Vol 82, No 4 (2010)


Arterial hypertension and hypertensive disease (syndromic diagnosis and nosological syndrome)

Gogin E.E., Gogin E.E.


Fundamental innovations in the study of the regulatory mechanisms of circulation in the past 20-30 years (evidence for the role of the endothelium in local hemodynamic control, the basic significance of the tissue (paracrine) link of the angiotensin mechanism of not only as a vasoconstrictor, but also a trigger of a slow pressor component that leads to resistance bed arterial remodeling) have required the concept of the pathogenesis of hypertensive disease (HD) (essential hypertension) to be reconsidered, confirmed its qualificational (nosological) isolation (by the criterion of the presence of an attributive functional and structural sign). The new refined and concrete information on the pathogenesis of HD and its associated cardiovascular disease has shown to give doctors reliable landmarks to optimize drug therapy: both symptomatic (to accelerate effective blood pressure control) and basic (to eliminate endothelial dysfunction and to restore remodeled arteries and microcirculation) therapies.
Terapevticheskii arkhiv. 2010;82(4):5-10
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Diagnosis of moderate and high hypertriglyceridemia in patients in polyclinic practice: primary and secondary lipid metabolic disturbances

Rozhkova T.A., Titov V.N., Amelyushkina V.A., Yarovaya E.B., Malyshev P.P., Meshkov A.N., Kukharchuk V.V., Rozhkova T.A., Titov V.N., Amelyushkina V.A., Yarovaya E.B., Malyshev P.P., Meshkov A.N., Kukharchuk V.V.


Aim. To define clinical and biochemical differences in groups of patients with moderate (m4.5 mmol/l and high (more than 4.5 mmol/l) blood triglyceride (TG) levels. To define the markers of biochemical and lipid parameters that could specify an algorithm for the differential diagnosis and treatment of different forms of hypertriglyceridemia. Subjects and methods. Patients (96 (54%) females) aged 12 to 71 years (median 50 years; quartiles, 41-61 years) with a TG level of more than 2.3 mmol/l and the following diseases: coronary heart disease (CHD) (44.8%), myocardial infarction (13.5%), arterial hypertension (87.9%), xanthomas (36.5%), and a family history of diseases (51%). The diagnosis of hyperlipidemia included a classical algorithm for clinical, biochemical, and clinicogenealogical examinations. Extended biochemical blood analysis, the determination of lipoprotein cholesterol (C), TG, low-density lipoprotein C, lipid electrophoresis, and assay of apolipoproteins A1, B-100, E, and C3 were made. Results. The groups with moderate (m4.5 mmol/l and high (more than 4.5 mmol/l) blood triglycerides showed no differences in age and gender, systolic and diastolic blood pressures, the incidence of coronary heart disease, arterial hypertension, peripheral artery atherosclerosis, cardiac arrhythmias, and xanthomas. There was a significant correlation of high TG levels with smoking (a risk factor) and with the indicators of other metabolic disturbances - total C, chylomicrones, lipoprotein(a), LP-E-total, LP B:E, LP-C3-total, and LP-C3, which determined the impact of nutrition (and the development of pancreatitis), but also had a hereditary predisposition through the polygenic mechanisms of gene expression under the influence of a number of factors. Conclusion. Higher TG levels correlated with the parameters, the diagnosis of which makes it possible to reveal additional metabolic disturbances via environmental and polygenic mechanisms.
Terapevticheskii arkhiv. 2010;82(4):10-17
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Secondary repolarization changes in patients with left ventricular hypertrophy

Blinova E.V., Ryabykina G.V., Sakhnova T.A., Blinova E.V., Ryabykina G.V., Sakhnova T.A.


