[Russian Eligibility Criteria for Prescribing Menopausal Hormone Therapy to Patients With Cardiovascular and Metabolic Diseases. Consensus Document of RSC, RSOG, RAE, EUAT, RAP]

Menopausal symptoms can impair the life of women at the peak of their career and family life. At the present time, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormone therapy is the fear of physicians to do more harm to patients than good. Caution is especially important when it comes to women with concurrent diseases. Moreover, it should be recognized that there is a shortage of high-quality research on the safety of MHT for underlying chronic non-infectious diseases and common comorbidities. The presented consensus analyzed all currently available data from clinical trials of various designs and created a set of criteria for the appropriateness of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, physicians of various specialties who advise menopausal women will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real-life practice.

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Aim. To determine the incidence of left atrial (LA) and/or LA appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation (AF) (NAF) or atrial flutter (AFL) on transesophageal echocardiography (TEE) before elective catheter ablation (CA) or cardioversion (CV) and characterize the predictors of LA/LAA thrombosis among the indicators available in the routine practice of cardiologists and general practitioners.

Material and methods. In this retrospective, single-center, casecontrol study, the medical records of 1994 patients with NAF or AFL for the period 2014-2019, who underwent TEE before CA or elective CV, were analyzed. A thrombus in the LA/LAA was detected in 33 (1,6%) of them. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic and clinical parameters, transthoracic echocardiography data, and laboratory results were analyzed as potential predictors of LA/LAA thrombosis.

Results. Patients with LA/LAA thrombosis were older (mean age, 64,8±1,6 vs 59,4±10,8 (p=0,01), more often had persistent or longstanding persistent AF, hypertension, heart failure, enlarged LA, lower left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate, as well as more severe symptoms according to the modified European Heart Rhythm Association (EHRA) score and a higher CHA2DS2-VASc score (median, 4,0 vs 2,0; p=0,0001). Oral anticoagulants were taken by 88% of patients; there were no significant differences in the presence and composition of anticoagulant therapy between the groups. Functional class (FC) according to the modified EHRA score (odds ratio (OR), 5,4; 95% confidence interval (CI): 1,9814,96; p=0,001) and LVEF were independent predictors of LA/LAA thrombosis (OR, 0,87; 95% CI: 0,80-0,95; p=0,002). For EHRA class 3-4, the OR was 5,1; 95% CI: 2,3-11,4 (p<0,0001), for LVEF <48% — 7,4; 95% CI: 1,2-46,7 (p=0,03). For EHRA class 3-4, the sensitivity for LA/LAA thrombosis was 93,7%, specificity — 71,9%, positive predictive value — 50,0%, negative predictive value — 87,6%; for LVEF <48% — 66,7, 32,3, 31,9 and 91,6%, respectively.

Conclusion. In the studied group of patients with NAF or AFL, without severe structural heart disease and severe concomitant diseases, most of whom received oral anticoagulants, LA/LAA thrombosis at TEE before elective CA or CV was detected in 1,6% of cases. Among the indicators available in routine medical practice, the severity of arrhythmia symptoms, assessed by the modified EHRA score, and lower LVEF were independent predictors of LA/LAA thrombosis.

Comparison of endovenous laser ablation and conservative treatment in acute thrombophlebitis of the varicose great saphenous vein: rationale, design and first results of clinical trial

Thrombophlebitis of the superficial lower limb veins is one of the most common complications of chronic vein disease. Nowadays a long-term (at least 45 days) subcutaneous injection of fondaparinux sodium or heparin in combination with elastic compression of the limb is recommended for treatment of superficial vein thrombosis with a moderate risk of thrombus propagation to deep venous system. However, long-term use of anticoagulants is not always possible and sometimes contraindicated. Endovenous laser ablation (EVLA) around thrombus-free junction of great or small saphenous veins without subsequent long-term use of anticoagulants seems to be a promising intervention for treatment of acute thrombophlebitis of varicose superficial veins.

