Diagnostic and prognostic aspects of angina pectoris preceding myocardial infarction in long-term follow-up

AIM: To trace relations of premyocardial infarction (preMI) angina, myocardial reserves and clinical peculiarities within a year of outpatient follow-up. MATERIAL AND METHODS: Coronary and myocardial reserves were studied in 320 MI survivors using veloergometry, transesophageal pacing (TEP), 24-h ECG monitoring, echocardiography. Cardiac output reaction to TEP was assessed. RESULTS: Patients with preMI attacks of stable angina had coronary reserve 47.9% less than they had before MI while cardiac failure by NYHA criteria aggravated by 33.3%. Myocardial ischemia at bicycle exercise in these patients developed much later and its threshold rose by 34.2%. The degree of cardiac ejection fall in TEP in patients without angina before MI was 2.4 times greater than in patients without history of IHD. There were specific features of diastolic relaxation of the myocardium and variability of cardiac rhythm in the compared groups though the groups did not differ significantly by arrhythmia events and morphological characteristics of the scar zone. Survival showed a tendency to lowering of lethal outcome risk in the compared groups followed up since the observation month 6 without significant differences depending on the presence of preMI angina. CONCLUSION: PreMI angina contributes to formation of coronary and myocardial reserves which are better to assess at TEP and with analysis of hemodynamic reaction to induced rise in heart rate.     

Pilot experience in Russia with external contrapulsation in patients with coronary heart disease

AIM: To examine effects of programmed external contrapulsation (ECP) on the clinico-functional status, quality of life (QOL) in patients with coronary heart disease (CHD), stable angina of FC II-IV resistant to medication. MATERIAL AND METHODS: Eighteen patients with CHD, stable angina of FC III-IV (2 females and 16 males, mean age 63.6 +/- 7.4 years) have completed a course of ECP including 35 one-hour procedures 5-6 times a week for 7 weeks. Ten patients had cardiac failure (NYHA FC II-III). Before and after ECP course the patients were examined using QOL assessment by Minnesota questionnaire, complex echo-cardiography, bicycle exercise test, perfusion myocardial scintigraphy with 99m-Tc-4,2-methoxy-isobutilisonitril, 24-h Holter ECG monitoring, enzyme immunoassay for plasma natriuretic propeptides. RESULTS: Significant subjective QOL improvement (p < 0.01) was noticed by all the patients. Anginal attacks and nitrates doses reduced at least 2-fold. Exercise tolerance rose significantly (p < 0.01), bicycle exercise test was positive in 5 patients, the rest stopped the test after achievement of submaximal heart rate (HR) and fatigue. Most of the patients exhibited improvement of myocardial perfusion. Patients with abnormal myocardial contractility showed a moderate trend (p < 0.03) to an increase in left ventricular ejection fraction. By 24-h ECG, mean HR diminished significantly (p < 0.02). CONCLUSION: ECP is highly effective and safe in combined therapy of CHD, stable angina resistant to drug therapy, in impossibility of myocardial revascularization, including patients with cardiac failure. This manifests in a significant abatement of angina, lower doses of nitrates, improvement of exercise tolerance, quality of life, myocardial perfusion and hemodynamic indices.     

Dobutamine Stress Echocardiography and Exercise Electrocardiography for Risk Stratification in Medically Treated Unstable Angina

Previous reports have demonstrated the superiority of exercise echocardiography over exercise electro-cardiography (ex-ECG) for risk stratification in patients with medically stabilized unstable angina (UA). We sought to analyze the prognostic value of dobutamine stress echocardiography (DSE) compared with ex-ECG for risk stratification in patients with UA. METHODS: Ninety-two patients with medically treated UA were studied (mean age 65 +/- 11 years, 24 women, 42% of patients had electrocardiographic abnormalities on admission). Dobutamine stress echocardiography and treadmill ex-ECG were performed on the third day after hospital admission. End points were recurrent UA, myocardial infarction (MI), or cardiac death. RESULTS: Mean follow-up was 24 +/- 7 months. During follow-up, 22 patients had cardiac events (18 recurrent UA, 2 MI, 2 cardiac deaths). The event-free survival rate was 80% for patients with negative DSE results for ischemia and 52% for those with positive DSE results (log rank 9.57; P =.002), compared with an event-free survival rate of 79% for patients with negative ex-ECG results and 66% for those with positive ex-ECG results (log rank 2.06; P = not significant). Left ventricular dysfunction (P =.01) and a positive dobutamine stress echocardiogram (P =.03), but not a positive exercise electrocardiogram, were independent predictors of cardiac events during follow-up. CONCLUSIONS: Dobutamine stress echocardiography performed early in medically treated patients with UA predicts cardiac events during follow-up more accurately and with more specificity than ex-ECG does in this population.     

