Vol 90, No 9 (2018)

Articles
Arterial hypertension in the light of current recommendations
Chazova I.E.
Abstract
Arterial hypertension (AH) refers to the most common cardiovascular diseases. The expert community regularly creates recommendations on the definition, diagnostics and treatment of hypertension. The most significant documents are recommendations American Medical Societies and the European Society for Hygiene in association with the European cardiological society. The latter document, as a rule, is fundamental for the creation of Russian recommendations on AH. Similarities are discussed in the article and differences in perceptions of the classification of hypertension, target levels of blood pressure, approaches to non-drug and drug therapy of the disease.
Terapevticheskii arkhiv. 2018;90(9):4-7
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Features of the clinics and treatment of patients with obesity and hypertension (according to the National register of arterial hypertension)
Oshchepkova E.V., Lazareva N.V., Chazova I.E.
Abstract
The purpose of this study lied in the examination of the clinical characteristics and assessment of the quality of treatment for patients with arterial hypertension (AH) with obesity according to the National Registry of the AH. Materials and methods. The frequency of obesity in a sample of patients with AH, observed in 2010-2016. in polyclinics and cardiological dispensaries for cardiovascular diseases (CVD), was 38.3%, of which the incidence of severe obesity (grade III) was 8%. Women account for the majority of obese AH patients (72%). Results. The study revealed the burden of AH patients with obesity in the following risk factors for CVD: dyslipidemia, hyperglycemia and a history of early cardiovascular disease. Relatively often in patients with hypertension with obesity, there were lesions of target organs (hypertrophy of the left ventricle, chronic kidney disease of the third stage), CVD [ischemic heart disease (CHD), chronic heart failure (CHF) II-IV functional class NYHA] and diabetes mellitus type 2 These data indicate that patients with AH obesity refers to a high and very high cardiovascular risk. The conclusion. Conducted antihypertensive and hypolipidemic therapy (statins) in patients with AH obesity was not optimal, only 30% of patients achieved the target level of BP and 23.6% - the target level of total cholesterol.
Terapevticheskii arkhiv. 2018;90(9):8-14
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Features of the clinical picture in patients of middle age with essential hypertension
Parfenov V.A., Ostroumova T.M., Ostroumova O.D., Pavleyva E.E.
Abstract
Aim. To evaluate the presence and the severity of the complaints (headache, dizziness, memory loss, concentration of attention, sleep disturbances, decreased mood, increased anxiety), the state of cognitive functions, emotional status and quality of night sleep in treatment-naïve middle-aged patients with mild to moderate EAH compared to healthy volunteers of the same age. Materials and methods. 103 treatment-naïve patients with EAH aged 40-59 years at the enrollment, who met the inclusion/exclusion criteria and provided written informed consent (46 men, mean age 53.6±0.8 years) and 50 healthy volunteers (17 men, mean age 51.5±1.0 years) with normal blood pressure (BP) level - control group - were enrolled to the study. Mean EAH duration was 2.9±5.7 years. Cognitive assessment included Montreal cognitive assessment, 10-words learning task, verbal fluency test, TMT, Stroop color and word test. Anxiety and depression were evaluated via Hamilton rating scales (HARS and HDRS). 24-hours ambulatory BP monitoring (ABPM) was performed according to European guidelines. Results. 70% of patients with EAH complained of memory disturbance, 68% - lack of attention, 22% - sleep disturbances, 12% - dizziness, 9% - headache. It took statistically significant more time for patients with EAH to perform on TMT B (p<0.05), they had significantly higher TMT B - TMT A difference score (p<0.01) and lower mean MoCA score (p<0.05). Patients with EAH had significantly higher mean score in Hamilton anxiety (2.1±3.7) and depression (1.1±2.4) rating scales compared to controls (0.3±0.9 points, p<0.01 and 0.1±0.5 points, p<0.001, respectively). Patients with EAH who complained of sleep disturbances had low sleep quality (8.7±2.8 points). Among patients with EAH who complained about headaches 66.6% had episodic migraine and chronic tension type headache (33.4%). Those patients had a substantial impact of headache on life and daily living according to HIT-6 (mean score - 57.5±6.1). Only 2 patients out of 12 with complains about dizziness had benign paroxysmal positional vertigo and Ménière's disease. Conclusion. Complaints about memory dysfunction, lack of attention, sleep disturbances, less common - dizziness and headaches, are most typical in patients with EAH on the early stages of the disease. They differ from healthy volunteers of the same age by having cognitive impairment and higher anxiety and depression scores. Patients with EAH who complained about sleep disturbances had low sleep quality. Headache in patients with EAH was due to episodic migraine and tension type headache which had a negative impact on life and daily living.
Terapevticheskii arkhiv. 2018;90(9):15-26
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PCSK9 Inhibitor causes a decrease in the level of oxidatively modified low-density lipoproteins in patients with coronary artery diseases
Lankin V.Z., Tikhaze A.K., Viigimaa M., Chazova I.E.
Abstract
Aim. We study the dynamics of oxidatively modified low-density lipoprotein (ox-LDL) content in blood plasma, as well as changes in the activity of key antioxidant enzymes such as Se-containing glutathione peroxidase (GSH-Px) Cu,Zn-superoxide dismutase (SOD) and catalase in erythrocytes of patients with coronary artery disease during treatment with PCSK9 inhibitor (ewolocumab). Materials and methods. The study included 9 men (59 ± 10 years) with coronary artery disease with atherosclerotic lesion at least one main coronary artery according to coronary angiography. Patients took standard therapy before taking the study, everyone took the maximum tolerated dose of statins. Since the target cholesterol levels of low-density lipoprotein cholesterol (LDL-C) were not achieved during the statin therapy, patients were prescribed lipid-lowering therapy with the inclusion of the inhibitor PCSK9-emocoucumab from Amgen 420 mg once a month. The content of lipid metabolism indices was determined by standard biochemical methods. The level of ox-LDL in the blood plasma was determined by the immunochemical method. The activity of antioxidant enzymes was determined in blood erythrocytes using biochemical techniques Results. Cholesterol-lowering drug of the new type - inhibitor protein convertase subtilisin/kexin type 9 (PCSK9) evolocumab (Amgen) not only effectively lowers the level of cholesterol in low density lipoprotein (LDL), but also significantly reduces the content of oxdatively modified LDL in blood plasma. Unlike statins, the inhibitor of PCSK9 does not cause a decrease in the activity of antioxidant enzymes of the blood. Conclusion. PCSK9 inhibitor has no effect on the parameters of oxidative stress.
Terapevticheskii arkhiv. 2018;90(9):27-30
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The association of lipoprotein(a) and apolipoprotein(a) phenotypes with peripheral artery disease
Tmoyan N.A., Ezhov M.V., Afanasieva O.I., Klesareva E.A., Razova O.A., Kukharchuk V.V., Pokrovsky S.N.
Abstract
Aim. Lipoprotein(a) [Lp(a)] is an independent risk factor of coronary heart disease (CHD) and myocardial infarction. Data about the role of Lp(a) in the development of peripheral artery disease (PAD) is controversial and uncertain. The aim of the study was to evaluate the association between Lp(a), apolipoprotein(a) [apo(a)] phenotypes and PAD. Materials and methods. The study included 998 patients (707 male and 291 female, average age 60±12). The patients were divided into 4 groups depending on the presence or absence PAD and CHD: group I (n=188, PAD+CHD+), group II (n=78, PAD+CHD-), group III (n=407, PAD-CHD+), group IV (n=325, PAD-CHD-). Results. The level of Lp(a) was significantly higher in groups I, II, III in comparison with patients of control group (group IV): 34 [15; 80], 30 [10; 49], 22 [8; 60] mg/dl vs. 15 [6; 35] mg/dl respectively, p<0.01 in all cases. Lp(a) level was higher in the group I than in the other groups (p<0.05). The prevalence of elevated Lp(a) level (≥ 30 mg/dl) was significantly higher in groups I, II, III than in control group: 54%, 50%, 43% respectively vs. 30%, p<0.01 in all cases. The prevalence of Lp(a) ≥ 30 mg/dl was more frequent in the group with PAD and CHD than in the group with CHD and without PAD (p=0.02). The odds ratio (OR) of PAD in the presence of elevated Lp(a) level was 1.9 (95%CI, 1.4-2.5, p<0.01). Low molecular weight (LMW) apo(a) phenotype was met more frequently in groups I, II, III compared to group IV: 46%, 56%, 52% respectively vs. 28%, p<0.01. LMW apo(a) in the patients without CHD was associated with PAD (OR 3.3; 95% CI, 1.6-6.8, p<0.01), and there was no association with the patients with CHD. In logistic regression analysis adjusted for age, sex, hypertension, obesity, smoking, diabetes, LDL-C, Lp(a) and LMW apo(a) phenotype were independent predictors of PAD when included separately. Conclusions. Elevated level of Lp(a) and LMW apo(a) phenotype are independent risk factors of PAD. The level of Lp(a) in the patients with PAD and CHD was higher than in the case of isolated lesion of each vascular pool. Higher level of Lp(a) is associated with more severe atherosclerosis involving more than one vascular pools.
Terapevticheskii arkhiv. 2018;90(9):31-36
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Screening of familial hypercholesterolemia among patients in age under 40 years old exposed by duplex scanning of carotid arteries, by the local registry data
Gaisenok O.V., Kurnosov P.A., Leonov A.S., Zateyshchikov D.A.
