Problems of anticoagulant therapy in elderly cancer patients with atrial fibrillation and hemorrhagic stroke

The problems of antithrombotic and first of all, anticoagulant therapy in patients with concomitant oncological and cardiovascular pathology, especially in gerontological practice, remain to be unsolved. The need to use anticoagulants is dictated by a high risk of thromboembolism in cancer patients combined with age-associated atrial fibrillation. The risk of hemorrhage increases with the age; moreover, there is a risk of dangerous drug interactions due to the need of polymorbid pathology treatment. Thus, the clinical situation sometimes creates difficulties in choosing a proper tactic in patient management and following the existing treatment standards. A clinical case of a patient of an elder age with the recurrence of lung cancer, which has an established high-risk of thromboembolism, and with paroxysmal form of atrial fibrillation and new oral anticoagulants treatment, is considered

Cardioncology in Russia: Start-Off and Prospects

The progress in improving the survival of cancer patients in Russia, as well as throughout the world, means that in the next years it is going to be an increase in the number of disabled people who has achieved remission, or who faces the consequences of high-dose polychemotherapy and/or radiotherapy between courses of cancer treatment. Until recently, the two main socially significant medical problems in Russia, cancer and cardiac, have been rarely united into one. Publications on this topic appeared only in specialized cancer journals and were unknown by a wide range of cardiologists and internists, therefore the involvement of these specialists in the study of theoretical and practical aspects of the management of patients with malignant tumors was limited. Creation of the International Society of Cardioncology (ICOS) contributed to the development of an interest in this interdisciplinary field of modern medicine. However, even today cardiac problems of cancer patients in Russia mostly are limited to the cardiotoxicity studying, but, according to the position of the authors a great attention should be paid to the systemic reactions, including cardiovascular reactions of the organism to the tumor, as well as to the therapeutic issues and cardiac rehabilitation of cancer patients

Therapeutic rehabilitation of cancer patients. Why and what for?

Types of oncological rehabilitation and its objectives are described. It includes information on many manifestations of oncological diseases that an internist has to deal with, which are conditioned not only by the oncological process itself, but by the cancer treatment conducted, as well as the attitude of doctors and patients to cancer pathology. The specific characteristics of the “cancer disease” are described, as well as a combination of somatic disorders which depends on the ongoing or arrested tumor development. It is necessary for doctors to observe the cancer patients before, during and after treatment for complication of cancer or treatment over the life span

Ion- and osmoregulating renal functions in patients with type 2 diabetes mellitus

Aim. The study of ion- and osmoregulating renal functions in patients with type 2 diabetes mellitus (T2DM) for individual predictive assessment of renal response to exenatide treatment. Materials and methods. In total, 41 patients with T2DM were included in the study (12 males, 29 females). Compensated and subcompensated heart failure was observed in 80% and 20% of the patients, respectively. Nephropathy in the microalbuminuria stage was diagnosed in 34% of these patients. The patients’ ages ranged from 34 to 82 years. The mean duration of T2DM was 7 ± 1 years. The mean value of glycated haemoglobin was 8.1 ± 0.4 mmol/l. The control group included 16 healthy women, aged 24‒36 years. Ion- and osmoregulating renal functions and glycaemia levels were assessed after water loading and exenatide treatment (5 µg). Blood serum and urine osmolalities were measured using a micro-osmometer (Advanced Instruments 3300). Capillary blood glucose concentrations were determined using a test system (Accu-Chek Go). Serum and urine levels of urea, protein, creatinine, cholesterol, triglycerides, HDL, LDL, alanine aminotransferase and aspartate aminotransferase as well as cations were determined on a biochemical analyser (Erba XL-200 and Architect c8000), flame photometer (Sherwood-420) and atomic absorption spectrophotometer (Shimadzu AA-6200). Results. Reabsorption of solute-free water on the background of endogenous vasopressin action was not disturbed in patients with T2DM. An increase in solute free water clearance in response to water load occurred in healthy subjects as well as in patients with T2DM. After exenatide administration, a correlation between the changes in urinary sodium excretion and blood glucose levels was found (p 0.01). The increase in diuresis in oedema exenatide-treated patients was attributed to the rise of renal sodium excretion; there is a strong correlation between values of sodium excretion during the control period and after exenatide injection (p 0.001). Conclusions. The results indicate the prognostic significance of initial kidney function to assess the capacity for removal of water and ions and the subsequent reactions to exenatide

Remote consequences of polychemical and radiation therapy: cardiac valve disease complicated by infective endocarditis. Diagnostic and management problems

One of the quite frequent long-term effects of radiation therapy of malignant tumors, such as breast cancer and Hodgkin’s lymphoma primarily, when the irradiation of the mediastinum is performed, is the development of radiation-induced valvular disease. It is noted that the clinical manifestation of valve dysfunction can typically arise approximately 5 years after a course of anticancer radiotherapy. Thereafter in these patients increases the risk of infective endocarditis. However, in therapeutic and oncological clinical practice the difficulty of identifying and making the differential diagnosis of endocarditis in patients with “cancer” history is still quite common. At the moment cases of infective endocarditis after polychemotherapy and radiation therapy are not widely covered for cardiologists and internists in the medical literature. In addition before starting specific treatment due to the possible threat of infectious complications, including endocarditis, in oncology guidelines it is recommended to patients to make a thorough oral cavity sanitation, while the internists are little aware of this need, both at the stage of antitumor therapy and at late period. Today, with the increasing number of patients who are healed or achieved long-term remission after the anticancer treatment, including elderly people, it is necessary to raise the awareness among internists about occurrence options of comorbid disease in these group

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI) : a phase 3, placebo-controlled, randomised trial

Background: Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. Methods: The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). Findings: Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8–3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74–0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, p interaction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78–1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75–1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48–2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36–3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74–1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75–0·95, p=0·005, in contrast to patients without PCI where it did not, p interaction=0·012. Benefit was present irrespective of time from most recent PCI. Interpretation: In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk