Computed Tomography Myocardial Perfusion Imaging With Transesophageal Atrial Pacing Stress Test in Patients With Borderline Stenoses in the Coronary Arteries: a Comparison With Fractional Flow Reserve.

Aim      To evaluate the diagnostic accuracy of cardiac perfusion computed tomography (PCT) with transesophageal electrocardiostimulation (TE ECS) for detection of ischemia in patients with borderline coronary stenosis (50-75 %) compared to measurements of fractional flow reserve (FFR).Material and methods  The study included 25 patients with borderline (50-75 %) coronary stenosis as per data of computed tomography angiography (CTA) or coronary angiography (CAG). Later the patients underwent invasive measurement of FFR and cardiac PCT on a 320-row detector tomograph in combination with the TE ECS stress test.  FFR values <0.8 indicated the hemodynamic significance of stenosis. Myocardial perfusion was evaluated visually based on consensus of two experts.Results All patients completed the study protocol. Cardiac pacing duration was 6 min for all patients. Four patients required intravenous administration of atropine sulphate. PCT with TE ECS detected significant for FFR stenoses with sensitivity, specificity, and predictive value of a positive result and predictive value for a negative result of 47, 90, 87, and 53 %, respectively.Conclusion      PCT with TE ECS in combination with CTA can be considered as an informative method for simultaneous evaluation of the condition of coronary arteries and detection of myocardial ischemia. This method is particularly relevant for assessing the hemodynamic significance of borderline coronary stenoses.

[Computed Tomography Coronary Angiography Possibilities in "High Risk" Plaque Identification in Patients with non-ST-Elevation Acute Coronary Syndrome: Comparison with Intravascular Ultrasound].

Aim      To evaluate structural characteristics of atherosclerotic plaques (ASP) by coronary computed tomography arteriography (CCTA) and intravascular ultrasound (IVUS).Material and methods  This study included 37 patients with acute coronary syndrome (ACS). 64-detector-row CCTA, coronarography, and grayscale IVUS were performed prior to coronary stenting. The ASP length and burden, remodeling index (RI), and known CT signs of unstable ASP (presence of dot calcification, positive remodeling of the artery in the ASP area, irregular plaque contour, presence of a peripheral high-density ring and a low-density patch in the ASP). The ASP type and signs of rupture or thrombosis were determined by IVUS.Results The IVUS study revealed 45 unstable ASP (UASP), including 25 UASP with rupture and 20 thin-cap fibroatheromas (TCFA), and 13 stable ASP (SASP). No significant differences were found between distribution of TCFA and ASP with rupture among symptom-associated plaques (SAP, n=28) and non-symptom-associated plaques (NSAP, n=30). They were found in 82.1 and 73.3 % of cases, respectively (p>0.05), which indicated generalization of the ASP destabilization process in the coronary circulation. However, the incidence of mural thrombus was higher for SAP (53.5 and 16.6 % of ASP, respectively; p<0.001). There was no difference between UASP and SASP in the incidence of qualitative ASP characteristics or in values of quantitative ASP characteristics, including known signs of instability, except for the irregular contour, which was observed in 92.9 % of UASP and 46.1 % of SASP (p=0.0007), and patches with X-ray density ≤46 HU, which were detected in 83.3 % of UASP and 46.1 % of SASP (р=0.01). The presence of these CT criteria 11- and 7-fold increased the likelihood of unstable ASP (odd ratio (OR), 11.1 at 95 % confidence interval (CI), from 2.24 to 55.33 and OR, 7.0 at 95 % CI, from 5.63 to 8.37 for the former and the latter criterion, respectively).Conclusion      According to IVUS data, two X-ray signs are most characteristic for UASP, the irregular contour and a patch with X-ray density ≤46 HU. The presence of these signs 11- and 7-fold, respectively, increases the likelihood of unstable ASP.

[Factors associated with an increase in spatial and frontal QRS-T angles in patients with anterior myocardial infarction].

