The study of the prognostic value scales of assessing the risk of adverse coronary events in patients with acute coronary syndrome without ST-segment elevation in combination with comorbid conditions

Objective: to identify the most prognostically significant scale risk assessment of patients with acute coronary syndrome without ST-segment elevation in combination with diabetes mellitus type 2, chronic renal failure, multifo-cal coronarocardiosclerosis, dyscirculatory encephalopathy. Material and methods. 260 patients with acute coronary syndrome without ST-segment elevation were divided into 4 groups according to the presence of severe concomitant diseases: patients with diabetes mellitus type 2 (71 people), chronic renal failure (49), multifocal lesions of the coronary arteries (76) and patients with dyscirculatory encephalopathy of grade 2-3, including ischemic stroke (64). All patients were stratified by major scales risk: TIMI, GRACE, PURSUIT. The development of negative coronary events was assessed in hospital and during the year after discharge. On the basis of the results, all scales were studied using the criterion of Mann-Whitney and identified the most predictably significant groups of patients with specific comorbid conditions. Results. It is revealed that the significance of the scales TIMI and GRACE in the study of distant forecast (up to 6 months) is the most reliable with acute coronary syndrome without ST-segment elevation in combination with diabetes mellitus type 2. For the patients with combination with chronic renal insufficiency the best prognostic significance was obtained by the GRACE scale in the study of hospital risk and forecast up to 6 months. TIMI and GRACE scales in the study of hospital risk and forecast up to 6 months had the greatest prognostic significance for the patients with acute coronary syndrome without ST-segment elevation on the background of multifocal lesions of the coronary arteries. For the patients with dyscirculatory encephalopathy of the 2nd and 3rd grades, the greatest prognostic significance was obtained by stratification of risk on PURSUIT and GRACE scales in the study of hospital risk and forecast up to 6 months. Conclusion. The results demonstrate the necessity of a differentiated approach to the risk stratification of patients with acute coronary syndrome without ST-segment elevation depending on the grade of a severe comorbid disease

Клинические и морфологические особенности повреждения миокарда и течения фульминантного миокардита на фоне СOVID-19, диагностика и тактика лечения

In a review article based on my own clinical experience of managing patients with acute myocardial injury and fulminant myocarditis, taking into account expert recommendations on the clinical treatment of myocardial damage associated with novel coronavirus infection a National clinical geriatric medical research center, division of cardiovascular diseases, the Chinese geriatrics society, Department of cardiology, Beijing Medical Association and European clinics discusses the pathogenesis, diagnosis and treatment of myocardial damage and FM patients, infected with SARS-CoV-2 in the context of the COVID-19 pandemic. Clinical features and diagnostic criteria are presented, including screening tests of markers of myocardial damage in the form of a highly sensitive troponin test, a natriuretic peptide. The article discusses in detail the pathogenesis and mechanisms of myocardial damage, including immune mechanisms, cytokine storm, systemic inflammation with macro- and microvascular dysfunction and the development of myocardial dysfunction with acute heart failure, hypotension, cardiogenic shock and/or life-threatening heart rhythm disorders caused by hypoxia and metabolic disorders at the cellular level. Features of the clinical course of fulminant myocarditis in infected patients (SARS-CoV-2) in the conditions of the COVID-19 pandemic are presented. For the first time, a detailed histo-morphological analysis of pathological myocardial injuries and complications is presented on the basis of unique autopsy material on post-mortem diagnostics of various pathoanatomic autopsies of those who died from COVID-19 in Moscow. Based on the clinical, functional and morphological material, the Protocol of etiopathogenetic treatment is presented. The basis of standard therapy is considered antiviral drugs, immunoglobulin G, the use of monoclonal antibodies to interleukin-6, anticoagulants, glucocorticoids, depending on the clinical situation, cardioprotectors and symptomatic treatment are recommended to maintain the heart, which in combination can achieve a certain clinical effectiveness. As adjuvant cardioprotective targeted therapy, the sodium salt of phosphocreatine is considered in order to preserve the myocardium, maintain its contractility and vital activity.В обзорной статье обсуждаются вопросы патогенеза, диагностики и лечения повреждения миокарда и фульминантного миокардита у больных, инфицированных SARS-CoV-2, в условиях пандемии COVID-19. Представлены клинические особенности и диагностические критерии, включающие скрининговые тесты маркеров повреждения миокарда в виде высокочувствительного тропонинового теста, натрийуретического пептида. Детально обсуждаются вопросы патогенеза и механизмы повреждения миокарда, включающие иммунные механизмы, цитокиновый шторм, системное воспаление с макро- и микроваскулярной дисфункцией и развитием дисфункции миокарда с острой сердечной недостаточностью, гипотензией, кардиогенным шоком и/или жизнеугрожающими нарушениями ритма сердца, обусловленные гипоксией и метаболическими нарушениями на клеточном уровне. Представлены особенности клинического течения фульминантного миокардита у больных, инфицированных SARS-CoV-2, в условиях пандемии COVID-19. Впервые представлен детальный гистоморфологический анализ патологических повреждений миокарда и осложнений на основе уникального аутопсийного материала по посмертной диагностике многообразных патологоанатомических вскрытий умерших от COVID-19 в Москве. На основании клинико-функционального и морфологического материала представлен протокол этиопатогенетического лечения. В зависимости от клинической ситуации для поддержания работы сердца в качестве метаболической адъювантной кардиопротективной таргетной терапии рассматривается натриевая соль фосфокреатина с целью поддержания сократительной способности и жизнедеятельности миокарда. Для улучшения прогноза у больных с COVID-19, перенесших острое повреждение миокарда, фульминантный миокардит, в протокол лечения рекомендовано введение кардиопротективной терапии, которая в комбинации со стандартной терапией позволяет достичь клинической эффективности