СТАТИНОТЕРАПИЯ ПОСЛЕ ОСТРОГО КОРОНАРНОГО СИНДРОМА: УРОКИ РЕАЛЬНОЙ КЛИНИЧЕСКОЙ ПРАКТИКИ

Aim. To evaluate the effcacy of statin therapy in patients with acute coronary syndrome in real clinical practice and to develop the monitoring of the quality of patients’ management.Methods.  255 patients with acute coronary syndrome who have undergone stenting of the infarct-related coronary artery were included in the study using the continuous sampling method. The follow-up period was 12 months. All the patients received atorvastatin at a dose of 20 mg were included in the «Omsk Segion State Program» (Program) – the control group. The comparison group consisted of 112 patients with acute coronary syndrome who have undergone the stenting of the infarctrelated coronary artery, but who were not included in the Program and were routinely prescribed statins by general practitioners in the outpatient settings. Medical record abstracts and outpatient medical records were analyzed to estimate prescribed statin therapy regimens and clinical and laboratory fndings. The experts analyzed real clinical practice of statin prescription and monitored its effcacy and safety according to the recent guidelines on dyslipidemia. A novel method for improving the quality of statin therapy has been developed and introduced. Statistical analysis was processed using biometric statistical methods.Results. We found that cardiologists (control group) and general practitioners (comparison group) had low adherence to the current guidelines on dyslipidemia. The effcacy and safety of statin therapy regimens and duration were not monitored. Only 9.8% of patients in the control group and 3.6% of the patients in the comparison group achieved the target levels of low-density lipoprotein cholesterol (less than 1.8 mmol/l) within the 12-month follow-up (p = 0.096).Conclusion. Healthcare professionals’ low adherence to the current guidelines on dyslipidemia led to the need to develop the monitoring of the quality of patients’ management within 12 months after acute coronary syndrome.Цель. Провести анализ эффективности статинотерапии больных после острого коронарного синдрома в реальной клинической практике для разработки способа контроля качества ведения пациентов.Материалы и методы. Методом сплошной выборки в исследование включены 255 пациентов, перенесших острый коронарный синдром и стентирование инфаркт-зависимой коронарной артерии, наблюдавшихся у врачей-кардиологов 12 месяцев после события и получавших аторвастатин в дозе от 20 мг в рамках реализации «Государственной программы Омской области "Развитие здравоохранения Омской области"» в части бесплатного лекарственного обеспечения (Программа) – группа контроля. Группу сравнения составили 112 пациентов после острого коронарного синдрома со стентированием инфаркт-зависимой коронарной артерии, не включенных в Программу, получавших статины в рамках назначений врачей-терапевтов в поликлиниках по месту жительства. Проанализированы выписки из историй болезни и медицинские карты амбулаторных больных для оценки данных клинических и лабораторных исследований пациентов, реальной клинической практики статинотерапии. Проведен экспертный анализ реальной клинической практики назначения статинов, контроля их эффективности и безопасности по отношению к актуальным клиническим рекомендациям по дислипидемии. Разработан и внедрен способ улучшения качества терапии статинами. Материал обработан с использованием методов биометрической статистики.Результаты. Выявлена низкая приверженность врачей-кардиологов (группа контроля) и врачей-терапевтов (группа сравнения) к актуальным клиническим рекомендациям по дислипидемии. Не соблюдались объемы и сроки контроля эффективности и безопасности статинотерапии. Отсутствие назначения высоких доз статинов было не обосновано. Это привело к достижению через 12 месяцев наблюдения целевых значений холестерина липопротеидов низкой плотности (менее 1,8 ммоль/л) лишь у 9,8% пациентов в группе контроля и у 3,6% пациентов в группе сравнения (p = 0,096).Заключение. Низкая приверженность врачей к актуальным клиническим рекомендациям по дислипидемии обусловила необходимость разработки способа контроля качества ведения пациентов в течение 12 месяцев после острого коронарного синдрома

Клинические аспекты включения пациентов с ишемической болезнью сердца после реваскуляризации миокарда в программу физической медицинской реабилитации на амбулаторном этапе

