Репозиторий Университета

© 2018 Limited Liability Company KlinMed Consulting. All Rights Reserved. In the clinical practice a physician quite often is at a loss due to “freedom of choice” granted by availability of direct oral anticoagulants (DOAC). If a patient with nonvalvular atrial fibrillation (AF) has indications for therapy with anticoagulants which DOAC should be preferred? What are benefits for a patient with ischemic heart disease and AF when definite NOAC is chosen and what are risks inherent of this choice? Answers to such questions are given in this paper.

© 2018 Stolichnaya Izdatelskaya Kompaniya. All rights reserved. This article affects the problems of using NOAC in the most defenseless groups of patients with atrial fibrillation: those who have high bleeding and high thromboembolic risk and elderly. The focus is on comparison of effectiveness and safety of NOACs based on randomized clinical trials (RCT) and real-world data (RWD). The possible reasons for the different interpretation of the data of the RCT and the RWD are shown. Use of NOAC in reduced doses prescribing according to RCT and RWD are shown. Our own 13-month observation of patients 75 years and older with very high thromboembolic risk (CHA2DS2-VASc-4,5 points) on rivaroxaban therapy are presented. Good efficacy and safety of full and reduced doses of rivaroxaban were demonstrated: only 2 episodes of small bleedings and no large bleedings (ISTH criteria) were detected as well as no thromboembolic events. Thus, even difficult patients with AF and comorbidity may be safely and effectively treated with NOACs taking into consideration integrated approach and correction of modifiable risk factors.

© 2018 Limited Liability Company KlinMed Consulting. All Rights Reserved. Is this paper discuss problems of selection of anticoagulant therapy in elderly patients with atrial fibrillation, use of unreasonably low doses of anticoagulants, their risks and adherence to therapy is discussed in the paper.

© 2018 Stolichnaya Izdatelskaya Kompaniya. Aim. To study the changes in the stiffness of the arterial wall, vasomotor function of the endothelium, and appearance of new cases of atrial fibrillation (AF) in patients with arterial hypertension with long-term treatment with lisinopril. Material and method. 66 hypertensive patients with cardiac sinus rhythm at the age of 48-64 years (mean age 58.4±4.2 years) were included into the study. They were randomized into 2 groups: patients of group 1 (n=35) were prescribed lisinopril or a combination of lisinopril with hydrochlorothiazide over the 5-year follow-up; patients of group 2 (control) did not receive angiotensin converting enzyme inhibitors or angiotensin II receptor blockers. The follow-up duration was from September 2010 until June 2016. It included telephone calls once every 3 months and annual clinical, instrumental and laboratory examination. The new-onset AF was identified by the 24-hour Holter ECG monitoring results and by patient symptom diaries. Results. New-onset AF was registered in 2 patients (6%) in the lisinopril group and in 4 patients (13%) from the control group (p=0.001) over the 5-year follow-up. Lisinopril significantly reduced AF incidence in hypertensive patients. The patients on lisinopril were found to have no significant changes in the left ventricular mass index and left atrial size according to echocardiography done after the 5-year follow-up whereas in the patients of control group both parameters increased significantly. Lisinopril contributed to the maintenance of endothelial vasodilator function and prevented increase in arterial wall stiffness. Conclusion. Long term lisinopril treatment was found to significantly reduce the AF incidence in hypertensive patients over the 5-year follow-up. Lisinopril demonstrated organoprotective properties throughout the cardiovascular disease continuum and can be recommended for primary prevention of arrhythmia in hypertensive patients..

© 2018 Stolichnaya Izdatelskaya Kompaniya. The article presents a clinical observation of the left atrial appendage thrombosis in a 51-year-old female patient with a paroxysmal form of nonvalvular atrial fibrillation which occurred despite long-term anticoagulant therapy with apixaban in a full dose (5 mg b.i.d.), and the patient's management. The patient was admitted with recurrent symptomatic paroxysm for more than 48 hours, because of which, in accordance with the recommendations, transesophageal echocardiography was performed before an emergency rhythm restoration. Thrombus in the left atrial appendage 0.5×1.03 cm in size was detected. It was decided to refrain from the immediate restoration of the rhythm due to the very high risk of thromboembolic complications. In connection with the categorical refusal of the patient from warfarin, it was decided to replace apixaban with another direct oral anticoagulant - dabigatran 150 mg bid for a period of 4 weeks followed by performing a control transesophageal echocardiographic study. As a result, no thrombus was found on control echocardiography. The particularity of this observation is concomitant hypertrophic cardiomyopathy and diabetes mellitus type 1 in this patient..

