Vol 81, No 5 (2009)


Evgeny Ivanovich Chazov - the 80th anniversary of birth

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Terapevticheskii arkhiv. 2009;81(5):6-8
pages 6-8 views

Medical care in the past and present: losses and gains

Chazov E.I., Chazov E.I.
Terapevticheskii arkhiv. 2009;81(5):9-13
pages 9-13 views

Atherosclerosis: disputable and unsolved problems in the first decade of the XXI century

Kukharchuk V.V., Kukharchuk V.V.


The end of the XX century brought the discovery of the mechanism regulating cholesterol metabolism in humans and understanding of the cause of family hypercholesterolemia. Statins, introduced in early 1990es, failed to solve all the problems of atherosclerosis. Statins reduce blood cholesterol, but can also suppress activity of inflammation in the vascular wall, activity of peroxidation, can block proliferation of smooth muscular cells. The role of all these mechanisms should be carefully investigated as well as efficacy of innovative drugs.
Terapevticheskii arkhiv. 2009;81(5):14-19
pages 14-19 views

Spontaneous reperfusion of infact-related artery in patients with ST elevation myocardial infarction

Ruda M.Y., Kuz'min A.I., Merkulova I.N., Samko A.N., Merkulov E.V., Sozykin A.V., Akasheva D.U., Ruda M.Y., Kuzmin A.I., Merkulova I.N., Samko A.N., Merkulov E.V., Sozykin A.V., Akasheva D.U.


Aim. To characterize a clinical course of ST elevation myocardial infarction (STEMI) and spontaneous reperfusion of the coronary arteries (SR) as well as in patients after reperfusion trombolytic therapy (TLT) and/or transluminal ballon coronary angioplasty (TBCA); to compare effectiveness of different approaches to treatment of SR patients: conservative - early medication and active - TBCA on the first postmyocardial 24 hours. Material and methods. We studied 479 patients admitted to hospital not later than 6 hours since STEMI onset and either having SR (n = 49) or treated using active methods of coronary circulation restoration - prehospital thrombolysis (n = 127), thrombolysis after hospitalization (n = 127), primary TBCA (n = 60) and TBCA after initiation of TLT (n = 116). We made a more detailed analysis on the sample of 149 SR patients. Results. SR was diagnosed in 10.2% cases with STEMI and occurred much earlier than recovery of coronary circulation due to TLT and/or TBCA. Patients with SR developed Q-MI, right ventricular infarction, cardiac failure and atrioventricular block less frequently. They had the lowest peak activity of creatin phosphokinase and a higher left ventricular ejection fraction versus patients without SR (50.7 ± 6.8 and 45.4 ± 6.6%, respectively; p < 0.05). As showen by coronaroangiography, SR patients had no"no reflow" phenomenon (0% and 17%, respectively). Active policy of SR patients treatment had no significant advantages over conservative treatment. Conclusion. Early SR had more favourable course of MI, less mass of the affected myocardium and better contractile function of the left ventricle. The conservative policy of STEMI treatment in the presence of SR is more effective than the active one if a due control over the patients' condition is provided.
Terapevticheskii arkhiv. 2009;81(5):20-29
pages 20-29 views

N-terminal fragment of the brain natriuretic peptide and proinflammatory cytokines in patients with coronary heart diseas

Shalaev S.V., Volkova S.Y., Shalaev S.V., Volkova S.Y.


Aim. To determine plasmic concentrations of NT-proBNP, TNFalpha and IL-6 in patients with coronary heart disease (CHD) complicated with chronic cardiac failure (CCF); to compare these parameters with hemodynamic and functional ones. Material and methods. A total of 157 CHD patients (84.1% males, mean age 54.3 ± 6.8 years) were divided into 3 groups matched by sex and age according to the presence of CCF and left ventricular (LV) or systolic dysfunction. Results. CCF patients with LV dysfunction or intact LV function had much higher plasmic concentrations of neurohumoral mediators than CHD patients without CCF. A plasmic NT-proBNP level over 1000 fmol/ml was associated with a 5.5-fold increase in the relative risk of LV diastolic dysfunction for CCF patients (rR 5.6; 95% CI 1.4-30.0; p = 0.0065) while an IL-6 level over 6.1 pg/ml was associated with a 9-fold increase in this risk (rR 8.9; 95% CI 2.3-35.4; p = 0.00001). Plasmic NT-proBNP and IL-6 levels went up in correlation with a CCF functional class. A plasmic level of TNFalpha correlated with anginal functional class. Conclusion. Changes in plasmic levels of the above neuromediators are associated with changes in some LV function and functional parameters of CCF patients.
Terapevticheskii arkhiv. 2009;81(5):30-35
pages 30-35 views

