Rational Pharmacotherapy in Cardiology

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Vol 11, No 2 (2015)
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116-123 758

Aim. To study the structure and incidence of the in-hospital anticoagulants prescription in patients at high risk of thromboembolic events (TEE) and to evaluate clinical characteristics of anticoagulated patients (by the example of the University Clinical Hospital (UCH) №1 of I.M. Sechenov First Moscow State Medical University (FMSMU).

Material and methods. The cross-sectional retrospective study held in UCH №1 of the FMSMU, enrolled 677 patients with atrial fibrillation (AF) for whom the prevention of TEE was indicated.

Results. Of 677 analyzed cases (women 70%, men 30%) only 61% of the patients received appropriate anticoagulant therapy. Warfarin was prescribed in 73% of the cases, of them unsatisfactory international normalized ratio (INR) control (time in therapeutic range less than 60%) was revealed in 79%. 8.45% of the vitamin K antagonist treated patients developed hemorrhagic complications. 16% of the patients received novel oral anticoagulants (dabigatran – 14%, rivaroxaban – 2%). Bleeding was fixed in 4.2% of the dabigatran treated patients and in 14.3% - in case of rivaroxaban therapy.

Conclusion. More than a third of non-valvular AF patients receive inadequate antithrombotic therapy in routine clinical practice. 75% of the anticoagulated patients are prescribed the vitamin K antagonists (typically warfarin) as a traditional anticoagulant. At that, only in 21.7% of the patients receiving vitamin K antagonists, this therapy may be considered adequate. Low incidence rate of the novel oral anticoagulants prescription despite the advantages of such treatment also calls attention.

124-131 607

Aim. To study the types of cardiac pathology, particularities of its dynamics and the most effective options of therapy in patients with alcoholic disease during 3 years after complete cessation of alcohol.

Material and methods. After screening of 1740 patients with alcohol dependence stage 2-3 (F10.2 ICD-10; n=1740) 260 men aged 22 to 74 years that had completely withdrawn from alcohol consumption were included into the study. Standard clinical and laboratory examination was performed in all patients at baseline and at the visits. Patients were divided into 2 groups: group 1 (n=190) - patients with alcoholic disease with any cardiovascular disease; group 2 (n=70) - patients with alcoholic disease without cardiovascular diseases.

Results. Patients with paroxysmal ventricular rhythm disorders often (81.3%) need in constant antiarrhythmic therapy within 36 months after the alcohol cessation, and patients with paroxysmal supraventricular arrhythmias - only in 16.2% of cases. Beta-blockers, as well as combination of beta-blocker + amiodarone are the most effective antiarrhythmic drugs for the correction of paroxysmal supraventricular and ventricular rhythm disorders. The combination of beta-blocker + dihydropyridine calcium antagonists + amiodarone is the most effective to achieve simultaneous antihypertensive and antiarrhythmic effects.

Conclusion. Patients with alcoholic disease, who had withdrawn from alcohol consumption, require the identification of cardiac pathology. The optimal period of its observation is 36 months. Patients with paroxysmal ventricular rhythm disorders have the most unfavorable prognosis. These patients require continuous antiarrhythmic therapy.

132-138 577

The combination of risk factors that make up a metabolic syndrome increases the risk of cardiovascular disease and type 2 diabetes. In the presence of insulin resistance the effects of risk factors combine, thereby increasing the probability of the development of cardiovascular disease and its complications.

Aim. To study the effect of insulin resistance on the formation and progression of metabolic syndrome components on the basis of a 5-year follow-up.

Material and methods. An outpatient examination of clinically healthy patients aged 20-65 years (n=711; 327 men and 384 women) was conducted. The average body mass index did not exceed 34.5 kg/m2. Biochemical blood analysis was performed to assess the state of lipid and carbohydrate metabolism. Insulin resistance was diagnosed using HOMAIR>2.6.

Results. It has been detected that patients with insulin resistance have significantly higher incidence of the combination of three or more components of the metabolic syndrome (p<0.01). The incidence of multicomponent syndrome among the examined patients with insulin resistance was 69.7%, which is 1.8 times higher than in patients with initially preserved tissue sensitivity to insulin.

