Vol 83, No 9 (2011)

Editorial
High arterial rigidity is a significant but not obligatory factor of arterial hypertension in persons over 60 years of age
Boytsov S.A., Rogoza A.N., Kanishcheva E.M., Luk'yanov M.M., Boitsov S.A., Rogoza A.N., Kanischeva E.M., Lukianov M.M.
Abstract
Aim. To ascertain whether high arterial rigidity is obligatory in arterial hypertension (AH) and the presence of AH is obligatory in patients with rigid arteries. Material and methods. Volume sphygmography (VS) was made in 153 patients aged 60-86 years: 96 patients with untreated AH of degree 1-3 (40 males aged 71.0±7.6 years) and 57 normotensive subjects without cardiovascular symptoms (31 males aged 66.6±6.2 years). VS measured ankle-shoulder velocity of the pulse wave (PWVas) and cardiac-ankle vascular index (CAVI). PWVas > M+STD and CAVI > M+2STD (STD is deviation from mean value) were considered above normal for the age. Results. Hypertensive patients had significantly higher arterial rigidity than normotensives (PWVas 17.8±3.0 and 15.6 ± 2.3 m/s, respectively, p = 0.00001); CAVI - 9.7±2.1 and 8.6±1.1, respectively, p = 0.0003). Arterial rigidity in hypertensive patients occurred significantly more frequently than in normotensive subjects: by PWVas in 46 and 25% cases (p = 0.01), by CAVI - in 41 and 5% cases (p < 0.0001), respectively. It is essential that arterial rigidity was not increased in 54% hypertensive patients by PWVas and in 75% by CAVI. Conclusion. PWVas and CAVI were higher in elderly hypertensives than in elderly normotensives but elevated arterial rigidity was not obligatory in hypertensives while 25% elderly normotensives had it. Thus, elevated arterial rigidity is an essential but not obligatory mechanism of AH development in the elderly.
Terapevticheskii arkhiv. 2011;83(9):5-9
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The extent of coronary stenosis and the level of antibodies to atherogenic lipoproteins in patients with coronary heart disease
Urazgil'deeva S.A., Titkov A.Y., Vasina L.V., Tsaregorodtseva V.V., Gurevich V.S., Urazgildeeva S.A., Titkov A.Y., Vasina L.V., Tsaregorodtseva V.V., Gurevich V.S.
Abstract
Aim. To study association between the level of antibodies to oxidized low-density lipoproteins (anti-OLDL) and the extent of coronary stenosis (CS) in patients with coronary heart disease (CHD). Material and methods. Sixty CHD patients were examined for titer of anti-OLDL, levels of total cholesterol (TC), LDLP cholesterol, HDLP cholesterol, triglycerides. Selective coronarography (SC) was made on demand. Results. Elevated titer of anti-OLDL was found only in 12 examinees. It was significantly lower in CHD women than in men. No significant differences by anti-OLDL were found in CHD patients with and without significant risk factors. SC registered in all CHD examinees local stenosis of different severity. Stenosis in 3 coronary arteries was detected in 31 cases, in 2 coronary arteries - in 14, in 1 coronary artery - in 15 patients, most frequently the affection was located in the diagonal branch of the left coronary artery. Stenosis of the left coronary artery trunk was diagnosed in one case. The correlation analysis revealed a strongly significant positive correlation between content of anti-OLDL and the degree of CS. Conclusion. The level of anti-OLDL in CHD patients directly correlates with the degree of CS and is a marker of coronary atherosclerosis severity.
Terapevticheskii arkhiv. 2011;83(9):10-13
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Acardioprotective drug nikorandil in coronary heart disease
Malysheva A.M., Martsevich S.Y., Ginzburg M.L., Malysheva A.M., Martsevich S.Y., Ginzburg M.L.
