[Has the era of warfarin terminated?].

Warfarin has for a long time been considered the "gold standard" of oral anticoagulant therapy. Positive effects of this agent are unambiguously supported by accumulated evidence-based data convincingly confirming a decrease in the risk for thrombolytic complications in patients with many diseases of the cardiovascular system: atrial fibrillation, thrombosis of deep veins of extremities, pulmonary artery thromboembolism. However, warfarin has a series of disadvantages complicating its practical application: the necessity of individual adjustment of the dose to maintain the International Normalized Ratio (INR) within the limits of the target values, clinically significant interactions with other drugs and foodstuffs. In this connection, the advent of new oral anticoagulants such as dabigatran, rivaroxaban, and apixaban is associated with great hopes concerning increased efficiency and safety of anticoagulant therapy. However, while the results of large-scale clinical trials are promising, the data on using these agents in real clinical practice suggest that prescription and administration of new oral anticoagulants should be approached with great caution, thoroughly weighing potential risks and benefits. Therefore, switching over the patients with the already adjusted dosage of warfarin and stable values of the INR to new drugs seems hardly advisable.

[The prevalence of anxiety and depression in different regions of the Russian Federation and its association with sociodemographic factors (according to the data of the ESSE-RF study)].

AIM: To study the prevalence of anxiety and depression by psychometric methods (the Hospital Anxiety and Depression Scale (HADS) in different regions of the Russian Federation (RF), which are characterized by various climatic, geographic, economic, and demographic indicators. SUBJECTS AND METHODS: The investigation used the data of the multicenter epidemiological survey of cardiovascular diseases in different regions of the Russian Federation--the ESSE-RF study. The subjects of the study were representative samples from unorganized male and female populations aged 25-64 years from 10 RF regions. The survey included a total 16,877 people (6244 men and 10,623 women). All the examinees were interviewed using a standard questionnaire. An analysis involved their gender, age, education level, place and region of residence, and income and morbidity level. The HADS validated in Russia was used to rate the level of anxiety/depression. RESULTS: The total prevalence of higher anxiety and depression averaged 46.3 and 25.6%, respectively. Respondents with clinical anxiety/depression constituted more than one third of those who had a higher level of these conditions. In the examined population, the moderate level of anxiety/depression was 7.5 ± 0.06 and 5.1 ± 0.04, respectively. The population of Volgograd, Samara, Saint Petersburg, and Tomsk had the similar values of the moderate level of anxiety/depression (p > 0.05). The lowest level of anxiety/ depression (p < 0.0001) was seen in the dwellers of Tyumen (5.9 ± 0.1 and 3.4 ± 0.1, respectively) and the highest in the Republic of North Ossetia-Alania (NOA) (8.4 ± 0.1 and 6.8 ± 0.1, respectively). These regions showed the lowest and highest prevalence of higher anxiety (22% in Tyumen and 59.8% in the Republic of NOA (p < 0.0001). CONCLUSION: All the 10 selected RF regions differing in demographic, economic, climatic, and geographical parameters are characterized by a high level of anxiety that remains statistically significant after adjusting for gender and age, so are parameters, such as income and morbidity levels are present in only 4 of the 10 regions.

[Prognostic value of left bundle brunch block in patients with acute coronary syndrome].

AIM: to assess rognostic value of ECG signs of left bundle brunch block (LBBB) using database of registries of acute coronary syndromes (ACS) RECORD 1 (2007-2008) and 2 (2009-2011). MATERIAL AND METHODS: Total number of included patients was 2452, 2321 patients (94.9%) had no signs of LBBB, for 5 patients (0.2%) there was no information on the presence of LBBB. Among 126 patients (5.1%) with LBBB it was designated as "new" in 72 (2.9%), "old" in 39 (1.6%), and of "unknown duration" in 15 (0.6%) patients. For further analysis we combined patients with "new" and "unknown duration" LBBB (n=87 [3.5%]). Among these patients 43 (49.5%) were considered as having ST elevation (STE) and 44 (50/5%) - non STE ACS. RESULTS: Patients with LBBB were significantly older, had more concomitant diseases, more severe course of ACS, and higher GRACE score. Patients with new LBBB irrespective of ACS type significantly less often received active drug therapy while reperfusion therapy was significantly less often used in patients with LBBB and diagnosed STE myocardial infarction. Unfavorable events such as cardiogenic shock, death, death and myocardial infarction during hospitalization occurred more often among patients with STEACS and new LBBB. CONCLUSION: Patients with ECG signs of LBBB at the background of ACS were characterized by severe clinical course of the disease and have unfavorable short term prognosis. However quality of hospital care of these patients was significantly worse compared with average quality of care of patients with ACS without LBBB.

[The rational approach to the estimation of the myocardial infarction size].

