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Issue. Articles

1(13) // 2006





Intra-arterial thrombolytic therapy for acute occlusions of the lower extremities main arteris

A.I. Pityk, V.A. Prasol

Unsatisfactory results of the operative treatment of the lower extremities main arteries (LEMA) acute occlusions stimulate the search for less traumatic methods of restoring the main bloodstream which could be as efficient as surgical methods. The method of thrombolytic therapy (TLT) can be considered as a rival method to operative interventions in case of acute arterial occlusions, because this method is as effective in extremity revasculation as operative intervention.

The purpose of this research was to evaluate the efficacy of intra-arterial TLT as the initial method of treating LEMA acute occlusions by means of evaluating the technical and nearest clinical results.

Material and methods. During 2002 — 2005, 32 patients with acute occlusions of femoral-popliteal segment arteries underwent intra-arterial TLT. The mean age of the patients was (62.4 ± 10.8) years, 81 % of them were male. The mean duration of acute leg ischemia was (6.8 ± 5.5) days. The cause of acute arterial occlusion of 17 patients was thrombosis and of 15 patients — embolism. 27 patients were treated with streptokinase and 5 patients — with urokinase.

Results. Trombolysis was technically successful in 71.9 % of patients. Clinical improvement was achieved in 68.7 % of patients, whose symptoms of acute extremity ischemia disappeared completely. 25.0 % patients underwent balloon angioplasty of arterial stenoses revealed after TLT. Trombolysis was more effective in treating embolisms than thromboses (86.7 % vs 52.9 %, p < 0.05). The 30-day mortality was 9.4 %, overall amputation rate was 22 %. Overall complication rate was 25 %, major bleeding complications constituted 12.5 %. In case of technically successful TLT the tibial arteries were patent in 71.9 % patients, in case of failure — only in 33.3 % (p < 0.05). The average duration of TLT was (46.3 ± 16.8) hours, the average dose of streptokinase was (565 ± 226) thousand IU and urokinase — (31 ± 10) million IU.

Conclusions. Technical success of intra-arterial TLT was achieved in 71.9 % cases of LEMA acute occlusions. At the same time the efficacy of thrombolysis in case of embolic LEMA occlusions was higher than in case of thrombotic occlusions. The frequency of severe hemorrhagic complications of intra-arterial TLT in case of LEMA acute occlusions was 12.5 %, amputations — 21.9 %. The state of tibial artery patency is a predictor of the successful intra-arterial TLT. In order to improve TLT results it is expedient to apply endovascular and surgical interventions to correct unsatisfactory results of thrombolysis and residual occlusive and stenotic lesions of the arteries.

Keywords: acute arterial occlusion, embolism, thrombosis, intra-arterial thrombolytic therapy, thrombolysis



Echocardiographic evaluation of the probability of reconstructive surgical procedure aimed at correction of mitral regurgitation

Yu.A. Ivaniv, L.V. Kulyk, O.S. Kuziv

The proportion of patients with mitral regurgitation (MR) who undergo reconstructive surgery is increasing in recent years. At the same time the echocardiographic methods are improving.

The purpose of the research was to conduct the retrospective investigation of echocardiograghy ability to estimate adequately the possibility of valve-saving reconstructive surgery in MR patients.

Materials and methods. 84 consecutive cases of surgical treatment of "pure" MR during the period of September 2000 — October 2004 were analyzed. Echocardiograghy was performed to all the patients, particular attention being paid to revealing the MR mechanism and the possibilities of a reconstructive procedure. The probability of the latter was assessed as high, mean or low.

Results. MR was estimated as functional in 6 cases (7.2 %), organic with leaflets hypermobility in 60 (71.4 %) and organic without leaflets hypermobility in 18 (22.4 %) cases. Reconstructive procedure on the valve as a primary surgery was performed in 34 patients (40.5 %). Most commonly, valve repair was performed in functional MR (83.5 %), in organic MR with leaflets hypermobility it was performed in 41.7 % cases, mostly with flailing or prolapsed medial scallop of the posterior leaflet. In case of organic MR without leaflets hypermobility, restorative surgery was performed only in 22.2 % cases. Preoperative assessment of valve repair probability turned out to be quite accurate. Restorative surgery was performed in 21 (72.4 %) out of 29 cases with high probability, in 11 (47.8 %) out of 23 patients with mean probability and in 2 (6.3 %) out of 32 patients with low probability.

Conclusions. Thoroughly performed echocardiographic examination allows predicting the probability of reconstructive surgery in MR and makes it possible to classify the cases according to their allocation to the different probability groups with adequate accuracy.

Keywords: mitral valve; mitral regurgitation, echocardiography



Long-term results of percutaneous recanalization of chronic coronary artery occlusions

Yu.N. Sokolov, M.Yu. Sokolov, A.V. Tsyzh, N.Yu. Chubko

Recanalization of chronic coronary artery occlusions is one of the most serious constraints during the use of percutaneous methods for ischemic heart disease (IHD). Besides the difficulties connected with the conducting of the special instrument for recanalization through the occluded segment, there is a problem of preserving the renewed coronary blood flow for a long period.

