Capabilities of Cardioprotective Therapy in the Treatment and Prevention of Heart Failure in the Postinfarction Period

Recently, numerous and quite convincing data has been accumulated on the effectiveness and safety of lipid-lowering drugs, beta-blockers, antiplatelet and antihypertensive drugs in patients with chronic heart failure (CHF), depending on the origin of the latter. The practitioner is suggested to use several drugs of different classes at the same time in order to reduce cardiovascular mortality, as well as the risk of recurrent myocardial infarction and ischemic stroke. In CHF, metabolism in cardiomyocytes varies depending on the stage of the disease. The changes that occur in the postinfarction period are compensatory in nature, which contributes to the partial improvement of impaired metabolism, while others, on the contrary, further inhibit the processes of energy production in the myocardium. In our research paper we will discuss some capabilities of metabolic therapy of CHF and prospects in the treatment and prevention using hawthorn extract; analyze the features of interaction of some well-known cardioprotective drugs with long-term antiplatelet therapy in the postinfarction period. Initiation of therapy with a new drug in addition to clopidogrel, such as trimetazidine, may adversely affect antiplatelet activity of clopidogrel (TRACER study, 2019). As a compromise, some herbal cardioprotective drugs may be used. Hawthorn preparations containing vaso- and cardioactive substances have significant potential in the treatment of cardiovascular diseases. Diversified mechanism of action of hawthorn has a significant impact on various parts of the cardiovascular system. Clinical trials of more than 4,000 patients confirm that standardized hawthorn extracts are effective as adjunctive therapy in the treatment of NYHA stage I–III CHF. The main two-year results of the WISO cohort study showed that the three pivotal symptoms of heart failure — fatigue (p = 0.036), stress dyspnea (p = 0.020) and palpitations (p = 0.048) — were significantly less marked after treatment in the hawthorn group versus comparative group. Cochrane analysis (2009) of studies investigating hawthorn extract included 14 studies where hawthorn was used primarily as an adjunct to conventional treatment. Exercise tolerance increased significantly during the treatment with hawthorn extract. Thus, the weighted difference between the average double multiplication rates during cardiac stress test (CST) was 122.76 W/min, whereas end-diastolic pressure in the right ventricle and myocardial oxygen consumption decreased with hawthorn treatment (a weighted mean difference was 19.22 mmHg per 1 min). The reported side effects were infrequent, mild and transient. A special hawthorn extract is indicated for the treatment of patients with NYHA stage II heart failure as an alternative and supplement to the standard evidence-based drug therapy. The beneficial effect on clinical symptoms allowed patients in the Crataegus group to reduce the use of angiotensin-converting enzyme (ACE) inhibitors from 54 to 36% (p = 0.004), cardiac glycosides from 37 to 18% (p = 0.001), diuretics from 61 to 49% (p = 0.061), beta-blockers from 33 to 22% (p = 0.052). At the same time, SPICE and HERB CHF studies show greater efficacy of Crataegus preparations in the treatment of mild to moderate heart failure (NYHA stage I–II). Higher doses (1800 mg) may be required for critically ill patients in order to achieve sustained improvement. Analysis of the data available to date is promising but suggests the need for a more focused approach to dosing based on the disease severity.

Leriche Syndrome as a Long-Term Continuum of Vascular Injury: from the Initial Clinical Manifestations to Possible Fatal Outcome (Significance of Interdisciplinary Cooperation Based on Own Clinical Observations)

Leriche syndrome typical signs include incapability for erection maintaining, fatigue feeling originating from both lower limbs, bilateral claudication with ischemic pain and lack or reduction of peripheral pulse (starting from femoral segment) combined with paleness or coldness of both lower limbs. The disease commonly affects men, and risk factors include hypertension, diabetes mellitus, hyperlipidemia and smoking. Currently the disorder is referred to type D aortoiliac injuries according to Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Data on psychiatric morbidity in Leriche syndrome is scarce. Some publications are dedicated in such a state to depressive disorder and erectile dysfunction, which were observed in psychiatric outpatient department. These may have several reasons, such as obesity, hypertension, diabetes mellitus, hypercholesterolemia and lower urinary tract symptoms. Moreover, erectile dysfunction is believed to be a strong predictor of general and coronary atherosclerosis. Leriche syndrome and penis arteries obstructive disease are considered to be two main reasons of impotence. Other reasons of Leriche syndrome may be lifestyle factors which are common with atherosclerosis: insufficient physical exercises, imbalanced diet and smoking. Statistics on psychiatric morbidity in Leriche syndrome is hard to receive because of multiple risk factors, partially because of atherosclerosis, which is the risk for vascular depression. The article represents historical data about prominent doctors in the history of vascular surgery who touched upon the problems of Leriche syndrome. The authors describe their own clinical observations of acute patient with prolonged development of full clinical manifestation with fatal outcome.

