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Issue. Articles

№1(41) // 2013

 

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1.

 

The mechanism of occurrence of myocardial ischemia in case of myocardial bridges

Ye.К. Gogayeva

In this issue we present a mathematical model of myocardial bridge aimed at studying the mechanism of occurrence of myocardial ischemia in case of this anomaly. One of the major causes of myocardial ischemia in myocardial bridges is the prolongation of systolic compression of coronary arteries in the first phase of diastole. Additional factors that can lead to myocardial ischemia were divided into anatomical and functional.

Keywords: myocardial ischemia, myocardial bridge, coronary flow, diastolic dysfunction.

2.

 

Risk assessment and results of aortic endoprosthesis in elderly patients

S.N. Furkalo, I.V. Khasianova, M.V. Kostylev, S.V. Sukhachуоv

The purpose – to compare the data of predictive risk assessment of abdominal aortic endovascular prostheses by POSSUM system considering recommendations of the Society of Vascular Surgery (SVS/AAVS) with the results of treatment.

Materials and methods. Results of 20 patients (all males) with abdominal aortic aneurysm who were treated between 2006 and 2011 were analyzed. The patients’ ages ranged from 70 to 78 years (mean age was 72.1 years). Complex preoperative examination included physical examination, laboratory tests, ECG, and echocardiography, coronaroventriculography in patients with coronary artery disease. The main method of visualization of the aneurysm was a spiral computed tomography. In all patients included in the study the endovascular aortic replacement with implantation of the Excluder (GORE) prosthesis was performed. Prognostic data were compared with the actual results of endovascular intervention.

Results and discussion. The results of surgery are largely determined by comorbidity and anatomic features of the aneurysm itself. Assessment of complications and death risk can choose the preferred intervention type in each patient. Apply of the V-POSSUM scale is accompanied with overstated prognostic risks with regard to the patients before endovascular intervention, and in such studies it can be used as a guide only, SVA/AAVS scale is more consistent with the real picture and some with it the risk of interference is almost equal to the results of treatment. Our results confirm the literature data that the benefits of endovascular intervention by patients with «good» anatomy and a high risk of open surgery.

Conclusions. The experience with the endovascular abdominal aortic aneurysm prosthesis in patients of older age groups demonstrates the high efficiency of the direct and relative safety of interventions, including patients with concomitant cardiovascular disease.

Keywords: abdominal aortic aneurysm, aortic stenting, POSSUM scale.

3.

 

Vascular endothelial growth factor in patients with first grade arterial hypertension

V.F. Kubyshkin , T.A. Mangiliova, K.D. Malyi

The purpose – to compare the concentrations of vascular endothelial growth factor (VEGF), soluble receptor of the first type of vascular endothelial growth factor (sVEGFR1) and placental growth factor (PlGF) in blood plasma and genetic polymorphism of VEGF in patients with essential hypertension of I and II stages and increased blood pressure of I degree and in those without increased blood pressure to identify possible causes of changes in VEGF level and its relationship with increased blood pressure.

Materials and methods. The study involved 79 patients with first grade arterial hypertension and 54 patients with optimal or normal blood pressure which formed the control group. The groups were age and gender matched. VEGF, sVEGFR1 and PlGF in plasma were determined by enzyme immunoassay. Polymorphism of single nucleotide gene VEGF –634 G/C і –2578 C/A was studied with the use of polymerase chain reaction.

Results and discussion. The average concentration of the free VEGF in plasma of patients with first grade arterial hypertension (312.8 pg/ml ± 25.6 pg/ml) was significantly higher (p <0.01) than in the control group (206.1 pg/ml ± 18.6 pg/ml). There was no difference between overage sVEGFR1 and PlGF plasma concentrations in the main and control groups. Also we did not find any intergroup differences between the frequencies of –634 G/C and –2578 C/A alleles and –634 GG, GC, CC and –2578 CC, CA, AA genotypes in the promoter region of VEGF gene. The concentration of VEGF in patients with high blood pressure was higher in the presence of genotype –634 GG than genotype –634 GA (p <0.05).

Conclusions. Increased content of VEGF in serum is characteristic of patients with first grade arterial hypertension. It is not associated with changes in concentration of sVEGFR1, PlGF and the frequency of detection of alleles and allele combinations of –634 G/C and –2578 C/A gene of VEGF. Most likely, the increase of VEGF expression in first grade arterial hypertension reflects the body’s response to the increased blood pressure which is more expressed in patients with genotype –634 GG than in those with genotype –634 GC.

Keywords: arterial hypertension, vascular endothelial growth factor, soluble receptor of the first type of vascular endothelial growth factor, placental growth factor, vascular endothelial growth factor gene polymorphism.

4.

 

Сосудистый эндотелиальный фактор роста у больных артериальной гипертензией І степени

В.Ф. Кубышкин , Т.А. Мангилёва, К.Д. Малый

Цель работы – сравнение концентрации сосудистого эндотелиального фактора роста (VEGF), растворимого рецептора первого типа сосудистого эндотелиального фактора роста (sVEGFR1) и плацентарного фактора роста (PlGF) в плазме крови, а также исследование генетического полиморфизма VEGF у больных эссенциальной артериальной гипертензией І и ІІ стадии с повышением артериального давления І степени и у обследованных без повышения артериального давления для выявления возможных причин изменения уровня VEGF при артериальной гипертензии и его взаимосвязи с повышением артериального давления..

Материалы и методы. Обследовано 79 больных артериальной гипертензией I степени, 54 пациента с оптимальным или нормальным артериальным давлением вошли в группу контроля. Группы не отличались по возрасту и полу. Уровни VEGF, sVEGFR1 и PlGF в плазме крови определяли методом иммуноферментного анализа. Полиморфизм единичного нуклеотида гена VEGF –634 G/C и –2578 C/A исследовали с помощью полимеразной цепной реакции.

Результаты и обсуждение. Средняя концентрация свободного VEGF в плазме крови больных артериальной гипертензией I степени (312,8 пг/мл ± 25,6 пг/мл) была значительно выше (p < 0,01), чем в контрольной группе (206,1 пг/мл ± 18,6 пг/мл). Не выявлено различий средних концентраций sVEGFR1 и PlGF в плазме у обследованных основной и контрольной групп. Также не обнаружено существенных межгрупповых отличий частот выявления аллелей –634 G/C и –2578 C/A и генотипов –634 GG, GC, CC и –2578 CC, CA, AA в промоторной области гена VEGF. Концентрация VEGF у пациентов с повышенным артериальным давлением была выше при генотипе –634 GG, чем –634 GA (p < 0,05).

Выводы. Повышение содержания VEGF в плазме крови характерно для больных артериальной гипертензией I степени. Оно не связано с изменением концентрации sVEGFR1, PlGF и частотой выявления аллелей и аллельных сочетаний –634 G/C и –2578 C/A гена VEGF. Наиболее вероятно, рост экспрессии VEGF при артериальной гипертензии I степени отражает реакцию организма на повышение артериального давления, которая более выражена у пациентов с генотипом –634 GG, чем –634 GC.

Keywords: артериальная гипертензия, сосудистый эндотелиальный фактор роста, растворимый рецептор первого типа сосудистого эндотелиального фактора роста, плацентарный фактор роста, полиморфизм гена сосудистого эндотелиального фактора роста.

5.

 

Evaluation and comparison of the effectiveness of intraoperative microfoam phleboscleroobliteration, endovenous laser coagulation and standard phlebectomy for treatment of varicose veins of lower extremities

V.I. Palamarchuk, V.A. Khodos, V.M. Krуsa

The purpose – to assess and compare the efficacy of intraoperative microfoam phleboscleroobliteration, endovenous laser coagulation (EVLC) and standard phlebectomy in treatment of varicose veins of lower extremities.

Materials and methods. A comparative evaluation of the results of surgical treatment of three groups of patients with varicose veins of the lower extremities of C2 – C5 class in the CEAP (Clinical Etiological Anatomical Pathophysiological) classification was carried out. The first (primary) group consisted of 53 patients (С2 – 32, С3 – 12, С4 – 6, С5 – 3) who were operated on with the use of intraoperative catheter microfoam stem phleboscleroobliteration (ICMSP), the second (representative) group included 51 patients (С2 – 34, С3 – 10, С4 – 5, С5 – 2) who were operated on with the use of EVLC, the third (representative) group was composed of 52 patients (С2 – 35, С3 – 9, С4 – 5, С5 – 3) who underwent standard phlebectomy according to Babcock.

Results and discussion. Analysis of frequency and nature of the side effects and complications, duration of rehabilitation, cosmetic results showed ICMSP and EVLC advantage over the standard phlebectomy according to Babcock. Comparative analysis of treatment of varicose veins of the lower extremities revealed no significant differences between the two most common minimally invasive methods (ICMSP and EVLC) neither in the number and nature of postoperative complications, nor in terms of rehabilitation; it found no difference in the ultrasonic inspection of the picture of the fibrous degeneration of venous trunks that underwent laser or scleroobliteration, recorded no differences in the number of relapses of the disease, showed no advantage in cosmetic results.

Conclusions. The number of complications after combined intraoperative catheter microfoam stem phleboscleroobliteration and endovasal laser coagulation is much smaller, and the degree of their severity is insignificant compared to the complications of conventional phlebectomy (by all indications differences from the first group were statistically significant p < 0.05). The average duration of labor activity recovery after intraoperative catheter microfoam stem phleboscleroobliteration and endovasal laser coagulation is much smaller than after the standard phlebectomy – by 4.3 and 4.1 times, respectively (differences between the first and the second groups are statistically significant (p < 0.001).

Keywords: varicose veins, scleroobliteration, endovasal laser coagulation.

6.

 

Predictors of progression of carotid artery lesion in patients with essential hypertension

L.A. Mishchenko, Ye.P. Svishchenko, O.A. Yarynkina

The purpose – to investigate the 5-year dynamics of intima—media thickness of carotid arteries in connection with changes of blood pressure and indices of systemic inflammation, lipid, carbohydrate, purine metabolism and microalbuminuria, and detection of predictors of carotid damage progression in patients with essential hypertension (EH).

Materials and methods. Basic and follow-up (in 5 years) clinical examination, 24-hour blood pressure monitoring, carotid dopplerography, determination of plasma creatinine, glucose, insulin, C-reactive protein, uric acid, plasma lipids and 24-hour urinary albumin excretion were performed in 80 EH patients.

Results and discussion. In patients with EH, the progression of thickening of carotid artery intima—media is associated with the rise of average day pulse pressure (r = 0.26; p = 0.03) and the increase of plasma total cholesterol (r = 0.32; p = 0.003), cholesterol of low density lipoproteins (r = 0.33; p = 0.002), serum uric acid (r = 0.26; p = 0.02) and the growth of microalbuminuria (r = 0.30; p = 0.006). Basic intima—media thickness (β = –0.406; p = 0.001) and C-reactive protein level (β = 0.591; р < 0.001) are predictors of intima—media thickening progression in EH patients.

Conclusions. In patients with hypertension, the progression of carotid artery lesions in the form of carotid intima—media thickness is directly associated with an average daily pulse and arterial BP rise and with the increase of plasma total cholesterol at the expense of atherogenic cholesterol of low density lipoproteins, serum uric acid and the increase of microalbuminuria. C-reactive protein level is an independent predictor of intima—media thickening rise in EH patients.

Keywords: essential hypertension, intima—media thickness, systemic inflammation, metabolic cardiovascular risk factors.

7.

 

Surgery of critical ischemia of the lower extremities

V.A. Chernіak

The purpose – to mprove the results of surgical treatment of patients with chronic critical ischemia of the lower limbs (CCILE).

Materials and methods. The work is based on the results of the survey 890 patients CCILE who were hospitalized and operated on in Cardiovascular Surgery from 1998 to 2006, all patients were examined for detection multifocal atherosclerosis combined with chronic critical ischemia of the lower extremities (CCILE), were divided into 2 groups: group A (control), where the patients were examined by conventional methods, and group B (main), where they used the methods and algorithms for diagnosis of its own design.

