Эндоваскулярное лечение стеноза почечной артерии, вызванного фибромускулярной дисплазией. Клинический случай

Introduction. Fibromuscular dysplasia (FMD) is an idiopathic, non-atherosclerotic, non-inflammatory disease of arteries. Careful research into this disorder showed that FMD has been found in every arterial bed in the body; the most common arteries affected are renal arteries and extracranial sections of carotid and vertebral arteries. The clinical presentation is determined by the localization of the vasculature affected and the stenosis severity. Today FMD is a very rare disease with the incidence of 4 per 1000 people. The diagnosis today is difficult and may take a long time. According to the latest European Society of Cardiology guidelines renal artery balloon angioplasty is indicated for patients with FMD; if a good angiographic result is achieved (no dissection, TIMI 3 flow) no renal artery stenting required. The treatment success depends on the early diagnosis.Materials and Methods. This paper presents a clinical case of renal artery stenosis caused by fibromuscular dysplasia that was treated successfully with balloon angioplasty without stenting.Results and discussion. Protracted process of diagnosing this disease may result in deteriorating quality of life and poor outcomes such as difficult-to-control hypertension and its sequelae, TIA, stroke, aneurism dissection or rupture. It is worth pointing out that FMD diagnosis may be incidental when imaging is performed for other reasons, or when there is a systolic murmur at arteries in an asymptomatic patient who does not have classic atherosclerosis risk factors. According to the latest guidelines endovascular treatment is indicated for patients with FMD to manage the hypertension; this has proven very effective in improving quality of life.Введение. Фибромускулярная дисплазия (ФМД) — идиопатическое, не атеросклеротическое, не воспалительное поражение артерий. Тщательное изучение данной патологии показало, что при ФМД поражаются все сосудистые русла, наиболее чаще встречаемые — это почечные артерии и экстракраниальные отделы сонных и позвоночных артерий. Клиническая картина ФМД определяется локализацией пораженного сосудистого бассейна и  тяжестью стеноза. На сегодняшний день ФМД является весьма редким заболеванием. Его распространенность примерно 4 на 1000 человек. Своевременная диагностика затруднена, и диагностический поиск может занять много времени. Согласно последним рекомендациям Европейской ассоциации кардиологов пациентам с ФМД показана баллонная ангиопластика почечной артерии, при хорошем ангиографическом результате (отсутствие диссекции, кровоток TIMI 3) без имплантации стента в почечную артерию. Успех лечения зависит от ранней диагностики заболевания. Материалы и методы. В статье представлен клинический случай успешного эндоваскулярного лечения стеноза почечной артерии, вызванного фибромускулярной дисплазией, при помощи баллонной ангиопластики без стентирования.Результаты и обсуждение. Длительная диагностика заболевания может привести к ухудшению качества жизни и неблагоприятным исходам, таким как плохо контролируемая гипертензия и ее последствия, ТИА, инсульт, диссекция или разрыв аневризмы. Следует отметить, что ФМД может быть обнаружена случайно, когда визуализация выполняется по другим причинам или когда слышен систолический шум при аускультации артерий у бессимптомного пациента без классических факторов риска атеросклероза. По современным рекомендациям пациентам со стенозом почечных артерий при ФМД для лечения гипертонии показано эндоваскулярное лечение, которое дает хороший эффект в улучшении качества жизни.Заключение. Эндоваскулярная баллонная ангиопластика почечной артерии может успешно применяться у пациентов с фибромускулярной дисплазией

Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients With Nonvalvular Atrial Fibrillation : Data From ROCKET AF

M. Kaste on työryhmän ROCKET AF Steering Comm jäsen.Background-Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all-cause mortality may guide interventions. Methods and Results-In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose-adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all-cause mortality in the 14 171 participants in the intention-to-treat population. The median age was 73 years, and the mean CHADS(2) score was 3.5. Over 1.9 years of median follow-up, 1214 (8.6%) patients died. Kaplan-Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all-cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33-1.70, P= 75 years (hazard ratio 1.69, 95% CI 1.51-1.90, P Conclusions-In a large population of patients anticoagulated for nonvalvular atrial fibrillation, approximate to 7 in 10 deaths were cardiovascular, whereasPeer reviewe

