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№1(45) // 2014






Benefits of heart rate control with combination of ivabradine and β-blocker compared to full-dose β-blocker therapy, regarding the impact on exercise tolerance, longitudinal systolic and diastolic myocardial function and NT-proBNP levels in pat

К. М. Amosova, Yu.V. Rudenko, E. V. Andreev, I.Yu. Katsytadze, A. B. Bezrodniy

Purpose — to compare the effect of the combination of bisoprolol and ivabradine and titration to the target dose on exercise tolerance, dynamic longitudinal systolic and diastolic function of the left ventricle, according to the pulsed tissue Doppler, and NT-proBNP levels in patients with chronic ischemic heart disease (IHD) with moderately severe chronic heart failure and left ventricular systolic dysfunction.

Materials and methods. Single-blind, parallel-group study included 78 IHD patients aged < 60 years (54.0 ± 2.3 years) with a sinus rhythm > 70 per 1 min (stable angina pectoris of I — II functional class), documented myocardial infarction (MI) > 3 months, mild hypertension, and ejection fraction (EF) 38 — 45 %, who received ACE inhibitors and β-blockers, 2.5 mg/day. In group 1 (n = 40), bisoprolol was titrated to 5 mg/day and ivabradyn was added (5.0 to 7.5 mg twice a day; 12.4 ± 0.5 mg/day), in group 2 (n = 38), bisoprolol was titrated to 10 mg/day (9.1 ± 0.4 mg/day). At baseline and after 2 months of treatment, patients underwent treadmill test according to Bruce protocol and measurement of such parameters as ejection fraction, velocity of the mitral ring, the ratio of flow velocities and mitral ring (E/E’) using pulsed tissue Doppler and plasma NT-proBNP by ELISA.

Results and discussion. HR at rest and systolic BP were similar in both groups at the beginning of the research 78.6 ± 3.6 vs 81.4 ± 3.7 bpm and 135.4 ± 5.8 vs 132.4 ± 5.8 mmHg, and at 2 months of treatment 66.4 ± 2.9 vs 64.9 ± 2.9 bpm and 124.2 ± 5.4 vs 125.2 ± 5.7 mmHg; p > 0.05). Fatigue and/or dyspnea were predominant reasons for treadmill test termination in both groups at the beginning of the research (55 % vs 47.5 %) and in two months of treatment (68.6 % vs 60 %). In 2 months, systolic velocity of the mitral ring in group 1 as compared to group 2 was S'lat — 8.11 ± 0.4 and 7.61 ± 0.38 cm/s, S'sept — 6.97 ± 0.41 and 6.47 ± 0.36 cm/s, S'ant — 7.2 ± 0.36 and 6.1 ± 0.29 cm/s (all p < 0.01); the ratio of E/E’ — 8.2 ± 0.38 and 9.5 ± 0.52 (p < 0.01). EF in patients of the two groups at the time of observation was 42.0 ± 1.9 vs. 44.1 ± 2.3 % and 41.7 ± 2.0 vs. 44.6 ± 2.3 %, respectively (all p > 0.05), NT-proBNP — 186.0 ± 11.2 vs. 164.0 ± 9.4 pg/ml (p < 0.05) and 173.0 ± 10.4 vs. 167.0 ± 10.1 pg/ml (p > 0.05).

Conclusions. Combination of ivabradine with bisoprolol during 2 months of treatment of patients with chronic ischemic heart disease with moderate heart failure and left ventricular systolic dysfunction, left ventricular ejection fraction < 45 % and sinus rhythm improves exercise tolerance, which is associated with a significant increase in the chronotropic reserve, as well as the improvement of segmental systolic and diastolic left ventricular function according to pulsed tissue Doppler imaging at an unchanged left ventricular ejection fraction, which was not observed during monotherapy with higher doses of bisoprolol, despite the same heart rate deceleration. Combination treatment of these patients with ivabradine and beta-blockers is accompanied by a decrease of plasma levels of NT-proBNP within 2 months, while in case of monotherapy by bisoprolol the figure does not change.

Keywords: heart rate, heart failure, exercise tolerance, bisoprolol, ivabradine.



Prediction of revascularization outcomes in patients with critical lower limb ischemia by reactivity of foot microcirculation

V. N. Pshenichnyy, Y. V. Rodin

Рurpose — to elaborate the criteria of transcutaneous oxymetry to predict the outcomes of infrainguinal revasculization using functional tests in patients with critical lower limbs ischemia (CLLI).

Materials and methods. In our study we have analyzed the experience of observation and surgical treatment of 76 patients with various combinations of atherosclerotic artery occlusions in femoral-popliteal segment. Infrainguinal reconstructions have been performed in 37 cases, two-level reconstructions — in 20 cases, and lumbar sympathectomy — in 19 cases. In preoperative period in addition to routine methods, all patients underwent transcutaneous oxymetry with Radiometr apparatus (Denmark) with positional functional test.

