Prevalence, morphologic characteristic and predictors of organization of atrial auricle thrombi four weeks after anticoagulant preparation to scheduled electrical cardioversion of atrial fibrillation.

Goal: to study thrombosis prevalence and predictors of thrombi organization in atrial auricles in persistent non-valvular atrial fibrillation (NVAF) in patients undergoing transesophageal echocardiography (TEE) 4 weeks after oral anticoagulant therapy (OAC). Materials and methods: a total of 133 consecutive patients with NVAF, who underwent TЕE before electrical cardioversion (ECV) were included in the study. Results: The mean age of the participants was 60,3±0,9 years, 95 (71,4%) were men. The mean term of the last AF episode was 6,5±0,6 months. Duration of AF less than 1 year was in 47 (35,3%) patients, from 1 to 5 years – in у 61 (45,8%) patients, over 5 years – in 25 (18,8%) patients. 14 (10,5%) patients had underlying coronary artery disease (CAD), 84 (63,2%) patients had arterial hypertension, 31 (23,3%) had both CAD and arterial hypertension, 4 (3,0%) had cardiomyopathy, 80 (60,2%) were obese. NYHA I FC of heart failure (HF) was diagnozed in 8 (6,0%) patients, II FC – in 94 (70,7%) patients and III FC – in 31 (23,3%) patients. GFR > 90 ml/min/1,73m² was in 9 (6,8%) patients, in 74 (55,6%) it was decreased to 60-89 ml/min/1,73m², in 50 (37,6%) patients GFR was 30-59 ml/min/1,73m². In stratification of risk of thromboembolism complications (TEC) 91 (68,4%) fell into the high-risk group with the CHA2DS2-VASc score ≥ 2,  32 (24,1%) patients were in the moderate-risk group and 10 (7,5%) had CHA2DS2-VASc score 0. TEE was performed in all patients 4 weeks after effective OAC therapy. In 40 (37,6%) patients thrombi were detected in the left atrial auricle and in 26 (65,0%) patients they were organized. In 10 (7,5%) patients thrombis were detected in right atrial auricles and in 7 (70,0%) patients they were organized. In 63 (47,4%) patients thrombi were found in both atrial auricles and in 25 (39,7%) patients they were organized. Correlation was found between detection of non-organized thrombi, duration of AF less than 1 year and increase of total cholesterol. Thrombus organization was assotiated with AF duration more than 1 year. Conclusions: Clinical predictors linked with detection of non-organized atrial auricles thrombi in NVAF patients 4 weeks after OAC therapy are duration of AF less than 1 year, increase of total cholesterol, while thrombi organization is assotiated with AF duration more than 1 year

Серцево-судинний ризик у пацієнтів з неклапанною персистуючою фібриляцією передсердь

