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Ремоделирование миокарда у пациентов с хронической сердечной недостаточностью и имплантированными модуляторами сердечной сократимости
Ремоделирование миокарда у пациентов с хронической сердечной недостаточностью и имплантированными модуляторами сердечной сократимости
Сафиуллина А.А., Ускач Т.М., Добровольская С.В., Саидова М.А., Жиров И.В., Терещенко С.Н. Ремоделирование миокарда у пациентов с хронической сердечной недостаточностью и имплантированными модуляторами сердечной сократимости по данным эхокардиографии. Терапевтический архив. 2021;93(12):1443–1450. DOI: 10.26442/00403660.2021.12.201218
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Аннотация
Цель. Изучить влияние модуляции сердечной сократимости на обратное ремоделирование и работу миокарда у пациентов с хронической сердечной недостаточностью (СН) по данным эхокардиографии (ЭхоКГ).
Материалы и методы. В группе из 40 пациентов с сочетанием хронической СН и фибрилляцией предсердий проанализированы динамика стандартных ЭхоКГ-параметров и эффективность миокардиальной работы левого желудочка (ЛЖ) на фоне 12-месячной терапии модуляции сердечной сократимости (МСС).
Результаты. Полученные результаты свидетельствуют о статистически значимом положительном влиянии МСС на параметры ремоделирования ЛЖ и эффективность миокардиальной работы по данным ЭхоКГ.
Заключение. Трансторакальная ЭхоКГ является основным методом визуализации и предоставляет большие возможности для оценки эффективности лечения СН, в том числе и немедикаментозными методами, такими как МСС. Оценка миокардиальной работы ЛЖ у пациентов с СН и имплантированными устройствами МСС является перспективным научным и практическим методом исследования.
Ключевые слова: сердечная недостаточность, фибрилляция предсердий, модуляция сердечной сократимости, миокардиальная работа, эхокардиография
Materials and methods. In a group of 40 patients with a combination of chronic HF and atrial fibrillation (AF), the dynamics of standard EchoCG parameters and the effectiveness of myocardial work of the left ventricle (LV) against the background of 12-month therapy of cardiac contractility modulation (CCM) were analyzed.
Results. The results obtained indicate a statistically significant positive effect of CCM on LV remodeling parameters and the effectiveness of myocardial work according to EchoCG.
Conclusion. Transthoracic echocardiography is the main imaging method and provides great opportunities for evaluating the effectiveness of HF treatment, including non-drug methods such as CCM. Evaluation of LV myocardial function in patients with HF and implanted CCM devices is a promising scientific and practical research method.
Keywords: heart failure, atrial fibrillation, cardiac contractility modulation, myocardial work, echocardiography
Материалы и методы. В группе из 40 пациентов с сочетанием хронической СН и фибрилляцией предсердий проанализированы динамика стандартных ЭхоКГ-параметров и эффективность миокардиальной работы левого желудочка (ЛЖ) на фоне 12-месячной терапии модуляции сердечной сократимости (МСС).
Результаты. Полученные результаты свидетельствуют о статистически значимом положительном влиянии МСС на параметры ремоделирования ЛЖ и эффективность миокардиальной работы по данным ЭхоКГ.
Заключение. Трансторакальная ЭхоКГ является основным методом визуализации и предоставляет большие возможности для оценки эффективности лечения СН, в том числе и немедикаментозными методами, такими как МСС. Оценка миокардиальной работы ЛЖ у пациентов с СН и имплантированными устройствами МСС является перспективным научным и практическим методом исследования.
Ключевые слова: сердечная недостаточность, фибрилляция предсердий, модуляция сердечной сократимости, миокардиальная работа, эхокардиография
________________________________________________
Materials and methods. In a group of 40 patients with a combination of chronic HF and atrial fibrillation (AF), the dynamics of standard EchoCG parameters and the effectiveness of myocardial work of the left ventricle (LV) against the background of 12-month therapy of cardiac contractility modulation (CCM) were analyzed.
Results. The results obtained indicate a statistically significant positive effect of CCM on LV remodeling parameters and the effectiveness of myocardial work according to EchoCG.