Results and discussion. The study has revealed that in 88 % of cases, CLLI was caused by atherosclerotic affection in aorthalinguinal, femoral-popliteal and tibial-pedal segments in their various combinations. Besides, up to 70 % of patients did not have clear angiographic information about both pedal arterial arches before the operation. We have analyzed the values of transcutaneous oxymetry before and after orthostatic test in 75 patients with CLLI having questionable angiographic outflow. The beneficial operative result (regress of limbs ischemia and patency of reconstructed segment) has been attained in 41 cases. In 35 patients, positive clinical and haemodinamic effect has not been achieved. We have also fixed that there was no significant difference of basal transcutaneous pO2 in patients with favourable and unfavourable postoperative results (7.4 ± 2.6 vs 8.2 ± 1.4 mmНg; p = 0.2). Orthostatic pO2 Hg increase of more than 20 mmHg enables to reliably predict the favourable outcomes of infrainguinal reconstruction (р = 0.001), lumbar sympathectomy (р = 0.01), but is not reliable in two-level extremity revasculization (р = 0.09). According to the data of transcutaneous oxymetry after orthostatic test the negative prediction of surgical treatment turned out to be true in 84.4 % of operated patients, and positive prediction — in 87.5 %.

Conclusions. The microcirculation analysis by transcutaneous oxymetry after postural tests makes it possible to predict the outcome and thus to choose the optimal method of revasculization in the critical lower limbs ischemia.

Keywords: chronic critical ischemia of lower limbs, reconstructive surgery, transcutaneous oxymetry, prediction.



Effectiveness of a unified step treatment algorithm to control blood pressure in patients with hypertension in ambulatory practice: PERFECT findings

К. М. Amosova, Yu. V. Rudenko, O. I. Rokita, I. Yu. Katsitadze on behalf of a group of researchers

Purpose — determining the effectiveness of the “Programme of blood pressure (BP) control optimization in patients with arterial hypertension”, which would provide standardized step algorithm of antihypertensive therapy on the basis of a fixed combination of amlodipine and perindopril, correct home BP monitoring and educational materials for patients on achieving the target office and normal home BP in patients with uncomplicated hypertension (UH) and improve their adherence to treatment in routine ambulatory cardiology practice.

Materials and methods. The open prospective study PERFECT comprised 53 Kyiv city ambulatory cardiologists which included into the study 501 patients aged 35 to 70 years (mean age 58.0 ± 0.4 years) with UH and BP > 160/100 mmHg, if they were treated previously, or ≥ 140/90 mmHg, if they were not treated. 6 visits took place and 2 additional as needed within 6 months. During the 1 visit the doctor determined BP using a standardized automatic device Microlife BPW200 with a universal cuff. Patients were provided with automatic oscillometric device Microlife BP3AG, trained in using it, informed on lifestyle modifications and prescribed fixed combination of perindopril and amlodipine (Bi-Prestarium, Servier, France) at a dose of 5/5, 5/10, 10/5 or 10/10 mg at physician’s choice (step 1). Before each subsequent visit, the patient during 7 days twice a day independently measured the BP and recorded the results in a log. If no target office BP ( < 140/90 mmHg) is achieved, on subsequent visits the dose of Bi-Prestarium was increased to the maximum tolerated (step 2) and consistently prescribed indapamide-retard (Arifon-retard, Servier, France) 1,5 mg per day (step 3), spironolactone 25 mg twice per day (step 4), moxonidine in the dosage of 0.2 mg to 0.6 mg per day or 4 — 8 mg of doxazosin per day (step 5). In patients who received antihypertensive therapy prior to study entry, during 1 visit and in all patients during the final visit, adherence to treatment through a questionnaire (X. Girerd et al., 2001) was evaluated. Evaluation of the effectiveness of treatment was conducted on the primary endpoints: the amount (%) of patients who achieved the target office BP after 6 months and patients with “normal” home BP ( < 135/85 mmHg), and secondary endpoints: change in adherence to treatment and the incidence of side effects of antihypertensive therapy.

Results and discussion. 431 (86 %) patients completed the study (mean age 57.3 ± 0.5 years), including 191 (44.3 %) males, 93 (22 %) of them with grade 3 hypertension. After 6 months, mean office systolic BP decreased from 165.8 ± 0.8 to 130.9 ± 0.5 mmHg, diastolic — from 97.2 ± 0.5 to 79.2 ± 0.4 mmHg (all p < 0.0001). The target office BP was achieved in 82.8 % of patients, including 69.9 % of patients with grade 3 hypertension; target office and normal home BP was achieved in 63.1 % of patients. Low levels of adherence to treatment was fixed in 181 (50.7 %) patients during 1 visit and in 25 (7 %) during the final visit; high levels of adherence was fixed in 92 (25.8 %) and 178 (49.9 %) patients, respectively, (all p < 0.001).

Conclusions. The prescription to UH patients of standardized algorithmic antihypertensive therapy based on a fixed combination of perindopril and amlodipine with home BP control and education program in routine ambulatory cardiology practice allowed in 6 months of treatment to reach the target office BP in 82.8 % of patients and to decrease the home BP to normal levels (≤ 135/85 mmHg) in 63.1 % of cases. This approach allowed us to increase the frequency of high and moderate patients’ adherence to treatment according to the questionnaire of Girerd X to 93 % or 43.7 %, compared to the original.

