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Rational Pharmacotherapy in Cardiology

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Vol 12, No 6 (2016)
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https://doi.org/10.20996/1819-6446-2016-12-6

ORIGINAL STUDIES

622-630 352
Abstract

Aim. To estimate the effectiveness of lipid-lowering therapy (LLT) at outpatient and hospital treatment stages in patients at high and very high cardiovascular risk during 2011-2015.

Material and methods. In a cross-sectional epidemiological study we analyzed LLT in hospital patients for the period April-May 2011, 2012 and 2015. All data were obtained from randomly selected case-records of patients (n=548; 20% of all hospital patients over the study period). Risk categories of patients as well as target levels of low density lipoprotein (LDL) cholesterol were determined according to the current clinical guidelines for the respective year. Outpatient LLT was administered in local out-patient clinics and hospital one – in the clinic of State Research Centre for Preventive Medicine.

Results. The most commonly prescribed group of lipid-lowering drugs was statins, while combined treatment or monotherapy with other lipid-lowering agents were used only in rare cases. From 2011 to 2015 the proportion of patients taking statins before admission increased from 20% to 49.8% (from 23.1% up to 29.6% of patients at high cardiovascular risk and from 28% up to 68.5% of patients at very high cardiovascular risk, respectively). During hospitalization the proportion of individuals receiving statins increased from 49.8% to 72.9%, from 29.6% to 74% and from 68.5% to 95.3% in general group, among patients at high and very high cardiovascular risk, respectively. In 2015 LDL cholesterol target levels were achieved in 14.8% and 7.1% of patients at high and very high risk, respectively. In-hospital rate of simvastatin administration reduced from 33.6% to 0.5%, whereas prescription of atorvastatin and rosuvastatin increased from 31.4% to 64.5% and from 3.6% to 9.9%, respectively. Average dose of statins (in conversion to atorvastatin) increased from 10 mg to 20 mg in high-risk patients and from 10 mg to 40 mg – in very high risk group.

Conclusion. Positive trend in frequency of LLT prescription was demonstrated in patients at high and very high cardiovascular risk during 2011-2015. Nevertheless, significant number of patients in out-patient clinics still remains under non-optimal treatment. 

631-637 490
Abstract

Aim. Expert assessment of real clinical practice compliance with national guidelines on management of patients with chronic heart failure (HF) before the opening of the Expert Center of HF treatment.

Material and methods. All patients admitted to 2 city clinical hospitals of Moscow with HF were included into the register. Clinical, demographic, laboratory and instrumental characteristics and medical treatment before and during hospitalization were evaluated, as well as recommendations contained in the discharge summary.

Results. 300 patients with HF were included into the register. The mean age was 75 years (39, 95); the proportion of men – 44%. 95% of patients had HF IIIV (NYHA), among them 24% HF II, 61% HF III, 15% HF IV (NYHA). HF with reduced ejection fraction (HFrEF) was found in 45% of patients. 22% of the patients did not receive medical treatment before admission. 34% of patients with HFrEF received ACE inhibitors/angiotensin receptor blockers (ARBs), of which only 23% in effective dose. β-blockers were prescribed in 41% of HFeEF patients, of which 22% in the target dose. A third of patients needed in mineralocorticoid receptor antagonists (MRA) received spironolactone. During hospitalization 81% of HFrEF patients received ACEI therapy, 12% – ARBs, 91% – β-blockers, 90% – MRA, 81% – loop diuretics and 13% – thiazide diuretics. According to the discharge summary 5% of patients did not receive post-discharge blocker of the renin-angiotensin-aldosterone system without explanation in the medical documentation. β-blocker with proven efficacy was prescribed to 70% of HFrEF patients. Spironolactone was recommended after discharge in 89% of HFrEF patients.

Conclusion. Implementation of register of hospitalized patients with HF gives an opportunity to identify shortcomings in the provision of medical care both in outpatient and inpatient stages. 

638-644 825
Abstract

Aim. To study the factors associated with a poor annual prognosis in patients with acute stroke and prognostic role of pathological ankle-brachial index (ABI).

