[Modern strategies for the management of patients who have suffered ischemic stroke or transient ischemic attack]. / Sovremennye strategii vedeniya bol'nykh, perenesshikh ishemicheskii insul't ili tranzitornuyu ishemicheskuyu ataku.

Modern strategies for secondary prevention of ischemic stroke (IS) are based on long-term use of drugs from three main pharmaceutical groups (antihypertensive, lipid-lowering and antithrombotic drugs). In practical terms, the most difficult thing for a practitioner is the choice of antithrombotic therapy with anticoagulants or antiplatelet agents. Antithrombotic therapy for patients with acute cerebrovascular accidents has changed significantly in recent years. Clinical guidelines mention traditional and new oral anticoagulants, and the family of antiplatelet agents that can be used in clinical practice has expanded. The possibilities of differentiated antithrombotic therapy depending on the pathogenetic subtype of IS have expanded. The concept of early secondary prevention, new in angioneurology, suggests the possibility of more aggressive management of patients using a combination of antithrombotic drugs. In connection with the increase in life expectancy of patients who have suffered a IS, the issues of choosing drugs with good efficacy and a better safety profile have become relevant. The article discusses the practical aspects of managing patients in the acute period of the disease, during the period of early secondary prevention (90 days), if long-term use of basic treatment strategies is necessary (years).

[A Case of Successful Thrombolysis on the Verge of a Reperfusion Revolution in Coronary Cardiology and Vascular Neurology].

Thrombolytic therapy (TLT), as a method of treatment, began to develop in the second half of the 50s of the last century. At that time, there was an accumulation of data on its effectiveness, side effects and contraindications, as well as the development of fibrinolytic drugs, such as fibrinolysin, streptokinase, urokinase, and the conditions for their administration. Official recognition of TLT in regulatory documents began only in the 80s after the development of more effective and safe tissue plasminogen activators. However, on the threshold of an era of development in this area in the treatment of patients with thrombosis of the coronary, carotid, and other peripheral vascular regions, the researchers obtained conflicting data on the results of the use of thrombolytics. There was no concept of a therapeutic window for the use of TLT, there was no data on possible combinations of thrombolytic drugs with anticoagulants, the high probability of bleeding prevented widespread introduction of the method into clinical practice. At that time, vascular imaging and laboratory diagnostics were not sufficiently developed, there was no consensus of the world's leading experts on the benefits of thrombolysis. The use of TLT in acute arterial thrombosis required not only clinical experience, but also courage and ability to make non-standard decisions. The authors of the article analyze in detail the case of rescuing a patient with progressive thrombotic occlusion of the arteries of the brain stem. Then the pioneer in the field of thrombolytic therapy E. I. Chazov and his colleagues took responsibility for the application in this situation of an insufficiently studied treatment method with uncertain consequences. This decision was not due to the identity of the patient or the threat of an internal investigation. Marshal or soldier - it did not matter for E. I. Chazov and his colleagues. If doctors in this clinical situation relied on recommendations, orders and standards, then such a patient would have to wait thrombolysis for another 30 years.

[REGRESSION OF ATHEROSCLECROTIC LESIONS: MEDICAMENTAL AND ALIMENTARY FACTORS].

The article reports results of clinical studies aimed to elucidate the influence of medicines on the size and density of atherosclerotic plaques in the walls of coronary and cerebral arteries. The phenomenon of regression of atherosclerotic lesions in the survivors of Leningrad siege during a long period of starvation is analyzed. The influence of inhibitors of angiotensin-converting enzyme on apoptosis of smooth muscle and foam cells of atherosclerotic plaques in the sanological mechanisms of atherosclerosis is discussed. The concept of natural regression of atherosclerosis is formulated and the necessity of development of the methods for is pharmacological activation are formulated.

[Ideology of the modern system of stroke prevention].

