The Clinical Evolution of Diffuse Myocardial Fibrosis in Patients With Arterial Hypertension and Heart Failure With Mildly Reduced Ejection Fraction Treated by Olmesartan or Sacubitril / Valsartan.

Aim      A 12-month evaluation of the potentialities of the angiotensin II receptor inhibitor olmesartan (Olme) and the angiotensin receptor and neprilysin inhibitor (ARNI) sacubitril/valsartan in patients with arterial hypertension (AH) and dyslipidemia in the dynamics of the following indicators of chronic heart failure (CHF): N-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), LV global longitudinal strain (LV GLS) in diffuse myocardial fibrosis (MF) previously diagnosed by magnetic resonance imaging (MRI).Material and methods  Olmesartan medoxomil (n=56) and sacubitril/valsartan (n=63) were used for 12 months in patients with hypertension, dyslipidemia and NYHA functional class II-III CHF with mid-range LVEF (CHFmrEF). MF was diagnosed by the following MRI criteria: late gadolinium enhancement and an increased proportion of extracellular matrix (33% or more). The frequency of persisting late gadolinium enhancement and the increased proportion of extracellular matrix (33% or more) was evaluated at 12 months; changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), NT-proBNP, and LV GLS were evaluated after 3, 6, and 12 months of follow-up.Results Baseline parameters did not differ between groups. The late gadolinium enhancement and increased proportion of extracellular matrix were present at baseline in all patients of both groups (100%; p=1.0). Already at 3 months, statistically significant decreases in SBP and DBP were observed in both groups. In addition, the LV GLS monitoring showed LV GLS significantly increased in both groups after 3 months and continued changing after 6 and 12 months. The NT-proBNP concentration significantly decreased in both groups already after 3 months and continued to decrease after 6 and 12 months. At 6 and 12 months, sacubitril/valsartan was superior to olmesartan in reducing SBP and NT-proBNP and in restoring LV GLS. At 12 months, the incidence of persisting, abnormal late gadolinium enhancement and increased proportion of extracellular matrix was significantly less in the ARNI group.Conclusion      Olmesartan was demonstrated effective in the multi-modality therapy of CHFmrEF and MF in patients with AH and dyslipidemia. ARNI was superior to olmesartan in this regard, but further research of this issue is required.

[Lung Ultrasound: new Opportunities for a Cardiologist].

This review focused on ultrasound examination of lungs, a useful complement to transthoracic echocardiography (EchoCG), which is superior to chest X-ray in the diagnostic value. The lung acoustic window always remains open and allows obtaining high-quality images in most cases. For a cardiologist, the major points of the method application are determination of pleural effusion and lung congestion. This method has a number of advantages: it is time-saving; cost-effective; portable and accessible; can be used in a real-time mode; not associated with radiation; reproducible; and highly informative. The ultrasound finding of wet lungs would indicate threatening, acute cardiac decompensation long before appearance of clinical, auscultative, and radiological signs of lung congestion. Modern EchoCG should include examination of the heart and lungs as a part of a single, integrative ultrasound examination.

[Myocardial ischemia in patients with hypertrophic cardiomyopathy].

Authors present is comprehensive clinical and instrumental evaluation of patients with HCM with myocardial ischemia. 104 patients (38.4% of men) with HCM were examined, mean age 58.2±14.7. The examination included risk factors assessment for CAD, ECG, Echo, stress ECG test, 24-hour ECG monitoring. In the presence of myocardial ischemia, CAG (n=66) and MSCT of the coronary arteries (CA) (n=4) were performed. All patients were split up on 2 groups: I - 70 HCM patients with myocardial ischemia, 67.3%, and II (the control group) - 34 HCM patients without myocardial ischemia, 32.7%. The group I was divided on 2 subgroups: 1 - 29 patients with coronary atherosclerosis (41.4%), 2 - 41 patient without coronary atherosclerosis (58.6%). Age (p=0.046), family history (p=0.037), higher systolic and diastolic arterial pressure, long-term arterial hypertension (p<0.05) were determined as significant risk factors for CAD. Smaller diameter of LAD (p=0.008), higher LV mass index, greater LV diastolic function disorder (p<0.05) were detected in group 2 compared to group II. The decrease in myocardial perfusion (MBG scale) was associated with high LV mass index and cardiac arrhythmias. The frequency of concomitant coronary atherosclerosis among HCM patients with myocardial ischemia was determined as 41.4%. Analysis of traditional risk factors for CAD in patients with HCM revealed the strong relation to age, aggravated by a family history of CAD, blood pressure level and duration of hypertension. Smaller diameter of LAD, higher LV mass index, greater LV diastolic function disorder were observed in HCM patients with myocardial ischemia without CAD.

