Painless Ischemia Research Articles

COMPLEX REHABILITATION OF ISCHEMIC HEART DISEASE PATIENTS AFTER CORONARY BYPASS OPERATION WITH THE USE OF BIOLOGICALLY ACTIVE ADDITIVES

Aim: The purpose of the work was to study the possibility of using Dihydroquercetin in rehabilitation programs for patients with coronary artery disease after Coronary artery bypass grafting (CABG) surgery in order to increase the effectiveness of rehabilitation, which has notable scientific and practical significance. Materials and Methods: The methodological basis of the research is based on systemic, historical, terminological, and informational approaches. Results: The results of the study showed the high clinical effectiveness of Dihydroquercetin in the complex medical rehabilitation of patients with coronary artery disease who underwent the operation. The pill intake did not affect indicators of carbohydrate and lipid metabolism, which indicates its metabolic neutrality. None of the patients had any worsening of the condition, increased frequency of angina attacks, or episodes of painless ischemia. All patients indicated good tolerability of the drug, and improvement in general well-being (reduction or disappearance of shortness of breath, decrease in pain intensity, increase in activity, improvement in sleep). The implementation of the optimized rehabilitation program also contributed to the improvement of the psycho-emotional state of the patients. Conclusions: Сomplex medical rehabilitation of patients with coronary heart disease after Coronary artery bypass grafting surgery according to a program with the inclusion of Dihydroquercetin helps to improve the rheological properties of blood, strengthen the active vasomotor mechanisms of MC regulation, improve indicators of central and peripheral hemodynamics, blood oxygenation, increase in exercise tolerance, improve psycho-emotional the condition, which ultimately ensure an increase in the rehabilitation effect.

Painless ischemia in diabetes mellitus

The main purpose of the current research work was to study the importance of the clinical identification of persons with painless ischemia in diabetes mellitus and discuss potential treatment interventions. The current study was conducted on articles published during the previous 15 years. Furthermore, recent references to retrieved research articles were studied. Unfortunately, over the last decade or two, another trend has emerged: the prevalence of obesity and diabetes mellitus has increased. The world’s population is aging, and older people are more likely to have trouble maintaining appropriate glucose levels during fasting or postprandial periods. These developments add to the world’s population’s ongoing burden of diabetes and heart disease. The research article reviews a study related to painless ischemia in diabetes mellitus This data covers obesity and other diabetes mellitus antecedents in middle-aged and elderly people all around the world. We resulted that painless ischemia in diabetes mellitus Preinfarct angina and classic myocardial infarction chest discomfort is usually absent. 3) They usually have congestive heart failure, which is frequently accompanied by painless myocardial ischemia during stress testing. Painless ischemia was more common in diabetics regardless of the severity of ischemia, but painless ischemia was less common in non-diabetics with severe ischemia. As a result, diabetic individuals with neuropathy and retinopathy should be managed with extra care.

CLINICAL AND FUNCTIONAL FEATURES OF THE COURSE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS WITH AUTONOMIC NEUROPATHY

Diabetic neuropathy (DN) is one of the most common complications of diabetes mellitus (DM), which leads to severalconditions that reduce performance and threaten thepatient's life. Neuropathy against the background of diabetes takes the topplace, accounting for 40% of all neuropathies, ahead of alcoholic neuropathy [2]. Diabetic neuropathy is a combination of syndromes of damage to the nervous system with a predominant lesion of its various parts (sensorimotor or autonomic).Keywords:Diabetes mellitus,diabetic autonomic cardiac neuropathy, circadian index, heart denervation, painless ischemia

ДИАГНОСТИКА ДИАБЕТИЧЕСКОЙ КАРДИАЛЬНОЙ АВТОНОМНОЙ НЕЙРОПАТИИ

Diabetes mellitus is a severe disease that leads to an early disability and premature death. Diabetic cardiac autonomic neuropathy (DCAN) is a serious and frequent complication of diabetes mellitus with a poor prognosis. Timely diagnosis of DCAN can have important clinical implications, since DCAN is an independent risk factor for cardiovascular mortality, arrhythmias, painless ischemia, and other cardiovascular disorders. Despite this, until now, in clinical practice, they are rarely engaged in an active search for the symptoms of DCAN and it remains a poorly studied and rarely diagnosed complication of diabetes mellitus. The article discusses the methods of detecting and assessing DACN in clinical practice, including the assessment of clinical manifestations, the use of reflex cardiovagal tests and common instrument6al diagnostic methods.

