Improving outpatient care in chronic heart failure

Despite advances in pharma and high-technology medicine, the rate of burdensome hospital admissions and mortality in patients with chronic heart failure (CHF) remains high. Over half of all admission-entailing decompensations have been repeatedly shown to emerge from non-compliance with outpatient prescriptions. Poor adherence to medication and non-medication treatment can only be broken by improving the patient’s awareness of the disease and his closer monitoring by healthcare professionals. The power of clinical and laboratory illness monitoring in line with the recommended quality criteria of medical aid in heart failure (HF) is strongly limited today by time resources available in outpatient and midwifery clinics. Meanwhile, an international and certain domestic experience has been built up to run CHF outpatient centres with involvement of specially-trained nursing and senior medical staff. Analytic evidence on such centres suggests a reduction in mortality and hospitalisation rate among the visiting patients. To combat existing drawbacks of CHF outpatient care, the National Medical Research Center of Cardiology in alliance with the Specialist Society of Heart Failure have developed the nurses’ guidelines for CHF rooms and are launching a medical staff training programme to manage CHF rooms, registry and data analysis. Furthermore, a procedure has been developed for patient routing to regional CHF outpatient cabinets that is being actively deployed in the Tyumen Region

Perspectives on the Use of Transthoracic Echocardiography Results for the Prediction of Ventricular Tachyarrhythmias in Patients with Non-ischemic Cardiomyopathy

Aim. To perform a comparative analysis of indicators of transthoracic echocardiography (TE), to establish echocardiographic predictors and their predictive role in the occurrence of stable ventricular tachyarrhythmia (VT) paroxysms in patients with nonischemic chronic heart failure (HF) and cardioverter-defibrillator (ICD) implanted for primary prevention of sudden cardiac death.Material and Methods. A prospective study was carried out, which included 166 patients with nonischemic HF at the age of 54 (49; 59) years with the left ventricle ejection fraction (LV EF) ≤35% and an ICD implanted. The observation time was 24 months. The primary endpoint was the first-ever stable paroxysm of VT (lasting for ≥30 seconds), detected in the «monitor» zone of VT, or paroxysm of VT, which required ICD therapy.  A total of 34 TE indicators were evaluated. Chi-square, Fischer, Manna-Whitney, single-factor logistic regression (LR), and multi-factor LR were used for data processing and analysis and for predictive modelling. Model accuracy was estimated using 4 metrics: ROC curve area (AUC), sensitivity, specificity and diagnostic efficiency.Results. During the two-year observation, 32 patients (19.3%) had a primary endpoint. The average time of occurrence of a stable VT episode was 21.6±0.6 months (95% confidence interval [CI] 20.5-22.8 months). The value of LV end-systolic dimension was the only parameter independently associated with VT (odds ratio 2.8 per unit increase, 95% CI 1.04-7.5; p=0.042). The complex analysis of echocardiographic indicators made it possible to identify 5 factors with the greatest predictive potential, which are linearly and nonlinearly related to occurrence of VT. These included the LV end-diastolic and end-systolic volumes, LV mass, index of relative LV wall thickness, upper-lower size of the right atrium. The metrics of the best predictive model were: AUC – 0.71 0.069 with 95% CI 0.574-0.843; specificity 50%, sensitivity 90.9%; diagnostic efficiency 57.1%.Conclusion. The study made it possible to evaluate the possibilities of the results of TE in predicting the probability of VT occurrence in patients with nonischemic HF and reduced LV EF. Predictive indicators have been identified that can be used to stratify the arrhythmic risk in the exposed cohort of patients

Possibilities for predicting ventricular tachyarrhythmias in patients with heart failure with reduced ejection fraction based on surface electrocardiography. First results from a single-center prospective study

According to current clinical guidelines, the risk of life-threatening ventricular tachyarrhythmias (VTAs) in patients with heart failure (HF) is determined by left ventricular ejection fraction (LVEF). The available clinical and experimental data indicate the imperfection of this one-factor approach, which specifies the need to search for new predictors of VTAs. In this prospective study, we performed a comparative analysis of surface electrocardiographic parameters in HF patients with LVEF ≤35% without syncope or sustained ventricular arrhythmias in history, who were implanted with cardioverter defibrillator as a primary prevention of sudden cardiac death. During the two-year follow-up, the primary endpoint (new-onset persistent VTA episode, or VTA/ventricular fibrillation that required electrotherapy) was recorded in 42 patients (25,5%). The secondary endpoint (an increase in LVEF by 5% or more of the initial level against the background of cardiac resynchronization therapy) was more often recorded in the group of patients without VTAs (41 (33%) vs 4 (9,5%), p=0,005). The studied cohort of patients was characterized by a left axis deviation (72%), LV hypertrophy signs (84%), impaired intra-atrial (P wave duration of 120 (101-120) ms) and intraventricular conduction (QRS duration of 140 (110-180) ms), ventricular electrical systole prolongation (QTcor — 465 (438-504) ms). Differences between the groups divided depending on reaching the primary endpoint in terms of the Cornell product, Cornell voltage index and ICEB, as well as the detection rate of complete left bundle branch block morphology had levels of significance close to critical (p=0,09; p=0,05; p=0,1; p=0,09, respectively). The multivariate predictive model included following factors: Cornell product, Tp-Te/ QRS, P wave duration (diagnostic efficiency of the model was 60%: sensitivity, 61,1%, specificity, 59,6%; p=0,007)

