Search

The primary diagnosis of “dilation cardiomyopathy” is syndromal, and demands clarification of nosological origins. In the article, the specifics of such diagnostics is discussed. Clinical case is provided that illustrates the ways of management, diagnostics and treatment of the essential (primary, genetically determined) dilation cardiomyopathy. Patient of 22 year old with no family history, at the ages 20 and 21 y.o. had cardioembolic strokes. Paroxysmal atrial fibrillation was found, raised creatine kinase levels up to 349-1045 U/L, decreased ejection fraction 17%. Heart failure rapidly progressed. In endomyocardial biopsy there was homogenisation of cardiomyocytes, subendocardial lipomatosis with borderline virus-negative myocarditis. By Senger direct sequencing, the novel variant p.E372 in gene LMNA was found, heterozygous. Implantation of CRT-D was done, and in 4 months — cardiac transplant.

Dilation cardiomyopathy (DCMP) remains a disease with poor prognosis.Aim. To study the importance of risk stratification improvement for fatal outcomes, especially sudden cardiac death (SCC), with the aim for on-time prevention procedures, as the previously proposed non-invasive electrophysiological predictors — heart rhythm turbulence (HRT) and variability (HRV), microvolt alternation of T wave (mTWA), deceleration capacity (DC) and acceleration capacity (AC) in DCMP are not studied well enough.Material and methods. During 4 years there was follow-up of 54 DCMP patients and sinus rhythm at the age 42 [30;58] year-old (36 males) and control group — 54 persons with no cardiovascular pathology (32 males, mean age 47 [27;64] y.o.). At baseline the Holter monitoring was done, of ECG with HRV, HRT, DC, AC, mTWA assessment, and echocardiography. Patients took standard treatment of chronic heart failure (CHF); part of cardioverter-defibrillator (CD) implanted was 18,5%.Results. Mean ejection fraction (EF) in the main group was 32% [22;38], signs of CHF had 93% of patients. Those with DCMP differed from the main group by significantly lower values of SDNN, pNN50, DC, TO, TS, higher AC and mTWA in early morning. During 4 years there was 1 SCD, and 7 died from CHF progression; there was 1 adequate shock in CD patient (totally 9 deaths). Comparing to those survived, died patients had had lower EF, HRV, DC, maximal mTWA values, higher end diastolic volume, CHF class, AC, mTWA, number of episodes of non-sustained ventricular tachycardia (nsVT) in morning. Under monofactorial analysis there was significant influence on fatal outcome risk of the following (in order of declining significance): EF (odds ratio (OR) 32), SDNN (OR 21), DC (OR 9), AC (OR) 7, pNN50 (OR 6), nsVT (OR 5,2; p=0,05). In multifactor analysis the only independent predictor of fatal outcomes was the decrease of EF of the left ventricle less than 26% (sensitivity 80%, specificity 90%).Conclusion. DCMP patients, comparing to persons with no cardiovascular pathology, have decreased HRV and DC, increased AC, more common pathological HRT, increase of mTWA in early morning, and in those died these specifics was more prominent. In monofactor analysis the non-invasive electrophysiological predictors associated with poor DCMP prognosis, were AC, SDNN DC, pNN50, nsVT. However the most significant and the only independent predictor of fatal outcomes in DCMP patients is the decrease of EF. If to apply the EF less than 26% as a criteria of high risk, it predicts the 32 times increase of fatal outcomes risk with sensitivity 80% and specificity 90%.

The main clinical presentation of noncompaction myocardium (NCM) as nosologic unit are thromboembolic syndrome, heart failure, mostly ventricular arrhythmias and ischemia itself, related to insufficient myocardium blood supply under the noncompacted layer. Also, there are only sporadic cases of myocardial infarction described (MI), including “idiopathic”, in NCM.Aim. To check the prevalence of acute MI in patients with NCM, the specialties of clinical picture, diagnostics, and its probable specific mechanisms, influence on prognosis and its ways of prevention.Material and methods. Totally, 10 patients included, 7 males and 3 females, mean age — 46,3±15,8 y. o., (30 to 76 y. o.) among 85 patients with verified NCM diagnosis, set in accordance with harmonized visual criteria, and developed MI on this background. In 4 cases the NCM is confirmed with three visualizing criteria (EchoCG, MSCT, MRI of the heart), in 4 other — with the two. Mean follow-up was 10,5 [1,75; 32,25] months — from 1 month to 1 year. All patients underwent ECG, ambulatory ECG recording by Holter, EchoCG, assessment of antibodies against various heart antigens, PCR for DNA of parvovirus and B19, as well as herpes group, in blood; 7 coronary arteriographies, 7 MSCT of the heart, measurement of Troponin (n=7), morphological investigation of the heart with PCR-diagnostic of viral infection (n=6), MRI (n=5) and myocardium scintigraphy with 99mТс (n=6).Results. In 4 among 10 patients the development of MI was the first presentation of NCM. Prevalence of coronary atherosclerosis in those with MI and NCM was 20%, however in most cases development of MI was not related with coronary atherosclerosis. Intracardiac thrombosis was verified in 60% of patients with MI, embolism to other organs in 30%. The following mechanisms of MI established: 1) thromboembolism to coronary arteries if thrombi are present in the left chambers of the heart (atrium a. w.a. ventricle), verified in 1 patient at autopsy, and is suspected in other five; 2) concomitance of myocarditis, incl. viral, with microvasculitis development and thrombosis of intramyocardial arteries and focal necrosis in ischemized myocardium (n=6); 3) thrombosis of coronary arteries with presence of hemodynamically significant atherosclerosis (probably 1 patient); 4) sudden worsening of blood supply under noncompacted layer under the circumstances of low cardiac output by secondary origins.Conclusion. MI is typical and unrare complication of NCM: its prevalence reached 11,8% in separate registry of 85 patients with NCM syndrome. Four probable mechanisms of MI (necrosis) in NCM (embolism, thrombosis, myocarditis, microcirculation disorder) might be comorbid. The development of MI leads to serious worsening of the baseline systolic dysfunction and ventricular rhythm disorders: mortality among MI patients with NCM is 20% with the mean time of follow-up 10,5 months. As a preventive matter against MI in NCM should be concerned the anticoagulants at least for atrial fibrillation and in systolic dysfunction, on-time diagnostics and myocarditis management.