ПОЛОВОЙ ДИМОРФИЗМ КЛИНИЧЕСКИХ И ЭЛЕКТРОКАРДИОГРАФИЧЕСКИХ ИЗМЕНЕНИЙ У БОЛЬНЫХ БЕЗБОЛЕВОЙ ИШЕМИЕЙ МИОКАРДА 3 ТИПА

Безболевая ишемия миокарда у больных сахарным диабетом 2-го типа является довольно распространенным явлением, поскольку ее частота колеблется от 15 до 64,7%. Цель исследования заключалась в анализе полового диморфизма клинических и электрокардиографических проявлений у представителей разного пола. Для достижения цели исследования проведен комплекс клинических и инструментальных исследований морфофункционального состояния сердца. В результате проведенных исследований установлено, что половой диморфизм безболевой ишемии миокарда у мужчин появлялся вначале дебютом приступов болевой стенокардии, у женщин, напротив, болевые приступы стенокардии во времени следовали за безболевой ишемией. У мужчин безболевая ишемия сопровождалась классической иррадиацией стенокардической боли в левую руку, челюсть и межлопаточное пространство, ощущением перебоев в деятельности сердца. У женщин безболевая ишемия миокарда сопровождалась сердцебиением, одышкой или отсутствием кардиальных жалоб. Половой диморфизм ЭКГ-признаков проявлялся в виде преобладания у мужчин желудочковой экстрасистолии и гипертрофии/перегрузки левых отделов сердца. У женщин с безболевой ишемией на ЭКГ в отличие от мужчин преобладали синусовая аритмия и суправентрикулярная экстрасистолия.

Clinical-functional features in the course of a silent ischemic heart disease form depending on stenting

Objective: to analyze the remote prediction of reperfusion therapy by stenting on the indicators of myocardial ischemia in patients with painless coronary heart disease (CHD) with postinfarction cardiosclerosis. Material and methods. The subject of the study was the study of 67 patients with painless myocardial ischemia (BIM), which occurred in people with postinfarction cardiosclerosis, among which 29 patients with BIM who had myocardial infarction (MI) with revascularization in the acute period by stenting (Group I) and 38 patients with BIM who had experienced the MI without a stenting (II group). Results. The absence of revascularization in the acute period of MI can negatively affect the state of myocardial perfusion and provoke ischemic heart muscle in patients with SMI. This is manifested by more intense manifestations of ischemic changes detected during Holter monitoring of electrocardiography (HM ECG). These studies allow SMI to be considered as a disease, which leads to a decrease in the electrical stability of the myocardium. It was established that for patients with SMI without stenting, characterized by higher average daily values of the number of ischemic episodes per day, the total daily duration of depression of the segment ST, the total amplitude of depression ST, the average duration of one ischemic episode compared with individuals after the conducted stenting (p<0,05). Conclusions. The absence of revascularization in the acute period of myocardial infarction can negatively affect the state of myocardial perfusion and predispose to ischemic heart muscle in patients with painless ischemia of the myocardium.

Evaluation of the efficiency of combined pharmacotherapy with the use of trimetazidine with prolonged release in patients with stable angina in outpatient practice

To evaluate the effectiveness of complex pharmacotherapy with the inclusion in the treatment regimen of trimetazidine with a prolonged release in patients with stable angina. The pilot study included 22 patients aged 45-75 years with combined cardiovascular pathology. In addition to the received therapy, all patients were prescribed the original trimetazidine with a prolonged release at a dose of 80 mg/day (Preductal® OD, Servier, Russia). The observation period was 2 months. The survey included the double implementation of the following methods: the number of strokes per week, the frequency of use of short - acting nitrates per week, blood pressure, heart rate, echocardiography, daily ECG monitoring, assessment of the quality of life (questionnaire SF-36, questionnaire of patients with stable angina SAQ). When assessing the effect of ongoing pharmacotherapy on clinical and echoCG indicators in patients of the study group, significant positive dynamics was registered in the form of reducing the number of angina attacks and the number of short - acting nitrates used per week, a slight positive dynamics of EF on echoCG, episodes of pain and painless ischemia were eliminated according to the results of Holter monitoring), a significant positive dynamics of quality of life indicators was noted. Combined pharmacotherapy of patients with stable exertional angina with the inclusion of the trimetazidine with a prolonged release at a dose of 80 mg/day (Predductal® OD, Servier, Russia) has a significant positive pharmacodynamic effect in the form of an increase in the antianginal effect, improvement of Holter monitoring indicators and quality of patients life.