Aim    To determine existence of a relationship between any clinical, echocardiographic and coronarographic factors and increased spatial QRS-T (sQRS-T) angle and frontal QRS-T (fQRS-T) angle in patients with anterior myocardial infarction.Material and methods    This study included 137 patients aged 62 [53; 72] years with anterior acute myocardial infarction managed at the A.L. Myasnikov Institute of Clinical Cardiology. fQRS-T was calculated as the module of difference between the frontal plane QRS complex axis and the T wave axis. sQRS-T was calculated as a spatial angle between QRS and T integral vectors from a synthesized vectorcardiogram.Results    fQRS-T values for a group (median [25th; 75th percentile]) were 81 [37; 120]°; sQRS-T values were 114 [80; 141]°. The correlation coefficient between fQRS-T and sQRS-T values was 0.41 (p<0.001). fQRS-T weakly but statistically significantly correlated with patients' age (r=0.28; p=0.001), left ventricular ejection fraction (LV EF, r= -0.22; p=0.01), and glomerular filtration rate (r=-0.32; p=0.0002). sQRS-T weakly but statistically significantly correlated with left ventricular end-diastolic dimension (r=0.24; p=0.0048), LV EF (r=-0.28; p=0.0009), and the number of affected segments according to echocardiography data (r=0.27; p=0.002). fQRS-T values were significantly higher in the presence of concurrent arterial hypertension. sQRS-T values were significantly higher in the presence of a history of chronic heart failure. Both fQRS-T and sQRS-T values increased with increasing number of affected blood vessels and Killip class of acute heart failure.Conclusion    In patients after anterior acute myocardial infarction, increases in fQRS-T and sQRS-T are associated with more severe damage of the vasculature, decreased LV EF, and, thus, more severe clinical course of disease.

[Contrast-induced acute kidney injury in patients with stable coronary artery disease: the most important risk factors and prevalence].

AIM: The aim of our study was to assess the prevalence of contrast-induced acute kidney injury (CI-AKI) in patients with stable coronary artery disease (CAD) receiving optimal medical treatment with indications to coronary angiography and intraarterial administration of contrast agents. MATERIALS AND METHODS: 1023 patients with stable CAD were included in the open prospective observational cohort study. The CI-AKI was defined as a rise in serum creatinine 25% from baseline. The mean age of the study group was 61.710.1 years; 72.4% were males and 84.4% had arterial hypertension. A multiple logistic regression model of prediction of CI-AKI was created. RESULTS: CI-AKI developed in 132 (12.9%) of the patients. The multiple logistic regression model included gender, BMI, weight, age, heart failure, diabetes mellitus, arterial hypertension, anemia, hyperuricemia, proteinuria and baseline serum creatinine. Area under the curve for the model was 0.749 (95% confidence interval 0.7030,795;p0.0001). When trying to build a prognostic model, including baseline GFR and contrast volume, the model lost significance and the AUC diminished. CONCLUSION: The CI-AKI remains quite a common kidney injury developing in patients with stable CAD undergoing percutaneous interventions. Several risk factors need to be assessed very carefully before any intervention requiring intraarterial contrast media administration especially in patients with comorbidities.

[Contrast-induced acute kidney injury in chronic coronary artery disease patients with diabetes mellitus and obesity].

AIM: To assess the influence of diabetes mellitus and obesity on contrast-induced acute kidney injury risk in patients with chronic coronary artery disease requiring percutaneous coronary intervention. MATERIALS AND METHODS: 1023 patients with chronic coronary artery disease were enrolled in a prospective, open, cohort study (ClinicalTrials.gov ID NCT04014153). Contrast-induced acute kidney injury was defined as an increase of 25% or more, or an absolute increase of 0.5 mg/dl or more in serum creatinine from baseline value, assessed at 48 hours following the administration of the contrast. The majority of the patients were overweight male ones with BMI 29.25.5 kg/m2. The primary endpoint of the study was the development of contrast-induced acute kidney injury according to KDIGO criteria. RESULTS: The prevalence of contrast-induced acute kidney injury was 12.9% (132 patients). 21.2% suffered from diabetes mellitus, 43% were obese and 12.9% had both diabetes mellitus and obesity. Diabetes wasnt a statistically significant independent risk factor of the contrast-induced acute kidney injury, as well as the combination of diabetes and obesity. In the group of obese patients the prevalence of contrast-induced acute kidney injury was higher (13.4%vs12.5%), but didnt meet statistical significance (p=0.7, OR 0.924, 95% CI 0.641.325). According to the multiple logistic regression model, female gender, age, BMI, weight, arterial hypertension, baseline creatinine were the risk factors of the contrast-induced acute kidney injury development (AUC 0.742,p0.0001). CONCLUSION: Diabetes mellitus was not associated with higher incidence of contrast-induced acute kidney injury. The prevalence of contrast-induced kidney injury was higher in the group of patients with BMI30 kg/m2, but didnt meet statistical significance and needs further evaluation in larger studies.

