The aim – to study heart structure and function according to the results of MR and ultrasound imaging, heart rate variability parameters, immune status indices in patients with myocarditis and to detect prognostic markers of unfavorable myocarditis clinical course.
Material and methods. Fifty two patients with clinically suspected acute diffuse myocarditis, sinus rhythm and heart failure with reduced LV ejection fraction (LV EF ≤ 40 %), among them 30 men and 22 women were examined. They were divided into two groups: 1st group – 27 patients with recovery of left ventricular ejection fraction (> 40 %) in 12 months, 2nd group – 25 patients without restoration of myocardial contractile function (LV EF ≤ 40 %). Within the 1st month after disease onset and after 12 months magnetic resonance imaging (MRI) of the heart, transthoracic echocardiography, Holter ECG monitoring with HRV parameters and examination of the immune status were performed.
Results. Left ventricular ejection after 12 months observation in patients of the 1st group increased by 27.8 % (P<0.01) and averaged 48.7 %, in patients of the 2nd group – by 12.4 % (P>0.05), on average to 38.5 %. Within the 1st month after myocarditis onset, myocardial edema at MRI was detected in 100 % and early contrast accumulation – in 92.3 % of patients (n=48). After 12 months of follow-up, both study groups were comparable by the results of detection of myocardial edema (18.5 and 20 %, respectively), and early contrast accumulation (22.2 and 28 %, respectively). The amount of delayed contrast accumulation zones at 12 months was significantly higher in patients in the second group – 42 (80.7 %) and 45 (86.5 %). The SDNN indicator in the 1st group increased by 18.3 % (P<0.05) for 12 months, while in the 2nd group it increased by 9.6 % (P>0.05). Number of ventricular arrhythmias and episodes of an unstable ventricular tachycardia after 12 months in patients of the 2nd group almost 2 and 2.5 times (P<0.01) respectively, exceeded the similar indicators of the 1st group.
Conclusions. In patients with myocarditis, in which LV EF remained ≤ 40 % after 12 months, significantly greater amount of delayed contrast accumulation and a decrease of HRV parameters were noted, related to more frequent development of ventricular arrhythmias. Patients with myocarditis having sites with delayed MRI accumulation of contrast, had a significantly higher risk of developing episodes of unstable ventricular tachycardia after 12 months of follow-up, according to Fisher’s exact test (F=0.012, OR=6.88).
The aim – to estimate changes of the myocardial structural and functional state and intracardiac hemodynamics in patients with non-valvular permanent atrial fibrillation (PAF) under treatment with β-blockers (BB), to determine the critical value of the heart rate being a negative predictor of the echocardiographic parameters during 6 month monitoring, to identify the preference for one of the HR control strategies.
Material and methods. 30 patients were included in this study. The duration of observation was 238.3±17.0 days, it consisted in 3 visits. Titration of the BB dose lasted 67.7±10.3 days (the interval between the first and second visits). Treatment with maximal or maximal tolerable dose of BB lasted 170.6±17.7 days (the interval between the second and final visits). During the follow-up period, echocardiography was performed twice – at 2 and 3 visits.
Results. During follow-up period significant changes were revealed, i.e. increase of LV end-diastolic dimension and its index in the general group and in women; of LV end-diastolic volume in women; the increase of LV mass index in the general group and in women; basal and transverse diameters of the RV and its area in diastole; pressure in the LA; early diastolic mitral in flow velocity and its relation to early diastolic mitral annular velocity; diameters of the PA and aorta root, mitral regurgitation. Correlation analysis revealed relationship between rate of mitral annular systolic velocity and the degree of severity of mitral regurgitation with the mean daily HR value according to 24 h Holter ECG. Along with lenient heart rate control after 6 months significant increase of the the interventricular septum thickness, basal RV diameter and PA diameter was observed; fractional change of the RV area decreased. At achievement of strict heart rate control fractional change of the RV area significantly increased compared to lenient one.
Conclusions. During follow-up period in patients with PAF we observed progression of LV diastolic dysfunction, heart valve dysfunction and increase of heart chambers, more significant in women, due to pressure overload. The median daily heart rate > 91 beats/min recorded during Holter ECG is a predictor of systolic function deterioration according to the tissue Doppler. Strict heart rate control has an advantage over the lenient one to improve the myocardial structural and functional state, the size and contractility of the right heart.
The aim – to evaluate the effectiveness and safety of warfarin therapy in patients with atrial fibrillation (AF) in the anticoagulation practice, the rate of CYP2C9, CYP4F2, VKORC1 genes polymorphism and their interrelation with hemorrhagic complications among Zaporizhzhia region residents.
Material and methods. We studied 41 patients with AF (mean age – 68.2±1.2 years, men – 19, women – 22) enrolled in a 1-year out-patient observation in the anticoagulation practice of Zaporizhzhia State Medical University clinics. All patients were treated with warfarin. CYP2C9, CYP4F2, VKORC1 genes polymorphism was determined using polymerase chain reaction method.
