Personalized medicine in non-communicable diseases: latest advances and future prospects

Since the human genome was decoded more than 15 years ago, there has been a huge leap forward in the development of genomic and post-genomic technologies. Personalized medicine is engaged in implementing these technologies in clinical practice by developing new methods for risk assessment, diagnosis, and treatment of diseases taking into account individual features of the patient. Significant progress has been achieved in decoding genetic bases of chronic noninfectious diseases; new markers for the risk of complications and targets for effects of drugs are being searched for. This review highlights promising directions in the development of personalized medicine, the problems facing modern scientists, and possible ways to solve them

Features of pulmonary thromboembolism in women

Pulmonary artery embolism (PAE) is usually a diagnosis of exclusion. Verification of a more common pathology takes time, which may become critical for treatment of pulmonary embolism and saving the patient’s life. Since PAE is an acute disease, the time window for medical care largely determines the prognosis. Therefore, the differential diagnostic process should include thromboembolism already at the first visit. It is important to determine risk factors for PAE taking into account the patient’s personality and gender. Obtained data may help the physician to determine quickly the expedience of visualizing studies, such as ventilation/perfusion scintigraphy, angiopulmonography, computed tomographic angiopulmonography. For women, it is important to collect specific information, such as the presence of large uterine fibroids, use of combined oral contraceptives or hormonal replacement therapy; to ask how long ago the patient had pregnancy and delivery, whether she has thrombophilia or oncological diseases.

Focus ultrasound for cardiology practice. Russian consensus document

This document is a consensus document of Russian Specialists in Heart Failure, Russian Society of Cardiology, Russian Association of Specialists in Ultrasound Diagnostics in Medicine and Russian Society for the Prevention of Noncommunicable Diseases. In the document a definition of focus ultrasound is stated and discussed when it can be used in cardiology practice in Russian Federation.

Analysis of the compliance of the prescribed therapy with the EURO FORTA system in polymorbidic patients of elderly and old age with CHF

Aim To study the consistency of the prescribed therapy with the EURO FORTA (2018) system in polymorbid patients with chronic heart failure (CHF) according to data of the local registry.Material and methods The study included 313 patients with CHF aged 75±8.2 years. The Charlson Comorbidity Index (CCI) and the number of diseases (1–2, 3–5, >5) were calculated for all patients. Inpatient and outpatient treatment was assessed according to the EURO FORTA (2018) system based on polymorbidity degree, age, gender, and CHF type and severity.Results For the retrospective analysis of outpatient treatment, 5 groups of patients were isolated based on the drug class in the EURO FORTA system: group 1, patients treated only with class A drugs (3.51 %); group 2, class A and B drugs (22.36 %); group 3, class A, B, and C drugs (17.25 %); group 4, class A, B, C, and D drugs 10.86 % (А, В, С, D) and 16.31 % (А, В, D); and group 5, patients without an outpatient drug therapy (29.71 %). For the analysis of inpatient treatment, 4 groups of patients were isolated based on the drug class in the EURO FORTA system: group 1, patients treated only with class A drugs (0.32 %); group 2, class A and B drugs (15.97 %); group 3, class A, B, and C drugs (57.19 %); and group 4, separately analyzed patients treated with class C and D drugs or only D in combination with class A and B drugs. Thus, 28.11 % of patients at the outpatient stage and 82.75 % of patients at the inpatient stage received drugs with questionable efficacy/safety profiles (class C); 27.17 % of patients at the outpatient stage and 26.52 % at the inpatient stage received potentially inappropriate drugs (class D). At the outpatient stage in groups 2-4, most of patients (51.43–70.59 %) had >5 diseases (pmg=0.020). At the inpatient stage, there were no significant differences between groups in the number of diseases (pmg=0.349). The groups were comparable in the left ventricular ejection fraction depending on the CHF type (pmg=0.027 and pmg=0.778) at both stages of treatment. For instance, the same patient with preserved left ventricular ejection fraction could be included into EURO FORTA group 2 for the analysis of outpatient treatment while after prescription of the inpatient treatment, he/she could be included into group 3; pmg (intergroup, detecting differences for comparison of 3 groups) exceeded 0.017; therefore, the groups were comparable in the number of CHF patients with reduced, mid-range, and preserved left ventricular ejection fraction.Conclusion Every second patient of the study had more than 5 diseases. Every third patient did not take any drugs at the outpatient stage. 28.11 % of patients received EURO FORTA class C drugs and 27.17% of patients received class D drugs at the outpatient stage. The drugs to be avoided in CHF, included primarily nonsteroid anti-inflammatory drugs (NSAIDs) and class I and III anti-arrhythmic medications (except for amiodarone). At the inpatient stage, 82.75 % of patients received EURO FORTA class C drugs and 26.52 % of patients received class D drugs. NSAIDs and ciprofloxacin prevailed among the drugs to be avoided in CHF.