Drug-eluting stents: long-term safety

Karpov Y.A., Samko A.N., Buza V.V., Karpov Y.A., Samko A.N., Buza V.V.


The review concerns the problem of late thromboses of drug-eluting stents and their influence on late prognosis of the patients; presents long-term results of the trial of sirolimus-eluting stents implanted to patients with coronary heart disease; analyses mechanisms of development of late stent thrombosis, data from different meta-analyses and registers comparing long-term outcomes in patients with implanted sirolimus-eluting stents and metallic stents; suggests risk factors of late thromboses of drug-eluting stents; presents original evidence on 3.5-year follow-up of patients with implanted sirolimus-eluting stents and metallic stents.
Terapevticheskii arkhiv. 2009;81(5):36-40
pages 36-40 views

Difficulties in evaluating the efficacy of antiplatelet therapy in clinical practice

Buryachkovskaya L.I., Uchitel' I.A., Sumarokov A.B., Popov E.G., Buryachkovskaya L.I., Uchitel I.A., Sumarokov A.B., Popov E.G.


Aim. To evaluate platelet activity changes in patients with coronary artery disease (CAD) treated with aspirin, clopidogrel and combination of these drugs; to estimate the rate of resistance of CAD patients to antiplatelet treatment. Material and methods. 199 patients with stable CAD were included in the study. Of them, 83 were given aspirin, 46 received clopidogrel, 34 - double antiplatelet therapy (both aspirin and clopidogrel). The trial also studied an additional group of 18 CAD patients on double antiplatelet therapy who had hemorrhages. The control group consisted of 25 healthy volunteers. Platelet aggregation was measured both by a mean size of aggregates (MSA) and light transmission (LTM, Born method) using BIOLA platelet aggregation analyzer. A platelet shape, leukocyte-platelet aggregates (LPA) and erythrocyte-platelet aggregates (EPA) in the whole blood were studied using scanning electron microscopy. The levels of IL-6 and sVCAM were also measured. Results. It was found that 59.8% patients with CAD had high platelet reactivity revealed in 94.9% of cases by measuring spontaneous and induced by 0.1 mcM ADP platelet aggregation. LTM revealed increased platelet reactivity only in 10.7% patients. Resistance to aspirin correlated with the presence of LTA (r = 0.629, p = 0.0001) and the number of large "reticulated" platelets (r = 0.334, p = 0.001). Low platelet reactivity was associated with the presence of circulating EPA (r = -0.362, p = 0.008). Administration of clopidogrel did not decrease platelet reactivity to normal levels in 34.7% patients which correlated with the presence of LPA and EPA. In 83.3% patients with hemorrhages platelet aggregation, induced by 5.0 mcM, ADP was dramatically decreased. Conclusion. Resistance to antiplatelet therapy is related to platelet heterogeneity, the presence of inflammation and state of erythrocytes. LT is capable to reveal only a part of patients resistant to antiplatelet drugs. To fully identify these patients, it is necessary to register spontaneous platelet aggregation and aggregation induced by low doses of ADP. Redundant inhibition of platelet reactivity could be the cause of hemorrhagic events.
Terapevticheskii arkhiv. 2009;81(5):41-46
pages 41-46 views

Controlling blood pressure: how well are we doing?

Lanfan K., Lenfant C.


The author analyses global prevalence of arterial pressure and its impact on population mortality and disability, draws attention to insufficient efficacy of this disease treatment, low awareness of the population about this disease and compliance of the patients. To achieve target arterial pressure, cooperation is necessary between the physician and the patient.
Terapevticheskii arkhiv. 2009;81(5):47-49
pages 47-49 views

The role of atherosclerosis risk factors in development of coronary artery disease in young men

Ezhov M.V., Afanas'eva O.I., Kambegova A.A., Afanas'eva M.I., Trukhacheva E.P., Naumov V.G., Pokrovskiy S.N., Ezhov M.V., Afanasyeva O.I., Kambegova A.A., Afanasyeva M.I., Trukhacheva E.P., Naumov V.G., Pokrovsky S.N.


