JUSTIFICATION OF TECHNOLOGIES FOR ORGANIZING MEDICAL CARE FOR PATIENTS WITH HIGH CARDIOVASCULAR RISK ON THE EXAMPLE OF THE BREST REGION (PART 1)

In order to substantiate organizational measures for early detection and tertiary prevention of cardiovascular diseases, the causal relationships of high morbidity, disability, and mortality due to cardiovascular diseases, coronary heart disease and its complications were studied in the population of the Brest region in the period from 2006 to 2010. Measures to improve the organization of preventive medical examination of patients from cardiovascular risk groups with prognostically unfavorable outcomes were suggested. Through the implementation of an organizational experiment in 2012-2017, it was possible to achieve a positive medical and social effect, expressed in increasing the availability of multi-level and high-tech care to patients in need, as well as in improving the medical and demographic indicators of the Brest region in general and in the diseases of the circulatory system in particular, which formed the basis of the second part of this article.

PROGNOSTIC FACTORS OF WOLFF-PARKINSON-WHITE SYNDROME IN CHILDREN

Objective: to determine the prognostic factors determining the severity of Wolff-Parkinson-White syndrome (WPW) in children. Methods: a retrospective analysis of the course of the disease was performed in 108 children with WPW syndrome aged 13.6 (12-16) years. Depending on the number of attacks of paroxysmal tachycardia (PT), all children were divided into 2 groups: group A consisted of 47 children (43.5%) with a history of no more than three attacks of PT and they were rare; group B included 61 children (56.5%) with frequent (more than once a month) attacks of PT, more than four in the history. We studied: the family history, the clinical picture of the disease, the nature of paroxysmal tachycardia, the effectiveness of treatment, and the results of instrumental studies. Using the method of mathematical modeling, the informative value of each feature was determined, and the diagnostic value was determined. Results: age and gender differences in the development of WPW syndrome in children were established. The presence of a family history of ECG signs of ventricular preexcitation is a reliable sign (p=0.02), contributing to more frequent PT attacks. More frequent development of PT attacks was noted in patients with mitral valve prolapse (p=0.03) and additional chords in the left ventricular cavity (p=0.001). In the group with frequent PT attacks, signs of sinus node dysfunction were detected more often (<0.001). According to the echocardiographic study, children with frequent PT attacks were more likely to have disorders in the form of thickening of the interventricular septum in the diastole (p=0.010) and signs of diastolic dysfunction of the right ventricle (p = 0.010). Conclusion: The factors of prognostic value include: male gender, the presence of the expressed symptoms of the attack of PT and PT frequency more than once per month, low vagal efficiency on relieving the attack, a history of frequent attacks, a family history of ECG characteristics of premature ventricular excitation, the presence of signs of sinus node dysfunction during 24 hours without the attack and the signs of arrhythmogenic myocardial dysfunction by echocardiography.

SURGICAL TREATMENT OF PSEUDOANEURYSM OF THE FREE LEFT VENTRICLE WALL: A CLINICAL CASE

Today diseases of the cardiovascular system are the leading cause of death in many countries. The key role in this pathology is played by ischemic heart disease. An extreme manifestation of ischemic heart disease - myocardial infarction is one of the main causes of complications and mortality in patients with ischemic heart disease. One of the most formidable complications of acute myocardial infarction is heart rupture, which most often leads to death, more than 60% of cases occurring in the prehospital stage. Many studies of similar groups of patients show a wide spread in assessing the incidence and mortality of this pathology. The development of myocardial ruptures has two frequency peaks: the first day and 5-7 days from the onset of AMI. The most common case is acute rupture of the free wall of the left ventricle with extensive hemorrhage in the pericardium leading to a fulminant death. The development of a pseudoaneurysm of the left ventricle is a very rare outcome of the myocardial rupture. There are no convincing data on the incidence of pseudoaneurysms as a result of myocardial infarction (according to many authors, it is less than 0.5% of all cases of myocardial infarction). This type of rupture is most favorable in terms of the possibility of providing assistance. The complexity of providing care to patients with pseudoaneurysms of the left ventricle lies in their low frequency of occurrence and often asymptomatic nature of the course, which complicates the diagnosis of this pathology. Timely diagnosis plays a key role in avoiding a fatal outcome, since the vast majority of pseudoaneurysms are extremely unstable and, except occasional cases, require urgent surgical intervention. This article describes a clinical case of a patient who underwent surgical treatment for pseudoaneurysm of the free wall of the left ventricle as a result of myocardial infarction. The article also presents a brief literature review of the available isolated data on risk factors for myocardial rupture, methods of diagnosis and treatment of this pathology.

