[Drug prevention of pulmonary embolism in orthopedic practice: traditional and novel approaches].

We consider in this review traditional and novel approaches to drug prevention of pulmonary embolism (PE) which in predominant number of cases is related to deep vein thrombosis of lower extremities. Risk of PE development is especially high in patients after orthopedic hip or knee surgery. Modern recommendations contemplate use of unfractionated and low molecular weight heparins, vitamin K antagonists (warfarin in the first place), fondaparinux. Oral direct anticoagulants related to selective inhibitors of blood coagulation factors IIa (thrombin) and Xa have appeared recently and proved their preventive efficacy and safety in randomized controlled studies. Preventive efficacy and safety of dabigatran among direct selective factor IIa (thrombin) inhibitors and of rivaroxaban, apixaban, and edoxaban among direct selective factor IIa inhibitors have been studied best.

[Complications and clinical outcomes in remote period in patients subjected to percutaneous coronary interventions on chronic total occlusions of coronary arteries].

Percutaneous coronary interventions (PCI) on chronic total occlusions have been always associated with worse immediate results compared with interventions on nonoccluded arteries. From initial stage of development of interventional cardiology up to present time intervention on chronic occlusions has remained one of most technically sophisticated procedures. This is related to difficulties which arise during passage of chronic occlusions with guide wires and balloons. Therefore large proportion of patients with occlusions of coronary arteries were directly sent to coronary bypass surgery. However in recent decade interventional cardiologists have created special wires and other tools for penetration of chronic occlusions. At the same time technique of revascularization of this type of coronary lesions has also improved. All this resulted in increased success rate of interventions. Moreover a number of trials have proven clinical advantages of revascularization of chronic coronary artery occlusions what serves as an extra stimulus for implementation of PCI. In this review we present results of clinical studies which might be of interest both for interventionalists and noninvasive cardiologists.

[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.

[Thienopyridines in the treatment and prevention of cardiovascular diseases. Part I. Ticlopidine].

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 first communication pharmacodynamics and pharmacokinetics of the first thienopyridine ticlopidine are described in detail. Results of randomized studies in which cerebro and cardioprotective efficacy and safety of ticlopidine was studied in patients with cerebrovascular, peripheral artery diseases, and acute coronary syndromes are discussed. It has been established that ticlopidine is more effective and safe in patients having undergone coronary and femoral bypass surgery. Results of meta analyses have shown which evidence that ticlopidine is not less and may be more effective than clopidogrel in patients after coronary bypass surgery. Most frequent and most severe side effects of ticlopidine and measures of their prevention are also considered.

[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.

[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.

[Hypercholesterolemia in men and women of various age. Part II. The problem of efficacy and safety of statins].

Hypocholesterinemic drugs from the statins class are effective means of primary and secondary prevention of ischemic heart disease (IHD) in middle aged men who comprised predominant majority of patients participating in randomized controlled trials (RCT). Proofs of favorable influence of statins on origination and progression of IHD in women and elderly people are less convincing. In majority of RCTs of therapy with statins results of which were analyzed separately for men and women no lowering of rates of coronary events were found among women and people older then 65 - 70 years. Moreover in some trials increases of all cause mortality were observed in statin treated patients at the account of deaths from non-cardiovascular causes (cancer deaths in particular). In the PROSPER trial pravastatin not only turned out useless in men and women aged 70 - 82 years, but significantly increased rate of breast cancer. In ALLHAT-LLT in patients aged 65 years and older and in women pravastatin lowered neither total number of nonfatal myocardial infarctions and IHD deaths, nor total mortality. In SPARCL and TNT in which efficacy and safety of high dose statin (e.g. atorvastatin 80 mg/day) was assessed there occurred augmentation of risk of hemorrhagic stroke and mortality from noncardiovascular causes including cancer and infections. One of meta-analyses of RCTs revealed significant increase in breast cancer risk associated with treatment with statins, in another meta-analysis more close relationship was noted between statins and development of cancer in elderly patients. Thus the problem of efficacy and safety of long-term therapy with statins remains open and requires further investigation.

[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.

[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.

[Antihypertensive drugs and malignant neoplasia]. / Antigipertenzivnye preparaty i zlokachestvennye novoobrazovaniia.

Analysis of epidemiological, cohort and randomized studies of antihypertensive drugs containing reports of development of malignant neoplasms shows that long term use of some antihypertensive drugs while preventing cardiovascular complications has been associated with increased risk of malignancies. Most convincing evidence exists for association between the use of diuretics and renal cancer. Association between the use of reserpine and breast cancer in women, between atenolol and some types of cancer in elderly men also can not be ruled out. There is no proof of existence of either negative or positive correlation between malignant neoplasia and long-term use of calcium antagonists, angiotensin converting enzyme inhibitors or angiotensin receptor blockers.