The basic differences of updated Guidelines (2010) in comparison with previous ones (2001, 2006) are discussed, namely - the classification of atrial fibrillation, evaluation of its course and severity, and treatment approaches. Therapy strategies which were significantly changed are considered in details.

Aim. To compare antihypertensive, antianginal and antiischemic efficacy of β1-selective adrenoblockers (betaxolol and metoprolol tartrate) in patients with arterial hypertension (HT) of 1-2 degree associated with stable angina class II.Material and methods. 100 patients (aged 23-66 y.o.) with HT associated with stable angina or without angina were involved in the study. Patients were randomized into 2 groups (G1 and G2). G1 patients were treated with betaxolol, and G2 patients – with metoprolol tartrate. Ambulatory BP and electrocardiogram monitoring, exercise stress-test, echocardiography, evaluating of respiratory function, blood analysis was performed initially and in 30 and 90 days of treatment.Results. Target BP level was reached in 44 (88%) patients treated with betaxolol (average daily dose 10±4 mg). 34 patients of G1 took 10 mg daily. Target BP level was reached in 41 (82%) patients treated with metoprolol tartrate (average daily dose 150±27 mg). 30 patients of G2 took 150 mg daily. Exercise tolerance increased and a number of ischemic ST segment depressions reduced significantly in both groups. There were no significant differences in antihypertensive, antianginal, and antiischemic efficacy between groups.Conclusion. Betaxolol advantage is an ability to maintain target BP level more than 24 hours. A possibility to take betaxolol once a day raises patient’s compliance with therapy.

New data and perspectives of antithrombotic therapy are highlighted in patients with atrial fibrillation. Factors of warfarin therapy efficacy, as well as the possibility of new antithrombotic drugs are considered. Special attention are paid to the direct thrombin inhibitors — dabigatran. Possibilities and usage prospects of dabigatran in patients with atrial fibrillation are discussed in detail in the light of new results of RE-LY trial.

Aim. To study a rate of resistance to acetylsalicylic acid (ASA) and clopidogrel and clinical outcomes in patients with atherosclerosis and diabetes mellitus type 2 (DM2).Material and methods. 154 patients were involved in the study and split into two groups. 100 patients (47 men, 53 women; aged 66,4±7,8 y.o.) with ischemic heart disease (IHD) (which was presented by angina pectoris, class I-III, or myocardial infarction history) were included into the first group (G1). Other 54 patients (38 men, 16 women; aged 64,1±10,2 y.o.) with IHD associated with obliterative atherosclerosis of lower limb were included into the 2nd group (G2). Platelet aggregation was evaluated by Born's method (inducers of platelet aggregation were arachidonic acid and ADP). Reduction of platelet aggregation ≥20% after arachidonic acid induction was considered as criterion of resistance to ASA. Patients were considered as resistant, partly resistant and sensitive to clopidogrel if platelet aggregation reduced on Results. Rate of ASA and clopidogrel resistance in patients with DM2 was significantly higher than these in patients without DM2 (48% vs 16% respectively, р=0,003 in G1; 42% vs 7% respectively, р=0,007 in G2).Conclusion. Resistance to antiplatelet drugs is observed more often in patients with DM2 and can result in increased risk of cardiovascular complications.

Background. Chronic heart failure (CHF) progression is accompanied by remodeling of muscular, collagen and vascular elements of myocardium. This can lead to increase in serum concentrations of myocardial lesion markers (cardiac troponin I (TrI) and myoglobin) which seem to correlate with poor prognosis in patients with CHF.Aim. To estimate correlations between cardiac TrI, myoglobin, creatine phosphokinase MB-fraction (MB-CPK) serum concentrations and disease severity and prognosis in CHF patients.Material and methods. Fifty eight patients with CHF of different etiology were included into the study. Physical examination, clinical and biochemical blood assays, chest X-ray study, echocardiography and ECG daily monitoring (initially and at the end of the study) were carried out. TrI and myoglobin levels were estimated by immunoenzymometric assay. The follow-up period was 6 months. The following end points were used: CHF worsening caused hospital admission, acute myocardial infarction, and lethal outcome.Results. Mean TrI and myoglobin concentrations equaled 0.04 [0.02; 0.06] ng/ml and 62.95 [35.86; 77.28] μg/l, respectively. Demographic characteristics of patients (gender, age) did not influence these markers levels. TrI concentration correlated with CHF severity: it was significantly higher in patients with CHF of functional class (FC) III-IV than in those with CHF of FC I-II (p

Aim. To evaluate the incidence of acetylsalicylic acid (ASA) and clopidogrel resistance in patients with acute coronary syndrome with ST-segment elevation and to find out possible clinical factors, contributing to this state.Material and methods. 58 patients with acute coronary syndrome with ST-segment elevation (49 men, 9 women) were included into the study. Age of patients ranged from 37 tо 84 y.o. (60,8±12,3 y.o. in average). Platelet aggregation was assessed by the Born’s method. Level of arachidonic acidinduced aggregation ≥20% considered as ASA resistance. Decreasing of ADP-induced platelet aggregation ≥20% considered as ASA resistance. Decreasing of ADP-induced platelet aggregation

Possibilities of modern antiplatelet and antithrombotic therapy at percutaneous coronary interventions in patients with coronary artery disease are surveyed. Data of multicenter randomized clinical trials and meta-analyses are discussed. Possibilities of various drugs at percutaneous coronary interventions are reported from position of the international clinical guidelines.

