Open Access e-Journal Cardiometry. Issue 13 - November 2018 by Mikhail Rudenko

Issue 13. November 2018 | Cardiometry | 103

104 | Cardiometry | Issue 13. November 2018

Content November 2018 / Issue №13 8

Cardiotoxicity: a challenge for modern oncology

22 Motion of blood formed elements in a pulsatile hemodynamic flow

Oleg I. Kit, Elena M. Frantsiyants, Elena A. Dzhenkova,

Vladimir I. Timoshenko, Nikolay N. Chernov

Oksana V. Katelnitskaya, Alla I. Shikhlyarova,

This paper offers some results obtained in our studies on

Aleksandr B. Sagakyants, Ekaterina V. Verenikina,

the motion of individual formed elements in blood with due

Yuriy А. Gevorkyan, Yuriy А. Fomenko,

regard of a pulsatile flow of the plasma in the blood vessels.

Vladimir S. Trifanov, Aleksey N. Shevchenko

An analysis of the process of the motion of the blood par-

The article provides a modern vision of the problem of

ticles having different shapes in a pressure wave variable

cardiotoxicity in oncology. Integrity and generality of nodal

field of the pressure wave has been completed herein.

pathogenetic events in the body in case of carcinogenesis, antitumor therapy and cardiopathology are caused by similar mechanisms at different hierarchical levels. Identity of potential risk factors, including inflammation, aging, obesity, diabetes and smoking, has been noted. Similarly, in the

27 Actions and effects of malignant tumor growth and chronic neurogenic pain exer ted on the glutathione system in cardiac mitochondria in experimental animals

development of metabolic syndrome and carcinogenesis,

Irina V. Neskubina, Elena М. Frantsiyants,

the level of growth factors (IGF-1), neoangiogenesis, hor-

Ekaterina I. Surikova, Irina V. Kaplieva,

mones and other triggers of oncological and cardiovascu-

Lyubov К. Trepitaki, Lyudmila А. Nemashkalova,

lar pathology is increasing. It is important that a variety of

Yulia A. Pogorelova, Alla I. Shikhlyarova,

clinical manifestations of cardiotoxicity are due to the rapid

Galina V. Zhukova, Pavel N. Anistratov,

expansion of the number of therapeutic options for effects.

Viktoria L. Volkova, Natalia А. Chertova, Oksana Е. Zhenilo, Anna А. Cherkasova,

15 The prospects for applications of cardiometric approach in evaluation of cardiotoxicity under Anthracyclines therapy in patients with breast cancer

Olga G. Selezneva The aim hereof is to study the glutathione system peculiarities in the cardiac mitochondria in experimental animals against the background of a tumor process, chronic pain and the

Alla I. Shikhlyarova, Lyubov Y. Vladimirova,

combined effect both of chronic pain and the tumor process.

Natalia М. Tikhanovskaya, Yulia Y. Arapova,

35 Cardiometry in oncology: new digital possibilities for analyzing the cardiovascular system state in cancer patients

Tatiana P. Protasova, Elena А. Sycheva, Lyudmila А. Ryadinskaya, Aza А. Lyanova, Irina L. Popova, Natalia А. Abramova, Kristina А. Novoselova, Anna E. Storozhakova,

Alla I. Shikhlyarova, Mikhail Y. Rudenko,

Maria О. Ezhova, Yuliana S. Shatova,

Vladimir А. Zernov, Elena М. Frantsiyants,

Aleksandr E. Lisutin, Viktoria V. Pozdnyakova,

Elena А. Dzhenkova, Lyubov Y. Vladimirova,

Irina R. Dashkova, Stella M. Babieva

Lyudmila Y. Rozenko, Dmitriy A. Rozenko,

The aim is to study the action and effects of antitu-

Nailya К. Guskova, Larisa N. Vaschenko,

mor

Yulia Y. Arapova, Tatiana P. Protasova,

polychemotherapy

(PCT)

with

Anthracyclines

on the cardiovascular system performance in pri-

Elena А. Shirnina, Tatiana А. Barteneva, Marina А.

mary oncological patients with breast cancer (BC).

Gusareva, Vitaly I. Voshedsky, Inna V. Pavlyatenko

The study involved 21 females (49.8 ± 0.5 years) diag-

The new high-tech era begins not with supply of an inno-

nosed with BC. PCT has been conducted in a neoadjuvant

vative product to the market, but rather with an intellec-

regimen in 18 patients and in an adjuvant one with Doxo-

tual leap in the field of open issues in fundamental engi-

rubicin (60 mg/m ) and Cyclophosphamide (600 mg/m )

neering, healthcare and education. In the present essay,

in 3 patients. The cardiovascular system functional state

an example of the successful translation of mathematical,

has been evaluated during six courses of PCT with the use

physics- and engineering-related philosophy into the dig-

of the Cardiocode device.

ital platform of Cardiometry is discussed.

Issue 13. November 2018 | Cardiometry | 1

42 Effect of slow coronary flow on signalaveraged electrocardiogram Hossein Nough, Elahe Rafiei khoshnood,

58 Functional state of the blood coagulation system in postsurgery period in patients with malignant tumors of the GI tract

Aryan Naghedi, Leila Hadiani, Mohammad Vahid Jorat

Oksana V. Katelnitskaya, Oleg I. Kit, Nailya K. Guskova,

The slow flow coronary or decreased coronary TIMI flow

Kristina А. Avanesova, Igor I. Katelnitsky,

rate is characterized by delayed pacification of coronary

Dmitry S. Petrov, Aleksandr V. Shaposhnikov,

vessels in the absence of any evidence of obstruction cor-

Sergey N. Dimitriadi, Anna V. Chubaryan,

onary artery disease and is detected by coronary angi-

Dmitry V. Burtsev, Yulia N. Krokhmal,

ography. In the present study, we aimed to evaluate the

Ekaterina О. Vasilieva

effects of slow coronary artery flow on signal-averaged

The present paper analyzes changes in coagulation system

electrocardiogram (SAECG) as a possible indicator of in-

markers in 64 patients with malignant tumors of the GI in

creased risk for ventricular arrhythmias and sudden car-

surgical treatment. Results obtained when using parame-

diac death.

ters of the expanded coagulogram and a new global hemostatic assessment test with the use of Thrombodynamics

48 The state of free-radicals procceses in cardiomyocytes in rats under the action of Doxorubicin and protection by Preductal

recorder T2 have been evaluated. Based on the findings, we have developed models for predicting postoperative venous thrombosis and compared different methods for the coagulation system examinations. The thrombodynamics

Oleg I. Kit, Elena M. Frantsiyants, Irina V. Neskubina,

test allows us to assess the state of thrombotic readiness

Ekaterina I. Surikova, Elena V. Shalashnaya,

in the postoperative period in 26.56% of patients with GI

Lyudmila A. Nemashkalova, Natalia D. Cheryarina,

cancer upon the standard anticoagulant prevention.

Olga V. Kozyuk, Yulia A. Pogorelova, Larisa S. Kozlova,

The aim of our research work was to investigate the state

66 The state of hydrolytic processes in the myocardium and its draining lymphocytes in rats under the effect of Doxorubicin under protective Trimetazidine premedication

of the lipid peroxidation system – the antioxidant protec-

Elena М. Frantsiyants, Ekaterina I. Surikova,

tion system (LPO-AOS) in heart tissue in rats received eit

Irina V. Kaplieva, Lidia K. Trepitaki,

her Doxorubicin alone or in combination with Preductal

Irina V. Neskubina, Elena V. Shalashnaya,

premedication.

Valeria A. Bandovkina, Larisa S. Kozlova,

Valeria A. Bandovkina, Irina V. Kaplieva, Lidia K. Trepitaki, Roman E. Myagkov, Mikhail А. Kozhushko, Sergey V. Sanamyants, Mikhail А. Averkin, Roman Е. Tolmakh

Yulia A. Pogorelova, Lyudmila A. Nemashkalova,

54 Assessment of the efficacy of a peroral anticoagulant after surgical resection of gastric cancer

Natalia D. Cheryarina, Irina S. Tavaryan, Olga V. Kozyuk, Lyudmila Y. Rozenko, Pavel G. Sakun, Vladimir S. Trifanov

Oksana V. Katelnitskaya, Oleg I. Kit, Igor I. Katelnitsky,

The aim hereof is to study the activity of cathepsin D

Maksim N. Duritsky, Nailya K. Guskova,

(CatD), alkaline phosphatase (ALP) and acid phosphatase

Petr N. Gabrichidze, Viktoria R. Zakharchenko,

(AP), the antitryptic activity (ATA) of acid-stable inhibitors

Aleksandr V. Snezhko, Yuriy А. Przhedetskiy,

(ASI) in rats in heart tissue and its draining lymphocytes

Sergey I. Poluektov, Alla V. Pustovalova

under introduction of Doxorubicin and protection with

Patients suffering from gastric cancer have a high risk of

Trimetazidine.

postoperative thrombotic complications and often use

The study has been carried out on outbred male rats (50

anticoagulants. Direct oral anticoagulants absorb in the

animals) weighing 150-160 g: the reference group con-

proximal region of the digestive tract. Consequently, a re-

sists of 10 animals; group 1 (20 animals) has experienced

duction in anticoagulating activity is possible. In the pres-

injections of Doxorubicin in physiological saline at a dose

ent research given is an evaluation of the anti-Xa activity

of 2 mg/kg, 5 times; group 2 (20 animals) has undergone

upon administration of Rivaroxaban at a fixed dose of 20

the above-mentioned Doxorubicin medication after pre-

mg once daily in oncological patients after gastrectomy

liminary protection with Trimetazidine for 5 days at a dose

or cases of extensive resection of the stomach.

of 35 mg/kg.

2 | Cardiometry | Issue 13. November 2018

75 Disorders of the cardiovascular system performance in the early post-castration period in patients with locally advanced cervical cancer and their correction with the low-dose xenon therapy

96 A brief analysis of the use of non-linear timefrequency filtering for processing ECG signals Yeldos A. Altay, Artem S. Kremlev Some current trends of the use of non-linear time-frequency filtering approach to ECG signal processing are dis-

Alla I. Shikhlyarova, Natalia N. Popova,

cussed herein. A brief review of an application potentiality

Anna P. Menshenina, Yulia Y. Arapova,

of non-linear filtration is offered for long-term ECG signal

Tatiana P. Protasova, Andrey А. Korobov,

processing. Possible problems of long-term monitoring,

Andrey V. Yakushin, Larisa N. Vaschenko,

related to measurements interference and noise of ECG

Dmitry А. Burtsev, Olga V. Khokhlova,

signal, are revealed. To eliminate the revealed problems,

Viktoria Y. Przhedetskaya, Viktoria А. Ivanova

in further research, an implementation of a processing sys-

The aim hereof is to study the cardiovascular system dis-

tem using the non-linear-threshold time-frequency filtering

orders in the early post-castration period in patients with

method is planned. It is expected to improve an accuracy

locally advanced cervical cancer and a possibility of cor-

of cardiac data processing considering features of interfer-

rection of such disorders with the low-dose xenon therapy.

ence and measurement noise of different intensity.

81 Ruptured mycotic hepatic artery aneurysm associated with methicillin sensitive staphylococcal endocarditis

99 Metabolic processes evaluation in cardiac muscles on the basis of cardiometry Vladimir A. Zernov, Konstantin K. Mamberger,

Hamidreza Varastehravan, Hasan Salmanroghani,

Dmitry F. Makedonsky, Sergey M. Rudenko

Aryan Naghedi

The article briefly discusses the cardiometric approach to

Hemobilia is a rare cause of upper gastrointestinal hemor-

the evaluation of metabolic processes in cardiac muscle.

rhage. Classical presentations of hemobilia are biliary colic,

Reactions occurring during the various phases of the car-

jaundice, hematochezia and melena. Persistent bleeding

diac cycle, primarily in the QRS complex, are shown. The

sometimes requires urgent therapeutic intervention, such

dynamics of energy processes occurring before and after

as angiographic intervention or surgery. It may be sec-

physical load, as well as the reactions occurring during it,

ondary to trauma, inflammatory disorders, gallstones or

are presented. The ECG derivative is used.

tumors. Hepatic artery aneurysm rupture is a rare cause of gastrointestinal bleeding. Mycotic hepatic artery aneu-

101 American Heart Association congress

rysm is not a common vascular lesion, but it is considered

Konstantin K. Kamyshev

to be a late complication of bacterial endocarditis.

On November 10-12, 2018, the American Heart Association (AHA) annual conference was held in Chicago (Illinois,

86 Features of the psychosomatic state in lung cancer patients and psychopathophysiological aspects of cardiovascular diseases

USA). The three-day conference was attended by several thousand doctors, developers of medical equipment, entrepreneurs and other experts in the field of cardiology from around the world.

Galina V. Zhukova, Alla I. Shikhlyarova, Natalia М. Maschenko, Elena А. Shirnina, Mikhail S. Zinkovich, Tamara G. Airapetova, Pavel А. Anistratov, Lyudmila Y. Rozenko, Larisa N. Vaschenko, Dmitry V. Burtsev, Marina А. Gusareva, Olga V. Kozyuk, Aleksey N. Shevchenko The aim hereof is a comprehensive study of the mental, adaptive and hormonal status in patients with lung cancer with varying prevalence of the malignant process. The obtained results are compared with data on the psychosomatic state and subclinical disorders in the thyroid system in patients with cardiovascular diseases. Issue 13. November 2018 | Cardiometry | 3

Cardiometry

Basic and applied research. Theory, practice, therapy, engineering, philosophy & methodology. ISSN 2304-7232 Open Access e-Journal www.cardiometry.net EDITORIAL Editor-in-chief

Deputy editor

Prof. Vladimir Zernov

Prof. Mikhail Y. Rudenko

Russian New University

Moscow, Russian Federation

Taganrog, Russian Federation

phone/fax: +7 (495) 925-03-83

phone/fax: +7 (8634) 312-403

e-mail: zernov@cardiometry.net

e-mail: journal@cardiometry.net

Editorial board Prof. Howard Robert Horvitz

Prof. Vyacheslav M. Tyutyunnik

Massachusetts Institute of Technology

Tambov Department of Russian AcaÂdemy of Natural Sciences

Cambridge, USA

(RANS), PreÂsident of INTERNATIONAL INFORMATION NOBEL CENTER (IINC)

Prof. Yury V. Gulyaev

Tambov, Russian Federation

Kotelnikov Institute of Radio Engineering and Electronics of RAS Moscow, Russian Federation

Prof. Gury P. Stupakov Academician (Full Member) of the

Prof. Roman M. Baevsky

Russian Academy of Sciences (RAS)

State Research Center of the Russian Federation (IBMP)

Moscow, Russian Federation

Dr. Olga K. Voronova Prof. Sergey G. Chefranov

Voronezh State University

A.M. Obukhov Institute of Atmospheric Physics

Voronezh, Russian Federation

Moscow, Russian Federation

Prof. Sergey N. Zaguskin Dr. Sergey V. Kolmakov

Southern Federal University, Research Institute of Physics

University Central Hospital Kuopio, Department of Psychiatry

Rostov-on-Don, Russian Federation

Kuopio, Finland

Prof. Vladimir A. Vecherkin Prof. Galina V. Gorelova

Nesmeyanov Institute of Organoelement Compounds, Russian

Southern Federal University

Academy of Sciences

Taganrog, Russia

Moscow, Russian Federation

Oleg I. Kit Rostov Research Institute of Oncology Rostov-on-Don, Russian Federation

Editorial council Dr. Christian Muller

Dr. Hong Lei

Medizinische Universitat Wien

Chinese Chongqing School of Traditional Chinese Medicine

Vienna, Austria

Chongqing, China

4 | Cardiometry | Issue 13. November 2018

Dr. Alberto Alfie

Dr. Marwan Refaat

Hospital Nacional Prof. A. Posadas

American University of Beirut Medical Center

Buenos Aires, Argentina

Beirut, Lebanon

Prof. Mohammad Aleem

Dr. Pablo Avanzas

Cairo University

Hospital Universitario Central de Asturias

Cairo, Egypt

Asturia, Spain

Prof. Jorge Moreno-Lopez

Dr. Chandra Mani Adhikari

Sveriges lantbruksuniversitet, Department of Biomedical Sciences

Shahid Gangalal National Heart Centre

and Veterinary Public Health

Kathmandu, Nepal

Uppsala, Sweden

Dr. Marko Banovic Dr. Saad Al Bugami

Specialist of Internal Medicine at University Clinical Centre of Serbia

King Faisal Cardiac Center

Belgrade, Serbia

Dammam, Saudi Arabia

Prof. Alejandro Barbagelata Prof. Boris I. Leonov

Duke University Cardiovascular Society, Duke University

All-Russian Scientific Research Institute for Medical Instrument

Durham, USA

Engineering Moscow, Russian Federation

Prof. Vitaly S. Polikarpov Southern Federal University

Dr. Zied ben El hadj

Taganrog, Russian Federation

Medical School of Tunis Tunis, Tunisian Republic

Prof. Dimitrios Karakitsos Clinical Assistant Professor of Medicine, University of South Carolina

Dr. Nancy Aggeli

Columbia, USA

Thivas General hospital Tecnological Institute Thivas, Greece

JOURNAL INFORMATION Editorial Front Office

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Radio str., 22 Moscow Russia 105005

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phone/fax: +7 (495) 925-03-83

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Oleg I. Kit, MD, Professor, Corresponding Member of the Russian Academy of Sciences, Honored Doctor of the Russian Federation, General Director of the Rostov Research Institute of Oncology at the Ministry of Healthcare of the Russian Federation

6 | Cardiometry | Issue 13. November 2018

Dear Reader! Our Journal’s quest for scientific frontiers leads to publications on hot topics in research, and the current Journal issue is supporting this general rule. Following this way, we are presenting hereby one of the hottest themes: Cardiology in Oncology. In this connection, it should be mentioned that it has been just Cardiometry that has been capable of assessing toxicity actions and effects produced both by a malignant tumor and anticancer therapy on the human hemodynamics and the cardiac muscle metabolic processes using the most advanced noninvasive Cardiocode device & technology. The pilot studies associated with these challenging research topics have been conducted by Russian researchers at the Rostov Research Institute of Oncology, Rostov-on-Don, Russia. You, dear Reader, can find in the current issue encouraging results of the research work conducted on the basis of fundamental sciences: Cardiometry, Adaptation Medicine, Mitochondria-Related Energetics of the heart and Biochemistry, which reveal the true mechanisms of disorders or abnormalities in hemodynamics and cardiotoxicity. It is the concern of modern oncology to seek new ways how to overcome these problems; therefore many clinical aspects of cardiovascular system abnormalities and disorders in blood coagulation system, those associated with the postcastration syndrome and psychosomatic disorders pertaining thereto are surveyed in this Journal issue. Please, consider the offered publications as a “relay race” to gain in applications of the theory of adaptation reactions by a human organism and laws of their initiation and production that has been discovered by outstanding Russian researchers L.Garkavi, E.Kvakina and M. Ukolova at the above Research Institute in 1975. So, the first slot of the relay race has been our CARDIOMETRY No.7. But not only the pilot studies’ reports prepared by the researches from Rostov Research Institute of Oncology are contained herein: our Reader can enjoy a rigorous treatment of motion of individual formed elements in blood under the conditions of the pulsatile flow of blood plasma in blood vessels. The paper treating this fascinating subject as a profound analysis of motion of blood particles in a variable wave field is also offered herein. This article is a supplementary contribution to the theory of Cardiometry. It should be mentioned that the basis for this paper is factual evidence obtained by Russian researchers from the Scientific School headed by Prof. Vladimir Timoshenko, the recognized expert in hydrodynamics. We believe the papers by Iranian cardiologists published by us deserve attention of our Readership: one of the papers treats of a technique of assessment of coronary flow that is very close to our cardiometric approach. The proposed original technique is focused on the key problem of an imbalance in functioning between systemic circulation and pulmonary circulation. It should be remarked that classical cardiology ignores this fact, but it is evident that the imbalance is responsible for a reduction in blood volumes to fill the coronary arteries. It has become a good tradition that our publications awaken fresh research interest in our Readers, and some of them, referring to our Journal, have succeeded in defining their new exploration areas, outlines and ideas. Let’s hope the current issue will open again some new ways for our followers in science. Sincerely yours, Editorial Board Cardiometry Issue 13. November 2018 | Cardiometry | 7

REVIEW

Submitted: 16.7.2018; Accepted: 2.8.2018; Published online: 21.11.2018

Cardiotoxicity: a challenge for modern oncology

Imprint Oleg I. Kit, Elena M. Frantsiyants, Elena A. Dzhenkova, Oksana V. Katelnitskaya, Alla I. Shikhlyarova, Aleksandr B. Sagakyants, Ekaterina

Oleg I. Kit , Elena M. Frantsiyants , Elena A. Dzhenkova ,

V. Verenikina, Yuriy А. Gevorkyan, Yuriy А. Fomenko, Vladimir S.

Oksana V. Katelnitskaya1, Alla I. Shikhlyarova1*,

Trifanov, Aleksey N. Shevchenko. Cardiotoxicity: a challenge for

Aleksandr B. Sagakyants , Ekaterina V. Verenikina , 1

modern oncology. Cardiometry; Issue 13; November 2018; p.8-14;

Yuriy А. Gevorkyan , Yuriy А. Fomenko , Vladimir S. Trifanov ,

DOI: 10.12710/cardiometry.2018.13.814; Available from: http://

Aleksey N. Shevchenko

www.cardiometry.net/issues/no13-november-2018/cardiotoxicity

Rostov Research Institute of Oncology, Ministry of Healthcare of the Russian Federation Russia, 344037, Rostov-on-Don, 14th Line st. 63

Corresponding author: e-mail: shikhliarova.a@mail.ru

Abstract The article provides a modern vision of the problem of cardiotoxicity in oncology. Integrity and generality of nodal pathogenetic events in the body in case of carcinogenesis, antitumor therapy and cardiopathology are caused by similar mechanisms at different hierarchical levels. Identity of potential risk factors, including inflammation, aging, obesity, diabetes and smoking, has been noted. Similarly, in the development of metabolic syndrome and carcinogenesis, the level of growth factors (IGF-1), neoangiogenesis, hormones and other triggers of oncological and cardiovascular pathology is increasing. It is important that a variety of clinical manifestations of cardiotoxicity are due to the rapid expansion of the number of therapeutic options for effects. This thesis is illustrated by vivid examples of the use of anthracycline-based drugs whose mechanism of action is aimed at damaging genetic targets. The use of monoclonal antibodies - trastuzumab, is directed against HER2 / ErB2 receptors in breast cancer and is accompanied by distinct signs of cardiotoxicity especially in the elderly. A new strategy to enhance the targeted cytotoxic immune response to cancer cells (Ipilimumab, Nivolumab) has a chance to cause autoimmune myocarditis and myositis. Modern anti-angiogenic methods of cancer therapy, including inhibition of VEGF, significantly increase the risk of myocardial ischemia, hypertension and atherosclerosis. This indicates the need for monitoring of complications, a targeted selection of preventive and curative strategies, as well as attention to the mechanisms of tissue homeostasis in the implementation of the antitumor effect.

Keywords Cardiotoxicity, Cardiopathology, Carcinogenesis, Trastuzumab, Tissue homeostasis, Antitumor effect 8 | Cardiometry | Issue 13. November 2018

Presently much evidence has been obtained that cancer and cardiovascular diseases have a similar biologi cal mechanism of their development. In a complex process of carcinogenesis, cells are exposed to effects of several genetic "shocks" before their complete neoplastic degeneration and initiation of the program of growth, invasion and metastasis [1]. In a like manner, the pathogenesis of cardiovascular diseases is organized as a multi-step process. Known are many existing potential risk factors common to cancer and cardiovascular diseases, such as inflammation, aging, obesity, diabetes mellitus, hypodynamia, diet and smoking. But it does not exclude that in addition there may be many other mechanisms that might also be classified as the same risk factors for cancer and cardiovascular diseases [2].

Inflammation

It has been long been known that there is a connection between inflammation and cancer available. Known are associations between some chronic infections and cancer diseases, that is, for example, human papillomavirus and cervical cancer [3], Helicobacter pylori and stomach cancer, Epstein-Barr virus and cancer [4,5]. With the passage of time, it has been recognized that inflammation in the tumor micro-environment promotes malignant transformation and carcinogenesis. Approximately 10-20% of the cancer cases occur at the site of chronic inflammation [6]. At present, it is also known that atherosclerosis was originally considered a disease associated with a disorder in lipid metabolism, characterized by inflammation. Many cardiovascular diseases risk factors (hypertension, tobacco use, hyperlipidemia and insulin resistance) cause atherosclerosis by stimulating the adhesion of endothelial cells and promoting the attachment of leukocytes to the blood vessels walls, that leads to inflammation [5,7,8]. Elevated levels of in

pro-inflammatory biological markers, such as C-reactive protein (CRP), is closely allied to cardiovascular diseases [9].

Age

It is known that the rate of the majority of the cancer types increases with age. In developed countries, 78% of all newly identified cancer types cover individuals aged over 55. In a similar manner, an increase in the cardiovascular disease risk is reported to be associated with age, too. Although 4.3% of individuals aged 18 to 44 years suffer from a heart disease, this occurrence increases to 12% for people aged 45 to 64 years, 24.6% for individuals aged 65 to 74 and reaches 35% in subjects older than 75 years [2].

Metabolic syndrome

Proved has been the relationship between obesity and many types of cancers, including adenocarcinoma of the esophagus, pancreas and liver, as well as colorectal, postmenopausal breast, endometrial and renal cancers [10]. In an extensive meta-analysis by Renehan et al. [11], an increase in body mass index of 5 kg / m2 was significantly attributed to a risk of esophageal adenocarcinoma (relative risk 1.52, P <0.001), thyroid cancer (RR 1.33, P = .02), colon cancer (RR 1.24, P <.001) and kidney cancer in male individuals (RR 1.24, P <.0001), and endometrial cancer (RR 1.59, P <.0001), gallbladder cancer (RR 1, 59, P = 0.04), adenocarcinomas of the esophagus (RR 1.51, P <0.0001) and kidney cancer in female individuals (RR 1.34, P <.0001). Obesity is associated with an increased risk of cardiovascular diseases. The relative risk rate for cardiovascular disease is higher for those who have excessive weight (for male individuals on average RR 1.21, for female individuals RR 1.20) or obesity (male individuals RR 1.46, female individuals RR 1.64). Within the framework of the metabolic syndrome, obesity is associated with pro-inflammatory and pro-thrombotic conditions, insulin resistance and atherogenic dyslipidemia [12,13]. This is evidence that certain biological mechanisms associating the inflammatory condition and the metabolic syndrome both with cardiovascular diseases and cancers are available. One of the common factors is an elevated level of insulin-like growth factor (IGF-1) that is detected in metabolic syndrome and pathogenesis by tumor growth in experimental l models [14-17].

It is known that the development of breast cancer and endometriosis is associated with an elevated level of estrogens. An increase in the level of estrogen is usually observed under obesity. Biologically, estrogen is linked to tumor proliferation. Leptin, considered to be associated with cardiovascular disease [18], is correlated both with obesity and tumor growth. It is probable that it regulates the expression of cyclin D1 and Mcl-1 to stimulate the growth of malignant cells by activating the PI3K / Akt and MEK / ERK1 / 2 pathways in cancer [19]. Recent studies have provided a large amount of evidence in favor of the idea of the association of insulin resistance and cancer [20,21]. It has been established that breast cancer cells overexpress the insulin receptor, and insulin-associated IGF-1 promotes cell proliferation by stimulating the proliferation and metastasis of cancer cells [22]. Using this line of reasoning, it should be mentioned that arterial hypertension is one of the metabolic syndrome factors. In hypertension, the vascular endothelial growth factor (VEGF) increases, and the latter is also involved to provide neoangiogenesis in tumor growth [23]. Some studies show the relationship between hyperlipidemia, which is also a factor in the metabolic syndrome, and breast cancer [24,25]. The relationship between hyperlipidemia and cardiovascular diseases has long been known.

Tobacco use

Smoking cigarettes contributes to the development of cardiovascular diseases, including stroke, myocardial infarction and hypertension [26]. Obtained has been the evidence for the relationship between the use of nicotine and the pathogenesis both of cardiovascular diseases and cancer by inhibiting apoptosis and increasing angiogenesis [27].

Correlation between the cardiovascular and oncological diseases

Taking into account the common risk factors for cancer and cardiopathology, it is not surprising that many patients suffering from cancer also have cardiovascular diseases. Similarly, many individuals with cardiovascular diseases also have a history of cancer [2]. One more study [28] shows that 62% of patients with cancer of different locations had an excessive weight or obesity, 55% of patients suffered from hypertension, and 21% had diabetes of type 2. This study Issue 13. November 2018 | Cardiometry | 9

is consistent with many other published papers [29]. It is often the case, when cancer patients have an increased cardiac risk already at the stage of diagnostics, before they begin to receive chemotherapy or radiation. Another study [30] demonstrates that patients with prostate cancer have a higher occurrence rate of elevated levels of blood pressure, hyperlipidemia and glucose resistance as compared with conditionally healthy subjects. Besides, it is reported metabolic syndrome is also more frequently found in the above cohort of this sort [31]. Thus, the results of an increase in cardiac risk factors, when giving a cancer diagnosis, if to compare with the respective reference groups of individuals, supply an additional evidence for the common biology triggering both cardiovascular diseases and cancer.

Cardiotoxicity in cancer treatment

The existing cancer treatment methods include conventional surgery, radiotherapy and standard approaches to chemotherapy; it should be mentioned that the other two new methods have been expanded over the last decades: molecular targeted therapy (MTT) and immunotherapy [32]. The rapid growth in the number of therapeutic options offered nowadays for the treatment of cancer, which may trigger the development of cardiovascular complications in patients, is an ever-increasing challenge both for oncologists and cardiologists. In this connection, it should be noted that the common risk factors for cancer and cardiovascular diseases play a significant role in this association [33]. Besides, an increase in the survival rate favored to identify the cardiac toxicity as a problem, which results from the antitumor therapy. Anti-tumor drugs of several classes affect the cardiac muscle leading to damages of the myocardial cells, that finally results in the appearance of a number of clinically significant effects, including electrophysiological abnormalities, symptomatic heart failure (HF), and even death [34]. Clinical peculiarities are represented by a large range of cardiovascular manifestations, or events, including bradycardia, tachycardia, cardiomyopathy, elevated pulse pressure, hypotension, arrhythmia, reduced left ventricular ejection fraction (LVEF), troponinemia, QT prolongation, myocarditis, myocardial infarction, pericarditis, acute coronary syndromes and congestive heart failure [35,36]. Cardiomyopathy after the use of anthracyclines is the most well-known and described kind of cardiotox10 | Cardiometry | Issue 13. November 2018

icity induced by chemotherapy. Therefore, accordingly, this mechanism has been studied most thoroughly. This type of cardiotoxicity causes the death of cardiomyocytes and is conventionally referred to as type I [37,38]. The mechanism of the action of anthracyclines initiates an interruption of the cell replication by intercalation with DNA, as well as the inhibition of topoisomerase II. Mechanisms of cardiac toxicity are not completely identified, but they are widely recognized in respect of the oxidative stress due to the formation of oxygen active forms. The interaction occurs both with the topoisomerase IIÎą, which is overexpressed in malignant cells and is one of the therapeutic targets, and the topoisomerase IIÎ˛, which is expressed in cardiomyocytes [34]. It is evidenced that the anthracyclines can reduce the proliferation of cardiomyocyte precursors, impairing the recovery from physiological and pathological stress factors and inhibiting the ErbB and NRG-1 signaling pathways [39,40]. Reasoning from some proposed concepts of the mechanisms of toxicity, many therapies, both new and those generally accepted in the treatment of cardiovascular diseases, are considered as preventing or reversing the cardiotoxicity induced by anthracyclines. Despite the fact that anthracyclines have dominated among the clinical problems associated with the cardiotoxicity of anti-tumor therapy for many years, the widespread use of monoclonal antibodies, Trastuzumab, directed against HER2 / ErbB2 receptors for the treatment of breast cancer, has revealed clear signs of cardiac toxicity in their use [41]. The overall occurrence of Trastuzumab-related cardiotoxicity varies depending on the assessment of the population. In the main clinical trials, the incidence of symptomatic congestive heart failure (CHF) ranged from 0.8% to 5.1%, and the rate of the reduced left ventricular ejection fraction from 3.5 to 19% [4245]. It has been noted that the cardiotoxicity indicators associated with Trastuzumab are significantly higher in the elderly individuals [46-48]. A certain success has been achieved in the treatment of several types of malignant tumors, including disseminated melanoma, when using the agents which inhibit immune control points. Ipilimumab is the first antibody against CTLA-4 approved by FDA in 2011, and Nivolumab is the second antibody against PD-1 approved by FDA in 2014. This revolutionized strategy of the anti-cancer treatment opened a new era [49,50]. Anticytotoxic T-lymphocyte-associated antigen 4

(CTLA-4) and protein-programmed protein-1 (PD1) with cells are particularly useful for the treatment of diseases such as melanoma [51]. Typically, cancer cells can use these receptors to avoid the destruction due to the T cells by binding to CLTA-4, reducing and activating the naive T cells, or by expressing ligand protein-1 (PD-L1), mediating the regulation of the T- cells and apoptosis [52] The inhibitors such as Ipilimumab (anti-CTLA-4 monoclonal antibody), Pembrolizumab and Nivolumab (anti-PD-1 monoclonal antibodies), bind and disable the inhibitory effects of the receptor sites, thereby enhancing the cytotoxic immune response to cancerous cells [49]. However, in this case, the therapeutic effects vanish due to the appearing cardiotoxic effects [53-55]. It has been established that the T cell responses can be non-specific to cancer cells, and can also target the normal tissue that leads to frequent, immune-related side effects. It has been recently reported on the cardiotoxicity in the form of a potentially fatal myocarditis, especially in case of Ipilimumab and Nivolumab combination therapy [56]. Known are at least several cases of the cardiotoxicity associated with the immune control point inhibitors with manifestations such as myocarditis and complete heart block, although these data probably underestimate the true picture of the complications [53-56]. Based on biopsy of tumor, as well as the heart and skeletal muscle in two patients who experienced acute myocarditis, Johnson et al [56] suggested that the activated T cells can be targeted at an antigen that is shared by the tumor and the myocytes in the skeletal and cardiac muscles. This â&#x20AC;&#x153;targetâ&#x20AC;? effect eventually leads to autoimmune myocarditis and myositis. In a similar way, the chimeric antigen receptor (CAR) -T therapy had valuable advantages for treatment of the B cell lymphoblastic leukemia (B-ALL). Mechanically, the functions of CAR-T are reduced to the fact that the native T cells are designed to express the chimeric antigen receptor at the cell membrane. The receptor is linked to an external binding domain to specifically recognize and bind to tumor antigens. CAR-T also has an internal activation domain, which subsequently activates the T cell, when CAR-T is bound to its target. In patients with B-ALL the CAR-T therapy is effective in 70-90% of cases (Jackson Johnson et al., 2016). However, the occurrence of IRAE also increased along with the combination therapy, reaching 96% in patients, who received Ipilimumab and Nivolumab [58]. The CAR-T therapy and ACT

are both associated with risks of cardiotoxicity. The CAR-T-therapy, in particular, is connected to cytokine release syndrome (CRS), an inflammatory response that correlates with the activation of the CAR-T cells. CRS manifestations include arrhythmias, decreased LVEF and QT prolongation [59]. The vascular endothelial growth factor and its corresponding receptors, VEGFR, are one of the most important pathways of tyrosine kinase. VEGF-A is the most representative component, and the VEGF signaling pathway plays a central role in influencing the vascular system [60]. It is demonstrated that modern anti-angiogenic methods of therapy, including inhibition of VEGF, have an adverse effect on the cardiovascular system [36,61,62]. In case of the anti-VEGF therapy with tyrosine kinase inhibitors (imatinib, dasatinib, nilotinib, bosutinib, sunitinib, sorafenib, axitinib, and ponatinib), known are cases of hypertension, ischemic damage to the heart muscle and rapid progression of atherosclerosis [63]. Inhibition of the VEGF pathway can lead to endothelial dysfunction resulting from the disorder of the normal endothelial homeostasis mediated by nitrogen oxide [60]. A meta-analysis conducted after the use of sunitinib showed an increased relative risk of cardiovascular complications. The risk of myocardial ischemia caused by sunitinib was 3.03 times higher if to compare with placebo [64]. Ponatinib was associated with significant cardiovascular toxicity, reported to have 10% of the cardiovascular, 7% of the cerebrovascular and 7% of the peripheral side effects within 28 months after the treatment. Hypertension was diagnosed in 26% of the patients received this drug [64]. Both conventional chemotherapeutic agents and the most advanced methods of treatment of malignant neoplasms have an important effect on the myocardial tissue, provoking arrhythmia, ischemia, and even death of patients. The mechanism of this toxicity refers to the "target" therapeutic mechanisms of anti-tumor medication that indicates a possible inevitable relation between these vital chemotherapeutics and the cardiovascular toxicity. As new treatment methods are developed and introduced in practice, especially when they are used in treatment in the elderly patients showing a depleting heart reserve, it is of great importance that oncologists work closely with cardiologists to monitor and control complications of this sort. It is also vital to recognize the multi-factor featured processes that lead to the development of cardiovascular Issue 13. November 2018 | Cardiometry | 11

diseases in patients suffering from malignant tumors [34]. Considering the above, several strategies have been proposed to prevent the appearance of cardiovascular complications after the use of anti-tumor agents. However, none of them can be recognized as completely safe and meeting all applicable standards of treatment, that is connected with the complexity of various types of cardiac complications. Besides, it should be noted that cardiac dysfunction can also manifest itself many years after the completion of anti-cancer therapy that makes it difficult to properly evaluate preventive and curative strategies. What counts for the implementation of the best suited treatment tactics, it is the proper understanding of the biochemical and molecular mechanisms involved, which are initiated by anti-cancer agents and which may affect the cardiomyocytes and the immune cells [65].

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

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ORIGINAL RESEARCH

Submitted: 20.9.2018; Accepted: 15.10.2018; Published online: 21.11.2018

The prospects for applications of cardiometric approach in evaluation of cardiotoxicity under Anthracyclines therapy in patients with breast cancer Alla I. Shikhlyarova , Lyubov Y. Vladimirova , 1*

of course 6 of PCT, a decline in adaptation functions and a disorder in compensatory processes in the myocardium against the background of development of uncompensated distress have been detected. Thus, the application of the cardiac cycle phase analysis method, along with the conventional methods for monitoring of the cardiovascular system performance, allows revealing disorders in its performance at early stages that is important for prevention of cardiovascular pathology,

Natalia М. Tikhanovskaya1, Yulia Y. Arapova1, Tatiana P. Protasova1,

which may result from PCT.

Elena А. Sycheva , Lyudmila А. Ryadinskaya , Aza А. Lyanova , 1

Irina L. Popova1, Natalia А. Abramova1, Kristina А. Novoselova1,

Keywords

Anna E. Storozhakova , Maria О. Ezhova , Yuliana S. Shatova ,

Cardiotoxicity, Chemotherapy, Anthracyclines, Breast cancer, Car-

Aleksandr E. Lisutin1, Viktoria V. Pozdnyakova1, Irina R. Dashkova1,

diometric approach, Electrocardiogram, Myocardial metabolism,

Stella M. Babieva

Baevsky index

Rostov Research Institute of Oncology, Ministry of Healthcare

Imprint

of the Russian Federation

Alla I. Shikhlyarova, Lyubov Y. Vladimirova, Natalia М. Tikha-

Russia, 344037, Rostov-on-Don, 14th Line st. 63

novskaya, Yulia Y. Arapova, Tatiana P. Protasova, Elena А. Sycheva,

Corresponding author:

Lyudmila А. Ryadinskaya, Aza А. L’yanova, Irina L. Popova, Natalia

e-mail: shikhliarova.a@mail.ru, phone: +7 (905) 431-92-67

А. Abramova, Kristina А. Novoselova, Anna E. Storozhakova, Maria О. Ezhova, Yuliana S. Shatova, Aleksandr E. Lisutin, Viktoria V.

Aims

Pozdnyakova, Irina R. Dashkova, Stella M. Babieva. The prospects

The aim is to study the action and effects of antitumor poly-

for applications of cardiometric approach in evaluation of car-

chemotherapy (PCT) with Anthracyclines on the cardiovascular

diotoxicity under Anthracyclines therapy in patients with breast

system performance in primary oncological patients with breast

cancer. Cardiometry; Issue 13; November 2018; p.15-21; DOI:

cancer (BC).

10.12710/cardiometry.2018.13.1521; Available from: http://www. cardiometry.net/issues/no13-november-2018/cardiotoxicity-

Materials and methods The study involved 21 females (49.8 ± 0.5 years) diagnosed with BC. PCT has been conducted in a neoadjuvant regimen in 18 patients and in an adjuvant one with Doxorubicin (60 mg/m2) and Cyclophosphamide (600 mg/m2) in 3 patients. The cardiovascular system functional state has been evaluated during six courses of PCT with the use of the Cardiocode device. At the same time, the conditions of the cardiovascular system have been assessed before PCT and during the fourth course using EchoCG and ECG.