Abstract
Nicorandil, opener of potassium channels, was studied in Russia and abroad. Its cardioprotective, anti-ischemic, pharmacokinetic and pharmacodynamic properties are reviewed as well as side effects and area of application in patients with stable coronary heart disease (CHD). The trial have found efficacy of nicorandil in prevention of anginal attacks. Also, the drug increases exercise tolerance. Administration of nicorandil is indicated before intervention on coronary arteries for reproduction of the effect of myocardial preconditioning. Nicorandil is recommended for treatment of patients with chronic stable coronary heart disease.
Terapevticheskii arkhiv. 2011;83(9):14-19
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Early invasive and non-invasive approach in the treatment of non-ST elevation acute coronary syndrome
Akinina S.A., Mayorova T.A., Belousov V.V., Shalaev S.V., Akinina S.A., Maiorova T.A., Belousov V.V., Shalaev S.V.
Abstract
Aim. The aim of the study is to assess the efficiency of early invasive treatment versus conservative treatment for patients with non-ST acute coronary syndrome (ACS), and to study immediate results of percutaneous coronary intervention (PCI) in terms of the risk of adverse events. Material and methods. The investigation includes 112 patients with non-ST ACS having risk of adverse outcome determined by the GRACE system. More than half of the patients (77/68.8%) underwent diagnostic coronary angiography within 72 hours of admission, and the decision was made on a subsequent treatment strategy (early invasive or conservative approach). In-hospital outcomes (cardiac deaths, nonfatal MI, reMI), cumulative frequency of these events have been studied according to the risk assessment scale GRACE and treatment strategy. Results. Low risk was determined in 33.9% of patients, intermediate - in 32.1%, and high - in 33.9%. On the whole, frequency of myocardial revascularization was assessed as 56.3%. Fifty-one (45.5%) patients received early invasive treatment, 12 (10.7%) - coronary artery bypass grafting (CABG). A conservative approach was used in 49 cases (43.8%). An early invasive treatment was given to 20 patients (52.6%) from each of the low- and high-risk groups, 11 (30.6%) - from the intermediate risk group. In-hospital cardiac deaths were observed only in the high-risk group, and this number was higher in case of conservative treatment versus early invasive treatment: 3 (30%) versus 1 (50%). Non-fatal MIs in the form of re(MI) were also diagnosed only in the high-risk group following conservative treatment: 2 (20.0%). Nevertheless, no reliable difference in the frequency of each complication was found (p = 0.095; p = 0.1). Significant differences in the high-risk group were proven while comparing the impact of early invasive and conservative approaches on the cumulative frequency of in-hospital death and (re)MI cases (50.0% versus 5.0%; p = 0.009). No benefits of an early invasive approach were identified for low-risk and intermediate risk groups. Conclusion. Early invasive approach compared with a conservative approach in high risk patients with non-ST acute coronary syndrome can improve clinical outcomes with a decrease in the total frequency of in-hospital death, reMI.
Terapevticheskii arkhiv. 2011;83(9):20-24
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Long-term prognosis in patients with acute non-ST elevation myocardial infarction depending on dynamics of tissue myocardial dopplerography
Krasnosel'skiy M.Y., Koshkina E.V., Polupan A.A., Gmyzina A.I., Ponomarev G.V., Tsurko V.V., Krasnoselsky M.Y., Koshkina E.V., Polupan A.A., Gmyzina A.I., Ponomarev G.V., Tsurko V.V.
