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Issue. Articles

2(34) // 2011

 

 

1.

 

Systemic ecological theory of etiology and development of the most common vascular diseases

D.D. Zerbino

Results and synthesis of thirty year’s research are presented. The increase in number of vascular diseases entirely depends on the degree of pollution of human environment (professional, industrial, urban, paraprofessional, household) by xenobiotics. This modern global phenomenon leads to diseases which we have collectively defined as «environmental abnormality», «environmental illnesses» (D.D Zerbino, 1996). Long-term cross-clinical and pathomorphological studies, retrospective and prospective checking searches for the causes of vascular damages among people of young and middle age (under 50 years), which were carried out by us and my students, have shown the main thing – vascular diseases develop predominantly among young males of working professions who contact with xenobiotics. On the ground of system analysis, the theory of open biological systems (L. Bertalanffy), postulates of severe medical and biological problems (D. Derner) and our own researches, the «Systemic ecological theory of etiology and development of the most common diseases of the vascular system» was developed. The essence of the theory is to disclose the chain of progressive changes in vascular system from the initial action of the etiological stimulus – the xenobiotic – to the development of the latent pathology and further – to the formation of vascular system disease. Chronization of process completes with myocardial infarction, stroke or vascular insufficiency of other organs.

2.

 

Immediate results of repeated coronary artery bypass grafting in patients with ischemic heart disease

V.I. Ursulenko, A.V. Rudenko, A.V. Kupchinskyi, N.N. Pilipenko, M.A. Obeid, L.S. Dzakhoyeva, N.M. Verich

The purpose to study the causes and timing of recurrence of angina after coronary artery bypass grafting (CABG) on a beating heart, to assess the possibility of repeated operations and their immediate results.

Materials and methods. 5.238 CABG operations on a beating heart were performed with a hospital mortality rate of 0.9 % for the period from 2000 to 2009 in M.M. Amosov National Institute of Cardiovascular Surgery of the Academy of Medical Sciences of Ukraine. In addition to general clinical examinations, including X-ray of the chest, the definition of vital lung capacity and gastroscopy, all patients underwent ECG in 12 standard leads, echocardiography, coronary, graft- and ventriculography of the left ventricule, pulmonary artery pressure measurement, Doppler ultrasound of cerebral vessels and, if necessary, computed tomography of the brain. Repeated CABG was indicated in case of return of myocardial ischemia and recurrent angina. The character of the narrowing of the coronary arteries (CA), or shunt, did not permit to eliminate these diminutions by roentgen endovascular method. An anatomic base for successful repeated CABG is the presence of lumen diameter of 1.5 mm or over below the stenosis place of the CA which are to be grafted.

Results and discussion. During this period, due to return of myocardial ischemia and recurrent angina, repeated coronary arteriography and bypass angiography were performed in 263 patients. Shunts were functioning in 42 (15.9 %) patients, the degree of damage to the native (originally unaffected) coronary arteries did not change. The onset of substernal chest pain which patients took for the return of angina may be associated with hypertension, a slight stenosis of the aortic valve, the initial postinfarction cardiomyopathy (ejection fraction

Keywords: coronary artery bypass grafting, the beating heart, myocardial ischemia, recurrent angina, repeated coronary artery bypass grafting.

3.

 

Age-dependent analysis of clinical variants and forms of vertebral artery syndrome for patients with extravascular compression in segment V1V2

V.G. Mishalov, L.M. Yakovenko, V.A. Cherniak, V.V. Sulik, S.V. Dybkaliuk, R.V. Sulik, V.Yu. Zorgach, .M. Zozulia

The aim to analyze the occurrence of clinical variants of vertebral artery syndrome (VAS) for patients with extravascular compression of vertebral artery (ECVA) in segment of V12, depending on the form of VAS and the age of patients, to suggest a points scale for VAS forms assessment.

