CC BY
12DOI: 10.12731/wsd-2017-4-34-46 UDC 616.127-005.8
MYOCARDIAL REVASCULARIzATION IN ACUTE CORONARY SYNDROME IN UDMURT REPUBLIC
Kuzmina N.M.
The urgency of the investigated problem is caused by high mortality from cardiovascular diseases. The aim of the study is to evaluate the results of myocardial revascularization in acute coronary syndrome. In the study of this problem, theoretical and empirical methods are applied: analysis of literature, study and generalization of innovative medical experience, analysis, synthesis, observation.
Materials and methods. We studied retrospectively 125 case histories of patients who entered the Republican Clinical Diagnostic Center in 2015 with the diagnosis of acute coronary syndrome (ACS) for percutaneous coronary intervention (PCI) and treated in the department of acute myocardial infarction No.1. All patients underwent PCI. These patients have a stent in the coronary artery. The 95 patients were admitted to the control echocardiography 1.8-2 years after PCI. The data was analyzed using the Microsoft Excel program.
Results. Basically there is a rescue or prepared PCI in our republic. In 77% of patients, the pathological wave Q / QS was formed at the time of admission. The left ventricle ejection fraction was higher and the number of nonfunctional zones of myocardium was lower in patients who had undergone PCI later. The echocardiography results are improving with an increase of the time from onset of the disease to percutaneous coronary interventions.
Conclusions. It is shown that at the time of reoxygenation the formation of reactive oxygen species sharply increases and can damage the cell. This article can be useful for cardiologists, intervention surgeons, therapists, medical students, interns, postgraduate students.
Keywords: ischemic heart disease; acute coronary syndrome; myocardial infarction; unstable angina; percutaneous coronary interventions; lipid per-oxidation.
РЕВАСКУЛЯРИЗАЦИЯ МИОКАРДА ПРИ ОСТРОМ КОРОНАРНОМ СИНДРОМЕ В УДМУРТСКОЙ РЕСПУБЛИКЕ
Кузьмина Н.М.
Актуальность изучаемой проблемы обусловлена высокой смертностью от сердечно-сосудистых заболеваний. Целью работы является оценка результатов реваскуляризации миокарда при остром коронарном синдроме.
Материалы и методы. Ретроспективно было изучено 125 историй болезни пациентов, поступивших с острым коронарным синдромом в отделение острого инфаркта миокарда №1 БУЗ УР «Республиканского клинико-диагностического центра МЗ УР». Всем пациентам проведено чрескожное коронарное вмешательство (ЧКВ), установлен стент в коронарную артерию. 95 пациентам была проведена контрольная эхокар-диогарфия спустя 1,8-2 года после ЧКВ. Данные были проанализированы при помощи программы Microsoft Excel.
Результаты. В основном в Удмуртии в 2015 году проводилось спасительное или отсроченное ЧКВ. У 77% пациентов к моменту поступления сформировался патологический зубец Q/QS. Фракция выброса больше, количество афункциональных зон меньше у пациентов с большим временем от начала клиники до ЧКВ.
Выводы. Это говорит о том, что возможно во время реоксигенации активируется перекисное окисление липидов и свободные радикалы повреждают клетки. Данная статья может быть полезна врачам-кардиологам, терапевтам, интервенционным хирургам, ординаторам, аспирантам.
Ключевые слова: ишемическая болезнь сердца; острый коронарный синдром; инфаркт миокарда; нестабильная стенокардия; чрескожное коронарное вмешательство; перекисное окисление липидов.
1. Introduction
1.1. Relevance
Ischemic heart disease (IHD) is a socially significant disease. IHD is characterized by a high prevalence among the population, a recurring course of the disease, repeated and prolonged inpatient treatment. Exacerbation of IHD is an acute coronary syndrome. Acute coronary syndrome (ACS) is one of the most frequent causes of hospitalization of patients.
1.2. Literature Review 1.2.1 Atheroslerosis
Worldwide, coronary artery disease (CAD) is the most frequent cause of death. Over seven million people die from CAD every year, accounting for 12.8% of all deaths. Every sixth man and every seventh woman in Europe will die from myocardial infarction [1, p. 733].
