[Albuminuria as a marker of atherosclerosis burden and a possible predictor of adverse events in patients with polyvascular disease]

BACKGROUND

The role of albuminuria as a marker of the atherosclerosis burden and a predictor of prognosis in patients with polyvascular disease (PD) has been little studied.

AIM

To evaluate the prevalence, association with atherosclerosis burden, and prognostic value of albuminuria in relation to cardiovascular and bleeding complications in patients with PD.

MATERIALS AND METHODS

The data was obtained from the prospective registry REGATA-1 (NCT04347200). Seventy four patients (75.7% males, median age 67 [61-69] years) with PD (CAD and peripheral arterial disease) were enrolled. All patients received aspirin and rivaroxaban 2.5 mg. The albumin-creatinine ratio in a single morning urine sample, estimated glomerular filtration rate (eGFR), and von Willebrand factor levels were determined.

RESULTS

Mild albuminuria (10-29 mg/g) was detected in 45.9% of patients, moderate and severe (≥30 mg/g) - in 29.7%; eGFR<60 ml/min - in 21.7%, chronic kidney disease (CKD) according to the full KDIGO criteria (eGFR and/or albuminuria ≥30 mg/g) - twice as often (39.2%). The frequency of nephroprotective therapy prescription was insufficient. The level of albuminuria did not correlate with von Willebrand factor (endothelial dysfunction marker), but was associated with affecting of 4-5 vascular beds (ROC AUC 0.775; p=0.011). During the follow-up (12 [8-18] months) 3 patients developed MACE, 11 - BARC 2-3 bleedings. Neither albuminuria nor eGFR were predictors of MACE, bleeding, or net clinical benefit. CKD (KDIGO) was also not associated with bleedings. CKD (KDIGO) was independent predictor of MACE (in significant multiple regression model beta - coefficient for CKD was 0.097; p=0.042), however, the small number of end points allows us to speak only of a hypothesis-generating trend. The implementation of CKD (KDIGO) has increased the predictive value of the REACH score.

CONCLUSION

Albuminuria is highly prevalent in patients with PD. It is a marker of atherosclerosis burden. CKD, diagnosed taking into account the level of albuminuria, can be used in a comprehensive assessment of cardiovascular risk in this category of patients.

[Patent foramen ovale as the cause of recurrent embolic strokes. Case report]

А clinical case of a young patient with recurrent ischemic strokes is presented. The problems of diagnostic embolic strokes are discussed. We set out the algorithm for identifying patients, in whom patent foramen ovale is the most probable cause of embolic stroke. Detailed consideration of imaging diagnostic methods possibility is included. Hypothesis of probable source of cardioembolism from patent foramen ovale is presented. Recommendations for the secondary prevention of recurrent ischemic stroke, associated with patent foramen ovale, are provided. We also considered the issues of antithrombotic treatment.

[Coagulation activity of circulating membrane microparticles in patients with cardiovascular diseases]

Membrane microparticles (MP) are released by activated or damaged cells and are able to accelerate blood clotting (coagulation). MP possess coagulation activity since all of them contain on their surface phosphatidylserine (PS), a substrate for the assembly of coagulation complexes, and some of them tissue factor (TF), the primary initiator of coagulation cascade reactions. We compared the coagulation activity and amount of MP in the blood of healthy donors (n=34) and patients with myocardial infarction (MI) (n=32), advanced atherosclerosis (AA) (n=32) and idiopathic pulmonary arterial hypertension (IPAH) (n=19). Total MP fraction was obtained from blood plasma by sedimentation at 20000 g, 30 min. The coagulation activity of PM isolated from 100 μl of donor and patient plasma was determined using a modified recalcification test. MP were added to substrate plasma devoid of endogenous MF, plasma was recalcified, and clotting was recorded by changes in optical density (A450), determining lag phase (min) and maximum rate (Vmax, %A450/min). MP were counted by flow cytometry as PS+ particles (lactadgerin-FITC staining) smaller than 1 μm and their concentration was expressed as 105 MP/μl plasma. MP in all patient groups accelerated plasma clotting more effectively than donor MP. Lag phase compared with donors (11.8 [11.0-13.1] median and interquartile range) was shorter in patients with AA (8.8 [7.0-10.3], p.

