Тематичний Архів | Category Archives: Original researches

N.V. Lozynska, Yu.A. Ivaniv Ultrasonоgraphic analysis of the fetal heart rhythm: clinical significance and differential diagnosis of bradyarrhythmias

The aim – 1) to evaluate the possibilities of ultrasound fetal heart examination in the detection and differential diagnosis of bradyarrhythmias; 2) to study the influence of arrhythmias on fetal hemodynamics; 3) to examine the role of fetal echocardiography in the management of prenatally diagnosed bradyarrhythmias for determining the optimal pregnancy and delivery tactics.

Material and methods. The analysis of echocardiographic examinations of the fetal heart from April 1996 to July 2016 has been performed. During this period 2073 pregnant women were examined and 213 cases of fetal heart arrhythmias were detected. Ultrasound examination of the fetal heart was conducted according to the general protocol. The anatomy of the fetal heart was assessed based on segmental analysis. Rhythm of the fetal heart was determined by simultaneous recording of mechanical events (contractions of the atria and ventricles), which are the consequence of electrical activity, with estimation of the ratio between them, as well as the measured time intervals of the cardiac cycle with calculation of their ratio. For this purpose, various ultrasound techniques (M-method, color, pulse-wave and tissue Doppler) have been used.

Results. During the study period 45 cases of fetal bradyarrhythmias were detected, (2.2 % of the number of all patients examined and 21.1 % of all arrhythmias). They included 20 cases (44.5 %) of periodic bradycardia of different duration, 9 cases (20 %) of sustained sinus bradycardia, 9 cases (20 %) of complete atrioventricular block, 5 cases (11 %) of blocked atrial bigeminy and 2 cases (4.5 %) of 2nd degree atrioventricular block. Persistent fetal bradycardia requires a complete echocardiographic examination to exclude structural pathology and assess possible hemodynamic complications. Bradyarrhythmias with a frequency of ventricular contractions of more than 60 bpm are well tolerated by the fetuses due to various adaptive mechanisms. Permanent forms of arrhythmia with a frequency less than 55 bpm, as usual, lead to serious hemodynamic comromise even in the absence of fetal congenital heart defects.

Conclusions. Ultrasound fetal heart examination provides not only the identification and reliable differential diagnosis of various types of fetal bradyarrhythmia, but also an assessment of its hemodynamic consequences and prenatal period monitoring of the fetal condition. This makes possible to choose the tactics of pregnancy management, determine the frequency of follow-up examinations, plan the time, place and route of delivery. The majority of fetal bradyarrhythmias are non-threatening rhythm disorders.

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O.A. Koval, A.V. Khomych, S.V. Romanenko, A.S. Skoromna New clinical-echocardiographic method to reveal obstructive сoronary artery disease presence with index of coronary obstruction calculation: its characteristics and verification

The aim – to elaborate and to validate the combined non-invasive method to reveal the obstructive сoronary artery disease (CAD) presence using its clinical pretest probability value in conjunction with tissue Doppler data of local systolic wall motion.

Material and methods. 81 pts with typical anginal and atypical chest pain and known absence of structural myocardial diseases as well as history of myocardial infarction and coronary revascularization, 64 % men, age 56.2±9.9 yrs old were examined. All patients were divided into investigational (teaching) and checking group (49 and 32 patients, accordingly) comparable by age, gender and main comorbidities rates. The index of coronary obstruction (INCO) was expressed in conventional units and was calculated as the ratio of CAD pretest probability to mean systolic wall motion velocity of 12 myocardial segments by tissue Doppler imaging.

Results. Invasive angiography identified obstructive lesions of coronary arteries in 37 patients, including 23 patients (47 %) of the investigational group and 14 (44 %) in checking group. The investigational group patients’ INCO composed 7.8±3.8 conv units with bimodal distribution of the parameter and cut-off point at 8 conv units which corresponds to 80 % sensitivity and 91 % specificity, AUC in ROC analysis 0,965. Comparable diagnostic properties of INCO at 8 conv units were confirmed during the further analysis in checking group with 85 % sensitivity and 95 % specificity, AUC 0.971.

