Pauls Stradiņš Clinical University Hospital

INTRODUCTION:Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are currently recommended as one of the four pillars of treatment in heart failure (HF) with reduced ejection fraction (HFrEF). Following the approval of dapagliflozin in 2020, real-world data are relevant for the medical community and payers. This study aimed to characterize the patient population with dapagliflozin initiated for HFrEF in clinical practice in 9 countries from Central Eastern Europe and the Baltic Area (CEE-BA). METHODS:EVOLUTION-HF CEE-BA is a multicentre, multi-country, observational, longitudinal study conducted in 102 centres in Bulgaria, Croatia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, and Slovenia. All treatment decisions were at the discretion of the patient's healthcare providers, based on the locally approved product information and routine clinical practice. Patients with type 1 diabetes, prior treatment with dapagliflozin or other SGLT2i, and initiation of dapagliflozin outside the approved HFrEF indication were excluded. The baseline period covered 12 months prior to dapagliflozin initiation, with prospective follow-up continuing up to 12 months or until loss to follow-up, death, or study discontinuation, whichever occurred first. Descriptive statistics and Kaplan-Meier methods were used. RESULTS:A total of 1131 patients with HFrEF were included in the full analysis set. Ischaemic aetiology was present in 52% of patients. The mean left ventricular ejection fraction was 32%. The most frequent comorbidities were atrial fibrillation (46%), type 2 diabetes (37%), and chronic kidney disease (29%). At the time of dapagliflozin initiation, 93% of patients received any combination of a renin-angiotensin-aldosterone system inhibitor (RAASi), beta-blocker (BB), or mineralocorticoid receptor antagonists (MRA). Of all patients, 60% received concomitantly all three classes plus dapagliflozin for their HFrEF. Except for dapagliflozin, which was administered as 10 mg/day, optimal doses were recorded for 14% for any RAASi, 17% for BB, and 25% for MRA. At 6- and 12-month follow-up, maintenance of dapagliflozin treatment was recorded in 95% and 96% of patients, respectively. The real-world median time to discontinuation of dapagliflozin has not been reached. The percentage of patients receiving all four classes recommended in HFrEF remained stable over the study period. Adverse events were reported spontaneously, as in routine clinical practice in each centre. CONCLUSION:This large non-interventional study provides a contemporary perspective of the treatments used in HFrEF over 1-year follow-up. Despite high dapagliflozin persistence rates, a low proportion of patients received complete guideline-directed medical therapy in optimal doses. Improvement of HF management decisions across the CEE-BA region is warranted.

BACKGROUND:Dedicated randomised studies on intravascular imaging guidance in unprotected left main coronary artery (LMCA) disease are lacking. AIMS:We aimed to investigate the clinical feasibility of optical coherence tomography (OCT) guidance in percutaneous coronary intervention (PCI) of true LMCA bifurcation lesions and to evaluate its prognostic impact compared with angiographic guidance. METHODS:Patients with true LMCA bifurcation lesions who were randomised to either OCT or angiographic guidance in the OCTOBER Trial were included. The feasibility of OCT guidance was assessed as the proportion of patients with successful and analysable OCT pullbacks before, during, and after stenting. Clinical outcomes between the two groups were compared based on the incidence of a composite of major adverse cardiac events (MACE), comprising cardiac death, any myocardial infarction, or target lesion revascularisation. RESULTS:In total, 227 patients were included (OCT: 111, angiography: 116). OCT guidance was successful, with 98% of cases having a pre-stenting pullback performed and 96% a final pullback, as per protocol. The proximal LMCA stent edge was analysable in 43% of patients, and in the remaining 57%, only 5% were limited by insufficient image quality. No statistically significant difference in MACE was observed between the two groups (OCT: 14.4% vs angiography: 18.4%, hazard ratio 0.78, 95% confidence interval: 0.39-1.51). CONCLUSIONS:OCT-guided PCI in true LMCA bifurcation lesions was clinically feasible, but visibility of the LMCA ostium was limited by short pullbacks, insufficient clearance, or guide catheter shadowing. OCT guidance was associated with a non-significant reduction in MACE, consistent with the effect estimate in the main trial.