The purpose of the research was to compare the efficacy of using traditional stents without coating and eluting-stents in treatment of chronic coronary artery occlusions in the remote period after the operation.

Material and methods. 102 patients with chronic manifestations of ischemic heart disease were enrolled in the study with the purpose of comparing the efficacy of using uncoated stents and stents coated with medications in treatment of occlusive lesions of coronary arteries. Group A (n = 62) consisted of patients after recanalization of complete chronic occlusion with the use of uncoated stents, and group B (n = 40) - of patients after recanalization of complete chronic occlusion with the use of stents coated with medications.

Results. As a result of long-lasting observation of the patients after recanalization of chronic occlusion and implantation of two types of stents, we reavealed that coronary stenting - is an effective way of renewing the blood flow in the occluded coronary arteries in case of moderately decreased function of the left ventricle. The implantation of stents after recanalization is effective in restoring the tolerance to physical loading. As evidenced by the long-lasting observation (36 months), stents coated with medications were more efficient than uncoated stents in retaining patency of coronary arteries which had been occluded before. The survival rate without restenoses in group A was 88.7 %, in group B - 100 %, the survival rate without MACE was 87.1 % and 95.0 % respectively.

Conclusions. Coronary stenting is an effective way of renewing the blood flow in chronic coronary artery occlusions. It contributes to substantial increase of tolerance to physical loading. During 36 months stents coated with medications are more efficient than uncoated stents in retaining patency of coronary arteries which were occluded before. This fact was evidenced by the higher survival rate of patients without restenoses (100 % in group B and 88 % in group A) and survival rate without MACE (95.0 % and 87.1 % respectively).

Keywords: chronic coronary artery occlusions, recanalization, stenting, eluting-stent



Sudden death in Ukraine: influence of crisis ecological factors

D.D. Zerbino, O.R. Malyk, T.M. Solomenchuk

The purpose of the research was to summarize the results of forensic medical examinations of sudden deaths from exogenous and endogenous causes in Ukraine taking into account the ecological situation in the regions of Ukraine; to study the dynamics of coefficients of death rate in Ukraine in comparison with the standardized indices.

Materials and methods. We studied 325 accompanying messages of annual statistical reports (to form # 42) of the Main Bureau of Forensic Medical Examination of Ukraine obtained from 25 regions. 5 regions were singled out taking into account the variety of environmental, economic, ecological and social conditions. 9 regions with the greatest number of autopsies were chosen for the comparative analysis. The graphs of the ratio of forensic medical examinations of those who died from exogenous and endogenous causes were built with taking into consideration the proportion of the number of cases in percents to the total number of residents in the region. We studied the dynamics of death rate taking into account the number of cases (M ± m) in percents to the number of residents of the region in three periods: I period — 1987—1991, II period — 1992—1996, III period — 2000—2004.

Results. In 1987—2004 the number of forensic medical examinations in Ukraine resulting from violent death increased by 1.6 times, non-violent sudden death - increased by 2.6 times, the number of cases of sudden death from circulatory system diseases increased by 2.1 times. The indices of the standardized coefficients of death rate in the country increased in all basic classes of death reasons by 17 % among men, and among women — decreased by 23.5 %. But in comparison with the similar indices of death rate among the population of the developed countries, the standardized coefficients of general death rate in Ukraine both among men and women were higher by 1.9 times and 1.2 times, respectively. In 2004 the biggest number of lethal cases from the diseases of circulatory system was observed in the industrial regions, Donetsk, Kharkiv, Dnipropetrovsk, Zaporizhia, in particular; the percentage of lethal cases in proportion to the population of every region ranged from 0.101 to 0.143 %, while in the agricultural regions, such as Zhitomir, Khmelnytsky, Lviv, Rivne, where the ecological pressing of the industry is considerably less substantial, — from 0.035 % to 0.064 %. The proportion of death rate from the diseases of circulatory system to all the causes of death in Ukraine according to the standardized coefficients is 53 % among men, and 95 % — among women. Of all the regions of the country, in the period of 17 years, the biggest growth of lethal cases from the diseases of circulatory system was fixed in Donetsk (by 2.4 times), the smallest — in Khmelnytsky (by 1.7 times) regions.

Conclusions. The highest indices of sudden death rate of people from the diseases of circulatory system, according to the results of the forensic medical examination, were fixed in the industrial regions of the South-Western part of Ukraine (Donetsk, Kharkiv, Dnipropetrovsk, Zaporizhia) — from 0.101 to 0.143 %. In the agricultural regions (Zhitomir, Khmelnytsky, Lviv, Zakarpattia, Rivne) with a smaller index of industrialization and ecological pollution, this figure is 2.2 — 2.9 times smaller. The biggest growth of the number of lethal cases from the diseases of circulatory system, according to the results of the forensic medical examinations in the period of 17 years, was fixed in Donetsk (by 2.4 times), the smallest — in Khmelnytsky (by 1.7 times) regions.

Keywords: sudden death, diseases of circulatory system, ecology, violent and non-violent death



The processes of nitric oxide synthesis in chronic hyperimmunocomplexemia and their changes under quercetine influence in vitro

I.V. Valchuk, V.V. Chopyak, S.I. Pavlovitch, O.O. Moibenko

The aim of the research was to estimate the mutual influence of neutrophils and endotheliocytes on the processes of nitric oxide synthesis in vitro in chronic hyperimmunocomplexemia (CHIC) and their changes in conditions when these cells are incubated with Corvitin, water soluble form of quercetine.