Conclusions. New complex non-invasive diagnostic method including INCO calculation based on CAD pretest probability and local systolic wall motion velocities evaluation by tissue Doppler was proposed. High INCO sensitivity and specificity at value – 8 conv units to determine obstructive lesions in coronary arteries were shown. INCO calculation may be widely used at the first step of non-invasive diagnosis in suspected CAD, as well as for determination of the further strategy in patients after coronary revascularization.

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V.P. Ivanov, Т.D. Danilevych Antiarrhythmic efficiency of eplerenon in complex therapy of patients with arterial hypertension and frequent recurrences of atrial fibrillation

The aim – to determine antiarrhythmic efficiency of eplerenone in the complex therapy of patients with arterial hypertension (AH) and frequent recurrences of atrial fibrillation (AF).

Material and methods. 146 patients with AH II stage and frequent recurrences of AF were examined. The age of the patients was from 37 till 86 years. Among them 68 (46.6 %) were males. Permanent antiarrhythmic therapy was prescribed in all patients. The antiarrhythmic efficiency was evaluated by patient-reported frequency of AF attacks and their course. Fixed combinations of perindopril with indapamide and losartan with hydrochlorothiazide were used as a starting antihypertensive therapy. Eplerenone 25 mg daily was added in a number of the patients. All patients were examined by determining serum aldosterone levels and daily ECG monitoring.

Results. Usage of eplerenone during 6 months decreased frequency of recurrences of AF and increased the duration of the period between recurrences (4.8 vs. 3.2 times, P=0.04). Antiarrhythmic effect of eplerenone was accompanied by significant increase of cases with complete elimination of supraventricular premature contractions (SPC) (P<0.001) and AF episodes (p=0.05), significant decrease of daily SPC frequency (P=0.007) and supraventricular paroxysmal tachycardias / atrial flutter episodes (P<0.04), decrease of QT interval dispersion (P<0.04). The probability of complete antiarrhythmic efficacy with additional use of eplerenone was significantly more in case of the adrenal AF (P<0.03). Factors increasing the probability of complete antiarrhythmic efficacy of eplerenone were: daily heart rate > 78 per minute, the ratio of left atrium /right atrium < 1.45, using of losartan in a dose of 100 mg/day, the dynamics of systolic blood pressure (BP) at the 4th week of treatment according to data of office measurement of BP > 32 mm Hg, and plasma level of aldosterone > 150 pg/ml.

Conclusions. Eplerenone provided additional antiarrhythmic effect in patients with AH and paroxysmal AF. Positive antiarrhythmic effect of eplerenone accompanied by a significant increase in cases with a complete elimination of SPC and AF episodes, significant decrease in the frequency of SPC for the day and SVPT/AF episodes, decrease in the dispersion of QT interval. The probability of complete antiarrhythmic efficacy with additional use of eplerenone significantly increases in the case of adrenal variant and decreases in the case of vagal varian of AF. As factors that increase the probability of complete antiarrhythmic efficacy of eplerenone are: daily HR > 78, the ratio LA/RA < 1.45, using of losartan in a dose of 100 mg/day, the dynamic of systolic BP at the 4th week of treatment according to data of office measurement of BP > 32 mm hg and plasma level of aldosterone > 150 pg/ml.

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L.G. Voronkov, A.S. Solonovych, A.V. Liashenko The state of cognitive function in patients with chronic heart failure and reduced left ventricular ejection fraction depending on the main clinical, demographic and hemodynamic parameters

The aim – to investigate clinical and other factors associated with cognitive dysfunction in patients with chronic heart failure (CHF) and reduced left ventricular ejection fraction.