Results of cardiovascular risk factors assessment of 133 patients with persisting non-valvular atrial fibrillation (AF) (main group) being admitted for electrical cardioversion performance and comparison of these risk factors with cardiovascular risk profile of 6535 AF patients from Cohort 1 of the international GARFIELD registry (group of comparison) are revealed in the article. Patients in the main group were older than 65 years (33,8%), in European population of GARFIELD registry the majority of patients older than 65 years – 73,8%; p<0,001. There were more women in European population of GARFIELD registry in comparison with our patients (44,8% vs 28,6%;р<0,001). With regard to co-morbidity characteristics, patients in our study had higher BMI (31,9 ± 5,7 vs 28,5 ± 5,2; p<0,001), hypercholesterolaemia (72,9% vs 46,1%; p<0,001), moderate renal dysfunction (GFR 30-59 mL/min) (36,8% vs 12,1%; p<0,001) and alcohol abuse (6,8% vs 1,1%). Number of patients with the risk of thromboembolism complications (TEC) ≥ 2 score by CHA2DS2-VASc was higher in European population of GARFIELD registry (86,0% vs 68,4%, <0,001), that is explained by prevalence of elderly patients in this group. The use of oral anticoagulants for thromboembolism prevention in high risk patients was low in both groups (approximately 70,0%), a large majority of patients in both groups were not treated effectively (64,1% vs. 55%, p = 0,148). Prevalence of TEC in case-history was similar in both groups (11,4% vs 15,9%, p = 0,141). So in our study patients with persistent non-valvular AF are characterized by higher cardiovascular risk in younger age in comparison with European population of AF patients from GARFIELD registry. For identification of “truly low-risk” patients with TEC, further improvement of risk stratification is required.В статье представлены результаты изучения характеристик сердечно-сосудистого риска 133 пациентов с персистирующей неклапанной фибрилляцией предсердий (ФП) (основная группа), которые были госпиталазированы для проведения плановой электрической кардиоверсии и ре­зуль­таты сравнения их сердечно-сосудистого риска с европейской популяцией пациентов с ФП Когорты 1 (6535 пациентов) международного регистра GARFIELD (группа сравнения). Среди пациентов нашего исследования старше 65 лет было 33,8% обследованных, в европейской популяции регистра GARFIELD таких пациентов было 73,8% (р<0,001). В основной группе отмечается меньшее количество женщин (28,6% против 44,8%; р<0,001). У участников нашего исследования чаще встречались такие факторы сердечно-сосудистого риска как ИМТ ≥ 30 (31,9 ± 5,7 против 28,5 ± 5,2; p<0,001), гиперхолестеринемия (72,9% против 46,1%; p<0,001), ХБП со СКФ 30-59 мл/мин./1,73м³ (36,8% против 12,1%; p<0,001), злоупотребление алкоголем (6,8% против 1,1%, р<0,001). Большее количество пациентов с риском тромбоэмболических осложнений (ТЭО) ≥ 2 баллов по шкале CHA2DS2-VASc у пациентов ригистра GARFIELD (86,0% против 68,4%, р<0,001) объясняется большим коли­чеством пациентов старше 75 лет (43,5% против 9,0%, р<0,001) в этой группе. Частота назначения оральных антикоагулянтов пациентам высокого риска ТЭО была одинаково низкой (около 70%) в двух группах, при этом у 64,1% пациентов в основной группе и у 55,0% пациентов в группе сравнения (p = 0,148) не был достигнут терапевтический уровень гипокоагуляции. Отмечается одинаковое количество ТЭО в анамнезе в обеих группах (11,4% и 15,9%, p = 0,141). Таким образом, пациенты с персистирующей неклапанной ФП в нашем исследовании характеризуются более высоким сердечно-сосудистым риском в более молодом возрасте в сравнении с пациентами европейской популяции регистра GARFIELD. Для идентификации пациентов «действительно низкого» риска ТЭО необходимо дальнейшее совершенствование шкалы CHA2DS2-VASc.Results of cardiovascular risk factors assessment of 133 patients with persisting non-valvular atrial fibrillation (AF) (main group) being admitted for electrical cardioversion performance and comparison of these risk factors with cardiovascular risk profile of 6535 AF patients from Cohort 1 of the international GARFIELD registry (group of comparison) are revealed in the article. Patients in the main group were older than 65 years (33,8%), in European population of GARFIELD registry the majority of patients older than 65 years – 73,8%; p<0,001. There were more women in European population of GARFIELD registry in comparison with our patients (44,8% vs 28,6%;р<0,001). With regard to co-morbidity characteristics, patients in our study had higher BMI (31,9 ± 5,7 vs 28,5 ± 5,2; p<0,001), hypercholesterolaemia (72,9% vs 46,1%; p<0,001), moderate renal dysfunction (GFR 30-59 mL/min) (36,8% vs 12,1%; p<0,001) and alcohol abuse (6,8% vs 1,1%). Number of patients with the risk of thromboembolism complications (TEC) ≥ 2 score by CHA2DS2-VASc was higher in European population of GARFIELD registry (86,0% vs 68,4%, <0,001), that is explained by prevalence of elderly patients in this group. The use of oral anticoagulants for thromboembolism prevention in high risk patients was low in both groups (approximately 70,0%), a large majority of patients in both groups were not treated effectively (64,1% vs. 55%, p = 0,148). Prevalence of TEC in case-history was similar in both groups (11,4% vs 15,9%, p = 0,141). So in our study patients with persistent non-valvular AF are characterized by higher cardiovascular risk in younger age in comparison with European population of AF patients from GARFIELD registry. For identification of “truly low-risk” patients with TEC, further improvement of risk stratification is required

Clinical course and risk prediction of permanent atrial fibrillation development in patients with chronic heart failure and mid-range ejection fraction of the left ventricle.