Aim. To estimate a risk factor frequency of venous thromboembolism (VTE) in patients urgently hospitalized in hospitals, and also to estimate of patients part having effective prevention of VTE.Material and methods. ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk of Venous Thrombosis in Acute Hospital Care Setting) is the international register. Patients of 40 years and older hospitalised in therapeutic departments as well as patients of 18 years and older hospitalised in surgical departments (358 hospitals in 32 countries) were included in the register. The case history analysis of all patients was performed for estimation of risk VTE and evaluation of preventive therapy quality according to American College of Chest Physicians (ACCP) Recommendation 2004.Results. Totally 68 183 patients (including 30 827 (45%) surgical patients and 37 356 (55%) therapeutic patients) were enrolled in Global ENDORSE Register. Russian centers enrolled 4 788 patients (including 2 829 (59%) surgical patients and 1 959 (41%) therapeutic patients). Totally 35 329 (51,8%) patients enrolled in Global ENDORSE Register (64,4% of surgical patients (19 842) and 41,5% of therapeutic patients (15 487)) had VTE risks. In Russia 2 188 enrolled patients (45,7%) had VTE risks (52% of surgical patients (1 470) and 36,7% of therapeutic patients (718). Totally 17 732 (50,2%) patients enrolled in Global Register ENDORSE and having VTE risks received VTE preventive therapy according to АССР Recommendations 2004. In Russia 521 (23,8%) patients enrolled in Global ENDORSE Register and having VTE risks received VTE preventive therapy according to АССР Recommendations 2004. It is more than 2 times less in comparison with world level (р

The problem of antiplatelet drug choice in patients with atrial fibrillation is discussed. Authors give special attention to new alternative drugs for prevention of thrombotic complications apart from old known antiplatelet drugs.

Basic principles of the management of patients with atrial fibrillation (AF) are discussed taking into account recommendations of the European Society of Cardiology (2010). Peculiarities of AF diagnosis, clinical course and severity estimation, approaches to complications prevention and therapy strategy choice in patients with AF (rhythm control or heart rate control) are presented.

Aim. The nosological diagnostics in patients with the baseline syndromic diagnosis “dilated cardiomyopathy” (DCMP) with the use of myocardial biopsy and evaluation of complex treatment (cardiotropic, antiviral, immune suppressing, surgical), including virus-positive and virus-negative patients with myocarditis.Material and methods. Totally, 220 patients included with DCMP syndrome, 69 women and 151 men (31,4% and 68,6%), from 16 to 77 y. o. (mean age — 47,5±12,5,) with dilation and systolic dysfunction of the left ventricle (LV); end diastolic size (EDS) more than 5,5 cm; ejection fraction (EF) less than 50%, and absence of exclusion criteria. Mean EDS was 6,5 [6,0; 7,1] cm, EF — 30,3±10,1%, dp/dt 659 [535; 774,25] mmHg, VTI — 10,8±3,9 cm.The assessments were done of the anticardial antibodies via immune enzyme assay (IEA) and PCR-diagnostics of viral genome in blood of 95,5% patients, tread-mill test (5,9%), coronary arteriography (41,8%), MSCT (67,7%), MRI (22,3%), scintigraphy with 99mТс-MIBI (31,4%), genetic consultation and DNA-diagnostics via sequencing by Senger (21,8% and 16,8%). Morphological study of myocardium was done in 84 (38,2%) patients, incl. 52 endomyocardial biopsies (EMB) with PCR for parvovirus B19 genome and herpes viruses.Results. By the data of clinical-morphological assessment, viral genome in blood was revealed in 21% patients, in myocardium — 52%, definite myocarditis was set in 48%, possible — 8%, genetical DCMP — in 12%, myocarditis with genetic cardiomyopathy — 23% (incl. those with pathogenic mutations in genes MYBPC3, DSP, DSG2, LMNA, EMD, DES, TTR, DTNA), idiopathic DCMP — in 9%. In 59% patients myocarditis was primarily chronic, in more than one third of patients there was combination of several causes for DCMP (incl. alcohol). Short-term and long-term results of treatment were evaluated in 127 patients with myocarditis: 52 virus-positive by blood and/or myocardium (myocarditis morphologically proved in 73,1%) and 75 virus-negative (biopsy in 30,7%), that differed by a little lower EDS LV and lower EF. Significant differences by immunity activation (titres of anticardial antibodies) were not found; in 7% there was isolated viral myocarditis, in 34% — viral-immune; in 59% — immune. If viruses were found, therapy ordered with acyclovir, gancyclovir, entecavir, i. v. immunoglobulines; elimination of virus from the blood reached in 81% of patients. If there was tolerance to cardiotropic therapy and high immune activity, immune suppression therapy (IST) was ordered: in 51% of virus-positive and 62,7% virus-negative patients: steroids 30 [22; 40] and 24 [16; 32] mg/day, azathioprin 1-2 mg/kg, hydroxychloroquine 200 mg/day. In 12,0 [6,0; 20,0] months it was found that only in IST group there was remarkable decrease of CHF FC, LV sizes, MPPA and increase of EF LV from30,3±10,6% to 39,2±11,9% independently from presence or absence of viral genome. In absence of IST such dynamics was not found. The best results were found in virus-negative patients receiving IST (mortality 9,8%, need for surgical treatment 21,3%), the worst — in virus-positive patients without IST (66,7% and 61,1%, respectively).Conclusion. Nosological nature of DCMP syndrome can be defined in most cases; usually there is myocaditis in its origin. IST in high immune activity of myocarditis (high titers of anticardial antibodies) leads to significant increase of EF, decrease of the left ventricle size, MPPA, mortality and necessity of surgery in virus-negative, as in virus-positive patients.