Relationship between the D-dimer and von Willebrand factor levels and the development of gastrointestinal bleeding in patients with stable coronary artery disease: data from the registry of long-term antithrombotic therapy REGATTA-1

Aim. To study the role of von Willebrand factor (VWF) and D-dimer (DD) as predictors of upper gastrointestinal bleeding (GIB) in patients with stable coronary artery disease (CAD).

Material and methods. The study included patients with stable CAD who are members of the prospective registry of long-term antithrombotic therapy (REGATTA-1) (ClinicalTrials.gov Identifier: NCT04347200). The primary endpoints were actionable GIBs (Bleeding Academic Research Consortium type 2-5). Cut-off points for DD and VWF were determined by ROC analysis. The predictive significance of an increase in VWF and DD was assessed by the logistic regression.

Results. The study included 408 patients (men, 77,5%; mean age, 61,3±10,8 years). The median follow-up period was 2,5 [1,1-14,7] years. DD was determined in all patients, including 36 patients with GIB, while VWF — in 169 patients (28 patients with GIB). An increase in DD >928 ng/ml was an independent predictor of GIB, including taking into account clinical risk factors (odds ratio (OR), 3,26 [95% confidence interval (CI), 1,43-7,42] (p=0,0047), or the previously developed REGATTA scale score (OR, 3,73, 95% CI: 1,65-8,43 (p=0,0015)). VWF >105% was also an independent predictor of GIB (OR, 14,02; 95% CI: 1,41-139,42 (p=0,023)); in the REGATTA scale model  — OR 11,3, 95% CI: 1,43-88,83 (p=0,021). The increase in both markers was most unfavorable, since the proportion of those with GIB was 41,4%, while among patients with normal DD and increased VWF — 14,9%, and with low values of both markers — 0%. OR of GIB in patients with an increase in both markers was 4,1 (95% CI: 1,6-10,3 (p=0,003)).

Conclusion. In patients with stable CAD, an increase in VWF and DD was associated with an increase in GIB risk regardless of the presence of clinical risk factors.

High plasma D-dimer and von Willebrand factor levels are associated with risk of upper gastrointestinal bleeding in patients with chronic coronary syndromes receiving long-term antiplatelet therapy

Purpose

Plasma von Willebrand factor (VWF) and D-dimer levels have been proposed as markers of endothelial damage, coagulation activation and subsequent cardiovascular events. Thrombotic and hemorrhagic burdens are closely related. However, the association of coagulation markers with bleeding complications in pts with atherosclerosis remains unclear.

We aimed to assess the predictive value of D-dimer and VWF levels for upper gastrointestinal bleeding (UGIB) in patients with chronic coronary syndromes (CCS) receiving long-term antithrombotic therapy.

Patients and methods

Single center prospective Registry of Long-term AnTithrombotic TherApy (REGATTA-1 NCT04347200) included 934 pts with CCS (78.6% males, age 61±10.7 yrs, 76% after elective PCI). The UGIB annual incidence was 1.9 events per 100 patient-years.

VWF was determined in 28 pts with UGIB and 141 controls, matched for age, sex and main clinical risk factors. D-dimer was determined from 28 and 380 pts respectively

Results

The median for VWF was 139 [interquartile range 107–168]%. The median for D-dimer was 443,8 [interquartile range 272.5–702.4] ng/ml. ROC analysis revealed acceptable discriminatory ability for VWF (cut off &gt;105%; AUC=0.67, 95% CI: 0.59–0.74, p=0.001) and for D-dimer (cut off &gt;928 ng/ml; AUC=0.63, 95% CI: 0.59–0.68, p=0.002). High levels of coagulation markers remained significant in regression model adjuster for ESC panel of UGIB risk factors. OR for D-dimer = 3.4, 95% CI: 1.09–10.66; p=0.03). OR for VWF = 11.74, 95% CI: 1.19–116.18; p=0.03).

Conclusion

VWF and D-dimer should be considered as valuable prognostic biomarkers to improve the prediction of UGIB in addition to well-known scoring systems in CCS patients receiving long-term antithrombotic therapy.

Funding Acknowledgement

Type of funding sources: None.

Antithrombotic therapy in the elderly and senile age: the consensus opinion of experts of the Russian Association of Gerontologists and Geriatricians and the National Society of Preventive Cardiology

В данном документе обсуждаются особенности АТТ у лиц пожилого и старческого возраста в различных клинических ситуациях.