Abstract
The aim of the study - to identify patients with probable FH among Duplex-2013 registry patients under the age of 40 years, to analyze their lipid spectrum and duplex carotid artery data, to evaluate the changes of their lipid spectrum parameters. Materials and methods. The Duplex-2013 registry database was used for this study (n=2550). Patients under the age of 40 years were selected for follow-up analysis (n=192). Results. 20 of them were selected on the basis of Simon Broome criteria as patients with possible FH. The FH group (n=20) and the control group (n=172) had significant differences in age (35.1 ± 4.01 vs. 32.62 ± 5.29, p=0.044), male gender (18 of 20 (90%) vs 92 of 172 (53%), p=0.003), TC (7.64 ± 0.63 vs 5.34 ± 0.91, p=0.0001) and LDL-C cholesterol (5.45 ± 0.62 vs 3.28 ± 0.78, p=0.00001). When comparing the groups by the combined criterion of atherosclerosis (IMT > 1.0 mm and / or atherosclerotic plaque in the carotid artery >20%), it was noted that signs of carotid atherosclerosis were more often recorded in the FH group compared with the control group (40% vs 26%). Repeated laboratory studies of TC and LDL-C in the FH group after 2.5 years showed their significant dynamics (7.64 ± 0.63 vs 6.03 ± 1.04, p=0.007, 5.45 ± 0.63 vs 3.84 ± 1.24, p=0.035). Conclusions. The frequency of detection of FH in the cohort study was 1:10 (11% of all patients). Thus, patients referred for duplex scanning of carotid arteries can be a potential target for screening for FH.
Terapevticheskii arkhiv. 2018;90(9):37-41
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Characteristic of fibrotic myocardial lesions associated with life-threatening ventricular tachyarrhythmias in patients with ischemic and non-ischemic cardiomyopathies
Shlevkov N.B., Zhambeev A.A., Gasparyan A.Z., Shitov V.N., Stukalova O.V.
Abstract
Aim. To identify the features of myocardial scar and fibrosis associated with the occurrence of malignant ventricular tachyarrhythmias (VTs) in high-risk patients with ischemic (ICMP) and non-ischemic cardiomyopathy (NICMP). Materials and methods. This prospective study included 50 patients (41 men, 9 women), age = 60 ± 13 years, 30 patients of them with ICMP and 20 patients with NICMP, who underwent echocardiography (Echo) and contrast magnetic resonance imaging (MRI) of the heart followed by implantation of cardioverter-defibrillators (ICD) or resynchronizing devices with defibrillator (CPTD) to prevent sudden cardiac death. Results. Sustained VTs were reported in 20/30 (67%) patients with ICMP and in 5/20 (25%) patients with NICMP on follow-up [26 (22-37) months]. Successive univariate and ROC-analyses of Echo and MRI-indices between patients with and without recurrence of VTs found different results for ICMP and NICMP patients groups. In ICMP patients the VTs were associated with wide transmural fibrosis on contrast MRI that covered 3 or more segments of left ventricular. These segments were preferably localized in the middle parts of the inferior and inferolateral segments of the left ventricle. The independent predictors of VTs in NICMP patients were non-transmural fibrosis at 4.5% of the left ventricular mass by contrast MRI as well as low left ventricular ejection fraction (less than 26%) by Echo. Conclusion. To determine the indications for implantation of the ICD and CRTD for primary prevention of sudden cardiac death, it is advisable to take into account not only the value of ejection fraction of left ventricular, but also the features of the fibrosis of the left ventricle by contrast MRI of the heart.
Terapevticheskii arkhiv. 2018;90(9):42-47
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Risk factors and in-hospital outcomes of acute kidney injury that developed after coronary artery bypass grafting in patients with stable angina
Kremneva L.V., Suplotov S.N.
Abstract
The aim of the study is to assess frequency, risk factors and in-hospital outcomes of acute kidney injury after coronary artery bypass grafting in patients with stable angina. Materials and methods. The study included patients with stable angina pectoris and indications for coronary artery bypass grafting. We examined 93 patients aged 58±7.6 years, with duration of coronary heart disease 6±6.0 years. Previous myocardial infarction had 79.6% of patients. Arterial hypertension was present in 92.5% of patients. Multi-vessel coronary disease was registered in 94.6%, stenosis of the left main coronary artery > 50% was in 16.1% of patients. Coronary artery bypass grafting in conditions of artificial circulation was performed in 89.2% of patients, coronary grafting on working heart was held in 10.8% of patients. At initial stage, on the first and second days after coronary grafting the level of creatinine was determined by the method of Jaffe. The presence, the severity of acute kidney injury after (AKI) coronary artery bypass grafting was evaluated according to the criteria KDIGO (2012). We took into account in-hospital complications: cardiac death, intraoperative myocardial infarction (iMI), stroke, atrial fibrillation (AF), acute heart failure (AHF) according to requirement in intraaortic balloon pump, and the use of adrenaline. Results. The proportion of persons with transient AKI stage 1 after coronary artery bypass grafting was 31.2%, those of 2 stage was 3.2%. The development of AKI was associated with cases of AHF. The increase in the duration of therapy with adrenaline - more than 1±1.8 days (median) - was connected with increase of the relative risk of AKI developing in 1.9 times. The incidence of cardiac death, iMI, strokes, paroxysmal AF did not differ among patients with AKI and without it. Conclusion. The frequency of transient AKI after coronary artery bypass grafting was 34.4%. The development of AKI is associated with AHF that occurred during coronary artery bypass grafting. The frequency of hospital complications did not differ among patients with AKI after coronary artery bypass grafting and without it.
