Risk assessment and prevention of venous thromboembolism among hospitalized patients: Results of the regional multicenter study

Introduction. Venous thromboembolism (VTE) is a major public health issue that is frequently underestimated. The primary objective of this multicenter study was to identify patients at risk for VTE, and to define the rate of patients receiving appropriate prophylaxis in the regions of Kazakhstan.Materials and methods. Standardized case report forms were filled by trained medical doctors on one predefined day in selected hospitals. Data were analyzed by independent biostatistician. Risk of VTE was categorized according to Caprini score which was recommended by 2004 American College of Chest Physicians (ACCP) guidelines.Results. 432 patients from 4 regions of Kazakhstan; 169 (39.10%) medical patients and 263 (60.9%) surgical patients were eligible for the study. Patients were at low (10%), moderate (19.2%), high (33.6%) and very high risk (37.3%) for VTE. The main risk factors (RF) of VTE among hospitalized patients were heart failure (HF), obesity, prolonged bed rest, and the presence of acute non-infective inflammation. From total number of hospitalized patients with RF with indications to VTE prophylaxis, 58.1% of patients received pharmacological prophylaxis and only 24.6% of them received VTE prophylaxis according ACCP. On the other hand, 23.5% patients with the risk of VTE but who were not eligible for it received pharmacological prophylaxis.Conclusion. These results indicate the existence of inconsistency between eligibility for VTE prophylaxis on one hand and its application in practice (p < 0.001). Risk factors for VTE and eligibility for VTE prophylaxis are common, but VTE prophylaxis and guidelines application are low.

The risk of bleeding minimization with direct oral anticoagulants

This review is devoted to the safety issues of anticoagulant therapy prescribed for the prevention of stroke and systemic embolism in patients with atrial fibrillation. Direct oral anticoagulants are considered worldwide in accordance with the guidelines for the diagnosis and treatment of atrial fibrillation as the preferred anticoagulant choice for the prevention of stroke and systemic embolism. Direct oral anticoagulants in comparison with vitamin K antagonists generally have similar efficacy, but different safety profiles, primarily, this concerns the risk of large extracranial and, primarily, gastrointestinal hemorrhages. To minimize the risk of bleeding during therapy with direct oral anticoagulants, an individual approach to the choice of the drug for each individual patient is required after assessing the risk of bleeding, searching for a potential bleeding substrate, correcting existing risk factors and eliminating, if possible, the substrate. When choosing an anticoagulant therapy, special attention should be paid to the most vulnerable categories of patients, such as patients of older age groups and patients with concomitant chronic kidney disease. Among the direct oral anticoagulants registered in the Russian Federation, according to meta-analyzes of key randomized clinical trials and real clinical trials, apixaban has the most optimal benefit: risk ratio in a wide range of patients, including vulnerable populations. Dynamic observation, including regular assessment of renal function, control of clinical blood analysis, erythrocyte and platelet levels, after prescribing an individually selected anticoagulant to the patient, ensures the maximum safety of therapy. Small, so-called, annoying bleeding is not a reason for canceling the anticoagulant, but requires a careful search for the causes of bleeding and their correction.

A case of successful surgical treatment of a ruptured giant aneurysm of the infrarenal aorta in an elderly patient

Today, abdominal aortic aneurysm surgery is a fairly well-studied area of medicine. Nevertheless, some questions remain rather debatable. No clear criteria for giant aneurysms have been developed so far. The available foreign and domestic literature reports about 40 cases of surgical treatment of giant abdominal aortic aneurysms, 16 of which are cases of aneurysm rupture. Open surgery remains the method of choice in the treatment of giant aneurysms due to the pronounced technical difficulties of endovascular intervention. The authors present a case of successful surgical treatment of a giant aneurysm rupture in an elderly patient. The peculiarity of this patient's condition is the occurrence of aneurysm rupture after hospital admission. The patient refused surgical treatment for two years after aneurysm detection. On examination after admission, multispiral computed tomography revealed an aneurysm size of 101 mm. On the eve of surgery, pain syndrome in the left abdomen and tachycardia appeared. Aneurysm rupture was suspected and the patient was urgently admitted to the operating room. The surgery was performed under the conditions of machine reinfusion of autoblood. The patient underwent abdominal aortic aneurysm resection with linear prosthesis and retroperitoneal hematoma removal. The postoperative period had no peculiarities. On the 10th day after the operation the patient was discharged in satisfactory condition to the outpatient treatment. This clinical case demonstrates the possibility of successful surgical treatment of giant aneurysm rupture in elderly patients.

