The purpose of our study was analysis of myocardial hypoenhancement areas (MHAs) found by multidetector computed tomography (MDCT) in patients with non-ST elevation acute coronary syndrome (NSTEACS) and comparison of these findings with results of standard methods of diagnostics of myocardial infarction and ischemia [electrocardiography (ECG) and echocardiography (ECHO)]. Methods. MHAs were found in 18 of 21 patients with non-ST segment elevation myocardial infarction (NSTEMI) (85.7%) and only in 3 of 22 patients with unstable angina (UA) (13.6%, p<0.0l). In patients with NSTEMI MHAs were interpreted as foci of myocardial necrosis while in patients with UA MHAs could represent either undiagnosed myocardial damage or myocardial ischemia. It was shown previously that “ischemic” MHAs disappear after successful revascularization, whereas defects caused by necrosis remain unchanged for many months. Patients with UA and MHAs (n=3) underwent MDCT in 1 year after revascularization. In 1 patient MHA disappeared and in 1 it decreased in size. In these cases, probably, MHAs represented myocardial ischemia where. In the 3-rd patient the defect size remained unchanged and was considered to be a sign of undiagnosed NSTEMI. Most patients with MHAs had ST-segment ECG dynamics (78% of patients with NSTEMI, 66.7% of patients with UA). In all cases, localization of ST-segment deviation on ECG, myocardial wall motion abnormalities at ECHO and MHAs by MDCT coincided. Detection of MHAs and wall motion abnormalities correlated with each other as the frequency of occurrence (r=0.4; p=0.01), and number of segments involved (r =0.7; p<0.05).

Indications for coronary revascularization in patients with stable coronary heart disease (CHD), presented in the current international guidelines are largely based on the clinical trials conducted sometimes more than 30 years ago. ISCHEMIA is the major multicenter international randomized trial intended to answer the question about the optimal treatment strategy in stable coronary artery disease at the present time. Purpose. To analyze the most important baseline characteristics of patients enrolled in the ISCHEMIA study in one Russian site. Methods. The principal inclusion criteria are a positive stress test (in our center, exercise stress echocardiography) of at least moderate risk and obstructive coronary heart disease confirmed by coronary computed tomography angiography (CCTA). Main exclusion criteria are a significant stenosis of the left main coronary artery by CCTA, clinical progression/destabilization of the ischemic heart disease, angina of IV CCS class, left ventricular ejection fraction (EF) <35%. Enrolled patients are randomized into the conservative or invasive treatment groups. Results. We analyzed the data of 28 randomized patients who completed at least 6 months of follow-up. Mean pts age is 62.6±5.5 years, 75% are males. ^e prevalence of risk factors (RFs) is the following: arterial hypertension - 93%, diabetes mellitus -29%, history of smoking - 64%, family history of CHD - 36%. 36% of pts have the history of myocardial infarction; the median duration of clinical CHD is 24 months. Mean EF is 65%. 100% of patients are taking aspirin, >80% -beta blockers, >80% - ACE inhibitors/ARBs. ^ey are at well controlled resting heart rate (<70 bpm in 82%) and blood pressure (<140/90 mm Hg in 82%). The level of depression by the PHQ-8 scale is 5.35±4.11 (average for chronic diseases). The lipids control and lipid-lowering therapy are inadequate: low density lipoprotein cholesterol (LDL C) is 2.55 (2.04-4.08) mmol/l, LDL C is below 1.8 mmol/l in 18%, only 33% of pts are taking a high-intensity statin. At the end of the 6-month follow-up, LDL C was 2.07 (1.79-2.53), a decrease of 19 (0.58-43.5) %, p=0.003. LDL C was <1.8 mmol/l in 28% of patients and 63% were taking a high-intensity statin. Mean angina CCS class at baseline was 1.8±0.6, 79% of patients having the 2nd CCS class. At the stress test, 78% completed the load of >5 METs, the median ischemic area was 4.0 (3.5-5.5) segments, in 71% the ischemia in the left anterior descendent artery region was provoked. The ratio of interventional to surgical revascularization in the invasive group was 1.2, indicating anatomically diffuse CHD in 45% of these patients. Conclusion. In ISCHEMIA pts enrolled in our center, the main RFs, except the lipid-related, were well controlled at baseline; the lipid-related RFs improved after 6 months. Ischemic symptoms were mild or moderate, but the variables of the stress test and low PCI:CABG ratio indicate the study pts are moderate or high risk pts.