Aim. To estimate the detection rate of tension syndrome and nonspecific repolarization changes in patients with arterial hypertension (AH). Subjects and methods. The electrocardiograms of 234 patients with AH (104 males and 130 females) were analyzed, by taking into account the magnitude of blood pressure (BP) elevation, the degree of an overall cardiovascular risk, the grade of hypertensive disease (HD), the presence of coronary heart disease (CHD), as well as echocardiographic and electrocardiographic voltage criteria for left ventricular hypertrophy (LVH). Results. The classical tension syndrome and nonspecific repolarization changes were observed in 7 and 26% of cases, respectively; no significant differences were found in their detection rates between the males and females. The frequency of repolarization changes were associated with the presence of CHD in the women and with the magnitude of BP elevation, the degree of a cardiovascular risk, the grade of HD, and the presence of both echocardiographic and electrocardiographic signs of LVH. Conclusion. Ventricular repolarization changes in patients with AH are a sign of severe cardiac lesion and determine the need for meticulous attention.
Terapevticheskii arkhiv. 2010;82(4):17-22
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The clinical and functional evaluation of cardiac electrical instability in patients with silent myocardial ischemia

Tatarchenko I.P., Pozdnyakova N.V., Morozova O.I., Zaytseva A.V., Tatarchenko I.P., Pozdnyakova N.V., Morozova O.I., Zaitseva A.V.


Aim. To study markers of myocardial electrical instability in patients with coronary heart disease (CHD) during silent myocardial ischemic episodes. Subjects and methods. Eighty-two patients with stable CHD (mean age 62.6 ± 5.4 years) were examined. In addition to standard physical examination, a complex of their study comprised 12-lead electrocardiography (ECG), Holter ECG monitoring, exercise testing, echocardiography, average signal (AS) ECG recording with identification of late ventricular potentials (LVP), analysis of cardiac rhythm variability (CRV), and estimation of QT interval duration. Results. The study revealed that a combination of Holter ECG monitoring and exercise testing (bicycle ergometry) was required to diagnose silent CHD and to evaluate functional condition severity. Diurnal myocardial ischemia and the number of silent ischemic episodes were found to associate with AS-ECG readings, QT interval dispersion, and LF/HF ratio. In patients with silent CHD, the incidence of Q-wave myocardial infarction and the frequency of high-grade ventricular premature beats were higher, late ventricular potentials were more frequently found, and autonomic vegetative control of sinus rhythm proved to be more significantly impaired. Conclusion. No pain signal in patients with CHD leads to underestimation of the seriousness of the situation and, accordingly, to inadequate measures for its elimination therefore early diagnosis and correction of silent myocardial ischemia are prognostically important in preventing life-threatening acute manifestations of CHD and arrhythmic complications.
Terapevticheskii arkhiv. 2010;82(4):22-27
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Tissue myocardial Doppler echocardiographic evaluation of right heart function and the level natriuretic peptides in patients with pulmonary hypertension of various etiologies

Andreeva Y.A., Saidova M.A., Martynyuk T.V., Masenko V.P., Chazova I.E., Andreeva Y.A., Saidova M.A., Martynyuk T.V., Masenko V.P., Chazova I.E.


