Practical aspects of antithrombotic therapy in patients with atrial fibrillation and coronary artery disease

Atrial fibrillation (AF) is the most common cardiac arrhythmia, which is associated with an increased risk of cardiovascular death. The latter is partly due to the common combination with coronary artery disease (CAD). If indicated, patients with AF need continuous direct oral anticoagulant therapy to prevent thromboembolic events. In addition, patients with CAD who require urgent or elective percutaneous coronary intervention require dual antiplatelet therapy. Therefore, physicians often face a dilemma when choosing the most appropriate antithrombotic therapy regimen for AF patients undergoing percutaneous coronary intervention. Integrating two medication approaches to treat a single patient with a combination of AF and CAD is challenging and must strike a balance between high efficacy and safety. This article provides an overview of studies on this issue

CARDIORENAL INTERACTION IN DECOMPENSATED CHRONIC HEART FAILURE

Aim. To investigate the prevalence of cardiorenal interactions, predictors of development, variants of clinical course, and outcomes of acute kidney injury (AKI) in patients with acute decompensation of chronic heart failure (ADCHF).Material and methods. Patients (n=278) with clinical manifestations of ADCHF were included into the study. All patients underwent clinical, laboratory and instrumental investigation. Renal function was assessed using the CKD-EPI formula to calculate glomerular filtration rate (GFR). Hydration was assessed using the bioimpedance analyzer ABC-01 "Medass" (Russia). Chronic kidney disease (CKD) and AKI were diagnosed according to the criteria of the latest Russian and international guidelines. Six phenotypes of AKI were identified: outpatient and hospital acquired, transient and persistent, de novo, and on the background of CKD.Results. CKD was detected in 125 (45%) patients. AKI developed in 121 (43.5%) patients, and in 52.9% of cases was nosocomial, in 53.7% transient and in 52.1% of cases occurred in patients without history of CKD. The risk of in-hospital mortality compared with patients without AKI significantly increased only in patients with nosocomial AKI (14.1 and 3.8%, p<0.05), AKI de novo (14.3 and 3.85%, p <0.05) and persistent (25 and 3.8%, p<0.001). Patients with these variants of AKI as compared to patients without AKI had more pronounced hydration, as well as less frequent prescription of loop diuretics and beta-blockers during outpatient treatment.Conclusion. The high rate (67.6%) of cardiorenal interactions was found out in patients admitted to hospital with ADCHF. Unfavorable prognostic phenotypes of AKI were hospital acquired, persistent AKI and AKI de novo. Patients with these phenotypes had a more pronounced hydration and inadequate outpatient therapy

Cardiovascular risk factors and diabetic foot syndrome in south indian diabetic population

The diabetic foot syndrome is one of the most frequent reasons for hospitalization among the diabetic population and also one of the most common cause for lower-limb amputation. Apart from the obvious associated morbidity, patients with diabetic foot have an increased risk of death from cardiovascular diseases. Correction of glycaemia, serum lipids and blood pressure lead to a regress in progression of diabetes complications. In this article, the influence of cardiovascular risk factors on occurrence and progression of the diabetic foot syndrome in the Indian diabetic population during a 1-year follow up was analyzed

Influence of intravenous ferric carboxymaltose on non-invasive parameters of left ventricular myocardial work in patients with heart failure with reduced ejection fraction

