Cardiovascular risk management system: prerequisites for developing, organization principles, target groups

[Decompensated heart failure with reduced ejection fraction: overcoming barriers to improve prognosis in the "vulnerable" period after discharge]

Frequency of hospitalizations for decompensated heart failure (HF) and associated costs are steadily increasing worldwide. An episode of HF is a risk marker, reflects a change in the course of disease, a high probability of adverse events, and requirement for using all options to improve the prognosis. This article discusses barriers and ways to overcome them in managing HF patients with low ejection fraction. An evidence-based, disease-modifying therapy exists for this HF phenotype. Administration of the therapy along with additional, novel drugs that improve outcomes, and organization of medical care are essential during the "vulnerable period" after discharge from the hospital.

[The frequency and profile of drug treatment in subjects with dyslipidemias and cardimetabolic diseases in an urban russian population older then 55 years]

Aim      To analyze frequency and profile of the lipid-lowering therapy (LLT) in patients with dyslipidemia (DLP) and cardiometabolic diseases (CMD) in a population sample aged 55-84 years at the current time (2015-2017).Material and methods  Despite guidelines on DLP treatment and the availability of effective and safe lipid-lowering drugs, control of DPL in primary and secondary prevention of cardiovascular diseases (CVD) is insufficient. Knowledge of the level of pharmaceutical correction of DLP in the Russian population is limited; it requires an LLT assessment in various regions and in a wide age range, and a regular monitoring taking into account changing approaches to the correction of DLP. A random population of men and women aged 55-84 years (n=3 896) was evaluated in Novosibirsk in 2015-2017 (project HAPIEE). A joint DLP category was established as low-density lipoprotein cholesterol (LDL-C) ≥3.0 mmol/l, or total cholesterol (TC) ≥5.0 mmol/l, or triglycerides (TG) ≥1.7 mmol/l, or LLT. The combined group of DLP and CMD included ischemic heart disease (IHD), type 2 diabetes mellitus (DM2), and DLP. Regular LLD treatment for the recent 12 months, excluding the dosage of medicines, was assessed using the Anatomic Therapeutic Chemical (ATC) classification. The conditional control of serum lipids was taken as the achievement of LDL-C <3.0 mmol/l, TC <5.0 mmol/l, and TG <1.7 mmol/l.Results In the study sample, the total prevalence of DLP and CMD was 88 % (82.8 % for men and 91.3 % for women, p<0.001). 48.3% of patients in the IHD group, 35.0% in the DM2 group, 29.4% in the DLP group, and 32.8% in the CMD group took LLT. Control of serum lipids was achieved in 18.3% (37.9 % of patients on LLT) of patients with IHD; 9 % (25.6 % of patients on LLT) of patients with DM2; 7.3 % (24.8 % of patients on LLT) of patients with DLP; and 9.0 % (27.6 % of patients on LLTсреди) in the DLP and CMD group. Women with DM2 and DLP more frequently achieved lipid control than men (p<0.001). 98.7 % of study participants took statins as LLT.Conclusion      In the sample of urban population aged 55-84 years in 2015-2017, 90 % of patients had DLP or CMD, and at least ¾ of them required blood lipid control. The lipid control was achieved in every fifth IHD patient and in approximately 40% of those who took LLT. For DM2 or DLP patients, the lipid control was achieved in every tenth patient and in approximately 25% of those receiving LLT. Frequency of lipid control in IHD patients was comparable for men and women; in DM2 and DLP, men less frequently achieved the lipid control than women. About 70% of patients in the combined DLP and CMD group and more than 50% of IHD patients did not take LLT, which considerably contributed to the insufficient lipid control in primary and secondary prevention of atherosclerotic CVDs in this population.

Identifying Early Vascular Ageing in Patients With Metabolic Syndrome: Unresolved Issues and a Proposed Novel VAmets Score

PURPOSE

To identify the features of early vascular ageing (EVA) in patients with metabolic syndrome (MetS), to assess the accuracy of existing methods for determining vascular age in MetS, and to derive a new score (VAmets) for the calculation of vascular age and predicting EVA in patients with MetS.

METHODS

Prospective open cohort study using routinely collected data from general practice. A total of 750 patients (age, 35-80 yrs old) with MetS were examined. EVA syndrome was detected in 484 patients with MetS and carotid-femoral pulse wave velocity (cfPWV) values exceeding average expected for age values by 2 or more standard deviations (SD).

