OPTIMIZATION OF ACUTE MYOCARDITIS TREATMENT

Aim. This paper is aimed at investigating the possibility of preventing an adverse outcome of acute viral myocarditis by means of optimal pharmacotherapy without the use of surgical treatment methods.Results. We describe a clinical case of acute viral myocarditis in a 60-year old female patient. According to the conducted echocardioscopy, the dilatation of the heart cavities and the complete insufficiency of the mitral and tricuspid valves were identified. A cumulative effect of the chosen optimal pharmacotherapy, which included an angiotensin converting enzyme inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist and a loopback diuretic with neurohumoral properties taken in optimal doses, allowed congestion signs to be rapidly eliminated, a reverse remodeling of the heart to be achieved and the heart size to be returned normal values. The double blockade of aldosterone receptors using eplerenone and torasemide prevented both the development of fibrosis in the myocardium and the formation of irreversible dilated cardiomyopathy.Conclusion. The application of antiviral and immunomodulatory therapy, along with the maximum possible doses of drugs used to treat chronic heart failure, allowed the patient’s cardiohemodynamic parameters to be returned to normal values. A timely combination therapy should be used to avoid the formation of dilated cardiomyopathy, thus improving the prognosis of the disease

Triple-combined hypolipidaemic therapy in familial hypercholesterolaemia: clinical cases

Background. The prevalence of heterozygous familial hypercholesterolaemia (HeFH) comprises 1 per 250 people. The risk of premature cardiovascular disease (CVD) is 20 times higher in HeFH patients among the general population. CVD develops in HeFH patients under 20 years of age, and they usually do not survive to 30 years. Therefore, the primary treatment track here is correction of dyslipidaemia to prevent atherosclerosis progression and CVD. Clinical Case Descriptions. The article describes the clinical cases of familial dyslipidaemia in 47-yo patient M. and his 75-yo mother P. The patient had a visit related to blood pressure (BP) surges up to 140/90 mm Hg. In history: acute myocardial infarction (AMI) in maternal grandfather at 50 years and own uncle at 32 years. The patient’s cardiovascular risk factors: male gender, dyslipidaemia (total cholesterol (TC) 15.8 mmol/L), overweight (body mass index 29.9 kg/m2), familial history of young CVD, sedentary lifestyle (employed as manager), psychological and socioeconomic factors (work-related stress pressure), resting heart rate 88 beats/min. The patient was immediately ordered a combined hypolipidaemic therapy including rosuvastatin 20 mg, ezetimibe 10 mg, telmisartan 40 mg once daily for blood pressure correction. In 1-month therapy, cholesterol dropped to 4.4 mmol/L, low-density lipoprotein (LDL) cholesterol – to 2.2, but triglycerides remained high at 3.9 mmol/L. Fenofi brate added to therapy at 145 mg 1 time. Another 1-month therapy allowed the overall reduction of TC to 3.7, LDL cholesterol to 1.9, triglycerides to 2.17 and high-density lipoproteins to 1.19 mmol/L. Past 3 months, a further drop was observed in triglycerides to 1.7 mmol/L. Hence, a triple hypolipidaemic therapy facilitated the target LDL and triglyceride values without involving expensive medications like PCSK9 blockers. The patient’s mother also achieved the target basic lipidogram owing to a triple lipid-lowering therapy.Conclusion. The case is of interest to exemplify a successful triple lipid-lowering therapy in patients with familial hypercholesterolaemia

Mitral valve prolapse as cause of terminal ventricular complex ischaemia: a clinical case

Background. Mitral valve prolapse has common prevalence of 1% in population. Patients with mitral valve prolapse (MVP) continue to pose a major challenge in practical cardiology for its nonspecific manifestations, usually, palpitations and atypical chest pain. Several studies have demonstrated a high incidence of ventricular arrhythmias in individuals with MVP. MVP was observed in 2.3% of patients with sudden cardiac death. Comparing to the common population with sudden cardiac death, MVP patients belonged to a younger age group and less frequently had concomitant cardiovascular pathology.Clinical Case Description. Patient T. referred with complaints of transient constricting chest pain at rest and exercise, dyspnoea at exercise. A total duration of ST-T segment displacement episodes was 168 min, with painless episodes prevailing. Spiral computed angiography did not reveal calcinosis, soft coronary atherosclerotic plaques or abnormal arterial origins. Severe ventricular repolarisation abnormalities with sinusoidal T-U waves morphology in MVP are harbingers of sudden cardiac death, despite a normal QT interval duration. The T wave inversion in the lower lead and ventricular extrasystole also comprise the risk factors for sudden cardiac death in patients with MVP.Conclusion. Mitral valve prolapse caused an ischaemic ST-T segment depression in a young woman indicating a high risk of sudden cardiac death and need for immediate drug therapy. The Russian recommendations on treatment of connective tissue dysplasia and known literature suggest magnesium preparations as a preferred medication. Beta-blockers are effective in increased sympathetic nervous system reactivity or tone. Collagen synthesis stimulators, vitamins C, D, P, group B, preparations of magnesium, calcium, manganese, copper and antihypoxants are also recommended. Treatment with bisoprolol and magnesium orotate eliminated ischaemia and ventricular extrasystoles and improved the patient’s condition

