dispensary. This woman, otherwise healthy, gave birth 30 days ago, which was her fourth birth. She negates hypertension and earlier heart disease. She has been smoking for 18 years now, about 10 cigarettes per day. Her brother had a heart attack last year. The complaints began 4 days before, with a sudden onset of pain behind the chest, intensity 5/10, lasting for 15 minutes. She reported to the competent institution, performed an electrocardiogram (ECG) (**Figure 1**) and proposed to continue testing at a hospital setting. She came to the hospital after 2 days, and ECG was performed (**Figure 2**). She was hospitalized, a positive troponin was established (82 pg/ml n.v <14), understood as acute coronary syndrome (ACS). Patient had quitted treatment on her own initiative and came to our institution the next day without any documentation. After the exam and ECG (**Figure 3**), her husband and she were presented with the possible course and outcome of the disease. She was hospitalized and classic treatment for ACS was administrated (no fibrinolytic agent was applied). She had no chest pain. ECG without evolution (**Figure 4**). Troponin values on the rise (180,6 ng/ml). She was scheduled emergent coronary angiography. In the evening before the scheduled coronarography, pain behind the chest bone 5/10 occurs, with elevation of the ST segment in the inferior and anterior region persisting for more than 20 minutes. The administration of nitroglycerin and intravenous nitrate is painless and pain-free, but elevation persists. She was sent urgently to the catheterization room. A spontaneous dissection of left anterior descending artery was found, and a continuation of drug therapy was proposed. At the follow-up examination a month later, she had subjectively no complaints. Coronary artery dissection is a rare cause of acute coronary syndrome but is accompanied by high mortality. Dissection should be thought of in young people with chest pain, especially in young women. FIGURE 1. Initial 12-lead electrocardiogram, 4 days before hospitalisation, revealing anterolateral ST-segment changes (in leads D1, aVL and V2-V6). FIGURE 2. 12-lead electrocardiagram shows prominent anterior T wave inversions. FIGURE 3. 12-lead electrocardiogram shows negative T-wave inversion in leads D1, D2, aVL and V2-V6. FIGURE 4. 4. ST-segment elevations in leads D2, D3, aVF and V2-V6.

Sandra Prša, Ivana Petrović Juren, Ante Anić, Ivana Smoljan, Darija Baković Kramarić, Kristina Milevoj Križić, Andreja Čleković-Kovačić, Vlasta Soukup Podravec, Iva Ladić, Gabriela Bašković

**Introduction:** Most patients with atrial fibrillation (AF) should receive anticoagulant therapy to reduce the risk of systemic embolization. However, there are varying degrees of bleeding risk associated with anticoagulation thus reducing the number of candidates for this therapy. The left atrial appendage (LAA) is the usual source of clot embolisms. Percutaneous approaches, often referred to as LAA exclusion procedures, mechanically prevent embolization of LAA thrombi. (1, 2) We consider the placement of percutaneous LAA Occlusion Device (Amplatzer Amulet device) a good choice for patients with high bleeding risk. **Case report:** We present a male, 67-year-old patient with permanent AF, diabetes mellitus, hypertension, (CHADS VASc Score 3) who was admitted to Department of Neurology with nontraumatic intracerebral hemorrhage twice in the same year. First time during oral anticoagulation therapy with warfarin and second time while receiving dabigatran. Since patient had recurrent bleeding on anticoagulant therapy, and his neurological deficit was fully recovered we considered him as ideal patient for LAA Occlusion Device implantation. A transesophageal echocardiogram (TEE) showed a large thrombus almost protruding from the LAA to the left atrium (**Figure 1**), and treatment with low molecular weight heparin with consecutive monitoring with TEE every six weeks followed mild resolution of thrombus and the patient was sent to interventional cardiologist in University Hospital Centre Split where he was amicably admitted for the life threatening malignant thrombus. After the usual pre-procedural processing including MSCT left atrial angiography, patient was subjected for Amplatzer Amulet Occluding Device 31 mm, with no signs of early complications. Post-procedural patient was receiving dual antiplatelet therapy for six months. Six weeks after implantation TEE exam showed no thrombosis on device, no leak and clots inside the left atrium (**Figure 2**). FIGURE 1. Large thrombus protruding from the left atrial appendage to the left atrium. FIGURE 2. Amplazer Amulet Occluding Device; transesophageal echocardiogram – two chamber (atrial appendage) view. **Conclusion:** The importance of the LAA in thromboembolic risk among patients with AF provides the rationale for ligation, amputation, or occlusion of the LAA, especially in patients who are candidates for, but cannot receive oral anticoagulation, or those at high risk for bleeding with oral anticoagulation.

Jurica Petranović, Rea Levicki, Ivan Barišić, Ile Raštegorac, Vladimir Dujmović, Darko Počanić

**Introduction**: Lyme disease is caused by the spirochete Borrelia Brugdorferi. It manifests as erythema migrans but can also cause central neuropathy, arthritis and carditis. (1) Cardiac manifestations include conduction abnormalities with varying degrees of atrioventricular block and other rhythm disturbances. (2) The incidence of Lyme disease increases from west to east across Europe, with the highest incidence in Slovenia (155/100 000). (3) **Case report**: We observed a 32-year-old male patient who presented to the Emergency Department with recurrent syncope. Electrocardiography recorded intermittent total atrioventricular block, with an average heart rate of 25/min. A temporary pacemaker (Oscor Pace 101H, Single Chamber External Pacemaker) was implanted emergently using right jugular access. He had been on Sovsko lake near Čaglin village in Požega-Slavonia county 7 days prior to admittance, after which he had fever and chills for 2 days followed by diarrhea for 1 day. We started empirical treatment with intravenous ceftriaxone due to suspected Lyme disease. No tick bites on skin were found. **Results**: Results of serological testing showed that IgM Lyme titer (ELISA) was positive >5.23, also CLIA IgM were positive (IgM >190, IgG >240), followed by positive IgM and IgG Western Blot. Considering these results, we continued ceftriaxone treatment according to guidelines for 6 weeks. Echocardiography demonstrated normal left and right ventricular systolic function with no valvular dysfunction. First 3 days continuous pacing was required, afterwards for 7 days only intermittent pacing in night hours was required. In the end, the patient maintained normal sinus rhythm at 65-75 bpm. Two days after, the external pacemaker and active fixation lead was removed. **Conclusion**: Lyme borreliosis infection can cause conduction abnormalities, including total atrioventricular block in structurally healthy heart. Conduction abnormalities are reversible with the use of proper antibiotic treatment.

Snezana Lazic, Vekoslav Mitrovic, Maja Sipic, Dragisa Rasic, Aleksandar Davidovic, Slavica Pajovic

**Introduction**: The major electrocardiographic feature of Brugada syndrome is a distinct ST-segment elevation in the right precordial leads. Patients with spontaneously emerging Brugada ECG have a high risk of sudden arrhythmic death secondary to ventricular tachycardia/fibrillation. The ECG manifestations of Brugada syndrome are often dynamic. Type 1 pattern is diagnostic of Brugada syndome and is characterized by a coved ST segment elevation ≥2 mm, followed by a negative T wave. (1-3) **Case report**: 23-years-old male has been hospitalized due to piercing pain in the left hemithorax and chills and fever lasting for several hours. He experienced such complaints for the first time in his life. He does not use tobacco, alcohol or psychoactive substances. He plays football for recreation. He reported severe family history: his father died at age of 36, and two paternal uncles died before their age of 25. At admission, he is conscious, oriented, mildly dyspneic, febrile (39.8˚C); BP 115/70 mmHg. Laboratory: WBC 13.9 x 109/L, neutrophils 85%, CRP 87; urine culture showed Escherichia coli >100.000/mL. He has been treated with antipyretic/paracetamol, antibiotic according to antibiogramme, and rehydration therapy. The initial ECG showed type 1 Brugada sign: cove ST elevation in V1-3 with negative T waves; RBBB (**Figure 1**). After a 12 hours of hospitalization, the ECG showed type 2 Brugada sign: saddle-shaped elevation of ST-segment and J point in V2 (**Figure 2**). After 24 hours of hospitalization, the ECG showed type 3 Brugada sign (**Figure 3**). At discharge 7 days later, type 1 Brugada sign develops again – a cove ST elevation in V1-2 and a saddle ST elevation in V3 (**Figure 4**). Ajmaline test has been performed according to protocol. During administration of a maximum dose of 70 mg, a >2 mm ST elevation was detected in V2-3, making the test positive. Electrophysiological study involved right femoral vein access with quadripolar catheter to the right ventricle. Programmed stimulation did not induce ventricular tachycardia/fibrillation. The patient was not indicated for ICD for prevention of sudden cardiac death. FIGURE 1. Brugada type 1 pattern. FIGURE 2. Brugada type 2 pattern. FIGURE 3. Brugada type 3 pattern. FIGURE 4. Brugada type 1 pattern at discharge. **Conclusion**: Family history and electrocardiography are the cornerstones of diagnosis of Brugada syndrome even today. Hyperthermia helped damask typical type 1 Brugada sign that showed dynamic changes. Our patient did not meet the criteria for implantation of ICD device.

Rreze Koshi

**Introduction**: Secondary (or functional) mitral regurgitation (MR) frequently accompanies heart failure syndromes and is associated with poor prognosis. (1) Initial surgical approaches failed to impact on outcome in contrast with optimized medical therapy, cardiac resynchronization therapy (CRT), long-term ventricular assist devices, and cardiac transplantation. **Case report**: The aim of this case is to follow up the median age of the female patient with restrictive cardiomyopathy which is idiopathic and with incipient type 2 diabetes and hypothyroidism. The patient was diagnosed 9 years ago, and she was in regular therapy with beta-blockers, ACE-inhibitors, antithrombotic and diuretics. The echocardiography was with grade 2+ MR, grade 1+ aortic regurgitation grade 1+ tricuspid regurgitation, and with EF 40%. Last year she was admitted again which is acute pericarditis and arrythmia which was not corrected with antiarrhythmics. The analyses of antiphospholipid syndrome were negative, but she was with hypothyroidism and cholelithiasis which is also treated. The patient was also in therapy of arrythmia drugs, also continuing with diuretics and antidiabetics, but advised for resynchronization ICD or CRT. She was admitted for resynchronization and she is with CRT and the same medical therapy without antiarrhythmics and continuing treatment of diabetes and hypothyroidism. **Conclusion**: The patient with idiopathic restrictive cardiomyopathy should follow up and considering a good medication therapy and should convinced for further step of general condition to be treated and carriage for life.

Amina Godinjak, Amer Iglica, Ira Tančica, Miralem Đešević, Adis Kukuljac

Sudden cardiac arrest is one of the most unexpected, dramatic, and life-threatening events in medicine. (1) Although targeted temperature management is widely used in medical and coronary intensive care units in developed countries, this practice is still not widely used in developing countries. This is the first case report describing the use of targeted temperature management in patients after cardiac arrest in Bosnia and Herzegovina. When out-of-hospital cardiac arrest (OHCA) occurs in younger patients, we must diligently search for less frequent causes of cardiac arrest in the absence of structural heart disease. In this paper, we present three young patients experiencing non-coronary OHCA. The causes of cardiac arrest were: Wolf-Parkinson-White syndrome, drug overdose and long-QT syndrome. All patients were resuscitated according to the advanced cardiac life support guidelines. They were admitted to the medical intensive care unit, and treated with targeted temperature management (TTM), with a target temperature between 32°C and 36°C, which was maintained constantly for 24 hours. After completion of TTM all patients regained full consciousness and were discharged from hospital without any neurological sequelae. This report further demonstrates the feasibility of TTM in limited resource settings, and should encourage other intensive care units in Bosnia and Herzegovina and further afield to use TTM in adult patients after OHCA, because it is technically feasible in developing countries.