Copyright: © 2018 Sapelnikov et al. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 License. Mitral valve disease, including dysfunction of the mitral valve, is often accompanied by atrial fibrillation. Among the patients with prosthetic mitral valves, atrial fibrillation occurs in 30-50% cases. Development of atrial arrhythmias and incisional tachycardia in the early and late postoperative periods can significantly influence patients' rehabilitation and prognosis. Our clinical case describes a patient with a mechanical mitral valve and incisional tachycardia, which led to progression of heart failure and reduced left ventricular systolic function. The patient underwent catheter ablation with non-invasive myocardium mapping. The case reveals the potentials of treatment of incisional tachycardia and atrial fibrillation, which do not respond to drug therapy. Modern methods of visualization enable the cardiac surgeons to reduce possible intraoperative risks and development of complications in this group of patients.

© 2018 Russian Electronic Journal of Radiology.All Rights Reserved. Purpose. Modern methods of diagnostics and visualization allow timely identifying and sometimes even preventing the development of complications. Our clinical case demonstrates the possibilities and diagnostic algorithm of such serious complication of catheter ablation as pulmonary vein (PV) stenosis. Materials and methods. 61-year old patient after repeated catheter ablations is presented. Results. The use of echocardiography and MSCT allowed determining the stage and characteristics of PVs stenosis. Catheter ablation is one of the most common and effective methods in atrial fibrillation treatment. However, significant increase in number of operations and specialists who perform catheter ablation, leads to appearance of specific complications. Modern methods of visualization and diagnostics allow to timely recognize and sometimes even prevent the development of complications. Conclusion. An echocardiography and MSCT are the main instruments in diagnostics of PVs stenosis.

© 2018 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved. Aim. To evaluate the changes of endothelial function in arterial hypertension (AH) patients with paroxysmal atrial fibrillation (AF) in treatment with propafenone (Propanorm, PRO.MED.CS Praha a.s.) in comparison with bisoprolol. Material and methods. To the study, 62 AH patients included with paroxysmal AH, age 45-63 y.o. (mean age 54,5±3,7 y.o.). Patients were randomized to 2 groups: 32 of group 1 (main) for rhythm-control were taking propafenone (Propanorm, PRO.MED.CS Praha a. s.) 450 mg daily, and 30 of group 2 (comparison) were taking bisoprolol for rate control. The groups were comparable by gender, age, severity of AH and duration of arrhythmia. Changes in endothelium vascular motion function and biochemical markers of endothelial dysfunction were assessed at inclusion and in 12 months of therapy. Results. Sinus rhythm retention in propafenone group facilitated the improvement of vascular motion function of endothelium - endothelium dependent vasodilatation of brachial artery showed tendency to rise significantly from 5,4±0,3% to 6,9±0,1% (р=0,01). In patients taking bisoprolol for pulse reduction during 12 months, there was negative tendency from 4,8±0,2% to 3,6±0,1% (р=0,003), that points on worsening of endothelial function with persistent AF. Repeat measurement of biochemical markers of endothelial dysfunction revealed that in 12 months there is raise of endothelin concentration in both groups. Value of the collagen-binding activeness of von Willebrand factor in 12 months significantly reduced from 131±12 to 118±6 U/dL (р<0,05) in those retaining sinus rhythm with propafenone, and increased from 135±11 U/dL to 147±12 U/dL in those with rate control by bisoprolol. Conclusion. In AH patients with paroxysmal AF retention of sinus rhythm with propafenone facilitated the improvement of vascular motion function of endothelium and decrease of collagen binding activeness of von Willebrand factor.

