Vol 83, No 12 (2011)

Articles
Cardiorenal syndromes: pathogenetic, clinicodiagnostic, prognostic and therapeutic aspects
Moiseev V.S., Kobalava Z.D., Moiseev V.S., Kobalava Z.D.
Abstract
Current information on cardiorenal and renocardial relations with clinicopathophysiological disorders in which primary impairment of the heart or kidneys leads to secondary functional and morphological abnormality in the other organ is analysed. Acute decompensation of cardiac failure is wide spread pathology which can be complicated by both acute and chronic lesion of the kidneys. Acute renal failure in cardiogenic shock in patients with ST elevation acute myocardial infarction deteriorates prognosis and raises lethality. Administration of radiopharmaceutical in patients with myocardial infarction and coronary heart disease with stents may induce nephropathy. Synergic affection of the heart and kidneys is observed in diabetes mellitus, systemic lupus erythematosus, amyloidosis, infectious endocarditis and some other diseases.
Terapevticheskii arkhiv. 2011;83(12):5-11
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Structural and functional parameters of the vascular bed in premenopausal hypertensive women
Khabibulina M.M., Khabibulina M.M.
Abstract
Aim. To study structural and functional characteristics of the vascular bed in premenopausal women with arterial hypertension (AH) and changes in hormone levels. Material and methods. Duplex scanning of the common carotid arteries (CCA) was made in 180 females with premenopausal hypertention. Results. Hypertensive women in premenopause with sexual hormones unbalance exhibited a wide CCA lumen in the absence of hemodynamically significant stenosis. This evidences for marked structural and functional changes of the vascular wall in the form of arteriosclerosis. Such patients' postocclusive reactive hyperemia test demonstrates a significant decline of vasomotor endothelial function, 43% cases show an inertial type of the vasomotor reaction reflecting an important role of hormonal unbalance in AH progression primarily due to increased stiffness of the vascular wall and endothelial dysfunction. Conclusion. Premenopausal women with hypertension and hormonal unbalance should be examined with consideration of the fact that impaired status of sexual hormones is an independent factor of risk of AH progression and they should be referred to a separate group of follow-up. Their treatment policy must be formed by both cardiologist and gynecological endocrinologist.
Terapevticheskii arkhiv. 2011;83(12):11-15
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Efficacy of hypobaric hypoxia in the treatment of arterial hypertension in postmenopausal women
Tin'kov A.N., Konstantinova O.D., Kshnyaseva S.K., Tinkov A.N., Konstantinova O.D., Kshnyaseva S.K.
Abstract
Aim. To assess efficacy of adaptation to periodic hypobaric hypoxia (PHH) in the treatment of postmenopausal women with arterial hypertension (AH). Material and methods. The method of adaptation to PHH in the pressure chamber Ural-1 (22 three-hour daily sessions, pressure 460 mmHg) was used in 46 postmenopausal AH women (mean age 53,8 ± 3,9 years). The method was assessed for effects on blood pressure (BP), symptoms of menopausal syndrome, body mass, levels of some hormones, lipid and carbohydrate metabolism. Results. Adaptation to PHH reduced systolic pressure by 13,9%, diastolic one - by 8,2%, the levels of folliculestimulating and luteinising hormones by 26,8 and 21,5%, respectively, cholesterol - by 14,7, glucose - by 21,3, insulin - 20,2%; estradiol and dehydroepiandrosteron sulphate concentrations rose by 19,3 and 15,2%, respectively. Conclusion. Adaptation to PHH produced an antihypertensive effect and a positive trend in clinicometabolic indices in AH women in postmenopause.
Terapevticheskii arkhiv. 2011;83(12):16-19
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Efficacy of ivabradin in combined treatment of patients with postinfarction systolic chronic cardiac failure
Potapenko A.V., Abdulazizov O.S., Dyachuk L.I., Kiyakbaev G.K., Kobalava Z.D., Moiseev V.S., Potapenko A.V., Abdulazizov O.S., Dyachuk L.I., Kiyakbaev G.K., Kobalava Z.D., Moiseev V.S.