Results and discussion. It was established that the development of CCILE was underlain by a number of mechanisms which triggered the transition of ischemic tissues to anaerobic glycolysis, pathological systemic inflammatory process, respiratory hypoxia, where a crucial role belonged to the disordered venous hemodynamics. Along with widely spread (87.2 %) concurrent multifocal atherosclerosis, the pathological processes playing a leading role in unsatisfactory results of the surgical treatment for CCILE were studied. Therefore, the solution of problem of diagnosis and treatment for CCILE and the development of new diagnostic methods and algorithms allowed us to improve the identification of concomitant atherosclerotic lesions in three basins from 6.9 to 32.7 %, in four basins from 1.7 to 9.4 %, and in five and more basins from 0.3 to 3.4 % (p < 0.001). The use of the proposed algorithm for preoperative preparation, which takes into account the pathogenetic features of the disease course, allowed us to reduce the number of primary amputations of the lower extremities from 10.2 to 4.2 % (p < 0.001). Similarly, the use of the proposed methods for revascularization of the lower extremities allowed the number of secondary amputations to be reduced from 37.7 to 12.7 % (p < 0.001).

The original methods were developed for the reconstruction of vascular bed in concurrently damaged arterial basins and used in 153 (30 %) patients of the basic group. Owing to them, postoperative mortality was reduced from 5.2 to 2.6 % in the immediate period, from 6.5 to 1.4 % in the short-term period, from 14.6 to 5.4 % in the intermediate period, and from 15.1 to 3.5 % in the long-term period (p < 0.001 vs. control for each period).

Conclusions. The proposed complex approach to solution of the problem of diagnosis and surgical treatment for CCILE ensures good and satisfactory results in 95.8 % in the immediate period, 89.7 % in the short-term period, 95.6 % in the intermediate period, and 90.0 % in the long-term period (p < 0.05 vs. control for each period).

Keywords: chronic critical ischemia of the lower extremities, multifocal atherosclerosis, pathogenesis, diagnosis, surgical treatment.

8.

 

Cerebrovascular reactivity in patients with type 2 diabetes mellitus

Ya.A. Sayenko, A.V. Kovalenko, B.M. Mankovskyi

The purpose – to examine cerebrovascular reactivity in patients with type 2 diabetes as a potential risk factor for acute and chronic disorders of cerebral circulation by using transcranial Doppler sonography.

Materials and methods. A total of 53 patients with type 2 diabetes and 50 age and gender matched persons without diabetes and clinical signs of cerebrovascular pathology forming the control group were examined. Cerebral hemodynamics in the medium cerebral artery was studied using transcranial Doppler sonography, which allowed to investigate the linear blood flow parameters and to evaluate the functions of the central mechanisms of regulation on the instrument Elegra Siements (USA). The following functional tests were used to determine cerebrovascular reactivity: hypercapnic, cold, orthostatic, the test with bilateral compression and decompression of hand, hyperventilation.

Results and discussion. The study showed that patients with type 2 diabetes had mean blood flow velocity of (105.37 ± 0.73) and (104.95 ± 0.72) cm/s in the right and left middle cerebral arteries, which was significantly lower than the indicators in the control group (117.37 ± 2.02) and (118.04 ± 2.01) cm/s, respectively, (p < 0.05). During the functional tests the blood flow velocity in the medium cerebral artery of patients with type 2 diabetes was as follows: hypercapnic – (112.80 ± 0.78) cm in the right and (112.57 ± 0.82) cm/s in the left, in the control group – (145.70 ± 3.32) and (144.82 ± 3.25) cm/s, respectively; cold – (116.12 ± 1.05) and (116.16 ± 1.01) cm/s, respectively, in patients with diabetes mellitus and (144.09 ± 2.67) and (142.69 ± 2.70) cm/s, respectively, in the control group; orthostatic – (110.56 ± 0.86) and (110.38 ± 0.98) cm/s, respectively, in diabetic patients, in the control group – (127.18 ± 2.28) and (127.10 ± 2.34) cm/s, respectively; tests with bilateral compression and decompression of hand – (109.35 ± 0.53) cm/s in the right and (109.11 ± 0.58) cm/s in the left middle cerebral arteries of diabetic patients, in the control group – (129.10 ± 2.35) and (128.55 ± 2.44) cm/s, respectively; hyperventilation – (96.77 ± 0.49) and (96.77 ± 0.54) cm/s, respectively, in patients with diabetes, in the control group – (97.37 ± 2.20) and (98.64 ± 1.19) cm/s, respectively. These figures show a decrease in the background blood flow in the brain of patients with type 2 diabetes. Cerebrovascular reactivity coefficient was used for a more detailed description of changes in the cerebral blood flow. During the hypercapnic test, it was (7.13 ± 0.55) % in the right and (7.37 ± 0.76) % in the left middle cerebral arteries of diabetic patients, in the control group it was (23.91 ± 1.41) and (22.39 ± 1.23) %, respectively. During the cold test, the coefficient of cerebrovascular reactivity in the right and left middle cerebral arteries of patients with type 2 diabetes was (10.27 ± 0.85) and (10.87 ± 1.16) %, in the control group it was (22.99 ± 1.29) and (21.00 ± 1.17) %, respectively. During the orthostatic test, this indicator in the right and left middle cerebral arteries of diabetic patients was (4.19 ± 0.79) and (4.84 ± 0.84) %, in the control group it was (7.77 ± 0.56) and (7.12 ± 0.60) %, respectively. During the test with bilateral compression and decompression of hand in diabetic patients, the coefficient of cerebrovascular reactivity was (3.83 ± 0.39) % in the right and (3.64 ± 0.37) % in the left middle cerebral arteries, in the control group it was (9.53 ± 0.97) and (8.4 ± 0.81) %, respectively. During the hyperventilation test in diabetic patients it was (7.99 ± 0.34) and (7.91 ± 0.29) % in the right and left middle cerebral arteries, in the control group it was
(17.00 ± 1.93) and (16.30 ± 0.95) %, respectively (p < 0.05).

