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Материалы и методы. Препарат был назначен 12 пациентам со стабильной стенокардией 3 функционального класса в дозе 5 мг 2 раза в день, через 1 месяц дозировка у 10 больных увеличилась до 7,5 мг 2 раза в день. Средний возраст больных 72,1 лет, у 78% выявлялась ЧСС свыше 80 уд/ мин. Все пациенты принимали базовую терапию статинами, ИаПф и/или АКК, антиагрегантами, 84% - нитраты. Продолжительность лечения составила 3 месяца. Эффективность терапии оценивалась по количеству приступов стенокардии и по потребности в нитратах короткого действия.
Результаты. На фоне приема Кораксана у всех больных выявлено достоверное урежение ЧСС на 20 уд/мин, значительно уменьшилась частота приступов стенокардии, что в свою очередь, привело к снижению потребности в нитроглицерине и изокете-спрей. Посредством нагрузочного теста 6-минутной ходьбы отмечено достоверное улучшение толерантности к физической нагрузке у всех пациентов. У одного больного зарегистрирована брадикардия до 48 уд/мин, других нежелательных явлений на фоне приема Кораксана не выявлено.
Заключение. Кораксан (ивабрадин) является препаратом выбора при лечении пациентов со стабильной стенокардией, сопровождающейся нарушением ритма.
KETAMINE-PROPOFOL COMBINATION FOR INDUCTION IN CARDIAC SURGERY PATIENTS
Tojiboyev R, Konakbay B, Vershinin M.
National Scientific Medical Research Center, Astana, Kazakhstan
Anesthetic management of patients with severe heart disease aims at prevention of myocardial damage by optimizing the myocardial oxygen demand/supply ratio. Induction of anesthesia using high doses of narcotics alone or with benzodiazepines was favored by many practitioners before the introduction of the concept of 'fast-track' anesthesia. However it is associated with bradycardia, rigidity and delayed intubation. Other commonly used hypnotic agents include Pentothal, Etomidate, Versed, Ketamine and Propofol. The cardiovascular effects of ketamine are secondary to maintaining the sympathetic tone and include increased cardiac output, heart rate, mean arterial pressure and central venous pressure. Propofol has centrally mediated hypotensive effects as well as peripheral vasodilator properties that result in a decrease in the systemic vascular resistance and blood pressure by 15-30%.The heart rate either decreases or remains unchanged, while the cardiac output and oxygen consumption decrease after a full induction dose. We use a combination of Ketamine and Propofol for the induction of anesthesia for our patients undergoing cardiopulmonary bypass for myocardial revascularization or valve repair/replacement procedures with poor left ventricular function. The combination consists of about 40-50% of the full induction dose of each agent; thereby minimizing the untoward hemodynamic effects associated with the use of either agent alone.We examined the hemodynamic parameters during and immediately following induction of anesthesia in patients undergoing cardiac surgery. Arterial pressure monitoring was placed under local anesthesia before induction in all patients. Patients were divided into 2 groups that were matched for the underlying pathology, comorbidities and age. Group I was induced with a combination of Fentanyl (5-7mcg/kg) and Relanium (5-10 mg) and group II was induced with a combination of Ketamine (0.5 -1 mg/ kg) and Propofol (0.5- 1 mg/kg).
Results: Group I patients had a greater drop in heart rates (30-50%) when compared to patients in group II, where the heart rate did not change or slightly increased (5-10 %). This bradycardia was accompanied by a concomitant drop in the arterial blood pressure in patients with stenotic valve lesions, necessitating immediate pharmacological intervention.
Conclusion: The use of Ketamine in combination with Propofol for the induction of anesthesia in unstable cardiac surgery patients result in stable hemodynamic parameters. This combination is particularly beneficial for patients with severe stenotic valve lesions and with left main stem coronary artery disease, since it has minimal effects on the heart rate and blood pressure.The Ketamine-Propofol combination is a useful alternative for induction of anesthesia for cardiac surgery patients.
CLINICAL AND EPIDEMIOLOGICAL METHODS OF DIAGNOSIS AND PROPHYLAXIS CARDIOVASCULAR DISEASES INDUCED BY ENDOTHELIAL DYSFUNCTION AT OFFSPRING OF
PEOPLE WHO HAD BEEN EXPOSED RADIATION
Pivina L.M.
State Medical University, Semey, Kazakhstan
Long monitoring of Semipalatinsk region people who were exposed to ionizing radiation in consequence of 40 year nuclear testing certifies about increasing of prevalence of circulatory system diseases. Conducting of the research in cohort, which exposed to direct radiation, showed that for all types of death from cardiovascular diseases (CVD) relative risk in exposed cohort composed 2,29 [2,13;2,47].
