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Issue. Articles

№4(48) // 2014

 

Обкладинка

 

1.

 

Arterial hypertension standardizated step-by-step treatment algorithm and program of treatment adherence of patients with diabetes mellitus in outpatient practice

К. М. Amosova, Yu. V. Rudenko

Purpose — to determine the effectiveness of arterial hypertension standardizated step-by-step simplified treatment algorithm in order to achieve target office and normal home (≤ 135/85 mmHg) arterial blood pressure (BP) levels in patients with arterial hypertension and diabetes mellitus (DM) II type comparing to patients without DM and elevate patients adherence to the treatment in a general outpatients practice of a cardiologist.

Materials and methods. Open retrospective examination included 54 outpatient cardiologists from Kyiv hospitals and 431 patients aged 35 till 70 years old (mean age 57.3 ± 0.5 with not complicated primary hypertension with arterial pressure > 160/100 mmHg and who came through treatment before or patients with arterial pressure ≥ 140/90 mmHg without previous treatment. Within 6 months 6 main visits and 2 additional ones were held according to necessity. On the first visit a cardiologist took pressure with standardized automatic device Microlife BPW200 with an universal cuff. Patients received an oscillometric automated device Microlife BP3AG1. Patients were taught how to use it, how to change the way of life and they were administered fixed combination of perindopril and amlodipine (Bi-prestarium, Servier, France) at a dose 5/5, 5/10, 10/5 or 10/10 mg doctor’s choice (first step). Before the next visit a patient took his pressure himself 7 days a week twice a day and fixed results in a diary. In case of the failure to achieve target office pressure level (< 140/90 mmHg) Bi-prestarium dose was increased till maximum tolerable (second step) and Indapamide retard (Arifon Retard, France) 1.5 mg per day was sequentially administered (third step); spironolacton 25 mg twice per day (fourth step): moxonidin 0.2 till 0.6 mg per day or doxasonin 4 — 8 mg per day (fifth step). The treatment adherence was assessed with a questionnaire X. Girerd during the first visit in patients who received anti hypertensive therapy before the examination and in all patients during the last visit. Treatment efficiency was assessed according to patients number without DM with the office pressure level < 140/90 mmHg, patients number with DM with the office pressure level < 140/90 mmHg and < 140/85 mmHg after 6 months of observation, patients treatment adherence.

Results and discussion. According to examination results DM II type was revealed while the first visit in 71 (16.5 %) patients (first group), was not revealed in 360 (83.5 %) patients (second group). Patient from both groups were comparable by sex, BP III stage frequency and left ventricle hypertrophy, glomerular filtration and smokers number (р > 0.05). Patients with DM were older, had higher indexes of heart contractions and general cholesterol level in blood (р < 0.05), more frequent ischemia cases (р < 0.01), obesity (р < 0.001), complicated family anamnesis data (р < 0.01). After 6 moths of treatment average systolic office BP decreased from 166.4 ± 1.3 to 131.6 ± 1.0 mmHg and from 165.6 ± 0.7 to 130.9 ± 0.5 mmHg, diastolic — from 96.4 ± 1.1 to 78.7 ± 0.9 mmHg and from 97.6 ± 0.5 to 79.4 ± 0.4 mmHg in the 1st and 2nd group correspondingly. It was accompanied by normalization of home BP in 63.4 and 63.1 % cases correspondingly (all р < 0.01). Office BP level < 140/90 mmHg was achieved in 74.7 % patients of 1st group and in 84.5 % patients of 2nd group (р < 0.05), office BP level < 140/85 mmHg — in 67.6 % patients with DM II type. The number of patient with low treatment adherence reduced from 39.4 till 10.6 % (р < 0.01) in 1st and from 45 till 6.1 % (р < 0.001) in 2nd group. (р < 0.001). The number of patient with high treatment adherence increased from 31.8 till 50 % (р < 0.05) in 1st and from 32.7 till 50.9 % in 2nd group (р < 0.001).

Conclusions. Step-by-step treatment algorithm application based on fixed combination of perindopril and amlodipine together with BP home control and educational program in cardiologists outpatient practice allowed to achieve office BP level < 140/90 mmHg in 74.7 %, and < 140/85 mmHg — in 67.6 % patients with DM II type and in 84.5 % patients without DM after 6 months of therapy. It was accompanied with home BP level decrease till normal level (≤ 135/ 85 mmHg) in 63.4 and 63.1 % cases correspondingly. This approach is effective regardless DM presence and allows to provide high treatment adherence according to X. Girerd questionnaire in 89.4 % patients with DM and in 93.9 % patient without DM.