POSITRON EMISSION TOMOGRAPHY WITH 18F -FDG IN THE DIAGNOSIS OF PROSTHETIC HEART VALVE ENDOCARDITIS

Purpose. The purpose of the article is to evaluate the diagnostic significance of positron emission tomography / computed tomography with 18F -fluorodeoxyglucose (18F -FDG PET/CT) for the diagnosis of prosthetic endocarditis. Methods of research. The study included 82 patients with suspected prosthetic endocarditis in accordance with the criteria proposed by Duke University [1-5]. The patients received hospital treatment at the State Institution RSPC "Cardiology" from January 2016 to March 2021. The study was of a prospective, non-randomized, single-center cohort design. The duration of the monitor period was 12 months from the moment of patients’ inclusion in the study. Whole-body positron emission tomography / computed tomography (PET/CT) examinations were performed in 82 patients. 27 patients were selected for surgical treatment. Conservative treatment group included 16 patients. 27 patients were selected into the observation group, they were suspected to have prosthetic heart valve infection in the primary referral and underwent PET/CT scanning, according to which the diagnosis of prosthetic endocarditis was excluded. The event under the study did not develop in this group during the year of observation. Results and conclusion. The history of infective endocarditis was not statistically significant and did not increase the risk of developing prosthetic endocarditis in the sample presented. The Duke criteria are less reliable in establishing the diagnosis of prosthetic endocarditis. The median number of days from the date of the first prosthesis implantation to the onset of prosthetic endocarditis was about 4 years. This study revealed that the development of the infectious process in the area of the prosthesis was noted in a more distant postoperative period compared to literature data. Histological confirmation of infection was noted in 100% (27 patients) of cases in reoperated patients. The presence of a more formidable complication such as valve ring abscess located mainly in the projection of the aortic valve ring was quite common in both groups. Presepsin and Interleukin-6 have a statistically significant (U = 394,50 p = 0,01 and U = 94,50 p = 0.004) value in the prognosis of prosthetic endocarditis. Considering the data obtained from ROC analysis, it can be said that the cut-off point at which it is possible to diagnose prosthetic endocarditis based on PETCT is 2.85. The presented methods for the interpretation of whole-body FDG-PET/CT images of patients with suspected infectious complications after cardiac surgery, as well as with the presence of prosthetic endocarditis, show high sensitivity and specificity.

EARLY AND ALTERNATIVE MARKERS OF CHRONIC HEART FAILURE IN PATIENTS WITH DIABETES MELLITUS

Aim: to assess the relationship of proinflammatory cytokines and chemokines with the levels of natriuretic peptides in patients with diabetes mellitus (DM). Materials and methods. A total of 155 patients (14 men and 61 women) with type 1 and type 2 diabetes, aged 34 to 84 years, were examined. All patients underwent standard clinical and laboratory examination, with an assessment of the levels of pro-inflammatory cytokines (interleukin 6 (IL-6), tumour necrosis factor alpha (TNF-alpha), chemokines (monokine induced by interferon-gamma (MIG), regulated upon activation, normal T cell expressed and presumably secreted (RANTES), growth factors (fibroblast growth factor-23 (FGF-23), vascular endothelial growth factor (VEGF-A), natriuretic peptides (B‐type natriuretic peptide (BNP), N‐terminal fragment of B‐type natriuretic peptide (proBNP). Renal function was assessed based on the levels of serum creatinine, glomerular filtration rate (GFR), which was calculated according to the CKD-EPI formula, and albuminuria, which was assessed as albumin/creatinine ratio (A/C). An echocardiographic examination was conducted according to the standard protocol with the calculation of dimensional, volume and speed characteristics. Statistical data analysis was performed using smSTATA 14.2 for Mac (2018). Results. 57% DM patients had BNP and proBNP levels exceeding the diagnostic values of BNP >35 pg/ml and/or proBNP >125 pg/ml. The levels of BNP and proBNP positively correlated with the levels of homocysteine, uric acid, IL-6, С-reactive protein (CRP), high-sensitivity C-reactive protein (hsCRP), A/С, creatinine, cystatin C, TNF-alpha, chemokines (MIG, RANTES), growth factors (FGF-23, VEGF-A) (p <0.05). According to multiple regression analysis, predictors for increased proBNP were IL-6, A/K, creatinine (ß=0.70, p<0.001, ß=3.51, p=0.01, ß=0.97, p=0.01, respectively). ROC analysis determined the highest diagnostic significance of creatinine for the prediction of increased proBNP. The significance of IL-6 proved higher than A/С (AUC-0.777). Thus, when the level of IL-6 (AUC-0.789) was 3.1 mg/ml, the sensitivity and specificity for increased proBNP concentration were 71.9% and 71.2%, respectively. Conclusion. IL-6 might be an independent predictor of increased levels of natriuretic peptide in patients with diabetes. Further study of the role of pro-inflammatory cytokines in the development of cardiovascular diseases will make it possible to finally decode the mechanisms of their pathogenesis, which will further allow us to understand their complex effect on the body and obtain information for the development of new effective and safe specific medicines.