Conclusions. Doppler study of middle cerebral artery was used to detect the reduction of rate of cerebral blood flow and the deterioration of cerebrovascular reactivity in patients with type 2 diabetes, which can be one of the risk factors for chronic and acute cerebrovascular events in these patients.

Keywords: type 2 diabetes mellitus, coefficient of cerebrovascular reactivity, velocity of flow in the middle cerebral artery, functional tests.

9.

 

Long-term clinical and laboratory effects of drug correction of iron deficiency in patients with coronary chronic heart failure and concomitant anemia without obvious causes of iron loss and its effect on the functional status of patients

Ye.N. Amosova, V.N. Tsaralunga, N.N. Sidorova

The purpose – to assess the long-term clinical and laboratory effects of a three-month drug correction of iron deficiency in patients with chronic heart failure of coronary origin and concomitant anemia without obvious causes of iron loss and its effect on the functional status of patients.

Materials and methods. We observed 51 patients over 50 years old (mean age 68.1 years ± 1.5 years) with chronic heart failure of coronary genesis of II–IV functional class (FC) by NYHA, the majority (78.4 %) of them had ejection fraction (EF) of the left ventricle (LV) > 45 % and iron deficiency anemia. They underwent a three-month therapy with an oral iron preparation Actiferin in the dose of 103.5 mg/day. The criterion for anemia was lowering of the hemoglobin (Hb) level to 130 g/l or more in men and 120 g/l or more in women. Iron deficiency was diagnosed on the basis of reduction of color index, erythrocyte indices and serum iron level. In 28–36 (32.8 ± 0.7) months we contacted the patients by telephone and invited to a re-examination 25 (49 %) of them, including 16 (64.0 %) women and 9 (36 %) men. Prior to the study 21 (84.0 %) patients had stable angina pectoris not higher than III FC, 5 patients (20.0 %) had postinfarction cardiosclerosis, 25 patients (100.0 %) had essential hypertension. Chronic heart failure of the I stage was observed in 5 (20.0 %) patients and that of the IIA stage – in 24 (96.0 %). According to echocardiography, LV EF < 45 % was in registered in 2 (8.0 %) patients. The survey involved a test of six minutes’ walk, Doppler echocardiography with assessment of systolic function of LV and iron metabolism in blood serum which were determined at baseline, after 3 months of therapy with Actiferin and in (32.8 ± 0.7) months.

Results and discussion. Immediately after the oral therapy with Actiferin we observed a significant positive dynamics of indicators of Hb – from (97.7 ± 2.2) g/l (75–117 g/l) to (128.8 ± 0.9) g/l (123–137 g/l) (p < 0.001), which was accompanied by an increase in serum iron from (6.9 ± 0.3) to (12.9 ± 0.3) mmol/l (p < 0.001) and transferrin saturation with iron from (8.5 ± 0.5) to (17.6 ± 0.6) % (p < 0.001) and ferritin content – by 37.1 % (p < 0.01). In (32.8 ± 0.7) months after the ferrotherapy we observed a negative dynamics of all indicators of erythrocyte stem. Thus, the concentration of Hb decreased by 6.3 %, Ht – by 4.8 %. Indices of Hb, Nt, color index and average volume of erythrocyte remained significantly higher than the initial values (by 19.0; 19.3; 6.1 and 4.1 %, respectively, p < 0.001, p < 0.01). Indicators of iron metabolism also reduced: iron levels in blood serum – by 21.7 %, transferrin saturation – by 24.4 % (p < 0.001) and the amount of ferritin decreased by 29.5 % (p < 0.05), which indicates a decrease in body iron stores and increase of iron deficiency. FC by NYHA worsened in 22 (88.0 %) patients: III FC – from 4.0 to 48.0 % of patients (p < 0.001), and only in 2 (8.0 %) patients the functional status suited I FC. Thus, the clinical effect of exchange rate correction of iron deficiency was fragile. In (32.0 ± 0.7) months, the six minutes’ walk distance decreased by 21.2 % – from (467.4 ± 8.5) to (368.2 ± 16.3) m (p < 0.001), average values of end-diastolic and end-systolic volumes were back to original ones, and EF of LV decreased by 7.3 % (p > 0.05) as compared to the data 3 months later.

Conclusions. Without maintenance therapy with iron preparations in (32.8 ± 0.7) months after the end of three-months’ administration of these drugs orally, the patients with chronic heart failure of II–IV FC by NYHA and iron deficiency anemia (Hb 75–117 g/l) manifested the decrease of positive effect: the level of Hb and iron metabolism indices remained higher than the initial ones (Hb – by 6.3 %, transferrin saturation – by 24.4 %, ferritin – by 29.5 %). Negative laboratory dynamics was accompanied by the deterioration of the functional state to one FC by NYHA in 88 % of patients and the decrease in six-minutes’ walk distance by 38.8 %, yet it remained 22.3 % higher than the initial one.

Keywords: chronic heart failure, anemia, iron deficiency.

10.

 

The effect of dihydropyridine calcium antagonists on ultrastructural changes in the myocardium of the left ventricle in rats with experimental doxorubicin-induced cardiomyopathy

S.V. Pakrуshen

The purpose – to examine the effect of dihydropyridine calcium antagonists dimeodipine and amlodipine on the development of anthracycline cardiomyopathy, according to a comparative study of ultrastructural morphological changes of the left ventricular myocardium.

Materials and methods. The experiment was conducted on 74 adult guinea nonlinear white rats of both sexes who had anthracycline cardiomyopathy modeled by a four-fold intraperitoneal injection of doxorubicin at a dose of 5 mg/kg with intervals of 1 week. Only doxorubicin was injected to the animals of group 1 (n = 34). Rats of group 2 (n = 20), starting from the day of 3rd administration of doxorubicin, were treated by amlodipine at a dose of 1.5 mg/kg; likewise the rats of group 3 (n = 20), starting from the day of 3rd administration of doxorubicin, were prescribed dimeodipine at a dose of 1.5 mg/kg daily for 28 days. The animals were observed for 28 days of the experiment and the following 14 days. Ultrastructural changes in the nuclear apparatus and chromatin, sarcoplasmic reticulum tubules and near-nuclear space, morphometric changes in myofibrils and mitochondria were determined in the animals that survived (group 1 – 18 or 52.9 %, group 2 – 11 or 55 %, group 3 – 10 or 50 %) on the 1st day after the end of experiment.