Acute myocardial infarction and cardiogenic shock in patient with COVID-19

The conditions of the pandemic caused by the novel coronavirus infection (COVID-19) are associated with overloading intensive care units, conversion of hospitals, and changes in routing of patients with acute cardiovascular pathology. At the same time, medical practice is still challenged to provide medical care to patients with acute coronary syndrome (ACS). Patients with COVID-19 and acute myocardial infarction (AMI) are at a higher risk of death while the incidence of this combination of diseases will be growing. This article describes a case of diagnosis and treatment of COVID-19 in a 69-year-old patient who was urgently hospitalized with cardiogenic shock associated with ACS, electrocardiographic signs of complete left bundle branch block, and left ventricular ejection fraction of 19 %. Coronary angiography with stenting was successfully performed in the conditions of extracorporeal membrane oxygenation. The patient received long-term intensive therapy in the intensive care unit followed by symptomatic treatment in the cardiac surgery unit. The patient’s condition gradually improved and he was discharged from the hospital on the 56th day. The strategy of intensive care and active follow-up helped saving life of the patient with COVID-19 and AMI.

The value of the spatial QRS–T angle for assessing the severity of heart damage in patients with arterial hypertension

Aim To study the relationship between clinical, echocardiographic, and laboratory indexes with increased QRS–T spatial angle (sQRS–T) in patients with arterial hypertension (AH).Material and methods The study included 160 patients with AH, 61 (38 %) men and 99 (62 %) women aged 58 [49; 67] years. Patients with ischemic heart disease or His bundle blocks were not included. Echocardiography was used to determine the left ventricular end-diastolic dimension (LV EDD), left ventricular posterior wall thickness (LVPWT), interventricular septal thickness (IVST), relative wall thickness (RWT), left ventricular myocardial mass (LVMM), and LVMM index (LVMMI). Also, the following indexes were analyzed: office systolic and diastolic blood pressure (SBP, DBP), disease duration, body mass index, plasma levels of glucose, cholesterol, and creatinine, and glomerular filtration rate. The QRS-T spatial angle was calculated as an angle between the integral vectors QRS and T using a vectorcardiogram derived from a 12-lead digital electrocardiogram. Data are presented as median (25th percentile; 75th percentile].Results The QRS-T spatial angle for the group was 65 [43; 90]°. The QRS–T spatial angle increased with increases in the AH grade (grade 1 AH, 55 [37; 74]°; grade 2 AH, 60 [41; 82]°; grade 3 AH, 88 [62; 107]°; р<0.0001); the AH stage (stage 1, 50 [41; 77]°; stage 2, 68 [44; 93]°; stage 3, 78 [59; 110]°; р=0.0002), and the cardiovascular risk degree (low and moderate risk, 49 [37; 70]°, high risk, 62 [43; 88]° (р=0.005); very high risk, 88 [61; 117]° vs. high risk, 62 [43; 88]° (р=0.0002). The QRS–T spatial angle was greater with diabetes mellitus (78 [60; 117]°) than without it (63 [43; 89]°) (р=0.03). Weak but significant correlations were found between sQRS–T and body mass index (r=0.2; p<0.01), SBP (r=0.4; p<0.0001), DBP (r=0.2; p<0.01), LV EDD (r=0.2; p<0.01), LV PWT (r=0.3; p<0.001), IVST (r=0.3; p<0.001), LVMM (r=0.3; p<0.001), LVMMI (r=0.3; p<0.001), and blood glucose (r=0.2; p<0.01).Conclusion In patients with AH, a large QRS-T spatial angle is related with significantly higher values of SBP and DBP, LV dimension, blood glucose, and body mass index.