Keywords: essential hypertension, target blood pressure, perindopril, amlodipine, fixed low-dose combination, adherence to treatment.



Factors associated with increased risk of adverse cardiovascular events in patients suffering from ischemic heart disease with verified coronary artery atherosclerosis at long observation

L. N. Yakovleva, V. Y. Tseluyko

Purpose — to determine independent clinical-anamnestic, instrumental parameters and genetic factors associated with an increased risk of adverse cardiovascular events (ACVE) in patients suffering from ischemic heart disease (IHD) with angiographically verified coronary artery (CA) atherosclerosis at long observation.

Materials and methods. 318 IHD patients (mean age 59.2 ± 6.9 years) with verified according to selective coronary angiography (SCG) atherosclerosis of at least one CA (stenosis > 30 %) were examined. Evaluation of patients included determination of the ankle-brachial index (ABI), Doppler sonography of the lower extremities vessels (LEV) and carotid arteries (CA) with a quantitative assessment of the intima-media thickness (IMT), as well as determination of glomerular filtration rate (GFR) by MDRD formular. Standard medical therapy was prescribed to all patients. The observation period lasted 28.4 ± 4.8 months. Combined endpoint of the study was cardiovascular death, myocardial infarction (MI), unstable angina, need for myocardium revascularization, and acute cerebrovascular accident. Study of the angiotensin converting enzyme (ACE) I/D polymorphism was performed using polymerase chain reaction.

Results and discussion. 82 (25.8 %) patients in whom the study endpoints occurred were included in group I, 236 patients without ACVE composed group II. According to univariate analysis, the probability of ACVE development in the examined patients was increased in the presence of hypertension (AH) (OR = 2.06; 95 % CI 1.05 — 3.84; p = 0.04), diabetes mellitus (DM) of type 2 (OR = 2.12; 95 % CI 1.15 — 3.92; p = 0.02), abdominal obesity (OR = 1.82; 95 % CI 1.1 — 3.01; p = 0.02), smoking (OR = 2.03; 95 % CI 1.21 — 3.36; p = 0.006), family history of cardiovascular disease (CVD) early onset (OR = 1.81; 95 % CI 1.0 — 2.95; p = 0.02), more than one MI in anamnesis (OR = 2.06; 95 % CI 1.11 — 3.84; p = 0.02), reducing EF < 45 % (OR = 1.77; 95 % CI 1.05— 2.99; p = 0.03), decline in renal function (OR = 1.89; 95 % CI 1.1 — 3.25; p = 0.02), as well as at atherosclerotic lesions of CA (OR = 2.28; 95 % CI 1.23 — 4.23; p = 0.01) and LEV (OR = 1.93; 95 % CI 1.11 — 3.35; p = 0.02), the lesions of three CA (OR = 1.77; 95 % CI 1.06 — 2.94; p = 0.05) and diffuse type of lesion according to SCG (OR = 3.56; 95 % CI 1.15 — 5.59; p = 0.04. The presence of DD genotype was associated with an increased likelihood of ACVE in patients with verified CA atherosclerosis (OR = 1.87, 95 % CI 1.10 — 3.18; p = 0.03). Stepwise regression analyzes revealed independent association of ACVE development with the presence of AH (β = 0.11; B = 0.11; p = 0.03), type 2 DM (β = 0.10; B = 0.12; p = 0.05), ABI decrease < 0.9 (β = –0.20; B = –0.51; p = 0.0003), the diffuse type of CA lesion (β = 0.13; B = 0.21; p = 0.01), and the DD genotype of I/D polymorphism in ACE gene (β = 0.14; B = 0.07; p = 0.01).

Conclusions. Independent factors associated with increased risk for adverse cardiovascular events in IHD patients with angiographically verified coronary atherosclerosis are hypertension, type 2 diabetes, smoking, reduced ABI less than 0.9, a diffuse type of coronary lesion according to the SCG and the presence of DD genotype of insertion-deletion polymorphism in ACE gene.

Keywords: coronary heart disease, long-term prognosis, risk factors, genetic polymorphism.



Stages of reconstructive interventions in patients with multilevel occlusive-stenotic arterial lesions of the lower extremities in distal and ultradistal localization

A. М. Bytsay

Purpose — to improve the effects of surgical treatment of multilevel atherosclerotic occlusive-stenotic arterial lesions of infrainguinal (ultradistal) localization by optimizing the tactics of reconstructive surgery.

Materials and methods. The work is based on the retrodiction of intermediate results of surgical repairs on the main artery of lower limbs in 48 patients which had 52 surgical repairs (2007 — 2012). Most patients were men (46 patients (95.8 %)) and there were 2 women (4.2 %). The average age was 65.4 ± 8.5 years. Ischemia of lower limb tissue was measured by criteria of European Consensus paper (ТАSC II). Stage III of arterial insufficiency was detected in 36 (69.2 %) patients, stage IV — in 16 (30.8 %). Duplex scanning, ultrasonic Doppler examination, X-ray contrast arteriography, intravenous contrast computed tomography were used in research-diagnostic base of studying the abnormalities of lower limb regional circulatory dynamics.

