Vol 8, No 5 (2018)
LECTURES
327-332 1881
Abstract
Tobacco use is the leading preventable cause of premature morbidity and death in the world and it is responsible for approximately 15 years of healthy life lost. The world average smoking prevalence is 21% (35% for men and 6% for women), with the worst situation in low- and middle-income countries. In the Russian Federation, 31% of adults smoke (51% of men and 14% of women); meanwhile in the last decade the prevalence of smoking declines by about 1% per year. From a clinical standpoint, smoking is a behavioral disorder caused by psychophysical dependence from nicotine. Tobacco dependence is associated with the characteristic smoking habits and withdrawal symptoms that prevent successful cessation. The role of physician is to identify smokers on a regular basis, increase their readiness to quit, and support them during a quit attempt. Smoking status should be assessed in any patient who seeks medical care. All tobacco users should be encouraged to quit in a clear and personalized manner. The further content of medical care is determined by the patient’s willingness to make a quit attempt. For those who are not ready to discuss smoking cessation, physician should express readiness to help in a quit attempt at any time. For the patients who are not ready to quit at this time, physician should initiate brief motivational intervention and discuss possible benefits of smoking cessation and obstacles to successful quitting. For those who are ready to quit, physician provides behavioral counselling and prescribes medications (nicotine replacement therapy or nicotinic receptor partial agonists). At the follow-up visits in a week and a month after the quit date, physician should discuss treatment effectiveness and problems with smoking habits. For continued smokers physician should reassess their readiness to quit at the following visits and repeat motivational interviewing. Screening tests for smoking-related diseases should be recommended when necessary.
REVIEW ARTICLE
333-345 5796
Abstract
Biomarkers (various laboratory biochemical markers), such as natriuretic peptides (NP), soluble ST2 receptor, copeptin, galectin-3, are widely studied in patients with chronic heart failure (CHF). The European Society of Cardiology recommends the determination of blood NP level in suspicion of HF and its use as one of the mandatory diagnostic criteria for CHF with preserved and mid-range ejection fraction. Dynamics of NP concentration may be predictor of the effectiveness of the therapy and the necessity of the titration of the dose of HF drugs. Neprilyzin destroys NP, but does not destroy their precursors, including NT-proBNP. Therefore, it is necessary to use NT-proBNP as a marker of therapeutic efficacy and prognosis when using neprilysine inhibitors (sacubitril). ST2 is a protein receptor for interleukin-33 (IL-33). The transmembrane ST2 (ST2L) binds to IL-33 and forms the IL-33/ST2L complex, which has a cardioprotective effect, prevents the development of myocardial hypertrophy, fibrosis and apoptosis. The soluble ST2 receptor (sST2) is a “trap” for IL-33 and neutralizes the protective effects of the IL-33/ST2L complex, which leads to hypertrophy and fibrosis of the myocardium, dilatation of the chambers and reduction of the contractility of the heart. It can be considered as a marker of unfavorable prognosis in heart failure, but it is not specific. Copeptin is a part of the arginine-vasopressin, or antidiuretic hormone, precursor which plays an important role in the pathogenesis of CHF. Since arginine-vasopressin has a short half-life and is unstable outside the body, copeptin is being actively investigated. Its level increases during the CHF decompensation and relates with the functional class of CHF. A combined measurement of the concentration of copeptin and NP may improve the risk stratification in CHF patients. Galectin-3 is a peptide that stimulates the activation of fibroblasts and the development of fibrosis. It increases in CHF patients and is associated with the severity of the condition, systolic and diastolic LV dysfunction and prognosis. Currently, NP are the best biomarkers that can and should be used in routine clinical practice. To prove the need for widespread use of other biomarkers, additional research is needed.
346-360 1614
Abstract
The presented review concerns to current interventional methods of acute pulmonary embolism treatment. The article provides a rationale for catheter approaches, detailed description of patient selection and risk stratification including an estimation of thromboembolic burden, risk degree of acute pulmonary embolism, bleeding risk assessment, and patient-specific considerations. The review contains the up-to-date classification of pulmonary embolism on the basis of 30-day mortality assessment and estimation of disease outcome according to the conventional and simplified Pulmonary Embolism Severity Index. A special attention is paid to interventional methods peculiarly, in particular to catheter directed thrombolysis, rheolytic thrombectomy, thrombus fragmentation and aspiration. The results of studies concerning efficiency and safety of endovascular methods in treatment of pulmonary embolism patients are reported. It was emphasized importance of further investigation of various clinical aspects using these methods for obtaining of comprehensive information about treatment of the dangerous disease associated with significant morbidity and mortality.