Results and conclusions Against the background of PCT with Anthracyclines noted are the cumulative changes in the blood vessel hemodynamics as reduced blood volumes ejected from the left ventricle and the atria and as alterations in the Rheogram signal. Observed is predominance of exchange of anaerobic energy over the aerobic one, characterized by a high level of the lactate concentration and accompanied by a decrease in the oxygen concentration on course 3, an increase in the phosphocreatine level on course 4 and its decrease during courses 5 and 6 of PCT. By the end

under-anthracyclines-therapy

Introduction

In reference literature we can find data on adverse actions and effects of antitumor therapy methods on various organs and systems in the organism, including the cardiovascular system, but unfortunately these data and materials are not quite concrete [1-3]. Within the diversity of the antitumor therapy complications, cardiotoxicity is of the greatest concern. As opposed to the tissues with intensive proliferative capacity, the cardiac muscle consists of myocardiocytes having a limited proliferative and regenerative potential that determines development of persistent manifestations of toxicity, as a rule. [4]. According to the practical recommendations of the Russian Society of Clinical Oncologists (RUSSCO), "cardiotoxicity" is a term that includes various undesired phenomena associated with the cardiovascular system against the background of drug therapy in cancer patients [5]. Issue 13. November 2018 | Cardiometry | 15

Concomitant pathology should be taken into account, when selecting specific therapy, treatment schedules and regimens as well as predicting possible undesired side effects. Issues of tolerability of special methods for breast cancer (BC) treatment attract attention of not only oncologists, but also doctors of related specialties: therapists, cardiologists, anaesthesiologists, and others. How well the organism tolerates the stress associated with the malignant disease and its treatment depends on the available functional reserves in the organism. Unfortunately, there are no reliable tests or criteria which can make possible to evaluate the true interrelation between a growing cancerous tumor and an organism: some peculiarities of the macroorganism life may considerably affect the prognosis [2,3]. It has given a rise to our studies devoted to the peculiarities of changes in the cardiovascular system state in breast cancer patients at the stage of the antitumor chemotherapy application. Anthracycline antibiotics, Alkylating agents, Taxanes,Fluoropyrimidines and Trastuzumab have the most damaging effect on the cardiovascular system. According to the EWER classification, all cytostatic drugs are divided, depending on the type of the damaging effect on the cardiovascular system, into type I (with irreversible myocardial dysfunction due to myocardiocyte death (Anthracyclines)) and type II (with reversible dysfunction of myocardiocytes due to mitochondrial and protein damage (Trastuzumab)) [6]. There are a number of factors contributing to the appearance of early chronic cardiotoxicity: age under 4 years or over 65 years, female sex, thoracic radiation therapy, combined cytotoxic therapy, left ventricular ejection fraction (LVEF) less than 55%, the presence (in anamnesis) of compensated cicatricial myocardial changes, arterial hypertension, diabetes mellitus, ischemic heart disease, obesity [7]. Prior to the antitumor therapy, the following examination procedure is recommended: collection of complaints and anamnesis, physical examination with arterial pressure (AP) measurement, echocardiography (EchoCG) for LVEF assessment, the standard 12 lead electrocardiography (ECG), biochemical blood test, study of cardiac biomarkers, especially in patients with a high risk of developing left ventricular (LV) dysfunction. Certain algorithms exist for managing patients receiving antitumor therapy associated with development of the LV dysfunction in heart failure (HF) [5]. 16 | Cardiometry | Issue 13. November 2018

The Cardiocode device is a Russian portable cardio-analyzer of a new generation, developed by NTO "Cardiocode", Taganrog. The Cardiocode software provides immediately a single-stage noninvasive assessment of electrophysiological, metabolic and bio-adaptation parameters of the myocardium in combination with a prognosis of the cardiovascular system functional potential. The original examination algorithm includes recording of an extended spectrum (up to 10) of phases in each cardiac cycle, calculation of stroke blood volumes in different phases of the cardiac cycle, delivery of estimated parameters of the oxygen, lactate and phosphocreatine concentration in arbitrary units and stress index of the cardiac regulation systems. Mentioned are the following capabilities of the Cardiocode technology: express diagnostics “hereand-now”, noninvasive measurement of phase-related blood volumes, an assessment of heart life expectancy (for the first time in the world), an evaluation and a prediction of the cardiovascular system functional conditioning (for the first time in the world), detection of the sudden cardiac death signs, monitoring of population. The prompt identification of cardiovascular disorders in the terms of the phase analysis determines the unique possibility to adequately assess the damaging cardiotoxic effect of antitumor therapy and effectiveness of rehabilitation measures. In accordance with the above, the aim herein is to study the action and effects of antitumor polychemotherapy (PCT) with the use of Anthracyclines on the cardiovascular system performance in cancer primary patients suffering from breast cancer (BC).

Materials and methods

The study involved 21 females (49.8 ± 0.5 years) diagnosed with primary BC, exposed to polychemotherapy (PCT) at the Rostov Research Institute of Oncology (RRIO) in 2018. The criteria for including patients in the study are the following: – primary patients with BC scheduled for neo/adjuvant chemotherapy; – use of Doxorubicin; – the presence of cardiovascular system pathologies and other concomitant diseases (under satisfactory ECG and echocardiography parameters) is not a criterion for excluding patients from this study. An assessment of the tumor incidence rate, localization and histological analysis of the tumor in the patient population has shown the following: the tumor

Table 1. Tumor incidence rate according to the TNM classification

Table 2. Occurrence of molecular-biological subtypes of breast tumors in the cohort under studies

Stage of disease

Absolute quantity

Relative quantity

Molecularbiological subtype

Absolute quantity

Relative quantity

T2-4N0M0

42,9%

Luminal subtype A

52,4%

T2-4N1M0

47,6%

Luminal subtype B

28%

N N2M0

4, 75%

19%

N N3M0

4, 75%

Triple negative subtype

incidence rate according to the TNM classification in the examined patients corresponds to T2-4N0M0 in 9 patients (42.9%), T2-4N1M0 in 10 patients (47.6% %), Т2N2M0 in 1 patient (4.75%) and Т2N2M0 in 1 patient (4, 75%) (see Table 1 herein). The left breast has been affected by BC in 11 patients (52.4%); the right breast cancer has been found in 9 patients (42.8%), and bilateral synchronous breast cancer has been detected in 1 patient (4.8%). According to the histological examination data, the following molecular-biological subtypes of tumors have been identified in the above patients: luminal subtype B in 11 patients (52.4%), luminal subtype A in 6 patients (28%)and triple negative subtype in 4 patients (19 %) (see Table 2 herein). According to the level of marker Ki67, the distribution of the patients is as follows: Ki67 ≥ 20% (15 patients, 71.4%), Ki67 ≤ 20% (6 patients, 26.8%). The HER2/Neu overexpression has not been detected in patients (see Table 3 herein). The following concomitant diseases have been revealed: arterial hypertension of degree1-2, AH0-1, with risk of 2-4, in 9 patients (42.8%); chronic heart failure of stage 1, FC 2, in 6 patients (28.6%); hyperalimentation of degree 1-3, in 1 patient (4.8%); autoimmune thyroiditis in 1 patient (4.8%); myocardial dystrophy in 3 patients (14.2%); exertional angina pectoris, FC2, in 3 patients (14.2%); heart rhythm disorders in the form of transient ventricular extrasystole in 1 patient (4.8%); type 2 diabetes mellitus at the compensation stage in 1 patient (4.8%); migraine in 1 patient (4.8%). Six patients (28.6%) have been recorded to be free of concomitant diseases. PCT has been performed in a neoadjuvant regimen in 18 patients, and an adjuvant therapy with the use of Doxorubicin (60 mg/m2) and Cyclophosphamide (600 mg/m2) has been completed in 3 patients. As an accompanying therapy, according to the indications, the patients have been prescribed omeprazole, prednisolone, ademetionine, inosine, famotidine. The cardiovascular system has been monitored before course 1 and before course 4 of PCT on the basis

of ECG and EchoCG data. The cardiovascular system functional state has been monitored on each of the six PCT courses with the Cardiocode device: before the beginning of course 1 (the background state), a day before the beginning of course 2, before course 3, etc. An ECG and a Rheogram (a Rheo) have been synchronously recorded with the use of the normal ECG electrodes for 30 seconds in the sitting position and 30 seconds in the standing position employing the cardiometric device Cardiocode. The electrodes for ECG and Rheogram recording have been located in the area of the aorta and the heart apex, while the upper electrode has been fixed to the bone zone in the aortic area; the lower one below the xiphoid process on the soft tissues; the additional electrodes used for the Rheography aside from the signal electrodes, and the ground electrode in the lower part of the body surface With the application of the Cardiocode software, an analysis of the measured blood phase volumes, the Baevsky tension index (TI) evaluation for R-R intervals and an assessment of the myocardial metabolic processes have been conducted. According to the durations of the cardiac cycle phases, stroke blood volumes (SV, ml), minute volumes (MV, l/ml), volumes of blood flowing into the ventricle during the early diastole (PV1, ml) and the atrial systole (PV2, ml), blood volumes ejected by the ventricle during rapid (PV3, ml) and slow ejection (PV4, ml) have been calculated noninvasively using the hemodynamic equation by G. Poyedintsev - O. Voronova [8]. The stability of the state of the regulatory systems has been determined on the basis of the TI values, and the TI values ranged from 100 to 500 arbitrary units have been considered as the norm; the TI values exceeding 500 have been classified as overtension, and the TI indicators less than 100 have been interpreted as a weak state of the regulatory systems [8]. The cardiac metabolic processes have been assessed according to the parameters of the oxygen, lactate and phosphocreatine concentrations, calculated Issue 13. November 2018 | Cardiometry | 17

Table 3. Data on cancer marker indicators in the group under studies Level of expression

Absolute quantity

Relative quantity

Ki67≥ 20%

71,4%

Кi67 ≤ 20%

26,8%

HER2/Neu overexpression

by the method offered by S.A. Dushanin [9] that has been translated into the Cardiocode software. As to the aerobic process, the parametric values varying in the ranges 0.7 ... 0.85, 0.6 ... 0.65, 0.5 ... 0.55 have been taken as the norm; the norm for the anaerobic-glycolytic process is assumed to be within the range 3.0 ... 7.0; and we have adopted the indicative values 2.0 ... 4.0 as the normal values for the anaerobic allocate process, respectively [8]. The statistics data have been analyzed with the Statistica 10.0 software (StatSoft, USA). The comparison of the cardiovascular activity parameters at different stages of PCT has been carried out using the Student's criterion. Taking into account the Bonferroni correction, it has been assumed that the values p<0.017 are significantly reliable. The study has been carried out in accordance with the ethical principles for medical research involving human subjects (the Declaration of Helsinki, Finland, 1964).

Results

The cardiovascular system state evaluation in patients before the beginning of PCT has demonstrated that the hemodynamic characteristics (see Table 4 herein) and the conditions of the regulatory systems according to the TI classes have corresponded to the norm (see Figure 1), that the myocardial energy state according to the concentrations of oxygen (0.6 arbitrary units, Figure 2) and phosphocreatine (2.5 arbitrary units, Figure 2) are within the normal limits, the level of lactate (at a norm of 2.0 - 4.0 arbitrary units) is equal to 8.2 arbitrary units (see Figure 2) and indicates an accumulation of the latter. In accordance with the EchoCG recorded before the PCT examination, 25% of the patients have initial atherosclerotic alterations in the aortic valve cusps and the aortic base, 30% of the patients have suffered from a physiological relative mitral tricuspid valve insufficiency of the first degree, and in 27% of the cases initial signs of left ventricular hypertrophy have been found. 18 | Cardiometry | Issue 13. November 2018

Upon the completion of course 1 of PCT, observed has been a decrease in volumes of blood ejected by the ventricle during the rapid (PV3), up to 26.28 ml, and slow, to 18.01 ml, ejection (PV4) phases (see Table 4 herein). Pronounced is an increase in the TI values up to 329,6 arbitrary units (Figure 1) and the lactate content up to 11, 0 arbitrary units (Figure 2В) that is above the norm, the upper limit of which is 4.0 arbitrary units. The phosphocreatine concentration in this case is recorded to be 3.7 arbitrary units: it corresponds to the highest limit of the norm (Figure 2С). On course 1 of PCT, noted has been a decrease in the volume of blood entering the ventricle during the atrial systole down to 16.8 ml (PV2), against the background of the reduced PV3 (26.4 ml) and PV4 (18.06 ml) parameters, remaining at the same level (see Table 1 herein). The TI value increases up to 484.6 arbitrary units (see Figure 1 herein). The phosphocreatine level sharply increases (p<0.017) and corresponds to its maximum value of 6.8 arbitrary units that exceeds the background values by 36.8% and are higher than the norm (see Figure 2C herein). The oxygen level, decreased on course 3 down to 0.5 arbitrary units, the lower limit of the norm, has reached the level of 0.7 arbitrary units on course 4 of PCT (see Figure 2А herein). Beginning with course 4 of PCT, in 75% of the patients the Rheogram has demonstrated some signal delays in the form of a "step" (marked off by arrows in Figure 3 herein), which is a marker of hemodynamic disorders in the coronary arteries [8]. A control examination of the cardiovascular system on the PCT course 4 using EchoCG and standard ECG has shown that after the four courses of PCT, 22% of the patients have suffered from sinus tachycardia; in 77.8% of the cases found have been atherosclerotic alterations in the aortic valve cusps and the aortic base; in 55,6% of the patients detected have been initial signs of left ventricular hypertrophy; 55.6% in the patients cohort have demonstrated a reduction in myocardial recovery processes in the posterior lower portions of the left ventricle; in 22.2% revealed has been slowing of atrial myocardial conduction and signs of myocardial hypoxia. On courses 5 and 6 of PCT, the values of PV1, PV2, PV3 and PV4 continued to decrease (p<0.017): on course 6 the PV1 parameter has been recorded to be 40% below the background values and is equal to 14.4 ml; PV2 is 80% less than the background parameters and has reached 17, 6 ml; PV3 is identified to be 21.8

Table 4. The main characteristics of heart hemodynamics during six courses of PCT

Course of PCT

Parameters

PV1

PV2

PV3

PV4

50,8±2,2

3,96±0,1

36,13±0,8

22,94±1,2

32,7±2,1

22,41±1,1

45,6±0,8

3,56±0,2

23,87±01,2

20,4±0,8

26,28±1,8*

18,01±0,6*

43,1±0,2

3,54±0,13

24,37±1,3

19,58±0,4

26,08±0,6

17,87±2,3

44,9±0,5

3,24±0,1

27,62±0,3

16,8±0,5*

26,4±2,1

18,06±0,5

42,6±1,1

3,56±0,24

20,75±0,6*

18,2±0,2*

25,09±1,8

17,02±0,1

36,78±0,1

3,75±0,1

14,5±0,3*

17,6±0,6*

21,8±0,9

14,05±0,1*

Note: * significantly reliable variances at p<0,01.

ml, i.e. 66.7% below the respective background values, PV4 has been detected to be 14.05 ml, 62.7% less than the background parameters, respectively (see Table 4 herein). The tension index continued to increase and has reached 530.7 and 558.8 arbitrary units on course 5 and 6 of PCT, respectively (see Figure 1 herein). The lactate level has increased by more than 50% in comparison with the respective background value and is above the norm (p <0.017). On course 5 detected has been the maximum increase in lactate up to 15.9 arbitrary units (p <0.017) (see Figure 2B). The phosphocreatine level has decreased to the lowest value of the norm: 2.7 and 2.5 arbitrary units (see Figure 2С).

Discussions

The cardiovascular complications arising from the cardiotoxic effect of antitumor therapy are one of the main causes of mortality growth in cancer patients [10]. Despite an intensive progress of cardio-oncology, addressing studying the mechanisms of the antitumor therapy, the cardiotoxic actions and effects, we have to solve one of the key problems of cumulative PCT: it is prediction of development of possible cardiovascular disorders, their early diagnostics and effective therapy [11, 12]. In the present study, in order to improve effectiveness of an early detection of cardiovascular disorders, when conducting PCT with the use of Anthracyclines, the standard methods for monitoring cardiovascular function (EchoCG, ECG) together with the new cardiac cycle phase analysis technology, offering the "here and now" express diagnostics, have been used. As a result, against the background of PCT, revealed have been the following cumulative changes in the cardiovascular system hemodynamic parameters, indicating insufficient blood flow to the heart: we have noted that, upon course 1 of PCT, the blood volumes, ejected by the left ventricle, have been reduced, and upon course

Figure 1. The Baevsky tension index during six courses of PCT

3, the blood volumes, entering the left ventricle, have been decreased. Despite the fact that the numerical values of the volumes are within the limits of the norm, the revealed tendency can be recognized as a predictor for disorders and abnormalities in the cardiac performance. The Rheogram data also indicate the presence of the disorders in coronary vessel hemodynamics after three courses of PCT. The assessment of the myocardial energy state has shown that, against the background of PCT, the anaerobic energy exchange processes predominate, as evidenced by the high level of lactate. The observed sharp increase in the phosphocreatine concentration on course 4 and the lactate level on course 5 of PCT is a response to a decrease in the level of oxygen at the third level of PCT, i.e. we have observed a compensation of the anaerobic energy exchange at the expense of the anaerobic allocate one. In passing, it should be noted that the dynamics of changes in the level of oxygen, lactate and phosphocreatine concentrations during six courses of PCT bears witness to a decline in energy supply to the myocardium. The TI system parameter also is an indicator of the intensity in the cardiovascular system performance: until course 4 Issue 13. November 2018 | Cardiometry | 19

Figure 2. Assessment of metabolic processes in the myocardium during six courses of PCT: А – oxygen level , B – lactate level , С – phosphocreatine level.

Figure 3. The Rheo curve before the beginning of PCT (A) vs. the Rheo curve on PCT course 4 (B)

the system has been found in the state of compensated distress; on course 5 and 6 of PCT the system passes into uncompensated distress that indicates a crisis in the functioning of the adaptation systems. The EchoCG and ECG examinations performed on course 4 of PCT also have demonstrated building-up of loading on the cardiac performance: noted are the atherosclerotic alterations in the heart blood vessels, left ventricular hypertrophy and diminished recovery processes in the myocardium. According to the obtained results, the alterations traced in the cardiovascular system performance against the background of PCT are found to be cumulative. First of all, noted is the decrease in the cardiac hemodynamics that is further reflected in the tension of the cardiovascular system performance and its transition to the anaerobic energy exchange. The greatest changes in the parameters of cardiovascular hemodynamics and the energy state have been revealed on course 4 of PCT. Taking into account the decline in the adaptation functions and the disorder in myocardial compensatory processes, it is advisable to select an effective therapy capable of reducing the risk of developing cardiovascular disorders and abnormalities at the stage of PCT.

Conclusions

1. Against the background of PCT with the use of Anthracyclines we observe the cumulative alterations in the vessel hemodynamics, reflected in a reduction of 20 | Cardiometry | Issue 13. November 2018

the blood volumes ejected by the left ventricle and the atria as well as Rheogram signal changes. 2. We have revealed that there is predominance of the anaerobic energy exchange at the stages of PCT, the characteristic features of which are as follows: a high level of the lactate concentration, a decrease in the oxygen concentration on course 3, an increase in the phosphocreatine concentration on course 4 and a decrease of the latter on courses 5 and 6 of PCT. 3. PCT leads to a decline in the adaption functions and compensatory processes in the myocardium; it results in the development of uncompensated distress. 4. The application of the cardiac cycle phase analysis technology, along with the conventional methods for monitoring the cardiovascular system parameters, allows revealing disorders and abnormalities in the performance of the heart and blood vessels at early stages.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Demidov VP, Ostrovcev LD, Volkova MА. Mammary cancer. Combined and complex treatment of patients with malignant tumors: a guide for doctors. Мoscow: Medicina; 1989. [in Russian]. 2. Fauchi AS, Harrison BE. Principles of Internal Medicine. Мoscow: Praktika; 2002. [in Russian]. 3. Wood МE, Bunn PA. Hematology/Oncology Secrets. Мoscow: Binom; 2000. 4. Semenova АI. Cardio-neurotoxicity of antitumor drugs (pathogenesis, clinic, prevention, treatment). Prakticheskaya onkologiya. 2009;10:168-76. [in Russian] 5. Moiseenko VM. Practical Recommend. for Medicinal Treatm. Malignant Tumors (RUSSCO). Мos.: Rossiyskoe obshhestvo klinicheskoy onkologii; 2017. [in Russian]. 6. Ewer MS, Martin FI, Henderson C, et al. Cardiac safety of liposomal antracyclines. Semin. Oncol. 2004;31:161-81. 7. Von Hoff DD, Layard MW, Basa P. Risk factors for doxorubicin-induced congestive heart failure. Ann. Intern. Med. 1979;91:710-7.

8. Rudenko MYu, Zernov VA, Voronova OK, et al. Guide for "Cardiocode" Using the Method of the Analysis of the Phase of the Heart Cycle. Taganrog: IKM; 2015. 9. Dushanin SА, Beregovoj YV, Tsvetkova OА, et al. Multifactorial Express Diagnostics System for Functional Preparedness of Athletes under Current and Operational Medical Pedagogical Control. Kiev: Kievskaya knizhnaya fabrika «ZHovten'»; 1986. [in Russian]. 10. Ewer MS, Ewer SM. Cardiotoxicity of anticancer treatments. Nat. Rev. Cardiol. 2015;12:620. doi: 10.1038/nrcardio.2015.65. 11. Cardiovascular Toxicity Induced by Chemotherapy and Target Drugs. Practical Recommendations. М.: RUSSCO; 2013. [in Russian]. 12. Kit OI, Shikhlyarova AI, Turkin IN, et al. Use of physical factors of electromagnetic nature for decreasing complications in respiratory and cardiovascular systems in patients after surgical treatment of lung cancer. Cardiometry. November 2017;11:64–70; DOI: 10.12710/cardiometry.2017.11.6470.

Issue 13. November 2018 | Cardiometry | 21

REPORT

Submitted: 29.6.2018; Accepted: 13.8.2018; Published online: 21.11.2018

Motion of blood formed elements in a pulsatile hemodynamic flow Vladimir I. Timoshenko1, Nikolay N. Chernov1* 1

Southern Federal University Russia, 347900, Taganrog, Shevchenko st. 2

Corresponding author: phone: +7 (928) 908-11-77, e-mail: nnchernov@sfedu.ru

Abstract This paper offers some results obtained in our studies on the motion of individual formed elements in blood with due regard of a pulsatile flow of the plasma in the blood vessels. An analysis of the process of the motion of the blood particles having different shapes in a pressure wave variable field of the pressure wave has been completed herein.

Keywords Blood formed elements, Motion, Pressure wave variable field, Human circulatory system, Physical models of motion of formed elements

Imprint Vladimir I. Timoshenko, Nikolay N. Chernov. Motion of blood formed elements in a pulsatile hemodynamic flow. Cardiometry; Issue 13; November 2018; p.22-26; DOI: 10.12710/cardioÂ metry.2018.13.2226; Available from: http://www.cardiometry.net/ issues/no13-november-2018/pulsatile-hemodynamic-flow

Introduction

Circulating blood represents a suspension comprised of the plasma as the blood liquid component and formed elements suspended therein, which are as follows: erythrocytes, leukocytes and thrombocytes, the sizes of which range up to 10 micrometers. Hemodynamic processes, which occur in different phases within a cardiac cycle, determine the respective blood flow volumes, which are considered to be one of the major criteria for an assessment of the cardiovascular system performance. Electrical potential traced as an electrocardiogram controls the blood flow in the blood vessels in order to provide all required parameters of hemodynamics. From an analysis of an electrocardiogram, which can be interpreted as a sequence of simple sinusoidal signals [1], it may be deduced that the blood flow is managed under smoothly changing 22 | Cardiometry | Issue 13. November 2018

energetic processes in each cardiac cycle, which show their maxima and minima, from their growing till their decaying. An actual frequency of these processes is dictated by the heart rate and cannot exceed 5 Hz that refers to 300 heart beats per minute. A knowledge of biophysics processes of blood circulating flows, considering motion of the formed elements in a pulsatile blood flow, is of crucial importance. A set of the respective blood volumes and associated dynamic fluctuations thereof are considered to be a valuable diagnostics parameter for assessing of hemodynamic processes is. A simulation of the hemodynamic process on the basis of empirical equations by G.M.Poyedintsev â&#x20AC;&#x201C; O.K.Voronova [2] according to their concept of elevated fluidity regime, existing in the circulatory system, has made it possible to bring an analysis of volumetric parameters of a cardiovascular cycle to a new higher level [3]. However it should be noted that many factors of biophysics, responsible for the motion of blood as a suspension, comprising the liquid plasma and the formed elements suspended therein, are still not clearly understood. There is still a poor understanding of how the blood laminar flow process is organized: erythrocytes, leukocytes and thrombocytes, circulating in blood vessels, are non-spherical in their shape. So, it is supposed that the blood elevated fluidity phenomenon, determined by pulsations by the blood vessel walls, should be accompanied by oscillations of the blood formed elements. Considering the above, an attempt is made in our paper to analyze the process of the motion of the blood elements in a variable field of a pressure wave.

Materials and methods

The construction of our fresh theory of the motion of the blood formed elements is based on a solution of a number of physics-related problems. Following this way, it should be stressed that the key problem within the context is an investigation of the behavior of individual particles and the system of these smallest particles in a variable field of pressure. The solution of this problem allows discovering applicable laws and regularities of the major physical mechanism of the laminar flow of the elements in a variable pressure field. The formed elements, which are suspended in the liquid medium, under the action of the oscillations, are

involved into different types of the motion. And the viscosity of the medium plays a significant role therein. The laws, regularities and general rules of the motion of a single spherical fluid element in a viscous medium are quite sufficiently treated in papers by G. G. Stokes, L.D. Landau, E.M. Lifshits [4] and other researchers. In monographs by N.A. Fuks [5], a theory of the behavior of an individual particle in a viscous medium under the action of different forces is comprehensively studied. Based on the key results of this theory, the description of the behavior of individual particles and their system in a variable pressure field will be discussed herein below. The formed particles, residing in a field of periodical mixing in a viscous medium, are subjected to external forces, resistance forces and forces of interactions between the particles. As a result of the collective action of the above forces, a motion of the particle relative to the medium is initiated. By the external forces we usually mean gravity, electrostatic forces etc. Those forces, acting on a particle, exerted by a resting medium (in case of the particle motion) or a moving medium, are usually not ranked as the external forces. They are referred to as the forces of the resistance. In cases, when the particles are involved in an oscillatory movement in a variable pressure field, the resistance forces should be regarded as the acting ones, so that they may be taken into account as the external forces. The force, exerted by the medium, which acts on a single particle, can be computed from a solution to the Navier-Stokes equation. For a spherical solid particle having radius R, the solution to the Navier-Stokes equation: ∂V 1 + ( V∇ ) V = − grad p + ν∆V ∂t ρc

(1)

for a viscous incompressible medium, in case of an arbitrary function of time for medium velocity Uc(t), leads to formulation of an expression for time-variable force F , acting on the particle, as given below:

F = 6 πηRV +

4 3

πR ρ c g + t

+ 6R

πρ c η

∫ dt 0

2 3

πR ρ c dt i t − ti

dV dt

+ (2)

where V = (Uc – Up) is velocity of flow past a particle, Up is velocity of the particle, η is a coefficient of the dynamic viscosity of the medium; ν = η/ρс is a coefficient of the kinematic viscosity, ρс is density of the medium; g is gravitational acceleration; ti is typical time at the inverse Fourier transform of the function V(t); p pressure. The formula (2) holds for small Reynold numbers Re = 2R|V|/ν. The first term in the right side expresses the Stoke’s force of the resistance at a constant velocity of the motion, equal to the instantaneous value of flow past at a given instant. The second term represents the Archimedes force, or the buoyant force. The third and the fourth terms are the forces of the resistance, which are associated with an energy consumption required to initiate the motion of the medium itself. In this case, the third term corresponds to the force of inertia for a potential flow past a medium. It can be interpreted as a mass added to the particle, that is equal to one half liquid displaced by the particle itself. The fourth term is associated with an energy input to initiate the motion of the medium areas, adjacent to the particle, due to the mechanism of the internal friction (viscosity). Under the oscillatory motion of the medium, the velocity of the medium Up, and, consequently, the flow past velocity are functions of time. However temporal variations in the velocity will not alter the pattern of the viscous motion of the particle, provided that the condition of the quasi-stationarity [6] is met: ωR 2 ∂V (3) ν∇ 2 V ≈ 1 ∂t ν where ω = 2πf is a circle frequency. The condition of the quasi-stationarity is very crucial for studies on issues associated with effects made by oscillations on liquid dispersed media, and it is fulfilled for the heart pulse frequencies. In addition, we should mention that there may be some other factors and properties of the particles capable of influencing the nature of the motion of these smallest components, the sizes of which are in the range of few microns, as follows: their non-sphericity, fluctuating lability, etc. The actions and effects thereof can be taken into account by introducing the respective correction coefficients. But it is often the case, when they are ignored to a rough approximation. The motion of the blood formed elements in a variable pressure field can be defined by a system of parameters derived from the solution of the equation of the motion. Issue 13. November 2018 | Cardiometry | 23

The differential equation of the motion of an individual particle in a viscous medium can be written on the basis of the basic law of dynamics as follows: mp

dU p dt

dU c 4 = m p g + πR 3ρc − F, 3 dt

(4)

where mp = ⁴⁄₃πRρp is mass of the particle, ρp is density of its matter. As compared to the other constituents in (4), the action of gravity on the micron-sized particles is negligible, so that it may be ignored. Upon such simplification, the formula (4) becomes an equation of one-dimensional motion of the particle, and all values included therein can be written as the scalars. Upon substitution of (2) into (4), taking into account the signs of the acting forces and normalizing on the т0 basis, the equation of the motion takes the form as follows:  ρ 1 + c  2ρp −

 dU p 3 ρc dU c 1 − − ( Uc − Up ) −  2 ρp dt τ  dt

9ρp

2πρc τ mp

⋅∫

d ( Uc − Up ) dt i

⋅

dt i t − ti

(5)

2 2 R ρp

= where τ = is time of relaxation of the 6πηR 9 η particle. Due to smallness of the ρс/ρp relation between the density of the blood plasma and that of the matter of the formed particle, we may neglect the respective terms in the equation (5). The influence produced by the integral member in (5) is also insignificant. As a result, for our analysis of the behavior of the aerosol particles in a field of periodically varying forces, the following approximate equation obtained from (5) is applied for displacements: d2 xp dt

1 dx p 1 dx c = τ dt τ dt

(6)

where xp and xc are current values of displacements of the particle and the medium, respectively. From (6), by substituting the harmonic function of the medium displacement, the parameters of the oscillatory motion of the formed particles can be easily found, which are fully suitable for applications in practice. If we set Uc = U0cos ωt, then for a steady-state regime we have U p = U 0 n ⋅ cos ( ωt − φ ) V = U 0 m ⋅ sin ( ωt − φ )

24 | Cardiometry | Issue 13. November 2018

(7)

where n = cos φ = 1/(1+ω2τ2)1/2 is a coefficient of entrainment, m = sin φ = ωτ2 /(1+ω2τ2)1/2 is a coefficient of flow past, φ is a phase shift due to inertia of the particle, which is referred to oscillations of the medium and defined by the following equation: (8) tg φ = ωτ The obtained parameters are appropriate for the case Re << 1. Under the viscous conditions of flow past, at Re > 0,5, due to the inertia action exerted by the medium, the actually operating force differs to some extent from the Stokes’ force value. The influence of the medium inertia on the operating force can be taken into account by the Oseen's correction [7]. An effect of the applications of the Oseen’s correction on the parameters of the oscillatory motion of an individual particle is analyzed further herein. When considering various aspects of the theory of the motion of particles of this sort, some problems arise, the solutions of which imply the fact that the shape of the particle plays a significant role, for instance, when finding a field of erythrocytes flow past. In such cases, the real non-spherical particles should be replaced by the corresponding physical models. It is evident that an extended ellipsoid of revolution (Figure 1a) and the flattened one (Figure 1b) may be judged to be the adequate physical models of the real formed particles. At sufficiently large ratios of their axes, the ellipsoids of revolution may be treated as the adequate physical models of the particles both of flat and extended shape, and in case when there is a relatively small difference in the sizes of their axes, the ellipsoids of revolution take the form similar to a spherical one. For the extended ellipsoid of revolution and the flattened one, we have succeeded in obtaining relatively compact expressions for the force of the resistance, the component of the velocity of flow past in a sound field etc. In this connection, it should be noted that difficulties associated with the mathematics, which appear in formulating the above expressions, discourage applying a unified physical model of the real formed elements, namely, an arbitrary three-axes ellipsoid of revolution. Depending on the nature of the motion in the stationary viscous medium, a non-spherical particle may have different orientations. When the free settling rate is small (the purely viscous regime of flow past), the non-spherical particles are oriented in an arbitrary way with reference to the direction of their motion [6]. Sufficiently large-scale particles retain their initial orienta-

Figure 1. Physical models of the formed elements of nonspherical shape. Legend: a – an extended ellipse of revolution; b – a flattened ellipse of revolution

tion, while small-sized particles have to take all possible orientations due to the Brownian motion. The absence of a definite orientation can be explained by the fact that the torque, applied to the particles of irregular shapes, under the purely viscous regime of flow past, is equal to zero [6]. When the Reynold’s number Re reaches values of the order of 0,05-0,1, the character of the motion changes. In doing so, the non-spherical particles seek to take such a position, which provides for perpendicularity of their highly developed edges and faces to the direction of the motion [6]. As a Re value grows, such orientation of the non-spherical particles becomes more and more clearly defined. It is precisely the torque, the value of which is now other than zero, that is responsible for the orientation of the particles under the conditions. As the degree of the orientation increases, the ability of the particles to move falls off that it is especially noticeable in the direction of their motion. It results in the fact that the non-spherical particles, the developed edges and faces of which are oriented perpendicularly to the direction of the motion, are executing a zigzag or a spiral motion when settling. This effect is most pronounced at the plate-shaped particles. The orientation of the extended and flat-shaped particles is observed in flows showing velocity gradients directed perpendicularly to the flow. When the polar axis of an ellipsoidal particle is in the velocity variation plane, the velocity gradient induces flipping of the extended ellipsoid of revolution to position the polar axis thereof in the direction of the flow, and flipping of the flattened ellipsoid of revolution to position the equatorial axis of the latter in the direction of the flow, correspondingly [7-15]. The above phenomena were experimentally reproduced in colloid solutions and suspension media. It should

be mentioned that the behavior of the formed elements in flows showing velocity gradients remains to be explored. Small nanometer-scale particles, which represent a majority, are practically fully entrained by the medium oscillations. In this case, their orientation depend on a Re number value. At Re values, which are below a certain critical value, the ellipsoid particles are oriented in the same manner as it is the case with the particles fully entrained by the oscillatory movement. At Re number values exceeding the critical value, the particles show the orientation as those particles, which do not participate in the oscillations of the medium. In case with the purely viscous regime of flow past, at the Reynolds number Re << 1, for a non-spherical body, the force of the resistance is expressed by the Stokes formula, but with another coefficient. The form of this coefficient was obtained by Oseen in his work [5]. If we denote the semi-major axis of the ellipsoid of revolution by С , the ratio of the major axis to the minor axis by N, and the dynamics viscosity of the medium by η, then the resistance of the medium to the motion of a single ellipsoid element in a sound field can be expressed by the following formula: (9) F = 6 πηkCV where k is a form factor of a particle. F = 6πηkCV ( k B cos 2 θ + k n sin 2 θ )

(10)

At N → 1 the expression (10) transforms to the known Stokes formula for the force of the resistance of the sphere in the viscous medium.

Conclusions

Our analysis of the computations obtained according to the above mentioned formulated expressions has shown that the shape of the formed elements in blood significantly influences the values of the entrainment and flow past coefficients. The orientation of the elliptical particles in a variable pressure field exerts a weak effect on the entrainment and flow past coefficients. As to the erythrocytes, which are shaped as flattened ellipsoids of revolution, observed is a decrease in the coefficient of entrainment and an increase in the past flow coefficient with a growing inclination angle with reference to the blood flow θ. More significant changes in the coefficients of entrainment and flow past are reported to be for the particles showing higher axes ratios. The formulated theoretical reasoning Issue 13. November 2018 | Cardiometry | 25

and the obtained computation data are supported by the known experimental studies of the motion of the blood formed elements in the blood vessels.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Rudenko MY. Problems and prospects for the study of hemodynamics based on electrocardiograms. Scientific and study guide. Moscow: RosNOU, 2006. 12 p. [in Russian] 2. Voronova OK. Development of models and algorithms of the automated estimation of transport function in cardiovascular system: Dissertation. Voronezh: VorSTU; 1995 [in Russian] 3. Shiller N, Osipov MA. Clinical echocardiography. Moscow: Practice, 2005. 344 p. [in Russian] 4. Landau LD, Lifshitz EM. Mechanics of continuous media. M.-L., 1944. 244 p. [in Russian] 5. Fuks NA. The mechanics of aerosols. Moscow: Publishing House of the Academy of Sciences, 1955. 351 p. [in Russian] 6. Hydroacoustic encyclopedia. Ed. by Timoshenko VI. Taganrog: Publishing house of TRTU. 2000. p. 456. [in Russian] 7. Timoshenko VI, Chernov NN. Interaction and diffusion of particles in a sound field. Monograph. Rostov-on-Don: Rostizdat LLC, 2003. 304p. [in Russian]

26 | Cardiometry | Issue 13. November 2018

8. Chernov NN, Zagray NP, Laguta, MV, Varenikova AY. Method for determining size of inhomogeneity localization region based on analysis of secondary wave field of second harmonic. Journal of Physics: Conference Series. 22 May 2018;1015(3). Article No. 032081. 9. Gong X, Liu X, Zhang D. Study of third-order nonlinear parameter C/A for biological specimens. Nonlinear Acoustics â&#x20AC;&#x201C; Fundamental and Applications. 2008; Proceedings of 18th International Symposium on Nonlinear Acoustics ed B.O. Enflo, C.M. Hedberg, L Kari and Melville (New York: American Institute of Physics). 10. Borisov AV, Kuznetsov SP, Mamaev IS, Tenenev VA. Describing the motion of a body with an elliptical cross section in a viscous uncompressible fluid by model equations reconstructed from data processing. Technical Physics Letters. 2016;42(9):886-90. doi: 10.1134/S1063785016090042. 11. Vetchanin EV, Mamaev IS, Tenenev VA. The self-propulsion of a body with moving internal masses in a viscous fluid. Regular and Chaotic Dynamics. 2013;18(12):100-17. doi: 10.1134/S1560354713010073. 12. Aul'chenko SM, Kaledin VO, Shpakova YV. Forced oscillations of shells of revolution in a viscous fluid flow. Technical Physics Letters. 2009;35(2):114-6. doi: 10.1134/S1063785009020059. 13. Chernov NN, Laguta MV, Varenikova AY. Research of appearance and propagation of higher harmonics of acoustic signals in the nonlinear media. Journal of Pharmaceutical Sciences and Research. November 2017;9(11):2241-6. 14. Bur'Kov DV, Starchenko IB, Timoshenko VI. Scattering of parametric array signals by spherical unregularities. 4th International Conference on Actual Problems of Electronic Instrument Engineering, APEIE 1998 â&#x20AC;&#x201C; Proceedings, Volume 1998, September, 1998, Pages 263-264. 15. Voronin VA, Kotlyarov VV, Kuznetsov VP, et al. Investigation of a receiving parametric array with extended base. Akusticheskii Zurnal. March 1992;38(2):353-6.

ORIGINAL RESEARCH

Submitted: 21.6.2018; Accepted: 12.7.2018; Published online: 21.11.2018

Actions and effects of malignant tumor growth and chronic neurogenic pain exerted on the glutathione system in cardiac mitochondria in experimental animals

mL, glutathione -S- transferase (GST) in ng/mL and superoxide dismutase-2 (SOD-2) in pg/mL. The statistics data have been calculated using the Statistica 6.0 software.

Results In case of a chronic pain and a tumor process, in the cardiac mitochondria a low concentration of GPx-1, SOD-2 and a high level of GSSG are detected. The amount of GR increases in case of chronic pain and decreases under a malignant process.

Irina V. Neskubina , Elena М. Frantsiyants , Ekaterina I. Surikova ,

The combined effect of a chronic pain and a malignant process

Irina V. Kaplieva , Lyubov К. Trepitaki , Lyudmila А. Nemashkalova ,

leads to a decrease in GSH against the background of an ele-

Yulia A. Pogorelova , Alla I. Shikhlyarova , Galina V. Zhukova ,

vated GSSG level. The enzymatic component of the glutathione

Pavel N. Anistratov1, Viktoria L. Volkova1, Natalia А. Chertova1,

system (GPx-1, GR, GST) in the cardiac mitochondria in case of

Oksana Е. Zhenilo , Anna А. Cherkasova , Olga G. Selezneva

the combined actions and effects is characterized by a cumula-

tive potential. The GSH/GSSG ratio in all experimental groups is 1

Rostov Research Institute of Oncology,

statistically significantly lower than the intact values.