Materials and methods. The results of prospective clinical-neurological examination of 250 patients with VAS were presented: group I 34 (13.6 %) patients (15 (44.1 %) males and 19 (55.8 %) females, average age (41.2 3.6) years) with functional reflectional angiospastic form; group II 156 (62.4 %) patients with functional compressive-irritative form (74 (47.5 %) males and 82 (52.5 %) females, average age (44.7 5.2) years) and group III 60 (24 %) patients (33 (55 %) males and 27 (45 %) females, average age (58.3 6.4) years) with organic form of VAS caused by ECVA in segment V12. All patients were treated in 20082011 in clinical bases of O.O. Bohomolets NMU: in the department of cardiovascular surgery of Kiev ACH, clinic of vascular surgery of HMCH of Ukraine MD. Analysis of major clinical variants of VAS in patients with ECVA was performed.

Results and discussion. The findings show the prevalence of patients with the syndrome of Barre-Leu (125 (92.6 %) persons) and the syndrome of autonomic disorders (110 (81.5 %) persons) in 1845 year age group. However, the frequency of cochleovestibular and vestibulo-ataxic syndromes increased in patients of older age groups. Thus, vestibulo-ataxic syndrome was observed in 30 (22.2 %) patients of 1845 years age group, in 40 (61.5 %) patients of 4659 years age group, in 41 (82.0 %) patients of 6074 years age group. Ophthalmic syndrome was observed with similar occurrence in all of the above age groups. The anamnestic study revealed that in younger age group, transient ischemic attacks were observed in 9 (6.7 %) patients, in middle age group in 10 (15.4 %) patients, and among elderly patients in 13 (26.0 %) persons, where in 5 (10.0 %) of them this clinical variant was diagnosed repeatedly. Drop-attacks were registered in 2 patients of 4659 years of age. Also in 4 (3.0 %) patients of younger age group and in 2 (3.1 %) patients of age group of 4659 year old persons, a momentary loss of consciousness during a sharp turn of the head was registered, which was regarded as the syndrome of Unterharnscheidt.

Conclusions. In the group of young and middle aged persons, the dominant mechanisms of VAS formation were reflexive, namely, muscular-tonetic and vegetative-vascular, syndromes. In the elderly, VAS of compression genesis beard the marks of chronic cerebral ischemia (r = -0.27, p = 0.04). The obtained results specify the clinical diagnostic criteria of patients with VAS caused by extravascular compression, and allow to approach on a case-by-case basis to the choice of treatment tactics, according to a clinical variant of VAS, focusing on the age of the patients. In our opinion, the proposed scale of Hoffenberth for estimating the forms of VAS of compression genesis will help to unify criteria for the diagnosis and differential patterns of treatment of this pathology.



Keywords: vertebral artery syndrome, extravascular compression, clinical variants, form, age groups.

4.

 

The effect of reducing heart rate with a combination of ivabradine and

E.N. Amosova, Sui Yao, A.B. Bezrodnyi, I.V. Prudkyi, Yu.V. Rudenko, O.M. Herula

The purpose to evaluate the effect of controlling the heart rate (HR) using a combination of ivabradine and metoprolol as compared to monotherapy with high doses of metoprolol on remodeling, left ventricular (LV) systolic function and the plasma level of atrial natriuretic peptide (NT-proANP) in patients after Q wave myocardial infarction (MI) with ejection fraction (EF) < 45 % and moderate acute left ventricular failure (ALVF) in early (1 month) and late (6 months) periods.