Abstract
Aim. To study long-term prognosis in patients with non-ST elevation acute myocardial infarction (AMI) with reference to changes in myocardial tissue dopplerography (MTD) in the course of treatment. Material and methods. MTD echocardiography was conducted in 88 non-ST elevation AMI (mean age 58.0±9.8 years) and 34 healthy volunteers (mean age 58.0±9.8 years). Measurements were made of the velocity of systolic, early and late diastolic peaks at 4 levels of interventricular septum, anterior, lateral and inferior walls of the left ventricle (LV). MTD was repeated before the discharge from hospital. The patients were followed up for 10-18 months after the discharge. Results. By MTD results the patients were divided into 3 subgroups: 1 -an asymmetric decrease of MTD values - 17(19.3%) patients who had a 20% reduction of the systolic and early diastolic peak velocity compared to healthy controls on one or two adjacent LV walls; subgroup 2 - a diffuse decline of MTD values - 61 (69.3%) patients. Their velocity of systolic and early diastolic peaks was subnormal on all the walls, all levels of estimation; subgroup 3 - 10 (11,4 %) patients without MTD changes. These proportions changed in the course of treatment: the number of patients with a diffuse decrease of MTD values reduced to 31 (35.3%), the number of patients with an asymmetric MTD decrease rose to 37 (42%), and with unchanged MTD rose to 20 (22.7%) patients. The rate of development of congestive cardiac failure (CCF) and asymptomatic LV dysfunction in the long-term period was significantly higher in the subgroup with retained diffuse decrease of MTD values. Conclusion. The treatment of non-ST elevation AMI reduces the number of patients with a diffuse decrease of MTD values and elevates the number of patients with asymmetric decrease of MTD and unchanged MTD. Persistence of MTD diffuse changes is an unfavourable prognostic factor in relation to CCF and LV silent dysfunction.
Terapevticheskii arkhiv. 2011;83(9):25-29
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Relationship between a concentration of lipoprotein-associated secretory phospholipase A2 and markers of subclinical atherosclerotic lesion of arterial wall in patients with low and moderate risk by SCORE scale
Urazalina S.Z., Titov V.N., Vlasik T.N., Balakhonova T.V., Karpov Y.A., Kukharchuk V.V., Boytsov S.A., Urazalina S.G., Titov V.N., Vlasik T.N., Balakhonova T.V., Karpov Y.A., Kukharchuk V.V., Boitsov S.A.
Abstract
Aim. To show relations between a concentration of lipoprotein-associated secretory phospholipase A2 (LPPLa2) and markers of subclinical atherosclerotic lesion of the arterial wall in patients with low and moderate risk by the SCORE scale. Material and methods. A total of 378 individuals with low and moderate risk of atherosclerotic lesion of the arterial wall (285 females, 93 males) were divided into groups by 1) age and sex, 2) number of atherosclerotic plaques (ASP) in the carotid arteries: 0ASP (n = 158), ASP (n = 61), more than one ASP (n = 159); 3) plaque characteristics: homogeneous (n = 31), heterogenous (n = 189), 4) the presence of ASP in CA and level of LPPLa2 in the blood (with high content - n = 137, with normal content - n = 83). Duplex CA scanning was made to estimate intima-media thickness (IMT), to detect AP in the CA. Computer sphygmography estimated velocity of the pulse wave (PWV) from the carotid to femoral artery. Normal values of IMT and PWV were estimated individually with reference to gender and age. LPPLa2 was measured immunoturbodimetrically using diagnostic kits (PLAC Test Elisa Kit, diaDexus, USA), shreshold value < 200 ng/ml. Results. LPPLa2 content medians in different age groups in males and females differed insignificantly. LPPLa2 concentration in the groups of patients regarding ASP in CA was elevated in relation to the threshold value (200 ng/ml) in all the groups but did not significantly differ: 216 (179-257) ng/ml in the group 0ASP, 226 (190-274) ng/ml - in the group of patients 1ASP and 212 (174-254) ng/ml - in the group of patients more than one ASP (p > 0.05). In the groups with homogeneous and heterogenous ASP significant differencies were neither between the medians nor between frequency of deviation from normal (p = 0.28). 25.5% patients from the group with an elevated level of LPPLa2 had ASP with a hypoechogenic component. Conclusion. No significant correlation was revealed between concentration of LPPLa2, IMT PWV, number of ASP and carotid stenosis.