Conclusion. Transthoracic echocardiography is the main imaging method and provides great opportunities for evaluating the effectiveness of HF treatment, including non-drug methods such as CCM. Evaluation of LV myocardial function in patients with HF and implanted CCM devices is a promising scientific and practical research method.
Keywords: heart failure, atrial fibrillation, cardiac contractility modulation, myocardial work, echocardiography
Полный текст
Список литературы
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11. Kloppe A, Boesche L, Aweimer A, et al. Acute and short term safety and feasibility of the new OPTIMIZER SMART-system: Is it reasonable to avoid an atrial lead? EP Europace. 2018;20(Suppl. 1):i48-8. DOI:10.1093/europace/euy015.128
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13. Chan J, Edwards NFA, Khandheria BK, et al. A new approach to assess myocardial work by non-invasive left ventricular pressure–strain relations in hypertension and dilated cardiomyopathy. Eur Heart
J Cardiovasc Imaging. 2019;20(1):31-9. DOI:10.1093/ehjci/jey131
14. Nagueh SF, Bhatt R, Vivo RP, et al. Echocardiographic evaluation of hemodynamics in patients with decompensated systolic heart failure. Circ Cardiovasc Imaging. 2011;4(3):220-7.
DOI:10.1161/CIRCIMAGING.111.963496
15. Bajraktari G, Pugliese NR, D'Agostino A, et al. Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients. Cardiol Res Pract. 2018;2018:1-8. DOI:10.1155/2018/3139861
16. Manganaro R, Marchetta S, Dulgheru R, et al. Echocardiographic reference ranges for normal non-invasivemyocardial work indices: results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging. 2019;20(5):582-90. DOI:10.1093/ehjci/jey188
17. Саидова М.А., Сохибназарова В.Х., Авалян А.А., Терещенко С.Н. Сравнительная оценка применения технологий спекл-трекинг эхокардиографии в двухмерном и трехмерном режимах у больных с хронической сердечной недостаточностью с сохранной и сниженной систолической функцией левого желудочка. Кардиологический вестник. 2020;15(1):64-71 [Saidova MА, Sokhibnazarova VH, Avalyan АА, Tereshchenko SN. Comparative evaluation of speckle tracking echocardiography technologies in two-dimensional and three-dimensional modes in patients with chronic heart failure with preserved and reduced systolic function of the left ventricle. Russian Cardiology Bulletin. 2020;15(1):64-71 (in Russian)]. DOI:10.36396/MS.2020.16.1.009
18. Yu CM, Chan JY, Zhang Q, et al. Impact of cardiac contractility modulation on left ventricular global and regional function and remodeling. JACC Cardiovasc Imaging. 2009;2(12):1341-9. DOI:10.1016/j.jcmg.2009.07.011
19. Kuschyk J, Roeger S, Schneider R, et al. Efficacy and survival in patients with cardiac contractility modulation: Long-term single center experience in 81 patients. Int J Cardiol. 2015;183:76-81. DOI:10.1016/j.ijcard.2014.12.178
20. Anker SD, Borggrefe M, Neuser H, et al. Cardiac Contractility Modulation Improves Long-Term Survival and Hospitalizations in Heart Failure With Reduced Ejection Fraction. Eur J Heart Fail. 2019;21(9):1103-13. DOI:10.1002/ejhf.1374
21. Kadish A, Nademanee K, Volosin K, et al. A randomized controlled trial evaluating the safety and efficacy of cardiac contractility modulation in advanced heart failure. Am Heart J. 2011;161(2):329-37.e2. DOI:10.1016/j. ahj.2010.10.025
22. Abraham WT, Nademanee K, Volosin K, et al. Subgroup Analysis of a Randomized Controlled Trial Evaluating the Safety and Efficacy of Cardiac Contractility Modulation in Advanced Heart Failure. J Cardiac Fail. 2011;17(9):710-7. DOI:10.1016/j.cardfail.2011.05.006
23. Kloppe A, Lawo T, Mijic D, et al. Longterm survival with Cardiac Contractility Modulation in patients with NYHA II or III symptoms and normal QRS duration. Int J Cardiol. 2016;209:291-5.