Andreja Čleković-Kovačić, Renata Ivanac Janković, Ivana Petrović Juren, Vlasta Soukup Podravec, Sandra Prša, Kristina Milevoj Križić, Iva Ladić, Gabrijela Bašković

**Introduction:** Inflammation is the dynamic process of defense made of chronological changes which are repercussions of the body on injury or infection, It is made of complex biological and biochemical reactions which includes crucial cells of the immune system and many lots of biological mediators stimulated with mechanical injuries, toxins, infections and reaction hypersensitivity. Because of the disorders of the homeostatic system it is bigger probability of appearing thromboembolic incidence especially in patients with some disorders. Dilated cardiomyopathy is disease with structural and functional changes of heart muscle. (1-6) In the following case report the 43-year-old male with earlier known secondary dilated cardiomyopathy who presented with a pneumonia and thrombus in left and right ventricle. **Case report**: 44-year-old male patient with earlier known secondary dilated cardiomyopathy (post myocardial; from 2014) was hospitalized because of right pneumonia and heart failure. He was presented with dyspnea and chest pain and with elevated inflammation markers, D-dimer, and NT-proBNP). Because of chest pain we did the CT pulmonary angiography and we exclude pulmonary embolism. Echocardiography showed the dilatated (EDD 75 mm) left ventricle (LV) with reduced EF 25-28%. In akinetic apical part of the LV we noticed the thrombus (7x6 mm) (**Figure 1**). The right ventricle (RV) was dilatated (40 mm) with reduced contractility: TAPSE 13 mm, and RVEF around 30%. In the RV we noticed thrombus (32x22 mm) (**Figure 2**). With the TEE we confirm the formation of the thrombus (20x30 mm) in the apical part of the LV. With the antibiotic therapy (piperacillin with tazobactam and then with azithromycin and tetracycline and with the other medicaments) we achieve regression of pneumonia and resolution of symptoms of heart failure. In the further processing (in the tertial institution) with the cardiac magnetic resonance we prove that the formation in the left and the right heart was thrombus. The patient was prepared for heart transplantation. FIGURE 1. Thrombus in the left ventricle. FIGURE 2. Thrombus in the right ventricle. **Conclusion**: Every additional disease can complicate the earlier known heart disease especially with inflammation which has the procoagulant activity that encourages appearing thrombus. We must be more careful in the patient with some of the heart disease so that we do not predict it.

Chakir Mariame

**Introduction**: Patients that present overt hyperthyroidism, are more prone to a venous or arterial thrombosis (1-3). Multiple mechanisms can explain the procoagulant changes in the hemostatic system in this population. Hereby, we report the case of a patient with Grave’s disease, presenting overt hyperthyroidism, associated with pulmonary embolism. The aim of this report is to emphasize the pathophysiological patterns responsible of the emergence of venous thrombosis (VT) in hyperthyroidism, as well as to discuss the increased probability of VT in this population. **Case report**: 44-year-old woman, with a past medical history of Grave’s disease, treated during the previous year before her admission by carbimazole 30 mg daily, presented to the emergency department with a fever, productive cough, hemoptysis and painful breathing during the last couple of days. In the previous weeks she had noticed swelling and redness of her right leg. The diagnosis of VT of the lower limb was confirmed by a venous ultrasound of the lower extremities and she was put on vitamin K antagonists 10 days before she presented to the emergency department for her exertional dyspnea. No risk factors for venous thrombosis were present. On physical examination she had a breathing frequency of 30 per minute, an air saturation of 92%, a temperature of 38.6 °C and, pulse rate of 120 beats per minute. The ECG showed a sinus tachycardia of 120 bpm and an S1Q3 aspect. CT scan has shown proximal right pulmonary emboli in the right upper and lower lobe with infarction of the basal right lung. Laboratory data revealed a TSH of 0.005mE/l and FT4 of >70 pmol/l. The thrombophilic tests were negative. The patient received heparin, followed by oral anticoagulant therapy with a vitamin K antagonist with a favorable evolution. By presenting this case, our aim is to emphasize the fact that hyperthyroidism can be a risk factor for venous thromboembolism, as indicated previously by a small number of retrospective studies. This patient had no identifiable risk factors for VTE. Possible predisposing factors for the development of VT and PE in patients with thyrotoxicosis are also in line with Virchow’s triad. **Conclusion**: Patients with hyperthyroidism may often have accompanying endothelial dysfunction, decreased fibrinolytic activity, and hypercoagulable states which contribute to the development of VT.

Silvija Canecki-Varžić

**Introduction**: Diabetic foot ulceration (DFU) is associated with high morbidity, mortality, and represents the leading cause of hospitalization in patients with diabetes. Peripheral arterial disease (PAD), present in half of patients with DFU, is an independent predictor of lower limb amputation (LLA) and can be difficult to diagnose in a diabetic population. Underdiagnosis and undertreatment of critical PAD are frequent. (1-3) To our knowledge there is no data about LLA incidence in Croatia neither in diabetics nor in nondiabetics. Our aim was to determine the incidence of amputation in patients with diabetes mellitus in Osijek-Baranja County. **Patients and Methods**: This was a tertiary-care-based retrospective study involving adult patients in whom amputation were performed for reasons relating to complication of PAD and/or diabetes in the University Hospital Centre Osijek from 1st January 2008 to 31st December 2018. We calculated LLA rates using estimates of the population with diabetes derived from CroDiab registry and Croatian Institute for Public Health for Osijek-Baranja County. LLAs were further categorized by level of amputation as follows: minor (toe and foot) and major (above foot and below knee, and above knee). **Results**: There were 1551 LLAs in ten-year period. Smaller proportion of amputation was above foot (49.3% vs 59.3%). LLA rates per 1,000 adults with diabetes decreased 29% between 2010 and 2013 and then increased 76% between 2014 and 2018 (**Figure 1**). We observed the same pattern in both minor and major LLA but rates of amputation above knee steadily increased 2.65 times between 2010 and 2018 (from 0.69 to 1.83 LLA per 1,000 patients). FIGURE 1. Total, minor and major lower limb amputation incidence per 1,000 adults with diabetes mellitus. LLA = lower limb amputation. **Conclusion**: This study confirmed high rate of lower limb amputation in diabetic patients in Osijek-Baranja County which is representative for east Croatia region. After a decline of low limb amputations in diabetic patients between 2011 and 2013, LLA rates began to increase from 2014 to 2018. Reasons for that reversal trend are unclear. It can be due to poor management of CVD risk factors, poor glycemic control, and failure in early detection of PAD. It is also possible that change in health policy and organization of diabetes care together with socioeconomic factors could affect trends of LLA. Incidence rate of LLA in our population is important for further improvements in diabetes care and for decisions in health policy.

Ljljana Banfić, Majda Vrkić Kirhmajer, Marijan Pašalić

**Background:** Prevalence of deep vein thrombosis (DVT) in octogenarians is increasing according to the demographic trends. ACCP guidelines (1) published 2016 dramatically influenced on therapeutic strategies in favor of NOACs versus VKA in DVT/PE treatment. Non inferior efficacy and greater safety if treated with NOACs was the privilege for therapy in elderly. Seniors are vulnerable mostly because of increased risk of bleeding, various comorbidities so they are usually undertreated if VKA was prescribed. Retrospective analysis from our University Center would reveal DVT treatment changes in elderly patients in the past 45 months that might be influenced by new guidelines recommendation. **Patients and Methods:** Analysis included 97 DVT hospitalized patients aged 83.9±4.34 treated in Department of Cardiovascular diseases, University of Zagreb School of Medicine, in 45 months period (2016-2019). Proximal DVT occurred in 78.2%, 70% DVT was provoked (cancer related in 35%, 21.6% trauma, 7.6% surgery related, 9.6% bed rest, 19.5% were already treated with anticoagulants because of atrial fibrillation). **Results:** For the whole observed period (2016-2019) 18% of patients were initially on admission treated with NOACs and 38% were switched to NOACs on hospital discharge for continued therapy. DVT treatment using non VKA has significantly (p=0.008) positive trend with respect of creatinine clearance values. Only 8.6% population were prescribed NOACs for the extended therapy for DVT or VTE in year 2016. In 2018 and 2019 53% of octogenarians were treated with NOACs for at least 3 months. **Conclusions**: DVT pharmacotherapy in senior population according to observational study revealed significant changes in the 45 months period according to our Centar data. Long term treatment for DVT in octogenarians was significantly changed, with the positive trend favoring NOACs versus VKA (p=0.008).

Adem Yılmaz, Mustafa Serdar Yılmazer, Feyza Kurt

**Introduction:** Dual-chamber pacemaker implantation in patients with high grade AV block is a lifesaving intervention. Unfortunately, one of the most important drawbacks is its ventricular stimulation and the resultant LV systolic dysfunction due to left bundle brunch block. In recent years, in order to avoid these drawbacks and to potentialize patients’ own intrinsic conduction, novel algorithms have been developed by multiple pacemaker manufacturers. ‘‘Search AV’’ is one of the algorithms. (1-3) This study’s objective is to evaluate whether LV longitudinal deformation (assessed with automated function imaging-AFI) will improve after engagement of the Search AV function. Secondary objective was comparison of serum ProBNP values levels. **Patients and Methods:** It is a cross-over design study where patients remained on solely pacemaker stimulation for the first 30 days. During the second month, Search AV was engaged, and the above-mentioned parameters were evaluated. At zero-point, basic pacemaker and echocardiographic parameter were measured. After 30 days, patients are switched to the “Search AV” group. After 4 weeks, the second time battery control, Speckle Tracking Echocardiography (STE) based AFI with LV longitudinal strain analysis was performed and ProBNP were measured. Echopac were analyzed with the program again. **Results**: In subgroup analysis, when the cut off value for RV pacing rate was considered to be %40, in the group of ventricular pacing rate %40 and below, the decrement of ProBNP was found to be more significant by comparing %40 and higher pacing rate group (p=0.001). The decrement of AFI values at the end of the 2nd month were not statistically significant (p=0.189). However, when the cut off value for RV pacing rate was considered to be %30 the AFI value which demonstrates the improvement of LV function showed significant increasement (p=0.031) likewise statistically significant decrement of ProBNP values (p=0.027). **Conclusion**: Search AV is one these algorithms which reduces ventricular artificial stimulation with compromising patients’ lifes. When adjusting these algorithms, target the RV pacing rate should be below % 30, not % 40 as mentioned in the previously published papers. Indeed, further long-term prospective studies with homogenous patients are needed to prove this argument.

Richard Matasić, Ivica Šafradin, Danijela Krnjić, Dubravka Milača, Davor Radić

**Introduction**: Over the past couple of decades, the use of cardiac implantable electronic devices (CIEDs) has increased significantly. Because of that and because of increased life expectancy of patients, this has led to an increase in the number of the device and lead complications. Consequently, there is a growing need to perform lead removal. Today, lead removal is a specialized procedure with well-defined indications. Indication for lead removal can be infection (infective endocarditis, pocket infection, pocket erosion, bacteremia), lead-related (fracture, insulation defect, dislocation-if the lead cannot be repositioned, dysfunction-for reasons other than lead fracture and insulation defect, CIED upgrade/need for additional lead(s), perforation) and chronic pain due to a periosteal reaction (1). Lead removal can be explantation (removal of leads with a dwell time of less than 1 year and using simple traction), extraction (removal of leads with a dwell time of more than 1 year or with the use of specialized equipment (locking stylets, snares, cutting tools, telescoping and laser sheats) regardless of implant time) and cardiothoracic surgical procedure. **Patients and Methods**: We retrospectively analyzed the characteristics, types of devices, and indications for lead removal in 70 patients at University Hospital Centre Zagreb between January 2014 and July 2019. **Results**: Average patient age was 67.6 years and most patients were male (74.3%). 78.6% of patients were on anticoagulation or antiplatelet therapy, and 50% had chronic renal failure or diabetes mellitus. Two most common indications for lead removal were lead dislocation (28 patients) and pocket infection/erosion (20 patients). Average lead dwelling time was 27.4 months. 38 explantations, 30 extractions, and 2 surgical removals were performed. Total of 99 leads was removed, 1.28 per procedure. **Conclusion**: The procedure was successful in all patients. There was no recurrence of infection after infected device extraction. Besides 2 cases of pericardial effusion (which were not hemodynamically significant), no other major complication (cardiac tamponade, cardiac avulsion, SVC tear, death) were observed.