Conclusion. The follow-up study of patients with insulin resistance shows that in the absence of correction of metabolic disorders, the development of multicomponent disorders that make up a metabolic syndrome occurs.

139-143 815

Currently, a greater emphasis is placed on the search for additional biomarkers of chronic heart failure (CHF). Galectin-3, a marker of fibrosis and inflammation, has shown himself as a biomarker of CHF in many studies, but the dynamics of its levels in patients with concomitant diabetes mellitus (DM) type 2 is not well-studied.

Aim. To identify diagnostic significance of galectin-3 plasma level evaluation and its correlations with echocardiographic criteria for patients with CHF and DM type 2.

Material and methods. The study included 33 patients with ischemic CHF (all patients had a history of myocardial infarction) and DM type 2. The patients were divided into two groups according to the left ventricle (LV) ejection fraction (EF): a group with CHF and preserved ejection fraction (PEF) (EF≥50%) and with CHF and reduced ejection fraction (EF<50%). Patients underwent clinical laboratory tests and Doppler echocardiography; moreover, the levels of brain natriuretic peptide (BNP) and galeсtin-3 were measured.

Results. The mean level of galectin-3 in blood plasma in the group with CHF and PEF was significantly higher than in the group with CHF and reduced EF (p=0.007). In the group with CHF and PEF a positive correlation between the level of galectin-3 and diastolic LV function E/E' was found (r=0.620, p=0.01). A significant correlation between galectin-3 level and LV systolic function was stated in the group with reduced EF (r=0.53; p<0.05), while in the group with PEF, the correlation was not significant (p=0.225). In the group of patients with reduced EF a negative correlation between galectin-3 and the volume of left atrium was revealed (r=-0.53; p<0.05).

Conclusion. Galectin-3 can be used as a diagnostic biomarker primarily in patients with CHF and PEF.

144-148 752

Aim. To study the peculiarities of hemodynamic disorders in patients with rheumatoid arthritis (RA) and arterial hypertension (HT), and in patients with hypertension but without RA using the integral indicators of arterial stiffness.

Material and methods. The study included 106 RA patients (group 1), among them 83 (78%) women and 23 (22%) men, mean age 45.3±10.3 years. The group of comparison (group 2) included 63 patients (22 (35%) women and 41 (65%) men, mean age 47.9±12.8 years) with HT stages 1-3. The control group (group 3) consisted of 32 healthy volunteers: 19 women and 13 men, mean age 24.7±5.34 years. All patients underwent ECG and echocardiography. The model of cardiovascular system was used to calculate the modulus of volume elasticity (MVE), mean arterial blood pressure (BP) and total peripheral vascular resistance (TPR); stroke volume and cardiac output were measured using echocardiography.

Results. Significant differences in the parameters of BP, arterial stiffness and TPR were identified in patients with RA and HT as compared with the patients of the control group. Arterial stiffness in RA patients with HT, as well as without it, was significantly higher and TPR was lower than in hypertensive patients. RA patients with HT were older and had significantly higher values of cardiac output than those without HT. In RA patients hyperkinetic type of hemodynamics was observed in 53.8% of the cases, eukinetic - in 34.9%, hypokinetic - in 11.3%. Hypertensive patients had same types of hemodynamics in 3.2%, 61.9%, and 34.9%, respectively. In healthy people hyperkinetic type was observed in 22.9% of the cases, eukinetic - in 65.6%, hypokinetic - in 12.5%.

Conclusions. RA patients as compared with healthy people had significantly higher arterial stiffness indices regardless of BP. At that, hyperkinetic type of hemodynamics prevailed in RA patients, while in hypertensive patients and healthy people - the eukinetic one. Increased stroke volume and cardiac output at high arterial stiffness can be one of the causes of HT in RA patients.


149-152 809

Aim. To study the clinical forms of atrial fibrillation (AF), cardiovascular risk factors and comorbidities in these patients; to perform monitoring of complications and mortality in AF; to assess the quality of diagnosis and treatment of AF in real outpatient practice.