Renal artery aneurysms

Renal artery aneurysms are a rare condition and are usually found when other abdominal organ diseases are being searched. Among the causes of renal artery aneurysms, atherosclerosis and fibromuscular dysplasia predominate. However, they can also be observed in congenital Ehlers-Danlos syndrome, neurofibromatosis, arteritis, and due to traumatic effects. Most patients have an asymptomatic course of the disease. Literature data suggest slow growth of aneurysms, and their progression is associated with arterial hypertension, absence of wall calcification and pregnancy in young women. The aim of surgical treatment is to prevent aneurysm rupture, eliminate the risk of renal parenchyma embolism and correct arterial hypertension. Most authors believe that surgical treatment is indicated for asymptomatic course of the disease when the aneurysm is over 20 mm in diameter, aneurysm growth is over 5 mm within a year, arterial hypertension resistant to drug therapy, renal artery dissection and aneurysm presence in women of childbearing age. There are a number of surgical and endovascular techniques to restore renal blood flow. Both open and endovascular interventions are used for renal artery trunk surgery. For aneurysms of the renal artery branches, aortorenal shunting by autovenous or internal iliac artery as well as extracorporeal surgeries are more often used. The use of endografts is most appropriate for localization of aneurysms in the renal artery trunk, while embolization with microspirals and glue is most effective for saccular aneurysms. The embolization technique can cause embolization of the renal parenchyma itself as a potential complication, which aggravates arterial hypertension. The authors present the literature and their own data on various techniques to restore the renal blood flow. Up to 80-90% of the operated kidneys can be saved in the long term. Reconstructive surgery reduces the level of arterial pressure and reduces the number of antihypertensive drugs used and the need for renal replacement therapy.

Reticulated platelets – a new risk factor of atherothrombosis?

In this review we described the properties of reticulated platelets (RP) and showed how variations of their content might influence platelet activity, efficacy of antiplatelet drugs and the rate of thrombotic events in patients with cardiovascular diseases. RP represent a minor platelet fraction containing residual RNA from megakaryocytes. Platelets have no nucleus and do not synthesize RNA de novo, and RNA of megakaryocytic origin is destroyed during their circulation. That is why only recently produced “young” platelets contain RNA. In healthy donors RP are identified by staining with the RNA specific fluorescent dyes by flow cytofluorimetry or using standard protocols in modern flow haematological analyzers. RP content in blood reflects the level of thrombocytopoesis in the bone marrow. RP on average amounted from 3 to 10% of all platelets in the circulation depending on the method applied for their determination. RP absolute amount and/or their percentage is changed in haematological diseases associated with the alterations of megakaryocyte productive properties. RT measurements in patients with cardiovascular diseases have shown that their content is increased in acute coronary syndrome patients. RP are larger and functionally more active in comparison with not reticulated forms. They more frequently incorporate into the platelet aggregates and contain more intracellular granules. Increase of RT content in the circulation correlates with the increase of the average size and functional activity in the whole platelet population. High RP content in patients with cardiovascular diseases reduces antiaggregative effects of aspirin and P2Y12 APD receptor antagonists and increases the risk of atherothrombotic events.

