[Combined use of the GRACE ACS risk score and comorbidity indices to increase the effectiveness of hospital mortality risk assessment in patients with acute coronary syndrome].

AIM: To assess the possibilities of using comorbidity indices together with the GRACE (Global Registry of Acute Coronary Events) scale to assess the risk of hospital mortality in acute coronary syndrome (ACS). MATERIALS AND METHODS: The registry study included 2,305 patients with ACS. The frequency of coronary angiography was 54.0%, percutaneous coronary intervention (PCI) 26.9%. Hospital mortality with ACS was 4.8%, with myocardial infarction 9.4%. All patients underwent a comorbidity assessment according to the CIRS system (Cumulative Illness Rating Scale), according to the CCI (Charlson Comorbidity Index) and the CDS (Chronic Disease Score) scale, according to their own scale, which is based on the summation of 9 diseases (diabetes mellitus, atrial fibrillation, stroke, arterial hypertension, obesity, peripheral atherosclerosis, thrombocytopenia, anemia, chronic kidney disease). All patients underwent a mortality risk assessment using the GRACE ACS Risk scale. RESULTS: It was found that the CDS and CIRS indices are not associated with the risk of hospital mortality. With CCI3, the frequency of death outcomes increased from 4.1 to 6.1% (2=4.12, p=0.042). With an increase in the severity of comorbidity from minimal (no more than 1 disease) to severe (4 or more diseases) according to its own scale, hospital mortality increased from 1.2 to 7.4% (2=23.8, p0.0001). In contrast to other scales of comorbidity, our own model more efficiently estimates the hospital prognosis both in the conservative treatment group (2=8.0, p=0.018) and in the PCI group (2=28.5, p=0.00001). It was in the PCI subgroup that the comorbidity factors included in their own model made it possible to increase the area under the ROC curve of the GRACE scale from 0.80 (0.740.87) to 0.90 (0.850.95). CONCLUSION: CCI and its own comorbidity model, but not CDS and CIRS, are associated with the risk of hospital mortality. The model for assessing comorbidity on a 9-point scale, but not CCI, CDS and CIRS, can significantly improve the predictive value of the GRACE scale.

[Assessment of Outcomes and Treatment Tactics in Patients With Non-ST-Elevation Acute Coronary Syndrome: Data of Five-Year Follow-up].

PURPOSE: to study the role of clinical factors and treatment tactics in the development of adverse outcomes in patients with non-STelevation acute coronary syndrome (NSTEACS) for five years follow up. MATERIALS AND METHODS: The study included 415 patients with NSTEACS observed for 60±4 months from the date of discharge. Adverse events (AE) were unstable angina (UA), myocardial infarction (MI), ischemic stroke or patient's death. The favorable 5-year outcome was identified in 200, adverse outcome - in 178 patients. Statistical processing was performed using STATISTICA 8.0 software package and MedCalc 11.0. RESULTS: Total mortality for 60 months was 16.1% (n=61). Highest mortality, maximal number of hospitalizations due to MI (41.1%) and UA (49.6%) were observed during first 12 months. Greatest impact on the development of AE produced: history of MI, higher GRACE score, age >54 years (p=0.0021), stenosis in brachiocephalic arteries, ischemic changes on admission ECG and reduced left ventricular ejection fraction (LVEF) ≤ 52% (p=0.0001). Five-year survival rate was influenced by coronary angiography (p=0.0001) and percutaneous coronary intervention (PCI) during index hospitalization (p=0.0039). DISCUSSION: Mortality and frequency of AE in this register were close to generally reported. The observed adverse impact on the long-term outcome of such risk factors such as age over 60 years, history of MI, ischemic ECG changes at admission, decreased LVEF corresponded to literature data. Our study proved the need for coronary imaging in patients with NSTEACS to determine treatment strategy in in hospital period as these factors affected the 5-year survival. CONCLUSION: During five-year follow-up AE occurred in 47.1% of patients with NSTEACS. Maximal number of patients with AE was registered during the first (24.7%) and fifth (13.8%) year of observation. The development of AE was associated with older age, history of MI and coronary artery bypass grafting, ischemic ECG changes, decreased LVEF, higher GRACE score, and brachiocephalic artery stenosis. Carrying out diagnostic coronary angiography and PCI with stenting during hospitalization in patients with NSTEACS was associated with favorable 5-year outcome.

