ENDOTHELIAL DISFUNCTION AND ITS CORRECTION IN PATIENTS WITH ACUTE MIOCARDIAL INFARCTION IN COMBINATION WITH NON-ALCOHOLIC STEATOHEPATITIS

Abstract

The reason for the development of acute coronary syndrome (ACS) and myocardial infarction (MI) is considered to be the rupture of the atheromatous plaque and the formation of a blood clot in the coronary artery, which causes progressive stenosis. At the same time, the key role and such pathogenetic factors as dislipidemia, systemic low intensity inflammation, peroxide stress and endothelial function disorders, which underlie the violation of energetic metabolism and ischemic damage of cardiomyocytes, are discussed in the last time. The indicated pathogenetic mechanism of development of ACS (MI) provides the possibility of medication influence on these pathological processes of metabolic and cytoprotective therapy.

The aim of the study – to improve the existing therapeutic programs of ACS (MI) in combination with non-alcoholic steatohepatitis (NASH) through a differentiated approach of therapy depending on the presence or absence of violations of the functional state of the liver.

Materials and methods. The study of 95 patients with acute myocardial infarction, depending on the revealed violations of the functional state of the liver, was divided into 2 groups. The main study group included 53 patients with ACS (MI) in combination with NASH and violations of the functional state of the liver. Control group consisted of 42 patients with acute myocardial infarction (MI) who had not been diagnosed with functional hepatic failure (FHF). 32 patients of the main and 22 from control group received standard treatment of myocardial infarction, according to the Uniform Protocols of the Ministry of Health of Ukraine. Another 21 patients of the main group and 20 from the control group received modified treatment with an additional inclusion of 4.2 g of L-arginine and 2.0 g of
L-carnitine (Tivorel) 5 days course intravenously in the solution for infusion of 100 ml once a day.

Results and Discussion. In patients with MI who had a violation of the functional state of the liver, the underlying disease proceeded with various complications in 42 (79.2 %): epistenocarditis pericarditis in 21 (39.8 %) (in the control group in 8 (19 %) patients). Rhythm or conduction disturbances, manifested by paroxysmal tachyarrhythmias, transient atrioventricular blockades and blockade of the Gis bundle legs, extrasystolic arrhythmia were found in patients of the main group in 35.5 % (and 21.4 % in the control group). Left ventricular aneurysm was diagnosed in 15.9 % patients of the main group, and only in 4 (9.5 %) patients from control. At the same time there was a violation of the systolic and diastolic function of the left ventricle (more significant with comorbidity, ejection fraction ((EF) = (42.12±1.13) %) than in the control (EF = (48.23±1.16) %), which were closely related to the more pronounced left ventricular remodeling processes in the acute period of myocardial infarction in the patients of the main group. Violations of the functional state of the liver in patients with myocardial infarction at the beginning of treatment were manifested by the presence of a cytolysis syndrome, intrahepatic cholestasis, lipid and protein synthesis. At the same time in patients with ACS (MI) were revealed the significant changes of vascular endothelial function, that were the base for inclusion in complex therapy of patients with comorbid rate of L-arginine and L-carnitine. Complex treatment of patients with myocardial infarction in combination with NASH and violations of the functional state of the liver with the inclusion of L-arginine and L-carnitine contributed to the restoration of energy supply of myocardial contractility, endothelial function of blood vessels, antioxidant protection of the organism and reduction of clinical and laboratory manifestations of cytolytic and cholestatic syndromes, which, at last provided more favorable duration of this comorbid pathology.

Conclusions. There are mutual suppressive disorders of central and peripheral hemodynamics, endothelial function of the vessels, violation of lipid-protein synthesis, detoxification, energy-supplying function of the liver in patients with myocardial infarction in combination with non-alcoholic steatohepatitis, that substantially impairs the clinical course of the basic pathological process, further exacerbates systolic and diastolic function of the heart and contributes to more frequent development of complications of ACS (MI). Inclusion in the complex program of treatment of patients with ACS (LM) L-arginine and L-carnitine contributes the restoration of endothelial function of blood vessels, antioxidant protection of an organism and increases energy supply of cardiomyocytes, which is accompanied by improvement of contractile function of the myocardium and reduction of clinical and laboratory manifestations of cytolytic and cholestatic syndromes of these patients.