Kardiologiya最新文献

Aim: To study the plasma proteome of patients with type 1 acute myocardial infarction (AMI) to identify potential markers for long-term prognosis of the risk for developing cardiovascular complications.

Material and methods: The study included 64 patients with type 1 AMI with and without ST segment elevation who underwent primary percutaneous coronary intervention upon admission. The following information on cardiovascular events was collected for 36 months after admission: death from cardiovascular pathology, recurrent AMI, stroke, repeat myocardial revascularization and/or endarterectomy. Peripheral blood sampling followed by a plasma proteome analysis using chromatography-mass spectrometry was performed in all patients before hospitalization.

Results: During 36 months after hospitalization, cardiovascular complications were detected in 23 (36%) patients. These patients were included in the group with an unfavorable prognosis, while the remaining patients made up the group with a positive prognosis. A mass spectrometric analysis of the plasma proteome and comparison of the groups identified seven differentially represented proteins. Also, a multivariate regression analysis, ROC curves, and Kaplan-Meier models showed that four proteins (apolipoprotein C1, complement factor H, di-N-acetylchitobiase, and ficolin-2) were predictors of the risk for developing cardiovascular complications in the long term. An integrated parameter was developed that took into account the plasma concentrations of all four above proteins. This parameter was used to construct a model for assessing the risks of unfavorable long-term prognosis in AMI patients with a sensitivity of 87% and a specificity of 78%.

Conclusion: The study results demonstrated that plasma concentrations of apolipoprotein C1, complement factor H, di-N-acetylchitobiase, and ficolin-2 are reliable prognostic markers for assessing the risks of cardiovascular events in patients with AMI in the long term.

Aim: To study the associations between risk factors, clinical characteristics, severity of brachiocephalic artery (BCA) atherosclerosis and severity of coronary artery (CA) disease in patients with acute coronary syndrome (ACS).

Material and methods: The study included patients with any type of ACS and obstructive coronary artery disease confirmed by coronary angiography. A quantitative analysis of coronary angiography data was performed with an assessment of the number of CAs with significant stenosis and calculation of the SYNTAX score. The major clinical and laboratory parameters that are risk factors for atherosclerosis and/or affect the cardiovascular prognosis were assessed; for patients with ACS without ST segment elevation (NSTE-ACS), the risk score was calculated by the GRACE scale. The BCA ultrasound examination was performed with a quantitative analysis of atherosclerotic burden.

Results: The study included 312 patients aged 64 [56, 72] years; the proportion of men was 69.2%. The frequency of lesions of 1, 2 and 3 coronary arteries was 34.6, 35.3, and 30.1%, respectively; the SYNTAX score was 14 [9, 21]. According to the results of univariate analysis, the number of stenotic CAs and the SYNTAX score were associated with age, smoking history, history of ischemic heart disease, diabetes mellitus (DM), the presence of non-stenotic CA lesions, the GRACE score in NSTE-ACS, and the Charlson comorbidity index. An inverse correlation was found for the level of physical activity and a slightly weaker one for the glomerular filtration rate and high-density lipoprotein cholesterol (HDL-C). In multivariate models, the only independent predictors of the number of stenotic CAs were HDL-C (odds ratio, OR 0.37, 95% confidence interval, CI 0.17-0.81; p=0.012) and the smoking history (OR 1.30, 95% CI 1.12-1.52; p=0.001), a coefficient of determination of the model R2 of 18%, SYNTAX score with a history of myocardial infarction (ß=6.40, 95% CI 3.22-9.58; p<0.001), insulin-dependent DM (ß=9.44, 95% CI 3.50-15.38; p=0.002), GRACE score for NSTE-ACS (ß=0.06, 95% CI 0.01-0.11; p<0.014), and a coefficient of determination of the model R2=20%.

Conclusion: Patients with ACS show significant, independent associations of the severity of coronary atherosclerosis with HDL-C, smoking duration, history of myocardial infarction, insulin-dependent diabetes, and the GRACE score in NSTE-ACS. Variability in the severity of CA lesions is only to a small extent determined by risk factors, clinical characteristics, and the severity of concomitant carotid atherosclerosis.