Comparative analysis of left ventricular strain parameters in patients with heart failure of ischemic and non-ischemic genesis

Aim. To carry out a comparative analysis of left ventricular (LV) strain parameters, determined by the two-dimensional strain imaging in patients with heart failure (HF) with LV ejection fraction (EF) ≤35%, depending on the origin of HF.Material and methods. The study included 133 patients with NYHA class 3-4 HF with LVEF ≤35%, taking optimal therapy. Based on the HF origin, 2 following groups of patients were formed: ischemic cardiomyopathy (ICM) (n=70), nonischemic cardiomyopathy (NICM) (n=63). All patients underwent speckle-tracking echocardiography.Results. All patients included in the study showed significant alterations in longitudinal strain parameters in most myocardial segments, most pronounced in the basal and middle parts of the LV. Comparative analysis of the peak systolic longitudinal strain showed the worst characteristics in patients with ICM were found in the apical segments (p=0,008), and in patients with NICM, in the basal segments of the LV (p=0,046). The studied groups had comparable LV global longitudinal and circumferential strain (p=0,26; p=0,67; respectively).Conclusion. Groups of patients with HF of ischemic and non-ischemic origin, despite comparable LVEF values, differ in the distribution of the decrease in local longitudinal strain of LV segments. The worst strain characteristics in patients with ICM and NICM are detected in LV apical and basal segments, respectively

Biomarkers in predicting mortality from cardiovascular events in patients with heart failure and an implanted cardioverter-defibrillator

Aim. To study the role of blood biomarkers in predicting death from cardiovascular events in patients with heart failure with reduced ejection fraction (HFrEF) within one year after cardioverter defibrillator (ICD) implantation.Material and methods. This one-center observation study included 384 HFrEF patients (men, 84%, NYHA class III – 74%, NYHA class IV – 7%), who underwent prospective observation for 1 year after ICD implantation. The study of the original panel of modern biomarkers (blood electrolytes, C-reactive protein, creatinine, soluble growth stimulation expressed gene 2 (sST2), N-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3), allowing to evaluate HF pathogenesis was conducted. Based on the blood creatinine concentration, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula was used to estimate the glomerular filtration rate (GFR).Results. In a one-year observation, the primary endpoint was recorded in 35 patients (11%). Single-factor logistic regression showed 3 biomarkers with the greatest predictive potential (p<0,01), related to the occurrence of the investigated endpoint. The concentration of potassium and NT-proBNP, the GFR (CKD-EPI) was included in the multi-factor predictive model with diagnostic efficiency of 68% (sensitivity of 60%, specificity 71%). It was shown that the cardiovascular death risk increased by 2,64 (OR=2,64; 95% CI: 1,28-5,46; p=0,007) at GFR <60 ml/min/1,73 m2 and increased by 3,32 (OR=3,32; 95% CI: 1,26-8,73; p=0,012) at NT-proBNP >2000 pg/ml.Conclusion. The study of blood biomarkers is promising and in demand for the prediction of adverse outcomes of HF. According to the data obtained, the factors «GFR <60 ml/min/1,73 m2» and «NT-proBNP >2000 pg/ml» may be relevant for one-year mortality prediction