Correlation of somatotropic hormone with post-infarction myocardial remodelling and clinical prognosis in patients with myocardial infarction]

To evaluate pathogenetic link of ischemic heart dysfunction with the level of endogenic STH in myocardial infarction (MI) patients at different MI stages and to specify prognostic value of STH for MI outcomes, we examined 78 males on MI day 21-26, month 3-6 and a year later. 20 healthy males served control and 17 patients with ischemic heart diseases without MI according to coronaroventriculography (CVG) were a comparison group. STH was measured in all the patients with radioimmunoassay, CVG was made according to M. Judkins. We found that in patients with high level of endogenic STH (> 1 nm/l) within the first postmyocardial infarction month development of reparative and adaptive fibrosis continues 3 to 6 months and is more favorable. If STH physiological level maintains, myocardial contractility remains satisfactory for a long period. In high STH levels, patients with myocardial ischemia more frequently exhibit ventricular arrhythmia. Low STH blood levels lead to left ventricular dilatation, deterioration of cardiac contractility, stenotic coronary atherosclerosis, intracardiac hemodynamics and IHD clinical course. Lethal outcomes occur more frequently.     

Acute Coronary Syndromes: Diagnosis and Management, Part I

The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non—ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization in the United States. A quick but thorough assessment of the patient''s history and findings on physical examination, electrocardiography, radiologic studies, and cardiac biomarker tests permit accurate diagnosis and aid in early risk stratification, which is essential for guiding treatment. High-risk patients with UA/NSTEMI are often treated with an early invasive strategy involving cardiac catheterization and prompt revascularization of viable myocardium at risk. Clinical outcomes can be optimized by revascularization coupled with aggressive medical therapy that includes anti-ischemic, antiplatelet, anticoagulant, and lipid-lowering drugs. Evidence-based guidelines provide recommendations for the management of ACS; however, therapeutic approaches to the management of ACS continue to evolve at a rapid pace driven by a multitude of large-scale randomized controlled trials. Thus, clinicians are frequently faced with the problem of determining which drug or therapeutic strategy will achieve the best results. This article summarizes the evidence and provides the clinician with the latest information about the pathophysiology, clinical presentation, and risk stratification of ACS and the management of UA/NSTEMI.ACC = American College of Cardiology; ACE = angiotensin-converting enzyme; ACS = acute coronary syndrome; ADP = adenosine diphosphate; AHA = American Heart Association; BNP = B-type natriuretic peptide; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CHF = congestive heart failure; CI = confidence interval; CK-MB = muscle and brain fraction of creatine kinase; CRP = C-reactive protein; CURE = Clopidogrel in Unstable Angina to Prevent Recurrent Events; ECG = electrocardiography; ED = emergency department; GP = glycoprotein; HR = hazard ratio; IV = intravenous; LDL = low-density lipoprotein; LMWH = low—molecular-weight heparin; LV = left ventricular; MI = myocardial infarction; NSTEMI = non—ST-segment elevation MI; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation MI; TIMI = Thrombolysis in Myocardial Infarction; UA = unstable angina; UFH = unfractionated heparinThe term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and covers the spectrum of clinical conditions ranging from unstable angina (UA) to non—ST-segment elevation myocardial infarction (NSTEMI) to ST-segment elevation myocardial infarction (STEMI). Unstable angina and NSTEMI are closely related conditions: their pathophysiologic origins and clinical presentations are similar, but they differ in severity. A diagnosis of NSTEMI can be made when the ischemia is sufficiently severe to cause myocardial damage that results in the release of a biomarker of myocardial necrosis into the circulation (cardiac-specific troponins T or I, or muscle and brain fraction of creatine kinase [CK-MB]). In contrast, the patient is considered to have experienced UA if no such biomarker can be detected in the bloodstream hours after the initial onset of ischemic chest pain. Unstable angina exhibits 1 or more of 3 principal presentations: (1) rest angina (usually lasting >20 minutes), (2) new-onset (<2 months previously) severe angina, and (3) a crescendo pattern of occurrence (increasing in intensity, duration, frequency, or any combination of these factors). Each year in the United States, approximately 1.36 million hospitalizations are required for ACS (listed either as a primary or a secondary discharge diagnosis), of which 0.81 million are for myocardial infarction (MI) and the remainder are for UA. Roughly two-thirds of patients with MI have NSTEMI; the rest have STEMI.¹     

