Prediction of massive coronary thrombosis of the infarct-related artery in ST-elevation myocardial infarction.

Aim    To identify clinical, laboratory and angiographic predictors for development of massive coronary thrombosis in patients with ST-segment elevation myocardial infarction (STEMI).Material and methods    This prospective, single-site study included 137 patients with STEMI (mean age, 66.5±13.2 years). Among these patients, 59 were in the group of massive coronary thrombosis and 78 patients were in the group of minor thrombosis. To identify predictors for the development of massive coronary thrombosis, medical history data, blood count and biochemistry, coagulogram, and angiography data were analyzed. A predictive model was constructed using the method of binary logistic regression followed by a search for the optimum value of the prognostic function with a ROC analysis. Results    The study showed statistically significant roles of total bilirubin, platelets, prothrombin ratio (PTR), activated partial thromboplastin time (APTT), and presence of inferior myocardial infarction in prediction of massive coronary thrombosis in STEMI. The model sensitivity was 71.2 %, specificity 75.6 %, and overall diagnostic efficacy 73.7 %.Conclusion    The predictive model for the development of massive coronary thrombosis in STEMI based on laboratory and instrumental data potentially allows assessing the thrombus load in the infarction-involved coronary artery and determining the optimum tactics of percutaneous coronary intervention in patients with STEMI. This reduces the probability of distal embolization with fragments of the disintegrated thrombus and improves the prognosis of STEMI patients both during the stay in the hospital and in the long-term. According to results of this study, the prognostic model for massive coronary thrombosis in STEMI based on such indexes as the platelet count, PTR, APTT, total bilirubin, and presence of inferior myocardial infarction provides accurate predictions in 73.7 % of cases. Independent predictors of massive coronary thrombosis were inferior myocardial infarction and total bilirubin.

The influence of the Ini-tial Severity of Coronary Artery Lesion (by the Syntax Score) on the Midterm Prognosis of Patients With Acute Myocardial Infarction Without ST Segment Elevation.

Aim      To study the effect of the baseline severity of coronary artery damage according to the SYNTAX scale (baseline score of coronary lesions, BSCL) on the mid-term prognosis in patients with non-ST segment elevation acute myocardial infarction (AMI) (NSTEMI), and to identify the threshold BSCL value that determines high and low risks of adverse cardiac outcomes.Material and methods  A retrospective analysis was performed for the hospital treatment of patients with NSTEMI (n=421) who had undergone percutaneous coronary intervention (PCI). 256 patients with a repeated hospitalization in mid-term (11.6±3.2 months) were selected for the study. These patients were followed up for the incidence of acute coronary syndrome (ACS), unscheduled repeated myocardial revascularization (URR), and of the composite endpoint (CEP) that included at least one the following events: death, recurrent AMI, unstable angina (UA), and URR. The effect of BSCL on the incidence of these events in mid-term was proven (р<0.05), and then the BSCL threshold value was determined, which allowed segregation of patients into groups of high and low risk of adverse cardiac outcomes.Results The threshold BSCL value for the risk of ACS was determined as score 14 (odds ratio, OR, 2.79; 95 % confidence interval, CI: 1.32-5.89); for URR and CEP, score 13 (OR, 2.21; 95 % CI: 1.22-4.01 and OR, 2.38; 95 % CI: 1.32-4.31, respectively). Since these threshold values were comparable, for the composite category of events (CEP), the BSCL threshold comprised score 13, and namely this value was taken as a base. According to the multifactorial Cox regression at BSCL score ≥13, the probability of earlier CEP in mid-term was 2.44 times higher than at lower BSCL values (OR, 2.44; 95 % CI: 1.41-4.21; р=0.001). Furthermore, according to the Kaplan-Meier estimate, the effect of BSCL on the survival without adverse cardiac outcomes becomes significant starting from the second half-year (р=0.001, log-rank test).Conclusion      In NSTEMI patients, the SYNTAX baseline score of coronary lesions >13 is an independent predictor of adverse cardiac outcomes in mid-term starting from the second half-year. Thus, patients with BSCL ≥13 should undergo a follow-up examination no later than at 6 months independent on their clinical condition..

