«Doctor as a drug» in a stroke follow-up

Each year about 400 000 people in Russia get strokes. Whereas an acute treatment takes place in specialized intensive care units in hospitals, follow-up is handed over to general (rarely – private) practitioner. The majority of stroke survivors show low adherence to follow-up resulting in repeated hospitalizations and growth of multi-morbidity burden. With COVID-19 pandemic negatively affecting availability of medical services and increasing health risks for stroke survivors, a physician-patient relation becomes the means of persuading patients to healthpromoting behaviour.Highlights. We described a new concept of illness. Within its framework we have shown the role of a physician-patient relationship in the improvement of follow-up adherence in the post-stroke patient during COVID-19 pandemic.Abstract. Each year about 400 000 people in Russia get strokes. Whereas an acute treatment takes place in specialized intensive care units in hospitals, follow-up is handed over to general (rarely - private) practitioner. The majority of stroke survivors show low adherence to follow-up resulting in repeated hospitalizations and growth of multi-morbidity burden. With COVID-19 pandemic negatively affecting availability of medical services and increasing health risks for stroke survivors, a physician-patient relation becomes the means of persuading patients to health-promoting behaviour

Therapy for hypertension and dyslipidemia: potential of Lipertans (on the example of a clinical observation)

The article presents epidemiological data on the high prevalence of hypertension and dyslipidemia comorbidity in the general population, as well as shows the leading role of these key cardiovascular risk factors in the development of cardiovascular events. At the same time, within the primary prevention, the adherence of patients to the lipid-lowering therapy remains low. Fixed-dose combinations (Lipertans) based on antihypertensive (amlodipine, perindopril) and lipid-lowering drugs (atorvastatin) can significantly increase the effectiveness of therapy

КОНТРОЛЬ ЛИПИДОВ У ПАЦИЕНТОВ ПОСЛЕ ПЕРЕНЕСЕННОГО ИНФАРКТА МИОКАРДА — ЭФФЕКТИВНЫЙ ИНСТРУМЕНТ УПРАВЛЕНИЯ СЕРДЕЧНО-СОСУДИСТЫМ РИСКОМ

The review article highlights the views reflected in the recent clinical guidelines related to high-intensity statin treatment and non statin cholesterol lowering drugs in patients with very high cardiovascular risk after myocardial infarction and the purpose of therapy. The article tells about the approaches to controlling lipidogramic parameters after high-intensity statin therapy was prescribed and to the prescription of PCSK9 inhibitors (Alirocumab) after an acute coronary event. The report was compiled on the basis of the available materials from the national and foreign databases (e-Library, Library’s MEDLINE/PubMed database).  В обзорной статье освещены позиции современных клинических рекомендаций в отношении назначения высокоинтенсивной терапии статинами и нестатиновыми холестеринснижающими препаратами у пациентов очень высокого сердечно-сосудистого риска после перенесенного инфаркта миокарда, а также цели терапии. Обозначены подходы к контролю параметров липидограммы после назначения высокоинтенсивной терапии статинами и к назначению ингибиторов PCSK9 (алирокумаб) после развития острого коронарного события. Для составления обзорной статьи использованы доступные материалы из отечественных и зарубежных библиотечных баз данных (e-Library, Library’s MEDLINE/PubMed database). 

Российские и европейские рекомендации 2020 года по ведению пациентов с острым коронарным синдромом без подъема сегмента ST: упростились ли подходы к антитромботической терапии?

Highlights. Prescribtion patterns of antithrombotic therapy in patients with non-ST-segment elevation acute coronary syndromes have been comapred in 2020 Russian and European clinical practice guidelines for the management of NSTEMI patients.A comparative assessment of novel approaches of antiplatelet and anticoagulant therapy recommended in 2020 European and Russian clinical practice guidelines for the management of patients with non-ST-segment elevation acute coronary syndrome is reported. In prescribing antiplatelet therapy, ESC guidelines suggest focusing attention on a more complex set of regimens to balance ischemic and hemorrhagic risks. Approaches to prescribing anticoagulant therapy do not differ in the recommendations of two medical societies. Fondaparinux has compelling advantages over other drugs regarding the combination of efficacy and safety in patients.Основные положения. Статья содержит сравнение данных об особенностях назначения антитромботической терапии пациентам с острым коронарным синдромом без подъема сегмента ST в европейских и российских клинических рекомендациях 2020 г.В обзорной статье освещено сравнение подходов назначения антиагрегантной и антикоагулянтной терапии, представленных в актуальных европейских и российских клинических рекомендациях по ведению пациентов с острым коронарным синдромом без подъема сегмента ST электрокардиограммы. Акцентировано внимание на более сложном наборе схем назначения анти-тромбоцитарной терапии в европейских рекомендациях 2020 г., что определяется необходимостью индивидуальной оценки баланса ишемических и геморрагических рисков. Подходы назначения антикоагулянтной терапии не различаются в документах двух научных сообществ. Фондапаринукс демонстрирует убедительные преимущества в эффективности и безопасности в сравнении с другими препаратами