Ivana Jurin, Marko Lucijanić, Andjela Jurišić, Tomislava Bodrožić Džakić Poljak, Jasmina Ćatić, Boris Starčević, Irzal Hadžibegović

**Aim**: To investigate clinical outcomes in patients with atrial fibrillation exposed to different types of anticoagulant drugs within a single institution retrospective registry. **Patients and Methods**: A cohort of 758 consecutive patients with non- valvular atrial fibrillation receiving anticoagulation therapy after first referral to our institution in a period from 2012 to 2018. We analyzed demographic and clinical data, first choice anticoagulation therapy and time of any of the following clinical outcomes: death, thromboembolic event, and major bleeding and performed univariate and multivariate analyses. **Results**: There were 434 (57%) patients receiving warfarin, and 178 (23%) and 146 (20%) patients receiving dabigatran and AntiXa, respectively. There was a statistically significant trend of increase in frequency of DOAC use over time (P=0.002). Patients anticoagulated with warfarin were significantly older, had lower eGFR and LVEF, had more frequent chronic heart failure, coronary artery disease, permanent atrial fibrillation, higher CHA2DS2VASC and higher HAS-BLED scores than DOAC receiving patients (P<0.05 for all comparisons). Only 11% of patients on warfarin had acceptable recorded time in therapeutic range values. Univariately, there were significantly more events in patients treated with warfarin than with DOACs (p<0,001 for all events). After adjusting for age, eGFR, and EFLV time to death (HR=5.08, 95% CI (2.23-11.61), P<0.001) and time to thromboembolic event (HR=3.38, 95% CI (1.30-11.12), P=0.045) were significantly shorter in warfarin then in DOAC treated patients, whereas time to major bleeding (HR=1.01, 95% CI (0.84-2.55), P=0.110) did not differ significantly. **Conclusion**: Patients with higher risk received warfarin more frequently, possibly due to reimbursement issues. Patients receiving warfarin experience significantly higher adjusted risks of thrombosis and death, probably reflecting differences in patients’ characteristics and predetermined risks for stroke or other cardiovascular events at baseline. Although the use of DOACS increased over time, changes in DOAC availability for all patients should be made to optimize patterns of anticoagulation in atrial fibrillation. (1)

Anja Stanović, Marta Begovac, Juraj Jug, Rea Levicki, Dubravka Memić, Kristina Gašparović, Martina Lovrić Benčić

**Background**: Atrial fibrillation (AF), the most common arrhythmia in the general population, is associated with accelerated cognitive decline in comparison with healthy individuals (1). Some studies reported that the duration of exposure to AF increases the risk of dementia (2). Objective: The aim of this study was to evaluate the reported link between AF and its characteristics, such as type and duration, and cognitive abilities in affected individuals. **Patients and Methods**: 105 patients (63 males, 42 females, aged 67.29±24.54 years) from the University Hospital Centre Zagreb outpatient department were enrolled in the study. The average duration of paroxysmal AF was 46.52, and of persistent AF 87.94 Mo. The patients’ cognitive abilities were evaluated using Mini Mental State Examination (MMSE). Other confounding factors were analyzed: body mass index, comorbidities (hypertension, diabetes, hyperlipidemia, ischemic heart disease, etc.), level of education, prescribed medications, blood biochemistry, and echocardiographic parameters. **Results**: No significant differences between MMSE scores of patients with paroxysmal and persistent AF were found (27.43 in those with paroxysmal and 27.09 in those with persistent AF, p=0.5698). Statistical analysis also showed no correlation between the duration of AF and MMSE results (r=-0.0805, p=0.451), which was in contrast with predicted findings. However, we found a statistically significant difference between MMSE scores of patients grouped by their achieved level of education (24.60, 27.70, 28.25 and 28.22 in patients with primary, secondary, post-secondary and tertiary level of education, respectively, p=0.00002), and a correlation with estimated glomerular filtration rate (r=0.199, p<0.05) and heart rate (r=-0.2291, p=0.026). Female participants had lower MMSE scores than males (26.31 in females and 27.89 in males, p=0.038) and participants’ age also affected their MMSE results (r=-0.2866, p=0.003). **Conclusion**: The results of this pilot study do not support previously described correlations between the duration and type of AF and cognitive deterioration, at least not measurable by MMSE. Our results indicated that the strongest predictor of one’s MMSE score is the achieved level of education. This research will be continued, and we expect more reliable results on a larger cohort of patients.

Filip Mustač, Martina Matovinović, Tomislav Mutak, Maja Baretić, Barbara Barun, Juraj Jug, Rea Levicki, Ines Vinković, Lada Bradić, Ana Jelaković, Martina Lovrić Benčić, Bojan Jelaković

**Introduction**: Breathing-related sleep disorders (out of them, especially obstructive sleep apnea (OSA)) are often present in obese patients. Significant correlation between conditions such as OSA or metabolic syndrome and some anthropometric measures, most notably neck circumference (NC) has been found (1). Our goal was to examine the difference in STOP-Bang questionnaire score in obese patients depending on presence of hypertension and to see whether the use of it can be useful as a screening test for OSA. **Patients and Methods**: This cross-sectional study was carried out in a tertiary healthcare centre in an outpatient clinic for treatment of obesity. 49 participants (BMI >30kg/m2) were included. Welch t-tests were used to compare STOP-Bang questionnaire scores to our researched subjects. **Results**: Mean age was 50.29±11.91 years. Overall mean BMI was 44.64±8.12 kg/m2. There was not significant correlation between STOP-Bang questionnaire score and sex: t(9.486)=-2.17; p=.06, diabetes mellitus: t(7.821)=-2.07; p=.07 nor prediabetes: t(19.696)=-0.92; p=.37. However, patients with hypertension (**Figure 1**) had significantly higher score on STOP questionnaire than patients without hypertension: t(24)=-3.32; p=.003. FIGURE 1. Results on the STOP-Bang questionnaire depending on the presence of hypertension. **Conclusion**: Our results showed that obese patients with hypertension have higher score on the STOP-Bang questionnaire and consequently higher chance of OSA. Bakhai et al. have also shown that hypertension is an independent risk factor for OSA (2). Thus, the STOP-Bang questionnaire could be an effective tool in obese hypertensive patients as a screening test to increase the percentage of newly diagnosed OSA and initiate timely treatment.

Filip Mustač, Martina Matovinović, Tomislav Mutak, Barbara Barun, Juraj Jug, Rea Levicki, Martina Lovrić Benčić, Ana Jelaković, Bojan Jelaković

**Introduction**: Excessive daytime sleepiness (EDS) is a very common complaint, especially in obese patients and is a potentially alarming symptom related to many risk factors and comorbidities (1). In obese patients obstructive sleep apnea (OSA) is quite common. Our goal was to assess the connection between EDS and hypertension in Croatian obese patients. **Patients and Methods**: This cross-sectional study was carried out in a tertiary healthcare centre in an outpatient clinic for treatment of obesity. 49 participants were included. Inclusion criterion was BMI>30 kg/m2. Epworth Sleepiness Scale (ESS), consisting of 8 questions, every question ranged from 0-3 (overall range 0-24) was used to assess EDS. Spearman correlation coefficient, Welch t-test, chi-squared test and regression analysis were used. They were divided into 4 and 3 categories. 4 categories: 0-7, 8-9, 10-15 and 16-24. Many researches take ESS score 10 or greater as excessive daytime sleepiness, so our results were also interpreted as 3 categories: 0-7, 8-9 and 10 or greater. **Results**: Mean age of our participants was 50.29 ± 11.91 years. Overall mean BMI was 44.64±8.12 kg/m2. Results on ESS divided into 4 categories (**Figure 1**) were statistically significant correlated to hypertension: χ2= 9.61; p = .02. Also, results on ESS in 3 categories (**Figure 2**) were statistically significant correlated to hypertension: χ2(2) = 9.43; p = .009. Results on ESS were not significantly connected to AHI index (ESS in 4 categories: χ2(9)=8.43, p=.49; ESS in 3 categories: χ2(6)=6.45, p=.37). Furthermore, results on ESS were not correlated to sex (ESS in 4 categories χ2(3)=0.85, p=.84 and ESS in 3 categories: χ2(2)=0.56, p=.76). FIGURE 1. Scores on Epworth Sleepiness Scale divided into 4 categories depending on the presence of hypertension. FIGURE 2. Scores on Epworth Sleepiness Scale divided into 3 categories depending on the presence of hypertension. **Conclusion**: Our results show that the presence of hypertension alters the result on the ESS and is most visible in the so-called “borderline” area for the ESS score 8-9 in both divisions (into 3 and 4 categories), which shows a possible underestimation of the risk of the population achieving the result on the ESS <10, which is consistent with the studies of Borsini et al. (2)

Rea Levicki, Juraj Jug, Ines Vinković, Filip Mustač, Martina Matovinović, Lada Bradić, Jadranka Sertić, Martina Lovrić Benčić

**Introduction**: Region near the gene encoding methylenetetrahydrofolate reductase (MTHFR) is among eight loci associated with blood pressure. (1-3) The aim of this study is to show connection between polymorphism of MTHFR C667T and hypertension, diabetes, prediabetes and obstructive sleep apnea in obese Croatian patients. **Patients and Methods**: We included 88 patients from a multidisciplinary weight management program in which genetic analysis on MTHFR gene polymorphism was tested. Patients were divided in 3 groups: 36 patients with MTHFR C677T healthy genotype CC (27 women, 9 men; age 46.4±10.1 year; BMI 44.9±8.8 kg/m2), 38 patients with MTHFR C677T heterozygous mutation CT (27 women, 11 men; age 46.9±11.4 year; BMI 44.6±8.6 kg/m2), 14 patients with MTHFR C677T homozygous mutation TT (12 women, 2 men; age 50.1±15.5 year; BMI 40.2±6.9 kg/m2). In each group the incidence of hypertension, prediabetes, diabetes and obstructive sleep apnea (OSA) was determined. **Results**: Patients with genetic mutation MTHFR C677T:CT (**Figure 1**) had the highest incidence of arterial hypertension (65.8%), diabetes (18.4%), prediabetes (18.4%) and OSA (31.6%) with the highest average apnea hypopnea index (AHI) of 17.3±24.7, even 13.2% of patients used continuous positive airway pressure (CPAP). Patients with healthy genotype MTHFR C677T:CC had lower incidence of arterial hypertension (44.4%), prediabetes (11.1%), diabetes (13.9%), OSA (25%), average AHI 11.3±15.9 and only 8% of patients used CPAP. Patients with MTHFR C677T:TT polymorphism had the lowest arterial hypertension incidence (42.9%), the highest prediabetes incidence (42.9%), middle OSA prevalence (28.6%), AHI 7.7±7.6. FIGURE 1. The graph shows hypertension, prediabetes and obstructive sleep apnea distribution in the group of patients with methylenetetrahydrofolate reductase cytosine-to-thymidine substitution at nucleotide 677 healthy genotype CC, heterozygous mutation CT and homozygous mutation TT. MTHFR C677T:CC - methylenetetrahydrofolate reductase cytosine-to-thymidine substitution at nucleotide 677 healthy genotype CC; MTHFR C677T:CT - methylenetetrahydrofolate reductase cytosine-to-thymidine substitution at nucleotide 677 heterozygous mutation CT; MTHFR C677T:TT - methylenetetrahydrofolate reductase cytosine-to-thymidine substitution at nucleotide 677 homozygous mutation TT. **Conclusion**: MTHFR C677T:CT polymorphism is the most common gene polymorphism in our group of morbidly obese patients. MTHFR C677T:CT polymorphism compared to MTHFR C677T:CC and MTHFR C677T:TT polymorphisms carries the highest risk for arterial hypertension, metabolic disorders (diabetes) and obstructive sleep apnea. Homozygotes MTHFR C677T:TT carries the highest risk for prediabetes. Further investigation is needed to explore this correlation.

Juraj Jug, Rea Levicki, Ines Vinković, Filip Mustač, Martina Matovinović, Lada Bradić, Martina Lovrić Benčić

**Introduction**: Obesity is a well-known risk factor for developing hypertension. Prehypertensive patients (with an average 24h monitored blood pressure between 120/85 and 139/89mmHg) rarely get physician’s attention despite their differences from non-hypertensive patients. (1, 2) **Patients and Methods**: We enrolled 42 obese female patients (age range from 26 to 69 years) from a multidisciplinary weight management program (BMI range 30 to 49.9 kg/m2). Firstly, because of estradiol levels, patients were divided into two groups, younger than 50 years (A) and older (B). Due to the average values of patient’s ambulatory monitored blood pressure, patients were additionally put into three groups (1 = below 120/85mmHg, 2 = between 120/85 to 139/89mmHg 3 = above 140/90mmHg). Systolic dipping profile, estradiol levels, and average nocturnal heart rate were also checked. **Results**: Prehypertensive obese patients older than 50 years (B) had higher nocturnal heart rate (58.50 vs. 70.25/min; p<0.05). Even though differences were found in younger patients, they were not statistically significant. Systolic dipping profile was different and age-dependent (Non-dippers A: 44.00%; B 82.35%; p=0.02). The number of non-dippers in the younger group was highest in group 2 (66% vs. 20% in group 1; p=0.03) while there were no differences in the older group. The prehypertensive group had very similar results to hypertensive patients. Estradiol levels (**Figure 1**) were age independently lower in non-dippers (A: 185.5 vs. 201.07, NS; B: 71.9 vs. 87.0, NS) and also in hypertensive patients (A: 111.0 vs 192.6 pmol/L, p=0.21; B: 59.0 vs. 98.0 pmol/L). FIGURE 1. Estradiol concentration in three groups of patients depending on ambulatory monitored blood pressure. **Conclusion**: Our results showed that estradiol levels seem to be protective in terms of blood pressure stability, systolic dipping profile and nocturnal heart rate probably due to its impact on autonomic nerve system functionality. Because of a small number of patients further investigation is needed to prove the statistical significance of this statement.