[Possibilities of Stress Computed Tomography Myocardial Perfusion Imaging in the Diagnosis of Ischemic Heart Disease].

Computed tomography angiography (CT-angiography, CTA) allows noninvasive visualization of coronary arteries (CA). This method is highly sensitive in detecting coronary atherosclerosis. However, standard CTA does not allow evaluation of the hemodynamic significance of found CA stenoses, which requires additional functional tests for detection of myocardial ischemia. This review focuses on possibilities of clinical use, limitations, technical aspects, and prospects of a combination of CT-angiography and CT myocardial perfusion imaging in diagnostics of ischemic heart disease.

[Comparison of myocardial contrast stress-echocardiography and standard stress-echocardiography in detecting myocardial ischemia in patients with different severity of coronary artery stenoses].

AIM: To compare diagnostic value between standard stress-echocardiography and myocardial contrast stress echocardiography in detection of myocardial ischemia in patients with different severity of coronary artery stenoses. MATERIALS AND METHODS: Myocardial contrast stress-echocardiography and standard stress-echocardiography were performed in 38 patients with coronary artery stenoses over 50% by angiography. Of all lesions 39 were intermediate (5075%) and 33 over 75% stenoses. Fractional flow reserve (FFR) was measured in 12 coronary arteries. During myocardial contrast stress-echocardiography wall motion and myocardial perfusion was assessed. RESULTS: Adequate visualisation increased from 81.6% in unenhanced segments to 96.1% in contrast-enhanced segments. The sensitivity, specificity, and diagnostic accuracy of standard stress-echocardiography and myocardial contrast stress-echocardiography in intermediate (5075%) coronary stenoses were 44%, 83%, 56% and 56%, 94% и 64% respectively compare to angiography. Taking into account the 12 arteries with evaluated FFR, these parameters increased to 52%, 93% и 65% in standard stress-echocardiography and to 68%, 100% and 75% in myocardial contrast stress-echocardiography. In coronary stenoses over 75% the sensitivity, specificity, and diagnostic accuracy of standard stress-echocardiography and myocardial contrast stress-echocardiography were 78%, 88%, 80% and 86%, 100%, 92% respectively Conclusion. Use of contrast-enhanced stress-echorardiography significantly increased the diagnostic value of this method by improving endocardial border visualization and possibilities of myocardial perfusion assessment.

[Pharmacoinvasive Approach to the Treatment of Acute ST-Segment Elevation Myocardial Infarction. Current State of the Problem].

The articled focused on the pharmacoinvasive approach to the treatment of acute ST-segment elevation myocardial infarction. Current guidelines prioritize the primary transcutaneous coronary intervention. However, in both the Russian Federation and other countries, there are some peculiarities (logistic issues, specific aspects of infrastructure of medical facilities), which may hamper timely conduction of the endovascular treatment. In such cases, the thrombolytic therapy subsequently supplemented with transcutaneous coronary intervention would appear the most effective strategy aimed at the earliest recovery of coronary perfusion. The authors provided results of major studies that used such approach and the effect of using the thrombolytic therapy with recombinant prourokinase, a Russian third generation thrombolytic drug.

[Factors Associated with the Increase in Spatial and Frontal QRS-T Angles in Patients with Inferior Myocardial Infarction].