The paper contains review of published data on various methods of quantitative assessment of myocardial infarction (MI) with demonstration of their advantages and drawbacks. Comparative analysis of applicability of existing biochemical markers of necrosis for measurement of the volume of myocardial damage is also presented. Troponin I level measured in 72 hours after onset of chest pain appears to be the most reliable predictor of MI size but its use is justified only in patients with restored perfusion. Troponin T level measured in 72 hours after onset of acute coronary syndrome also correlates closely with MI size but does not depend on the character of reperfusion. Estimation of MI size based on blood concentration of troponins is more precise than methods based on levels of creatine phosphokinase and its MB fraction.

[Long-term results of radiofrequency catheter ablation of long-lasting persistent atrial fibrillation: five years of follow-up].

AIM: To evaluate long-term results of radiofrequency catheter ablation (RFA) vs. rate-control strategy in patients with long-lasting persistent atrial fibrillation (AF) METHODS: We assessed 5-years results in 66 patients (53.3+/-12.3 years old, 8 women) with long-lasting persistent AF who underwent RFA (ablation group), as well as in age-gender-AF duration-matched patients who were treated with rate-control strategy (rate-control group).The ablation strategy consisted of wide-area circumferential lines around pulmonary veins, roof lines and extensive RFA of the left atrial substrate modification using a three-dimensional mapping system. Incidence of sinus rhythm (SR) maintenance, death, stroke, myocardial infarction (MI), worsening of heart failure (NYHA) were evaluated after 5 years of follow-up. RESULTS: After 5 years of follow up SR was present in 38 (56%) of 42 who were under follow up patients of ablation group and all patients had AF in rate-control group (95% CI 0.02247-0.3598; p=0.0001). Seventeen (27%) patients of ablation group continued to take atniarrhythmic drugs. 29 (44%) patients of ablation group vs. 48 (73%) patients of rate-control group received warfarin (95% CI 0.442-1.1; p=0.046) at five years of follow up. After five years of follow up the incidence of MI, stroke, worsening of heart failure functional class, and death in the ablation/rate-control groups were 0%/7.5% (95% CI 0.05247-0.30898; p=0,006), 0%/9% (95% CI 0.08903-0.32561; p=0.001), 6%/25% (95% CI 0.147-0.894; p=0.006), and 0.02%/0%, respectively. CONCLUSIONS: In patients with long-lasting persistent AF ablation strategy results in stable SR in the majority of patients, and decreased incidence of cardiovascular events compared with rate-control strategy during up to 5 years of follow-up.

[Vasovagal syncope or epilepsy: how to avoid errors in diagnosis].

Transitory loss of consciousness might have multiple mechanisms of development among which vasovagal syncope and epilepsy have the greatest significance. It is thought that in every forth patient the initial diagnosis is erroneous because of similarity of clinical picture and even well prepared specialists are not secured against mistakes. Aim of this review is to stress key points of diagnosis from the point of view of a cardiologist and epileptologist.

[Clinical features and history of vasovagal syncope].

Aim of this investigation was to study special characteristics of natural course of vasovagal syncope (VVS). During 3 years we examined 212 patients (44% men) in accordance with recommendations of European Society of Cardiology using tilt tests according to Westminster or Italian protocols for confirmation of vasovagal genesis. Depending on results of initial investigation patients were divided into 2 groups: group 1 comprised 144 patients (68%) satisfying criteria of VVS; group 2 comprised other patients (n=41, 19%) with transitory loss of consciousness of unclear origin. Patients with VVS were significantly younger (mean age 35.1+/-13.6 and 44.4+/-13.,9 years, respectively; <0.01) with earlier appearance of first episode of fainting (16 vs. 39 years; <0,01). In most cases VVS appeared in the age younger than 35 years. Accuracy of anamnestic method for diagnosis of VVS was 99%. Forty one percent of patients with classical VVS had several potential causes of fainting (situational syncope, paroxysms of tachyarrhythmia, epilepcy). This could lead to mistakes at initial stage of diagnostics. Progressive clinical course was observed in 15% of patients and was associated either with syncopi of other, including nonvagal origin, or with increased frequency of previously stereotypical attacks. In every second patient with initially frequent recurrences of VVS we observed long spontaneous remissions. Nondrug methods of treatment were effective in 43% of these patients. Tilt test had high informative power for diagnostics of VVS. With this its informativity was low in patients with onset of fainting attacks in middle age and with atypical clinical picture.

[Assessment of vasovagal origin of syncope based on history features].

Study aim was to elaborate questionnaire for diagnostics of vasovagal syncope (VVS) based on data of anamnesis. We examined 182 patients (mean age 37.1+/-14.3 years, 78 men, 104 women). Initial examination included anamnesis, physical examination, electrocardiography at rest, measurement of blood pressure in orthostasis. Each patient was asked 82 questions describing duration of symptoms, characteristics of episodes of loss of consciousness, symptoms of prodromal period before loss on consciousness and in the period of recovery. As a standard method of VVS diagnostics of we used tilt test (TT) according to Westminster or Italian protocols. Using methods of statistical analysis we created questionnaire for diagnostics of VVS. Tilt-positive group comprised 108 patients (age 35.9+/-14.6 years, 45% men), tilt-negative group comprised 74 patients (age 36.1+/-14.3 years, 39% men). Of 82 testing questions 8 had probability ratio (PR) >1 and were significant predictors (<0.05) of positive TT. Seven questions had <1 and were significant predictors (<0.05) of negative TT. These questions were included into logistical regression analysis. The final variant of the questionnaire comprises 15 vasovagal origin questions. Total score necessary for diagnosis of VVS is more or equal 1. Sensitivity of questionnaire for prediction of positive result of TT was 95%, specificity - 57%. This allows to using it as a screening test for selection of further method of investigation in patients with episodes of loss of consciousness.