Contemporary diagnosis and management of unstable angina

Unstable angina (UA) is one of the acute coronary syndromes, a group of conditions that also includes non-ST elevation myocardial infarction (MI) and ST elevation MI. The underlying pathogenic substrate of all these entities is the unstable coronary plaque with an overlying intracoronary thrombus. Initial management for the patient with suspected UA includes a resting electrocardiogram and oral administration of aspirin. ST-segment elevation indicates acute MI with the need for urgent reperfusion therapy. Patients without ST-segment elevation commonly have a mixture of UA and non-ST elevation MI; initial management is similar with assessment of near-term risk of MI or death as the next step. Features of UA indicating high risk include persistent ST-segment depression, persistent ischemic pain, elevated troponin level, or features of heart failure. Such patients undergo intensive medical therapy with heparin (unfractionated or low-molecular-weight), beta-blockade, and IIb/IIa antiplatelet agents, usually followed by coronary angiography and percutaneous intervention. The timing of intervention depends on the patient's response to therapy. Intermediate- or low-risk patients (including those presenting to the emergency department) can be managed with a chest pain unit strategy, and those with normal results on serial electrocardiograms, cardiac marker studies, and functional testing can be safely discharged home. Others are admitted for elective angiography, intensive medical therapy, or both. Assessment of coronary risk factors and their modification is an important component of long-term therapy for both high-risk and low-risk patients with UA, as well as those determined to have had non-ST elevation MI.     

Preliminary data on combined assessment of tolerance to exercise,left ventricular contractile function in ischemic heart disease patients taking bradycardic agents

AIM: To study effects of bradicardia induced by atenolol, diltiazem and ivabradin on exercise tolerance, myocardial perfusion and left ventricular contractile function in patients with stable angina pectoris. MATERIAL AND METHODS: The trial included 7 male patients aged 57 +/- 2.6 years with coronary heart disease, stable angina of functional class II free of cardiac failure and severe arterial hypertension, with a positive and reproducible VEM test after therapy discontinuation. For 10 consecutive days with 5-day intervals, all the patients received atenolol, diltiazem, ivabradin in doses lowering heart rate at rest by 20% from the initial level. Before the treatment all the patients were studied with VEM test, perfusion synchronized single-photon emission computerized tomoscintigraphy of the myocardium (PSSPECT) at rest and exercise. On day 10 of each drug intake PSSPECT and VEM test were performed if the expected heart rate was achieved. RESULTS: Each of the studied drugs resulted in a 22-24% reduction in the heart rate at rest accompanied by a significant rise in exercise tolerance, improvement of performance and myocardial perfusion. There were no significant changes in left ventricular contractility. CONCLUSION: A 20% reduction in resting heart rate due to monotherapy with drugs having a bradicardic effect leads to positive changes in exercise tolerance and myocardial perfusion.     