Materials and methods. A total of 62 patients were examined aged (61.5 2.2) years with acute primary Q wave MI with sinus rhythm of HR > 70 per 1 min, LV EF < 45 % and ALVF no higher than Killip class II on the first day of the disease. 71 % of them received reperfusion therapy. Patients were randomized into two groups: 1st (n = 30) patients treated with metoprolol tartrate in an initial dose of 6.25 mg twice a day followed by increasing doses until HR of about 60 per 1 minute or until the most tolerable dose (final average dose of metoprolol is 116.5 5.8 mg/day). Patients in group 2 (n = 32) received metoprolol tartrate in an initial dose of 6.25 mg twice a day with its consequent increase up to 2537.5 mg twice a day and from 4th-6th day ivabradine in an initial dose of 2.5 mg twice daily, increasing to 5 mg and 7.5 mg twice a day until achieving HR of about 60 per 1 minute, or the most tolerable dose (final mean dose of ivabradine 12.8 0.6 mg/day, metoprolol tartrate 50.8 1.7 mg/day). Patients in both groups were comparable by clinical and demographic characteristics, inpatient and outpatient treatment within 6 months of observation which was generally accepted. The examination of patients, in addition to the generally accepted one, included echocardiography on the 1st, 57th and 25th days and in 6 months after the onset of the disease with determination of end-diastolic and end-systolic LV volume, end-diastolic index (EDI), end-systolic, stroke and cardiac indexes, LV EF, regional contractility index (RCI) of anteroposterior size of the left atrium and right ventricle, end-diastolic thickness of posterior wall and interventricular septum, expansion of MI zone. Normative values of indices of the heart morphofunctional state were obtained when examining 20 healthy persons of the control group matched by age and sex ratio with patients in both groups. On 1st, 2nd and 25th days, the plasma levels of NT-proANP were measured by immunoassay (ELISA). Normative values of NT-proANP were obtained when examining 12 healthy volunteers matched by age and sex ratio with MI patients.

Results and discussion. On 1st day of study, both groups had no substantial differences in indicators of cardiohemodynamics and plasma levels of NT-proANP. HR was similar in all periods of observation. On 1st day it was (86.8 1.6) and (85.6 1.8) per 1 min, respectively, on 57th day (67.8 1.5) and (68.3 1.6) per 1 min, on 25th day (61.4 1.7) and (60.5 1.8) per 1 min and in 6 months (62.5 1.3) and (61.2 1.5) per 1 min (all p > 0.05). Patients in both groups did not differ significantly in occurrence of severe MI complications (one class increase of ALVF 16.7 and 12.5 %; MI relapse 10 and 6.3 %; hospital mortality 9.1 and 0 %; all p > 0.05). In 1st group, baseline EDI was (72.6 1.5) ml/m2. On day 25, it increased by 11.8 %, and 6 months later by 13.2 % (p < 0.01). In 2nd group, the EDI on day 1 was (72.3 1.5) ml/m2, on day 25 (76.5 1.4) ml/m2 (compared with the 1st group, p < 0.05) after 6 months (75.4 1.5) ml/m2 (p > 0.05 compared with the baseline). Starting with day 25, the EDI in group 2 was significantly lower than in group 1 (p < 0.05). In 1st group of patients on day 1, EF was (38.9 1.6) % and did not change significantly for 6 months (all p > 0.05). However, the EF in 2nd group increased from (38.8 1.5) to (46.5 1.5) % (p < 0.01) by day 25 and up to (48. 4 1.6) % (p < 0.01) in 6 months and was by 19.2 % higher than in group 1 (p < 0.01). Throughout the study period in group 1 there were no significant changes in RCI, but in group 2 by day 25 it decreased by 10.1 % compared to the baseline, and after 6 months by 13.8 % (all p < 0.01). Plasma NT-proANP level in group 1 did not change significantly up to day 25 as compared to group 1: (3572.4 207.1) versus (3487.2 3572.4) pmol/l (p > 0.05). However in group 2, it decreased from (2495.7 305.1) to (2281.3 198.4) pmol / l (p < 0.01).

Conclusions. For patients with Q wave MI with LV EF < 45 %, moderate ALVF and sinus rhythm, the addition of ivabradine to treatment with b-adrenergic blockers, while having the same compared to therapy with high doses of b-blockers negative chronotropic effect, contributes to improving global and segmental LV systolic function and reducing plasma levels of NT-proANP by day 25 and preventing early (in 1 month) and late (in 6 months) dilatation and remodeling of LV.