Terapevticheskii arkhiv. 2018;90(9):48-52
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The periprocedural myocardial damage prevention during elective percutaneous coronary intervention as a result of pharmacological preconditioning with an oral form of nicorandil in patients with stable coronary artery disease. Pilot study
Gostishchev R.V., Soboleva G.N., Samko A.N., Rogoza A.N., Minasyan A.A.
Abstract
The purpose of the study is to prove the effectiveness of pharmacological preconditioning caused by nicorandil in patients with stable coronary heart disease (CHD) during the elective percutaneous coronary intervention (PCI). Materials and methods. We included 88 patients with a stable form of CHD, who were going to pass the elective PCI, in the study. As the method of blind randomization envelope method was used. There were formed two groups or patients: the first group involved 45 patients - were treated with nicorandil (Cordinic, PIQ-FHARMA LLC) (the main group) the other group included 43 patients who were treated by the standard therapy (the comparison group). The basic antianginal therapy was allowed to use in both groups: beta-blockers, calcium antagonists, ATE inhibitors / angiotensin II receptor blockers, statins, acetylsalicylic acid, blockers of P2Y12 receptor platelets. The admission of prolonged form of nitrates before the PCI was allowed in the second group. Patients from the 1st group were to take nicorandil 2 days and 1 day before the PCI at the 30 mg/day dose, then 20 mg orally 2 hours just before PCI, and one more time 6 hours after the PCI - 10 mg nicorandil. Highly sensitive troponin (HS-Tp) as a biomarker of irreversible damage to the myocardium was evaluated before PCI and after PCI in 24 hours. Were used highly sensitive troponin (HF-Tr) and creatine phosphokinase-MB as an irreversible myocardial damage biomarkers. The analysis of which was conducted before PCI and 24 hours after the surgery. Results. The obtained data shows the significant differences of an increase in hs-Tp in 24 hours after PCI in patients with no admission of nicorandil (117 ng/l) as compared with the nicorandil group (73 ng/l), p = 0.04. There were significant differences in the 24 hours increment in hs-Tp in the control group, it was higher (112 ng/l) than in the nicorandil group (67 ng/l), p = 0.03. There was also a significant decrease in CK-MB after 24 hours in the nicorandil group (2.7 ng/L) compared to the control group (2.0 ng/L), p = 0.008. Also the frequency of the troponin increase above the UNL(upper normal level) in the nicorandal group, was significantly (p = 0.03) lower (in 62% of cases compared to 85% of the control group). Conclusion. The prevention of the complications during the percutaneous myocardial revascularization should be considered with the position of the most suitable pharmacological support. The appointment of the oral form of nicorandil (Cordinic, PIQ-FHARMA LLC) for 2 days and 1 day before PCI 30 mg/day, then 20 mg 2 hours before the PCI and 10 mg after 6 hours after the surgery reduces the risk of intraoperative myocardial damage. The obtained data give an opportunity to extend the indications for nicorandil's appointment in the drug support during PCI in patients with stable coronary artery disease.
Terapevticheskii arkhiv. 2018;90(9):53-59
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Risk factors for diastolic left ventricular myocardial dysfunction in patients with chronic kidney disease
Rudenko T.E., Kamyshova E.S., Vasilyeva M.P., Bobkova I.N., Solomakhina N.I., Shvetsov M.Y.
