The aimof the study was to create a patient portrait, to evaluate prognosis, and establish the principles of therapy in patients with acute coronary syndrome without ST elevation with non-obstructive coronary atherosclerosis in comparison with the obstructive coronary atherosclerosis group.Material and Methods. Data come from the acute coronary syndrome register REСORD-3 that was implemented in the Emergency Cardiology Department of Cardiology Research Institute, Tomsk National Research Medical Centre, along with 45 other centers in Russia. Patients with myocardial infarction without ST segment elevation who were exposed to coronary angiography were separated into two independent groups based on whether they had MINОСА or not: 148 persons with non-obstructive coronary atherosclerosis and 537 persons with obstructive coronary atherosclerosis.Results. Non-obstructive coronary atherosclerosis group, compared to obstructive coronary atherosclerosis, comprised 75 women (50.7%) compared to 177 men (32.9%). Hypertension was detected less often in this group: 120 (81.1%) versus 475 (88.5%). The rates of diabetes mellitus were 16 (10.8%) versus 115 (21.4%) and the rates of smoking were 162 patients (30.2%) versus 32 (21.6%), respectively, in patients with and without non-obstructive coronary atherosclerosis. Non-obstructive coronary atherosclerosis group had significantly lower rate of individuals with diagnostic increase in cardiospecific enzymes. This may be indicative of non-prolonged myocardial ischemia that, in some cases, does not lead to necrosis. The final diagnosis of non-ST segment elevation myocardial infarction was significantly less confirmed in patients with non-obstructive coronary atherosclerosis (14.8 vs. 45.3%). However, in this group, the “other cardiac cause of hospitalization” was more frequent (29.7 vs. 2.2% of cases), which explains the need to continue the diagnostic search to exclude all possible causes of the chest pain. The variety of final diagnoses in patients with acute coronary syndrome with non-obstructive coronary atherosclerosis and “clean” coronary arteries should encourage a thorough analysis of the pathogenesis in each of these patients.Conclusion. A typical acute coronary syndrome patient with non-obstructive coronary atherosclerosis without ST segment elevation was represented by a 59 (53:65)-year-old woman with traditional risk factors for coronary heart disease, but the incidence of each of these factors was less than in the obstructive coronary atherosclerosis group. Final diagnosis of non-ST segment elevation myocardial infarction was confirmed significantly less often in patients with non-obstructive coronary atherosclerosis. The mortality rates did not differ between groups and were minimal. Acute coronary syndrome patients with non-obstructive coronary atherosclerosis without ST segment elevation were less likely to receive ticagrelor and statins in hospital, but they were administered more often with fondaparinux. Patients with non-obstructive coronary atherosclerosis at discharge were less likely to be recommended to take antiplatelet agents, statins, and nitrates.

Material and methods. The data used, from the acute coronary syndrome registry RECORD-3, in the emergency cardiology department of Tomsk SRI of Cardiology, together with another 51 center in Russia. Based on the absence of presence of NOCA, patients with ST elevation myocardial infarction, who had undergone coronary arteriography, were selected to two independent groups: 27 with NOCA and 571 with OCA.Results. There were no significant differences in the clinical portrait of NOCA and OCA patient. However, palpitation followed angina attack in NOCA patients. In the NOCA, there was significantly lower number of persons with diagnostically relevant raise of cardio specific enzymes. Indirectly, it points on temporary ischemia with no necrosis, or that the area of necrotic myocardium is not large. In NOCA patients, statistically more significantly were absent reciprocal ECG changes. Endpoints as mortality and novel heart failure development had tendency to statistically more significant decrease of prevalence in NOCA patients. As final diagnosis at discharge, in NOCA patients more often another diagnosis was mentioned (including unstable angina, etc.), but not myocardial infarction. The key issues in hospital management of these two groups were identical, except more often prescription of dihydropiridine calcium channel blockers to NOCA patients, and rarer prescription of antiplatelet drugs at discharge.Conclusion. Regardless the fact that prognosis in ACS with NOCA and intact arteries is better than in OCA, it is necessary to analyze thoroughly pathogenesis of the disease in every case, as in this category of patients especially, it is most heterogenic. As these patients have comorbid factors, it is necessary to select the leading one, and to intensify efforts on this factor directly.