The prospective single-center randomized open-label clinical trial was dedicated for comparison the efficacy and safety of three following treatments options for patients with acute thrombosis of the varicose great saphenous vein and location of thrombi in the trunk and/ or its large inflows: EVLA close to saphenous vein junction without anticoagulation, EVLA and 7 days of anticoagulation and noninvasive treatment with anticoagulation for 45 days (subcutaneous injections of the fondaparinux 2,5 mg). Class 2 compression stockings are used in all patients. Adverse outcomes are recorded at 7, 45 and 90 days after randomization. These include the progression of superficial vein thrombosis, recurrent superficial vein thrombosis, thrombosis involvement of the superficial segment of the perforating vein up to the fascia, deep vein thrombosis according to compression ultrasound, and pulmonary embolism with symptoms. Bleedings according to the World Society of Thrombosis and Hemostasis and the Academic Research Consortium classification as well other complications are also recorded. The first 30 patients included in the study have a low incidence of venous thrombosis risk factors and localization of the thrombus relatively far from the saphenofemoral junction. EVLA resulted in persistent cessation of venous blood flow at the intervention site. New episodes of venous thrombosis were noted only in the group of medical treatment — deep vein thrombosis of the contralateral tibia 5 days after stopping of 45-day treatment with fondaparinux and thrombus in the recanalized inflow of the great saphenous vein without involving its trunk at the 21st day after stopping of 45-day injection of fondaparinux. There were no complications in the area of intervention and bleedings.

["Guiding lights" for the diagnosis of chronic thromboembolic pulmonary hypertension in the flow of patients with pulmonary embolism]

On December 13, 2021, an expert council was held to determine the position of experts of different specialties regarding the reasons for the low level of diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) in real clinical practice in a pandemic of a new coronavirus infection and possible ways to improve detection in patients with pulmonary embolism (PE) ) in history. The reasons for the low level of diagnosis of CTEPH are the insufficient level of knowledge of specialists, especially primary care physicians; lack of clear regulatory documents and expert centers for the management of this category of patients. Primary diagnosis of CTEPH in a pandemic can be strengthened through the widespread use of telemedicine for consultations of primary care physicians with specialists from expert centers; to maximize the role of echocardiography and computed tomography (CT) as differential diagnostic tools for dyspnea, in particular in patients with COVID-19. To increase the detection rate of CTEPH, diagnostic vigilance is required in patients with risk factors and episodes of venous thromboembolism. To improve the screening of CTEPH, it is necessary to create an algorithm for monitoring patients who have had PE; provide educational activities, including through the media; create materials for patients with accessible information. The regulatory documents should designate the circle of responsible specialists who will be engaged in long-term monitoring of patients with PE. Educational programs are needed for primary care physicians, cardiologists, and other physicians who come into the field of view of patients with CTEPH; introduction of a program to create expert centers for monitoring and managing patients with the possibility of performing ventilation-perfusion lung scintigraphy, cardiopulmonary stress test, CT, right heart catheterization. It seems important to build cooperation with the Ministry of Health of Russia in order to create special protocols, procedures for managing patients with PE and CTEPH.

Prevention of Cardioembolic Complications in Patients with Atrial Fibrillation: Efficacy and Safety of Left Atrial Appendage Isolation and Oral Anticoagulants

Aim. To study the outcomes frequency and structure in patients with atrial fibrillation (AF) depending on the cardioembolic events preventing method: left atrial appendage (LAA) isolation, direct oral anticoagulants (DOACs) or warfarin.

Material and methods. A prospective observational study included patients with AF and high risk of cardioembolic complications and without contraindications to anticoagulants. Patients who refused long-term oral anticoagulants taking underwent LAA isolation, the rest of the patients received DOACs or warfarin. The observation period was 3 years. Mortality, cardioembolic complications and major bleeding (according to GARFIELD criteria) cumulative incidence was assessed.