Material and methods. The experiment was conducted on pubescent male rats with body mass of 200 — 250 g. All investigations were carried out on intact animals and animals with CHIC. The experimental CHIC model was created using C. Cochrane and D. Koffler method. The influence of Corvitin (produced by Borschahivsky Cemical and Pharmaceutical Plant, Ukraine) on the functional activity of neutrophils and endotheliocytes of intact animals and animals with modeled CHIC was determined. The level of nitric oxide synthesis in incubated neutrophils and endotheliocytes was measured by the activity of indecibel (iNOS) and total constitutive (cNOS) NO-synthases, the content of stable metabolites of NO — NO2-, NO3-anions and the level of cyclic neucleotides — cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). The activity of cNOS and iNOS was studied using the colorimetrical method in incubated neutrophils and endotheliocytes; the content of NO2-anions was determined in colorimetrical reaction with the help of Grece's reagent using Green's method. The content of NO3-anions was determined using spectrophotometric method, the level of cyclic neucleotides — using the radioimmunoassay technic and test-systems of the firm Amersham (England).

Results. In the conditions of incubation of neutrophils and endotheliocytes taken from animals with CHIC, the neutrophils concentration of NO2-anions increased from (5.48 ± 0.62) to (48.0 ± 6.77) pmol/mg (p < 0.05), while in the endotheliocytes the decrease of NO2-anions concentration from (123.3 ± 12.83) to (61.02 ± 4.47) pmol/mg (p < 0.05) and the increase of NO3-anions level from (3.67 ± 0.58) to (9.5 ± 1.15) nmol/mg (p < 0.05) were fixed. In the conditions of incubation of endotheliocytes the activity of iNOS was increased from (2.79 ± 0.48) to (7.93 ± 1.35) pmol/min/mg (p < 0.05). In the presence of Corvitin the neutrophils level of NO2-anions decreased from (48.0 ± 6.77) to (24.74 ± 3.7) pmol/mg and the activity of iNOS — from (29.22 ± 4.9) to (8.37 ± 1.42) pmol/min/mg (p < 0.05), which was not accompanied by substantial increase of cNOS activity. NO2-anions level in endotheliocytes increased from (61.02 ± 4.47) to (235.07 ± 18.91) pmol/mg (p < 0.05) and the activity of iNOS decreased from (7.93 ± 1.35) to (1.99 ± 0.28) pmol/min/mg (p < 0.05). Moreover, in the presence of Corvitin the content of cGMP in the neutrophils increased from (3.98 ± 0.64) to (32.0 ± 5.28) fmol/mg (p < 0.05) and cAMP/cGMP ratio decreased from (10.08 ± 1.85) to (1.76 ± 0.36) conventional units (p < 0.05). In the endotheliocytes the presence of Corvitin caused the increase of both cAMP content from (34.53 ± 5.48) to (57.62 ± 6.1) fmol/mg (p < 0.01) and cGMP content — from (4.47 ± 0.81) to (9.88 ± 1.64) fmol/mg (p < 0.05) without substantial changes of their ratio.

Conclusions. In the conditions of combined in vitro incubation of neutrophils and endotheliocytes of rats with experimental CHIC we fixed the selective increase of indecibel NO-synthase in the endotheliocytes and the increase of NO2-anions in neutrophils. The incubation of neutrophils and endotheliocytes with Corvitin in CHIC leads to substantial decrease of iNOS activity both in neutrophils (by 3.5 times) and in endotheliocytes (by 4 times), which is accompanied by the increase of cGMP level in the neutrophils (by 8 times) and in the endotheliocytes (by 2.2 times) as well as the increase of cAMP content (by 1.6 times) in the endotheliocytes.

Keywords: neutrophil, endotheliocytes, nitric oxide, cyclic neucleotides, chronic hyperimmunocomplexemia, Corvitin



Evaluation of vasoactive nitric oxide pool in hypertensive patients and its changes during drug therapy

S.N. Polyvoda, A.A. Cherepok

Aim. To evaluate the change of vasoactive nitric oxide pool (NO) in hypertensive patients, its dependence on the indices of oxidant stress and endothelium function and possibilities of correction by antihypertensive therapy.

Material and methods. 72 hypertensive patients (II stage, II—III degree of arterial hypertension, mean age 54.2 ± 2.7 years) and 28 practically healthy persons were examined. NO synthesis level was assessed by determining NADPH-diaphorase activity of thrombocytes as the marker of NO-synthase (enzyme responsible for NO synthesis) activity; end metabolites of NO (NOx) level in blood serum was determined for the NO vasoactive pool assessment; immune enzyme assay with estimation of 3-nitrotyrosine content in the blood serum was used to evaluate the quantity of NO, which, influenced by free radicals, had been metabolized to peroxinitrite. 8-isoprostan blood serum content was determined with immune enzyme assay as the marker of free radicals production level. Vascular endothelium functional state was assessed by the activity of von Willebrand factor in peripheral blood by the original method. Hypertensive patients were examined before and then 1 and 12 months after the beginning of monotherapy with enalapril.