Material and methods. The study included 345 patients (age 63.6±7.8 years, 181 males and 164 females) with ischemic stroke that were observed for 1 year. All patients were divided into 2 groups: Group 1 included patients with favorable annual outcome of stroke; Group 2 included patients that during a year had any clinical events including death. All patients underwent a standard neurological and instrumental examination including assessment of peripheral arteries status by sphygmomanometry.

Results. Both groups did not differ by age and sex. The frequency of unfavorable outcomes (death, re-stroke, cardiovascular events) 1 year after ischemic stroke was 29.5%. Chronic heart failure, atrial fibrillation, previous cardiovascular events, presence of peripheral atherosclerosis, overweight were identified most commonly in Group 2. Patients of Group 2 initially had a rough neurological deficit. The pathological ABI was detected in 70.7% of patients in Group 2 vs 33.8% of patients in Group 1 (p=0.000001). A strong relationship of pathological ABI with a poor outcome of stroke was found by regression analysis.

Conclusions. Detection of pathological ABI in patients with ischemic stroke makes it possible to reveal peripheral atherosclerosis and to carry out the targeted preventive measures in these patients. Risk stratification can contribute to more individual and effective secondary prevention in patients with cerebrovascular disease. 

645-653 296
Abstract

Aim. To assess the main features of the clinical course of acute cerebrovascular accident (ACVA), its short-term and long-term outcomes and quality of pharmacotherapy based on hospital register.
Material and methods. The hospital register of acute stroke (AS) was organized in one of the cardiovascular centers in Moscow city. The results of the pilot part of the study are presented (170 patients hospitalized from January 01, 2014 to September 30, 2014 with ACVA living in the service area of one of the closest outpatient clinics). Presence of cardiovascular diseases (CVD) and their risk factors (RF), prehospital therapy, short-term complications including death and pharmacotherapy recommended to survived patients were analyzed using hospital medical records. During ambulatory follow-up (prospective part of the register) the vital status and pharmacotherapy were assessed.
Results. The majority of patients with AS had concomitant CVD (on average 2 per patient) and non CVD (on average 1.2 per patient). Data on the risk factors of CVD and their complications were reflected insufficiently in the medical records. Most patients in the prehospital period did not receive adequate treatment for the reduction in the cardiovascular risk. 90 patients survived and were discharged. 1.5-2 years after discharge, information on the vital status was available for 78 (86.7%) patients. 61 of them (78.2%) were alive and 17 (21.8%) died.
Conclusion. The pilot part of the REGION register revealed that the majority of patients with AS have concomitant CVD and non-CVD. The overall quality of pharmacotherapy, primary and secondary prevention of ACVA was far from that recommended in clinical guidelines, especially during follow-up in outpatient clinic.

654-660 453
Abstract

Aim. To assess the effect of nicorandil added to the standard therapy of patients with stable ischemic heart disease (IHD) on the quality of life (QoL).

Material and methods. Patients with verified IHD (stable angina; n=120) were included into double-blind, placebo-controlled, parallel group study. All patients in the study received metoprolol tartrate (100 mg daily). Nicorandil was added (10 mg BID, and then after 2 weeks 20 mg BID) to the treatment of patients of the main group. Placebo was added to treatment of patients in the control group. The study duration was 6 weeks. QoL was assessed by theSeattle questionnaire (SAQ) and visual analogue scale (VAS) at baseline and at the end of the study.

Results. A significant decrease in the number of angina attacks was found in the nicorandil group compared to baseline [from 3.0 (2.0, 5.0) to 1.2 (0.7, 2.0); p<0.01] and compared to the placebo group [2.0 (1.0, 3.0); p=0.02]. The positive dynamics of QoL and functionality of patients with IHD was observed in the nicorandil group at the end of the study. It was demonstrated by significant improvement in all SAQ scales compared to baseline. Positive dynamics in the control group was found only in three scales (limitation of physical activity, frequency of angina attacks and patient attitude to the disease). VAS data revealed a significant increase in the integral index in patients of the main group (from 65.0±14.5 to 69.3±15.1; p=0.07), that was significantly higher than this in control group (64.6±15.1; p=0.02) at the end of the study.

