[The differences between the guidelines of the European Society of Cardiology and the American College of Cardiology/ American Heart Association for oral P2Y12 inhibitor therapy in the management of patients with acute coronary syndromes].

The analysis of the evidence that formed the basis for the current guidelines of the European Society of Cardiology (ESC) on oral therapy by antithrombotic drugs for acute coronary syndromes (ACS), and a comparison with the U.S. guidelines. The ESC guidelines, published during 2011-2012, declared the superiority of prasugrel and ticagrelor over clopidogrel in patients with ACS without ST elevation and myocardial infarction (MI) with ST elevation. These guidelines are based in each case on a subgroup analysis of a single study using either prasugrel (TRITON), or ticagrelor (PLATO). In contrast, the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines, published in 2012-2013, are more balanced, conservative and present evidence-based outlook, suggesting no proven extra benefit of one P2Y12 antagonist over the other(s). The ESC guidelines regarding the findings of the superiority of prasugrel or ticagrelor over clopidogrel are overly optimistic and not always evidence-based. A small frequency of clinical use of prasugrel and ticagrelor in the world in general and Europe in particular, suggests a discrepancy between the traditionally appointed treatment and published ESC guidelines.

[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.

[Optimal method of revascularization in patients with multivessel coronary artery involvement for application of drug eluting stents: percutaneous coronary interventions in comparison with coronary bypassing].

Drug eluting stents (DES) which appeared in the beginning of 21-st century allowed to elevated percutaneous coronary interventions (PCI) to a novel level. High efficacy of DES has been proven in a row of conducted clinical studies: after their implantation low percentage of in stent restenosis and low rate of repetitive target vessel revascularizations have been obtained. At the same time there occurred definite improvements in the technique of coronary bypass surgery. Therefore a question of choice of optimal method of revascularization in patients with multivessel lesions remains open. In this review we present results of a row of large studies in which coronary bypassing and PCI with implantation of DES has been compared in patients with multivessel lesions.

[The use of tirofiban in invasive treatment of patients with non-ST-elevation acute coronary syndrome].

The study assessed 123 patients with non-ST-elevation acute coronary syndrome who were randomized into two groups: percutaneous coronary intervention (PCI) (62 patients) and PCI against background of tirofiban injection (61 patients). The results of the study were estimated during the early (up to 30 days) and the late (up to 180 days) follow-up. It was stated that the use of tirofiban has led to the increase of minor bleedings (11% versus 4.8%, p<0.05), but the total amount of bleedings between the groups did not differ: 19.7% in the tirofiban group versus 14.5% in group I. The use of tirofiban has led to the significant growth of the LV ejection fraction (5+/-4% versus 2+/-3%, p<0.05) and increment of the LV wall motion index (0.28+/-0.18 versus 0.12+/-0.21, p<0.001). There was no difference in the frequency of the early events: 9.6% versus 8.2% in the groups without and with the use of tirofiban accordingly (p<0.05). The use of tirofiban was associated with the decrease in the frequency of all events during the first 180 days after PCI: 30.7% in group I and 13.1% in the tirofiban group (p<0.005). Absence the main cardiovascular complications according to Kaplan-Meier method for all patients amounted to 77+/-6%, in the group of the patients who received tirofiban 88+/-6%, and 64+/-8% in the group of the patients who did not receive tirofiban (p=0.009). Thereby, the use of tirofiban in the treatment of the patients with non-ST-elevation acute coronary syndrome does not lead to the increase in the frequency and severity of bleedings. At the same time, the use of tirofiban in the treatment of the patients with acute coronary syndrome has a significant influence on the growth of the LV wall motion index and the LV ejection fraction by increasing them. Under these conditions when using tirofiban in the late period the frequency of all events during PCI is 2.3 times lower compared to the patients who did not receive tirofiban.

[Percutaneous coronary interventions on unprotected left main coronary artery: contemporary outlook of the problem].

UNLABELLED: Coronary bypass surgery in patients with lesions in unprotected left main coronary artery (LMCA) remains gold standard of treatment. However there is a tendency to more frequent use of percutaneous coronary interventions (PCI) in patients with such lesions. Is PCI of LMCA justified, what is complication rate of PCI of LMCA? In order to answer these questions we analyzed modern studies in which PCI with the use of standard metal and drug eluting stents were carried out in patients with lesions in unprotected LMCA. Studies in which PCI was compared with coronary bypass surgery was also reviewed. CONCLUSION: Registry data, in which PCI and coronary bypass surgery were compared showed promising results of PCI, but designs of these studies did not allow to make unequivocal conclusion. The authors of considered studies has agreed that for definite reply randomized multicenter trials are required.

[Efficacy and safety of enoxaparin use during drug-eluting stents implantation].

We assessed possibility of the use of low molecular heparin enoxaparin during percutaneous coronary interventions (PCI) with implantation of drug eluting stents. Enoxaparin was administered to 225 (0.3 mg/kg intraarterially via catheter) and 215 (0.5 mg/kg intravenously) patients. In comparison group (n=207) we used unfractionated heparin (UFG) intravenously according to standard scheme under control of activated clotting time. Stents implanted (n=797) were Cypher, Taxus, and Endeavor. Immediate angiographic success was 100%. During 48 hours after PCI pronounced bleeding (4.3%) and blood transfusions predominated in UFG treated patients. Number of bleedings was minimal after the intra-arterial use of enoxaparin (0.3 mg/kg). However total rate of all adverse events after PCI turned out to be minimal (7.0%) in the group of patients receiving enoxaparin intravenously (0.5 mg/kg). Thus the use of low molecular heparin enoxaparin is justified during implantation of drug eluting stents. Its optimal dose according to data obtained is 0.5 mg/kg intravenously.

