Leonid L. Bershtein

Given the high medical and social significance of atherosclerotic cardiovascular diseases (ASCVD), great attention is paid to improving approaches to their primary prevention. This article discusses new approaches to assessing the risk of cardiovascular diseases and their prevention. Considerable focus has been placed on the use of the SCORE2 scale, developed on the basis of current data on morbidity and mortality from cardiovascular diseases in Europe and accounting for both fatal and nonfatal cardiovascular events as outcomes. Ways to refine risk using clinical and laboratory risk modifiers are discussed. Also considered is the introduction into clinical practice of instrumental methods, including assessment of the coronary artery calcium score and ultrasound analysis of carotid artery atherosclerotic plaque, which allows for refinement of the probability of events in intermediate-risk patients. The place of these techniques in current clinical guidelines is discussed, as well as the potential of CT coronary angiography in primary cardiovascular prevention. The presented data will help cardiologists and general practitioners to correctly assess risk in practice in individuals without clinical signs of ASCVD. A separate section is devoted to the assessment of cardiovascular risk in type 2 diabetes mellitus (T2DM) and chronic kidney disease. These are special patient categories in which cardiovascular risk is generally high or very high. Therefore, risk calculation using risk scores is not performed in these patients. The mechanisms of the influence of T2DM and chronic kidney disease on atherogenesis, endothelial dysfunction, and the development of heart failure are discussed. Current concepts of the pathogenesis and therapeutic approaches for a special very high-risk condition, diabetic nephropathy, are highlighted, with an emphasis on the role of the new third-generation selective nonsteroidal mineralocorticoid receptor antagonist, finerenone. Attention to it is driven by the fact that it is the first drug of this class to be used in the primary prevention of ASCVD. The results of large randomized clinical trials are presented, which confirmed its efficacy in reducing cardiovascular and renal outcomes in patients with T2DM and albuminuric diabetic nephropathy, predominantly without established ASCVD. Thus, the article familiarizes the reader with updated algorithms for the primary prevention of ASCVD. Particular attention is paid to very high-risk patients due to T2DM and chronic kidney disease, and to the role of the new selective mineralocorticoid receptor inhibitor, finerenone, in their treatment.

Due to the routine use of endovascular revascularization and improved medical therapy, the majority of acute coronary syndrome (ACS) cases now have an uncomplicated course. However, in spite of the currently accepted secondary prevention standards, the residual risk of remote major adverse cardiovascular events (MACEs) after ACS remains high. Ultrasound carotid/subclavian atherosclerotic plaque assessment may represent an alternative approach to estimate the MACE risk after ACS and to control the quality of secondary prevention. Aim: To find the most important clinical predictors of MACEs in contemporary patients with predominantly uncomplicated ACS treated according to the Guidelines, and to study the potential of the longitudinal assessment of quantitative and qualitative ultrasound carotid/subclavian atherosclerotic plaque characteristics for MACE prediction after ACS. Methods: Patients with ACS, obstructive coronary artery disease (CAD) confirmed by coronary angiography, and carotid/subclavian atherosclerotic plaque (AP) who underwent interventional treatment were prospectively enrolled. The exclusion criteria were as follows: death or significant bleeding at the time of index hospitalization; left ventricular ejection fraction (EF) p-values < 0.05; HR and 95% CI values varied minimally across regression models). The baseline quantitative carotid/subclavian AP characteristics and their 6-month longitudinal changes were not associated with MACEs. All predictors retained significance after the internal validation of the models, and models based on the baseline predictors also demonstrated good calibration; the latter were used to create MACE risk calculators. Conclusions: In typical contemporary patients with uncomplicated interventionally treated ACS, diabetes, decreased EF, Charlson comorbidity index, non-prescription of beta-blockers at discharge, and three or more uncontrolled risk factors after 6 months were the most important clinical predictors of MACEs. We also demonstrated that a lower value of AP GSM reflecting the plaque vulnerability, measured at baseline and after 6 months, was associated with an increased MACE risk; this effect was independent of clinical predictors and risk factor control. According to our knowledge, this is the first demonstration of the independent role of longitudinal carotid/subclavian AP GSM assessment in MACE prediction after ACS.