PANCREATOGENIC MORPHOSTRUCTURAL CHANGES IN THE HEART, LUNGS AND OTHER TARGET ORGANS IN DESTRUCTIVE PANCREATITIS

Introduction. Pathomorphological changes in destructive pancreatitis develop both in the pancreas and in various organs and tissues, it determining the clinical course and outcome of the disease. Most often in destructive pancreatitis, the cardiopulmonary system is affected, as well as the liver, kidneys, and brain. Damage to these target organs is one of the main elements of pathogenesis and thanatogenesis in destructive pancreatitis and is of interest not only for surgeons, but also for other clinical specialists, including cardiologists. Aim. To conduct a retrospective analysis of the most common morphostructural changes in the cardiopulmonary system and other target organs based on the results of autopsy reports of the deceased from destructive forms of acute and chronic pancreatitis and to identify the most characteristic morphostructural changes in the target organs. Materials and methods. A retrospective analysis of the findings of histological examination of target organs of 203 patients who died from acute pancreatitis (K.85) and chronic pancreatitis with an outcome of pancreonecrosis (K. 86) in the in-patient surgical departments and intensive care and resuscitation units of Minsk over the period of 2015-2019 was performed. Results. In the course of study, we investigated the nature and structure of morphostructural changes in the pancreas and target organs (heart, lungs, liver, kidneys, spleen, and stomach) in destructive pancreatitis. Conclusions. In destructive pancreatitis, deep dystrophic, necrotic, circulatory and inflammatory changes are observed not only in the pancreatic tissue, but also in the target organs, which are primarily the heart, lungs, liver, kidneys and brain. In the myocardium, edema, circulatory and dystrophic changes are detected, in the lungs - edema, circulatory changes and alveocyte damage. In the pancreas, necrosis, leukocyte infiltration and hemorrhages are noted, i.e. both necrotic and inflammatory changes are observed at the same time. In the liver, the most typical changes are leukocyte infiltration of the portal tracts, fatty dystrophy of hepatocytes, vascular fullness and dilation of capillaries, central veins and sinusoids. The kidney tissue is dominated by circulatory changes, necrosis and dystrophy of the epithelium of the convoluted tubules, which are the morphological substrate of acute renal failure. Edema, circulatory and dystrophic changes are detected in the brain.

STRUCTURAL AND FUNCTIONAL LEFT HEART CHANGES IN THE WORKING AGE INDIVIDUALS WITH OBSTRUCTIVE SEEP APNEA SYNDROME (OSAS)

The aim of the study. To assess the echocardiographic signs of structural and left heart functional changes in the working age individuals with obstructive sleep apnea syndrome. Materials and methods. Cross-sectional prospective observational study of 67 working age individuals was performed. The main group included 45 patients diagnosed with obstructive sleep apnea syndrome. The control group consisted of 22 subjects without any pathology revealed by means of polysomnography. There were no significant differences in gender, age, body mass index, presence of diabetes mellitus, arterial hypertension in patients of both groups. To assess the structural and functional changes in the left heart all subjects underwent echocardiographic heart examination in M and B modes, pulse-wave and tissue Doppler study. Results. According to echocardiographic studies of working age patients with OSAS, the anteroposterior size of the left atrium (LA) and the LA volume index are statistically significantly higher than those in the control group: 38.0 (36.0 - 40.0) mm versus 35.0 (30, 3 - 38.0) mm (p <0.01) and 35.0 (33.0 - 37.0) ml / m2 versus 30 (29.3 - 31.0) ml / m2 (p <0.001), respectively. Mean group values of the end-diastolic volume (115.0 (99.5 - 135.5) ml versus 95.0 (72.5 - 104.8) ml (p <0.01)), the end-systolic volume (47.0 (34.0 - 56.0) ml versus 35.0 (27.3 - 41.5) ml (p <0.01)), the thickness of the posterior wall of the left ventricle (LV) (11.0 (10, 0 - 12.0) mm versus 10.0 (9.00 - 10.8) mm (p <0.05)) in the main group exceeded the required data in the group of healthy individuals. While comparing LV diastolic function in patients with obstructive sleep apnea syndrome with the group of people without intermittent hypoxia, higher indicators of the slowing time of the early left ventricle diastolic filling DT 187.0 (154.0-196.0) ms versus 155.0 (130.0 - 169.0) ms were recorded (p < 0.05) and the velocity of late diastolic movement of the mitral valve lateral wall Am 12.0 (10.0 - 14.0) cm / s versus 9.0 (8.0 - 12.0) cm / s (p <0.05). A direct moderate relationship was established between the presence of intermittent hypoxia and structural and functional changes in the left heart: the LP volume index (r = 0.422, p <0.01), LV end-diastolic volume (r = 0.351, p <0.005), end-systolic LV volume (r = 0.315, p <0.05) and the rate of late diastolic LV filling Am (r = 0.373; p <0.05), and inverse - between the apnea / hypopnea index and the ratio of the rate of early and late diastolic LV filling E \ A (r = -0.371, p <0.05). Conclusion. Echocardiographic examination of working age patients with newly diagnosed obstructive sleep apnea syndrome revealed a significantly more frequent tendency of the left heart region remodeling according to the myocardial hypertrophy type, diastolic left ventricle dysfunction and dilatation of the left atrium associated with the presence of intermittent hypoxia.

