Stress-induced cardiomyopathy in the absence of complaints

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy that generally runs with the clinical manifestations of acute coronary syndrome and left ventricular asynergy, which are caused by emotional, psychological, or physical stress, is most frequently encountered among the unclassified cardiomyopathies. A clinical case of this myocardial lesion without clinical manifestations, but with transient electrocardiographic changes and evident impairment of left ventricular contraction is described.</p

Reduced costs with bisoprolol treatment for heart failure - An economic analysis of the second Cardiac Insufficiency Bisoprolol Study (CIBIS-II)

Background Beta-blockers, used as an adjunctive to diuretics, digoxin and angiotensin converting enzyme inhibitors, improve survival in chronic heart failure. We report a prospectively planned economic analysis of the cost of adjunctive beta-blocker therapy in the second Cardiac Insufficiency BIsoprolol Study (CIBIS II). Methods Resource utilization data (drug therapy, number of hospital admissions, length of hospital stay, ward type) were collected prospectively in all patients in CIBIS . These data were used to determine the additional direct costs incurred, and savings made, with bisoprolol therapy. As well as the cost of the drug, additional costs related to bisoprolol therapy were added to cover the supervision of treatment initiation and titration (four outpatient clinic/office visits). Per them (hospital bed day) costings were carried out for France, Germany and the U.K. Diagnosis related group costings were performed for France and the U.K. Our analyses took the perspective of a third party payer in France and Germany and the National Health Service in the U.K. Results Overall, fewer patients were hospitalized in the bisoprolol group, there were fewer hospital admissions perpatient hospitalized, fewer hospital admissions overall, fewer days spent in hospital and fewer days spent in the most expensive type of ward. As a consequence the cost of care in the bisoprolol group was 5-10% less in all three countries, in the per them analysis, even taking into account the cost of bisoprolol and the extra initiation/up-titration visits. The cost per patient treated in the placebo and bisoprolol groups was FF35 009 vs FF31 762 in France, DM11 563 vs DM10 784 in Germany and pound 4987 vs pound 4722 in the U.K. The diagnosis related group analysis gave similar results. Interpretation Not only did bisoprolol increase survival and reduce hospital admissions in CIBIS II, it also cut the cost of care in so doing. This `win-win' situation of positive health benefits associated with cost savings is Favourable from the point of view of both the patient and health care systems. These findings add further support for the use of beta-blockers in chronic heart failure

ISCHEMIC SYNDROMES AND CYTOPROTECTION (TRIMETAZIDINE)

Ischemic syndromes and cytoprotection (trimetazidine)

Stress-induced cardiomyopathy in the absence of complaints

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy that generally runs with the clinical manifestations of acute coronary syndrome and left ventricular asynergy, which are caused by emotional, psychological, or physical stress, is most frequently encountered among the unclassified cardiomyopathies. A clinical case of this myocardial lesion without clinical manifestations, but with transient electrocardiographic changes and evident impairment of left ventricular contraction is described.</p

MASS IN THE RIGHT ATRIUM IMITATING A TUMOR IN BEHCET’S DISEASE

The objective is to describe a rare clinical case of Behcet’s disease with right atrium thrombosis and suspicion of a heart tumor.Materials and methods. Woman,  34 years old, in December of 2015 sought medical help at a local outpatient facility, and then from a gynecologist at the Central Clinical Hospital of Civil Aviation due to painful ulcers in the genital area and fever. Her state was considered a nonherpetic infection, antiviral therapy was administered. Ulcers in the oral cavity and genital area were first diagnosed in August of 2015. In April of 2016, aphthous stomatitis developed. The patient also complained of oral ulcers, fatigue, body temperature increase up to subfebrile values, slight shortness of breath during physical activity, discomfort in the upper part of the stomach. Ultrasound of the abdominal organs and heart had shown a mass resembling a thrombus in the hepatic vein and inferior vena cava which reached the right atrium. The size of the non-mobile mass in the atrium was 38 × 25 mm. The patient was hospitalized in a cardiological department.The following examinations were performed: standard laboratory tests, electrocardiogram, repeat ultrasound of the abdominal organs and heart, X-ray of the chest, oncocytomarker tests, magnetic resonance imaging (MRI),  spiral computed tomography (SCT) with contrast of the pelvic and abdominal organs.Subsequently, due to uncertain diagnosis the patient was consulted at the A.N. Bakoulev Scientific Center for Cardiovascular Surgery, N.N. Blokhin Russian Cancer Research Center, V.A. Nasonova Research Institute of Rheumatology.Results. Ultrasound of the heart and abdominal organs had shown a large mass in the inferior vena cava extending to the right atrium, which lead to a suspicion of a myxoma or thrombosis. After MRI of the heart and abdominal organs, an infectious thrombus in the heart and inferior vena cava was suggested. SCT with contrast of the pelvic and abdominal organs, oncocytomarker tests didn’t show any pathology. The combination of aphtous ulcers of the mouth and genitalia and inferior vena cava thrombosis allowed to suspect the Behcet’s disease. This diagnosis was confirmed at the V.A. Nasonova Research Institute of Rheumatology. Prescribed immunosuppressive therapy (meripred, azathioprine, colchicine), which is still ongoing, led to a decrease in inflammatory activity (С-reactive protein), reduction of the thrombus in the right atrium and inferior vena cava. Currently, the patient continues to receive the prescribed immunosuppressive therapy. No complaints, feeling healthy, working. The patient remains under the care of physicians.Conclusion. This clinical case demonstrates diagnostic complications of detection of masses in the heart which can represent a tumor or a thrombus. In the described case, diagnosis of the Behcet’s disease was facilitated by typical aphtous ulcers of the mucosa of the mouth and genitalia and development of vasculitis with subsequent thrombosis of the inferior vena cava and right atrium

