Recommendations and Associated Levels of Evidence for Statin Use in Primary Prevention of Cardiovascular Disease: A Comparison at Population Level of the American Heart Association/American College of Cardiology/Multisociety, US Preventive Services Task Force, Department of Veterans Affairs/Department of Defense, Canadian Cardiovascular Society, and European Society of Cardiology/European Atherosclerosis Society Clinical Practice Guidelines

Background: Despite using identical evidence to support practice guidelines for lipid-lowering treatment in primary prevention of cardiovascular disease (CVD), it is unclear to what extent the 2018 American Heart Association/American College of Cardiology/Multisociety, 2016 US Preventive Services Task Force (USPSTF), 2020 Department of Veterans Affairs/Department of Defense, 2021 Canadian Cardiovascular Society, and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines differ in grading and assigning levels of evidence and classes of recommendations (LOE/class) at a population level. Methods: We included 7262 participants, aged 45 to 75 years, without history of CVD from the prospective population-based Rotterdam Study. Per guideline, proportions of the population recommended statin therapy by LOE/class, sensitivity and specificity for CVD events, and numbers needed to treat at 10 years were calculated. Results: Mean age was 61.1 (SD 6.9) years; 58.2% were women. American Heart Association/American College of Cardiology/Multisociety, USPSTF, Department of Veterans Affairs/Department of Defense, Canadian Cardiovascular Society, and European Society of Cardiology/European Atherosclerosis Society strongly recommended statin initiation in respective 59.4%, 40.2%, 45.2%, 73.7%, and 42.1% of the eligible population based on high-quality evidence. Sensitivity for CVD events for treatment recommendations supported with strong LOE/class was 86.3% for American Heart Association/American College of Cardiology/Multisociety (IA or IB), 69.4% for USPSTF (USPSTF-B), 74.5% for Department of Veterans Affairs/Department of Defense (strong for), 93.3% for Canadian Cardiovascular Society (strong), and 66.6% for European Society of Cardiology/European Atherosclerosis Society (IA). Specificity was highest for the USPSTF at 45.3% and lowest for European Society of Cardiology/European Atherosclerosis Society at 10.0%. Estimated numbers needed to treat at 10 years for those with the strongest LOE/class were ranging from 20 to 26 for moderate-intensity and 12 to 16 for high-intensity statins. Conclusions: Sensitivity, specificity, and numbers needed to treat at 10 years for assigned LOE/class varied greatly among 5 CVD prevention guidelines. The level of variability seems to be driven by differences in how the evidence is graded and translated into LOE/class underlying the treatment recommendations by different professional societies. Efforts towards harmonizing evidence grading systems for clinical guidelines in primary prevention of CVD may reduce ambiguity and reinforce updated evidence-based recommendations.

A trimetazidin hatásosságának összehasonlítása a revaszkularizált és a nem revaszkularizált stabil anginás betegeken a ONECAPS-vizsgálat alapján

Összefoglaló. Bevezetés: A közelmúltban publikált ATPCI-vizsgálat azt eredményezte, hogy közvetlenül a sikeres revaszkularizáció után alkalmazott trimetazidin biztonságos volt, de nem volt effektívebb a cardiovascularis halál, anginarekurrencia, cardialis hospitalizáció tekintetében, mint a random kettős vakmódszerrel alkalmazott placebo. Célkitűzés: Az általunk korábban végzett ONECAPS nyitott, obszervációs vizsgálat retrospektív analízisét kívántuk elvégezni annak eldöntésére, hogy az anginás betegeknél van-e különbség a trimetazidin prolong hatásosságában annak megfelelően, hogy korábban revaszkularizáció történt. Módszer: 1670, anginás betegből 1008 nem volt revaszkularizálva, míg 662 korábban revaszkularizáción esett át. Az életkorban, társbetegségben nem volt különbség a két csoport között. A betegeknél a heti anginaszámnak és a nitroglicerin-fogyasztásnak, illetve az angina súlyosságának a változását vizsgáltuk a trimetazidin prolong 80 mg napi egyszeri alkalmazása során a revaszkularizált és a nem revaszkularizált betegcsoportban. Eredmények: Mind a revaszkularizált, mind a nem revaszkularizált betegcsoportban szignifikáns csökkenést (p<0,0001) eredményezett a trimetazidin mind a heti anginaszámban, mind a rövid hatású nitroglicerin fogyasztásában. Emellett mindkét betegcsoportban növekedett a Kanadai Cardiovascularis Társaság (CCS) osztályozása szerinti I. súlyosságú angina aránya, és csökkent a CCS III., illetve CCS IV . aránya is. Mindezt a hatást úgy érték el, hogy a revaszkularizált betegeknél 90% felett volt a sztatin, az ACEI/ARB, illetve a béta-blokkoló használata. Következtetés: A trimetazidin prolong napi egyszeri 80 mg adása szignifikánsan csökkenti a heti anginaszámot, nitroglicerin-fogyasztást, illetve az angina súlyosságát. Ezen hatása független attól, hogy a beteg korábban részesült-e revaszkularizációban vagy sem. Orv Hetil. 2021; 162(29): 1167–1171. Summary. Introduction: The recently published ATPCI study resulted in the safety of trimetazidine administered immediately after successful revascularization but was not more effective (cardiovascularis death, recurrence of angina, hospitalization for cardiac event) than the randomized double-blind placebo. Objective: A retrospective analysis of our previously published ONECAPS open-label observational study was performed to determine whether there was a difference in the efficacy of trimetazidin prolong in the angina patients according to whether or not they had previously undergone revascularization. Method: Of the 1670 angina patients, 1008 were not revascularized, while 662 had previously undergone revascularization. There was no difference in age or comorbidity between the two groups. Patients were examined for changes in weekly angina, short-acting nitroglycerin use and angina severity during once-daily administration of trimetazidine prolong 80 mg in revascularized and non-revascularized study groups. Results: In both the revascularized and non-revascularized group, trimetazidine resulted in a significant reduction (p<0.0001) in both weekly angina count and short-acting nitroglycerin use. In addition, the proportion of angina with Canadian Cardiovascular Society (CCS) I increased and the proportion of CCS III and CCS IV decreased in both patient groups as well. All of this effect was achieved with statin, ACEI/ARB, and beta-blocker use above 90% in revascularized patients. Conclusion: Trimetazidine prolong 80 mg once daily significantly reduced the number of angina per week, the use of short-acting nitroglycerin per week, and the severity of angina. This effect is independent of whether the patient has previously received revascularization. Orv Hetil. 2021; 162(29): 1167–1171.