Comorbid diabetes mellitus (DM) in patients with ischemic heart disease (IHD) is a serious factor that significantly impairs the life prognosis and increases the risk of cardiovascular complications (CVC) as well as the likelihood of death. The residual risk of developing CVC in such patients is largely determined by the high thrombotic status, that is associated with hypercoagulation characteristic of DM. Hypercoagulation causes activation of both platelet and coagulation pathways, which leads to an increased susceptibility to thrombosis. In this context, the combined administration of the anticoagulant rivaroxaban (Xarelto®) 2.5 mg and acetylsalicylic acid (ASA) can significantly reduce this risk by affecting both mechanisms of thrombus formation and thereby improving the prognosis. Rivaroxaban 2.5 mg in combination with ASA is the only available strategy to intensify the antithrombotic therapy in patients with stable IHD and DM with no history of ischemic events. Importantly, such therapy should be initiated as early as possible to prevent clinically significant CVCs and improve patients' quality of life.

Aim: To identify predictors and construct a model for predicting left ventricular (LV) ejection fraction (EF) in patients with ST-segment elevation myocardial infarction (STEMI).

Material and methods: This was a prospective registry study of patients with STEMI admitted within the first 24 hours of the disease onset. Patients were evaluated and treated according to the current clinical guidelines. On the first day of STEMI, concentrations of growth stimulating factor, proprotein convertase subtilisin-kexin type 9 (PCSK9), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin I and C-reactive protein were measured. Echocardiography was performed on the first day and on day 10-12 of admission; LVEF was calculated by the Simpson method. The study included 138 patients; 3 patients were excluded from this part of the study due to death before repeat echocardiography. Based on the LVEF value on day 10-12 of STEMI, the patients were divided into the groups with preserved LVEF (pLVEF) ≥50% (n=34), reduced LVEF (rLVEF) ≤40% (n=21), and moderately reduced LVEF (mrLVEF) 41-49% (n=80).

Results: The ordinal regression analysis showed that the factors influencing LVEF in STEMI patients included a history of chronic heart failure, Killip class II-IV acute heart failure at the index hospitalization, the development of LV dilation and postinfarction aneurysm, and an increase in NTproBNP. Based on the obtained estimates of the regression parameters, a prognostic model was constructed that showed the highest sensitivity of the model for predicting rLVEF, 94.4%, mrLVEF, 92.9%, and a lower sensitivity for predicting pLVEF, 62.5%.

Conclusion: In the presence of a history of chronic heart failure, Killip class II-IV acute heart failure, developed LV dilation and postinfarction aneurism, and elevated NTproBNP, patients with STEMI are expected to have lower LVEF values.

The main treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is radical surgery, pulmonary thromboendarterectomy (PEA). However, about 40% of patients with CTEPH are inoperable due to distal pulmonary vascular lesions or the severity of hemodynamic disorders. Almost 30% of patients with CTEPH experience persistent or recurrent pulmonary hypertension after surgery, that requires a drug treatment with PAH-specific drugs. This review presents current data on the use of targeted therapy in patients with CTEPH. The review addresses the place, indications, and the evidence base for using the main groups of specific drugs, including stimulators of soluble guanylate cyclase, phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, and prostacyclin analogues.

Aim: To evaluate characteristics of atherosclerotic plaques (ASP) remaining after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) by coronary computed tomography angiography (CCTA).

Material and methods: Among 249 patients (193 men) with ACS aged 58±10 years, 183 (73.5%) had myocardial infarction, 66 (26.5%) had unstable angina. CCTA was performed after PCI at 3-7 days after the onset of ACS according to the standard protocol: in 41 patients, on a 64-slice tomograph (Aquilion 64, Toshiba, Japan) and in 208 patients, on a 640-slice tomograph with 320 rows of detectors (Aquilion ONE Vision Edition, Toshiba, Japan). CCTA of all patients was performed on a Vitrea workstation. Patients with at least one non-calcified ASP were included.

