Reducing geographic inequalities in access times for acute treatment of myocardial infarction in a large country: the example of Russia.

Background: Russia has the largest area of any country in the world and has one of the highest cardiovascular mortality rates. Over the past decade, the number of facilities able to perform percutaneous coronary interventions (PCIs) has increased substantially. We quantify the extent to which the constraints of geography make equitable access to this effective technology difficult to achieve. Methods: Hospitals performing PCIs in 2010 and 2015 were identified and combined with data on the population of districts throughout the country. A network analysis tool was used to calculate road-travel times to the nearest PCI facility for those aged 40+ years. Results: The number of PCI facilities increased from 144 to 260 between 2010 and 2015. Overall, the median travel time to the closest PCI facility was 48 minutes in 2015, down from 73 minutes in 2010. Two-thirds of the urban population were within 60 minutes' travel time to a PCI facility in 2015, but only one-fifth of the rural population. Creating 67 new PCI facilities in currently underserved urban districts would increase the population share within 60 minutes' travel to 62% of the population, benefiting an additional 5.7 million people currently lacking adequate access. Conclusions: There have been considerable but uneven improvements in timely access to PCI facilities in Russia between 2010 and 2015. Russia has not achieved the level of access seen in other large countries with dispersed populations, such as Australian and Canada. However, creating a relatively small number of further PCI facilities could improve access substantially, thereby reducing inequality

The management of acute myocardial infarction in the Russian Federation: protocol for a study of patient pathways

Death rates from cardiovascular disease in Russia are among the highest in the world. In recent years, the Russian government has invested substantially in the healthcare system, with a particular focus on improving access to advanced technology, especially for acute myocardial infarction (AMI). This protocol describes a study to understand the management of AMI in different Russian regions, investigating the role of patient, clinical, and health system characteristic

Management of patients with acute ST-segment elevation myocardial infarction in Russian hospitals adheres to international guidelines

Objective - Russia has one of the highest cardiovascular mortality rates. Modernisation of the Russian health system has been accompanied by a substantial increase in uptake of percutaneous coronary intervention (PCI), which substantially reduces the risk of mortality in patients with acute ST-elevation myocardial infarction (STEMI). This paper aims to describe contemporary Hospital treatment of acute STEMI among patients in a range of hospitals in the Russian Federation. Methods - This study used data from a prospective observational cohort of 1128 suspected patients with myocardial infarction recruited in both PCI and non-PCI hospitals across 13 regions and multiple levels of the health system in Russia. The primary objective was to examine the use of reperfusion strategies in patients with STEMI. Results - Among patients reaching PCI centres within 12 hours of symptom onset, the vast majority received angiography and PCI, regardless of age, sex and comorbidity, in line with current European Society of Cardiology guidelines. Conclusion- Patients reaching Russian hospitals are very likely to receive appropriate treatment, although performance varies. The best hospitals can serve as beacons of good practice as PCI facilities continue to expand across Russia where geography allows

SOCIO-ECONOMIC DAMAGE BY ACUTE CORONARY SYNDROME IN RUSSIAN FEDERATION

Aim. To estimate the economic damage by acute coronary syndrome (ACS) in Russia in 2006-2009. Material and Methods. Direct costs and economic losses associated with ACS were estimated. The structure of direct costs includes the costs of hospitalization, medical emergencies, out-patient visits, high-tech medical care, as well as drug therapy in outpatient treatment. Losses in the economy associated with ACS include loss of gross domestic product due to death in working-age, temporary disability and payments of disability benefits. Estimation of economic damage by cardio-vascular diseases was based on analysis of Russian Ministry of Health official statistics. Results. Approximately 520,000 cases of ACS are registered annually (36,4% - myocardial infarction, 63,6% - unstable angina). Trend to increased mortality from myocardial infarction, especially among women, was found during the analyzed period. From 2000 to 2009 this index rose from 34.9 to 41.1 per 100,000 of population among women, and from 52.3 to 55.9 per 100,000 of population among men. Total direct costs of health care for patients with ACS in 2009 amounted to almost 21 billion rubles, and indirect – 53.5 billion rubles. The total economic damage by ACS in Russia in 2008-2009 exceeded 70 billion rubles per year. Conclusion. ACS in Russia is connected with significant social and economic damage. Most part of this damage is indirect losses in economy due to premature mortality of working aged men

Level and correlations of soluble suppression of tumorigenicity 2 protein in heart failure and its relationship with clinical and paraclinical characteristics of patients

Aim. To establish the correlations of the soluble suppression of tumorigenicity 2 protein (sST2) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with some clinical and paraclinical characteristics of patients with heart failure (HF).Material and methods. The study included 130 patients with HF (men — 54, women — 76, mean age, 64,3±8,3 years) from the regional registry of HF patients in the Voronezh Oblast. All patients underwent echocardiography and general clinical investigations. In addition, the serum levels of sST2 and NT-proBNP were determined and their correlations with other parameters were studied.Results. The blood level of sST2 in HF patients was 339,8 [266;405] pg/ml. In the study sample of patients with HF, sST2 levels correlated with right atrial (r=0,49) and right ventricular (r=0,32) sizes, left ventricular end-diastolic dimension (r=0,34) and volume (r=0,33), left ventricular early diastolic filling rate (r=-0,35), blood calcium level (r=-0,55) and functional class of exertional angina (r=-0,37).Conclusion. The data obtained may indicate a pathogenetic relationship between sST2 and systolic and diastolic dysfunction of the left ventricle and right heart