Material and methods. 124 patients with stable CHF and reduced left ventricular ejection fraction (< 40 %), NYHA II–IV not older than 75 years were examined. Vital signs, routine laboratory tests, glomerular filtration rate by CKD-EPI, electrocardiography and ehocardiography parameters were studied. Cognitive function was evaluated by standard neuropsychological tests – MMSE (Mini Mental State Examination), Shulte and HADS. Cognitive dysfunction was defined as MMSE ≤ 26 points. Apart from routine examination, quality of life evaluation by The Minnesota Living with Heart Failure Questionnaire (The MLHFQ); evaluation of functional capacity by Duke Activity Status Index, endothelium-dependent vasodilation test were performed. Results. Cognitive dysfunction (abnormal MMSE) was observed in 85 (68.6 %) patients. There was no significant differences of MMSE and Schulte test results in men and women, groups of patients with atrial fibrillation (AF) and sinus rhythm. Instead, a significantly worse MMSE and Schulte tests were observed in groups of patients with higher NYHA class (Р<0.001 for both tests), arterial hypertension (P=0.04 and P=0.012, respectively), coronary heart disease (Р<0.001 for both tests) and after myocardial infarction (Р<0.001 and P=0.002, respectively). The group of elderly patients had significantly worse MMSE and Schulte scores (Р<0.001 for both tests). Levels of systolic blood pressure, heart rate and left ventricular ejection fraction did not significantly affect cognitive function, while lower glomerular filtration rate was associated with presence of the cognitive dysfunction. There was a significantly higher prevalence of cognitive dysfunction in patients with diabetes (P=0.049). At the same time, MMSE and Schulte tests were significantly worse in patients with anemia (P=0.02 and Р<0.001, respectively) and renal dysfunction (GFR < 60 ml/(min · 1,73 m2)) (P=0.003 and Р<0.001, respectively). Conclusion. Cognitive dysfunction was observed in 68.6 % of stable CHF patients. There was no significant influence of heart rate, systolic blood pressure, left ventricular ejection fraction, atrial fibrillation and COPD on cognitive tests. Cognitive dysfunction in patients with CHF is associated with older age, coronary heart disease, history of hypertension and myocardial infarction, anemia and renal dysfunction.

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K.M. Amosova, O.V. Vasylenko, K.P. Lazareva, N.V. Shyshkina, Yu.О. Sychenko, I.I. Gorda, A.V. Sablin, N.V. Melnichenko, Yu.V. Rudenko, A.B. Bezrodnyi, K.I. Cherniaieva, I.I. Burlachenko The clinical characteristics of patients with arterial hypertension, symptoms of heart failure and preserved ejection fraction depending on E/e´ at rest and under physical exertion

The aim – to study clinical characteristics of patients with arterial hypertension, symptoms of heart failure and preserved left ventricular (LV) ejection fraction (EF) depending on the value of E/e´ at rest and after submaximal exercise testing (SET).

Material and methods. A prospective study involved 103 patients, average age 65.4±10.8 years, with clinical signs of heart failure, LV EF ≥ 50 % and signs of LV diastolic dysfunction. Echocardiography with tissue Doppler, SET, applanational tonometry were conducted. The level of NT-proBNP was studied. According to E/e´, patients were divided into 3 groups: E/e´ > 13 at rest (group І), E/e´ > 13 after SET (group ІІ), E/e´ < 13 after the SET (group ІІІ). Results. Group І included 64 (62.1 %), group ІІ – 24 (23.3 %), group ІІІ – 15 (14.5 %) patients. Patients were comparable regarding age, gender, frequency of earlier myocardial infarction and the average level of systolic blood pressure. Patients of group І, compared to those in groups ІІ and ІІІ, more often had atrial fibrillation, chronic kidney disease and anemia (all Р<0.01). Frequencies of diabetes mellitus and obesity in group ІІ were larger than in group ІІІ: 12 (50 %) and 4 (26.6 %); Р<0.05) and 15 (62.5 %) and 3 (20 %); Р<0.01), respectively. Severity of heart failure by NYHA was greatest in group І, less – in group ІІ and the smallest – in group ІІІ (all Р<0.01). Group ІІ, compared to group ІІІ, had worse exercise tolerance based on submaximal exercise test duration (7.2±1.7 and 8.6±1.9 minutes, Р<0.01) and power (50.0±19.9 and 68.3±22.0 W, Р<0.02), higher left atrial volume index (LAVI) 38.7±1.2 and 35.3±1.2 ml/m2 Р<0.05, left ventricular myocardial mass index (LVMI) 138.7±13.7 and 128.0±35.1 mg/m2 Р<0.05 and levels of NT-proBNP 422.8±93.8 and 134.3±53.5 pg/ml. Conclusions. Patients with E/e´ > 13 at rest differ from those with E/e´ increase after SET, by decrease of exercise tolerance and higher frequency of comorbidities. In patients with arterial hypertension, heart failure II–III classes NYHA and unchanged E/e´ at rest, its increase more than 13 after SET was noted in 61.5 % patients, and was associated less exercise load, greater frequency of obesity and type 2 diabetes, greater LVMI and LAVI and higher levels of NT-proBNP.