Results: Among all ASPs, non-calcified ASPs predominated, 609 of 785 (77.6%), including 400 soft and 209 combined ones. Signs of obstruction (stenosis ≥50%) were noted in 72.2% of non-calcified ASPs. ASPs were characterized by a pronounced burden, 69 [61.4; 74.2]%, and a low minimum density, 31 [23; 37] HU, which was consistent with mature plaques with a lipid core. Various signs of ASP instability were observed in 6-35.3% of cases. There were 2 [2;3] (1 to 6) affected coronary arteries (CAs) and 3 [2;4] (1 to 7) ASPs, including calcified ones, per patient. 77.7% of ASPs were located in the CA proximal and middle segments. Obstructive stenosis was detected in 92% of patients. The number of ASPs with obstructive stenosis ranged from 0 to 7 per patient, with a median of 2 [1;3]. In 44% of patients, stenosis was 70% or more. The maximum burden of non-calcified ASPs was high, 74.3±12.1%; their maximum and total length were 13.8±10.4 mm and 26.5±19.7 mm, respectively; and the ASP minimum density was low, 25 [17;32] HU. ASPs with a low-density area of ≤46 HU and ≤30 HU were detected in 24.9% and 14.8% of patients, respectively. Other CCTA signs of instability were quite common: punctate calcifications in 52.2% of patients, coronary positive remodeling in 37%, the presence of "ring-like enhancement" in 16.1%, an uneven plaque contour in 26.7%, and at least one sign of ASP instability in 73% of patients.

Conclusion: After PCI, patients with ACS still have rather many ASPs, including those with CCTA signs of instability, with stenosis >50%; more than a third of the plaques had stenosis >70%; the plaques were extended and localized mainly in the proximal and middle sections of the main CAs.

The article presents a clinical case of secondary cardiomyopathy in an HIV patient with plasmablastic lymphoma due to the combined pathology (HIV infection with ongoing antiretroviral therapy in combination with antitumor therapy), in which the use of multimodal imaging contributed to establishing the correct diagnosis and excluding the unjustified use of invasive methods for diagnosing ischemic heart disease.

Objective: This study aimed to investigate the association between dapagliflozin and the incidence of atrial fibrillation (AF) and atrial flutter (AFL), along with its impact on all-cause mortality in patients with diabetes mellitus (DM).

Material and methods: Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this meta-analysis conducted a comprehensive search across PubMed, Embase, and ClinicalTrials.gov databases up to June 2021. We focused on randomized controlled trials (RCTs) that compared dapagliflozin with a placebo. Trial sequential analysis (TSA) was utilized to assess the reliability of the findings. All statistical analyses were performed using Review Manager software.

Results: The final analysis included nine studies, encompassing a total of 30,235 patients. The findings indicated a statistically significant reduction in the incidence of AF / AFL in the dapagliflozin group compared to the placebo group (relative risk (RR) = 0.73, 95 % confidence interval (CI) = 0.59 to 0.89, p=0.002), although this result was not corroborated by TSA. The occurrences of AF and all-cause mortality were also lower in the dapagliflozin group than in the placebo group (RR = 0.71, 95 % CI = 0.57 to 0.89, p=0.003 and RR = 0.90, 95 % CI = 0.82 to 0.98, p=0.02, respectively). However, TSA did not confirm these outcomes.

Conclusion: Dapagliflozin appears to offer a significant protective effect against AF / AFL and may reduce the risk of all-cause mortality in patients with DM. However, further research is needed to confirm these findings due to the lack of confirmation by TSA.

Aim: Evaluation of the clinical and diagnostic role of stepwise stress echocardiography (Stress Echo) with exercise using the ABCDE protocol in patients with myocardial infarction (MI).