Peripheral atherosclerosis and abdominal aortic aneurysm as a new risk factors of upper gastrointestinal bleeding in patients with stable CAD receiving long-term antithrombotic therapy

Funding Acknowledgements

Type of funding sources: None.

Background

Upper gastrointestinal bleeding (UGIB) is the most common hemorrhagic complication in stable CAD patients receiving antithrombotic therapy. It seems that atherosclerotic burden may increase the overall bleeding frequency. However, this factor has never been taken into account with UGIB risk assessment.

We aimed to assess the predictive value of atherosclerotic burden (peripheral atherosclerosis – PAD and abdominal aortic aneurysm - AAA) for UGIB in patients with stable CAD receiving long-term antithrombotic therapy.

Patients and Methods. A single center prospective Registry of Long-term AnTithrombotic TherApy (REGATTA-1 NCT04347200) included 934 pts with stable CAD (78.6% males, median age 61 [IQR 53-68] yrs). 77,3 %  of patients received dual antiplatelet therapy due to recent PCI with a switch to aspirin monotherapy after 6 months. 17,6% of patients received aspirin only, 5,1 % of patients received oral anticoagulants because of concomitant atrial fibrillation. Risk assessment of UGIB was performed according to the 2015 European Society of Cardiology guidelines (we were not able to identify only Helicobacter pylori infection). Additional ultrasound screening for PAD (lower limbs and cerebrovascular beds) and AAA was applied. The primary outcome was any overt UGIB (BARC ≥2).

Results

 The frequency of PAD was 18,8%, AAA – 2,4%, PAD and/or AAA -  20,5%. In a total 2335 person-years of follow-up (median follow-up - 2,5 yrs, IQR 1,1 – 5.1), UGIB occurred in 51 patients (incidence at 1 year 1,9 per 100 patients).  The median time to first occurrence of UGIB was 72 [IQR 13-214] days. Comparing the Kaplan-Meyer curves, the UGIB developed three times more often in patients with coexisted PAD and/or AAA vs isolated CAD (19.8% vs 6.5%, Log-Rank p = 0.00006). The difference remains consisted in regression model taking in account 2015 ESC panel of UGIB risk factors (OR 3.4; CI 1.7–6.9, p = 0,0005).

Conclusions

Atherosclerotic burden (concomitant PAD and/or AAA) is an independent predictor of UGIB in patients with stable CAD receiving long-term antithrombotic therapy.

Performance of PRECISE-DAPT Score for predicting upper gastrointestinal bleedings in patients with stable coronary artery disease on long-term antithrombotic therapy

Funding Acknowledgements

Type of funding sources: None.

Background

PRECISE-DAPT score has become developed for predicting the risk of bleedings in patients treated with coronary stenting and subsequent 1-year dual antiplatelet therapy. The utility of PRECISE-DAPT score in the setting of all-comer CAD population with different regimes of long-term antithrombotic therapy remains unclear. Upper gastrointestinal bleeding (UGIB) is the predominant hemorrhagic complication in CAD patients; however, the PRECISE-DAPT capacity with respect to this type of bleeding has never been evaluated.

Purpose

to evaluate the role of PRECISE-DAPT score in the assessment of upper gastrointestinal bleeding risk in patients with stable coronary artery disease (CAD) receiving long-term antithrombotic therapy.

Methods

Data were obtained from single center prospective Registry of Long-term AnTithrombotic TherApy (REGATTA-1 NCT04347200). The PRECISE-DAPT score was calculated in a total of 434 patients with stable CAD (77,4% males, median age 61 [IQR 55-69] yrs). Most of the patients 93,6 % received DAPT due to recent PCI with a switch to aspirin monotherapy after 6 months. 1,4 % of patients received aspirin only, 22 (5,1%) of patients received oral anticoagulants because of concomitant atrial fibrillation. The primary outcome was any overt UGIB (BARC ≥2).

Results

In a total of 451 person-years of follow-up (median follow-up was 378 days, IQR 365-421), UGIB occurred 40 patients (incidence at 1 year 8.9 per 100 patients).  The median time to first occurrence of UGIB was 55 [IQR 8-115] days. Median PRECISE-DAPT score was 12 points [IQR 6; 20].  The cut-off value for PRECISE-DAPT score to predict UGIB was 16 points (AUC = 0.732, p = 0.0001, 95% CI 0.367-0.827) that correspond to at least moderate bleeding risk according to original score discrimination. Kaplan-Meier bleeding rates were separated by score cut-off (Log-Rank p &lt; 0,001) and the risk difference remains consisted in regression model (OR 2.79 [1.07-7.29]; p = 0.0348).