Scrotal variceal bleeding during rivaroxaban therapy as alarming sign in senescent patients: A clinical case

Background. The past decade has witnessed the advent of direct oral anticoagulants (DOACs) into clinical practice for the prevention and treatment of venous thromboembolism, as well as stroke prevention in atrial fibrillation (AF) patients. A serious complication of anticoagulant treatment is bleeding. Randomised controlled trials have shown that the risk of already developed bleeding does not reduce upon a DOAC replacement. In such cases, the bleeding cause diagnosis and elimination are recommended instead of a anticoagulant replacement. An anticoagulant treatment can only be resumed once the elimination is completed.Clinical Case Description. Patient K., 81 yo, was emergently admitted to a cardiology ward of the Rostov Regional Clinical Hospital with a clinical picture of bilateral pulmonary embolism of small arterial branches confirmed in multislice computed angiopulmonography. Apart from venous embolism, persistent atrial fibrillation was detected as an additional indication for DOAC treatment. A CHA2DS2-VASc risk of thrombosis was 6, HAS-BLED risk of bleeding — 2. Glomerular filtration rate at bleeding was 90 mL/min/1.73 m2. The patient was prescribed rivaroxaban at 20 mg daily. Past 2 years and 3 months, rivaroxaban has been withdrawn due to bleeding developing from scrotal veins. An urologist examination revealed a bilateral spermatic cord veins dilation. A Valsalva test revealed persistent retrograde veinous blood flow. Varicocele detected on both sides.The patient underwent venous occlusion of left internal spermatic vein following an Ivanissevich procedure. The cause of bleeding was eliminated. The patient resumed rivaroxaban 1 week since the operation.Conclusion. The case describes a rare cause of bleeding that has been established at a continued new DOAC therapy

Поздние осложнения новой коронавирусной инфекции: клиническое наблюдение

According to the literature, exudative pleurisy and pericarditis are considered rare complications of the new coronavirus infection. This estimation can be explained by the fact that statistical studies cover mainly the hospital treatment of this disease. The true frequency of these complications and their consequences are not fully understood.Aim. The study of late complications of the new coronavirus infection in the form of pleurisy and pericarditis.Conclusion. In our case, a 62-year-old patient with the new coronavirus infection confirmed by polymerase chain reaction, severe bilateral polysegmental viral pneumonia, CT3, 60% on day 43 after the onset of clinical symptoms, was found to have manifestations of pleurisy and pericarditis during outpatient treatment. Cardiac MRI is the most informative method for detecting small pericardial and pleural effusions. The diagnostic capabilities of this method are superior to ultrasounography of the heart and pleural cavities and computed tomography of the lungs. Administration of colchicine 1.0 g per day for 1 month allowed not only to the elimination of pericarditis and pleurisy, but also the reduction of pressure in the right ventricle, probably by reducing the damage to the pulmonary parenchyma.Редкими осложнениями новой коронавирусной инфекции (НКИ), согласно литературным данным, являются экссудативный плеврит и перикардит. Это объясняется преимущественным охватом статистическими исследованиями стационарного этапа лечения данного заболевания. На самом деле истинная частота этих осложнений и последствия до конца не изучены.Целью исследования явилось изучение поздних осложнений НКИ в виде плеврита и перикардита.Заключение. В представленном клиническом наблюдении проявления плеврита и перикардита обнаружены у пациентки 62 лет на фоне НКИ, подтвержденной методом полимеразной цепной реакции, двусторонней полисегментарной вирусной пневмонии тяжелой степени (60 % поражения легочной ткани – 3-я степень по данным компьютерной томографии – КТ) на 43-й день от момента появления клинических симптомов, на амбулаторном этапе. Наиболее информативным методом для выявления малого перикардиального и плеврального выпота является магнитно-резонансная томография (МРТ) сердца. Диагностические возможности МРТ превосходят таковые при ультразвуковом исследовании сердца и плевральных полостей, а также КТ легких. При назначении колхицина в дозе 1,0 г в сутки на 1 мес. отмечено не только устранение явлений перикардита и плеврита, но и снижение давления в правом желудочке, вероятно, за счет уменьшения объема повреждения легочной паренхимы