Keywords: essential arterial hypertension, diabetes mellitus, target arterial pressure, perindopril, amlodipine, fixed low dose combination, treatment adherence.

2.

 

Major amputation complications in patients with chronic critical ischemia of the lower limbs: a retrospective study

N. Yu. Litvinovа, V. A. Chernyak, O. V. Strepetova, О. І. Kefeli-Yanovskа, I. I. Plyuta

Purpose — to analyze the treatment results in patients with atherosclerotic ulcer-necrotic lesions of the lower limbs due to chronic critical ischemia, to identify the causes of unsatisfactory amputation results.

Materials and methods. Retrospective study included data analysis of 256 case histories of patients treated at the Department of Vascular Surgery in 2008 — 2011, who underwent major amputation (level — above knee amputation (AKA), below knee amputation (BKA)). To determine the amputation level the following survey methods were performed: ultrasonic duplex scanning, angiography. Amputation level was determined according to clinical signs, special methods of research for regional vascular reserve, main and collateral circulation in the limbs, microcirculation and tissue trophicity assessment. The final level of amputation was adjusted during surgery after a visual assessment of the degree of blood supply to the crossed muscles. All patients postoperatively received basic conservative therapy: analgesic therapy, anti platelet therapy, anticoagulation, antibacterial therapy. The primary surgical stump wound healing was considered as the satisfactory immediate results of amputation. Suppuration, secondary healing, re-amputation and death we assigned to unsatisfactory results.

Results and discussion. After the major amputations of the lower limbs 103 % (n = 103 patients recovered without complications, there were serious complications in 19.1 % (n = 49), moderate — 26.6 % (n = 68), lethal outcome — 14.1 % (n = 36). Patients after BNA demonstrated significantly higher percentage of deep wound infection and dehiscence of surgical wounds. Thirty-days post amputation mortality, ischemic stroke were also significantly higher in AKA. The analysis of the results of amputation of the lower extremities showed that the greatest number of complications appeared in the group of patients older than 60 years, probably due to the more common lesion of vital vascular regions, p < 0.05. But complications with postoperative wound occurred more frequently in patients aged 50 — 59 after BKA, smokers.

Conclusions. Level of significant complications of high amputations is relatively high, at an early postoperative period. Ischemic heart disease with impaired ventricular function affects the outcome of amputation. Unfavorable prognosis is reduced left ventricular ejection fraction below 40 %. The greatest number of complications was in the group of patients older than 60 years, but complications with postoperative wound occurred more frequently in patients aged 50 — 59 after tibial amputation and smokers. 30-days post-amputation mortality and incidence of ischemic stroke were significantly higher among patients after amputation at the thigh. Mortality in the first three years after high amputation in patients with CCILL is growing and reaches 69.5 %.

Keywords: chronic critical lower limb ischemia, amputation, complications.

3.

 

Symptoms and clinical characteristics of patients with the newly detected atrial fibrillation

O. I. Zharinov, Yu. I. Zalizna, K. O. Mikhalev

Purpose — to carry out the comparative analysis of myocardium structural and functional condition, concomitant disease determination frequency and clinical symptoms in patients with the newly detected atrial fibrillation (NDAF) depending on complaints intensity associated with arrhythmia.

Materials and methods. 124 patients were included into the study, 55 males and 69 females aged from 24 till 88 years old (mean age 62 ± 14) with NDAF. All patients were under the treatment in Kyiv regional cardiac clinic from October 2011 till June 2012. Patients with NDAF associated with acute coronary syndrome, brain circulation impairment, congenital or acquired hear failure, surgery were excluded. Patients were taken body weight index, arterial pressure, levels of blood glucose, glycated hemoglobin, creatinine, potassium blood plasma, C-reactive protein, lipid profile indexes, thyrotropic hormone, cardiac contractions average frequency with daily ECG. Echocardiographic monitoring was performed with ultrasound system SD 800 (Philips, USА) according to protocol in M- and B-modes.