Conclusion(s): PRECISE DAPT score demonstrated good discriminatory capacity (cut-off 16 points) with respect to UGIB in patients with stable CAD receiving long-term antithrombotic therapy.

Clinical Characteristics and Factors Associated with Poor Outcomes in Hospitalized Patients with Novel Coronavirus Infection COVID-19

Aim      To evaluate the clinical picture and factors associated with unfavorable outcomes in admitted patients with COVID-19.Material and methods This study included all patients admitted to the COVID Center of the National Research Center of Cardiology of the Russian Ministry of Health Care from May 1 through May 31, 2020. Clinical demographic, laboratory, and instrumental indexes and associated factors were studied with one-way and multivariate logistic regression analysis.Results This study included 402 patients aged 18 to 95 years (mean age, 62.9±14.6 years); 43.0 % of them were older than 65 years. COVID-19 was frequently associated with chronic comorbidities, including arterial hypertension (74.4 %), obesity (41.6 %), history of ischemic heart disease (12.9 %), atrial fibrillation (18.9 %), type 2 diabetes mellitus (DM) (13.0 %), and oncological diseases (9.2 %). 13.0 % of patients were smokers; less than 10% had chronic lung diseases. 3.9% of patients had a combination of COVID-19 and acute coronary pathology, including acute myocardial infarction (MI) in 3.2 % (13) and unstable angina in 0.7 % (3). The most frequent clinical manifestation of COVID-19 were four symptoms: cough (81.1 %), weakness (80.3 %), shortness of breath (71.6 %), and fever (62.7 %). 46.5% of patients had shortage of breath and chest pain/compression, 40.3% had headache, 31.1% had myalgia, 28.8% had anosmia, and 25.5% had ageusia. Arterial oxygen saturation was &lt;93.0 % in 55.7 % of cases. According to laboratory blood tests the patients had anemia (58.2 %), lymphopenia (34.8 %), neutropenia (19.2 %), thrombocytopenia (11.9 %), and increased levels of high-sensitivity C-reactive protein (hsCRP, 87.3 %), interleukin-6 (89.3 %), ferritin (62.1 %), and D-dimer (49.2 %). 56.2% of patients required various regimens of oxygen support. 83 (20.6%) patients were admitted to intensive care and resuscitation units; invasive artificial ventilation was performed only for 34 (8.5 %) patients. In-hospital mortality was 7.7 % (31 / 402). One-way regression analysis identified major factors associated with death during the stay in the hospital: age &gt;55 years, NEWS scale score &gt;4.0, oxygen saturation &lt;92.0 %, blood glucose &gt;5.4 mmol/l, hs-CRP &gt;25.7 mg/l, and creatinine clearance &lt;72.0 ml/min. Furthermore, the risk increased with increasing degree of changes in each factor. According to results of the multivariate regression analysis, three most significant predictors of the hard endpoint, all-cause death during the stay in the hospital, were more than 5-fold increases in aspartate aminotransferase and/or alanine aminotransferase compared to normal levels (relative risk (RR) 16.8 at 95 % confidence interval (CI) 5.0-56.3, р&lt;0.001), pronounced changes in the lungs consistent with a CT-4 picture as shown by computed tomography (CT) (RR 13.4; 95 % CI 3.9-45.5, р&lt;0.001), and MI/unstable angina during the stay in the hospital (RR 11.3; 95 % CI 1.4-90.6, р=0.023). The probability of death was also considerably increased by chronic obstructive pulmonary disease, impaired kidney function (creatinine clearance estimated by Cockcroft-Gault &lt;60.0 ml/min), type 2 DM, oncological diseases, and dementia.Conclusion      This study established factors associated with unfavorable outcomes in admitted patients with COVID-19. This will allow identifying in advance patients with a high risk of complications that require increased attention to take more active diagnostic and therapeutic measures at prehospital and hospital stages.