361-365 1010
Abstract
The Community-acquired Pneumonia (CAP) is an urgent problem of modern medicine due to its high incidence, morbidity, the increasing resistance of a microflora to antibacterial therapy, a large number of complications and a high lethality. Now in a pathogenesis of pneumonia the leading value belongs to various changes of metabolism, including an induction of peroxide oxidation of lipids and formation of an oxidizing stress. The importance is attached to violations of a functional condition of a liver at pneumonia which pathogenetic mechanisms of damage are diverse, including with participation of a vascular endothelium. At the same time in realization of therapeutic approaches on a normalization of metabolism of cages of an organism the priority part is assigned to oxidation substrata. It is shown that the succinatecontaining medicines realize various pharmacological effects, providing in general cytoprotective action that allows to consider them as perspective the compositions having hepatoprotective activity which are necessary in complex therapy of the community-acquired Pneumonia (CAP).
ORIGINAL ARTICLES
STUDYING OF COMORBID PATHOLOGY AT THE 2 TYPES DIABETES AS THE COMPLICATION OF THE METABOLIC SYNDROME
366-371 1989
Abstract
Purpose. To define features of comorbid pathology at patients with a 2 types diabetes, to estimate a possibility of use of indexes of a comorbid pathology in the management of these patients. Materials and methods. Patients with a 2 types diabetes participated in a research. The retrospective analysis of medical records with calculation of indexes of a comorbid pathology for the systems CIRS, Kaplan-Feinstein, Charlson was made. Taking into account the received indexes at patients prognostic indicators of percentage risk of lethality within the next year and 10-year survival were defined. Correlation interrelations between laboratory indicators of components of a metabolic syndrome and values of indexes of a a comorbid pathology are defined. Results. It was defined that in structure of comorbid pathology at the chosen patients diseases of cardiovascular, nervous and genitourinary systems prevail. Besides the specified systems, at women specific gravity of pathology of endocrine system is big. With age the tendency to prevalence of comorbid pathology of the specified systems remains and also the augmentation of average score of indexes of a comorbid pathology on all systems, deterioration in prognostic indicators is taped. Statistically significant direct link between indexes of a comorbid pathology and separate components of a metabolic syndrome, an experience of a disease of patients is also taped.
372-381 931
Abstract
The aim: to assess the short-term prognostic value of different types of hyponatremia in patients hospitalized for acute decompensated chronic heart failure. Material and methods. A prospective study included 396 patients hospitalized for acute decompensated chronic heart failure. Hyponatremia was diagnosed in cases of serum sodium level less than 135 mmol/l. The pre-hospital hyponatremia was defined as a decreased serum sodium level on admission, whereas the hospital hyponatremia was referred to cases occurred during hospitalization. In patients with pre-hospital hyponatremia drop of sodium levels ≥ 3 mmol/l during hospitalization was defined as a progressive hyponatraemia. The influence of different types of hyponatremia on the hospital prognosis was determined, while the composite primary endpoint was all-cause mortality and/or transfer to the intensive care unit. Results. Patients with hyponatremia were older and had more severe clinical signs of chronic heart failure, lower left ventricle ejection fraction and higher diastolic dysfunction than normonatremic patients. After adjustment for age, comorbidity and severity of chronic heart failure in Cox regression models hyponatremia was an independent predictor of all-cause mortality and transfer to the intensive care unit (odds ratio 3.1; p < 0.05). Pre-hospital hyponatremia had a higher prognostic value on outcome compared with hospital hyponartemia (odds ratio 3.9 versus 2.9, respectively; p < 0.05). Progressive hyponatremia was associated with a marked increase of mortality and transfer to the intensive care unit (odds ratio 6.8; p < 0.05). Conclusion. Pre-hospital and hospital hyponatremia are independent predictors for short-term outcomes in patients hospitalized for acute decompensated chronic heart failure. Progression of the pre-hospital hyponatremia is associated with significantly increase of all-cause mortality and risk of transfer to the intensive care unit.