Elderly patient with atrial fibrillation and coronary risks

The incidence of atrial fibrillation (AF) and coronary heart disease (CHD) increases with age. Obviously, this is largely due to the coincidence of risk factors for the occurrence and progression of AF and risk factors for the occurrence and progression of atherosclerosis, including coronary atherosclerosis. Vitamin K antagonists, which are necessary for stroke prevention in patients with AF, are also reported to be able to prevent thrombotic complications of coronary atherosclerosis. No studies specifically designed to compare direct oral anticoagulants (DOACs) and vitamin K antagonists in the prevention of coronary thrombosis have been conducted, However, analysis of the results of randomized controlled trials ARISTOTLE, AUGUSTUS, PIONEER AF-PCI, REDUAL PCI, RE-LY and ROCKET AF indicates that in general DOACs are not inferior to warfarin in the ability to protect patients with AF from myocardial infarction and stent thrombosis. Accordingly, in stable patients with non-valvular AF (who have not suffered an acute coronary syndrome in the next 1 year or planned coronary stenting in the next 6 months) they can be used as monotherapy, without simultaneous administration of antiaggregants. Taking into account the data obtained in patients with sinus rhythm who recently had acute coronary syndrome in the randomized controlled trial ATLAS-ACS 2, as well as with stable atherosclerotic disease in the randomized controlled trial COMPASS, the greatest evidence base in the prevention of coronary complications has been accumulated with rivaroxaban. At the same time, the results of the COMPASS study, as well as analysis of daily medical practice indicate its additional benefits in patients with peripheral atherosclerosis.

Sulodexide in the treatment of post-thrombotic disease complicated by the development of trophic defects of the lower extremities in patients with COVID-19 pneumonia

Introduction. The problem of care for patients with trophic venous ulcers remains an urgent medical and social problem, which has been aggravated again against the background of the COVID-19 pandemic in 2020-2021. As is now known, after a COVID-19 viral infection, most patients with cardiovascular diseases experience a significant exacerbation of these ailments. This is also true for postthrombotic lower extremity disease (PTD). Many patients with edematous or edematous-painful forms of PTB after COVID-19-associated pneumonia experience formation of trophic ulcers of the distal parts of the lower extremities.Aim. To study characteristic features of the course of ulcerative process in PTB in patients after COVID-19-associated pneumonia and to search safe and effective means, accelerating wound epithelialization in such patients.Material and methods. Efficiency of sulodexide use in conservative therapy of 16 patients with PTB, in whom trophic defects (venous ulcers) of the lower third of the shin and foot first appeared after pneumonia due to SARS-CoV-2 infection, was evaluated. At the same time, trophic ulcers were highly resistant to conventional therapy aimed at their healing. All 16 patients were unable to achieve epithelialization more than one month after the occurrence of trophic ulcers. Results. According to the results of this study it was found that the use of sulodexide as an angiotropic agent having, among other things, anti-inflammatory effect on the vessel wall in patients with trophic ulcers formed after COVID-19-associated pneumonia is justified.Conclusions. The treatment of trophic defects of the lower limbs in patients with PTB after COVID-19-associated pneumonia has a number of regular features. Sulodexide showed high efficacy as an angiotropic agent, whose pharmacological properties are adequate to the pathogenesis of trophic ulcers taking into account the course of infection caused by SARS-CoV-2.

Modern concepts of the place of acetylsalicylic acid in the treatment of patients with various manifestations of atherothrombosis

The review is devoted to the analysis of the significance of acetylsalicylic acid (ASA) in the primary and secondary prevention of various manifestations of atherothrombosis. The results of the ARRIVE, ASPREE and ASCEND studies are considered, based on which the evidence base for the use of reduced low-dose ASA (75-100 mg) for primary prevention of cardiovascular diseases (CVD), including patients with diabetes mellitus is formed. Nevertheless, the question of the significance of ASA in primary prevention of CVDs has not been finally resolved, because the results of the latest TIPS-3 study, published in 2020, showed that the combination of enteric-coated ASA with a polypill consisting of a statin and three hypotensive drugs, compared with placebo, reduces the frequency of cardiovascular episodes (CVEs) in individuals without CVDs but with average cardiovascular risk. ASA is an immutable component of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS), in patients with coronary heart disease, subjected to planned stenting. Recently, evidence has been obtained about the impact of bleeding on prognostic outcomes, so there is a clear trend to reduce the duration of aspirin therapy in patients with atrial fibrillation and ACS or undergoing planned stenting. A new trend is enhancement of ASA therapy with a second antithrombotic drug in patients with stable manifestations of atherothrombosis with high risk of thrombotic complications. Thus, modern recommendations suggest to enhance ASA therapy with a vascular dose of rivaroxaban (2.5 mg 2 p/day) or a P2Y12-receptor platelet inhibitor. ASA appears to be a classic antiaggregant and an essential partner for new antithrombotic drugs.