Keywords: If channel inhibitor, myocardial infarction,

5.

 

Features of daily dynamics of blood pressure in hypertensive patients with constant and variable heart ventricle rate frequency of heart ventricle contractions

T.A. Mangilova

The purpose to compare the performance variability of blood pressure (BP) and the magnitude of its nocturnal decline in patients with elevated and normal BP under constant and variable heart ventricles rate (VR) and to assess the impact of heart rate variability (HRV) on changes in BP during the day.

Materials and methods. 56 patients were examined with artificial pacemaker with constant frequency of stimulation. Average age (63.1 1.1) years, mean VR (68.2 1.1) per 1 min. The control group included 49 patients of similar age ((63.8 0.7) years) with the physiological fluctuations in heart rate (HR), in which the average HR per day was (69.3 1.1) per 1 min. Arterial hypertension (AH) was found in 37 patients of the main group (average BP per day: systolic (140.5 1.5) mm Hg, diastolic (82.0 1.4) mm Hg) and in 31 control patients (average BP per day: systolic (142.4 1.1) mm Hg, diastolic (83.2 1.3) mm Hg). The groups were matched by age, sex ratio, the detection rate and the severity of BP, frequency of concomitant chronic coronary heart disease and history of myocardial infarction as well as severity of chronic heart failure. All the patients after discontinuation of antihypertensive therapy underwent daily BP monitoring with the definition of its variability in the daytime and night-time and intensity of nocturnal decline in BP (circadian index).

Results and discussion. Rise of systolic BP variability in hypertensive as compared to normotensive patients was revealed in both groups: with constant VR at daytime (14.4 0.5 % versus 11.9 0.6 %, p < 0.01) and at nighttime (12.2 0.6 % versus 9.8 0.6 %, p < 0.01) and with sinus rhythm at daytime (15.4 0.6 % versus 12.2 0.7 %, p < 0.001) and at nighttime (14.6 0.6 % versus 10.6 0.9 %, p < 0.001). Comparison of BP variability in hypertensive patients with fixed and variable VR gave the following results: the absence of HRV is accompanied by a decrease in diastolic blood pressure variability in day time (9.3 0.4 % versus 10.8 0.5, p < 0.05) and at nighttime (7.4 0.5) versus (10.3 0.6) %; p < 0.001) and systolic blood pressure variability at night ((12.2 0.6) versus (14.6 0.6) %; p < 0.01). Circadian indices of systolic (0.7 0.9 %) and diastolic (-1 1.2 %) BP in patients with AH and constant VR were significantly lower (p < 0.05 and p < 0.01, correspondingly) then circadian indices of systolic (4.7 1.7 %) and diastolic (6.7 2.0 %) BP in patients with AH and sinus rhythm.

Conclusions. Rise of systolic BP variability is typical of patients with AH at day- and nighttime. Constant VR in patients with AH promote reduction of BP variability: diastolic both at day- and nighttime and systolic at nighttime. Hypertensive patients with constant VR and absence of HRV manifest reduction of systolic and diastolic BP circadian indices as compared to patients with AH and sinus rhythm.



Keywords: blood pressure variability, heart rate variability, circadian index, arterial hypertension.

6.

 

Effect of sildenafil on exercise tolerance, dyspnea and indicators of endothelial dysfunction in patients with pulmonary arterial hypertension

K.M. Amosova, L.F. Konoplva, T.I. Gavrylenko, I.V. Krichinska

The purpose to determine the effect of therapy with phosphodiesterase-5 inhibitor sildenafil on the severity of dyspnea, exercise tolerance and endothelial function in patients with idiopathic pulmonary arterial hypertension (IPAH).