Conclusion. Nicorandil addition to the standard therapy of patients with IHD (stable angina) demonstrated improvement in the QoL, assessed by SAQ questionnaire and VAS.

661-668 336
Abstract

Aim. The analysis of non-adherent behavior factors, improvement of the management of patients with arterial hypertension (HT) and anxiety due to increase of compliance, by non-drug treatment in addition to antihypertensive drug therapy.

Material and methods. 209 patients with HT and anxiety were included into the study. Adherence to the drug therapy was assessed by Moriski Green's questionnaire. Anxiety disorders were diagnosed by the Hospital Anxiety and Depression Scale. Intensity of subjectively endured stress was estimated by the Visual Analogue Scale of stress at work and home, quality of life – by SF-36 questionnaire.

Results. 149 factors were studied and the factors influencing adherence to treatment were defined in this cohort of patients. On the basis of selected factors and results of binary logistical regression a forecasting technique for non-adherent behavior of patients with HT and anxiety was created. Changes in adherence to treatment after cycle of trainings atSchool ofHealth by the standard program (n=104) or after the same trainings with the special "Non-Drug Method of Influence" additionally (n=105) were assessed. Training of patients with HT and anxiety at School of Health with the use of "NonDrug Method of Influence" raised a level of adherence to drug antihypertensive therapy by 35.4Ѓ}3.3%, in comparison with initial data (χ.=8.96; р=0.049) with maintaining achieved results during 24 months of follow-up.

Conclusion. The basic advantage of "Non-Drug Method of Influence" is that exercises of a progressing muscular relaxation and operated mental visualization normalize blood pressure indices, raise adherence to drug antihypertensive treatment with maintaining achieved results during 24 months of follow-up.

669-674 325
Abstract

Aim. To study the changes in indicators of 24-hours blood pressure (BP) monitoring during the antihypertensive treatment with amlodipine in hypertensive women with normal psycho-emotional status or with subclinical depression.

Material and methods.  29 women with stage 2 hypertension were divided into 2 groups. 24-hours BP monitoring was performed in Group 1 (n=15; mean age 45.4±1.7 years; with normal psycho-emotional status) and Group 2 (n=14; mean age 46.7±1.3 years; with subclinical depression) at base- line and after 1 month of amlodipine treatment. We analyzed the dynamics of the following indicators: time index (VI), load measurement index (AI) of increased and reduced systolic (SBP) and diastolic (DBP) BP, reflecting the influence of hypertension and hypotension on the target organs.

Results.  BP variability during the day was higher in group 2 than in group 1. Increase in load by increased DBP at night was found during amlodipine therapy in both groups: from 34.5±8.7 to 84.8±14.8 (p=0.006) in the Group 1 and from 38.5±10.2 to 95.3±14.7 (p=0.004) in the Group 2. Be- sides increase in load by reduced SBP during a day was also observed in both groups: from 9.1±3.2 to 45.4±12.8 (p=0.0039) in the Group 1 and from 0.5±0.06 to 53.8±13.1 (p=0.0016) in the Group 2. DBP variability at night increased from 7.5±0.8 to 10.3±0.8 (p=0.011) in the Group 1 and from 8.5±0.4 to 9.7±0.8 (p=0.083) in the Group 2. Increase in severity of subclinical depression according to HADS was demonstrated in Group 2 after one month of treatment with amlodipine.

Conclusion.  The use of amlodipine requires regular control of 24-hours BP monitoring indices and assessment of mental and emotional status dynamics

ASSOCIATED PROBLEMS OF CARDIOLOGY

675-680 655
Abstract

Aim. To study the presence, severity and qualitative characteristics of «burnout syndrome» in patients with «workplace hypertension» (WPH), in comparison with patients with essential hypertension and healthy people.

Material and methods. Untreated patients with hypertension stage II, degree 1-2 (n=170; age 32-52 years; mean age 46.7Ѓ}4.1 years) were examined. Group 1 included 85 patients with WPH (mean age 44.7Ѓ}4.3 years) and Group 2 included 85 patients without WPH (mean age 47.4Ѓ}4.5 years). The duration of hypertension on average was 7.2Ѓ}2.6 years and was comparable in both groups. The control group included 82 healthy subjects (mean age 44.9Ѓ}3.1 years). The Russian version of the Maslach Burnout Inventory (MBI) was used to diagnose «burnout syndrome».