Aim      To identify clinical, echocardiographic, and angiographic factors related with an increase in the frontal QRS-T angle (fQRS-T) and the spatial QRS-T angle (sQRS-T) in patients with inferior myocardial infarction.Material and methods  The study included 128 patients aged (median [25th percentile; 75th percentile]) 59.5 [51.5; 67.0] years diagnosed with inferior wall acute myocardial infarction. fQRS-T was calculated as a module of difference between the QRS axis and the Т axis in the frontal plane. sQRS-T was calculated by a synthesized vectorcardiogram as a spatial angle between the QRS and Т integral vectors.Results The fQRS-T for the group was 54.0 [18; 80] and sQRS-T was 80.1 [53; 110]. The correlation coefficient for fQRS-T and sQRS-T values was 0.42 (p<0.001). Both fQRS-T >80° and sQRS-T >110° compared to their lower values were associated with a higher frequency of history of postinfarction cardiosclerosis (44% and 12 %, respectively; p<0.05), a lower left ventricular ejection fraction (51 [47; 60]% at fQRS-T >80° and 55 [50; 60]% at fQRS-T <80° (p<0,05); 49 [44; 57]% at sQRS-T >110° and 57 [51; 60] % at sQRS-T <110° (p<0.01); more frequent development of acute heart failure (16 and 2 %, respectively; p<0.05); and early postinfarction angina (13 and 2 %, respectively; p<0.05). The increased fQRS-T was associated with a higher incidence of damage to the circumflex artery (45 and 20 %, respectively; p<0.05). The increased sQRS-T was associated with a history of arterial hypertension (97 and 76 %, respectively; p<0.05), chronic heart failure (22 and 3 %, respectively; p<0.05), chronic kidney disease (19 and 4 %, respectively; p<0.05), and a larger myocardial lesion (mean number of damaged segments by echocardiography was 3.8 [2; 6] at sQRS-T >110° and 2.6 [1; 4] at sQRS-T <110°; p<0.01). sQRS-T was significantly greater in multivascular damage (87 [68; 121]° than in one- or two-vascular damage (72 [51; 100]°; p<0.05). sQRS-T values were significantly lower with spontaneous reperfusion (66 [29; 79] than without spontaneous reperfusion (77 [55; 115]°; p<0.05).Conclusion      In patients after inferior wall acute myocardial infarction, increases in fQRS-T and sQRS-T were associated with more severe damage of coronary vasculature, decreased left ventricular ejection fraction, and more severe course of disease.

[Spontaneous Coronary Artery Dissection].

During several recent decades spontaneous coronary artery dissection (SCAD) has been known as one of causes of development of acute coronary syndrome (ACS). It has been assumed that this condition is extremely rarely met and is associated with pregnancy and postpartum period. The use in clinical practice of high sensitivity troponin, coronary angiography (CAG) in early period of ACS, in conjunction with the growing awareness of doctors about this pathology led to a revision of the viewse on prevalence of the disease. At present SCAD is considered as one of the causes of ACS in young and middle-aged women. In this review we present results of studies of pathogenesis, diagnostics, and treatment of SCAD, describe various angiographic types of this disease, and discuss problems of choice of optimal strategy of management of patients with SCAD.

[Experience with Prasugrel in the Treatment of Patients with Acute Coronary Syndrome].

