Modern approaches in the treatment of patients with Paget-Schretter syndrome

Goal. Consider the management of patients with effort thrombosis (Paget-Schretter syndrome).The article presents the modern vision of the problem of effort thrombosis. This review is aimed at describing the epidemiology, pathophysiology, diagnosis and treatment of patients with Paget-Schretter syndrome. SPS occurs spontaneously, as a rule, in young, healthy and active patients aged 20-30 years after strenuous physical activity. The ratio of men and women is 2:1, recently there has been a growing trend among women. The main complaints of patients with SPS include swelling of the affected limb, discomfort when moving the affected arm, pain and heaviness when trying to raise the arm up. When examining these patients, attention is paid to hyperemia of the skin or their cyanotic nature, pasty limbs, as well as an enhanced venous pattern on the shoulder, the so-called Arshel sign. The diagnosis is based on the data of anamnesis, physical examination, the “gold standard of diagnostics” – ultrasound examination of veins, the sensitivity and specificity of which is 70-100%. The first step in the diagnosis can be the evaluation of the D-dimer, with its negative values, the SPSH is rejected. With an obvious clinic and controversial results of serial ultrasound examinations, other imaging methods are used, such as computed contrast tomography, magnetic resonance imaging, the diagnostic value of which is especially significant in occlusive venous thrombosis.SPS differs not only from DVT of the lower extremities, but also from secondary DVT of the upper extremities, which determines the peculiarities of management of this category of patients, including surgical treatment aimed at preventing subclavian vein compression in the future. The article summarizes the experience in the management of patients with blood thrombosis.

Clinical case of a patient with pulmonary capillary hemangiomatosis: rapid progression or lost time?

The article describes a clinical case of a 37-year-old patient with pulmonary capillary hemangiomatosis of functional class IV according to the WHO classification with difficulties of diagnostic search and features of PAH-specific therapy.Pulmonary arterial hypertension - group 1 in the clinical classification is represented by several forms of pathology, including very rare diseases such as pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis.The difficulties of diagnostic search consist in the absence of specific symptoms, a variety of interstitial or focal changes according to spiral computed tomography, and the final diagnosis can be made only after performing a lung biopsy, which is associated with a high risk of possible complications. During the initial treatment and examination of the patient, clinical and hemodynamic parameters did not immediately allow to suspect the presence of pulmonary capillary hemangiomatosis. And only the difficulties of the patient’s management associated with the lack of the expected effect of the therapy with PAH-specific drugs served as the basis for further diagnostic search.Against the background of taking vasodilators, with the normalization of hemodynamic parameters, the progression of respiratory and right ventricular insufficiency was noted in the patient. According to the results of an additional examination, a diagnosis of pulmonary capillary hemangiomatosis was established, therapy was corrected and further tactics of management and treatment of the patient were determined. Currently, the patient is awaiting transplantation at V.I. Shumakov national medical research center and receives specific therapy with riociguate 2.5 mg TID and bosentan 125 mg BID.

COVID-19 pandemic challenges: on the way to overcome obstacles in realization of PAH-specific therapy treatment goals

Our observation demonstrates a case of a 40-year-old female with idiopathic pulmonary arterial hypertension World Health Organization functional class III, who was admitted to NMRC of Cardiology repeatedly due to disease progression including dyspnea worsening and exercise tolerance decrease after previous COVID-19 infection on riociguat (7.5 mg daily), macitentan (10 mg daily) and selexipag (1600 mcg daily) therapy. Clinical examination demonstrated high-risk status according to the expected 1-year mortality. Due to unreleased treatment goals and high-risk status, we performed transition from selexipag to inhale iloprost. After therapy escalation the patient demonstrated a significant improvement in clinical condition, dyspnea reduction and exercise tolerance increase. The current treatment strategy for pulmonary arterial hypertension is based on regular multiparametric risk stratification approach in PAH patients. The impact of COVID-19 may become an important cause of clinical worsening in PAH patients during COVID-19 pandemic. Directed on vasodilatation and antiproliferation mechanisms of action of PAH-specific drugs are supposed to be protective in COVID-19 patients. However, the probability of clinical worsening in PAH patients despite PAH-specific therapy intake needs to be closely monitored to perform timely treatment correction in order to achieve low-risk status and to improve the prognosis of PAH patients.

