Репозиторий Университета

© 2018 Stolichnaya Izdatelskaya Kompaniya. All rights reserved. This article affects the problems of using NOAC in the most defenseless groups of patients with atrial fibrillation: those who have high bleeding and high thromboembolic risk and elderly. The focus is on comparison of effectiveness and safety of NOACs based on randomized clinical trials (RCT) and real-world data (RWD). The possible reasons for the different interpretation of the data of the RCT and the RWD are shown. Use of NOAC in reduced doses prescribing according to RCT and RWD are shown. Our own 13-month observation of patients 75 years and older with very high thromboembolic risk (CHA2DS2-VASc-4,5 points) on rivaroxaban therapy are presented. Good efficacy and safety of full and reduced doses of rivaroxaban were demonstrated: only 2 episodes of small bleedings and no large bleedings (ISTH criteria) were detected as well as no thromboembolic events. Thus, even difficult patients with AF and comorbidity may be safely and effectively treated with NOACs taking into consideration integrated approach and correction of modifiable risk factors.

© 2018, Media Sphera Publishing Group. All rights reserved. Venous surgery prescribed to the patients receiving anticoagulation therapy for the treatment of atrial fibrillation especially with the use of warfarin is considered to constitute a serious challenge due to the increased risk of the development of venous thromboembolism and other hemorrhagic complications in case of withdrawal of the anticoagulant. A clinical case of successful perioperative management of the patient with varicose veins with the use of long-term warfarin therapy for the management of atrial fibrillation is presented. Several surgical clinics refused to treat the patient on a regular basis on the ground of impracticability of any invasive procedures because of the patient’s condition taking into consideration the involuntary intake of the anticoagulation agent and the concomitant cardiac pathology. We performed the primary clinical examination and duplex ultrasound study of the patient who was found to have varicose veins in right lower extremity (С2, 3S, Ер, Аs, p, Pr2,18, LII) with the international normalized ratio (INR) being 3,64. We confirmed the indication for the surgical treatment and offered the patient high ligation, stripping and phlebectomy. Prior to surgery, the patient was switched to a subcutaneous injection of enoxaparin. After reducing INR down to less the 2.0, we performed surgery under spinal anesthesia. The anticoagulation treatment was restarted 12 hours after the operation. No complications was documented within the first weeks after the intervention. The patient was switched back to warfarin therapy.

© 2018 Limited Liability Company KlinMed Consulting. All Rights Reserved. Purpose: to elucidate predictors of development of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary artery thromboembolism (PTE). Material and methods. We included in this study 210 patients hospitalized with diagnosis of submassive and massive PTE from 2013 to 2017. In 1 to 3 years after initial hospitalization these patients were invited for control examination. According to results of this examination patients were divided into two groups: with (group 1, n=45) and without (group 2, n=165) signs of CTEPH. Severity of pulmonary artery vascular bed involvement was assessed by multislice computed tomography (MSCT) angiography and lung scintigraphy. For detection of thrombosis in the inferior vena cava system we used ultrasound angioscanning. Examination also included echocardiography. Results. In the process of mathematical analysis, the following risk factors for the development of CTEPH embolism were determined: duration of thrombotic history (group 1 - 13.70±2.05 days, group 2- 16.16±1.13 days, p=0.015), localization of venous thrombosis in the lower extremities (the most favorable - shin veins, popliteal, and common femoral veins, unfavorable - superficial femoral vein). The choice of the drug for thrombolytic and anticoagulant therapy: streptokinase and urokinase were significantly more effective than alteplase, rivaroxaban was superior to the combination of unfractionated or low molecular weight heparins with warfarin. Also, risk factors for the development of CTEPH were the initial degree of pulmonary hypertension and tricuspid insufficiency, as well as the positive dynamics of these indicators at the background of thrombolytic or anticoagulant therapy. Of concomitant diseases, significant risk factors for development of CTEPH were grade 3 hypertensive disease, diabetes mellitus, postinfarction cardiosclerosis. On the other hand, age, gender, degree of severity at the time of admission, presence of infarction pneumonia, surgical prevention of recurrent pulmonary embolism, number of pregnancies and deliveries, history of trauma and malignancies, cardiac arrhythmias produced no significant impact on the development of CTEPH.

© 2018 Media Sphera Publishing Group. All Rights Reserved. Aim - the objective of the present work was to analyze the data obtained in a study involving a group of patients presenting with recurrent deep vein thrombosis and/or bleeding who had been treated with the use of vitamin K antagonists. Material and methods. A total of 116 patients presenting either with recurrent deep vein thrombosis (n=10) or bleeding that developed while patients had been on the therapy with vitamin K antagonists were enrolled in the study. We performed clinical and instrumental examination as well as laboratory testing of the hemostatic system. All the patients received warfarin during 6 months or longer with 32 of them taking this medication to prevent deep vein thrombosis and the remaining 84 for the treatment of various cardiac diseases. The results of the clinical, instrumental, and laboratory studies provided a basis for the choice of the treatment strategies. Results. Sixty seven of the 116 patients were treated non-surgically while 27 patients were operated (25 urgently and two within 2 days after the admission to the hospital). 20 patients underwent endoscopic hemostasis, in two others the hematoma was punctured under ultrasound guidance. Eight patients presenting with recurrent deep vein thrombosis received the conservative treatment reduced to the correction of anticoagulation therapy (they were first switched from warfarin to heparins with the subsequent resumption of warfarin treatment using the individually adjusted doses of the drug). Two patients with free-floating thrombi in the main veins required the surgical intervention to prevent pulmonary embolism. The conservative treatment of the patients with bleedings included the withdrawal of warfarin together with the simultaneous administration of vitamin K1, fresh frozen plasma, and prothrombin complex concentrate in different combinations taking into consideration the results of clinical examination and laboratory testing. The conservative treatment was successful in all the cases. No severe complications, life-threatening conditions or death were documented. Conclusion. The patients receiving vitamin K antagonists are at enhanced risk of both a relapse of venous thromboembolism and bleedings. The timely started and appropriate management can prevent the severe complications.