Lada Bradić, Martina Lovrić Benčić, Juraj Jug, Martina Matovinović, Kristina Gašparović, Rea Levicki

**Introduction**: Obesity is an epidemic that carries significant cardiovascular (CV) burden. Autonomic dysfunction, characterized by reduced vagal tone and sympathetic overactivity, has been found in diabetes, hypertension, heart failure, metabolic syndrome, and other conditions. Heart rate decrease after exercise, or heart rate recovery (HRR) reflects cardiac autonomic activity. Decreased HRR is a powerful predictor of CV disease, CV and all-cause mortality. (1-3) **Patients and Methods**: A total of 54 obese patients (24% male, 76% female), age 22-66 (mean 47 year), BMI 29.4-53.3 (mean 40.3 kg/m2), were enrolled in a multidisciplinary weight management program. Treadmill testing was done initially and after 6-month follow-up. Standard Bruce protocol was used to assess exercise capacity and passive HRR (15 sec, 3 and 6 min into the recovery period, as per institutional protocol). Control group was composed of age- and sex-matched non-obese subjects. **Results**: Obese subjects had significantly slower HRR (HRR0:15 6.1 vs. 9.1 BPM, HRR3:00 57.8 vs. 66.6 BPM, HRR6:00 63.3 vs. 72.7 BPM; p=0.0216, 0.0006, 0.0004, respectively). Exercise capacity was also significantly lower in comparison to control (6.7 vs. 8.6 METs; p=0.000001), with reduced exercise time (6.0 vs. 8.2 min; p=0.000001). Sixteen subjects that reached 6-month follow-up lost 5.4 kg on average. Exercise capacity increased mildly (6.4 to 7.1 METs; NS), as well as total exercise time (5.6 to 6.6 min; NS). **Discussion and Conclusion**: Physiological HRR kinetics follows exponential decay function. Rapid first phase, mediated by vagal reactivation is followed by a gradual HRR decline, dominated by sympathetic withdrawal. We found significantly slower HRR over different time-points in the obese, which reflects autonomic imbalance. Functional aerobic capacity was also significantly reduced. Somewhat improved functional capacity and dynamics of HRR after weight loss did not reach statistical power. To conclude, we found evidence of significantly impaired cardiac autonomic function in obese subjects, together with reduced functional capacity. As the study is ongoing, we hope to demonstrate sustained effect of exercise and diet on autonomic function. Potential benefit on mortality and CV risk reduction should encourage patients and health care providers to manage obesity more vigorously.

Zrinka Sertić, Tomislav Letilović, Mladen Knotek, Tajana Filipec Kanižaj, Mario Stipinović, Darko Počanić, Inga Starovečki, Darko Vujanić, Helena Jerkić

**Introduction**: Transthoracic echocardiography (TTE) is recommended as the standard of care in evaluation of cardiovascular (CV) disease in liver (LT) and kidney (KT) transplant candidates. (1, 2) Guidelines for preoperative CV assessment are oriented at the immediate perioperative period and non-ischemic CV processes that would predict poor outcomes after LT and KT are defined less clearly. Aim: to establish whether ≥moderate mitral (MR), tricuspid regurgitation (TR) or ≥mild aortic stenosis (AS) on pretransplant TTE are associated with mortality, graft survival or major CV adverse events (MACE) in the late postoperative period (>30 days). **Patients and Methods**: Patients were stratified into cohorts based on the presence of ≥moderate MR, TR and ≥mild AS. Exclusion criteria was loss to follow up, incomplete TTE findings and death within 30 days of transplantation. MACE were defined as stroke, myocardial infarction (MI) or heart failure. Patient survival was defined as time from transplantation to death or last follow-up and graft survival as time from transplantation to last follow-up, death, graft dysfunction or re-transplantation. Outcomes of interest were compared between cohorts via logistic or Cox regression. **Results**: 306 LT (median age 59, IQR 53-64) and 196 KT patients were included (median age 52, IQR 40-61). Median follow up was 36 months for LT (range 14.3 – 55.9), 40,5 months for KT (range 18-64.9). MACE occurred in 4.25% LT and 4.59% KT recipients. Upon univariate analysis AS was associated with MACE in KT recipients but crossed the significance level after adjusting for common confounders (age, sex, hypertension, diabetes, smoking). 11.76% LT and 9.69% KT recipients died. The most common cause of death was sepsis. MR was found to be associated with LT patient survival, but the association was lost after adjusting for age. In an age adjusted model MR was found to be associated with KT patient survival (HR 2.97, 95% CI 1.06-8.26, P=0.037). Graft survival was not associated with any potential predictors. **Conclusion**: Associating TTE findings with adverse outcomes after LT and KT might help distinguish patients who would benefit from closer management in the late postoperative period. Moderate or more severe MR was found to be associated with late mortality in KT recipients, however the significance of this is yet to be determined in larger sample studies.

Zvonimir Ostojić, Vlatka Rešković Lukšić, Blanka Glavaš Konja, Marija Mance, Ivica Šafradin, Joško Bulum, Jadranka Šeparović Hanževački

**Introduction**: More than mild paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) represents one of the negative predictive factor for survival and quality of life after TAVI (1). However, quantification and definition of more than mild PVR remains to be unified. Most commonly used 3 stage grading scheme is often insufficient (2). Aim of this research was to assess differences in incidence of more than mild PVR during and after TAVI comparing 3 and 5 grades staging schemes. **Patients and Methods**: Study included 40 patients that underwent TAVI between July 2016 and January 2019 in general anesthesia with transesophageal echocardiography (TEE) during procedure. TEE exams had to be sufficiently recorded to quantify PVR with both grading schemes. Parameters used for PVR quantification and differences between models are presented in **Table 1**. ### TABLE 1: Transesophageal echocardiography parameters used for paravalvular regurgitation quantification in the 3-class and 5-class grading schemes. | **3-class grading scheme** | Trace/mild | Trace/mild | Moderate | Moderate | Severe | | --- | --- | --- | --- | --- | --- | | Circumferential extent of PVR (%) assessed with CD | 1-20 | | 20-30 | | >30 | | **5-class grading scheme** | Trace/mild | Mild to moderate | Moderate | Moderate to sever | Sever | | Valve stent shape | Normal | Usually normal | Often elliptical/abnormal | Usually elliptical/abnormal | Elliptical/ abnormal | | >1 regurgitation jet | No | Possible | Often present | Usually present | Usually present | | Regurgitation jet visible | No | Possible | Often visible | Usually visible | Visible | | Jet with at its origin (% of LVOT diameter) assessed with CD | 1-15 | 15-30 | 30-45 | 45-60 | >60 | | Circumferential extent of PVR (%) assessed with CD | 30 | >30 | [†] PVR – paravalvular regurgitation; CD – color Doppler; LVOT – left ventricle outflow tract. **Results**: After initial valve implantation 10 (25%) patients had more than mild PVR when quantified using 3 grade model compared to 19 (47.5%) using 5 grade model (p<0.001). Furthermore, 2 patients with severe PVR assessed by 5 stage model were stratified as having moderate PVR using 3 stage model. In total 14 (35%) patients underwent postdilatation and in 3 (7.5%) of them additional valve was implanted. As final result more than mild PVR was present in 2 (5%) patients using 3 grade model and in 12 (30%) using 5 grade model (p=0.027). Detailed stratification of PVR severity is presented in **Table 2**. ### TABLE 2: Detailed analysis of paravalvular regurgitation severity between compared models after initial valve implantation and at the end of procedure. | | **3-class staging scheme** | **5-class staging scheme** | **3-class staging scheme** | **5-class staging scheme** | | --- | --- | --- | --- | --- | | | **after initial implantation** | | **end of procedure** | | | None – N(%) | 5 (12.5) | 5 (12.5) | 5 (12.5) | 5 (12.5) | | Trace or mild – N(%) | 25 (62.5) | 16 (40) | 33 (82.5) | 23 (57.5) | | Mild to moderate – N(%) | / | 9 (22.5) | / | 10 (25) | | Moderate – N(%) | 8 (20) | 4 (10) | 2 (5) | 2 (5) | | Moderate to severe – N(%) | / | 2 (5) | / | 0 (0) | | Severe – N(%) | 2 (5) | 4 (10) | 0 (0) | 0 (0) | **Conclusion**: Utilization of proposed 5 stage grading scheme for evaluation of PRV after TAVI provides more detailed stratification of PVR compared to 3 stage model. The largest difference between models is observed in patients with borderline, mild to moderate PVR. Whether this have implications on patient clinical outcome remains to be determined.

Gokhan Perincek, Sema Avci, Ferdi Kahraman

**Objective**: The aims of this study were to evaluate atrial electromechanical delay (AEMD) of patients with chronic obstructive pulmonary disease (COPD) in acute and stable periods (1-3) and echocardiographic changes of these patients. **Patients and Methods**: A prospective cross-sectional study. Setting: Kars Harakani State Hospital Subjects: 45(22 females, 23 males) patients with acute COPD exacerbation and the control group was stable period of the same patients. Interventions: The first echocardiography was performed in the first 24 hours. The second echocardiographic examination was performed after 3-month. Main outcome measures: Atrial conduction times and systolic-diastolic functions of the right-left heart were evaluated conventional and tissue Doppler Imaging. Plasma levels of CAR and other inflammatory markers were recorded. Statistical analysis was carried out using SPSS software. **Results**: At the end of 3-month, lateral/tricuspid, lateral/mitral and septal AEMD were significantly reduced; right ventricle basal, mid and vertical diameters, tricuspid annular plane systolic excursion, Amax tricuspid, tricuspid regurgitant velocity, systolic pulmonary arterial pressure and systolic motion tricuspid; left atrium diameter, left ventricle end-diastolic diameter, interventricular septum thickness, mitral Ea/Aa ratio, systolic motion mitral, systolic motion septal and heart rate differed; CRP, CAR, and neutrophil to lymphocyte ratio were significantly reduced.

Josip Varvodić, Dubravka Šušnjar, Ivana Jurin, Jasenka Grgurić, Boris Starčević, Frane Paić, Igor Rudež

**Objective**: We can observe an increase in incidence and prevalence of patients with aortic valve stenosis in the general population. The gold standard in aortic valve therapy is aortic valve replacement. Preoperative planning is essential for good outcomes, as the severity of stenosis and calcifications can sometimes be extremely progressive and even involve the aortic root and ascending aorta. There is not enough research on comparation of CT scan analysis of aortic valve stenosis and echocardiography which is the golden standard of disease diagnosis. (1-3) **Patients and Methods**: We have analyzed 88 patients [age: 70.01±9.066 (mean±SD); female: n=45, 51.1%]. Among the patients, 12 had bicuspid aortic valve leaflet structure while the rest of the patients (n=76, 86.4%) exhibited TAV stenosis. Degree of aortic stenosis was assessed according to mean pressure gradient (MPG), peak pressure gradient (PPG), aortic valve area (AVA) indexed aortic valve area (AVAi) and maximum speed through aortic valve (Vmax). These were compared with calcium score (AVCS) calculated from CT scan. All of these patients were observed in the operating room during surgery and valves analyzed after explantation. All of the patients underwent aortic valve replacement. **Results**: Average AVCS values (median + IQ range) were 3306.3 (1995.4 – 4820.6) [female: 2215 (1463.35 – 3372.85); male: 4093.5 (3133.3 – 5274.4). Average AVCS values for BAV patients were 3063.5 (3323.125 – 4868.9) and 3106.55 (1965.375) – 4780.125) for TAV patients. There were significant correlations between AVCS and AVAi (Spearman’s ρ=−0.24, P=0.025), PPG (ρ= 0.38, P< 0.001), MPG (ρ= 0.36, P= 0.001) V max (ρ= 0.37, P < 0.001) and gender (ρ= 0.485, P < 0.001) while AVA values showed no significant correlation with AVCS (ρ= -0.066, P = 0.540). Overall survival was similar not depending of severity of calcifications and stenosis, however clamp time and surgery time were longer for patients with severely calcified valves which means calcium scoring as a parameter should also be taken in consideration during preoperative planning. **Conclusion**: Careful preoperative planning is essential for good outcome of surgery, here we have proven the connection between echocardiography parameters of aortic stenosis and calcium score calculated by CT scan.

