2020 Том 4, №2
 



Atrial fibrillation and adherence to oral anticoagulation: review of clinical cases
M.S. Dzeshka, S.L. Boyko, N.V. Shpak, V.A. Snezhitskiy
Prevalence of atrial fibrillation (AF) is continuously increasing. Stroke in AF patients is the most unfavorable complication of arrhythmia, clinical course being severer, neurological deficit pronounced, and mortality higher compared to stroke patients without AF. Oral anticoagulation (OAC) results in significant reduction of stroke and systemic embolism but at the same time is compromised by haemorrhagic complications. High adherence to treatment is essential for effectiveness and safety of OAC. Nonetheless, poor adherence to treatment in case of chronic diseases requiring drug regimen remains unresolved. Social, economic and demographic factors, patient’s psychological markers, inertia of the healthcare system, formalism in the implementation of recommendations in routine clinical practice, violation of the continuity between inpatient and outpatient care, limited resources and other factors lead to low adherence among patients with AF. Refusal of OAC, intermittent treatment, delayed medication with OAC, failure to follow recommendations for the control of modifiable risk factors associated with anticoagulant therapy, are transformed into a high level of cardiovascular and cerebrovascular events in patients with AF. This article presents an analysis of three clinical cases of patients with complicated AF, discusses treatment from the standpoint of evidence-based medicine, the role of low adherence in the development of complications, and obstacles to increasing adherence.
Clinical case of treatment of a patient with portal hypertension developed as a result of portal vein thrombosis
E.V. Mahiliavets
Abstract. Non-cirrhotic causes of the development of portal hypertension make upabout 10%. The factors leading to its development are the development of thrombosis in the portal vein system, occlusion due to pancreatitis, pancreatic tumors, and other causes. Acute bleeding from esophageal varices is a formidable complication of portal hypertension, regardless of its etiology. The tactics of treatment and prevention of bleeding from esophageal varices in patients with portal vein thrombosis generally corresponds to that for intrahepatic portal hypertension in liver cirrhosis with some additions. Aim. Presentation of the results of clinical observation of an open Hassab operation (esophagogastric devascularization without esophageal transection + splenectomy) in a patient with portal vein thrombosis complicated by portal hypertension and esophageal varices, as well as a short literary excursion on this issue.
Unstable angina pectoris or unstable coronary syndromes?
N.P. Mitkovskaya, O.V. Laskina, Patrick Teefy
Unstable angina pectoris (UA) is a variant of acute coronary syndrome without ST segment elevation (NSTEACS), which is characterized by the absence of biochemical criteria for myocardial damage, a change in the clinical picture of angina pectoris (an increase in the functional class of angina pectoris, the appearance of resting angina and a high probability of transformation of the process into myocardial infarction (MI)). UA and the developed MI without ST segment elevation (NSTEMI) are not accompanied by the appearance of a pathological Q wave and are characterized by a general complex pathogenesis associated with progressive atherosclerosis, a non-occlusive thrombus in the area of erosion or rupture of an atherosclerotic plaque, vasospasm, coronary microcirculatory dysfunction or other causes of imbalance between oxygen intake and oxygen consumption resulting in myocardial ischemia, and are distinguished by increased levels of myocardial necrosis in the blood in case of NSTEMI. It is difficult to differentiate UA and NSTEMI in the first hours of the development of the process when a decision is made on reperfusion technologies and drug therapy without laboratory, and in some cases, additional examination with visualization of the probable new loss of viable myocardium, therefore, the diagnosis and management of these two clinical conditions are usually considered in the same clinical recommendations. The article discusses various mechanisms of the development of myocardial ischemia, diagnostic and therapeutic invasive and non-invasive technologies that improve the prognosis of patients with UA.
