The review takes into consideration the problems of effectiveness and safety of anticoagulant therapy in patients with venous thromboembolic complications. together with literature data we provide the results of our own study of optimization of long-term anticoagulant therapy in venous thromboembolic comlications. Particularly the results provided of comparison of standard therapy by high-molecular weight heparin (5 days or more) and warfarin and therapy by treatment dosages of enoxaparine with the prolonged treatment to one month in outpatient practice. Also the opportunities discussed for the usage of novel oral anticoagulants — dabigatran elexilate, rivaroxaban, apixaban — as for the treatment of acute thrombosis episode, as in long-term period. the detailed view is presented at the defining of optimal duration of anticoagulant therapy and the factor influencing the effectiveness and safety of long-term treatment. As the latter we recommend to use laboratory markers: d-dimer and thrombin-activating fibrinolysis inhibitor.

Aim. to study differences in clinical course and patient management in patients with confirmed and non-confirmed thromboemboly of pulmonary artery. Material and methods. An analysis of the data from 321 patients was performed, those consequently hospitalized with suspected PE from 03.10.2010 to 17.07.2013. Patients with further ruled out PE consisted the I group (n=65, 32M), mean age 53,1±14,34. group II included 256 patients (128М) with PE confirmed by investigations, mean age 58,3±13,5. the anamnesis analyzed, clinical and physical signs, laboratory, functional-diagnostic, ultrasound, x-ray and other (totally 60) parameters. Results.  the groups significantly differed only by the prevalence of clinical susceptibility of PE by the Wells and  geneva scores — 20% and 3,85%, resp. (p<0,01). Risk factors of venous thromboembolism: acute thrombosis of lower extremities veins and postthromboflebitic disease were significantly more common in II group. ECg analysis showed that in the I group the classic pattern Mcginn-White (sI-qIII) was found in 19 patients (29,2%), but in the II group — in 106 patients (41,4%), (p=0,072). By EchoCg, the enlargement of RV was found in 27 (42,2%) patients having the signs of pulmonary hypertension due to other diseases. In the II group the increase of RV was significantly more common — in 175 (70%) patients (p<0,0001).  the level of systolic pressure in pulmonary artery was significantly higher in the II group (62,02±23,7 vs. 45,3±20,6 mmhg in patients of I group; р<0,0001). In the I group the d-dimer level was higher in 43 patients (70,5%), as in the II group — in 226 patients (92,2%). Visualization (MdCt , APg) in the I group was done for 23 patients (35,4%) that helped to rule out PE diagnosis. In the II group these studies were done for 173 (77,6%) patients of whom in 139 (80%) there were signs of pulmonary artery thrombosis. Conclusion. the obtained data confirmed the meaning of nonspecificity of clinical presentation and laboratory and most instrumental methods in patients with suspected PE. By this reason the key point in management of patients should be strict following the recommended stages of diagnostics and treatment.

The review concerns on the testing of platelet function in Chd patients receiving antiplatelet medications.  the results are shown of the main large-scale studies demonstrating the relationship of the residual platelet activity level with the development of ishemic and hemorrhagic complications. the analysis is done of the causes of insufficient suppressing of platelet function as the response to clopidogrel. the guidelines of major international expert organizations are discussed on problem of sensitivity to aggregants testing and possible modification of antiplatelet treatment.

