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39
Complicated heredity with disorders of lipid exchange was reli- Disorders of lipid exchange and obesity were more significant in
ably more significant in the group with SAH (82.5% versus 30.7%, the group with SAH compared with LAH (82.5%). p<0.01). Similar results in the group with SAH were obtained in Thus, the most significant risk factors of arterial hypertension in
relation to obesity (78.1%). children and adolescents were hypodynamics, irrational nutrition,
and complicated heredity.
References:
1. Bunina Y. Risk factors of the development of primary arterial hypertension in children and adolescents/Y. Bunina, N. Minilova, U. Rov-da//Doctor: Monthly scientific-practical journal. - 2010. - No 1. - P. 40-43 (in Russian).
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DOI: http://dx.doi.org/10.20534/ESR-16-11.12-97-102
Fozilov G Hurshid, PhD the interventional cardiologist in the department of Endovascular surgery of the Republican Specialized Centre of Cardiology, Tashkent, Uzbekistan Abdullaev Timur A., MD, PhD, prof the Head of department of Heart failure of the Republican Specialized Centre of Cardiology, Tashkent, Uzbekistan.
Bekbulatova Regina Sh. PhD the Head of department Ultrasound Diagnostic of the Republican Specialized Centre of Cardiology, Tashkent, Uzbekistan.
Karimov Anvar M. the resident of Heart failure department of the Republican Specialized Centre of Cardiology, Tashkent, Uzbekistan.
Tsoy Igor A.,
the resident of Heart failure department of the Republican Specialized Centre of Cardiology,
Tashkent, Uzbekistan. E-mail: Hurshid.uzb.1976@rambler.ru
Clinical efficacy of percutaneous coronary intervention in patients with coronary artery disease with low left ventricular ejection fraction in the long term
Abstract
Aims: to study the clinical and hemodynamic efficacy of percutaneous coronary intervention in patients with coronary artery disease with a low left ventricular ejection fraction in the near and long-term follow-up.
Methods and results: In a prospective observation we studied analysis of the life and dynamics parameters of intracardiac hemodynamics in 65 (47.1%) patients with low left ventricular ejection fraction (less than 45%). In our study, the incidence of angiographic success with stent implantation in patients with coronary artery disease with a low left ventricular ejection fraction was 92.3% (60), the immediate success of the procedure was 85.7% (59), and the clinical success of in-hospital — 85.7% (59). The survival rate in the long term without the development of large cardiac complications was 83.1% (54). The incidence of MACE was 16.9% (11). The LVEF increasing was observed in 60% (39) patients, decreasing of the LVEF in 15.4% (10) patients and in 10.8% (7) patients it was not changed. In patients with a positive growth in LVEF after PCI in the long-term observation reversibility of LV remodeling processes were registered.
Conclusion: Percutaneous coronary intervention in patients with coronary heart disease with decreased myocardial contractility improves left ventricular ejection fraction, thereby contributing to improved quality of life. In the long period, there was significant increasing in the average left ventricular ejection fraction up to 43,5% ± 6.9% and initial index was 38.5 ± 4.9% (p = 0.000). Keywords: Percutaneous coronary intervention; left ventricular ejection fraction; stent; major adverse cardiovascular events.
Introduction
Severe left ventricular dysfunction in patients with coronary artery disease is a predictor of poor prognosis. A significant portion of patients with coronary artery disease has dramatically decreased myocardial contractility, resulting in progress of chronic heart failure [1]. The prognosis for patients with chronic heart failure (CHF) is extremely unfavorable: according to the Rotterdam study 5-year survival in CHF is only 35% [2], and according to the Framingham study, within 6 years after the onset of clinical symptoms inadequate circulation die about 80% of men and 65% of women [3].
The mortality of ischemic etiology of inadequate blood circulation 1.4-3.8 times higher than in patients with hypertrophic genesis, dilatational and others [4; 5].
Coronary heart disease (CHD) patients with low left ventricular ejection fraction (LVEF) are the most prognostically unfavorable contingent of cardiac patients during myocardial revascularization operations due to the high risk of arrhythmias, congestive heart failure associated with surgery myocardial injury [6; 7].