Results. During one year hemorrhagic complications (small bleedings) arose in 22 (53.66 %) patients with AF, receiving warfarin therapy. Bleedings were significantly more frequent in the group of patients with VKORC1 gene mutation: 69.5 % vs. 37.5 %, respectively (χ2=5.331; Р<0.05). It was found that the relative risk of bleeding under warfarin treatment in patients with VKORC1 gene mutation is 1.97 (95 % CI 1.039; 3.751; Р<0.05).
Conclusions. VKORC1 polymorphism is associated with increased frequency of hemorrhagic complications in patients with AF taking warfarin, indicating the relevance of a personalized approach to the warfarin dose titration using pharmacogenetic testing.
The aim – to evaluate clinical and echocardiographic predictors of ischemic stroke in patients with non-valvular atrial fibrillation and flutter (AF-AFl).
Material and methods. In a prospective observational study with a median follow-up of 36.8 months we examined 293 patients with non-valvular AF-AFl with a mean age 60.5±10.4 years, 81 (27.65 %) patients were females. Mean CHA2DS2-VASc score was 2.25±1.46. All patients underwent clinical examination and transthoracic echocardiography. Transesophageal echocardiography was performed in 263 (89.8 %) patients.
Results. Ischemic stroke (IS) occurred in 32 (10.92 %) cases: non-fatal IS – in 26 (8.87 %) cases, fatal IS – in 6 (2.05 %) cases. Onset of IS was associated with left atrial (LA) volume index ≥ 49 ml/m2 (Р=0,011), left atrial appendage spontaneous echo contrast (SEC) 3–4+ (Р<0.001), interventricular septum thickness (IVS) ≥ 1.7 cm (Р=0.02) and class EHRAm III–IV (Р<0,001). SEIL scale (SEC 3–4 + – 1 point, EHRAm III–IV – 1 point, IVS thickness ≥ 1.7 cm – 1 point, LA index ≥ 49 ml/m2 – 1 point) was an independent predictor of occurrence of IS, relative risk (RR) 2.38 (95 % CI 1.68–3.37), Р<0.001, independent of CHA2DS2-VASc, RR 1.28 (95 % CI 1.0–1.62), Р=0.045.
Conclusions. SEIL scale may be used for assessment the risk of ischemic stroke In patients with AF-AFl independent of CHA2DS2-VASc scale.
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.
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.
The aim – to study the control of blood pressure in patients over 55 years of age suffering from arterial hypertension as part of primary care or family practice, the concordance of the treatment to the existing guidelines, and the effectiveness of therapy revision in view of the age-specific peculiarities of treatment.
Material and methods. 102 physicians from various regions of Ukraine took part in the «СИСТЕМА 2» study. It enrolled patients over 55 years of age who sought medical advice in out-patient clinics for arterial hypertension (a total of 2,040 patients).
Results. Among patients who took antihypertensive drugs (91.6 %), the mean SBP was 167 mm Hg, and achievement of the target level was observed only in 6.9 % of the cases. In the treatment of arterial hypertension in patients over 55 years of age, the age-specific peculiarities of development and treatment of arterial hypertension, presented in the guidelines, were not taken into account. RAAS blockers are commonly used in monotherapy and in combination therapy but not diuretics and/or calcium antagonists which are recommended. Therapy revision and prescription of the fixed combination of amlodipine and indapamide provides reduction of blood pressure and achievement of the target level in 67 % cases at 3 months. At the same time, there is a high compliance rate (96.6 % at 3 months).
Conclusions. Arterial hypertension control is extremely unsatisfactory in Ukraine. Mean office SBP in patients taking antihypertensive drugs is 167 mm Hg. Only 6.9 % of patients achieve goal SBP level. In treatment of patients aged 55 and up, age pecularities are not taken into account. The most widely used are RAAS inhibitors, instead of recommended diuretics and/or calcium channel blockers. Combination of amlodipine and indapamide provides achievement of goal SBP level after 3 months of treatment in 67 % of cases with high treatment compliance. Antihypertensive effect is more pronounced in patients with higher baseline BP, in patients switched from RAAS inhibitors, in co-administration with statins and in females. Antihypertensive effect is lower in smokers.
The aim – to evaluate the place of ethacysin in the contemporary treatment of arrhythmias by means of retrospective analysis of 30 years experience in the treatment of heart rhythm disorders in a cohort of cardiorheumatology patients, including comorbidity with diabetes mellitus and chronic obstructive pulmonary disease; to investigate catamnesis and survival of these patients for 15 years.
Material and methods. A 30 years’ experience of treatment of extrasystoles and paroxysmal / persistent atrial fibrillation (AF) with ethacizine in 74 patients without significant structural heart disease has been analyzed retrospectively. Maximal duration of continuous therapy was 12 years, maximal duration of intermittent therapy was 20 years. In different periods, ECG, Holter ECG monitoring, echocardiography, heart rate variability analysis, dispersion of repolarization, late ventricular potentials, exercise stress testing, pharmacological tests were used along taking into account underlying condition and monitoring of treatment effectiveness.
