medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2022-16-21-8-18medsovet-7195Research ArticleЦЕРЕБРОВАСКУЛЯРНЫЕ ЗАБОЛЕВАНИЯCEREBROVASCULAR DISEASESКриптогенный инсульт. Часть 3: предсердная кардиопатия и скрытая фибрилляция предсердийCryptogenic stroke. Part 3: atrial cardiopathy and silent atrial fibrillationhttps://orcid.org/0000-0003-2670-4172ДеминД. А.DeminD. A.

Демин Дмитрий Алексеевич, врач-невролог

414011, Астрахань, ул. Покровская Роща, д. 4

Dmitry А. Demin, Neurologist 

4, Pokrovskaya Roshcha St., Аstrakhan, 414011

demin2404@mail.ruhttps://orcid.org/0000-0001-6061-8118КулешА. А.KuleshA. A.

Кулеш Алексей Александрович, д.м.н., профессор кафедры неврологии и медицинской генетики

614000, Пермь, ул. Петропавловская, д. 26

Aleksey А. Kulesh, Dr. Sci. (Med.), Professor of the Department of Neurology and Medical Genetics 

26, Petropavlovskaya St., Perm, 614990

aleksey.kulesh@gmail.comhttps://orcid.org/0000-0002-6484-286XЯнишевскийС. Н.YanishevskiyS. N.

Янишевский Станислав Николаевич, д.м.н., заведующий научно-исследовательской лабораторией неврологии и нейрореабилитации, профессор кафедры неврологии и психиатрии, главный научный сотрудник научно-исследовательской лаборатории технологий прогнозирования риска развития сердечно-сосудистых осложнений Научного центра мирового уровня «Центр персонализированной медицины»

197341, Санкт-Петербург, ул. Аккуратова, д. 2

Stanislav N. Yanishevskiy, Dr. Sci. (Med.), Head of the Research Laboratory of Neurology and Neurorehabilitation, Professor of the Department of Neurology and Psychiatry, Chief Researcher of the Research Laboratory of Technologies for Predicting the Risk of Cardiovascular Complications of the World-class Scientific Center “Center for Personalized Medicine” 

2, Akkuratov St., St Petersburg, 197341

stasya71@yandex.ruhttps://orcid.org/0000-0003-1848-216XКлимчукД. О.KlimchukD. O.

Климчук Денис Олегович, врач-кардиолог

414011, Астрахань, ул. Покровская Роща, д. 4

Denis О. Klimchuk, Сardiologist 

4, Pokrovskaya Roshcha St., Аstrakhan, 414011

cheguevaralives@rambler.ruhttps://orcid.org/0000-0001-5679-4100МехряковС. А.MekhryakovS. A.

Мехряков Сергей Александрович, врач ультразвуковой диагностики

614107, Пермь, ул. КИМ, д. 2

Sergey А. Mekhryakov, Ultrasound Diagnostics Doctor 

2, KIM St., Perm, 614107

heartolog@gmail.comhttps://orcid.org/0000-0002-8305-1115СыромятниковаЛ. И.SyromyatnikovaL. I.

Сыромятникова Людмила Илариевна, д.м.н., профессор кафедры пропедевтики внутренних болезней №1

614000, Пермь, ул. Петропавловская, д. 26

Lyudmila I. Syromyatnikova, Dr. Sci. (Med.), Professor of the Department of Propaedeutics of Internal Diseases No. 1 

26, Petropavlovskaya St., Perm, 614990

ilarievna@gmail.comhttps://orcid.org/0000-0002-3847-9366ВиноградовО. И.VinogradovO. I.

Виноградов Олег Иванович, д.м.н., профессор, заведующий кафедрой неврологии с курсом нейрохирургии Института усовершенствования врачей

105203, Москва, ул. Нижняя Первомайская, д. 70

Oleg I. Vinogradov, Dr. Sci. (Med.), Professor, Head of the Department of Neurology with the course of Neurosurgery of the Institute of Advanced Medical Training 

70, Nizhnyaya Pervomayskaya St., Moscow, 105203

olvinog1975@gmail.comhttps://orcid.org/0000-0001-5239-744XЧазовС. А.ChazovS. A.