ST-elevation myocardial infarction and acute ischemic kidney injury
E.Yu. Brankovskaya, L.V. Kartun, E.V. Hodosovskaya, N.P. Mitkovskaya
The aim of the study was to investigate specific clinical manifestations, homeostasis indices and parameters of the cardiovascular system in patients with acute ST-elevation myocardial infarction (STEMI) and acute ischemic kidney injury. Methods. 173 patients with STEMI participated in the study. The study group consisted of 111 patients with acute ischemic kidney injury associated with myocardial infarction (MI); 62 patients with MI and normal kidney function were enrolled in the comparison group. Clinical, anthropometric, laboratory, and instrumental diagnostic methods were used. Results. Compared with patients of the MI and normal kidney function group, those with MI and acute ischemic kidney injury had a higher average heart rate, required more prolonged vasopressor and/or inotropic therapy, and more frequently developed tachyarrhythmias with adverse prognostic impact and postinfarction aneurysms. The study revealed that patients of the MI and acute ischemic kidney injury group demonstrated more severe dilatation of the left ventricle (LV), more pronounced reduction in myocardial LV contractility according to echocardiography results; they developed multivessel coronary artery disease more frequently. Furthermore, patients of this group had a higher incidence of infarction-associated artery damage located in the proximal segments of major coronary arteries and more frequently developed thrombotic occlusion in the infarction-affected artery. Patients with MI and acute ischemic kidney injury had higher levels of inflammatory, myocardial necrosis, hemostasis and neurohormonal activation markers. Higher concentration of neutrophil gelatinase-associated lipocalin (uNGAL) was observed in patients with MI and acute ischemic kidney injury; moreover, in 14,1% of patients belonging to this group, elevated levels of this marker preceded the diagnostically significant increase in creatinine concentration and decrease in glomerular filtration rate.
Arterial hypertension and atrial fibrillation: molecular genetic aspects of pathogenesis and complex therapy, focus on the renin-angiotensin-aldosterone system
N.V. Bukvalnaya, L.V. Yakubova, V.A. Snezhitskiy
This article is devoted to the effect of the renin-angiotensin-aldosterone system on the development and maintenance of atrial fibrillation on patients with arterial hypertension. It is noted that the adverse effects of the renin-angiotensin-aldosterone system end products, angiotensin II and aldosterone, can be caused not only by their hyperproduction, but also by the activation of the transforming growth factor β1 initiated by them. This cytokine initiates the process of fibrosis in the left atrium, which is a substrate of arrhythmia. The article features the results of multicenter clinical trial demonstrating the effectiveness of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and mineralocorticoid receptor antagonists in the prevention of atrial fibrillation. The review includes the analysis of the effect of polymorphic variants of the angiotensin-converting enzyme gene ((I/D) ACE), the angiotensin II receptor gene type 1 ((A1166C) AGTR1), the aldosterone synthase gene (C/T (-344) CYP11B2) and the gene of the transforming growth factor β1 (G/C (+915) TGFB1) on the development of arterial hypertension and atrial fibrillation, as well as on the effectiveness of therapy with renin-angiotensin-aldosterone system blocking drugs.
Modern opportunities for diagnosis and treatment of systemic vasculitis with kidney involvement in children: researchers own data (part 2)
I.A. Kazyra, A.V. Sukalo
The aim of the study was to analyze clinical, laboratory, immunological, morphological data of children with systemic vasculitis (SV) with kidney involvement to assess mediators of the formation and progression of the disease, as well as factors affecting prognosis. Methods. 20 children (15 girls, 5 boys) with morphologically verified nephritis due to SV (age from 5 to 17 yrs, median 13.5), were under observation at the “2nd Children’s Clinical Hospital” Minsk from 2012–2020. The features of the onset of the disease in childhood are presented, the analysis of clinical, laboratory, immunological (serum concentration of T- and B-lymphocyte activation markers (RANTES and BAFF), proinflammatory (caspase 1, IL1β and TNFα), vascular (VEGF) and tissue (TGF1β) growth factors), metabolic parameters (adiponectin, leptin, obestatin, vitamin D 25 (OH) D), instrumental, morphological changes, and factors affecting the course and outcome. Statistics was carried out using the Statistica 10.0, SPSS.
Fibroblast growth factor 21 from the perspective of a promising marker of metabolic disorders and premature aging in polymorbid cardiovascular pathology in young and middle-aged people
Galina A. Proshchai, Sergey V. Dudarenko, Alexander S. Partcerniak, Elena Yu. Zagarskikh, Sergey A. Partcerniak
Objective: To evaluate the possibility of using fibroblast growth factor 21 (FGF 21) as a marker of metabolic disorders and premature aging in polymorbid cardiovascular pathology. Research methods: 199 men aged 35–55 years who were stratified into 3 groups were examined: group A – 117 patients with type 2 diabetes mellitus (type 2 diabetes), polymorbid cardiovascular disease (PCVD), obesity, androgen deficiency and anxiety-depressive disorders (ADD); group B – 55 patients with PCVD, obesity and ADD; group C – control group (n = 27). The examination of patients included a laboratory study of the level of FGF 21, indicators of carbohydrate and lipid metabolism, hormonal status, as well as daily monitoring of blood pressure and ECG. Results and conclusions. When compared with the control group, the level of FGF 21 was 3 times higher in the presence of type 2 diabetes. The most intense increase in FGF 21 levels was observed in groups of patients with several diseases. An increase in the level of FGF 21 in young and middle-aged people is probably due to a compensatory reaction to the existing androgen deficiency, disorders of carbohydrate and lipid metabolism. Strong correlations between FGF 21 and glucose, HDL cholesterol, total testosterone, ALT, and SBP during the day allow FGF 21 to be considered an early marker of cardiovascular disease and premature aging (PA) in young and middle-aged people.