Results and discussion. Ultrastructural changes of cardiomyocytes in rats after administration of doxorubicin are manifested by massive portions of myocytolysis, expressed as pathological changes of mitochondria, increased sarcoplasmic reticulum. Partial normalization of the state of myofibrils, a significant increase in the volume density of myofibrils by 23.3 and 23.1 % (p < 0.05), the decrease of swelling of the intercellular space, the absence of pathological changes in the sarcoplasmic reticulum and T-tubules system, a significant increase in volume density of mitochondria by 25 and 25.4 % were defined in animals of groups 2 and 3.

Conclusions. Calcium antagonists (amlodipine and dimeodipine) in trial rats with experimental doxorubicin cardiomyopathy promote partial recovery of myofibrils and increase in their volume density in cardiomyocytes by 23.3 and 23.1 %, respectively, as well as increase in the volume density of mitochondria by 25 and 25.4 %, respectively.

Keywords: cardiotoxicity, ultrastructure, doxorubicin, amlodipine, dimeodipine.

11.

 

Prospects for the use of cord blood for treatment of lower limb ischemia

N.Yu. Litvinova, R.V. Saliutin, L.A. Panchenko, Yu.V. Nagalіuk, O.V. Panchuk

The problem of vascular diseases of the lower limbs has not yet been solved despite the progress of the world thought in medicine. Prospects for the use of cord blood for the treatment of lower limb ischemia is a very important and urgent issue that requires research and approbation.

Keywords: tissue transplantation, cord blood, treatment of lower limb critical ischemia.

12.

 

Possibilities of pharmacological therapy of high tromboembolic risk in therapeutic inpatients

Ye.A. Koval

The review highlights the pathogenesis of venous thromboembolism, clinical significance, risk factors and the incidence of this complication in patients of therapeutic profile. A brief description of M. Hoffman and D.M. Monroe’s model of hemostasis was presented as well as the possibilities of increase of antithrombotic therapy efficiency in clinical practice with its use. The data on clinical trials of MEDENOX, PREVENT, ARTEMIS and meta-analyses that argue the expediency of use of low molecular weight heparins and synthetic inhibitor of factor Xa of fondaparinux for the prevention of venous thromboembolism in patients. Current views on the optimal duration of prophylactic treatment of venous thromboembolism were characterized. Information is presented about the new generation of anticoagulants, in paticular, apiksaban, dabigatran and rivaroxaban that were used for radical changes in the nature and modalities of thromboprophylaxis in seriously sick patients according to the results of ADOPT and MAGELLAN researches. Guidelines are presented on a rational choice of an anticoagulant for different groups of patients based on the effectiveness of prophylaxis of venous thromboembolisms and the safety of treatment regarding hemorrhagic complications.

Keywords: hemostasis, venous thromboembolism, antithrombotic therapy, anticoagulants, hemorrhagic complications.

13.

 

Idiopathic thrombosis in surgery

V.G. Mishalov, V.M. Seliuk, L.B. Мalynovska, O.I. Voitovych

The article describes one of the most complex and unresolved issues of vascular disease – a problem of idiopathic thromboses. Detection of etiological factor of thrombosis and associated choice of strategy and tactics of further treatment affect the quality and duration of patients’ life. Cancer and thrombophilia are among the main causes of idiopathic thromboses. According to the risk of thrombosis, the degree of severity of the disease and the presence of concomitant disease the patients are divided into four groups. A common standard of treatment, prevention and subsequent diagnosis of the etiological factor has not yet been developed for patients with idiopathic thromboses. The «golden standard» in the treatment of acute thromboses is anticoagulant therapy of at least 3 months duration with consideration of risk of recurrent thrombosis and anticoagulant-related bleeding, and subsequent transition to indirect anticoagulants.

Keywords: idiopathic thrombosis, cancer, thrombophilia, antiphospholipid syndrome, hyperhomocysteinemia, D-dimer, anticoagulant therapy.

14.

 

Osteoprotegrin as a potential marker of vascular remodeling and global cardiovascular risk

А.Ye. Berezin, А.А. Kremser

The review considers the prognostic value of osteoprotegrin for identifying patients with a high risk of unfavorable cardiovascular events. The prospects are discussed of using osteoprotegrin as an indicator of onset and progression of cardiac and vascular remodeling in the population of patients with a documented cardiovascular disease. Information has been provided about the possible link between the calcification of the arterial wall and the circular level of osteoprotegrin in selective cohorts of patients, including patients with chronic kidney diseases requiring replacement procedure.

Keywords: osteoprotegrin, cardiovascular risk, mortality, survival, prognosis.

15.

 

Остеопротегерин как потенциальный маркер васкулярного ремоделирования и сердечно-сосудистого риска

А.Е. Березин, А.А. Кремзер

В обзоре рассмотрено прогностическое значение остеопротегерина для идентификации пациентов с высоким риском возникновения неблагоприятных сердечно-сосудистых событий. Обсуждены перспективы использования остеопротегерина в качестве индикатора возникновения и прогрессирования кардиального и васкулярного ремоделирования в популяции пациентов с документированным сердечно-сосудистым заболеванием. Приведены данные о возможной ассоциации между кальцификацией артериальной стенки и циркулирующим уровнем остеопротегерина в селективных когортах больных, включая пациентов с хроническими заболеваниями почек, требующими заместительной процедуры.

Keywords: остеопротегерин, сердечно-сосудистый риск, смертность, выживаемость, прогноз.

16.