Results. Signs of «burnout syndrome» were found in the hypertensive patients of both groups. The high and medium levels of the «burnout syndrome» severity according to all three analyzed factors (emotional exhaustion, dehumanization/depersonification, and personal achievements) were found in 59% of WPH patients, in 36% of hypertensive patients without WPH, and in 9% of healthy individuals. Most of WPH patients had high emotional exhaustion compared with other groups (27.5Ѓ}3.67 points vs 24.6Ѓ}4.3 and 20.1Ѓ}5.7 points in group 2, and group of healthy, respectively; p<0.05). Hypertensive men rated themselves as less successful professionally in comparison with women. Hypertensive women were more prone to emotional exhaustion and dehumanization/depersonification in comparison with men. 

Conclusion. Signs of «burnout syndrome» were found significantly more often in hypertensive patients in both groups than in healthy people. Medium and high intensity of all forms of «burnout syndrome» occurred in patients with WPH in comparison with healthy people and hypertensive patients without WPH.

681-684 228
Abstract

Aim. To study the effect of antiviral therapy (AVT) on some cardiohemodynamics indicators in patients with chronic viral hepatitis (CVH) and viral liver cirrhosis (VLC).

Material and methods. Doppler echocardiography, tissue Doppler echocardiography, 24-hour ECG monitoring, assessment of the blood flow in the portal vein and in the splenic artery were performed in patients with CVH (n=16) and VLC (n=16) initially and after the course of AVT with interferon and ribavirin leading to sustained virological response.

Results. The improvement of systolic and diastolic function of the left ventricle (LV), decrease inLV myocardial mass (from 170 [225.5;213.5] to 159 [146;167] g; p<0.001), and size of the left atrium (LA; from 37 [34;40] to 35.5 [33;38] mm; p<0.001) were found in patients with CVH after AVT. Reduction in the autonomic nervous system tonus was also observed. Decrease in the blood flow rate in the splenic artery (from 107 [95;126.2] to 77 [67.2;99] cm/s; p<0.001) and in the portal vein (from 29 [20;31] to 19 [18;23] cm/s; p<0.001) were detected. Reduction inLV myocardial mass, LA size, systolic blood pressure in pulmonary artery (from 34 [29;38] to 30 [26;31] mm Hg; p<0.001), and the autonomic nervous system tonus were also observed after AVT in patients with VLC. The correlations between the maximum speed of the first negative peak (Em) in the mitral valve fibrous ring and increased viral load (r=0.31; p<0.05), as well as between the diameter of the portal vein and pulmonary artery pressure (r=0.77, p<0.05) were found.

Conclusion. Results of the study suggest that patients received AVT have better cardiohemodynamic indicators than patients without specific treatment.

685-691 270
Abstract

Aim. To study possible variants of changes in structural and functional parameters of central hemodynamics in liver cirrhosis classes A, B, C (Child– Pugh) to improve the early diagnostics of extrahepatic complications.

Material and methods. Parameters of central hemodynamics were studied in 107 patients with liver cirrhosis of viral etiology classes A, B, C (ChildPugh) with different levels of serum interleukins (interleukin-2, interleukin-6, tumor necrosis factor alpha).

Results. Significant changes in the central hemodynamics parameters were not revealed in liver cirrhosis of classes A and B. In patients with liver cirrhosis of class С the following significant changes of the left and right heart were found: thickening of the interventricular septum and left ventricular posterior wall up to 12.9Ѓ}1.3 and 13.5Ѓ}1.4 mm respectively; increase in left atrium up to 43.1Ѓ}4.7 mm; right ventricular dilatation up to 38.6Ѓ}4.1 mm and pulmonary artery up to 35.7Ѓ}3.1 mm with an increase in pressure in it up to 35.7Ѓ}3.1 mm Hg. The rate and variants of changes in structural and functional parameters of central hemodynamics correlated with the stages of the liver cirrhosis compensation and the interleukins serum levels.