At the present there are principles of cardiopulmonary resuscitation (CPR) which are reflected in the recommendations of the AHA and ESC of 2010. They include strict rules on well-timed and proper closed-chest cardiac massage. According to these rules chest compressions should be repeated at least 100 times per minute at a depth of not less than 5 cm. To comply with the standards is not easy even for skilled staff, operator tiredness quickly leads to decrease in CPR quality. Various mechanical devices for closed-chest cardiac massage are used nowadays. One of them is LUCAS system. In some studies LUCAS system showed an efficacy and safety comparable with manual closed-chest cardiac massage. Design features of the LUCAS device do not disturb other life maintaining activities — defibrillation, mechanical ventilation. The device permeability for X-rays makes possible the use of LUCAS in cath labs, if CPR is needed during the intervention procedure. LUCAS system can serve as an alternative tool for CPR. It can be used in intensive care units, as well as be at the disposal of special emergency teams.

Aim. To study prevalence of resistance to acetylsalicylic acid, clopidogrel and dual resistance in percutaneous coronary intervention (PCI), to identify clinical risk factors of resistance development, to study effects of concomitant therapy on resistance development, to identify relationship between risk of cardiovascular complications and activity of platelet aggregation, to assess safety of dual antiplatelet therapy , and to suggest possible ways to overcome clopidogrel resistance. Material and Methods. Patients (n=100) with stable angina class II-IV, that were planned for PCI, were included in the study. Patients randomized to group A (n=53) received clopidogrel 75 mg daily for 7 days before PCI, and later were allocated to subgroups of clopidogrel sensitive or resistant depending on platelet aggregation. In resistant subgroup clopidogrel daily dose was increased to 150 mg for the whole next period of observation. Patients randomized to group B (n=47) received a loading dose of clopidogrel 300 mg one day before PCI. Depending on the results of platelet reactivity assessment, patients were split into sensitive or resistant subgroups. Patients of resistant subgroup received the second loading dose of clopidogrel 300 mg before PCI and started to take clopidogrel 150 mg daily after PCI. Patients of sensitive subgroup did not receive the second clopidogrel loading dose and started to take clopidogrel in usual daily dose of 75 mg. The combined endpoint (after 6 and 12 months) included cardiovascular death, recurrent nonfatal myocardial infarction, recurrent angina, acute ischemic stroke, acute impairment of peripheral circulation. Results. Increased reactivity of platelets to acetylsalicylic acid was detected in 21% of patients. Resistance to clopidogrel in both groups was 56%. Double resistance was registered in 8% of patients. The development of resistance to clopidogrel was related with obesity (p=0.014) and hyperglycemia (p=0.017). 4 and 11 cardiovascular events were registered in 6 and 12 months, respectively. Conclusion. To assess efficacy of antiplatelet therapy it is advisable to study platelet aggregation before and shortly after PCI, especially in patients with obesity and glucose metabolism disturbances. Knowledge of changes in platelet aggregation during clopidogrel therapy can be usefull for timely correction of antiplatelet therapy. Increase in clopidogrel dose up to 150 mg a day is one of the possible way to overcome resistance to clopidogrel.

The clinical, cell and genetic factors are distinguished among reasons for resistance to antiplatelet drugs. There are many methods to detect sensitivity to antiplatelet drugs, but they all have disadvantages. Moreover, there is no unified approach for interpretation of received results, and no recommendations for their practical use. It is necessary to work out unified procedure to assess platelet function, to define indications for its usage and to work out unified criteria of resistance. Individualized approach and each patient’s peculiarities consideration are essential when prescribing antiplatelet therapy.

Aim. To evaluate antianginal and antiischemic efficiency of nebivolol in patients with stable angina pectoris.Material and methods. 100 patients with ischemic heart disease showing stable exertional angina pectoris and having no contraindications to beta-blockers were studied. After 5-7 days of control period 50 randomly selected patients began to take nebivolol in initial dose of 5mg once daily and 50 patients started to take metoprolol in initial dose of 50 mg twice daily. Duration of treatment was 8 weeks. Efficiency of treatment was assessed according to the results of control treadmill assessment and control daily ECG monitoring.Results. 56-day therapy with nebivolol at a dose of 7,5 mg per day results in increase in duration of treadmill test before angina or ST depression (p