Terapevticheskii arkhiv. 2011;83(9):29-35
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Pharmacological protection of the myocardium with reamberin in coronary artery bypass grafting in patients with postinfarction angina
Sidorenko G.I., Gelis L.G., Medvedeva E.A., Ostrovskiy Y.P., Lazareva I.V., Sevruk T.V., Shibeko N.A., Petrov Y.P., Sidorenko G.I., Gelis L.G., Medvedeva E.A., Ostrovsky Y.P., Lazareva I.V., Sevruk T.V., Shibeko N.A., Petrov Y.P.
Abstract
Aim. To assess efficacy of reamberin in preoperative preparation and after coronary bypass (CB) in patients with macrofocal myocardial infarction (MI) complicated with postinfarction angina. Material and methods. A total of 45 patients with Q-positive MI complicated with postinfarction angina pectoris entered the trial. The study group consisted of 20 (44.4%) patients given 200-400 ml injections of 1.5% reamberin solution for 3 days before coronary artery bypass grafting (CABG) and 3-5 days after it. The control group consisted of 25 (55.6%) patients given basic therapy without cardioprotection. ECTG-60, echocardiography, CM-ECG, laboratory tests were made before CABG. CABG was made in conditions of artificial blood circulation in all the patients. Results. Clinical stabilization was observed after direct myocardial revascularization in hospitalized 25 (100%) patients of the study group and 22 (88%) patients of the control group. Early postoperative acute cardiac failure (ACF) developed in 3 (12%) patients from the study group and 9 (36%) from the control group (p = 0.04), arrhythmia occurred in 2(8%) and 8(32%) patients, respectively (p = 0.03). Two (8%) control patients died in early postoperative period from acute cardiac failure. Perioperative MI occurred in 2(8%) control patients. After 12 months of the follow-up, patients of the study group had no recurrent angina pectoris, while among the controls 4(16%) patients had recurrent angina of FC III. After surgical intervention at discharge and 12 months after treatment patients of both groups improved systolic and diastolic functions of the left ventricle. Normalization of the diastolic function was registered in 80% patients of the study group (p < 0.001) and in 44% from the control group (p < 0.001) after 1 year follow-up. Conclusion. Reamberin reduces the number of postoperative complications, ischemic damage to the myocardium, significantly improves systolic and diastolic functions of the left ventricle.
Terapevticheskii arkhiv. 2011;83(9):35-40
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Dilated cardiomyopathy as a clinical syndrome: experience with nosological diagnosis with biopsy and treatment approaches
Blagova O.V., Nedostup A.V., Kogan E.A., Dzemeshkevich S.L., Frolova Y.V., Sedov V.P., Gagarina N.V., Sulimov V.A., Abugov S.A., Zaklyaz'minskaya E.V., Donnikov A.E., Kadochnikova V.V., Kupriyanova A.G., Zaydenov V.A., Beletskaya L.V., Blagova O.V., Nedostup A.V., Kogan E.A., Dzemeshkevich S.L., Frolova Y.V., Sedov V.P., Gagarina N.V., Sulimov V.A., Abugov S.A., Zaklyazminskaya E.V., Donnikov A.E., Kadochnikova V.V., Kupriyanova A.G., Zaidenov V.A., Beletskaya L.V.