Aim. To study the role of growth factors ((vascular endothelial growth factor (VEGF), platelet derived growth factor AB (PDGF-AB) and basic fibroblast growth factor (FGF-basic)) in the development and progression of chronic heart failure (CHF) in patients with ishcemic heart disease (IHD). Materials and methods. We included in this study 94 patients with CHF. The control group comprised 32 persons. Blood serum levels of growth factors were determined at baseline and after 12 months of observation by enzyme-linked immunosorbent assay. Results. VEGF, PDGF-AB and FGF-basic play an important role in the pathogenesis and progression of heart failure in patients with IHD, determining the increased risk of adverse cardiovascular events in this pathology. Serum activity of growth factors characterizes the severity and course of CHF: with disease progression levels of VEGF and FGF-basic decrease and PDGF-AB concentration increases. Initial low level of VEGF expression regardless of the sex of the patient’s sex, significantly low level of FGF-basic and significantly high PDGF-AB in men characterizes unfavorable course of CHF. Conclusion. A correlation has been established between blood serum levels of VEGF, PDGF-AB and FGF-basic and severity and course of CHF.

Objective. To assess the significance of melatonin, NT-proBNP and morphological markers of myocardial remodeling for predicting the risk of complications after coronary artery bypass grafting (CABG) in patients with ischemic heart disease and chronic heart failure (CHF). Materials and methods. We included in this study 83 patients who underwent CABG in the period from September 2013 to October 2014. All patients before CABG underwent standard laboratory and instrumental examination. Concentrations of melatonin and NT-proBNP were measured in 2 days before and after surgery. The evaluation of morphological markers of myocardial remodeling (expression of MT2 melatonin receptors [MTR2], caspase-3, bcl-2) was carried out in tissue samples taken at biopsies of the right atrial appendage during CABG. Results. Analysis of groups of patients with favorable and unfavorable hospital outcomes revealed no significant differences in serum levels of NT-proBNP. There was a significant decrease in the level of melatonin in the subgroup of patients with unfavorable outcome of CABG in combination with high comorbid load and high degree of apoptosis of cardiomyocytes at the background of moderate and high MTR2 expression. Comparative assessment of pharmacotherapy prior to CABG revealed favorable effect on myocardial remodeling of a combination of perindopril and amlodipine. Conclusion. Preoperative evaluation of the level of melatonin sulfate, apoptosis markers, and comorbid load can serve as prognostic factors of complicated course of the postoperative period after CABG in patients with CHF. The combination of perindopril and amlodipine in patients with heart failure with preserved ejection fraction exerted a significant cardioprotective effect on the myocardium, contributing to a decrease of the apoptotic dominant.

In an noninterventional observational open multicenter program CHRONOGRAF the prevalence of markers of chronic kidney disease (CKD) was studied in 1600 patients with arterial hypertension with and without type 2 diabetes mellitus. Glomerular filtration rate (GFR) was calculated (CKD-EPI formula) and albuminuria (AU) was determined as albumin/creatinine (A/ Cr) ratio in the morning portion of urine. In 49.4% of patients decreased GFR <60 ml/min/1.73 m² and/or A/Cr >30 mg/ g was detected. Decrease of GFR <60 ml/ min/1.73 m² was found in 34.8% of patients, albuminuria >30 mg/g - in 32.6%, combination of reduced GFR and high/very high AU - in 18%. High or very high level of combined risk of progression to CKD and cardiovascular complications had 28.5% of patients.

We present in this paper modern views on components, physiological and pathophysiological effects of the renin-angiotensin system, pathways of its hyperactivation at various stages of the cardiovascular continuum. Special emphasis is made on angiotensin receptor blockers (sartans). Basing on results of analysis of randomized clinical trials of these agents we have outlined clinical situations in which prescription of one or another drug from this group is preferable. For patients with multiple risk factors of cardiovascular complications preferable agent is telmisartan, for patients with nephropathy - irbesartan, for survivors of acute myocardial infarction - valsartan, while for patients with clinical signs of chronic heart failure with low ejection fraction 3 agents can be designated as preferrable - losartan, valsartan, and candesartan.