Determination of the Need for Reconstructive Surgical Interventions Using Conduits of Biological Origin in Acute Arterial Insufficiency

The aim of the study was to determine the structure of the pathology that causes acute arterial insufficiency, which requires the implementation of surgical interventions, including reconstructive operations using conduits of various origins; to identify the needs for grafts of biological origin. Material and methods. A retrospective analysis of 212 case histories of patients with acute arterial insufficiency of the lower extremities who underwent open surgery on the arteries of the lower extremities at the department of vascular surgery of the Gomel Regional Clinical Cardiology Center from 2017 to 2019 was performed. Results and discussion. As a result of the study, the following issues were identified. Surgical treatment of acute arterial insufficiency, which developed due to thrombosis with the progression of atherosclerotic lesions, requires reconstructive surgery using various plastic materials as patches and conduits in 60% of the total number of open operations. There is a serious need for materials of biological origin as a plastic material for the treatment of acute arterial insufficiency, which developed against the background of atherosclerotic vascular damage, because 59% of the total number of primary operations were bypass surgeries, of which, in 73.7% of cases, for various reasons, synthetic transplants were used. The high frequency of repeated surgical interventions, reaching 28.9% of the total number of operations, more often on injured limbs in 97% of patients, including those after application of autological venous conduits in 40.7% of cases, is a serious problem that needs to be solved by searching for new sources for biological materials. Atherosclerotic damage to the contralateral limb occurred in 53.2% of patients with thrombosis and in 17.8% with embolism, while in 62.6% of patients with thrombosis, the degree of chronic arterial insufficiency in the contralateral limb was greater than 2 (Fontaine’s classification of chronic limb ischemia), which is indicative for reconstructive surgical interventions.

Features of Treatment of Hypertensive Patients with Concomitant Obesity: Unknown about the Known

Introduction. Arterial Hypertension is the most common disease of the circulatory system. Today we can talk about it as a non-infectious epidemic. Obesity is a risk factor and a frequent comorbid condition in hypertension. The aim. Given the role of dopamine metabolism as one of the pathogenetic triggers of hypertension and obesity, to study the effect of a dopamine receptor agonist bromocriptine in this category of patients. Materials and methods. We examined 111 hypertensive patients with concomitant obesity and 18 hypertensive patients without obesity with dopamine (DA) metabolism disorders. 24 patients with concomitant obesity received the dopamine receptor agonist bromocriptine and the calcium antagonist amlodipine to correct their DA metabolism disorders. The level of DA was determined according to the daily excretion of DA in the urine by fluorometric method. Determination of angiotensin II (ATII) was performed using enzyme-linked immunosorbent assay. The concentration of lipids was determined using the enzymatic colorimetric method, blood pressure was assessed using Daily Monitoring of Blood Pressure (ABPM), the condition of the endothelium was determined using D.S Celermajer’s endothelium-dependent vasodilation assessment. Results. Concomitant obesity leads to a deeper impairment in the dopaminergic system, RAAS, lipid spectrum and endothelial status. Bromocriptine and amlodipine treatment resulted in a significant increase in urinary DA excretion by 1.77 times (77.4%) and a trend towards blood ATII increase, which confirms the assumption of similar mechanism of action of dopamine agonists and angiotensin II receptor antagonist; positivization of lipid spectrum parameters: significant reduction of total cholesterol by 5.7%, TG by 14.01%, LDL by 5.5%. Regarding other lipid metabolism, such as HDL, there was a trend towards increase by 4.6%, combined with a significant improvement in endothelium-dependent vasodilation by 54.8%, lower blood pressure and a positive modulating effect of the combination of these drugs on the daily blood pressure profile against the background of a significant decrease in body weight by 8.8%.