[Upper gastrointestinal bleeding in patients with stable coronary artery disease (registry of antithrombotic therapy "REGATТA" results)]

INTRODUCTION

Upper gastrointestinal (UGI) bleeding is a common complication of antiplatelet therapy. Data from real clinical practice that characterize the range of risk factors for UGI bleeding, prophylactic proton pump inhibitors (PPIs) therapy, bleeding frequency and their long-term effects in patients with stable coronary artery disease (CAD) are limited.

AIM

To identify predictors of UGI bleeding in patients with stable CAD, to assess the role of PPI in the prevention of bleeding and the long-term prognosis of patients after bleeding.

MATERIALS AND METHODS

934 patients with stable CAD (median age 61 [5368] years, 78.6% men) were included in the single institution prospective REGistry of Long-term AnTithrombotic TherApy (REGATTA). Atherosclerosis of peripheral arteries (APA) and abdominal aortic aneurysm (AAA) screening was performed by doctor decision, as well as esophagogastroduodenoscopy. 76% of patients received dual antiplatelet therapy for 612 months after elective PCI. PPIs were prescribed in 28.3% of cases.

RESULTS

The median follow-up was 2.5 [1.15.1] years. The frequency of overt UGI bleeding was 1.9 per 100 patients per year. Anamnesis of peptic ulcer disease (OR 4.7; 95% CI 1.911.8;p=0.001), erosion of the upper gastrointestinal tract (OR 6.7; 2.716.6;p=0.00004 ), as well as concomitant diseases associated with a decrease in blood supply to the mucosa, such as heart failure HF (OR 6.1; 2.316.0;p=0.0002), AAA (OR 9.3; 2.534.2;p=0.0008) and APA (OR 2.3; 0.985.5;p=0.05) turned out to be independent predictors of UGI bleeding. The frequency of AAA among those who underwent UGI bleeding was 19.6% (in patients without bleeding 1.4%;p0.001). 90.2% of patients with UGI bleeding received PPI; the frequency of UGI bleeding in patients receiving pantoprazole and omeprazole did not differ significantly. After UGI bleeding, rebleeding rate was 7.8%, thrombotic events (TE) rate 31.4%, mortality rate 17.7% for 30 days, 19.4% for 1 year and 35.3% for the entire observation period. The predictors of deaths were AAA (OR 92.5; 7.7107.9;p0.0001), APA (OR 4.2; 1.0317.2;p=0.045) and HF (OR 34.5; 8.5140.6;p0.0001). The worst prognosis was expected for patients who underwent UGI bleeding and thrombotic events: 2/3 of these patients died.

CONCLUSION

In a prospective analysis of patients with stable CAD, we identified UGI bleeding was a significant risk factor for late thromboembolism and death, compared with patients without bleeding. Predictors of UGI bleeding and poor prognosis are factors that indicate atherothrombotic burden abdominal aortic aneurysm, peripheral atherosclerosis and HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04347200.

[The balance of benefit and risk in prescribing antithrombotic therapy for patients with coronary artery disease. How to deal with the gastrointestinal bleeding problem?]

The review focuses on upper gastrointestinal (GI) bleeding in patients with ischemic heart disease (IHD) receiving an antithrombotic therapy. Approaches to risk stratification for GI bleeding and correction of modifiable factors that determine the probability of such events are addressed in detail. Recommendations are provided for administration of stomach-protecting drugs. The interrelation of risk factors for thromboses and bleedings is stressed, and possible indications for a multicomponent antithrombotic therapy in patients with stable IHD are discussed.

[Use of Statins, Anticoagulants, Antiaggregants and Antiarrhythmic Drugs in Patients With COVID-19. The Agreed Experts' Position of Russian Society of Cardiology, Eurasian Association of Therapists, National Society on Atherothrombosis, Societies of Experts in Urgent Cardiology, Eurasian Arrhythmology Association]

This article discusses relevant aspects in the treatment of patients with COVID-19. Up-to-date information about principles for administration of statins, antithrombotics, and antiarrhythmics is presented. The authors addressed in detail specific features of reversing heart rhythm disorders in patients with coronavirus infection and the interaction of antiarrhythmic and antiviral drugs. Recommendations are provided for outpatient and inpatient antithrombotic therapy for patients with COVID-19. Issues of antithrombotic and antiviral drug interaction are discussed.