Remodeling in cardiac failure of functional class I due to arterial hypertension associated with ischemic heart disease

Hemodynamics and ventricular remodeling were studied echocardiographically in 192 men with heart failure (NYHA functional class I), arterial hypertension (AH) of stage I-III and clinical picture of ischemic heart disease (IHD). The latter presented in the patients with stable angina pectoris of FC I-II (SAP), unstable angina pectoris (UAP) without foci, paroxysmal atrial fibrillation, acute myocardial infarction (MI), postinfarction cardiosclerosis (PC) with SAP or UAP. The control group consisted of 41 healthy men. The patients had AH stage 1. The patients and healthy controls differed significantly by the size of the aorta, left atrium, thickness of the interventricular septum and posterior wall of the left ventricle. There was a significant left-ventucular hypertrophy in the groups with patients with MI, SAP and PC, UAP and PC (p < 0.001). In these groups the type of left ventricular remodeling was characterized as excentric type of left ventricular hypertrophy without its delatation. Normal left ventricular geometry was in healthy men, SAP, UAP, paroxysmal actual fibrillation.     

Assessing the clinical and economic burden of coronary artery disease: 1986-1998

BACKGROUND: The acute phase of coronary artery disease (CAD) is dramatic and receives much attention because of its high mortality and associated treatment cost. However, the acute phase typically resolves within 30 days whereas CAD is a chronic disease, which most patients will live with for more than a decade. We compared the clinical and economic burden of CAD during the acute phase (first 30 days) with that in the postacute phase (31st day through 10 years). METHODS: We included acute coronary syndrome (ACS) patients with significant CAD receiving an initial cardiac catheterization at Duke University Medical Center between 1986 and 1997 with follow-up continuing through 1998. Inpatient medical costs were estimated from ACS clinical trial and economic study data. Costs were adjusted to 1997 values and discounted at 3% per annum. RESULTS: Our study included 9,876 ACS patients (5,557 with an acute myocardial infarction [MI] and 4,319 with unstable angina [UA]). Acute MI patients had higher 30-day mortality than UA patients (5.6% vs. 2.3%, P <0.001). In addition, acute MI and UA patients had significant 10-year unadjusted and adjusted survival differences (both P <0.001). For patients who survived to 30 days, there was no difference in 10-year survival between acute MI and UA patients before adjustment (P = 0.472). After adjustment, however, unstable angina patients who survived to 30 days had greater survival than myocardial infarction patients (P = 0.011). Mean 10-year discounted ACS inpatient medical costs were $45,253 ($23,510 acute phase and $21,819 postacute phase, P = 0.002). Ten year costs for unstable angina patients were $46,423 ($21,824 acute phase and $24,599 postacute phase, P = 0.003); ten year costs for myocardial infarction patients were $44,663 ($24,823 acute phase and $19,840 postacute phase, P <0.001). CONCLUSIONS: We found that the clinical and economic burden of CAD continues long after a patient's acute event has resolved and that postacute CAD cardiac event rates and inpatient medical costs may be higher than previously estimated. With much of all medical costs occurring in the postacute phase, the potential for effective secondary prevention therapies is substantial.     

Pumpan in the treatment of ischemic heart disease associated with arterial hypertension]

AIM: To study effectiveness of natural combined medicine pumpan in patients with ischemic heart disease (IHD) including cases with concomitant arterial hypertension (AH). MATERIAL AND METHODS: 35 patients with different forms of IHD (myocardial infarction, stable and unstable angina pectoris of functional class III-IV) received conventional treatment combined with pumpan given for 7-11 weeks. Changes in clinical condition, biochemical blood indices, ECG, echo-CG, 24-h arterial pressure monitoring data were investigated. RESULTS: The addition of pumpan to the standard therapy reduced frequency of anginal attacks, improved intracardiac hemodynamics, psychic and adaptive indices. CONCLUSION: Pumpan is a good adjuvant to conventional treatment of various IHD forms including combination of IHD with AH. Pumpan enables reduction in the required doses of beta-blockers, ACE inhibitors, nitrates, sedatives. It also provides hypocoagulatory and hypocholesterolemic effect.     