The purpose of the study was to establish clinical features of permanent atrial fibrillation (AF) in patients with heart failure mid-range ejection fraction (HFmrEF) and to develop a mathematical model for predicting arrhythmia development. The study included 42 patients with IHD, arterial hypertension (AH), permanent AF and HFmrEF (1 group), mean age – 68.0±1.2 years (21 men and 21 women) and 36 patients with CAD / АH and HFmrEF without AF, mean age- 67.5±0.7 years (22 men and 14 women). The results of the study show, that patients with permanent AF and HFmrEF are characterized by the higher diastolic arterial pressure, higher values of the LDLP, iESV LV, index of end-systolic volume of LV septal thickness and lower EF of the LV in comparison with patients without AF. Patients with permanent AF and HFmrEF also have increased plasma levels of hsCRP, IL-1β, IL-6 and IL-10 in comparison with patients without AF. A mathematical model with scoring system of hsCRP, IL-1β, LV mass index, HDLP, LDLP was developed to assess the risk of AF development in patients with HFmrEF with accuracy of 85.9%, sensitivity of 85.7% and  specificity of 86.1%

Management of patients with pulmonary arterial hypertension against of systemic sclerodermia (part 1).

Pulmonary arterial hypertension (PAH) is a serious condition caused by the damage to the small pulmonary vessels, leading to the increase of pulmonary artery pressure, pulmonary vascular resistance, development of right ventricular failure and death. PAH is one of the actual problems of modern medicine due to low survival rate, rapid disability of the patients and a high cost of treatment. PAH is one of the leading causes of death in systemic scleroderma (SSD). PAH associated with scleroderma is a unique phenotype combining the manifestations of both SSD and PAH, the pathogenetic mechanisms of which modify the clinical picture and the course of these conditions. Timely diagnosis and treatment of PAH show significant effect on survival rates, however, early detection of PAH is still difficult in SSD due to several factors. The main causes are restriction of modern screening methods and polyorganic involvement in SSD. In comparison with other subgroups of PAH the patients with SSD-PAH poorly answer to the specific PAH therapy. SSD-PAH, along with idiopathic pulmonary hypertension (IPAH), belongs to group I of pulmonary hypertension classification and according to modern consensus has a similar pathogenesis and clinical picture, however, differences in the response to therapy in these groups are observed, that indicates the role of other pathobiological mechanisms. Recent investigations explain these differences by such factors as autoimmune and inflammatory responses, more severe vascular remodeling and direct myocardial damage in the SSD. Drug therapy of PH in SSD is similar to that in IPAH and includes prostaglandins, endothelin receptor antagonists, calcium channel blockers, which are prescribed in cases of a positive vasoreactive test, PDE-5 inhibitors. In this literature review we showed traditional and new methods of PAH treatment and their relevance to SSD-PAH in accordance with randomized clinical trials

Management of patients with pulmonary arterial hypertension against systemic sclerodermia (part 2).

Pulmonary arterial hypertension (PAH) is a serious condi­tion caused by the damage of the small pulmonary vessels, leading to the increase of pulmonary artery pressure, pulmonary vascular resistance, development of right ventricular failure and death. PAH is one of the actual problems of modern medicine due to low survival rate, rapid disability of the patients and a high cost of treatment. PAH is one of the leading causes of death in systemic sclerodermia (SSD). PAH associated with scleroderma is a unique phenotype combining the manifestations of both SSD and PAH, the pathogenetic mechanisms of which modify the clinical picture and the course of these conditions. Timely diagnosis and treatment of PAH show significant effect on survival rates, however, early detection of PAH is still difficult in SSD due to several factors. The main causes are restriction of modern screening methods and polyorganic involvement in SSD. In comparison with other subgroups of PAH the patients with SSD-PAH poorly answer to the specific PAH therapy. SSD-PAH, along with idiopathic pulmonary hypertension (IPAH), belongs to group I of pulmonary hypertension classification and according to modern consensus has a similar pathogenesis and clinical picture, however, differences in the response to therapy are observed in these groups, that indicates the role of other pathobiological mechanisms. Recent investigations explain these differences by such factors as autoimmune and inflammatory responses, more severe vascular remodeling and direct myocardial damage in the SSD. Drug therapy of PH in SSD is similar to that in IPAH and includes prostaglandins, endothelin receptor antagonists, calcium channel blockers, which are prescribed in cases of a positive vasoreactive test, PDE-5 inhibitors. In this literature review we showed traditional and new methods of PAH treatment and their relevance to SSD-PAH in accordance with randomized clinical trials

