Permanent Form Of Atrial Fibrillation Research Articles

ОСОБЕННОСТИ ДИАГНОСТИКИ И ВЕДЕНИЯ ПАЦИЕНТКИ С СИНДРОМОМ ФРЕДЕРИКА (КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ)

Description of a clinical case. The article presents a clinical observation of a 77-year-old patient with newly diag-nosed Frederick’s syndrome, which is a combination of a permanent form of atrial fibrillation and complete atrioven-tricular block. An exacerbation of chronic pancreatitis was the reason for hospitalization of the patient. The patient had no complaints of bradycardia or syncope, but treatment of the underlying disease was difficult due to the development of acute kidney injury against the background of chronic kidney disease and uncompensated chronic heart failure. The cause of the development of Frederick’s syndrome was pronounced myocardium remodeling due to diseases that make up the classic complex of metabolic syndrome – coronary heart disease, arterial hypertension, type 2 dia-betes mellitus and obesity. Conclusion. The analysis of a few domestic and foreign literature sources showed that the development of Frederick’s syndrome is associated with a worsening prognosis and the development of various complications, which is usually underestimated by attending physicians. Taking into account the difficulties of diagnosis and management of patients with this pathology, it is necessary to be wary of the development of Frederick’s syndrome, especially in comorbid elderly and senile patients. Timely medical correction and referral of the patient for surgical treatment will improve the prognosis and reduce mortality in patients with atrial fibrillation.

Atrial fibrillation and obstructive sleep apnea syndrome: results of a retrospective study

Objective – to study the incidence and risk factors of atrial fibrillation (AF) in patients with obstructive sleep apnea syndrome (OSA), verified according to screening respiratory monitoring during sleep, performed during hospitalization in a therapeutic hospital. Design and methods. The study performed a retrospective analysis of 291 case histories of patients hospitalized in a therapeutic clinic in 2021-2022. All patients underwent overnight respiratory monitoring as part of the initial screening examination for sleep-disordered breathing. Results. Obstructive sleep apnea syndrome was identified in 216 patients, mild severity – in 27,8%, moderate severity – in 20,3%, severe severity – in 26,1% of patients. The incidence of atrial fibrillation in patients with diagnosed OSA was 28,7% and was significantly higher in patients with severe apnea compared to patients with mild apnea (p=0,043). According to the results of the analysis of the reasons underlying the development of AF in patients with verified apnea, arterial hypertension was identified in 96,8% of patients, chronic heart failure in 72,6%, coronary heart disease in 51,6%, thyrotoxicosis in 6,5%, sick sinus syndrome in 4,8% of patients, 19,4% of patients without structural heart damage. In severe apnea, the permanent form of AF was more common (p=0,008), and in mild OSA, paroxysmal AF was more common (p=0,024). It was found that the volumes of the left and right atria in patients with AF and severe OSA are greater than in patients with mild apnea. Conclusion. AF in OSA often occurs in patients without organic heart disease. The most common risk factors for AF in patients with OSA were arterial hypertension, found in 96,8% of subjects, as well as obesity (in 74,2%). The incidence of AF in patients with severe apnea is higher than in patients with mild apnea. The permanent form of AF is detected more often, and atrial volumes are larger in patients with severe OSA compared to patients with mild sleep-disordered breathing.

The 4q25/PITX2 SNP rs6817105 and Atrial Fibrillation in Uzbek Patients with Arterial Hypertension

Background: Atrial fibrillation (AF) is one of the most common cardiac arrhythmias and a major predictor of morbidity and mortality. In recent years, genome-wide association studies (GWAS) have identified common genetic variants associated with a higher risk of AF. The aim of our research was to study the possible association of the 4q25/PITX2 SNP rs6817105 with the risk of developing AF in patients with arterial hypertension (AH) in the Uzbek population. Methods and Results: The study included 142 AH (Grades 1-3; ESC/ESH, 2018) patients of Uzbek nationality who were initially diagnosed with paroxysmal form (15[10.6%]), persistent form (43[30.3%]), and permanent form of AF (84[59.1%]). The mean age of these patients was 64.8±10.9 years. AF was verified using ECG Holter monitoring. The control group (n=88) consisted of AH patients without AF with a mean age of 56.5±12.3 years. Echocardiography was carried out according to the recommendations of the American Society of Echocardiography in M- and B-modes. We genotyped SNP rs6817105 (T>C) and examined the relationships among rs6817105 genotype, clinical characteristics, and echocardiographic parameters in AH patients with AF and non-AF AH patients (controls). The rs6817105 minor C allele frequency was significantly higher in AH patients with AF than in non-AF AH patients (71.8% vs. 59.7%, P=0.007). Analysis of the multiplicative model for the rs6817105 SNP showed a significant risk of AF in the carriage of the C allele (OR=1.72, 95% CI: 1.16-2.56, P=0.007). The dominant and additive models for the rs6817105 SNP showed a significant risk of AF with the carriage of the CC+CT genotypes (OR=3.16, 95% CI: 1.37-7.27, P=0.005) and the homozygous CC genotype (OR=1.63, 95% CI: 0.95-2.81, P=0.008), respectively. The allelic distribution showed that the carriage of the C allele was dominant in permanent and persistent AF (110/68.75% vs. 50/31.25% for the T allele [(χ2=22.50, P=0.000], and 73.61% (64/74.41%) vs. 26.39% (22/25.58%) for the T allele [χ2=20.512, P=0.000], respectively). Among AH patients with paroxysmal AF, the C allele prevailed to the greatest extent: 20(90.9%) vs. 2(9.1%) for the T allele (χ2=14.727, P=0.000), indicating a significant accumulation of the C allele and CC genotype among patients with paroxysmal AF. In general, in AH patients with AF, carriers of the CC genotype, the left atrial volume index (LAVI) was significantly higher than the carriers of the CT and TT genotypes: 46.8±13.9 ml/m2 vs. 40.4±13.0 ml/m2 and 36.1±11.0 ml/m2, respectively (P=0.0083). Conclusion: Our results indicate the rs6817105 minor C allele and CC genotype are associated with the risk of developing AF in AH patients of Uzbek nationality. The highest accumulation of the rs6817105 minor C allele and CC genotype is found in paroxysmal AF. In carriers of the rs6817105 CC genotype, the LAVI was significantly larger than in carriers of the CT and TT genotypes.