Aim. To study structural and functional changes of the right ventricle (RV) in patients with pulmonary hypertension (PH) of various etiologies and to assess an association of these changes with the levels of natriuretic peptides (NP). Subjects and methods. The study enrolled 102 patients with PH (29 with idiopathic PH (IPH), 15 with PH in the presence of chronic pulmonary thromboembolism (PTE), 18 with HP associated with scleroderma systematica (SS), 13 with PH in the presence of chronic obstructive pulmonary disease (COPD), 15 with PH associated with congenital heart disease, 12 with residual PH and a control group of 21 healthy volunteers. Conventional echocardiography (EchoCG) and tissue myocardial Doppler (TMD) EchoCG were performed. The plasma levels of brain NP (BNP) and atrial NP were measured. Results. Conventional EchoCG revealed the most significant remodeling of the heart and pulmonary artery in patients IPH and the least one in those with COPD. TMD findings suggest that RV diastolic function was most and less significantly impaired in patients with IPH and in those with COPD, respectively, and corresponded to the level of NT-proBNP in patients with PH. In patients with PTE with SS, RV diastolic dysfunction (DD) dominated over systolic ones, the functional class and the level of NT-proBNP being comparable with those in patients with ILH. TMD could reveal RV DD in a larger proportion of patients with PH (in all groups) than could Doppler EchoCG. The ratio of the maximum RV early filling velocity to RV tricuspid valve (TV) ring peak movement rate in early diastole (TV E/EM) corresponded to the levels of NP and the magnitude of cardiac remodeling in patients with PH. ROC analysis revealed the intrinsic separating values of TV E/Em from the mitral ring (MR E/Em) which allowed the patients with higher NT-proBNP levels to be identified with a high sensitivity and a high specificity. An aggregate of factors, such as age, right atrial volume, and PA systolic pressure as shown by conventional EchCG and TMD readings, identified patients with PH and elevated NT-proBNP with 73.3% sensitivity and 90.7% specificity. Conclusion. TMD has advantages over conventional EchoCG in the detection of RV DD associated with elevated NP levels in patients with PH.
Terapevticheskii arkhiv. 2010;82(4):27-34
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Experience in using ultrasonography to detect pulmonary extravascular fluid in patients with heart failure

Grishin A.M., Alekhin M.N., Sidorenko B.A., Grishin A.M., Alekhin M.N., Sidorenko B.A.


Aim. To study the possibilities of ultrasonography to detect abundant pulmonary fluid accumulation, by recording the ultrasound lung comets (ULCs). Subjects and methods. One hundred and forty coronary heart disease patients (aged 68.6 ± 15.7 years) with signs of heart failure: acute left ventricular heart failure (acute left ventricular heart failure (ALVHF) in 19 patients and chronic heart failure (CHF) in 121, were examined. EchoCG, lung X-ray study and ultrasonography (USG) were performed to reveal ULCs on admission and over time. Results. On admission, lung USG recorded multiple ULCs in all patients (n = 15) in the ALVHF group. Repeated lung USG showed a decrease in the amount of ULCs in response to diuretic therapy. In the group of patients with Functional Classes (FC) III-IV CHF (n = 19), primary lung USG indicated multiple and single ULCs in 11 (57.9%). Repeated lung USG demonstrated a decrease in the amount of ULCs in response to diuretic therapy. In the FC I-II CHF (n = 106), primary lung ULCs identified multiple and single ULCs in 12 (11.3%). In the group of 19 apparently healthy individuals, single ULCs were revealed in 3 (15.8%) cases. Conclusion. The decreased number of ULCs in patients with CHF shows a high correlation with the efficiency of diuretic therapy. In patients with CHF, the detection rate of ULCs depends on the severity of CHF.
Terapevticheskii arkhiv. 2010;82(4):35-39
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Exercise echocardiography in patients with stable angina pectoris concurrent with chronic obstructive pulmonary disease: safety, informative value, and performance conditions

Grigor'eva N.Y., Mazalov K.V., Kuznetsov A.N., Grigoryeva N.Y., Mazalov K.V., Kuznetsov A.N.


Aim. To define the safety, informative value, and performance conditions of exercise echocardiography (EchoCG) in patients with stable angina (SA) concurrent with chronic obstructive pulmonary disease (COPD). Subjects and methods. Forty patients aged 45 to 66 years (mean age 54.8 ± 4.9 years) with Functional Class (FC) II-III SA concurrent with COPD and 40 patients aged 46 to 65 years (mean 56.6 ± 4.9 years) with FC II-III SA without COPD were examined. All the patients underwent exercise EchoCG during the chosen therapy. Results. Exercise EchoCG is safe in patients with SA with COPD. To enhance the informative value of this test and to achieve the ischemic threshold in patients of this category require the use of adequate bronchodilator therapy. In this case, the informative value of the technique is 75%. Conclusion. Exercise EchoCG in patients with SA concurrent with COPD may serve as a reliable tool in determining exercise endurance during antianginal, bronchodilator therapy and in assessing its adequacy.
Terapevticheskii arkhiv. 2010;82(4):39-42
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Diagnosis of thromboembolism of the pulmonary artery branches at Tomsk hospitals in 2003-2007 according to autopsy data

Vasil'tseva O.Y., Vasil'tsev Y.S., Vorozhtsova I.N., Drozdov V.F., Krestinin A.V., Karpov R.S., Vasiltsev Y.S., Vasiltseva S.Y., Vorozhtsova I.N., Drozdov V.F., Krestinin A.V., Karpov R.S.