МНЕНИЕ ВРАЧЕЙ О РОЛИ ОТДЕЛЬНЫХ ФАКТОРОВ СМЕРТНОСТИ ОТ БОЛЕЗНЕЙ СИСТЕМЫ КРОВООБРАЩЕНИЯ В РЕГИОНАХ РОССИЙСКОЙ ФЕДЕРАЦИИ

Background. Currently, the influence of specific factors on mortality rates for circulatory system disease (CSD) is actively studied by numerous researches. Purpose. To study and compare medical care practitioners’ estimation of the factors affecting the mortality statistics for CSD in different regions of the Russian Federation.Materials and Methods. Federal State Institution “National Research Centre for Preventive Medicine” compiled a questionnaire submitted to the Public Health Departments of the regions and researchers in preventive medicine and public health care from different regions of Russia. All the interviewees scored the influence of six factors as a leading cause of death (comorbid somatic pathology; comorbid psychopathology; comorbid alcohol and drug use disorders; non-compliance to treatment; ignorance of the major risk factors for CSD or refusal of their prevention; ignorance of the main manifestations (symptoms) of life-threatening diseases or complications) on mortality rates for CSD using a 1-to-5 rating scale. A total of 226 completed questionnaires were received: 37 questionnaires were completed by medical care practitioners from the Kemerovo region, 70 – from the Rostov region and 119 – from other regions of the Russian Federation. Three comparison groups were established.Results. There were no statistically significant differences in the scores between the comparison groups of medical care practitioners. The average impact of comorbid somatic pathology according to the medical care practitioners’ estimation was 3,5; comorbid psychopathology – 2,7; comorbid alcohol and drug use disorders – 3,5; non-compliance to treatment – 4; ignorance of the major risk factors for CSD or refusal of their prevention – 3,8; ignorance of the main manifestations (symptoms) of life-threatening diseases or complications requiring first aid and emergency medical service – 3,9. Despite certain differences in the medical care practitioners’ estimation of the influence of selected factors on mortality rates for CSD (Kendall’s coefficient of concordance W=0,181) the degree of agreement was statistically significantly (p<0.0001) different from zero.Conclusion. All these factors, estimated by the medical care practitioners, affect mortality rates for CSD. There were no statistically significant differences between the comparison groups’ estimates of the factors affecting mortality rates for CSD. There was a statistically significant low concordance between medical care practitioners in the use of the 1-to-5 rating scale.Актуальность. В настоящее время продолжаются исследования по оценке влияния отдельных факторов на смертность от болезней системы кровообращения (БСК). Цель: изучить и сравнить мнение врачей-специалистов о факторах, оказывающих влияние на статистические показатели смертности от БСК в различных регионах РФ.Материалы и методы. В ФГБУ ГНИЦ профилактической медицины Минздрава России была составлена анкета, направленная в департаменты здравоохранения регионов, научным работникам – специалистам в области профилактической медицины и общественного здоровья здравоохранения. Экспертам предлагалось ответить на вопросы, оценивая вклад каждого из представленных шести факторов (коморбидная соматическая патология; коморбидная психическая патология, коморбидная патология на фоне употребления алкоголя и наркотиков, невыполнение рекомендаций врача, незнание основных факторов риска развития БСК или отказ от их коррекции, незнание основных проявлений (симптомов) жизнеугрожающих заболеваний или их осложнений) как ведущей причины смерти на смертность от болезней системы кровообращения по пятибалльной шкале. Всего было получено 226 заполненных анкет, из них 37 – от специалистов, работающих в Кемеровской области, 70 – Ростовской области, 119 – других регионов РФ. Таким образом, сформированы три группы сравнения.Результаты. Не выявлено статистически значимых различий в ответах на вопросы между группами врачей. Средний балл влияния коморбидной соматической патологии, по мнению врачей, составляет 3,5; коморбидной психической патологии – 2,7; коморбидной патологии, обусловленной употреблением алкоголя и наркотиков, – 3,5; невыполнением рекомендаций врача – 4; незнание основных факторов риска развития БСК или отказ от их коррекции – 3,8; незнание основных проявлений (симптомов) жизнеугрожающих заболеваний или их осложнений, требующих первой помощи и экстренной медицинской помощи, – 3,9. Несмотря на определенные различия в мнении врачей относительно влияния каждого из рассматриваемых факторов на смертность от БСК (коэффициент конкордации Кенделла W=0,181) степень согласия статистически значимо (р<0,0001) отличается от нуля.Вывод. Все перечисленные факторы, по мнению врачей, оказывают значительное влияние на смертность от БСК. Статистически значимых различий между мнениями групп врачей в оценке факторов, влияющих на смертность БСК, не выявлено. Имеется статистически значимая, но низкая степень согласия врачей в бальной оценке рассматриваемых факторов

Appointment of lipid-lowering therapy in the Russian population: comparison of SCORE and SCORE2 (according to the ESSE-RF study)

