The Clinical Evolution of Diffuse Myocardial Fibrosis in Patients With Arterial Hypertension and Heart Failure With Mildly Reduced Ejection Fraction Treated by Olmesartan or Sacubitril / Valsartan.

Aim      A 12-month evaluation of the potentialities of the angiotensin II receptor inhibitor olmesartan (Olme) and the angiotensin receptor and neprilysin inhibitor (ARNI) sacubitril/valsartan in patients with arterial hypertension (AH) and dyslipidemia in the dynamics of the following indicators of chronic heart failure (CHF): N-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), LV global longitudinal strain (LV GLS) in diffuse myocardial fibrosis (MF) previously diagnosed by magnetic resonance imaging (MRI).Material and methods  Olmesartan medoxomil (n=56) and sacubitril/valsartan (n=63) were used for 12 months in patients with hypertension, dyslipidemia and NYHA functional class II-III CHF with mid-range LVEF (CHFmrEF). MF was diagnosed by the following MRI criteria: late gadolinium enhancement and an increased proportion of extracellular matrix (33% or more). The frequency of persisting late gadolinium enhancement and the increased proportion of extracellular matrix (33% or more) was evaluated at 12 months; changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), NT-proBNP, and LV GLS were evaluated after 3, 6, and 12 months of follow-up.Results Baseline parameters did not differ between groups. The late gadolinium enhancement and increased proportion of extracellular matrix were present at baseline in all patients of both groups (100%; p=1.0). Already at 3 months, statistically significant decreases in SBP and DBP were observed in both groups. In addition, the LV GLS monitoring showed LV GLS significantly increased in both groups after 3 months and continued changing after 6 and 12 months. The NT-proBNP concentration significantly decreased in both groups already after 3 months and continued to decrease after 6 and 12 months. At 6 and 12 months, sacubitril/valsartan was superior to olmesartan in reducing SBP and NT-proBNP and in restoring LV GLS. At 12 months, the incidence of persisting, abnormal late gadolinium enhancement and increased proportion of extracellular matrix was significantly less in the ARNI group.Conclusion      Olmesartan was demonstrated effective in the multi-modality therapy of CHFmrEF and MF in patients with AH and dyslipidemia. ARNI was superior to olmesartan in this regard, but further research of this issue is required.

[Ability to Overcome the Thrombocyte Resistance to Acetylsalicylic Acid in Patients With Coronary Artery Disease After Myocardial Revascularization With Coronary Stenting].

Resistance to acetylsalicylic acid (ASA) in patients with coronary artery disease is a poor predictor for the development of atherothrombotic complications. In 277 patients with coronary artery disease suffered uncomplicated coronary angioplasty with stent implantation, we was estimated arachidon-induced platelet aggregation during treatment with acetylsalicylic acid by bedside VerifyNow Assay test at 28-90 days after the intervention. It was found that 18.9% of the 144 patients receiving a combination of ASA 75 mg with 15.2 mg of magnesium hydroxide had true (laboratory) resistance to ASA. At the same time on the original enteric coated ASA 100 mg, we can found only 0.8% resistance to ASA among 129 patients. We made switch from combination of ASA 75 mg with 15.2 mg of magnesium hydroxide to original enteric coated ASA 100 mg and repeat VerifyNow Assay test at 2-4 days and found lost of resistance in 92% of 28 patients. Thus, resistance to the ASA is not constant, it depends on the form and the applied dose of ASA, and eliminating more than 92% when ASA changes from ineffective to effective form.

[Prediction of severe cardiac complications with the help of myocardial perfusion scintigraphy in patients with residual chronic total occlusion after percutaneous coronary interventions].