Materials and methods. The study included a total of 32 patients with IPAH 24 (75 %) women and 8 (25 %) men aged (28 2.2) years, and 20 clinically healthy individuals matched by age and gender (control group). The examination of patients with IPAH and healthy persons involved the identification of dyspnoea level on Borg scale, a 6-minute walk test, determination of endothelin-1 level and von Willebrand factor activity in serum by immunoenzyme method before and 24 weeks after treatment with sildenafil in a dose of 50 mg/day.

Results and discussion. Distance of 6-minute walk after 24 weeks of treatment with sildenafil increased from (355 19.5) to (452 20.3) m, and dyspnea decreased from (6.9 0.9) to (4.4 0.6) points (p < 0.05). In patients with IPAH compared with healthy individuals, the levels of endothelin-1 in plasma was 7.1 times higher (1.4 0.24) compared to (0.2 0.02) fmol/l (p < 0.001), the activity level of von Willebrand factor 10.2 times higher (2.2 0.6) compared to (0.2 0.01) IU / ml (p < 0.001). After treatment, these figures decreased by 36.4 and 28 % (p < 0.05) in patients with IPAH. An inverse correlation was found between the absolute value of reduction of endothelin-1 level and the absolute and relative growth of 6-minute walk distance (r = 0.67 and 0.63, respectively). There was also an inverse correlation between the absolute decrease in EF and these parameters (r = 0.68 and 0.63, respectively) (p < 0.01).

Conclusions. In patients with IPAH and chronic heart failure of IIIII NYHA class, the treatment with sildenafil in the dose of 50 mg/day for 24 weeks leads to an increase in 6-minute walk distance by 27 % on average, a decrease in dyspnea on Borg scale by 37.8 % and a decrease in systolic pulmonary artery pressure by 14 %. The patients with IPAH and chronic heart failure of IIIII NYHA class revealed plasma levels of endothelin-1 elevated by 7.1 times on average and activity of von Willebrand factor by 10.2 times as compared with healthy persons of the same age, which confirms their role in the pathogenesis of the disease. Sildenafil treatment in a dose of 50 mg/day for 24 weeks reduced plasma levels of endothelin-1 by 36.4 % and the activity of von Willebrand factor by 28 %. The expression of absolute reduction of these parameters correlated with the absolute and relative decrease of dyspnea and increase in 6-minute walk distance.



Keywords: endothelial dysfunction, pulmonary hypertension, endothelin-1, the activity of von Willebrand factor, sildenafil.

7.

 

Implications of endovenous laser coagulation in patients with different diameters of ostial part of the great saphenous vein

S.V. Kadochnikov

The purpose to improve the quality of treatment for patients with varicose veins of lower extremities by clarifying the indications for the choice of the method of endovenous laser coagulation (EVLC) for different diameters of ostial part of the great saphenous vein (GSV).

Materials and methods. 60 patients with varicose veins of C2-C3 CEAP class were under study. While performing ultrasound studies, the diameter of GSV was measured, according to which the patients were divided into groups. Surgical treatment was performed, the volume of which (isolated EVLC, the combination of EVLC and crossectomy) depended on the diameter of ostial part of GSV.

Results and discussion. Results of the treatment of patients with varicose veins were studied. The comparison of the results showed that the isolated EVLC in patients with a diameter of ostial part of GSV over 10 mm is accompanied by a higher (by 70 %) rate of recanalization than in patients who underwent EVLC in combination with crossectomy.

Conclusions. The initial diameter of GSV must be taken into consideration when determining indications for EVLC. Particularly important area for the formation of recanalization is the ostial part of GSV. The revealing of GSV ostial part diameter exceeding 10 mm in ultrasound is an indication for the combined intervention EVLC and crossectomy. Their performance in this group of patients reduces the number of complications such as recanalization (by 70 %), the formation of a painful taenia in the treated vein by (41.7 %). EVLC without crossectomy can be performed in patients with a GSV ostial part diameter smaller than 10 mm.



