Algorithm of Differentiated Approach to the Treatment of CHD Patients with Impaired Homocysteine and Vitamin D Metabolism before and after Coronary Artery Bypass Grafting
Abstract
For many years, cardiovascular diseases have been a major cause of morbidity and mortality worldwide. In modern society these have become one of the most pressing medical and social problems. To date, progression of coronary heart disease (CHD) and its complications is strongly associated with increased homocysteine (HC) level and hypovitaminosis D. However, medical literature does not sufficiently cover the issues of drug treatment of patients with metabolic disorders after coronary artery bypass grafting, therefore, more detailed study of this problem is required.
The aim. To develop a differentiated approach to the medical treatment of CHD patients before and after direct myocardial revascularization.
Materials and methods. The study analyzed the data of 133 patients, 117 (87.96%) men and 16 (12.03%) women, diagnosed with CHD. In these patients, the levels of homocysteine and vitamin D were evaluated. Depending on the levels of hyperhomocysteinemia and vitamin D, the patients were divided into 3 groups.
Results. About 70% of the patients examined had elevated blood homocysteine levels greater than 15 ¤mol/L. Based on selective CAG (MSCT CA) findings and complete examination, myocardial revascularization was indicated in 133 patients, as recommended by the 2018 ESC/EACTS Guidelines on myocardial revascularization. In 95% of cases (126 patients), direct myocardial revascularization was performed. All the patients received standard therapy preoperatively, and after getting results of HC and vitamin D tests, metabolic therapy, including folic acid, vitamins B6, B12 and D, depending on HC and vitamin D levels, was prescribed.
Conclusions. Hyperhomocysteinemia and hypovitaminosis D provoke impaired endothelial vasomotor function and activate neointimal hyperplasia. Patients with hyperhomocysteinemia and vitamin D deficiency should receive metabolic therapy based on folic acid, vitamins B 6 and B12, and vitamin D, both preoperatively and postoperatively. The first control of HC and vitamin D levels is carried out within 3 months after the treatment initiation.
References
- Nykonenko OS, Chmul KO, Nykonenko AO, Osaulenko VV, Efimenko NF. Prognostic value of homocysteine and vitamin D for patients with ischemic heart disease and multifocal atherosclerosis. Zaporozhye medical journal. 2018;20(1):31–5. https://doi.org/10.14739/23101210.2018.1.121880
- Wang N, Chen C, Zhao L, Chen Y, Han B, Xia F,etal. Vitamin D and nonalcoholic fatty liver disease: bi-directional Mendelian randomization analysis. EBioMedicine. 2018;28:187–93. https://doi.org/10.1016/j.ebiom.2017.12.027
- Moretti R, Caruso P, Dal Ben M, Conti C, Gazzin S, Tiribelli C. Vitamin D, homocysteine, and folate in subcortical vascular dementia and Alzheimer dementia. Front Aging Neurosci. 2017;9:169. https://doi.org/10.3389/fnagi.2017.00169
- Aronov DM, Lupanov VP. [Atherosclerosis and coronary heart disease: some aspects of pathogenesis]. The Journal of Atherosclerosis and Dyslipidemias. 2011;1(2): 48–56. Russian.
- Sherbak SG, Sarana AM, Makarenko SV, Kamiliva TA, Maximov AG. [Some genetical peculiarities of metabolism of homocysteine, folate, and nitric oxide as risk factors of ischemic heart disease]. Herald of the Northwestern State Medical University named after I.I. Mechnikov. 2016;8(1):123–30. Russian.
- Naumau AV, Danilchyk IV, Sarana YuV. [Three Ways of Homocysteine Remethylation]. Journal of the Grodno State Medical University. 2016;2(54):27–32. Russian.
- Naumov AV. [Homocysteine. Biomedical problems]. Minsk: Professionalnye izdaniya; 2013. Russian.
- Kostuchenko GI. [Hyperhomocysteinemia Clinical Significance, Age Cheracteristics, Diagnosis and Correction]. Clinical gerontology. 2007;13(4):32–40. Russian.
- SkvortsovYuI,KorolkovaAS.[Homocysteineasariskfactor of ischemic heart disease development (review)]. Saratov Journal of Medical Scientific Research. 2011;7(3):619–24. Russian.
- Fefelova EV, Tsybikov NN, Tereshkov PP, Sepp AV, Izmestyev SV. [Mechanism of Hypercoagulation at Experimental Hyperhomocysteinemia]. Tromboz, gemostaz i Reologia. 2015;4(64):27–30. Russian.
- Fefelova YeV, Izmestyev SV, Sepp AV, Tsybikov NN. [Morphological changes in the myocardium due to the action of homocysteinea]. In: Major aspects of clinical and experimental medicine. Major aspects of clinical and experimental medicine: Proceedings of the Materials of the All-Russian Scientific and Practical Conference dedicated to the 60th anniversary of the Chita State Medical Academy; 2013 Oct. 17–18; Chita, Russia. Chita; 2013. p. 189–90. Russian.
- Dedov II, Melnichenko GA. [Clinical guidelines Vitamin D deficiency: diagnosis, treatment and prevention]. Moscow; 2014. p. 10–5. Russian.
- Pigarova EA, Rozhinskaya LYa, Belaya JE, Dzeranova LK, Karonova TL, Ilyin AV, Melnichenko GA, Dedov II. [Russian Association of Endocrinologists recommendations for diagnosis, treatment and prevention of vitamin D deficiency in adults]. Problems of Endocrinology. 2016;62(4):60–84. Russian. https://doi.org/10.14341/probl201662460-84