Efficacy of trimetazidine – an inhibitor of free fatty acids oxidation in the treatment of patients with stable angina pectoris and heart failure

Aim To evaluate efficacy of modified-release trimetazidine (TMZ) included into the standard therapy for patients with stable angina and chronic heart failure (CHF) as a part of a subgroup analysis in the PERSPECTIVE study.Material and methods The study included 806 patients: group 1 (n=691), patients receiving a standard therapy and modified-release TMZ (TMZ group); and group 2 (n=115), patients receiving a standard therapy (control group). Total duration of the study was 12 months.Results In the TMZ group, the weekly number of angina attacks decreased by 41.9% (p<0.0001) in 2 months and by 69.6 % (from baseline, р<0.0001) in 12 months, and the frequency of nitroglycerine dosing decreased by 40.8 % (р<0.0001) and 67.7 % (р<0.0001), respectively. In the control group, the respective values did not change. In the TMZ group compared to the control group, the QT interval was shorter (7.9 %; р<0.05), the left ventricular (LV) end-systolic dimension was reduced (13.4 %; р<0.01), interventricular septal thickness and LV posterior wall thickness were decreased (9.5 %; р<0.01 and 12.2 %; р<0.01, respectively), and the ejection fraction was increased (11.4; р<0.05). Following the TMZ treatment, the leukocyte count in peripheral blood was decreased (5.3 %; р<0.01) and the serum concentration of high-sensitivity C-reactive protein was decreased (30.7 %; р<0.01) vs. increases of these indexes in the control group (17.9 %; р<0.05 and 17.8 %; р<0.05, respectively). The proportion of patients hospitalized for exacerbation of CHF or angina for 12 months was 8.6 % in the TMZ group and 15.7 % in the control group (p=0,001).Conclusion In patients with stable angina and CHF, inclusion of modified-release TMZ into the standard therapy decreases the number of angina attacks, reduces the activity of inflammatory factors, and improves the course of disease.

Impact of anemia on outcomes in on-pump coronary artery bypass surgery patients

Aim To study the contribution of preoperative anemia to the prognosis of adverse clinical events (mortality, complications, transfusion) in patients with ischemic heart disease (IHD) after myocardial revascularization in the conditions of artificial circulation.Material and methods This retrospective cohort study included 1 133 patients with IHD who had undergone isolated myocardial revascularization in the conditions of artificial circulation in 2019. The primary endpoints were mortality and a composite endpoint that included, in addition to mortality, cases of acute coronary syndrome, heart, respiratory and renal failure, neurological deficit, and infectious complications. The secondary endpoints were duration of artificial ventilation of more than 12 h, duration of stay in the resuscitation and intensive care unit (RICU) of more than one day, and duration of postoperative inpatient treatment of more than 7 days. Results Preoperative anemia was found in 196 (17.3 %) patients. The anemia was not associated with mortality but increased the risk of the composite endpoint, prolonged artificial ventilation, stay in RICU for more than one day, and red blood cell transfusion. Despite the absence of a relationship between red blood cell transfusion and mortality, the use of transfusion was associated with increased risks of the composite endpoint and prolonged stay in the RICU and hospital.Conclusion Preoperative anemia is a risk factor for adverse outcomes of myocardial revascularization in the conditions of artificial circulation. Timely treatment of preoperative anemia may improve outcomes of the treatment.

