Тематичний Архів | Category Archives: Atherosclerosis and coronary disease

N.M. Tereshchenko Exercise training as an integral part of cardiac rehabilitation in patients in the early post-infarction period: clinical and functional parallels

Material and methods. The study involved 91 male patients aged 33-68 (average age (52.3±1.5) years with Q-wave MI. In the first hours after MI onset, all patients had urgent coronary angiography, a stent was inserted into the culprit coronary artery and drug therapy was administered in accordance to the current protocols and guidelines. Depending on the amount of physical rehabilitation, the patients were divided into two groups: group 1 included 47 patients who underwent physical cycling course training (three times a week, a total of 30 sessions), group 2 consisted of 44 patients whose rehabilitation consisted in distance walking and remedial exercises. The examinations were carried out at discharge from the inpatient department (12–15 days). Both clinical, instrumental and biochemical tests were performed after 4, 6 and 12 months following MI.

Results. At the initial stage, the patients of either group didn’t demonstrate differences in clinical indicators or medical history data. At the first survey, the threshold power level and the cost of the work performed according to the indicator of the ratio of dual product to the level of performed work (DP/A) didn’t differ significantly. After 30 training sessions, the threshold power increased significantly (125.0 (125.0–140.0) W in group 1 at the value of DP/A 0.92 (0.76–1.17) units). In group 2, the threshold power increased to 100.0 (75.0–100.0) W, but at the level of DP/A (1.73±0.18) units. One year after MI the level of threshold power increased to 140,0 (125.0–150.0) W at low cost (1.17 (0.98–1.32) units) in group 1, while in group 2 the level of threshold power decreased and approached the data of the first survey (75,0 (75.0–100.0) W) with a significant increase of the cost of work (2.41 (1.73–3.36) units). Such dynamics of the indicators of exercise tolerance was accompanied by changes of hemodynamic indices.

Conclusions. Exercise training program increased physical tolerance with better parameters of bicycle ergometry after its interruption and preserving of the effect during one year after MI. This was accompanied by optimization of the remodeling and restoration of wall kinesis. The exercise training program contributed to improving the physical fitness in patients with late opening of the infarction-related coronary artery disease and incomplete revascularization. The effect of exercise training was short-lived and limited in multifocal lesions.

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O.A. Yepanchintseva, O.J. Zharinov, K.O. Mikhaliev, B.M. Todurov Predictors of early postoperative complications in patients with stable coronary artery disease after coronary artery bypass grafting

Material and methods. A retrospective observational single-center study included 576 consecutive pts with stable CAD (mean age 61±9 years, 491 (85.2 %) males, 85 (14.8 %) females), undergoing isolated CABG. We analyzed demographic, clinical, laboratory, echocardiographic, coronary angiographic, intra- and postoperative data, and assessed health-related quality of life. In total, EPOC were registered in 112 (19.4 %) cases. Acute kidney injury (n=55) and acute heart failure (n=49) were the most frequent major EPOC (9.5 % and 8.5 %, respectively). Two patients (0.4 %) died early after CABG.

Results. At univariate analysis, EPOC were related to the following baseline parameters: age; body mass index (BMI); heart failure NYHA class; permanent AF; severe diabetes mellitus (DM); poor kidney function (by estimated glomerular filtration rate (eGFR)); left atrium and left ventricular (LV) end-diastolic volume index; LV systolic dysfunction; LV hypertrophy; aortic and mitral valve regurgitation; three-vessel CAD. At multivariate analysis, the independent predictors of EPOC were as follows: BMI (per 5 kg/m2 increase vs < 25.0 kg/m2 as reference (r): OR 1.38 (95 % CI 1.06–1.79); Р=0.017); DM severity (per each severity category increase vs no DM (r): OR 1.75 (95 % CI 1.47–2.10); Р<0.001); eGFR (per each 30 ml/min/1.73 m2 decrease vs ≥ 90 ml/min/1.73 m2 (r): OR 2.29 (95 % CI 1.58–3.31); Р<0.001); and LV ejection fraction (EF) (< 40 % vs. 40–49 % vs. ≥ 50 % (r): OR 1.92 (95 % CI 1.49–2.49); Р<0.001). Conclusions. Multiple characteristics related to EPOC reflected comorbidity burden in the study cohort. Independent predictive value of baseline BMI, DM severity, eGFR and LV EF should be taken into account for risk stratification before CABG.

