New ECG criteria for differential diagnosis of wide QRS complex tachycardias with right bundle branch block pattern.

AIM: To evaluate standard 12-lead ECG indices for the differential diagnosis of wide QRS tachycardias with right bundle branch block (RBBB) pattern. MATERIALS AND METHODS: Study analyses the 244 ECG indices in 111 patients (79 males and 32 females, age 53±17 years) with RBBB tachycardias, who underwent electrophysiological studies. First step includes retrospective analysis of QRS characteristics in 20 patients with ventricular tachycardias (VT), 24 pts with aberrant supraventricular tachycardias (SVT+RBBB) and 14 pts with antidromic SVTs (WPW). ROC- and multifactorial analyses were performed to develop diagnostic ECG algorithms. The prognostic accuracy of the algorithms was subsequently evaluated on a prospective group of patients with RBBB tachycardias (n=53). RESULTS: ECG criteria of RBBB VTs were: 1) the presence Q-wave in lead II, 2) the duration interval R(peak)-S(end) >100 ms in lead V5. ECG criteria for antidromic SVTs with RBBB were: 1) the duration of the R wave in lead I ≥80 ms, 2) the absence of split (M-sharp) R-waves in lead V2, 3) the absence notch in ascending S wave in lead aVL. The accuracy of the algorhythm for diagnostic of VTs with RBBB was 83% (sensitivity 100%, specificity 73%). The accuracy of the algorhythm for diagnostic of antidromic SVTs with RBBB was 91% (sensitivity 85%, specificity 96%). CONCLUSION: The proposed algorithms are based on new ECG criteria for the differential diagnosis of wide QRS complexes tachycardias with RBBB pattern, unlike the previous algorithms.

Role of electrocardiographic and echocardiographic types of left bundle branch block in prediction of response to cardiac resynchronization therapy.

AIM: To assess the value of the complex analysis of electrocardiographic (ECG) variants and echocardiographic (echo) manifestation of left bundle branch block (LBBB) in predicting the success of cardiac resynchronization therapy (CRT). MATERIALS AND METHODS: The study included 39 patients (mean age 61.49±9.0 years) on sinus rhythm with LBBB, QRS duration ≥130 ms, left ventricular ejection fraction (LVEF) ≤35%, heart failure (HF) NYHA II-IV despite optimal pharmacological therapy during 3 month. All patients had undergone CRT-D implantation. Depending on presence or absence of ECG-criteria, proposed by D.G. Strauss et al., patients were divided into 2 groups: 1 group - strict LBBB, proposed by D.G. Strauss et al. (n=29) and 2 group - other patients (n=10). In addition to standard echocardiography, global longitudinal 2-dimensional strain (GLS) and LBBB contraction pattern have been performed initially and in 6 months after implantation. Response to CRT was defined as decrease in LV end-systolic volume by >15% after 6 months of follow-up. RESULTS: Typical LBBB echo contraction pattern was detected in 25 patients (64% of all included). These patients had more pronounced longitudinal dissynchrony and a more expressed global longitudinal strain before CPT-D implantation (p<0.05). 27 patients (69% of all included) were included in the "response" group, the remaining 12 patients (31% of all included) - the "non-response" group. In the "response" group the morphology of the QRS complex was significantly more likely to meet the criteria, proposed by D.G. Strauss et al., than other variants (23 vs. 6, respectively, p=0.02), and the echo contraction pattern of this patients more often corresponded to "typical" LBBB (24 vs. 1, p=0.001). All patients, who had the ECG criteria, proposed by D.G. Strauss et al., and echo "typical" LBBB contraction pattern, responded on CPT. Moreover, the proportion of these patients in the "response" group was rather high - 81.5% (22 of 27 patients). CONCLUSION: ECG criteria LBBB, proposed by D.G. Strauss et al., identify patients with delayed transseptal interventricular conduction due to complete LBBB, what is a good target for CPT. Evaluation of the echo contraction pattern based on the definition of longitudinal myocardial deformation by means of a two-dimensional strand technology allows predicting the success of CPT in patients with LBBB. Patients with «typical¼ LBBB contraction pattern show more pronounced global longitudinal strain and larger longitudinal dissynchrony compared with other patients, and it explains their better response to CPT. Complex analysis of strict LBBB ECG criteria and echo contraction pattern are promising parameters in predicting beneficial response to CRT in patients with HF.

[Cardiac resynchronization therapy in patients with permanent atrial fibrillation].

