Atherosclerosis of the carotid and coronary arteries in elderly patients with acute coronary syndrome.

Aim    To study the relationship between severities of the carotid artery injury and the atherosclerotic process in coronary arteries of elderly patients with acute coronary syndrome (ACS).Material and methods    The study included 110 patients aged >75 years. Based on the degree of maximal carotid stenosis according to data of duplex scanning (DS), all patients were divided into group I, (>50% stenosis) and group II (<50% stenosis).Results    According to coronary angiographic data, multivessel disease was observed in 63.6 % of patients. Patients of group I more frequently had three-vessel coronary artery disease than patients of group II (35.8 and 5.3 %, р<0.001). Coronary angiography and DS showed that 82.7 % patients (in group II, not all carotid stenoses were hemodynamically significant) had a combined damage of coronary and carotid arteries; carotid artery stenoses of >50% were associated with three-vessel coronary artery disease. A correlation between atherosclerosis of carotid and coronary arteries was found. Considering this correlation, a scale was introduced that suggested the severity of coronary atherosclerosis based on DS of carotid arteries. The score was assigned by assessing the degree of maximal stenoses in carotid arteries. A ROC analysis has determined a threshold score suggestive of the severity of coronary atherosclerosis: score <6, absence of >70% coronary stenosis; score >6, likely presence of >70% coronary stenosis (sensitivity, 70 %; specificity, 89 %).Conclusion    Combined coronary and carotid artery disease was detected in 82.7% of elderly patients with ACS. A correlation between the severity of atherosclerosis in carotid and coronary arteries was found. DS of carotid arteries can be extensively used in evaluation of elderly patients with ACS, which will allow additional stratification of patients at high risk of cerebrovascular and recurrent cardiovascular diseases.

[Capecitabine and vasospastic angina: a clinical case].

The article presents a clinical case of a 78-year-old female patient with a clinical picture of vasospastic angina during the capecitabin treatment. The issues under discussion include difficulties of diagnosing vasospastic angina, a potential danger and incidence of coronary vasospastic reactions during chemotherapy with drugs of this group, and current approaches to prevention and correction of fluoropyrimidine cardiotoxicity. The presented clinical case confirms that vasospasm is a manifestation of capecitabin cardiotoxicity. This case also illustrates the importance of interaction and co-ordination of the work of oncologists and cardiologists at all stages of care of oncological patients.

[The Clinical Value of no-Reflow Phenomenon in the Routing Operation of The Regional Vascular Center].

Coronary no-reflow phenomenon (CNR) is a complication of primary percutaneous coronary intervention (PCI). According to different reports, CNR occurs in 10 to 60 % of cases. Despite the long history of studying this phenomenon many issues remain unsolved. This article presents a clinical case of electrocardiographically confirmed ST-segment elevation myocardial infarction. In this case, the CNR phenomenon occurred during PCI and was associated with heart rhythm disorders, left ventricular (LV) cavity dilatation with a decrease in LV contractility, and formation of intracavitary thrombus. The patient asked for medical care late, which could influence the development of CNR. This case demonstrates the clinical significance, diagnostic characteristics, and successful drug correction of the no-reflow phenomenon.

[Takotsubo Cardiomyopathy as a Consequence of Myocardial Infarction. It is Possible?]

Takotsubo cardiomyopathy (TCM) is a well-known complication of many conditions associated with emotional or physical stress. Abnormal catecholamine release has been hypothesized to be the main cause of TCM. Myocardial infarction (MI) is associated with release of large amounts of catecholamines. We present here two cases in which patients simultaneously suffered from acute MI and TCM. In these elderly women without prior history of severe somatic diseases we have not revealed any external stressing factor responsible for the initiation of the disease. Therefore, we have considered primary coronary event (acute MI) to be a triggering factor of TCM manifestation.

[Characteristics of immune response and inflammatory reaction in atherothrombotic stroke and myocardial infarction]. / Osobennosti immunnogo otveta i vospalitel'noi reaktsii pri aterotromboticheskom insul'te i infarkte miokarda.