Abstract
Purpose of the study. To examine the frequency and risk factors for the development of diastolic dysfunction (DD) of the left ventricle (LV) of the heart in patients with chronic kidney disease (CKD). Materials and methods. The study included 225 patients with stage I-CKD of non-diabetic etiology (median age 47.0 years, 50.2% of women). Depending on the degree of decrease in the glomerular filtration rate (GFR), all patients were divided into 3 groups. Group 1 (n=70) consisted of patients with GFR 89-45 ml / min / 1.73 m2, group 2 (n=120) - patients with GFR 44-15 ml / min / 1.73 m2, group 3 (n=35) - patients with GFR <15 mL / min / 1.73 m2. The control group includes persons without CKD. All patients underwent general clinical examination and transthoracic echocardiography; in 86 patients the level of cystatin C in the blood serum was determined. Results. Hypertrophy of the left ventricle (LVH) of the heart was detected in 87 (38.7%) of 225 patients with CKD. Hypertrophic type (type I) of myocardial DD is diagnosed in 90 (41.4%) of 225 patients with CKD. The incidence of myocardial left ventricular dysfunction of the 1st type increased with a decrease in GFR, amounting to 30, 40 and 60% in groups 1, 2 and 3, respectively. The systolic function of the left ventricular myocardium was preserved. Patients with DD were older, they had a higher body mass index (BMI), a more pronounced decrease in GFR, a higher level of fibrinogen. They were more likely to have LVH. The level of cystatin C as the kidney function worsened, but when comparing the mean levels of cystatin C in patients with the presence / absence of DD in the groups isolated depending on the stage of CKD, no statistically significant differences were found. According to the multivariate analysis, the independent predictor of DD was the age (odds ratio 1.106, 95% confidence interval 1.051-1.157, p=0.00001). The conclusion. DD of the myocardium of the LV is detected on average in 40% of patients with CKD, the frequency of its development increases with the progression of renal dysfunction. The development of DD is influenced by traditional factors of cardiovascular risk (age, BMI), as well as the decline in GFR and closely related structural remodeling of LV myocardium.
Terapevticheskii arkhiv. 2018;90(9):60-67
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The level of NT-proBNP in ambulatory patients with chronic heart failure with preserved ejection fraction of the left ventricle
Kirillova V.V., Sokolova L.A., Meshchaninov V.N., Pershanova V.I.
Abstract
The prevalence of chronic heart failure (CHF) remains high. Echocardiography is a reliable method of diagnosing heart failure. Determination of brain natriuretic peptide allows to identify patients with the most probable diagnosis of heart failure, which requires further instrumental examination of patients. Aim. To study the level of the brain natriuretic peptide in patients with diastolic chronic heart failure with preserved left ventricular ejection fraction. Materials and methods. The study included 96 outpatients with diastolic chronic heart failure I-III functional class with a preserved left ventricular ejection fraction at the age of 65.06 ± 1.15 years and 50 practically healthy people aged 39.90 ± 1.64 years as a control group who underwent a preventive examination. The level of the N-terminal fragment of the medullary natriuretic peptide (NT-proBNP) in serum was determined using a test system (Vector-Best, Russia). Results. The concentration of NT-proBNP in patients with diastolic heart failure with a preserved left ventricular ejection fraction was 108.18 ± 21.64 in the range from 0.0 to 1212.3 pg/ml compared to the control of 7.6 ± 1.38 pg/ml, p<0.05. A positive correlation was found between the concentration of NT-proBNP and the area of the left atrium (r=0.35), left ventricular E/e '(r=0.6), and left ventricular end-systolic volume (r=0.48). The level of NT-proBNP had no correlation with the functional class of CHF (r=0,23), as well as with the stage of CHF (r=0,23). Conclusions. Thus, patients with diastolic CHF with a preserved ejection fraction in 67% of cases had a level of NT-proBNP in the blood less than the diagnostic threshold. The concentration of NT-proBNP in the serum positively correlates with increased pressure in the cavity of the left ventricle, the end-systolic volume in it and the area of the left atrium.
Terapevticheskii arkhiv. 2018;90(9):68-72
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Intravital and postmortem diagnostics of myocardial hypertrophy of the left ventricle:identity or convention?
Bogomolov S.N., Kulikov A.N., Tikhonova J.A., Solntsev V.N., Rybakova M.G., Gudkova A.Y., Kuchmin A.N.
Abstract
The aim of the study is to assess the compliance of the results of electrocardiographic (ECG) and echocardiographic diagnostic methods of hypertrophy of left ventricular myocardium (LVH) with the postmortem finding of measurement of left ventricular myocardium mass (LVM). Materials and methods. We examined the data of intravital study of anthropometric measurements [age, height, weight, body mass index (BMI)], instrumental results [12-lead ECG, EchoCG], as well as the postmortem finding (direct measurement of LVM at autopsy) in 15 patients of general therapy department. While analyzing ECG we studied as conventional ECG criteria for the detection of LVH as well as the author's own criteria based on two models (regression and discriminant analyses), including voltage, sex and age criteria. Echocardiographic diagnostic method used to calculate LVM (according to ASE formula) and left ventricular mass index (LVMI). Postmortem finding of LVM was carried out according to the standard measurement method. According to the absence of the single conventional postmortem finding of measurement of LVH, we considered three different variants of the postmortem finding of LVH: the criterion of K. Bove et al. (CB); the criterion of A.M. Lifshitz, also called ventricular index (VI) and the criterion of P. Casale - the left ventricular mass index at autopsy (LVMI). Results and discussion. Conventional ECG criteria for the detection of LVH showed high specificity (71-100%) using any method of the postmortem finding of measurement, but were characterized by extremely low sensitivity (0-37.5%). Their overall diagnostic accuracy was higher on using K. Bove or A.M. Lifshitz criteria (40-66.7%) and low - on using the criterion of P. Casale (13.3-40%). The author's ECG criteria were less specificity (50-100%) and had higher sensitivity (54-75%), and their diagnostic accuracy remained higher and showed small dependence on the method of the postmortem finding of measurement of LVH (60-66.7%). Conclusion. Usually the ECG criteria to diagnose left ventricular hypertrophy were expectedly showed low sensitivity using any method of the postmortem finding of measurement. Meanwhile, the author's own ECG criteria associated with the most sensitive electrocardiographic characteristics to LVH and sex and age-specific indexes of the examined patients exceeded the conventional ECG criteria in sensitivity and diagnostic accuracy.