Cardioprotective potential of chronopharmacotherapy in patients with arterial hypertension who had a transient ischemic attack

Aim Analysis of the cardioprotective effectivity of chronopharmacotherapy in patients with arterial hypertension (AH) after transient ischemic attack (TIA).Material and methods 174 patients with AH and TIA were evaluated. All patients were randomized to three groups based on the dosing schedule of chronopharmacotherapy: group 1 (n=59), patients receiving indapamide retard 1.5 mg and valsartan 160 mg, both in the morning; group 2 (n=58), indapamide retard 1.5 mg in the morning and valsartan 160 mg in the evening; group 3 (n=57), indapamide retard 1.5 mg in the morning and valsartan 80 mg in the morning and evening. Echocardiography (EchoCG) (ALOKA SSD 2500, Japan) was performed for all patients at baseline and at 12 months of the treatment. Statistical analysis of results was performed with the Statistica 12.0 (StatSoftInc, USA) software.Results Before the treatment, EchoCG parameters did not significantly differ between the patient groups. After 12 months of the treatment, positive changes in the end-systolic dimension (ESD), interventricular septal thickness (IVST), thickness of the left ventricular posterior wall (TLVPW), LV myocardial mass (LVMM), LVMM index (LVMMI), ejection fraction (EF), ratio of transmitral early peak flow velocity and late filling flow velocity (E/A), and isovolumetric velocity relaxation time (IVRT) were more pronounced in the group of sartan evening dosing (group 2) than in the group of sartan single morning dosing (group 1) (p<0.05). In group 3, the changes in ESD, IVST, TLVPW, LVMM, LVMMI, EF, E/A ratio, deceleration time (DT) of LV, and IVRT were significantly greater than those in group 1, whereas the dynamics of ESD, IVST, TLVPW, LVMM, LVMMI, E/A ratio, and DT were better in group 3 than in group 2 (p<0.05). In addition, a significantly greater number of patients with normalized LV geometry was registered in group 3 compared to groups 1 and 2 (p<0.05). The number of patients with normal LV diastolic function after the treatment was also significantly greater in group 3 than in group 1 (p<0.05) and comparable with group 2.Conclusion The morning dosing of indapamide retard and the b.i.d. dosing of valsartan provided more pronounced beneficial changes in major EcoCG indexes and improvement of LV geometry and diastolic function than the sartan single dosing only in the morning or evening in combination with the diuretic.

Heart failure with preserved left ventricular ejection fraction in patients with obstructive sleep apnea syndrome: prognostic value of biomarkers

Aim To study the role of soluble ST2 (sST2), N-terminal pro-brain natriuretic peptide (NT-proBNP), and С-reactive protein (CRP) in patients with chronic heart failure and preserved left ventricular ejection fraction (CHF with pLVEF) and syndrome of obstructive sleep apnea (SOSA) in stratification of the risk for development of cardiovascular complications (CVC) during one month of a prospective observation.Material and methods The study included 71 men with SOSA with an apnea/hypopnea index (AHI) >15 per hour, abdominal obesity, and arterial hypertension. Polysomnographic study and echocardiography according to a standard protocol with additional evaluation of left ventricular myocardial fractional changes and work index were performed for all patients at baseline and after 12 months of observation. Serum concentrations of sST2 , NT-proBNP, and CRP were measured at baseline by enzyme-linked immunoassay (ELISA).Results The ROC analysis showed that the cutoff point characterizing the development of CVC were sST2 concentrations ≥29.67 ng/l (area under the curve, AUC, 0.773, sensitivity 65.71 %, specificity 86.11 %; p<0.0001) while concentrations of NT-proBNP (AUC 0.619; p=0.081) and CRP (AUC 0.511; р=0.869) were not prognostic markers for the risk of CVC. According to data of the ROC analysis, all patients were divided into 2 groups based on the sST2 cutoff point: group 1 included 29 patients with ST2 ≥29.67 ng/l and group 2 included 42 patients with ST2 <29.67 ng/l. The Kaplan-Meyer analysis showed that the incidence of CVC was higher in group 1 than in group 2 (79.3 and 28.6 %, respectively, p<0.001). The regression analysis showed that adding values of AHI and left ventricular myocardial mass index (LVMMI) to sST2 in the model increased the analysis predictive significance.Conclusion Measuring sST2 concentration may be used as a noninvasive marker for assessment of the risk of CVC development in patients with CHF with pLVEF and SOSA within 12 months of observation. Adding AHI and LVMMI values to the model increases the predictive significance of the analysis.