Aim.  to study the significance of residual platelet reactivity (RPR) to adenosine diphosphate (ADP) and carriage of the gene cythochrome P450 CyP2C19 polymorphisms in relationship to the bleeding risk in stable CHD patients, undergoing planned PCI and receiving double antiplatelet therapy with aspirin and clopidogrel. Material  and  methods. In stable CHD patients after planned PCI we studied genotypes of polymorphic gene markers, related to clopidogrel metabolism (CyP2C19*1,*2,*3,*17) and studied RPR to ADP at clopidogrel treatment with Verifynow P2y12 analyzer (Accumetrics, США, San Diego, USA) at planned clinic visit in 5-12 months of treatment. Results. In CHD patients receiving double antiplatelet therapy for panned PCI during 12 months, minor clinically non-significant bleedings (MCNS) were the most prevalent, 51,1% noted them during follow-up, and major bleedings (MB) occured in 3,2%, minor clinically significant (MCs) — 9%. MCNS are the reason for DAT interruption in 14-15% patients after planned PCI. the value of RPR to ADP less than 205 PRU in stale CHD with aspirin and clopidogrel after planned PCI 7,8 times increases the risk of MCNS bleedings. In stable CHD with DAT after planned PCI during 12 months there was no any relationship of thrombotic outcomes and revascularization with the value of RPR to AdP.  there was relationship noted between the value of RPR to ADP and carriage of slowly functioning alleles of clopidogrel metabolism. MCNS are not related to major bleedings and reflect effectiveness of antiplatelet therapy, that is confirmed also by significantly lower rate of recurrent revascularizations due to restenosis and absence of stent thrombosis in the group of MCNSB.

Current guidelines recommend use of anticoagulants (preferably fondaparinux) until hospital discharge in non-invasively treated patients (pts) with non-ST-segment elevation acute coronary syndrome (NSTEACS).  however, some evidence exists that anticoagulants may be safely stopped earlier in low-risk aspirin-treated pts. Aim. To assess markers of hemostasis activation and in-hospital events rate after very early discontinuation of fondaparinux in non-invasive treatment of low-risk pts hospitalized with NSTEACS. Material and methods. 53 pts admitted with NSTEACS at median 2,3 h after last episode of chest pain were included into prospective non-comparative study. All pts had GRACE score ≤108, negative tn t (cut-off 0,03 ng/ml), and no st-segment deviation >0,1 mV. Aspirin and beta-blockers were used in all cases while clopidogrel in 35 (66,0%) only. After single subcutaneous injection of fondaparinux at presentation no anticoagulants were used. Plasma thrombin-antithrombin (tAt), d-dimer (dd), plasmin-antiplasmin (PAP) levels, plasminogen activator inhibitor-1 (PAI-1) activity and its complex with tissue plasminogen activator (tPA/PAI-1) level were measured at median 18,0 and 42,5 hours after fondaparinux. 12-lead ECG monitoring was started at median 21,2 h after fondaparinux and continued for median 38,6 h.  Treadmill stress test was performed on days 4-18 (median 9) after hospitalization. Pts were followed until hospital discharge (median 14 days). Results. Plasma  tAt ,  dd and PAP levels increased after discontinuation of  fondaparinux: medians 3,1 and 3,3 ng/l (p=0,002), 359 and 486 ng/l (p=0,002), 471 and 498 ng/l (p=0,052), respectively. Increase at least one of these markers of hemostasis activation was revealed in 49 (92,5%) pts. Ischemic  st-segment deviations on ambulatory ECg were found in 13 pts (24,5%). First episode appeared at median 51,8 hours after fondaparinux and only one was symptomatic. tAt , dd and PAP levels as well as their changes were not associated with recurrence of ischemia. Positive result of treadmill test was obtained in 12 Conclusion. While in non-invasive treatment of low-risk nstEACs pts very early discontinuation of fondaparinux was associated with activation of coagulation this laboratory finding was not related to recurrence of ischemia and clinical events rate was low. (25,0%) pts (5 with and 7 without ischemic  st-segment deviations on ambulatory ECg; p=0,25).  during hospital stay, no patient died or had myocardial infarction; 3 had recurrent angina.

The review takes into consideration the diagnostic significance of the main screening coagulologic tests under the light of modern views on the role of vessel wall, plasma proteins and blood cells in the dynamics of thrombin formation and its activities regulation.

Aim. To study functional condition of the skin microvessels by laser doppler flowmetry (LDF) with functional tests comparing to the parameters of myocardial flow reserve by the data of single-photon emission computed tomography (SPECT) in patients with microvascular angina (MVA).

Material and methods. Totally 44 patients with MVA included at the age of 58 [51;62] years and 30 healthy voluteers. LDF was performed on the skin of forearm with functional tests and perfusion SPECT with exercise or pharmacological test with sodium adenosinetriphosphate.