Results and discussion. Patient were distributed into three groups: without palpitation (n = 27), with moderate palpitation (n = 42), with marked palpitation (n = 55). Compared groups did not differ in number of patients with arterial hypertension and ischemic disease. Female prevailed among the patients with marked palpitation (p = 0.031). They had low level of glycated hemoglobin (p = 0.031), chronic form of AF (р = 0.018), elevated average daily cardiac contractions frequency (р < 0.001), left atrium smaller size (р < 0,001), higher left ventricular ejection fraction (р = 0.001). Symptom class associated with AF was determined with EHRA scale. I and II class included 42 (33.9 %), III class — 65 (52.4 %) and IV class — 17 (13.7 %) patients. Patients of different classed did not differ in sex ratio, age, concomitant disease frequency and risk degree of embolic complications.

Conclusions. Female with NDAF more often have complaints associated with arrhythmia, elevated CCF, left atrium smaller size, higher left ventricular ejection fraction, low level of glycated hemoglobin comparing to patients without complaints.

Keywords: atrial fibrillation, newly detected, symptoms, EHRA scale, concomitant disease.

4.

 

Bioresorbable vascular stents: characteristics of the application and clinical experience

S. М. Furkalo

Purpose — to analyze direct clinical application results, imaging structure characteristics and implantations of the first bioresorbable stent Absorb.

Materials and methods. The study involved 46 patients with coronary artery disease (CAD) who were implanted 60 stents Absorb. The age was: 52.1 ± 4.1 years, 45 patients (97.8 %) were male. The clinical picture was characterized by unstable course of the disease in 6 cases (13.0 %), Cardiac angina of II — III functional class was noted in other cases — 40 (87 %). 10 patients previously had stenting and 4 patients underwent coronary artery bypass. One patient experienced previous endoprosthesis of abdominal aorta.

Results and discussion. Stenting with implantation of 1 stent Absorb was performed in 33 patients, 2 stents were implanted in 11 cases and in one case 4 bioresorbable stents were implanted. In one case coronary and carotid stenting were performed simultaneously. Conventional double antiplatelet therapy method was applied. In all patients the early postoperative period was uneventful; there were no cases of failure of implantation or acute thrombosis of stent. On the model in vitro the stent polymer structure characteristic while implantation is demonstrated. Modern information technologies were applied to visualize the process- optical coherent tomography and computed tomography.

Conclusions. Our experience of the use of bioresorbable stents in patients with CAD suggests the possibility of application of this technology in patients with difficult coronary lesions, such as chronic total occlusion, bifurcation, diffuse disease, venous bypass etc. Further study is needed both for immediate and long-term outcomes of interventions for the widespread introduction of biodegradable stents in routine practice of interventional cardiology departments.

Keywords: bioresorbable stents, coronary artery disease, implantation methodics, optical coherent tomography.

5.

 

Coronary artery tortuosity phenomenon in the development of ischemia clinical manifestations

E. O. Lebedeva, A. I. Pliska, M. M. Grusha

The aim — to the study of the relationship between the phenomenon of coronary arteries tortuosity and ischemic heart disease.

Materials and methods. We performed a retrospective analysis of our database of 1404 patients with ischemic heart disease, caused by tortuosity of coronary arteries, which were examined and treated in the Amosov National Institute of Cardiovascular Surgery of NAMS of Ukraine. According to coronarography results and presence of artery tortuosity, coronary atherosclerosis and its intensity patients were divided into the following groups: patients with coronary artery tortuosity without atherosclerosis (n = 252); patients with coronary artery tortuosity with the narrowing less 50 % (n = 92); patients with coronary artery tortuosity with the narrowing more than 50 % (n = 244); patients without coronary artery tortuosity with narrowing more than 50 % (n = 816). All patients underwent general clinical examinations according to the standard protocol. Statistical validation of indexes differentiation was assessed by Pirson fitting criterion or χ2-test.

Results and discussion. Retrospective data analysis evidenced that typical pain syndrome was present in 248 (98 %) patients with coronary artery tortuosity without atherosclerosis. According to anamnestic data 60 (23.8 %) patients with ischemia without atherosclerosis came through acute myocardial infarction. The number of vascular disorders increased in case of coronary artery tortuosity with atherosclerosis. But the configuration of atherosclerosis is not a key factor for the coronary flow impairment. While the configuration of atherosclerosis can influence the level of systemic arterial pressure.

Conclusions. Coronary artery tortuosity is an independentand additional burdening factor in the development of ischemic heart disease.

Keywords: tortuous coronary arteries, myocardial ischemia, ischemic heart disease.

6.