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

FACTOR ANALYSIS AND INDIVIDUAL PROGNOSIS FOR THE PATIENTS WITH FIRST REVEALED ARTERIAL HYPERTENSION

Aim. To conduct a comparative research of a variety of angiographic scales with the aim to choose strict and useful scoring system for coronary artery lesion estimation. Material and methods. The cohort of patients is investigated with the age of 25-86 y. (n=502, 70,7% males), who at FSBI "SSRCPM" of the Ministry of Health were underwent coronary arteriography. To evaluate the severity of atherosclerosis by the angiography results the scoring systems Gensisni and SYNTAX were used. Quantitative evaluation of stenoses was done using the software of "General Electric Innova 4100".Results. The groups were formed acorrding to absence, mild or severe coronary atherosclerosis using the Gensini and SYNTAX scores, and also by coronary stenoses prominence. The significant association between all three methods was shown: Spearman correlation coefficient about 0,87. Quantity of points by Gensini and SYNTAX increases according to the quantity of arteries involved. But usage of Gensini score with addition of cut-off points makes more precise the identification of patients with severe coronary arteries lesion.Conclusion. The Gensini scale and the cut-off points provided makes it possible a relevant estimation of coronary arteries lesion and improves the decision whether to revascularize or not

ASSOCIATION BETWEEN THE DEGREE OF CORONARY ATHEROSCLEROSIS, RISK FACTORS, AND MARKERS OF CAROTID AND PERIPHERAL ARTERY ATHEROSCLEROSIS

Aim. To investigate the associations between the presence and degree of coronary atherosclerosis, cardiovascular risk factors, and atherosclerosis of other localisation.Material and methods. The cohort of 98 patients (61 men and 37 women; age 18–80 years) underwent an extensive clinical, biochemical, and instrumental examination, including coronary angiography. All participants were divided into three groups by the degree of coronary artery (CA) atherosclerosis: stenosis of 0–20%, 21–70%, and ≥71%.Results. There was no marked between-group difference in the noninvasively assessed markers of the atherosclerosis of other localisation (ankle-brachial index and intima-media thickness). However, there was a significant positive correlation between CA atherosclerosis and smoking, overweight, and diabetes mellitus. The degree of CA atherosclerosis was significantly associated with hyperglycemia and positive exercise test results. The lowest levels of low-density lipoprotein cholesterol (LDL–CH) among patients with the most severe CA atherosclerosis could be due to the fact that this group also had the highest proportion of individuals who were treated with statins and achieved target LDL–CH levels.Conclusion. A further investigation is needed, with the focus on additional biochemical and other parameters, in order to identify the best determinants of the CA atherosclerosis degree and the acute complication risk for each patient

Endovascular Treatment of Renal Artery Stenosis Caused by Fibromuscular Dysplasia. A Clinical Case Report

Introduction. Fibromuscular dysplasia (FMD) is an idiopathic, non-atherosclerotic, non-inflammatory disease of arteries. Careful research into this disorder showed that FMD has been found in every arterial bed in the body; the most common arteries affected are renal arteries and extracranial sections of carotid and vertebral arteries. The clinical presentation is determined by the localization of the vasculature affected and the stenosis severity. Today FMD is a very rare disease with the incidence of 4 per 1000 people. The diagnosis today is difficult and may take a long time. According to the latest European Society of Cardiology guidelines renal artery balloon angioplasty is indicated for patients with FMD; if a good angiographic result is achieved (no dissection, TIMI 3 flow) no renal artery stenting required. The treatment success depends on the early diagnosis.Materials and Methods. This paper presents a clinical case of renal artery stenosis caused by fibromuscular dysplasia that was treated successfully with balloon angioplasty without stenting.Results and discussion. Protracted process of diagnosing this disease may result in deteriorating quality of life and poor outcomes such as difficult-to-control hypertension and its sequelae, TIA, stroke, aneurism dissection or rupture. It is worth pointing out that FMD diagnosis may be incidental when imaging is performed for other reasons, or when there is a systolic murmur at arteries in an asymptomatic patient who does not have classic atherosclerosis risk factors. According to the latest guidelines endovascular treatment is indicated for patients with FMD to manage the hypertension; this has proven very effective in improving quality of life