Aim of the study was assessment of prognostic value of exercise myocardial perfusion scintigraphy in patients with stable and unstable angina in whom revascularization by percutaneous coronary intervention (PCI) was incomplete and at least one chronic total coronary artery occlusion (CTO) remained after PCI. Between March 2002 and December 2007 569 consecutive patients with multivessel lesions were subjected to SPECT imaging of myocardial perfusion after incomplete revascularization of the myocardium by PCI. At least 1 residual CTO was found in 129 patients (79% men, mean age 64+/-8 years). Primary outcomes were defined as cardiac death or myocardial infarction. Secondary outcomes were registered in 10 (7.9%) and 15 (11.9%) patients, respectively, with moderate and large transitory disturbances of perfusion. Logarithimic range criterion was statistically significant in patients distributed to groups by total estimation of rest in relation to cardiac complications. Univariate and multivariate Cox proportional hazards regression analysis gave additional important information for prediction of severe and nonsignificant cardiac complications when scintigraphic data were added to angiographic and clinical data, left ventricular ejection fraction, and results of treadmill test. Early monitoring with the use of myocardial scintigraphy by SPECT method is associated with increasing prognostic value relative to severe cardiac complications in patients subjected to incomplete revascularization by PCI, and having at least one residual chronic total occlusion.

[Comparative assessment of risk factors and hospital results in male and female patients underwent to coronary artery bypass surgery].

There are controversial data on relatively unfavorable effect of female gender on postoperative mortality of patients underwent to coronary artery bypass grafting (CABG). In order to assess risk factors and hospital outcomes after elective CABG we studied retrospectively data on patients who had undergone CABG in Sani Konuogly medical center (Gasiatep, Turkey) during the period from March 2002 to March 2010. For elimination of unfavorable effect of old age we included into analysis data from patients younger than 65 years. In accordance with study aim all patients (n=2692) were divided into two gender groups 1966 men (mean age 54,01 years) and 726 women (mean age 54.35 years). Diabetes (48.3 and 26.9%; p=0.0001), arterial hypertension (76.6 and 28.4%; p=0.00001), and obesity (50 42%; p=0.03) were more frequent among women while smoking (44.5 and 10.3%; p=0.0001), hyperlipidemia (37.6 and 21.5%; p=0.0002), and history of myocardial infarction (31.3 and 17.3%; p=0.06) were more often registered among men. Mortality was insignificantly higher in women (1.6 and 0.9%; p=0.06). Perioperative Q-wave myocardial infarction was more frequent among men than among women (1.5 and 0.4% respectively; p=0.04). It is necessary to conduct prospective well controlled study for exclusion of gender influences on perioperative outcomes in patients subjected to CABG .

[Clinical and angiographical factors influencing improvement of left ventricular function after implantation of dare-metal stents in patients with chronic total occlusions of coronary arteries].

INTRODUCTION: Effect on left ventricular (LV) contractility of percutaneous coronary interventions (PCI) with implantation of bare-metal stents in patients with chronic total occlusions (CTO) of coronary arteries (CA) has not been completely studied. Aim of this study was to assess effect of PCI with implantation of bare-metal stents ("L+", Relisys, U) on LV ejection fraction (EF) and to investigate clinical and angiographical factors capable to affect restoration of LVEF. MATERIAL AND METHODS: We included in this study 154 patients after successful implantation of bare-metal stents in CTO of main epicardial CA. For assessment of LV function we performed echocardiographical examination before and in 6 months after PCI. RESULTS: Significant increase of LV EF (from 50.4 +/- 10.7 to 56.1+/-11.3%, p<0.0001), decreases of LV end diastolic (from 86.2+/-17.9 to 80,8+/-18,1 ml/m2, p<0.001) and end systolic (from 41.4+/-14.9 t 34.7+/-13.8 ml/m2 (p<0,001) volumes took place after implantation of stents. Multivariate analysis showed that initial LVEF <50%, duration of occlusion <2 months and absence of diabetes mellitus were independent predictors of improvement of LVEF. CONCLUSION: Implantation of bare-metal stents in patients with CTO CA affects positively LVEF during first 6 months after PCI especially in patients with lowered LVEF, in patients without diabetes mellitus, and duration of occlusion less or equal 2 months.

[Inhospital and 12-months results of percutaneous coronary interventions with implantation of Paclitaxel eluting stents in patients with long de novo coronary artery lesions].