RATIONAL MARKET RELATIONS IN THE MODERN RUSSIAN HEALTHCARE: PRACTITIONERS’ EXPERIENCE (PART I)

The challenging process of Russian healthcare reforms includes development of the healthcare concept (up to 2020) by the Ministry of Health and Social Development. The reforms are planned by prominent health managers and economy scientists who are well-recognised theorists but rarely, if ever, visit medical clinics and hospitals. As these experts have contradictory views on the Russian healthcare concept, we propose that the opinion of practitioners, such as the authors of this article, who have been working at hospital and treating patients on daily basis for several decades, has its own professional value and potential to improve prevention and treatment quality. Should the Russian healthcare be free of charge, according to Article 41 of the Russian Federation Constitution, or should it be based on market health insurance, according to the Head of the High School of Economics, Mr E.G. Yasin? At the moment, this is the main point of debates on the Russian healthcare concept. The authors believe that for the patients’ sake, the Russian healthcare system should combine both approaches

RATIONAL MARKET RELATIONS IN THE MODERN RUSSIAN HEALTHCARE: PRACTITIONERS’ EXPERIENCE (PART II)

More active out-of-pocket payment for medical care by wealthy people would allow increasing healthcare funding for deprived groups of the Russian population. The country has objective prerequisites for creating elite medicine. On the other hand, there is a need to develop and approve by law the lists of medical services, provided for free as a part of regional programs of state-guaranteed healthcare, in accordance with regional medico-economic standards. Additionally, it is necessary to provide free access to these services for all citizens, especially the deprived ones

The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial

Background: In patients with heart failure, beta-blochade has improved morbidity and left-ventricular function, but the impact on survival is uncertain. We investigated the efficacy of bisoprolol, a beta(1) selective adrenoceptor blocker in decreasing all-cause mortality in chronic heart failure. Methods: In a multicentre double-blind randomised placebo-controlled trial in Europe, we enrolled 2647 symptomatic patients in New York Heart Association class III or IV, with left-ventricular ejection fraction of 35% or less receiving standard therapy with diuretics and inhibitors of angiotensin-converting enzyme. We randomly assigned patients bisoprolol 1.25 mg (n=1327) or placebo (n=1320) daily, the drug being progressively increased to a maximum of 10 mg per day. Patients were followed up for a mean of 1.3 years. Analysis was by intention to treat. Findings: CIBIS-II was stopped early, after the second interim analysis, because bisoprolol showed a significant mortality benefit. All-cause mortality was significantly lower with bisoprolol than on placebo (156 [11.8%] vs 228 [17.3%] deaths with a hazard ratio of 0.66 (95% CI 0.54-0.81, p<0.0001). There were significantly fewer sudden deaths among patients on bisoprolol than in those on placebo (48 [3.6%] vs 83 [6.3%] deaths), with a hazard ratio of 0.56 (0.39-0.80, p=0.0011). Treatment effects were independent of the severity or cause of heart failure. Interpretation: beta-blocker therapy had benefits for survival in stable heart-failure patients. Results should not, however, be extrapolated to patients with severe class IV symptoms and recent instability because safety and efficacy has not been established in these patients

The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial

Background In patients with heart failure, beta-blochade has improved morbidity and left-ventricular function, but the impact on survival is uncertain. We investigated the efficacy of bisoprolol, a beta(1) selective adrenoceptor blocker in decreasing all-cause mortality in chronic heart failure. Methods In a multicentre double-blind randomised placebo-controlled trial in Europe, we enrolled 2647 symptomatic patients in New York Heart Association class III or IV, with left-ventricular ejection fraction of 35% or less receiving standard therapy with diuretics and inhibitors of angiotensin-converting enzyme. We randomly assigned patients bisoprolol 1.25 mg (n=1327) or placebo (n=1320) daily, the drug being progressively increased to a maximum of 10 mg per day. Patients were followed up for a mean of 1.3 years. Analysis was by intention to treat. Findings CIBIS-II was stopped early, after the second interim analysis, because bisoprolol showed a significant mortality benefit. All-cause mortality was significantly lower with bisoprolol than on placebo (156 [11.8%] vs 228 [17.3%] deaths with a hazard ratio of 0.66 (95% CI 0.54-0.81, p<0.0001). There were significantly fewer sudden deaths among patients on bisoprolol than in those on placebo (48 [3.6%] vs 83 [6.3%] deaths), with a hazard ratio of 0.56 (0.39-0.80, p=0.0011). Treatment effects were independent of the severity or cause of heart failure. Interpretation beta-blocker therapy had benefits for survival in stable heart-failure patients. Results should not, however, be extrapolated to patients with severe class IV symptoms and recent instability because safety and efficacy has not been established in these patients