[Clinical Case Demonstrating Use of Trimetazidine In the Treatment of Stable Angina].

In a patient with multiple involvement of distal coronary artery bed and recurrence of angina at the background of optimal drug therapy addition of trimetazidine was associated with increase of tolerance to physical exercise and improvement of quality of life.

[Risk factors for and prognostic value of multifocal atherosclerosis in patients with diabetes mellitus].

AIM: To study the prognostic value of multifocal atherosclerosis (MFA) in patients with diabetes mellitus (DM) at high risk for myocardial ischemia who need coronary angiography (CAG). SUBJECTS AND METHODS: The investigation included 148 patients: 25 with type 1 DM (DM1), 73 with type 2 DM (DM2), and 50 without DM who had undergone CAG. Duplex ultrasound scanning of lower limb vessels and brachiocephalic and renal arteries was carried out in all the patients. RESULTS: Involvement of two or more vascular beds was noted in 60% of the patients with DM1, in 68.4% of those with DM2, and in 34% of those without DM (p < 0.05). Regression analysis showed that the risk factors of MFA were defined to be myocardial infarction (MI) in the history (OR=2.4; p=0.02), DM (OR=3.9; p=0.0002), smoking (OR=2.4; p=0.05), elevated creatinine (OR=6.5; p=0.002) and fibrinogen (OR=6.8, p=0.004) levels. Among the DM patients, there were 26.5% of those who had achieved a main assessment criterion (a combined end point (CEP)), such as death, urgent hospitalization for heart failure, nonfatal MI, nonfatal stroke, lower extremity amputation, double creatinine levels, and achievement of end-stage renal failure during a 24-month follow-up. In patients without carbohydrate metabolic disturbances, this indicator was 12% (p=0.01). During the prospective study, a total of 6.1% of patients died in the DM group; all the patients in the non-DM group completed the study. Calculation of survival rates by the Kaplan-Meier method indicated that the DM patients with concurrent atherosclerotic lesion had achieved CEP significantly more frequently than the comparison group. Such differences were absent among the persons without carbohydrate metabolic disturbances. CONCLUSION: The regression analysis has shown that prior MI, DM, smoking, creatinine and fibrinogen levels are factors associated with the development of MFA in the examined groups. In the patients with DM, concurrent atherosclerosis of two or more vascular beds is an important factor for the progression of cardiovascular and renal diseases.

[Prevalence and risk factors of extra-coronary artery disease in patients with diabetes which confirmed atherosclerosis of coronary arteries].

AIM: To assess prevalence and risk factors of extra-coronary artery disease (peripheral artery (PA) disease (D) of lower extremities (LE), brachiocephalic arterial (BCA) stenosis (S), renal arterial (RA) S in type 1 and 2 (T1 and T2) diabetes (D) patients (P) with confirmed atherosclerosis of coronary arteries (CA). MATERIAL: 100 P (48 with T2D, 18 with T1D, 34 without diabetes - PWD), with hemodynamically significant atherosclerosis of CA confirmed by coronary angiography. METHODS: All patients underwent duplex ultrasonography of PA LE, BCA, RA. Other studies included assessment of clinical characteristics and measurement of the following parameters: profibrogenic cytokines (transforming growth factor [TGF] beta1, matrix metalloproteinase 9 [MMP9], monocyte chemotactic protein-1 [MCP-1], regulated on activation normal T-cell expressed and secreted [RANTES), markers of endothelial dysfunction (von Willebrand factor [VWF], homocystein [HCYST], plasminogen activator inhibitor-1 [PAI-1], vascular cell adhesion molecule [VCAM], soluble intercellular adhesion molecules-1 [sICAM], vascular endothelial growth factor [VEGF], asymmetric dimethylarginine [ADMAD, N-terminal fragment of pro-brain natriuretic peptide (NT-pro BNP), fibroblast growth factor 23 (FGF-23), and fibrinogen. RESULTS: Portions of P with multivessel CA disease were similar in all three groups (T1D - 88.9, T2D - 85.5, WD - 82.3%). Coexistence of atherosclerosis in 2 or more vascular beds was identified in 85.3% of T2D and in 50% of WD P (p = 0.005). In T1D group 61.1 and 11.1% of P had atherosclerosis in 2 and 3 vascular beds, respectively. Levels of profibrogenic cytokines and factors of endothelial activation (RANTES, MMP-9, PAI-I, VCAM, sICAM, ADMA) were significantly higher in P with diabetes vs P WD. P with diabetes and multifocal atherosclerosis demonstrated significant increases of CRP, fibrinogen, NT-proBNP, VWF, PAI-1, ADMA, sICAM, and decrease of GFR compared with P with atherosclerosis in 1 vascular bed. Logistic regression model identified diabetes, reduced renal function, previous myocardial infarction, smoking, ADMA and fibrinogen as factors associated with presence of multifocal atherosclerosis. CONCLUSION: Coexistence of atherosclerosis in two or more vascular beds was more frequent in P with diabetes and hemodynamically significant CA atherosclerosis than in PWD. It was associated with renal and cardiac dysfunction, excessive activation of mediators of inflammation, hemostasis, and factors of endothelial damage.

[Renal artery stenosis in patients with type 2 diabetes mellitus: clinical signs, diagnosis, prognostic value].