Ministry of Healthcare of the Russian Federation *

Russia, 344037, Rostov-on-Don, 14th Line st. 63

Conclusion

Corresponding author:

According to the results from this study, we may conclude that

e-mail: super.gormon@yandex.ru

chronic pain and a tumor process exert systemically an effect on the animal's organism, but in doing so they affect different

Aim

members of the regulation in the LPO-AOP system. A disorder

The aim hereof is to study the glutathione system peculiarities

in the glutathione system performance triggers an activation of

in the cardiac mitochondria in experimental animals against the

molecular oxygen and a change in the redox potential that in its

background of a tumor process, chronic pain and the com-

turn affects the subcellular level of the regulation and, in gener-

bined effect both of chronic pain and the tumor process.

al, the entire cellular metabolism. The revealed abnormalities in the energy system of the cardiac mitochondria can be consid-

Materials and methods

ered as stressor disorders. The combined effect of a chronic pain

The experiment has been carried out in female mice of the

and a malignant process is treated by the organism as a double

C57BL / 6 line (n = 28), aged 8 weeks, with an initial body mass

stress with an imbalance in the antioxidant glutathione system.

of 21-22 g. The animals have been divided into the following groups: an intact group as the reference (n = 7), a test group

Keywords

with a reproduction of the chronic pain model (n = 7), a com-

Cardiac mitochondria, Experimental melanoma В16/F10, Chronic

parison test group (B16/F10), which covered the animals with

neurogenic pain, Mice, Glutathione system

standard subcutaneously inoculated melanoma B16/F10 (n = 7), and the main experimental group (chronic pain + B16/F10)

Imprint

of mice with B16/F10 melanoma inoculated 3 weeks after the

Irina V. Neskubina, Elena М. Frantsiyants, Ekaterina I. Surikova,

chronic pain model development (n = 7). All rodents have been

Irina V. Kaplieva, Lyubov К. Trepitaki, Lyudmila А. Nemashkalova,

decapitated with a guillotine upon completion of 3 weeks of

Yulia A. Pogorelova, Alla I. Shikhlyarova, Galina V. Zhukova, Pavel

the experiment (on 21 day of the experiment). After decapita-

N. Anistratov, Viktoria L. Volkova, Natalia А. Chertova, Oksana Е.

tion, the animal hearts have been quickly removed with the use

Zhenilo, Anna А. Cherkasova, Olga G. Selezneva. Actions and

of coolants, and mitochondria have been isolated. In the ob-

effects of malignant tumor growth and chronic neurogenic pain

tained mitochondrial samples, using standard IFA test systems,

exerted on the glutathione system in cardiac mitochondria in

the following levels have been determined: reduced glutathi-

experimental animals. Cardiometry; Issue 13; November 2018;

one (GSH) in nmol/L , oxidized glutathione (GSSG) in nmol/L,

p.27-34; DOI: 10.12710/cardiometry.2018.13. 2734; Available

glutathione peroxidase-1 (GPx-1) in ng/mL, glutathione perox-

from: http://www.cardiometry.net/issues/no13-november-2018/

idase-4 (GPx-4) in ng/mL, glutathione reductase (GR) in ng/

glutathione-system-in-cardiac-mitochondria Issue 13. November 2018 | Cardiometry | 27

Introduction

A tumor is a local process, but its development cannot but affect the activity of oxidative processes in other organs and tissues in the organism. A close connection between cardiovascular disorders and a tumor disease is a well-known fact. The spectrum of cardiac abnormalities in this case is quite wide and is associated with reactive free radicals, which damage not only the membranes of cardiomyocytes, but also their subcellular structures. It is common knowledge that the main "respiratory" organelle in the cell is a mitochondrion, which contains a large number of active enzymes and coenzymes in the respiratory chain and is a potential source of free radicals in a one-electron oxygen reduction [1, 2]. In order to control the level of active forms of oxygen (AFO), the mitochondria contain a multi-line defense system and mechanisms of antioxidant enzymes that allows maintaining the normal performance of the organelle without significant disorders. This system includes superoxide dismutase (SOD), glutathione peroxidase (GPx) and glutathione reductase (GR) [3, 2]. In ischemic states, a malfunctioning of the mitochondrial respiratory chain is observed with an increased free electrons flux and the formation of reactive oxygen species [4]. The active forms of oxygen themselves can modify proteins and nucleic acids that initiates lipid peroxidation, which leads to disintegration of the cell plasma membranes and as a final result to cell death [5]. In antioxidant protection, the most important role is assigned to the glutathione system [6]. Glutathione is found in all cells and tissues of living organisms and is of great importance for oxidation-reduction reactions due to the ability of the cysteine sulfhydryl group (SH) to reversibly enter into chemical combinations. Glutathione undertakes the following very important functions in the organism: it provides the functional activity of proteins, including enzymes, protects cells from active oxygen species, maintains the membrane activity and participates in the exchange of eicosanoids; it is a cysteine reserve; it makes an effect on the synthesis of nucleic acids, participates in the metabolism of xenobiotics, increases resistance to harmful factors and influences proliferative processes [7]. The glutathione antiperoxide system effectively protects cells from peroxidative stress, and usually serious damage may be observed only if it is deficient or depleted. Glutathione is the basic component of the cell redox buffer. It is believed that the main physiological role of reduced 28 | Cardiometry | Issue 13. November 2018

glutathione is to protect and restore thiol groups of protein molecules during their oxidation or binding. In addition to the cofactor supply, by this means the thiol redox control of enzyme activity is realized. In general, the glutathione system is crucial in resistance to various chemical factors of the environment, and it is an important wide-range protective mechanism of the cell [6]. Pathological processes in the organism are often accompanied by a pain syndrome. At present, the commonly accepted opinion is that chronic pain is not a symptom of any disease, but represents an independent disease [8]. It has been demonstrated that painful effects of different nature cause changes in the main types of metabolism, mobilization of adaptive metabolic mechanisms, tissue damage and, that is especially important, dysfunction of the vascular system [9]. Pain is one of the most common symptoms in cancer patients, and with the progression of the disease its occurrence rate increases. The type of pain and its intensity depend on the location of the tumor and the stage of the disease. Pain is present in 30 to 50% of the patients with antitumor therapy and in 65 to 90% of the patients showing oncological progression; 33% of the patients suffer from pain after the completion of an anti-cancer treatment [10]. As a rule, the causes of pain in cancer patients are multi-factorial direct and indirect effects of cancer, side effects of antitumor therapy and concomitant diseases. The pathophysiological mechanisms are combined, and they include both nociceptive (somatic and/or visceral) and neuropathic (neurological) components [10, 11]. In this regard, the study of the antioxidant processes under pathology accompanied by pain syndrome is the topical issue in current research. The aim hereof is to study of the glutathione system peculiarities in the cardiac mitochondria in experimental animals against the background of a tumor process, chronic pain and the combined effect made by chronic pain and the tumor process.

Materials and methods

The study has been carried out in female mice C57BL /6 (n = 28), aged 8 weeks, with an initial body weight of 21-22 g. The animals have been provided by the Federal State Public Institution, the Andreevka Branch at the Research Center for Biomedical Technologies, the Federal Medical & Biological Agency (Moscow Region, Russia). The cell line of the mouse

B16/F10 melanoma metastasizing into the lungs has been used herein. The tumor strain has been supplied by the Russian National Oncology Research Center “N.N. Blokhin” at the RAMS (Moscow, Russia). Animals have been kept under natural lighting conditions with their free access to water and food. All the studies have been carried out in accordance with the requirements and conditions of the "International Guiding Principles for Biomedical Research Involving Animals" and the associated National Order Regulation No.267 dd. 19.06.03 “Approved Rules and Regulations for Laboratory Practices” issued June 19, 2003 by the Ministry of Healthcare of Russian Federation. The rodents have been divided into the following experimental groups: an intact animal group as the reference (n = 7), a test group with a reproduction of the chronic model pain [12](n = 7), a comparison test group (B16/F10), which contains mice with standard subcutaneous transplantation of melanoma B16/F10 (n = 7), and the main test group (chronic pain + B16/ F10) with the mice with the B16/F10 melanoma inoculated 3 weeks after the chronic pain model development (n = 7). The main test group mice (chronic pain + B16/F10) have been subjected to sciatic nerve ligation on 2 sides under Xylo-Zoletil anesthesia. Three weeks after healing the operation wound, 0.5 ml of a suspension containing the B16/F10 melanoma tumor cells in a physiological saline at a 1:10 dilution has been injected subcutaneously under the right scapula. In the comparison test group (B16/F10), melanoma B16/ F10 has been subcutaneously inoculated at the same dose and in the same volume as it is the case with the main test group, but without reproducing the chronic pain model. With respect to the standard inoculation, the tumor appears in 100% of the cases, grows rapidly enough and on the 12-16th day of the growth metastasizes mainly hematogenously into the lungs (60-90%) and more rarely into the liver and the spleen. All manipulations with animals have been made in the special box. Tools, utensils and hands have been disinfected in a conventional manner. All animals have been decapitated with a guillotine upon completion of 3 weeks of the experiment (on 21 day of the experiment). After decapitation the animal hearts have been quickly removed with the use of coolants, and mitochondria have been isolated according to the Egorov M.V. - Afanasiev S.A. method [13]. In the obtained mitochondrial samples, using the standard IFA test systems, determined have

been the following data: reduced glutathione (GSH) in nmol/L (Bio Source, USA), oxidized glutathione (GSSG) in nmol/L (Bio Source, USA), glutathione peroxidase-1 (GPx-1) in ng/mL (Ab Frontier, South Korea), glutathione peroxidase-4 (GPx-4) in ng/mL (Clod-Clon Corporation, CNDR), glutathione reductase (GR) in ng/mL (Cusabio, CNDR), glutathione -Stransferase (GST) in ng/mL (Ivvundiagnostik, FRG) and superoxide dismutase-2 (SOD-2) in pg/mL (Ab Frontier, South Korea). A statistical analysis of the results has been carried out using the Statistica 6.0 software (Stat-Soft, 2001). The data in Tables herein are represented in the form of M±m, where M is an arithmetic mean value, and m is the standard error of the mean. Variances have been assessed by the Student's criterion, and they have been considered to be statistically significant at p <0.05.

Results

In the present study, it has been found that the level of oxidized glutathione (GSSG) in the cardiac mitochondria in animals (females) with chronic pain (test group) exceeds intact animal values by 1.6 times; at the same time, on the contrary, we have observed a decrease in the GR concentration by 36% and a reduction in the Gpx-1 and SOD-2 levels by 1.4 and 1.6 times, respectively (see Table 1 herein). The concentration of reduced glutathione and GST in the cardiac mitochondria in the test group animals has been identified to be at the level of the intact values. In animals experiencing chronic pain, a deficiency in GPx-1 in the cardiac mitochondria is detected. Some researchers reveal a close relationship between a decrease in the GPx-1 concentration and a rise in the occurrence rate of cardiovascular disorders [14, 15, 16]. We have found that chronic pain in animals has not affected the level of reduced glutathione (GSH). It occurs probably due to the fact that the reduced glutathione is depleted from mitochondria much later than that from the cytosol [15]. GSH is synthesized in the cytosol only, from where it penetrates into the other compartments of cells. GSH penetrates through the inner membrane (Мi) into the mitochondrial matrix, where it reaches 10-15% of the cellular level and undertakes protection of the mitochondria from oxidative stress. Immediately in the cardiac muscle, the reduced glutathione penetrates through the inner membrane through the oxoglutarate carrier, which is Issue 13. November 2018 | Cardiometry | 29

Table 1. Actions and effects of pathological processes on glutathione system in cardiac mitochondria in mice Markers

Intact animals as the reference

Test group animals (chronic pain only)

Comparison test group (tumor В16/F10 only)

Main experimental group (tumor В16/F10 + chronic pain)

Reduced glutathione (GSH) (nmol/L)

170373,2± 14001

169562,9± 11722

213090,1± 168001,2

113355,4± 91631,2,3

Glutathione oxidized (GSSG) (nmol/L)

361,16±28,2

590,79±49,81

569,19±50,21

474,16±41,31

GPx-1 (ng/mL)

0,501±0,03

0,355±0,021

0,31±0,021

1,037±0,081,2,3

GR (ng/mL)

1,591±0,08

2,159±0,11

0,574±0,041,2

9,324±0,71,2,3

Glutathione-Stransferaseng/mL

7,254±0,5

7,928±0,6

7,165±0,5

8,886±0,61,3

SOD-2(pg/mL)

1085,6±89,1

673,87±57,51

525,1±49,81

1099,6±87,72,3

Notes: 1 – statistically significant in relation to the intact group values; 2 – statistically significant in relation to the test group values (chronic pain); 3 – statistically significant in relation to the comparison test group values (tumor В16/F10).

part of a metabolic pathway responsible for the electrically neutral GSH exchange. In case of a malignant process, in the comparison test group animals detected has been an elevated level of GSH, which is 25% higher than it is the case with the intact group, and an increased level of GSSG, which is recorded to be 1.58 times greater if to compare with the intact animals. At the same time, the concentration of enzymes GPx-1, GR and SOD in the cardiac mitochondria has been reduced by 1.6, 2.8 and 2 times, respectively. If to compare with the values in the test group animals (chronic pain), statistically significant changes have been detected in the GSH and GR levels. Thus, the GSH level has been revealed 25.6% higher, while GR, on the contrary, has been recorded to be significantly lower, by 3.8 times. The concentration of glutathione -S- transferase (GST) in the cardiac mitochondria in the chronic pain and tumor-bearing animals has not demonstrated statistically significant differences from the intact group values. The combined effect of chronic pain and the tumor process has contributed to a significant, 1.5 times, decrease in the level of GSH in the cardiac mitochondria, and a 1.3 times increase in GSSH, a 2.1 fold build up in GPx-1, a 5.8 fold increase in GR and a rise of 22,5% in GST in relation to the values in the intact animals. SOD has been recorded to be at the level of the intact values. If to compare with the values in the animals experiencing chronic pain only, the level of GSH has been reduced by a factor of 1.5, while the levels of GPx-1, GR and SOD have demonstrated a 2.9-, 4.3and 1.6-fold increase, respectively. Comparing the result of the combined effect of chronic pain plus the 30 | Cardiometry | Issue 13. November 2018

tumor growth with the respective data in the group having tumor growing only, we have detected a 1.9 times lower GSH concentration, but the level of GPx-1 has been identified to be 2.2 times higher, the GR concentration has been found to be 16.2 higher, the GST level has increased by 24%, and a 2.1 times increase of the SOD concentration has been reported, too. Table 2 given herein demonstrates the values of the glutathione system component ratios, reflecting the maintenance of the redox homeostasis. Such an imbalance has produced a disorder in the performance of the physiological cascades of antioxidant enzymes. As an indicator of the antioxidant enzymes protective efficacy, the ratio of the SOD /GPx activity, which characterizes the systemic interrelation in the action of antioxidants and reflects a change in the enzymatic antioxidant protection balancing, can be used. Thus, noticed has been a decrease in the SOD/ GPx-1 ratio under the tumor growth by 1.3 times and under the tumor growth & chronic pain combined action by 2 times in relation to the intact group of animals (see Table 2 herein). It should be noted that the SOD/GPx-1 ratio value in case of the combined action has been reported to be lower, by 1.7 and 1.5 times, respectively if to compare with the chronic pain and the tumor growth conditions. The GSH/GPx-1 ratio, as well as the SOD/GPx-1 ratio value, in case of the combined action, has been considered as the lowest as compared with the ratio values in the other study groups. Thus, the SOD/GPx-1 ratio has been reduced by 3.1 times, as compared with the intact values, by 4.4 times in the chronic pain group and by 6.3 times in the tumor growth group animals, respectively. The

Table 2. Indicators of the glutathione cascade in mice cardiac mitochondria against the background of pathological processes Indicators

Intact animals as the reference

Test group animals (chronic pain)

Comparison test group (tumor В16/F10)

Main experimental group (tumor В16/F10 + chronic pain)

GSH/ GSSG

4,7±0,3

2,9±0,191

3,7±0,281,2

2,4±0,181,3

GSH/GPx-1

3,4±0,27

4,8±0,31

6,9±0,51,2

1,1±0,081,2,3

SOD/GPx-1

2,2±0,16

1,9±0,11

1,7±0,111

1,1±0,061,2,3

GR/GPx-1

3,2±0,21

6,1±0,471

1,8±0,111,2

9,0±0,71,2,3

Notes: 1 - statistically significant in relation to the intact group values; 2 - statistically significant in relation to the test group values (chronic pain only); 3 - statistically significant in relation to the comparison test group values (tumor В16/F10 only).

decrease in the GSH/GPx-1 ratio is associated with a change in the detoxifying properties of GPx-1 by switching between the elimination of hydroperoxides and the oxidation of GSH, in case of chronic pain and the tumor process, the consumption of GPx-1 increases, and an increase in the SOD/ GPx-1 ratio indicates a low production of hydroperoxides. The GR/GPx-1 ratio in the animals experiencing the pain syndrome has been recorded 2 times higher than the respective intact animal values, while under the tumor process, on the contrary, a 1.7-fold decrease has been detected. Besides, GR/GPx-1 in animals with the tumor process has been found 3.3 times lower in comparison with the chronic pain animal group values. The combined action (the tumor process plus chronic pain) has led to a significant increase in the GR/GPx-1 ratio as compared with the values in all study groups: by 2.8 times in comparison with the intact animal group, by 1.5 times if compared with the chronic pain animal group and by 4.8 times as against the comparison test group (tumor B16/F10). The GSH/GSSG ratio, reflecting the oxidation-reduction balance of glutathione, for the chronic pain animals in their cardiac mitochondria, has been recorded to be 1.6 times lower than the intact animal value, and 1.3 times lower than that reported under the tumor process condition. By comparing the values of the GSH/GSSG ratios for two mono-exposure cases (chronic pain, tumor growth), we have detected their higher values, a 1.3 fold increase therein, just under the growing tumor conditions. The combined action has resulted in a reduction of GSH/GSSG ratio in comparison with intact animals by 2 times and with the tumor bearing ones by 1.6 times, respectively (see Table 2 herein). The GSH/GSSG reduction indicates a decline in the glutathione system redox potential. With a decrease in the GSH/GSSG ratio under the oxidative

stress conditions, thiol groups of proteins can be reversibly modified and form mixed disulfides between the SH groups of proteins and the SH groups of molecules with low molecular weight [17]. In this case, GSH serves as a "trap" for free radicals [2], and pathological states, including development of a neoplasm, results in a depletion of the GSH resource [18, 19]. Thus, any of the above described actions has provoked changes in the glutathione system performance in the cardiac mitochondria in the experimental animals. So, it has been established that the chronic pain syndrome induces an increase in oxidized glutathione and glutathione reductase, which is treated to be the only enzyme, which reduces oxidized glutathione, while the detected decrease in GPx-1 may indicate the consumption of selenium (Se) used to neutralize intracellular hydrogen peroxide. The review by A.I. Pashova et al. also provides evidence for a decrease in GPx in the organism under cardiovascular diseases and cancer [20]. Consequently, the chronic pain syndrome causes disorders and abnormalities in the cardiac performance. A three-week tumor growth of melanoma is the terminal stage of development of the malignant process in experimental animals. At this stage of growth, melanoma reaches its maximum, often necrotizing and metastasizing. The animal’s weight is found considerably reduced, and the organs lose their weight and acquire an atypical color [11]. In case of the tumor growth in animals, on day 21 of the experiment, the glutathione peroxidase and glutathione reductase parts of the antioxidant defense are inhibited in the mitochondria of the cardiac muscle, and, at the same time, GST turns out to be more resistant to the actions and effects of the tumor process. The level of oxidized glutathione is rather high, that indicates a shift in Issue 13. November 2018 | Cardiometry | 31

the oxidative homeostasis towards peroxidation, but however a high level of reduced glutathione is also detected. It may indicate that, in case of the melanoma growth and development, resetting and reformatting of the performance of the organs takes place to satisfy the needs of the tumor itself. The peculiarities of the growth and development of melanoma, arisen due to its localization just on the skin, under the involvement of the entire skin cover vascular system, undoubtedly, affect the cardiac performance by resetting the mitochondrial energy system. We believe that from the cytosol, due to increased permeability of the intracellular membranes, a more intensive supply of reduced glutathione into the mitochondria is provided. The combined action (tumor growth + chronic pain) on day 21 of the experiment has resulted in a stimulation practically of the entire glutathione enzyme system (GPx-1, GR, GST) and led to a depletion of reduced glutathione, while the accumulation of oxidized glutathione has been recorded to remain at the level produced by the mono-exposures, namely, under the conditions of the tumor growth or chronic pain. The combination of chronic pain and tumor growth has led to a general disproportion in the glutathione system components in the cardiac mitochondria. It is assumed that the transformed cells show an elevated level of antioxidant enzymes to protect cells from death [21, 22, 23]. In particular, it is known that GPx1 is responsible for the regulation of cellular hydroperoxides and can protect from oxidative stress, but an excess of GPx-1 can also produce harmful actions and effects due to the lack of significant cellular oxidants [24, 25] that leads to restorative stress and is characterized by the absence of oxidants and / or reduction of excess equivalents [26]. Although the reductive stress may seem like a new concept: it has been known for some time that the absence of cellular oxidants can reduce the cell growth reactions. There is fresh evidence for additional cellular and physiological effects made due the absence of cellular oxidants and the accumulation of excess of reducing equivalents, including alterations in the formation of the disulfide bond of the protein, the diminished mitochondrial function and declined cellular metabolism. It is a matter of general experience that until the present time there has been no complete understanding of the physiological states capable of initiating a reductive stress. Such states as hypoxia, hyperglycemia and other stresses inhibiting the mitochondrial function cause an excessive accu32 | Cardiometry | Issue 13. November 2018

mulation of cellular reducing equivalents [27, 28, 29]. Besides, in some models of experimental cardiomyopathy, excessive reducing equivalents and an excess of GPx-1 should be attributed to the mechanism of cardiac dysfunction [33, 31]. In human individuals, GPx-1 is involved in the modulation of certain cancers and the occurrence of cardiovascular diseases [14]. Glutathione transferases conjugate to GSH some toxic products of LPO (nonenals, decinals), contributing to their excretion from the organism [20]. The main function of glutathione reductase is to reduce the oxidized glutathione to the sulfhydryl form of GSH, and in doing so to increase the level of reduced glutathione without enhancing its synthesis [32, 33]. We think that the revealed decrease in GSH accompanied by the increase in GST are most likely associated with the conjugation of reduced glutathione to toxins, caused by the combined action of the tumor growth and chronic pain syndrome.

Conclusions

According to the results of this study, we can conclude that chronic pain and tumor process have their actions and effects on the animal's organism in a systemic manner, but at the same time they address different components of the regulation in the LPOAOP system. A disorder in the glutathione system performance initiates an activation of molecular oxygen and a change in the redox potential, which in its turn affects the subcellular level of the regulation and, in general, all cellular metabolism. The revealed disorders and abnormalities in the energy system of the cardiac mitochondria can be considered as stressors. The combined effect of chronic pain and malignant process is treated by the organism as a double stress with an imbalance of the antioxidant glutathione system.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Chesnokova NP, Ponukalina EV, Bizenkova MN. Molecular and cellular mechanisms of inactivation of free radicals in biological systems. Successes of modern science. 2006;7:29-36. [in Russian] 2. Kalinina EV, Chernov NN, Novichkova MD. The role of glutathione, glutathione transferase and glutathione redoxin in the regulation of redox-dependent processes. Advances in biological chemistry. 2014;54:299-348. [in Russian] 3. Kulinsky VI, Kolesnichenko LS. Glutathione mitochondria. Biochemistry. 2007;72(7):856-9. [in Russian] 4. Bolshakov MA, Zharkova LP, Ivanov VV, et al. Human and animal physiology. Bulletin of Tomsk State University. Biology. 2012;3(19):122-36. [in Russian] 5. Andreev AY, Kushnareva EY, Starkov AA. Metabolism of reactive oxygen species in mitochondria. Biochemistry. 2005;70(2):246-64. [in Russian] 6. Menshchikova EB, Lankin VZ, Zenkov NK. Oxidative stress. Prooxidants and antioxidants. Moscow: Slovo, 2006. 556 p. [in Russian] 7. Kravtsov AA, Kozin SV. Glutathione: physiological role. XII International Scientific and Practical Conference. ISTC "Science and Education". 2016. p.22-24. [in Russian] 8. Yakhno NN, Kukushkin ML. Chronic pain: biomedical and socio-economic aspects. Bulletin of RAMS. 2012;9:54-8. [in Russian] 9. Reshetnyak DV, Smirnova VS, Kukushkin ML. Gender differences with changes in blood biochemical parameters in rats in response to acute somatic and chronic neurogenic pain. Pain. 2004;2(3):12-6. [in Russian] 10. Leppert W, Zajaczkowska R, Wordliczek J, Dobrogowski J, Woron J, Krzakowski M, Pathophysiology and clinical characteristics of pain in most common locations in cancer patients. J. Physiology and Pharmacology. 2016; 67(6):787-99. 11. Kit OI, Frantsiyants EM, Kotieva IM, et al. Some mechanisms for increasing the malignancy of melanoma against the background of chronic pain in female mice. Russian journal of pain. 2017;2:14-20. [in Russian] 12. Kotieva IM. Features of monoamine metabolism in pain and pain structures of the brain in the dynamics of chronic pain. Dissertation. Rostov-on-Don. 1999. 169 pages. [in Russian] 13. Egorova MV, Afanasyev SA. Isolation of mitochondria from cells and tissues of animals and humans: Modern methodological techniques. Siberian Medical Journal. 2011;26(1):22-8. [in Russian]

14. Edith Lubos, Joseph Loscalzo and Diane E. Handy. Glutathione Peroxidase-1 in Health and Disease: From Molecular Mechanisms to Therapeutic Opportunities Antioxid Redox Signal. 2011. Oct 1. 15(7). Р. 1957-1997. doi: 10.1089/ars.2010.3586. 15. Kulinsky VI, Kolesnichenko LS. Glutathione system. Synthesis, transport, glutathione transferase, glutathione reductase. Biomedical chemistry. 2009;55(3):255-77. [in Russian] 16. Torzewski M. Ochsenhirt V. Kleschyov AL. Oelze M. Daiber A. Li H. Rossmann H. Tsimikas S. Reifenberg K. Cheng F. Lehr HA. Blankenberg S. Forstermann U. Munzel T. Lackner KJ. Deficiency of glutathione peroxidase-1 accelerates the progression of atherosclerosis in apolipoprotein E-deficient mice. Arterioscler Thromb Vasc Biol. 2007. №27. Р.850-857. 17. Gilge J.L., Fisher M., Chai Y.C. The effect of oxidant and the non-oxidant alteration of cellular thiol concentration on the formation of protein mixed-disulfides in HEK 293 cells. PLoS One. 2008. 3 (12). Р. 4015. 18. Pastore A., Federici G., Bertini E., Piemonte F. Analysis of glutathione: implication in redox and detoxification. Clin. Chim. Acta. 2003. 333 (1). Р. 19-39. 19. Gening TP, Fedotova AY, Dolgova DR, et al. On the issue of the mechanisms of oxidative stress in the erythrocytes of the organism-tumor carrier. Ulyanovsk Biomedical Journal. 2017;3:107-15. [in Russian] 20. Pashov AI, Tskhay VB, Grebennikova EK, Sivova EN. Oxidant stress and glutathione redox system in carcinogenesis. Mother and child in Kuzbass. 2012;3(50):3-8. [in Russian] 21. Dukhin AO, Shapievsky BM, Bagdasarova ZZ, Khachatryan LT. Modern aspects of treatment tactics in patients with endometrial hyperplastic processes. Mother and child: the Xth All-Russian Forum. Moscow, 2009. p. 302-303. [in Russian] 22. Frenchman EM, Sidorenko YS, Rosen LY. Lipid peroxidation in the pathogenesis of tumor disease. Rostov-on-Don, 1995. 176 p. [in Russian] 23. Francis J.A., Weir M.M., Ettler H.C. et al.Should preoperative pathology be used to select patients for surgical staging in endometrial cancer? Int. J. Ginecol. Cancer. 2009;9(3):380-4. 24. Handy DE, Lubos E, Yang Y, et al. Glutathione peroxidase-1 regulates mitochondrial function to modulate redox-dependent cellular responses. J Biol Chem. 2009;284:11913-21. 25. McClung JP, Roneker CA, Mu W, et al. Development of insulin resistance and obesity in mice overIssue 13. November 2018 | Cardiometry | 33

expressing cellular glutathione peroxidase. Proc Natl Acad Sci U S A. 2004;101:8852-7. 26. Rajasekaran NS, Connell P, Christians ES, et al. Human alphaB-crystallin mutation causes oxido-reductive stress and protein aggregation cardiomyopathy in mice. Cell. 2007;130:427â&#x20AC;&#x201C;39. 27. Kim JW, Gao P, Dang CV. Effects of hypoxia on tumor metabolism. Cancer Metastasis Rev. 2007;26:291-8. 28. Nyengaard JR, Ido Y, Kilo C, Williamson JR. Interactions between hyperglycemia and hypoxia: implications for diabetic retinopathy. Diabetes. 2004; 53:2931-8. 29. Tilton RG. Diabetic vascular dysfunction: links to glucose-induced reductive stress and VEGF. Microsc Res Tech. 2002;57:390-407.

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30. Rajasekaran NS, Connell P, Christians ES, et al. Human alphaB-crystallin mutation causes oxido-reductive stress and protein aggregation cardiomyopathy in mice. Cell. 2007;130:427â&#x20AC;&#x201C;39. 31. Zhang X, Min X, Li C, et al. Involv. of reduct. stress in the cardiomyo. in transgen. mice with card.-spec. overexpr. of heat shock prot. 27. Hypertens. 2010;55:1412-7. 32. Zenkov NK, Lankin VZ, Menshchikova EB. Oxidative stress: Biochemical and pathophysiological aspects. Moscow: MAIK Nauka/ Periodica, 2001. 343 p. [in Russian] 33. Gorbenko MV, Popova TN, Shulgin KK, Popov SS. The activ. of the glutat. antiox. syst. under the act. of melaxen and valdoxan on the backgr. of hyperter. in rats. Biomedical chemistry. 2013;59(5):541-9. [in Russian]

ESSAY

Submitted: 10.9.2018; Accepted: 29.9.2018; Published online: 21.11.2018

Cardiometry in oncology: new digital possibilities for analyzing the cardiovascular system state in cancer patients

broadening the notion of cardio-oncology from the perspective of the cardiotoxicity pathogenesis under the cancer development conditions and in treatment thereof.

Keywords Cardiometry, Oncology, Hemodynamics, Cardiometric approach,

Alla I. Shikhlyarova , Mikhail Y. Rudenko , Vladimir А. Zernov , 1*

Cardiotoxicity pathogenesis, Prediction, ECG, Rheogram, Metabolic

Elena М. Frantsiyants , Elena А. Dzhenkova , Lyubov Y. Vladimirova , 1

parameters, The Baevsky stress index, Cardiac cycle phase analysis

Lyudmila Y. Rozenko1, Dmitriy A. Rozenko1, Nailya К. Guskova1,

Imprint

Larisa N. Vaschenko1, Yulia Y. Arapova1, Tatiana P. Protasova1, Elena А. Shirnina , Tatiana А. Barteneva , Marina А. Gusareva ,

Alla I. Shikhlyarova, Mikhail Y. Rudenko, Vladimir А. Zernov, Elena

Vitaly I. Voshedsky , Inna V. Pavlyatenko

М. Frantsiyants, Elena А. Dzhenkova, Lyubov Y. Vladimirova, Lyud-

mila Y. Rozenko, Dmitriy A. Rozenko, Nailya К. Guskova, Larisa N. 1

Rostov Research Institute of Oncology,

Vaschenko, Yulia Y. Arapova, Tatiana P. Protasova, Elena А. Shirnina,

Ministry of Healthcare of the Russian Federation

Tatiana А. Barteneva, Marina А. Gusareva, Vitaly I. Voshedsky, Inna

Russia, 344037, Rostov-on-Don, 14th Line st. 63

V. Pavlyatenko. Cardiometry in oncology: new digital possibilities

Russian New University

for analyzing the cardiovascular system state in cancer patients.

Russia, 105005, Moscow, Radio str., 22

Cardiometry; Issue 13; November 2018; p.35-41 ; DOI: 10.12710/

Corresponding author:

cardiometry.2018.13.3541; Available from: http://www.cardiometry.

e-mail: super.gormon@yandex.ru

net/issues/no13-november-2018/cardiovascular-system-state

Abstract The new high-tech era begins not with supply of an innovative product to the market, but rather with an intellectual leap in the field of open issues in fundamental engineering, healthcare and education. In the present essay, an example of the successful translation of mathematical, physics- and engineering-related philosophy into the digital platform of Cardiometry is discussed. The theory of hemodynamics, the laws of axiomatics, logic and adaptation can be expressed in terms of mathematics. The original analytical software used in PC-assisted device Cardiocode allows carrying out a phase analysis of the hemodynamics within an extended range. Pilot studies conducted by us in cancer patients at the stages of multi-course chemotherapy have revealed abnormalities and disorders in hemodynamics, energy exchange and adaptation expectancy of the heart at early stages of cancer treatment that is of prognostic significance. Pronounced processes of destabilization in hemodynamics, a suppressed energy exchange and a degradation of adaptation capabilities by the end of the chemotherapy courses involves the appearance of cardiotoxic effects. Based on records covering the specific frequencies discovered in ECG & Rheogram, the R-R interval scatter plots, the metabolic parameters and the Baevsky stress index, we have demonstrated cardioprotective influence made by xenon as a possible solution of the indicated problem. Thus, the Cardiocode technology supports diagnostics by offering an original cardiometric approach, significantly

In the reference literature on cardiology and onco logy, many common reference marks for pathogenesis of these most common and dangerous human disea ses can be found. Indeed, the multilevel mechanisms of the control and regulation of the homeostasis in biological systems, from a genome to an organism as a whole, are designed and work according to the same unique principle of the cause-effect determination. The integrity of the process design makes it possible to clearly identify the key stones marking pathogenetic alterations in the cardiovascular system against the background of the development of cancer or, on the other hand, detect abnormalities and disorders in rhythm genesis, metabolism and adaptive heart capabilities induced by tumor growth and toxogenic effect of drugs and radiation therapy. There is a similarity in the potential risk factors for both diseases: an acute or chronic inflammation, metabolic disorders and hypodynamia, which may accompany a human individual from adolescence to adulthood [1-7]. An important thesis should be emphasized that at the present stage of high speed development of strategies and technologies in cancer treatment it is crucial to preserve and use the fundamentals and discoveri es of the laws governing the control and regulation in living systems in the most expedient manner. But, Issue 13. November 2018 | Cardiometry | 35

unfortunately, sometimes we can see that some largescale theoretical concepts and promising conceptual ideas cannot find their applications in practice. This is a barrier to further development and transformation of medicine into a science supported by a fundamentally new methodology. As noted by A.I. Semenova from the N.N. Petrov Oncology Research Institute, St. Petersburg, Russia, the current knowledge on pathogenesis and risk factors for cardiotoxicity has allowed developing and implementing a number of effective techniques aimed at its prevention and early detection: radionuclide ventriculography, echocardiography, serial myocardial biopsy, an identification and an analysis of plasma markers in cardiac dysfunction [8]. We should mention that the leading technology for the functional cardiovascular system diagnostics remains electrocardiography (ECG). Modern in-hospital and portable cardio-analyzers are indispensable at any medical institution, because they make possible to immediately obtain informative parameters of heart failure and select the most adequate cardiotropic therapy for any nosology, including cases if oncological diseases. Nowadays, it should be stated that issues associated with developing a supplementary cardiometric analysis, based on a fresh mathematical approach, have become the biggest challenge. So, the cardiometric analysis deserves our attention. The existing cardiographic devices should be furnished with a new option to use a supplementary digital technology based on cardiometry, the feasibility of which stems from the needs of outer space exploration, as it has been mentioned more than once by Sergey Korolev, the Architect of the Soviet Space Program. In this context, it has been expected that the new mathematical approach thereto is capable of identifying and analyzing fluctuations, variability and changes in the performance of the cardiovascular system under functional loads both on the Earth and in space, including pathological processes, in particular, oncopathology. Let us consider an example of the successful implementation of the multidisciplinary approach using the theory of hemodynamics, the laws of axiomatics and logics for an expanded cardiac cycle phase analysis. Probably, it would be beneficial to demonstrate new capabilities of cardiometry in oncology, show the prospects and the reliability of the metabolic marker 36 | Cardiometry | Issue 13. November 2018

assessment of the efficiency of the cardiovascular system performance under development and treatment of malignant tumors, as well as the capability to predict a heart life expectancy in cancer patients. Adhering to the above philosophy, a joint pilot research project has been conducted by the Rostov Research Institute of Oncology, the Russian Ministry of Healthcare, and Russian New University (ROSNOU, Moscow, Russia). Before we proceed further let us discuss: what are the basic components of a new digital cardiometric platform? Firstly, the translation of the complex mathematical model of hemodynamics by G.M. Poyedintsev O.K. Voronova into practice has become possible because of the discovery and the proper mathematical description of the law of blood flow in large vessels, when blood moves along the vessels in the regime of elevated fluidity. This regime is called the "third flow regime" in contrast to the laminar and turbulent flows, and it is characterized by minor friction losses due to the unique ring pattern made by alternating layers of blood elements and plasma [9]. Secondly, M.Yu. Rudenko and V.A. Zernov have experimentally established and mathematically substantiated the previously unknown law of generation of a stable interference of arterial pressure waves in blood vessels within the areas of the local rise in the wavesâ&#x20AC;&#x2122; impedance. At the same time, under an occlusive blood flow, at an effective impedance of the vessel, the phenomenon of the stable interference is naturally manifested only for one portion of the reflected wave, the magnitude of which is directly proportional to the increase in the impedance of the vessel, and the other portion of the wave travels unchanged [10]. Thirdly, the mathematical model of hemodynamics with the digitized law of arterial pressure wave interference, established considering the characteristics of the energy and adaptation potential of the cardiac muscle and the blood vessels, has been embodied in a brilliant design idea of simultaneous recording of the hemodynamics phase structure and the cardiac performance data. The above mentioned phase structure covers an extended range of the phases of each cardiac cycle (up to 10), the blood stroke volume in different phases of the cycle, the calculated parameters of some metabolites (oxygen, lactate, phosphocreatine) according to the technique by S.A. Dushanin; it also allows identifying the wave ranges of the cardiac rhythm genesis for an identifi-

Figure 1. Improved scheme of the mechanism of electromechanical coupling of the activation of ion channels, the energy supply processes and the cardiac performance actuation

cation of the adaptation reactions by the Garkavi system method [11] and determining the Baevsky index [12]. Thus, on the basis of the laws of mathematics, physics, chemistry and the theory of living systems adaptation, the original complex analytical software for Cardiocode, a PC-assisted device of a new generation, has been developed. This device is designed to deliver noninvasively hemodynamic data and assess the hemodynamic performance of the heart and the coronary vessels upon recording synchronously a single lead ECG and RHEO in the aortic area for 30 seconds in sitting position and 30 seconds in standing position followed by further processing. The small sizes of the device makes it possible to immediately obtain most informative parameters of hemodynamics and provide an express diagnostics under the most unfavorable conditions, with ensuring at the same time the reliability of the calculated phase analysis multi-para-

metric criteria. A high level of the novelty of the offered Cardiocode technology implies also realization of the capabilities for evaluating the phase-related biochemical processes, which are responsible for the quality of the heart muscle contractility, taking into account the electrochemical ion processes of generation of the Action Potential (AP) and the electromechanical coupling between the contraction and hemodynamic processes (see Figure 1 herein). From point S to j, the cardiac performance is governed by electromechanical coupling (EMC). The S-L phase of tension pictures the aortic valve opening. The action potential (AP) is equal to zero, the calcium ions begin entering the muscle fiber cells, and due to EMC the contraction takes place under anaerobic conditions with lactate production. At time L, the aortic valve starts its opening and opens fully at point j. Segment L-j is a rapid ejection phase. EMC continues Issue 13. November 2018 | Cardiometry | 37

its work. The AP value is equal to zero, the K ions start leaving the cells for the intercellular space. This is an aerobic process, when phosphocreatine undertakes a significant role. At point j the first part of the slow ejection phase starts and ends at the beginning of the Тн wave generation. The AP returns to its initial value, the tension decreases, and the available blood amount reduces the pressure on the muscle fibers of the heart ventricles. Due to a difference in the pressures, blood enters the aorta, expands the latter and increases the pressure on the baroreceptors, which generate AP, so than the T wave, indicating the aorta expansion, on an ECG curve is generated. The aim herein is to determine the clinical value of the offered supplementary cardiometric analysis as a new noninvasive technology used for identification of the cardiotoxicity signs at early and late stages of chemotherapy and assess the predictive capabilities of the Cardiocode device and technology.

А) Aerobic processes

Materials and methods

Twenty-one female patients with breast cancer T24N1M0 (90.5%) on PCT with the use of Doxorubicin at a dose of 60 mg/m2 per 1 course (6 courses in total) have been enrolled into our studies. 126 recoding cases within the framework of ECG and Rheo monitoring have been treated employing the Cardiocode phase analysis technology. In parallel, conventional standard clinical laboratory methods, involving the generally accepted medical equipment for examination (BC, CBC, IBS, US, EchoCG), have been applied according to standard schedules. At the same time, psychological testing of anxiety level, emotional background and energy balance (Lüscher-Test) have been carried out. The types of the integral adaptation reactions by the organism according to the concept by L. Kh. Garkavi have been identified, and the Baevsky index has been computed in the patients of the above mentioned cohort.

B) Anaerobic glycolytic processes Figure 2. Dynamics of oxygen saturation (A) and lactate production (B) at the initial stages of PCT in patients with breast cancer

Results

The results of our studies on the cardiotoxic actions and effects, detected upon completion of 3 courses of PCT in breast cancer treatment, have shown first and foremost abnormalities and disorders in the fundamental metabolic processes affecting the energy resources of the heart (see Figure 2 herein). As follows from the calculated data, already after the first course of PCT observed is a compensatory rise in the oxygen concentration, with the mainte38 | Cardiometry | Issue 13. November 2018

Figure 3. Hemodynamic parameters upon completion of 3 cour ses of PCT (screenshot)

nance of this elevated level under its weak fluctuating dynamics. The lactate quantity increases, especially upon completion of the second course of PCT that finally indicates an increase in loading on the heart (see Figure 3 herein).