Surgical Reconstruction of Mitral-Tricuspid Insufficiency Combined with Biatriomegaly in Marfan Syndrome

The aim. To analyze the results of introduction of complex reconstruction of the left and right parts of the heart in Marfan syndrome combined with mitral-tricuspid insufficiency, biatriomegaly and left ventriculomegaly.
 Materials and methods. As an example of this pathology, we present our observation. Female patient T., 24 years old, was examined and treated from 7/27/2022 to 8/17/2022 at the Department of Surgical Treatment of Acquired Heart Diseases of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine with a diagnosis: Marfan syndrome. Stage IV mitral-tricuspid insufficiency. Biatriomegaly. High pulmonary hypertension. Permanent form of atrial fibrillation (for 10 years, since 2011). IIB heart failure with left ventriculomegaly with reduced left ventricular ejection fraction. NYHA functional class IV+. The patient underwent surgery in the following volume: mitral valve replacement with full preservation of the valve apparatus + tricuspid valve plasty with the imposition of a support ring + triangular plasty of the left atrium with its partial resection + resection of the right atrium.
 Results. Within 4 months after surgery, echocardiographic parameters showed significant decrease in the volume of the left ventricle, the diameters of both atria. In addition, there was a significant decrease in the level of N-terminal pro-brain natriuretic peptide and manifestations of heart failure.
 Conclusion. Taking into account the initial serious condition of the patient with Marfan syndrome and advanced mitral-tricuspid heart disease, left ventriculomegaly with a reduced left ventricular ejection fraction, biatriomegaly (left atrium 7.2 cm, right atrium 6.5 cm), permanent form of atrial fibrillation, complex reconstruction of the left and right parts of the heart leads to an improvement in the functional state of the myocardium.

Mid-term follow-up of atrioventricular node ablation and conduction system pacing without a ventricular backup lead in atrial fibrillation-induced tachycardiomyopathy - a single-center experience

Abstract Funding Acknowledgements Type of funding sources: None. In the permanent form of atrial fibrillation (AF), ablation is not recommended or has failed and the only option is rate control. The most effective rate control strategy is atrioventricular node (AVN) ablation, but this renders the patient pacing-dependent. Several observational studies have shown that both His bundle pacing (HBP) and left bundle branch area pacing (LBBAP), provide a narrower QRS complex and a more synchronous ventricular activation compared to right ventricular pacing. Current guidelines recommend placing a ventricular backup lead as a safety measure. We present our mid-term follow-up data on the feasibility of AVN ablation and physiological pacing without a ventricular backup lead in patients with tachycardiomyopathy due to rapidly conducted permanent AF. MATERIAL AND METHODS A total of 25 patients with permanent AF and HF and rate control failure with AVN-blocking drugs, that underwent physiological pacing and AVN ablation at our institution, were included in this retrospective review. During the procedure, HBP was the first option, followed by LBBAP if the His bundle was not captured at a threshold below 2.5V at 1 ms. The lead was connected to a single chamber pacemaker, without a backup pacing lead. In the same setting, using a femoral vein approach, a 4-mm tip ablation catheter was used to perform AVN ablation. Patient and procedural characteristics were recorded as well as the electrical parameters and complications at the follow-up visits. Results The mean age of the patients was 69 ± 12.4 years and 64% were males. The heart rate was 133±20.43 bpm and the ejection fraction was 28.84±9.02 %. 17 patients had normal QRS complex, 3 had right bundle branch block and 5 had left bundle branch block patterns. HBP was successful in 9 patients (36%) and LBBAP in 16 patients (64%). In patients with a baseline-wide QRS, physiological pacing significantly reduced the QRS duration (135.25±17.58 vs. 159±32.38 ms, p=0.04). The paced QRS complex was significantly narrower in HBP than LBBAP (95.67±14.37 vs. 129.88±17.46 ms, p<0.001). There was a significantly lower pacing threshold for LBBAP (0.77±0.3 V at 1 ms vs. 0.87±0.72 V at 0.4 ms, p<0.05) and better sensitivity for LBBAP (6.23±4.56 mV vs. 10.2±5.19 mV, p=0.66). The fluoroscopy time was non-statistically different between HBP and LBBAP (13.21±15.47 min vs. 18.72±12.95 min, p=0.35). AV node ablation was successful in all patients. The mean follow-up period was 524±110.2 days. 11 patients became pacemaker-dependent. There was no significant difference in pacing thresholds for both LBBAP (0.67±0.27 V at 0.4 ms, p=0.24) and HBP (0.87±0.56 V at 1 ms, p=0.485) patients and there was no recurrence in AV node conduction. No lead dislodgements were recorded. Conclusions AVN ablation and physiological pacing is feasible and safe without the need for a backup ventricular pacing lead, thus minimizing the risks and costs associated with a higher lead burden.