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L.G. Voronkov, V.V. Gorbachova, A.V. Lіashenko, T.I. Gavrilenko, L.S. Mkhitaryan Iron metabolism parameters in patients with chronic heart failure and reduced left ventricular ejection fraction depending on basic demographic, clinical and instrumental characteristics

The aim – to study the iron metabolism parameters in patients with chronic heart failure (CHF) and reduced left ventricular ejection fraction (rLVEF) depending on main clinical characteristics of patients obtained during the instrumental study.

Material and methods. During period from January 2016 till February 2018, 134 stable patients with CHF (113 (84.3 %) of men and 21 (15.7 %) of women), 18–75 years old, NYHA class II–IV, with left ventricular ejection fraction < 40 % were screened. Patients were included at a clinical compensation phase. Quality of life was assessed by the Minnesota living with heart failure questionnaire (MLHFQ), physical activity was estimated by the Duke University index, functional status – by assessing the 6-minute walking test (6MWT) and a standardized lower limb extension test. Results and discussion. Iron deficiency was found in 83 (62 %) of 134 patients with CHF and rLVEF. There were no significant differences of iron metabolism in regard to CHF etiology and most co-morbidities. The presence of anemia was associated with lower ferritin, transferrin saturation (TSAT) and serum iron levels, and the presence of renal dysfunction – with the latter two. Patients in NYHA III–IV class had significantly lower TSAT and serum iron levels. The ferritin level was significantly higher only in group of patients with better muscular endurance, while TSAT and serum iron levels were also significantly higher in patients with greater 6-minutes walking distance, better hip muscles endurance, greater physical activity index and fewer scores by the Minnesota quality of life scale. Ferritin has shown a significant correlation with serum iron levels and hemoglobin. TSAT level correlated with a serum iron level, hemoglobin, limb muscles endurance, 6-minute walking test result, physical activity index and MLHFQ score. Conclusions. Iron deficiency has been revealed in 62 % of patients with CHF and rLVEF. The plasma ferritin level is lower in patients with anemia and with worse muscle endurance. TSAT and serum iron levels are lower in patients with NYHA III–IV class, anemia, renal dysfunction, worse physical tolerance indicators and poorer quality of life. Both ferritin and TSAT demonstrate a relation to hemoglobin and iron plasma level, additionally TSAT – with physical activity index, 6-minutes walking test distance (6MWT), quadriceps femoris muscle endurance and MLHFQ quality of life.

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N.V. Dovgan, O.M. Parkhomenko, Ya.M. Lutay Acute coronary syndrome without ST-segment elevation on electrocardiogram: clinical and anamnestic factors of poor prognosis at hospital period

The aim – to study the risk factors of an unfavorable prognosis and identify patients groups with high risk of complications after acute coronary syndrome (ACS).

Material and methods. A total of 490 patients (pts) hospitalized with ACS without ST-segment elevation (74.49 % men and 25.51 % women, average age 58.78±0.44 yrs) with acute clinical destabilization that occurred no more than 72 hours before admission to the hospital were examined. The diagnosis of acute myocardial infarction (MI) or unstable angina pectoris was established according to the ESC guidelines. The anamnestic and clinical factors affecting the course of the hospital period were identified. The end points of the study, in addition to the clinical signs, were additionally formed combined endpoint: MI/cardiovascular death/recurrent angina pectoris (MI/CVD/RAP), MI/CVD/acute heart failure (MI/CVD/AHF), MI/CVD/ AHF/RAP.