 

Insulin resistance correlation with global contractility and relaxation of the left ventricle in patients with ischemic chronic heart failure

О. E. Berezin, О. О. Kremser, T. О. Samura, Yа. V. Malinovsky, S. V. Oleshko

Purpose — to evaluate the correlation between insulin resistance (IR) and the state of the global contractility and relaxation in patients with ischemic chronic heart failure (CHF).

Materials and methods. The study prospectively involved 300 patients with documented coronary artery disease and chronic heart failure at the age of 48 to 62 years. A design of the study was non-randomized prospective open cohort study. Patients with the following diseases were excluded: diabetes mellitus, myocardial infarction with Q wave during 30 days prior the study, angina of exertion IV functional type, non controlled arterial hypertension, severe renal and hepatic diseases, oncology, symptomatic arterial hypertension, brain stroke, cranial trauma 3 months prior to the study, creatinine level in blood more 440 μmol/l, glomerular filtration velocity less 35 ml/min and other disorders which can interrupt the study. Evaluation of hemodynamic was performed using transthoracic B-mode echocardiography with Impulse Doppler regime and Tissue Doppler Imaging. Speckle Tracking Imaging method was performed for left ventricular global strain determination. Multi-spiral contrast-enhanced tomography-angiography and contemporary angiography were used to visualize coronary arteries at baseline. Blood samples for biomarkers measurements were collected at baseline prior to study entry. ELISA methods for measurements of circulating level of NT-pro-brain natriuretic peptide were used. Insulin resistance was verified by the homeostasis model assessment (HOMA-IR) for all patients enrolled in the study. All subjects were graduated according IR presentation at baseline. Statistical analysis of the results obtained was carried out in SPSS system for Windows, Version 20 (SPSS Inc, USA). The data were presented as mean and standard error or 95 % confidence interval; median and interquartile range.

Results and discussion. Left ventricular apex rotation in a counterclockwise direction was observed in 10 (7.8 %) and 23 (13.5 %) CHF patients without and with exiting IR respectively (p = 0.046). Mean values of Rotapex and RotRapex in CHF patients without IR were –1.03 ± 0.15° and –3.32 ± 1.45 s–1 respectively, but in patient study population with IR these values were –2.67 ± 0.12° and –8.54 ± 3.11 s–1 respectively (p = 0.001 for all cases). By multivariant logistic regression analysis, independent predictors of IR in patients with CHF were Speckle Tracking Imaging-related phenomenon of ventricular apex rotation in a counterclockwise direction, reduction in global left ventricular longitudinal strain and strain rate, as well as circulating NT-pro-brain natriuretic peptide. The most significant predictors of decreased global strain and strain rates in CHF patients were myocardial infarction, NYHA CHF class, left ventricular ejection fraction, obesity, multivessel coronary artery disease. In this combination of IR with other predictors of the deformation reduction characteristics of the LV myocardium compared to using only IR did not significantly impact on the identification of patients with the most pronounced decline in global contractility of left ventricle.

Conclusions. IR may be an additional factor contributing in the development of the global contractile myocardial dysfunction beyond exiting type 2 diabetes mellitus.

Keywords: insulin resistance, global contractility and relaxation, chronic heart failure, ischemic heart disease.

7.

 

Level of circulating VE-catherin as a predictor of cardiovascular disorders in patients with chronic lymphocytic leukemia in remission

B. B. Samura

Purpose — to evaluate the prognostic value of circulating VE-catherin level for cumulative survival in patients with chronic lymphocytic leukemia in remission.

Materials and methods. One hundred fifty six out patients with chronic lymphocytic leukemia in full or partial remission were enrolled in the study. Observation period was up to 12 months. Blood samples for biomarkers measurements were collected. ELISA method for measurements of circulating level of VE-catherin was used. Hemodynamic evaluation was performed by transthoracic echocardiography.

Results and discussion. Two hundred sixteen cumulative clinical events occurred in 51 patients (37.2 %) within the follow-up, with their distribution being as follows: 7 deaths, 122 cardiac arrhythmias, 16 cardiac ischemic events, 3 strokes, 30 chronic heart failures and 38 hospital admissions for cardiovascular reasons. Medians of circulating levels of VE-catherin in free-events subject cohort and subjects cohort with cardiovascular events were 0.31 ng/ml (95 % confidence interval [CI] 0.19 — 0.43 ng/ml) and 1.49 ng/ml (95 % CI 1.07 — 1.91 ng/ml) (p < 0.001). In multivariate logistic regression circulating VE-catherin independently predicted cumulative cardiovascular events (odds ratio = 1.10; 95 % CI 1.01 — 1.13; p = 0.001) within 12 months of observation period.