Medium-term outcomes after correction of long coronary artery lesions with biodegradable vascular scaffolds
N. P. Strygo, V. I. Stelmashok, O. L. Polonetsky
Aim. To establish efficacy and safety of endovascular correction of long coronary lesion with biodegradable scaffolds in comparison with everolimus-eluting metallic coronary stents. Materials and methods. From 2013 to 2018 in Republican Scientific and Practical Centre «Cardiology», Minsk, endovascular correction of long (more than 25 mm) coronary artery lesions was performed on 80 patients. Randomly patients were divided into 2 groups: group 1 (n = 40) – endovascular correction with the biodegradable everolimus-eluting vascular scaffold Absorb BVS, and group 2 (n = 40) – endovascular correction with the everolimus-eluting metallic stent Xience V/Xience Pro. Results. In 12-month observational period there were no cases of death or myocardial infarction in both groups. One-year primary endpoint (death + myocardial infarction + target lesion failure) was 10% in group 1 (scaffolds BVS Absorb) and 8.75% in group 2 (Xience stents), 4 and 3 cases of target lesion failure accordingly (p > 0.05). As secondary endpoints there were 3 cases of target lesion revascularization registered and 4 cases of target vessel revascularization in each group, 5 cases of target vessel failure in group 1 and 4 cases in group 2 (p > 0.05). There was 1 case of confirmed and 1 case of probable scaffold thrombosis in group 1 (cumulative rate 5%), no cases of stent thrombosis in group 2 (p = 0.49). Conclusion. Long lesion correction with biodegradable scaffolds shows similar one-year clinical and angiographic results in comparison with everolimus-eluting stents. Combined endpoint risk (all death cases + myocardial infarction + revascularization due to target lesion failure) statistically did not differ in one-year period in both groups.
Рulse waves рropagation in small vessels: measurement results and modelling approaches
A.I. Kubarko, V.A. Mansurov, A.D. Svetlichny, L.D. Ragunovich
The objective of the research work was to develop devices and algorithm for synchronous recording of pulse waves and ECG for measuring the delay time of pulse waves in the branches of various arteries relative to the R wave on an ECG, and to carry out computer simulation of the pulse wave propagation process to determine the dependence of the pulse wave propagation velocity on branching and other hemodynamic and morphological parameters of blood vessels.
Cardioprotective efficiency of the combined application of remote ischemic pre- and post-conditioning in rats in case of miocardial ischemia/reperfusion
V.V. Sevrukevitch, F.I. Vismont
The cardioprotective efficacy of the combined use of remote ischemic preconditioning (RIPreC) and remote ischaemic postconditioning (RIPostC) in experimental myocardial ischemia/reper fusion was studied in rats. Experimental myocardial ischemia/reperfusion was reproduced by a 30-minute occlusion of the left coronary artery followed by a period of 120-minute reperfusion. Remote ischemic conditioning was reproduced by short-term occlusion of both femoral arteries followed by reperfusion of the extremities beginning at the following time points: RIPreC – 25 minutes before the end of the myocardial ischemia period, RIPostC – 10 minutes after the end of the myocardial ischemia period, RIPreC + RIPostC – 25 minutes before the start and 10 minutes after the end of myocardial ischemia. It was shown that the combined use of RIPreC and RIPostC had a comparable cardioprotective effect in comparison with each of these methods taken separately. Possible reasons explaining the lack of potentiation of the cardioprotective effect of the combined use of RIPreC with RIPostC can presumably be attributed to: 1) achieving maximum cardioprotection, i.e. the impossibility to further reduce the area of myocardial ischemia, 2) the effect on similar intracellular cardioprotective mechanisms in different conditioning modes.