New opportunities for biomarkers in cardiovascular risk stratification. Resolution of Advisory board

Early detection of people with a high-risk of developing cardiovascular diseases is a key point of the prevention strategy. The existing risk scales have a number of limitations: insufficient accuracy for an individual or the appearance of a “residual risk”. Existing approaches to improving the accuracy of risk prediction include the use of biomarkers. Troponin I is promising, which has proven its prognostic value in healthy and asymptomatic individuals at the population level. For example, the BiomarCARE study with the participation of 74 thousand people from 5 countries showed an association of increased troponin I concentration and the frequency of cardiovascular events and overall mortality. Similar results were obtained in other cohorts. The simulation results indicate the potential economic feasibility of using troponin I for the purpose of risk stratification. The first pilot Russian study was conducted, which made it possible to describe the population distribution of troponin levels. It confirmed the prognostic significance of the biomarker in relation to the development of cardiovascular outcomes in men in the Russian population. Further studies on large cohorts are needed to clarify the results of the pilot project

Pre-hospital delays among patients with acute coronary syndrome in the Russian Federation: a multicentre prospective observational cohort study (the AMIR Study)

Objective: This study aimed to describe total pre-hospital delays (symptom onset to admission), patient delays (symptom onset to calling for help), and transport delays (calling for help to admission) experienced by patients with acute coronary syndrome (ACS) in Russia and identify factors associated with longer delays. Methods: A prospective observational cohort study of ACS patients with myocardial infarction recruited in hospitals providing percutaneous coronary intervention (PCI) and those that do not (non-PCI) in 13 regions and at multiple levels of the health system in Russia. Data were collected on pre-hospital delays between symptom onset and admission to the hospital providing definitive treatment, divided into patient delay (time between symptom onset and calling for help) and transport delay (time between calling for help and admission). Results: Of 902 patients, 701 (77.7%) had full data on pre-hospital delays. The median total pre-hospital delay in our study was 5.1 h, the median patient delay was 1.5 h, and the median transport delay was 2.1 h. Patient delays did not differ by age and sex, although having an ST-elevation myocardial infarction (STEMI) and certain symptom presentations, including severe pain, reduced delays. Transport delays were markedly reduced in those transported by emergency medical services (EMS) and taken directly to the hospital of definitive treatment (rather than to one closer but unable to offer PCI). Although transport delays were reduced in those using EMS, just half of the patients using EMS had a transport delay of <2 h (first medical contact to admission). Among all patients taken directly to the hospital by EMS, 70% were STEMI patients. Of these STEMI patients, 78% had a transport delay of 2 h or more. Among these patients, only 16.0% received thrombolysis in the ambulance. As expected, regional differences were apparent with all types of delay, with the greatest variation found in transport delays. Conclusion: Delays are currently longer than the European Society of Cardiology guidelines for STEMI patients and other severe cases. Reducing patient delays will reduce overall delays. Transport delays are inevitable in many regions of Russia, but better triage of patients, increased use of EMS, and early thrombolysis in EMS, particularly for STEMI patients facing excessive transport delays, will reduce delays and buy time before PCI

Mother-fetus immunogenetic dialogue as a factor of progeny immune system development

Despite the advances in medicine, about 4 million children under the age of 6 months die annually around the world due to infection, which is 450 deaths per hour (UNISEF, 2009). The degree of development of the immune system of children born in time is determined by many factors, including the immunogenetic similarity or difference of mother and fetus organisms, which, in turn, is due to the genotypes of mating pairs, as well as the selection of surrogate mothers during in vitro fertilization. From our review of the literature, it follows that immunogenetic interactions of mother and fetus organisms, which occur at all stages of pre- and postnatal development, have a signifcant effect on the resistance of offspring to infections and allergens. Before implantation, the mother’s immune responses are formed under the influence of semen fluid antigens, leukocytes and cytokines, as well as under the influence of the genes of the major histocompatibility complex, which are expressed in embryos at the stage of two cells. After implantation, transplacental transfer of immunoglobulins and immunocompetent cells becomes of immunomodulating importance. It is important to emphasize that, although substances with a high molecular weight usually do not pass through the placenta, this rule does not apply to immunoglobulin G (IgG), which, with a molecular weight of about 160 kDa, overcomes the transplacental barrier due to binding to the fetal Fc receptor. The level of IgG in newborns usually correlates with the level of maternal antibodies. During the period of natural feeding, the immune protection of newborns is provided by the mechanisms of innate immunity and the factors of humoral immunity of mothers. It has been shown that immunoglobulins from the milk of many animal species are transferred through the neonatal intestinal epithelium to the blood. Since breast milk contains large amounts of various immunoactive components, including proteins, cytokines, hormones, immunoglobulins, exosomes containing micro-RNA, and viable immune cells, the immunomodulating effects of breast milk persist even after elimination of maternal immunoglobulins from the blood of the offspring, up to maturation. Analysis of a large body of experimental data shows that the study of mechanisms of “motherfetus” and “mother-newborn” interactions are the basis of a knowledge base needed to fnd means of life-long directed modulation of the descendants’ immune status