Conclusions. Among patients with chronic lymphocytic leukemia in remission increased circulating VE-catherin associates with increased cumulative cardiovascular events within 12 months.

Keywords: VE-catherin, chronic lymphocytic leukemia, survival, prognosis.

8.

 

Повышение эффективности ресинхронизационной терапии путем радиочастотной абляции желудочковой экстрасистолии

Б. Б. Кравчук, Р. Г. Малярчук, О. З. Параций, М. М. Сычик

Цель работы — оценить изменения гемодинамических и клинических показателей после проведения радиочастотной абляции (РЧА) желудочковых эктопий в группе пациентов, резистентных к ресинхронизационной терапии (РТ).

Материалы и методы. В обзорном проспективном одноцентровом нерандомизированном исследовании приняли участие 16 больных, которым была произведена имплантация ресинхронизирующих электрокардиостимуляторов или кардио вертеров-дефиблилляторов с апреля 2003 г. по июнь 2013 г. и которые также имели желудочковую экстрасистолию. Критерии включения в исследование: увеличение фракции выброса левого желудочка < 5 %, увеличение конечносистолического объема < 10 %, а также отсутствие улучшения качества жизни больных в течение года после имплантации ресинхронизирующего устройства. Больные, которые отвечали данным критериям, считались резистентными к РТ. С целью оценки геометрических и волюмометрических параметров камер сердца до и после имплантации ресинхронизационных устройств проводили электрокардиографическое исследование по стандартной методике. Сердечный ритм до и после имплантации оценивали с помощью 24-часового холтеровского мониторирования (ХМ) ЭКГ. Электрофизиологическое картирование желудочковой экстрасистолии проводили по стандартным протоколам электрофизиологического исследования и при помощи системы навигации NavX. Из исследования исключены больные, которым было необходимо проведение антитахикардической стимуляции или дефибрилляции. Также были исключены больные с фибрилляцией предсердий, частота которой составляла более 1 % всех комплексов QRS во время ХМ ЭКГ.

Результаты и обсуждение. РЧА желудочковых эктопий у лиц, резистентных к РТ, приводит к значительному улучшению клинического состояния больных и эхокардиографических параметров. Таким образом, уже через 6 мес после РЧА был выявлен ответ на РТ и улучшение средней фракции выброса левого желудочка (с (26,2 ± 5,5) до (32,7 ± 6,7) %; p < 0,001), конечносистолического размера левого желудочка (с (5,83 ± 0,55) до (5,62 ± 0,32) см; p < 0,001), конечнодиастолического размера левого желудочка (с (6,83 ± 0,83) до (6,51 ± 0,91) см; p < 0,001), конечносистолического объема левого желудочка (с (178 ± 72) до (145 ± 23) мл; p < 0,001), конечнодиастолического объема левого желудочка (с (242 ± 85) до (212 ± 63) мл; p < 0,001). Средний функциональный класс сердечной недостаточности по NYHA до РЧА составлял 3, а после — 2. Прекращение бивентрикулярной стимуляции посредством отключения РТ-устройства приводит к восстановлению клинического состояния и параметров ЭхоКГ до первоначальных значений (до РЧА).

Выводы. Частая желудочковая экстрасистолия является одной из причин отсутствия ответа на РТ. Успешная РЧА желудочковой экстрасистолии приводит к значительному улучшению клинического состояния и эхокардиографической картины больных, резистентных к РТ. Таким образом, РЧА желудочковой экстрасистолии может быть эффективным методом повышения чувствительности к РТ лиц, резистентных к РТ.

Keywords: ресинхронизационная терапия, кардиовертеры-дефибрилляторы, желудочковая экстрасистолия, сердечная недостаточность.

9.

 

Interrelations of left ventricular myocardial remodeling parameters with biomarkers tissue vascularization in patients with essential hypertension

G. V. Demydenko

Purpose — to investigate the activity of adipokine apelin, vascular endothelial growth factor, vasoactive pool of nitric oxide in patients with essential hypertension (ЕН).