Results and discussion. 10 (19.2 %) patients with multilevel occlusive affections of femoropopliteal segment had a femoropopliteal sequential bypass surgery. Distal anastomosis was formed with the popliteal artery (tibia arteries) below the knee joint cleft. In case of absence of the appropriate autovein, at detection of calcinosis of peripheral arteries and also at rapidly progressive atherosclerotic process, the femoropopliteal bypass surgery was made by adding autovenous plastic repair of distal anastomosis irrespective of the level of its formation. Autovenous plastic repair by Neville was more preferable because of the easy implementation and lower risk of formation of abnormal turbulent flows in the anastomosis area. Remodelling of femoropopliteal segment in 42(80.8 %) of patients was complemented by the formation of an outflow tract — a popliteus-foot bypass. A bypass renewal of femoropopliteal segment by semi-open endarterectomy was performed in 8 (15.4 %) patients. A remodelling of the same area by bypass surgery was made to 34 (65.4 %) patients. Capacity analysis of pedal artery in the zone of formation of distal anastomosis was estimated with the help of intraoperative flow measurement. As a matter of fact, the further surgical approach to the remodeling of femoropopliteal segment depended on the flow parameters of the zone of foot segment. The nearest postoperative period was complicated by thrombosis of the remodelled artery segment in 3 (10 %) patients of the comparison group and in 2 (9.1 %) patients of the main group. A thrombectomy from bypasses was made to 3 (10 %) patients of the comparison group. 2 of them (6.7 %) had re-thrombosis and had abscission of a limb. Thrombectomy from the remodelled segment was made to 2 (9.1 %) patients of the main group. On day 2 they had re-thrombosis. Subsequently, 1 (4.5 %) patient had an abscission of a limb. There were no fatal cases.

Conclusions. Compliance to hemodynamic criteria when determining the indications for reconstructive surgery in patients with multilevel occlusive arterial disease of lower extremities enables reducing the risk of thrombotic complications during momentary interference and achieving the same effects as in case of staging remodeling. While performing the ultradistal autovenous bypassing, the priority should be given to the orthograde method.

Keywords: obliterating atherosclerosis, occlusion, bypass.



Dynamics of lipid metabolism and adipocytokines in patients with morbid obesity after medical and surgical treatment of obesity

O. I. Mitchenko, A. S. Lavrik, A. A. Shkroba, V. Y. Romanov, I. V. Chulaevska, O. Y. Kulik

Purpose — to study the dynamics of lipid profile parameters in patients with morbid obesity before and 6 months after medicamental and surgical treatment for obesity.

Materials and methods. We examined 164 patients with morbid obesity (BMI > 40 kg/m2) which formed two groups. The 1st group included 81 patients who were treated with diet and drug Stifimol. The 2nd group included 83 patients who underwent bariatric surgery (gastric banding or gastric bypass surgery). All patients were examined before and 6 months after treatment of obesity. They underwent clinical examination, determination of anthropometric parameters, determination of the concentrations of total cholesterol, triglycerides, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, leptin, adiponectin and index leptin/adiponectin.

Results and discussion. 6 months after treatment, in 1st and 2nd groups there was a significant decrease in weight and BMI. 1st group patients reduced the body weight by 5.5 kg (4.6 %), 2nd group patients — by 35 kg (22.8 %). As a result, there was a significant decrease in total cholesterol (by 6.9 % in men and 3.6 % in women of 1st group; by 19.7 % in men and 22 % in women of 2nd group), triglycerides (by 15.4 % in men and 14.3 % in women of 1st group; by 33.3 % in women and men of 2nd group), and increased HDL cholesterol (by 8 % in men, 7.7 % in women of 1st group, by 20 % in men and 9 % in women of 2nd group). In 2nd group there was a significant decrease in leptin levels (by 39.4 % in men and 52.4 % in women). In 1st group patients, no significant changes in leptin levels were found.

Conclusions. Using medicamental and surgical methods for treatment of obesity was accompanied by weight loss. A significant reduction in body weight was observed in patients of the 2nd group, which was associated with more significant changes in lipid profile and a significant decrease in leptin levels in patients of the 2nd group.

Keywords: morbid obesity, dyslipidemia, cardiovascular risk, medicamental treatment, surgical treatment.



Diagnostic value of abdominal aorta aneurysm and intraluminal thrombus volume for determining treatment strategies and predicting the risk of rupture

A. A. Nykonenko, A. L. Makarenkov

Purpose — to study the effect of the volume of intraluminal thrombus of abdominal aortic aneurysm on the growth and the risk of rupture of the aneurysm for determining the subsequent treatment.

Materials and methods. The analysis of data of 21 patients with infrarenal aortic aneurysm was conducted. All patients were males. Mean age was 70.19 ± 9.29 years. Studies were performed on the 4-detector unit Toshiba Asteion and the 64-detector GE Optima 660. Dimensions of aneurysm were estimated. The volume of the aneurysm was evaluated with the use of special methods.

Results and discussion. Small abdominal aortic aneurysms were detected in 8 (38 %) patients (the volume of aneurysmal expansion — 87.827 cm3). Symptomatic large aneurysm was detected during the examination in 6 (28.5 %) patients (the volume of aneurysm — 426.222 cm3). Aneurysm ruptures were detected in 7 (33.3 %) patients (the volume of the aneurysm — 288.403 cm3).