Results. By LDF of the skin data and warm test, in patients with MVA there is statistically significant decrease of dilatatory microcirculatory reserve comparing to healthy subjects. A relationship is revelaled of dilatatory potential by LDF of the skin with electrical stimulation, and the parameters of myocardial perfusion reserve by SPECT of myocardium with exercise test in MVA.

Aim. To study dynamics of stiffness parameters in various type arteries, renal function and renal circulation in arterial hypertension (AH) and ischemic heart disease (CHD ) with decompensated 2 type diabetes mellitus (DM2) on the sitagliptin therapy during 24 weeks.

Material and methods. Totally 30 patients included, with decompensated DM2 (HbA1c >7%) and AH, most having also CHD. The dynamics of carbohydrate and lipid metabolisms were assessed, arterial wall stiffness in various structural and functional types, renal function and renal circulation at the background of sitagliptine therapy during 24 weeks.

Results. There was no dynamics by the parameters of arterial wall stiffness in various types of arteries, as in renal function and renal circulation among the patients in sitagliptin (n=15) and comparison (n=15) groups. However in those achieved compensation of DM2 on sitagliptin (n=8) we found a decrease of stiffnes index β of brachial artery (muscular type) by 37% from baseline (p<0,01). There was no dynamics of stiffness in muscle-elastic or muscular types of arteries.

Conclusion. In patients with hipertension disease and ischemic heart disease with DM2 on glucoselowering therapy there was no dynamics by the parameters of aortic, common caritid artery stiffness and renal circulation during 6 months followup. However on the therapy by dipeptidilpeptidase-4 inhibitor (sitagliptin) during 6 months and compensation of DM2 (HbA1c <7%) there was a decrease of brachial artery stiffness (muscular type).

Aim. To assess the occurence of hemodynamically non-significant multifocal atherosclerosis (from 30% and more), renal dysfunction and their influence on the outcomes of in-hospital period of patients underwent coronary bypass surgery (CABG).

Material and methods. The perioperational period of 720 patients analyzed, who were operated in 2011-2012 y. Before CABG all patients were assessed by colored duplex scanning of extracranial arteries and arteries of lower extremities to reveal the signs of multifocal atherosclerosis (MFA), also the creatinine concentration was measured in 1 day before and 7 days after CABG, and GFR was calculated by MDRD equation. The prevalence of worse outcomes was assessed after the operation (myocardial infarction, stroke, acute renal failure, remediastinotomy, death) during in-hospital period.

Results. The prevalence of hemodynamically non-significant MFA (30% and more) in patients with CHD after CABG was 48%. Renal dysfunction (RD), by a decrease of GFR <60 ml/min/1,73 m2, developed in 16% of patients underwent CABG. Concomitance of MFA and RD was 21,3%. It was found that in a quarter of patients after CABG there was an adverse outcome that was more prevalent among only those with RD: in 37,9% vs. 22,3% (p=0,03). There were no significant differents found by the prevalence of an adverse outcome in patients only with MFA. Concomitance of MFA and RD was associated with higher chance of adverse outcome in CABG with CHD: in 39,7% cases vs. 23,8% (p=0,006).

Conclusion. The high prevalence of MFA and RD (21,3%) was reveled in CHD patients, underwent CABG. Concomitance of MFA and RD is associated with the development of adverse outcome in CABG. It is stated that this exact group of patients is characterized by the highest amount of earlier CABG complications. The main influence on this is of RD, however it is not possible to definitely distinguish the grade of prognostic value of MFA and RD due to common pathophysiological factors of the development of both and quite complicated mechanisms of their influence and worsening.

Aim. To evaluate the efficacy of CCAPC in complex treatment of the patients with multifocal atherosclerosis and involvement of the heart and lower extremities arteries.