Josip Varvodić, Savica Gjorgjievska, Davor Barić, Daniel Unić, Mislav Planinc, Marko Kušurin, Dubravka Šunjar, Sandra Jakšić Jurinjak, Ivana Jurin, Nikola Bulj, Igor Rudež

**Objective**: Aortic valve replacement (AVR) is still the most commonly used therapeutic option for patients suffering from AR. Aortic valve repair (AVRep) is an attractive alternative method, since it avoids the risks of prosthesis-related complications. (1-3) We would like to present our experience with the Yacoub root remodeling, valve sparing technique with the extraaortic expansible ring. **Patients and Methods**: Between November 2014 and July 2019, a total of 79 patients (52.6±13.3 years; 15.2% female, EuroScore II of 3.15%±2) underwent AVRep, 12 due to isolated cusp malcoaptation and 67 associated with aortic root dilatation. Reconstruction was done with the Coroneo Extraaortic Ring (27 (25-31)), and the Gelweave graft (28 (26-32)). 44 patients had a tricuspid valve, 33 patients had a bicuspid valve, and 2 patients had an unicuspid valve. Concomitant procedures included Mvrep and TVrep in 4 patients, CABG in two patents. Aortic arch was replaced in two patients, two patients underwent hemiarch replacement, and two patients had aortic arch replacement with stented conduit and placement of stent in descending thoracic aorta (EVITA stent graft Jotec GmbH). Echocardiography was used to determine AR severity grade preoperatively, during immediate post-operative period (within 7 days from operation) and at early follow-up. **Results**: In postoperative follow-up no patients died. Freedom from reoperation was 88% (10/79) and there were 2 patients reoperated due to early postoperative regurgitation, one patient was reoperated due to AI after two years, and one was operated due to pseudoaneurysm formation after 2.5 years. A significant decrease in LV end-diastolic diameter was observed (LVEDD) (60mm preoperatively, 53 mm postoperatively) with further decrease at early follow-up. At follow up none of the patients had major AR (AR0=61, AR1+=14, AR2+=4). **Conclusions**: We have proved that AVRep is a good alternative for patients with aortic insufficiency and leads to LV reverse remodeling with comparable results in terms of LVEDD and LVEF immediately post-operatively and at early follow up. It is feasible to use this technique in tricuspid, bicuspid, as well as unicuspid valves with excellent results.

Marija Mance, Vlatka Rešković Lukšić, Ivan Bitunjac, Blanka Glavaš Konja, Martina Lovrić Benčić, Joško Bulum, Zvonimir Ostojić, Dubravka Šipuš, Jadranka Šeparović Hanževački

**Introduction**: Age and gender may influence the incidence of aortic regurgitation (AR) and its severity. Significant aortic regurgitation (sAR) is often treated surgically especially when symptomatic or when systolic function declines. (1) The aim of this study was to evaluate the outcomes in patients with sAR according to treatment strategy, age and gender differences in our study population. **Patients and Methods**: In this retrospective descriptive single-centre study an overall of 107 patients (22 female, 85 male) with significant AR in the last 5 years were analyzed. Patients were treated according to valid recommendations, surgically (SUR) or conservatively (CON), except for 5 patients who refused surgery. Baseline and follow up (FU) data (AR severity, left ventricle ejection fraction (LVEF), ascending aorta diameter (AA), treatment, comorbidities and major adverse cardiovascular events (MACE) during FU), from documented medical history and digital imaging data were collected and analysed. Additional sub-analysis was performed according to sex and age differences (above vs. below the age of 50). For statistical analysis a Chi-Square test was used. **Results**: In the overall study population, during an average FU of 3.8 years, 16 patients (15%) developed MACE with no statistically significant difference between gender (p=0.846). Forty-six (43%) patients were surgically treated (87% male, 13% female) and 61 (54%) conservatively. LVEF did not worsen in FU period (54.1%, vs. 53.8%). In SUR, median age was 54 years, severe AR was present in 93%, incidence of MACE was 21.7%, 80.4% patients were symptomatic and 14.5% had dilatation of AA more than 50 mm. In CON, MACE was present in 9.8% during FU (p=0.87), median age was 64 years. Moderate AR (48% vs 6.5%) and AA from 40-49 mm (80 vs 35%) was present more frequently as well as arterial hypertension (82 vs 70%) and chronic renal disease (23.2 vs 16.6%). The incidence of MACE was not found to be age-related (p=0.426). **Conclusion**: In patients with sAR treated by either surgery or medication therapy only, during 3.8 years of FU, LVEF remained unchanged, while incidence of MACE was not found to be related to treatment strategy nor gender. In surgically treated patients, as expected, AR was more severe and AA was more dilated, while neither age nor gender had an impact on the incidence of MACE.

Boško Skorić, Dora Fabijanović, Marijan Pašalić, Ana Reschner Planinc, Hata Botonjić, Jana Ljubas Maček, Maja Čikeš, Ivo Planinc, Jure Samardžić, Hrvoje Jurin, Daniel Lovrić, Hrvoje Gašparović, Višnja Ivančan, Davor Miličić

**Background:** Decrease in platelet count following the induction with polyclonal anti-thymocyte globulin (ATG) is deemed as an adverse event, while decrease in lymphocyte count represents a therapeutic goal (1). Still, the effect on platelets may represent an important part of ATG anti-rejection mechanisms. **Patients and Methods:** This was a retrospective single-center study of consecutive HTx (heart transplantation) patients (pts) from February 2010 to February 2018 in University Hospital Centre Zagreb. All pts received rATG (Thymoglobulin®) 1.5 mg/kg daily during the first 5 days. Complete blood count with differential was assessed on days 0, 7 and 14 after HTx. The incidence of cellular-mediated rejection (ACR) was monitored for two years after HTx. ACR was classified according to ISHLT classification from 1990 and expressed as ACR of grade 1B or higher (≥1B). **Results:** A total of 159 pts were transplanted. Median age was 55 years (IQR, 47-62 years), 76% were male. A total of 27 pts (17%) experienced ACR ≥1B during 24 months. Pts with ACR of grade ≥1B had higher platelet count on day 7 (145 vs 104 x 103/µL, p3/µL, p=0.19) and there was no correlation between ALC and platelet counts on day 7 (Pearson’s correlation coefficient was 0.064, p=0.459). Conversely, more rejection was observed in pts with higher ALC on day 14 (326 vs 190 x 103/µL, p=0.035), with a trend towards statistical significance in the relationship with higher platelet count (210 vs 199 x 103/µL, P=0.076). In the univariate analysis, higher platelet count on day 7, younger recipient age and negative pre-transplant Cytomegalovirus (CMV) IgG serology were found as predictors of the ACR ≥1B in the first 2 years after HTx (**Table 1**). In multivariable model, platelet count on day 7 and pre-transplant CMV serostatus were independent predictors of rejection. ROC analysis of the aforementioned model showed a satisfying AUC of 0.75. ### TABLE 1: Univariate Analysis of Acute Cellular Rejection (ACR of grade ≥1B) in the first 2 years after heart transplantation. | **Variable** | **HR** | **95% CI** | **p value** | | --- | --- | --- | --- | | **Recipient age, years** | **0.961** | **0.939-0.984** | **0.001** | | Recipient gender Male | 0.625 | 0.281-1.392 | 0.25 | | **Positive pre-transplant recipient CMV IgG** | **0.319** | **0.133-0.766** | **0.011** | | Donor/recipient CMV mismatch | 2.646 | 0.778-8.994 | 0.119 | | Donor age, years | 0.971 | 0.943-1.001 | 0.059 | | Donor gender Male | 1.594 | 0.643-3.949 | 0.314 | | Pre-transplant mechanical circulatory support | 1.677 | 0.573-4.908 | 0.345 | | Ischemia time, min | 1.001 | 0.995-1.007 | 0.678 | | Absolute lymphocyte count on day 7, x 10**3**/µL | 1.000 | 0.999-1.002 | 0.446 | | Absolute lymphocyte count on day 14, x 10**3**/µL | 1.001 | 1.000-1.001 | 0.074 | | **Platelet count on day 7, x 103/µL** | **1.007** | **1.002-1.013** | **0.006** | | Platelet count on day 14, x 10**3**/µL | 1.004 | 1.000-1.008 | 0.074 | | Positive post-transplant CMV PCR | 0.501 | 0.118-2.127 | 0.349 | | Calcineurin inhibitor, No. (%) Tacrolimus vs Cyclosporine | 0.840 | 0.393-1.796 | 0.653 | [†] CMV = Cytomegalovirus; PCR = polymerase chain reaction. **Conclusion:** Decrease in platelet count following the induction with rATG is strongly related to less graft rejection that is independent from the lymphodepleting effect. This indicates the importance of platelet involvement in anti-rejection mechanisms of ATG induction, and consequently a possible rationale for targeting platelets in future immunosuppressive regimens.

Vlatka Rešković Lukšić, Marija Mance, Zvonimir Ostojić, Dejan Došen, Ivan Bitunjac, Kristina Gašparović, Jadranka Šeparović Hanževački

**Aim**: To investigate prevalence of arrythmias and thromboembolic events, as well as long term outcomes among patients diagnosed and treated of non-compaction cardiomyopathy (NCC) according to current recommendations in University Hospital Centre (UHC) Zagreb. **Patients and Methods**: A single center retrospective study was conducted. Patients newly diagnosed with NCC in UHC Zagreb during period 2009-2018 were analyzed. The diagnosis was confirmed by both echocardiography and cardiovascular magnetic resonance. Hospital database and charts were used for clinical data, echocardiography data was obtained from digital database using EchoPac. Patients were followed-up clinically and by the means of echocardiography. **Results**: 32 patients (pts), 18 men (53.25%) were included. At the time of diagnosis (baseline), mean age was 47.7±15.4 years, majority of pts (84.38% of pts, N=27) were in functional NYHA class ≥2, with mean NT-proBNP values of 3870±6619 ng/L. Echocardiography revealed reduced left ventricular systolic function; baseline ejection fraction (EF) was 27.52±11.94%. Patients were discharged with heart failure therapy: beta-blockers (30 pts, 93.75%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (29 pts, 90.63%), angiotensin receptor–neprilysin inhibitor (1 pts, 3.13%), mineralocorticoid receptor antagonists (28 pts, 84.38%); and 26 pts (81.25%) required symptomatic diuretic use. Cardiac resynchronization therapy with defibrillator was implanted in 11 pts (34.38%) and implantable cardioverter defibrillator (ICD) in 16 pts (50%). At baseline, 9 pts (28.13%) were already receiving anticoagulation due to previous thromboembolic events (**Table 1**). At discharge, 17 pts (53.13%) were anticoagulated (warfarin in 14 pts, 82.35%, novel direct oral anticoagulants in 3 pts, 17.65%). Mean follow-up period was 3.42±3.31 years. At the end of follow up period, functional improvement was observed: 21.88% (N=7) pts were in NYHA ≥2 status (p<0.05), with manifest, but statistically nonsignificant reduction of NT-proBNP levels (1260±2266 ng/L, p=0.063). Control echocardiography revealed significant improvement in EF (40.24±11.39%, p<0.001). There were no new thromboembolic events. While arrythmias were common at the time of diagnosis (**Table 1**), there was only one ICD activation during follow-up. None of the pts have died, 1 patient received heart transplant and 2 were implanted with left ventricular assist device. ### TABLE 1: Number of patients diagnosed with thromboembolic events and arrythmias at the time of diagnosis and at the end of the follow-up period. | Number of patients: | **At diagnosis** | **At follow up** | | --- | --- | --- | | **THROMBOEMBOLIC EVENTS** | | | | Left ventricular thrombus | 3 (9.38%) | 0 (0) | | Stroke/TIA | 4 (12.50%) | 0 (0) | | Other embolus | 1 (3.13%) | 0 (0) | | **ARRYTHMIAS** | | | | Atrial fibrillation | 3 (9.38%) | 7 (21.88%) | | nsVT | 15 (46.88%) | 8 (25.00%) | | Sustained VT | 1 (3.13%) | 4 (12.50%) | | ICD activation | 0 (0%) | 1 (6.25%) | [†] TIA = transient ischemic attack; nsVT = non-sustained ventricular tachycardia; VT = ventricular tachycardia; ICD = implantable cardioverter defibrillator. **Conclusion**: Optimal medical treatment in patients with NCC (1) corresponds with good long-term outcomes, functional improvement, and low risk of recurrent thromboembolic events or malignant arrythmias.