UNLABELLED: In our study we compared effect of cardiac resynchronization therapy (CRT) in chronic heart failure (CHF) patients with permanent atrial fibrillation (AF) and patients with sinus rhythm. Special feature of our work was that patients with permanent atrial fibrillation didnt have obligatory ablation of atrio-ventricular node but underwent aggressive rate control to achieve more than 90% of biventricular (BV) complexes. We used 24 hours Holter monitoring because there are data that this method is more accurate than CRT counters. METHODS: We included 30 patients: 21 patients with sinus rhythm and 9 patients with permanent AF with ejection fraction <35%, II-IV NYHA class and wide QRS (>120 ms). We examined patients before implantation of CRT and after 6 months. RESULTS: mean NYHA class decreased from III to II. Distance at 6-min walk test increased by 107 m in AF group and by 105 in sinus rhythm group. EF increased by 7% in AF group and by 6% in sinus rhythm group. Mean time of further observation was 2 years (from 10 months to 5 years). There was 1 death (11.1%) in AF group and 3 deaths (15%) in sinus rhythm group (p>0,05). CONCLUSION: CRT is effective in CHF patients with permanent AF and pharmacological rate control if percent of BV pacing is more than 90% on Holter monitoring.

[Changes of parameters of hemodynamics and systems of neurohumoral regulation in patients with implanted cardiac pacemakers after switching from DDD to VVI pacing mode].

To study complex of pathogenetic changes arising during VVI mode single chamber ventricular pacing we temporarily (for 1 hour) switched pacing mode from dual (DDD) to single (VVI) chamber stimulation in 11 patients. Parameters studied were cardiac output (CO), total peripheral vascular resistance (TPVR), levels of precursors of atrial and inactive fragment of brain natriuretic peptides (pro-ANP and NT-pro-BNP, respectively), noradrenaline, aldosterone, and renin activity in blood plasma. Reprogramming of pacing mode was associated with 21.4% lowering of CO and 11.4% elevation of TPVR according to impedance cardiography data, and augmentation of pro-ANP secretion from 429.79 to 620.22 fmol/l. At the background of VVI pacing there was a tendency to increase of noradrenaline blood concentration without significant changes of aldosterone concentration and plasma renin activity.

[Stroke and other thromboembolic complications of atrial fibrillation. Part VII. Prevention of cardioversion related thromboembolism].

In part VII of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors analyze data on frequency and contemporary approaches to prevention of thromboembolic complications related to cardioversion. The stress is made on importance of prescription of indirect anticoagulants to all patients with duration of atrial fibrillation exceeding 48 hours. International normalized ratio should be controlled during anticoagulant therapy and be kept between 2.0 and 3.0 at least for 3-4 weeks before and after restoration of sinus rhythm. Absence of atrial thrombi at transesophageal echocardiography does not exclude possibility of thromboembolic complications of cardioversion conducted without anticoagulant therapy.

[Atrial fibrillation: choice of the method of pharmacological cardioversion].

The paper considers circumstances under which it is expedient or not expedient to perform cardioversion in patients with paroxysmal or persistent atrial fibrillation. It contains discussion of benefits, limitations and drawbacks of electrical and pharmacological methods of cardioversion. American College of Cardiology/American Heart Association/European Society of Cardiology Guidelines for the Management of Patients With Atrial Fibrillation are presented. These guidelines suggest amiodarone, dofetilide, ibutilide, propafenone, flecainide, and quinidine as first line therapy because of their proven efficacy. Efficacy of intravenous disopyramide and procainamide in some patients with recent onset atrial fibrillation is recognized with certain reservations. The use of azimilide and dronedarone is considered promising. In Russia nibentan and ethacizine can be also used. Special emphasis is made on the possibility of wide use (including self-administration) of loading doses of oral propafenone for cardioversion in some categories of patients with atrial fibrillation of recent onset.

[Stroke and other thromboembolic complications of atrial fibrillation. Part VI. Choice of optimal approach and drugs for prevention of stroke].

In part VI of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors analyze data of randomized trials comparing various approaches to the treatment of atrial fibrillation: cardioversion with subsequent use of antiarrhythmic drugs for maintenance of sinus rhythm and control of rate of ventricular rhythm with obligatory concomitant use of anticoagulants. Approach aimed at sinus rhythm maintenance by means of repetitive cardioversions and long term antiarrhythmic therapy has not been associated with lowering of mortality, rates of stroke or other thromboembolic complications. The use of antithrombotic drugs represent a sole reliable method of stroke prevention in patients with persistent and chronic AF. The paper contains consideration of indications for prescription of warfarin and aspirin to these patients.

[Stroke and Other Thromboembolic Complications of Atrial Fibrillation. Part III. Prevention With Other Antithrombotic Agents.]. / Insul't i drugie tromboémbolicheskie oslozhneniia pri mertsanii predserdii. Chast' IV. Profilaktika s pomoshch'iu drugikh antitromboticheskikh sredstv1.

In part IV of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors present data on clinical pharmacology of low molecular weight heparins, ximelagatran, indobufen, triflusal, dipyridamole, ticlopidine, and clopidogrel. Efficacy of direct thrombin inhibitor ximelagatran was found in randomized trials to be similar to efficacy of warfarin however the use of ximelagatran required no laboratory control of coagulation parameters. Preventive efficacy of indobufen, triflusal, dipyridamole, ticlopidine, and clopidogrel was assessed in trials on patients with cardiovascular diseases substantial number of whom had atrial fibrillation. Data of retrospective analysis of these trials are scrutinized in this review.