BACKGROUND: Dual antiplatelet therapy (DAPT) with aspirin and one of inhibitors of P2Y12 receptors (clopidogrel, ticagrelor, prasugrel) is an international standard of receptors (clopidogrel, ticagrelor, prasugrel) is an international standard of is an international standard of treatment strategy in patients with acute coronary syndrome (ACS). PURPOSE: to analyze experience of prasugrel use in the National Medical Cardiology Research Center in comparison to similar groups of patients treated with other P2Y12 inhibitors for determination of optimal place of DAPT with prasugrel in ACS patients. Materials and methods. We included in this retrospective study 40 patients who received therapy with prasugrel, ticagrelor, or clopidogrel in connection with urgent percutaneous coronary intervention (PCI) performed in the Department of Urgent Cardiology from May to December 2018. We analyzed specific characteristics of prasugrel treated patients including disease history, features of clinical presentation and coronary anatomy, use of strategies of escalation and de-escalation, as well as inhospital mortality, development of complications and side effects. Results. New P2Y12 inhibitors were more effective in patients with higher risk of atherothrombosis compared with risk of bleeding. Median of implanted stents in ticagrelor and clopidogrel groups was equal to 1, in the prasugrel group - 2 stents per PCI. When multivascular stenting was performed the choice usually was made in favor of prasugrel or ticagrelor, excluding cases with presence of limiting factors - use of oral anticoagulants (OAC) (n=4) and prehospital thrombolytic therapy (n=5). Of note was close to statistical significance high number of side effects related to ticagrelor use (n=3, 23.08%, p=0.057). There were no significant differences between groups in rates of unfavorable outcomes and complications. Conclusion. Administration of prasugrel can be considered in patients with high risk of atherothrombosis: with diabetes, with large number of implantable stents. The choice between ticagrelor and prasugrel can be made with consideration of the potential for side effects that significantly impair the quality of life of patients. Main limitations for application of both prasugrel and ticagrelor are the need to permanent use of OAC, prehospital thrombolytic therapy, and higher cost compared to clopidogrel.

[Endovascular closure of a ventricular septal defect from Takotsubo Syndrome].

Takotsubo Syndrome is a transient condition characterized by left ventricular systolic dysfunction. Although the prognosis is excellent in most cases, rare cases of serious complications can occur. We present a case of a 81-year - old woman with Takotsubo Syndrome complicated by ventricular septal rupture that was successfully closed with an occluder Occlutech with good immediate and long - term outcomes.

[Glycoprotein IIb-IIIa antagonist Monafram in primary angioplasty of patients with acute coronary syndrome without st segment elevation].

Glycoprotein (GP) llb-llla anagonist monafram is the F(ab)2 fragments of anti GP llb llla monoclonal antibody FraMon (CRC64). Efficacy and safety of monafram in primary coronary angioplasty of patients with acute coronary syndrome without ST segment elevation (non ST ACS) was evaluated in this study. Monafram was introduced intravenously to 284 patients just before angioplasty at standard dosage - 0.25 mg/kg as single i.v. bolus. Control group included 203 patients. All patients received aspirin (loading dose 300 mg and then 75 mg daily) and more than 90% - clopidogrel (loading dose 300-600 mg and then 75 mg daily). Within 30 days of follow up period monafram decreased by more than 2.5 fold the total amount of unfavorable outcomes (cardiovascular death, myocardial infarction and indications for repeat revascularization due to angina recurrence) - from 19.2% to 7.4% (p<0.001). The rate of indications for revascularization was most strongly decreased - by more than 7 times - from 7.9% to 1.1% (p<0.001). The number of myocardial infarctions was reduced by more than 2 times - from 8.4% to 3.9% (p=0.057). The amount of lethal outcomes did not differ between two groups (2.9% and 2.4% in the control and monafram groups, respectively). In the control group 8.9% patients received monafram during primary angioplasty due to urgent indications. Monafram did not cause any allergic reaction in all tested patients. Major bleeding was registered in one (less than 0.5%) and deep thrombocytopenia (<20000 platelets per 1 ul) - in 3 (1.1%) out of 284 patients. The data obtained indicated that monafram decreased the number of thrombotic complications in non ST ACS patients undergoing angioplasty upon the dual antiplatelet therapy (aspirin+clopidogrel) and without significant increase of dangerous side effects.

[An experience of the use of stem cells in the treatment of patients with myocardial infarction and low ejection fraction].

We present our own experience of assessment of effect of cell therapy on functional state of the myocardium in patients with lowered contractile capacity of the left ventricular myocardium. Intracoronary administration of stem cells in acute myocardial infarction is a safe method of treatment. It does not cause additional damage of the myocardium and does not provoke appearance of malignant arrhythmia. Cell therapy does not affect global left ventricular function. Data we have obtained demonstrate tendency to improvement of myocardial contractile function in dynamics in the majority of studied patients, including patients of the comparison group. This most probably indicates that the given process has been caused by restoration of blood flow to surviving cardiomyocytes after transluminal coronary angioplasty and improvement of function. Confirmation of participation of administered cells in myocardial contraction and improvement of perfusion requires further clinical investigations.