Amina Godinjak, Miralem Đešević, Amer Iglica, Adis Kukuljac

**Objective**: The aim of this study was to investigate whether statin therapy influenced outcomes in patients with acute heart failure (HF). (1, 2) **Patients and Methods**: Eighty five patients with diagnosis of HF were included in the study. For each patient the following data were obtained: gender, age, comorbidities and medications. New York Heart association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. Outcome points were: hospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. **Results**: Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy. **Conclusion**: Statin therapy is associated with substantially better long-term outcomes in patients with HF.

Azra Durak-Nalbantić, Alen Džubur, Nafija Serdarević, Aida Hamzić-Mehmedbašić, Faris Zvizdić, Enisa Hodžić, Marina Vučijak-Grgurević, Alden Begić, Akif Mlaćo, Zenisa Gljiva-Gogić

**Introduction**: A progress in the management of cardiovascular disease leads to a decrease in mortality, but heart failure (HF) seems to be an exception. Today, the rate of rehospitalization and mortality after acute heart failure is still very high. Lower ejection fraction (EF) means worse prognosis, but recent studies are reporting that HF patients with preserved EF have no better survival compared to patients with reduced EF (1). Goal: to investigate a possible difference in the outcome of HF patients with reduced (HFREF) and preserved ejection fraction (HFPEF). **Patients and Methods**: In 222 patients hospitalized in acute HF (138 with reduced EF and 74 with preserved EF) were determined routine laboratory test, including BNP. The LVEF cutoff for diagnosing of HFPEF was above 45%. Patients were followed for the next 18 months for the occurrence of 1. readmission due to repeat decompensation and 2. mortality. **Results**: BNP at discharge was higher in HFREF compared to HFPEF group [699.3 (271.8-1519.1) pg/ml vs 263.3 (134.4-502.2) pg/ml, p <0.001]. During 18-month follow-up 129 patients (58.11%) were readmitted due to decompensation, but there was no significant difference between group: in HFREF group was hospitalized 87 (63.04%) patients compared to 42 (50%) patients in HFPEF group (p=0.077). There was no difference in the rate of readmission in 1-month (p=0.7), 6-month (p=0.24), and 12-month follow up (p=0.16) in HFREF vs HFPEF group. In Kaplan-Meier curve there was no significant difference in the mean time of the occurrence of readmission due to decompensation: in HFREF group 2.2 (95% CI=1.58-2.8) months and in HFPEF group 2.33 (95% CI=1.3-3.4) months (p=0.89) (**Figure 1**). In HFREF 18-month survival was 43.5% (60/138) and in HFPEF group was 56.0% (47/84) and the difference was not significant (p=0,096). In the Kaplan-Meier curve, there was no difference in time of survival in 18-month follow-up (p=0.9): mean time of survival in HFREF was 3.8 (95% CI=3.0-4.7) months and in HFPEF 3.75 (95% CI=2.5-5.0) months (**Figure 2**). There was no difference in mortality in 1-month (p=0.8), 6-month (p=0.16) and 12-month follow up (p=0.08). FIGURE 1. Admission due to decompensated heart failure in the group of heart failure patients with reduced (HFREF) and preserved ejection fraction (HFPEF). FIGURE 2. Kaplan-Meier survival curve in in the group of heart failure patients with reduced (HFREF) and preserved ejection fraction (HFPEF) in an 18-month period. **Conclusion**: Rate of rehospitalization due to decompensation and mortality is not different between HFREF and HFPEF group. Preserved EF is not related to better survival in patients with HF.

Josip Anđelo Borovac, Joško Božić, Duška Glavaš

**Goals**: Outcomes following acutely decompensated heart failure (ADHF) are poor and associated with increased mortality and morbidity. Various risk stratification systems have been developed in the past to predict mortality and rehospitalizations in this population. The S2PLiT-UG score was recently introduced to stratify ADHF patients in three risk categories in respect to all-cause mortality during 1-year post-discharge period. (1) In this work, we aimed to determine associations of S2PLiT-UG score with functional disease burden estimated by NYHA class and biomarkers including high sensitivity cardiac troponin I (hs-cTnI), NT-proBNP and C-reactive protein (CRP). **Patients and Methods**: A cohort of 106 consecutive ADHF patients enrolled at the Cardiology Department during 2018-2019 were included in the study. S2PLiT-UG score calculation and laboratory analyses were performed for each patient at index admission. **Results**: Fifty-six (52.8%) patients were designated as low, 24 (22.6%) as intermediate, and 26 (24.6%) as high risk according to S2PLiT-UG score stratification. Patients significantly differed (p=0.021) in respect to their NYHA class with mean values of 2.85±0.57, 3.10±0.61, and 3.33±0.56 for low, intermediate, and high-risk group, respectively. Troponin values were significantly higher in high risk compared to intermediate and low-risk groups (148.4±72 vs. 68.2±48 vs. 42.2±24 ng/L; p=0.025, respectively). Similarly, NT-proBNP levels were highest in the high-risk group (13740±7884 pg/mL) followed by intermediate (7811±5668 pg/mL) and low-risk group (4195±1632 pg/mL), p=0.002. Finally, CRP values differed across groups with the high-risk group exhibiting highest CRP value (21.8±14.8 mg/L) compared to intermediate and low-risk group (17.5±15.8 and 12.2±11.3 mg/L, respectively), however, this result was not significant (p=0.327). S2PLiT-UG score positively correlated with NYHA class (r=0.300, p=0.004), hs-cTnI (r=0.303, p=0.009), NT-proBNP (r=0.353, p=0.001) and CRP (r=0.203, p=0.069). **Conclusion**: Among ADHF patients, higher S2PLiT-UG score values, calculated at index admission, are associated with higher functional disease burden and increased levels of circulating biomarkers reflecting myocardial injury and ventricular overload, but not systemic inflammation.

Ines Vinković, Filip Lončarić, Petra Mjehović, Dorja Sabljak, Vedrana Vlahović, Grgur Salai, Klara Klarić, Toni Radić, Saša Pavasović, Nina Jakuš, Dora Fabijanović, Ivo Planinc, Maja Čikeš, Davor Miličić

**Background and Aim**: There are still wide knowledge gaps in myocardial infarction with non-obstructive coronary arteries (MINOCA) - a heterogeneous entity seen in 1-10% of patients with acute coronary syndrome (ACS) (1). The aim is to determine characteristics of MINOCA in the Croatian branch of the ISACS-CT registry, and compare them to age- and gender-matched patients with unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI). **Patients and Methods**: The study included 2487 patients with ACS. MINOCA was defined by simultaneous cardiac troponin levels >0.014 ng/L, symptoms of ischemia or significant ST-T changes in the ECG, and an absence of coronary artery stenosis of ≥ 50% on angiography. Age and gender-matching was performed from the remaining cohort by randomly sampling patients from the UA, STEMI and NSTEMI subgroups, based on the mean age ± 5 years and the gender ratio of the MINOCA group. **Results**: MINOCA was seen in 2.5% (n=63) of the cohort, initially categorized as UA (37%), NSTEMI (48%) and STEMI (16%). Median age was 62 (53, 71) years, 56% male. After age- and gender-matching, there were 36 UA (10% of the UA cohort), 135 NSTEMI (15%) and 198 STEMI (16%) patients in the ACS control subgroups. MINOCA patients had a lower prevalence of diabetes, hypertension, dyslipidemia, chronic kidney disease and tobacco use as compared to UA and NSTEMI. MINOCA patients used less antiplatelets, beta-blockers and statins before hospitalization. MINOCA and STEMI subgroups had a high incidence of chest pain symptoms and a short time from symptom onset to hospitalization. In the first 24h of hospitalization, less MINOCA patients were treated with antiplatelets and statins, and at discharge, they were less frequently prescribed with antiplatelet drugs compared to UA and NSTEMI (**Table 1**). In-hospital mortality was low, with no deaths in MINOCA and UA patients, and 2 and 3 deaths in NSTEMI and STEMI, respectively. ### TABLE 1: Baseline characteristics and the comparison of patients with myocardial infarction with non-obstructive coronary arteries, unstable angina, ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. | | **VARIABLES** | **MINOCA** **(n=63)** | **UA** **(n=36)** | **NSTEMI** **(n=135)** | **STEMI** **(n=198)** | **P-value** | **Misssing** | | --- | --- | --- | --- | --- | --- | --- | --- | | **ACS type** | UA | 37 | - | - | - | | 0 | | NSTEMI | 48 | - | - | - | | 0 | | | STEMI | 16 | - | - | - | | 0 | | | **General characteristics** | Age | 62 | 60 | 62 | 62 | 0.692 | 0 | | Male gender | 56 | 56 | 56 | 56 | 1 | 0 | | | BMI | 28.7 | 31.2 | 29.3 | 27.7 | **0.001** | 36 | | | Systolic blood pressure at admission | 145 | 150 | 140 | 140 | **0.003** | 20 | | | Family history of CAD | 27 | 31 | 31 | 26 | ns | 0 | | | Diabetes | 18 | 28 | 36 | 23 | **0.017** | 0 | | | Insulin therapy | 2 | 8 | 11 | 7 | 0.087 | 0 | | | Hypertension or on th | 77 | 92 | 82 | 76 | 0.118 | 1 | | | Smoking or ex-smoker | 36 | 56 | 42 | 62 | **<0.001** | 6 | | | Hypercholestroleamia or on therapy | 58 | 86 | 69 | 53 | **<0.001** | 5 | | | Angina classified by CCS | 7 | 13 | 14 | 5 | 0.057 | 13 | | | Unstable angina at rest | 8 | 49 | 11 | 2 | **<0.001** | 8 | | | Heart failure NYHA 2+ | 5 | 3 | 3 | 2 | 0.412 | 7 | | | COPD | 2 | 6 | 6 | 7 | 0.539 | 7 | | | Chronic kidney disease | 5 | 12 | 12 | 4 | **0.028** | 7 | | | **Theraphy before admission** | Aspirin | 35 | 43 | 32 | 18 | **0.002** | 6 | | Other antiplatlet therapy | 18 | 24 | 10 | 6 | **0.006** | 8 | | | ACEi | 49 | 57 | 47 | 40 | 0.249 | 6 | | | Beta-blockers | 44 | 49 | 41 | 22 | **<0.001** | 6 | | | Statins | 30 | 39 | 32 | 18 | **0.007** | 6 | | | **ACS presentation** | Two or more 20 mins chest pain episodes in the previous 24 hrs | 21 | 48 | 50 | 41 | **0.014** | 33 | | Onset <6 hours | 63 | 44 | 46 | 70 | **<0.001** | 3 | | | Chest pain | 97 | 92 | 90 | 98 | **0.004** | 1 | | | Abnormal ECG | 46 | 46 | 63 | 99 | **<0.001** | 1 | | | LBBB | 4 | 0 | 1 | 5 | 0.514 | 6 | | | ST elevation | 19 | 6 | 4 | 81 | **<0.001** | 0 | | | ST depression | 10 | 14 | 22 | 15 | 0.147 | 0 | | | Q wave | 5 | 11 | 8 | 15 | 0.074 | 0 | | | T wave inversion | 3 | 17 | 26 | 10 | **<0.001** | 0 | | | Initial descision for PCI treatment | 63 | 83 | 86 | 99 | **<0.001** | 0 | | | **Therapy at admission** | Nitrates | 45 | 57 | 47 | 34 | **0.021** | 10 | | Aspirin 24h | 100 | 100 | 96 | 96 | 0.394 | 2 | | | Clopidogrel | 71 | 86 | 90 | 69 | **<0.001** | 2 | | | Other antiplatelet therapy | 10 | 9 | 13 | 46 | **<0.001** | 3 | | | Statins 24 | 84 | 97 | 95 | 95 | **0.030** | 1 | | | ACEi 24h | 82 | 86 | 74 | 71 | 0.127 | 3 | | | Beta blockers 24h | 76 | 81 | 75 | 66 | 0.122 | 2 | | | GP IIb/IIIa | 3 | 12 | 10 | 50 | **<0.001** | 7 | | | | **VARIABLES** | **MINOCA** **(n=63)** | **UA** **(n=36)** | **NSTEMI** **(n=135)** | **STEMI** **(n=198)** | **P-value** | **Misssing** | | **Lab results** | Troponin T | 0.07 | 0.02 | 0.18 | 0.35 | **<0.001** | 15 | | Troponin T peak | 0.2 | 0.04 | 0.7 | 3.64 | **<0.001** | 25 | | | CRP | 2 | 38 | 30 | 25 | **0.001** | 35 | | | CRP-peak | 4 | 39 | 33 | 58 | **0.005** | 52 | | | Creatinemia | 90 | 88 | 90 | 80 | **0.024** | 5 | | | WBC | 7.5 | 8.9 | 9.0 | 11.3 | **<0.001** | 5 | | | Hemoglobin | 139 | 143 | 140 | 141 | 0.606 | 5 | | | Cholesterol | 4.7 | 5.1 | 5.2 | 5.0 | 0.419 | 15 | | | Tryglicerides | 1.28 | 1.61 | 1.63 | 1.40 | **0.001** | 15 | | | HDL-C | 1.3 | 1.17 | 1.10 | 1.17 | **0.003** | 15 | | | LDL-C | 2.87 | 3.68 | 3.71 | 3.68 | 0.322 | 15 | | | Kaliemia | 4.2 | 4.3 | 4.3 | 4.1 | **0.020** | 19 | | | Na | 140 | 140 | 140 | 139 | **<0.001** | 21 | | | CK peak | 207 | 161 | 165 | 1229 | **<0.001** | 42 | | | **Theraphy at discharge** | Aspirin at discharge | 94 | 100 | 97 | 96 | 0.446 | 0 | | Clopidogrel at discharge | 44 | 89 | 87 | 54 | **<0.001** | 0 | | | Other antiplatelet therapy at discharge | 0 | 8 | 8 | 47 | **<0.001** | 1 | | | Anticoagulants at discharge | 21 | 11 | 7 | 18 | **0.012** | 0 | | | ACEi at discharge | 81 | 81 | 81 | 81 | ns | 1 | | | Beta-blockers at discharge | 79 | 81 | 84 | 80 | 0.804 | 0 | | | Statins at discharge | 89 | 97 | 95 | 94 | 0.360 | 1 | | | Other lipid lowering drugs at discharge | 3 | 6 | 12 | 8 | 0.202 | 0 | | | Diuretics at discharge | 24 | 36 | 28 | 27 | 0.624 | 2 | | | Antiarrhythmics at discharge | 18 | 17 | 12 | 8 | 0.533 | 2 | | | Outcomes | Duration of hospitalisation | 4 (2, 5) | 3 (2, 5) | 4 (3, 7) | 5 (1, 7) | **0.005** | 0 | | EF at discharge | 55 | 60 | 55 | 50 | **<0.001** | 22 | | | Hospital mortality | 0 | 0 | 2 | 3 | 0.573 | 0 | | [†] MINOCA - Myocardial infarction with non-obstructive coronary arteries; UA - Unstable angina; STEMI - ST-segment elevation myocardial infarction; NSTEMI - Non-ST-segment elevation myocardial infarction; ACS - Acute coronary syndrome; BMI - Body mass index; CAD - Coronary artery disease; CCS - Canadian Cardiovascular Society; NYHA - New York Heart Association; COPD - Chronic obstructive pulmonary disease; ACEi - Angiotensin-converting-enzyme inhibitor; ECG – Electrocardiogram; LBBB - Left bundle branch block; GP IIb/IIIa - Glycoprotein IIb/IIIa; WBC - White blood cells; EF - Ejection fraction **Conclusion**: MINOCA patients are mainly categorized as UA and NSTEMI at presentation, but have less comorbidities, more pronounced symptoms of typical chest pain, a shorter time from symptoms to hospitalization, lower levels of statin and antiaggregation prescription at admission, and antiaggregation at discharge. In-hospital mortality confirms MINOCA as low risk, however, long-term registry follow-up is needed to learn about longer term outcomes.