Conclusion. Changes in parameters of central hemodynamics in liver cirrhosis depends on the stage of compensation. The most pronounced systolic and diastolic myocardial dysfunctions were observed in cirrhosis Class C, with high levels of portal pressure and high concentrations of serum interleukins. Concentric remodeling of the left ventricular and isolated ventricular septal hypertrophy were the worst types of the left ventricular remodeling. These variants of ventricular geometry were accompanied by the most severe impairments of diastolic function.

NOTES FROM PRACTICE

692-697 300
Abstract

Clinical case of resistant hypertension in a patient with metabolic syndrome is presented. Features of hypertension in metabolic syndrome and features of metabolic syndrome in women of pre- and postmenopausal age are also considered. Understanding the features of metabolic syndrome in women, as well as features of hypertension and metabolic syndrome will improve the results of treatment in patients with resistant hypertension.

698-702 258
Abstract

Stenosis of the left main coronary artery (LMCA) is the most formidable atherosclerotic coronary artery disease due to its importance. The prognosis in patients with significant hemodynamic lesion of LMCA is unfavorable and associated with high mortality. LMCA disease is an absolute indication for myocardial revascularization with the highest class of recommendation and level of the evidences. This article provides a clinical case of balloon angioplasty with stenting of "unprotected" LMCA with concomitant proximal occlusion of the right coronary artery.

PREVENTIVE CARDIOLOGY AND PUBLIC HEALTH

703-710 356
Abstract

Aim. To estimate an efficiency of influenza vaccination in patients with circulatory system diseases diseases (CSD) under 3-year follow-up in outpatient clinics.

Methods. The efficiency of influenza vaccination was investigated in CSD patients followed up at 2Ivanovo outpatient clinics and 2Saratov ones. The investigation enrolled 817 people, including 367 patients who consented to Grippol Plus influenza vaccination and 450 who refused.

Results. During 36-month follow-up after being included in the study the vaccinated group showed a significantly fewer influenza and acute respiratory viral infections than the non-vaccinated group (28 and 442; р<0.0001). The vaccinated group had fewer CSD worsening cases per patient (p=0.04) and CSD-associated hospitalization rates (p=0.006) than the non-vaccinated group. In the vaccinated group, the total number of cases of cerebral stroke, myocardial infarction, deaths from cardiovascular diseases (CVD) was significantly less (17) compared with non-vaccinated (38), р=0.03. The risk of infectious diseases and acute cardiovascular event (myocardial infarction, stroke, death from CVD) was significantly lower in the group of vaccinated patients: by 36% (p=0.001) and by 59% (p=0.008), respectively.

Conclusion. Influenza vaccination, as an essential component of complex medical prevention, leads to reduction in incidence of infectious diseases and of CSD worsening including myocardial infarction, stroke, and death from CVD in patients under 3-year monitoring in outpatient clinics
711-717 261
Abstract

Aim. To study the prevalence of ECG ischemic disorders assessed by theMinnesota code on a sample of people over 50 years, depending on gender, age and employment.

Material and methods. The results of a survey of a representative sample of the unorganized population of 13 regions, participants of the ESSE-RF program in 2012-2014, were included into the study (n=8334 people; men - 2784, women - 5550). Analysis of the prevalence of ECG changes was carried out by the Minnesota code in groups of 50-54, 55-59 and 60-64 years old, depending on gender and employment (employed and unemployed).

Results. Pathological changes were recorded on the ECG more often in men compared to women – Q(QS)-wave (5% vs 1.9%), atrial fibrillation (2.1% vs 0.8%; p<0.01), conduction abnormalities (2.7% vs 1.6%; p<0.002) with a maximum in 60-64 years old (4.4% vs 2.6%; p<0.01), respectively. ST segment depression and the T wave abnormalities (myocardial ischemia) occurred more often in women than in men (6.9% vs 5.1%, respectively; p<0.001), with a significant increase of these changes in women after 60 years old. The prevalence of ECG abnormalities increases with age. Significant rise of ECG-changes prevalence was found in men at the age of 55-59 years (pathological QQS, myocardial ischemia, left ventricular hypertrophy); and in women – at 60-64 years (myocardial ischemia, atrial fibrillation, conduction abnormalities). Almost two-fold increase in the incidence of arrhythmias and conduction abnormalities was found in men and women aged 60-64 years, regardless of employment status.