Cardiomyopathy and multiple arterial thrombosis in a patient with severe tachyform atrial fibrillation after COVID-19

We present a case of cardiomyopathy with a reduced left ventricular ejection fraction of up to 18%, multivessel arterial thrombosis in a patient who had undergone severe COVID-19 3.5 months earlier. The cardiopathy was initially considered as an outcome of SARSCoV2-induced myocarditis, but MRI with delayed gadolinium contrast revealed no fibrosis or evidence of active myocarditis. A detailed collection of the medical history showed that the duration of tachyform atrial fibrillation exceeded the 4 months indicated in the medical records. Oligosymptomatic manifestation of arrhythmia occurred 8 months earlier, the patient did not consult a physician due to epidemic conditions. Coronary angiography revealed subtotal stenosis of the anterior descending artery. Most probably, the cardiopathy was arrhythmogenic and ischemic. After achieving normosystole and coronary stenting, the left ventricular ejection fraction was 25-27%. At the first hospitalization 4 months ago, left atrial auricular thrombus was detected. After COVID-19 the patient received inadequately low dose of apixaban 5 mg per day. Three weeks after COVID-19, the patient was diagnosed with infarction of the right kidney, wall thrombosis in the abdominal aorta, thrombosis of the superficial femoral, deep femoral, popliteal, anterior tibial arteries on the left, right popliteal artery; thrombotic complications could have developed both in situ and as a result of cardioembolism. Administration of dabigatran 300 mg per day and aspirin helped to dissolve the thrombus in the left atrial auricle, improve the course of intermittent claudication, and avoid recurrent thrombotic complications. COVID-19 could contribute to the progression of atherosclerosis, more malignant course of atrial fibrillation, development of thrombosis, but coronavirus infection is not the only cause of severe disease in a patient. СOVID-19 can not only be the cause of direct lesions of the heart and vessels, but also have an indirect negative effect - to delay the detection of cardiac pathology and be the cause of its hypodiagnosis under the mask of “postcovid”.

Diagnostic efficiency of myocardial perfusion computed tomography with transesophageal pacing in patients with an initial diagnosis of acute coronary syndrome

Introduction. Computed tomography angiography (CTA) is widely used to detect atherosclerotic changes in coronary arteries (CA). However, the method is limited by the impossibility to perform functional assessment of detected stenoses. Perfusion computed tomography of the myocardium (PCT) can be used for this purpose.Aim of the study. To assess diagnostic accuracy of PCT of the myocardium with transesophageal electrocardiostimulation (TEES) and stress-echocardiography (stress-echoCG) with veloergometry (VEM) in detection of transient ischemia in patients with initial diagnosis of “acute coronary syndrome” (ACS) with borderline stenoses (50–75%) in CA in relation to measurements of fractional flow reserve (FFR).Materials and Methods. The study included 30 patients with the initial diagnosis of ACS with borderline (50–75%) stenoses in CA according to CTA or coronary angiography (CAG). Subsequently, they underwent myocardial PCT with 320-row detector with TEES, as well as stress-echoCG with VEM. Invasive FFR measurement was used as a reference method. FFR value < 0.8 indicated hemodynamic significance of stenosis. Myocardial perfusion was assessed visually. Regional myocardial contractility of the left ventricle was assessed by stress-echoCG.Results. All patients were examined according to the stated protocol. PCT with TEES revealed FFR-significant stenoses with sensitivity, specificity, prognostic value of positive result and prognostic value of negative result 56, 93, 90, 65% respectively, stress-echoCG with VEM 62, 93, 91, 68% respectively.Conclusion. Myocardial PCT with TEES enables to detect perfusion defects associated with transient ischemia, and the diagnostic accuracy of the method in comparison with FFR is comparable with the already well-proven stress-echoCG. The use of PCT with TEES in combination with CTA can be considered as a promising diagnostic tool in patients without known coronary anatomy and with suspected ACS.