ORIGINAL INVESTIGATIONS
The purpose was to reveal the value of separate indications for myocardial revascularization as well as their combinations for choosing invasive or conservative strategy of treatment in patients with stable coronary artery disease (CAD) during 2012–2015 years.
Materials and methods. The retrospective data of 1196 patients (mean age: 52.5 ± 8.4 years; 77,0 % men) were analyzed, from the register of patients with stable CAD (2012–2015 years), who had separate indications for myocardial revascularization and their combination. Patients were divided into 2 groups: with an invasive (n = 481 patients without considering the revascularization method) and conservative (n = 715 patients) treatment strategy. Indications for revascularization are taken from the recommendations of the European Society of Cardiology 2014.
Results. The most common indication for myocardial revascularization was the presence of any coronary stenosis in combination with the limiting angina in the context of optimal medication (88.1 % in the invasive treatment group, 94.3 % in the conservative therapy group, p < 0.001). In half of the patients in both groups this indication was found in isolation, in the rest – in combination with other indications for surgical treatment. Among the combinations of indications, significant differences between the groups showed the following. Stenosis of the LM >50 % + proximal stenosis LAD >50 %+ limiting angina pectoris occurred in 1.5 % of the patients in the invasive treatment group versus 3.8 % with the conservative strategy (p = 0.020). Proximal stenosis LAD >50 % was more common among operated patients (10.6 % vs 4.6 % in the conservative treatment group, p <0.001). Two- and three-vessel lesions + ejection fraction LV <40 % + limiting angina pectoris also occurred more frequently in the invasive treatment group (2.5 % vs 0.6 % in the conservative strategy group, p = 0.006).The remaining indications for myocardial revascularization and their combination were equally common in both groups.
Conclusion. The presence of isolated proximal LAD stenosis or multivessel lesion with reduced left ventricular function accompanied with limiting angina was associated with the choice of invasive strategy in patients with stable CAD (data for 2012–2015 years). The lesion LM combined with proximal stenosis LAD and limiting angina pectoris and requiring coronary artery bypass grafting was associated with the choice of a conservative strategy. Almost half of the patients (48.6 %) had revascularization to improve the quality of life.
The study objective is to examine the effectiveness of physical rehabilitation in patients after coronary bypass surgery at the stationary stage.
Materials and methods. The study included 112 patients with ischemic heart disease and saved systolic function of the left ventricle (heart ejection fraction >35%) after coronary artery bypass surgery (CABS). The first group consisted of 60 patients who received standard program of physical rehabilitation with controlled training on treadmill in early postoperative period. Cardiovascular exercises with intensity of 3–6 metabolic equivalents (MET) started at 3–4 days after surgery on treadmill and continued until discharge from the hospital; simultaneously careful monitoring of hemodynamic parameters was performed. The second (control) group included 52 patients who received standard physical rehabilitation activities. At the end of stationary stage of physical rehabilitation all patients completed the questionnaire SF-36 Health Status Survey.
Results. Initially, according to clinical, demographic and perioperative characteristics the compared groups did not differ statistically. At the end of the program of physical rehabilitation for the average value of the total post-operative bed-day in the first (median was 8) and in the second group (median was 9) statistically significant differences were obtained (p <0.0001), which were in favor of the studied population. In the first group tolerance to physical exertion increased by 3 MET and in general it was 6 MET. According to the results of the questionnaire SF-36 in the group of patients with cardiovascular exercises, the average indexes of physical, role functioning, mental health were significantly different from the results in the control group (accordingly p = 0.0038, p <0.0001, p = 0.033).
Conclusion. Implementation in the program of physical rehabilitation in patients after CABG controlled cardiovascular exercise on treadmill at a hospital stage does not increase the incidence of complications, and the use of elements of early rehabilitation help to improve tolerance to physical exertion. In addition, the program of early physical rehabilitation improves subjective health parameters according to the questionnaire of life quality assessment SF-36 and reduces the duration of the postoperative bed-day.Objective: to carry out a complex assessment of life quality (LQ) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) according to SF-36 questionnaire.
Materials and methods. The study included 20 patients who underwent in-patient examination and treatment in City Clinical Hospital № 1 n.a. N.I. Pirogov (Moscow City Healthcare Department) to confirm the diagnosis of CTEPH and for selection of drug therapy. All patients completed a standardized SF-36 questionnaire. The possible association of various parameters of this questionnaire with both clinical and instrumental data of patient’s examination was studied.
Results. Statistically significant correlations between the clinical symptoms of the disease, the severity of pulmonary hypertension, and the assessment of the possible physical activity of patients with CTEPH with various scales of mental and physical functioning of SF-36 questionnaire have been obtained.