Effects of Xuefu Zhuyu Granules on Patients with Stable Coronary Heart Disease: A Double-Blind, Randomized, and Placebo-Controlled Study

Despite advances in the drug treatment strategy for stable coronary heart disease (CHD), the mortality of CHD continues to rise. New or adjuvant treatments would be desirable for CHD. Xuefu Zhuyu granules are derived from the formula of traditional Chinese medicine. To determine whether Xuefu Zhuyu granules might have adjuvant effects on stable CHD, we conducted a controlled clinical trial. Patients with stable CHD were enrolled and randomly assigned to receive Xuefu Zhuyu granules or placebo for 12 weeks in addition to their standard medications for the treatment of CHD. The primary endpoints comprise the Canadian Cardiovascular Society Angina Grading Scale (CCS class), echocardiographic measures, Seattle Angina Questionnaire (SAQ), and coronary artery CT. The secondary endpoints included the parameters of nailfold capillary measurement and cutaneous blood perfusion (CBP). After 12 weeks of follow-up, there was a great improvement of the Canadian Cardiovascular Society Angina Grading Scale (CCS class) in the Xuefu Zhuyu group compared with the placebo group ( p < 0.01 ). Also, a decrease was found in the percentage of patients with CCS class II in the Xuefu Zhuyu group between follow-up at 12 weeks and baseline ( p < 0.01 ). We observed a significant increase in SAQ scores of physical limitation ( p < 0.01 ) and treatment satisfaction ( p < 0.05 ) in patients receiving Xuefu Zhuyu treatment at 12 weeks in comparison with those at baseline, but not in placebo treatment ( p > 0.05 ). Amelioration in coronary artery stenosis in the Xuefu Zhuyu group was noted ( p < 0.05 ). Xuefu Zhuyu granule treatment led to great improvements in cutaneous blood perfusion at follow-up of 12 weeks compared with placebo ( p < 0.05 ). These findings suggest that on a background of standard medications, Xuefu Zhuyu granules have the ability to further improve the prognosis of patients with stable CHD.

Post-COVID Syndrome and Tachycardia: Theoretical Base and Treatment Experience

The coronavirus pandemic showed not only an increase in levels of excess morbidity and mortality in the acute phase, but also persisting symptoms 4 weeks after the onset of the disease. A review of international studies on the prevalence and diversity of the manifestations of postcoid syndrome is presented. The data on such a manifestation of post-COVID syndrome as postural orthostatic tachycardia syndrome (POTS) are accumulating. Pathogenetic mechanisms, modern diagnostic criteria and research data on the prevalence of this syndrome are presented in the article. The Canadian Cardiovascular Society has proposed medications as a treatment for POTS, including the sinus node If channel inhibitor ivabradine. Data from several studies showing the effectiveness of this drug for POTS, including after suffering COVID-19, are presented in the article. Clinical data on the prevalence of tachycardia among patients admitted to the Sechenov University hospital are presented. About 18% of patients with hypertension and 21% of patients with normal blood pressure had a high heart rate. A clinical example of the use of ivabradine in a patient after a coronavirus infection is presented. Drug interactions and individual tolerance of ivabradine in patients after coronavirus infection are being discussed. The authors put forward the hypothesis about the further prospect of using ivabradine in the treatment of clinical manifestations of postcoid syndrome on the basis of literature data and their own experience.