DOI:10.1016/j.ijcard. 2016.02.001
24. Liu M, Fang F, Luo XX, et al. Improvement of long-term survival by cardiac contractility modulation in heart failure patients: A case-control study. Int J Cardiol. 2016;206:122-6. DOI:10.1016/j.ijcard.2016.01.071
25. Röger S, Michels J, Heggemann F, et al. Long term impact of cardiac contractility modulation on QRS duration. J Electrocardiol. 2014;47(6):936-40. DOI:10.1016/j.jelectrocard.2014.08.011
26. Abi-Samra F, Gutterman D. Cardiac contractility modulation: a novel approach for the treatment of heart failure. Heart Fail Rev. 2016;21(6):645-60. DOI:10.1007/s10741-016-9571-6
27. Ревишвили А.Ш., Артюхина Е.А., Амирасланов А.Ю., и др. Первый опыт лечения пациентов с хронической сердечной недостаточностью методом имплантации устройств, модулирующих сокращения сердца. Вестник аритмологии. 2017;90:12-8 [Revishvili ASh, Artyukhina EA, Amiraslanov AYu, et al. The first experience of treatment of patients with chronic heart failure using cardiac contractility modulation device. Journal of Arrhythmology. 2017;90:12-8 (in Russian)].
28. Mando R, Goel A, Habash F, et al. Outcomes of Cardiac Contractility Modulation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Cardiovasc Ther. 2019;2019:9769724. DOI:10.1155/2019/9769724
2. Liu L, Eisen HJ. Epidemiology of heart failure and scope of the problem. Cardiol Clin. 2014;32:1-8,vii. DOI:10.1016/j.ccl.2013.09.009
3. Seferovic PM, Ponikowski P, Anker SD, et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019;21(10):1169-86. DOI:10.1002/ejhf.1531
4. Lund LH, Jurga J, Edner M, et al. Prevalence correlates, and prognostic significance of QRS prolongation in heart failure with reduced and preserved ejection fraction. European Heart J. 2013;34:529-39. DOI:10.1093/eurheartj/ehs305
5. Steffel J, Robertson M, Singh JP, et al. The effect of QRS duration on cardiac resynchronization therapy in patients with a narrow QRS complex: A subgroup analysis of the EchoCRT trial. Eur Heart J. 2015;36(30):1983-9. DOI:10.1093/eurheartj/ehv242
6. Wang TJ, Larson MG, Levy D, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation. 2003;107:2920-5. DOI:10.1161/01.CIR.0000072767.89944.6E
7. The SOLVD Investigators. N Engl J Med. 1992;327:685-91.
8. Pappone C, Augello G, Rosanio S, et al. First Human Chronic Experience with Cardiac Contractility Modulation by Nonexcitatory Electrical Currents for Treating Systolic Heart Failure: Mid-Term Safety and Efficacy Results from a Multicenter Study. J Cardiovasc Electrophysiol. 2004;15:418-27. DOI:10.1046/j.1540-8167.2004.03580.x
9. Kwong JS, Sanderson JE, Yu CM. Cardiac contractility modulation for heart failure: a meta-analysis of randomized controlled trials. Pacing Clin Electrophysiol. 2012;35(9):1111-8.
DOI:10.1111/j.1540-8159.2012.03449.x
10. Giallauria F, Vigorito C, Piepoli MF, Coats SAJ. Effects of cardiac contractility modulation by non-excitatory electrical stimulation on exercise capacity and quality of life: anindividual patient’s data meta-analysis of randomized controlled trials. Int J Cardiol. 175:352-7. DOI:10.1016/j.ijcard.2014.06.005
11. Kloppe A, Boesche L, Aweimer A, et al. Acute and short term safety and feasibility of the new OPTIMIZER SMART-system: Is it reasonable to avoid an atrial lead? EP Europace. 2018;20(Suppl. 1):i48-8. DOI:10.1093/europace/euy015.128
12. Roger S, Schneider R, Rudic B, et al. Cardiac contractility modulation: first experience in heart failure patients with reduced ejection fraction and permanent atrial fibrillation. Europace. 2014;16(8):1205-9. DOI:10.1093/europace/euu050
13. Chan J, Edwards NFA, Khandheria BK, et al. A new approach to assess myocardial work by non-invasive left ventricular pressure–strain relations in hypertension and dilated cardiomyopathy. Eur Heart
J Cardiovasc Imaging. 2019;20(1):31-9. DOI:10.1093/ehjci/jey131
14. Nagueh SF, Bhatt R, Vivo RP, et al. Echocardiographic evaluation of hemodynamics in patients with decompensated systolic heart failure. Circ Cardiovasc Imaging. 2011;4(3):220-7.
