Pretest probability of coronary artery disease as a factor for optimizing invasive diagnostics in routine clinical practice

According to the European Society of Cardiology guidelines, patients with chest pain requires the calculation of pretest probability (PTP) of coronary artery disease (CAD), followed by the identification of diagnostic tactics.Aim. To analyze the registry of patients with stable CAD in order to assess the frequency of PTP calculation, as well as the validity of diagnostic tactics choice depending on its level.Material and methods. The data of the registry of patients with stable CAD for the periods from 2012 to 2014 and from 2017 to 2019 were analyzed. We assessed the number of CAD patients, proportion of men, and distribution of patients depending on angina functional class. In addition, data on PTP calculation, as well as distribution of patients and diagnostic strategy selected depending on its value was analyzed. To assess differences (p) in pairwise comparisons, Student’s t-test was used. Differences were considered significant at p<0,05. Statistical analysis was performed using Microsoft Office Excel 2010 (Microsoft, USA) and STATISTICA 6.0 (StatSoft Inc., USA).Results. In 2017-2019, the number of detected CAD cases and proportion of men increased. In both time periods, an insufficient level of calculating PTP of CAD remains. In patients with intermediate PTP, 15-85% of priority tactics are invasive interventions, and with high PTP, the percentage of invasive methods does not reach the proper level, which does not correspond to modern guidelines for the management of CAD patients and leads to misappropriation of funds and healthcare resources.Conclusion. According to medical records, PTP can be determined in less than half of patients. In CAD patients with intermediate PTP, non-invasive studies are not carried out in full, since coronary angiography is preferred. In patients with a high PTP, invasive diagnostics is insufficient

COMPARISON OF FOSINOPRIL AND ATENOLOL EFFECT ON HEART 0.1 HZ-RHYTHMS SYNCHRONIZATION AND BLOOD MICROCIRCULATION IN PATIENTS WITH ARTERIAL HYPERTENSION

Aim. To compare the effect of fosinopril and atenolol on synchronization of heart 0.1 Hz-rhythms and blood microcirculatory.Material and methods. 63 patients at the age of 47±8 with hypertension (HT) of grade 1-2 were enrolled in the study. 0.1 Hz-oscillations in heart rate variability (HRV) and in filling of microcirculatory bed were registered during passive tilt test under spontaneous breathing. The duration of each stage of test was 10 min. Synchronization was estimated as a phase difference between 0.1 Hz-rhythms of heart rate and filling of microcirculatory bed. Frequency values of HRV spectrum in LF- and HF-ranges were also assessed.Results. Fosinopril and atenolol showed comparable effect on blood pressure (BP) reduction. Atenolol decreased in heart rate significantly. Treatment with either fosinopril or atenolol in patients with significant vegetative dysfunction resulted in repair of functional interaction between heart 0.1 Hz-regulation and microcirculatory bed. Functional dissociation of 0.1 Hz-regulation mechanisms was observed under the treatment with fosinopril or atenolol in patients with initially sufficient interaction.Conclusions. Fosinopril and atenolol influenced similarly on heart 0.1 Hz-mechanisms and microcirculation autonomic regulation in patients with HT. Atenolol is a drug of choice in patients with sympathicotony. Both drugs should be administered in according with an individual level of 0.1-Hz rhythms synchronization assessed before start of the treatment

Медицинская помощь больным острым коронарным синдромом в 2018 году: данные федерального регистра