AIM: To study characteristics of ischemic tissue damage basing on the assessment of the correlations between markers of immune response, inflammation and apoptosis in patients with myocardial infarction (MI) and atherothrombotic stroke (AS). MATERIAL AND METHODS: Concentrations of matrix metalloproteinase-9 (MMP-9), immune complexes with cryogenic properties, soluble Fas-ligand, tumor necrosis factor alpha, interleukin-10 measured with ELISA as well as the activity of spontaneous apoptosis of mononuclear cells and surface expression of Toll-like receptors-4 and intracellular heat shock proteins measured with flow cytofluorometry were determined in the blood of 93 patients with the first AS and 94 patients with MI without concomitant inflammation in the 1st and 7th day of the disease. RESULTS AND CONCLUSION: Increased levels of the markers of immune response, inflammation, apoptosis and destruction of the extracellular matrix were identified at the beginning of MI and AS. The results provide the evidence that similar mechanisms may be involved in ischemic tissue damage. Multivariate analysis conducterd by of principal component analysis correlation matrix revealed the specificity of the relationships between all of these markers. This is the completely new approach to assessin the role and importance of defined parameters in the acute period of the myocardial ischemia and brain.

Design of tissue engineering implants for bone tissue regeneration of the basis of new generation polylactoglycolide scaffolds and multipotent mesenchymal stem cells from human exfoliated deciduous teeth (SHED cells).

Cultures of multipotent mesenchymal stromal cells from the pulp of human deciduous teeth (SHED cells) were characterized. The cells were used for population of 3D biodegradable polylactoglycolide scaffolds; their osteogenic potential was preserved under these conditions. Implantation of the scaffolds to mice induced no negative reactions in the recipients. These results suggest that the use of polylactoglycolide scaffolds populated with SHED cells is a promising approach for creation of implants for bone defect replacement.

Relationship between apoptosis and expression of heat shock proteins in peripheral blood lymphocytes of patients with myocardial infarction.

We studied activity and dynamics of apoptosis of peripheral blood lymphocytes in patients with myocardial infarction and analyzed the relationship of these processes with expression of heat shock proteins with a molecular weight of 70 kDa playing an essential role in preventing cell death. Thus, we first demonstrated activation of apoptosis in peripheral blood cells of patients with myocardial infarction compared to the control (healthy individuals) and revealed the expected negative correlation between the expression of heat shock proteins with a molecular weight of 70 kDa by lymphocytes and intensity of their death. The observed dynamics of mononuclear cell apoptosis in the peripheral blood of patients with myocardial infarction can reflect activity of programmed cardiomyocyte death in the focus of ischemic injury.

Cryoglobulin composition in patients with myocardial infarction.

The formation of an ischemic focus in the myocardium is paralleled by autoimmune processes involving immunoglobulins with abnormal thermal solubility, cryoglobulins. Serum levels of cryoglobulins and their complexes were measured in 25 patients with Q-forming myocardial infarction on days 1, 2, 3, 7, and 14 of the disease. Cryoprotein levels were measured by spectrophotometry, concentrations of IgM, IgA, IgG, and fibronectin by ELISA. Cryocomplexes in patients with myocardial infarction consist of polyclonal immunoglobulins of the main classes IgG and IgM, less often IgA, while cryoglobulinemia in this patient population is referred to type III according to the commonly used classification by Brouet. Fibronectin was detected in the cryocomplexes throughout the entire period of observation, its dynamics being opposite to that of the cryocomplexes level.

[The significance of Toll-like receptors in the development of ischemic lesion].

A role of immune processes in the development of ischemic lesion is reviewed. Special attention is drawn to key receptors of innate immunity--Toll-like receptors (TLR). Main types of these receptors, their ligands, key mechanisms involved in the TLR signal transduction are characterized. The data of experimental and clinical studies of innate immunity factors in the development of ischemic stroke and myocardial infarction are summarized. The authors discuss the similarity of results, the main causes of which may be the evolutional conservatism of TLR and presence of the common pathological process (artery atherosclerosis) in different vascular beds as a common cause that underlie brain and myocardial ischemia.

[Cryoglobulins in patients with ischemic stroke].