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V.І. Tseluyko, M.M. Doloh, O.A. Leonenko Influence of the phenomenon of no-reflow after percutaneous coronary intervention on long-term prognosis in patients with ST elevation acute myocardial infarction (results of a prospective study)

The aim – to determine the impact of the «no-reflow» phenomenon (NRP) after percutaneous coronary intervention (PCI) upon long-term prognosis in patients with ST elevation myocardial infarction (STEMI) and the effect of NRP on the incidence of complications of acute myocardial infarction during the acute period.

Material and methods. 105 patients with STEMI aged 36 to 85 years were studied, the mean age was 60.40±2.03 years. PCI was performed immediately after the diagnosis of STEMI, an average of 7.6±1.2 hours after the onset of the first symptoms. No-reflow was determined after the recanalization of the infarct-related artery (IRA) as the absence of optimal myocardial perfusion using the MBG (Myocardial blush grade, MBG ≤ 2) scale. Patients in whom NRP was fixed were assigned to the main group, n=18 (17.1 %), patients whose angiographic data met the criteria for successful PCI were appropriately allocated to the control group, n=87 (82.9 %). The final combined point was nonfatal repeated myocardial infarction, nonfatal stroke, cardiovascular death (CVD), and repeated hospitalization for the recurrence of the angina pectoris within one year after intervention.

Results. In the main group, postinfarction angina (OR 3.79, 95 % CI 1.08–13.42, Р<0.05), acute left and/or right ventricular failure was significantly more frequent (OR 7.98; 95 % CI 1.89–33.65, Р<0.05) and there were more cases of ventricular fibrillation (OR 12.14, 95 % CI 2.03–72.67, Р<0.05). At the end of 10.9±1.6 months it was found that the incidence of the combined endpoint in the patients of the main group is significantly higher than in the control group (OR 3.89, 95 % CI 1.36–11.24, Р<0.05). The greatest contribution to the difference between the groups at the combined endpoint was made by the discrepancy between the study groups for CVD (OR 10.38, 95 % CI 2.55–42.18, Р<0.05) Conclusions. NRP in patients STEMI after PCI is related to the development of postinfarction angina, acute left and/or right ventricular failure, ventricular fibrillation. The strongest link was established between the development of NRP and cardiovascular mortality during the first 30 days in patients after intervention. It was not possible to establish connection between NRP and re-hospitalization for the resumption of angina pectoris, the incidence of non-fatal recurrent myocardial infarctions and non-fatal strokes.

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I.E. Malynovska, O.B. Kuchmenko, V.O. Shumakov, N.M. Tereshchenko, L.S. Mkhitaryan, I.N. Ievstratova, N.M. Vasylynchuk, T.F. Drobotko Clinical and biochemical peculiarities at the different stages of cardiac rehabilitation in patients after myocardial infarction

The aim – to study the dynamics of indices of the exercise tolerance and the qualitative status of the main classes of lipoproteins together with activity of corresponding enzymes in patients after acute myocardial infarction (MI) during the first 6 months of follow-up.

Material and methods. 76 patients were included in the study (mean age 52.2±1.2 years). They received basic therapy according to the current guidelines, including emergent stenting. 41 pt (1st gr) in addition to standard medical treatment had the course of 30 cycle ergometer exercise trainings 3 times per week in individual regimen and 35 pts (2nd gr) underwent medical treatment and walking without trainings. All of them were examined on the 14–16th days of myocardial infarction and in dynamics at 2,5; 4 and 6 months. Blood biochemistry assays were performed on the 14–16th days and in 5 months after myocardial infarction.