Purpose. To study capabilities of perfusion-metabolic myocardial scintigraphy for prediction of the left ventricular (LV) reverse remodeling after comprehensive surgical treatment of ischemic cardiomyopathy (ICMP). Methods. Жє study included ICMP patients aged 56±7 years (n=32) who underwent surgical correction of LV dysfunction (myocardial revascularization, LV reconstruction, and mitral valve restoration). Inclusion criteria were significant coronary artery disease; myocardial infarction; New York Heart Association (NYHA) class III-IV heart failure; LV ejection fraction (EF) ≤45%; LV end-systolic index (ESI) >60 mL/m²; and LV akinesia or dyskinesia according to echocardiography. Before surgery all patients were subj ected to scintigraphy with^99mTc-MIBI (to assess perfusion) and with¹²³I-BMIPP (to assess myocardial metabolism). Scintigraphy results were expressed as median and lower; upper quartile (Me [lQj hQ]). Ue clinical status and ventricular volume indicators were evaluated before surgery, in the early post-operative period (up to 4 weeks), and in the late post-operative period (12 months). Results. At 12 months after intervention patients were divided into two groups: group 1 comprised patients (n=18) with beneficial outcome of the operation that stopped LV remodeling (ESI decreased, remained unchanged, or increased by <15% compared with early postoperative period. Group 2 comprised patients (n=14) in whom LV remodeling progressed despite successful surgery (ESI increased ≥15% compared with early postoperative period). Groups did not significantly differ by preoperative echocardiography data and clinical status. Significant differences were found in the following scintigraphic parameters: metabolic defect on delayed images (26.5% [20.6%; 32.4%] vs. 38.2% [16.2%; 44.1%], p=0.02), and perfusion-metabolic mismatch (PMM) on early (5.9% [- 5.9%; 7.4%] vs. 1.5% [- 7.4%, 1.5%], p=0.02,) and on delayed (14.7% [5.9%; 27.9%] vs. 4.4% [2.9%; 7.4%], p <0.0001) scans in groups 1 and 2, respectively. PMM on delayed scans had the largest area under the ROC-curve (AUC=0.778, p<0.0001). PMM cutoff value of 12% allowed to predict the efficacy of comprehensive surgical treatment for LV dysfunction with sensitivity and specificity of 100 and 56%, respectively. Conclusion. In patients with ICMP results of myocardial perfusion-metabolic scintigraphy can be used in prognostication of reverse cardiac remodeling in the postoperative period.

Le review is devoted to the problem of medication adherence in elderly patients with chronic heart failure. We consider here specificity of approach to management of elderly outpatients, groups of factors associated with medication adherence, and possible ways to improvement of compliance to treatment in patients from the senior age group with heart failure.

The prevalence of multicomponent therapy in treatment of cardiovascular diseases makes fixed combinations of drugs very useful. The fixed combination of rosuvastatin with ACE inhibitor lisinopril and calcium antagonist amlodipine allows to control effectively two main cardiovascular risk factors: hypercholesterolemia and arterial hypertension. The efficacy of each of the components and their combined administration in primary and secondary prevention of cardiovascular disease has been demonstrated in clinical studies. Ue convenience of several drugs combination in a single tablet increases adherence to therapy facilitating regular intake of all treatment components and reliably reducing the risk of cardiovascular complications.

We present in this article 2 cases of successful pharmacological restoration of sinus rhythm by a new class III antiarrhythmic drug refralon in patients with obesity and persistent atrial fibrillation. In both cases, the effective use of refralon was preceded by repeated ineffective attempts of electrical cardioversion. In the article we discuss the role of obesity as the factor leading to a substantial increase of transthoracic electrical resistance, and thus significantly reducing the probability of sinus rhythm restoration by means of electrical cardioversion. The clinical examples described in this article clearly show that the use of refralon may represent a unique clinical alternative to electrical cardioversion for sinus rhythm restoration in patients with persistent atrial fibrillation, and in some cases where the success of electrical cardioversion is obviously questionable, like in patients with severe obesity, the use of refralon seems preferable.

The article presents a clinical case of development of noncoronary myocardial necrosis with cardiac rupture in a young woman at a background of severe stress.