Results of dynamic Follow-Up for Patients with Myocardial Infarction without Obstructive Lesion of Coronary Arteries: Data of the Overall Register for Acute Coronary Syndrome in Krasnodar Region

Background Myocardial infarction (MI) without obstructive lesion of coronary arteries (MINOCA) has incidence to 14%. Despite its high prevalence, MINOCA is paid not enough attention, therefore some patients can not receive appropriate treatment. Aim Evaluating the long-term results of clinical observation in patients with MINOCA in comparison with patients with obstructive damage and the subsequent revascularization of myocardium. Material On the basis of Scientific Research Institute RCH – 1 the multicenter cohort observation was organized. Patients from the register CROCS (the register of acute coronary syndrome in Krasnodar Region) with the diagnosis MI were divided into two groups: MINOCA including patients without obstructive damage of coronary arteries and MINOCA including patients with obstructive injury and the subsequent stenting a heart attack connected artery. All patients in 12 months would have control assessment during which they had objective survey; electrocardiography; daily monitoring; test of six-minute walking, echocardiography. Results In the MINOCA group in 12 months after the acute coronary event in 21.5% cases there were tension stenocardia, in 16.2% – a painless form of myocardial ischemia was revealed, in a group of patients with MINOCA stenocardia of tension was revealed at 12.5% and 8.4% – with painless ischemia. The group of patients with MINOCA is characterized by more reliable decrease in both parameters of heart rate variability, and turbulence of heart rate. MINOCA is followed by statistically significant increase in risk of ACS development and death within 12 months. All indicators had reliable difference. Conclusion Patients with MINOCA are a special group, their differential characteristics demand definite diagnostic efforts.

Hypertrophic Cardiomyopathy: The Time-Synchronized Relationship between Ischemia and Left Ventricular Dysfunction Assessed by Highly Sensitive Troponin I and NT-proBNP.

The aim of this study was to compare NT-proBNP using the absolute values and NT-proBNP/ULN values that were standardized by age and gender between three subgroups: those without ischemia (negative hs-troponin I and no anginal pain (hsTnI-/AP-)), those with painless ischemia (hsTnI+/AP-), and those with painful ischemia (hsTnI+/AP+). Additionally, echocardiographic parameters were compared in these three subgroups. The absolute value of NT-proBNP was significantly higher in the painful ischemia subgroup (hsTnI-/AP- vs. hsTnI+/AP- vs. hsTnI+/AP+: 502 (174-833) vs. 969 (363-1346) vs. 2053 (323-3283) pg/ml; p = 0.018 for the whole-model analysis). The standardized value of NT-proBNP/ULN was gradually increased (hsTnI-/AP- vs. hsTnI+/AP- vs. hsTnI+/AP+: 3.61 + 0.63 vs. 6.90 + 1.31 vs. 9.35 + 1.87; p = 0.001 for the whole-model analysis). In the comparison between subgroups (hsTnI-/AP- vs. hsTnI+/AP- vs. hsTnI+/AP+), two echocardiographic parameters increased significantly. The left ventricular maximum wall thickness (LVMWT) at diastole was 1.99 ± 0.08 cm vs. 2.28 ± 0.13 cm vs. 2.49 ± 0.15 cm (p = 0.004 for the whole-model analysis). The maximal gradient of the provoked left ventricular outflow tract (LVOT) gradient increased significantly in only the painful-ischemia subgroup (11 (7-30) mmHg vs. 12 (9.35-31.5) mmHg vs. 100 (43-120) mmHg). In conclusion, both painless ischemia and painful ischemia are associated with a gradual, significant increase in NT-proBNP/ULN in comparison to the double-negative hsTnI/AP subgroup. In contrast, NT-proBNP is significantly higher in only the subgroup with painful ischemia.