[Ocular microcirculation after revascularization of the internal carotid artery in the early postoperative period]. / Mikrotsirkulyatsiya glaza posle rekonstruktivnykh operatsii na sonnykh arteriyakh v rannem posleoperatsionnom periode.

Carotid artery stenosis is the most common cause of ischemic stroke and transient ischemic attacks in the population of developed countries. Carotid endarterectomy (CEA) and carotid stenting (CAS) are effective treatments for carotid stenosis. In view of the need to improve the diagnosis of this condition and the anatomical relationship of the internal carotid arteries and vessels of the eye, studying retinal microvasculature has become an urgent problem. The theory suggesting that changes in ocular blood flow parameters may reflect disease status in patients with internal carotid artery (ICA) stenosis requires further investigation. PURPOSE: To study the impact of CEA and CAS interventions on ocular blood flow in patients with clinically significant ICA stenosis in the early postoperative period. MATERIAL AND METHODS: Thirty-two patients with hemodynamically significant stenosis (≥75%) of the left or right ICA were examined using optical coherence tomography angiography (OCT-A) and flowmetry before and after CEA or CAS in order to assess the changes in ocular blood flow parameters. RESULTS: There were no significant differences in hemodynamic parameters in the eyes on the side of the stenotic and non-stenotic ICA before revascularization. In the early postoperative period (3-7 days) in the ipsilateral eyes, there was an increase in blood flow density and vascular density at the level of the superficial and deep plexuses in the macular area (p≤0.05), as well as an increase in the ocular blood flow volume, the level of tolerated intraocular pressure (p≤0.05) and a decrease in intraocular pressure (p≤0.05) bilaterally. In the contralateral eyes, after ICA revascularization there was a partial improvement in microcirculation parameters according to OCT-A (p≤0.05). Peripapillary blood flow density and peripapillary vessel density did not change significantly either on the ipsilateral or the contralateral side. CONCLUSION: In patients with clinically significant ICA stenosis, ICA revascularization by stenting or endarterectomy contributed to an improvement in retinal microcirculation and retrobulbar blood flow in both eyes. OCT-A and flowmetry allow non-invasive assessment of retinal microvessels and retrobulbar blood flow, and the measurements provided by these methods can serve as valuable biomarkers for predicting and monitoring hemodynamic changes in patients who undergo CEA and CAS surgeries.

Prognostic Value of Residual Coronary Artery Lesions on the SYNTAX Scale in Patients with Acute Myocardial Infarction without SТ Segment Elevation in the Mid-Term Period.

Aim      To study the effect of residual coronary injury after a percutaneous coronary intervention (PCI), as evaluated with the SYNTAX scale (residual SYNTAX score, RSS), on the mid-term prognosis for patients with non-ST elevation acute myocardial infarction (NSTEMI) and also to determine threshold RSS values for patients at high and low risk of adverse cardiac events.Material and methods  A single-center, retrospective study was performed. From 421 patients with NSTEMI after PCI with stenting, 169 patients were selected who originally had multivessel coronary disease and who had undergone a repeated inpatient examination, including mid-term (11.7±3.0 mos.) coronary angiography. The endpoints were recurrent clinical manifestations of angina, repeat revascularization (RR), unstable angina (UA), recurrent acute myocardial infarction (AMI), cardiac death, and also a composite endpoint (major adverse cardiac events, MACE) that included UA, recurrent AMI, and cardiac death. After revealing a significant direct correlation between RSS and the probability of recurrent AMI, UA, MACE, or RR (p <0.05) using the ROC analysis, we have established threshold RSS values that divided patients into groups with high and low risk of the cardiac events listed above.Results For a significantly high risk of recurrent AMI (area under the curve, AUC 0.79±0.05; 95 % confidence interval, CI 0.68-0.89; р=0.048), the threshold RSS score was 8 (sensitivity 100 %, specificity 70.9 %). For UA and MACE, the RSS scores were both 3 (AUC 0.68±0.5; 95 % CI 0.58-0.79; p=0.005 and AUC 0.71±0.05; 95 % CI 0.61-0.8; p=0.001, respectively). The probability of UA during the observation period with RSS >3 was 4.07 times higher and that of MACE was 5.23 times higher than with RSS<3 (95 % CI 1.44-11.49; р=0.01 and 95 % CI 1.88-14.53; р=0.001, respectively).Conclusion      The study demonstrated a significant, direct correlation between the RSS and the risk of adverse cardiac events in patients with NSTEMI during one year of observation. Specific threshold values were obtained, which may help in choosing both the extent of revascularization and the tactics for postoperative management of patients.