Figure 4. Evaluation of the cardiac rhythms frequency characteristics with the use of spectral analysis

Then, as scheduled, the phases of the ejection of blood to the aorta are recorded (L-j signifies the rapid ejection, and j-T refers to the slow ejection). The given data indicate that after the first course of PCT, suppression of the blood ejection to the aorta is found as the primary stress inducing effect. We have detected an increase in the load in the atrial systole (+ 14.29%) and building-up of the aorta pump function (+ 17.43%). After 3 courses of PCT, the partially compensated ejection function is diminished, that indicates an accumulated fatigue in the heart muscle fibers. These findings can also be supported by the rheographic curves, which are displayed on the monitor screen below the ECG curve. The Rheo curves recorded in parallel with the ECG curves demonstrate that after course 4 of the administered PCT, a delay in the ejection manifests itself in the form of a "clear-cut step" on the curves that is a pronounced sign of hemodynamic abnormalities and disorders in the coronary arteries. When evaluating the degree of tension in the systems responsible for the control and regulation of the cardiac activity during PCT, the distress syndrome is evidently manifested as one of the deepest integrative forms of the abnormalities in the physiological adaptation system. Pathogenetic mechanisms of distress development at a certain stage induce an increase in compensatory capabilities of CNS as well as the cardiovascular, endocrine, thymic-lymphatic and other systems in the organism. The phase of compensated distress is retained till course 3 of PCT, but the further growth of tension and energy expenditures contributes to a phase transition to a state of uncompensated distress and a crisis in the adaptation systems, as evidenced by real data obtained in the patients completing course 5 and 6 of the anticancer drug medication. Another important analytical aspect of assessing cardiotoxicity in cancer patients is the spectral anal-

ysis of the frequency characteristics of the cardiac rhythms in the patients (see Figure 4, left plot, herein). This is one of the most valuable informative approaches, which allows a better understanding of the priorities given by the autonomous nervous system control and regulation, when either the sympathetic or the parasympathetic subsystem is activated. The spectrogram segments indicating the initial state before PCT marked by the ovals (see Figure 4 left picture herein) are exemplary patterns of a well-balanced rhythm genesis, showing slow (respiratory) and rapid oscillations of different spectral densities. In contrast to this, upon completion of 6 PCT courses, found are a low-frequency spectrum only (see Figure 4, right plot, herein). A significant predominance of slow waves in the cardiac rhythm on course 6 of PCT is a clear marker of the stress tension in the regulation systems, and a sharp decrease in the spectral density of the cardiac rhythm rapid oscillations, even in a calm state, indicates an unfavorable prognosis. Such prognostic findings may be useful for the physician-chemotherapist and the cardiologist, when choosing the proper tactics in the restorative cardiotropic therapy. Often, not the monotherapeutic factor, but rather complex multisystem regulation medication can be chosen. Another exemplary case to demonstrate the effectiveness of application of cardiometry is an assessment of restorative xenon therapy in cancer patients. It is well known that the development of postcastration syndrome at the stage of ovariectomy in patients of reproductive age with hormone-positive breast cancer is accompanied by a severe dysfunction of their regulatory systems, overtension and depletion of the metabolic and contractile processes in the myocardium. In 20 patients with hormone-dependent breast cancer, the cardioprotective effect of xenon has been Issue 13. November 2018 | Cardiometry | 39

Figure 5. Assessment of the state stability in the form of the scatter plots of RR-intervals

studied in their complex therapy at the stage of surgical castration. The used clinical laboratory studies, examination techniques and equipment have been used the same in the xenon effect investigations as it is the case with the above mentioned cohort of the breast cancer patients. The cardioprotective effectiveness of xenon is confirmed by the data upon phase analysis of hemodynamic parameter produced by processing of the respective ECG and Rheo curves. The obtained data bear witness to the cardiovascular stability and the absence of the regulatory system tension, when using xenon exposures. An assessment of the state stability in the form of the scatter plots of RR-intervals and stroke blood volumes with calculation of the stress index provided by the "Cardiocode" software is presented in Figure 5 herein. Calculation of the concentrations of oxygen, lactate and phosphocreatine in the myocardium in patients with hormone-positive breast cancer after panhysterectomy and the use of the xenon-oxygen mixture in the early postcastration period have demonstrated that the oxygen level has been normalized, and the aerobic and anaerobic oxidation of substrates of mitochondrial energy, expressed as the ratio of phosphocreatine concentration and lactate concentration, has been balanced. 40 | Cardiometry | Issue 13. November 2018

Conclusions

Thus, the applications of the Cardiocode technology for an analytical quantitative examination of the cardiovascular system performance should be viewed as an optional extra, which may be effectively added to the conventional electrocardiographic and ultrasound examinations to predict cardiotoxic effects in cancer treatment. The supplementary aspects of hemodynamic disorders, assessment of energy and adaptation resources, especially at the early stages of chemotherapy and in other types of cancer treatment, are identified and discussed in our studies. Taking into account the latest requirements for the use of digital technologies and devices in medicine (eHealth, e-technology), the cardiometric technology is based on the applications of mathematical analysis to dynamic biological systems. The principles and mathematical patterns inherent in this e-technology, as they first appear, may touch off a skeptical reaction in the scientific community, since an innovative technology does not deal with conventionally used substrates for the study of metabolism. However, the challenging issue on applications of the digital approach to be immersed in a new data world cannot be overestimated, where each accurately calculated, statistically valid, value is a key to understanding the top secrets of the control and regulation of the cardiovascular system performance

in cancer patients, including the most severe cases of anti-cancer drug medication conditions. From the above line of reasoning, we may conclude the following: 1. The complex study of development of the cardiotoxic effect processes at the stages of multi-course breast cancer polychemotherapy on the basis of the phase and spectral analysis of hemodynamics, the metabolic and adaptation status of the cardiovascular system performance, carried out by the Cardiocode software as an optional extra, effectively added to the conventional electrocardiographic and ultrasound examinations, represents a supplementary actual, prognostically significant, aspect of the cardiac diagnostics, testing and examination. 2. New resources of the cardiometric analysis may offer possibilities of conducting screening in cancer-treated patients to determine effectiveness of correcting measures to eliminate or even fully avoid cardiotoxic effects of aggressive methods of malignant tumor treatment, with the use of cardiotropic means both of the specific and nonspecific nature. 3. The study of correlative relations between analog models of experimental oncology, including biochemical, electrophysiological and other aspects of the mechanism of development and prevention of cardiotoxicity within the framework of the study of tumor-bearing animals, when conducting chemotherapy in combination with cardioprotective factors and measures, contributes to strengthening of the fundamentals of the cardiometry phase analysis in terms of hemodynamics, energy and adaptation in a living organism.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. De Vita VT, Lawrence TS, Rosenberg SA, editors. De Vita, Hellman and Rosenbergs cancer: principles and practice of oncology. 10th River-woods (IL):Wolters Kluwer; 2014. 2. Blaes A, Prizment A, Koene RJ, Konety S. Cardio-oncology Related to Heart Failure Common Risk Factors Between Cancer and Cardiovascular Disease. Heart Failure Clinics. 2017;13(2):367-80. http://doi. org/10.1016/j.hfc.2016.12.006 3. Heinzerling L, Ott PA, Hodi FS, et al. Cardiotoxicity associated with CTLA4 and PD1 blocking immunotherapy. J Immunother Cancer. 2016;4:50. doi:10.1186/s40425-016-0152-y 4. Cheng F, Loscalzo J. Autoimmune cardiotoxicity of cancer immunotherapy. Trends Immunol. 2017;38:778. doi:10.1016/j.it.2016.11.007 5. Jain V, Bahia J, Mohebtash M, Barac A. Cardiovascular complications associated with novel cancer immunotherapies. Curr Treat Options Cardiovasc Med. 2017;19:36. doi:10.1007/s11936-017-0532-8 6. Markman TM, Nazarian S. Arrhythmia and Electrophysiological Effects of Chemotherapy: A Review. Oncology. 2016; 91(2):61â&#x20AC;&#x201C;8. doi:10.1159/000446374 7. Markman TM, Markman M. Cardio-Oncology: mechanisms of cardiovascular toxicity. F1000 Research. 2018;7:113. http://doi.org/10.12688/f1000research.12598.1, 2018 8. Semenova AI. Cardio and neurotoxicity of anticancer drugs (pathogenesis, clinic, prevention, treatment). Practical oncology. 2009;10(3):168-76. [in Russian] 9. Theoretical principles of cardiac cycle phase analysis. Moscow, Helsinki: IKM publishing house, 2007. 336 p. 10. Rudenko MY, Zernov VA, Voronova OK. Study of Hemodynamic Parameters Using Phase Analysis of the Cardiac Cycle. Biomedical Engineering. July 2009;43:15 [in Russian] 11. Garkavi LKh, Kvakina EB, Kuzmenko TS, Shikhlyarova AI. Antistress reactions and activation therapy. Activation reaction as a way to health through self-organization processes. Ekaterinburg: Philanthropist, V.1, 2002, 196 p.; Đ˘.2, 2003, 217 p. [in Russian] 12. Parin VV, Baevsky RM, Gazenko OG. Heart and circulation under space conditions. Cor et vasa. 1965; 32:165-84.

Issue 13. November 2018 | Cardiometry | 41

ORIGINAL RESEARCH

Submitted: 2.9.2018; Accepted: 25.9.2018; Published online: 21.11.2018

Effect of slow coronary flow on signal-averaged electrocardiogram

Keywords Late potential, Slow coronary flow, Signal-averaged electrocardiogram, Sudden cardiac death, Ventricular arrhythmias

Hossein Nough , Elahe Rafiei khoshnood , Aryan Naghedi , 1

Leila Hadiani1*, Mohammad Vahid Jorat1

Imprint Hossein Nough, Elahe Rafiei khoshnood, Aryan Naghedi, Leila

Yazd Cardiovascular Research Center,

Hadiani, Mohammad Vahid Jorat. Effect of Slow Coronary Flow on

Shahid Sadoughi University of Medical Sciences

signal-averaged electrocardiogram. Cardiometry; Issue 13; No-

Iran, 97514, Yazd, Bahonar Sq.

vember 2018; p.42-47; DOI: 10.12710/cardiometry.2018.13.4247;

Автор, отвечающий за переписку:

Available from: http://www.cardiometry.net/issues/no13-novem-

e-mail: dr_lehadiani@yahoo.com

ber-2018/effect-of-slow-coronary-flow

Abstract The slow flow coronary or decreased coronary TIMI flow rate is characterized by delayed pacification of coronary vessels in the absence of any evidence of obstruction coronary artery disease and is detected by coronary angiography. In the present study, we aimed to evaluate the effects of slow coronary artery flow on signal-averaged electrocardiogram (SAECG) as a possible indicator of increased risk for ventricular arrhythmias and sudden cardiac death.

Methods The study included 43 patients with angiographically proven normal coronary arteries and slow coronary flow (mean age = 53.7 ± 8.3 years), and 43 patients with angiographically proven normal coronary arteries without associated slow coronary flow (mean age = 52.8 ± 8.5 years). Coronary flow rates of all subjects were documented by thrombolysis in myocardial infarction frame count (TIMI frame count). SAECG was performed for each subject and late potentials were measured.

Results There was no statistically significant difference between the two groups in respect to age, gender, presence of hypertension, diabetes mellitus, opium addiction, cigarette smoking, typical angina, and positive exercise, blood sugar, white blood cell count and platelet count. There was a significant difference between the two groups in respect to the lipid profiles, uric acid level, body mass index, hemoglobin and positive CRP (P < 0.05). Abnormal SAECG was more frequent in SCF compared to control subjects (P=0.003).

Conclusion Abnormal SAECG and late potentials, indicating increased risk for ventricular arrhythmias and cardiovascular mortality was found to be significantly higher in patients with slow coronary artery flow. 42 | Cardiometry | Issue 13. November 2018

Introduction

Slow coronary flow (SCF) was first described by Tambe et al. in 1972, and is defined as delayed opacification of coronary vessels during angiography without any evident obstructive disease [1]. It has been suggested that this phenomenon should be distinguished from occurrence of slow flow in the context of coronary reperfusion therapy, coronary artery spasm, coronary artery ectasia, myocardial dysfunction, valvular heart disease, and certain connective tissue disorders involving coronary microvasculature [1]. The overall incidence of SCF has been reported as 1% among patients undergoing coronary angiography, especially in patients with acute coronary syndrome [2]. In the TIMI-IIIA study, the incidence of SCF was approximately 4% among patients who presented with unstable angina and had no or insignificant epicardial coronary artery disease [3]. Although the pathophysiological mechanisms of slow coronary flow phenomenon remain uncertain, there are several hypotheses that have been suggested: occlusive disease of small coronary arteries [4, 5], the imbalance between vasoconstrictor and vasodilatory factors and autonomic dysfunction [6-8], the platelet function disorder [9, 10] and Inflammation [11, 12]. In addition, a few cases of sudden cardiac death have been reported in patients with SCF [13, 14]. Moreover, SCF was found to be associated with prolonged QT interval and QT dispersion and T wave alternans [15, 16]. The SAECG is a technique to find the underlying pathophysiology of malignant reentrant arrhythmias [17]. It has therefore been applied to identify individuals at risk for sudden cardiac death, particularly in the context of coronary artery disease, acute myocardial infarction, and left ventricular dysfunction [18,

19]. The clinical significance of late potentials can be illustrated by the following observations [20-23]. Late potentials had a negative predictive accuracy of 95 to 99 percent, suggesting that only 1 to 5 percent of individuals recovering from an acute MI with a normal SAECG will experience sustained ventricular arrhythmias or sudden cardiac death (SCD) [20-22]. A meta-analysis of post-MI patients reported a greater than six-fold increase in arrhythmic events (sustained VT or SCD) in patients with an abnormal SAECG [23]. In the present study, we aimed at evaluating the effects of slow coronary artery flow on the SAECG and late potentials as a possible indicator of increased risk for ventricular arrhythmias and SCD.

Methods

Patients with suspicion of IHD due to typical angina of positive noninvasive test such as exercise stress test or myocardial perfusion test who had normal epicardial coronary arteries on coronary angiogram were eligible for the study as the case and control groups based on angiographic result of coronary flow rate. Patients with the presence of atherosclerotic coronary artery disease, coronary ectasia, congenital coronary anomalies, uncontrolled hypertension, ven¬tricular systolic dysfunction, left ventricular wall motion abnormalities, chronic obstructive pulmonary disease, severe anemia, history of cardiac revascularization, valvular heart disease, left ventricular hypertrophy, atrial fibrillation, bundle branch block, evidence of any other intraventricular conduction defect, or electrolyte abnormalities, ST-T change (ST depression or elevation, T inversion ), short or long PR interval and ventricular preexcitation were excluded from the study. No subjects were taking agents that could affect the SAECG, late potentials or autonomic tone, especially antiarrhythmic agents, digitalis, beta-blockers or calcium antagonists. Late potentials are defined by three criteria [24]. Total filtered QRS duration, voltage in the terminal portion of the QRS (usually the last 40 msec) and duration of the terminal QRS that is below a particular amplitude (usually 40 mcV), called the late potential duration. The most commonly used algorithms employ a 40 or 25-Hz high-pass filter. Using the 40-Hz filter, a Task Force Committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology suggested the following definition of late potentials [25]. Filtered QRS duration > 114 msec, terminal (last 40 msec) QRS root mean square

voltage < 20 mcV and low amplitude (< 40mcV) late potential duration > 38 msec. SAECG was performed in numbers of QRS in normal sinus rhythm for all subjects and three criteria of late potentials were measured.

Study sample

Our study population consisted of 43 patients with normal coronary ar¬teries, but documented slow coronary flow on coronary arteriography (27 (%62.8) male, 53.7±8.3 years) and 43 control group patients with nor¬mal coronary arteries and normal coronary flow (25 (%58) male, 52.8±8.5 years) matched for age and gender. Patients’ demographics and medical history were obtained by an interviewing or from hospital recorded files. The subjects were defined as hypertensive if their blood pressure was ≥140/90 mmHg or if they were receiving any antihypertensive medica¬tion. Diabetes mellitus was defined as the presence of a history of an¬ti -diabetic medication usage or fasting glucose level above 126 mg/dl. Current cigarette smoking was defined as regular smoke of tobacco product/products one or more times per day within the 30 days prior to admission. We also defined opium use according to the DSM-IV Criteria for Substance Dependence as regularly consumption of inhalatory opium more than three times per week and/or oral opium daily [26].

Coronary angiography and TIMI frame counts

Selective coronary angiography was performed using the standard Judkins’ technique at 30 frames/sin multiple angulated views. Left ventriculography was performed in a right and left anterior oblique view using a pigtail catheter. During coronary angiography, a contrast agent was manually injected. The TIMI frame count in each angiogram was calculated as the mean value obtained by using the thrombolysis in myocardial infarction (TIMI) frame count (TFC) method. This calculation was performed by the two observers blinded to the clinical details of the individual case [27]. The TFC of the left anterior descending artery (LAD) was assessed in either the right anterior oblique view with caudal angulations or the left anterior oblique view with cranial angulations and that of left circumflex artery (LCX) and right coronary artery (RCA) usually in straight left anterior oblique views. The first frame used for evaluating each TFC was the first frame in which the dye fully entered the artery with ante grade Issue 13. November 2018 | Cardiometry | 43

motion and the last frame was defined as the frame when the dye first entered the distal landmark branch. Study participants with a TFC greater than two SDs from the normal published range for anyone of the three vessels were accepted as having SCF [27].

Statistical Analysis

Continuous variables were expressed as mean ± SD and categorical variables were expressed as percentage. Comparison of categorical and continuous variables between two groups was performed using the chisquare test and unpaired t-test, respectively. A P-value of <0.05 was considered statistically significant.

Results Clinical characteristics of the study population

The clinical characteristics and laboratory parameters of SCF patients and control subjects are presented in Table 1. No marked differences in the age, gender, cigarette smoking, opium addiction, presence of hypertension, diabetes mellitus, the clinical presentations (typical angina, positive exercise test), white blood cell and platelet count were observed between SCF patients and control subjects. Uric acid level, lipid profile (total cholesterol, LDL-cholesterol and triglyceride), body mass index (BMI), hemoglobin level and positive CRP of SCF patients were significantly higher than those in control subjects and HDL-cholesterol was significantly lower than those in control group (P<0.05).

TIMI frame count of the study population

Patients with SCF had higher TFC in all of the major epicardial coronary arteries than control subjects. The mean TFC was 55.8 ± 14.1 vs. 29.8 ± 6.6 frames for LAD, 38.2 ± 15.1 vs. 21.02 ± 1.98 frames for RCA, and 32.4 ± 10.9 vs. 20.3 ± 1.9 frames for LCX (Table 2).

SAECG results

Abnormal SAECG was more frequent in SCF compared to control group (Table 3). In 21 patients with SCF and 8 patients without SCF one of three criteria of abnormal SAECG was positive.

Discussion

The main finding of this study was that abnormal SAECG is significantly higher in patients with slow coronary flow documented by TIMI frame count than those with normal coronary flow. SAECG abnormal44 | Cardiometry | Issue 13. November 2018

ities were present in 48.8% of patients with SCF compared to only 8.6% of patients without SCF. In this study, patients with SCF had more increase in uric acid level than control groups and this is in agreement with Kalay et al. [28]. In the present study, SCF was associated with higher hemoglobin level than the control subject as stated by Yildirim et al. [29]. BMI and lipid profile (total cholesterol, LDL-cholesterol and triglyceride) was higher in SCF patients than control group that is in accordance with Turhan et al. [30] and Elsherbiny et al [31]. Sudden cardiac arrest leading to SCD is a common problem in developed countries that is predominantly due to ventricular tachycardia (VT) or fibrillation (VF). SAECG is a noninvasive method for detection of underlying pathophysiology of reentrant arrhythmias such as ventricular tachycardia [18, 19]. It has therefore been applied to the identification of individuals at risk for SCD, particularly in the context of coronary heart disease, healed myocardial infarction, or left ventricular dysfunction. The disrupted myocardium by inflammation, fibrosis or scar that is substrate for VT, leads to electrical potentials beyond the activation time of normal surrounding myocardium. There electrical potentials are too small for detection in surface ECG and should be detected by signal average ECG. The SAECG facilitates the detection of small microvolt level signals with computerized averaging of ECG complexes during sinus rhythm. Among patients with a remote myocardial infarction (MI), SAECG abnormalities are present in up to 93 percent of those with a history of VT, compared to only 18 to 33 percent without prior VT [32]. This observation has inspired efforts to use the SAECG to predict future arrhythmic risk. The high prevalence of SAECG abnormalities in coronary heart disease patients who had a history of ventricular arrhythmia, particularly ventricular tachycardia, has led to interest in the use of the SAECG in risk-stratification for arrhythmic events in patients who had an acute MI. SAECG abnormalities are less common in patients with a history of VF. Late potentials on the SAECG are noticeable in only 21 to 65 percent of patients with VF [33, 34]. Conversely, some studies reported spectral abnormalities in these patients that may be similar to those seen in patients with VT [35]. Slow runoff dye in the coronary arteries during selective coronary angiography is known as slow coronary artery flowince its original description in 1972 by

Table 1. Demographic and clinical characteristics of patients and control subjects SCF group (N=43)

NCF group (N=43)

Clinical and hemodynamic Age (years)

53.7±8.3(30-68)

52.8±8.5(30-67)

Sex(male/female)

27/16

25/18

0.66

Cigarette smoking(n/%)

18/41.9

15/34.9

0.51

Opium addiction(n/%)

12/27.9

7/16.3

0.19

Hypertension(n/%)

22/51.2

19/44.2

0.52

Diabetes mellitus(n/%)

16/37.2

14/32.6

0.65

Typical angina pectoris(n/%)

33/76.7

Positive exercise test(n/%)

19/44.2

BMI(kg/m2)

27.17±3.2

25.57±2.84

0.016

Biochemical and hematological parameters Uric Acid (mg/dl)

5.49 ± 1.05

4.5 ± 0.78

< 0.00001

BS (mg/dl)

113.3 ± 32.4

115.5 ± 37.8

0.77

Total cholesterol (mg/dl)

193.4 ± 35.5

176.6 ± 38.6

0.031

LDL cholesterol (mg/dl)

128.8 ± 25.7

111.2 ± 31.9

0.0061

HDL cholesterol (mg/dl)

42.4 ± 5.93

46.6 ± 8.31

0.00077

Triglyceride (mg/dl)

212.4 ± 74.9

168.5 ± 59.6

0.0035

WBC (×103cell/ul)

7.02 ± 1.86

6.92 ± 1.49

0.78

Platelet (×103cell/ul)

206.8 ± 57.4

217.6 ± 59.3

0.39

CRP positive (n/%)

21/48.8

12/27.9

0.046

Hemoglobin (mg/dl)

15.07 ± 1.54

13.89 ± 1.65

0.001

Table 2. Thrombolysis in Myocardial Infarction (TIMI) Frame Counts of Patients and Control Subjects TIMI

SCF (N=43)

NCF (N=43)

LAD

55.8 ± 14.1

29.8 ± 6.6

< 0.00001

LCX

32.4 ± 10.9

20.3 ± 1.9

< 0.00001

RCA

38.2 ± 15.1

21.02 ± 1.98

< 0.00001

mean

42.8 ± 13.4

23.7 ± 2.8

< 0.00001

Table 3. Comparison of SAECG measurements between patients and control subjects Signal averaged ECG

SCF (N=43)

NCF (N=43)

Total filtered QRS duration≥114ms (% / n)

30.2/13

9.3/4

0.015

Voltage in the last 40 ms< 20 mcv (% / n)

20.9/9

9.3/4

0.13

Late potential duration below 40 mcv>38 ms (% / n)

46.5/20

16.3/7

0.0025

One of parameter is positive (% / n)

48.8/21

18.6/8

0.003

Tambe et al [1]. The phenomenon of slow dye progression in the coronary arteries is well known to invasive cardiologists. However, over all these years only scarce attention has been paid to this phenomenon and consequently, its clinical significance has remained un-

clear. Some authors have suggested that an abnormal increase of small vessel resistance was the cause of the slow progression of the dye in selective coronary angiography [5, 36]. Histopathological studies have revealed the existence of fibromuscular hyperplasia, Issue 13. November 2018 | Cardiometry | 45

medial hypertrophy, myointimal proliferation, and endothelial degeneration in microvascular circulation from the right ventricular biopsy specimens of patients with slow coronary artery flow[5]. It has been suggested that these histopathological changes lead to an abnormally increased microvascular tone [5, 36]. The present study was limited by the small sample size. Also, the effect of the volume, rate, and pressure of the contrast injection on the measurement of TIMI frame count should be considered as a limitation. Another limitation is difference in BMI between two groups.

Conclusion

In conclusion, we found that abnormal SAECG, indicating increased risk for ventricular arrhythmias and cardiovascular mortality, is significantly higher in patients with slow coronary artery flow. However, further long-term prospective studies are needed to establish the significance of abnormal SAECG in patients with slow coronary flow.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All authors contributed in revising the draft and approval of the final version of the manuscript. ERK contributed in data collection and analysis, writing the manuscript and editing. HN contributed in designing and conducting the study. MVJ contributed in designing and conducting the study, as well as data collection. MM contributed in writing the manuscript and data analysis. Research Project Number: 3174.

References

1. Tambe A, et al. Angina pectoris and slow flow velocity of dye in coronary arteries—a new angiographic finding. American heart journal. 1972;84(1):66-71. 2. Singh S, Kothari S, Bahl V. Coronary slow flow phenomenon: an angiographic curiosity. Indian Heart J. 2004;56(6):613-7. 3. Diver DJ, et al. Clinical and arteriographic characterization of patients with unstable angina with46 | Cardiometry | Issue 13. November 2018

out critical coronary arterial narrowing (from the TIMI-IIIA Trial). The American journal of cardiology. 1994;74(6):531-7. 4. Mangieri E, et al. Slow coronary flow: clinical and histopathological features in patients with otherwise normal epicardial coronary arteries. Catheterization and cardiovascular diagnosis. 1996;37(4):375-81. 5. Mosseri M, et al. Histologic evidence for small-vessel coronary artery disease in patients with angina pectoris and patent large coronary arteries. Circulation. 1986;74(5): 964-72. 6. Sarıkaya S, et al. Assesment of Autonomic Function in Slow Coronary Flow using Heart Rate Variability and Heart Rate Turbulence. Angiol. 2013;2(117):2. 7. Camsarl A, et al. Endothelin-1 and nitric oxide concentrations and their response to exercise in patients with slow coronary flow. Circulation journal: official journal of the Japanese Circulation Society. 2003;67(12):1022-8. 8. Yuksel S, et al. Abnormal nail fold capillaroscopic findings in patients with coronary slow flow phenomenon. Int J Clin Exp Med. 2014;7(4):1052-8. 9. Demir M, Melek M. Evaluation of plasma eosinophil count and mean platelet volume in patients with coronary slow flow. Clinics. 2014;69(5):323-6. 10. Seyyed-Mohammadzad MH, et al. Slow Coronary Flow Phenomenon and Increased Platelet Volume Indices. Korean circulation journal. 2014;44(6):400-5. 11. Ucgun T, et al. Serum visfatin and omentin levels in slow coronary flow. Revista Portuguesa de Cardiologia. 2014;33(12):789-94. 12. Durakoğlugil ME, et al. Increased circulating soluble CD40 levels in patients with slow coronary flow phenomenon: an observational study. Anadolu Kardiyol Derg., 2013;13(1):39-44. 13. Amasyali B, et al. Aborted sudden cardiac death in a 20-year-old man with slow coronary flow. International journal of cardiology. 2006;109(3):427-9. 14. Saya S, et al. Coronary slow flow phenomenon and risk for sudden cardiac death due to ventricular arrhythmias: a case report and review of literature. Clinical cardiology. 2008;31(8):352-5. 15. Karaman K, et al. New Markers for Ventricular Repolarization in Coronary Slow Flow: Tp-e Interval, Tp-e/QT Ratio, and Tp-e/QTc Ratio. Annals of Noninvasive Electrocardiology. 2014;1(1):1-7. 16. Surgit O, et al. The Effect of Slow Coronary Artery Flow on Microvolt T-Wave Alternans. Acta Cardiologica Sinica. 2014;30(3):190-6.

17. Kuchar DL, et al. Late potentials on the signal-averaged electrocardiogram after canine myocardial infarction: Correlation with induced ventricular arrhythmias during the healing phase. Journal of the American College of Cardiology. 1990;15(6): 1365-73. 18. De Bakker J, et al. Reentry as a cause of ventricular tachycardia in patients with chronic ischemic heart disease: electrophysiologic and anatomic correlation. Circulation. 1988;77(3):589-606. 19. Pogwizd SM, et al. Reentrant and focal mechanisms underlying ventricular tachycardia in the human heart. Circulation. 1992;86(6):1872-87. 20. McGuire M, et al. Natural history of late potentials in the first ten days after acute myocardial infarction and relation to early ventricular arrhythmias. The American journal of cardiology. 1988;61(15):1187-90. 21. Kuchar DL, Thorburn CW, Sammel NL. Late potentials detected after myocardial infarction: natural history and prognostic significance. Circulation. 1986;74(6): 1280-9. 22. Denniss AR, et al. Changes in ventricular activation time on the signal-averaged electrocardiogram in the first year after acute myocardial infarction. The American journal of cardiology. 1987;60(7):580-3. 23. Steinberg JS, et al. Predicting arrhythmic events after acute myocardial infarction using the signal-averaged electrocardiogram. The American journal of cardiology. 1992; 69(1):13-21. 24. Simson MB. Use of signals in the terminal QRS complex to identify patients with ventricular tachycardia after myocardial infarction. Circulation. 1981;64(2):235-42. 25. Breithardt G, et al. Standards for analysis of ventricular late potentials using high-resolution or signal-averaged electrocardiography: a statement by a task force committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. Journal of the American College of Cardiology. 1991;17(5):999-1006. 26. Association AP. Diagnostic and statistical manual of mental disorders: DSM-IV-TRÂŽ. 2000: American Psychiatric Pub.

27. Gibson CM, et al. TIMI frame count a quantitative method of assessing coronary artery flow. Circulation. 1996;93(5):879-88. 28. Kalay N, et al. The relationship between inflammation and slow coronary flow: increased red cell distribution width and serum uric acid levels. Turk Kardiyol Dern Ars. 2011;39(6):463-8. 29. Yildirim M, et al. Thrombin activatable fibrinolysis inhibitor. Herz. 2013. p. 1-8. 30. Turhan H, Yetkin E. The relation between insulin resistance and slow coronary flow: The development of microvascular dysfunction in insulin resistant state may be a plausible explanation. International journal of cardiology. 2006;111(3):474-5. 31. Elsherbiny IA, Shoukry A, Tahlawi MAE. Mean platelet volume and its relation to insulin resistance in non-diabetic patients with slow coronary flow. Journal of cardiology. 2012;59(2):176-81. 32. Cain ME, et al. Signal-averaged electrocardiography. Journal of the American College of Cardiology. 1996;27(1):238-49. 33. Denniss AR, et al. Differences between patients with ventricular tachycardia and ventricular fibrillation as assessed by signal-averaged electrocardiogram, radionuclide ventriculography and cardiac mapping. Journal of the American College of Cardiology. 1988;11(2):276-83. 34. Martinez-Rubio A, et al. Electrophysiologic variables characterizing the induction of ventricular tachycardia versus ventricular fibrillation after myocardial infarction: relation between ventricular late potentials and coupling intervals for the induction of sustained ventricular tachyarrhythmias. Journal of the American College of Cardiology. 1993;21(7):1624-31. 35. Lindsay BD, et al. Noninvasive detection of patients with ischemic and nonischemic heart disease prone to ventricular fibrillation. Journal of the American College of Cardiology. 1990;16(7):1656-64. 36. Beltrame JF, et al. The angiographic and clinical benefits of mibefradil in the coronary slow flow phenomenon. Journal of the American College of CardioÂ logy. 2004; 44(1):57-62.

Issue 13. November 2018 | Cardiometry | 47

ORIGINAL RESEARCH

Submitted: 27.8.2018; Accepted: 17.9.2018; Published online: 21.11.2018

The state of free-radicals procceses in cardiomyocytes in rats under the action of Doxorubicin and protection by Preductal

the SOD/TPA ratio by 27% with an increase in the E/A ratio by 30.8%. The above mentioned condition of the components of the antioxidative protection of cardiomyocytes was accompanied by an accumulation of MDA therein, the level of which was reported to be 28% higher as compared with that in the intact animals. In rodents of group 2, the use of Preductal induced the

Oleg I. Kit , Elena M. Frantsiyants , Irina V. Neskubina ,

normalization of activity of SOD, catalase, TPA, levels of vitamins

Ekaterina I. Surikova , Elena V. Shalashnaya ,

A and E, coefficients of activity of antioxidant ferments and vita-

Lyudmila A. Nemashkalova1, Natalia D. Cheryarina1,

mins. The MDA level was found to be the same as it was the case

Olga V. Kozyuk , Yulia A. Pogorelova , Larisa S. Kozlova , 1

with the intact rats, but at the same time it was by 31,3% lower as

Valeria A. Bandovkina , Irina V. Kaplieva , Lidia K. Trepitaki , Ro1

compared with the data recorded in the group 1 animals.

man E. Myagkov , Mikhail А. Kozhushko , 1

Sergey V. Sanamyants1, Mikhail А. Averkin1, Roman Е. Tolmakh1

Conclusion The Doxorubicin medication leads to a disorder in the perfor-

Rostov Research Institute of Oncology, Ministry of

mance of the physiological cascade of antioxidative ferments

Healthcare of the Russian Federation

and vitamins in the heart tissue; it is accompanied by activa-

Russia, 344037, Rostov-on-Don, 14th Line st. 63

tion of lipid peroxidation. The target of the action of Preductal

Corresponding author:

as cytoprotection is the antioxidation protection cascade as a

e-mail: super.gormon@yandex.ru

whole that contributes to suppression of Doxorubicin-induced oxidative stress in the heart muscle.

Aims The aim of our research work was to investigate the state of the

Keywords

lipid peroxidation system – the antioxidant protection system

Сardiomyocyte, Doxorubicin, Preductal, Lipid peroxidation, Antiox-

(LPO-AOS) in heart tissue in rats received either Doxorubicin

idant protection

alone or in combination with Preductal premedication.

Imprint Materials and methods

Oleg I. Kit, Elena M. Frantsiyants, Irina V. Neskubina, Ekaterina I. Su-

Our experimental studies were carried out in mature male albi-

rikova, Elena V. Shalashnaya, Lyudmila A. Nemashkalova, Natalia D.

no rats from outbread stocks (the cohort covered 50 animals)

Cheryarina, Olga V. Kozyuk, Yulia A. Pogorelova, Larisa S. Kozlova,

with an individual body mass from 150 to 160 g. The cohort

Valeria A. Bandovkina, Irina V. Kaplieva, Lidia K. Trepitaki, Roman E.

included the following groups of the rats: the reference group

Myagkov, Mikhail А. Kozhushko, Sergey V. Sanamyants, Mikhail А.

covered 10 intact animals; group 1 (20 rats) received dosage of

Averkin, Roman Е. Tolmakh. The state of free-radicals procceses in

Doxorubicin of 2mg/kg, five times, up to a cumulative dose of

cardiomyocytes in rats under the action of Doxorubicin and protec-

10 mg/kg; group 2 (20 animals) medicated as follows: the 5-day

tion by Preductal. Cardiometry; Issue 13; November 2018; p.48-53;

introduction of Preductal with dosage of 35 mg/kg followed by

DOI: 10.12710/cardiometry.2018.13.4853; Available from: http://

Doxorubicin medication according to the same schedule used

www.cardiometry.net/issues/no13-november-2018/procceses-

in group 1. MDA, levels of the A & E vitamins, SOD and catalase

in-cardiomyocytes

activity, Total Peroxidase Activity (TPA), the ratios E/A, SOD/TPA and SOD/catalase were assessed in heart tissue. Statistics data were processed with original software Statistica 6,0.

Results The Doxorubicin medication results in a decline in antioxidant protection components: reported are a decrease in SOD by 38,7%, catalase by 23,1%, TPA by 31,3%, and the levels of vitamins of A and E by 21% and 39%, respectively. We also noted a SOD/catalase ratio decline by 21,3% and a reduction in 48 | Cardiometry | Issue 13. November 2018

Introduction

Statistics data on cardiotoxicity from Anthracyclines in oncological patients make many researchers the challenge in searching for more effective ways to exclude or even avoid the adverse side effects of this sort of medication [1, 2]. The experts gave a detailed consideration to ways of prevention of cardiotoxicity due to Anthracyclines’ medication, including their limited use in chemotherapy against malignant

tumors that has immediately affected efficacy of the medication so that it might be inacceptable in general. Cardiac toxicity is one of the severest side effects of antitumor therapy [3]. The cardiac toxicity induced by Anthracycline chemotherapy medicines: Doxorubicin, Epirubicin, Rubomycin and similar cytostatic agents, each of them showing their own cardiotoxicity profile, has become a topical issue of special concern in oncology [3]. The basis for the destroying action produced by the Anthracyclines on tissues, including those in the heart, is their mechanism of direct damaging of a cardiomyocyte due to activation of oxidation of the cardiomyocyte membrane by free radicals [4]. Doxorubicin is capable of binding to contractile proteins of myocytes that in addition to myofibrillar lysis may considerably reduce myocardial contractility [5]. It has been expecting that a growing number of individuals healed of malignant tumor diseases would demonstrate the high probability to suffer and die from Anthracyclines-medication mediated cardiac diseases induced by the relevant chemotherapy [6]. At present, the use of cardioprotective drugs seems to have the greatest promise [7, 8, 9]. It is known that the main mechanism of the cardiotoxic action of Adriamycin is activation of peroxidation processes in cardiomyocytes [7]. The performance of the POL-antioxidants system under the normal physiological conditions is well compensated according to the feed-back principle, and the maintenance of the natural antioxidant activity in blood and tissues in the organism is one of the main indicators of homeostasis. There is evidence for the fact that it is precisely the free-radicals oxidation that causes metabolic reactions in aerobic organisms [10]. Therefore, explorations of these processes can give us not only valuable information about pathogenic mechanisms of development of metabolism disorders under different pathological conditions, but also to better understand the action of various medication agents on the organism and adequately assess the mechanism of their action. It is common knowledge that the mechanism of the action of cardiaс cytoproter Preductal is manifested in changes in intensity of lipid peroxidation; it activates potassium transport and increases synthesis of membrane phospholipids. All this results in a decrease in intracellular acidosis, normalization of energy metabolism of myocardium and diminishing manifestations of ischemia [11, 12]. The aim of our trials was to study the condition of the antioxidative system in the heart tissue in rats received

Doxorubicin alone or in combination with Preductal given prior to the Doxorubicin medication.

Materials and methods

Our experimental studies were carried out in 50 mature male albino rats from outbread stocks, with a body mass from 150 to 160 g, which were divided into the following groups: – the reference group composed by intact animals; – group 1 (20 rats) received the Doxorubicin intravenous medication with a dosage of 2mg/kg, five times, up to cumulative dose of 10 mg/kg; – group 2 (20 animals) medicated as follows: the 5-day Preductal medication with the use of feeding stomach tube, with a dosage of 35 mg/kg body mass followed by the Doxorubicin medication according to the same schedule as it was the case with group 1 above. All involved animals were kept under natural illumination conditions and had free access to feed and water. All experiments were carried out according to the applicable requirements and conditions set forth in Convention for the Protection of Vertebrate Animals used for Experimental or other Scientific Purposes and the associated National Order Regulation No.267 dd. 19.06.03 “Approved Rules and Regulations for Laboratory Practices” issued by the Ministry of Healthcare of Russian Federation. Every manipulation on animals was performed in a special box. Tools, utensils and hands were disinfected in a conventional manner. Upon expiration of 7 days after completion of the Doxorubicin medication, rats were decapitated by using a guillotine. Upon the decapitation, we used chilling agents in fast harvesting vital tissue of the heart; we obtained the 10% cytosol fractions extracted with the use of a 1M potassium phosphate buffer with a pH of 7,4, containing 0,1% Tween-20 and 1% BSA. We determined in the biological samples the following: MDA concentration [13], concentrations of vitamins A and E [14], SOD activity [15], catalase activity [16], total peroxidase activity (TPA) [17], content of sulfhydryl groups as listed below: total of the SH-groups, nonprotein and protein SH groups [18]; we calculated the following coefficients: the E/A, SOD/TPA and SOD/catalase ratios. Statistical analysis of the obtained results was performed with Software Statistica 6,0 (Stat-Soft, 2001). The calculated values are given in Tables herein as M±m, where M is the arithmetic mean, and m is mean error. Issue 13. November 2018 | Cardiometry | 49

The variances were evaluated according to Student's t-test criteria and were considered to be significant at Ń&#x20AC;<0,05.

Results and discussion

It was found that the concentrations of vitamins E and A in the cardiac muscle after the Doxorubicin use (group 1) were respectively 21% and 39,3% lower, than it was reported for the intact animals in the reference group, so that an increase in the E/A ratio in the heart tissue upon Doxorubicin effect was identified to be greater by 30,8% as compared with the intact animal heart tissue (see Table 1 herein). The activity of antioxidative ferments SOD, catalase and TPA in cardiomyocytes in animals of group 1 was reported to be 38,7%, 23,1% and 31,3% less than the respective reference values. Moreover, the SOD/catalase ratio was found to be 21,3% lower as compared with the same parameter in the reference group. Our outcomes are in agreement with the data of a number of other researchers which also indicate a decline in activity of antioxidant ferments under the action Doxorubicin [19, 20]. The concentration of sulfhydryl groups (SH) (see Table 2) in cardiomyocytes in rats after the Doxorubicin use was statistically significantly reduced; the concentration of the total of the SH groups was 27,5% less and that of the nonprotein SH groups was recorded to be 29% less as compared with the respective values in intact cardiomyocytes. The above results are consistent with the data obtained by Carlson et al. (2001) who have shown that Doxorubicin is responsible for a drop in the recovered glutathione in the organism. The drop of the amount of the protein sulfhydryl groups might be attributed both to their oxidation in the process of activation of free-radicals reactions and a change in the number of the protein molecules. It is known that Doxorubicin inhibits protein biosynthesis in the organism [21, 22]. The above condition of the constituents of the antioxidative protection of cardiomyocytes was accompanied by an accumulation of MDA, the level of which exceeded the normal values by 28% (see Table 2 herein). In general, we may notice that the use of the above specified dosage of Doxorubicin provokes suppression of activity of antioxidative ferments in the rat heart, lowering of the level and the ratio between the vitamins-antioxidants and low-molecular thioles that results in its turn in accumulation of one of the final products of free-radicals oxidation of lipids: malondialdehyde and in a drop in the level of sulfhydryl 50 | Cardiometry | Issue 13. November 2018

groups of proteins, which are markers of the structural and functional intactness of cell membranes. The change in the ratio expressing the accumulation of the vitamins in the myocardial tissue under the action of this sort bears witness to a pronounced drop in permeability of the histo-hematological barrier. The premedication with Preductal as cardio-protecting agent resulted in prevention of a drop in the level of the antioxidative ferments due to the use of Doxorubicin. So, the level of vitamin E in the heart muscle in rats was found to be 55% higher and the level of vitamin A therein was by 2,3 times greater than it was the case with the animals who received Doxorubicin only. The E/A ratio decreased by 35%. As compared with the intact rodents, the concentration of vitamin E and that of vitamin A were detected to be 23% and 43% higher, respectively (see Table 1 herein) that was an indication that the histo-hematological barrier permeability became normal. We also noticed the normalization of activity of SOD, catalase, TPA and the ratios of activity between the antioxidative ferments (see Table 1 herein) in the heart muscle. The use of Preductal has resulted in an increase in the number of sulfhydryl groups in the heart muscle in rats as compared with the animals from group 1 as follows: the number of the total sulfhydryl groups became 2 times greater, the number of the nonprotein groups increased by 81,5% and that of the protein groups was recorded to be 87,7% higher. In that case, the level of the sulfhydryl groups in cardiac muscle exceeded the data recorded in the intact rats as indicated below: the total sulfhydryl groups by 53%, the nonprotein sulfhydryl groups by 30% and the protein groups by 67%. The MDA level was normalized; it was found to be 31,1% less as compared with the values in group 1 of the animals (see Table 2 herein). It is common knowledge that cardiomyocytes under aerobic conditions are protected from free-radicals damaging by systems responsible for the maintenance of the antioxidative mechanism. As to the tissues in the organism and in the heart, SOD ferments, catalase and Glutathione peroxidase as well as non-fermentative antioxidants like vitamins A & E, thiols are classed with this type of the protective mechanisms [23, 24]. The key mechanism of neutralization of superoxide radicals is represented by SOD, which catalyzes dismutation of the above anions into hydrogen peroxide as main producer of the hydroxyl radical and oxygen.