THE CLINICAL SIGNIFICANCE OF THE DAILY MONITORING OF HOLTER ECG IN CHRONIC GLOMERULONEPHRITIS AT THE PREDIALYSIS STAGE OF THE DISEASE

This article presents the results of our own research: comprehensive clinical and laboratory examinations, including data from the daily Holter monitoring of the electrocardiogram (DMEKG) in 169 patients with chronic glomerulonephritis at the predialysis stage of the disease. According to the DMEKG, 60.3% of the persons examined by us had episodes of supraventricular group extrasystoles, and ventricular group extrasystoles in 28.9%. In addition, 11.2% of patients had atrial ventricular blockade (incomplete / partial), 8.8% had atrial fibrillation and painless ischemia in an amount of from 1 to 3 episodes per day in 14.7%. Depending on the average heart rate (HR) according to the DMEKG, patients with chronic glomerulonephritis were divided into two subgroups. Subgroup “A” included 38 patients with heart rate less than or equal to 70 beats / min, in subgroup “B” — 131 patients with a heart rate of more than 70 beats / min. With equal values of uric acid, total cholesterol cholesterol, HDL cholesterolcholesterol, TG, plasma creatinine and blood fibrinogen in subgroup “B” there was a statistically significant increase in LDL cholesterol concentration(3.58 (2.74; 5.54) mmol / l vs. 2, 82 (2.30; 3.86) mmol / l; p &lt;0.05) and a decrease in the calculated GFR (70.4 (48.8; 96.3) ml / min vs. 85.7 (31.5; 103,1) ml / min; p &lt;0.05) compared with subgroup “A”. In the subgroup “B” a tendency was observed to increase the degree of daily excretion of protein with urine. The data obtained confirm the fact that the conduct of the DMEKG with the analysis of heart rate is of significant clinical importance for the diagnosis of cardiovascular disorders and the p revention of cardiovascular complications in chronic glomerulonephritis at the predialysis stage of the disease.

Influence of molsidomine (Sidnofarma) on indices of central hemodynamics and tolerance disorders to physical activity in patients with stage II arterial hypertension

Today in Ukraine up to 73,3% of all deaths occur in three classes of causes of death: circulatory system diseases, external causes of death and neoplasm. The first place is occupied by diseases of the circulatory system (30,67%). At the same time, more than a third are patients with AH. Among residents of cities, this figure is 30%, and in rural areas – 36%. However, AH is a significant risk factor for coronary heart disease. According to the latest official data, the prevalence of the combination of AH and IHD among the adult population is 63,3% of cases, the incidence is 58,8%.The objective: to study the effect of molsidomine (Sindhnopharm) on the indices of central hemodynamics and the violation of physical activity tolerance in patients with stage II arterial hypertension without obvious clinical signs of coronary heart disease.Materials and methods. The survey included 100 patients with stage II AH without obvious symptoms of stable coronary artery disease, the mean age of which was 59,2±1,7 years. All patients were examined at the beginning of the study and after the treatment, provided by modern standards of curative treatment of patients with AH. The results of bicycle ergometry, daily monitoring of ECG and echocardiography standard therapy was performed according to the national recommendations. Patients of the first group in addition to the main treatment was assigned sidnofarm in a dose of 2 mg twice a day for 3 weeks.Results. When performing daily monitoring of the ECG, it was revealed that 46 patients (92%) and 44 patients (88%) of the second group had attacks of «painless ischemia» from 1 to 3 attacks within 24 hours, up to 4 minutes maximum. In both groups before the treatment, patients with low and medium tolerance to physical exertion (according to the results of VEM) prevailed. And a violation of the diastolic function of the left ventricle (echocardiography). After the examination, patients were prescribed treatment for three weeks. Patients of the first group received basic therapy, according to treatment standards. In addition to the main therapy for these patients, sildnofarm was added at a dose of 2 mg twice daily.Conclusion. The use of Sidnofarma 2 mg twice a day has a positive effect on the symptoms of ischemia in patients with Stage II AH. Against the background of Sidnofarma, the number of seizures of «painless ischemia» was significantly reduced in comparison with the second group. As the results of the study showed in the patients of the first group, who received additionally sydnofarm to the basic therapy, the tolerance to exercise was better. The number of patients who reached the load of 100 W was 50% greater (1 group 46%, the second only 26%). Also, among the patients of the 1st group there was not one who would stop at a power of 50 W, while in the group of 2 such patients there was 10%. Thus, we noted that the stabilization of blood pressure in patients with AH of the second degree increases tolerance to physical exertion, but using sydnofarm can achieve significantly better results, even in a short period of treatment. Taking into account the obtained data, it is advisable to recommend the use of sidnofarm to patients with stage II arterial hypertension, even in the absence of clinical manifestations of stable coronary artery disease.