ІМПЛЕМЕНТАЦІЯ СИМУЛЯЦІЙНОГО ТРЕНІНГУ НАДАННЯ НЕВІДКЛАДНОЇ ДОПОМОГИ ДЛЯ СТУДЕНТІВ 6 КУРСУ ПРИ ВИВЧЕННІ ДИСЦИПЛІНИ “ВНУТРІШНЯ МЕДИЦИНА” (ОГЛЯД ЛІТЕРАТУРИ ТА ВЛАСНИЙ ДОСВІД)

The aim of the work – to analyze, generalize existing points of view in the education system, which affect the issue of necessity, effectiveness and features of the simulation programs use for medical students. The main body. An overview of modern literature on the implementation of simulation methods in medical education. Simulation training is one of the effective ways to learn how to manage errors. Simulation training allows to learn how to work in accordance with modern algorithms for diagnosis and emergency care, to develop team interaction and coordination, to increase the level of implementation of complex medical manipulations and to evaluate the effectiveness of their own actions. In particular, at the Internal Medicine Department No. 3 of Dnipropetrovsk Medical Academy a method of simulation training is developed  involving university staff as “standardized patients” for modeling clinical situations of differentiation and assistance in various urgent states. Conclusions. In our view, this implementation of the simulation training is a valuable tool for improving the professional skills of medical students. Elements of this technique are applicable at different stages of educational activity: not only in the development of skills in emergency care, but also during the final certification of the 6th year students.Мета роботи – аналіз, узагальнення існуючих точок зору в системі освіти, які торкаються питання про необхідність, ефективність та особливості використання симуляційних програм навчання студентів-медиків. Основна частина. Проведено огляд сучасної літератури по впровадженню симуляційних методів навчання в медичній освіті. Симуляційне навчання є одним з ефективних способів навчитися керувати помилками. Симуляційне навчання дозволяє навчатися працювати відповідно до сучасних алгоритмів діагностики та надання невідкладної допомоги, виробити командну взаємодію та координацію, підвищити рівень виконання складних медичних маніпуляцій та оцінити ефективність власних дій. Зокрема, в ДЗ “ДМА МОЗ України” на кафедрі внутрішньої медицини 3 розроблена методика імітаційного навчання із залученням співробітників ВНЗ в якості стандартизованих пацієнтів для моделювання клінічних ситуацій диференціації та надання допомоги при різних невідкладних станах. Висновки. На наш погляд, дана імплементація симуляційного тренінгу є цінним інструментом вдосконалення професійних навичок студентів медичних вузів. Елементи даної методики застосовні на різних етапах освітньої діяльності: не тільки при відпрацюванні навичок невідкладної допомоги, а також при проведенні підсумкової атестації студентів 6 курсу

Modern tactics of managing patients with pulmonary arterial hypertension associated with systemic connective tissue diseases.