Results. There was no difference in main clinical and anamnestic indices in patients of both groups at the first examination. Regular cycle ergometer exercise trainings led to the significant increase of the level of work capacity at the 4th month from (60.7±3.0) to (114.0±2,9) kJ (P<0.05) with better economic efficiency of heart work. The level of tolerance to physical load which was achieved by pts in the 1st gr was preserved 2 months at least after physical training stopping (112.0±3.9) kJ (P<0.05). At the same time these indexes in the 2nd gr were (59.1±3.8), (65.8±3.0) and (69.8±4.4) kJ, respectively with worse economic efficiency of heart work. At the 1st exam it was established high level of free radical oxidation of proteins, associated with oxidation of low density lipoproteins (LDL), very low density lipoproteins (VLDL), and high density lipoproteins (HDL) with higher index of their oxidative modification and blood atherogenic potential. The accomplished training program significantly decreased the content of free radical oxidation of proteins in blood serum and lipoproteins (LDL+ VLDL, HDL). Conclusions. The efficiency of physical training program at the cycle ergometer in early period after myocardial infarction was established during 6-months follow up. Regular activities in individual regimen in addition to standard medical treatment (with emergent stenting) led to significant increasing of the level of the completed work and economic efficiency of heart work. These clinical effects may be explained by the decreasing of intensity of oxidative stress and inflammation, the improvement of qualitative status of lipoproteins. After stopping of physical trainings the achieved tolerance to physical load was preserved at least for two months.

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O.A. Yepanchintseva, O.J. Zharinov, K.O. Mikhaliev, B.M. Todurov Left ventricular dysfunction before planned surgical revascularization. Features of the «grey area»

The aim – to study the clinical characteristics of patients with stable coronary heart disease (CHD) and heart failure (HF) with mid-range left ventricular (LV) ejection fraction (EF) (40–49 %; HFmrEF), undergoing the planned coronary artery bypass grafting (CABG) in the real-life clinical practice settings.

Material and methods. We conducted a cross-sectional one-center study and consecutively enrolled 622 patients with stable CHD (mean age 61±9 yr, 526 (84.6 %) males and 96 (15.4 %) females), undergoing planned CABG. We analyzed demographic, clinical, laboratory, echocardiographic and coronary angiographic data. The population of enrolled patients was stratified into three groups according to the LVEF degree: group 1 (LVEF ≥ 50 %; 350 (56.3 %)); group 2 (LVEF 40–49 %; 11 (18.5 %)); and group 3 (LVEF < 40 %; 157 (25.2 %)). Results. The set of parameters in group 2, having intermediate values when compared to groups 1 and 3, were: the frequency of baseline aldosterone antagonists administration; the frequency of patients without mitral and tricuspid regurgitation; the frequency of patients with moderate or severe mitral regurgitation; mean systolic pulmonary artery pressure; the frequency of patients with LV aneurysm, detected by coronary ventriculography. Conclusion. The population of patients with CHD and HFmrEF, undergoing CABG in the real-life clinical practice settings, is associated with clinical heterogeneity. Further studies are warranted, aimed to determine the predictors of favorable and unfavorable dynamics of LVEF in this category of patients in the post-CABG period.

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O.M. Parkhomenko, O.I. Irkin, Ya.M. Lutai, S.P. Kushnir,D.О. Bilyi, A.O. Stepura, Yu.M. Sokolov, M.Yu. Sokolov, V.Yu. Kobylyak, A.S. Kryvchun Effect of various regimens of lipid-lowering therapy on the efficacy of urgent myocardial revascularization and development of left ventricular remodeling in patients with acute coronary syndrome with ST segment elevation

The aim – to evaluate the effect of different regimes of lipid lowering therapy on the effectiveness of urgent myocardial revascularization and the development of cardiac remodeling in patients with acute coronary syndrome with ST segment elevation (STEMI).

Material and methods. The study involved 135 STEMI patients admitted an average of 4.5 hours after symptoms onset and treated with primary percutaneous intervention. Lipid-lowering treatment was prescribed immediately after presentation. Patients were randomly assigned to one of four groups treated by moderate (group I and group II) or high (group III and group IV) intensity lipid-lowering therapy. Group I (26 patients) was assigned to atorvastatin 10 mg / ezetimibe 10 mg combination, group II (24 patients) – to atorvastatin 40 mg, group III (42 patients) – to atorvastatin 40 mg / ezetimibe 10 mg combination, and group IV (43 patients) – to atorvastatin 80 mg. Echocardiography was performed in all the patients during first 24 hours after symptoms onset and 90 days after STEMI development. Left ventricular (LV) dilatation was defined as at least 25 % increase of end-diastolic volume.