Results. Most patients had arterial hypertension (AH) (77.35 %) and ischemic heart disease (IHD) (72.04 %) in the anamnesis, including a previous MI – 43.06 %. There were 34.08 % active smokers and 53.88 % – smokers in the past; overweight was detected in 16.53 %, type II diabetes mellitus (DM) – in 16.12 %. Acute HF, MI and death were detected with similar frequency in men and women. RAP developed in women more often than in men (46.4 % vs 29.3 %, respectively, Р<0.001). Ventricular arrhythmias (VA) were registered more often in men (15.1 % vs 6.4 %, Р<0.05). There were no significant differences in the middle and older groups. AHF, RAP, and MI/CVD/RAP, MI/CVD/AHF and MI/CVD/AHF/RAP have developed or progressed more often in men with DM than in women. In men, the presence of DM in 2 times increases AHF developing risk (Р<0.05) during the hospital period, 4 times the risk of progression AHF (Р<0.01), 2 times the risk of RAP, MI/CVD/RAP, MI/CVD/AHF/RAP (Р<0.05, in all cases) and almost 5 times the risk of MI/CVD/AHF (Р<0.01). Significant differences during the hospital period are observed in pts younger than 55 yrs and older than 65 yrs. There were no differences in middle age pts. The IHD history significantly increased the AHF progression, RAP development and the frequency of combined endpoint: MI/CVD/RAP, MI/CVD/AHF, MI/CVD/AHF/RAP. The previous MI did not affect the development of the hospital period complications of ACS without ST elevation. Chronic heart failure (CHF) in the history significantly increased the risk of AHF development during the hospital period of ACS, as well as the risk of AHF developing on the 1st day of the disease, the development of RAP and combined CT: MI/CVD/RAP, MI/CVD/AHF/RAP. The presence of AH significantly increased RAP development risk by 26 %. Conclusions. Factors of poor prognosis of the hospital period in patients with ACS without ST segment elevation include DM in men, IHD, CHF and AH in the history. The risk of RAP, MI/CVD/RAP, MI/CVD/AHF/RAP are significantly higher in women than in men, while VA reliable more frequently develop in men. The most important gender differences regarding development of hospital complications are observed in patients younger than 55 yrs.

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L.М. Babii, V.О. Shumakov, О.P. Pogurelska, Yu.O. Khomenko, L.F. Kisilevich Short- and long-term outcomes in patients after ST-elevation myocardial infarction with urgent percutaneous coronary intervention

The aim – to study clinical and functional characteristics of patients with ST-segment elevation myocardial infarction (STEMI), the terms of urgent percutaneous coronary intervention (PCI), the coronary artery lesions, gender and age, the parameters of intracardiac hemodynamics depending on the time to PCI; to assess the end-points at 1 year follow-up.

Material and methods. Between Feb till May 2015 we conducted a single-center prospective study and enrolled 108 patients with STEMI that underwent PCI (coronary angiography with stenting). We analyzed the terms of PCI after acute coronary syndrome symptoms onset, demographic, anamnestic, clinical, echocardiographic, angiographic data, as well as characteristics of interventions. We studied end-points, such as death, recurrent non-fatal MI, unstable angina, at 12 months follow-up after STEMI. Data on clinical outcomes were available in 100 of 108 patients (92.6 %).

Results. According to the study results, half of STEMI patients underwent PCI within 3.5 hours; only 20.4 % patients – within the optimal time window (up to 2 hours); 60 % of patients – from 2 to 6 hours. Only 47 % of patients underwent complete revascularization. However, stenotic lesions ≥ 70 % were identified in 40 % of patients. Severe coronary lesions, suitable for CABG, were detected in 14 % of cases. Large LV aneurysm with intramural thrombus formation was diagnosed in 4 % of patients. Females, compared to males, were older, with the more prevalent concomitant hypertension and diabetes mellitus. Only 33 % of patients were judged as low-risk patients, according to the PAMI-II criteria. At 1 year follow-up, 3 % patients died from recurrent MI. These patients had single- or two-vessel disease, with stenting of the culprit artery. Among patients suitable for CABG, surgical revascularization was performed only in 1/3 cases.

Conclusions. The registry data allow to assess the profile of STEMI patients undergoing PCI, as well as short-term (at discharge) and long-term (at 1 year follow-up) outcomes.