PAim. To develop a comprehensive clinical and morphological approach to the nosological diagnosis and treatment of "idiopathic" arrhythmias (IA) and the syndrome of dilated cardiomyopathy (DCM).Material and methods. Patients (n=320) with IA (n=190; 117 women, age 45.3±14.8 years) and DCM (n=130, 41 women, age 46.9±12.5 years) were included in the main group. 51 people (patients with ischemic heart disease; heart valve disease, hypertrophic cardiomyopathy, who underwent open-heart surgery; healthy volunteers) were included in the control group. Along with the standard tests evaluation of the level of anti-heart antibodies (185 patients with IA and 122 with DCM), viral serology (166 and 122), multispiral computed tomography (42 and 88), cardiac magnetic resonance imaging (41 and 22), coronary angiography (19 and 54), myocardial biopsy/autopsy (19/0 and 33/9) were performed.Results. According to morphological study infectious-immune myocarditis was found in 78.9% of IA and 66.7% of DCM-patients, arrhythmogenic right ventricular dysplasia in 5.3% and 4.8% of patients, respectively. Other genetic cardiomyopathies, including combination with myocarditis were revealed in other patients. The frequency of the viral genome detection in the myocardium in IA, DCM and the control group was 17.6%, 66.7% and 77.1%, respectively. However in the control group the incidence of myocarditis and anti-heart antibodies titers were significantly lower, while in the main group a strong correlation between myocarditis and anti-heart antibodies titers was found. The algorithm of noninvasive nosological diagnostics was developed; it allowed to verify diagnosis in 95% of IA patients and 89% DCM patients.Conclusion. Nosological cause of IA and DCM syndrome can be diagnosed in most patients by using an integrated clinical and morphological approach.

Indirect comparisons of new oral anticoagulants are performed with focus on their safety. Apixaban, an oral inhibitor of Xa factor, nowadays can be considered as a drug with very good safety profile according to randomized trials results and performed indirect comparisons.

Part I (Diagnostics), was published in the journal “Rational Pharmacotherapy in Cardiology” 2014;10(1):62-72Aim. To develop a comprehensive clinical and morphological approach to the nosological diagnosis and treatment of "idiopathic" arrhythmias (IA) and the syndrome of dilated cardiomyopathy (DCM).Material and methods. Patients (n=320) with IA (n=190; 117 women, age 45.3±14.8 years) and DCM (n=130, 41 women, age 46.9±12.5 years) were included in the main group. 51 people (patients with ischemic heart disease; heart valve disease, hypertrophic cardiomyopathy, who underwent open-heart surgery; healthy volunteers) were included in the control group. Along with the standard tests evaluation of the level of anti-heart antibodies (185 patients with IA and 122 with DCM), viral serology (166 and 122), multispiral computed tomography (42 and 88), cardiac magnetic resonance imaging (41 and 22), coronary angiography (19 and 54), myocardial biopsy/autopsy (19/0 and 33/9) were performed.Results. According to morphological study infectious-immune myocarditis was found in 78.9% patients with IA and 66.7% patients with DCM, arrhythmogenic right ventricular dysplasia in 5.3% and 4.8% of patients, respectively. Other genetic cardiomyopathies, including combination with myocarditis were revealed in other patients. The frequency of the viral genome detection in the myocardium in IA, DCM and the control group was 17.6%, 66.7% and 77.1%, respectively. However in the control group the incidence of myocarditis and anti-heart antibodies titers were significantly lower than in the main group, where a strong correlation between myocarditis and anti-heart antibodies titers was found. The algorithm of noninvasive nosological diagnostics was developed; it allowed to verify diagnosis in 95% of IA patients and 89% DCM patientsThe basic therapy (antiviral drugs, corticosteroids, hydroxychloroquine, azathioprine) was performed in some patients with myocarditis. Improving of the antiarrhythmic effect of treatment in patients with IA, a significant increase in ejection fraction, a reducing of the size of the heart chambers and of pulmonary artery pressure in patients with DCM, a reducing of the need in surgical treatment (including in the virus-positive patients) occurred as results of treatment.Conclusion. Nosological cause of IA and DCM syndrome can be diagnosed in most patients by using an integrated clinical and morphological approach. This allows managing effective etiotropic and pathogenetic treatment.

Ambiguous data about comparability regarding clinical outcomes for prehospital thrombolysis, coupled with timely coronary angiography, and primary percutaneous coronary intervention (PCI) in the early after acute ST-segment elevation myocardial infarction (STEMI), there are now.In the STREAM trial 1892 patients with STEMI diagnosed within 3 hours after onset of symptoms, and whom it was impossible to perform primary PCI within 1 h after the first medical contact, were randomly assigned into two treatment groups: a) primary PCI b) prehospital thrombolytic therapy with bolus tenecteplase (dose decreased by half in patients aged ≥75 years) in combination with clopidogrel and enoxaparin followed by admission to the hospital, where it was possible to perform PCI. Emergency coronary angiography performed if thrombolysis failed. Coronary angiography and PCI of the infarct-related artery were performed in the period from 6 to 24 hours after randomization and thrombolytic therapy in the case of an effective thrombolysis. Primary endpoints include a composite of death, shock, congestive heart failure, or reinfarction up to 30 days.The primary endpoint occurred in 116 of 939 patients (12.4 %) of the thrombolysis group and in 135 of 943 patients (14.3%) of the primary PCI group (relative risk in the group thrombolysis 0.86, 95% confidence interval 0.68-1.09, p=0.21). Emergency angiography was required in 36.3% of patients in the thrombolysis, and the remaining patients, coronary angiography and PCI were performed at a mean of 17 hours after randomization and thrombolytic therapy. Thrombolysis group had more intracranial hemorrhages than primary PCI group (1.0% vs 0.2%, p=0.04; after correction protocol and dose reduction by half of tenecteplase in patients ≥75 years: 0.5% vs. 0.3%, p=0.45). The rate of non- intracranial bleeding in two treatment groups did not differ.Prehospital thrombolysis followed by coronary angiography and timely PCI provide effective reperfusion in patients in the early stages of STEMI that was not possible to carry out primary PCI within 1 h after the first medical contact. Nevertheless, fibrinolysis was associated with a slight increase in the risk of intracranial bleeding.