Eurasian clinical guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndrome (NSTE-ACS)

The EAC Guidelines represent the views of the EAC, and were produced after careful consideration of the scientific and medical knowledge, and the evidence available at the time of their publication. The EAC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the EAC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the EAC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the EAC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the EAC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

Hospital and mid-term results of simultaneous correction of coronary and carotid arteries

Study objective: to present the immediate and mid-term results of onestage surgical treatment of patients in the volume of CEE and CABG based on a differentiated approach to patient selection.Materials and methods: in FCCVS n.a. S.G. Suhanov, Perm developed an algorithm for choosing treatment tactics in patients with combined atherosclerotic lesions of the coronary and brachiocephalic arteries. According to this algorithm, for the period from 01.07.2014-01.01.2021, one-stage correction of CABG + CEE was performed in 104 patients. The primary endpoints were all-cause death, acute myocardial infarction (MI), transient ischemic attack (TIA), and stroke. Hospital and midterm results were analyzed. The average follow-up time in the study of mid-long-term results was 40.3 ± 20.4 months.Results: in the study of hospital outcomes, the mortality rate was 0%. There were recorded 3 (2.9%) cases of perioperative stroke and 1 (0.9%) case of myocardial infarction. There were no cases of TIA. The combined endpoint (death, acute MI, stroke, TIA) reached 4 (3.8%) patients. In the study of mid-term results, we were able to contact 96 patients out of 104 operated on (92.3%). The survival rate was 94.8%. 5 (5.2%) people died. There were 2 (2.1%) cases of myocardial infarction, 4 (4.1%) cases of stroke.Conclusions: simultaneous revascularization of the carotid and coronary regions of CABG + CEE is safe and allows adequate elimination of the lesion in both regions.

Weather dependence of medical rehabilitation efficiency in patients with ischemic heart disease on the resort of the South Coast of Crimea

The aim of this work is to assess the influence of the climatic and weather characteristics of the South Coast of Crimea (SCC) on the effectiveness of health resort medical rehabilitation (MR) of patients with ischemic heart disease (IHD).Materials and methods. A study was carried out in a group of 276 patients with IHD. The influence of climatic and weather characteristics of the SCC were assessed using the methods developed by the «ARI n.a. I.M. Sechenov» - modified clinical index on weather pathogenicity (CIPP-M) and MR assessment according to the criteria of the» International classification of functioning, disabilities and health» (ICF).Results. Regression equations for the dynamics of the ICF b2401, b280, b4301 and b440 domains on the values of air temperature (AT-M), atmospheric pressure variability (APV), air temperature variability (ATV-M) wind speed (WS-M) and total CIPP-M have been developed, which allow to reliably form a rehabilitation prognosis for patients with IHD for all terms of health resort treatment in the SCC.Conclusions. The use of modernized clinical indices of weather pathogenicity allows one to adequately assess and predict the effect of weather dynamics and form a rehabilitation prognosis for patients with IHD.

The influence of geomagnetic and seismic parameters on mortality from cardiovascular pathologies in the Shamakhi Region of the Republic of Azerbaijan

Aim. Study of the dependence of mortality from CVD on helio-seismic indicators in the Shamakhi region of the Republic of Azerbaijan.Materials and methods. 352 case histories of patients who died in 2013 from various diseases were reviewed. The relationship was established between the number of deaths, their causes, distribution by sex and age with the magnitude of earthquakes, the depth of the epicenter and seismological activity by months. The data obtained were statistically processed using the Statistica 12.0 for Windows software package (Statsoft Inc., USA). To establish correlations, Pearson Chi-Square Tests was calculated, the results were considered reliable at p <0.05.Results. Statistically significant (p <0.001) more deaths were observed at the age of 80-89 years in men, and at the age of 70-79 years in women. Also, the relationship between mortality and the depth of the seismic process and the magnitude of the earthquake was established, in particular, the greatest number of deaths was observed at a depth of the seismic process <10 km and with a magnitude of 1.1-2.0 ml. In all months, the number of deaths was higher with a magnitude of 1.1-2.0 Ml. Statistically significant (p <0.005) was the fact that the nosology of the studied diseases was dependent on the age of the patients. Thus, a greater number of deaths in all age groups accounted for heart failure. A statistically significant (p <0.005) dependence of the depth of the seismic process on the month of death of patients was established, in particular, for all months, deaths coincided with the depth of the process less than 10 km. At the age of 40-70 years, a significantly greater number of deaths were from heart failure in men, and from 70 years and above in women.Conclusion. Thus, there is a close correlation between geomagnetic changes and mortality from CVD, which is realized in the form of an increase in the frequency of cases and deaths, and the number of these cases increases with the age of patients and changes in the magnitude and depth of the earthquake.