Abstract
Aim. To study possibility of nosological diagnosis in patients with dilated cardiomyopathy (DCMP) with use of myocardial biopsy. Material and methods. The trial enrolled 62 patients (23 females) with DCMP syndrome (end diastolic left ventricular size > 5.5 cm, ejection fraction < 55%). Mean age of the patients was 46.0±12.8 years. The examination included diagnosis of viral infections (Herpes virus, parvovirus B19), measurement of anticardial antibodies titer, 99Tc-MIBI single photon emission computed tomography of the myocardium, multislice computed tomography, MRT of the heart, coronarography, morphological study of the myocardium (n = 20) with application of polymerase chain reaction (PCR) for H.simplex viruses of types 1, 2 and 6, herpes zoster, Epstein-Barr, cytomegalovirus, parvovirus B-19, adenoviruses. The control group (20 operated patients with valvular heart disease and coronary heart disease) was examined for viral genome in the blood and myocardium. Results. Complex examination of DCMP patients showed the following distribution by nosological entuities: myocarditis (n = 41, 66.1%) including virus-positive (n = 14), primary DCMP (n = 16, 25.9%) including with non-compact myocarditis (NCM) in 3, with debute at delivery of the child - in 3. Arrhythmogenic right ventricular dysplasia combined with viral myocarditis (n = 2), genetic myopathy (n = 1) and Takayasu disease (n = 1) combined with NCM, isolated NCM (n = 1) were diagnosed in the rest cases. Morphological investigation of the myocardium was made in 20 patients: diagnosis of myocarditis and primary DCMP were made in 70% (including in 2 patients with CHD) and 20%. Detection of viral genome was 20 and 15% in the study and control group, respectively, in the myocardium - in 57.9 (test for parvovirus B19 was not made in 26%) and 65.0% (complete diagnosis).All the virus-positive patients with DCMP were diagnosed to have signs of active/borderline myocarditis. Diagnostic criteria and poor prognosis factors were defined. Conclusion. The nosological diagnosis of DCMP was made in all the examinees basing on the complex of clinical, case history and device evidence. The diagnosis was morphologically verified in 33.9% patients. Treatment approaches are developed.
Terapevticheskii arkhiv. 2011;83(9):41-48
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Pandemic flu in Russia: special features of a clinical course and the absence of early etiotropic therapy as a risk factor of severe forms of the disease
Kolobukhina L.V., Merkulova L.N., Shchelkanov M.Y., Burtseva E.I., Lavrishcheva V.V., Samokhvalov E.I., Al'khovskiy S.V., Prilipov A.G., Proshina E.S., Avdeev S.N., Sutochnikova O.A., Bazarova M.V., Kelli E.I., Tserukalova N.D., Blank I.A., Shestakova O.M., Kolivashko O.N., Arseneva T.V., Ambrosi O.E., Shul'dyakov A.A., Popov A.F., Simakova A.I., Malyshev N.A., Chuchalin A.G., L'vov D.K., Kolobukhina L.V., Merkulova L.N., Schelkanov M.Y., Burtseva E.I., Lavrischeva V.V., Samokhvalov E.I., Alkhovsky S.V., Prilipov A.G., Proshina E.S., Avdeev S.N., Sutochnikova O.A., Bazarova M.V., Kelli E.I., Tserukalova N.D., Blank I.A., Shestakova O.M., Kolivashko O.N., Arseneva T.V., Ambrosi O.E., Shuldyakov A.A., Popov A.F., Simakova A.I., Malyshev N.A., Chuchalin A.G., Lvov D.K.
Abstract
Aim. To assess efficacy and safety of ingavirin in the treatment of the flu caused by pandemic virus of flu A (H1N1) sw1 in hospitalized patients compared with oseltamivir. Material and methods. A population-based comparative multicenter trial included 194 patients with verified diagnosis of the flu aged 18-60 years with marked clinical symptoms, body temperature over 38 °C and duration of the disease 48 hours maximum. The patients were randomized into 2 groups: group 1 (n = 152) received ingavirin (90 mg once a day), group 2 received oseltamivir (n = 42) in a dose 150 mg twice a day. Duration of the course was 5 days. Results. Ingavirin and oseltamivir normalized body temperature within treatment hours 24-36 if therapy was initiated in the first disease hours 27.0±10.0 and 31.9±10.4. Mean duration of the fever for ingavirin was 35.1±14.5 hours, for oseltamivir - 26.3±13.0 hours (p < 0.817). The antiviral medicines significantly reduced duration of intoxication (head ache, weakness), catarrhal symptoms (cough, tracheitis, rhinitis), rate of complication vs patients untreated with antivirus drugs (n = 30). Conclusion. The results of the treatment show safety and efficacy of ingavirin in uncomplicated flu caused by pandemic virus of flu A (H1N1) sw1 in inpatients. Early etiotropic therapy is a basic treatment policy able to reduce the number of severe complications and lethality.