© 2018 Stolichnaya Izdatelskaya Kompaniya. В последние годы наблюдается очевидная тенденция увеличения в популяции числа пожилых больных. Эти пациенты в большинстве случаев страдают несколькими коморбидными заболеваниями, что значительно утяжеляет прогноз и усложняет тактику ведения. Представлен клинический случай пожилой пациентки, длительное время страдающей сахарным диабетом 2 типа, получающей инсулинотерапию, нахо- дящейся на программном гемодиализе из-за терминальной хронической почечной недостаточности, а также имеющей постоянную форму фибрилляции предсердий. Пациентка была госпитализирована в ГКБ №1 им Н.И. Пирогова по поводу острого повторного инфаркта миокарда. Проведено экстренное чрескожное коронарное вмешательство, стентирование инфаркт-зависимой артерии стентом с лекарст- венным покрытием. Послеоперационный период осложнился развитием острой кровопотери на фоне кровотечения из верхних отделов желудочно-кишечного тракта, тяжелой анемии сочетанного генеза (постгеморрагической, нефрогенной), что потребовало от врачей принятия нестандартных решений по выбору антитромботической терапии. Данный клинический случай иллюстрирует сложности ведения пожилых полиморбидных пациентов в реальной клинической практике, и спорные вопросы, возникающие при назначении им антитромботической терапии, особенно, после развившегося кровотечения. Рекомендательные документы не могут дать ответ на все вопросы, которые ставит перед врачом повседневная практика. В каждом конкретном случае возобновление антитромботической терапии и ее оптимальный выбор для пожилого полиморбидного пациента с развившимся кровотечением является предметом дискуссии, и представляет для лечащего врача настоящий вызов.

© 2018 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved. A literature review provided, on the usage of various schemes of perioperational anticoagulation therapy (ACT) in atrial fibrillation patients undergoing scheduled surgery. It is noted that clinicians quite often pass through a situation when patients taking ACT require invasive investigations and surgery. Perioperational management of such category of patients is complicated as, on the one hand, the surgery under ACT is associated with intraoperational hemorrhagic complications, and, on the other hand, ACT cessation might increase the risk of thrombotic complications. The variants assessed, of different periprocedural ACT in patients taking vitamin K antagonists. It was found that as an alternative to continuous ACT recently, bridge therapy with low molecular weight heparins applied, aiming the decrease of the risk of bleeding in adequate thromboprophylaxis. The results of clinical trials provided on the assessment of bridge therapy in surgery. Risk stratification approaches presents for thromboembolic and hemorrhagic complications in surgery.

© 2018 Stolichnaya Izdatelskaya Kompaniya. Acute myocardial infarction (AMI) is one of the main causes of morbidity and mortality, both in the Russian Federation and around the world. Approximately, in up to 10% of patients with clinical diagnostic features of AMI, early angiography does not reveal an occluded vessel or possibly any evidence of coronary artery disease. These patients constitute an intriguing subgroup referred to as "Myocardial Infarction with Non-Obstructive Coronary Arteries" (MINOCA). MINOCA is a collective concept that unites many different pathologies, which determines the essential heterogeneity of the etiological factors. Coronary artery embolism is recognized as an important non-atherosclerotic cause of AMI. In turn, the most common underlying disease in those with coronary embolism is the atrial fibrillation. The advantages of reperfusion strategy and cardioprotective therapy in the treatment of obstructive arteriosclerosis are well studied, widely presented in the literature and supported by a strong evidence base, while the issues of diagnosis and treatment of patients with MINOCA are currently widely discussed We present two clinical cases of embolic myocardial infarction in patients with atrial fibrillation, diagnosed in our clinic in 2017..