Aim. To determine the clinical factors affecting the timely reference of patients with coronary artery disease after myocardial revascularization to Phase 3 cardiac rehabilitation.Methods. 773 patients with coronary artery disease (CAD) who underwent myocardial revascularization were recruited in a study. Of them, 77 (9.96%) underwent coronary artery bypass grafting and 696 (90.04%) underwent PCI. Within 1 month of discharge, patients were examined by a cardiologist in the outpatient hospital and then referred to the cardiac rehabilitation team to assess their eligibility. The eligibility for exercise rehabilitation was assessed based on the results of general examination, clinical and laboratory findings. The prevalence of absolute and relative contraindications to exercise rehabilitation was measured.Results. 10% of CAD patients after myocardial revascularization had absolute contraindications and 29.6% had relative contraindications to exercise rehabilitation. The presence of relative contraindications (exaggerated blood pressure response (>80/100 mm Hg) to exercise or a decrease in systolic blood pressure ≥20 mm Hg, ventricular extrasystole and tachycardia, paroxysmal tachyarrhythmias in response to exercise, active gastroduodenal ulcer, and less than 1 month after its exacerbation, moderate heart valvular disease (aortic stenosis), decompensated carbohydrate metabolism disorders) required the management of risk factors limiting patients on the participation in exercise rehabilitation. The routing of CAD patients after myocardial revascularization at Phase 3 cardiac rehabilitation was developed and introduced in the Clinical Cardiological Dispensary in the Omsk region.Conclusion. Most patients with CAD after myocardial revascularization should be referred to exercise rehabilitation. These patients rarely have absolute contraindications (about 10%). Despite relative contraindications are rather high (about 30%), risk factors limiting patient participation in exercise rehabilitation are managed successfully. Optimal routing of patients contributes to their prompt recruiting to cardiac rehabilitation. Effective management of cardiovascular risk factors allows recruiting more patients in exercise rehabilitation.Цель. Определить клинические факторы, влияющие на своевременность включения пациентов с ишемической болезнью сердца (ИБС) после реваскуляризации миокарда в программу физической реабилитации (ПФР) с использованием тренажеров на третьем (амбулаторном) этапе медицинской реабилитации.Материалы и методы. В исследование методом сплошной выборки включены 773 пациента с ИБС после реваскуляризации миокарда: 77 (9,96%) больных, перенесших аортокоронарное шунтирование, и 696 (90,04%) - стентирование, обратившихся в первые трое суток после выписки из сосудистых центров к врачу-кардиологу БУЗОО «ККД», принятых для диспансерного наблюдения и направленных в течение месяца после перенесенного сердечно-сосудистого события к врачу-кардиологу - специалисту по медицинской реабилитации БУЗОО «ККД». На основании результатов общеклинического и клинико-лабораторного обследований определена распространенность абсолютных и относительных противопоказаний для включения пациентов в ПФР с использованием тренажеров. Оценка динамики эффективности физической реабилитации на тренажерах не являлась задачей настоящего исследования.Результаты. 10% пациентов с ИБС после реваскуляризации миокарда имели абсолютные, 29,6% - относительные противопоказания к участию в ПФР на тренажерах. Наличие относительных противопоказаний (повышение артериального давления в ответ на физическую нагрузку более 180/100 мм рт. ст. или снижение систолического артериального давления ≥20 мм рт. ст., желудочковая экстрасистолия и тахикардия опасных градаций, пароксизмальные тахиаритмии, язвенная болезнь желудка и двенадцатиперстной кишки в стадии обострения и ранее месяца после обострения, умеренно выраженный порок сердца (аортальный стеноз), декомпенсация нарушений углеводного обмена) потребовало коррекции факторов, ограничивших участие пациентов в ПФР. Разработана и внедрена в работу БУЗОО «ККД» маршрутизация пациентов с ИБС после реваскуляризации миокарда на третьем (амбулаторном) этапе медицинской реабилитации.Заключение. Большинство пациентов с ИБС после реваскуляризации миокарда должны быть включены в ПФР на тренажерах, так как абсолютные противопоказания встречаются достаточно редко (около 10%), а факторы, ограничивающие участие в физических тренировках (относительные противопоказания), несмотря на высокую распространенность (около 30%), могут быть скорректированы на этапе кардиореабилитации. Оптимальная маршрутизация пациентов определяет своевременность включения в ПФР. Коррекция факторов риска прогрессирования сердечно-сосудистых заболеваний способствует включению в ПФР наибольшего количества пациентов