Results. Hypertensive patients manifested the decrease of NOx content in the blood serum (18.0 ± 0.67 mcmol/l versus 25.4 ± 1.56 mcmol/l in controls, p < 0.01), elevation of 3-nitrotyrosine content (0.5 ± 0.02 nmol/l versus 0.1 ± 0.01 nmol/l in controls, p < 0.001), increase of 8-isoprostan blood serum content (101.5 ± 0.97 pg/ml versus 35.3 ± 1.69 pg/ml in controls, p < 0.001) as well as von Willebrand factor activity (141.4 ± 1.22 % versus 112.5 ± 2.07 % in controls p < 0.01), without significant changes of NADPH- diaphorase activity. After 12 months of treatment with angiotensine-converting enzyme inhibitor enalapril we observed the decrease of 3-nitrotyrosine blood serum content (by 65.8 % in comparison with its level in patients after 1 month of treatment, p < 0.01), along with 8-isoprostan content (by 51.1 %, p < 0.01) and von Willebrand factor activity (by 4.9 %, p < 0.05). In addition, we fixed the increase of NOx content by 32.5 % in comparison with the initial level and by 22.1 % in comparison with the level after 1 month of therapy (p < 0.05).

Conclusions. Hypertensive patients manifest the decline of NO end metabolites level in blood serum, which is an indirect proof of vasoactive nitric oxide pool decrease. The decrease of NO vasoactive pool in hypertensive patients is associated with the increase of its oxidation in the condition of oxidant stress and endothelial dysfunction. 12 months of treatment with the angiotensine-converting enzyme inhibitor enalapril results in recovery of NO end metabolites normal level in blood serum and von Willebrand factor.



Resilient and elastic properties of elastic and muscular type of arteries in patients with mild and temperate arterial hypertension and the impact of losartan therapy on them in comparison with amlodipine

Yu.M. Sirenko, H.D. Radchenko, S.M. Kushnir

The aim of this research was to determine the main independent factors which are closely correlated with pulse wave velocity (PWV) in the elastic and muscular type of arteries in patients with mild and temperate arterial hypertension (AH) and to compare the anti-hypertensive efficiency and impact of losartan and amlodipine on resilient and elastic properties of these arteries.

Material and methods. 36 patients with mild and temperate AH were enrolled in the study. Losartan was administered in the doze of 50mg/day (1st group; n = 14) or amlodipine in the doze of 5mg/day (2nd group; n = 22). If within a month the target AP was not achieved, the doze of the medication was doubled for 1 month. If the therapy was not effective enough, hydrochlorthiazide in the doze of 12.5mg/day was added. The duration of the treatment was 3 months. At the beginning and at the end of the treatment, all the patients underwent: office measurements of systolic (SAP) and diastolic (DAP) arterial pressure, heart rate (HR); 24-hour AP monitoring; measuring of PWV in the arteries of elastic (PWVe) and muscular (PWVm) types using the apparatus "Complior" ("Artech Medical", France), connected to the personal computer. Echocardiography, electrocardiography and biochemical blood test were performed only at the beginning of the research.

Results. We determined that PWVe had significant positive correlation with age, AH stage, glucose level, HR (r was 0.409, 0.431, 0.384, 0.318, respectively) and negative correlation with mean 24-h and daytime DAP, daily index (DI) for SAP and DAP, creatinine clearance level (r was –0.398, –0.453, , –0.326, –0.356, –0.422, respectively). Multi-variant regressive analysis showed that age, AH stage, DI for DAP and mean daytime DAP were independent values. PWVm had positive correlation with AH stage, mean 24-h DAP (r was 0.330, 0.300, respectively) and negative correlation with mean 24-h and daytime pulse (PAP) AP, the degree of night time decrease of DAP (DI for DAP) (r was –0.406, –0.428, –0.365, respectively). Independent factors were AH stage, DI for DAP, mean 24-h PAP. Losartan and amlodipine were effective in achieving the target AP in 71.4 and 72.7 %, respectively (p > 0.05). PWVm decreased in both groups, which was the evidence that the resilient and elastic properties of elastic and muscular type of arteries in both groups improved (in the 1st - to 7.39 ± 0.62, in the 2nd - to 8.82 ± 0.67; p < 0.05). PWVm changes had significant positive correlation with the changes of mean 24-h SAP (r = 0.55; p = 0.01) and DAP (r = 0.47; p = 0.03). PWVe decreased only in the 1st group (to 5.82 ± 0.43, p < 0.05). The intensity of this change didn't depend on the degree of AP decrease.

Conclusions. The treatment of patients with mild and temperate AH by both losartan and amlodipine was effective in achieving substantial decrease of PWV in the arteries of muscular type, which was the evidence that the resilient and elastic properties of muscular type of arteries in both groups improved. At the same time, in all the patients, the pulse wave velocity changes in the arteries of this type had positive correlation with changes of mean 24-h SAP and DAP. PWV in the arteries of elastic type substantially decreased only in case of losartan therapy and didn't depend on the degree of AP decrease.