EXERCISE TOLERANCE TESTS IN THE DIAGNOSIS OF CORONARY HEART DISEASE, TESTING OF PATIENTS WITH MYOCARDIAL INFARCTION AND REVASCULARIZATION

Exercise tolerance test is one of the most commonly used non-invasive cardiac tests used to diagnose coronary heart disease, determine prognosis, and evaluate treatment. Treadmill test or bicycle ergometry allows determining how much more expensive and complex follow-up examination is necessary for the patient: myocardial perfusion scintigraphy with stress, stress echocardiography, multispiral computed tomography, as well as defining more clearly the indications for coronary angiography. The article presents modern ideas about a differentiated approach to performing exercise tolerance tests in patients with coronary heart disease, myocardial infarction, and revascularization.

INDEPENDENT PREDICTORS AND PROGNOSIS OF LONG-TERM MYOCARDIAL INFARCTION IN PATIENTS WITH UNSTABLE ANGINA AFTER CORONARY ARTERY STENTING

Objective. to develop independent predictors for predicting long-term myocardial infarction (MI) in patients (pts) with unstable angina (UA) after coronary artery stenting (PCI) based on the results of a seven-year follow-up. Materials and Methods. The study involved 165 pts with UA and coronary artery stenting (PCI). PCI was performed in 3.2±1.6 days after admission to the in-patient department. Drug-coated stents (Xience V and Biomatrix) were used, the average number of stents was 2.1±0.8 per person, the average length of the stented area was 43.12±25.6 mm, and the average diameter of the implanted stents was 3.12±0.5 mm. All patients were assessed for troponin I, myeloperoxidase, and C-reactive protein levels; coagulation hemostasis was assessed; and a thrombin generation test was performed. The aggregatogram was performed on the analyzer Multiplate (ASPI-test, ADP-test). The patients underwent echocardiography, coronary angiography. Double antithrombotic therapy with clopidogrel 75 mg and acetylsalicylic acid 75 mg was prescribed for 12 months. The follow-up period was 7±1.6 years. Results. Repeated UA developed in 91 (55.2%) pts during a 7-year follow-up period, myocardial infarction was registered in 21 (12.7%) pts. Cardiovascular mortality was 7.3%. Independent predictors of MI risk included: baseline D-dimer level ≥796 ng/ml AUC 0.766 (RR 5.272; 95% CI 2,125-13,082), endogenous thrombin potential ≥2294.5 nM*min AUC 0.912 (RR 4,769; 95% CI 2,457-10,546), N-terminal fragment of brain natriuretic peptide (NTproBNP) ≥816 pg/ml AUC 0.794 (RR 1,935; 95% CI 1,218-3.075), homocysteine level ≥16 µmol/l AUC 0.707 (RR 1.971; 95% CI 1.140-3.406), highly sensitive C-reactive protein ≥6.4 g/l AUC 0.790 (RR 1.333; 95% CI 1.081-1.644), number of affected arteries≥ 3 AUC 0.714 (RR 2.129; 95% CI 1.237-2.664). The developed model for predicting myocardial infarction included the initial level of endogenous thrombin potential≥2294.5 nM * min, D-dimers ≥796 ng / ml, and the number of affected coronary arteries≥ 3. For the developed model, the AUC was 0.964, which corresponds to the excellent quality of the model. Conclusion. The prognosis of myocardial infarction in patients with unstable angina and stenting of the coronary arteries receiving the standard antiplatelet therapy involves laboratory criteria that reflect the activation of the hemostatic system and the residual thrombogenic risk.

SARS Co-V-2 CORONAVIRAL INFECTION IN PREGNANT WOMEN (CLINICAL DATA USE "6 City Clinical Hospital")

The article analyzes the features of the course of pregnancy in 110 women hospitalized in the Healthcare Institution “6th City Clinical Hospital” of Minsk for SARS CoV-2 coronavirus infection in April-October 2020. The authors studied the anamnestic data of pregnant women, analyzed the clinical data and the data from the instrumental and laboratory examinations of pregnant women with SARS CoV-2 coronavirus infection in the Republic of Belarus. A comparative analysis was carried out dealing with the treatment of pregnant women for coronavirus infection with SARS CoV-2 in a hospital setting.