Terapevticheskii arkhiv. 2011;83(9):48-53
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Multicenter trial of olmesartan. Main results
Ageev F.T., Svirida O.N., Ageev F.T., Svirida O.N.
Abstract
Development and introduction into practice of medicines reducing activity of the renin-angiotensin-aldosteron system the key element of which is angiotensin II (ATII) resulted in a significant improvement of efficacy of cardiovascular diseases treatment. Angiotensin converting enzyme (ACE) inhibitors and ATII receptor blockers (BRA II) effectively reduce arterial pressure, have a nephroprotective action in patients with diabetes mellitus, inhibit development of left ventricular hypertrophy. Unlike ACE inhibitors, BRA II do not exhibit the phenomenon of ATII concentration escape, they completely depress ATII interaction with AT1-receptors while AT2-receptors keep their ability to interact with this hormone. High probability of target arterial pressure achievement in the treatment with BRA II encourage higher compliance of the patients. The review of multicenter trials performed in 2007-2010 concerns a new BRA II representative - olmesartan medoxomil (OM). The trials run in two directions: hypotensive activity of OM and vaso- and other organ-protective OM properties.
Terapevticheskii arkhiv. 2011;83(9):54-60
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Chronic cardiac failure in the XXI century
Tereshchenko S.N., Zhirov I.V., Tereschenko S.N., Zhirov I.V.
Abstract
Wide clinical application of modern prophylactic, diagnostic and therapeutic methods has significantly improved clinical outcomes of cardiovascular disorders. However, much progress is not seen in survival of patients with chronic cardiac failure (CCF). Three possible causes of this situation are analysed: absence of evidence base in the treatment of CCF patients free of systolic dysfunction, difficulties in management of patients with end-stage CCF, need in new markers of CCF. Approaches to solution of these problems and CCF treatment optimization in general are discussed.
Terapevticheskii arkhiv. 2011;83(9):60-66
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Acute coronary syndrome in patients with type 2 diabetes mellitus
Ametov A.S., P'yanykh O.P., Aslandziya E.N., Ametov A.S., Pianykh O.P., Aslandzia E.N.
Abstract
According to evidence obtained from large epidemiological studies, an incidence rate of acute coronary syndrome (ACS) in diabetics is 2-3 times higher than in general population. Relevant invalidity and mortality is much higher than in patients free of diabetes. In type 2 diabetes mellitus a high risk of an unfavourable course and outcome of myocardial infarction was registered both within 30 postinfarction days and 1-3 years of follow-up.Poor prognosis persists despite adequate and early treatment. The results of the attempts to correct MI prognosis in diabetics by means of carbohydrate metabolism correction (multicenter trials DIGAMI-1, DIGAMI-2) are reviewed.
Terapevticheskii arkhiv. 2011;83(9):66-70
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Statins in primary prophylaxis of cardiovascular diseases
Kobalava Z.D., Villeval'de S.V., Kobalava G.D., Villevalde S.V.
Abstract
The review summarises data on statins efficacy in primary prophylaxis of cardiovascular complications. Main results of the JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial are analysed in detail. Its role in possible changes in current recommendations on prophylaxis and treatment of atherosclerosis is shown. Statins are considered as drugs essential in the strategy of improvement of life quality.
Terapevticheskii arkhiv. 2011;83(9):70-75
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From classification medicine to clinical medicine (late XVIII century 1870s) Communication 1. Early formulation of the new style of medical thinking (clinical thinking)
Stochik A.M., Zatravkin S.N., Stochik A.M., Zatravkin S.N.
Abstract
This communication is devoted to appearance of a qualitatively different methodological approach to problems of practical medicine in 1890s. This approach gave rise to formation of a new style of medical thinking (clinical thinking) and development of clinical medicine.
Terapevticheskii arkhiv. 2011;83(9):75-80
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