RESULTS

The presence of type 2 diabetes and insulin resistance (IR) were associated with greater risk of EVA in MetS patients; the odds ratios were 2.75 (95% confidence interval [CI]: 2.34, 3.35) and 1.57 (95% CI: 1.16, 2.00), respectively. In addition, the risk of EVA increased by 76% with an increase in homeostatic model assessment ofinsulin resistance (HOMA-IR) by 1 unit, by 17% with an increase in high-sensitivity C-reactive protein (hs-CRP) by 1 mg/L, by 4% with an increase in diastolic blood pressure (DBP) by 1 mmHg, and by 1% with each (1) μmol/L increase in the level of uric acid (UA). The area under the curve (AUC) for predicting EVA in patients with MetS was 0.949 (95% CI: 0.936-0.963), 0.630 (95% CI: 0.589-0.671), 0.697 (95% CI: 0.659-0.736) and 0.686 (95% CI: 0.647-0.726), for vascular age calculated from carotid-femoral pulse wave velocity (cfPWV), Systematic COronary Risk Evaluation (SCORE) scale, QRESEARCH cardiovascular risk algorithm (QRISK-3) scale, and Framingham scale, respectively. Diabetes mellitus and clinical markers of IR (yes/no), HOMA-IR and UA level were used to develop a new VAmets score for EVA prediction providing a total accuracy of 0.830 (95% CI: 0.799-0.860). Based on the results of the study, a VAmets calculator was developed for diagnosing EVA in patients with MetS. (The calculator is available online at https://apps.medhub.pro/evams/) CONCLUSION: Carotid-femoral pulse wave velocity is at present the most widely studied index of arterial stiffness and fulfils most of the stringent criteria for a clinically useful biomarker of EVA in patients with MetS. There are parallel efforts for the effective identification and integration of a simple clinical score into clinical practice. Our score (VAmets) may accurately identify patients with MetS and EVA on the basis of widely available clinical variables and classic cardiovascular risk factors, and may assist in prioritising the calculation and use of vascular age in routine care.

Features of antihypertensive therapy and real-world prescription of selective imidazoline receptor agonists in Russia vs other countries: STRAIGHT study data analysis

Analysis of routine clinical practice of hypertensive patient management represents one of the important tools in the search for further ways to minimize hypertension-associated cardiovascular and renal adverse outcomes. Aim. To compare the strategies for hypertension management and features of clinical use of I1-imidazoline receptor (I1-IR) agonists in the Russian Federation and other countries where the STRAIGHT (Selective imidazoline receptor agonists Treatment Recommendation and Action In Global management of HyperTension) study was conducted. Materials and methods. It was a cross-sectional online study involving physicians of various specializations. The study was conducted from January 18 to July 1, 2019, in seven countries with a high rate of I1-IR agonist prescription, including Russia. Results. A total of 125 (4.5%) responders filled out the survey in the Russian Federation, which was somewhat lower than in other countries (6.8%). The participants were mostly general practitioners (54.0%) and cardiologists (42.0%), while in other countries greater diversity was seen. Most Russian physicians (83.0%) seemed to rely on national clinical guidelines in their routine practice, while in other countries the US guidelines were more popular (66.0%). The majority of responders stated that they took into account the traditional risk factors of hypertension when initiating the therapy; every second responder noted if sleep apnea was present. Awareness of I1-IR agonists, their prescription rate and their preference were higher in Russia. The main reported benefits of I1-IR agonists were their efficacy, including in resistant hypertension, and their metabolic effects (in Russia). Most participants preferred I1-IR agonists as third-line therapy (65.0% in Russia vs 60.0% in other countries) and in combination with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blockers (ARB) (55.0% in Russia vs 54.0% in other countries). Compared to responders from other countries, Russian physicians prescribe I1-IR agonists as first-line (15.0% vs 5.0%) and second-line (48.0% vs 21.0%) therapy more often. Conclusion. Russian physicians were the most aware of I1-IR agonists and tended to prescribe drugs of this class for hypertension management more often, and I1-IR agonist combination with ACEi was preferable compared to physician responders from other countries. Antihypertensive efficacy and metabolic effects were reported as the major benefits of I1-IR agonist therapy.

[Analysis of healthcare for patients with cardiovascular diseases in Russian Federation in comparison with the practice of Europe and USA]

The medical community, researchers and healthcare organizers are constantly challenged by comparing key indexes reflecting the effectiveness of cardiovascular care, primarily for the dynamic assessment and implementation of the world's best practices to reduce cardiovascular mortality. The analysis of health care for patients with cardiovascular diseases (CVD) is a complex, multicomponent process, the structure and key tools of which differ from country to country. Using different data sources, methodological and analytical approaches creates certain limitations and barriers to the assessment. In order to update the ideas about the modern coordinate system and tools for assessing cardiovascular care, the authors presented practices for analyzing major indexes in Russia, European countries, and the United States. The review presents sources of statistical data, principles for assessing risk factors, cardiovascular morbidity and mortality, and specific features of monitoring the availability and quality of cardiovascular care.

[Modern content and improvement of high cardiovascular risk strategy in reducing mortality from cardiovascular diseases]

The article describes the modern content of the high-risk strategy, which, along with the population strategy, forms the basis of a set of measures to reduce mortality from cardiovascular diseases. The high cardiovascular risk strategy is carried out at the individual level in outpatient structures as a part of primary and secondary prevention of cardiovascular diseases, and is also implemented in hospitals when performing elective surgical procedures, including high-tech interventions. Improving this strategy within the framework of primary health care involves the development of a system of high-risk offices, telemedicine consulting, remote monitoring of physiological parameters on the basis of a regional medical information system, and in the future, on the basis of a uniform vertically integrated medical information system. The development of the high-risk strategy as a part of inpatient practice occurs through the further replication of high technologies and the implementation of new types of them.