Table 1. Data on condition of antioxidative system in heart tissue upon the use of Doxorubicin and Preductal in experimental studies Data

Reference group: reference values n=10

Use of Doxorubicin (group 1) n=20

Use of Doxorubicin and Preductal (group 2) n=20

SOD (un./g of tissue)

136,4±6,3

83,6±6,21

154,5±12,32

TPA (un./g of tissue)

3,2±0,2

2,2±0,11

3,6±0,22

Catalase (nmol/g of tissue)

2872±111,3

2210±23,51

3114±27,22

Vit. E (arb.un.)

21,9±2,0

17,3±1,51

26,8±1,61,2

Vit. A (arb.un.)

8,4±0,7

5,1±0,41

12,0±0,91,2

SOD/Catalase

4,7±0,3

3,7±0,21

5,0±0,42

SOD/TPA

42,6±3,8

38,0±3,2

42,9±4,1

Е/ А vitamin ratio

2,6±0,5

3,4±0,21

2,2±0,22

Notes: 1 – statistically significantly reliable in relation to intact animals in the reference group; 2 – statistically significantly reliable in relation to values in group 1 Table 2. Concentrations of sulfhydryl groups and malondialdehyde in heart tissue upon experimental Doxorubicin and Preductal medication Data

Reference group values n=10

Doxorubicin medication (group 1) n=20

Doxorubicin and Preductal medication (group 2) n=20

MDA (нМ nm)

42,5±4,3

54,6±4,61

37,5±2,82

Total SH-groups (mcM)

20,4±1,8

14,8±1,31

31,2±2,51,2

Nonprotein SH-groups (mcM)

7,6±0,5

5,4±0,31

9,8±0,61,2

Protein SH-groups (mcM)

12,8±1,0

11,4±0,9

21,4±1,81,2

Notes: 1 – statistically significantly reliable in relation to the reference group; 2 – statistically significantly reliable in relation to values in group 1

Considering metabolism, it should be stated that Н2О2, preventing formation of ОН--, catalase and peroxidase play an important role there. The antioxidative ferments are concentrated in the cytoplasm of cells [25]. Much evidence [26, 27] points to the fact that vitamin E captures free radicals, which are forming in a cell, and in doing so, it provides protection of the membranes in cells of organs, including the membranes of the cells in the heart, from lipid peroxidation. Vitamin E is acting in synergism with vitamin A, which is capable of capturing radicals, reacting with vitamin E, and in such a manner letting vitamin E to be recovered. Due to lipophilicity of the above vitamins, they serve as intra-membrane antioxidants. Low-molecular thiols are in dynamic equilibrium with respect to all sulfhydryl groups in a cell. The mixture of disulfides and proteins constitute the bulk of the common pool of gluthatione in a cell [28, 29]. A shift in the disulfide-sulfide balance in cells is generally treated as a marker of oxidative stress [30, 31]. Upon an analysis of the obtained data, it should be noted that the use of Doxorubicin results in suppression of all protective system in the myocardial tissue,

and the first it disturbs the normal operation of the physiological cascade of the antioxidative ferments and vitamins that is accompanied by activation of lipid peroxidation in cardiomyocytes; it also leads to a disruption of their structural and functional organization. It is evident that the action of Preductal as cytoprotective agent is addressed the cascade of the antioxidative protection in general. In this connection, first and foremost we should mention the antioxidative ferment systems. An elevation of activity of the enzymes under the action of Preductal takes place in combination with the normalization of their ratios that is more important than activation of some individual enzymes, since a change in the natural cascade of the antioxidative ferments in either direction involves formation of fairly reactive radicals of oxygen. An essential role plays also the fact that Preductal promotes accumulation of vitamins A and E in cardiomyocytes and induces an increase in the number of thiol compounds and proteins, containing sulfhydryl groups, in the heart tissue. The action of this mechanism of the above agent results in suppression of oxidative stress in the heart, developed due to the Doxorubicin medIssue 13. November 2018 | Cardiometry | 51

ication. It is not improbable that owing to the capability of Preductal to activate antioxidative systems in a cell it might be quite reasonable to use this agent in treatment of ischemic disease of the heart.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Dmitriev VL, Avzhenin AV, Volkova NV, Supronchuk NV, Babina IL. Cardiomyopathy in chemoradiotherapy in patients with breast cancer. Moscow: RAMS. 2009. 160 p. [in Russian] 2. Albini A, Pennesi G, Donatelli F, et al. Cardiotoxicity of аnticancer drugs: the need for cardio-jncology and cardio-jncological prevention. J Natl Cancer Inst. 2010;102(1):14-25. 3. Matyash MG, Kravchuk TL, Vysotskaya VV, et al. Antacycline-induced cardiotoxicity: mechanisms of development and clinical manifestations. Siberian oncol. journal. 2008; 6(30):64-9. [in Russian] 4. Orel NF. Cardiotoxicity of anthracyclines: the possibility of overcoming. Mod. oncol. 2004;6(3):121-4. [in Russian] 5. Bovelli D, Plataniotis G, Roila F. Минимальные клинические рекомендации Европейского общества медицинской онкологии. Москва, 2010. [in Russian] 6. Balluzek MF, Ionova AK. Cardio-oncology in treatment and rehabilitation programs of oncological patients. Russ J Cardiol. 2014;5(109):75–80. 7. Gershanovich ML. Cardiotoxicity of antitumor anthracycline antibiotic agents and the possibility of its prevention by cardioxane (dexrazoxane) in oncological practice. Vopr. Oncology. 2001;47(1): 119-22. [in Russian] 8. Reznikova EA, Koryonok VK, Nechaeva GI, Merkulov VN. Effect of the drug reamberin on the cardiotoxic effect of anthracyclines in the treatment of locally advanced breast cancer. Bulletin of the St. Petersburg Medical Academy named after I. I. Mechnikov. 2004;4:123–6. [in Russian] 52 | Cardiometry | Issue 13. November 2018

9. Merkulov VN, Kosenok VK, Nechaeva GI, Reznikov AS, Reznikova EA. Evaluation of the cardiotoxic effects of chemotherapy for breast cancer. Experim. Clin. Pharmacology. 2010;7:36-9. [in Russian] 10. Men'shchikova EB, Lankin VZ, Zenkov NK, Bondar IA, Krugovykh NF, Trufakin VA. Oxidative stress. Prooxidants and antioxidants. Mos.: Slovo, 2006; 553 p. [in Russian] 11. Bubnova MG, Aronov DM, Salmanova AS. Preuktal MV in the treatment of postprandial angina pectoris in patients with coronary heart disease. Lechebnoye delo. 2011;2:40-50; [in Russian] 12. Bannani H, Bernard M, Baertz D. Changes in intracellular sodium and pH during ischemia reperfusion are attenuated by trimetazidine: com parison between low and zero flow ischemia. Cardiovasc. Res. 2000;47:688–96. 13. Clinical oncohematology. A guide for doctors. Ed. by Volkova MA. Mos.: "Meditsina". 2001; 576 p. [in Russian] 14. Vladimirov YA, Archakov AI. Peroxide oxidation of lipids in biological membranes. Moscow: "Nauka", 1972; 252 p. [in Russian] 15. Cherniauskene RC, Varshkyavichene Z, Gribauskas PS. Simultaneous fluorimetric determination of the concentration of vitamins E and A in serum. Lab. delo. 1984;6: 362-365. [in Russian] 16. Beauchamp C, Fridovich I. Superoxide dismutase: Improved assays and assay applicable to acrylamide gels. Anal. biochem. 1971;44:276-81. 17. Korolyuk MA, Ivanova LI, Mayorova IG, Tokarev V.E. Method for determination of catalase activity. Lab. delo. 1988;1:16-8. [in Russian] 18. Pokrovsky AA. Biochemical methods of research in the clinic. Moscow. 1969; 349-51. [in Russian] 19. Folomeev VF. Photocolorimetric ultramicro method of quantitative determination of sulfhydryl groups of protein and non-protein compounds of blood. Issues of oncology. 1984;30(7):12-23. [in Russian] 20. Sycheva EA. Evaluation of cardiotoxicity and the possibility of its correction with chemotherapy on the autosomes of the body in the complex treatment of breast cancer. Author's abstract. Dissertation. Rostovon-Don, 2003, 18 p. [in Russian] 21. Abramov ME, Mashchelueva AY, Chichikov EI. Doxorubicin: Contribution to modern antitumor therapy. Ef. oncol., hemat. and radiol. 2010;3:46-9. [in Russian] 22. Mashkovsky MD. Medicinal products. A manual for doctors. Moscow: New Wave Publishing House LLC, 2002. 608 p. [in Russian] 23. Astashkin EI, Glaser ML. Pharmacol. regul. of the exchange of energy substrates in cardiomyo. in patho-

log. conditions associated with ischemia. Cardiovasc. ther. and prevent. treatm. 2006;5(7):112â&#x20AC;&#x201C;23. [in Russian] 24. Dotsenko OI, Dotsenko VA, Mischenko AM. The activity of superoxide dismutase and catalase in erythrocytes and some tissues of mice and under conditions of low-frequency vibration. Physics of the living. 2010;18(1):107-13. [in Russian] 25. Indutny AV, Vysokogorsky VE, Bykov DE. The level of products of free radical oxidation in the heart and blood plasma in diabetes mellitus in combination with chronic alcohol intoxication. Biomedical Chemistry. 2010;56(2):257-65. [in Russian] 26. Zenkov NK, Lankin VZ, Men'shchikova EB. Oxidative stress: biochem. and pathophys. aspects. Mos.: MAIK "Nauka / Interperiodica". 2001. 343 p. [in Russian] 27. Shikh EV. Vitamins with antiox. prop. in the prev. and treatm. of acute respirat. infections in children. Issues of modern pediatrics. 2013;12(4):142-7. [in Russian]

28. Solovyeva EY, Mironova OP, Baranova OA. Free radical processes and antioxidant therapy in cerebral ischemia. Jour. neurol. psychiat. 2008;108(6):37-42. [in Russian] 29. Kravtsov AA, Kozin SV. Glutathione: a physiological role. MCSN "Science and education". In the collection: EUROPEAN RESEARCH. Collection of the XII International Scientific and Practical Conference articles. 2017. p.22-24. [in Russian] 30. Masella R, DiBenedetto R, Vari R, Filesi C, Giovannini C. Novel mechanisms of natural antioxidant compounds in biological systems: involvement of glutathione and glutathione-related enzymes. J. Nutr. Biochem. 2005;16(10): 577â&#x20AC;&#x201C;86. 31. Buko IV, Polonetskiy LZ, Moiseenok AG. Glutathione erythrocytes, indicators of oxidative stress and inflammation in acute coronary syndromes. Arterial hypertension. 2014;20(3):172-81. [in Russian]

Issue 13. November 2018 | Cardiometry | 53

ORIGINAL RESEARCH

Submitted: 22.8.2018; Accepted: 12.9.2018; Published online: 21.11.2018

Assessment of the efficacy of a peroral anticoagulant after surgical resection of gastric cancer

tablets to this category of patients it is necessary to control the absorption of medical drugs.

Keywords Gastrectomy, Anti-XA activity, Rivaroxaban, Vein thrombosis

Oksana V. Katelnitskaya , Oleg I. Kit , Igor I. Katelnitsky , 1*

Maksim N. Duritsky1, Nailya K. Guskova1, Petr N. Gabrichidze1,

Imprint

Viktoria R. Zakharchenko , Aleksandr V. Snezhko ,

Oksana V. Katelnitskaya, Oleg I. Kit, Igor I. Katelnitsky, Maksim

Yuriy А. Przhedetskiy1, Sergey I. Poluektov1, Alla V. Pustovalova1

N. Duritsky, Nailya K. Guskova, Petr N. Gabrichidze, Viktoria R.

Zakharchenko, Aleksandr V. Snezhko, Yuriy А. Przhedetskiy, Sergey 1

Rostov Research Institute of Oncology, Ministry of

I. Poluektov, Alla V. Pustovalova. Assessment of the efficacy of a per-

Healthcare of the Russian Federation

oral anticoagulant after surgical resection of gastric cancer. Cardi-

Russia, 344037, Rostov-on-Don, 14th Line st. 63

ometry; Issue 13; November 2018; p.54-57 ; DOI: 10.12710/cardi-

Rostov State Medical University

ometry.2018.13.5457; Available from: http://www.cardiometry.net/

Russia, 344022, Rostov-on-Don, Nakhichevansky lane 29

issues/no13-november-2018/surgical-resection-of-gastric-cancer

Corresponding author: e-mail: katelnickaya@yandex.ru

Aims Patients suffering from gastric cancer have a high risk of postoperative thrombotic complications and often use anticoagulants. Direct oral anticoagulants absorb in the proximal region of the digestive tract. Consequently, a reduction in anticoagulating activity is possible. In the present research given is an evaluation of the anti-Xa activity upon administration of Rivaroxaban at a fixed dose of 20 mg once daily in oncological patients after gastrectomy or cases of extensive resection of the stomach.

Materials and methods The study cohort covered 20 patients after surgical treatment of gastric cancer having normal renal/hepatic function. The patients received Rivaroxaban at a fixed dose of 20 mg once daily to prevent venous thromboembolic complications.

Results When evaluating absorption and bioavailability of 20 mg of Rivaroxaban sufficient anti-Xa blood plasma activity (1.37±0.16 UI/ml) was recorded. However, in 5 patients the absorption of a therapeutic agent was not-critical, their average anti-Xa activity being 0.32 ± 0.14 UI/ml.

Conclusions Absorption of peroral anticoagulants in most patients who have experienced extensive stomach resections, is satisfactory. However, the level of anticoagulant activity showed significant changeability, as in a quarter of patients malabsorption of rivaroxaban was observed. Thus, when prescribing anticoagulant 54 | Cardiometry | Issue 13. November 2018

Introduction

Gastric cancer dominates among oncological diseases of the gastrointestinal tract (GIT). It is an independent risk factor of vein thrombosis development. Curative treatment of gastric cancer is based on surgical methods. On the other hand, operative treatment increases by 20 times venous thromboembolic complications (VTE) rate occurrence. Thus, vein thrombosis is considered the key cause of death in oncological patients during the first month of postoperative period [1]. Treatment standard of cancer-associated thrombosis is using low-molecular-weight heparin (LMWH) for the period not less than 6 months [2]. Yet the given vein thrombosis therapy has a number of disadvantages, namely: necessity of daily injection, high treatment cost, complications (thrombocytopenia, allergic reactions, osteoporosis, etc.). Thus, upon anticoagulating VTE therapy in oncology observed is a three-time increase in risk of thrombosis recurrence and two-, five, six-time increase of hemorrhagic complications as compared to overall population [3]. One of the recent research works of cancer-associated thrombosis reveals that cumulative recurrence rate of VTE amounts to 52% [4]. Notwithstanding the achievements in VTE diagnosis and treatment, vein thrombosis remains the leading cause of death in in oncological patients [5, 6]. It is fair to assume that high VTE recurrence rate as well as high lethality rate is connected with low LMWH therapy adherence in oncological patients. In 2017 Russian references of oncology specialists RUSSO raised the responsibility of the therapy of on-

cological thrombosis using direct oral anticoagulant agents (DOACs): apixaban, dabigatran etexilate and rivaroxaban [2]. Several significant research works proved rivaroxaban to be as effective as vitamin K antagonists for VTE treatment showing similar recurrence rate and hemorrhagic complications [7]. Direct oral anticoagulant agents (DOACs) do not require routine monitoring of the therapy. They are not subject to diet restrictions and don’t have wide interaction with medical agents as compared to warfarin. That is why DOACs are more attractive for longterm drug therapy and are expected to enhance the quality of life of oncological patients. However, the possibility of using DOACs after extensive resection of the stomach is still to be discussed. As new anatomic interrelations are formed, the bolus is not treated with hydrochloric acid. Besides, stomach motility which provides rhythmical flow of food into the intestine is lost, thus causing malabsorption. For this reason, these patients have problems with absorption of nutritional substances as well as with absorption of oral drugs. The aim of our research is to assess the possibility of using rivaroxaban in oncological patients after extensive stomach resections when treating vein thrombosis.

Materials and methods

In the present research work 20 oncological patients with venous thromboembolism (VTE) have been examined. All patients were treated and observed in Rostov Research Institute of Oncology. The patients were chosen according to the following criteria: diagnosed gastric cancer, gastrectomy or subtotal stomach resection in anamnesis, presence of venous thromboembolic complications in subacute stage, age of 18 and older, bodyweight from 50 to 110kg. The withdrawal criteria were as follows: severe renal or hepatic failure, recent bleeding, cytochrome P450 3A4 (CYP3A4)- and P-glycoprotein-dependent treatment for the past 14 days, disaggregate medication. The average age of the patients was 58.25±2.01. Significant domination of male patients (18 patients – 80%) was observed. The average body mass index (BMI) was 27 kg/ m2 (± 5.1 kg/m2). The average Creatinine Clearance index (Cockcroft-Gault Equation) was 79.3±7.1 ml/min. Most frequently tumor localization was observed in the stomach body (60%) and was represented by adenocarcinoma of the stomach (80%). In 70% of cases

gastrectomy was performed, in 25% of cases distal subtotal stomach resection was performed, in 5% of cases proximal subtotal stomach resection was performed. The prevalence rate of oncological disease is presented in Table 1. To investigate the proper absorption of DOACs we examined the patients taking rivaroxaban as its pharmacodynamic effect correlates with plasma concentration, thus making it possible to evaluate absorption by anti-Xa activity. The medication is direct Xa-inhibitors, it indirectly inhibits thrombin generation. It absorbs quickly, herewith Cmax is recorded within 2 – 4 hours after medication administration. According to Mueck et al. rivaroxaban does not accumulate to a great degree in case of long medication intake. It is mainly absorbed from the proximal gastric lumen with bioavailability of about 80 – 90% [8]. In experiments in healthy people it is stated that 30% of medication absorption occurs in gaster and duodenum. In the proximal ileum segment absorbed is about 50% of medication, the rest is absorbed in distal ileum segment [8]. In connection with the thrombotic events development (Table 2) the patients received in acuity the curative LMWH dose, later on receiving DOACs mainly rivaroxaban at a dose 20mg once daily. Blood sampling was performed 4 hours after taking anticoagulants in the presence of the doctor (dosage of Rivaroxaban was chosen according to RUSSO recommendations [2], it was 20mg once daily). Venous blood sampling was performed from the vein at the cubital fossa without a tourniquet or with the shorttime use (not longer than 1 min.) of a tourniquet to control the blood flow, using vacuum technology. The blood was immediately mixed with 3.2% sodium citrate concentration in 9:1 ratio. Then the blood was centrifuged at 3000 – 4000 r/min for 15 minutes at room temperature to obtain poor in thrombocytes plasma. Afterwards poor in thrombocytes plasma was used within 2 hours at the latest. Hemostasis system diagnostics was carried out using the automatic analyzer STAGO that performs clotting, chromogenic and immunological assays on plasma samples. For quantitative estimation of rivaroxaban in blood plasm various methods can be used. Although, method of chromogenic anti-Xa activity assay is considered to be reliable and reproducible. The level below 0.10 anti-XA IU/ml eliminates the presence of direct XA factor inhibitors [9]. Issue 13. November 2018 | Cardiometry | 55

Table 1. Basic data of the analyzed patient cohort Characteristic Number of patients Average age Gender Male Female Tumor localization Gastric body Antrum Gastric cardia Staging according to T Т1 Т2 Т3 Т4 Staging according to N N1 N2 N3 Staging according to M M0 M1

Table 2. Occurrence of VTE in oncological patients

Qyantity

Number of patients (%)

The popliteo-crural region

12 (60%)

The femoropopliteal region

7 (35%)

The iliofemoral region

1 (5%)

Combination of DVT (deep vein thrombosis) with PE (pulmonary embolism)

20 58,25 ± 2,01 18 (90%) 2 (10%) 12 7 1

0 1 15 4 11 7 2 20 0

Histological type of tumor Adenocarcinoma of the stomach Signet ring cell carcinoma (SRCC) Poorly differentiated cancer

16 3 1

Surgery type Gastrectomy Distal subtotal stomach resection Proximal subtotal stomach resection

14 5 1

When using rivaroxaban for treatment observed is dose-dependent prolongation of prothrombin time [PT] and activated partial thromboplastin time (aPTT). This fact was considered when defining the given indices. Rivaroxaban activity was measured by testing PT Neoplastin Plus (PT, Diagnostica Stago) and a heparin-calibrated antifactor Xa assay Liquid Anti-Xa (Diagnostica Stago). J. Bever in his research work proved that it is possible to evaluate the concentration of rivaroxaban, apixaban and edoxaban using the results of quantitative assessment of heparin-calibrated antifactor Xa activity (STA®-Liquid anti-Xa) [11]. Statistical data analysis was performed using Statistica 6.1 program. The mean values, the standard deviation of the mean, the mean squared deviation, the median and interquartile ranges were defined. To reveal the hemostatic profile interrelation Spearman rank correlation coefficient was calculated. The interrelation was recognized as significant at р<0.05. 56 | Cardiometry | Issue 13. November 2018

Vein thrombosis localization

Results

When assaying plasma samples in oncological patients receiving a therapy dose of rivaroxaban, revealed was the significant dependency of PT and anti-Xa activity indices (р<0.05). Similar intercorrelation between aPTT indices and anti-Xa activity indices was not identified (р=0.563). Thus, aPTT does not possess the required sensibility for monitoring anticoagulating activity of rivaroxaban (Table 3). The average anticoagulating activity of rivaroxaban (anti-Xa) in plasma samples accounted for 1.37 UI/ml (95% CI: from 0.67 to 2.07). According to T. Sakaguchi, in patients with creatinine clearance 80 ml/min and more therapeutic range for rivaroxaban was equal to 1.04 – 2.17 UI/ml. The Japanese research also revealed that anti-Xa activity level increase above 2.19 UI/ml with sensibility of 68.2% and specificity of 73.6% is an independent factor of hemorrhagic complications upon rivaroxaban therapy [12]. Based on the abovementioned data, anti-Xa level equal to or above 1 UI/ml was considered to be effective activity. Our research revealed that in 25% of patients the anti-Xa activity index was below therapeutic range, this fact was recorded on two occasions after gastrectomy and on three occasions after distal subtotal stomach resection. The average anticoagulating activity in the observed patients upon administration of rivaroxaban was equivalent to only 0.32 ± 0.14 UI/ml. A 2.0 UL/ml level increase (hemorrhage predictor) was recorded on neither occasion during DOACs therapy. No hemorrhagic complications were observed in our research. No similar data concerning DOACs therapy in patients after proximal stomach resection was found. In PDER PAN research in patients with a short bowel syndrome DOACs concentration in blood plasm showed considerable variability indicating the need for re-monitoring in order to eliminate the drug

Table 3. Hemostasis parameters during rivaroxaban treatment Index

Reference range

On rivaroxaban treatment (M±m)

aPTT (sec.)

24 – 35

34,19 ±1,57

Anti-Xa activity (UI/ml)

0 – 0,1

1,37±0,16

12 – 17

19,8±0,73

absorption deficiency. Although the authors conclude that rivaroxaban or dabigatran etexilate can be used as an alternative to LMWH in certain patients with the given syndrome under close monitoring [13].

Conclusions

Extensive resection of the stomach can cause absorption disorder of nutrients, electrolytes, water and peroral drug treatment that is accompanied by difficulties with the introduction of drugs in this group of patients. It is especially true for drugs with proximal absorption in gastrointestinal tract having narrow therapeutic level or being vital for the patient’s treatment, such as anticoagulant tablets. The obtained data point at strong variability of plasm anti-Xa activity of the patients receiving rivaroxaban. Herewith, in one quarter of patients who had received proximal stomach resection, recorded was low anticoagulating activity. Thus, administration of direct oral anticoagulant agents for VTE therapy in oncological patients after surgical resection of gastric cancer requires monitoring the drug absorption and anti-Xa activity.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Agnelli G, Bolis G, Capussotti L, et al. A clinical outcome-based prospective study on venous throm-

boembolism after cancer surgery: the @RISTOS project. Ann. Surg. 2006;243 (1):89–95. 2. Russian Society of Clinical Onkology. http://www. oncology.ru/russco/ [in Russian] 3. Schulman S, Zondag M, Linkins L, et al. Recurrent venous thromboembolism in anticoagulated patients with cancer: management and short-term prognosis, J. Thromb. Haemost. 2015 Jun 13;1010–8. 4. Chee CE, Ashrani AA, Marks RS, et al. Predictors of venous thromboembolism recurrence and bleeding among active cancer patients: a population-based cohort study. Blood. 2014;123(25):3972–8. 5. Chew HK, Wun T, Harvey D, et al. Incidence of venous thromboembolism and its effect on survival among patients with common cancers, Arch. Int. Med. Am. Med. Assoc. 2006 Feb 27;166:458–64.   6. Khorana AA, Francis CW, Culakova E, et al. Thromboembo- lism is a leading cause of death in cancer patients receiving outpatient chemotherapy. J. Thromb. Haemost. 2007;5:632–4.   7. Prins MH, Lensing AW, Bauersachs R, et al. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb. J. 20 Sep 2013;11:1.   8. Mueck W, Stampfuss J, Kubitza D, et al. Clinical Pharmacokinetic and Pharmacodynamic Profile of Rivaroxaban. Clin Pharmacokinet. 2014;53:1–16. DOI 10.1007/s40262-013-0100-7. 9. S. Rathbun A, Tafur R, Grant N, et al. Comparison of Methods to Determine Rivaroxaban anti-factor Xa activity. Thrombosis Research. 2018; 164:S168–S171. 10. Samama MM, Contant G, Spiro TE, et al. Laboratory assessment of rivaroxaban: a review. Thrombosis Journal. 2013;11:11. 11. Beyer J, Trujillo T, Fisher S, et al. Evaluation of aheparin-calibrated Antifactor Xa assay for measuring the anticoagulant effect of oral direct Xa inhibitors. Clin. Appl. Thromb. Hemost. 2016;22:423–8. 12. Sakaguchi T, et al. Monitoring of anti-Xa activity and factors related to bleeding events: A study in Japanese patients with nonvalvular atrial fibrillation receiving rivaroxaban. Journal of Cardiology. 2017;70:244–9. 13. Cheung YW, Barco S, Mathôt RAA, van den Dool E, et al. Coppens Pharmacokinetics of dabigatran etexilate and rivaroxaban in patients with short bowel syndrome requiring parenteral nutrition: The PDER PAN study. Thrombosis Research. 2017;160:76–82. Issue 13. November 2018 | Cardiometry | 57

REPORT

Submitted: 20.6.2018; Accepted: 10.7.2018; Published online: 21.11.2018

Functional state of the blood coagulation system in postsurgery period in patients with malignant tumors of the GI tract Oksana V. Katelnitskaya , Oleg I. Kit , Nailya K. Guskova , 1*

Kristina А. Avanesova , Igor I. Katelnitsky , Dmitry S. Petrov , 2

Anna V. Chubaryan , Dmitry V. Burtsev , Yulia N. Krokhmal , 1

Ekaterina О. Vasilieva

Rostov Research Institute of Oncology, Ministry of Healthcare of the Russian Federation Russia, 344037, Rostov-on-Don, 14th Line st. 63

Rostov State Medical University Russia, 344022, Rostov-on-Don, Nakhichevansky lane 29

Corresponding author: e-mail: katelnickaya@yandex.ru

Abstract The present paper analyzes changes in coagulation system markers in 64 patients with malignant tumors of the GI in surgical treatment. Results obtained when using parameters of the expanded coagulogram and a new global hemostatic assessment test with the use of Thrombodynamics recorder T2 have been evaluated. Based on the findings, we have developed models for predicting postoperative venous thrombosis and compared different methods for the coagulation system examinations. The thrombodynamics test allows us to assess the state of thrombotic readiness in the postoperative period in 26.56% of patients with GI cancer upon the standard anticoagulant prevention. High levels of the thrombinemia markers and hypercoagulation at the fibrin clot growth rate have been detected after the surgery. Correlation between the plasma fibrinogen levels and the fibrin clot density has been observed. Therefore, the proposed highly sensitive global assessment test of the hemostatic system allows us to detect hypercoagulation and evaluate the efficacy of a preventive dose of low molecular weight heparin (LMWH).

Keywords Hemostasis system, Thrombinemia, Thrombodynamics, Gastric cancer, Colon cancer

Imprint Oksana V. Katelnitskaya, Oleg I. Kit, Nailya K. Guskova, Kristina А. Avanesova, Igor I. Katelnitsky, Dmitry S. Petrov, Aleksandr V. 58 | Cardiometry | Issue 13. November 2018

the blood coagulation system in postsurgery period in patients with malignant tumors of the GI tract. Cardiometry; Issue 13; November 2018; p.58-65; DOI: 10.12710/cardiometry.2018.13.5865; Available from: http://www.cardiometry.net/issues/no13-november-2018/

Aleksandr V. Shaposhnikov1, Sergey N. Dimitriadi1, 1

Burtsev, Yulia N. Krokhmal, Ekaterina О. Vasilieva. Functional state of

malignant-tumors-of-the-gi-tract

Shaposhnikov, Sergey N. Dimitriadi, Anna V. Chubaryan, Dmitry V.

Introduction

At present, cancer incidence and mortality rates in Russia tend to rise, malignant neoplasms (MN) of the stomach and the colon being dominant. The mortality during the first year after diagnosing gastric cancer reaches 54.1%, in case of rectosigmoid and colon cancer reported are 34.1% and 30.6%, respectively [1,2]. Venous thromboembolic complications (VTE) are a second cause of mortality in oncological patients. For this reason, a number of researchers attribute oncological diseases to acquired thrombophilias [3-6]. When venous thromboembolic complications are examined using radiofrequency data analysis and ultrasound angiography, deep vein thrombosis (DVT) and/or superficial vein thrombosis (SVT) are recorded in one third of postoperative patients [7, 8]. Typically vein thrombosis is easily found in patients with the verified diagnosis of the pulmonary or pancreatic adenocarcinoma, the adenocarcinoma of the female reproductive system and GI tract [3, 4, 9]. Beside the present tumorous disease, the risk of the VTE complications is influenced by many factors. An additional risk depends on the age, the anamnesis, the presence of the concurrent diseases, the extent of surgery, the types of anesthesia, the patient postsurgery activation, the required chemotherapy and radiation treatment [4, 10]. In oncology, in order to prevent the VTE complications at different treatment stages, Unfractionated Heparin, Low Molecular Weight Heparin (LMWH) and oral anticoagulants are used. Normalization of the markers of thrombinemia is considered to be the criterion of efficacy of thrombotic event risk avoidance. However, in many oncological patients despite anticoagulant agents usage, an elevation of the above mentioned indices is recorded over a long period of time. In retrospect, the mentioned fact indicates lack of efficacy of thrombosis prevention. Therefore, it is problematic to evaluate the preventive dose of the anticoagulant

agent and to make dose adjustment if required at a given time, considering the markers of thrombinemia only. It is possible to analyze the VTE prevention efficacy based on a standard coagulogram only, according to elevation of thrombinemia markers, consequently providing a retrospective analysis of the effect of the performed standard protocol treatment [11]. In our opinion, an individual approach accompanied by regular monitoring of the hemostatic profile may reduce risk of VTE development in oncological patients. Most of the laboratory tests researching the hemostasis system are aimed at determining concentrations or activity of the certain factors and coagulation inhibitors. Thus, using the standard coagulation tests it is possible to detect either deficiency or deficit, in one of the coagulation factors or pathology of one of the hemostasis components Investigations of the hyper-coagulation markers address the subject of thrombus formation only. However, we see little point in the use of the markers for evaluating efficacy immediately during the therapy or prevention at a given moment. Only after a few days or weeks of the therapy or prevention it is possible to make a retrospective evaluation of efficacy of the measures for using anticoagulants for correction of the state of the thrombotic readiness.

Aims

The research work aims at evaluating the coagulating function of blood using standard hemostasiological tests and a global test for evaluation of coagulating system during the surgical treatment of oncological patients having malignant neoplasms of the stomach and the colon.

Materials and methods

The study cohort covered 64 patients receiving surgical treatment of malignant neoplasms of the stomach and the colon in the thoracoabdominal unit of Rostov Research Institute of Oncology. The average age of the patients was 62.27, s=10.64. Gastric cancer was diagnosed in 31 patients (48.44%), and colon cancer was diagnosed in 33 patients (51.56%). Cancer staging was represented as follows: stage I – 3 patients (4.69%), stage II – 8 patients (12.50%), stage III – 35 patients (54.69%), and stage IV – 18 patients (28.13%) (see Table 1 herein). Stomach and rectosigmoid colon adenocarcinoma has a peak incidence in the above cohort.

12 hours before the surgery all patients received the standard LMWH preventive dose recommended by the Russian Association of Phlebologists (40mg subcutaneous injections of Enoxaparin daily) [12]. For VTE risk stratification the Caprini score was used. The mean value equivalent to 8.47 enabled to refer the patients to the group with high VTE risk development during the postoperative period. When analyzing statistical relationship between the postoperative vein thrombosis and VTE risk factors, no reliable connection between the postoperative thrombotic episode and gender, age, thrombotic anamnesis, surgery type, the presence of remote metastases, disease stage and histological type of tumor has been found (see Table 1 herein). An examination of the hemostasis markers was carried out during pre-surgery (initial data in patients were recorded) and 7–10 days after the surgery. Venous blood sampling from the ulnar vein was performed without a tourniquet or with the shorttime use (not longer than 1 min.) of a tourniquet to control the blood flow, using a collection needle with a wider lumen. The blood samples were put into blood specimen tubes and containers with a sodium citrate solution, herewith high-vacuum technique was used. Then the blood samples were centrifuged at 3000 – 4000 r/min for 15 minutes at a room temperature to obtain platelet-poor plasma. The hemostasis system diagnostics was carried out at least 2 hours after blood taking using the automatic analyzer STA Compact (France) that performs clotting, chromogenic and immunological assays on plasma samples. To assess hypo- and hyper-coagulation of the hemostatic system and efficacy of the LMWH dose, Thrombodynamics Recorder T-2 has been used on the first day of the postoperative period. Thrombodynamics Recorder T-2 provides the early global coagulation test of plasma dynamics. The most sensitive method which enables detecting risk of hemorrhage and thrombus formation has been developed by the Hematology Research Center at RAMS (Russia). The method is based on video microscopy to directly monitor spatial clot formation due to imitation of vessel wall damage. The process of the fibrin clot formation is initiated by a tissue factor concentrated on the spatial flat surface under the conditions close to blood clotting in vivo rather than in the entire plasma volume under investigation. The fibrin clot is generated due to activation of the tissue factor in the unstirred thin layer of the examIssue 13. November 2018 | Cardiometry | 59

Table 1. Comparison of preoperative VTE risk factors in the patients with and without thrombosis after surgery Absence of thrombosis (n=59)

Presence of thrombosis (n=5)

Male

33 (91.67%)

3 (8.33%)

Female

26 (92,86%)

2 (7,14%)

Absent

42 (91,30%)

4 (8,70%)

Present

17 (94,44%)

1 (5,56%)

Not found

57 (91,94%)

5 (8,06%)

Found

2 (100,0%)

0 (0,0%)

Curative

42 (91,30%)

4 (8,70%)

Cytoreductive

17 (94,44%)

1(5,56%)

Adenocarcinoma

47 (94,00%)

3 (6,0%)

Neuroendocrinological cancer

0 (0,00%)

Signet ring cell carcinoma

9 (100,00%)

0 (0,00%)

Squamous cell cancer

2 (100,0%)

0 (0,0%)

Poorly differentiated cancer

1 (33,33%)

2 (66,67%)

3 (100,0%)

0 (0,0%)

8 (100,00%)

0 (0,00%)

III

31 (88,57%)

4 (11,43%)

17 (94,44%)

1 (5,56%)

Marker Gender Remote metastases VTE in anamnesis Type of surgery

Histological type of tumor

Cancer stage

p 1

0,42

0,44

Note: p – significance of variances in the markers in the subgroups of the patients with and without post-operative thrombotic complications

ined plasma. It is illuminated with red-light emitting diodes in a thermostatic chamber. Hereafter computer data processing is performed. In doing so, the following markers are evaluated: – clotting lag time (T lag), i.e. a time lag from the moment of thromboplastin contact till the moment of the fibrin clot formation (0.7 – 1.4 min); – initial clot growth rate (Vi), i.e. starting segment of the graph of the clot-size – time dependence (ranging from 2 to 6 minutes from the onset of the clot growth (36–54µm / min); – stationary clot growth rate (Vst): according to a slope calculated is an approximating stationary segment of the graph of the clot-size – time dependence (ranging from 15 to 25 minutes from the onset of the clot growth) (19–30µm/min); – clot size (CS): it is an integral indicator characterizing the overall clot growth process (800–1200µm/min); – clot density (CD) characterizes the density of the formed clot (15000–32000 c.u.); – appearance of spontaneous clots (not present normally), i.e. time of the appearance of fibrin clots away from the flat end of a plastic insert (activator). 60 | Cardiometry | Issue 13. November 2018

Statistical data analysis was performed using the Statistica 6.1. software. Mean values, mean square deviations, medians and interquartile intervals were defined. To detect significant variances between the groups with different binary variable values, the Mann–Whitney U test was used. The relationship was considered to be significant at p<0.05.

Results

Initially, an increased level of fibrinogen (4.49 g/ l±2.46), soluble fibrin monomer complexes (SFMCs) (6.49±3.15 mg/100 ml) and D-dimers (0.97±1.01 mkg/ml) were characteristic for the patients. Herewith, antithrombin insufficiency was recorded in 7 patients (10.94%). Thrombocytosis was detected in 6 cases (9.37%). Thrombocytopenia that did not require a LMWH dose reduction was detected in 4 cases (6.25%). No significant differences in the initial data of the test items in patients with VTE development in postoperative period (or without postoperative period) were detected (Table 2 herein). An increase of the concentration of fibrinogen (4.76±1.27g/l), SFMCs (6.77±3.92mg/100ml) and D-di-

Table 2. Comparison of initial homeostasis parameters in patients with and without venous thrombosis in postoperative period Pre-operative indices of the patients (norm, measuring units)

Absence of post-operative thrombosis (n=59)

Presence of post-operative thrombosis (n=5)

Mean (M)

Standard deviation (s)

Mean (M)

Standard deviation (s)

APTT (24–35 sec.)

29,72

3,75

30,02

1,66

0,86

INR (close to 1.0)

1,12

0,20

1,04

0,05

0,41

Thrombin time (14–20 sec.)

16,57

2,79

16,40

2,03

0,89

Fibrinogen (2.0–4.0 g/l)

4,54

2,55

3,99

1,00

0,64

Antithrombin (75–125 %)

87,90

15,23

89,60

8,59

0,81

SFMCs (up to 4.0 mg/100ml)

6,42

3,16

7,40

3,19

0,51

D-dimer (up to 0.5 mkg/ml)

0,96

1,04

0,56

0,88

Hemoglobin (120–160 g/l)

115,93

23,89

113,80

35,57

0,85

Hematocrit (30–55 %)

37,45

5,93

36,94

10,37

0,86

273,78

106,06

338,80

116,86

0,20

Thrombocytes (180–360∙10 /l) 9

Note: p – significance of variances in the markers in the patients with and without postoperative thrombotic complications Table 3. Comparison of characteristics of patients with and without thrombosis 7-10 days after surgery Pre-operative indices of the patients

Absence of thrombosis (n=59)

Presence of post-operative thrombosis (n=5)

Mean (M)

Standard deviation (s)

Mean (M)

Standard deviation (s)

APPT (24–35 sec)

35,87

7,64

38,38

8,00

0,3813

INR (close to 1.0)

1,35

0,34

1,45

0,49

0,9800

Thrombin time (14–20 sec.)

17,51

6,20

12,87

4,53

0,0367

Fibrinogen (2.0–4.0 g/l)

4,82

1,28

4,05

1,07

0,1433

Antithrombin (75–125%)

88,75

14,85

70,80

11,84

0,0115

SFMCs (up to 4.0 mg/100ml)

6,27

3,21

12,70

6,70

0,0260

D-dimer (up to 0.5 mkg/ml)

1,10

0,83

2,42

1,05

0,0041

Hemoglobin (120-160 g/l)

102,10

18,06

93,20

5,76

0,2992

Hematocrit (30–55 %)

34,70

4,73

31,60

3,79

0,1849

Thrombocytes (180–360∙109/l)

295,54

174,32

359,60

141,92

0,1094

Note: p-significance of variances in the markers in the patients with and without postoperative thrombotic complications

mer (1.21±0.92mkg/ml) was recorded in the patients 7 – 10 days after the surgery. Herewith, in 8% of the cases an antithrombin shortage was recorded and in 11 patients (17.18%) thrombocytosis was detected. A low-level hypocoagulation in terms of the APPT marker (36.06±7.63 sec.) was identified. During the second stage the thrombin time, INR values and the antithrombin level did not show significant changes. Thus, in patients with VTE during the second week of the postoperative period the markers of thrombinemia, namely, SFMC and D-dimers are significantly increased, whereas the antithrombin level is lowered. Consequently, it is

possible to detect thrombotic complications at the stage of their realization (Table 3 herein). According to thrombodynamics test results on the first day after the surgery the mean values of the indices are within the limits of the normal coagulation upon administration of the standard preventive dose of an anticoagulant (Enoxaparin at a fixed dose of 40 mg once daily) except for the marker of spontaneous clots formation in 6.25% of the cases. Besides, it should be considered that despite the Enoxaparin administration, the markers of the initial and stationary fibrin clot growth rate are found on the Issue 13. November 2018 | Cardiometry | 61

Table 4. Thrombodynamics markers on day 1 after surgery Marker

Mean (M)

Median (Me)

Lower quartile (LQ)

Upper quartile (UQ)

Standard deviation (s)

Clot density (c.u.)