The Choice of Treatment Tactics for Thromboembolism of the Pulmonary Artery of Medium-High Risk and Chronic Kidney Disease

A clinical analysis of an elderly patient with medium-high-risk pulmonary thromboembolism and chronic kidney disease is presented. Recommendations on modern principles of diagnosis, choice of treatment tactics in patients with this pathology are given. Much attention is paid to the safety of anticoagulant treatment.

Proton pump inhibitors receiving and prognosis of patients after scheduled percutaneous coronary interventions

AIM

The urgency of the study is determined by the lack of data necessary in order to assess the safety of prolonged use of proton pump inhibitors (PPI) in patients with IHD combined with anti-aggregant therapy. The aim of the study was to study the relationship between the use of PPI and the risk of thrombotic complications in patients undergoing planned procedures of percutaneous coronary interventions (PCI) and receiving dual antiplatelet therapy.

MATERIALS AND METHODS

The study is a prospective register of patients who successfully underwent planned percutaneous coronary intervention (PCI). The effect of PPI (omeprazole and pantoprazole) on the frequency of the combined end point cardiovascular death, ACS, AI, TIA, peripheral arterial thrombosis and PE was assessed using the Log-Rank criterion, as well as in a multivariate analysis (Cox proportional risk regression model).

RESULTS

A total of 391 patients were included in the study (23.1% women, mean age 61.2 years ± 10.4 years). The median duration of follow-up was 18 months. During this period of time, 34 adverse events were recorded. Log-Rank analysis showed that the proportion of patients without adverse events in the omeprazole group was significantly lower in comparison with patients who did not receive PPI (0.56 vs. 0.84, Log-Rank p=0.003), and for pantoprazole no such pattern was found (0.89 against 0.84, Log-Rank p=0.21). The average level of residual platelet reactivity (ORT), as well as the number of patients with high ORT (> 208 PRU), did not differ significantly between the groups of omeprazole, pantoprazole and the group of patients not receiving PPI. According to multivariate analysis, omeprazole was an independent predictor of thrombotic complications after a planned PCI (OR 3.75, 95% confidence interval 1.72-8.17, p=----0.0009).

CONCLUSION

Long-term use of omeprazole (at least 30 days) is an independent predictor of thrombotic complications in patients who underwent planned PCI.

[Factors determining prognosis of patients with stable ischemic heart disease (results of a five years prospective study)]

Risk stratification seems to be very important in patients with stable coronary artery disease (CAD). However, the prognostic scales are now available only for the early risk assessment in patients with acute coronary syndromes and in patients undergoing percutaneous coronary interventions. Aim of the study was to assess the frequency of cardiovascular events (CVE) during 5 years of follow-up in patients with stable CAD and to construct a long-term risk prediction model for these patients. 503 patients (mean age 59.4 years) were included in the study. The follow-up period ranged between 3.0 and 7.5 years (mean 5.0 years). Main end points were fatal and non-fatal cardiovascular events: cardiovascular death, acute coronary syndromes, ischemic stroke, transient ischemic attack, peripheral arterial thrombosis, and need for revascularization in any affected vascular area. Total frequency of events was 31.0% (5.7/100 patient years). Independent predictors of events were: severity of angina, three vessel coronary disease, previous myocardial infarction, previous stroke/ transient ischemic attack, peripheral arterial disease, obesity, chronic kidney disease and history of erosive gastritis. The presence of more or equal 3 risk factors was significantly associated with increased frequency of CVE.

[Pharmacogenetics of clopidogrel and its clinical significance]

The review is devoted to pharmacogenetics of clopidogrel and its value for the clinic. Mechanism of action of clopidogrel and main trials which has proven its efficacy are presented as well as results of main large studies including authors own results demonstrating dependence of clinical efficacy of clopidogrel on carriage of polymorphisms of gene of CYP2C19 which accomplishes metabolism of the drug in the liver. Problems of interaction of clopidogrel with proton pump inhibitors and other drugs as well as ways of overcoming "resistance" to clopidogrel are considered. Clinical efficacy of other P2Y12 receptors of platelets in patients with IHD is characterized in comparison with clopidogrel.