Surgical Reconstruction of Mitral Restenosis Complicated by a Critically Small Left Ventricular Cavity and Giant Left and Right Atriomegaly (Clinical Case)

Background. Comprehensive reconstruction of the left and right parts of the heart in giant left atriomegaly, adequate tactics of mitral valve replacement in case of concomitant tricuspid insufficiency and dilation of the right atrium lead to an improvement in the functional state of the myocardium as early as at the hospital stage.
 Case description. Patient B., a 67-year-old woman, was examined and treated from July 12 to August 2, 2016 at the Department of Surgical Treatment of Acquired Heart Diseases of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine with a diagnosis: stage IV mitral restenosis, condition after closed mitral commissurotomy in 2001, critically small cavity of the left ventricle, giant left atriomegaly, IV degree tricuspid insufficiency, right atriomegaly, high pulmonary hypertension, permanent form of atrial fibrillation for 15 years since 2001, NYHA class IV heart failure, IIB.
 The patient underwent surgical intervention: mitral valve replacement + W-shaped plastic surgery of the left atrium in combination with dosed resection of left atrium + tricuspid valve plasty with the imposition of a support ring + resection of the right atrium.
 Conclusion. Given the initial serious condition of the patient with advanced mitral restenosis, critically small left ventricular cavity, giant left atriomegaly of 169.4 × 115.8 mm (according to computed tomography) and high pulmonary hypertension (65 mm Hg), concomitant pathology of the right parts of the heart (tricuspid insufficiency and right atriomegaly), adequate tactics in mitral valve replacement and radical correction of the left atriomegaly lead to an improvement in the functional state of the heart as early as at the hospital stage.

Features of post-infarction chronic heart failure in patients with a new coronavirus infection COVID-19

Background. The coronavirus pandemic has caused a rapid increase in the number of cases and high deaths worldwide. A new coronavirus infection in the presence of an initial cardiac pathology can provoke decompensation of chronic heart failure.
 Aim. To study the clinical features of postinfarction chronic heart failure occurring against the background of a new coronavirus infection.
 Material and methods. The study included 80 patients with decompensated chronic heart failure. Three groups have been formed. In patients of the first group (n=40), who underwent inpatient treatment for a new coronavirus infection, the cause of chronic heart failure was a previous Q-myocardial infarction. In patients of the second group (n=20), who did not tolerate COVID-19 earlier and at the time of the current hospitalization, the cause of chronic heart failure was a previous Q-myocardial infarction. The third group (n=20) consisted of patients with chronic heart failure of ischemic etiology without postinfarction cardiosclerosis, not previously and at the time of examination infected with the SARS-Cov-2 virus. Statistical analysis was carried out using the IBM SPSS Statistics V26 program. The KolmogorovSmirnov, KruskalWallis, and Pearson 2 tests were used.
 Results. Symptoms of left and right ventricular heart failure were equally common in all groups. Patients of the studied groups had a history of paroxysmal and permanent forms of atrial fibrillation, while the latter variant was more common in patients of the first group with chronic heart failure with postinfarction cardiosclerosis and coronavirus infection. According to echocardiography, the most pronounced structural and functional changes in the myocardium were also found in patients of the first group with postinfarction heart failure and a new coronavirus infection. Thus, statistically significant differences related to the size of the left atrium, end diastolic volume and end systolic volume of the left ventricle, systolic pressure in the pulmonary artery. An increase in the end systolic volume of the left ventricle by 94.6% was registered in the first group compared with the third group of patients (p=0.001). Systolic pressure in the pulmonary artery in the first group was 14.2% higher than the normal values (p 0.001), while in patients of the second and third groups this indicator was within the normal range.
 Conclusion. In patients with postinfarction cardiosclerosis suffering from a new coronavirus infection, symptoms of chronic heart failure are more pronounced, characterized by a significant decrease in exercise tolerance; cardiac arrhythmias are more often recorded, and structural and functional changes in the myocardium are of a maladaptive nature.

Assessment of adherence to therapy in comorbid patients

Objective. To evaluate adherence to therapy in patients with hypertension (HTN) and atrial fibrillation (AF) in combination with extracardiac comorbid pathology. Design and methods. In an observational cohort study, 884 patients aged 45–65 years with AF (paroxysmal and persistent form) and HTN were observed, in combination with extracardiac comorbid diseases: diabetes mellitus (DM), n = 123; abdominal obesity (AO), n = 171; chronic obstructive pulmonary disease (COPD), n = 137, hypothyroidism, n = 156; thyrotoxicosis, n = 112. The comparison group consisted of 185 patients with AF and HTN, without concomitant extracardiac pathology. Clinical, anthropometric parameters, the Morischi–Green adherence test were evaluated in the work. To assess the social aspects of low adherence, special questionnaires were developed. All statistical calculations were performed using the Rstudio program. Results. Among patients with AF and HTN, 66 % had concomitant extracardiac comorbid pathology, 20 % of them with DM; COPD was detected in 22 % of patients, and AO was observed in 44 % of patients, 6 % patients had thyroid disease. 15,2 % patients were insufficiently adherent (ADH), 37,2 % were not adherent to therapy (NADH), and only 47,8 % respondents were adherent to therapy. The duration of HTN was not a significant motivation for adherence, because the NADH group had a significantly longer duration of arterial hypertension compared with the ADH group (12.3 vs 10.5 years; p < 0.03); patients with the permanent form of AF were more than ADH (p = 0,001), and the adherence did not differ between groups depending on extracardiac diseases. The blockers of the renin-angiotensin-aldosterone system showed the greatest use — up to 66 %, while adherent patients were more likely to take single-pill combination (SPC) of perindopril (SPC indapamide/perindopril and SPC amlodipine/indapamide/perindopril) (p = 0,003; p = 0,01). Based on the analysis, it was found that the presence of a family, higher education, income level, motivation and trust in doctors are significant factors that increase adherence to treatment. Conclusions. The problem of non-commitment has been and remains one of the most complex and difficult to solve. The main reason for low adherence among patients with AF with concomitant extracardiac diseases was polypharmacy, and it is associated with the use of a large number of drugs and a complex treatment regimen. Thus, the limitation of the use of fixed combinations is one of the main reasons for the lack of adherence and needs to be addressed soon.