В последние годы в связи с широким применением ангиографии все чаще диагностируется кардиомиопатия (КМП) такотсубо (takotsubo), для которой характерны изменения ЭКГ, сходные с таковыми у больных с острым коронарным синдромом, повышение маркеров некроза сердечной мышцы и отсутствие значимого поражения КА. При вентрикулографии в типичных случаях выявляется транзиторное баллонирование верхушки левого желудочка. Патофизиологические механизмы, лежащие в основе этого заболевания, остаются до конца не выясненными, хотя многие исследователи относят его к редкой обратимой форме нейрогенной КМП. Авторами описан первый диагностированный ими случай КМП такотсубо, имеющий в целом типичные клинические и лабораторные проявления.

BACKGROUND:Complete following existing guidelines for management of acute coronary syndrome (ACS) is known to be associated with better outcomes. Partly this is explained by lesser adherence to recommendations in high risk patients. Aim of our study was to assess relationship between degree of following current guidelines and in hospital outcomes independently from initial assessment of risk.METHODS:Each key recommendation from guidelines issued between 2008 and 2011 (13 for STE ACS, 12 for NSTE ACS) was given weight of 1. Sum of these units constituted index of guideline adherence (IGA). IGA was retrospectively calculated for 1656 patients included in Russian independent ACS registry RECORD-2 (7 hospitals, duration 04.2009 to 04.2011). The patients were divided into 2 groups according to quartiles of IGA distribution: 1) low adherence group (quartiles I-II); 2) high adherence group (quartiles III-IV).RESULTS:In low adherence compared with high adherence group there were significantly more patients more or equal 65 years (=0.0007), with chronic heart failure [CHF] (<0.0001), previous stroke (<0.0001), atrial fibrillation [AF] (=0.0002), Killip class more or equal II (=0.0065), high risk of death by GRACE score (=0.035). Inhospital mortality was 9.3 and 2.4% in low and high adherence group, respectively (p<0.0001). The following independent predictors of inhospital death were identified: IGA quartiles I-II (odds ratio [OR] 4.0; 95% confidence interval [CI] 2.3-7.1; <0.0001), high GRACE score (OR 3.3; 95% CI 1.8-6.0; <0.0001), admission systolic BP less or equal 100 mm Hg (OR 3.1; 95% CI 1.8-5.4; <0.0001), admission serum glucose more or equal 8 mmol/l (OR 2.9; 95% CI 1.8-4.7; <0.0001), age more or equal 65 years (OR 2.3; 95% CI 1.3-4.0; =0.005), ST elevation more or equal 1 mm on first ECG (OR 1.7; 95% CI 1.1-2.5; =0.013). From groups with low and high adherence to guidelines we selected pairs of patients (n=588) with similar (or close) age, type of ACS, GRACE score, Killip class, presence of other important risk factors (CHF, AF, previous stroke), and formed 2 equal subgroups without significant differences in important demographic, anamnestic, clinical and laboratory data. Hospital mortality was 7.8 and 2.7% in low and high adherence subgroup, respectively (p<0.0001).CONCLUSIONS:In RECORD-2 ACS registry low adherence to guidelines was more frequent among high risk patients and was independent predictor of inhospital death. Association between degree of guidelines adherence and outcomes persisted after equalizing groups by some factors of risk of mortality.

In the last decade with the wide applying of angiography the cardiomyopathy (CMP) Tako-tsubo became diagnosed more often. It's characterized by the ECG abnormalities which are similar as those in acute coronary syndrome, elevating of myocardial injury biomarkers and absence of obvious atherosclerosis of coronary arteries. Left ventriculography usually shows the characteristics apical ballooning. Pathophysiology mechanisms underlying the disease are well not understood, but most investigators attribute it to reversible form of neurogenic CMP. A case of CMP Takotsubo with almost typical clinical and laboratory dates now first diagnosed and described by the authors in their practice.

В настоящей статье изложены основные этапы учения об инфаркте миокарда. Отражен вклад коллектива авторовв разработку и внедрение некоторых новых методов диагностики и лечения больных инфарктом миокарда. Приведены основные направления деятельности отделения неотложной кардиологии НИИ кардиологии СО РАМН:накопление и анализ собственных статистических данных о больных инфарктом миокарда; участие в регистрахбольных острым коронарным синдромом; внедрение и сравнительная оценка эффективности различных методов экстренной реперфузии миокарда; изучение структурнофункциональной перестройки сердца в условияхреперфузионной терапии; разработка и внедрение в клиническую практику новых методов диагностики и лечения ранних и поздних осложнений инфаркта миокарда.