Conclusions. By analyzing the volume of aortic aneurysm it is possible to reliably estimate the degree of aneurysmal expansion for determining the treatment strategy and the risk of aneurysm rupture. The study showed a significant increase in the volume of the aneurysm and thrombus. Increase of the thrombus volume gives evidence of an increased risk of aneurysm rupture.

Keywords: abdominal aortic aneurysm, aneurysm volume, contrast computer tomography.



Indicators of hemovascular homeostasis and level of vasculotropic autoantibodies in elderly coronary heart disease patients with clinically distinct chronic heart failure

V. Yu. Zharinova, J. S. Butynets

Purpose — evaluation of the functional state of the endothelium, the activity of platelets, blood rheology and levels of autoantibodies to TrM- 03, PAPPA-A, ANCA, eNOS in elderly patients suffering from coronary heart disease with distinct clinical congestive heart failure with reduced ejection fraction and without such.

Materials and methods. The study involved 75 patients aged 60 — 74 years (mean age 68.4 ± 4.2 years). 45 of them (the study group) had coronary heart disease (CHD): stable angina pectoris of II — III FC, chronic heart failure (CHF) of IIA—IIB stage with left ventricular systolic dysfunction. 30 patients (comparison group) had CHD: stable angina pectoris of II — III FC, CHF of stage I with preserved ejection fraction. They were hospitalized in the cardiology department of D. F. Chebotarev Institute of Gerontology of NAMS of Ukraine. The control group consisted of 22 healthy elderly persons (mean age 64 ± 3.6 years). The functional state of the endothelium (FSE) was evaluated by using laser Doppler flowmetering in dual-channel laser Doppler flowmetering ЛАКК-2 (Russia) in the middle third of the inner surface of the forearm. Platelet aggregation activity was studied in dual-channel laser analyzer of platelet aggregation 230LA (Биола, Russia) by Turbodimetric method; blood viscosity — by using a rotary viscometer AKP-2 (Russia) at shear rate of 10 s–1, 20 s–1, 200 s–1 with the calculation of the strain index (SI) and erythrocyte aggregation index (EAI). The level of autoantibodies to TrM — 03, PAPP-A, ANCA, eNOS was determined in ELISA analyzer StatFax 2100 (USA). Statistical processing of data was carried out using the program Statistic 8.0.

Results and discussion. Analysis of results of our study indicate that elderly patients with chronic heart failure (ejection fraction < 45 %) compared to patients with preserved LVEF and control group revealed: decrease in microcirculation — 3.24 ± 0.77, 6.97 ± 0.03 and 8.53 ± 0.09 pF. units, capillary reserve — 133.5 ± 10.3, 147.9 ± 11.2 and 189.0 ± 13.5 % and the estimation parameters characterizing FSE — 46.8 ± 1.8, 60.4 ± 2.2 and 74.6 ± 3.1 %; increase of level of spontaneous — 6.43 ± 0.42, 5.14 ± 0.44 and 2.70 ± 0.15 %, respectively, adrenaline-induced — 47.89 ± 5.22, 38.62 ± 4.46 and 16.80 ± 0.80 % and ADP-induced — 51.88 ± 3.99, 36.62 ± 3.05 and 12.20 ± 0.10 % aggregation of platelets and increased blood viscosity. Also, patients with systolic myocardial dysfunction had significantly increased titers of autoantibodies to TrM-03 — 17.0 ± 1.8, 10.7 ± 1.2 and 7.0 ± 0.6 conv. units; PAPP-A — 52.2 ± 3.1, 14.0 ± 1.1 and 8.0 ± 0.7 conv. units; ANCA — 24.6 ± 2.1, 12.2 ± 0.7 and 6.0 ± 0.4 conv. units, eNOS — 14.96 ± 1.3, 6.0 ± 0.4 and 9.5 ± 0.4 conv. units compared with the same parameters of patients without systolic myocardial dysfunction. The results of the correlation analysis reveal the relationship between high titer of vasculotropic autoantibodies and changing parameters of hemovascular homeostasis.

Conclusions. In elderly CHD patients with clinically distinct chronic heart failure and ejection fraction < 45 %, compared to chronic CHD patients without chronic heart failure, revealed an expressive endothelial dysfunction of vascular microcirculation, according to the test with reactive hyperemia, which is associated with increased aggregation of platelet activity, increased blood viscosity and titer of vasculotropic autoantibodies to TrM-03, PAPP-A, ANCA, eNOS. Titers of vasculotropic autoantibodies correlate with an increased blood viscosity in microvessels, adrenaline-induced aggregation and reduced rates of flow in the microcirculation vessels in conditions of cuff sample.

Keywords: chronic heart failure, functional state of the endothelium, platelet aggregation activity, blood viscosity, capillary reserve, vasculotropic autoantibodies.