A new method of non-drug treatment of resistant hypertension – renal denervation is considered. General information about resistant hypertension, method of renal denervation, the results of clinical studies on efficacy and safety, as well as own clinical case are presented.

Aim. To study the effect of renal denervation on blood pressure (BP), myocardium function and vegetative status in patients with resistant hypertension (HT).Material and methods. Patients with a provisional resistant HT diagnosis (n=62; 41.3% male) were included into the study. 17 patients were selected for renal denervation after correction of previous antihypertensive therapy and examination to exclude symptomatic HT. Two patients refused the procedure, 1 patient hadn’t undergone renal denervation due to anatomical features (renal artery diameter

Aim. To study the structure and incidence of the in-hospital anticoagulants prescription in patients at high risk of thromboembolic events (TEE) and to evaluate clinical characteristics of anticoagulated patients (by the example of the University Clinical Hospital (UCH) №1 of I.M. Sechenov First Moscow State Medical University (FMSMU).Material and methods. The cross-sectional retrospective study held in UCH №1 of the FMSMU, enrolled 677 patients with atrial fibrillation (AF) for whom the prevention of TEE was indicated.Results. Of 677 analyzed cases (women 70%, men 30%) only 61% of the patients received appropriate anticoagulant therapy. Warfarin was prescribed in 73% of the cases, of them unsatisfactory international normalized ratio (INR) control (time in therapeutic range less than 60%) was revealed in 79%. 8.45% of the vitamin K antagonist treated patients developed hemorrhagic complications. 16% of the patients received novel oral anticoagulants (dabigatran – 14%, rivaroxaban – 2%). Bleeding was fixed in 4.2% of the dabigatran treated patients and in 14.3% - in case of rivaroxaban therapy.Conclusion. More than a third of non-valvular AF patients receive inadequate antithrombotic therapy in routine clinical practice. 75% of the anticoagulated patients are prescribed the vitamin K antagonists (typically warfarin) as a traditional anticoagulant. At that, only in 21.7% of the patients receiving vitamin K antagonists, this therapy may be considered adequate. Low incidence rate of the novel oral anticoagulants prescription despite the advantages of such treatment also calls attention.

Aim. To evaluate the possibility to increase the effectiveness and safety of anticoagulation therapy in nonvalvular atrial fibrillation (AF) under the circumstances of an office for anticoagulation control located at the University Clinics.Material and methods. Observational prospective study (registry), included 325 patients with nonvalvular AF, taking various anticoagulation drugs for the prevention of thromboembolic complications (TEC). Mean duration of follow-up is 24±12 months.Results. At the current moment about 95% of patients continue taking anticoagulants and follow-up in the office of anticoagulation control. Totally there were 37 bleedings marked, of those 19 minor and 18 major. By the general quantity of bleeding cases there is no significance in the difference between warfarin and “novel” anticoagulants (NOAC) (p>0,05). Major bleedings significantly more common in warfarin group than in NOAC (p

Aim. To analyze the results of first 50 endomyocardial biopsies (EMB) in general care clinic, to clarify the selection criteria and procedure role in management decision in patients with various noncoronarogenic diseases of myocardium. Material and methods. Totally 50 patients included, who had been underwent EMB during 2007-2014 (31 men, mean age 44,3±13,5). Investigation included the level of anticardiac antibodies (n=49), DNA of herpes group viruses and parvovirus B19 by PCR in blood (n=40) and myocardium (n=49), scintigraphy of myocardium (n=20), MDCT (n=21), MRI (n=17), coronary arteriography (n=22), genetician consultation (n=15). EMB of the right ventricle was done using biopsy forceps STANDARD 5.5 F 104 FEMORAL (Cordis). The materials were coloured with hematoxyline-eosine, picrofucsine by Van Hison, Schiff reactives, Pearls, red congo. The study was approved by the Ethics Comitteeof FMSMU. Results. Indications for EMB were set for 3 groups of patients: 1. With dilated cardiomyopathy (DCMP) as a syndrome, including the probability of acute/ subacute myocarditis (n=7), allergic myocarditis (n=1), myocarditis with myocardial infarction (n=1), vasculitis (n=3), possible myocarditis in long-lasting course of DCMP (n=9), in patients with non-compact myocardium, myodystrophy of Emeri-Dreyfus and possible arrhythmogenic dysplasia of the right ventricle (n=7). 2. With "idiopathic" rhythm and conduction disorders (n=18), including high probability of myocarditis (n=13), vasculitis (n=2), necessity for differentiation of myocarditis and genetic cardiomyopathies (n=3). 3. With the syndrome of primary myocardial hypertrophy (n=3). EMB was informative in all patients, myocarditis found in 82,6%.Conclusion. The criteria for high diagnostic value of EMB is nosological way of selection. In addition to current scenarios it is aimfull to perform EMB if clinically significant ischemia with non-changed coronary arteries, with suspected myocarditis in patients with genetic cardiomyopathies, inborn defects, CHD and other established heart diseases. The EMB results define the tactics of medication and surgical treatment.