The composition of circulating immune complexes with cryo-properties (cryo-IC) were determined in 70 patients on days 1, 2, 3, 7, 14 and 21 after ischemic carotid stroke. The quantitative and qualitative assessments of cryo-IC content were conducted on a spectrophotometer and on a vertical electrophoresis, respectively. Concentrations of immunoglobulins (Ig) M, A and C, fibronectin, percentage of IgM with rheumatoid factor activity, IgG isotypes (IgG1, IgG2, IgG3, IgG4) were measured with ELISA. The control group included 15 healthy age- and sex-matched people. Compared to the controls, the cryo-IC content was higher in 100% of patients studied, it was higher in atherothrombotic variant than in cardioembolic one. The cryo-IC level was directly correlated with the clinical state severity (p < 0.01). IgG, IgM and fibronectin were observed in 100%, IgA--in 11% and IgM with rheumatoid factor activity--in 6% of patients. The percentage of IgG1 and IgG2 was not less than 90% of the total amount, with the IgG1 percentage about 50%. Cryo-IC changing in the time in dependence on ischemic variant were formed on different stages of development of acute brain ischemia. Dependence of concentrations of fibronectin and IgG, IgA, IgM on the time of observation was similar for both variants of ischemic stroke, but with a time axis shift, running faster and with a smaller range of changes of parameters studied in cardioembolic than in atherothrombotic stroke.

[Dynamics of blood fibronectin and its correlation with the phenomenon of cryoglobulinemia in patients with ischemic stroke].

Seventy patients with carotid ischemic stroke (38 with atherothrombotic and 32 with cardioembolic variants) were examined. The dynamics of fibronectin level and its correlation with blood cryoglobulins concentrations were evaluated in the 1st, 2nd, 3rd, 7th, 14th and 21st days after disease onset. The quantitative assessment of cryoglobulins content was carried out using spectrophotometric method; fibronectin concentration was measured by ELISA. In patients with atherothrombotic variant of stroke, the level of fibronectin in the blood serum and in the cryocomplex was higher compared to patients with cardioembolic variant in the 1st day (p < 0.001) and during all the period of the study (p < 0.05). The concentration of cryocomplexes in the blood serum of patients with ischemic stroke was in reverse correlation with percentage of fibronectin in their content and with the pathogenetic variant of ischemia (r = -0.94; p < 0.05 and r = -0.87; p < 0.05 or atherothrombotic and cardioembolic variants, respectively).

[Role of innate immunity receptors in development of acute myocardial infarction].

AIM: To assess influence of toll-like receptors (TLR) ligands on the production of proinflammatory cytokine (TNFalpha) by peripheral blood mononuclear cells in patients with acute myocardial infarction (AMI). MATERIALS AND METHODS: Peripheral blood mononuclear cells (PBMC) obtained from 13 patients with AMI on 1st and 14th day and from 17 healthy donors were stimulated by peptidoglycan, poly(I:C), lypopolysacchide, zimozan, flagellin and CpG oligodeoxynucleotides, which are ligands of TLR1/2, TLR3, TLR4, TLR2/6, TLR5 and TLR9 respectively. Spontaneous and induced by ligands production of TNFalpha was evaluated in supernatants of PBMC. RESULTS: Increased spontaneous production of TNFalpha by PBMC in patients with AIM was revealed on 1st day of the disease. Ligands of TLR2/6 and TLR4 demonstrated marked stimulatory effect on the production of TNFalpha by PBMC in patients with AMI compared with group of healthy subjects. CONCLUSION: Increased production of TNFalpha by PBMC in patients with AMI indicates the activation of TLR2 and TLR4 on PBMC. Hyperactivation of TLRs during acute pathologic conditions results in excessive production of proinflammatory cytokines, specifically TNFalpha, and can induce damage of cells and tissues involved in acute pathologic process.

[An effect of perindopril on the level of tumor necrosis factor-alpha and matrix metalloproteinase-9 in peripheral blood in the acute period of atherothrombotic ischemic stroke and myocardial infarction].

Twenty-nine patients with acute atherothrombotic ischemic stroke and 36 patients with acute Q-wave myocardial infarction have been studied. Each group has been stratified into 2 subgroups: patients of subgroups A received an ACE inhibitor perindopril in the complex therapy from the 1st day of disease. Patients of subgroups B were not assigned to this drug. Along with routine tests, the level of tumor necrosis factor-alpha and matrix metalloproteinase-9 (MMP-9) measured with ELISA using test-systems (BCM Diagnostics, USA) and reagents (R&D, England) have been determined. The administration of perindopril did not cause side-effects, including arterial hypotonia after the first dosage, in patients in the acute period of atherothrombotic ischemic stroke and myocardial infarction. Perindopril may decrease the activity of MMP-9 in these patients and produces an anticytokine effect. Some similar mechanisms of ischemic lesions of the heart and the brain and a commonness of biochemical "response" to the same medical intervention (the administration of an ACE inhibitor perindopril) in patients of both groups were found. The results support the pathogenetic validity of perindopril therapy in the secondary prevention of ischemic stroke and myocardial infarction.