Effects of levosimendan on left ventricular functional remodelling and exercise intolerance: a tissue Doppler study

Levosimendan is a calcium sensitizer that demonstrates enhanced myocardial contractility. There is little information concerning the effect of levosimendan on left ventricular tissue parameters and exercise capacity. We evaluated the effects of a 24-h course of levosimendan therapy on cardiac tissue parameters in 30 patients, aged 48 - 70 years, admitted to our hospital for the management of decompensated heart failure. All patients underwent echocardiographic examination using tissue Doppler imaging (TDI) and a 6-min walk test. Systolic myocardial velocity of the mitral annulus (Sm) was significantly increased in levosimendan-treated patients compared with placebo-treated patients. There was a positive correlation between Sm and exercise capacity. Levosimendan might be expected to increase cardiac contractile force, especially Sm velocity, in parallel with exercise tolerance. The study has also shown that the progress of ventricular function after levosimendan treatment in patients with exercise intolerance could be monitored effectively by Sm velocity measurements using TDI.     

急性心肌梗死患者心血管危险因素及相关疾病回顾性分析

目的:探讨不稳定型心绞痛的预后影响因素。方法:102例急性心肌梗死患者按发病前2个月心绞痛类型分为稳定型心绞痛组(SA组)43例和不稳定型心绞痛组(UA组)59例。调查2组既往心血管病危险因素及相关疾病控制情况,分析其对不稳定型心绞痛患者心血管事件的影响。结果:UA组有冠心病家族史、糖尿病史、高血压病史及血脂异常史的比例与SA组比较差异无显著性意义,但在吸烟史方面UA组明显高于SA组(P<0.05);与SA组比较,UA组有相关疾病的患者血糖、血压、血脂水平及心功能控制不良较为突出(P<0.05)。结论:吸烟、左室功能差、血压、血脂和血糖水平控制不良可能是影响不稳定型心绞痛预后的重要危险因素。     

2型糖尿病心血管病变患者联合3项检测的意义

目的评估2型糖尿病(T2DM)心血管病变患者联合检测糖化血红蛋白A1C(HbA1C)、肌钙蛋白I(cTnI)及超敏C反应蛋白(hs-CRP)的意义。方法 137例T2DM患者作为病例组,分为糖尿病组(DM组)、糖尿病心肌病组(DCM组)及糖尿病合并冠心病组(DM合并CHD组)。其中DM合并CHD组又分为稳定型心绞痛组(SA组)、不稳定型心绞痛组(UA组)、心肌梗死组(MI组)3个亚组。30例健康体检者作为健康对照组。分别测定各组HbA1C、cTnI及hs-CRP水平,分析其相关性。结果 (1)病例组HbA1C、cTnI和hs-CRP水平明显高于健康对照组(P<0.01)。(2)HbA1C水平在病例组间比较差异无统计学意义(P>0.05),cTnI和hs-CRP水平逐渐升高(P<0.01)。SA及UA组cTnI升高不明显(P>0.05),而hs-CRP已明显升高(P<0.01)。MI组cTnI与hs-CRP升高最为明显(P<0.01)。Spearman等级相关分析提示,cTnI与hs-CRP水平与DM合并CHD各组病情呈正相关(cTnI:r=0.759,P<0.05;hs-CRP:r=0.733,P<0.05)。(3)DM合并CHD组hs-CRP水平是DM组的3倍以上,DCM组是DM组的2倍以上。结论联合检测HbA1C、cTnI、hs-CRP可以较全面地反映T2DM患者平均血糖水平、心肌受损程度以及心血管慢性炎性反应状态,可作为早期预防、诊断T2DM心血管病变有效的综合性指标。     

Effect of flosequinan in patients with acute-onset heart failure complicating acute myocardial infarction