AIM: To define the prevalence, clinical features, risk factors, and prognostic value of atherosclerotic renal artery stenosis (RAS) in patients with type 2 diabetes mellitus (T2DM). SUBJECTS AND METHODS: One hundred and fifty-seven T2DM patients (63 males and 94 females) aged over 50 years were examined. Screening for RAS was carried out by duplex ultrasound scanning (DUSS); the diagnosis was verified by multispiral computed tomography and magnetic resonance imaging. Moreover, the detection rate of RAS was analyzed from the selective angiographic readings of 30 patients with T2DM and 26 coronary angiography patients without DM who had undergone coronary angiography (CA). RESULTS: In the total group of T2DM patients, the RAS detection rate was 36.9%, as evidenced by DUSS and 43.3% by selective renal artery angiography in the patients who had undergone CA. The factors associated with the development of RAS were smoking (relative risk (RR) = 3.3; p < 0.001); atherosclerosis of coronary (RR = 4.28; p < 0.001) and peripheral (RR = 3.38; p < 0.02) arteries, isolated systolic hypertension (RR = 3.9; p < 0.01), and anemia (RR = 6.4; p < 0.001). In patients with T2DM, RAS was one of the important factors of progressive renal and cardiac diseases and increased mortality determined by the combined end point: death, emergency hospitalization for heart failure, myocardial infarction, double creatinine, and end-stage renal failure (RR = 6.28; p < 0.001). CONCLUSION: The optimization of prognosis in T2DM patients with RAS requires its timely clinical identification in combination with other types of renal lesion, aggressive correction of the mechanisms of the progressive process, and development of medical and endovascular therapies.

[Contrast-induced nephropathy in coronarography of patients with type 2 diabetes mellitus: risk factors, prognostic significance, prophylactic approaches].

AIM: To determine risk factors, prognostic implications and prophylaxis of contrast-inducible nephropathy (CIN) during coronarography (CG) in patients with type 2 diabetes mellitus (DM). MATERIAL AND METHODS: Records for 151 patients with type 2 DM and 50 non-diabetic patients examined with CG in A.N. Bakulev Research Center for Cardiovascular Surgery in 2000-2007 were analysed retrospectively. All the patients have undergone clinical examination including tests for blood serum creatinine before and after 48 hours after CG, standard ECG and echocardiography. Glomerular filtration rate was estimated by MDRD formula. Selective CG was made with application of contrast agent Omnipak-300 (iohexol). RESULTS: CIN after CG more frequently developed in diabetics than in non-diabetic patients matched for age, renal function, dose of contrast medium and hydration regime (40.4 and 16%, respectively; p < 0.002). Risk of CIN in patients with type 2 DM was associated with cardiac failure of NYHA class III-IV, anemia, dose of the contrast agent, intake of diuretic drugs before and after the procedure, multiple affection of the coronary vessels, necessity of intervention. Patients with type 2 DM and CIN showed more rapid decline of the renal function, more frequently developed severe cardiovascular events, had worse 1-year survival. CONCLUSION: High probability of CIN and its prognostic significance in type 2 DM patients necessitates assessment of an individual risk for taking preventive measures during conduction of contrast diagnostic procedures.

[Left ventricular remodeling in patients in patients with thyrotoxicosis].

The aim of this paper was to investigate cardiac remodelling in thyrotoxicosis. The geometric parameters of the left ventricle (LV) and the readings of tissue Doppler echocardiography were compared in 27 patients (mean age 53.3±9.2 years) who had first-diagnosed moderate thyrotoxicosis without concomitant cardiac pathology and in 16 healthy individuals (mean age 45.1±4.7 years). The baseline data and the results of incremental treadmill exercise tests were analyzed. It was shown that in the relatively early periods of thyrotoxicosis development, there were decreases in the left ventricle (LV) longitudinally and transversely and in the thickness of LV, without altering its sphericity and conicity. Along with weight loss, there were reductions in cardiac sizes with decreases in the local rates of cardiac wall movement, peak systolic and early diastolic rates of mitral movement velocities. During a treadmill test, there was a drastic reduction in the exercise tolerance threshold as compared to healthy individuals: 57.81±14.7 and 148.3±11.7 W, respectively.

[Cardiac functional reserve and left ventricular parameters in patients with diffuse toxic goiter after drug correction of euthyroidism with thiamazol].

The aim of the investigation was to assess the time course of structural-and-functional and spatiogeometric changes following drug correction of euthyroidism in patients with diffuse toxic goiter and to determine prospects for restoring the cardiac functional reserve after elimination of thyrotoxicosis. The geometric parameters of the left ventricle (LV) and the readings of tissue Doppler echocardiography and exercise tests were compared in 27 female patients (mean age 53.3±9.2 years) who had thyrotoxicosis and 6 months after thyrosole-induced normalization of thyroid-stimulating and thyroid hormone. There were significant increases in myocardial mass and peak systolic and diastolic mitral ring motion rates and an increasing trend for LV linear sizes after correction of euthyroidism. Despite the fact that there were no significant differences in the majority of LV geometric parameters, with euthyroidism achievement, the cardiac functional reserve doubled as compared with the baseline values (105.7±11.4 and 57.8±14.7 W, respectively; p < 0.001), but remained below the control level (148.7±11.7 W; p < 0.05), which may contribute to the development of heart failure in future under certain conditions.

[Disturbances of thyroid function after coronary angiography].

Frequency of thyroid gland functional disturbances after introduction of iodine-containing radiographic contrast agents during coronary angiography was studied in 146 patients, residents of the zone of borderline iodine deficit. Frequency of thyroid pathology was high at baseline (39%). Functional state of the thyroid gland was assessed before and 1, 3, 6, 12 months after investigation. During first month after coronary angiography there were several new cases of thyrotoxicosis and hypothyroidism, as well as deterioration of preexisting functional disturbances of the thyroid. Patients with baseline pathology and functional disturbances of thyroid gland before conduction of coronary angiography should be included into risk group of development of iodine induced states.