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The Clinician

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Vol 13, No 1-2 (2019)
View or download the full issue PDF (Russian)
https://doi.org/10.17650/1818-8338-2019-13-1-2

EDITORIAL

ORIGINAL INVESTIGATIONS

34-40 798
Abstract

Objective: evaluation of the effectiveness of selection for coronary angiography of women who have applied to a cardiologist for thoracalgia and dorsalgia and regarded primarily as having a clinic of stable angina.

Materials and methods. 108 women (median age 59.5) applying to cardiologist due to chest pain were included in a cross-sectional study and underwent coronary angiography. Subjects with identified clinically significant atherosclerotic coronary lesions were compared to persons with intact coronary arteries.

Results. One-, two- and three-vessel lesions were diagnosed in accordingly 16; 21 and 26 % of patients. Intact coronary arteries were detected in 37 % subjects. In 17 of 40 persons with intact structure of the coronary arteries spasm of the coronary arteries was diagnosed. Odds ratio for atherosclerotic coronary arteries lesions in type 2 diabetic persons were 7.91 (1.74–36.00), for hypertension odds ratio 4.79 (1.52–15.01). Severe angina (3 and 4 functional class) was significantly more often diagnosed in women with identified coronary atherosclerosis. Severe coronary atherosclerosis was associated with absence of negative or doubtful results, whereas intact coronary vessels, negative and questionable results revealed more than half of the women. The obtained data reflect the relevance of the development of more effective algorithms for diagnosis of coronary artery disease in women, since the gender peculiarities of the formation of coronary atherosclerosis have been clearly confirmed in a number of large studies.

Conclusion. Medical history, physical load tests results, and subject’s emotional status should be evaluated to assess the feasibility of coronary angiography.

41-54 984
Abstract

The aims of study – a development of biochemical algorithms of early diagnostic of severity of CHF in patients with DM and IHD and analyze interrelationships between plasma redox-potential, as a marker of progressive of tissues metabolic remodeling and cardiac hypertrophy and markers of progressive of DM, neurohumoral markers of severity of CHF, and frequency of heart rhythm disturbances.

Materials and methods. 172 patients, male / female (45–65 years), with diagnosis of DM (metabolic decompensation of carbohydrate metabolism, HbА1c – 7.4 ± 1.9 %) during 3–15 years, accompanied with IHD and symptoms of CHF I–IV NYHA functional class (FC). The first point of investigation was examined markers of DM progression HbА1c, changes in FC of HCHF and evidenced prognostic neurohumoral markers of myocardial dysfunction NT-proBNP, and as a second (surrogate) point – changes in redox-potential NAD / NADH and total pool of pyridine nucleotides.

Results. Mean NYHA FC CHF in cohort of DM patients and IHD was 2.4 ± 1.2, mean point of CHF estimated by scale of symptoms of CHF was 6.7 ± 0.6, mean distance in 6-minute test was 212 ± 26 m, concentration of neurohumoral markers of myocardial dysfunction NT-proBNP 178 ± 26 fmol / l at the level of HbA1c = 7.8 ± 1.0 %, mean redox-potential of plasma, НАД / НАДН, 0.71 ± 0.06 and total pool of pyridine nucleotide 15.1 ± 1.2 μmol / mg protein of plasma. For the first time was shown that changes in redox-potential and sum of pyridine nucleotide coupled with severity of CHF (FC of CHF), eliminated the correlation between NAD / NADH and HbA1c (r = –0.79, p<0.001), and NTproBNP (r = –0.73; р <0.001), and increasing of tumor necrosis factor alpha (TNF-α, r = –0.73; р <0.001). Simultaneously maintenance decreasing of NAD / NADH and sum of pyridine nucleotide in plasma of patients with DM and IHD coupled with increasing of daily mean values of paired supraventricular and ventricular extrasystoles.

Conclusions. In patients with DM and CHF with left ventricular dysfunction the decreasing of redox-potential level in plasma could be recommended as a markers of increasing of metabolic remodeling and progression of cardiac hypertrophy.

REVIEW

19-26 2010
Abstract

Coronary heart disease is the leading cause of death worldwide. Over the past few decades, life expectancy has increased, which has led to an aging population in developed countries, so the average age of patients with acute coronary syndrome (ACS) has steadily increased in recent decades. The inclusion of elderly and senile patients in randomized clinical trials does not reflect the age-related association of these diseases. However, antithrombotic therapy and interventional treatment are the basis of treatment in patients with ACS of any age, including the elderly. For older patients, there may be a mismatch between chronological and biological age. The question of how close the treatment of elderly patients with ACS is to the level of current recommendations and whether it is possible to apply them unconditionally in this group of patients does not have a definite answer. Current recommendations and the underlying randomized clinical trials are focused on any one disease, whereas in the elderly in most cases multimorbid pathology occurs. In general, elderly patients with ACS should be treated using the same methods as younger patients, however, the presence of comorbid diseases in an elderly patient naturally increases the risk of complications, makes the patient’s prognosis heavier, significantly affects treatment tactics, limits the possibility of using conventional approaches when choosing a drug therapy.