 

Predictors and triggers of type 2 diabetes mellitus and cardiovascular events regarding dietary habits

O.P. Kikhtіak

Results of clinical and experimental investigations regarding causes of type 2 diabetes mellitus and cardiovascular events are generalized in this work. Besides well-known causative factors like overeating and sedentary life style, the influence of other aspects is revealed. In particular, negative influence of frequent food intake related to specific effects of glucose is detected, namely timedependent potentiating and time-dependent inhibition. Interrelation between generations was identified in experiments on rodents: excessive consumption of high-carbohydrate and fatty foods promotes inadequate insulin response in their offsprings. The abundance of meat and fish in the diet is also associated with an increase in the incidence of type 2 diabetes mellitus, dyslipidemia, coronary heart disease, while vegetarianism is recommended for the prevention of these pathological conditions.

Keywords: type 2 diabetes mellitus, cardiovascular events, dietary habits, vegetarianism.

17.

 

Пищевые предикторы и провокаторы развития сахарного диабета 2 типа и сердечно-сосудистых поражений

О.П. Кихтяк

В работе обобщены результаты клинических и экспериментальных исследований, указывающих на причины развития сахарного диабета 2 типа и сердечно-сосудистых событий. Кроме общеизвестных факторов, таких как переедание и малоподвижный образ жизни, обнаружено влияние и многих других аспектов. В частности, показано негативное влияние частого приема пищи, которое связывают со специфическим эффектом глюкозы, а именно: времязависимым потенцированием и времязависимым угнетением. Определена также взаимосвязь между поколениями в экспериментах на грызунах: неумеренное потребление высокоуглеводной и жировой пищи способствует развитию неадекватного инсулинового реагирования у их потомков. Обилие мясных и рыбных продуктов в питании также связывают с увеличением частоты развития сахарного диабета 2 типа, дислипидемии, ишемической болезни сердца, в то время как вегетарианство рекомендуют для профилактики развития этих патологических состояний.

Keywords: сахарный диабет 2 типа, сердечно-сосудистые события, пищевые привычки, вегетарианство.

18.

 

Long-term clinical and laboratory effects of drug correction of iron deficiency in patients with coronary chronic heart failure and concomitant anemia without obvious causes of iron loss and its effect on the functional status of patients

Ye.N. Amosova, V.N. Tsaralunga, N.N. Sidorova

The purpose – to assess the long-term clinical and laboratory effects of a three-month drug correction of iron deficiency in patients with chronic heart failure of coronary origin and concomitant anemia without obvious causes of iron loss and its effect on the functional status of patients.

Materials and methods. We observed 51 patients over 50 years old (mean age 68.1 years ± 1.5 years) with chronic heart failure of coronary genesis of II–IV functional class (FC) by NYHA, the majority (78.4 %) of them had ejection fraction (EF) of the left ventricle (LV) > 45 % and iron deficiency anemia. They underwent a three-month therapy with an oral iron preparation Actiferin in the dose of 103.5 mg/day. The criterion for anemia was lowering of the hemoglobin (Hb) level to 130 g/l or more in men and 120 g/l or more in women. Iron deficiency was diagnosed on the basis of reduction of color index, erythrocyte indices and serum iron level. In 28–36 (32.8 ± 0.7) months we contacted the patients by telephone and invited to a re-examination 25 (49 %) of them, including 16 (64.0 %) women and 9 (36 %) men. Prior to the study 21 (84.0 %) patients had stable angina pectoris not higher than III FC, 5 patients (20.0 %) had postinfarction cardiosclerosis, 25 patients (100.0 %) had essential hypertension. Chronic heart failure of the I stage was observed in 5 (20.0 %) patients and that of the IIA stage – in 24 (96.0 %). According to echocardiography, LV EF < 45 % was in registered in 2 (8.0 %) patients. The survey involved a test of six minutes’ walk, Doppler echocardiography with assessment of systolic function of LV and iron metabolism in blood serum which were determined at baseline, after 3 months of therapy with Actiferin and in (32.8 ± 0.7) months.

Results and discussion. Immediately after the oral therapy with Actiferin we observed a significant positive dynamics of indicators of Hb – from (97.7 ± 2.2) g/l (75–117 g/l) to (128.8 ± 0.9) g/l (123–137 g/l) (p < 0.001), which was accompanied by an increase in serum iron from (6.9 ± 0.3) to (12.9 ± 0.3) mmol/l (p < 0.001) and transferrin saturation with iron from (8.5 ± 0.5) to (17.6 ± 0.6) % (p < 0.001) and ferritin content – by 37.1 % (p < 0.01). In (32.8 ± 0.7) months after the ferrotherapy we observed a negative dynamics of all indicators of erythrocyte stem. Thus, the concentration of Hb decreased by 6.3 %, Ht – by 4.8 %. Indices of Hb, Nt, color index and average volume of erythrocyte remained significantly higher than the initial values (by 19.0; 19.3; 6.1 and 4.1 %, respectively, p < 0.001, p < 0.01). Indicators of iron metabolism also reduced: iron levels in blood serum – by 21.7 %, transferrin saturation – by 24.4 % (p < 0.001) and the amount of ferritin decreased by 29.5 % (p < 0.05), which indicates a decrease in body iron stores and increase of iron deficiency. FC by NYHA worsened in 22 (88.0 %) patients: III FC – from 4.0 to 48.0 % of patients (p < 0.001), and only in 2 (8.0 %) patients the functional status suited I FC. Thus, the clinical effect of exchange rate correction of iron deficiency was fragile. In (32.0 ± 0.7) months, the six minutes’ walk distance decreased by 21.2 % – from (467.4 ± 8.5) to (368.2 ± 16.3) m (p < 0.001), average values of end-diastolic and end-systolic volumes were back to original ones, and EF of LV decreased by 7.3 % (p > 0.05) as compared to the data 3 months later.

Conclusions. Without maintenance therapy with iron preparations in (32.8 ± 0.7) months after the end of three-months’ administration of these drugs orally, the patients with chronic heart failure of II–IV FC by NYHA and iron deficiency anemia (Hb 75–117 g/l) manifested the decrease of positive effect: the level of Hb and iron metabolism indices remained higher than the initial ones (Hb – by 6.3 %, transferrin saturation – by 24.4 %, ferritin – by 29.5 %). Negative laboratory dynamics was accompanied by the deterioration of the functional state to one FC by NYHA in 88 % of patients and the decrease in six-minutes’ walk distance by 38.8 %, yet it remained 22.3 % higher than the initial one.