Filip Puškarić, Zvonimir Ostojić, Nina Jakuš, Ivo Planinc, Marijan Pašalić, Joško Bulum, Davor Miličić, Maja Čikeš

**Background**: A plethora of studies have proven the increase in cardiovascular risk associated with smoking in all age groups (1), including the one at the focus of this study – the young (2, 3). With regard to the total number of coronary arteries (CA) with significant stenoses, one might expect current smokers to have more affected CA than non- and former smokers. Aim: To explore the relationship between smoking status and the total number of CA with significant stenoses in a young ST-segment elevation myocardial infarction (STEMI) population. **Patients and Methods:** Data were attained from medical records of 147 patients (mean age 43.9±6.5 years) hospitalized with STEMI at the University Hospital Centre Zagreb from January 2012 to October 2018, with a cut-off age at 45 years for men (n = 93) and 55 years for women (n = 54). Patients were divided in 2 groups based on smoking status – non- and former smokers (N = 29 (20%), with former smokers making up 9/29 or 31% of the group), and current smokers (N = 118 (80%)). To evaluate whether smoking status was associated with a higher total number of CA with significant stenoses, Pearson’s chi-squared test was performed. During post hoc testing, the p value was adjusted to maintain the familywise error rate at 0.05 (p = 0.008) and compared to p values of each subgroup. **Results:** The two groups had no significant differences in baseline characteristics (**Table 1**). In both groups, the majority of patients (58.6% vs. 74.6%) had only one affected CA, followed by two (27.6% vs. 19.5%) and three (13.8% vs. 5.9%) CA. Pearson’s chi-squared test showed no statistically significant difference in the total number of affected CA between the two groups (p = 0.176). Post hoc testing confirmed statistically insignificant associations in all subgroups (p > 0.008, **Table 2****)**. In multiple regression (F (2, 144) = 9.27, p 2adjusted = 0.10), age (B = 0.03, p = 0.001) and family history for cardiovascular disease (B = 0.30, p = 0.003) remained associated with the number of affected CA. ### TABLE 1: Patient characteristics. | Characteristic | **Non-smokers and former smokers** **(N = 29)** | **Current smokers** **(N = 118)** | **P-value** | | --- | --- | --- | --- | | Age – years | 43.4 ± 6.9 | 44.0 ± 6.4 | 0.698 | | Female sex – n (%) | 10 (34.5) | 44 (37.3) | 0.780 | | Body mass index – kg/m2 | 29.6 ± 5.4 | 28.6 ± 4.8 | 0.290 | | Hypertension – n (%) | 16 (55.2) | 55 (46.6) | 0.410 | | Diabetes mellitus – n (%) | 2 (6.9) | 10 (8.5) | 0.782 | | Family history for cardiovascular disease – n (%) | 16 (55.2) | 65 (55.1) | 0.993 | ### TABLE 2: Contingency table analysis of smoking status and the total number of coronary arteries with significant stenoses. | | | **Number of coronary arteries with significant stenoses** — One | **Number of coronary arteries with significant stenoses** — **Two** | **Number of coronary arteries with significant stenoses** — **Three** | **Total** | | --- | --- | --- | --- | --- | --- | | **Non-smokers and former smokers** | Count | 17.0 | 8.0 | 4.0 | 29.0 | | Expected Count | 20.7 | 6.1 | 2.2 | 29.0 | | | % within group | 58.6% | 27.6% | 13.8% | 100.0% | | | **Adjusted p value** | **0.088** | **0.338** | **0.149** | | | | **Current smokers** | Count | 88.0 | 23.0 | 7.0 | 118.0 | | Expected Count | 84.3 | 24.9 | 8.8 | 118.0 | | | % within group | 74.6% | 19.5% | 5.9% | 100.0% | | | **Adjusted p value** | **0.088** | **0.338** | **0.149** | | | | **Total** | Count | 105.0 | 31.0 | 11.0 | 147.0 | | Expected Count | 105.0 | 31.0 | 11.0 | 147.0 | | | % of total | 71.4% | 21.1% | 7.5% | 100.0% | | [†] Note. The critical p value was adjusted to maintain a familywise error rate of 0.05 (p = 0.008). **Conclusion:** Within our dataset of young patients with STEMI, a very high proportion (reaching 80%) were active smokers. A similar total number of CA was affected by significant stenoses, regardless of smoking status. However, caution should be exercised when interpreting these results that require additional input on comorbidities and risk factors enabling conclusions to be drawn from a broader context.

Saša Pavasović, Jure Samardžić, Hrvoje Jurin, Marijan Pašalić, Boško Skorić, Maja Čikeš, Danijel Lovrić, Jana Ljubas Maček, Ivo Planinc, Dubravka Šipuš, Davor Miličić

**Introduction**: Targeted temperature management (TTM) is recommended in the European Resuscitation Council Guidelines for Post-resuscitation Care. (1) However, previous studies report controversial results on the effect of TTM on platelet function (PF) in patients on dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors. Hypothesis: To assess if the effect of DAPT on platelet inhibition in patients undergoing TTM for out-of-hospital cardiac arrest (OHCA) is reduced compared to patients on the same therapy not undergoing this procedure. **Patients and Methods**: Clinical characteristics and PF were analyzed in 56 consecutive patients admitted to the Department of Cardiology at the University Hospital Centre between January 2012 and January 2019 under the diagnosis of acute myocardial infarction (AMI). Out of these 56 patients, 17 underwent TTM to 34°C (Intervention group) while the other 39 did not (Control group). Both groups received the loading dose of DAPT. We analyzed residual PF using the Multiplate® PF analyzer ADP test. Platelet function tests (PFT) were performed 18-24 hours after therapy initiation in both groups and 18-24 hours after return to normal body temperature of 36.5° C in the TTM group. The control group had an average temperature of 36.5° C at the time of the PFT. **Results**: There were 39 patients with a mean (SD) age of 63.2 (9.9) years in the Control group and 17 patients with a mean (SD) age of 58.6 (8.2) in the Interventional group. There were no significant differences in the baseline parameters between the groups (history of IHD, hyperlipidemia, diabetes mellitus, smoking, gender, prior medical therapy, current medical therapy). At the first time point (18-24 hours after initiating therapy) the intervention group had a significantly higher residual PF when compared to the control group (31.5 U vs 17.9 U; p<0.05). This difference is no longer present 18-24 hours after return to normothermia (p=0.2) (**Figure 1**). FIGURE 1. Platelet function in the interventional (hypothermia) and control (normothermia) group. NS = non-significant. **Conclusion**: Our study shows that TTM decreases the effect of DAPT on PF in patients with AMI undergoing TTM for OHCA. This is in line with the findings published by Uminska et al (2) who showed that TTM severely decreases the bioavailability of P2Y12 inhibitors in this group of patients. These findings indicate that patients with AMI who experienced an OHCA undergoing TTM could have an impaired response to standard DAPT.

Saša Pavasović, Dubravka Šipuš, Jure Samardžić, Hrvoje Jurin, Marijan Pašalić, Boško Skorić, Maja Čikeš, Danijel Lovrić, Jana Ljubas Maček, Ivo Planinc, Davor Miličić

**Introduction**: Dual antiplatelet therapy (DAPT) represents one of the pillars in the treatment of acute coronary syndromes (ACS) (1). In the past the most commonly used combination of antiplatelet drugs has been acetylsalicylic acid (ASA) and clopidogrel. Clopidogrel had a high incidence rate of high residual platelet reactivity and has, in recent years, been replaced with ticagrelor, a more potent platelet inhibitor with a more uniformed response across the patient population. The effect of high dose atorvastatin on platelet reactivity mediated by ASA and clopidogrel is well researched, however no studies have been published analyzing this effect when clopidogrel is substituted with ticagrelor. Purpose: To investigate if high dose atorvastatin modifies PF mediated by DAPT in patient with ACS as measured by platelet function tests (PFTs). **Patients and Methods**: We analyzed clinical characteristics and PF in patients presenting with ACS at the Department of Cardiovascular Diseases at the University Hospital Centre Zagreb from December 2015 to February 2018. Primary endpoint was PF after treatment with DAPT and/or high dose atorvastatin. We analyzed PF using the Multiplate platelet function analyzer. PFTs were performed 18-24 hours after therapy initiation. None of the patients were taking statins before the index event. **Results**: There were 35 patients with a mean (SD) age of 61.6 (12.2) years in the atorvastatin group and 29 patients with a mean (SD) of 62.6 (9.6) years in the no-atorvastatin group. Both groups were identical in all the baseline parameters except history of hyperlipidemia (34.5% vs 65.7%, P=0.023). There were no significant differences between the two groups in PF analyzed with PFTs (**Figure 1**). The difference in residual platelet reactivity remained non-significant even after adjusting for sex, age and hyperlipidemia as the only co-variate that was significantly different between the group (P=0.432). FIGURE 1. Platelet reactivity with and without high dose atorvastatin. NS = non-significant. **Conclusion**: In this pilot study on a limited sample we found no difference in residual PF in patients on DAPT weather they are on treatment with high dose atorvastatin or not. These results show that the pleiotropic effects of atorvastatin on platelet reactivity are not significant in patients taking DAPT with ticagrelor and ASA. ## Acknowledgments This pilot study was funded by Croatian Science Foundation.

