42Диабетическая кардиомиопатия: особенности сердечно-сосудистого ремоделирования Караваев П. Г., Веклич А. С., Козиолова Н. А.Цель. Определить особенности сердечно-сосудистого ре моделирования у больных диабетической кардиомиопатией в сравнении со здоровыми лицами. Материал и методы. В амбулаторных условиях среди больных с впервые выявленным сахарным диабетом (СД) 2 типа до начала терапии была выделена группа больных с диабетической кардиомиопатией (ДКМ) с диастолической дисфункцией левого желудочка (ДД ЛЖ) согласно критериям включения и исключения, вторую группу составили здоровые лица соответствующего возраста. Структурно-функциональное состояние сердца изучалось с помощью эхокардиографии и определения N-терминального фрагмента мозгового натрийуретического пептида (Nt-proBNP) в крови, артерийпо данным объемной сфигмоплетизмографии. В крови определялись маркеры фиброза: тканевый ингибитор матриксных металлопротеиназ 1 типа (TIMP-1) и С-концевой телопептид проколагена 1 типа (CTP-1). Результаты. Частота встречаемости диабетической кардиомиопатии у больных с вновь выявленным СД 2 типа составила 18,7%. ДД ЛЖ была взаимосвязана не только с СД 2 типа, но и ожирением (r=0,48; р=0,029), уровнем АД даже в диапазоне нормальных значений ((r=0,42; р=0,031 для систолического АД; (r=0,39; р=0,042) для диастолического АД). Концентрация Nt-proBNP в диапазоне нормальных значений и TIMP-1 были выше в группе с ДКМ в сравнении с группой здоровых лиц (p<0,001 и p<0,001, соответственно). CTP-1 был ниже в первой группе, по сравнению со второй (p<0,001). В группе больных с ДКМ регистрировался более высокий индекс CAVI1 (сердечно-лодыжечно-сосудис тый индекс) в сравнении с группой здоровых (p<0,001). Заключение. ДД ЛЖ не может быть представлена, как патогномоничный критерий для ДКМ. Концентрация Nt-proBNP в диапазоне нормальных значений 76,23±14,47 пг/мл, не достигающих диагностических критериев ХСН, увеличение в TIMP-1 и снижение CTP-1 могут быть рассмотрены, как дополнительные маркеры ДКМ. Учитывая тот факт, что при формировании ДКМ происходят два параллельных процесса, проявляющихся ремоделированием сердца и артерий, индекс CAVI1 может быть также рассмотрен как дополнительный маркер ДКМ.Ключевые слова: диабетическая кардиомиопатия, фиброз, жесткость артерий.
Aim To evaluate the prevalence of iron deficiency (ID) in Russian patients with heart failure (HF).Material and methods Iron metabolism variables were studied in 498 (198 women, 300 men) patients with HF. Data were evaluated at admission for HF (97 %) or during an outpatient visit (3 %). ID was determined according to the European Society of Cardiology Guidelines.Results 83.1 % of patients had ID; only 43.5 % of patients with ID had anemia. Patients with ID were older: 70.0 [63.0;79.0] vs. 66.0 years [57.0;75.2] (p=0.009). The number of patients with ID increased in parallel with the increase in HF functional class (FC). Among patients with ID, fewer people were past or current alcohol users (p=0.002), and a greater number of patients had atrial fibrillation (60.1 vs. 45.2 %, p=0.016). A multiple logistic regression showed that more severe HF (HF FC) was associated with a higher incidence of ID detection, whereas past alcohol use was associated with less pronounced ID. An increase in N-terminal pro-brain natriuretic peptide (NT-proBNP) by 100 pg/ml was associated with an increased likelihood of ID (odds ratio, 1.006, 95 % confidence interval: 1.002–1.011, p=0.0152).Conclusion The incidence rate of HF patients is high in the Russian Federation (83.1 %). Only 43.5 % of these patients had anemia. The prevalence of ID in the study population increased with increases in HF FC and NT-proBNP.