Conservative treatment of these patients is usually not sufficiently effective, and mortality in patients belonging to the III-IV functional classes is about 50% per year [8; 9]
Adequate revascularization improves contractile function of the myocardium due to ischemia [9]. Today, according to various studies, clear evidence of the effectiveness and safety of coronary artery bypass grafting (CABG) in patients with CHD and low LVEF is obtained [10; 11; 12].
However, the oscillation frequency of hospital mortality from 2.5% to 11% during CABG, presence of contraindications or high risk for its implementation, make the choice of the optimal method for the treatment of patients with coronary artery disease with low LVEF, one of the problems for practical cardiology and cardiac surgery [12]. In this connection, a special scientific and practical interest is the study of the immediate and long-term results of percutaneous coronary interventions (PCI) in these patients.
Objective: to study the clinical and hemodynamic efficacy of PCI in patients with CHD with a low LVEF in the immediate and long-term follow-up.
Methods.
For the period from 1 January 2013 to 1 December 2014 in the department of endovascular surgery of our clinic PCI were performed in 1266 patients with various forms of CHD. In CHD patients with low left ventricular ejection fraction PCI were performed in 11.9% (138) patients. PCI was performed without detection of myocardial viability, indications for intervention were: the presence of angina, dyspnoea, hemodynamic instability, signs of myocardial ischemia, according to non-invasive methods, provided that, in accordance with coronary angiography data, these patients had coronary artery stenosis > 50%. Angiographic success was defined as successful delivery and deployment of the stent or bioresorbable vascular scaffolds with achievement of <20% final residual stenosis. Procedure success was defined as angiographic success and no major periprocedural complications (dissection of the coronary artery damaging vessel flow — TIMI flow 2 or less, perforation of the coronary artery, emergent coronary artery bypass grafting). Major Adverse Cardiovascular Event (MACE) included death, acute myocardial infarction and coronary artery bypass surgery which took place during the period of observation. Left ventricular ejection fraction was determined by echocardiography method Teicholz and was performed on Philips ClearVue 350 ultrasound machines, by using 3.5 MHz transthoracic transducer. In a prospective observation we studied analysis of the life and dynamics parameters of intracardiac hemodynamics in 65 (47.1%) patients with low LVEF (less than 45%). Informed consent was obtained from all patients before participation in the study, and the protocol was approved by the Human Investigation Committee of our institution.
The characteristics of patients with coronary heart disease with low ejection fraction in whom coronary angiography was performed, followed by stenting of coronary arteries are shown in table number 1.
Table 1. - The clinical characteristics of patients
Variable All patients n (65)
Male/female n (%) 52 (80)/13 (20)
Mean age (years) 59.5± 8.4
Dyslipidaemia n (%) 59 90.7
Hypertension n (%) 57 87.7
Diabetes n (%) 26 40.0
CABG or PCI in history (up to 1 year) n (%) 2 3.1
Previous MI n (%) 45 69.2
Angina pectoris FC II (CCS) n (%) 1 1.5
Angina pectoris FC III (CCS) n (%) 23 35.4
Angina pectoris FC IV (CCS) n (%) 2 3.1
Unstable angina n (%) 10 15.4
Acute myocardial infarction n (%) 29 44.6
LVEF (average)% 38.5±4.9
the average end-diastolic diameter (mm) 64.3±7.9
the average end-systolic diameter (mm) 50,4±7.9
the average end-diastolic volume (ml) 209.9±59.2
the average end-systolic volume (ml) 129±44
CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; MI, myocardial infarction; FC, functional class; CCS, Canadian Cardiovascular Society; LVEF, left ventricular ejection fraction.
During the diagnostic coronary angiography in 65 patients with CHD and low LVEF, atherosclerotic lesions were found in 163 arteries, which averaged 2.5 per artery in 1 patient. According to selective coronarography, three-vessel coronary lesions were present in 47.7% (31) patients, two-vessel disease in 29.2% (19) and single vessel disease in 23.1% (15) patients.
The most common lesions were located in the left anterior descending artery (LAD) — 57 (34.9%); in the right coronary artery
(RCA) — 38 (23.3%); in the circumflex artery — 33 (20.3%); obtuse marginal branch of the circumflex artery — 10 (6.2%); in posterior interventricular branch — 9 (5.6%); in the diagonal branch — 8 (4.9%); in the postero-lateral branches — 3 (1.8%) and intermediate artery — 2 (1.2%). Hemodynamically significant (>50%) stem lesion of the left coronary artery (LCA) was found in 3 (1.8%) cases.