Abstract
Aim. To study effects of ivabradin on clinicohemodynamic and prognostic parameters in patients after myocardial infarction (MI) with systolic chronic cardiac failure (SCCF). Material and methods. A population-based randomized prospective trial enrolled 49 patients (40 males - 81,6%, mean age 63,1 ± 8,1 years) with sinus rhythm and a longer than 3 month history of MI. The patients were randomized into 2 groups: 23 patients of group 1 received standard treatment plus ivabradin, 26 patients of group 2 received standard treatment alone. Follow-up was 36,1 ± 6,2 months. We analysed the trend in heart rate (HR), blood pressure (BP), parameters of echocardiography, ECG, levels of electrolytes, creatinin in blood plasma, frequency of hospitalizations, recurrent non-fatal MI and lethality (combined end point). Results. In the end of the trial ivabradin significantly decreased HR from 71 to 64 b/m. Frequency of combined end point of efficacy was 30,4 and 50% in group 1 and 2, respectively. In group 1 primary end point in high baseline HR occurred more frequently than in HR < 70 b/m in 6 (50%) and 1 (9,1%) cases, respectively, but these differences were not significant (p = 0,068). In group 2 the differences were significant - 9 (90%) and 4 (25%) cases, respectively (p = 0,004). By none of the parameters of ECG, plasma electrolytes, creatinine level significant intergroup differences were found. Conclusion. In the same trend in BP and ECG, group 1 patients showed significant and more pronounced HR lowering than group 2 patients. Addition of ivabradin to standard treatment of SCCF after MI promoted less frequency of hospitalizations, recurrent non-fatal MI, fatal cardiovascular events. This effect was especially strong in high baseline HR.
Terapevticheskii arkhiv. 2011;83(12):19-26
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Calcium channels blocker felodipin: perspectives in the treatment of arterial hypertension and chronic cardiac failure with normal ejection fraction
Drapkina O.M., Ashikhmin Y.I., Drapkina O.M., Ashikhmin Y.I.
Abstract
The article is devoted to issues of clinical diagnosis and treatment of patients with chronic cardiac failure and normal ejection fraction (CCF-NEF). Original clinical trials of felodipin efficacy designed to be maximally close to every-day clinical practice in Russia included hypertensive patients with CCF-NEF. The results of these trials bring about the conclusion that felodipin not only maintain blood pressure at the target level but also improves diastolic function of the myocardium.
Terapevticheskii arkhiv. 2011;83(12):26-34
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Clinicofunctional assessment of electric cardiac unstability in diastolic dysfunction of the left ventricle in patients with coronary heart disease
Tatarchenko I.P., Pozdnyakova N.V., Morozova O.I., Petrushin I.A., Solov'eva K.V., Tatarchenko I.P., Pozdnyakova N.V., Morozova O.I., Petrushin I.A., Solovyeva K.V.
Abstract
Aim. To study parameters characterizing electric myocardial unstability in coronary heart disease (CHD) patients with different variants of diastolic dysfunction (DD) of the left ventricle (LV). Material and methods. The study included 86 outpatients (26 females, 60 males, mean age 57,3 ± 5,6 years) who had myocardial infarction (MI) more than 1 year before the trial with stable course of CHD during a previous month, LV ejection fraction more than 45% and with a stable sinus rhythm. Group 1 consisted of 36 patients with abnormal LV relaxation, group 2 - of 28 patients with pseudonormal LV DD, group 3-22 patients with a restrictive type of LV DD. The following examinations were made: Holter ECG monitoring, echocardiography, signal-average ECG with isolation of late ventricular potentials (LVP), estimation of heart rate variability, ventricular repolarization (Q-T interval dispersion, corrected interval Q-T). Results. The following variants of LV DD were detected: type 1 - 42%, type 2 - 32,5%, type 3 - 25,5%. LV DD progression was accompanied with enhancing vegetative imbalance and sympathetic activity: in the group with abnormal relaxation - in 52,5% patients, in the group with a restrictive type - in 93,3%. CHD patients with restrictive DD had more frequent LVP (chi-square = 4,1; p < 0,05) and visualization of anomalous contractility zones (60%), ventricular extrasystole (VE) was registered in 100% cases (VE of grade IV-V in 43,3%), QTc and QTd were higher than threshold - 450.2 ± 5,4 and 71,2 ± 6,5 ms. Conclusion. Because of multifactorial genesis of electric unstability, perfection of diagnosis and prognosis of risk in CHD patients with aggravation of LV DD demands a complex analysis of parameters respecting functional condition of the myocardium, relations between electric and structural-geometric remodeling of the heart.
Terapevticheskii arkhiv. 2011;83(12):34-38
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Total body water and recurrent atrial fibrillation
Menzorov M.V., Shutov A.M., Serov V.A., Menzorov M.V., Shutov A.M., Serov V.A.