Background and Objectives: Pulmonary vein isolation (PVI) is an established rhythm control strategy for atrial fibrillation (AF). In many healthcare systems, increasing demand and limited procedural capacity have resulted in prolonged waiting times. The primary aim of this study was to evaluate the association between waiting time for PVI and AF progression. Secondary aims were to assess the relationship between waiting time and AF-related complications, healthcare utilization, and clinical factors associated with higher risk of progression. Materials and Methods: We performed a single-center observational cohort study of patients on the waiting list for PVI at Pauls Stradiņš Clinical University Hospital between 2016 and 2023. Results: A total of 341 patients completed structured ambulatory follow-up to assess the complication and progression rates of AF. The mean age was 64.8 ± 10.5 years, 50.9% were male, and the median waiting time was 37.2 months (IQR 15.0–61.3). AF progression occurred in 25.7% (n = 88) of patients, with longer waiting time independently associated with progression (OR, 1.017 per month; 95% CI, 1.006–1.028; p < 0.05). Electrical cardioversion during the waiting period was associated with a lower likelihood of progression (OR, 0.32; p = 0.029), and Class IC antiarrhythmic therapy was associated with reduced risk of AF progression (HR 0.78; p = 0.013). During follow-up, 45.2% of patients were hospitalized for AF paroxysms, 29.6% underwent electrical cardioversion, and 13.5% experienced complications including stroke and heart failure decompensation. Left atrial volume index and left ventricular ejection fraction were inversely correlated (ρ = −0.355, p < 0.05), but neither was associated with waiting time. Conclusions: Longer waiting times for PVI are associated with AF progression and substantial interim healthcare utilization due to complications. Strategies to prioritize higher-risk patients may help prevent disease progression and reduce complication burden.

Kounis syndrome is an acute coronary syndrome occurring in temporal association with an allergic or anaphylactic reaction. Recognition may be particularly challenging in patients with established coronary artery disease, in whom hypersensitivity-mediated mechanisms may coexist with conventional causes of acute myocardial infarction. We report a 62-year-old man with known coronary artery disease and previous percutaneous coronary interventions who developed loss of consciousness, generalized urticaria, facial swelling, dyspnea, and hemodynamic instability shortly after two wasp stings. He received intramuscular adrenaline and supportive treatment for anaphylaxis. Severe chest pain subsequently developed, with ST-segment elevation and a dynamic increase in cardiac troponin. Emergency coronary angiography demonstrated a critical lesion extending from the distal left main coronary artery into the proximal left anterior descending artery. Intravascular ultrasound performed before stent implantation demonstrated an intimal flap and dissection plane. Intravascular ultrasound-guided percutaneous coronary intervention with drug-eluting stent implantation achieved a satisfactory acute result. Subsequent allergological evaluation demonstrated Hymenoptera venom sensitization; baseline serum tryptase measured approximately five weeks after the event was within the reference range. The close temporal relationship between anaphylaxis and myocardial infarction supports suspected type II Kounis syndrome, while coronary dissection was identified as the culprit lesion morphology; its causal relationship to the hypersensitivity reaction remains uncertain.

Acute type A aortic dissection during pregnancy is a rare but life-threatening condition, with an estimated incidence of approximately 4 cases per 1 million women aged 15–45 years. Hormonal and hemodynamic changes during pregnancy are factors that may predispose to aortic dissection. These changes begin in the first and second trimesters but are most pronounced in the third trimester and the early postpartum period. Genetic syndromes, such as Marfan syndrome, significantly increase the risk of aortic dissection. A 41-year-old pregnant woman at 31 weeks of gestation with genetically confirmed Marfan syndrome presented with acute, severe, sharp retrosternal chest pain lasting four hours, radiating to the neck, accompanied by weakness and dizziness. Transthoracic echocardiography revealed dilation of the ascending aorta without significant aortic valve regurgitation. Computed tomography angiography confirmed the diagnosis of Stanford type A aortic dissection. Following a multidisciplinary team decision, an initial cesarean section with subsequent uterine artery embolization was performed, followed by emergency ascending aortic replacement. The patient and the newborn were successfully discharged on postoperative day 20. Although aortic dissection during pregnancy is rare, clinicians must maintain a high suspicion index for pregnant women presenting with severe chest pain. Careful monitoring of patients with suspected or confirmed connective tissue disorders is essential. This case demonstrates that acute type A aortic dissection may occur in pregnant patients with Marfan syndrome despite only moderate aortic root enlargement and highlights the value of rapid multidisciplinary management, including coordinated obstetric, endovascular, and cardiac surgical intervention.