Aim. To assess non-invasive parameters of left ventricular (LV) myocardial work in patients with heart failure with reduced ejection fraction (CHrEF) and iron deficiency (ID) after ferric carboxymaltose (FCM) therapy.Material and methods. There were following inclusion criteria: LV ejection fraction (EF) ≤40%; body >70 kg, receiving best medical therapy (BMT) in recommended doses in accordance with the guidelines of the European Society of Cardiology and the Russian Society of Cardiology. Median age was 67±11,7 years (men, 83%), while median LVEF and N-terminal pro-brain natriuretic peptide was 29% and 315 ng/ml, respectively. Patients were randomized by the envelope method. The first group consisted of 19 patients who received therapy with intravenous FCM 1500 mg in 2 injections with an interval of one week between injections in addition to BMT. The control group consisted of 16 patients who received BMT without FCM. All patients underwent a standard echocardiography, and non-invasive LV myocardial work was assessed immediately before inclusion in the study and after 3 months.Results. In the first group of patients receiving FCM therapy, an increase in LVEF (29,1±10,3 vs 35,4±11,1; p=0,001), mitral annular plane systolic excursion (1,2 (1;1,6 ) vs 1,5 (1,3;1,9), p=0,001), LV global longitudinal strain (-7 (-5;-8) vs -8 (-6;-11), p=0,007) and non-invasive indicators of myocardial work (global work index (826±314 vs 1041±354), p=0,0001; global constructive work (1173±388 vs 1435±405), p=0,0001; global work efficiency (85 (82;87) vs 86 (82;88), p=0,017)). There were no significant changes in the studied parameters in the BMT group.Conclusion. Patients with HFrEF and ID treated with FCM showed a significant increase in LV systolic function, including non-invasive myocardial work parameters, compared with the control group

EFFECT OF SACUBITRIL/VALSARTAN ON NATRIURESIS, DIURESIS AND BLOOD PRESSURE IN HYPERTENSIVE PATIENTS

Aim. To study the effect of sacubitril/valsartan compared with valsartan on natriuresis, diuresis, blood pressure (BP) and the level of biomarkers in hypertensive patients.Material and methods. Hypertensive patients (n=16) received sacubitril/valsartan 400 mg QD or valsartan 320 mg QD for 7 days in a double-blind,-randomized, cross-over study. The change in 24-hour diuresis and natriuresis, fractional urinary sodium excretion, and BP level have been studied, as-well as soluble biomarkers: cyclic guanosine monophosphate (cGMP), plasma brain natriuretic peptide (BNP), mid-regional precursor of the atrial natriuretic-peptide (MR-proANP) and the N-terminal precursor of the brain natriuretic peptide (NT-proBNP).Results. The trend toward higher levels of 24-hour natriuresis on Day 1 (21%, p=0.068) was found in the sacubitril/valsartan group compared to-valsartan one. Fractional sodium excretion was significantly higher in the sacubitril/valsartan group on Day 1 after 6 hours (50%, p=0.004) and subsequent-samples up to 12 hours; the maximum effect was achieved 2-4 hours after taking the medication (mean value 2.08, p=0.005). Sacubitril/valsartan-therapy compared with valsartan therapy was associated with a significant increase in 24-hour diuresis on Day 1 (41%, p<0.05), but not on Day 7-(15%, p=0.134). Sacubitril/valsartan therapy, in contrast to valsartan therapy demonstrated a significant increase in 24 h cGMP urinary excretion-on Day 1 (95%, p<0.001) and Day 7 (83%, p=0.001). Sacubitril/valsartan lowered BP more effectively than valsartan [on Day 7, 12 hours after-taking the drug, the differences were13.6 mm Hg (p=0.004) for systolic and6.7 mm Hg (p=0.03) for diastolic BP. The decrease in the level of-NT-proBNP and MR-proANP in plasma and the transient increase in the level of BNP were found in the sacubitril/valsartan group. Both sacubitril/valsartan and valsartan therapies were well tolerated and safe.Conclusion. Sacubitril/valsartan therapy in hypertensive patients compared with valsartan therapy was associated with transient increase in natriuresis and diuresis, more pronounced decrease in BP and changes in biomarker levels reflecting persistent inhibition of neprilysin and decrease in myocardial wall tension

Delaminating Intramyocardial Hematoma in Patients with Heart Failure with Reduced Ejection Fraction: а Series of Clinical Cases

Delaminating intramyocardial hematoma (DIMH) is a rare and potentially life-threatening complication of acute myocardial infarction. Currently, only isolated reports of cases of myocardial dissection have been published, and until recently, the diagnosis of DIMH was carried out during autopsy or surgery. The article describes echocardiographic criteria and discusses some aspects of the therapy of this pathology. The description of clinical cases of noninvasive diagnosis of DIMH in men aged 60 and 62 years hospitalized with the clinic of decompensation of chronic heart failure is given. This complication in the presented patients was diagnosed using transthoracic echocardiography, thanks to which it was possible to identify the dissection of the myocardium, as well as to trace the dynamics of the organization of an intramyocardial hematoma into a parietal thrombus. Various approaches to patient management are demonstrated: conservative tactics allowed to successfully stabilize the course of chronic heart failure in the first patient, while the condition of the other required the transplantation of a donor heart a few months after discharge from the hospital