Material and methods. The register of patients with AF, visited an outpatient clinic of Yaroslavl from 01 January to 31 December 2013, was created. Quality of AF patient examination in the outpatient clinic was assessed. Morbidity and mortality of these patients were monitoring during 12 months by the contacts with patients, their relatives and doctors in charge.

Results. The typical patient with AF has advanced age, mainly permanent AF and compromised history of cardiovascular diseases. 12-month monitoring of 212 outpatients with AF showed high mortality and the need for hospitalization due to cardiovascular diseases in this group. A total number of these patients was 99 or 46.7% of patients included into the register.

Conclusion. The irregularity of observation and the lack of examination of patients with AF may be the reasons of the increased rates of mortality and complications in this group of outpatients.

153-158 532

Aim. To evaluate the frequency of prescription, efficacy and patients adherence to statin therapy in a cohort of patients with ischemic heart disease (IHD), confirmed by coronary angiography data, during the period from 2004 to 2010 based on the data from the PROGNOZ IBS register.

Material and methods. The PROGNOZ IBS register database was used in the study. The data of 550 patients from a cohort of patients with the confirmed IHD, who had undergone coronary angiography from 2004 to 2008 (303 of them were on the follow-up visit) were included in the final analysis.

Results. Low frequency of statins prescription in patients with stable IHD prior to hospitalization in 2004-2007 and a significant improvement of its quality during the stay in a specialized cardiology unit were revealed in the PROGNOZ IBS register. The frequency of statin prescription at discharge increased from 10% to 85.5% (in most cases original drugs were used), but the prescribed doses were usually inadequate. Target blood lipid levels were not achieved in the majority of patients. The level of low density cholesterol <2.5 mmol/L at discharge was present in 6.3% of the patients (the short period of hospitalization insufficient for the achievement of statins maximum effect should be taken into consideration). 67% of patients had good adherence to lipid-lowering therapy 3.9 years after the admission, however, the original drugs had been replaced by a variety of generics in most patients. The efficacy of the therapy was inadequate: the target levels of total cholesterol (<4.5 mmol/L) and low density cholesterol (<2.5 mmol/L) were achieved in 40% of patients, of low density cholesterol (<2.0 mmol/l) - in 15.8%.

Conclusion. Low frequency of statins prescription in patients with stable IHD before the admission to the hospital, its significant growth during the stay and its reduction after the discharge were revealed. The treatment efficacy was low at all stages of the observation. Patients' adherence to statin therapy in the outpatient setting remains inadequate.


159-164 474

Clinical case history of endovascular intervention in infarct related coronary artery with 4 sirolimus-eluting stents implantation and their further thrombosis during early postoperative period is described. Percutaneous coronary intervention was successful after the balanced medication with 2 antiplatelet drugs (acetylsalicylic acid and clopidogrel) and heparin. There were not any reasons for additional prescription of antiplatelet medicine. It seems that one of the main reasons of the stent thrombosis was the extended area of 4 sirolimus-eluting stents implantation into the affected vessel. After the analysis of our clinical case history we propose that for stent thrombosis prevention in multistent (≥4 drugeluting stents) interventions it is necessary to apply additional antiplatelet drug – glycoprotein IIb/IIIa inhibitor eptifibatide.


165-166 511

Key findings of IMPROVE-IT trial and their possible significance for clinical practice are discussed.

167-169 491

Aim. To study the opinion of doctors about the possibility of statins prescription to patients with cardiovascular diseases and concomitant chronic liver diseases.

Material and methods. Сross-sectional questioning of the random sample of physicians was performed. Results. 70 physicians (internists - 61.4%, cardiologists - 20.0%, neurologists - 5.7%, endocrinologists - 4.3%, and others) were interviewed. Work experience in the specialty of doctors was 25 years (14; 32.5). 22.9% of doctors completely exclude the possibility of statins prescription to patients with cardiovascular disease if they have concomitant liver disease. 70% of physicians consider it possible to use statin therapy in patients with liver disease, but only under certain conditions. Only a third of them, mostly internists, are ready to prescribe statins under condition of acceptable initial transaminase changes, and almost half of these doctors consider it possible to use statin therapy in patients with concomitant liver diseases only when serum transaminase levels are normal.