[Postregistration study of comparative assessment efficacy of the use of fixed combination of nebivolol and amlodipine for the treatment of patients with moderate and high degree of arterial hypertension].

AIM: of the study was to assess efficacy of the use of fixed combination of nebivolol and amlodipine in patients with moderate and high degree of arterial hypertension (AH). MATERIAL AND METHODS: Patients with diagnosis of primary AH (n=124) were divided into 2 groups by random sample method. Patients of group 1 (n=62) received of fixed combination of nebivolol and amlodipine, while those of group 2 (n=62) received free combination of nebivolol and amlodipine. Study drugs were administered both as initial therapy and replacement of preceding treatment. Duration of observation was 3 months with visits after first 2 weeks and in 1, 2, and 3 months after enrollment. RESULTS: Starting from 2nd week visit of fixed combination of nebivolol and amlodipine treated patients had significantly lower levels of systolic and diastolic AP. Already after 2 weeks of combined two-component therapy 60% of group 1 and 52% of group 2 patients achieved target AP. Target AP was achieved by the end of month 1 by 86 and 71%, of month 2 - by 93 and 78% of patients in groups 1 and 2, respectively. In 3 months almost all patients had target AP, but in 1.6% of group 1 and 2.3% of group 2 patients this level was achieved after addition of a thiazide diuretic. Patients receiving of fixed combination of nebivolol and amlodipine achieved noromosyslolia more quickly compared with patients who received free combination of nebivolol and amlodipine. CONCLUSION: Combined therapy with fixed combination of nebivolol and amlodipine appears to be one of effective approaches to treatment of patients with moderate and high degree AH.

[Role of multidetector computed tomography and stress- echocardiography in assessment of risk of cardiological complications of non-cardiac surgery].

AIM: to compare results of coronary angiography with data of multi-slice computed tomography (MSCT) - angiography, and analyze rate of detection of hemodynamically significant coronary artery lesions during preoperative examination of patients. MATERIAL AND METHODS: We analyzed case histories of 92 patients (median age 59 years) examined prior to surgery on non-coronary vessels or for exclusion of ischemic heart disease. All patients were subjected to selective coronary angiography (CA) and MSCT - angiography. According to results of CA we formed 2 groups - with coronary artery stenoses >70% (n=55, group 1) and <70% (n=37, group 2). In 46 patients (50%) dobutamine stress echocardiography was performed for detection of concealed coronary insufficiency. RESULTS: CA revealed hemodynamically significant stenoses >70% (>50% in left main coronary artery) in 91 of 324 arteries. MSCT angiography detected stenosis >50% in 184 of 324 arteries; in 148 patients results of MSCT were confirmed by presence of hemodynamically significant stenoses at coronary angiography (sensitivity 86%). Absence of lesions or presence of stenoses <50% were noted at MSCT in 368 arteries; in 345 cases this was confirmed by coronary angiography (predictive value of negative result 94%, specificity 91%). Result of dobutamine stress echocardiography was positive in 41% of patients in group 1 and in 20% - of group 2 (<0.001). Sensitivity of stress echocardiography for detection of significant stenoses was 41%, specificity - 80%, negative predictive value - 14%. CONCLUSION: Diagnostic value of MSCT for detection of coronary artery stenoses >70% have better sensitivity, specificity, negative and positive predictive value of compared with stress echocardiography. Results of this study confirm value of MSCT angiography for diagnosis of coronary atherosclerosis and allow to recommend it as a screening method for detection hemodynamically significant coronary artery involvement before extracardiac surgery.

[Role of kidney injury molecule-1 (KIM-1) for inhospital event risk assessment after coronary artery bypass surgery].

AIM: To assess value of kidney injury molecule-1 (KIM-1) for prediction of inhospital events in CAD patients undergoing coronary artery bypass graft (CABG) surgery. MATERIAL AND METHODS: We analyzed postoperative course of 719 patients subjected to CABG in Research Institute for Complex Issues of Cardiovascular Diseases between March, 2011 and April, 2012. In all patients we measured creatinine concentrations, glomerular filtration rate (GFR) by MDRD and urine KIM-1 levels before and on day 7 after CABG. Major unfavorable events (myocardial infarction, stroke or transient ischemic attack, acute or decompensated chronic renal failure or remediastinotomy) were registered during hospital stay. The EuroSCORE (European System for Cardiac Operative Risk Evaluation) risk of operative mortality was calculated for each patient. RESULTS: Patients with different EuroSCORE risk had similar serum creatinine levels while KIM-1 concentrations in urine were significantly higher in patients with moderate and high EuroSCORE risk as compared with low-risk patients. Patients who experienced postoperative events had significantly higher KIM-1 both before and after surgery while there were no differences in such renal dysfunction markers as creatinine and GFR. CONCLUSION: Preoperative elevated KIM-1 can act as a marker of complicated postoperative period after CABG.