[Heart rate variability in the prognosis of tilt-testing results].

Study aim was assessment of dynamics of spectral parameters of heart rate variability (HRV) during the Westminster and Italian protocols of tilt-test (TT). We included in this study 114 patients with recurrent vasovagal syncope (VVS). Basing on TT results we distinguished 4 groups of patients: with positive result of the Westminster protocol (WPTT) (group 1, n=30); with negative result of WPTT (group 2, n=23); with positive result of the Italian protocol (IPTT) (group 3, n=44); with negative result of IPTT (group 4, n=11). Control group comprised 14 healthy persons without history of syncope. Spectral parameters of HRV were analyzed in 3 five minutes intervals (before TT in horizontal position, during first and last 5 minutes of orthostasis). Structure of vasovagal responses was similar for all TT protocols used. In lying position in patients of groups 1-3 lower values of LF1 and LF1/HF1 were registered, as well as high values of HF1 compared with the control group and patients with negative results of IPTT. Initial stage of TT in patients with positive result of WPTT (group 1) was characterized by almost twofold increase of LF values (n.u.) and decrease of HF parameters (n.u.) compared with other patients. In the group 1 during the second period.

[Permanent cardiac pacing in vasovagal syncope and carotid sinus syndrome].

Vasovagal syncope and carotid sinus syndrome are common conditions in young and elderly people, respectively, mostly with benign prognosis. Nevertheless, severe or "malignant" syncopal attacks in some patients may be associated with life-threatening injury. Unfortunately, up to now almost all drug trials have failed to demonstrate any benefit in preventing syncope and interventional approach (pacemaker) may be appropriate. This article contains literature review and discussion of indications for pacing in vasovagal syncope and carotid sinus syndrome.

[Wall motion abnormalities and hemodynamic parameters in patients with left bundle branch block during exercise echocardiography].

Study aim was to investigate dynamics of local contractility and hemodynamic parameters during exercise stress echocardiography (EEcho) in patients with left bundle branch block (LBBB). We examined 23 patients (15 men, 8 women) aged 48-65 years (mean age 53.9+/-8.1 years). Bicycle EEcho was accomplished according to standard protocol. Patients without clinical signs of ischemic heart disease (n=11) comprised group 1, patients after myocardial infarction (n=12) - group 2 (subgroup 2A - with negative test result, subgroup 2B - with worsening of local left ventricular contractility during EEcho). At baseline group 1 patients had significantly better hemodynamic parameters (ejection fraction - EF, left ventricular end diastolic volume - LVEDV) and no abnormalities of local contractility. Exercise tolerance was also the highest in this group. Insignificant worsening of postexercise EF occurred in patients of subgroup 2B (from 46+/-10.5 to 44,2+/-9.4%). In group 1 EF significantly increased (from 56.8+/-10.5% to 64.7+/-15.4%, <0.05), in subgroup 2A tendency to EF increase up to 48.7+/-9.9% was registered. Lowering of local contractility abnormalities index was noted also only in patients of subgroup 2B (from 1.54+/-0.4 to 2.17+/-0.37 (p<0.01). LVEDV compared with initial values tended to decrease in both groups (however differences between groups were not significant). Positive echocardiographic response was associated with significant changes of transmitral blood flow. Angiographically clean coronary arteries were found in 8 of 10 patients in group 1. Six group 2 patients with history of typical clinical picture of angina and myocardial infarction) had multivessel lesions in coronary vascular bed. EEcho result was positive in 5 of 6 group 2 patients. Thus EEcho possesses high potential for diagnosis of coronary atherosclerosis in patients with LBBB. This allows recommending it as a first line method in patients with this pathology.

[Distributions of polymorphisms of genes of some components of hemostasis in patients with ischemic heart disease].

We have studied structure of polymorphisms of genes of blood clotting factors II, V, VII, platelet membrane glycoprotein IIIa (GPIIIa) and enzyme methylenetetrahydrofolate reductase (MTHFR) in patients with ischemic heart disease (IHD). In this cohort of patients most prevalent are polymorphism PLAA1/A2 of GPIIIa gene and 677T/T polymorphism of MTHFR gene. Inconsistency of existing evidence on effect of R/Q genotype of FVII gene on early development of IHD and myocardial infarction (MI) is underlined, and data on the absence of protective effect of Q allele on early development of MI are presented. Activating effect of PLAA1/A2 polymorphism of GPIIIa gene and 677T/T polymorphism of MTHFR gene on morphofunctional state of platelets is proved.