Results. We included 245 patients: 46 patients were treated with LAA isolation, 100 with warfarin, and 99 with DOACs. Multivariate regression analysis demonstrated a statistically significant advantage of LAA occluder in terms of combined endpoint achieving frequency compared to warfarin (hazard ratio [HR] 3.10; 95% confidence interval [CI] 1.01-9.54; p=0.049), and to DOACs (HR 3.44, 95% CI 1.15-10.29; p=0.027). A similar result was obtained for all-cause mortality (HR 5.24; 95% CI 1.12-24.55; p=0.036 and HR 5.58; 95% CI 1.22-25.49; p=0.027, respectively). There were no significant differences in bleeding rates between the groups.

Conclusion. This observational study demonstrates the superiority of LAA isolation as a first-line therapy over DOACs and warfarin in patients with AF and high risk of cardioembolic complications. Randomized trials are required to confirm these observations.

Evolution of Approaches to Therapeutic Prevention and Treatment of the New Coronavirus Infection

The means of drug intervention for the prevention and treatment of new coronavirus infection (COVID-19) are discussed. Changes in approaches aimed at the main links of pathogenesis and capable of positively influencing the course and outcome of the disease that have been implemented after the appearance of the results of numerous randomized trials are presented. Some aspects of the ongoing study of the problem are characterized.

Physiological and pathophysiological aspects of short-term middle-altitude adaptation in humans

The review presents up-to-date information on the physiological and pathophysiological aspects of short-term middle-altitude adaptation in healthy individuals and patients with various chronic diseases. Unlike acute mountain sickness, which develops going to ≥3000, the physiological aspects of human adaptation to 2000-2500 m remain insufficiently studied. However, these altitudes are the most visited among tourist groups and individually.

Physiological and pathophysiological aspects of short-term middle-altitude adaptation in humans

The review presents up-to-date information on the physiological and pathophysiological aspects of short-term middle-altitude adaptation in healthy individuals and patients with various chronic diseases. Unlike acute mountain sickness, which develops going to ≥3000, the physiological aspects of human adaptation to 2000-2500 m remain insufficiently studied. However, these altitudes are the most visited among tourist groups and individually.

The role of platelet glycoprotein IIb / IIIa inhibitors in current treatment of acute coronary syndrome

Current management of patients with acute coronary syndrome (ACS) includes a dual antiplatelet therapy with acetylsalicylic acid and a platelet P2Y12 receptor inhibitor. For patients without a high risk of bleeding, prasugrel and ticagrelor are preferred, since their effect is more pronounced, less dependent on metabolism of a specific patient, and occurs faster that the effect of clopidogrel. The prescription rate of platelet glycoprotein IIb/IIIa (GP IIb / IIIa) receptor inhibitors has considerably decreased. However, these drugs remain relevant in percutaneous coronary interventions in patients with a high risk of coronary thrombosis or a massive coronary thrombus, in thrombotic complications of the procedure, and in the "no-reflow" phenomenon. The intravenous route of GP IIb / IIIa inhibitor administration provides their effectiveness in patients with difficulties of drug intake or with impaired absorption of oral medications. This review presents clinical and pharmacological characteristics of various GP IIb / IIIa inhibitors and data of randomized clinical studies and registries of recent years that evaluated results of their use in patients with ACS.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Additional evidence against widespread use of inpatient antiplatelet therapy in coronavirus infection: data from a randomized controlled trial

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Additional evidence against widespread use of inpatient antiplatelet therapy in coronavirus infection: data from a randomized controlled trial

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Anticoagulants after Discharge in Patients with COVID-19: What we Know at the End of 2021