Materials and methods. 152 patients with EH aged 30 — 80 years were examined. Vasoactive pool of nitric oxide activity was investigated with biochemical method. Apelin-12 levels and vascular endothelial growth factor in serum were investigated with ELISA. Ultrasound of the heart was performed in accordance with the recommendations of the European and Ukrainian Association of Echocardiography. Relative wall thickness (RWT) that reflects geometrical changes of left ventricle (LV) was calculated as RWT = (posterior wall thickness (PWT) + interventricular sept thickness (IVT)) / diastolic size). Changes in RWT were classified according to gender.

Results and discussion. In patients with EH, myocardial remodeling was found in 72.37 % of cases, accompanied with endothelial dysfunction (dysbalance of nitric oxide pool was characterized by depositing of NO, activation of iNOS). Significant differences in groups were found in nitrite activity, S-nitrozothiol, iNOS. iNOS activity raised proportionally PWRWT (r = 0.48), IVT (r = 0.56), RWT (r = 0.64, р < 0.05). Increasing of apelin and vascular endothelial growth factor (VEGF) was proportionally to RWT, which is confirmed by correlations (VEGF — RWT (r = 0.54), RIVT (r = 0.52), PWRWT (r = 0.56), apelin (r = 0.85); apelin — іndex end diastolic volume (r = –0.48), іndex end diastolic size (r = –0.41), іndex end systolic volume (r = –0.41), RWT (r = 0.62), RIVT (r = 0.2), PWRWT (r = 0.60)).

Conclusions. Endothelial dysfunction was revealed in 89 % of patients with EH, that was accompanied with dysbalance of nitric oxide pool. Increasing of apelin and vascular endothelial growth factor was proportionally to increasing of RWT, which is confirmed by correlations. The presence of a positive significant correlation of apelin with vascular endothelial growth factor and LV wall thickness parameters indicate the involvement of these peptides in the process of cardiac remodeling in hypertensive patients.

Keywords: essential hypertension, heart remodeling, apelin, vascular endothelial growth factor.

10.

 

Accuracy and predictive value of the novel risk score of unfavorable clinical outcomes based on circulating biological markers evaluation in patients with chronic heart failure

О. E. Berezin, О. О. Kremser

Purpose — tо creatе of an evaluation cardiovascular risk score, based on an analysis of circulating biomarkers of CHF.

Materials and methods. It was studied prospectively the incidence of fatal and non-fatal cardiovascular cases, as well as the fatal outcomes frequency from any cause in a cohort of 388 patients with chronic heart failure during 3 years of observation. Circulating levels of NT-pro brain natriuretic peptide (NT-pro-BNP), galectin-3, high-sensitivity C-reactive protein (hs-CRP), osteoprotegerin and its soluble receptor sRANKL, osteopontin, osteonectin, adiponectin, endothelial apoptotic microparticles (EAM) and endothelial progenitor cells (EPC) were measured at baseline.

Results and discussion. Median follow-up of patients included in the study was 2.76 years (range 1.8 — 3.4 years). 285 cardiovascular cases were determined, including 43 fatal outcomes and 242 readmissions. NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, sRANKL/osteoprotegerin ratio, CD14+CD309+Tie2+ EPA, EAM and EAM/CD14+CD309+ EPA ratio were determined as independent predictors of clinical outcomes in patients with CHF. Index of cardiovascular risk was calculated by mathematical summation of all ranks of independent predictors, which occurred in the patients included in the study. The findings showed that the average value of the index of cardiovascular risk in patients with CHF was 3.17 units (95 % CI 1.65 — 5.10 units). Kaplan — Meier analysis showed that patients with CHF and the magnitude of the risk of less than 4 units have an advantage in survival when compared with patients who obtained higher values of ranks cardiovascular risk score. Novel original risk predictive score proposed for heart failure patients is superior Seattle Heart Failure Model, Heart Failure Risk Calculator, National Heart Care Projecа irrespective observation period, as well as it is better than Barcelona Bio-HF posed for two-years and three-years risk assessment.

Conclusions. Assessment biomarker risk score of fatal and non-fatal cardiovascular cases, constructed on measurement of circulating NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, EAM and the ratio of the EAM/CD14+CD309+ EPA, allows reliably predict the probability of patients with CHF survival, regardless to age, gender, state of the contractile function of the myocardium of the left ventricle and the number of comorbidities.

Keywords: chronic heart failure, biomarkers, cardiovascular risk, predictive value.

11.