Features of circadian regulation and cardiac rhythm disorders in patients with arterial hypertension and frequent recurrences of atrial fibrillation

The aim — to determine the features of circadian regulation and cardiac rhythm disorders according to Holter monitoring of electrocardiogram (HM ECG) in patients with arterial hypertension (AH) and frequent recurrences of atrial fibrillation (AF), depended on the clinical form and vegetative variant of arrhythmia.Materials and methods. There were examined 146 patients aged from 37 to 86 years with AH stage II complicated by frequent recurrences of AF. As a comparison group, 26 patients were examined aged 39 to 74 years with AH II stage without AF, that was ruled out with anamnesis data and HM ECG. The duration of the arrhythmic anamnesis ranged from 1 to 30 and mean duration was 5.7 ± 0.5 years. Paroxysmal form of AF was in 56 (38.4 %) patients and persistent form of AF was in 90 (61.6 %) patients. The anamnesis of AH ranged from 1 to 40 and mean duration was 11.6 ± 0.6 years. All patients underwent HM ECG according to the standard protocol.Results and discussion. In groups with AH and AF in contrast to group without AH, the total number of supraventricular premature contractions (SPC) per day was higher (p < 0.0001). In the groups with AH and AF there was the prevalence of the pair and group of SPC (p < 0.0001). Short asymptomatic episodes of supraventricular paroxysmal tachycardia (SVPT) were defined in 35.7 % of patients with paroxysmal and in 33.3 % of patients with persistent AF. SVPT wasn’t defined in group with AH (p < 0.001). The analysis of painless myocardium ischemia cases demonstrated statistically significant differences in such cases registration in patients with persistent AF comparing with patients without AF (38.9 and 19.2 % respectively; p = 0.05). The dispersion of the interval QT was significantly higher in the groups of patients with AF in comparison with group without AH (p < 0.05). The ratio of the dispersion PQ/QT was lower in groups of AH and AF compared with the group of AH (p < 0.05).The daily heart rate (p < 0.04) and the circadian index (CI) (p = 0.02) are significantly lower and the mean daily number of asymptomatic SVTS episodes is significantly higher (p < 0.04) in patients with vagal variant of AF. In patients with mixed variant of AF the value of CI (p < 0.05), the daily amount of SPC (p < 0.04) and the number of episodes of paired and group SPC (p < 0.04) are significantly higher.Conclusions. In groups of AH and AF in comparison with group owithout AH, the number of SPC, paired and group SPC, SVPT were higher, increasing of the dispersion of QT and dispersion ratio PQ/QT was observed. The study did not reveal any fundamental differences between clinical forms of AF. The heart rate and CI are significantly lower and the number of asymptomatic episodes of the SVTS is significantly higher in patient with vagal variant of AF. The CI value, daily amount of SPC and episodes of paired and group SPC were significantly higher in patients with mixed variant of AF.

The clinico-functional heterogeneity of changes in the coronary and cerebral blood circulation with the arterial hypertonia of the I stage

Purpose of this investigation: to determine the early signs of the typological disturbances of coronary and cerebral blood circulation with the arterial hypertonia of the I stage. Materials and the methods. Is carried out a study of cardio-cerebrovascular system in 147 men in the age of 30-59 years with the arterial hypertonia of the I stage, control group they composed 37 clinically healthy men at the age from 29 to 42 years. Results and their consideration. Substantial changes in the coronary and cerebral blood flow with the I stage of arterial hypertonia to the development of the clinical manifestations of the defeat of the vessels of heart and brain are revealed. Is carried out daily monitoring arterial pressure and electrocardiogram, rhythmocardiography, bicycle ergometry, echocardiography, transcranial dopplerography, ultrasonic diagnostics of the main arteries of head and neck. Statistical processing of the results of a study is carried out by the standard methods within the framework of software Statistica for Windows, version 6 and recommended in the management on the biomedical statistics. Obtained by us data give grounds for expanding the criteria, which characterize the defeat of the target organs at the early stage arterial hypertonia. To these criteria we carried the clinical signs of the initial manifestations of the insufficiency of the blood supply of brain and discirculatory encephalopathy of the I stage, and also painless ischemia of the myocardium in the absence of stenocardia and its equivalents, presence of the minimum signs of the disturbance extra and intracranial blood flow (high-speed indices and the asymmetry of blood flow, the index of cerebrovascular reactivity and the presence of microembolic signals). Conclusions. The clinico-functional heterogeneity of changes in the coronary and cerebral blood circulation with the arterial hypertonia of the I stage requires the revision of the standards of the inspection of patients with the development of the increased numbers of arterial pressure, and also start of the new criteria of the early defeat of heart and brain in clinical recommendations.