Conclusion. The study of QL parameters increases the possibilities for a comprehensive assessment of health status in patients with CTEPH. Based on this finding, SF-36 questionnaire can be used in routine clinical practice to assess the disease severity. Increasing the patient’s number as well as carrying out a dynamic QL study according to sex and age of patients with SF-36 questionnaire will further allow to develop additional criteria for assessing the effectiveness of therapy.
The aim of our study was to determine the characteristics of structural and functional changes of myocardium and aorta by echocardiography in women with ischemic heart disease (IHD) cause-specific from the presence of osteoporosis.
Materials and methods. We examined 170 postmenopausal women aged from 57 to 78. Inclusion criteria: female gender, age over 50 years, the presence of menopause, the presence of IHD. Exclusion criteria: endocrine system diseases, severe heart failure, respiratory insufficiency, secondary osteoporosis. Postmenopausal osteoporosis was diagnosed according to the Clinical Recommendations for the Prevention and Management of Osteoporosis Patients (2016). All women were divided into 2 groups: group 1 – 72 women with proven diagnosis of osteoporosis and IHD, group 2 – 98 patients with isolated IHD (comparison group). IHD was represented by 2 forms: angina pectoris and postinfarction cardiosclerosis. The frequency of postinfarction cardiosclerosis was not statistically different between groups. Also the groups were comparable in age, weight, body-weight index, levels of peripheral (office) blood pressure.
Results. In women with osteoporosis and IHD we revealed higher values of interventricular septum thickness (p = 0.034), left ventricle posterior wall (p = 0.004), and the relative thickness of left ventricular posterior wall (p = 0.0038). An increasing rate of left ventricular hypertrophy was observed in patients with combination of osteoporosis and IHD – 51.4 % versus 39.8 % in women with IHD without osteoporosis (p = 0.002). Osteoporosis was associated with a higher incidence of diastolic left ventricular dysfunction: 90 % versus 70.4 %, as well as with pathological types of left ventricular remodeling (p = 0.01); concentric remodeling type dominated among women with combined pathology (p = 0.09). A higher incidence of aorta calcification 1.86 times (p = 0.00013) and calcified aortic stenosis (13.8 % versus 4.08 %; p = 0.02) were noted in patients with osteoporosis.
Conclusion. We found that osteoporosis in postmenopausal women was associated with an increasing of heart remodeling parameters, an increasing of diastolic dysfunction frequency and pathological types of left ventricle geometric remodeling with prevalence of concentric type remodeling. Patients with osteoporosis had a higher prevalence of aortic calcification and calcified aortic stenosis.The aim of study: to estimate the frequency of postoperative complications and the ways of their reduction in patients after performing «large volume» surgical interventions on the example of radical cystectomy (RCE).
Materials and methods. The study included 73 patients who underwent RCE. All patients were divided into 2 groups: the main group consisted of 29 patients who remained under the active supervision of the therapist throughout the entire hospitalization and underwent preoperative preparation (cardiac examination, correction and prescription of medication). The comparison group comprised 44 patients whose medical history was retrospectively analyzed. Patients of this group did not undergo advanced therapeutic monitoring, both in the preoperative and postoperative period.
Results. In patients of the main group, despite the presence of concomitant pathology in most cases, including cardial pathology, the frequency of postoperative complications was statistically significantly lower than in the comparison group. There were no lethal cases from cardioembolic complications in patients undergoing active therapeutic monitoring. The observation of the therapist throughout the entire hospitalization, as well as the use of the surgical protocol of early activation of the patient, significantly reduced the length of hospitalization, as well as the length of stay in the intensive care unit.
Conclusion. The introduction of the program of preoperative preparation and therapeutic postoperative monitoring led to a reduction in the incidence of cardiac death and duration of hospitalization in patients undergoing extensive surgical intervention.
The study objective is to investigate gender and age structure of multiple chronic conditions (MCC) among patients seeking medical help from a primary care physician.
Materials and methods. In total, 1940 patients under the care of primary care physicians in several polyclinics of Ryazan and the Ryazan Region were examined: 646 men and 1294 women aged 18–99. The list of conditions included cardiovascular disorders, lung, gastrointestinal, kidney diseases, oncological diseases, diabetes mellitus, etc. All diagnoses were made per the generally accepted criteria. The patients were divided into 5 age groups; age and gender structure of MCC, as well as polymorbidity index (total number of conditions per 1 patient), were determined.
Results. Among all patients with MCC in all age groups, the number of women was larger than men. In the structure of MCC, predominance of cardiovascular disorders, diseases of the kidneys and joints was observed. With age, the fraction of patients in whom the majority of organs and systems was affected increased. However, in older patients, peptic ulcer disease, diabetes mellitus, oncological and autoimmune diseases were comparatively rare. In men, the mean number of diseases per 1 patient was higher, but after 75 years of age the number of conditions in women exceeded the number in men. In obese patients, age increase led to quicker polymorbidity increase than in normal patients. The gender differences consisted of the prevalence of stomach/duodenal peptic ulcer, non-specific lung diseases, obliterating atherosclerosis of the lower extremities in men, and kidney diseases, diabetes mellitus type 2 in women.