Цель исследования. Изучить частоту и структуру новых случаев тромбоэмболии ветвей легочной артерии (ТЭЛА) среди умерших в стационарах Томска за период 2003-2007 гг. Материалы и методы. Проанализированы протоколы вскрытий и истории болезни всех пациентов (n = 442) с диагностированной прижизненно и/или посмертно ТЭЛА и умерших в стационарах Томска с 01.01.03 по 31.12.07. При проведении системного патолого-анатомического исследования использовали метод полного извлечения органов (полная эвисцерация по Шору). Для расчета колеблемости всех значений использовали дисперсию, при оценке статистических связей - корреляционный анализ. Результаты. Из 442 больных у 217 (50,9%) тромбоэмболия явилась непосредственной причиной смерти, а у 225 (49,1%) усугубила течение основного заболевания. По числу умерших с ТЭЛА I ранговое место принадлежало койкам терапевтического профиля (60,6%), II - хирургическим койкам (26,9%), III - онкологическим (9,1%). Основным источником ТЭЛА, помимо наиболее распространенного тромбоза в системе нижней полой вены (65,1%), в 25,6% явился тромбоз правых полостей сердца. Заключение. Выявленные особенности возникновения новых случаев ТЭЛА в стационарах Томска в 2003-2007 гг. могут стать основой планирования органами здравоохранения мероприятий по улучшению диагностики и совершенствованию лечебной и профилактической помощи при ТЭЛА в лечебно-профилактических учреждениях.
Terapevticheskii arkhiv. 2010;82(4):42-44
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Positron emission tomography in the diagnosis of atherosclerotic plaques in cancer patients

Sergienko V.B., Panchkovskaya E.V., Manukova V.A., Rudas M.S., Sergienko V.B., Panchkovsky E.V., Manukova V.A., Rudas M.S.


Aim. To assess the capacities of radionuclide diagnosis of atherosclerotic changes in the great vessels in cancer patients. Materials and methods. 18F-fluorodeoxyglucose positron emission tomography (PET) was used to image unstable atherosclerotic plaques in the aorta and great vessels. Whole-body radiodiagnostic studies were retrospectively analyzed in 500 cancer patients of different ages and with different forms of neoplasms. Results. Tomographic images showed atherosclerotic plaques in 21% of the patients with the verified diagnosis of coronary heart disease (CHD) and in 17% without its clinical manifestations. Conclusion. The study showed it possible to identify a cardiovascular risk in cancer patients
Terapevticheskii arkhiv. 2010;82(4):45-48
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The clinical diagnostic value of a study of the activity of enzymes of the guanyl branch of purine metabolism in patients with ankylosing spondyloarthritis

Zborovskiy A.B., Mozgovaya E.E., Martem'yanov V.F., Slyusar' O.P., Stazharov M.Y., Bedina S.A., Zborovsky A.B., Mozgovaya E.E., Martemyanov V.F., Slyusar O.P., Stazharov M.Y., Bedina S.A.