The continuous increase in the numbers of coronary heart disease (CH D) patients warrants the search for the new therapeutic approaches, which could be used when the standard methods are contraindicated or ineffective. One of the methods in CH D treatment is angiogenesis stimulation, i.e. increasing the number of coronary arteries (CA), which "substitute" the local CA defect. At the moment, there are several methods proposed for angiogenesis stimulation, among which enhanced external counterpulsation (EEC P) had demonstrated clinical effectiveness. EECP is indicated in resistant and unstable angina, chronic heart failure, acute myocardial infarction, and cardiogenic shock. This non-invasive method is particularly important in patients with severe CH D and impossibility of myocardial revascularisation.

The article presents the basic stages of myocardial infarction (MI) study. The contribution of authors to the development and implementation of new diagnostic methods in the treatment of MI patients is reflected. Basic work areas of Cardiac emergency department of Tomsk Institute of Cardiology are presented: gathering and analyzing of proper statistical data of MI patients; participation in register of patients with acute coronary syndrome; implementing and comparative evaluation of effectiveness of various methods of emergency myocardial reperfusion; the study of structural-functional heart remodeling amid reperfusion therapy; development and implementing into clinical practice of new diagnostic and treatment methods of early and late complications of MI.

At present there is clinical evidence that the method of Enhanced External Counterpulsation (EECP) is an effective method of treatment of coronary heart disease. This medical case demonstrates clinical efficacy of EECP in a patient with acute coronary syndrome in preparation for coronary bypass surgery.

Background: Leucoaraiosis is a prognostic factor for stroke, myocardial infarction, cognitive impairment or dementia, and associated with aging and vascular risk factors such as arterial hypertension (AH) and diabetes mellitus (DM). The aim of this study was to evaluate potential role of both metabolic factors and blood pressure (BP) in development of periventricular leucoaraiosis. Methods: Ambulatory 24-hours blood pressure monitoring (ABPM), brain MRI using Magnetom-Open (0.2 T), assay of plasma lipids, HbA1, fasting and postprandial insulin and glucose were performed in 51 hypertensive diabetic patients (AH + DM group, 11 men, aged 40 to 61 y.o.) and 152 hypertensive patients without DM (AH group) matched for age and sex. Resuts: Brain MRI detected periventricular leucoaraiosis in hypertensive diabetic pts more frequently than in hypertensive pts without DM (73% vs. 56%, p < 0.05), despite both lower levels of SBP/DBP and duration of AH in the AH + DM group than in the AH group (142/87 vs. 178/111 mmHg, p < 0.001 and 9 ± 7 vs. 12 ± 7 y., p < 0.001, resp.). Multiple regression analyses with a model containing duration of AH and DM, ABPM parameters and fasting glucose were performed to identify factors associated with degree of leucoaraiosis in AH + DM group. The factors significantly associated with greater leucoaraiosis were systolic BP-24 h (p = 0.013), pulse BP-24 h (p = 0.014), systolic BP-nighttime (p = 0.003), fasting glucose (p = 0.034) and duration of DM (0.006). It has been noted, that the extent of leucoaraiosis is affected by such parameters as SBP-24 h > 145.7 ± 1.6 mm Hg, pulse PB-24 h > 60.4 ± 1.3 mm Hg and fasting glucose level > 7.3 ± 0.4mmol/l (parameters of linear model: R = 0.60, R2 = 0.37, p = 0.018). Relationships between severity of leucoaraiosis and levels of plasma lipids were not found. Conclusion: Our study suggests that diabetes mellitus contributes to leucoaraiosis in hypertensive patients. Increased blood pressure and both the level of hyperglycemia and the duration of diabetes mellitus but no parameters of lipid metabolism are related with the degree of periventricular leucoaraiosis in hypertensive diabetic patients.

Comparative study results revealed some difference in the treatment effect between beta-blockers cardvedilol and bisporolol. Blood pressure, metabolic parameters, early brain damage were monitored by MRI in 51 patients having arterial hypertension and diabetes mellitus of the type 2. Both drugs had significant antihypertensive effect but it was more prominent in bisoprolol treatment. Improvement in liquorodynamics disturbances was concluded to be caused by decreased blood pressure.

Study results of evaluating MRI detectable structural changes in the brain of hypertensive patients with the 2-nd type diabetes mellitus and comparing them with structural changes in hypertensive patients without the 2-nd type diabetes mellitus are given in the article. Hypertensive patients with the 2-nd type diabetes mellitus were shown to DM have more prominent MR detectable signs of cerebrovascular pathology.