This review discusses reasons for prolonged use of anticoagulants after discharge of patients with COVID-19 without additional indication for anticoagulation. Data regarding rate of thrombotic and thromboembolic complications in patients with COVID-19 after discharge from the hospital are presented. Large randomized controlled trials EXCLAIM, ADOPT, MAGELLAN, APEX  and MARINER with prolonged use of anticoagulants in patients hospitalized  with acute nonsurgical diseases  before pandemia  of COVID-19 are discussed.  The first prospective  randomized controlled  trial MICHELLE with direct oral anticoagulant rivaroxaban in a dose 10 mg once daily after discharge of patients with COVID-19 with high risk at least venous thromboembolism are analyzed. It seems that the most relevant approach  for the determination  of indications for prolonged use of anticoagulants in doses dedicated for primary prevention of venous thromboembolism after discharge of patients with COVID-19 without apparent indication for anticoagulation is a modified IMPROVE VTE risk score with the addition of elevated in-hospital D-dimer  level. And the most well-studied approach  for anticoagulation in these patients is a direct peroral anticoagulant rivaroxaban 10 mg once daily for 35 (and  possibly up to 45) days after discharge.

Regional differences in cardiac mortality rates in Russia: the role of statistical features

Aim. To analyze the contribution of cardiac causes to all-cause mortality, to characterize the differences in standardized mortality rates (SMRs) in Russian regions, as well as to identify promising directions for improving establishment of cardiovascular death and its coding.

Material and methods. We used the Federal State Statistics Service (Rosstat) data on the mortality rate and the average annual population in one-year age groups for 2019. To calculate the SMR, the European Standard Population was used. For each cardiac death, the SMR from 23 causes was calculated, which were combined into 4 groups, and for each of these groups, the regional mean and standard deviation of SMR in Russian regions were estimated.

Results. In 2019, the cardiac SMR in Russian regions was 301,02±77,67, which corresponded to 30,5±5,8% of all death causes. At the same time, the coefficient of variation of regional cardiac SMR was 25,8%. In general, in 60,9±13,8% of cases, the cause of cardiac death was chronic diseases, mainly related to atherosclerosis. The proportion of deaths from acute types of coronary artery disease was 17,3±9,7%, deaths not associated with atherosclerosis (heart defects, myocardial diseases, etc.)  — 17,5±8,2%, deaths associated with hypertension  — 4,2±5,2%. The coefficient of variation of regional SMR was 34,66, 64,47, 50,99 and 122,7, respectively.

Conclusion. Significant regional differences in SMR from certain cardiac causes and groups of causes, as well as their contribution to mortality pattern, were revealed. It is necessary to continue the research on the methodology of statistical recording of certain cardiovascular diseases.

Increased level of cardiac troponin I determined by a highly sensitive method: clinical significance beyond the assessment of the severity and prognosis of acute and chronic diseases

See: Shalnova S. A., Drapkina O. M., Kontsevaya A. V., Yarovaya E. B., Kutsenko V. A., Metelskaya V. A., Kapustina A. V., Balanova Yu. A., Litinskaya O. A., Pokrovskaya M. S. Pilot project to study the association of troponin I with cardiovascular events in the population of Russian region in Original articles, pp. 185-192.

Value of comparative studies of "real clinical practice" in modern cardiology. Position paper based on the expert council discussion dated 12/18/2020

On December 18, 2020, an expert council was held with the participation of members of the Russian Society of Cardiology, the Eurasian Association of Ther-apists, the National Society for Atherothrombosis, the National Society for Evi-dence-Based Pharmacotherapy, and the Russian Heart Failure Society. The event was devoted to the discussion of the correct use of research data of "real clinical practice" in decision making.

Prediction of left atrial thrombus in patients with nonvalvular atrial fibrillation referred to catheter ablation or cardioversion: comparison of different risk scores

Funding Acknowledgements

Type of funding sources: None.

Background. Left atrial thrombus (LAT) is the main source of cardiac emboly in patients with non-valvular atrial fibrillation (NAF). Several risk scores – mostly modified CHADS2 and CHA2DS2-VASc – were offered to predict LAT in patients with NAF. However, their relative predictive value requires further evaluation.

Purpose. Compare the ability of different risk scores to predict LAT before catheter ablation or cardioversion in patients with NAF.