Cost-effectiveness study of the MitraClip system for mitral regurgitation treatment in inoperable patients

The study aims to estimate the MitraClip system’s cost-effectiveness compared with optimal medical therapy in adult patients with inoperable mitral regurgitation and assess its impact on the budget of the Russian Federation health system.Materials and methods. The cost-effectiveness analysis of the MitraClip system was carried out using the Markov model. The time horizon was three & five years. The budget impact analysis (BIA) model compared the costs of treating patients distributed across different management practices. Standard management practice included only optimal medical therapy. Expected management practice included different patient allocation between the MitraClip system and optimal medical therapy. The time horizon for the budget impact analysis was five years. Results. The incremental cost-effectiveness ratio (ICER) per additional quality-adjusted life-year (QALY) gained of the MitraClip system in comparison with optimal medical therapy was 6,271,657 rubles in three years and 3,451,342 rubles in five years. Based on the BIA results of the MitraClip system, its use would lead to an increase in costs by 12.6 billion rubles (+6.09%, minimal scenario), by 37.8 billion rubles (+18.28%, optimal scenario) or by 63 billion rubles (+30.47%, maximum scenario).Conclusion. As a result of the analysis performed, it was found that economic efficiency is noted with an increasing time horizon of up to five years. The obtained ICER values are comparable with the average values obtained in other foreign cost-effectiveness studies. The use of this technology will lead to an increase in direct medical costs by 6.09% over five years compared to the current management practice. In more comprehensive MitraClip system implementation (maximum scenario), direct medical costs will increase by 30.47% compared to the current management practice.

Algorithm for assessing the total 10 years risk of death from cardiovascular diseases in women 25-64 years old in Tyumen (Tyumen risk scale)

Purpose: To define total 10-year cardiovascular mortality risk in Russian females in dependence on traditional and psychosocial risk factors (RF) and to design the algorithm of its estimation.Methods. The study included non-organized population of Central Administrative district of Tyumen city. Epidemiological study, based on the representative selection of 1000 females aged 25-64 years. Screening respond was 81.3%. Cardiovascular mortality rate within 10 years was studied. Totally, 31 cases of cardiovascular death were registered in female cohort within 10year follow-up. We used a multivariate Cox regression model to estimate hazard ratio (HR) and confidence interval (CI). Relations between mortality rate and factors such as age, smoking, education, occupation, marital status, systolic and diastolic blood pressure (SBP and DBP), body mass index, total cholesterol, cholesterol of low and high density lipoproteins were analyzed.Results. To build a model of total cardiovascular risk, six statistically significant indicators were selected: age (HR – 1.099, 95% CI 1.032-1.1.69), SBP (1.026, 95% CI 1.011-1.041), primary education (4.315, 95% CI 1.878-9.910), work associated with heavy physical labor (4.073, 95% CI 1.324-12.528), executives (3.822, 95% CI 1.386-10.537) and marital status (2.978, 95% CI 1.197-7.409). Based on these data, model for total cardiovascular mortality risk in females was designed with good predictive accuracy (AUC was 0.882, 95% CI – 0.833 – 0.930).Conclusion. Thus, created mathematical model, built based on statistically significant traditional and psychosocial RF, makes it possible to effectively predict the total cardiovascular risk at the individual level in the female population.

ADVANCE research 20 years later

Observational and interventional studies have shown that intensive blood pressure control may benefit in patients with diabetes. The Action in Diabetes and Vascular Disease: Preterax and Diarnicron MR Controlled Evaluation (ADVANCE) international randomized, controlled, clinical trial was launched in 2001. According to the results of the study, the risk of major micro- and macrovascular events (primary endpoint) significantly decreased by 9%, while the risks of cardiovascular death and death from any cause decreased by 18% and 14%, respectively. There was a decrease in the risks of microvascular complications – any renal event, the appearance or worsening of nephropathy and the appearance of microalbuminuria by 21%, 18% and 21%, respectively. The results of the antihypertensive part of the ADVANCE study supplemented the expanding evidence base and served as the basis for changing clinical guidelines for the management of patients with hypertension and diabetes. According to the updated joint guidelines of the European Society of Cardiology / European Association for the Study of Diabetes (ESC/EASD), the target systolic / diastolic blood pressure levels should be 130/80 mmHg, with some exceptions, and the fixed combination of the RAAS blocker with a diuretic or calcium antagonist is suggested as first-line therapy.The observational ADVANCE-ON study, which enrolled 8494 patients out of 11 140 patients randomized to the ADVANCE study, found a memory effect, or ‘inheritance’, in which intensive blood pressure control during the study had a beneficial effect on various outcomes after its termination. These findings highlight the importance of achieving and maintaining optimal blood pressure control to reduce the risk of micro- and macrovascular complications.