Vol 27, No 3 (2020)

Atrial fibrillation (AF) is the most common arrhythmia worldwide. An important trend in modern healthcare is the high prevalence of comorbidities in clinical practice, especially the presence of concomitant diseases is found in patients with a cardiological profile, and from this point of view patients with AF are no exception. Most often, AF coexists with arterial hypertension, coronary heart disease (CHD), chronic heart failure (CHF), and chronic kidney disease (CKD). A fundamental principle in the management of AF patients is the administration of appropriate anticoagulant therapy. To date, the use of direct oral anticoagulants (DOACs) is a priority in this issue. One of the representatives of this drug class is apixaban, which has confirmed its advantages in patients with AF and has its own body of evidence for clinical efficacy and safety, including comorbidity settings. Apixaban has demonstrated consistently high efficacy in patients with AF and CHD, CHF, and CKD, and its clinical potential and safety profile are not different from that in the general population. The focus of comorbidity is also on the lesions of the gastrointestinal mucous membrane in patients with AF, which potentially increase the risk of this location bleedings. Taking into account the results of DOACs pivotal studies, it can be said that apixaban does not significantly affect the risk of gastrointestinal bleeding. An interesting aspect of the clinical pharmacology of DOACs and, in the first place, apixaban is also the absence of a negative effect on the processes of osteogenesis and mineralization of bone tissue, which, as is known, is present in vitamin Kantagonists. Additional evidence of the optimal profile of the effectiveness and safety of apixaban in the presence of comorbidities is the inclusion of this drug in international clinical guidelines and consensus documents for the management of patients with concomitant diseases.

Spasticity is a clinical condition characterized by a velocity-dependent increase in muscle tone or tonic tendon reflexes in combination with other symptoms of damage to the upper motor neuron (UMN). Spasticity is considered a positive symptom of UMN, resulting from a loss of the inhibitory descending effect of the central nervous system (CNS) on the underlying structures and the development of hypersensitivity of reflex arcs at the spinal cord level. Various diseases can lead to the development of spasticity: stroke, cerebral palsy (CP), traumatic brain injury (TBI), spinal cord injury (SCI), multiple sclerosis (MS), neurodegenerative diseases, etc. The article discusses in detail the pathophysiology of spasticity in various diseases, as well as the heterogeneity of the mechanisms of the formation of spasticity syndrome. The results of modern studies on the efficacy of botulinum toxin type A (BTA) in the treatment of spasticity are presented. BTA is effective as an independent method for treating focal spasticity of various etiologies: stroke, CP, SCI, TBI, and MS, and the adjuvant method in combination with other approaches for generalized spasticity. Additional studies are required for the further evaluation of the BTA efficacy in treating spasticity in these diseases.

Ischemic stroke (IS) occupies a priority position in the structure of acute cerebrovascular events and is an important social problem due to the high rates of its incidence, mortality and disability. The most successful method of treating ischemic stroke is the method of reperfusion therapy in the first hours of the onset of the disease, which is aimed to restoration of blood flow in the occluded artery. There are 2 main methods of reperfusion in IS - systemic thrombolytic therapy (STLT) with recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy. Systemic TLT with alteplase is the «gold» standard for the treatment of IS patients in the first 4.5 hours from the onset of the disease in the absence of contraindications. The safety and efficacy of alteplase in cerebral stroke have been demonstrated in many randomized clinical trials; blood clots in larger vessels, however, are poorly susceptible to the pharmacological effects of alteplase, which reduces the effectiveness of systemic TLT in cases of occlusion of proximal intracranial arteries. The results of large randomized MRCLEAN, ESCAPE, EXTEND-IA, SWIFTPRIME, and REVASCAT trials were published in 2015, and the class and level of evidence 1A was assigned to the thrombectomy, and in 2018 this treatment was included in the updated American Heart Association/American Stroke Association recommendations for early management of patients with acute IS.