A review of the literature on the problem of one of the rare manifestations of systemic diseases - pulmonary arterial hypertension is presented. The necessity of early and thorough differential diagnosis, verification of the diagnosis using invasive methods for assessing central hemodynamics is substantiated. A model for screening patients with systemic scle­roderma, which simplifies the determination of indications to set the research methods that allow to verify the diagnosis is proposed. Modern approaches to drug therapy are described, and questions of improving the patients’ survival with this prognostically unfavorable pathology are discussed

Діастолічна функція лівого шлуночка та рівень N-кінцевого промозкового натрійуретичного пептиду у хворих на фібриляцію передсердь

In our study 100 consecutive non-valvular permanent atrial fibrillation patients with NYHA I – III heart failure, 43 - 86 years old (65 men and 35 women) were examined. Control group consisted of 30 patients with arterial hypertension and coronary artery disease matched by age, sex with basic group. Relationship of NT-proBNP with echocardiographic parameters of left heart were studied. Transthoracic echocardiography with tissue doppler measurements were performed on echocardiograph “SONOS7500”. For left ventricular filling pressure assessment ratio Em/Ea was used due to its diagnostic value in atrial fibrillation (regardless of left ventricular ejection fraction). Mean left ventricular filling pressure was increased in patients with heart failure: in atrial fibrillation group and controls as well. In comparison with controls atrial fibrillation group was more likely to have higher both systolic and diastolic left atrial square and volume. According to Em/Ea in 95% of patients with non-valvular atrial fibrillation high left ventricular filling pressure was observed, this testifies to diastolic dysfunction. This parameter correlated well with left atrial square and volume during systole and diastole. Correlation between NT pro-BNP level and NYHA class of  heart failure, left ventricular filling pressure was determined in patients with atrial fibrillation. Tissue doppler echocardiography makes it possible to diagnose left ventricular diastolic dysfunction in atrial fibrillation patients.Обследовано 100 пациентов с постоянной формой фиб­рилляции предсердий неклапанного генеза и хронической недостаточностью І – ІІІ функционального класса в возрасте 43 – 86 лет, из них 65 мужчин и 35 – женщин. Контрольную группу составили 30 пациентов с ИБС и ГБ, сопоставимых по возрасту и полу с основной группой. Изучали уровень N-проМНП и его связь с эхокардиографическими показателями функции левых отделов сердца у данной категории больных. Эхокар­диографическое исследование и тканевая допплерография проводились на аппарате «SONOS 7500». Для оценки давления наполнения левого желудочка рассчитывали соотношение Em/Ea, которое полностью сохраняет свое диагностическое значение (независимо от фракции выброса левого желудочка) при фибрилляции предсердий. Средний показатель давления наполнения левого желудочка был увеличен у больных с хронической сердечной недостаточностью, как при постоянной фибрилляции предсердий, так и на фоне синусового ритма. Было установлено достоверное увеличение размеров левого предсердия, его площадей и объемов в систолу и ди­астолу в группе пациентов с фибрилляцией предсердий в сравнении с группой контроля. По данным показателя Еm/Eaу 95% пациентов с фибрилляцией предсердий неклаппаного генеза выявлено повышение давления наполнения левого желудочка, что свидетельствует о нарушении диастолической функции. Данный пока­затель достоверно коррелировал с объемами и площадями левого предсердия в систолу и диастолу. Уста­новлена достоверная связь между уровнем N-проМНП и функциональным классом сердечной недо­ста­точности, уровнем давления наполнений левого желудочка у пациентов с фибрилляцией предсердий. Использование тканевого допплеровского исследования позволяет диагностировать нарушение диасто­лической функции левого желудочка при фибрилляции предсердий.In our study 100 consecutive non-valvular permanent atrial fibrillation patients with NYHA I – III heart failure, 43 - 86 years old (65 men and 35 women) were examined. Control group consisted of 30 patients with arterial hypertension and coronary artery disease matched by age, sex with basic group. Relationship of NT-proBNP with echocardiographic parameters of left heart were studied. Transthoracic echocardiography with tissue doppler measurements were performed on echocardiograph “SONOS 7500”. For left ventricular filling pressure assessment ratio Em/Ea was used due to its diagnostic value in atrial fibrillation (regardless of left ventricular ejection fraction).Mean left ventricular filling pressure was increased in patients with heart failure: in atrial fibrillation group and controls as well. In comparison with controls atrial fibrillation group was more likely to have higher both systolic and diastolic left atrial square and volume. According to Em/Ea in 95% of patients with non-valvular atrial fibrillation high left ventricular filling pressure was observed, this testifies to diastolic dysfunction. This parameter correlated well with left atrial square and volume during systole and diastole. Correlation between NT pro-BNP level and NYHA class of  heart failure, left ventricular filling pressure was determined in patients with atrial fibrillation. Tissue doppler echocardiography makes it possible to diagnose left ventricular diastolic dysfunction in atrial fibrillation patients

Prevalence, Morphologic Characteristic and Predictors of Organization of Atrial Auricle Thrombi Four Weeks After Anticoagulant Preparation to Scheduled Electrical Cardioversion of Atrial Fibrillation.