Material and methods. Totally 74 patients included (66 men and 8 women), mean age 63,2±9,3 y.: 32 (43%) with IIa stage and 42 (57%) with IIb stage of lower extremities ischemia; 58 (80%) with II functional class of angina and 16 (20%) with III functional class (by CCS). CCAPC was performed on a “CARDIOPULSAR” software-hardware complex. The protocol of the study consisted in 30 procedures by 60 min. per day. Efficacy of CCAPC was assessed by the changes in EchoCG, 6-minute walking test, DPW, ABI, LDF, activity index DASI, Edinburgh questionnaire of intermittent claudication.

Results. The regression of clinical symptoms was found in all patients after the treatment by CCAPC in cardiosynchronized angioregimen: the significant increase of exercise tolerance was found as DPW, ABI, DASI values, microcirculation parameters by LDF. The assessment of EchoCG parameters (EDS, ESS, EDV, ESV, LVEF) and functional class of angina revealed that after the course of CCAPC coronary blood flow did not change significantly. All patients had a subjective improvement: physical activities increased, dyscomfort in lower extremities decreased as the feelings of chills and cold.

Conclusion. CCAPC is a novel important non-invasive effective and safe method of multifocal atherosclerosis treatment involving the heart and lower extremities vessels.

Aim. To study a prognostic significance of moderate and severe lesion of coronary vessels by SYNTAX related to an occurence of in-hospital complications of ST elevation acute myocardial infarction (STEMI) after endovascular treatment.

Material and methods. The severity of coronary lesion was assessed by SYNTAX in 330 consequent patients (274 men and 56 women), mean age 53,6±8,9, admitted in 4,2 hours (mediana) and in 2,1 and 7,9 hours (25th and 75th percentiles) from the onset of STEMI clinical picture. SYNTAX calculation was done afterwards by the results of coronary angiography. The assessed patients were divided into two groups: of moderate and severe coronary lesion (SYNTAX ≥23), and mild lesion (SYNTAX 0-22).

Results. It was found that SYNTAX ≥23 is an independent prognostic factor for lethal outcomes (OR=10,8; 95% CI: 3,0-39,4; p<0,0001), AF (OR=3,9; 95% CI: 1,5-9,9; p=0,004) and VF (OR=3,7; 95% CI: 1,3-10,2; p=0,013), no-reflow (OR=3,6; 95% CI: 1,1-11,7; p=0,036), pulmonary edema (OR=3,0; 95% CI: 1,2-7,6; p=0,018), pleural effusion (OR=4,3; 95% CI: 1,4-13,1; p=0,010), acute left ventricle aneurisms (OR=3,9; 95% CI: 1,2-12,3; p=0,022), cardiac asthma (OR=5,8; 95% CI: 1,4-23,6; p=0,014), and heart failure Killip ≥ II (OR=2,6; 95% CI: 1,3-5,2; p=0,008).

Conclusion. Moderate and svere coronary lesion by SYNTAX is an independent prognostic factor for lethal outcomes, arrhythmias, no-reflow, pulmonary edema, pleural effusion, acute left ventricle aneurisms, cardiac asthma and heart failure of Killip ≥ II during in-hospital stage of care in patients with myocardial infarction and endovascular treatment.

Aim. T o develop a block-scheme for short-term personified prognosis of clinical outcome of acute coronary syndrome (ACS) into Q-myocardial infarction at prehospital stage.

Material and methods. Totally 68 patients included with the diagnosis of ACS. As prognostic factors we used the most informative intervals of concentrations of the markers for subclinical nonspecific inflammation, endothelial dysfunction, cardiospecific changes in the immune system and serum cardiomarkers. For testing of those mentioned we used the hard-phased immunoenzyme assay. The relative risk (RR) with confidence intervals (CI) were calculated, as the absolute risk (AR), diagnostic efficacy (DE) of the methods used related to clinical outcomes of ACS into Q0MI related to the risk factor studied (intervals of markers concentrations). Statistic processing was done with software Statistica 6.0 and Biostat 4.03.