[Decreased Heart Rate Variability in Sickle Cell Anemia as Effect of Pulmonary Arterial Hypertension].

Decreased heart rate variability (HRV) is associated with increased mortality risk in various diseases. The objective of this investigation:to study HRV in patients with sickle cell anemia (SCA) and to assess the effect of pulmonary arterial hypertension (PAH) on HRV in these patients. Materials and methods. HRV registration and Doppler echocardiographic assessment of systolic pulmonary arterial pressure (PAP) was carried out in 61 stable patients with SCA and 24 healthy subjects. Results. Low frequency power (LFP) and high frequency power (HFP) were decreased in SCA patients compared to healthy subjects. Among SCA patients, PAH patients had lower  LFP and HFP than patients without PAH. In SCA patients, systolic PAP showed significant negative correlation with LFP and HFP. Conclusion. HRV is significantly decreased in SCA patients, especially in those with PAH. HRV may be particularly useful in early detection of PAH patients who may have worse prognosis and higher mortality risk.

[The Clinical use of Stress Echocardiography in Ischemic Heart Disease Cardiovascular Ultrasound (2017)15:7. Translation authors: Arystan A.Zh., Fettser D.V.]

Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows detecting myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependence on operator expertise, the lack of outcome data (a widespread problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.

[Radial Approach for Percutaneous Coronary Interventions in Patients With Ischemic Heart Disease: Advantages and Disadvantages, Complications Rate in Comparison With Femoral Approach].

During recent 10-15 years, percutaneous coronary interventions (PCI) have reached a new level of efficacy and safety. Rate of serious coronary complications has decreased. That to a greater degree exposes the problem of peripheral complications at the site of arterial approach. At the same time portion of patients older than 75 years in the total pool of PCI constantly increases. Number of patients with pronounced obesity also grows each year. Radial approach for PCI allows to substantially decrease rate of peripheral complications at the account of lowered rate of bleedings, and to shorten duration of hospitalization. In this literature review we present results of a number of relevant clinical studies including those which contained groups of elderly patients and of patients with obesity. We also have summarized main advantages and disadvantages of radial approach as compared with femoral approach for coronary angiography and PCI.

[Signs of diabetic cardiomyopathy in patients with controlled arterial hypertension and early postprandial hyperglycemia].

AIM: To study signs of diabetic cardiomyopathy (DCM) in nondiabetic patients with controlled arterial hypertension (AH) and glycemic response during first hour of glucose tolerance test (GTT). MATERIAL AND METHODS: Patients (n = 47) with controlled AH were divided into 2 groups according to results of GTT with 75 g of glucose: patients of group 1 (n = 22) had glucose level ≤ 200 mg/dl during 1-st hour of GTT; other patients (n = 25) composed group 2. Examination of all patients included transthoracic echocardiography, ultrasound Dopplerography, tissue Doppler (TD) and 24-hour Holter ECG monitoring. Using data of these methods we calculated left ventricular (LV) mass and the following characteristics of mitral ring: E/A, TD e', TD a', TD s', TD e'/a'/. The following characteristics of heart rate variability were obtained: standard deviation of normal RR intervals (SDNN), low and high frequency (LF, HF) power, LF/HF ratio. RESULTS: Patients of group 2 had higher LV mass (229.5 ± 58.2 vs. 192.1 ± 50.6 g; p = 0.036), more pronounced changes of TD e'/a' (0.71 ± 0.25 vs. 1.06 ± 0.58; p = 0.011), lower SDNN both during day (85.4 ± 14.1 vs. 112.5 ± 31.3 ms, p = 0.007) and night (82.2 ± 22.1 vs. 105.9 ± 28.5 ms, p = 0,004) time, higher nocturnal LF/HF ratio (3.75 ± 4.02 vs. 1.72 ± 0.81, p = 0,029). CONCLUSION: In patients with controlled arterial hypertension (AH) and glycemic response during first hour of GCT we revealed various pronounced manifestations of DCM. These data constitute a basis for further studies.

