[Antithrombotic therapy after X-ray endovascular treatment: are there specific features in patients with diabetes mellitus?].

According to the current guidelines for the intervention treatment of patients with coronary heart disease, the primary and secondary prevention of cardiovascular events is long-termpharmacotherapy with platelet function inhibitors. Although undeniable progress has been made in the use of this group of medicaments, there are, however, issues calling for further investigation in the population of diabetic patients in particular. Along with the general principles of thrombosis, there are mechanisms that cause additional platelet hyperactivity in the presence of insulin deficiency and insulin resistance, metabolic and cellular disorders induced by hyperglycemia. The risk of resistance to standard antithrombotic therapy suggests a search for alternative ways to inhibit platelet aggregation, which is particularly relevant in diabetic patients.

[Fatal coronary artery spasm in a patient with thyrotoxicosis].

According to some data up to 20% of patients with thyrotoxicosis suffer from vasospastic angina. But presence of coronary artery spasm can be rarely confirmed. We describe a case of development of spasm of coronary arteries in a patients with severe thyrotoxicosis. Despite active treatment of thyrotoxicosis and use of drugs aimed at prevention of coronary spasm this patient with minor changes in coronary arteries (according to autopsy data) developed episode of acute myocardial ischemia leading to lethal outcome. This clinical case shows that patients with thyrotoxicosis and documented transitory myocardial ischemia should receive therapy with thyrostatics and drugs preventing coronary spasm in maximal doses until stable normalization of levels of thyroid hormones.

[Single-step endovascular revascularization of the kidney, lower limb and endovascular reconstruction of abdominal aortic aneurysm in a patient with type 2 diabetic mellitus].

Presented in the article is a clinical example of surgical treatment of a patient with a severe course of type 2 diabetes mellitus, multiple lesions of coronary arteries, lower-limb arteries with the development of lower-limb ischaemia, bilateral lesions of renal arteries and chronic renal insufficiency, the presence of an aneurysm of the infrarenal portion of the aorta. The unique nature of the case report consists in joint work of endocrinologists, cardiologists, specialists in purulent surgery and reoentgenovascular surgeons, also in carrying out simultaneous endovascular reconstructive operation on various vascular basins: stenting of the right renal artery, balloon angioplasty and stenting of the left leg arteries and endovascular prosthetic repair of the abdominal aortic aneurysm. The comprehensive treatment of the patient resulted in safe performance of the endovascular intervention, saving the supporting function of the limb, improvement of glycemic control, decreasing the risk of sudden death on the background of abdominal aortic aneurysm rupture, decreased rate of progression of renal insufficiency, better control of symptoms of angina pectoris and cardiac failure. Also the article reflects importance of rendering medical care for patients with multifocal atherosclerosis and diabetes mellitus, also showing the necessity of creating multi-modality medical centres and working out of algorithms for treatment of this patient cohort.

[Management of coronary artery disease in diabetic patients with lower limb critical ischaemia: assessment of operational risk, drug therapy and indications for interventions].

Despite obvious progress in management of diabetes mellitus, the DM-related complications rate remains inadmissibly high. Macroangiopathy is known to rank first amongst complications of diabetes mellitus, and coronary artery disease remains to be the major cause of death. Analysed herein are peculiarities of the clinical course in diabetic patients presenting with coronary artery disease and lower limb critical ischaemia, followed by discussing the issues concerning drug therapy, preoperative examination, and methods of diagnosis in this cohort of patients prior to vascular operations, assessment of the preoperative risk, indications for coronarography and myocardial revascularization. Also presented are the results of the main clinical trials dedicated to preoperative myocardial revascularization, including those in diabetic patients with limb critical ischaemia, and finally highlighting current importance of optimizing approaches to managing and working out algorithms of treatment policy for diabetic patients with a combination of coronary artery disease, diabetes mellitus, and critical limb ischaemia.

[Cost-effect clinical analysis in choice of methods of coronary heart disease diagnosis].