Background. Atherosclerotic lesions of the coronary arteries (coronary artery disease, myocardial infarction) and peripheral arteries (brachiocephalic arteries, lower limb arteries) are a serious cause of diseases and mortality. Currently widespread hypercholesterolemia is the main significant risk factor for the development of such atherosclerotic diseases. Objective. Identification of the features of lipid-lowering therapy with statins, including rosuvastatin, in patients with moderate (polygenic) and severe (familial, hereditary) hypercholesterolemia (HCE) with different phenotypes of hyperlipidemia (HLE) in current outpatient practice. Methods. Study included patients with different HLE phenotypes in the outpatient practice of the LIPID-PRACTIC register for the period 2009-2016 (1173 individuals) aged 18-84 years (mean age 49.6 ± 10.5 years); 40.3% men. All patients underwent routine clinical examination and diagnosis of HLE phenotypes by cholesterol and triglyceride levels, according to ICD-10 codes, assessment of familial HCE (FHCE) in groups with moderate and high cholesterol levels. Results. The frequency of different HLE phenotypes and FHCE in groups with moderate and high cholesterol levels in current outpatient practice was determined. Also, the frequency of appointment of lipid-lowering therapy with statins, including rosuvastatin, in these groups was assessed. Conclusion. It was revealed that the initial level of moderate or severe HCE, the HLE phenotype in accordance with the ICD-10 code (E78.0 - E78.2), and the high triglycerides levels are not taken into account in appointment of therapy with statins for patients; all of this leads to the error diagnosis of the HLE phenotype and FHCE. As a result, patients do not receive effective lipid-lowering therapy, including highly effective statins, and this reduces their adherence to therapy (no effect) in both primary and secondary prevention.

Background. Statolocomotor disorders in combination with emotional and cognitive disorders after cerebral stroke are associated with low efficiency of rehabilitation measures and low quality of life of patients. Objective. Evaluation of the effectiveness of complex rehabilitation with the inclusion of stabilometric training with biofeedback (BFB) and antidepressant in patients with poststroke motor, emotional and cognitive impairment at the late recovery period. Methods. We conducted a randomized clinical open controlled trial. 110 patients in the late recovery period of ischemic stroke (IS) were followed-up; there were 67 women and 43 men, the mean age was 58.0±9.74 years. The prescription of IS onset averaged 228.59±31.9 days. The first (main) group included 72 stroke patients who received vortioxetine and BFB-stabilometric training along with the standard treatment regimen. The control group consisted of 38 stroke patients whose rehabilitation complex did not include an antidepressant. Results. By the end of the follow-up, in the main group of patients CP statistically significantly equalized in both planes (significantly along the X axis; p<0.05), the length of the statokinesiogram decreased by an average of 27.4%; the Romberg coefficient improved (from 55.8±6.81 to 95.2±6.47; p<0.05), earlier motor and social adaptation was noted (an increase in Barthel index from 58.2±3.0 up to 84.4±2.9; p<0.001), as well as improved quality of life according to the EuroQol EQ-5D-5L (from 46.3±2.3 to 72.3±2.6; p<0.05) . Analysis of the dynamics of the emotional state according to the HADS showed a decrease in the total score for the depression subscale in 53 (73.6%) patients of the main group by the 8th week of therapy to an average of 6.8. The clinical effect was observed after 4 weeks, reaching a maximum by the 8-12th week of rehabilitation. HADS changes have been associated with improved walking characteristics. Conclusion. The complex of rehabilitation measures with the inclusion of vortioxetine and BFB-stabilometric postural training significantly improved postural stability, cognitive and emotional status of patients.