Conclusion. Given the poor prognosis of ischemic ECG abnormalities, even their low prevalence indicates to unfavorable epidemiological situation among people around retirement age (55-64). These results emphasize the need for practitioners to careful attention to the ECG-abnormalities with poor prognosis in patients pre-retirement and retirement age. They may also be useful for practical public health as a basis for planning, developing, implementing and monitoring the effectiveness of prevention programs aimed at health promotion among Russian population of older age group.

INNOVATIVE CARDIOLOGY

718-724 284
Abstract

Aim. To study the effect of transcatheter aortic valve implantation (TAVI), performed by different types of prostheses and various surgical access, on the prognosis of patients with critical aortic stenosis and comorbidities.

Material and methods. Patients (n=130) that had consistently performed 80 TAVI by Edwards valve transfemoral (n=50) and transapical (n=30) access, as well as 50 transcatheter aortic valve replacement by CoreValve system were included into the study. Complications including perioperative mortality, total 30-day mortality, as well as post-hospital mortality were registered during aortic valve replacement, immediately after surgery, before the expiry of 30 days. Mean follow-up was 2.2 years (range 0.2 to 5.2 years).

Results. Hospital mortality was on average 6.9%. 121 patients had been discharged from the department after the surgery. The number of deaths in the post-hospital period was 14.8%. Valve type and the type of access had no effect on post-hospital mortality. Men died more than 2.5 times often than women, regardless of age. Atrioventricular block, pacemaker implantation, and history of chronic obstructive pulmonary disease were the most significant prognostic factors. An important role of minor stroke and renal failure should be noted. Mortality did not depend on the surgical access or valve type. All parameters characterizing the intervention were significantly associated with mortality, both during and after surgery. The proportion of survivors at the end of the first year of observation using Corvalve system was 86.9%, Edwards valve by transfemoral access - 88% and Edwards valve by transapical access – 85.4% (insignificant differences for all groups, p>0.05). Two-year survival was 77.5%, 82.5% and 82.7%, respectively (also insignificant differences for all groups, p>0.05).

Conclusion. TAVI is the method of choice, reasonable alternative approach for surgical valve replacement in patients with high surgical risk, although mortality after TAVI is still quite high and amounted to 6.9% in our study. It makes it possible to extend life and improve its quality that is of great social importance in the global trend of an aging population.

POINT OF VIEW

725-732 340
Abstract
Abdominal obesity (and the closely related metabolic syndrome) is one of the most common diseases in the world. The urgency of the problem of the progression of abdominal obesity is not only in its high prevalence, but also in the formation of a high risk of developing cardiovascular disease and diabetes type 2. The main reasons for the rapid development of obesity are considered high-calorie food (which includes not only the quantity but also the quality of edible products), sedentary lifestyle and genetic predisposition. Until now there are underway great controversies about the procedures of fast and trouble-free weight loss. There are many studies on the treatment of various components of metabolic syndrome. Despite a number of different pharmaceutical drugs developed for the treatment of abdominal obesity, non-drug therapies come first as well as the organization of the right way of life, which is difficult and sometimes impossible task for the clinician. One of the main reasons is the lack of time in doctor during outpatient consultations. To resolve this issue the role of "School of Health" is considered in order to effectively reduce the body weight of patients with metabolic syndrome and maintaining long-term results. It is expected that the implementation of the "School of Health" in the complex treatment of patients with metabolic syndrome will more broadly inform patients about their disease, improve the motivational and cognitive components of plants, and increase compliance to carry out the doctor's prescription. A review of the prevalence and root causes of abdominal obesity is presented, as well as analysis of the effectiveness of existing “Schools of Health” in the clinical practice for the treatment of various chronic diseases.
733-742 446
Abstract