According to the results of coronary angiography, 192 hemodynamically significant stenoses of the coronary arteries were found. The results of morphometric analysis of hemodynamically significant stenoses (stenosis > 50%) of the main epicardial arteries in CHD patients with low LVEF are shown in table number 2.
Table 2. - Morphological characteristics of coronary artery stenosis
Type stenosis by classification ACC/AHA Stenosis Occlusive lesions Total
Type «A» n (%) 12 (6.2) 0 12 (6.2)
Type «B» n (%) 88 (45.8) 8 (4.2) 96 (50.0)
Type «C» n (%) 47 (24.5) 37 (19.3) 84 (43.8)
Total 147 (76.5) 45 (23.5) 192 (100)
ACC, American College Cardiology; AHA, American Heart erosclerotic lesions of varying severity were revealed. The results Association. of our quantitative analysis of coronary artery stenosis in patients
In conducting the quantitative analysis of coronary artery ste- with coronary artery disease with low LVEF, are presented in table nosis in patients with coronary artery disease with low LVEF ath- number 3.
Table 3. - The results of the quantitative analysis of the coronary arteries in patients with coronary artery disease with a low LVEF
The extent of the vessel constriction n %
Total occlusion 39 20.3
Functional occlusion 6 3.1
Stenosis of 75-99% 85 44.3
Stenosis from 50 up to 74% 62 32.3
TOTAL: 192 100
Statistical analysis
Statistical analysis of the results was carried out by calculating the arithmetic mean (M), root mean square (standard) deviation (SD), standard error of the arithmetic mean (m). The significance of differences was determined according to Student's t test. To analyze the significance of differences between the quality indicators it was used x2 test. Differences were considered statistically significant at p <0.05. Data are presented as M ± m.
Results
Totally 77 endovascular procedures were performed in 65 patients: in 53 (81.5%) patients was performed in a single step, in 12 (18.5%) in two steps. While deciding on the matter of intervention dividing into two phases we focused on the total time of the intervention, fluoroscopy time, the amount of contrast agent, the general course of angioplasty (successful recanalization, the presence or absence of complications, the general condition of the patient). In 100% (77) cases PCI were performed by access via radialis.
During 77 endovascular procedures the intervention was undertaken in 94 coronary artery segments totally. Direct coronary stenting was performed in 20 (21.3%) segments, transluminal balloon angioplasty (TBA) and stenting in 54 (57.4%); recanalization, TBA and stenting was performed in 14 (14.9%); recanalization attempt was made in 5 (5.3%) segments, and 1 (1.1%) segment was limited to holding TBA.
In a total number of 115 implanted stents (in average 1.8 stents per patient), 80% (92) were drug-eluting stents (BioMatrix Biosensors Inc, Newport Beach, Calif; XIENCE V Abbot Vascular, Tem-ecula, USA; Resolute integrity Medtronic, Inc., Minneapolis, USA); 15.6% (18) bare metal stents (Coflexus, Balton, Warszawa, Poland)
and 4.6% (5), bioresorbable vascular scaffolds (Absorb, Abbot Vascular, Temecula, USA).
In our study, the incidence of angiographic success with stent implantation in patients with coronary artery disease with a low left ventricular ejection fraction was 92.3% (60), the immediate success of the procedure was 85.7% (59), and the clinical success of in-hospital — 85.7% (59). The frequency of complications was 12.3% (8) of the cases; of them developed coronary artery dissection in 5 cases; in 2 cases developed one «no-reflow» phenomenon and there was bleeding from the gastrointestinal tract. The incidence of acute myocardial infarction (AMI) and death at an immediate time was 0.
The survival rate in the long term without the development of large cardiac complications was 83.1% (54). The incidence of MACE was 16.9% (11), ofwhich 12.3% (8) developed a lethal outcome, in 3.1% (2) — non-fatal myocardial infarction and in 1.5% (1) case the coronary artery bypass surgery operation was executed. Lethal outcome occurred in 8 (12.3%) patients: in 7 cases as a result of sudden death and in one due to complications development after prostatectomy surgery. The LVEF increasing was observed in 60% (39) patients, decreasing of the LVEF in 15.4% (10) patients and in 10.8% (7) patients, it was not changed. In patients with a growth in LVEF after PCI in the long-term observation reversibility of left ventricular remodeling processes were registered.