Abstract
Aim. To specify the relationship between content of total body water and recurrent atrial fibrillation (AF) of non-valvular etiology. Material and methods. Pharmacological amiodaron cardioversion followed by amiodaron supportive anti-arrhythmic therapy was made in 76 patients (47 males, 29 females, mean age 58 ± 8 years) with persistent AF of non-valvular etiology. Measurements were made of the height, body mass, arm circumference, thickness of the lipocutaneous fold above the biceps. Body mass index (BMI) and arm muscular circumference were estimated. Body composition was calculated according to Watson formula. Results. Fifty three (70%) patients with recurrent AF had overweight or obesity. Body fat mass in patients with frequent (1 recurrence and more for 3 months) and rare AF recurrences did not significantly differ (24,4 ± 10,6 and 30,0 ± 13,8 kg, respectively; p = 0,064). Total body water was significantly less (36,8 ± 5,2 and 42,7 ± 5,4 kg, respectively; p = 0,0009) in patients with frequent AF recurrences. Multifactor regression analysis showed that content of total body water, irrespective of gender and age, inversely correlates with an early AF recurrence (R2 = 0,24; beta = -0,49; p = 0,0003). Conclusion. Low content of body water is associated with a risk of early AF recurrence.
Terapevticheskii arkhiv. 2011;83(12):39-42
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Thrombin-activated inhibitor of fibrinolysis and efficacy and safety of long-term warfarin treatment in patients with venous thromboembolic complications
Vorob'eva N.M., Panchenko E.P., Dobrovol'skiy A.B., Titaeva E.V., Ermolina O.V., Balakhonova T.V., Khasanova Z.B., Postnov A.Y., Kirienko A.I., Vorobyeva N.M., Panchenko E.P., Dobrovolsky A.B., Titaeva E.V., Ermolina O.V., Balakhonova T.V., Khasanova Z.B., Postnov A.Y., Kirienko A.I.
Abstract
Aim. To study effects of thrombin-activated fibrinolysis inhibitor (TAFI) on efficacy and safety of long-term anti-coagulant treatment in patients with venous thromboembolic complications (VTEC). Material and methods. A total of 111 patients with a history of an episode of deep vein thrombosis (DVT) and/or pulmonary artery thromboembolism (PATE) entered the study. All the patients received unfractionated or low-molecular heparin for at least 5 days than switch on warfarin (target values of INR 2,0-3,0). Baseline blood levels of TAFI were measured. The patients were followed up for 18 months. Recurrent (DVT/TAFI and hemorrhagic complications (HC) were end points. Also, frequency of complete lysis of deep vein thrombi was assessed after 12 months of treatment. Results. A TAFI level varied from 50 to 217% (median 106%, interquartile rage 90-133%). TAFI concentration positively correlated with fibrinogen and thromb size. The patients were divided into two groups depending on TAFI content: group 1 patients had low TAFI (under 25th percentile; < 90%); patients of group 2 had high TAFI (above 25th percentile; > 90%). Group 1 patients were characterized by less stable anticoagulation. This association did not depend on genetic characteristics which determine sensitivity to warfarin (CYP2C9 and VKORC1). Low TAFI was associated with reduced risk of DVT for 18 months and higher probability of complete lysis of the thrombi after 12 months of anticoagulant therapy compared to VTEC patients with high TAFI. No differences were found by TAFI level in patients with HC and without HC, but in HC patients low TAFI was associated with spontaneous hemorrhages and bleeding in therapeutic INR values. Conclusion. The results of this pilot study evidence that a TAFI level can be one of the factors influencing efficacy and safety of long-term anticoagulant therapy in patients with VTEC on warfarin treatment.
Terapevticheskii arkhiv. 2011;83(12):43-48
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Pharmacokinetic and pharmacodynamic characteristics of antihypertensive drugs in the treatment of hypertensive patients with chronic diseases of the liver
Mikheeva O.M., Drozdov V.N., Komisarenko I.A., Mikheeva O.M., Drozdov V.N., Komisarenko I.A.