LECTION

55-64 3683
Abstract

The article presents current data on the prevalence and etiology of community-acquired pneumonia, shows the contribution of each of the possible pathogens to the structure of the disease. The diagnostic criteria for pneumonia are given. The main algorithms for assessing the severity of pneumonia and the prognosis of the disease using different scales: CURB-65 / CRB-65, PORT (PSI), are described. The purpose of the test is to determine the place of treatment: outpatient or in the in-patient department, in the general department or in the intensive care unit. The criteria for IDSA / ATS (American Thoracic Society / American Society of Infectious Diseases), as well as the SMART-COP / SMRCO scale to determine the need for hospitalized patients in the intensive care unit, are reviewed. The Aliberti and PES scales are given, assessing the risk of the presence of resistant pathogens in community-acquired pneumonia. Modern recommendations on the empirical choice of antibacterial drugs depending on individual patient factors are presented: anamnestic indications for treatment with antimicrobials during the preceding three months, hospitalization within six months before the onset of pneumonia, the presence of comorbidities, the severity of the disease, the risk of resistant pathogens. The average therapeutic doses of antibacterial drugs for the treatment of community-acquired pneumonia in patients with normal renal function are indicated. The questions of the optimal duration of treatment of pneumonia depending on the etiology are considered, the criteria of sufficiency of antibacterial therapy are presented. The reasons for the possible ineffectiveness of the empirical antibiotic therapy of community-acquired pneumonia are described. The importance of identifying a particular form of community-acquired pneumonia – severe community-acquired pneumonia is emphasized. Described drugs for the treatment of severe community-acquired pneumonia. The issues of prevention of pneumonia were discussed, its importance in the strategy of reducing mortality according to the World Health Organization was emphasized.

CASE REPORT

65-71 1467
Abstract

Objective: to describe a rare case of infective endocarditis (IE) with isolated localization in the pulmonary valve (PV).

Materials and methods. We observed primary IE with isolated localization in the PV in a 27-year-old female patient without risk factors of right-side IE.

Results. The disease was caused by Streptococcus gordonii and proceeded acutely with typical signs of right-side IE: fever above 38 °С, chills, clinical picture of bilateral septic embolic abscess pneumonia, as well as secondary anemia, secondary thrombocytopenia, and glomerulonephritis. Echocardiography showed large vegetations in the PV prolapsing in the right ventricle and pulmonary artery.

Conclusion. IE with localization in the PV should be suspected in patients with fever and clinical picture of septic embolic pneumonia in absence of other embolic situations.

72-79 1245
Abstract

The aim of the work was to study the clinical case of systemic amyloidosis.

Materials and methods. Patient Ch., 63 уears old, have admitted to the regional cardiological dispensary with complaints of short stabbing pains in the heart, without reaction to nitroglycerin, interruptions in the work of the heart, mainly at night, shortness of breath with little exertion, weakness, swelling of the legs and feet in September 2018. Sick from April 2016, when was dyspnea on exertion. The high level of creatinine, normochromic anemia have detected. In June 2016 chronic pyelonephritis was diagnosed. In August 2018, a right-sided hydrothorax was diagnosed, a pleural puncture was performed.

Results. Laboratory and instrumental research methods were performed. Based on anamnesis data (normochromic anemia, proteinuria, increased creatinine in the blood), clinical picture, data of instrumental studies (restrictive cardiomyopathy, bilateral hydrothorax) clinical diagnosis was made: systemic amyloidosis the kidneys and heart with chronic kidney disease C5 and chronic heart failure. Histological evidence of amyloid and determination of the variant of amyloidosis by immunohistochemical method was recommended. But the patient died before the study. The histological verification of the diagnosis was carried out at the autopsy.

Conclusion. This clinical observation is an example of late diagnosis of systemic amyloidosis and postmortal verification of the diagnosis, which is associated with the nonspecific symptoms and the rapidly progressing course of the disease. This case is interesting because amyloidosis proceeded under the guise of other diseases, quickly led to the development of severe heart and renal failure and to the death of the patient before verifying the disease.

80-85 2356
Abstract

Objective. To describe the difficulties of diagnosis of Waldenström macroglobulinemia in a patient with atypical clinical picture.

Materials and methods. Patient K., 57 years old, came in outpatient department with complaints of unilateral increase in submandibular lymph nodes on the right, discomfort in the nasopharynx, cough without sputum, increased fatigue. During the examination she was consulted by: an infectious disease specialist, otolaryngologist, surgeon, dentist, phthisiologist, hematologist and oncologist consulted her. To confirm the diagnosis conducted diagnostic activities: dynamic assessment of laboratory parameters, examination program cancer search (including multislice computed tomography and magnetic resonance imaging of various areas), with the exception of tuberculosis, monogenically study proteins in the blood and urine tests, biopsy of the ileum, immunohistochemistry trepanobiopsy.

Results. During the 4‑year examination in the patient’s blood, an M-gradient in the gamma zone was detected, monoclonal immunoglobulin М-κ 19.3 g / l, Bens-Jones-κ protein in urine (daily proteinuria 0.45 g) was detected during immunofixation. In the myelogram at the light-optical level, the number of cell elements was significantly reduced with a pronounced lymphoid proliferation of 40 %, the granulocytic series and erythropoiesis were relatively narrowed, and plasma cells 6 %. Immunomorphological picture trepanobiopsy our patient based on the data of laboratory methods of research corresponds to the defeat of the bone marrow in Waldenström’s disease-κ, secretion of M-paraprotein. An important feature that allowed to go on the right path of diagnosis was almost pathognomonic for tumor lymphoproliferation, detection of Bens-Jones protein in the urine, which was absent in the onset of the disease.

Conclusion. This clinical case is interesting not only by the complexity of the diagnosis of macroglobulinemia of Waldenström in General, but also by the atypical, erased clinical disease in our patient.

Medical history

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ISSN 1818-8338 (Print)
ISSN 2412-8775 (Online)