Aim. To identify risk factors for acute decompensated heart failure (ADHF) in patients with type 2 diabetes (T2D).Material and methods. In the cardiology department, 129 patients with ADHF were registered within 8 months, 59 (45,7%) of them had T2D. The study included 117 ADHF patients who were divided into two groups depending on the presence of T2D: group 1 (n=49; 41,9%) — patients with T2D, group 2 (n=67; 55,9%) without T2D. The ADHF was verified by rapid progress of hypoperfusion and congestion, which required emergency hospitalization and inotropic and/or intravenous diuretic therapy. In the first 48 hours of hospitalization, echocardiography was performed, levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and creatinine were determined; the glomerular filtration rate was estimated.Results. The incidence of T2D among patients with ADHF was 45,7%. There were following risk factors for ADHF in T2D patients: diabetic ketoacidosis (p=0,002), hypertensive crisis (p=0,017), history of acute coronary syndrome (p=0,048), atrial fibrillation (p=0,030), chronic kidney disease (p=0,003), pneumonia (p=0,035), progression of anemia (p=0,049), low prevalence of beta-blockers use (p=0,001), use of inappropriate antidiabetic drugs for HF patients (sulfonylureas, insulin). ADHF, assessed by NT-proBNP level, was significantly more severe in T2D patients (p=0,001) with pronounced congestion symptoms (p=0,001), which led to an increase in the need for diuretic therapy (p=0,002). Cardiac remodeling in T2D patients with ADHF is characterized mainly by the preserved left ventricular ejection fraction (LVEF), severe LV diastolic dysfunction (LVDD) and LV hypertrophy (LVH).Conclusion. The development of ADHF in T2D patients is associated with various risk factors and is characterized by severe congestion symptoms, high need for diuretic therapy, mainly preserved LVEF in combination with severe LVDD and LVH.
Aim. To determine additional diagnostic criteria for atrial cardiomyopathy in patients with type 2 diabetes (T2D) and paroxysmal/persistent atrial fibrillation (AF).Material and methods. This cross-sectional screening clinical study included 80 patients with AF and T2D, who were divided into 2 groups depending on the left (LAVI) or right atrial volume index (RAVI) according to echocardiography: the first group included 49 patients with increased LAVI, while the second — 31 patients without changes in LAVI and RAVI. Inclusion criteria were presence of paroxysmal or persistent AF, T2D, age up to 65 years. There were following exclusion criteria: current smoking and less than 1 year old, the presence of cardiovascular and pulmonary diseases, heart failure, implanted artificial pacemaker, prior radiofrequency ablation; valvular heart disease and prosthetics; acute myocarditis, infective endocarditis, hypertrophic, dilated, and restrictive cardiomyopathies, storage diseases, severe liver diseases; thyroid disorders; cancer; acute inflammatory and infectious diseases; alcohol abuse, dementia and mental illness.Results. The groups did not differ significantly in terms of sex, age, cardiovascular risk factors, risk of stroke and bleeding when using anticoagulants, clinical and laboratory parameters, and the structure of drug therapy. The following parameters significant differ between the groups: LAVI (according to study design), mid-regional pro-atrial natriuretic peptide (MR-proANP), glomerular filtration rate (GFR) calculated by creatinine, tissue inhibitor of matrix metalloproteinases 1 (TIMP-1). For MR-proANP, GFR, TIMP-1, ROC curves were created in order to determine its clinical significance and operational characteristics of parameters. GFR, as a diagnostic criterion, showed unsatisfactory clinical significance when constructing the ROC curve: AUC (area under the curve) was 0,38. The MR-proANP of 62,3-85 pmol/L and TIMP-1 of 156 ng/ml and higher allows verification of atrial cardiomyopathy in patients with T2D and AF at AUC of 0,83 (95% confidence interval (CI), 0,73; 0,92) and 0,90 (95% CI, 0,83; 0,98), respectively.Conclusion. The blood MR-proANP concentration of 62,3-85 pmol/L is diagnostic for atrial cardiomyopathy in patients with T2D and AF with the sensitivity and specificity of 96,8% and 75,5%, respectively, while TIMP-1 values of 156 ng/ml and above had the sensitivity and specificity of 90,3% and 87,8%, respectively.
This review presents prevalence of type 2 diabetes mellitus (DM) in patients with ischemic heart disease (IHD), risk factors in common, and a considerable worsening of prognosis in their combination. The authors addressed pathophysiological mechanisms of platelet dysfunction and negative changes in the coagulation system in IHD patients with type 2 DM, which predetermine activation of the prothrombotic pathway of hemostasis formation. Difficulties in optimal selection of antithrombotic therapy were demonstrated for both patients with type 2 DM without a history of cardiovascular diseases and IHD patients with type 2 DM. The authors paid attention to the fact that results of randomized clinical studies (RCS) that included patients with type 2 DM and acute coronary syndrome or after coronary revascularization cannot be extrapolated to the entire population of patients with stable IHD. At present, the preferable choice of antithrombotic therapy for patients with type 2 DM and stable IHD is a combination of rivaroxaban 2.5 mg twice a day and acetylsalicylic acid 100 mg/day. This combination provides a maximal clinical benefit compared to other strategies presented in RCS.
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