Aim. To evaluate the quality of reperfusion, medical therapy, as well as the short-term outcomes in patients with acute coronary syndrome (ACS) in 2018 using the data of the national ACS registry.Methods. Medical records of 30,594 ACS patients (62% - men, the mean age of 65±11,2 years) treated in 30 regions of the Russian Federation in 2018 were selected in the National ACS Registry and analyzed. The rate and timing of percutaneous coronary intervention (PCI) and fibrinolysis, prescription of aspirin, clopidogrel, beta-blockers, statins, and in-hospital mortality rate were assessed.Results. Fibrinolysis was performed in 29.9% of patients with ST-segment elevation acute coronary syndrome. 54,3% of patients with ST-segment elevation ACS underwent PCI. 47.7% and 60.5% of patients were treated within 30 minutes of first medical contact to fibrinolysis and 90 minutes to primary PCI. 95.6% of patients received aspirin, 84.9% - clopidogrel, 88.8% - beta-blockers, and 93.4% - statins. The inhospital mortality was 2.9%.Conclusion. The main clinical performance and quality measures for medical therapy in 2018 were high according to the National ACS Registry. PCI prevailed among the selected reperfusion strategies. However, the timing of both, PCI and fibrinolysis, was insufficient.Цель. Оценить качество мероприятий по реперфузии миокарда, медикаментозной терапии, а также краткосрочные исходы лечения у больных острым коронарным синдромом (ОКС) по данным Федерального регистра за 2018 г.Материалы и методы. Проанализированы данные 30 594 пациентов (62% мужчин, средний возраст 65±11,2 года) из 30 регионов Российской Федерации, полученные из Федерального регистра ОКС за 2018 г. Оценены частота и своевременность чрескожных коронарных вмешательств (ЧКВ) и тромболизиса, назначение аспирина, клопи-догрела, бета-блокаторов, статинов, уровень госпитальной летальности.Результаты. Тромболитические препараты назначали 29,9% пациентов с ОКС с подъемом сегмента ST, ЧКВ выполнено 54,3% больных ОКС с подъемом сегмента ST. Тромболизис выполнен в течение 30 мин 47,7% больных, ЧКВ в течение 90 мин - 60,5% пациентов. Характеристики медикаментозного лечения: аспирин назначали 95,6% больных, клопидогрел - 84,9%, в—блокаторы - 88,8%, статины - 93,4% пациентов с ОКС, включенных в Федеральный регистр. Госпитальная летальность составила 2,9%.Заключение. По данным Федерального регистра больных ОКС в 2018 г. отмечено высокое качество основных мероприятий медикаментозной терапии. Мероприятия по реперфузии миокарда характеризуются преобладанием ЧКВ. Своевременность выполнения реваскуляризации миокарда (как тромболизиса, так и ЧКВ) недостаточная

The importance of pharmacogenetic research for optimization of antihypertensive treatment

As time goes by, significant individuality of antihypertensive drugs effectiveness may be clarified by pharmacogenetic research methods. Pronounced variability of pharmacological response may be caused by mononucleotide substitutions in genes, coding biotransformation enzymes. The present work is dedicated to investigation of allelic variants of functionally defective genes CYP2D6 and CYP2C9 in patients with arterial hypertension. Possible relation of distinct associations of polymorphous gene variants with difference in individual sensitivity to beta-blockers and angiotensin receptor blockers was shown

INDICATIONS FOR MYOCARDIAL REVASCULARIZATION – ARE THEY USING EQUALLY FOR CHOOSING OF INVASIVE STRATEGY IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE?