Results. The use of ethacizine was effective in 71.3 % of patients, including AF interruption – in 61.7 %, ventricular ectopy control – in 78.9 %, maintenance of sinus rhythm in patients with paroxysmal AF – in 58.4 % cases. Therapy was more effective in vagus-mediated AF in which the use of antiarrhythmic agents is limited. No serious adverse events were registered throughout the whole period of observation, indicating at acceptable ethacizine safety profile. Most of adverse reactions were predictable (22.7 %) and described in the medication insert. These were related to the antiarrhythmic effect and might be classified into 3 categories: 1) general, extracardiac (4.5–9.1 %); 2) associated with electrophysiological effect upon myocardium (18.1 %), considered to be within the normal limits; 3) occasional cases (right bundle branch block, Brugada type 1 ECG pattern, asymptomatic episode of ventricular tachycardia), leading to the discontinuation of the drug.
Conclusions. Overall, ethacizine was effective and safe even for the long-term use provided the patients are selected properly (those without significant structural heart disease) and the recommended algorithm of use and control is followed.
The aim – to investigate remodeling of left heart chambers in patients with essential hypertension and left ventricular hypertrophy (LVH) under one-year treatment with renin-angiotensin system blockers by means of longitudinal, circular deformation of left ventricle (LV) myocardium and contractile, reservoir and conductive functions of left atrium (LA).
Material and methods. The study involved 64 patients (women – 56 %) with arterial hypertension. Patients were divided into groups. 22 patients receiving angiotensin II receptor blockers (ARB), mean age 57.5±1.6 years, constituted group 1. The 2nd group included 26 patients on angiotensin-converting enzyme inhibitors (ACEI), mean age 59.4±1.4 years. Besides, patients were divided depending on LVH severity: group A was presented by 35 patients with mild and moderate LVH; group B – 13 patients with severe LVH. In all patients we performed echocardiography and speckle tracking echocardiography with analysis of longitudinal global systolic strain (LGSS), circumferential global systolic strain (CGSS) and their rates, early (EDSR) and late LV diastolic strain, LA early and late diastolic SR, LA systolic deformation (LASD).
Results and discussion. Longitudinal contractile LV function improved under treatment. This was supported by LGSS increase by 6 and 5 % in groups 1 and 2, respectively. When diastolic function was analyzed, EDSR was found to be higher by 6 and 4 % in groups 1 and 2, respectively at the end of observation period. Also, LASD was revealed to be higher in groups 1 and 2 by 9 and 8 %, respectively, compared to that before treatment. Thus, treatment with ARBs and ACEIs resulted in improvement of both systolic and diastolic functions of LV and reservoir LA function.
Conclusion. In groups A and B myocardial mass index decreased by 5 and 10 %, respectively. In the group with severe LVH along with longitudinal improvement CGSS reliably increased by 10 % compared to that before treatment.
The aim – to determine the predictors of regression of left ventricular hypertrophy (LVH) in patients with critical aortic stenosis (AS) after aortic valve replacement (AVR).
Material and methods. In one-center study, the results of a prospective observation in 119 patients with AS sequentially examined before and 6–12 months after the AVR surgery were analyzed. Among them were 74 (62.2 %) men and 45 (37.8 %) women, median age 63 years (quartiles 56.5–72.0 years). All patients underwent clinical, laboratory and instrumental studies before the operation, including transthoracic echocardiography (TTE) and coronary angiography. Depending on the changes of the left ventricular myocardial mass index (IMM LV) 6–12 months after AVR, all patients were retrospectively divided into two groups: in 52 (43.7 %) patients, the relative decrease in the IMM LV was from 0 to 30 %, and in 67 (56.3 %) – more than 30 % (maximum – 63 %).
Results. Median relative decrease of IMM LV after AVR after 6–12 months was 32.31 % (quartiles 23–40 %). Patients with less dynamics of IMM LV were characterized by a greater frequency of concomitant hypertension, angina pectoris and a large number of hemodynamically significant stenoses of the coronary arteries. The group of patients with large LVH regression was characterized by larger volume of the left atrium, larger IMM LV, lower initial left ventricular ejection fraction (LVEF), higher Tei index, lower MAPSE and systolic wave s, longer corrected QT interval. According to the multivariate analysis, the predictors of more severe LVH regression were the initial IMM LV, LVEF, mitral regurgitation, the duration of the corrected QT interval, and the absence of concomitant multivessel lesions of the coronary arteries. The accuracy of the prediction of the group with weaker dynamics of the IMM LV was 73.3 %, with a pronounced LVH regression – 79.7 %, the overall accuracy of the model was 76.9 %.
Conclusions. The severity of the IMM LV decrease is one of the most important indicators of the long-term effect of AVR in patients with critical AS. Output LVM, LVEF, mitral regurgitation, the duration of the corrected QT interval, and the absence of concomitant multivessel coronary artery lesions are independent predictors of a more favorable dynamics of IMM LV 6–12 months after AVR.