Modern views of stroke prevention are discussed. Novel and traditional concepts of pathogenesis of acute disorders of cerebral circulation are summarized for the first time, methods for individual prognostication of vascular events are proposed. Universally recognized strategies of stroke prophylaxis are analysed and new approaches to differential preventive treatment depending on the probability of development of pathogenetic variants of cerebral circulation disturbances are proposed. Organizational aspects of preventive cardioneurology are considered.

[Cardiogenic ischemic stroke].

The place of cardiogenic ischemic stroke in the structure of acute cerebral circulation disorders is discussed with reference to modern methods of prognostication, diagnostics, treatment and clinical features of cardiogenic strokes.

[Clinico-instrumental characteristics of arterial hypertension, liable to the ishemic stroke].

Clinico-instrumental characteristics of arterial hypertension, liable to the ishemic stroke were studied. The pecularities of clinical, neurological picture of disease and results of instrumental methods of examination were determined. These peculiarities let to educe the course of arterial hypertension, liable to the ishemic stroke. This course appeared because of hypertensional macroangiopathy during 3-5 years, two atherosclerotic stenosis of brachiocephalic arteria, occlusions and stenosis of these arterias, left ventricular hypertrophy of hypodynamic type, circulatory dynamics against the bad daily profile of arterial pressure and/or increased variability of arterial pressure accompanied with ischemic attacks, signs of chronicle heart failure and circulatory encephalopathy. The scheme of the examination of patients with AH during the long-term examination with the goal of prophylaxis IS was offered.

[Organizational principles in prophylaxis of stroke].

Modern system of insult prophylaxis intends development of 2 directions: population strategy and individual tactics. The effectiveness of population strategy depends on quality of health survey and of sanitarian-educational work. The effectiveness of individual tactics depends on intensity of clinical, laboratorial and instrumental checkup and elaborating an adequate correction of representative syndromes. Model of an individual prophylaxis of insult exists in the 2nd Central Military Clinical Hospital of P.V. Mandryka more then 15 years. According to the result of yearly health survey, therapist, in cooperation with cardiologist and neurologist, elaborates a "plan of health", which intends decrease of negative factor's influence and using medicinal substances, correcting the representative syndromes. High-technological algorithms of checkup include ultrasonics surveys of brachycephaly vessel and of the heart, an entire-day electrocardiogram monitoring or loading test, large bio-chemistry tests, directed to finding hyper-coagulation and dislipidemia. The experience of work demonstrates large capabilities in increasing of effectiveness of prophylaxis programs. These capabilities permit decrease sickness rate of insult--to the 30% during latter years.

[The clinical features of arterial hypertension complicated by an old ischemic cerebral stroke].

The course of arterial hypertension (AH) was evaluated retrospectively in 306 patients, who had undergone annual hospital examination and treatment during the previous five years. After five years, AH had got complicated with ischemic cerebral stroke (ICS) in 147 patients (group 1). AH had not got complicated with ICS in 149 patients (group 2). These patients had been observed for another five years. By the end of the study, 98 patients had remained in group 1, and 100 patients had remained in group 2. Mean term of observation had been 10.3 +/- 0.8 years in group 1, and 10.1 +/- 0.9 years in group 2. Clinico-anamnestic analysis revealed the following peculiarities of the course of AH complicated by ICS: a longer AH course before the development of ICS; faster deterioration of AH in a period of 10 years; faster deterioration of chronic cardiac insufficiency and discirculatory encephalopathy; more frequent combination with coronary heart disease and carbohydrate exchange; more frequent development of transitory ischemic attacks (TIA); TIA became more frequent before the development of ICS; in 70% of group 1 patients TIA was located in the place of a future ICS. The authors suggest that slowly and quickly progressing AH forms should be differentiated according to the progression of the risk of cardiovascular complications.

[Some features of coronary artery disease combined with vertebrogenic thoracoalgias].

The subjects of the study were 4223 patients who were examined for heartache between 1998 and 2005. The patients were divided into three groups. Group I were 617 patients with isolated vertebrogenous cardiomyalgia; group II included 1238 patients with coronary heart disease; group III consisted of 2368 who suffered from both conditions. On the basis of clinicoinstrumental examination differential diagnostic criteria were derived.