Keywords: chronic heart failure, anemia, iron deficiency.

19.

 

Pulmonary embolism (basic information and personal supervision)

N.T. Vatutin, N.V. Kalinkina, Ye.V. Yeshchenko, V.B. Kostogryz, S.S. Kasem

This article presents data concerning epidemiology, pathophysiology, clinical picture, diagnosis and treatment of pulmonary embolism. An interesting case from practice is described in details.

Keywords: pulmonary embolism, diagnosis, treatment.

20.

 

Отдаленные клинико-лабораторные результаты медикаментозной коррекции железодефицита у больных коронарогенной хронической сердечной недостаточностью с сопутствующей анемией без явных причин потери железа и ее влияние на функциональное состояние больных

Е.Н. Амосова, В.Н. Царалунга, Н.Н. Сидорова

Цель работы — оценить отдаленные клинико-лабораторные результаты трехмесячной медикаментозной коррекции железодефицита у больных с хронической сердечной недостаточностью коронарного генеза с сопутствующей анемией без явных причин потери железа и ее влияние на функциональное состояние больных.

Материалы и методы. Под нашим наблюдением находился 51 больной старше 50 лет (в среднем 68,1 года ± 1,5 года) с хронической сердечной недостаточностью коронарного генеза ІІ—ІV функционального класса (ФК) по NYHA, в большинстве (78,4 %) — с фракцией выброса (ФВ) левого желудочка (ЛЖ) > 45 % и железодефицитной анемией. Им проведена трехмесячная терапия пероральным препаратом железа «Актиферрином» в дозе 103,5 мг/сут. Критериями анемии было снижение уровня гемоглобина (Hb) до 130 г/л и больше у мужчин и до 120 г/л и больше у женщин. Дефицит железа диагностировали на основании снижения цветового показателя, эритроцитарных индексов и уровня сывороточного железа. Через 28—36 (32,8 ± 0,7) мес мы связались с больными по телефону и пригласили на повторное обследование 25 (49 %) пациентов, в том числе 16 (64,0 %) женщин и 9 (36 %) мужчин. К началу исследования у 21 (84,0 %) больного была стабильная стенокардия напряжения не более ІІІ ФК, у 5 (20,0 %) — постинфарктный кардиосклероз, у 25 (100,0 %) — эссенциальная артериальная гипертензия. Хроническую сердечную недостаточность І стадии отмечали у 5 (20,0 %) пациентов и ІІA — у 24 (96,0 %), ФВ ЛЖ < 45 %, по данным эхокардиографии, была у 2 (8,0 %) больных. Обследование включало тест с шестиминутной ходьбой, допплерэхокардиографию с оценкой показателей систолической функции ЛЖ, обмена железа в сыворотке крови, которые определяли исходно, после 3 мес терапии «Актиферрином» и через (32,8 ± 0,7) мес. Результаты и обсуждение. Сразу после окончания пероральной терапии «Актиферрином» отмечали значительную положительную динамику показателей Hb — с (97,7 ± 2,2) г/л (75—117 г/л) до (128,8 ± 0,9) г/л (123—137 г/л) (р < 0,001), что сопровождалось повышением уровня сывороточного железа с (6,9 ± 0,3) до (12,9 ± 0,3) мкмоль/л (р < 0,001) и насыщения трансферрина железом с (8,5 ± 0,5) до (17,6 ± 0,6) % (р < 0,001), а также содержания ферритина — на 37,1 % (р < 0,01). Через (32,8 ± 0,7) мес после окончания ферротерапии зафиксирована отрицательная динамика всех показателей эритроцитарного ростка. Так, концентрация Hb снизилась на 6,3 %, гематокрит — на 4,8 %. При этом показатели Hb, гематокрита, цветовой показатель и средний объем эритроцита сохранялись существенно выше исходных (соответственно на 19,0; 19,3; 6,1 и 4,1 %; р < 0,001, р < 0,01). Снизились и показатели обмена железа: уровень железа сыворотки крови — на 21,7 %, насыщение трансферрина железом — на 24,4 % (р < 0,001), а количество ферритина уменьшилось на 29,5 % (р < 0,05), что свидетельствует об уменьшении запасов железа в организме и увеличении железодефицита. ФК по NYHA ухудшился у 22 (88,0 %) больных: ІІІ ФК — с 4,0 до 48,0 % (р < 0,001), и только у 2 (8,0 %) пациентов функциональное состояние соответствовало І ФК. Таким образом, клинический эффект курсовой коррекции железодефицита оказался нестойким. Через (32,0 ± 0,7) мес дистанция шестиминутной ходьбы уменьшилась на 21,2 % — с (467,4 ± 8,5) до (368,2 ± 16,3) м (р < 0,001), средние величины конечнодиастолического и конечносистолического объемов вернулись к исходным, а ФВ ЛЖ снизилась по сравнению с данными через 3 мес на 7,3 % (р > 0,05).

Выводы. Без поддерживающей терапии препаратами железа внутрь через (32,8 ± 0,7) мес после окончания трехмесячного приема этих препаратов внутрь у больных хронической сердечной недостаточностью І—IV ФК по NYHA и железодефицитной анемией (Hb 75—117 г/л) уменьшился положительный эффект: уровни Hb и показатели обмена железа сохранились выше исходных (Hb — на 6,3 %, насыщение трансферрина железом — на 24,4 %, ферритин — на 29,5 %). Отрицательная лабораторная динамика сопровождалась ухудшением функционального состояния на один ФК по NYHA у 88 % больных и уменьшением дистанции шестиминутной ходьбы на 38,8 %, но сохранялась на 22,3 % выше исходной.

Keywords: хроническая сердечная недостаточность, анемия, дефицит железа.

21.

 

Влияние антагонистов кальция дигидропиридинового ряда на ультраструктурные изменения миокарда левого желудочка у крыс с экспериментальной доксорубициновой кардиомиопатией

С.В. Пакришень

Цель работы — изучить влияние антагонистов кальция дигидропиридинового ряда димеодипина и амлодипина, по данным сравнительного изучения ультраструктурных морфологических изменений миокарда левого желудочка, на развитие антрациклиновой кардиомиопатии.