Управление риском развития ишемических событий у пациентов с мультифокальным атеросклерозом и сахарным диабетом 2-го типа

The review article presents current positions about prevalence of multifocal atherosclerosis and type 2 diabetes mellitus in patients with coronary artery disease (CAD). Existing approaches to the assessment and management of high risk of ischemic events in such patients are identified. Based on the results of clinical trials, the main positions have been identified on risk prevention of cardiovascular complications in patients with combination of multifocal atherosclerosis and type 2 diabetes mellitus. The results of the COMPASS study on the use of a combination of rivaroxaban 2.5 mg twice a day and a low dose of acetylsalicylic acid in patients with CAD and/or multifocal atherosclerosis are presented, which is accompanied by a significant reduction in the risk of cardiovascular events. This approach demonstrated a increase in the risk of massive bleedings, but mainly in the first year of treatment and without significant subsequent increase. At the same time, in the group of combination therapy rivaroxaban and acetylsalicylic acid there was no increase in the frequency of the most severe bleeding - fatal, intracranial and into the critical organs, compared to the group of monotherapy of acetylsalicylic acid. These two facts show a perfectly acceptable level of hemorrhagic risk for translation into real clinical practice. Hemorrhagic risk management capabilities were considered in a CoMPASS study by prescribing proton pump inhibitors to patients. The data on the COMPASS sub-analysis on evaluation of effectiveness and safety of combined antithrombotic therapy in patients with CAD and/or multifocal atherosclerosis and type 2 diabetes mellitus are presented. They showed the possibility of usage such approach in patient management in routine clinical practice. Patients with very high risk of ischemic events: ischemic heart disease and multifocal atherosclerosis, as well as type 2 diabetes mellitus, particularly need to improve approaches to antithrombotic therapy.В обзорной статье представлены современные данные о распространенности мультифокального атеросклероза (МФА), сахарного диабета (СД) 2-го типа у пациентов с ишемической болезнью сердца (ИБС). Обозначены существующие подходы к оценке и управлению высоким риском ишемических событий у таких пациентов. На основании результатов проведенных клинических исследований выделены основные позиции по профилактике риска сердечно-сосудистых осложнений у пациентов с сочетанием МФА и СД 2-го типа. Представлены результаты исследования COMPASS по применению комбинации ривароксабана 2,5 мг два раза в день и низкой дозы ацетилсалициловой кислоты у пациентов с ИБС и/или МФА, что сопровождается значимым снижением риска сердечно-сосудистых событий. Такой подход продемонстрировал закономерное увеличение риска больших кровотечений, но в основном в первый год лечения и без значительного последующего повышения. При этом в группе комбинированной терапии ривароксабаном и АСК не отмечалось повышения частоты наиболее тяжелых кровотечений - фатальных, внутричерепных и в критически важные органы, в сравнении с группой монотерапии АСК. Эти два факта свидетельствуют о вполне приемлемом уровне геморрагического риска для трансляции в реальную клиническую практику. Возможности управления геморрагическим риском рассматривались в ходе проведения исследования COMPASS путем назначения ингибиторов протоновой помпы (ИПП) пациентам. Представлены данные субанализа исследования COMPASS по оценке эффективности и безопасности комбинированной антитромботической терапии у пациентов с ИБС и/или МФА и СД 2-го типа, которые показали возможность использования такого подхода к ведению пациентов в рутинной клинической практике. Больные с очень высоким риском развития ишемических событий - с ишемической болезнью сердца и мультифокальным атеросклерозом, а также с сахарным диабетом 2-го типа - особенно нуждаются в улучшении подходов к антитромботической терапии

ВЫЯВЛЕНИЕ ЛАТЕНТНОГО НЕКОРОНАРНОГО АТЕРОСКЛЕРОЗА У ПАЦИЕНТОВ С ОСТРЫМ КОРОНАРНЫМ СИНДРОМОМ. ЕСТЬ ЛИ СМЫСЛ?