28624

28906

26302

31089

3380

Stationary clot growth rate (µm/min)

28,48

28,00

25,05

31,40

4,571

Clotting lag time (min)

1,18

1,00

0,90

1,20

1,326

Initial clot growth rate (µm/ min)

53,66

54,60

51,10

57,55

5,920

Clot size (CS)с (µm)

1136

1133

1045

1252

136,24

Spontaneous clots (min.)

0,34

0,00

1,394

Table 5. Thrombodynamics markers within the period 7 – 10 days after surgery Marker

Mean (M)

Median (Me)

Lower quartile (LQ)

Upper quartile (UQ)

Standard deviation (s)

Clot density (c.u.)

29616

29735

27286

32687

3632

0,0085

Stationary clot growth rate (µm/ min)

27,19

26,75

24,70

30,00

4,423

0,13

Clotting lag time (min)

1,10

0,90

1,20

0,202

0,039

Initial clot growth rate (µm/min)

53,26

54,15

50,35

58,80

7,638

0,81

Clot size (CS) (µm)

1149

1170

1026

1278

188,65

0,28

Spontaneous clots (min.)

0,37

0,00

1,85

0,93

Figure 1. Correlation between clot density and fibrinogen level

Fig.2. Scatter plots of the canonical values for the discriminant

7 – 10 days after the surgery (r=0.70, p=0.00000).

model for prediction of postoperative thrombosis based on the patients’ markers during the preoperative period.

boundary of hyper-coagulation (Tab. 4). Thus, we were able to identify a group of patients (26.56%) with an insufficient effect of the anticoagulant used, where we may more likely expect development of postoperative venous thrombosis. For this sort of the patients we offer to increase the LMWH dose to 60 mg per day. 62 | Cardiometry | Issue 13. November 2018

Within the period 7 – 10 days after the surgery the mean value of the initial and stationary clot growth rate, the clot size and the clot density have been found to be in correspondence to the norm (see Table 5 herein). Spontaneous clot formation has been revealed in one patient (1.56%). When using the given method of

Table 6. Classification matrix for prediction of postoperative thrombosis based on characteristics of patients in preoperative period Percentage

Absence of thrombosis

Distal thrombosis

Proximal thrombosis

Absence of thrombosis

49,15

Distal thrombosis

100,0

Proximal thrombosis

66,67

Total

51,56

Lines: observable classes, columns: predicted classes Table 7. Comparison of characteristics of thrombodynamics in patients with and without thrombosis on day 1 after surgery Pre-operative markers of the patients

Absence of thrombosis (n=59)

Presence of thrombosis (n=5) p

Mean (M)

Standard deviation (s)

Mean (M)

Standard deviation (s)

Cloth density (c.u.)

28693

3431

27805

2884

0,43

Stationary cloth growth rate (µm/ min)

28,24

4,61

31,30

3,29

0,057

Сlotting lag time (min.)

1,21

1,378

0,86

0,13

0,064

Initial clot growth rate (µm/min)

53,23

5,84

58,76

4,63

0,036

Clot size (µm)

1132

138,30

1190,60

105,51

0,41

Spontaneous clots (min.)

0,00

0,000

4,40

2,88

0,0031

Note: p – significance of variances in the markers in the patients with and without postoperative thrombotic complications. Таблица 8. Classification matrix for prediction of postoperative thrombosis based on the characteristics of the patients after surgery Percent

Absence of thrombosis

Distal thrombosis

Proximal thrombosis

Absence of thrombosis

100,00

Distal thrombosis

100,00

Proximal thrombosis

66,67

Total

98,44

Lines: observable classes, columns: predicted classes

the VTE prevention, in 6 patients (9.38%) hyper-coagulation (insufficient efficacy of LMWH) has been observed by the second week of the postoperative period. To evaluate the compliance of the coagulogram markers with the thrombodynamics recorder T-2 parameters, the fibrinogen level and clots density have been analyzed. It has been found that clots density 7 – 10 days after the surgery correlates well with the fibrinogen concentration in blood (r=0.7006 p<0.00001) (see Figure 1 herein). To identify the possibility of the postoperative thrombosis prediction, the discriminant method has been used taking into account the complete set of initial data as follows: gender, age, localization, stage and histological type of tumor, operation type, the VTE anamnesis, the Саprini scale score and the hemostatic profile (the dis-

criminant matrix). After excluding the least informative markers from the analysis, no clear division into studied subgroups has been obtained (see Figure 2 herein). We have compared the thrombodynamics markers recorded on the first day after the surgery in the patients with and without VTE (Table 7 herein). The group having thrombosis has demonstrated higher levels of the initial and stationary clot growth rates as well as a reduction in the clotting lag time. The most significant is recording of spontaneous clots, whereas in the subgroup without VTE no cases of spontaneous clots formation have been revealed (p<0.00001). The discriminant statistical model based on thrombodynamics markers has resulted in the following. Fig.3 shows a clear-cut division of the patients with thrombosis and without thrombotic complicaIssue 13. November 2018 | Cardiometry | 63

Table 9. Statistical significance of markers of the model for prediction of postoperative thrombosis based on the markers of thrombodynamics in patients on day 1 of the postoperative period Marker

p-level

Clot density (c.u.)

0,54

Stationary cloth growth rate (µm/ min)

0,83

Сlotting lag time (min.)

0,97

Initial clot growth rate (µm /min)

0,21

Clot size (µm)

0,095

Spontaneous clots (min.)

0,000000

Fig.3. Scatter plots of the canonical values for the discriminant model for prediction of postoperative thrombosis based on the laboratory parameters of thrombodynamics.

tions into subgroups. One of the patients was falsely referred to the subgroup without thrombosis, since no spontaneous clots formation has been observed in him. The classification matrix presents the similar pattern (Table 8 herein). It may be concluded that the spontaneous clots rate has the greatest effect on the variances between the named subgroups as compared to the fibrin clot size, which produces the least effect thereon. The other thrombodynamics test markers have no prognostic value (see Table 9 herein). At the same time, it is possible to predict VTE development with a high accuracy on the first day after surgery (98.44). Сonsequently, the use of thrombodynamics recorder T-2 allows delivering the relevant data necessary for the prediction of development of thrombotic complications as well as for evaluation of efficacy of the anticoagulant preventive dose. We have reliable revealed the significant relationship between the spontaneous clots formation on the first day after the surgery and thrombotic complications against the background of the administration of the anticoagulant preventive dose (р=0.0031).

Conclusions

When the proposed method of the VTE prevention is employed, the thrombotic event readiness risk in oncological patients is avoided or excluded in the most effective way. Anticoagulant therapy with an adjusted dose compensates the increasing postoperative thrombinemia in the above patients under studies. An individually selected Enoxaparin dose reduces VTE development to 6.25%. The above mentioned coagulogram and the thrombodynamics markers allow us to make a highly accu64 | Cardiometry | Issue 13. November 2018

rate prediction of development of possible thrombotic complications during the postoperative period.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Kaprin AD, Starinskiy VV, Petrova GV. Malignant neoplasms in Russia in 2015 (morbidity and mortality). Мoscow, 2017. 250 p. [in Russian] 2. Arkhipova OE, Chernogubova EA, Likhtanskaya NV, et al. Analysis of occurrence of oncological diseases in the Rostov region. Spatial-time statistic. Fundamental'nye issledovaniya. 2013;7-3:504-10. [in Russian] 3. Khorana AA, Francis CW, Culakova E, et al. Thromboembolism is a leading cause of death in cancer patients receiving out – patient chemotherapy. J Thromb Haemost. 2007;5(3):632-4.  [in Russian] 4. Makatsariya AD. Thrombohemorrhagic complications in obstetric-gynecological practice: guidance for physicians. Мoscow, 2011. 1056 p. [in Russian] 5. Khorana AA. Venous Thromboembolism Prevention in Cancer Outpatients. J. Natl. Compr. Canc. Netw. 2013;11(11):1431-8.

6. Monreal M, Trujillo-Santos J. Screening for occult cancer in patients with acute venous thromboembolism. Curr. Opin. Pulm. Med. 2007;13:368-71. 7. Rasmussen MS. Prolonged thromboprophylaxis with low molecular weight heparin after major abdominal surgery. Curr. Opin. Pulm. Med. 2007;13:389-92. 8. Lee Agnes YY. Treatment of venous thromboembolism in cancer patients. Best Practice & Research Clinical Hematology. 2009;22:93â&#x20AC;&#x201C;101. 9. Kit OI, Frantsiyants EM, Kozlova LS, et al. Free and bound plasmin in tum. and adjacent tiss. of men and women with esophag.l squamous cell carcinoma.

Sovremennye problemy nauki i obrazovaniya. 2017, No. 2. [in Russian] 10. Ay C, Vormittag R, Dunkler D, et al. D-dimer and prothrombin fragment 1 2 predict venous thromboembolism in patients with cancer: results from the Vienna cancer and thrombosis study. J Clin OncolĐžgy. 2009;27(25):4124-9. 11. Momot AP, Tsyvkina LP, Taranenko IA, et al. Modern methods of recognition of thrombotic readiness. Barnaul, 2011. 138 p. [in Russian] 12. Russian clinical guidelines for the diagnosis, treatment and prevention of venous thromboembolic complications (VTEC). Flebologiya. 2015;9(4):2-52. [in Russian]

Issue 13. November 2018 | Cardiometry | 65

ORIGINAL RESEARCH

Submitted: 17.7.2018; Accepted: 10.8.2018; Published online: 21.11.2018

The state of hydrolytic processes in the myocardium and its draining lymphocytes in rats under the effect of Doxorubicin under protective Trimetazidine premedication

compare with the level in the reference animals. Ratios CatD/ ATA, CatD/ASI in the myocardium have been considerably decreased by 25.4% and 24.2%, and in the lymphocytes all the ratios remained at the level of values in the reference animals. In group 2 in the myocardia and lymphocytes a significant decrease in enzyme activity by 23-31%, on the average, as compared with reference animals, has been observed, and, at the same time, all the ratios have been at the level of the reference animals.

Elena лю. Frantsiyants , Ekaterina I. Surikova , Irina V. Kaplieva , 1

Conclusions

Lidia K. Trepitaki1, Irina V. Neskubina1, Elena V. Shalashnaya1, Valeria A. Bandovkina , Larisa S. Kozlova , Yulia A. Pogorelova ,

The dynamics of the studied indicators recorded for the hearts

Lyudmila A. Nemashkalova1, Natalia D. Cheryarina1,

in the group 1 rats reflect an intensification of catabolic process-

Irina S. Tavaryan , Olga V. Kozyuk , Lyudmila Y. Rozenko ,

es and the activation of inflammation in myocardial tissue as a

Pavel G. Sakun , Vladimir S. Trifanov

manifestation of the toxic effect of Doxorubicin. The dynamics

of indicators in the group 2 rats demonstrates the lack of activa1

Rostov Research Institute of Oncology, Ministry of

tion in the processes of autophagy/apoptosis and the absence

Healthcare of the Russian Federation

of a pronounced local inflammation that is caused by the cardi-

Russia, 344037, Rostov-on-Don, 14th Line st. 63

oprotective action of Trimetazidine.

Corresponding author: phone: +7 (904) 501-83-62, e-mail: super.gormon@yandex.ru

Keywords Cardiotoxicity, Doxorubicin, Trimetazidine, Cathepsin D, Acid phos-

Aims

phatase, Alkaline phosphatase

The aim hereof is to study the activity of cathepsin D (CatD), alkaline phosphatase (ALP) and acid phosphatase (AP), the anti-

Imprint

tryptic activity (ATA) of acid-stable inhibitors (ASI) in rats in heart

Elena лю. Frantsiyants, Ekaterina I. Surikova, Irina V. Kaplieva, Lid-

tissue and its draining lymphocytes under introduction of Doxo-

ia K. Trepitaki, Irina V. Neskubina, Elena V. Shalashnaya, Valeria

rubicin and protection with Trimetazidine.

A. Bandovkina, Larisa S. Kozlova, Yulia A. Pogorelova, Lyudmila A. Nemashkalova, Natalia D. Cheryarina, Irina S. Tavaryan, Olga

Materials and methods

V. Kozyuk, Lyudmila Y. Rozenko, Pavel G. Sakun, Vladimir S. Tri-

The study has been carried out in outbred male rats (50 an-

fanov. The state of hydrolytic processes in the myocardium and

imals) weighing 150-160 g: the reference group consists of

its draining lymphocytes in rats under the effect of Doxorubi-

10 animals; group 1 (20 animals) has experienced injections

cin under protective Trimetazidine premedication. Cardiome-

of Doxorubicin in physiological saline at a dose of 2 mg/kg,

try; Issue 13; November 2018; p.66-74 ; DOI: 10.12710/cardi-

5 times; group 2 (20 animals) has undergone the above men-

ometry.2018.13.6674; Available from: http://www.cardiometry.

tioned Doxorubicin medication after preliminary protection

net/issues/no13-november-2018/hydrolytic-processes-in-the-

with Trimetazidine for 5 days at a dose of 35 mg/kg. In the myo-

myocardium

cardium and its draining lymphocytes determined has been the following: CatD, ATA, ASI, ALP, AP, ratios CatD/ATA, CatD/ASI and AP/ALP. The statistical significance has been evaluated using the Mann-Whitney criterion.

Results In the group 1 animals in their myocardia and lymphocytes observed has been a statistically significant increase in the activity of CatD by 42.4 and 64.6%, respectively, AP and ALP by 2.22.3 times on the average, ASI and ATA by 1.8-1,9 times if to 66 | Cardiometry | Issue 13. November 2018

Introduction

The use of more intensive chemotherapeutic schedules in modern oncology not only leads to an increase in the duration of disease-free survival and the number of patients cured of cancer, but also to an increased risk of side effects, primarily produced the cardiovascular system. The development of cardiac complications against the background of antitumor chemotherapy results in a decrease in its effectiveness

(in case of reduction of chemotherapy courses provided to patients), a deterioration in the quality of life and its duration in those patients, who may be potentially cured, and especially those who have already had cardiovascular pathology [1-3]. Many anti-tumor drugs show cardiotoxicity, among them is a large group of Anthracycline antibiotics, which so far are widely used in various chemotherapeutic schedules due to their high efficacy [4]. The cardiotoxicity developing during their use can be acute, chronic or delayed, manifesting years after the termination of therapy [5-8]. Cardiotoxic effects of anthracyclines are attributed to the type 1 cardiotoxicity, characterized by the development of apoptosis or myocardial necrosis as a result of the cumulative dose-dependent effect. Cardiotoxicity of this type is dangerous due to its limited reversibility, resistance to therapy, and it causes a deterioration in cardiac prognosis. Nowadays various methods of cardiac protection are being actively developed against the background of oncological patients therapy with Anthracycline-based drugs [9]. Histological signs characterizing the cardiotoxicity of Anthracyclines include, in particular, an abundant vacuolization of cardiomyocytes, disorganization of myocardial fibers that is related to the mechanism of the action of these chemotherapeutic agents on myocardial cells. The enhancement of free radical oxidation in cardiomyocytes offers an increased permeability in their internal membranes, mitochondrial dysfunction, exit of the Ca ions and lysosomal enzymes with their entry into the cytoplasm, and development of apoptosis or necrosis [9,10].It is known that Trimetazidine, used in cardiology, has a protective effect in case of ischemia and development of oxidative stress in cardiomyocytes due to modulation of their energy metabolism, restoration of the intracellular ATP level, reduction of the intracellular acidosis and calcium dysfunction intensity and activation of antioxidant protection [11]. In this connection, in our opinion, it would be intriguing to study the activity of hydrolytic processes occurring in the heart tissue after the Doxorubicin medication under the preliminary protection by Trimetazidine, as it is known that proteolytic enzymes, changing the functional properties of proteins and thus controlling various biochemical processes, play an important role in the physiology both of individual organs and the organism as a whole.

Thus, the aim of our study is to study the activity of a number of proteolytic enzymes and the activity of proteolysis inhibitors in the heart tissue and its draining lymphocytes in rats in case of the Doxorubicin use under the Trimetazidine preliminary protection.

Materials and methods

The study has been carried out on outbred male rats (50 animals) weighing 150-160 g. The animals have been kept under natural lighting conditions with free access to water and food. All the studies have been performed in accordance with applicable international norms and regulations (European Communities Council Direсtive 86/609/EEC) and the associated National Order Regulation No.267 dd. 19.06.03 “Approved Rules and Regulations for Laboratory Practices” issued June 19, 2003 by the Ministry of Healthcare of Russian Federation. Doxorubicin and Trimetazidine (Preductal MB) have been used in our experimental work. The animals have been divided into 3 groups as follows: the reference group (10 animals) has received injections of a sterile physiological saline; group 1 (20 animals) has been treated with intravenous injections of Doxorubicin in a physiological saline at a dose of 2 mg/kg, 5 times; group 2 (20 animals) has undergone the above-mentioned Doxorubicin therapy after their preliminary protection with Trimetazidine for 5 days at a dose of 35 mg/kg administered perorally through the feeding tube. Seven days after the termination of the Doxorubicin administration, the rodents have been decapitated, their hearts have been rapidly removed and chilled; the hearts were homogenized in the physiological saline, and lymphocytes have been isolated from the heart tissue according to a density gradient of Fikkol/ Verografin of 1.078 g/cm3 (3x106 cells/ml working concentration of the lymphocyte suspension); we have obtained the 10% cytosolic fractions prepared using a 0.1 M potassium phosphate buffer with a pH of 7.4 containing 0.1% Tween-20 and 1% BSA. In the heart tissue and its draining lymphocytes, the activity of cathepsin D (CatD) [12] and acid-stable inhibitors (ASI), general antitriptical activity (ATA) [13], and the activity of alkaline phosphatase (ALP) and acid phosphatase (AP) have been determined by the unified method with the use of Olvex Co. reagent kits. The obtained results have been recalculated per gram of the heart tissue or per mg of protein in lymphocytes. The protein concentration has been assessed by Issue 13. November 2018 | Cardiometry | 67

Table 1. Indicators of the hydrolytic system in heart tissue and its draining lymphocytes, when using Doxorubicin and Trimethazidine in the experiment Reference group

Group 1 (introduction of Doxorubicin in physiological saline)

Group 2 (introduction of Doxorubicin after Trimetazidine protection)

Myocardium (/g tissue)

Lymphocytes (/mg protein)

Myocardium (/g tissue)

Lymphocytes (/mg protein)

Myocardium (/g tissue)

Lymphocytes (/mg protein)

CatD (nm)

528±51,6

83,0±8,0

752±64,3 p1<0,05

136,6±12,3 p1<0,05

400±39,2 p1<0,05 p2<0,05

57,1±4,2 p1<0,05 p2<0,05

ATA (nm)

1,1±0,2

5,3±0,4

2,1±0,3 p1<0,05

9,8±0,8 p1<0,05

0,8±0,2 p2<0,05

3,7±0,3 p1<0,05 p2<0,05

ASI (nm)

2,5±0,4

8,1±0,5

4,7±0,6 p1<0,05

15,1±1,6 p1<0,05

1,8±0,4 p2<0,05

5,7±0,5 p1<0,05 p2<0,05

AP (nm)

13200±121,6

10,9±1,0

27300±254,6 p1<0,05

22,4±2,3 p1<0,05

10100±96,4 p1<0,05 p2<0,05

7,7±0,8 p1<0,05 p2<0,05

ALP (nm)

1100±98,3

3,8±0,9

2400±22,7 p1<0,05

8,8±0,9 p1<0,05

840±76,4 p1<0,05 p2<0,05

2,9±0,3 p1<0,05 p2<0,05

CatD/ ATA

478,8±44,2

15,7±1,6

CatD/ ASI

221,5±19,3

10,2±1,0

AP/ALP

12±1,1

2,9±0,3

358,1±34,2 p1<0,05 160±14,2 p1<0,05 11,4±1,0

13,9±1,2 9,0±0,8 2,5±0,2

504,3±47,3 p2<0,05 212,2±20,1 p2<0,05 12,0±1,1

15,4±1,2 10,0±0,9 2,7±0,3

Note: The data are represented in the M±m form. Statistically significant variances are as follows: р1 in relation to the values in the reference animals; р2 in relation to the values in group 1.

Lowry method. The values of ratios CatD/ATA, CatD/ ASI and AP/ALP have been calculated The statistical processing of the results has been carried out with the original Statistica 10.0 software; in each group the mean value ± standard error of the mean (M ± m) has been determined. The significance of differences has been evaluated using the Mann-Whitney nonparametric criterion. Variance at a significance level p <0.05 have been considered to be statistically significant.

Results

The results of the study are presented in Table 1 herein. In the group 1 rats, in their heart tissue we observed a statistically significant increase in all the studied parameters compared to the level in the reference group: cathepsin D activity has been 42.4% higher, ATA and ASI have been increased by 1.9 times, and the acid and alkaline phosphatase activity has been reported to be 2,1 and 2,2 times higher, respectively. At the same time, the CatD/ATA and CatD/ASI values, which characterize the state of the protease inhibitor system, have been statistically significantly reduced by 25.4% and 24.2%, respectively, and the AP/ALP ratio 68 | Cardiometry | Issue 13. November 2018

has not differed from that in the reference group. A significant increase in the following studied parameters has also been observed in the lymphocytes in the rodents of this group: CatD has been increased by 64.6%, ASI and by ATA 1.8 times, AP has been found 2.1 times and ALP 2.3 times greater, respectively. However, the values of ratios CatD/ATA, CatD/ASI and AP/ALP remained at the level of the reference unaffected animals. In the group 2 animals we observed counter-tendency dynamics of the studied parameters, both in the heart tissue and lymphocytes. When introducing Doxorubicin after the Trimetazidine protection, a statistically significant decrease in CatD by 24.2%, AP and ALP on the average by 23.6% in the heart tissue compared to that in the reference animals, but no statistically significant changes in the ATA, ASI, CatD/ ATA, CatD/ASI and AP/ALP values have been recorded. In lymphocytes we observed a statistically significant decrease in all the studied parameters by 23-31%, and, at the same time, no significant change in the ratios of CatD/ATA, CatD/ASI and AP/ALP in comparison with the corresponding level in the reference group has been identified. As a result, in animals, who

received Doxorubicin after protection with trimetazidine, in the heart tissue, statistically significantly lower activity of CatD (by 46.8%), AP and ALP (2.2 times on the average), ATA and ASI (by 61, 8% on the average) in comparison with the group 1 animals’ indicators, have been detected. At the same time, the values of CatD/АТА and CatD/ASI have been found to be significantly higher: their increases were 38-39%. In the lymphocytes a statistically significantly lower level of all the studied parameters has been observed, namely, they decreased by 2.4-3.0 times in comparison with the level in group 1. Analyzing the dynamics of the hydrolytic system activity indicators, we can note the same direction of the changes found in the heart tissue and its draining lymphocytes. In the group with the use of Doxorubicin introduced in physiological saline, a significant increase in the activity of all components of the studied system has been revealed in comparison with the level in the reference animals, and, as opposed to it, in the group of animals, who had received Trimetazidine protection, a decrease in the activity of the hydrolytic system components has been observed. As a result, in the group 1 animals, a small, but statistically significant, decrease in the CatD/ATA and CatD /ASI values in the heart tissue may indicate a predominance of proteolytic activity inhibition processes, while in the group 2 animals the absence of changes in these ratios (in comparison with the level in the reference animals) indicates that the protease inhibitor system is balanced, and the hydrolytic processes activity is generally maintained at the reference level. Attention should also be drawn to the absence of statistically significant changes in these values for lymphocytes in both groups of animals that may indicate a more balanced response by lymphocytes to the medication action if to compare with the reaction of the myocardium.

Discussion and Conclusions

Various mechanisms of cardiotoxicity of Anthracyclines have been described in the present-day literature, but the main triggers are the development of free-radicals stress, mitochondrial dysfunction (with disordered metabolism of high-energy phosphates) and dysregulation of the calcium homeostasis. The next step is a change in gene expression, activation of the ubiquitin-proteasome system, apoptosis and induction of immunogenic reactions. Thus, it is obvious that the Anthracycline cardiotoxicity is a multifacto-

rial multi-stage process leading to apoptosis of cardiomyocytes. As a result of the myocardium damage, clinical signs of heart failure develop [14,15]. Despite the understanding of importance of nucleus- and mitochondria-related events in the cardiotoxicity induced by Doxorubicin, nowadays an idea of a decisive role of functioning of lysosomes and the associated autophagy dysregulation in cardiomyocytes is being extensively elaborated [16,17]. Autophagy is a universal cellular process, which is treated to be a protective mechanism, which maintains the cell viability due to the elimination by isozymal proteases (cathepsins A, B, D, H and L) of the damaged cells or undesired proteins and organelles. In pathological states, autophagy is initiated to protect cells from stress stimuli or, alternatively, to contribute to cell death. The obtained data demonstrate the key role of autophagic processes in cardiac physiology and pathology: an accumulation of damaged proteins and organelles in cardiomyopathies of various genesis has been discovered [18]. Conducted were studies, which attribute the Doxorubicin-induced cardiotoxicity to the dysregulation of macroautophagy, mitophagy, and chaperone-mediated autophagy through the disruption of functioning of the transcription factors, which are also responsible for the regulation of the lysosomal function [19,20]. In cardiomyocytes exposed to Doxorubicin, changes in proteolytic processes are detected, but the role they play in the Doxorubicin-provoked cardiotoxicity remains unclear. The degree of the dysregulation of autophagy in response to the influence produced by Doxorubicin depends on the type of cardiotoxicity model used, on the concentration of the active substance and the duration of the Doxorubicin action [20]. During the formation of defective mitochondria in cells, the process of mitophagy (the elimination of the improperly functioning mithochondria) in lysosomes is triggered, which, as revealed, is sensitive to the Doxorubicin exposure [21,22].This form of autophagy is of a great importance in cells with a high density of mitochondria, in particular in cardiomyocytes. The Doxorubicin-induced disorder of mitophagy through the dysregulation of various cytosolic and mitochondrial signaling pathways leads to a deterioration in the physiological elimination of damaged mitochondria and to the accumulation thereof, that increases the production of active oxygen species and aggravates the ATP deficiency [20]. Issue 13. November 2018 | Cardiometry | 69

An important point is that structural changes in the heart tissue appear much earlier than clinical manifestations of heart failure. This means that the compensatory mechanisms are capable of supporting the heart performance for a certain time against the growing myocardium damage. In accordance with the above, it can be assumed that an enhancement in the activity of lysosomal enzymes such as cathepsin D, acid and alkaline phosphatases, observed in this study in the group 1 animals, bearing witness to the activation of proteolytic processes in the heart tissue, may be a manifestation of the acute toxic effect produced by Doxorubicin upon its introduction in a physiological saline. In the study by Leto G. et al. (1987) it is shown that changes in the cathepsin D activity in the cardiac muscle in mice have been detected after each introduction of Doxorubicin [23]. In the research work done by Hilfiker-Kleiner D. et al. (2007) it has been found that enhancing the expression of cathepsin D and its activity can mediate a progression of heart failure through prolactin cleavage [24]. In our case, an activation of the autophagy processes, in particular mitophagy, probably takes place that may be interpreted as a protective reaction of heart tissue in response to Doxorubicin damage of the most important cardiomyocyte organelles: mitochondria. In the review by Ghosh R, Pattison JS. (2018) it is shown that an exposure to Doxorubicin intensifies autophagic processes, and inhibition of these processes weakens the manifestations of cardiotoxicity induced by Doxorubicin. The authors suggest a possible protective role of the autophagy processes in the Doxorubicin-induced cardiotoxicity [18]. For a long time it has been believed that the main function of cathepsin D is to cleave damaged proteins in lysosomes and phagosomes as a result of activation of endocytosis and autophagy. However, it has now become known that, besides, cathepsin D undertakes many physiological functions associated with the activation of precursors of a number of enzymes, hormones, growth factors, thus participating in the maintenance of the tissue homeostasis, development of the apoptosis processes, remodeling of the extracellular matrix and generation of an immune response [25-27]. Analyzing the results obtained in our study, we can also assume that an increase in the activity of cathepsin D in the heart in the group 1 rats is an indication of the activation of the cardiomyocyte apoptosis processes as a result of the Doxorubicin action, 70 | Cardiometry | Issue 13. November 2018

since it is known from the literature that cathepsin D is one of the key mediators of the induced apoptosis (via caspase-dependent and caspase-independent mechanisms), and its pro-apoptotic effect can be produced both at the expense of the proteolytic activity and in a way independent thereon [26,28-31]. However, depending on the intracellular context and stress stimulus cathepsin D can manifest not only proapoptotic, but also anti-apoptotic effect. The study by Sagulenko V. et al. (2008) shows that an elevation of the expression of cathepsin D in neuroblastoma cells leads to a weakening of Doxorubicin-induced apoptosis due to activation of the Akt path, one of the main paths of the cell survival [32]. The investigation work by Oliveira C.S. et al. (2015) discovers an antiapoptotic effect of cathepsin D in colorectal cancer cells under the activation of the mitochondrial apoptotic cascade [33]. Du F. et al. (2017) demonstrate that increasing the expression of cathepsin D promotes the viability of renal tubule cells, preventing lysosomal apoptosis and stabilizing the membrane potential of mitochondria under toxic effects of glycosylation products [34]. In our study, however, it is impossible to unambiguously identify which sort of effects, pro- or anti-apoptotic, is produced by cathepsin D in this case. In our opinion, an enhancement in the activity of phosphatases in the heart tissue in response to the Doxorubicin effects also deserves attention. Although these enzymes have been studied for a long time, but their biological functions in the body are still not finally determined. At present, it is known that acid phosphatase is defined as a multifunctional enzyme that catalyzes not only hydrolytic dephosphorylation reactions, but also plays an important role in the ATP-dependent regulation of the calcium homeostasis and, as supposed, can participate in the reactions of generation of reactive oxygen species (due to the presence of iron atoms in the active center) [35-37]. For some isoforms of acid phosphatase of plant origin, the connection with the intracellular production of reactive oxygen species (mainly in the process of cell autolysis) and the manifestation of the peroxidase activity under stress conditions are shown [38,39]. Despite the fact that alkaline phosphatase is available in great numbers in many tissues in the organism and there is a rich variety of its isozyme forms, its exact physiological function remains to a great extent still unexplored. It has been found that this enzyme is of great significance in phosphoric and calcium metab-

olism; some studies show the participation of alkaline phosphatase in the regulation of protein phosphorylation, apoptosis and development of cardiovascular diseases [40,41]. The activation of cathepsin D, acid and alkaline phosphatases, detected in this study, could be considered in general as a marker of intensification of catabolic processes in rat myocardial tissue resulting from Doxorubicin toxicity. The simultaneous considerable activation of ASI and ATA leads to a change in the proteinase inhibitor system towards weakening of intracellular proteolysis, as evidenced by a decrease in the CatD/ATA and CatD/ASI values. An increase in the antitryptic activity and the tissue-related acid-stable inhibitors’ activity can be associated with the functioning of the inflammation regulation mechanisms in the heart tissue, and the resulted proteinase-inhibitory balance probably reflects the severity of the inflammation. The triggering of inflammation in the myocardial tissue can also be indicated by the activation of proteolytic enzymes in the myocardium-draining lymphocytes. To date, it is known that various cathepsins, including cathepsin D, are key modulators of congenital and adaptive immune reactions, and they are involved in the activation/inhibition of cytokines, which play a crucial role in the development of inflammatory reactions, and an imbalance in the functioning of cathepsins in the immune system cells can lead to chronic inflammation, autoimmune disorders and, as a result, cause pathological damages to cells and tissues [42]. Thus, the observed dynamics of the hydrolytic system performance in the heart tissue in rats upon introduction of Doxorubicin in a physiological saline represents a complex picture of the manifestation of the acute chemotherapy-drug induced toxicity and the protective response of the organism to myocardial damage. The possibility of cardioprotection in cancer patients treated with the use Anthracycline-based schedules has been actively explored in recent decades, resulting in defining several approaches that differ in their protection mechanism. One of them is the use of cardioprotective agents (for example, Decrazoxane, a free radical acceptor), and any molecule, which is capable of directly reducing myocardial damage, slowing down the sequential remodeling of the myocardium or contributing to the restoration of its physiological metabolic activity, can have a cardioprotective effect [9,43,44]. The use of Trimetazidine (Preductal MB),

which precedes the introduction of Doxorubicin, in the group 2 animals in the context of our study, falls into the above approach pattern. Trimetazidine is a medical drug of metabolic action with a large evidence base in cardiology, which has demonstrated its high efficacy and safety in chronic heart failure both of ischemic and nonischemic genesis. The molecular mechanism of the action of this drug is associated with its capability to slow down the oxidation of fatty acids and enhance the oxidation of glucose and, in doing so, contribute to the preservation of energy metabolism in cardiomyocytes. As a result of the activation of glycolysis, which supplies ATP, the transmembrane Са2+ ion flux is normalized. The use of Trimetazidine diminishes intensity of intracellular acidosis. Improving the metabolism of membrane phospholipids, Trimetazidine reduces the permeability of membranes and increases their resistance to damage, weakens leukocyte infiltration of reperfused and ischemic tissues of the heart, contributing to a decrease in the size of the myocardial damage focus. Under intensive physical loads, the use of Trimetazidine retards the development of tissue hypoxia and enhances the contractility of the myocardium [45]. In case of the experimental myocardial infarction, the preventive introduction of Trimetazidine promotes a decrease in the necrosis zone [46]. The experimental study by Salouege I. et al (2014) shows that the Doxorubicin therapy accompanied by Trimetazidine medication during 3 days results in a decrease in the surface of apoptotic and necrotic areas, as well as of areas with lymphoid infiltration and inflammatory reaction in the histological sections of the rat heart, that has demonstrated the cardioprotective action of Trimetazidine in the model of the acute Doxorubicin-induced cardiotoxicity [47]. The experimental study by Moustafa A.M. et al. (2006) shows the preventive administration of Trimetazidine performed 5 days prior to initiation of the Doxorubicin therapy changes the dynamics of the creatine phosphokinase-MB level that indicates a considerable reduction in heart damage. At the ultrastructural level, the use of Trimetazidine leads to a lack of mononuclear cell infiltration of the myocardium, a decrease in markers of oxidative stress, and an increase in the antioxidant activity that is evidence for the normal functioning of the mitochondria [48]. Analyzing the results obtained in the group 2 animals, we did not observe the activation of the Issue 13. November 2018 | Cardiometry | 71

cathepsin D hydrolytic enzymes, acid and alkaline phosphatases both in the heart tissue and its draining lymphocytes that can be considered as a sign of the absence of the activation of autophagy and apoptosis processes (or their minor expression). On the contrary, we observed a slight decrease in the activity of those enzymes in comparison with those in the reference animals, as well as a slight decrease in the inhibitor activity of heart-draining lymphocytes. However, the absence of significant changes in the CatD/ATA, CatD/ASI and AP/ALP values as compared to the reference group indicates the proteinase/inhibitor system balance is available both in heart tissue and its draining lymphocytes and that a pronounced local inflammatory process with the use of the above Doxirubicin schedule of doxorubicin introduction is not present. In our opinion, such results may be determined by the Trimetazidine premedication, which normalizes the cardiomyocytes energy metabolism and the intracellular medium acidity, reduces the leukocyte infiltration in the heart tissue and prevents the development of acute the Doxorubicin-induced cardiotoxicity.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

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26. Masson O, Bach AS, Derocq D, Prébois C, Laurent-Matha V, Pattingre S, Liaudet-Coopman E. Pathophysiological functions of cathepsin D: Targeting its catalytic activity versus its protein binding activity? Biochemistry. 2010; 92(11):1635-43. doi: 10.1016/j.biochi.2010.05.009. 27. Pereira H, Oliveira CS, Castro L, Preto A, Chaves SR, Côrte-Real M. Yeast as a tool to explore cathepsin D function. Microbial Cell. 2015; 2(7):225-34. doi: 10.15698/mic2015.07.212. 28. Ollinger K. Inhibition of cathepsin D prevents free-radical-induced apoptosis in rat cardiomyocytes. Archives of Biochemistry and Biophysics. 2000; (373):346-51. 29. Kagedal K., Johansson U., Ollinger K. The lysosomal protease cathepsin D mediates apoptosis induced by oxidative stress. FASEB Journal. 2001;15:1592-4. 30. Emert-Sedlak L., Shangary S., Rabinovitz A., Miranda M.B., Delach S.M., Johnson D.E. Involvement of cathepsin D in chemotherapy-induced cytochrome c release, caspase activation, and cell death. Molecular Cancer Therapeutics. 2005;4:733-42.DOI: 10.1158/1535-7163.MCT-04-0301. 31. Beaujouin M, Baghdiguian S, Glondu-Lassis M, Berchem G, Liaudet-Coopman E. Overexpression of both catalytically active and -inactive cathepsin D by cancer cells enhances apoptosis-dependent chemo-sensitivity. Oncogene. 2006; 25:1967-73.doi: 10.1038/sj.onc.1209221. 32. Sagulenko V, Muth D, Sagulenko E, Paffhausen T, Schwab M, Westermann F. Cathepsin D protects human neuroblastoma cells from doxorubicin-induced cell death. Carcinogenesis. 2008; 29(10):1869-77. doi: 10.1093/carcin/bgn147. 33. Oliveira CS, Pereira H, Alves S, Castro L, Baltazar F, Chaves SR. et al. Cathepsin D protects colorectal cancer cells from acetate-induced apoptosis through autophagy-independent degradation of damaged mitochondria. Cell Death and Disease. 2015; (6):e1788. doi: 10.1038/cddis.2015.157. 34. Du F, Wang T, Li S, Meng X, Zhang HY, Li DT. et al. Cathepsin D protects renal tubular cells from damage induced by high glucose independent of its enzymatic activity. American Journal of Translational Research. 2017; 9(12):5528-37. 35. Kaija H, Alatalo SL, Halleen JM, Lindqvist Y, Schneider G, Väänänen HK, Vihko P. Phosphatase and oxygen radical-generating activities of mammalian purple acid phosphatase are functionally inIssue 13. November 2018 | Cardiometry | 73

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43. Shujkova KV, Emelina EI, Gendlin GE, Storozhakov GI. Cardiotox. of modern chemotherapeutic drugs. Atmosfera. Novostikardiologii. 2012; 3:9-19. [in Russian] 44. Vasyuk YuA, Shkolnik EL, Nesvetov VV, Shkolnik LD, Varlan GV, Pilshchikov AV. Disorders of myocardial metabolism on the background of chemotherapeutic treatment, as well as the possibility of their correction. Consiliummedicum. Kardiosomatika. 2013; 4(2):11-5. [in Russian] 45. Shchetinin PP. The role of metabolic cardioprotection in the pharmacotherapy of ischemic heart disease.Aktualnye problem gumanitarnyh I estestvennyhnauk. 2015; (8-2):125-9. [in Russian] 46. Dehina L, Vaillant F, Tabib A, Bui-Xuan B, Chevalier P, Dizerens N, et al. Trimetazidine demonstrated cardioprotective effects through mitochondrial pathway in a model of acute coronary ischemia. Naunyn-Schmiedeberg's archives of pharmacology. 2013; 386(3):205–15.doi: 10.1007/s00210-012-0826-z. 47. Salouege I, Ben Ali R, Ben Saïd D, Elkadri N, Kourda N, Lakhal M, Klouz A. Means of evaluation and protection from doxorubicin-induced cardiotoxicity and hepatotoxicity in rats. Journal of Cancer Research and Therapeutics. 2014; 10(2):274-8. doi: 10.4103/0973-1482.136557. 48. Moustafa AM, Shalahy AA. Impact of trimetazidine on doxorubicin-induced acute cardiotoxicity in mice: a biochemical and electron microscopic study. Egyptian Journal of Histology. 2006; 29(1):125–36.

List of abbreviations

ATA - antitryptic activity ATP - adenosine triphosphate BSA- bovine serum albumin CatD - cathepsin D ASI - acid-stable inhibitors AP - acidic phosphatase ALP - alkaline phosphatase

ORIGINAL RESEARCH

Submitted: 3.9.2018; Accepted: 28.9.2018; Published online: 21.11.2018

Disorders of the cardiovascular system performance in the early post-castration period in patients with locally advanced cervical cancer and their correction with the low-dose xenon therapy

exchange in the myocardium, pronounced neurovegetative and psychoemotional disorders have been revealed. The use of the low-dose xenon therapy in the main test group patients has contributed to normalization of myocardial metabolism, recovery of the aerobic energy exchange, and neutralization of neurovegetative and psychoemotional manifestations of the post-ovariectomy syndrome. Thus, the diagnostics of cardiovascular disorders in the early postsurgery period as well as the correction of the disorders and abnormalities with the low-dose

Alla I. Shikhlyarova , Natalia N. Popova , Anna P. Menshenina ,

xenon therapy are of great importance in the prevention of

Yulia Y. Arapova , Tatiana P. Protasova , Andrey А. Korobov ,

cardiovascular diseases in oncogynecologic patients with the

Andrey V. Yakushin , Larisa N. Vaschenko , Dmitry А. Burtsev , 1

post-ovariectomy syndrome.