[Optimization of organizational approaches to management of patients with atherosclerosis].

Despite undoubted achievements of modern cardiology in prevention and treatment of atherosclerosis, cardiologists, neurologists, and vascular surgeons are still facing severe stenotic atherosclerotic lesions in different vascular regions, both symptomatic and asymptomatic. As a rule hemodynamically significant stenoses of different locations are found after development of acute vascular events. In this regard, active detection of arterial stenoses localized in different areas just at primary contact of patients presenting with symptoms of ischemia of various locations with care providers appears to be crucial. Further monitoring of these stenoses is also important. The article is dedicated to innovative organizational approaches to provision of healthcare to patients suffering from circulatory system diseases that have contributed to improvement of demographic situation in Kuzbass.

[Analysis of approaches to assessment of persistent loss of capacity to work in patients who had undergone coronary bypass surgery].

Aim of the study was to assess factors influencing decisions about persistent disability of patients after coronary bypass surgery (CBS). By method of continuous sampling (registry study) we examined 427 working age patients who had undergone CBS. Although surgical treatment was effective rehabilitating factor most patients after CBS at inspection in institutions of medical social expertise were unreasonably classified as having low degree of restoration of ability to work. Possible explanations of this were incomplete volume of conducted tests, lack of relation between presence of functional class of angina and real clinical picture of this syndrome, absence of objective criteria of the presence of myocardial ischemia and tolerance to physical exercise, ill-timed referral to medical social inspection.

[Role of renal dysfunction and multifocal atherosclerosis in assessment of prognosis of patients presenting with ST-elevation acute coronary syndrome].

AIM: To assess incidence and severity of renal dysfunction as well as its prognostic value in patients with ST elevation myocardial infarction (STEMI) and multifocal atherosclerosis (MFA). MATERIAL AND METHODS: We enrolled in this study 529 patients with STEMI in whom we estimated creatinine clearance rate (eGFR) and glomerular filtration rate (eCrCl) using Cockcroft-Gault equation and Modification of Diet in Renal Disease (MDRD) formula, respectively. Duplex ultrasonography of lower extremity and extracranial arteries was performed in 423 patients on day 5-10 of hospitalization. Signs of MFA were found in 95% of patients. Hospital mortality was 10.9%. One year survival of 397 patients was assessed by the telephone contacts. Thirty nine patients (9.8%) died. RESULTS: GFR in 35.5% of patients was 30-60, and in 4.9% - less than 30 ml/min/1.73 m2. At the same time 29.5% of patients had CCr 30 - 60, and 3.0% - less than 30 ml/min. Progressive decreases of eCCr and eGFR were observed in patients with incipient MFA (stenosis <30%); relationship between MFA and eGRF was more close. Presence of renal dysfunction in patients with STEACS and MFA was associated elevation of both hospital and 1 year mortality. CONCLUSION: Any manifestation of peripheral atherosclerosis and impairment of renal function should be considered as independent predictors of cardiovascular events in patients after STEMI.

[The role of matrix metalloproteinases in assessment of prognosis in patients with ST-elevation myocardial infarction during hospital stay].

Aim of the study was to investigate role of matrix metalloproteinases (MMP) in assessment of prognosis of repetitive cardiovascular events during hospital stay of patients with ST-elevation (STE) myocardial infarction (MI). We consecutively included into this study 175 patients with diagnosis of STEMI. Content of MMP-1, MMP-3 and MMP-9 in blood serum was measured at admission and on day 12 after onset of disease. Levels of all MMPs on day 12 were 1.1-1.6 times higher than on day 1 of MI (<0.05). Comparison of groups of patients with favorable and unfavorable outcome showed that patients with unfavorable outcome had higher median concentrations of MMP-3 and MMP-9 on day 1; this tendency was maintained on day 12. However these differences were significant only for MMP-9. Compared with patients with favorable outcome levels of this marker in patients with unfavorable outcome were higher by 19.4% (=0.04) on day 1 and by 48.8% (=0.03) on day 12. At logistic regression analysis for MMP-9 and unfavorable outcomes during hospital stay area under ROC-curve did not exceed 0.5. But when only inhospital deaths were considered 2 for MMP-9 (day 1) was 14.3 (<0.0001) while area under ROC-curve was 0.72 (0.64; 0.78; =0.02). Thus in patients with STEMI high concentrations of MMP-9 on day 1 of STEMI can come forward as independent marker of unfavorable outcome during hospital stay.