Keywords: arterial hypertension, arteries of elastic and muscular type, pulse wave velocity, losartan, amlodipine



Comparative evaluation of tolerance and efficacy of spiraprilum and Enalapril in case of coronary syndrome without ST segment elevation in patients with concomitant arterial hypertension

A.N. Parkhomenko, Ya.M. Lutay, N.V. Dovgan

The purpose of this research was to evaluate the safety and efficacy of angiotensin-converting enzyme (ACE) inhibitor spiraprilum in comparison with those of Enalapril in case of their administration from the first 24 hours of treatment in hospital to patients with acute coronary syndrome (ACS) without ST segment elevation who have concomitant arterial hypertension and undergo standard anti-anginal therapy.

Material and methods. The investigation included 100 patients (68 men and 32 women) admitted to the reanimation and intensive care unit of Strazhesko Institute of Cardiology with the diagnosis of "unstable angina" (UA) or "acute myocardial infarction (AMI) without ST segment elevation on the ECG". All the patients suffered from AH of II—III degree during (4.2 ± 1.0) years on average. The patients were randomized on the 1st day of hospitalization into two groups using the method of random sampling. The 1st group included 40 patients who were administered spiraprilum (Quadropril, "Pliva") from the first 24 hours of hospitalization as a supplement to the basic therapy, the 2nd group — of 60 patients who were administered enalapril (Berlipril, Berlin-Chemie). Along with the common clinical and laboratory methods of research, we conducted 24-h monitoring of AP with the help of portable devices ABPM-04 ("Meditech" company, Hungary) as well as the estimation of the intra-cardiac hemodynamics with the help of sector two-chamber echocardiograph "Toshiba-SSH 40A" in "Dual" regime, four-chamber position. Electrophysiological properties of myocardium were estimated by the parameters of high resolution ECG (HR ECG) on the 1st and 10th days of observation.

Results. As early as on the 7th day of therapy, the 1st group patients demonstrated the tendency to decreasing the mean level of systolic AP (sAP): (133.2 ± 2.6) vs. (138.6 ± 2.1) mmHg in the 2nd group patients (p < 0.1). By the 10th day this difference achieved reliability: (131.4 ± 2.5) in the 1st group patients vs. (140.3 ± 3.4) mmHg in the 2nd group patients (p < 0.05). The dynamics of the diastolic AP (dAP) in both groups had no significant difference. But the analysis of the data obtained during the study of electrophysiological properties of myocardium evidence that they improved in the 1st group patients by the 10th day of therapy. The index of RMS (the amplitude of root-mean-square deviation of filtered summarized intensive QRS complex terminal part) of HR ECG in the 1st group patients increased from (54.2 ± 3.6) to (64.5 ± 3.9) µV (by 19.0 %; p < 0.05), while LAS (the duration of low-amplitude oscillations of terminal part of filtered summarized intensive QRS complex) had the tendency to decreasing from (22.1 ± 2.1) to (16.9 ± 2.9) µV (by 23.5 %; p < 0.1).

Conclusions. ACE inhibitor spiraprilum is a safe remedy for complex therapy of patients with ACS without Q-wave accompanied by AH. Spiraprilum therapy in the dose of 6 mg per day provides a more adequate control of AP in this category of patients by the 10th day than Enalapril therapy in the dose of 20 mg per day. As evidenced by HR ECG, spiraprilum is effective in improving homogeneity of depolarization processes by the 10th day of therapy, which isn't fixed in case of therapy by Enalapril.

Keywords: acute coronary syndrome, myocardial infarction, unstable angina, ACE inhibitors, spiraprilum



Main peripheral blood flow and flow-dependent vasodilation: prognostic value in patients with chronic heart failure

I.A. Shkurat

The aim of the work was to evaluate the prognostic value of indices of the main peripheral blood flow (MPBF) and flow-dependent vasodilation (FDVD) in patients with hemodynamically stable chronic heart failure (CHF).

Materials and methods. We investigated 151 patients with CHF of II-IV NYHA functional class (FC) caused by ischemic heart disease (111 patients) or dilated cardiomyopathy (40 patients) with left ventricle ejection fraction (LV EF) < 40 %. The average NYHA functional class was (2.86 ± 0.05) conventional units, the average left ventricle ejection fraction was (32.48 ± 0.63) %. The brachial artery (BA), the blood flow in the posterior tibial artery (PTA), the dorsal artery of foot (DAF) were investigated with the use of the linear ultrasound probe in the frequency range of 7 MHz (ultrasound system "Sonoline Omnia", Siemens, Germany) with the evaluation of the peak systolic (Vps), maximal end diastolic (Ved) velocities of blood flow in PTA and in DAF, as well as the index of the peripheral resistance (RI) in PTA and DAF. Endothelial function was studied using the test with reactive hyperemia. Kaplan-Meier method was used to investigate the cumulative survival in the period of 12 months for each particular index in both groups of patients based on "below median vs. above median" approach.