Aim. To determine distribution of different atherosclerosis risk factors and their correlation with severity of coronary arteries (CA) affection in young men. Material and methods. A total of 235 males aged 28-45 years were examined with coronarography which detected more than 50% narrowing in one or several major CA in 200 patients (the study group with coronary artery disease), 35 males without coronary stenosis served control. Atherosclerosis risk factors, serum lipids, lipoprotein(a), fibrinogen, C-reactive protein (CRP) were assessed. Results. Smoking and hyperlipidemia (HLE) were registered in the study group more frequently. The level of lipoprotein(a) above 30 mg/dl was recorded in 98 (49%) and 7 (20%) patients of the study and control group, respectively (p = 0.001). As shown by a correlation analysis, the number of affected CA was associated with smoking (r = 0.2; p < 0.001), HLE (r = 0.23; p < 0.001), concentration of total cholesterol (r = 0.23; p < 0.0.001), lipoprotein (a) (r = 0.26; p < 0.001) and CRP (r = 0.26; p < 0.05). The level of lipoprotein(a) in patients with myocardial infarction and occluded artery was significantly higher than in patients without myocardial infarction and non-occlusive CA affection. Conclusion. The presence and severity of coronary atherosclerosis in young men with coronary artery disease are associated with smoking, HLE and high concentration of lipoprotein (a).
Terapevticheskii arkhiv. 2009;81(5):50-53
pages 50-53 views

Long-term results of coronary endovascular revascularisation with eluting sirolimus-stents in patients with coronary heart disease comorbid with type-2 diabetes mellitus: evidence from 18-month prospective study

Teplyakov A.T., Torim Y.Y., Kuznetsova A.V., Rybal'chenko E.V., Krylov A.L., Karpov R.S., Teplyakov A.T., Torim Y.Y., Kuznetsova A.V., Rybalchenko E.V., Krylov A.L., Karpov R.S.


Aim. To study long-term results of 3-42-month (mean 18.1 ± 1.2 month) of a prospective clinically and angiologically controlled follow-up after coronary endovascular revascularisation with sirolimus-eluting stents (SES) in patients with coronary heart disease (CHD) comorbid with type 2 diabetes mellitus (DM). Material and methods. A total of 108 CHD patients with angina pectoris resistant to antianginal therapy were divided into 2 groups: 51 CHD patients with mild and moderate type-2 DM (group 1); 57 CHD patients free of diabetus (group 2). All the patients have undergone successful coronary endovascular revascularisation with SES. Anti-ischemic efficacy and safety of stenting were studied in the course of 18-month prospective follow-up. Results. An anti-ischemic effect of stenting in hospital setting was achieved in all the patients. 18 months after stenting frequency and severity of anginal attacks reduced in group 1 by 70.6%, daily need in nitroglicerine - by 71.9%, in group 2 - by 87.1 and 93.1%, respectively. As a result, exercise tolerance improved in group 1 by 38.3%, in group 2 - by 40.8%. Quality of life improved by 22.7 and 25.1%, respectively. Most of the patients showed no deterioration of carbohydrate and lipid metabolism compensation. Recurrent angina and symptoms of painless myocardial ischemia occurred in 39.3 and 14% patients of group 1 and 2, respectively. More frequent causes of the recurrence were progression of coronary artery atherosclerosis de novo and Cypher stent restenosis (11.8 and 3.5% in group 1 and 2, respectively). Conclusion. SES implantation provided good anti-ischemic efficacy in 60.7 and 86% CHD patients with and without DM, respectively. It significantly improved exercise tolerance and quality of life.
Terapevticheskii arkhiv. 2009;81(5):54-59
pages 54-59 views

Combined treatment of arterial hypertension (results of the international program CLIP-ACCORD)

Chazova I.E., Ratova L.G., Chazova I.E., Ratova L.G.