 

Inflammatory markers, lipid profile and ε2/ε3/ε4-polimorphism of apolipoprotein Е gene correlation with the effectiveness of lipid-lowering therapy in patients with coronary heart disease

L. N. Prystupa, O. V. Psarova

Genetic factors that accelerate the development of atherosclerosis and coronary heart disease include protein genes changes related to lipid synthesis and regulation of their metabolism, and various genetic defects in genes that control the function of the vascular wall. According to the literature, there is the link between the increasing of inflammatory markers, lipid profile of the patient, ε2/ε3/ε4 — gene polymorphism of apolipoprotein E (ApoE) and the effectiveness of lipid-lowering therapy in patients with coronary artery disease. ε2/ε3/ε4 — polymorphism is the most studied gene polymorphism ApoE and identified in more than 50 populations of the world, significantly affects the metabolism of lipoproteins. The consistent increase in the concentration of total cholesterol ε2 to ε3 and ε4, and this pattern is established for different populations. Data on comparison of the contents of C-reactive protein (CRP) and markers of inflammation depending on the ε4-allele carriers in the available literature are limited and contradictory. For example, the results AGES-Reykjavik Study showed lower levels of CRP in ε4-carriers, contrary to several other studies. It is known that statins and cholesterol absorption inhibitors also reduce CRP and concentration. One of the important factors for maintaining homeostasis sterols — a genetic polymorphism of ApoE. The literature suggests that the effectiveness of measures used for the correction of lipid disorders varies in individuals with different genotypes ApoE gene. So, ε2 allele carriers showed maximum efficiency appointment of statins and exercise, and in carriers of allele ε4 — diet low in fat and use probucol. There are also some ethnic differences in the frequency of ε4-allele detection in patients with coronary artery disease that deserves further in-depth study. The study of the relationship of inflammatory markers, lipid profile and ε2/ε3/ε4 — ApoE gene polymorphism and the mechanism of their influence on the development of coronary heart disease will identify risk groups and develop evidence-based individual treatment and prevention.

Keywords: coronary heart disease, atherosclerosis, dyslipidemia ApoE gene polymorphism, C-reactive protein, lipid profile, statins.

12.

 

Why does arteriosclerosis and atherosclerosis etiology remain unknown? «Thinking logic» and «unsolved problems»

D. D. Zerbino

The article deals with causes due to which the etiology of such widespread vascular diseases as arteriosclerosis and atherosclerosis remains unknown. The author proposes to solve this problem taking into account German philosopher Dietrich Dörner’s statement about the solution of medical and biological problems which is stated in his scientific work «The failure logic. Thinking logic in difficult situations». Complications emerged while atherosclerosis etiology research are caused by: a) great absolute case numbers; b) exponential increase of their number; c) long latent period when years put off causes from consequences; d) detection complexity; e) absolute problem novelty; f) complex cause-effect structure by the way of a net; g) evidenced indeterminate action sequence; h) time extended «feedback loop»; i) inefficient problem solution methods which were used before. The first-priority task for modern cardiologists is preventive medicine problems solution in order to create the conception of vascular pathology primary prevention.

Keywords: arteriosclerosis, atherosclerosis, Dietrich Dörner’s statements, unsolved problems.

13.

 

Биорезорбируемые коронарные стенты: особенности применения и собственные результаты

С. Н. Фуркало

Цель работы — проанализировать непосредственные результаты клинического применения, особенности структуры, визуализации и имплантации первого биорезорбируемого коронарного стента Absorb.

Материалы и методы. Под наблюдением находились 46 больных ишемической болезнью сердца (ИБС), которым были имплантированы 60 стентов Absorb (Abbott, США). Мужчин было 43 (93,4 %). Возраст больных составил в среднем (52,1 ± 4,1) года. Клиническая картина характеризовалась нестабильным течением заболевания в 6 (13,0 %) случаях, стенокардия II — III функционального класса отмечена в остальных 40 (87,0 %) случаях. Стентирование ранее перенесли 10 пациентов и аортокоронарное шунтирование — 4. Один больной ранее перенес эндопротезирование брюшного отдела аорты.

