ПУТИ ОПТИМИЗАЦИИ РЕЗУЛЬТАТОВ РЕВАСКУЛЯРИЗАЦИИ У ПАЦИЕНТОВ С МУЛЬТИФОКАЛЬНЫМ АТЕРОСКЛЕРОЗОМ

Purpose. To perform a comparative assessment of diagnostic tools and strategies of myocardial revascularization in patients with and without polyvascular disease (PolyVD) based on the findings of perioperative analysis.Materials and methods. The medical records of 2 828 patients, aged 32–84, consecutively admitted to the clinic of the Research Institute for Complex Issues of Cardiovascular Diseases between January, 2006, and July, 2010, for coronary artery bypass surgery, were retrospectively reviewed. All the patients were divided into two groups: Group 1 included 448 (15,48 %) PolyVD patients with clinically manifested or angiographically confirmed obliterating (≥ 60 %) non-cardiac artery lesions. Group 2 (the control group) included 1691(59,79 %) patients without any clinical symptoms of non-coronary atherosclerosis. The incidence rate, structure and causes of in-hospital mortality and type I neurological disorders (i.e. strokes and transient ischemic attacks) were assessed in both groups.Results. The incidence rate of significant non-cardiac occlusive stenotic lesions in patients with coronary artery disease (CAD), who had to undergo CABG, was 15,84 %. Simultaneous revascularization of coronary and non-coronary arteries was performed in 2,46 % of patients with CAD and PolyVD and multi-stage surgical procedures were chosen in other cases.Conclusions. The outcomes of CAD surgical treatment were improved in this group of patients due to the implementation of a multidisciplinary team approach, which ensured a proper diagnosis of polyvascular disease.Цель. Провести сравнительную оценку диагностических и тактических аспектов хирургической реваскуляризации миокарда среди пациентов с наличием и отсутствием мультифокального атеросклероза (МФА) на основе анализа периоперационных результатов.Материалы и методы. В основе работы – ретроспективное изучение сплошной выборки историй болезни 2 828 больных в возрасте от 32 до 84 лет, которым в период с января 2006 по июль 2010 года в клинике НИИ КПССЗ проводили коронарное шунтирование (КШ). Пациенты были разделены на две группы: I группа из 448 (15,84 %) пациентов с МФА, с клинически манифестирующими либо ангиографически подтвержденными облитерирующими (≥ 60 %) поражениями некардиальных артерий. II группа (контроля) из 1 691 (59,79 %) пациента без клинических признаков внекардиального атеросклероза. У пациентов обеих групп оценивали частоту, структуру и причины госпитальной летальности и неврологических нарушений первого типа (т. е. инсульты и транзиторные ишемические атаки). 695 пациентов с незначительными стенозами были исключены из исследования.Результаты. Распространенность значимых окклюзионно-стенотических поражений некардиальных артерий среди пациентов с ишемической болезнью сердца (ИБС), требующих КШ, составила 15,84 %. Лишь в 2,46 % случаев больным с ИБС и МФА проводили симультанные реконструкции коронарных и некардиальных артерий, в остальных случаях использовали этапные хирургические вмешательства.Заключение. В рамках работы мультидисциплинарной бригады и за счет более активного подхода, направленного на диагностику мультифокального поражения, удалось добиться улучшения результатов оперативного лечения ИБС у данной категории больных

Rivaroxaban with or without aspirin in stable cardiovascular disease

BACKGROUND: We evaluated whether rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary cardiovascular prevention. METHODS: In this double-blind trial, we randomly assigned 27,395 participants with stable atherosclerotic vascular disease to receive rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg once daily). The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction. The study was stopped for superiority of the rivaroxaban-plus-aspirin group after a mean follow-up of 23 months. RESULTS: The primary outcome occurred in fewer patients in the rivaroxaban-plus-aspirin group than in the aspirin-alone group (379 patients [4.1%] vs. 496 patients [5.4%]; hazard ratio, 0.76; 95% confidence interval [CI], 0.66 to 0.86; P<0.001; z=−4.126), but major bleeding events occurred in more patients in the rivaroxaban-plus-aspirin group (288 patients [3.1%] vs. 170 patients [1.9%]; hazard ratio, 1.70; 95% CI, 1.40 to 2.05; P<0.001). There was no significant difference in intracranial or fatal bleeding between these two groups. There were 313 deaths (3.4%) in the rivaroxaban-plus-aspirin group as compared with 378 (4.1%) in the aspirin-alone group (hazard ratio, 0.82; 95% CI, 0.71 to 0.96; P=0.01; threshold P value for significance, 0.0025). The primary outcome did not occur in significantly fewer patients in the rivaroxaban-alone group than in the aspirin-alone group, but major bleeding events occurred in more patients in the rivaroxaban-alone group. CONCLUSIONS: Among patients with stable atherosclerotic vascular disease, those assigned to rivaroxaban (2.5 mg twice daily) plus aspirin had better cardiovascular outcomes and more major bleeding events than those assigned to aspirin alone. Rivaroxaban (5 mg twice daily) alone did not result in better cardiovascular outcomes than aspirin alone and resulted in more major bleeding events