AIM: To select optimal methods of coronary heart disease (CHD) diagnosis in patients with different CHD probability using cost-effect analysis. MATERIAL AND METHODS: The trial included 102 patients admitted to hospital because of suspected CHD. The initial CHD probability was determined according to G.A. Diamond table. CHD diagnosis was made with application of Holter ECG monitoring (88 patients), treadmill test (67 patients), dobutamine stress echocardiography (echo-CG, 31 patients), stress single photon emission computed tomography (SPECT, 30 patients), multislice computed tomography (MSCT) with contrast study of coronary arteries (14 patients). Non-invasive tests were followed by coronaroangiography. The cost-effect method was used for analysis of the above methods cost efficacy. RESULTS: MSCT specificity was 96%, specificity of the other methods - 70-75%. SPECT was most sensitive (96%), Holter ECG monitoring was the least sensitive (49%). Efficacy of all the diagnostic tests was maximal in moderate probability of CHD. In spite of its moderate specificity and sensitivity, treadmill test was the cheapest and, therefore, most cost effective in all the groups. Specification of CHD probability by 1% required 17.4 roubles in low risk groups, 9.4 and 24.7 roubles in moderate and high risk, respectively. CONCLUSION: CHD diagnosis should be started with treadmill test.

[The clinical economic analysis of the methods of ischemic heart disease diagnostics].

The clinical economical analysis was applied to assess the application of different techniques of ischemic heart disease diagnostics - the electro-cardiographic monitoring, the treadmill-testing, the stress-echo cardiographic with dobutamine, the single-photon computerized axial tomography with load, the multi-spiral computerized axial tomography with coronary arteries staining in patients with different initial probability of disease occurrence. In all groups, the best value of "cost-effectiveness" had the treadmill-test. The patients with low risk needed 17.4 rubles to precise the probability of ischemic heart disease occurrence at 1%. In the group with medium and high risk this indicator was 9.4 and 24.7 rubles correspondingly. It is concluded that to precise the probability of ischemic heart disease occurrence after tredmil-test in the patients with high probability it is appropriate to use the single-photon computerized axial tomography with load and in the case of patients with low probability the multi-spiral computerized axial tomography with coronary arteries staining.

[Comparative analysis of methods used for coronary artery disease diagnostics].

The aim of the study was to determine effective diagnostic methods for use in patients with different probabilities of coronary artery disease (CAD). The 102 subjects were distributed into 3 groups according to CAD risk: low risk (n = 13), moderate risk (n = 29), and high risk (n = 60). The following examinations were performed: Holter ECG monitoring (88 patients), treadmill test (67 patients), stress-echoCG with dobutamine (31 patients), single phase emission computed tomography (SFECT) (30 patients), and multispiral computed tomography (MSCT) with coronary arterial contrasting (14 patients). After non-invasive tests, all patients underwent coronaroangiography. According to the study, MSCT and SPECT were the most effective techniques for CAD diagnostics. The application of all these tests is justified most in cases of moderate risk of stenosing coronary arterial lesion.

[The effects of beta-adrenoblocker therapy on the physical working capacity of patients with chronic heart failure of various origin].

The purpose of the study was to evaluate the influence of metoprolol succinate and carvedilol on the physical ability (FA) of patients with chronic heart failure (CHF) of different etiologies. The subjects of the study were 108 patients with postinfarction cardiosclerosis and 39 patients with dilated cardiomyopathy with I to V functional class (FC) CHF and left ventricular ejection fraction of less than 45%. The dynamics of functional parameters were assessed after 6 to 12 months of carvedilol therapy (57 patients) or metoprolol (81 patients) therapy. Therapy with beta-adrenoblockers resulted in a significant decrease in CHF FC (by 0.80 +/- 0.57; p < 0.05), an increase in the distance of six-minute walking test (by 110.7 +/- 86.5 m; p < 0.001) and everyday activity according to DASI questionnaire. The improvement was more substantial in patients with non-ischemic CHF. Peak oxygen consumption during treadmill test did not change, but CO2 ventilatory equivalent increased. The results demonstrate that carvedilol and metoprolol improve subjective and submaximum parameters of the functional status of patients with CHF without changing maximal FA.