[Stroke and other tromboembolic complications in atrial fibrillation. Part I. Prevalence and risk factors]. / Insul't i drugie tromboémbolicheckie oslozhneniia pri mertsanii predserdii.Chast' I. Rasprostranennost' i faktory riska.

In a series of papers the authors discuss problems of epidemiology and drug prevention of stroke and other thromboembolic complications in patients with atrial fibrillation. Part I contains data on frequency of strokes in different categories of patients as well as review of main risk factors and mechanisms of development of stroke and other systemic embolic complications in various types of atrial fibrillation. Application of transthoracic and transesophageal echocardiography for assessment of risk of stroke and other systemic emboli is also discussed.

[Stroke and Other Thromboembolic Complications of Atrial Fibrillation. Part III. Prevention With Aspirin]. / Insul't i drugie tromboémbolicheskie oslozhneniia pri mertsanii predserdii. Chast' III. Profilaktika s pomoshch'iu aspirina.

In part III of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors present data on clinical pharmacology of aspirin as well as discussion of results of randomized trials in which cerebroprotective efficacy and safety of the use of aspirin for primary and secondary prevention of thromboembolism was studied in comparison with placebo and warfarin. According to cumulative data of 6 randomized studies average stroke risk lowering caused by aspirin was 22%. In primary prevention of stroke aspirin did not increase substantially frequency of serious bleedings. However in secondary prevention trials its use was associated with significant increase of serious bleeding rates. Thus in patients with atrial fibrillation aspirin compared with warfarin less effectively prevents stroke but causes fewer serious bleedings.

[Stroke and Other Thromboembolic Complications of Atrial Fibrillation. Part II. Prevention With Warfarin]. / Insul't i drugie tromboémbolicheskie oslozhneniia pri mertsanii predserdii. Chast' II. Profilaktika s pomoshch'iu varfarina.

In part II of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors present data on clinical pharmacology of oral anticoagulants as well as discussion of results of randomized studies demonstrating high efficacy of warfarin in primary and secondary prevention of thromboembolism. According to cumulative data of 7 randomized trials average stroke risk lowering in patients with atrial fibrillation associated with the use of warfarin is 62%. Total bleeding rates during treatment with oral anticoagulants fluctuate between 5 and 10%; about half of these bleedings are serious.

[Stroke and other thromboembolic complications of atrial fibrillation. Part v. The use of drugs without antithrombotic or antiarrhythmic properties.]. / Insul't i drugie tromboémbolicheskie oslozhneniia pri mertsanii predserdii. Chast' V. Ispol'zovanie lekarstvennykh sredstv bez antitromboticheskikh i antiaritmicheskikh svoistv.

In part V of a series of papers on epidemiology and drug prevention of stroke and other thromboembolic complications of atrial fibrillation the authors analyze data of randomized trials exhibiting ability of long term use of beta-adrenoblockers, angiotensin converting enzyme inhibitors, angiotensin receptor antagonists and statins to prevent atrial fibrillation. They also discuss results of short term studies demonstrating improved efficacy of electrical and pharmacological cardioversion in patients with atrial fibrillation after pretreatment with verapamil, beta-adrenoblockers, and angiotensin receptor antagonists, and present data indicating that monotherapy with verapamil, beta-adrenoblockers, angiotensin receptor antagonists and statins can facilitate maintenance of sinus rhythm after cardioversion in patients with persistent atrial fibrillation.

[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.

[Calcium metabolism of the thrombocytes in ischemic heart disease]. / Sostoianie kal'tsievogo obmena v trombotsitakh pri ishemicheskoi bolezni serdtsa.

Changes in Ca++ concentration were studied in platelets of patients with acute myocardial infarction, unstable or stable angina pectoris and those of healthy donors by means of fluorescent probe Quin-2 AM. Influence of aggregation inductors on the process of Ca++ level increase in these cells was also investigated. Intracellular Ca++ concentration increased in patients with acute myocardial infarction in the presence of PAF 2.10(-7) M (1337 +/- 255 nM) and in the presence of ADP 10(-5) M (1767 +/- 296 nM). A certain increase in calcium responses to stimulators was observed also in patients with unstable or stable angina pectoris. Dynamic follow up of patients with acute myocardial infarction starting from the 14th day demonstrated significant fall in intracellular Ca++ concentration (from 1767 +/- 296 nM to 834 +/- 186 nM, p less than 0.01). Platelet sensitivity to inductors during the course of therapy did not change significantly in patients with stable angina pectoris and tended to decrease in those with unstable angina pectoris (from 707 +/- 274 nM to 410 +/- 95 nM, p greater than 0.05). Increase in platelet aggregability and in calcium responses to stimulators in patients with IHD is an evidence of calcium metabolism disturbances which play an important role in the pathogenesis of the disease.