ACS refers to any group of clinical signs or symptoms that allow suspected acute myocardial infarction (MI) or unstable angina (UA). With ACS, the likelihood of developing myocardial infarction with all its consequences (arrhythmias, heart failure) increases, and the high death rate of patients remains significant [2, p. 825].
It is considered that the cause of IHD is atherosclerosis of the heart vessels. The most significant complications of the atherosclerotic process are:
1. A hemodynamically significant narrowing of the artery lumen due to an atherosclerotic plaque protruding into the lumen of the artery (Fig. 1).
2. Destruction of the fibrous capsule, its ulceration, platelet aggregation and the genesis of a parietal thrombus (Fig. 1).
3. The rupture of the fibrous capsule of the atherosclerotic plaque and the loss of the contents of the detritus lipid core into the lumen of the vessel. The detritus lipid core can become a source of embolism or the formation of a parietal thrombus.
4. Hemorrhage into the plaque from newly formed microvessels. It also can contributes to the rupture of plaque cover and the formation of a thrombus on the surface of the atherosclerotic plaque.
5. The deposition of calcium salts in atheromatous masses, interstitial substance and fibrous tissue, it significantly increase the density of atherosclerotic plaque [3, p. 13].
Fig. 1. Atherosclerotic plaque
1.2.2 Percutaneous coronary interventions The fight against IHD is very active now. The goal is to save the lives of patients. Progress in this field is associated with the development of high-tech medical care in acute coronary syndrome in the form of percutaneous coronary interventions (PCI) (Fig. 2) [4, p. 1598].
Fig. 2. PCI
Types of PCI:
- Primary PCI is defined as an emergent percutaneous catheter intervention in the setting of ACS, without previous fibrinolytic treatment. Lower mortality rates among patients undergoing primary PCI are observed in centres with a high volume of PCI procedures. Primary PCI is effective in securing and maintaining coronary artery patency and avoids some of the bleeding risks of fibrinolysis [5, p. 19]; [6, p. 13]; [7, p. 2686];
- Rescue PCI is an intervention performed in a symptom-responsible artery that remains occluded after the administration of thrombolytic agents. In settings where primary PCI cannot be performed within 120 min of FMC by an experienced team, fibrinolysis should be considered, particularly if it can be given pre-hospital (e.g. in the ambulance) and within the first 120 min of symptom onset [8, p. 2512]; [9, p. 429]; [10, p. 2851]. It should be followed by consideration of rescue PCI or routine angiography [11, p. 94].
- Prepared ("facilitated") PCI is a planned intervention within 12 hours of the development of symptoms of MI, occurring shortly after the use of fibrinolytic agents and / or platelet IIb / IIIa receptor blockers [12, p. 156].
The logistics algorithm for acute myocardial infarction is represented in Figure 3.
Fig. 3. Prehospital and in-hospital management and reperfusion strategies within 24 h of FMC (adapted from Wijns et al.) [13, p. 2501]; [19, p. 15].
1.2.3. Lipid peroxidation At the same time, the complex problem of atherosclerosis cannot be reduced to the level of cholesterol and lipoproteins in the blood. In recent years, the literature discusses the role of lipid peroxidation (LPO) in the etiology and pathogenesis of atherosclerosis.
Indeed, the membranes of cells and subcellular organelles, as well as blood plasma lipoproteins contain phospholipids. There are polyunsaturated fatty acids (PUFAs) are localized.in the b-position of phospholipids. PUFAs are readily subjected to free radical peroxide oxidation in the presence of oxygen with formation of corresponding lipid peroxides [14, p. 1413]; [15, p. 305]; [16, p. 299].
Active forms of oxygen damage the structure of DNA, proteins and various membrane structures of cells [17, p. 127]. As a result of the appearance of hydrophilic zones in the hydrophobic layer due to the formation of hydroperoxides of fatty acids water, sodium, calcium ions can penetrate into the cells, which leads to the swelling of cells, organelles and their destruction[18, p. 257]; [19, p. 340]. Peroxide oxidation is also activated in tissues that underwent first ischemia and then reoxygenation, which occurs in spasm of the coronary arteries and their subsequent expansion [9, p. 429].