Comparative analysis of clinical, electrocardiographic, angiographic and echocardiographic data of indigenous and non-indigenous residents of Yakutia with coronary artery atherosclerosis

AimThe aim of the study is to compare clinical, angiographic, electrocardiographic, echocardiographic data between indigenous and non-indigenous residents of Yakutia.Study designWe performed cross-sectional analysis of the Registry of Selective Coronary Angiography (SCAG) of the Yakutsk Republican Hospital for the period from 2004 to 2007. All patients (n=1,233) were admitted to hospital from all 35 regions of the Sakha Republic (Yakutia). Initially, 12 (1%) patients, who had abnormal coronary arteries and 259 (21%) patients with normal coronary arteries were excluded from this study. From the remaining 962 (78%) patients with detected coronary artery atherosclerosis 394 (41%) patients were excluded for having congenital heart malformations due to possible influence on the outcomes of examination for myocardial hypertrophy. Finally, only 568 patients were selected for further examinations.MethodsWe analyzed clinical data, and the findings of selective angiography, multi-detector computed tomography (CT), electrocardiography (ECG), 24-hour Holter ECG monitoring and echocardiography.Results(a) In the Sakha Republic (Yakutia) single-vessel coronary disease, coronary stenosis with 50–75% and 75–90% of constriction were detected more often among indigenous males, while multiple-vessel coronary stenosis was detected more often among non-indigenous males as well as stenosis with more than 90% of constriction. Lower calcium score mean (349.1±129.8 vs. 621.8±115.2) was observed among indigenous patients compared to non-indigenous patients; (b) Painless myocardial infarction, painless ischaemia, arterial hypertension and atrial fibrillation were detected more often among indigenous male compared to non-indigenous participants; (c) Based on the results of ECG and echocardiographic examinations, left ventricular (LV) hypertrophy, particular eccentric type of hypertrophy, was found more commonly among indigenous than non-indigenous males; and (d) By laboratory findings, indigenous males had significantly lower triglyceride levels, while platelet counts were higher compared to non-indigenous patients. Obesity was observed less frequently among indigenous men compared to non-indigenous men.ConclusionThe differences observed in this study are disputable and call for further studies. Collection of reliable data for women should be the aim of future studies.

Effectiveness of the fixed-dose combination therapy with perindopril and amlodipine in coronary heart disease patients after coronary artery bypass graft surgery

Aim.To study the effectiveness of the fixed-dose combination therapy with perindopril and amlodipine (Prestance 5/5 mg/d) in coronary heart disease (CHD) patients after coronary artery bypass graft (CABG) surgery.Material and methods.The clinical trial included 65 patients (37 men, 28 women aged 45-68 years; mean age 56,3±3,5 years) after CABG. All patients were randomised into two groups: the control group (CG; n=35) and the main group (MG; n=30). Both groups received antiplatelet agents and statins, while the MG patients additionally received Prestance (5/5 mg/d). Prestance therapy started three-four weeks after CABG and lasted for four months. All participants underwent 24-hour monitoring of ECG and blood pressure (BP), Doppler echocardiography, and Doppler ultrasound of brachial and common carotid arteries.Results.Compared to the CG, the MG demonstrated decreased incidence of pain and painless ischemia episodes, reduced maximal ST segment depression and its total duration, and increased rate threshold of myocardial ischemia. In addition, Prestance therapy was associated with improved systolic and diastolic heart function and significantly improved endothelium-dependent vasodilatation. In patients with normal BP, Prestance (5/5 mg/d) did not cause hypotension, but reduced excessive BP variability. In the MG, acute coronary syndrome (ACS) was registered in 1 individual (3,3 %), while in the CG, it was registered in 4 patients (11.4 %), and in 3 cases, coronary artery stenting was performed.Conclusion.In patients with normal BP, Prestance (5/5 mg/d) therapy in the early post-CABG period had a pronounced anti-ischemic, cardio- and vasoprotective effects, and also prevented excessive BP variability.