Results. Patients from groups III and IV showed a tendency to the reduction of post-MI LV dilatation after 3 month of treatment (Р<0.1). In our study use of high intensity lipid-lowering therapy reduced the risk of LV remodeling by 30 % (p<0.05), that was also associated with significantly higher LDL reduction. Having no initial differences, on the 90th day the average LDL level was 1.63±0.40 in patients with high intensity treatment vs. 2.21±0.30 mmol/l in patient with therapy of moderate intensity (Р<0.01). Conclusion. The use of high-intensity lipid-lowering therapy with achievement of target LDL levels after STEMI can reduce the incidence of post-MI LV dilatation.

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N.D. Oryshchyn, Yu.A. Ivaniv Predictors of ischemic mitral insufficiency in patients with systolic left ventricular dysfunction after myocardial infarction of different localization

The aim – to estimate the role of geometric parameters of mitral valve deformation and remodeling of the left ventricle (LV) in the formation of mitral insufficiency in patients with systolic dysfunction after myocardial infarction (MI) of different localization.

Material and methods. We assessed 99 patients with left ventricular (LV) systolic dysfiunction after MI with mild to severe mitral insufficiency. We evaluated mitral insufficiency by means of echocardiography through determining EROA (effective regurgitant orifice area), assessed indexes of LV global and local remodeling. mitral insufficiency was moderate and severe in 36 patients with anterior MI (group 1) and in 43 patients with inferior/posterior MI (group 2), the control group consisted of 21 healthy individuals.

Results. In both groups of patients rates of global and local LV remodeling were significantly higher than in the control group (P<0.0001). Sphericity index was significantly higher in group 1, compared to group 2 (P=0.003). The indexes of local remodeling were significantly higher in group 1, especially anterior papillary muscle (PM) tethering distance (Р=0.03), posterior displacement of the anterior PM (Р=0.03), PM height (Р=0.01), interpapillary distance (Р=0.02). Correlation between EROA and sphericity index in group 1 was revealed (Kendall τ 0.46, P<0.0001), in group 2 this correlation was weak (Kendall τ 0.23, Р=0.016). In group 1 correlation of EROA with anterior and posterior PM tethering distance was revealed (Kendall τ 0.41 and 0.52, P<0.0001). In group 2 EROA correlation with posterior PM tethering distance and anteroposterior mitral valve diameter was revealed (Kendall τ 0.36 and 0.48, P<0,0001). Correlation between EROA and inferior apical segment akinesia and WMSI of posterior PM was revealed in group 1 (Kendall τ 0.71 and 0.51, P<0.0001), and relation between mitral insufficiency and obstructive lesion in circumflexus (Cx) and right coronary artery (RCA) (Р=0.0008 та Р=0.002) in this group. Conclusions. LV spherisation and PM dislocation are more pronounced in ischemic CMP after anterior MI, compared to inferoposterior MI. Apical and posterior PM displacement, akinesia of inferior apical segment, Cx and RCA obstruction are major determinants of ischemic mitral insufficiency after anterior MI, while posterior PM tethering and anteroposterior mitral annular dilatation are determinants of mitral insufficiency after inferoposterior MI. The obtained data might determine surgical approaches in ischemic mitral insufficiency of different mechanisms.

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V.Y. Tseluyko, O.D. Yarova Results of Holter ECG monitoring in patients with atherosclerosis of the arteries of lower extremities and factors associated with the revealed disorders

The aim – to evaluate the results of ECG daily monitoring in patients with peripheral arterial disease (PAD) of the lower extremities and to investigate association with clinical and genetic (T(–786)C polymorphism of the eNOs gene promoter parameters.

Material and methods. The study involved 100 men with lower extremities PAD, average age 60.7±0.9 years. We performed Holter monitoring, echocardiography, Doppler ultrasound of the lower extremities and carotid arteries, selective coronary angiography. The study of allelic polymorphism of eNOs gene promoter was performed by polymerase chain reaction.