Goal: to study thrombosis prevalence and predictors of thrombi organization in atrial auricles in persistent non-valvular atrial fibrillation (NVAF) in patients undergoing transesophageal echocardiography (TEE) 4 weeks after oral anticoagulant therapy (OAC). Materials and methods: a total of 133 consecutive patients with NVAF, who underwent TЕE before electrical cardioversion (ECV) were included in the study. Results: The mean age of the participants was 60,3±0,9 years, 95 (71,4%) were men. The mean term of the last AF episode was 6,5±0,6 months. Duration of AF less than 1 year was in 47 (35,3%) patients, from 1 to 5 years – in у 61 (45,8%) patients, over 5 years – in 25 (18,8%) patients. 14 (10,5%) patients had underlying coronary artery disease (CAD), 84 (63,2%) patients had arterial hypertension, 31 (23,3%) had both CAD and arterial hypertension, 4 (3,0%) had cardiomyopathy, 80 (60,2%) were obese. NYHA I FC of heart failure (HF) was diagnozed in 8 (6,0%) patients, II FC – in 94 (70,7%) patients and III FC – in 31 (23,3%) patients. GFR > 90 ml/min/1,73m² was in 9 (6,8%) patients, in 74 (55,6%) it was decreased to 60-89 ml/min/1,73m², in 50 (37,6%) patients GFR was 30-59 ml/min/1,73m². In stratification of risk of thromboembolism complications (TEC) 91 (68,4%) fell into the high-risk group with the CHA2DS2-VASc score ≥ 2, 32 (24,1%) patients were in the moderate-risk group and 10 (7,5%) had CHA2DS2-VASc score 0. TEE was performed in all patients 4 weeks after effective OAC therapy. In 40 (37,6%) patients thrombi were detected in the left atrial auricle and in 26 (65,0%) patients they were organized. In 10 (7,5%) patients thrombis were detected in right atrial auricles and in 7 (70,0%) patients they were organized. In 63 (47,4%) patients thrombi were found in both atrial auricles and in 25 (39,7%) patients they were organized. Correlation was found between detection of non-organized thrombi, duration of AF less than 1 year and increase of total cholesterol. Thrombus organization was assotiated with AF duration more than 1 year. Conclusions: Clinical predictors linked with detection of non-organized atrial auricles thrombi in NVAF patients 4 weeks after OAC therapy are duration of AF less than 1 year, increase of total cholesterol, while thrombi organization is assotiated with AF duration more than 1 year

Structural and functional predictors of atrial appendages thrombi organization in persistent non-valvular atrial fibrillation patients

Goal: to study predictors of atrial appendages thrombi organization in persistent non-valvular atrial fibrillation patients. Materials and methods: a total of 133 consecutive patients with non-valvular atrial fibrillation, who underwent transoesophageal echocardiography before electrical cardioversion, were included in the study. Results: in 40 (37,6%) patients thrombus were detected in left atrial appendage and in 26 (65,0%) patients they were organized. In 10 (7,5%) patients thrombus were detected in right atrial appendage and in 7 (70,0%) patients they were organized. In 63 (47,4%) patients thrombi were found in both atrial appendages and in 25 (39,7%) patients they were organized. Hemodynamic and morphological predictors of left atrial appendage thrombus in non-valvular atrial fibrillation patients were not found. Thrombus organization in right atrial appendage was assotiated with increased left atrial and right atrial indexed area and volume in systole and diastole, increased thickness of rear wall of left ventricle. Conclusions: predictors of right atrial appendage thrombi organization in non-valvular atrial fibrillation patients are increased left atrial and right atrial indexed area and volume in systole and diastole, increased thickness of rear wall of left ventricle