Hemodynamic parameters of left ventricular defined by echocardiography before and after percutaneous coronary intervention in patients with growth of LVEF are presented in table number 4.
Table 4. - Hemodynamic parameters of left ventricular defined by echocardiography before and after percutaneous coronary intervention
Parameters Before PCI After PCI Р-value
the average end-systolic dimension (ESD) mm 52.4±7.7 47.6±6.7 0.004
the average end-diastolic dimension (EDD) mm 67.0±7.7 62.4±6.7 0.007
the average end-systolic volume (ESV) ml 150.1±49.4 108.3±38.9 0.000
the average end-diastolic volume (EDV) ml 236.7±57.9 200.3±57.9 0.007
LVEF (average)% 38.5±4.9 43.5±6.9 0.000
LVEF, left ventricular ejection fraction.
Discussion
Treatment of patients with ischemic heart disease with decreased myocardial contractility, despite the achievements of modern cardiology and cardiovascular surgery, remains a matter of debate even at present time. Most patients with CHD and low ejection fraction are candidates for heart transplantation, but on a number of socio-eco-nomical reasons, this task is the most complicated to be performed, and often this kind of care for such patients becomes simply inaccessible. In conducting medical therapy, according to the data of CASS study (Coronary Artery Surgery Study), among patients with coronary heart disease with left ventricular ejection fraction from 35% to 49%, a four-year survival comprised 71% ofcases, but in patients with left ventricular ejection fraction less than 35% survival rate for the same period of observation do not exceed 50% [13].
As for bypass surgery, numerous randomized researches were carried out in patients with a low (less than 40%) LVEF, a good long-term implementation forecast was shown in bypass surgery application, however, the postoperative complications such as hospital mortality, stroke, ventricular arrhythmia, low cardiac output syndrome, sternal wound complications in this group of patients with LVEF remained high [6; 14].
In the latest years, in CHD patients with low left ventricular ejection fraction percutaneous coronary interventions have been widely used. Today it is not possible to clearly answer the question whether PCI is the alternative to CABG or it is a step in the surgical treatment of these patients. In this regard, our task was to study the immediate and long-term results of percutaneous coronary interventions in these patients.
Our investigation included 65 (47.1%) patients with low left ventricular ejection fraction (less than 45%) subjected to percutaneous coronary intervention, where we have managed to study their long-term results (for 24 months). Male patients accounted for — 80.0% (52) and female — 20.0% (13). The age of patients ranged from 39 to 76 years, and the average was 59.5 ± 8.4 years. In 44.6% (29) cases PCI were performed in patients with acute myocardial infarction; 40.0% (26) cases with stable angina FC II-IV, and in 15.4% (10) cases with progressive angina. Left ventricular ejection fraction ranged from 27.3% to 45% and averaged 38.5 ± 4.9%. According to selective coronary three-vessel coronary lesions were present in 31 (47.7%) patients, two-vessel in 19 (29.2%) and single vessel disease in 15 (23.1%) patients.
In accordance with data of N. Serota and co-authors, who analyzed the results of percutaneous coronary interventions in 73 patients with ejection fraction of the left ventricular lower than 40%, male and female comprised 72.6% (53) and 27.4% (20) respectively. The average age of patients was 62 ± 10 years. Single vessel disease was in 13 (18%) patients, two-vessel disease — in 36 (49%), three-vessel — in 24 (33%) [15].
In Serrano Jr. and co-authors current study of 162 patients with low left ventricular ejection fraction (22 ± 5%) were subjected to further surgical correction and it was found one vessel disease in 50
(30%) patients; two-vessel disease in 62 (37%) patients and in 56 (33%) patients three-vessel coronary disease [9].
In 2005 Farhan Aslam and co-authors published data of 149 patients with LVEF less than 40% (in average 35 ± 10%) after successful PCI. Patients under this study were mostly male (75%). Congestive heart failure was diagnosed in 33% of patients, angina pectoris — 13%, unstable angina — in 34%, left ventricular ejection fraction less than 30% — 35% ofpatients. Multivessel coronary disease was diagnosed in 80% of patients [16].