Results and discussion. The patients were divided into 2 groups: I – 63 (63 %) without ischemic heart disease (IHD), ІІ – 37 (37 %) patients with IHD. Decreased glomerular filtration rate (GFR), which was more often recorded in group II, was related to the ventricular arrhythmias (Р=0.03) and atrial fibrillation (Р=0.02). Supraventricular arrhythmias were found in 42 patients. Patients of the II group, in which supraventricular arrhythmias were registered, more often were carriers of C allele (Р=0.008). Ventricular arrhythmias were detected in 27 patients. Among them, patients with concomitant coronary artery disease were more likely to be carriers of C allele (Р=0.002). There was a relationship between atrial fibrillation and angina (Р=0.045), past myocardial infarction (MI) (Р=0.02, including repeated one, Р=0.0001), decrease in GFR (Р=0.02). Conduction defects were more often recorded in group II (Р=0.01).

Conclusions. Ischemic ECG changes are significantly associated with the younger age (Р=0.045), the earlier onset of PAD (Р=0.02), the presence of the C allele the polymorphism eNOs promoter gene (Р=0.002), symptoms of carotids damage (p=0.004) and suffered acute cerebrovascular disorders (Р=0.007). According to Holter ECG monitoring, arrhythmias and blockades were detected in both clinical groups.

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A.V. Rudenko, M.L. Rudenko, O.A. Beregovyy Specifics of postinfarction rupture of the interventricular septum

The aim – to determine the most informative diagnostic markers of severity of post-infarct interventricular septal rupture (PIIVSP), as well as the most effective methods of treatment of this complication based on their own experience in treating patients.

Material and methods. During the period from 1991 to 2017, 65 patients with PIIVSP were treated, average age (59.1±6.7) years: 44 (67.7 %) men aged 52–73 years (average 57.4±9.5 years) and 21 (32.3 %) women aged 64–76 years (average 62.2±11.7 years). 41 patients had a posterior localization of the defect, at 24 – anterior localication.

Results. PIIVSP leads to complicated hemodynamic disorders, related to the size of PIIVSP, the amount of blood loss through the gap, the size of the IM zone, the degree of damage to the coronary arteries and the presence of necrosis of the papillary muscles. Congestive heart failure and cardiogenic shock are important factors influencing the results of treatment of PIIVSP. A main factor determining the development of congestive heart failure and cardiogenic shock in patients with PIIVSP in its anterior localization is a left ventricular dysfunction, resulting from widespread myocardial necrosis. A method of surgical geometric reconstruction of left ventricle with one «sandwich» patch was used. The mortality was 13.8 %, mostly because of acute heart failure.

Conclusions. Surgical treatment of PIIVSP is a method of choice, since it is most effective compared to medication and endovascular therapy, providing defect closure and restoration of left ventricle geometry.

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M.М. Dolzhenko, V.E. Dosenko, L.E. Lobach The recessive pattern of inheritance of аldosterone synthase gene and indicators of diastolic function of left ventricle in patient with coronary heart disease and postinfarction cardiosclerosis

The aim – was to investigate the possible association of the aldosterone synthase gene (CYP11B2) polymorphism and the recessive pattern of inheritance with left ventricular diastolic function in patients with coronary heart disease and postinfarction cardiosclerosis (PIC).

Material and methods. One hundred patients (age 57.3±8.9 years) were examined by general clinical methods. The study included patients with a history of myocardial infarction for more than 6 months and up to 2 years from the date of the event. Genetic testing was performed by polymerase chain reaction in real mode. The study material was venous blood of patients with coronary heart disease, PIC. Echocardiography was done for the evaluation of diastolic function in all patients.

Results. The E wave velocity parameters were higher among patients with TT + TC genotype compared to the data of patients with CC genotype. The wave-velocity parameters A were higher, and DT was longer in patients with CC variant of the genotype compared to the TT + TC variant of the aldosterone synthase gene polymorphism, which indicates a greater frequency of LV relaxation disturbance in patients with CC variant of polymorphism compared to TT + TC variant of the genotype. The indices of higher diastolic LV diastolic pressure, an increase in its preload (E/E´, AR) were higher in the group of patients with TT and TC, a variant of aldosterone synthase gene polymorphism. The patients with TT + TC variant of polymorphism more often encountered more severe forms of LV diastolic dysfunction (pseudonormalization, restriction) compared with the data of patients with a variant of polymorphism of the aldosterone synthase gene (P<0.0001), which indicates a more severe course of the disease in these patients. Conclusion. The risk of developing more severe forms of diastolic LV dysfunction in patients with TT + TC genotype CYP11B2 is higher, compared to the CC genotype in patients with IHD, PIC.

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