Conclusion. The main causes of polymorbidity are old age and obesity. In the structure of MCC, cardiovascular diseases, kidney and joint disorders are the most common. A gender difference in the incidence of some diseases is observed.
CASE REPORT
The study objective is to demonstrate characteristics of prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) for ankylosing spondylitis (AS) through a clinical case.
Materials and methods. Male patient N., 34 years old, sought medical help complaining of pain in the cervical, thoracic, and lumbar spine, predominantly at night, at rest; limited range of motion in cervical and lumbar spine, pain in the area of external thigh surface, morning tightness longer than 2 hours. Stomachache after eating was also a complaint. The first episode of inflammatory pain was 10 years ago. Diagnosis of AS was determined 2 years ago, NSAIDs were prescribed which the patient didn’t take regularly. Based on clinical and laboratory examination, the following diagnosis was made. Main disorder: ankylosing spondylitis, late stage, stage III bilateral sacroiliitis, frontal spondylitis, high activity (BASDAI 5, 7, ASDAS-CRP 2, 7), HLA-В27-associated, with extra-articular manifestations (stage II bilateral coxitis, tendinitis of the shoulder rotator cuff muscle – superspinatus, supraspinatus, teres minor muscle, trochanteritis on both sides). Secondary diagnosis: NSAID-gastropathy, gastroesophageal reflux disease with esophagitis, gastroduodenitis associated with H. pylori. Meloxicam 15 mg/day in constant continuous regimen, methotrexate 12.5 mg SC once a week, folic acid 1 mg 5 days a week, sirdalud 4 mg 2 times a day, H. Pylori eradication therapy, glucocorticoid administration in the area of inflamed entheses were prescribed.
Results. During the patient’s visit a month later, significant positive dynamics were observed: decreased pain in the lumbar, cervical, and thoracic spine, decreased pain in the shoulder joints, pain relief in the area of the greater trochanters, full active and passive range of motion in the shoulder joints. Duration of morning tightness was 1.5 hours. No complaints of pain in the epigastric region. In blood test: clinical and biochemical characteristics without abnormalities, С-reactive protein decreased from 62.5 to 20 mg/l. BASDAI 4, 3, ASDAS-CRP 2.0. Treatment with NSAIDs, methotrexate, proton pump inhibitor, folic acid was continued.
Conclusion. NSAIDs are leading drugs for treatment of AS. Their prescription allows to relieve spinal pain and tightness, decreases enthesitis manifestations, exudative changes in the joints, allows to prevent or slow down structural changes in the spine. A very important treatment aspect is providing patients with information on the necessity of long-term continuous administration of NSAIDs and basic drugs, as well as on possible adverse events, regular laboratory control, necessity of gastroprotective drugs. Effectiveness of meloxicam in AS therapy was proved in a number of multicenter studies with a large number of patients. Meloxicam’s effectiveness is comparable to traditional NSAIDs – the “golden standard” (diclofenac, piroxicam, naproxem), but it’s more safe.
REVIEW
Degeneration of the intervertebral disk (IVD) is a pathological process resulting from an interplay between genetic and environmental factors causing structural and functional damage of the IVD and neighboring structures. It is the first stage of degenerative cascade in the vertebral motion segment. Initiation and progression of IVD degenerative processes traditionally involves several factors: inadequate mechanical load, decreased diffusion of nutrients through the arch laminae, and genetic factors playing a significant role in the development of degenerative changes. Three categories of candidate genes whose coding variants are associated with different forms of degenerative changes in the IVD are identified, a conceptual model of genetic interactions in degenerative disease of the disk is developed. The study of the role of structural changes in back pain genesis, evaluation of risk factors allow to optimize the tactics of patient care and find new therapeutic solutions preventing disease progression.
EDITORIAL
Interstitial lung diseases (ILDs) are a heterogenous group of disorders and pathological conditions of known and unknown nature characterized by extensive and, generally, bilateral damage of the respiratory part of the lungs (alveoli, respiratory bronchioles). Until recently, there weren’t any effective therapies for patients with progressive pulmonary fibrosis, partly because of limited knowledge of the disease pathogenesis. However, in the last decade, new data of etiological, genetic factors and pathogenetic mechanisms of ILD were obtained. Currently, only two drugs were proven effective for treatment of patients with interstitial pulmonary fibrosis: pirfenidone and nintedanib which affect the rate of progression of restrictive changes in the lungs. The search for drugs is continuing in accordance with the growing understanding of pathogenetic mechanisms of ILDs. Notably, recent years saw an “explosion” of pre-clinical studies.
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