[Ventricular extrasystole as manifestation of viral myocarditis and myopericarditis in young patients].

AIM: To investigate relationship between frequent and complicated ventricular extrasystole (VE) in young patients and previous viral myocarditis (VM); to study VE long-term prognosis. MATERIAL AND METHODS: We examined 75 patients with mild and moderate myocarditis which developed after acute respiratory infections and other viral diseases (Coxsackie infection was serologically confirmed in 49%; flu, paraflu and adenoviral infection--in 8%). Acute myocarditis was diagnosed basing on the data of ECG, activity of cardiospecific enzymes and isoenzymes, x-ray, echocardiography, Holter ECG monitoring, exercise tests. The patients were followed up from 3 to 26 years (mean 14.6 years). RESULTS: Bigeminal polymorphic extrasystoles and bigemia sites persisted for the whole periods of observation. They could disappear at resting ECG but were registered at 24-h ECG monitoring in all the cases. Echocardiography detected fibrous alterations of the pericardium with its thickening in 89% cases. Exercise tolerance test at the end of the study recorded normal physical performance in 89.3% patients. This suggests a favorable disease outcome. Low physical performance, moderate dilation of the left ventricle and ejection fraction lowering to 48% requiring medication were observed only in 4 patients who were capable to work. CONCLUSION: Frequent and complicated VE after viral myocarditis were present at resting ECG for many years in 42.3% patients. Holter 24-h ECG monitoring registered VE in all the examinees. 89% patients had fibrous lesions of the pericardium showing that viral myocarditis in most cases runs as myopericarditis, in some cases being subclinical.

The use of statistical methods for predicting the status of patients with acute cerebral and coronary ischemia.

The most significant informative clinical laboratory parameters were determined and the exceptional value of cryoglobulin concentrations for predicting the clinical status was demonstrated. The efficiency of the proposed protocol of selective plasmapheresis for patients with atherothrombotic variant of stroke is confirmed, mathematical models describing and predicting the patient status are plotted.

[Crioglobulinemia in cerebral and coronal atherothrombosis].

Forty-seven patients: group A--17 patients with acute ischemic atherothrombotic stroke and group B--30 patients with acute Q-formation myocardial infarction. The levels of dynamics and comparative clinical relevance of crioglobulinemia in patients of the both groups have been evaluated. Crioglobulines (CG) in the peripheral blood serum were determined at 1, 2, 3, 7th and 14th days after the disease development. On the 1st day, the elevated CG level similar in the both groups as well as similarity of crioglobulinemia dynamics in whole was observed. In the group A, but not in the group B, the CG level was directly correlated with disease severity (p<0,05). In the group B, there was a trend, which depended on the blood CG level on the 1st day of the disease and on the presence of previous stenocardia (p<0,1).

[Dilated cardiomyopathy resulting from asymptomatic and subclinical myocarditis]. / Dilatatsionnaia kardiomiopatiia kak iskhod bessimptomnykh i subklinicheskikh miokarditov.

The paper presents data on 10 patients with dilated cardiomyopathy (DCM) or chronic myocarditis with fatal outcomes in whom heart failure was preceded by abnormal ECG changes originally regarded as the manifestations of coronary heart disease or small myocardial infarction. The clinical course of the disease and morphological studies suggest that the ECG changes were associated with pre-existing asymptomatic viral myocarditis.

[Long-term outcomes of viral myopericarditis in young patients]. / Otdalennye nabliudeniia pri virusnykh mioperikarditakh u lits molodogo vozrasta.

Long-term follow-up (mean 14.1 +/- 6.6 years) of 54 young patients who have undergone acute viral myopericarditis of mild or moderate severity demonstrates a favourable outcomes in the majority of the examinees in spite of residual fibrous changes in the myocardium registered at ECG. Fibrous pericardial thickening detected in 89.4% patients at echocardiography is proposed as a differential-diagnostic indicator of old myopericarditis.