© 2018 Media Sphera Publishing Group.All rights reserved. Purpose: To assess the prevalence of atrial fibrillation (AF) and use of antithrombotic agents in adult patients with acute coronary syndrome (ACS). Materials and Methods. We consecutively enrolled all ACS patients (n=1155) who were hospitalized in two Moscowbased percutaneous coronary intervention centers (each center performs over 500 PCIs a year) between October 2017 and February 2018. AF was diagnosed in 204 patients (17.7%). The risk of thromboembolic complications was assessed using the CHA2DS2-VASc Score. The risk of hemorrhagic complications was assessed using the HAS-BLED Score. The data were processed using StatSoft Statistica 10.0 and IBM SPSS Statistics v.23 software. Results. The prevalence of diagnosed AF was 13.6%, while the prevalence of undiagnosed AF was 4.1%. Of the 179 discharged patients with AF, only 2 had a low risk of ischemic stroke (IS). One hundred and fifty patients (83.8%) eligible for oral anticoagulant therapy received oral anticoagulants. Patients with diagnosed AF were administered oral anticoagulants (OACs) significantly more often than patients with undiagnosed AF [125 (91.9%) vs. 25 (58.1%), р 0.001]. Novel oral anticoagulants (NOACs) were administered four times more often than vitamin K antagonists [120 (80.0%) vs. 29 (19.3%), р0.001]. Rivaroxaban was used in 51.3% of cases. Of the 29 patients treated with warfarin, only 3 (10.3%) achieved the target international normalized ratio (INR) at discharge. Of the 107 patients who underwent percutaneous coronary intervention (PCI), 77 patients (80%) received an OAC and two antiplatelet agents (with 74% receiving this three-agent therapy for one month), 11 patients (10.3%) received an OAC and an antiplatelet agent, and 18 patients (16.8%) received two antiplatelet agents. The only antiplatelet agent used as part of the three-agent therapy was clopidogrel. The three-agent therapy without PCI was administered in 43.1% of cases. Conclusion. We found that the prevalence of AF in patients with ACS was high. The fact that doctors administered NOACs suggests that they are aware of the need to use these agents to prevent thromboembolic complications in AF patients.

© 2018 Media Sphera Publishing Group. All rights reserved. Purpose: To assess effectiveness of algorithms of minimization of right ventricular pacing (MRVP) for prevention of progression of atrial fibrillation (AF), lowering of frequency of hospitalizations due to cardiovascular causes, and mortality in patients with sick sinus syndrome (SSS) and history of paroxysmal AF compared with standard compared with dual-chamber pacing (DDDR). Materials and methods. We included in this single-center prospective study 74 consecutive patients with indications to permanent DDDR pacing because of SSS combined with documented history of paroxysmal AF. Patients were randomized in the groups of DDDR pacing (n=3 6) and with activated algorithms of MRVP (n=38). Pacemaker check up was made after 6 months during I year after device implantation. Primary composite endpoint included development of persistent AF, hospitalization due to cardiovascular causes, and all cause death. Results. During follow-up there was no statistically significant difference in achievement of the primary endpoint (27.8 and 18.4% in groups of DDDR pacing and activated algorithms of MRVP respectively (relative risk 1.29% confidence interval 0.43 to 3.86; p=0.25). Rate of development of persistent AF in both groups was comparable (8.6 and 5.3% in DDDR and MRVP groups, re-spectively; p=0.47). Median AF burden was 6.0 (0;42) and 6.0 (0;42) min/day in DDDR and MRVP groups, respectively (p=0.67). Conclusion. Our study failed to demonstrate advantages of the use of algorithms of decreasing "unmotivated" right ventricular pacing over standard regimen of standard DDDR pacing in patients with SSS and history of paroxysmal AF.