DOI:10.1161/CIRCIMAGING.111.963496
15. Bajraktari G, Pugliese NR, D'Agostino A, et al. Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients. Cardiol Res Pract. 2018;2018:1-8. DOI:10.1155/2018/3139861
16. Manganaro R, Marchetta S, Dulgheru R, et al. Echocardiographic reference ranges for normal non-invasivemyocardial work indices: results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging. 2019;20(5):582-90. DOI:10.1093/ehjci/jey188
17. Saidova MА, Sokhibnazarova VH, Avalyan АА, Tereshchenko SN. Comparative evaluation of speckle tracking echocardiography technologies in two-dimensional and three-dimensional modes in patients with chronic heart failure with preserved and reduced systolic function of the left ventricle. Russian Cardiology Bulletin. 2020;15(1):64-71 (in Russian). DOI:10.36396/MS.2020.16.1.009
18. Yu CM, Chan JY, Zhang Q, et al. Impact of cardiac contractility modulation on left ventricular global and regional function and remodeling. JACC Cardiovasc Imaging. 2009;2(12):1341-9. DOI:10.1016/j.jcmg.2009.07.011
19. Kuschyk J, Roeger S, Schneider R, et al. Efficacy and survival in patients with cardiac contractility modulation: Long-term single center experience in 81 patients. Int J Cardiol. 2015;183:76-81. DOI:10.1016/j.ijcard.2014.12.178
20. Anker SD, Borggrefe M, Neuser H, et al. Cardiac Contractility Modulation Improves Long-Term Survival and Hospitalizations in Heart Failure With Reduced Ejection Fraction. Eur J Heart Fail. 2019;21(9):1103-13. DOI:10.1002/ejhf.1374
21. Kadish A, Nademanee K, Volosin K, et al. A randomized controlled trial evaluating the safety and efficacy of cardiac contractility modulation in advanced heart failure. Am Heart J. 2011;161(2):329-37.e2. DOI:10.1016/j. ahj.2010.10.025
22. Abraham WT, Nademanee K, Volosin K, et al. Subgroup Analysis of a Randomized Controlled Trial Evaluating the Safety and Efficacy of Cardiac Contractility Modulation in Advanced Heart Failure. J Cardiac Fail. 2011;17(9):710-7. DOI:10.1016/j.cardfail.2011.05.006
23. Kloppe A, Lawo T, Mijic D, et al. Longterm survival with Cardiac Contractility Modulation in patients with NYHA II or III symptoms and normal QRS duration. Int J Cardiol. 2016;209:291-5.
DOI:10.1016/j.ijcard. 2016.02.001
24. Liu M, Fang F, Luo XX, et al. Improvement of long-term survival by cardiac contractility modulation in heart failure patients: A case-control study. Int J Cardiol. 2016;206:122-6. DOI:10.1016/j.ijcard.2016.01.071
25. Röger S, Michels J, Heggemann F, et al. Long term impact of cardiac contractility modulation on QRS duration. J Electrocardiol. 2014;47(6):936-40. DOI:10.1016/j.jelectrocard.2014.08.011
26. Abi-Samra F, Gutterman D. Cardiac contractility modulation: a novel approach for the treatment of heart failure. Heart Fail Rev. 2016;21(6):645-60. DOI:10.1007/s10741-016-9571-6
27. Revishvili ASh, Artyukhina EA, Amiraslanov AYu, et al. The first experience of treatment of patients with chronic heart failure using cardiac contractility modulation device. Journal of Arrhythmology. 2017;90:12-8 (in Russian).