Methods. In a retrospective single-center study, medical records of 1994 patients with NAF who underwent transesophageal echocardiography before catheter ablation or cardioversion were analyzed. LAT was identified in 33 (1.6%) of them. For the control group 167 patients without LAT were randomly selected from this database. Logistic regression analysis and C-statistic were used for evaluation and comparison of predictive values of CHADS2, R2CHADS2, CHA2DS2-VASc, R-CHA2DS2-VASc, R2CHA2DS2-VASc, CHA2DS2-VASc-RAF, mCHA2DS2-VASc and CHA2DS2-VASc-AFR scores.

Results. The mean age of studied patients was 60.3 ± 10.9 years, 110 (55%) of them were males. The mean CHA2DS2-VASc score was 2.54 ± 1.79.

Results of univariate analysis and C-statistic for above mentioned risk scores are presented in the table. Each of them was associated with LAT. In comparison with a CHA2DS2-VASc score C-statistic was significantly higher for CHA2DS2-VASc-RAF and CHA2DS2-VASc-AFR scores (p values 0.03 and 0.001 respectively).

In multivariate analysis only CHA2DS2-VASc-RAF score was associated with LAT (OR 1.37; 95% CI 1.21-1.55, p &lt; 0.0001). OR for LАT in patients with CHA2DS2-VASc-RAF &gt;3 was 12.8 (95% CI 3.75-43.9; p &lt; 0.0001) with sensitivity, specificity, positive and negative predictive values 90.6%, 57.1%, 33.3% and 58.9% respectively.

Conclusion. In a group of patients with NAF and relatively low incidence of LAT all studied scores were associated with LAT and CHA2DS2-VASc-RAF score has appeared the most informative. Predictors of LAT in patients with NAF Risk stratification models OR (95% CI) p-value C-statistic (95% CI) CHADS2 2.12 (1.55-2.91) &lt;0.0001 0.77 (0.68-0.85) R2CHADS2 2.00 (1.53-2.62) &lt;0.0001 0.78 (0.69-0.87) CHA2DS2-VASc 1.65 (1.36-2.05) &lt;0.0001 0.74 (0.65-0.84) R-CHA2DS2-VASc 1.64 (1.34-2.03) &lt;0.0001 0.76 (0.66-0.85) R2CHA2DS2-VASc 1.59 (1.32-1.92) &lt;0.0001 0.76 (0.66-0.85) CHA2DS2-VASc- RAF 1.35 (1.27-1.52) &lt;0.0001 0.84 (0.76-0.91) mCHA2DS2-VASc 1.83 (1.42-2.35) &lt;0.0001 0.75 (0.65-0.85) CHA2DS2-VASc-AFR 1.75 (1.41-2.17) &lt;0.0001 0.80 (0.71-0.88)

COVID-19 from the interdisciplinary standpoint. Round table

On February 25, 2021, an expert round table was held, which considered the problem of interdisciplinary discussion of a coronavirus disease 2019 (COVID-19) and the development of joint actions for management of patients with chronic noncommunicable diseases during a pandemic.

Prevention of cardiovascular events in patients with stable coronary artery disease: myocardial revascularization or pharmacological treatment?

This review describes the results of randomized, controlled clinical trials comparing the outcomes of stable coronary artery disease after myocardial revascularization and non-invasive treatment, including the recently published results of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA). New potentials for improving the prognosis in stable coronary artery disease with the help of drug treatment are characterized, the role of which has not yet been evaluated in studies comparing the effectiveness of invasive and conservative approaches to the management of such patients.

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.

[Direct Oral Anticoagulant Edoxaban in Patients with Non-Valvular Atrial Fibrillation: Results of Direct Comparison with Warfarin]

This review analyzes results of a large prospective, randomized, double-blind, placebo-controlled clinical study ENGAGE AF-TIMI 48 that compared efficacy and safety of warfarin, a vitamin K antagonist, and edoxaban, an oral inhibitor of activated coagulation factor X. The review addresses important practical aspects of using edoxaban in patients with nonvalvular atrial fibrillation.