Material and methods: This single-site study included 75 patients (mean age 61.6±9.8 years; 84% men) after MI. The median time since MI was 1231.0 [381.5; 2698.5] days. All patients underwent Stress Echo using a five-step protocol. Step A identified impaired local contractility, step B identified the sum of B lines, step C identified the left ventricular (LV) contractile reserve, step D identified the coronary reserve in the anterior interventricular branch, and step E identified the heart rate reserve. The Stress Echo result was assessed by scores from 0 (all steps negative) to 5 (all steps positive). The effects of positive steps and the sum of Stress Echo scores on the incidence of the need for repeat revascularization were assessed.

Results: The frequency of positive results was 36% for step A, 18.7% for step B, 80.0% for step C, 53.3% for step D, and 50.7% for step E. In 4 (5.3%) patients, all steps were negative (score 0); in 3 patients (4%), they were positive (score 5). Coronary angiography after Stress Echo during the follow-up period was performed in 26 (34.7%) patients; the need for repeat revascularization was determined in 17 (22.7%) patients. The predictors of the need for repeat revascularization according to a multivariate analysis were positive step A, chest pain pattern, and LV end-diastolic volume at peak exercise (p<0.001). A statistically significant effect of positive step A on survival without a need for repeat revascularization was observed in patients with a history of MI (p=0.020).

Conclusion: Among all the parameters of the integrated approach with Stress Echo, the emergence of new areas of impaired LV local contractility in patients after MI remains the main guideline for prescribing an angiographic study and a significant predictor of a need for repeated revascularization. However, the study results suggest that a further investigation of the effect of each positive step and the total ABCDE Stress Echo score on the prognosis for postinfarction cardiovascular complications is promising.

Aim: Comparative assessment of structural changes in cardiomyocyte mitochondria of the right atrial appendage and the mitochondrial respiratory function in peripheral blood leukocytes in a cohort of patients after acute decompensated heart failure (ADHF) and with stable chronic heart failure of ischemic etiology with reduced ejection fraction (CHFrEF) or moderately reduced ejection fraction (CHFmrEF) of the left ventricle.

Material and methods: The study analyzed 40 micrographs of right atrial appendage cardiomyocytes obtained from 12 patients with CHFrEF and CHFmrEF. The study protocol was registered on ClinicalTrials.gov: NCT05770349. Electron microscopy was performed with a JEM-1400 transmission electron microscope (Subdiffraction Microscopy Collective Use Center at the Electron Microscopy Department of the Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University). The total area of interfibrillar mitochondria was calculated as a ratio of the total surface area of mitochondria located between the cardiomyocyte contractile fibers to the total area of the interfibrillar space. The respiratory activity of isolated mitochondria was assessed in oxygenated standard incubation media. Patients were divided into two groups based on the occurrence of an ADHF episode within 12 months before inclusion in the study: Group 1 (n=19), patients without ADHF and Group 2 (n=21), patients with an episode of ADHF.

Results: Most of the clinical and anamnestic parameters were comparable between the study groups. Analysis of the mitochondrial respiratory function in peripheral blood leukocytes showed reduced values of the respiratory control level (RCL) in both study groups, 2.14 [2; 2.32] and 2.55 [1.36; 2.84] conv. units. The total area of interfibrillar mitochondria was 41.7 [32; 58]% in the group without ADHF and 33 [21; 46]% in patients with ADHF (p=0.048); significant correlations were found between this parameter and the distance walked in the 6-min walk test (r=0.482; p=0.002) and the peak oxygen consumption during exercise (r=0.395; p=0.012). A ROC analysis was used to determine a threshold value of the total area of interfibrillar mitochondria in patients with ADHF: the cutoff point was 32%.

Conclusion: A decrease in the total area of interfibrillar mitochondria of the right atrial appendage cardiomyocytes of less than 32% as measured by electron microscopy is characteristic of patients with a previous episode of ADHF with reduced and moderately reduced left ventricular ejection fraction. The study results confirm the development and persistence of ultrastructural changes in cardiomyocytes after ADHF.