[The role of markers of inflammation in assessment of prognosis in patients with ST-elevation myocardial infarction combined with disturbances of carbohydrate metabolism].

Diabetes mellitus (DM) is not only an independent risk factor (RF) of development of atherosclerosis, but it substantially worsens prognosis of patients with acute myocardial infarction (MI). Results of this study evidence that presence of disturbances of carbohydrate metabolism (DM or impaired glucose tolerance (IGT) in patients with ST elevation MI manifests with higher activity of the inflammatory process compared with patients with MI without abnormalities of carbohydrate metabolism. Unfavorable 1 year prognosis in patients with ST elevation MI is associated with higher concentrations of inflammation markers assessed on days 10-14 from onset of the disease: in patients with DM and IGT- of sCD40 ligand, in patients without disturbances of carbohydrate metabolism - C-reactive protein, in all patients irrespective of presence of carbohydrate metabolism abnormalities - interleukin 12.

[Pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery].

More than 230 million surgical operations are performed yearly in the world and this number is continually growing. Thirty days mortality in moderate and high risk non-cardiac surgery is about 2% and exceeds 5% in patients with high cardiac risk. European Society of Cardiology (ESC) issued specific guidelines in 2009. ESC experts created clear stepwise algorithm for assessment of risk of cardiac complications in preoperative period and use of diagnostic and curative procedures aimed at its lowering. This allows to avoid unjustified investigations and drug therapy in operations with low cardiac risk and stresses significance of perioperative medical treatment. This review contains an analysis questioning some statements of the novel ESC guidelines such as reduction of preoperative cardiac tests and prophylactic revascularization of coronary arteries before operations with intermediate and high risk of cardiac complications.

[Predictors of non-fulfillment of reperfusion therapy in patients with ST-elevation acute coronary syndrome].

At present reperfusion therapy in ST-elevation (STE) acute coronary syndrome (ACS) is carried out in majority of countries not more than in 70% of cases. We analyzed predictors of non-fulfillment of reperfusion therapy in patients with STEACS included into ACS registry conducted in the Kemerovo cardiological dispensary. Reperfusion therapy was not carried out in 154 patients with STEACS (36.2%). Main predictors of non-fulfillment of reperfusion were age older than 75 years (odds ratio [OR] 47.97, 95% confidence interval [CI] 19.47-118.21), admission later than in 12 hours after onset of disease (OR 4.29, 95%CI 1.52-12.13), history of myocardial infarction (OR 2.68, 95%CI 1.11-6.48). Thus there are factors including subjective ones which preclude full-fledged use of contemporary recommendations on the management of patients with STEACS.

[Phenomenon of preoperative stress in patients with ischemic heart disease. Assessment of its clinical and prognostic significance]. / Fenomen predoperatsionnogo stressa u bol'nykh IBS. Otsenka ego klinicheskoi i prognosticheskoi znachimosti.

AIM: To assess preoperative stress in patients with ischemic heart disease (IHD) and its influence on the course of early intraoperative period. MATERIALS AND METHODS: 79 patients scheduled for aortocoronary bypass operation were studied to assess the phenomenon of preoperative psychoemotional stress (clinical characteristics, personal anxiety, humoral and vegetative regulation. RESULTS: 24 hours before operation IHD patients became anxious, coronary insufficiency and arrhythmia aggravated as shown by Holter ECG monitoring. Initial insufficiency of the antioxidant system, disturbances of the platelet-vascular hemostasis, hyperlipidemia and dyslipoproteinemia enhanced. Preoperative changes due to stress reaction affected the course of early intraoperative period. CONCLUSION: It is necessary to apply individual schemes of stress-limiting preoperative preparation in IHD patients.