[Pulmonary hypertension and right ventricular failure. Part VIII. Diagnosis, course, and prognosis of primary (idiopathic) pulmonary arterial hypertension].

In a series of articles the authors discuss literature data concerning epidemiology of pulmonary hypertension (PH), its modern classification; peculiarities of its pathogenesis and treatment in various diseases and conditions. In the eight communication they describe presentations of PH and methods of its instrumental diagnostics. This part also contains discussion of problems of differential diagnosis of diseases which can be complicated by PH, contemplation of natural course of primary (idiopathic) PH and factors determining its prognosis.

[Pulmonary hypertension and right ventricular failure. Part VI. Classification and pathomorphology of primary pulmonary arterial hypertension].

In a series of articles the authors discuss literature data concerning epidemiology of pulmonary hypertension (PH), its modern classification; peculiarities of its pathogenesis and treatment in various diseases and conditions. In the sixth communication they present classification of PH accepted at the Third World PH Symposium (venice, Italy, 2003). This classification abandons terms "primary" and "secondary" PH. Primary PH which is now recommended to be called "idiopathic pulmonary arterial hypertension" is grouped in one category with familial cases of PH, PH associated with administration of anorexigens, collagen vascular disease, congenital systemic to pulmonary shunts, portal hypertension and hyperthyroidism, as well as with pulmonary veno-occlusive disease and and pulmonary capillary hemangiomatosis, taking into consideration similarity of histopathological changes of vascular tree, pathophysiology and therapeutic approaches in these forms of PH.

[Causes and outcomes of coronary arteries perforations].

Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions. Aim of this study--to assess inhospital and long term outcomes in patients in whom perforation occurred during coronary intervention and elucidation of predictors of coronary artery perforation. Between May 1997 and October 2002 perforations were formed in the course of percutaneous interventions in 127 patients what amounted 1.08% of 11,793 patients, subjected to coronary interventions, and 0.77% of 16,494 treated coronary segments. Causes of perforations were complex stenoses, chronic occlusions, calcified lesions, small predicted and minimal vessel lumen, high percent stenosis, use of excimer laser or thromboextrator. Rates of arterial perforations and subsequent adverse events including cardiac tamponade and urgent coronary artery bypass surgery as well as mortality had been declining throughout observation period.

[Clinical, angiographical, and procedural causes of acute vessel closure during transluminal coronary intervention]. / Klinicheskie, angiograficheskie i protsedurnye prichiny vnezapnogo zakrytiia sosuda vo vremia transliuminal'nogo koronarnogo vmeshatel'stva.

AIM: To elucidate factors related to acute vessel closure (AVC) after transluminal coronary intervention. METHODS: From population of 10439 patients subjected to transluminal coronary intervention 2 groups were formed: with (n=885) and without (n=885) acute vessel closure (AVC). Twenty five clinical, angiographical and procedural characteristics of patients of these 2 groups were included into mono and multifactorial logistic regression analysis. RESULTS AND CONCLUSION: The following factors were univariate predictors of acute vessel closure: smoking [odds ratio (OR) 1.42], unstable angina (OR=2.130, acute myocardial infarction within previous 24 hours (OR 2.76), cardiogenic shock (OR 4.31), urgent procedure (OR 1.94), eccentric stenosis (OR 1.67), calcified lesion (OR 2.21), preexisting thrombosis (OR 3.79), lacerated complicated stenosis (OR 2.02), tortuous lesion (OR 1.35), low operator experience (OR 3.37), balloon angioplasty as sole procedure (OR 1.66), concomitant rheolytic thrombectomy (OR 1.95), urgent stenting (OR 1.45). Elective stenting significantly lowered risk of acute vessel thrombosis. Multifactorial step-up analysis selected the following independent predictors of AVC: smoking, acute myocardial infarction within previous 24 hours, cardiogenic shock, preexisting thrombosis, lacerated complicated stenosis, and concomitant rheolytic thrombus extraction. Thus only elective stenting significantly reduced risk of AVC.

[Invasive cardiology: focus on restenosis. Part II]. / Invazivnaia kardiologiia: fokus na restenoz. Chast' II.

In-stent restenosis represents a pathological process which histology is different from that of restenosis after balloon angioplasty. In-stent restenosis is mainly caused by neointima proliferation. This part of review deals with technologies of prevention of in-stent restenosis including novel stent designs and coatings aimed at suppression of neointima proliferation.

[Invasive cardiology--focus on restenosis. Part I]. / Invazivnaia kardiologiia: fokus na restenoz. Chast' I.

In-stent restenosis is mainly caused by neointima proliferation and represents a pathological process which histology is different from that of restenosis after balloon angioplasty. Frequency of in-stent restenoses increases parallel with progressively increasing number of procedures of coronary stenting. The review summarizes results of research devoted to restenosis pathology and pathogenesis including animal studies, presents methods of mechanical treatment of in-stent restenoses (balloon inflation, direct and rotational atherectomy), as well as techniques of beta and gamma irradiation aimed at prevention of restenosis development.

[Prospective analysis of conservative treatment of acute coronary syndrome]. / Prospektivnyi analiz konservativnogo lecheniia ostrogo koronarnogo sindroma.

The in-hospital and intermediate outcomes in 341 patients with acute coronary syndrome treated with conservative (non-invasive) interventions were analysed. The coronary reperfusion was achieved in 59% patients with acute myocardial infarction (MI) treated with thrombolysis, but in 27% patients with MI treated only heparin and aspirin. In-hospital survival was 91% in 93 patients with MI treated with thrombolysis and 82% in 71 patients with MI without thrombolysis. On 6 month survival was 86% in patients with MI treated with thrombolysis, 70% in patients with MI without thrombolysis, 79% in patients with non-Q-wave MI and 88% in patients with unstable angina.