The clinical and prognostic signifi cances of different degrees of non-coronary atherosclerosis in acute coronary syndrome (ACS) patients were reported in the study fi ndings. A high (95 %) prevalence of non-coronary atherosclerosis, the degree of which was progressing in more than 70 % of patients 12 months after ACS, was defi ned. Moreover, the clinical and prognostic importance of polyvascular disease (PolyVD) in ACS and the necessity of early detection of non-coronary atherosclerosis in ACS patients were determined to optimize risk estimation. Interleukin-12, tumor necrosis factor-α were considered to be the markers of subclinical infl ammation of polyvascular disease (PolyVD) and ACS; their possible application in modern statistical risk estimation models of ACS were suggested. The perspective areas in fundamental and clinical studies of polyvascular disease were proposed to the further research. Представлены результаты исследований клинической и прогностической значимости некоронарного атеросклероза различной степени выраженности у пациентов с острым коронарным синдромом (ОКС). Выявлена высокая (до 95 %) распространенность некоронарного атеросклероза, степень которого прогрессирует у более чем 70 % пациентов через 12 месяцев после ОКС. Определена клинико-прогностическая значимость феномена МФА при ОКС и необходимость раннего выявления некоронарного атеросклероза у пациентов с ОКС для оптимизации рискометрии. Выявлены маркеры активации субклинического воспаления при мультифокальном атеросклерозе (МФА) и ОКС – интерлейкин-12, фактор некроза опухоли-α; обозначены возможности их применения в современных статистических моделях рискометрии при ОКС. Намечены перспективные направления фундаментальных и клинических исследований в области мультифокального атеросклероза.

Association of cardiovascular biomarkers with myocardial and coronary imaging characteristics in patients having acute myocardial infarction and type 2 diabetes mellitus

Aim. To assess the dynamic changes and clinical significance of biomarkers of inflammatory processes in patients with acute myocardial infarction (MI) with/ or without type 2 diabetes mellitus (T2DM) and primary percutaneous coronary intervention (pPCI) at various stages of treatment.Methods. 96 patients with acute MI after pPCI were examined. The level of inflammation markers was measured 4 times: before pPCI (first day from admission to the hospital), on the third day, 7–10 days (before discharge from the hospital) and 40–45 days after pPCI.Results. All groups of patients with MI showed an increase in the plasma activity of biomarkers of inflammatory processes. After pPCI for 40–45 days, there is a significant difference in the concentration of biomarkers, depending on the comorbid T2DM presence. Strong associations were found between cardiovascular biomarkers and post-MI cardiac remodeling and coronary atherosclerosis progression.Conclusion. The assessment of the levels of biomarkers of inflammatory processes may have additional clinical value in estimating the course of MI, including patients with T2DM at the postinfarction stages. Aim. To assess the dynamic changes and clinical significance of biomarkers of inflammatory processes in patients with acute myocardial infarction (MI) with/ or without type 2 diabetes mellitus (T2DM) and primary percutaneous coronary intervention (pPCI) at various stages of treatment.Methods. 96 patients with acute MI after pPCI were examined. The level of inflammation markers was measured 4 times: before pPCI (first day from admission to the hospital), on the third day, 7–10 days (before discharge from the hospital) and 40–45 days after pPCI.Results. All groups of patients with MI showed an increase in the plasma activity of biomarkers of inflammatory processes. After pPCI for 40–45 days, there is a significant difference in the concentration of biomarkers, depending on the comorbid T2DM presence. Strong associations were found between cardiovascular biomarkers and post-MI cardiac remodeling and coronary atherosclerosis progression.Conclusion. The assessment of the levels of biomarkers of inflammatory processes may have additional clinical value in estimating the course of MI, including patients with T2DM at the postinfarction stages.