We studied the hemodynamic effect of a single dose of the new direct-acting vasodilator, flosequinan, in ten patients with severe acute-onset heart failure complicating acute myocardial infarction (MI) resistant to high iv doses of diuretics, nitrates, and dobutamine. Flosequinan was added to conventional therapy at 3.8 +/- 0.5 days after infarction in the form of a single 100-mg oral dose. Hemodynamic measurements were performed every hour for 4 h after administration, without any other drug being added. The nitrate infusion rate was kept constant. Flosequinan produced hemodynamic improvement in this group. The effect peaked at 1 to 2 h and remained at this level at 4 h. Pulmonary capillary wedge pressure decreased from 27.2 +/- 5.4 to 16.4 +/- 3.0 mm Hg, and cardiac output increased from 3.5 +/- 0.3 to 4.1 +/- 0.4 L/min (p less than .001 for both). Cardiac index, stroke index, and left ventricular stroke work index were significantly increased. Pulmonary arterial and right atrial pressures, and systemic and pulmonary vascular resistances were also significantly reduced. Heart rate was not significantly altered. Mean systemic arterial pressure was slightly reduced. Flosequinan administration was not associated with symptomatic hypotension, cardiac arrhythmias, or other adverse events, and the hemodynamic effect was not related to the pretreatment serum sodium concentration. We conclude that flosequinan is effective in producing acute hemodynamic improvement in patients with heart failure complicating acute MI resistant to conventional therapy.     

Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction.

We sought to investigate the relation between left ventricular (LV) and right ventricular (RV) function assessed with the Doppler-derived myocardial performance index (MPI), to assess serial changes, and to investigate the prognostic value of biventricular assessment of cardiac function after a first myocardial infarction (MI). To do so, serial Doppler echocardiography was performed in 77 consecutive patients with a first MI. Right ventricular MPI correlated significantly with LV MPI (r = 0.51, P <.0001). In patients with echocardiographic signs of RV MI, the RV MPI was significantly higher (0.59 +/- 0.18 versus 0.44 +/- 0.19, P =.001), whereas no difference in LV MPI was seen (0.55 +/- 0.19 versus 0.56 +/- 0.13, P = not significant). Right ventricular MPI showed a rapid normalization during follow-up, whereas LV MPI did not decrease. During follow-up, 23 patients died of cardiac causes or were readmitted because of worsening heart failure. Multivariate Cox analysis indicated LV MPI (relative risk 4.9 [95% CI 1.8-13.5], P =.002) and RV MPI (relative risk 3.8 [1.3-17.0], P =.01) to be predictors of cardiac events. Thus the RV MPI is frequently abnormal after a first MI but normalizes rapidly on follow-up, and biventricular assessment of cardiac function may improve the prognostic accuracy compared with LV assessment alone.     

Management and outcomes of acute coronary syndrome with minimal myocardial necrosis: analysis of a large prospective registry from a non-interventional centre

The aim of this study was to assess the clinical risk of minimal myonecrosis below the cut-off for acute myocardial infarction (MI) in comparison with other grades of acute coronary syndrome (ACS). One-thousand four hundred and sixty seven consecutive patients with ACS admitted between May 2001 and April 2002 were studied in a non-interventional centre. Patients were divided into unstable angina (UA) (cTnT < 0.01 microg/l), non-ST elevation ACS with minimal myonecrosis (0.01 or= 0.1 microg/L) and ST elevation myocardial infarction (STEMI). UA (n = 638) was associated with the fewest events at 6 months (2% cardiac death or MI). Patients with any myonecrosis (n = 829) had worse outcomes (6-month cardiac death or MI 18.3-23.3%). Compared with ACS patients with minimal myonecrosis, UA patients were at significantly lower risk (OR 0.21, 95% CI 0.12-0.45, p < 0.001), NSTEMI patients were at similar risk (OR 1.45, 95% CI 0.89-2.35, p = 0.13), and STEMI patients were at higher risk (OR 2.12 95% CI 1.26-3.85, p = 0.008) in adjusted analyses. Nearly 85% of cardiac deaths occurred within 6 months. The risk of adverse events was higher among patients managed by non-cardiologists (OR 1.66, 95% CI 1-2.75, p = 0.049). Patients with non-ST elevation ACS and minimal myonecrosis are a high-risk group more comparable with NSTEMI and clearly distinguishable from patients with UA.     