28. Mando R, Goel A, Habash F, et al. Outcomes of Cardiac Contractility Modulation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Cardiovasc Ther. 2019;2019:9769724. DOI:10.1155/2019/9769724
2. Liu L, Eisen HJ. Epidemiology of heart failure and scope of the problem. Cardiol Clin. 2014;32:1-8,vii. DOI:10.1016/j.ccl.2013.09.009
3. Seferovic PM, Ponikowski P, Anker SD, et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019;21(10):1169-86. DOI:10.1002/ejhf.1531
4. Lund LH, Jurga J, Edner M, et al. Prevalence correlates, and prognostic significance of QRS prolongation in heart failure with reduced and preserved ejection fraction. European Heart J. 2013;34:529-39. DOI:10.1093/eurheartj/ehs305
5. Steffel J, Robertson M, Singh JP, et al. The effect of QRS duration on cardiac resynchronization therapy in patients with a narrow QRS complex: A subgroup analysis of the EchoCRT trial. Eur Heart J. 2015;36(30):1983-9. DOI:10.1093/eurheartj/ehv242
6. Wang TJ, Larson MG, Levy D, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation. 2003;107:2920-5. DOI:10.1161/01.CIR.0000072767.89944.6E
7. The SOLVD Investigators. N Engl J Med. 1992;327:685-91.
8. Pappone C, Augello G, Rosanio S, et al. First Human Chronic Experience with Cardiac Contractility Modulation by Nonexcitatory Electrical Currents for Treating Systolic Heart Failure: Mid-Term Safety and Efficacy Results from a Multicenter Study. J Cardiovasc Electrophysiol. 2004;15:418-27. DOI:10.1046/j.1540-8167.2004.03580.x
9. Kwong JS, Sanderson JE, Yu CM. Cardiac contractility modulation for heart failure: a meta-analysis of randomized controlled trials. Pacing Clin Electrophysiol. 2012;35(9):1111-8.
DOI:10.1111/j.1540-8159.2012.03449.x
10. Giallauria F, Vigorito C, Piepoli MF, Coats SAJ. Effects of cardiac contractility modulation by non-excitatory electrical stimulation on exercise capacity and quality of life: anindividual patient’s data meta-analysis of randomized controlled trials. Int J Cardiol. 175:352-7. DOI:10.1016/j.ijcard.2014.06.005
11. Kloppe A, Boesche L, Aweimer A, et al. Acute and short term safety and feasibility of the new OPTIMIZER SMART-system: Is it reasonable to avoid an atrial lead? EP Europace. 2018;20(Suppl. 1):i48-8. DOI:10.1093/europace/euy015.128
12. Roger S, Schneider R, Rudic B, et al. Cardiac contractility modulation: first experience in heart failure patients with reduced ejection fraction and permanent atrial fibrillation. Europace. 2014;16(8):1205-9. DOI:10.1093/europace/euu050
13. Chan J, Edwards NFA, Khandheria BK, et al. A new approach to assess myocardial work by non-invasive left ventricular pressure–strain relations in hypertension and dilated cardiomyopathy. Eur Heart
J Cardiovasc Imaging. 2019;20(1):31-9. DOI:10.1093/ehjci/jey131
14. Nagueh SF, Bhatt R, Vivo RP, et al. Echocardiographic evaluation of hemodynamics in patients with decompensated systolic heart failure. Circ Cardiovasc Imaging. 2011;4(3):220-7.
