Vol 83, No 9 (2011)

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.

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.

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.

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.

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.

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.

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.