382-388 2692
Abstract
The article is devoted to medical activity of the sons of the outstanding Russian clinician and scientist Sergey Petrovich Botkin (1832-1889) — Evgeny Sergeevich Botkin (1865-1918) and Sergey Sergeevich Botkin (1859-1910). Sergey Petrovich Botkin is the founder of the first in Russia and one of the largest scientific therapeutic schools. Among the doctors who were trained in the clinic of the Military medical Academy in the years of work of Sergei Petrovich Botkin, were his sons, however, traditionally in the publications on the scientific clinical school of Sergei Petrovich Botkin, their names are not mentioned among his students. The authors made an attempt to trace the stages of the life of the sons of Sergei Petrovich Botkin, in particular, study and work in the Military medical Academy, scientific training abroad, medical activities in medical institutions of St. Petersburg and organization of medical care as part of the red cross during the Russian-Japanese war (1904-1905). The work of Yevgeny Botkin as a court physician of the family of the last Russian Emperor Nicholas II is considered separately. The article reveals the influence of the person S.P. Botkin and his closest disciples on E.S. Botkin and S.S. Botkin, as well as the continuity of clinical views and research of S.P. Botkin and his sons. The authors emphasize the similarity of ethical principles of medical activity, which guided Sergey Petrovich Botkin and his sons. The materials presented in the article confirm that the sons of Sergey Petrovich Botkin — Evgeny Sergeevich Botkin and Sergey Sergeevich Botkin — belong to his scientific clinical school.
389-393 1060
Abstract
This article presents the results of the clinical and statistical evaluation of the calls of patients with atrial fibrillation (AF) by the data of the emergency medical service in Moscow. Ambulance teams was performed a voluntary questionnaire survey of 5003 patients with AF. There were 17% of emergency calls for heart rhythm disturbances from the total number of cardiovascular diseases and 88% of these arrhythmias was AF. A clear trend was observed in the prevalence of AF in men of working age and in women in the older age group. Among the respondents prevails paroxysmal form of AF in 70.1% of cases. The average score on the risk scale of thromboembolic complications in patients with atrial fibrillation/flutter CHA2DS2-VASc was 3.56±1.71. The average score on the scale of risk assessment of ischemic stroke in patients with nonrheumatic atrial fibrillation/flutter CHADS2 was 1.85±1.13. The number of patients with a score of two or more on both scales was 87.7% and 59.3% respectively. 28% of patients with AF asked for medical help at least 48 hours after the onset of the paroxysm. Regular observation by a cardiologist is carried out in 50.5% of cases, by a therapist in 62.8%, jointly by a therapist and a cardiologist in 45% respectively. Continuous oral anticoagulant therapy is performed in 29.8% of patients with AF. The percentage of medical evacuations of patients with AF increased from 23.8% in 2015 to 27.1% in 2016. The study showed that regular clinical and statistical analysis of the effectiveness of medical care for patients with AF at all stages of medical surveillance is necessary.
ANALYSIS OF CLINICAL CASES
394-402 1221
Abstract
A clinical case of a 56-year-old man is presented in which only ventricular tachycardia without clinical and ECG criteria of myocardial ischemia is recorded on the exercise test. The ventricular tachycardia was the only reason for stopping the test. This clinical case demonstrates all the difficulties in determining the genesis of ventricular arrhythmias induced by exercise. The purpose of the work was to show all the difficulties in determining the genesis of exercise-induced ventricular arrhythmia. The literature references related to the exercise-induced ventricular arrhythmia differentiation is rather poor. It is only known that if a patient develops and progresses ventricular arrhythmia, a tredmill test is considered questionable. Exerciseinduced ventricular arrhythmias especially ventricular tachycardia, are the most dangerous. Therefore, additional diagnostic methods were used to reveal the main disease as the background of ventricular tachycardia. Results of pharmacological test with nitroglycerine were the indication of the ischemic origin of ventricular tachycardia. Coronary angiography did not reveal coronary artery stenoses. Positron emission tomography revealed coronary microcirculation disturbance after which a decision about metabolic therapy with Mexicor was made. The correct choice of the drug (Mеxisor) was confirmed by the results of control studies — improvement of metabolism and antiarrhythmic effect. The article concludes that the choice of the treatment exercise-induced ventricular arrhythmia in patients with stable coronary artery disease should be individual and pathogenetic.
ISSN 2226-6704 (Print)
ISSN 2411-6564 (Online)
ISSN 2411-6564 (Online)