Aim. To investigate antihypertensive efficacy and safety of a fixed combination of ACE inhibitor enalapril with thiaside diuretic drug hydrochlorothiaside (HCT) in hypertensive patients with a high and very high risk of cardiovascular complications. Material and methods. The trial has covered 7796 hypertensive patients from 28 cities (42 clinics) of Russia, Ukraine, Belarus and Georgia. All the patients had a high and very high risk of cardiovascular complications. The protocol provides for measurements of clinical arterial pressure, 24-h monitoring of arterial pressure. Diabetic patients' plasma was examined for glucose concentrations. All the patients received enalapril in combination with HCT in doses from 10/6.25 to 40/25 mg/day for 3 months. Results. After 3 month treatment target systolic arterial pressure (SAP) was achieved in 81% patients, diastolic pressure (DAP) - in 88%, by SAP and DAP - 77%. By 24-h blood pressure monitoring, 24-h, diurnal and nocturnal blood pressure significantly decreased in 60 patients. Target 24-h blood pressure was achieved in 78% patients. Pressure load parameters lowered significantly for SAP and DAP for 24 hours, diurnal and nocturnal pressure. Glucose levels in patients with diabetes mellitus (n = 1263) diminished from 7.3 to 6.4 mmol/l (p < 0.0001). Conclusion. A fixed combination of enalapril with HCT was effective in hypertensive patients with a high and a very high risk of cardiovascular complications. It provided a target level of blood pressure in 77% patients and significantly reduced SAP, DAP and PAD.
Terapevticheskii arkhiv. 2009;81(5):60-63
pages 60-63 views

Effects of renin-angiotensin system blockers on left ventricular hypertrophy and biochemical markers of collagen balance in patients with hypertensive hypertrophy

Ovchinnikov A.G., Serbul V.M., Ageev F.T., Ovchinnikov A.G., Serbul V.M., Ageev F.T.


Aim. To evaluate the effect of ACE inhibitor enalapril, AR blocker candesartan and their combination on left ventricular hypertrophy (LVH) and content of biochemical markers of collagen balance in patients with hypertensive LV hypertrophy. Material and methods. A total of 66 patients with arterial hypertension with LV hypertrophy were divided into two groups. Group 1 (n = 33) received candesartan (8-16 mg/day), group 2 (n = 33) received enalapril (10-20 mg/day). In effective hypotensive response to the initial treatment, it was continued for 6 months. If in two months of monotherapy the effect was unsatisfactory, the other drug was added. At baseline and upon 6 months of treatment all the patients were examined for myocardial mass index (MMI), matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of matrix metalloproteinase-1 (THMP-1) in the blood. Results. In effective initial treatment with candesartan 6-month treatment lowered LV MMI by 13.9%, while in enalapril group - only by 1.5%. In addition of the second drug in ineffective initial therapy the reduction was 5.1%. THMP-1 did not change during the trial. Conclusion. In patients with hypertensive LVH candesartan more effectively treated LVH. The addition of the second RAS blocker in insufficient efficacy of the initial one significantly reduces LV MMI. A significant antifibrotic effect was achieved only in case of simultaneous use of two RAS blockers.
Terapevticheskii arkhiv. 2009;81(5):64-70
pages 64-70 views

Contribution of neurohumoral dysfunction and overweight to the course of essential hypertension

Bunova S.S., Bunova S.S.


Aim. To determine the role of neurohumoral dysfunction and overweight in a clinical course of arterial hypertension (AH). Material and methods. 200 participants of the study aged 30-60 years with AH degree I-II with low, moderate and high overall cardiovascular risk and mean disease duration 11.1 ± 9.5 years were examined for body mass index, levels of leptin, soluble leptin receptor, insulin, serotonin and adrenoreactivity. Results. Neurohumoral dysfunction correlated with body mass index. It manifested with elevation of insulin and leptin levels, sympathetic hyperactivity and a decrease of serotonin. Conclusion. One of the mechanisms forming and sustaining AH in patients with overweight is leptin-dependent sympathetic hyperactivity while serotonin system activation is more important for patients with normal body weight. Hypertensive patients with obesity demonstrate insulin-dependent hyperleptinemia.
Terapevticheskii arkhiv. 2009;81(5):71-74
pages 71-74 views

Heart rate variability in patients with neurocardiogenic syncopes

Abdrakhmanov A.S., Abdrakhmanov A.S.