A review contains a description of the most common methods of evaluation and monitoring of "endothelial dysfunction" that are assessed in terms of their information content and applicability in the practice of medicine. The term "endothelial function" is interpreted primarily as a function of the regulation of capillary blood flow, carried out by the expense of the dynamic change of the phase of vasoconstriction and vasodilatation in vessels of resistive type (in accordance with the changing needs of cellular metabolism). Assessment of endothelial dysfunction is understood as a generalized indicator of the extent and nature of violations of the regulation of peripheral circulation. It includes an assessment of imbalances between endotheliumdependent vasoconstrictor and vasodilating factors or mismatch of the local and central regulation of capillary blood flow in response to various functional tests or other effects (eg, cold test, or test with local ischemia). All methods of endothelial dysfunction assessment in the survey are divided into invasive and non-invasive. The main feature of invasive methods lies in the direct effect on the endothelium of the coronary or other vessels by introducing into these vessels vasoactive substances such as acetylcholine. Response to the test (vasoconstriction or vasodilation) is evaluated by coronary angiography or by ultrasound. Non-invasive methods of the assessment of endothelial dysfunction or functions of regulation of the peripheral circulation are regarded as the most promising for widespread use. There are two basic methods that underlie functional tests: methods PAT (peripheral arterial tone) and PHG (polyhepatography). Assessment of endothelial dysfunction in many modern scientific researches is important. They are regarded as the causative factors of many different diseases. Such assessments can be useful in everyday medical practice. Assessment of endothelial function provides the clinician with critical information essential for a personalized selection of therapy. In particular, for taking into account the individual characteristics of the local and central regulatory system response of peripheral blood circulation in the various functional tests, or other effects.

743-748 430
Abstract

This review is devoted to the study of issues relating to the features of associated course of chronic heart failure (CHF) and diabetes mellitus (DM). The modern views on the epidemiology, pathogenesis of DM and CHF are systematized. The pathogenesis of diabetic cardiomyopathy is described in details. The results of the well-known studies that show the negative impact of DM on CHF prognosis are presented. The principles of CHF pathogenetic therapy in patients with DM including the role of neurohormonal modulators are analyzed. The results of multicenter studies in patients with CHF and concomitant DM type 2 show that almost all first-line drugs recommended for CHF treatment are effective in patients with DM.

CURRENT QUESTIONS OF CLINICAL PHARMACOLOGY

749-757 928
Abstract

The article discusses the choice of anticoagulant in different patterns of acute coronary syndrome (ACS). According to current recommendations three groups of agents are used as anticoagulants in ACS: unfractionated heparin (UFH) and low molecular weight heparin (LMWH), fondaparinux, and bivalirudin. UFH was the main parenteral anticoagulant therapy for ACS for several decades, including percutaneous coronary interventions, but a number of limitations and side effects of the drug contributed to the emergence of new anticoagulants with lower molecular weight. Among the LMWH, which have a higher bioavailability and significant convenience of administration, only enoxaparin has significant clinical advantage over UFH considering the prognosis for patients with ACS. At the same time throughout the period of ACS, including invasive procedures, change of heparin products is extremely undesirable, since switching from enoxaparin to UFH and vice versa, not only reduces the effectiveness of the treatment, but also increases the risk of bleeding. Fondaparinux has optimal efficacy/safety profile in ACS with no ST elevation, regardless of the chosen tactics. If it is unavailable, enoxaparin or UFH may be an alternative. Bivalirudin is the optimal alternative to UFH in combination with GP IIb/IIIa platelet receptor blockers in case of invasive treatment strategy. In patients with impaired renal function with glomerular filtration rate (GFR)<30 mL/min/1.73m2 enoxaparin dose should be reduced to 1 mg/kg, 1 time a day, with GFR <15 mL/min/1.73m2 the drug is contraindicated. Fondaparinux safety is superior to enoxaparin in patients with chronic kidney disease, however the drug is not recommended in GFR<20 ml/min/1.73m2. In this case UFH should be preferred due to the ease of monitoring anticoagulant activity and the ability to quickly neutralize its activity in the case of bleeding.

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