[The no-Reflow Phenomenon During Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction due to Massive Coronary Thrombosis. Pathogenesis and Predictors of no-Reflow].

Despite successful and timely revascularization of the infarct-related artery, myocardial tissue remains underperfused in some patients. This condition is known as the no-reflow phenomenon, which is associated with a worse prognosis. The first part of the systematic review on no-reflow focuses on description of the no-reflow pathogenesis and predictors. This phenomenon has a complicated, multifactorial pathogenesis, including distal embolization, ischemic injury, reperfusion injury, and a component of individual predisposition. Meanwhile, this phenomenon undergoes spontaneous regression in some patients. Several studies have demonstrated the role of definite biomarkers and clinical indexes as risk predictors for no-reflow. The significance of each pathogenetic component of no-reflow is suggested to be different in different patients, which may warrant an individualized approach in the treatment.

[Choice of an alternative access in failed endovascular intervention through the right radial artery]. / Vybor al'ternativnogo dostupa pri neudache éndovaskuliarnogo vmeshatel'stva cherez pravuiu radial'nuiu arteriiu.

The transradial access has deservedly become the 'gold standard' while performing various X-ray endovascular interventions both diagnostic and therapeutic ones. However, along with all its advantages, it is not without disadvantages. These difficulties for the most part are related to peculiarities of the anatomy of upper-limb arteries. It is exactly complex anatomy that is the most common cause of complications and compelled change of the access while using the right radial artery. The purpose of our study was to examine the symmetry of complex anatomy of upper-limb arteries in order to choose an optimal and safe way of conversion of the access in case of forced refusal from the right radial access. For this reason there was developed an open multicentre registry acronymized as COMPAAS (COMPlex Anatomy of Arteries and Symmetry). During the work of this Registry from February to December 2018, correspondents of the study became 35 colleagues from 23 clinics of 11 cities of Russia. The working group analysed a total of 127 patients presenting with 157 variants of complex anatomy of lower limb arteries: high bifurcation of the radial artery (84), complete loop or tortuosity (66), and compartmental calcification of brachial arteries (7). The anatomy of arteries on the opposite upper extremity was studied based on angiographic findings. The most frequent variant (84 cases) of complex anatomy was high bifurcation of the radial artery at the level of the a. brachialis (20.9% of cases), with the origin of the brachial artery at the level of the a. axillaris being revealed half as often (9.9%). The maximum percentage of symmetry was observed in the group of patients presenting with compartmental calcification of upper-limb arteries (85.7%). Complete loop or marked (more than 100°) tortuosity of arteries on both arms was revealed in 54% of cases. Besides, in 25% of cases, tortuosity was combined with the high origin of the radial artery. It is noteworthy that none of the 127 patients appeared to have complex anatomy on the a. ulnaris. When revealing pronounced calcification of arteries of the forearm or a combination of high bifurcation with tortuosity, it seems feasible to decide upon conversion of the access to the femoral one (a. femoralis) or ulnar (a. ulnaris). In isolated high bifurcation on the right, effective conversion to the contralateral (left) radial approach is possible in not less than 75% of cases.

[The dynamics and prognostic value of cerebral natriuretic peptide and C-reactive protein under acute cardiac infarction depending on tactic of treatment].

The sampling consisted of 102 patients with acute cardiac infarction with ST elevation up to 6 hours from the onset of disease. The subjects were divided into three groups: group I with primary stent procedure, group II with deferred stent procedure during 24 hours after effective thrombolytic therapy and group III with isolated effective thrombolytic therapy. The Doppler-echocardiography was applied to all patients. In every group the evaluation was carried out to dynamics NT-proBNP and C-reactive protein. In group III with isolated effective thrombolytic therapy in sub-acute period of cardiac infarction NT-proBNP increased more than twice in comparison with groups of patients with stent procedure. The values of C-reactive protein were lower than in groups I and II. The dynamics of NT-proBNP and C-reactive protein depend on mode of regeneration of coronary blood flow and level of increase of NT-proBNP corresponds the type of diastolic dysfunction of left ventricle of heart.