Conclusion. The physicians often and sometimes unreasonably find it impossible to use statin in patients with cardiovascular diseases and concomitant chronic liver diseases.


170-176 595

Aim. To study the effect of magnesium orotate, magnesium/pyridoxine combination and magnesium sulfate on fibroblast morphofunctional characteristics in cell culture of fibroblasts (McCoy line).

Material and methods. The study of fibroblasts (McCoy line) with the addition of magnesium-containing preparations (magnesium orotate, magnesium/pyridoxine combination, magnesium sulphate) to the culture medium was performed using scanning and transmission electron microscopy.

Results. When adding into the media magnesium orotate or magnesium/pyridoxine combination, significant changes in morphofunctional state of fibroblasts were noted, which were absent when adding magnesium sulfate. At that fibroblasts significantly promoted synthetic and secretory activity. This was expressed in the formation of amorphous and fibrous components in well-formed cell layers.

Conclusion. Stimulation by magnesium ions of the proliferative activity of fibroblasts is shown in the morphological analysis of the effect of magnesium orotate or magnesium in combination with pyridoxine and magnesium sulfate on morphological and functional organization of fibroblasts. Revealed the predominant influence of magnesium orotate, and a less pronounced effect of magnesium in combination with pyridoxine on biosynthetic processes in the cells, including the synthesis of amorphous and fibrous components (protocollagen and elastin) of the extracellular matrix founded.


177-181 838

The role of aldosterone in pathophysiological processes is considered. The effects of the selective antagonist of mineralocorticoid receptor eplerenone are analyzed. The advantages of eplerenone compared with spironolactone are discussed.

182-189 713

Resistant hypertension is defined as hypertension uncontrolled with optimal doses of three antihypertensive agents, one of which is a diuretic. The up-to-date approaches to optimal pharmacologic and interventional treatment are discussed. Special emphasis is placed on some controversial aspects of new interventional procedures for resistant hypertension correction.

190-195 2213

Currently, there is rather contradictory evidence on the effectiveness of a low sodium diet for the prevention of various diseases. At that, it is a generally accepted fact, that it is necessary to reduce salt intake in order to reduce high blood pressure. An internist should remember that the degree of blood pressure reduction is individual and not always depends on the level of salt intake. Moreover, the low-sodium diet helps to reduce the rate of telomere shortening, thereby slowing down the aging process.


196-201 616

The question of mutual influence of risk factors for cardiovascular and renal diseases with a focus on atrial fibrillation is considered. Modern approaches to the prevention of major macrovascular events in patients with comorbidity are evaluated.

202-208 887

Despite progress in reducing the risk of hypertension (HT) complications, control of blood pressure (BP) levels remains inadequate. Dihydropyridine calcium channel blockers show antihypertensive effect due to significant vasoselective action with a minimal impact on a conductive system of the heart. Lercanidipine is a dihydropyridine calcium channel blocker of the third generation with high lipophilicity and long-lasting action. Lercanidipine had shown both in monotherapy and in combination with ACE inhibitors or angiotensin II blockers the good antihypertensive effect with stable BP profile throughout the day, organoprotection that slowed down the progression of HT complications, metabolic neutrality and safety in mild to moderate HT.

209-216 558

Apixaban is a "new" oral anticoagulant, direct Xa factor inhibitor with a good evidence base of the efficacy in the prevention of ischemic stroke in patients with atrial fibrillation. The article is devoted to apixaban use in clinical practice: examination before apixaban administration, clinical situation when laboratory control and monitoring are needed, drugs interactions (at the level of CYP3A4, P-gp), management of patients with bleeding because of apixaban therapy (including antidotes application), perioperative management of patients receiving apixaban.


217-218 291
Prof. V.V. Skibicky is 60!


219-221 314

Yevgeny M. Tareev – a man, who had been ahead of the time in medical science (interview with Academician N.A. Mukhin).


222 299

In memory of Andrey A. Alexandrov.

231-232 332

Results of the IV International Forum on Cardiology and Internal Medicine.

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ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)