Results. The patients with CHF demonstrated substantially lower values of blood flow at rest (Vps and Ved) in PTA and DAF than the controls. Along with the decrease of MPBF indices, the patients with CHF revealed the substantial increase of RI in PTA and DAF. Lower values of Vps and Ved in PTA are associated with a less favorable prognosis (p = 0.057; p = 0.04, respectively); bigger values of RI in DAF had statistically significant association with the survival of the investigated patients (p = 0.04). The cumulative survival analysis of patients in the period of 12 months depending on the value of the growth of BA diameter in the phase of reactive hyperemia revealed that a smaller value of the growth of BA diameter in the phase of reactive hyperemia (DD J 6.8 %) is associated with substantially less favorable prognosis for life (p = 0.047) than in patients with a bigger value of this index.

Conclusions. As evidenced by the results of the research, it's possible to use the estimation of MPBF parameters (Vps and Ved in PTA, RI in DAF) and BA FDVD (along with results of other instrumental methods) for making prognosis of CHF patient's survival. It allows estimating the efficacy of different methods of treatment.

Keywords: chronic heart failure, main peripheral blood flow, flow-dependent vasodilation, prognosis



Specific features of clinical manifestations of primary right ventricular heart failure and myocardial dysfunction of heart ventricles at rest depending on the degree of infringement of cardiovascular system functional condition

K.M. Amosova, L.F. Konoplyova, O.O. Gonza, Yu.V. Rudenko

Objective. To estimate the features of clinical manifestations as well as systolic myocardial function of the right and left ventricles (RV and LV) of heart at rest in patients with primary right ventricular heart failure (PRVHF) resulting from idiopathic pulmonary hypertension (IPH) depending on the degree of infringement of cardiovascular system functional condition.

Materials and methods. 25 patients with IPH aged (28.6 ± 2.7) were surveyed. The patients were divided into two groups: 14 patients with the — functional class (FC) according to NYHA and 11 patients with the —V functional class according to NYHA. To estimate the functional condition of the cardiovascular systems we determined the tolerance of the patients to physical loading according to the data of 6 minutes' walk test. To estimate the systolic function of LV and RV and their remodeling the standard indices of Doppler-echocardiogram were used. The reliability of index differences in the groups was estimated by Kolmogorov—Smirnov's criterion, the correlation analysis was carried by means of Pearson's linear correlation coefficient.

Results. The clinical manifestations of PRVHF of the — FC according to NYHA are caused dyspnea during usual physical load, while the signs of systemic venous stagnation as unstable peripheral edemas are marked only in 21.4 % of patients. In patients with —V FC according to NYHA peripheral edemas were present in 90.9 %, including permanent — in 36.3 %, enlarged liver — in 45.4 %. The distance of 6 minutes' walk was, respectively, 517 ± 26m and 379 ± 40m ( < 0.001) and was shorter in comparison with the healthy (560.2 ± 43.5m, < 0.05) only in —V FC according to NYHA.

The systolic function of RV at rest in the patients with — FC according to NYHA was characterized by the increase of its diameter (in parasternal access — 28.7 ± 1.6 mm versus 31.4 ± 1.6 mm in the healthy, < 0.001), which was accompanied by the decrease of the end-diastolic index (EDI), end-systolic index (ESI) and stroke index (SI) of LV at rest (by 23.0 %, 22.2 % and 23.4 %, respectively < 0.05). The patients with —IV FC according to NYHA, in comparison to those with — FC according to NYHA, while having the same level of pulmonary artery systolic pressure (PASP) (75.6 ± 5.9 and 85.4 ± 5.9 mm mercury, respectively, > 0.05), are marked with further increase of RV diameter (up to 35.0 ± 2.7 mm, < 0.001), decrease of its shortening fraction (SF) (18.9 ± 0.8 % versus 23.0 ± 2.0 %) and the increase of LV stroke index (by 41.2 %) at the expense of EDI reduction (by 43.0 %, all < 0.05). The reliable correlation connections between NYHA FC and the distance of 6 minutes' walk as well as between both these indices and the indices of RV and LV systolic function at rest ( < 0.001) were revealed.

Conclusions. Initial PRVHF of NYHA — FC is manifested only as dyspnea during moderate physical loading, which does not result, however, in essential shortening of 6 minutes' walk distance. The decrease of SI and the increase of RV diameter at rest allow verifying it. The shortening of 6 minutes' walk distance by PRVHF patients is associated with further decrease of SI at rest caused by the decrease of LV EDI resulting from the deterioration of RV systolic function, accompanied by the increase of RV, right atrium and vena cava inferior dilatation.

Keywords: primary right ventricular heart failure, systolic dysfunction of the right ventricle, functional condition of the cardiovascular system



The correlation between the changes of antioxidant system and nitric oxide metabolism in patients with chronic kidney disease accompanied by arterial hypertension

I.I. Topchiy, T.V. Gorbach, T.N. Bondar

Aim. To determine the content of stable nitric oxide (NO) metabolites in patients with arterial hypertension (AH) accompanied by chronic kidney disease (CKD) and its correlation with the indices of the antioxidant system.