Keywords: varicose veins, endovenous laser coagulation, crossectomy.

8.

 

Comparative effectiveness of antiplatelet drugs for patency of infra-inguinal shunts in patients with chronic circulatory insufficiency of lower extremities

V.G. Mishalov, N.Yu. Litvinova

The review of randomized studies presents data about the effectiveness of the use of different antiplatelet agents for shunt patency, limb preservation and survival of patients with chronic circulatory insufficiency of the lower extremities after infra-inguinal bypass surgery. The comparative effectiveness and safety of the drug Plavix (clopidogrel) is evaluated.

Keywords: lower extremity ischemia, ifra-inguinal bypass graft, graft patency, antiplatelet therapy.

9.

 

Biomarkers in heart failure new objectives of therapeutic tactics?

V.A. Vizr, V.V. Popov, N.P. Kopitsa, I.N. Voloshyna

The survey contains information that summarizes the results of several randomized clinical trials. Until now, serum levels of B-type natriuretic peptide (BNP) or N-terminal precursor of peptide (NTproBNP) have been used as a biomarker of chronic heart failure. Prognostic significance of new markers that reflect changes in the structure and function of the myocardium are actively explored. The results of the TIME-CHF study suggest that an active intensive treatment of heart failure, aimed at reducing the level of BNP, may favorably affect clinical outcomes and endpoints in patients aged 60 to 74, which is not observed in elderly patients. Such an approach obviously cannot yet be recommended for routine use in clinical practice, and its clinical efficacy will require further large-scale randomized studies.

Keywords: heart failure, biomarkers, clinical trials.

10.

 

Modern ideas about the diagnosis and treatment of chronic heart failure: place of angiotensin receptor blockers

V.K. Tashchuk, T.O. Ilashchuk

Modern aspects of diagnosis and treatment of heart failure, causes, neurohumoral factors, development patterns and their impact on treatment are related to the use of classical therapeutic approaches – diuretics, digitalis, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, b-blockers, aldosterone antagonists. Optimization of long-term prognosis in these patients predetermines the search for new approaches, including the use of angiotensin receptor blockers – a highly effective antiremodeling remedy.

Keywords: heart failure, angiotensin receptor blockers, sympathoadrenal system, renin-angiotensin-aldosterone system.

11.

 

Femoral vessel injury complicated with arrosive bleeding and successful extraanatomic bypass grafting

Ye.V. Yermolaev

Infections are frequent complication in surgery of vascular trauma which results in secondary amputation in the majority of cases. Arosive bleeding from vascular anastomoses can be the only manifestation of this complication with mortality rate up to 87 %. Extraanatomic bypass grafting is a possible way of restoration of magistral blood flow in such cases. S., 29-year-old male, was admitted to Vascular Dept. of Zaporizhzhya Regional Clinical Hospital with stab-cut wound of right thigh and damage to the femoral artery and vein. In 25 days after auto-venous superficial femoral artery bypass grafting, recidive arrosive bleeding emerged at zone of the arterial reconstruction. The femoral artery was ligated and, because of severe limb ischemia, obturatory extraanatomic iliacfemoral bypass grafting was carried out with cone vascular prosthesis GORE-TEX Vascular Graft Standard Wall 6–8 mm. Pulsation on foot arteries was restored after the surgery with compensation of limb circulation. The patient was discharged in satisfactory condition. Extraanatomic bypass grafting allows restoring magistral blood flow and avoiding amputation in case of infection in the area of injured vessels of primary wound.

Keywords: vascular infection, arrosive bleeding, extraanatomic bypass grafting.

Current Issue Highlights

4(60) // 2017

Cover preview

K. M. Amosova 1, I. I. Gorda 1, A. B. Bezrodnyi 1, G. V. Mostbauer 1, Yu. V. Rudenko 1, A. V. Sablin 2, N. V. Melnychenko 2, Yu. O. Sychenko 1, I. V. Prudkiy 1&a

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