Результаты и обсуждение. Стентирование с имплантацией 1 стента Absorb выполнено у 33 больных, 2 стента были имплантированы в 11 случаях и в 1 случае установлены 4 биорезорбируемых стента. В одном случае стентирование коронарных артерий выполнено одновременно со стентированием внутренней сонной артерии. Применяли традиционный режим двойной антиагрегантной терапии. У всех больных ранний послеоперационый период прошел без осложнений, не зарегистрированы случаи неудачной имплантации или острого тромбоза стента. На модели in vitro продемонстрированы особенности полимерной структуры стента при его имплантации. Для визуализации применены современные высокоинформативные методики — оптическая когерентная томография и компьютерная томография.

Выводы. Наш опыт применения биорезорбируемых стентов у больных ИБС свидетельствует о возможности использования этой технологии в различных клинических и ангиографических ситуациях. Необходимо дальнейшее изучение как непосредственных, так и отдаленных результатов вмешательств для широкого внедрения биорезорбируемых стентов в рутинную практику отделений интервенционной кардиологии.

Keywords: биорезорбируемый стент, ишемическая болезнь сердца, методика имплантации, оптическая когерентная томография.

14.

 

Осложнения высоких ампутаций у больных с хронической критической ишемией нижних конечностей: ретроспективное исследование

Н. Ю. Литвинова, В. А. Черняк, О. В. Стрепетова, Е. И. Кефели-Яновская, И. И. Плюта

Цель работы — проанализировать результаты лечения больных с атеросклеротическими язвенно-некротическими поражениями нижних конечностей на фоне хронической критической ишемии, выявить причины неудовлетворительных результатов ампутации.

Материалы и методы. В ретроспективное исследование включены данные анализа историй болезни 256 пациентов, проходивших лечение в отделении сосудистой хирургии Александровской клинической больницы г. Киева в 2008 — 2011 гг., которым была выполнена высокая ампутация (уровень — бедро, голень). Для определения уровня ампутации выполняли ультразвуковое дуплексное ангиосканирование и рентгеноконтрастную ангиографию. Уровень ампутации определяли по клинической картине ишемии, применяли специальные методы исследования, характеризующие регионарный сосудистый резерв, магистральное и коллатеральное кровообращение в конечностях, микроциркуляцию и трофику тканей. Окончательный уровень ампутации устанавливали во время операции после визуальной оценки степени кровоснабжения пересеченных мышц. Все пациенты в послеоперационный период получали базисную консервативную терапию: обезболивающую, антиагрегантную, антикоагулянтную, антибактериальную. При анализе результатов лечения удовлетворительным ближайшим результатом ампутации считали первичное заживление послеоперационной раны культи. Нагноение, вторичное заживление, реампутацию, а также летальный исход отнесли к неудовлетворительным результатам ампутации.

Результаты и обсуждение. После больших ампутаций нижних конечностей выздоровели без осложнений 103 (40,2 %) пациента, серьезные осложнения наблюдали у 49 (19,1 %) больных, умеренные — у 68 (26,6 %), летальный исход — у 36 (14,1 %). У больных после ампутации нижних конечностей на уровне голени достоверно чаще развивалась глубокая раневая инфекция и расхождения краев послеоперационной раны. Тридцатидневную смертность и ишемические инсульты достоверно чаще регистрировали в группе с ампутациями нижних конечностей на уровне бедра. Проведенный анализ результатов ампутации на нижних конечностях показал, что наибольшее количество осложнений оказалось в группе больных старше 60 лет, что, видимо, связано с более распространенным поражением жизненно важных сосудистых участков (р < 0,05). В то же время осложнения со стороны послеоперационной раны чаще возникали у больных в возрасте 50 — 59 лет после ампутации нижних конечностей на уровне голени и курильщиков.

Выводы. Уровень существенных осложнений высоких ампутаций нижних конечностей в ранний послеоперационный период достаточно высок. Ишемическая болезнь сердца с нарушением сократительной функции миокарда влияет на результат ампутации конечности. Прогностически неблагоприятным является снижение фракции выброса левого желудочка ниже 40 %. Наибольшее количество осложнений оказалось в группе больных старше 60 лет, но осложнения со стороны послеоперационной раны чаще возникали у больных в возрасте 50 — 59 лет после ампутации на уровне голени и курильщиков. Тридцатидневная послеампутационная смертность и частота ишемических инсультов головного мозга достоверно выше у больных после ампутации на уровне бедра. В первые три года после высокой ампутации смертность у больных с хронической критической ишемией нижних конечностей ежегодно растет и достигает 69,5 %.

Keywords: хроническая критическая ишемия нижних конечностей, ампутация, осложнения.

Current Issue Highlights

№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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