Background. Ischemic stroke (IS) is one of the leading causes of death and disability worldwide. There are atherothrombotic (ATS) and cardioembolic (CES) subtypes of IS. For timely diagnosis and prediction of outcomes for different IS subtypes, an important task is to identify the most informative biomarkers, including genetic ones. Objective. Search for genetic biomarkers to predict the outcome of various IS subtypes based on an analysis of the CD46 gene expression level. Methods. The study used RNA samples of 79 unrelated individuals, including 21 patients with CES, 20 with ATS, 21 with transient ischemic attack, and 17 healthy individuals. In order to study the role of the CD46 gene in the development of IS, we performed a molecular genetic analysis of its expression level. Results. The important role of the CD46 gene in the development of ATS has been shown. A comparative analysis with the control group showed that ATS men showed a significant increase in the CD46 gene expression level, while in women, on the contrary, the the CD46 gene expression level was significantly lower. Conclusion. The data obtained indicate the important role of the CD46 gene in the development of this pathology and the possibility of its use as a genetic biomarker of the atherothrombotic IS.

Hypothyroidism is characterized by thyroid hormones deficit endocrinopathy, which could initiated by different reasons. Last years the raise of incidence of drug-induced hypothyroidism was noted. Hypothyroidism considered drug-associated if patient takes drug which known as reason of decrease thyroid function or hypothyroidism resolves by this drug withdrawal. Risk factors of drug-induced hypothyroidism are already established hypothyroidism, concomitant autoimmune disease, previously established thyroiditis Hashimoto, thyroidectomy, effect Wolff-Chaikoff realization (blockade of thyroid hormone synthesis when a large amount of iodine is introduced into the organism; living in districts with sufficient iodine intake, family history (the presence of disease in relatives), eating disorders. The most frequent reason of drug-induced hypothyroidism is amiodarone intake, tetracycline antibiotics, tyrosine kinase inhibitor, anticancer drugs, anti-epileptic drugs, as well as iodine-containing contrast agents. For the treatment of drug-induced hypothyroidism, it is necessary to cancel the drug, against the background of which it has developed, in addition, resort to replacement therapy with levothyroxine sodium. As a preventive measure for drug-induced hypothyroidism, it is recommended to avoid using drugs with this side effect and use an adequate amount of iodine to prevent iodine deficiency, and correct thyroid dysfunction in a timely manner.

The review article considers the role of increased intestinal permeability in the development of cardiovascular diseases such as arterial hypertension, chronic heart failure, arteriosclerotic lesions of the arteries, and discusses the relationship between increased intestinal permeability and endothelial dysfunction. The possibility of correcting increased intestinal permeability is also considered; in this context, the mechanism of action and pleiotropic effects of the gastro- and enteroprotector rebamipide, which is currently recognized as the only corrector of increased intestinal permeability, are discussed.

Background. Arterial hypertension (AH) is a risk factor for the development of severe cardiovascular complications. During menopause, women have poor control of blood pressure (BP) and an increased risk of cardiovascular complications. Description of the clinical case. This article discusses the clinical case of a patient L. 51 years old, who complained of periodic headaches (especially against the background of physical and psycho-emotional stress), frequent dizziness, “noise and ringing" in the ears, severe fatigue during physical and emotional stress, periodic mild forgetfulness, leading to a decrease in mental performance, disorganization that interferes with the implementation of professional activities. The patient was in menopause for 2 years. Based on complaints, as well as data of physical examination, instrumental and laboratory tests, the diagnosis of second stage arterial hypertension, 2nd degree, high risk (risk 3) was established. The target blood pressure for this patient, taking into account her age and the absence of chronic kidney disease, is 120-129/70-79 mm Hg. The patient received therapy with the combined drug Gipotef. After 3 weeks of taking Gipotef, the patient reached the target blood pressure values, the daily profile of her blood pressure returned to normal; she noted a regression of headaches, an improvement in overall well-being, increased performance, the disappearance of a sensation of “noise and ringing" in the ears, greater concentration, less distraction. Conclusion. Thus, Gipotef had a complex effect: it effectively lowered blood pressure, improved the quality of life and contributed to the prevention of cardiovascular risks in a patient with arterial hypertension and menopausal disorders.