Цитокиновый профиль пациентов с сочетанной кардио- и офтальмопатологией

Сочетанная кардиологическая и офтальмологическая патология имеет высокую распространённость в старших возрастных группах населения и общие патогенетические механизмы, к числу которых, безусловно, относится нарушение цитокинового профиля. Однако цитокиновый профиль крови практически не анализировался у пациентов пожилого возраста с сочетанной ишемической болезнью сердца с глаукомой. Цель исследования – изучение цитокинового профиля у пациентов с сочетанной кардио- и офтальмопатологией. Исследование выполнено в Тамбовском филиале МНТК «Микрохирургия глаза имени академика С.Н. Федорова» в двух группах: пациенты с сочетанной ишемической болезнью сердца с глаукомой (n=58 человек) и пациенты с ишемической болезнью сердца (n=49 человек), имеющих в обоих случаях одинаковый возраст 60-74 лет. Диагностика глаукомы проведена в соответствии с критериями «Национального руководства по глаукоме». Для диагностики ишемической болезни сердца выполнялись электрокардиографические, эхокардиографические, рентгенографические, энзимные исследования. Определение цитокинов в плазме крови проводилось на аппарате «Beckton Dickinson FACS Canto 2 (USA)» с помощью специального набора CBA (BD Biosciences, USA). Среди пациентов сравниваемых групп одинакового возраста выявлены достоверные различия по большинству цитокинов, а именно преимущественное повышение у пациентов с сочетанной кардио- и офтальмопатологией относительно группы с ишемической болезнью сердца. Повысилось в плазме крови пациентов с ишемической болезнью сердца, сочетанной с глаукомой, содержание IL-5, IL-12, IFN-γ, TNF-α c достоверным различием по сравнению с пациентами с ишемической болезнью сердца. Однако наивысшее увеличение среди рассматриваемых цитокинов характерно для IL-6 и IL-17, составившее у пациентов с сочетанной кардио- и офтальмопатологией 23,8±1,1 пг/мл и 20,2±1,7 пг/мл против 6,3±0,3 пг/мл и 7,9±0,5 пг/мл соответственно у пациентов с ишемической болезнью сердца. Вместе с тем существенно снизился уровень IL-4 и IL-10 до 2,2±0,2 пг/мл и 6,4±0,4 пг/мл против 4,8±0,3 пг/мл и 11,9±0,6 пг/мл. Использование логистической регрессии позволило определить величины относительного риска изученных цитокинов крови и разработать нескорректированные и скорректированные модели, согласно которым наиболее тесная ассоциация с риском развития сочетанной ишемической болезни сердца с глаукомой установлена для IL-6 и IL-17, с величинами относительного риска в нескорректированной модели 2,87 и 2,71 соответственно (p<0,001). Однако в скорректированной модели ассоциация IL-6 с сочетанной ишемической болезнью сердца с глаукомой повысилась до 2,92 (ДИ 2,80-3,27, р=0,004), а IL-17 уменьшилось до 2,64 (ДИ 2,51-2,85, р=0,003). Установлена также достоверная ассоциация IL-4, IL-5, IL-12, IFN-γ и TNF-α с сочетанной ишемической болезнью сердца с глаукомой. Исследование продемонстрировало новые ассоциации системных цитокинов с риском развития сочетанной ишемической болезнью сердца с глаукомой

Myocardial bridging: non-invasive diagnostics and management

The article discusses a case of episodes of asymptomatic ST-T depression during exercise in a 37-year-old patient with complaints of irregular heartbeat, tachycardia up to 100 bpm, not related to exercise. According to contrast-enhanced multislice computed tomography, in the middle third, a muscle bridge with stenosis of up to 30% was found. The diagnosis was made: Congenital coronary artery anomaly: transmyocardial muscular bridge of the middle third of left anterior descending artery with stenosis up to 30%. Class 1 silent myocardial ischemia. Stage 0, class 0 chronic heart failure. Using non-invasive coronary imaging, it was possible to identify the cause of transient ST-T depression and to choose the appropriate therapy

Amiodarone-Induced Hypothyroidism

Aim: to present a clinical case of amiodarone-induced hypothyroidism in a patient with paroxysmal atrial fi brillation.Results. Before taking amiodarone, the patient suffered from subclinical hypothyroidism. The level of thyroid stimulating hormone (TSH) was 6.2 mIU/L, thyroxine (T4) — 9.2 pmol/L. Against the background of taking amiodarone in a maintenance dose of 200 mg per day 5 days a week with a break of 2 days, clinically severe hypothyroidism developed with a TSH level of more than 16 mIU/L. An electrocardiogram (ECG) recorded sinus bradycardia with a heart rate (HR) of 37 beats per minute. Paroxysms of atrial fi brillation have stopped. According to the daily ECG monitoring recorded throughout the sinus rhythm with maximum heart rate of 92 beats/min., minimum of 35 beats/min. The circadian rhythm profi le was correct. No pauses were detected for more than two seconds. Transient atrioventricular block was of 1 degree (during sleep). Ectopic activity was represented by supraventricular extrasystoles 112 per day: 107 single, 1 pair, 1 group. Ventricular extrasystoles: 55 per day: polymorphic, solitary. No diagnostically signifi cant elevation or depression of the ST segment was detected. After the abolition of amiodarone, thyroid function was recovered. Levothyroxine was not prescribed. However, paroxysms of atrial fi brillation began to occur again. For the prevention of paroxysms, sotalol 160 mg per day was prescribed.Conclusion. Thus, the development of clinically pronounced amiodarone-induced hypothyroidism has contributed to the existing thyroid dysfunction in the patient. The assessment of the thyroid gland function and its further monitoring in the process of taking the drug is prescribed. Amiodarone therapy is performed in case of ineffectiveness of other antiarrhythmic drugs and, as a rule, is not used for primary prescription