Terapevticheskii arkhiv. 2018;90(9):73-80
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Exudative-constrictive tuberculous pericarditis in combination with arthritis in cardiologist practice: thoracoscopic biopsy as a diagnosis and treatment method
Blagova O.V., Alijeva I.N., Nedostup A.V., Kaburova A.N., SenchihiN P.V., Parshin V.D., Kogan E.A.
Abstract
The goal is to present the possibilities of diagnosis verification, the features of the clinical picture of tuberculous pericarditis in the therapeutic clinic and the results of its treatment. Materials and methods. The paper presents clinical observation and a general analysis of 10 cases of tuberculous pericarditis in patients aged 31-79 (mean age 58.0 ± 15.1 years), 6 women and 4 men. Diagnostic puncture pericardium was performed on two patients, pleural puncture - on three Thoracoscopic biopsy of hilar lymph nodes and lung (n=1), pleura (n=1), supraclavicular lymph node biopsy (n=1). Dyskin test was carried out, as well as sputum examination, multispiral computed tomography, oncological search. Results. A 31-year-old patient with a massive effusion in the pericardial cavity, pleural lesion, arthritis of the left knee joint, whose results of the pericardial effusion and sputum were not diagnosed, tuberculosis was detected only with thoracoscopic biopsy of the lung and intrathoracic lymph nodes; the treatment via prednisolone and subtotal pericardectomy was performed. Among 10 patients with MSCT of the lung, changes were noted in general, but in only one case they were highly specific. Diaskin test is positive in 70%. In the study of punctata, bronchoalveolar flushing, Koch bacteria were not detected; at sputum in microscopy and biological sample BC was detected in two patients. The lymphocytic character of effusion in the pericardium / pleura is noted in 4 out of 5 cases. At a biopsy of lymphonoduses and a lung at 2 patients the picture of a granulomatous inflammation with a caseous necrosis. Pericarditis was predominantly large (from 2 cm and more) effusion, signs of constriction were noted in 50% of patients. Conclusion. Tuberculosis is one of the frequent causes of pericarditis in the Moscow therapeutic clinic. The most lymphocytic effusion with fibrin and the development of constriction. The negative results of all laboratory tests for tuberculosis do not exclude a diagnosis, It is necessary to use invasive morphological diagnostics, including thoracoscopic biopsy.
Terapevticheskii arkhiv. 2018;90(9):81-87
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Renal denervation with a resistant arterial hypertension: the results of a five-year follow-up
Glybochko P.V., Svetankova A.A., Rodionov A.V., Maltseva A.S., Sulimov V.A., Fomin V.V.
Abstract
Aim. To evaluate the 5-year results of renal denervation (RDN) in patients with resistant arterial hypertension (AH). Materials and methods. The study included 14 patients to whom, during the 2011-2013 period RDN has been completed. Before and after the intervention, office blood pressure, quality of life indicators according to the EQ-5D questionnaire, mass index bodies, indicators of kidney function were duly assessed. Results. Five years after RDN, office BP decreased from 165/110 to 139/95 mm Hg. Art. (p<0.05), with the average number of of drugs decreased from 4.6 to 3.1. 12 months after the RDA, the quality of Life, based on the questionnaire EQ-5D has increased from 60 to 80 points, by the fifth year the indicator fell to 74 points. Body mass index during 5 years decreased from 33.8 ± 3.5 to 30.9 ± 3.0 kg/m2. Mean plasma creatinine initially and after 5 years remained within the normal range, the mean the GFR score after 5 years being decreased by 9.5 ml/min/1.73 m2. Conclusion. RDN can be regarded as effective and safe method of additional treatment of patients with resistant hypertension.
Terapevticheskii arkhiv. 2018;90(9):88-91
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Proton pump inhibitors receiving and prognosis of patients after scheduled percutaneous coronary interventions
Komarov A.L., Shakhmatova O.O., Muraseeva V., Novikova E.S., Guskova E.V., Panchenko E.P.