[Effect of design of standard metallic stents on neointimal hyperplasia and restenosis].

Coronary stents became an integral part of treatment of ischemic heart disease (IHD). Number of percutaneous coronary interventions (PCI) in patients with IHD in Russia constantly growing. At a certain stage of development of interventional cardiology drug eluting stents (DES) were created and became actively used. Compared with metallic stents (MS) drug eluting stents allow to substantially reduce risk of restenosis. However DES did not replace MS and the latter are still used in about 50% of PCI in Russia. Design of standard MS and thickness of struts might affect extent of neointimal proliferation which develops after stent implantation and eventually determines remote outcomes of IHD treatment. Thereby choice of optimal MS remains an actual problem. In this review we present results of clinical studies which compared MS with different design and thickness of struts.

[Effect of intracoronary and intravenous administration of tirofiban loading dose in patients underwent percutaneous coronary interventions because of acute coronary syndrome].

Aim of this multicenter retrospective study was assessment of effect of intracoronary administration of tirofiban loading dose in troponin positive patients with acute coronary syndrome (ACS). We analyzed multicenter data base of patients subjected to percutaneous coronary interventions (PCI) because of ST-elevation or non-ST elevation ACS from October 2010 to October 2011. Patients who received loading doses of aspirin (300 mg) and clopidogrel (600 mg) before PCI and tirofiban (10 mg/kg bolus with subsequent infusion 0.15 mg/kg/min for 24 h) were selected for the study (n=133, 89 with intravenous and 44 - intracoronary administration of tirofiban loading dose). We assessed hospital mortality, myocardial reinfarctions (reMI), necessity of target vessel revascularization (TVR) and pronounced bleedings. There were no significant differences in mortality, reMI, and TVR between two groups. However major adverse cardiac events was significantly less in patients who received intracoronary tirofiban (6.8 vs. 21.3% in i.v. group; p=0.046). Hospital stay was significantly shorter in intracoronary compared with i.v. group (3.84+/-0.96 vs. 4.55+/-1.11 days; p=0.001). Rates of bleedings did not differ significantly between groups. Thus compared with i.v. intracoronary administration of tirofiban loading dose allows lower rate of major adverse cardiac events as well as to shorten length of hospital stay of patients with ACS.

[Prediction of severe cardiac complications with the help of myocardial perfusion scintigraphy in patients with residual chronic total occlusion after percutaneous coronary interventions].

Aim of the study was assessment of prognostic value of exercise myocardial perfusion scintigraphy in patients with stable and unstable angina in whom revascularization by percutaneous coronary intervention (PCI) was incomplete and at least one chronic total coronary artery occlusion (CTO) remained after PCI. Between March 2002 and December 2007 569 consecutive patients with multivessel lesions were subjected to SPECT imaging of myocardial perfusion after incomplete revascularization of the myocardium by PCI. At least 1 residual CTO was found in 129 patients (79% men, mean age 64+/-8 years). Primary outcomes were defined as cardiac death or myocardial infarction. Secondary outcomes were registered in 10 (7.9%) and 15 (11.9%) patients, respectively, with moderate and large transitory disturbances of perfusion. Logarithimic range criterion was statistically significant in patients distributed to groups by total estimation of rest in relation to cardiac complications. Univariate and multivariate Cox proportional hazards regression analysis gave additional important information for prediction of severe and nonsignificant cardiac complications when scintigraphic data were added to angiographic and clinical data, left ventricular ejection fraction, and results of treadmill test. Early monitoring with the use of myocardial scintigraphy by SPECT method is associated with increasing prognostic value relative to severe cardiac complications in patients subjected to incomplete revascularization by PCI, and having at least one residual chronic total occlusion.

[Comparative assessment of risk factors and hospital results in male and female patients underwent to coronary artery bypass surgery].