Results. Depending on the complex analysis of the results we formulated a blockscheme of short-term personified prognosis of clinical outcome of ACS into Q-MI. The scheme included the most informative intervals of concentrations. Personified shortterm prognosis of clinical outcome of ACS into Q-MI and prehospital stage was related to the concentrations of cardiomarkers: TP-I from 2,2 до 2,7 ng/ml, BNP-32 from 1079 to1270 pg/ml; inflammtion markers : CRP from 20 to 25 mg/L, IL-1β from 0,54 to 1,54 pg/ml and TNF-α from 1,1 to 1,6 pg/ml; endothelial dysfunction markers: NO from 7 to 11 mcM/L, ET from 5 to 6 fM/ml, ММР-9 from 270 to 370 ng/ml and TIMP-1 from 140 to 150 ng/ml; immunomarkers: N P from 20 to 28 nM/ml, AB to KL from 15 to 20 U/ml and in 75% cases there are AB to cardiomyocytes. Patients having these parameters at their admission are in the higher risk group of clinical outcome ACS into Q-MI.

Conclusion. In the cases when at admission the parameters of inflammation, endothelial dysfunction, serum cardiomarkers and immunomakrers match with the intervals of concentrations mentioned in the block-scheme, these patients are in the group of higher risk of outcome ACS into Q-MI. This lets even at earlier stage of hospitalization to perform the treatment procedures in accordance with the standards of treatment of the patients with occlusing lesions of coronary arteries, that lead to a large focus of MI.

Aim. To study the changes in expenses for the usage of the novel medication serelaxine in treatment of decompensated chronic heart failure.

Material and methods. At the core of study — buit-up Mark model that takes into consideration two scenarios of the disease course in patients with decompensated CHF: the usage of standard treatment and standard treatment with serelaxine add-on. Probability of the shift from one condition to another for both groups is calculated based on the results of international clinical trials Pre-Relax-AHF and Relax-AHF as by the data of Russian registry ORAKUL-RF. The sources of information on the price of the resources involved were open. As the whole data was not completely comparable in the build-up of the model we made some presuppositions: time hoirizon of observation — 1 year; results of Pre- Relax-AHF and Relax-AHF extrapolated to 1 year; serelaxine was prescribed only in the first episode of CHF decompensation therapy; mean rate of deaths in decompensated CHF in all age groups was the same; dynamics of mortality inside the each time cutoff (1 month, 2-6 months, 7-12 months) was similar. Except of the direct medical expenses the followinf were also calculated: amount of undercollected GDP as a result of economically active patients death; expenses for repeated hospitalizations; expenses for emergency calls; expenses for the treatment of heart failure exacerbation; size of undercollected GDP as a result of no-show of the patient at workplace for economically active patients.

Results. Expenses for hospitalization and emergency calls in serelaxine group due to lower rate of hospitalizations were almost two times lower comparing to the standard therapy group: 40,9 and 19,3 mln. rubles per 1000 patients, respectively. While using serelaxine the GDP losses due to temporary disability (the size of undercollected GDP) in the group of 1000 patients decreased by 11,5 mln. rubles, or 50%, and if to include the death related losses — by 29,3 mln. rubles (36,5%) by 1 year. Additional expenses for drug therapy of heart failure by serelaxine are compensated by the decrease of general expenses (including additional therapy by serelaxine) by 7,4-28% in patients of economically active age with decompensated CHF.

Conclusion. Serelaxine as drug with the main clinical properties as the decrease of general and cardiovascular mortality, positive influence on the level of nephrologic complications and hospitalizations, shows economical superiority in the management of economically active age patients. Currently the use of serelaxine in patients with decompensated CHF might optimize the expenses of Russian healthcare budget related to the treatment of patients with this condition.

The recent data is considered on the prevalence, electrophysiology, mechanisms and risk factors of sudden cardiac death in patients after acute myocardial infarction. The data is shown about Holter monitoring of ECG as a method (these methods are in use in systems like Astrocard® Holtersystem, GE Healthcare MARS, medilog® DARWIN), that stratifies the risk of sudden cardiac death development. The prognostic role and importance of specific parameters of 24-hour ECG monitoring is studied, correlating with the higher risk of life-threatening rhythm disorders that are the main mechanisms of sudden cardiac death. The estimation of the main predictors of electrical instability of myocardium is done.