2. Materials and Methods 2.1. The aim
The aim of the study is to evaluate the results of myocardial revascularization in acute coronary syndrome.
2.2 Research objectives
The research objectives are: 1) to see the time of PCI; 2) to consider the structure of ACS; 3) to study the age of patients; 4) to study the kinds of the lesion of the coronary arteries; 4) to study the parameters of echocardiography.
2.3. Hypothesis
Hypothesis. Early revascularization in the first minutes of ACS does not always have a positive effect on the myocardium, the contractile function of the myocardium decreases.
2.4. Inclusion criteria: the presence of ACS, the absence of previously transferred coronary artery bypass grafting (CABG) or stenting of the coronary arteries (CA).
2.5. Exclusion criteria: previous CABG or CA stenting, active tuberculosis, prisoners, incompetent persons.
2.6. Proсess of the study
We studied retrospectively 155 case histories of patients who entered the Republican Clinical Diagnostic Center in 2015 with the diagnosis of acute coronary syndrome (ACS) for percutaneous coronary intervention (PCI) and treated in the department of acute myocardial infarction No.1. The data was analyzed using the Microsoft Excel program.
All patients underwent PCI. These patients have a stent in the coronary artery. Patients were admitted to the control echocardiography 1.8-2 years after PCI.
3. Results
With unstable angina was received 22 patients, with acute myocardial in-farction-133 patients.
Age averaged 59 years ± 10.62 (min-34 years, max-88 years, mode-66 years). The body mass index (BMI) is on average-27.02 ± 2.87 (mode-25.71).
The time from the onset of pain to the "balloon" in 32 patients was 1-6 hours, 11 patients-6-12 hours, 112 patients-more than 12 hours.
In 77% of patients, pathological wave Q / QS was formed.
Thrombolytic therapy was performed in 27% of cases at the prehospital stage.
Lesion of the left main coronary artery was in 42 patients (stenoses within 15-80%), in 14 patients (9%) stenoses reached 50-80%.
Stenoses of more than 75% in the proximal segment of the anterior inter-ventricular artery was identified in 64 patients (41%), in the middle section - in 61 patients (39%), in the distal segment - in 17 patients (11%).
Stenoses of more than 75% in the proximal segment of the left circumflex coronary artery artery was identified in 28 patients (38%), in the middle section - in 13 patients (18%), in the distal segment - in 32 patients (44%).
Stenoses of more than 75% in the proximal segment of the right coronary artery artery was identified in 26 patients (25%), in the middle section - in 59 patients (58%), in the distal segment - in 17 patients (17%).
All patients underwent stenting of the infarct-dependent coronary artery. The protocols of echocardiography are analyzed. The left ventricle ejection fraction (LVEF) averaged 55.98 ± 7.81% (min-28%, max-73%), the final diastolic volume of the left ventricle (LV) was 139.82 ± 29.33 ml (min-74 ml, max-313 ml).
Interrelationships were revealed (Pirson coefficient):
- a direct statistically significant relationship between the time from onset of the disease to the "balloon" and the left ventricle ejection fraction (r = 0.3, p <0.05);
- a direct statistically significant relationship between the time from onset of the disease to the "balloon" and the number of zones with regional wall-motion abnormalities of the LV (r = -0.18, p <0.05);
- inverse correlative statistically significant relationship between lesion of the left main coronary artery and LVEF (r = -0.16, p <0.05);
- a direct correlation statistically significant relationship between the body mass index and lesion of the left main coronary artery (r = 0.24, p <0.05).
Identified by the Spearman rank correlation coefficient:
- a inverse statistically significant relationship between the time from onset of the disease to the "balloon" and the left ventricle ejection fraction after 1.8-2 years from PCI (rs = -0.331, p<0.01);
- a inverse statistically significant relationship between the time from onset of the disease to the "balloon" and the left ventricle end-diastolic volume after 1.8-2 years from PCI (rs = -0.17, p<0.05);
- a inverse statistically significant relationship between the time from onset of the disease to the "balloon" and the right ventricle end-diastolic volume after 1.8-2 years from PCI (r = -0.583, p<0.01).