Olga V. Khokhlova1, Viktoria Y. Przhedetskaya1, Viktoria А. Ivanova1

Keywords 1

Rostov Research Institute of Oncology, Ministry of

Locally advanced cervical cancer, Post-ovariectomy syndrome,

Healthcare of the Russian Federation

Xenon therapy, Electrocardiogram, Myocardial metabolism,

Russia, 344037, Rostov-on-Don, 14th Line st. 63

Baevsky adaptive tension index*

Corresponding author: phone: +7 (905) 431-92-67, e-mail: shikhliarova.a@mail.ru

Imprint Alla I. Shikhlyarova, Natalia N. Popova, Anna P. Menshenina, Yulia Y.

Aims

Arapova, Tatiana P. Protasova, Andrey А. Korobov, Andrey V. Yakushin,

The aim hereof is to study the cardiovascular system disorders in

Larisa N. Vaschenko, Dmitry А. Burtsev, Olga V. Khokhlova, Vikto-

the early post-castration period in patients with locally advanced

ria Y. Przhedetskaya, Viktoria А. Ivanova. Assessment of the efficacy

cervical cancer and a possibility of correction of such disorders

of a peroral anticoagulant after surgical resection of gastric cancer.

with the low-dose xenon therapy.

Cardiometry; Issue 13; November 2018; p.75-80; DOI: 10.12710/cardiometry.2018.13.7580; Available from: http://www.cardiometry.net/

Materials and methods The study involved 28 female patients of reproductive age (49.8 ± 0.5 years) diagnosed with locally advanced cervical cancer. The main test group consisted of 16 patients, who received the xenon therapy in addition to the main treatment in the early post-castration period. The reference group included 12 female patients without xenon therapy. The cardiovascular system functional state was evaluated with cardiac analyzer Cardiocode at three stages: before surgical intervention, on postsurgery day 3 and upon the completion of the therapy.

Results and conclusions Early manifestations of the post-ovariectomy syndrome in the postsurgery period in female patients with locally advanced cervical cancer were accompanied by a disorder in the cardiovascular bio-adaptive and metabolic regulatory mechanisms of the uncompensated distress type, an excess of the phosphocreatine concentration and a decrease in the oxygen level in the myocardium. Upon the completion of the therapy in the reference group patients, changes in the coronary vessels hemodynamics, the dominance of the anaerobic energy

issues/no13-november-2018/low-dose-xenon-therapy

Introduction

As evidenced by the annual world statistics data, cervical cancer (CC) is diagnosed in 529,400 patients [ 1], ranked the 7th among all malignant tumors and the 3rd among tumors in the cohort of female patients [2]. Treatment of patients with locally advanced CC is a complex, stage-by-stage process, including the surgical stage (an extended nerve-sparing extirpation of the uterus with appendages, the upper third of the vagina with pelvic lymphadenectomy) supported by chemoradiotherapy [3,4]. As a result of the surgical treatment, against the background of a sudden discontinuance of the ovarian functions, menopause with clinical manifestations of the post-castration syndrome [5,6], which are expressed by neurovegetative and psychoemotional disorders [7], develops already in the early postsurgery period. Against the background of the neurovegetative disorders, under a deficit of the ovarian hormones, Issue 13. November 2018 | Cardiometry | 75

noted are disorders and abnormalities in the cardiovascular system performance [8], associated with the development of coronary oxidative stress [9], death of myocardial cells [10], disturbances of ion transport in cardiomyocytes [11,12] as well as of myocardial contractility functions [13]. As a rule, conventional hormonal methods are most often used for correction of the post-ovariectomy syndrome manifestations, but in fact, there is no unified standard plan or schedule to eliminate the symptoms of the induced menopause in oncogynecologic patients of reproductive age after their antitumor treatment [14]. Taking into account that minimally invasive methods of regenerative therapy are preferred for this category of patients, the use of the inert gas xenon, which produces not only analgesic, but also cardioprotective, immunomodulatory and hormonomodulating effects [15,16], is a promising way to solve the above formulated problems.

Aim

The aim of this study is to identify disorders and abnormalities in the cardiovascular system functional state in the early postsurgery period in female patients after ovariectomy and assess the possibility of their correction with the use of the low dose xenon therapy.

Materials and methods

Our study has covered 28 female patients of reproductive age (39.4 Âą 3.7 years), diagnosed with locally advanced cervical cancer, who have completed their complex treatment in a hospital maintained by the Rostov Research Institute of Oncology, Ministry of Healthcare of the Russian Federation, in 20162017. The first stage of the treatment includes the nerve-sparing extirpation of the uterus with appendages and the upper third of the vagina with pelvic lymphadenectomy. According to the TNM classification, the degree of the tumor process spread has corresponded to pT1bN0M0 (n=12), pT2aN0M0 (n=16), and according to the histological analysis, it has been classified as squamous cell carcinoma cancer of different degrees of differentiation. The main test group has included 16 patients, who have been treated with the use of xenon (XeMedÂŽ (medical xenon), RU No. LS-000121) in addition to the basic anticancer therapy. The xenon therapy sessions have been performed by an anesthesiologist employing therapeutic complex KTK-01. The xenon-ox76 | Cardiometry | Issue 13. November 2018

ygen mixture is supplied to the face mask within a closed circuit (a gas container volume is 4 liters). During the session, a patient is in a state of superficial sleep, but she remains capable of maintaining the possibility of verbal contact. The session duration is 15-20 minutes, and after its completion, an additional oxygenation is provided. In order to reduce the risk of a negative response in case of an increased sensitivity to the therapy, the course of xenon therapy begins with a low dose of xenon in the xenon-oxygen mixture, up to 10-12%, followed by a 2-4% increase, reaching the recommended therapeutic dose of 20-22% by the fifth session. In the reference group of 12 patients no xenon therapy has been applied. To diagnose the post-ovariectomy syndrome, the modified menopausal Kupperman-Uvarova index has been used. An ECG has been recorded with cardiometric device Cardiocode at three stages: before surgery, on postsurgery day 3 and upon completion of the therapy (on the day of discharge from the hospital). A single-lead ECG and a Rheogram of each patient have been produced synchronously for 30 seconds in the lying position and 30 seconds in the sitting position. The ECG and Rheogram electrodes are placed in accordance with the recommended procedure [17]. The durations of the cardiac cycle phases and the respective parameters of hemodynamics, namely stroke volume (SV, ml), minute volume (MV, l/ml), volumes of blood entering the ventricle during the early diastole (PV1, ml) and the atrial systole (PV2, ml), blood volumes ejected by the ventricle during rapid ejection phase (PV3, ml) and slow ejection phase (PV4, ml) have been calculated noninvasively using the hemodynamics equation by G. Poyedintsev - O. Voronova [8] supported by the Cardiocode software [17]. The stability of the regulatory system state has been determined on the basis of the Baevsky TI values: the TI values ranged from 100 to 500 arbitrary units have been considered as the norm, the values exceeding 500 have been classified as overtension, and those under 100 have been considered as a weak state of the regulatory systems [17]. The cardiac metabolic processes have been assessed by parameters of the oxygen, lactate and phosphocreatine concentrations, computed by the S.A. Dushanin method, aided by the Cardiocode software. As to the aerobic process, the parameter values varying in the ranges 0.7 ... 0.85, 0.6 ... 0.65, 0.5 ... 0.55 have

been considered as the norm; the normal values for the anaerobic-glycolytic process have been assumed to be 3.0 ... 7.0, and the normal levels for the anaerobic-allocation process have been taken to be 2.0 ... 4.0, respectively [17]. The statistics data have been analyzed with the Statistica 10.0 software (StatSoft, USA). The comparison of the cardiovascular activity parameters at different stages of the studies has been carried out using the Student's criterion. Taking into account the Bonferroni correction, the values p<0.013 have been considered to be significantly reliable. The experimental study has been completed in accordance with the ethical principles for medical research involving human subjects (Declaration of Helsinki, Finland, 1964).

Results

Our assessment of the performance of the cardiovascular system before the surgical treatment has shown no significant disorders in hemodynamic functions, and the relevant parameters have been found to be within the age-related norm (see Table 1 herein). However, it has been noted that all patients have demonstrated the state of compensated distress, under the conditions of which the mean TI value has reached 402 ± 12.6 arbitrary units. At the same time, the calculated metabolic values have indicated that there has been a significant accumulation of lactate in the myocardium up to 21.27 arbitrary units, under a normal oxygen concentration of 0.52 arbitrary units and the phosphocreatine level of 3.76 arbitrary units. (see Figure 1 herein). An analysis of the neurovegetative and psychoemotional status in patients of both groups on postsurgery day 3 has shown that 85% of the patients have had a clear tendency to increasing the degree of the major

manifestations of the postovariectomy syndrome and that in 15% only the tendency has been reported to be weak. The most frequently recorded neurovegetative disorders are the following: increased arterial blood pressure (67%), headaches and sweating (66%), dizziness (68%) and elevated excitability (75%). There mentioned should be also complaints about frequent changes in mood (85%), memory loss and irritability (68%) and anxiety (87%). On postsurgery day 3, in the reference group patients and in the main test group patients, despite the absence of significant changes in the hemodynamic parameters, TI has increased by 1.3 times and reached 530 ± 21.3 arbitrary units, that indicates an aggravation of the uncompensated distress. At the same time, the oxygen concentration in the myocardium has decreased to the lower limit of the norm (0.49 arbitrary units), the elevated lactate level has decreased by 2 times reaching 10.8 arbitrary units (p <0.01), but even these lactate values have exceeded the norm. Despite the fact that the level of phosphocreatine has increased to 5.03 arbitrary units (p <0.01), the change in the metabolism parameters bears witness to an imbalance in the processes of the energy metabolism with the dominance of the anaerobic respiration (see Figure 1 herein). In the patients of the main test group, upon completion of the xenon therapy, no disorders in the hemodynamic parameters have been found (see Table 1 herein). The calculated cardiometric parameters have demonstrated that there is a unidirectional tendency to normalization of the bioadaptive and metabolic processes in the myocardium. Despite the fact that the TI value of 666.7 ± 24.7 arbitrary units has indicated a retardation of the transition of the uncompensated distress into a compensated form thereof, the change in the metabolic processes has been clearly revealed.

Figure 1. Metabolic processes in the myocardium at three stages of examination: А – oxygen concentration, B – lactate concentration, С – phosphocreatine concentration. Note: Beige background indicates the limits of the norm for each parameter. Issue 13. November 2018 | Cardiometry | 77

Table 1. The main characteristics of heart hemodynamics at three stages of experimental studies Parameters

PV1

PV2

PV3

PV4

Before surgical treatment

47,8±7,6

4,1±0,7

30,1±2,4

24,0±2,9

32,1±2,9

22,0±1,9

Postsurgery period

58,3±4,9

5,3±0,4

34,9±3,1

30,6±4,2

34,6±2,9

23,7±0,1

Upon completion of the xenon therapy

56,7±7,1

4,7±0,6

32,4±6,3

24,3±4,1

33,7±4,2

23,1±2,9

Upon completion of treatment without xenon therapy

48,6±1,4

4,3±0,2

27,5*±3,3

25,2±3,4

28,8±0,9

19,7*±0,6

Note: * reliably significant variances at p<0,013

In this case, the xenon therapy has resulted in a stable maintenance of the oxygen concentration at its normal level (0.5 arbitrary units), which has exceeded its reduced level in the reference group by 1.6 times. As compared with the reference group patients, we have observed a decrease in the lactate concentration by 2.0 times, the values of which have been found to be reduced in the postsurgery period reaching the normal level of 7.7 arbitrary units. The same case is with the phosphocreatine level, which has reached the value of 3.8 arbitrary units (see Figure 1 herein). An essential feature of the above cases is that against the background of the xenon therapy, we have succeeded in full mitigation of the neurovegetative and psychoemotional manifestations of the castration syndrome in the patients under study. As opposed to the main test group, in the reference group upon the completion of the standard therapy without using xenon-oxygen inhalations, a significant hemodynamic disorder has been diagnosed, mainly due to a decrease in cardiac cycle phase volumes PV1 (from 34.9 ± 3.1 to 27.5 ± 3.3 ml, p <0.013) and PV4 (from 23.7 ± 0.11 to 9.7 ± 0.6 ml, p <0.013). This has been confirmed by a reduction in the volume of blood entering the ventricle in the early diastole and ejected by the left ventricle during the slow eje ction phase (see Table 1 herein). The TI value has demonstrated even a greater increase and has reached the value of 693.6 ± 15.7 arbitrary units that is in correspondence with the stable state of uncompensated distress. The oxygen concentration has been recorded to be much lower than the norm: 0.30 arbitrary units (p <0.013), the lactate level has reliably exceeded the norm reaching values significantly higher than those identified after the surgical treatment: 15.5 arbitrary units (p <0.013), and the level of phosphocreatine has remained much above the norm, demonstrating an imbalance in the processes of the cellular energy supply and the predominance of anaerobic energy exchange (see Figure 1 herein). 78 | Cardiometry | Issue 13. November 2018

At the same time, complaints about increased arterial blood pressure (59%), headaches and dizziness (48%), sweating (52%), sleep disturbances (48%), increased fatigue (100%), pessimistic attitude to life (94%), apathy, poor sleep and low working capacity (75%), aggressiveness (66%), depression (50%) and anxiety (63%) have been observed to remain and even intensify in the reference group.

Discussion

In modern clinical oncology, the practical application of therapy and rehabilitation measures targeted at improving the quality of life of patients at all stages of their antitumor treatment is given the highest priority [18]. Females of reproductive age with malignant tumors in the reproductive system are considered to be one of the most vulnerable categories among the cancer patients. The severity of their recovery in the postsurgery period can be explained by development of disorders and abnormalities at the different systemic levels in the organism, and they are primarily associated with the postovariectomy syndrome. Their cardiovascular performance disorders, caused by estrogen deficit, are attributed to delayed changes manifested in epicardial obesity and coronary calcinosis [19]. The study by Mitkovskaya et al. [19] shows that in females with the postovariectomy syndrome the myocardial hypertrophy and remodeling of left ventricle with abnormalities of its diastolic function often develop, and they have a high risk of cardiovascular diseases, having an unfavorable outcome in 46.4% of the cases. The present study confirms the possibility of development of unfavorable pathogenic conditions responsible for the appearance of cardiac performance disorders in the early period after the nerve-sparing extirpation of the uterus and appendages with the upper third of the vagina in the cervical cancer patients. First of all, the high TI values recorded in the said cohort of the patients indicate that we deal with

a stable tension state of the uncompensated distress dominating in the organism. This contributes to the appearance of the cardiovascular system performance disorders and abnormalities that is clearly reflected in suppression of the hemodynamic processes, accompanied by an enhancement of neurovegetative reactions such as high blood pressure, complaints about hot flashes, headaches, dizziness, etc. In addition, the tension in the myocardial metabolic processes, associated with the dominance of the anaerobic character of the energy-forming processes, is noted. The given alterations without an appropriate corrective therapy may result in a high risk of cardiovascular diseases. The use of the low-dose xenon therapy in the patients in the main test group has produced normalization of the myocardial metabolism, the recovery of the aerobic metabolism, as well as elimination of neurovegetative and psychoemotional abnormalities associated with the postovariectomy syndrome. This approach should be treated as a valuable alternative which may be offered the above mentioned female patients, whose quality of life against the background of uncompensated distress after the surgical stage of their treatment is seriously deteriorated. The obtained data bear witness to the necessity of the above method for rehabilitation of patients with postovariectomy syndrome already in the early postsurgery period in order to reduce the risk of cardiovascular disorders and recover their neurovegetative and psychoemotional state as criteria for increasing the functional and social status and quality of life in the reproductive age female patients.

Conclusions

1. Against the background of the early manifested postovariectomy syndrome in the postsurgery period, in the patients of the reference and main test group, noted are a decrease in the cardiovascular system adaptive resources due to their transition to a stable state of uncompensated distress, accompanied by a reduction in the coronary vessel blood circulation, a decrease in the oxygen level and an imbalance of the bioenergetic processes with the dominance of the anaerobic energy exchange, pronounced neurovegetative and psychoemotional disorders and abnormalities. 2. The use of the low-dose xenon therapy for the above test cohort of the patients contributes to normalization of the myocardial metabolism, the recovery of the aerobic energy exchange, as well as elimination of

neurovegetative and psychoemotional disorders and abnormalities of the postovariectomy syndrome that significantly improves the quality of life of the reproductive age patients of this category. Editor's note: The Baevsky adaptive tension index is also known in English reference literature as “the Baevsky index” or “the Baevsky stress index”

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Jemal А, Vineas P, Brey F, Torre L, Formand D. The Cancer Atlas. Atlanta, GA: American Cancer Society; 2014. 2. Аksel' EM, Filonenko EV. Rehabilitation of oncogynecologic patients at the stages of combined treatment. Vestnik vosstanovitel'noj khirurgii. 2016;5:1-5. [in Russian] 3. Kuznetsov VV, Lebedev АI, Morkhov KYU, Gritsaj АN. Surgery of invasive uterine cancer. Prakticheskaya onkologiya. 2002(3):178-182. [in Russian] 4. Zola P, Tripodi E, Zanfagnin V, Balima Poma C, Perotto S, Modafarri P, Marta F, Fuso L. Treatment of early cervical cancer: survival, complication and economical aspects. Sibirskij onkologicheskij zhurnal. 2012(51):5-13. [in Russian] 5. Pokul' LV, YAs'ko BА, Evtushenko ID. Personal resources to overcome post-rectionectomy syndrome in women of reproductive age after antitumor treatment. Аkusherstvo i zhenskie bolezni. 2009(LVIII):19-23. [in Russian] 6. Belotserkovtseva LD, Kovalenko LV, Korneeva EV, SHishanok OYu. Clinical and metabolic manifestations of postovariectomy syndrome in women of reproductive and premenopausal periods. Vestnik Sankt-Peterburgskogo universiteta. 2008(11):97-110. [in Russian] 7. Peshikov OV. Alternative ways of correction of neurovegetative disorders in women with surgical menoIssue 13. November 2018 | Cardiometry | 79

pause complicated by postovariectomy syndrome. Tikhookeanskij meditsinskij zhurnal. 2011(34):56-58. [in Russian] 8. Parks RJ, Bogachev O, Mackasey M, et al. The impact of ovariectomy on cardiac excitation-contraction coupling is mediated through cAMP/PKA-dependent mechanisms. J. Mol. Cell Cardiol. 2017(111):51-60. doi: 10.1016/j.yjmcc.2017.07.118. 9. Barp J, Sartório CL, Campos C, et al. Influence of ovariectomy on cardiac oxidative stress in a renovascular hypertension model. Can. J. Physiol. Pharmacol. 2012;9:1229-34. doi: 10.1139/y2012-078. 10. Lin YY, Cheng YJ, Hu J, et al. The coexistence of hypertension and ovariectomy additively increases cardiac apoptosis. Int. J. Mol. Sci. 2016;12:E2036. doi: 10.3390/ijms17122036. 11. Parks RJ, Bogachev O, Mackasey M, et al. The impact of ovariectomy on cardiac excitation-contraction coupling is mediated through cAMP/PKA-dependent mechanisms. J. Mol. Cell Cardiol. 2017;111:51-60. doi: 10.1016/j.yjmcc.2017.07.118. 12. Nahar K, Kabir F, Islam P, et al. Cardioprotective effect of Amaranthus tricolor extract in isoprenaline induced myocardial damage in ovariectomized rats. Biomed Pharmacother. 2018;103:1154-62. doi: 10.1016/j.biopha.2018.04.151. 13. Hou H, Zhao Z, Machuki JO, et al. Estrogen deficiency compromised the β2AR-Gs/Gi coupling: impli-

80 | Cardiometry | Issue 13. November 2018

cations for arrhythmia and cardiac injury. Pflugers Arch. 2018;470:559-70. doi: 10.1007/s00424-017-2098-4. 14. Molchanov SV, Kolomiets LА, Gridneva TD. Role of rehabilitation in life quality improvement for cancer patients of reproductive age anticancer treatment. Sibirskij onkologicheskij zhurnal. 2012;51:46-9. [in Russian] 15. Burov NE, Potapov VN. Application of Xenon in Med. Мos.: GVKG im. N.N. Burdenko; 2012. [in Russian] 16. Kit OI, Frantsiyants EM, Men'shenina АP, Moiseenko TI, Ushakova ND, Popova NN, Yankushin АV. Role of plasmapheresis and xenon therapy in correcting the acute effects of surgical menopause in patients with cervical cancer. Nauchnyj zhurnal KubGАU. 2016;117:1-15. [in Russian] 17. Rudenko MY, Zernov VА, Voronova OK, Mamberger KK, Makedonskij DF, Rudenko SM. Recommendations for Working with the Cardiocode Device Using the Heart Cycle Phase Analysis Method Taganrog: Izd-vo IKM; 2015. 18. Karitskij АP, CHulkva VА, Pesterova EV, Semiglazova TYu. Rehabilitation of a cancer patient as a basis for improving the quality of his life. Voprosy onkologii. 2015;61:180-4. [in Russian] 19. Mit'kovskaya NP, Pateyuk IV, Statkevich TV, et al. Functional state of the cardiovascular system and cardiovascular risks in women with postovariectomy syndrome. Mezhdunarodnyi zhurnal serdtsa i sosudistykh zabolevanii. 2017;5:4-10. [in Russian]

CASE REPORT

Submitted: 6.8.2018; Accepted: 24.8.2018; Published online: 21.11.2018

Ruptured mycotic hepatic artery aneurysm associated with methicillin sensitive staphylococcal endocarditis Hamidreza Varastehravan1, Hasan Salmanroghani1, Aryan Naghedi1* 1

Shahid Sadoughi University of Medical Sciences and Healthcare Services Iran, 97514, Yazd, Bahonar Sq.

MVR and AVR operations were performed in Afshar Heart Center, Yazd, Iran and coil embolization was done in Cardiology Department, Shahid Sadoughi Hospital, Yazd, Iran *

Corresponding author: phone: +98 (938) 156-17-37, e-mail: a.naghedi@yahoo.com

Abstract Hemobilia is a rare cause of upper gastrointestinal hemorrhage. Classical presentations of hemobilia are biliary colic, jaundice, hematochezia and melena. Persistent bleeding sometimes requires urgent therapeutic intervention, such as angiographic intervention or surgery. It may be secondary to trauma, inflammatory disorders, gallstones or tumors. Hepatic artery aneurysm rupture is a rare cause of gastrointestinal bleeding. Mycotic hepatic artery aneurysm is not a common vascular lesion, but it is considered to be a late complication of bacterial endocarditis. We present a 43 years old man with history of bacterial endocarditis that led to aortic valve replacement (AVR) and mitral valve replacement (MVR) about 9 months ago, with present complaint of rectal bleeding and dizziness. Angiographic studies suggested ruptured mycotic aneurysm in right hepatic artery, which was successfully treated with coil embolization.

Keywords Hemobilia, Hepatic, Mycotic, Aneurysm, Bacterial endocarditis, Aortic valve replacement, Mitral valve replacement, Coil embolization

Imprint Hamidreza Varastehravan, Hasan Salmanroghani, Aryan Naghedi. Ruptured Mycotic Hepatic Artery Aneurysm Associated with Methicillin Sensitive Staphylococcal Endocarditis. Cardiometry; Issue 13; November 2018; p.81-85; DOI: 10.12710/cardiometry.2018.13.8185; Available from: http://www.cardiometry.net/ issues/no13-november-2018/ruptured-mycotic-hepatic-artery

Introduction

The term hemobilia describes bleeding into the biliary system from any suggested origin [1]. One cause of hemobilia is rupture of hepatic artery aneurysm that is a rare vascular lesion [2] and can occur due to laparoscopic cholecystectomy, per cutaneous liver biopsy and blunt trauma [3]. Mycotic hepatic artery aneurysm is a vascular pathology which can be associated with bacterial endocarditis [4]. Its incidence is lowered due to development of effective antibiotics [5]. But if ruptures of these aneurysms occur, they are usually followed by fatal outcomes [6]. We present a patient with hemobilia due to the ruptured mycotic hepatic artery aneurysm as a result of Methicillin Sensitive Staphylococcus aureus (MSSA) bacterial endocarditis.

Case

A 43 years old man was admitted in emergency ward with neurological complaint such as cervical pain and upper limb paresthesia. The patient was febrile and during diagnostic work-ups Methicillin Sensitive Staphylococcus aureus (MSSA) endocarditis was suggested and echocardiographic studies revealed large vegetation on anterior mitral valve with severe mitral regurgitation and large vegetation on aortic valve with moderate to severe aortic insufficiency. According to acquired clinical and imaging data, septic emboli to cervical spinal cord and abscess formation was diagnosed to be the cause of his symptoms and thus effective antibiotics including Vancomycin 500mg QID, Gentamicin and ciprofloxacin 500mg BID were prescribed for him. Considering evidences of cervical cord compression, he was candidate for decompression surgery, but because of unstable hemodynamics and acute pulmonary edema due to severe destruction of two cardiac valves, he was transferred to cardiac operating room emergently to undergo aortic and mitral valve replacement surgery. The patientâ&#x20AC;&#x2122;s neurological condition enhanced without any CNS intervention, and so antibiotic therapy was continued for him for 6 weeks, and the patient was discharged after an uneventful course in hospital under treatment of antibiotics and therapeutic dose of warfarin. After 9 months, he was readmitted to hospital with epigastric pain, dizziness and rectal bleeding. In physical examination he was not febrile. His blood pressure was 80/60 mmHg, and his pulse rate was 114 Issue 13. November 2018 | Cardiometry | 81

Figure 1. Gastroduodenal artery and left hepatic artery normally branched from common hepatic artery.

Figure 2. Right hepatic artery branched from superior mesenteric artery instead of common hepatic artery as a normal variation

beats per minute; his conjunctiva was pale, and his sclera was icteric. Prosthetic aortic and mitral valve metallic sounds were auscultable, and epigastric tenderness was recorded. He was under treatment with warfarin 2.5mg daily. Laboratory data revealed the following data: white blood cell (WBC): 19800, hemoglobin (Hb): 6.2, mean corpuscular volume (MCV): 80, platelet (Plt): 129000, prothrombin time (PT): 18, partial thromboplastin time (PTT): 42 international normalized ratio (INR): 4/4, aspartate aminotransferase (AST): 561, alanine transaminase (ALT): 290, 82 | Cardiometry | Issue 13. November 2018

alkaline phosphatase (ALP): 488, Total bilirubin: 2.5 and Direct bilirubin :1.4, blood urea nitrogen (BUN): 45 and creatinine (Cr): 0.9. Chest X ray findings were as follows: no acute lung process; the normal electrocardiogram (EKG) was recorded. He received two packed blood cells in emergency ward and underwent urgent upper gastrointestinal (GI) endoscopy. Endoscopic studies couldn’t indicate any active bleeding site. In his abdominal ultrasound imaging the liver span was reported 107mm with heterogeneous and coarse parenchyma, dilated intrahepatic biliary ducts and sludge in gallbladder. No other pathology was reported in ultrasound imaging. The next day of hospitalization patient’s condition regressed, and he complained of massive hematochezia. In physical examination he was still pale and icteric. His blood pressure was measured 90/40 mmHg, and his pulse rate was 106 beats per minute. Epigastric tenderness was recorded in physical examination. Measured Hb equaled 6.4. Urgent upper GI endoscopy was done for the second time. In second endoscopy there was no bleeding lesion along gastric mucosa, but there was fresh blood in second and third portion of duodenum without active bleeding site. Thus warfarin intoxication and bleeding from liver lesion or vascular pathology was suggested. Endoscopic retrograde cholangio-pancreatography (ERCP) investigation was suggested and done to find the bleeding source. ERCP results highly recommended diagnosis of hemobilia. The mentioned patient’s past history of bacterial endocarditis with septic emboli to cervical spinal cord, infectious vascular lesion was highly recommended and considering patient’s poor hemodynamic condition and low hemoglobin levels despite of receiving more packed cells in ICU, angiographic studies were indicated and done. In celiac artery angiography, the common hepatic artery, the gastroduodenal artery and the left hepatic artery were normal (Figure No.1), but the right hepatic artery was not visualized. His superior mesenteric artery (SMA) was normal, but his right hepatic artery was branched from SMA as a normal variation (Figure No.2), and one aneurysmal lesion with active contrast leakage into biliary ducts was discovered (Figure No.3). Considering unstable clinical and hemodynamic condition, right hepatic artery embolization was performed using coil embolization technique. After angiographic intervention and embolization, his bleeding stopped and his hemodynamics became

stable the next day, and he was finally discharged with therapeutic range of INR (Figure No.4).

Discussion

The term hemobilia was first used by Sandblom to describe bleeding into biliary system after a sub capsular liver injury in 1948 [7], but this term is now used to describe bleeding into the biliary system from any origin [1]. Bleeding caused by ruptured hepatic artery aneurysm (HAA) into the common bile duct was first reported by Jackson in 1821[8]. In a major clinic study by Abbas and colleagues between 1980 and 1998, among 306 patients with visceral artery aneurysm diagnosis, the aneurysm was sited in HAA in 36 patients (12%). Among 36 patients with HAA aneurism twenty-three patients (64%) were males, and 13 patients (36%) were females. The mean presentation age was 62.2 years (range, 20-85 year). HAA aneurisms are at definite risk of rupture (14%). Rupture risk factors include multiple HAA and non-atherosclerotic origin [9]. The most common sites of communication between the aneurysm and biliary tract are the common bile duct or hepatic ducts (76.2 per cent). Main features of hemobilia are biliary colic, jaundice, hematochezia and melena, and the bleeding may be recurrent. However, most patients do not present all four symptoms [10]. The pain originated from hepatic artery aneurysm is better sensed in the epigastrium or right upper quadrant or may radiate to the back [11]. The precise cause of HAA remains unclear yet. In the early twentieth century, most HAAs were mycotic, followed by bacterial endocarditis as the most frequent cause [5]. But nowadays mycotic HAAs are seldom seen, because of earlier antibiotic therapy for infections [12]. Mycotic hepatic artery aneurysm is important but is rare and accounts 0.1% of all arterial aneurysm [2]. At first, Osler described mycotic artery aneurysm in 1885 [13]. Its definition is an infectious break in artery wall that forms a blind-sac contiguous to arterial lumen. Maybe its pathogenesis is seeding of infected emboli into lumen of normal vessel leading to inflammation and necrosis and then weakening and dilation of arterial wall [14]. Most prevalent sites of involvement are the aorta, the peripheral artery, the cerebral artery, and the visceral arteries such as the superior mesenteric artery and the liver, spleen and kidneyâ&#x20AC;&#x2122;s arteries [15]. In hepatic artery aneurysm, the common hepatic artery is the most prevalent site (63%), and then the right hepatic artery (28%) is the most prevalent, but the left hepatic artery

Figure 3. Filling of right hepatic artery pseudo aneurysm with contrast before coil embolization.

Figure 4. Successful coil embolization.

(5%) is less involved, and at the end both right and left hepatic arteries involved together are the rarest cases (4%) [16]. Mycotic aneurysm in our patient was sited in his right hepatic artery, and mycotic hepatic artery aneurysms demonstrate high risk of rupture [4]. Most common etiologic pathogens are Streptococcus and Staphylococcus groups. Some other germs causing mycotic aneurysms are gram-negative bacteria, fungal infections such as aspergillus or candida, and even mycobacterium [15]. There are few cases of mycotic hepatic artery aneurysm with staphylococcal endocarditis in literatures [17, 18]. Staphylococci cause Issue 13. November 2018 | Cardiometry | 83

20% to 30% of the cases of infectious endocarditis (IE), and 80% to 90% of these cases are caused by coagulase positive Staphylococcus aureus [19]. In a recent review of endocarditis cases at Duke University Medical Center from 1993 to 1999, in S aureus IE patients, 60% of the cases were involved by MSSA bacteremia, whereas 40% of the cases were involved by MRSA infection [20]. MSSA is associated with significantly higher rates of IE than MRSA. Community-acquired methicillin sensitive staphylococcus aureus (MSSA) is the cause of the most cases of MSSA endocarditis [21]. Hill and colleagues in 2008 reported that MSSA patients had significantly more unknown origin of bacteremia and experienced a significantly higher rate of major emboli compared to MRSA infected patients [22]. In our case, the patient was infected by methicillin sensitive staphylococcus aureus, which caused endocarditis with aortic and mitral valves involvement leading to AVR and MVR. Color Doppler ultrasonography, computed tomography (CT) scan, CT angiography and magnetic resonance (MR) angiography resulted in increased identification of asymptomatic hepatic artery aneurysms [23]. Magnetic resonance imaging can distinguish blood from stones and sludge and may be helpful when the diagnosis is uncertain. The diagnosis of hemobilia is most frequently confirmed by upper endoscopy or ERCP [24]. Today the most useful diagnostic test is selective arteriography of the celiac axis, the hepatic artery, or superior mesenteric artery [25]. Embolization with coil plays an important role in management of intrahepatic aneurysms in high risk surgery candidates and proximal aneurysm [9], thus for high risk surgery candidate patients arterial embolization is highly recommended, which is a simple, safe, and effective treatment for hemobilia with lower morbidity and mortality compared to surgery [26]. Open surgical treatment options for HAA include ligation, excision, venous grafting, synthetic grafting, and hepatic resection [5]. Surgical options are suitable for patients with low risk of surgery and usually distal aneurysms [27].

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

84 | Cardiometry | Issue 13. November 2018

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Beaumont R, et al. Hemobilia a Rare Entity: Case Report and Literature Review. Annals of Clinical and Laboratory Research, 2016; 4(4). 2. Kim G, et al. A case of ruptured mycotic hepatic artery aneurysm successfully treated using arterial embolization. Yeungnam Univ. Jour. of Med., 2012;29(1): 24-7. 3. Ferrari AP, et al. Hemobilia caused by a mycotic aneurysm of the hepatic artery treated by enbucrilate injection during ERCP. Gastrointestinal Endoscopy. 2003; 57(2):260-3. 4. Chaudhari D, et al. Hepatic Artery Mycotic Aneurysm Associated with Staphylococcal Endocarditis with Successful Treatment: Case Report with Review of the Literature. Case Reports in Hepatology. 2013. p. 3. 5. Pitton MB, et al. Visceral artery aneurysms: Incidence, management, and outcome analysis in a tertiary care center over one decade. European Radiology. 2015;25(7): 2004-14. 6. Liu EY, J Crawford, and H Haddad, Hemothorax due to Ruptured Mycotic Aneurysm of Intercostal Arteries Associated with Infective Endocarditis. Case Reports in Medicine, 2017. p. 3. 7. Sandblom P. Hemorrhage into the biliary tract following trauma — “traumatic hemobilia”. Surgery. 1948;24(3):571-86. 8. Jackson J. Aneurysin of hepatic artery bursting into the hepatic duct Med. Magaz.(Boston), 1834. 3: p. 115. 9. Abbas MA, et al. Hepatic artery aneurysm: factors that predict complications. Journal of Vascular Surgery. 2003;38(1):41-5. 10. Devakumar Murugesan S, et al. Massive Hemobilia: A Diagnostic and Therapeutic Challenge. World Journal of Surgery. 2014; 38(7):1755-62. 11. Peter G, et al. Hepatic artery aneurysm: a rare case of obstructive jaundice with severe hemobilia. Annals of gastroenterology. 2014;27(3):288-9. 12. González I, et al. Symptomatic Peripheral Mycotic Aneurysms Due to Infective Endocarditis: A Contemporary Profile. Medicine (Baltimore), 2014. 93(1). 13. Osler W. The Gulstonian Lectures, on Malignant Endocarditis. Br Med J. 1885; 1(1262):467-70. 14. Mylonakis E. and SB Calderwood. Infective Endocarditis in Adults. New England Journal of Medicine. 2001;345(18):1318-30.

15. Lee WK, et al. Infected (mycotic) aneurysms: spectrum of imaging appearances and management. Radiographics. 2008;28(7):1853-68. 16. Park IW, et al. Delayed rupture of mycotic hepatic artery aneurysm in a patient with infective mitral endocarditis-first case in Korea. Korean Circulation Journal. 2007; 37(1):43-6. 17. Jordan M, Razvi S, Worthington M. Mycotic hepatic artery aneurysm complicating Staphylococcus aureus endocarditis: successful diagnosis and treatment. Clin Infect Dis. 2004;39(5):756-7. 18. Tierney AB, Palmer FJ. Mycotic Aneurysm of the Right Hepatic Artery Presenting with Obstructive Jaundice. Australasian Radiology. 1987;31(1):50-2. 19. Tong SY, et al. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clinical microbiology reviews. 2015;28(3): 603-61. 20. Cabell CH, et al. Changing patient characteristics and the effect on mortality in endocarditis. Archives of internal medicine. 2002;162(1):90-4. 21. Abraham J, et al. Staphylococcus aureus bacteremia and endocarditis: the Grady Memorial Hospital

experience with methicillin-sensitive S aureus and methicillin-resistant S aureus bacteremia. Am Heart J. 2004;147(3):536-9. 22. Hill E, et al. Methicillin-resistant versus methicillin-sensitive Staphylococcus aureus infective endocarditis. European Journal of Clinical Microbiology & Infectious Diseases. 2008;27(6):445-50. 23. Goulenok T, et al. Infective Endocarditis with Symptomatic Cerebral Complications: Contribution of Cerebral Magnetic Resonance Imaging. Cerebrovascular Diseases. 2013;35(4):327-36. 24. Kim KH, Kim TN. Etiology, clinical features, and endoscopic management of hemobilia: a retrospective analysis of 37 cases. Korean J Gastroenterol. 2012;59(4): 296-302. 25. El Hajj II, et al. Life threatening hemobilia after endoscopic retrograde cholangiopancreatography (ERCP). Digestive and Liver Disease. 2017;49(12): 1336-7. 26. Navuluri R. Hemobilia. in Seminars in interventional radiology. 2016. Thieme Medical Publishers. 27. Zaydfudim VM, Angle JF, Adams RB. Current Management of Hemobilia. Current Surgery Reports. 2014;2(5):54.

Issue 13. November 2018 | Cardiometry | 85

ORIGINAL RESEARCH

Submitted: 14.8.2018; Accepted: 7.9.2018; Published online: 21.11.2018

Features of the psychosomatic state in lung cancer patients and psychopathophysiological aspects of cardiovascular diseases

type of the response.

Conclusions The relationship between the characteristics of AR in patients with lung cancer and the cancer process prevalence is shown herein. It is assumed that thyroxine is involved in the formation of the positive

Galina V. Zhukova , Alla I. Shikhlyarova , Natalia М. Maschenko ,

psychoemotional states in the studied patients. The combination

Elena А. Shirnina , Mikhail S. Zinkovich , Tamara G. Airapetova ,

of the euphoric reaction with the maximum AR scores in patients

Pavel А. Anistratov1, Lyudmila Y. Rozenko1, Larisa N. Vaschenko1,

with resectable lung cancer without detected metastases indicates

Dmitry V. Burtsev , Marina А. Gusareva , Olga V. Kozyuk ,

that there is a psychophysiological mechanism of restraining tumor

Aleksey N. Shevchenko

development; at the same time, it demonstrates that there is the

need to refine the concept of the euphoric type of the response. 1

Rostov Research Institute of Oncology, Ministry of

The obtained results indirectly count in favor of the cardiovascu-

Healthcare of the Russian Federation

lar diseases therapy approaches, which involve the use of thyroxin

Russia, 344037, Rostov-on-Don, 14th Line st. 63

drugs in accordance with the algorithms of activation therapy.

Corresponding author: phone: +7 (908) 194-29-99, e-mail: galya_57@mail.ru

Keywords Lung tumors, General non-specific adaptation reactions of the

Aim

organism, Euphoric reaction, Depression, Thyroxine, Cardiovas-

The aim hereof is a comprehensive study of the mental, adaptive

cular diseases

and hormonal status in patients with lung cancer with varying prevalence of the malignant process. The obtained results are

Imprint

compared with data on the psychosomatic state and subclinical

Galina V. Zhukova, Alla I. Shikhlyarova, Natalia М. Maschenko, Ele-

disorders in the thyroid system in patients with cardiovascular

na А. Shirnina, Mikhail S. Zinkovich, Tamara G. Airapetova, Pavel А.

diseases.

Anistratov, Lyudmila Y. Rozenko, Larisa N. Vaschenko, Dmitry V. Burtsev, Marina А. Gusareva, Olga V. Kozyuk, Aleksey N. Shevchenko.

Materials and methods

Features of the psychosomatic state in lung cancer patients and psy-

The characteristics of general non-specific adaptation reactions

chopathophysiological aspects of cardiovascular diseases. Cardiom-

by the organism (AR), the level of personal and situational anx-

etry; Issue 13; November 2018; p.86-95; DOI: 10.12710/cardiome-

iety, the severity of depression, and the reactions to the disease

try.2018.13.8695; Available from: http://www.cardiometry.net/issues/

are studied in 28 lung cancer patients with resectable and un-

no13-november-2018/psychosomatic-state-in-lung-cancer-patients

resectable tumors. The “Antistress” expert software is used for the qualitative and quantitative evaluation of AR. The level of the adrenocortical and thyroid axis hormones in blood serum is studied in patients with resectable tumors.

Results The relationship between the AR characteristics and the malignant process prevalence, a decrease in the ACTH concentration, an elevated level of cortisol and thyroxine are noted. The mental status has been characterized by non-depressiveness and dominance of the euphoric reaction to the disease. In patients with resectable tumors without detected metastases, who have shown the euphoric reaction, the maximum scores of AR are observed with a higher thyroxine concentration as compared with those in patients with metastases and low adaptation status, who have demonstrated the hypochondriacal 86 | Cardiometry | Issue 13. November 2018

Introduction

Nowadays the issues on psychosomatic regulation in pathologies that cause the greatest lethality, namely cardiovascular diseases and malignant tumors of various localization, become the hottest. Elucidation of psychophysiological mechanisms of an adaptation to a malignant process is one of the most important problems in oncology [1, 2]. The influence of personal characteristics of patients suffering from oncological diseases on the effectiveness of treatment, quality and duration of their life is evidenced [1, 3, 4]. At the same time, the issue on the relationship between psychoemotional reactions of patients and the dynamics of the organism's regulatory system state with varying prevalence of the malignant process remains poorly understood.

