Дифференцированный подход в диагностике, формулировке диагноза, ведении больных и статистическом учете инфаркта миокарда 2 типа (согласованная позиция)

Aim. Compare radiological patterns of COVID-19 pneumonia with pulmonary histology in deceased patients. Materials and methods. The analysis of recent lifetime CT studies of deceased patients was performed with the identification of all existing and leading CT symptoms, including “ground glass”, “crazy paving”, consolidation, as well as the symptom complex (pattern) of organizing pneumonia. Based on the CT symptoms, we selected the target points for taking the specimens by 3-D reconstructions. At the autopsy the lungs were entirely fixed into the front and then marked on CT sections cut from 1 to 3 pieces that were placed in paraffin and processed according to the standard technique, stained with hematoxylin and eosin and fuchsin-facelina. The specimens were analyzed by identifying all available histology changes and selecting the leading one. Results. 45 targeted pieces of lung tissue were obtained from 14 deceased COVID-19 patients (7 men/ 7 women), with an average age of 77.1 ± 12.9 (49–90 years). In deceased patients with the presence of the "ground glass" symptom, in most cases (57.1%) revealed an increase in intra-alveolar cellularity, hyaline membranes, desquamation of the alveolar epithelium and infiltration of the interalveolar septum by lymphocytes, which corresponds to the exudative phase of diffuse alveolar damage (DAP). Mosaic histological changes with alternation of filled alveoli (intraalveolar edema, clusters of red blood cells, macrophages, lymphocytes) and air alveoli were detected from the areas of “crazy paving” zones. Several cases demonstrated interstitial edema and lymphoid infiltration of interalveolar partitions of different severity without their thickening. Areas of consolidation were histologically represented by extensive intraalveolar hemorrhages and / or typical zones of hemorrhagic infarcts in 45.5% of cases. Perilobular consolidation, subpleural cords, symptoms of “halo” and “reverse halo”, which we considered as part of the symptom complex of organizing pneumonia in 43% of cases, morphologically corresponded to organizing pneumonia (the proliferative phase of DAP), as well as to distelectases. Conclusion. Comparison of CT patters and post-mortem pulmonary histology in COVID-19 deceased patients demonstrated that CT symptoms and patterns correspond to certain morphological changes of different phases of DAP.

Background: Acute heart failure (AHF) is one of the leading causes of admissions to the emergency department (ED). There is a need to develop an easy-to-use score that can be used in the ED to risk-stratify patients with AHF and in hospitalization decisions regarding cardiac wards or intensive care units (ICUs). Methods: A retrospective observational study was conducted at a city hospital. The data from the presentation of AHF patients at the ED were collected. The combined primary endpoint included death from any cause during hospitalization or transfer to an intensive care unit (ICU) for using inotropes/vasopressors. Feature selection was performed using artificial intelligence. Results: From August 2020 to August 2021, 908 patients were enrolled (mean age: 71.6 ± 13 years; 500 (55.1%) men). We found significant predictors of in-hospital mortality and ICU transfers for inotrope/vasopressor use and built two models to assess the need for ICU admission of patients from the ED. The first model included SpO₂ < 90%, QTc duration, prior diabetes mellitus and HF diagnosis, serum chloride concentration, respiratory rate and atrial fibrillation on admission, blood urea nitrogen (BUN) levels, and any implanted devices. The second model included left ventricular end-diastolic size, systolic blood pressure, pulse blood pressure, BUN levels, right atrium size, serum chloride, sodium and uric acid concentrations, prior loop diuretic use, and pulmonary artery systolic blood pressure. Conclusions: We developed two models that demonstrated a high negative predictive value, which allowed us to distinguish patients with low risk and determine patients who can be hospitalized and sent from the ED to the floor. These easy-to-use models can be used at the ED.