PECULIARITIES OF STRUCTURAL CHANGES IN THE BRAIN SUBSTANCE IN PATIENTS WITH ARRHYTHMIAS DEPENDING ON THE SEVERITY OF COGNITIVE DISORDERS.

The aim: To evaluate the structural changes of the brain in relation to the formation of cognitive disorders (CD) in patients with arrhythmias. Materials and methods: 147 patients with different clinical forms arrhythmias against the background of ischemic heart disease were examine. At the first stage, all patients with arrhythmias assessed cognitive functions. At the second stage, patients were distributed divided into two groups: the main group patients with CD, control - patients without CD. These groups underwent computed tomography examination of the brain. Results: CD were established in 83% patients with arrhythmias. Mild CD were more often diagnosed in patients with persistent form of atrial fibrillation (AF), severe CD - in patients with permanent form of AF and atrioventricular blockade ІI-III degrees. Neuroimaging changes were found in 73.8% patients with CD and in 36% patients without CD. They were manifested by atrophic changes of the cortex, internal hydrocephalus, a decrease in the density of the brain sub¬stance of the periventricular area. In patients with CD, compared to patients without CD, showed lacunar foci with predominant localization in the parietal and frontal lobes of the brain, periventricular and subcortical leukoaraiosis. Multiple correlations were established between CD and structural changes of the brain. Conclusions: The increase in the severity of CD in patients with arrhythmias is associated with atrophic changes at the cortical-subcortical level, accompanied by the phenomena of internal hydrocephalus, periventricular and subcortical LA, lacunar foci, with a predominant localization in the frontal-temporal-occipital lobes, in the visual hump and basal ganglia of both cerebral hemispheres.

Thrombodynamics Test in Assessing the Risk of Thrombus Formation in Patients with Atrial Fibrillation Taking Direct Oral Anticoagulants

Aim. To evaluate thrombus characteristics in patients with atrial fibrillation (AF) taking different direct oral anticoagulants (DOACs) using Thrombodynamics test.Materials and methods. Thrombodynamics test was performed in 100 patients with paroxysmal and permanent forms of AF taking different DOACs, dose choice was done in accordance with the instructions for drugs use. For analysis samples of fresh citrated platelet-free plasma were taken just before regular DOACs dose intake (trough concentration). Statistical data processing was carried out using R software packages.Results. All patients had no history of thrombosis or bleeding before inclusion in this study. All parameters of Thrombodynamics test taken at residual concentration of DOACs were in general within reference values, that is in the area of normal coagulation: spatial clot growth rate (V) – 26.56 (25.0; 29.2) μm/min, the time to the start of clot growth (Tlag) – 1.05 (0.85; 1.27) min, initial spatial clot growth rate (Vi) – 44.3±7.7 μm/min, stationary spatial clot growth rate (Vst) – 26.5 (24.9; 28.4) μm/min, clot size (CS) – 999.7 (912.9; 1084.7) μm, clot density (D) – 22883.1±3199.9 arb. units. D was appeared to be higher in women [22947.7 (21477.5; 22947.7) vs men [22124.8 (19722.8; 22124.8), p=0.035] and Tlag was significantly higher in patients with chronic heart failure [1.2 (1.0; 1.2) vs 1.0 (0.8; 1.0), p=0.008]. A correlation was found between level of creatinine and Tlag parameter, glomerular filtration rate (GFR) and clot density. With an increase in the level of creatinine in the blood and a decrease in GFR, respectively, there was an increase in Tlag parameter (p-value 0.038); with an increase in GFR, clot density decrease (p-value 0.005).Conclusion. All parameters of Thrombodynamics test on residual concentration of DOACs were within reference values that indicated optimal anticoagulant effect of all DOACs. The obtained data of normal coagulation at the residual concentration of the anticoagulant are consistent with the previously obtained data on the safety and effectiveness of DOACs using other methods. Further studies with clinical end points are needed to assess the clinical value of this method.

Risk Factors for the Development of Atrial Fibrillation in the Kazakh Patients

BACKGROUND: Atrial fibrillation (AF) is the most common persistent heart rhythm disorder. AIM: Assessment of clinical predictors of atrial fibrillation in the Kazakh population. METHODS: An analytical clinical and epidemiological study of 75 patients with AF of Kazakh nationality. Descriptive analysis of medical records was carried out and the results of laboratory and instrumental research methods. Statistical analysis was carried out using the Statistica 6.0 Software package from StatSoft Inc. (USA) and MS Excel. RESULTS: In the majority of the studied patients (86.7%), atrial fibrillation was associated with hypertension, in 49.3% of patients was diagnosed with coronary artery disease. A permanent form of atrial fibrillation was observed in 63%, in 20% AF manifested itself in the form of paroxysms, in 17% AF was persistent. AF, which arose against the background of CHF, was established in 41.3% of the patients studied by us, while a decrease in LVEF below 40% was observed in 21.3% of the examined patients. In our study, diabetes mellitus was diagnosed as a comorbid pathology in 24% of patients and diabetes mellitus correlated with permanent AF in 66.7%. Thyroid pathology was observed in 9.3% cases. CRHD as a concomitant disease occurred in 12% of cases. In 5.7% of cases, AF was registered as idiopathic (primary) without a history of cardiovascular and concomitant pathology. Smoking as a risk factor was observed in 16%, alcohol consumption, was noted by 8 patients (10.7%). In 40% of cases, patients with AF were obese, 45.3% of the patients were overweight (BMI ≥25).