No Pain, No Gain

Myocardial ischemia, the major cause of mortality and morbidity in the United States, accounts for nearly 20% of all deaths.1 The prognosis of patients with acute myocardial infarction is strongly related to the amount of tissue destroyed during ischemia/reperfusion; hence, limiting this injury is of paramount importance for reducing the morbidity and mortality associated with ischemic heart disease.2,3 Over the past 40 years, several hundred pharmacological or nonpharmacological therapies have been reported to alleviate ischemia/reperfusion injury in experimental animal models; unfortunately, few of these results have been reproducible, and, with the exception of early reperfusion, none have been translated into clinical therapies.4 These sobering facts provide a cogent rationale for a reassessment of the models and methodologies that have been used heretofore to test the efficacy of putative cardioprotective interventions. The obvious translational failure in this field calls for a new paradigm in which preclinical studies must be done as rigorously as their clinical counterparts, that is, using clinically relevant animal models, appropriate statistical methods, and a multicenter, randomized, blinded design using centralized core laboratories for data analysis.4 This paradigm would also improve our understanding of the mechanism of cardiomyocyte death during ischemia/reperfusion. Article p 3617 One facet of ischemic biology that has received relatively little attention is the role of cardiac sensory nerves. Myocardial ischemia/reperfusion is known to cause the release of bradykinin and protons, both of which activate the vanilloid receptor 1 (VR1, also known as transient receptor potential vanilloid type 1 [TRPV1]) on the capsaicin-sensitive cardiac sensory nerves (unmyelinated [type C] or thinly myelinated [A-δ] fibers).5 The VR1 is a nonselective cation channel that plays an important role in the polymodal detection of noxious stimuli such as low pH and heat.6 It can also be activated by chemicals such as capsaicin …

Clinical Features, Triage, and Outcome of Patients Presenting to the ED With Suspected Acute Coronary Syndromes But Without Pain: A Multicenter Study

We studied the impact on triage and outcome of patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome (ACS) but without a complaint of pain. Data from a prospective clinical trial of patients with symptoms suggesting an ACS in the EDs of 10 US hospitals comparing patient demographics, clinical variables, and outcomes was used to perform a secondary analysis. Of 10,783 subjects, a final diagnosis of an ACS was confirmed in 24% of which 35% had acute myocardial infarction (AMI) and 65% unstable angina pectoris (UAP). Pain was absent in 6.2% of patients with acute ischemia and in 9.8% of those with AMI. Compared to similar patients who presented with pain, patients with painless ischemia were older, were more commonly women, had more cardiac and related diseases. Among patients with AMI, fewer patients without pain were admitted to critical care units compared to similar patients with pain. Among patients with AMI, logistic regression predicting lack of pain identified age, heart failure and diabetes, with only age and heart failure among all with ACS. After controlling for clinical features, lack of pain during acute ischemia predicted increased hospital mortality. We concluded that age and heart failure are independently associated with painless ACS, in addition to diabetes among those with AMI. Lack of pain predicts increased hospital mortality in patients with ACI through mechanisms that remain to be elucidated. There is a need for greater awareness in the general public of the different manifestations of ACS to enhance the recognition of and prompt response to their symptoms.

Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: A multicenter study

We studied the impact on triage and outcome of patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndromes (ACS) but without a complaint of pain. Data from a prospective clinical trial of patients with symptoms suggesting an ACS in the EDs of 10 US hospitals comparing patient demographics, clinical variables, and outcomes was used to perform a secondary analysis. Of 10,783 subjects, a final diagnosis of an ACS was confirmed in 24% of which 35% had acute myocardial infarction (AMI) and 65% unstable angina pectoris (UAP). Pain was absent in 6.2% of patients with acute ischemia and in 9.8% of those with AMI. Compared to similar patients who presented with pain, patients with painless ischemia were older, were more commonly women, had more cardiac and related diseases. Among patients with AMI, fewer patients without pain were admitted to critical care units compared to similar patients with pain. Among patients with AMI, logistic regression predicting lack of pain identified age, heart failure and diabetes, with only age and heart failure among all with ACS. After controlling for clinical features, lack of pain during acute ischemia predicted increased hospital mortality. We concluded that age and heart failure are independently associated with painless ACS, in addition to diabetes among those with AMI. Lack of pain predicts increased hospital mortality in patients with ACI through mechanisms that remain to be elucidated. There is a need for greater awareness in the general public of the different manifestations of ACS to enhance the recognition and prompt response to their symptoms. mortality

Severity of exercise-induced ischemia with chest pain and recovery from ischemia after the disappearance of chest pain.