Abstract
The urgency of the study is determined by the lack of data necessary in order to assess the safety of prolonged use of proton pump inhibitors (PPI) in patients with IHD combined with anti-aggregant therapy. The aim of the study was to study the relationship between the use of PPI and the risk of thrombotic complications in patients undergoing planned procedures of percutaneous coronary interventions (PCI) and receiving dual antiplatelet therapy. Materials and methods. The study is a prospective register of patients who successfully underwent planned percutaneous coronary intervention (PCI). The effect of PPI (omeprazole and pantoprazole) on the frequency of the combined end point cardiovascular death, ACS, AI, TIA, peripheral arterial thrombosis and PE was assessed using the Log-Rank criterion, as well as in a multivariate analysis (Cox proportional risk regression model). Results. A total of 391 patients were included in the study (23.1% women, mean age 61.2 [Symbol] 10.4 years). The median duration of follow-up was 18 months. During this period of time, 34 adverse events were recorded. Log-Rank analysis showed that the proportion of patients without adverse events in the omeprazole group was significantly lower in comparison with patients who did not receive PPI (0.56 vs. 0.84, Log-Rank p=0.003), and for pantoprazole no such pattern was found (0.89 against 0.84, Log-Rank p=0.21). The average level of residual platelet reactivity (ORT), as well as the number of patients with high ORT (> 208 PRU), did not differ significantly between the groups of omeprazole, pantoprazole and the group of patients not receiving PPI. According to multivariate analysis, omeprazole was an independent predictor of thrombotic complications after a planned PCI (OR 3.75, 95% confidence interval 1.72-8.17, p=-0.0009). Conclusion. Long-term use of omeprazole (at least 30 days) is an independent predictor of thrombotic complications in patients who underwent planned PCI.
Terapevticheskii arkhiv. 2018;90(9):92-100
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The economic burden of chronic thromboembolic pulmonary hypertension in Russian Federation
Chazova I.E., Martynyuk T.V., Valieva Z.S., Nakonechnikov S.N., Nedogoda S.V., Salasyuk A.S., Taran I.N., Gratsianskaya S.E.
Abstract
Aim. The aim of current study was to estimate the economic burden of the chronic thromboembolic pulmonary hypertension (CTEPH) in Russia based on patient registry. Materials and methods. Cost of illness study was based on data derived from CTEPH patient registry that was developed at the Division of hypertension of FSBI “National Medical Research Center of Cardiology”. Demographic and clinical patient characteristics were analyzed with descriptive statistic methods. Cost of illness study was performed from the state perspective and with bottom-up approach. Bootstrapping was used for calculation of average costs per patient/year. Within the study direct costs (medical costs: outpatient, inpatient, emergency, PAH-specific therapy, concomitant therapy; non-medical costs: pension due to disability status, payments for patients on sick-leave) and indirect costs (loss in GDP) were estimated. Results. Overall, 113 CTEPH patients (67 women and 46 men) from 33 Russian regions were included, mean age of patients with CTEPH was 54.6±13.95 years. Most of the patients (55%) were in able-bodied age. It was found that about half of patients with diagnosed CTEPH had a disability. Average duration of disease at the time of analysis was 6.88±11.41 years. Period from the first occurrence of symptoms to the confirmation of diagnosis of CTEPH was 2.58±5.21 years on average. More than 70% of patients had III and IV FC (WHO) at the time of diagnosis. Mean number of outpatient visits was 1.97±1.65 per patient/year, and inpatient visits were reported for 59% of patients. About 54% of patients used PAH-specific therapy, moreover 46% patients had interruptions of PAH-specific therapy (58.4±66.3 days). The total costs of CTEPH per patient/year were calculated as 805,901 RUB. The overall burden of CTEPH in Russia for total CTEPH population (470 patients) was 379 million RUB per year. Conclusions. CTEPH is the rare disease that is characterized with later diagnosis due to absence of disease-specific symptoms. Therefore economic burden of the CTEPH is significantly low in comparison to widespread cardiovascular diseases. Development of network of expert PH-centers and increase of the access for PAH-specific therapy will help to increase the quality of health care for patients with CTEPH.
Terapevticheskii arkhiv. 2018;90(9):101-109
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Clinical observation of a patient with arterial hypertension and obstructive sleep apnea syndrome
Larina V.N., Bart B.Y., Mironova T.N., Litvin A.Y., Kylbachinckaya O.M.
Abstract
Представлено клиническое наблюдение пациентки с артериальной гипертензией и синдромом обструктивного апноэ сна, получающей лечение в амбулаторно-поликлинических условиях.
Terapevticheskii arkhiv. 2018;90(9):110-114
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Family hyperaldosteronism type I: a clinical case and review of literature
Chikladze N.M., Favorova O.O., Chazova I.E.