It is known that both the tumor process and cardiovascular disorders are conditioned to a great extent by developing chronic stress and general non-specific adaptation reactions (AR) of low levels of reactivity [5-7]. This allows assuming the presence of similar features in the psychosomatic regulation of the state in the cancer patients and those, who suffer from cardiovascular diseases, associated with the noted AR. Thus, some results of our psychophysiological adaptation study in the cohort of the cancer patients may be useful for an analysis of intersystem disorders and developments of fresh therapeutic approaches to treat cardiovascular system diseases. The aim hereof is a comprehensive study of the mental, adaptive and hormonal status in lung cancer patients with a varying prevalence of the malignant process. An additional task is to compare the obtained results with the current literature on the psychosomatic state in those patients, who have cardiovascular diseases in connection with some issues on the therapeutic use of thyroxin medication.

Materials and methods

The studies are carried out in accordance with the ethical standards of the Helsinki Declaration (1964), providing for the receipt of patients' prior written consent. Before the treatment, the patients have been evaluated according to the Karnovsky scale. 28 patients with lung cancer, who received surgical and chemoradiation treatment, have been examined and divided into 3 groups depending on the verified diagnosis. Group 1 includes 10 patients (mean age 59 Âą 2 years) with unresectable lung tumors, who have received conservative antitumor treatment with platinum-containing regimens of chemotherapy and (or) distant gamma-therapy (DGT). Group 2 and group 3 consist of patients with resectable tumors, who have been subjected to surgical and adjuvant treatment. At the same time, in the patients in group 2 revealed have been metastases (T2-3N1-2M0-1), and in the group 3 patients with resectable lung cancer no metastases have been detected. Group 2 includes 7 patients (mean age 60 Âą 1 years), and group 3 covers 11 patients (mean age 55 Âą 3 years), respectively. The evaluation of the AR type and its intensity is performed according to the leukogram based on a 200 cell count, considering the total number of leukocytes, in accordance with the Garkavi-Kvakina-Ukolova

method [6, 8]. At the same time, the relative number of lymphocytes is used as a signal indicator for each AR type [6, 8, 9]. The other parameters of the blood count make it possible to estimate the AR intensity, associated with the level of reactivity in the organism, where the current AR has been developing. The hematological analysis data are processed with expert software "Antistress", which allows assessing the AR quantitative characteristics and representing them as scoring [6, 10]. The above software provides tracing of changes in the scores of the AR type and intensity in a wide range, from tens to several thousand points. At the same time, four ranges of the levels in the organism's reactivity are separated, at which the "high", "medium", "low" and "very low" ARs can develop. The minimum scores (up to 50) correspond to the stress AR at the "very low" levels of reactivity, and the maximum score (6400) relates to the elevated activation AR at the "high" levels of reactivity, which contributes to the most pronounced and balanced activation of the regulatory systems and an increase in the organism non-specific resistance [10]. Blood sampling for leukogram and identifying the AR type and its intensity, as well as the AR scoring have been performed 4-5 times for each patient in the above cohorts of the patients in the lung cancer treatment in hospital. When studying the mental status of patients, the level of personal (PA) and situational anxiety (SA) have been assessed by the Spielberger-Khanin test (the State Trait Anxiety Inventory); a differential diagnosis of depressive states and conditions close to depression has been performed according to the Zung Self-Rating Depression Scale, adapted by T.I. Balashova, and the type of an attitude towards the disease has also been identified. To determine the types of attitudes toward the disease, the PQBI (Personal Questionnaire by the Bekhterev Institute) method has been used. The noted examinations have been performed in patients with their admission to hospital. SA has also been evaluated by the end of treatment, before discharging from the hospital. Hormonal studies have been performed only in patients with resectable malignant tumors in groups 2 and 3. The levels of thyroid hormones, ACTH and cortisol in the blood serum have been determined by the electrochemiluminescent method with the use of the Cobas e 411 analyzer. The tests have been completed before the surgery, as well as on postsurgery days 1 and 10. Issue 13. November 2018 | Cardiometry | 87

Table 1. Characteristics of adaptation reactions (AR) and types of reaction to the disease in patients with lung cancer with varying prevalence of the tumor process Group of patients Indicator

1. Unresectable tumors (n=10)

2. Resectable tumors metastases are detected (n=7)

3. Resectable tumors metastases are not detected (n=11)

Stress and anti-stress AR LLR, VLLR (100%)

Stress and anti-stress AR LLR, VLLR (76%). anti-stress AR MLR and HLR (24%).

NS AR, scores

738 ± 119 N=43

487 ± 126 N=30

1305 ± 113 N=47 • ••

Type of reaction to disease

Euphoric (4) 40% Harmonic (2) 20% Anxious (2) 20%

Euphoric (2) 28% Hypochondriacal (2) 28%

Euphoric (5) 45% Harmonic (3) 28%

Legend: n - number of patients in the group, N - number of determinations of the AR indicators in patients of the corresponding group during hospital treatment; anti-stress AR – anti-stressor adaptation reaction; LLR, VLLR – low and very low levels of reactivity, MLR – medium level of reactivity, HLR – high level of reactivity, NS AR – numerical score of AR. Notes: • differs from the values in patients of group 1, p <0.01-0.05; •• differs from the values in patients of group 2, p <0.010.05

The Student's t-test and the Wilcoxon-Mann-Whitney test supported by the Statistica 8 software have been employed for statistical processing of the study results.

Results and discussions

Values of the general condition assessment according to the Karnovsky scale in patients at their admission have been found in the range of 80-90%. The tumor process, as well as traumatic and toxic effects of antitumor treatment (surgical, medicinal, DHT) caused negative alterations in the patient's adaptation status. The development of the stress and tensioned-type anti-stress ARs has been observed in all the studied groups in the overwhelming majority of cases (see Table 1 herein). At the same time, detected is a relationship between the intensity of unfavorable changes in the AR characteristics and the tumor process prevalence. Thus, in the presence of unresectable tumors or resectable tumors with detectable metastases, the lowest scores of the above AR types are noted (refer to Table 1 herein). The adaptation status in the group 3 patients with resectable tumors without detected metastases is more favorable. It is manifested in an increase in the anti-stress ARs percentage in general and the occurrence of the anti-stress AR of training, calm activation and elevated activation at the medium and even at the high levels of reactivity (up to 24%). Such changes are reflected in the AR scores. This quantitative indicator of the adaptation status in the patients of group 3 is 1.8 and 2.7 times higher than 88 | Cardiometry | Issue 13. November 2018

that recorded in the patients of groups 1 and 2, respectively (see Table 1 herein). The volumes of surgical interventions in the group 2 and group 3 patients show no significant differences. Pneumonectomy is performed in cases 3 and 4, lobectomy in cases 1 and 3, atypical resections in cases 3 and 4, respectively, in groups 2 and 3. With a similar volume of surgical intervention, the quantitative indicator of the adaptation status varies in patients of different groups. Thus, in case of atypical resection of lungs in the presence of metastases, the score of AR in the postsurgery period is significantly lower than that in group 3: the scores are reported to be 95 ± 18 and 1305 ± 278 (p <0.01), respectively. In case of pneumonectomy, a similar difference between the groups in the value of the considered indicator is expressed at the level of a tendency (p <0.1): the scores are 202 ± 41 and 526 ± 148 referred to groups 2 and 3, respectively. These results allow stating that the differences in the quantitative characteristics of the adaptation status in group 2 and 3 patients do not depend on the volume of surgical intervention, but they are associated with the presence of metastases. It is common knowledge that oncological diseases are often featured by anxiety-phobic reactions and depressive states and can be accompanied by serious mental complications [1, 11]. In the present study, neither alterations, requiring professional psychiatric care, nor pronounced depressive conditions have been recorded in the overwhelming majority of the examined patients. The PA level has varied in the range of

34–62. In the studied groups observed are a greater number (just 1-2 persons more) of the patients with high PA than with the moderate one. As to this indicator, the groups have shown no variances in statistics. The level of PA is 43.8 ± 1.9, 48.3 ± 2.7 and 45.3 ± 2.1, recorded in groups 1, 2 and 3, respectively. The level of the situational anxiety has varied in the range of 34-70 and in most cases has corresponded to the level of personal anxiety. A moderate level of SA in highly anxious patients has been observed in single cases, and a high level of this indicator in patients with moderate PA has been noted more often, namely in 2-3 patients in each group. A comparison study of PA and SA within the group and a comparison analysis of SA in patients from different groups have not revealed significant variances in the analyzed indicators. Depression was recorded only in one patient, that is, in the studied groups it has been practically not observed. This result is consistent with the data obtained by other researchers using another method, namely the "Hospital Anxiety and Depression Scale", which has indicated the absence of depression in the patients with malignant lung tumors, in contrast to those patients with many other localizations of the tumor process [11]. In our opinion, the question of the possible reasons for the absence of depression under such a serious pathology as lung cancer is of separate interest and requires special discussion and a further in-depth study. At the same time, it is possible to assume that there is a certain connection between the depressiveness of oncothoracal patients with their psychic reaction to the disease and some peculiarities in their hormonal status, revealed in the course of this study. Thus, according to the results obtained with PQBI, the euphoric type of the reaction is presented in all the studied groups of patients (39% of the cases), and in groups 1 and 3 this type of reaction is dominant (40% and 45% of the cases, respectively) (see Table 1 herein). The harmonic type thereof is a second most frequently found in the given groups. The patients with unresectable lung cancer show the anxious type of the response. In group 2, in the after-surgery patients with detected metastases, in addition to the euphoric reaction, a hypochondriacal type of response to the disease is observed, which is contrasted in its nature therewith. It is just in that group recorded has been the only case of depression with the hypochondriacal type of the response to the disease. In addition to the listed reactions to the disease, some other types of the

response, namely the anosognosic, sensitive, obsessive-phobic and neurasthenic types, have been noted in some patients of the examined groups. In the patients with the euphoric and harmonic types of the response, a moderate and a high level of PA have been observed practically in the same number of the cases. In the patients with unresectable lung cancer (group 1) and postsurgery patients with detected metastasis process (group 2), the AR scores for the euphoric type of the response are quite variable and show no differences under other types of the response to the disease. In the patients of groups 1 and 3, who have demonstrated the harmonic type of response, no significant features of the AR scoring have been detected. In accordance with the generally accepted assessment, among all the main types of the response to the disease recorded in the examined patients, only the harmonic type may indicate a rational attitude towards the disease and suggest an adequate mobilization of the relevant mental and physiological protection mechanisms. The mechanism of the psychological protection in case of the euphoric type of the response, which turned out to be the most frequent in the examined patients, is associated with a non-rational attitude to the disease, ignoring the disease and seeking to "displace" the problem, hoping that "everything will somehow manage by itself ”. The typical signs of this sort of reactions include an unreasonably highly excited mood and a dismissive, careless attitude to the disease and treatment [12]. Meanwhile, in the group 3 patients, with resectable lung cancer without detected metastases, the development of the most favorable AR and the highest (including the maximum) AR scores has been found as typical just in the patients demonstrating the euphoric type of response (see Table 2 herein). This difference is especially pronounced before the surgery, when the AR scores in five patients with the euphoric type of the response are recorded to be 2.2 times higher than those in patients of the same group with other types of the response, including patients with the harmonic type of the reaction (see Figure 1 herein, p <0.05). In these five patients the postsurgery period has exhibited a favorable course. At the end of the treatment, the AR scores in the examined patients have also exceeded those found in patients of the same group with the other types of the response to the disease (see Figure 1 herein, p <0.05). Issue 13. November 2018 | Cardiometry | 89

Table 2. Characteristics of adaptation reactions (AR) in patients with resectable lung tumors without detected metastases (group 3) with the euphoric type of response to the disease Type of reaction to disease Indicator

Euphoric type of response (n=5)

Harmonic and other types of response (n=6)

Anti-stress AR LLR, VLLR (69%) AR MLR and HLR (31%)

Stress and anti-stress AR LLR, VLLR (82%) AR MLR and HLR (18%)

NS AR

1877Âą352 N=22 *

923Âą214 N=25

Legend: see Table 1 given above herein. Notes: *differs from values in patients with the harmonic and other types of response to disease, p <0.05

The revealed differences bear witness to a pronounced activation of the physiological protection mechanisms in the patients with resectable lung cancer without detected metastases, who demonstrate the euphoric type of the response. In our opinion, this combination of the physiological and mental status indicators can reflect the existence of a protective psychosomatic mechanism that is capable of inhibiting the spread of the tumor process in the lungs. It allows us to make an assumption that we deal with the psycho-physiological heterogeneity of the euphoric reaction to the disease and with the qualitatively different variants thereof, and that it is evidence for the need to further refine and extend the concept of the euphoric type of the mental reaction. As it has been noted, our comprehensive study of the conditions in the lung cancer patients has included an assessment of the hormonal parameters in the groups 2 and 3 patients before surgery as well as after it, on postsurgery days 1 and 10. The results of the hormonal analysis have indicated a reduced initial concentration of ACTH (1.7 times lower than the minimum values within the norm zone, p <0.01), a further decrease in its level on postsurgery day 1 (1.5 times, p <0.05) and a weak tendency to an increase of this indicator to the initial values by postsurgery day 10 (see Figure 2A herein). At the same time, the level of cortisol before surgery has been significantly higher than the normal values (almost 1.5 times higher than the upper limit of the norm zone, p <0.05); it has decreased to the upper limits of the norm range on postsurgery day 1, and on postsurgery day 10 we have again observed an increase of the parameter reaching the initial values (see Figure 2B herein). Thus, the ACTH and cortisol levels show a similar dynamics. Besides, the picture, in general, has reflected an excessive tension of the pi90 | Cardiometry | Issue 13. November 2018

tuitary-adrenal system and the functional depletion of its core member. The results of studying the thyroid hormones level are of particular interest. The concentration of triiodothyronine (T3) in blood in the examined patients has remained within the normal range, while the average level of thyroxine (T4) has demonstrated an increase at all stages of the study by 15-30% as compared with the maximum values within the norm range (p <0.05, see Figure 2C herein). Probably, in some patients with lung cancer, an increase in the T4 level in blood might be associated with retarding the processes of its deiodination due to the inhibitory effect of high doses of endogenous cortisol on the activity of deiodinases in peripheral tissues [13]. At the same time, in the majority of the patients, no pronounced cardiac disorders, typical for thyrotoxicosis, have been observed during the treatment. It should be noted that nowadays the data on the effects of thyroid hormones on the development of cardiovascular diseases are contradictory and inconsistent. Along with numerous research works, which consider thyroid hormones as risk factors [14-16], there is also evidence available for the positive effects produced by the thyroxine medication on the condition of the cardiovascular system with a myocardial infarction risk reduction [16-18]. As we may think, the concentration of endogenous T4 in most patients with lung cancer corresponds to a range that is safe with respect to development of cardiac disorders. It is a matter of general experience that thyroid hormones make positive effects on the mental processes. Thus, thyroid hormones can have a pronounced therapeutic effect under affective disorders and in decreasing cognitive functions, which are now associated with their effect on the noradrenergic and serotonergic systems of the central nervous system [19].

Figure 1. Scores of the AR structure in the group 3 patients with resectable lung cancer without detected metastases in case of euphoric and other types of mental response to disease before surgery (I) and at the end of hospital treatment (II)

According to current conceptions, thyroid-stimulating hormones and neurotransmitters of the central nervous system build a single neurohumoral system involved in providing the brain integrative functions. Moreover, the differential sensitivity of various tissues to T3 and T4 has been demonstrated [20]. The existence of some specific core effects of T4, in particular, is evidenced by the data on a partial replacement of T3 by T4 that improves mood and neuropsychological functions in patients with hypothyroidism [21]. Thus, it may be assumed that the depressiveness and dominance of the euphoric reaction in patients with lung cancer, to a certain extent, may be attributed to the central effects produced by T4. Besides, the fact of the increased concentration of this hormone in oncothoracal patients fits the data on the effectiveness of supraphysiological doses of T4 in the treatment of bipolar mood disorders [22]. In our opinion, an indirect evidence for the T4 involvement in the processes associated with the formation of psychoemotional states in the patients under studies is the variance reported for the considered indicator values in patients with differing psychophysiological characteristics (see Figure 3 herein). Thus, in three patients of group 2 with the hypochondriac type of the response (among which the only case of true depression has been noted), the lowest level of T4, not exceeding the upper limit of the normal values range, has been observed. Somewhat higher indicator values (by 15%, p <0.05) are demonstrated in the group 3 patients with the euphoric type of the response, who

have demonstrated the maximum AR score among all the studied patients. In the remaining patients with resectable tumors, the T4 level was the highest, 29 and 49% higher than that identified in the patients with the euphoric and hypochondriacal reactions to disease, respectively (see Figure 3, p <0.01). The correlation between the T4 level in blood of in the lung cancer patients and their reactions to disease might reflect a nonlinear character of intersystem connections. In patients with clearly opposite reactions, i.e. the euphoric and hypochondriac ones, the difference in T4 is significantly less than in patients in each of these categories and in other patients with resectable tumors. Perhaps, even minor changes in the T4 concentration in the range close to the upper limit of the norm may have a significant effect on the psychosomatic state in the lung cancer patients. Thus, patients with resectable lung tumors without detected metastases, who demonstrated the positive dynamics of the state and the highest AR scores, have been classified according to their specific features as follows: the euphoric type of the response to the disease and the thyroxine level, slightly exceeding the upper limit of the normal range. Due to the similarity of the psychopathophysiological mechanisms of the development of tumor and cardiac pathologies and the urgency of the issue on the use of thyroid hormones in the cardiovascular therapy, it is of interest to compare the obtained results with the data on the psychosomatic status in patients suffering from cardiovascular diseases. As known, cardiac disorders are most closely related to mental processes [23-25]. Evidenced are a pronounced anxiety and depression in patients with cardiovascular diseases, which are often aggravated and transformed into various psychosomatic disorders: depressive, anxious, hypochondriac abnormalities etc. [26, 27]. A clear relation between the negative psychoemotional reactions and subsequent development of acute states and lethality has been established [25, 28]. At the same time, some issues on changes in the neuroendocrine system, contributing or hindering the development of cardiac disorders still remain to be urgently solved. At present, accumulated has been much evidence for the effects produced by thyroid hormones and subclinical thyroid states on the occurrence and the course of the cardiovascular system diseases. It is known that even a slight change in the level of thyroid hormones in blood can unfavorably affect the Issue 13. November 2018 | Cardiometry | 91

Figure 3. The concentration of thyroxine (T4) in blood of patients with resectable lung cancer, who demonstrated some psychophysiological characteristics. The "Euphoria, gr. 3" are patients without detected metastases with the euphoric reaction to disease. The “Hypochondr., gr. 2" are patients with metastases, with the hypochondriac type of reaction noted. “The rest" are all after-surgery patients, except for the patients listed above. Notes: * differs from the values in "The rest” patients, p<0,05; ** differs from the values in the "Euphoria, gr. 3” patients, p<0.05

Figure 2. Dynamics of levels of hormones in pituitary-adrenal and thyroid axes in postsurgery lung cancer patients in hospital treatment: at the beginning of treatment, on postsurgery days 1 and 10

cardiovascular system performance due to altering the condition of the vascular endothelium and myocardium, shifts in arterial pressure, dyslipidemia, development of coronary atherosclerosis, etc. [16, 18, 92 | Cardiometry | Issue 13. November 2018

29] The relation between the cardiac disorders and the development of both subclinical thyrotoxicosis and hypothyroidism is established [14, 15]. In this case, the subclinical thyrotoxicosis is featured by a decrease in the level of thyrotrophic hormone in the absence of a departure from the norm by the thyroid hormone concentration, while the subclinical hypothyroidism is characterized by an elevated level of the thyrotrophic hormone under the normal concentrations of T4 and T3 [29]. The correlation between the thyrotropic hormone level and the thyroid hormone concentrations in these subclinical states bear witness to disrupted control & regulation relations in the thyroid system and shifts in the sensitivity by organs and tissues to the effects made by T3 and T4. Thus, in case of the subclinical hypothyroidism, despite the fact that the T4 level is within the normal limits, actually, observed is a deficit of this hormone. The thyroid hormone deficit detected already at the subclinical stage may lead to development of hypercholesterolemia, diastolic arterial hypertension, hypercoagulation and other negative processes in the cardiovascular system, up to and including acute states and lethality [29, 30]. This is the reason for using the T4 medication (in particular, levothyroxine) in the therapy of cardiovascular diseases. It has been known that the brain is very sensitive to a lack of thyroid hormones. At the level of the men-

tal processes, it often reveals itself in an increase in the level of anxiety and the development of depression [29, 31]. So, in patients suffering from cardiovascular diseases, both the cardiovascular and psychoemotional disorders may be associated to a considerable extent with a deficit of thyroid hormones. Moreover, whereas the use of levothyroxine under manifest hypothyroidism is not in doubt, the reasonability of using the T4 drugs under subclinical hypothyroidism remains still a subject of debate [17, 18, 29]. It springs from inconsistencies between the outcomes of clinical trials and the unresolved issue on how to properly define the upper limit of the normal value range of the thyrotropic hormone level. Thus, a comparison of the obtained results with the information available in the current literature allows us to conclude that the psychosomatic state of the patients with resectable lung cancer without detected metastases, characterized by the euphoric reaction to disease, a relatively high adaptation status and a slightly elevated level of thyroxine, has been found to be essentially more favorable than the state typical for the patients with cardiovascular diseases. The psychosomatic profile of the latter is close to the state of the cancer patients with metastases, who have demonstrated the hypochondriac type of the response to the disease and low AR scores and whose T4 level has not exceeded the upper limit of the norm. At the same time, the patients with the euphoric reaction and a relatively high adaptation status have shown the T4 level difference from the â&#x20AC;&#x153;hypochondriacs" by 15% only that is significantly less than that found in the other examined patients. When extrapolating the obtained results to psychophysiological processes in cardiac pathology, we may assume that we are dealing with a non-linear character of the effect produced either by a deficit or an excess of thyroid hormones on the state of the patients suffering from cardiovascular diseases; we may also anticipate that the next close range above the upper limit of the T4 level normal values should be treated as critical. In this regard, the issue on adequate dosing of the T4 medication under subclinical hypotension acquires great importance. In our opinion, in order to optimize the therapy of cardiovascular disorders with the use of thyroid hormone medication, it is reasonable to apply the activation therapy methods, which include dosing of biologically active substances, taking into account an individual sensitivity of an

organism, and which are aimed at increasing the patient's adaptation status [6, 32, 33].

Conclusions

1. We have shown that there is a certain relationship between the AR characteristics and the tumor process prevalence in patients with lung cancer available. 2. The absence of cases of true depression in the overwhelming majority of patients and the occurrence of the euphoric reaction to the disease, an increased in most cases level of thyroxin and a difference therein in patients, who have demonstrated variance in their reactions to the disease, allows us to assume that thyroxine is involved in the formation of positive psychoemotional states in patients with lung cancer. 3. The combination of the euphoric type of the response to the disease with the highest adaptation status in patients with resectable lung cancer without detected metastases may bear witness to the fact that there is a psychophysiological mechanism, capable of inhibiting the development of the tumor process; in this connection, it should be noted that it is required to refine and finalize the concept of the euphoric type of the response. 4. The revealed features of the psychosomatic status in the patients under studies can supplement the characteristics of the lung cancer patient state and serve as the basis for the development of additional therapeutic actions, effects and exposures. 5. The obtained results indirectly count in favor of the cardiovascular diseases therapy approaches, which involve the use of the thyroxin medication. In this case, the issue of adequate dosing in the hormonal therapy is of great importance, and it is reasonable to apply the activation therapy algorithms and methods in order to provide adequacy and effectiveness in dosing of the above medication.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript. Issue 13. November 2018 | Cardiometry | 93

References

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Issue 13. November 2018 | Cardiometry | 95

SHORT REPORT

Submitted: 29.6.2018; Accepted: 13.8.2018; Published online: 21.11.2018

A brief analysis of the use of non-linear time-frequency filtering for processing ECG signals Yeldos A. Altay1*, Artem S. Kremlev1 1

The Federal State Autonomous Higher Education Institution, The St.-Petersburg National IT, Mechanics and Optics Research University Russia, 197198, Saint-Petersburg, Kronverkskiy av. 49

Corresponding author: phone: +7 (952) 278-52-53, e-mail: aeldos@inbox.ru

Abstract Some current trends of the use of non-linear time-frequency filtering approach to ECG signal processing are discussed herein. A brief review of an application potentiality of non-linear filtration is offered for long-term ECG signal processing. Possible problems of long-term monitoring, related to measurements interference and noise of ECG signal, are revealed. To eliminate the revealed problems, in further research, an implementation of a processing system using the non-linear-threshold time-frequency filtering method is planned. It is expected to improve an accuracy of cardiac data processing considering features of interference and measurement noise of different intensity.

Keywords ECG signal, Physiological noise, Time-frequency filtering, ThresÂ hold filtering, Empirical modes

Imprint Yeldos A. Altay, Artem S. Kremlev. A brief analysis of the use of non-linear time-frequency filtering for processing ECG signals. Cardiometry; Issue 13; November 2018; p.96-98; DOI: 10.12710/ cardiometry.2018.13.9698; Available from: http://www.cardiometry. net/issues/no13-november-2018/processing-ecg-signals

Introduction

The analysis of long-term processing of electrocardiography signals (ECG) at the present time is an actual task in the area of modern technologies of data processing. A long-term study of ECG signal in practice is carried out on the basis of portable devices, which allow recording a diagnostic signal under physical activity of an individual [1-4]. A long-term recording of the ECG signals under the above condi96 | Cardiometry | Issue 13. November 2018

tions makes it possible to study and identify clinically relevant biomarkers of cardiovascular abnormalities, which cannot be detected during a short-term recording of the ECG signals at rest [1,3]. An ECG signal is a non-stationary multi-component, complexly structured, signal, which is individual for each biological object [6]. In practice, on the basis of the analysis of some multi-component (local) areas, the functional state of the cardiovascular system is assessed. The non-stationary of an ECG signal is determined with the variability of the local areas of the P, Q, R, S, T waves, that is attributed to the biological origin of the detectable signal [6]. Moreover, the local areas of the P, Q, R, S, T waves and their combinations, according to their diagnostic significance, are usually called the QRS complexes, the PQ, ST, TP segments and the RR, PQ, QT, ST intervals [6] (see Figure 1 herein).

Features of ECG signal interference and ECG signal filtering

It is known that the procedure for ECG signal longterm recording is characterized by the presence of additive interference and noise of physiological and electrical nature, which may differ in their intensity, spectral characteristic and distribution [1-3]. The problems associated with intense interference of the ECG signals are very diverse [2.5]; their presence significantly reduces accuracy of the detection of amplitude and time parameters of the ECG bio-signal morphology [2.6] and produces an imitation of false heart arrhythmias (abnormalities) [7]. Increasing accuracy and effectiveness in the detection of the morphology ECG signals primarily depends on the decision on what filtration method should be used [2]. To date, for the long-term ECG signal recording, mainly employed are filtering algorithms by Wiener, Chebyshev and Butterworth, which are capable to exclude minor interference and noises and which were imported from the conventional short-term recording technologies, however, these conventional approaches [5,8] have some disadvantages as discussed below. Such approaches to the longterm processing analysis lead to the rejection of the diagnostic areas due to interference and distortions of the amplitude-time parameters of the ECG signals. In general, the percentage of the rejection of inacceptable long-term ECG recordings due to interference has increased from 3.7% to 12.7% [7]. Thus, to reduce the

Figure 1. ECG signal components

rejection percentage rejection of the recorded cardiac cycles, it is a challenging issue to design and develop some fresh interference filtering algorithms, having considerable promise, which allowing increasing the accuracy of the detection of the morphologies under the lowest distortion of the ECG signals. Our analysis revealing the specific feature of the interference enables one to improve the decision-making on the selection of the best method of filtering interference in ECG signal processing. During the long-term recording of ECG signals, following types of interference can be identified: power line interference, muscle noise, movement artifacts and baseline wander. All these types of the interference (except for the power line interference) have an a priori unknown wide frequency spectrum overlapping with the frequency spectrum of the ECG signal. Especially susceptible to overlapping is the spectral characteristics of the ECG signal during long-term recording. Intensity of the overlapping varies depending on physical activity. Intensity of the physiological interference during the recording changes depending on physical load, age of a person, movements of the recording electrodes and movements of a biological object. In addition, the spectral density shows a non-Gaussian distribution in the frequency range of this interference type [2]. The use of linear filters under overlapping frequency spectra does not allow filtering out the ECG signal without distortion. A non-linear filter makes possible to process the signals under the conditions of overlapping of the frequency spectra of the interference with a signal [9]. One of the promising approaches to the processing of ESG signals is an application of non-linear threshold filters based on the time-frequency representation of the signal [2.10]. The peculiarity of this method consists in a decomposition of a signal to em-

pirical modes (frequency components), the filtration of individual components (interference, noise) and the subsequent reconstruction of the analyzed signal in the time-frequency domain. In doing so, it is assumed that when using such methods for long-term processing, gain in the accuracy in detecting the morphology of the ECG signals under minimized distortion of the amplitude and time parameters is obtained. Empirical modes are multi-component constituents of a signal, which are amplitude- and frequency-modulated, varying with time [11]. For the long-term processing of the ECG signals, in some papers first proposed has been an application of a non-linear threshold filter by Nonnegative-Garrote type, based on the time-frequency representation of the signal [1,2,10]. This method is designed for sequential extraction of diagnostic information from the TP segment of the ECG signals. But at the same time, it is known that because of the physiological and clinical specific features during the long-term recording, the reference points of the TP segment on the ECG signal morphology are not always detectable. In some situations this segment is generally missing at all, for example, under the ventricular extra systole and other arrhythmias [4]. In such cases, the application of this approach for the purpose of the long-term monitoring of the cardiovascular conditions leads to difficulties in identifying the ECG signal morphology due to the missing TP segment. In order to overcome this drawback, based on the Nonnegative-Garrote approach, we have selected the most promising types of adaptive threshold filters, which are based on Hard Threshold (1), Soft Threshold (2), and Non-linear Exponential Sigmoid Function (3) [12,13]. The formulas (1), (2), (3) show the equations of d j (k ), if d j (k ) > T    d j (k ) =   0, if d j (k ) ≤ T 

(1)

sign (d j (k )) × ( d j (k ) − T), if d j (k ) > T    d j (k ) =   (2) 0, if d j (k ) ≤ T      2  (d − T ) −   , − T d T 1 ≥ d j ,k −T j, k ( )   j, k   T 1 + e k    ^   d j, k = 0, d j, k < T  (3)       2    ( d j, k + T ) −  − 1 T , d T ≤ − d j ,k + T j, k ( )     k T 1 + e    Issue 13. November 2018 | Cardiometry | 97

the selected non-linear threshold filters, namely, a hard threshold filter, a soft threshold filter (2) and a threshold filter based on the exponential sigmoid function (3). where dj,k are the processed threshold level coefficients j, T – a threshold, which determines the level of interference. As to the above listed types of the threshold filters, at present they are widely used in wavelet filtration of the ECG signal. A peculiarity of the combination of the selected types of the threshold filters according to the method of empirical modes allows processing of the ECG signals on adaptive a posteriori basis, that is always justified for the purpose of the processing and the analysis of diagnostic signals and that requires less computing resources. In this case, there is no need to use a priori information of the maternal wavelet functions.

Conclusion

Thus, based on the topical issues on the ECG signal processing, in the future it is planned to implement the method of the non-linear time-frequency filtering to improve the accuracy of the signal morphology detection during the cardiac data processing and thereby improve the accuracy of diagnosing diseases of the cardiovascular system in the time-frequency plane.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Bodin ON, Krivonogov LJu, Lomtev EA. Anti-interference electrocardiosignals processing in a non-invasive cardiac diagnostics. Almaty: LEM.; 2016. [in Russian]

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2. Krivonogov LJu, Altay EA, Bodin ON. Noise-resistance processing electrocardiosignals in a free activity. Vestnik aritmologii. 2016;228. [in Russian] 3. Hodkinson EC, Neijts M, Sadrieh A, et al. Heritability of ECG Biomarkers in the Netherlands Twin Registry Measured from Holter ECGs. Frontiers in Physiology. 2016(7):1-9. doi:10.3389/fphys.2016.00154. 4. Baranovskij AL, Nemirko AP, Kalinichenko AN. Kardiomonitory. Apparatura nepreryvnogo kontrolja JeKG. Moscow: Radio i svjaz'; 1993. [in Russian] 5. Rangajjan RM. Analysis of biomedical signals. Moscow: Fizmatlit.; 2010. [in Russian] 6. Nemirko AP, Manilo LA, Kalinichenko AN. Mathematical analysis of biomedical signals and data. Moscow: Fizmatlit.; 2017. [in Russian] 7. Makarov LM, Komolyatova VN, Pervova EV, et al. National Russian guidelines on application of the methods of Holter monitoring in clinical practice. Russian Journal of Cardiology. 2014 (2):6-71. 8. Ustimenko VO, Klochko EA, Bidun AV. Improving the quality of electrocardiac signal filtration using the Wiener and Chebyshev filter. Radiojelektronika i radiojelektronnoe apparatostroenie. 2017(2):1-8. [in Russian] 9. Sorokin SV, Shherbakov MA. Comparative analysis of the nonlinear filtering techniques of signals and images. “Nadezhnost' i kachestvo” International symposium; Penza State University, Penza, Russia; 2006. [in Russian] 10. Bodin ON, Krivonogov LJu, Tychkov AJu. Method of adaptive suppression of noise in electrocardiosignal. Patent RF No.2486862. Bjul. 2013. No.19. [in Russian] 11. Han G, Lin B, Xu Z. Electrocardiogram signal denoising based on empirical mode decomposition technique: an overview. Journal of Instrumentation. 2017(3):1-19. doi: 10.1088/1748-0221/12/03/P03010. 12. Han G, Xu Z. Electrocardiogram signal denoising based on a new improved wavelet thresholding. Review of Sci. Instr. 2016(8):1-7. doi: 10.1063/1.4960411. 13. Oussama EB, Rachid L, Khalifa E, Abdenbi A, Wissam J. ECG signal performance de-noising assessment based on threshold tuning of dual-tree wavelet transform. Biomedical engineering online. 2017(1):118. doi: 10.1186/s12938-017-0315-1.

SHORT REPORT

Submitted: 2.11.2018; Accepted: 16.11.2018; Published online: 21.11.2018

Metabolic processes evaluation in cardiac muscles on the basis of cardiometry Vladimir A. Zernov , Konstantin K. Mamberger , 1

Dmitry F. Makedonsky1, Sergey M. Rudenko1* 1

Russian New University Russia, 105005, Moscow, Radio str., 22

Corresponding author: phone: +7 (908) 194-29-99, e-mail: rudenko@cardiometry.net

Abstract The article briefly discusses the cardiometric approach to the evaluation of metabolic processes in cardiac muscle. Reactions occurring during the various phases of the cardiac cycle, primarily in the QRS complex, are shown. The dynamics of energy processes occurring before and after physical load, as well as the reactions occurring during it, are presented. The ECG derivative is used.

Keywords Metabolic process, ECG, Cardiac cycle phase, Cardiac muscle, Derivative, Physical load

Imprint Vladimir A. Zernov, Konstantin K. Mamberger, Dmitry F. Makedonsky, Sergey M. Rudenko. Metabolic processes evaluation in cardiac muscles on the basis of cardiometry. Cardiometry; Issue 13; November 2018; p.99-100; DOI: 10.12710/cardiometry.2018.13.99100; Available from: http://www.cardiometry.net/issues/no13-november-2018/ metabolic-processes

Introduction

The processes of the dynamic contraction and static muscle tension are provided by the biochemical reactions. Thus, the main QRS complex, in which the transition from the muscles relaxation to the static tension occurs, is provided with oxygen stocked during the diastole. At the same time, the initial process of muscle contraction is carried out with the maximum initial stock of ATP in the mitochondria. The low oxygen content is reflected in the rate of heart muscles contraction [1-9]. What can be controlled by the first derivative of ECG? The amplitude of the first

derivative will indicate the power of contraction. The smaller is the amplitude, the less is the power.

Materials and methods

Considering the heart anatomy and the fact that the QRS complex is formed by the interventricular septum and myocardium contraction amplitudes, first the interventricular septum contracts, as it is exposed to a lesser resistance since the myocardium muscles are not pre-loaded yet. When the myocardium muscles are contracted, they are exposed to a greater load than the interventricular septum, as the interventricular septum remains static. It allows evaluating the difference in energy consumption for each group of muscles. It is enough to compare the amplitude of the first derivative, characterizing the muscle contraction rate during the Q – R and R - S periods.The general formula will be of a simple form as follows: W = R'/ S' (relative units) where: W – conventional energy of the process; R' – the amplitude of the ECG first derivative characterizing the interventricular septum contraction rate; S '-the amplitude of the ECG first derivative characterizing the myocardium contraction rate.

Results

The practice shows that the method has a high sensitivity. The data before and after training are very informative and indicate trends of heart energy resource dynamics. Considering that the QRS complex is a basic part of the cardiac cycle and the muscles are evaluated from the time of complete relaxation to the time of creation of the initial conditions for other energy processes, the studies have shown that the W rate evaluates the energy level corresponding to the aerobic processes in the body. Therefore, can be used for the aerobic processes evaluation. After an intensive load, the W rate for aerobic processes will decrease. The studies have shown that the W rate is linked to acid –alkaline balance. However, if W is greater than 1, it is close to the lower limit of blood glucose level. The processes in the S - L phase occur in the same way as it is the case with the QRS complex. The essential difference is that they occur against the background of the interventricular septum and myocardium muscles tension. A combination of dynamic and static muscle performance is observed herein. This phase is very Issue 13. November 2018 | Cardiometry | 99

important in hemodynamics of circulation. Its performance forms the blood flow structure that allows providing blood flow with minimal friction. Then the L - j rapid ejection phase begins. At the beginning of this phase the aortic valve opens, and blood starts flowing into the aorta. The studies have shown that this phase can be manifested on ECG several times only in case of great physical load.The multiple phase manifestation occurs only in case of necessity to intensify the phosphocreatine reactions due to high physical loads [10,11] It should be noted that all above reactions are closely interconnected. Their common basis is the balance of oxygen and carbon dioxide in the body. Their transport systems: L â&#x20AC;&#x201C; carnitine, serotonin and tryptophan are also important.

Discussion and conclusions

The method allows efficiently and easily monitoring the metabolic processes in the heart muscle. Further research is aimed at building a scale of correlation between the relative units used in the method and the conventional generally accepted units mmol/liter.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest None declared.

Author contributions

All the authors read the ICMJE criteria for authorship and approved the final manuscript.

References

1. Chapleau MW. Baroreceptor Reflexes (book chapter). Primer on the Autonomic Nervous System2012: 161165. doi: 10.1016/B978-0-12-386525-0.00033-0.

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2. Garkavi L. Activation therapy. ISBN 5-7507-01794. Rostov-on-Don: Rostov State University; 2006. [in Russian] 3. Kenny D, Polson JW, Martin RP, Caputo M, Wilson DG, Cockcroft JR, et al. Relationship of aortic pulse wave velocity and baroreceptor reflex sensitivity to blood pressure control in patients with repaired coarctation of the aorta. American Heart Journal. August 2011;162(2):398-404. 4. La Rovere MT, Maestri R, Pinna GD. Baroreflex sensitivity assessment - latest advances and strategies. Interventional Cardiology (London). 2012;7(2):89-92. 5. Morrisona SF, Barmana SM, Gebber GL. Baroreceptor influences on cardiac-related sympathetic nerve activity. Brain Research. 28 May 1984;301(1):175-8. 6. Sleight P. Reflex control of the heart. The American Journal of Cardiology. 22 October 1979;44(5):889-94. 7. Rudenko MY, Zernov VA, Voronova OK. Fundamental Research on the Mechanism of Cardiovascular System Hemodynamics Self-Regulation and Determination of the Norm-Pathology Boundary for the Basic Hemodynamic Parameters and Analysis of the Compensation Mechanism as a Method of Revealing the Underlying Causes of the Disease. Heart Rhythm. November 2012;9(11):1909. doi: 10.1016/j.jelectrocard.2013.09.016. 8. Rudenko MY, Zernov VA, Voronova OK. Study of Hemodynamic Parameters Using Phase Analysis of the Cardiac Cycle. Biomedical Engineering. July 2009;43(4):151-5. 9. Rudenko M, Zernov V, Voronova O, Rudenko S, Mamberger K, D. M. Periodic table ECG phase changes (electrocardiography basics). ISBN 978-5-86746116-5, MosŃ ow. 2013. 10. Dushanin SA. Advanced methods for investigation of energy metabolism in muscles performance. Kiev. 1984. [in Russian] 11. Dushanin S. System for multi-factor express diagnostics of sportsmen functional conditioning under current operative medical & pedagogic control. Kiev. 1986. [in Russian]

On November 10-12, 2018, the American Heart Association (AHA) annual conference was held in Chicago (Illinois, USA). The three-day conference was attended by several thousand doctors, developers of medical equipment, entrepreneurs and other experts in the field of cardiology from around the world. The representative of Russia, namely the researcher of the Russian New University Kamyshev K.V., also took an active part therein. A great variety of topics were considered by the participants. Among them are such fields as blood flow biophysics, ECG interpretation and hemodynamic parameters calculation, i.e. the areas where the Russian New University achieved the greatest success. The University innovations attracted widespread attention and received wide recognition. The conference provided all participants with a unique opportunity to show their developments and share ideas within the community, and it was organized and conducted in the most perfect manner. The Russian New University staff thanks colleagues from the American Heart Association (AHA) for the invitation and warm welcome: we are looking forward to further cooperation!

Konstantin V. Kamyshev Russian New University, 105005, Moscow, Russia +7 (908) 183-34-98, camyshevrus@gmail.com The Russian New University staff thanks colleagues from the American Heart Association (AHA) for the invitation and warm welcome and looks forward to further cooperation! https://professional.heart.org/professional/EducationMeetings/MeetingsLiveCME/ScientificSessions/ UCM_316900_Scientific-Sessions.jsp Issue 13. November 2018 | Cardiometry | 101

2019 European Society of Cardiology congresses

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