[Comparative efficacy of conservative and invasive treatment of patients with stable form of ischemic heart disease (according to results of five year prospective study)]

Despite high immediate efficacy of percutaneous coronary interventions (PCI) in relation to symptoms of angina the problem of influence of this method of treatment on duration of life and prognosis in stable ischemic heart disease (IHD) remains unsolved. Aim of our study was to compare efficacy of conservative therapy with drugs of proven effect on prognosis and of percutaneous coronary interventions in combination with optimal drug therapy in patients with stable ischemic heart disease (IHD) during 5 years of follow up. We included into this study 503 patients (387 men and 116 women, mean age 59 years). Groups of conservative and invasive treatments comprised 179 and 302 patients, respectively; mean durations of follow-up were 5.6+/-1.3 and 4.1+/-1.6 years, respectively, p=0.001. Study end points were fatal and nonfatal cardiovascular complications (CVC) (cardiovascular death, acute coronary syndrome, transitory ischemic attack, peripheral arterial thrombosis) and composite endpoint defined as sum of all CVC and cases of revascularization of the involved vascular bed. Cumulative rates of all fatal and nonfatal CVCs was 5.3 and 4.8 per 100 patient/years in groups of conservative and invasive treatment, respectively (relative risk [RR] 0.96, 95% confidence interval [CI] 0.6 to 1.5; p=0.9). Rates of composite end point were 7.1 and 7.3 per 100 years in groups of conservative and invasive treatment, respectively (relative risk [RR] 1.02, 95% confidence interval [CI] 0.7 to 1.3; p=0.8). According to the presence of independent clinical predictors of worst prognosis (class II-III angina, history of myocardial infarction, three vessel or left main stem coronary artery disease, concomitant signs of atherothrombosis in cerebral and peripheral vascular beds, obesity, abnormal renal function, history of erosive gastritis) all patients were divided in groups of low, moderate, and high risk. In low risk IHD patients invasive strategy worsened remote prognosis of myocardial infarction, stroke, and cardiovascular death, as well as of repetitive revascularization.

[Factors determining clinical effectiveness of clopidogrel and prognosis of patients with stable ischemic heart disease]

Aim of the study was to elucidate genetic and drug factors affecting efficacy of clopidogrel in patients with ischemic heart disease - inhabitants of central region of Russian Federation. We included 399 patients with IHD (79% men, mean age 58.3+/-9 years) receiving long term therapy with clopidogrel 75 mg/day (during stable manifestations of the disease) or 75-150 mg/day in combination with aspirin (in relation with recent elective percutaneous interventions). We studied carriage of polymorphisms of genes controlling intestinal absorption of clopidogrel (ABCB1 C3435T), activation of clopidogrel in the liver (CYP2C19 *1 *2), and also registered concomitant administration of proton pump inhibitors (PPI). Then we determined relationship of these factors to development of vascular complications (vascular death/myocardial infarction/requirement in revascularization) during 18 months followup. Among studied genetic factors carriage of allele variants CYP2C19 *1/*2 and *2/* (found in 25.5 and 1.8% of patients, respectively), possessed prognostic significance. In the group of clopidogrel monotherapy carriage of at least one *2 allele was associated with increased rate of vascular complications (33.3% vs. 11.3%) including thrombotic complications (27.7% vs. 3.2%; =0.01). In patients receiving 75 mg/day of clopidogrel in combination with aspirin total rate of thrombotic complications as well as of all adverse unfavorable outcomes was higher in *2 carriers compared with wild type homozygotes (14.0% vs.8.7% and 21.0% vs. 15.8%, respectively). In patients receiving double dose clopidogrel in combination with aspirin we found no worsening of outcomes associated with CYP2C19*2 carriage. In the multifactorial risk model independent predictors of vascular complications turned out to be CYP2C19 *2/*2 homozygosity (RR 4.9; =0.02) and concomitant PPI administration ( 1.8; p=0.05).

[Disturbances of homocysteine metabolism as a risk factor of cardiovascular diseases development: effect on prognosis and possibilities of correction with drugs]

Classical risk factors of development of cardiovascular diseases does not allow to detect all persons needing active prevention. Because of this reason great attention is given to novel biomarkers one of which is homocysteine. Most widely-spread causes of elevation of homocysteine level are such factors as deficit of folic acid and B6 and B12 vitamins, as well as genetic peculiarities. Main damaging effect of homocysteine is activation of atherothrombosis. Therapy with folic acid causes significant lowering of homocysteine level. Effect of therapy with vitamins on the risk of development of cardiovascular diseases has been assessed both in observational epidemiological studies and large prospective randomized trials. Their results are controversial. The present review is devoted to the analysis of these trials.