Aim. To assess the diagnosis of the activity of a pathological process in patients with ankylosing spondyloarthritis (AS) and to reveal purine metabolic (PM) changes in relation to the clinical features of AS. Materials and methods. The serum activities of the PM enzymes: xanthine oxidase (XO), guanine deaminase (GDA), guanosine deaminase (GSDA), purine nucleoside phosphorylase (PNP), guanosine phosphorylase (GP), and adenosine deaminase (ADA) were determined in 55 patients (51 males and 4 females) aged 36.0 ± 1.4 years). A control group comprised 30 apparently age- and gender-matched healthy individuals, as in the study group. Results. On admission, the patients were found to have increased XO, GDA, PNP, and GD activities and decreased GSDA activity. The higher activity of the process was observed, the greater activities of GDA, XO, PNP, GP and the lower activity of GSDA and ADA were. There were the enzymatic activity differences that depended on the degree of pathological process activity, clinical form, the magnitude of X-ray changes, and the degree of joint functional insufficiency. Conclusion. The findings suggest that there may be PM disturbances in the immunocompetent cells.
Terapevticheskii arkhiv. 2010;82(4):48-52
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Hyperfiltration is an early sign of evolving chronic renal disease in males with metabolic syndrome

Novikova M.S., Shilov E.M., Borisov V.V., Novikova M.S., Shilov E.M., Borisov V.V.


Aim. To study the time course of changes in glomerular filtration rate (GFR) in different age groups of males with metabolic syndrome (MS). Subjects and methods. Eighty-six male patients with MS whose age 35 to 69 years (mean age 53.6 years) were examined. The patients were divided into 3 age groups: 1) 30-50 years (mean age 43.5 years; n = 30); 2) 50-60 years (mean age 54.9 years; n = 36); 3) 60-70 (mean age 66 years; n = 20). The study included only MS patients with stages I-III chronic renal disease (CRD) (according to the NKF K/DOQI classification, 2002). GFR was determined by the Cockroft-Gault formula corrected and uncorrected for a standard body surface area (GFRst, GFRc-g). The obtained values of GFRst and GFRc-g were compared with the population-based standards determined for each formula. The authors identified an increased GFRst (> 110 ml/min/1.73 m2), a normal GFRst (60-110 ml/min/1.73 m2), and a decreased GFRst (< 60 ml/min/1.73 m2), as well as an increased GFRc-g (> 120 ml/min), a normal GFRc-g (80-120 ml/min), and a decreased GFRc-g (< 80 ml/min). GFRst < 60 ml/min/1.73 m2) was defined as CRD. Results. Each age group was found to have deviations of GFR from the normal values towards both its increase and decrease. The young age group showed a larger number of patients with increased GFR and a smaller number of patients with decreased GFR than did the old age group. This trend was seen for both GFRst and GFRc-g, but in the latter case, the spread of hyperfiltration was higher in the age group of 30-50 years and in the total group of patients. Conclusion. In the first age group, a predominance of hemofiltration precedes the development of CRD in the third age group and may reflect the trend of MS-induced renal lesion.
Terapevticheskii arkhiv. 2010;82(4):52-56
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Experience in personifying the standard treatment of patients with hemophilia A: results of a multicenter Russian open-labeled prospective study evaluating the use of haemoctin

Zozulya N.I., Plyushch O.P., Zozulya N.I., Plyushch O.P.


Aim. To evaluate the clinical efficiency, tolerability, safety, and immunogenicity of replacement therapy with haemoctin SDH (Biotest Pharma GmbH, Germany) in pretreated patients with hemophilia A (HA). Subjects and methods. The pretreated patients (n = 140) with varying GA from 12 regions of the Russian Federation received haemoctin replacement therapy (for prophylaxis and if needed) during a year. The levels of coagulation factor VIII, its inhibitor, HIV-1/HIV-2, the markers of hepatic and renal diseases, clinical blood test were determined and a virological study was made thrice during this period at an interval of 6 months. The therapy was considered to be effective if the pain syndrome regressed within 24 hours after the last administration of the drug and/or bleeding stopped. The results of a one-year follow-up of 106 patients receiving haemoctin monotherapy were analyzed. Results. The history data suggest that there are problems in the diagnosis of hereditary coagulopathies (the mean age of diagnosis verification of 3.5 years; no family history data in 67% of cases), there is a need for the guaranteed provision of patients with adequate quantities of the drug due to the fact that a third of patients had life-threatening bleedings/hemorrhages and that the patients (46%) need additional examination and treatment for comorbidity according to the standards of therapy. Compliance of haemoctin doses and regimens with their timely individual correction ensures a 3-fold reduction on average in the incidence of the hemorrhagic syndrome, an increase in quality of life, and a decrease in the frequency of analgesic use (from 21% to 0). Treatment is satisfactorily tolerated. There is evidence for the safety and low immunogenicity of the drug. Conclusion. To enhance the efficiency of therapeutic-and-prophylactic care to patients with GA and to optimize their quality of life, a personification approach to treatment is recommended, by individually choosing drugs, their doses and regimens.
Terapevticheskii arkhiv. 2010;82(4):56-61
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Myocardial metastasis of Wilms' tumor as a cause of focal electrocardiographic changes