Abstract
Aim. To determine optimal treatment of arterial hypertension (AH) in patients with hepatic cirrhosis (HC) basing on pharmacokinetic and pharmacodynamic characteristics of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenoblockers (BAB). Material and methods. A total of 360 patients with AH of the second degree, steatosis and alcoholic HC of class A according to Child-Pue participated in the study. The control group consisted of 120 patients with peptic ulcer in remission and normal function of the liver. The patients' treatment with enalapril (pharmacologically inactive prodrug), lisinopril (biologically active substance), atenolol (hydrophilic drug) and metoprolol (lipophylic drug) was analysed. Results. Lisinopril showed a better hypotensive effect than enalapril in AH patients with HC. BAB decreased blood pressure in all hypertensive patients. Atenolol and metoprolol effectively reduced blood pressure in 88,89% patients with AH and HC. Bradycardia episodes in atenolol treatment were observed in 14,4% patients while in metoprolol treatment - in 22,2% patients, this evidencing for pronounced shifts in pharmacokinetic parameters of metoprolol exposed to hepatic metabolism. Conclusion. Biological activity is an essential criterion of choice of ACE inhibitor in patients with hepatic pathology. Enalapril, for example, as a pharmacological inactive prodrug, is metabolized in the liver to acquire activity, whereas lisinopril has a direct biological activity and has, therefore, a stronger hypotensive action in AH patients with HC. BAB should be selected by the ability to effectively control blood pressure and heart rate without inducing bradycardia the appearance of which necessitates correction of dose regimen with reduction of day dose.
Terapevticheskii arkhiv. 2011;83(12):49-55
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Postgastroresectional syndromes in therapeutic practice
Ruchkina I.N., Lychkova A.E., Kuz'mina T.N., Kostyuchenko L.N., Ruchkina I.N., Lychkova A.E., Kuzmina T.N., Kostyuchenko L.N.
Abstract
Aim. To specify policy of nutritive support late after radical gastric resection. Material and methods. Patients with postgastroresectional dystrophy were examined using standard techniques and estimation of intestinal electric activity (registration of body surface biopotentials on Conan-M myngograph). Results. Frequency-amplitude parameters of the intestine serve the basis for choice of mixtures for enteral correction. Nutritive support provided for on demand pharmaconutrients - microbiotic correctors. Conclusion. Myography gives additional information for decisions on the policy of nutritive support.
Terapevticheskii arkhiv. 2011;83(12):55-57
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Variability of intima-media thickness of the common carotid arteries in Moscow city population without clinical symptoms of atherosclerosis
Sobenin I.A., Surin S.A., Karagodin V.P., Myasoedova V.A., Kirichenko T.V., Chuprakova O.V., Kozhevnikova Y.A., Kovalevskaya L.O., Orekhov A.N., Sobenin I.A., Surnin S.A., Karagodin V.P., Myasoedova V.A., Kirichenko T.V., Chuprakova O.V., Kozhevnikova Y.A., Kovalevskaya L.O., Orekhov A.N.
Abstract
Aim. To determine borderline values of intima-media thickness (IMT) of the common carotid arteries (CCA) in Moscow sitizens without clinical symptoms of atherosclerosis. Material and methods. A total of 885 (277 males and 608 females) Moscow sitizens aged 20-79 years free of clinical symptoms of atherosclerosis participated in population-based epidemiological trial. CCA IMT was measured at ultrasonic scanning of the carotid arteries in high-resolution regimen. Results. The trial provided data on variability of CCA IMT borderline values in different age groups of adult Moscow metaethnic population without clinical symptoms of atherosclerosis with gender reference. Quartile distribution of CCA IMT values enabled primary evaluation of predisposition of the population studied to atherosclerosis. Conclusion. This pilot study is the first to give Russian data on variability of population borderline values of CCA IMT obtained in the study of a representative sample. Russian data give additional material to European geographic gradiet CCA IMT and allow more accurate ultrasonographic identification of predisposition to atherosclerosis in persons with silent disease.
Terapevticheskii arkhiv. 2011;83(12):58-62
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Secondary autoimmune hemolytic anemia as a result of B19 parvovirus persistence in immunodeficient patients
Yaguzhinskaya O.E., Fevraleva I.S., Elizhbaeva M.A., Levina A.A., Semenova G.M., Bugar' N.Y., Tsybul'skaya L.M., Varlamova E.Y., Shitareva I.V., Tsyba N.N., Kravchenko S.K., Yaguzhinskaya O.Y., Fevraleva I.S., Elizhbaeva M.A., Levina A.A., Semenova G.M., Bugar N.Y., Tsybulskaya L.M., Varlamova E.Y., Shitareva I.V., Tsyba N.I., Kravchenko S.K.