Predicting development of thromboembolic complications and complications in patients after mitral valve replacement with mechanical prostheses

The aim of the study. To develop a mathematical model for predicting the development of thromboembolic complications and bleeding in patients after mitral valve replacement with mechanical prostheses based on an analysis of a number of risk factors – age, compliance, heart rate at the postoperative stage, prosthesis manufacturer, hemostasis indicators.Materials and methods. There were examined 260 patients. The following risk factors were analyzed: patient compliance (Morisky-Green test), heart rate at the postoperative stage, prosthesis manufacturer (MedInzh, Carbomedics, ATS, On-X), hemostasis indices (international normalized ratio, activated partial thromboplastin time, D-dimer, fibrinogen, soluble fibrin-monomeric complexes).Results of the study and conclusion. The frequency of thromboembolic complications was 5.2 cases, bleeding 4.7 cases per 1000 patient-months. With an increase in the level of soluble fibrin-monomeric complexes by 1 g/L, the risk of thromboembolic complications increases by 1.63 times, the presence of a MedInzh’s prosthesis increases the risk of thromboembolic complications by 2.04 times compared to prostheses of other companies, with paroxysmal or permanent forms of atrial fibrillation the risk thromboembolic complications increase 16.29 times compared with patients with sinus rhythm. In compliant patients, the risk of bleeding is 52.5 (1/0.08) times lower than in non-compliant patients; with an increase in the activated partial thromboplastin time by 1 sec, the risk of bleeding increases by 1.07 times.

Disease-Modifying Therapy of Chronic Heart Failure on the Background of Heart Rhythm and Conductivity Disorders (Clinical Case)

The article presents a clinical case of the development and progression of chronic heart failure (CHF) in a patient with postinfarction cardiosclerosis after implantation of a permanent pacemaker due to binodal dysfunction. The progression of CHF was exacerbated by the patient's transition to a permanent form of atrial fibrillation. Complex therapy for CHF, including cardiac resynchronization therapy, drug therapy with valsartan + sacubitril, empagliflozin, eplerenone, metoprolol succinate (quadrotherapy) led to a complete recovery of the ejection fraction (EF) of the left ventricle. After the patient stopped taking one of the components of quadrotherapy (valsartan + sacubitril), there was a tendency to decrease in EF. The clinical case emphasizes the importance of the timely transformation of traditional permanent pacing into cardiac resynchronization therapy and the appointment of complex modern drug therapy for CHF. When an improvement or restoration of EF is achieved, it is advisable to continue the therapy against which the improvement was obtained in order to avoid the negative consequences that are possible when the components of the quadrotherapy are cancelled.

Diagnosis difficulties in elderly patients with atrial fibrillation and complete atrioventricular block

The association of atrial fibrillation (AF) with complete atrioventricular block (CAVB) is a common clinical feature in elderly patients. It is characterized by the loss of specific symptoms of AF (palpitations, intermissions); in the first place may come CAVB symptoms: dizziness, Morgagni–Adams–Stokes (MAS) attacks. Aim. The article objective is to illustrate the dynamic changes in the course of AF with the development of CAVB on the example of a clinical case and to discuss the difficulties in timely diagnosis and therapy correction. Case presentation. A 75-year-old male was diagnosed with a rapid ventricular response form of AF. The onset of CAVB caused the transition from rapid ventricular response form of AF to slow ventricular response form, which was initially accompanied by a subjective improvement in the patient’s condition. As the disease progressed, the patient’s condition worsened due to the development of MAS attacks. The elderly patients with a permanent form of AF require constant cardiac monitoring by an experienced specialist who has appropriate vigilance in management of patients with arrhythmias, awareness about possible concomitant conduction disorders. This provides comprehensive cardiac support, including timely pacemaker implantation which gives more options for AF symptoms monitoring and heart rate control, has a positive modifying effect on drug therapy. Conclusions. Changes in the clinical picture of AF after development of CAVB can lead to late diagnosis of CAVB, inadequate therapy and untimely pacemaker implantation, as a consequence, to progression of concomitant pathology and the development of life-threatening complications, as in our clinical case.

Comparative efficacy and predictive value of fixed combination of amlodipine and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker in patients with coronary heart disease, post-infarction cardiosclerosis and hypertension

