Некоторые особенности лечения ишемической болезни сердца у женщин. Часть 2

Abstract

Применение гиполипидемических средств, ингибиторов ангиотензинпревращающего фермента, блокаторов рецепторов ангиотензина, кардиопротекторов и др., хирургического лечения ишемической болезни сердца (ИБС) у лиц женского пола и влияние гормонозаместительной терапии (ГЗТ) на ИБС у женщин показано во второй части обзора. Несмотря на полученные гендерные различия, остается много недосказанного: в отношении ряда препаратов специфические гендерные исследования не проведены, нет четкой систематизации разрозненных данных относительно прогностической значимости выявленных гендерных различий, зачастую недостаточный охват женщин в широкомасштабных исследованиях, что существенно снижает их ценность. Необходимы дальнейшие исследования с целью оптимизации терапии ИБС с позиции установленных гендерных особенностей; Застосування гіполіпідемічних засобів, інгібіторів ангіотензінперетворюючого ферменту, блокаторів рецепторів ангіотензіну, кардіопротекторів та ін., хірургічного лікування ішемічної хвороби серця (ІХС) у осіб жіночої статі і вплив гормонозамісної терапії (ГЗТ) на ІХС у жінок показано у другій частині огляду. Незважаючи на отримані гендерні відмінності, залишається багато недоговореного: по відношенню до ряду препаратів специфічні гендерні дослідження не проведені, немає чіткої систематизації окремих даних щодо прогностичної значущості виявлених гендерних відмінностей, часто спостерігається недостатнє охоплення жінок у широкомасштабних дослідженнях, що суттєво знижує їхню цінність. Необхідними є подальші дослідження з метою оптимізації терапії ІХС з позицій встановлених гендерних особливостей; Using of hypolipidemic drugs, angiotensin-converting enzyme inhibitors (ACEI), angiotensin recep¬tors blockers (ARB), cardial protectors and others, surgical treatment of the ischemic heart disease (IHD) among female persons and influence of hormonal replacement therapy (HRT) upon IHD among women are presented in the 2nd part of the review. It is showed that generally (without taking into account insignificant scanty original researches) plasmatic con¬centrations of statins among women are higher than among men. That is why the risk of the side effects’ develop¬ment at statins among women also is higher (but recommendations concerning to diminishing of drug’s dose among women are absent!). A role of statins in the secondary prophylaxis is confirmed by the numerous researches: 4S (Scandinavian Simvastatin Survival Study); CARE (Cholesterol and Recurrent Events trial); HPS (Heart Protection Study); UCSF-SCOR (University of California San Francisco – Specialised Center of Research); HERS (Heart and Estrogen/progestin Replacement Study) and others. Many data direct to the same effects of estrogens and statins on both the lipid specter of the blood and the other results of the estrogen insufficiency, for example, osteoporosis. Now question about condition and possibility of correction of lipid metabolic imbalance among women of child¬bearing age remains open. Statins are used as drug of choice among women of high coronary risk. Among women of the group of low and moderate risk their prescription must be more careful (taking into account often hypertri-glyceridemia). Preparations, containing highly purified ω-3 polyunsaturated fatty acids (ω-3 PFA), are of a great interest. Positive influence of the preparation upon decrease of death risk is demonstrated. It is caused mainly by its arrhythmogenic effect. There is information about improvement of prognosis in the case of using of ω-3 PFA during the acute stage of myocardial infarction (MI) in a greater degree among women. Using of ω-3 PFA is safe, without a teratogenic and embryotoxic effect, including a reproductive period. But convincing information about gender peculiarities of this drug is absent yet. Prescription of ACEI is recommended in case of combination of IHD with hypertensive disease (HD) and/or diabetes mellitus (DM) and also when heart failure is present. Pharmacokinetic gender distinctions were revealed for ramipril (its higher concentration in female plasma). The researches CON¬SENSUS (Cooperative North Scandinavian Enalapril Survival Study) were the first to reveal gender distinctions of ACEI’ prescription for their influence upon long-term prognosis. More often development of side effects, of cough particularly, among women was demonstrated. Metabolic neutrality is an important peculiarity for successful using of ARB among women. Information concerning gender distinctions of pharmacokinetics of ARB is absent. The analysis of results of study ПРИМА revealed the same effectiveness of trimethazidine MB among men and women. It allows to recommend this metabolic myocardial cytoprotector to all patients with IHD (including the patients with complicated chronic heart failure) regardless of sexual distinctions. Some scientists mark the important clinical role of L-arginine in the therapy of IHD among women. Endothelial dysfunction is the main mechanism of development and progressing of microvascular ischemia. That is why emaciation of L-arginine’s reserves and activity of eNOS is the most typical of this pathology. Frequency of the complications after operations among women is higher in com-parison with men. It concerns first of all coronary angioplasty. Data of literature concerning to results of coronary bypass grafting among women is contradictory. In spite of conclusions about cardioprotective action of estrogens which were made before performed researches (WISE, HERS, WHI and others) didn’t confirm hopeful effects of HRT. There is an opinion that prescription of HRT has protective importance only during the early menopausal peri¬od and premenopausal period. There is an interesting opinion about effectiveness of estrogens in the prophylaxis of IHD only when beginning of the treatment is before occurrence of the signs of progressing atherosclerosis. Nowa days a question about prescription of HRT for correction of climacteric disorders among women with cardiovascular pathology remains debatable. The questions concerning using of low doses of estrogen-progesterone therapy for correction of menopausal diso rders has lately been discussed. It promotes diminishing of amount of side effects with keeping of positive influence of HRT. Combinative treatment with using of HRT and statins has been proposed as a way out for the last years According to recommendations ESC (2013) concerning the primary and secondary prophylaxis of cardiovascular pathology, both hormonal therapy and selective modulators of estrogen-receptors are declared useless/ineffective during menopause.