Clustering in dimension reduction for function approximation problem

In order to reduce the dimension of input vectors before construction of ap-proximation MAVE-type methods (minimum average variance estimation) can be used, however they are very computationally intensive. In the present work the modification of method MAVE is described which allows substantial decrease of algorithm run time at the expense of small error increase

Clustering in dimension reduction for function approximation problem

In order to reduce the dimension of input vectors before construction of ap-proximation MAVE-type methods (minimum average variance estimation) can be used, however they are very computationally intensive. In the present work the modification of method MAVE is described which allows substantial decrease of algorithm run time at the expense of small error increase

Approximation of multidimensional dependency based on an expansion in parametric functions from the dictionary

In the present work method for construction of approximation of unknown multidimensional dependency based on data sample is proposed. Approximation is constructed in the class of linear expansions in parametric functions from the dictionary. Parameters of the functions from the dictionary are estimated using gradient methods and expansion coefficients are calculated using adap-tively regularized method of least squares. Regularization is used to increase the stability of iterative estimation of parameters. For additional improvement of stability/generalization ability of approximation specially developed method for boosting is used

Dimension reduction as a part of function approximation problem

Usually in case of approximation of high-dimensional unknown dependencies the "curse of dimensionality" problem arises. In order to deal with such problem preliminary dimension reduction of input vector should be done. In this paper the methodology for integration of dimension reduction procedure into the method for construction of function approximation is proposed. Developed method al¬lows choosing optimal combination of dimension of compression transformation and complexity of a model used for approximation avoiding overtraining of approximating function. Application of proposed method to real and artificial data shows good performance in terms of accuracy

Dimension reduction as a part of function approximation problem

Usually in case of approximation of high-dimensional unknown dependencies the "curse of dimensionality" problem arises. In order to deal with such problem preliminary dimension reduction of input vector should be done. In this paper the methodology for integration of dimension reduction procedure into the method for construction of function approximation is proposed. Developed method al¬lows choosing optimal combination of dimension of compression transformation and complexity of a model used for approximation avoiding overtraining of approximating function. Application of proposed method to real and artificial data shows good performance in terms of accuracy

Antihypertensive Efficacy of Fixed Combination of Amlodipine and Ramipril in Patients with Arterial Hypertension and Very High Cardiovascular Risk

Aim. To evaluate the antihypertensive efficacy and tolerability of a fixed combination of amlodipine and ramipril in hypertensive patients with very high cardiovascular risk. Material and methods. A retrospective cohort study of real clinical practice of prescribing antihypertensive drugs according to 255 medical records of outpatient hypertensive patients with a history of acute coronary syndrome (ACS) and coronary artery stenting was performed in the first part. An open observational study was performed in the second part. 69 people older than 18 years with a history of ACS and coronary artery stenting, without reaching the target blood pressure (BP) level while using free combinations of antihypertensive drugs and with indications for a fixed combination of ramipril and amlodipine were included into the study. Analysis of self-monitoring of BP, office BP, daily BP monitoring (ABPM) and patients’ adherence to treatment (Morisky-Green test) initially, after 4 and after 12 weeks of taking the fixed combination of ramipril and amlodipine was performed to assess the clinical efficacy of the studied drug. Results. It was found that 42.0% of patients did not follow the recommendations for regular intake of antihypertensive drugs. So, hypertension of all patients regarded as false-refractory, which was the basis for the prescription of the fixed combination of ramipril and amlodipine in accordance with clinical guidelines for the diagnosis and treatment of hypertension. After 4 weeks of therapy, there was significant decrease in office BP with the achievement and preservation of the target level by the 12th week, normalization to the 12th week of day and night BP variability in 54.9% of patients. 78.0% of patients followed medical recommendations for regular administration of antihypertensive drugs, none of the patients had adverse events. Conclusion. The use of fixed combinations of drugs, in particular, amlodipine and ramipril as a part of multicomponent therapy in hypertensive patients with very high cardiovascular risk, led to the achievement of target BP by the 4th week of therapy and stable preservation of antihypertensive effect in 12 weeks of treatment as well as gradual normalization of day and night BP variability in more than half of patients. Fixed combination of ramipril and amlodipine allowed to improve adherence of patients to cardiovascular diseases