One of the most informative integral indexes of environment influence on human health is health condition of exposed descendants. Depositing of "mutagenic load" and decreasing of individual heterozygosity leads to limitation of organism abilities to answer by adaptation and compensatory protection reactions on external influence, leading to development of the multifactorial diseases.
Aim of our research is conducting of complex epidemiological and clinical-laboratory monitoring among offspring of people who had been exposed in consequence of nuclear testing at Semipalatinsk proving ground, in order to identify risk groups of vascular pathology, induced by endothelial dysfunction, their early diagnosis and elaboration of rehabilitation programs. On the basis of creation of system of the individual forecasting of risks of development CVD for persons born from exposed parents and following generation, lies principle of determination of genetically conditioned predisposition. For every member of patient's family ill by IHD, including of his parents, brothers, sisters and children, created individual chart of CVD development risk on the basis of determination of genes-candidates of development and also in accordance with SCORE scale.
Performed evaluation of diagnostic and prognostic significance of determination of nitrogen oxide metabolites in blood and urine, and also condition of endothelial dysfunction at patients with high risk factors. Also we had conducted patient's life quality as prognostic factor with the help of sociologic research with evaluation of nosological, syndromal and individual aspect in CVD formation. Results of conducted work are bases in elaboration of program of revealing, monitoring, adherence of patients with CVD to the treatment and creation of recommendations for rehabilitation measures in ambulatory conditions.
PROTOCOL-GUIDED DIURETIC MANAGEMENT IN CARDIAC SURGERY INTENSIVE CARE UNIT: COMPARISON OF FUROSEMIDE BY CONTINUOUS INFUSION AND INTERMITTENT BOLUS
Tojiboyev R, Zhanturganov M, Albazarov A, Mendykulov S, Kulchukov R.
National Scientific Medical Research Center, Astana, Kazakhstan.
Objective: To evaluate the safety and relative effectiveness of two diuretic protocols in the intensive care unit (ICU).
Design: Prospective, randomized comparative study.
Patients: Fourty-five post cardiac surgery intensive care unit patients with fluid overload for which aggressive diuresis were intended.
Interventions: Enrolled patients were randomized to fluid management strategies combining fluid restriction and individually adjusted diuretic therapy by either continuous or bolus infusions of furosemide, titrated to achieve negative hourly fluid balance.
Measurements and main results: Cumulative intake minus output (primary endpoint); change in serum creatinine, and length of ICU and hospital stay (secondary endpoints). Diuresis by continous infusion protocol was more reliable, safe, and effective.
Conclusions: Protocol-guided diuretic management, with individualized titration of dosage to defined physiologic endpoints can be readily and safely implemented in the Cardiac Surgery intensive Care Unit. Continuous diuretic regimens appear more effective in achieving negative fluid balance. Larger studies with a randomized control arm are needed before these protocols can be recommended as routine practice.
ПЕРВЫЙ КЛИНИЧЕСКИЙ ОПЫТ ПРИМЕНЕНИЯ АЛЛОГЕННЫХ МОНОНУКЛЕАРНЫХ
СТВОЛОВЫХ КЛЕТОК ПРИ ОСТРОМ КОРОНАРНОМ СИНДРОМЕ
Джолдасбекова А.У., Абсеитова С.Р., Ешмуратов Б.К., Князова Г.Ж., Габдуллина Г.Н.
Национальный научный медицинский центр, Астана, Казахстан
Идея регенеративной терапии с использованием своих или чужих стволовых клеток, а также использование специфических факторов роста, которые стимулируют выход стволовых клеток в периферический кровоток, на сегодняшний день уже стала реальностью. Лечение ишемической болезни сердца (ИБС), инфаркта миокарда (ИМ), сердечной недостаточности прошло большой путь - от медикаментозной коррекции и хирургического вмешательства до регенерационной терапии стволовыми клетками (клеточной кардиомиопластики).
Целью данного исследования явилось изучение возможности применения мононуклеарных клеток костного мозга (МККМ) для улучшения состояния миокарда у больных с острым коронарным синдромом с систолической дисфункцией левого желудочка с EF<45%, направленных на реваскуляризацию миокарда.
Материалы и методы: 11 пациентам с острым коронарным синдромом (ОКС), поступившим экстренно в кардиологическое отделение ННМЦ, после проведения чрескожных коронар-