4. Discussion
An overwhelming number of patients were admitted to the PCI laboratory at 12 hours or more from the onset of symptoms. Basically, there is a rescue or prepared PCI. In 77% of patients, the pathological wave Q / QS was formed at the time of admission. The left ventricle ejection fraction was higher and the number of nonfunctional zones of myocardium was lower in patients who had undergone PCI later. The echocardiography results are improving with an increase of the time from onset of the disease to PCI. Patients with a longer pain-balloon time had a lower end-diastolic LV volume, a smaller right ventricular cavity in the diastole, a smaller LV ejection fraction due to reduced end-diastolic LV volume and a hypo / akinesia zone after 1.8-2 years from PCI.
5. Conclusions
The formation of a thrombus leads to the occlusion of the lumen of the vessel and the development of ischemia in the corresponding part of the myocardium (tissue hypoxia). If rapid medical measures are taken to destroy the thrombus, oxygen supply (reoxygenation) is restored in the tissue. It is shown that at the time of reoxygenation the formation of reactive oxygen species sharply increases and can damage the cell. Thus, despite the rapid restoration of blood circulation cells are damaged at the corresponding site of the myocardium by the activation of peroxidation.
6. Recommendations
This article can be useful for cardiologists, intervention surgeons, therapists, medical students, interns, postgraduate students.
References
1. Andersen H.R., Nielsen T.T., Rasmussen K., Thuesen L., Kelbaek H., Thays-sen P., Abildgaard U., Pedersen F., Madsen J.K., Grande P., Villadsen A.B., Krusell L.R., Haghfelt T., Lomholt P., Husted S.E., Vigholt E., Kjaergard H.K. & Mortensen L.S. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med, 2003, no. 349, pp. 733-742.
2. Bonnefoy E., Lapostolle F., Leizorovicz A., Steg G., McFadden E.P., Dubi-en P.Y., Cattan S., Boullenger E., Machecourt J., Lacroute J.M., Cassagnes J., Dissait F., & Touboul P. Primary angioplasty vs. pre-hospital fibrinolysis in acute myocardial infarction: a randomised study. Lancet, 2002, no. 360, pp. 825-829.
3. Novitsky V.V., Goldberg E.D. Pathophysiology. Vol. 2. 2009, pp. 13-16.
4. Bonnefoy E., Steg P.G., Boutitie F., Dubien P.Y., Lapostolle F. & Touboul P. Comparison of primaryangioplastyand pre-hospital fibrinolysis in acute myo-cardial infarction (CAPTIM) trial: a 5-year follow-up. Eur Heart J, 2009, no. 30, pp. 1598-1606.
5. Ph. Gabriel Steg ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 2012, Vol. 33, no. 20, pp. 2569-2619. doi: 10.1093/eurheartj/ehs215
6. Keeley E.C., Boura J.A.& Grines C.L. Primary angioplasty vs. intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet, 2003, no. 361, pp. 13-20.
7. Morrison L.J., Verbeek P.R., McDonald A.C., Sawadsky B.V. & Cook D.J.. Mortality and pre-hospital thrombolysis for acute myocardial infarction: A meta-analysis. JAMA, 2000, no. 283, pp. 2686-2692.
8. Pinto D.S., Frederick P.D., Chakrabarti A.K., Kirtane A.J., Ullman E., Dejam A., Miller D.P., Henry T.D. & Gibson C.M. Benefit of transferring ST-seg-ment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase. Circulation, 2011, no. 124, pp. 2512-2521.
9. Severina E.S. Biochemistry, 2003, pp. 429-433.
10. Steg P.G., Bonnefoy E., Chabaud S., Lapostolle F., Dubien P.Y., Cristofini P., Leizorovicz A. & Touboul P. Impact of time to treatment on mortality after pre-hospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial. Circulation, 2003, no. 108, pp. 2851-2856.
11. Widimsky P., Budesinsky T., Vorac D., Groch L., Zelizko M., Aschermann M., Branny M., St'asek J. & Formanek P. Long distance transport for primary an-gioplasty vs. immediate thrombolysis in acute myocardial infarction. Final re-
suits of the randomized national multicentre trial - PRAGUE-2. Eur Heart J, 2003, no. 24, pp. 94-104.