[The influence of acetyltransferase activity phenotype on the frequency of in-stent restenosis in patient with CHD].

Coronary artery stenting is a priority treatment of different forms of coronary heart disease. Hence, the importance of intrastent restenosis. This study demonstrates the relationship between acetylation rate and frequency of restenosis following coronary stenting with special reference to patients with chronic coronary heart disease. This knowledge may be helpful for the improvement of endovascular treatment using drug-coated stents.

[Combination of prehospital systemic thrombolytic therapy with endovascular procedures in the treatment of patients with acute myocardial infarction].

Since July 2002 we have been conducting a study of efficacy of prehospital thrombolytic therapy combined with subsequent endovascular procedures in the treatment of patients with acute myocardial infarction. Fifty nine patients received prehospital fibrinolysis with tissue-type plasminogen activator (TPA, n=28) or streptokinase (n=31) within 6 hours after onset of symptoms. TPA infusion compared with that of streptokinase was associated with smaller ischemic myocardial damage and lower frequency of side effects (3.6 and 38.7%, respectively). Angioplasty or stenting of infarct related arteries were carried out in 47 of these patients. The group of patients subjected to endovascular interventions was characterized by a low rate of in-hospital cardiac events and zero mortality.

[A clinical case of successful combination of endovascular and surgical correction of multifocal atherosclerotic signs in an elderly patient]. / Sochetanie éndovaskuliarnoi i khirurgicheskoi korrektsii proiavlenii mul'tifokal'nogo ateroskleroza u patsientki pozhilogo vozrasta.

Combination of the methods of interventional cardioangiology with current techniques of vascular surgery allows a considerable broadening of the potential for the treatment of different signs of multifocal atherosclerosis in "high risk" patients. For instance, a 70-year-old patient (height 152 cm, weight 32 kg; initial concentration of serum creatinine 174 mumol/l) with the clinical evidence of progressing angina pectoris and critical ischemia of the lower extremities underwent angioplasty (the first stage) using a transradial access and stenting of the critically narrowed circumflex branch of the left coronary artery and angioplasty of the proximal segment of the right coronary artery. Good angiographic and clinical results were obtained. This provided a possibility of accomplishing aortofemoral bifurcation bypass grafting. So, the staged combined treatment made it possible to eliminate the life- threatening signs of multifocal atherosclerosis and to improve disease prognosis in an elderly patient classified with a group of inoperable subjects.

[Development of transmural myocardial infarction in young persons with intact coronary arteries during methadone use for the treatment of heroine addiction]. / Transmural'nyi unfarkt miokarda u molodykh bol'nykh s neizmenennymi koronarnymi arteriiami, prinimavshikh metadon.

Linkage between acute coronary syndrome and narcotic drug (cocaine) intake was first described by D. Colleman in 1982. However risk of development of acute myocardial infarction during replacement therapy after opioid withdrawal has not been elucidated. The paper contains description of two cases of development of myocardial infarction in young persons with intact coronary arteries who received synthetic opioid methadone for facilitation of heroine discontinuation. These clinical cases should draw attention of physicians to side effects of the use of methadone for the treatment of heroine addiction.

[Comparative long-term outcomes of balloon angioplasty of uni- or multi-vessel lesions in coronary disease]. / Sravnitel'nye otdalennye rezul'taty ballonnoi angioplastiki pri odnososudistom i mnogososudistom porazhenii koronarnogo rusla.

A study has been carried out on long-term results of transluminal balloon angioplasty (TLBAP) in case of mono- and multivascular lesion of coronary bed (CB). During long-term follow-up (16.3 +/- 3.8 months) a high survival rate was observed after treatment procedure both in mono- (97.1%) and multivascular (98.75%) lesion. However, patients with monovascular lesion had lesser probability of being subjected to additional revascularization procedure and greater probability of avoiding angina pectoris in long-term follow-up unlike patients with multivascular lesion of coronary arteries (85.7% vs 63.8%). At the same time a good angiographic angioplastic effect of dilated vessel remained in equal number of patients: 66.7% with monovascular lesion and 68.6% with multivascular lesion. Therefore, it is advantageous to use TLBAP both in mono- and multivascular CB lesion.