Medical prevention of post-transfusion complications after transfusion therapy applied in case of severe obstetric blood loss
F.N. Karpenko, A.V. Novik, E.D. Rasyuk, V.V. Pasyukov, V.N. Bordakov, T.V. Vaganova, O.V. Karpenko
The article presents an analysis of the modern approach to the treatment of acute obstetric hemorrhage. Some features of the preparation of leukodepleted and pathogen-reduced blood components are shown and indications for use in severe obstetric blood loss are determined. It has been shown that the pathogen reduction of blood components leads to a decrease the level of coagulation factors (coagulation factor VIII, fibrinogen in fresh frozen plasma) by 20–30 %, the activity and number of platelets by 15–20 % in platelet concentrate, does not affect the morphological usefulness of platelets. A “package” of blood components for the provision of emergency transfusion therapy for obstetric bleeding has been calculated. The need for a given quantity of blood components was determined – 2.3 “packages” per 1000 births. The proposed “emergency obstetric care packages” and the organization of their centralized delivery to medical healthcare organizations ensure a high degree of readiness of the blood service to comply with the “golden hour” rule for treating acute severe obstetric hemorrhage and minimize post-transfusion reactions and complications when using them. Pathogen-reduced blood components are expensive. Therefore, their use in clinical practice is indicated for the decreed contingents of recipients: for organ and tissue transplantation, in neonatology, oncohematology and for recipients with “multiple transfusions of blood, its components”, in cardiac surgery and obstetric practice.
Transdermal delivery of drugs and its role in therapy of cardiovascular diseases
N.S. Golyak
Introduction. Transdermal delivery of medicinal substances is based on the penetration of the active pharmaceutical ingredient through the intact skin, its further entry into the systemic bloodstream and, thereafter, to the target organ. Currently, gels, ointments, emulsions and transdermal therapeutic systems (transdermal patches) are used as transdermal agents. Transdermal patches are able to provide a target constant concentration of medicinal substances in blood plasma for a long time (from 1 to 7 days). Transdermal delivery has a number of advantages: increased bioavailability of medicinal substances due to the elimination of losses associated with metabolism in the gastrointestinal tract and in the liver; reducing the risk of adverse reactions which can be caused by leveling of concentration jumps of the medicinal substances in the blood; painlessness and convenience; possibility to change the dose by varying the area of the patch and the duration of use; possibility to stop the treatment at any time, etc. For patients with chronic diseases requiring constant repeated oral administration of drugs, suffering from dysphagia and diseases of the gastrointestinal tract, the transdermal route of administration is the most optimal. In some cases, when the patient is unconscious, suffers from sclerosis, or has impaired vital functions (for example, the ability to breathe and swallow independently), transdermal delivery is optimal and in some cases is the only alternative. Purpose. To analyze the current range of drugs for transdermal delivery, to assess the role and prospects of using transdermal delivery in the treatment of cardiovascular diseases. Methods. The search for literary data was carried out using the PubMed and Google search engines among Russian – and English-language original articles. The search of registered drugs in the form of transdermal patches was carried out using drugs registries of the United States and other countries. When searching, the terms «transdermal delivery», «transdermal patch», «bisoprolol», «clopidogrel», «transdermal delivery», «transdermal patch» were used. Conclusion. In the global pharmaceutical market, transdermal delivery is used for a limited number of medicinal substances of different pharmacotherapeutic groups, of which only three medicinal substances (nitroglycerin, clonidine, bisoprolol) are used in the treatment of cardiovascular diseases. Many attempts have been made to obtain and evaluate transdermal patches with angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, antiplatelet agents used in the treatment of cardiovascular diseases, but the volume of these studies is insufficient for registration and clinical use.
Herbal medicines for treatment of cardiovascular diseases marketed in the Republic of Belarus
I.L. Kurs, N.S. Gurina
Aim. Marketing research in the segment of herbal medicines for the treatment of the diseases of the cardiovascular system in the Republic of Belarus. Methods. The study of the healthcare market was carried out using analytical and statistical methods by analyzing data from the State Register of Medicines of the Republic of Belarus (as of 01.01.2020) and the database of sales of medicines and biologically active food additives «IQVIA» (data on the sale of medicines for 2019). Data processing was carried out using the Microsoft Office Excel 2016 software package. Results. As of 01.01.2020, 51 herbal medicines from group C (according to the anatomical-therapeutic-chemical classification «Cardiovascular system») were registered in the Republic of Belarus by 29 manufacturers from 10 countries. Most herbal medicines for treatment of cardiovascular diseases are imported (54.90%). According to originality criterion generic herbal medicines from this segment prevail, both in terms of the number of registered names (78.43%) and sales volumes in cash (53.86%) and in kind (96.49%). In terms of composition, monocomponent herbal medicines prevail (56.86%). Among monocomponent medicines the majority of herbal medicines for the treatment of cardiovascular diseases are domestic (31.37% of the total number of registered herbal medicines for the treatment of cardiovascular diseases), while among the combined ones the greater part is imported (33.33%). In terms of sales in kind, monocomponent herbal medicines prevail (74.98%), whereas in monetary terms combined ones predominate (40.65%). Conclusion. It is a promising perspective for domestic enterprises to develop combined herbal medicines for the treatment of cardiovascular diseases in order to provide the population with more affordable medicines from this segment, as well as to implement the principles of import substitution in the healthcare market of the Republic of Belarus.