There are controversial data on relatively unfavorable effect of female gender on postoperative mortality of patients underwent to coronary artery bypass grafting (CABG). In order to assess risk factors and hospital outcomes after elective CABG we studied retrospectively data on patients who had undergone CABG in Sani Konuogly medical center (Gasiatep, Turkey) during the period from March 2002 to March 2010. For elimination of unfavorable effect of old age we included into analysis data from patients younger than 65 years. In accordance with study aim all patients (n=2692) were divided into two gender groups 1966 men (mean age 54,01 years) and 726 women (mean age 54.35 years). Diabetes (48.3 and 26.9%; p=0.0001), arterial hypertension (76.6 and 28.4%; p=0.00001), and obesity (50 42%; p=0.03) were more frequent among women while smoking (44.5 and 10.3%; p=0.0001), hyperlipidemia (37.6 and 21.5%; p=0.0002), and history of myocardial infarction (31.3 and 17.3%; p=0.06) were more often registered among men. Mortality was insignificantly higher in women (1.6 and 0.9%; p=0.06). Perioperative Q-wave myocardial infarction was more frequent among men than among women (1.5 and 0.4% respectively; p=0.04). It is necessary to conduct prospective well controlled study for exclusion of gender influences on perioperative outcomes in patients subjected to CABG .

[Two years experience of the use of a penetration catheter (Tornus) recanalization during percutaneous coronary interventions on chronic total occlusions].

We included in this study 43 patients chronic total occlusions (CTO) subjected percutaneous coronary interventions (PCI) with the use of penetration catheter (Tornus) in 2009-2010. Penetration catheter was applied only in those cases when it was not possible to introduce low profile coronary dilatation catheter into the site of occlusion. After penetration of CTO by a guide wire a channel was formed by a manually rotated penetration catheter. The Tornus catheter was successfully passed into distal part of an artery in 81.4% of cases. In other.

[Clinical and angiographical factors influencing improvement of left ventricular function after implantation of dare-metal stents in patients with chronic total occlusions of coronary arteries].

INTRODUCTION: Effect on left ventricular (LV) contractility of percutaneous coronary interventions (PCI) with implantation of bare-metal stents in patients with chronic total occlusions (CTO) of coronary arteries (CA) has not been completely studied. Aim of this study was to assess effect of PCI with implantation of bare-metal stents ("L+", Relisys, U) on LV ejection fraction (EF) and to investigate clinical and angiographical factors capable to affect restoration of LVEF. MATERIAL AND METHODS: We included in this study 154 patients after successful implantation of bare-metal stents in CTO of main epicardial CA. For assessment of LV function we performed echocardiographical examination before and in 6 months after PCI. RESULTS: Significant increase of LV EF (from 50.4 +/- 10.7 to 56.1+/-11.3%, p<0.0001), decreases of LV end diastolic (from 86.2+/-17.9 to 80,8+/-18,1 ml/m2, p<0.001) and end systolic (from 41.4+/-14.9 t 34.7+/-13.8 ml/m2 (p<0,001) volumes took place after implantation of stents. Multivariate analysis showed that initial LVEF <50%, duration of occlusion <2 months and absence of diabetes mellitus were independent predictors of improvement of LVEF. CONCLUSION: Implantation of bare-metal stents in patients with CTO CA affects positively LVEF during first 6 months after PCI especially in patients with lowered LVEF, in patients without diabetes mellitus, and duration of occlusion less or equal 2 months.

[Possibilities of recanalization of chronic coronary occlusions with penetration catheter <>].

Percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) remain one of most difficult parts of interventional cardiology. Introduction of novel devices and methods of recanalization of CTO have facilitated fulfillment of these interventions and increased number of successful procedures. Howere a number of cases it is impossible to position a balloon in the site of occlusion even after its successful crossing with a guidewere. Penetration catheter Tornus was specifically created for such cases. It allows to form a channel in CTO for subsequent dilation and stent implantation. We present a review of available clinical studies assessing efficacy of the use of Tornus catheter during PCI for CTO, as well as results of its comparison with efficacy of rotational atherectomy. Authors of these studies concluded that Tornus catheter was highly effective in cases when it was not possible to pass a catheter for changing usual "RotaWire" guide with the aim of conducting rotational atherectomy, or in cases of impossibility to pass a balloon along a guidewere for predilation of the occlusion site. At the same time the use of penetration catheter had no advantages over rotational atherectomy.