Thus, in our study, as well as in many mentioned above data, among CHD patients with reduced myocardial contractility prevailed male patients, multivessel coronary disease often occured in them.
In our study, the frequency of angiographic success with stent implantation in patients with coronary heart disease with a low LVEF fraction was 92.3% (60), the immediate success of the procedure was 85.7% (59). The frequency of complications was in 12.3% (8) cases; out of them the coronary artery dissection developed in 62.5% (5) cases; in 25% (2) cases «no-reflow» phenomenon developed and there was bleeding from the gastrointestinal tract. The incidence of myocardial infarction and death in-hospital equaled to 0. The survival rate in the long term period (24 months) without development of MACE comprised 83.1% (54). The incidence of MACE comprised 16.9% (11), ofwhich 12.3% (8) developed lethal outcome, in 3.1% (2) — nonfatal myocardial infarction, and in 1.5% (1) cases CABG was performed.
In 2008 Briguori and co-authors published the data on treatment results of 337 patients with LVEF of 35% or less, where stents were implanted in period from April 1993 to March 2004. Hospital period was uneventful in 322 (95.3%) patients. Hospital mortality was 1.5%. During the two-year observation period, 83 died (24.6%) patients (group 1) and 254 (75.4%) were alive (group 2). Sudden death occurred in 65% ofcases. Acute myocardial infarction occurred more frequently in group 1 (18% vs 5.4%, p = 0.001). Cardioverter-de-fibrillators were implanted in 6.7% ofpatients in group 1 and 20.7% of patients in group 2 (p = 0.005). LVEF improved significantly only in the 2nd group — from 29 ± 6 to 35 ± 11% (p = 0.001), while in group 1 remained unchanged (p = 0.30). Independent predictors of death in long-term period were acute myocardial infarction (95% p = 0.001), left ventricular ejection fraction was less than 25% (p = 0.006) and the completeness of revascularization (p = 0.020) [17].
V. Kunadian et al. in 2012 conducted a meta-analysis of studies using PCI in patients with systolic dysfunction of the left ventricular (ejection fraction less than or equaled to 40%) to determine the performance of hospital and long-term (over 1 year) mortality. This meta-analysis included 4766 patients totally. The average age of the patients was 65 years (95% CI: 62-68), 80% of them were men (95% CI: 75-84%). The average left ventricular ejection fraction was 30% (95% CI: 27-33%). Hospital mortality was 1.8% (39/2202, 95% CI: 1.0-2.9%). The long-term mortality (within 24 months) was 13.6% (401/2937, 95% CI: 11.0-20.7%). According to the results of clinical studies, the authors concluded that the conduct of PCI in patients
with left ventricular systolic dysfunction is as possible with a low inhospital and long-term mortality as in coronary bypass surgery [18].
Thus, based on the analysis of our own data and on the above mentioned studies, it is evident that percutaneous coronary intervention is a safe method of revascularization in patients with low left ventricular ejection fraction.
In the study oflong-term outcomes ofPCI by echocardiography, left ventricular ejection fraction ranged from 30% to 61.5%, and the average was 43.5 ± 6.9% (p = 0.000). Increasing the LVEF was observed in 60% (39) patients, a decrease in 15.4% (10) patients and in 10.8% (7) patients LVEF was not changed. Patients with left ventricular ejection fraction increase after PCI in the remote period marked regression of left ventricle remodeling processes. According to echocardiogram data in these patients average end-diastolic dimension before PCI was 67.0 ± 7.7 mm, after PCI was 62.4 ± 6.7 (p = 0.007), and the end-systolic dimension before interference was 52.4 ± 7.7 mm, after interference was 47.6 ± 6.7 (p = 0.004). Middle end-diastolic volume before PCI was 236.7 ± 57.9, and after PCI was 200.3 ± 57.9 (p = 0.007); average end-systolic volume before PCI was 150.1 ± 49.4 ml, after PCI was 108.3 ± 38.9 (p = 0.000) ml.