Material and methods. We examined 113 patients with CKD of I—III stage and patients suffering from essential hypertension (EH) of II stage with moderate AH. 57 of them were men (50.4 %) and 56 — women (49.6 %), mean age 45.6 ± 5.4 years. The comparison group consisted of 20 practically healthy persons comparable by gender and age with the main groups. The Ist group consisted of 37 patients with EH of the IInd stage, the 2nd group — of 34 patients with chronic glomerulonephritis (CGN), IIIrd — of 42 patients with diabetic nephropathy (DN). All the patients underwent complex clinical examination. The instrumental study included: electrocardiography at rest, chest X-ray, quantitative two-dimensional echocardiography and echosonoscopy of kidneys. To study NO metabolism we determined the content of L-arginine using the aminoacid analyzer AAA-339 (Czech Republic), the level of nitrite anion (NO2) in the blood serum by spectrophotometric method with Griss reagent, S-nitrosotiole in the blood plasma by fluorometric method. The total NO content, which is the sum of its stable metabolites — (NO2 + NO3), was determined by the reagent set "Total NO" made by RDS (England). The activity of the processes was judged by the concentration of crimson dialdehyde (CDA) in the blood serum. The state of the antioxidant system was estimated by the content of SH-groups, activity of superoxide dismutase (SOD), glutathione peroxidase (GPO), catalase (C) in the blood serum.

Results. The research of the indices of pro- and antioxidant systems of blood showed that the content of CDA was increased in case of CGN by 43.5 % and 50.2 % (p < 0.01), in case of DN — by 26.3 % and 32.2 % (p < 0.05) in comparison with both the control group and the group of EH patients respectively. The SOD activity was decreased in the Ist group by 9.2 % (p < 0.05), in the IInd group — by 33.2 % (p < 0.01), in the IIIrd group — by 25.9 % (p < 0.01) in comparison with the control group. GPO activity, C and the concentration of total SH-groups in all the groups of patients was decreased in comparison with the control group (all p < 0.05). The patients of all the groups were marked with substantial decrease of NO-synthase — L-arginine substratum level: by 1.9 times in EH patients (p < 0.05), by 9.3 times — with CGN (p < 0.01), by 4.6 times — with DN (p < 0.01) as well as the decrease of NO-nitrite anion endogenous synthesis marker: by 21.5 % in case of CGN (p < 0.05), by 23.1 % in case of DN (p < 0.05) in comparison with the control group. The indirect relation was fixed between the S-nitrosotiole plasma level and GPO activity in the blood (r = –0.58, p < 0.05).

Conclusions. CKD patients with secondary AH and EH reveal the reduced quantity of NO L-arginine precursor and the increased quantity of NO — S-nitrosotiole stable metabolite. The increase of S-nitrosotiole quantity in patients with AH accompanied by CKD may be related to the increase of inducible NO-synthase activity and the decrease of GPO activity.

Keywords: secondary arterial hypertension, essential hypertension, nitric oxide, L-arginine, antioxidant system



Comparative analysis of frequency of some cardiovascular risk factors in patients at young and mature age after myocardial infarction

D.I. Besh

The aim of the research was to compare the frequency of some cardiovascular risk factors in patients at young (before age 40) and older age after myocardial infarction (MI).

Material and methods. Questionnaire inquiry of 105 patients after myocardial infarction was performed. The main group consisted of 75 persons at young age (from 25 to 40 years old) and the comparison group consisted of 30 patients over age 50 (from 50 to 75 years old). The research was conducted using a specially worked out questionnaire which allowed carrying out a detailed analysis of possible MI risk factors: smoking; exposure to xenobiotics; conditions of life; diseases preceding MI development; the presence of a cardiovascular pathology in the family anamnesis; concomitant pathology; allergic reactions, etc.

Results. Clinical signs of angina pectoris were fixed in 22 (29.3 %) patients of the main group and in 22 (73.3 %) (p < 0.001) patients of the comparison group, arterial hypertension (AH) was present in 28.3 % and 66.7 %, respectively, hypodynamia in 17.3 % and 50.0 %, adiposity — in 15.0 % and 57.7 %, diabetes mellitus — in 3.3 % and 16.7 %, cardiovascular diseases (MI, stroke) occurred in the family anamnesis in 53.3 % vs. 23.3 % patients (all p < 0.01—0.001). At the same time, the number of smokers in the main group constituted 76.0 % vs. 33.3 % in the comparison group, the continuous professional exposure to xenobiotics was registered in 81.3 % vs. 23.3 % patients (all p < 0.001). Representatives of working professions prevailed in the main group — 74.7 % vs. 33.3 %, p < 0.001.

Conclusions. The development of MI is much more often preceded by exposure to xenobiotics and smoking in young adults (before age 40) than in older patients, while stable angina pectoris, AH, adiposity, diabetes mellitus and hypodynamia are fixed much more seldom.

Keywords: myocardial infarction, young age, risk factors



The role of angiotensin II receptor antagonists in treatment of chronic heart failure

.Y. Zharinov

The idea of using angiotensin II receptor antagonists (ARA II) in the treatment of chronic heart failure (CHF) is aimed at avoiding some adverse effects of angiotensin-converting enzyme inhibitors (ACEI), providing more complete blockade of renin-angiotensin-aldosterone system and improving the compliance of patients to the treatment. The results of the recently performed clinical trials provide sufficient background for including ARA II into the standards of CHF management. From point of view of evidence-based medicine and cost-efficiency ratio, ARA II (losartan, candesartan) are the best alternative means of CHF treatment in case of ACEI intolerance. The addition of ARA to ACEI doesn't provide advantages regarding the decrease of mortality, but makes it possible to improve the control of clinical symptoms and to increase the efficiency of prevention of circulatory impairment decompensation. The combination of ARA group preparations (i.e., candesartan and valsartan) with ACEI is especially feasible in case of restrictions to treatment with other neurohumoral modulators.