Comparative Efficacy of Single Pill Combinations of Azilsartan Medoxomil/Chlorthalidone and Losartan/Hydrochlorothiazide in Patients with Hypertension and Heart Failure with Preserved Ejection Fraction

Aim. To study the effects of azilsartan medoxomil/chlorthalidone (AZM/CTD) and losartan/hydrochlorothiazide (LOS/HCT) combinations for NTproBNP levels, 6-minute walk test results, hydration status along with their antihypertensive efficacy according to clinical and 24-hour blood pressure in patients with hypertension and heart failure with preserved ejection fraction (HFpEF).Material and methods. An open randomized study included 56 patients with uncontrolled or untreated hypertension and HFpEF. Patients randomized to receive the AZM/CTD 40/12.5 mg/day (group 1; n=28) or LOS/HCT 100/12.5 (group 2; n=28) within 4 weeks. Patients who did not achieve the target BP <140/<90 mm Hg study drug dose was intensified: in the first group, an increase in the dose of AZM/CTD 40/25 mg/day, in the second group, an increase in the dose of LOS/HCT 100/25 mg/day. The observation period was 12 weeks. All patients underwent a clinical examination with an assessment of symptoms and/or signs of HF, laboratory and instrumental studies, including NT-proBNP, ambulatory blood pressure (BP) monitoring, applanation tonometry, a 6-minute walk test (6MWT), echocardiography. In order to assess the status of hydration, bioimpedance vector analysis (BIVA) was performed. HFpEF was diagnosed according to the HFA-PEFF algorithm. The results were considered statistically significant at p<0.05.Results. After 12 weeks, 92% of patients in the first and 78% of patients in the second group reached the target clinical BP (р<0,05). Average daily BP <130/ <80 mm Hg was reached by 82% of patients treated with the combination of AZM/CTD, compared with 67% treated with the combination of losartan/HCT (p<0.05). After 12 weeks, patients from both groups showed a significant decrease in systolic and diastolic blood pressure, central blood pressure, and a decrease in pulse wave velocity, which was more significantly significant in the first group of patients (p<0.05). During therapy in both groups of patients, a significant decrease in the level of NT-proBNP was observed: in the first group from 300 [199; 669] pg/ml to 156 [157; 448] pg/ml (p=0,003), in the second group from 298 [180; 590] pg/ml to 194 [140; 360] pg/ml (p=0,006), an increase in the distance during the 6MWT from 317 [210; 398] m to 380 [247; 455] m (p=0,006) in in the first group and an improvement in the hydration status according to the BIA data, but more significantly significant in the first group (p<0.001).Conclusion. In patients with hypertension and HFpEF, therapy with the AZM/CTD combination compared with LOS/HCT is accompanied by a more pronounced antihypertensive effect in terms of ambulatory and peripheral blood pressure, central blood pressure, NTproBNP levels, increased distance in 6MWT and achievement of euvolemia status

Громкое опровержение «громкого опровержения»: много шума… из ничего?

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О репрессиях ω -3 полиненасыщенных жирных кислот адептами доказательной медицины