Abstract
Family hyperaldosteronism type I (glucocorticoids-remediable hyperaldosteronism) is a rare form of symptomatic arterial hypertension (AH), which often leads to the development of cerebrovascular complications. The disease is caused by the formation of the chimeric gene CYP11B2/CYP11B1. Expression of the chimeric gene is regulated by adrenocorticotropic hormone, and glucocorticoid therapy leads to a decrease in aldosterone secretion and normalization of blood pressure. The article presents the first clinical case of this monogenic disease diagnosed by us in Russia. The features of clinical course and treatment of the patient have been traced in the dynamics for 40 years of observation. Modern approaches to the diagnosis and treatment of this rare family form of hypertension are discussed.
Terapevticheskii arkhiv. 2018;90(9):115-122
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Worksite hypertension as a model of stress-induced arterial hypertension
Ostroumova O.D., Kochetkov A.I.
Abstract
The review presents a modern view on stress as a risk factor for the development of arterial hypertension (AH). A variety pathogenic mechanisms responsible for increase of blood pressure during stress exposure are described in detail. The importance of the sympathetic activation as a key link in the development of stress-induced AH and initiation of a cascade of pathophysiological reactions that realize their adverse effects at the level of the whole organism is underlined. Particular attention is paid to worksite AH as a variant of stress-induced hypertension due to its wide prevalence and association with an increased risk of cardiovascular complications, primarily myocardial infarction and stroke. Epidemiological data and results of recent metanalysis are presented, indicating the high significance of job strain as a risk factor for adverse cardiovascular events. The actual psychological stress reduction programs are described. Possibilities of using β-blockers in patients with stress-induced hypertension as drugs affecting the central pathogenetic trigger of this disease are considered. The advantages of using bisoprolol as a highly selective β-blocker are considered taking into account the available body of evidence for its effectiveness in patients with worksite AH, as well as its metabolic neutrality and target-organ protective properties.
Terapevticheskii arkhiv. 2018;90(9):123-132
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Determination of predictors of successful recanalization of the chronic occlusions of coronary arteries by means of CT-coronarography method
Veselova T.N., Aznaurova N.K., Ternovoy S.K.
Abstract
The review illuminated actual issues of the diagnostic efficiency of computed tomography (CT) of the coronary arteries in the planning of the procedure percutaneous coronary intervention (PCI) in patients with chronic occlusion of coronary arteries (CTO). The results of researches of detection of predictors of unsuccessful recanalization according to traditional coronary angiography (CAG) and CT angiography were presented. The major CT characteristics of the CTO, which can supplement the coronary angiography data to predict outcomes of the PCI were discussed.
Terapevticheskii arkhiv. 2018;90(9):133-137
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Arterial hypertension at the workplace: risk factors and the population value
Strizhakov L.A., Babanov S.A., Lebedeva M.V., Moiseev S.V., Fomin V.V.
Abstract
The article presents data of domestic and foreign authors on the relationship between occupational factors and arterial hypertension. The role of latent arterial hypertension, its frequency in the population, the lesion of the target organs and the prognosis in comparison with normotensive individuals, arterial hypertension of the "white coat" and stable arterial hypertension have been analyzed. Arterial hypertension in the workplace is a form of latent arterial hypertension. The authors review the influence of harmful production factors (physical, chemical), as well as psychosocial stress on the risk of developing arterial hypertension.The risk of developing hypertension in specified groups of workers has been analyzed separately. The place of production-related diseases in modern occupational pathology in the Russian Federation. A wider implementation of measures aimed at early diagnosis and prevention of arterial hypertension in workers is proposed.
Terapevticheskii arkhiv. 2018;90(9):138-143
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Vitamin D deficiency and cardiovascular pathology
Podzolkov V.I., Pokrovskaya A.E., Panasenko O.I.
Abstract
Vitamin D deficiency is widespread worldwide and present in about 30-50% of population. In most cases, this problem is associated with musculoskeletal system pathology: rickets in children, and osteomalacia or osteoporosis in adults. However, in recent years, convincing data was obtained on the links between vitamin D deficiency and cardiovascular pathology. Low Vitamin D levels in humans are associated with the unfavorable cardiovascular risk factors, such as arterial hypertension (AH), diabetes mellitus, and dyslipidemia, which are the predictors of the severe cardiovascular diseases, including strokes and infarctions. It has been demonstrated that vitamin D has a strong vasoptotective effect via endothelial dysfunction improvement, prevents blood vessels and myocardium remodeling, improves blood pressure parameters, reduces the risk of development of left ventricular hypertrophy, slows down fibrosis, reduces the risk of atherosclerosis, reduces insulin resistance, and also affects inflammation and immunity. This article provides data of Russian and foreign studies demonstrating the effect of Vitamin D deficiency on the development of atherosclerosis, AH, heart rhythm disorder and progression of chronic heart failure.
Terapevticheskii arkhiv. 2018;90(9):144-150
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