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O.M. Parkhomenko, Ya.M. Lutay, O.I. Irkin, D.O. Bilyi, A.О. Stepura, S.P. Kushnir, O.A. Skarzhevskyi, O.V. Shumakov Clinical, anamnestic characteristics and course of in-hospital period in young patients with ST-elevation acute coronary syndrome

The aim – to compare the clinical, anamnestic characteristics and course of in-hospital period in patients of different age groups with ST-elevation acute coronary syndrome.

Material and methods. Were analyzed the data of 835 patients with ST-elevation acute coronary syndrome admitted to the emergency departments from January 2000 to December 2015. Patients were divided into two groups: I group – < 45 years of age (n=189), II group ≥ 45 years (n=646). Results. The average age of patients in the I group was (37.8±6.5) years, in the II group – 59.3±8.1 years (Р<0.0001). Among the patients in group I there were more men (Р<0.0001). The mean body mass index (BMI) in young patients was 28.7±4.6 kg/m2 compared to 27.8±4.2 kg/m2 in group II (Р<0.021). The frequency of diabetes mellitus in patients of the I group was 4.2 %, arterial hypertension – 41.8 %. Young patients were much less likely to have a history of myocardial infarction or stroke and concomitant heart failure. The anterior localization of myocardial infarction in group I patients was registered in 59.8 % cases vs 51.9 % in the II group, Р=0.045; there were no significant differences regarding frequency of posterior and lateral infarctions. The average time from the development of symptoms to hospitalization in the I group was 9.7±7.6 hours, and in group II – 4.5±5.3 hours (Р<0.001). Conclusions. Patients under 45 years of age with ST-elevation acute coronary syndrome are heterogeneous. The most important risk factors for the development of AMI in these patients are smoking, overweight and heredity. Hypertension and diabetes mellitus in young patients were much less frequent than in the older age group. In-hospital course of AMI in young patients was more favorable with fewer complications.

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O.S. Sychov, A.O. Borodai, Yu.V. Zinchenko, E.S. Borodai, S.I. Deyak Left atrial thrombus and/or sludge resolution and cardioversion in patients with non-valvular atrial fibrillation – flutter at repeated transoesophageal echocardiography

The aim – to evaluate the rate of resolution of left atrial appendage (LAA) thrombus and sludge after the use of anticoagulation therapy and evaluate the safety of cardioversion in patients with residual LAA thrombus and/or sludge on repeated transoesophageal echocardiography (TOE).

Material and methods. 39 patients with LAA thrombus and/or sludge on baseline TOE were included into the prospective observational study. The mean age was 61.7±9.5 years, mean CHA2DS2-VASc score 2.85±1.3, 11 (28.2 %) were females.

Results. There were 27 patients with LAA thrombus, 22 with LAA sludge, in 10 (45.45 %) cases thrombus was accompanied with sludge. After detection of thrombus and/or sludge, anticoagulation therapy was prescribed for 51.8±10.7 days before next TOE. Warfarin was prescribed in 19 (48.72 %) cases and treatment with novel oral anticoagulants (NOAC) – in 20 (51.28 %) patients. Complete thrombus resolution was noted in 18 (66.7 %) out of 27 cases, similar in both groups: in warfarin group it was found in 4/12 (33.3 %) and in NOAC group in 5/15 (33.3 %) of cases. In all cases residual thrombi had reduced size and were immobile. Sludge resolution rate was noted in 9 (40.9 %) out of 22: in warfarin group it was found in 7/11 (63.64 %) and in NOAC group – in 6/11 (54.55 %) cases. Cardioversion was registered in 14 (56 %) of patients with residual thrombus and/or sludge, among them 7 were with residual LAA thrombus: 3 patients had spontaneous cardioversion during first 30 days of follow-up, and DCC was performed in 4 highly symptomatic patients. There were no stroke or thromboembolic events during 30 days of follow-up. All patients were highly adherent to anticoagulation therapy.

Conclusions. Residual thrombi are frequent founding at repeated TOE. It seems that cardioversion might be considered in patients with reduced and immobile thrombi, being adherent to anticoagulation therapy.

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