Aim. To investigate chronotropic heart regulation and prognostic significance of heart rate variability (HRV) in patients with neurocardiogenic syncopes (NCS). Material and methods. A total of 90 patients (25 healthy controls and 65 patients with documented HRV, mean age 33.9 ± 17.4 years) were divided into 3 groups depending on an NCS type (cardioinhibitory, n = 18; vasodepressive, n = 25; mixed, n = 22). All the examinees have undergone a long-term passive head-up tilt table test with registration and analysis of HRV. Results. A cardioinhibitory NCS variant was characterized by slow heart rate (both at rest and test), increased mode amplitude - Amo (by 28, 1, 21, 6 and 46.8% at rest, tilt test, in rehabilitation, respectively), range of deviation (RD) (by 47, 1, 62, 5 and 52.9%, respectively). A simultaneous rise of indices characterizing activity of the sympathic and parasympathic parts of the autonomic nervous system led to the absence of significant differences of the integral parameters (Amo/RD; index of regulatory system tension) vs control. Still more marked changes in the indices of cardiovascular vegetative regulation were registered in a vasodepressive NCS, but the differences with the control were moderate. Vegetative tonicity and reactivity in mixed NCS represent an intermediate variant between cardioinhibitory and vasodepressory types. Conclusion. In NCS patients circadian HRV was less than in the controls. The parasympathic tonicity prevails in all NCS types. Moreover, NCS is affected by episodes of activation of sympathico-adrenal system. Typical HRV in different NCS variants allows using this method for their diagnosis, prognosis and follow-up of the patients.
Terapevticheskii arkhiv. 2009;81(5):75-77
pages 75-77 views

The thrombolysis in myocardial infarction (TIMI) study group experience

Braunval'd E., Braunwald E.


The article presents the history of development of various methods of reperfusion therapy in myocardial infarction. The method of intracoronary thrombolysis was developed and used in Russia in 1976. In 1984 the TIMI Study Group initiated large-scale long-term trial of thrombolytic therapy in myocardial infarction and unstable angina pectoris. Some basic results of the study are outlined.
Terapevticheskii arkhiv. 2009;81(5):78-83
pages 78-83 views

Fozinopril in the treatment of cardiorenal syndrome in chronic cardiac failure

Tereshchenko S.N., Zhirov I.V., Tereschenko S.N., Zhirov I.V.


Renal dysfunction is an independent risk factor of chronic cardiac failure (CCF) and death due to this disease. CCF patients are elderly patients with diabetes mellitus, arterial hypertension and long-term chronic cardiac insufficiency. CCF patients do not often have left ventricular systolic dysfunction, renal affection is not associated with low ejection syndrome. Renal affection in CCF is primarily caused by activation of the system rennin-angiotensin, inflammation, disturbed bioavailability of nitric oxide, hyperactivation of the sympathetic nervous system. ACE inhibitors correct pathophysiological disorders of renal flow in CCF. Fosinopril shows the highest efficacy and safety in management of cardiorenal syndrome in CCF patients. Fosinopril can alsoprevent renal dysfunction in CCF patients.
Terapevticheskii arkhiv. 2009;81(5):84-87
pages 84-87 views

Prophylaxis of cardiovascular diseases in rheumatoid arthritis

Novikova D.S., Popkova T.V., Nasonov E.L., Novikova D.S., Popkova T.V., Nasonov E.L.


One of the key causes of lethality in rheumatoid arthritis (RA) are cardiovascular catastrophes (myocardial infarction, stroke, sudden cardiac death) resultant from early development and rapid progression of atherosclerotic vascular lesion. The article presents current approaches to prevention of cardiovascular diseases in RA including assessment of overall cardiovascular risk for design of optimal strategy of correction of modification factors increasing probability of cardiovascular complications, strong control over inflammation and adequate use of drugs which may be harmful (glucocorticosteroids, nonsteroid anti-inflammatory drugs). Much attention is paid to perspectives of ACE inhibitors, angiotensin II receptor blockers, statins, TNFalpha inhibitors in prevention of cardiovaskular complicatoin in RA
Terapevticheskii arkhiv. 2009;81(5):88-88
pages 88-88 views

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