We implanted 59 paclitaxel eluting Apollo stents to 48 patients with ischemic heart disease (IHD) and long de novo coronary artery lesions in 2007 with 100% immediate success rate without inhospital major cardiac complications. One patient developed hematoma at femoral artery puncture site. There were no cases of restenosis among 18 patients subjected to control angiography after 6 months. One patient had acute myocardial infarction in area supplied by nontarget artery. Control angiography after 12 months was carried out in 81.3% of patients while 14.6% of patients who refused angiography were examined with stress tests. Restenosis of stented segments was found in 3 (5.3%) patients, diameter loss was 0.32+/-0.45 mm. All these patients were subjected to repeat PCI. During follow up myocardial infarctions were registered in 4.2% of patients, overall rate of serious cardiac complications was 11.6%. PCI with implantation of paclitaxel was safe and effective with acceptable rate of major cardiac complications. Our results evidence in favor of further use of these stents.

[Thienopyridines in the treatment and prevention of cardiovascular diseases. Part V. Combination of clopidogrel and acetylsalicylic acid in the treatment of stable patients with atherothrombotic cardiovascular diseases].

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 fifth communication we consider data of two randomized studies in which efficacy and safety of clopidogrel in combination with acetylsalicylic acid (ASA) has been assessed in comparison with ASA in stable patients with atherothrombotic cardiovascular disease. It has been shown in both studies that in stable patients with atherothrombotic cardiovascular disease long-term therapy with combination of clopidogrel and ASA was no more effective than monotherapy with ASA or clopidogrel but was associated with high risk of hemorrhagic complications. Thus contrary to acute coronary syndromes and percutaneous interventions with stenting combinations of clopidogrel and ASA is not indicated to patients with stable course cardiovascular diseases.

[Stenting of unprotected left main coronary artery: complications during 3 years follow up].

Aim of investigation was to study complications during 3 years follow up of patients after implantation of standard metal stents (SMS) in unprotected left main coronary artery (LMCA). Patients with high risk of surgery (n=124) with stenting of unprotected LMCA performed between August 2002 and November 2004 were included in this investigation. Study end points were death, myocardial infarction, repeat vessel revascularization. Success of intervention was achieved in 96.7% of cases. Mean duration of follow up was 38.1 +/- 1.8 months. Death due to cardiac causes was registered in 6.5% of cases, 3 of these deaths were sudden. Noncardiac mortality was 3.2% (4 patients died). Peripheral complications were noted in 1 case: in one patient pseudoaneurism of femoral artery developed and was successfully resolved by compression under ultrasound control. Restenosis in stented segment during follow up was noted in 25 patients (20.2%). Repeat percutaneous coronary intervention (PCI) was carried out in 18 patients. In other cases patients were referred to coronary bypass surgery. Total survival of patients in the investigation was 95.2, 91.9, 90.3% in 1, 2, an 3 years, respectively. Despite high success of PCI of unprotected LMCA with the use of SMS and relatively low percent of restenosis it is necessary to use this method carefully in the treatment of patients with lesions in unprotected LMCA. We consider PCI in unprotected LMCA justified only in patients with high risk of surgical intervention who are not suitable candidates for coronary bypass surgery.

[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.

[Restenosis after bare-metal stents implantation in small coronary arteries.].

Potential of bare uncoated metal stents in prevention of restenosis in coronary arteries with diameter of 2.2-3.0 mm in comparison with balloon angioplasty (BA) was studied in 426 patients with ischemic heart disease (mean age 58+/-11 years, 16% women, 8% with diabetes, total cholesterol 211+/-44 mg/dl, all received aspirin and clopidogrel). BA was carried out in 214 patients (mean artery diameter 2.45+/-0.25 mm) and coronary stenting (CS) - in 212 patients (mean artery diameter 2.43+/-0.27 mm). Immediate success rate was 85.5 and 96.2% in BA and CS groups, respectively (p<0.001). When complementary methods of revascularization were taken into account success rate of the whole intervention was 100% in both groups. Inhospital cardiovascular complications developed in 3.7 and 2.8% of patients in BA and CS groups, respectively (p=ns). During 6 months of follow-up rates of target vessel restenosis and repeat percutaneous interventions were 24.3 and 15.6% (p=0.034) while total rate of complications related to target vessel was 36.9 and 26.9% in BA and CS groups, respectively (p=0.035). Thus CS compared with BA in patients with low risk of restenosis development in small coronary arteria provides better immediate, inhospital and remote results.

[Two-year results after implantation of a metallic stent EPHESOS in patients with coronary heart disease].