Aim . To study the associations between risk factors, clinical characteristics, severity of brachiocephalic artery (BCA) atherosclerosis and severity of coronary artery (CA) disease in patients with acute coronary syndrome (ACS). Material and methods . The study included patients with any type of ACS and obstructive coronary artery disease confirmed by coronary angiography. A quantitative analysis of coronary angiography data was performed with an assessment of the number of CAs with significant stenosis and calculation of the SYNTAX score. The major clinical and laboratory parameters that are risk factors for atherosclerosis and/or affect the cardiovascular prognosis were assessed; for patients with ACS without ST segment elevation (NSTE-ACS), the risk score was calculated by the GRACE scale. The BCA ultrasound examination was performed with a quantitative analysis of atherosclerotic burden. Results . The study included 312 patients aged 64 [56, 72] years; the proportion of men was 69.2%. The frequency of lesions of 1, 2 and 3 coronary arteries was 34.6, 35.3, and 30.1%, respectively; the SYNTAX score was 14 [9, 21]. According to the results of univariate analysis, the number of stenotic CAs and the SYNTAX score were associated with age, smoking history, history of ischemic heart disease, diabetes mellitus (DM), the presence of non-stenotic CA lesions, the GRACE score in NSTE-ACS, and the Charlson comorbidity index. An inverse correlation was found for the level of physical activity and a slightly weaker one for the glomerular filtration rate and high-density lipoprotein cholesterol (HDL-C). In multivariate models, the only independent predictors of the number of stenotic CAs were HDL-C (odds ratio, OR 0.37, 95% confidence interval, CI 0.17-0.81; p=0.012) and the smoking history (OR 1.30, 95% CI 1.12-1.52; p=0.001), a coefficient of determination of the model R2 of 18%, SYNTAX score with a history of myocardial infarction (ß=6.40, 95% CI 3.22-9.58; pConclusion . Patients with ACS show significant, independent associations of the severity of coronary atherosclerosis with HDL-C, smoking duration, history of myocardial infarction, insulin-dependent diabetes, and the GRACE score in NSTE-ACS. Variability in the severity of CA lesions is only to a small extent determined by risk factors, clinical characteristics, and the severity of concomitant carotid atherosclerosis.

Aim. To characterize the association between cardiovascular risk factors and clinical and paraclinical variables with the severity of concomitant carotid and subclavian atherosclerosis in patients with acute coronary syndrome (ACS).Material and methods. Patients with ACS of any type, having obstructive coronary artery disease (CAD) confirmed by coronary angiography, underwent an ultrasound of the carotid and subclavian arteries with quantitative plaque assessment. The most important clinical, echocardiographic, angiographic and laboratory variables that contribute to atherosclerosis and/or affect the cardiovascular prognosis were evaluated. In patients with ACS considered ad the CAD onset, retrospective calculation of Systematic Coronary Risk Evaluation2 (SCORE2) score was performed.Results. A total of 312 patients aged 64 (56, 72) years (male, 69,2%) were studied. The detection rate of carotid/subclavian plaque was 86% and was higher in patients with more severe CAD — 79,4, 87,0, 92,6% in patients with 1-, 2- and 3-vessel disease respectively (p=0,027). However, 20% of patients with 2-/3-vessel CAD had no carotid/ subclavian atherosclerosis. Most of the traditional cardiovascular risk factors and other studied echocardiographic, angiographic, laboratory variables, as well as SCORE2 in patients with CAD onset did not demonstrate independent association with the severity of carotid/ subclavian atherosclerosis. The variability of the total plaque area (TPA) was explained by related multifactor regression model only to a small extent, R²=13%. Age (β 0,76, 95% CI 0,24-1,29, p=0,004), glomerular filtration rate (β -0,44, 95% CI -0,76 — -0,13, p=0,006); peripheral artery disease (β 19,50, 95% CI 1,63-37,37, p=0,033) demonstrated a significant independent association with TPA.Conclusion. In patients with ACS, only age, glomerular filtration rate and history of peripheral artery disease demonstrated the independent associations with carotid/subclavian atherosclerotic burden. Assessed variables explained 13% of TPA variability.

Aim      Analysis of inter- and intra-study variability of changes in the atherosclerotic plaque (ASP) total height and total area, the main quantitative indexes that were planned to be used in the present study for assessment of the atherosclerotic load of carotid arteries. Material and methods  The incidence of recurrent cardiovascular complications (CVC) within 1 year after acute coronary syndrome (ACS) ranges from 7-9 % (in studies) to 34 % (in clinical practice). This indicates insufficient efficacy of traditional approaches to secondary prevention of coronary heart disease. We proposed a study to test a hypothesis that the dynamics of ASP parameters in carotid and subclavian regions can serve as an alternative criterion for the adequacy of secondary prevention after ACS. The analysis was performed on subgroups of main study participants. These patients had ACS of any type documented by coronary angiography with an ASP confirmed by ultrasound of the brachiocephalic arteries (BCA) during the index hospitalization. BCA ultrasound was performed to analyze the inter- and intra-study variability of BCA atherosclerotic load, the ASP total height (Hsum) and total area (ASPTA), in 20 and 24 patients of the main study, respectively. Results of the repeated ultrasound were evaluated in 30 patients of the main study after 6 months of follow-up. Results The inter-study variability of each index was significantly higher than the intra-study variability which was consistent with results of previous studies. The intra-study variability of Hsum was 0.10 (95 % confidence interval, CI – 0.23–0.44) mm and ASPTA, 1.05 (95 % CI, – 0.54–2.63) mm ² . The variability values were considerably smaller than the changes for 6 months: Hsum, 0.92 (95 % CI, – 0.64–2.49) mm and ASPTA, 3.67 (95 % CI, 0.42–6.91) mm ² , although the difference did not reach statistical significance. The above results were obtained at an early stage of the study during the adaptation of specialists to the protocol. Conclusion The study results suggest a possibility of a fairly reliable assessment of the dynamics of quantitative indexes of carotid ultrasound 6 months after ACS.