Aim – assessment of quality of life (QoL) in patients with rheumatoid arthritis (RA) with the presence and severity of bronchopulmonary lesions.Materials and methods. The study included 104 patients with RA and 100 patients not suffering from RA and verified chronic respiratory diseases. The analysis of the QOL of patients using questionnaires EQ-5D (EuroQoL Group, 1990) and SGRQ (St. George's Hospital questionnaire to assess respiratory function), performed spirometry, bodyplethysmography , pulse oximetry, the definition of lung diffusioncapacity, multispiral computed tomography of the lungs.Results. Performance of all scales and the resulting indices of questionnaires EQ-5D and SGRQ showed a significant decrease in QoL ofRA patients compared with those in control group and the general population. A correlation index of EQ-5D with vital capacity (r = 0.47;p < 0.001) and diffusion capacity (r = 0.67; p < 0.01) of the lungs is revealed. The main reason for the reduction of indices of the questionnaire SGRQ in patients with RA was the presence of shortness of breath. The multi-factorial origin of dyspnea in patients with RA with theessential role of bronchopulmonary lesions was established.Conclusion. Bronchopulmonary lesions in the underlying disease have an adverse impact on the QOL of patients with RA. Promising directions for improving the QOL of RA patients with bronchial lesions can be considered for activities for the conservation of respiratory lung function, exercise control RA activity, elimination of anemia correction of psycho-emotional disturbances of anxiety-depressive character.

Coronary angioplasty is an important component of coronary heart disease (CHD) management. There is a substantial evidence of the need for dual antiaggregant therapy (clopidogrel and aspirin) in this clinical group, both before and after the intervention. The development of thrombotic complications during antiaggregant therapy suggests the antiplatelet drug resistance. The prevalence of this condition varies from 5% to 45% for aspirin, and from 20% to 45% for clopidogrel, depending on the assessment method and the specific clinical group. For dual antiplatelet therapy, the resistance prevalence is 6-8%. Presently, the gold standard method of the platelet functional activity assessment is optical aggregometry. To assess the resistance to aspirin, arachidonic acid is used as an aggregation inductor, with the calculation of absolute aggregation levels. To assess the resistance to clopidogrel, ADP is used as an aggregation inductor, and the relative aggregation parameters are calculated. The development of aspirin resistance is influenced by biological, clinical, and genetic factors. The clopidogrel resistance is associated with certain medications, hyperglycemia, atherosclerosis, and CYP2C19*2 gene polymorphism. Identification of the patients resistant to antiplatelet drugs enables the clinicians to adjust the antiplatelet treatment reasonably early and to reduce the risk of cardiovascular events. The possible methods of overcoming antiplatelet drug resistance are to double the loading and maintenance doses of clopidogrel and to use new agents.

Aim. To assess the association between ω-3 index of erythrocytes and demographic, electrophysiological, and echocardiographic (EchoCG) predictors of sudden cardiac death (SCD) in patients with coronary heart disease (CHD) and ventricular arrhythmias (VA). Material and methods. The study included 25 patients with a verified diagnosis of CHD and VA. Gas chromatography method was used to measure the content (%) of eicosapentaenoic (EPA) and docosahexaenoic (DHA) polyunsaturated fatty acids (PUFA) in peripheral blood erythrocytes, with the calculation of a summary (EPA + DHA) ω-3 index. All participants underwent 24-hour electrocardiography (ECG) monitoring, with the assessment of maximal, minimal, and mean heart rate (HR), heart rate variability (HRV) parameters (SDNN and pNN50), heart rate turbulence (TO and TS), microvolt T wave alternans (mTWA), and the number of ventricular extrasystoles (VE) and transient and persistent ventricular tachycardia (VT) episodes. All patients also underwent EchoCG. Results. In examined patients, the values of ω-3 index of erythrocytes varied from 1,12% to 6,4% (mean 3,74%, 95% CI 2,02-4,38%). There was a weak correlation between ω-3 index or EPA levels (%) and the HRV parameter of pNN50. In addition, ω-3 index or DHA levels (%) negatively correlated with the daily VE number. The 5:00 AM value of mTWA (II lead, update factor 1/8) weakly correlated withω-3 index and DHA levels. There was a moderate positive correlation between E/A ratio and omega-3 index, or EPA and DHA levels. Conclusion. Patients with CHD and VA were characterised by low ω-3 index values and high (56%) or moderate (44%) levels of cardiovascular risk. The values of ω-3 index positively correlated with the daily VE number and negatively correlated with E/A ratio and pNN50 parameter of HRV.

Comparison of literature and calculated data on vapor-liquid equilibrium for systems formed by products of propylene oxide synthesis was carried out. On the basis of models NRTL and UNIQUAC the literature data on vapor-liquid equilibrium for the investigated systems were optimized. The values of model parameters and their deviations were estimated. The corresponding phase diagrams were calculated and plotted.

The paper presents the evolution in the modern approaches towards antiplatelet therapy (aspirin, clopidogrel) in acute coronary syndrome, as well as the results of the studies on effectiveness and safety of such new antiaggregant medications as prasugrel and ticagrelor.