AIM: To evaluate two-year results of using a metallic stent EPHESOS in patients with native atherosclerotic lesion of coronary arteries (without prior interventions). MATERIAL AND METHODS: The stent was implanted to 731 patients. 53% had manifestations of unstable angina. 42% of the lesions were complicated. The length of the stenosis was 15.5 +/- 6.8 mm, 44% stenoses were long. RESULTS: The success of stenting was 99.6%. Cases of acute and subacute thrombosis were absent. Non-Q wave myocardial infarction in primary hospitalization developed in 4 patients. For 6 months, cardiovascular complications (death, angina, restenosis, repeated revascularization) occurred in 21%. Angiographic control follow-up of 6 months maximum covered 329 (45%) patients. Hemodynamically significant restenosis was detected in 18% patients. Cardiovascular complications for 24 months occurred in 39%. CONCLUSION: The EPHESOS stent has demonstrated a stable long-term effect on prevention of thrombosis and restenosis in the majority of patients with a relatively high risk of intervention.

[Predictive role of exercise tests in development of restenosis in patients after coronary stent implantation].

Bicycle exercise tests were carried out in 2 weeks -- 9 months after successful stent implantation in 1463 patients. Result of exercise test was positive in 472 and negative -- in 991 patients. At control angiography which was performed within 1 week after exercise test binary in-stent restenosis >50% was found in 326 of 1463 patients. Sensitivity, specificity, predictive value of positive and negative results of exercise test for the presence of restenosis were 85, 83, 59 and 5%, respectively.

[Long-term results of the use of TAIS coronary stent. Data of prospective follow-up for 18 months].

The stent was placed in 528 coronary artery segments (39% complicated lesions) in 448 patients with coronary artery disease and no previous invasive interventions. Immediate angiographic success was 99.8% with no case of acute thrombosis. Six months survival without restenosis, angina, and reintervention was 83%. Repeat angiography was carried out in 432 patients with 502 stented stenoses. Index of vessel diameter loss and level of restenosis were 0.32+/-0.26, and 15,6%, respectively. Fifty four patients with in-stent restenosis were subjected to successful repeat revascularization. Eighteen months survival without myocardial infarction and reintervention was 70%. The study demonstrated favorable effect of TAIS on 18 month rate of thrombosis and restenosis in patients with native atherosclerotic lesions.

[Efficacy and safety of coronary stenting during diagnostic coronary angiography in patients with stable angina].

UNLABELLED: The authors assessed the in-hospital and long-term (up to 6 months) results of coronary stenting conducted just after diagnostic coronarography during a common procedure in patients with stable angina pectoris on effort. The 2001-2002 study included 2277 patients. The clinical indications for catheterization were Functional Classes II-IV stable angina on effort in 83 % of patients and silent ischemia in 17%. The study excluded patients with previous coronarography, acute coronary syndrome on admission, renal failure, left ventricular ejection fraction <30%, and left trunk stenosis. All the patients received aspirin and clopidogrel before catheterization. RESULTS: 57% of patients had multivessel disease; full revascularization was performed in 59% of the patients with multivessel disease. The coronary intervention was successful in 100% of cases. Significant in-hospital events (myocardial infarction without Q wave) were in 1.2% of cases. The mean length of hospital stay was 2.9 +/- 2.4 days. The rate of stent thrombosis for as long as 30 days was 0.2%. Recurrent angina and/or positive exercise tests were in 12% during 6 months. CONCLUSION: immediate stening is effective and safe in most patients with stable angina during diagnostic catheterization. It does not increase immediate and late complications.

[Achievements of invasive cardiology 2003. Part I.]. / Dostizheniia invazivnoi kardiologii. 2003 g. Chast' I.

The authors present a review of research works completed or conducted in 2003 which according to their opinion contributed most to the rapidly progressing field of invasive/interventional cardiology. The year passed was characterized by wide introduction into clinical practice of stents coated with antirestenotic agents, substantial advances in pharmacological support and improvements of safety of coronary interventions, active studies of contrast induced nephropathy and assessment of novel devices for myocardial protection against distal embolism during interventions both on coronary arteries and vein grafts. Recent results of comparisons of mechanical and pharmacological myocardial reperfusion in acute ST-elevation myocardial infarction can be considered revolutionary for clinical cardiology. Part I of the review deals with invasive treatment of acute coronary syndrome and pharmacological support of coronary interventions.