Kositsyna I.V., Tereshchenko S.N., Golubev A.V., Draganenko S.I., Zhirov I.V., Kositsyna I.V., Tereshchenko S.N., Golubev A.V., Draganenko S.I., Zhirov I.V.


Nephroblastoma (Wilms' tumor) is an embryonic tumor, an adenomyosarcoma that is casuistically rarely encountered in adults. It most commonly develops in children aged 1 to 5 years. This type of malignancy does not usually spread to the myocardium. The paper presents a clinical case of Wilms' tumor in an adult female patient with a solitary metastasis in the heart.
Terapevticheskii arkhiv. 2010;82(4):62-64
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Multiple myeloma: estimation of the extent of a process by magnetic resonance imaging

Polishchuk P.R., Petrenko L.I., Kryuchkov M.I., Morozov S.P., Brodetskiy B.M., Polishchuk P.R., Petrenko L.I., Kryuchkov M.I., Morozov S.P., Brodetsky B.M.


The paper presents a case history of multiple myeloma in a female patient. Its diagnosis was established only 10 years after the onset of the disease, which results in severe invalidity (she was treated with calcium preparations in accordance with the diagnosis of generalized osteoporosis. Persistent therapy with calcium preparations was ineffective; the number of pathological fractures increased. Further bone study and current instrumental imaging methods could make a precise diagnosis and use etiotropic treatment, which yielded a positive clinical effect. The data on high-technology studies, body magnetic resonance imaging used in the diagnosis of the diseases accompanied by bone destructive changes are given. The problems in the diagnosis of multiple myeloma are outlined.
Terapevticheskii arkhiv. 2010;82(4):64-67
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Value of exercise electrocardiography and other current instrumental studies in the evaluation of percutaneous coronary interventions and in the detection of restenosis

Lupanov V.P., Lupanov V.P.


The current instrumental studies (graded exercise echocardiography (ECG)), exercise tests in combination with myocardial imaging (echocardiography, myocardial perfusion scintigraphy) used to evaluate restenosis after percutaneous coronary interventions (PCI) in patients with coronary heart disease are considered. The sensitivity, specificity, and prognostic value of these studies versus coronarography in the diagnosis of restenosis after PCI are given. The capabilities of other diagnostic techniques (ultrasound study of brachial artery dysfunction, intravascular ultrasound study of coronary arteries, multispiral computed tomography, etc.) are analyzed. It is emphasized that periodic use of exercise ECG tests after PCI has no advantages over their performance only on the basis of the clinical findings of the impact on quality of life, functional status, and clinical signs.
Terapevticheskii arkhiv. 2010;82(4):67-73
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Mini-invasive methods for diagnosis of diffuse interstitial lung disease

Terpigorev S.A., Terpigorev S.A.


The paper specifies a place of various invasive diagnostic methods in suspected diffuse interstitial lung disease. It considers the problems associated with transbronchial, video-assisted thoracoscopic, and open biopsy of lung tissue and intrathoracic lymph nodes in this pathology and analyzes the informative value and safety of these methods, as well as indications for and contraindications to their use.
Terapevticheskii arkhiv. 2010;82(4):74-78
pages 74-78 views

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