[Problems of insufficient control of target blood pressure levels in the outpatient practice]

AIM

Assessment of the frequency of reaching the target level of blood pressure (BP) and the factors affecting it in outpatients with arterial hypertension (AH).

MATERIALS AND METHODS

An open, one-stage, comparative study involving 64 patients with hypertension and 47 without hypertension at the age of 40 to 59 years. All patients underwent physical examination, assessment of cardiovascular risk (CVR), 24-hour blood pressure monitoring (ABPM), echocardiography (ECHOCG), color duplex scanning of brachiocephalic arteries.

RESULTS

Patients with hypertension and comparison groups were comparable in age, sex, smoking, history of myocardial infarction. 1st degree of hypertension was present in 26.6%, 2nd in 40.6%, 3rd in 12.5% of patients. Obesity was detected in 24.3% of patients and all patients with obesity had AH. The SCORE score in individuals with hypertension was 4.94.5; in the comparison group, 2.32.6 (p0.001). Non-stenosing atherosclerosis was present in 54.8% and 88%, p=0.020, and atherosclerotic plaque in the vascular lumen was present in 45.3% and 12% of patients with and without hypertension, respectively (p0.001). 68.8% were constantly treated, and the target BP was reached in 31.3% of patients with hypertension. Male gender (OR 1.68; 95% CI 1.6828.49; p=0.007), obesity (OR 4.78; 95% CI 1.1420.29; p=0.033), concomitant pathology (OR 3.09; 95% CI 1.029.37; p=0.046) were negative, and dyslipidemia (OR 0.10; 95% CI 0.010.84; p=0.033) was positive, affecting the achievement of the target level of blood pressure.

CONCLUSION

The target level of blood pressure was achieved in 31.3% of outpatients with hypertension, mainly in women. Among patients who did not reach the target level of blood pressure, men, individuals with high SSR and obesity predominated. Concomitant pathology and obesity are negative, and dyslipidemia was positively associated with the achievement of the target level of blood pressure, which must be taken into account when developing measures for prevention and treatment.

Analysis of mortality in patients with heart failure after de­compen­sation during long-term follow-up in specialized medical care and in real clinical practice

Background Mortality from chronic heart failure (CHF) remains high and entails serious demographic losses worldwide. The most vulnerable group is patients after acute decompensated HF (ADHF) who have a high risk of unfavorable outcome.Aim To analyze risks of all-cause death (ACD), cardiovascular death (CVD), and death from recurrent ADHF in CHF patients during two years following ADHF in long-term follow-up with specialized medical care and in real-life clinical practice.Material and methods The study successively included 942 CHF patients after ADHF. 510 patients continued out-patient treatment in a specialized CHF treatment center (CHFTC) (group 1) and 432 patients refused of the management in the CHFTC and were managed in out-patient clinics at the place of patient’s residence (group 2). Causes of death were determined based on inpatient hospital records, postmortem reports, or outpatient medical records. Cases of ACD, CVD, death from ADHF, and a composite index (CVD and death from ADHF) were analyzed. Statistical analysis was performed with the software package Statistica 7.0 for Windows, SPSS, and statistical package R.Results Patients of group 2 were older, more frequently had functional class (FC) III CHF and less frequently FC I CHF compared to group 1. Women and patients with preserved left ventricular ejection fraction (LV EF) prevailed in both groups. Results of the Cox proportional hazards model for ACD, CVD, death from ADHF, and the composite mortality index showed that belonging to group 2 was an independent predictor for increased risk of death (р<0.001). An increase in CCS score by 1 also increased the risk of death (р<0.001). Baseline CHF FC and LV EF did not influence the mortality in any model. Female gender and a higher value of 6-min walk test (6MW) independently decreased the risk of all outcomes except for CVD. An increase in systolic BP by 10 mm Hg reduced risk of all fatal outcomes. At two years of follow-up in groups 2 and 1, ACD was 29.9 % and 10.2 %, (OR, 3.7; 95 % CI: 2.6–5.3; p <0.001), CVD was 10.4 % and 1.9 % (OR, 5.9; 95 % CI: 2.8–12.4; p<0.001), death from ADHF was 18.1 % and 6.0 % (OR, 3.5; 95 % CI: 2.2–5.5; p<0.001), and the composite mortality index was 25.2 % and 7.7 % (OR, 4.1; 95 % CI: 2.7–6.1; р<0.001). Analysis of all outcomes by follow-up period (3 and 6 months and 1 and 2 years) showed that the difference between groups 2 and 1 in risks of any fatal outcome was maximal during the first 6 months.Conclusion The follow-up in the system of specialized medical care reduces risks of ACD, CVD, and death from ADHF. The first 6 months following discharge from the hospital was a vulnerability period for patients after ADHF. The CCS score impaired the prognosis whereas baseline LV EF and CHF FC did not influence the long-term prognosis after ADHF. Protective factors included female gender and higher values of 6MW and systolic BP.