[Inhospital and 12-months results of percutaneous coronary interventions with implantation of Paclitaxel eluting stents in patients with long de novo coronary artery lesions].

We implanted 59 paclitaxel eluting Apollo stents to 48 patients with ischemic heart disease (IHD) and long de novo coronary artery lesions in 2007 with 100% immediate success rate without inhospital major cardiac complications. One patient developed hematoma at femoral artery puncture site. There were no cases of restenosis among 18 patients subjected to control angiography after 6 months. One patient had acute myocardial infarction in area supplied by nontarget artery. Control angiography after 12 months was carried out in 81.3% of patients while 14.6% of patients who refused angiography were examined with stress tests. Restenosis of stented segments was found in 3 (5.3%) patients, diameter loss was 0.32+/-0.45 mm. All these patients were subjected to repeat PCI. During follow up myocardial infarctions were registered in 4.2% of patients, overall rate of serious cardiac complications was 11.6%. PCI with implantation of paclitaxel was safe and effective with acceptable rate of major cardiac complications. Our results evidence in favor of further use of these stents.

[Implantation of the paclitaxel-eluting stent Apollo in patients with stable angina pectoris: long-term angiographic and clinical results].

AIM: to assess the long-term angiographic and clinical results of percutaneous coronary interventions (PCI) with implantation of the drug-eluting stent (DES) Apollo in patients with stable angina pectoris. SUBJECTS AND METHODS: The study enrolled 48 patients with stable angina who had been implanted with 59 stents. A follow-up of the patients lasted 12 months. RESULTS: The intervention was successful in 100% patients. Following 12 months, 81.3% of the patients underwent angiography that demonstrated that the vascular diameter decreased by 0.32 +/- 0.45 mm and the rate of restenosis was reduced by only 5.3%. The frequency of evident cardiac complications over 12 months was as high as 11.6%. CONCLUSION: The DES Apollo provides a way of safely performing PCI, by achieving a high of angiographic success rate. The application of this stent yields long-term good angiographic and clinical results in patients with stable angina pectoris.

[Thienopyridines in the treatment and prevention of cardiovascular diseases. Part V. Combination of clopidogrel and acetylsalicylic acid in the treatment of stable patients with atherothrombotic cardiovascular diseases].

In a series of articles the authors consider clinical pharmacology and experience of clinical application of blockers of platelet P2Y12 receptors, most well known representatives of which ticlopidine and clopidogrel according to chemical structure belong to thienopyridine derivatives. In the fifth communication we consider data of two randomized studies in which efficacy and safety of clopidogrel in combination with acetylsalicylic acid (ASA) has been assessed in comparison with ASA in stable patients with atherothrombotic cardiovascular disease. It has been shown in both studies that in stable patients with atherothrombotic cardiovascular disease long-term therapy with combination of clopidogrel and ASA was no more effective than monotherapy with ASA or clopidogrel but was associated with high risk of hemorrhagic complications. Thus contrary to acute coronary syndromes and percutaneous interventions with stenting combinations of clopidogrel and ASA is not indicated to patients with stable course cardiovascular diseases.

[In-hospital and long-term (to 3 years) results of using bare-metal stents in patients with coronary artery disease and chronic kidney disease].