Материалы и методы. Эксперимент проведен на 74 подопытных нелинейных белых половозрелых крысах обоих полов, которым путем четырехкратного с интервалом в 1 нед внутрибрюшного введения доксорубицина в дозе 5 мг/кг была смоделирована антрациклиновая кардиомиопатия. Животным 1-й группы (n = 34) вводили только доксорубицин. Крысам 2-й группы (n = 20), начиная с дня третьего введения доксорубицина, вводили амлодипин в дозе 1,5 мг/кг, крысам 3-й группы (n = 20), также начиная с дня третьего введения доксорубицина, назначали димеодипин в дозе 1,5 мг/кг ежедневно в течение 28 сут. За животными наблюдали в течение 28 сут эксперимента и следующих 14 сут. У выживших животных (1-я группа — 18, или 52,9 %, 2-я — 11, или 55 %, 3-я — 10, или 50 %) в 1-е сутки после окончания эксперимента определяли ультраструктурные изменения ядерного аппарата и хроматина, канальцев саркоплазматической сети и околоядерного пространства, морфометрические изменения миофибрилл и митохондрий.

Результаты и обсуждение. Ультраструктурные изменения кардиомиоцитов у крыс после введения доксорубицина проявляются массивными участками миоцитолиза, выраженными патологическими изменениями митохондрий, расширением саркоплазматического ретикулума. У животных 2-й и 3-й групп определяются частичная нормализация состояния миофибрилл, достоверное увеличение объемной плотности миофибрилл на 23,3 и 23,1 % (p < 0,05), уменьшение отека межклеточного пространства, отсутствие патологических изменений в саркоплазматическом ретикулуме и системе Т-трубочек, достоверное увеличение объемной плотности митохондрий на 25 и 25,4 %.

Выводы. Антагонисты кальция (амлодипин и димеодипин) у подопытных крыс с экспериментальной доксорубициновой кардиомиопатией способствуют частичному восстановлению миофибрилл и увеличению их объемной плотности в кардиомиоцитах на 23,3 и 23,1 % соответственно, увеличению объемной плотности митохондрий на 25 и 25,4 % соответственно.

Keywords: кардиотоксичность, ультраструктура, доксорубицин, амлодипин, димеодипин.

22.

 

Оценка риска и результаты эндопротезирования аорты у пациентов старших возрастных групп

С.Н. Фуркало, И.В. Хасянова, М.В. Костылев, С.В. Сухачёв

Цель работы — сопоставить данные прогностической оценки степени риска эндоваскулярного протезирования брюшной аорты по системе POSSUM c учетом рекомендаций Общества сосудистой хирургии (SVS/AAVS) с результатами лечения.

Материалы и методы. В анализе приведены результаты лечения 20 пациентов (все мужчины) с аневризмой абдоминального отдела аорты, находившихся на лечении в период 2006—2011 гг. Возраст пациентов — 70—78 лет (в среднем — 72,1 года). Комплекс дооперационного обследования включал физикальный осмотр, лабораторные исследования, ЭКГ и эхокардиографию, коронаровентрикулографию для пациентов с ишемической болезнью сердца. Основным методом визуализации аневризмы являлась спиральная компьютерная томография. Всем пациентам, включенным в исследование, было выполнено эндоваскулярное эндопротезирование аорты с имплантацией протеза Excluder (GORE). Прогностические данные сопоставляли с реальными результатами эндоваскулярного вмешательства.

Результаты и обсуждение. Результаты хирургического вмешательства во многом определяются сопутствующей патологией и анатомическими особенностями собственно аневризмы. Оценка риска осложнений и летального исхода позволяет выбрать предпочтительный вид вмешательства у каждого пациента. Применение шкалы V-POSSUM сопровождалось завышением прогнозируемых рисков применительно к больным, которым предстоит эндоваскулярное вмешательство; и в подобных исследованиях она может быть использована только как ориентировочная; шкала SVA/AAVS более соответствует реальной картине, и определенные с ее помощью риски вмешательства практически совпадают с результатами лечения. Полученные нами результаты подтверждают данные литературы, что преимуществами эндоваскулярного вмешательства пользуются пациенты с «хорошей» анатомией и с высоким риском открытого вмешательства.

Выводы. Опыт осуществления эндоваскулярного протезирования аневризмы абдоминального отдела аорты у больных старших возрастных групп свидетельствует о высокой непосредственной эффективности и относительной безопасности вмешательств, в том числе и у больных с сочетанной сердечно-сосудистой патологией.

Keywords: аневризма брюшного отдела аорты, эндопротезирование аорты, шкала POSSUM.

23.

 

Идиопатические тромбозы в хирургии

В.Г. Мишалов, В.М. Селюк, Л.Б. Малиновская, О.И. Войтович

В статье изложена одна из самых сложных и нерешенных проблем сосудистой патологии — проблема идиопатических тромбозов. Выявление этиологического фактора тромбоза и связаный с ним выбор стратегии и тактики последующего лечения влияют на качество и продолжительность жизни пациентов. Среди главных причин идиопатических тромбозов выделяют злокачественные новообразования и тромбофилии. Согласно факторам риска развития тромбоза, степени тяжести заболевания и наличия сопутствующей патологии больные делятся на четыре группы. У пациентов с идиопатическими тромбозами до настоящего времени не разработаны общепринятые стандарты лечения, профилактики и последующей диагностики этиологического фактора. Золотым стандартом в лечении острых тромбозов остается антикоагулянтная терапия, которая должна проводиться не менее 3 месяцев с учетом риска рецидива тромбоза и антикоагулянтно-связанных кровотечений, с последующим переходом на непрямые антикоагулянты.

Keywords: идиопатический тромбоз, злокачественные новообразования, тромбофилия, антифосфолипидный синдром, гипергомоцистеинемия, D-димер, антикоагулянтная терапия.

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№4(60) // 2017

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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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