The effect of dalargin on the hemodynamics in acute myocardial infarct complicated by clinical death]

Cardiac output and myocardial contractility have been studied in dogs with experimental myocardial infarction complicated by 5 min clinical death. Control animals (16 dogs) were intravenously injected physiologic saline, while test animals (12 dogs) were administered leu-enkephalin analogue dalargin at a dose of 100 micrograms/kg, 20 min and 6-h after recovery. It has been established that dalargin improved basic hemodynamic parameters due to normalization of cardiac contractility, arrhythmia removal and reduction of the peripheral resistance. The data obtained make it possible to recommend dalargin for combined therapy of postresuscitation hemodynamic disturbances in acute myocardial infarction.     

Early postoperative complications and prevention of them in ischemic heart disease patients after direct myocardial revascularization

AIM: To specify risk factors affecting development and frequency of complications early after the bypass operation in direct myocardial revascularization. MATERIAL AND METHODS: 455 patients with ischemic heart disease (IHD) of whom 392 (86.2%) had stable angina pectoris class III-IV, 25 (5.5%) had unstable angina pectoris (UAP) and 38 (8.5%) had survived myocardial infarction (MI) underwent autovenous coronary artery bypass operation. IHD combined with arterial hypertension in 103 (22.6%), diabetes mellitus type II in 67 (14.7%), cardiac failure (CF) stage IIa in 97 (21.3%) patients. The ejection fraction (EF) was 37.8 +/- 3.3% in 113 (24.8) patients, in the others it was 46.7 +/- 2.7%. RESULTS: Early postoperative complications arose more frequently in patients with UAP, MI, CF and low EF. Postoperative acute cardiovascular failure was registered in 132 (29.5%) patients, arrhythmia--in 60 (13.4%), perioperative MI--in 13 (2.9%) patients. CONCLUSION: The most significant risk factors of postoperative complications in the above patients are the following: UAP, MI, CF, low EF. These risk factors should be allowed for in preparation of patients for coronary bypass surgery.     

Hypertrophic cardiomyopathy: a review of etiology and treatment

Hypertrophic cardiomyopathy (HCM) is a congenital cardiac disease with an estimated prevalence of 1:500 in the population. Individuals with HCM can present with clinical manifestations that include left ventricular outflow obstruction, cardiac dysrhythmias, diastolic heart failure, cardiac angina, and sudden cardiac death. Current treatments include pharmacologic intervention to reduce heart rate and ventricular contractility as well as surgery or septal alcohol ablation to reduce myocardial septal size. Implantable cardiac defibrillators are considered a treatment option in individuals with HCM who are at an increased risk for sudden cardiac death. The identification of persons at risk for complications related to HCM is important for reducing mortality and morbidity in this population. In addition, diagnosis of HCM in an individual allows the healthcare provider caring for these patients to screen, educate, and institute timely preventative measures in other members of the family. The purpose of this review is to provide clinicians caring for cardiac patients with a guide for recognition, diagnosis, prevention, and treatment of HCM.     

Dobutrex stress echocardiography: clinical and prognostic value, side effects

AIM: To study informative value of dobutrex echocardiography (DEC) in diagnosis of myocardial ischemia and viability, in prognostication of angina pectoris and myocardial infarction (MI), evaluation of DEC side effects. MATERIAL AND METHODS: DEC was conducted in 74 patients with unconfirmed diagnosis (they had ischemic heart disease risk factors, atypical cardialgia) and 32 ischemic heart disease patients. RESULTS: DEC proved to be an effective diagnostic tool in diagnosis of myocardial ischemia in patients with new-onset atypical cardialgia (informative value 73.6%). This test gives prognosis of the disease and improves treatment policy in patients with angina of effort and MI. The most serious and frequent side effects of DEC arising at the highest dobutrex dose were paroxysmal tachycardias (3.76%) and ventricular arrhythmias (6.58%). In most cases (99.1%) they discontinued after the test and did not require antiarrhythmic treatment. Thus, the test is relatively safe. CONCLUSION: Echocardiography with dobutrex load should be used in practical cardiology more intensively.