12. Wijns W., Kolh P., Danchin N., Di Mario C, Falk V., Folliguet T., Garg S., Huber K., James S., Knuuti J., Lopez-Sendon J., Marco J., Menicanti L., Ostojic M., Piepoli M.F., Pirlet C., Pomar J.L., Reifart N., Ribichmi F.L., Schalij M.J., Sergeant P., Serruys P.W., Silber S., Sousa Uva M., Taggart D., Vahanian A., Auricchio A., Bax J., Ceconi C., Dean V., Filippatos G.& Wheatley D.J. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 2013. European Heart Journal, European Society of Cardiology. http://www.escardio.org/ guidelines.
13. Windecker S., Zembala M. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2010, no. 31, pp. 2501-2555.
14. Zijlstra F, Hoorntje J.C., de Boer M.J., Reiffers S, Miedema K, Ottervanger J.P., van 't Hof A.W. & Suryapranata H. Long-term benefit of primary angio-plastyas compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med, 2008, no. 341, pp. 1413-1419.
15. Basiev V.A. Clinical characteristics of patients with cardiovascular diseases. In the world of scientific discoveries. 2010. № 6-3, pp. 305-306.
16. Basiev V.A. Dynamics of cardiac rhythm disturbances and electrical indices in IHD patients before and after surgery. In the world of scientific discoveries. 2011. V. 16. № 4, pp. 299-304.
17. Basiev VA, Astakhova Z.T. Improvement of the system of rehabilitation and quality of life of patients with coronary heart disease. In the world of scientific discoveries. 2012. No. 5.3, pp. 127-136.
18. Alexander K.P., Newby L.K., Armstrong P.W. et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation, 2007, Vol. 15, no. 19, pp. 257-258.
19. Le Quintrec J., Bussy C., Golmard J.-L. et al. Randomized Controlled Drug Trials on Very Elderly Subjects: Descriptive and Methodological Analysis of Trials Published Between 1990 and 2002 and Comparison With Trials on Adults. J. Gerontology, 2005, Vol. 60, no. 3, pp. 340-344.
20. Zaretsky A.P. Models and algorithms of decision support for stenting of the coronary arteries. The dissertation author's abstract on competition of a scientific degree of the candidate of engineering science, 2015. http://tekhnosfera.
comImodeli-i-algoritmy-podderzhki-prinyatiya-resheniy-pri-stentirovanii-kor-onarnyh-arteriy#ixzz4rdnVsdle
Список литературы
1. Andersen H.R., Nielsen T.T., Rasmussen K., Thuesen L., Kelbaek H., Thays-sen P., Abildgaard U., Pedersen F., Madsen J.K., Grande P., Villadsen A.B., Krusell L.R., Haghfelt T., Lomholt P., Husted S.E., Vigholt E., Kjaergard H.K. & Mortensen L.S. A comparison of coronary angioplasty with fibrino-lytic therapy in acute myocardial infarction. N Engl J Med, 2003, no. 349, pp. 733-742.
2. Bonnefoy E., Lapostolle F., Leizorovicz A., Steg G., McFadden E.P., Dubien P.Y., Cattan S., Boullenger E., Machecourt J., Lacroute J.M., Cassagnes J., Dissait F., & Touboul P. Primary angioplasty vs. pre-hospital fibrinolysis in acute myocardial infarction: a randomised study. Lancet, 2002, no. 360, pp. 825-829.
3. Novitsky V.V., Goldberg E.D. Patofiziologiya [Pathophysiology]. Vol. 2. 2009, pp. 13-16.
4. Bonnefoy E., Steg P.G., Boutitie F., Dubien P.Y., Lapostolle F. & Touboul P. Comparison of primaryangioplastyand pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: a 5-year follow-up. Eur Heart J, 2009, no. 30, pp. 1598-1606.
5. Ph. Gabriel Steg ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 2012, Vol. 33, no. 20, pp. 2569-2619. doi: 10.1093leurheartjlehs215
6. Keeley E.C., Boura J.A.& Grines C.L. Primary angioplasty vs. intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet, 2003, no. 361, pp. 13-20.
7. Morrison L.J., Verbeek P.R., McDonald A.C., Sawadsky B.V. & Cook D.J. Mortality and pre-hospital thrombolysis for acute myocardial infarction: A meta-analysis. JAMA, 2000, no. 283, pp. 2686-2692.