Coronary revascularization is one of the most studied treatment modalities in cardiology; however, there is no consensus among experts about its indications in patients with stable coronary artery disease (SCAD). Contemporary data regarding the role of revascularization in SCAD are in clear conflict with the current European guidelines. This article discusses the main statements of the most significant American and European Guidelines on myocardial revascularization of the last decade and also analyzes the appropriateness of revascularization to improve the prognosis and symptoms in SCAD in the light of new research data, primarily the ISCHEMIA study (NCT01471522) and the ACC/AHA 2021 Revascularization Guidelines based on them. Data on the revascularization in SCAD obtained after the completion of ISCHEMIA (including the interim analysis of ISCHEMIA-EXTEND) and their potential significance are discussed. The results of ISCHEMIA sub-analyses in the most important “controversial” subgroups (3-vessel disease, proximal left anterior descending artery disease, strongly positive stress test, etc.) are reviewed, as are the results of the ISCHEMIA-CKD substudy in patients with severe chronic kidney disease (CKD).

Background: Patients with significant (≥50%) left main disease (LMD) have a high risk of cardiovascular events, and guidelines recommend revascularization to improve survival. However, the impact of intermediate LMD (stenosis, 25%–49%) on outcomes is unclear. Methods: Randomized ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) participants who underwent coronary computed tomography angiography at baseline were categorized into those with (25%–49%) and without (P _interaction =0.049). The invasive strategy improved angina-related quality of life and the benefit was durable throughout follow-up without significant heterogeneity based on intermediate LMD status. Conclusions: In the ISCHEMIA trial, there was no meaningful heterogeneity of treatment benefit from an invasive strategy regardless of intermediate LMD status except for a greater absolute risk reduction in nonprocedural MI with invasive management in those with intermediate LMD. An invasive strategy increased procedural MI, reduced nonprocedural MI, and improved angina-related quality of life. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01471522.

Coronary revascularization is one of the most studied types of interventions in cardiology, but there is no consensus among specialists about the indications for its implementation in patients with chronic coronary syndromes (CCS). The data of recently completed clinical trials on the role of revascularization in CCS clearly contradict the current Guidelines, emphasizing the high effectiveness of modern conservative therapy. This paper discusses the main recommendations of the most significant American and European Guidelines on myocardial revascularization, and also analyzes the appropriateness of revascularization to improve the prognosis and symptoms in chronic coronary syndromes in view of the new research data, primarily the ISCHEMIA study (NCT01471522). Its strengths and limitations are discussed in detail. The data on the expediency of revacularization in CCS, obtained after the completion of ISCHEMIA and its potential significance, as well as subgroup analyses of ISCHEMIA, including in the most important ‘problem’ subgroups (3-vessel disease, proximal LAD disease, severe ischemia on stress test, etc.) are discussed. The paper also discusses the important achievements in modern drug therapy of chronic coronary syndromes, primarily antithrombotic therapy. The data of the COMPASS study (NCT01776424) are discussed, based on which the addition of a second antithrombotic drug – rivaroxaban in a small dose (2.5 mg BID) – is recommended for patients with CCS without atrial fibrillation who have high-risk characteristics. Indications the administration of dual antithrombotic therapy to patients with CCS, comparative results of its various regimens in relation to the prevention of cardiovascular complications, the risk of bleeding and the net clinical effect are given.

Atherosclerotic cardiovascular disease is the leading cause of death in the world, primarily in low-and middle-income countries, including Russian Federation. According to WHO experts, the global atherosclerotic cardiovascular disease epidemic can be brought under control mainly by improving the cardiovascular prevention. This paper describes the modern principles of risk assessment in people without manifested atherosclerotic cardiovascular disease, as well as considers drug and non-drug methods of primary prevention.