VALUE OF SPECIFIC PARAMETERS AND INTEGRATIVE INDICES OF TREADMILL TEST FOR THE ASSESSMENT OF CORONARY STENOSIS SEVERITY

Aim. To assess the value of specific parameters and integrated indices (II; such as Duke Index (DI), Centre for Preventive Medicine Index (CPMI), and modified CPMI) of the treadmill test in the diagnostics of coronary stenosis severity among patients with stable coronary heart disease (CHD).Material and methods. The study included all patients (260 permanent residents of Moscow City or Moscow Region) who were admitted to the State Research Centre for Preventive Medicine with the CHD diagnosis and who underwent coronary angiography (CAG) and treadmill test in the period between January 1st 2004 and December 31st 2007.Results. There were statistically significant associations between the main treadmill test parameters and the severity of coronary artery (CA) atherosclerosis. The larger number of stenosis-affected CA was associated with a higher prevalence of chest pain and treadmill tests with positive results and ST segment depression >1 mm, as well as with a decreased total duration of treadmill test. Similarly, the increased risk, as assessed by treadmill test indices (DI, CPMI, and modified CPMI), was linked to an increased number of stenosis-affected CA. Modified CPMI demonstrated the highest diagnostic value for the assessment of coronary atherosclerosis severity.Conclusion. The treadmill test parameters which demonstrated their diagnostic value for the assessment of CHD severity included the following: positive test results, retrosternal chest pain as the reason for test discontinuation, ST segment depression >1mm, and short total duration of the test. Overall, all II demonstrated their high value in CHD diagnostics. Modified CPMI was the most effective II in the assessment of CA atherosclerosis severity

FIRST RESULTS OF CHD PROGNOSIS STUDY

Aim — to investigate the prognostic value of different risk factors associated with stable angina in a contemporary population of patients,to identify the key prognostic features, to evaluate the risk distribution and to construct a reliable tool for the risk prediction.Materials and methods. Prospective observational cohort study, conducted between January, 2004 and December, 2007 in Moscow, Russia. 641 patients were included on the basis of planned hospitalization to National Research Center for Preventive Medicine (Moscow) with a clinical diagnosis of coronary heart disease and performance of coronary angiography. 5 years follow‑up period (median time 3.9 years, min. 0.76 years, max. 6.52 years). 551 patients were followed-up by phone interview, among them: 432 men (78%, (age 57.7 ± 0.4), 119 women (age 60.3 ± 0.7), 354 of them attended follow-up visit and were secondary examined. Univariate and multivariate Cox regression model was used to identify independent predictors of events. Variables were selected in a stepwise forward manner. The probabilityof survival was calculated using the Kaplan—Meier method, and survival were compared using the long-rank test.Results. Annual death rate from all cause was 11.38 per 1000 patient-years at risk. The primary endpoint (combined all-cause mortality, nonatal MI, non-fatal stroke/TIA) was registered in 13.61% of cases, with annual rate of 17.34 per 1000 patient-years at risk. Frequency of the secondary endpoint (cardiovascular adverse events, such as CV death, non-fatal MI, non-fatal stroke/TIA, recurrent angina, endovascular revascularization, CABG) was registered in 36% of all followed‑up cases.Conclusion. This article describes the first results of PROGNOS IBS study — a comprehensive patient registry. Our data demonstrates the risk factors distribution and morbidity/mortality rates in the contemporary population of patients. A score will be developed to estimate risk probability of death and adverse cardiovascular events.</p