© 2018 Stolichnaya Izdatelskaya Kompaniya. The choice of anticoagulant therapy in patients with atrial fibrillation (AF) and concomitant diseases - coronary heart disease (CHD), including acute coronary syndrome (ACS) in history, peripheral arterial disease (PAD), is discussed in the article. The overall mortality and incidence of myocardial infarction in patients with CHD and AF is higher than in patients with AF without CHD. Patients with AF and PAD compared to patients with AF without PAD have higher risks both stroke and systemic embolism. The prescription of triple antithrombotic therapy is necessary for patients with a combination of AF and CHD who underwent percutaneous coronary interventions (in ACS or elective surgery). The possibility of prescription and duration, the choice of specific drugs and their doses should be determined individually, based on the risks of ischemic events associated with stenting, the risk of ischemic stroke and bleeding. Use of new oral anticoagulants (NOAC) instead of vitamin K antagonists (eg, warfarin), low doses of NOAC, studied in trials and proven efficacy in the prevention of stroke/systemic embolism, the use of clopidogrel as a drug of choice from the P2Y12 inhibitor group, the use of low doses of acetylsalicylic acid (ASA), the routine administration of drugs from the proton pump inhibitor group is recommended to minimize the risk of bleeding. The data of subanalysis of the ARISTOTEL randomized clinical trial, indicating a high profile of efficacy and safety of apixaban in patients with AF, depending on the presence of CHD, PAD, concomitant use of ASA, are also presented in the article. The benefits of apixaban over warfarin for reducing the risk of stroke/systemic embolism, total mortality and the risk of bleeding in a subgroup of CHD patients are just as obvious as in the general population of the ARISTOTLE study, and in the subgroup of patients without CHD. Treatment with apixaban, both in the subgroup of patients taking ASA, and a subgroup of patients without ASA, is accompanied by a lower risk of strokes and systemic embolism and a lower incidence of major bleeding. The risk of stroke or systemic embolism was similar in patients with AF and PAD randomized to the apixaban group or to the warfarin group, as well as in patients with AF without PAD. Patients with AF and PAD who received apixaban or warfarin had a similar incidence of major bleeding or clinically significant minor bleeding..

© 2018 Media Sphera Publishing Group. All rights reserved. This article presents an overview of data of Russian and foreign literature on possible associations between cognitive impairment and atrial fibrillation (AF). It includes modern classification of cognitive impairment, mechanisms of the effect of AF on cognitive functions and development of dementia, recommendations for the prevention of cognitive impairment in patients with AF. Special attention is paid to the assessment of cognitive status, and safe anticoagulant therapy, which is a priority in the prevention of cognitive impairment in patients with AF. Analysis of literature showed greater efficacy and safety of drugs from the group of Non-Vitamin K Antagonist Oral Anticoagulants (NOAC), rivaroxaban in particular, in comparison with warfarin. Drugs from the NOAC group can be recommended for prevention stroke, cognitive impairment and dementia in elderly patients with AF.

© 2018 Kryukov et al. Introduction: Difficulties in non-vitamin K anticoagulant (NOAC) administration in acute stroke can be associated with changes in pharmacokinetic parameters of NOAC such as biotransformation, distribution, and excretion. Therefore, obtaining data on pharmacokinetics of NOAC and factors that affect it may help develop algorithms for personalized use of this drug class in patients with acute cardioembolic stroke. Patients and methods: Pharmacokinetics of apixaban in patients with acute stroke was studied earlier by Kryukov et al. The present study enrolled 17 patients with cardioembolic stroke, who received 5 mg of apixaban. In order to evaluate the pharmacokinetic parameters of apixaban, venous blood samples were collected before taking 5 mg of apixaban (point 0) and 1, 2, 3, 4, 10, and 12 hours after drug intake. Blood samples were centrifuged at 3000 rpm for 15 minutes. Separate plasma was aliquoted in Eppendorf tubes and frozen at —70°C until analysis. High-performance liquid chromatography mass spectrometry analysis was used to determine apixaban plasma concentration. Genotyping was performed by real-time polymerase chain reaction. CYP3A isoenzyme group activity was evaluated by determining urinary concentration of endogenous substrate of the enzyme and its metabolite (6-β-hydroxycortisol to cortisol ratio). Statistical analysis was performed using SPSS Statistics version 20.0. The protocol of this study was reviewed and approved by the ethics committee; patients or their representatives signed an informed consent. Results: ABCB1 (rs1045642 and rs4148738) gene polymorphisms do not affect the pharmacokinetics of apixaban as well as CYP3A5 (rs776746) gene polymorphisms. Apixaban pharmacokinetics in groups with different genotypes did not differ statistically significantly. Correlation analysis showed no statistically significant relationship between pharmacokinetic parameters of apixaban and the metabolic activity of CYP3A. Conclusion: Questions such as depending on genotyping results for apixaban dosing and implementation of express genotyping in clinical practice remain open for NOACs. Large population studies are required to clarify the clinical significance of genotyping for this drug class.