According to D. Dudek et al., who studied the results of PCI in patients with coronary artery disease with ejection fraction less than 40% in the long term with the follow-up examination, the increase in LVEF from 38.4 ± 6 to 15 ± 50.4% (p = 0.005) was revealed. Their study included 29 patients (average age 54.4 ± 11.0 years) who were examined in 6 months after successful PCI. The authors noted significant improvement in LVEF in patients I and II functional class (FC) NYHA (from 5 to 40.4 ± 58.1 ± 9%, p = 0.0001) compared with patients belonging to the III and IV FC by NYHA, where LVEF remained virtually unchanged (from 31.4 ± 9 to 11 ± 31.8%, p = ns) [19].
Younes Nozari et al. reported on 115 patients with coronary artery disease and low ejection fraction of the left ventricle, these patients were implanted drug-eluting stents with medicine coverage. Echocardiography was performed the day before PCI, the next day, and after 3-6 months. Echocardiography indices were compared with the results of repeated studies. The average age of the patients was 57.8 ± 8.38 years, average ejection fraction was 40.52 ± 6.36% on the day before PCI, 41.83 ± 7.14% — the next day and 44.0
± 7.89% — in 3-6 months after PCI. In authors opinion, PCI improves LVEF in the research group of patients [20].
Thus, obtained data in the course of these studies, as well as the world literature data shows that percutaneous coronary intervention in CHD patients with decreased myocardial contractility provide improvement in left ventricular ejection fraction, thereby contributing to improved quality of life.
Limitations
Unfortunately in our study, we could not evaluate viability myocardium at patients CHD with a low LVEF before PCI and not all of them enrolled in research for long term estimation. In addition, we did not compare percutaneous coronary intervention with coronary artery bypass grafting and with medical therapy of these patients. A larger patient population and longer follow-up would be needed for evaluate of clinical results of the PCI at patients CHD and reduce LVEF.
Conclusion
Analysis of our experience shows that in patients with coronary artery disease with a low left ventricular ejection fraction (less than 45%), percutaneous coronary intervention is an effective and safe method of revascularization. Hospital mortality and development of AMI after PCI was zero, and it was 16.9% in the long term frequency of MACE, survival in the observed periods of12 to 24 months without MACE comprised 83.1%.
Percutaneous coronary intervention in patients with coronary heart disease with decreased myocardial contractility improves left ventricular ejection fraction, thereby contributing to improved quality of life. In the long period, there was significant increasing in the average left ventricular ejection fraction up to 43.5% ± 6.9% and initial index was 38.5 ± 4.9% (p = 0.000).
Acknowledgements
The authors greatly appreciate the support of medical staff from the Republican Specialized Centre of Cardiology and it's director MD, PhD, professor Ravshanbek Kurbanov.
Funding
'This work was supported by the Uzbekistan Academy of Science [ADSS 15.13.3] and the Republican Specialized Centre of Cardiology'.
Conflicts of Interest: none declared.
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DOI: http://dx.doi.org/10.20534/ESR-16-11.12-102-103
Sharipova Iroda Pulatovna, Senior Researcher of Scientific Research Institute of Virology of the Ministry of Health of Uzbekistan Sharapov Saidhon Mahmudhanovich, virologist doctor of Scientific Research Institute of Virology of the Ministry of Health of Uzbekistan Lokteva Lyubov Mikhailovna virologist doctor of Scientific Research Institute of Virology of the Ministry of Health of Uzbekistan Rakhmanova Jamila Amanovna, assistant professor of Tashkent Institute of Postgraduate Medical Education Mustafayev Khayrulla Murtazaevich, scientific consultant of Scientific Research Institute of Virology of the Ministry of Health of Uzbekistan E-mail: evovision@bk.ru
Prevalence human papillomavirus with high-risk among women with precancerous diseases of the cervix uteri
Abstract: The article presents research data 515 women who carried out the molecular biological study of cervical scrapings under the opportunistic screening for human papillomavirus (HPV) in the Institute of Virology of the Ministry of Health of Uzbekistan, aimed gynecologists after a visual inspection, and is suspected of precancerous and background diseases of the cervix. In 100 (19.4%) out of 515 women HPV genetic material has been found with high oncogenic risk that corresponds to the average level of HPV prevalence worldwide.
Thus, HPV testing in a primary marker cervical pathology studies will reduce the volume five-fold to redistribute more attention to the real risk of women with cervical cancer, which in turn will increase the effectiveness of preventive screening. Keywords: Human papillomavirus, oncogenic risk, preventive screening.