[Role of D-dimer in diagnosis of venous thrombosis and embolism]

AIM

To analyze efficiency of semi-quantitative fast D-dimer test in diagnosis of deep vein thrombosis (DVT) and thromboembolism of pulmonary artery (TPA).

MATERIAL AND METHODS

The study enrolled 42 patients (26 males and 16 females) aged 25 to 86 years. 30 and 12 of them were suspected to have DVT and TPA, respectively. DVT was verified at ultrasound dopplerography and radionuclide phlebography in 16 of 30 suspects. TPA was verified by x-ray, perfusion scintigraphy of the lungs and at autopsy (one case) in 7 of 12 suspects. D-dimer levels in the blood were measured by latex parts agglutination reaction. The parts were covered with monoclonal antibodies to D-dimer. The reagents were provided by the kit Roche/Diagnostica Stago.

RESULTS

The D-dimer test was positive in 20 of 23 DVT patients and negative in 3 cases (13%). Of 19 patients with rejected diagnosis of DVT/TPA the test was negative in 17(89.4%) and positive in 2 patients (10.6%). Thus, sensitivity and specificity of the D-dimer test was 87% and 89.4%, respectively.

CONCLUSION

High sensitivity of the test allows to use it in screening for DVT/TPA. Negative D-dimer test rejects DVT, while positive test needs verification by other methods.

[Soluble P-selectin - a marker of platelet activation and vessel wall injury: increase of soluble P-selectin in plasma of patients with myocardial infarction, massive atherosclerosis and primary pulmonary hypertension]

AIM

A comparative analysis of the content of the soluble form of cell adhesion protein P-selectin in the blood plasma of patients with acute myocardial infarction (AMI), massive atherosclerosis (MA) and primary pulmonary hypertension (PPH), investigation of the relationship between plasma content of P-selectin and known markers of platelets and endothelial cells activation, preliminary assessment of the prognostic value of P-selectin determination.

MATERIALS AND METHODS

This study included 16 patients with AMI, 20 patients with MA, 21 patients with PPH and 18 healthy donors. The follow-up was 1-5 years. End-points in the group of patients with AMI were recurrent acute coronary syndrome and coronary artery by-pass operation, in the group with MA--thrombotic complications (acute coronary syndrome, ischemic stroke) and in the group with PPH--death. P-selectin was measured by ELISA and platelet factor 4 (PF4), thromboxane B2 (TXB2), endothelin-I and stable prostacyclin metabolite 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha) by means of commercial ELISA kits.

RESULTS

Mean level of P-selectin in blood plasma of patients with AMI (1 day) (361 +/- 18 ng/ml), MA (410 +/- 31 ng/ml) and PPH (627 +/- 83 ng/ml) was increased in comparison with the group of healthy donors (269 +/- 12 ng/ml) (everywhere p < 0.001). In AMI, P-selectin was increased on day 1 only, on days 2, 3 and 10-14 of the disease the level of P-selectin was significantly lower than on day 1 and did not differ from the control level in the group of donors. In patients with MA a significant correlation was detected between plasma content of P-selectin and platelet activation marker PF4 (r = 0.606, P = 0.007) and in patients with PPH between the content of P-selectin and another platelet activation marker TXB2 (r = 0.622, p = 0.013). However, no correlation was found in PPH patients between the content of P-selectin and markers of endothelial activation and/or damage (endothelin-1 and 6-keto-PGF1 alpha). Difference in the concentration of P-selectin in patients with or without end-points during the follow-up period was detected in patients with AMI (353 +/- 14 ng/ml and 451 +/- 24 ng/ml, p = 0.009) and PPH (477 +/- 58 ng/ml and 927 +/- 184 ng/ml, p = 0.017) but not with MA (426 +/- 37 ng/ml and 361 +/- 24 ng/ml, p = 0.295).

CONCLUSION

The level of P-selectin in plasma was increased in patients with acute thrombosis (AMI, 1 day) as well as in patients without clinical signs of thrombosis but with a massive injury of the vasculature (MA and PPH). The increase of P-selectin was, presumably, caused by its secretion from activated platelets since its concentration in plasma correlated with platelet concentration but not endothelial activation markers. Preliminary data indicate that blood plasma soluble P-selectin may be considered as a potential prognostic marker in AMI and PPH.