The purpose was to reveal the value of separate indications for myocardial revascularization as well as their combinations for choosing invasive or conservative strategy of treatment in patients with stable coronary artery disease (CAD) during 2012–2015 years.Materials and methods. The retrospective data of 1196 patients (mean age: 52.5 ± 8.4 years; 77,0 % men) were analyzed, from the register of patients with stable CAD (2012–2015 years), who had separate indications for myocardial revascularization and their combination. Patients were divided into 2 groups: with an invasive (n = 481 patients without considering the revascularization method) and conservative (n = 715 patients) treatment strategy. Indications for revascularization are taken from the recommendations of the European Society of Cardiology 2014.Results. The most common indication for myocardial revascularization was the presence of any coronary stenosis in combination with the limiting angina in the context of optimal medication (88.1 % in the invasive treatment group, 94.3 % in the conservative therapy group, p < 0.001). In half of the patients in both groups this indication was found in isolation, in the rest – in combination with other indications for surgical treatment. Among the combinations of indications, significant differences between the groups showed the following. Stenosis of the LM >50 % + proximal stenosis LAD >50 %+ limiting angina pectoris occurred in 1.5 % of the patients in the invasive treatment group versus 3.8 % with the conservative strategy (p = 0.020). Proximal stenosis LAD >50 % was more common among operated patients (10.6 % vs 4.6 % in the conservative treatment group, p <0.001). Two- and three-vessel lesions + ejection fraction LV <40 % + limiting angina pectoris also occurred more frequently in the invasive treatment group (2.5 % vs 0.6 % in the conservative strategy group, p = 0.006).The remaining indications for myocardial revascularization and their combination were equally common in both groups.Conclusion. The presence of isolated proximal LAD stenosis or multivessel lesion with reduced left ventricular function accompanied with limiting angina was associated with the choice of invasive strategy in patients with stable CAD (data for 2012–2015 years). The lesion LM combined with proximal stenosis LAD and limiting angina pectoris and requiring coronary artery bypass grafting was associated with the choice of a conservative strategy. Almost half of the patients (48.6 %) had revascularization to improve the quality of life

IMPLEMENTATION OF EVIDENCE-BASED CLINICAL-AND-MORPHOLOGICAL APPROPRIATE USE CRITERIA FOR CORONARY REVASCULARIZATION IN PATIENTS WITH ACUTE CORONARY SYNDROME IN RUSSIA

Aim. To study possibility of using the evidence-based clinical-andmorphological appropriate use criteria for percutaneous coronary interventions (PCIs) for expert evaluation of high-technology procedures implementation in patients with acute coronary syndrome (ACS) in Russia.Materials and methods. The appropriateness of performed PCI was assessed in patients with ACS, underwent coronary revascularization. The potential need in PCI was determined in ACS patients refused from coronary revascularization. Assessment was performed with the help of ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update (ACCF 2012). Data from 65,912 ACS patients, containing in Russian ACS Registry (2010–2011) were examined.Results. ACCF 2012 criteria allow to assess the clinical appropriateness of PCI in 79.2% of patients underwent coronary revascularization and to determine the potential need in PCI in 80.6% of patients, refrained from coronary revascularization. Among ACS patients underwent PCI (n=9147), intervention was appropriate in 68.9% of cases. Inappropriate PCI was revealed in 4.6% of cases. Among patients refrained from PCI (n=56765), coronary revascularization was potentially appropriate in 57.9% of cases.Conclusion. ACCF 2012 clinical-and-morphological criteria allow to judge on appropriateness of performed PCI and to evaluate the potential need in PCI among the most part of Russian ACS patients. In present study coronary revascularization was appropriate in the majority of ACS patients. It was shown possible to use the evidence-based clinical-andmorphological criteria for expert evaluation of high-technology procedures implementation in Russian ACS patients

ASSESSMENT OF MYOCARDIAL REPERFUSION QUALITY IN PATIENTS WITH ACUTE CORONARY SYNDROME AND ST SEGMENT ELEVATION, BASED ON THE CRITERIA BY THE AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION

Aim. To use the criteria by the American College of Cardiology/American Heart Association (ACC/AHA), in order to assess the quality of myocar-dial reperfusion in Russian patients with acute coronary syndrome (ACS) and ST segment elevation (STE-ACS).Material and methods. We analysed the clinical data of 25682 patients with STE-ACS, who were treated (2010–2011) in Russian hospitals participating in the Russian ACS Registry. The following ACC/AHA indicators (2008) were used: “time to thrombolysis” — the percentage of STE-ACS patients who received thrombolysis within 30 minutes after admission; “time to primary percutaneous coronary intervention (PCI)” — the per-centage of STE-ACS patients in whom primary PCI started within 90 minutes after admission; and “reperfusion” — the percentage of STE-ACS patients who underwent any reperfusion intervention within 12 hours after the chest pain onset.Results. Among 25682 STE-ACS patients, any reperfusion intervention (PCI and/or thrombolysis, in any order) were performed in 12043 (46,9%). Among 7437 STE-ACS patients who underwent thrombolysis, 5119 (69%) met the inclusion criteria. In this group, the indicator “time to thrombolysis” was met in 3342 patients (65,3%). Among 5405 STEACS patients who underwent PCI, 3993 (73,9%) met the inclusion criteria. In these patients, the indicator “time to primary PCI” was met in 2797 (70%). Finally, among 25135 (97,9%) patients with STE-ACS who were included in the analyses, the indicator “reperfusion” was met in 9800 (38,9%).Conclusion. The main problem of the health care for Russian patients with STE-ACS is the limited reperfusion coverage. However, the reperfusion quality could be regarded as satisfactory

Blood pressure control in primary care patients with arterial hypertension: analysing the Hypertension Register data

Aim. (1) To investigate clinical characteristics of primary care patients with arterial hypertension (AH), according to the achievement of target blood pressure (BP) levels; (2) to assess the effectiveness of therapeutic measures aimed at achieving target BP and maintaining its long-term control. Material and methods. This retrospective analysis included the data from ambulatory medical records of 5558 AH patients, who attended primary care centres in 2007. Clinical characteristics were compared in patients with achieved vs. non-achieved target BP levels. According to the national AH guidelines (2004), the completeness of examination, pharmaceutical therapy tactics, and frequency of the follow-up were assessed in both groups. Results. Based on the 2007 data, target BP levels were maintained in 28% of AH patients. Mean BP level was 144/87 mm Hg. Patients with optimal BP levels, compared to their peers with inadequate BP control, had significantly (p<0,001) higher prevalence of angina pectoris (40,4% vs. 30,1%, respectively) or previous myocardial infarction (19,4% vs. 8,4%), as well as higher frequency of lipid profile assessment, creatinine measurement, and echocardiography. Mean number of prescribed antihypertensive medications was 2,08 vs. 1,60, respectively. Mean number of clinical visits per year was 4,07 vs. 2,99, while mean interval between the visits reached 72,3 vs. 62,7 days, respectively. Regardless of the target BP achievement, the quality of diagnostic and therapeutic management did not comply with the recommended standards. Conclusion. Patients with optimal BP control were characterised by a more severe clinical course, as well as by a wider scope and higher frequency of diagnostic and therapeutic procedures. At the primary care level, the quality of AH diagnostics and treatment did not comply with the recommended standards; therefore, mean BP levels in the AH Register sample were higher than the target ones

PHARMACOTHERAPY QUALITY IN PATIENTS WITH ARTERIAL HYPERTENSION OBSERVED IN PRIMARY CARE PRACTICE. HYPERTENSION REGISTER DATA

Aim. To assess (on the basis of Russian national guidelines on arterial hypertension (HT), 2004) quality of pharmacotherapy measures among hypertensive patients observed in primary care practice. Material and methods. Data on 12 604 patients with HT (7 819 women, 4 785 men, aged 59.5±12.0 years) from 13 regions of Russia observed in primary care units during 2007 were enrolled in the study. Compliance with recommendations on decision making about pharmacotherapy need (risk category assessment) and adequacy were evaluated. Results. 64% of patients with HT had no drug prescriptions in their outpatient card in 2007. 4 880 patients from 12 604 enrolled HT patients (38.7%) had all data necessary for risk assessment. 3920 patients (31% of the whole studied group) had pharmacotherapy indications (high or very high risk). Only 819 HT patients (6.5% of the whole number of enrolled patients) had antihypertensive pharmacotherapy completely corresponding to their clinical status. Conclusion. The quality of pharmacotherapy measures carried out in primary care practice during 2007 did not conform to HT guidelines