Методический подход к прогнозированию риска нонкомплаенса пациентов с инфарктом миокарда

Aim. To develop a methodological approach in order to predict the risk of noncompliance in patients with myocardial infarction.Methods. 416 patients were questioned in the single-centered, prospective, non-randomized study using the original author's method. The patients were treated in specialized cardiological departments of the city of Kemerovo with the diagnosed myocardial infarction. The methodological approach to predicting the risk of non-compliance in patients with myocardial infarction covered 29 factors in 6 main blocks: sociodemographic and socio-economic characteristics, health status, medical and pharmaceutical culture of the patient, awareness of medical and pharmaceutical services, patient adherence to medical recommendations.Results. Patients with myocardial infarction were characterized by insufficient adherence to the therapy, low awareness of the disease, which can negatively affect the longterm disease prognosis. The identification of a large number of subjective factors limiting adherence to the therapy is the reason for the widespread use of noncompliance risk measurement among patients with myocardial infarction, which will allow determining the range of the risk group for each individual patient.Conclusion. The adherence to the treatment of patients with myocardial infarction is revealed as 80% which is indicated as low and requires the prophylactic use of educational and psychological programs that increase medical and social awareness and readiness to comply with the doctor's recommendations, and also justifies the need for complex risk measurement of non-compliance patients for personalized identification and addressing risk factors for poor adherence to therapy. Цель. Разработать методический подход к прогнозированию риска нонкомплаенса пациентов с инфарктом миокарда (ИМ).Материалы и методы. В представленном одноцентровом проспективном нерандомизированном исследовании по оригинальной авторской методике проанкетированы 416 пациентов, пролеченных в кардиологических отделениях НИИ КПССЗ с диагнозом «инфаркт миокарда». Методический подход по прогнозированию риска нонкомплаенса пациентов с ИМ охватывал 29 различных факторов, влияющих на развитие данного заболевания.Результаты. Пациентам с ИМ свойственны ограниченная приверженность лечению и слабая информированность о заболевании, что может оказывать неблагоприятное влияние на развитие болезни. Выявление значительного количества факторов, ограничивающих приверженность терапии, служит поводом для широкого применения рискометрии нонкомплаенса среди пациентов с ИМ, что позволит определять диапазон группы риска для каждого отдельного больного.Заключение. Выявленная приверженность больных ИМ составляет 80%, что соответствует низкому показателю и свидетельствует о необходимости особых требований к профилактическим мероприятиям, а также обосновывает потребность в комплексной рискометрии нонкомплаенса пациентов для персонифицированной идентификации и устранения факторов риска недостаточного следования назначениям врача

Three Year Prognosis of Patients with Myocardial Infarction Depending on the Body Weight Index: Data of the Kemerovo Acute Coronary Syndrome Registry

Aim. To study the effect of body mass index (BMI) on the 3-year prognosis of patients after myocardial infarction (MI).Material and methods. The study is based on data from a 3-year observation of patients with MI from the Kemerovo registry of acute coronary syndrome (n=1366). The characteristics of patients with MI, distributed by the BMI, were determined, the outcomes were analyzed, the risk factors and predictors for the vascular events and mortality were identified.Results. Obesity was detected in 32.2% people with MI (I degree – 22.3%; II – 7.7%; III – 2.3%), lack of BMI at 0.5%, normal BMI at 20.5%, overweight at 46.9%. Patients with different BMI showed a comparable incidence of recurring MI. In patients with normal BMI, when compared with patients with obesity, unstable angina pectoris (UA), heart failure (HF) and strokes developed often. In patients with normal BMI compared with obese patients, fewer deaths from all causes were recorded within 3 years after MI. A similar pattern with respect to the group with normal BMI in terms of high overall mortality was obtained among patients with overweight who had a lower UA. Patients with obesity was favorable in relation to the development of HF, strokes and overall mortality than patients with overweight. Differences in the 3-year outcomes in the group of patients with MI and underweight were not found when compared with patients with normal and overweight, however, they had a higher of strokes compared with patients with obesity. At patients with I degree obesity within 3 years after MI UA, HF, strokes were less. Patients with III degree obesity, the maximum frequency of total mortality was recorded. The development of death from all causes during the observation period in patients with MI and obesity was associated with: male, smoking, multivessel arterial diseases, non-endovascular reperfusion, acute HF with MI, history of vascular events and angina pectoris; whereas with overweight: multifocal atherosclerosis and arterial hypertension; with a deficit of BMI: non-reperfusion; with normal BMI: heredity for cardiovascular diseases, dyslipidemia and atrial fibrillation.Conclusion. 3 years after MI patients with obesity of the I degree are less likely than patients with obesity of II-III deaths from all causes are recorded; these patients are less likely than patients with normal weight to develop strokes, HF, UA. Thus, patients with MI and the presence of I degree obesity are characterized by better survival during 3 years of observation