Pulmonary hypertension associated with systemic sclerosis

L. F. Konopleva, S. H. Ter-Vartanyan, D. A. Reshotko, N. V. Shebeko, L. S. Alexeeva

The lecture deals with the issue of distribution, diagnosis, clinical manifestations and treatment of pulmonary hypertension (PH) in patients with systemic sclerosis (SS), in which its prevalence, according to different authors, is 9 — 65 %. The mortality rate for these patients at the advanced stage of the disease reaches 40 %. The current theories of pathogenesis of LH are based on endothelial dysfunction which leads to increased synthesis of vasoconstrictors, decreased activity of NO-synthase, vascular remodeling of the pulmonary circulation, increase in pulmonary vascular resistance and right ventricular dysfunction. PH has no pathognomonic signs, and in the early stages it is not clinically diagnosed. Early diagnosis requires annual echocardiography of SSc patients including those who are asymptomatic. Catheterization of the right part of the heart is the gold standard of confirming the diagnosis, assessing the severity of the pathology and denying the pathology of the left heart. Drug therapy for PH in patients with SS is similar to that for idiopathic PH (calcium channel blockers with mandatory vasoreactive test before their administration, prostanoids, endothelin antagonists, inhibitors of PDE-5), but today the effectiveness of treatment and remote prognosis for such patients are still not good enough. The lecture describes two clinical cases of PH associated with SS observed by the authors.

Keywords: pulmonary hypertension, pulmonary arterial hypertension, systemic sclerosis, systemic connective tissue disease, endothelial dysfunction.



Modern antiplatelet therapy in patients with cardiovascular disease

I. I. Kobza, T. B. Rudyk, T. I. Kobza

Modern approach to antiplatelet therapy in cardiovascular disease involves the use of multiple antiplatelet means with different mechanisms of blocking the platelet activity. The formation of such a strategy is based on a long search of effective and safe drugs of antiplatelet action and selecting their combinations. The authors reviewed the recent world literature representing the experience of using various options of antiplatelet therapy in patients with cardiovascular disease. Frequent development of resistance to aspirin and clopidogrel requires finding new safe and effective antiplatelet therapy. Cilostazol is virtually the only drug that has a large evidence base for the treatment of intermittent claudication. A number of studies have confirmed the benefits of cilostazol over other desagregants in the prevention of restenosis both after reconstructive operations on the arteries and after stenting. Positive effect of the drug on the progression of atherosclerosis, secondary prevention of cardiovascular events (myocardial infarction, stroke), the consequences of stroke, critical limb ischemia and lipid metabolism requires further study.

Keywords: antiplatelet therapy, cardiovascular disease, cilostazol.



Deformations of internal carotid arteries: problems of etiology, pathogenesis and morphologenesis

D. D. Zerbino, Yu.I. Kuzyk

This review analyzes literature on the etiology, pathogenesis, clinical and pathomorphological manifestation of innate and acquired deformations of internal carotid arteries (DICA) and strategy of treatment of patients. We discussed questions of onset and development of deformations of vessels in children, younger and elderly persons. Congenital DICA leading to coiling, C- and S-tortuosity of these vessels are genetically determined diseases associated with disembryogenetic disorders. Violations of muscular and elastic structure of vessels underlie them. Typical clinical manifestations of the pathology include seizures. Transient cerebrovascular violations and ischemic stroke are extremely rare. Secondary degenerative vascular changes, such as atherosclerosis, arteriolosclerosis, hypertension, and possibly chronic exposure to toxic substances and neck injuries are the basis of acquired DICA. Typical types of deformations are kinking, elongation and angulations. Morphologically they are revealed by fibrosis adventitia, media and less often — by intima with changed elastics and angiitis vasa vasorum. They occur predominantly in women after 60 years. Clinically they are detected as transient stroke, ischemic stroke, which leads to their poor prognosis. A working hypothesis has been offered of innate and acquired DICA, which takes into account all known and possible causes and risk factors for pathological tortuosity. The hypothesis, however, requires further research, supplements and evidence of the legality of its existence.

Keywords: internal carotid artery, carotid deformation, kinking, tortuosity, coiling, cerebrovascular deficiency.



Changes in hemostatic system and gene polymorphisms of platelet glycoprotein IIb/IIIa in patients with coronary heart disease

L. N. Prystupa, I. I. Savenko

According to the current understanding, the pathogenesis of coronary heart disease includes a separate link — coronary thrombosis at the place of plaque rupture, impaired hemostasis, leading to increased intravascular coagulation and thrombosis. Primary thrombosis in the area of vascular damage is caused by gradual processes: the adhesion of platelets and their activation and aggregation. After activation, platelets may enter a process of aggregation with each other and create a platelet thrombus. Hemostatic platelet link activation in combination with the processes of atherogenesis may lead to the development of cardiovascular complications. Gene’s polymorphism plays an important role in thrombogenesis, particularly in polymorphism of platelet glycoprotein IIb/IIIa which encodes the hemocoagulation and fibrinolysis factors and affects platelet aggregation. In this context, candidate genes have been selected that are involved or could potentially be involved in the pathogenesis of coronary artery disease and modification of antithrombotic therapy.

Keywords: coronary heart disease, platelets, polymorphism, glycoprotein receptors, antiplatelet therapy, aspirin resistance.



Malignant mesothelioma of pericardium

V. V. Kostyushov, V. V. Selivanov, I. I. Bokal

The paper presents the clinical observation of malignant mesothelioma of the pericardium diagnosed during the patient’s life. We describe the complaints, anamnesis of the disease and features of its clinical course. The results of X-ray and computer studies of the chest, abdomen and pelvis, complete blood count and basic biochemical parameters have been presented. The results of cytological examination of the pleural fluid and pericardium confirmed iron complexes with malignant epithelial cells in these fluids. The case of clinical observation is of interest to practitioners.

Keywords: malignant mesothelioma of pericardium, haemopericardium, clinical course, diagnosis, prognosis.



Differentiated approach to treatment of patients with atherosclerotic occlusive stenotic defeat of aortoiliac segment

Ye. Yu. Hardubey, I. S. Polinchuk, Yu. V. Sidorko

Purpose — to improve the results of surgical treatment of patients with bilateral atherosclerotic lesions of aortoiliac segment (ALS) by developing a differentiated approach depending on the stage of ischemia and the nature of localization of the atherosclerotic process.

Materials and methods. The study is based on data of surgical treatment of 115 patients divided into two groups. 1st group consisted of 64 (55.6 %) patients who underwent bilateral reconstruction of the ALS, and 2nd — of 51 (44.4 %) patients with unilateral reconstruction with the same type of lesion.

Results and discussion. It has been proved that unilateral reconstruction can be performed in case of the occlusion of the iliac arteries or critical stenosis on one side with a distinct collateral blood flow and ischemia of exertion only on this side. After this reconstruction, parameters of regional blood flow (regional systolic blood pressure, blood flow velocity, malleolar-brachial index) were analyzed and no signs of steal syndrome of the lower extremity were revealed. Administration of antiplatelet and lipidlowering therapy to patients with atherosclerotic lesions of the ALS in the postoperative period is appropriate and allows significant (p < 0.05) reduction of mortality and number of amputations with mortality from 20.0 % (negative compliance) to 8.7 % (those who took drugs).

Conclusions. Thus, the introduction of a differentiated approach depending on the stage of ischemia and the nature of localization of the atherosclerotic process can lead to improvement of immediate and long-term results of complex treatment of patients with lower limb preservation and survival in 72 % in case of bilateral reconstructions and in 86.1 % — in case of unilateral reconstructions in the fifth year of observation.

Keywords: aortoiliac segment, complex treatment, complications.



Эффективность унифицированного пошагового алгоритма лечения для обеспечения контроля артериального давления у больных с артериальной гипертензией в амбулаторной практике: результаты исследования ПЕРФЕКТ

Е. Н. Амосова, Ю. В. Руденко, О. И. Рокита, И. Ю. Кацитадзе

Цель работы — определить эффективность «Программы по оптимизации контроля артериального давления у больных с артериальной гипертензией», которая бы предусматривала унифицированный пошаговый упрощенный алгоритм антигипертензивной терапии на базе фиксированной комбинации амлодипина и периндоприла, корректного домашнего мониторирования артериального давления и образовательных материалов для пациентов по достижению целевого офисного и нормального домашнего артериального давления (АД) у больных с неосложненной артериальной гипертензией (АГ) и повышения их приверженности к лечению в общей амбулаторной практике врача-кардиолога.

Материалы и методы. В открытом проспективном исследовании ПЕРФЕКТ приняли участие 53 амбулаторных кардиолога лечебных учреждений Киева, которые включили в исследование 501 пациента в возрасте от 35 до 70 лет (средний возраст 58,0 года ± 0,4 года) с неосложненной эссенциальной АГ, с АД > 160/100 мм рт. ст. у лечившихся ранее или ≥ 140/90 мм рт. ст. у нелечившихся. В течение 6 мес проводили шесть визитов и два дополнительных по необходимости. Во время первого визита врач определял АД с помощью стандартизированного автоматического прибора Microlife BPW200 с универсальной манжеты. Больного обеспечивали осциллометрическим автоматическим прибором Microlife BP3AG1, обучали им пользоваться, проводили беседу по модификации образа жизни и назначали фиксированную комбинацию периндоприла и амлодипина («Би-Престариум», «Сервье», Франция) в дозе 5/5, 5/10, 10/5 или 10/10 мг по выбору врача (1-й шаг). Перед каждым последующим визитом больной 7 сут дважды в день самостоятельно измерял АД и фиксировал результаты в дневнике. В случае недостижения целевого офисного АД ( < 140/90 мм рт. ст.) на последующих визитах повышали дозу «Би-Престариума» до максимально переносимой (2-й шаг) и последовательно назначали индапамид-ретард («Арифон-ретард», «Сервье», Франция) по 1,5 мг/сут (3-й шаг), спиронолактон по 25 мг 2 раза в сутки (4-й шаг), моксонидин в дозе от 0,2 до 0,6 мг/сут или доксазозин по 4 — 8 мг/сут (5-й шаг). У больных, которые получали антигипертензивную терапию до включения в исследование, во время первого визита, а у всех больных на заключительном визите оценивали приверженность к лечению с помощью анкеты (X. Girerd и соавт., 2001). Оценку эффективности лечения проводили по первичным конечным точкам: количество больных, достигших целевого уровня офисного АД через 6 мес наблюдения и больных с «нормальным» домашним АД ( < 135/85 мм рт. ст.) и вторичными конечными точками: изменения в приверженности к лечению и частота побочных эффектов антигипертензивной терапии.