DOI:10.1161/CIRCIMAGING.111.963496
15. Bajraktari G, Pugliese NR, D'Agostino A, et al. Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients. Cardiol Res Pract. 2018;2018:1-8. DOI:10.1155/2018/3139861
16. Manganaro R, Marchetta S, Dulgheru R, et al. Echocardiographic reference ranges for normal non-invasivemyocardial work indices: results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging. 2019;20(5):582-90. DOI:10.1093/ehjci/jey188
17. Саидова М.А., Сохибназарова В.Х., Авалян А.А., Терещенко С.Н. Сравнительная оценка применения технологий спекл-трекинг эхокардиографии в двухмерном и трехмерном режимах у больных с хронической сердечной недостаточностью с сохранной и сниженной систолической функцией левого желудочка. Кардиологический вестник. 2020;15(1):64-71 [Saidova MА, Sokhibnazarova VH, Avalyan АА, Tereshchenko SN. Comparative evaluation of speckle tracking echocardiography technologies in two-dimensional and three-dimensional modes in patients with chronic heart failure with preserved and reduced systolic function of the left ventricle. Russian Cardiology Bulletin. 2020;15(1):64-71 (in Russian)]. DOI:10.36396/MS.2020.16.1.009
18. Yu CM, Chan JY, Zhang Q, et al. Impact of cardiac contractility modulation on left ventricular global and regional function and remodeling. JACC Cardiovasc Imaging. 2009;2(12):1341-9. DOI:10.1016/j.jcmg.2009.07.011
19. Kuschyk J, Roeger S, Schneider R, et al. Efficacy and survival in patients with cardiac contractility modulation: Long-term single center experience in 81 patients. Int J Cardiol. 2015;183:76-81. DOI:10.1016/j.ijcard.2014.12.178
20. Anker SD, Borggrefe M, Neuser H, et al. Cardiac Contractility Modulation Improves Long-Term Survival and Hospitalizations in Heart Failure With Reduced Ejection Fraction. Eur J Heart Fail. 2019;21(9):1103-13. DOI:10.1002/ejhf.1374
21. Kadish A, Nademanee K, Volosin K, et al. A randomized controlled trial evaluating the safety and efficacy of cardiac contractility modulation in advanced heart failure. Am Heart J. 2011;161(2):329-37.e2. DOI:10.1016/j. ahj.2010.10.025
22. Abraham WT, Nademanee K, Volosin K, et al. Subgroup Analysis of a Randomized Controlled Trial Evaluating the Safety and Efficacy of Cardiac Contractility Modulation in Advanced Heart Failure. J Cardiac Fail. 2011;17(9):710-7. DOI:10.1016/j.cardfail.2011.05.006
23. Kloppe A, Lawo T, Mijic D, et al. Longterm survival with Cardiac Contractility Modulation in patients with NYHA II or III symptoms and normal QRS duration. Int J Cardiol. 2016;209:291-5.
DOI:10.1016/j.ijcard. 2016.02.001
24. Liu M, Fang F, Luo XX, et al. Improvement of long-term survival by cardiac contractility modulation in heart failure patients: A case-control study. Int J Cardiol. 2016;206:122-6. DOI:10.1016/j.ijcard.2016.01.071
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25. Röger S, Michels J, Heggemann F, et al. Long term impact of cardiac contractility modulation on QRS duration. J Electrocardiol. 2014;47(6):936-40. DOI:10.1016/j.jelectrocard.2014.08.011
26. Abi-Samra F, Gutterman D. Cardiac contractility modulation: a novel approach for the treatment of heart failure. Heart Fail Rev. 2016;21(6):645-60. DOI:10.1007/s10741-016-9571-6
27. Revishvili ASh, Artyukhina EA, Amiraslanov AYu, et al. The first experience of treatment of patients with chronic heart failure using cardiac contractility modulation device. Journal of Arrhythmology. 2017;90:12-8 (in Russian).
28. Mando R, Goel A, Habash F, et al. Outcomes of Cardiac Contractility Modulation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Cardiovasc Ther. 2019;2019:9769724. DOI:10.1155/2019/9769724
Авторы
А.А. Сафиуллина*1, Т.М. Ускач1,2, С.В. Добровольская1, М.А. Саидова1, И.В. Жиров1,2, С.Н. Терещенко1,2
1 ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*a_safiulina@mail.ru
1 National Medical Research Center of Cardiology, Moscow, Russia;
2 Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*a_safiulina@mail.ru
1 ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*a_safiulina@mail.ru
________________________________________________
1 National Medical Research Center of Cardiology, Moscow, Russia;
2 Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*a_safiulina@mail.ru
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