Keywords: angiotensin II receptor antagonists, chronic heart failure, angiotensin-converting enzyme inhibitors



The concept of selective specific inhibition of If channels in cardiology: clinical value

E.N. Amosova

The frequency of heart rate (FHR) increase is associated with raised mortality, which is especially expressed in patients with coronary heart disease (CHD). The anti-ischemic effect of beta-blockers (BB) is realized due to reduction of FHR, which is accompanied by improvement of survival rate of the patients after myocardial infarction with the presence of heart failure. But BB have a number of contra-indications and side effects, which substantially limits the potential of their use and makes it necessary to create medications with negative chronotropic effect of another mechanism of action. Such medications are selective and specific blockers of If natrium and potassium channels of pacemaker cells whose first representative is ivabradine. Numerous controlled investigations showed its clinically significant antianginal and anti-ischemic effect on patients with stable angina pectoris, comparable with the effect of BB therapy and therapy by blockers of calcium channels. The important advantage of ivabradine over the existing antianginal drugs is the absence of side effects, except for temporary visual impairment which became the reason for the termination of treatment of less than 1 % patients. Ivabradine is most of all indicated to patients with stable angina pectoris who have contra-indications to BB administration and in case when these drugs can't be used because of side effects, as well as to patients with vasospastic and microvascular angina pectoris. The use of specific blockers of If channels is also rather perspective in acute left ventricular heart failure which demands long treatment with sympathomimetic amines, as well as in diastolic heart failure of CHD patients especially those with tendency to sinus tachycardia.

Keywords: inhibitors of If channels, ivabradine, angina pectoris



Variants of thromboangiitis obliterans (Buerger's disease) clinical course

M.M. Bagriy, V.I. Slyvka

Buerger's disease belongs to rare forms of vasculitis. The disease is little known to the majority of doctors, though any specialist may come across it in his practice. Lesions of veins and arteries of lower and upper extremities: thrombophlebitis migrans, pain at rest, ischemic necroses, intermittent claudication, Raynaud's phenomenon prevail in the clinical picture. Generalization of the process with the vascular involvement of other organs is possible in the dynamics of thromboangiitis progression. As a result, several forms of the disease with visceral manifestations are singled out: visceral and visceral-peripheral forms with predominant lesion of the heart, brain and organs of digestion.

Keywords: thromboangiitis obliterans (Buerger's disease), thrombophlebitis migrans, arteritis



The experience of applying catheter radiofrequency ablation of para-nodal cardiac ways in gestation period

V.K. Grin, D.L. Kharytonchyck, A.S. Kuznetsov, A.V. Churylov, E.A. Soloviova

The problem of pregnancy of women with cardiac rhythm and conductivity impairments is becoming urgent. Frequent extrasystoles constitute the group of cardiac rhythm impairments unfavorable in terms of prognosis, especially in the pregnant. Among paroxysmal rhythm impairments in pregnant women the most common one is paroxysmal supraventricular tachycardia, which is connected with the cardiac pathology.

The aim of the research was to describe the experience of applying radiofrequency ablation of para-nodal conducting cardiac ways in the pregnant with paroxysmal tachycardia.

Material and methods. Patient B., 27 years old, pregnant for the first time, was admitted to the cardiosurgical department of V.K. Husak Emergency and Plastic Surgery Institute with complaints about the pronounced weakness, onsets of accelerated heartbeat up to 180 per minute. The above-mentioned complaints first appeared 11 years ago. The patients received out-patient and inpatient treatment more than once. The complex of pharmacotherapy included anti-arrhythmic medications. In the course of pregnancy the onsets of tachycardia became more frequent. AV junction tachycardia had been diagnosed before. Diagnosis: idiopathic paroxysmal AV-junction tachycardia . Chronic heart failure of zero degree. Pregnancy I, 33—34 weeks. Operation was performed: radiofrequency ablation of para-nodal ways. The post-operative period was smooth. The uterus was in normotonus, the fetus's heartbeat was rhythmic, to 148 per 1 minute, the cardiotocogram corresponded to the pregnancy period without any signs of pre-natal hypoxia. The pregnancy ended in pathological delivery at term of a mature fetus.

Results. The cardiovascular system is susceptible of sufficient adaptation and dynamic changes, beginning with the first weeks of pregnancy. Changes of hormone background influence the functioning of the heart. Estrogens increase the excitability of myometrium. The patients with paroxysmal supraventricular tachycardias demonstrate high anesthesiology risk along with threat of cardiovascular complications. The adequate stabilization of heart functioning in the pregnant with rhythm impairments is a necessary condition of successful course of pregnancy and delivery.

Keywords: paroxysmal supraventricular tachycardia, catheter radiofrequency ablation, pregnancy

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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