Чазов Станислав Александрович, ординатор кафедры неврологии и медицинской генетики

614000, Пермь, ул. Петропавловская, д. 26

Stanislav А. Chazov, Resident of the Department of Neurology and Medical Genetics 

26, Petropavlovskaya St., Perm, 614990

schazov97@gmail.comФедеральный центр сердечно-сосудистой хирургииРоссияFederal Center for Cardiovascular SurgeryRussian FederationПермский государственный медицинский университет имени академика Е.А. ВагнераРоссияVagner Perm State Medical UniversityRussian FederationНациональный медицинский исследовательский центр имени В.А. АлмазоваРоссияAlmazov National Medical Research CenterRussian FederationГородская клиническая больница №4РоссияCity Clinical Hospital No. 4Russian FederationНациональный медико-хирургический центр имени Н.И. ПироговаРоссияNational Medical and Surgical Center named after N.I. PirogovRussian Federation202216112022021818Copyright © Демин Д.А., Кулеш А.А., Янишевский С.Н., Климчук Д.О., Мехряков С.А., Сыромятникова Л.И., Виноградов О.И., Чазов С.А., 20222022Демин Д.А., Кулеш А.А., Янишевский С.Н., Климчук Д.О., Мехряков С.А., Сыромятникова Л.И., Виноградов О.И., Чазов С.А.Demin D.A., Kulesh A.A., Yanishevskiy S.N., Klimchuk D.O., Mekhryakov S.A., Syromyatnikova L.I., Vinogradov O.I., Chazov S.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/7195

Предсердная кардиопатия (ПК) и скрытая фибрилляция предсердий (ФП) – потенциальные причины эмболического криптогенного инсульта (embolic stroke of undetermined source, ESUS), своевременная диагностика которых может существенно изменить направление вторичной профилактики и снизить риск повторной мозговой катастрофы. В статье обсуждаются клинические и радиологические маркеры кардиоэмболии, концепция предсердной кардиопатии, ее электрокардиографические, эхокардиографические и сывороточные маркеры, а также возможности медикаментозной профилактики повторного инсульта. Наиболее применимыми в ежедневной работе признаками ПК служат данные ЭКГ (конечная отрицательная часть зубца P в отведении V1 > 5000 μV х мс, наджелудочковые экстрасистолы и далекозашедшая межпредсердная блокада), 24-часового холтеровского мониторирования ЭКГ (≥ 480 наджелудочковых экстрасистол в сутки, пароксизмы наджелудочковой тахикардии ≥ 20 комплексов), трансторакальной (диаметр левого предсердия > 40 мм, индекс диаметра левого предсердия ≥ 3 см/м2, индекс объема левого предсердия > 34 мл/м2) и чреспищеводной эхокардиографии (феномен спонтанного эхоконтрастирования, скорость кровотока в ушке ЛП < 20 см/с), а также концентрация NT-proBNP > 250 пг/мл. Целесообразно индивидуальное, междисциплинарное решение вопроса о назначении антикоагулянта при сочетании: (1) наличия структурных и функциональных маркеров ПК, (2) кардиоэмболического паттерна инфаркта мозга или окклюзии интракраниальной артерии по данным визуализации и (3) высокого тромбоэмболического риска и вероятности выявления ФП по оценочным шкалам (CHA2DS2-VASc, AF-ESUS и C2HEST). Наибольшую пользу от назначения антикоагулянтной терапии могут получить пациенты с повторным ESUS на фоне адекватной вторичной профилактики с выраженной ПК, типичным кардиоэмболическим визуализационным паттерном и высоким риском тромбоэмболических событий.

Atrial cardiopathy (AC) and silent atrial fibrillation (AF) are potential causes of embolic cryptogenic stroke (embolic stroke of undetermined source, ESUS) timely diagnosis of which can significantly change the direction of secondary prevention and reduce the risk of repeated brain catastrophe. The article discusses clinical and radiological markers of cardioembolism, the concept of atrial cardiopathy, its electrocardiographic, echocardiographic and serum markers, as well as the possibility of drug prophylaxis of recurrent stroke. The most applicable AC features in daily operation are the ECG data (p-wave terminal force in lead V1 > 5000 μV x ms, supraventricular extrasystoles and advanced interatrial block), 24-hour ECG monitoring (≥ 480 supraventricular extrasystoles per 24-hour, paroxysms of supraventricular tachycardia ≥ 20 complexes), transthoracic (diameter of left atrium > 40 mm, index of diameter of left atrium ≥ 3 cm/m2, index of volume of left atrium > 34 ml/m2) and transesophageal echocardiography (spontaneous echo contrast phenomenon, blood flow rate in LA appendage <20 cm/s) and NT-proBNP concentration > 250 pg/ml. An individual, interdisciplinary decision to prescribe an anticoagulant when combined: (1) the presence of structural and functional AC markers, (2) cardioembolic pattern of a cerebral infarction or intracranial artery occlusion by visualization data and (3) high thromboembolic risk and probability of detection of AF on assessment scales (CHA2DS2-VASc, AF-ESUS and C2HEST). The greatest benefit of prescribing anticoagulant therapy can be obtained by patients with recurrent ESUS in whom sufficient secondary prevention and expressed AC, typical cardioembolism imaging pattern and high risk of thromboembolic events have already been achieved.

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The authors declare that there are no conflicts of interest present.