Analysis of the Risks of Stroke, Bleeding and Death in Elderly Patients with Nonvalvular Atrial Fibrillation who Received Various Oral Anticoagulants under the Program Medicare, USA

Nonvitamin K antagonist oral anticoagulants (NOACs) are widely used in patients with nonvalvular atrial fibrillation. There were numerous studies in which NOACs were investigated and compared with warfarin; however, no randomized trials were performed to compare efficacy and safety of various NOACs with each other. We announce a cohort study of a large group of patients with nonvalvular atrial fibrillation who were allocated to warfarin (n = 183,318) or a standard dose of dabigatran (150 mg twice daily; n = 86,198), rivaroxaban (20 mg once daily; n = 106,389), or apixaban (5 mg twice daily; n = 73,039) under the program Medicare in the period from October 2010 to September 2015. Primary outcomes were stroke, bleeding and death. Hazard ratios (HR) and 95% confidence intervals (CI) for the outcomes were estimated using Cox proportional hazards regression. Each of the studied NOAC was compared with warfarin and with each other. All the subjects had similar baseline characteristics. Moreover, patient groups were balanced for all covariates (age, gender, comorbidities etc). Dabigatran, rivaroxaban, and apixaban were associated with lower risk of thromboembolic stroke, bleeding and death compared with warfarin, so their benefit-harm ratio was more favorable than that of warfarin. The risk of stroke was similar for all the studied NOACs, but the risk of bleeding and death was higher for rivaroxaban. This allows for the conclusion that dabigatran and apixaban had more favorable benefit-harm ratio than rivaroxaban.

Mortality Factors in COVID-19 Patients with Preexisting Cardiovascular Disease

Due to the COVID-19 outbreak, management of patients with severe cardiovascular disease has become much more complicated. The paper describes first-hand experience of managing a COVID-19 patient with chronic heart failure secondary to myocardial infarction who died from sudden cardiac death. Mortality risk factors in COVID-19-associated cardiac patients are discussed. The authors describe a case of a female patient B., 67 years old, who was taken to the hospital by ambulance with a preliminary diagnosis of community-acquired right lower lobe pneumonia, respiratory failure (RF) II (SpO294%). Coronary heart disease (CHD). Athero-sclerotic and postinfarction (2019) cardiosclerosis. Permanent atrial fibrillation. Hypertension, stage III, grade 3, risk 4 (stroke, 2019). Heart failure (HF) II-A (NYHA class II). Rapid tests for the diagnosis of influenza A and B and detection of COVID-19 antibodies IgG and IgM were negative. From the patient’s history it was found out that over the last 2 months she was in a private medical rehabilitation center. Nine days before her hospitalization, her relatives took her home. According to them, the patient developed fever (37.5–38.4 °C) 4 days before hospitalization, she took paracetamol in her discretion. On admission, her body temperature was 37.5 °C. The patient was hospitalized to the triage department; on the day of hospitalization, her nasopharyngeal lavage was taken for real-time PCR (polymerase chain reaction) for COVID-19. During the hospital stay the patient’s condition stabilized. The next day after hospitalization, the maximum body temperature was within 37.0 °C, shortness of breath decreased, heart rate slowed, RF disappeared, room-air SpO2increased up to 96%. According to the results of echocardiography, the left ventricle (LV) pump function remained preserved (LV ejection fraction was 50%), LV cavities were slightly enlarged, and valvular pathology was characterized by moderate mitral and tricuspid insufficiency. The area of hypokinesia due to myocardial infarction was determined only in the apical segment of the lateral wall and was compensated due to moderate left ventricular hypertensive hypertrophy (left ventricular mass index 129 g/L2). R wave amplitude on the electrocardiography was preserved, which indicated relative compensation of the central hemodynamics of the patient B. On day 2 of hospitalization, the patient’s condition remained stable. The body temperature normalized, leg swelling disappeared, cough and shortness of breath decreased, physical activity significantly improved. The patient was examined by an infectious disease specialist. After receiving the COVID-19 test result (positive PCR test), it was agreed to transfer the patient to a coronavirus hospital for further treatment in the infectious department. However, the patient died suddenly. Final diagnosis: coronavirus disease. COVID-19. Community-acquired bilateral lower lobe pneumonia (viral). Respiratory failure (RF) – 0. CHD. Atherosclerotic and postinfarction (2019) cardiosclerosis. Permanent atrial fibrillation. Hypertension, stage III, grade 3, risk 4 (stroke, 2019). HF II-B. Since dissection was not performed, the exact cause of death is unknown. The article describes important aspects of diagnosis and treatment that can prevent mortality. The authors emphasize that prevention and control of infectious diseases should be prioritized at any time. Individual measures of diagnosis and treatment should be taken considering specific local epidemic situations.