8. Pinto D.S., Frederick P.D., Chakrabarti A.K., Kirtane A.J., Ullman E., Dejam A., Miller D.P., Henry T.D. & Gibson C.M. Benefit of transferring ST-seg-ment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase. Circulation, 2011, no. 124, pp. 2512-2521.
9. Severina E.S. Biokhimiya [Biochemistry], 2003, pp. 429-433.
10. Steg P.G., Bonnefoy E., Chabaud S., Lapostolle F., Dubien P.Y., Cristofini P., Leizorovicz A. & Touboul P. Impact of time to treatment on mortality after pre-
hospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial. Circulation, 2003, no. 108, pp. 2851-2856.
11. Widimsky P., Budesinsky T., Vorac D., Groch L., Zelizko M., Aschermann M., Branny M., St'asek J. & Formanek P. Long distance transport for primary angioplasty vs. immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial - PRAGUE-2. Eur Heart J, 2003, no. 24, pp. 94-104.
12. Wijns W., Kolh P., Danchin N., Di Mario C, Falk V., Folliguet T., Garg S., Huber K., James S., Knuuti J., Lopez-Sendon J., Marco J., Menicanti L., Ostojic M., Piepoli M.F., Pirlet C., Pomar J.L., Reifart N., Ribichmi F.L., Schalij M.J., Sergeant P., Serruys P.W., Silber S., Sousa Uva M., Taggart D., Vahanian A., Auricchio A., Bax J., Ceconi C., Dean V., Filippatos G.& Wheatley D.J. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 2013. European Heart Journal, European Society of Cardiology http://www.escardio.org/ guidelines.
13. Windecker S., Zembala M. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2010, no. 31 pp. 2501-2555.
14. Zijlstra F., Hoorntje J.C., de Boer M.J., Reiffers S, Miedema K, Ottervanger J.P., van 't Hof A.W. & Suryapranata H. Long-term benefit of primary angio-plastyas compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med, 2008, no. 341, pp. 1413-1419.
15. Басиев В.А. Клиническая характеристика пациентов с сердечно-сосудистыми заболеваниями // В мире научных открытий. 2010. № 6-3. С. 305.
16. Басиев В.А. Динамика нарушений сердечного ритма и электрических показателей у пациентов ИБС до и после хирургического вмешательства // В мире научных открытий. 2011. Т. 16. № 4. С. 299-304.
17. Басиев В.А., Астахова З.Т. Улучшение системы реабилитации и качества жизни больных с ишемической болезнью сердца // В мире научных открытий. 2012. № 5.3. С. 127-136.
18. Alexander K.P., Newby L.K., Armstrong P.W. et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation, 2007, Vol. 15, no. 19, рр. 257-258.
19. Le Quintrec J., Bussy C., Golmard J.-L. et al. Randomized Controlled Drug Trials on Very Elderly Subjects: Descriptive and Methodological Analysis
of Trials Published Between 1990 and 2002 and Comparison With Trials on Adults. J. Gerontology, 2005, Vol. 60, no. 3, pp. 340-344. 20. Зарецкий А.П. Модели и алгоритмы поддержки принятия решений при стентировании коронарных артерий. Автореферат диссертации на соискание учёной степени кандидата технических наук, 2015. http://tekhnosfera. com/modeli-i-algoritmy-podderzhki-prinyatiya-resheniy-pri-stentirovanii-koronarnyh-arteriy#ixzz4rdnVsdle
DATAABOUT THE AUTHOR Kuzmina Natalya Mikhailovna, Postgraduate
Izhevsk State Medical Academy
281, Kommunarov Str., Izhevsk, 426034, Russian Federation
natalyes89@mail.ru
SPIN-code: 4120-3455
ORCID: 0000-0001-6778-9817
ResearcherID: N-7164-2017
ДАННЫЕ ОБ АВТОРЕ
Кузьмина Наталья Михайловна, аспирант кафедры госпитальной терапии
Ижевская государственная медицинская академия Минздрава России
ул. Коммунаров, 281, г. Ижевск, 426034, Российская Федерация natalyes89@mail.ru