[On the issue of the diagnosis "boundary arterial hypertension"].

Many-year observation of patients with arterial hypertension revealed that late diagnosis of the initial stage of the disease was typical. Time elapsed from the first medical record of an arterial pressure (AP) of higher than 140/90 mmHg to the moment the diagnosis of arterial hypertension was made was 4.5 +/- 1.6 years in 16 out of the 198 subjects. The authors offer new criteria for the diagnosis of boundary arterial hypertension based on 24-hour AP monitoring (unfavorable type of 24-hour AP profile) and veloergometry (hypertensive response to physical load). Active screening for boundary arterial hypertension based on instrumental examination is recommended, and an algorithm for its search is offered.

[The change of the degree of arterial hypertension after ischemic cerebral stroke according to 24-hour arterial pressure monitoring results].

The paper presents a retrospective analysis of the medical records of 147 patients with arterial hypertension (AH) and old ischemic cerebral stroke (ICS), who had undergone annual hospital treatment and 24-hour arterial pressure monitoring (24HAPM) for five years before ICS developed. The patients were observed and underwent 24HAPM during five years after ICS as well. The changes in average 24-hour systolic arterial pressure (SAP av.) within the 10 years were analyzed in 98 of the 147 patients who had remained in the group by the end of the observation period. The changes in SAP av. after ICS were variable. Most patients displayed slight SAP av. growth by the end of the investigation; at the same time, in 6 of the 98 patients SAP av. became lower by 7 mbar or more after ICS. The authors suppose that this decrease in the arterial pressure occurred due to the disappearance of cerebral ischemic focus in the area of ICS. The authors propose the term "ischemic cerebrovascular AH" and an algorithm of the examination of AH patients with non-stable arterial pressure due to brachiocephalic arterial pathology.

[Treatment of arterial hypertension after ischemic cerebral stroke].

Lethality associated with secondary cerebral stroke is higher than in primary one. Data on the clinical course of arterial hypertension after stroke are contradictory. In recent years, the risk of a repeated ischemic stroke has been considered to be in a direct correlation with both systolic and diastolic blood pressure (BP), while the optimal BP level differs depending on the type of the stroke. Lowering BP should not exceed the ability of brain flow autoregulation to maintain normal cerebral perfusion. Data on the effectiveness of different groups of antihypertensive drugs in terms of secondary stroke prevention are contradictory. It has been reported that the risk of a secondary cerebral stroke lowered depending on the degree of BP decrease. At the same time, various antihypertensive drug classes were directly compared only in MOSES study. As far as secondary stroke prevention is concerned, differences between these classes suggest the existence of other than hypotensive mechanisms of their action. The presence of carotid atherosclerosis may compromise cerebral perfusion and predispose the patient to a second stroke, when a hypotensive effect is achieved.

[The peculiarities of serum levels of S100b protein and antibodies to it in patients with crisis and stable essential hypertension].

The article covers the results of research into the levels of S100b protein and antibodies to it in the serum of patients with crisis and stable essential hypertension. The results show that neutrophic protein dysmetabolism plays an important role in the pathogenesis of hypertonic dyscirculatory encephalopathy and the forming of cognitive disorder syndrome. The data obtained suggest that hypertensive crises lead to pathologic changes in hematoencephalic barrier permeability and the development of autoimmune reactions with participation of neutrophic proteins.

[Neurological syndromes associated with homocystein dismetabolism].

The article summarizes the results of clinical, neurological, and laboratory examination of patients with hyperhomocysteinemia. The data obtained suggest the existence of common pathobiochemical mechanisms of homocystein, cholesterol, and myelin dysmetabolism. The authors demonstrate that neurological manifestations of hyperhomocysteinemia are associated with the processes of demyelinization in the central and peripheral nervous systems.