The role of x-ray endovascular surgery in the treatment of obliterating atherosclerosis of the lower extremity arteries in elderly and senile patients
S.V. Mshar, V.А. Yanushko
Obliterating atherosclerosis ranks third in the system of cardiovascular disease. With age the incidence of peripheral artery disease increases and makes 3–5% in general population. The most difficult group of patients with peripheral artery disease (PAD) or obliterating atherosclerosis is elderly patients. Currently there is a tendency to increase the life expectancy and aging of the Belarusian population. Elderly and senile patients with obliterating atherosclerosis (PAD) are characterized by a multi-level lesion and damage to the distal parts of the arterial bed, an increase in the number of comorbidities, a high risk of cardiovascular death, and seeking medical help often at the stage of critical lower limb ischemia. Patients at high risk of cardiovascular complications with intermittent lameness are subject to conservative treatment. When developing a clinic for critical lower limb ischemia, due to the low effectiveness of conservative methods of treatment, it is worth considering revascularization of the lower limb arteries. Open surgical methods of treatment are associated with a high risk of complications and mortality. X-ray endovascular methods of treatment of patients of the older age group are characterized by a lower risk of complications, lower injury rate. The use of low-injury x-ray endovascular and hybrid methods of treatment in elderly and senile patients can improve the results of treatment (reduce the frequency of amputations, reduce the risk of complications, improve the quality of life).
Chronic obstructive pulmonary disease and cardiovascular diseases: pathogenetic mechanisms of comorbidity and pharmacological interactions
D.Yu. Ruzanov, E.I. Davidovskaya, A.A. Pleshko, E.A. Grigorenko, I.V. Buynevich
The publication provides a brief overview of the most significant pathogenetic and pathophysiological mechanisms that will explain the phenomenon of comorbidity of chronic obstructive pulmonary disease (COPD) and cardiovascular pathology (CVD). Moreover, in this review is considered the potential impact of the recommended treatment of COPD on the risks and course of cardiovascular diseases from the perspective of evidence-based medicine. It has been shown that COPD and cardiovascular diseases share single risk factors, common pathogenetic mechanisms, unidirectional pathophysiological processes, similar clinical symptoms and effects synergistically with respect to adverse events and outcomes, which allows us to attribute this combination to category of comorbid pathology. The presented results of randomized clinical trials and meta-analyzes demonstrate that currently no COPD guidelines contain detailed clinical recommendations for assessing cardiovascular risk in this category of patients, nor are there enough guidelines for the treatment of COPD in patients with cardiovascular disease or vice versa. In terms of international experience, it is substantiated that the comorbid pathology of COPD and CVD should not be considered isolated from each other.
Current aspects of drug therapy of chronic heart failure syndrome
T.V. Statkevich, N.P. Mitkovskaya
Chronic heart failure (CHF) is an important problem for the country, which has both medical and socio-economic aspects. The presence of the syndrome not only significantly increases the risks of an unfavorable course of diseases underlying its etiological basis, but in itself, through the development of decompensation, causes a high frequency of deaths. Despite all the advances in pharmacotherapy, the prognosis of heart failure remains poor. More than 40% of patients die within 4 years after the diagnosis of heart failure, and the one-year mortality rate for patients with severe CHF (NYHA class IV) exceeds 50%. The foregoing determines the need and importance of using all possible drug and non-drug therapy technologies aimed at reducing mortality, increasing the duration and quality of life of patients with CHF, as well as reducing the number and likelihood of decompensation and related hospitalizations, and makes this direction one of the priorities in medicine. The article describes current approaches to the treatment of patients with CHF syndrome from the perspective of evidence-based medicine and taking into account the recommendations of leading international organizations for the treatment and prevention of cardiovascular diseases. The drugs used were analyzed in terms of their influence on clinical symptoms, quality of life of patients, the risk of hospitalization due to decompensation of CHF, and mortality rates. The emphasis is made on the possibilities, mechanism of action and further prospects for the use of a new class of drugs in the treatment of CHF, acting at the level of the renin-angiotensin-aldosterone system and the system of neutral endopeptidases – inhibitors of angiotensin-neprilisin receptors.