Aim . The aim of this study was to evaluate the clinical and cost-effectiveness of computed tomography angiography (CTA), which includes CT coronary angiography and a “triple rule-out” protocol, in intermediate-risk patients with suspected non-ST-segment elevation acute coronary syndrome (NSTEACS) in the emergency room (ER) of the regional vascular center in the structure of a multidisciplinary hospital in Moscow. Material and methods . This continuous single-site study included patients hospitalized in a multidisciplinary hospital with a referral diagnosis of NSTEACS within 69 days. Patients at intermediate risk who met the inclusion criteria underwent CTA after the initial examination in the ER. If coronary artery disease or an alternative significant diagnosis was excluded, patients were discharged from the hospital on the day of admission. As a comparison method, the costs of treating these patients were assessed if a standard protocol was used. According to this protocol, patients, after the initial examination, were hospitalized in the intensive care unit for patients with myocardial infarction (ICU-MI) and then in the cardiology department for observation and further examination. Clinical economic analysis was performed using the cost minimization method and the tariff method of cost estimation. Results . For 69 days, 289 patients (59.5% men, mean age 71.7±8.6 years) were admitted to the ER with a referral diagnosis of NSTEACS. In 30 of them, a non-cardiological disease was identified that required routing to other specialized units. 37 (14.3%) of intermediate-risk patients underwent CTA. In 27 of them (10% of all patients), no significant coronary stenosis, signs of pulmonary embolism (PE), or aortic dissection were detected, and the patients were discharged from the ER. 10 patients (4% of all patients) who had significant coronary artery stenoses, PE, or aortic dissection were hospitalized. 72 intermediate-risk patients had exclusion criteria for CTA. The economic benefit from using CTA for excluding ACS in the ER, as compared to the standard approach, was 1,602,450 rubles for the study period. The estimated benefit per year was 8,476,728 rubles. Conclusion . The introduction of CTA and the “triple rule-out” protocol for intermediate-risk patients in the ER can significantly improve the process of excluding the diagnosis of NSTEACS, reduce the number of unnecessary hospitalizations and optimize the use of hospital capacity. According to the results of our study, this approach is applicable in at least 14% of patients with suspected NSTEACS (at least 33% of intermediate-risk patients).

Tachycardia-induced cardiomyopathy (TIC) is a reversible subtype of dilated cardiomyopathy (DCM) resulting from sustained supraventricular or ventricular tachycardia and diagnosed by the normalization of left ventricular ejection fraction (LVEF) after stable sinus rhythm restoration. The aim of this study was to determine the contribution of cardiac magnetic resonance (CMR) to the differential diagnosis of TIC and DCM with persistent atrial arrythmias in patients hospitalized for the first time with heart failure (HF) with reduced LVEF of nonischemic origin. A total of 29 patients (age: 58.2 ± 16.9 years; males: 65.5%; average EF: 37.0 ± 9.5%) with persistent atrial tachyarrhythmia and first decompensation of HF without known coronary artery diseases were included in this study. The patients successfully underwent cardioversion and were observed for 30 days. The study population was divided into groups of responders (TIC patients; N = 16), which implies achieving FF > 50% or its increase > 10% in 30 days of TIC, and non-responders (N = 13). The increase in left ventricle (LV) volumes measured using CMR was significantly higher in the non-responder group when compared with the responders (114.8 mL ± 25.1 vs. 68.1 mL ± 10.5, respectively, p < 0.05). Non-responders also demonstrated decreased interventricular septum thickness (9.1 ± 0.8 vs.11.5 ± 1.3, respectively, p < 0.05). Late gadolinium enhancement (LGE) was observed in 12 patients (41.4%). The prevalence of LGE was increased in the non-responder group (25.0% vs. 65.1%, respectively, p = 0.046). Notably, a septal mid-wall LGE pattern was found exclusively in the non-responders. Epicardial adipose tissue thickness was decreased in the non-responder group versus the TIC patients. Conclusion: Patients with TIC were found to have smaller atrial and ventricular dimensions in comparison to patients with DCM. In addition, LGE was more common in DCM patients.

Acute myocardial infarction (AMI) is one of the main causes of morbidity and mortality, both in the Russian Federation and around the world. Approximately, in up to 10% of patients with clinical diagnostic features of AMI, early angiography does not reveal an occluded vessel or possibly any evidence of coronary artery disease. These patients constitute an intriguing subgroup referred to as “Myocardial Infarction with Non-Obstructive Coronary Arteries” (MINOCA). MINOCA is a collective concept that unites many different pathologies, which determines the essential heterogeneity of the etiological factors. Coronary artery embolism is recognized as an important non-atherosclerotic cause of AMI. In turn, the most common underlying disease in those with coronary embolism is the atrial fibrillation. The advantages of reperfusion strategy and cardioprotective therapy in the treatment of obstructive arteriosclerosis are well studied, widely presented in the literature and supported by a strong evidence base, while the issues of diagnosis and treatment of patients with MINOCA are currently widely discussed We present two clinical cases of embolic myocardial infarction in patients with atrial fibrillation, diagnosed in our clinic in 2017.