[Prognosis of unstable angina resulting from restenosis after percutaneous angioplasty of saphenous vein grafts]. / Prognozirovanie nestabil'noi stenokardii vsledstvie restenoza posle chreskozhnoi angioplastiki venoznykh shuntov.

AIM: To assess frequency of unstable angina due to restenosis after percutaneous angioplasty of venous grafts and to elucidate risk factors of its development. MATERIAL AND METHODS: Percutaneous interventions were successfully performed in 100 out of 106 patients with venous graft stenoses. These patients were followed up for 17+/-11 (maximum 36) months. RESULTS: Unstable angina due to venous graft restenosis developed in 24% of patients. Patients with unstable angina compared with those without were characterized by higher frequency of hyperlipidemia (83 vs. 51%, respectively, p=0.032), lower rate of stenting (46 and 72%, respectively, p=0.032), greater residual stenosis (15+/-13 and 9+/-8%, respectively, p=0.008). At multifactorial regression analysis the following factors were significant predictors of unstable angina: hyperlipidemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.64-8.39), and residual stenosis after intervention (OR 1.04, 95% CI 1.01-1.07, p=0.04). In a subgroup of patients with hyperlipidemia there was a tendency to greater rate of unstable angina among patients not taking statins compared with users of statin (50 and 29%, respectively, p=0.083). CONCLUSION: Unstable angina developed in (1/4) of patients after balloon dilatation of venous grafts and hyperlipidemia was its most powerful predictor.

[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.

[Achievements of Invasive Cardiology 2003. Part II.]. / Dostizheniia invazivnoi kardiologii. 2003 g. Chast' II.

The authors present a review of research works completed or conducted in 2003 which according to their opinion contributed most to the rapidly progressing field of invasive/interventional cardiology. The year passed was characterized by wide introduction into clinical practice of stents coated with antirestenotic agents, substantial advances in pharmacological support and improvements of safety of coronary interventions, active studies of contrast induced nephropathy and assessment of novel devices for myocardial protection against distal embolism during interventions both on coronary arteries and vein grafts. Recent results of comparisons of mechanical and pharmacological myocardial reperfusion in acute ST-elevation myocardial infarction can be considered revolutionary for clinical cardiology. Part I of the review deals with invasive treatment of acute coronary syndrome and pharmacological support of coronary interventions.

[Effectiveness of excimer laser coronary angioplasty in treatment of patients with in-stent restenosis]. / Effektivnost' éksimernoi lazernoi koronarnoi angioplastiki v lechenii bol'nykh s restenozom posle koronarnogo stentirovaniia.

In-stent restenosis (ISR), when treated with balloon angioplasty (PTCA) alone, has an angiographic recurrence rate of 30-85%. Ablating the hypertrophic neointimal tissue prior to PTCA is an attractive alternative, however late outcomes of such treatment have not been fully determined. This multicenter case control study assessed angiographic and clinical outcomes of 137 consecutive procedures in 125 patients treated for ISR with either PTCA alone (n = 58) or excimer laser assisted coronary angioplasty (ELCA, n = 67). Demographics were similar. Lesions selected for ELCA compared with those selected for \PTCA were longer (17.1+/-9.9 mm vs. 13.6+/-9.1 mm; p=0,034), more complex (ACC/AHA type C: 36,5% vs. 14,3%; p=0,006), and with reduced antegrade flow (TIMI flow < 3: 18,9% vs. 4,8%; p = 0,025). ELCA- and PTCA treated patients had similar rates of procedural success (98,5 and 98,3%, respectively, p=1,0), major clinical complications (3,0% and 8,6%; respectively, NS), major cardiac events at 1 year (37,3 and 46,6%. respectively, NS), and target lesion revascularization (32,8 and. 34,5%; respectively, NS). These data suggest that ELCA in patients with complex in-stent restenosis is as safe and effective as PTCA. Despite higher lesion complexity in ELCA-treated patients, no increase in event rates was observed.