The aim of the work – to analyze the effectiveness of a fixed combination of amlodipine and angiotensin-converting enzyme (ACE) inhibitor (lisinopril) or angiotensin II receptor blocker (valsartan) in patients with coronary heart disease (CHD), post-infarction cardiosclerosis (PIC), arterial hypertension (AH) regarding the blood pressure (BP) control and impact on a composite endpoint. Materials and methods. General clinical examination of 108 patients with PIC and AH was done at the Cardiology Department of Shupyk National Healthcare University of Ukraine within 12 months. Patients were divided into two groups. The first group patients (n = 50) were assigned to receive a fixed combination of valsartan and amlodipine (160 mg and 5 mg, respectively), and the second group patients (n = 58) were treated with a fixed combination of lisinopril and amlodipine (10 mg and 5 mg, respectively). Patients were followed-up for 12 months, including general clinical examination, office BP measurements, 24-hour BP monitoring, echodopplerography, monitoring of the composite endpoint. Exclusion criteria were hemodynamically significant heart valve lesions, permanent or temporary cardiac pacing, acute heart failure and implanted cardioverter-defibrillator, permanent form of atrial fibrillation, acute cerebrovascular disorder, decompensation of severe somatic pathology. Statistical analysis of the data obtained was performed using Microsoft Excel, IBM SPSS Statistics v. 23. Descriptive data were presented as arithmetic mean ± standard deviation (M ± SD) in the case of normal distribution of variables, data with distribution other than normal were presented in Me format (Q25; Q75), where Me was the median, Q25, Q75 – lower and upper quartiles (Q25; Q75), or as a percentage for categorical values with Pearson’s Chi-square (χ2) calculation. Differences in mean values were considered statistically significant at a level of Р < 0.05. Results. According to all statistical criteria, BP indicators did not differ in both patient groups. Systolic office BP in the first group was 133.00 (123.00; 140.25) mm Hg., in the second group – 130.00 (122.00; 140.00) mm Hg. In the first group, diastolic office BP was 81.00 (79.50; 81.00) mm Hg and in the second group – 80.00 (75.00; 86.00) mm Hg. No statistically significant differen­ces were found in the study groups when assessing mean BP levels during the 24-hour monitoring. In the assessment of index values, systolic BP load was higher than normal in 58 % of patients in the first group and in 56.9 % of patients in the second group (χ2 = 0.01; P = 0.53). The assessment of diastolic BP load indices revealed increased diastolic BP index in 72 % of patient in the first group and in 75.9 % – in the second group (χ2 = 0.2; P = 0.4). The number of patients with BP higher or less than 130/80 mm Hg was compared. Systolic BP was above and below 130 mm Hg in 56 % and 44 %, respectively, of the first group patients; the distribution was 37.9 % and 62.1 % in the second group. Therefore, the percentage of patients with target systolic BP was higher in the second group (χ2 = 3.52; P = 0.046). Analyzing the composite endpoint, a statistically significant difference in the Kaplan–Meier curves via the statistical criterion using a log-rank test (P = 0.007) was detected. Conclusions. No statistically significant differences were found in the analysis of office blood pressure and 24-hour blood pressure monitoring between amlodipine with lisinopril and amlodipine with valsartan groups. The detailed analysis revealed a greater percentage of patients with target blood pressure below 130/80 mm Hg among those under 65 years of age receiving amlodipine with lisinopril (χ2 = 3.52; P = 0.046). The better prognostic value of the fixed combination of amlodipine with lisinopril compared to the combination of amlodipine with valsartan (P = 0.007) was demonstrated by the endpoint analysis.

ИЗУЧЕНИЕ ПОКАЗАТЕЛЕЙ ВАРИАБЕЛЬНОСТИ РИТМА СЕРДЦА У БОЛЬНЫХ С ПАРОКСИЗМАЛЬНОЙ ФОРМОЙ ФИБРИЛЛЯЦИИ ПРЕДСЕРДИЙ НА ФОНЕ ПРОФИЛАКТИЧЕСКОГО ПРИЕМА МЕТОПРОЛОЛА И КОРДАРОНА В ТЕЧЕНИЕ ГОДА

This work is devoted to the dynamic study of heart rate variability indicators for one year in patients with paroxysmal atrial fibrillation treated with antiarrhythmic drugs metoprolol and cordarone. The study found that patients treated with metoprolol monotherapy had a weakening of parasympathetic effects on the heart, due to a decrease in Mean by 12.9%, Mo by 13%, Amo by 29.4%, SDNN by 28.3% compared to the group of healthy individuals, but they differed in stable indicators of heart rate variability and 33% retained sinus rhythm during the year. With cordarone monotherapy, there was a curative effect of sympathetic and parasympathetic effects on the heart, as indicated by an increase in: Mean by 15.9%, Mo by 15.9%, IVR by 95.5%, Amo by 41.1% and a decrease in SDNN by 37.5%, compared with the group of healthy individuals at the initial stage. A year later, a negative dynamics was revealed - the predominance of sympathetic influences on the heart compared to the groups of healthy individuals and the control due to an increase in: IVR by 363.3% and 238.5%; VPR by 116.7% and 106%; Amo by 111.2% and 72.9; IN by 304% and 246.8%; PAPR by 92% and 79.1%, respectively. During the year, 39% of patients left the study due to the replacement of antiarrhythmic therapy and 16.5% due to the development of a permanent form of atrial fibrillation. In the remaining patients in the study, in comparison with their initial data, there was a predominance of sympathetic effects on the heart due to an increase in IVR by 137%. In combination therapy with metoprolol and cordarone, there were no significant changes in heart rate variability compared to the initial ones. Initially, there was a decrease in overall heart rate variability due to a decrease in SDNN by 28.4% and a decrease in parasympathetic effects on the heart due to an increase in Amo by 45.2% and a decrease in Delta X by 32.9% compared to the group of healthy individuals. After a year, 40% left the study due to the replacement of antiarrhythmic therapy and 30% due to the development of a permanent form of atrial fibrillation. During dynamic observation of patients, it was found that the following indicators have the most important prognostic value in the development of atrial fibrillation: SDNN, Delta X and RMSSD. Therefore, it is very important to register an ECG with the measurement of these indicators at least once every 3 months for timely correction of treatment.