Antiarrythmic therapy is one of the most problematic areas of modern medicine, with a constant search for new, more effective and safe medications. One of these new agents is dronedarone — a Class III antiarrythmic drug, with a structure similar to that of amiodarone, but without iodine in its molecule. Dronedarone interacts with different types of ion channels, and is at least as effective as amiodarone. At the moment, the dronedarone dosage of 400 mg twice a day is the best-studied therapeutic regimen for this medication. The paper analyses the results of published clinical trials of dronedarone, with the focus on ANDROMEDA and ATHENA studies. The former demonstrated that in patients with severe chronic heart failure, dronedarone increased all-cause mortality. The latter showed that in the dronedarone group, the combined incidence of cardiovascular death and cardiovascular hospitalisation was significantly lower than in the placebo group — 31,9 % vs. 39,4 %, respectively. In addition, dronedarone significantly reduced the annual risk of stroke — by 34 %, from 1,8 % to 1,2 % (p=0,027). Dronedarone safety could be regarded as satisfactory, with the majority of withdrawal cases due to such adverse effects as nausea and diarrhoea.

Aim. To study lipid peroxidation (LP), pro-oxidant status, and antioxidant protection in coronary heart disease (CHD) patients with stable angina and post-infarction cardiosclerosis, who underwent coronaroangiography (CAG). Material and methods. The study included 32 CHD patients with Functional Class II-III angina, who underwent CAG, and 22 relatively healthy controls. Before CAG, plasma levels of lipids, PL products, uric acid, ceruloplasmin (CP), transferrin (RF) and methemoglobin (electron paramagnetic resonance), homocysteine (highly effective liquid chromatography), superoxide dismutase (SOD) and glutathione peroxidase (GP) in red blood cells were measured. Results. In CAG, severe coronary artery pathology was registered: occlusions of at least 70% comprised 63,7% of the total stenosis rate. Severe lipid metabolism and PL disturbances, as well as decrease in tissue and plasma antioxidant enzymes (SOD by 10%, GP by 46%, CP/TF by 33%) – were observed, comparing to the control group. There was a direct correlation between coronary artery stenosis rate and age (r=0,4) or levels of total cholesterol, low-density lipoprotein cholesterol (r=0,3), and PL product, MDA (r=0,34). Inverse correlation between stenosis number and antioxidant enzyme levels was also registered in CHD patients for SOD (r=-0,5), GP (r=-0,3), and CP/TF (r=-0,3). Conclusion. Coronary artery atherosclerosis severity was affected by tissue and plasma antioxidant enzyme levels, as well as by LP manifestation.

The work has studied opportunities for ТЕ EPS in serial testing of antiarrhythmic drugs testing to prevent recurrent arrhythmia in patients with atrial fibrillation. Antiarrhythmic drug adjustment was performed in 85 patients with paroxysmal atrial fibrillation. Serial testing implied the usage of all 4 series of antiarrhythmic drugs. Individual effective antiarrhythmic therapy was adjusted in 83 (98 %) patients. Class I drug appeared to be most effective (in 89 % patients) with the best individual result for Cordarone which achieved effect in 61 % cases when administered as 600-800 mg daily. To obtain most reliable results of pharmacological antiarrhythmic therapy adjustment in patients with paroxysmal atrial fibrillation during diagnostic transesophageal electrical stimulation (TEES) and during serial testing of antiarrhythmic drugs it is rational to use "non-aggressive" methods of atrial fibrillation induction: accelerating, frequent and programmed atrial stimulation with one or two delayed stimuli.

Comments on American College of Cardiology, American Heart Association and European Society of Cardiology Guidelines (2006) for the management of patients with atrial fibrillation.

The aim of the study was to estimate the effectiveness of transesophageal electrophysiologic assay in diagnostics of paroxysmal nodal reciprocating tachycardias compared to intracardiac electrophysiologic assays and working out treatment strategies in patients with supraventricular paroxysmal tachycardias.We have studied 100 patients with nodal reciprocating tachycardias. Diagnostic transesophageal stimulation was performed in all, and intracardiac electrophysiologic assays to elaborate the nature and mechanism of tachycardias in 85. Effective antiarrhythmic treatment was adjusted by using transesophageal electrophysiologic assays. Series of tests supposed the usage of all 4 classes of antiarrhythmic drugs.Comparative analysis of the data obtained showed the in most cases there was no reliable difference between anterograde functional and effective refractory periods of various parts of the conductive system, as measured by transesophageal and intracardiac electrophysiologic assays. We have worked out principal electrophysiologic criteria of diagnosing paroxysmal nodal reciprocating tachycardias based on transesophageal assays.Individually effective antiarrhythmic treatment was managed in 96% cases. Class I drugs proved most effective (in 70% patients), and propranolol had the best individual result in the daily dose of 20-40 mg (in 50% patients).

The subject of this study is the rural settlements of the Tyumen district in the first quarter of the 20th century. It is noted that during this period, the Tyumen district was situated at the heart of the Tyumen region, ranking first in terms of population size (44,545 people) and the area of territory covered (5.4 thousand square kilometers). The paper examines changes in the number and typology of settlements within the Tyumen district through the lens of its rural localities. It has been established that the district’s settlement network consisted of 177 localities, falling into 11 types, with villages making up a significant proportion — over 50%. This fact indicates that in long-settled regions, settlement networks have existed in virtually unchanged forms despite various external and internal factors. Fifteen villages were identified as creating the framework of the Tyumen district’s settlement network, demonstrating resilience and successfully adapting to new conditions. For instance, data from 1912 and 1926 show that population numbers in these localities were growing, especially in those settlements occupying advantageous (central) positions within the existing network. Many villages in the Tyumen district attained this status during the Soviet period, even though at the beginning of the 20th century they were mere villages. Successful new connections between settlements were facilitated by transportation factors (the presence of railways, tract roads, and a navigable water artery — the Tura River).