COVID-19: hemostatic parameters and specifics of antithrombotic treatment

In this review changes of hemostatic parameters in patients with COVID19 and their practical value are discussed. Current approaches to prevention and treatment of thrombotic/thromboembolic complications in patients with COVID-19 are considered.

[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.

[Rivaroxaban in prevention of stroke in elderly patients with non-valvular atrial fibrillation]

Data regarding efficacy and safety of direct oral anticoagulant rivaroxaban in prevention of stroke in elderly polymorbid patients with non-valvular atrial fibrillation are presented. In this aspect results of randomized clinical trial in direct comparison of rivaroxaban and warfarin in patients with non-valvular atrial fibrillation ROCKET-AF are discussed. Results of rivaroxaban use in elderly patients in real medical practice are also considered.

Atherothrombotic stroke in non-valvular atrial fibrillation

The review analyzes data on the detection rate of and the abilities to predict and prevent non-cardioembolic strokes in non-valvular atrial fibrillation. According to accumulated facts, vitamin K antagonists in non-valvular atrial fibrillation are noted to be inferior to antiplatelet drugs in efficiency in preventing non-cardioembolic (atherothrombotic in particular) strokes, and the widespread use of oral anticoagulants in combination with antiplatelet drugs does not generally reduce the incidence of poor outcomes, markedly increasing the risk of serious bleeding. Nevertheless, it is conceivable that this combination antithrombotic therapy may be useful for certain categories of patients at the highest risk for atherothrombotic stroke and at relatively low risk for hemorrhagic complications. Cohorts of patients, to whom such an approach should be reasonable considered to be applied, have not yet been identified.

Ischemic Heart Disease in Subjects of Young Age: Current State of the Problem. Features of Etiology, Clinical Manifestation and Prognosis

In addition to conventional risk factors in young patients with ischemic heart disease (IHD) numerous other risk factors including genetics play an important role in its causation. Molecular genetic testing is recommended for the detection of monogenic diseases with a high risk of developing IHD, such as familial hypercholesterolemia. In majority ofyoung patients, the first manifestation of IHD is an acute coronary syndrome. Young patients with IHD more often have normal coronary arteries or single-vessel coronary disease, and in up to 20% of them cause of myocardial ischemia is not related to atherosclerosis. In general, young patients with IHD have better prognosis. However, there are sex differences in IHD outcomes the prognosis of patients with premature IHD and reason for this is still unclear.

Elderly Patient Management Problems: Antithrombotic Therapy Selection Features. Clinical Case

The growing population of elderly people is the main «antithrombotic drugs consumer» because there is higher prevalence of thromboembolic diseases (acute coronary syndrome, venous thromboembolism, atrial fibrillation) among them than among younger people. Elderly people have high risks of both thromboembolic and bleeding complications associated with antithrombotic drugs using. Antithrombotic drug choice is based on individual careful estimation of the «risk/benefit» ratio. Sometimes real clinical practice gives us problems and questions, having no answers in any guidelines. Such a difficult clinical case of elderly patient management is presented in this article.

[Practical Aspects of the Use of Oral Anticoagulant Rivaroxaban for the Prevention of Adverse Outcomes After Acute Coronary Syndrome]

This review examines the reasons for long-term use of anticoagulants after an acute coronary syndrome, the study analysis the results of ATLAS ACS 2-TIMI 51 and with the main features of the use of rivaroxaban for the prevention of adverse outcomes in patients of this category that are important from a practical point of view.

Enoxaparin in cardiovascular disease: how to improve effectiveness and safety?

The review analyses the specifics of enoxaparin therapy in the most prevalent cardiovascular diseases, such as acute coronary syndrome, venous thromboembolism, and atrial fibrillation. The decision strategy is presented for difficult and non-standard clinical situations (renal dysfunction, elderly age, heparin medication change, or abnormal body weight), when the optimal balance between effectiveness and safety requires modifying the standard treatment protocols.