The severity of exercise-induced painful ischemia and its recovery after the disappearance of pain are unknown. The aim of this study was to investigate the difference in severity of ischemia at both exercise and postexercise between painful ischemia and painless ischemia. After injections of technetium-99m tetrofosmin at peak ergometer exercise and thallium-201 at 3 minutes postexercise, dual-isotope single photon emission tomography was performed in 78 patients with angiographically proven ischemic heart disease. The extent of ischemic areas (the number of areas), the depth of ischemia in the ischemic area (the severity score of ischemia) and the extension of ischemia toward long axis of the left ventricle (the number of left ventricular levels with ischemic areas in apical, middle, and basal levels) at both exercise and postexercise were compared on the basis of the presence of pain and a history of diabetes mellitus (DM). The symptoms improved within 3 minutes postexercise in all painful ischemia patients. Of 59 patients with reversible ischemia, except for 4 painful ischemia patients with DM, the extent and depth of ischemia at postexercise were more severe in 14 painful ischemia patients without DM and 13 painless ischemia patients with DM than 28 painless ischemia patients without DM (extent; 2.9 +/- 1.7 areas, 3.5 +/- 2.8 areas versus 1.4 +/- 1.8 areas, P = 0.005, depth; 3.8 +/- 3.1 scores, 5.8 +/- 5.4 scores versus 1.9 +/- 3.0 scores, P = 0.0084, respectively) despite a comparable severity of ischemia at peak exercise (extent; 5.4 +/- 2.6 areas, 6.0 +/- 2.4 areas versus 4.3 +/- 3.3 areas, depth; 9.3 +/- 5.7 scores, 10.7 +/- 7.3 scores and 7.5 +/- 8.1 scores, all NS). The extension of ischemia toward long-axis of the left ventricle at both peak exercise and postexercise was more severe in the former 2 groups than the latter group (peak exercise; 2.4 +/- 0.6 levels, 2.5 +/- 0.7 levels versus 1.9 +/- 0.8 levels, P = 0.0263, postexercise: 1.8 +/- 0.7 levels, 1.5 +/- 0.9 levels versus 0.8 +/- 0.8 levels, P = 0.0014, respectively). The presence of chest pain is related to the extension of ischemia toward long-axis of the left ventricle, and the disappearance of pain was not related to the recovery of ischemia.

Silent Myocardial Ischemia

Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. Since its original description in the 1970s, it has undergone intensive investigation, and its clinical significance is now well established. This review will serve as an update on the pathophysiology, detection, prevalence, prognosis, and treatment of silent ischemia in both asymptomatic patients and those with angina, whether stable or unstable. ### Pain Studies No discussion of silent ischemia is complete without consideration of the cardiac pain mechanism. Although much has been learned about this subject, much is still uncertain. The afferent fibers that run in the cardiac sympathetic nerves are usually thought of as the essential pathway for the transmission of cardiac pain (Figure 1). The atria and ventricles are abundantly supplied with sympathetic sensory innervation; from the heart, the sensory nerve endings connect to afferent fibers in cardiac nerve bundles, which in turn connect to the upper 5 thoracic sympathetic ganglia and the upper 5 thoracic dorsal roots of the spinal cord. Within the spinal cord, impulses mediated by this sympathetic afferent route probably converge with impulses from somatic thoracic structures onto the same ascending spinal neurons. This would be the basis for cardiac pain referred to the chest, wall, arm, back etc. In addition to this “convergence-projection theory,” the contribution of vagal afferent fibers must be acknowledged for an explanation of cardiac pain referred to the jaw and neck. How these vagal fibers are activated remains unclear. Furthermore, somatic localization of ischemic pain cannot predict the site of myocardial ischemia (anterior, inferior, or lateral) from one patient to the next. Figure 1. Mechanisms of cardiac pain. From Droste and Roskamm (used with permission).4 The actual “trigger” that stimulates the sensory nerve endings remains elusive. If a chemical pain stimulus is involved, …