Patients (n=727) who had been subjected to implantation of one or several standard stents in 2004 were included into this study. These patients were divided into 3 groups according to initial level of glomerular filtration rate (GFR, MDRD equation): group 1 - 466 patients with GFR >60 ml/min/1,73 m(2), group 2 - 233 patients with GFR 30 - 60 ml/min/1,73 m(2), group 3 - 38 patients with GFR <30 ml/min/1,73 m(2). In all group 2 and 3 patients prevention of contrast induced nephropathy (CIN) was implemented: hydration before and after angiography, limitation of intake of nephrotoxic drugs, N acetylcysteine 600 mg/day orally. In all group 2 and 3 patients only contrast preparation iodixanol was used. Total amount of contrast did not exceed 350 ml in patients with GFR 45-59 ml/min/1.73 m(2) and 250 ml - with GFR <45 ml/min/1.73 m(2). In all patients with GFR 60 ml/min/1.73 m(2) low osmolar contrast preparations were used (total amount - less then 600 ml per patient). Immediate success of PCI was similar in all groups (99.4%, 98.2% 97.4%, respectively). Rate of CIN rose significantly in groups 2 and 3 (0.4%, 4.9%, 13.2%, respectively, <0.001). Before 6 months after PCI restenosis developed more frequently with lowering of GFR (group 1 - 11%, group 2 - 22%, group 3 - 34%, <0.001). Myocardial infarction developed by 3 years in 6, 10, and 26% of patients in groups 1, 2, and 3, respectively. Lethality during 3 years was 5, 10, and 24% in groups 1, 2, and 3, respectively. Regression analysis showed that as a whole 3 years rate of myocardial infarction rose 1.57 times in group 2 compared with group 1, and 3.91 times in group 3 compared with group 1. Mortality by 3 years rose 1.93 times in group 2 compared with group 1, and 4.52 times in group 3 compared with group 1. Thus, presence of initially lowered GFR increases risk of CIN after elective implantations of standard stents, leads to rise of restenosis rate by 6 months and increase of mortality and rate of nonfatal myocardial infarction by 3 years.

[The role of reduction of glomerular filtration rate in outcomes of drug-eluting stents implantation in patients with ischemic heart disease and chronic kidney disease].

Patients (n=432) subjected to percutaneous coronary interventions (PCI) with implantation of one or more drug eluting stents (DES) in 2005 were included in this study. These patients were divided into 3 groups according to baseline glomerular filtration rate (GFR): group 1 - GFR 60 ml/min/1.73 m2, n=271, group 2 - GFR 30-60 ml/min/1.73 m2, n=132, group 3 - GFR <30 ml/min/1.73 m2, n=29. In all patients only contrast preparation iodixanol was used and prevention of contrast induced nephropathy (CIN) was implemented. Immediate success of PCI was higher and comparable between groups. Rate of development of CIN turned out significantly higher in groups 2 and 3 (6.8 and 17.2% compared with 0.7% in group 1, <0.001). During 12 months of follow up restenosis rate was higher in groups 2 and 3 (15.9 and 27.6% compared with 6.6% in group 1, <0.001). Lowered GFR became predictor of long term (up to 3 years) mortality in patients with CKD as for group 2 compared with group 1 relative risk (RR) of death was 1.77 (95%CI 1.19-3.74, =0.001), and for group 3 compared with group 1 - 3.69 (95%CI 1.58-6.87), =0.001. In addition lowered GFR was predictor of nonfatal myocardial infarction (MI) up to 3 years: for group 2 compared with group 1 RR 1.69 95%CI 1.12-3.07, =0.009, for group 3 compared with group 1 RR 3.44 95%CI 1.37-6.19, =0.001. The conducted study showed that initially lowered GFR after stenting increased risk of development of CIN, led to rise of restenosis rate and repeat revascularizations up to 12 months, and also appears to be predictor of death and nonfatal MI in remote period up to 3 years.

[Thienopyridines in the treatment and prevention of cardiovascular diseases. III. therapeutic application of clopidogrel as monotherapy (without acetylsalicylic acid)].

In a series of articles the authors consider clinical pharmacology and experience of clinical application of blockers of platelet P2Y12 receptors, most well known representatives of which ticlopidine and clopidogrel according to chemical structure belong to thienopyridine derivatives. In the third communication we consider data of randomized studies in which efficacy and safety of clopidogrel monotherapy has been assessed in comparison with acetylsalicylic acid (ASA), ticlopidine, warfarin, as well as ASA in combination with extended release form of dipyridamole in various cardio-vascular diseases. Results of these studies indicate that efficacy of monotherapy with clopidogrel is comparable with that of ASA, ticlopidine, warfarin, and ASA in combination with extended release form of dipyridamole. Clopidogrel significantly more rarely causes ulcerogenic and other hemorrhagic complications than ticlopidine, but is substantially more expensive. Therefore prescribing of clopidogrel as monotherapy is justified only in those cases when ASA and ticlopidine are contraindicated or induce pronounced side effects.