Результаты и обсуждение. Исследование закончил 431 (86 %) больной в возрасте в среднем (57,3 ± 0,5) года, в том числе 191 (44,3 %) мужчина, 93 (22 %) из них с АГ 3-й степени. Через 6 мес среднее систолическое офисное АД снизилось с (165,8 ± 0,8) до (130,9 ± 0,5) мм рт. ст., диастолическое — с (97,2 ± 0,5) до (79,2 ± 0,4) мм рт. ст. (все р < 0,0001). Целевое офисное АД достигнуто у 82,8 % больных, в том числе 69,9 % пациентов с АГ 3-й степени, целевое офисное и нормальное домашнее АД — у 63,1 %. Низкий уровень приверженности лечению имел во время первого визита 181 (50,7 %) больной, на заключительном — 25 (7 %), высокий — 92 (25,8 %) и 178 (49,9 %) соответственно (все р < 0,001).

Выводы. Применение у больных с неосложненной АГ пошагового алгоритма лечения на основе фиксированной комбинации периндоприла и амлодипина вместе с контролем домашнего АД и образовательной программой в амбулаторной практике врачей-кардиологов позволило достичь через 6 мес лечения целевого уровня офисного АД у 82,8 % пациентов с АГ, в 63,1 % случаев снизилось домашнее АД до нормального уровня (≤ 135/ 85 мм рт. ст.). Такой подход позволил увеличить частоту высокой и умеренной приверженности пациентов к лечению, по данным анкеты X. Girerd, до 93 %, или на 43,7 % по сравнению с исходной.

Keywords: эссенциальная артериальная гипертензия, целевое артериальное давление, периндоприл, амлодипин, фиксированная низкодозовая комбинация, приверженность к лечению.



Прогнозирование исхода реваскуляризации конечности при критической ишемии по реактивности микроциркуляторного русла стопы

В. Н. Пшеничный, Ю. В. Родин

Цель работы — разработать неинвазивную методику прогнозирования исхода реваскуляризирующих операций у больных с хронической критической ишемией нижних конечностей (ХКИНК).

Материалы и методы. Проанализирован опыт обследования и хирургического лечения 76 больных с атеросклеротическими окклюзиями артерий бедренно-подколенного сегмента в различных сочетаниях. 37 больным выполнены инфраингвинальные реконструкции артерий, 20 — двухэтажные реконструкции артерий аорто-подвздошного и бедренно-подколенного сегментов и 19 — поясничные симпатэктомии. В предоперационный период всем пациентам, кроме рутинных методов исследований, проходимость плантарной артериальной дуги оценивали с помощью транскутанного оксигенометра ТСМ 2 («Radiometr», Дания).

Результаты и обсуждение. У 88 % пациентов причиной хронической критической ишемии нижних конечностей явилось сочетанное поражение нескольких артериальных сегментов, включая артерии аорто-подвздошного и бедренно-подколенного и берцово-стопного сегментов в различных сочетаниях. Кроме того, почти у 70 % оперированных больных не было четкой ангиографической информации о состоянии тыльной или подошвенной артериальной дуги стопы. Мы изучили результаты исследования базальной микроциркуляции и ортостатического теста при полярографии у 76 пациентов с ХКИНК с сомнительным состоянием дистального русла, по данным ангиографии. Благоприятный результат оперативного лечения (регресс ишемии конечности и функционирование зоны реконструкции) достигнут у 41 оперированного. У 35 пациентов клинического и гемодинамического улучшения состояния конечности не наступило. Отмечено, что исходное базальное напряжение кислорода (TcpO2) в коже стопы у оперированных пациентов с благоприятным и неблагоприятным результатами достоверно не отличалось (7,4 мм рт. ст. ± 2,6 мм рт. ст. по сравнению с 8,2 мм рт. ст. ± 1,4 мм рт. ст.; p = 0,2). Ортостатический прирост pO2 более 20 мм рт. ст. позволял достоверно прогнозировать благоприятный исход инфраингвинальных реконструкций (р = 0,001) и поясничной симпатэктомии (р = 0,01), но он был недостоверный при двухэтажных реконструкциях артерий аорто-подвздошного и бедренно-подколенного сегментов нижних конечностей (р = 0,09). Отрицательный прогноз оперативного вмешательства по данным ортостатической пробы при транскутанной оксигенометрии оказался достоверным у 84,4 %, а положительный — у 87,5 % больных.

Выводы. Анализ микроциркуляции с помощью ортостатического теста при транскутанной оксигенометрии помогает прогнозировать результат лечения и выбрать оптимальный метод реваскуляризации нижних конечностей при критической ишемии.

Keywords: хроническая критическая ишемия нижних конечностей, реконструктивная хирургия, транскутанная оксигенометрия, прогнозирование.

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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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