Aim. In 2021, the European Society of Cardiology (ESC) guidelines for the prevention of cardiovascular diseases (CVDs) were published, where a new SCORE2 CVD risk assessment model was introduced. In our work, we compared approaches to determine the indications for initiating lipid-lowering therapy in the Russian population aged 25-64 years according to the guidelines for the diagnosis and treatment of lipid metabolism disorders of the Russian National Atherosclerosis Society (2020) and ESC guidelines for CVD prevention (2021).Material and methods. The ESSE-RF epidemiological study was conducted in 12 Russian regions. All participants signed informed consent and completed approved questionnaires. We performed anthropometric and blood pressure (BP) measurements, as well as fasting blood sampling. In total, 20665 people aged 25-64 years were examined. The analysis included data from 19546 respondents (women, 12325 (63,1%)).Results. Of the 19546 participants, 3828 (19,6%) were classified as high or very high CV risk based on the 9 criteria: BP ≥180/110 mm Hg, total cholesterol >8,0 mmol/l, low-density lipoprotein (LDL) >4,9 mmol/l, lipid-lowering therapy, chronic kidney disease (CKD) with glomerular filtration rate <60 ml/min/1,73 m2, type 2 diabetes, previous stroke and/or myocardial infarction. Of 3828 people, lipidlowering therapy was indicated in 3758 (98%) (criteria for LDL ≥1,8 mmol/l and LDL ≥1,4 mmol/l, respectively, high and very high risk). In addition, 5519 individuals aged <40 years were excluded from further analysis due to the lower age threshold of models. For 10199 participants aged >40 years without established CVD, diabetes, CKD, cardiovascular risk stratification was performed according to the SCORE and SCORE2. Of them, according to the Russian National Atherosclerosis Society (2020) and ESC 2021 guidelines, lipid-lowering therapy was indicated for 701 and 9487 participants, respectively.Conclusion. Using the new approach proposed by the ESC in 2021, the number of patients aged 40-64 years without CVD, diabetes and CKD with indications for lipidlowering therapy for primary prevention in Russia increases by 14 times compared with the 2020 Russian National Atherosclerosis Society guidelines

Pathogenic Variant Rs1471414348of the TTN Gene in the Patient with Familial Left Venticular Noncompaction Cardiomyopathy

The clinical, instrumental and molecular-genetic studies for proband and family members for identification of family form of left ventricular noncompaction cardiomyopathy (LVNC) presented in the article. According to the results of the examination, the diagnosis LVNC was made. Drug therapy was adjusted, and a cardioverter defibrillator was implanted for the primary prevention of sudden cardiac death. Given the hereditary nature of the disease, family screening was conducted. By the family screening the disease was diagnosed in the mother of proband. Later, was made exome sequencing in a group of genes related to the development of left ventricular noncompaction cardiomyopathy. One likely pathogenic variant (rs1471414348, stop codon) in the TTN gene was detected. The discovered variant was validated by Sanger sequencing and was detected only in the proband and his mother, and was absent in other relatives. There were no other pathogenic and probably pathogenic variants in genes associated with the development of left ventricular noncompaction and other cardiomyopathies. As a result of family screening the new cases were diagnosed, the pathogenic variant of the TTN gene was identified, that is probably responsible for the development of the LVNC phenotype

НОЗОЛОГИЧЕСКАЯ СТРУКТУРА СМЕРТНОСТИ ОТ БОЛЕЗНЕЙ СИСТЕМЫ КРОВООБРАЩЕНИЯ в 2006 и 2013 годах

The article provides the results of the assessment of mortality parameters from circulatory system disease (CSD) in Russia in the period from 2006 to 2013. The comparative analysis of the nosological structure of causes of death from CSD was performed. Standardized mortality ratio from CSD decreased by 29,1 % in 2013 compared to 2006. Mortality rates caused by CSD prevail in total mortality rates, in particular in the >75 years age group, accounting for 70 % of all deaths. The vast number of deaths was caused by coronary artery disease, i. e. the cases that were not related to acute coronary events. Mortality rates after myocardial infarction (MI) have declined in all age groups < 80 years. Due to the increase in mortality rates after MI in the age groups > 80 years, there was no significant shift in mortality rates after MI in the total population. Recent amendments to the nosological coding of causes of death make difficult to perform the comparative assessment of mortality rates in a number of CSD. However, there was a significant number of deaths from SCD, which clinical interpretation is complicated by the current classification coding, thus, raising problems in the planning and organization of medical and social care, aimed at reducing mortality from SCD.В статье дана оценка показателей смертности от болезней системы кровообращения (БСК) в России в динамике с 2006 по 2013 г., проведен сравнительный анализ нозологической структуры причин смерти по данному классу заболеваний. Стандартизованный показатель смертности от БСК в 2013 г. снизился по сравнению с 2006 г. на 29,1 %. Доля смертей от БСК в структуре общей смертности высока, особенно в возрастных группах старше 75 лет, составляя около 70 % смертей от всех причин. Подавляющее число смертей от ишемической болезни сердца – это случаи, не связанные с острыми коронарными событиями. Смертность от инфаркта миокарда (ИМ) сократилась во всех возрастных группах моложе 80 лет, но, учитывая рост смертности от ИМ в возрастных группах старше 80 лет, существенной динамики показателей смертности от ИМ в популяции в целом, не выявлено. Сравнительная оценка показателей смертности по ряду заболеваний класса БСК затруднена в связи с внесением изменений в краткую номенклатуру причин смерти за текущий период. В структуре БСК как в 2006 г., так и в 2013 г. отмечается значительное число случаев смерти, текущая классификация которых вызывает проблемы с клинической интерпретацией, а следовательно, проблемы с планированием и организацией медико-социальной помощи, направленной на снижение смертности от БСК