The subject of this article is the obvious crisis of evidence-based medicine in the 21st century. As a typical example of a contemporary “evidence-based study”, here we analyze in detail a text published in 2018 in the Cochrane Database Syst Rev journal under the code number “CD00317F. The authors claim that ω -3 polyunsaturated fatty acids (PUFAs) are not effective either for the prevention of cardiovascular mortality or for any other outcomes mentioned by the authors. A detailed analysis of this text, however, pointed to gross violations of data collection and processing. By using modern mathematical methods for big data analysis we were able to demonstrate clearly that the authors of the text CD003177 used clinically heterogeneous cohorts of patients. We then selected a subsample of 19 clinically homogeneous studies (total of 64771 patients) and conducted a meta-analysis of this data. According to the results, an increase in consumption of ω -3 PUFA -eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids - by 1 g/day was associated with a significant decrease in the risk of mortality by an average of 5% (OR - 0.945, 95% CI - 0.907-1.008; P=0.054). This meta-analysis was based on the modified clinical, laboratory and anthropometric criteria in the selected studies. In addition, we used the most important characteristics of ω -3 PUFAs pharmaceutical forms and the modern statistical analysis of biomedical data. With the above modifications, we managed to select a homogeneous subsample of clinically relevant studies. We also applied methods of sentiment analysis to demonstrate a subjective approach used by the above authors regarding the role of PUFAs in the prevention of cardiovascular morbidity. Using the language of today social media, some adepts of evidence-based medicine implement propaganda techniques to literally “repress” ω -3 PUFAs.Предметом настоящей статьи является очевидный кризис доказательности в медицине 21-го века. В качестве типичного примера современного нам «доказательного исследования», выступает статья, опубликованная в 2018 г. в журнале «Cochrane Database Syst Rev» под кодовым номером «CD003177». Составители этого текста утверждают, что ω -3 полиненасыщенные жирные кислоты (ПНЖК) не эффективны ни для профилактики кардиоваскулярной смертности, ни для каких-либо других упоминаемых авторами исходов. Детальный аудит данного текста, однако, указал на грубейшие нарушения по сбору и обработке данных. Применение современных математических методов анализа больших данных позволило наглядно доказать тот факт, что авторы текста CD003177 использовали клинически неоднородные выборки пациентов. Выделенная нами подвыборка из 19 однородных исследований включила 64771 пациентов и позволила провести метаанализ, указавший на значимое понижение риска общей смертности в среднем на 5% (О.Ш. - 0,945,95% ДИ - 0,907-1,008; Р=0,054) при повышении потребления ω -3 ПНЖК в виде эйкозапентаеновой (ЭПК) и докозагек-саевой кислот (ДГК) на каждые 1 г/сут. Проведенный нами метаанализ отличает, во-первых, уточненный учет клинико-лабораторных и антропометрических описаний отдельных исследований, во-вторых, учет важнейших характеристик фармацевтических различных форм ω -3 ПНЖК, в-третьих, адекватное применение современных подходов к анализу биомедицинских данных, результатом чего явилось выделение однородной подвыборки клинически адекватных исследований. Методы сентимент-анализа также продемонстрировали субъективный подход, использованный вышеупомянутыми авторами в отношении роли ПНЖК в профилактике сердечно-сосудистых заболеваний. Используя термины современных социальных медиа, некоторые адепты доказательной медицины применяют пропагандистские методы, чтобы в буквальном смысле слова «репрессировать» ω -3 ПНЖК

Leading Factors of Progression in Patients with Cardiac Amyloidosis

Aim. To describe prognostic meaning of cardiac and other principal clinical manifestations of systemic AL-amyloidosis in their interrelations.Material and methods. It has been made long-time survival analysis of 147 patients with systemic AL-amyloidosis. In the special investigation group (n=58) of AL (n=55) and ATTR (n=3) amyloidotic cardiopathy patients there were evaluated prognostically important structural and functional changes in myocardium with standard and impulse-wave tissue dopplerometric echocardiography in comparison with NTproBNP serum levels.Results. Even though significantly increased nowadays surviving of AL-amylodotic patients (Me=90 months) it has been found that as at previously time orthostatic hypotension and amyloid cardiopathy are being most severe initial syndromes (median 25 months), but after 1 year from diagnosis influence of these syndromes on surviving had decreased and most low surviving was more common in patients with CKD 3-5 (median 28 months). Influence of CKD 3-5 on surviving was associated predominantly with intracardial hemodynamics deterioration. Together with decreased systolic shortening strain rate (48,5%) decreased filtration rate (47,9%) was second of main factors contributing into NTproBNP increasing in effective multiple regression model (R=0,702, F(4,21)=5,095, p=0,005). NTproBNP level in less degree depended on renal clearance.Conclusion. Heart damage is one of the most prognostically unfavorable manifestations of systemic amyloidosis due to a sharp deterioration in the elastic properties of the myocardium, in the process of further development of amyloidosis, the leading factor in progression is the deterioration of the profile of cardiorenal interactions, the marker of which is the level of NTproBNP