[Results of clinical trials of a novel glycoprotein IIb-IIIa antagonist framon in high-risk coronary angioplasty].

New glycoprotein (GP) IIb-IIIa antagonist preparation framon (Monafram), is the F(ab')(2) fragment of a monoclonal antibody FRaMon directed against GP IIb-IIIa. This preparation blocks GP IIb-IIIa binding with fibrinogen and inhibits platelet aggregation both in vitro and upon intravenous administration. Safety and ability of framon to prevent thrombotic complications in high risk coronary angioplasty (CA) was evaluated in the present study. FRAMON was injected intravenously into 153 patients just before the start of procedure as a single bolus at the dose of 0.25 mg/kg. Control group was formed of 126 patients who underwent angioplasty without GP IIb-IIIa blockers. After framon administration there were no allergic reactions or major bleedings, deep thrombocytopenia (< 50000/microl) developed in 1 patient (< 1%), and antibodies against framon were detected in less than 5% of patients. Number of unfavorable outcomes (cardiovascular death, myocardial infarction, angina recurrence) within 1 month after CA was 3 times higher in control group than in the group of patients treated with framon (11.4% and 3.3%, respectively, p = 0.018). The effect of framon was most strongly pronounced within the first day after procedure -- administration of the drug reduced number of acute thromboses from 6.5% to 0.7% (p = 0.013). Significant differences between numbers of end points was still preserved at 6 months after procedure (25.7 and 14.2% in control and framon groups, respectively, p = 0.023). The data obtained proved safety and clinical efficacy of framon administration in coronary angioplasty with high risk of thrombotic complications.

[Impairment of cardiac sympathetic function in patients with acute myocardial infarction and unstable angina]. / Narusheniia simpaticheskoi innervatsii serdtsa u bol'nykh s ostrym infarktom miokarda i nestabil'noi stenokardiei

AIM: To assess the state of sympathetic innervation of the heart in patients with acute coronary syndrome. MATERIAL: Patients with Q-myocardial infarction (MI, n=36), non-Q-MI (n=13), and unstable angina (UA, n=9). METHODS: Each subject underwent single-photon emission computed tomography (SPECT) and planar scintigraphy using iodine-123 metaiodobenzylguanidine ((123)I-MIBG) for assessment of cardiac sympathetic function. We analyzed early (15 minutes) and delayed (4 hours) images after (123)I-MIBG administration. Resting (99m)Tc-MIBI myocardial scintigraphy was performed for evaluation of myocardial perfusion. Location, extent (%) and severity (Un.) of defects were determined using <> program. (123)I-MIBG did not accumulate in myocardium of 3.5% patients. All other patients demonstrated (123)I-MIBG accumulation defects. These defects were colocolized with (99m)Tc-MIBI uptake abnormalities. However both extent and severity of sympathetic innervation defects exceeded those of perfusion defects in all patients. Mean extent and severity of sympathetic neuronal damage areas were the greatest in patients with Q-MI (41+/-8% and 1119+/-377 Un. respectively) and the least in patients with UA (22+/-12% and 602+/-353 Un., respectively). On the contrary the mean extent of areas with sympathetic endings dysfunction but normal perfusion was the largest in UA group and the least in Q-MI group (18+/-11 and 10+/-7%, respectively, p<0,05). CONCLUSION: Impairment of cardiac sympathetic function in patients with acute coronary syndrome could be detected by SPECT with (123)I-MIBG. Locations of (123)I-MIBG and (99m)Tc-MIBI defects were similar but sympathetic dysfunction areas were larger than areas with reduced perfusion. This result suggests higher sensitivity of sympathetic endings to ischemia compared with cardiomyocytes. Myocardial areas with sympathetic endings dysfunction but normal perfusion can be defined as myocardium at risk.