Structural and functional changes of the heart in chronic heart failure with preserved left ventricular ejection fraction with excess body weight depending on the presence and form of atrial fibrillation

The aim. To examine the features of structural and functional changes of the heart in patients with chronic heart failure with preserved left ventricular ejection fraction (CHF pr EF) with excess body weight depending on the presence and form of atrial fibrillation (AF). Materials and methods. The study involved 248 patients with CHF pr EF and excess body weight, the mean age was 65.0 ± 11.0 years, 146 females (58.9 %) and 102 males (41.1 %). The first group included 181 patients without concomitant AF, the mean age was 64.0 ± 11.0 years, 110 females (60.8 %) and 71 males (39.2 %); the second group included 67 patients with AF, the mean age was 67.9 ± 11.3 years, 36 females (53.7 %) and 31 males (46.3 %). Subjects with AF were further divided into subgroups: 7 patients with paroxysmal AF, the mean age – 6.7 ± 10.4 years, 3 females (42.9 %) and 4 males (57.1 %), 12 patients with persistent AF, the mean age – 70.8 ± 10.3 years, 10 females (83.3 %) and 2 males (16.7 %); 48 patients with permanent AF, the mean age – 67.3 ± 11.7 years, 23 females (47.9 %) and 25 males (52.1 %). Results. Patients with concomitant AF had a significantly larger aorta diameter (by 3.0 %), systolic left atrium size (LAs) (by 14.5 %), right atrium size (RA) (by 8.3 %), left ventricle end-diastolic size (LVEDS) (by 7.1 %), left ventricle end-systolic size (LVESS) (by 10.6 %), right ventricle size (RV) (by 13,1 %), mean pulmonary artery pressure (by 20.0 %) and the prevalence of LV eccentric hypertrophy (by 21.0 %; P ˂ 0.001). At the same time, LV wall relative thickness (LV RT) was lower by 6.3 %, LV EF – by 3.4 % and the frequency of LV concentric hypertrophy – by 19.1 % (P ˂ 0.001). In permanent form of AF compared to paroxysmal one, significantly larger LAs (by 10.6 %), RA (by 10.9 %), LV myocardial mass (LV MM) (by 18.1 %) and LV MM index (by 21.1 %) were determined and in contrast to persistent AF, LAs (by 9.8 %), RA (by 11.4 %), LVEDS (by 15.6 %), LVESS (by 15.8 %), RV (by 27, 9 %), LV MM (by 29.8 %), LV MMI (by 14.9 %) were predominant, at the same, LVRT was 12.8 % less. Conclusions. In patients with CHF pr EF and excess body weight, concomitant AF is associated with greater dilatation of the heart cavities, eccentric hypertrophy predominance, decreased LV contractility and pulmonary hypertension. Compared to other forms, permanent AF is characterized by severe structural and functional changes in the heart, maximal manifestations of LV dilatation and hypertrophy.

Dynamics of psycho-emotional status in patients with a constant form of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Ivano-Frankivsk National Medical University Topicality. Atrial fibrillation (AF) is the most common chronic heart rhythm disorder, occurring in 1-2% of people in the general population. Stable coronary heart disease, hypertension, heart failure, obesity are risk factors for AF progression. Psycho-emotional stress, anxiety and depression can also cause AF. Goal. To investigate the dynamics of the effectiveness of treatment of psychoemotional status in patients with persistent AF. Materials and methods. We examined 62 patients with a permanent form of AF, treated in the cardiology department. Patients were divided into groups: group 1a - (n = 16), received basic therapy; 1b group - (n = 16), patients who in combination treatment received mebicar; Group 1b - (n = 15) patients who received carvedilol in addition to standard therapy; Group 1g (n = 15) consisted of patients receiving combination therapy with carvedilol and mebicar. In order to study the psychological state of patients with AF, L. Reeder"s scale of psychosocial stress, perceived stress-10, hospital scale of anxiety and depression (HADS) were used. Results. The dynamics of the scale of perceived stress-10 in patients with a permanent form of AF in the dynamics of treatment showed a decrease in stress resistance after 2 weeks and a month and a half of treatment (p1 <0,001; p2 <0,001) (p1 - the significance of the difference compared to before and after p2 - the significance of the difference between the values compared with the value after 1.5 months of treatment (p <0,05) During treatment, the proportion of people with high and medium stress decreased by 31,43% in the group of standard treatment, and 39,95% in the group of patients where mebicar was used. It should be noted that in the same group before treatment was dominated by high levels of stress, and the average level was much less common. The share of high stress levels decreased from 53,34 to 6,66%. In this group of patients, the reduction in the score of stress was 17,78%. The level of stress in patients taking carvedilol decreased by 25,89%, and in the group where mebicar was used by 13,68%. Under the influence of standard therapy, the level of stress decreased by 13%, but this figure was not significant, despite the fact that in this group the number of patients decreased from high to medium stress. In the treatment of patients with anxiolytic drug should be noted a significant reduction in psychosocial stress (p1-2 <0,001). It was found that against the background of psychopharmacotherapy in patients with AF there was a reduction from clinical to subclinical levels of anxiety and depression. It should be noted that the course of therapy with carvedilol adversely affected the course of anxiety and depression. Conclusion. According to our study, psychometric parameters improved significantly against the background of comprehensive treatment in all groups of patients.

Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy

Congestive heart failure resulting from non-ischemic dilated cardiomyopathy (DCM) with secondary functional mitral regurgitation (FMR) is associated with poor prognosis. Medical treatment results in a 1-year survival of 52% to 87% and a 5-year survival of 22% to 54%, with highest survivals observed in more recent years, probably reflecting improvements in medical therapy. Non-surgical interventions involve cardiac resynchronization therapy. In addition to medical treatment, cardiac resynchronization therapy (CRT) should be considered in patients with New York Heart Association (NYHA) class II– IV HF, left ventricular ejection fraction (LVEF) =35%, normal sinus rhythm and left bundle branch block with QRS >150 ms. In these patients, CRT can also facilitate left ventricular (LV) reverse remodeling and reduce associated FMR.
 The aim of this study was to investigate the features of symptomatology and to analyze the risk factors for acute heart failure (AHF) in patients with DCM and persistent severe functional mitral regurgitation despite CRT and optimal guideline-directed medical therapy (GDMT).
 Materials and methods. After providing informed consent, 144 patients with severe FMR were involved in the study. Concomitant tricuspid valve regurgitation was registered in 142 (98.6%) cases. The median LVEF was 27.0 (23.0-31.6)%. 40 (27.8%) patients had a permanent form of atrial fibrillation, and 24 (16.7%) patients had a first-degree atrioventricular node block. The median NT-proBNP was 2600 (2133-3200) pg/ml, indicating the presence of severe chronic heart failure.
 Results. The median term after CRT device implantation was 36 (3.5-60) months. A comparative analysis between DCM patients with and without CRT revealed statistically significant differences between clinical characteristics, namely: age (p=0.020), lower heart rate (p=0.004), lower hemoglobin (p=0.017), higher erythrocyte sedimentation rate (ESR) (p=0.000) and more frequent AHF at the hospital stage (p=0.030). The incidence of AHF at the hospital stage was 13.8% in patients with CRT and 3.5% in those without CRT. The calculated odds ratio of AHF was 4.44 (95% confidence interval (CI) 1.039-18.971), and the relative risk of AHF was 3.966 (95% CI 1.054-14.915).
 Discussion. FMR has been reported to persist in about 20% to 25% of CRT patients and, in an additional 10% to 15%, it may actually worsen after CRT. In this subset of CRT non-responders, reduced reverse remodeling, increased morbidity, and increased mortality have been reported compared with CRT patients in whom FMR was significantly reduced or abolished.
 Conclusions. The results of our study demonstrate that severe functional mitral regurgitation despite cardiac resynchronization therapy in patients with dilated cardiomyopathy is a significant risk factor for AHF and subsequent hospitalizations for heart failure.

Клініко-інструментальна характеристика й п’ятирічне виживання чоловіків і жінок із хронічною серцевою недостатністю та зниженою фракцією викиду лівого шлуночка залежно від наявності цукрового діабету 2-го типу

Мета роботи – порівняти клініко-інструментальні показники та кумулятивне виживання жінок і чоловіків із хронічною серцевою недостатністю (ХСН) на тлі ішемічної хвороби серця (ІХС) з гіпертонічною хворобою (ГХ) або без неї, зі зниженою фракцією викиду лівого шлуночка (ФВЛШ), залежно від наявності в них цукрового діабету (ЦД) 2-го типу. Матеріали і методи. Проведено ретроспективний аналіз 490 історій хвороб пацієнтів, які спостерігалися у відділі серцевої недостатності в період з 2011 до 2018 р., з ХСН ІІ–ІV функціонального класу (ФК) за NYHA, ФВЛШ ≤ 40 %, віком 40–80 років (медіана (квартилі) – 64 (56,00; 69,00) роки). У досліджувану групу увійшли переважно хворі з ІХС у поєднанні з гіпертонічною хворобою (ГХ) – 403 (82,2 %) пацієнти, з ізольованою ІХС – 55 (11,2 %) та з ізольованою ГХ – 32 (6,6 %). Більшість хворих (278 (56,7 %) осіб) мали постійну форму фібриляції передсердь. Серед досліджуваних було 373 (76,1 %) чоловіки та 117 (23,9 %) жінок. Порівняння проводили в групах чоловіків та жінок залежно від наявності в них ЦД 2-го типу. Пацієнтів залучали в дослідження у фазу клінічної компенсації, тобто в еуволемічному стані.Результати та обговорення. Встановлено, що поширеність ЦД 2-го типу в досліджуваній популяції чоловіків із ХСН та зниженою ФВЛШ суттєво менша, ніж у популяції жінок. Між досліджуваними групами не виявлено статистично значущих відмінностей щодо етіології виникнення, тяжкості перебігу ХСН за ФК за NYHA, а також структурою коморбідних станів. Також не виявлено статистично значущих відмінностей за віком, середньодобовою частотою скорочень серця, показниками систолічного та діастолічного артеріального тиску. Попри очікування, рівні інсуліну, як у чоловічій, так і у жіночій когортах статистично значуще не відрізнялися в пацієнтів із супутнім ЦД 2-го типу та без ЦД. У когорті чоловіків із ХСН зі зниженою ФВЛШ та супутнім ЦД 2-го типу виявлено статистично значуще вищий індекс маси тіла, більший передньозадній розмір лівого передсердя, більшу швидкість клубочкової фільтрації, нижчий рівень азоту сечовини та майже вдвічі менший рівень циркулюючого цитруліну порівняно з аналогічною жіночою когортою. У жінок із ХСН зі зниженою ФВЛШ та супутнім ЦД 2-го типу порівняно з жінками без супутнього ЦД статистично значуще меншими були ФВЛШ та розмір лівого передсердя, статистично значуще більшими виявилися рівень циркулюючого цитруліну та співвідношення Е/е´. Аналіз функціонального стану нирок показав погіршання азотовидільної функції нирок у пацієнтів досліджуваних груп за наявності ЦД 2-го типу. Показник п’ятирічного виживання чоловіків із ХСН зі зниженою ФВЛШ залежно від наявності в них ЦД 2-го типу не відрізнявся. Водночас при аналізі впливу ЦД 2-го типу на тривалість життя в жінок із ХСН зі зниженою ФВЛШ спостерігали статистично значуще гірший прогноз.Висновки. Пацієнти з ХСН зі зниженою ФВЛШ та наявністю ЦД 2-го типу характеризуються гіршим клінічним перебігом захворювання лише в жінок, що поєднується з ознаками більш вираженого ураження органів-мішеней (серце, нирки), гіршою азотовидільною функцією нирок. Наявність ЦД 2-го типу в чоловічій когорті не впливає на тривалість життя, в той час як у жінок із ЦД 2-го типу п’ятирічне виживання було значно нижчим порівняно з таким у жінок без ЦД.