Abstract
Aim. To ascertain informative value of immunological diagnosis of B19 parvovirus in combination with polymerase chain reaction (PCR); to analyse frequency of development of secondary autoimmune hemolytic anemia (AIHA) in immunodeficient patients as a result of virus persistence - persistent infection eliminated only by treatment causing suppression of erythropoiesis. Material and methods. B19 parvovirus detection was performed in blood serum of 207 subjects: 144 patients with anemia (Hb < 100 g/1) and 500 blood donors. DNA of parvovirus B19 was detected in the sera by PCR, antibodies to this virus - by enzyme immunoassay (EIA). IgG, IgM, IgA and components of compliment Clq, C3 on the surface of erythrocytes were detected by EIA in anemic patients. Results. Parvovirus infection was registered in 30% patients, in 70% the infection was persistent. The latter were diagnosed to have secondary AIHA. Conclusion. Combined application of PCR and EIA extends potentialities of diagnosis of infection caused by B19 parvovirus. Persistence of the parvovirus provokes onset of symptomatic hemolytic anemia in immunodeficient patients.
Terapevticheskii arkhiv. 2011;83(12):62-68
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Efficacy of rifaximine in intestinal bacterial overgrowth syndrome in patients after cholecystectomy
Mechetina T.A., Il'chenko A.A., Mechetina T.A., Ilchenko A.A.
Abstract
Aim. To define frequency of onset of small intestinal bacterial overgrowth syndrome (SIBOGS) in patients with postcholecystomy syndrome (PCS); to substantiate necessity of microflora correction and assess efficacy of rifaximine in the doses 800 and 1200 mg/day. Material and methods. A breath hydrogen test (BHT) was made in 82 PCS patients. Rifaximine was given to 40 SIBOGS patients: 20 of them received the drug in a dose 800 mg/day and 20 - in a dose 1200 mg/day for 7 days. The efficacy was estimated by attenuation of the clinical symptoms and parameters of BHT. Results. SIBOGS was detected in 73% of PCS patients. This was an indication for antibacterial treatment. Rifaximine in a dose 800 mg/day failed to attenuate pain and to eliminate dyspeptic syndromes in some patients, BHT in them was not normal. Administration of rifaximine in a dose 1200 mg/day normalized BHT in 90% patients and eliminated clinical symptoms in most of the patients. Conclusion. Rifaximine in a dose 1200 mg/day vs 800 mg/day in PCS patients with SIBOGS is more effective as it eliminates clinical symptoms and normalizes BHT.
Terapevticheskii arkhiv. 2011;83(12):68-73
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Treatment of diabetes mellitus in dialysis patients
Bondar' I.A., Klimontov V.V., Bondar I.A., Klimontov V.V.
Abstract
Diabetes mellitus is a key cause of chronic kidney disease (CKD) in developed contries. Disorders of glucose metabolism regulation in CKD are explained by insulin resistance, decreased insulin clearance, weak hormonal response to hypoglycemia. These disturbances appear in inhibition of glomerular filtration rate under 60 ml/min. Hemodialysis treatment raises the risk of hypoglycemic conditions due to glucose elimination from blood circulation during the sessions and improvement of sensitivity to insulin. Use of glucose-containing solutions for dialysis, step-by-step achievement of normoglycemia, monitoring of blood glucose during dialysis sessions are recommended for reducing the risk of hypoglycemic conditions in DM patients on dialysis. Insulin is the most common preparation in the treatment with use of hemodialysis in diabetics. Tiasolidindions (pioglitason, rosiglitason) and analogues of dipeptidilpeptidase of type IV (sitagliptin, saxagliptin) can be administered in type 2 diabetics without insulin insufficiency. As solutions for peritoneal dialysis contain glucose, such dialysis may entail such metabolic complications as fat accumulation, metabolic syndrome. Intraperitoneal introduction of insulin allows avoiding hyperinsulinemia and in some cases to decrease the risk of hypoglycemia. Side effects of intraperitoneal insulin administration are significant absorption of insulin on the surface of the systems for intraperitoneal dialysis, higher rate of peritonitis, subcapsular hepatic steatosis. In the absence of controlled studies the mode of insulin administration in patients on peritoneal dialysis should be chosen individually basing on potential risk and benefit for the patient and experience of the dialysis center. It should be remembered that adequate sugar-reducing treatment is necessary for prevention of complications and prolongation of survival of diabetics on dialysis.
Terapevticheskii arkhiv. 2011;83(12):73-77
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From classification medicine to clinical medicine (the end of the XVIII century 1870s). Communication 4. Health care in the end of the XVIII century first half of the XIX century
Stochik A.M., Zatravkin S.N., Stochik A.M., Zatravkin S.N.
Abstract
This communication deals with problems in health care which existed in the end of the XVIII century - first half of the XIX century.
Terapevticheskii arkhiv. 2011;83(12):78-80
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