Petra Mjehović, Filip Lončarić, Dora Fabijanović, Nina Jakuš, Dorja Sabljak, Ines Vinković, Vedrana Vlahović, Grgur Salai, Toni Radić, Klara Klarić, Saša Pavasović, Ivo Planinc, Maja Čikeš, Davor Miličić

**Background and Aim**: The relevance of dual antiplatelet therapy (DAPT) in acute ST-segment elevation myocardial infarction (STEMI) is well-established (aspirin and P2Y12 inhibitors). (1) The role of glycoprotein (GP) IIb/IIIa inhibitors in clinical practice is not completely defined. Administration in the event of thrombotic complications is considered reasonable, although there is no evidence for routine use in primary percutaneous coronary intervention (pPCI). The aim was to analyze early outcomes of STEMI patients (pts) in the Croatian branch of the ISACS-CT (International Registry of Acute Coronary Syndromes in Transitional Countries) registry, depending on received antiaggregation therapy. **Patients and Methods**: Data were gathered retrospectively from pts hospitalized between January 2012 to October 2017. The study included 2503 pts with acute coronary syndrome, from which 48.9% (n=1224) were diagnosed with STEMI. The patients were divided into 4 groups depending on administered antiaggregation therapy. **Results**: For 7.8% (n=96) pts antiaggregation therapy data were missing, and 5.8% (n=71) were not treated with DAPT. Remaining 1057 (86.4%) pts were analyzed. Aspirin was administered in 95% of pts in the first 24 hours. 41.9% (n=443) of pts were additionally treated with clopidogrel, 16.1% (n=170) with ticagrelor, 28.6% (n=302) with clopidogrel and eptifibatide, and 13.4% (n=142) with ticagrelor and eptifibatide (**Table 1**). The groups did not differ in comorbidities, while pts receiving eptifibatide had lower systolic blood pressure on admission. Patients treated with eptifibatide were more frequently male, smokers, of younger age, had more thrombotic complications seen on coronary angiography (predominantly distal embolisation and “no-reflow” phenomenon) and lower in-hospital mortality. In a multivariable regression model adjusted for age, gender, hypertension, diabetes, and pPCI, increasing age (OR=1.1), diabetes (OR=1.9) and pPCI (OR=0.5) remained relevant to in-hospital mortality. ### TABLE 1: Patients’ characteristics. | | **ASA+** **Clopidogrel** **(n=443)** | **ASA+** **Ticagrelor** **(n=170)** | **ASA+ Clopidogrel + Eptifibatide (n=302)** | **ASA + Ticagrelor + Eptifibatide (n=142)** | **p-value** | | --- | --- | --- | --- | --- | --- | | **Male gender, n (%)** | 296 (66.8) | 112 (65.9) | 224 (74.2) | 110 (77.5) | 0.020 | | **Age (IQR)** | 63 (53, 75) | 66 (55, 77) | 62 (54, 71) | 59 (52, 68) | 0.002 | | **Hypertension, n (%)** | 294 (68.9) | 119 (73.0) | 199 (66.6) | 91 (64.1) | 0.348 | | **Hypercholesterolemia, n (%)** | 179 (44.8) | 68 (43.0) | 150 (51.2) | 76 (54.3) | 0.085 | | **Diabetes mellitus, n (%)** | 106 (24.3) | 37 (22.3) | 51 (16.9) | 34 (23.9) | 0.106 | | **Chronic kidney disease, n (%)** | 32 (9.3) | 10 (6.1) | 23 (8.0) | 7 (5.0) | 0.344 | | **Smoking, n (%)** | 221 (55.4) | 87 (58.8) | 179 (61.9) | 96 (69.6) | 0.025 | | **HR median (IQR)** | 80 (70, 92) | 80 (71, 94) | 80 (70, 92) | 78 (66, 92) | 0.318 | | **SBP median (IQR)** | 138 (120, 150) | 135 (115, 153) | 130 (112, 145) | 130 (120, 150) | 0.017 | | **Creatinine (IQR)** | 95 (81, 112) | 83 (72, 101) | 93 (78, 111) | 81 (69, 95) | 2, n (%)** | 105 (31.1) | 48 (30.4) | 77 (25.8) | 31 (22.1) | 0.161 | | **PCI - number of treated lesions >1, n (%)** | 57 (19.6) | 38 (25.7) | 55 (18.9) | 26 (18.7) | 0.350 | | **Thrombotic complications, n (%)** | 29 (8.7) | 9 (6.0) | 48 (16.5) | 29 (20.7) | <0.001 | | **Distal coronary embolisation** | 3 (0.9) | 1 (0.7) | 12 (4.1) | 13 (9.3) | | | **“No-reflow” phenomenon** | 10 (3.0) | 3 (2.0) | 11 (3.8) | 5 (3.6) | | | **Other** | 16 (4.8) | 5 (3.3) | 25 (8.6) | 11(7.8) | | | **In-hospital mortality, n (%)** | 33 (7.4) | 14 (8.2) | 9 (3.0) | 5 (3.5) | 0.020 | [†] ASA - acetylsalicylic acid; IQR - interquartile range; HR - heart rate; SBP - systolic blood pressure; hsTnT - high-sensitive troponin T; LVEF - left ventricular ejection fraction; pPCI - primary percutaneous coronary intervention; PCI - percutaneous coronary intervention. **Conclusion**: STEMI patients that are young, male and smokers are more frequently treated with eptifibatide, likely due to a higher burden of thrombotic complications. Unlike the choice of antiaggregation therapy, increasing age, diabetes and non-invasive management of STEMI were associated with in-hospital mortality.

Sam Hughes, Camilla Baker, Abhirami Gautham

**Background**: Following an acute coronary event, the current process of referring a patient for Coronary Artery Bypass Grafting (CABG) at New Cross Hospital, Wolverhampton, has the potential to be improved. At present, patients can wait up to 5 days before being referred to cardiothoracics, often becoming more unwell during the delay. At times, patients become too unwell to undergo the planned surgery. Moreover, additional delays frequently arise due to difficulty tracking the referral. **Objective**: To reduce the number of days between coronary angiogram to cardiothoracic review from 3 to 1 AND the number of days between coronary angiogram to CABG from 6 to 5. **Method**: The following 2 measures / PDSA cycles were implemented; - Cycle 1: Same-Day Referrals - Upon reviewing the coronary angiogram, if the consultant cardiologist on-call deems the patient to be a ‘clear surgical candidate’, then a ‘same day’ referral to cardiothoracics for pre-assessment via the Teliologic system is made. - Cycle 2: ‘Post-Angiogram’ Assessment Page [Green Form] - Instead of utilizing numerous non-specific continuation sheets, a dedicated pro-forma is used to document the coronary angiogram results and to track the patient’s subsequent plan (**Figure 1**). FIGURE 1. Flow chart outlining the current process of referring cardiology inpatients for coronary artery bypass grafting (CABG) procedure at New Cross Hospital, with each intervention labelled to highlight where in the chain the intended benefit will occur in order to increase overall efficiency of the process. **Results**: Coronary angiogram to cardiothoracic review reduced from 3 to 2 days, whilst from coronary angiogram to CABG reduced from 6 to 5 days. In addition, the average total length of stay has reduced by 3 days, improving patient outcomes and saving the hospital an average of £1200 per patient. **Discussion and Conclusion**: At present, the decision on when anti-platelets [Ticagrelor in particular] should be stopped prior to surgery, varies from 2 days to 7 days, depending on both the patient’s presentation & the personal preference of each surgeon. (1) This is the focus of Cycle 3, namely to implement local trust guidelines on stopping anti-platelets prior to CABG. Simple improvements in communication have significantly increased the efficiency of this referral process. For example, in cycle 2 we created a single, unified pro-forma which could be easily identified & updated by each member of the team, improving consistency, continuity of care & avoiding potential delays for surgery due to mis-placed documentation. In turn, this has reduced patient morbidity & made significant cost savings.

Hazar Harbalioglu, Caner Turkoglu, Taner Seker, Alaa Quisi, Omer Genc, Gokhan Alici, Samir Allahverdiyev, Ahmet Oytun Baykan, Mustafa Gur

Background: Although, there are several studies comparing single and two-stent techniques in patients with bifurcation lesions, evidence in patients presenting with myocardial infarction (MI) is still insufficient. (1-3) We aimed to assess the short- and long-term outcomes of provisional and two-stent techniques of bifurcation lesions in patients with acute coronary syndromes (ACS). Patients and Methods: 2992 patients with MI who underwent percutaneous coronary intervention (PCI) were enrolled in the present study. Of 2992 patients, 385 patients with MI had bifurcation lesions. The Synergy between PCI with TAXUS™ and Cardiac Surgery (SYNTAX) score, pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow, post-PCI TIMI flow, duration of procedure, angiographic features, post-PCI side branch loss, 1- and 12-month mortality rates were noted. Results: 169 (43.9%) patients had ST-segment elevation MI, whereas 216 (56.1%) patients had non-ST-segment elevation MI. 355 (92.2%) patients underwent provisional stenting and 30 (7.8%) patients underwent two-stent technique. Side branch loss was observed in 40 patients (11.2%) in the provisional group and 1 patient (3.3%) in the two-stent group (p=0.2). Compared to provisional group, durations of angiography and revascularization in two-stent group were significantly longer (p<0.001 and p<0.001). Both 1-month and 12-month mortality rates were similar in provisional and two-stent groups (4.2% vs. 3.3%, p=0.8 and 11.5% and 13.3%, p=0.7; respectively). Conclusion: In patients presenting with ACS and bifurcation lesions, procedural success, side branch loss, as well as short- and long-term mortality were similar in both provisional and two-stent techniques.

Davor Miličić

October 17-20, 2019 Dubrovnik, Croatia Welcome to Croatia, welcome to the 6th Dubrovnik Cardiology Highlights! The ESC Update Meetings in Dubrovnik began in 2009 based on the decision of the ESC Education Committee under the presidency of Professor Otto A. Smiseth. It was agreed from the start that the Dubrovnik Meeting would be organized by the Croatian Cardiac Society and endorsed as the ESC Update Meeting in Cardiology. We are also very proud that this is the third time the Meeting has been organized under the patronage of the Medical Department of the Croatian Academy of Sciences and Arts. Over the years, only two of four members of the ESC Update Meetings have survived – the Davos Meeting that started in 1975, and the youngest one – the Dubrovnik Cardiology Highlights, which is now celebrating its 10th anniversary. Its founding fathers are still enthusiastically organizing and chairing the Meeting: Otto A. Smiseth and myself, with support of our co-directors: Thiery Gillebert, Dan Gaita and Zlatko Fras. Maja Čikeš soon joined as the Scientific Secretary of the Meeting, with the help of Cardiology Fellows of the Department of Cardiovascular Diseases, University Hospital Centre Zagreb. We hope you will enjoy our Scientific Programme for the 2019 Highlights, because of its comprehensiveness, selection of relevant topics, presentation of the newest ESC guidelines, and recommendations and position papers. Special thanks go to the Faculty, who will enrich the Meeting with their outstanding talks and interactive chairmanship, but we would also like to thank all participants, who will surely provide invaluable contributions to the Meeting with their curiosity and vivid discussions. As previously, we are continuing with interactive posters and with the already traditional Zagreb-Zurich Fellows’ Session. On this occasion, we are particularly happy to host fifty (!) Turkish colleagues led by Professor Oktay Ergene, the president of the Turkish Society of Cardiology. Do not miss the Joint Croatian-Turkish Session within the Meeting! We are also grateful to our sponsors for their unrestricted donations and for the attractive Exhibition at the Meeting. Their Satellite Symposia will undoubtedly also enrich the Programme with the newest topics covering drugs and devices in cardiology. Last but not least, our PCO, the “Spektar” Company, did a great job as always, and they deserve our deep gratitude for the technical organization and logistics. Dear colleagues, let the unique beauty of Dubrovnik be once again our frame and inspiration for enjoying both the Scientific Programme and our professional networking, for reviving old and starting new friendships! Sincerely yours, Professor **Davor Miličić**, MD, PhD, FESC, FACC